What the lab technician sees under the microscope when testing a patient for anti-SSA antibodies. These are human epithelial cells to which blood was added from a patient who has anti-SSA antibodies, proving that that person is positive for anti-SSA. Photo credit below
Know your labs, such as the anti-SSA test when you have lupus!
The anti-SSA test is also called SSA antibody I recommend that all lupus patients get copies of their labs every time they are done. Look up any abnormal results from a reliable source to know what they mean. If you cannot find a reliable source, then ask your doctor.
Remember… Knowledge is Power!
So, let’s talk about anti-SSA (also called anti-Ro).
Anti-SSA is measured as a blood test in red-top tubes
​Anti-SSA antibody: Also called Anti-Sjögren’s Syndrome A, Sjögren’s Anti-SS-A, Ro Antibody
Why is anti-SSA also called anti-Ro?
Anti-SSA and anti-SSB antibodies were first discovered in 1961 in people who had Sjögren’s syndrome. This systemic autoimmune disorder attacks the body’s moisture-producing glands, commonly causing dry eyes and dry mouth. The medical terms for them are “Sjögren’s syndrome-A” and “Sjögren’s syndrome-B” antibodies (or SSA and SSB for short). In 1969, another laboratory described antibodies in people who had lupus and named them anti-Ro and anti-La. “Ro” and “La” were the first two letters of the last names of the lupus patients in whom the antibodies were initially found (Robert and Lane respectively, according to Dubois’ Lupus 9th edition). Researchers later showed that anti-SSA was the same as anti-Ro and that anti-SSB was the same as anti-La. These terms are now interchangeable, with anti-SSA meaning the same thing as anti-Ro and anti-SSB meaning the same thing as anti-La.
How often does it occur?
Anti-SSA is more commonly positive in SLE patients than anti-SSB. SSA is positive in 20% to 60% of people who have SLE (depending on the patient population and the laboratory method used to detect the antibodies). Anywhere from 75% to 95% of people who have Sjögren’s syndrome are positive for this antibody. It can be present in any of the systemic autoimmune diseases and nonautoimmune conditions.
Subacute cutaneous lupus erythematosus (papulosquamous or psoriasiform type) in a systemic lupus patient with high positive anti-SSA (photo by Don Thomas, MD, shared with patient’s signed permission)
Some things may occur more often in people positive for anti-SSA antibodies:
People who have SLE (systemic lupus erythematosus) and are anti-SSA positive have an increased risk of developing rashes with sun exposure (especially subacute cutaneous lupus), inflammation of the lungs (pneumonitis), shrinking lung syndrome, inflammation of the liver (hepatitis), inflammation of the pancreas (pancreatitis), inflammation of the heart (myocarditis), low platelet counts (thrombocytopenia), low lymphocyte counts (lymphopenia), and an overlap syndrome with Sjögren’s.
IMPORTANT NOTE: From the list above, the most important ones are sun-sensitive rash and Sjögren’s. Most do not develop the other problems, but are listed for your knowledge. Your doctor will monitor your liver enzymes and blood counts (hopefully every 3 months) and make sure to let your doctor know if you get chest pain, shortness of breath, bruising, rash, dry mouth or dry eyes.
Anti-SSA positive patients should particularly avoid ultraviolet light and become UV protection fanatics. Please download and follow my UV protection handout from this page:
https:///www.lupusencyclopedia.com/lupus-secrets.html
ANA-negative SLE patients and anti-SSA
Although it is rare, some people who have SLE and are negative for ANA are positive for SSA antibody. If someone is thought to have SLE, but their ANA is negative, doctors should check for SSA antibodies. A newer ANA test, called “HEp-2000 ANA” (by a laboratory called Immuno Concepts in Sacramento, California), may be better at showing ANA positivity in these patients who are SSA antibody positive.Â
Anti-SSA can become positive years before SLE occurs
SSA antibody can be positive in someone many years before they develop lupus or Sjögren’s. It is one of the earliest antibodies to appear in many patients. This was figured out from blood samples of Army soldiers at the old Walter Reed Army Medical Center (Washington, DC) where I did my rheumatology fellowship.
