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Ivo Boudakov, Ph.D.
Ver. 2016
Hypersensitivity
IMMUNOLOGY (BMIC550)
Learning Objectives
FYI
 Topics and keywords to be discussed: Hypersensitivity I, II, III, and IV.
Description of Hypersensitivity type V reaction. Rhesus disease (Erythroblastosis
fetalis). Autoimmune hemolytic anemia. Idiopathic thrombocytopenia purpura. Cold
hem-agglutinin disease. Graves disease. Arthus Reaction. Serum sickness.
Glomerulonephritis. Rheumatoid arthritis. Systemic lupus erythematosus (SLE).
Tuberculin test. Contact sensitivity
131. List the Gell and Coomb’s classification of hypersensitivity
132. Describe the pathophysiologic mechanisms associated with Type I (IgE)-
mediated injury.
133. Compare and contrast the acute phase reaction with the late phase reaction
in anaphylaxis.
134. Explain the role of eosinophils in allergic and anaphylactic reaction.
135. Discuss the therapeutic modulation of Type I hypersensitivity. Explain the
proposed mechanism underlying “desensitization” (“allergy shots”).
136. Explain the principles underlying the RAST test and skin test. Explain how
they can be used as diagnostic tools.
2
Learning Objectives
FYI
136. List the categories of intervention for patients susceptible to Type I
hypersensitivities.
137. Explain the principle underlying desensitization therapy.
138. Describe allergic asthma.. Describe the bronchial wall changes that occur in
asthma.
139. Compare and contrast Type II and Type III hypersensitivity reactions.
140. Compare complement mediated cell lysis and antibody dependent cell
cytotoxicity.
141. Compare immunopathology of Goodpasture’s syndrome and SLE.
142. Compare and contrast drug induced Type I and Type II hypersensitivity
reactions.
143. Discuss the underlying reasons for the development of Erythroblastosis
fetalis.
144. Describe Type IV cell mediated hypersensitivity.
145. Recall the basis for, and examples of, contact hypersensitivity.
146. Explain the principle of, and immunology of a Mantoux test.
147. Describe granulomatous formation.
3
Hypersensitivity
 Under some circumstances immune system reaction causes
tissue and organ damage instead of protection
 Such reactions are collectively known as hypersensitivity
 Reaction could occur in two situations:
against environmental antigens
against self (autologous) antigens which is usually linked
to tolerance failure
 Allergen is an antigen that causes harmful reaction and
technically it is linked with type I hypersensitivity.
4
Basic characteristics of Hypersensitivity
 Reaction is antigen specific
 Reaction depends on the participation of antibodies or
lymphocytes
 Prior exposure to an antigen is required (sensitization)
First contact with an antigen produces no detectable
reaction, but sensitizes the immune system
 Secondary and any other re-exposure to the same antigen
elicit the hypersensitive reaction
Additional re-exposures to the same antigen may increase
or sometimes decrease the sensitivity of the reaction
5
ANTIBODY MEDIATED
Hypersensitivity - Four (Five) Types
 Type I (Immediate Hypersensitivity)
IgE mediated reaction such as allergy or anaphylaxis
 Type II (Cytotoxic Hypersensitivity)
Antibody dependent (IgM or IgG) cytolytic reactions
 Type III (Immune Complex Hypersensitivity)
Immune complex reactions (mediated by IgM or IgG)
 Type IV (Delayed Hypersensitivity -DTH)
cell mediated immunity, such as tuberculin test
 Type V (Noncytotoxic or Stimulatory Hypersensitivity)
same underlining mechanism as type II hypersensitivity (IgG
6
or IgM) but instead of damage it alters tissue activation
Type I – Immediate Hypersensitivity
 Limited number of allergens when deposited in low doses on
mucosal epithelial cells or skin trigger mast cells activation
 Allergens include
Pollens, trees, grass, and dust
Food allergens
Milk, eggs, fish, cereals, nuts
Insect bites, mite feces, dogs, cats
Reaction against drugs (penicillin) and other haptens,
mold spores, etc.
7
Clinical Presentation of Type I Hypersensitivity
 Wheel and flair – almost immediate
vasodilation with infiltrate presenting as
wheel and inflammation around
 Atopic dermatitis (atopic
eczema) – itchiness which is not
caused by histamines
hence anti-histamines would not
help with eczema
1/5 infants (due to fragile skin)
8
vs. 1/50 adults develop eczema
Clinical Presentation of Type I Hypersensitivity
 Hives (urticaria) – itchiness
linked to histamine release
Individual lesions usually do
not last longer than 1-2 days
healthy lung
airway
inflamed
lung airway
 Asthma – allergens act on the
tracheobronchial tree
Inflammation causes edema of
PENTAX Medical Company.
the airway wall
Hyper-secretion of mucus
9
causes airflow obstruction
Clinical Presentation of Type I Hypersensitivity
 Allergic rhinitis: (hay fever) –
acts on the mucus membranes of
the nose and eye
Congestion, itchiness, and
sneezing
10
Clinical Presentation of Type I Hypersensitivity
 Anaphylaxis: life threatening reaction do to systemic flood
of immunomodulators triggered by allergens (peanuts, bee
sting, shellfish food, penicillin, etc.)
lower-air way obstruction and hypotension caused by
intense constriction of bronchioles and bronchi,
contraction of smooth muscles, and dilatation of capillaries
 Food allergy will cause inflammation, diarrhea, and/or
vomiting
if the allergen penetrates the GIT wall then it may cause
systemic reactions:
skin eruptions (urticaria), bronchospasm, and
anaphylactic shock
11
Allergic March
 Eczema (atopic dermatitis) is often linked with food allergy,
asthma, or allergic rhinitis (hay fever)
This order is also known as atopic (allergic) march
 Children with atopic dermatitis are more likely to develop
asthma or rhinitis
12
http://e-allergy.org/eng/contents/sub03_01.html
Mechanism of Type I
Hypersensitivity
 Immediate reaction is a quick
release of preformed
immunomodulators, known as
mast cells degranulation:
Histamine: vascular dilation,
smooth muscle contractions
13
Proteases: tissue damage
Mechanism of Type I
Hypersensitivity
 Late phase can be broken
into two blocks:
Switch in the expression
drives production of lipid
mediators from arachidonic
acid – known as slowreacting substance of
anaphylaxis (SRS-A)
Hours later there is a
14
recruitment of eosinophils
and neutrophils due to
release of cytokines (TNFα; IL-4; IL-13) causing
localized inflammation
Immediate vs. Late Reaction
15
Mechanism of Type I Hypersensitivity
 Sensitization phase – allergen triggers IgE production
some individuals (20%) are genetically predisposed to make
IgE against harmless environmental antigens
Association between some HLA alleles and allergic reaction
has been documented for number of allergens.
 TH2 drives IL-4 production leading to IgE buildup
 Mast cells in the mucosal tissues or under the skin have high
affinity FcεRI which binds IgE even in absence of allergen
 Activation phase – re-exposure to allergen associates with
existing IgE bound to FcεRI on mast cells within minutes
Mast cells are activated leading to immediate and
16
followed by late reaction of type I hypersensitivity
Type I- Hypersensitivity
Primary mediators
Histamine
Vascular permeability, smooth muscle contraction
Serotonin
Neurotransmitter – smooth muscle contraction
ECF-A
Eosinophil chaemotaxis
NCF-A
Neutrophil chaemotaxis
Proteases
mucus secretion, connective tissue degradation
Tryptase
serine proteinase of mast cells
Heparin
initiates bradykinin production causing swelling, anaphylaxis
Secondary Mediators
Leukotrienes vascular permeability, smooth muscle contraction
vasodilation, smooth muscle contraction or dilation , platelet
Prostaglandins
activation
Bradykinin
vascular permeability, smooth muscle contraction
numerous effects causing activation of vascular endothelium,
Cytokines
eosinophil recruitment and activation
Cells involved in type I hypersensitivity
Mast cells
Degranulation leading to release of inflammatory mediators
TH2
IL-4 production promotes Ig class switch to IgE, blocks TH1
Eosinophils
Produces a variety of mediators and cytokines: IL3 and IL5
17
Allergy (Skin Prick) Test
18
http://www.medicalook.com/tests/Allergy_Skin_Tests.html
5
Diagnosis
 In vivo skin prick test with batteries of allergens
takes 5 -30 min to observe wheal and flare reaction
Late-phase reaction – may last 24 hours
More edematous then the early reaction
Dense infiltration of eosinophils and T cells
 ELISA: measurement of allergen specific serum IgE
 Radio-allergo-sorbent test (RAST) is serum based and
permits identification of specific IgE against potential
allergens.
RAST is now consider obsolete do to the development of
the more sensitive “fluorescence enzyme-labeled assays”
19
Hygiene Hypothesis
 Allergic individuals have increase of allergen specific CD4
TH2 cells greater amount of IL-4 which inhibits TH1
 There is an increasing evidence that lack of exposure to
bacteria (stimulation of the Th1 responses) in early life
favors the Th2 phenotype.
 Lower incidence of allergic disease in individuals who farm
or live in rural communities: they are presumably exposed to
organisms from livestock.
 Lower incidence of allergic disease in third world countries
with limited access to sanitation facilities
20
Treatment
 Environmental: avoidance of allergen
 Pharmacological treatment
Antihistamine: block histamine receptors
Sodium cromoglycate: prevents degranulation by
stabilizing the cell membrane of mast cells and basophils
Epinephrine: the most effective for life saver
Reverses anaphylactic shock caused by histamine: relaxes
smooth muscles, decrease vascular permeability
Increase heart beat rate – increase blood pressure
Corticosteroids:
Block metabolic pathways involving arachidonic acid
They have general anti-inflammatory effects
21
Underlining Mechanism of
Immunotherapy by Desensitization
SLIT - sublingual
immunotheraphy;
SCIT - subcutaneous
immunotheraphy
22
Update in the Mechanisms of Allergen-Specific Immunotheraphy; Allergy
Asthma Immunol Res; v.3(1); Jan 2011 ; Tunc Akkoc,1 Mübeccel Akdis,2
and Cezmi A. Akdi
Immunotherapy by Desensitization
 Desensitization also known as allergy vaccination
 Small amounts of allergen are injected on regular intervals to
switch the response away from TH2 induced IgE
IFN cytokine production by TH1 suppresses TH2
IgG4 production driven by IL-10 cytokine (Tr1 and
others) wipes away the available allergen
Suppresses production of IL-4 by TREG blocks TH2
 Desensitization has to be done under doctor’s monitoring
due to a risk of anaphylactic reaction and if stopped it is lost.
23
Type II – Cytotoxic Hypersensitivity
 Antibodies involved are IgG and/or IgM
 Occurs when specific antibodies attack antigens on cell
surfaces, tissues, or organs.
 Such antibodies will initiate:
Damage (e.g. cell lysis) due to activation of the complement
Attack by neutrophils through Fc receptor and release of
cytokines, oxygen radical, and other inflammatory mediators
Opsonization and phagocytosis of cells such as RBC
Killing of antibody coated cells by antibody dependent cellular
cytotoxicity (ADCC)
24
Type II – Cytotoxic Hypersensitivity
25
Examples of Type II Cytotoxic Hypersensitivity
 Blood transfusion reactions
Individuals with blood type O have natural IgM antibodies
against blood type A and B antigens
If type O person receives blood transfusion of type A or B, the
preformed IgM will bind and lyse the transfused RBC
 Rh incompatibility reactions: Erythroblastosis fetalis
Rh antigen first isolated in Rhesus monkey
Rh are antigens on RBC, like the AB antigens
A person could
Express the antigen as homozygous dominant (Rh+Rh+) or
heterozygous (Rh+Rh-)
Lack the antigen as homozygous recessive, (Rh-Rh-)
26
Hypersensitivity Type II: Rhesus Disease.
27
Hypersensitivity Type II: Rhesus Disease
 There is a potential problem when a Rh- Rh- mother
conceives Rh+Rh- fetus from Rh+ father
 First child (Rh+ ) will normally be born without problems
 During delivery the mother will be sensitized by Rh+antigen
 IgG antibodies are produced against Rh factor (anti-D ; anti-
RhD) and will circulate in the mother
 Next time the woman gets pregnant with Rh positive fetus,
IgG will cross the placenta and destroy fetal red blood cells
 This is known as hemolytic disease of the newborn:
erythroblastosis fetalis
28
Prevention of Erythroblastosis Fetalis
 Treatment is in a form of a passive immunization
Rh negative mothers are given RhoGAM: human preparation
of anti-RhD IgG antibodies
Given about 28 weeks of pregnancy, and within 72 hours after
childbirth.
RhoGAM prevents sensitization of the maternal immune
system to Rh D antigens that causes rhesus disease.
A possible mechanism is that RhoGAM mopes away the
reacting anti-RhD antibodies (RhoGAM is in minute amounts).
Currently it is believed that RhoGAM is tolerogenic and
induces some kind of regulatory cells.
The widespread use of anti-Rho(D) immunoglobulin have led
29
to disappearance of the Rh disease
Daily Mail:
“Man with the golden arm' saves 2million babies in half a century of
donating rare type of blood”
Read more: http://www.dailymail.co.uk/news/worldnews/article-1259627/Mangolden-arm-James-Harrison-saves-2million-babies-half-century-donating-rare-blood.html
 An Australian man who has been donating his extremely rare
kind of blood for 56 years has saved the lives of more than two
million babies. James Harrison, 74, has an antibody in his
plasma that stops babies dying from Rhesus disease, a form of
severe anaemia. He has enabled countless mothers to give birth
to healthy babies, including his own daughter, Tracey, who had
a healthy son thanks to her father's blood. Mr Harrison has been
giving blood every few weeks since he was 18 years old and
has now racked up a total of 984 donations. When he started
donating, his blood was deemed so special his life was insured
for one million Australian dollars. He was also nicknamed the
'man with the golden arm' or the 'man in two million‘.His blood
has since led to the development of a vaccine called Anti-D. He
said: 'I've never thought about stopping. Never.' He made a
pledge to be a donor aged 14 after undergoing major chest
surgery in which he needed 13 litres of ……….
30
Examples of Type II Cytotoxic Hypersensitivity
31
Noncytotoxic or Stimulatory Type II
Hypersensitivity Also Known as Type V
 Auto-antibodies (IgG or IgM) against receptors instead of
destroying the tissue they will alter their function
Instead of cell lyses the antibodies will interfere by blocking or
enhancing receptor function
 Graves disease: Stimulating auto-antibodies
against thyroid-stimulating hormone (THS)
receptor on thyroid cells: hyperthyroidism
 Symptoms: fatigue, nervousness, increased
sweating, palpitation, weight loss and heat
intolerance
 Children born from mothers with Grave’s
disease may show hyperthyroidism (IgG)
32
 Associated with HLA-DR3; and others: HLA-Bw35, etc.
