Basic Principles of Immunology 1. From the following, identify a specific component of the adaptive immune system that is formed in response to antigenic stimulation: A. Lysozyme B. Complement €. Commensal organisms D. Immunoglobulin Inmunology/Apply knowledge of fundamental biological characteritisllmmune system/I 1D 2. Which wo organs are considered the primary lymphoid organs in which immunocompetent cells originate and mature? A Thyroid and Peyer's patches 8B. Ihymus and bone marrow . Spleen and mucosal-associated lymphoid tissue (MALT) D. Lymph nodes and thoracic duct ImmunologylApply knowledge of fundamental biological characteristiesllmmune system/Organs/1 3A ‘What type of B cells are formed after antigen stimulation? AA. Plasma cells and memory B cells B. Mature B cel €. Antigen-dependent B cells D. Receptor-activated B cells ImmunologylApply knowledge of fundamental biological characteristics/Immune system/Cells/1 ae 4, T cells travel from the bone marrow to the thymus, for maturation. What is the correct order of the maturation sequence for T cells in the thymus? ‘A. Bone marrow to the cortex; after thymic education, released back to peripheral cixculation B, Maturation and selection occur in the cortex: migration to the medulla; release of mature T cells to secondary lymphoid organs . Storage in either the cortex or medulla; release of T calls into the peripheral circulation ). Activation and selection occur in the medulla mature T cells are stored in the cortex until activated by antigen ImmunologylApply knowledge of fundamental biological characterissislImmune system{Cells!] 3.1 Answers to Questions 1-4 Immunoglobulins a specic part ofthe adaptive immune system and is formed only in response to a specific antigenic stimulation. Complement, Iysozyme, and commensal organisms all act nonspecifically 3 a partof the ad system, These three components do not require any type of specific antigenic stimulation ‘The bone marrow and thymus are considered primary Iymphoid organs because immunocampetent cells ether originate or mature them, Some immunocompetent cells mature or reside int bone marrow (the source ofall hematopoietic cel) Until transported to the thymus, spleen, or Peyer's patches, where they process antigen or manufactur antibody. Tlymphocytes, ater crighnating in the bone marco, travelto the thymus to mature and sifferentate surface immu Mature & cells ex globulin that may crosslink a foreign antigen, thus form the activated 8 cell and lea internalization of antigen. The activated B cell gives tse to plasma cells that produce ane secrete immunoglobulins and memory cells that reside in lymeho d organs. Immature T cells travel from the bone marrow to the thymus to mature into funct in the thymus, maturation sequence that begins int moves to the medulla of the thymus. Thymic factors such as thymosin and thymopoietin and cells within ‘the thymus such as mactophages and dendritic cells assist in this sequence. WMter completion of th maturation cycle, T cells are released to secondary Iympho'd organs to await antigen recogni activation Is undergo ase contexand 778 Chapter 3| Immunology 5, Which cluster of differentiation (CD) marker appears during the first stage of T-cell development and remains present as an identifying marker for T cells? ACDI B.CD2 ©. cD3 D.CD4 or CDS, ImmunologylApply principles of basic laboratory proceduresT celliMarkers/1 6. Which markers are found on mature, peripheral helper T cells? A.CDI, CD2, D4 8, CD2, CD3, CD8 ¢. CDI, CD3, CD4 D.CD2, CD3, C4 ImmunologylApply knowledge of fundamental biological characteristic! celtiMarker/] 7, Which T cell expresses the CD8 marker and acts specifically to kill tumors or virally infected cells? A. Helper T B.T suppressor CT cytotoxic D.T inducer/suppressor ImmunologylApply knowledge of fundamental biological characteristisIT celldCytokines!1 8. How are cytotoxic T cells (T cells) and natural killer (NK) cells similar? A. Require antibody to be present B. Effective against virally infected cells €. Recognize antigen in association with HLA class TW enatkers D. Do not bind to infected cells Immunology Apply knowledge of fundamental biological characterste/L.ymphocytes/Fanctions1 9, What is the name of the process by which, phagocytic cells are attracted to a substance such as a bacterial peptide? A. Diapedesis B, Degranulation €. Chemotaxis D. Phagotaxis ImmunologylApply knowledge of fundamental biological characteristislimmune system{Celll 10. All of the following are immunologic functions of complement except A Induction of an antiviral state B. Opsonization ©. Chemotaxis D. Anaphylatoxin formation Immunolog/Apply knowledge of fundamental biological characteristics/ComplemensiFunctions!1 11. Which complement component is found in both the classic and alternative pathways? ACL B.C4 © Factor D .c3 InmunologtApply knowledge of fundamental biological characteristics Complement Components! Answers to Questions 5-11 5. B The CD2 marker appears during the fist stage of T-cell development and can be used to differentiate Tells from ather lymphocytes. This T-lymphocyte receptor binds sheep red blood cells (RBCS). This peculiar cnaracterstc was the basis for the classic E rosette test once used to enumerate Tells in peripheral blood, CD? isnot specific for Tels, however, and is also found en large granular lymphocytes (LGL or natural kiler (NK) cells, 6. D Mature, peripheral helper T cells have the CD2 (Erosette), CD3 (mature T cell, and CD4 (helper) markers 7. C Teytotoxéc cells recognize antigen in association with major histocompatibilty complex (MHC) class complexes and act against target cels that exoress foreign antigens. Frese include viral antigens and the human leukocyte antigens (HLA) that are the target of graft rejection, 8 B Both Tc and NK calls are effective against virally infected cells and neither requites antibody to be present to bind to infected cells NK cells do rot exhibit MHC class estiction, whereas actvation of Te cells requires the presence of MHC class molecules in association withthe vial antigen, 9. Chemotaxis isthe process by which phagocytic cells are attracted toward an area where they detect a clsturbance in the normal functions of body tissues. Products from bacteria and viruses, complement ‘components, coagulation proteins, and cytckines from ‘other immune cells may al act as chemotactic factors 10. A Complement components are serum proteins that function in opsonization, chemotaxis, and anaphylatoxin formation but do not induce an antival state in target cells. This function is performed by interferons 11. D Bis found in both the classic and alternative {akemate) pathways ofthe complement system. In the classic pathway, C3b forrns a complex on the cell with C402a that enzymatically cleaves CS. In the alternative pathway, C3b binds to an activator on the cell surface. It forms a complex with factor ‘called C3b8 which, lke C4b2a3b, can spit C3.12. Which immunoglobulin(s) help(s) initiate the classic complement pathway? A IgA and IgD B. IgM only IgG and IgM D.IgG only, ImmunologylApply knowledge of fundamental biological characteritis!ComplementiActivation/1 13. How is complement activity destroyed in vitro? A. Heating serum at 56°C for 30 min B. Keeping serum at room temperature of 22°C for Thour . Heating serum at 37°C for 45 min D. Freezing serum at 0°C for 24 hours ImmunologylApply knowledge of fundamental biological characteristics! ComplemenslActivation/1 14, What is the purpose of C3a, C4a, and C5a, the split products of the complement cascade? To bind with specific membrane receptors of lymphocytes and cause release of cytotoxic substances B. To cause increased vascular permeability, contraction of smooth muscle, and release of histamine from basophils €.To bind with membrane receptors of macrophages to facilitate phagocytosis and the removal of debris and foreign substances D. To regulate and degrade membrane cofactor protein after activation by C3 convertase ImmunolegyApply knowledge of fundamental biological characteristics! Complement!Anaphylatoxins!1 15. Which region of the immunoglobulin molecule can bind antigen? AFab B.Fc cq, D.Cy ImmunologylApply knowledge of fundamental biological characteristis/Immunoglobulins! Structures! 