PATHOLOGY

Immunopathology 1
Dr. Joselli c. Rueda-cu
I. The Immune System a. General Features b. Mechanisms of Protection c. Cellular Components d. Categories of the Immune System e. MHC Molecules II. Hypersensitivity Reactions a. Type I b. Type II c. Type III d. Type IV III. Transplant Rejections

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July 26- 28, 2011

c. Dendritic Cells Produce type I interferons which inhibit viral infection and replication One of two important cellular reactions of innate immunity as anti-viral defense together with NK cells d. Natural Killer Cells Protect against viruses and intracellular bacteria e. Plasma Proteins Complement system proteins Lysis f. Lung Surfactant Lowers surface tension of the lungs Component of innate immunity Provides protection against inhaled microbes. B. Adaptive (Acquired/Specific) Immunity Stimulated by antigens/ microbes Antigens (Ag) Foreign bodies accessed by the immune system as substance to be destroyed. B lymphocytes Most responsible for destruction of the antigen by maturing to a plasma cell then releasing antibodies Recognition of microbial and non-microbial substances Develops after exposure to microbes More powerful than innate immunity in combating infections

THE IMMUNE SYSTEM General Features of the Immune System

The Immune system o Vital for survival that protects us from the environment filled with deadly microbes and infectious pathogens Immunopathologic States o Immunodeficiency Renders and individual an easy prey of infections and tumours o Hyperactive May cause fatal disease, as in the case of an overwhelming allergic reaction Hypersensitivity diseases o Autoimmune Immune reaction against self Immune system loses its normal capacity to distinguish self from non-self

Mechanisms of Protection

The Complement System

Component of both Innate and Adaptive Immunity o Cause cell lysis o In Innate Immunity: It is activated by binding to microbes Uses Alternate and Lectin pathways Mannose-binding Lectin and C-reactive protein Coat microbes for phagocytosis and complement activation C reactive protein indication of an inflammatory process o In Adaptive Immunity: Activated by binding to antibodies using Classical pathways

Fig 1. Innate and Adaptive Immunity

A. Innate (Natural/Native) Immunity First line of defense Recognizes microbes, protection against infections Present before infection Components: a. Epithelial Barriers Mechanical barriers against entry of microbes from external environment Produce anti-microbial molecule such as defensins and lymphocytes b. Phagocytic Cells Mostly neutrophils and macrophages One of two cellular reactions of innate immunity that causes inflammation If absent, a persons immune system is congenitally impaired

Cell and Tissues of the Immune System T-Lymphocytes

Thymus derived cellular immune response 60-70% of lymphocytes Anatomic residence: a. Thymus b. Found in paracortical areas of lymph nodes c. Periarteriolar sheaths of the spleen Contain T-cell receptors which bind Major Histocompatibility Complex (MHC) molecules on the surface of Antigenpresenting cells

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 Subsets: 1. Cytotoxic T cells 70% to 80% of circulating blood lymphocytes Majority of the T-lymphocytes Express CD8+ surface receptors Destroy infected and tumour cells 2. Helper T cells Help/ facilitate in microbial destruction Express CD4+ surface receptors Contain T-cell receptors (TCRs) which: Are polymorphic antigen-binding molecules Bind antigens associated with MHC on other cells Analogous to surface immunoglobulins (Ig) of B cells Can rearrange their genes to respond to antigenic stimuli 3. Suppressor T cells Express pan T-markers (pan- means everything/ a lot) including CD2, CD3 and CD5 Note: CD3 are invariant molecules (meaning, its identical in all T cells) which bind to the TCR forming the TCR complex Signal transduction pathways in T cells once antigen is presented in these complexes T cell responses. TCRs are Polymorphic Ag-binding molecules, analogous to surface Ig that binds Ag associated with MHC on other cells.

Macrophages
Second line of defense Seen in cellular immune response They can serve as APCs and they can be Activated Activated Macrophages o Express MHC class II receptor o Cytokine activation of CD4+ cells enhances microbicidal properties of macrophages and augments their ability to kill tumor cells Antigen Presenting Cell o Induction of cell mediated immune response Process the antigens in phagocytosed microbes and present peptide fragments to T cells T-cells become more sensitive to the bacteria that the macrophage caries T-cells then produce cytokines that enable macrophages to destroy the bacteria In Effector phase of humoral immunity o They phagocytose microbes opsonised (Making microbes more palatable/ edible by macrophage) by IgG or C3b

MLE Q: Only cytokines are involved, no antibodies

Note: According to Dr. Cu Macrophage (when presenting antigens to T cells) tells T-Lymphocytes Im carrying something I cannot destroy, will you help me?

