chapter five

Immunological disorders and

immunotherapy

5.1 Introduction
The human immune system is a defense organization within the body that protects against
diseases. The immune system basically consists of several cells that identify and kill the
invading pathogens and tumor cells. The immune system detects a wide variety of agents
such as bacteria, viruses, and parasitic worms. The term “immunity” was first used during
430 bc and later on, in the eighteenth century, research experiments were conducted with
scorpion venom that showed that certain dogs and mice are immune to scorpion venom.
Various theories have been hypothesized to show that the human body has an intrin-
sic defense against disease and not until 1891 was it revealed that microorganisms are
responsible for various infectious diseases. Besides bacteria, viruses were also established
as human pathogens in 1901, with the discovery of the yellow fever virus. One of the major
tasks of the immune system is to defend the body from any kind of harmful infections.
It has been shown that disease detection is complicated, as pathogens can evolve rapidly
and with time can produce a completely new organism to avoid the immune defense sys-
tem, which allows pathogens to successfully infect hosts. It has been reported that many
organisms (bacteria and viruses) have evolved that cause severe health problems around
the world.

5.2  Immune system

It has been reported that all higher orders of vertebrates, including animals and humans,
have more advanced defense mechanisms to fight against infection. Moreover, the human
defense system consists of many types of proteins, cells, organs, and tissues that interact in
an intricate and dynamic way to defend the human body against diseases and infections.

5.3  Classification of immune system

The primary function of an immune system is protecting the body from any infection. The
immune system is basically creating a physical barrier to prevent pathogens such as bacte-
ria and viruses from entering the organism. The immune system can be broadly classified
into two major types: the innate immune system and adaptive immune system.

5.3.1  Innate immune system

The innate immune system contains cells and mechanisms that defend or fight against
infection by other microorganisms in a generalized manner, which suggests that the cells
of the innate system identify and respond to pathogens in a common way, and it does not

109
110 Biotechnology in medical sciences

Cellular Humoral

Acquired immunity

Immunity

Innate immunity

Cellular Humoral

Figure 5.1  Classification of immunity.

convene long-lasting or protective immunity to the host (Figure 5.1). It has been reported
that innate immune systems offer immediate defense against infection and are found in
all plants and animals. It has been found that the innate immune system generally consists
of three components—membrane barrier, inflammation, and complement system—to pro-
tect the cells from infections. In case a pathogen breaks these barriers, the innate immune
system provides an immediate response to control pathogen entry. In case pathogens can
successfully evade the innate response, a host body possesses another layer of protection
called the adaptive immune system, which can be activated by the innate response. At
this point, the immune system familiarizes its response during an infection to increase its
recognition of the pathogen. This enhanced response against pathogens is then remem-
bered in the form of an immunological memory after the pathogen has been removed, and
allows the adaptive immune system to withstand faster and stronger attacks each time
this pathogen is detected (Figures 5.2 and 5.3).

5.3.1.1  Physical barrier

In innate immune systems, the epithelial surfaces of a cell form a physical barrier that
is highly resistant to most infectious agents and acts as the first line of defense against
invading pathogenic organisms. Bacteria and other infectious agents can be removed from
the skin epithelium by the process of desquamation, while bacteria and other infectious
agents present in the gastrointestinal and respiratory tracts can be removed by peristal-
sis movement. It has been reported that the gut pathogenic bacteria can be prevented by
secreting toxic substances by healthy bacteria or by competing with pathogenic bacteria
for nutrients. Interestingly, the flushing act of tears and saliva helps prevent the infection
of the eyes and mouth regions.
It has been reported that inflammation is one of the first responses of the immune
system due to bacterial or viral infection. Inflammation is generally stimulated by chem-
ical factors released by damaged cells and helps to establish a physical barrier against
infections. Also, immune systems promote the healing of damaged tissues or cells follow-
ing the removal of pathogens. During inflammation, the immune system releases vari-
ous kinds of chemical factors that include histamine, bradykinin, and serotonin. Later on,
Chapter five:  Immunological disorders and immunotherapy 111

Mast cell Macrophage

Dendritic cell
Monocyte
B cell

Neutrophil
T cell

Adaptive immunity Immunity Innate immunity

Opsonization Enhancement of immunologic memory

Lysis of pathogens Elimination of self-reactive B cells

Promotion of T-cell response

Chemotaxis

Cell activation Augmentation of antibody response

Slow response Rapid response

Figure 5.2  Difference between innate and adaptive (acquired) immunity.

Immunodeficiencies Autoimmune disease Hypersensitivity

Immune disease

Figure 5.3  Types of immune diseases.

prostaglandins also sensitize pain receptors that cause a vasodilation of blood vessels at
the location and employ phagocytes, especially neutrophils. These neutrophils then trig-
ger other parts of the immune system to attack the pathogenic infections. Inflammation
leads to the development of various symptoms that include redness of the skin, heat, swell-
ing of the organ, pain in the body or parts of the body, and possible dysfunction of the
organs or tissues involved. In addition to this, the complement system is a biochemical
cascade of the immune system that helps to clear pathogens in the body. The cascade is
basically composed of plasma proteins that are synthesized in the liver, mainly by hepato-
cytes. These proteins work together to trigger the recruitment of inflammatory cells of the
immune system to upset the plasma membrane of an infected cell, resulting in the death
of the pathogens.

5.3.2  Cellular network of innate immune system

The white blood cells (WBCs), identified as leukocytes, are different from other cells of the
body because they are normally associated with a particular organ. It has been reported
112 Biotechnology in medical sciences

that leukocytes are able to move freely in the body and network with cellular debris, for-
eign particles, and invading pathogenic microorganisms. Interestingly, most innate leuko-
cytes cannot multiply or reproduce on their own, unlike other body cells. These leukocytes
are the products of hematopoietic stem cells present in the bone marrow and we briefly
describe the various types of innate leukocytes.

5.3.2.1  Mast cells

In the human body, mast cells are basically innate immune cells that reside in the con-
nective tissue and in the mucous membranes, and these cells are closely associated with
defense against pathogens and wound healing. After activation, mast cells speedily release
some granules that are equipped with histamine and heparin and chemotactic cytokines
into the host cell environment. It has been reported that histamines open blood vessels,
causing irritation or inflammation, and recruit neutrophils and macrophages to defend the
host cells (Figure 5.4).

5.3.2.2 Phagocytes
Phagocytes are basically immune cells that engulf pathogens or particles to protect the
body from any infection. It has been reported that phagocytes engulf a particle or patho-
gen by extending parts of its plasma membrane and wrapping the membrane around the
particle until it is completely enveloped and covered. Once the pathogen is completely
covered, the lysosome, which contains enzymes and acids, starts killing and digesting the
foreign particle or organism. It has been described that phagocytes generally patrol the
human body searching for pathogens, and are also able to respond to molecular signals
produced by other cells, which are called cytokines. There are various types of phagocytic
cells reported in the human immune system that include neutrophils, macrophages, and
dendritic cells as described in the following sections (Figure 5.5).

