Lecture 23-Primary Immunodeficiences 2

Lecture 24-Autoimmunity _ Rheumatology 55

Lecture 25-Immune Mediated Vasculitis 103
DLA Notes on Immunology of Transplantation 151
DLA Notes on Primary Immunodeficiency 201
DLA Notes on Vasculitis 240
DLA-Video Lecture_Acquired immunodeficincy 254
DLA Notes on Hypersensitivity _ immune testing 300
 Lecture 23:
Primary
Immunodeficiency
Disorders
Dr. R. Tey

1
 Immunodeficiency
• Abnormality of immune function that
increases susceptibility to infection
– Patients usually identified due to “too
many” infections
– Severe infections with “unusual”
organisms may also be a clue

2
 Types of Immunodeficiency

• Primary (genetic) or congenital

– Disorders of T cells, B cells (Ab),
phagocytes, or complement
• Secondary or acquired
– Iatrogenic (due to medical treatment)
– HIV infection
– Other viral or metabolic disorders

2.7% of US adults identify as currently immunosuppressed.

Harpaz R, et al. JAMA 316:2548, 2016 (2013 Natl Health Interview Survey)
3
 Incidence of Immunodeficiency
• Primary immunodeficiency, 1:10,000
– Including IgA deficiency, 1:476
– Including acquired deficiency, 1:50 Total IgG
<400 mg/dL
• Compare with:
– Cystic fibrosis, 1:2500
– Phenylketonuria, 1:14,000
– Sickle cell disease, 1:72,000 in US
• 1:500 in African Americans

Stiehm ER. Immunologic Disorders in Infants and Children, 4th Ed 4

 Distribution of Primary
Immunodeficiencies
2% complement
deficiency

18% phagocytic deficiencies

50%
antibody 10% cellular deficiencies
deficiencies
20% combined cellular
& Ab deficiencies

Stiehm ER. Immunologic Disorders in Infants and Children, 4th Ed

5
Primary Immunodeficiency Disorders discussed in
Lecture and DLA

• Severe Combined Immunodeficiency (SCID)

• DiGeorge Syndrome
• Bruton’s Agammaglobulinemia
• Common Variable Immunodeficiency (CVID)
• Isolated IgA Deficiency
• Hyper IgM syndrome
• Hyper IgE syndrome
• Chediak-Higashi Syndrome
• Chronic Granulomatous Disease
• Wiskott Aldrich Syndrome
• Ataxia-Telangiectasia
• Complement deficiencies
• C1 Inhibitor Deficiency (Hereditary angioedema)
6
 Severe Combined
Immunodeficiency (SCID)
• Rare, fatal genetic syndrome
characterized by absence of T and B
(and sometimes NK) cell function
– T, B, and/or NK cells may be absent
– If untreated, patients typically die of
infection by age 2
– At least 16 genes have been implicated

7
 Fatal Infections in SCID
• T cell defects lead to opportunistic
fungal and viral infections.
• Antibody defects make patients
susceptible to bacterial infections.
• Unchecked replication of
organisms without immune
response causes severe disease.
8
 Gene Defects in SCID
• Cytokine expression and signaling
– IL2RG, JAK3, IL7RA, BCL11B
• Generation of antigen receptor
– RAG1, RAG2, ARTEMIS, PRKDC
• Migration & survival of precursors
– ADA, CORO1A, AK2
• Defects in lymphocyte activation
– PTPRC/CD45, CD3E, CD3D, CD3Z, IKBKB
Al-Herz W, et al. Front Immunol. 5:162, 2014
9
 AK2

CORO1A, BCL11B

RAG-1
RAG-2
ARTEMIS JAK3, CD3, CD45, IL7RA, BCL11B
PRKDC

IKBKB

IL2RG, JAK3, IKBKB, BCL11B

SCID blocks T and B cell development

and/or activation pathways. 10
 X-Linked SCID (SCID-X1)
(due to IL2RG mutation)
• Most common form
of SCID (78 of 170, Also IL-21R

46% at Duke).
• Occurs in boys.
• The c chain is a
signaling
component of
receptors for IL-2,
IL-4, IL-7, IL-9, IL-15,
and IL-21.

11
 X-Linked SCID
IL-2 IL-4
IL-7 IL-9 IL-7 X T cells
IL-15 IL-21 IL-15 X NK cells .

B cells develop but do not

produce antibody.

 c

Result is T- NK- B+ SCID
JAK3
JAK1

No signal
12
 Clinical Manifestations
• Repeated and severe infections,
particularly with viruses & fungi
• Multiple infections may be present in a
single patient
• Death due to infection by 6 – 12 months
of age if untreated

13
 Treatment of SCID-X1
Standard
• Bone marrow transplantation of
care
– HLA-identical donor (sibling) in USA
– Haplo-identical donor (parent) 96%
success
• In utero or after birth before
• Gene therapy to replace c 3 mo

– Clinical trials in Europe (since 1999)

showed correction using a retroviral
vector containing c, but with risk of
leukemia

McCormack et al. New Engl J Med. 350:913-922, 2004

Hacein-Bey-Abina S, et al. New Engl J Med. 363:355-364, 2010
Hacein-Bey-Abina S, et al. New Engl J Med. 371:1407-1417, 2014 14
 SCID due to JAK3 Mutation

• Autosomal
Also IL-21R
recessive X
• T- NK- B+ X X
phenotype, same
as SCID-X1, but
more rare X
– 11 of 170 (7%)
at Duke
– Boys and girls

15
 Take Home Lesson
• Mutations in the same pathway may
lead to similar phenotype.
– What seems like one disease clinically
may be due to mutations in one of several
different genes that are required to
generate a particular function.

16
 ADA-Deficient SCID
• Lack of ADA enzyme leads to toxic
levels of nucleotide metabolites
– High in thymus due to extensive cell death
and in BM due to extruded RBC nuclei
• T- B- NK- SCID
– 28 of 170 (17%) Duke SCID patients
• Can treat with PEG-ADA, stem cell
transplant, or gene therapy (D/C PEG-ADA
prior)

Blaese RM, et al. Science 270:470-475, 1995

Aiuti A, et al. New Engl J Med. 360:447-458, 2009 17
 ADA-Deficient SCID
Feedback
regulation
Lack of
inhibits Ribonucleotide
dCTP dNTPs
dNTP reductase
dGTP blocks
synthesis
dTTP DNA
synthesis
dATP
High
dGTP
levels activate
caspase-9
ADA PNP
d-adenosine d-inosine hypoxanthine

Generated by cell death in the thymus and

breakdown of RBC nuclei in the bone marrow
18
 IL7RA-deficient SCID
• Mutation in IL-7 receptor  chain
– T- B+ NK+ phenotype
– 3d most common form of SCID
– 17 of 170 (10%) Duke cases
• Implies that defective signaling through
IL7R is responsible for T cell defect in
X-SCID

19
DiGeorge
Syndrome
• Develop-
mental
anomalies
involving 3d
& 4th
pharyngeal
pouches
(24 d – 7 wks)

20
 DiGeorge Syndrome
• Thymus hypoplastic or absent
– Variable loss of T cell immunity
• Absence of parathyroids
– Hypocalcemic seizures
• Congenital heart disease
• Abnormal mouth, ears, or facies

21
 Causes of DiGeorge Syndrome
• Deletion of 22q11
TBX1 gene
– 11 (38%) of 29 Duke DGS pts (transcription
factor)
• Deletion of 10p13
• CHARGE association (31% at Duke)
– Coloboma, Heart defect, choanal Atresia,
growth Retardation, Genital hypoplasia,
Ear defects/deafness CHD7 gene?

• Infant of diabetic mother (17% at Duke)

22
 Defects in CHARGE

Coloboma: gap in
structures of the eye
(eyelid, iris, lens, Choanal atresia: lack of
choroid, retina) continuity of nasal airway
23
 Complete DiGeorge Syndrome

• Absence of thymus
• Profound immunodeficiency
– No T cell function
– Death from infection by age 2 without specific
immune reconstitution
• Patients may have oligoclonal
(uneducated, autoimmune) T cells in
atypical complete DGS.
See Stone CA, et al. Ann Allergy Asthma Immunol 118: 640-642, 2017

24
Diagnosis of Complete DGS
• Low T cell numbers
– Can be high in atypical cDGS due to
proliferation of oligoclonal (extrathymic) T
cells
• Low naïve T cell numbers
– <50 naïve T cells (CD45RA+ CD62L+)/mm3
• Low T cell receptor excision circles
– <100 TRECs/105 T cells
– TRECs indicate thymic development

25
 Complete DiGeorge Syndrome
• Treated by thymus transplantation
– Ongoing clinical trial at Duke
• 1st report: Long-term survival and immune
reconstitution of 7 of 12 patients
Markert et al. Blood 102:1121-1130, 2003
• Current survival 43/60 (72%)
Markert et al. Clin Immunol. 135:236-246, 2010

26
 Antibody Deficiency
(Hypogammaglobulinemia)
• Defect in B cell development
– BTK, 5/14.1Ig, BLNK
• Defect in B cell function
– ICOS, AID/UNG, NEMO, CD40
• Defect in B/T interactions
– SH2D1A (SAP), CD40L
• Unknown
– IgA deficiency, some causes of CVID

27
Normal B Cell Activation

28
 Bruton’s X-Linked
Agammaglobulinemia (XLA)
• Caused by a mutation in the BTK gene
(Xq21.22)
• The Bruton’s or B cell tyrosine kinase
(Btk) protein is associated with the B
cell antigen receptor
– Drives maturation signals
– Without Btk, maturation stops after heavy
chain rearrangement

29
 Bruton’s X-Linked
Agammaglobulinemia (XLA)

• Failure of B cell precursors to mature

into functional B cells
– Usually limited to males
– Affected patients become symptomatic
at ~6 mo, when maternal Ig is depleted
• Recurrent pyogenic infections
– Organisms normally cleared by
opsonization and phagocytosis
30
 Infections in XLA
• Sinopulmonary infections
– H. flu, S. pneumoniae, Staph. aureus
• Enteroviral infections, including
encephalitis and meningitis
– Echovirus, poliovirus, coxsackievirus
• Giardia (normally resisted by IgA)

31
 Diagnostic Criteria for XLA
• Absent circulating B cells (nl = ~10% of PBL)
• CD19+ B cell precursors present in marrow
• Cytoplasmic heavy chain, with absence of
surface and secreted Ig
• Rudimentary germinal centers in lymphoid
organs (small/no tonsils, LN)
• Plasma cells are absent
• Decreased serum Ig (all subclasses)

32
 Pathways Causing
Agammaglobulinemia

• XLA (BTK mutation)

• Autosomal recessive
(Very rare)
–  heavy chain
– 5/14.1 surrogate
light chain
– Ig
– BLNK (B cell linker)

33
 Treatment of
Agammaglobulinemia
• Antibody replacement
– i.v. immunoglobulin
• With treatment, most affected
individuals survive to adulthood.

