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Atypical clinical presentation of a subset of patients with anti-RNA polymerase III - non-scleroderma cases associated w...
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Title: Atypical clinical presentation of a subset of patients with anti-RNA polymerase III - non-scleroderma cases associated with dominant RNA polymerase I reactivity and nucleolar staining
Series Title: Arthritis Res Ther 13(4): R119
Physical Description: Journal Article
Creator: Satoh, Minoru
Publisher: BioMed Central
Place of Publication: London
Publication Date: July 22, 2011
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Abstract: INTRODUCTION: Anti-RNA polymerase III (RNAP III) antibodies are highly specific markers of scleroderma (SSc) and associated with a rapidly progressing subset of SSc. The clinical presentation of anti-RNAP III positive patients, onset of Raynaud's phenomenon (RP) and SSc in unselected patients in rheumatology clinic were evaluated. METHODS: Autoantibodies in sera from 1966 unselected patients (including 434 systemic lupus erythematosus (SLE), 119 systemic sclerosis, scleroderma (SSc), 85 polymyositis/dermatomyositis (PM/DM)) in a rheumatology clinic were screened by radioimmunoprecipitation. Anti-RNAP III positive sera were also tested by immunofluorescence antinuclear antibodies and anti-RNAP III ELISA. Medical records of anti-RNAP III positive patients were reviewed. RESULTS: Among 21 anti-RNAP III positive patients, 16 met the ACR SSc criteria at the initial visit but five did not; diagnoses were vasculitis, early polyarthritis, renal failure with RP, interstitial lung disease, and Sjogren's syndrome. The first two patients developed rapidly progressive diffuse SSc. An additional case presented with diffuse scleroderma without RP and RP developed 2 years later. Anti-RNAP III antibodies in these 6 cases of atypical clinical presentation were compared with those in 15 cases of typical (SSc with RP) cases. Anti-RNAP III levels by ELISA were lower in the former group (P = 0.04 by Mann-Whitney test) and 3/6 were negative versus only 1/15 negative in the latter (P<0.05 by Fisher's exact test). Three cases of non-SSc anti-RNAP III positive patients had predominant reactivity with RNAP I with weak RNAP III reactivity and had a strong nucleolar staining. Three anti-RNAP III patients who did not have RP at the initial visit developed RP months later. Scleroderma developed prior to RP in 5/16 (31%) in the anti-RNAP III group, but this was rare in patients with other autoantibodies. The interval between the onset of RP to scleroderma was short in anti-RNAP III positive patients. CONCLUSIONS: Anti-RNAP III antibodies are highly specific for SSc, however, a subset of patients do not present as typical SSc. The interval between RP and scleroderma is short, and 31% of patients developed scleroderma prior to RP in this group. Anti-RNAP III positive patients may not present as typical SSc and detecting anti-RNAP III may have predictive value.
Acquisition: Collected for University of Florida's Institutional Repository by the UFIR Self-Submittal tool. Submitted by Minoru Satoh.
Publication Status: Published
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Source Institution: University of Florida Institutional Repository
Holding Location: University of Florida
Rights Management: All rights reserved by the submitter.
System ID: IR00000705:00001