Type V Hypersensitivity: Myasthenia Gravis
 Auto-antibodies against acetylcholine (Ach) receptor will block
the binding of acetylcholine at the neuromuscular junction:
Initially there is suppression of neuromuscular signaling and
eventual damage of acetylcholine receptors
 Pregnant mother can transfer IgG antibodies to the unborn
children causing transient neuromuscular dysfunction
Symptoms include:
muscle weakness that improve with rest
blurry or double vision (diplopia)
eyelid drooping (ptosis)
difficulty in swallowing
shortness of breath
impaired speech
33
Hypersensitivity Type III: Immune Complex
34
Type III: Immune Complex Hypersensitivity
 Triggered by high level of circulating immune complex
(IC) when IgG or IgM binds foreign (infection) or self
antigens
 Under normal conditions circulating Ag/Ab complex is
cleared by monocytes / microphages
excessive amount of antigen leads to overwhelming amount
and deposition of immune complex (Ag-Ab) that monocytes
fail to remove
 Immune complex can be deposited in various tissues: skin,
kidney, blood vessels, joints, lungs and leads to
complement activation and induction of inflammation
attraction of neutrophils followed by tissue damage
35
Examples of Type III Hypersensitivity
 Arthus reaction (cutaneous vasculatis):
Localized cutaneous and subcutaneous inflammatory
response triggered by injection and deposition of antigen
Localized inflammation starts with complement activation
e.g. on blood vessel: results in vasodilatation and rupture
of blood vessels, edema, induration, and some cases
hemorrhagic necrosis of local tissue
 Farmer’s lung: (alveolar inflammation)
Inhalation of antigen, e.g. mould from Actinomyces
species or various Aspergillus species , mouldy hay grain
Causing hypersensitive pneumonia
36
Examples of Type III Hypersensitivity
 Serum sickness: originally has been observed as reaction
against treatment with horse serum as passive immunization
Type III systemic inflammatory response to the presence of
immune complexes .
not like arthus reaction which is localized)
Symptoms appear few days after exposure to antigen and
include
Fever, urticaria (hives), arthralgia, lymphadenopathy,
spleenomegaly
Symptoms disappear after few days when antibody level
increases and antigen level falls down
37
Circulating Ag-Ab Complex in Serum Sickness
http://www.foamem.com/2014/03/27/briefs-serum-sickness-like-reaction/
2014, Brad Sobolewski, MD, MEd
38
Delayed Type IV Hypersensitivity
 Delayed type hypersensitivity (DTH) is also known as cell-
mediated immune memory response
 It is entirely relying on T lymphocyte function and
antibody-independent mechanism
 The response is delayed because it takes hours (days) to
recruit inflammatory cells and often lasts for days.
 The T cell response may be directed against
Auto-antigens
Fixed chemicals that get in contact with skin, e.g. contact
dermatitis
Transplant tissue
39
Microbes
Delayed Type IV Hypersensitivity
 Sensitization stage:
Contact of T cell with antigen on APC
This results in the activation of the naïve T cell (priming)
 Challenge state:
Repeated exposure or persistent antigens will drive APC
presentation to T cell (TH1, TH2, and TH17) which will
proliferate and deliver their effector function
This results in localized overproduction of cytokines and
recruitment of macrophages will eventually cause tissue
damage or granulomas
If antigen (pathogen) elimination is delayed, the activated T
40
cells and macrophages will continue producing cytokines and
triggering inflammation
Delayed Type IV Hypersensitivity
 Steps following the cytokine release
Accumulation of macrophage to the site, which can
transform to:
giant cells – fusion of activated macrophages
epithelioid cells – activated macrophages that are
resembling epithelial cells,
Continue to secrete cytokines
Attract eosinophils to site which will degranulate and
cause tissue damage
Indiscriminate cytotoxicity by activated macrophages,
neutrophils, NK cells, Tc cells driven by cytokines
41
Delayed Type IV Hypersensitivity
 Persistent antigens will result in chronic granuloma:
Mass composed of giant cells, epithelioid, proliferating
lymphocytes, proliferating fibroblasts and formation of
fibrosis
Formation of excess fibrous connective tissue in an
attempt of the organism to isolate and wall off the
infection, the antigen trigger, or the foreign material
 If the accumulated macrophages and monocytes destroy the
antigen then the lesion will heal
 Unfortunately the more tissue is damage the more self-
antigens are released and this perpetuate the reaction
42
Mechanisms of
Type IV
Hypersensitivity
43
Examples of Type IV Hypersensitivity
 Tuberculin test – Mantoux (PPD) test
Injection of tuberculin to the skin to check for previous
Mycobacterium tuberculosis infection
Reaction is characterized by erythema and induration –
reaches maximum 24-48hrs
44
Purified Protein Derivative – PPD ; Anastácio Q. SousaI,II; Margarida M.L. PompeuII; C. Jaime Araujo FilhoI; Telma R.B.S. QueirozI; J. Clementino
FerreiraII ; http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702006000600015
Examples of Type IV Hypersensitivity
 Contact dermatitis (sensitivity) – caused by contact with
small molecules, e.g. nickel, formaldehyde, poison oak,
poison ivy (the hapten urushiol), hair dyes
the small molecules acts as
a hapten in contact with
skin or other body proteins
the sensitized person develops erythema, itching, eczema,
blisters, or necrosis of skin with 12 – 48 hours.
45
Type IV Hypersensitivity Skin Patch Test
Results are analyzed at 48h/72h
46
1)
2)
https://i.ytimg.com/vi/zY26QENqe3A/maxresdefault.jpg
Indian journal of dermatology; Year : 2014 | Volume : 59 ; Aeroallergen patch testing in patients of suspected contact dermatitis ; Nelee Bisen1,
Shrutakirthi D Shenoi2, C Balachandran2
Delayed hypersensitivity reactions
Type
contact
tuberculin
Reaction
Clinical
time
appearance
Antigen and site
48-72 hr
eczema
lymphocytes, followed epidermal ( organic
by macrophages;
chemicals, poison ivy,
edema of epidermis
heavy metals, etc.)
48-72 hr
local
induration
lymphocytes,
monocytes,
macrophages
intradermal (tuberculin,
lepromin, etc.)
hardening
macrophages,
epitheloid and giant
cells, fibrosis
persistent antigen or
foreign body presence
(tuberculosis, leprosy, etc.)
21-28
granuloma
days
47
Histology
Examples of Type IV Hypersensitivity
 Granulomatous inflammations observed in:
Sarcoidosis
Crohn disease
 Hashimoto’s thyroiditis
 Allograft rejection,
 Graft versus Host Disease (GvHD)
 Diabetes mellitus type 1
 Multiple sclerosis
 Superantigen mediated diseases (toxic shock syndrome)
 Ankylosing Spondylitis
48
References
 Basic Immunology by Abbas et al, 4th edition, 2014
Chapter 11; page 207-223
49
Ivo Boudakov, Ph.D.
Ver. 2016
Autoimmunity
IMMUNOLOGY (BMIC550)
Learning Objectives
FYI
 Topics and keywords to be discussed: Autoimmune diseases – T and B cell
dependency. Self and non-self antigens. Central and peripheral immune tolerance.
Immune tolerance failure: genetic and gender predisposition. Role of infections in
autoimmunity. Review various autoimmune diseases. Antibody mediated diseases:
Autoimmune hemolytic anemia; Idiopathic thrombocytopenic purpura; Goodpasture
Syndrome; Cold Agglutinin Disease; Myasthenia gravis; Graves’s disease;
Pernicious anemia; Systemic lupus erythematosus (SLE); Hashimoto’s thyroiditis.
Cell mediated diseases: Insulin dependent diabetes mellitus; Multiple sclerosis;
Autoimmune polyendocrinopathy syndrome (APS-1); Mixed diseases: Rheumatoid
arthritis; Treatment.
149. Explain and link to clinical presentation central and peripheral tolerance.
150. Explain antigen sequestration as it relates to tolerance and how tolerance
can be broken.
151. Define the terms molecular mimicry and cross reactivity. Explain how
infectious diseases could play in the development of autoimmunity.
152. List disorders that have a known association with MHC genes (Supporting
charts).
2
Learning Objectives
FYI
153. For each of the disorders/disease listed in the accompanying table be able to
discuss:
 (i) name of the disorder
 (ii) primary cause underlying the disorder
 (iii) autoantigen (if present)
 (iv) autoantibodies(if present)
 (v) characteristic features
 (vi) investigations
 (vii) mechanism of the pathology
154. For each of the disorders listed in the accompanying table, determine the
immunological processes that lead to the pathology observed.
155. For each of the disorders listed in the accompanying table discuss at least
one potential immunological therapy and provide a rationale for that
choice.
3
Autoimmune diseases
 Failure of immune tolerance will cause over reaction against
self antigens eventually leading to autoimmunity
 Many people experience an autoimmune symptoms during
their lifetime but they are usually short-lived and selfresolving. The autoimmune symptoms maybe initiation by:
infection
tissue damage due to trauma
 Auto-reactive antibodies produced in most of these cases are
harmless and they do not lead to serious pathology
 If the immune system cannot return to its resting state then
chronic and debilitating autoimmunity will develop
4
Examples of Tolerance Failure Driving
Autoimmunity
Failure in
Primary mediators
Central
tolerance
• Autoimmune polyendocrine syndrome type 1
(APS-1), due to defect in AIRE gene function
Antigen
segregation
Peripheral
anergy
•
•
•
•
•
Uveitis;
Multiple sclerosis (MS)
Insulin-dependent diabetes mellitus (type 1);
Hashimoto thyroiditis
Immune-dysregulation polyendocrinopathy
Regulatory cells
enteropathy X-linked (IPEX) syndrome
• Rheumatic fever;
Antigen mimicry • Graves Disease;
• Lyme arthritis
5
Prevalence of Autoimmune Diseases
1800
1700
1600
1400
1200
Reported Average Prevalence of Autoimmunity Rates per 100,000
Individuals-per-year According to Various Worldwide Studies
1100
1000
800
600
400
200
739
500
350
300
300
270
220
160
150
110
100
90
25
14
13
12
12
0
6
Compiled Studies: The Cost Burden of Autoimmune Disease: The Latest Front in the War on Healthcare Spending ; National Coalition of Autoimmune Patient Groups
(NCAPG), in March 20103.
12
5
Multifactorial
Disorders
 Autoimmune diseases are
multifactorial by nature
 Sex hormones (e.g. gonadal
sex steroids) are important
modulators of the immune
and autoimmune response
7
Nature Immunology 2, 777 - 780 (2001) ; Sex differences in autoimmune disease Caroline C.
Whitacre; http://www.nature.com/ni/journal/v2/n9/fig_tab/ni0901-777_ft.html
Gender Determined Ratio in Autoimmunity
Disease
Hashimoto's thyroiditis
Primary biliary cirrhosis
Sjogren's syndrome
Systemic lupus erythematosus
Chronic active hepatitis
Graves' disease
Rheumatoid arthritis
Scleroderma
Multiple sclerosis
8
Sex (Female:Male)
50:1
9:1
9:1
9:1
8:1
7:1
4:1
4:1
2:1
What Causes Breakdown of Immune Tolerance?
 Hormone influence/sex
Autoimmune diseases are more common in women than men
Severity of autoimmune diseases in women tends to ameliorate
during pregnancy and they follow a relapse after giving birth
Sex hormones affect the immune response by modifying the
patterns of gene expression
 Age:
Frequency of autoimmune disease increases with age
Autoimmune diseases almost non existent in childhood
First appearance is in the age of 20 - 40 years
Failure of the immune regulatory mechanisms with age
9
advancement
What Causes Breakdown of Immune Tolerance?
 Autoimmune diseases tend to be common among members
of the same families when they share some HLA haplotypes
probably due to an increased likelihood of presenting certain
autoimmune antigen (hypothesis that still has to be proven)
 It may be possible that other genes linked with HLA genes
are responsible
 There is direct linkage between some HLA types and the
increased risk of disease occurrence compare to the general
public
Note: keep in mind that various literature sources have
variations in the listing of HLA haplotypes linked to the
same autoimmune disorders
10
Risk of Autoimmune Linked to Sex and HLA
Disease
Multiple sclerosis
Type 1 diabetes
HLA allele
DR2
DQ2 + DQ8
4.8
20
10
N/A
DQ6
0.2
N/A
14
25
3.7
25
4.2
3.2
N/A
-1
4-5
-1
3
4-5
5.8
10-20
14.4
87.4
10
-1
0.3
<0.5
DQ8
DR3/DR4 heterozygote
Graves' disease
DR3
Myasthenia grads
DR3
Rheumatoid arthritis
DR4
Hashimoto thyroiditis
DR5
Systemic lupus
DR3
erythematosus (SLE)
Pemphigus vulgaris
DR4
Ankylosing spondylitis
B27
Acute anterior uveitis
B27
11
Relative risk Sex (F:M)
SOURCE: modified from Janeway's Immunobiology 8th ed., 2012
Role of Infections
 Many autoimmune diseases follow infectious episodes
Possible explanation is molecular mimicry where the
pathogen is having a cross reacting antigen with the host
e.g. Yersinia enterocolitica share epitopes with thyroid
stimulating hormone
 Microbial material may serve as an adjuvant for self
antigens, which will make them immunogenic
 Microbial materials acting as mitogens where numerous
clones of lymphocyte are activated in non-specific manner
causing polyclonal activation
usually dormant self reacting lymphocytes can be
12
stimulated against self tissue in such instances
Viruses
Bacteria
Table 66-2. Microbial infections associated with autoimmune diseases. ;
Review of Medical Microbiology and Immunology, 13e. Warren Levinson;
LANGE (NOTE: know the entries in bold font)
13
Microbe
Streptococcus pyogenes
Campylobacter jejuni
Escherichia coli
Chlamydia trachomatis
Shigella species
Yersinia enterocolitica
Borrelia burgdorferi
Hep B virus; EBV; Measels; others
Hepatitis C virus
Measles virus
Coxsackievirus B3 (myocitic Tc damage)
Coxsackievirus B4 (in mice only so far)
Cytomegalovirus
Human T-cell leukemia virus
Autoimmune Disease
Rheumatic fever
Guillain-Barre syndrome
Primary biliary cirrhosis
Reiter's syndrome
Reiter's syndrome
Graves' disease
Lyme arthritis
Multiple sclerosis
Mixed cryoglobulinemia
Allergic encephalitis
Myocarditis
Type 1 diabetes mellitus
Scleroderma
HTLV-associated myelopathy
Causes of Tolerance Breakdown
 Alteration of normal proteins
Drugs or compounds from pathogens can bind to normal
proteins and make them immunogenic
Procainamide (antiarrhythmic agent) induces systemic
lupus erythromatousus (SLE)
 Release of sequestered antigens
Trauma or infection exposes hidden antigens to the
immune system
Example: anterior uveitis- primarily to the anterior
segment of the eye. Causes:
post-surgical (most common cause) ; trauma (second
14
most common cause) ; herpesvirus infection ; others
Table 66-1. Important Autoimmune Disease, 13e. Warren Levinson;
LANGE
Type of Response
Antibody to receptors
Antibody to cell
components other than
receptors
Cell-mediated
15
Autoimmune Disease
Myasthenia gravis
Graves' disease
Insulin-resistant diabetes
Lambert-Eaton myasthenia
Systemic lupus erythematosus
Rheumatoid arthritis
Rheumatic fever
Hemolytic anemia
Idiopathic thrombocytopenic purpura
Goodpasture's syndrome
Pernicious anemia
Hashimoto's thyroiditis
Insulin-dependent diabetes mellitus
Addison's disease
Acute glomerulonephritis
Periarteritis nodosa
Guillain-Barre syndrome
Wegener's granulomatosis
Pemphigus
IgA nephropathy
Allergic encephalomyelitis and multiple
sclerosis
Celiac disease
FYI
Main Targets
Acetylcholine receptor
TSH receptor
Insulin receptor
Calcium channel receptor
dsDNA, histones
Joint tissue
Heart and joint tissue
RBC membrane
Platelet membranes
Basement membrane of kidney and lung
Intrinsic factor and parietal cells
Thyroglobulin
Islet cells
Adrenal cortex
Glomerular basement membrane
Small and medium-sized arteries
Myelin protein
Cytoplasmic enzymes of neutrophils
Desmoglein in tight junctions of skin
Glomerulus
Reaction to myelin protein causes
demyelination of brain neurons
Enterocytes
The Spectrum of
Autoimmune Diseases
Fig. 26.3 Autoimmune diseases
may be classified as organspecific or non-organ-specific
depending on whether the
response is primarily against
antigens localized to particular
organs, or against widespread
antigens.