The recommended dose of IVIG is 2g/kg body weight, given

every 3-4 weeks. At the 2015 cost of $75/g, this would cost
$97,500/yr if given to a 50 kg (110 lb) person every 4 wks .

34
 Common Variable
Immunodeficiency (CVID)
• A heterogenous “diagnosis” for patients
with antibody deficiency, infections,
autoimmunity, and lymphoproliferation
caused by:
– Defective B cell differentiation
• Defects in CD19, CD20, CD21, CD81, BAFFR, (TACI?)
– Defects in B-T interactions
• SH2D1A (SLAM-associated protein, SAP) deficiency
• Deficiency of ICOS/CD278 (inducible co-stimulator)
• LRBA deficiency
– Other mutations still unknown

Salzer U, et al. Ann NY Acad Sci. 1250:41-49, 2012 35

 CVID
• LRBA deficiency results in decreased CTLA4
protein in Tregs & activated T cells.
• CTLA4 normally resides in T cell endocytic
vesicles; released to surface on activation
• Competes with CD28 for CD80/86 to down-
regulate co-stimulation
• LRBA-deficient CVID responds to abatacept,
a CTLA4-Ig fusion protein and to
chloroquine, that inhibits lysosomes to
prevent CTLA4 degradation*
* Lo B, et al. Science 349:436-440, 2015 36
Clinical Manifestations of CVID

• Recurrent infections
– Sinopulmonary (pyogenic bacteria)
– Herpesvirus
– Enterovirus (meningoencephalitis)
– Giardia lamblia
• 20% develop autoimmunity (RA)
• ↑ risk of lymphoma & gastric CA

37
 Isolated IgA Deficiency
(serum IgA ≤ 5 mg/dL; normal: 130-250 mg/dL)

• Discovered in 1957 in sick patients and in

1964 in healthy people
• Characterized by very low levels of both
serum & secretory IgA
• Prevalence varies from 1:223 to 1:3000 in
different populations
• Usually asymptomatic
• May have increased sinopulmonary & GI
infections (giardia), allergy, or
autoimmune disease (RA, SLE)

38
 Isolated IgA Deficiency
(serum IgA ≤ 5 mg/dL; normal: 130-250 mg/dL)

• Differentiation of naïve B cells to IgA-

secreting plasma cells is impaired.
– Molecular basis is still unclear.
• In absence of IgA, mucosal barrier function
is abnormal, exposing immune cells to
macromolecules that induce Ab that react or
cross-react with self-molecules.

IgA-deficient patients may develop fatal anaphylaxis

to IgA in transfused blood, since their immune system
sees IgA as a foreign antigen.
39
 Disorders of Phagocytes
• Disorders of phagocyte function

40
 Chediak- www.pathpedia.com

Higashi
Syndrome
• Autosomal recessive
• Mutations in the CHS1/LYST gene
affect microtubule function.
– Defective granule formation
– Defective degranulation leads to delayed
release of bacteriocidal enzymes.
– Defective formation of melanin granules
leads to albinism, visual defects 41
Chediak-Higashi Syndrome
• Recurrent pyogenic infections
• Mean survival 10 yrs
• Partial oculocutaneous albinism
• Impaired vision
• Neurologic
abnormalities
Bone marrow transplant corrects
the immunologic but not the
neurologic abnormalities of CHS.
42
ahsmediacenter.pbworks.com
 Chronic
Granulomatous
Disease
• Repeated
infections
• Severe acne
• Nasal
inflammation
• Granuloma
formation
• Gingivitis

43
Chronic Granulomatous Disease

Lymphadenopathy in CGD can be massive, 
as shown in this 12 year old boy from Iran, 
who presented with Staph. aureus bacteremia.
Esfandbod M & Kabootari M. New Engl J Med. 367:753, 2012 44
Chronic Granulomatous Disease
• Phagocytes cannot generate sufficient
H2O2 to counteract microbial catalase
• Results in recurrent infections with
catalase-positive organisms
– Staph. aureus
– Burkholderia cepacia
– Serratia marcescens
– Aspergillus species
– Nocardia species

45
 Chronic
Granulomatous
Disease
• Due to
dysfunction
of the
NADPH
oxidase
complex

46
 Diagnosis of CGD

CGD 
No change
neutrophil Load with 
dichlorodihydro‐
fluorescein diacetate
(DCFH‐DA) then
stimulate with
phorbol ester
Control   Green color
neutrophil

Respiratory Burst Assay

47
Respiratory Burst Assay

Normal patient48
Flow Cytometric
Diagnosis of CGD

CGD patient 49
 Dx and Treatment of CGD
• Mean age at diagnosis
– 3 yrs for X-linked form
– 8 yrs for AR forms (can be much later)
• Treatments
– Anti-microbial prophylaxis with trimethoprim-
sulfa, itraconazole, and/or IFN-
– Stem cell or gene therapies await optimal
myeloablation and vectors
• Multiple gene trials: leukemia in 2 of (8?) pts

50
 Survival in CGD is Predicted
by ROS Production
1 – 5% chance
This was a of death per
study of 287 year relates
patients to residual
from ROS
244 kindreds, production,
with 154 so small
different increases
mutations. may be very
beneficial.

Kuhns DB, et al. New Engl J Med. 363:2600-2610, 2010

51
 Summary
• The molecular basis of
immunodeficiency diseases is best
understood by study of normal
immunologic processes.
• Immunodeficiency results when
maturation and/or activation of immune
cells is impaired.

52
Kuby
Immunology,
4th Edition 53
 Lecture 24:
Autoimmune &
Rheumatologic
Diseases
Dr. R. Tey

1
 Immunologic Tolerance
• Specific unresponsiveness to an Ag as
a result of exposure of lymphocytes to
that Ag.
• Loss of central and/or peripheral
tolerance to self-antigens results in
autoimmunity.

2
 Central Tolerance
• Immature self-reactive T or B cell
clones that recognize self-Ag are
eliminated during development.
– Negative selection in thymus
– Receptor editing in BM
• Some self-reactive cells may escape
these processes.

3
 T Cell
Activation

•Requires 2 signals:
•Signal 1 via TCR
•Signal 2 via co-
stimulatory
molecules
•Signal 1 in absence
of signal 2 leads to
anergy.
4
 Peripheral Tolerance

• Anergy: functional inactivation of

lymphocytes following encounter with
Ag
– Ag presention w/o co-stimulation
• Suppression by T regulatory cells
• Activation-induced cell death

5
 Breakdown of Tolerance

Upregulation
of costimulators

X
6
 “Immune Ignorance”
• Failure to elicit immune response due
to sequestering of Ag away from
immune cells
– Immune-privileged sites
• Testis, eye, brain
– ? Gut mucosal barrier
• Enteric bacteria

7
 Autoimmune Disease
• Requires:
– The presence of an immune reaction
specific for a self-Ag
– Evidence that this reaction is 1˚ not 2˚ to
tissue damage
– The absence of another well-defined cause
of the disease

8
 Autoimmune Diseases
• Typically complex, multigenic disorders
• Arise from:
– Susceptibility genes that contribute to
breakdown of self-tolerance; AND
– Environmental triggers that promote
activation of self-reactive lymphocytes

9
 Genetic Susceptibility to
Inflammatory Diseases
Disease  HLA allele  Odds Ratio † 
Rheumatoid arthritis  DRB1, 1 Shared Epitope allele  4 
(anti‐CCP Ab positive)  DRB1, 2 Shared Epitope  alleles  12 
DRB1*0301‐DQA1*0501‐
4  Inherited variants in
DQB1*0201 haplotype  genes for immune
DRB1*0401‐DQA1*0301‐ regulation, bacterial
Type 1 diabetes  8 
DQB1*0302 haplotype  sensing, and cytokine
DRB1*0301/0401 haplotype  responses can also
35  increase risk for
heterozygotes 
inflammatory and
Multiple sclerosis  DRB1*1501  3 
autoimmune diseases
Systemic lupus  DRB1*0301  2 
erythematosus  DRB1*1501  1.3 
B*27 (mainly B*2705 and 
Ankylosing spondylitis  100‐200 
B*2702) 
DQA1*0501‐DQB1*0201 
Celiac disease  7 
haplotype 
10
Modified from Robbins & Cotran Pathologic Basis of Diseases, 9th edition
 Role of Infections
• Up-regulate co-stimulators leading to
breakdown of anergy.
• Polyclonal activation of B cells
producing autoAb
• Release or alteration of self-Ag that
allows development of new T cell
responses
• Immune response against microbe can
cross-react against normal tissues.

11
12
 Immune-Mediated
Inflammatory Diseases
• Mediated by Abs and immune
complexes
– Organ-specific (MG, Graves disease)
– Systemic (SLE, PAN)
• Mediated by T cells
– Organ-specific (Type I DM, MS)
– Systemic (RA, SS, Sjogren’s, IBD)

13
 Graves’ Disease
• Most common cause of hyperthyroidism
– 20-50 cases per 100,000 persons
– Peak at 30-50 yo, but can occur anytime
• Symptoms are weight loss, fatigue, heat
intolerance, tremor, palpitations, palpable
goiter (<60 yrs), A-fib (>60 yrs)
• Ophthalmopathy occurs in 50-70%
– Eyelid lag or retraction, proptosis, double
vision, exposure keratopathy, optic nerve
compression

Smith TJ, Hegedus L. New Engl J Med. 375:1552-1565, 2016 14

15
 Myasthenia
Gravis
Caused by autoAbs
that impair
e.g. pyridostigmine
neurotransmission,
~80%
inducing weakness
1-10%
of skeletal muscle.
10-15% of patients
Usually involves
Assoc. with
1-3% thymus disease,
are negative for
these autoAbs
eye muscles (diplopia
including thymoma
& ptosis), which is the
only site in 15%.

Biomarkers
for severe disease
15% of MG pts have
a 2nd autoimmune
disease: thyroiditis >
SLE > RA
Gilhus NE. New Engl J Med.
16
375:2570-2581, 2016
 Systemic Lupus Erythematosus
• SLE is a chronic autoimmune disease
caused by pathogenic auto-antibodies
and immune complexes that fix
complement, activate inflammatory
responses, and mediate tissue damage.