5.3.2.3 Macrophages
Macrophages are large leukocytes that are able to move outside the vascular system and
enter the areas between cells in the hunt of invading pathogens. It has been reported

Mast cell

Mast cell activation

Muscle cells Nerve cells Endothelial cells Hematopoietic cells Epithelial cells

Tissue remodeling Functional changes (acute) Inflammation

Takes days or weeks Takes hours or days

Figure 5.4  Mast cells and their role in innate and acquired immunity.
Chapter five:  Immunological disorders and immunotherapy 113

Foreign Viruses Bacteria

particles

Antibodies form aggregates

Killing of bacteria and viruses

by special proteins in the body

Antibody and antigen

aggregates are ingested
by phagocytic cells

Figure 5.5  Role of phagocytic cells in immune protection.

that these macrophages are the most efficient phagocytes, and can kill large numbers of
bacteria or other cells or microorganisms. The attachment of anti-bacterial molecules to
receptors of a macrophage terminates the bacterial population through respiratory spurt,
causing the release of reactive oxygen species. It has been reported that pathogens can also
stimulate the macrophage to produce chemokines, which command other cells to the site
of infection.

5.3.2.4 Neutrophils
Because of the presence of granules in their cytoplasm, neutrophils, eosinophils, and baso-
phils are known as granulocytes. Neutrophils are also known as polymorphonuclear cells
(PMNs) due to their typical lobed nuclei. It has been reported that neutrophil granules
contain a variety of toxic elements that destroy or inhibit the growth of bacteria and fungi.
Like macrophages, neutrophils attack pathogens by activating a respiratory spurt that
contains oxidizing agents, including free oxygen radicals, hydrogen peroxide, and hypo-
chlorite. It has been reported that neutrophils are the most plentiful type of phagocyte,
normally representing 50–60% of the total mobile leukocytes, and they are usually the first
type of cells to reach the site of an infection. It has been estimated that the bone marrow
of a healthy adult human being produces more than 100 billion neutrophils per day, and
produces more than 10 times more neutrophils during acute inflammation or infection.

5.3.2.5  Dendritic cells

Dendritic cells are phagocytic cells present in human tissues that are in contact with the
external atmosphere, primarily the skin, where they are referred to as Langerhans cells,
and the inner mucosal lining of the nose, stomach, intestines, and lungs. The structure of
dendrite cells closely resembles neuronal dendrites; that is why they are called dendritic
cells. They have no association with neuronal cells. It has been suggested that dendritic
114 Biotechnology in medical sciences

Epithelial wall

Antigen
Migration and maturation

Immature
dendrite cell

Dendritic
precursor Mature
B cell dendritic cell
B
B
B

T
T Dendrite cell
T cell apoptosis
T Lymphocyte
T Lymphoid
activation organ T

Figure 5.6  Dendritic cells and their biological actions.

cells are very vital in antigen performance and assist as a link between the innate and
adaptive immune defense system (Figure 5.6).

5.3.2.6  Basophils and eosinophils

Basophils and eosinophils are known to relate to the neutrophils. Moreover, the basophils
release histamine upon parasite entry, which are critical in the defense against parasites,
and are also involved in allergic reactions. These basophils during activation secrete a
highly toxic protein and free radicals that instantly kill bacteria and parasites; however,
they are also known to cause cell and tissue damage during allergic-related reactions.

5.3.2.7  Natural killer cells

Natural killer (NK) cells are an important member of the innate immune defense system
that does not attack invading pathogens or microbes. In contrast to phagocytes, NK cells
can terminate compromised host cells, such as cancerous cells or virus-infected cells. They
are called NK cells because of an initial idea that these NK cells do not require activation
to kill cells (Figures 5.7 and 5.8).

5.3.3  Adaptive immune system

The adaptive immune system is basically a defense system in the human body that
remembers the entry and action of each and every pathogen. Moreover, adaptive immune
response is antigen specific and needs the recognition of specific antigens during antigen
presentation. Antigen specificity can allow the generation of responses that are tailored to
specific pathogens or pathogen-infected cells in the body. The special adaptive capability
of immune cells is maintained in the body by memory cells.
Chapter five:  Immunological disorders and immunotherapy 115

KIR MHC-I
SHP-1
Target
NK + MHC
Class I

LYSIS

KIR

NK + Target

LYSIS

Figure 5.7  NK cell: The major histocompatibility (MHC) Class-I (MHC-I) molecules are normally
expressed on the surface of virtually all cells of the body. Most pathogens do not display the MHC-I
marker, and as a result, are easily identified by a killer cell.

Cancer specific Natural killer cell

antibody

Tumor cell Tumor cell

Receptor

A: Cancer specific antibody binds the B: Natural killer cells bind cancer specific antibody which
receptors located on the cancer cells attached to receptors located on the cancer cells and lead
to kill destruction of tumor cells

Figure 5.8  NK cell destroying cancerous cells.

5.3.3.1 Lymphocytes
The lymphocytes belong to the adaptive immune system. There are two different types
of lymphocytes, B cells and T cells. These cells are generally derived from hematopoi-
etic stem cells in the bone marrow. Moreover, B cells take part in the humoral immune
response, while T cells are mainly involved in cell-mediated immune response. Both B
and T cells contain receptor molecules that distinguish specific targets. For example, T
cells recognize a pathogen only after antigens are processed and presented in combination
116 Biotechnology in medical sciences

with major histocompatibility complex (MHC) molecule. There are two major subtypes of
T cells—killer T cells and helper T cells. Killer T cells can only identify antigens coupled
to Class-I MHC molecules, while helper T cells only identify antigens coupled to Class-II
MHC molecules. A third, minor subtype is the gamma–delta T cells that distinguish inte-
gral host antigens that are not attached to MHC receptors.

5.3.3.2  Killer T cells

Killer T cells are a subtype of T cells that can either kill cells that are infected with viruses
and pathogens, or make them dysfunctional. It has been shown that killer T cells are acti-
vated when T cell receptor binds to antigens of another MHC cell. Moreover, the recogni-
tion of this MHC–antigen complex is aided by a coreceptor localized on the T cell, which
is also called CD-8. It has been suggested that T cells travel throughout the body in hunt
of cells where the MHC-I receptors contain this antigen. As soon as an activated T cell
makes contact with such cells, it releases cytotoxins that form holes in the target cell’s
plasma membrane, and subsequently allow ions, water, and toxins to enter inside the cell.
Furthermore, the entry of another toxin called granulysin (a protease) persuades the target
cell to undergo apoptosis. More significantly, destroying host cells by T cells is particularly
important in preventing the replication of viruses.

