Improvement of indirect immunofluorescence technique to detect antineutrophil cytoplasmic antibodies and its impact on test positivity rate

The indirect immunofluorescence (IIF) technique for antineutrophil cytoplasmic antibodies (ANCA) detection is subject to substantial differences across laboratories. This study aimed to assess the impact of improvements in the IIF-ANCA technique on the positivity rate of ANCA tests. A cross-sectional study was performed with serum samples from patients with ANCA-associated vasculitis (AAV), autoimmune hepatitis (AIH), and ulcerative colitis (UC). A paired analysis was performed for IIF-ANCA results using the traditional method and a modified protocol after a series of specific adjustments in the technique based on the protocol of IIF-ANCA test performed at a nation-wide private laboratory in Brazil. ANCA specificity was assessed by ELISA for anti-proteinase 3 (PR3) and anti-myeloperoxidase (MPO) antibodies. Sixty-one patients were evaluated. The positivity rate of IIF-ANCA tests at disease presentation performed at the University reference laboratory was 32.3% in AAV, AIH, and UC patients, whereas the positivity rates of IIF-ANCA and ELISA tests in other laboratories were 75.0 and 72.7%, respectively. After modifications in the IIF-ANCA technique, there was a significant increase in the positivity rate (14.8 vs 34.3%; P=0.0002) and in median titers [1/40 (1/30-1/160) vs 1/80 (1/40-1/80); P=0.0003] in AAV, AIH, and UC patients. UC had the highest increment in positive results from 5.3 to 36.8%. There was poor agreement between MPO- or PR3-ANCA and both IIF-ANCA techniques. In conclusion, modifications in the IIF-ANCA protocol led to a significant improvement in its positivity rate and titers.

Lupus-like nephritis with positive anti-neutrophil cytoplasmic antibodies and negative antinuclear antibodies / Nefrite semelhante à lúpica com anticorpos citoplasmáticos antineutrófilos positivos e anticorpos antinucleares negativos

Abstract Antineutrophil cytoplasmic antibodies (ANCAs) are associated with small vessel vasculitis but their prevalence is not rare in other immune diseases. In lupus nephritis (LN), their pathological role and clinical relevance have been the target of controversial views. We present a case of acute kidney injury and nephrotic syndrome in a young woman with diffuse global proliferative and membranous nephritis on her kidney biopsy, showing a full-house immunofluorescence pattern, very allusive of class IV + V LN, but lacking associated clinical criteria and laboratory findings to support the diagnosis of systemic lupus erythematosus (SLE). Furthermore, the patient presented with high titers of ANCA, steadily decreasing alongside the renal function and proteinuria improvements, with mycophenolate mofetil (MMF) and steroid treatment. The authors believe this is a case of lupus-like nephritis, in which ANCAs are immunological markers, although they are not directly involved in the pathogenesis.

Resumo Os anticorpos anticitoplasma de neutrófilos (ANCAs) estão associados à vasculite de pequenos vasos, no entanto, a sua prevalência não é rara em outras doenças imunológicas. Na nefrite lúpica (LN), o seu papel patológico e relevância clínica têm sido alvo de pontos de vista controversos. Apresentamos um caso de lesão renal aguda e síndrome nefrótica em uma jovem com nefrite proliferativa difusa e membranosa em sua biópsia renal, muito alusivo a NL classe IV + V, com um padrão full house na imunofluorescência, mas sem critérios clínicos e achados laboratoriais para corroborar o diagnóstico de lúpus eritematoso sistêmico (LES). Não obstante, a paciente apresentou títulos elevados de ANCA, que diminuiram progressivamente com a melhoria da função renal e da proteinúria, após tratamento com micofenolato de mofetil (MMF) e esteróide. Os autores acreditam que se trata de um caso de nefrite semelhante à nefrite lúpica, em que os ANCAs são marcadores imunológicos, embora não estejam diretamente envolvidos na patogênese.

Vasculitis ANCA positiva inducida por Propiltiouracilo. Reporte de caso

La vasculitis asociada a propiltiouracilo (PTU) y ANCA es una enfermedad rara con una incidencia de 0,47-0,71 casos por cada 10 000 pacientes. Afecta principalmente a los vasos de menor calibre. Piel, riñones y pulmones son los más afectados. El diagnóstico requiere alta sospecha clínica y se apoya en estudios histopatológicos de las lesiones en piel y serología positiva para ANCA. La suspensión del medicamento suele bastar como manejo de la enfermedad. Mujer de 45 años de edad, con historia de consumo de PTU durante 2 años, desde su diagnóstico de hipertiroidismo; presentando placas purpúricas dolorosas en ambos miembros inferiores.