17
 Reprinted
from
Tsokos GC.
New Engl J Med.
365:2110-2121,
2011

18
 Epidemiology of SLE
• Peak incidence at 20-30 yrs
• Affects predominately females
– 9:1 F:M during childbearing yrs
– 2:1 F:M for children & elderly
• 2-3X higher incidence in blacks and
Hispanics vs. whites

19
Genes Associated with SLE

Includes
specific
alleles of
HLA-DQ
and
deficiency of
the early
complement
components
C2, C4, or
C1q.

Tsokos GC. New Engl J Med. 20

365:2110-2121, 2011
 SLE
Pathogenesis
Serous
membranes
Joints 95% 40%

60% 80% 15% 30% 50%

Tsokos GC. New Engl J Med. 365:2110-2121, 2011 21

 Homogenous
Rim (Abs to ds DNA) (Abs to chromatin, histones, dsDNA)

Speckled (Abs to Sm, RNP, SS-A, SS-B) Nucleolar (Abs to RNA) 22

Identification of Specific ANA
1. Add dilutions of patient or normal serum.

2. Detect bound antibody.

3. Compare.

….etc.

Sm Scl-70 Jo-1 Ro La ds DNA

Abs to dsDNA + Sm are virtually diagnostic of SLE

23
 Inflammatory Bowel Disease

• IBD is characterized by chronic

mucosal immune activation in
response to intestinal bacteria in
a genetically susceptible person
– Ulcerative colitis (UC)
– Crohn disease (CD)

24
 Clinical Characteristics
• Females > males
• Peak onset in teens-20’s or >60 yo
• More common in developed
countries
• Relapsing /remitting episodes of
abdominal pain, bloody diarrhea,
tenesmus, ± fever
• High risk of colon cancer

IBD
25
 Summary

• Autoimmunity
results from
breakdown of self-
tolerance plus
environmental
triggers that
promote activation
of self-reactive
lymphocytes.

26
Robbins and Cotran Pathologic Basis of Disease, 7th Ed.
Rheumatologic
Diseases

27
 Rheumatoid Arthritis

• A chronic, systemic inflammatory

disease that principally attacks the
joints
– Produces a nonsuppurative proliferative
synovitis that often progresses to joint
destruction and ankylosis (immobility)
– Can affect many tissues or organs

28
 Serology of RA
• Ig specific for the Fc portion of IgG is
present in 80% of patients
– Leads to formation of immune complexes
– Not causative, but a marker of disease
activity
• More recently, antibodies against
citrullinated proteins (ACPA) have been
identified and implicated in
pathogenesis.

29
 (Swollen or tender)
(shoulders, elbows, hips, knees, and ankles)

metacarpophalangeal, proximal
interphalangeal, 2nd – 5th meta-
tarsophalangeal, thumb inter-
phalangeal, and wrists

(anticitrullinated protein antibody)

30
Arthritis Rheum. 62:2569–2581, 2010
 The Joint
Lesion
in RA

Robbins Pathologic Basis of

Disease, 8th Ed. Fig. 26-42 31
Rheumatoid Arthritis

32
Rheumatoid Nodule

33
 Systemic Sclerosis
(Scleroderma)

• Characterized by:
– Extensive fibrosis in skin ± GI, kidney,
lung, and other viscera
– Vasculopathy
– Immune dysfunction
• Mechanistic understanding is
currently limited, but some recent
advances.
34
Clinical Characteristics of SS
• Female : male = 3:1
• Peak incidence 50 – 60 yrs
• Striking skin changes
• Raynaud’s phenomenon (1st Sx in 70%)
• Dysphagia (50%)
• Hypertension
40-70%
• Pulmonary fibrosis
have autoAbs to
– Pulmonary hypertension
Topoisomerase
• Renal failure (Scl-70), which is
highly specific

35
 CREST (Limited Scleroderma)
• Calcinosis (Calcium deposits in skin)
• Raynaud’s phenomenon
• Esophageal dysmotility
• Sclerodactyly
• Telangiectasia
No lung or kidney
involvement

90% have anti‐centromere Abs
36
Calcinosis

May leak a
chalky liquid

emedicine.medscape.com 37
Raynaud’s Phenomenon

emedicine.medscape.com 38
 Sclerodactyly

Robbins and Cotran Pathologic Basis of Disease, 7th ed.

Subcutaneous fibrosis leads to immobilization of fingers. 
Loss of blood supply causes ulcerations. 39
Telangiectasias

emedicine.medscape.com 40
 Dermatomyositis

• Inflammatory disorder of skin and 
skeletal muscle
– Classic rash with lilac or brown discoloration 
of eyelids and periorbital edema
– Scaly erythematous patches over knuckles, 
elbows, & knees
• Muscle weakness, esp. proximal
– Difficulty getting out or chair or climbing steps

41
 Dermatomyositis
• Can occur in adults or children
– Ages 5 - 15 or 40 - 60 are peak
• AutoAbs present
– Anti-aminoacyl tRNA synthase (Jo-1),
11-20%
– Anti-nuclear helicase, 5-10%
– Anti-annexin XI, 60% of pediatric pts

42
Dermatomyositis

The violet to brown

discoloration is an
important
diagnostic clue
(Gottron’s sign).

www.ncbi.nlm.nih.gov/pubmedhealth/ 43
 Sjogren Syndrome
• Characterized by dry eyes and mouth
caused by immune-mediated
destruction of lacrimal and salivary
glands
– Keratoconjunctivitis sicca
– Xerostomia
• Most common in women between ages
of 50 and 60

44
 Sjogren Syndrome

• ANA positive in most (50‐80%)
• SS‐A (Ro) Abs in 70‐95%
• SS‐B (La) Abs in 60‐90%
• Lymphocytic infiltration and fibrosis 
of salivary glands

45
Sjogren Syndrome

46
Sjogren Syndrome

Lip biopsy
47
Disease AutoAb Against %  Patients Comments

SLE ds DNA 40‐60 Nephritis; specific for SLE

U1‐RNP 30‐40

Sm 20‐30 Specific for SLE

Ro (SS‐A)/La (SS‐B) 30‐50 Neonatal lupus; & heart block

phospholipids 30‐40 Anti‐phospholipid syndrome

Generic ANAs 95‐100 Not specific for SLE

Systemic sclerosis DNA topoisomerase1 30‐70 Specific for systemic sclerosis

Centromeric A,B,C 20‐40 CREST

RNA pol III 15‐20 Acute onset; assoc. with cancer

Sjogren syndrome Ro (SS‐A) 70‐95

La (SS‐B) 60‐90

Autoimmune  myositis Jo‐1 25 Interstitial lung disease

Mi‐2 5‐10 Dermatomyositis

TIF1  15‐20 Dermatomyositis, cancer

Rheumatoid arthritis CCP (cyclic citrullinated 60‐80 Specific for RA

peptides)
48
Rheumatoid factor 60‐70 Not specific for RA
 Lecture 25:
Immune-Mediated
Vasculitis
Dr. R. Tey

1
 Vasculitis
• Defined by inflammation within the
vascular wall
• Classified by:
– Types of vessels affected
– Role of immune complexes
– Role of specific autoAbs
– Presence of granulomas
– Demographics

2
 Mechanisms
• Immune complex deposition
– Endogenous Ags Ag Ag
– Drug hypersensitivity YC
– Viral infection (e.g. HBsAg+Ab)
• Anti-neutrophil cytoplasmic Abs
– (Myeloperoxidase) MPO-ANCA (p-ANCA)
– (Proteinase-3) PR3-ANCA (c-ANCA)
• Anti-endothelial cell Abs

3
 Vessel 
Size Disease Description

Large Giant cell arteritis Granulomatous inflammation; often involves 

(Temporal arteritis) temporal artery. Usually occurs at >50 yo

Takayasu arteritis Granulomatous inflammation in persons younger

than 50 yo

Medium Polyarteritis nodosa Necrotizing inflammation typically involving renal 

arteries but sparing lungs

Kawasaki disease Arteritis with mucocutaneous LN syndrome; occurs 

in children; coronary artery aneurysms

Small Pulmonary granulomatous  Granulomatous inflammation in resp. tract;

polyangiitis necrotizing in small vessels; PR3‐ANCA
(Wegener granulomatosis)
Eosinophilic granulomatosis Eosinophil‐rich granulomatous inflamm. in respir. 
with polyangiitis tract; necrotizing in small‐med. vessels; assoc. with 
(Churg‐Strauss syndrome) asthma, eosinophilia, & MPO‐ANCA (40‐50%)
Microscopic polyangiitis Necrotizing vasculitis, glomerulonephritis, and 
Robbins Pathologic Basis of Disease, 8th edition.
pulmonary capillaritis; MPO‐ANCA 4
Large Vessel Vasculitis

5
 Giant Cell Arteritis
• a.k.a temporal or cranial arteritis
• Affects elastic-rich major arteries
– Temporal artery
– Ophthalmic artery
– Aorta
– Branches of carotid
– Heart and lungs

6
 Clinical Features
• Constitutional symptoms
– Fever, fatigue, weight loss
• Severe headache and facial pain
– Often unilateral and most intense along
temporal artery
• Visual disturbances
– Diplopia
– Blindness This is a medical emergency!!

7
 Clinical Features
• Most common form of vasculitis in the
elderly in US (age ≥50 required to Dx)
• ~50% of cases are associated with
polymyalgia rheumatica
– Syndrome of pain and muscle stiffness
associated with inflammation in selected
muscle groups, predominately in neck,
shoulders, upper arms and pelvic girdle

8
 Diagnostic
Criteria

9
Weyand CM, et al. NEJM 371:50-57, 2014
 Pathogenesis of GCA
• Activated DCs in vessel wall recruit T
cells and M to form granulomatous
infiltrates. US-FDA approved
tocilizumab
– IL-12/Th1/IFN-γ and IL-6/Th17/IL-17 axis (anti-IL-6R mAb)
to treat GCA

– Familial & ethnic clustering suggests a in May 2017;

Superior to
prednisone alone,
genetic susceptibility NEJM 377:317, 2017

• Intimal proliferation obstructs lumen.

• Proteolytic and elastolytic enzymes
promote remodeling of affected arteries.
10
Weyand CM, et al. NEJM 371:50-57, 2014
 Giant Cell
Arteritis
• Affected vessels may
be thickened, nodular,
and tender.

