IMMUNOLOGIC TOLERANCE

/AUTOIMMUNITY

PROFESSOR .S. ELESHA

 PATHOGENESIS OF
IMMUNOLOGIC TOLERANCE

Immunologic tolerance is a state in which

the individual is incapable of developing
immune response to a
specific antigen.
Several mechanisms albeit, poorly
understood, have been postulated to
explain the tolerant state.
They can be broadly classified into two
groups:
Central tolerance and peripheral tolerance
 CENTRAL TOLERANCE (CLONAL
DELETION).
This refers to death (deletion) of self-reactive T
and B lymphocyte clones during their
maturation in the central lymphoid organ
(thymus and the bone marrow).
Deletion of intra-thymus _Tcells has been
intensively investigated.
Experiment with transgenic mice which
provide abundant evidence that Lymphocytes
that bear receptor for auto-antigens undergo
apoptosis within the thymus during the
process of T – cell maturation.
It is proposed that many autologus protein
antigen including antigens thought to be
restricted to peripheral tissues are
processed and presented by thymic APCS
in association with self – MHC molecules.
A protein called AIRE (autoimmune
Regulator) is thought to stimulate
expression of many “peripheral” self
antigens in the thymus and is thus critical
for deletion of immature self –reactive T-
cells.
Mutations in the AIRE gene (Spontaneous
or created in knockout mice ) are the
causes of an autoimmune poly-
endocrinopathy .
The developing T cells that express high –
affinity receptors for such self –antigens
are negatively selected or deleted, and
therefore the peripheral T cell pool is
lacking or deficient in self – reactive T cells
Some immature T cells that encounter self
-antigens in the thymus escape deletion;
Clonal deletion is also operative in B cells
When developing B cells encounter a
membrane –bound antigen within the bone
marrow they undergo apoptosis.
Clonal deletion of self –reactive
lymphocytes in far from perfect.
 PERIPHERAL TOLERANCE
The auto-reactive T cells that escape intra-thymic
deletion can cause tissue injury unless they are
incapacitated in the peripheral tissues.
Several mechanisms are in place to inactivate
such auto-reactive T –cells. They include the
following:
1. Clonal anergy
2. Suppression by regulatory T – cells
3. Clonal deletion by activation – induced cell death
4. antigen sequestration
 1. Clonal anergy.
This refers to prolonged or irreversible
functional inactivation of lymphocytes
induced by encounter
with auto-antigens under inappropriate
conditions.
Activation of antigen specific cells require two
signals: (a) recognition of antigen in
association with self- MHC molecules on
the surface of APC, and
(b) a set of co-stimulatory signals:
 CD28 which is T-cell - associated, a
receptor, which must bind to its ligands
B7-1 on APC (costimulator B7 – 1 and β7 -
2) Once lymphocytes become anergic,they
cannot be activated even if the relevant
antigen is presented by competent APC
(dendritic cells ) that can deliver co-
stimulation, Because costimulatory
molecules are not expressed or are weakly
expressed on most normal tissues, -
the encounter between auto-reactive
T –cells and their specific self –antigen may lead
to anergy.
A receptor called CTLA – 4 also binds to B7
ligands and this can send inhibitory signal to T –
cells that recognise self antigens. Anergy affects
B cells in the tissue as well; it is believed that if
B cell encountered an antigen in the absence of
specific helper T cells the B cell becomes unable
to respond to subsequent antigen stimulation
and may be excluded from lymphoid follicles.
1. Suppression by Regulatory
T cells
Recent evidence, most from experiment in mice,
has emphasized the role of a population of
lymphocytes
(T-cells) called regulatory T cells in preventing
autoimmune reactions. Regulatory T cells may
develop in the thymus, as a result of recognition
of auto antigens, or they may be induced in the
periphery. The best
defined regulatory T cells are CD4 + cells that
costitutively express CD 25, the α (alfa) chains
of IL – 2 receptor,
but some CD4 + cells lacking CD25
may serve the same function. The
mechanisms of the inhibitory actions
are not fully defined.There is some
evidence that peripheral suppression of
auto- reactivity may be mediated, in
part, by the secretions of
cytokines,such as IL – 10 and TGF–β.
which inhibit lymphocyte activation and
effector function.
A transcription factor of the forkhead family,
called foxp3 is required for the development
and function of CD4 + CD25 + regulatory T –
cells.
Mutations in foxp3 result in severe
autoimmunity in humans and mice; in
humans, these mutations are the cause of an
autoimmune disease called IPEX (for
Immune dysregulated polyendocrinopathy,
