Immunology

IMMUNOLOGY USMLE ENDPOINT
LYM P H O I D S T R U C T U R E S
Immune system organs
1° organs: (lymphocyte maturation)
 Bone marrow—immune cell production, B cell maturation
 Thymus—T cell maturation
2° organs: (lymphocyte activation)
 Spleen, lymph nodes, tonsils, mucosal associated lymphoid tissue (Peyer’s
patches), cutaneous associated lymphoid tissue.
 Allow immune cells to interact with antigen.
Lymph node:
 A 2° lymphoid organ that has many afferents, 1 or more efferents.
 Encapsulated, with trabeculae.
 Functions are:
1. Macrophages  nonspecific filtration.
2. Storage of B and T cells.
3. Immune response activation.
4. Site where plasma cells synthesizes antibodies.
1- Cortex
 Follicles
1. Site of B-cell localization and proliferation. In outer cortex.
2. 1° follicles are dense and dormant.
3. 2° follicles have pale central germinal centers and are active (proliferating
B cells).
4. In agammaglobulinemia, germinal centers and primary lymphoid follicles
do not form due to an absence of B cells.
1 | DR AHMED SHEBL LYM P H O I D S T R U C T U R E S

2- Medulla: Consists of:

 Medullary cords (closely packed lymphocytes and plasma cells).
 Medullary sinuses communicate with efferent lymphatics and contain reticular
cells and macrophages.
3- Paracortex:
 Houses T cells.
 Region of cortex between follicles and medulla.
 Contains high endothelial venules through which T and B cells enter from blood.
 Not well developed in patients with DiGeorge syndrome.
 Paracortex enlarges in an extreme cellular immune response (eg, viral infection).

 Mucosa-associated lymphoid tissue (MALT)

1. MALT is unencapsulated lymphoid tissue that lines the respiratory tract,
digestive tract, and genitourinary tract.
a. These are often divided into the gut-associated lymphoid tissue (GALT),
the bronchus-associated lymphoid tissue (BALT), and the nasal-associated
lymphoid tissue (NALT), as well as others.
b. GALT contains highly organized lymphoid tissue known as Peyer
patches.
These are found in the lamina propria and submucosa of the ileum and
are separated from the intestinal lumen by a layer of flattened epithelial
cells known as microfold cells (M cells).
 M cells constantly sample the intestinal lumen and transcytose
antigens to the underlying Peyer patches.
 There, APCs phagocytose the antigens and present them to
resident T cells and B cells.

Lymph drainage associations
4 | DR AHMED SHEBL Lymph drainage associations

Spleen
 Located in LUQ of abdomen, anterior to left kidney, protected by 9th-11th ribs.
 The spleen contains white pulp and red pulp, surrounded by a fibrous capsule:
1. Red pulp contains large numbers of red blood cells.
 Sinusoids are long, vascular channels in red pulp with fenestrated
―barrel hoop‖ basement membrane.
2. Macrophages and other antigen-presenting cells (APCs) phagocytose
antigens found in the red pulp and bring them to the marginal zone
surrounding the white pulp, where they present those antigens to
lymphocytes in the white pulp.
3. White pulp contains large numbers of white blood cells.
 Within the white pulp is a central artery, surrounded by a band of
T cells called the periarterial lymphatic sheath (PALS).
 White pulp also contains organized follicles of B cells.
4. The spleen also sequesters roughly one-third of the body’s platelets.
 Location of immune cells in the spleen:
1. T cells  (PALS) within the white pulp.
2. B cells  follicles within the white pulp.
3. Macrophages  marginal zone.
 It is where antigenpresenting cells (APCs) capture blood-borne
antigens for recognition by lymphocytes.
 Macrophages remove encapsulated organisms.
Splenic dysfunction: (eg, postsplenectomy, sickle cell disease.)
 ↓ IgM  ↓ complement activation  ↓ C3b opsonization  ↑ susceptibility to
encapsulated organisms ―Splenic macrophages remove encapsulated bacteria‖.
 Vaccinate patients undergoing splenectomy against encapsulated organisms
(pneumococcal, Hib, meningococcal).
5 | DR AHMED SHEBL Spleen

Postsplenectomy:
 Howell-Jolly bodies (nuclear remnants).
 Target cells.
 Thrombocytosis (loss of sequestration and removal).
 Lymphocytosis (loss of sequestration).
Thymus
 Derived from the third branch pouch; enlarges during childhood and then begins to
atrophy in puberty.
(Thymus is derived from the Third pharyngeal pouch.)
 Located in the anterosuperior mediastinum.
 Site of T-cell differentiation and maturation.
 T cells = Thymus
 B cells = Bone marrow
 Encapsulated.
6 | DR AHMED SHEBL Thymus

 Structure:
 Cortex:
 Dense with immature T cells;
 Medulla:
 Pale with mature T cells and Hassall
corpuscles A containing epithelial reticular
cells.
 Hypoplastic in DiGeorge syndrome and severe combined
immunodeficiency (SCID).
 Thymoma:
 Benign neoplasm of thymus.
 Associated with myasthenia gravis and superior vena cava syndrome.
 Normal neonatal thymus ―sail-shaped‖ on CXR B, involutes with age.
7 | DR AHMED SHEBL Thymus

LYMPHOCYTES
Innate vs adaptive immunity
 UW: Major adaptive immune mechanisms that prevent reinfection with the influenza
virus include anti-hemagglutinin antibodies.
 Antibodies to neuraminidase are not the main source of protection against
reinfection although they have some protective effect (decrease extent of viral
invasion and shedding).
8 | DR AHMED SHEBL LYMPHOCYTES

Major histocompatibility complex I and II

 MHC encoded by HLA genes.
 Present antigen fragments to T cells and bind T-cell receptors (TCRs).
9 | DR AHMED SHEBL Major histocompatibility complex I and II

 MHC Class I pathway:

 Present self-antigen, tumor antigen, or antigen synthesized by the cell due to
viral infection of that cell.
 This pathway of antigen presentation is referred to as the endogenous
pathway.
 Proteins in the cytoplasm are degraded by a proteasome and then transported
into the rough endoplasmic reticulum where they are loaded onto MHC Class I
molecules by TAP and subsequently routed to the cell surface via the Golgi
apparatus.
 They are never processed within acidified lysosomes.
 MHC Class II pathway:
 Material in the environment such as bacterial organisms, viral particles or
freely circulating antigenic material is taken up by antigen presenting cells and
degraded by acidification after endosome-lysosome fusion or phagosome-
lysosome fusion.
 Concurrently, MHC Class II molecules are synthesized in the rough
endoplasmic reticulum and routed to the endosomes by the Golgi apparatus.
 Each MHC class II molecule has a peptide fragment called an invariant chain
bound to its antigen binding site.
 The invariant chain acts to guide the MHC Class II molecule during sorting in
the Golgi and occupy the binding site until the molecule enters an acidified
endosome where it can bind foreign protein.
 Fusion of the vesicles containing MHC Class II with the acidified
phagolysosomes containing foreign antigen leads to degradation of the
invariant chain and loading of antigen onto the MHC Class II molecule.

 The MHC Class II molecule-protein antigen complexes are then displayed on

the surface of antigen presenting cells where they are available to bind the T-
cell receptors (TCR ) on T-lymphocytes and initiate a T-cell response to the
antigen they display.
 Without lysosomal acidification, antigen processing in association with
MHC class II antigens would not occur, and MHC Class II would be unable to
bind antigen and therefore, unable to bind the TCR.
HLA subtypes associated with diseases

Natural killer cells

 Part of the innate immune system and function in a fashion very similar to CD8+
CTLs with some differences:
 They express neither CD8 nor CD4 on their cell surfaces.
 Identified by specific markers (CD16, CD56).
 Do not require the thymus for maturation and are present in athymic patients.
 Have no antigen-specific activities, do not require exposure to antigen for
activation, and do not possess antigen memory ability.
 Activity enhanced by:
 IL-2, IL-12, IFN-α, and IFN-β.
 Secretes:
 IFN-γ  activates macrophages.
 Induced to kill when:
 Exposed to a nonspecifc activation signal on target cell.
 And/or to an absence of MHC I on target cell surface.
 Kill by: (do not directly lyse cells)
 Perforin and granzymes to induce apoptosis of virally infected cells and
tumor cells.
 Antibody-dependent cell-mediated cytotoxicity (CD16 binds Fc region of
bound Ig, activating the NK cell).
12 | DR AHMED SHEBL Natural killer cells

Major functions of B and T cells

B cells
 Humoral immunity.
 Recognize antigen—undergo somatic hypermutation to optimize antigen
specificity.
 Produce antibody—differentiate into plasma cells to secrete specific
immunoglobulins.
 Maintain immunologic memory—memory B cells persist and accelerate future
response to antigen.
T cells
 Cell-mediated immunity.
 CD4+ T cells
 Help B cells make antibodies and produce cytokines to recruit phagocytes
and activate other leukocytes.
 CD8+ T cells
 Directly kill virus-infected cells.
 Delayed cell-mediated hypersensitivity (type IV).
 Acute and chronic cellular organ rejection.
 Rule of 8: MHC II × CD4 = 8; MHC I × CD8 = 8.
Differentiation of T cells
13 | DR AHMED SHEBL Major functions of B and T cells