Salvarini et al. NEJM 347:261, 2002 11

 Histology
• Granulomatous inflammation with
multi-nucleated giant cells centered on
the internal elastic lamina, which is
often disrupted
• OR mononuclear infiltrate w/o giant
cells; may have fibrinoid necrosis
• Obliteration or thrombosis of the
vascular lumen

12
 Histopathology

Giant cell 13
Kelly NP, et al. New Engl J Med. 377:2267‐2272,  2017
arteritis
(an excellent case‐based discussion of GCA)
Takayasu Arteritis
a.k.a pulseless disease

Classically affects the aortic arch;

Also affects major aortic branches (~34%);
or pulmonary arteries (~50%)

14
 Clinical Features
• Fatigue, weight loss, fever
• Vascular insufficiency
– Of upper extremities
• Coldness, numbness, weak pulse but lateral
symmetry of BP
– Of carotid
• Postural dizziness, vision changes
– Of lower extremities
• Claudication
• Affects those under 50 yrs
15
Diagnostic Criteria

The presence of three of the six 
criteria is highly suggestive of the 
diagnosis of Takayasu arteritis.
91% sensitivity
98% specificity

This table is from a case report of Takayasu arteritis in:

Mansour MK, et al. New Engl J Med. 376:1973-1981, 2017 16
 Pathogenesis
• Unclear; may involve
– T cell-mediated (type IV) hyper-sensitivity
– Genetic component
• Increased prevalence in Japan and in HLA-
DR4-positive individuals

17
 Histology
• Granulomatous arteritis, involving
primarily media and adventitia
– Healing lesions may contain mostly
lymphocytes
• Transmural fibrous thickening, with
severe luminal narrowing
– Grossly, aortic intima may be wrinkled and
orifices of major branches narrowed.

18
Takayasu arteritis

19
Takayasu arteritis

20
 Vasculitis of 
Medium‐sized Vessels

21
Polyarteritis Nodosa

Can affect medium to small

arteries of essentially any
organ except lungs

22
 Clinical Features of PAN
• Typically young - middle aged adults
– M:F 2-3:1
• Constitutional symptoms
– Malaise, fever, weakness, weight loss
• Vascular lesions (± hypertension)
• Exacerbations and remissions
– Abdominal pain, melena, infarcts,
glomerulonephritis, renal failure, death

23
 Pathogenesis of PAN
• Still uncertain
– 30% have chronic hepatitis B, with HBsAg-
HBsAb complexes (Type III HS)
– Not associated with ANCA
• A familial form of PAN was recently
identified to be associated with recessive
mutations in the CECR1 gene that
encodes adenosine deaminase-2.
– Compromised endothelial integrity,
endothelial cell activation, inflammation, and
defective differentiation of M2 macrophages

Zhou Q, et al. New Engl J Med. 370:911-920, 2014 24

Elkan PN, et al. New Engl J Med. 370:921-931, 2014
 Histology of PAN

• Transmural inflammation of vessels

– Neutrophils, eosinophils, mononuclear
inflammatory cells
• May have fibrinoid necrosis
• Lesions may be segmental, non-
circumferential, and of varying age
– Can vary from necrosis to fibrosis
– Segmental fibrotic lesions form “nodules”

25
Polyarteritis nodosa

26
27
 Fibrinoid Necrosis

In PAN, lesions commonly involve only part of vessel circumference.

28
Fig. 9-25, Robbins Basic Pathology, 9th edition
 Kawasaki Disease
a.k.a. mucocutaneous lymph node syndrome

Affects small and medium-sized

arteries of skin, ocular and oral
mucosa, coronary arteries

Occurs in infancy and

early childhood (80% < 4 yrs)
29
 Clinical Features
• Fever
• Conjunctivitis
• Erythematous, desquamative rash
– Involves palms and soles
• Lymphadenopathy,
– Generally a single cervical LN
• Coronary artery involvement
– Arrhythmias, aneurysms, MI, heart failure

30
 Pathogenesis

• Characterized by cytokine storm with

elevated TNF, IL-6, G-CSF, IL-1β, IL-17
• Possible mechanisms:
– DTH (type IV HS) T cell responses to an
unknown antigen (? infectious agent)
– Stimulation of endothelial cells, which
express activation antigens
– Production of anti-endothelial Abs, leading
to damage (type II HS)

31
 Histology
• Arteritis similar to PAN, but with more
severe inflammation of the intima
• May progress from smaller to larger
vessels
• May result in myocarditis, valvulitis, or
pericarditis in later stages

32
Vasculitis Involving 
Small Vessels

33
Pulmonary Granulomatous Polyangiitis
(Wegener’s Granulomatosis)

Affects small to
medium-sized arteries

Most common in
middle-aged adults,
M>F
34
 Clinical Features of PGP/WG
• Upper respiratory inflammation
– Severe sinusitis
– Bloody nasal discharge
• Pulmonary symptoms
– Cough
– Hemoptysis
– Shortness of breath

35
 Clinical Features of PGP/WG
• Renal manifestations
– Hematuria
– Rapidly progressive renal failure
• May also involve other organs
– Eyes
– Skin
– Heart (less common)

36
 Pathogenesis
• ? T-cell mediated (type IV)
hypersensitivity to inhaled
environmental or infectious agent
• Formation and deposition of immune
complexes (type III HS)
• 95% of cases have PR3-ANCA that may
activate neutrophils and cause tissue
damage

37
 Histology
• Necrotizing granulomas of upper
respiratory tract (ears, nose, sinuses,
throat)
• Necrotizing granulomatous vasculitis,
especially in lungs
• Necrotizing glomerulonephritis, often
with crescents

38
PGP/WG

39
Eosinophilic Granulomatosis
with Polyangiitis
(previously called Churg-Strauss Syndrome)

A necrotizing vasculitis classically

associated with asthma and allergic rhinitis
that affects medium-small-sized arteries & veins,
& characterized by marked eosinophilia,
↑ serum IgE, and granuloma formation.
40
Diagnostic Criteria for EGP/CSS

≥ 4 of 6 gave
sensitivity of 85% &
specificity of 99.7%
for EGP/CSS in
907 total patients
with vasculitis

Masi AT et al.
Arthritis Rheum.
33:1094-1100, 1990

(additional criteria developed in 2012)

From: Palamara K, et al. N Engl J Med 2017;377:1569-1578, 2017

This reference provides an excellent case-based discussion of EGP 41
 Histology
• Granulomatous and/or necrotizing
vasculitis
• Extravascular granulomas
• Large numbers of eosinophils

42
EGP/CSS

43
Buerger’s Disease
a.k.a. thromboangiitis obliterans

Affects medium and small

arteries and veins,
especially tibial and radial arteries

44
 Clinical Features of Buerger’s Disease

• Vascular insufficiency of
limbs
– Raynaud’s phenomenon
– Claudication
– Severe pain even at rest
• May be complicated by
thrombophlebitis,
ulceration, or gangrene
• Most common in males,
aged 25-50 yrs
– Virtually always
associated with smoking ?

45
 Pathogenesis
• Unclear, but may involve immune
reactivity to or direct toxicity of
tobacco derivatives
• Associated with HLA-A9 and B5
– High incidence in Israel, Japan, India
 Histology
• Segmental acute and chronic arteritis
• Vascular thrombosis
– Thrombus may contain necrosis
surrounded by granulomatous
inflammation
• Inflammation often spreads to
adjacent nerves and veins.

47
Buerger’s Disease

48
DLA Notes on Immunology
of Transplantation

1
 Histocompatibility Antigens
Cell-surface molecules that bind
antigenic peptides and are recognized
by antigen-specific receptors on T cells
(antigen presentation).

2
Histocompatibility (HLA) Antigens
• Class I: expressed by most nucleated
cells; present antigen to CD8+ T cells
• Class II: expressed by limited subset
of cells, including dendritic /
Langerhans’ cells, macrophages, B
cells, activated T cells, stimulated
endothelium; present antigen to CD4+
T cells

3
 Histocompatibility Molecules
are Polymorphic

• Different molecules bind and present

different peptides.
• Many different alleles are present in the
population.
• Histocompatibility molecules can
themselves act as antigens in setting of
organ transplantation.

4
Histocompatibility Gene Loci

Human chromosome 6
5
HLA Haplotypes

Since HLA
genes are on the
same
chromosome,
they are
inherited as a
group

6
Kuby Immunology, 4th ed.
 Tissue Matching
• Matches are made at 3 loci:
HLA-A, HLA-B, HLA-DR
Child 1 & 2
are half-matched
to each parent,
but not to each
other

Matches
described
as 0 to 6.

7
 Types of Transplants
• Vascularized solid organs
– Kidney, liver, heart, lung (common)
– Pancreas, small bowel, composite tissues
(face, hand) (rare)
• Other tissues
– Bone marrow or other blood products
– Cornea
– Skin
– Thymus

8
 Site of Graft
• Orthotopic: Implanted in same site as
organ it replaces
– Heart, liver
• Heterotopic: Implanted in site distinct
from the organ it replaces
– Kidney, thymus

9
Donor-Recipient Combinations
• Autograft: donor and recipient are the same
individual
• Isograft: donor and recipient are genetically
identical
• Allograft: donor and recipient are
genetically disparate but same species
• Xenograft: donor and recipient are different
species
– Concordant: pre-formed Ab absent
– Discordant: pre-formed Ab present

10
 Types of Allograft Donors
• Living related
– Kidney, liver, bone marrow
• Living unrelated
– Bone marrow, kidney
• Cadaveric
– Solid organ, cornea, skin

11
 Results of Transplantation
• Allograft survival
– Chimerism
• Allograft rejection
– Hyperacute
– Acute
– Chronic
http://en.wikipedia.org/wiki/Chimera_(mythology)

Chimera: in Greek mythology,

a 3-headed (lion, snake, goat)
fire-breathing monster
12
Hyperacute Allograft Rejection
Onset: minutes to hours after anastomosis of
graft

Time course: minutes to hours

Mechanism: binding of preformed antibodies to

graft antigens (HLA, ABO, other), followed by
complement fixation, attraction of
neutrophils, and tissue damage
(Type II hypersensitivity)

13
Hyperacute Allograft Rejection
Site of attack: vascular endothelium
(kidney and heart)

Histology: hemorrhage, edema, vascular

necrosis, acute inflammation
(neutrophils), Ig in vessel wall, fibrin-
platelet thrombi

Therapy: no satisfactory therapy available

14
15
16
17
 Causes of Prior Sensitization

Blood transfusions
Pregnancy
Previous allografts
Natural immunity (ABO blood group)

18
 Avoidance of
Hyperacute Rejection
• Cross-matching
– Testing of recipient serum for antibodies
that react with donor lymphocytes (PBMC,
LN, spleen)
– Can do this using cytotoxicity assays or
flow cytometry