16
SOURCE: Immunology ; 6th Edt. ; Ivan Maurice Roitt, Jonathan Brostoff,
David K. Male ; 2001
Organ specific
FYI
Hashimoto's thyroiditis
Primary myxoedema
Thyrotoxicosis
Pernicious anaemia
Autoimmune atrophic gastritis
Addison's disease
Premature menopause (few cases)
Insulin-dependent diabetes mellitus
Stiff-man syndrome
Goodpasture's syndrome
Myasthenia gravis
Male infertility (few cases)
Pemphigus vulgaris
Pemphigoid
Sympathetic ophthalmia
Phacogenic uveitis
Multiple sclerosis (?)
Autoimmune haemolytic anaemia
Idiopathic thrombocytopenic purpura
Idiopathic leucopenia
Primary biliary cirrhosis
Active chronic hepatitis (hbsag negative)
Cryptogenic cirrhosis (some cases)
Ulcerative colitis
Atherosclerosis(?)
Sjogren's syndrome
Rheumatoid arthritis
Dermatomyositis
Scleroderma
Mixed connective tissue disease
Anti-phospholipid syndrome
Discoid lupus erythomatosus
Systemic lupus erythomatosus (SLE)
Non-organ specific
Examples of Type II Cytotoxic Hypersensitivity
 Goodpasture syndrome: antibodies against glomerular
basement membrane (GBM) antigen {collagen alpha-3 (type
IV) protein; gene COL4A3} present in lung and kidney.
Symptoms: coughing blood (lung) and burning sensation
during urination.
Leads to lungs and kidney failure.
Treatment is based on immunosuppressant (corticosteroids and
cyclophosphamide)
 Rheumatic fever (note: this is not rheumatoid arthritis)
Antigens from the cell wall of Streptococcus can induce cross-
reacting auto-antibodies against myocardial antigens
Causes myocarditis, rheumatoid arthritis, inflammation
17
Examples of Type II Cytotoxic Hypersensitivity
 Autoimmune hemolytic anemia
Self generated antibody against ones own RBC causes
destruction and very short half life of the RBCs
Etiology is not clearly known, but drugs have been implicated
Symptoms include: fatigue, fever, jaundice, splenomegaly, and
anemia
 Idiopathic thrombocytopenia purpura:
Self made anti-platelets antibodies
which will cause bleeding spots in skin
petechiae; purpura
bleeding in various organs: gums,
gasterointestianl tract, genitourinary
tract
18
Examples of Type II Cytotoxic Hypersensitivity
 Drugs can also induce thrombocytopenia and it is known as
drug-induced-thrombocytopenia: hundreds of various drugs:
sulfonamides, antihistamine drugs, NSAIDs, etc.
 Cold (hem) agglutinin disease:
Infection triggers: Mycoplasma pneumonaie, EBV, CMV, etc.
Auto-antibodies target RBC only at temp. lower than 37 C
Destruction of RBC noted mostly in the arms and legs
Unless the production of new RBC keeps up with the rate of
destruction, the person will suffers of anemia
Cold agglutinins – cross reacting IgM antibodies against RBC
Coombs test could be false negative if not properly performed:
19
because IgM are raised, react, and activate compliment only at
low temperature against glycophorin on RBC.
Drug Known to Induce Type II Hypersensitivity
 Some drugs will act as hapten when combine with cell
surface structures, inducing production of antibodies
as a result the cells are destroyed following complement
fixation, cell lysis, or opsonization
 Sedormid (a sedative drug) binds to platelets and will
induce antibody production
This results in platelet destruction (thrombocytopenia) and
leads to purpura – bleeding
 Chloramphenicol – binds to white blood cells,
Results in agranulocytosis (decreased WBC count)
 Chlorpromazine (tranquilizer) or phenoacetin (analgesic):
Bind to RBC and causes hemolytic anemia
20
Glomerulonephritis – Type III
 Glomerulonephritis (glomerular nephritis, GN): a renal
disease linked to inflammation of the glomeruli (small blood
vessels in the kidneys).
Circulating immune complex is frequently prerequisite for
glomerulonephritis
usually follows skin infection by group A streptococci and it
appears about 10 days after infection, e.g. post-streptococcal
acute glomerulonephritis
The inflammatory process damages the basement membrane
causing linkage of serum proteins – proteinuria
21
Systemic lupus erythematosus (SLE)- Type III
 It is initiated by immune-complex hence type III
 Auto-antibodies against double stranded DNA and other
part of the cell nucleus: histones, nuclear protein
 Systemic, multi-organ
inflammation affects
kidney, skin, joints,
muscles, lungs
22
Systemic lupus erythematosus (SLE)- Type III
 Specific etiology is not always known although that in some
cases a link is established with some drugs (>30):
Most prominent are procainamide (antiarrhythmic agent),
hydralazine (high blood pressure), isoniazid (antibiotic)
 Symptoms:
Prominent skin erythematous rash around the nose and
cheeks – butterfly rush
Mixed connective tissue involvment overlapping with
rheumatoid arthritis
Renal involvement
Central nervous system involvement (50%): depression,
psychoses, seizures
23
HLA Association with SLE Varies Between
FYI
Different Ethnic Groups
 The disease mainly affects women: age of 20-60 years old and is
associated with various HLA markers / ethnicities
Author
Caucasian
Arnett
Fernades et al.
Reivelle et al.
Rudwaleit et al.
Barron et al.
Rudwalet et al. and
Hong et al.
Hashimoto et al.
and Doherty et al.
Wilson et al.
Liphaus et. al.
24
Ethnic Groups
Black
Asian
Mixed
HLA-DR2/DR3
-
-
-
HLA-DR2
-
-
-
-
HLA-DR2
-
-
-
HLA-DR2
-
-
HLA-DR2
-
-
HLA-DR3
-
-
HLA-DR9
-
-
-
HLA-DR15 (2)
-
-
-
HLA-DR1/DR4
HLA-DR7
HLA-DR15 (2) HLA-DR8
HLA-DR7
SOURCE: http://www.scielo.br/pdf/rhc/v57n6/a06v57n6.pdf / REV. HOSP. CLÍN. FAC. MED. S. PAULO 57(6):277-282, 2002 / Bernadete de L. Liphaus, Anna
Carla Goldberg, Maria Helena B. Kiss and Clovis A. A. Silva ; ANALYSIS OF HUMAN LEUKOCYTE ANTIGENS OF CLASS II-DR IN BRAZILIAN CHILDREN
AND ADOLESCENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS
Rheumatoid arthritis – Type III / IV
 During the active phase of the disease patients have high level of
rheumatoid factor and low level of complement is observed
 Anti-citrullinated protein antibodies (ACPAs) are relatively
new highly sensitive and specific markers that are superior
alternative of the rheumatoid factor (RF) for predicting and
monitoring the disease progression
25
Rheumatoid arthritis – Type III / IV
 Chronic inflammatory autoimmune disease of primarily affecting
small joints of the hands and feet and associated with HLA-DR4
 Common among women between 30-50 years of age
 Etiology is not completely understood and may also be infectious
leading to degradation of cartilage and bone erosion.
 Synovial membrane of the inflamed joint is infiltrated with T
cells (CD4), plasma cells, macrophages, synovial fluid with high
level of cytokines: TNF, IL-1 (type IV)
 Individuals with this disease form “rheumatoid factor” which
are IgM and IgG antibodies against the Fc region of normal
autologous IgG antibodies
 Deposition of immune complex on blood vessels and synovial
26
membrane will activate complement (type III)
Type 1 Diabetes Mellitus – Type IV
 Diabetes mellitus type 1 also known as juvenile diabetes
or insulin dependent diabetes mellitus (IDDM)
Destruction of pancreatic beta cells in the islets of Langerhans
due to auto-reactive T cell mediated cytotoxicity
there is no synthesis of insulin causing insulin dependency
Auto-antibodies area also produced that may serve as disease
monitoring markers, but their direct role in the disease outcome
is not clear:
Anti- islet cell; enzyme glutamic acid decarboxylase; insulin
 Epidemiology:
Affects 1 in 500 people in the US ; childhood onset but also
27
happens in early 30s and 40s; associated with HLA-DR3,
DR4, DQ2, DQ8 haplotypes
Type 1 Diabetes Mellitus – Type IV
 Viral infection seems to play role and often precedes the
onset of IDDM.
 Probably this s the case of Antigenic mimicry linked to
 Mumps; Cytomegalovirus, Influenza, Coxsackievirus
 There is a similarity between 6-amino acid sequence of
coxsackievirus protein and glutamic acid decarboxylase
 Isolated coxsackievirus B4 strain from IDDM patient causes
IDDM in mouse animal models
 Similarly mumps and coxsackievirus can destroy islet cells
in vitro
28
Multiple sclerosis – Cell Mediated Type IV
 Affects the nervous system by
demyelination of the white matter in brain
 Symptoms include motor weakness, ataxia,
impaired vision, mental aberrations
Mediated by auto-reactive T cells and
activated macrophages.
 Viral infection may also play role:
Multiple sclerosis patients have high
elevated level of anti measles antibodies
T cell clones derived from a MS patient
reacted against both myelin basic protein
and Epstein Barr virus
29
Autoimmune polyendocrinopathy syndrome
(APS-1) – Type IV
 Multiple autoimmune diseases are linked to APS-I:
 Present with hypothyroids, hypogonadism, and infertility
 Candidiasis, vitiligo (skin depigmentation),
alopecia (baldness)
 Addison’s disease (pernicious anemia): symptoms include
chronic adrenal insufficiency and hypocortisolism
 In the absence of functional AIRE it would be no self
tolerance to peripheral tissue antigens
 An autosomal recessive disorder mapped to AIRE gene on
chromosome 21 with >42 known mutations
30
Autoimmune polyendocrinopathy syndrome
(APS-1) – Type IV
 AIRE is a transcription factor capable of regulating the
expression of various tissue specific proteins in thymus
 its expression tissue within the thymic medullary epithelial
cells leads to negative selection
 hence it directs development of central T cell tolerance during
T cell development that takes place in the thymus.
 Treatment- targets individual disease present in APS patents:
 Endocrine: levothyroxine for hypothyroids, fludrocortison
for Addinson’s disease
 Anti-infectious treatment during candidiasis outbreaks
31
Treatment of Autoimmune Diseases
 Each disease has an individual approach
 In organ specific autoimmune disease the target will be the
organ and treating for a metabolic correction/control:
Treated with insulin for IDDM
Anti-thyroid drugs for Graves’ disease
Replacing damaged tissue - stem cell research
 Immunotherapy
Monoclonal antibodies against certain cytokines
Anti TNF antibodies or use of soluble receptors for TNF (as
decoy) for rheumatoid arthritis
32
Treatment
 Chemotherapy
Suppression of the immune response to reduce symptoms, but
this increases the risk of opportunistic infections
Anti-inflammatory drugs
Corticosteroids: control inflammatory lesion by inhibiting
the influx of neutrophils and other phagocytic cells
Immunosuppresive drugs
Cyclosporin: inhibits cytokine synthesis by T cells
Other drugs such as azathioprine – nucleoside analogue that
inhibits DNA synthesis: prevent proliferation of lymphocytes
33
References
 Basic Immunology by Abbas et al, 4th edition, 2014
Chapter 11; page 207-223
34
Ivo Boudakov, Ph.D.
Ver. 2016
Autoimmunity
IMMUNOLOGY (BMIC550)
Learning Objectives
FYI
 Topics and keywords to be discussed: Primary and secondary
immunodeficiencies. B cell and antibody deficiencies: Bruton’s disease (X – linked
infantile agammaglobulinemia) ; Transient hypogammaglobulinemia; Common
variable hypogammaglobulinemia; Selective immunoglobulin deficiencies;
Immunoglobulin deficiency with increased IgM; Selective IgA deficiency. T cell
deficiencies: DiGeorge Syndrome, Chronic mucocutaneous candidiasis, Duncan’s
Syndrome; X-linked (IPEX) Syndrome. Combined T & B cell deficiencies: Severe
combined immunodeficiency syndrome (SCID- XSCID, ADA, JAK3), WiskottAldrich syndrome, Ataxia telangiectasia. Phagocytic deficiencies: Chronic
granulomatous disease, Chediak Higashi; Leukocyte adhesion deficiency syndrome
(LAD-I), Cyclic Neutropenia. IFN- receptor deficiency. Complement deficiency:
Paroxysmal nocturnal hemoglobinuria; Hereditary angioedema; C3; 5-9 complement
deficiency.
156. Explain the difference between congenital (primary) versus acquired
immunodeficiency.
157. Learn examples of acquired immunodeficiencies and their causes. List the
extrinsic factors that lead to immunodeficiencies.
158.
2 Recall the immunological abnormalities associated with HIV infection.
Learning Objectives
FYI
159. For each of the primary immunodeficiencies listed in the accompanying
chart, learn
 (i) name of the disorder
 (ii) defect in the disorder
 (iii) how the disorder manifests
 (iv) mechanism of pathology
 (v) characteristic features
 (vi) immunological treatment
160. Explain why, or why not, gene therapy could be used as a therapeutic
intervention for each of the disorders.
161. Explain the defect in (a) SCID and (b) X-SCID and why these defects lead
to dysfunction in both T cell and B cell immunity. Identify the cytokines
that signal via CD132.
162. Explain the role of JAK kinases and STAT proteins in signal transduction as
well as the role of adenosine deaminase.
3
Learning Objectives
FYI
163. Compare and contrast Bruton’s agammaglobulinemia, (X-linked
agammaglobulinemia/ hypogammaglobulinemia), Transient
Hypogammaglobulinemia of Infancy, and Common Variable
Immunodeficiency with respect to features in the attached table.
164. Describe the defect in DiGeorge Syndrome and explain why these
individuals are particularly prone to viral and fungal infections.
165. Describe the features of selective IgA deficiency and explain why IvIG is
not suitable as therapy. Explain why IvIG could actually be detrimental to
the patient.
166. Describe the defect in LAD-1 (leukocyte adhesion defect-1) and what is the
consequence.
167. Describe the consequences and clinical manifestation of a defect in (a) C3
and (b) C5-C9.
168. Describe the defect in Hereditary Angioneurotic Edema (HANE)/
Hereditary Angioedema (HAE), effect on complement function, and
clinical manifestations
4
Learning Objectives
FYI
169. Describe the defect in paroxysmal nocturnal hemoglobinuria (PNH), the
effect of the complement function, and the clinical manifestation.