Dendritic Cells

B-Lymphocytes
Bone marrow derived humoral immune response 10-20% of lymphocytes Anatomic residence: a. Bone marrow b. Blood c. Cortex of lymph nodes and germinal centers d. Splenic white pulp e. Lymphoid follicles Responses to protein antigens require help from CD4+ T cells Engages CD40, necessary for B cell maturation and secretion of IgG, IgA and IgE antibody CD40 Member of the Tumor Necrotic Factor (TNF)-receptor family and by cytokines activated helper T lymphocytes express CD40 ligand, which specifically binds to CD40 expressed on B cells B cells express several molecules on their surface (just like TCRs in T cells) responsible for response activation (ex. CD40, Fc receptors, CD21 etc.) o CD4+ T cells engage CD40, a member of the TNF receptor family o CD40 is necessary for B cell maturation and the secretion of IgA, IgE and IgG antibodies o Activated helper T lymphocytes express the CD40 ligand (CD40L), which specifically binds to CD40 expressed on B cells. o Mutations in the gene encoding CD40 ligands may result to X-linked hyper-IgM syndrome No IgG production o The 3 types of mutation in CD40 ligands are Translocation, Amplification and Point Mutation. (TAP) Note: Ig and Ig are 2 invariant proteins of B cell antigen receptor complex (much like CD3 of T cells) needed for signal transduction pathways B cell responses. Fc receptors are proteins found on the surface of cells that contribute to the protective functions of the immune system.

Fig 2. The role of dendritic cells in capturing microbial antigens from epithelia and transporting them to regional lymph nodes. Immature DC (ex. Langerhans cell in epithelia) respond to microbes and are activated Migrate to lymph nodes via lymphatic vessels DC recruited to T- cell zones of lymphoid organs to function as APCs to T cells. Please refer to Fig. 6-10 p. 194 of Robbins for a clearer image.

Resident phagocytes Found under the lining epithelium which is the most common entry site of antigens 10-20% of circulating peripheral lymphocytes Most important antigen presenting cells for initiating primary immune response against protein antigens Location: (MLE Q) o Under epithelia, the most common entry site of antigens and interstitial of all tissues where Ag maybe produced

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 Types: 1. Interdigitating dendritic cells/ simply dendritic cells Most important antigen presenting cells for initiating primary IR against protein antigens 2. Langerhans cells Immature dendritic cells within the epidermis. 3. Follicular dendritic cells Germinal centers of lymphoid follicles in spleen and LN Bears Fc receptors for IgG and C3b Trap antigen bound to antibody (Ab) or complement proteins Improving quality of humoral immune response Play a role in the pathogenesis of AIDS Note: Two major types according to Robbins namely interdigitating and follicular

Fig 3. Immunoglobulin molecule. Note that there are two heavy (H) chains and two light (L) chains linked by disulfide bonds. Each heavy and light chain has a constant (C) and a variable (V) region. It is the variable regions in the Fab portion that react with a specific antigen and give rise to the diversity of immunologic response. Immunoglobulin can attach via the Fc portion to a variety of cells with Fc receptors.

Natural Killer Cells

10-15% of peripheral lymphocytes Kill variety of tumor cells, virally infected cells, some normal cells without previous sensitization Do not bear T-cell receptors, surface Ig nor the traditional T or B markers Nucleus is not segmented Morphologic name: Large granular lymphocytes Histological appearance: Huge lymphocytes Has two receptors: Inhibitory receptor and activating receptor Cancer patients take interferon for the possibility that NK cells will destroy the foreign bodies. Cytokines IL-2, IL-15 and IL-12 regulate NK cells activity o IL-2 and IL-15 Proliferation of NK cells o IL-12 Activates killing and secretion of IFN-

Steps in Humoral Immunity 1. Naive IgM and IgD B cell binds microbe 2. Helper T cells help B cells via: a. CD40 on B cells recognize CD40L of T cells b. IL-4 (secreted by TH2 helper cells) lead to matured B cells/ plasma cells IgE production c. TH1 helper cells stimulated IgG Ab production 3. Class switching and affinity maturation occurs mainly in germinal centers 4. Antibody secretion by plasma cells Abs bind to microbes neutralizing them, preventing them from infecting cells. IgG act as opsonins

