Professional Documents
Culture Documents
SERIES EDITOR
Dan Horton-Szar
BSc(Hons), MBBS (Hons), MRCGP
Northgate Medical Practice, Canterbury, Kent, UK
FACULTY ADVISORS
Caroline Shiach
BSc(Hons), MBChB, MD, FRCPath, FRCP
Consultant Haematologist, University Department of Haematology,
Wythenshawe Hospital, South Manchester University Hospitals NHS Trust,
Manchester, UK
Matthew Helbert
MBShB, FRCP, FRCPath, PhD
Consultant Immunologist, Manchester Royal Infirmary, Manchester, UK
Haematology
and Immunology
Yousef Gargani
Medical Student
Manchester Medical School
Manchester, UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2012
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Series editor foreword
The Crash Course series first published in 1997 and now, 15 years on, we are still
going strong. Medicine never stands still, and the work of keeping this series
relevant for today’s students is an ongoing process. These fourth editions build on
the success of the previous titles and incorporate new and revised material, to keep
the series up-to-date with current guidelines for best practice, and recent
developments in medical research and pharmacology.
We always listen to feedback from our readers, through focus groups and student
reviews of the Crash Course titles. For the fourth editions we have completely
re-written our self-assessment material to keep up with today’s ‘single-best answer’
and ‘extended matching question’ formats. The artwork and layout of the titles has
also been largely re-worked to make it easier on the eye during long sessions of
revision.
Despite fully revising the books with each edition, we hold fast to the principles
on which we first developed the series. Crash Course will always bring you all the
information you need to revise in compact, manageable volumes that integrate
basic medical science and clinical practice. The books still maintain the balance
between clarity and conciseness, and provide sufficient depth for those aiming at
distinction. The authors are medical students and junior doctors who have recent
experience of the exams you are now facing, and the accuracy of the material is
checked by a team of faculty advisors from across the UK.
Dr Dan Horton-Szar
v
Prefaces
Author
Haematology and immunology are two words that are sure to strike fear into most
medical students. They both have the reputation of being complex, lab-based
specialities that lose their importance once we reach the ‘real world’. In reality,
knowledge of both haematology and immunology are immensely important for the
practice of all specialities, both clinical and lab-based. This includes topics ranging
from anaemia, which is encountered by all clinicians; to non-steroidal
anti-inflammatory drugs, which are prescribed by junior doctors throughout
the world.
Yousef Gargani
Faculty advisors
Immunology and haematology are two of the most rapidly moving disciplines in
modern medicine. In these two disciplines molecular discoveries are rapidly
translated into diagnostic tests and treatments. In this Crash Course you’ll read
about exciting stuff such as designer drugs for leukaemia and gene therapy for
immunodeficiency.
The flip side of all this progress is that these two subjects are not always taught in an
up-to-date fashion and some of the newer facts get missed out. It’s been a pleasure
to work with Yousef on this edition of the book. His charm, intelligence and energy
will take him a long way.
vi
Acknowledgements
Figure acknowledgements
Figure 12.7 adapted with permission from C Janeway. Immunobiology, 4th edition.
Churchill Livingstone, 1999
Figs. 1.4, 10.5, 10.10, 10.15, 10.18 and 12.11, and Figs 10.20 and 12.20 adapted
with permission from I Roitt, D Male and I Brostoff. Immunology, 4th edition.
Mosby, 1996
Figs. 2.1, 2.12 and 11.3 taken with permission from A Stevens and J Lowe. Human
Histology, 2nd edition. Mosby, 1997
Fig. 1.6 adapted with permission from C Haslett (editor). Davidson’s Principles and
Practice of Medicine, 18th edition. Churchill Livingstone, 1999
Fig. 5.8 reproduced with permission from M Makris and M Greaves. Blood in
Systemic Disease. Mosby, 1997
Fig. 6.17 adapted with permission from T Gordon-Smith and J Marsh. Medicine
(Haematology Part 1). The Medicine Publishing Company, 2000
Figs. 2.16, 3.1, 3.7, 3.12, 4.2, 4.6, 4.8, 4.11, 5.9 reproduced with permission from
Dacie & Lewis Practical Haematology, 10e, Churchill Livingstone, 2006
Figs. 9.8, 12.2, 12.10, 12.14 reproduced with permission from R Nairn and
M Helbert. Immunology for medical students, 2nd edition. Mosby, 2007
Figs. 2.15, 4.4 reproduced with permission from Dr Shiach and the library of Central
Manchester University Hospitals
vii
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Contents
ix
Contents
x
Principles of haematology 1
Objectives
1
Principles of haematology
Self
replication
Bone marrow
IL-3
Lymphoid CFU-GEMM
progenitor
GM-CSF
IL-6
IL-2
B lymphocyte NK cell CFU-GM Basophil Eosinophil Megakaryocyte Erythroid
progenitor progenitor progenitor progenitor progenitor
Thymus
Platelets
Fig. 1.1 Overview of haemopoiesis. Blood cells are derived from pluripotent stem cells usually found in the bone marrow. Exposure
to different growth factors promotes the development of the different cell lines. CFU-GEMM, granulocyte, erythrocyte, monocyte,
megakaryocyte colony-forming unit; (CFU-GM, granulocyte, monocyte colony-forming unit; NK, natural killer; G-CSF, granulocyte
colony-stimulating factor; GM-CSF, granulocyte–macrophage colony-stimulating factor; IL, interleukin; M-CSF, macrophage
colony-stimulating factor; TPO, thrombopoietin; EPO, erythropoietin.).
2
Bone marrow 1
Venous
Central sinusoid
longitudinal
vein
Adipocytes
Extracellular
matrix fibres
stroma forms specific adhesion contacts with pro-B cells. • Anteriorly: the stomach, tail of the pancreas and left
As B cells develop, they migrate towards the central axis colic flexure
of the marrow cavity and become less dependent on • Medially: the left kidney
stromal contact. Immature B cells that bind to self cell- • Posteriorly: the diaphragm, and ribs 9–11.
surface antigen are removed from the repertoire at this
stage. B cells move to the spleen or lymph nodes for final
maturation. T lymphocyte precursors leave the bone mar- Structure
row early in development and are transferred to the thy- The spleen is surrounded by a dense, irregular, fibro-
mus for maturation. NK cells accumulate in secondary elastic connective tissue capsule that projects fibres,
lymphoid tissue (tonsils, lymph nodes and spleen) prior known as trabeculae, into the organ. The two main types
to activation. of tissue found within the spleen are red pulp and white
pulp. These are separated by a marginal zone (Fig. 1.4).
Red pulp
THE SPLEEN The red pulp is made up of venous sinuses and splenic
cords. The splenic cords are composed of reticular
The spleen is a secondary lymphoid organ. It is the site fibres. This region predominantly contains erythrocytes
of B and T cell proliferation and of antibody formation, but has a large number of macrophages and dendritic
and an important component of the reticuloendothelial cells. The red pulp removes old or defective erythro-
system. It is specialized to filter blood, much as the cytes, white blood cells and platelets from the
lymph nodes filter lymph, and is a major site of immune circulation.
response to blood-borne antigens. Blood supply to the
spleen is via the splenic artery. Blood is drained via the
splenic veins, which join the superior mesenteric vein to White pulp and marginal zone
form the portal vein. The central arteriole is surrounded by a periarteriolar
The spleen is an intraperitoneal organ, normally lymphoid sheath (PALS) which predominantly con-
measuring between 6 and 13 cm; its relations are: tains T cells. These branch between B cell follicles that
4
The spleen 1
Germinal centre
of secondary
follicle
Marginal
zone
could be primary (unstimulated) but will be secondary them, thus reducing the amount that are circulating
(stimulated) in most patients. The PALS and follicles (see Hypersplenism below).
constitute the white pulp. The white pulp is surrounded
by a marginal zone containing plasma cells, T and B lym-
Embryology
phocytes, macrophages and dendritic cells. The marginal
zone is supplied by venous sinuses that have gaps as wide The spleen begins as a mesodermal proliferation in the
as 2–3 mm between the endothelial cells. The following primitive gut during the fifth week of fetal development.
functions occur in the marginal zone: It is connected to the body wall by the lienorenal liga-
• Antigen-presenting cells sample blood for antigens ment and to the stomach by the gastrolienal ligament.
• Lymphocytes exit the circulation and migrate to their
respective domains
• Monocytes enter the spleen and become macrophages.
Disorders of the spleen
Here they can attack blood-borne microorganisms
• Lymphocytes and dendritic cells come into contact, HINTS AND TIPS
allowing initiation of an immune response (see
Chapter 10). The spleen must increase significantly in size in
The spleen also acts as a reservoir for platelets (20–40% order for it to be palpated below the costal margins;
of total pool), erythrocytes (< 5%) and granulocytes thus a palpable splenic edge always indicates
(30–50%). If the spleen enlarges for whatever reason splenomegaly.
it filters more cells, either pooling them or destroying
5
Principles of haematology
6
The spleen 1
Splenectomy Lymphadenopathy
Indications for splenectomy (removal of the spleen) The lymph nodes can become enlarged during any infec-
include: tive or inflammatory disease, but can be an important in-
• Severe splenic trauma dicator of haematological disease. Acute presentation of
• Treatment of hypersplenism, – although this is now rapidly expanding painful nodes is likely to be a sign of
rare due to the advent of more modern therapies infection. Slow growth of painless nodes is often haema-
• Splenic cysts tological in origin. If lymphadenopathy is localized, the
• Tumours of the spleen and adjacent organs. cause is more likely to be localized. Common causes of
Following splenectomy, the patient should be en- lymphadenopathy are shown in Figure 1.6.
couraged to mobilize as soon as possible because they
are at high risk of thrombosis (see Chapter 6 for throm-
boprophylaxis). There is a lifelong increased risk of in- Fig. 1.6 Causes of lymphadenopathy
fection for all individuals without a functioning spleen, Cause Example
particularly with encapsulated organisms (e.g. Neisseria
meningitides, Streptococcus pneumoniae, Haemophilus Infective Streptococcus spp.
influenzae), as the spleen usually removes them. Man- Mycobacterium tuberculosis
Epstein–Barr virus
agement should thus include the following: HIV
• Pneumococcal vaccine should be given (preferably Toxoplasmosis
more than 2 weeks before surgery), with boosters ev- Brucellosis
ery 5–10 years Histoplasmosis
Coccidioidomycosis
• Hib and meningococcal vaccine should also be given
if the patient has not already been immunized Neoplasia Leukaemias
• Lifelong prophylactic antibiotics are recommended Lymphomas
(with penicillin V or erythromycin) Secondary, e.g. lung, breast
• Standby antibiotics should be kept by the patient, to Connective tissue Rheumatoid arthritis
start if any symptoms of infection develop disease Systemic lupus erythematosus
• Patients should be warned that tropical infections
Drugs Phenytoin
(e.g. malaria) are more likely to be severe
Para-aminosalicylic acid
• Urgent hospital admission if infection develops.
Others Sarcoidosis
Amyloidosis
7
Intentionally left as blank
Red blood cells
and haemoglobin 2
Objectives
9
Red blood cells and haemoglobin
Cl−
5
2 4
Carbonic
1 anhydrase
CO2 CO2 + H2O H2CO3 HCO3− + H+
3 6
physical solution H+ + Hb HbH+
Tissue Blood
Fig. 2.2 Carbon dioxide (CO2) transport. CO2 is transported in both red blood cells and the plasma. Only the intracellular
pathways are shown. (1) CO2 moves along a concentration gradient from tissue to blood. (2) Carbonic anhydrase (not present in
plasma) catalyses the formation of carbonic acid (H2CO3) from H2O and CO2. (3) H2CO3 dissociates into protons (Hþ) and
bicarbonate ions (HCO3 ). (4) HCO3 diffuses along a concentration gradient into the plasma. (5) Chloride ions (Cl) enter the cell
to maintain electroneutrality, a process known as the ‘chloride shift’. (6) Hþ, produced as a result of the dissociation of H2CO3 and
carbamino compounds, is not able to leave the cell. Imidazole groups on the haemoglobin molecule buffer the protons.
10
Erythropoiesis 2
Reticulocyte Reticulocytes:
• are anucleate (nucleus is extruded)
• contain some organelles, including ribosomes
• synthesize 20–30% of total haemoglobin
• are released from the bone marrow
• mature after 1–2 days in peripheral blood
• account for 1–2% of the red cell count
• are distinguished from mature erythrocytes by brilliant
cresyl blue staining (precipitated RNA appears blue)
11
Red blood cells and haemoglobin
O2 sensor in kidney
Other stimuli,
e.g. androgens
Negative
EPO production feedback
erythrocyte production
• stem cells erythrocytes
• proliferation and differentiation
of progenitors
• Shorter cell-cycle time
O2 to kidney
• After chemotherapy or bone marrow transplantation Ferric iron is poorly absorbed compared to haem, thus
• Anaemia of chronic disease putting vegetarians and vegans at an increased risk of iron
• Myelodysplastic syndromes. EPO can be combined deficiency. Consumption of vitamin C with a source of
with G-CSF. ferric iron aids its absorption, as vitamin C forms com-
plexes with and reduces the ferric iron to ferrous.
Normal uptake and excretion of iron is illustrated in
HINTS AND TIPS
Figure 2.5. The total iron store of the body is around 4 g,
Athletes often train at higher altitudes, with lower mainly as haemoglobin (Fig. 2.6). The daily requirement
partial pressures of oxygen, to stimulate erythropoietin is normally around 1 mg. Absorption is controlled by
(EPO) production and therefore erythropoiesis. This proteins in the gut. The rate of iron transfer from
epithelial cells to plasma responds to iron requirements,
improves their oxygen carrying capacity and,
e.g. it is high when stores are low or the rate of erythro-
therefore, endurance. Athletes have also been known
poiesis is high.
to use synthetic EPO (illegally) for the same effect.
12
Iron and haem metabolism 2
Iron overload
There is no mechanism for the excretion of excess iron.
~25% stored in 0.1% bound ~ 4.9%
reticuloendothelial to transferrin in myoglobin,
Consequently, iron overload can occur as a result of:
system as protein in plasma cytochromes • Increased absorption
complexes, ferritin and other
and haemosiderin
• Parenteral administration.
enzymes
Excess iron can result in organ damage if it is depos-
ited in the tissues. The heart, liver and endocrine organs
are particularly at risk.
Increased absorption
This can be either primary or secondary, and results
from the following:
• Primary/hereditary haemochromatosis—an autoso-
~ 70% incorporated mal recessive disorder characterized by excessive
into haemoglobin intestinal absorption of iron
• Massive ineffective erythropoiesis as seen in thalas-
saemia syndromes or congenital dyserythropoietic
anaemia
• Dietary excess—rare in the developed world but
Fig. 2.6 Distribution of iron in the body, totalling 4 g. sometimes seen in sub Saharan Africa.
13
Red blood cells and haemoglobin
14
Haemoglobin 2
Albumin
Conjugates
with
glucuronic acid
Liver
Recycled
Bile
Oxidized Excreted
in gut in urine
Excreted in faeces
15
Red blood cells and haemoglobin
16
The cytoskeleton of the red cell 2
O2
Venous Arterial THE CYTOSKELETON
blood
saturation
blood OF THE RED CELL
(%) Myoglobin
(hyperbolic curve)
100 Structure
Haemoglobin A The erythrocyte plasma membrane is supported by a
75
(sigmoidal curve) dense, fibrillar, protein shell—the cytoskeleton.
CO2
The red-cell cytoskeleton:
CO2
H+ H+ • Maintains cell shape and confers strength to the eryth-
2,3-DPG 2,3-DPG
50
temp
rocyte membrane, allowing the cell to withstand the
temperature
stresses of the circulation
• Permits flexibility, which is important in erythrocyte
25 circulation.
The proteins of the plasma membrane, categorized
0
into integral and peripheral, are important constituents
10 20 30 40 50 60 70 50 90 100
of the cytoskeleton (Fig. 2.12). The band numbers refer
p O2 (mmHg) to their mobility on electrophoresis.
17
Red blood cells and haemoglobin
Hexokinase*
ADP
Surface proteins
glucose-6-phosphate
There are numerous surface proteins interacting with
Hexose monophosphate
plasma. Many are linked by the glucosyl phosphatidyli- shunt
nositol (GPI) anchor. Somatic mutation in the gene for
Fructose-6-phosphate
phosphatidylinositol glycan protein A (PIG-A) results in
the condition paroxysmal nocturnal haemoglobinuria ATP
(PNH) (see p. 29). Phosphofructokinase 1*
ADP
Fructose-1,6-diphosphate
(2)ADP
Luebering–Rapoport
shunt
Glycolysis and the (2)ATP
Embden–Meyerhof pathway
(2) 3-phosphoglycerate
This is the glycolytic pathway common to all cells of the
human body whereby glucose is metabolized to lactate
(Fig. 2.13). There is a net yield of two ATP molecules,
(2) 2-phosphoglycerate
but no net NADH production.
glucose þ 2Pi þ 2ADP ! 2 locate þ 2ATP þ 2H2 O
(2) phosphoenol pyruvate
Defects of glycolytic enzymes are rare. Approximately
95% are associated with pyruvate kinase and are re- (2)ADP
Pyruvate kinase*
stricted to red blood cells. Insufficient ATP is produced
(2)ATP
to maintain the structural integrity of the red cell, lead-
ing to premature cell death and a haemolytic anaemia (2) pyruvate
(see p. 27).
(2)NADH
18
Full blood count and reticulocyte count 2
Male Female
Red-cell count 4.4–5.8 10 /L 12
4.0–5.2 1012/L
Haemoglobin 13–17 g/dL 12–15 g/dL " Polycythaemia
Packed cell volume or 40–51% 38–48% # Anaemia
haematocrit
Mean cell volume 80–100 fL " (macrocytic) Vitamin B12 or folate deficiency,
pregnancy, neonates, alcohol or chronic liver
disease (may be haemolysis or aplastic anaemia)
# (microcytic) Iron deficiency, thalassaemia or
anaemia of chronic disease
Mean cell haemoglobin 27–32 pg
# (hypochromic) Occurs with microcytosis
Mean cell haemoglobin 32–36 g/dL
concentration
Reticulocyte count 1–2% of circulating red cells " (reticulocytosis) Haemolytic anaemias and after
10–100 109/L acute blood loss
(reticulocytopenia) Impaired red-cell production
Packed cell volume, otherwise known as the haematocrit, is equal to the red-cell count multiplied by the mean cell volume. Mean cell
haemoglobin is the haemoglobin divided by the red-cell count, while the mean cell haemoglobin concentration is the haemoglobin divided by
the haematocrit. Automated analysers are increasingly able to carry out reticulocyte counts, although they are also carried out on peripheral
blood films stained with new methylene blue. The normal range represents values for 95% of the population (mean 2 standard deviations).
19
Red blood cells and haemoglobin
to remember that normal ranges vary between popula- film shows the morphology of blood cells and can show
tions and different laboratories. inclusions within the cells.
20
Peripheral blood film 2
21
Intentionally left as blank
Red blood cell disorders 3
Objectives
ANAEMIA CAUSED BY
HAEMATINIC DEFICIENCY
Anaemia is a common problem worldwide, affecting as
much as one-third of the world‘s population. It can be
caused by decreased production or increased destruc- Iron-deficiency anaemia
tion of erythrocytes, or by blood loss. The causes of Iron deficiency is the most common cause of anaemia
anaemia worldwide will reflect local patterns of disease. worldwide. It occurs most frequently in women of re-
In the UK the most common cause of anaemia is iron productive age. If iron utilization outweighs intake,
deficiency. In hospitals, however, anaemias secondary stores eventually become depleted resulting in anaemia.
to chronic disease predominate. In some developing Causes of iron-deficiency anaemia include:
countries, human immunodeficiency virus (HIV), tu-
• Decreased iron intake, e.g. due to poor diet
berculosis (TB), hookworm and malaria are the most
• Increased iron requirement, e.g. during growth,
important causes.
pregnancy and lactation
The physiological response to anaemia is an attempt
• Chronic blood loss, e.g. heavy menstrual bleeding or
to maintain adequate oxygenation of the body. The
gastrointestinal (GI) blood loss
level of 2,3-DPG rises to ensure that oxygen is unloaded
• Decreased iron absorption, e.g. after gastrectomy.
at the tissues. The cardiac output increases and the cir-
culation becomes hyperdynamic. This can be detected
by a rapid pulse and the appearance of heart murmurs. HINTS AND TIPS
Anaemic patients are often pale. Symptoms vary
depending on the cause. They are listed in Figure 3.1, Iron deficiency in premenopausal women is most
and include: commonly caused by menstrual losses. Iron deficiency
anaemia in a postmenopausal woman or a man should
• Fatigue
• Dyspnoea raise suspicion of a gastrointestinal (GI) bleed, such as a
• Palpitations peptic ulcer or an occult GI cancer.
• Headache
• Tinnitus
• Anorexia and bowel disturbance. The signs and symptoms of iron-deficiency anaemia
Anaemias may be classified either morphologically or (Fig. 3.1) are often only apparent when the haemo-
by cause. Anaemias are micro-, normo- or macrocytic, globin level drops below 8 g/dL.
23
Red blood cell disorders
24
Anaemia of chronic disease 3
Making the diagnosis of anaemia of chronic disease • Lead poisoning, which inhibits both haem and globin
or iron-deficiency anaemia synthesis and can also cause abdominal pain and
neuropathies.
If the MCV is exceptionally low (< 70 fL), iron
deficiency is the most likely cause.
The important concept to understand is that in
anaemia of chronic disease there is no deficiency of
iron, only a deficiency in the ability to utilize iron stores. A summary of the causes of microcytic anaemias is
Therefore, serum iron is low in both conditions. shown in Figure 3.3.
• Assessment of iron status in iron deficiency:
– Serum iron: low
– Ferritin: low HINTS AND TIPS
– Serum transferrin: increased or normal
Chronic renal failure is almost always associated with
– Serum transferrin receptors: increased
anaemia. A decreased renal mass results in reduced
• Assessment of iron status in chronic disease:
production of erythropoietin (EPO). The anaemia is
– Serum iron: low
usually normochromic normocytic.
– Ferritin: increased or normal
– Serum transferrin: decreased or normal
– Serum transferrin receptors: decreased or normal.
Megaloblastic anaemias
Other important causes of microcytic anaemia are In megaloblastic anaemias, impaired DNA synthesis re-
thalassaemia traits. These haemoglobin defects are de- sults in the appearance of megaloblasts (abnormal red
tailed on page 31. cell precursors) in the marrow. Megaloblasts are large
cells which contain relatively large abnormal nuclei
Other causes of microcytic anaemia that should be with finely dispersed chromatin. Anaemia occurs
considered are: because megaloblasts are removed by bone marrow
• Sideroblastic anaemia (which can be hereditary or phagocytes (ineffective erythropoiesis). Megaloblastic
acquired) is a refractory anaemia characterized by anaemia is usually due to deficiency of vitamin B12
and/or folate. Both act as coenzymes in the pathway
increased bone marrow iron and the presence of
of DNA synthesis. Haematological findings include:
ringed sideroblasts (red-cell precursors containing
iron granules surrounding the nucleus). Cells in the
• Macrocytic anaemia (leucopenia and thrombocyto-
penia in severe megaloblastic anaemia)
peripheral blood are hypochromic. Some respond to
• Hypersegmentation of neutrophil nuclei (right shift)
vitamin B6, particularly those with the hereditary
• Megaloblasts seen on bone marrow smear
type. Vitamin B6 is a cofactor for haem synthesis, and • Low serum vitamin B12 levels or reduced red cell
deficiency prevents iron incorporation. folate content.
Haemoglobin
Cytosol
25
Red blood cell disorders
26
Anaemia due to increased red-cell destruction (haemolytic anaemias) 3
megaloblastic anaemia has been diagnosed (i.e. low Hb, Erythropoiesis can be increased from the normal
high MCV) it is important to refrain from treating folate base-line up to seven-fold, therefore haemolysis may
deficiency without being sure that there is no concurrent be compensated and not cause anaemia. Increased
vitamin B12 deficiency. If there is a possibility of vitamin erythropoiesis results in more reticulocytes being re-
B12 deficiency, supplements should be given at the same leased into the circulation which raises the MCV.
time as folic acid to prevent the irreversible and debili- Reduced red cell lifespan can be caused by erythro-
tating neurological complications. cyte defects or extracorpuscular defects, as shown in
Figure 3.5.