SUMMARY ANCA vasculitis associated to propylthiouracil (PTU) is a rare condition with an incidence of 0.47-0.71 cases per 100,000 patients. It affects mainly minor caliber blood vessels. The skin, kidneys and lungs are the organs most affected. To make the diagnosis it is necessary to have a high index of suspicion and rely on histopathologic findings of skin lesions plus a positive ANCA test. Stopping the inducing drug is usually necessary to manage this condition. We report the case of a 45-year-old woman who consumed PTU for two years for the treatment of hyperthyroidism presenting with painful purpuric plaques in the lower limbs.

Antineutrophil cytoplasmic antibodies in patients treated with methimazole: a prospective Brazilian study / Anticorpos anticitoplasma de neutrófilos em pacientes tratados com metimazol: um estudo prospectivo brasileiro

Abstract Introduction: The side effects of antithyroid drugs are well known. Antineutrophil cytoplasmic antibody-associated vasculitis is a severe adverse reaction. Most studies evaluating antineutrophil cytoplasmic antibodies related to antithyroid drugs have been carried out with patients treated with propylthiouracil, but less information is available for methimazole. Furthermore, most studies that investigated antineutrophil cytoplasmic antibodies related to antithyroid drugs were conducted on Asian populations. Objective: To evaluate the frequency of antineutrophil cytoplasmic antibodies and antineutrophil cytoplasmic antibodies-positive vasculitis in an adult population of Brazilian patients treated with methimazole. Methods: This was a prospective study. We evaluated patients ≥18 years with Graves' disease who have been using methimazole for at least 6 months (Group A, n = 36); with Grave's disease who had been previously treated with methimazole but no longer used this medication for at least 6 months (Group B, n = 33), and with nodular disease who have been using methimazole for at least 6 months (Group C, n = 13). Results: ANCA were detected in 17 patients (20.7%). Four patients (4.9%) had a strong antineutrophil cytoplasmic antibodies-positive test. The frequency of antineutrophil cytoplasmic antibodies was similar in the groups. When Groups A and B were pooled and compared to Group C to evaluate the influence of Grave's disease, and when Groups A and C were pooled and compared to Group B to evaluate the influence of methimazole discontinuation, no difference was found in the frequency of antineutrophil cytoplasmic antibodies. No difference was observed in sex, age, etiology of hyperthyroidism, anti-TSH receptor antibodies, dose or time of methimazole use between patients with versus without antineutrophil cytoplasmic antibodies. The titers of these antibodies were not correlated with the dose or time of methimazole use. None of the antineutrophil cytoplasmic antibodies-positive patient had clinical event that could potentially result from vasculitis. Conclusion: This clinical study of a Brazilian population shows a considerable frequency of antineutrophil cytoplasmic antibodies in patients treated with methimazole but the clinical repercussion of these findings remains undefined.

Resumo Introdução: Os efeitos adversos de drogas antitireoidianas são conhecidos. Vasculite associada a anticorpos anticitoplasma de neutrófilos é uma reação adversa grave. A maioria dos estudos que avaliam anticorpos anticitoplasma de neutrófilos relacionado a drogas antitireoidianas envolveu pacientes tratados com propiltiouracil, entretanto menos informação se encontra disponível para o metimazol. Além disso, a maioria dos estudos que investigaram anticorpos anticitoplasma de neutrófilos relacionado a drogas antitireoidianas foi conduzida em populações asiáticas. Objetivo: Avaliar a frequência de anticorpos anticitoplasma de neutrófilos e vasculite anticorpos anticitoplasma de neutrófilos-positivo em uma população adulta de pacientes brasileiros tratados com metimazol. Método: Este foi um estudo prospectivo. Avaliamos pacientes ≥ 18 anos com doença de Graves com o uso de metimazol há pelo menos seis meses (Grupo A, n = 36); com doença de Graves previamente tratados com metimazol, mas que não usaram esse medicamento por pelo menos seis meses (Grupo B, n = 33) e com doença nodular em uso de metimazol há pelo menos seis meses (Grupo C, n = 13). Resultado: Anticorpos anticitoplasma de neutrófilos foram detectados em 17 pacientes (20,7%). Quatro pacientes (4,9%) tinham anticorpos anticitoplasma de neutrófilos fortemente positivos. A frequência de anticorpos anticitoplasma de neutrófilos foi semelhante nos grupos. Quando os Grupos A e B foram somados e comparados ao Grupo C para avaliar a influência da doença de Graves, e quando os Grupos A e C foram somados e comparados ao Grupo B para avaliar a influência da interrupção do metimazol, não foi encontrada diferença na frequência de anticorpos anticitoplasma de neutrófilos. Não houve diferença em relação a sexo, idade, etiologia do hipertireoidismo, anticorpos antirreceptor de TSH, dose ou tempo de uso de metimazol entre pacientes com e sem anticorpos anticitoplasma de neutrófilos. Os títulos desses anticorpos não se correlacionaram com dose ou tempo de uso de metimazol. Nenhum paciente anticorpos anticitoplasma de neutrófilos-positivo apresentou evento clínico resultante de vasculite. Conclusão: Este estudo clínico de uma população brasileira apresenta frequência considerável de anticorpos anticitoplasma de neutrófilos em pacientes tratados com metimazol, mas a repercussão clínica desse achado permanece indefinida.