II. Cell-Mediated Immunity

Activation of T lymphocytes and elimination of intracellular microbes Mediated by T lymphocytes T-cell receptors (TCR) o Genetically programmed to recognize specific antigens o Can rearrange their alpha and beta genes to respond to antigenic stimuli Macrophages process the antigen and present it with class II Human Leukocyte Antigen (HLA) to the CD4+ cells Cytokines such as interleukin (IL) and tumor necrosis factor (TNF) are elaborated by activated T cells to enhance cellular immune reactions A. CD4+ helper lymphocytes Help B cells make antibody (therefore B cells are not exclusively for humoral immunity) Help generate cytotoxic T cells Macrophages process antigen and present it with class II HLA to the CD4+ cells Participate in delayed hypersensitivity reactions (TYPE IV) 60% of peripheral T lymphocytes Secrete and respond to growth factor IL-2 cytokine Proliferation and increase in number of CD4+ T cells

MLE Q: Killing dependent on cell to cell contact enhanced by

interferon and IL-12

MLE Q: Antibody Dependent Cell mediated Cytotoxicity

(ADCC): Ability to lyse IgG coated target cells due to CD16 cell surface molecules secrete cytokines such as IFN-

MLE Q: What receptor enhances NK cell killing? Answer: CD16

Note: CD16 is an Fc receptor of NK cells for IgG. It confers the ability on NK cells to lyse IgG-coated target cell. This reaction is called ADCC. NK cells are early line of defense because of the ability to kill a variety of infected and tumor cells. It activates macrophages by secreting IFN- which provides an early defense against intracellular microbes.

Two Broad Categories of the Immune System I. Humoral Immunity

Activation of B lymphocytes and elimination of extracellular microbes B-cell lymphocyte mediated via production of antibody MLE Q:Often develops as a response to soluble antigens B cells account for about 20% of circulating lymphocytes Immunoglobulin gene rearrangements allow tremendous diversity of responses to many antigens. Protects against extracellular microbes and toxins Can mutate/change in genetic coding to have different responses

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Table 1. Characteristics of the different CD4+ Subsets

CD4+ Subsets

TH1

TH2 IL-4 Stimulate B cells to differentiate into IgEsecreting plasma cells IL-5 Activates eosinophils IL-13 Mucus secretion

TH17 (Recently discovered)

Cytokine secreted

IFN-- potent macrophage activator

IL-17- play a role in several inflammatory diseases

2. Class II MHC Molecules: In the D region (DR) Narrowly distributed Mostly on mononuclear inflammatory cells (macrophages, B cells and dendritic cells) Help induce CD4+ cells Encoded in loci/region: HLA D (3 subregions: DP, DQ and DR) Recognized by CD4+ T lymphocytes Detected by mixed lymphocyte assay Importance of HLA Transplantation Regulation of some immune responses Virus-infected cells with class I antigen are lysed by CD8+ cells that can recognize the virus-cell complex MLE Q: Class II antigens help induce CD4+ cells Its association with a variety of diseases Inheriting HLA-B27 90% of developing ankylosing spondylitis and several postinfectiousarthropaties HLA-DR 2, -DR3 and DR4 with autoimmune diseases Notes: HLA system is highly polymorphic Meaning there are many alleles of each MHC gene in the population. Each individual inherits one set of these alleles, which is different from the alleles of other individuals. This is why there is a barrier in organ transplantation. No 2 individuals (other than identical twins) are likely to express the same MHC molecules and therefore grafts exchange between these individuals are recognized as foreign and attacked by the immune system. An individual inheriting a specific MHC molecule has its own consequences/ advantages. Ex. Inheriting MHC Class II specific for Ragweed pollen would be genetically prone to pollen allergies. In contrast, inheriting MHC Class II for bacterial antigens provide resistance to infection by evoking a protective antibody response.

