Immunopathology

1
Salma Haddad
Overview

Allergy
Cancer
Autoimmunity
Infection
Transplant
rejection
Understand the basis for normal protective immune responses

• Constitutive/physical barriers to infection

• Cells of the innate immune response
• Macrophages, neutrophils, dendritic cells, NK cells
• Complement
• Cytokines and chemokines
• Cells of the adaptive immune response
• T and B cells
Immunology 101

Innate Adaptive
Macrophages, neutrophils, T and B cells
dendritic cells, NK cells, mast cells
etc
Fast Slow
No memory Memory
Germline encoded Somatic recombination
Non-specific Specific
Immunology 101

T cells B cells
Maturation in thymus Maturation in bone marrow
T cell receptor B cell receptor
TCR binds to antigen via MHC BCR binds directly to antigen
Receptor is surface bound Soluble antibody production
Cellular and humoral effectors Only humoral effectors
 T cell

CD4 T cell (T helper/Th) CD8 T cell (cytotoxic/CTL)

(cancer cells/virally
infected cells)
Th1 cell Treg cell
(intracellular (negative
bacteria ) Th2 cell regulator)
(allergy/parasites)
B cell
Immunology 101
MHC I MHC II
Found on all nucleated cells Found only on antigen presenting cells
(APCs) (dendritic cells, macrophages, B
cells)
Presents endogenous antigen Presents exogenous antigen
Binds to CD8 TCR Binds to CD4 TCR
Immunodeficiency
 Understand how deficiencies in immune responses result in
increased susceptibility to infectious disease

• Primary – inherited
• Secondary – to some other cause
• Physiological – to be expected
• Neonates, pregnancy, old age
 Production

Maturation

Migration

Neutrophils

Opsonisation

Phagocytosis and
killing

Recruitment of cells
Reticular dysgenesis
• Failure of stem cells to differentiate along myeloid or lymphoid lineage
• Failure of production of: Neutrophils, Lymphocytes,
Monocyte/macrophages, Platelets

• Fatal in very early life unless corrected with bone marrow transplantation

• Autosomal recessive severe SCID (most severe form)

• Mutation in mitochondrial energy metabolism enzyme adenylate kinase 2
(AK2)
Neutrophil maturation
Kostmann’s syndrome
• Specific failure of neutrophil maturation (untimely apoptosis)
• Autosomal recessive severe congenital neutropenia
• Classical form due to mutation in HCLS1-associated protein X-1
(HAX1)

• Clinical: recurrent bacterial and fungal infections

• Treatment: responds very well to G-CSF

Cyclic neutropenia
• Specific failure of neutrophil maturation
• Autosomal dominant episodic neutropenia every 4-6 weeks
• Mutation in neutrophil elastase (ELA-2)

• Clinical: increased bacterial/fungal infections every few weeks with

good health in between

• Treatment: G-CSF. Improves after puberty.

Migration and adhesion
• CD18 (integrin b2) usually expressed on neutrophils
• Bind to ligands on endothelial cells
• Regulate neutrophil adhesion/transmigration
Leukocyte adhesion deficiency
• CD18 deficiency
• Failure of neutrophils to exit bloodstream (cannot bind to ICAM1)

• Clinical:
• Very high neutrophil counts in blood
• Absence of pus formation
• Delay in umbilical cord sloughing

• Treatment: haematopoietic stem cell transplant

Killing
• Oxidative killing
• NADPH oxidase complex converts oxygen into reactive oxygen species –
superoxide and hydrogen peroxide

• Non-oxidative killing
• Release of bacteriocidal enzymes such as lysozyme and lactoferrin into the
phagolysosome
Chronic granulomatous disease
• Absent respiratory burst
• Deficiency of one of components of NADPH oxidase (often X-linked)
• Inability to generate oxygen free radicals
• Impaired killing of intracellular micro-organisms

• Clinical: Pus, granuloma formation, lymphadenopathy and

hepatosplenomegaly

• Treatment: IFN-g
Investigations for phagocyte deficiency
• FBC – neutrophil count
• Leukocyte adhesion markers assay
• Nitroblue tetrazolium test – oxidative killing (cells turn blue if active)
• Dihydrorhodamine flow cytometry – similar to NBT
Questions
• Which cell of the immune system makes pus when it dies?
• Which cell is specialized to present antigen?
• A boy comes in with abscesses and a positive NBT. What is the likely
diagnosis?
Complement
Complement deficiency
• Failure of opsonisation = failure of phagocytosis