Enteropathy, X – linked.)
3. Clonal Deletion by Activation –
Induced Cell Death.
CD4+ - T cells that recognize self – antigens
may receive signals that promote their death by
apoptosis
This process is called activation – induced cell
death, because it is a consequence of T- cell
activation.
Mechanisms,
The Fas – FasL system *Lymphocytes as
well as many other cells express Fas (CD95), a
member of the TNF-receptor family.
FasL, a membrane protein is structurally
homologous to the cytokine TNF, is expressed
mainly on activated CD4 + T-cells. The
engagement of Fas by FasL induces apoptosis
of activated CD4 + T cells and may underlie
the peripheral deletion of auto reactive T cells.
It is believed that those self –antigens that are
abundant in peripheral tissues cause repeated
and persistent stimulation of self antigen
specific T- cell,
 leading eventually to their elimination via
Fas- mediated apoptosis.
This mechanism is illustrated by two
strains of mice that are natural
“knockouts” of Fas and FasL.
The lpr mice have mutation in the Fas
gene while the gld mice are born with
defective FasL. Mice of both strains
develop severe autoimmune disease akins
to human SLE,
but unlike human SLE these mice also
suffer from generalized lympho-
proliferation. A few human subjects have
been identified with SLE – like
autoimmunity and generalized
lymphoproliferation associated with
mutation in the Fas gene.
The disease is called autoimmune
lymphoproliferative syndrome.
 The importance of this mechanism of cell
death in self-tolerance is not established.
Recently, another mechanism of activation
induced cell death has been proposed
also based on studies in mice.
It is postulated that if T_cells recognize self
–antigen, they express a pro-apoptotic
member of the BCL family called BIM, and
this protein inhibits the gene of the anti-
.apoptotic members of the family
4. Antigen Sequestration.
Some antigens are hidden from the immune
system because the tissues in which they are
located do not communicate with the blood and
lymph. Examples include the lens protein of the
eye, spermatozoa of the testis and myelin basic
proteins of the brain.
These organs are called immune privileged
sites. if the antigens of these tissues are
released as a consequence of trauma, immune
response resulting in inflammation may occur
and damage of the organ may occur.
This is the postulated mechanism for
posttransmatic uveitis and orchitis
 AUTOIMMUNE DISEASES:
Autoimmunity is immune reaction to self
antigen, a growing number of diseases
have been attributed to autoimmunity,
but in many the evidence is not firm. At
least three requirements must be met
before a disease is categorized as truly
due to autoimmunity:
1. The presence of an autoimmune reaction
2. Evidence that such a reaction is not due
to tissue damage,
 e. g, resulting from infection, but is of
primary pathogenic significance; and
3.The absence of another well defined cause
of the disease. The autoimmune disorders
may result from tissue injury caused by T
cells or antibodies that react against self –
antigens.
The autoimmune disorders form a
spectrum, one end of which the immune
response is directed against a single organ
or tissue,
resulting in organ- specific disease, and on
the other end are diseases in which the
immune reaction is against widespread
antigens, resulting in generalised or
systemic disease
In the middle of the spectrum falls
Goodpasture syndrome in which antibodies
to basement membranes of lung and
kidney induce lesions in these organs.
It is obvious that autoimmunity results from
loss of self – tolerance.
MECHANISMS OF AUTOIMMUNE
DISEASES.
It is now clear that a single mechanism
cannot explain the various autoimmune
diseases.
There are a number of ways by which
tolerance can be bypassed, thus
terminating a previously unresponsiveness
to auto-antigens. More than one defect can
be present in each disease, and the defects
vary from one disorder to the other.
The pathogenesis of auto-immunity
appears to involve immunologic,
genetic and infection, particularly viral
factors, interacting, through poorly
understood complex mechanisms.
Tolerance to an auto-antigen involves
CD4 + T cells and B-cell, CD4 + T cell
is tolerant to the carrier portion of an
auto-antigen while B cell is tolerant to
the haptenic portion.
CD4 + T-cells’ tolerance is at low
concentration and is long lasting .
B cell tolerance is at high concentration
and is short-lived .
CD4 -+ T cells is therefore the principal
cell that maintains tolerance. Bypass of
CD4 + T cell tolerance predisposes to
autoimmunity. Four general immunologic
mechanisms for loss of tolerance have
been postulated.
 A. BY-PASS OF HELPER T CELL
TOLERANCE .

