IMMUNO-SERO SEMI-FINALS - Azotemia

Diagnostic feature: Presence of M protein

Immunoproliferative Disorders Diagnostic Test: Electrophoresis

MULTIPLE MYELOMA Note: AZOTEMIA vs UREMIA

Definition: B cell malignancy characterized by Both increase BUN but uremia shows signs &
abnormal proliferation of plasma cells able to symptoms
produce a monoclonal immunoglobulin (M protein)
Incidence:
3-9 cases 100,000 population/year
more frequent in elderly
modest male predominance
Clinical Forms:
MM
Solitary Plasmacytoma
Plasma Cell Leukemia

M Protein:
- is seen in 99% of cases in serum and/or urine.
IgG > 50% WALDENSTROMS MACROGLOBULINEMIA
IgA 20-25% Indolent lymphoma
IgE and IgD 1-3% Occurs > 30 yrs; usually > 60 yrs
Light chain 20& Characterized by:
- 1% of cases are nonsecretory - proliferation of lymphoplasmatic and plasma cells
Clinical Manifestations: related to malignant behavior - monoclonal IgM
of plasma cells and abnormalities produced by M Clinical Presentation:
protein - Asymptomatic
Plasma Cell Proliferation: - Symptomatic
- multiple osteolytic bone lesions weight loss
- hypercalcemia fatigue
- bone marrow suppression (pancytopenia) lymphadenopathy
Monoclonal M protein hepatosplenomegaly
- decreased level of normal immunoglobulins sensorimotor peripheral neuropathy
hypersensitivity hyperviscosity syndrome
Clinical Symptoms: - Generalized Neurologic Dysfunction
- Bone pains, pathologic features (coma)
- Weakness & fatigue - Bleeding diathesis (impaired platelet
- Serious infection function)
- Renal failure - Hypervolemia (progressing to congestive
- Bleeding diathesis heart failure)
Laboratory Tests: Laboratory Findings:
- ESR > 100 - Anemia, thrombocytopenia
- Anemia, thrombocytopenia - Hyperproteinemia
- Rouleaux in peripheral blood smear - Prolongation of APTT, PT
- Marrow plasmacytosis >10-15% Diagnosis:
- Hyperproteinemia - Monoclonal IgM
- Hypercalcemia - Lymphoplasmatic cells in the bone marrow and
- Proteinuria peripheral blood
Treatment:
- Chemotherapy (Chlorambucil, CHOP) ORGAN SPECIFIC
- Plasmapheresis Autoimmune disease Antigens
Addisons disease Microsomal proteins of
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AUTOIMMUNITY Acute disseminated Basic protein of myelin
encephalomyelitis
Autoimmunity Origins Hashimotos Thyroglobulin
Horror Autotoxicus: Literally, the horror of self- Thyroiditis Microsomal Antigen
toxicity IDDM Islet cells
A term coined by Germal Immunologist Paul Goodpastures Type IV of collagen
Ehrlich (1854-1915) to describe the bodys Syndrome membrane
innate aversion to immunological self- Graves disease TSH receptors
destruction Myasthenia gravis Acetylcholine receptors
Autoimmune Chronic Smooth muscles
AUTOIMMUNITY active hepatitis
- basically means immunity to self Pernicious Anemia Gastric Parietal cell
- a condition that occurs when the immune system antigens, Intrinsic
mistakenly attacks and destroys healthy body tissue factor
- failure of immune tolerance may kulang pa dito sa table.sino may kopya?
- IMMUNE TOLERANCE failure of the immune
system to mount an immune response to an antigen Causes of Autoimmunity:
- FEMALES are prone to autoimmune disorders self
General Signs of Autoimmunity Disease: environment
- Increase gammaglobulins Genes and Autoimmunity
- Presence of decrease antibodies
The concept that a single gene mutation leads to
- Depressed levels of serum complement
a single autoimmune disease is the exception not
- Immune complexes in serum
the rule
- Decrease T suppressor (Ts) cell
Because of this autoimmune disease are
generally classified as complex disease as there
Autoimmunity Classification
is not a single pinpoint-able gene
- can be classified into clusters that are either organ-
ENVIRONMENT
specific or systemic
- Pathogens, drugs, hormones and toxins are just a
few ways that the environment can trigger
autoimmunity
DRUGS AND TOXINS
Drugs -e.g. Procainamide (Pronestyl)
- Drug induced lupus
Toxins - e.g. Toxic Oil Syndrome
- Occurred in Spain (1981) after people ate
contaminated olive oil
- People developed unique illness marked by lung
disease, eosinophilia, and excessive IgE
Treatment: The key to treating autoimmunity is
IMMUNOMODULATION (adjustment of immune
response to a desired level)
LUPUS ERYTHEMATOSUS
Types: Staining Pattern ANA Disease Association
1. Discoid HOMOLOGOUS Anti-DNP Rheumatoid disease
(solid or diffuse) Anti-nDNA SLE
2. Systemic Anti-dsDNA Sjogrens Syndrome
3. Drug-induced Anti-ssDNA MCTD
Hydralazine hydrochloride - antihypertensive PERIPHERAL (ring, Anti-DNP Active stage of SLE
Procainamide hydrochloride - anti-arrythmia membranous, Anti-nDNA Sjogrens Syndrome
4. Neonatal shaggy) Anti-dsDNA
Anti-ssDNA
Anti-Ro/SS-A (Anti-Robert Soluble Speckled (mottled, Anti-ENA SLE
Substance) pepper-dots) (extractable RA
Anti-La/SS-B (Anti-Lane Soluble Substance) nuclear MCTD
antigen)
Anti-Smith
Systemic Lupus Erythematosus