Induced by

IFN- and IL-12

IL-4 IgE production Mast cell and eosinophil activation

TGF-, IL-1 etc Recruitment of neutrophils and monocytes Extracellular bacteria and fungi Immunemediated chronic inflammatory diseases (often autoimmune)

Function

Macrophage activation IgG production

Host defense against

Intracellular microbes Immunemediated chronic inflammatory diseases (often autoimmune)

Helminthic parasites, allergens

Role in disease

Allergies

B. CD8+ suppressor lymphocytes Cytotoxic (mostly occur during cell-cell contact) 30% of circulating T lymphocytes Destroy infected and tumour cells

Major Histocompatibility Complex (MHC) Molecules

Physiologic function: To display peptide fragments of proteins for recognition by antigen-specific cells. Play key roles in regulating T cell-mediated IR

MLE Q: MHC or human leukocyte antigen (HLA) complex is on

chromosome 6 Two Classes of MHCs 1. Class I Antigens: A, B and C Present on all nucleated cells and platelets (therefore is not seen in RBCs) Only class A and B are important in blood typing Encoded in loci/ regions HLA A, B and C Tested for and detected by serologic means "C" antigens unimportant A number of alleles are present and each person inherits one from each parent Thus, a person might be HLA typed as: a. A 5, 10 b. B 11, 41

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HYPERSENSITIVITY REACTIONS
Table 2. Mechanisms of Immunologically Mediated Diseases Type Prototype Disorder Immune Mechanisms Production of IgE antibody Immediate release of vasoactive amines and other mediators from mast cells Recruitment of inflammatory cells (late-phase reaction) Production of IgG, IgM Binds to antigen on target cell or tissue Phagocytosis or lysis of target cell by activated complement or Fc receptors; Recruitment of leukocytes Deposition of antigen-antibody complexes Complement activation Recruitment of leukocytes by complement products and Fc receptors Release of enzymes and other toxic molecules Activated T lymphocytes i. Release of cytokines and macrophage activation ii. T cell-mediated cytotoxicity Pathologic Lesions Vascular dilation, edema, smooth muscle contraction, mucus production, inflammation

Immediate (type I) hypersensitivity

Anaphylaxis; allergies; bronchial asthma (atopic forms)

Antibodymediated (type II) hypersensitivity

Autoimmune hemolytic anemia; Good pasture syndrome

Cell lysis; inflammation

2. Lipid Mediators - de novo synthesis and release (2 mediators) a. Leukotrienes b. Prostaglandin c. Platelet-activating factor d. Bradykinins Steps: 1. 1st exposure: Allergen binds to antibody 2. TH2 cells secrete IL-4 Stimulate IgE production 3. IgEs Fc portion binds to mast cells nd 4. 2 exposure: Allergen binds to IgEs Fab portion (This same IgE is the one bounded to a mast cell due to 1st exposure to allergen) 5. Bridging of Fc receptors Mast cell degranulation (Release of histamine and serotonin, leukotrienes, prostaglandin and bradykinin)

Immune complexmediated (type III) hypersensitivity

Systemic lupus erythematosus; some forms of glomerulonephrit is; serum sickness; Arthus reaction

Necrotizing vasculitis (fibrinoid necrosis); inflammation

Fig 4. TYPE I hypersensitivity

Cell-mediated (type IV) hypersensitivity

Contact dermatitis; multiple sclerosis; type I, diabetes; transplant rejection; tuberculosis

Perivascular cellular infiltrates; edema; cell destruction; granuloma formation

Remember: 1st exposure to antigen produces IgE but NO degranulation of mast cell 2nd/re-exposure: Bridging of IgE to mast cell with antigen Degranulation Inflammatory cell infiltrates Immediate Reaction (In minutes) Vasodilation, vascular leakage, smooth muscle spasm and glandular secretions Late Phase Reaction (2-24 hours) Leukocyte infiltration, epithelial damage, bronchospasms In late phase reaction, eosinophils are particularly important

Type I (Immediate) Hypersensitivity

Occurs within minutes after an antigen combines with an antibody (IgE) bound to mast cells in previously sensitized individuals Anaphylaxis o Occurs in individuals with prior sensitization o Promotes mast cell proliferation and IgE production of plasma cells o IgE and mast cells bind in places such as the respiratory tract mucosa o Most threatening if person has it in the respiratory tract because patient can die due to asphyxia. It can cause vasodilation and bronchoconstriction which decreases effective blood circulation and may lead to shock Mast cells Found near blood vessels and nerves Almost same with Basophils, except that it does not roam around the circulation Contains granules: 1. Preformed and Stored in Cytoplasm (1 mediators) a. Vasoactive amines Histamine and serotonin (vasodilation and bronchoconstriction) b. Enzymes Cause tissue damage and kinin production c. Proteoglycans Heparin

Types of Anaphylaxis
1. Systemic Characterized by vascular shock, widespread edema and difficulty in breathing Cx: Itching, hives skin erythema, laryngeal edema, vomiting, abdominal cramps, diarrhea, laryngeal obstruction. Patient may go into shock and die in an hour Ex. Drug allergies (anaphylaxis), Food allergies (peanuts), Asthma, Insect toxins (bee sting), hay fever

Fig 5. Acute laryngeal edema due to anaphylactic reaction to penicillin. A form of Type I hypersensitivity reaction where preformed IgE antibody on mast cells quickly reacts with antigen. Mast cells release histamine and other mediators leading to edema.