Haemolysis can occur within the circulation or be
extravascular:
HINTS AND TIPS
• Extravascular haemolysis: is the route by which red
Red cell folate is low in both vitamin B12 and folate cells are normally broken down and occurs in the
deficiency. A serum folate should be used to macrophages of the spleen, bone marrow and liver.
differentiate between the two. • Intravascular haemolysis: is the destruction of red
cells within the circulation. It is characterized by
all of the features of extravascular haemolysis
(Fig. 3.4), as well as by the following:
– Haemoglobinaemia: Hb is released into the
ANAEMIA DUE TO INCREASED bloodstream
– Absence of plasma haptoglobins: normally, free Hb
RED-CELL DESTRUCTION
binds haptoglobin to form a complex that is re-
(HAEMOLYTIC ANAEMIAS) moved by macrophages in the reticuloendothelial
system. Thus, intravascular haemolysis normally
In haemolytic anaemias, red cells have a shortened life- results in the removal of more haptoglobins
span because they are destroyed at an accelerated rate. – Haemoglobinuria: the Hb concentration exceeds
This increased red-cell destruction leads to anaemia, the tubular reabsorptive capacity and Hb is there-
which stimulates increased EPO production, leading to fore excreted in the urine
compensatory erythropoiesis. The clinical features of – Haemosiderinuria: free Hb is absorbed by proximal
haemolytic anaemias result from the increased red- tubule cells of the kidney resulting in intracellular
cell destruction and the compensatory increase in red-cell deposits of haemosiderin; these are shed in the urine
production (Fig. 3.4). – Methaemalbuminaemia: some of the Hb is oxi-
dized and binds to albumin.
27
Red blood cell disorders
Hereditary elliptocytosis
Dysfunction of spectrin This autosomal dominant disorder is also due to abnor-
Spectrin synthesis binding to band 4.1 protein malities of the cytoskeletal proteins and is most com-
and actin
monly caused by failure of spectrin dimers to form
tetramers. It is clinically similar to, but milder than, he-
reditary spherocytosis. A high proportion of elliptical
Spectrin deficiency red cells are seen on the peripheral blood film.
Enzyme defects
Detachment of cytoskeleton
from cell membrane Pyruvate kinase deficiency
This is a rare autosomal recessive condition affecting the
glycolytic pathway, which results in a lack of ATP pro-
duction. Erythrocytes become rigid and are destroyed.
Loss of membrane in microvesicles The blood film shows a poikilocytosis and distorted
‘prickle’ cells (known as acanthocytes, also seen post-
splenectomy). Splenectomy might improve, but not
cure, severe anaemias. Like sickle-cell anaemia, patients
Spherical erythrocytes (smallest
surface area:volume ratio) with pyruvate kinase deficiency can tolerate very low Hb
levels due to their oxygen dissociation curve shifting to
the right.
28
Anaemia due to increased red-cell destruction (haemolytic anaemias) 3
29
Red blood cell disorders
Coombs test can be demonstrated. There are three types Paroxysmal cold haemoglobinuria is a subset of cold
of AIHA: AIHA in which haemolysis occurs at higher tempera-
1. Warm AIHA (occurs at body temperature) tures but antibody binding occurs at cold temperatures.
2. Cold AIHA (usually occurs below room temperature) This usually presents in children after a viral infection.
3. Paroxysmal cold haemoglobinuria. The laboratory features of warm and cold AIHAs are
compared in Figure 3.9.
Warm AIHA can be idiopathic or secondary to auto-
immune disease (especially systemic lupus erythemato-
sus (SLE)), leukaemias (especially chronic lymphocytic
leukaemia), lymphomas and drugs (e.g. mefenamic Alloimmune haemolytic anaemias
acid). The clinical features are as follows: Alloimmune haemolytic anaemias are caused by a reac-
• Anaemia tion between antibodies and blood cells from different
• Jaundice people. This occurs following:
• Splenomegaly (almost always, although often very • Transfusion of ABO-incompatible blood
mild) • Transfer of maternal antibodies across the placenta
• Evans’ syndrome, which is the combination of warm in haemolytic disease of the newborn
AIHA and idiopathic thrombocytopenic purpura • Allogeneic transplantation.
(ITP) (very rare).
Identified causes should be eliminated. Patients gen-
erally respond well to steroids but other immunosup- Drug-induced immune haemolytic anaemias
pressive therapies (e.g. azothiaprine), the monoclonal
anti-B-cell antibody rituximab or splenectomy might Certain drugs (e.g. penicillin, cephalosporins and flu-
also be required. darabine) can precipitate haemolysis via a variety of
Cold AIHA can be idiopathic or secondary to lym- immune mechanisms.
phoma, leukaemia or infection (e.g. mycoplasma pneu-
monia, Epstein–Barr virus). The clinical features are as
follows: Other causes of haemolysis
• Symptoms worse in cold weather • Mechanical trauma:
• Acrocyanosis (purplish discolouration of the skin) due – Classically with mechanical heart valves
to vascular sludging arising from red-cell agglutination – Microangiopathic haemolytic anaemia occurs
• Raynaud‘s phenomenon. when fibrin is deposited in small vessels. This is
Treatment involves the elimination of any cause and seen in haemolytic uraemic syndrome, thrombotic
keeping the patient warm. The monoclonal antibody thrombocytopenic purpura, disseminated carci-
rituximab (anti-CD20) has been shown to be effective noma, malignant hypertension and Gram-
in idiopathic cold AIHA and cold AIHA associated with negative septicaemia. It is characterized by red cell
B-lymphoproliferative diseases. fragments (schistocytes) in the blood film
30
Haemoglobinopathies 3
– March haemoglobinuria is caused by damage to Severity of disease depends on which abnormal genes
red cells in the feet during long periods of walking have been inherited and whether the individual is het-
or running. The blood film does not show erozygous or homozygous.
fragments a-Thalassaemia is most common in South-East Asia
• Chemicals and toxins, e.g. lead poisoning, some and West Africa. There is a deletion of one, two, three
snake venoms or all four a-globin chain genes. The number of
• Infection, e.g. malaria deleted genes relates to the severity of disease, although
• Burns. deletion of all four a-globin chains is incompatible
with life.
Deficiency of one globin chain results in the com-
pensatory production of the other to form the Hb
HAEMOGLOBINOPATHIES molecule. An excess of a-chains (in b-thalassaemia) or
b-chains (in a-thalassaemia) results in abnormal aggre-
Thalassaemias gation within red-cell precursors, predisposing them
to phagocytosis by bone marrow macrophages. Any
HINTS AND TIPS abnormal red cells that reach the circulation have a
shortened lifespan. A number of clinical syndromes
In thalassaemias, the inheritance of defective genes are recognized, based on the severity of the anaemia
encoding for the a- or b-globin chains results in their (Fig. 3.10).
reduced production.
b-Thalassaemia major
b-Thalassaemia occurs most commonly in Mediterra- In b-thalassaemia major, homozygosity for defective
nean countries, South-East Asia and Africa. There is a genes causes b-chain production to be severely reduced.
partial or complete failure of b-globin chain production. Investigation reveals:
The abnormal b-chain genes are denoted bþ and • Microcytic hypochromic anaemia (Hb 2–3 g/dL)
b for partial or complete deficiency, respectively.
0
and reticulocytosis (at 6–9 months if not transfused)
31
Red blood cell disorders
Sickle-cell syndromes
The sickle Hb (HbS) gene is prevalent in tropical Africa
and parts of the Mediterranean, Middle East and India.
Up to 40% of the population can be heterogenous in
some areas. Sickle-cell trait is thought to afford some
protection against Plasmodium falciparum malaria and
therefore HbS genes are positively selected in areas
where malaria is endemic.
In HbS, a single base-pair substitution in codon 6 of
the b-chain replaces glutamic acid with valine. Deoxy-
genated HbS is 50 times less soluble than deoxygenated
HbA and it aggregates and polymerizes to form long in-
tracellular fibres called tactoids. This causes elongation
of the red cell into a rigid sickle shape (Fig. 3.12). Re-
oxygenation can initially reverse the sickling process
but, after repeated episodes, the red cells become
irreversibly sickled.
HbS polymerizes best with other HbS molecules. The
presence of other types of Hb (e.g. HbF or HbA) reduces
sickling. Therefore, sickle-cell anaemia is not apparent
Fig. 3.11 Skull radiograph of a child with b-thalassaemia
until approximately 6 months of age, when HbF levels
major. The ‘hair-on-end’ appearance is pathognomonic. It is
caused by extramedullary haemopoiesis.
fall. Individuals with sickle-cell trait are usually asymp-
tomatic and those who are double heterozygotes for
sickle-cell and haemoglobin C disease usually have clin-
• Basophilic stippling (the presence of small dots, seen ically milder forms of the disease. There are four impor-
in the periphery of erythrocytes on the blood film), tant syndromes associated with HbS:
target cells and normoblasts on peripheral blood 1. Sickle-cell anaemia
film 2. Sickle-cell trait
• Absence of HbA on electrophoresis 3. Sickle-cell haemoglobin C disease
• A ‘hair-on-end’ appearance on skull X-ray 4. Sickle-cell b-thalassaemia.
(Fig. 3.11). Bony changes are caused by expansion
Sickle-cell anaemia (homozygous for HbS, denoted
of haemopoietic bone marrow from its normal sites.
bsbs) is the most serious of these. Features of sickle-cell
Treatment is by regular blood transfusions (about anaemia are listed in Figure 3.13. Management strate-
one a month), splenectomy and/or bone marrow trans- gies include:
plantation. Chelation therapy is given to prevent iron
• Pneumococcal, meningococcal and Hib vaccines
overload.
• Penicillin prophylaxis
• Folic acid supplements
b-Thalassaemia minor • Avoidance of factors precipitating infarctive crises
• Prompt treatment of infection
This is often known as b-thalassaemia trait. It affects
• Management of infarctive crises with fluids, analge-
those who are heterozygous. Patients are often asymp-
sia (including opiates), warmth and antibiotics if
tomatic, but will usually have microcytic red blood
necessary
cells and a mild anaemia. Recognition of this syn-
• Blood transfusions and exchange transfusions when
drome is important as it has implications for genetic
necessary
counselling and can also mimic iron-deficiency anae-
• Prevention of iron overload (rare).
mia, for which inappropriate iron therapy might
be given. Sickle-cell trait (heterozygous, HbSA, bsb) individ-
uals are generally asymptomatic. Sickling occurs at very
low partial pressures of oxygen that are rarely reached in
HINTS AND TIPS vivo. Both HbA and HbS bands are detectable on elec-
trophoresis but sickled cells are not usually seen. Hae-
Whereas thalassaemias are characterized by a moglobin solubility test is positive.
deficiency of either a- or b-globin chains, sickle-cell Sickle-cell haemoglobin C disease (HbS/HbC, bsbc)
syndromes result in a deformed form of the b-globin arises from carriage of two different abnormal b genes.
chain. HbC (bc) also results from a single base-pair substitu-
tion at codon 6; however, in this case lysine is the
32
Investigation of haemoglobinopathies 3
new base. It is clinically similar to, but less severe than, INVESTIGATION OF
sickle-cell anaemia. Patients are more susceptible to HAEMOGLOBINOPATHIES
thrombosis and pulmonary embolism and are more
likely to develop proliferative retinopathy.
Sickle-cell b-thalassaemia (bsb0 or bsbþ) shares its
Electrophoresis
clinical features with sickle-cell anaemia, but its severity Electrophoresis is a method used to separate out
is variable and depends on the amount of normal biological molecules of similar size. An electric current
b-chain synthesis. is passed through a medium containing the mixture, in
33
Red blood cell disorders
Sickle-cell
trait
Sickle-cell/
HbC disease
34
Polycythaemia (erythrocytosis) 3
35
Intentionally left as blank
White blood cells 4
Objectives
37
White blood cells
9 – 15 µm
Azurophilic granules
• similar to lysosomes
• contain – myeloperoxidase
– acid hydrolases
– lysosome
– defensins
Specific granules
• contain – lysosome
Glycogen Multilobed – lactoferrin
(2–5) – collagenase
nucleus – vitamin B12
binding protein
Fig. 4.2 Normal lymphocytes are quite small (on average 9 mm Fig. 4.4 Normal neutrophils have a characteristic multilobed
diameter). They contain very little cytoplasm and occasional nucleus (connected by chromatin). The cytoplasm is granular.
azurophilic granules.
25 µm
Vacuole
Lysosome
Pseudopodia
are often
present
MHC class II
for antigen
presentation
Large kidney- Nucleoli
shaped nucleus
38
Differentiation of white cells 4
Location
They are primarily found in the tissues, spending less
than 1 hour in blood.
Function
Their primary function is to combat parasitic infection.
Eosinophils are seen in allergic and certain malignant
disease processes. They also phagocytose antigen–
antibody complexes.
Basophils
Appearance and structure
Basophils (Figs 4.8 and 4.9) are 14–16 mm in diameter
with a bilobed, ’S-shaped’ nucleus. They are named
after their highly basophilic cytoplasmic specific granules,
but also contain azurophilic granules. Specific granules
(0.5 mm in diameter) are large, membrane-bound, round
or oval structures. They push into the plasma membrane
causing a ’roughened perimeter’. The granules contain
Fig. 4.6 Normal monocytes are large. The nucleus tends to heparin, histamine, chemotactic factors and peroxidase.
be folded, not lobed, and the cytoplasm contains very fine
granules.
Location
Eosinophils Basophils undergo maturation in the bone marrow over
2–7 days. They are found in the peripheral blood, and
Appearance and structure last for up to 2 weeks.
Eosinophils (Figs 4.7 and 4.8) are similar to neutrophils
but are larger and measure 12–17 mm in diameter. Their
Function
nucleus is sausage-shaped and usually bilobed. They have Basophils are functionally very similar to mast cells, al-
a small, central Golgi apparatus and limited rough en- though they are of two different lineages. Unlike baso-
doplasmic reticulum and mitochondria. Eosinophils phils, mast cells are located in the tissues. Through
contain large, ovoid, specific granules and azurophilic interactions with immunoglobulin E (IgE) basophils
granules. The specific granules (1–1.5 mm long) have a cause local inflammatory responses. Basophils are not very
crystalloid centre containing major basic protein, eosino- well understood and the extent to which they participate
philic cationic protein and eosinophil-derived neurotoxin. in immune reactions in vivo is unclear. They are thought
The outside of the granule contains several enzymes, to mediate immediate (type I) hypersensitivity reactions
including histaminase, peroxidase and cathepsin. such as asthma and anaphylaxis (see Chapter 12), along
with mast cells. Recent studies in mice show that basophils
are important in a new pathway of anaphylaxis involving
12–17 µm
IgG and platelet-activating factor (PAF).
39
White blood cells
14 – 16 µm
High-affinity receptors
for IgE Fc domain CFU-GM
Basophilic granules
• contain – heparin
– histamine
– chemotactic factors
– peroxidase Promonocyte Myeloblast
'Roughened' perimeter
Monocyte Promyelocyte
Irregular nucleus
Neutrophil
DIFFERENTIAL WHITE COUNT
Fig. 4.10 Production of myeloid cells and monocytes.
The differential white count breaks down the white-cell
Eosinophils and basophils are formed by a process similar to the
count to identify the level of each of the five peripheral one shown for neutrophils. CFU-GM, granulocyte, monocyte
white cell lines: neutrophils, lymphocytes, monocytes, eo- colony-forming unit.
sinophils and basophils. This is automated and uses stains,
cell size and light scatter to differentiate between the differ-
ent cells. The parameters for white cells and platelets, and
the diagnostic inferences made from their abnormalities, White cells are visualized in the peripheral blood
are given in Figure 4.12. As with all normal ranges, they film and abnormalities in their appearance indicate
vary in different populations and in different laboratories. various disease processes (Fig. 4.13).
40
Differential white count 4
41
White blood cells
REACTIVE PROLIFERATION
OF WHITE CELLS • Neutropenia (granulocytopenia): reduction in
neutrophils (< 1.8 109/L)
• Agranulocytosis: severe, acute reduction in
Leucocytosis
neutrophils (< 0.5 109/L in peripheral blood).
Leucocytosis is an increase in the total white cell Is associated with risk of infection and can be fatal
count (> 11 109/L). One leucocyte type, most com- • Lymphopenia: reduction in lymphocyte count
monly neutrophils, tends to predominate, with small (<1.5 109/L).
increases in other types. Diseases associated with
increases in white-cell count are listed in Figure 4.14.
Inadequate granulopoiesis
Reduced or ineffective production of neutrophils in the
LEUCOPENIA bone marrow results in neutropenia. This can be gener-
alized bone marrow failure such as:
• Aplastic anaemia (see p. 34): a group of disorders
• Leucopenia: reduction in white blood cells characterized by anaemia, thrombocytopenia and
(<4 109/L), most commonly neutrophils neutropenia
42
Leucopenia 4
• Invasion of the bone marrow in leukaemias and – Due to drug therapy, e.g. chlorpromazine
lymphomas. Neutropenia is accompanied by anae- – Hypersensitivity and anaphylaxis
mia and thrombocytopenia • Hypersplenism causing splenic sequestration of
• Megaloblastic anaemia due to vitamin B12 or folate neutrophils
deficiency (see p. 25): this leads to impaired • Severe infection (e.g. typhoid, miliary tuberculosis)
DNA synthesis, resulting in abnormal granulocyte resulting in increased peripheral utilization.
precursors that are more susceptible to destruction.
• Chemotherapy
• Myelodysplasia. Drug-induced neutropenia
Or a specific failure of neutrophil production: Drug-induced neutropenia is increasing in frequency.
• Congenital (Kostmann’s syndrome) Two mechanisms operate:
• Exposure to certain drugs (Fig. 4.15) 1. Direct toxicity: interference with protein synthesis
• Cyclical. or cell replication of pluripotent stem cells causes
a dose-dependent, generalized bone marrow
depression.
Accelerated removal of granulocytes
2. Immune-mediated destruction of neutrophils: this
• Immune-mediated destruction: is not related to drug dose and usually occurs early
– Idiopathic in the course of the therapy.
– Secondary to other autoimmune diseases, e.g.
Felty’s syndrome (rheumatoid arthritis associated
with leucopenia and splenomegaly) Causes of lymphopenia
Lymphopenia is most commonly secondary to minor,
Fig. 4.15 Drugs that can cause neutropenia community-acquired viral infections. Other causes of
lymphopenia are:
• Chemotherapy
• Analgesic and anti-inflammatory agents (aminopyrine, • Corticosteroid and other immunosuppressive therapy
phenylbutazone) • Trauma or surgery
• Hypnotics and sedatives (clozapine, mianserin, • Cushing’s syndrome
imipramine) • Systemic lupus erythematosus (SLE)
• Antimalarials (chloroquine) • Hodgkin’s lymphoma
• Diuretics and antihypertensives (furosemide)
• Anticonvulsants (phenytoin, carbamazepine)
• HIV infection and AIDS.
• Antithyroid drugs (carbimazole) Mild lymphopenia has little in the way of clinical
• Antibiotics (chloramphenicol, co-trimoxazole, consequences and it is only in situations of prolonged
imipenem) severe lymphopenia, such as that seen in HIV-positive
• Hypoglycaemic agents (tolbutamide)
• Antirheumatoid drugs (gold, sulfasalazine) patients, where significantly clinical sequelae are
evident.
43
Intentionally left as blank
Haematological malignancies 5
Objectives
45
Haematological malignancies
Chronic myeloid
Polycythaemia Primary
(granulocytic)
rubra vera thrombocythaemia
leukaemia
46
Introduction to haematological malignancies 5
patients develop acute leukaemia or myelofibrosis. The irradiation is sometimes beneficial. Chemotherapy with
main causes of death are thromboses and acute leukae- hydroxycarbamide or a-interferon 2b can slow or re-
mia. However, if the red cell count is kept low, the prog- verse fibrosis. Median survival is 5 years. Approximately
nosis is good. Modern therapy extends 50% survival 10% of cases transform into acute myeloblastic leukae-
beyond 10 years compared to historical figures of less mia (AML).
than 2 years.
Myelodysplastic syndromes
Myelofibrosis Myelodysplasias are acquired neoplastic disorders of
Also known as primary myelosclerosis, idiopathic mye- bone marrow, with replacement of normal cells by a
lofibrosis is characterized by clonal proliferation of clone of abnormal (dysplastic) cells. These cells are un-
pluripotent stem cells. Idiopathic myelofibrosis can be able to mature normally, usually affecting at least two
preceded by other myeloproliferative conditions; 25% cell lines (erythrocytes, granulocytes, monocytes or
of cases are preceded by polycythaemia rubra vera. Bone platelets) and as a result blast cells may accumulate.
marrow is replaced by fibrous tissue produced by fibro- The dysmorphic cells are easily recognizable on micros-
blasts in conjunction with proliferation of dysplastic copy with an increasing blast cell count indicating a
megakaryocytes. Extramedullary metaplasia is also a poorer prognosis. Common features of myelodysplasias
feature, with the spleen being the primary site, resulting include the following:
in massive splenomegaly. The same process may also • Occurs most commonly in the elderly and in males
result in hepatomegaly. The disease affects individuals • Slowly progressive disease, often with anaemia, easy
from middle-age onwards. Clinical features include bruising or bleeding and infections
constitutional symptoms of weight loss, night sweats • May follow chemo- and/or radiotherapy for another
and fever, or those relating to anaemia (fatigue, short- condition
ness of breath and palpitations) or splenomegaly (ab- • Normal or increased bone marrow cellularity
dominal pain due to the mass effect). Laboratory • Cytopenias
features at presentation include anaemia, leucocytosis • Progression to AML.
and thrombocytosis. The blood film is often diagnostic,
The traditional classification was the French-
revealing:
American-British (FAB) classification, but this was re-
• Granulocyte precursor cells vised by the World Health Organization (WHO) in
• Nucleated red blood cell precursors 2008 (Fig. 5.2). Prognosis is calculated using the Inter-
• Tear-drop poikilocytosis (tear-drop-shaped national Prognostic Scoring System (IPSS) based on the
erythrocytes). percentage of bone marrow blast cells. Generally speak-
Supportive care (including transfusions of red cells ing, the greater number of blasts and the presence of
and platelets) can be useful, and splenectomy or splenic cytopenias indicate a worse prognosis.
Fig. 5.2 The French-American-British (FAB) and World Health Organization (WHO) classifications of myelodysplastic
syndrome subtypes
FAB classification WHO classification
Refractory anaemia (RA) – bone marrow RA
blasts < 5%, < 1% blasts in the blood Refractory cytopenia and multilineage dysplasia (RCMD)
Myelodysplastic syndrome with isolated deletion of
chromosome 5q
Myelodysplastic syndrome – unclassified
Refractory anaemia with ringed sideroblasts (RARS) – as RARS
for RA with ringed sideroblasts > 15% of erythroblasts Refractory cytopenias with multilineage dysplasia and
ringed sideroblasts
RA with excess blasts (RAEB) – bone marrow blasts RAEB-1 (5–9% bone marrow blasts)
5–20%, blasts in the blood < 5% RAEB-2 (10–19% bone marrow blasts)
RAEB in transformation (RAEBt) – as RAEB but bone Patients with > 20% blasts are now recognized as having
marrow blasts 20–30% or Auer rods present acute myeloid leukaemia
Chronic myelomonocytic leukaemia (CMML) – any Now removed from myelodysplastic syndromes and part of
of the above þ > 1.0 x 109/L monocytes the myelodysplastic-myeloproliferative overlap syndromes.
47
Haematological malignancies
As well as the morphological appearance, cytogenetic These blast cells can be seen on peripheral blood films.
changes will influence prognosis and treatment. Thus The majority of cases have no known cause, although
cytogenetic analysis should be undertaken at presenta- they can progress from both the myeloproliferative
tion. Treatment, until recently, has been mainly sup- and myelodysplastic disorders. The incidence increases
portive with blood and platelet transfusions, as well with age (median 70 years) with an average of 4 per
as antibiotics if needed. There is evidence that the use 100,000 per year. The 5-year survival rate is over 50%
of biological therapy such as EPO and G-CSF will im- in children and about 30–50% in adults who are trea-
prove survival in some patients. Younger patients with ted. Elderly patients have a poorer prognosis. AML is as-
more advanced disease will be treated with intensive sociated with:
chemotherapy and possibly bone marrow transplanta- • Radiation exposure
tion. There may also be a role for thalidomide and its • Toxins: benzene, alkylating agents
derivatives. • Hereditary abnormalities, e.g. Down syndrome
• Pre-existing haematological disease: chronic mye-
Leukaemia loid leukaemia (CML), myelodysplastic syndromes.
