Immunology for Surgery

Prof Anura Weerasinghe

MBBS(Col), MD(Col), DCH(Col),
DTM&H(London), MRCP(UK),
FRCP(Edin) & PhD(Japan)

Professor of Physiology
Faculty of Medicine
University of Kelaniya
Ragama
 Topics
• Immunity to cancer and transplantation
• Immunodeficiency
• Hypersensitivity
• Tolerance and autoimmunity
Immune response against
tumours and transplants
 Objectives
• Tumour and transplant antigens
• Immune surveillance against tumour
cells
• Immunological mechanisms of rejection
and graft-versus-host disease (GVHD)
 Tumour antigens
• Sparse evidence to support protective
immunity elicited by tumour antigens
• May be used as tumour markers
• May be used as targets for tumour
vaccines
• May be used as targets for antibodies and
effector T cells generated against these
antigens (Immunotherapy)
 Types of tumour antigens
• Mutated self protein
– In melanoma
• Product of oncogene
– Her-2/neu in breast cancer
• Products of mutated tumour suppressor
gene
– p53 in colon, breast & lung cancers
 Carcinogenesis

Chemical Physical

Defect in DNA

Biological
 Point mutation Gene deletion

DNA defect

Chromosomal DNA repair

translocation
 Types of tumour antigens
• Mutated self protein
– In melanoma
• Product of oncogene
– Her-2/neu in breast cancer
• Products of mutated tumour suppressor
gene
– p53 in colon, breast & lung cancers
• Aberrantly self protein
– onco-foetal antigens
 Oncofetal antigens

Although highly associated with some

tumours, both on their cell surface and
in the serum, oncofetal antigens are not
unique to tumour cells since they are
also found on cells during embryonic
development and are found at very low
levels in normal human serum.
 Oncofetal antigens
• Carcinoembryonic antigens (CEA)
- GI cancers
• Alpha-fetoprotein
- Hepatoma
 Types of tumour antigens
• Mutated self protein
– In melanoma
• Product of oncogene
– Her-2/neu in breast cancer
• Products of mutated tumour suppressor gene
– p53 in colon, breast & lung cancers
• Aberrantly self protein – onco-foetal antigens
• Oncogenic virus
– HPV in cervical cancer
– EBV in lymphoma / Nasopharyngeal carcinoma
– Hepatitis B in hepatoma
That the immune system surveys constantly
for neoplastic cells and destroys them, is
suggested by the observation of increased
incidence of tumours of lymphoid or
epithelial cells in immunodeficient animals
and humans.
 Immune surveillance

The immune system surveys constantly

for neoplastic antigens associated with a
newly developing tumour and destroys
the cells bearing them.
Immune mechanisms operating
against tumours
• Activated macrophages
• NK cells
• Antibody and complement
• Antibody dependent cellular toxicity
• Cytotoxic T cells
 Molecules involved in the
first-line defense
Complements - Promote action of
macrophages
- lysis of the target cell
Cytokines - augment immune response

Eg; INF- activate both macrophages

and NK cells
 Antibody mediated tumour
rejection

Complement Antibody-dependent
dependent cellular cytotoxicity
cytotoxicity

Play a role in leukaemia

Not very effective in solid tumours
 Complement mediated
cytotoxicity
Mediated by antibodies
Tumour cell + Antibody
Particularly IgM

Trigger classical complement pathway

C3b and C5b

Opsonization Lysis
 Antibody-dependent cellular
cytotoxicity

NK cells Direct interaction

+ with tumour cells
IgG

Release of cytotoxic
“Sensitized” tumour cell
molecules
eg; perforin
Discuss the role of following
cells/molecules in immune
response to tumours
• T lymphocytes
• NK cells
• Macrophages
• Antibodies
Immunology of Transplantation

• Immune Response to graft cells

• Immunology of graft dysfunction
• Strategies to prevent rejection
• Treatment of acute rejection
 Immune response to graft
cells
Recognition
Self from non-self
Transplantation antigens
Histocompatibility Complexes
Major
Minor
Blood group antigens
 Immune Response to graft
cells
Presentation of Transplantation antigens

