Professional Documents
Culture Documents
Agam is a group of budding medicos, who are currently doing their under graduation in
various Medical Colleges across Tamil Nadu and Pondicherry. The group was initiated on 18th
November 2017, in the vision of uniting medicos for various social and professional causes.
We feel delighted to present you Agam Pathology notes prepared by Agam Divide and Rule
2020 Team to guide our fellow medicos to prepare for university examinations.
This is a reference work of 2017 batch medical students from various colleges. The team
took effort to refer many books and make them into simple notes. We are not the authors of the
following work. The images used in the documents are not copyrighted by us and is obtained from
various sources.
Dear readers, we request you to use this material as a reference note, or revision note, or
recall notes. Please do not learn the topics for the 1st time from this material, as this contain just the
required points, for revision.
Acknowledgement
On behalf of the team, Agam would like to thank all the doctors who taught us Pathology.
Agam would like to whole heartedly appreciate and thank everyone who contributed towards the
making of this material. A special thanks to Vignesh M, who took the responsibility of leading the
team. The following are the name list of the team who worked together, to bring out the material in
good form.
• Neelavathi S
• Vignesh. J
• Dharani D
• Gokula Samyuktha S
• Mahalakshmi K
• Dhyaneshwar Ra
• Harish Kumar M
• Hariharan V P
• Hannasha M Priyadharshini
• Sowmya T D
• Vimal K
• Vignesh. M
• Varsha L
• Muthamil Selvi E
• Kaushik N R
DISEASES OF IMMUNE SYSTEM
ESSAY:
1. Classify amyloidosis. Details about it
2. SLE
3. Morphology of Graft Rejection
4. AIDS
5. Hypersensitivity reactions
6. Classify primary immunodeficiency syndromes. Details about it
SHORT NOTES:
1. Graft versus Host Disease
2. Major Histocompatibility Complex
3. Mast cell
4. T- Lymphocytes
5. Primary amyloidosis
6. Bence-Jones proteins
7. Mechanisms of autoimmunity
8. Fibronectin
9. Acute Phase reactants
10.Hyper IgM syndrome
SHORT ANSWERS:
1. Sites of biopsy of amyloidosis
2. Staining character of amyloidosis
3. Sago spleen
4. Chronic granulomatous disease
5. Morphology of spleen in SLE
6. Amyloid reaction
7. LE phenomenon
8. NK cells
9. Anti-nuclear antibodies
10.Cytokines
UPDATES
PATHOLOGY AGAM
ESSAY
1. AMYLOIDOSIS
It is a condition associated with a number of inherited and inflammatory disorders in
which extracellular deposits of fibrillar proteins are responsible for tissue damage and
functional compromise
Physical nature:
Non-branching fibrils (Electron microscopy)
Cross –beta pleated sheets (X-ray crystallography) {reason for apple green
birefringence in PPL}
Chemical nature: 95%- Fibrillar protein, 5%- P component
Three most common forms of amyloid are:
AL (Amyloid light chain)
AA (Amyloid associated)
Aβ (β-Amyloid protein)
Other forms of amyloids:
ATTR (Transthyretin)
Aβ2m (β2-Microglobulin)
Prion proteins
CLASSIFICATION OF AMYLOIDOSIS:
Amyloidosis
SYSTEMIC/GENERALIZED AMYLOIDOSIS
Primary Amyloidosis:
Primary amyloidosis is associated with Plasma Cell Dyscrasias
Normally plasma cells secrete Immunoglobulins.
In plasma cell dyscrasias, there is abnormal increase in secretion of light chains of
Ig which forms amyloid
5-15% of Multiple myeloma patients develop systemic amyloidosis
Secondary Amyloidosis:
It is also known as reactive systemic amyloidosis
It is known as secondary amyloidosis because it is secondary to an associated
chronic inflammatory condition (Rheumatic arthritis/Tuberculosis/Crohn disease/
ulcerative colitis) or cancers (Hodgkin lymphoma/Renal cell carcinoma)
Here, SAA synthesis by liver cells is stimulated by IL-6 and IL-1
AGAM PATHOLOGY
Hemodialysis-associated amyloidosis:
Patients of renal failure undergoing long-term dialysis can develop amyloidosis as
a result of increased β2-Microglobulin
These patients present with carpal tunnel syndrome due to β2-Microglobulin
deposition.
HEREDITARY AMYLOIDOSIS:
Familial Mediterranean fever:
This is an Autosomal recessive autoinmflamatory syndrome with
Here there is an excessive production of IL-1 in responsive to inflammatory
response.
Familial Amyloidotic Polyneuropathy:
This is an autosomal dominant disorder.
Here ATTP (transthyritin) is accumulated as amyloid
LOCALIZED AMYLOIDOSIS:
Senile cardiac amyloidosis (ATTR):
Senile cardiac amyloidosis is seen in 50% of people above the age of 70 years.
The deposits are seen in the heart and aorta.
The type of amyloid in these cases is ATTR but without any change in the protein
structure of TTR.
Senile cerebral amyloidosis (Aβ, APrP):
Senile cerebral amyloidosis is heterogeneous group of amyloid deposition of
varying etiologies that includes sporadic, familial, hereditary and infectious.
Some of the important diseases associated with cerebral amyloidosis and the
corresponding amyloid proteins are:
Alzheimer’s disease (Aβ),
Down’s syndrome (Aβ) and
Transmissible spongiform encephalopathies (APrP) such as in:
Creutzfeldt-Jakob disease
Fatal familial insomnia
Mad cow disease.