Usually, however, there is no obvious cause.
Features common to leukaemias Patients are often acutely unwell at presentation and
Leukaemias are a group of disorders characterized by ac- can present with:
cumulation of clonal white blood cells in bone marrow. • Anaemia, malaise, sweats, weight loss
The leukaemic ‘blast’ cells are non-functional and re- • Infections (chest, mouth, skin)
place normal bone marrow, encroaching on normal • Bleeding
haemopoietic cell development. This leads to anaemia, • Skin infiltration (gums M4/5)
neutropenia and thrombocytopenia. • Leucostasis.
48
Introduction to haematological malignancies 5
The haematological consequences of AML are treated to are mainly myelocytes and neutrophils but blasts are de-
improve symptoms and outcome. This includes transfu- tectable in the early, chronic phase. An increase in baso-
sions of red cells/platelets, leukopheresis to reduce blood phils is characteristic. It accounts for 15% of all
viscosity and the prevention/treatment of infection. leukaemias. The average incidence is 1 in 100,000, peak-
ing between 40 and 60 years of age. It is rare in children
AML and there is a slight male preponderance. Clinically, it
runs a predictable course, with three identifiable phases
Patients usually present with a short history of recurrent of the disease:
sore throats or easy bruising. A blood count reveals
1. Chronic
anaemia and thrombocytopenia. The white-cell blood
2. Accelerated
count (WBC) may be low or high but there will be blast 3. Blast crisis (AML/ALL).
cells in the bone marrow which may also be seen in the
People normally present in the chronic phase follow-
blood. These patients require immediate admission to ing an incidental finding on a full blood count or with
hospital. If they are not treated with intensive constitutional (malaise, weight loss, sweats) or leuco-
chemotherapy they will rapidly die of sepsis or static symptoms. Many patients will quickly transform
bleeding. to an accelerated or blast crisis stage, if untreated.
Stem cell transplantation (SCT) involves using high- The Philadelphia chromosome is a pathognomonic
dose chemotherapy (and or radiotherapy) to destroy all translocation between chromosomes 9 and 22, written
cancerous cells in the bone marrow, and they are then as t(9:22), associated with CML. This translocation,
replaced with (disease-free) haemopoietic stem cells. found in granulocytic, erythrocytic and megakaryocytic
The new stem cells can be sourced from the bone precursor cells, fuses parts of two genes (BCR–ABL) to
create an abnormal tyrosine kinase, which plays a piv-
marrow, hence the name bone marrow transplant, or
otal role in the genesis of chronic phase CML. Tyrosine
can be a peripheral blood stem cell transplant (PBSCT).
kinase inhibitors (TKI) are now the cornerstone of CML
These cells can come from the patient’s own body treatment, as opposed to chemotherapeutic agents,
(autologous SCT) or from another person (allogenic which were popular in the past. A TKI, imatinib (traded
SCT). This other person is usually a human leucocyte as Glivec), is now first line for the chronic phase of CML,
antigen (HLA)-matched relative, in order to prevent and provides good remission rates. Bone marrow trans-
host immune rejection, which is known as graft-versus- plantation is potentially curative, especially in young
host disease (GVHD). Immunosuppressive drugs such patients; however, the benefits of treatment must be
as cyclosporin and methotrexate are used to reduce the weighed against the risks of transplantation.
incidence of GVHD. Median survival before the introduction of imatinib
Other complications of SCT include graft failure, was 5½ years. Short term (at 5 years) observational
studies show that imatinib produces better complete cy-
opportunistic infections, and interstitial pneumonitis.
togenetic remission than other therapies, but long-term
(> 10 years) studies are ongoing. 65% of patients
started on imatinib remain well at 10 years. Good prog-
nostic factors include:
HINTS AND TIPS • Youth
• Small spleen at presentation
The term ‘remission’ refers to the disappearance of the • Low white-cell count at presentation.
signs and symptoms of the disease. This can be
permanent or a patient may suffer from a relapse.
Sometimes ‘complete remission’ is used to describe a Acute lymphoblastic leukaemia
clinical disappearance as well as a biochemical or ALL accounts for 80% of all childhood leukaemias and
histological return to normality. 60% of cases present before 20 years of age. It is the most
common cancer in children. The peak incidence occurs
between 2 and 10 years of age. Presentation outside of
this range confers a poorer prognosis. The most com-
Chronic myeloid leukaemia mon presenting symptoms are fatigue, bruising, bleed-
CML, also known as chronic granulocytic leukaemia, is ing, infections and hepatosplenomegaly. ALL may be
a progressive accumulation of mature myeloid cells in associated with:
blood and bone marrow. At presentation the white-cell • Radiation
count is usually in the range 20–200 x 109/L (normal • Chemicals
range 4–11 109/L), but can be much higher. These • Down syndrome.
49
Haematological malignancies
50
Introduction to haematological malignancies 5
51
Haematological malignancies
52
Introduction to haematological malignancies 5
53
Haematological malignancies
54
Investigations of haematological malignancies 5
55
Intentionally left as blank
Haemostasis 6
Objectives
Three local mechanisms are employed to try to avoid Platelet structure and production
blood loss: The normal discoid circulating shape is maintained by a
1. Local neurohumoral factors, such as endothelin re- band of 10–15 parallel microtubules located around the
leased by cells adjacent to the injury, induce tran- circumference. Platelets have two tubular systems: the
sient vasoconstriction. Reducing the flow of blood dense tubular system and the surface-opening canalicular
minimizes blood loss as well as maximizing interac- system. Platelets contain two types of granule, a and d,
tions between platelets, clotting factors and the ves- which contain molecules involved in platelet aggregation.
sel wall. Haemopoietic stem cells differentiate to form mega-
2. Primary haemostasis utilizes circulating platelets to karyoblasts. Megakaryoblasts mature by endomitosis,
form an adhesive plug to slow bleeding. expanding cytoplasmic volume and increasing the num-
3. Secondary haemostasis (the coagulation cascade) ber of nuclear lobes without dividing. This forms a poly-
involves circulating plasma proteins. They produce ploid megakaryocyte, which can produce 2000–7000
a fibrin network that stabilizes the platelets and platelets. Cytoplasmic processes protrude into sinusoids
traps both red and white blood cells. This stable plug where they fragment into proplatelets, which then dis-
remains until cellular processes repair the damage. perse as individual platelets, with the megakaryocyte
57
Haemostasis
58
Antiplatelet drugs 6
vWF
Subendothelium
(collagen myofibrils)
Procoagulant function
ANTIPLATELET DRUGS
Platelet aggregation rearranges membrane phospholipid,
forming an ideal site for important coagulation reactions Given the important role of platelets in thrombosis,
to take place (see the coagulation pathway, p. 63). platelets are the target of certain pharmacological inter-
ventions to reduce risk of thrombotic diseases such as
myocardial infarctions and strokes. The mechanisms
Tissue repair of action of some antiplatelet drugs is shown in
Figure 6.4.
Platelets stimulate wound healing through platelet-
Aspirin is a non-specific, irreversible COX (cyclo-
derived growth factor (PDGF), which is mitogenic for
oxygenase) inhibitor. COX enzymes are required to
vascular smooth muscle cells and fibroblasts.
form TxA2. The effect of aspirin lasts for the life
of that platelet. Aspirin is used for secondary preven-
tion of cardiovascular disease, and has been shown
HINTS AND TIPS to be effective in reducing risk. The dose is nor-
mally 75 mg. In acute ischaemic events (myocardial
The bleeding is the time it takes for a small cut to stop
infarction, MI or ischaemic stroke) 300 mg of chew-
bleeding, representing the formation of a platelet plug.
able or dispersible aspirin should be taken as soon as
It is a method of assessing platelet function, and is possible.
increased in patients with platelet disorders. It is rarely Clopidogrel is an ADP receptor antagonist and is
used, and there is controversy regarding its clinical used to prevent further ischaemic events in those who
utility. have suffered vascular events in the past. It is also used
with aspirin in the management of acute coronary
59
Haemostasis
Phosphodiesterase
AMP
Platelet
Endothelial cells
syndromes. Prasugrel is a new drug that comes from the Reduced platelet count
same family and appears to achieve greater platelet inhi-
bition. An increased risk of bleeding means that it is re-
(thrombocytopenia)
served for specific situations, such as in patients Decreased platelet production
undergoing percutaneous transluminal coronary inter-
vention (PTCI). This is the most common cause of thrombocytopenia.
Dipyridamole is a phosphodiesterase inhibitor. It in- The causes are listed in Figure 6.6.
hibits the breakdown of cAMP to AMP, keeping cAMP Generalized disease of the bone marrow
levels high and Ca2þ low. Dipyridamole is often used Decreased megakaryocyte production, and therefore
in combination with aspirin for treatment following a platelet production, can be part of a wider clinical
stroke or a transient ischaemic attack (TIA). picture. Aplastic anaemia is associated with generalized
GPIIb/IIIa inhibitors include the monoclonal anti- bone marrow failure. Bone marrow infiltration, e.g. due
body abciximab, as well as eptifibatide and tirofiban. to metastatic carcinoma, also reduces the number of
Abciximab is used in high-risk patients undergoing marrow megakaryocytes.
PTCI. Eptifibatide and tirofiban are used with unfractio-
nated heparin and aspirin to treat early MI. GPIIb/IIIa Specific impairment of platelet production
inhibitors should only be used by a specialist, as the risk Drugs (thiazide diuretics, ethanol and cytotoxics) can
of severe bleeding is high. cause thrombocytopenia by several mechanisms:
• Depressing the whole bone marrow
• Specifically impairing megakaryocyte development
PLATELET DISORDERS or proliferation.
Viruses can impair platelet production by invading
The normal concentration of platelets in blood is 150– the megakaryocyte, e.g. measles. HIV precipitates the de-
400 109/L. A reduced platelet count (thrombocytope- velopment of antiplatelet antibodies and suppresses
nia) or defects of platelet function can cause bleeding megakaryocytes, causing thrombocytopenia in 50% of
(Fig. 6.5). patients.
60
Platelet disorders 6
Fig. 6.5 Platelet count and bleeding tendency Fig. 6.6 Causes of reduced platelet production
Immune destruction
Acute immune thrombocytopenic purpura (ITP) is a
Decreased platelet survival
self-limiting, postviral illness most common in children.
The causes of decreased platelet survival are listed The platelet count is usually less than 20 109/L. It
in Figure 6.7. is hypothesized that the immune response following
61
Haemostasis
62
The coagulation cascade 6
– FVIIa Factor Xa
FVIIa + tissue factor + Ca2+ + FVa + Ca2+
Prothrombin
– FXIa
Fibrinogen Fibrin
– FIXa
– FVIIIa
Thrombin time
FIXa + FVIIIa + Ca2+
(tenase)
Activated partial thromboplastin time
63
Haemostasis
FXa FXa-FVa-Ca2+
The intrinsic pathway
The ’intrinsic’ pathway begins entirely within the circu- Prothrombin Thrombin
lation. It starts when FXII comes into contact with a neg-
atively charged surface, such as a negatively charged Fibrinogen Fibrin
platelet, and is then activated. FXIIa activates FXI. FXIa
converts FIX to FIXa, which in turn cleaves FVIII into
FVIIIa. Some downstream products such as FXa and FIIa Fig. 6.9 The updated clotting cascade. TF, tissue factor; Ca2þ,
amplify this process. The result of the instrinsic pathway calcium ions.
is the production the trimolecular complex of FIXa,
FVIIIa and calcium ions. This complex is a very potent
and FX. The activated platelet membrane then provides
activator of FX, and is known as ’tenase’. The common
the catalysts for the efficient conversion of prothrombin
pathway then follows, resulting in fibrin formation.
to thrombin by FXa on its own. If the trigger is sufficient
and enough thrombin is formed it converts FV, FVIII,
Fibrin and FXI to their active forms, By this time very little
thrombin has been produced.
The final step of the secondary coagulation process is
The reactions associated with the propagation step
the degradation of the plasma protein fibrinogen into
occur on the surfaces of activated platelets. FIXa binds
small fibrin monomers. These fibrin monomers poly-
to the newly formed FVIIIa forming the tenase complex
merize spontaneously, by hydrogen bonds, to form
(FIXa-FVIIIa-Ca2þ). This complex is a much more po-
long fibres and subsequent complex networks around
tent activator of FX than the TF-FVIIa complex. This
the primary platelet plug. FXIIIa further stabilizes the
new FXa can then form the prothrombinase complex
clot by forming covalent cross-links between the fibrin
(FXa-FVa-Ca2þ) which is 300,000 times more potent
polymers.
at converting prothrombin to thrombin than FXa
alone.
Initiation and propagation
The cascades, as explained above, have been the ac- Regulatory pathways
cepted interpretations of the clotting system for de-
A complex regulatory system limits the positive feed-
cades. However, as can be appreciated from these
back mechanisms and prevents extension of coagula-
theories, certain clotting factors are important for their
tion outside the site of injury. During the initiation
own production; the most obvious one being throm-
step tissue factor pathway inhibitor (TFPI) can bind
bin. Thrombin acts in reactions that are above itself
FXa preventing the initial production of thrombin.
in the cascade, making the cascade approach seem re-
The TFPI-FXa complex then inhibits TF-FVIIa complex
dundant. The more recent interpretation of coagula-
bringing the initiation step to a halt.
tion sees the two ’separate’ cascades as being closely
linked in two phases:
• Initiation Proteins C and S
• Propagation. During the propagation step the activated protein C
Initiation begins with TF binding to activated FVIIa pathway is the main form of natural anticoagulation.
(see Fig. 6.9). The FVIIa-TF complex activates both FIX Protein C is a serine protease that destroys the
64
The coagulation cascade 6
–
Protein C Activated Reductase HCO3–
protein C
Vitamin K
Vitamin K
epoxide
Carboxylase
Protein S
(cofactor) γ-carboxyglutamyl residue
Mature factor precursor
Role of calcium
Reduced Enhanced
coagulation fibrinolysis Adequate levels of calcium are needed to allow clotting,
by activating the vitamin-K-dependent factors. Reduc-
ing calcium within the test tube can prevent coagulation
Fig. 6.10 Actions of proteins C and S to limit thrombus of blood samples. This is done by:
formation.
• Citrate ! deionizes calcium
activated cofactors Va and VIIIa. It also enhances fibri- • Ethylenediaminetetraacetic acid (EDTA) ! precipi-
nolysis by inhibiting tissue plasminogen activator in- tates calcium.
hibitor (PAI). Protein C is activated when thrombin
binds to thrombomodulin on the surface of endothelial Fibrinolysis
cells. Protein S is a cofactor for protein C (Fig. 6.10).
In blood, the fibrinolytic system breaks down excessive
Both proteins C and S are dependent on vitamin K
thrombus formation in the lumen of the vessels, thus pre-
(see Fig. 6.11).
venting luminal occlusion. Plasminogen is activated, by
cleaving an arginine–valine bond, to form plasmin. Acti-
Antithrombin vation can be intrinsic or extrinsic, by non-human agents,
Antithrombin (sometimes still called its former name, e.g. tissue plasminogen activator (tPA) and by urokinase.
antithrombin III) is a potent inhibitor of thrombin, Thrombin-activated fibrinolysis inhibitor, plasminogen
FIXa, FXa and FXIIa. AT binds to the serine residue in activator inhibitor, a2-antiplasmin, closely regulate
the active site of these factors. The inhibitory effect of fibrinolysis.
AT is potentiated by heparin.
Tissue plasminogen activator
Role of vitamin K tPA is released from activated endothelial cells and is the
most important activator of fibrinolysis. It binds to and
Factors II, VII, IX and X undergo post-translational activates fibrin-bound plasminogen. This ensures that
g-carboxylation of glutamic acid residues. The modifica- plasmin production is localized to the thrombus.
tion of these factors allows them to bind calcium ions
and platelet phospholipid membranes. The process,
outlined in Figure 6.11, requires vitamin K as a cofactor. Plasmin
Vitamin K is fat soluble and deficiency is often a result of Plasmin cleaves peptide bonds in fibrin to produce degra-
malabsorption. A large proportion of our vitamin K is dation products of various sizes. Small fragments, termed
liberated from our foods by commensal bacteria in ’D’ fragments, are produced following thrombin
65
Haemostasis
66
Clotting factor disorders 6
secondary
haemostasis
vWF
platelet coagulation
vasoconstriction
release reaction cascade
-
primary
haemostasis
protein C and S,
antithrombin III
platelet
aggregation
fibrin
-
fibrinolysis
stable haemostatic
plug plasmin
67
Haemostasis
68
Thrombosis 6
suffer from thromboses and bleeding simultaneously. commonly occurs in the lower limbs, for example a DVT
Coagulation is activated in two ways: in the deep veins of the leg. Axillary vein thrombosis is
1. Release of tissue factor from damaged tissues, rare, and tends to affect young, active men. The most
monocytes or red blood cells serious complication of venous clots is embolization
2. Activation of factors XI and XII by endothelial cell to the pulmonary vasculature, creating a pulmonary
dysfunction. embolism (PE).
Virchow’s triad provides a framework to think about
There is generalized fibrin deposition on vascular en-
the risk factors for VTE formation.
dothelium, with extensive consumption of platelets and
coagulation factors. Small vessels are obstructed, lead-
ing to tissue damage and multiple organ dysfunction. Changes in blood flow
Fibrin deposition activates the fibrinolytic pathway
and results in the formation of fibrin degradation prod- Normally blood flow is smooth (laminar). If the blood
ucts (FDPs). FDPs inhibit fibrin polymerization and, con- flow becomes turbulent or if there is any stasis of blood
sequently, impair coagulation. The net result is a bleeding there is a risk that the clotting system will be activated,
disorder due to a lack of platelets and clotting factors, and and clots formed. Atrial fibrillation and mechanical
inhibition of fibrin polymerization by FDPs. In DIC, PT, heart valves carry an increased risk of ATE and so pa-
APTT and thrombin clotting times can all be prolonged, tients with either of these are usually anticoagulated.
while platelet counts and fibrinogen levels are low. The calf muscles of the leg normally act as a second
Causes of DIC include: heart, pumping venous blood against gravity back to
• Acute: obstetric complications, septicaemia, trauma, the heart. During periods of immobility this pumping
massive blood loss action is lost and stasis of blood occurs, increasing the
• Chronic: liver disease, malignancy. risk of VTE.
The management of DIC involves treatment of the
underlying disorder and supportive care with transfu-
sion of fresh frozen plasma, cryoprecipitate and platelets.
Changes within the walls
Heparin, activated protein C and antifibrinolytics, such of blood vessels
as aminocaproic acid, may also have a role. DIC is im- Factors such as smoking, hypercholesterolaemia, hyper-
mensely dangerous and requires specialist intervention. tension, infection and immune-mediated damage con-
tribute to endothelial injury and subsequent thrombus
THROMBOSIS formation.
69
Haemostasis
70
Thrombosis 6
71
Haemostasis
at a lower dose. The specific antidote to warfarin is and heparin-induced thrombocytopenia (HIT), which
vitamin K, which can be administered orally or is a rare but serious problem. The risk of complications
intravenously. If the overdose has resulted in severe is less for LMWH than for unfractionated heparin.
bleeding, prothrombin complex concentrate (PCC)
should be used.
Thromboprophylaxis
Heparin
Hospital inpatients and patients undergoing surgery
Heparin is a glycosaminoglycan that potentiates the ac- (especially obstetric and orthopaedic) are at a higher
tions of AT. Standard (unfractionated) heparin contains risk of VTE. Hospitals now require a VTE assessment
molecules ranging in weight from 5000 to 30,000 kDa. of all inpatients, taking into account mobility and
The different chain lengths affect both activity and clear- comorbidities. Strategies to prevent VTEs include good
ance, with the larger molecules being cleared more hydration, early mobilization, compression stockings
quickly. The activated partial thromboplastin time and LMWH.
(APTT) is used to monitor unfractionated heparin ther-
apy. Low-molecular-weight heparin (LMWH) has a
mean molecular weight of 5000 kDa. LMWH is moni-
tored only in renal failure and pregnancy. Monitoring Therapeutic fibrinolysis
is with an anti-Xa assay. LMWH differs from standard If a clot does occur fibrinolytic agents can be used. Fibri-
heparin because: nolytics are used in a life-threatening VTE, PE, MI and
• It has greater activity against FXa than thrombin CVA. They attempt to restore blood supply to an area
• It has reduced protein binding and clearance of the circulation that has been occluded by a fibrin clot.
• Interactions with platelets are reduced. There are different fibrinolytic agents available:
LMWHs are commonly used, as subcutaneous injec- • Streptokinase: derived from group A b-haemolytic
tion, in the acute management of DVT and PE. Warfarin streptococci. It binds to plasminogen to form a com-
therapy is often started within 2 days and heparin plex that can activate other plasminogen molecules.
stopped when the INR is > 2.0. LMWH is the anticoag- It is highly antigenic
ulant of choice for prophylaxis against venous throm- • Urokinase: derived from human kidney cells. It is a
bosis following surgery and is increasingly used as a tPA originally isolated in urine
prophylactic against DVT in non-surgical patients. • Recombinant tPA: synthesized from human cells. It
Long-term unfractionated heparin therapy can result is highly specific for plasminogen and has a short
in osteoporosis. Other complications include bleeding half-life of 2–6 minutes.
72
Blood transfusion 7
Objectives
73
Blood transfusion
reaction as a result of an incompatibility between donor Transfused blood must be ABO-compatible with the
and recipient blood. Adverse immunological reactions recipient’s blood, otherwise recipient antibody will
occur because there are a variety of antigens on the sur- cause agglutination and haemolysis of the transfused
face of red cells. Thus, when an individual is exposed to cells. For example, if group A red cells are given to a
red blood cells with different antigens (to which they are group O recipient, anti-A antibodies in the recipient’s
therefore not self-tolerant), they are attacked by the serum will destroy the donor cells.
immune system. The resultant reactions can be severe Ideally, ABO-identical blood is used; however, if this
and life-threatening. is not possible, compatible blood can be used. Blood
cells of group O are not affected by anti-A or anti-B an-
tibodies and can, therefore, be given to patients of any
blood group. Consequently, blood group O is referred
RED-CELL ANTIGENS to as the universal donor, although it should be borne
in mind that the serum of individuals with group O
The surfaces of red cells are covered with antigenic mol- blood will contain anti-A and anti-B antibodies. It is
ecules. Over 400 different groups of antigens have been always more desirable to use group-specific red cells
identified, although only some of these are clinically for transfusion. Conversely, AB individuals are universal
important in blood transfusion. recipients because they do not possess anti-ABO anti-
bodies and can receive blood of any ABO type.
ABO antigens
The ABO system consists of three allelic genes, A, B and Rhesus antigens
O, which code for sugar-residue transferase enzymes. Rhesus (Rh) antigens are stronger immunogens and the
The ABO antigen, known as the H antigen, is a glycopro- antibodies generated are clinically important.
tein or glycolipid with a terminal L-fructose: They are known as C, D and E, but the D antigen is the
• The O gene is amorphous, i.e. it has no effect on most important clinically; it is the D antigen that is referred
antigenic structure and leaves antigen H unchanged to when describing someone as ‘rhesus positive’ or ‘rhesus
• The group A gene product adds N-acetyl galactos- negative’. D antigen is the strongest immunogen.
amine to the H antigen The D antigen is coded for by the RhD gene. The pres-
• The group B gene product adds the sugar D-galactose. ence of just one RhD allele (written as ‘D’) results in the
The ABO gene has three alleles, corresponding to the D antigen being present. The lack of a RhD gene is writ-
three antigens. Genes coding for A and B antigens are ten as ‘d’. Thus, Rh positive individuals are DD or Dd,
both co-dominant. Inheritance of the three ABO alleles Rh negative individuals are dd. Approximately 85% of
can lead to six different genotypes and four possible Caucasians are Rh positive and 15% are Rh negative. In-
phenotypes (Fig. 7.1). terestingly, only 1% of individuals from Asia, and even
By 6 months of age, the immune system will have fewer people of African origin, are Rh negative.
been exposed to A- and B-like antigens in intestinal bac- Anti-D antibodies are only generated when a Rh
teria and food substances. IgM antibodies develop negative individual is exposed to Rh positive red cells
against A and/or B antigens, unless these antigens are pre- following transfusion or pregnancy. All anti-D anti-
sent on red cells (self-tolerance). Therefore, individuals bodies are IgG. Approximately 70% of Rh negative indi-
with neither A or B red-cell antigens (group O) will have viduals produce anti-D antibodies after receiving Rh
both anti-A and anti-B antibodies. Those with both A and positive blood and they will develop transfusion reac-
B red-cell antigens (group AB) will have neither antibody. tions when re-transfused with Rh positive blood. As well
as D positive individuals, those with C, c and E antigens
may have a haemolytic reaction after transfusion, which
Fig. 7.1 ABO blood groups is usually delayed rather than immediate.