Hemorragia alveolar difusa secundaria a vasculitis asociada a ANCA. Recaída durante hemodiálisis / Diffuse alveolar hemorrhage secondary to ANCA-associated vasculitis. Relapse during hemodialysis

Resumen La hemorragia alveolar difusa (HAD) masiva es una complicación inusual de los pacientes con vasculitis ANCA, frecuentemente amenaza la vida y está asociada con una mortalidad de hasta el 100%. La información en la literatura acerca del tratamiento en casos refractarios y cuando el paciente se encuentra en diálisis es escasa. Se presenta el caso de un paciente con vasculitis p-ANCA con compromiso renal y pulmonar en el escenario de síndrome pulmón-riñón, con múltiples recaídas de hemorragia alveolar a pesar de tratamiento con corticoide, azatioprina, ciclofosfamida y terapia de recambio plasmático. Se instauró manejo con anticuerpo monoclonal anti CD20 e inmunoglobulina, logrando resolución del episodio de hemorragia alveolar y permaneciendo sin actividad. Se resalta la utilidad del rituximab como estrategia terapéutica en casos refractarios. (Acta Med Colomb 2019; 44: 111-114).

Abstract Massive diffuse alveolar hemorrhage (DAH) is an unusual complication of patients with ANCA vasculitis that frequently threatens life and is associated with mortality up to 100%. In formation in the literature about treatment in refractory cases and when the patient is on dialysis is scarce. The case of a patient with p-ANCA vasculitis with renal and pulmonary involvement in the lung-kidney syndrome scenario, with multiple relapses of alveolar hemorrhage despite treatment with corticosteroid, azathioprine, cyclophosphamide and plasma exchange therapy is presented. Management with anti-CD20 monoclonal antibody and immunoglobulin was estab lished, achieving resolution of the episode of alveolar hemorrhage and remaining without activity. The usefulness of rituximab as a therapeutic strategy in refractory cases is highlighted. (Acta Med Colomb 2019; 44: 111-114).

A Pediatric Case of a D-Penicillamine Induced ANCA-associated Vasculitis Manifesting a Pulmonary-Renal Syndrome

D-penicillamine has been reported to cause antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis presenting as rapidly progressive glomerulonephritis or pulmonary-renal syndrome mostly in adults. We report a pediatric case of D-penicillamine induced ANCA-associated vasculitis that manifests as a pulmonary-renal syndrome with a mild renal manifestation. A 13-year-old girl who has been taking D-penicillamine for five years under the diagnosis of Wilson disease visited the emergency room because of hemoptysis and dyspnea. She had diffuse pulmonary hemorrhage, microscopic hematuria, and proteinuria. Myeloperoxidase ANCA was positive, and a renal biopsy revealed pauci-immune crescentic glomerulonephritis. Under the diagnosis of D-penicillamine-induced ANCA-associated vasculitis, D-penicillamine was switched to trientine, and the patient was treated with plasmapheresis, glucocorticoid, cyclophosphamide, and mycophenolate mofetil. Pulmonary hemorrhage improved rapidly followed by the disappearance of the hematuria and proteinuria five months later.

Antineutrophil cytoplasmic antibodies in Chinese patients with tuberculosis

Abstract INTRODUCTION: Based on reports, infection with Mycobacterium tuberculosis is believed to induce the development of antibodies that are considered to be biological indicators for the diagnosis of some other diseases. However, conflicting results have been published regarding the presence of antineutrophil cytoplasmic antibodies (ANCAs) in patients with tuberculosis. We aim to study the seroprevalence of ANCA in a population of Chinese patients with tuberculosis, which may lead to the misdiagnosis of vasculitic disorders. METHODS: The study was conducted from January 2016 to May 2017 to evaluate the presence of ANCA in 103 Chinese patients using indirect immunofluorescent assay. An enzyme-linked immunosorbent assay was performed for anti-myeloperoxidase (MPO) and anti-proteinase 3 (PR3) detection. RESULTS: Perinuclear ANCA (p-ANCA) was detected in 4.8% (5/103) of patients, whereas cytoplasmic ANCA (c-ANCA) was not detected; 1.9% (2/103) of patients with tuberculosis was positive for anti-MPO antibodies, and none had anti-PR3 antibodies. Both anti-MPO-positive patients were diagnosed with ANCA-associated vasculitides. CONCLUSIONS: ANCA positivity may be more related to vasculitis and immunological disorders than to a M. tuberculosis infection. Therefore, to improve diagnostic accuracy, patients with M. tuberculosis who are ANCA positive should be investigated for concurrent diseases, including the effects of drugs. Therefore, even in tuberculosis epidemic area, ANCA seropositivity, detected by ELISA, is still more suggestive of ANCA-associated vasculitides.

