Clinical associations of serum Golgi apparatus antibodies in an immunology laboratory cohort.

INTRODUCTION: Anti-Golgi antibodies (AGAs) are rare antibodies that are found as distinct, polarised cytoplasmic staining on the HEp-2 substrate. METHODS: We performed a review of patients that demonstrated this autoantibody in a large laboratory cohort in Australia. Over a 24-month period, all patients that had a sample submitted for routine antinuclear antibodies (ANAs) that had AGA staining were retrospectively identified. Medical records were perused to identify clinical associations. RESULTS: There were 23 813 ANAs identified with 34 patients (0.14%) demonstrating AGA staining. AGAs were found in a variety of inflammatory disorders, malignancies and liver diseases. They did not associate with any other significant ANA, and in contrast with previous studies, we did not find any association with systemic autoimmune rheumatic diseases. CONCLUSIONS: Anti-Golgi antibodies are rare, non-specific and possibly a bystander phenomenon. Future studies are required to study the origin and longitudinal clinical associations of these autoantibodies.

Gastric Cancer Screening in Common Variable Immunodeficiency.

Individuals with common variable immunodeficiency (CVID) have an increased risk of gastric cancer, and gastrointestinal lymphoma, yet screening for premalignant gastric lesions is rarely offered routinely to these patients. Proposed screening protocols are not widely accepted and are based on gastric cancer risk factors that are not applicable to all CVID patients. Fifty-two CVID patients were recruited for screening gastroscopy irrespective of symptoms or blood results and were compared to 40 controls presenting for gastroscopy for other clinical indications. Overall, 34% of CVID patients had intestinal metaplasia (IM), atrophic gastritis or moderate to severe non-atrophic gastritis, which can increase the risk of gastric cancer, compared to 7.5% of controls (p < 0.01). Focal nodular lymphoid hyperplasia, a precursor lesion for gastrointestinal lymphoma, was seen in eight CVID patients (16%), one of whom was diagnosed with gastrointestinal lymphoma on the same endoscopy. High-risk gastric pathology was associated with increased time since diagnosis of CVID, smoking, Helicobacter pylori, a low-serum pepsinogen I concentration, and diarrhea, but not pepsinogen I/II ratio, iron studies, vitamin B12 levels or upper gastrointestinal symptoms. There was a lower rate of detection of IM when fewer biopsies were taken, and IM and gastric atrophy were rarely predicted by the endoscopist macroscopically, highlighting the need for standardized biopsy protocols. The prevalence of premalignant gastric lesions in patients with CVID highlights the need for routine gastric screening. We propose a novel gastric screening protocol to detect early premalignant lesions and reduce the risk of gastric cancer and gastric lymphoma in these patients.

Macaque liver substrate for evaluating dense fine speckled-like patterns on HEp2010 cells.

Antinuclear antibody (ANA) detection by indirect immunofluorescence (IIF) is instrumental in the evaluation of systemic autoimmune diseases (SADs). The dense fine speckled (DFS) ANA staining predominantly associates with anti-DFS70, an autoantibody that is thought to exclude the presence of SAD. However, the DFS pattern may mask the presence of other ANA patterns that may be clinically relevant. Our laboratory uses the HEp2010 substrate which contains both HEp2 and liver substates. The aim of this study was to determine whether negative liver nucleus immunofluorescence could exclude the presence of antibodies to extractable nuclear antigens (ENA) in sera with DFS-like patterns. One hundred consecutive sera samples suspicious for DFS pattern, along with 15 sera of control patterns (positive metaphase bars) were included in the study. Each sample was examined separately on HEp2010 (Euroimmun) and liver by two independent readers. Anti-DFS70 was assessed by line and chemiluminescent immunoassays. DFS-like sera were more likely to be liver nucleus-negative compared with control sera. Of the liver-negative sera, 61/64 (95.3%) were deemed anti-ENA negative. Using the liver substrate in the evaluation of anti-ENA had a sensitivity of 90.0% and a negative predictive value of 95.4%. In our cohort, concurrent evaluation of sera with the liver substrate helped rule out the presence of other anti-ENA. This technique may be a safeguard for DFS-like ANA patterns that may mask underlying anti-ENA on IIF.

Validation of phospholipase A2 receptor direct immunofluorescence staining in the diagnosis of primary membranous glomerulonephritis.