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2. Local (Atopy) Affects 10% of people Allergens include: Pollen, animal fur, dust, food etc. Easily sensitized to allergens that cause a localized cutaneous swelling when inhaled or ingested Specific diseases include: Urticaria (hives), angioedema, allergic rhinitis (hay fever), bronchial asthma, skin allergy, conjunctivitis and food allergies.

2. Inflammation Abs are deposited to fixed tissues (basement membrane and extracellular matrix) Activate complement system Formation of the membrane attack complex which disrupts membrane integrity Examples: Good Pasteurs syndrome Ab targets kidney glomerular basement membrane/ GBM. Immunofloresces of GBM show a linear pattern because GBM becomes antigenic Linear deposition of cells. 3. Cellular Dysfunction/ Stimulation In some cases, antibodies directed against cell surface receptors impair or dysregulate function without causing cell injury or inflammation. Examples: a. Dysfunction: In myasthenia gravis, there are acetylcholine receptor antibodies in the motor end plates of skeletal muscles which block neuromuscular transmission and diminish muscular response Muscle weakness. Ach has no receptor to bind to since the receptors are occupied by Ab thus no contraction occurs. Manifestations: 1st: Ptosis (bilateral) 2nd: Difficulty in breathing b. Stimulation: In Graves disease, antibodies against the thyroid-stimulating hormone receptor antibodies on thyroid epithelial cells stimulate the cells, leading to hyperthyroidism c. Dysfunction: In pernicious anemia, anti-parietal cell antibodies are present Decreased absorption of Vit. B12.

Fig 6. Hay Fever. A form of localized anaphylaxis with Type I hypersensitivity where allergens in plant pollens contact IgE bound to mast cells then causing the release of granules containing mediators such as histamine that promote vasodilation and edema. Beneath the nasal mucosa at the left, eosinophils have been attracted. The plasma cells seen here have collected due to the chronic nature of the antigenic stimulation.

Type II (Antibody-Mediated) Hypersensitivity Caused by antibodies that react with antigens present on cell surfaces or in the extracellular matrix or altered cell surface antigens Complement dependent reactions: Antibody directed against antigen on cells (circulating red blood cells) or extracellular materials (basement membrane). Resulting Ag-Ab complexes activate complement (via the classic pathway) causing cell lysis and extracellular tissue damage.

Antibody-Dependent Cell-mediated Cytotoxicity (ADCC)

Antibody-mediated cell destruction may also occur via ADCC: o Low concentrations of IgG or IgE (in the case of parasites) Coat target cells Inflammatory cells such as NK (natural killer) cells, monocytes, and granulocytes bind to the immunoglobulin Fc receptors Lyse, but DO NOT phagocytize, the target cells

Fig 7. In the above diagram, a red blood cell has antigen fixed on its surface to which antibody attaches. The attached antibody sets off the complement cascade, which ends with the formation of the "membrane attack complex" of C5-9 which causes lysis of the cell. Other complement components may be generated, such as the opsonin C3b.

Mechanisms of Type II Hypersensitivity

1. Phagocytosis and Opsonization Examples: a. Transfusion reactions wherein incompatible red blood cells (RBCs) or serum is transfused b. Autoimmune hemolytic anemia in which antibodies are made against ones own RBCs c. In erythroblastosis fetalis, there is an antigenic difference between the mother and the fetus When maternal IgG crosses the placenta, it destroys fetal RBCs

Fig 8. A macrophage with Fc receptors on its surface is able to recognize a target cell coated with antibody via the Fc receptor portion of the attached antibody. The macrophage can then demolish the targeted cell by elaboration of proteases. (Macrophage releasing proteases) tissue necrosis; inflammation

Examples of ADCC a. Transplant rejection b. Immune reactions against neoplasms c. Immune reactions against parasites Antireceptor antibodies: IgG antibody is directed against receptors in target cells, resulting in complement-mediated destruction of the receptors.

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This may lead to: Glomerulonephritis Serum sickness Vasculitis

Fig 9. In the diagram, antibody is directed against acetylcholine receptors at the motor end plate of a muscle, blocking the receptors and diminishing the muscular response. This is the mechanism for muscle weakness in myasthenia gravis.