(marker for
Disease of multiple systems SLE)
Immune complex disease characterized by Anti-RNP
overproduction of autoantibodies Nucleolar Anti-RNP Scleroderma
Arthritis - most common manifestation Discrete Centromere Calcinosis
Manifests itself by skin lesions butterfly Reynauds
phenomenon
rash/RED WOLF (red rash across nose and Esophageal dysmotility
cheeks
aka WOMENS DISEASE C - Calcinosis
Women > Men because of estrogen R - Reynauds Phenomenon
E - Esophageal dysmotility
Laboratory Observations S - Sclerodactyly
Presence of anti-nuclear antibodies (ANA) - T - Telangiectasia
not diagnostic of SLE
Le cell - PMN leukocyte with ingested LE RHEUMATOID ARTHRITIS
body, often in rosette formation - Autoimmune disease causing chronic inflammation
Hypocomplementemia of the joints and periarticular tissue
Hypergammaglobulinemia - Rheumatoid factor
Group of immunoglobulins that interacts
Serologic Tests: specifically with the Fc portion of IgG
Antinuclear Antibody (ANA) Visible Method molecule (anti-antibodies_
- Principle: Indirect Immunoenzyme IgM
- Hep2 cells (Nuclear Antigen) + Patient Anti-cyclic citrullinated peptide (marker for
serum (w/ ANA) + AHG + stain Positive for RA)
ANA = brown cytoplasmic/nuclear stain Arthrocentesis - process of collecting synovial
Indirect Fluorescent Antibody Test Detection fluid from a joint
- Principle: Indirect Immunofluorescence
- most commonly used method Laboratory Tests:
- Label: Fluorophores Rose Waaler Test - most commonly used method
- Positive result: Fluorescence (Green) Sheep Cell Agglutination Test (Rose et al)
- Hep2 cells (w/ nucleus) + Serum Reaction Latex Fixation Test (Singer and Plotz)
+ AHG with stain = Positive result (color Sensitized Alligator Erythrocyte Test (Cohen et
formation) al)
Bentonite Flocculation Test (Bloch and Bunim)
SEROLOGY
- study of antigen-antibody reaction in vitro
When to use serology?
- Unable to culture infectious agent
- Confirmatory of etiologic agent identification
- Diagnosis of immunologically-related disorders (ex.
autoimmune disorders)
- Determination of immune status (ex. immunity to
Rubella, Hepatitis B)
Serologic Test
- test that involves antigen-antibody reaction
Types of Serologic Test:
Forward Serologic Test - detect unknown
antigens using known or commercial antisera
Ex: Direct Blood Typing/Red Cell Typing
Backward Serologic Test - detect the presence of reaction
unknown antibodies in the serum of patient by
using known commercial antigen
Ex: Indirect Blood Typing
Preservation of Serum:
Physical - Refrigerate for 72 hours at 4-60C
Chemical - Merthiolate
5% phenol or tricresol
Inactivation of Serum:
- to remove complement because it interferes in
some serologic tests
Physical - Heat serum at 560C for 30 minutes or heat
at 60-620C for 3-4 minutes only
Chemical - Choline chloride
Immunologic Reactions:
Primary - combination of antigen-antibody; non-
visible reaction
Secondary - demonstrates antigen-antibody;
visible reaction
Tertiary - immunologically in vivo; biologic
reaction is detectable
Ex: phagocytosis or opsonization
Secondary Immunologic Reaction Test
1. Precipitation
- Antigens involved are soluble
- There must be optimum ratio of antigen &
antibody
PROZONE - Ab > Ag (False negative)
POSTZONE - Ab < Ag (False negative)
ZONE OF EQUIVALENCE- Ab = Ag
Precipitation in a fluid medium
Turbidimetry - turbidity, concentration
Nephelometry - light scattered,
concentration
PRECIPITATION BY PASSIVE IMMUNODIFFUSION
Advantage: Cheap
Disadvantage: Time-consuming
Passive - no enhancement media
ELECTRICITY - Example of enhancement media
Purpose of enhancement media - to speed up
1. Single diffusion, Single Dimension (Ouidin
Test)
End Result: Precipitin line (Ag-Ab reaction)
Semiquantitative - exact concentration is
unknown
2. Single diffusion, Double Dimension (Radial
Immunodiffusion)
Quantitative: diameter is directly
proportional to concentration
End result: Precipitin ring
2 Methods:
Fahey Method (Kinetic Diffusion)
-18 hours
- reaction is not allowed to full completion
Mancini Method (Endpoint Diffusion)
-IgG: 24 hours; IgM: 50-72 hours
- reaction is allowed to full completion
3. Double Diffusion, Double Dimension
(Ouchterlouny Technique)
Both antigen and antibody is moving
1st generation test for HBsAg
Qualitative: presence/absence of antigen
Patterns:
A. Identity - smooth curve
B. Partial Identity - spur formation; not
exactly the same, they share a common
epitope
C. Non-identity - cross/intersect
A. Direct Agglutination - antigens are found on the
surface of the particles
Ex:
Blood Typing
Kauffman & White - used to serotype Salmonella spp.
Weil Felix - Rickettsia infection
Widal - Typhoid fever
Cold Agglutinin - Mycoplasma pneumoniae (causes
Primary Atypical Pneumonia)
B. Passive Agglutination - antigen is artificially
attached to a particulate carrier
Ex: Cells, Latex, Bentonite, Celloidin, Charcoal