In Alzheimer’s disease, deposit of amyloid is seen as
Congophilic angiopathy (amyloid material in the walls of cerebral blood
vessels),
Neurofibrillary tangles and
In senile plaques.
PATHOLOGY AGAM
Endocrine amyloidosis (Hormone precursors):
Some endocrine lesions are associated with microscopic deposits of amyloid. The
examples are as follows:
Medullary carcinoma of the thyroid (from procalcitonin i.e. ACal).
Islet cell tumour of the pancreas (from islet amyloid polypeptide i.e. AIAPP or
amylin).
Type 2 diabetes mellitus (from pro-insulin, i.e. AIns).
Pituitary amyloid (from prolactin i.e. APro).
Isolated atrial amyloid deposits (from atrial natriuretic factor i.e. AANF).
Familial corneal amyloidosis (from lactoferrin i.e. ALac).
MORPHOLOGY:
KIDNEY:
Amyloidosis is most common in kidney.
Amyloid deposition begins from mesangium and involves other parts later.
Patient presents with:
Proteinuria,
Urinary casts are positive
Kidney size is increased
SPLEEN:
Sago spleen - Deposits limited to splenic follicles, producing tapioca like appearance
on gross (Like javvarisi / Sabudhana)
Lardaceous spleen – Amyloid involves walls of splenic sinuses and connective tissue
framework in red pulp (World Map Like gross Picture)
LIVER:
Hepatomegaly
Amyloid appears 1st in the space of disse and progressively encroaches adjacent
parenchyma
HEART:
More commonly involved in senile systemic amyloidosis.
Deposits begin in sub-endocardium affect the conduction system causing arrhythmia.
Restrictive cardiomyopathy(most common cause is amyloidosis)
AGAM PATHOLOGY
JOINTS:
Knee joint and wrist joint are most commonly involved.
In wrist it causes carpal tunnel syndrome
GIT: Macroglossia
DIAGNOSIS:
Specimen is obtained from abdominal fat pad aspirate > rectal biopsy >tongue biopsy.
Staining (Congo red staining)
Under polarized light Apple green birefringence
Under light microscopy – salmon pink appearance
Electron microscopy – Non branching fibrils are observed
X-Ray crystallography – reveals β-plated sheets
Scintigraphy – done with the help of amyloid P
Gross stain:
On painting the cut surface of kidney gross specimen with lugols iodine, it
changes to mahagony brown color.
Then on addition of H2SO4 it turns to blue color in case of amyloidosis
Other stains used for amyloid:
H&E stain ,
PAS (Magenta colored),
Methyl violet and crystal violet,
Trioflavin stain (immunofluroscenece stain)
PATHOLOGY AGAM
2. SYSTEMIC LUPUS ERYTHEMATOSUS
Systemic lupus erythemaosus (SLE) is an autoimmune disease involving multiple
organs, characterized by a vast array of auto antibodies, particularly antinuclear
antibodies (ANAs), in which injury is caused mainly deposition of immune complexes and
binding of antibodies to various cells and tissues.
TYPES:
Systemic or disseminated form is characterized by acute and chronic inflammatory
lesions widely scattered in the body and there is presence of various nuclear and
cytoplasmic auto antibodies in the plasma.
Discoid form is characterized by chronic and localised skin lesions involving the bridge
of nose and adjacent cheeks without any systemic manifestations. Rarely, discoid
form may develop into disseminated form.
STAINING PATTERNS:
Diffuse staining – seen in all types of autoantibodies
Rim staining – seen in antibodies against ds-DNA
Speckled pattern – seen most commonly
Nucleolar pattern – seen in antibodies against RNA
Centrometric pattern – seen in patients with SLE and systemic sclerosis
ETIOPATHOGENSIS:
The fundamental defect in SLE is the failure of mechanisms that maintain self-tolerance.
GENETIC FACTORS:
Family members have a high risk for developing SLE
There is a high rate concordance in monozygotic twins
Alleles of HLA-DQ locus have been linked to produce certain autoantibodies
AGAM PATHOLOGY
IMMUNOLOGIC FACTORS:
Several immunologic aberrations may result in persistence and uncontrolled
activation of self-reactive lymphocytes.
Failure of self-tolerance in B cells
CD4+ helper T cell may escape tolerance and produce pathogenic autoantibodies to
nuclear antigens
TLR engagement by nuclear DNA and RNA contained in immune complexes may
activate B lymphocytes
Type I Interferons play a role in lymphocyte activation of B cells
MECHANISM OF INJURY:
Type III hypersensitivity reaction:
Most of the systemic lupus is caused by immune complexes DNA- anti- DNA
complexes can be detected in the glomeruli and small blood vessels.
T cell infiltrates are also frequently seen in kidneys.
Type II hypersensitivity reaction:
Autoantibodies specific for red cells, white cells and platelets opsonize these cells
and promote their phagocytosis and lysis
Antiphospholipid antibody syndrome(APLA):
Patients with antiphospholipid antibodies may develop venous and arterial
thromboses.
When it is
Associated with SLE → 2o antiphosholipid antibody syndrome
Not associated with SLE → 1o antiphospholipid antibody syndrome
CLINICAL FEATURES:
SLE, like most other auto immune diseases, is more common in women in their 2nd to
3rd decades of life.
SLE is a multisystem disease and thus a wide variety of clinical features may be
present.
The severity of disease varies from mild to intermittent to severe and fulminant.
