Antinuclear Antibody (ANA)

How is the test used?

The antinuclear antibody (ANA) test is used as a primary test to help evaluate a person for autoimmune disorders that affect many tissues and organs throughout the body (systemic) and is most often used as one of the tests to help diagnose systemic lupus erythematosus (SLE). However, a positive ANA test by itself does not diagnose any one particular disease.

Depending on a person's signs and symptoms and the suspected disorder, ANA testing may be followed by additional tests for specific autoantibodies. Some of these tests are considered subsets of the general ANA test and detect the presence of autoantibodies that target specific substances within cell nuclei, including anti-dsDNA, anti-centromere, anti-nucleolar, anti-histone and anti-RNA antibodies. An extractable nuclear antigen (ENA) panel (anti-RNP, anti-Sm, anti-SS-A, anti-SS-B, Scl-70, anti-Jo-1) may also be used in follow up to a positive ANA.

These supplemental tests are used in conjunction with a person's clinical history and physical examination findings to help diagnose or rule out autoimmune disorders, such as Sjögren syndrome, polymyositis and scleroderma.

Different laboratories may use different test methods to detect ANA.

• Indirect fluorescent antibody (IFA)—this method is the traditional approach. A person's blood sample is mixed with cells that are affixed to a slide. Autoantibodies that may be present in the blood react with the cells. The slide is treated with a fluorescent antibody reagent and examined under a microscope. The presence (or absence) and pattern of fluorescence is noted.
• Immunoassays—laboratories may also use immunoassay to screen for ANA and may only use IFA to confirm positive results or results that are not clearly positive or negative. These methods are usually performed on automated instrumentation. They may be less sensitive than IFA in detecting ANA but may be more specific for autoimmune disorders.

When is it ordered?

The ANA test is ordered when someone shows signs and symptoms that a healthcare practitioner suspects are due to a systemic autoimmune disorder. People with autoimmune disorders can have a variety of symptoms that are vague and non-specific and that change over time, progressively worsen, or alternate between periods of flare ups and remissions.

Some examples of signs and symptoms include:

• Low-grade fever
• Persistent fatigue, weakness
• Arthritis-like pain in one or more joints
• Red rash (for lupus, one resembling a butterfly across the nose and cheeks)
• Skin sensitivity to light
• Hair loss
• Muscle pain
• Numbness or tingling in the hands or feet
• Inflammation and damage to organs and tissues, including the kidneys, lungs, heart, lining of the heart, central nervous system, and blood vessels

What does the test result mean?

A positive ANA test result means that autoantibodies are present. In a person with signs and symptoms, this suggests the presence of an autoimmune disease, but further evaluation is required to assist in making a final diagnosis. Again, some people without disease can have a positive ANA test.

Positive ANA test results may be reported in different ways, depending on the test method.

Amount of autoantibody present

• Indirect fluorescent antibody (IFA)—the results are reported as a titer. Titers are expressed as ratios, which are obtained by diluting a portion of the blood sample with saline (salt water). For example, a titer result 1:320 means that one part blood sample was mixed with 320 parts of saline and this was lowest ratio at which ANA was still detected. The lower the dilution ratio at which ANA is still detected, the higher the titer and the greater the amount of autoantibody present.
• Immunoassay (enzyme linked immunosorbent assay, ELISA, or enzyme immunoassay, EIA)—the results are usually reported as a number with an arbitrary unit of measure (abbreviated as a "U" on the report, for example). A positive result from this method will be a number of units that is above the laboratory's reference number (cutoff) for the lowest possible value that is considered positive.
   

Patterns of cellular fluorescence
In addition to a titer, positive results on IFA will include a description of the particular type of fluorescent pattern seen. Different patterns have been associated with different autoimmune disorders, although some overlap may occur. Some of the more common patterns include:

• Homogenous (diffuse)—associated with SLE, mixed connective tissue disease, and drug-induced lupus
• Speckled—associated with SLE, Sjögren syndrome, scleroderma, polymyositis, rheumatoid arthritis, and mixed connective tissue disease
• Nucleolar—associated with scleroderma and polymyositis
• Centromere pattern (peripheral)—associated with scleroderma and CREST (Calcinosis, Raynaud syndrome, Esophageal dysmotility, Sclerodactyly, Telangiectasia)
   

An example of a positive result using the IFA method would give the dilution titer and a description of the pattern, such as "Positive at 1:320 dilution with a homogenous pattern."

