IMMUNODIAGNOSIS

OF SLE
(Systemic Lupus
Erythematosus)

Tanaya Komutarin

SLE (Systemic Lupus

Erythematosus)
Case Study:

A young woman develops a rash in a sunexposed area

--her face.

She has also developed painful lesions in t

pulps of
her toes.

SLE (Systemic Lupus

Erythematosus)
Case Study:

A skin biopsy is taken for direct

immunofluorescence &
shows her skin contains deposits of IgG &
complement.

A section from
a fresh skin biopsy
is incubated with
anti-human IgG
tagged with a
fluorescent label.

When viewed
under an ultraviolet
light microscope,
IgG in the tissue
produces green
fluorescence.

SLE (Systemic Lupus

Erythematosus)
Case Study:

She was also found to have some

abnormalities on blood
testing.

These included an antinuclear antibody (do

by indirect
immunofluorescence) & anti DNA antibodie
(by ELISA).

The slide shows antinuclear antibody by

indirect immunofluorescence. A piece of animal
tissue is mounted on a slide, and the patient's IgG is
bound to nuclei in the tissue.

SLE (Systemic Lupus

Erythematosus)
Case Study:

Note that the DNA antibodies found in the

blood sample
do not bind nuclei in vivo.

This is because the IgG antibodies form immu

complexes
with DNA that has been released from cells.

SLE (Systemic Lupus

Erythematosus)

an autoimmune disease mediated by immu

complexes
,that is, type III hypersensitivity.
The hypersensitivity reaction in SLE is
mediated by
antibodies against DNA & other nuclear
components,
such as ribonucleoproteins.

SLE (Systemic Lupus

Erythematosus)

How high levels of antibodies against D

ribonucleoproteins are generated?

Although SLE is an antibody-mediated dise

key
step in its pathogenesis is the loss of T-ce
tolerance
to DNA.

SLE (Systemic Lupus

Erythematosus)

Genes play an important role in the pathoge

of
SLE; the concordance rate for SLE in identi
twins
is 60%.

SLE is more frequent in individuals who inh

HLA
allele DR2.

SLE (Systemic Lupus

Erythematosus)

In addition, polymorphisms in the genes for deb

clearing
proteins are also important.

Some proteins of the innate immune system are

in
clearing up cellular debris. For ex., MBL & com
component C1q can recognize & bind fragment

- These DNA fragments are then cleared, perha

through
phagocytosis.

SLE (Systemic Lupus

Erythematosus)

Patients with low levels of C1q, or MBL, are at high

for SLE, presumably because DNA produced as a r
cell death is able to trigger production of anti-DNA a

Toll-like receptor 9, expressed on B cells & dendritic

has a physiologic role in recognizing bacteria by bin
unmethylated CpG motifs.

Normally, recognition of bacterial CpG DNA motifs l

increased immunoglobulin secretion by B cells or in
secretion by dendritic cells.

SLE (Systemic Lupus

Erythematosus)

In patients with SLE, immune complexes contain

are
capable of stimulating Toll-like receptor 9.

This leads to increased secretion of type I interfe

may
provide additional stimulation for B cells to perp
secretion of anti-DNA antibodies.

15

SLE (Systemic Lupus

Erythematosus)

Infections may promote the process by increasing

apoptosis
of cells & triggering additional secretion of type I
interferons.

Two additional factors affect the development of S

general,
autoimmune diseases are more common in wom
although SLE
is an extreme example, affecting women 20 times
frequently than men.

SLE (Systemic Lupus

Erythematosus)

The higher incidence of autoimmunity in women i

probably
related to higher levels of the sex hormone estro

SLE can sometimes develop shortly after starting

estrogencontaining contraceptive pills, & it often gets wors
pregnancy, when estrogen levels are high.

SLE (Systemic Lupus

Erythematosus)

Estrogen has the physiologic effect of increasing

production, & it may thus increase autoantibody s

Some autoimmune diseases (e.g., IDDM) affect m

women
equally. These autoimmune diseases tend to be
by T
cells rather than antibody.

SLE (Systemic Lupus

Erythematosus)

Exposure to ultraviolet light (UV) has a role in trig

SLE,
& sun-exposed skin is often affected by a charac
rash.

It is not yet clear how UV has these effects. One

mechanism is that UV induced apoptosis in cells
skin.