T cell

APC T cell

T cell
 Immunology of Graft
Dysfunction
• Hyperacute rejection (Within minutes)
– Unrecognized ABO incompatibility
– Antibodies to HLA class I (positive
cross-match)
• Acute (days or weeks)
– CTL (CD8) mediated
• Chronic (months or years)
– CD4 mediated
 Humoral rejection

Antigen antibody Complexes

Activation of Complement cascade

Chemotaxis & Inflammation

Occlusion of capillaries & prevent vascularization

Strategies to Prevent Rejection
• Hyperacute/Acute - ABO
compatibility Tissue
matching
Immunosuppresive
Therapy
• Chronic - Careful tapering of
Immunosuppressive Tissue
matching
 GVHD
• A disease occurring in BMT recipients
that is caused by the reaction of mature
T cells in the marrow graft against
alloantigen in host cells.
• Requirements for GVHD;
– Immuno-competent graft cells &
immuno-incompetent host
Eg; blood transfusion in SCID
 Summary
• Tumour and transplant antigens
• Immune response in immune
surveillance against tumour cells
• Immunological mechanisms of rejection
and graft-versus-host disease
Immunodeficiency
 Objectives
• Classification of Immunodeficiency
• When to suspect
• How to investigate
 Classification of
immunodeficiencies
• Primary – usually congenital (inherited)
– The result of a failure of proper development
of the humoral or cellular immune system
• Secondary – acquired
– The consequences of other diseases and
their treatments.
 Primary immunodeficiency
• Complements
– Recurrent meningococcal meningitis
• Phagocytes
– Recurrent Staphylococcal skin sepsis
• Humoral immunity
– Severe or recurrent extracellular bacterial
infections
• Cellular immunity
– Recurrent intracellular bacterial or viral
infections.
 Complement deficiency
• C3 deficiency
– Recurrent infections with encapsulated
organisms
• Pneumococcus, Streptococcus & Neisseria
• Deficiencies in Membrane Attack
Complex (MAC) components
– Increased susceptibility to infections with
Meningococcus eg; Neisseria
 Extrinsic Phagocytic defects
• resulting from
– Deficiency of antibody or complement
• Defective opsonization
– Suppression of phagocytic activity
• Eg by Glucocorticoids or autoantibodies
 Deficiency of Humoral
immunity
• Primary antibody deficiency mainly
results from abnormal development of B
cell system.
• The overall lack of antibodies mean that
the patients suffer from recurrent
bacterial infections, predominantly by
Pneumococcus, Streptococcus &
Haemophilus
 B cell deficiencies
• Abnormal B cell maturation
– Lack of Stem cells
• Severe Combined Immunodeficiency (SCID)
– B cells fail to develop from B cell precursors
• Bruton’s agammaglobulinaemia
– B cells do not switch antibody classes from
IgM
• Hyper-IgM syndrome
• B cells that do not respond to signals
from other cells
– Common Variable Immunodeficiency
– Transient hypogammaglobulinaemia
 B cell deficiencies
• Severe Combined Immunodeficiency
(SCID)
– Functional impairment of both B and T
lymphocyte limbs of the immune response.
– Inheritance is either X-linked or autosomal
recessive
• Bruton’s Agammaglobulinemia
– X-linked inheritance
• Isolated immunoglobulin defects
– IgA deficiency is the commonest
 Cellular Immunodeficiency
• Result in recurrent viral, fungal,
mycobacterial and protozoan infections
• Lack of Thymus
– Di George’s syndrome
• Stem cell defect
– SCID
DiGeorge syndrome;
cellular immunodeficiency

