|Year : 2012 | Volume
| Issue : 1 | Page : 16-19
Anti golgi antibodies and cryoglobulins
Moushumi Lodh1, Debakanta Pradhan2, Manoranjan Sahoo3, Shantanu Das4
1 Department of Biochemistry, The Mission Hospital, Durgapur, West Bengal, India
2 Department of Microbiology, The Mission Hospital, Durgapur, West Bengal, India
3 Department of Medicine, The Mission Hospital, Durgapur, West Bengal, India
4 Department of Pulmonology, The Mission Hospital, Durgapur, West Bengal, India
|Date of Web Publication||10-Dec-2012|
Department of Biochemistry, Sr. Consultant and Head, Institute of Lab Medicine and Research, The Mission Hospital, Immon Kalyan Sarani, Sector 2C, Bidhannagar, Durgapur, West Bengal - 713 212
Source of Support: None, Conflict of Interest: None
Systemic autoimmune diseases are probably the greatest masqueraders in clinical medicine and dependence on laboratory testing is very high. Some of the antibodies directed to cytoplasmic autoantigens are well characterized, such as anti-mitochrondial, anti-ribosomal, anti-microsomal and anti-Golgi complex autoantibodies. Anti-Golgi autoantibodies are polyclonal and often mainly of the IgG isotype. We have detected cytoplasmic anti-Golgi antibody (AGA) and cryoglobulins in a 52 year old female admitted for hematuria and altered consciousness. She was a type 2 diabetes mellitus in urosepsis, with positive rheumatoid factor. Serum from the patient reacted to the Golgi complex by an indirect immunofluorescence technique on HEp-2 cells. The patient tested negative for viral serology and ANA. There were features of joint pain, absence of skin rashes, positive rheumatoid factor, negative ANA, positive anti Golgi antibodies along with features of sepsis. This led us to the diagnosis of Sjogren syndrome presenting with uremic encephalopathy and interstitial pneumonia. A positive anti Golgi antibody pattern must be looked for in an ANA negative patient with suspicious clinical features. We also review the earlier case reports on anti golgi antibodies available.
Keywords: Anti golgi antibodies, hep-2 cell line, indirect immunofluorescence
|How to cite this article:|
Lodh M, Pradhan D, Sahoo M, Das S. Anti golgi antibodies and cryoglobulins. Indian J Allergy Asthma Immunol 2012;26:16-9
| Introduction|| |
It is rare to detect autoantibodies specifically against antigens of the Golgi complex, an organelle involved in terminal processing, sorting and transporting of proteins to their final destinations. Anti-Golgi autoantibodies (AGAs) were reported mostly from sera of clinical patients with autoimmune diseases, especially Sjgren's syndrome (SS) and systemic lupus erythematosus (SLE). ,, It has been reported in non-autoimmune diseases like idiopathic late onset cerebellar ataxia and viral infections, e.g., Epstein-Barr virus (EBV) and human immunodeficiency virus.  Our case report is particularly important because the 52 year old female presented to the emergency department with complaints that did not suggest any underlying autoimmune disease. However ANA testing and anti golgi antibody testing, done routinely, helped us detect the autoimmune disorder that otherwise would have again escaped diagnosis.
| Case Report|| |
A 52 year old female was admitted with history of hematuria, abdominal pain, vomiting and fever since last 7 days and altered mental status for the last 3 days prior to admission. Patient complained of pain in the hand joints also since last six months.
On examination, there was mild pallor, edema, and bilateral crepts on both lung fields. Abdomen was soft, non tender.patient was drowsy and disoriented. Patient complained of weakness in the limbs and clumsiness since 6 months. There were findings of dryness of mouth, dry eyes (with specific ocular surface changes termed keratoconjunctivitis sicca), dryness of the nose, throat, skin, and vagina. The oral mucosa was dry and erythematous, saliva was not expressible. Laboratory tests revealed the following results (reference ranges in paranthesis).
Hemoglobin was 9.2 g/dl [12-15], Total leucocyte count was 11100/cmm [4000-10,000/cumm]. platelets and differential count were within reference ranges. ESR was 140 mm 1 st hour [5-15], RA factor was 30.38 IU/ml [upto 20] and CRP was 11.98 mg/L [upto 6 mg/L]. Other blood test results were as follows: urea 184 mg/dl (15-40), creatinine 4.9 mg/dl [0-1.5], AST 96 U/L (0-35), ALT 76 U/L (0-35), albumin 2.4 g/dl [3.5-5], total protein 6.6 g/dl [6.5-8.1]. Serum cryoglobulins were present [Figure 1]. The protein was soluble at 37 degrees C, and cryoglobulinemia was estimated by centrifugation after incubation at 4 degrees C for 7 days and confirmed by agarose gel electrophoresis and immunofixation to be mixed polyclonal cryoglobulinemia. Serology for HIV, HBsAg, HCV were negative. There was no history or evidence of past head and neck radiation treatment, preexisting lymphoma, sarcoidosis, graft versus host disease, use of anticholinergic drugs. Procalcitonin 3.29 ng/ml [<0.5], serum triglyceride 192 mg/dl [<150], phosphorus levels were 9.7 mg/dl [2.5-4.5] and calcium was 7 mg/dl [8.4-10.2]. Serum folate and vitamin B12 levels were within reference range. Serum ferritin levels were 862.8 ng/ml [10-200 ng/ml]. C3 69.8 mg/dl (90-180) and C4 complement level was 21.6 mg/dl (20-40) Anti CCP was negative at 1.2 U/ml [<5]. No anti-DNA antibody, or anti-Jo-1 antibody was detected. Antibodies against golgi apparatus was seen on Hep2 cells indirect immunofluorescence in a titre of 1:160 [Figure 2]. The fluorescence was of net-like granular structures lying at one side of the cell nucleus. Controls supplied with the kit are tested with each run (Homogenous pattern, Titre 1:128). IgG was 3000 mg/dl (700-1600), IgM 6000 mg/dl (40-230) and LDH 645 U/L (266-500). Anti-Ro 60(SS-A) autoantibodies were positive on line immunoassay and Enzyme immunoassay.