An alternative is that UV induced skin damage tri

release of proinflammatory cytokines, such as TN
I
interferons, which either costimulate B cells or ad
tissue damage.

Multiple events are required to trigger systemic lupus erythematosus (SLE)

A model for the pathogenesis of systemic lupus erythematosus (SLE)

SLE (Systemic Lupus

Erythematosus)
- The series of events that may be required to trigger SLE.

- Low levels of antinuclear antibody are present in many healthy

individuals.
- It is known that several years before the development of SLE
symptoms, antinuclear antibody levels can increase.
- In addition, the production of antibodies specifically against
double-stranded DNA commences.
- The factors that switch patients from symptom-free to
symptomatic SLE are not well documented but probably
include infections, UV exposure, and estrogens.

Laboratory Diagnosis
SLE autoantibodies

antinuclear

antibodies (ANA)
antiphospholipid antibodies (APL)
ANA serology

systemic autoimmune diseases

Laboratory Diagnosis

ANA

Indirect
immunofluorescence
HEp-2

cell
titer

ANA

specific

antibodies

Laboratory Diagnosis

Antibodies

SLE

Antibodies
chromatin-associated
antigens anti-DNA, anti-histone, antichromatin anti-nucleosome
Antibodies
ribonucleoproteins
anti-Sm, anti-RNP, anti-Ro/SSA, antiLA/SSB
Antibodies

CNS lupus
anti-neuronal, anti-ribosomal-P protein

Immunodiagnosis of
SLE
Anti-Sm antibodies

- .. 1966

antibodies
targets
antibodies

snRNPs
anti-Sm antibodies
snRNP

Anti-Sm antibodies

- Anti-Sm antibodies
( 99)
SLE

rheumatic

diseases

1 11
SLE

(Americal College of
Rheumatology criteria for the
classification of systemic

Anti-Sm antibodies

- anti-Sm
SLE

nti-DNA

- anti-Sm
SLE

HLA-DQw6
HLADR7

Anti-Sm antibodies
ANA
anti-Sm antibodies
FANA speckled pattern
anti-Sm

immunodiffusion
immunoblotting
immunoprecipitation
ELISA

Anti-Sm antibodies
Indirect immunofluorescence (indirect

fluorescence assay: IFA)

fluorescent
microscope fluorescent antinuclear
antibody (FANA)

(substrate)

antihuman immunoglobulin

RA (Rheumatoid arthritis)

(ch
polyarthritis)

(chronic inflammatory synovitis)

synovial

RA (Rheumatoid arthritis)

2-3

30-40

A model for pathogenesis of Rheumatoid arthritis

RA (Rheumatoid arthritis)

cell-mediated
immune response immune complex proces

lymphocyte T lymphocyt
( CD4+cell)
B lymphocytes

IgG

rheumatoid factor

RA (Rheumatoid arthritis)

(immune co

complement
mediat
cytokines
interleukins, interferons, t
necrosis factor
enzymes growth factors

neutrophils

RA (Rheumatoid arthritis)

pannu

RA (Rheumatoid arthritis)

(ex

-
- (rheumatoid arthritis)
- rheumatoid nodule
-



Sjogrens

RA (Rheumatoid arthritis)

rheumatoid factor
IgM IgG rhe
factor

lab rheumatoid fac
IgM

Rheumatoid factor

endocarditis,
acute viral infection, tuberculosis, hepatits

cirrhosis, malignancy, (p
vaccination)

RA (Rheumatoid arthritis)

Ame
Rheumatic
Association (1987)
1.
(morning stiffness)

2.
3

, ,

,
,

3.
1

4.
(symmetrical arthriti
5.

(rheumatoid n

The Determination of Rheumatoid

Factor by Latex
Agglutination

RF non-organ specific autoimmunity

Fc Fragment IgG autoantib
IgM

IgG IgA

Rheumatoid arthritis (RA) 90%

The Determination of Rheumatoid

Factor by Latex
Agglutination

: Latex particles ( polymer

Polystyrene Latex)

0.81 coate

IgG fraction
human serum

RF

tube slide

The Determination of Rheumatoid

Factor by Latex
Agglutination

RF

negative

Latex agglutination RF
Immunofluorescent
Immunoabsorbent ELISA
RF I

Passive agglutination

RF
IgM

The Determination of Rheumatoid

Factor by Latex
Agglutination

RF
Rheumatoid arthritis (RA)

Hanson 3.8%

4 , 25.6% 4-12 ,