​It is essential that people found to have a positive SSA antibody (but not have evidence of having lupus, Sjögren’s, or any associated disease) be checked regularly by a doctor. I recommend that people in this situation learn what the symptoms of lupus and Sjögren’s are, and if any occur, to see a rheumatologist right away. Also, it is a good idea to see a rheumatologist regularly (such as once or twice a year) to have a proper physical examination and labs done. SLE can be potentially diagnosed by blood work (such as finding low blood counts or protein in the urine), yet the person may feel perfectly fine. The faster a proper diagnosis is made, the better the person usually does. Of course, someone who is SSA antibody positive may never develop any disease with it, but it better to be safe. I’d also recommend that someone in this category (antibody positive but no disease) avoid all potential triggers that may cause lupus.
Around 2% of anti-SSA women can have a baby with “neonatal lupus.” Make sure to have your obstetrician check a fetal heart check starting at around 16 weeks
Important pregnancy information about anti-SSA:
One of the most important potential problems is that this antibody can cross through the placenta and enter the fetus of a woman who is positive for this antibody. These antibodies can potentially cause tissue damage in the unborn baby’s heart or skin (called neonatal lupus) whose mother is anti-SSA positive. Fortunately, this occurs in only about one out of fifty mothers who are positive for anti-SSA.
​However, suppose a mother with SSA antibody has one child with neonatal lupus. In that case, her chances of each subsequent baby having neonatal lupus are approximately 20%.
For more in-depth information on autoantibodies like anti-SSA and lupus:
from “The Lupus Encyclopedia” preliminary write up for the upcoming 2nd edition, by Don Thomas, MD and Johns Hopkins University Press
References for the above can be found under chapter 4 here:
https:///www.lupusencyclopedia.com/references.html
Photo credit (1st photo of lab test HeP immunofluorescence of anti-SSA test = from www.wikipedia.com article on Anti-SSA/anti-Ro antibodies, photo by Simon Caulton
Have you seen cases where the SSA antibodies show up after having lupus for several years? I was found to have positive antiphospholipid and anti ds dna antibodies back in 2019, and my SSA and SSB antibodies were negative at the time. But, in the past month I’ve started to notice my eyes and mouth feeling drier, and sometimes my jaw/salivary gland areas feel sore, so I’ve been wondering whether I should have the SSA and SSB checked again. Or would it not change management whether I have overlapping Sjogrens or not because I already get the regular “lupus labs” and see a rheumatologist every three months? They are already pretty sure I have overlapping SSc along with lupus. The prospect of adding a third systemic disorder to my list is kind of depressing.
Great question, showing quite a bit of knowledge since you added “or would it not change management.” It probably would not change management since Sjogren’s overlap can occur in the absence of anti-SSA. However, if you are of child-bearing age, it would be important if you were going to consider getting pregnant in the future.
Of note, scleroderma overlap absolutely can cause dry mouth and eyes. This happens frequently due to scarring of the glands. This is a very different cause than the inflammatory cause from Sjogren’s. In a patient with SLE/SSc overlap syndrome with negative anti-SSA, the scleroderma would be the more likely cause.
However, following all the advice for dry mouth and dry eyes from the Sjogren’s Foundation at Sjogrens.org can be very helpful.
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My Ana and double stranded DNA wen away after years of being positive but now I have positive anti chromatin. I can’t find much information on this lab
This is an unusual circumstance. ANA and anti-dsDNA becoming negative is a great prognostic sign. However, we do not really know if becoming chromatin antibody positive changes things. Anti-chromatin antibody is very closely related to anti-DNA antibodies. One could theorize that the anti-dsDNA becoming negative is the most important thing and that the anti-chromatin antibody is simply a less specific “equivalent.” If I had to bet or theorize, I would think this is overall a good thing…. I hope you do well… Donald Thomas, MD
If you have a positive ANA. ANA titer of 1:1280 and tested postive for SS-A (antibody only) no others. And you have clinical symptoms more consistent with Lupus rather than Sjorgren’s is that enough to diagnose Lupus? I don’t have the dry eye, mouth, and other gland issues that come with Sjorgen’s.