170. Explain why aging leads to acquired immunodeficiency.
5
Immunodeficiency
 Primary immunodeficiencies can be grouped based on the
type of defect:
B cell development and function deficiency (~50%)
T cell development and function deficiency (~30%)
Combined B cell and T cell deficiency
Phagocytes deficiency (~18%)
Complement deficiency (~2%)
 Primary deficiencies are usually hereditary (congenital)
 Secondary deficiencies are acquired complication following
another diseases, e.g. HIV infection, nutritional
abnormalities, or medications / medical treatments
6
Immunodeficient Diseases
B cells &
Antibody
deficiencies
X – linked infantile agammaglobulinemia (Bruton agammaglobulinemia)
Transient hypogammaglobulinemia
Common Variable Immune Deficiency (CVID) or Common Var. Hypogammaglobulnemia
Selective immunoglobulin deficiencies
DiGeorge Syndrome (Congenital Thymic Aplasia)
Chronic mucocutaneous candidiasis
Duncan’s Syndrome (X – linked-lymphoproliferative syndrome )
Hyper-IgM syndrome (failure in class switch)
IL-12 receptor deficiency (IL-12 induces Th1 differentiation /proliferation)
Combined
T & B cell
deficiencies
T cells
deficiencies
Type
Severe combined immunodeficiency syndrome (SCID)
Wiskott-Aldrich syndrome
Phagocytes
deficiency
Ataxia telangiectasia
Chronic granulomatous disease (CGD)
Chediak-Higashi syndrome
Job’s syndrome (hyper-IgE syndrome)
Leukocyte adhesion deficiency syndrome
Cyclic Neutropenia – low neutrophil count
Myeloperoxidase deficiency
Interferon gamma receptor (IFN-g receptor) deficiency
Hereditary angioedema
Complement Paroxysmal nocturnal hemoglobinuria
deficiency Recurrent infections and autoimmune diseases
7
Disorders linked to C1-C9 complement component deficiencies
B cell or Antibody Deficiencies
B cells Deficiency
 Patients with B cell deficiencies have increased
susceptibility to extra cellular bacterial infection and failure
to neutralize viruses
Especially encapsulated bacterial infections due to their
resistance to phagocytosis therefore highly dependent on B cell
immunity and intact antibody synthesis
 Immunoglobulin impairment is directly linked to major
problems with opsonization and complement fixation
 T cell mediated immunity is normal
T cell deficiency is linked to viral and other intracellular
pathogens (Herpes simplex virus, Mycobacterium, and
Listeria), fungal and protozoa infections
8
B cells Deficiency
Bruton disease
(X- linked hypo-gamma-globulinemia)
 Described in 1952 by Ogden Bruton. Other names:
 X-linked agammaglobulinemia; X-linked hypogammaglobulinemia;
Bruton type agammaglobulinemia, Sex-linked agammaglobulinemia
 Sex linked with frequency 1 in 50,000 to 100,000 new-borns
 Female carriers are immunologically normal, but at
homozygous stage they will be B cell deficient as well
 Cell mediated immunity (CMI) is normal
 Pre-B cells are present but fail to mature leading to almost
no detectable mature B cell in the peripheral blood:
Low levels of all immunoglobulin (IgG, IgA, IgM, IgD, IgE)
9
B cells Deficiency
Bruton disease
(X- linked hypo-gamma-globulinemia)
 First symptoms appear in childhood (>6 months) with
clearance of the protective maternal antibodies
This patient presented with
recurrent otitis and areas of
cellulitis in the diaper area.
Pseudomonas aeruginosa and
Staphylococcus aureus were
isolated from the skin lesions.
Symptoms include otitis
media, bronchitis,
septicemia, pneumonia,
arthritis, etc.
 Most commonly associated pathogens are:
Haemophilus influenzae & Streptococcus pneumonia
Intestinal protozoa - Giardia lamblia causing malabsorption
 20% of the children develop arthritis most probably because
of joint infections
10
B cells Deficiency
Bruton disease
(X- linked hypo-gamma-globulinemia)
 Mutation is in of Bruton tyrosine kinase (Btk, located at
Xq21to Xq22)
 regulatory genes needed for pre B cells differentiation
Diagnosis is based on no blood circulating CD19 or
CD20 cells by fluoro-cytometric assays (FACS) detection
or low levels of all antibody immunoglobulin classes
 Treatment is by passive immunization with periodic
injections of large amounts of IgG (IVIG)
maintains a person for 20 – 30 years
Antibiotics treatment to infections could be use but
frequently with poor response or no response
11
Transient Hypogammaglobulinemia
B cells Deficiency
 Delayed onset of normal IgG production around fifth to
sixth month of life.
Transient deficiency of IgG that can last few months to as
long as 2 years.
All other immunoglobulins are normal expressed
 Deficiency in various functions of T helper cell influences
IgG diminishing class switch
 Specific treatment is not offered unless there is a recurrent
infections which handled with antibiotics
IVIG (400-800 mg/kg) can be offered, but this has been
12
linked to delay in the long term resolution of the transient
hypogammaglobulinemia status
B cells Deficiency
Common Variable Immune
Deficiency (CVID) {Hypogammaglobulinemia}
 It is relatively common (1 in 25000) with high variability
of Ig production – can be either low or high levels of Igs
 Usually it appears during adulthood in 30s or early 40s, but
in 20% of the cases can be childhood disease
 It is a relatively slow onset that take few years to develop
with first sings to be frequent and/or unusual infections
 There is no clear genetic correlation although that few genes
have been proven involved in the symptomatics.
 The nature of defects in B cells ranges from:
Absence of B cells proliferation in response to antigen
Normal proliferation of B cells but only IgM production
13
B cells Deficiency
Common Variable Immune
Deficiency (CVID) {Hypogammaglobulinemia}
 Both male & females are equally affected with some having
decrease only in IgG and IgA; others have decrease in all
three major types of immunoglobulins (IgG, IgA and IgM)
 Patients have higher risk of pyogenic bacterial infection and
in many cases risk of developing autoimmune diseases:
hemolytic anemia, thrombocytopenia (low platelets),
systemic lupus erythematousus (SLE)
 Treatment
Antibiotic treatment for infections
Combined with passive low doses of IVIG injections
14Patients
can live up to 70-80 years with this deficiency
Selective Immunoglobulin
Deficiencies (and IgA Deficiency)
B cells Deficiency
 Low levels of one of the five classes of antibody and normal
levels for other immunoglobulins
 IgA deficiency is the most common primary antibody
deficiencies (1 in 500 Caucasian) compare to IgG and IgM
deficiencies
 In some patients with IgA deficiency some of the IgG sub-
classes maybe also low (usually IgG2 and/or IgG4)
 Although that IgM and IgG deficiencies are rare they are
more serious than IgA
15
Selective Immunoglobulin
Deficiencies (and IgA Deficiency)
B cells Deficiency
 IgA deficiency is linked with:
recurrent sinus and lung infections
Allergic reactions, and autoimmunity probably due to the
recurrent triggers by mucosal infections
Risk of anaphylactic shock during blood transfusion due to
reaction against donor IgA
 Treatment
Wide spectrum antibiotics
Passive immunity for IgA deficiency does not exist
16
because the antibody delivery is required in the mucus
membrane
T cells deficiency
T cells Deficiency
 Patients with T- cell defects have recurrent viral, protozoa,
and fungal infections
 Since B cell function largely dependent on T cell therefore
the humoral immunity is also hampered
 Diseases common linked to T cell deficiencies are:
Infections
Allergy
Lymphoid malignancies
Autoimmune disease
17
DiGeorge Syndrome
(Congenital Thymic Aplasia).
T cells Deficiency
 Has been linked to a deletion on chromosome 22 (22q11.2)
but has not been linked to a single gene.
 Defect in the embryological development of 3rd and 4th
pharyngeal pouches is linked to
Failure of both thymus and parathyroids development, thymic
aplasia - defective or absence of thymus
Some improvement with age is probably due to development of
small amounts of thymic tissue that will support T cells
Hypoparathyroidism leads to cardiovascular abnormalities
 Could be hereditary or congenital (present at birth) with
variation in the phenotype even within the same family
18
DiGeorge Syndrome
(Congenital Thymic Aplasia).
T cells Deficiency
 Large variation in presentation spectrum: congenital heart
disease, defects in the palate, neuromuscular problems with
closure (velo-pharyngeal insufficiency), learning disabilities,
mild differences in facial features, recurrent infections.
 Completely absent or few abnormal T cells
B cell, plasma cells, and serum immunoglobulins levels are
detected but in subnormal levels
 Most common among patients are intracellular infections
(viruses) and yeast infections such as Candida albicans and
Pneumocystis carinii , but patient they should be able to cope
with most common bacterial infections
 Should never be immunized with live attenuated viral vaccines
19
DiGeorge Syndrome
(Congenital Thymic Aplasia).
T cells Deficiency
 CATCH 22- Cardiac defects, Abnormal faces, Thymus
underdevelopment, Cleft palate, Hypocalcaemia, and chr.22
20
DiGeorge Syndrome
(Congenital Thymic Aplasia).
T cells Deficiency
 Prognosis is very poor in untreated patients. Treatment:
Antibiotic for infections and other supportive medicine
 Thymic transplantation for DiGeorge syndrome infants may
restore the functionality of T cells but not the other defects
Transplantation of donor tissue either from infants less
than 6 months of age or fetal thymus (less than 14 wk of
gestation)
this is to avoid graft-versus-host (GvHD) reaction.
Donor thymus provides sufficient number of thymic
epithelial cells allowing successful development of T cells
from the recipient bone marrow.
21
Chronic Mucocutaneous Candidiasis
T cells Deficiency
 It is not a specific disorder but a heterogeneous group of
disorders presenting with recurrent or persistent superficial
skin infections, usually Candida albicans.
Affects the skin, mucous membranes, and nails.
Selective defect in functioning of T cells (TH1 and TH17)
against C.albican. Usually normal cellular response
towards other pathogens and normal B cell functions.
 Can be inherited and affects equally
males and females
 Other complications may include
adrenal and parathyroid deficiencies.
22
SOURCE: http://emedicine.medscape.com
 Treatment is very difficult.
T cells Deficiency
Duncan syndrome
(X-linked lymphoproliferative syndrome)
 It is a very rare disease linked to two different X-linked genes,
therefore two different forms of this syndrome (XPL1 and XPL2)
 Disease is present in males with mothers being carriers
 Patient do not present with major symptoms until they are
infected with Ebstein-Barr virus (EBV)
 XPL1 has been mapped in 1998 to Xq25 (1998) mutation of SH2
domain on SAP signaling protein (128-amino acid coding
SH2D1A gene) impairing activation of T and NK cells
Such deficiency leads to functional suppression of T cells that
renders them unable to kill EBV-infected B cells
Inability to kill causes T-cell proliferation leading to increased
23
risk of lymphoma or other lymphoproliferative diseases
T cells Deficiency
Duncan syndrome
(X-linked lymphoproliferative syndrome)
 Symptoms are fulminant infectious mononucleosis (EBV);
hypogammaglobulinemia; lymphoma; hemophagocytic
lymphohistiocytosis (too many activated immune cells)
 Low prognosis where most of the patients (60-70%) will not
surviving to 10 years of age.
The median age of onset is 3-5 years with 1-2 months median
survival
 The only cure is allogeneic stem cell transplantation
Preemptive treatment to block B cells with anti-CD20:
(rituximab) until EBV is reduced has been proven effective
(Milone MC; Blood. 2005)
24
Severe Combined Immunodeficiency Disease
Combined T and B cells
(SCID)
 NOTE: this condition(s) will be discussed in a form of small
groups clinical case active learning approach
 Failure of stem cells to differentiate into T and/or B cells
 Various gene defects will cause similar clinical SCID type
of presentation that usually affects T, B and/or NK cells:
XSCID – deficiency in common gamma (c) chain which
affects cytokine receptors: IL-2R, IL-4R, IL-7R, IL-9R, IL-15R, IL-21R
Bare lymphocyte syndrome (type 2) defect in MHC class II
Absent TCR and BCR – defects in RAG1 and RAG2 genes
Defect in adenosine deaminase (ADA)
Defect in JAK-3 kinase
25
Severe Combined Immunodeficiency Disease
Combined T and B cells
(SCID)
 (a) T. B. and NK cells are differently
affected in different types of SCID
depending on the genes involved
RAG1; RAG2; Artemis,
LIG4
ADA
 (b) Defective gene frequency in
SCID patients
Many genes
Common gamma chain
(c) {XSCID} and JAK3
kinase
1. T cells are driven by
IL7
2. NK cells are driven
by IL15
26
SOURCE: Harald Mikkers, Karin Pike-Overzet, &
Frank J.T. Staal, Pediatric Research (2012) 71,
427–432 doi:10.1038/pr.2011.65
Severe Combined Immunodeficiency Disease
Combined T and B cells
(SCID)
 SCID patients should not receive live vaccine, and are
highly prone to viral, bacterial, fungal and protozoal
infections:
Cytomegalovirus, Pneumocystis carinii, and Candida.
 Treatment:
Bone marrow transplantation with histocompatible tissue
Partially HLA matched (haplotype) bone marrow
transplantation with eliminated mature donor T cells.
Gene therapy – year 2000 trials were successful (10 patients)
until the retroviral vector insertion triggered a proto-oncogene
resulting in death of 4 patients due to leukemia
27
Ataxia-Telangiectasia
Combined T and B cells
 Ataxia telangiectasia (ATM) gene codes for serine/threonine
protein kinase involved in DNA repair
an autosomal (chromosome 11) recessive gene with
various mutations (nonsense, missense) causing
variability in this disease severity
 It is a neurodegenerative disorder: ataxia – uncoordinated
muscle movement
 Telangiectasia - dilation of small blood vessels (more
noticeable in the facial area, eye): spider veins
 Other symptoms: high incidence of malignancy
(particularly leukemias), chromosomal instability; raised
alpha-feto-protein levels
28
Ataxia-Telangiectasia
Combined T and B cells
 Immunodeficiency linked to defect in repair of double
stranded DNA brakes during V(D)J recombination and class
switch. This affects:
T-cells and their functions are reduced to various degrees.
B cell numbers with IgM concentrations are normal to low.
Significantly reduced IgG, IgE and IgA (in 70% of the cases)
Low number of blood lymphocytes
 Ataxia-Telangiectasia outcome and treatment:
Only symptomatic and supportive treatment
no definitive cure treatment exists
Highly variable life expectancy – patients frequently
29
die in their teens or early 20s
Wiskott-Aldrich Syndrome
Combined T and B cells
 Presents in boys as a triad
pyogenic infection
severe eczema - first month of life
thrombocytopenia – petechia and
bleeding due to defective platelets
 Parents have poor response to polysaccharide antigen;
increased risk of severe autoimmune disease and malignancy
 Various mutations are mapped to an X-linked gene (WASp)
that is expressed in hematopoietic stem cells
responsible for actin cytoskeleton rearrangement and
possibly signaling in lymphocytes and platelets.
30
Wiskott-Aldrich Syndrome
Combined T and B cells
 The Immunological defects are due to inability of T cells to
become polarized which consistently gets worse and
decreased antibody production
 Antibody profile is variable:
Reduced IgM concentrations
Both IgA and IgE levels are elevated.