16. Which region determines whether an immunoglobulin molecule can fix complement? AVa DC, ImmunolegyiApply knowledge of fundamental biological characteristics! mmunoglobulins Structures] 3.1 | Basie Principles of Immunology 79 17, Which immunoglobulin class(es) has (have) a J chain? IgM B. IgE and IgD C.IgM and sig D.1gG3 and IgA ImmunologylApply knowledge of fundamental biological characterisicllmmunoglobulinsStructures 1 Answers to Questions 12-17 12. C Both IgG and IgM are the immunoglobulins that help teinltiate the activation ofthe classic complement pathway. IgM is a more porent complement activator, however 13. A Complement activtyin serumin vito is destroyed byheating the serum at 56°C for 30 min. In test procedures where complement may interfere with the test system, it may be necessary to destroy complement activity in the test sample by heat 14, B Ca, Céa, and Ca are split products of the complement cascade that participate in various biological functions such as vasodilation and smooth ‘muscle contraction, These small peptides act as anaphylatoxins, eg, effector molecules that participate in the inflammatory response to assist in the destuction and clearance ef foreign antigens. 15. A The Fab (fraament antigen binding) is the region of the immunoglobulin molecule that can bind antigen, ‘Two Fab fragments are formed from hydrolysis of the immunoglobulin molecule by papain. Each consists ofa light chain and the V, and C,., regions cof the heavy chain. The vatable regions ot the light ang heavy chains interact, forming a specific antigen-combining ste 16. B The composition and structure of the constant region of the heavy chain determine whether that immunoglobulin wil fix complement. The Fe fragment (ragment crysalizable) is formed by partial immunoglobulin digestion with papain ard includes the C,, and C,,, domains of both heavy chains. The complement component Ciq molecule will bind to tne C,, region of a IgG or loM molecule, 17. © Both lgMand secretory IgA nave a J chain joining individual molecules together the J chain in IgM joins five molecules and the J chai in sIgA joins we molecules.80 Chapter | Immunology 18, Which immunoglobulin appears first in the primary immune response? AlgG B.IgM CIga D.IgE. ImmunologylApply knowledge of fundamental biological characteristislimmunaglobulins/Functions!l 19. Which immunoglobulin appears in highest titer in the secondary response? AlgG B.IgM CIgA. D. gk. ImmunologiApply knowledge of fundamental biological characteristicslmmunoglobulin/Function/1 20. Which immunoglobulin can cross the placenta? AlgG B.IgM Iga. D.IgE. ImmunologylApply knowledge of fundamental biological characteristicslImmunoglobulins/Functions/1 21. Which immunoglobulin cross links mast cells to release histamine? AlgG B.IgM clga, D. IgE. ImmunologylApply knowledge of fundamental biological characteristislimmunaglobulins/Functions/l 22. All of the following are functions of immunoglobulins except: A. Neutralizing toxic substances B, Facilitating phagocytosis through opsonization €. Interacting wich Tg cells to lyse viruses D. Combining with complement to destroy cellular antigens Immunology Apply knowledge of fundamental biological characteristicsllmmunoglobulins!Functions/ 23. Which of the following cell surface molecules is classified as an MHC class II antigen? AHLAA B.HLAB HLA-C D. HLA-DR ImmunologylApply knowledge of fundamental biological characteristics MHCIHLA antigens! Answers to Questions 18-23 18. B The fist antibody to appear in the primary immune response 19 an antigen is IgM. The titer of antviral IgM (eg. lgM antibody to cytomegalovirus [ant-CM is mote specific for acute or active viralinfection than IgG and may be measured to help differentiate active from prior infection 19. A Ahigh ter ofloG characterizes the secondary Immune response. Consequently, IgG antibodies comprise about £0% of the total immunogleoulin concentration in normal serum, 20. A IgGs the only immunoglobulin class that can cross the placenta. All subclasses of lgG can cross the placenta, but IgG? crosses more slowly. This process requites tecogrition of the Fe region ofthe IgG by placenta cells These cells take up the IG fram the ‘maternal blood and secrete it nto the fetal blood, providing humoral immunity so tre neonate for the first few months ater delivery, 21. D Igk isthe immunoglobulin that crosslinks with basophils and mast cel’. IgE causes the release of such immune response modifies a histamine and mediates an allergic immune response, 22. C Cytotoxic T cells lyse virally infected cells crectly, without requirement for specific antioady. The Te cell isactivated by val antigen that i associated with MHC class Imolecules on the surface ofthe infected cell, The actvated T. cel secretes several toxins, such as tumor necrosis factor, which destroy the infected celland virions 23, D The MHC region is located on the shor arm of, ‘chromasome 6 and codes for antigens expressed fon the surface of leukocytes and tissues. The MHC ragion genes control immune recagnition, their products include the antigens that determine transplantation rejection. HLACDR antigens are expressed on B cells. HLA-DR2, DRS, DR4, and DRS antigens snow linkage with a wide range of autoimmune diseases24, Which MHC class of molecule is necessary for antigen recognition by CD4-positive T cells? A. Chass I C. Chass IIT D. No MHC molecule is necessary for antigen recognition InmunologylApply knowledge of fundamental biological characteristic MHCiEunctions/1 25. 25. Which of the following are products of HLA class III genes? A. T-cell immune receptors B. HLA-D antigens on immune cells €. Complement proteins C2, C4, and Factor B 26. D. Immunoglobulin V; regions Immunology Apply knowledge of fundamental biological characteristics MHCIFunctions/1 26. What molecule on the surface of most T cells recognizes antigen? A IgT, a four-chain molecule that includes the tau heavy chain’ B, MHC protein, a two-chain molecule encoded by the HLA region . CD3, consisting of six different chains 27. D. TER, consisting of two chains, alpha and beta ImmunologylApply knowledge of fundamental biological characteristis!Functions!1 27. The T-cell antigen receptor is similar to immunoglobulin molecules in that it: ‘A. Remains bound to the cell surface and is never secreted B, Contains V and C regions on each of its chains €. Binds complement D. Can cross the placenta and provide protection to a fetus Immunology/Apply knowledge of fundamental biological characterised TeR(Functions!2 Bt 28, Toll-like receptors are found on which cells? AT calls B, Dendritic cells ©. Beells D. Large granular lymphocytes ImmunologylApply knowledge of fundamental biological characteristislinnate immune system! Toll-like reeeptors!1 3.1 | Base Principles of Immunolegy 81 Answers to Questions 24-28 24, B Helper Tlymphocytes (CDt-positive Tcels) recognize antigens only in the context ofa clas molecule. Because class ll antigens are expressed on, macrophages, monocytes, nd 8 cals, the helper T-cell response is mediated by interacsion with processed antigen on the surface ofthese cells ‘Complement components C2 and C4 of the classic pathway and Factor of the alternative pathway are dlass lll molecules. HLACA,HLAr8, and HLA-C antigens are classified as class antigens, nd HLAD, HLACDR, HLA-DO, and HLADP antigens as class Il antigens. cell have a membrane bound receptor (cel receptor or TCR) that is anzigen speci. This two- chain molecule consists of a single a-chain, similar to ‘an immunaglobul n Iight chain, and a single B-chain, similar to an immunaglobulin heavy chain. Some T cells may express ay-8 receptor instead of the 48 molecule. There is not heavy chain, MHC and ( 169) in an IFA assay, A similar titer would be expected for an ENA positive specimen, although the pattern would be speckled. Complement testing would not be indicated with this low t in a 55-year-old female 3. C Therimor peripheral immunofluorescence technique’ is most commonly fourd 1 cases of active SLE. The responsible autoantibody is hghly correlated to anti-double-stranded DNA fanti-dsDNA) fern seen in indirect 4. D The ANAELISA\s a screening assay. A postive result may be followed up by more spectfc antibody ELISA tests or an ANA immunofluorescence test to determine pattern and titer. The ANA ELISA does not screen for rheumatoid factor. 