Brandi: SLE and Sjogren’s has a ton in common. Even many of their immunologic abnormalities are very similar. It can sometimes be difficult to tell the difference between one or the other or if someone has both (SLE with Sjogren’s disease overlap). One out of three SLE patients are anti-SSA positive; 60-70% of Sjogren’s patients are as well. I have many SLE patients who are anti-SSA positive and who do not have Sjogren’s. However, it does increase the risk for developing Sjogren’s disease, sun sensitive rashes, congenital heart block, neonatal lupus, heart inflammation, etc, so those are the things you want to keep in mind (though most of our anti-SSA positive patients do not get these (except the photosensitivity is incredibly common).
I am SSA positive (went from 3.6 down to 3). ANA went negative. Low complement C4, low ceruloplasmin, slightly low iron. Tingling in hands and feet. Migraines. Sore wrists. No swelling. Nursing an 11 month old. Dizzy upon standing. No other clinical symptoms. Should I pursue liver studies / tilt table? EKG is fine. Haven’t done SFN biopsy. Halter monitor fine
Julia: With anti-SSA and low C4 complement, I’d have a high suspicion for the possibility of an autoimmune disorder. If I discovered that the tingling is peripheral neuropathy on EMG and there is no other cause, then at least an undifferentiated connective tissue disease would be entertained. Just from what you tell me, and EMG/NCS of the hands and feet, and possibly a Tilt Test (autonomic dysfunction is underdiagnosed) would be considered in one of my patients. We know from the 2003 Arbuckle study that anti-SSA could appear 5-7 years before a diagnosis of systemic lupus. Don’t stop seeking answers. I wish our diagnostic tests were more advanced than they are. Too many patients end up with no answer for too long of a time….
Thank you, Donald. It is hard to get the ear of physicians at times. I check the boxes of a few things and take a break. Tilt table isn’t really something anyone administers in Houston, TX. I have also, perhaps unrelatedly, found I have abnormal P41 AB, perhaps an old infection. I did have Vibrio in high school. Who knows, I suppose.
What can I do now to prevent the development of disease? I have changed my diet to be very clean and absent and sugar / gluten / many lectins and dairy. It seems to help the tingling but could be correlation versus causation. I have not other classic Lupus markers or clinical presentation of Sjogrens yet. I also have low copper, once again could be completely unrelated. There is little out there on what I can do to understand my body and prevent disease which I find a bit frustrating.
In addition to UV protection, avoiding smoking, learning to respond healthy to stress, maintaining normal body weight:
Very important for all #lupus #SLE patients to teach their relatives. The OMRF showed that a high percentage of family members developed lupus (especially those with less than 7 hours sleep) over 6 years. Let’s add:
– Get at least 7 hours good quality of sleep nightly
– Don’t take Echinacea or eat too much mung bean sprouts or alfalfa sprouts
– Drink alcohol in moderation (eg no more than 5 oz of wine per 24 hours)
– Floss and brush teeth daily to help prevent periodontal disease.
– Have your vitamin D level monitored; take a vitamin D supplement if it is low.
– Even avoid second-hand smoke.
– Avoid sulfa antibiotics (add to allergy list).
– Eat a diet rich in omega-3 fatty acids (flaxseed, cold-water fish, chia seed, walnuts, etc).
– Consider eating “resistant starches” regularly (legumes, peas, overnight oats, etc).
– Ensure adequate dietary intake of selenium (meats and seafood) and zinc (nuts, lentils, fortified breakfast cereals).
– Consider decreasing exposure to phthalates (lipstick, plastics, cosmetics).
– Do daily breathing exercises; practice mindfulness.
– Avoid exposure to pesticides.
– Avoid using hair dyes. https://journals.sagepub.com/doi/10.1177/0961203318778368
Thank you, I will follow this. I really appreciate you! What I’m also hearing is this may not develop into disease.