Paquimeningitis y glomerulonefritis crescéntica en vasculitis p-ANCA / Pachymeningitis and crescentic glomerulonephritis in p-ANCA vasculitis

Resumen Las vasculitis asociadas a anticuerpos contra el citoplasma del neutrófilo configuran patologías multisistémicas caracterizadas por afectar pequeños vasos. Se ha descrito compromiso de sistema nervioso central en 2-8% de los casos, rara vez al inicio del cuadro clínico. Este corresponde al caso de un hombre de 67 años de edad con vasculitis p-ANCA, quien debutó con proptosis, paquimeningitis y disfagia severa. Posteriormente deterioro renal, necesidad de hemodiálisis, ciclofosfamida y recambio plasmático terapéutico con lo cual alcanza criterios de remisión parcial y egresa de diálisis. Las vasculitis ANCA se relacionan con una amplia gama de signos y síntomas inespecíficos. La edad de aparición, creatinina inicial y requerimiento de diálisis, son factores pronósticos. El inicio oportuno del tratamiento es fundamental, requiriendo por tanto un alto índice de sospecha. (Acta Med Colomb 2018; 43: 107-110).

Abstract Vasculitis associated with antibodies against the neutrophil cytoplasm they form multisystemic pathologies characterized by affecting small vessels. Central nervous system involvement has been described in 2 - 8% of cases, rarely at the beginning of the clinical picture. This corresponds to the case of a 67-year-old man with p-ANCA vasculitis, who debuted with proptosis, pachymeningitis and severe dysphagia. Subsequently, renal deterioration, the need for hemodialysis, cyclophosphamide and therapeutic plasma exchange, with which it reaches criteria of partial remission and dialysis discharge. ANCA vasculitis is associated with a wide range of nonspecific signs and symptoms. The age of onset, initial creatinine and dialysis requirement are prognostic factors. The timely initiation of treatment is fundamental, requiring therefore a high index of suspicion. (Acta Med Colomb 2018; 43: 107-110).

Severe microscopic polyangiitis with unilateral vocal cord paralysis as initial manifestation / Parálisis unilateral de cuerda vocal como manifestación inicial de poliangitis microscópica grave

Abstract Case Description: A 16 year-old female who presented with initial ear, nose and throat manifestations who later progressed to severe renal disease, requiring hemodialysis after 11 months of unique laryngeal involvement. Clinical Findings: Unilateral vocal cord paralysis without other symptoms or signs, but with positive perinuclear anti-neutrophil cytoplasmic antibodies (ANCA) and anti-myeloperoxidase autoantibodies, followed an unfavorable course months later with rapidly progressive glomerulonephritis. Renal biopsy confirmed an ANCA-associated vasculitis. She was diagnosed with microscopic polyangiitis. Treatment and Outcome: High-dose glucocorticoids, intravenous cyclophosphamide, plasma exchange and finally, hemodialysis and renal transplantation. Clinical Relevance: In contrast to granulomatosis with polyangiitis (Wegener), ear, nose and throat manifestations in microscopic polyangiitis are uncommon, while involvement of the lungs and kidneys are usual. We present a case with an isolated rare involvement, which progressed to severe disease. This atypical case warns about laryngeal symptoms as initial manifestation of an anti-myeloperoxidase positive systemic vasculitides, and emphasizes the relevance of close observation when unexplained isolated conditions with accompanying evidence of autoimmunity, in this case high levels of specific autoantibodies, are present.