– Failure of the parathyroids

and thymus to develop
– Appearance of
hypocalcemic tetany
shortly after birth
– Occurs in both males and
famales
– A number of physical
abnormalities
 Partial Combined Immune
Deficiency
• Wiskott-Aldrich Syndrome
– X-linked recessive disorder
– Characterized by the presence of eczema,
thrombocytopenic purpura, and increased
susceptibility to infection.
• Ataxia-Telangiectasia
– Autosomal recessive disorder
– Ataxia
– Telangiectasia
– Recurrent sinopulmonary infections
Molluscum contangiosum
 Secondary (acquired)
immunodeficiency
• Commonest immunodeficiency
• Contributes a significant proportion to
hospital admissions
• Mainly affects the phagocytic and
lymphocytic functions
• Results from infection (HIV), malnutrition,
aging, cytotoxic therapy etc.
 Factors causing secondary
immunodeficiency
• Malnutrition - Protein-calory malnutrition
and lack of certain dietary elements (eg; Iron,
Zinc); world-wide the major predisposing
factor for secondary immunodeficiency.
• Tumors – direct effect of tumors on the
immune system by effects on
immunoregulatory molecules or release of
immunosppressive molecules, eg TGF.
• Cytotoxic drugs/irradiation – widely used
for tumor therapy, but also kills cells important
to immune responses, including stem cells,
neutrophil progenitors and rapidly dividing
lymphoyctes in primary lymphoid organs.
 Factors causing secondary
immunodeficiency
• Aging – decreased T and B cell responses
and changes in the quality of the response.
• Trauma – increased infections probably
related to release of immunosuppressive
molecules such as glucocorticoids.
• Diabetes mellitus
• Immunosuppressive microbes – malaria,
measles and HIV.
 When to suspect

• Recurrent infections
• Severe infections not responding to
appropriate antibiotics
• Unusual infections
• Opportunistic infections
• Opportunistic cancers
 Investigations to assess
quantitative or qualitative
defects of
• the antibody-mediated immunity
• the cell-mediated immunity
• the complement cascade
• the phagocytes
 Evaluation of antibody
mediated immunity
• Simple electrophoresis
• Quantitative estimation of immunoglobulins
– IgA, IgG, IgM
Evaluation of cell-mediated immunity
• DTH skin tests to common antigens –
candida, tuberculin
• Determine
– Total lymphocyte count
– T cell number in blood
– T cell subpopulation percentages
(eg; CD4 & CD8)
Evaluation of cell-mediated
immunity
• Delayed type of
Mantoux test hypersensitivity
skin tests to
common
antigens eg;
Tuberculin
Flowcytometer
 Evaluation of the complement
cascade
• Quantitative estimation of individual
complement components
 Evaluation of the phagocytic
functions
• Determine total granulocyte and
monocyte count
• Assay for
– Phagocytosis
• Nitroblue tetrazolium (NBT) assay
– Chaemotaxis
 Diagnosis and treatment of
immunodeficiency
• Family history – Since defective genes can be
inherited, an investigation into the family history is
especially important in the diagnosis of primary
immunodificiencies
• Evaluation of specific immune components
• Antibiotics and antibodies – Antibiotic therapy
is the standard treatment for infections. In
addition, antibodies from a pool of donors are
used for antibody deficiencies
• Bone marrow transplants and gene therapy
 Summary
• Classification
• When to suspect
• How to investigate
Hypersensitivity
 Objectives
• List hypersensitivity reactions and
describe
– Immunopathological basis
– Clinical presentations
– Principles of management of each type
• Describe the management of
anaphylactic shock
 Immune response

Protective Damage to
host tissues

Hypersensitivity

Autoimmunity
 Original Classification of
hypersensitivity by Gell and
Coombs
Type Immune mechanisms
I IgE antibodies
II Ab & complement
III Ag/Ab complexes
IV T cell mediated
 Present classification of
hypersensitivity

Gell & Coombs classification

of hypersensitivity
+
Type V Antibody mediated
(stimulatory or blocking)
 Time of appearance
Type I 2 to 30 minutes
(immediate)
Type II 5 to 8 hours
(Cytotoxic) (Intermediate)
Type III 2 to 8 hours
(Immune complex) (Intermediate)
Type IV 24 – 72 hours
(delayed)
 IgE mediated Type 1
hypersensitivity: Allergy
• Commonest type of hypersenisivity
• Range from mild to fatal (anaphylaxis)
• Some individuals (atopic) have a genetic
predisposition to make high levels of IgE
• Allergy affects 17% of the population
• Allergic reaction can occur to normally,
harmless antigens (such as pollen or
foodstuffs) and microbial antigens (fungi
or worms)
Mechanism of type 1
hypersensitivity