Tolerance of CD4+ helper T cell is critical to the

prevention of autoimmunity. Tolerance to auto
antigen is often associated with clonal deletion or
anergy of carrier specific helper T cells in the
presence of fully competent hapten –specific B
cell.
Therefore tolerance can be broken if CD4+ T cell
tolerance is bypassed. Experimentally there are
several ways by which this can be accomplished
and some of these may have relevance to
human autoimmunity.
Modification of the molecule:
If the autoantigenic determinant (hapten)
is complexed to a new carrier, the carrier
portion may be recognized by nontolerant
T cell as foreign → co-operation with
hapten – specific B cells → production of
auto antibodies.
The modification of the molecule can arise
in the following ways;
Compexing of self- antigen with drugs or
carrier protein of a micro-organism→ an
auto-antigenic new carrier → non-
recognition by CD4 + cells as self →
autoimmune reaction
Alfa methyldopa may cause alteraction of
RBC surface, thus producing a new carrier
for an Rh antigen hapten that stimulates Β
cells. → production of autoantibody.
* Partial Degradation of Auto-antigen
This could expose new antigenic
determinants.
Partially degraded collagen or
enzymatically altered thyroglobulin or
gamma globulin are more immunogenic
than the native species Immune
responses against the microbial antigens
may result in the activation of self reactive
lymphocytes. This phenomenon is known
as molecular mimicry.
Several infectious agents cross-react with
human tissue through their haptenic determinant
(B- cell epitopes).
The infectious micro-organisms may trigger an
antibody response by presenting the cross-
reacting haptenic determinant in association with
their own carrier, to which the helper T-cell are
not tolerant .The antibody so formed may then
damage the tissue that shares the cross-
reacting determinants.
A clear example of such mimicry is
rheumatic heart disease in which
antibodies against streptococcal, M –
protein cross react with the M-protein in
the sarcolemma of cardiac muscles.
Molecular mimicry cross-reactions may
also apply to T cell epitopes.
Once the infectious agents provoke tissue
damage, their continued presence is not
necessary because tissue injury releases
more self- antigens.
B. POLYCLONAL B –
LYMPHOCYTE ACTIVATION.
Autoimmunity may occur if self-
reactive or anergic clones of B- cells
are stimulated by antigen –
independent mechanisms. Many
micro-organisms and their products
are capable of causing polyclonal (I .e,
antigen non-specific) activation of B –
cells.
lipopolysaccharide (endotoxin). EBV
Infection of B cells has similar effect
because human B – cells have receptors
(CDI9) for EBV.
C, IMBALANCE OF SUPPRESSOR
– HELPER T-CELL FUNCTION
Any loss of suppressor T- cell function will cause
hyperactivity of B - cells and autoimmunity,
conversely, excessive –T cell helper may drive B
cells to extremely high levels of autoantibody
production, Some experimental evidence
supports this concept. There is an age –
associated loss of suppressor
T- cells in the NZB/NZW( Fi Hybrid ) mice, which
develop an autoimmune disease similar to
human SLE as they age.
D EMERGENCY OF
SEQUESTERED ANTIGEN.
Some antigens are hidden from the immune
system because the tissues in which these
antigens are located do not communicate
with the blood and lymph.
It is clear that inductions of tolerance require
interaction between the antigen and the
immune system.
The antigen of the testis (spermatozoa ), eye
(lens crystalline ) and brain (myelin basic
protein )are completely sequestered during
development.
These organs are referred to as immune –
privileged sites because it is difficult to induce
immune responses to antigens in these sites.
If as a result of inflection or trauma their
antigens are released, the result may be an
immune response that leads to prolonged
tissue inflammation and injury.
This is the postulated mechanism for post-
traumatic orchitis and uveitis.
 GENETIC FACTORS IN
AUTOIMMUNITY
The development of autoimmunity is related to
the inheritance of susceptibility genes, which
may influence the maintenance of self –
tolerance, and the environment, particularly
infection, which promotes the activation of self
reactive lymphocytes.
Role of susceptibility Genes:
Most autoimmune diseases show a strong