Resumen Descripción del caso: Una mujer de 16 años se presentó inicialmente con manifestaciones otorrinolaringológicas y posteriormente progresó hacia enfermedad renal grave, requiriendo hemodiálisis después de 11 meses de tener exclusivamente afección laríngea. Hallazgos clínicos: parálisis de cuerda vocal unilateral sin otros síntomas ni signos, pero con autoanticuerpos anticitoplasma de neutrófilo (ANCA) con patrón perinuclear y especificidad contra mieloperoxidasa, siguiendo un curso desfavorable meses después con desarrollo de glomerulonefritis rápidamente progresiva. La biopsia renal confirmó una vasculitis asociada con ANCA (VAA). Se diagnosticó entonces como poliangitis microscópica. Tratamiento y desenlace: Glucocorticoides a dosis altas, ciclofosfamida endovenosa, recambio plasmático y finalmente, hemodiálisis y transplante renal. Relevancia clínica: en contraste con la granulomatosis con poliangitis (Wegener), las manifestaciones otorrinolaringológicas en poliangitis microscópica son poco comunes, mientras que la afección pulmonar y renal es común. Presentamos un caso con afección inusual aislaea, que progresó a enfermedad grave. Este caso atípico enfatiza sobre los síntomas laríngeos como manifestación inicial de una vasculitis antimieloperoxidasa positiva, y subraya la relevancia de una estrecha observación cuando condiciones aisladas inexplicables, que como en este caso se acompañan de evidencia de autoinmunidad manifestado por presencia de niveles altos de autoanticuerpos, se presentan para su atención.

Experiment Analysis of Antineutrophil Cytoplasmic Antibodies(ANCA)-associated Vasculitis Combined with Pulmonary Fibrosis / 华中科技大学学报(医学版)

Objective To explore the clinical features of antineutrophil cytoplasmic antibodies-associated vasculitis com-bined with pulmonary fibrosis and the relationship of laboratory results.Methods Totally,33 patients with antineutrophil cyto-plasmic antibodies-associated vasculitis were divided into pulmonary fibrosis group(group A)and non-pulmonary fibrosis group (group B).Fourteen patients with connective tissue diseases-related pulmonary fibrosis served as disease control group,and 12 healthy people as normal control group.The levels of ANCA,plasma creatinine,high-sensitivity C-reactive protein,fibrinogen and D-dimer were detected.Results The creatinine level was significantly higher in group B than in disease control group and normal control group.The creatinine level was higher in group A than in disease control group and normal control group,with-out significant differences.The levels of FIB,D-D,and hsCRP were significantly higher in the group A,group B and disease con-trol group(all P< 0.05).In the group A,MPO expression was positively associated with FIB concentration(r= 0.64,P<0.05).Conclusion In pulmonary fibrosis disease,early detection of ANCA has clinical value in the diagnosis of AASV.And the higher concentration of M PO may hint thrombus formation.

Membranous glomerulonephritis combined with anti-neutrophil cytoplasm antibody-associated crescentic glomerulonephritis / 第二军医大学学报

Objective To study the clinicopathological features of membranous nephropathy(MN) with ANCA-associated crescentic glomerulonephritis (ANCA-associated CGN). Methods 79 cases diagnosed as MN with ANCA associated CGN were selected from the whole English and Chinese literatures and a similar case was from our hospital. Total 80 casess were included in this study to summarize the clinicopathological features, treatment and prognosis. Results 44 male and 36 female patients were included. The average age was 56. 8±13. 1 years and the average disease onset period was 3. 2±3. 6 months. In 95% cases, MN and ANCA associated CGN occurred simultaneously. 93. 8% patients presented renal dysfunction onset of the disease, the common clinical manifestation were nephrotic syndrome with rapidly progressive glomerulonephritis. All patients were serum ANCA positive and 88. 2% cases were MPO-ANCA positive. The average 24h proteinuria was 5. 27±4. 3g and SCr was 420. 7±307μmol/L. Renal biopsy showed crescent formation and GBM thicken. Immunofluorescence showed IgG and C3 deposits were positive. Prednisone combined with CTX could improve the prognosis. 62. 7% cases reached relieve remission. Conclusions The coexistence of ANCA associated CGN and MN was rare. The pathogenesis of this condition is still unclear. Immunosuppressive therapy might improve the outcome.

3 cases of cocaine - levamisole syndrome in Medellín / Presentación de tres casos de síndrome cocaína - levamisol en Medellín

El levamisol es un antihelmíntico de uso veterinario que ha sido utilizado como aditivo a la cocaína con el objetivo de aumentar los efectos psicotrópicos de dicha sustancia. Esta mezcla produce reacciones como agranulocitosis, vasculitis cutánea y modulación del sistema inmune. Solamente el reconocimiento, tratamiento adecuado y la suspensión del consumo de esta sustancia lleva a la desaparición de las lesiones y sugiere fuertemente el diagnóstico. Presentamos tres casos de síndrome cocaína/levamisol en Medellín y una revisión de la literatura con algunos conceptos de esta enfermedad.

Levamisole, an anthelmintic veterinary product is known to be used as an additive to cocaine that enhances the psychotropic effects of this substance. This mixture leads to reactions such as agranulocytosis, skin vasculitis and modulation of the immune system. Only the proper recognition, treatment of this entity and discontinuation of this substance consumption, leads to the disappearance of lesions; strongly suggesting the diagnosis. We present three cases of cocaine/levamisole syndrome in the city of Medellin and a review of the literature with some concepts related to this pathology.

