Anti-Nuclear Antibody positive

Disclaimer

These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Introduction

Anti-nuclear antibodies (ANAs) are present in healthy individuals; therefore, they are not a useful ‘screening’ test for rheumatological conditions. Most children with a positive ANA do not have a rheumatological disease. ANAs may also be positive in a number of non-rheumatological diseases, including malignancy and viral infections (e. g. Epstein-Barr Virus).

Due to the poor specificity of ANAs, the Australian Rheumatology Association’s advice is:

‘Do not order antinuclear antibody (ANA) testing without symptoms and/or signs suggestive of a systemic rheumatic disease.’ ^{1, 2, 3}

Juvenile Idiopathic Arthritis (JIA)

ANAs have no diagnostic utility in making or excluding the diagnosis of juvenile idiopathic arthritis.

Connective tissue disease (E.g. Systemic Lupus Erythematosus (SLE), scleroderma)

In patients who have signs or symptoms of a connective tissue disease, ANA and sub-serology testing (anti-dsDNA, ENA) are useful as part of the diagnostic process.

Some of signs and symptoms of connective tissue disease are:

Photosensitivity
Malar or vasculitic rash
Skin change
Arthritis
Recurrent mucocutaneous ulcerations
Alopecia
Recurrent fevers of unknown cause
Weight loss.

Pre-referral investigations and management

Blood Tests:
- FBP
- UEC
- LFT
- ESR
- CRP

Urinalysis

These investigations should capture any systemic processes requiring further evaluation.

If the ANA has been requested due to symptoms of non-specific arthralgia (without arthritis), myalgia or fatigue, consider:

Iron Studies
- supplement as appropriate
Vitamin D levels
- supplement as appropriate
Thyroid function tests
- and treat as appropriate as up to 50% of patients with autoimmune thyroid disease are ANA positive
Consider referral to a physiotherapist for review
- many non-specific joint pains in children are related to biomechanics and/or hypermobility and/or deconditioning and may benefit from assessment and treatment with a physiotherapist
In adolescents:
- consider sleep hygiene, screen time and other factors that may contribute to fatigue
- see sleep disruption and tiredness pre-referral guidelines

When to refer

Persistent signs and symptoms suggestive of a connective tissue disease (e.g. SLE, scleroderma), should prompt referral to a paediatric rheumatologist irrespective of laboratory investigations.

How to refer

Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
Routine non-urgent referrals from private hospitals are made via the PCH Referral Office (Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au)
Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 2222 to discuss referral with the on-call Rheumatologist.

Essential information to include in your referral

Signs and symptoms suggestive of a connective tissue disease such as SLE or scleroderma
Current treatments and history of failed treatments
Results of any investigations.

References

Medicinewise NPS. Recommendations Australian Rheumatology Association. Do not order antinuclear antibody (ANA) testing without symptoms and/or signs suggestive of a systemic rheumatic disease [Internet]. Choosing Wisely Australia. [cited 2022 Jun 28]. Available from: https://www.choosingwisely.org.au/recommendations/ara2
Rodriguez, M., Tesher, MS., Wagner-Weiner, L. Demystifying the positive antinuclear antibody test in children: A clinical review. Pediatr Ann [Internet]. 2015 [cited 2022 Jun 28];44(6):e131-5. Available from: https://pubmed.ncbi.nlm.nih.gov/26114367/
McGhee, JL., Kickingbird, LM., Jarvis, JN. Clinical utility of antinuclear antibody tests in children. BMC Pediatr [Internet]. 2004 [cited 2022 Jun 28];4:13. Available from: http://dx.doi.org/10.1186/1471-2431-4-13
O'Sullivan, M., McLean -Tooke, A., Loh, R. Antinuclear antibody test [Internet]. Royal Australian College of General Practitioners. 2013 [cited 30 June 2022]. Available from: https://www.racgp.org.au/afp/2013/october/antinuclear-antibody-test/

Reviewer/Team:	Rheumatology team	Last reviewed:	Aug 2022
		Review date:	Aug 2025

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