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RESEARCHARTICLE OpenAccessAtypicalclinicalpresentationofasubsetof patientswithanti-RNApolymeraseIII-nonsclerodermacasesassociatedwithdominantRNA polymeraseIreactivityandnucleolarstainingAngelaCeribelli1,MalgorzataEKrzyszczak2,YiLi2,StevenJRoss1,2,JasonYFChan2,EdwardKLChan1, RufusWBurlingame3,TylerTWebb3,MichaelRBubb2,EricSSobel2,4,WestleyHReeves2,4andMinoruSatoh2,4*AbstractIntroduction: Anti-RNApolymeraseIII(RNAPIII)antibodiesarehighlyspecificmarkersofscleroderma(systemic sclerosis,SSc)andassociatedwitharapidlyprogressingsubsetofSSc.Theclinicalpresentationofanti-RNAPIII positivepatients,onsetofRaynaud sphenomenon(RP)andSScinunselectedpatientsinarheumatologyclinic wereevaluated. Methods: Autoantibodiesinserafrom1,966unselectedpatients(including434systemiclupuserythematosus (SLE),119SSc,85polymyositis/dermatomyositis(PM/DM))inarheumatologyclinicwerescreenedby radioimmunoprecipitation.Anti-RNAPIIIpositiveserawerealsotestedbyimmunofluorescenceantinuclear antibodiesandanti-RNAPIIIELISA.Medicalrecordsofanti-RNAPIIIpositivepatientswerereviewed. Results: Among21anti-RNAPIIIpositivepatients,16mettheAmericanCollegeofRheumatology(ACR)SSccriteria attheinitialvisitbut5didnot;diagnoseswerevasculitis,earlypolyarthritis,renalfailurewithRP,interstitiallung disease,andSjgren ssyndrome.ThefirsttwopatientsdevelopedrapidlyprogressivediffuseSSc.Anadditional casepresentedwithdiffusesclerodermawithoutRPandRPdevelopedtwoyearslater.Anti-RNAPIIIantibodiesin these6casesofatypicalclinicalpresentationwerecomparedwiththosein15casesoftypical(SScwithRP)cases. Anti-RNAPIIIlevelsbyELISAwerelowerintheformergroup( P =0.04byMann-Whitneytest)and3of6were negativeversusonly1of15negativeinthelatter( P <0.05byFisher sexacttest).Threecasesofnon-SScantiRNAPIIIpositivepatientshadpredominantreactivitywithRNAPIwithweakRNAPIIIreactivityandhadastrong nucleolarstaining.Threeanti-RNAPIIIpatients,whodidnothaveRPattheinitialvisit,developedRPmonthslater. SclerodermadevelopedpriortoRPin5outof16(31%)intheanti-RNAPIIIgroup,butthiswasrareinpatients withotherautoantibodies.TheintervalbetweentheonsetofRPtosclerodermawasshortinanti-RNAPIIIpositive patients. Conclusions: Anti-RNAPIIIantibodiesarehighlyspecificforSSc;however,asubsetofanti-RNAPIIIpositive patientsdonotpresentastypicalSSc.TheintervalbetweenRPandsclerodermainthisgroupisshort,and31%of patientsdevelopedsclerodermapriortoRPinthisgroup.Anti-RNAPIIIpositivepatientsmaynotpresentastypical SScanddetectinganti-RNAPIIImayhavepredictivevalue. *Correspondence:minoru.satoh@medicine.ufl.edu2DivisionofRheumatologyandClinicalImmunology,Departmentof Medicine,UniversityofFlorida,1600SWArcherRoad,Gainesville,FL326100221,USA FulllistofauthorinformationisavailableattheendofthearticleCeribelli etal ArthritisResearch&Therapy 2011, 13 :R119 http://arthritis-research.com/content/13/4/R119 2011Ceribellietal.;licenseeBioMedCentralLtd.ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin anymedium,providedtheoriginalworkisproperlycited.

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IntroductionSpecificautoantibodiesinsystemicrheumaticdiseases areusefulbiomarkersassociatedwithcertaindiagnoses and/orclinicalmanifestations[1].Severalautoantibodies,includinganti-topoisomeraseI(topoI),-centromere(ACA),-RNApolymeraseIII(RNAPIII),-U3RNP/ fibrillarin,and-Th/To,havebeenreportedtobeassociatedwithscleroderma(systemicsclerosis,SSc);some areconsideredhighlyspecificdiseasemarkerswhile othersareconsideredrelativelyspecific[2].Anti-RNAP IIIthatisconsideredhighlyspecificforSSc,isarelativelynewdiseasemarkerofSSc;however,ithas becomeapopulartestinthelastseveralyearsthanksto thewideavailabilityofcommercialELISAkits[1,2]. Detectinganti-RNAPIIIinsomeundiagnosedpatients wouldnotbetotallyunexpected,consideringthatautoantibodiesareusuallyproduc edpriortotypicalclinical manifestations[3].However,detectionofanti-RNAPIII innon-SScpatientsorpriortoclinicalSSchasrarely beenreported[4].Although anti-RNAPIIIantibodies areassociatedwithrapidprogressionofthediseaseand theintervalbetweentheonsetofRaynaud sphenomenon(RP)andSScisshort[2,5],thetimecourseofthe onsetofRPandSSchasnotbeenwelldescribed.Inthe presentstudy,theclinicalfeaturesofanti-RNAPIII positivepatientsinacohortofanunselectedpopulation inarheumatologyclinicthatincludesundiagnosed patientsandpatientswitha widevarietyofdiagnosis, werecharacterized.Therel ationshipsamongdetection ofanti-RNAPIIIantibodies ,onsetofRP,anddevelopmentofsclerodermatousskinchanges,werealsosystematicallyanalyzed.MaterialsandmethodsPatientsAll1,966subjectsenrolledintheUniversityofFlorida