What is the management approach for a patient with a negative Antinuclear Antibody (ANA) test but positive anti-double-stranded Deoxyribonucleic Acid (anti-dsDNA) antibodies?

Management of Patients with Negative ANA but Positive Anti-dsDNA Antibodies

For patients with negative ANA but positive anti-dsDNA antibodies, a comprehensive evaluation for systemic lupus erythematosus (SLE) is strongly recommended despite the atypical serological profile, as this combination can still represent true SLE in patients with high clinical suspicion. 1

Diagnostic Approach

• When ANA is negative but anti-dsDNA is positive, the diagnosis will fundamentally depend on the patient's clinical characteristics, as this serological profile is uncommon but clinically significant 1
• Confirmation of the anti-dsDNA result using a different method is recommended, particularly using Crithidia luciliae immunofluorescence test (CLIFT) which offers high clinical specificity 1
• If the initial anti-dsDNA was detected using solid phase assays (SPA) like ELISA or FEIA, confirmation with CLIFT is particularly important to rule out false positives 1
• The laboratory should be requested to repeat the anti-dsDNA assays in a new sample if the inconsistency between negative ANA and positive anti-dsDNA continues 1

Additional Testing to Consider

• Test for anti-nucleosome antibodies, which may precede ANA in SLE pathogenesis and show high sensitivity (83.33%) and specificity (96.67%) for SLE 1
• Evaluate for antiphospholipid antibodies (anticardiolipin, anti-β2GP1, lupus anticoagulant) as 30-40% of SLE patients are positive for these antibodies 1
• Test for anti-extractable nuclear antigens (anti-ENA), particularly anti-Smith (Sm) antibodies which are highly specific for SLE 1, 2
• Assess complement levels (C3, C4), as low levels are associated with SLE activity 1, 2
• Check for anti-C1q antibodies, which are found in almost 100% of patients with active lupus nephritis 1

Clinical Monitoring

• Patients should undergo periodic clinical follow-up as anti-dsDNA antibodies may be detected long before the development of clear clinical signs 1
• The follow-up interval should be determined by clinical findings and physician judgment 1
• Monitor for common SLE manifestations in multiple organ systems, particularly mucocutaneous, musculoskeletal, and renal involvement 3
• Use disease activity indices such as SLEDAI (SLE Disease Activity Index) to objectively assess disease activity 1

Management Considerations

• If SLE is diagnosed based on clinical features despite the atypical serological profile, standard SLE therapy should be initiated 3
• For patients with systemic manifestations, hydroxychloroquine is recommended for arthralgia, arthritis, or constitutional symptoms 4
• Short-term oral glucocorticoids may be considered for acute inflammatory manifestations 4
• For organ-threatening disease, immunosuppressive agents should be considered 4
• In patients with lupus nephritis, monitor anti-dsDNA levels and complement regularly as these correlate with disease activity 1

Common Pitfalls to Avoid

• Do not dismiss the possibility of SLE solely based on a negative ANA result when anti-dsDNA is positive 1, 5
• Avoid relying on a single method for anti-dsDNA detection; confirm with a second method (preferably CLIFT) 1
• Do not assume that all positive anti-dsDNA results indicate SLE, as false positives can occur with certain assays 5, 6
• Remember that anti-dsDNA antibodies may be present in ANA-negative patients with clinical SLE in approximately 12% of cases 5, 7
• Be aware that different laboratories use different methods and cutoffs for ANA and anti-dsDNA testing, affecting result interpretation 2

Long-term Monitoring

• If SLE is diagnosed, use anti-dsDNA (not ANA) to monitor disease activity 1
• A quantitative assay should be used for monitoring, preferably with the same method used in diagnosis and performed by the same laboratory 1
• Always use anti-dsDNA and complement levels in patient follow-up, even if they were negative/normal in previous monitoring visits 1
• Be aware that some patients lack correlation between serological results and clinical characteristics (serologically active but clinically quiescent SLE) 1