Positive selection
 Thymic cortex.
 The process by which only T cells expressing a TCR that is able to bind self MHC
are allowed to survive.
 Those cells expressing a TCR that is not specific for self MHC are signaled for
elimination by apoptosis.
 Involves interaction of T cells with thymic cortical epithelial cells expressing self
MHC.
Negative selection
 Thymic medulla.
 T cells expressing TCRs with high affinity for self-antigens undergo apoptosis or
become regulatory T cells.
 Involves interaction of the developing T cells with thymic medullary epithelial and
dendritic cells.
 This process serves to eliminate T cells that may be overly autoreactive against self-
antigens and therefore may play a role in autoimmunity if not destroyed.
 Tissue-restricted self-antigens are expressed in the thymus due to the action of
autoimmune regulator (AIRE); deficiency leads to autoimmune polyendocrine
syndrome-1.
14 | DR AHMED SHEBL Major functions of B and T cells

Antigen receptors of B and T lymphocytes
UW: With flow cytometry, a cell is found to have both CD4 & CD8 surface
antigens. Identify the cell?
 Immature cortical T lymphocytes. Immature T-lymphocytes express both
the CD4 and CD8 cell surface antigens in addition to a complete TCR. These
lymphocytes exist in the thymic cortex where they undergo positive selection
and in the thymic medulla where they undergo negative selection.
15 | DR AHMED SHEBL Antigen receptors of B and T lymphocytes

UW: Apoptosis in lymphocytes:

 The Fas receptor is expressed on T-lymphocytes and plays an important role in
the pathogenesis of numerous diseases, including cancer and autoimmune
disorders.
 Once activated, T lymphocytes begin to express FasL, which can bind to Fas on
the same cell or adjacent lymphocytes.
 During initial clonal expansion, activated T lymphocytes are resistant to Fas-
induced apoptosis.
 However they become more sensitive with progressive stimulation.
 In the constant presence of stimulating self-antigens, activated T lymphocytes
eventually undergo apoptosis in a process known as activation-induced cell
death.
 Mutations involving Fas or FasL impair this process resulting in excessive
accumulation of autoreactive T-cells and the development of autoimmune
diseases such as systemic lupus erythematosus.
16 | DR AHMED SHEBL Antigen receptors of B and T lymphocytes

Helper T cells
17 | DR AHMED SHEBL Helper T cells

 UW: Granuloma formation:

 Manifestation of cell-mediated immunity.
 Driven by products of TH1 type CD4+ helper T cells:
 IL-2  stimulates TH1 type cell proliferation (autocrine).
 Interferon-y (IFN-y)  macrophage activation.
 Langhans giant cells are characteristic of granulomatous conditions.
 They have multiple nuclei peripherally organized in the shape of a
horseshoe.
 The macrophages that form these giant cells are activated by T H1
lymphocytes.
 UW: CD4+ T helper cells are the predominant type of lymphocyte found in sarcoid
granulomas.
 Intraalveolar and interstitial accumulation of CD4+ T cells in sarcoidosis often
results in high CD4+/CD8+ T-cell ratios in bronchoalveolar lavage fluid.
18 | DR AHMED SHEBL Helper T cells

Cytotoxic T cells
 Kill virus-infected, neoplastic and donor graft cells by inducing apoptosis.
 Release cytotoxic granules containing preformed proteins (eg, perforin, granzymes).
 Cytotoxic T cells have CD8, which binds to MHC I on virus-infected cells.
Regulatory T cells
 Functions (inhibitory to the immune system):
1- Inhibit B cells from producing antibodies.
2- Inhibit CD4 and CD8 T-cells.
3- Activated regulatory T cells (Tregs) produce anti-inflammatory cytokines
(eg, IL-10, TGF-β).
4- Dysfunction of regulatory T cells has been strongly implicated in many
autoimmune disorders.
 Identified by
1- Expression of CD3, CD4, CD25, and FOXP3.
 IPEX (Immune dysregulation, Polyendocrinopathy, Enteropathy, X-linked)
syndrome:
1- Genetic deficiency of FOXP3  autoimmunity.
2- Characterized by enteropathy, endocrinopathy, nail dystrophy, dermatitis,
and/or other autoimmune dermatologic conditions.
3- Associated with diabetes in male infants.
T cell subsets
19 | DR AHMED SHEBL Cytotoxic T cells

T-cell activation
 APCs: B cells, dendritic cells, Langerhans cells, macrophages.
 Two signals are required for T-cell activation, B-cell activation, and class switching.
T-cell activation
 T cells require two signals for activation.
 Dendritic cell (specialized APC) samples antigen,
processes antigen, and migrates to the draining
lymph node.
 Th cell activation:
1. The first signal involves binding of the TCR
(CD4) to MHC class II on an APC.
2. The second signal (or co-stimulatory signal)
commonly comes from the engagement of
CD28 on the T cell with B7 (either CD80 or
CD86) on the APC.
3. Alternatively, the co-stimulatory signal may come from cytokines such as IL-2.
 Tc cell activation:
1. The first signal involves binding of the TCR (CD8) to MHC class I on
infected/ damaged cells.
2. The co-stimulatory signal is the same as in T h cell activation.
Macrophage lymphocyte interaction

1. Th1 cells secrete IFN-γ, which enhances the ability of monocytes and
macrophages to kill microbes they ingest.
2. This function is also enhanced by interaction of T cell CD40L with CD40 on
macrophages.
21 | DR AHMED SHEBL T-cell activation

B cells activation and functions

B-cell function:
1. The main function of B cells is to produce antibodies to support the
adaptive immune response.
2. B cells are defined by the surface expression of CD19, CD20, CD21, as well
as IgM and IgD.
3. After encountering antigen and becoming activated, they transform into

plasma cells, which produce large quantities of Ig against that antigen.
a. B cells are mainly activated by cytokines produced by Th2 cells,
such as IL-4, IL-5, and TGF-β.
4. Once activated, some B cells become memory B cells, which lie dormant
until they encounter their cognate antigen again, at which point they can
rapidly begin producing antibodies in response.
a. Memory B cells decrease in number with age. This is why vaccine
efficacy is decreased in the elderly.
5. B cells that produce Igs against self-antigens are signaled to undergo
apoptosis in the bone marrow in a negative selection process similar to that
seen in thymic T cells.
21 | DR AHMED SHEBL B cells activation and functions

B-cell activation and class switching

1. Th-cell activation as above.
2. B-cell receptor–mediated
endocytosis; foreign antigen is
presented on MHC II and recognized
by TCR on Th cell.
3. CD40 receptor on B cell binds CD40
ligand (CD40L) on Th cell.
4. Th cell secretes cytokines that
determine Ig class switching of B
cell. B cell activates and undergoes
class switching, affinity maturation,
and antibody production.
 Dendritic cells:
 Covered by long membranous extensions resembling the dendrites of
nerve cells.
 All display class I and II MHC and a B7 protein (either CD80 or
CD86).
 All also have CD40 which can interact with T-cells to further
activate the antigen presenting cell.
 Purpose: capture Ag at one site and present Ag at another location.
This is accomplished by migration to the LN for presentation to the
T cells.
 Different types:
 Langerhans cells, found in the epidermal layer of the skin
(cutaneous associated lymphoid tissue)
 Interstitial dendritic cells, in all organs except brain.
22 | DR AHMED SHEBL B cells activation and functions

Antibody structure and function

 Fab region:
1. Containing the variable/ hypervariable regions.
2. Consisting of light (L) and heavy (H) chains recognizes antigens.
 Heavy chain contributes to Fc and Fab regions.
 Light chain contributes only to Fab region.
Fab:
 Fragment, antigen binding
 Determines idiotype: unique
antigen-binding pocket; only
1 antigenic specificity
expressed per B cell
Fc:
 Constant
 Carboxy terminal
 Complement binding
 Carbohydrate side chains
 Determines isotype (IgM,
IgD, etc)
Generation of antibody diversity (antigen independent)

1) Random recombination of VJ (light-chain) or V(D)J (heavy-chain) genes.
i. The main mechanism by which a static genome can generate highly
variable Fab regions to bind to a nearly infinite variety of antigens.
ii. Variable (V), joining (J), and diverse (D) segments in the DNA undergo
genetic rearrangement during B-cell development.
iii. The recombinase-activating genes 1 and 2 (RAG1, RAG2) facilitate this
process. Mutations in either of these genes results in severe combined
immunodeficiency as this process is occurring in both B cell (Igs) and T
cells (TCRs).
iv. V(J)D recombination is also responsible for generating diverse TCRs.
2) Random addition of nucleotides to DNA during recombination by terminal
deoxynucleotidyl transferase (TdT).
i. Adds bases into the DNA strand each time V, D, and J segments are
spliced, in a random fashion.
3) Random combination of heavy chains with light chains.
23 | DR AHMED SHEBL Antibody structure and function


Generation of antibody specificity (antigen dependent)

1. Somatic hypermutation and affinity maturation (variable region)
 Somatic hypermutation:
1. Within the germinal center of the lymph node, affinity
maturation is accomplished by the process of somatic
hypermutation where the DNA coding for the
immunoglobulin variable region is mutated randomly at a
very high rate.
2. This process results in new immunoglobulins with similar,
better, or worse affinity for the antigen; only B cells
expressing antibody with enhanced affinity for antigen will
be selected for.
3. This occurs after a B cell recognizes an antigen and becomes
activated.
4. The resulting antibody will usually still recognize the target
antigen, but, depending on the mutations, its affinity may be
either increased or decreased.
5. B cells that produce antibodies with higher affinity will be
preferentially activated as more antigen is encountered,
causing them to proliferate.
2. Isotype switching (constant region)
Antibody functions:
 Bind to antigen.
 Neutralize the pathogen.
 Opsonize the pathogen.
 Activate the complement (Fc region of IgM and IgG fixes complement  MAC.)

