Lab 10/27/11 : Immunology Case Studies

Name: ________________________________________ TA: ________________________________________

**YOU MUST COMPLETE TWO OF THESE & TURN IN BEFORE THE EXAM 11/3/11 TO RECEIVE CREDIT FOR LAB** Immuno Case Study 01 Paul Stein Paul Stein was 7yr old and had enjoyed perfect health until 2 days after he returned from a hike with his Boy Scout troop, when itchy red skin eruptions appeared all along his right arm (see pictures). Within a day or two, the rash had spread to his trunk, face, and genitals. His mother gave him the antihistamine Benadryl (diphenhydramine hydrochloride) orally to suppress itching, but it only provided partial relief. The rash did not improve and a week after it first appeared he was brought to the dermatology clinic at University Children s Hospital. Physical exam revealed large patches of raised, red, elongated blisters oozing clear fluid on his body and extremities. Paul also had swollen eyelids and a swollen penis. There was no history of fever, fatigue, or any other symptom. A contact sensitivity reaction to poison ivy was diagnosed. Paul was given a corticosteroid-containing cream to apply to the skin lesions three times a day, and Benadryl (25mg) to take orally 3 times daily. He was asked to shampoo his hair, wash his body thoroughly with soap and water, and cut his nails short. Two days later, his parents reported that although no new eruptions had appeared, the old lesions were not significantly better. Paul was then given the corticosteroid prednisone orally, starting at a dose of 2 mg/kg per day, which was gradually decreased over a period of 2 weeks. The topical steroid cream was discontinued. Within a week, the rash had almost disappeared. Upon stopping the prednisone, there was a mild flare-up of the lesions and this was controlled by application of topical steroid for a few days. Paul recovered fully and went back to his scout troop. He gave a demonstration on how to identify poisonous plants and to hike smarter with covering clothing, helping his fellow scouts.

Answer the following questions: 1) What is your diagnosis for what is wrong with Paul? 2) How does this condition occur? Explain (I m looking for a molecular answer not just what he touched what cells and processes might be going on?) 3) Paul should take great care to avoid this for the rest of his life. Why? 4) What do antihistamines (e.g., Benadryl) and corticosteroids (e.g., Prednisone) do for patients? 5) What is Paul s body reacting against? What are the consequences of that?

Immuno Case Study 02 Always Sick Jason

**YOU MUST COMPLETE TWO OF THESE & TURN IN BEFORE THE EXAM 11/3/11 TO RECEIVE CREDIT FOR LAB** Jason, a 6-yr-old boy who lives on a farm, has convinced his parents that he should be allowed to take care of the chicks that are in the hay loft area of the barn. He is intrigued with his brood of chicks and spends hours just lying down in the hay to watch them or dragging hay over to their nest. When he is not in the barn, Jason is helping his mother in their new garden. After several weeks of this regimen, Jason started having difficulty breathing and seemed to always be coughing. Jason seems to be sick rather often The parents took him to their family physician, who has already treated Jason for a severe diaper rash (Candida albicans) when he was an infant and again over the past few years for numerous severe bacterial infections. The physician ordered several tests, including a complete blood count (CBC) and differential, total serum immunoglobulins, immunization antigen titer, T-cell function test, and a bronchoalveolar lavage to use for culture. The WBC count showed a mild leukocytosis, but the differential indicated a normal percentage of each cell type. Total immunoglobulin levels were acceptable as were the antibody titers to immunization responses. T-cell function was normal, but not overly potent. Culture of the bronchial lavage revealed the fungal pathogen Aspergillus fumigatus, a fungus found in nature that survives inside macrophages. Upon finding this, a chest X-ray was ordered and showed multiple white signals in the lung (note: air in the lungs should be black ). This lead to a new clue about Jason s illness and a test for reactive oxygen species (ROIs) was ordered. Answer the following questions: 1) What might be wrong with Jason? Can you explain how Jason s condition might occur (again, looking for mechanisms here )? 2) How might things escape our immune defenses? 3) Look up some of the tests performed (in bold) and explain what the healthcare team might learn from this 4) Define the following (I know you can just cut/paste from Google, but I d like you to put it in YOUR words): a. Immunoglobulin b. T-cell c. Macrophage d. Leukocytosis 5) Aspects of this case involve what we commonly call allergies. What things in this case could be triggers of allergic responses?

Immuno Case Study 03 Dennis Fawcett **YOU MUST COMPLETE TWO OF THESE & TURN IN BEFORE THE EXAM 11/3/11 TO RECEIVE CREDIT FOR LAB** Dennis Fawcett was 5yr old when he was referred to the Children s Hospital with a severe acute infection of the ethmoid sinuses. His mother reported that he had had recurrent sinus infections since he was 1yr old. Dennis had pneumonia from an infection with Pneumocystis carinii (a fungus) when he was 3yr old. These infections were successfully treated with antibiotics. While he was in the hospital, Group A Streptococcus (S.pyogenes) was cultured from his nose and throat. The physicians caring for Dennis expected that he would have a brisk rise in his white cell count as a result of his severe bacterial infection, yet his white cell count was 4200/uL (normal count = 50009000/uL). 26% of his WBC s were neutrophils, 56% lymphocytes, and 28% monocytes. Thus, his neutrophil count was very low, whereas his lymphocyte number was normal, and monocytes were high. Seven days after admission, during which he was treated with antibiotics successfully, his serum was tested for antibodies against streptolysin O (SLO, an Ag produced by Group A Strep). When no antibodies to the SLO were found, his serum immunoglobulins were measured. The IgG level was 25 mg/dL (normal = 600-1500 mg/dL), IgA was undetectable (normal = 150-225 mg/dL), and his IgM level was 210 mg/dl (normal = 75-150 mg/dL). A lymph node biopsy showed poorly organized structures with an absence of secondary follicles and germinal centers.

