Connective Tissue Diseases

  • Diagnosis
  • Algorithms
  • Monitoring
  • Background
  • Pediatrics
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

  • Patient with systemic symptoms, including arthralgias, arthritis, skin rashes, anemia, renal dysfunction, pleuritis, pericarditis

Laboratory Testing

  • Nonspecific testing
    • CBC – rule out infection
    • C-reactive protein (CRP)
    • Antinuclear antibodies (ANA) testing
      •  ANA, IgA, by ELISA
        • Negative – possible scenarios
          • No connective tissue disease (CTD) present
          • False-negative result – consider systemic sclerosis (scleroderma SSc), polymyositis/dermatomyositis (PM/DM), inactive systemic lupus erythematosus (SLE)
            • If strong suspicion for CTD, consider disease-specific antibody tests or panels
            • Positive – ANA HEp-2, IgG, by IFA (result pattern suggests underlying disease)
              • ANA reported patterns and diagnoses
                • Centromere – limited cutaneous scleroderma (lcSSc), CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia)
                • Cytoplasmic – PM, DM, SLE, SSc
                • Peripheral/rim/homogenous – SLE, drug-induced lupus erythematosus (DIL)
                • Nucleolar – SLE, SSc, PM DM
                • Speckled – SLE, Sjögren syndrome, mixed connective tissue disease (MCTD)/undifferentiated connective tissue disease (UCTD), diffuse cutaneous scleroderma (dcSSc), unidentified specificities or markers of low prevalence in CTD – see Connective Tissue Disease Testing Algorithm for more specific antibody testing patterns
              • False-positive results may be induced by age, certain infections, cancers, and drugs
              • ANA may be positive in inflammatory diseases (eg, autoimmune liver diseases)
              • Titer level has no bearing on diagnosis or disease severity once it is above established normal level
      • Other testing
        • Rheumatoid factor IgM antibodies – if musculoskeletal complaints are present
        • If suspicion for connective tissue disease is low, consider drug-induced lupus erythematosus (DIL), chronic autoimmune disease, chronic hepatitis C virus
        • Urinalysis – rule out glomerulonephritis associated with connective tissue disease
        • Anti-neutrophil cytoplasmic antibodies (ANCA) – rule out vasculitis associated with connective tissue disease

    Differential Diagnosis

    • Once diagnosis has been made, use monitoring tests based on organ involvement
      • Urinalysis – acceptable screen for renal disease
      • If cytopenias present, follow with sequential CBCs
      • Certain treatment drugs require liver function testing

    Several autoimmune connective tissue diseases may present with similar features. These diseases include systemic lupus erythematosus, Sjögren syndrome, mixed connective tissue disease, systemic sclerosis (scleroderma), inflammatory myopathies (polymyositis/dermatomyositis [PM/DM]), and undifferentiated connective tissue disease.

    Epidemiology

    • Incidence – 15-50/100,000, depending on disease
    • Age – onset is 15-40 years; peak onset in 20s
    • Sex – M<F, 1:6-10

    Pathophysiology

    • Circulating antigen-antibody complexes affect a variety of organs
    • Multisystem disease presentation
    • Antigen/antibody complexes affect a variety of organs in connective tissue diseases
    • ANA antibodies are the most common antibodies and may precede the onset of connective tissue disease
    • Certain antibodies may show specificity for certain diseases (eg, SSA 52, SSA 60, and SSB antibodies for Sjögren syndrome)
    • ANA antibodies are not specific for connective tissue disease and may also be associated with
      • Infectious diseases
      • Cancers
      • Other autoimmune disorders (eg, autoimmune liver disease)
      • Advanced age

    Clinical Presentation

    • Cardiopulmonary – pleuritis, pericarditis, fibrosis, chest pain
    • Constitutional – fever, anorexia, weight loss
    • Dermatologic – skin rashes, Raynaud phenomenon, photosensitivity
    • Gastrointestinal – gastroesophageal reflux disease
    • Hematologic – cytopenias (involving neutrophils, erythrocytes, and platelets)
    • Musculoskeletal – arthralgias, arthritis, synovitis, myopathy
    • Neurologic – seizures, encephalopathy
    • Otorhinolaryngologic – sicca syndrome, oral ulcers
    • Renal – proteinuria, glomerulonephritis

    Clinical Background

    Epidemiology

    • Incidence – varies by disease but lower than in adults
    • Sex – M<F for most disorders
    • Age – presents more often >10 years