Immunoglobulin isotypes
 All isotypes can exist as monomers.
 Mature, naive B cells prior to activation express IgM and IgD on their surfaces.
 They may differentiate in germinal centers of lymph nodes by isotype switching.
 Isotype class switching: (from IgM to other types of immunoglobulins)
1. The primary immune response to a new antigen initially results in plasma
cells that only produce IgM.
2. Isotype switching later occurs in the germinal centers of lymph nodes and
requires interaction of the CD40 receptor on B-cells with the CD40 ligand
(CD154) expressed by activated T-cells.
3. IgG is the main serum immunoglobulin of the secondary response.
IgG
 Main antibody in 2° (delayed) response to an antigen.
 Most abundant isotype in serum.
 Functions:
1. Fixes complement.
2. Opsonizes bacteria, neutralizes bacterial toxins and viruses.
3. Crosses the placenta (provides infants with passive immunity).
 Half-life is about 21 days.
IgA
 Prevents attachment of bacteria and viruses to mucous
membranes.
 Does not fix complement.
 Monomer (in circulation) or dimer (with J chain when
secreted).
1. Secretory IgA is formed from the association of ten
distinct protein molecules.
2. These ten proteins include four immunoglobulin light chains and four
immunoglobulin heavy chains to form the two IgA molecules, one protein known as
the J chain, and a final protein known as the secretory component.
3. While most of the components of the molecule are produced by plasma cells, the
secretory piece is synthesized by epithelial cells.
4. This component facilitates the movement of secretory IgA through the mucosal
membranes, and prevents its degradation in secretions.
 Crosses epithelial cells by transcytosis.
 Produced in GI tract (eg, by Payer patches) and protects against gut infections (eg,
Giardia).
1. Selective IgA deficiency  recurrent giardiasis.
 Most produced antibody overall, but has lower serum concentrations.
 Released into secretions (tears, saliva, and mucus) and breast milk.
1. Particularly important as a component of the colostrum, or the first breast milk fed to
an infant after birth, where it functions to provide the infant with passive mucosal
immunity.

 UW: The live attenuated oral (Sabin) poliovirus vaccine produces a stronger mucosal
secretory IgA immune response than does the inactivated poliovirus (Salk) vaccine.
This increase in mucosal IgA offers immune protection at the site of viral entry by
inhibiting attachment to intestinal epithelial cells.
 UW: Certain bacteria (eg, N gonorrhoeae, N meningitidis, Streptococcus pneumoniae,
Haemophilus influenzae) produce IgA proteases that cleave IgA at its hinge region
(yielding Fab and compromised Fc fragments), thus decreasing its effectiveness. This
facilitates bacterial adherence to mucosa (possibly due to easier bacterial access to
mucosal surface or immune disguise by binding to released Fab fragments among
others).

IgM
 Produced in the 1° (immediate) response to an
antigen.
 Fixes complement but does not cross the placenta.
 Antigen receptor on the surface of B cells.
 Monomer on B cell, pentamer with J chain when
secreted.
 Pentamer enables avid binding to antigen while humoral response evolves.
IgD
 Unclear function. Found on surface of many B cells and in serum.
IgE
 Binds mast cells and basophils; cross-links when exposed to allergen, mediating
immediate (type I) hypersensitivity through release of
inflammatory mediators such as histamine.
 Lowest concentration in serum.
 Contributes to immunity to worms by activating eosinophils.
Eosinophils play a role in host

defense during parasitic infection.
When stimulated by antibodies
bound to a parasitic organism, they
destroy the parasite via antibody-
dependent cell-mediated
cytotoxicity with enzymes from
their cytoplasmic granules.
 UW: Omalizumab (anti-IgE) is used in moderate-to-severe asthma.

 Many asthmatics frequently have allergies as a trigger due to a high IgE
response in the body.
 Omalizumab decreases the allergic response.
 Studies have shown that patients receiving omalizumab have fewer
exacerbations of asthma and are able to discontinue the use of oral
glucocorticoids and decrease the dose of inhaled steroids.

Antigen type and memory

Thymus-independent antigens
 Antigens lacking a peptide component (eg, lipopolysaccharides from gram ⊝
bacteria); cannot be presented by MHC to T cells.
 Weakly immunogenic; vaccines often require boosters and adjuvants (eg,
pneumococcal polysaccharide vaccine).
1. Streptococcus pneumonia, Neisseria meningitidis, and Haemophilus influenza
are encapsulated bacteria whose polysaccharide capsule components can be
covalently bound to protein carriers and used as vaccine antigens.
2. The protein carriers convert the polysaccharides from T-cell independent to T-
cell dependent antigens.
3. Approved carrier proteins include:
A. Mutant nontoxic diphtheria toxin.
B. Neisseria meningitidis outer membrane protein complex.
C. Tetanus toxoid.
Thymus-dependent antigens
 Antigens containing a protein component (eg, diphtheria vaccine).
 Class switching and immunologic memory occur as a result of direct contact of B
cells with Th cells.
29 | DR AHMED SHEBL Antigen type and memory

Immune response
Acute-phase reactants
 Factors whose serum concentrations change significantly in response to inflammation.
 Produced by the liver in both acute and chronic inflammatory states.
 Induced by IL-6.
POSITIVE (UPREGULATED)
 C-reactive protein:
 Opsonin  facilitates phagocytosis.
 Fixes complement.
 Measured clinically as a nonspecific sign of ongoing inflammation.
 Ferritin:
 Binds and sequesters iron to inhibit microbial iron scavenging.
 Fibrinogen:
 Coagulation factor; promotes endothelial repair.
 Correlates with ESR.
 Hepcidin:
 ↓ Iron absorption (by degrading ferroportin) and ↓ iron release (from
macrophages)  anemia of chronic disease.
 Serum amyloid A:
 Prolonged elevation can lead to amyloidosis.
NEGATIVE (DOWNREGULATED)
 Albumin:
 Reduction conserves amino acids for positive reactants.
 Transferrin:
 Internalized by macrophages to sequester iron.
31 | DR AHMED SHEBL Acute-phase reactants

Complement
 System of hepatically synthesized plasma proteins that play a role in innate immunity
and inflammation.
 Membrane attack complex (MAC) defends against gram ⊝ bacteria.
ACTIVATION
 Classic pathway  by IgG or IgM mediated. (GM makes classic cars.)
 Alternative pathway  by microbe surface molecules.
 Lectin pathway  by mannose or other sugars on microbe surface.
FUNCTIONS
 C3b—opsonization. (C3b binds bacteria.)
 C3a, C4a, C5a—anaphylaxis.
 C5a—neutrophil chemotaxis.
 C5b-9—cytolysis by MAC.
Opsonins
 C3b and IgG are the two 1° opsonins in bacterial defense; enhance phagocytosis.
(Opsonin (Greek) = to prepare for eating.)
 C3b also helps clear immune complexes.
Inhibitors (prevent complement activation on self-cells (eg, RBCs).

 Decay-accelerating factor (DAF, aka CD55).
 C1 esterase inhibitor
31 | DR AHMED SHEBL Complement

Complement disorders
Complement protein deficiencies
 Early complement deficiency (C1-C4):
 Increased risk of severe, recurrent pyogenic sinus and respiratory tract
infections.
 Increased risk of SLE.
 ↑ Susceptibility to type III hypersensitivity reactions.
 Terminal complement deficiencies (C5–C9) (membrane attack complex):
 ↑ Susceptibility to recurrent Neisseria bacteremia.
 UW: Clinically, N. meningitides presents with high fever, chills,
altered mentation, petechial skin rash from Neisseria-induced small-
vessel vasculitis (especially affecting palms and soles), and ultimately
septic shock.
 The treatment is intravenous ceftriaxone for at least 2 weeks.
Complement regulatory protein deficiencies

 C1 esterase inhibitor deficiency:
 Causes hereditary angioedema due to unregulated activation of kallikrein 
↑ bradykinin.
 Characterized by ↓ C4 levels.
 ACE inhibitors are contraindicated.
 C1 esterase inhibitor is inhibited directly by bradykinin, which
explains the rare but life-threatening angioedema that may result as a
side effect of angiotensin-converting enzyme (ACE) inhibitors (ACE is
responsible for the degradation of bradykinin).
 Paroxysmal nocturnal hemoglobinuria (CD55 deficiency):
 A defect in the PIGA gene preventing the formation of anchors for
complement inhibitors, such as decay-accelerating factor (DAF/CD55) and
membrane inhibitor of reactive lysis (MIRL/CD59).
 Causes complement-mediated lysis of RBCs.
32 | DR AHMED SHEBL Complement disorders

Important cytokines
33 | DR AHMED SHEBL Important cytokines

CYTOKINES SECRETED BY MACROPHAGES (IL-1, 6, 8, 12, TNF- α)

 Interleukin-1
 Causes fever, acute inflammation. ―Hot T-bone stEAK‖:
 Activates endothelium to express adhesion IL-1: fever (hot).
molecules. IL-2: stimulates T cells.
 Induces chemokine secretion to recruit WBCs. IL-3: stimulates bone
 Interleukin-6 marrow.
IL-4: stimulates IgE
 Causes fever.
production.
 Stimulates production of acute phase proteins.
IL-5: stimulates IgA
 Interleukin-8
production.
 Major chemotactic factor for neutrophils. IL-6: stimulates aKute-
 ―Clean up on aisle 8.‖ Neutrophils are recruited phase protein
by IL-8 to clear infections. production.
 Also induces phagocytosis in neutrophils once
they have arrived.
 Interleukin-12
 Induces differentiation of T cells into Th1 cells.
 Activates NK cells.
 Tumor necrosis factor-α
 Produced by macrophages in response to bacterial endotoxin and causes
symptoms of septic shock (eg, fever, hypotension, and tachycardia) when
released in large amounts.
 Pro-inflamatory
 Activates endothelium, causes WBC recruitment, vascular leak.
 IL-1, IL-6, and TNF-α can mediate sepsis.
 Causes cachexia in malignancy.
 Maintains granulomas in TB.
 TNF- is directly inhibited by the monoclonal antibodies infliximab,
adalimumab, and golimumab as well as the fusion protein etanercept.