Normal, elevated or reduced IgG levels
 Supporting therapy: anti inflammatory drugs; IvIG; bone
marrow transplant may be helpful
31
Chronic Granulomatous Disease
(CDG)
Phagocyte Deficiencies
 Defect in the phagosome oxidative microbicidal killing function
by neutrophils and monocytes. Pathogens are phagocytosed but
not kill.
Impaired function of NADPH oxidase, which is required for
generation of peroxidase and superoxides
Mutations include: deletions, frame-shift, nonsense, and
missense in either X-linked (protein p91-PHOX) or autosomal
recessive gene (CYBA and NCF1) all linked to NADPH
1 in 200,000 people (in US), with ~20 new cases per year.
 The intracellular survival of pathogens results in the formation
of a granuloma, which can become large enough to cause
obstruction of the stomach, esophagus, or bladder.
32
Chronic Granulomatous Disease
(CDG)
Phagocyte Deficiencies
 Case: A 12-year-old boy | fever, chills, sweats, productive cough, nausea, and
vomiting | Recurrent pneumonias since the age of 5 years | On physical examination febrile, tachycardic, and tachypneic; diffuse rhonchi were heard in both lungs. The
patient also had finger clubbing, splenomegaly, and massive lymphadenopathy in the
cervical, axillary, and preauricular areas (Panel A) and the epitrochlear and inguinal
areas (Panel B) of his body. Blood cultures grew Staphylococcus aureus. A chest
radiograph (Panel C) and computed tomography of the chest revealed multiple
bilateral abscesses in both lungs. Successfully treated with trimethoprim–
sulfamethoxazole, levofloxacin, and voriconazole, with nearly complete resolution of
symptoms.
33
SOURCE: Chronic Granulomatous Disease | Mohsen Esfandbod, M.D., and Maryam Kabootari, M.D. | N Engl J Med 2012; 367:753August 23, 2012
Chronic Granulomatous Disease
(CDG)
Phagocyte Deficiencies
 Most of patients are males with symptoms appearing during
first 2 years of life.
 CDG patient are very susceptible to opportunistic infection
and most common are :
Staphylococcus aureus ; certain Gram negative bacilli; fungi –
Aspergillus fumigatus and Candida
 Diagnoses is done by
Nitroblue Tetrazolium test
(NBT) where defective
phagocytes take-up the salt,
but cannot oxidize it.
 Positive (normal) results
34
SOURCE: The Journal of Infectious Diseases 2003; Severe Clinical Forms of X91 CGD;
Marie Jose´ Stasia et. al.
have violet precipitates.
Treatment: Chronic
Granulomatous Disease (CDG)
Phagocyte Deficiencies
 Chemotherapy:
Aggressive therapy with wide spectrum antibiotics and
antifungal agents.
 Immunotherapy
Administration of interferon gamma (IFN-) – stimulate the
production of superoxide in phagocytic cells
Bone marrow transplant from HLA matching donor
 Gene therapy:
The disease is a result of a single gene defect which allows for
a correction strategy by gene therapy.
Transfer of functional gene in bone marrow stem cells isolated
35
from the patient gives some encouraging results
Leukocyte Adhesion Deficiency
Type I (LAD-I) Syndrome
Phagocyte Deficiencies
 An autosomal recessive mutation in β2 (beta-2) integrin (CD18)
which takes part in LFA-1 and other integrin structures
LFA-1 mediate adhesion of T-cells, B-cells, macrophages and
neutrophils to the endothelial cells
As a result of the defect neutrophils and other cells cannot
emigrate through the vessel wall to the infected site
 Patients are highly susceptible to pyogenic
infections with variable severity
 Delayed separation of the umbilical cord is the
earliest sign of LAD-1
Figure 1: Skin lesions in LAD-1
SOURCE: Journal of Clinical Neonatology
Year : 2014 | Volume : 3 | Issue : 2 |
Page : 109-111 ; Unusual neonatal
presentation of type I LAD ; Bonny B Jasani
et. al.
36
 Treatment by bone marrow transplant, various
stem cell technologies combined with possible
gene therapy for CD18.
Interferon-gamma Receptor
Deficiency
Phagocyte Deficiencies
 Chemotherapy:
Aggressive therapy with wide spectrum antibiotics and
antifungal agents.
 Immunotherapy
Administration of interferon gamma (IFN-) – stimulate the
production of superoxide in phagocytic cells
Bone marrow transplant from HLA matching donor
 Gene therapy:
The disease is a result of a single gene defect which allows for
a correction strategy by gene therapy.
Transfer of functional gene in bone marrow stem cells isolated
37
from the patient gives some encouraging results
Chediak-Higashi Syndrome
Phagocyte Deficiencies
 Mutation in LYST (Lysosomal Trafficking Gene Regulator) gene
causes accumulation of large cytoplasmic granules which cannot
fuse with lysosomes and affects phagocytes, TC and NK cells
 This results in inability to destroy targets, leading to;
Increase of bacterial, viral, and fungal infections
Reduction in skin and eye pigmentation causing: silver hair,
partial albinism, and photophobia
 Treatment:
Antibacterial and antifungal drugs
Bone marrow transplantation as long term
option
38
SOURCE: 1) http://www.medicalrealm.net/what-is-genetic-disorder---chediak-higashi-syndrome.html
2) http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?20/9/20628 ; Robert L Baehner, MD.
Cyclic neutropenia
Phagocyte Deficiencies
 Low neutrophil count (neutropenia), less than 200/ul for the
duration of 3 to 5 days repeated in cycles of 21 days
Autosomal dominant mutation in the neutrophil elastase
(ELANE) gene is responsible for short lived neutrophils that
makes it for a period of low count
 One of the rarest types of neutropenia: 1 in every 106 people,
compare to other forms neutropenia (congenital and idiopathic)
which more common with 1in 2x105 frequency
 Symptoms: only during neutropenic stage patients are susceptible
to life-threating bacterial infection and usually
 Seems that the condition improves after puberty.
 Treatment includes G-CSF (granulocyte colony stimulating
39
factor)
Phagocyte Deficiencies
Job Syndrome (Autosomal
Dominant Hyperimmunoglobulin E (IgE)
 There is a typical facial features
presented with prominent forehead, deepset eyes, broad nasal bridge
 Typical triad presentation with eczema,
eosinophilia, recurrent skin and pulmonary
infections with average survival age of 27
 Symptoms start from early childhood with Staphylococcus
aureus, Streptococcus pneumoniae, Haemophilus influenzae
 It is common to have skin abscesses with Staph. Aureus
 Treatment is predominantly focused on pharmacotherapy to
reduce morbidity symptomatic and prevent complications
40
SOURCE: http://emedicine.medscape.com/article/886988-overview
Phagocyte Deficiencies
Job Syndrome
Cytokines and JAK-STAT3 Signaling
 Various mutations in STAT3 gene will influence the JAK-
STAT signaling pathway and will result in increase of IL-6;
TGF- and decrease in IFN- ; IL-12; TNF-α upon cytokine
stimulation
41
Interferon-gamma Receptor
Deficiency
Phagocyte Deficiencies
 Mutation in the receptor gene encoding either the ligand-
biding portion or the signal transducing portion of the
receptor for interferon gamma.
 Symptoms are associated with increased infections especially
mycobacterial infections due to macrophage failure
 Individuals with this defect should not be immunized with
BCG ( live attenuated vaccine)
42
Secondary/Acquired Immunodeficiency
 The secondary are more frequent that that the primary
immunodeficiencies.
 They result as secondary complications to a prior change of
the physical or health status of the patient.
Infection
Malignancies
Malnutrition
Liver damage
Aging
Therapeutic agents such as radiation or drugs
43
Secondary/Acquired Immunodeficiency
 Infection:
Viral: measles infection, HIV
Bacterial: S. pneumonia, H. influenzae, M. leprae
Protozoan: malaria parasite
 Therapeutic agents
X rays
Cytotoxic drugs/ cancer therapy
Immunosuppressive drugs used in transplantation;
Corticosteroids
 Other diseases can be a prerequisite for secondary
immunodeficiency: sickle cell anemia, diabetes mellitus,
burns, rheumatoid arthritis, renal malfunction, etc.
44
Secondary/Acquired Immunodeficiency
 Malnutrition reduces the supply of amino acid for the synthesis
of Ig, complement, and other products
 Liver damage due to infection or alcohol consumption might
affect components of the innate humoral immunity such as
complement protein synthesis / acute phase proteins
 Aging is linked to complex changes of many parts of the immune
system resulting in increased infections
Increased production of pro-inflammatory cytokines: TNF-,
IL-1/6 is linked to age related diseases:
 such
as Alzheimer’s, Parkinson’s, Atherosclerosis
Decreased production of IL-2 hampers T cell activities
Increased B cell activity with aging is associated with
45
increase of autoimmune diseases
Age Related Changes to the Immune System
 Table 9.1 Immune deficiencies observed in normal elderly
individuals.
46
NEUTROPHILS
Decreased phagocytic activity
Decreased microbicidal activity
CELL-MEDIATED IMMUNITY
Decreased CD3+ cells
Increased Th2 subset and decreased Thl subset
Decreased lymphocyte proliferation
Decreased CD28 expression
Decreased delayed type hypersensitivity
Increased production of proinflammatory cytokines
HUMORAL IMMUNITY
Increased autoantibodies
Decreased ability to generate primary immune responses
NATURAL KILLER CELLS
Increased percentage
Decreased cytotoxic activity
Malignancies - Acquired Immunodeficiency
 Monoclonal gammopathies, e.g. Waldenstrom
macroglobulinemia
cancer of B cell, resulting in overproduction of antibdies
with monoclonal nature, mainly IgM antibodies
 Multiple myeloma – cancer cells that originate from plasma
cells
Bence-Johes proteins – a mareker for multiple myeloma –
monoclonal globulin protein or immunoglobulin light chain
 Hodgkin's disease
Lymphoma (cancer of the lymphatic system, lymph nodes,
47
etc. ) where they for a abnormal giant neoplastic cells
known as Reed-Steinberg
Hereditary Angioedema C1
Inhibitor Deficiency
Complement Deficiencies
 Autosomal dominant deficiency of C1-esterase inhibitor
gene with a frequency of about 1/50,000 - 1/150,000 people
 In the absence of one of the two copies of C1-INH inhibitor
is sufficient to dysregulate three different cascades and cause
the observed symptoms:
Complement – classic (C1) and MBL (MASP-2) pathways
Coagulation – factor XI and XII leading to fibrin buildup
Contact cascade – resulting in increased bradykinin levels
 Patients experience recurrent episodes of angioedema of
skin and the mucosa of gastrointestinal tract upon a trigger
There is absence of urticaria or rush that distinguishes HAE
48
from allergic reaction
Hereditary Angioedema C1
Inhibitor Deficiency
Complement Deficiencies
 Functional deficiency of C1-INH will allow anyone of those
three pathways to run to be dysregulated and presents with the
underlined hereditary angioedema symptomsMorgan BP. N Engl J Med 2010;363:581-583.
49
Hereditary Angioedema C1
Inhibitor Deficiency
Complement Deficiencies
 May cause airway obstruction due to leakage of vasoactive
proteins and fluid in the larynx
 Treatment: Purified C1-inhibitor, fresh frozen plasma (FFP),
kallikrein inhibitor; but not anti-allergic drugs
50
Paroxysmal Nocturnal
Hemoglobinuria
Complement Deficiencies
 Hematopoietic stems cell have a anchor
(GPI – glycosyl phosphatidylinositols)
that mounts a set of regulatory proteins
on the cell surfaces to protect them from
unwanted complement attack
 Some of those regulatory proteins involve
decay accelerating factor (DAF; CD55)
membrane inhibitor of reactive lysis (MIRL; CD59)
 The main defect is due to various mutations in the X-linked
phosphatidylinositol glycan A (PIGA) enzyme which takes
part in formation of GPI. Hence absent protection of the cell
51 surfaces from the complement mount attacks
Paroxysmal Nocturnal
Hemoglobinuria
Complement Deficiencies
 Most prominent complement
mediated cell lyses is for the red
blood cells, but also in other cells
like platelets are also affected
 Most obvious symptoms are the
episodes of black urine (hemolysis)
particularly in early morning hours.
 RBCs are lyse 24/7 , but at night
there is a concetration of urine which
marks the significant color change
 Treatment is mostly supportive with anti-hemolytic drugs, iron
for the anemia, recombinant erythropoietin or androgens to
stimulate erythropoiesis, anticoagulants for thrombosis
52
Paroxysmal Nocturnal Complement Deficiencies
Hemoglobinuria – Symptoms and Prognosis
 Anemia that impairs quality of life
Disabling fatigue (80%) ;
Abdominal (44%) and Chest Pain (33%) ; Dyspnea ;
(64%) ; Hemoglobinuria (62%) ; Renal impairment
(14%) Poor physical functioning
 Thrombosis
venous ; liver, mesenteric, dermal, cerebral ; arterial;
myocardial infarction ; cerebral vascular accident
 PNH is a rare disease with annual rate of 1-2 cases per million
 Median survival rate is 10-20 years from the time of diagnosis
without disease-modifying and supportive treatment
53
SOURCE: http://geneticdiseasesforlife.blogspot.com/2010/10/paroxysmal-nocturnal-hemoglobinuria.html
Deficiencies in C1-C9 Proteins
Complement Deficiencies
 Depending on which part of the complement components (C1-
C9) are deficient this can lead to either susceptibility to
pathogenic infections and/or severe autoimmune reactions
 Classical pathway deficiencies (C1, C4, C2) is linked to:
 recurrent bacterial infections in C2 deficiency
autoimmune diseases (SLE, atherosclerosis) due to inability to
clear the immune complexes after antibody formation
 MBL pathway members also includes C2, C4 and are linked to:
recurrent bacterial infection, mainly in the childhood
 Alternative pathway deficiency (properdin, factor B and factor
D) causes:
pyogenic and Neisseria spp. infections, but NOT immune
54
complex disease
Complement
Deficiencies
55
Source: Advanced Diagnostic
Laboratories National Jewish Health
Complement Deficiencies
Deficiencies in C1-C9 Proteins
Complement Deficiencies
 C3 deficiency- infection with pyogenic bacteria and
Neisseria spp.
sometimes immune-complex disease
 membrane attack complex (MAC) deficiencies (C5-C9)
(terminal path)
mostly Neisseria spp. infections
 Leiner's disease – early infancy systemic disorder
 deficiency of C5 (also reported with C3 and C4 deficiency).
 chronic diarrhoea, seborrhoeic dermatitis; recurrent infections
 Deficiencies of the complement regulatory protein
 autoimmune disorders
56
References
 Basic Immunology by Abbas et al, 4th edition, 2014
Chapter 11; page 207-223
57
Ivo Boudakov, Ph.D.
Ver. 2016
Transplantation Immunology
IMMUNOLOGY (BMIC550)
Learning Objectives
FYI
 Topics and keywords to be discussed: Transplantation: autograft, isograft:,
allograft, xenograft. Cellular and humoral graft rejection. Chronic, acute, and hyperacute graft rejection. Minor antigens. HLA compatibility. Immunosuppressive drugs
and graft survival. GvHD. Fetus as an allograft.
