EPIC CODE: LAB5322 Dysautonomia, Autoimmune/Paraneoplastic Evaluation, Serum
Additional Codes
Sunquest: ADEMM
Mayo: DYS2
Ordering Guidance
Multiple neuroimmunology profile tests are available. For testing that is performed with each profile, see Autoimmune Neurology Antibody Matrix.
Necessary Information
Provide the following information:
-Relevant clinical information
-Ordering provider name, phone number, mailing address, and e-mail address
Specimen Required
Patient Preparation:
1. For optimal antibody detection, specimen collection is recommended before initiation of immunosuppressant medication or intravenous immunoglobulin treatment.
2. This test should not be requested in patients who have recently received radioisotopes, therapeutically or diagnostically, because of potential assay interference. The specific waiting period before specimen collection will depend on the isotope administered, the dose given, and the clearance rate in the individual patient. Specimens will be screened for radioactivity prior to analysis. Radioactive specimens received in the laboratory will be held 1 week and assayed if sufficiently decayed or canceled if radioactivity remains.
3. Patient should have no general anesthetic or muscle-relaxant medications in the previous 24 hours.
Collection Container/Tube:
Preferred: Red top
Acceptable: Serum gel
Submission Container/Tube: Plastic vial
Specimen Volume: 4 mL
Forms
If not ordering electronically, complete, print, and send a Neurology Specialty Testing Client Test Request (T732) with the specimen.
Secondary ID
92121Useful 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 |
GANG | AChR Ganglionic Neuronal Ab, S | No | Yes |
ANN1S | Anti-Neuronal Nuclear Ab, Type 1 | No | Yes |
CS2CS | CASPR2-IgG CBA, S | No | Yes |
CRMS | CRMP-5-IgG, S | No | Yes |
DPPIS | DPPX Ab IFA, S | No | Yes |
LG1CS | LGI1-IgG CBA, S | No | Yes |
PCAB2 | Purkinje Cell Cytoplasmic Ab Type 2 | No | Yes |
Reflex Tests
Test ID | Reporting Name | Available Separately | Always Performed |
---|---|---|---|
AMPCS | AMPA-R Ab CBA, S | No | No |
AMPIS | AMPA-R Ab IF Titer Assay, S | No | No |
AMPHS | Amphiphysin Ab, S | No | No |
AMIBS | Amphiphysin Immunoblot, S | No | No |
AN1BS | ANNA-1 Immunoblot, S | No | No |
AN2BS | ANNA-2 Immunoblot, S | No | No |
CRMWS | CRMP-5-IgG Western Blot, S | No | No |
DPPCS | DPPX Ab CBA, S | No | No |
DPPTS | DPPX Ab IFA Titer, S | No | No |
GABCS | GABA-B-R Ab CBA, S | No | No |
GABIS | GABA-B-R Ab IF Titer Assay, S | No | No |
NMDCS | NMDA-R Ab CBA, S | No | No |
NMDIS | NMDA-R Ab IF Titer Assay, S | No | No |
PC1BS | PCA-1 Immunoblot, S | No | No |
PCTBS | PCA-Tr Immunoblot, S | No | No |
PCABP | Purkinje Cell Cytoplasmic Ab Type 1 | No | No |
PCATR | Purkinje Cell Cytoplasmic Ab Type Tr | No | No |
Testing Algorithm
If indirect immunofluorescence assay (IFA) patterns suggest collapsin response-mediator protein (CRMP)-5-IgG, then CRMP-5-IgG Western blot is performed at an additional charge.
If IFA patterns suggest amphiphysin antibody, then amphiphysin antibody and/or amphiphysin immunoblot is performed at an additional charge.
If IFA pattern suggests antineuronal nuclear antibodies (ANNA)-1 antibody, then ANNA-1 and ANNA-2 immunoblot is performed at an additional charge.
If IFA pattern suggests Purkinje cytoplasmic antibody (PCA)-1 antibody, then PCA-1 immunoblot is performed at an additional charge.
If IFA pattern suggests PCA-Tr antibody, then PCA-Tr immunoblot is performed at an additional charge.
If IFA pattern suggests PCA type 1or type trace, then the appropriate antibody specific IFA is performed at an additional charge.
If IFA pattern suggests N-methyl-D-aspartate (NMDA)-receptor, then NMDA-receptor cell-binding assay (CBA) and NMDA-receptor titer are performed at an additional charge.
If IFA pattern suggests alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA)-receptor, then AMPA-receptor CBA and AMPA-receptor titer are performed at an additional charge.
If IFA pattern suggests gamma-aminobutyric acid B (GABA-B)-receptor, then GABA-B-receptor CBA and GABA-B-receptor titer are performed at an additional charge.
If IFA pattern suggests dipeptidyl-peptidase-like protein-6 antibody (DPPX) antibody, then DPPX antibody CBA and DPPX titer are performed at an additional charge.