CYTOKINES SECRETED BY ALL T CELLS (IL-2, 3)

 Interleukin-2
 Functions:
 Stimulates growth of helper, cytotoxic, and regulatory T cells, and NK
cells.
 Secreted by:
 T helper cells.
 Antigen binding to the T cell receptor stimulates the secretion of IL-2
and the expression of IL-2 receptors (IL-2R).
 Drugs:
 Recombinant IL-2 (aldesleukin) is used to treat metastatic renal cell
carcinoma and metastatic melanoma.
 Basiliximab, which blocks the action of IL-2 by binding the IL-2
receptor on cells, is used to prevent transplant rejection.
UW: patient with renal cell carcinoma is given IL-2 (aldesleukin)  the tumor regress.
Explain why??
The increased activity of T cells and natural killer cells is thought to be responsible for
IL-2 s anti-cancer effect on metastatic melanoma and renal cell carcinoma.
 Interleukin-3
 Supports growth and differentiation of bone marrow stem cells.
 Functions like GM-CSF.

CYTOKINES FROM Th1 CELLS

 Interferon-γ
 Secreted by:
 NK cells and T cells in response to antigen or IL-12 from
macrophages.
 Functions:
 Stimulates macrophages to kill phagocytosed pathogens.
 Inhibits differentiation of Th2 cells.
 Also activates NK cells to kill virus-infected cells.
 Increases MHC expression and antigen presentation by all cells.
UW: Autosomal recessive deficiencies of the IFN-gamma receptor (or other elements
of this pathway) result in disseminated mycobacterial disease in infancy or early
childhood, including disseminated infection by the BCG vaccine strain if administered.
Once identified, these patients require lifelong treatment with continuous
antimycobacterial antibiotics.
UW: Pulmonary tuberculosis infection is controlled through the action of CD4+, TH1
lymphocytes and macrophages. These cells work together to contain M. tuberculosis
within a caseous granuloma, which offers the macrophages inside an opportunity to kill
the remaining organisms if the necrotic area is small enough.
UW: ↑ susceptibility of patients with silicosis to pulmonary tuberculosis, why?
 In silicosis, there may be disruption of macrophage phagolysosomes by
internalized silica particles.
 Macrophage killing of intracellular mycobacteria may be impaired as a
result.

FROM Th2 CELLS

 Interleukin-4
 Induces differentiation of T cells into Th2 cells.
 Promotes growth of B cells. Enhances class switching to IgE and IgG.
 Interleukin-5
 Promotes growth and differentiation of B cells.
 Enhances class switching to IgA.
 Stimulates growth and differentiation of eosinophils.
 Interleukin-10
 Attenuates inflammatory response (anti-inflammatory).
 Decreases expression of MHC class II and Th1 cytokines.
 Inhibits activated macrophages and dendritic cells.
 Also secreted by regulatory T cells.
 TGF-β and IL-10 both attenuate the immune response.
Other interleukins:
 IL-11
 Stimulates the growth of megakaryocytes and granulocyte-macrophage
progenitors in the bone marrow.
 Oprelvekin is a recombinant form of IL-11 that is administered to patients
after chemotherapy treatments to stimulate the bone marrow to produce
platelets.
 IL-12
 Secreted by:
 APCs
 Intracellularly infected cells.
 It is one of the main cytokines that stimulates the development of Th 1
responses.

Respiratory burst (oxidative burst)

 Involves the activation of the phagocyte NADPH oxidase complex (eg, in
neutrophils, monocytes), which utilizes O2 as a substrate.
 Plays an important role in the immune response  rapid release of reactive oxygen
species (ROS).
 NADPH plays a role in both the creation and neutralization of ROS.
 Myeloperoxidase is a blue-green heme-containing pigment that gives sputum its
color.
 Phagocytes of patients with CGD can utilize H2O2 generated by invading organisms
and convert it to ROS.
 Patients are at ↑ risk for infection by catalase ⊕ species (eg, S aureus, Aspergillus)
capable of neutralizing their own H2O2, leaving phagocytes without ROS for fighting
infections.
 Pyocyanin of P aeruginosa functions to generate ROS to kill competing microbes.
 Oxidative burst also leads to K+ influx, which releases lysosomal enzymes from
proteoglycans.
 Lactoferrin is a protein found in secretory fluids and neutrophils that inhibits
microbial growth via iron chelation.
38 | DR AHMED SHEBL Respiratory burst (oxidative burst)

Interferon-α and -β
 A part of innate host defense against both RNA and DNA viruses.
 Interferons are glycoproteins synthesized by virus-infected cells that act locally on
uninfected cells, “priming them” for viral defense by:
 Downregulating protein synthesis to resist potential viral replication.
 Upregulating MHC expression to facilitate recognition of infected cells.
 Promoting apoptosis of infected cells, limiting the ability of viruses to spread
through the tissues.
Cell surface proteins

 MHC I present on all nucleated cells (ie, not mature RBCs).
T cells
 TCR (binds antigen-MHC complex)
 CD3 (associated with TCR for signal transduction)
 CD28 (binds B7 on APC)
 CXCR4/CCR5 (co-receptors for HIV)
Helper T cells
 CD4, CD40L
Cytotoxic T cells
 CD8
 CXCR4/CCR5
Regulatory T cells
 CD4, CD25
B cells
 Ig (binds antigen)
 CD19, CD20, CD21 (receptor for EBV), You can drink Beer at the Bar when you’re
21: B cells, Epstein-Barr virus, CD21.
 CD40
 MHC II, B7
Macrophages
 CD14 (receptor for PAMPs, eg, LPS), CD40
 CCR5
 MHC II, B7 (CD80/86)
 Fc and C3b receptors (enhanced phagocytosis)
39 | DR AHMED SHEBL Interferon-α and -β

NK cells
 CD56 (suggestive marker for NK)
Hematopoietic stem cells

 CD34
Tolerance
 Immunologic unresponsiveness to self-antigens.
 Central tolerance is acquired within the fetal thymus during negative
selection.
 Peripheral tolerance develops by means of T-cell anergy, which is the
functional inactivation of T-cells that are reactive to self-antigens.
Anergy
 State during which a cell cannot become activated by exposure to its antigen.
 T and B cells become anergic when exposed to their antigen without
costimulatory
signal (signal 2).
 It occurs when self-reactive T cells bind MHC molecules without
receiving the necessary costimulatory signal (ie, binding of CD28 on
T cells with the B7 on antigen-presenting cells).
 Another mechanism of self-tolerance.
41 | DR AHMED SHEBL Tolerance

Effects of bacterial toxins

 Superantigens (S pyogenes and S aureus):
 Cross-link the β region of the T-cell receptor to the MHC class II on
APCs.
 Can activate any CD4+ T cell  massive release of cytokines.
 Endotoxins/lipopolysaccharide (gram ⊝ bacteria)
 Directly stimulate macrophages by binding to endotoxin receptor
TLR4/CD14.
 Th cells are not involved.
Antigenic variation
 Classic examples:
 Bacteria—Salmonella (2 flagellar variants), Borrelia recurrentis
(relapsing fever), N gonorrhoeae (pilus protein).
 Viruses—influenza, HIV, HCV
 Parasites—trypanosomes
 Some mechanisms for variation include DNA rearrangement and RNA
segment reassortment (eg, influenza major shift) or protein mutations (eg,
influenza minor drift).
Passive vs active immunity
41 | DR AHMED SHEBL Effects of bacterial toxins

Vaccination
 Induces an active immune response (humoral and/or cellular) to specific
pathogens.
Live attenuated vaccine:

 Microorganism loses its pathogenicity but retains capacity for transient
growth within inoculated host.
 Induces cellular and humoral responses.
 MMR and varicella are live vaccines that can be given to patients with HIV
who have a CD4 cell count > 200/mm3.
Pro:
 Induces strong, often lifelong immunity.
Con:
 May revert to virulent form.
 Often contraindicated in pregnancy and immunodeficiency.
Examples:
 Adenovirus (nonattenuated, given to military recruits), Polio (sabin),
Varicella (chickenpox), Smallpox,
BCG, Yellow fever, Influenza (intranasal), MMR, Rotavirus
―Attention! Please Vaccinate Small, Beautiful Young Infants with MMR
Regularly!‖
Inactivated or killed vaccine:

 Pathogen is inactivated by heat or chemicals.
 Maintaining epitope structure on surface antigens is important for immune
response.
 Mainly induces a humoral response.
Pro:
 Safer than live vaccines.
Con:
 Weaker immune response; booster shots usually required.
Rabies, Influenza (injection), Polio (Salk), hepatitis A (―R.I.P. Always‖).
42 | DR AHMED SHEBL Vaccination

Subunit
 Includes only the antigens that best stimulate the immune system.
Pros:
 Lower chance of adverse reactions.
Cons:
 Expensive, weaker immune response.
Examples:
 HBV (antigen = HBsAg), HPV (types 6, 11, 16, and 18), acellular pertussis
(aP), Neisseria meningitidis
(various strains), Streptococcus pneumoniae, Haemophilus influenzae type b.
Toxoid
 Denatured bacterial toxin with an intact receptor binding site.
 Stimulates the immune system to make antibodies without potential for
causing disease.
Pros:
 Protects against the bacterial toxins.
Cons:
 Antitoxin levels decrease with time, may require a booster.
 Clostridium tetani, Corynebacterium diphtheriae
UW: Inactivated (killed or component) viral vaccines predominantly generate a

humoral immune response instead of a cell-mediated immune response.
In contrast, live attenuated viral vaccines can generate a strong cell-mediated immune
response in addition to providing humoral immunity.

