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Test Code ADE Autoimmune Dysautonomia Evaluation, Serum

Useful For

Investigating idiopathic dysautonomic symptoms

 

Directing a focused search for cancer in patients with idiopathic dysautonomia

 

Investigating autonomic symptoms that appear in the course or wake of cancer therapy and are not explainable by recurrent cancer or metastasis (detection of autoantibodies in this profile helps differentiate autoimmune dysautonomia from the effects of chemotherapy)

Profile Information

Test ID Reporting Name Available Separately Always Performed
ADEI Dysautonomia, Interpretation, S No Yes
ANN1S Anti-Neuronal Nuclear Ab, Type 1 No Yes
STR Striational (Striated Muscle) Ab, S Yes Yes
CCN N-Type Calcium Channel Ab No Yes
ARBI ACh Receptor (Muscle) Binding Ab Yes Yes
GANG AChR Ganglionic Neuronal Ab, S No Yes
VGKC Neuronal (V-G) K+ Channel Ab, S No Yes
GD65S GAD65 Ab Assay, S Yes Yes
CCPQ P/Q-Type Calcium Channel Ab No Yes

Testing Algorithm

If indirect immunofluorescence assay (IFA) (ANN1S) patterns are indeterminate, then paraneoplastic autoantibody Western blot is performed at an additional charge.

 

If IFA patterns suggest CRMP-5-IgG, then CRMS and/or CRMP-5-IgG Western blot is performed at an additional charge.

 

If IFA patterns suggest amphiphysin antibody, then AMPHS and/or amphiphysin Western blot is performed at an additional charge.

 

If IFA pattern suggests antineuronal nuclear antibody type 2 or type 3, Purkinje cell cytoplasmic antibody type 1, type 2, or type trace, and/or anti-glial nuclear antibody type 1, then ANN2S, ANN3S, PCABP, PCAB2, PCATR, and/or AGN1S is performed at an additional charge.

 

If IFA pattern suggests NMO/AQP4-IgG, then NMO/AQP4-IgG FACS is performed at an additional charge.

 

If NMO/AQP4-IgG FACS screen requires further evaluation, then NMO/AQP4-IgG FACS titration is performed at an additional charge.

 

If IFA pattern suggests NMDA-R, then NMDA-R CBA and/or NMDA-R titer is performed at an additional charge.

 

If IFA pattern suggests AMPA-R, then AMPA-R CBA and/or AMPA-R titer is performed at an additional charge.

 

If IFA pattern suggests GABA-B-R, then GABA-B-R CBA and/or GABA-B-R titer is performed at an additional charge.

 

If acetylcholine (Ach) receptor binding antibody is >0.02, then ACh receptor modulating antibodies and CRMP-5-IgG Western blot are performed at an additional charge.

 

If VGKC >0.00, LGI1-IgG CBA, S and CASPR2-IgG CBA, S are performed at an additional charge.

                                                                                                                                             

See Autoimmune Dysautonomia Evaluation Testing Algorithm in Special Instructions

Method Name

CCN, GD65S, ARBI, ARMO, GANG, VGKC, CCPQ: Radioimmunoassay (RIA)

WBN, ABLOT: Western Blot

ANN1S, ANN2S, ANN3S, PCABP, PCAB2, PCATR, AMPHS, CRMS, AGN1S, AMPIS, NMDIS, GABIS: Indirect Immunofluorescence Assay (IFA)

STR: Enzyme Immunoassay (EIA)

NMDCS, AMPCS, GABCS, LG1CS, CS2CS: Cell-Binding Assay (CBA)

NMOFS, NMOTS: Flow Cytometry

Reporting Name

Autoimmune Dysautonomia Eval, S

Specimen Type

Serum


Necessary Information


Include relevant clinical information, name, phone number, mailing address, and e-mail address (if applicable) of ordering physician.



Specimen Required


Container/Tube:

Preferred: Red top

Acceptable: Serum gel

Specimen Volume: 4 mL


Seattle Children's Hospital Note:

Collect 4 - 8 mL whole blood in Red or Gold Top.

Specimen Minimum Volume

2 mL

Specimen Stability Information

Specimen Type Temperature Time
Serum Refrigerated (preferred) 28 days
  Frozen  28 days
  Ambient  72 hours

Reject Due To

Hemolysis

Mild OK; Gross reject

Lipemia

Mild OK; Gross reject

Icterus

Mild OK; Gross reject

Other

NA

Reference Values

CATION CHANNEL ANTIBODIES

N-Type Calcium Channel Antibody

≤0.03 nmol/L

P/Q-Type Calcium Channel Antibody

≤0.02 nmol/L

AChR Ganglionic Neuronal Antibody

≤0.02 nmol/L

Neuronal VGKC Autoantibody

≤0.02 nmol/L

Glutamic Acid Decarboxylase (GAD65) Antibody                            

≤0.02 nmol/L

 