    Clinical Presentation

    • Cardiopulmonary – chest pain, pericarditis, pleuritis
    • Constitutional – fever, anorexia, weight loss (most common)
    • Dermatologic – skin rash, Raynaud syndrome, photosensitivity
    • Gastrointestinal – abdomen pain, diarrhea, hepatitis
    • Musculoskeletal – arthralgias, arthritis, synovitis, myopathy, weakness

    Diagnosis

    Indications for Testing

    • Appropriate clinical presentation, including arthritis, arthralgias, skin rashes, anemia, pleuritis, pericarditis

    Laboratory Testing

    • Nonspecific testing
      • Refer to Diagnosis tab
    • ANA testing
      • Refer to Diagnosis tab and Connective Tissue Disease Testing Algorithm
    • Other testing
      • Rheumatoid factor IgM antibodies – rule out juvenile idiopathic arthritis if musculoskeletal complaints are present

    Differential Diagnosis

    Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

    Nuclear Antibody (ANA) by IFA, IgG 0050639
    Method: Semi-Quantitative Indirect Fluorescent Antibody

    Recommended Use 

    Preferred ANA screening test for connective tissue diseases

    Limitations 

    Only cytoplasmic, nuclear mitotic apparatus (NuMA), and/or nuclear dot pattern will be reported if observed; titers are not performed

    Dual or mixed patterns will not be reflexed; additional testing for dual or mixed patterns should be determined by the ordering physician

    A negative ANA by IFA test does not rule out the presence of connective tissue disease 

    Anti-Nuclear Antibody (ANA), IgG by IFA with Reflex by IFA Pattern 2008467
    Method: Semi-Quantitative Indirect Fluorescent Antibody/Qualitative Enzyme-Linked Immunosorbent Assay/Semi-Quantitative Enzyme-Linked Immunosorbent Assay/Semi-Quantitative Multiplex Bead Assay/Qualitative Immunoblot

    Recommended Use 

    Initial screen for autoimmune connective tissue diseases

    One or more reflexive tests may be added, depending on the ANA pattern detected

    Limitations 

    Only cytoplasmic, nuclear mitotic apparatus (NuMA), and/or nuclear dot pattern will be reported if observed

    Titers are not performed

    Dual or mixed patterns will not be reflexed; additional testing for dual or mixed patterns should be determined by the ordering physician

    A negative ANA by IFA test does not rule out the presence of connective tissue disease 

    Anti-Nuclear Antibodies (ANA), IgG by ELISA with Reflex to ANA, IgG by IFA 0050080
    Method: Qualitative Enzyme-Linked Immunosorbent Assay/Semi-Quantitative Indirect Fluorescent Antibody

    Recommended Use 

    Aid in initial diagnosis of connective tissue disease

    Detects antibodies against dsDNA, histone, SS-A (Ro), SS-B (La), Smith, snRNP/Sm, Scl-70, Jo-1, centromere, and an extract of lysed HEp-2 cells

    Reflex pattern – if ANA are detected by ELISA, then ANA by IFA titer will be added

    Limitations 

    Results are not disease specific

    ANA ELISA assays have lower sensitivities for antibodies associated with nucleolar and specked ANA-IFA patterns

    Connective Tissue Diseases Profile 0051668
    Method: Semi-Quantitative Multiplex Bead Assay

    Recommended Use 

    Confirmatory tests for specific and more common connective tissue disease

    Components include Sm (ENA) antibody; RNP (U1) (ribonucleic protein); SSA (Ro); SSB (La); Jo-1; ribosomal P protein; centromere; and scleroderma (Scl-70)

    Systemic Sclerosis Comprehensive Panel 2013325
    Method: Qualitative Immunoblot/Semi-Quantitative Indirect Fluorescent Antibody/Semi-Quantitative Multiplex Bead Assay/Semi-Quantitative Enzyme-Linked Immunosorbent Assay

    Recommended Use 

    Comprehensive evaluation of systemic sclerosis (SSc)

    Indicated when suspicion for SSc is high and patient presents with features of overlap disease

    Panel includes anti-nuclear antibody (ANA) titer, anti-nuclear antibody (ANA) pattern, anti-Scl-70, anti-RNA polymerase III antibody, anti-centromere antibody, anti-U1 RNP antibody, anti-fibrillarin (U3 RNP), anti-PM/Scl antibody