• Clinical:
• Increased risk of encapsulated bacterial infections
• N. meningitidis
• S. pneumoniae
• Haemophilus influenza
• SLE – if early components of classical pathway involved
Investigation of complement
• CH50 – measures classical pathway activity
• AP50 – measures alternative pathway activity
SLE
 Failure of stem cells to differentiate
(myeloid and lymphoid lineage)
Production Reticular dysgenesis AR SCID
Mx: HSCT

Severe neutropenia
Kostmann’s HAX-1 mutation
Mx: G-CSF

Maturation Infections due to neutropenia

every few weeks
Cyclic neutropenia ELA-2 mutation
Mx: G-CSF

CD18 (integrin b2) deficiency

Leukocyte adhesion No pus, Delayed UC separation

Neutrophils Migration deficiency
Increased neutrophil count
during infection
Mx: HSCT

Complement and
Infections with
Opsonisation antibody encapsulated bacteria
deficiencies

Phagocytosis Chronic Abscesses

granulomatous Positive NBT test
and killing disease Mx: IFN-g

Recruitment of Cytokine
cells deficiencies
 Thymic
maturation

Selection
T cells
Cytokine release

Lymphoid
progenitors T-B cell
communication

Maturation
B cells

Class switching
Severe Combined Immunodeficiency
• Features
• Many different forms
• Mutation of gamma chain of IL2 receptor on Xq13.1 most common (X-linked
SCID)
• Required for receptors for IL2, 4, 7, 9, 15, 21
• à inability to respond to cytokines
• à early arrest of T and NK cells, immature B cells
Severe Combined Immunodeficiency
• Unwell by 3 months of age (protected beforehand by IgG from
mother across placenta then colostrum) with:
• Infections of all types
• Failure to thrive
• Persistent diarrhoea
• Unusual skin disease
• Colonisation of infant’s empty bone marrow by maternal lymphocytes
• Graft versus host disease

• Treatment: BMT
 Lymphocyte development
Immature
B-Cells
Lymphoid progenitors

Stem Cells
Neglect
Pre T-Cells Useless (does not
recognise MHC)
B-cells
Dangerous (binds too
Thymus strongly to MHC)
Useful (recognises
MHC weakly

Immunoglobulin-secreting
plasma cells Export of mature T-cells to the periphery
DiGeorge syndrome
• Features
• Thymic aplasia

• Clinical
• Cardiac abnormalities
• Abnormal facies
• Thymic aplasia (T cell lymphopenia)
• Cleft palate
• Hypocalcaemia/hypoparathyroidism
• 22q11.2 deletion
Selection of CD4+ T lymphocytes
MHC Class II
deficiency
Double positive Single positive
Bone Marrow CD4+8+ CD4+ lymphocytes
Pre-T cells thymocytes
4 4

Active selection of cells

that recognise peptides
in conjunction with
MHC Class II

Thymus
Bare lymphocyte syndrome type II
• Features
• Defect in regulatory factor X and class II transactivator = absent expression of
MHC class II

• Profound deficiency of CD4+ cells

• Usually have normal number of CD8+ cells
• Normal number of B cells
• Failure to make IgG or IgA antibody

• Treatment: antibiotics, IVIg, BMT

Investigation of T cell deficiencies:
• Total white cell count and differential
• Remember that lymphocyte counts are normally much higher in children than
in adults
• Lymphocyte subsets
• Quantify CD8 T cells, CD4 T cells as well as B cells and NK cells
• Serum immunoglobulins and protein electrophoresis
• Production of IgG is surrogate marker for CD4 T cell helper function
• Functional tests of T cell activation and proliferation
• Useful if signaling or activation defects are suspected
• HIV test
B cell maturation
Bruton’s X-linked hypogammaglobulinaemia
• Defective B cell tyrosine kinase gene