CenterforAutoimmuneDiseases(UFCAD)registry from2000to2010werestudied.Diagnosesofthe patientsinclude434SLE,119SSc,85polymyositis/dermatomyositis,andvariousotherdiagnoses,andmany remainedundiagnosedforaspecificsystemicautoimmunedisease.Ateachvisitoftheenrolledsubjects,a formwithastandardchecklistofsymptomsandphysicalfindings,includingRaynaud sphenomenonand sclerodermatousskinchanges,wasfilledoutbyphysiciansinadditiontoanentryinthemedicalchart.The datafromtheformwerethenenteredintoacomputer database.Clinicalinformationforthestudywasfrom thedatabaseandchartrecords.Raynaud sphenomenon wasdefinedassuddenreversiblewhitepallorofacral structures,whichtypicallyisfollowedbycolorchanges topurplethentored[6].Theprotocolwasapprovedby theInstitutionalReviewBoard(IRB).Thisstudymeets andisincompliancewithallethicalstandardsin medicine.Informedconsent ,includingthepublication ofthestudy,wasobtainedfromallpatientsaccordingto theDeclarationofHelsinki.ImmunoprecipitationAutoantibodiesinserafromtheinitialvisitofeach patientwerescreenedbyimmunoprecipitation(IP) using35S-methioninelabeledK562cellextract.AntiRNAPIIIweredeterminedusingreferencesera[4].Specificityofautoantibodiesw asdeterminedusingpreviouslydescribedreferencesera[7].ImmunofluorescentantinuclearantibodiesImmunofluorescentantinucl ear/cytoplasmicantibodies (HEp-2ANAslides;INOVADiagnostics,SanDiego, CA,USA)weretestedusinga1:80-dilutedhuman serumandDyLight488donkeyIgGF(ab )2anti-human IgG(gamma-chainspecific,1:200dilution;Jackson ImmunoResearchLaboratories,Inc.,WestGrove,PA, USA)[8].ELISASeraweretestedforIgGanti-RNAPIIIantibodiesusing acommercialELISAkit(QUANTALiteRNAPolIII, INOVADiagnostics)followingthemanufacturer s instruction.StatisticalanalysisDatabetweengroupswerecomparedbytheMannWhitneytestusingPrism5.0forMacintosh(GraphPad Software,Inc.,SanDiego,CA,USA). P <0.05wasconsideredsignificant.ResultsAutoantibodiestoRNApolymeraseI/IIIwerefoundin 21patients(1.1%of1,966);18Caucasians,2African Americans,and1ofmixedethnicbackground.Sixteen of21caseshadadiagnosisofSScattheinitialvisit while5didnot(Table1).IntheCaucasianpatients,14 outof18werediagnosedashavingSScattheinitial visit.Fourpatients(cases1,3,4,5)didnotfulfillthe SSccriteriaattheinitialvisitwhenserumanti-RNAPI/ IIIantibodiesweredetected.TwoAfricanAmerican patientshadadiagnosisofSScattheinitialvisit.A patientofmixedethnicbackgrounddidnotmeetthe AmericanCollegeofRheum atology(ACR)criteriaat theinitialvisit(case2).PatientswhodidnotmeetSSc criteriaattheinitialevaluationaresummarizedbelow andinTable1.Abriefhistoryofanadditionalcase6, inwhichsclerodermatouschangewasfollowedbyRP twoyearslater,isalsodescribed. Case1:Afifty-year-oldfemalewashospitalizedfor shortnessofbreathandchestpaininMarch2000. NumbnessinherleftseconddigitalsodevelopedandCeribelli etal ArthritisResearch&Therapy 2011, 13 :R119 http://arthritis-research.com/content/13/4/R119 Page2of7

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becameprogressivelyischemicandpainful,resultingin amputationduetogangreneinAprilofthatyear.A hypercoagulablestatesecondarytomalignancywassuspected,butnothingwasfound.InMay2000,shedevelopedischemicareasonthetipsofthefingersandtoes, andwasputonanticoagulationtherapy.HerANA (speckledpattern,titer1:640)andanti-RNAPI/IIIantibodieswerepositivebutnosclerodermaorRPwas noted.Prednisolone(40mg/day)wasstartedandher conditionwasfollowedatherlocalclinic.Shedeveloped proximalsclerode rmaandsclerodermarenalcrisisin March2001. Case2:A39-year-oldfemaledevelopedpolyarthritis involvingthemetacarpophalangealjoints(MCPs),proximalinterphalangealjoints(PIPs),wristsandanklesin August2004.Theinitialdiagnosiswasearlysynovitis withoutevidenceofsystemi crheumaticdisease.Rheumatoidfactor(RF)andanti-CCPwerenegativebut ANA(speckledpattern,titer1:160)andanti-RNAPI/III antibodieswerepositive.Shedevelopedsclerodermatous changesinherfingers,forearmsandfaceinOctober 2004,whichrapidlyprogressedtoproximalscleroderma inNovember.Monthlyi.vcyclophosphamidetherapy wasstarted,followedbypre dnisolone(50mg/day)in