See Autoimmune/Paraneoplastic Dysautonomia Evaluation Algorithm
Method Name
AMPHS, AMPIS, ANN1S, CRMS, DPPIS, DPPTS, GABIS, NMDIS, PCAB2, PCABP, PCATR: Indirect Immunofluorescence (IFA)
AMPCS, CS2CS, DPPCS, GABCS, LG1CS, NMDCS: Cell Binding Assay (CBA)
CRMWS: Western Blot (WB)
AMIBS, AN1BS, AN2BS, PC1BS, PCTBS: Immunoblot (IB)
GANG: Radioimmunoassay (RIA)
Reporting Name
Dysautonomia, Autoimm/Paraneo, SSpecimen Type
SerumSpecimen Minimum Volume
2.5 mL
Specimen Stability Information
Specimen Type | Temperature | Time | Special Container |
---|---|---|---|
Serum | Refrigerated (preferred) | 28 days | |
Frozen | 28 days | ||
Ambient | 72 hours |
Reject Due To
Gross hemolysis | Reject |
Gross lipemia | Reject |
Gross icterus | Reject |
Clinical Information
Autoimmune dysautonomia encompasses disorders of peripheral autonomic synapses, ganglionic neurons, autonomic nerve fibers, and central autonomic pathways mediated by neural-specific IgG or effector T cells. These disorders may be idiopathic or paraneoplastic, subacute or insidious in onset, and may present as a limited disorder or generalized pandysautonomia. Pandysautonomia is usually subacute in onset and severity and includes impaired pupillary light reflex, anhidrosis, orthostatic hypotension, cardiac arrhythmias, gastrointestinal dysmotility, sicca manifestations, and bladder dysfunction. Limited dysautonomia is confined to one or just a few domains, is often mild, and may include sicca manifestations, postural orthostatism and cardiac arrhythmias, bladder dysfunction, or gastrointestinal dysmotilities. Diagnosis of limited dysautonomia requires documentation of objective abnormalities by autonomic reflex testing, thermoregulatory sweat test, or gastrointestinal motility studies.
The most commonly encountered autoantibody marker of autoimmune dysautonomia is the neuronal ganglionic alpha-3-acetylcholine receptor (AChR) autoantibody. This autoantibody to date is the only proven effector of autoimmune dysautonomia. A direct relationship has been demonstrated between antibody titer and severity of dysautonomia in both alpha-3-AChR-immunized animals and patients with autoimmune dysautonomia. Patients with high alpha-3-AChR autoantibody values (>1.0 nmol/L) generally have profound pandysautonomia. Dysautonomic patients with lower alpha-3-AChR autoantibody values (0.03-0.99 nmol/L) have limited dysautonomia.
Importantly, cancer is detected in 30% of patients with alpha-3-AChR autoantibody. Cancers recognized include small-cell lung carcinomas, thymoma, lymphoma, and adenocarcinomas of breast, lung, prostate, and gastrointestinal tract. Cancer risk factors include a past or family history of cancer, history of smoking, or social or environmental exposure to carcinogens. Early diagnosis and treatment of the neoplasm favors neurologic improvement and lessens morbidity.
Autoantibodies to other onconeural proteins shared by neurons, glia or muscle (eg, antineuronal nuclear antibody-type 1 [ANNA-1], collapsin response-mediator protein-5 neuronal [CRMP-5-IgG]) serve as additional markers of paraneoplastic or idiopathic dysautonomia. A specific neoplasm is often predictable by the individual patient's autoantibody profile.