The correlation between toll-like receptor 9 gene 2848G/A polymorphism and primary anti-neutrophil ;cytoplasmic antibodies associated small vasculitis / 中华风湿病学杂志

Objective To investigate the correlation between toll-like receptor 9 (TLR9) gene 2848G/A polymorphism and primary antineutrophil cytoplasmic antibodies (ANCA) associated small vasculitis (AAV). Methods A case-control study was performed among 135 patients diagnosed with AAV and 140 disease-free control and we test the serum biochemical parameter. Polymorphism was analyzed by polymerase chain restricted fragments length polymorphism. As for statistic method, according to the character of data, we performed t-test, chi-square test, Spearman grade related analysis and one-way ANOVA. Results ① The frequencies of AA, GG, GA genotype of TLR9 2848 in AAV patients were 14.07%, 38.52%, and 47.71%, respectively; ② Significant increase in IgM was observed in AA genotype than GG+GA genotype in AAV patients (F=4.561, P0.05). Conclusion AA, GA and GG genotypes are detected in TLR9 2848G/A in patients with AAV in Guangxi, without significant correlation with susceptibility to primary AAV in Guangxi.

Investigation on the serum marker of MPO-ANCA associated vasculitis in active phase / 医学研究生学报

Objective Antineutrophil cytoplasmic antibody (ANCA) associated vasculitis(AAV)is a systemic necrotizing small-vessel vasculitis, and myeloperoxidase(MPO) is one of the main antigens that ANCA can recognize.This study was to investigate the clinical significance of MPO, activated complement C5a fragment and ceruloplasmin ( Cp) in the peripheral blood of patients with MPO-ANCA associated vasculitis ( MPO-AAV) in active phase by observing their changes. Methods 132 MPO-AAV patients at active stage were selected as the patient group, while the control group was made up of 30 healthy controls.Peri-nuclear ANCA (p-ANCA) and MPO-ANCA in the patient group were detected by IIF and ELISA, respectively.The levels of MPO, Cp and C5a in both groups were tested by ELISA.The Birmingham vasculitis activity score (BVAS) of every patient was calculated.In the patient group, the relationship among MPO, Cp, C5a and MPO-ANCA were analysed, and the association between BVAS and each of them was also explored. Results The levels of MPO, CP, C5a in the patient group were significantly higher than those in the health control group [MPO:400.7(333.5~506.1) vs 286.9(225.5~329.1)IU/L, P<0.001;C5a:336.7 (277.6~403.5) vs 236.8 (204.2~304.1) ng/mL, P<0.001;Cp:481.1 (387.9~535.9) vs 326.9 (177.1~405.5) ng/mL,P<0.001].The associations between MPO and Cp, C5a and MPO, C5a and Cp in the patient group were statistically significant ( r=0.663, P<0.001;r=0.792, P<0.001;r=0.637, P<0.001, respectively).No significant correlation was found in MPO-ANCA and any of these indexes.MPO-ANCA had a positive association with the total BVAS, the kidney BVAS, and the lung BVAS ( r=0.247, P=0.004;r=0.339,P<0.001 and r=0.191, P=0.028, respec-tively) .p-ANCA had a positive correlation with the kidney BVAS ( r=0.208, P=0.017) while C5a had a negative correlation with the kidney BVAS ( r=-0.207, P=0.018) . Conclusion The levels of MPO, Cp and C5a increased significantly in the peripheral blood of MPO-AAV patients in active phase.The complex interactions among MPO, Cp, C5a and ANCA might influence the clinical damage in MPO-AAV.Notablely, the influence from MPO-ANCA might be most obvious while C5a might affect renal damage more markedly.

Atypical Wegener's Granulomatosis Accompanied with Rheumatoid Arthritis: A Case Report

Wegener's granulomatosis (WG) is highly correlated with cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA). Patients with rheumatoid arthritis (RA) rarely contract WG. Although several concurrent cases have been reported overseas, there are no known cases in Korea. Here we report a unique case of RA with atypical WG testing positive for perinuclear ANCA (p-ANCA) and negative for anti-myeloperoxidase (MPO) antibodies. The 62-yr-old female patient presented with multiple joint pain and showed typical blood test results for RA, i.e., an elevated erythrocyte sedimentation rate and C-reactive protein concentration, and positive for rheumatoid factor and anti-cyclic citrullinated peptide antibodies. RA was clear based on a total score of 10 when applying the classification criteria developed by the American College of Rheumatology/European League Against Rheumatism (2010). In an autoimmune target test, speckled and skeleton patterns were observed. In an ANCA test, p-ANCA was observed (titer, 1:2,560), and tests for anti-proteinase 3 (PR3) and anti-MPO antibodies were negative. After admission, multiple nodules were detected on a chest X-ray and a computed tomography scan. We suspected that she had rheumatic nodules or vasculitis and performed an open lung biopsy. We detected necrotic granulomatous vasculitis, classified as WG, thus leading to WG diagnosis. In conclusion, WG was diagnosed in an RA patient who was negative for c-ANCA (negative PR3) and positive for p-ANCA (negative anti-MPO), and this peculiar finding is likely to improve diagnosis in cases of RA with atypical WG.