genetic predisposition. The HLA genes are the
best defined among the predisposing genes.
The underlying mechanism however remains
obscure. it is clear both in experimental
animals, and in humans that genetic factors
determine the frequency and the nature of
autoimmune diseases.
Attention is focused on the relationship of
autoimmunity to Class II MHC -molecules.
This conclusion is based on the following:
Familial clustering of several autoimmune
disease, such as SLE, autoimmune haemolytic
anaemia and autoimmune thyroiditis
 2. Linkage of several autoimmune
diseases with HLA, especially class II
antigens: HLA – B27( ankylozing -
spondylitis), HLA -DR4 or HLA –DRI or
both alleles (rheumatoid arthritis and
type1diabetes mellitus);
3. . Induction of autoimmune disease in
transgenic rats. It is postulated that the
presence of particular MHC alleles affect
the negative selection of T- cells in the
thymus or the development of regulatory
T-cells,
3. but actual evidence for the possibility
is weak. It should be noted that many
normal individuals inherit the MHC
alleles that are disease- associated in
patient population, and normal MHC
molecules are capable of, presenting
self – antigens.
Therefore the presence of particular
MHC alleles is not, by itself the cause
of autoimmunity.
 MICROBIAL AGENTS IN
AUTOIMMUNITY
Many autoimmune diseases are associated with
infections and clinical flare- ups are often
preceded by infectious prodromes.
Two mechanisms have been postulated to
explain the link between infections and
autoimmunity
First, infections may up-regulate the expression
of costimulators on APCS. If these cells are
presenting self – antigens, the result may be a
breakdown of clonal anergy.
Second, some microbes may express antigen
that have the same amino acid sequences
as self- antigens .the result may be a
breakdown of clonal energy and activation of
T cell-specific for self –antigen. This
phenomenon is called molecular mimicry.
- The tissue injury that is common in infection
may release self-antigen and structurally
altered self –antigen so that they are able to
activate T- cells that are non-tolerant to
these new or altered antigens.
- Infections may induce cytokines that recruit
lymphocytes, including potentially self –
reactive lymphocytes, to sites of self –
antigens.
- Once an autoimmune disease has been
induced, it tends to be progressive,
sometimes with sporadic relapses and
remissions. An important mechanism for the
persistence and evolution of autoimmune
disease is the phenomenon of epitope
spreading
- Infections, and even the initial autoimmune
response, may release and damage self –
antigens and expose epitopes of the antigens
that are normally concealed from the immune
system, or cryptic .
 The result is continuing activation of new
lymphocytes that recognize the previously
cryptic epitopes, Since these epitopes were
not expressed normally, the lymphocytes
did not become tolerant to these.
- Thus, regardless of the initial triggers of an
autoimmune disease, the progression and
chronicity of the response may be
maintained by continued recruitment of
auto-reactive T-cells that normally
recognize cryptic self- determinants.
 The induction of such auto-reactive T- cells
is referred to as epitope spreading
because the immune response “ spreads”
to determinants that were initially not
recognised.
- Microbes can trigger autoimmune reactions
in several ways:
First, viral antigens and autoantigens may
become associated to form immunogenic
units.
- Second ,some viruses (e .g EBV) are non-
specific polyclonal B-cell mitogens,
and may thus induce formation of auto-
antibodies.
- Third, viral infection may result in loss of
suppressor T – cells function by
mechanisms that are at present not clear.
- Viruses and other microbes, particularly
certain bacteria such as Streptococci and
Klebsiella, may share cross – reacting
epitopes with self –antigens.
Certain infectious agents cause powerful
activation of CD4 + T – cells by release of
IL -2.
 Autoimmune Disease
Organ –Specific Systemic
Hashimoto thyroiditis Systemic lupus erythematosus
Autoimmune haemolytic anaemia Rheumatoid arthritis
Autoimmune atrophic gastritis of Sjogren syndrome
Pernicious anaemia
Multiple sclerosis Reiter syndrome
Autoimmune Inflammatory myopathies*