Usually targeted organs are musculoskeletal system, skin, kidneys, nervous system,
lungs, heart and blood vessels, GI system and haematopoietic system.
Fatigue and myalgia are present in most cases throughout the course of disease.
Severe form of illness occurs with fever, weight loss, anemia and organ related
manifestations.
The disease usually runs a long course of flare-ups and remissions
Renal failure is the most frequent cause of death.
PATHOLOGY AGAM
MORPHOLOGY:
KIDNEY:
Upto 50% of SLE patients have significant renal involvement. Six patterns of
glomerular disease are seen in SLE:
Class I: Minimal mesangial lupus nephritis
Very uncommon and characterized by immune complex deposition in mesangium
Class II: Mesangial proliferative lupus nephritis
Characterized by proliferation of mesangial cells as well as immune complex
deposition on mesangium
Class III: Focal lupus nephritis
There is involvement of <50% of glomeruli.
Affected glomeruli may exhibit swelling and proliferation of endothelial and
mesangial cells associated with leukocyte accumulation, capillary necrosis and
hyaline thrombi.
Patients presents with mild hematuria, proteinuria and may progress to Acute renal
insuffiency
Class IV: Diffuse lupus erythamatosis
Most common and severe form of lupus nephritis.
There is involvement of >50% glomeruli and show proliferation of mesangial,
endothelial and epithelial cells.
Lesions may progress to scarring of glomeruli.
Patients present with hematuria, proteinuria and mild hypertension. (Wire loop
lesion)
Class V: Membranous lupus nephritis
Due to sub epithelial deposition of immune complexes, there is diffuse thickening of
capillary walls. It is associated with proteinuria or nephrotic syndrome.
Class VI: Advanced sclerosing lupus nephritis
It is characterized by sclerosis of >90% of the glomeruli and represents end stage
renal disease.
SKIN:
Butterfly rash – erythema in face along bridge of nose and cheeks (MALAR RASH)
Utricaria, bullae, maculopapular lesions
Vasculitis with fibrotic necrosis
CVS:
Myocarditis
Mitral / Aortic valve stenosis or regurgitation
Libman – Sachs endocarditis
Coronary artherosclerosis
AGAM PATHOLOGY
Blood vessels: Acute nerotizing vasculitis of small arteries and arterioles and may progress
into fibrosis and lumen narrowing
Spleen: Spleenomegaly, capsular thickening and follicular hyperplasia
Lungs: Pleuritis, plueral effusion, interstital fibrosis and so pulmonary hypertenti
Joints: Non erosive synovitis
CNS: Neuropschycotic syndromes ascribes to vasculitis or non-immune occlusion of small
vessels
ACUTE REJECTION:
Occurs within days/after termination of immunosuppressive therapy.
Acute cellular/T-Cell mediated rejection
Type-I : Tubulitis
Type-II : Endotheliitis
Type-III : Necrosis of vessel wall
Shows cellular infiltration of CD4+ & CD8+ & T-Cells
Acute Ab- mediated rejection
Damage to glomeruli & blood vessels
Deposition of C4d
PATHOLOGY AGAM
CHRONIC REJECTION:
Intimal thickening with inflammation.
Glomerulopathy
Peritubular capilaritis
Shows interstitial mononuclear cell infiltrates, including NK cells & plasma cells
AGAM PATHOLOGY
4. AIDS
INTRODUCTION:
AIDS: Acquired Combined Immunodeficiency Syndrome
Caused by: HIV [ Human Immunodeficiency Virus]
Characterized by: Severe immunosuppression causing
Opportunistic infections
Secondary neoplasms
CNS manifestations
70% Africa
People living with AIDS: 34 million
20% Asia
EPIDEMIOLOGY:
High risk groups include:
Homosexual / bisexual men
IV drug abusers
Hemophiliacs
Heterosexual contacts (mostly from men to women)
Recipients of blood and its components
HIV infection of the newborn
Parenteral transmission:
IV drug abusers
Hemophiliacs (Factor VIII and IX)
Frequent blood transfusion recipients
PATHOLOGY AGAM
ETIOLOGY – HIV:
Non transforming human retrovirus
Family: Lentivirus
2 forms:
HIV-1: US, Europe and most of the world
HIV-2: West Africa and India
STRUCTURE OF HIV:
Spherical in shape
Outer envelope (derived from host cell membrane)
Inner core, containing:
Capsid protein – p24
Nucleocapsid protein – p7/p9
Enzymes
Reverse transcriptase: Form proviral DNA
Integrase
Protease: Cleave precursor proteins
Genome: HIV-1 RNA with gag, pol, and env genes
p24 is the most abundant viral antigen [detected by ELISA]
The viral core is surrounded by matrix protein – p17
Envelope contains 2 glycoproteins gp120 and gp41
AGAM PATHOLOGY
VIRAL REPLICATION:
HIV is inefficient at infecting naïve T-cells
Presence of the enzyme APOBEC3G
Cytosine to Uracil mutation in viral protein
In mature T-cells: APOBEC3G is inactivated
Viral protein Vif: promotes degradation of APOBEC3G
Subversion from within
Sequences flanking HIV contain NF-ҡB binding site
Stimulation of cells (by antigen or cytokine) causes the release of NF-ҡB (which
enters the nucleus and binds to the promotor of several genes, including those of