Cytoplasmic-anti-neutrophil cytoplasmic antibodies targeting myeloperoxidase in Wegener's granulomatosis: A rare phenomenon.

Wegener’s granulomatosis (WG) patients can rarely have antineutrophil cytoplasmic antibodies (ANCAs) directed against myeloperoxidase (MPO), producing a cytoplasmic pattern on indirect immunofluorescence (IIF). This has important implications in the diagnosis and pathophysiology of the disease. We present to you a report of three cases of WG, demonstrating a cytoplasmic- ANCA pattern on indirect IIF, but directed against MPO. It is necessary to diagnose a patient taking into account both the autoimmune test results and the clinical features.

Abordagem terapêutica das vasculites pulmonares / Therapeutic approach to pulmonary vasculitis

Muitas vasculites sistêmicas acometem o trato respiratório. O acometimento mais frequente é o do parênquima pulmonar pelas vasculites de pequenos vasos ANCA associadas (antineutrophil cytoplasmic antibodies), que incluem a granulomatose com poliangite (GPA, antiga granulomatose de Wegener), a poliangite microscópica (MPA), granulomatose eosinofílica com poliangite (EGPA, antiga doença de Churg-Strauss). Este artigo propõe-se a revisar o tratamento dessas doenças de acordo com recomendações da liga europeia de combate ao reumatismo (EULAR), com base no estádio e na atividade de doença, incluindo as terapia usadas na indução e na manutenção de remissão, assim como nos casos refratários ao tratamento convencional

There are many vasculitis that affect the respiratory tract. The pulmonary parenchyma is the most frequently involved and occurs mainly in ANCA associated small vessel vasculitis (antineutrophil cytoplasmic antibodies), which include granulomatosis with polyangitis (GPA, formely Wegener's granulomatosis), microscopic polyangitis (MPA), eosinophilic granulomatosis with polyangitis (EGPA formely Churg-Strauss Syndrome). This article reviews the treatment of them, according to EULAR (European League Against Rheumatism) recommendations, which are based on stage and severity of disease, including induction and maintance therapy, and therapy of refractory disease

A study on clinical values of antineutrophil cytoplasmic antibody detection in diagnosis of rheumatic diseases / 国际检验医学杂志

Objective To investigate the clinical values of antineutrophil cytoplasmic antibody (ANCA) detection in the diagnosis of rheumatic diseases .Methods 965 patients with rheumatic diseases were taken as rheumatic group ,including 256 cases of SLE , 124 of mixed connective tissue disease(MCTD) ,336 of rheumatoid arthritis(RA) ,166 of Sjogren′s Syndrome(SS) ,45 of systemic sclerosis(SSc) and 38 of dermatomyositis .400 healthy people were served as the control group .Indirect immunofluorescence (IIF) was employed to detect the cytoplasmic ANCA (c-ANCA ) ,perinuclear ANCA (p-ANCA ) .Enzyme-linked immunosorbent assay (ELISA) was utilized to assay the anti-myeloperoxidase(MPO) antibody among patients with positive ANCA .Results Difference of positive rates of serum ANCA of subjects in rheumatic group and control group showed statistical significance (P<0 .01) ,and the differences of positive rates of serum p-ANCA and c-ANCA of subjects with positive ANCA between the two group were also sta-tistically significant(P<0 .01) .The positive rate of serum p-ANCA of patients with SLE was markedly higher than those with MCTD ,RA ,SS ,SSc ,dermatomyositis and healthy people in control group (P< 0 .05) ,while that of patients with MCTD was obviously higher than those with RA ,SS ,SSc ,dermatomyositis and healthy people in control group (P<0 .05) .The positive rate of anti-MPO antibody of 165 patients with positive ANCA in rheumatic group was 58 .4% ,which was significantly higher than that in control group(3% )(P<0 .01) .The positive rate of patients with positive ANCA and impaired renal function in rheumatic group was 55 .4% ,which was obviously higher than those of patients with negative ANCA in rheumatic group (21 .8% ) and control group (6 .25% )(P<0 .01) .Conclusion Serum ANCA detection is of important significance for prevention of nephrotoxic damage in pa-tients with rheumatic diseases .