183. Understand the terms autograft, isograft, allograft, and xenograft in
Transplantation.
184. Compare and contrast hyperacute, acute, and chronic graft rejection.
185. Recall that the major molecular target in graft rejection is the alloMHC/allo peptide.
186. Explain differences between major and minor MHC antigens.
187. Explain why graft survival is dependent on the inhibition of T cells.
188. Explain the immunological processes in Graft versus Host Disease (GvHD)
and contrast it with Host versus Graft Disease HvGD.
189. Describe the immune properties of (i) the recipient who receiving the tissue
and (ii) the donor tissue, under conditions that lead to graft versus host.
2
Learning Objectives
FYI
190. Describe tissue differences in clinical transplantation and their prognosis.
191. Explain three potential problems of immunosuppression for transplant
patients and what would be the consequences if immunosuppression is not
giving.
3
Terminology in Transplantation Immunology
 Transplantation is the act of transferring cells, tissues, or
organs from one site to another
 Depending on the transplanted tissue or organ (also known
as graft) there are different types of transplantations:
Autograft: transfer of an individual’s own tissue to another
body site
Isogeneic (syngeneic) graft: transfer of tissue between
genetically identical individuals, like monozygotic twins or
inbreed strain (e.g. lab mouse strain)
Allogeneic graft: graft between genetically different
members of the same species.
Xenogeneic graft: transfer of tissue between different
4
species (human and pig grafts)
5
Graft Rejection
2
1
3
3
6
Graft Rejection
 Adaptive immune response (not the innate response) is
responsible for graft rejection
 Autografts and isografts (syngeneic grafts) are easily
accepted as the graft is recognized as self tissue
 Allograft and xenograft are usually rejected as they are
recognized by the adaptive immune system as non-self
Allografts are acutely or chronically rejected unless a
mistake is made to avoid ABO antigen rejection
Xenografts are more frequently rejected due to
hyperaccute rejection mechanism because of preformed
natural antibodies against xeno-antigens
7
Comparisons Between Accepted and Rejected Grafts
8
Allograft Transplant Rejection
 Without immunosuppressant drugs allografts are rejected
 First set of allogeneic graft rejection:
the first time an allograft is done it seems to be initially
accepted with blood vessels getting reconstituted
the graft seems morphologically and functionally healthy for
only about a week.
 Around day 7 a post-transplantation inflammation becomes
evident and the graft is invaded by lymphocytes and
macrophages – cellular immunity
 The blood vessels within the graft undergo necrosis resulting
in reduction of circulation
9
Allograft Transplantation and Rejection
 With time the necrosis extends within the initial graft which
assumes a scab like appearances and sloughs off by the end
of the second week.
 Clearly this is T- cell mediated reaction and the main cause
is cellular based immune rejection
 Second set of allograft rejection from the same donor
Second graft from the same donor is much more rapidly and
vigorously rejected than the first graft
The vascularization process quickly gets interrupted by the
inflammatory response and infiltration of lymphocytes and
macrophages
Necrosis sets early, the graft sloughs off by the 6th day
10
due to the immune memory
Graft Rejection:
Host Versus Graft Disease (HvGD)
 Histological examination of the rejection site shows:
T - lymphocytes (both CD4 and CD8)
Monocytic cells (monocytes/macrophages)
 Because the second rejection is faster and more aggressive
than the first rejection the site contains memory cells.
 Individual that lack thymus (T cell deficient) do not reject
graft
 B cell deficient individuals normally reject grafts
this shows the role of cell mediated immune response
 Rejection slows or does not occur in immunocompromised
11
individuals
Mechanism of Graft Rejection
 HLA antigens play a major role in graft rejection leading to
acceptance or rejection
 The more MHC alleles are shared between the donor and the
recipient, the slower the rejection process would be
 Both MHC classes (I and II) are involved
Most tissues have MHC class I antigen responsiveness
DR locus of MHC class II is of significant importance
 There is a direct graft recognition where recipient T cells
directly recognize the donor HLAs as foreign to reject
 There is an indirect graft recognition where recipient T
cells recognize processed and presented alloantigens on
12 the surface of recipient APC inside the grafted organ
Direct and Indirect Recognition of Donor Graft
 Recipient CTLs
attack on the graft
tissue activated by
donor APC
 It is currently believed that this is the more common
mechanism during acute graft rejection
13
Indirect Recognition of Donor Graft
 Recipient APC can digest and present alloantigens (such as
donor MHCs) on the surface of recipient MHCs
 Due to cross-presentation mechanisms donor APCs will be
capable of presenting to both CD4 and CD8 recipient’s T
lymphocytes as foreign and stimulate immune response
this will result in cytokine release and inflammation in the
grafted organ/tissue
 The current believe is that indirect recognition has a more
prominent role in the chronic graft rejection
 Even complete matching at all MHC loci will not ensure
100% graft survival due to other antigens known as minor
histocompatibility antigens (MiHA)
14
Minor Histocompatibility Antigens (MiHA)
 Essentially any allelic variation between the donor and the
recipient that is different from HLA polymorphism is
considered minor antigen that may trigger graft rejection
 Minor antigens that can cause incompatibility are
H-Y antigen (a mediator of testicular organization; Smcy,
gene): encoded on the Y chromosome and present only in
all normal male tissues
HA-2 minor histocompatibility antigen derived from the
contractile protein myosin
Blood group antigens
 Minor antigens have important clinical implication in blood
15
transfusion and in boon marrow transplantation
Hyper-acute Type of Graft Rejection
 Occurs within minutes to few hours after transplantation
 Hyper-acute rejection is fully preventable with proper match
of blood type allogeneic donor tissue
16
Hyper-acute Type of Graft Rejection
 It is mediated by preformed natural antibodies that
quickly attack the donor tissue
when they bind to the donor vascular endothelium, they
fix the complement and cause endothelial damage
coagulation blocks blood supply to the grafted tissue
 It is prominent in xenograft transplantation, because
humans have natural antibodies to several animal antigens
 In allograft it is common with blood type incompatibility
ABO type antibodies bind to all tissues, not just RBCs,
cause blood clotting, endothelial cell damage by
complement.
17
Acute Type of
Graft Rejection
 It is a result
of cellular
mediated
adaptive
immunity
 Occurs about 10 days to few weeks after the graft is transplanted
 Graft is rejection by a recipient who has not previously been
sensitized to the graft from the same donor
 Histological examination shows infiltration of lymphocytes and
macrophages due to MHC graft mismatch and insufficient
immunosuppressive treatment
18
Chronic Type of Graft Rejection
 Occurs months to years after tissue transplantation has
assumed normal function and survival
 It is mediated by both cellular (T lymphocytes and
macrophages) and humoral immunity
 Allogeneic antibody-antigenic complexes are detectable at
19
the site of rejection
Chronic Type of Graft Rejection
 The main pathologic feature is vascular injury resulting in
atherosclerosis
 TH cellular immune response plays an important role by
releasing pro-inflammatory cytokines and causing
inflammation, leading to
graft atherosclerosis (narrowing of blood vessels) and
fibrosis formation
 Currently chronic graft rejection is the main type of graft
rejection, while acute rejection is successfully managed by
immunosuppressive prophylaxis and graft MHC match
20
HLA/MHC Typing
 Finding the closes match between the recipient and the
donor maximum of 12 MHCs loci is done in different ways
Mixed lymphocyte reaction (a relatively old way)
Serology –complement fixation test using antibodies
DNA technology – the molecular techniques are more
specific and sensitive by using either PCR detection of
gene sequencing
 Tissue typing and correct matching is usually limited to 3
most important loci (paternal and maternal)
HLA-A, HLA-B, and HLA-DR
The following three loci are of lesser importance: HLA-C,
21
HLA-DP, and HLA-DQ
HLA/MHC Typing
 Mixed leukocyte reaction (MLR): mix of lymphocytes
from two unrelated individuals will recognize and stimulate
each other as foreign causing cell culture proliferation
More cell proliferation – high antigenicity
Less cell proliferation – lower antigenicity
 Serological testing is using a panel of antibodies specific to
the different HLA antigens
Cells from donor or recipient are mixed with specific sera
Complement is added
Cells bearing HLA antigens to a particular sera will be
lysed by the complement
22
Graft Versus Host Disease (GvHD)
 Bone marrow or hematopoietic stem cell (from donors blood)
transplantation is becoming a widely used approach in leukemia
treatment or correction of inherited defects (e.g. SCID, etc.)
 The recipient bone marrow is removed to allow adoption of new
hematopoietic system
 The danger is that donor T cell will react against the recipient
tissues causing Graft Versus Host Disease (GvHD)
This is relatively common with immunocompromised recipient
and insufficient HLA match with the donor alloantigens
Can be avoided by depleting donors tissue of donor’s T cells by
using anti T cell monoclonal antibody
 Even with a sufficient HLA match there is still risk of GvHD due
23
to the existence of the minor histocompatibility antigens
Graft Versus Host Disease (GvHD) Symptoms
 Sever immunodeficiency till the donor graft is established
 Acute GvHD warning signs:
Skin: very faint to severe sunburn-like
rashes, or blisters
Stomach and intestines: nausea, loss of
appetite, vomiting, diarrhea, abdominal
discomfort, abdominal bloating, blood
Liver: jaundice, dark urine,
 Chronic GvHD warning signs: in addition to the above
signs the skin texture thickens, join arthritis like pain, dry
eyes changes, mucosal irritation linked to pain in the mouth,
genitals, lungs.
24
SOURCE: http://bestpractice.bmj.com/best-practice/images/bp/en-gb/946-1-hlight default.jpg
Prevention of Graft Rejection
 Although find the closet HLA match is important, the need
for it has been reduced with the advancement in the
immunosuppressive therapies
in bone marrow only finding a match is still of great
importance for successful transplantation
 Immunosuppressive agents have systemic action which will
cause complications such as
Susceptibility to infections or development of cancers
 Two approaches in immunosuppression:
Chemical immunosuppressants
Monoclonal antibodies against
25
TCR, CD3, CD8, CD4, CD40; IL-2 receptor (CD25)
Drugs Acting on Suppression of the Cell Cycle
26
FROM: Roitt's Essential Immunology 12th ed. - P. Delves, et. al., (Wiley-Blackwell, 2011)
Drug
Mechanism of action
Block DNA synthesis
Prevent correct DNA replication through
formation of phosphoramide mustard
Cyclophosphamide
metabolite: which creates crosslinks between
and within DNA strands leading to cell death
Blocks DNA replication by virtue of its
Mycophenolate
conversion into a purine analog mycophenolic
mofetil
acid; It also suppresses CD25; CD154
(CD40L); CD28
Azathioprine
It is a purine analog that inhibits an enzyme
Methotrexate
Inhibits the metabolism of folic acid
Reduces inflammation by blocking expression of
cytokines: TNF-α, IFN-, IL-1, IL-2, IL -6; Inhibition
Corticosteroids
of neutrophil adherence to endothelial cells,
Suppression of monocytes/macrophages functions
Blocks lymphocyte proliferation by inhibiting IL-2R
Rapamycin
signaling
27
ADAPTED from: Basic Immunology by Abbas et al, 5th edition, 2016
Drug
Cyclosporine
and tacrolimus
Mechanism of action
Blocks T cell cytokine production by inhibiting the
phosphatase calcineurin and thus blocking activation of
the NFAT transcription factor and production of
cytokines (IL-2)
Binds to and depletes T cells by promoting
Anti-thymocyte
phagocytosis or complement-mediated lysis (used to
globulin
treat acute rejection)
Inhibits T cell proliferation by blocking IL-2 binding;
Anti-IL-2
receptor (CD25) may also opsonize and help eliminate activated IL-2R
expressing T cells
antibody
CTLA4-Ig
(belatacept)
Anti-CD52
(alemtuzumab)
28
Inhibits T cell activation by blocking B7 co-stimulator
binding to T cell CD28
Depletes lymphocytes by complement-mediated lysis
ADAPTED from: Basic Immunology by Abbas et al, 5th edition, 2016
Unadjusted One- and Five-Year Patient Survival by Organ
Organ Transplanted
1-Year Survival
5-Year Survival
Kidney
Deceased Donor
94.8%
80.6%
Living Donor
98.0%
90.3%
Pancreas alone
96.7%
88.1%
Pancreas after kidney
96.6%
83.9%
Kidney-pancreas
95.0%
86.1%
Liver
Deceased donor
86.9%
73.6%
Living donor
90.6%
76.1%
Intestine
81.0%
53.6%
Heart
87.8%
74.4%
Lung
84.0%
52.6%
Heart-Lung
75.0%
49.7%
Source: 2007 OPTN/SRTR Annual Report, Table 1.13.
29
Unadjusted One- and Five-Year Graft Survival by Organ
Organ Transplanted
1-Year Survival 5-Year Survival
Kidney
Deceased Donor
90.0%
67.5%
Living Donor
97.3%
80.2%
Pancreas alone
80.1%
50.6%
Pancreas after kidney
78.5%
58.1%
Kidney-pancreas (kidney)
92.9%
77.9%
Kidney-pancreas (pancreas)
86.2%
72.5%
Liver
Deceased donor
82.3%
67.6%
Living donor
84.1%
68.6%
Intestine
73.4%
36.9%
Heart
87.3%
73.2%
Lung
82.3%
49.7%
Heart-Lung
75.0%
73.2%
Source: 2007 OPTN/SRTR Annual Report, Table 1.13.
30
The Fetus is a De Facto Tolerated Allograft
 A fetus carries paternal as well as maternal
MHC antigens
 The paternal MHCs are foreign to the
mother and should act as allograft
 Fetus is not reject by the mother
 Several tolerogenic mechanism have been
suggested
31
FROM: Kenneth Murphy-Janeway's immunobiology 8th ed.2012
Mechanisms of Fetal Tolerance
 Maternal T cells do not interact
with the placenta because:
Cells on the outer layer do not
express classical MHC antigens.
 Presence of complement inhibitory
proteins on the placental outer layer
 Mothernal T cell have tolerance to
parental MHC antigens (in murine
experiments) during pregnancy
 Local nonspecific
32
immunosuppression at the outer
layer of the placenta – by inhibitory
cytokine production
FROM: Roitt's Essential Immunology 12th ed. - P. Delves, et. al., (Wiley-Blackwell, 2011)
Regulation of Tolerance is Happening at the
Developmental Stage
 Burnet’s Hypothesis:(1949)
During the development of the immune system in neonatal
stage the antigens are recognized as self.
Immune system becomes tolerant to these antigens by
clonal deletion
 Medawar proved Burnet’s Hypothesis by inducing tolerance
in experimental animals.
Together Burnet & Medawar have won Nobel Prize in
1960 for their work.
33
34
Regulation at the Developmental Stage
 Evidence from Dizygotic cattle twins (Dr. Ray Owen 1945)
 Same mother (C) was mated with two different bulls (A and
B) to produce dizygotic twin calves (d and e) which have
shared the blood supply in utero
Therefore the calves will also share each others alloantigens
Once the calves grow (D and E) they can accept graft from
each other without rejection
Antigen tolerization should happen before full development of
the immune system at early embryo or neonatal stage.
Dr. Owen observations led to Burnet's clonal hypothesis and
the experiments on the induced unresponsiveness by Dr.