5. A. Antinistone antibodies (and also ani cause the solid or homog commonly found in patients with SLE, RA, mixed connective tissue disease, and Sjogren’s syndrome, Antibodies to the centromere of chromosomes is a marker for the CREST (calcinosis, Raynaud's phenomenon, esophageal dystunciion sclerodactyly, and telangiectasia} form of systemic sclerosis DNA antibodies) 6. C High titer anti-Smis indicative of SLE Ant-Smis one of two antibadies against saline extractable nuclear antigens the other being anti-RNP. These antibodies cause a speckled pattern of immunciluorescence, 9100 Chapter 3 | Immunology 7 10. nn, Which disease is east likely when a nucleolar pattern occurs in an immunofluorescence test for antinuclear antibodies? AMCTD B, Sjgren’s syndrome SLE D. Scleroderma Immunology/Correlate laboratory data with physiological processeIFI2 . What antibodies are represented by the nucleolar pattern in the immunoffuorescence test for antinuclear antibodies? ‘A. Antihistone antibodies B. Anti-dsDNA antibodies . Anti-ENA (anti-Sm and anti-RNP) antibodies D. Anti-RNA antibodies Immunology/Correlate laboratory data with physiological proceses/IFI1 ‘Which test would best distinguish between SLE and MCTD? ‘A. Multiplex or ELISA test for anti-SM and an-RNP B. Immunofluorescence testing using Crithidia as substrate C. Slide agglutination testing D. Laboratory tests cannot distinguish between, these disorders Immunology/Evaluate laboratory data to recognize and report the need for additional testing! Autoimmune/Tesing/3 ‘An ANA test on HEp-2 cells shows nucleolar staining in interphase cells and dense chromatin staining in mitotic cells. ‘The most likely cause of this staining pattern is: A. Anxifibrillarin antibody B. Antiribosomal p antibody A serum with nucleolar and homogencous patterns D. Technical artifact Immunology!Correlate laboratory data with physiological proceses/IF/1 ‘Which immunofluorescence pattern indicates the need for ENA testing by Ouchterlony immunodiffusion, Multiplex, or ELISA assays? A. Homogeneous or solid B. Peripheral or rim © Speckled D. Nucleolar ImmunologytEvaluate laboratory data to recognize and report the need for additional testing! Autoimmune/Tesing/3 12 Which of the following is used in rapid slide tests for detection of rheumatoid factors? A. Whole IgM molecules B. Fe portion of the IgG molecule . Fab portion of the IgG molecule D. Fe portion of the IgM molecule InmunologtApply knowledge of fundamental biological characteristic RA/Testing/1 Answers to Questions 7-12 Be 10. oe 2. A Allofthe diseases except MCTD may cause a rucleobar pattern of immunofluorescence. Nucleolat fluorescence is caused by antRNA antibodies ands, seen in about 50% of patients with scleroderma, D_Ant-RNA antibocies are represented by the nucleolar pattern. This pattemn may be seen in most systemic autoimmune diseases and is especialy cornmon in patients with scleroderma. Ant-&NA and ant-Sm ate ‘ot usually found in patients with mixed connective tissue cisease. Ths is a syndrome involving aspects OfSLE, RA scleroderma, and polymyositis immunofluorescence pattern mast often seen in MTD isthe speckled pattern caused by anti-ANP. A The Ouchterlony (double) immunodiffusion assay may be used to identify and different Sm from anti-RNP. Multiplex and ELISA assays, using puted o° recombinant antigens, are also available for ths testing. AnttSm with or without anti-RNP is found in aporoximately one tnird of SLE patients AntiRN? in the absence: om is found in over 95% of MCTD patients A Antifiorilarin antibody has this appearance Ribosomal p antibody has nucleolar staining and a backaround homogeneous and cytoplasmic stain. combination nucleolar/narmageneous specimen will lso show homogeneous staining in the interohase cels. Ths pattern is not seen in typical technical anifacts _Aspeckled pattern is often due o the presence of antibodies against the extractable nuclear antigens, such as $m, RNP, SSA, and $58, Homegenous an antibodies to double-stranded DNA. neous pattern may also be seen o deoxytibonuclear pr an ENA, Nucleolar patterns often toRNA cr fbrilarin B. Rheumatoid factors react with the Fc portion of the IgG molecule and are usualy IgM. This the bass of rapid agglutination tests for RA Paticles of latex or cells are coated with IG. Addition of serum containing rheumatoid factor resus in visible agglutination13. Which of the following methods is /east likely to 14, 15. 16. V7. give a definitive result for the diagnosis of RA? A. Nephelometric measurement of anti-IgG B. Agglatination testing for rheumatoid factor ©. Anti CO D. Immunofluorescence testing for antinuclear antibodies Immunology/Select routine laboratory procedures! Autoimmune RA/Testing/1 ‘Which disease might be indicated by antibodies to smooth muscle? A. Avophic gastritis B. Autoimmune hepatitis . Myasthenia gravis D. Sjogren's syndrome ImmunologylApply knowledge of fundamental biological characteristic Autoimmune!Testing/1 Antibodies to thyroid peroxidase can be detected by using agglutination assays. Which of the following diseases may show positive results with this type of assay? A. Graves’ disease and Hashimoto's thyroiditis B. Myasthenia gravis C. Granulomatous thyroid disease D. Addison’s disease ImmunologylSelect routine laboratory proceduresl Autoimmune/Tesing/ ‘What is the main use of laboratory tests to detect antibodies to islet cells and insulin in eases of insulin-dependent diabetes mellitus (IDDM)? A.To regulate levels of injected insulin B. To diagnose IDDM To rule out the presence of other autoimmune diseases D. To screen susceptible individuals prior to destruction of cells ImmunologylSelect routine laboratory procedures! AutoimmunelDDM/Testing/1 A patient presents with clinical symptoms of celiac disease. Tests for anti-tissue transglutaminase and antigliadin antibodies are negative. Which of the following tests should be ordered? A.IgG level B.HLA DQ yping HLA DR yping D. IgM level Immunology/Select routine laboratory procedures! Autoimmune/Celiac disease! Testing/2 3.4 | Autoimmune Diseases 101 Answers to Questions 13-17 13. D Patients with RA often show a homogeneous pattern 14.8 15.8 16. D 7.8 offluorescence in tests for antinuclear antibodies, However, this pa systemic autoimmune diseases and in many normal persons ata titer below 10. The first two methods lsted may be used to identify ant+lg, which is required to establish a diagnosis of RA Anti CCP is a specific assay for heumatoid arthris, Antioadies to smooth muscle are found in the serum (of up to 708 of patients with active chronic he and up to 50% ofp h primary biliary inthis. Antibodies to thyroid peroxidase may b in both Graves'disease (nyperthyroidism Hashimoto's thyroiitis hypothyroidism) Ifa postive results found to thytoid peroxidase, thyroxine levels can be measured to cistinguish between the two diseases. Fasting hyperalycemia isthe pximary finding usee to diagnose IDDM For individuals wth an inherited susceptibily tothe development of IDDM, laboratory tests for the detection of antibodies to islet cells and insulin may hele to initiate early treatment before complete destruction off cells While antibodies to tissue transglutaminase and gladin ate often found in celiac disease, their combined