Phenotype/red-cell Genotype Antibodies
antigens
RhD haemolytic disease of the newborn
O (44%) OO Anti-A and anti-B
If blood from a Rh positive fetus enters the circulation of
A (42%) AO or AA Anti-B an Rh negative mother, alloimmunization can occur.
B (10%) BO or BB Anti-A Small amounts of fetal blood are transferred during
the third trimester and at birth. Mothers develop anti-
AB (4%) AB None D IgG antibodies, which cross the placenta into the fetal
Percentages indicate the prevalence in the UK population. circulation during the course of the second pregnancy. If
the second fetus is Rh positive, the IgG antibodies
74
Cross-matching and blood transfusion 7
induce immune haemolysis of fetal red cells, which can antibodies to blood group antigens other than
result in hydrops fetalis. those of the ABO and Rh systems
– Screening cells and cell panels (to identify the an-
tigen against which the antibody is reacting)
Prevention of RhD haemolytic disease 3. Each unit of donor blood to be transfused is then
of the newborn tested against the patient’s serum to identify atypical
antibodies in the patient. This then makes that unit
Passive immunization is used to prevent maternal anti-
of donor blood unusable by other patients.
D antibody production. Therefore, all Rh negative preg-
nant women are given an intramuscular injection of Cross-matching normally takes under an hour but
anti-D IgG at 28 weeks’ gestation (and sometimes 34 can take longer if antibodies are present. Most hospitals
weeks depending on the preparation). If a Rh negative will only hold cross-matched blood for 24 hours.
mother gives birth to a Rh positive child she should Another pre-transfusion test is called ‘group and
recieve another dose within 72 hours of the birth. The save’. This is used when blood is not needed immedi-
injected antibody coats Rh positive fetal red blood cells, ately but may be needed in the near future. It involves
which are removed by the reticuloendothelial system testing the patient’s sample and storing it for 7 days.
(RES) before the mother produces her own anti-D anti- If, in that period, the patient needs a transfusion com-
bodies. Anti-D antibody should also be given to Rh neg- patible blood can be provided within 15 minutes.
ative mothers after all ‘sensitising events’, including
abortions, ectopic pregnancies and amniocentesis.
Emergency transfusions
HINTS AND TIPS During emergency situations patients often have not
Red-cell antigens other than rhesus D, such as C, Kell had a cross-match sample taken. If a patient needs
blood immediately a cross-match sample should be
and ABO incompatibility, can also cause haemolytic
taken and O negative blood given. There are exception-
disease of the newborn. ABO incompatibility may lead
ally rare circumstances, including the management of
to anaemia and jaundice in the newborn. It is usually neonatal emergencies, where whole blood is preferable.
short-lived and rarely requires therapy.
75
Blood transfusion
76
Cross-matching and blood transfusion 7
Other blood products • Multiple clotting factor deficiencies, e.g. severe liver
disease, warfarin overdose, massive transfusion and
Platelets thrombotic thrombocytopenic purpura where it is
Platelets are stored at room temperature (on an oscillat- used in plasma exchange
ing tray to prevent clumping) and have a half-life of 4–5 • Specific coagulation factor replacement where no
days. They can be obtained from a pool of 6–10 blood concentrate is available
donors or from a single donor via apheresis. Indications • Plasma loss (albumin solution is used in many cases,
for platelet transfusion include: e.g. burns).
• Patients who are bleeding and who have a platelet
count < 50 109/L
HINTS AND TIPS
• Following massive transfusion resulting in dilu-
tional thrombocytopenia Compatibility of plasma is the opposite of red cells, e.g.
• Patients with platelet dysfunction who are bleeding O plasma contains anti-A and anti-B antibodies so it
• Prophylactically in patients with thrombocytopenia should only be given to O recipients.
who are undergoing surgery or who have bone mar-
row failure.
Cryoprecipitate
Apheresis
Cryoprecipitate is the insoluble precipitate formed
Apheresis allows the removal of one specific component
when FFP is thawed at 4 C. It contains factors VIII,
of blood such as platelets. Blood withdrawn is separated vWF, factor XIII and fibrinogen, and is given to control
and the selected component taken out. The rest of the bleeding associated with defects thereof. Cryoprecipi-
blood is then returned to the donor. The time this takes tate can also be of use in chronic renal failure, advanced
depends on the blood component required and is usually liver failure, disseminated intravascular coagulation and
in the region of 1–2 hours. following massive blood transfusion.
Importantly, since most of the blood taken is
returned, a large amount of the select component can
be taken. This means that the recipient is exposed to
Clotting factor concentrates
products from fewer donors, and thus the chance of Specific clotting factor concentrates can be given to pa-
adverse reactions and infections is reduced. tients with clotting factor deficiencies (see Chapter 6).
White cells
Fresh-frozen plasma Granulocyte concentrates can be given to infected neu-
Fresh-frozen plasma (FFP) contains albumin, immuno- tropenic patients not responding to antibiotic therapy,
globulins and all the clotting factors. Indications for FFP but this is rare because of the risk of cytomegalovirus
transfusion include: (CMV) transmission.
77
Intentionally left as blank
Principles of immunology 8
Objectives
79
Principles of immunology
80
An overview of immunology 8
B lymphocytes T lymphocytes
• Plasma cells • T helper cells
(producing (CD4+)
Fig. 8.2 Components of the innate and adaptive immune antibodies)
• Cytotoxic
systems T cells (CD8+)
81
Principles of immunology
82
The innate immune system 9
Objectives
Innate defences can be classified into three main groups: • Competing with pathogenic bacteria for nutrients
1. Barriers to infection and attachment sites
2. Cells • Production of antibacterial substances.
3. Serum proteins and the complement system. The use of antibiotics can disrupt the normal flora,
making pathogenic organisms more likely to cause
disease.
BARRIERS TO INFECTION
CELLS OF INNATE IMMUNITY
Physical and mechanical
The cells of the innate immune system consist of:
Skin and mucosal membranes act as physical barriers to
the entry of pathogens. Tight junctions between cells • Phagocytes
prevent the majority of pathogens from entering the • Degranulating cells
body. The flushing actions of tears, saliva and urine pro- • Natural killer cells.
tect epithelial surfaces from colonization. High oxygen
tension in the lungs, and body temperature, can also
inhibit microbial growth.
Phagocytes
In the respiratory tract, mucus is secreted to trap Phagocytes (macrophages and neutrophils) engulf and
microorganisms. They are then mechanically expelled by: then destroy pathogens. Macrophages are long-lived
• Beating cilia (mucociliary escalator) sentinel cells stationed at likely sites of infection; upon
• Coughing infection they release cytokines that recruit the shorter-
• Sneezing. lived but more actively phagocytic neutrophils.
83
The innate immune system
G-CSF. A high neutrophil count is part of the acute • MHC and B7 molecules (to activate the adaptive
phase response (see below). Neutrophils can be acti- immune response).
vated and recruited either by IL-8 and TNF secreted by Macrophages can be activated by:
macrophages, or by IL-17 secreted by T cells of the adap-
• Cytokines such as IFN-g
tive immune system.
• Contact with complement or products of blood
coagulation
• Direct contact with the target through PRM
HINTS AND TIPS
stimulation.
Neutropenic individuals are at an increased risk of Following activation, macrophages become more
serious bacterial infections. These patients should be efficient phagocytes and have increased secretory and
treated early and aggressively to reduce the chance of microbicidal activity. They also stimulate the adaptive
sepsis. immune system by expressing higher levels of MHC
class II molecules and secreting cytokines.
In comparison to neutrophils, macrophages:
• Are longer-lived (they do not die after dealing with
Mononuclear phagocyte system pathogens)
Monocytes and macrophages comprise the other major • Are larger (diameter 25–50 mm), enabling phagocy-
group of phagocytic cells. Monocytes account for tosis of larger targets
5–10% of the white cell count and circulate in the blood • Move and phagocytose more slowly
for approximately 8 hours before migrating into the tis- • Retain Golgi apparatus and rough endoplasmic retic-
sues, where they differentiate into macrophages; these ulum and can therefore synthesize new proteins, in-
macrophages can live for decades. Some macrophages cluding lysosomal enzymes and secretory products
become adapted for specific functions in particular tis- • Can act as antigen-presenting cells (APCs).
sues, e.g. Kupffer cells in the liver and glial cells in the
brain. Monocytes also differentiate into osteoclasts
and microglial cells. Killing by phagocytes
In comparison to monocytes, macrophages: The process of phagocytosis allows cells to engulf matter
• Are larger and longer-lived that needs to be destroyed. The cell can then digest the
• Have greater phagocytic ability material in a controlled fashion before releasing the con-
• Have a larger repertoire of lytic enzymes and secre- tents. The process of phagocytosis is shown in Figure 9.1.
tory products.
Macrophages phagocytose and destroy their targets Natural killer (NK) cells
using similar mechanisms to neutrophils. The rate of
phagocytosis can be greatly increased by opsonins such NK cells utilize cell-surface receptors to identify virally
as IgG and the complement protein C3b (neutrophils modified or cancerous cells. NK cells do not require
and macrophages have receptors for these molecules, T cell help to kill pathogens, although they are more
which may be bound to the antigenic surface). Intracel- effective when T helper cells secrete IFN-g. One set of
lular pathogens, e.g. Mycobacterium, can prove difficult receptors activates NK cells, initiating killing; others
for macrophages to kill. They are either resistant to de- inhibit the cells:
struction inside the phagosome or can enter the macro- • Activating receptors include calcium-binding
phage cytoplasm. For the immune system to act against C-lectins, which recognize certain cell-surface carbo-
these pathogens, T cell help is required. hydrates. Because these carbohydrates are present on
In addition to phagocytosis, macrophages can secrete the surface of normal host cells, a system of inhibi-
a number of compounds into the extracellular space, tory receptors acts to prevent killing
including cytokines (TNF, IL-8 and IL-1) and hydrolytic • Killer inhibitor receptors (KIRs), members of the im-
enzymes. Macrophages are also able to process and pre- munoglobulin gene superfamily, are specific for
sent antigen in association with class II MHC molecules. class I MHC molecules. Human NK cells also express
Macrophages express a wide array of surface mole- an inhibitory receptor (a heterodimer CD94:NKG2)
cules including: that detects non-classical class I MHC molecules.
• Fc-gRI–III (receptors for the Fc portion of IgG, types NK cells can also destroy antibody-coated target cells
I–III) and complement receptors irrespective of the presence of MHC molecules, a process
• Pattern recognition molecules (PRMs) known as antibody-dependent cell-mediated cytotoxic-
• Cytokine receptors, e.g. TNF-a and interferon-g ity. This occurs because killing is initiated by cross-
(IFN-g) linking of receptors for the Fc portion of IgG1 and IgG3.
84
Cells of innate immunity 9
Pathogen
85
The innate immune system
TNF receptor
6
Intracellular
signalling
Apoptosis
Target cell
Antigen
Mast cell
Acute phase proteins
The acute phase response is a systemic reaction to
Ca2
+ infection or tissue injury, where macrophages release
IgE
cytokines IL-1, IL-6 and TNF; these cytokines reach
the liver through the circulation. The liver responds
FcεRI by increasing its production of certain plasma proteins.
receptor These so-named acute phase proteins (APPs) are:
• C-reactive protein
• Serum amyloid A
• Complement components
• Fibrinogen
Degranulation • a1-Antitrypsin
• Caeruloplasmin
Fig. 9.3 Activation of mast cells by immunoglobulin E (IgE). • Haptoglobulin.
IgE, produced by plasma cells, binds via its Fc domain to The change in plasma concentration is accompanied
receptors on the mast cell surface. Cross-linking of these by fever, leucocytosis, thrombocytosis, catabolism of
receptors by an antigen causes an influx of calcium ions (Ca2þ)
muscle proteins and fat deposits. Synthesis of APPs is
into the cell. Calcium ions cause a rapid degranulation of
inflammatory mediators from the mast cell.
enhanced by cytokines secreted by macrophages and
endothelial cells. The two main APPs are C-reactive
surface (as well as host tissues) and cationic protein acts protein (CRP) and serum amyloid A (SAA).
as a neurotoxin, damaging the parasite’s nervous tissue. The extent of the rise in the plasma concentration of
different APPs varies:
• Increased 50% above normal levels: caeruloplasmin
SOLUBLE PROTEINS • Increased several fold above normal levels: a1-
glycoprotein, a1-proteinase inhibitor, haptoglobu-
The soluble proteins that contribute to innate immunity lin, fibrinogen
(Fig. 9.5) can be divided into antimicrobial serum • 100–1000-fold increase: CRP, SAA.
agents and proteins produced by cells of the immune The concentration of other plasma proteins, most
system. notably albumin and transferrin, falls.
86
Soluble proteins 9
87
The innate immune system
88
Soluble proteins 9
Activated C4 and C2
C3 convertase
Common pathway
dies via osmotic lysis. The MAC appears to be the only • Decay accelerating factor: this accelerates decay of
way the immune system has of killing one family of bac- C3 convertase
teria, the Neisseria (a family that includes meningococ- • C1 inhibitor: inhibits C1
cus and gonococcus). • Factor I and membrane cofactor protein: cleave C3b
The cleaved fragments C3a and C5a are anaphylotox- and C4b
ins which are chemoattractant for other immune cells • CD59 (protectin): prevents the formation of the
which follow the concentration gradient to the infec- membrane attack complex (MAC).
tion. Complement also opsonizes bacteria as macro-
phages have receptors for C3b. Hereditary angioedema
These functions are summarized in Figure 9.7.
Deficiency in even one of these inhibitory components
can result in significant disease. For example, deficiency in
Inhibitors of complement C1 inhibitor results in hereditary angioedema (HAE; see
Fig. 9.8) types I and II, conditions where there is activation
As we have seen, complement can activate spontane-
ously through the alternative pathway. Complement of the classical pathway with minimal stimulation. This is
is regulated by inhibitory molecules which are necessary of particular significance if the stimulation is in the larynx
to prevent complement-mediated damage of healthy as it can lead to uncontrolled swelling. This laryngeal
cells. There are nine complement inhibitors which act oedema can obstruct the airway and without infusion of
at various levels throughout the pathway: C1 inhibitor can prove fatal. The clinical picture resembles
• Membrane cofactor protein, complement receptor anaphylaxis (see Chapter 12) and patients are often
type 1, C4b-binding protein and factor H: these pre- treated with adrenaline, which has no effect.
vent assembly of C3 convertase
89
The innate immune system
90
The adaptive immune system 10
Objectives
91
The adaptive immune system
Plasma
membrane
92
The immunoglobulin domain 10
Peptide-binding cleft
Plasma membrane
Disulphide bond
Fig. 10.4 Structure of class I and class II major histocompatibility molecules (MHC). The peptide binding cleft of a class I
molecule is also shown as seen from above.
MHC restriction molecules are found on nearly all nucleated cells. Class
I MHC molecules present endogenous antigens, such as
T cells are only able to recognize antigen in the context
those found in cells infected by viruses or intracellular
of self-MHC molecules (self-MHC restriction). CD8þ
bacteria. Thus CD8þ T cells recognize virally altered cells
T cells recognize antigen only in association with class
and destroy them (see p. 112). Class II MHC molecules
I MHC molecules (class I MHC restricted). CD4þ cells
present exogenous antigens that may have been phago-
recognize antigen only in association with class II
or endocytosed into intracellular vesicles.
MHC molecules (class II MHC restricted).
Professional antigen-processing cells process and pre-
sent antigen to CD4þ T cells in association with class II
Antigen processing molecules. These cells express high levels of class II
and presentation MHC molecules. Professional APCs include:
MHC molecules do not present whole antigen, the • Dendritic cells, including Langerhans’ cells
antigen being degraded into peptide fragments before • Macrophages
binding can occur. There are different pathways of • B cells.
antigen processing for class I and class II MHC; A summary of the differences between class I and
these pathways are summarized in Figure 10.5. Class I class II MHC molecules is shown in Figure 10.6.
93
The adaptive immune system
MHC–antigen
complex Invariant chain
Peptides
Antigen
Rough ER
Ribosome
Proteosome
Nucleus
Fig. 10.6 Differences between class I and class II major histocompatibility molecules
Class I Class II
Size of bound 8–9 amino acids 13–18 amino acids (binding cleft more open)
peptide
Peptide from Cytosolic antigen Intravesicular or extracellular antigen
Expressed by All nucleated cells, especially T cells, B cells, B cells, macrophages, other antigen-presenting
macrophages, other antigen-presenting cells, cells, epithelial cells of the thymus, activated
neutrophils T cells
Recognized by CD8þ T cells CD4þ T cells
Structure and function The role of CD4 and CD8 in antigen–receptor binding is
shown in Figure 10.7.
of CD4 and CD8
CD4 and CD8 are ‘accessory’ molecules that play an
important role in the T cell–antigen interaction. CD4 GENERATION OF ANTIGEN
and CD8 have two important functions: RECEPTOR DIVERSITY
• They bind MHC class II and class I molecules, respec-
tively, thereby strengthening the T cell–antigen There are approximately 208 possible antigens, each
interaction requiring a corresponding receptor. The human ge-
• They function as signal transducers. nome contains only 30,000 genes and so each receptor
94
Generation of antigen receptor diversity 10
Plasma
membrane
Signalling
molecule
TCR–CD3 complex
cannot be coded by a single gene. Instead this diversity Rearrangement is completed and functional Ig chains
is achieved by genetic recombination, a process where are produced before the B cell encounters antigen
segments of information are cut and pasted from (Fig. 10.8).
the gene. The presence of multiple V, D (heavy chain only) and
T cell receptor and immunoglobulin are the only J gene segments, and the apparently random selection of
genes to undergo genetic recombination. these segments, generates considerable diversity, which
can be calculated (Fig. 10.9).
HINTS AND TIPS A similar process occurs in T cells: a- and g-chain var-
iable domains have V and J segments; b- and d-chains
Rearrangement of gene segments allows antibodies have V, D and J segments.
with an immense variety of specificity to be produced
from a relatively small amount of DNA.
Junctional diversity
The formation of junctions between the various gene
segments produces an opportunity for increased diver-
sity, where nucleotides are added or subtracted at
Genetic rearrangements random to form the joining segments.
Before genetic recombination occurs, we say the gene Junctional flexibility and N-nucleotide addition
segments are in germline configuration. Rearrangement When exons are spliced, there are slight variations in
only occurs in the variable domain (those that code for the position of segmental joining. In addition, up to
the active site) as the other segments of the receptor re- 15 nucleotides can be added to the D–J and the V–DJ
main constant. Each variable domain is encoded by a joints. This occurs only in heavy chains and is catalysed
random combination of one of each of the V, D (heavy by terminal deoxynucleotidyl transferase (TdT).
chain only) and J exons (nucleic acid sequences). Fol- Both junctional flexibility and N-nucleotide addition
lowing genetic rearrangement, one exon remains which can disrupt the reading frame, leading to non-functional
codes for a variable domain. The C exons encode the rearrangements. However, formation of productive rear-
constant regions. Heavy-chain C gene segments are clus- rangements increases antibody diversity. The V–J, V–DJ
ters of exons, each of which encodes either a domain or and VD–J joints fall within the antigen-binding region
a hinge region of the constant region. of the variable domain. Therefore, diversity generated
Following rearrangement, the clonal progeny of at these joints will impact on the antigen specificity of
each B cell will produce Ig of a single specificity. the Ig molecule.
95
The adaptive immune system
DJ joining
5' 3'
VH1 VH2 VHn D1 D2 JH2 JH3 JH4 JH5 JH6 C C␦ C␥3 C␥1 C␣1 C␥2 C␥4 C⑀ C␣2
V joins with DJ
5' 3'
VH1 D2 JH2 JH3 JH4 JH5 JH6 C C␦ C␥3 C␥1 C␣1 C␥2 C␥4 C⑀ C␣2
Transcription
Translation
Fig. 10.8 Rearrangement of the heavy chain is similar to that of the light chain, although the join between D and J segments occurs
first. In an unstimulated B cell, the heavy-chain mRNA that is transcribed contains both the Cm and Cd segments. The mRNA can
be differentially spliced such that both IgM and IgD will be produced. They will both exhibit the same antigen binding specificity.
Given the fact that light chain can associate with any heavy chain, and from the number of gene segments present in germline DNA, it is possible
to calculate the number of different molecules that can be produced. The extent of the contribution of junctional flexibility, N-nucleotide
addition and somatic hypermutation is not known but will be significant.
Somatic hypermutation mutations decrease the antibody’s specificity for the an-
Somatic hypermutation is a process that increases the af- tigen and apoptosis is stimulated in these cells; others
finity of antibody for its antigen and is also called affin- result in antibody of increased specificity—these are
ity maturation. B cells that are dividing by mitosis to positively selected for. Antibodies produced later in
increase in number in order to combat infection are the primary immune response, and in the secondary im-
allowed to undergo mutation in their variable domain mune response, will therefore have an increased affinity
(the only cells in the body permitted to do so). Some for antigen.
96
Humoral immunity 10
The TCR does not exhibit somatic hypermutation. proliferation, variable regions of the immunoglobulin
Diversity is generated only in developing T cells, which genes undergo somatic hypermutation. This process
can be deleted if they are either self-reactive or non- occurs in the germinal centre of the follicle. Follicular
functional. dendritic cells present antigen, to which the B cells
with the highest affinity will bind. This causes the ex-
pression of bcl-2, which prevents B cells undergoing
Class switching apoptosis. Therefore, the highest-affinity clones are
This is the process whereby a single B cell can produce positively selected. In order for B cells to produce an-
different classes of Ig that have the same specificity. The tibody, they require help from T cells. Activated T
mechanism is not well understood but involves ‘switch helper cells provide the help needed by producing cy-
sites’—DNA sequences located upstream from each tokines (IL-2, IL-4, IL-5, and IL-6). This acts as a further
heavy chain C gene segment (except Cd). Possible method of regulation within the immune system, as
mechanisms include: both B cells and T cells need exposure to the offending
• Differential splicing of the primary transcript (see antigen in order for a response to be evoked. An over-
Fig. 10.8) view of clonal selection of B cells is given in
• A looping out and deletion of intervening heavy Figure 10.11.
chain C gene segments (and introns)
• Exchange of C gene segments between
chromosomes. Structure and function of antibody
This process underlies the class switch from IgM in The structure of immunoglobulin is shown in
the primary response to IgG, IgA or IgE in the secondary Figure 10.12.
response. Cytokines are important in controlling the Immunoglobulin molecules (using IgG as an exam-
switch. ple) are composed of two identical heavy and two
Recognition molecules and their diversity are impor- identical light chains, linked by disulphide bridges. The
tant for the generation of a specific, adaptive immune light chains consist of one variable and one constant
response. The adaptive immune response can be domain, while the heavy chain contains one variable
humoral or cell-mediated. and three constant domains. Digestion of IgG with
papain (papaya protinase 1, an enzyme derived from
papayas) produces two types of fragment:
1. Two Fab fragments (bind antigen) consisting of the
HUMORAL IMMUNITY light chain and two domains of the heavy chain
(denoted VH and CH1)
B cells and antibody production 2. One Fc fragment (binds complement) consisting of
The humoral immune response is brought about by the remainder of the heavy chain (CH2 and CH3).
antibodies, which are particularly efficient at eliminat-
ing extracellular pathogens. Antigen can be cleared
from the host by a variety of effector mechanisms, The light chain
which are dependent on antibody class or isotype The light chain is comprised of a variable, amino (N)
(see p. 99): terminal domain and a constant domain at the carboxy
(C) terminal.