cytokines)
This, in turn, activates transcription of HIV proviral DNA
vpr gene
Mucosal DC Follicular DC
PATHOLOGY AGAM
PHASES OF HIV:
Acute retroviral syndrome:
Infection of CD4+ T cells and Dendritic cells in the mucosa
Regional lymph nodes infection (as shown in flow chart) – within days
Viremia. Dissemination of virus – 3 to 7 weeks
Development of immune response
N.B.:
Occurs – 3 to 6 weeks after exposure
Resolves – in 2 to 4 weeks (spontaneously)
HIV-1 RNA levels (measure of extent of viremia) is a marker of HIV progression
Viral set point – the viral load at the end of acute phase (equilibrium b/w virus
and response are attained)
CDC classified HIV into 3 categories based on the CD4+ count:
≥500
200 – 499
<200
Clinical AIDS:
Breakdown of host defense and severe increase in plasma virus
Typical symptoms:
Long term fever (>1 month)
Diarrhea
Fatigue
Weight loss
Onset of AIDS indicator diseases (given below)
AGAM PATHOLOGY
CLINICAL FEATURES OF AIDS:
Opportunistic infections:
Protozoan:
Cryptosporidiosis/ isosporidiosis – Persistent diarrhea
Pneumocytosis (P. jiroveci) - Pneumonia
Toxoplasmosis - Encephalitis
Fungal:
Candidiasis – Oral, vaginal and esophageal
Cryptococcosis - Meningitis
Coccidioidomycosis
Histoplasmosis
Bacterial:
Mycobacteriosis (M. avium-intracellulare, M. tuberculosis)
Narcoidosis
Salmonella
Viral:
Cytomegalovirus – Eye and GIT
Herpes simplex virus – Mucocutaneous ulceration
Varicella zoster virus
Neoplasms:
Kaposi sarcoma:
Vascular tumor
Proliferation of spindle-shaped cells
Express markers of endothelium and smooth muscle
Produce proinflammatory and angiogenic factors
Slit-like vascular spaces (lesion- primitive mesenchyme)
Caused by KS herpesvirus (KSHV) / human herpesvirus 8 (HHV8)
Linked with primary effusion lymphoma and Castleman disease
Lymphomas:
Proliferation of B cells with chronic, latent viral infection
B cell hyperplasia in early HIV infection
Increased risk of mutation
MYC – Burkitt lymphoma
BLC6 – Large B cell lymphoma
Hodgkin’s lymphoma
Oral hairy cell leukoplakia
Carcinoma of cervix and anal cancer
PATHOLOGY AGAM
CNS manifestations:
Meningoencephalitis
Aseptic meningitis
Vacuolar myelopathy
Peripheral neuropathy
HIV associated neurocognitive disorder
TREATMENT:
HAART:
Highly Active Anti-Retroviral Therapy
a.k.a Combined antiretroviral therapy
Combination of 3 or 4 drugs inhibiting HIV infection at many steps
Side effects:
Lipoatrophy (loss of facial fat)
Lipoaccumulation
Insulin resistance
Peripheral neuropathy
Primary cardiovascular, renal and liver disease
Immune reconstitution inflammatory syndrome:
Patients with advanced disease, when given antiretroviral therapy, develop
paradoxical clinical deterioration.
No vaccine is currently available
Hence, Prevention, Public health measures and ART are key measures.
MORPHOLOGY:
Lesions in the brain
B cell hyperplasia with enlarged follicles (early stage)
Lymphoid involution (late stage)
Germinal centers – Hyalinized
“burnt out” lymph nodes (atrophic)
Spleen and thymus “ –waste-lands” (absence of lymphocytes)
AGAM PATHOLOGY
5. HYPERSENSITIVITY REACTION
Hypersensitivity is an excessive and immune response to antigen leading to tissue
injury, disease or sometimes death in a sensitized individual.
TYPES:
Immediate / Type1
Ab-mediated / Type2
Immune complex mediated / Type3
Cell mediated/Type4
PATHOGENESIS:
First exposure
PATHOLOGY AGAM
On subsequent exposure
EXAMPLES
Asthma
Hay fever
Allergic rhinitis
Allergic dermatitis
Pollen allergy
TESTS
Casoni test
Theobald smith test
PK reaction
Schultz dal Phenomenon
ATOPY
Genetic predisposition to type 1 hypersensitivity
Atopic individuals tend to have high serum IgE levels and more IL4 producing TH cells
than does general population.
Exposure to drugs – antibiotic like penicillin can precipitate anaphylactic shock
Insect bite
AGAM PATHOLOGY
TYPE 2 / ANTIBODY MEDIATED
Antibody that react with Antigens present on cell surface or extracellular matrix
cause disease by destroying these cells, triggering inflammation or by interfering normal
function.
PATHOGENESIS:
Ab are directed against fixed Ag
Ab can be directed against:
Cell surface
Extracellular matrix or Basement membrane
Ag fixed to BM
Ag + Ab on BM activation
Complement activation
Enzyme release
PATHOLOGY AGAM
EXAMPLES: My blood group is Rh positive
My- Myasthenia gravis
Blood- Blood transfusion reaction
Group- Good pasture syndrome
Is- Insulin resistant diabetes, Immune hemolytic anemia
R- Rheumatic fever
H- Hyperthyroidism (Graves disease), Hyperacute rejection
Positive - pernicious anemia
Superimposed
Fibrinoid necrosis Ischaemic injury thrombosis
AGAM PATHOLOGY
TYPE 4 HYPERSENSTIVITY REACTIONS
PATHOGENESIS:
Activation of CD4 T cells leads to increased IL-2, IL-12, IFN - gamma leading to
granuloma formation.