sensitivity is less than 100%, Celiac disease isalmost exclusively associated with the presence of HLADQ2 and/or HLA DOB, These HLA genes are not diagnostic of celia disease, but provide a disease18. A speci 102 Chapter 3 | Immunology -n appears to have a perinuclear staining pattern in an antineutrophil cytoplasmic antibody (ANCA) immunoffuorescent assay using cthanol- fixed neutrophils, suggesting the possibility of a ANCA. On which of the following substrates ‘would this specimen display cytoplasmic speckling? A. Formalin-fixed neutrophils, B. Unfixed neutrophils . HEp-2 cells D. Rabbit kidney tissue ImmunologyiSelect routine laboratory procedures! AutoimmunelANCAlTesting!2 Answer to Question 18 18. A Antibodies toneutrophil cytoplasmic antigen demonstrating a perinuclear pastern af fluorescence indicate a diagnosis of vascults. However atypical ANCAsand ANAS also demonstrate a perinuclear staining pattern on ethano'-Fxed neutrophils, To differentiate these from pANCA, specimens appearing as a pANCA on ethanol-Fxed cells are tested on formalr-Fxed neutrophils, The myeloperoxidase containing granules that coalesce around the nuclear membrane during ethanol fixation wll ermain in the cytoplasm during formalin fixation, Thus, pANCA will have a cytoplasmic (CANCAY pattern on a formalin-fixed side, but ANAS will retain a perinuclear pattern and the ‘iuorescence will be diminishes.| Which of the following is a description of a type I hypersensitivity reaction? 'A. Ragweed antigen cross links with IgE on the surface of mas calls, causing release of preformed mediators and resulting in symptoms of an allergic reaction B. Anti-Fy# from a pregnant woman crosses the placenta and attaches to the Fy* antigen-positive red cells of the fetus, destroying the red cells Immune complex deposition occurs on the glomerular basement membrane of the kidney, Teading to renal failure D. Exposure to poison ivy causes sensitized T cells co release lymphokines that cause a localized inflammatory reaction ImmunologylApply knowledge of fundamental biological characteristcs/Hypersensitivity/2 2. Why is skin testing the most widely used method to test for a type I hypersensitivity reaction? A Ie causes less trauma and is more cost effective shan other methods B. Ic has greater sensitivity than in vitro measurements €. Ie is more likely co be positive for IgE-specifie allergens than other methods D. Ic may be used to predict the development of further allergen sensitivity Immunology/Apply principles of basic laboratory procedures Hypersensitivity! Testing! - Which in vitro test measures IgE levels against a specific allergen? A. Histamine release assay B. Radioimmunosorbent test (RIST) €. Fluorescent allergosorbent test (FAST) D. Precipicin radioimmunosorbent test (PRIST) ImmunologylApply principles of basic laboratory procedures|HypersensisivityllgE testing/1 A patient who is blood group O is accidentally transfused with group A blood and develops a reaction during the transfusion. What antibody is involved in this type II reaction? AlgM B. IgE IgG and IgE. D.IgG Immunology/Apply principles of basic laboratory procedures Hypersensisivity!Testing/1 3.5 Hypersensitivity Answers to Questions 1-4 LA aA Type limmediate hype cerstivty anaphylactic) responses ae characterized by Ig molecules binding tomast cells via the Fe receptor. Cross inking of surface Ig caused by binding of allergens causes, the mast cel to degranulate, releasing histamine and other chemical mediators of allergy. Answer B describes a type Il reaction; C describes a type ll reaction; and D describes a type I reaction, Skin testing is consi than in vitro antigen-specific k red much mote sensitive total or that measure e ‘The FASTis fluorescent assay that measures specic Ig; the RIST and PRIST tests are radioimmunoassay that measure total IgE. The FAST procedure has replaced the RAST, or racioallergosorbert assay. ‘The histamine release assay measures the amount ofistamine. Allergen assays are available based upon solid-nhase enzyme immunoassay The allergen is covalently bound toa cellulose solid phase and reacts with specific IgE In the serurn After washing, enzyme (B-galactosidase}-abeled ‘monoclonal ant-lgt is added The unbound antibody conjugate is washed away and fluorogenic substat [4methylumbellfery/-2-D-galactose) s added, Fluorescence is direct proportional to specific IgE 1gG and IgM are the antibodies involved in a type cytotoxic reaction, Naturally occurring antt in the form 910up O individual and would cause an immediate lransfusion action, Cell destruction occurs when antibodies bine to cells causing destuction via complement activation, thereby triggering intravascular hemolysis. Toh is present in the blood o 103,104 Chapter 3 Immunology 5. 10. ‘Which test would measure the coating of red cells by antibody as occurs in hemolytic transfusion reactions? A Indirect antiglobulin test (IAT) B, Direct antiglobulin test (DAT) ELISA D. Hemagglutination ImmunologylApply principles of basic laboratory procedures/Hemolytic reaction/1 1. Which test detects antibodies that have attached to tissues, resulting in a type-II cytotoxic reaction? ‘A. Migration inhibition factor assay (MIF) B, Direct immunofluorescence (IF) €. Immunofixation electrophoresis (IFE) D. Hemagglutination Immunology/Apply principles of basic laboratory procedures/Hemolytic reactions) . Which of the following conditions will most likely result in a false-negative DAT test? A Insufficient washing of RBCs B, Use of heavy chain-specific polyclonal anti-human Ig C. Use of excessive centrifugal force D. Use of a sample obtained by finger puncture ImmunologylApply knowledge to identify sources of crrorlHemolyic reactions/3 Which of the following tests is used to detect circulating immune complexes in the serum of some patients with systemic autoimmune diseases such as rheumatoid arthritis? A Ditect immunofluorescence 8B. Enzyme immunoassay C. Assay of cryoglobulins D. Indirect anciglobulin test ImmunologylApply knowledge of fandamental biological characteristics Hypersensitivity 9. All of the following tests may be abnormal in a type II] immune complex reaction except A. Cla-binding assay by ELISA B. Raji cell assay ©. CHgg level D. Mitogen response Immunology/Apply principles of special laboratory procedures/Hypersensisivity!Tesing/ ‘What immune elements are involved in a positive skin test for tuberculosis? AIgE antibodies B. T cells and macrophages . NK cells and IgG antibody D. B cells and IgM antibody Immunolog/Apply knowledge of fundamental biological characteristis/Hypersenstivity/ 1 Answers to Questions 5-10 5. B The DAT test measures antioody that has already A c 9.0 10. coated RECS in vivo. Direct artiglobulin and direct immunefluorescence tests use ant-immunogloulin todetect antioody-sensitzed calls. The direct IF test detects the presence of antibody that may cause a type Ileytotexic reaction. For ‘example, renal biopsies from patients with Goodpasture's syndrome exhibit a smooth pattern of fluorescence along the basement membrane after reaction with fluorescein isothiocyanate IQ) conjugated antiimmunoglobulin, The reaction detects antibodies against the basement membrane ‘of the alorerul Insufficient washing can cause incomplete removal of excess or unbound immunoglobulins and other proteins, which may neutralize the antiglobulin, reagent. Most autoimmune diseases invohe the formation cof antigen-antibody complexes that deposit inthe tissues, causing local inflammation and necrosis induced by complement activation, phagocytosis, WAC infiltration, and lysosomal damage. Some patients make monoclonal or polyclonal antibodies ‘ith theumatoid factor activity that bind to serum immunoglobulins, forming aggregates that are insoluble at 4°C, These circulating immune complexes are detected by allowing a blood sample to clot at 37°C, transferring the serum to a sedimentation rate tube, and then incubating the serum at °C for 3 days