Table 2

Cytoplasmic HEp-2 IIFA patterns

CodeAC pattern–—clinical relevanceRefs
AC-15FIBRILLAR LINEAR (see online supplementary table S2 for further details)
  • Found in patients with AIH type 1, chronic HCV infection, and celiac disease (IgA isotype); rare in SARD

17
  • If AIH type 1 is clinically suspected, it is recommended to confirm reactivity with smooth muscle antibodies (IgG isotype), typically detected by IIFA on rodent tissue (liver, stomach, kidney); anti-smooth muscle antibodies are included in the international criteria for AIH type 1

17,80
  • F-actin is the main target antigen of anti-smooth muscle antibodies in AIH type 1; autoantibodies to F-actin are of more clinical importance than antibodies to G-actin

81–83
Notes: Although anti-F-actin immunoassays are commercially available, technical issues relating to the sensitivity of these immunoassays should be taken into consideration.
AC-16FIBRILLAR FILAMENTOUS (see online supplementary table S2 for further details)
  • Found in various diseases, but AC-16 is not typically found in SARD

  • Antigens recognized include cytokeratins 8, 18, & 19, tubulin, and vimentin; specific immunoassays for these autoantibodies are currently not commercially available

AC-17FIBRILLAR SEGMENTAL (see online supplementary table S2 for further details)
  • Found very infrequently in a routine serology diagnostic setting

  • Antigens recognized include α-Actinin and Vinculin; specific immunoassays for these autoantibodies are currently not commercially available

AC-18DISCRETE DOTS (see online supplementary table S2 for further details)
  • Autoantibodies revealing the AC-18 pattern have been reported in distinct SARD and in a variety of other diseases; their prevalence in unselected or specified disease cohorts has not been thoroughly studied

84
  • Antigens recognized include GW-body (Processing or P body) antigens (Ge-1/Hedls, GW182, and Su/Ago2) and endosomal antigens (EEA1, CLIP-170, GRASP-1, and LBPA); specific immunoassays for these autoantibodies are currently not commercially available

Notes: Autoantibodies to GW-bodies and endosomes may yield slightly different HEp-2 IIFA patterns. 84, 85
AC-19DENSE FINE SPECKLED (see online supplementary table S2 for further details)
  • Found in patients with SLE and the anti-synthetase syndrome (a subset of AIM), interstitial lung disease, polyarthritis, Raynaud’s phenomenon, and mechanic’s hands; these features may occur in various combinations or as an isolated manifestation, especially interstitial lung disease

33, 86, 87
  • If SLE is clinically suspected, follow-up tests for antibodies to ribosomal P phosphoproteins (P0, P1, P2, C22 RibP peptide) are recommended; these antigens may be included in the routine ENA profile

  • Anti-RibP antibodies have been associated in some studies with neuropsychiatric lupus, and in childhood-onset SLE with autoimmune hemolytic anemia

86, 88, 89
  • If AIM, in particular the anti-synthetase syndrome, is suspected, it is recommended to perform follow-up tests for antibodies to tRNA synthetases; antigens are included in disease specific immunoassays (ie, inflammatory myopathy profile*)

26, 33
  • If AIM, in particular necrotizing myopathy, is suspected, it is recommended to perform follow-up tests for anti-SRP antibodies; the antigen is included in disease specific immunoassays (ie, inflammatory myopathy profile*)

26
Notes: The fine distinction between AC-19 and -20 may depend on HEp-2 substrates and/or antibody concentration; antibodies to both RibP as well as tRNA synthetases may be undetected in HEp-2 IIFA-screening.
AC-20FINE SPECKLED
  • Found in patients with the anti-synthetase syndrome (a subset of AIM), interstitial lung disease, polyarthritis, Raynaud’s phenomenon, and mechanic’s hands; these features may occur in various combinations or as an isolated manifestation, especially interstitial lung disease