Reference Values
Test ID |
Reporting name |
Methodology* |
Reference value |
ADEI |
Dysautonomia, Interpretation, S |
Medical interpretation |
NA |
GANG |
AChR Ganglionic Neuronal Ab, S |
RIA |
≤0.02 nmol/L |
ANN1S |
Anti-Neuronal Nuclear Ab, Type 1 |
IFA |
<1:240* |
CS2CS |
CASPR2-IgG CBA, S |
CBA |
Negative |
CRMS |
CRMP-5-IgG, S |
IFA |
<1:240* |
DPPIS |
DPPX Ab IFA, S |
IFA |
Negative |
LG1CS |
LGI1-IgG CBA, S |
CBA |
Negative |
PCAB2 |
Purkinje Cell Cytoplasmic Ab Type 2 |
IFA |
<1:240* |
Reflex Information:
Test ID |
Reporting name |
Methodology* |
Reference value |
AMPCS |
AMPA-R Ab CBA, S |
CBA |
Negative |
AMPIS |
AMPA-R Ab IF Titer Assay, S |
IFA |
<1:120 |
AMPHS |
Amphiphysin Ab, S |
IFA |
<1:240 |
AMIBS |
Amphiphysin Immunoblot, S |
IB |
Negative |
AN1BS |
ANNA-1 Immunoblot, S |
IB |
Negative |
AN2BS |
ANNA-2 Immunoblot, S |
IB |
Negative |
CRMWS |
CRMP-5-IgG Western Blot, S |
WB |
Negative |
DPPCS |
DPPX Ab CBA, S |
CBA |
Negative |
DPPTS |
DPPX Ab IFA Titer, S |
IFA |
<1:120 |
GABCS |
GABA-B-R Ab CBA, S |
CBA |
Negative |
GABIS |
GABA-B-R Ab IF Titer Assay, S |
IFA |
<1:120 |
NMDCS |
NMDA-R Ab CBA, S |
CBA |
Negative |
NMDIS |
NMDA-R Ab IF Titer Assay, S |
IFA |
<1:120 |
PC1BS |
PCA-1 Immunoblot, S |
IB |
Negative |
PCTBS |
PCA-Tr Immunoblot, S |
IB |
Negative |
PCABP |
Purkinje Cell Cytoplasmic Ab Type 1 |
IFA |
<1:240* |
PCATR |
Purkinje Cell Cytoplasmic Ab Type Tr |
IFA |
<1:240* |
*Methodology abbreviations:
Immunofluorescence assay (IFA)
Cell-binding assay (CBA)
Western blot (WB)
Radioimmunoassay (RIA)
Immunoblot (IB)
Neuron-restricted patterns of IgG staining that do not fulfill criteria for ANNA-1, CRMP-5-IgG, PCA-1, PCA-2, or PCA-Tr may be reported as "unclassified anti-neuronal IgG." Complex patterns that include nonneuronal elements may be reported as "uninterpretable."
Note: CRMP-5 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 800-533-1710 to request CRMP-5 Western blot.
Interpretation
Antibodies directed at onconeural proteins shared by neurons, muscle, and glia are valuable serological markers of a patient's immune response to cancer. These autoantibodies are not found in healthy subjects and are usually accompanied by subacute neurological symptoms and signs. It is not uncommon for more than one autoantibody to be detected in patients with autoimmune dysautonomia. These include:
-Plasma membrane cation channel antibodies (neuronal ganglionic [alpha-3]). All of these autoantibodies are potential effectors of autonomic dysfunction.
-Antineuronal nuclear autoantibody-type 1
-Neuronal and muscle cytoplasmic antibodies (CRMP-5 IgG)
A rising autoantibody titer in previously seropositive patients suggests cancer recurrence.
Cautions
Negative results do not exclude autoimmune dysautonomia or cancer.
Intravenous immunoglobulin (IVIg) treatment prior to the serum collection may cause a false-positive result.
Clinical Reference
1. Vernino S, Low PA, Fealey RD, Stewart JD, Farrugia G, Lennon VA: Autoantibodies to ganglionic acetylcholine receptors in autoimmune autonomic neuropathies. N Engl J Med. 2000 Sep 21;343(12):847-855
2. O'Suilleabhain PO, Low PA, Lennon VA: Autonomic dysfunction in the Lambert-Eaton myasthenic syndrome: serologic and clinical correlates. Neurology. 1998 Jan;50(1):88-93
3. Dhamija R, Tan KM, Pittock SJ, Foxx-Orenstein A, Benarroch E, Lennon VA: Serological profiles aiding the diagnosis of autoimmune gastrointestinal dysmotility. Clin Gastroenterol Hepatol. 2008 Sep;6(9):988-992
4. McKeon A, Lennon VA, Lachance DH, Fealey RD, Pittock SJ: Ganglionic acetylcholine receptor autoantibody: oncological, neurological and serological accompaniments. Arch Neurol. 2009 Jun;66(6):735-741
5. McKeon A, Lennon VA, LaChance DH, Klein CJ, Pittock SJ: Striational antibodies in a paraneoplastic context. Muscle Nerve. 2013 Apr;47(4):585-587
Method Description
Indirect Immunofluorescence Assay:
Before testing, patient's specimen is pre-absorbed 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 Nov;56(5):715-719; Honorat JA, Komorowski L, Josephs KA, et al: IgLON5 antibody: Neurological accompaniments and outcomes in 20 patients. Neurol Neuroimmunol Neuroinflamm. 2017 Jul 18;4(5):e385. doi: 10.1212/NXI.0000000000000385)
Radioimmunoassay:
Duplicate aliquots of patient specimen are incubated with (125)I-labeled antigen. Immune complexes, formed by adding secondary (goat) antihuman immunoglobulin, are pelleted by centrifugation and washed. Gamma emission from the washed pellet is counted, and mean counts per minute (cpm) are compared with results yielded by high positive and negative control sera. Specimen yielding cpm higher than the background cpm yielded by normal human specimen are retested to confirm positivity and titrated as necessary to obtain a value in the linear range of the assay. The antigen binding capacity (nmol per liter) is calculated from the cpm precipitated at a dilution yielding a linear range value.(Griesmann GE, Kryzer TJ, Lennon VA: Autoantibody profiles of myasthenia gravis and Lambert-Eaton myasthenic syndrome. In: Rose NR, Hamilton RG, eds. Manual of Clinical and Laboratory Immunology. 6th ed. ASM Press; 2002:1005-1012; 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 December;73[12]:1161-1166; Jones AL, Flanagan EP, Pittock SJ, et al: Responses to and outcomes of treatment of autoimmune cerebellar ataxia in adults. JAMA Neurol. 2015 Nov;72[11]:1304-1312. doi: 10.1001/jamaneurol.2015.2378)
Western Blot:
Neuronal antigens extracted aqueously from adult rat cerebellum, full-length recombinant human collapsin response-mediator protein-5 (CRMP-5), or full-length recombinant human amphiphysin protein is denatured, reduced, and separated by electrophoresis on 10% polyacrylamide gel. IgG is detected autoradiographically by enhanced chemiluminescence.(Yu Z, Kryzer TJ, Griesmann GE, Kim K, Benarroch EE, Lennon VA: CRMP-5 neuronal autoantibody: marker of lung cancer and thymoma-related autoimmunity. Ann Neurol. 2001 February;49[2]:146-154; Dubey D, Jitprapaikulsan J, Bi H, et al: Amphiphysin-IgG autoimmune neuropathy: A recognizable clinicopathologic syndrome. Neurology. 2019 Nov 12;93(20):e1873-e1880. doi: 10.1212/WNL.0000000000008472)
Immunoblot:
All steps are performed at room temperature (18 to 28° C) utilizing the EUROBlot One instrument. Diluted patient serum (1:101) is added to test strips (strips containing recombinant antigen manufactured and purified using biochemical methods) in individual channels and incubated for 30 minutes. Positive samples will bind to the purified recombinant antigen and negative samples will not bind. Strips are washed to remove unbound serum antibodies and then incubated with anti-human IgG antibodies (alkaline phosphatase-labelled) for 30 minutes. The strips are again washed to remove unbound anti-human IgG antibodies and nitroblue tetrazolium chloride/5-bromo-4-chloro-3-indolylphosphate substrate is added. Alkaline phosphatase enzyme converts the soluble substrate into a colored insoluble product on the membrane to produces a black band. Strips are digitized via picture capture on the EUROBlot One instrument and evaluated with the EUROLineScan software.(O'Connor K, Waters P, Komorowski L, et al: GABAA receptor autoimmunity: A multicenter experience. Neurol Neuroimmunol Neuroinflamm. 2019 Apr 4;6[3]:e552. doi: 10.1212/NXI.0000000000000552)
Cell Binding Assay:
Patient specimen 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: IIFT: Neurology Mosaics, Instructions for the indirect immunofluorescence test. EUROIMMUN; FA_112d-1_A_UK_C13, 02/2019)
Day(s) Performed
Report Available
7 to 10 daysSpecimen Retention Time
28 DaysPerforming Laboratory

Test Classification
This test was developed, and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. This test has not been cleared or approved by the US Food and Drug Administration.CPT Code Information
83519
86255 x 6
86255-AMPCS (if appropriate)
86256-AMPIS (if appropriate)
86255-AMPHS (if appropriate)
84182-AMIBS (if appropriate)
84182-AN1BS (if appropriate)
84182-AN2BS (if appropriate)
84182-CRMWS (if appropriate)
86255-DPPCS (if appropriate)
86256-DPPTS (if appropriate)
86255-GABCS (if appropriate)
86256-GABIS (if appropriate)
86255-NMDCS (if appropriate)
86256-NMDIS (if appropriate)
84182-PC1BS (if appropriate)
84182-PCTBS (if appropriate)
86255-PCABP (if appropriate)
86255-PCATR (if appropriate)
LOINC Code Information
Test ID | Test Order Name | Order LOINC Value |
---|---|---|
DYS2 | Dysautonomia, Autoimm/Paraneo, S | 99000-2 |
Result ID | Test Result Name | Result LOINC Value |
---|---|---|
83077 | CRMP-5-IgG, S | 94815-8 |
84321 | AChR Ganglionic Neuronal Ab, S | 94694-7 |
83138 | PCA-2, S | 94351-4 |
34270 | Dysautonomia, Interpretation, S | 69048-7 |
64279 | LGI1-IgG CBA, S | 94287-0 |
64281 | CASPR2-IgG CBA, S | 94285-4 |
64930 | DPPX Ab IFA, S | 82976-2 |
80150 | ANNA-1, S | 94342-3 |
36349 | Reflex Added | 77202-0 |