Medawar
35
Experimentally Induced Unresponsiveness
(Medawar)
 Acquisition of tolerance
in early stages of life
 Mice that are injected
with an antigen at an
early stage of
development will be
tolerized as adults for
this antigen
36
References
 Basic Immunology by Abbas et al, 4th edition, 2014
Chapter 10; page 196-204
37
Ivo Boudakov, Ph.D.
Ver. 2016
Tumor Immunology Immunology
IMMUNOLOGY (BMIC550)
Learning Objectives
FYI
 Topics and keywords to be discussed: Selected tumors and the relationship with
their host. Tumor associated antigens: Oncofetal antigens: alpha-fetoprotein (AFP),
carcino-embryonic antigen (CEA ). Immunity to tumors and mechanisms of escaping
the immune response. Immunotherapy.
171. Compare and contrast benign and malignant tumors.
172. Describe the patient populations in which the incidence of malignancy
increased.
173. List the particular malignancy(ies) that arise in immunosuppressed patients
or in patients that are using immunosuppressive drugs.
174. List the particular malignancy(ies) that arise in patients infected with (i)
Epstein Barr virus, (ii) human immunodeficiency virus (HIV).
175. List one tumor specific antigens and the malignancy with which it is
associated.
176. Explain the term “tumor associated antigen”.
177. Define “oncofetal” (tumor associated) antigens. List three malignancies
associated with oncofetal antigens.
2
Learning Objectives
FYI
178. Explain the relevance of oncofetal antigens in clinical practice for diagnosis
and or monitoring recurrence.
179. Discuss tumor markers play a role in tumor immunology. List four tumor
markers and the malignancy with which each is associated as well as their
role in diagnosis.
180. Describe three ways in which monoclonal antibodies are used to effect a
therapeutic “magic bullet effect”.
181. Compare and contrast the different tumors of the immune system
(leukemia, lymphoma, plasma cell). Where possible characterize unique
features of each.
182. Differentiate between Waldenstrom’s macroglobinemia and multiple
myeloma.
3
Benign vs. Malignant Tumors
 Benign tumors have the
cells grow as a compact
mass and remain at their site
of origin
 Malignant tumors present with uncontrolled cells growth
which can spread into surrounding tissue and to distant body
sites
 Benign tumors are diploid, low number of mitotic cell
counts with normal mitosis, and retain their specialization
 Malignant tumors are genetically “weird”: polyploidy,
abnormal mitosis with high mitotic count, loss of
4 specialization, wide range of structural differentiations
Malignancy Naming
 Carcinomas are epithelial cell tumors (e.g. breast, colon,
pancreas, and others)
 Leukemias are tumors of circulating blood cells
 Lymphomas are solid tumors in lymph nodes
 Myelomas are tumors of bone marrow cells
 Sarcomas are tumors of the soft tissue, or connective and
supportive tissue (e.g. bone, cartilage, fat, muscle, blood
vessels)
5
Link Between Cancer Development and
Immune Surveillance
 Immune surveillance theory states that there will be more
tumors in individuals whose immune system is suppressed
 Examples of the immune surveillance role against cancer
immunodeficient individuals have an increased rate of some
types of tumors (eg. Kaposi sarcoma in AIDS)
high rate of skin cancer among immuno-compromised patients
living in high sunshine regions
patient on immuno-suppressive drugs have high risk of
developing certain cancer – mainly viruses induced
blocking inhibitory receptors for various therapeutic reasons,
such as PD-1 and CTLA-4, will leads to tumor remission
6
Link Between Cancer Development and
Immune Surveillance
 Examples of the immune surveillance role against cancer
Certain age groups (elderly people) have an increased
occurrence of tumors, due to the fact that this age groups often
have less effective immune system.
Animal experiments supporting the immune surveillance
concept
immunocompetent animals will actively reject transplanted
tumors if they have been previously immunized against the
same tumor antigens
immunity can be adoptively transferred from an animal, in
which a tumor has regressed, to a naïve animal by injection
of lymphocytes (T cells)
7
Tumor
Immunosurveillance
 The same immune
response that is
mounted against
virally infected cells
is also acting against
tumors
 APC pickup a tumor
antigen and present it
on MHC II as well as
cross-presentation
on MHC I.
 This triggers CTL
(CD8 TC) activation
8
Tumor Immunosurveillance
 CTLs play an important role in immunological surveillance
but first time when they are activated they would need help
from TH (CD4) cells as well
 Cross-presentation is important to allow dendritic cells
(APC) present not just to TH (CD4) but also to TC (CD8)
9
which eventually turn into CTLs
Tumor
Immunosurveillance
10
Variety of Tumor Antigens
11
Tumor Immunosurveillance
 The current knowledge of the individual players in tumor
surveillance is still evolving
 Adaptive immunity mostly employs CTLs mediated
cytotoxicity through the mechanisms of activating apoptosis
and cytokine production: e.g. TNF-α (tumor necrosis factor)
 Role of innate immunity involves
NK cells can be further activated in presence of IL-2 into
Lymphokine Activated Killer cells (LAK) which are
highly lethal to tumor cells, even to NK resistant tumors
 Activated macrophages can kill tumors by:
by producing reactive oxygen intermediates
production of TNF-α (tumor necrosis factor)
12
Tumor – Host Relationship
 Most of human tumors are spontaneously developing tumors
and they might not be immunogenic
These are tumors developed by mutations
Their progression is not necessarily associated with failure
of the immune system
 To be recognized by immunosurveillance, tumor cells must
have antigens that are recognized as foreign, such as:
Altered antigens
Abnormal antigens
 The anti-tumor immune response is used for
diagnosis, prophylaxis, and immunotherapy
13
Tumor Genes
 Altered expression of normal self genes could be a result
of gene mutation by chemical, physical, or other means
may promote tumor growth
Silencing of tumor suppressor genes like p53 or RB
Up-regulated expression of proto-oncogene to make them
behave as oncogenes that are otherwise silent or under
control: RAS, WNT, MYC, ERK, others
 Oncogenic viruses are known to induce tumorigenesis upon
infection as a result of the following mechanisms:
Carrying their own viral oncogenes
Integration and disruption of host cell genome at a site
that alters normal host gene expression
14
Variety of Tumor Antigens
 Spontaneous tumors cause by mutation are very different
from virus induced tumors in their extreme antigenic
heterogeneity.
two tumors induced by the same chemical, in the same animal
will rarely share common tumor specific antigen
 Tumor specific antigens (TSA)
only found on specific tumors and never on normal cells which
gives a great potential for tumor specific targeting
 Tumor associated antigens (TAA)
these are not unique to tumors and can also be present on
normal cells in various circumstances
 Tumors can also be monitored by overexpression levels of
15
otherwise normal self proteins
Abnormal Cancergene
testis
expression antigens
Antigens
Nature of Antigen
Tumor Type
Caspase 8
Regulator of apoptosis
Squamous cell carcinoma
Surface
immunoglobuli
Specific antibody alter gene
Lymphoma
ns (IgG) /
rearrangements in B cell clone
Idiotype
1. MAGE-1
2. MAGE-3
3. NY-ESO-1
Normal testicular proteins in
1. Melanoma
male germ cells
2. Breast
(heterogeneous re-expression
3. Glioma
in many different tumors)
HER-2/neu
Receptor tyrosine kinase
Oncoviral
protein
Tumor Specific
Antigens (TSA)
or tumor
suppressor Ag
Some Tumor Antigens
1. HPV type 16
2. E6 and E7 Viral transforming gene product
proteins
16
1. Breast
2. Ovary
Cervical carcinoma
ADAPTED FROM: Kenneth Murphy-Janeway's immunobiology 8th ed.2012
Tumor Associated Antigens (TAA)
 TAA are antigens that appear in various tumors and are not
specifically linked to a single tumor type
 The cannot be used as targets for anti-tumor treatment, but a
good monitoring markers for tumor progression and
remission
 Example of such markers are oncofetal antigens:
these are genes that are normally expressed during embryonic
stage and supposedly kept silent during adult life
during oncogenesis the oncofetal antigens are up-regulated
 Alpha-fetoprotein (AFP)
 Carcinoembryonic antigen (CEA)
 Beta-chorionic gonadotropin (β-HCG)
17
Oncofetal Antigens
Antigens
Associated Tumors
Notes
1. Most patients with liver cancer; Used as a diagnostic as
well as prognostic index
Alpha-fetoprotein 2. Some cases of nonafter chemotherapy or
(AFP)
seminomatous testicular
surgery
cancer
High level of CEA is linked to
Carcinoembryonic
1. Colon and rectal carcinoma;
antigen (CEA)
2. Pancreatic, breast, lung,
stomach, and prostate cancer
1. Ovarian germ cell tumors;
Beta-chorionic
2. Gestational trophoblastic
gonadotropin (βdisease (hydatidiform mole and
HCG)
choriocarcinoma);
3. Testicular tumors
18
It is a glycoprotein
involved in cell adhesion
and used to monitor
recurrence and treatment
It is normally detected in
early pregnancy but it is
abnormal for nonpregnant women, man, or
late pregnancy
Carcino-embryonic Antigen (CEA )
 The production of CEA is happening in the fetal gut, liver
and pancreas and usually stops after birth.
 It can be also present in alcoholic cirrhosis patients,
smokers, as well as chronic obstructive pulmonary diseases
(COPD)
19
SOURCE: https://www.fascrs.org/patients/disease-condition/colon-and-rectal-cancer-follow-care
Alpha-fetoprotein (AFP)
 The antigen is normally expressed by fetal liver, yolk sac, and
gastrointestinal cells
 In addition to the liver and testicular cancer
it maybe detected in numerous other cases:
 pancreatic, gastric, lung tumors
 in liver cirrhosis of viral and alcoholic
origin
 It has immunosupressant activity
Healthy Liver
Fibrotic Liver
Cirrhotic Liver
Liver Cancer
A healthy liver Continuous liver
Scar tissue replaces normal, Formation of a
inflammation (e.g. Hepatitis healthy tissue, blocks blood malignant tumor in
B) can lead to fibrosis – a
flow and obstructs normal the liver.
formation of liver scar tissue functionality
20
SOURCE: http://livercancertreatment.club/wp-content/uploads/2016/02/level-4-liver-cancer-wDrL.jpg
Beta-Human Chorionic Gonadotropin (β-hCG)
 Normal protein expressed by trophoblastic epithelium of
the placenta and can be used for pregnancy test as well.
 Ovarian cancer and GTD, but in rare cases it can also be
seen in hepatic, breast, pancreatic, and gastric cancers
21
SOURCE:https://www.youtube.com/watch?v=NrTRPohUq6U
How Tumors Evade Immunosurveillance?
 1. Tumor cells – suppress antigen presentation
Due to lack of co-stimulatory molecules such as B7 the TC
cells are not able to be activated and become anergic (anergy)
Lack or reduced expression of
MHC class I avoids recognition of
tumors by TC cells
back-up mechanism - such cells
became susceptible to NK
2. Tumors may release of
immunosuppressive cytokines
TGF-β affects many mediators
and has an inhibitory effect on
TC cell differentiation
22
How Tumors Evade Immunosurveillance?
 3. Release of cytokines that induce suppressor TREG
lymphocytes
 4. Tumor cells might masking
23
their antigen by covering them
with mucin (substance found in
mucus secretion)
 5. Some tumors may shed their
unique antigens which block
antibodies and T cells away from
malignant cells surface.
 6. Tumor cells may express the
necessary marker to induce
apoptosis of TC cells
How Tumors Evade Immunosurveillance?
 7. Antigen concentration
Early tumor development the amount of antigen may be too
small to stimulate the immune system
Later due to the rapid proliferation of malignant cells, the
immune system is quickly overwhelmed with too high antigen
concentration.
 8. Tumors in the immunological privileged sites will not be
attacked by immune response (cornea of the eye)
 9. Tumors may develop into low antigen variant, that does
not stimulate the immune response.
24
Immunotherapy
 Immunotherapy in treating cancer
Enhance the immune system by active and passive means
which can be either specific or non-specific induction
 Active immunotherapy is when there is a direct induction of
the immunosurveillance in the patient:
Non-specific immunization with BCG (Bacillus Calmette-
Guerin); extracts of BCG, Corynebacterium parvum or
Corynebacterium diphtheriae , viral antigens with adjuvant,
killed tumor cells or their extract, or recombinant antigens.
Cytokines can be actively induced by immunization
 Passive immunotherapy is when the immunosurveillance is
not directly induced but rather transferred into the patient as
a passive recipient such as adoptive transfer method.
25
Passive Immunotherapy (Adoptive Transfer)
 Cytokines can be non-specific and passively administered,
unfortunately this is known to cause various side effects
IL-2 and TNF have been tried but are strong induction of
fever and toxic shock syndrome
Interferon, IFN alpha and IFN beta – promising results
with certain cancer types
 Dendritic cell vaccines (Engineered Antigen-Presenting
Cells)
the patient’s cells are specifically trained outside his body
to recognize the tumor antigens and transferred back to the
patient
26
Passive Immunotherapy (Adoptive Transfer)
 IL-2 activated killer cells “ex-vivo”
Patients own killer cells are activated by IL-2 in-vitro and
given back to the patient: results have wide variations
 Use of tumor specific monoclonal antibodies
 Anti-tumor antigen specific monoclonal antibodies could be
linked to a killer drug such as: toxin (diphtheria toxin), ricin,
radioisotopes, anti-tumor drugs
 Specific antibodies targeting:
Tumor markers: Anti-HER2; Anti-CD30; Anti-EGFR
(receptor for colorectal cancer)
Antibodies that will modulate the immune response
through either immunosuppressive or immunostimulatory
27 receptors.
Immunotherapy on The Works
28
Immunotherapy on The Works
29
Immunotherapies
30
B and T cell Malignancies
 B-cell malignancies are diverse set of diseases, clinically divided
into indolent (slow growth) and aggressive malignancies:
Leukemias (e.g CLL – chronic lymphocytic leukemia – 95% is
from B cells origin)
Lymphomas: Hodgkin (Reed-Sternberg cells) lymphomas and
most of non-Hodgkin lymphomas (NHL)
Myelomas (plasma cell neoplasms)
 T cell malignancies (neoplasms) are more uncommon
10%-15% of all non-Hodgkin's lymphomas
T cell acute lymphoblastic leukemia (T-ALL) ; 5% of the CLL
(Chronic Lymphocytic Leukemia) is T cell based
Adult T cell leukemia / lymphoma (ATLL) caused by HTLV-1
(human T lymphocyte virus)
31
Monoclonal Gammopathies
 A group of disease with abnormal proteins found in the
blood and produced by plasma cells (Ab producing B cells)
Variable symptoms:
Anemia; Fatigue ;
Weakness, Pain in the
bones or soft tissues;
Tingling in the feet or
the hands, Infections,
Bleeding, Weight loss,
Headache, Mental
changes, etc.
 Diagnoses of monoclonal gammopathies is usually based on
the type of abnormal proteins in the blood.
32
SOURCE: Mayo clinic ; Br J Haematol. 2006 Sep;134(6):573-89. Monoclonal gammopathy of undetermined significance. Kyle RA
Differential Diagnosis: Multiple Myeloma vs.