Dennis was given a booster injection of DPT vaccine. 14 days later, no antibody was detected to tetanus toxoid. Dennis had red blood cells of Group O. People with type O blood make antibodies against the A and B types of blood. This is because bacteria in the intestine have antigens that are closely related to A and B blood antigens. Dennis s anti-A titer was 1:3200 and his anti-B titer was 1:800, both very high. His anti-A and anti-B antibodies were of the IgM class only. His peripheral blood lymphocytes were examined and normal results were obtained. 11% of lymphocytes reacted with an antibody to CD19, a B-cell marker. 87% reacted with anti-CD3, a T-cell marker. 2% reacted with anti-CD65, a marker for NK cells. All his CD19+ B-cells had surface IgM and IgD. No CD40 could be detected on B-cells. Dennis had 2 older sisters. They were both well. There was no family history of unusual infection. Dennis was put on a treatment regimen of injectable IV gamma globulin, 600 mg/kg, each month and subsequently remained free of infection.

Answer the following questions 1) What does Dennis s infection tell us about his immune status and response? (i.e., why could Dennis not mount an effective immune response?) Should we be concerned about not finding IgA in the serum? 2) Based on the conclusions and test results, what is your diagnosis for what is wrong with Dennis?

Immuno Case Study 04 Helen Burns **YOU MUST COMPLETE TWO OF THESE & TURN IN BEFORE THE EXAM 11/3/11 TO RECEIVE CREDIT FOR LAB** Helen Burns was the second child born to her parents. She thrived until 6mo of age when she developed pneumonia in both lungs, accompanied by a severe cough and fever. Blood and sputum cultures for bacteria were negative, but a tracheal aspirate revealed the presence of abundant Pneumocystis carinii (a fungus). She responded fairly well to treatment with the anti-Pneumocystis drug pentamidine and seemed to recover fully. However, it became recurrent and dangerous to her growth and survival As her pneumonia was caused by an opportunistic pathogen, Helen was suspected to have severe combined immunodeficiency (SCID). A blood sample was taken and her peripheral blood monocytes were stimulated with a viral antigen (Va) and tested for T-cell stimulating functions. A normal T-cell proliferative response was obtained. Helen had received routine immunizations for polio and DPT. However, in further tests, her T-cells failed to respond to bacteria in vitro, although they responded normally when stimulated with other dendritic cells. When it was found that Helen s T-cells could not respond to a specific antigen, they measured the circulating antibodies (aka immunoglobulins or Ig s ) found in her serum, which were found to be very low. IgG levels were 96 mg/dL (normal is 600-1400 mg/dL). IgA was 6 mg/dL (normal is 60-380 mg/dL). IgM was 30 mg/dL (normal is 40345 mg/dL). These low immunoglobulin levels is indicative of poorly developed B-cells. Helen s white blood cell count was elevated at 20,000 cells/uL (normal is 4000-7000). Of these, 82% were neutrophils, 8% monocytes, and only 10% lymphocytes. This calculated number of 2000 lymphocytes is low for her age (normal = 3000+). When just T-cells were examined, she had ~388 CD8 T-cells, which was within normal ranges. However, her CD4 T-cells (~228) was much lower than normal, as it would be expected to be at least twice as high as CD8s counts. The presence of substantial numbers of T-cells and a normal response with allogenic cells rules out SCID. Helen s pediatrician referred her to the Children s Hospital for consideration for a bone marrow transplant, despite the lack of a diagnosis. When an attempt was made to HLA type Helen, her parents and her healthy 4-yr old brother, a DR type, could not be easily obtained from Helen s white blood cells. A long-term culture of her B-cells was made by transforming them with Epstein-Barr virus (that causes mononucleosis) and the transformed cells were analyzed. It was found that her B-cells did not express HLA-DQ or HLA-DR. As her brother did not have the same HLA type as Helen, it was decided to use her mother as a bone marrow donor. Helen was given 1 mg/kg of busulfan to depress bone marrow function, then 50 mg/kg of cyclophosphamide to ablate her bone marrow. The maternal bone marrow was depleted of T-cells to diminish the chance of graft-vs-host disease

developing and was administered to Helen via transfusion. The graft was successful and immune function was restored. Helen now lives a happy, healthy life, although she is monitored monthly for immune reactions and occasionally takes prednisolone.

Answer the following questions: 1) Helen was first thought to have SCID, but this diagnosis was eliminated. How do you explain this? (you might start by defining SCID ) 2) Based on the above conclusions and the results in the last 3 paragraphs, what is your diagnosis for what is wrong with Helen? Can you explain why Helen might have a low level of antibodies (Ig s)?