UW: 7 years-child injured & vaccinations are up-to-date. Why the patient does
never develops tetanus?
 Circulating antibodies that neutralize bacterial products.
 Tetanus
 Prevention by the tetanus toxoid (formaldehyde-inactivated
tetanus toxin) vaccination.
 This vaccination elicits humoral immunity specific for the
tetanus toxin (neutralization of the invading toxins).
 Treatment by Tetanus immune globulin and for tetanus
prophylaxis after an injury if the wound is grossly contaminated.
 Tetanospasmin
 Protein toxin produced by C. tetani that can travel by retrograde
axonal transport into the CNS.
 It has 2 components:
 Heavy chain  binds ganglioside receptors on neuronal
membranes.
 light chain  inhibits release of glycine and GABA
o Absence of these inhibitory neurotransmitters causes
sustained muscle contraction, or tetanus.
 Prominent signs and symptoms include masseter muscle spasm
(lockjaw), opisthotonos, dysphagia, and facial muscle spasm
(risus sardonicus).

UW: Influenza vaccines

 Include an inactivated (killed) vaccine administered by injection and a live-
attenuated vaccine given by nasal spray.
 Each seasonal influenza vaccine contains antigens (or attenuated virions) from 3 or
4 influenza A and B virus strains.
 Antigens from multiple influenza types are included in the vaccine because
antibodies against 1 strain confer limited or no protection against the others.
 Recommendations:
 Annual vaccination is recommended due to waning effectiveness over
time and because circulating strains of influenza change from year to year.
 All individuals age >6 months should be immunized, especially health care
workers and those at risk of serious complications such as the elderly
patients with chronic illness, and immunocompromised individuals.
 Inactivated versions of the influenza vaccine function
 Mainly by inducing neutralizing antibodies against the hemagglutinin
antigen in selected viral strains.
 Upon subsequent exposure to the influenza virus through natural infection,
these antibodies inhibit binding of hemagglutinin to sialylated receptors
on the host cell membrane.
 This prevents the live virus from entering cells via endocytosis.

Hypersensitivity types
 Four types: Anaphylactic and Atopic (type I), Cytotoxic (antibody mediated,
type II), Immune complex (type III), Delayed (cell mediated, type IV)
(ACID).
Type I
 Anaphylactic and atopic—free antigen crosslinks IgE on presensitized mast
cells and basophils, triggering immediate release of vasoactive amines that
act at postcapillary venules (ie, histamine).
 Reaction develops rapidly after antigen exposure because of preformed
antibody.
 Delayed phase results from mast cells and basophils releasing cytokines that
induce cellular inflammation.
 First (type) and Fast (anaphylaxis).
 Types I, II, and III are all antibody mediated.
 Test: skin test or blood test (ELISA) for allergen specific IgE.
 Example:
 Anaphylaxis (eg, food, drug, or bee sting allergies)
46 | DR AHMED SHEBL Hypersensitivity types


UW: Anaphylaxis results from widespread mast cell and basophil degranulation
and resultant histamine and tryptase release.
Tryptase is an enzyme that is relatively specific to mast cells, and elevated serum
levels of tryptase are often used to support a clinical diagnosis of anaphylaxis after
the patient has been stabilized.
Type II hypersensitivity
 Antibodies bind to cell-surface antigens  cellular destruction, inflammation,
and cellular dysfunction.
 Cellular destruction: cell is opsonized (coated) by antibodies, leading to
either:
 Phagocytosis and/or activation of complement system.
 NK cell killing (antibody-dependent cellular cytotoxicity).
 Examples:
 Autoimmune-hemolytic anemia.
 Immune thrombocytopenic purpura.
 Transfusion reactions.
 Hemolytic disease of the newborn.
 Inflammation: binding of antibodies to cell surfaces  activation of
complement system and Fc receptor-mediated inflammation.
 Examples:
 Goodpasture syndrome, Rheumatic fever.
 Hyperacute transplant rejection.
 Cellular dysfunction: antibodies bind to cell surface receptors  abnormal
blockade or activation of downstream process.
 Examples:
 Myasthenia gravis, Graves’ disease.

In subsequent pregnancies with an Rh(D)+ fetus, these antibodies cross the placenta
and opsonize fetal erythrocytes, causing hemolysis.
Anti-Rh immunoglobulin consists of IgG anti-D antibodies that opsonize Rh+ fetal
erythrocytes, promoting clearance by maternal reticuloendothelial macrophages and
preventing maternal Rh sensitization. It is routinely administered to Rh-negative
women at 28 weeks gestation and immediately postpartum.

Type III hypersensitivity

 Immune complex—antigen-antibody (IgG) complexes activate complement,
which attracts neutrophils; neutrophils release lysosomal enzymes.
 Can be associated with vasculitis and systemic manifestations.
 In type III reaction, imagine an immune complex as 3 things stuck together:
antigen-antibody-complement.
 Examples:
 SLE.
 Polyarteritis nodosa.
 Henoch-Schonlein purpura (IgA immune
complex mediated vasculitis).
 Poststreptococcal glomerulonephritis.
Serum sickness
 An immune complex disease in which antibodies to
foreign proteins are produced (takes 5 days).
 Immune complexes form and are deposited in
membranes, where they fix complement (leads to
tissue damage).
 More common than Arthus reaction.
 Most serum sickness is now caused by drugs (not serum) acting as haptens.
 Fever, urticaria, arthralgia, proteinuria, lymphadenopathy occur 5–10 days
after antigen exposure.
Arthus reaction
 A local subacute antibody mediated hypersensitivity reaction.
 Intradermal injection of antigen into a presensitized (has circulating IgG)
individual leads to immune complex formation in the skin.
 Characterized by edema, necrosis, and activation of complement.
 Antigen-antibody complexes cause the Arthus reaction.

Type IV hypersensitivity
 Two mechanisms, each involving T cells:
 Direct cell cytotoxicity:
 CD8+ cytotoxic T cells kill targeted cells.
 Example: Type 1 diabetes mellitus
 Delayed-type hypersensitivity:
 Sensitized CD4+ helper T cells encounter antigen and release
cytokines  inflammation and macrophage activation.
 Examples:
o Contact dermatitis (eg, poison ivy, nickel allergy).
 Intensely pruritic erythematous papules,
vesicles, or bullae that often form linear
patterns.
 Appears in areas where direct contact occurred.
o Graft-versus-host disease.
o Tests: PPD, patch test.
o Candida skin test.
 Response does not involve antibodies (vs types I, II, and III) or complement.
4T’s: T cells, Transplant rejections, TB skin tests, Touching (contact
dermatitis).
Fourth (type) and last (delayed).



Blood transfusion reactions
 UW: Acute hemolytic transfusion reactions:

 Example of an antibody-mediated (type II) hypersensitivity reaction.
 Anti-ABO antibodies (mainly IgM) in the recipient bind the corresponding
antigens on transfused donor erythrocytes, leading to complement
activation.
 Anaphylatoxins (C3a and C5a) cause vasodilatation and symptoms of
shock.
 While formation of the membrane attack complex (C5b-C9) leads to
complement-mediated cell lysis.
 UW: Patients with selective IgA deficiency
 Often form IgG antibodies directed against IgA (eg, anti-IgA antibodies).
 When transfused with blood or blood products containing small amounts of
IgA these patients may develop potentially fatal anaphylactic reactions.
 Gamma-globulin preparations should not be used for treatment of these
patients as it may increase the synthesis of anti-IgA antibodies.
54 | DR AHMED SHEBL Blood transfusion reactions

Autoantibodies
55 | DR AHMED SHEBL Autoantibodies

 The following autoantibodies are commonly seen in SLE:

1. Antinuclear antibodies (ANA):
i. Found in virtually all patients with SLE, as well as in patients
with other connective tissue disorders.
ii. This test is sensitive but not specific for SLE.
2. Anti-double stranded DNA (anti-dsDNA) antibodies:
i. Highly specific for SLE.
ii. Only about 60% of SLE patients have high anti-dsDNA titers, thus
absence of anti-dsDNA antibodies does not rule out the diagnosis.
3. Antibodies against small nuclear ribonucleoproteins (anti-snRNPs)
(anti-Smith antibodies):
i. Present in 20-30% of SLE patients and are also highly specific for
SLE.
ii. Absence of anti-Sm antibodies does not rule out the diagnosis.
 Up to 30% of patients with SLE have antiphospholipid antibodies, which can
cause
 Paradoxical aPTT prolongation.
 False-positive RPR/VDRL.
 UW: Rheumatoid arthritis is

