{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:17:03Z","timestamp":1787026623769,"version":"build-2736575974"},"reference-count":52,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T00:00:00Z","timestamp":1777334400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Immunol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The frequency of extractable nuclear antigen (ENA) seropositivity in patients with negative antinuclear antibodies (ANA) by indirect immunofluorescence (IIF) remains insufficiently characterized. We aimed to estimate the frequency of ENA seropositivity among ANA-IIF\u2013negative individuals (ENA+\/IIF\u2212), and to identify associated clinical and methodological determinants.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A systematic search of PubMed, EMBASE, Web of Science, and Scopus was conducted for studies published up to January 31, 2025. Studies evaluating ENA seropositivity in ANA-IIF\u2013negative patients using HEp-2 or HEp-2000 substrates were included. Meta-analysis was performed using the Freeman\u2013Tukey double arcsine transformation and random-effects models.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Twenty-eight studies, comprising 33 distinct patient groups and 28,552 ANA-IIF\u2013negative samples, were included. The pooled proportion of ENA+\/IIF\u2212 was 14.1% (95% CI: 10%\u201318.7%), with substantial heterogeneity (I\u00b2 = 99%). Subgroup analysis demonstrated significant variation according to clinical indication: 1.4% (95% CI: 1.1%\u20131.9%) in unspecified indications, 8.1% (95% CI: 6%\u201310.5%) in suspected connective tissue disease (CTD), and 44.1% (95% CI: 32.3%\u201354.6%) in confirmed CTD (p &amp;lt; 0.0001). Multivariable meta-regression identified the IIF cut-off dilution, anti-SSA\/Ro antibodies, and anti-tRNA synthetase antibodies as significant determinants of ENA+\/IIF\u2212 frequency.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>This meta-analysis confirmed that ENA seropositivity is not uncommon in ANA-IIF\u2013negative individuals, and it varies according to clinical context. A negative ANA-IIF result does not reliably exclude CTD, particularly in patients with strong clinical suspicion of CTD. These findings support a targeted, clinically driven ENA testing strategy, especially in conditions such as Sj\u00f6gren syndrome and inflammatory myopathies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Systematic Review Registration<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link>https:\/\/www.crd.york.ac.uk\/PROSPERO\/view\/<\/jats:ext-link>\n                      , identifier CRD420250654499.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fimmu.2026.1745828","type":"journal-article","created":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T05:35:35Z","timestamp":1777354535000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Frequency of extractable nuclear antigen seropositivity among individuals seronegative for antinuclear antibodies on indirect immunofluorescence: a systematic review and meta-analysis"],"prefix":"10.3389","volume":"17","author":[{"given":"Tarak","family":"Dhaouadi","sequence":"first","affiliation":[{"name":"Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University","place":["Tunis, Tunisia"]},{"name":"Faculty of Medicine of Tunis, University of Tunis El Manar","place":["Tunis, Tunisia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Imen","family":"Zamali","sequence":"additional","affiliation":[{"name":"Faculty of Medicine of Tunis, University of Tunis El Manar","place":["Tunis, Tunisia"]},{"name":"Clinical Immunology Department, Pasteur Institute of Tunis","place":["Tunis, Tunisia"]},{"name":"Laboratory of Transmission, Control and Immunobiology of Infection, Pasteur Institute of Tunis","place":["Tunis, Tunisia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahlem","family":"Ben 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(LR03SP01), Charles Nicolle Hospital, Tunis El Manar University","place":["Tunis, Tunisia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Taieb","family":"Ben Abdallah","sequence":"additional","affiliation":[{"name":"Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University","place":["Tunis, Tunisia"]},{"name":"Faculty of Medicine of Tunis, University of Tunis El Manar","place":["Tunis, Tunisia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samar","family":"Samoud","sequence":"additional","affiliation":[{"name":"Clinical Immunology Department, Pasteur Institute of Tunis","place":["Tunis, Tunisia"]},{"name":"Laboratory of Transmission, Control and Immunobiology of Infection, Pasteur Institute of Tunis","place":["Tunis, Tunisia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yousr","family":"Gorgi","sequence":"additional","affiliation":[{"name":"Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University","place":["Tunis, Tunisia"]},{"name":"Faculty of Medicine of Tunis, University of Tunis El Manar","place":["Tunis, Tunisia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yousr","family":"Galai","sequence":"additional","affiliation":[{"name":"Clinical Immunology Department, Pasteur Institute of Tunis","place":["Tunis, Tunisia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Imen","family":"Sfar","sequence":"additional","affiliation":[{"name":"Research Laboratory in Immunology of Renal Transplantation and Immunopathology (LR03SP01), Charles Nicolle Hospital, Tunis El Manar University","place":["Tunis, Tunisia"]},{"name":"Faculty of Medicine of Tunis, University of 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