NEURONAL NUCLEAR ANTIBODIES

Antineuronal Nuclear Antibody-Type 1 (ANNA-1)

<1:240

Antineuronal Nuclear Antibody-Type 2 (ANNA-2)

<1:240

Antineuronal Nuclear Antibody-Type 3 (ANNA-3)

<1:240

Anti-Glial/Neuronal Nuclear Antibody-Type 1 (AGNA-1)

<1:240

 

NEURONAL AND MUSCLE CYTOPLASMIC ANTIBODIES

Purkinje Cell Cytoplasmic Antibody, Type 1 (PCA-1)

<1:240

Purkinje Cell Cytoplasmic Antibody, Type 2 (PCA-2)

<1:240

Purkinje Cell Cytoplasmic Antibody, Type Tr (PCA-Tr)

<1:240

Amphiphysin Antibody

<1:240

CRMP-5-IgG

<1:240

Note: Titers lower than 1:240 are detectable by recombinant CRMP-5 Western blot analysis. CRMP-5 Western blot analysis will be done on request on stored serum (held 4 weeks). This supplemental testing is recommended in cases of chorea, vision loss, cranial neuropathy, and myelopathy. Call the Neuroimmunology Laboratory at 800-533-1710 or 507-266-5700 to request CRMP-5 Western blot.

 

Striational (Striated Muscle) Antibodies

<1:120

 

ACHR RECEPTOR ANTIBODIES

ACh Receptor (Muscle) Binding Antibody

≤0.02 nmol/L

AChR Receptor (Muscle) Modulating Antibody

0-20% loss of AChR

 

Neuromyelitis Optica (NMO)/Aquaporin-4-IgG FACS Assay

Negative

 

Paraneoplastic Western Blot

Negative

CRMP-5-IgG Western Blot       

Negative

Amphiphysin Western Blot

Negative

 

N-Methyl-D-aspartate receptor (NMDA-R)

CBA: Negative

IFA: <1:120

2-amino-3-(5-methyl-3-oxo-1,2- oxazol-4-yl) propanoic acid receptor (AMPA-R)

CBA: Negative

IFA: <1:120                    

Gamma-Amino Butyric acid-type B receptor (GABA-B-R)

CBA: Negative

IFA <1:120

Leucine-Rich Glioma Inactivated Protein-1 IgG (LGI1)

Negative

Contactin-Associated Protein-Like-2 IgG (CASPR2)

Negative

Method Description

Indirect Immunofluorescence Assay (IFA):

Before testing, patient's serum is preabsorbed with liver powder to remove nonorgan-specific autoantibodies. After applying to a composite substrate of frozen mouse tissues (brain, kidney, and gut) and washing, fluorescein-conjugated goat antihuman IgG is applied to detect the distribution and pattern of patient IgG binding.(Pittock SJ, Kryzer TJ, Lennon VA: Paraneoplastic antibodies coexist and predict cancer, not neurological syndrome. Ann Neurol 2004;56:715-719)

 

Radioimmunoassay (RIA):

Goat antihuman IgG and IgM is used as precipitant in all assays. Cation channel protein antigens are solubilized from neuronal or muscle membrane, in nonionic detergent, and complexed with a selective high-affinity ligand labeled with iodine.(I) I-labelled recombinant human glutamic acid decarboxylase (GAD65) antigen is used to confirm GAD65 autoantibody (when suspected from immunofluorescent staining pattern).(Griesmann GE, Kryzer TJ, Lennon VA: Autoantibody profiles of myasthenia gravis and Lambert-Eaton myasthenic syndrome. In Manual of Clinical and Laboratory Immunology, Sixth edition. Edited by NR Rose, RG Hamilton, et al. Washington, DC, ASM Press, 2002, pp 1005-1012; Walikonis JE, Lennon VA: Radioimmunoassay for glutamic acid decarboxylase [GAD65] autoantibodies as a diagnostic aid for stiff-man syndrome and a correlate of susceptibility to type 1 diabetes mellitus. Mayo Clin Proc 1998;73[12]:1161-1166)

 

Muscle acetylcholine receptor (AChR) modulating antibodies are detected by incubating the patient's serum for 14 hours with viable, noninnervated, monolayer cultures of human muscle cells. Percent loss of surface AChR is quantitated by probing with (125)I-alpha-bungarotoxin.(Howard FM Jr, Lennon VA, Finley J, et al: Clinical correlations of antibodies that bind, block, or modulate human acetylcholine receptors in myasthenia gravis. Ann NY Acad Sci 1987;505:526-538)

 

Enzyme Immunoassay (EIA):