For either method, the higher the value reported, the more likely the result is a true positive.

Conditions associated with a positive ANA test

• The condition most commonly associated with a positive ANA is SLE. About 95% of those with SLE have a positive ANA test result. If someone also has symptoms of SLE, such as arthritis, a rash, and skin sensitivity to light, then the person probably has lupus. A positive anti-dsDNA and anti-SM (often ordered as part of an ENA panel) help confirm that the condition is SLE.
   

Other conditions in which a positive ANA test result may be seen include:

• Drug-induced lupus—a number of medications may trigger this condition, which is associated with lupus symptoms. When the drugs are stopped, the symptoms usually go away. Although many medications have been reported to cause drug-induced lupus, those most closely associated with this syndrome include hydralazine, isoniazid, procainamide, and several anticonvulsants. Because this condition is associated with the development of autoantibodies to histones, an anti-histone antibody test may be ordered to support the diagnosis.
• Sjögren syndrome—About 80% of people with this condition have a positive ANA test result. While this finding supports the diagnosis, a negative result does not rule it out. A healthcare practitioner may want to test for two subsets of ANA: Anti-SS-A (Ro) and Anti-SS-B (La). (See ENA Panel)
• Scleroderma (systemic sclerosis)—About 60-95% of those with scleroderma have a positive ANA. In people who may have this condition, ANA subset tests can help distinguish two forms of the disease, limited versus diffuse. The diffuse form is more severe. The limited form is most closely associated with the anticentromere pattern of ANA staining (and the anticentromere test), while the diffuse form is associated with autoantibodies to Scl-70.
• Less commonly, ANA may occur in people with rheumatoid arthritis, Raynaud syndrome, arthritis, dermatomyositis or polymyositis, mixed connective tissue disease, and other autoimmune conditions. For more on these disorders, read the article on Autoimmune Diseases.
   

A healthcare practitioner must rely on test results, clinical symptoms, and the person's history for diagnosis. Because symptoms may come and go, it may take months or years to show a pattern that might suggest lupus or any of the other autoimmune diseases.

A negative ANA result makes lupus or another autoimmune disease unlikely diagnoses. It usually is not necessary to immediately repeat a negative ANA test; however, due to the episodic nature of autoimmune diseases, it may be worthwhile to repeat the ANA test at a future date if symptoms recur.

A person previously diagnosed with an autoimmune disease may have a negative ANA test if the condition is in a period of remission.

Aside from rare cases, further autoantibody (subset) testing is not necessary if a person has a negative ANA result.

Is there anything else I should know?

ANA testing is not used to track or monitor the clinical course of lupus; thus, serial ANA tests for diagnosed patients are not commonly ordered once a diagnosis is established.

Some infections, autoimmune hepatitis and primary biliary cirrhosis as well as other conditions mentioned above can give a positive result for the ANA test.

Can I have a positive ANA and not have an autoimmune disease?

Yes. About 3-5% of healthy individuals may be positive for ANA, and it may reach as high as 10-37% in healthy individuals over the age of 65 because ANA frequency increases with age. These would be considered false-positive results because they are not associated with an autoimmune disease. Such instances are more common in women than men.

Why is it called "antinuclear" antibody?

ANA are autoantibodies that are directed against certain components found in the nucleus of a cell, hence the name "antinuclear." Some of the antibodies associated with autoimmune disorders may also be directed against substances in the cytoplasm and may be detected by the ANA test as well.

My healthcare practitioner told me my ANA test is positive but isn't sure if I have lupus. How can this be?

Autoimmune diseases often have a systemic effect on the body and are very complex by nature. Your healthcare provider will interpret what the test results mean for you and may need to compare your test results as well as the severity of your symptoms over a period of time in order to make a definitive diagnosis. This additional time may also allow your healthcare provider to eliminate other possible causes of your symptoms.

In addition to autoantibody tests, what other tests might my healthcare practitioner order?

Your healthcare practitioner may also order laboratory tests that detect the presence of inflammation, such as erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP). A test for total immunoglobulins may be used to evaluate a person with SLE and a complement test may be done to monitor the course of the disease.