5.3.3.3  Helper T cells

The activation of helper T cells can result in the release of cytokines as well as stimulation of
macrophages such as killer T cells and B cells. The stimulation of B cells and macrophages
induces a proliferation of T helper cells. These T cells regulate both the innate and adaptive
immune responses and help the body to decide which kinds of immune responses to make
toward a specific pathogen. It has been reported that these helper T cells have no cytotoxic
activity and do not kill infected cells (Figure 5.9). Helper T cells express T cell receptors that
identify antigens attached to Class-II MHC molecules. It has been reported that helper T
cells have a weaker association with the MHC–antigen complex than killer T cells, which
means many receptors located on the helper T cell can be attached by an MHC antigen to
activate the helper cell. Moreover, helper T cell activation also requires longer duration of

Macrophage

Antigen
fragment

Class II MHC
molecule

T-cell receptor Helper T cell

Figure 5.9  Function of T helper cells.

Chapter five:  Immunological disorders and immunotherapy 117

assurance with an antigen-presenting cell. In addition, helper T cell activation results in

upregulation of molecules expressed on the T cell surface, which provide extra stimulatory
signals normally required to activate antibody-producing B cells.

5.3.3.4  B lymphocytes and antibodies

The B lymphocytes and antibody cells detect pathogens when the antibodies on their sur-
face attach to a specific foreign antigen. It has been described that this antigen–antibody
complex is taken up by the B cell and processed by proteolysis into peptides. Later on, the
B cells display these antigenic peptides on their surface of MHC Class-II molecules. As
soon as B cells are activated, they begin to multiply, and their offspring discharges mil-
lions of copies of the antibody that recognizes this antigen. Furthermore, these antibodies
can circulate in blood and stick to pathogens expressing the antigen, destroying these
pathogens with phagocytes.

5.3.3.5  Immunological memory

When B cells and T cells are activated and begin to reproduce, some of their offspring
can become long-lived memory cells. This process is called immunological memory. It
has been suggested that in all organisms, these memory cells can remember each and
every specific pathogen encountered and can enhance a strong response if the pathogen
is detected or enters again. This kind of immunological response is basically adaptive in
nature, because it occurs during the lifetime of an individual. It has been reported that
immunological memory can be classified as passive short-term memory or active long-
term memory.

5.3.3.6  Passive memory

It has been reported that newborn infants have no prior exposure to pathogens and are
particularly vulnerable to infections. During this critical period of child development, the
mother provides immunity against any kind of infection by producing a particular type of
antibody known as immunoglobulin-G, which is transported into the baby directly across
the placenta. These antibodies help the infant to fight against any infection. Furthermore,
mother’s breast milk contains antibodies that are transferred to the infant and protect
against bacterial infections until the newborn body can produce its own antibodies. This
type of development of immunity between the mother and child is called passive immu-
nity because the fetus does not make any antibodies on its own, it only borrows them from
the mother. It has been reported that passive immunity is only for a short duration of time,
up to several months. Interestingly, now, it is possible to induce protective passive immu-
nity in the infant by artificial ways.

5.3.3.7  Active memory and immunization

It has been suggested that long-term active memory is acquired following infection by
activating B cells and T cells. Active immunity can be produced by vaccination. The main
principle behind vaccination is called immunization where a patient is injected with an
antigen developed from a nonactive or killed form of pathogens to inspire the body to
develop specific immunity against that particular pathogen.

5.4  Immune diseases

The human immune system is remarkable in protecting the body from illness; however,
under disease conditions, the immune system may fail to defend the body against various
118 Biotechnology in medical sciences

infections. This is called an immune-compromised immune system. This condition makes

the body vulnerable to various viral, bacterial, or fungal infections. The immune-related
diseases can be classified into three broad categories such as immunodeficiency, autoim-
munity, and hypersensitivities.

5.4.1 Immunodeficiency
Immunodeficiency is a physiological condition where the immune system’s capacity to
fight infectious disease has become dysfunctional or entirely absent. In most cases, immu-
nodeficiencies are acquired diseases, but some people are born with defects in the immune
system, which is known as a primary immunodeficiency. It has been reported that a per-
son who has an immunodeficiency of any kind is considered to be immune-compromised
and such a person may be particularly vulnerable to opportunistic infections, in addition
to normal infections that could affect everyone.

5.4.1.1  Primary immunodeficiency

A number of rare diseases have been reported susceptible to infections from childhood
onward and many of these diseases are hereditary and autosomal recessive or X-linked
in nature. There are more than 80 primary immunodeficiency syndromes reported in
humans and they are generally grouped by their malfunctioning of lymphocytes or
granulocyte cells. The treatment of primary immunodeficiencies depends on the nature
of the defect, and may involve antibody infusions, long-term antibiotics, and stem cell
transplantation.

5.4.1.2  Acquired immunodeficiency

An immune deficiency that is caused due to external processes is called secondary or
acquired immunodeficiency. The common causes for secondary immunodeficiency are
malnutrition, aging, and particular medications such as chemotherapy, disease-modify-
ing antirheumatic drugs, and glucocorticoids, which are immunosuppressive drugs after
organ transplants. It has been reported that there are many specific diseases that directly
or indirectly impair the immune system and these include many types of cancer, predomi-
nantly those of the bone marrow and blood cells, such as lymphoma, leukemia, multiple
myeloma, and certain chronic infections. Immunodeficiency is also the hallmark of AIDS,
caused by HIV.

5.5 Autoimmunity
In a healthy person, immunity generally protects the person from all infectious diseases,
but in some individuals, it works against itself and destroys the person’s immune system.
This condition is generally known as an autoimmune disease. It has been suggested that
any disease fallouts from such an abnormal immune response are called an autoimmune
disease. Autoimmunity is frequently caused by a deficiency of germ cell development that
results in the development of a condition where body cells work against their own cells
and tissues. There are several examples of autoimmunity disease such as celiac disease,
Churg–Strauss syndrome, Hashimoto’s thyroiditis, Graves’ disease, idiopathic thrombo-
cytopenic purpura, diabetes mellitus type 1, systemic lupus erythematosus, Sjögren’s syn-
drome, and rheumatoid arthritis (RA).
Chapter five:  Immunological disorders and immunotherapy 119

Table 5.1  Name of Syndromes That Affect Various Body Organs

Name of syndrome Affected organ/tissue
Diabetes mellitus type 1 Pancreas
Celiac disease, pernicious anemia Intestine
Pemphigus vulgaris, vitiligo Skin
Autoimmune hemolytic anemia, Blood
idiopathic thrombocytopenic purpura
Myasthenia gravis Brain

5.5.1  Classifications of autoimmune diseases

Autoimmune diseases can be classified into systemic autoimmune disease and localized
autoimmune disorders, depending on the clinical and pathological features of each dis-
ease. The examples of systemic autoimmune diseases are Sjögren’s syndrome, scleroderma,
RA, systemic lupus erythematosus, and dermatomyositis. It has been proposed that these
disease conditions incline to be associated with autoantibodies to antigens, which are not
tissue specific. The names of affected organs/tissues with autoimmune disease are listed
in Table 5.1.