December.ShestartedhavingRPinFebruary2005and verapamilandbosentanwerestarted.RightheartcatheterizationinMarch2005suggestedmildpulmonary hypertension(PH).Sclerodermaprogressedtoinvolve thechest,shouldersandabdomen,andflexioncontracturesofthefingerswerenotedinMarch2005.Shewas hospitalizedin2008foranemiacausedbygastricantral vascularectasia(GAVE). Anotherverysimilarcasewasseen.A32-year-old Caucasianfemalewasclassifiedashavingearlysynovitis (wrists,MCP,PIPjoints)withapositiveANA(speckled andnucleolarpattern).Ayearlatershedevelopedproximalsclerodermaandvisit edtheUFCAD.RPdeveloped sixmonthslater. Case3:A57-year-oldfemale,whohada10-yearhistoryofRP,visitedaclinicforworseningRPinApril 2002,whenhydroxychroloquinewasstarted.InMay 2002shewashospitalizedelsewherefordyspnea, hypoxiaandanonproductive cough.Pleuraleffusions andheartfailurewerefound,andhercardiacejection fractionwas25%.Adiagnosisofdilatedcardiomyopathy wasmade.Shealsodevelopedhypertensionandrenal dysfunction.Prednisolone(60mg/day)andazathioprine werestartedbutthelatterwasdiscontinuedduetoa rash.InJuly2002,shedevelopedrenalfailureand hemodialysiswasstarted.Herkidneybiopsyrevealed thromboticmicroangiopathy.Decreasedsensationofher lowerleftlegwasdiagnosedasneuropathy.Shevisited UFCADinJuly2002.Nosclerodactylywasnotedbut oneteleangiectasiawasfoundinthedigit.ANA (speckledandnucleolarpattern,titer1:80)andantiRNAPI/IIIwerepositive. Case4:A67-year-oldfemalewhowasfollowedbya pulmonologistforathree-yearhistoryofrespiratory symptomswasreferredtotheUFCADforapositive ANA(speckledandnucleolar)andILD.Anti-RNAPI/ IIIantibodieswerepositive.Shedidnothaverheumatologicalsymptoms,includingarthritis,sclerodermatous changes,orRPattheone-yearfollow-up. Case5:A68-year-oldfemalewasfollowedforSjgren ssyndrome.Shehaddryeyes,adrymouthanda positivesalivaryglandbio psybutnosclerodermatous skinchanges,RPorILD.ShewasalsopositiveforACA byimmunofluorescence(Figure1Bpanel5) Table1Fiveanti-RNAPIIIpositivecasesthatwerenotclassifiedasSScattheirinitialvisit123 45 Initialf/uInitialf/u Diagnosis Vasculitis?SScPoly -arthritis SSc SineSSc?ILDSjgren ssyndrome Race/gender WF MixedF WF WF WF Anti-RNAPIII ELISA(u) 16 NA 99127 8 15 to47 42 Proximalscleroderma N Y <10mo NY 3mo NNN Sclerodactyly N Y <10mo NY 2mo NNN Pittingscar N N N N N N N ILD N N N N N Y N Raynaud sphenomenonN ? N Y 6mo Y For10y NN Other Renalcrisis 10mo Flex.cont PH ARF(TMA),DCMARF,acuterenalfailure;DCM,dilatedcardiomyopathy;W,white;F,female;Flexcont,flexioncontracture;f/u,followup;ILD,interstitiallungdisease;N,no;NA, notavailable;PH,pulmonaryhypertension;SSc,systemicsclerosis,scleroderma;TMA,thromboticmicroangiopathy;Y,yesCeribelli etal ArthritisResearch&Therapy 2011, 13 :R119 http://arthritis-research.com/content/13/4/R119 Page3of7

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Figure1 Anti-RNAPIIIantibodiesbyimmunoprecip itation,immunofluorescence,andELISA A ).Immunoprecipitationusing35SmethioninelabeledK562cellextract.35S-methioninelabeledK562cellextractwasimmunoprecipitatedbyserumsamplesfrompatientswith anti-RNApolymeraseI/III,whohadatypicalclinicalpresentations(Table1)andcontrols.RNAPs,RNApolymerases;I,II,III,twolargestsubunitsof RNApolymeraseI,II,andIII,respectively;laneI,II,III,areferenceserumwithanti-RNAPI/II/III;laneI,III,areferenceserumwithanti-RNAPI/III;1to 6,IPwithserafromcases1to6;NHS,normalhumanserum;positionsofmolecularweightmarkersarealsoindicated. B ).Immunofluorescence. HEp-2ANAslidewasstainedwithserafromcases1to6(Table1)at1:80dilutions. C).Anti-RNAPIIIlevelsbyELISA.Serafrom21caseswith anti-RNAPI/IIIweretestedbyELISA.Sixcasesofatypicalpresentation(Table1)and15casesoftypicalpresentationofSScareshown. P =0.04 byMann-Whitney;closedcircle,SSc;opencircles,atypicalcasesinTable1. D ).Anti-RNAPIIIlevelsovertime.Serafromcases2,4and6over timeweretestedbyanti-RNAPIIIELISA.Timepointsofonsetofsclerodermatousskinchange(blackarrowhead)orRaynaud sphenomenon (whitearrowhead)areindicated.Acut-off(20units)isshownasshadedarea. Ceribelli etal ArthritisResearch&Therapy 2011, 13 :R119 http://arthritis-research.com/content/13/4/R119 Page4of7