A mixture of sarcomeric proteins extracted from innervated rat skeletal muscle is used as antigen to detect striational antibodies (IgG, IgM, and IgA).(Cikes N, Momoi MY, Williams CL, et al: Striational autoantibodies: quantitative detection by enzyme immunoassay in myasthenia gravis, thymoma, and recipients of D-penicillamine or allogeneic bone marrow. Mayo Clin Proc 1988;63:474-481)

 

Western Blot (WB):

WB is performed when immunofluorescence assay screening for antineuronal nuclear antibody-type 1 is not interpretable due to interfering autoantibodies. A mixture of neuronal antigens extracted aqueously from adult rat cerebellum is denatured, reduced, and separated by electrophoresis on 10% polyacrylamide gel. Full-length recombinant human CRMP-5 antigen is used to confirm CRMP-5-IgG.(Yu Z, Kryzer TJ, Griesmann GE, et al: CRMP-5 neuronal autoantibody: marker of lung cancer and thymoma-related autoimmunity. Ann Neurol 2001;49[2]:145-154)

 

Cell Binding Assay (CBA):

Patient serum is applied to a composite slide containing transfected and nontransfected HEK-293 cells. After incubation and washing, fluorescein-conjugated goat-antihuman IgG is applied to detect the presence of patient IgG binding.(Package insert: EUROIMMUN AG. Stocker W. et al: Differenzierte Autoantikorper-Diagnostik mit BIOCHIP-Mosaiken. U Conrad, K. [Hrsg] Autoantikorper. Pabst-Verlag [1998] 78-99)

 

NMO-IgG Fluorescence-Activated Cell Sorting Assay (FACS):

Human embryonic kidney cells (HEK 293) are transfected transiently with a plasmid (pIRES2-Aequorea coerulescens green fluorescent protein [AcGFP]) encoding both green fluorescent protein (AcGFP) and AQP4-M1. After 36 hours, a mixed population of cells (transfected expressing AQP4 on the surface and AcGFP in the cytoplasm and nontransfected lacking AQP4 and AcGFP) are lifted and resuspended in live cell-binding buffer. Patient serum is then added to cells at a 1 in 5 screening dilution. After incubation and washing, the cells are resuspended in secondary antibody (AlexaFluor 647-conjugated goat-antihuman IgG; 1:2000 in LCBB), held on ice, washed, fixed with 4% paraformaldehyde, and analyzed by flow cytometry (BD FACSCanto; Becton, Dickinson and Co). Two populations are gated on the basis of AcGFP expression: positive (high AQP4 expression) and negative (low or no AQP4 expression). The median Alexafluor 647 fluorescence intensity (MFI) for the AcGFP-positive population indicates relative abundance of human IgG potentially bound to AQP4 surface epitopes; MFI for the GFP-negative population indicated nonspecifically-bound IgG. The IgG binding index is calculated as the ratio of the average MFI for duplicate aliquots of each cell population (MFI GFP positive/MFI GFP negative).We established conservative cutoff IgG binding index values of 2.00 for M1-FACS.

 

If FACS assay is positive at screening dilution, then NMOTS / Neuromyelitis Optica (NMO)/Aquaporin-4-IgG Fluorescence-Activated Cell Sorting (FACS) Titer Assay, Serum is performed at an additional charge. The patient serum is titrated to endpoint. The dilution where the IgG binding index is ≥2, is considered the endpoint dilution. If a patient is positive at a 1:5 dilution, but negative at 1:10 dilution, the endpoint will be reported as 5.

Day(s) and Time(s) Performed

ANN1S-1, ANN2S, ANN3S, PCABP, PCAB2, PCATR, AMPHS, CRMS, AGN1S, NMDIS, AMPIS, GABIS: Monday through Friday; 11:30 a.m. and 8 p.m.; Saturday and Sunday 8 a.m.

Striational (striated muscle) antibodies: Monday through Friday; 4 a.m. and 3 p.m.; Saturday 6 a.m.

N-type calcium channel antibody: Monday through Friday 11 a.m. and 6 p.m.; Saturday 6 a.m.; Sunday 6:00 a.m.

Acetylcholine receptor (muscle AChR) binding antibody: Monday through Friday 11 a.m., 6 p.m., and 10 p.m.; Saturday 6 a.m.; Sunday 6 a.m. and 10 a.m.

Ganglionic acetylcholine receptor (alpha3) autoantibody: Monday through Friday 11 a.m. and 6 p.m.; Saturday 6 a.m.; Sunday 6 a.m.

Neuronal (VGKC) autoantibody: Monday through Friday 11 a.m. and 6 p.m.; Saturday 6 a.m.; Sunday 6 a.m.

GAD65 antibody assay: Monday to Friday; 6 a.m. and 4 p.m.

P/Q-type calcium channel antibody: Monday through Friday 11 a.m. and 6 p.m.; Saturday 6 a.m.; Sunday 6 a.m.