• Activation of complement, leading to lysis or opso- The constant region can be k or l, but both light
nization of the microorganism chains within an Ig molecule will be the same; 60%
• Antibody-dependent cell-mediated cytotoxicity of human light chains are k.
(ADCC)
• Neutralization of bacterial toxins and viruses
• Mucosal immunity (IgA-mediated) The heavy chain
• Degranulation of mast cells – (IgE and IgG The heavy chain has a variable domain attached to sev-
mediated). eral constant domains. There are five classes of immu-
Activated and differentiated B cells, known as plasma noglobulin (Ig) in humans: IgG, IgA, IgM, IgE and
cells, produce antibodies. An overview of B cell activation IgD. The heavy chain determines the immunoglobulin
is given in Figure 10.10. class. The heavy chain can be g (IgG), a (IgA), m (IgM),
B cells are activated within follicles found in sec- E (IgE) or d (IgD). IgG, IgA and IgD have three constant
ondary lymphoid structures, e.g. lymph nodes and domains with a hinge region; IgM and IgE have four
spleen, only if they encounter specific antigen. During constant domains but no hinge region.
97
The adaptive immune system
The variable domain and IgD are monomeric, secreted IgA (sIgA) is usually
Each variable domain exhibits three regions that are present as a dimer, and secreted IgM as a pentamer.
hypervariable. The hypervariable regions on both light The sIgA molecule is made up of two IgA monomers:
and heavy chains are closely aligned in the immunoglob- a J chain and a secretory piece. The IgA dimer (J
ulin molecule. Together, they form the antigen-binding chain) is produced by submucosal plasma cells and
site and therefore determine the molecule’s specificity. enters the mucosal epithelial cell via receptor-
The hinge region mediated endocytosis, binding to the poly-Ig receptor.
The hinge allows movement and therefore greater Having passed from the basal to the luminal surface
interaction with epitopes. The hinge region is also the of the epithelial cell, the IgA dimer is secreted across
site of the interchain disulphide bonds. the mucosa, with part of the poly-Ig receptor (the se-
cretory piece) still attached.
Classes of antibody
The different properties of the immunoglobulin clas-
ses are shown in Figure 10.13. Different Ig classes The functions of antibodies
and subclasses are specific to each species. IgG, IgE The functions of Igs are shown in Figure 10.14.
98
Humoral immunity 10
T cell
Clonal expansion
99
The adaptive immune system
Lymphadenopathy
C1 C1
Lymph nodes can become enlarged (lymphadenopa-
thy) for several reasons, including infection. Causes of
Disulphide bond V Variable domain
lymphadenopathy are outlined on page 7.
N amino terminus C Constant domain
L or Light chain
C1 carboxy terminus
H or Heavy chain
HINTS AND TIPS
Fig. 10.12 Structure of IgG. Immunoglobulins are composed Lymphadenopathy can be a sign of infection.
from two identical light and two identical heavy chains. Understanding the drainage of lymph can lead you to
The chains are divided into domains, each of which is an the source of infection.
immunoglobulin fold. The variable domains form the
antigen-binding site. Digestion of the immunoglobulin
molecule with papain produces an Fc portion (which binds
complement) and two Fab portions (which bind antigen).
Mucosal-associated lymphoid
tissue (MALT)
Lymph nodes act as sites for initiation of the adaptive MALT consists of unencapsulated subepithelial lym-
immune response. Antigen is sampled, processed and phoid tissue found in the gastrointestinal, respiratory
presented by several professional APCs (macrophages and urogenital tracts (Fig. 10.16).
and dendritic cells). It can be subdivided into:
• Organized lymphoid tissue, e.g. tonsils, appendix,
Lymphocyte recirculation Peyer’s patches
• Diffuse lymphoid tissue located in the lamina
Lymphocytes move continuously between blood and
propria of intestinal villi and lungs.
lymph. Efferent lymph contains more lymphocytes than
afferent lymph because:
• Antigenic challenge results in stimulation and prolif- Organized lymphoid tissue
eration of lymphocytes
• Lymphocytes enter the lymph node directly from Respiratory tract
blood. MALT in the nose and bronchi includes the:
Lymphocyte recirculation is essential for a normal • Lingual, palatine and nasopharyngeal tonsils
immune response (Fig. 10.15). Approximately 1–2% • Adenoids
of the lymphocytic pool recirculates each hour. This • Bronchial nodules.
increases the chances of an antigenically committed The respiratory system is exposed to a large number
lymphocyte encountering complementary antigen. of organisms every day, most of which are cleared by the
Lymphocytes tend to recirculate to similar tissues. mucociliary escalator. Microorganisms that are not re-
For example, an activated lymphocyte that has migrated moved are presented by dendritic cells in the bronchi
from the skin to a local lymph node is most likely to and stimulate germinating centres.
100
Humoral immunity 10
Physical properties
Molecular weight 150 300 900 190 150
(kDa)
Serum concentration 13.5 3.5 1.5 0.0003 0.03
(mg/mL)
Number of subunits 1 2 5 1 1
Heavy chain g A m e d
Subclasses 4 2 — — —
Biological activities
Present in secretions ✗ ✓ ✓ ✗ ✗
Crosses placenta ✓ ✗ ✗ ✗ ✗
Complement fixation ✓ ✓ ✓✓✓ ✗ ✗
Binds phagocytic ✓ ✗ ✓ ✗ ✗
receptors
Binds mast cell ✓ ✗ ✗ ✓ ✗
receptors
Other features
Main role Main circulatory Major Ig in Main Ig in Allergy and Expressed on naı̈ve
Ig for secondary secretions primary immune antiparasitic B cell; function not
immune response response response known
101
The adaptive immune system
Lymph node
Afferent
lymphatic
tissues
Bronchus
associated
CELL-MEDIATED IMMUNITY
Cell-mediated immunity is mediated by T lymphocytes,
macrophages and NK cells. The cell-mediated immune
system is involved in the elimination of:
• Intracellular pathogens and infected cells (mainly
viruses, mycobacteria and fungi)
Peyer's • Tumour cells
patches
diffuse tissue • Foreign grafts.
The thymus plays an important role in cell-mediated
immunity because it is the site of T cell maturation.
Urogenital
lymphoid
tissue
102
Cell-mediated immunity 10
recognize self-MHC, and negatively select those T cells migrate towards the medulla where they encounter spe-
that recognize self-antigen with self-MHC. cialized epithelial cells. These cells express MHC class I
The thymus is a gland with two lobes, located in the and class II molecules. T cells that are able to bind self-
anterior part of the superior mediastinum, posterior to MHC to some extent will proliferate, resulting in posi-
the sternum and anterior to the great vessels and upper tive selection. The thymic epithelial cells have a unique
part of the heart. It can extend superiorly into the root of mechanism for expressing many of the body’s proteins
the neck and inferiorly into the anterior mediastinum. It (e.g. insulin) and peptides from these proteins are dis-
receives its blood supply from the inferior thyroid and played on MHC class I and class II molecules. T cells
internal thoracic arteries. Each lobe is surrounded by which recognize this self-antigen can be forced to un-
a capsule and is divided into multiple lobules by fibrous dergo apoptosis—so-called negative selection. A much
septa known as trabeculae. Each lobule is divided into smaller and more mature group of thymocytes survives
two regions (Fig. 10.18): to enter the medulla. Thymocytes continue to mature in
• An outer cortex the medulla and eventually leave the thymus, via post-
• An inner medulla. capillary venules, as mature, antigen-specific, immuno-
competent T cells. In total, only 1–5% of thymocytes in
Immature thymocytes (T cell progenitors) enter the
the thymus reach maturity, the remainder undergoing
thymus gland via the cortex, where they rapidly prolif-
programmed cell death (apoptosis). The T cells which
erate and rearrange their T cell receptor genes. They then
103
The adaptive immune system
Ectobranchial
canal
104
Cell-mediated immunity 10
Fig. 10.20 Differences between the T helper 1 (Th1), T helper 2 (Th2) and T helper 17 (Th17) cell subsets
Cytokines Th1 cells Th2 cells Th17 cells
secreted IL-2, IFN-g, TNF-b IL-4, IL-10 IL-17
Functions • Responsible for classical cell-mediated • Promote B cell activation • Promote
immunity reactions such as delayed-type • Involved in allergic neutrophil
hypersensitivity and cytotoxic T cell activation diseases and responses activation and
• Involved in responses to intracellular patho- to helminthic infections migration
gens, for example viruses, some protozoa • Involved in responses to • Involved in
and fungi and most bacteria extracellular pathogens, responses to
• Activate macrophages mostly bacteria bacteria and
fungi
Most Th cells are CD4þ and can be divided into five Development of T cells
subsets on the basis of the cytokines they secrete:
T cell precursors are produced in the bone marrow and
1. Th0 are transported to the thymus for development and mat-
2. Th1 uration. The aim of T cell development and maturation
3. Th2 is to select T cells with receptors that can recognize
4. Th17 foreign antigens in conjunction with self-MHC. Cells
5. Treg. with non-functioning receptors or that are strongly
Th0 cells arise as a result of initial short-term stimula- self-reactive are destroyed (Fig. 10.21).
tion of naı̈ve T cells; they are capable of secreting a broad
spectrum of cytokines. Prolonged stimulation results in
the emergence of Th1 and Th2 subsets. The cytokines re- Positive selection
leased by the Th1 and Th2 subsets modulate one an- Positive selection occurs in the thymic cortex. T cells
other’s secretion. The different cytokine profiles of the that are capable of binding self-MHC are allowed to
Th1, Th2 and Th17 subsets reflect their different immu- live, i.e. they are positively selected for, and T cells that
nological functions (Fig. 10.20). do not recognize self-MHC die. Furthermore, T cells
Most immune responses involve more than one that interact with MHC class I lose their CD4 (they
subset of T cells. For example staphylococcus (an ex- are now CD8 T cells) and T cells that interact with
tracellular bacterium) stimulates both Th2 and Th17 MHC class II lose their CD8 (becoming CD4 T cells);
responses. On the other hand, some responses this is MHC restriction. T cells that do not interact with
become very polarized. For example, the immune the MHC molecules undergo apoptosis, as they do not
system relies almost exclusively on Th1 cells to re- receive a protective signal as a result of the TCR–MHC
spond to mycobacterium tuberculosis, an intracellular interaction.
pathogen.
The fifth type of helper T cell has two main regulatory Negative selection
roles. The first is to dampen down the immune response T cells that are positively selected, but have high affinity
once an infection has been brought under control. The for MHC molecules and self-antigen, undergo negative
second is to regulate self-reactive T cells which have selection. Because thymic epithelial cells express many
managed to escape negative selection in the thymus. different proteins from around the body, this mecha-
Their action is via cytokines, including transforming nism destroys most self-reactive T cells.
growth factor-b (TGF-b) and IL-10.
105
The adaptive immune system
CD4 T
CD8
Cells move to periphery
CD4
CD40 CD40 ligand
CD8
‘Double positive’
(CD8 CD4) cells
MHC TCR
T ␣-TCR
Once T cells are activated they produce a wide range
CD3 of molecules with several functions. These are primarily
MHC-restricted, self-tolerant T cells cytokines, which may be pro- or anti-inflammatory
(see Fig. 10.20) or involved in activation of other
CD4 ␣-TCR CD8 ␣-TCR immune cells.
CD3 CD3
T T Superantigens
T cells can be activated in a non-specific fashion by
Cells move to periphery Cells move to periphery
superantigens. Superantigens cross-link between the
V-b domain of the TCR and a class II MHC molecule
106
Cell-mediated immunity 10
107
Intentionally left as blank
The functioning immune
system 11
Objectives
109
The functioning immune system
110
Response to tissue damage 11
Activated macrophage
Antigen
presentation
+ IL-12
IFN-γ Persistence
of stimulus
• Collagen synthesis via growth factors (e.g. PDGF) TNF-a is needed for granuloma formation and main-
and cytokines (IL-1, TNF-a) tenance. Interferon-g (IFN-g), released by activated T
• Remodelling via collagenases cells, causes macrophage transformation into epithelioid
• Simulation of T cell activity by secretion of IL-12. and multinucleate giant cells (which arise from the fusion
Lymphocytes and plasma cells are also present at the of several macrophages). The granuloma is surrounded
site of inflammation. In the case of chronic infections, by a cuff of lymphocytes and the migration of fibroblasts
both macrophages and T cells are required to control infec- results in increased collagen synthesis. Caseous necrotic
tion. An overview of chronic inflammation is given in areas (dry, ‘cheese-like’ white mass of degenerated tissue)
Figure 11.2. might be present in the centre of a granuloma.
The nature of the damaging stimulus determines the
type of granuloma formed. Inert particles (e.g. silica in
the lungs) are predominantly surrounded by macro-
Inflammation in disease phages. Microorganisms such as M. tuberculosis (which
Inflammation is intended to protect the host but can, causes tuberculosis) induce a persistent, delayed-type hy-
under certain circumstances, prove destructive. Anti- persensitivity (DTH) response, resulting in granuloma
genic persistence results in the continued activation formation in the lung and possibly leading to cavitation.
and accumulation of macrophages. This leads to the for- The granuloma formed is characterized by focal accumu-
mation of epithelioid cells (slightly modified macro- lation of lymphocytes and macrophages. Phagocytosis of
phages) and granuloma formation (Fig. 11.3). mycobacteria is not usually effective because the
111
The functioning immune system
Interferon
Interferons (IFNs) are produced by virally infected cells.
IFN-a and IFN-b act on neighbouring uninfected cells
by inhibiting transcription and translation of viral pro-
teins. IFN-g activates macrophages and natural killer
(NK) cells and enhances the adaptive immune response
by upregulating expression of major histocompatibility
complex (MHC) class I and class II molecules.
112
Immune response to pathogens 11
NK cell
Opsonization
+ +
Antibody
+
Macrophage
ADCC cytotoxicity
Opsonization
Th2 and complement
activation
Protein synthesis
CD4+ T cell
+
Th1 Interferons
+
MHC
+
Fig. 11.4 The immune response to viruses. Interferons, produced by virally infected cells, have three important actions. Interferon-a
and interferon-b induce an antiviral state in neighbouring cells (inhibition of viral transcription and translation). Interferon-g
activates macrophages and natural killer (NK) cells and upregulates major histocompatibility complex (MHC) molecules. NK cells kill
virally infected cells either by detecting the absence of MHC class I molecules or by antibody-dependent cell-mediated cytotoxicity
(ADCC). Macrophages phagocytose opsonized free virus and cell fragments, and produce further interferon. CD8þ (cytotoxic)
T cells sense viral peptides presented by MHC class I molecules and destroy the cell. CD4þ (helper) T cells help to activate
macrophages and are involved in the generation of antibody and cytotoxic T cell responses.
and the virus even when it is latent. Mechanisms that some bacteria enter host cells. Different immune mech-
prevent normal effector functions from being carried anisms operate, depending on whether the bacteria are
out primarily involve down regulation of MHC class I extracellular or intracellular.
expression. However, viruses can also interfere with
IFN or produce inhibitory cytokines. Infection of lym-
phocytes, and their death, reduces the ability of the im-
Extracellular bacteria
mune system to combat viral infection. Humoral immunity to extracellular bacteria
Complement
Immune response Bacteria activate complement via the lectin or alterna-
tive pathways. Activated complement products play a
to bacterial infection role in the elimination of bacteria, especially C3b (an
Bacteria are prokaryotic organisms. Their cell mem- opsonin), C3a and C5a (anaphylatoxins that recruit leu-
brane is surrounded by a peptidoglycan cell wall. Many cocytes), and the membrane attack complex (MAC),
bacteria also have a capsule of large, branched polysac- which can perforate the outer lipid bilayer of Gram-
charides. Bacteria attach to cells via surface pili, but only negative bacteria.
113
The functioning immune system
and are often immunosuppressive. They have complex Immune response to worms
lifecycles, with several different stages, and, therefore,
present the immune system with a variety of challenges. Multicellular parasites and worms pose a different prob-
Protozoal infection is often chronic, as the immune sys- lem to the immune system, as they are too large to be
tem is not very efficient at dealing with these organisms. phagocytosed by macrophages and neutrophils. These
Most of the pathology of protozoal disease is caused by worms tend to live on mucosal surfaces, and the immune
the immune response. system tries to dispose of these parasites by facilitating
their expulsion. The immune system does this by secret-
ing toxic chemicals onto mucosal surfaces, stimulating an
increase in mucus secretion and smooth muscle contrac-
Humoral immunity against protozoa tion, which together result in expulsion of the worm.
Complement and antibody are important during the Mast cells are stationed in tissues and have a similar
extracellular stage of infection. This opsonizes the pro- sentinel purpose, with respect to worm infection, as that
tozoa and can cause lysis or prevent infection. performed by macrophages for other types of infection.
Mast cells contain preformed granules and, when they
recognize parasitic infection through cross-linkage of
IgE or possibly Toll-like receptors, they degranulate, re-
Cell-mediated immunity against protozoa
leasing their preformed granules and other rapidly syn-
• Phagocytosis by macrophages, monocytes and neu- thesized chemicals onto the parasite. They also release
trophils is an important part of the immune re- proinflammatory cytokines that recruit eosinophils
sponse against protozoa and basophils.
• CD4þ T cells are activated in response to protozoal Mast cell preformed granules contain:
infection. T helper 1 cytokines, e.g. IL-2, IFN-g,
• Histamine: causes smooth muscle in the walls of the
TNF-b, are considered protective
gut to contract (expel the worm) and smooth muscle
• Cytotoxic CD8þ T cells are important in destroying pro-
of blood vessels to relax
tozoa that replicate within cells, e.g. the sporozoite
• Proteolytic enzymes: activate the complement sys-
stage of Plasmodium falciparum (which causes malaria)
tem including anaphylatoxins.
• NK cells and mast cells are often activated in protozoal
infection. The rapidly synthesized chemicals include prosta-
glandins and leukotrienes, both of which cause vasodi-
latation and contraction of smooth muscle in gut and
bronchial walls.
Examples of protozoal infection and Eosinophils secrete chemicals similar to those se-
evasion of the immune response creted by mast cells, excluding histamine. In addition
Protozoa have good mechanisms to prevent the initia- they secrete:
tion of an immune response. Strategies include: • Peroxidase that generates hypochlorous acid
• Escape into the cytoplasm following phagocytosis, • A cationic protein which damages the worm’s outer
e.g. Trypanosoma cruzi layers and paralyses its nervous system
• Prevention of complement actions, e.g. Leishmania • A basic protein that also attacks the outer layers of
spp. the worm.
• Gene switching to create antigen variation, e.g. Mast cells can be activated by IgE and, although this
trypanosomes probably evolved to deal with worm infections, it medi-
• Immunosuppression, e.g. trypanosomes. ates allergy (type I hypersensitivity).
115
Intentionally left as blank
Immune dysfunction 12
Objectives
117
Immune dysfunction
Allergen
IgE
FcεR
Degranulation
Granules contain
histamine, heparin Fig 12.2 Skin prick testing. The presence of an itchy wheal, in a
and enzymes short amount of time, indicates a positive result. Reading
clockwise from the top right: Positive control, negative contol,
Mast cell hazelnut, peanut, soya, peas, almond, cashew nut. This patient
is allergic to peanut, soya, peas, almonds but not to hazelnut or
Fig. 12.1 The immune mechanisms of type I hypersensitivity cashew nut.
reactions. Cross-linkage of IgE bound to cell surface receptors
on mast cells and basophils results in degranulation.
Lysis
2
Antibody acts as opsonin
for phagocytes
118
Hypersensitivity 12
119
Immune dysfunction
120
Allergy 12
Nasal congestion, watery nasal discharge and sneezing Atopic Pollen Itchy inflammation of
eczema Dust-mite the skin
occur after exposure to allergen. The most common al-
faeces
lergens are grass, flower, weed or tree pollens, which Some foods
cause a seasonal rhinitis (hay fever), and house-dust
mite faeces, which can cause a more perennial rhinitis.
Allergic attacks usually last for a few hours and are often (thickening of the skin). Eczema is often complicated
accompanied by itching and watering of the eyes. Skin by superinfection with bacteria, particularly Staphylococ-
prick tests can identify the allergen. cus aureus.
The most important treatment is topical (nasal) ste- Recently, mutations in a gene encoding for Filaggrin
roids; alternatives or adjuncts include antihistamines or (a protein that binds to keratin fibres in epithelial cells)
mast cell stabilizers such as sodium cromoglicate. has been associated with atopic eczema.
Avoidance of allergens is advised but is often difficult. The diagnosis of atopic eczema is usually clinical. To-
tal serum IgE, RAST for specific IgE and skin prick testing
Atopic/allergic eczema with common allergens are occasionally performed to
confirm the diagnosis of atopic eczema. Treatment of
Eczema or dermatitis can be caused by an allergic re-
eczema is mainly topical, except in more severe cases,
sponse. Dermatitis means skin inflammation. There are
when systemic steroids and immunosuppressants are
several types of dermatitis, including allergic (atopic)
used. Therapies include:
eczema (type I hypersensitivity reaction) and contact der-
matitis (a type IV hypersensitivity reaction). Contact • Emollients: moisturizes dry skin and reduces itching
dermatitis can be diagnosed by patch testing and treat- • Topical steroids: anti-inflammatory
ment is primarily by avoidance of the antigen (e.g. nickel). • Topical antibiotics or antiseptics: in infected eczema
Atopic eczema is most commonly the result of expo- • Oral antihistamine: reduces itching
sure to pollen or house-dust mite faeces. Common aller- • Ciclosporin: resistant cases might require immuno-
gens are shown in Fig. 12.7. About 10% of children are suppression.
diagnosed with eczema. Eczema commonly affects the
flexural creases and the fronts of the wrist and ankles.
In infancy and adulthood the face and trunk are often
Anaphylaxis
involved. The skin lesions are itchy, red, sometimes ve- Anaphylaxis is a medical emergency and can be fatal.
sicular and might be dry. Because of itching, the skin is However, it is rapidly reversible if treated properly.
often excoriated, which can lead to lichenification A systemic response to an allergen that is either
121
Immune dysfunction
122
Autoimmunity 12
123
Immune dysfunction
B cell
PMN
Inflamed
synovial
membrane
124
Autoimmunity 12
Infiltration of
mononuclear cells
Hashimoto’s thyroiditis
Hashimoto’s thyroiditis is the most common cause of
goitrous hypothyroidism (although there is also an
atrophic form). Antigen-specific cytotoxic T cells attack
the thyroid gland, leading to progressive destruction of
the epithelium. Marked lymphocytic infiltration
(mainly by B cells and CD4þ T cells) of the thyroid
gland is accompanied by migration of large numbers
of macrophages and plasma cells, resulting in the
formation of lymphoid follicles and germinal centres
within the thyroid. Due to unregulated T-helper
cell interaction with B cells, autoantibodies are
produced against thyroid antigens such as thyroid
peroxidase.
Fig. 12.10 A hand X-ray showing joint destruction and
erosions due to rhuematoid arthritis. Middle-aged females are most commonly affected
(female:male ratio as high as 20:1). The disease is asso-
ciated with the HLA-DR5 haplotype.
125
Immune dysfunction
126
Immune deficiency 12
127
Immune dysfunction
Fig. 12.17 Primary phagocyte deficiencies Fig. 12.18 Primary complement deficiencies
Disorder Features Disorder Features
Neutropenia See p. 43 Deficiency of classical Tend to develop immune
pathway components complex disease
Leucocyte Lack of b2-integrin molecules
adhesion results in impaired adhesion and C3 deficiency Prone to recurrent
deficiency extravasation of phagocytes pyogenic infections
Chronic Most commonly X-linked (can be Deficiency of C5, C6, Increased susceptibility
granulomatous autosomal recessive) inheritance. C 7, C8, factor D, to Neisseria infections
disease Lack of NADPH oxidase impairs properdin
killing of ingested pathogens, which
therefore persist. Can be tested by C1 inhibitor deficiency Causes hereditary
impaired reduction of nitroblue angioedema
tetrazolium by stimulated Deficiencies of almost all complement components have been
neutrophils described.
NADPH, nicotinamide adenine dinucleotide phosphate.
128
Immune deficiency 12
Viral envelope
Malignancy
Secondary immunodeficiency is particularly common
with tumours that arise from the immune system, such
as myeloma, lymphoma and leukaemia (see Chapter 5).
Many other tumours are immunosuppressive. This
is likely to provide the tumour cells with a selective advan- Two reverse transcriptase
molecules associated with viral RNA
tage, because they evade destruction by cytotoxic cells.