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Case6,(notincludedinTable1sinceshehadadiagnosisofSScattheinitialvisit),wasa61-year-oldCaucasianfemalewhodevelopedtinglingfingertips;carpal tunnelsyndromewassuspected.Thetinglingwasfollowedbyswellingandpaininherhandsandsclerodermatousskinchangestoherforearm.Shevisited UFCADandhadadiagnosisofdiffuseSSc.RPdevelopedtwoyearslater. Twopatients(cases1and2),whohadanti-RNAPIII withoutSScbutlaterdevelopedSSc,threepatientswho didnotmeettheSSccriteriaduringobservation(cases 3to5),andapatientwhohadSScwithoutRPand developedRPtwoyearslater(case6),wereclassifiedas atypicalpresentation cases.Anti-RNAPIIIantibodies inthese6caseswerecomparedwith15casesof typical presentation inwhichpatientshadSScwithRPwhen theyvisitedclinicandserumsampleswerecollected. Serafromallsixcasesof atypicalpresentation clearlyimmunoprecipitatedRNAPIandIII(Figure1A). TheintensityofRNAPIandIIIweresimilarintwo patientswhodevelopedSSclater(cases1and2,lanes1 and2inFigure1A)andapatientwithSScwhodevelopedRPtwoyearsafterthedevelopmentofSSc(case6, lane6).Incontrast,RNAPIwaspredominantwith muchweakerRNAPIIIinthreepatients,(cases3to5, lanes3to5inFigure1A),whodidnothaveadiagnosis ofSSc.RNAPIIIandIIareknowntodistributeinthe nucleiwhileRNAPIlocalizestothenucleoli[9,10]. Consistentwiththeirlocalizationpatterns,serafrom cases3to5(panels3to5inFigure1B)thathadpredominantRNAPIIP,haddominantnucleolarstaining comparedwiththeirnuclearstaining.Case5hadACA inaddition(Figure1Bpanel5). Levelsofanti-RNAPIIIweretestedbyELISAcomparingcaseswithatypicalpresentationvstypicalpresentationofSSc(Figure1C).Levelsofanti-RNAPIIIinthe formergroupwerelowerthanthoseinthelatter( P = 0.04byMann-Whitneytest).Also,anti-RNAPIIIELISA negative(<20units)wascommonintheformer(3of 6)vsthelattergroup(1of15, P =0.0526bytheFisher s exacttest).Specifically,2oftheELISAnegativepatients werecases3and4whohadweekbandsbyIPanddid notdevelopscleroderma.Thus,althoughallcases immunoprecipitatedRNAPII I,levelsofanti-RNAPIII byELISAwerelowerincaseswithatypicalclinicalpresentationscomparedwiththoseintypicalSSc. Sequentialserafromcases2,4,and6wereavailable fortestingbyanti-RNAPIIIELISA.Incase2,levelsof anti-RNAPIIIwerehigh(99units)attheinitialvisit despitecompletelackofscle rodermaorRP,indicating thatanti-RNAPIIIcanbeproducedpriortoclinical manifestationssimilartootherdiseasemarkerautoantibodies.Levelsofanti-RNAPIIIwentupwhenthe patientdevelopedsclerodermatousskinchanges followedbyRP.Incase4,anti-RNAPIIIbecamepositivewhilethepatientwasfollowedupforILD,butno clinicalchangeswereobserved.Incase6,thepatient hadlowlevelsofanti-RNAPIIIwhenshevisited UFCADwithdiffuseSScbutwithoutRP.HerantiRNAPIIIlevelsincreasedfrom33unitsto107unitsto 112unitspriortothedevelopmentofRPtwoyears later. RPisoftenthefirstsymptomofSScandmaystart manyyearspriortodevelopmentofSSc[2].Sincecases ofanti-RNAPIIIpositivepatientswhodevelopedsclerodermatouschangespriortoRPwerenoted,the sequenceofRPandsclerodermatouschangeswere reviewedcarefully,comparingSScpatientswithantiRNAPIIIvsotherspecifici tiesintheUFCADcohort (Table2cases3to5arenotincluded).Almostallof theSScpatientshadRPduringthecourseofthedisease regardlessoftheautoantibodyspecificity.However,only 3of17anti-RNAPIIIpositivepatientsdidnothaveRP bythetimeofinitialvisit( P =0.07vstopoIgroup, P = 0.01vsallotherscombined).Whenthemedicalhistory wascarefullyreviewed,sclerodermatouschanges appearedpriortoRPin31%(5of16)ofanti-RNAPIII patientswhilethisoccurredonlyinoneanti-topoIpositivepatientinothergroups(RNAPIIIvstopoI, P = 0.03;RNAPIIIvsACA, P =0.04;RNAPIIIvsothers, P =0.002).ThedevelopmentofRPandsclerodactylywere separatedbymorethanoneyearonlyin25%ofantiRNAPIIIpatientsvs50to58%ofindividualswith otherspecificities( P =0.08vsallothers).Thetime betweenRPandthedevelopmentofsclerodermawas shorterinanti-RNAPIIIvsACAgrouporallothers combined( P =0.03byMann-Whitney).DiscussionAnti-RNAPIIIantibodiesareconsideredhighlyspecificforthediagnosisofSSc.Amongfivepatientswho