5.6  Diagnosis of immune diseases

After learning about the various types and causes of immune diseases, the next step would
be to diagnose the various diseases to enable a physician to prescribe the appropriate treat-
ments to the patient. The diagnosis of autoimmune disorders is largely based on a precise
history and physical examination of the patient, and other pathological conditions such
as an elevated C-reactive protein. It has been shown that in several systemic disorders,
serological assays can be employed to detect specific autoantibodies and moreover, local-
ized disorders are best diagnosed by immunofluorescence of biopsy tissues. The levels of
autoantibodies are considered to know the level of the pathological condition of a patient.

5.6.1  Autoantibody test

Autoantibody tests are used to investigate the presence of chronic progressive arthritis-
type symptoms or unexplained fevers, fatigue, muscle weakness, and rashes. The antinu-
clear antibody (ANA) is a marker of the autoimmune process. It is positive with a variety of
different kinds of autoimmune diseases, but not very specific. Consequently, if an ANA test
is positive, it is often followed up with other tests associated with arthritis and inflamma-
tion, such as a rheumatoid factor, an erythrocyte sedimentation rate, a C-reactive protein,
or complements protein or complement levels. It has been shown that a single autoantibody
test is not analytical, but may give signs as to whether a particular disorder is likely or
unlikely to exist in patients. It has been recommended that each and every autoantibody
result should be considered individually and as part of the group. However, some disor-
ders such as systemic lupus erythematosus (SLE) may be more likely if several autoanti-
bodies are present; others such as mixed connective tissue disease may be more likely if a
single autoantibody such as a ribonucleic protein is the only one present. It has been sug-
gested that those patients who have more than one autoimmune disorder may have several
120 Biotechnology in medical sciences

detectable autoantibodies. Whether a particular autoantibody will be present is both very

individual and a matter of biostatistics. Each antibody will be present in a certain percent-
age of people who have a particular autoimmune disorder. For example, up to 80% of those
with SLE will have a positive double-strand anti-DNA autoantibody test, but only about
25–30% will have positive ribonucleoproteins (RNPs). It has been suggested that some indi-
viduals who do have an autoimmune disorder will have negative autoantibody test results,
but at a later date, as the disorder progresses, the autoantibodies can be developed.

5.7  Treatments of immune diseases

It has been suggested that most of the autoimmune diseases cannot be treated directly,
but can be treated as per the symptoms associated with the disease. In general conditions,
medical practitioners prescribe corticosteroid drugs, nonsteroidal anti-inflammatory drugs
(NSAIDs), or more powerful immunosuppressant drugs (methotrexate, azathioprine, and
cyclophosphamide) that suppress the immune response and stop the progression of the
disease. Moreover, radiation of the lymph nodes and plasmapheresis, a procedure that
eliminates the unhealthy cells and harmful molecules from the blood circulation, are
other ways of treating an autoimmune disease.

5.7.1  Diabetes mellitus type 1

Diabetes mellitus type 1 is a disease that results from autoimmune destruction of insulin-
producing β-cells of the pancreas that finally causes decreased level of blood and urine
glucose. It has been reported that type 1 diabetes is lethal unless treated with insulin injec-
tion or pancreatic transplantation. It has also been reported that diet may play a role in
the development of type 1 diabetes. Moreover, type 1 diabetes can be distinguished from
type 2 diabetes through a C-peptide assay, which measures endogenous insulin produc-
tion. It has been recommended that type 1 treatment must be continued for life in all
cases; however, lifelong treatment is difficult for many people as complications may be
associated with both low blood sugar and high blood sugar, as low blood sugar may lead
to seizures or episodes of unconsciousness and requires emergency treatment, while high
blood sugar may lead to increased exhaustion and can also result in long-term damage to
body organs.

5.7.1.1 Causes
There are various causes for the development of type 1 diabetes and one of the factors is
both genetic and environmental. It has been suggested that for identical twins, when one
twin can have type 1 diabetes, the other twin will only have type 1 diabetes 30–50% of the
time. Even with having exactly the same genome, one twin will have the disease, whereas
the other twin does not; this suggests that environmental factors, in addition to genetic
factors, can influence disease prevalence. It has been further shown that type 1 diabe-
tes is a polygenic disease, meaning many different genes contribute to its expression and
depending on the locus or the combination of loci on the chromosome, it can be dominant,
recessive, or somewhere in between. Moreover, the strongest gene, IDDM1 is situated in
the MHC Class-II region on chromosome 6, at the staining region 6p21.

5.7.1.2 Pathophysiology
Type 1 diabetes is not fully understood. In type 1 diabetes, the pancreatic β-cells produce
insulin hormones in the islet of Langerhans. Type 1 diabetes (Figure 5.10) was previously
Chapter five:  Immunological disorders and immunotherapy 121

Type 1 diabetes: Insufficient insulin

Glucose
Diminished
insulin

Insulin
receptor Glut-4

Defect in signaling Glucose

to glut-4 transporters

Depleted glucose uptake

Figure 5.10  Type 1 diabetes is caused by a loss or malfunction of the insulin- producing cells, called
pancreatic β-cells. Damage to β-cells results in an absence or insufficient production of insulin by
the body. Most cases of type 1 diabetes have an autoimmune basis, and the immune system mistak-
enly attacks and destroys β-cells. Since insulin is necessary to sustain life, the missing insulin has
to be replaced. The replacement insulin is administered by injection using a syringe or an insulin
pump, which delivers the insulin under the skin.

known as juvenile diabetes because it is one of the most frequent chronic diseases in chil-
dren; however, the majority of new-onset type 1 diabetes is observed in adults. It has been
suggested that the use of antibody testing (such as glutamic acid decarboxylase antibodies,
islet cell antibodies, and insulinoma-associated autoantibodies) are used to distinguish
between type 1 and type 2 diabetes (Figure 5.11).