3. Initiating Inflammation caused by deposition of IC Because small ICs are opsonised, they trigger complement system The resultant inflammatory lesions are the ff: Glomerulonephritis Red/white cell becomes immunogenic to own system, circulate and deposited in glomerular capillaries Vasculitis Deposited in and around small blood vessel inciting an inflammatory reaction Arthritis In joints Note: A single large exposure to antigen/ Ag excess in circulation leads to Acute Serum Sickness. Repeated or prolonged exposure Chronic form of Serum Sickness ex. Systemic Lupus Erythematosus (SLE).

Diseases caused by this mechanism include: Myasthenia gravis: Ach receptor antibody. Grave's disease (thyrotoxicosis): Anti-TSH receptor antibody Pernicious anemia: Anti-parietal cell antibody.

Type III (Immune Complex-Mediated) Hypersensitivity

Mediated by immune (Ag-Ab) complexes (IC) which promote tissue damage primarily through complement activation (alternate pathway) o C3b, as an opsonin, attracts neutrophils, which then release lysosomal enzymes. o C5a as a chemoattractant brings in neutrophils. o Serum complement is reduced as it is used up in this process.

Local Immune Complex Disease

Local immune complex disease: "Arthus" reaction o Arthus reaction Localized area of tissue necrosis from acute IC vasculitis. o Local injection of the antigen Immune complex formation Acute inflammatory hemorrhagic reaction and local dermal vasculitis. o Role in the development of hypersensitivity pneumonitis ("farmer's lung") Small complexes are deposited in the basement membrane of alveolar wall

Type IV (Delayed) Hypersensitivity

No anti-body formation Sensitization of T-lymphocyte CD4 containing leukocytes The lymphocyte with then secrete cytokines to act on the macrophage

CD4+ Lymphocyte-Mediated Responses

Fig. 10. Antibody-Antigen complex promotion

Antigen-antibody complexes are circulating and becoming trapped beneath the basement membrane of a small blood vessel, setting off the complement cascade and generating components that attract PMN's to generate an ongoing inflammatory response (Figure above). In this type of hypersensitivity reaction, there is a mark element of VASCULITIS. Immune complexes can be deposited systemically or locally (deposited near Basement membranes)

Delayed Mediated by sensitized CD4+ T lymphocytes, which process antigens in association with class II HLA molecules and release lymphokines The lymphokines promote a reaction (especially mediated through macrophages) beginning in hours but reaching a peak in 2 to 3 days. Hypersensitivity reactions with this mode of action include: o Granulomatous diseases (Mycobacteria Tuberculosis , fungi)

Systemic Immune Complex Disease

Pathogenesis of Systemic Immune Complex Disease 1. Ag-Ab complexes form in the circulatory system Protein/ Ag is introduced leading to formation of Abs in blood 2. Deposition of Immune Complexes in various tissues Larger immune complexes are quickly phagocytized by macrophages and removed. The larger they are, they are more easily recognized and phagocytized. The smaller to intermediate complexes formed within antigen excess may escape removal. They are the most pathogenic and are not recognized hence they are opsonized. These complexes are deposited to organs w/c filter at high pressure. (Glomeruli, Joints and BV)

Fig 11. Sequence of events in granuloma formation in response to Mycobacterium tuberculosis (MTB). The key cell in the process is the epithelioid macrophage.

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MLE Q: What produces caseation in TB?

Answer: Its the Immune Response, NOT the organism

MLE Q: What is the hallmark of granuloma formation?

Answer: Activation of macrophage Epitheloid cell formation o Tuberculin skin reactions Produced by intracutaneous injection of protein tuberculin from Bacillus in previously sensitized patient Accumulation of CD4+ T cells and macrophages around venules (perivascular cuffing)

Note: According to Robbins, T-cell mediated rejection has 2 pathways, Indirect and Direct. Direct pathways involve both CD4+ and CD8+ recognizing the donors APCs. Indirect pathways involve only CD4+ (type IV hypersensitivity) responding to recipients own APCs presenting donors antigen. D. Antibody mediated reactions: Mediated through: Complement-mediated cytotoxicity Antibody-dependent cytotoxicity (ADCC) Immune complexes Can also be termed rejection vasculitis, because the 1st target of the antibodies seems to be the graft vasculature Note: According to Dr. Cu, there is no granuloma in HIV because HIV kills CD4+ responsible for granuloma formation.