100–120 nm
Steroids, other drugs and radiation
Fig. 12.20 Structure of HIV-1. The envelope glycoproteins
Iatrogenic causes of immunosuppression are common. gp120 and gp41 are hypervariable. gp120 binds CD4, while
Immunosuppressive drugs can be given to suppress gp41 enables entry of the virus into the cell. The viral envelope is
inflammatory or autoimmune disease, or to prevent re- a lipid bilayer containing both viral glycoprotein antigens and
jection of transplanted material (see p. 137). Radiation host proteins.
129
Immune dysfunction
it to the lymph nodes where HIV can gain easy access to Diagnosis and monitoring of an HIV infection
CD4 T helper cells. Screening for HIV infection is performed using enzyme-
Transmission can also occur through infected blood: linked immunosorbent assays (ELISAs) to detect anti-
blood transfusions, intravenous drug abusers and nee- HIV antibodies. If the ELISA is positive, confirmatory
dlestick injury (0.3% risk from a single exposure). These tests must be carried out, e.g. a Western blot, which de-
routes do not require HIV to gain access through mu- tects antibodies against specific HIV proteins. As sero-
cous membranes and hence CC5 receptors. Vertical conversion (production of antibodies) might not take
transmission is especially important in developing place until 3 months after infection, there is a window
countries, occurring transplacentally during labour (ap- period when ELISA will be negative. This is a potential
proximately 25% of cases) or through breast milk. problem in blood transfusion.
In infants, anti-HIV IgG can be maternally derived
Immune response to HIV and persist for up to 18 months, making diagnosis of
Most individuals exposed to HIV sexually become HIV by ELISA unreliable. Detection of HIV by polymer-
chronically infected. Infected individuals produce anti- ase chain reaction (PCR) is used to confirm HIV infec-
body, but this is largely ineffective against intracellular tion in neonates.
virus. T cells inhibit HIV (by interferon secretion) or kill
infected cells. HINTS AND TIPS
The primary infection is often asymptomatic but may be
marked by a flu-like illness (fever, macular rash, mouth ul- False positives may occur with the HIV enzyme-linked
cers, splenomegaly and diarrhoea) in 15% of individuals. immunosorbent assay (ELISA) in those with recent
influenza vaccination, hepatic disease or a recent viral
HIV seroconversion illness infection.
Individuals infected with HIV develop symptoms as
their body starts to produce antibody to HIV. This is
called HIV seroconversion illness. The patient Determinations of CD4 T cell counts and measure-
experiences fever, rash, malaise, sore throat, diarrhoea ment of the viral load (serum HIV RNA) are useful in
and arthralgia; lymphadenopathy may also be present. assessing response to treatment and the prognosis.
Not all patients experience seroconversion illness, and it CD4 counts provide a guide of the current immuno-
is often diagnosed retrospectively. logical status of the patient (Fig. 12.21), whereas HIV
RNA levels predict what will happen to the patient over
the next few months and years.
How does HIV progress to AIDS? During the latent phase of the infection T cells are con-
1. Mutations: reverse transcriptase makes an error for stantly battling with the HIV, and gradually the CD4
roughly 1 in every 10,000 bases. Some of these muta- count falls. With the falling CD4 count, individuals be-
tions provide a selective advantage to the HIV, e.g. cells come susceptible to more and more organisms. Initially
of the immune system may no longer recognize them, these include virulent organisms such as Candida albicans
and another immune response has to start afresh. and Mycobacterium tuberculosis. However, as the CD4
2. Even if the immune system manages to clear the en- count continues to fall the individual is more susceptible
tire free virus, HIV can hide in host DNA and remain to opportunistic infections (Figure 12.22). When the
dormant for many years—the latent phase. Reactiva- CD4 count drops to < 200 cells/mL or the individual be-
tion of the host cell then results in production of gins to suffer from an infection indicative of AIDS (an
HIV RNA, and thus the infection continues. ‘AIDS-defining condition’), they are said to be suffering
3. HIV infects and destroys the cells that are responsi- from AIDS (as opposed to just being HIV þ ve).
ble for the immune response. As the CD4 count de-
clines, the cytotoxic T lymphocytes become less HINTS AND TIPS
effective as they are receiving less support from T
helper cells. Individuals with HIV should have their CD4 and viral
load levels checked every 3–6 months.
130
Immune deficiency 12
CD4 count
CD4 count
3
Viral load
0
Asymptomatic Early symptomatic AIDS
Initial infection
Cell attachment/fusion/entry
• fusion inhibitors, e.g. efuviritide
Reverse transcription
• nucleoside analogue reverse transcriptase inhibitors,
e.g. zidovudine, abacavir and tenovir
• non-nucleoside reverse transcriptase inhibitors,
e.g. efavirenz and nevirapine
Integration
transcription and post-transcriptional processing
131
Immune dysfunction
a selective advantage for a more resistant strain to In an ELISA an enzyme is attached to the antigen un-
develop. For this reason a combination of a least two der study, and catalyses the conversion of a colourless
classes of drug are used and they are not started until substrate to a coloured product. The amount of
there is evidence of CD4 T cell decline. This combina- coloured end-product is proportional to the amount
tion of more than one drug is known as highly active of antigen and can be measured using a spectrometer.
antiretroviral therapy (HAART). ELISAs are commonly used to measure specific anti-
Antibiotic prophylaxis against infections such as body in a patient’s serum so we will use this as a working
Pneumocystis carinii and Toxoplasma gondii is effective example:
and usually given when the CD4 count is < 200/mL. It • A plate containing the antigen for the antibody being
has been shown that antibiotic prophylaxis can be safely tested is exposed to the patient’s serum; any of the
stopped following immune restoration using treatment appropriate antibody present in the serum will bind
with antiretroviral therapy. the antigen on the plate.
Vertical transmission can be vastly reduced by: • The enzyme used to catalyse the production of the
• Delivering by Caesarean section coloured product (which is covalently attached to an
• Early antiretroviral use antibody that is specific for the Fc portion of the anti-
• No breast feeding. body in the patient’s serum) is added (see Fig. 12.24).
• The enzyme substrate is then added and the colour
conversion occurs.
INVESTIGATION OF IMMUNE Each of these steps is incubated for a consistent pe-
riod of time with any excess being washed before the
FUNCTION next substance is added.
In addition to the ELISA test we can detect antibody
Immunoassays by agglutination, for example:
This is a technique that uses antibody to identify antigen • Coombs test
or biological molecules. • Rheumatoid factor.
Enzyme
Monoclonal
anti-IgG
Specific IgG in
patient ’s serum
Viral antigen
Plate
Fig. 12.24 Enzyme-linked immunosorbent assay (ELISA). ELISA can be used to detect antigens but is most commonly used to
measure antibody to specific antigen (e.g. a virus) and this is shown. Viral antigen is bound to a plate and the patient’s serum added.
If specific IgG is present it will bind to the antigen. Enzyme labelled anti-IgG is added (binding to the patient’s IgG). The enzyme
converts a colourless substrate into a coloured product. The intensity of colour is relative to the amount of antigen.
132
Investigation of immune function 12
producing a very fine stream of cells in suspension, where antigen). The monoclonal antibodies are labelled with
only one cell at a time passes through a beam of laser dyes that fluoresce under laser light (immunofluores-
light. Sensors detect when a cell blocks the beam of light cence). Different types of dye allow the detection of spe-
and the amount of light scatter identifies the size and cific antigens (most machines use red and green
granularity of the cell. Various surface antigens on the cell fluorescence, but up to five colours are used by some ma-
can be bound by monoclonal antibodies (specific for one chines); CD4 counts (T cell counts) are done in this way.
133
Intentionally left as blank
Medical intervention 13
Objectives
Examples where passive immunity is used: A healthy immune system can cope with live
• Prevent hepatitis A and B infection attenuated vaccines. However, they should never be
• Prevent varicella zoster given to immunocompromised patients as they can
• Treat snake bites (anti-venom). cause severe infection.
135
Medical intervention
136
Transplantation 13
Vaccines are not 100% efficacious. A small propor- Unless the donor and recipient are immunologically
tion of individuals receiving vaccination will not re- identical, the recipient will mount a rejection response
spond adequately. However, by immunizing the against ‘foreign’ antigens expressed by the graft. The
majority of the population, non-responders are unlikely most important graft antigens responsible for an im-
to come into contact with the virus because the viral res- mune response in the recipient are the major histocom-
ervoir is reduced (herd immunity). patibility complex (MHC) molecules (see p. 92).
However, even when the donor and recipient are genet-
ically identical at the MHC loci, graft rejection can occur
Vaccination against toxins such as tetanus does not due to differences at other loci, which encode minor his-
provide immunity against the toxin-producing tocompatibility antigens. A rejection response can lead
bacterium (Clostridium tetani). Its benefits come from to loss of a graft. There are three types of graft rejection
(Fig. 13.5):
preventing the sequelae associated with the tetanus
toxin, i.e. tetanus of the masseter muscles (lock jaw). 1. Hyperacute: occurs within hours as a result of pre-
formed antibodies, type II hypersensitivity reaction
2. Acute: takes several days to develop, type IV hyper-
sensitivity reaction
You will notice that a number of vaccinations are 3. Chronic: occurs months to years after transplanta-
given simultaneously; this is not just for convenience. tion; can be caused by a variety of mechanisms. It
Given alone some of the subunit vaccines would not cannot be treated.
137
Medical intervention
138
Anti-inflammatory drugs 13
effects on the immune system, acting as immunosup- Steroids are contraindicated if there is evidence of
pressive and anti-inflammatory agents. Several gluco- systemic infection. Long-term high-dose steroid therapy
corticoids are available therapeutically, including: is usually avoided. When they are used long term, there
• Hydrocortisone: can be given intravenously in status should be regular checks on blood pressure, blood sugar
asthmaticus or topically for inflammatory skin and bone density. Care should be taken when reducing
conditions a dose of steroids. The adrenal cortex requires time to
• Prednisolone: oral preparations are given in many recover so sharp reductions in dose can result in an ad-
inflammatory or allergic conditions renal (Adisonian) crisis.
• Beclometasone: used as an aerosol in asthma or top-
ically for eczema.
Conditions commonly treated with steroids include: Non-steroidal anti-inflammatory
• Inflammatory bowel disease drugs (NSAIDs)
• Allergic conditions, e.g. asthma NSAIDs include a large number of drugs that can be
• Severe inflammatory skin conditions bought over the counter, e.g. aspirin, ibuprofen, diclo-
• Severe inflammatory rheumatological conditions. fenac. They are chemically diverse but all act to inhibit
Corticosteroids work primarily on phagocytes. They cyclo-oxygenase (Fig. 13.8). This attenuates, but does
inhibit the production of mediators of inflammation not abolish, inflammation. As well as their anti-
(prostaglandins, cytokines) and prevent antigen presen- inflammatory effects, NSAIDs have analgesic and anti-
tation. At high doses they have direct effects on pyretic actions. They are used primarily in conditions
lymphocytes. where pain is accompanied by inflammation, such as
rheumatoid arthritis.
Adverse effects and contraindications Cyclo-oxygenase (COX) mainly occurs as two isoen-
zymes: COX-1 and COX-2. COX-1 is responsible for the
Glucocorticoids cause many adverse effects at the high physiological prostaglandins that protect the gastric
doses required to produce an anti-inflammatory effect. mucosa, prevent platelet aggregation and protect renal
Glucocorticoids can cause hundreds of adverse effects, function. COX-2 is important for the formation of
and many patients find them too much to put up with. proinflammatory prostaglandins. Thus the important
The clinical features are similar to those seen in Cushing’s side-effects of NSAIDs, including peptic ulcers and renal
syndrome and some important adverse effects are shown failure, occur mainly as a result of COX-1 inhibition.
in Figure 13.7. Most NSAIDs block both COX isoenzymes, but some
are more active against one or the other. Selective
COX-2 inhibitors (e.g. celecoxib) were released in the
Fig. 13.7 Some adverse effects of glucocorticoids
and their prevention or treatment
hope of having anti-inflammatory effects without gas-
tric and renal side-effects; however, they were with-
Adverse effect Prevention or treatment drawn from the market due to an increased incidence
Diabetes Regular blood sugar of cardio- and cerebrovascular events.
measurements
Osteoporosis Bone density should be Aspirin
regularly monitored during Acetylsalicylic acid (aspirin) is anti-inflammatory but
steroid treatment. Patients, causes a lot of adverse effects. As a consequence of
especially the elderly, may need this, newer NSAIDs (e.g. ibuprofen) are usually pre-
bisphosphonates and calcium ferred for treatment of inflammatory conditions, be-
supplements
cause they exhibit fewer side-effects. Aspirin is far
Peptic ulcer Proton pump inhibitors may be more efficient at inhibiting COX-1 (hence the side-
required effects) and is used prophylactically in low doses in
Thin skin, easy No treatment, but early and people who have had strokes or have ischaemic heart
bruising and poor intensive intervention of disease because of its ability to inhibit platelet function
wound healing wounds is necessary to prevent (see p. 59).
chronic morbidity
Adrenal insufficiency Prevent sudden decreases in Paracetamol
dose, increase dose when ill and Paracetamol has good analgesic and antipyretic proper-
carry a steroid card. Treatment ties but little effect on inflammation. Thus it is not
is with resuscitation and steroid
replacement
strictly an NSAID but is usually grouped with them
for ease.
139
Medical intervention
-
5-lipoxygenase Cyclo-oxygenase NSAIDs
5-HPETE Endoperoxides:
• prostacyclin
• thromboxane A2
• prostaglandins
Leukotrienes
140
SELF-ASSESSMENT
Multiple choice questions (MCQs) . . . . . . . . 143
Extended matching questions (EMQs) . . . . . . 153
3. A 65-year-old patient receiving chemotherapy for a 8. Concerning haemoglobin, which one of the following
disseminated malignancy attends hospital with signs of is correct?
an infection. A full blood count reveals that he has a a. Adult haemoglobin contains 4 identical globin
neutrophil count of < 0.1 109/L (normal range 2.0– chains.
7.5 109/L). Which haemopoietic growth factor b. Each haemoglobin can carry 4 molecules of oxygen.
would help improve his neutrophil count? c. Oxygen binding follows a hyperbolic curve.
a. G-CSF. d. 2,3-diphosphoglycerate levels rise in hypoxia to
b. EPO. allow increased oxygen uptake by haemoglobin.
c. Romiplostim. e. The Bohr effect (a shift of the oxygen dissociation
d. Eltrombopag. curve to the right) is due to decreased Hþ
e. Stem cell factor. concentration.
4. A patient suffering with idiopathic thrombocytopenic 9. Concerning fetal haemoglobin, which one of the
purpura undergoes a splenectomy. She is advised to following is correct?
get the pneumococcal vaccine booster every a. It may be raised in b-thalassaemia syndromes.
5–10 years. Which of the following properties of b. It is composed of two a- and two b-globin chains.
Strep. pneumoniae make her prone to infection by c. It has a lower affinity for oxygen than adult
this organism? haemoglobin.
a. It is gram positive. d. It remains the primary haemoglobin in infants until
b. It is a-haemolytic. approximately 2 years of age.
c. It is encapsulated. e. It is normally about 2% of the haemoglobin in
d. It causes pneumonia. adults.
e. It is a diplococcus.
10. Regarding haem production and metabolism, which
5. Concerning bone marrow in the adult, which one of one of the following is correct?
the following is correct? a. Haem is produced in mitochondria in the liver.
a. It is the only tissue in the body capable of b. Haem is broken down by macrophages in the gut.
haemopoiesis . c. Haem consists of four Fe2þ ions and a
b. Yellow marrow is where haemopoiesis normally protoporphyrin ring.
takes place. d. Conjugated bilirubin is secreted into lymph.
c. It contains neutrophils which store iron for the e. Unconjugated bilirubin is water insoluble.
developing erythrocyte.
d. Red marrow is normally restricted to the axial 11. Concerning erythropoietin (EPO), which one of the
skeleton and the proximal ends of long bones. following is correct?
e. It contains red and yellow marrow, as well as red a. It is a steroid hormone.
and white pulps.
143
Multiple Choice Questions (MCQs)
144
Multiple Choice Questions (MCQs)
which of the following precautions is the most 28. Which one of the following white blood cells is the
important? least common white cell in the blood and is functionally
a. Measure initial vitamin B12. very similar to mast cells?
b. Do a pregnancy test. a. Neutrophils.
c. Check that she is not allergic to vitamin B12. b. Basophils.
d. Check that she doesn’t have swallowing difficulties. c. Eosinophils.
e. Measure serum folate. d. Monocytes.
e. Lymphoctyes.
23. Approximately how often are vitamin B12 injections 29. Which of the following statements describes
administered to patients with vitamin B12 deficiency? myelodysplastic syndromes?
a. Every week. a. Bone marrow disorders resulting in excess of one or
b. Every 4 weeks. more type of myeloid cell.
c. Every 3 months. b. Bone marrow disorders that result in the clonal
d. Every year. production of abnormal myeloid cells.
e. Every 3 years. c. A collection of diseases that result in a clonal
proliferation of white blood cells.
24. A newborn, Caucasian boy is noticed to be jaundiced. d. Clonal proliferations of lymphoid cells, mainly from
Full blood count reveals a macrocytic anaemia. The lymph nodes and extranodal tissue.
boy’s mother says that she thinks his estranged father e. Malignant proliferation of plasma cells.
had a splenectomy. A peripheral blood film is
performed and his red cells appear smaller and thicker 30. The Philadelphia chromosome is associated most
than normal. Which of the following is the most likely heavily with which malignancy?
diagnosis? a. Hodgkin’s lymphoma.
a. Glucose-6-phosphate dehydrogenase deficiency. b. Acute myeloid leukaemia.
b. Sickle cell anaemia. c. Chronic lymphoid leukaemia.
c. Pyruvate kinase deficiency. d. Chronic myeloid leukaemia.
d. Hereditary spherocytosis. e. Myeloma.
e. Β-thalassaemia major.
31. Bence-Jones protein is seen in which malignancy?
25. Which of the following features would suggest a. Hodgkin’s lymphoma.
b-thalassaemia minor, as opposed to b-thalassaemia b. Non-Hodgkin’s lymphoma.
major? c. Chronic myeloid leukaemia.
a. Onset of symptoms at 9 months of age. d. Chronic lymphocytic leukaemia.
b. Full blood count showing a severe microcytic, e. Myeloma.
hypochromic anaemia.
c. Skull X-ray showing ‘hair-on-end’ appearance.
32. A 3-year-old boy presented to his GP with a persistent
d. The presence of HbA on electrophoresis.
cough. Examination revealed bruising and splenomegaly.
e. Splenomegaly.
A full blood count showed that he was very anaemic and
his white blood cells were markedly raised. Which one of
26. Which one of the following statements about the following is the most likely diagnosis?
lymphocytes is correct? a. Non-accidental injury.
a. They are usually larger than other white cells. b. Viral upper respiratory tract infection.
b. Their nucleus is small to allow more granules. c. Acute lymphoblastic leukaemia.
c. They spend most of their time circulating in the d. Hodgkin’s lymphoma.
blood. e. Haemophilia A.
d. They come from myeloid stem cells.
e. B cells and natural killer (NK) cells tend to be 33. A 7-year-old boy from the Uganda presented to his GP
bigger than T cells. with a 2-week history of jaw pain, fatigue, fever and
sweating. Examination revealed a jaw mass. What is
27. Which one of the following statements about the most likely diagnosis?
neutrophils is correct? a. b-thalassaemia major.
a. Left shift means that the nuclei are b. Acute lymphoblastic leukaemia.
hypersegmented. c. Burkitt’s lymphoma.
b. They normally have one large, circular nucleus. d. Sickle cell anaemia.
c. Primarily respond to parasitic infections. e. Acute myleloid leukaemia.
d. Immature ‘band’ forms may appear in severe
sepsis. 34. A 21-year-old university student presents to his GP
e. They make up a small proportion of the circulating with a painless swelling in his neck. He also reports
white cells.
145
Multiple Choice Questions (MCQs)
146
Multiple Choice Questions (MCQs)
47. Which one of the following statements regarding d. CD4 positive T lymphocytes recognise antigen
haemolytic disease of the newborn (HDN) is correct? associated with MHC class II.
a. It usually occurs with the first child. e. The main function of plasma cells is to produce
b. It will not occur if the mother is rhesus D positive. cytokines.
c. Rhesus D incompatibility is normally due to IgM
antibodies. 53. A pregnant patient asks her GP about the benefits of
d. Anti-D antibody should be given to all rhesus D breast feeding. Which immunoglobulin is present in
negative mothers during pregnancy. colostrum (early milk), and protects the mucosal
e. It results in a mild anaemia due to haemolysis. surfaces of the intestines?
a. IgG.
48. Which one of the following signs would raise most b. IgM.
suspicion of an acute haemolytic transfusion c. IgA.
reaction? d. IgD.
a. Cyanosis. e. IgE.
b. Severe hypertension.
c. Low back pain. 54. Which one of the following is a phagocyte?
d. Hypothermia. a. Macrophage.
e. Bradycardia. b. Basophil.
c. B cell.
49. Massive transfusions can result in coagulopathies d. T cell.
because packed red cells are deficient in clotting e. The membrane attack complex.
factors. The two clotting factors most deficient are
factor V and which one other clotting factor? 55. During phagocytosis, the phagosome fuses with which
a. Factor II. one of the following organelles?
b. Factor VII. a. Nucleus.
c. Factor VIII. b. Lysosome
d. Factor IX. c. Mitochondrion.
e. Factor XII. d. Golgi apparatus.
e. Endoplasmic reticulum.
50. A 55-year-old woman undergoes a hysterectomy.
During surgery her vena cava is damaged. She 56. Which one of the following types of cell are the major
proceeds to lose a great deal of blood but the constituents in pus?
vena cava is eventually repaired. Over the course a. Plasma cells.
of the next 24 hours she receives 12 units of cross- b. Macrophages.
matched red cells. She appears much better. The c. Mast cells.
foundation doctor orders some clotting tests and d. Eosinophils
notices that the prothrombin time (PT) and the e. Neutrophils.
activated partial thromboplastin time (APTT) are
both prolonged. Which blood product should
57. Which one cell type can induce apoptosis of virally
be given?
modified or cancerous cells?
a. Albumin.
a. Neutrophils.
b. Fresh frozen plasma.
b. Mast cells.
c. O negative red cells.
c. Eosinophils.
d. Whole blood.
d. Natural killer cells.
e. Anti-D immunoglobulin.
e. B cells.
147
Multiple Choice Questions (MCQs)
148
Multiple Choice Questions (MCQs)
73. Which one of the following is an example of mucosal- 79. Most extracellular bacteria are killed by which
associated lymphoid tissue (MALT)? immunological cells?
a. Thymus. a. Cytotoxic CD8 positive T cells.
b. Inguinal lymph nodes. b. The membrane attack complex (MAC).
c. Bone marrow. c. CD4 positive T helper cells.
d. Peyer’s patches. d. Natural killer cells.
e. Thyroid. e. Phagocytes.
74. Concerning IgG immunoglobulin, which one of the 80. Which one of the following statements is true of
following statements is true? protozoal infections?
a. There are four Fab fragments. a. Protozoa tend to cause extracellular infections.
b. There are two Fc fragments. b. Protozoa have complex life cycles which present
c. The amino terminal (N) domain of the light chain is the immune system with a variety of challenges.
constant. c. Protozoa themselves cause significant damage to
d. The heavy chain determines the class of cells and tissues.
immunoglobulin. d. The immune system is efficient at dealing with
e. The domain at the carboxyl (C) terminal of the light protozoa, and infections are usually short-lived.
chain is variable. e. There are many protozoa that are pathogenic to
humans.
75. Regarding the immune response to viruses, which one
of the following is true? 81. Along with IgE and mast cells, which white blood cell is
a. Antibodies can neutralize virus particles, as well as most important in combating parasitic worm infections?
act as an opsonin against virally infected cells. a. Dendritic cells
b. Interferon gamma acts on neighbouring cells by b. Monocytes.
inhibiting transcription and translation of viral c. Neutrophils.
proteins. d. Eosinophils.
c. Viral peptides are presented on class II MHC e. Lymphocytes.
molecules.
d. CD4 positive T cells are able to destroy infected 82. Which type of immune dysfunction is characterized, in
cells. immunological terms, by IgE-mediated degranulation
e. CD8 positive T cells help antibody production, as of mast cells?
well as the recruitment and activation of a. Nickel allergy.
macrophages. b. ABO incompatibility.
c. Allergic rhinitis.