didnotmeettheSSccriteriaattheinitialvisit,two developedSScduringfollow-up;however,threedid not(Table1).Case3hadRPandanepisodeconsistent withsclerodermarenalcrisisandCcase4hadILD. AlthoughtheirSSc-likefeaturesinvolvinginternal organsarelimitedcomparedwithreportedcases [11,12],itseemsreasonabletosuspectthattheyhada pathogeneticconditionsimilartosystemicsclerosis sine scleroderma,inparticularwithdetectionofantiRNAPIII.Similarcasesofsclerodermarenalcrisis withminimalornofeaturesofSSc,somewithantiRNAPIIIantibodies,havebeenreported[13,14]. AlthoughweshouldnotclassifyallANA-positive acuterenalfailureorILDassystemicsclerosis sine scleroderma,identifyingSSc -specificautoantibodies mayproveusefulinunderstandingthepathogenetic mechanismandselectingtreatmentoptions.Ceribelli etal ArthritisResearch&Therapy 2011, 13 :R119 http://arthritis-research.com/content/13/4/R119 Page5of7

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Detectionofanti-RNAPIIIbyELISAinpatientswith diagnosisotherthanSScwasoccasionallyreported,but mostofthemwereinterpretedasfalsepositivesbased onnegativeresultsbyIP[15,16].ThepresenceofantiRNAPIIIconfirmedbyIPinnon-SScpatients,as showninthepresentstudy,wasrarelyreported[4,15]. SeveralstudiescomparedELISAandIPtoestimatespecificityandsensitivityofELISA.IPpositiveELISAnegative(falsenegative)isreportedin4to9%[15-17],while IPnegativeELISApositive(falsepositive)is12to15% [15,16].AlthoughconfirmationofIPnegativeappearsto beincomplete,otherstudysuggeststhatfalsepositive byELISAisaslowas~2%[17].Falsepositivesappear tobemorecommonamongweaklypositivesamplesor innon-SScpatients[15,16].Ourdatashowedthat19% (4of21,1laterbecamepositive)ofIPpositiveswere ELISAnegative(Figure1).Anti-RNAPIIIELISAhas beenshowntohaveagoodsens itivityandspecificity [15-17]andhasmadethetestingforthiscommonSSc antibodywidelyavailable.Thus,itsignificantlyhelps clinicalpracticesinceIPisnotavailabletomostclinicians.Nevertheless,itshouldbekeptinmindthatthere arefalsepositivesandfalsenegativesinELISA.Inparticular,cautiousinterpretationwillbenecessaryfor weaklypositivesamplesorpositivesamongnon-SSc patients.IPshouldremainthegoldstandardforantiRNAPIIIantibodytesting. Itisofinterestthatallthreecasesofnon-SScantiRNAPIIIpositivepatientshadpredominantRNAPI reactivitywithweakRNAP IIIreactivityandhada strongnucleolarstainingthatisnotalwaysseeninantiRNAPI/IIIpositiveSScpatie nts[17,18].Inaddition, anti-RNAPIIIlevelsincrea sedpriortodevelopmentof sclerodermaorRPincases2and6,suggestingacorrelationbetweenlevelsofanti-RNAPIIIanddiseaseactivity.Onestudysuggestedalinkbetweenincreasinglevels ofanti-RNAPIIIaftertheinitialvisitandincreasing totalskinscoreandonsetofrenalcrisisovertime[15]. Anotherstudyreportedanassociationofanti-RNAPIII levelsandskinscoreandanegativecorrelationwitha pulmonaryfunctiontest[19].Theseareconsistentwith thepresentcases;however,thecourseofanti-RNAPIII duringtheonsetofsclerodermatousskinchangesorRP hasnotbeenreportedpreviously. Auniquefeatureobservedinanti-RNAPIIIpositive SScpatientswasthelatedevelopmentofRP,which hasalsobeensuggested[2 ],butdetailswerenot reported.EvenifRPappearspriortoscleroderma,the intervalisoftenwithinayear,consistentwiththepreviouslyreportedrapidlyprogressivenatureofSScin anti-RNAPIIIpositivepatients[2,20].ThedevelopmentofRPaftertheinitialvisitwasobservedinonly threecaseswithanti-RNAPIIIbutdidnotappearin othergroupsatall,and31%(5of16)intheantiRNAPIIIgrouphadsclerodermapriortoRP.Incontrast,RPprecededsclerodermainmostcasesofSSc [2].SclerodermatousskinwithoutRPisconsidered characteristicofmalignancy-associatedpseudoscleroderma[21-23].However,a nti-RNAPIIIpositiveSSc shouldbeconsideredinthedifferentialdiagnosisof sclerodermawithoutRP,since31%ofouranti-RNAP IIIpositiveSScdevelopedsclerodermatouschanges priortoRP.ConclusionsInsummary,anti-RNAPIIIishighlyspecificforSScand relatedconditionseveninanunselectedpopulation fromarheumatologyclinic.IncaseswithatypicalSSc, dominanceofanti-RNAPIandstrongnucleolarstaining