C. Reverse Passive Agglutination - antibodies are

attached to particulate carriers
Application: CRP, RF determination

TYPES OF AGGLUTINATION REACTION:

Coagglutination
PRECIPITATION BY ELECTROPHORETIC Carrier: Bacterium
TECHNIQUES Example: Staphylococcus aureus, Hemophilus
Advantage: Less than 24 hours (w/ electricity) *Note: Bacteria/carrier act as the inert particle
Disadvantage: Expensive to which the antibody is attached
1. Rocket Electrophoresis (Laurell Technique) Agglutination Inhibition
RID + electrophoresis Positive Result - no agglutination
the total distance of antigen migration and Negative Result - with agglutination
precipitation is directly proportional to Example: hCG test
antigen concentration
2. Immunoelectrophoresis (IEP)
Confirmation of Bence Jones Protein
Useful procedures for the identification of
monoclonal proteins
Double diffusion + electrophoresis
3. Counter Immunoelectrophoresis (CIE)
Antigens and antibodies are placed on the
well directly opposite each other
4. Immunofixation Electrophoresis
Immunoprecipitation + electrophoresis
Bands are called immunoprecipitin bands

Western Blot - Protein (ex. detect HIV)

Northern Blot - RNA
Southern Blot - DNA

2. Agglutination
- Antigens involved are particulate