5.7.1.3 Diagnosis
One of the best approaches toward treating type 1 diabetes is first to confirm the nature
of the disease by diagnostic tools. Type 1 diabetes is checked by analyzing the plasma
glucose level and is diagnosed by fasting plasma glucose level at or above 126 mg/dL (con-
sidered as prediabetic conditions) and plasma glucose at or above 200 mg/dL (considered
as diabetic condition). It has been suggested that the diagnosis of other types of diabetes is
made in other ways that include ordinary health checkups, investigation of hyperglycemia
during other medical investigations, and secondary symptoms such as vision changes or
unexplainable fatigue. Diabetes is often detected when a person suffers a problem that
is frequently caused by diabetes, such as a heart attack, stroke, neuropathy, poor wound
healing, certain eye problems, certain fungal infections, foot ulcers, or delivering a baby
with hypoglycemia.
To confirm type 1 diabetes, most physicians prefer to measure a fasting glucose
level and according to the current definition, two fasting glucose measurements above
126 mg/dL are considered diagnostic for diabetes mellitus. Moreover, patients with fast-
ing glucose levels from 100 to 125 mg/dL are considered to have impaired fasting glu-
cose. Furthermore, patients with plasma glucose at or above 140 mg/dL but not over
122 Biotechnology in medical sciences

Type 2 diabetes: Insulin resistance

Glucose

Insulin

Insulin
receptor Glut-4

Defect in signaling
to glut-4 Glucose
transporters

Diminished glucose uptake

Figure 5.11  With type 2 diabetes, the pancreas still produces at least some insulin. But the cells are
ignoring insulin’s request for glucose transporters. For a time, the β-cells respond to this cellular
insubordination by pumping out more and more insulin. But eventually, the β-cells get fed up with
the overtime and quit overproducing insulin.

200 mg/dL, 2 h after a 75 g oral glucose load are considered to have impaired glucose
tolerance. Interestingly, among these two prediabetic states, the latter in particular is a
major risk factor for progression to full-blown diabetes mellitus as well as cardiovascu-
lar disease.

5.7.1.4 Management
One of the best practices to treat diabetic patients is control the blood insulin and glucose
level all the time. There are various treatment procedures available to manage diabetes.
Patients with type 1 diabetes are normally treated with insulin replacement therapy either
via subcutaneous injection or insulin pump, along with dietary management such as car-
bohydrate tracking, and careful monitoring of blood glucose levels using glucose meters.
Today, the most common insulin is the biosynthetically designed insulin that is synthe-
sized by using recombinant DNA technology. There are major global manufacturers of
insulin such as Eli Lilly and Company, Novo Nordisk, and Sanofi-Aventis, who make and
sell insulin injections worldwide.

5.7.1.5  Pancreas transplantation

In some cases where drug therapy fails to improve the patient’s conditions, pancreas
transplants are generally performed together with, or sometime after, a kidney transplant.
It has been suggested that introducing a new kidney requires taking the immunosup-
pressive drug treatment for a host body to accept a foreign organ. Nevertheless, pancreas
transplants alone can be sensible in patients with extremely labile type 1 diabetes mellitus
(Figure 5.12).
Chapter five:  Immunological disorders and immunotherapy 123

Donor

Recipient

Inferior vena cava Aorta

Bowel

Transplanted
duodenum Transplanted kidney

Transplanted pancreas
Transplanted ureter

Bladder

Figure 5.12  Kidney and pancreas transplantation.

5.7.1.6  Islet cell transplantation

Another approach to treat type 1 diabetes is to transplant islet cells, which are currently
the most commonly used approach in humans. In one procedure, islet cells are injected
into the patient’s liver, where they take up host cells and begin to produce insulin. It has
been suggested that the liver is expected to be the most reasonable choice because it is
more accessible than the pancreas, and β islet cells appear to produce insulin well in that
atmosphere. The patient’s body, however, will treat the new cells as foreign cells that can
be avoided by using immunosuppressor drugs. Consequently, now, patients also need to
undergo treatment involving immunosuppressants, which reduce the immune system
activity (Figure 5.13).

5.7.1.7  Issues with insulin injections

It has been suggested that the global diabetic population would touch near to 380 million
by 2025 and nearly one-third of the total diabetes patients will be from India and China.
It has been shown that 60% of the insulin available in the market today is available in the
injectable form such as syringes, pens, and pumps. Interestingly, insulin is the only gold
standard treatment for type 1 diabetes, and is also progressively recommended for the
treatment of type 2 diabetes. However, the use of insulin has several characteristic disad-
vantages that include itching, allergy, local pain, and insulin lipodystrophy around the
injection site.

5.7.1.8  Research trends

To minimize the side effects of current insulin injections, tremendous efforts by biotech-
nology or biopharmaceutical companies have been made to design a new class of insulin
drugs, as depicted in Table 5.2.
124 Biotechnology in medical sciences

Recipient
Donor

Liver

Isolation of
Pancreas
beta islet cells
Injection of beta islet cells
into patient’s pancreas

Figure 5.13  Pancreatic beta islet cell transplantation.

Table 5.2  Insulin Drugs in Pipeline

Insulin pipeline insight
Candidate Trial phase Formulation Technology Company
Alveair Phase I–II Inhaler formulation Polymer/ Coremed Inc.
bioadhesive
drug-delivery
platform
Oral-lyn Phase III and Buccal spray RapidMist delivery Generex
commercially technology Biotechnology
launched in
some countries
IN-105 Phase I–II Capsule Conjugated insulin Biocon Ltd.
formulation molecule
Undisclosed Preclinical Capsule Biodegradable Transgene Biotek
phase—animal formulation novel polymeric Ltd.
trials nanoparticles
Technosphere Phase III Inhaler formulation CPE-215 MannKind Corp.
and inhalant permeation
microparticle enhancement
formulation technology
U-Strip Preclinical Insulin patch U-Strip patch Encapsulation
phase—animal technology Systems Inc.
trials
Nasulin Phase II Intranasal insulin Bentley
spray Pharmaceuticals

5.7.2  Myasthenia gravis

Myasthenia gravis (MG) is an autoimmune neuromuscular disease leading to fluctuating
muscle weakness. This condition is developed by blocking acetylcholine receptors at the
postsynaptic neuromuscular junction that can inhibit the stimulative effect of the neu-
rotransmitter acetylcholine. It has been reported that myasthenia can be medically treated
Chapter five:  Immunological disorders and immunotherapy 125

Myasthenia gravis
Normal

IgG antibodies
Muscle
Muscle
Na+
Neuron
Na+ Endosome
Neuron
Na+

ACh

Muscle contraction No muscle contraction

Figure 5.14  This disease is caused by the production of IgG antibodies (antiacetylcholine recep-
tor antibodies) that attack the acetylcholine receptors of skeletal muscles. These antibodies cause
a decrease in the amount of acetylcholine receptors and ultimately decrease the action potential
achieved with stimulation.

with cholinesterase inhibitors or immunosuppressant drugs, and, in some selected cases,

thymectomy (surgical removal of the thymus gland) is also considered. It has also been found
that the disease can be prevalent in about 3 or 30 cases per million. Furthermore, MG
needs to be distinguished from congenital myasthenia syndromes that have similar symp-
toms (Figure 5.14).