Activation of CD8 T cells leads to direct destruction of viral and tutor cells by FAS-L
mechanism or granzyme perforin mechanism.
EXAMPLES:
Rheumatoid arthritis
Multiple sclerosis
Contact dermatitis
IBD
Psoriasis
6. IMMUNODEFICIENCY SYNDROMES
Immunodeficiencies can be divided into primary or secondary disorders.
Primary Immunodeficiencies are genetically acquired.
They are caused due to intrinsic defects in immune system (innate/ adaptive).
PATHOLOGY AGAM
DEFECTS IN INNATE IMMUNITY
A. DEFECTS IN LEUCOCYTE FUNCTION:
Leucocyte Adhesion Defect:
Individuals suffering from Leucocyte Adhesion Deficiency Type -1 have defective
synthesis of β2 Chains shared by LFA-1 and Mac-1 integrins
Leucocyte Adhesion Deficiency Type -2 – Absence of Sialyl-Lewis X Ligand leading to
defective fucosyl transferase.
Recurrent bacterial infection due to inadequate granulocyte function.
Defective Phagolysosome Function:
Chediak-Higashi Syndrome - Autosomal Recessive Condition
Defective fusion of Phagosomes and lysosomes → defective phagocytic functions.
Neutropenia, defective degranulation, delayed microbial killing seen.
Leucocytes have giant granules seen in peripheral smear.
Albinism, nerve defects, platelet defects seen.
Gene associated-LYST
Microbicidal Activity Defects:
Chronic Granulomatous Disease:
Defective bacterial Killing leading to recurrent infections.
Disease results from defective gene for phagocyte oxidase which is supposed to
generate superoxide (O2•-) ion.
Name of disease comes from the macrophage rich inflammation that tries to control
the infection when initial defense is inadequate.
This leads to collection of activated macrophages in wall of microbes leading to
granulomas.
Defects in TLR signaling:
TLR3 defect- recurrent HSV encephalitis
MyD88 defect- destructive bacterial pneumonia
AGAM PATHOLOGY
Deficiency of C1 inhibitor (C1 INH) leads to recurrent hereditary angioedema.
Proteases are not inhibited which leads to increased kallikrein, releasing vasoactive
bradykinin.
There is edema of skin and mucosal surfaces (larynx, GIT), leading to asphyxia /
vomiting.
PATHOLOGY AGAM
DEFECTS IN LYMPHOCYTE MATURATION:
A. SEVERE COMBINED IMMUNODEFICIENCY (SCID):
Treatment:
HSC Transplantation is the mainstay of treatment.
Gene therapy has been successful for X-linked SCID.
Patients with ADA deficiency have also been treated with HSC transplantation and
introducing the normal ADA gene into T-cell precursors.
AGAM PATHOLOGY
B. X-LINKED AGAMMAGLOBULINEMIA (BRUTON’S AGAMMA GLOBULINEMIA):
Etiology:
Mutation in Bruton Tyrosine Kinase (Btk) gene(Xq21.22) which is a cytoplasmic
tyrosine kinase gene.
Btk gene gives a kinase which is required for maturation of pre B-cell into B-cell
stage.
Mutation of Btk gene No B-cell Maturation (blocked at pre B-cell stage) No
light chains reduced production of Ig.
Clinical manifestation:
Seen in Males and doesn’t manifest till 6 months of age(protective effect of
maternal antibodies)
Recurrent bacterial infections of respiratory tract like pharyngitis, sinusitis, otitis
media etc.
Viral infections (e.g. echovirus, polio virus) and Giardia lamblia infections occur.
Characteristic Findings:
Absent or markedly decreased B lymphocytes in circulation.
Decreased serum levels of all classes of Ig’s.
Underdeveloped of germinal centers in lymph nodes, Peyer’s patches, appendix,
tonsils.
Absence of plasma cells. Normal T-cell immunity.
C. DIGEORGE SYNDROME (THYMIC HYPOPLASIA):
Cell mediated immunity due to reduced number of T-cells.
Etiology:
DiGeorge Syndrome is a T-cell deficiency arising from failure of development of 3rd
and 4th pharyngeal pouches – which normally gives rise to the thymus, parathyroid
glands, some of the clear cells of thyroid, ultimo branchial body.
Patients develop:
C - Cleft lip and cleft palate
A - Abnormal facies
T - Thymic hypoplasia
C - Cardiac defects
H - Hypocalcemia
Point deletion (22q11 deletion) in long arm of Chr. 22 seen.
Clinical manifestations:
Presents in infancy with congenital heart defects and severe hypocalcemia (due to
hypoparathyroidism)
Infant prone to recurrent or chronic viral, bacterial, fungal and protozoal infections.
T-cell zones of lymphoid organs are depleted.
PATHOLOGY AGAM
DEFECTS IN LYMPHOCYTE ACTIVATION AND FUNCTION:
A. HYPER-IGM SYNDROME:
Affected patients make IgM antibodies but are deficient in their ability to produce IgG,
IgA, IgE antibodies.
For functioning of CD4+ helper T cells, engagement of CD40 by CD40L is required, on
the B cells, macrophages and dendritic cells.
This causes class switching of Ig’s and maturation of B cells.
Etiology:
X-linked form: Caused by mutations in the gene encoding CD40L located on Xq26.