76. Varicella zoster evades the immune system by which d. Farmer’s lung.
one of the following mechanisms: e. Rheumatoid arthritis.
a. Being a latent virus.
b. Antigenic shift and drift. 83. Which one of the following investigations is most
c. Polymorphism. useful in type I hypersensitivity?
d. Infection of lymphocytes. a. Skin prick testing.
e. Modulation of MHC expression. b. Anti-double stranded DNA antibody assay.
c. Rheumatoid factor assay.
77. Which one of the following components of the d. Patch testing.
immune system can prevent bacterial pathogens e. C-reactive protein measurement.
present at a mucosal surface from entering the body?
a. Lysozyme. 84. Which one of the following is an example of type III
b. C3b. hypersensitivity?
c. Neutrophils. a. Eczema.
d. Dendritic cells. b. Farmer’s lung.
e. Secretory immunoglobulin A (sIgA). c. Asthma.
d. Haemolytic disease of the newborn.
e. Nickel allergy.
78. Which characteristic of Gram-negative bacteria makes
them susceptible to the membrane attack complex
85. Type IV hypersensitivity is mainly mediated by which
(MAC)?
cells?
a. They are prokaryotic.
a. Neutrophils.
b. They have pili.
b. Plasma cells.
c. They have capsule of branched polysaccharides.
c. CD8 positive T cells.
d. They have a lipid bilayer.
d. Mast cells.
e. They have flagellae.
e. T helper cells.
149
Multiple Choice Questions (MCQs)
88. Antibodies against tissue transglutaminase are most 95. Which of the following vaccines is a live attenuated
associated with which of the following autoimmune vaccine?
conditions? a. Diphtheria.
a. Rheumatoid arthritis. b. Bacille Calmette–Guérin.
b. Coeliac disease. c. Acellular pertussis.
c. Type I diabetes. d. Haemophilus influenzae type B.
d. Hashimoto’s thyroiditis. e. Influenza.
e. Pernicious anaemia.
96. Concerning vaccinations, which one of the following
89. Which of the following is an example of an statements is correct?
autoimmune disease caused by type IV a. An ideal vaccine should not be immunogenic.
hypersensitivity? b. The vaccines against measles, mumps and rubella
a. Contact dermatitis. (MMR) are recombinant vaccines.
b. Rheumatoid arthritis. c. Killed vaccines are more expensive than live
c. Systemic lupus erythematosus. attenuated vaccines.
d. Grave’s disease. d. Live attenuated vaccines produce a good cell-
e. Farmer’s lung. mediated response.
e. Recombinant vaccines can rarely induce disease,
especially in the immunocompromised.
90. Which one of the following cytokines is most involved
in the pathogenesis of rheumatoid arthritis?
a. Interleukin-8. 97. Concerning transplant rejection, which one of the
b. Tumour necrosis factor alpha. following statements is correct?
c. Interleukin-17. a. Hyperacute rejection only occurs once the
d. Transforming growth factor beta. recipient has synthesized antibody to the graft.
e. Interferon gamma. b. Acute cellular rejection is primarily mediated by
natural killer cells.
91. Rheumatoid factor is normally which one of the c. The mechanism of chronic rejection is
following? well-understood and easy to treat.
a. IgM anti-IgG antibodies. d. Hyperacute rejection is prevented by HLA-typing
b. IgA anti-IgM antibodies. the donor organ and recipient.
c. IgE anti-IgG antibodies. e. Acute cellular response takes several days to develop.
d. IgD anti-IgE antibodies.
e. IgG anti-IgM antibodies. 98. Which receptor is the target of newer anti-rejection
therapies?
92. Which one of the following is a secondary a. Tumour necrosis factor alpha receptor.
immunodeficiency? b. Transforming growth factor beta receptor.
a. DiGeorge syndrome. c. Interleukin-1 receptor.
b. Chronic granulomatous disease. d. Interleukin-2 receptor.
c. Acquired immunodeficiency syndrome. e. Interferon gamma receptor.
150
Multiple Choice Questions (MCQs)
99. Which one of the following is a common adverse effect c. Paracetamol is one of the most potent
of non-steroidal anti-inflammatory drugs? anti-inflammatory drugs.
a. Increased platelet aggregation. d. Blockade of the cyclo-oxygenase 2 (COX-2)
b. Gastritis. enzyme results in gastrointestinal side-effects.
c. Cushing’s syndrome. e. NSAIDs may be nephrotoxic and cause
d. Osteoporosis. bronchospasm.
e. Fever.
151
Intentionally left as blank
Extended Matching
Questions (EMQs)
1. Concerning red blood cells: Instruction: For each scenario described below, choose
the single most likely match from the above list of
A. Haemoglobin options. Each option may be used once, more than once,
or not at all.
B. Erythropoiesis
C. Bilirubin 1. Store iron in the form of ferritin and haemosiderin. This
D. Normoblasts iron is used for haemopoiesis.
E. Erythropoietin (EPO) 2. Type of bone marrow that is normally restricted to the
F. Haemostasis axial skeleton and proximal ends of the long bones.
G. Transferrin
3. Important for removing old and defective erythrocytes
H. Erythrocyte and platelets from the circulation.
I. Reticulocyte
4. Site of haemopoiesis in a fetus at 3 months.
J. Haemopoietic stem cells
5. Made up of the periarteriolar lymphoid sheath, along
Instruction: For each scenario described below, choose with B and T cell follicles.
the single most likely match from the above list of
options. Each option may be used once, more than once,
or not at all.
3. Concerning anaemia:
1. Highly glycosylated polypeptide hormone that stimulates
the differentiation and maturation of erythrocytes. A. Iron
B. Folate deficiency anaemia
2. Red blood cell component comprising two a-chains with
either two b- or two d-chains. C. Erythrocyte
D. Folate
3. Breakdown product of red blood cells, which is
E. Pernicious anaemia
conjugated in the liver and excreted in bile.
F. Aplastic anaemia
4. Immature red blood cells, present in the bone marrow, G. Vitamin B12
and in low numbers in the bloodstream.
H. Sickle cell anaemia
5. Process by which red blood cells are made in the bone I. Sideroblastic anaemia
marrow. J. Iron-deficiency anaemia
153
Extended Matching Questions (EMQs)
Instruction: For each scenario described below, choose Instruction: For each scenario described below, choose the
the single most likely diagnosis from the above list of single most likely match from the above list of options. Each
options. Each option may be used once, more than once, option may be used once, more than once, or not at all.
or not at all.
1. An X-linked disorder, affecting the hexose
1. A previously fit and well 26-year-old female is admitted monophosphate shunt.
to hospital with a severe dyspnoea, chest pain,
productive cough and fever. Her chest radiograph 2. A rare autosomal recessive condition affecting the
showed patchy consolidation. After several days of glycolytic pathway.
admission she begins to improve. The day before her
scheduled discharge she suffered from Raynaud’s 3. An autosomal dominant condition, with variable
phenomenon. A full blood count showed a penetrance. Red cells are less deformable and have
megaloblastic anaemia and a direct Coomb’s test was increased osmotic fragility.
positive. 4. A condition that results from inheriting one defective
2. A 4-year-old child of African origin presents to allele coding for b-chain production.
Accident and Emergency with a fever and painful, red 5. A woman comes to her GP asking advice about planning
hands and feet. FBC shows Hb 6.5 g/dL (normal her family. Her husband has hereditary eliptocytosis. What
range in children 11–14 g/dL) and mean corpuscular is the chance that each of her children will be affected?
volume (MCV) 100 fL (normal range in children
76–88 fL).
154
Extended Matching Questions (EMQs)
4. Cells which mediate the delayed stage in type I Instruction: For each scenario described below, choose the
hypersensitivity. single most likely match from the above list of options. Each
option may be used once, more than once, or not at all.
5. The appearance of hypersegmented neutrophils in
non-infectious inflammatory processes. 1. An immensely dangerous condition that results from
excessive activation of the coagulation cascade, followed
by activation of the fibrinolytic cascade.
155
Extended Matching Questions (EMQs)
156
Extended Matching Questions (EMQs)
17. Concerning immunization: 3. Molecules which bind and present peptide antigens
from intracellular pathogens.
A. Passive immunity
B. Plasma cells 4. Molecule that recognizes intracellular or phagocytosed
antigen when it is expressed simultaneously with the
C. Dead vaccine major histocompatibility complex (MHC) in which it is
D. Subunit vaccine lying.
E. Innate immunity
5. Family of related molecules found on cell surfaces
F. Active immunity which, upon recognizing a pathogen, activate the innate
G. Memory cells immune system.
158
Extended Matching Questions (EMQs)
4. Immunoglobulin from which all other immunoglobulins 1. The test needed to confirm a primary immunoglobulin
are derived in the process of class switch. deficiency.
5. Reaction of ABO antigens and antibodies in the blood. 2. The test used to measure CD4 counts.
20. Concerning B and T lymphocytes: 4. The test that uses radiolabelled antibodies to bind to,
and detect, antigens or antigen-antibody complexes.
A. CD8
5. The test used to confirm nickel allergy.
B. Myeloid stem cells
C. Plasma cells
D. Basophil
E. Memory B cells
22. Concerning hypersensitivity:
F. T helper cells
G. Cytotoxic T cells A. Skin prick test
H. Memory T cells B. Pigeon fancier’s disease
I. CD40 C. Post-streptococcal glomerulonephritis
J. Lymphoid stem cells D. Nickel allergy
E. Type I hypersensitivity
Instruction: For each scenario described below, choose the F. Type III hypersensitivity
single most likely match from the above list of options. Each
option may be used once, more than once, or not at all. G. Atopic eczema
H. ABO incompatibility
1. Induces B cells to become fully active and begin I. Type IV hypersensitivity
releasing antibody.
J. Anaphylaxis
2. Cells from which B and T lymphocytes originate.
Instruction: For each scenario described below, choose the
3. Cells with a vast amount of endoplasmic reticulum in single most likely match from the above list of options. Each
order to secrete large quantities of immunoglobulin. option may be used once, more than once, or not at all.
159
Extended Matching Questions (EMQs)
3. A type of hypersensitivity that results from IgE-mediated Instruction: For each scenario described below, choose the
mast cell degranulation. Allergic rhinitis is a form of this single most likely match from the above list of options. Each
hypersensitivity. option may be used once, more than once, or not at all.
4. A form of type II hypersensitivity. 1. The 15-year-old son of a patient known to have type I
hereditary angioedema presents to Accident and
5. A form of type III hypersensitivity. Emergency with breathing difficulty and facial oedema.
He has had no contact with potential allergens. He is
given a medication intravenously and his clinical state
begins to improve.
23. Concerning autoimmunity:
2. The most appropriate management for a patient with
A. Central tolerance suspected rheumatoid arthritis.
B. Graves’ disease
3. A graft between individuals of the same species.
C. Type II diabetes
D. Rheumatoid arthritis 4. A new class of drug that suppresses both T and B cell
proliferation and is used to treat transplant rejection.
E. Central tolerance
F. Molecular mimicry 5. A monoclonal antibody that targets tumour necrosis factor.
G. Systemic lupus erythematosus (SLE)
H. Wegener’s granulomatosis
I. Type I diabetes 25. Concerning the immune system
J. Peripheral tolerance in action:
A. Phagocytes
Instruction: For each scenario described below, choose
the single most likely match from the above list of B. Secretory immunoglobin A (sIgA)
options. Each option may be used once, more than once, C. Tumour necrosis factor alpha (TNF-a)
or not at all.
D. MHC class I
1. The autoimmune disease caused by the deposition of E. Natural killer cells
immune complexes, which often causes a F. The membrane attack complex (MAC)
photosensitive rash. G. Mast cells
2. The disease which is associated with individuals carrying H. Interferon alpha (IFN-a)
both HLA-DR3 and HLA-DR4. I. Plasma cells
3. The immunological process behind rheumatic fever. J. Toll-like receptors
4. The process in which self-reactive T cells and B cells are Instruction: For each scenario described below, choose the
eliminated. single most likely match from the above list of options. Each
option may be used once, more than once, or not at all.
5. A condition that results from stimulatory antibody
production. 1. The cells that release histamine in response to
immunoglobulin E stimulation, for example in parasitic
infections.
24. Concerning immunological 2. The cells that destroy most extracellular bacteria.
interventions: 3. The cytokine secreted by virally infected cells to
communicate with other cells.
A. Non-steroidal anti-inflammatory drugs (NSAIDs)
B. Early referral to a rheumatologist 4. Viral peptides are presented to CD8 positive T cells by
C. Corticosteroids this molecule.
D. Adrenaline 5. The cytokine involved in granuloma formation and
E. Interleukin-2 (IL-2) receptor blocker maintenance.
160
MCQ Answers
1. b. Liver and spleen. Refer to sites of haemopoiesis the right due to an increase in Hþ concentration
(p. 2) to answer this question. (a lower pH).
2. c. Thymus. 9. a. It may be raised in b-thalassaemia syndromes. This
3. a. G-CSF. G-CSF acts on the granulocyte precursors is to compensate for the deficiency in b-chains and
helping boost the neutrophil count. Erythropoietin therefore defective HbA. Fetal haemoglobin (HbF)
(EPO) stimulates erythrocyte production, while is composed of two a and two g-globin chains, and
eltrombopag and romiplostim are new therapeutic has a higher affinity of oxygen than HbA. HbF is
agents that encourage platelet production. Stem the primary haemoglobin in the later two-thirds of
cell factor acts on pluripotent stem cells fetal gestation and up to around 3 months of age.
encouraging their renewal; however, it is not used After that levels of HbF should be very low and in
clinically outside of clinical trials. adults there is normally < 1% HbF. 2% of
4. c. It is encapsulated. All of the above options are true haemoglobin in an adult is HbA2.
of Strep. pneumoniae. However, the spleen is 10. e. Unconjugated bilirubin is water insoluble. Haem is
involved in removing encapsulated organisms such produced in the mitochondria of immature red
as N. meningitides, Strep. pneumoniae and cells, and is broken down by macrophages in the
H. influenzae. Thus, post-splenectomy the patient bone marrow, liver and spleen. Haem consists of
is more prone to these infections. one Fe2þ ion at the centre of a protoporphyrin ring.
5. d. Red marrow is normally restricted to the axial Bilirubin is conjugated in the liver, making it water
skeleton and the proximal ends of long bones. Red soluble. It is then secreted in bile.
marrow is also where haemopoiesis occurs. Yellow 11. d. Blood levels of erythropoietin (EPO) are raised at
marrow is mainly fat but can become red marrow if higher altitudes. The major stimulus for EPO
the body’s haemopoietic demands increase. secretion is hypoxia, thus at higher altitudes where
Haemopoiesis normally occurs in the bone marrow partial pressures of oxygen are lower EPO levels
but should the need arise the spleen and the liver are raised. Although some EPO originates in the
can also resume their fetal haemopoietic role. liver the majority ( 90%) comes from the
Macrophages are found in the bone marrow and endothelial cells of the peritubular capillaries in the
store iron in the form of ferritin and haemosiderin. renal cortex. Androgens can increase EPO
Red and white pulps are found in the spleen, not production but this is not the major stimulus for
the bone marrow. secretion. Bilateral nephrectomy, rather than
6. c. They transport CO2. Erythrocytes are responsible splenectomy, decreases EPO production and can
for transporting O2 and CO2. They have no cause anaemia.
nucleus or organelles. Erythrocytes are derived 12. e. Total gastrectomy reduces absorption. Vitamin B12
from CFU-GEMM and have an average lifespan of binds to intrinsic factor (which is produced by the
120 days. They usually have a biconcave discoid parietal cells of the stomach) and is absorbed in the
shape. terminal ileum. It is stored in the liver. Vitamin D3 is
7. d. Primary haemochromatosis is caused by excessive synthesized in the skin.
absorption. Primary haemochromatosis is an 13. c. It is utilized in the metabolism of alcohol.
autosomal recessive condition characterized by Pernicious anaemia results in deficiency of vitamin
excessive absorption of iron. Iron is actively B12. Vitamin B12 is found exclusively in foods
absorbed in the duodenum and jejunum. There is derived from animals (e.g. meat, eggs, milk, fish),
no mechanism to excrete excess iron. Iron is whereas folic acid is found mainly in green
transported in the blood bound to transferrin, it is vegetables, as well as fortified breakfast cereals.
stored as ferritin when bound to apoferritin. Total 14. b. Renal failure. Normochromic, normocytic
body stores are 4 g4g, and normal daily anaemias are often caused by chronic disease.
requirement is 1 mg. Renal failure results in lower levels of the hormone
8. b. Each haemoglobin can carry 4 molecules of erythropoietin (EPO) and thus, anaemia. Iron
oxygen. Adult haemoglobin (HbA) is normally deficiency and thalassaemia are most commonly
made up of two a-chains and two b-chains. associated with microcytic anaemias. Pernicious
Oxygen binding to haemoglobin follows a sigmoid anaemia and hereditary spherocytosis are most
curve. However, the oxygen dissociation curve of commonly associated with megaloblastic
myoglobin is hyperbolic. 2,3-diphosphoglycerate anaemias.
levels rise in hypoxia to allow the release of oxygen 15. d. Raised serum transferrin. Iron deficiency anaemia
to the tissues. The Bohr effect shifts the curve to can cause brittle nails (koilonychias) rather than
161
MCQ Answers
leuconychia, which refers to white nails seen in result in the devastating neurological complication
hypoalbuminaemia. Iron deficiency classically subacute combined degeneration of the cord
results in microcytic, hypochromic red cells. Ferritin (SCDC). Thus concurrent folate deficiency must be
is normally reduced while transferrin (and the total ruled out. Overdoses of vitamin B12 are very rare,
iron-binding capacity) is increased. Subacute and mostly harmless, thus initial B12 levels are not
combined degeneration of the cord is a serious important. Vitamin B12 is safe in pregnancy; in fact
neurological complication associated with vitamin increased demand in pregnancy can be the trigger
B12 deficiency. for vitamin B12 deficiency, and it responds well to
16. d. Low total iron-binding capacity (TIBC). The TIBC is treatment. Vitamin B12 is normally given as
normally raised in iron deficiency anaemia. Both intramuscular injections and so swallowing
anaemia of chronic disease and iron deficiency difficulties are of no importance.
anaemia can cause a low haemoglobin, low serum 23. c. Every 3 months.
iron and a negative direct Coombs test. The direct 24. d. Hereditary spherocytosis. This is an autosomal
Coombs test is normally positive in autoimmune dominant condition which is relatively common in
haemolytic anaemias. Although anaemia of people of Northern European descent. Haemolysis
chronic disease is normally normocytic, it can also results in a megaloblastic anaemia. Splenectomy is
have a microcytic picture, like iron deficiency. sometimes used to prevent recurrent crises. The
17. d. Jaundice. Haem breakdown results in excess cells that appear smaller and thicker in his
unconjugated bilirubin, and therefore jaundice. peripheral blood film are spherocytes.
Excess bilirubin also results in pigment gall stones, 25. d. The presence of HbA on electrophoresis. Both
rather than cholesterol gallstones. Glossitis is a b-thalassaemia major and minor result in a
feature of iron deficiency, as well as folic acid and microcytic, hypochromic anaemia. However,
vitamin B12 deficiency. Haptoglobin is normally b-thalassaemia minor results in a mild anaemia
decreased in haemolysis, as it binds the free depending on the mutation. Onset before 9
haemoglobin. months of age, skull X-ray changes and
18. c. Constipation. Angina can be a symptom of severe splenomegaly are features of b-thalassaemia
anaemia, due to cardiac muscle hypoxia. major. In b-thalassaemia major there is no
Peripheral neuropathy is a feature of severe production of HbA.
vitamin B12 deficiency. Koilonychia is a feature of 26. e. B cells and natural killer (NK) cells tend to be bigger
iron deficiency anaemia. Mouth ulcers are than T cells. Lymphocytes are the smallest white
associated with iron and B vitamin deficiencies. blood cell, with a very large nucleus and few
19. b. Endoscopy of the gastrointestinal tract. The blood granules. When in the blood, they are only in
results suggest iron deficiency anaemia. Iron transit between the bone marrow and lymphoid
deficiency anaemia in a man, or a woman past the organs. They are derived from lymphoid stem cells.
menopause should prompt investigation for a 27. d. Immature ‘band’ forms may appear in severe
gastrointestinal (GI) bleed (peptic ulcer or occult GI sepsis. This is also known as left shift.
cancer). Iron deficiency in a woman of childbearing Hypersegmented nuclei are seen in right shift,
age is most commonly due to menstrual losses. which occurs in non-infectious inflammatory
20. e. Diabetes mellitus is a common complication. In processes. Neutrophils are normally very high in
haemochromatosis, iron is deposited in many bacterial infections. Neutrophils tend to have a
organs, including the pancreas which leads to multilobed nucleus, with lots of granules around it.
diabetes. The skin is often pigmented giving rise to They are normally the most abundant white cell
the expression ‘bronzed diabetes’. (40–80%).
Haemochromatosis occurs after autosomal 28. b. Basophils.
recessive inheritance of the HFE mutation. There is 29. b. Bone marrow disorders that result in the clonal
an excess of iron, rather than a deficiency. Clinical production of abnormal myeloid cells. a. describes
features normally present after the age of 40. the myeloproliferative disorders, c. describes
21. b. Low serum folate. This patient appears to have leukaemias, d. describes lymphomas and e.
alcohol problems. Alcohol causes folate deficiency describes myeloma.
because of malabsorption, malnutrition and 30. d. Chronic myeloid leukaemia. It is also present in a
increased utilization. Iron deficiency anaemia is the minority of acute lymphoblastic leukaemias, and
most common anaemia in the community, but a confers a worse prognosis.
macrocytic anaemia makes this unlikely. Vitamin
B12 also causes a megaloblastic anaemia, however 31. e. Myeloma.
there are large stores in the liver and deficiency is 32. c. Acute lymphoblastic leukaemia. These signs and
normally caused by pernicious anaemia or symptoms point towards a haematological
intestinal malabsorption. This patient doesn’t malignancy. ALL is the most common leukaemia in
appear to have either. children and should be ruled out. It is always
22. e. Measure serum folate. Administration of vitamin important to have non-accidental injury in mind
B12 to patients that have folate deficiency can when seeing young or vulnerable patients.
162
MCQ Answers
33. c. Burkitt’s lymphoma. Fatigue, fever and sweating more risk of clotting. The half-life of warfarin is
imply a haematological malignancy, most approximately 40 hours, so its effects take around
specifically a lymphoma. The age and ethnicity of 2 days to wear off. Warfarin often interacts with
the patient, coupled with the jaw mass make other medications, and therefore bleeding risk is
Burkitt’s lymphoma (endemic form) the most affected. Patients on warfarin should consult their
likely. A 2-week history makes a sickle cell crisis doctor or pharmacist before starting any new
unlikely. medication (including over-the-counter or herbal
34. d. Reed–Sternberg cells. This patient appears to be remedies).
suffering from Hodgkin’s lymphoma, which is 41. c. It irreversibly inhibits cyclo-oxygenase. a. describes
diagnosed with Reed–Sternberg cells on lymph the mechanism of clopidogrel. c. describes how
node biopsy. A pepper-pot skull is seen in dipyridamole works. e. describes warfarin.
myeloma. The Philadelphia chromosome is 42. d. Atrial fibrillation (AF). AF is associated with
pathognomonic for chronic myeloid leukaemia thrombotic risk and most patients with AF are
(and is sometimes seen in acute lymphoblastic anticoagulated with warfarin or aspirin. The other
leukaemia). A positive monospot test indicates answers are associated with an increased risk of
active Epstein-Barr infection. Having more than bleeding.
20% myeloid blast cells in the bone marrow is 43. b. Prothrombin. The vitamin K-dependent clotting
indicative of acute myeloid leukaemia. factors are factors II (prothrombin), VII, IX and X.
35. a. Primary polycythaemia. 44. e. anti-Xa assay.
