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Rheumatology · Test interpreter

Rheumatology serologies: what to order and what it means

Pick the presentation to get the panel that fits and what not to order, or enter results to see what they mean in this patient. A positive test in a patient without the matching features is often a false or bystander positive. Adults only.

Order presentation → panel + do-not-orderInterpret result + context → meaningSafety lines: GCA vision, pulmonary–renal, renal crisis, hot jointReviewed Oct 2026

1Mode

Results entered in Interpret are kept when you switch to Order; a note there counts them and offers a Clear button. The clinical picture and ANA carry across both modes.

2Clinical picture tick all that apply

Red flags

Context

Anticoagulant now needed for lupus anticoagulant

3ANA, if already done

HEp-2 indirect immunofluorescence. Titers do not apply to solid-phase ANA screens.

How it works

Pre-test probability, in one paragraph

A test result changes the odds you started with; it does not replace them. Post-test odds = pre-test odds × likelihood ratio. When the pre-test probability is low, even a specific test produces more false positives than true positives. Example with the anti-CCP likelihood ratio from Nishimura 2007 (LR+ 12.46): at a 2% pre-test probability a positive result gives about 20%; at 30% it gives about 84%. ANA is the extreme case: 13.3% of healthy adults are positive at 1:80 (Tan 1997), and SLE is rare, so most positive ANAs in people without lupus features are not lupus. See the likelihood ratios guide.

Classification criteria are not diagnostic criteria

The ACR/EULAR criteria for RA (2010), SLE (2019), Sjögren (2016), systemic sclerosis (2013), myositis (2017), APS (2023) and GCA (2022) were built to select uniform patients for studies. This tool quotes their antibody weights because they show how much each result counts, not to label a patient. A patient can have the disease without meeting criteria, and meet criteria without having it. The PMR 2012 paper says so directly: the criteria “are not meant for diagnostic purposes.”

ANA titer and ICAP pattern
HEp-2 titerHealthy adults positive (Tan 1997)
1:4031.7%
1:8013.3%
1:1605.0%
1:3203.3%

ICAP advises that, except for the centromere pattern (AC-3), each pattern needs an antigen-specific test before it is tied to a disease. The dense fine speckled pattern (AC-2) points away from systemic autoimmune disease only when the antibody is confirmed as anti-DFS70 and no other ENA antibody is present. Anti-SSA/Ro (Ro60), anti-Jo-1 and other myositis antibodies can be missed on HEp-2 screening, and cytoplasmic patterns may be reported as ANA-negative depending on the laboratory.

Antiphospholipid rules (2023 ACR/EULAR)

Laboratory points need at least one positive aPL within 3 years of a clinical criterion, and 3 or more points in both the clinical and the laboratory domains. Lupus anticoagulant: 1 point for a single positive, 5 for persistent. Anticardiolipin or anti-β2-glycoprotein I by ELISA, persistent: IgM moderate or high 1; IgG moderate (40–79 units) 4; IgG high in one 5; IgG high in both 7. Persistent means positive on 2 occasions at least 12 weeks apart. Moderate is 40–79 units and high is 80 units or more (Methods and Table 3 footnote; Table 1 prints “>80”, but 80 cannot be moderate). Lupus anticoagulant results taken on anticoagulation count only if a laboratory LA expert reviews and confirms them.

Not covered
  • Children and adolescents (ANA in JIA, uveitis screening): adults only.
  • IgG4, cryoglobulin typing, aldolase, CH50, anti-histone, anti-ribosomal P, anti-C1q, Ro52 versus Ro60, anti-PM/Scl, anti-Th/To, anti-U3-RNP, anti-SAE, anti-Ku, anti-mitochondrial and liver antibodies.
  • ICAP patterns other than those listed (AC-6, AC-7, AC-11 to AC-28, mixed patterns): read them with your laboratory.
  • Interpreting hepatitis B and C, HIV or parvovirus results (the tool says when to send hepatitis serology, not how to read it); Lyme testing beyond the Choosing Wisely limit.
  • Anti-GBM titer levels and assay differences, kidney biopsy reading, and urine sediment.
  • Treatment of any disease named here. For anticoagulation in APS, use the VTE treatment tool.
  • Cancer screening details for myositis antibodies (see IMACS 2023), and fetal echocardiography schedules for anti-SSA/Ro pregnancies (see ACR 2020 reproductive health guideline).
  • Crystal arthritis and synovial fluid analysis.
Versions and what was left out