Autosomal recessive form: Loss-of-function mutations involving either CD40 or
activation-induced cytidine deaminase (AID), a DNA-editing enzyme required for Ig
class switching and affinity maturation.
Clinical manifestation and findings:
Serum of patients have High or normal IgM but no IgA or IgE and low levels of IgG.
Patients present with recurring pyogenic infections due to less opsonizing IgG
antibodies.
Those with CD40L mutations are susceptible to Pneumocystis jiroveci because of
defective macrophage activation.
IgM antibodies may react with blood cells and cause autoimmune hemolytic
anemia, thrombocytopenia and neutropenia.
AGAM PATHOLOGY
Clinical Manifestation:
They are caused by antibody deficiency, & they resemble those of X-linked
agammaglobulinemia.
The patients typically present with recurrent sinopulmonary pyogenic infections.
In addition, about 20% of patients have recurrent herpesvirus infections.
Individuals are also prone to the development of persistent diarrhoea caused by G.
lamblia.
PATHOLOGY AGAM
IMMUNODEFICIENCIES ASSOCIATED WITH SYSTEMIC DISEASES
A. WISKOTT - ALDRICH SYNDROME:
It is an X-linked Recessive disease characterized by thrombocytopenia, eczema and
marked susceptibility to infections leading to early death.
Etiology:
Mutation in WASP gene at Xp11.23 (encoding Wiskott - Aldrich syndrome protein)
less levels of WASP.
WASP links membrane receptors to cytoskeletal elements. WASP gene mutations
affect not only T lymphocytes but also the other lymphocyte subsets and platelets.
Clinical Manifestations:
Present with recurrent bacterial infections, eczema and bleeding caused by
thrombocytopenia.
Thymus is normal.
Progressive depletion of T cells in peripheral blood and in the T-cell zones.
Increased risk of non-Hodgkin B-cell lymphomas.
Only treatment is HSC transplantation.
B. ATAXIA TELANGIECTASIA:
It is an autosomal-recessive disorder characterized by abnormal gait (ataxia), vascular
malformations (telangiectasia), neurologic deficits, increased incidence of tumors, and
immunodeficiency.
Etiology:
The gene responsible for this disorder is located on chromosome 11 and encodes a
protein called ATM (ataxia telangiectasia mutated) which is similar to
phosphatidylinositol-3 (PI-3) kinase, but is a protein kinase.
The ATM protein is a sensor of DNA damage (double strand breaks) and it activates
p53 by phosphorylation, which in turn can activate cell cycle checkpoints and
apoptosis in cells with damaged DNA.
Because of these abnormalities in DNA repair, the generation of antigen receptors
may be abnormal.
Clinical Manifestations:
Patients experience upper and lower respiratory tract bacterial infections, multiple
autoimmune phenomena, and increasingly frequent cancers with advancing age.
The most prominent humoral immune abnormalities are defective production of
isotype switched antibodies, mainly IgA and IgG2.
The T cell defects, are associated with thymic hypoplasia.
AGAM PATHOLOGY
SHORT NOTES
1. GRAFT VERSUS HOST DISEASE (GVHD)
Immunocompetent Immunocompromised
graft cells Attacks host cells
GvHD
Acute Chronic
Fibrosis
Sclerosis
Skin = Rashes Strictures
Liver = Jaundice Cholestasis jaundice
Intestine = Diarrhoea Thymic abnormalities
Eliminates
PATHOLOGY AGAM
2. MAJOR HISTOCOMPATIBILITY COMPLEX
AGAM PATHOLOGY
3. MAST CELLS
Mast: from Greek word meaning feeding, thus Mast cells-Feeding cells.
Mast cell was first observed by PAUL EHRLICH
Other Names: Mastocyte, Labrocyte.
Origin: Bone marrow derived cells that are widely distributed in the tissues.
STRUCTURE:
Resembles basophilic Granulocytes.
Contains:
Histamine
Heparin-an anticoagulant
Leukotienes
Platelet Activating Factor.
Have receptors for IgE and degranulate when cross-linked with antigen.
FUNCTION:
It acts as a receptor for IgE.
Has Electron dense granules.
Degranulation-Release contents when cross linked with antigen.
Role in allergy and anaphylaxis
Involved in wound healing, Angiogenesis, Defence against Pathogens and Blood brain
barrier functions.
MEDIATORS:
Lysosomal enzymes
Cytokines
Serine Protease
Histamine
Serotonin
Proteoglycan
ATP
Reactive Oxygen Species
Prostaglandin and leukotrienes
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CLINICAL SIGNIFICANCE:
Parasitic infections: Parasite(Protozoa and Helminth)
Allergy: Asthma, Eczema, Rhinitis, Conjuctivitis.
Anaphylaxis
Mast cell activation Syndrome.
4. T LYMPHOCYTE:
Cell Mediated Immunity. (Specific / Adaptive immunity) and delayed type of
hypersensitivity (75%-80%)
Origin: Bone marrow
Maturation/Differentiation: Thymus gland(It even matures further after leaving
Thymus)
STRUCTURE:
T cell Receptor:
Found on the surface of T cell membrane.
Has Alpha and Beta chain region corresponds Alpha and Beta Region of MHC.
TCR used for recognition of MHC.
Pan T cell Markers: CD2, CD3, CD5 and CD7.
SUBTYPES:
CD4+ T Helper cells
CD8+Suppresor / Cytotoxic T cells
Regulatory T cells
Memory T cells
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Helper T cells: (60%)
Also known as CD4 molecules
Binds to class II molecule
These cells are activated by cytokines.