19
 Acute Allograft Rejection
Onset: Days to months after grafting

Time course: Days

Mechanism: Production of donor-specific

antibodies by B cells or recognition of
graft HLA antigens by T cells, followed
by release of inflammatory lymphokines
by CD4 T cells or cytotoxicity by CD8 T
cells.
20
 Acute Humoral Rejection
(Antibody-Mediated)
Onset: Days to weeks after grafting

Time course: days

Mechanism: similar to hyperacute rejection, but

less fulminant; may involve donor-specific
antibodies produced after grafting or small
quantities of pre-formed antibodies
(Type II/III hypersensitivity)
Associated with deposition of the inactive complement component C4d
21
 Acute Cellular Rejection
Site of attack: variable, depending on organ
Kidney: tubules, interstitum
Liver: venous endothelium, bile ducts
Heart: myocytes
Lung: arterioles
Histology: infiltration of mononuclear leukocytes
(lymphocytes, macrophages), tissue damage;
in severe cases, hemorrhage and necrosis
Therapy: pulse steroids
anti-T cell antibodies (e.g., OKT-3)
22
Mononuclear infiltrate in tubules and interstitum 23
Mononuclear infiltrate in
tubules and interstitum 24
Liver biopsy: T cell attack on bile ducts and
venous endothelium 25
Avoidance of Acute Rejection
Donor-recipient matching:
HLA Typing
Mixed lymphocyte reaction
Pre-transplant conditioning:
Blood transfusions (?induces tolerance?)
Immunosuppressive agents
(e.g., antilymphocyte globulin)
Post-transplant therapy: Cyclosporine
Prednisone
Azathioprine
26
 Chronic Allograft Rejection
Onset: months to years after grafting

Time course: months to years

Mechanism: Recent evidence suggests specific

components of the rejection phenotype can be
linked to cell-mediated (Type IV), antibody-
mediated (Type II), immune complex-mediated
(Type III), and even immediate (Type I)
hypersensitivity processes.

27
 Chronic Allograft Rejection

Site of attack: variable, depending on organ

Kidney: vasculature (especially arteries),
tubules, interstitium
Liver: bile ducts (“vanishing bile duct syndrome”)
Heart: vasculature
Lung: bronchioles
Histology: fibrosis, atrophy, vascular thickening
(especially intimal)
Therapy: no satisfactory therapy available

28
Interstitial fibrosis

kidney 29
Fibrosis and vessel thickening 30
Thickening of capillary basement membranes 31
32
Vanishing bile ducts 33
Vascular changes in the heart 34
Rejection centered around bronchioles
35
Chronic Rejection in the Lung
(also seen in chronic GVHD, post HSCT)
Normal bronchiole Obliterative bronchiolitis

Barker AF, et al. New Engl J Med. 370:1820-1828, 2014 36

 Disruption of the
microvasculature
by transplantation
or alloimmune
injury leads to
defective airway
repair, with
subsequent
subepithelial
inflammatory and
fibrotic airway
narrowing

Barker AF, et al. New Engl J Med. 370:1820-1828, 2014 37

 Other Problems for Solid
Organ Grafts
• Recurrence of original disease
• Occurrence of new primary disease in
transplant
• Infection (bacterial, viral, fungal, parasitic)
– Graft
– Systemic
• Drug toxicity (e.g., cyclosporine)
• Failure of anastomoses
• Malignancies
– Lymphoproliferative disorders
– Skin cancers
38
 Indications for Bone Marrow
or Stem Cell Transplantation

• Heritable or acquired hematopoietic or

other deficiencies
– SCID
– Aplastic anemia
• Marrow reconstitution after cancer
therapy or radiation
– Leukemia or solid tumors
• Metabolic or neurologic diseases

39
 Recipient Pre-Conditioning
• Natural immunodeficiency
– SCID
• Ablative
– Radiation Destroys existing
– Chemotherapy immune cells

• Non-ablative
– “Makes room”

40
 Complications of BMT/HSCT
• Failure to engraft
• Graft –vs.–host disease (GVHD)
• Infection
– CMV reactivation
– Opportunistic infections
• Recurrence of previous disease

41
 Graft vs. Host Disease
• Occurs when immunologically
competent cells or their precursors are
transplanted into immunodeficient
recipients and the transferred cells
recognize alloantigens in the host
– Reactions are usually to HLA Ags

42
 Mechanisms
that
Contribute
to GVHD

43
Cohen J. Science 357:122-125, 2017
 Acute GVHD

• Occurs days – wks post-transplant

– Rash
– Destruction of bile ducts (jaundice)
– Gut mucosal ulceration (bloody diarrhea)
• Lesions are pauci-cellular
– Apoptosis is the characteristic lesion.
– Donor CTLs are effectors.

44
 Chronic GVHD
• Cutaneous fibrosis and destruction of
skin appendages
• Cholestatic jaundice
• Espohageal and GI strictures
• Lymphodepletion
• Autoimmunity possible

45
 Prevention and Rx of GVHD
• Molecular typing of HLA alleles
• Depletion of donor T cells in graft
– Decreased engraftment
– Loss of graft-vs-leukemia effect
• US FDA just approved ibrutinib, an anti-
BTK mAb for treatment of chronic
GVHD after hematopoietic stem cell
transplant.

46
Clicker questions

47
Which of the following correctly describes a kidney
donated by an identical twin?

A. Orthotopic allograft
B. Heterotopic allograft
C. Heterotopic isograft
D. Orthotopic isograft
E. Heterotopic autograft
0% 0% 0% 0% 0%

A. B. C. D. E.
48
A 45-year-old man with polycystic kidney disease
received a kidney from an unrelated cadaver
donor. The graft immediately began producing
urine and his serum creatinine level became
normal. However, 2 weeks later, the patient began
to produce blood-tinged urine. Which of the
following is most likely responsible?
A. Donor antibodies
B. Donor T cells
C. Recipient antibodies
D. Recipient T cells
0% 0% 0% 0% 0%
E. Failure of the graft
A. B. C. D. E.
vascular anastomoses 49
A 25-year-old woman with cystic fibrosis receives a
double lung transplant from a cadaveric donor.
Routine transbronchial biopsies are performed to
detect possible rejection. Which of the following
histologic findings would indicate chronic
rejection?
A. Thickening (arteriosclerosis) of arteries 0%
B. Interstitial fibrosis 0%
C. Neutrophilic infiltrates surrounding arteries 0%
D. Mononuclear infiltrates surrounding 0%
bronchioles
E. Mononuclear infiltrates surrounding arteries 0%
50
DLA Notes on additional
Primary
Immunodeficiency
Disorders that are not
covered in lectures

1
This DLA covers following primary
immunodeficiencies:

• Hyper IgM syndrome

• Hyper IgE syndrome
• Phagocyte adhesion disorders
• Wiskott Aldrich Syndrome
• Ataxia-Telangiectasia
• Complement-related disorders

2
 Hyper IgM Syndrome
• Normal numbers of B cells, but abnormal
function
– Normal or increased serum IgM
– IgG, IgE, & IgA absent
• Due to mutations in genes that affect Ig class
switching

3
Ig Class Switching

Kuby, Immunology,
4th Edition 4
 Genes Mutated in
Hyper IgM Syndrome

• X-linked
– CD40L (CD154)
– NEMO (NF-kB essential modulator)
• Required for CD40-induced NF-kB activation
• Autosomal recessive
– Activation-Induced cytidine Deaminase
– Uracil-DNA glycosylase (UNG)
– CD40

5
 Clinical Features of X-HIGM

IgG is
• In 79 patients (1997 – 2002): needed to
– >50% diagnosed by 1 yr of age opsonize
bacteria
• Pneumonia, URI, otitis, diarrhea
– Infections with encapsulated bacteria,
Pneumocystis, CMV, Cryptosporidium,
Cryptococcus, Candida, Histoplasma,
Bartonella

Winkelstein JA, Medicine 82:373-384, 2003

6
 Treatment of HIGM
• Ig replacement (iv Ig)
• Stem cell transplantation
– Requires conditioning with busulfan,
cyclophosphamide, ATG
– Can cure disease if performed before infectious
complications occur

7
 Hyper-IgE Syndrome
(Job Syndrome)

• Named after the biblical character Job

whose faithfulness was tested by affliction
with draining skin sores.
• People with this condition have severe
chronic skin infections.

8
 Clinical Presentation: HIES
• Persistent skin infection & abcesses
– “Cold”: no pain, heat, redness
• Recurrent sinusitis
• Eczema
• Eosinophilia and high IgE (>2000 U/ml; nl <300)
• Bone defects, including fractures (57%)
• Late or absent shedding of baby teeth (72%)

Grimbacher et al. New Engl J Med. 340:69-702, 1999 (study of 30 pts)9

 Hyper-IgE Syndrome

Grimbacher et al. New Engl J Med. 340:69-702, 1999 10

11 yo 8 yo

23 yo

Grimbacher et al. New Engl J Med. 340:69-702, 1999 11

 Pathogenesis of HIES
• Defects in Th17 function
– Hypomorphic mutations in STAT3 Autosomal
dominant

– Null mutation in Tyk2 (Tyr kinase) Autosomal

recessive – 1 pt

– DOCK8 mutations Autosomal

recessive

• Defective signal transduction for or

responses to multiple cytokines, including
IFN-g, IL-6, IL-10, IL-12, and IL-23

Minegishi & Karasuyama. Curr Allergy Asthma Rep. 8:386-391, 2008 12

 Disorders of Phagocytes
• Disorders of leukocyte adhesion aka
Leukocyte adhesion defect (LAD)

13
Normal Leukocyte Migration

Kuby, Immunology, 4th edition

14
 Kuby, Immunology, 4th edition

15
Rolling Activation Adhesion
 LAD, Type 1:
mutations in
b2-integrin
CD18 (LFA-1,
Mac-1, p150-95)

16
 LAD, Type 1 (CD18 mutation)

• CD18 is required for neutrophil

extravasation and aggregation.
– Elevated blood neutrophils
– Few neutrophils in tissues

Normal (+PMA) LAD (+PMA)

17
 LAD, Type 1
• Recurrent infections of skin, soft tissues,
respiratory and GI tracts
– Gram negative bacteria
– Staph. aureus
– Candida
– Aspergillus

18
 LAD, Type 1
• Delayed separation of the umbilical cord
• Poor wound
healing
• Peridontal
disease

LAD patient, post appendectomy

19
 Dx & Treatment of LAD, Type 1
• Diagnosis
– Flow cytometry to show lack of CD18
– DNA sequencing
• Treatment
– Neutrophil infusions
– Stem cell transplantation
• Requires chemotherapy; GVHD common
– Anti-IL-12/IL-23 therapy*