maybeseen.TheunusualpresentationoftheoccurrenceofsclerodermawithoutRPappearstobecharacteristicofanti-RNAPIIIpositiveSSc.Insomecases, internalorganinvolvement,suchasrenalorlungdisease,mayprecedeskinmanifestationofSSc,anddetectionofanti-RNAPIIIprovidesusefuldiagnosticand prognosticinformation. Table2Raynaud sphenomenonandautoantibodiesinsclerodermapatientsRNAPIII ( n =18) TopoI ( n =24) ACA ( n =15) U3RNP ( n =9) Th/To ( n =8) PrevalenceofRP94%(16/17)96%(23/24)100%(15/15)100%(9/9)87%(7/8) AbsenceofRPatfirstvisit (inRPpositivecases) 18%(3/16)1,20%(0/23)20%(0/15) 0%(0/9) 0%(0/7) SclerodermapriortoRP 31%(5/16)3,4,54%(1/23)30%(0/15)40%(0/9) 0%(0/8) RPtoscleroderma>1y 25%(4/16)653%(10/19)58%(7/12) 50%(4/8)57%(4/7) RPtoscleroderma (year,meanSD) 1.55.37,8(0.21.2)94.18.9 5.75.871.11.72.63.4RP,Raynaud sphenomenon1RNAPIIIvsothers, P =0.01;2RNAPIIIvsTopoI, P =0.07;3RNAPIIIvsTopoI, P =0.03;4RNAPIIIvsACA, P =0.04;5RNAPIIIvsothers, P =0.002;6RNAPIIIvs others, P =0.08;7RNAPIIIvsACA, P =0.03;8RNAPIIIvsothers, P =0.03;9Valueafterexcludinganoutlierthathas21yearsintervalbetweenRPto scleroderma.1-6byFisher sexacttest,7,8byMann-WhitneyCeribelli etal ArthritisResearch&Therapy 2011, 13 :R119 http://arthritis-research.com/content/13/4/R119 Page6of7

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Abbreviations ACA:anticentromereantibodies;ACR:AmericanCollegeofRheumatology; ANA:antinuclearantibodies;GAVE:gastricantralvascularectasia;ILD: interstitiallungdisease;IP:immunoprecipitation;IRB:InstitutionalReview Board;MCPs:metacarpophalangealjoints;PIPs:proximalinterphalangeal joints;PH:pulmonaryhypertension;PM/DM:polymyositis/dermatomyositis; RNAP:ribonucleicacidpolymerase;RF:rheumatoidfactor;RP:Raynaud s phenomenon;SLE:systemiclupuserythematosus;SS:Sjgren ssyndrome; SSc:systemicsclerosis:scleroderma;TopoI:topoisomeraseI;UFCAD: UniversityofFloridaCenterforAutoimmuneDiseases Acknowledgements WewouldliketothankMarleneSarmiento,AnnieChan,andtheUFGCRC staffandMatthewPaulusforassistancewithclinicaldatacollection. ThisstudywassupportedbyNIHgrantR01-AR40391andM01R00082from theU.S.PublicHealthServiceandbygenerousgiftsfromLupusLink,Inc. (DaytonaBeach,FL,USA)andMr.LewisM.SchotttotheUniversityof FloridaCenterforAutoimmuneDisease.Publicationofthisarticlewas fundedinpartbytheUniversityofFloridaOpen-AccessPublishingFund. Authordetails1DepartmentofOralBiology,UniversityofFlorida,1395CenterDrive, Gainesville,FL32610-0424,USA.2DivisionofRheumatologyandClinical Immunology,DepartmentofMedicine,UniversityofFlorida,1600SWArcher Road,Gainesville,FL32610-0221,USA.3INOVADiagnostics,Inc.,9900Old GroveRoad,SanDiego,CA,92131-1638,USA.4DepartmentofPathology, Immunology,andLaboratoryMedicine,UniversityofFlorida,1600SWArcher Road,Gainesville,FL32610-0221,USA. Authors contributions MEK,YL,SJR,JYFC,EKLC,RWB,TTWandMScarriedouttheimmunoassays. ACandMSdesignedthestudy.MSperformedthestatisticalanalysis.MRB, ESSandWHRenrolledpatientsforthestudyandmaintainedthedatabase. AC,MSandEKLCdraftedthemanuscript.Allauthorsreadandapprovedthe finalmanuscript. Competinginterests RWBandTTWareemployeesofINOVADiagnostics.Allotherauthorshave nocompetinginterests. Received:3March2011Revised:24May2011Accepted:22July2011 Published:22July2011 References1.SatohM,Vazquez-DelMercadoM,ChanEK: Clinicalinterpretationof antinuclearantibodytestsinsystemicrheumaticdiseases. Mod Rheumatol 2009, 19 :219-228. 2.SteenVD: Themanyfacesofscleroderma. RheumDisClinNorthAm 2008, 34 :1-15. 3.ArbuckleMR,McClainMT,RubertoneMV,ScofieldRH,DennisGJ,JamesJA, HarleyJB: Developmentofautoantibodiesbeforetheclinicalonsetof systemiclupuserythematosus. NEnglJMed 2003, 349 :1526-1533. 4.SatohM,AjmaniAK,OgasawaraT,LangdonJJ,HirakataM,WangJ, ReevesWH: AutoantibodiestoRNApolymeraseIIarecommonin systemiclupuserythematosusandoverlapsyndrome.Specific recognitionofthephosphorylated(IIO)formbyasubsetofhumansera. JClinInvest 1994, 94 :1981-1989. 5.SteenVD: Autoantibodiesinsystemicsclerosis. SeminArthritisRheum 2005, 35 :35-42. 6.SuzukiHI,MiyazonoK: EmergingcomplexityofmicroRNAgeneration cascades. JBiochem 2011, 149 :15-25. 