36. d. Trephine biopsy. 45. d. A couple who are both blood group O will only
37. c. It is associated with pathological arthrodesis. have group O children. The blood group O gene is
Inheritance is X-linked and it is unrelated to social recessive to both A and B genes. The most
class. Haemophilia A is caused by factor VIII common blood group is O. People who are
deficiency. Factor IX deficiency is haemophilia blood group AB will be self-tolerant to both A and
B. Epistaxis is a common feature of platelet B red cell antigens and so will have no A or B
disorders, as opposed to joint and muscle bleeds antibodies. Anti-A and anti-B antibodies are
which are more common in haemophilias. normally IgM. Group O plasma contains anti-A
38. b. The coagulation cascade culminates in thrombin and anti-B antibodies, and so can only be given to
cleaving fibrinogen into fibrin. The FIXa-FVIIIa- patients with blood group O.
Ca2þ is the tenase complex which is a potent 46. a. All anti-D antibodies are IgG. 85% of Caucasians
activator of FX. Prothrombin is cleaved by the are Rh D positive. Anti-D antibodies are acquired
prothrombinase complex (FXa-FVa-Ca2þ). The after sensitization (alloimmunization) e.g. transfusion
APTT measure the intrinsic pathway, while the of Rh D positive blood. The D antigen is the strongest
prothrombin time (PT) assesses the extrinsic immunogen of all the Rh antigens. Rh D positive
pathway. The surface of platelets is integral to the individuals have one or two D alleles (i.e. their
propagation step of haemostasis. Protein S is a genotype is Dd or DD). If both parents have a Dd
cofactor in the inactivation of FVa and FVIIIa. genotype there is a one in four chance that their child
39. e. Warfarin therapy. Warfarin affects the vitamin will not inherit a D allele. Their genotype would
K-dependent clotting factors (II,VII, IX and X) and therefore be dd, making them Rh D negative.
mainly affects the extrinsic pathway. The extrinsic 47. d. Anti-D antibody should be given to all rhesus D
pathway is measured with the prothrombin time negative mothers during pregnancy. HDN is most
(PT). Warfarin therapy is monitored using the commonly caused by rhesus D incompatibility, but
international normalised ratio (INR) which comes not exclusively. Other forms of incompatibility
from the PT. Haemophilias A and B (deficiency of (e.g. ABO) can occur. Rhesus negative mothers
factors VIII and IX respectively) effect the intrinsic require a sensitizing experience to create their own
pathway and therefore have prolonged activated anti-D antibodies. Thus it normally happens with
partial thromboplastin times (APTT). von pregnancies after carrying a rhesus positive child.
Willebrand’s disease affects platelets and therefore Rhesus D antibodies are always IgG. HDN is very
would most likely affect the bleeding time, rather serious and often results in hydrops fetalis.
than the clotting times (although it may cause 48. c. Low back pain.
a mild prolongation of the APTT). Protein
C deficiency would decrease the PT rather than 49. b. Factor VIII.
prolong it. 50. b. Fresh frozen plasma. This patient has received
40. c. Warfarin is teratogenic. For this reason a massive transfusion. Red cells are deficient in
anticoagulation during pregnancy should be in the clotting factors (specifically factors V and VIII),
form of heparin, which doesn’t cross the placenta. as well as platelets. The blood results from the
Warfarin affects the extrinsic pathway and hence is question indicate that she has a coagulopathy.
measured using the prothrombin time and The only answer from those available that
international normalised ratio (INR). A lower INR would replace her clotting factors is fresh
means a lower prothrombin time, and therefore frozen plasma.
163
MCQ Answers
51. c. It is composed of phagocytes and complement. 69. b. It begins to reduce in size after puberty. The
The other answers describe the adaptive immune embryonic thymus develops from the third
system. pharyngeal pouch. It is located in the anterior part
52. d. CD4þ T lymphocytes recognize antigen associated of the superior mediastinum and has two lobes.
with MHC class II. Antibodies are produced by A small minority of thymocytes mature and they
plasma cells. T helper cells are normally CD4þ. leave the thymus from the medulla via the
CD8þ T cells are not phagocytes, but can destroy postcapillary venules.
cells using other methods. 70. c. DiGeorge syndrome. Down, Edwards’ and Patau’s
53. c. IgA. IgA is present in high concentrations in syndromes are all caused by trisomies (21, 18 and
colostrum. It coats the mucosal surfaces of the 13 respectively). Graves’ disease is an autoimmune
gastrointestinal tract and affords some protection disease of the thyroid.
from pathogens while the immune system develops. 71. b. Staphylococcal enterotoxin. Toxic shock syndrome
54. a. Macrophage. is a very dangerous condition requiring prompt
55. b. Lysosome. fluid resuscitation and antibiotic therapy.
56. e. Neutrophils. 72. c. Homing due to integrin molecules. Histamine is
normally one of the chemical mediators released in
57. d. Natural killer cells. CD8þ T cells can also carry out acute inflammation, along with cytokines and
this function. chemokines. There is usually local vasodilatation
58. b. C-reactive protein. C-reactive protein (CRP) is an (hence redness and heat) with increased vascular
important marker of inflammation used clinically to permeability, which leads to an inflammatory
assess inflammation and monitor response to exudate and therefore swelling. Leucocytes leave
treatment. The other options are all cytokines. the blood and enter the tissues.
59. d. Antigen-antibody complexes activate C1. 73. d. Peyer’s patches. Other examples include the
a. describes the alternative pathway, while pharyngeal tonsils and the appendix.
c. describes the lectin pathway. b. Describes 74. d. The heavy chain determines the class of
the activation of B cells. e. Describes the activation immunoglobulin. There are two Fab fragments and
of cytotoxic T cells. just one Fc fragment. The N terminal of the light
60. d. C3b. Macrophages have a C3b receptor allowing chain is variable while the C terminal is constant.
the opsonization of some bacteria. C3a and C5a 75. a. Antibodies can neutralize virus particles, as well as
are responsible for recruiting phagocytes, as well act as an opsonin against virally infected cells.
as degranulation of mast cells. C1 is activated Interferon gamma activates macrophages and
during the classical pathway. natural killer cells. Viral peptides are presented on
61. c. Osmotic lysis. The membrane attack complex class I MHC molecules. The class I MHC molecules
(MAC), made up of C5b-C6-C7-C8-C9, punches a bind to CD8þ T cells enabling them to destroy
hole in the pathogen’s cell membrane, allowing infected cells. e. describes the actions of CD4þ T
water to rush in and destroy the pathogen. helper cells.
62. c. C1 inhibitor deficiency. 76. a. Being a latent virus.
63. b. The haplotype is found on chromosome 6. 77. e. Secretory immunoglobulin A (sIgA). sIgA can bind
64. e. Class switching. Somatic hypermutation and to bacteria and prevent them from binding to
affinity maturation are different names for the same epithelial cells.
process that increases the affinity of an antibody for 78. d. They have a lipid bilayer. This is the only
its antigen. Junctional diversity refers to the characteristic above that is particular to
increased variability in antibodies due to the Gram-negative bacteria. The MAC can perforate
formation of junctions between the various gene the lipid bilayer and cause osmotic lysis.
segments. Positive selection refers to the process in 79. e. Phagocytes.
which T cells that are able to recognize self-MHC
survive, whereas those that cannot do not. 80. b. Protozoa have complex life cycles which present
the immune system with a variety of challenges.
65. a. IgM.
81. d. Eosinophils.
66. c. Somatic hypermutation of immunoglobulin genes
occurs in the germinal centres. B cells are activated 82. c. Allergic rhinitis. IgE-mediated degranulation of
in the follicles of secondary lymphoid organs. The mast cells is the cause of type I hypersensitivity
expression of bcl-2 prevents apoptosis of the B- reactions.
cell. B cells are activated after dendritic cells 83. a. Skin prick testing. A small amount of the allergen is
present antigen. Activated T helper cells aid B cells injected into the skin. The response is compared to
in producing antibody by producing cytokines. a histamine control.
67. d. IgE. 84. b. Farmer’s lung. Type III hypersensitivity is due to
68. a. IgG. IgM, on the other hand, is the main immune complex deposition.
immunoglobulin involved in the primary immune 85. e. T helper cells. These cells secrete cytokines on
response. contact with the antigen resulting in the attraction
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and activation of macrophages. This process 96. d. Live attenuated vaccines produce a good
takes 24–72 hours to peak, hence the name cell-mediated response. Vaccines should be
delayed-type hypersensitivity. immunogenic if they are going to stimulate a host
86. d. IM adrenaline (0.5 mL of 1:1000). This dose is one response. The MMR vaccines are live attenuated
that should be known by all medical professionals. vaccines. Live attenuated vaccines are more
a. b. and c. are all used but later on in the expensive than killed vaccines, and can rarely
management. C1 inhibitor is used in hereditary induce disease in the immunocompromised.
angioedema. 97. e. Acute cellular response takes several days to
87. c. Myasthenia gravis. This disease is characterized by develop. Hyperacute rejection is rapid because
muscle weakness and fatigability. antibodies have been induced prior to
88. b. Coeliac disease. The anti-tissue transglutaminase transplantation e.g. by blood transfusion. It is
test is very sensitive and specific for coeliac disease prevented by cross-matching the donor cells and
but confirmation is needed with a duodenal recipient serum. Chronic rejection is not well
biopsy. understood and if it occurs, it cannot be treated.
Acute cellular rejection is mediated by T cells (as it
89. b. Rheumatoid arthritis. Type IV autoimmune is type IV hypersensitivity reaction).
diseases are characterized by autoimmune T cells
responses. Contact dermatitis is a form of type IV 98. d. Interleukin-2 receptor. IL-2 is the growth factor for
hypersensitivity, but is not autoimmune in nature. all lymphocytes, therefore blocking the receptor
causes severe immunosuppression.
90. b. Tumour necrosis factor alpha. TNF-a is important
for the infiltration of mononuclear cells and is the 99. b. Gastritis. Inhibition of COX-1 decreases
target of newer disease modifying anti-rheumatic gastroprotective prostaglandins, resulting in
drugs. increased stomach acid production. This can cause
gastritis and peptic ulcers. COX-1 blockade also
91. a. IgM anti-IgG antibodies. Rheumatoid factor is reduces platelet aggregation, hence aspirin is used
positive in approximately 75% of patients. as an antiplatelet agent. Cushing’s syndrome and
92. c. Acquired immunodeficiency syndrome. The rest osteoporosis are important adverse effects of
are forms of primary immunodeficiency. corticosteroid therapy. Non-steroidal anti-
93. c. A single-stranded RNA retrovirus. HIV possesses inflammatory drugs (NSAIDs) have antipyretic and
reverse transcriptase with allows it to manufacture analgesic properties as well as their actions against
double-stranded DNA which is incorporated into inflammation.
host cells genetic material. 100. e. Non-steroidal anti-inflammatory drugs (NSAIDs)
94. d. gp120. Once gp120 binds to the CD4 and CCR5 may be nephrotoxic and cause bronchospasm.
receptor a conformational change results in the NSAIDs act by inhibiting the COX enzymes.
expression of gp 41, which allows the virus to enter Hydrocortisone is given intravenously or topically.
the cell. Oral preparations of corticosteroids come in the
95. b. Bacille Calmette-Guérin. This vaccine immunizes form of prednisolone. Paracetamol is not a good
against tuberculosis. Live attenuated vaccines are anti-inflammatory but is a good antipyretic and
alive but with a reduced virulence. They should analgesic. The gastrointestinal side-effects of
never be given to immunocompromised patients. NSAIDs are mediated by COX-1 blockade.
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EMQ Answers
167
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168
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3. G. Clonal expansion of B and T lymphocytes in 3. C. Plasma cells are a mature type of B lymphocyte.
vaccination produces memory cells, which are They contain vast amounts of endoplasmic
activated in a secondary immune response. As a reticulum in order to produce a large quantity of
result, the secondary immune response is stronger, immunoglobulin.
occurs faster and lasts longer than the primary. 4. A. CD8 is a cell surface marker expressed on cytotoxic
4. A. The transfer of immunoglobulin from one individual T cells.
to another is termed passive immunity. 5. G. Cytotoxic T cells recognize antigen in conjunction
5. D. A subunit vaccine requires an adjuvant to improve with molecules of major histocompatibility complex
the immune response. (MHC) class I.
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Glossary
Active immunity Resistance to an infection or disease Haptens Small molecules which need to be bound to a
which develops as a result of infection or vaccination. large carrier molecule to be immunogenic.
Adaptive immunity An immune response which is HLA Human leucocyte antigen, the human form of
slow to respond, producing lasting immunity which MHC. Cell surface proteins that present antigen.
can be humoral or cell mediated. Hypersensitivity The inappropriate response of the
Adjuvant Substance which enhances the immune immune system to an antigen.
response to a vaccine. Immunity A state of relative resistance to a disease.
Agglutination The process by which suspended bacte- Immunoglobulin (Ig) A protein substance secreted
ria, cells or particles clump together. from plasma cells in response to infection.
Allergen Antigenic substance which stimulates a hyper- Inflammation Localized response to tissue damage
sensitivity reaction. characterized by redness, swelling, pain, oedema
ANCA Antinuclear cytoplasmic antibody, antibodies and increased white cell count.
directed against proteinase-3 (cANCA) or against Interferon A cytokine which is targeted against viruses
myeloperoxidase (pANCA). and intracellular bacteria.
Antibody Protein produced by B lymphocytes in Innate immune system Produces a non-specific re-
response to the presence of an antigen. sponse to an infection or disease.
Antigen Molecules which are recognized specifically by MHC Major histocompatibility complex, a cluster of
receptors on cells of the adaptive immune system. genes encoding for cell surface receptors which
Antigen-presenting cells Cells capable of presenting express antigen on the surface of cells.
antigenic material to cells of the adaptive immune Opsonin Substance that binds to a molecule to
system. enhance its uptake by a phagocyte.
Autoimmunity When the body’s own defences are Passive immunity Passage of immunity from one indi-
targeted against normal body cells. vidual to another.
Apoptosis Programmed cell death. Pathogen An organism that causes disease.
Atopy Possessing a genetic predisposition to an allergy. Pattern recognition molecules Molecules present
Chemotaxis The movement of cells in response to either in solution or on the surface of cells which
chemicals, often to a site of infection. are capable of recognizing molecules characteristic
Collectins A family of pattern recognition molecules, of infection.
present in solution, which stimulate the innate PCV Packed cell volume, measure of the proportion of
immune system in response to a pathogen. blood occupied by red blood cells.
Complement A series of enzymatic reactions stimu- Petechiae Punctuate haemorrhages < 2 mm in diame-
lated by the presence of a pathogen. ter, usually clustered.
Cytokine Intercellular molecules used to transmit mes- Polymorphism Slight differences in the genetic mate-
sages from one cell to another. rial of individuals within a population.
Degranulation The release of the preformed secretory Purpura Any condition with bleeding into the skin or
granule contents by fusion with the plasma mucous membrane.
membrane. Toll-like receptor Family of pattern recognition mole-
Ecchymoses (bruises) Diffuse flat haemorrhages cules on the cell surfaces which stimulate the innate
under the skin. immune system in response to a pathogen.
Erythropoietin A hormone, secreted by the kidney, Urticaria Also called hives or nettle rash, characterized
which regulates erythropoiesis. by an area of red inflammation and raised white
Haemorrhage Loss of circulating blood. bumps.
Haematocrit The relative volume of erythrocytes in the Vertical transmission Transmission of an infection
blood. from mother to fetus.
Haematoma Distinct local swelling caused by loss of Vaccine A suspension of antigenic material injected to
blood into a muscle or subcutaneous tissue. produce immunity against infection and disease.
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Index
Note: Page numbers followed by allogeneic grafts, 137 calculation of, 96t
b indicate boxes, f indicate figures and alloimmune haemolytic anaemia, 30 class switching, 97
t indicate tables. amyloidosis, 54 junctional diversity, 95–97
anaemia, 153–154 antigen-presenting cells 173, 80
aplastic, 34 antigenic drift, 112
A bone marrow in, 47f antigenic shift, 112
abciximab, 60 blood loss, 34 antiplatelet drugs, 59–60
ABO antigens, 74, 74f of chronic disease, 24–27 mechanism of action, 61f
acanthocytes, 21f clinical presentation, 154 antiretroviral drugs, 130–132, 131f
activated partial thromboplastin time, haemolytic, 27–31, 27f antithrombin, 65
63f, 72 alloimmune, 30 deficiency, 70
active immunity, 173, 135 autoimmune, 29–30, 30f, 126f apheresis, 77
active immunization, 135–137 bone marrow in, 55f aplastic anaemia, 34, 34f
types of vaccine, 135–137, 136f drug-induced, 30 bone marrow in, 55f
vaccination, 135 inheritance, 154 apoptosis 173, 86f
acute lymphoblastic leukaemia, 49–50 iron-deficiency, 23–24 aspirin, 46–47, 59, 139
acute myeloid leukaemia, 48–49, 49b bone marrow in, 55f asthma, 120–121
acute phase proteins, 86–88 megaloblastic, 25–27 atopic/allergic eczema, 121
C-reactive protein, 86f, 87 bone marrow in, 55f atopy 173, 117b
serum amyloid A, 88 pernicious, 26, 126f Auer rods, 41f
acute phase response, 88 sideroblastic, 25 autoimmune diseases
adaptive immune system 173, 80–81, anagrelide, 46 organ/cell-type-specific, 125–127,
81f, 91–107 anaphylaxis, 85, 121–122 126f
antigen processing and presentation, ANCA 173 diabetes mellitus, type 1, 126f, 127
93 angioedema, hereditary, 89, 90f Graves’ disease, 125–127, 126f,
antigen receptor diversity, 94–97 anisocytosis, 21f 127f
cell-mediated immunity see cell- anti-D antibodies, 74 Hashimoto’s thyroiditis, 125,
mediated immunity anti-inflammatory drugs, 138–140 126f
components of, 81f corticosteroids, 138–139, 139f systemic, 123–125
humoral immunity see humoral NSAIDs, 139–140, 140f rheumatoid arthritis, 120f,
immunity antibodies 173, 80 123–124, 125f
immunoglobulin domain, 91–94 bacteria, 114 systemic lupus erythematosus,
major histocompatibility complex classes, 98, 101f 119b, 123
173, 80, 92–93 functions, 98, 101f Wegener’s granulomatosis,
adjuvants 173 production, 97–98 124–125, 126f
adrenal insufficiency, 139f structure and function, 97–98, 100f vasculitides, 126f
adventitial reticular cells, 3 heavy chain, 97 autoimmune haemolytic anaemia,
agglutination 173, 101f hinge region, 98 29–30, 30f, 126f
agranulocytosis, 42–43 light chain, 97 autoimmune thrombocytopenia, 126f
AIDS/HIV, 129–132, 129f variable domain, 98 autoimmunity 173, 122–127, 160
diagnosis and monitoring, 130 viral infections, 112 antibody-mediated, 123
immune response, 130 antibody-dependent cell-mediated causes, 122–123
seroconversion illness, 130 cytotoxicity, 101f, 112 genetic predisposition, 122
transmission, 129–130 antibody-mediated reactions, 123 inappropriate MHC expression,
treatment, 130–132, 131f, 131t anticoagulation, 70–72, 71f 123
allergens 173 antigens 173 polyclonal activation, 123
allergic rhinitis, 121 ABO, 74, 74f cell-mediated, 123
allergy, 117–118, 120–122, 121f processing and presentation, 93, 94f central tolerance, 122
anaphylaxis, 121–122 rhesus, 74–75 immune-complex-mediated, 123
asthma, 120–121 antigen receptor diversity, 94–97 peripheral tolerance, 122
atopic/allergic eczema, 121 genetic rearrangements, 95–97, 96f prevention, 122
175
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Index
177
Index
178
Index
MALT see mucosal-associated lymphoid mycophenolate mofetil, 138 passive immunity 173
tissue myelodysplastic syndromes, 47–48, 47f passive immunization, 135
mannan-binding lectin, 88 myelofibrosis, 47 pathogens 173
mantle cell lymphoma, 52 bone marrow in, 55f immune response to, 112–115
March haemoglobinuria, 31 myeloid cells, left shift, 41f bacterial infections, 113
margination, 109 myeloma, 52–54 extracellular bacteria, 113–114,
mast cells, 85, 115 amyloidosis, 54 114f
degranulation, 86f, 101f bone marrow in, 55f intracellular bacteria, 114
mediators, 87f monoclonal gammopathy of protozoa, 114–115
response to helminthic infections, undetermined significance, 54 viral infections, 112–113, 113f
115 multiple, 52–53, 52f worms, 115
medical intervention, 135–140, 160 solitary (plasmacytoma), 53 pattern recognition molecules 173,
anti-inflammatory drugs, 138–140 Waldenström’s macroglobulinaemia, 79, 90
corticosteroids, 138–139, 139f 53–54 pepper pot skull, 53f
NSAIDs, 139–140, 140f myeloproliferative disorders, 45–47, 46f peptic ulcer, steroid-induced, 139f
immunization, 135–137 myelofibrosis, 47 peripheral blood film, 20
transplantation, 137–138, 138f primary polycythaemia, 46–47 peripheral tolerance, 122
prevention of rejection, 138 primary thrombocythaemia, 46 pernicious anaemia, 26, 126f
rejection mechanisms, 137, 138f myositis, 126f petechiae 173
megakaryoblasts, 57–58 Peyer’s patches, 92, 103f
megakaryocytes, 57–58 phagocytes, 79, 83–84
megakaryopoiesis, ineffective, 61
N mononuclear phagocyte system, 84
megaloblastic anaemia, 25–27 natural killer cells, 1, 80, 84–85, 86f, 115 neutrophils see neutrophils
bone marrow in, 55f neonate, protection of, 101f phagocytosis, 84, 85f, 115
folate deficiency, 26–27 neutralization, 101f phagosomes, 79
pernicious anaemia, 26 neutropenia Philadelphia chromosome, 49
vitamin B12 deficiency, 26 causes, 42–43 plasma cells, 80, 97
membrane attack complex, 80, 88–89 drugs causing, 43 chronic inflammation, 110
methotrexate, 118, 121 neutrophils, 1, 37, 38f, 41f, 80, immunoglobulin secretion, 113
MHC see major histocompatibility 83–84 plasma viscosity, 54
complex diseases associated with, 42f plasmacytoma, 53
microangiopathic haemolytic anaemia, hypersegmented, 41f plasmin, 65–66, 110
30 NOD, 90 platelets, 1, 57–59, 58f, 77
mixed connective tissue disease, 62f non-Hodgkin’s lymphoma, 51–52, 51f antiplatelet drugs, 59–60, 61f
MN antigens, 75 high-grade, 52 functions, 58–59, 59f
molecular mediators of inflammation, low-grade, 52 adhesion, 58
110, 110f non-steroidal anti-inflammatory drugs aggregation, 58, 60f
cell membrane phospholipid see NSAIDs procoagulant, 59
metabolites, 110 normoblasts, 11 release reaction, 58
complement system NSAIDs, 139–140, 140f tissue repair, 59
see complement system adverse effects and contraindications, structure and production, 57–58,
cytokines see cytokines 140 58f
coagulation system, 110 aspirin, 46–47, 59, 139 platelet count, 41f
fibrinolytic system, 110 paracetamol, 139 platelet disorders, 60–62, 61f
kinin system, 110 function defects, 62
monoclonal gammopathy of thrombocytopenia, 60–62, 62f
undetermined significance, 54 O decreased platelet production,
monocytes, 1, 38, 38f, 39, 39f, 41f, 84 60–61, 62f
opsonins 173, 84
diseases associated with, 42f decreased platelet survival, 61–62,
opsonization, 80, 90f, 101f, 123
mononuclear phagocyte system, 84 62f
osteoporosis, steroid-induced, 139f
mucosal-associated lymphoid tissue thrombotic thrombocytopenic
owl’s eye appearance, 50f
(MALT), 100–102, 102f purpura and haemolytic-uraemic
oxygen dissociation curve, 17f
gastrointestinal tract, 102 syndrome, 62
lymphocyte trafficking, 102 platelet-activating factor, 87f, 110, 110f
respiratory tract, 100–101 P platelet-derived growth factor, 110–111
multiple myeloma, 52–53, 52f Pneumocystis carinii, CD4 count, 131t
bone marrow in, 55f P antigens, 75 poikilocytosis, 21f, 47
clinical features, 52–53, 53f packed cell volume 173 polyangiitis, 126f
myasthenia gravis, 126f paracetamol, 139 polychromasia, 21f
Mycobacterium avium intracellulare, CD4 paroxysmal nocturnal polyclonal activation, 123
count, 131t haemoglobinuria, 29 polycythaemia, 35, 35f
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