5.7.2.1 Symptoms
One of the main symptoms of MG is that muscles become gradually weaker during periods
of activity and can improve after periods of rest. It has been shown that the muscles that
control the eyes and face are especially vulnerable to this disease. The muscles that control
the breathing function and neck and limb movements can also be affected. Interestingly,
the beginning of the disorder can be unexpected and symptoms are sporadic. The diag-
nosis of MG may be delayed if the symptoms are variable. In most cases, the first visible
symptom is weakness of the eye muscles; in others, difficulty in swallowing and inaudible
speech or sound may be the first clinical signs. The amount of muscle weakness involved
in MG varies among patients; extending from the eye muscles to the muscles that con-
trol breathing are affected. There are various pathological symptoms that include double
vision due to weakness of the muscles, an unstable or toddling gait, and weakness on the
hands. Also, in MG disease, a paralysis of the respiratory muscles can occur that requires
immediate medical intervention in the form of ventilation to sustain life.

5.7.2.2 Treatment
Myasthenia can be treated either by medication or by surgery. It has been reported that the
medication for myasthenia consists of cholinesterase inhibitors, as these drugs can improve
muscle function. The use of immunosuppressant drugs can also reduce the autoimmune
process. The drugs, namely, neostigmine and acetyl cholinesterase inhibitors: neostigmine
126 Biotechnology in medical sciences

and pyridostigmine, can improve muscle function by slowing the natural enzyme cholin-
esterase that degrades acetylcholine. In a common practice, physicians or doctors can start
the treatment with a low dose of pyridostigmine that can be increased until the anticipated
result is achieved. It has been suggested that pyridostigmine is a short-lived drug with
a half-life of about 4 h. There are a few immunosuppressive drugs such as cyclosporine,
mycophenolate mofetil, prednisone, and azathioprine, which can also be used for this con-
dition. It is a common practice for patients to be treated with a combination of drugs with
cholinesterase inhibitors. It has been found that treatments with some immunosuppres-
sive drugs take weeks to months before the effects are observed. Moreover, in serious
conditions, the drug plasmapheresis can be used to eliminate the putative antibody from
the blood circulation. Also, intravenous injection of immunoglobulins can be used to bind
the circulating antibodies. Interestingly, both these treatments have comparatively short
benefits. In case, drug therapy fails to control the myasthenia condition, then this problem
is tackle by the surgical removal of the thymus, although the surgical process is more con-
troversial in patients who do not show thymus abnormalities.

5.8 Summary
The human immune system is a defense system against diseases and infections. The
immune system basically consists of several cells that identify and kill the invading patho-
gens and tumor cells. The immune system detects a wide variety of agents such as bac-
teria, viruses, and parasitic worms. One of the major functions of the immune system is
to defend the human body from any kind of harmful infections and provide immunity.
There are various treatments of immunological disorders, such as antibiotics and vaccines.
Monoclonal antibodies are also being used on a regular basis to treat autoimmune con-
ditions (multiple sclerosis) where body cells actually attack and kill their own cells. In
multiple sclerosis, the immune system becomes dysfunctional and starts killing the body’s
own healthy cells. In this chapter, we have discussed the immune system, its components,
immunological disorders, and its treatment strategies.

5.9  Knowledge builder

Desquamation: Desquamation (from Latin desquamare, meaning “to scrape the scales off a
fish”), also called skin peeling, is the shedding of the outermost membrane or layer of a
tissue, such as the skin.
Lysosome: Lysosomes are cellular organelles that contain acid hydrolase enzymes that
break down waste materials and cellular debris. They can be described as the stomach
of the cell. They are found in animal cells, while their existence in yeasts and plants is
disputed. Some biologists say the same roles are performed by lytic vacuoles, while others
suggest that there is strong evidence that lysosomes are indeed found in some plant cells.
Histocompatibility complex: The MHC is a cell surface molecule encoded by a large gene
family in all vertebrates. MHC molecules mediate interactions of leukocytes, also called
WBCs, which are immune cells, with other leukocytes or body cells. MHC determines the
compatibility of donors for organ transplant as well as one’s susceptibility to an autoim-
mune disease via cross-reacting immunization. In humans, the MHC is also called human
leukocyte antigen (HLA).
Cytotoxins: Any substance that is poisonous to living cells.
Immune-compromised: A person who has an immunodeficiency of any kind is said
to be immune-compromised. An immune-compromised person may be particularly
Chapter five:  Immunological disorders and immunotherapy 127

vulnerable to opportunistic infections, in addition to normal infections that could affect

everyone.
Immunodeficiency syndromes: Primary immunodeficiencies are disorders in which
part of the body’s immune system is missing or does not function properly. To be con-
sidered a primary immunodeficiency, the cause of the immune deficiency must not
be secondary in nature (i.e., caused by another disease, drug treatment, or environ-
mental exposure to toxins). Most primary immunodeficiencies are genetic disorders;
the majority is diagnosed in children under the age of 1, although milder forms may
not be recognized until adulthood. About 1 in 500 people is born with a primary
immunodeficiency.
Celiac disease: Celiac disease is an autoimmune disorder of the small intestine that
occurs in genetically predisposed people of all ages from middle infancy onward.
Symptoms include pain and discomfort in the digestive tract, chronic constipation and
diarrhea, failure to thrive (in children), and fatigue. But these may be absent and symp-
toms in other organ systems have been described. Vitamin deficiencies are often noted in
people with celiac disease owing to the reduced ability of the small intestine to properly
absorb nutrients from food.
Churg–Strauss syndrome: Churg–Strauss syndrome is an autoimmune disease charac-
terized by medium- and small-vessel vasculitis in persons with a history of asthma and
allergy. Eventually leading to necrosis, it mainly involves the blood vessels of the lungs,
gastrointestinal system, and peripheral nerves, but also affects the heart, skin, and kid-
neys. It is a rare disease that is noninheritable and nontransmissible.
Hashimoto’s thyroiditis: Hashimoto’s thyroiditis or chronic lymphocytic thyroiditis is
an autoimmune disease in which the thyroid gland is attacked by a variety of cell- and
antibody-mediated immune processes. It was the first disease to be recognized as an auto-
immune disease. It was first described by the Japanese specialist Hakaru Hashimoto in
Germany in 1912.
Graves’ disease: Graves’ disease is an autoimmune disease. It most commonly affects
the thyroid, frequently causing it to enlarge to twice its size or more (goiter), and become
overactive. It has related hyperthyroid symptoms such as increased heartbeat, muscle
weakness, disturbed sleep, and irritability. It can also affect the eyes, causing bulging eyes
(exophthalmos). It affects other systems of the body, including the skin, heart, circulation,
and nervous system.
Idiopathic thrombocytopenic purpura: Idiopathic thrombocytopenic purpura, also known
as primary immune thrombocytopenic purpura and autoimmune thrombocytopenic pur-
pura, is defined as an isolated low platelet count (thrombocytopenia) with normal bone
marrow and the absence of other causes of thrombocytopenia. It causes a characteristic
purpuric rash and an increased tendency to bleed. Two distinct clinical syndromes mani-
fest as an acute condition in children and a chronic condition in adults. The acute form
often follows an infection and has a spontaneous resolution within 2 months. Chronic
idiopathic thrombocytopenic purpura persists longer than 6 months without a specific
cause.
Diabetes mellitus type 1: Diabetes mellitus type 1 (also known as type 1 diabetes), also
known as insulin-dependent diabetes or juvenile diabetes, is a form of diabetes mellitus
that results from autoimmune destruction of insulin-producing β-cells of the pancreas.
The subsequent lack of insulin leads to increased blood and urine glucose.
Systemic lupus erythematosus: Systemic lupus erythematosus is a systemic autoimmune
disease that can affect any part of the body. As it occurs in other autoimmune diseases, the
immune system attacks the body’s cells and tissue, resulting in inflammation and tissue
128 Biotechnology in medical sciences