Waldenström Macroglubulinemia
 Both malignancies cause Rouleaux
formation of RBCs which looks like a
stack of coins due to the high abnormal
concentration of immunoglobulins
Hepatospleenomegaly
Lymphadenopathy
Hyperviscosity
Bence Jones proteins in urine
Positive Coomb's test
Bony Lesions
M-protein type
33
Waldenström
Multiple Myeloma
Macroglubulinemia
--+
--+
--+
More common
Less common
Less common
More common
More common
Less Common
light chain only,
Monoclonal IgM
IgG, IgA, IgD
Differential Diagnosis: Multiple Myeloma vs.
Waldenström Macroglubulinemia
 Light immunoglobulin chains (or Bence Jones protein) are
small enough to be excreted with the urine:
More frequently associated with multiple myeloma or AL
amyloidosis.
 Whole immunoglobulins –usually called "M- spike protein" ("M"
stands for monoclonal) when in high levels can cause aggregates
of polymers from where the name macroglobulinemia is derived
in case Waldenström Macroglubulinemia this can cause the
blood to become too viscous
 Heavy chains production only is also possible.
34
Case Study: HIV with Multiple Myeloma
 A 45-year-old white man presented with an acute retroviral illness
characterized by fever, rash, lymphadenopathy, headache, and sore
throat. Shortly thereafter, he tested positive for HIV infection, with an
initial CD4+ cell count of 475/µL (normal, 460/µL or more) and an
HIV viral load of more than 800,000 copies/mL. He began an
antiretroviral regimen of nelfinavir, stavudine, and lamivudine.
Seven months later, his CD4+ cell count dipped below 400/µL in the
setting of a persistently detectable HIV viral load. Consequently, his
regimen was changed to hydroxyurea, zidovudine, didanosine,
saquinavir, and ritonavir.
 One year later, his hematocrit, which had previously been in the
normal range, fell to 30% despite with nondetectable HIV viral load
and a CD4+ cell count of 600/µL. Two months later the patient
complained of worsening fatigue and dyspnea on exertion. Serum
protein electrophoresis (SPEP) showed an increased M spike.
Thalidomide-Based Treatment for HIV-Associated Multiple Myeloma: A Case Report ; David M. Aboulafia, MD ; AIDS
35 SOURCE:
Read. 2003;13(8)
M Spike Protein in Multiple Myeloma
 Chart A presents serum protein electrophoresis of a patient
with multiple myeloma, where M spike of more than 5 g/dL.
the M spike is a monoclonal paraprotein production by the
malignant cells
 Chart B is the same patient after 9 months of combinatory
anti-myeloma regiment showing a significant reduction of M
spike.
36
SOURCE: http://www.medscape.com/viewarticle/460735 2
Next generation of immunotherapy for
melanoma. J Clin Oncol. 2008;26:3445-3455
FYI
37 Next generation of immunotherapy for melanoma. J Clin Oncol. 2008;26:3445-3455
References
 Basic Immunology by Abbas et al, 4th edition, 2014
Chapter 11; page 189-196
38
Ivo Boudakov, Ph.D.
Ver. 2016
Tumor Immunology Immunology
IMMUNOLOGY (BMIC550)
Learning Objectives
FYI
 Topics and keywords to be discussed: Passive and active vaccination. Live
(attenuated) and killed vaccines. Toxoid, subunit vaccines, adjuvants, antiserum..
192. Explain the concept of (i) recombinant vaccines and (b) DNA vaccines.
193. Describe the “prime / boost approach” to immunization.
194. Explain the terms: herd immunity, passive natural immunity, passive
artificial immunization, active immunization.
195. Explain the term “gamma globulins” and why it is passive artificial
immunization.
196. List advantages and disadvantages of live versus killed vaccine and explain
the differences in effectiveness.
197. Discuss the role of adjuvants in immunization and list some examples.
198. List vaccines that can be administered to immunosuppressed patients, and
explain why.
199. Discuss advantages and disadvantages of the oral live (Sabin) and killed
(Salk) polio vaccines.
2
Learning Objectives
FYI
200. Name two bacterial toxoid vaccines and explain the principles underlying
these vaccines.
201. Define tetanus toxin, tetanus toxoid, heterologous antiserum, homologous
antiserum.
202. Describe the causative agent of tetanus, the mechanism of infection and
consequence. Explain how “neonatal tetanus” can occur. Explain why
natural immunity to tetanus is not possible.
203. Explain the various clinical approaches to treating patients infected with C.
tetani spores.
3
Immunology: Prevention at Work (US Data)
Disease
Total cases
Diphtheria
206,939
Measles
894,134
Mumps
152,209
Pertussis
265,269
Poliomyelitis
21,269
Rubella
57,686
Tetanus
1,560
Year Cases in 1994 % Change
1921
2
-99.9%
1941
963
-99.9%
1968
1537
-99.9%
1934
4617
-99.9%
1952
0
-100%
1969
227
-99.9%
1923
51
-99.9%
The number of cases of illness in the U.S. in a representative year (either before
a vaccine was available or before it came into widespread use) with the number
of cases reported in 1994. (Modified: Abbas et. all; Basic Immunology; 2016)
4
Acquired Immunity
Naturally Acquired
Active
Antigens enter
body naturally;
produce antibodies
and specialized
lymphocytes
5
Passive
Antibodies
from mother
transferred to
the fetus
Artificially Acquire
Active
Antigens in
vaccines; body
makes antibody &
specialized
lymphocytes
Passive
Preformed
antibody in
immune serum
introduced by
injection
Various Types of Vaccinations
Live vaccines
Small pox (variola vaccine)
BCG (Bacille de Calmette–Guerin); Typhoid oral
Live Attenuated vaccine (Salmonella typhi); Typhus (Rickettsia sp.); Plague
Vaccines
(Yersinia pestis); Oral polio (Sabin vaccine); Yellow fever
virus; Measles; Mumps; Rubella; Intranasal Influenza;
Cholera; Typhoid (Salmonella typhi); Pertussis (whooping
Killed
cough, Bordetella pertussis); Plague; Rabies; Salk polio;
Inactivated
Intra-muscular influenza; Japanese encephalitis
vaccines
Toxoids
Diphtheria; Tetanus
Meningococcal polysaccharide vaccine;
Subunit Vaccines Pneumococcal polysaccharide vaccine;
Hepatitis B polypeptide vaccine
Conjugated
Meningococcal conjugate; Pneumococcal conjugate;
Haemophilus influenzae type B (Hib) conjugate
vaccines
Recombinant
Hepatitis B vaccine
vaccines
6
Live vs. Live Attenuated Vaccines
 Live cowpox virus was used to prevent from smallpox virus
infections as described by Edward Jenner in 1798.
 A vaccination campaign using live vaccinia virus (not to be
confused with cow- or small-pox virus) succeeded in worldwide
eradication of smallpox (1980) under the WHO lead.
the origin of vaccinia virus has not be clearly identified
 Live, attenuated vaccines are usually contagions strains that
have been weakened in the lab and can’t cause disease
frequently achieved by extensive multiple passages in various
animal species to get strains with diminished virulence
Main limitations: cannot be given to immunocompromised
patients; in isolated cases the vaccines can revert and induce
full-blown diseases ( live Sabin polio vaccine is known to
7 cause isolated cases of paralysis)
Live Attenuated vs. Killed Vaccines
 Live, attenuated vaccines are the closes to the natural active
immunization:
requires only single or maximum of two doses to achieve
lifelong immunity
elicit strong cellular and humoral (Ab) immune responses
 Inactivated (killed) vaccines are produced by heat, chemical, or
radiation treatment of live pathogens.
Advantage is their prolonged shelf life with minimum
maintenance requirements at room temperature.
 The disadvantage of inactivated (killed) vaccines is that they:
Require multiple boosting (injections)
Elicit weaker immune response which in many cases is mainly
humoral (Ab) immunity activation
8
Toxoid Vaccines
 Toxoid vaccines are used when the main phonology is due to
the toxins entering the body instead of damage doe to
bacterial growth
tetanus toxin and diphtheria toxin are both
exotoxins
exotoxins are proteins which can be
neutralized by chemical treatment with
formaldehyde
such inactivated “toxoids” are very effective
inducers of humoral immunity which
generates neutralizing defensive antibodies
9
Tetanus and Tetanus Toxoid Vaccines
 Tetanus toxin is a extremely potent neurotoxin which works
in very low concentration
such low concentration is below the limits of natural
immunogenicity and cannot lead to development functional
immune response
 In case that the mothers does not transfer tetanus protective
antibodies to the newborn infant there is a risk of acquiring
“neonatal tetanus”
This is usually observed when the
umbilical cord is not properly healed
or when non-sterile scissors are used
to cut the umbilical cord
10
Subunit Vaccines
 Instead of live or killed pathogen, individual structures
(antigens) from the pathogen are isolated and mixed in a
form of vaccine
It may contain anywhere between 1 to 20 antigens which
may target humoral (B cells) and/or cellular (T cells)
immunity
The individual antigens (epitopes) can be either isolated
from the actual pathogens, or produced in a lab through
DNA recombination technologies
 Such vaccines are safe because there is no danger of
reversing back to virulent pathogen strains
11
Conjugate Vaccines
 Conjugate vaccines are special (sub-) type of subunit vaccines
 Young children are lacking the capacity of the developed adult
immune system and therefore they frequently do not respond to
polysaccharide antigens such as bacterial capsules
 Way around of resolving such lack
of immunogenicity is to link
(conjugate) the polysaccharide
antigen with a protein which will
elicit strong T cell dependent B cell
response
12
DNA Vaccines vs. Recombinant Vaccines
 Recombinant vaccines are produced using DNA
recombination technologies and delivered in two ways:
inserted in a carrier vector (attenuated virus or bacteria) that is
given as a live organism to the person to be vaccinated –
recombinant vector vaccines
inserted in a model organism (like yeast) that is be used for
production of the corresponding antigens as vaccine subunits
 DNA vaccines are naked DNA molecules inserted in a
suitable DNA vector that will allow for expression in human
cells host cells. The DNA construct is introduced by:
Injection
Needleless technology using high-pressure DNA gun to deposit
gold particles coated with DNA in the tissue
13
Naked DNA Vaccines
 They are considered safe
 Current test although have still not produced an approved for
clinical use naked DNA vaccine, they have proven to be
Inducing strong immune response both cellular and humoral
Principle has been demonstrated working in human subjects
Most of the current clinical
studies are focused on
using cancer markers
during vaccination by
naked DNA vaccines
This is still largely work
in-progress
14
Herd Immunity
 “Vaccine refusal helped fuel Disneyland measles
outbreak, study says”
 “The measles outbreak traced to Disneyland has led to 22
cases of the disease in California and several in other states.”
The LA Times
15
Herd Immunity is Population Immunity
 Vaccines are safe as and the benefits for the population
outnumber the isolated negative cases due to potential
pathogenicity
 If 75% of children are
immunized against
diphtheria the disease
disappears in the
population
16
Immunoprophylaxis by Passive IgG transfer
 Passive transfer of immunity - transfer of Ig, immune sera
Sera collected from previously infected humans
Sera collected from laboratory infected animals, e.g. horse
Transfer of primed cytotoxic T lymphocytes
 Passive immunization with
immunoglobulin is
recommended for :
 For prophylaxis/treatment of
various infections or toxins
 Long-standing
immunodeficiency
17
 Steroid treatment
Immunotherapy – Passive Immunity
INFECTION
Tetanus
Diphtheria
Botulism; Gas
gangrene; Snake
or scorpion bite
Varicella zoster
Rabies
Hepatitis B
Hepatitis A
Measles
Cytomegalovirus
18
ANTIBODY SOURCE
HORSE HUMAN
USE
X
X
Prophylaxis
Treatment
X
—
Treatment
—
—
—
—
—
X
X
X
X
X
—
X
Treatment immunodeficiency
Post-exposure to vaccine
Treatment
Prophylaxis (Travel)
Treatment
Prophylaxis in patients
receiving immunosuppression
Table 14.1. Passive immunotherapy with antibody.
Passive Immunity with IvIG
 Intravenous immunoglobulin infusions (IvIG): empirically
discovered blood product of pooled IgG extracted from the
plasma of over one thousand blood donors
 IvIG is used in treatment for:
Primary immune deficiencies (plasma protein replacement
therapy at low dose: 100 to 400 mg/kg every 3 to 4 weeks)
Autoimmune diseases (high dose ≈1-2g/kg of body wt; for 6
months, followed by low dose maintenance therapy )
Acute Infections
 IvIG is very expensive product: at well over $50/g which
can go up to $8,000 for a single dose (average body weight
of 80 kg person at 2g/kg)
19
Mode of IvIG Action
 Mechanism of actual is not completely understood
especially in suppressing the autoimmune diseases
 Anti-infectious action is primarily conducted through
neutralization, opsonization, ADCC, complement activation
 Anti-inflammatory IvIG action is believed to be linked to
Anti-idiotypic network regulation
Activation of regulatory feedback
loop from low affinity FcRIIB
receptors
20
21
Off-label
Anti-inflammatory
(high-dose) therapy
Replacement
(low-dose)
therapy)
Licensed
Table 1. Examples of the clinical use of IVIG
Primary immunodeficiencies (CVID and others); HIV
infection; Bone marrow transplantation; B cell lymphocytic
leukemia; Multiple myeloma
Idiopathic thrombocytopenia purpura (first historically
approved therapy in 1981); Guillain-Barre syndrome;
Kawasaki disease; Chronic inflammatory demyelinating
polyneuropathy (CIDP)
Autoimmune neutropenia; Autoimmune hemolytic anemia; AntiFactor VIII autoimmune disease; Multiple sclerosis; Myasthenia
gravis; Stiff person syndrome; Multifocal neuropathy; Systemic
vasculitis (ANCA positive); Polymyositis; Dermatomyositis;
Rheumatoid arthritis; Systemic lupus erythematosus;
Antiphospholipid syndrome; Toxic epidermal necrolysis;
Autoimmune skin blistering diseases; Steroid-dependent atopic
dermatitis; Graft-vs-host disease; Sepsis syndrome
Other Immunotherapies
 Adoptive transfer of predominantly of autologous ex-vivo
modified immune cells (e.g. TC cells; Dendritic cells)
currently this has limited application especially of it is allograft
due to MHC restriction and class match
 Non-specific immunotherapy: non specific therapeutic
stimulation or down regulation of the immune system:
Non-specific stimulation by microbial products or triggers
e.g. Aldara (Imiquimod): activates immune cells through the
toll-like receptor 7 (TLR7) for genital warts (HPV)
Use of cytokines
To stimulate the immune response
22
Down regulate the immune response
Active agent
Action
cytokines
filtered bacterial
used by Coley (1909) against tumors
Microbial
cultures
products
BCG
some activity against tumors
effective in chronic: hepatitis B;
hepatitis C; herpes zoster; wart virus
IFNα
(HPV); prophylactic against common
cold (also some tumors)
effective in some cases of: chronic
IFN
granulomatous disease; lepromatous
leprosy leishmaniasis (cutaneous)
IL-2
leishmaniasis (cutaneous)
bone-marrow restoration after
G-CSF
cytotoxic drugs
TNF antagonists septic shock
Cytokine
IL-1 antagonists;
inhibitors
severe (cerebral) malaria?
IL-10
23
References
 Numerous various sources; please use this lecture as
main learning tool
24