I can’t find anyone to perform the tilt table around Houston. EMG was fine and supplementing with (deficient) copper / changing diet resulted in reduced to no tingling. In recent colonoscopy, I followed protocol but couldn’t get clean. They indicated I likely have low motility.
If I were to get pregnant, I’m hearing mixed feedback on the need for plaquenil.
Julie: thanks for letting me know! I copy and pasted the article from this section in my book. I changed “table” to a link where I recommend avoiding triggers. Have a Happy New Year and thanks for the comment.
Thank you for explaining anti-SSA here and on Reddit.
I was diagnosed with Sjogren’s in March 2022 with anti-SSA positive. I have been seeing a rheumatologist since April of 2022.
I had another anti-SSA test in 2023 and it was again positive. According to my rheumatologist, my disease activity has been low while my disease burden has been high. I have severe dry mouth. I have no dry eyes or other symptoms. My rheumatologist also said my anti-SSA was “just slightly above normal”
In a recent conversation with the rheum, I asked if the anti-SSA numbers for 2022 and 2023 could be given to me. The rheumatologist wrote to me via mychart that my 2022 anti-SSA (ELISA results) was 86. 2023 was 95. Both years they are strong positive. It is not “just slightly above normal” My rheumatologist wrote on mychart: “I usually don’t track these and would not support following further”.
I am not sure whether or not my disease activity was as low as the rheum said. I only have cevimiline as a treatment for dry mouth – it has very little efficacy on me. No other medication has been given to me for Sjogren’s.
The high numbers on the SSA reports from two years have given uncertainties and doubts.
I am 68 year old male. Other than Sjogren’s that bothers me a lot, I am in good health. My other lab results are good. I have no organ involvement. Based on my lab results, it’s unlikely that I will have the threat of lymphoma in the future. I walk 4.5 miles each day, 7 days a week.
Should I seek a second opinion from another rheumatologist? Your advice will be greatly appreciated! Thanks!
Henry: I agree with your rheumatologist. Anti-SSA has not been shown to fluctuate with disease activity, so it is not a test we tend to repeat on purpose (though it often is repeated due to being an automatic part of lab panels). It is most helpful in making a diagnosis of Sjogren’s disease and for predicting some possible complications in lupus.
Disease activity and how it responds to therapy is better measured by other tests such as ESR, CRP, immunoglobulin levels, anti-dsDNA levels, C3/C3/EC4d, anti-C1q, blood counts, protein in the urine, lever enzymes, history, physical exam and some times other tests like Doppler ultrasound of the joints, pulmonary function tests and high resolution chest CT scan results (depending on the problem).
Good for you for the exercise! Exercise, healthy diet (anti-inflammatory), UV light protection, etc are all so important!
I need help so bad I have been trying to tell doctors for years and they still don’t want to help me. They treat me like I’m just another person wanting drugs or they look at me for 5 mins and then tell me I don’t have it and they send me home with nothing to help me and my symptoms are getting worse. I had a blood test done where I am ana positive and ssb positive and the c protein is positive and I don’t understand why they are treating me this way with how bad I feel. I can say that I have felt like I’m dying and just waiting for it. I’ve been also having a lot of gastrointestinal problems along with other things my hair is falling out I’ve had to plug my drains and cut my hair short to keep it from clogging them. I have pain heat and sweeping in my joints plus I’ve been told I’ve got a heart problem but like I said no one seems to wanna help me and I’m scared. I also have some mental problems as well. I also have had anemia for years off and on blood and protein in my urine. I’m hurting and so sick……..
Back in 2017 after MRI showed changes on my paranoid glands, I was referred to do ANA/ENA tests.
Results came ANA negative and positive SSA/SSB, SSRo 52 titer 1.2, SSRo60 titer 8, SSLa titer 8.
They found out after that I was producing less saliva after a lip biopsy, however I never complained of xerostomia before.
Back then my major symptoms were was fatigue and muscular pain.
Even though I was diagnosed with SS, the doctor concluded that I didn’t quite fulfill the criteria for SS despite the biopsy and AntiRo.
She questioned if the lip biopsy came irregular due to the radiation I received a year before due to Thyroid cancer.