MLE Q: Would HIV in chronic stage have caseous

necrosis? Answer: NO, because no epitheloid formation that could destroy the organism. o Transplant rejection o Contact dermatitis Pre-sensitized lymphocytes led to this inflammatory reaction a couple of days after contact with the offending agent (poison oak, poison ivy)

Organ System Pathology Renal Transplant

3 Classic modes of rejection 1. Hyper-acute rejection: Occurs within minutes or hours after transplantation Kidney becomes cyanotic, mottled, flaccid and may excrete blood in urine (needed: erythropoietin tests) Ig and complement deposited in vessel wall Thrombi, endothelial injury and accumulation of neutrophils the site May lead to kidney infarction Preformed antibody causes immediate (minutes to hours) vascular injury via ADCC Due to previous sensitization through transfusion, pregnancy, or infections (through HLA cross-reacting bacterial or viral antigens) 2. Acute rejection Both cell mediated and humoral immunity involvement Acute Cellular rejection: Occurrence sometimes within days, usually within months, even sometimes years later when immunosuppressive therapy is discontinued. Cellular infiltrates with both CD4+ and CD8+ cells. Primarily T cell mediated cytotoxic damage There is tubular damage and vascular injury due to CD8+ Density of the infiltrate and extent of parenchymal damage determine severity (more inflammatory reaction, more tissue destruction due to dissolution of immune complex) Acute Vascular (or Humoral) Rejection (rejection vasculitis) Rejection primarily at the vasculature of the graft because of anti-donor antibodies 3 general stages: 1. Early: Subendothelial inflammation and hypertrophy of endothelium 2. Intermediate: moderate intimal proliferation with more significant wall inflammation 3. Severe: Significant fibrinoid necrosis (indicator of immune damage) and intimal proliferation.

CD8+ Lymphocyte (CTL)-Mediated Responses

CD8+ T cells generated Lyse specific cells Role of Class I HLA molecules: CTL bind MHC I Ag of cells, kill them, enacting cell mediated immune response Reactions with this mode: o Neoplastic cell lysis o Transplant rejection o Virus-infected cell lysis o Viral Hepatitis Note: Difference of Type 4 vs. Type 3 Greater phagocytosis, no membrane, no Ig participation

deposition

in

basement

TRANSPLANT REJECTIONS Two Important Pathologies in Transplant Rejection

Rejection of graft or donor organ Graft versus Host (GVH) disease Graft accepted but is manifesting symptoms, host reacting to transplanted organ

Immunologic Mechanisms
A. HLA system is a key factor. Reactions mediated by either T lymphocytes (cellular) or Ab (humoral) Major types of hypersensitivity reactions involved: II & IV B. The ABO system: Best characterized as the major blood group antigens Expressed on all cells except in the CNS Thus, matching for ABO compatibility is important for transplantation. C. T-cell mediated reactions: CD4+ cells generating delayed hypersensitivity reactions after recognizing foreign HLA class II (DR) antigens (seen in mononuclear cells) Cytotoxic CD8+ cells recognizing foreign HLA class I (A,B, or C) antigens (in all nucleated cells). The donor tissue or donor lymphocytes within the transplanted tissue carry the offending HLA antigens. Involves suppressor reactions.

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Fig 12. This is an Acute renal transplant rejection known as acute cellular tubulointerstitial rejection because most of the inflammation is in the interstitium. The glomerulus seen here is normal, but the tubules are infiltrated by many lymphocytes at the upper right (coagulative necrosis). Organ is still discernible.

Fig 15. Chronic vascular rejection at high magnification: thickened and fibrotic renal arteries; obliterated lumen. There is interstitial fibrosis and chronic inflammation. Such chronic rejection usually occurs slowly over several months to years following transplantation. This form of rejection, unlike acute cellular rejection, is difficult to treat.

Fig 13. At high magnification, the lymphocytes and plasma cells are seen around a renal tubule in a renal transplant patient with acute cellular rejection. This type of rejection can occur at any time following transplantation when immunosuppression is diminished. This is treated by administering cyclosporine and other immunosuppressive agents.