*Ley K. New Engl J Med. 376:1172-1174, 2017

*Moutsopoulos NM, et al. New Engl J Med. 376:1141-1146, 2017 20
 Neutrophils Control Inflammation at
Barrier Sites

Ley K. New Engl J Med. 376:1172-1174, 2017

Breach of barrier by bacteria upregulates macrophage transcription of IL-12 and IL-23, which then
promotes production of IL-17. Neutrophils are attracted via macrophage-produced chemokines to
“clean up” the infectious organisms. Eventually, uptake of apoptotic neutrophils via macrophage
receptors strongly inhibits secretion of IL-12 and IL-23. In LAD, failure of neutrophils to enter tissue,
undergo apoptosis, and be taken up by macrophages results in unchecked IL-12/IL-23-driven (Th17)
inflammation. Ustekinumab can interfere with this cycle to allow healing. 21
 VERY
RARE
LAD, Type 2 13 patients in 2014

• Similar immune phenotype due to absence of E-selectin

ligands (sialyl-LewisX or CD15s) that contain fucose
– Also mental retardation, short stature, distinct facies
– Can treat with oral fucose if due to defective fucose synthesis
but not if disease results from defective fucose transporter

X
No adhesion under conditions of shear
22
 Wiskott Aldrich Syndrome
• X-linked recessive
– Thrombocytopenia
– Eczema
– Recurrent infections
• Due to mutations in the WAS gene (protein =
WASp)

23
 Immune Characteristics of WAS
• Normal thymus early in disease
– Progressive T cell depletion in periphery
• Minimal to no Ab responses to polysaccharide
and protein Ags
– Low IgM; nl IgG; high IgA, IgE
• Autoimmunity (40-72%)
– Vasculitis, cytopenias, arthritis

24
 Pathogenesis of WAS
• WASp is involved in dynamic cytoskeleton
rearrangement.
– Cell migration
– Phagocytosis
– Ag presentation
– Immunological synapse
– Cytotoxic effector function
• Treatment requires replacement of defective
cells (HSCT) or gene therapy.

Hacein-Bey Abina et al. JAMA 313:1550-1563, 2015

Pai et al. Immunol Allergy Clin N Am 30:179–194, 2010
Qasim et al. Gene Therapy 16:1285–1291, 2009 25
Boztug et al. New Engl J Med. 363:1918-1927, 2010
 Ataxia-Telangiectasia
• Autosomal recessive
• Due to mutation in the ATM gene

Telangiectasia: dilated
small blood vessels

26
 Clinical Manifestations of A-T

• Ataxia due to cerebellar Purkinje cell

degeneration
• Telangiectasias
• Recurrent sinopulmonary infections
– Decreased serum Igs
– Poor T cell function
• Predisposition to cancer

27
 Pathogenesis of A-T
• ATM is a kinase with a critical role in repair of
ds DNA breaks, activation of NF-kB, and cell
cycle progression.
• Mutation causes defective:
– TCR & Ig rearrangement
– T cell activation
– Lymphocyte proliferation

28
Complement related
Immunodeficiencies

29
Complement in Host Defense
Properdin, Factors B & D

C2, C1q,r,s, C4

C5-9

Modified from Figure 2-14 Robbins and Cotran Pathologic Basis of Disease, 7th Ed. 30
 Deficiency of C2, C1[q,r,s], C4
• Defects in early components of the classical
pathway causes little to no increase in
infections.
– Alternative pathway sufficient for infection control
– Predisposes to SLE
– C2 deficiency most common

31
 C3 Deficiency
• C3 is required for both classical and
alternative pathways.
– Deficiency results in serious and recurrent
pyogenic infections
– Increased immune complex diseases
• Fc-receptor-dependent leukocyte activation is impaired

32
 C5-9 Deficiency
• Increased susceptibility to infections with
Neisseria
– These bacteria have thin cell walls and are
particularly susceptible to lytic action of
complement

33
 Effects of Complement Deficiency
Properdin, Factors B & D

Increased Pneumococcus
and Neisseria infections
X
Serious &
recurrent
C2, C1q,r,s, C4 pyogenic X
No effect infections
X X

Increased X
infections Increased Neisseria X
infections

C5-9

Modified from Figure 2-14 Robbins and Cotran Pathologic Basis of Disease, 7th Ed. 34
 C1 Inhibitor Deficiency
(hereditary angioedema)
• Autosomal dominant
– C1 inhibitor targets C1r, C1s, coagulation
factor XII, kallikrein
– Excessive production of bradykinin
– Life-threatening mucosal edema after trauma or
stress
• Treat with C1 inhibitor conc from pooled
plasma or therwise decrease bradykinin
production.

35
 Defects in C’ Regulation
• Glycophosphatidyl inositol linkages are required for
assembly of decay activating factor (CD55) and CD59
that regulate complement
• Paroxysmal nocturnal hemoglobinuria results from
mutations in the PIGA gene
– PIGA encodes an enzyme essential for GPI links
– Hemolysis results from excessive C’ activation on RBC
surface

36
Examples of Infections in
Immunodeficiencies

jirovecii

37
Clicker Question

38
A 24-year-old man who is diagosed to have paroxysmal
nocturnal hemoglobinuria is effectively treated with
eculizumab, a drug that inhibits the cleavage of C5 to
C5a and C5b.
What vaccination should this patient receive, if
possible, at least 2 weeks before starting
20%treatment?
20% 20% 20% 20%

A. Meningococcal
B. Influenza
C. Polio
D. Hepatitis B
E. Tetanus-diphtheria-acellular
A. B. C. D. E.
pertussis
39
 DLA Notes on
Immune-Mediated
Vasculitis:
Microscopic
polyangiitis
1
 Microscopic
polyangiitis

( ) Pulmonary granulomatous polyangiitis

Eosinophilic granulomatosis with polyangiitis ( )

(kids)

(> 50 y.o.)
Modified from
(< 50 y.o.) Robbins Pathologic Basis of Disease, 7th2 Ed
Microscopic Polyangiitis
Leukocytoclastic vasculitis
Hypersensitivity vasculitis

Affects arterioles, capillaries, and venules

3
 Clinical Features
• Skin lesions
– Palpable purpura
– Macules, vesicles
– Necrosis, ulceration
• Vascular lesions in other organs
– Lungs, brain, kidneys, GI
• Glomerulonephritis in 90%, infarcts

4
Microscopic polyangiitis
 Causes of
Microscopic Polyangiitis

• Henoch-Schonlein purpura
• Serum sickness
• Connective tissue diseases (SLE)
• Mixed cryoglobulinemia
• Chronic hepatitis B
• Lymphoproliferative disorders
• Reactions to drugs or pathogens
5
 Pathogenesis
• Antibody response to exogenous or autoantigen
(MPO-ANCA impt)
• Formation of immune complexes (Type III HS)
• Deposition of immune complexes in vessels, esp.
small venules
• Complement fixation (C5a=chemotactic)
• Infiltration by inflammatory cells (esp. PMNs) and
tissue destruction

6
Microscopic polyangiitis
7
Microscopic
polyangiitis

8
 Histology
• Lesions tend to be the same age
• Neutrophils infiltrate vessel walls and
broken-down neutrophils release nuclear
debris (leukocytoclasis)
• Vessel wall necrosis
• Immune complex deposition
– IgA (Henoch-Schonlein purpura)
– Mixed (SLE)

9
Microscopic polyangiitis
 Case Scenario
• A 38 yo previously healthy man presented
with progressive rash, abdominal pain,
arthralgia, and low grade fever that persisted
for 2 wks despite oral prednisolone Rx (30
mg/day).

10
 Cutaneous and GI Purpura

Biopsy showed leukocytoclastic vasculitis with IgA deposition,

c/w IgA vasculitis (Henoch-Schoenlein purpura).
11
Naruse G & Shimada K. New Engl J Med. 369:1843, 2013
Deposition of immune complexes (IgA)

12
 Why Are Deposits Just IgA in
Henoch-Schonlein Purpura?
• These patients produce a galactose-deficient IgA1; this
exposes an N-acetyl-galactosamine neoepitope that binds
to a (?anti-microbial or viral) anti-glycan IgA1.
• IgA1/C’ complexes normally bind to the asialoglycoprotein
receptor on hepatocytes for catabolism, but the epitope
for receptor binding is blocked on this particular Ag-Ab
complex.
– Instead of being degraded, these immune complexes
deposit in capillaries of the dermis and other organs.

Wyatt RJ & Julian BA. New Engl J Med. 368:2402-2414, 2013

13
Biopsy showed extravasated RBCs, a neutrophilic infiltrate,
fibrinoid necrosis, and nuclear debris. Most likely diagnosis?
a. Takayasu arteritis
b. Kawasaki disease
c. Microscopic polyangiitis

Answer: C 14
 Videolecture:
Acquired
Immunodeficiencies
Presenter: Chad M. McCall,
M.D. Ph.D. (a Visiting
Faculty)

1
 Secondary or Acquired
Immunodeficiency
• Iatrogenic
• Malignancy
• Malnutrition
• Renal disease
• Sarcoidosis
• AIDS
2
 Malignancy
• Cancer patients may be
immunosuppressed due to:
– Radiation or chemotherapy
(iatrogenic)
– Direct effects of tumor
• TGF-b, Tregs
• Myeloid-derived suppressor cells
• Indoleamine 2,3-dioxygenase (IDO)
– Toxic products of Trp breakdown inactivate effector
T cells and make DC immunosuppressive.