Checked 21 October 2026 (revised after an independent audit): EULAR 2025 PMR/large-vessel vasculitis recommendations (published July 2026) for GCA timing; ACR 2021 GCA guideline; KDIGO 2024 ANCA vasculitis with the KDOQI 2026 US commentary; 2017 and 2020 ANCA testing consensus statements; EULAR 2023 systemic sclerosis update; ACR/CHEST 2023 ILD guidelines; 2023 ACR/EULAR APS criteria; ISTH 2020 lupus anticoagulant guidance. Also KDIGO 2021 glomerular diseases and KDIGO 2022 hepatitis C in CKD for hepatitis and cryoglobulin testing. Infection mimics of ANCA vasculitis (endocarditis, hepatitis C, tuberculosis) and ANCA-inducing drugs are sourced to Bossuyt 2017 p. 690 and KDOQI 2026. Still expert opinion: cryoglobulin testing for purpura or neuropathy without kidney involvement. Left out because they could not be verified: pooled ANCA sensitivity figures, complement causes other than SLE, aldolase, any fetal monitoring schedule, and the BSR 2006 recommendation grades.

Sources

  1. Tan EM, Feltkamp TE, Smolen JS, et al. Range of antinuclear antibodies in “healthy” individuals. Arthritis Rheum 1997;40(9):1601–11 (HEp-2 IIF, 15 laboratories: positive in 31.7% at 1:40, 13.3% at 1:80, 5.0% at 1:160, 3.3% at 1:320). doi:10.1002/art.1780400909
  2. Damoiseaux J, Andrade LEC, Carballo OG, et al. Clinical relevance of HEp-2 indirect immunofluorescent patterns: the International Consensus on ANA patterns (ICAP) perspective. Ann Rheum Dis 2019;78(7):879–89 (Tables 1–2, AC-1 to AC-29). doi:10.1136/annrheumdis-2018-214436
  3. Aringer M, Costenbader K, Daikh D, et al. 2019 EULAR/ACR classification criteria for systemic lupus erythematosus. Arthritis Rheumatol 2019;71(9):1400–12 (Table 1 definitions, Table 2 weights; ANA ≥1:80 entry criterion, sensitivity 97.8% by meta-regression). doi:10.1002/art.40930
  4. American College of Rheumatology. Choosing Wisely: Five things physicians and patients should question, 21 February 2013 (#1 ANA sub-serologies; #2 Lyme testing). ACR pediatric rheumatology Choosing Wisely list, 2013: “Don’t repeat a confirmed positive ANA in patients with established JIA or SLE” (as reported by Ullman K, The Rheumatologist, 1 November 2013; secondary).
  5. Choosing Wisely Canada / Canadian Rheumatology Association. Nine tests and treatments to question in rheumatology, version 4.0, May 2025 (#1 ANA screening, #2 HLA-B27, #9 RF and ACPA).
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  11. KDIGO 2022 Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in CKD. Kidney Int 2022;102(6S):S129–S205 (Recommendation 1.1.1, 1C: screen for HCV at initial CKD evaluation; Recommendation 5.1 and Figure 4: hematuria, low C4, circulating cryoglobulins, systemic signs of cryoglobulinemia and rheumatoid factor mark typical HCV-associated glomerulonephritis). doi:10.1016/j.kint.2022.07.013
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  13. KDIGO 2024 Clinical Practice Guideline for the Management of ANCA-Associated Vasculitis. Kidney Int 2024;105(3S):S71–S116 (Practice Point 9.1.1; Figure 1 biopsy strategy; Figure 3 RPGN work-up: ANCA, ANA, anti-GBM, complement, exclude infection; anti-GBM text). doi:10.1016/j.kint.2023.10.008
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Educational reference only — not a substitute for clinical judgment, institutional protocols, or specialist advice. Calculations run in your browser; nothing you enter is sent or stored.