IMitogen stimulation is used to measure T-cell, -cell and nul-cel responsiveness, which is important in patients displaying anergy and other signs of Immunedeciency, The iq assay and the Raji cell assays detect circulating immune complexes that are present during 2 type reaction. The Ch level is usualy decreased owing to complement activation by the immune complexes. Raji cells are derived ‘fromm a malignant f-cellline that demonstrates C3 receptors but no surface membrane immunoglobulin. inmune complexes that have ‘xed complement will bind to Raj ces and can be Identified using radiolabeled or enzyme labeled ant-immunoglobulin. More recently, a C3 binding ELISA assay has replaced the Raji cell procedure Tells and macrophages ae the immune elements primarily responsible forthe cinical manifestations fa positive tuberculosis test. Reactions usualy take 72 hours to reach peak development and are istic of localized type WV celbmeciated itvty The skin reaction is characterized by alesion containing a mononuckear cell inftrate2 A patient receives a transfusion of packed red cells and fresh frozen plasma and develops an. anaphylactic, nonhemolytic reaction. She reports receiving a transfusion 20 years earlier. She had no reaction to the previous transfusion, but she did feel “poorly” a few weeks later. Which of the following transfused substances most likely elicited the reaction? Alga B. Group A antigen, . Rho (D) antigen D. An antigen belonging to the Duly system. ImmunologylApply knowledge of fandamental biological characteristic mmune deficieney/Hypersensitivityl3 A patient deficient in the C3 complement component would be expected to mount a normal: A. Type I and IV hypersensitivity response B. Type II and IV hypersensitivity response ©. Type I and III hypersensitivity response D. Type If and III hypersensitivity response ImmunologylApply knowledge of fundamental biological characteristisllmmune deficiency! Hypersenssivity/2 2A 35 | Hypersensitivity 105 Answers to Questions 11-12 1. A The fact that this isa nonhemalytic reaction suggests that a ron-red cell antigen may be Involved, Selective IgA deficiency occurs in aoproximately 1 in 700 individuals and is often asymptomatic, Indviduals deficient in IgA may ‘make an antibody against the « heavy chain ifthey are exnosed to IgA via a transfusion, This antibody may lead to a serum sickness reaction ifthe IgA is still present after antibody formation. Th’s could explain the “poor feeling” the patient had after the intial transfusion. A suosequent transfusion may lead 10 an Arthus reaction iflgG anti-igh is present or an anaphylactic reaction if If antilgA Is present ‘Complement s involved in types Il and il hypersensitivity, thus an individual deficient in ‘C3 willbe deficient in those responses, The complement deficiency should have no effect ‘on IgE (typel) or cell mediates (type WM) hypersensitvities.1. Which of the following symptoms in a young child 3. 106 3.6 Immunoglobulins, Complement, and Cellular Testing may indicate an immunodeficiency syndrome? ‘A. Anaphylactic reactions B. Severe rashes and myalgia €. Recurrent bacterial, fungal, and viral infections D. Weight loss, rapid heartbeat, breathlessness Immunology/Apply knowledge of fundamental biological characteristics/T cellTeting/1 2. What screening test should be performed first in a young patient suspected of having an immune dysfunction disorder? ‘A. Complete blood count (CBC) and white cell differential B, Chemotaxis assay €. Complement levels D. Bone marrow biopsy ImmunologylApply knowledge of fundamental biological characteristics/Selectsess/3 Which test should be performed when a patient hhas a reaction to transfused plasma products? A. Immunoglobulin levels B. T-cell count €. Hemoglobin levels D. Red cell enzymes Immunology/Evaluate laboratory and clinical data to specify additional tests/Selecttessl3 1. What is the “M” component in monoclonal gammopathies? A IgM produced in excess B. [l Heavy chain produced in excess €. Malignant proliferation of B cel D. Monoclonal antibody or cell line ImmunologylApply knowledge of fundamental biological characteristcslImmunoglobulins!Testing/ 2. A Thefts scteening tests performed in the i 4, D The M" componer Answers to Questions 1-4 1. © Animmunodeficiency syndrome should be considered in a young child who has a history of recurrent bacterial fungal, and viral infections manifested after the ciseppearance of maternal ig. Immunodeficiency disorders may involve deficiencies in production andor function of lymahoxytes and phagocytic cells or a deficiency in production of 8 complement factor, Choice of laboratory tests is based upon the ang history ation, age, evaluation ofa young patient who is suspect having an immune dysfunction are the C&C and differential White blood cells that are decreased in umber or abnormal in app further testing f sarance may inieate A reaction to plasma products may be found in an IgA-deficient person who has formed ant-Igh antibodies. Immunoglobulin levels would aid in this determination, Selective IgA deficiency is the ‘most common immunodeficiency disease and is characterized by serum IgA levels below 5 mg/l IgAis usually absent from secretions, but the count is usually normal refers to any monoclonal protein orca line produced in a monoclonal gammopathy such as multiple myeloma,5. A child suspected of having an inherited humoral immunodeficiency disease is given diphtheria tetanus vaccine. Two weeks after the immunization, his level of antibody to the specific antigens is measured. Which result is expected for this patient if he/she indeed has a humoral deficiency? A Increased levels of specific antibody B. No change in the level of specific antibody €. An increase in IgG-specific anbody but not IgM-specific antibody D. Increased levels of nonspecific antibody Immunology/Evaluate laboratory datal Immunoglobulins! Testingl2 . Which disease may be expected to show an IgM spike on an electrophoretic pattern? ‘A. Hypogammaglobulinemia B. Multicystic kidney disease €. Waldenstrém's macroglobulinemia D. Wiskott-Alkrich syndrome Immunology/Evaluate laboratory data to make identifications/Tmmunoglobulins/Testing!2 In testing for DiGeorge’s syndrome, what type of laboratory analysis would be most helpful in determining the number of mature T cells? ‘A. Complete blood count Nitroblue tetrazolium (NBT) test “cell enzyme assays ow cytometry Immunology/Bvaluate laboratory data to make identifications T cell Testing!2 . Interpret the following description of an immunofixation electrophoresis assay of urine. Dense wide bands in both the « and 2. lanes. No bands present in the heavy-chain lanes. A. Normal B. Light chain disease . Increased polyclonal Fab fragments D. Multiple myeloma Immunology/Evaluate laboratory data to make identifications/Tmmunoglobulins/Testing!2 Free monoclonal light chains are often present in the serum of multiple myeloma patients, and may be useful for disease monitoring. Which of the following assays would be recommended to detect the presence of serum-free light chains? A. Scrum protein electrophoresis B. Urine immunofixation €. Nephelometry D. ELISA Inmunology/Evaluate laboratory and clinical data to specify additional tess! Testing!2 5. B Inan immunodeficient pa 3.6 | Jmmuneglobulin, Complement, and Cellular Testing 107 Answers to Questions 5-9 the expected levels of specific antibody to the antigens in the ould be decreased or not present. This response provides evidence of deficient antibody production, Waldenstrom’s macroglobulinemia isa malignancy of plasmacytoid lymphocytes involving both the bbone marrow and lymph nodes. The malignant cells secrete monoclonal IgM and ate in transition from B cells to plasma cells. In contra ostealytic bore lesions are not found. DiGeorge's syndrome is caused by a developmental failure or hypoplasia of the thymus, and results in a deficiency of T ymphacytes and cel-medi immune function. The T-cell count