A study on clinical characteristics of 132 patients with vasculitis associated with antineutrophil cytoplasmic antibody to myeloperoxidase / 中华风湿病学杂志

Objective To analyze the clinical characteristics of vasculitis associated with antineutrophil cytoplasmic antibody against myeloperoxidase (MPO-ANCA),and to investigate preliminarily the relationship between MPO-ANCA and the clinical damages.Methods One hundred and thirty-two patients with primary antineutrophil cytoplasmic antibody (ANCA) associated vasculitis,which were diagnosed for the first time,were involved into this prospective study.All the patients had positive laboratory tests for peri-nuclear ANCA (p-ANCA) and MPO-ANCA.The characteristics of their clinical presentations were analyzed.The levels of p-ANCA and MPO-ANCA in the peripheral blood were detected and the relationship between the levels and the damages were explored.T-test and Spearman rank correlation analysis were used for statistical analysis.Results Of the 132 patients from 8 different clinical departments,128 (97.0％) were microscopic polyangiitis (MPA),3 (2.3％) were granulomatosis with polyangiitis (GPA),and 1 (0.7％) was eosinophilic granulomatosis with polyangiitis (EGPA).The mean age was (62±15) years old.The average time between onset of the disease and diagnosis was (10 ±18) months,and only 14 (10.6％) were diagnosed within one month.Among the major organ involvements,the occurrence of renal,lung,joint,heart,peripheral nerve,skin,and central nerve involvement was 72.0％(95 cases),67.4％(89 cases),26.5％(35 cases),19.7％ (26 cases),17.4％(23 cases),10.6％(14 cases) and 9.8％(13 cases),respectively.Lung was more susceptible to be involved among the aged in their early course [(66±11) years,(55±19) years,t=-3.478,P＜0.01; (6±10) months,(18±27) months,t=2.920,P＜0.01],and joint involvement was more common in the younger [(57±18) years vs (64±13) years,t=2.335,P＜0.05] patients.p-ANCA had no relationship with the disease activity or the range of organ involvements(r=0.013,P＞0.05; r=0.087,P＞0.05).MPO-ANCA had a positive association with disease activity but had no significant correlation with the range of organ involvements(r=0.258,P＜0.01; r=0.022,P＞0.05).Conclusion The MPO-ANCA associated vasculitis is not rare in our country.MPA is the most common vasculitis which mainly affects the aged population,and its diagnosis is often delayed due to the lack of characteristic clinical presentations.It is possible that MPO-ANCA may play a pathogenic role in vasculitis,and the various clinical manifestations might be related with the specificities of MPO-ANCA.

Association of HLA-DRB1 allele polymorphism and ANCA with the susceptibility to antithyroid drug-induced leucocytopenia in patients with Graves' disease / 中华内分泌代谢杂志

ObjectiveTo investigate the relationship of HLA-DRB1 allele polymorphism and antineutropil cytoplasmic antibody ( ANCA ) with the susceptibility to antithyroid drug ( ATD ) -induced leucocytopenia in the patients with Graves' disease (GD) in Anhui Han Chinese.MethodsThe HLA-DRB1 * 08032,DRB1 * 1501,and DRB1 * 0901 allele frequencies were determined by the polymerase chain reaction-based sequence-specific primer (PCR-SSP) method in 76 patients with Graves' disease who had ATD-induced leucocytopenia and 98 patients with Graves' disease treated with ATD,who were free from leucocytopenia.The other230 healthy subjects served as controls.Indirect immunofluorescence assay (IIF) was used to detect ANCA positive rate.Result( 1 ) Compared with the controls and the GD patients without leucocytopenia,the allele frequencies ofDRB1 * 08032 and DRB1 * 1501 in patients with ATD-induced leucocytopenia were significantly increased ( OR were 3.06,1.77,4.03,and 2.28,all P＜0.05),while that of HLA-DRB1 * 0901 was decreased ( OR were 0.33 and 0.43,both P＜0.05 ).(2)The ANCA frequencies were significantly increased in the GD patients with methimazole-induced leucocytopenia compared with those without leucocytopenia (x2 =4.878,P＜0.05 ).( 3 ) Compared with the GD patients not carrying DRB1 * 08032,DRB1 * 1501,and DRB1 * 0901 alleles,the ANCA positive rates were significantly increased in the GD patients carrying these alleles(x2 were 5.682,5.429,4.009,and 4.549,all P＜0.05).ConclusionsThe DRB1 * 08032 and HLA-DRB1 * 1501 alleles may be susceptible to ATD-induced leucocytopenia in Anhui Hans,while HLA-DRB1 * 0901 alleles may be protective or resistant gene.Immune response may be involved in the development of leucocytopenia.The occurrence of immune response is based on the genetic susceptibility.