• Pre B cells cannot develop to mature B cells causing absence of

mature B cells and no circulating Ig after ~ 3 months

• Recurrent infections during childhood, bacterial, enterovirus

Class switching
Selective IgA deficiency
• Prevalence = 1:600

• 2/3rd individuals asymptomatic and 1/3rd have recurrent respiratory

tract infections

• Genetic component but cause unknown

Hyper IgM syndrome
• Inability of B cells to class switch causing production of only IgM due to a T cell defect
• Most cases caused by mutation in CD40 ligand gene (CD40L, CD154)
• Encoded on Xq26
• Expressed by activated T cells – NOT on B cells

• Boys present in first few years of life with:

• Recurrent infections - bacterial
• Failure to thrive
• Pneumocystis jiroveci infection, autoimmune disease and malignancy

• Causes:
• Normal number circulating B cells
• Normal number of T cells and normal in vitro T cell responses
• Elevated serum IgM
• Undetectable IgA, IgE, IgG
• No germinal centre development within lymph nodes and spleen
• Failure of isotype switching
Common variable immune deficiency
• Heterogenous group of disorders with disease mechanism unknown

• Low IgG, IgA and IgE

• Clinical features
• Recurrent bacterial infections
• Often with severe end-organ damage
• Bronchiectasis, persistent sinusitis, recurrent GIT infection
• Autoimmune disease
• Granulomatous disease
Investigation of B cell deficiencies
• Total white cell count and differential
• Remember that lymphocyte counts are normally much higher in children than in adults
• Lymphocyte subsets
• Quantify B cells as well as CD4 T cells, CD8 T cells and NK cells
• Serum immunoglobulins and protein electrophoresis
• Production of IgG is surrogate marker for CD4 T cell helper function
• Functional tests of B cell function
• Specific antibody responses to known pathogens
• Measure IgG antibodies against tetanus, Haemophilus influenzae B and S. pneumoniae
• If specific antibody levels are low, immunise with the appropriate killed vaccine and repeat
antibody measurement 6–8 weeks later
• Functional tests have generally superceded IgG subclass quantitation.
Cytokine deficiencies
• IL-12 and IFN-g are important for T cell/macrophage interaction and
activation

• Clinical:
• Increased susceptibility to infection with intracellular organisms
• E.g. TB
 Thymic maturation DiGeorge CATCH-22

Bare lymphocyte MHC II deficiency

Selection
syndrome II Reduced CD4
T cells
Cytokine release Increased
IL-12/IFN deficiency
susceptibility to TB

T-B cell
communication
Failure of B cell maturation
B cell TK gene mutation
Maturation Bruton’s X-linked
No circulating Ig
Recurrent childhood infections
Lymphoid progenitors
Common
Selective IgA
B cells deficiency 2/3 asymptomatic
1/3 recurrent infections

X-linked mutation in CD40L

High IgM, Low IgG, A, E
Class switching
Infection, autoimmunity and
Hyper IgM malignancy
Mutation in IL2R
Deficiency in B, T and NK
X-linked SCID cells
FTT, infections, diarhhoea, Common variable Unknown cause
GvHD immune deficiency Normal IgM, low IgG, A, E
Questions
• Woman with recurrent chest infections is found to have reduced total
serum protein and autoimmune thrombocytopaenia.

• Girl has no CD4 cells, but present CD8 and B cells.

• Boy with no B cells, no Ig, normal CD4 and CD8 counts.

• Boy with no B cells, normal Ig, normal CD4 and CD8 counts.
Autoinflammation and autoimmunity
Autoinflammation
• Immunopathology in the absence of infection due to innate immune
response
• May be monogenic (rare) or polygenic (more common)
Monogenic auto-inflammatory disease
• Tend to cause periodic fevers
• Abnormal signalling via key cytokine pathways involving TNF/IL-1

• Example: familial Mediterranean fever

• Autosomal recessive
• MEFV mutation (encodes pyrin-marenostrin)
• Failure to regulate cryopyrin driven activation of neutrophils
Familial Mediterranean Fever
• Clinical presentation: periodic fevers lasting 48-96 hours associated with:
• Abdominal pain due to peritonitis
• Chest pain due to pleurisy and pericarditis
• Arthritis
• Long term risk of amyloidosis causing nephrotic syndrome and renal failure
• Treatment:
• Colchicine 500ug bd – binds to tubulin in neutrophils and disrupts neutrophil
functions including migration and chemokine secretion
• Anakinra (IL-1 R anatagonist)
• Etanercept (TNFa inhibitor)
• Type 1 IFN
Polygenic
autoinflammatory
disease
• Often discovered by linkage
analysis
 Hypersensitivity