Fast forward in 2021 I started with joint pain hands and feet, after months of testing, I got diagnosed with RA after CCP and RF were also positive.
Tried DMARDS and TNF, the last one just made my symptoms worse and trigged skin symptoms such as photosensitivity and rashes similar to psoriasis and eczema.
After two years of trying to find a medication and getting worse, I flew out for a second opinion in another country.
Test came ANA positive 1:320 and high levels of IgG.
The doctor based on the criteria of non erosive arthritis, IgG levels, positive ANA and mouth ulcer, had a big suspicious of SLE or Lupus overlap.
However she ordered further tests such as double stranded antibodies.
When I got back to my country, surprisingly enough the results came exactly the same as in 2017: ANA negative and only SSA/SSB positive with the exact same titers!! Ro52 1.2, Ro 60 8, La 8
With the exception that this time around, CN1A antibody came out positive.
*worth mention, I was on Deflazacort during the last tests
My symptoms are fatigue, joint pain, stiffness and muscle pain which have reduced my mobility significantly. To the point of being disable.
I’ve also have sun rash in chest and arms since 2016.
Doctors in my country still think is RA and SS because of Anti-Ro positivity however the other doctor thinks this only confirms the diagnosis of Lupus/overlap.
And of course this debate makes them disagree on my treatment route as well.
In 2017 results came ANA neg, SSRo 52 titer 1.2, SSRo60 titer 8.0, SSLa titer 8.0.
Diagnosed with SS even tho the doctor thought I didn’t cover all the criteria
Fast forward in 2021 RF and CCP pos. Diagnosed with RA
November 2023, ANA pos 1:320 and high levels of IgG.
Doctor no. 2 diagnosed Lupus or a possibility of Lupus overlap, based on four criteria: non erosive arthritis, IgG levels, ANA pos and mouth ulcer and sun rash.
She ordered ENA tests.
Jan 2024, same exact as in 2017: ANA negative, Ro52 1.2, Ro 60 8.0, La 8.0. With the exception, CN1A antibody came out positive this time around.
*worth mention, I was on Deflazacort during the last tests
My major symptoms are fatigue, joint pain, stiffness and muscle pain which have reduced my mobility significantly, to the point of being disable.
Doctors no.1 still think is RA and SS.
However doctor no.1 think the last tests only confirm the Lupus overlap diagnosis.
Tara: ANA and anti-SSA can actually be seen in all the systemic autoimmune diseases. This can even be seen in the healthy population. It all depends upon what else is going on.
The most common diagnoses for this are undifferentiated connective tissue disease, systemic lupus, and Sjogren’s.
However, we also see it in RA, polymyositis, scleroderma, and vasculitis.
I hope that helps (bottom line: ask your rheumatologist to put all the pieces of the puzzle together)… good luck!
My lab results show Ana positive but ds dna negative ,and anti ssa positive, protein in urine ,, now is it called sle with Sjogren’s , cause no dry mouth or eyes but i do get swollen glands any advice would help me
What makes the diagnosis is what we call in the medical world, “the phenotype.” What ever the signs and symptoms are eg arthritis, if a rash what type of rash, kidney inflammation?, joint damage?, lung involvement?, liver involvmement? low blood counts and if so which ones?
Dr Thomas,
I appreciate in advance you taking the time to read and reply. I am F, 55 yo (gallbladder removed 2017), ANA positive, SSA positive at 100, RF positive,Had urinary test first with High RBC, 2 weeks later repeated test and RBC was normal but had High WBC and bacteria (wonder if dryness has anything to do with it?) Also took eye dryness test which showed 5 in RE & 4 in LE (they put an anesthetic drop in my eye without wiping it off before putting the paper strip on my eye)
– I Have severe dry mouth, dry nose and dry eyes.
-For many years have been having cognitive problems and difficulty with memory
-Skin problems for years, rash’s (contact dermatitis), random consistent dry scaly patches all on neck, shoulders, and entire body very dry skin.