slow, but the level of immunaglobulins is usvally normal. Flow eytomety is most helofl in determining numoers and suspopulations of | cells Heavy wide bands seen witn both antix and antiek antisera indicate excessive light-chain excretion. Light-chain disease would show a heavy restricted band for one of the light-chain reactions, but ot booth. The fnding of excess hand x chains indicates a polyclonal gammopathy eased immunoglobulin turnover and excret'on of the light chains as Fab fragment Serum-free light chains are a sensitive indicator of a monoclonal gammopathy. They are present in sufficient quantity to show a band on a protein electrophoresis gel. Detecting light chains inthe urine is not an indicator of what she serum levels may be, Serum immunoglobulin heavy ana light chains are most commonly measured by rat fr endpoint nephelometry, ELISA assays are mast often used to measure specific antibody levels, not to quantitate immunoglobulin heayy- or light-chain isotypes,108 Chapter 3 | Immunology 10, What is measured in the CH. assay? A. RBC quantity needed to agglutinate 50% of antibody B, Complement needed to lyse 50% of RBCs . Complement needed to lyse 50% of antibody- sensitized RBCs D. Antibody and complement needed to sensitize 50% of RBCs ImmunologylApply principles of basic laboratory procedures!Complemeni/Testing/1 11. What type of disorders would show a decrease in C3, C4, and CHyy? A. Autoimmune disorders such as SLE and RA B, Immunodeficiency disorders such as common variable immunodeficiency ¢. Tumors D. Bacterial, viral, fungal, or paras Immunology/Evaluate laboratory data to make iddensifications!Complement{Testing!2 infections 12. All of the following tests measure phagocyte fanction except A. Leukocyte adhesion molecule analysis B. Di Hydro thodamine reduction assay NBT test D. IL-2 (interleukin-2) assay ImmunologylApply principles of basic laboratory procedures/Phagocytes!Testing/1 Answers to Questions 10-12 10. C The Chis the amount af complement needed to oe 12.0 Iyse 50% of standardized hemobsin-sensitized sheep RCS. Itis expressed as the reciprocal of the serum dilution resulting n 503% hemalyss. Low levels are associated with deficiency of some complement ‘components and active systemic autoimmune diseases in which complement is being consumed ‘The pattern of decreased C3, C4, and CHyy indicates classic pathway activation. This results in consumption of complement and is associated with SLE, serum sickness, subacute bacterial endocarditis, and other immune complex diseases, ‘The inflammatory response seen in malignancy and acute infections gives rise to an increase in complement components, Inmunodeficiency caused by an inherited deficiency in complement constitutes only about 1% of mmunodefciency diseases, Such disorders reduce the Cl, but involve a deficient serum level af only one complement factor The Di-hydro rhodamine reduction assay and NET tests ae used to diagnose chronic granulomatous ‘disease, an inherited disorder in which phagocytic Eells fal to kill microorganisms owing to adefect in peroxide production frespiratory bust). Leukocyte adhesion deficiency is associated with a defect in the production of integrin molecules on the surface of WECs and their granules. L-2s 2 eytakine produced by activated T, and B col’. k causes B-cell roliferation and increased production of antibody, interferon, anc ther cytokines. IL-2 can be measured by EIA and is Used to detect transplant rejection, which is associated vith an increase in the serum and urine levels1 3. Tumor Testing and Transplantation A patient had surgery for colorectal cancer, after which he received chemotherapy for 6 months. “The test for carcinoembryonic antigen (CEA) ‘was normal at this time. One year later, the bimonthly CEA was elevated (above 10 ng/mL). ‘An examination and biopsy revealed the recurrence of a small tumor. What was the value of the results provided by the CEA test in this elinieal situation? A. Diagnostic information B. Information for further treatment . Information on the immunologic response of the patient D. No useful clinical information in this case ImmunologylApply principles of basic laboratory procedures!TumorsiTesing/ 2. A carbohydrate antigen 125 assay (CA-125) ‘was performed on a woman with ovarian cancer. After treatment, the levels fell significantly. An examination performed later revealed the recurrence of the tumor, but the CA 125 levels remained low. How can this finding be explained? A. Test error B. CA-125 was the wrong laboratory test dcfetoprotein (AFP) is a better test to monitor €.CA-125 may not be sensitive enough when used alone to monitor tumor development D. CA-125 is not specific enough to detect only one ype of tumor ImmunologylApply principles of basic laboratory procedures! TumorsiTesing/3 ‘What is the correct procedure upon receipt of a test request for human chorionic gonadotropin. (CG) on the serum from a 60-year-old man? ‘A. Return the request; hCG is not performed B, Perform a qualitative hCG test to see if hCG is presenc €. Perform the test; hCG may be increased in testicular tumors D. Perform the test but use different standards and controls Immunology) Correlate laboratory data with physiological processes! Tumors FICGI3 3.7 Answers to Questions 1-3 Le AG Bac CEA Is a glycoprotein thats elevated in about 609% of patients with colorectal cancer and ane third or more patients with pulmonary, gastric, and pancreatic cancers. CEA may be positive n smokers, patients with crrhosis, Crohn's disease, and other nant conditions. Because sersitvty for malignant disease is low, CEA is not recommende: for use asa diagnostic est ‘CEAafter treatment i evidence of tu and the nees for second-look surgery. jovever, an elevated (€A-125 is @ tumor associated carbohydrate a thats elevated in 70%-8085 of patients wit cancer and about cancer, While an increase in CA-125 may indicate recurrent or progressive disease, fallue tod does not necessarily indicate the absence: growth hCG is normal rin pregnancy; tis increased in approximately 60% of patients wit testicular a lower percent with ovarian, Gl, breast, and pulmonary tumors Malignant cells secreting hCG may proauce only the B-subunit; therefore, qualtative and quantitative tests that detect only intact hormone may not be appropriate 109110 Chapter 3 Immoanology 4, ‘Would an hCG test using a monoclonal antibody against the f-subunit of hCG likely be affected by an increased level of follicle-stimulating hormone (FSH)? A. Yes, the B-subunit of FSH is identical to chat of hCG B. No, the test would be specific for the -subunit of hCG C. Yes, a cross reaction would occur because of structural similarities D. No, the structure of FSH and hCG are not at all similar Immunology/Evaluate laboratory data to check for sources of ero bCGITesting!3 5. Which of the following substances, sometimes used as a tumor marker, is increased two- or threefold in a normal pregnancy? A. Alkaline phosphatase (ALP) B. Calcitonin €. Adrenocortocotropic hormone (ACTH) D. Neuron-specific enolase Immunology/Tamor markers Testing/1 ‘What is an advantage of performing a prostate- specific antigen (PSA) test for prostate cancer? APSA is stable in serum and not affected by a digital-rectal examination B, PSA is increased only in prostatic malignaney CA normal serum level rules out malignant prostatic disease D. he percentage of free PSA is elevated in persons with malignant disease Immunology/ Correlate laboratory data with physiological proceses!Tumors/PSAI 7. Which method is the most sensitive for quantitation of AFP? A. Double immunodiffusion B, Electrophoresis ¢. Enzyme immunoassay D. Particle agglutination Immunology/Select appropriate methodAEP/1 Answers to Questions 4-7 4.8 a Luteinizing hormone, FSH, and hCG sharea common e-subunit but have aifferent 2 subunits. test for hCG using s monaclenal antibody would le specific for KCG provided thatthe antibady was directed against an