Harmless
Alloantigens
foreign antigens

Autoantigens
Gel & Coombs classification
• Type I : Immediate Hypersensitivity
• Type II : Antibody-dependent Cytotoxicity
• Type III : Immune Complex Mediated
• Type IV : Delayed Cell Mediated
Gel & Coombs classification
• Type I : Immediate Hypersensitivity
• Type II : Antibody-dependent Cytotoxicity
• Type III : Immune Complex Mediated
• Type IV : Delayed Cell Mediated
Type I immediate hypersensitivity
• Anaphylaxis
• Asthma
• Rhinitis
• Seasonal
• Perennial
• Food Allergy

• SOLUBLE antigen
Type I immediate hypersensitivity
• Primary exposure = Sensitisation not tolerance

• Secondary exposure = antigen cross-links IgE on mast cells/basophils

causing degranulation

• Measure serum tryptase

Type II antibody-dependent hypersensitivity
Clinical presentation depends on target tissue
• Organ-specific autoimmune diseases
• Myasthenia gravis (Anti-acetylcholine R Ab)
• Goodpasture’s (Anti-glomerular basement membrane Ab)
• Pemphigus vulgaris (Anti-epithelial cell cement protein Ab)
• Pernicious anaemia (Intrinsic factor blocking Abs)
• Autoimmune cytopenias (Ab mediated blood cell destruction)
• Haemolytic anaemia
• Thrombocytopenia
• Neutropenia
Type III Immune Complex Mediated
Hypersensitivity
• Antigen-Antibody complexes form in BLOOD

• Deposit in a tissue

• All antibody functions then happen there à VASCULITIS

• SLE
• Vasculitides

• Causes glomerulonephritis, arthritis, skin and lung pathology

Type IV Delayed Hypersensitivity Responses
• Cell mediated

• Th1 à Macrophage activation à TNFa (auto/alloimmunity)

• Th2 à Eosinophil activation à inflammatory mediators (allergy)
• CTL à granzyme and perforin release, induces apoptosis
(auto/alloimmunity)
Type IV
Autoimmunity
• Adaptive immune responses with specificity for self “antigens”
(autoantigens)

• Genetic predisposition
• Infections (molecular mimicry)
• Environmental factors

• Breakdown of T cell tolerance

Genetic predisposition
 Lymphocyte development
Immature
B-Cells
Lymphoid progenitors

Stem Cells
Neglect
Pre T-Cells Useless (does not
recognise MHC)
B-cells
Dangerous (binds too
Thymus strongly to MHC)
Useful (recognises
MHC weakly

Immunoglobulin-secreting
plasma cells Export of mature T-cells to the periphery

Suppression Exhaustion/deletion
by Tregs Lack of co- Ignorance (eye, after chronic
stimulation (anergy) CNS, testes) stimulation
Breakdown of central tolerance – APECED
• Autoimmune
• PolyEndocrinopathy-
• Candidiasis-
• Ectodermal
• Dystrophy

• Mutations of TF AIRE (causes expression of many self-antigens in thymus in

order to negatively select self-reactive T cells)
• Found in Medullary Thymic Epithelial cells (mTEC)
• No negative selection
Breakdown of central tolerance – SLE
• Genetic predispositions occur in genes relating to:
• induction of tolerance (B lymphocyte activation: CD22, SHP-1):
autoantibody production

• apoptosis (Fas, Fas-ligand): failure in cell death

• clearance of antigen (Complement proteins C1q, C1r and C1s):

abundance/persistence of autoantigen
Breakdown of peripheral tolerance – failure of
ignorance in sympathetic ophthalmia
Regulatory T cells (Tregs)

CD4+CD25+CTLA-4+FOXP3 +

Type of T
helper cell TF required for
IL-2 receptor Treg
Binds to B7,
development
preventing CD28
binding (negative
signal)
Thanks for listening!
• salma.haddad@gstt.nhs.uk
Questions