33, 90
  • Autoantibodies associated with the AC-20 pattern are primarily reported for the anti-Jo-1 antibody, which recognizes histidyl-tRNA synthetase; since AC-20 is not specific for Jo-1, it is recommended to perform a follow-up test for anti-Jo-1 antibodies; the antigen is included in the routine ENA profile, as well as in disease specific immunoassays (i.e., inflammatory myopathy profile*); the anti-Jo-1 antibodies are included in the classification criteria for AIM

91, 92
Notes: The fine distinction between AC-19 and -20 may depend on HEp-2 substrates and/or antibody concentration; antibodies to Jo-1 may be undetected in HEp-2 IIFA-screening.
AC-21RETICULAR/AMA
  • Commonly found in PBC, but also detected in SSc, including PBC-SSc overlap syndrome and PBC-SjS overlap syndrome

93–97
  • If PBC is clinically suspected it is recommended to perform a follow-up test for AMA, historically detected by IIFA on rodent tissue (liver, stomach, kidney); these autoantibodies are primarily directed to the PDH complex, and in particular the E2-subunit (PDH-E2); the antigen is included in disease specific immunoassays (i.e., liver profile*) as well as in some routine ENA profiles

93, 94
  • Additional antigens recognized include the E1α and E1β subunits of PDH, the E3-binding protein of PDH, and the 2-OGDC; these antigens are only included in extended disease specific immunoassays (i.e., extended liver profile*)

93, 94
AC-22POLAR/GOLGI-like (see online supplementary table S2 for further details)
  • Found in small numbers of patients with a variety of conditions

  • Antigens recognized include giantin/macrogolgin and distinct golgin molecules; specific immunoassays to detect autoantibodies directed to specific Golgi antigens are currently not commercially available

85
AC-23RODS and RINGS (see (online supplementary table S2 for further details)
  • Most commonly found in HCV patients who have been treated with pegylated interferon-α/ribavirin combination therapy, but autoantibodies revealing the AC-23 patterns were undetected prior to treatment; as the use of interferon-α/ribavirin in HCV treatment is decreasing, the frequency and clinical associations of the AC-23 pattern may change

98–101
  • Specific immunoassays to detect autoantibodies directed to specific Rods and Rings antigens, for instance IMPDH2, are not commercially available

Note: Presence of the AC-23 pattern depends on the HEp-2 cell substrate.
  • *Availability of the inflammatory myopathy profile, the SSc profile and the (extended) liver profile may be limited to specialty clinical laboratories.

  • AIH, autoimmune hepatitis; AIM, autoimmune myopathy; AMA, anti-mitochondrial antibodies; APS, antiphospholipid syndrome; Ago, argonaute protein; CENP, centromere-associated protein; CLIP, class II-associated invariant chain peptide; DFS, dense fine speckled; DM, dermatomyositis; EEA, early endosome antigen; ENA, extractable nuclear antigens; HCV, hepatitis C virus; IFA, indirect immunofluorescence assay; LAP, lamin-associated polypeptide; LBR, lamin B receptor; LEDGF, lens epithelial derived growth factor; NOR, nucleolus organizer region; NXP, nuclear matrix protein; PBC, primary biliary cholangitis; PCNA, proliferating cell nuclear antigen; PML, promyelocytic leukaemia; PM/Scl, polymyositis-scleroderma; RA, rheumatoid arthritis; RNApol, ribonucleic acid polymerase; RNP, ribonucleoprotein; SARD, systemic autoimmune rheumatic diseases; SLE, systemic lupus erythematosus; SMN, survival of motor neuron; SRP, signal recognition protein; SSc, systemic sclerosis; SjS, Sjögren’s syndrome; TIF, transcription intermediary factor; TRIM, tripartite motif; Tpr, translocated promoter region; dsDNA, double stranded deoxyribonucleic acid; hUBF, human upstream binding factor; tRNA, transfer ribonucleic acid.