Download Update on Laboratory Testing in Non

Arash Maleki, MD
Rasool Akram Hospital
Iran University of Medical Sciences (IUMS)
April 21, 2016
Uveitis
 Uveitis refers to a collection of about 30 diseases
characterized by intraocular inflammation.
The Confusion
• Uveitis
can be the first manifestation of a disease
or a diagnosis-clinching disease feature.
• In one study, only 17% of patients had definitive
diagnosis at initial presentation.
• Ultimately diagnosis or strongly suspected in
65%.
• 85% of these patients were diagnosed during the
longitudinal care based on repeated clinical and
laboratory evaluations.
The Frustration
• Negative work-up, labeled as “Idiopathic
Uveitis” has been reported up to 35% in
previous studies.
• Repeated review of medical history,
medical symptoms, ocular and systemic
examinations, and serologic evaluation can
be revealing in these patients.
Systematic Approach
 Location
 Course
 Clinicopathologic characteristics
 Patient age
 Social and geographic characteristics
 Source of inflammation (Host/systemic disease)
Diagnostic approach
 History taking and RoS
 Eye examination
 Extraocular examination
 Laboratory evaluation
Laboratory Evaluation
 Screening (syphilis, lyme disease, TB) Versus
(toxoplasmosis and HSV)
 More targeted testing (Bartonella)
 A key conception for the test is PPV.
 Two reasons for laboratory testing include: infections
and systemic diseases. HLA-B27 and ANA
Laboratory Evaluation
• Laboratory testing is limited to those studies to be of some
reasonable diagnostic value.
• General battery of tests is inappropriate.
• Extensive laboratory testing or referral to internists and
primary care physicians is not recommended.
• However, more extensive work-up is recommended in
recurrent uveitis (3 or more), granulomatous uveitis,
posterior uveitis, and postive RoS.
Laboratory Evaluation
 When there is no diagnostic clues, no work up is
recommended with the first episode of non-granulomatous
uveitis in adults. However, these patients should be
followed regularly for a positive hint.
 Basic laboratory studies include: CBC and differentiation,
basic metabolic panel, urinalysis, and ESR.
 Recurrent uveitis in the absence of a clue warrants
invetigation that includes: CBC, ESR, PPD or quantiferon
gold serum testing, HLA-B27, and FTA-ABS.
Laboratory Evaluation
 Subsequent testing is based on the results of screening
testing.
Common Tests in Non-infectious
Uveitis
 ESR
 ACE and Lysozyme
 ANCA (C, P, and atypical)
 Anti-phospholipid antibodies
 C3, C4, CH50
 Properdin factor B
 Soluble IL-2 receptor
 Raji cell assay
 C1q binding assay
 C-reactive protein (CRP)
 α1-acid glycoprotein
Common Tests in Non-infectious
Uveitis
 HLA typing
 RF and anti-CCP
 FTA-ABS or MHA-TP
 ILs levels (IL-6, IL-8, IL-10, and IL-12) especially IL-9, IL-10, and IL-17
 Hepatitis serology
 PCR
 PPD or QuantiFERON gold
Granulomatous Uveitis
 CBC and ESR
 ACE and Lysozyme
 + work-up for infectious uveitis
Posterior involvement and
Retinal Vasculitis
 CBC and ESR
 Soluble IL-2 receptor
 Raji cell assay
 C1q binding assay
 + Work-up for infectious uveitis
Genetic advances in Uveitis (GWAS)
 Genes encoding for HLAs, IL-23R, IL-10, STAT, STAT3, and
UBAC2 can be promising testing in the future. (Genome-wide
association studies)
Hou S, Kijlstra A, Yang P. Molecular Genetic Advances in Uveitis. Prog Mol Biol Transl Sci. 2015;134:283-98.
Dunn JP. Uveitis. Prime care. 2015;42(3):305-23.
Selmi C. Diagnosis and classification of autoimmune uveitis. Autoimmun Rev. 2014;13(4-5):591-4.
Conclusion
 Basic laboratory studies include: CBC and
differentiation, basic metabolic panel, urinalysis, and
ESR.
 Laboratory tests should be targeted and battery of
tests is not appropriate.
 Laboratory tests are not only for diagnosis but also for
prognosis and treatment.