Paraneoplastic autoantibody Western blot: Monday, Wednesday, Friday; 8 a.m.

Acetylcholine receptor (muscle) modulating antibodies: Monday through Thursday, Saturday; 12 p.m., Saturday; 8 a.m.

CRMP-5-IgG Western blot: Monday, Wednesday, Friday; 8 a.m.

Amphiphysin Western blot: Monday, Wednesday, Friday; 8 a.m.

NMDCS, AMPCS, GABCS, LGICS, CS2CS: Monday through Friday; 6 a.m.

NMO/AQP4 IgG FACS: Monday, Tuesday, Thursday; 6 p.m.

Seattle Children's Hospital Note:

TAT: 9 - 12 days

Performing Laboratory

Mayo Medical Laboratories in Rochester

Test Classification

See Individual Test IDs

CPT Code Information

83519-ACh receptor (muscle) binding antibody

83519-AChR ganglionic neuronal antibody

83519-Neuronal VGKC autoantibody

83519-N-type calcium channel antibody

83519-P/Q-Type Calcium Channel Ab

83520-Striational (striated muscle) antibodies

86255-AGNA-1 (if appropriate)

86255-Amphiphysin (if appropriate)

86255-ANNA-1

86255-ANNA-2 (if appropriate)

86255-ANNA-3 (if appropriate)

86255-CRMP-5-IgG (if appropriate)

86255-PCA-1 (if appropriate)

86255-PCA-2(if appropriate)

86255-PCA-Tr (if appropriate)

86341-GAD65 antibody assay

83519-ACh receptor (muscle) modulating antibodies (if appropriate)

84182-Paraneoplastic autoantibody Western blot confirmation (if appropriate)

84182-CRMP-5-IgG Western blot (if appropriate)

84182-Amphiphysin Western Blot (if appropriate)

86255-NMO/AQP4-IgG FACS (if appropriate)

86255-AMPCS (if appropriate)

86255-GABCS (if appropriate)

86255-NMDCS (if appropriate)

86256-AMPIS (if appropriate)

86256-GABIS (if appropriate)

86256-NMDIS (if appropriate)

86256-NMO/AQP4-IgG FACS titer (if appropriate)

86255-LG1CS (if appropriate)

86255-CS2CS (if appropriate)

 

LOINC Code Information

Test ID Test Order Name Order LOINC Value
DYS1 Autoimmune Dysautonomia Eval, S In Process

 

Result ID Test Result Name Result LOINC Value
8338 ACh Receptor (Muscle) Binding Ab 11034-6
81184 N-Type Calcium Channel Ab 33979-6
81185 P/Q-Type Calcium Channel Ab 33980-4
84321 AChR Ganglionic Neuronal Ab, S 42233-7
81596 GAD65 Ab Assay, S 30347-9
8746 Striational (Striated Muscle) Ab, S 8097-8
89165 Neuronal (V-G) K+ Channel Ab, S 41871-5
34270 Dysautonomia, Interpretation, S 69048-7
80150 ANNA-1, S 13997-2
36349 Reflex Added No LOINC Needed

Reflex Tests

Test ID Reporting Name Available Separately Always Performed
WBN Paraneoplastic Autoantibody WBlot,S No No
CRMWS CRMP-5-IgG Western Blot, S Yes No
ARMO ACh Receptor (Muscle) Modulating Ab No No
ABLOT Amphiphysin Western Blot, S No No
NMDCS NMDA-R Ab CBA, S No No
AMPCS AMPA-R Ab CBA, S No No
GABCS GABA-B-R Ab CBA, S No No
NMOTS NMO/AQP4 FACS Titer, S No No
NMDIS NMDA-R Ab IF Titer Assay, S No No
AMPIS AMPA-R Ab IF Titer Assay, S No No
GABIS GABA-B-R Ab IF Titer Assay, S No No
ANN2S Anti-Neuronal Nuclear Ab, Type 2 No No
ANN3S Anti-Neuronal Nuclear Ab, Type 3 No No
PCABP Purkinje Cell Cytoplasmic Ab Type 1 No No
PCAB2 Purkinje Cell Cytoplasmic Ab Type 2 No No
PCATR Purkinje Cell Cytoplasmic Ab Type Tr No No
AMPHS Amphiphysin Ab, S No No
CRMS CRMP-5-IgG, S No No
NMOFS NMO/AQP4 FACS, S Yes No
LG1CS LGI1-IgG CBA, S No No
CS2CS CASPR2-IgG CBA, S No No

Forms

If not ordering electronically, complete, print, and send a Neurology Specialty Testing Client Test Request (T732) with the specimen (https://www.mayomedicallaboratories.com/it-mmfiles/neurology-request-form.pdf).