Orchitis Goodpasture syndrome Systemic sclerosis (sclerodema)*

Autoimmune thrombocytopenia Polyarteritis nodosa*
Insulin- dependent diabetes
mellitus
Insulin- dependent diabetes
mellitus
Myasthenia gravis Graves disease
Primary biliary cirrhosis*
Autoimmune (chronic active)
Hepatitis*Ulcerative colitis
 IMMUNOPATHOLOGIC MECHANISMS OF
AUTOIMMUNE DISEASES

MEDIATION OF AUTOIMMUNE
DISEASES:-
MEDIATION IS DIVIDED INTO 3 MAIN
CROUPS:
1. Auto-antibodies directed against modified
and unmodified intracellular structures or
cell surfaces →complement mediated or
ADCC cellular or tissue destruction; also
anti- receptor antibodies.
Examples:
Autoimmune endocrinopathies – Addison
disease, Juvennile diabetes
Autoimmune haematological
disorders
Goodpastures syndrome
Myasthenia Gravis
Grave’s Disease (Exophthalmic
Thyrotoxicosis)
2 Formation of auto Ag-Auto Ab complexes
in intercellular fluid or general circulation
→ deposition → attraction of
granulocytes, monocytes and
complement factors (Immune –complex
mediated)
Example; a. S.L.E (Prototype)
b. Rheumatoid arthritis, etc
3 Production of lymphokines by T-cells
Biologic Effect of Anti -receptor Abs
Accelerating degradation of receptors,
e. g., Myasthenia Gravis
Mimicking action of activated receptors,
e. g., Grave’s disease and certain cases of
acanthosis Nigricans
Blocking hormone binding e.g. ataxia
telangiectasia; Insulin- resistant Diabetes in
60%.
 IMMUNOPATHOGENESIS &
ETIOPATHOGENENSIS OFAUTOIMMUNE
DISEASE
AUTOANTIBODY METHOD DETECTION
ORGAN SPECIFIC
Myasthenis gravis Anti-acetylcholine Immuoprecipitation of
1251-alpha- bungarotoxin conjugated AchR.

Graves Disease Thyroid stimulating Bioassay,measurement

(diffuse Toxic Ig(TBI) or anti –TSH of adenylcycla
activity goitre after receptor ato ab
incubation of Thyroid Tissue with Ig from
patients’
Serum, radio receptor assay for Ab
 Competing with TSH for the receptor
On thyroid membranes.

Hashimoto Abs to thyroglobulin RIA, tanned

thyroiditis erthrocyte

And to microsomal Ags agglutination complement fixation , IF

Insulin resist Anti-insulin receptor Inhibition of 125 1-insulin

DM with binding to receptor and on
Acanthosis monocytes or adipocytes
Nigerians

Insulin-resistant
DM with ataxia Anti-Insulin
telanglectasia receptor “
 Allergic rhinitis, Antibodies to B2-adre Biding of 1281-protcia A toAsthma,
nergic receptors lung membranes
functional pre-incubated
Autonomic with sera, Ability of abnormalities plasma to
inhibit
Binding of 1381-iodohydrony
Benzylpindolol(THYP) to calflung
Membranes;Immuno -
precipitation of soluble
receptors complexed with 1-IHPin the
presence of propanolol

Javenile IDDM Antibodies to Islet Cells Immuno florescences IF

Pernicious Abs to gastric parietal IF RIA (Radioimmunossay)

Anaemia cells and to B12
binding site of intrinsic
factor
Addison’s Abs to adrenal cells IF
Disease

Idiopathic Abs to antigen of IF

hypoparathy- parathyroid cells
roidism

Spontaneous Abs to sperm Agglutination and

Infertility Immobilization of
Spermatozoa

Premature Ovarian Abs to interstitial IF

Failure and corpus luteum
cells

Pemphigus Abs to intercellular

substances of skin &
mucosa IF
Bullous Pemphigoid Abs against basement
memb zone of skin &
mucosa IF

Primary biliary Abs to mitochondrial IF

Cirrhosis Ags

Autoimmune Anti-RBC antibodies Direct & Indirect

Hemolytic Coomb’s test
Anaemia

Idiopathic Anti-platelet
Thrombocy- antibodies IF
topenic
Purpura
Idiopathic Neutrophil
Neutropenia antibodies Agglutination, IF

Systemic
Good pasture’s Anti-basement IF, RIA
Syndrome membrane
antibodies

Rheumatoid Anti-alpha -globulin Sensitized - SRBC

Arthritis & antibodies to agglutination, RIA, IF

Sjogren’s Antibodies to EBV- relate Immunodiffusion

Syndrome Antigen

Systemic Lupus Anti- nuclear antibodies IF

Erytematosus (ANA)
Anti-ds - DNA Farr assay, solid
phase
Enzyme and RIA,
hemaglutination,

Counterelectrophoresis
Anti-SM Hemaglutination
antibodies immundiffusion, RIA

Anti lymphocytes IF,cytotoxicity

Anti-RBC Coomb’s test

antibodies