    Clinical sensitivity for ANA by IFA for SSc ranges from 90-95%; sensitivity for individual SSc-specific marker is dependent on ethnicity 

    Limitations 

    Negative antibody test result does not exclude SSc; 5-10% of SSc patients are ANA IFA negative

    Panel does not include Th/To

    Multiplex bead assay detects antibodies targeting the centromere protein B of the centromere complex

    Systemic Sclerosis Panel 2012057
    Method: Semi-Quantitative Indirect Fluorescent Antibody/Semi-Quantitative Multiplex Bead Assay/ Semi-Quantitative Enzyme-Linked Immunosorbent Assay

    Recommended Use 

    Indicated for patients with distinct features of SSc

    Reflex pattern – if ANA IFA is positive and SSc specific markers are negative, testing for other markers associated with SSc or connective tissue disease based on observed ANA IFA pattern(s) is performed (ethnicity or clinical presentation may be clinically useful)

    Components include anti-nuclear antibody (ANA) by IFA, IgG; scleroderma (Scl-70) antibody, IgG; and RNA polymerase III antibody, IgG

    Clinical sensitivity for ANA by IFA for SSc ranges from 90-95%; sensitivity for individual SSc-specific marker is dependent on ethnicity

    Limitations 

    Negative antibody test result does not exclude systemic sclerosis

    Panel does not include Th/To

    Polymyositis and Dermatomyositis Panel 2013992
    Method: Qualitative Immunoprecipitation/Semi-Quantitative Multiplex Bead Assay/Qualitative Immunoblot

    Recommended Use 

    May be useful for evaluation of patients with progressive proximal muscle weakness and/or cutaneous manifestations suggestive of dermatomyositis and/or associated connective tissue disease

    Components include Jo-1, PL-7, PL-12,  EJ, SRP, OJ, Mi-2, P155/140, SAE1, MDA5, NXP-2, and TIF1-γ antibodies

    Limitations 

    Results by themselves are not diagnostic; strong clinical correlation is recommended

    Negative results do not rule out a diagnosis of inflammatory myopathy or overlap syndrome

    Polymyositis Panel 2013990
    Method: Qualitative Immunoprecipitation/Semi-Quantitative Multiplex Bead Assay

    Recommended Use 

    May be useful for evaluation of patients with progressive proximal muscle weakness and antisynthetase syndrome

    Components include Jo-1, PL-7, PL-12, EJ, SRP, and OJ antibodies

    Dermatomyositis Panel 2013991
    Method: Qualitative Immunoprecipitation/Qualitative Immunoblot

    Recommended Use 

    May be useful for evaluation of patients with characteristic cutaneous manifestations of dermatomyositis with or without muscle weakness

    Components include Mi-2, P155/140 (TIF1-gamma), SAE1 (SUMO activating enzyme), MDA5 (CADM-140), NXP-2, and TIF1-gamma antibodies

    Interstitial Lung Disease Panel 2013993
    Method: Qualitative Immunoprecipitation/Semi-Quantitative Multiplex Bead Assay/Qualitative Immunoblot/Semi-Quantitative Enzyme-Linked Immunosorbent Assay/Quantitative Immunoturbidimetry

    Recommended Use 

    May be useful for evaluation of interstitial lung disease in the context of connective tissue disease

    Components include SSA 52 and 60 (Ro), Scl-70; Jo-1, PL-7, PL-12, EJ, Ku, SRP, OJ, PM/Scl-100, MDA5, NXP-2, rheumatoid factor, CCP, and ANA antibodies

    Myositis Extended Panel 2013961
    Method: Qualitative Immunoprecipitation/Semi-Quantitative Multiplex Bead Assay/Qualitative Immunoblot

    Recommended Use 

    May be useful in the differential evaluation of polymyositis, dermatomyositis, necrotizing autoimmune myopathy, or overlap syndromes associated with connective tissue disease

    Components include SSA 52 and 60 (Ro), RNP (U1) (ENA), Jo-1, Mi-2, PL-7, PL-12, P155/140 (TIF1-gamma), EJ, Ku, U2 sn RNP, SRP, OJ, SAE1, MDA5, NXP-2, TIF1-gamma (TIF1-γ), fibrillarin (U3 RNP), and PM/Scl-100 antibodies

    Limitations 

    Results by themselves are not diagnostic; strong clinical correlation is recommended

    Negative results do not rule out a diagnosis of inflammatory myopathy or overlap syndromes 