antigenic determinant on the carboxy terminal end of the B subunit, Isoenzymes of ALP are sometimes used as tumor markers but have a low specificity because they are also increased in nonmalignant diseases. These clude the placental-ike (heat-stable) ALP isoenzymes, which are found {infrequently} in some malignancies such as cancer of the lung; bone- derived ALP, which is a marker for metastatic bone cancer, and the fast migrating liver isoenzyme, which Isa marker for metastatic liver cancer. ACTH is secreted asan ectopic hormone in some patents with cancer ofthe kung, Calcitonin isa hormone produced by the medulla ofthe thyroid and is Increased in the serum of patients with medullary thyroid carcinoma, Neuron-specifc enolase isan enzyme that is used as a tumor matker primarly for rneurablastoma, FSAisa glycoprotein with protease activity that is spec forthe prostate gland High levels may be ‘caused by prostate malignancy, benign prostatic hyperiophy, or prostatitis, but PSA isnot increased by physical examination ofthe prostate. SA nasa Sensitty of 80% anda specify of about 75% for prostate cancer. The sensi is sufciently high to warant rs use as a screening test but sensitivity for stage A cancer below 60%. Mos f the serum PSA is bound to protease inhibitors such as -antinypsn and ay-antchymotypsin, Patents wth borderine PSAllevels (4-10 ng/ml) and alow percentage of fee PSA are mote lkely to nave cancer ofthe prostate than patients with anormal percentage of free PSA AAFP isa glycoprotein that is produced in about 80% 0% of patents with hepatoma and in alower percentage of patients with other tumors, including retinoblastoma, breast, uterine, and pancreatic ‘cancer, The upper reference limit for serum is only 10.ng/ml, which requites a senstive method of assay such as FIA. The high analysical sensitivity of immunoassays permits detect on of reduced AFP levels in maternal serum associated with Down syndrome, as wel as elevated levels assoc ated with spina bifida,10. 2 How is HLA typing used in the investigation of, ‘genetic diseases? A. For prediction of the severity of the disease B. For genetic linkage studies C. For direct diagnosis of disease D. Is not useful in this situation Immunology/Correlate clinical and laboratory datalHLA typing! . Select the best donor for a man, blood type AB, in need of a kidney transplant. A. His brother, type AB, HLA matched for cass IT antigens B, His mother, type B, HLA matched for class I antigens . His cousin, type ©, HLA matched for major class Il ancigens D. Cadaver donor, type ©, HLA matched for some class I and Il antigens Immunology/Correlase data with other laboratory data 0 assess test resuls! Transplantation! Testing/3 Interpret the following microcytotoxicity results: ‘AG and B12 cells damaged; At and Aw19 cells intact. A. Positive for Al and Awl9; negative for A9 and B12 B, Negative for Al and Aw19; positive for A and B12 . Error in tes system: retest D. Impossible to determine Immunology/Bvaluate laboratory data to make identifications/TransplantationtTesting!2 ‘Which method, classically used for HLA-D typing, is often used to determine the compatibility between a living organ donor and recipient? A Flow cytometry B, Mixed lymphocyte culture (MLC) C. Primed lymphocyte test (PLT) D. Restriction fragment length polymorphism (RFLP) ImmunologslApply principles of special procedures! Tramsplantation/EILA typing! SITUATION: Cells type negative for all HLA antigens in a complement-dependent cytotoxicity assay. What is the most likely cause? A. Too much supravital dye was added B. Rabbit complement is inactivated C. All leukocytes are dead D. Antisera is too concentrated ImmunologylEvaluate laboratory data to check for sources of erorlHILA typing/3 3.7 | Tumor Testing and Tramplantation 111 Answers to Questions 8-12 8. B HLAtyping is useful in predicting some genetic oA B B 8 diseases and for genetic counseling because certain HLA types show strong linkage to some diseases, HLA typing isnot specifically used to diagnose a disease or assess its severity. In linkage stucies, a disease gene can be predicted because itis located next to the locus of a normal gene with which it segregates. For example, the relative risk of developing ankylosing spondylitis is 87% in persons who are postive for HLAB2?, Analysis of family pedigrees forthe linkage marker and disease can be used to cetermine the probability that afarily member wil inert the disease gene twin or sibling donor ofthe same blood type and HLA matched for class antigens isthe best donor in this skuation, Class I antigens (HAD, HLA-DR, DQ, and DP) determine the abilty ofthe transplant recipient ro ecagrize the graft, The IIIA genes are located close together on chromosome 6, and crossover between HLA genes irate. Siblings with closely matched class Il antigens most likely nherited the same class Igenes. The probabiliy of siblings inheriting the same HLA haplotyees from both parents is 1: The microcytotoxicty testis based upon the reaction of specific antisera and HLA antigens on test cells Calls darnages by the binding of antibody and complement are datected with a supravital dye such as eosin, Flow cytometry can be used in transplantation te type serologically defined HLA antigens. The one-way mixed lymphocyte reaction is used to identity HLAD antigens on the donor's Wmphacytes and is usee for cross matching ving donors with transplant recipients. The assay s time consuming and would riot be used as part of a workue fora cadaver donor transplant HLA-D incompatibility is associated with the recognition phase of allograft rejection. The primed lymphocyte test is used to identiy HLA antigens Inactive rabbit complement may nor become fxed ‘to antibodies that have bound test leukocytes therefore, no lysis of cels will occur. Wnen the supravital dye is added, al cells will appear negative (exclude the dye} for al LAs.112 Chapter 3 | Immounology 13, What method may be used for tissue typing, instead of serological HLA typing? APCR B. Southern blotting ©. RFLP D. All of these options ImmunologylApply principles of special procedures! Transplantation ELA typing/1 Answer to Question 13, 13. D PCR Southern blotting, and testing for RFLP may all be used :o identify HLA genes. Many laboratories Use PCR technology for the routine determination of HLA type.Immunology Problem Solving 1. Which of the following serial dilutions contains an incorrect factor? 14,18, 1:16 BI 12,14 C15, 115, 1:45 D.1:2, 16, 1:12 InmunologylApply knowledge to recognize sources of cerrorlSerologicaldilutions/3 A patient was tested for syphilis by the RPR method and was reactive. An FTA-ABS test was performed and the result was negative. Subsequent testing showed the patient to have a high titer of anticardiolipin antibodies (ACAs) by the ELISA method. Which routine laboratory testis most likely to be abnormal for this patient? A. Activated partial thromboplastin time (APTT) B. Antismooth muscle antibodies €. Aspartate aminotransferase (AST) D. C3 assay by immunonephelometty ImmunologylApply knowledge to recognize sources of. errorlAnticardiolipinl3 . Inflammation involves a variety of biochemical and cellular mediators. Which of the following may be increased within 72 hours after an initial infection? ‘A. Neutrophils, macrophages, antibody, complement, Geyantitrypsin B, Macrophages, T' cells, antibody, haptoglobin, fibrinogen . Neutrophils, macrophages, complement, fibrinogen, C-reactive protein, D. Macrophages, cells, B cells, ceruloplasmin, complement ImmunologylApply principles of basic immunologic responseslInflammation!2 1D 2A ag 3.8 Answers to Questions 1-3 Al the dilutions are multiplied by the same a progression except the last one whereas 11610 1:12 isx 2 Threefold dilutions of 12dllution would resul in a1 followed bya 1:18 2016 5X3, Approximately $0%-70% of patients with ACA also have the lupus anticoagulant (LAC) in thei serum, The LAC is an immunoglobulin that interferes with