TH 1-elaborate IL-2 and IFN-gamma
TH 2-elaborate IL-4, IL-5, IL-6, IL-10
TH 17-activated by TGF-b,IL-6,IL-7,IL-23 → produces IL-17
Function:
Helps B cells to synthesize Antibodies
Activates Macrophages to destroy microbes.
Regulatory cells:
Small subset of CD4+T Lymphocytes.
Function: Prevents immune reaction against self-antigen
Memory T cells:
Antigen specific T cells.
Stimulated on re exposure.
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5. PRIMARY AMYLOIDOSIS
Amyloid is usually systemic in distribution and is of the AL type.
It is the most common form of amyloidosis.
The disorder is caused by a clonal proliferation of plasma cells that synthesize an Ig that
is prone to form amyloid due to its intrinsic physiochemical properties.
Best defined is the occurrence of systemic amyloidosis in 5% to 15% of individuals with
multiple myeloma, a plasma-cell tumor characterized by multiple osteolytic lesions
throughout the skeletal system.
The malignant plasma cells synthesize abnormal amounts of a single Ig (monoclonal
gammopathy), producing an M (myeloma) protein spike on serum electrophoresis.
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7. MECHANISM OF AUTOIMMUNITY
Inheritance of susceptible genes
Incidence is greater in monozygotic twins than in dizygotic twins
HLA genes contribute greater towards auto-immunity. (especially HLA-B27)
Non MHC genes associated with auto immunity are:
PTPN 22 Rheumatoid arthritis PTPN 22 Mutation Defective tyrosine
Inflammatory bowel disease phosphatise Excessive lymphocyte activation
Type I diabetes
NOD2 Crohn Disease Defective cytoplasmic sensor of bacteria in gut.
IL2RA Multiple Sclerosis IL-2 receptor defective Development of
effectors cells and regulation of immune
Responses affected.
Role of Infections
2 mechanisms are involved.
Upregulation of co - stimulators of APC when self Ag is presented, specific T-Cells
are activated in large amounts
Cross reactivity between microbial Ag and self Ag molecular mimicry.
8. FIBRONECTIN
Fibronectin is a prototypical Adhesive Glycoprotein
It is a large (450 kD) disulfide-linked heterodimer
It exists in 2 forms:
Tissue Fibronectin, Plasma Fibronectin
Synthesized by: Fibroblasts, Monocytes, Endothelium
Fibronectin has specific domains that can bind to distinct
Extra Cellular Matrix (ECM) components (e.g., collagen, fibrin,
heparin, and proteoglycans), as well as integrins
In healing wounds, tissue & plasma Fibronectin provide the
scaffolding for subsequent ECM deposition, angiogenesis, and
re-epithelialization.
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9. ACUTE PHASE REACTANTS
A variety of Acute phase reactant proteins (APR) are released in plasma in response to
tissue trauma & infection
APR are synthesized in Liver & Macrophage
Their Major role is to protect the Normal cells from harmful effects of toxic molecules
generated in inflammation & to clear waste materials away
Deficient of APR leads to severe form of diseases in the form of chronic & repeated
inflammatory response
EXAMPLES:
Transport proteins
Ceruloplasmin
Haptoglobin
Cellular protein factors
alpha 1 antitrypsin
alpha 1 chymotrypsin
alpha 2 antiplasmin
Plasminogen activator Inhibitor
Coagulation proteins
Fibrinogen
Plasminogen
Von willebrand Factor
Factor VIII
Anti-oxidants
Ceruloplasmin
Stress proteins
Hsp
Ubiquitin
Immune agents
Serum Amyloid A & P component
C - Reactive Protein (CRP)
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10. HYPER IgM SYNDROME
In this disorder, the affected patient make IgM antibodies, but deficient in their ability
to produce IgG, IgA, IgE antibodies
More common in Male than Female
Defective in B cell Antibody Class Switching → defective lymphocyte Activation &
Function
It is now known that defect in this disease affects the ability of helper T cells to deliver
activating signals to B Cells & Macrophages
FORMS:
X Linked Recessive (70%)
Mutation in gene encoding CD40L located on xq26
Autosomal Recessive
Loss of function mutation involving either CD40 or enzyme called activation
induced cytidine deaminase (AID) a DNA editing enzyme that is required for IgG
class switching & maturation
CLINICAL FINDINGS:
Increased IgM antibodies
Decreased IgE, IgA, IgG antibodies
Number of B & T cell Normal
CLINICAL FEATURES:
Recurrent pyogenic infections, because the level of opsonizing IgG antibody is low
Mutation with CD40L are susceptible to pneumonia (Pneumocystis jiroveci)
Occasionally, the IgM antibodies react with blood cells, giving rise to autoimmune
hemolytic anemia, thrombocytopenia, and neutropenia
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VERY SHORT NOTES
1. SITES OF BIOPSY OF AMYLOIDOSIS
The diagnosis of Amyloidosis depends on the histologic demonstration of amyloid
deposit in tissue
Renal Biopsy
Rectal Biopsy
Gingival tissues
Abdominal Fat aspirates (commonly used )
Sural Nerve Biopsy
Skin Biopsy
3. SAGO SPLEEN
Grossly,
Splenic enlargement is not marked and cut surface shows characteristic translucent
pale and waxy nodules resembling sago grains and hence the name.
Microscopically,
The amyloid deposits begin in the walls of the arterioles of the white pulp and may
subsequently extend out and replace the follicles.