3. Chronic rejection (Chronic transplant Glomerulopathy) More tissue fibrosis/ scar formation Scar formation Vessel obliteration Chronic rejection Renal failure Increase serum creatinine Tubular atrophy and shrinkage of renal parenchyma Intimal fibrosis with vascular thickening Renal ischemia Mononuclear infiltrates with prominent plasma cells and eosinophils Both T-cell and humoral mechanisms leads to increasing intimal fibrosis and ischemia Obliterates vessels, almost no blood supply to surrounding structures Hallmark of chronic rejection is increased fibrosis

Graft vs. Host Disease An immune reaction of the host against a graft (e.g. organ) 2 phases 1. Acute: Cell necrosis of skin and GI tract, cholestasis 2. Chronic: Over 100 days post transplant Dermal fibrosis, desquamative esophagitis, portal tract fibrosis Cholestasis 3 organs prominently involved: a. Liver (cholestasis) b. Intestine c. Skin (apoptosis of squamous epithelium and thickening of subepidermal region with increased hyalinization) In BM transplant, GvH is the greatest problem, however, in case of bone marrow malignancy transplant, graft vs. tumor effect is therapeutic Recall difference of necrosis and apoptosis( Board exam question)

Fig 16. Liver cholestasis. Seen above are large collections of yellow-green bile pigment within the bile canaliculli

Fig 14. Immunologic disease can also complicate solid organ transplantation. Here is a renal biopsy that demonstrates marked interstitial fibrosis in a patient with chronic vascular rejection.

Fig 17. Thickness of subepithelial region; hyalinization of skin. Besides the icterus (yellow color, or jaundice) in this skin there is a fine scaling rash in this patient following bone marrow transplantation with a 5 out of 6 antigen match. This is an example of graft versus host disease (GVHD) where donor lymphocytes attack host tissues.

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Fig 18. Apoptosis or single cell necrosis there is vacuolization and dissolution of epidermal cells along the basal layer, along with lymphocytes. At the arrow is a rounded pink apoptotic body.

Fig 20. By immunoperoxidase staining with antibody to CD3, the T-lymphocytes in the myocardium involved in this acute cellular rejection phenomenon in a heart transplant recipient can be identified here.

Liver Transplant
HLA is less important than simple matching of organ size (since most of these are done in children). Two modes of rejection: a. Acute rejection Seen within two months Mixed inflammatory portal and central vein infiltrates. b. Chronic rejection Continued inflammation, portal fibrosis, arteriolar thickening, and bile ductular necrosis Note: In heart liver and lungs, HLA matching is usually not even done, because anatomic compatibility (ex. Size), severity of underlying illness and minimizing the time of organ storage have much more benefits over HLA matching.

Bone Marrow Transplant

Two problems that are unique to bone marrow transplant are Graft versus host disease and immunodeficiency. HLA matching important to minimize GvHD. (GVHD) Donor lymphocytes attack recipient tissues having the offending HLA antigens. Chemotherapy agents used to prepare patient for marrow transplantation may result in hepatic veno-occlusive disease in the weeks following transplantation.

REFERENCES
Robbins Pathologic Basis of Disease: Disease of Immunity 2013B Trans: Immunopathology Dr. Cus Lecture

REVIEW QUESTIONS
1. One of the two important cellular reactions of innate immunity as anti-viral defense together with NK cells 2. This is necessary for B-cell maturation and secretion of IgA, IgG, and IgE 3. Most important antigen presenting cells 4. MHC Class II can be detected by _______ 5. In type I hypersensitivity, this causes mast cell degranulation. 6. What mechanism causes autoimmune hemolytic anemia in type II Hypersensitivity 7. TRUE/FALSE: In type III Hypersensitivity, deposition should takes place first before formation of immune complexes. 8. Would HIV in chronic stage cause caseous necrosis? 9. What type of classic mode of rejection is where fibrosis/scarring are predominantly seen? 10. The 3 organs predominantly involved in GVHD are skin, liver and ____.

Heart Transplant
HLA is less important than simple matching of organ size. Immunosuppressive therapy is carefully monitored in relationship to signs of rejection on endomyocardial biopsy. Two modes of rejection: o Acute cellular rejection: Lymphocytic infiltrates Possible myocardial fiber necrosis. o Acute vascular rejection: Immunoglobulin deposition in small arteries Vasculitis.

ANSWERS TO QUESTIONS

Fig 19. This is acute vascular rejection in a myocardial transplant tissue. The inflammatory reaction consists mostly of mononuclear infiltration (lymphocytes) and is seen mainly around small arteries, a vasculitis. Such a reaction can occur when the dose of immunosuppressive drugs is decreased in the months following transplantation. Increasing immunosuppressive therapy in these patients is not as effective as for acute cellular rejection.

SECTION B

UERMMMC Class 2014

Pathology 10

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