In vito coagulation tess: prothrombin time (PT), APTT and dilute Russells vier venom (ORW) tme, These tests require phospholipid for the activation of factor X About 30% of patients with antibodies to cardiolipin or phospholipids have a biolbaical false postive RPR result, Antismooth muscle is most ‘commonly associated with chronic active hepatits and increased AST with necrotic ver diseases Although ACA and LAC may be associated with SLE, the majorty of patients with these antibodies 2o not have lupus and would have a normal C3 level. The correct lit in which all mediators are involved in an inflammatory response within 72 hours after initial Infection, is neutrohils, mactopha nplement fibrinogen, anc atein, Phagocytic cells acute phase reactants, and “brinolic factors enter the ste of inflammation. Artigody and lymphocytes do not enter unt later. U3114 Chapter 3 | Immunology 4, An 18-month-old boy has recurrent sinopulmonary infections and septicemia. Bruton’s X-linked immunodeficiency syndrome is suspected. Which test result would be markedly decreased? A Serum IgG, IgA, and IgM B. Total T-cell coune €. Both B- and T-cell counts D. Lymphocyte proliferation with phycohemagglutinin stimulation Immunology/Correlate laboratory data with physiological proceseslmmunodeficiency!Testing/2 5. A patient received 5 units of fresh frozen plasma (FEP) and developed a severe anaphylactic reaction. He has a history of respiratory and gastrointestinal infections. Post-transfusion studies showed all 5 units to be ABO-compatible. What immunologic test would help to determine the cause of this transfusion reaction? A. Complement levels, particularly C3 and C4 B. Flow cytometry for T-cell counts €. Measurement of immunoglobulins D. NBT test for phagocytic function Immunology/Determine laboratory test Immunodeficiency! Testingl3 5. An IFE revealed excessive amounts of polyclonal IgM and low concentrations of IgG and IgA. What is the most likely explanation of these findings and the best course of action? ‘A. Proper amounts of antisera were not added: repeat both tests B, Test specimen was not added properly; repeat both procedures . Pacient has common variable immunodeficiency; perform B-cell count D. Patient has immunodeficiency with hyper-M: perform immunoglobulin levels Immunology/Correlate laboratory data with physiological proceses Immunodeficiency! Testing/3 SITUATION: A 54-year-old man was admitted to the hospital ater having a seizure. Many laboratory tests were performed, including an RPR, but none of the results were positive. The physician suspects a case of late (tertiary) syphilis ‘Which test should be performed next? A. Repeat RPR, then perform VDRL B, Treponemal test such as MHA-TP on serum €. VDRL on CSE D. No laboratory testis positive for late (tertiary) lis Immunology/Correlate laboratory data with physiological proceed Syphilis! Testing!3 Answers to Questions 4-7 aA 6D 7.8 Apatient with Bruton's inked agammaglobulinemia presents with clinical symptoms related to recurrent infections, demonstrated in the lbboratory by decreased or absert immunoglobulins. Perioheral blood & cells ae absent or markedly reduced, but Tells are normalin number and function. Because phytohemagalutinin sa T-cell rtogen, the lymphocyte proliferation test using PHA would be normal for this patient The patient had an anaphylactic reaction to 2 plasma product. Ths, combined with the history of respiratory and gastrointestinal infections, suggests 2 selective IaA deficiency. Measurement of Immunoglobulins would be helpfulin this case. Alow serum IgA and normal ig substantiate the diagnosis of selective IgA deficeney, Such patients frequently produce anti IgA, which soften respo Severe transfusion reaction wnen ABO-compatible plasma is adminis bbe for 8 Low plasma concentrations of IgG and IgA and an abundance of IgM is consistent with hypertgM syndrome. Most cases are Xlinked and result from a ‘mutation of the gene TNFSFS that encodes a receptor needed for switching immuneglobulin production Patients with common variable immrunadefciency have low serurn IgG, IgA, and IgM. Serum antibody tests such as RPR and VDRL are often negative in cases of late syphils, However, treponemal tests remain positive in over 9586 of cases, The VDR for diagnosis of neurosyphils bec tests remain positive after treatment. should be Used as the confirmatory test when the serum treponemal testis positive. However, the CSF VDRLis limited insensitivity and would net be postive ifthe serum NHA-TP or FTA-ABS was negative. fest on CSF isthe most specific test se weponemal8. A patient came to his physician complaining of a rash, severe headaches, stiff neck, and sleep problems. Laboratory tests of significance were an. elevated sedimentation rate (ESR) and slightly increased liver enzymes. Further questioning of the patient revealed that he had returned from a hunting trip in upstate New York 4 weeks ago. His physician ordered a serological test for Lyme disease, and the assay was negative. What is the most likely explanation of these results? A. The antibody response is not sufficient to be detected at this stage the clinical symptoms and laboratory results are 1 characteristic of Lyme disease . The patient likely has an early infection with hepatitis B virus D. Laboratory error has caused a false-negative result Immunology/Correlate laboratory data with physiological proceseL.yme testing/Testing/3 9. A 19-year-old girl came to her physician complaining of a sore throat and fatigue. Upon. physical examination, lymphadenopathy was noted. Reactive lymphocytes were noted on the differential, but a rapid test for IM antibodies was negative. Liver enzymes were only slightly elevated. What test(s) should be ordered next? ‘A. Hepatitis testing B. EBV serological panel €.HIV confirmatory testing D. Bone marrow biopsy Immunology/Correlate laboratory data with physiological proceses/Testing!3 10. A patient received 2 units of RBCs following surgery. Two weeks after the surgery, the patient ‘was seen by his physician and exhibited mild jaundice and slightly elevated liver enzymes. Hepatitis testing, however, was negative. What should be done next? A. Nothing until mote severe or definitive clinical signs develop B, Repeat hepatitis testing immediately . Repeat hepatitis testing in a few weeks D. Check blood bank donor records and contact donor(s) of transfused units Immunology! Correlate laboratory data with physiological processed Hepatitis Testing/3 38 | Immunology Problem Solving 115 11. A hospital employee received the final dose of the hepatitis B vaccine 3 weeks ago. She wants to donate blood. Which of the following results are expected from the hepatitis sereen, and will she be allowed to donate blood? A. HBsAg, positive; anti-FBe, negative—she may donate B. HBsAg, negative; anti-HBe, positive—she may not donate C. HBsAg, positive; anti-HBe, positive—she may not donate D, HBsAg, negative; anti-HBc, negative—she may donate Immunology!Correlate laboratory data with physiological processeslHepatitislTesting/3 Answers to Questions 8-11 8. A The antibody response to B burgdorferi may i develop until several weeks after intial infection. T antibody test should be followed by a test such as PCRto detect the DNA ofthe organism, Regardless o the test outcome, ifthe physician suspects Lyme disease, eaiment should begin immeciately 9. B An EBV serological panel would give a more accurate assessment than a rapid slide IM test. The time of, © ofthe various antibadies to the viral (othe clinical course of the infection, 10. C Thelevelof HBsAg may not have reached detectable levels, and antibodies to HBc and HCV would nat have yet developed. Waiting 1 or 2 weeks and repeating the tests may reveal evidence of hepatitis virus infection, 11. D She may donate if she is symptom free, The resoanse tohenatts 8 vaccre would include a postive result for anti atest not normaly ap donor testing. She will be negat ant-Hic