Degranulate:
Histamine

Products of
cell membrane
Cytokines lipids:
Leukotrienes
B cell Preformed
IL-4 metabolites
- histamine
IgE
Mast cell
Products of
Allergen membrane lipids
- Leukotrines
IL-5 - Prostaglandins
Eosinophil
 Clinical examples of type 1
hypersensitivity
• Rhinitis
• Anaphylaxis
• Bronchial asthma
• Urticaria/angio-oedema
• Food allergy
Urticaria Agio-oedema
 Diagnosis
• History
• Specific IgE antibody level
• Skin prick test
• Food elimination & challenge

Note; Patch test is done in Type IV hypersensitivity

Skin Prick Test
 Treatment
• Antigen avoidance
• Antihistamine
• Corticosteroids
• Leukotriene receptor antagonists
• Mast cell stabilizers
• Adrenaline
 Type II hypersensitivity
• Cytotoxic hypersensitivity
• IgG and IgM mediated
• Antibodies are directed mainly
to cellular antigens (e.g. on
erythrocytes) or surface
autoantigens
• Causes damage through
opsonization, lysis or antibody
dependent cellular cytotoxicity
 Clinical examples of type II
hypersensitivity
• Rhesus incompatibility
– IgG against RhD antigen
• Transfusion reactions
– Isohaemaglutinins against major blood
group antigens (A & B)
• Autoantigens
– Basement membranes of lung & kidney -
Goodpasture’s syndrome
– Acetylcholine receptor – Myasthenia gravis
– Erythrocytes – Haemolytic anaemia
• Drugs
 SDL
• Principles of Coombs test
 Treatment
• Exchange transfusion
• Plasmapheresis
• Immunosuppressives/cytotoxics
 Type III hypersensitivity
• Immune-complex mediated
• IgG against non-self or self antigens
– Eg; microbes, drugs including antisera &
autoantigens (eg; SLE)
• Activation of complement cascade
• Local damage: Arthus reaction
– Inhalation of bacterial spores – Farmer’s lung
– Avian serum/faecal proteins – Bird fancier’s
lung
• Systemic damage:
– Serum sickness
– Vasculitis
– Post streptococcal glomerulonephritis
 Treatment
• Corticosteroids
• Immunosuppressives/cytotoxics
• Plasmapheresis
• Monoclonal antibodies
 Type IV hypersensitivity
• Delayed type (Occurs 24 hours after
contact with antigens)
• Mediated by cells (T cells together with
dendritic cells, macrophages and
cytokines)
• Persistence presence of antigen leads to
the formation of granuloma
 Clinical examples for type IV
hypersensitivity
• Contact dermatitis with
– Small molecular weight chemicals
• Eg: Nickel, silica
– Molecules from some plants
• Eg; poison ivy
• Post primary tuberculosis
• Tuberculin test (Mantoux test)
 Treatment
• Immunosuppressives
• Corticosteroids
• Removal of antigen
 Type V hypersensitivity
• Blocking antibodies
– Anti-AChR antibodies in myasthenia gravis
– Blocks muscle contraction
• Stimulating antibodies
– Anti-TSHR antibodies in Graves disease
– Excess thyroid hormone secretion
 Treatment
• Treatment of individual disease
 Summary
• Classification of hypersensitivity
• Immunopathogenesis
• Clinical features
• Principles of management
of each type
Tolerance & Autoimmunity
 Objectives
• Define tolerance
• Mechanisms of tolerance
• Define autoimmunity and
autoimmune disease
• Mechanisms of autoimmunity
• Factors contributing to autoimmunity
• Spectrum of autoimmune diseases
• Principles of treatment
 Immunologic Tolerance

The unresponsiveness of the immune

system to self-antigens.
 Mechanisms of tolerance

Mechanisms that prevent immune

response to self antigens.
 Mechanisms of tolerance
• Central
– Negative selection
• T cells in the thymus
• B cells in the bone marrow
• Pheripheral
– T cells
• Functional unresponsiveness (Anergy)
• Death of the effector cell (apoptosis)
– B cells
• High concentration of self antigens in peripheral
lymphoid tissues become anergic
 Regulatory T cell
• CD4+CD25+ T cells
• Maintains tolerance to self-antigens
 Autoimmunity
The response of the adaptive immune
system to self antigens that occurs
when mechanisms of self-tolerance
fails.
 Autoimmune disease
A disease caused by tissue damage
resulting from a breakdown of
self-tolerance mechanisms.