 Autoimmune disease triggered by an unknown antigen.
 Cartilage components serve as autoantigens that activate CD4 T-cells
which in turn stimulate B-cells to secrete rheumatoid factor.
 An IgM antibody specific for the Fc component of self IgG.
56 | DR AHMED SHEBL Autoantibodies

Immunodefciencies
B-cell defect  Patients are at an increased risk of pyogenic infections particularly due to an
inability to mount a humoral immune response against organisms with a polysacchande
capsule such as Neisseria meningitidis, Haemophilus influenzae and Streptococcus
pneumonia.
The T-cell defect leads to infections with opportunistic pathogens such as Pneumocystis
jiroveci and herpes viridae.
57 | DR AHMED SHEBL Immunodefciencies

B-cell disorders
1- X-linked (Bruton) agammaglobulinemia
 DEFECT:
 A mutation in the gene for Bruton tyrosine kinase (BTK) prevents B-
cell maturation  failure of bone marrow pre-B cells (CD19+,
CD20+) to develop into mature, circulating B lymphocytes (CD19+,
CD20+, CD21+).
 These patients have extremely low levels of antibodies and have
underdeveloped lymphoid organs.
 X-linked recessive (↑ in Boys).
 PRESENTATION:
 Recurrent bacterial and enteroviral infections after 6 months (↓
maternal IgG).
 Giardia lamblia gastroenteritis.
 Findings:
 Absent B cells in peripheral blood, ↓ Ig of all classes.
 Absent/scanty lymph nodes and tonsils.
 Live vaccines contraindicated.
 UW: recurrent infections in the setting of intact T lymphocyte function
(positive response to Candida antigens) and very low immunoglobulin
levels are suggestive of X-linked agammaglobulinemia.
2- Selective IgA deficiency
 DEFECT
 Unknown. Most common 1° immunodeficiency.
 PRESENTATION:
 Majority Asymptomatic.
 Can see recurrent Airway and GI infections, Autoimmune disease, Atopy,
Anaphylaxis to IgA-containing products.
 Findings:
 ↓ IgA with normal IgG, IgM levels.
 ↑ Susceptibility to giardiasis.
 Giardia lamblia causes injury to the duodenal and jejunal mucosa
by adhering to the intestinal brush border and releasing molecules
that induce a mucosal inflammatory response.
 Secretory IgA, which impairs adherence, is the major component of
adaptive immunity against G lamblia infection.
 Conditions causing IgA deficiency predispose patients to chronic
giardiasis.

3- Common variable immunodeficiency

 DEFECT
 Defect in B-cell differentiation. Many causes.
 PRESENTATION:
 Usually presents after age 2 and may be considerably delayed.
 ↑ Risk of autoimmune disease, bronchiectasis, lymphoma,
sinopulmonary infections.
 Cell-mediated immunity is not as impaired as in SCID and thymic
aplasia is unlikely.
 Findings:
 ↓ Plasma cells, ↓ immunoglobulins.
T-cell disorders
1- Thymic aplasia (DiGeorge syndrome)
 22q11 deletion; failure to develop 3rd and 4th pharyngeal pouches  absent
thymus and parathyroids.
 Presentation:
 Parathyroid defect  tetany (hypocalcemia)  ↓ PTH, ↓ Ca2+.
 Thymic defect:
 Recurrent viral/fungal infections (T-cell deficiency).
 Absent thymic shadow on CXR.
 Conotruncal abnormalities (eg, tetralogy of Fallot, truncus
arteriosus).
2- IL-12 receptor deficiency

 ↓ Th1 response  ↓ IFN-γ  ↓ phagocytic activity for intracellular bacteria
 Disseminated mycobacterial and fungal infections.
 May present after administration of BCG vaccine.
 Autosomal recessive.

3- Autosomal dominant hyper-IgE syndrome (Job syndrome)

 Deficiency of Th17 cells due to STAT3 mutation  impaired recruitment of
neutrophils to sites of infection.
 Clinical presentations (FATED):
 Coarse Facies, cold (noninflamed) staphylococcal Abscesses,
retained primary Teeth, ↑ IgE, Dermatologic problems (eczema).
Bone fractures from minor trauma.
 Findings:
 ↑ IgE, ↓ IFN-γ.
 ↑ Eosinophils.
4- Chronic mucocutaneous candidiasis

 T-cell dysfunction.
 Many causes. Can result from congenital genetic defects in IL-17 or IL-17
receptors.
 Noninvasive Candida albicans infections of skin and mucous membranes.
 Absent in vitro T-cell proliferation in response to Candida antigens.
 Absent cutaneous reaction to Candida antigens.

B- and T-cell disorders

1- Severe combined immunodeficiency
 Defect: Several types including:
 Defective IL-2R gamma chain (most common, X-linked),
 Adenosine deaminase deficiency (autosomal recessive).
 Functions to deaminate adenosine to inosine as an initial step
in the elimination of excess adenosine from the cell.
 Adenosine accumulation is toxic to lymphocytes and leads to
widespread death of both T and B lymphocytes with resultant
combined cellular and humoral immunodeficiency.
 Presentations:
 Failure to thrive.
 Chronic diarrhea, thrush.
 Recurrent viral, bacterial, fungal, and protozoal infections.
 Treatment:
 Avoid live vaccines, give antimicrobial prophylaxis and IVIG.
 Bone marrow transplant curative (no concern for rejection).
 Attempts at retroviral gene therapy for this illness are promising.
 Findings:
 ↓ T-cell receptor excision circles (TRECs).
 Absence of thymic shadow (CXR), germinal centers (lymph node
biopsy), and T cells (flow cytometry).
 The Candida skin test:
 Gauges the delayed-type (type IV) hypersensitivity reaction.
 As all individuals have been exposed to the ubiquitous yeast
Candida, this is a good test of cell-mediated immunity.
 The key cells involved in cell-mediated immunity are
macrophages, CD4' helper T-cells, CD8 cytotoxic T-cells and
natural killer (NK) cells.
 Failure to generate a response to this test is referred to as
anergy.
 Anergy is expected in SCID, where there is hypoplasia of
both the B- and T-cell lines.

2- Ataxia-telangiectasia
 Defect:
 Defects in ATM gene  failure to repair DNA double strand breaks
 cell cycle arrest.
 Presentations:
 Triad: cerebellar atrophy
(Ataxia), spider Angiomas
(telangiectasia A), IgA
deficiency (↑ the risk of
sinopulmonary infection).
 Findings:
 ↑ AFP.
 ↓ IgA, IgG, and IgE.
 Lymphopenia, cerebellar atrophy.
 ↑ Risk of lymphoma and leukemia.
3- Hyper-IgM syndrome
 Defect:
 Most commonly due to defective CD40L on Th cells  class
switching defect.
 B cells will produce high levels of IgM but will never fully
mature to IgG-, IgA-, or IgE-producing plasma cells.
 X-linked recessive.
 Presentations:
 Severe pyogenic infections early in life.
 Opportunistic infection with Pneumocystis, Cryptosporidium, CMV.
 Infectious pneumonia is the most common cause of death.
 Findings:
 Normal or ↑ IgM.
 ↓↓ IgG, IgA, IgE.
 Failure to make germinal centers.

4- Wiskott-Aldrich syndrome
 Defect:
 Mutation in WASp gene; leukocytes and platelets unable to
reorganize actin cytoskeleton  defective antigen presentation.
 Presentations: WATER:
 Wiskott-Aldrich: Thrombocytopenia, Eczema, Recurrent (pyogenic)
infections.
 ↑ Risk of autoimmune disease and malignancy.
Phagocyte dysfunction
1- Leukocyte adhesion deficiency (type 1)
 Defect:
 Defect in LFA-1 integrin (CD18) protein on phagocytes; impaired
migration and chemotaxis. Autosomal recessive.
 Presentations:
 Recurrent skin and mucosal bacterial infections without pus.
 Impaired wound healing.
 Delayed (> 30 days) separation of umbilical cord.
 Findings:
 ↑ Neutrophils.
 Absence of neutrophils at infection sites.
2- Chédiak-Higashi syndrome
 Defect:
 Defect in lysosomal trafficking
regulator gene (LYST).
 Microtubule dysfunction in
phagosome-lysosome fusion;
autosomal recessive.
 Presentations:
 Recurrent pyogenic infections by staphylococci and streptococci.
 Partial albinism.
 Caused by abnormal melanin storage in melanocytes.
 Peripheral neuropathy, progressive neurodegeneration, nystagmus,
infiltrative lymphohistiocytosis.
 Findings:
 Giant granules (B, arrows) in granulocytes
and platelets.
 Pancytopenia, Mild coagulation defects.

3- Chronic granulomatous disease

 Defect:
 X-linked mutation affecting NADPH oxidase:
 Normal function of the enzyme within activated phagocytes
to do the following:
 Produce reactive oxygen species (eg, O2-, H2O2, HO-)
that act directly as antimicrobial agents.
 Also activate granule proteases (eg, elastase, cathepsin
G) present in phagosomes.
 ↓ Reactive oxygen species (eg, superoxide).
 ↓ Respiratory burst in neutrophils  impaired intracellular
killing by neutrophils and macrophages, leading to recurrent
bacterial and fungal infections.
 Presentations:
 Recurrent infections with catalase-positive bacteria & fungi.
 Catalase-positive organisms can destroy the hydrogen
peroxide produced by their own metabolic activity.
 In contrast, catalase-negative organisms cannot prevent
accumulation of bacterially-generated hydrogen peroxide
within phagosomes, allowing for some microbicidal activity
independent of host superoxide production.
 Lungs, skin, lymph nodes & liver most commonly involved.
 Diffuse granuloma formation.
 Findings:
 Measurement of neutrophil superoxide production:
 Abnormal dihydrorhodamine (flow cytometry) test (↓ green
fluorescence).
 Nitroblue tetrazolium dye reduction test (obsolete) fails to
turn blue.