    Rheumatoid Arthritis Panel 2003277
    Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay/Immunoturbidimetry

    Recommended Use 

    Preferred panel for the workup of suspected rheumatoid arthritis or undifferentiated inflammatory arthritides

    Components include cyclic citrullinated peptide (CCP) antibody, IgG, and rheumatoid factor

    Fibrillarin (U3 RNP) Antibody, IgG 2012173
    Method: Qualitative Immunoblot

    Recommended Use 

    Recommended for the diagnosis of systemic sclerosis in patients negative for centromere, Scl-70, or RNA polymerase III antibodies

    May predict skeletal muscle involvement and pulmonary arterial hypertension

    Limitations 

    Negative test result does not rule out the diagnosis of systemic sclerosis

    Test results alone are not diagnostic; results should be used in conjunction with other laboratory tests and clinical findings

    Anti-Neutrophil Cytoplasmic Antibody with Reflex to Titer and MPO/PR-3 Antibodies 2002068
    Method: Semi-Quantitative Indirect Fluorescent Antibody/Semi-Quantitative Multiplex Bead Assay

    Recommended Use 

    Preferred reflex panel for managing patients with a known diagnosis of vasculitis; may be assistive in evaluating suspected vasculitis
    For the workup of suspected vasculitis, the preferred panel is ANCA-associated vasculitis profile (ANCA/MPO/PR-3) with reflex to ANCA titer

    Panel includes ANCA, IgG; myeloperoxidase antibody and serine protease 3 antibody

    Reflex pattern – if screen is positive, titer and MPO/PR-3 antibodies testing will be added

    Guidelines

    Choosing Wisely. An initiative of the ABIM Foundation. [Accessed: Jun 2017]

    Meroni PL, Schur PH. ANA screening: an old test with new recommendations. Ann Rheum Dis. 2010; 69(8): 1420-2. PubMed

    van den Hoogen F, Khanna D, Fransen J, Johnson SR, Baron M, Tyndall A, Matucci-Cerinic M, Naden RP, Medsger TA, Carreira PE, Riemekasten G, Clements PJ, Denton CP, Distler O, Allanore Y, Furst DE, Gabrielli A, Mayes MD, van Laar JM, Seibold JR, Czirjak L, Steen VD, Inanc M, Kowal-Bielecka O, Müller-Ladner U, Valentini G, Veale DJ, Vonk MC, Walker UA, Chung L, Collier DH, Csuka ME, Fessler BJ, Guiducci S, Herrick A, Hsu VM, Jimenez S, Kahaleh B, Merkel PA, Sierakowski S, Silver RM, Simms RW, Varga J, Pope JE. 2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis Rheum. 2013; 65(11): 2737-47. PubMed

    General References

    Fritzler MJ. The antinuclear antibody test: last or lasting gasp? Arthritis Rheum. 2011; 63(1): 19-22. PubMed

    Ghirardello A, Bendo R, Rampudda ME, Bassi N, Zampieri S, Doria A. Commercial blot assays in the diagnosis of systemic rheumatic diseases. Autoimmun Rev. 2009; 8(8): 645-9. PubMed

    Kumar S, Aggarwal A. Approach to a patient with connective tissue disease. Indian J Pediatr. 2010; 77(10): 1157-64. PubMed

    Liu C, Ahearn JM. The search for lupus biomarkers. Best Pract Res Clin Rheumatol. 2009; 23(4): 507-23. PubMed

    Mammen AL. Dermatomyositis and polymyositis: Clinical presentation, autoantibodies, and pathogenesis. Ann N Y Acad Sci. 2010; 1184: 134-53. PubMed

    Schulte-Pelkum J, Fritzler M, Mahler M. Latest update on the Ro/SS-A autoantibody system. Autoimmun Rev. 2009; 8(7): 632-7. PubMed

    Singh S, Mehra S. Approach to polyarthritis. Indian J Pediatr. 2010; 77(9): 1005-10. PubMed

    Vaz CC, Couto M, Medeiros D, Miranda L, Costa J, Nero P, Barros R, Santos MJ, Sousa E, Barcelos A, Inês L. Undifferentiated connective tissue disease: a seven-center cross-sectional study of 184 patients. Clin Rheumatol. 2009; 28(8): 915-21. PubMed

    Medical Reviewers

    Tebo, Anne E., PhD, D(ABMLI), Medical Director, Immunology at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

    Last Update: June 2017