Autoimmune diseases can be

organ-specific or systemic.
 Mechanisms of autoimmunity
• A defect in the mechanisms of self-tolerance
– Molecular mimicry
• Eg; a cross-reactive antigen between heart muscle and
Group A Streptococci predisposes to the development of
rheumatic fever
– Modification of cell surface by microbes and drugs
(hapten-like manner)
• Drug-induced autoimmune haemolytic anaemia
• Thrombocytopenia following viral infections
– Presence of self reactive T cell in peripheral blood
• Extrathymic T cell development
– Failure of negative selection
• AIRE gene defect
Mechanisms of autoimmunity
• Polyclonal activation via microbial
antigens
– Eg; endotoxin and EBV
• Availability of normally sequestered self
antigens
– Eg; lens of eye, central nervous system,
thyroid and testes
• Dysregulation of idiotype network
– Eg; antibodies to insulin, TSH and
acetylcholine receptors
 Factors contributing to
autoimmunity
• Age
– Higher incidence in aged population
• Less stringent immune regulation by the ageing
immune system
• Gender
– Women have a greater risk than in men
• Neuroendocrine system influence
• Male:Female – SLE 10:1 – Grave’s disease 7:1
• Ankylosing spondylitis is almost exclusively a
male disease
 Factors contributing to
autoimmunity
• Infections
– Eg; EBV, Mycoplasma, Streptococci,
Borrelia burgdoferi (Lyme arthritis) and
malaria
• Drugs
– Eg; Procainamide (10% develop SLE like
syndrome)
• Immunodeficiency
– Eg: C2, C4, C5, C8 & IgA deficiency
 Factors contributing to
autoimmunity
• Genetic factors
Disease HLA Risk
Ankylosing spondylitis B27 90
Reiter’s disease B27 36
SLE DR3 15
Myasthenia gravis DR3 2.5
IDDM DR3/DR4 25
Psoriasis DR4 14
Multiple sclerosis DR2 5
Rheumatoid arthritis DR4 4
 Spectrum of autoimmune
diseases
• Organ specific
– Addision’s disease - Adrenal cortex
– Autoimmune haemolytic anaemia
– Grave’s disease - TSH receptors
– Guillain-Barre syndrome- Peripheral nerves
– Hashimoto’s thyroiditis - Thyroid peroxidase
– IDDM -  cells in pancrease
– PBC - pyruvate dehydrogenase
– Pemphigus - epidermal cells
– Pernicious anaemia - intrinsic factor
– Polymyositis- muscle
 Spectrum of autoimmune
diseases
• Several organs affected
– Goodpasture’s syndrome
• Basement membrane of kidney and lung
– Polyendocrine
• Multiple endocrine organs
• A group of cells affected
– Autoimmune haemolytic anaemia
– Autoimmune thrombocytopenia
 Spectrum of autoimmune
diseases
• Systemic
– Ankylosing spondylitis - vertebral
– Chronic active hepatitis - DNA
– Rheumatoid arthritis - IgG
(Rheumatoid factor)
– Scleroderma - nuclei &
centromeres
– SLE - dsDNA
– Wegerner’s granulomatosis – Cytoplasm of
the neutrophils
– PAN - Cytoplasm of the neutrophils
– Antiphospholipid syndrome
 Principles of treatment
• Metabolic control
– Graves disease
– Pernicious anaemia
• Immune modulators
– NSAID
– SAID
– Immunosuppressive cytotoxic drugs
• Removal of offending antibodies or immune complexes -
plasmapheresis
• Surgical
– Thymectomy & Splenectomy
• Screen for associated disorders
 Objectives
• Define tolerance
• Mechanisms of tolerance
• Define autoimmunity and
autoimmune disease
• Mechanisms of autoimmunity
• Factors contributing to
autoimmunity
• Spectrum of autoimmune diseases
Immunofluorescence technique
 ANA
• Diagnostic,
prognostic &
monitoring
 Anti ds-DNA
• SLE >90%
Ankylosing spondylitis
Achilles tendonitis in seronegative arthropathy
Oral ulceration in Behcet’s disease
Circinate balanitis in Reiter’s disease