Infections in immunodeficiency
 UW: Host defense against candida infection is provided by 2 immune system

components with distinct functions:
1. T lymphocytes (in particular TH cells)
 Important for prevention of superficial Candida infection (eg,
oral/esophageal candidiasis cutaneous candidiasis, Candida
vulvovaginitis).
 Conditions such as HIV (low TH cell count) ↑ the risk of superficial
candidiasis.
2. Neutrophils
 Prevent the hematogenous spread of Candida.
 Disseminated candidiasis (eg, Candidemia, endocarditis) is more likely
in patients who are neutropenic or otherwise immunocompromised (eg,
cancer with chemotherapy) and in those with inherited impairments of
phagocytosis.
66 | DR AHMED SHEBL Infections in immunodeficiency

Grafts
 Autograft  From self.
 Syngeneic graft (isograft)  From identical twin or clone.
 Allograft  From nonidentical individual of same species.
 Xenograft  From different species.
Transplant rejection
67 | DR AHMED SHEBL Grafts

 UW: Myocardium graft rejection:

 Acute rejection of the heart:
 Endomyocardial biopsy is a dense infiltrate of mononuclear cells
usually composed primarily of T-lymphocytes.
 Symptoms: heart failure resulting from systolic dysfunction such as
dyspnea on exertion or paroxysmal nocturnal dyspnea.
 Chronic rejection of the heart:
 Scant inflammatory cells and interstitial fibrosis.
 Chronic rejection is a process mediated by host T-lymphocytes and B-
lymphocytes as well as antibodies and classically occurs months to
years following solid organ transplantation.
 UW: Hypersensitivity myocarditis:
 Perivascular infiltrate with abundant eosinophils
 Mostly due to initiation of a new drug therapy, against which the body
mounts an atopic response.
 UW: Graft-versus-host disease:
 Can occur following transplantation of organs rich in lymphocytes (eg,
liver).
 T lymphocytes found in the donor organ become sensitized against the MHC
antigens of the recipient and subsequently attack the host's tissues.
 The skin, liver, and gastrointestinal tract are most frequently affected.
 UW: Chronic renal allograft rejection:
 Characterized by a gradual deterioration in renal function within 3 months
post-transplant in the absence of other precipitating events (eg, active acute
rejection, withdrawal of immunosuppression, drug toxicity).
 It is characterized by worsening hypertension, a progressive rise in serum
creatinine, and proteinuria with normal urinary sediment.
 The pathogenesis of chronic rejection is thought to begin with graft
endothelial damage mediated by low-grade cellular and humoral immune
responses directed against alloantigens.
 This results in obliterative fibrous intimal thickening and scattered
mononuclear infiltration of the surrounding tissues.
 Consequent renal ischemia and chronic inflammation cause shrinking of the
renal parenchyma with tubular atrophy and interstitial fibrosis.
 UW: Acute rejection:

 Prevention: with calcineurin inhibitors such as cyclosporine or tacrolimus.
 Treatment: with systemic corticosteroids in addition to continued use of
calcineurin inhibitors.
68 | DR AHMED SHEBL Transplant rejection


Immunosuppressants
 Agents that block lymphocyte activation and proliferation.
 Reduce acute transplant rejection by suppressing cellular immunity (used as
prophylaxis).
 Frequently combined to achieve greater efficacy with ↓ toxicity.
 Chronic suppression ↑ risk of infection and malignancy.

Mechanism of action of common immunosuppressive

drugs:
 In normal T cells, calcineurin is a protein phosphatase  dephosphorylates nuclear

factor of activated T cells (NFAT), which allows NFAT to enter the nucleus and bind
to IL-2 promoter.
 IL-2 stimulates the growth and differentiation of T cells and is an important
component of the immune response.
 Cyclosporine and tacrolimus inhibit calclneurin activation.
 Sirolimus (rapamycin):
 Functions as a proliferation signal inhibitor by targeting the mTOR pathway
an important stimulator of cell growth and proliferation.
 Specifically, sirolimus binds to the immunophilin FK-506 binding protein
(FKBP), forming a complex that inhibits mTOR.
 This leads to interruption of interleukin-2 signal transduction, preventing G1
to S phase progression and lymphocyte proliferation.
71 | DR AHMED SHEBL Mechanism of action of common immunosuppressive drugs:

Recombinant cytokines and clinical uses
72 | DR AHMED SHEBL Recombinant cytokines and clinical uses

Therapeutic antibodies
73 | DR AHMED SHEBL Therapeutic antibodies

P. 4
Interleukin- 13 Promotes P. 34
IgE production by B cells. Induces alternative macrophage activation.
Mmunotherapy
Toll-like receptor 7 Imiquimod Anogenital warts, actinic keratosis.
 Immunological response in Leprosy:
 Tuberculoid :
- Strong Th1 immunity → ↑↑ IL-2, IL-12, IFN-γ → activate macrophage → kill bacteria → damage
skin due to inflammation
 Lepromatous :
Strong Th2 – ↑↑ IL-4, IL-5, IL-10 → no macrophage activation → high bacterial load, negative lepromin tes
 The sequence of events that occur after B-cells encounter an antigen for the first time:
1. Some of the activated B-cells in the lymphoid organs and peripheral tissues differentiate into short
lived plasma cells that release IgM through T-cell independent B-cell activation
2. Majority of B-cells migrate to lymph nodes to form germinal centers → small amount of them changed
to memory cells which is kept dormant in lymph nodes until next immune action.
3. Majority of B-cells transform in the lymph nodes into antibody secreting plasma cells
4. In germinal centers, isotype switching also occurs → but this need interaction of CD40 receptro on B-
cells with CD40L on activated Th cells
5. Somatic hypermutation also occur in the germinal center which determine the affinity maturation of the
antigen
 Describe the secretion process of IgA & the source of secretory component
 after stimulation of the peyer patches → differentiate into plasma cells → synthetize the IgA dimers
linked by J-chain (serum IgA is monomer)
 IgA bind to polymeric Ig receptor (PIgR) found on the basolateral surface of the intestinal epithelium
cells → transcytosis.
 Other actions of C3a, C5a other than anaphylaxis:

 C3a → recruit and activate neutrophils, monocytes, eosinophils, basophils
 C5a → only eosinophils, basophils
 C3b clear the immune complexes form blood :

Immune complexes formed by type III hypersensitivity reaction bind to CR1 receptors on RBCs →
cleared in spleen & liver
 Importance of C3 in immune system: all 3 complement pathway converge to activate C3 into C3a
(recruit phagocytic cells), C3b (opsonin, activate C5 → MAC)
 The process of inititation the classical pathway of complement activation:
- IgM / IgG are the ones responsible for activation of classical pathway of complement
- C1 must bind the Fc portions of two different antibodies at specific C1 binding sites, so IgM activation
(travel in pentamer) is more easier than activation IgG
- IgM activation before antigen recognition is disabled as the complement binding sites are hidden in
the pentamer, before re-appear by conformational changes.
- The complement binding sites on Ig is different from Fc receptor binding site, complement attach to
proximal part of the Fc close to the hinge joint.
 the mechanism of opsonisation:
The antigen bind to the IgG to its Fab fragment, while the IgG itself bind to the macrophage by its Fc
portion  this binding stimulate the act of phagocytosis.
 Other opsonins : (+) mannose binding lectin, CRP
 Interleukins
 Mechanism of cachexia by TNF-α :

- Influence on hypothalamus → ↓↓ appetite
- ↑↑ BMR
- Also TNF-α → ↑↑ acute ohase reactant , not only b
 What are functions of type I & II interferons:
 Type I interferons (interferon α, β):
 Synthetized by human cells in response to viral infection
 They bind to receptors (apocrine / paracrine signaling) → ↑↑ enzymes to stop protein
synthesis as RHase L (endonuclease → ↓↓ all RNA) and protein kinase R (↓↓ eIF-2 → ↓↓
translation)
 These enzymes active only in presence of ds RNA (in viral replication ) so these changes only act
specifically on viral infected cells
 ↑↑ MHC-I → ↑↑ NK cell & Tc cells
 Type II interferon (interferon γ):

 Produced by Th1, NK cells ↑↑ Th1, MHC-II …. Immunological role.
 Actions of IL-8: it is produced from the macrophage triggering neutrophils to enter the site of infection,
induce phagocytosis in neutrophils.
 Polysaccharide vaccine only can be given to infancy that because immature huoral immune system
< 2 years, the vaccination given must be conjugated with tetanus toxoid to enhance T-cell activation 7
production of memory cells.
 the difference between pneumococcal polysaccharide & conjugate vaccine.
Polysaccharide vaccine (PPSV23) Pneumococcal conjugate vaccine (PCV13)

Contain more strains of bacteria (23) Less strains, narrower index
Antibody levels decline over 5 years Higher & long lasting immune response (due
to memory cells)
Not immunogenic in children < 2 years Strongly immunogenic in infancy
Used for all adults > 65 years. Part of routine children vaccination
Used for 2 – 64 years with chronic illness Used for all adults > 65 years
(they need its wide spectrum)
 Histological finding in serum sickness:

 Small vessel vasculitis with fibrinoid necrosis
 Intense neutrophil infiltration
 Deposition of IgG / IgM fixed with complement → hypo-complementemia (↓↓C3)
 Causes of serum sickness:

1) Chimeric monocloncal antibodies (-ximab)
2) Non-human immunoglobulin (e.g. venom antitoxins)
3) Non protein drugs e.g. (penicillin, cefaclor, TMP-SMX)
 The pathogenesis of type IV hypersensitivity reaction:

 Sensitization phase: (10 – 14 day) cutaneous dendritic cells (APCs) take up the hapten, express them
on MHC- I / II as hapten conjugated peptides → LN to interact with CD4 & CD8 T cells → activation
& clonal expansion.
 Elicitation phase: (2 – 3 days) rexposure to the same antigen (or after first exposure of highly
antigenic antigen) → hapten is taken up by the cells → activation of sensitized T cells →
inflammatory response
 Cause of anaphylactic reactions in patients with IgA deficiency
Patients with severe IgA deficiency → can form IgE antibodies against IgA. Wen blood is transfused; it
contains small amounts of IgA → bind to anti-IgA → anaphylaxis.
* So these patients should wear medical bracelet to receive blood washed from IgA
 Humoral immunodeficiency syndromes
 Immunological response of TB:

 After failure of the macrophage to kill the TB, it present its antigen on MHC-II and release of IL-12 →
differentiation of Th (CD4 cells) into Th1.
 Th1 → ↑↑ IFN-γ  ↑↑ ability of the macrophages to kill the bacteria, formation of granuloma that
wall off the mycobacteria to make the center of the granulomas acidic & hypoxic
 N.B.: after intial exposure, BCG is always negative, as it take around 8 weeks to be positive results
 In IL-12 receptor deficiency, IFN-γ ↓↓

 When antigens are presented by macrophage → ↑↑ IL-12 to help differentiation of T-cells to Th1 →
which produce IFN-γ
 Th1 response is the mainstream for TB, so here dissiminated TB will occur
 Adenosine deaminase deficiency cause SCID; ADA deaminate the adenosine to inosine to eliminate
adenosine from cells, as ↑↑ adenosine accumulation is toxic to lymphocytes.
 And the treatment is retroviral gene therapy.
 hyperimmunoglobin M syndrome
 Cascade of leucocyte migration :
 Rolling: due to attachment of neutrophils (Sialyl Lewis X or PSGL-1)to endothelium (E/P selectin) or
neutrophilic L-selectin
 PECAM-1 → they found primarily at the peripheral intercellular junctions of endothelial cells.
 different types of LAD:

 LAD1 (due to ↓↓ β2 integrin of Mac-1 & LFA1 = CD18) and LAD3 (↓↓ activation) → cause severe form
of LAD without pus formation, delayed separation of the cord, poor wound healing.
 LAD2 → mild with no separation of the cord, less severe infections .
 What is the target of NBT & DHR tests in diagnosis of CGD.

 They meaure the neutrophil superoxide production.
 NHT → failure of the neutrophils to turn blue on adding NHT = CGD
 Clinical picture of GVHD:

- The immune phenomena is mediated by T-cells not –cells
- Skin (earliest findings)  diffuse maculopapular rash, more on palm & sole +/- desquamate in
severe cases
- GIT  diarrhea, intestinal bleeding & abdominal pain
- Liver  abnormal elevated LFTs
 The signal transduction of mTOR pathway:

- when a growth factor bind to its receptor tyrosine kinase → autophosphyrylation → ↑↑
phosphoinsositide 3 kinse (PI3K) → [PIP2 → PIP3]
- This lead to activation of protein kinase B (AKt) “serine therionine protein kinase” → activation of
mTOR → induce angiogenesis, cell survival
- mTOR inhibited by PTEN (phosphate and tensin homolog) → remove phosphate from PIP3
 Mechanism of action of aldeslukin

- It is Il-2 agonist which have the following effects:
1) T-cells → ↑↑ IL-2 → ↑↑ IL-2R  IL-2/IL-2R interaction → ↑↑ action of CD4, CD8
2) Growth of B-cells
3) Activation of NK cells → it is the main mechanism behind its use for anticancer
 Mechanism of action of Alemtuzumab → ind to CD52 → stimulate direct cytotoxic effect through
complement fixation, ADCC
 Describe the signaling pathway of melaonoma and role of vemarfunib :

- V600E mutation of the BRAF (protein kinase) lead to more activation of the signaling → ↑↑
melanocyte proliferation.
 Mechanism of EGFR and its role in cencer and cancer therapy:
 EGFR is stimulated → downstream activation of KRAS → GTPase → stimulate cellular growth and
proliferation
 Many cancers (as colorectal, pancreas) → overexpress EGFR, activating mutation of KRASoncogene
 Monoclonal antibodies agaisne EGFR (cetuximab, panitumumab) → block EGFR → ↓↓ KRAS → ↓↓
cellular growth
 These drugs act only in normal (wild type) KRAS tumors, so genetic testing is a must prior to
administration of these drugs is essential to check either the KRASis normal or mutated as in
mutated KRAS the drug will not act as the downstream activation of cell growth is still intact
 Panitumumab → anti EGFR monocloncal antibody (as cetuximab)
 Her-2/ neu positive associated with highly aggressive tumor, in contrast ER/PR positive has better
outcome
 Role of Her/neu receptros

 Trastzumab is mab against Her2 receptors → prevent activation of tyrosine kinase
 Her2 oncogene is a part of epidermal gorwith factor receptor (C-erb2) with tyrosine kinase activity in
the intracellular domain.
 Tumors with ↑↑ HER2 → ↑↑ proliferation and resistance to apoptosis, with worse prognosis
 Mention the role of PD-1 in cancer immunotherapy:

- Programmed death receptor 1 (PD-1) expressed on the surface of activated T-cells, when bound to its
ligand (PD-L1) it ↓↓ Tc function → ↓↓ immunity
- Many cancers ↑↑ PD-L1
- B7 → react with CD 28 activate T cells, while bind to CTLA-4 to inhibit them
- Drugs against PD-1 used in melanoma and lung cancer; examples : nevolumab, pembrolizumab

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IMMUNOLOGY USMLE ENDPOINT

1 | DR AHMED SHEBL LYM P H O I D S T R U C T U R E S

2- Medulla: Consists of:

2 | DR AHMED SHEBL LYM P H O I D S T R U C T U R E S

 Mucosa-associated lymphoid tissue (MALT)

3 | DR AHMED SHEBL LYM P H O I D S T R U C T U R E S

Lymph drainage associations

4 | DR AHMED SHEBL Lymph drainage associations

5 | DR AHMED SHEBL Spleen

6 | DR AHMED SHEBL Thymus

7 | DR AHMED SHEBL Thymus

8 | DR AHMED SHEBL LYMPHOCYTES

Major histocompatibility complex I and II

9 | DR AHMED SHEBL Major histocompatibility complex I and II

 MHC Class I pathway:

11 | DR AHMED SHEBL Major histocompatibility complex I and II

 The MHC Class II molecule-protein antigen complexes are then displayed on

HLA subtypes associated with diseases

11 | DR AHMED SHEBL Major histocompatibility complex I and II

Natural killer cells

12 | DR AHMED SHEBL Natural killer cells

Major functions of B and T cells

13 | DR AHMED SHEBL Major functions of B and T cells

14 | DR AHMED SHEBL Major functions of B and T cells

Antigen receptors of B and T lymphocytes

15 | DR AHMED SHEBL Antigen receptors of B and T lymphocytes

UW: Apoptosis in lymphocytes:

16 | DR AHMED SHEBL Antigen receptors of B and T lymphocytes

17 | DR AHMED SHEBL Helper T cells

 UW: Granuloma formation:

18 | DR AHMED SHEBL Helper T cells

19 | DR AHMED SHEBL Cytotoxic T cells

Macrophage lymphocyte interaction

21 | DR AHMED SHEBL T-cell activation

B cells activation and functions

3. After encountering antigen and becoming activated, they transform into

21 | DR AHMED SHEBL B cells activation and functions

B-cell activation and class switching

22 | DR AHMED SHEBL B cells activation and functions

Antibody structure and function

Generation of antibody diversity (antigen independent)

23 | DR AHMED SHEBL Antibody structure and function

24 | DR AHMED SHEBL Antibody structure and function

Generation of antibody specificity (antigen dependent)

25 | DR AHMED SHEBL Antibody structure and function

26 | DR AHMED SHEBL Antibody structure and function

27 | DR AHMED SHEBL Antibody structure and function

Eosinophils play a role in host

 UW: Omalizumab (anti-IgE) is used in moderate-to-severe asthma.

28 | DR AHMED SHEBL Antibody structure and function

Antigen type and memory

29 | DR AHMED SHEBL Antigen type and memory

31 | DR AHMED SHEBL Acute-phase reactants

Inhibitors (prevent complement activation on self-cells (eg, RBCs).

31 | DR AHMED SHEBL Complement

Complement regulatory protein deficiencies

32 | DR AHMED SHEBL Complement disorders

33 | DR AHMED SHEBL Important cytokines

CYTOKINES SECRETED BY MACROPHAGES (IL-1, 6, 8, 12, TNF- α)

34 | DR AHMED SHEBL Important cytokines

CYTOKINES SECRETED BY ALL T CELLS (IL-2, 3)

35 | DR AHMED SHEBL Important cytokines