6. AMYLOID REACTION
The histologic diagnosis of amyloid is based on its staining characteristics.
The most common staining technique uses the dye Congo red, which under ordinary
light imparts a pink or red colour to amyloid deposits.
Under polarized light the Congo red-stained amyloid shows so-called apple-green
birefringence.
This reaction is shared by all forms of amyloid and is caused by the crossed β-pleated
configuration of amyloid fibrils.
Confirmation can be obtained by electron microscopy, which reveals amorphous non
oriented thin fibrils.
AA, AL, and ATTR types of amyloid can also be distinguished by specific immuno
histochemical staining.
7. LE PHENOMENON
In the pathogenesis of SLE, Autoantibodies specific for red cells, white cells, and
platelets opsonize these cells and promote their phagocytosis and lysis.
ANAs, which are involved in immune complex formation, cannot penetrate intact cells.
But if cell nuclei are exposed, however, the ANAs can bind to them.
In tissues, nuclei of damaged cells react with ANAs, lose their chromatin pattern, and
become homogeneous, to produce so-called LE bodies or hematoxylin bodies.
Related to this LE phenomenon is the LE cell, which is readily seen when blood is
agitated in vitro.
The LE cell is any phagocytic leukocyte (blood neutrophil or macrophage) that has
engulfed the denatured nucleus of an injured cell.
The demonstration of LE cells in vitro was used in the past as a test for SLE.
With new techniques for detection of ANAs, this test is now largely of historical
interest.
Sometimes, LE cells are found in pericardial or pleural effusions in patients.
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8. NATURAL KILLER CELLS-CYTOTOXIC LYMPHOCYTES
Structure:Large and Granular cytoplasm
Surface molecule CD16 CD56
Function:
Plays a major role in host rejection of tumor and viral infected cells.
NATURAL KILLER CELLS induce APOPTOSIS in virus-infected or tumour cells.
9. ANTINUCLEAR ANTIBODIES
They are directed against various nuclear antigens including DNA, RNA and proteins
(all together called generic ANAs) and can be grouped into different categories
10. CYTOKINES
Cytokines are soluble proteins, peptides and glycoprotein.
CLASSIFICATION:
Haematopoietin family
G-CSF,GM-CSF, Erythropoietin, Thrombopoietin, Interleukin 2,3,4,5,6,7,9
Chemokines family: Interleukin 8, MCP, NAP, PF.
Others: TNF, PDGF, TGF.
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UPDATES:
1. INNATE LYMPHOID CELLS:
Innate lymphoid cells (ILCs) are tissue-resident lymphocytes that lack T-cell antigen
receptors and cannot respond to antigens
They instead are activated by cytokines and other mediators produced at sites of tissue
damage.
They are thought to be sources of inflammatory cytokines during early phases of
immune reactions.
ILCs are classified into groups based on the dominant cytokines they produce:
Group 1 ILC producing Th1 cells
Group 2 ILC producing Th2 cells
Group 3 ILC producing Th17 cells
2. INTERFERONOPATHIES
RIG-like receptors (RLRs), named after the founding member RIG-I (retinoic acid-
inducible gene-I)
Cytosolic receptors for microbial DNA (RLRs) are often derived from viruses in the cell
They activate a pathway called STING (for stimulator of interferon genes), which leads
to the production of the antiviral cytokine interferon-α.
Excessive activation of the STING pathway causes systemic inflammatory disorders
collectively called interferonopathies.
6. RESERVOIRS OF HIV
Infected T follicular helper cells in the germinal centers are also reservoirs of HIV.
Since CTLs are largely excluded from germinal centers, these viral reservoirs cannot be
readily eliminated by the host immune response.
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5. HYPER ACUTE REJECTION
Hyperacute rejection is mediated by preformed antibodies specific for antigens on graft
endothelial cells.
The preformed antibodies may be natural IgM antibodies specific for blood group
antigens, or may be antibodies specific for allogeneic MHC molecules that were
induced by prior exposure of the organ recipient to allogeneic cells through blood
transfusions, pregnancy, or transplantation of another organ.
Immediately after the graft is implanted and blood flow is restored, the antibodies
bind to antigens on the graft vascular endothelium and activate the complement
system, leading to endothelial injury, thrombosis, and ischemic necrosis of the graft
Hyperacute rejection is rare because every donor and recipient are matched for blood
type, and potential recipients are tested for antibodies against the cells of the
prospective donor, a test called a cross-match.
Histology: Virtually all arterioles and arteries exhibit acute fibrinoid necrosis of their
walls and narrowing or complete occlusion of their lumens by thrombi
6. HAND
The clinical syndrome of CNS abnormalities is called HIV-associated neurocognitive
disorder (HAND).
It is believed that HIV is carried into the brain by both infected T cells and monocytes
(Robbins 9th edition: HIV is carried to brain by only monocytes – HIV isolates in brain
are exclusively M-tropic)
7. ONE LINERS
PD-1 receptor, an inhibitory receptor responsible for anergy, binds to two ligands, PD-
L1 and PD-L2 that are expressed on a wide variety of cells.
Endotheliitis (vascular pattern of acute cellular rejection) is also called intimal arteritis
Chronic rejection manifests as interstitial fibrosis and gradual narrowing of graft blood
vessels (graft arteriosclerosis)
Mutations affecting Th1 responses are associated with atypical mycobacterial
infections; the syndrome is called Mendelian susceptibility to mycobacterial disease.
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