|Figure 1: Protein that precipitated at 4-6°C and dissolved on warming to 37°C|
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|Figure 2: Indirect immunofluorescence staining of anti-Golgi antibodies just outside the nuclear membrane of Hep-2 cells with the patient's serum. Crescent-shaped cytoplasmic organelles that surround the nuclear membrane of Hep-2 cells are considered to be Golgi apparatus. Linear-shaped cytoplasmic filaments are also seen and considered to be cytokeratins|
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Microscopic examination of urine revealed albumin, blood, plenty of pus cells and some bacteria. Urine culture revealed klebsiella pneumonia with a colony count >100000. Anaerobic and aerobic blood culture was negative for any organism. Cystatin c levels were 3 mg/L [0.18-1.9] and estimated GFR 16 ml/min/1.73 sq metre. Tear flow measurement by Shirmer's 1 test performed without anesthesia was positive (≤5 mm in 5 min). Echocardiography revealed global hypokinesia, LV dysfunction, moderate PAH. Ejection fraction was 50%. USG of the whole abdomen revealed hepatomegaly with fatty changes grade 1, and left kidney enlarged in size. Chest computed tomography showed interstitial pneumonia with fine reticular shadow and honeycombing in both lower lobes. Therefore, a clinical diagnosis of Sjogren syndrome presenting with uremic encephalopathy and interstitial pneumonia was made.
She was managed conservatively with antibiotics, nebulisation, diuretics, proper fluid and electrolyte management and other supportive measures and symptomatic treatment Ocular involvement, manifested as keratoconjunctivitis sicca, was managed with local and systemic stimulators of tear secretion (pilocarpine 5 mg thrice daily) methotrexate and prednisolone was given for arthralgia. Treatment of oral manifestations included intense oral hygiene, prevention and treatment of oral infections, use of saliva substitutes, and local and systematic stimulation of salivary secretion. She was discharged 12 days after admission, in a stable condition.
| Discussion|| |
ANA are found in 80% cases and Anti Ro (SSA) in 60-90% cases of Sjogren's syndrome. , The sensitivity, specificity, positive predictive value, and negative predictive value for ANA-IFA were 87.2, 48.0, 29.1, and 93.9%, respectively, for the reference range of <1:160.  We did not get ANA positivity on IFA at 1:160 titre, but on LIA and EIA, SSA antibodies were positive. About one in 20 sera (6-4%) produce a cytoplasmic IF stain.  Rodriguez et al., the first to report autoantibodies directed against the Golgi complex in the serum of a patient with Sjögren's syndrome (SS), confirmed the anti golgi specificity by histochemical studies and by demonstrating that pre-absorption of the patient's serum against isolated golgi cisternae abolished the distinct perinuclear fluorescence.  Since then, several isolated reports have described the presence of anti-Golgi antibodies (AGAs) in several connective tissue diseases (CTDs). Golgi apparatus is the target organelle in a subset of myopathies. , Mohan et al. described AGAs in patients with acute glomerulonephritis, acute viral hepatitis, non-hodgkin's lymphoma and deep vein thrombosis  and discussed virus induced autoimmunity.
As clinical features, our patient had mild liver dysfunction and interstitial pneumonia features also reported by other authors. , Yang et al. showed the existence of antigens in type II epithelial cells (A549) as well as in hepatoma cell lines (HLE) speculating that the existence of AGA might be related to liver dysfunction and the onset of interstitial pneumonia. AGA-positive cases have also been described in non-autoimmune diseases, particularly hepatic disorder.  High erythrocyte sedimentation rate, Cryoglobulinemia, positive rheumatoid factor, polyclonal hyperglobulinemia is features of secondary Sjogren's syndrome. Ramos et al. reported presence of cryoglobulins in sera of 16% of patients with primary Sjogren's Syndrome.
Autoantibodies to nuclear antigens can be identified only by IFA due to their compartmentalization and higher localized antigen density in HEp2 cells.  During this screening we did not find any nuclear pattern but found Golgi complex pattern in the cytoplasm of HEp-2 cells. The indirect immunofluorescence (IIF) microscopy for ANAs is the gold standard for sensitivity in detecting ANAs and is usually used as the initial screening test. Tissue culture cells lines, such as the human laryngeal epithelioma cancer cell line (Hep-2 cells), are used most commonly in IIF testing, since such cell lines are more efficient substrates, have large nuclei and nucleoli, have a higher frequency of certain antigens, and are less costly. 
In general, anticytoplasmic antibodies are not disease specific; certain characteristic patterns on immunofluorescence assay (IFA) are of more diagnostic help than others. Furthermore, a negative ANA result may sometimes be misleading if the cytoplasmic IFA is ignored. We would strongly recommend including autoantibody testing by IFA as part of routine laboratory testing.
According to revised international classification criteria  for sjogren's syndrome, we diagnosed the case as Sjogren's syndrome based on oral symptoms, ocular symptoms, ocular sign of Schirmer test positivity and anti SSA positivity in serum, along with exclusion of HIV, HBsAg, HCV infection, past head and neck radiation treatment, preexisting lymphoma, sarcoidosis, graft versus host disease, use of anticholinergic drugs.
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[Figure 1], [Figure 2]