damage. It is a type III hypersensitivity reaction in which antibody–immune complexes

precipitate and cause a further immune response.
Sjögren’s syndrome: Sjögren’s syndrome is a systemic autoimmune disease in which
immune cells attack and destroy the exocrine glands that produce tears and saliva. It is
named after the Swedish ophthalmologist Henrik Sjögren (1899–1986), who first described it.
Rheumatoid arthritis: RA is an autoimmune disease that results in a chronic, systemic
inflammatory disorder that affects many tissues and organs, but principally attacks flex-
ible (synovial) joints. It can be a disabling and painful condition, which can lead to a sub-
stantial loss of function and mobility if not adequately treated.
C-reactive protein: C-reactive protein is a protein found in the blood, the levels of
which rise in response to inflammation. Its physiological role is to bind to phosphocholine
expressed on the surface of dead or dying cells (and some types of bacteria) to activate the
complement system via the C1Q complex.
IDDM1: Insulin-dependent diabetes mellitus 1.
Insulin lipodystrophy: Lipodystrophy or lipoatrophy is a recognized complication of
insulin injections due to loss of the adipose tissue layer at the sites of injection (prevalence
of 3.6%).

Further reading
Baets MH and Oosterhuis HJGH 1993. Myasthenia Gravis. United Kingdom: DRD Press, pp. 158. ISBN
3805547366.
Baulcombe D 2004. RNA silencing in plants. Nature 431 (7006): 356–363. doi:10.1038/nature02874.
PMID 15372043.
Bedlack RS and Sanders DB 2000. How to handle myasthenic crisis. Essential steps in patient care.
Postgrad Med 107 (4): 211–214, 220–222. PMID 10778421.
Bruce A, Johnson A, Lewis J, Raff M, Roberts K, and Walters P 2002. Molecular Biology of the Cell (4th
ed.) New York and London: Garland Science. ISBN 0-8153-3218-1. http://www.ncbi.nlm.nih.
gov/books/bv.fcgi?call=bv.View..ShowTOC&rid=mboc4.TOC&depth=2.
Calhoun RF, Ritter JH, Guthrie TJ et al. 1999. Results of transcervical thymectomy for myasthenia
gravis in 100 consecutive patients. Ann Surg 230 (4): 555–561. doi:10.1097/00000658-199910000-
00011. PMID 10522725.
Carroccio A, Brusca I, Iacono G et al. 2007. IgA anti-actin antibodies ELISA in coeliac disease: A mul-
ticentre study. Dig Liver Dis 39: 814. doi:10.1016/j.dld.2007.06.004. PMID 17652043.
Conti-Fine BM, Milani M, and Kaminski HJ 2006. Myasthenia gravis: Past, present, and future. J Clin
Invest 116 (11): 2843–2854. doi:10.1172/JCI29894. PMID 17080188.
de Kraker M, Kluin J, Renken N, Maat AP, and Bogers AJ 2005. CT and myasthenia gravis: Correlation
between mediastinal imaging and histopathological findings. Interact Cardiovasc Thorac Surg 4
(3): 267–271. doi:10.1510/icvts.2004.097246. PMID 17670406.
Dittrich AM, Erbacher A, Specht S et  al. 2008. Helminth infection with Litomosoides sigmodontis
induces regulatory T cells and inhibits allergic sensitization, airway inflammation, and hyper-
reactivity in a murine asthma model. J Immunol 180 (3): 1792–1799. PMID 18209076.
Dunne DW and Cooke A 2005. A worm’s eye view of the immune system: Consequences for evo-
lution of human autoimmune disease. Nat Rev Immunol 5 (5): 420–426. doi:10.1038/nri1601.
PMID 15864275.
Edwards JC and Cambridge G 2006. B-cell targeting in rheumatoid arthritis and other autoimmune
diseases. Nat Rev Immunol 6 (5): 394–403. doi:10.1038/nri1838. PMID 16622478.
Edwards JC, Cambridge G, and Abrahams VM 1999. Do self perpetuating B lymphocytes drive
human autoimmune disease? Immunology 97: 1868–1876.
Finlay B and Falkow S 1997. Common themes in microbial pathogenicity revisited. Microbiol Mol Biol
Rev 61 (2): 136–169. PMID 9184008. PMC 232605. http://mmbr.asm.org/cgi/reprint/61/2/136.
pdf.
Chapter five:  Immunological disorders and immunotherapy 129