Distinguishing between primary and secondary subtypes of membranous glomerulonephritis (MGN) is critical for its clinical management. We prospectively compared direct immunofluorescence (DIF) staining for phospholipase A2 receptor (PLA2R) on frozen renal biopsy with the presence of detectable serum PLA2R antibody assessed by enzyme linked immunosorbent assay (ELISA) in the diagnosis of primary MGN. Forty-six patients with biopsy-proven MGN were enrolled from April 2017 to June 2019 with 31/46 (67.4%) being primary and 15/46 (32.6%) being secondary as determined by comprehensive clinical assessment. This is currently deemed to be the gold standard for distinguishing primary from secondary MGN. Amongst the 31 primary MGN patients, 24/31 were positive on PLA2R DIF staining compared to 18/31 being positive on the PLA2R ELISA (p=0.03). Amongst the 15 secondary MGN patients, 1/15 was positive on PLA2R DIF compared to 0/15 on PLA2R ELISA (p=1.0). In conclusion, the presence of PLA2R staining on DIF demonstrated superior sensitivity and similar specificity compared to the detection of circulating PLA2R antibodies by ELISA in the diagnosis of primary MGN in a cohort of 46 patients with biopsy-proven MGN. We suggest that DIF should be considered as part of routine work-up in all newly diagnosed cases of MGN.

Comparative study of five serological assays for the diagnosis of paraneoplastic pemphigus.

Paraneoplastic pemphigus (PNP) is an autoimmune mucocutaneous blistering disease driven by autoantibodies against plakins expressed in mucosal epithelium. Diagnosis can be difficult as both clinical and biopsy features overlap with other blistering disorders, thus serology is important. Indirect immunofluorescence (IIF) on rat bladder substrate is the most widely used assay, but plakin-specific autoantibody assays have recently become available.The aim of this study was to compare the performance of five PNP assays in patients with mucosal blistering disease: IIF with rat bladder, monkey bladder and rat cardiac substrates, an envoplakin enzyme-linked immunosorbent assay (ELISA), and an envoplakin-transfected HEK cell based assay (CBA).Fifty-one patient serum samples, comprising three PNP patients and 48 disease controls, were collected along with 10 healthy control samples, and analysed using the five assays.IIF on rat and monkey bladder substrates both showed high specificity (97% and 95%, respectively), and correctly identified all three PNP sera. The envoplakin ELISA was equally specific (98%) but identified only one PNP patient. The CBA was difficult to interpret, and both this assay and IIF on rat cardiac substrate lacked specificity (82% and 83%, respectively).In this study IIF using either rat or monkey bladder substrates performed strongly, whilst the envoplakin ELISA seemed to lack sensitivity, and the CBA and IIF on rat cardiac substrate were inferior. Our findings suggest that traditional IIF-based assays remain the preferred approach in the serological diagnosis of PNP.

A dual-fixed neutrophil substrate improves interpretation of antineutrophil cytoplasmic antibodies by indirect immunofluorescence.

OBJECTIVES: To determine whether the addition of a formalin-fixed neutrophil substrate could improve interpretation and prediction of autoantigenic specificity in antineutrophil cytoplasmic antibody (ANCA) testing. METHODS: Routine diagnostic samples sent for ANCA testing were analyzed prospectively on a dual substrate of both ethanol- and formalin-fixed neutrophils. Positive samples on ethanol-fixed neutrophils were deemed "typical" if formalin-fixed neutrophils also stained, and "atypical" if not. Indirect immunofluorescence (IIF) results were correlated with antimyeloperoxidase (MPO) and anti-proteinase 3 (PR3) results with an enzyme-linked immunosorbent assay (ELISA). RESULTS: Of 1,426 samples, 201 from unique patients were ANCA-positive (200 on IIF, 1 on ELISA alone). Thirty-two (45%) of 71 typical ANCA staining patterns were positive for either an anti-MPO or anti-PR3 antibodies, whereas only one (0.8%) of 129 atypical patterns was ELISA-positive, in a patient without systemic vasculitis. Only one (3%) of 34 ELISA-positive samples had a negative IIF-ANCA (1/1,426 patients, 0.07%), and this patient did not have vasculitis. CONCLUSIONS: Concomitant staining on formalin fixation of IIF-positive ethanol-fixed ANCA samples improves the interpretation of ANCA testing and is predictive of vasculitis autoantigens MPO and PR3.