3
 Malnutrition
• The major cause of
immunodeficiency world-wide.
– 792 million in developing world
– 25-60% of US pts in long-term care
– 35-65% of US hospitalized patients
• Poor nutrition increases
vulnerability to infections.
Chinen & Shearer. J Allergy Clin Immunol 125:S195-203, 2010
Katona et al. Clin Infect Dis 46:1582–1588, 2008 4
 Malnutrition affects
thymus and T cell
function, as well
as Ab production

Treatments
must address
each of these
mechanisms
for long-term
success

Routine amoxicillin has no benefit

Isanaka S, et al. NEJM 374:444-453, 2016

5
Relman DA. Science 339:530-532, 2013
 Vitamin A
• Maintains integrity of respiratory
and intestinal epithelium
• Deficiency inhibits Th1 and Th17
cells & increases mortality from:
– Diarrhea
– Plasmodium falciparum malaria
– Measles

WHO estimates this causes 1.2 – 3 million deaths/yr (2008)

6
 (290 – 315 nm)

Vitamin D
• Generated non- 40-50% of total

Stored in
enzymatically in the skin in adipose tissue

response to sunlight.
• Certain kinds of fish are the
only significant dietary Reflects both solar
& dietary exposure.
sources, other than Active metabolite

supplementation.
• Serum level of 25-OH-D3 is
best measure of Vitamin D
status. Not biologically active

7
 Consequences of
Vitamin D Deficiency
• Rickets (rare)
• Osteoporosis and fractures
• Muscle weakness (↑ falls)
• Increased infections
• 30 – 50% ↑ in colon, prostate,
breast cancer
• ↑ multiple sclerosis, RA, OA Epidemiologic
• Hypertension (↑ cardiovasc. studies only
disease)

8
 Immune Effects of
Vitamin D Deficiency

• Decreased macrophage function

• Results in increased incidence of:
– Tuberculosis
– Respiratory infections
– Otitis media
– Auto-immunity

9
http://www.lung.ca/tb/tbhistory/sanatoriums/type.html
 Vitamin D Deficiency
• The most recent reviews suggest
that ≥ 20 ng/ml 25-OH-D3 in
serum is sufficient for bone
health in 97.5% of US population.
– Epidemiologic studies suggest that
higher levels may protect against
cancer or autoimmune disease.
• Randomized trials needed to rule out
that cancer or autoimmune disease
lower Vit D (reverse causation bias).
10
 Prevalence of Low Vitamin D
(serum 25-hydroxyvitamin D <20 ng/ml)
70
60
50
% deficient

40
30
20
10
0
1 2 3 4 5

1 = Hispanic & black adolescents (Boston)

2 = White preadolescent females (Maine)
3 = 15 – 49 yr black females (US, end of winter)
4 = Healthy students, physicians, residents (Boston)
5 = Saudi Arabian mothers at delivery (<10 ng/ml) 11
 Prevention of
Vitamin D Deficiency
• Recommended daily amount assumes
minimal sun exposure
– 600 IU, ages 1 – 70 yr
– 800 IU, adults ≥ 71 yr
• OR exposure of arms & legs for 5 – 30
min (10 am – 3 pm, twice per week)
– Tanning bed at 30% of time for tanning
• Target is >20 ng/ml serum 25-OH-D

12
Per 2011 Institute of Medicine report, as summarized in NEJM 364:1385-1387, 2011
 Vitamin C Deficiency
• Humans cannot synthesize
ascorbic acid.
– Must consume it in diet
• Lack of Vitamin C causes scurvy.
– Bone disease in growing children
– Hemorrhages and healing defects
due to impaired collagen X-linking

13
 Vitamin C &
Immune
Function
•Antioxidant action
protects against
damage induced by
respiratory burst or
inflammation.

•Other potential effects

are less clear.

14
 Elemental Deficiencies
• Zinc
– Required for thymic function
– Supplementation ↓ incidence and
mortality from pneumonia, diarrhea,
and malaria.
• Iron
– Important for neutrophil & T cell function
– Also necessary for pathogen replication

15
 Renal Disease
• Uremic patients have increased
incidence and severity of
infections vs. general population.
• Mortality due to sepsis ↑ 100 to
300X during dialysis
– Failure of memory antibody responses, despite multiple
immunizations
– Defective phagocyte chemotaxis & microbial killing
– Chronic immune activation.

16
 Sarcoidosis
• Characterized by non-caseating
granulomas in multiple organs
• Not a true immunodeficiency
– May have anergy despite extensive
local inflammation, due to
expansion of Tregs.

New Engl J Med. 357:2153-2165, 2007 17

 Clinical Characteristics
• Epidemiology
– African-American : Caucasian 3:1
– Females > males
– Peak incidence at 20-40 yrs of age
• Fatigue, fever, wt loss, rash
• Most also have pulmonary Sx
– Dry cough, SOB, chest pain

18
 Pathogenesis of
Sarcoidosis
• APC interact with
CD4+ T cells to induce
granuloma formation.
• Macrophages
activated in a Th2
environment trigger
fibrosis.

New Engl J Med. 357:2153-2165, 2007

19
Sarcoidosis

20
 Acquired
ImmunoDeficiency
Syndrome
HIV-1

• Caused by infection with the HIV-1 retrovirus.

• Characterized by profound HIV-related
immunodeficiency that leads to opportunistic
infections, secondary neoplasms, and
neurologic manifestations.

21
 Adults and children estimated to be living with HIV, 2015
Total: 36.9 million (34.3 – 41.4 m)

Eastern Europe
North America & & Central Asia
Western & Central Europe 1.5 million
2.4 million
Middle East & North Africa
Caribbean 240 000
280 000 Asia and the Pacific
5.0 million
Sub-Saharan Africa
Latin America 25.8 million
1.7 million

5.0% of adults
New
infections
Newly infected in 2014: 2.0 million (1.9 – 2.2m) ↓ by
35%
AIDS deaths in 2014: 1.2 million (1.0 – 1.6m) since
2000
Data from UNAIDS Fact Sheet, 2015 22
 HIV Life Cycle
1. HIV binds to CD4 and
one of 2 co-receptors,
then fuses with host
cell.
2. After fusion, the virus
releases its genetic
material (RNA).
3. RT converts HIV RNA
to DNA and it integrates
into the host genome.
4. Viral transcription,
5. Virus assembly
6. Budding
23
AIDSinfo, US Dept Health & Human Services
 Natural History of
HIV Infection

24
Robbins and Cotran Pathologic Basis of Disease, 7th ed.
 Acute Retroviral Syndrome
• Occurs in 40 – 90%
– Begins 3-6 wks after infection
– Lasts for 2 – 4 wks
• Sore throat, myalgias, fever, weight loss,
fatigue, lymphadenopathy, rash,
diarrhea, vomiting
• Subsequent viremia (HIV-1 RNA levels in
blood) is a useful prognostic marker of
disease progression.

25
 Chronic Infection Phase
• Often called clinical latency
• HIV is continuously replicating in LN
and spleen, but few infected cells are
present in the blood.
– 100 x 109 viral particles produced per day
– 1-2 x 109 CD4+ T cells die per day due to
the cytopathic effects of virus alone
– Despite this, clinical manifestations are
few

26
Mechanisms of T Cell Loss in HIV Infection

Destruction of thymus
Inflammatory architecture leads to
cell death decreased T cell production
Abortive
(pyroptosis) Infection of
quiescent cells

Chronic T cell activation

27
Modified from Robbins & Cotran Pathologic Basis of Disease, 7th Ed.
Anti-HIV Immune Responses

Robbins & Cotran Pathologic Basis of Disease, 7th Ed. 28

Progression of HIV Disease

Robbins & Cotran Pathologic Basis of Disease, 7th Ed. 29

30
 Effects of HIV on T Cells
• Qualitative defects can be detected
in asymptomatic HIV-infected
persons.
– Reduced Ag-induced proliferation
– Defects in intracellular signaling
– Loss of Th1 relative to Th2 responses
• ↑ susceptibility to viruses & intracellular
microbes
– Loss of memory T cell responses
31
 HIV Infection of Non-T Cells
• 10 – 50% of macrophages in lungs
& brain
– vpr gene allows replication in non-
dividing cells
– Virus buds off, since cells are
resistant to lysis
• Dendritic cells also infected
– Transport virus to LN; reservoir

32
Effects of HIV on Non-T Cells
• Impaired microbiocidal activity
• Decreased chemotaxis
• Decreased IL-1; inapprop. TNF
• Poor antigen presentation
• Polyclonal B cell activation
• Impaired response to new or
polysaccharide antigens
33
 Progression to AIDS
in absence of treatment
• Rapid progressors: 2-3 yrs
• Most people: 7 -10 yrs
• Long-term non-progressors: >10 yrs
– < 500 RNA copies/ml
• Elite controllers (50-75 RNA copies/ml)
– Object of considerable research to
understand mechanisms
For HIV-infected individuals with access to ART, life expectancy at diagnosis
now approximates that of uninfected individuals.
Fauci AS et al. JAMA 312:335-336, 2014 34
 HAART
• Highly active anti-retroviral therapy
can decrease viral replication and
prolong the clinically latent phase
indefinitely.
– Over 25 drugs from 6 classes
• Problems are therapy compliance,
side effects, resistance, and
cost/access.
While 3 of 4 people on ART live in sub-Saharan Africa,
67% of their infected men and 57% of infected women
were not receiving ART in 2013. 35
 Obstacles to HIV Clearance
• Latent infection occurs, defined as
integration of the provirus without
virus replication.
– Present in CD4+ cells
• Lymphocytes & macrophages in LN
• ~0.05% of resting CD4+ cells
– These cells live for months to years.

36
Is an HIV Vaccine Necessary to
End AIDS?*
• New HIV infections and AIDS-related
deaths are declining
– HAART/pre-exposure prophylaxis
– Preventing perinatal transmission
– Male circumcision (↓ infection by 2/3)
• But a safe and moderately effective
vaccine is still probably necessary.
*Fauci AS, Marston HD. New Engl J Med. 370:495-498, 2014
37
 HIV Vaccines
• Must generate broadly reactive
neutralizing Abs to prevent infection
– Relevant epitopes are poorly immunogenic,
masked, resemble host molecules, or
change rapidly (& lead to escape variants).
– Has been unclear how to generate these Abs
• Long CDRs, extensive hypermutation,
autoreactive
• Must generate HIV-specific CD8+ CTLs
– Latently infected cells will escape

See assigned article:

Haynes BF & Burton DR. Science 355:1129-1130, 2017
38
Prevention of HIV Infection

Discover Magazine, October 2011, pp.42-50 39

 Is Cure
of HIV
Possible?

Maybe………..

40
Study from Berlin
 Matt Sharp,
received self BM
made CCR5-neg.
( T cell half-life)
Tebas P, et al. NEJM
370:901-910, 2014

Timothy Ray Brown, the “Berlin patient”,

has remained free of detectable virus in
the absence of ART for >7 years after BMT
and is suggested to be cured.
Allers K, et al. Blood 117:2791-2799, 2011
Fauci AS et al. JAMA 312:335-3356, 2014

picture from: Cohen J. Science 332:784-788, 2011

41
 Early Treatment May Prevent
Establishment of Reservoir
Half-life of latent
(central memory) viral reservoir is
43-44 mo in adults,
(effector memory) so clearance would
take >73 yrs of
therapy.

Crooks AM, et al.

J Infect Dis
212:1361-1365, 2015

Prompt antiretroviral treatment appears to protect

seeding of latent reservoirs in long-lived Tcm cells.