Finlay B and McFadden G 2006. Anti-immunology: Evasion of the host immune system by bacterial
and viral pathogens. Cell 124 (4): 767–782. doi:10.1016/j.cell.2006.01.034. PMID 16497587.
Itoh S, Ichida T, Yoshida T et al. 1998. Autoantibodies against a 210 kDa glycoprotein of the nuclear
pore complex as a prognostic marker in patients with primary biliary cirrhosis. J Gastroenterol
Hepatol 13 (3): 257–265. PMID 9570238.
Jaretzki A, Barohn RJ, Ernstoff RM et  al. 2000. Myasthenia gravis: Recommendations for clinical
research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia
Gravis Foundation of America. Neurology 55 (1): 16–23. PMID 10891897. http://www.neurol-
ogy.org/cgi/content/full/55/1/16.
Jerne N 1974. Towards a network theory of the immune system. Ann Immunol (Paris) 125C (1–2):
373–389. PMID 4142565.
Juel VC 2004. Myasthenia gravis: Management of myasthenic crisis and perioperative care. Semin
Neurol 24 (1): 75–81. doi:10.1055/s-2004-829595. PMID 15229794.
Kerkar N, Ma Y, Davies ET, Cheeseman P, Mieli-Vergani G, and Vergani D 2002. Detection of liver
kidney microsomal type 1 antibody using molecularly based immunoassays. J Clin Pathol
55 (12): 906–909. PMID 12461054. http://jcp.bmj.com/cgi/pmidlookup?view=long&p
mid=12461054.
Kobayashi H 2005. Airway biofilms: Implications for pathogenesis and therapy of respiratory tract
infections. Treat Respir Med 4 (4): 241–253. doi:10.2165/00151829-200504040-00003. PMID
16086598.
Kubach J, Becker C, Schmitt E, Steinbrink K, Huter E, Tuettenberg A, and Jonuleit H 2005. Dendritic
cells: Sentinels of immunity and tolerance. Int J Hematol 81 (3): 197–203. doi:10.1532/IJH97.04165.
PMID 15814330.
Leite MI, Jacob S, Viegas S et al. 2008. IgG1 antibodies to acetylcholine receptors in “seronegative”
myasthenia gravis. Brain 131 (Part 7): 1940–1952. doi:10.1093/brain/awn092. PMID 18515870.
PMC 2442426. http://brain.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18515870.
Losen M, Martínez-Martínez P, Phernambucq M, Schuurman J, Parren PW, and De Baets MH 2008.
Treatment of myasthenia gravis by preventing acetylcholine receptor modulation. Ann N Y
Acad Sci 1132: 174–179. doi:10.1196/annals.1405.034. PMID 18567867.
Losen M, Stassen MH, Martínez-Martínez P et al. 2005. Increased expression of rapsyn in muscles
prevents acetylcholine receptor loss in experimental autoimmune myasthenia gravis. Brain 128
(Part 10): 2327–2337. doi:10.1093/brain/awh612. PMID 16150851.
McGrogan A, Sneddon S, and de Vries CS 2010. The incidence of myasthenia gravis: A systematic
literature review. Neuroepidemiology 34 (3): 171–183. doi:10.1159/000279334.
Oertelt S, Rieger R, Selmi C, Invernizzi P, Ansari A, Coppel R, Podda M, Leung P, and Gershwin M
2007. A sensitive bead assay for antimitochondrial antibodies: Chipping away at AMA-negative
primary biliary cirrhosis. Hepatology 45 (3): 659–665. doi:10.1002/hep.21583. PMID 17326160.
Pedreira S, Sugai E, Moreno ML et al. 2005. Significance of smooth muscle/anti-actin autoantibodies
in celiac disease. Acta Gastroenterol Latinoam 35 (2): 83–93. PMID 16127984.
Quinnell RJ, Bethony J, and Pritchard DI 2004. The immunoepidemiology of human hookworm infec-
tion. Parasite Immunol 26 (11–12): 443–454. doi:10.1111/j.0141-9838.2004.00727.x. PMID 15771680.
Rojo E, Martín R, Carter C, Zouhar J et al. 2004. VPEgamma exhibits a caspase-like activity that contrib-
utes to defense against pathogens. Curr Biol 14 (21): 1897–1906. doi:10.1016/j.cub.2004.09.056.
PMID 15530390.
Rosen FS, Cooper MD, and Wedgwood RJ 1995. The primary immunodeficiencies. N Engl J Med 333
(7): 431–440. doi:10.1056/NEJM199508173330707. PMID 7616993.
Sato KJ 2000. The HLA system. Second of two parts. N Engl J Med 343 (11): 782–786. doi:10.1056/
NEJM200009143431106. PMID 10984567.
Saunders K, Raine T, Cooke A, and Lawrence C 2007. Inhibition of autoimmune type 1 diabetes
by gastrointestinal helminth infection. Infect Immun 75 (1): 397–407. doi:10.1128/IAI.00664-06.
PMID 17043101.
Scherer K, Bedlack RS, and Simel DL 2005. Does this patient have myasthenia gravis? JAMA 293 (15):
1906–1914. doi:10.1001/jama.293.15.1906. PMID 15840866.
Seybold ME 1986. The office tensilon test for ocular myasthenia gravis. Arch Neurol 43 (8): 842–843.
PMID 3729766.
130 Biotechnology in medical sciences

Szostecki C, Guldner HH, Netter HJ, and Will H 1990. Isolation and characterization of cDNA encod-
ing a human nuclear antigen predominantly recognized by autoantibodies from patients with
primary biliary cirrhosis. J Immunol 145 (12): 4338–4347. PMID 2258622.
Téllez-Zenteno JF, Hernández-Ronquillo L, Salinas V, Estanol B, and da Silva O 2004. Myasthenia
gravis and pregnancy: Clinical implications and neonatal outcome. BMC Musculoskelet Disord
5: 42. doi:10.1186/1471-2474-5-42. PMID 15546494. PMC 534111. http://www.biomedcentral.
com/1471-2474/5/42. (Retrieved 2008-07-10).
Thieben MJ, Blacker DJ, Liu PY, Harper CM Jr, and Wijdicks EF 2005. Pulmonary function tests
and blood gases in worsening myasthenia gravis. Muscle Nerve 32 (5): 664–667. doi:10.1002/
mus.20403. PMID 16025526.
Uz E, Loubiere LS, Gadi VK et al. 2008. Skewed X-chromosome inactivation in scleroderma. Clin Rev
Allergy Immunol 34 (3): 352–355. doi:10.1007/s12016-007-8044-z. PMID 18157513.
Wållberg M and Harris R 2005. Co-infection with Trypanosoma brucei prevents experimental autoim-
mune encephalomyelitis in DBA/1 mice through induction of suppressor APCs. Int Immunol
17 (6): 721–728. doi:10.1093/intimm/dxh253. PMID 15899926. http://intimm.oxfordjournals.
org/cgi/content/full/17/6/721.
Wesierska-Gadek J, Hohenuer H, Hitchman E, and Penner E 1996. Autoantibodies against nucleopo-
rin p62 constitute a novel marker of primary biliary cirrhosis. Gastroenterology 110 (3): 840–847.
doi:10.1053/gast.1996.v110.pm8608894. PMID 8608894.
Wohlleben G, Trujillo C, Müller J et al. 2004. Helminth infection modulates the development of aller-
gen-induced airway inflammation. Int Immunol 16 (4): 585–596. doi:10.1093/intimm/dxh062.
PMID 15039389.
Zaccone P, Fehervari Z, Phillips JM, Dunne DW, and Cooke A 2006. Parasitic worms and inflam-
matory diseases. Parasite Immunol 28 (10): 515–523. doi:10.1111/j.1365-3024.2006.00879.x. PMID
16965287.