– Hands feel swollen and tend to wake up with fingers curled under
-Feels like my esophagus is smaller as I feel a difference when I swallow (like I have to eat smaller bites to go down smoothly )
-Right as I swallow, in the back of my throat, even the slightest spice burns (I used to be able to eat very spicy without incident).
-I also experience Intermittent debilitating pain in joints that come and go and last 3-4 days at a time. Especially if I get out of the hot spa (which I love taking a dip in the spa). -I also have issues with feeling bloated, inability to feel on and off that I can fully empty bladder.
-I also feel as though I have to take very deep breaths relatively consistently.
My Rheumatologist is suggesting the possibility of Sjogrens with a potential additional component.
Hello, Dr. Thomas. 58F. I was diagnosed with Sjogren’s five years ago, but I’ve had symptoms for 20 years. My ANA is 1:320 and I am positive for both SSA (Ro52 50.7, Ro60 > 1374.8) and SSB 187.7. My lupus labs are negative, but I have had a sun rash on my upper chest twice with modest sun exposure. I’m on 200 mg hydroxychloroquine/day; this is a half dose for my size.
Questions:
(1) I am curious about the extremely high Ro60 number. I was tested twice and it was the same “off the charts” value both times. What is the significance of this?
(2) The sun rashes only occurred in the past year, after I started hydroxychloroquine. Do you think these are due to Sjogren’s, due to the hydroxychloroquine, or possibly an indication of early lupus?
You are describing a classic anti-Ro (SSA) problem… sun sensitive rashes. We see this both in Sjogren’s and in SLE with positive anti-Ro.
HCQ actually helps to reduce sun sensitivity; you may need a higher dose. Ask your doctor to test a “trough, whole blook hydroxychloroquine blood level”… available from LabCorp, insurance covers it. Our goal drug level is 1000 – 1200 ng/mL in people with active inflammation.
Hi Dr. Thomas,
I had sun exposure mid-May from attending an outdoor concert – I got a sunburn on my face covering my cheeks and nose. Within the last month I have started experiencing more and more fatigue along with joint pain in my ankles, shoulder, wrists, fingers, now my knees and elbows. I’ve been getting headaches and light headedness lately as well. What I thought was a sun burn looks like a classic butterfly malar rash, which I still have on my face – it’s mild though – just looks like I’m flushed/blushing. I have a positive ANA – homogenous pattern with a 1:160 titer. I’m also positive for SSA, but negative for SSB and negative or have normal levels for all other labs.
I’m meeting with my Rheumatologist next week, but I’m anxious to know more now…
I suspected Lupus (SLE) once I put everything together – realized the rash and started feeling off…do you think this is correct? Or is Sjogren’s likely as well? Or will I get it later on (overlap)?
What does a positive SSA, but negative SSB mean?
Thank you for reading and taking time to respond.
SC: Anti-SSA patients are more apt to be sunsensitive. Having joint pains, sunsensitive rash, +ANA and anti-SSA can be seen in both SLE patients and Sjogren’s patients. A classic malar rash would be more typical of SLE. I hope you took photos to show your rheumatologist. They will want to check your blood counts, kidneys, etc to make sure nothing else is going on. Good luck.
I am pregnant with my 5th baby. I have SLE and have had a positive SSA for my other three pregnancies. However, my SSA is now coming back negative. Have you seen this? Should I be treated as a negative SSA mom or continue to check for fetal heart block vis ultrasounds with MFM as with prior pregnancies?
Erica: I have to preface this answer with the typical response that this does not replace the word of your doctor and should not be considered direct medical advice.
It is the anti-SSA that is the problem. If it is not there (negative result), then neonatal lupus fetal heart block should not be a problem (however, keep in mind that anti-SSB and very rarely anti-RNP have been implicated, but nothing like anti-SSA). Also, recent studies show that low levels of anti-SSA are much less likely to cause heart block compared to high levels.
In my patients with negative levels, I do not heart monitoring. With low levels, I tell the patient the data, and let them make the decision.
The elephant in the room, is how accurate is the lab? Not all labs are created equally.
Ask your rheumatologist, my suspicion is that they would most likely not recommend monitoring.
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