7.ReevesWH,NarainS,SatohM: Autoantibodiesinsystemiclupus erythematosus. In ArthritisandAlliedConditions.ATextbookof Rheumatology.. 15edition.Editedby:KoopmanWJ,MorelandLW. Philadelphia,PA:LippincottWilliamsandWilkins;2005:1497-1521. 8.YamasakiY,NarainS,HernandezL,BarkerT,IkedaK,SegalMS,RichardsHB, ChanEK,ReevesWH,SatohM: Autoantibodiesagainstthereplication proteinAcomplexinsystemiclupuserythematosusandother autoimmunediseases. ArthritisResTher 2006, 8 :R111-120. 9.HirakataM,OkanoY,PatiU,SuwaA,MedsgerTAJ,HardinJA,CraftJ: IdentificationofautoantibodiestoRNApolymeraseII.Occurrencein systemicsclerosisandassociationwithautoantibodiestoRNA polymerasesIandIII. JClinInvest 1993, 91 :2665-2772. 10.JonesE,KimuraH,VigneronM,WangZ,RoederRG,CookPR: Isolationand characterizationofmonoclonalantibodiesdirectedagainstsubunitsof humanRNApolymerasesI,II,andIII. ExpCellRes 2000, 254 :163-172. 11.PoormoghimH,LucasM,FertigN,MedsgerTAJr: Systemicsclerosissine scleroderma:demographic,clinical,andserologicfeaturesandsurvival inforty-eightpatients. ArthritisRheum 2000, 43 :444-451. 12.FischerA,MeehanRT,Feghali-BostwickCA,WestSG,BrownKK: Unique characteristicsofsystemicsclerosissinescleroderma-associated interstitiallungdisease. Chest 2006, 130 :976-981. 13.PhanTG,CassA,GillinA,TrewP,FertigN,SturgessA: Anti-RNA polymeraseIIIantibodiesinthediagnosisofsclerodermarenalcrisis sinescleroderma. JRheumatol 1999, 26 :2489-2492. 14.CanetJJ,CastaneJ,AlvarezM,NavaJM,LlibreJ: Sclerodermarenalcrisis sine scleroderma. Nephron 2002, 90 :119-120. 15.KuwanaM,OkanoY,PandeyJP,SilverRM,FertigN,MedsgerTAJr: Enzyme-linkedimmunosorbentassayfordetectionofanti-RNA polymeraseIIIantibody:analyticalaccuracyandclinicalassociationsin systemicsclerosis. ArthritisRheum 2005, 52 :2425-2432. 16.SatohT,IshikawaO,IhnH,EndoH,KawaguchiY,SasakiT,GotoD, TakahashiK,TakahashiH,MisakiY,MimoriT,MuroY,YazawaN,SatoS, TakeharaK,KuwanaM: Clinicalusefulnessofanti-RNApolymeraseIII antibodymeasurementbyenzyme-linkedimmunosorbentassay. Rheumatology(Oxford) 2009, 48 :1570-1574. 17.ParkerJC,BurlingameRW,WebbTT,BunnCC: Anti-RNApolymeraseIII antibodiesinpatientswithsystemicsclerosisdetectedbyindirect immunofluorescenceandELISA. Rheumatology(Oxford) 2008, 47 :976-979. 18.YamasakiY,Honkanen-ScottM,HernandezL,IkedaK,BarkerT,BubbMR, NarainS,RichardsHB,ChanEK,ReevesWH,SatohM: Nucleolarstaining cannotbeusedasascreeningtestforthesclerodermamarkeranti-RNA polymeraseI/IIIantibodies. ArthritisRheum 2006, 54 :3051-3056. 19.NihtyanovaSI,ParkerJC,BlackCM,BunnCC,DentonCP: Alongitudinal studyofanti-RNApolymeraseIIIantibodylevelsinsystemicsclerosis. Rheumatology(Oxford) 2009, 48 :1218-1221. 20.CavazzanaI,AngelaC,PaoloA,StefaniaZ,AngelaT,FrancoF: Anti-RNA polymeraseIIIantibodies:amarkerofsystemicsclerosiswithrapid onsetandskinthickeningprogression. AutoimmunRev 2009, 8 :580-584. 21.QuerfeldC,SollbergS,HuerkampC,EckesB,KriegT: Pseudoscleroderma associatedwithlungcancer:correlationofcollagentypeIand connectivetissuegrowthfactorgeneexpression. BrJDermatol 2000, 142 :1228-1233. 22.FujiiT,MimoriT,KimuraN,SatohS,HirakataM: Pseudoscleroderma associatedwithtransforminggrowthfactorbeta1-producingadvanced gastriccarcinoma:commentonthearticlebyVarga. ArthritisRheum 2003, 48 :1766-1767;authorrepy1767-1768. 23.KikuchiK,HoashiT,YazawaN,TamakiK: Pseudosclerodermaassociated withcancer. ClinExpDermatol 2006, 31 :381-383.doi:10.1186/ar3422 Citethisarticleas: Ceribelli etal .: Atypicalclinicalpresentationofa subsetofpatientswithanti-RNApolymeraseIII-non-sclerodermacases associatedwithdominantRNApolymeraseIreactivityandnucleolar staining. ArthritisResearch&Therapy 2011 13 :R119. Submit your next manuscript to BioMed Central and take full advantage of: Convenient online submission Thorough peer review No space constraints or color gure charges Immediate publication on acceptance Inclusion in PubMed, CAS, Scopus and Google Scholar Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Ceribelli etal ArthritisResearch&Therapy 2011, 13 :R119 http://arthritis-research.com/content/13/4/R119 Page7of7