Modified from Cohen J. Science 339:1262, 2013; 42

 Early Treatment and
HIV Persistence in Children

> 3 mo of age

< 3 mo of age

<48 hrs after birth

Luzuriaga K, Mofenson LM. New Engl J Med. 374:761-760, 2016 (Feb 25)
43
 WHO-Validated Elimination of
Mother-Child HIV Transmission
• Defined as:
– < 50 cases per 100,000 live births
– Transmission <5% if breast-feeding for at least 1 yr or
<2% if not
– HIV status known for > 95% of pregnant women
– ART received by >95% infected pregnant women
• Cuba was the first country to receive this
validation (July 2015).
– Thailand, Armenia, Belarus, and Republic of Moldova
added in June 2016

Luzuriaga K, Mofenson LM. New Engl J Med. 374:761-760, 2016

44
 Pre-Exposure Prophylaxis Can
Change the Course of the Epidemic
• Only 31% of people in San
Francisco at high risk of
infection used PrEP.
– Can now be used “on
demand”, before and after
at-risk sex
• If 65% used PrEP for 12
mo, the annual infection
rate would be halved.
• Early treatment + PrEP
could double that drop.

But the drugs only

work if taken!
Cohen J. Science 347:1055-1056, 2015 45
 Non-HIV/AIDS-related Adult-
Onset Immunodeficiency
• Reported in 85 Asian adults without HIV
infection or familial clustering
– Opportunistic infections, including
disseminated non-TB mycobacteria
– Due to high titers of autoantibodies against
IFN-g that block STAT1 phosphorylation.

Browne SK, et al. New Engl J Med. 367:725-734, 2012

46
 DLA Notes on
Hypersensitivity Reactions
and
Tests of Immune Function

1
 Hypersensitivity Reactions

• Immune reactions that cause injury

– Elicited by exogenous or self-antigens
– Due to imbalance between effector &
control mechanisms
– Associated with susceptibility genes
• Mechanisms of injury are the same
as for defense against pathogens.

2
 Hypersensitivity Reactions

• Type 1: immediate or anaphylactic

• Type 2: Ab-mediated
• Type 3: immune complex-mediated
• Type 4: delayed or cell-mediated
hypersensitivity

3
 Type I Hypersensitivity
(Anaphylactic or Immediate Type)
Mechanism: Antigen binds to specific
antibody (IgE) on surface of mast cell/
basophil, triggering release of
inflammatory mediators
Consequences: Acute (minutes to hours)
vasodilation, vascular leakage, smooth
muscle spasm, followed by infiltration
of mixed inflammatory cells and tissue
damage 4
 Type I (Immediate Type)

Prototypes:
Anaphylaxis; allergy;
some forms of asthma
(non-self antigens)

5
 Saline 90%
CD3- c-kit+ c48/80 50%

A B (granularity)

C D

Saline c48/80
6
 Robbins Pathologic
Robbins Pathologic
Basis of Disease,
Basis of Disease, 7
8th Ed 8th Ed
 Also involves complex regulation by T cells

Type I hypersensitivity

8
 Type II Hypersensitivity
(Antibody-Mediated)

• Mechanism: Antibody binds to cells or

other tissue components (e.g. basement
membranes) causing:
– Ab-dependent cellular cytotoxicity, mediated
by killer cells with Fc receptors
– Activation of the complement cascade &
phagocytosis of opsonized cells
– Direct effect

9
 Type II Hypersensitivity
(Antibody-Mediated)

Consequences:
Cell lysis,
attraction of
inflammatory
cells by
chemotactic
complement
components
or phagocytosis 10
 Opsonization & Phagocytosis
• Transfusion reactions
• Erythroblastosis fetalis
– Maternal IgG crosses placenta
• Autoimmune hemolytic anemia
• Some drug reactions
– Drug bound to cell surface acts as hapten;
anti-drug Abs kill cell

Type
11
II
 Inflammation
• Abs deposited in fixed tissues
(basement membrane, ECM) cause in
situ immune complex formation and
inflammation
– Hyperacute rejection of organ grafts
– “Idiopathic” membraneous
glomerulopathy

Type
12
II
 Idiopathic Membraneous
Glomerulopathy
• Most patients (70%) have circulating
auto-Abs to the phospholipase A2
receptor (PLA2R1) expressed on
podocytes.
• Auto-Abs vs.
THSD7A
occur in 5%

New Engl J Med.

Abs show THSD7A localization to podocyte foot processes.
372:1073-1075, 2015 13
 Effects on Cell Function
• Myasthenia gravis
– Abs to AChR prevent neuromuscular
transmission
• Graves disease
– Abs to TSH receptor stimulate thyroid
• Immune-mediated dermatitis
– Abs to intercellular junction proteins lead
to non-adhesion and blistering

Type14II
Immune-mediated dermatitis

Vesicle = fluid-filled raised lesion < 5 mm

Bulla = fluid-filled raised lesion > 5 mm15
 Type III
(Immune Complex-mediated)
Mechanism: Immune complexes (multimolecular
antigen-antibody complexes) accumulate
locally or systemically and activate
complement cascade

Consequences: Attraction of inflammatory cells

by chemotactic complement components,
tissue destruction by inflammatory cell
products
16
 Type III
(Immune
complex-
mediated)

Prototypes: serum
sickness (non-self
antigens),
systemic lupus
erythematosus
(self antigens)

17
 Type IV Hypersensitivity (DTH)

Mechanism: Activation of antigen-

specific T lymphocytes, leading to:
1) Secretion of inflammatory cytokines
- primarily by CD4+ T cells
2) Cytotoxicity
- primarily by CD8+ T cells

18
 Type IV Hypersensitivity (DTH)

Consequences: Accumulation of
inflammatory cells (predominantly
mononuclear), generally over several
days; tissue destruction by
inflammatory cell products, cell lysis

Reaction typically peaks between 48 and 96 hrs

19
Type IV Hypersensitivity (DTH)

Prototypes:
Tuberculosis,
contact
dermatitis,
cellular
transplant
rejection (non-
self antigens)
20
 Type IV Hypersensitivity (DTH)
• Naïve CD4+ T cells recognize Ag
presented by dendritic cells
• DC-produced cytokines drive
differentiation of Ag-specific T cells to
Th1 or Th17 cells
– Th1 cells activate macrophages
– Th17 cells secrete cytokines that attract
neutrophils & monocytes

21
 Type IV Hypersensitivity (DTH)
• Activated macrophages may become
epithelioid and form granulomas.
• CD8+ cytotoxic T cells may destroy Ag-
bearing target cells.

22
 Acid-fast stain

DTH response (tuberculosis) 23

 Summary of
Hypersensitivity Reactions
• Type 1: immediate or anaphylactic
(IgE/mast cell-mediated)
• Type 2: antibody-mediated
• Type 3: immune complex-mediated
• Type 4: delayed or cell-mediated
hypersensitivity (T cells)

24
 Clicker Question
A 45-year-old woman
presents to her
general practitioner
with complains about
pain on the inside of
her cheek. The
doctor sees several
small ulcers, and
biopsies the edge of
one:
25
Autoantibodies were found to which
cellular component?

A. Hemidesmosomes
B. Adherens junctions
C. Desmosomes
D. Tight junctions
E. Keratin 0% 0% 0% 0% 0%

A. B. C. D. E.

26
 Tests of
Immune Function

27
 Tests of Immune Function
• Lymphocyte enumeration
• Quantitation of specific antibody
• Leukocyte function assays
– Response to mitogens
– Response to antigens
– Respiratory burst assays

28
 Lymphocyte Enumeration
• Simplest assay is a CBC with manual
differential.

An absolute lymphocyte count

below 2500 cells/mm3 should
prompt further investigation

29
 Lymphocyte Enumeration

• Multi-color flow cytometric analysis of

peripheral blood mononuclear cells
– CD2, 3, 4, 8 (T cells)
– CD19, 20, 21, 22 (B cells)
– CD2, 16, 56 (NK cells)
– CD45, CD45RA, CD45RO (naïve vs memory)
– IL2R, MHC Class II (ability to activate)

30
T Cell Receptor Excision Circles

TRECs per mg DNA

•The presence of TRECs is a marker for development
within the thymus.
•T cells generated by clonal expansion lack TRECs.
31
Hale LP. Annals Diag Pathol. 8:50-60, 2004
 (KREC = k-deleting Recombination Excision Circle)

Light chain
rearrangements
begin after
successful IGH
heavy chain
rearrangements

Modified from: Serana F, et al. J Transl Med. 11:119, 2013 32

 Quantitation of Ab
• IgM, IgGs, IgA, IgE by multiplex
immunoassay
• Specific Abs by agglutination assays or
nephelometry
– Anti-diphtheria, -tetanus
– Anti-A, B blood groups
– Anti-Candida

33
Multiplex Immunoassay-1

Y Y

Y
Y
Anti-

Y
Y
Anti-
B C
Y Y
Y
Y
Y
Y

Anti-
A Antibody-coated

Y
Y
Y fluorescent beads Anti-
are selected for D
each analyte
Y
of interest.
34
 Multiplex Immunoassay-2

Y Y

Y
Y
Anti-

Y
Y
Anti-
C C
B
Y Y
Y
A
Y
Y
Y

Anti-
A Antibody-coated

Y
Y
Y Anti-
beads specifically D
bind to their Y
A analyte in a
complex mixture.
35
 Multiplex Immunoassay-3

Y Y Y

Y
Y
Anti-

Y
Y
Anti-
C C
B
Y Y Y
Y
A
Y
Y
Y

Anti- Fluorescence for

A each bead color is

Y
Y
Anti-
Y determined and D
quantitated based Y
A on a standard curve
Y

36
 Agglutination Assays

Commonly (Ab-coated
particles + Ag)
used
particles
are beads
or RBC
(Ag-coated
particles + Ab)

Polymer
Rev. 45:
59, 2005
37
 Respiratory Burst Assay
This assay measures the capability of neutrophils to undergo
oxidative metabolism to produce superoxide anion and
hydrogen peroxide. Patients with chronic granulomatous
disease (CGD) are unable to oxidize due to defects in their
oxidative capacity.

• Nitroblue tetrazolium assay:

– Formation of insoluble blue formazan crystals
in phagocytes capable of oxidant production
• Has been mostly replaced by a fluorescent
flow cytometric-based assay
38
 Respiratory Burst Assay

• Leukocytes isolated by centrifugation

– Loaded with lipophilic dye (DCFH-DA)
– Oxidation converts cleaved dye to
fluorescent form (DCF)
– Fluorescence is measured by flow
cytometry

39
Respiratory Burst Assay

Patient with CGD

Fluorescence →
40