IMMUNOLOGY & SEROLOGY MEDTECH

INSTITUTIONAL REVIEW / PATRICK SILAGON, JR. PEERS PH

IMMUNOLOGY AND SEROLOGY

OUTLINE
I Introduction
II Immunity
A Natural Defense System
i. External Defense System
ii. Internal Defense System
iii. 1st Line: Non – Specific External Defenses
iv. Immunity Defenses
B Acute Phase Reactants
i. Cytokines
ii. Serum Amyloid A (SAA)
iii. Complement
iv. Mannose – Binding Protein
v. Alpha 1 – Antitrypsin
vi. Haptoglobin
vii. Fibrinogen
viii. Ceruloplasmin
C Cellular Defense Mechanisms
i. Neutrophils (PMN)
ii. Eosinophils
iii. Basophils
iv. Mast Cell
v. Monocyte (Mononuclear cell)
vi. Tissue Macrophage
vii. Dendritic Cells
D Phagocytosis
i. Initiation
ii. Chemotaxis
iii. Engulfment
iv. Digestion
E Inflammation
F Nonspecific Immunity of Body Fluids
i. Lysozymes
ii. Properdin
iii. Betalysin
III Lymphoid Organ
A The Lymphoid System
B Specific Lymphocytes
C Primary Lymphoid Organ
i. Bone Marrow
ii. Thymus
D Secondary Lymphoid Organ
i. Spleen
ii. Lymph Nodes
E Immunogen
F Antigen
G Factors Influencing Immune Response
H Traits of Immunogen
I Haptens
J Precipitation / Agglutination
K Relationship of Antigen to the Host
i. Autoantigens
ii. Alloantigens
iii. Heteroantigens
iv. Heterophile Antigens
L Adjuvants
IV Major Histocompatibility Complex (MHC)
A Human Leucocyte Antigen (HLA)
V Agglutination VS. Precipitation
A Precipitation Reactions
B Antigen – Antibody Binding
C Precipitation Curve
D Prozone and Postzone
E Measurement of Precipitation by Light Scattering
i. Turbidimetry

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ii. Nephelometry
iii. Passive Immunodiffusion Techniques
iv. Electrophoresis Techniques
F Agglutination
i. Steps in Agglutination
ii. Enhancement of Lattice Formation
iii. Types of Agglutination Reactions
iv. Antiglobulin – Mediated Agglutination
VI Immunoglobulins
A Cleavage with Papain
B Pepsin Digestion
C Hinge Region
D Immunoglobulin G
E Immunoglobulin M
i. Function
F Immunoglobulin A
i. Immunoglobulin A2
G Immunoglobulin D
H Immunoglobulin E
VII Cytokines
A Cytokine Storm
i. Autocrine Stimulation
ii. Paracrine Stimulation
iii. Pleiotropic
B Cytokines in the Innate Immune Response
i. Interleukin – 1 (IL – 1)
ii. Tumor Necrosis Factor
iii. Interleukin – 6 (IL – 6)
iv. Chemokines
v. Transforming Growth Factor Beta (TGF – B)
vi. Interferons
C Cytokines in the Adaptive Immune Response
i. Th 1 Cytokines
ii. Th 2 Cytokines
D Cytokines Associated with T Regulatory Cells
E Colony Stimulating Factors
i. IL – 3
ii. GM – CSF (Granulocyte – Macrophage CSF)
iii. Erythropoietin
F Anti – Cytokine Therapies
i. Infliximab (Remicade)
ii. Etanercept (Enbrel)
iii. Zenapax
VIII Complement
A Plasma Complement CHON
B Three Pathway Reaction
i. Classical Pathway
ii. Alternative Pathway
iii. Lectin Pathway
IX Autoimmunity
A Autoimmune Diseases
B Systemic Lupus Erythematosus
i. Clinical Signs
ii. Clinical Diagnosis
iii. Immunologic Findings
iv. Laboratory Diagnosis
v. Treatment
C Rheumatoid Arthritis
i. Clinical Findings
ii. Immunologic Findings
iii. Laboratory Diagnosis of Rheumatoid Arthritis
iv. Rheumatoid Factor Testing
v. Testing Techniques
vi. Treatment
D Autoimmune Thyroid Diseases
i. Clinical Signs and Immunologic Findings for Hashimoto’s Thyroiditis
ii. Clinical Signs and Immunologic Findings for Grave’s Disease
iii. Laboratory Testing for Autoimmune Thyroid Disease
iv. Treatment for Autoimmune Thyroid Diseases
E Type 1 Diabetes Mellitus
i. Immunopathology
ii. Laboratory Testing
iii. Treatment
F Multiple Sclerosis
i. Symptoms
ii. Treatment
iii. Laboratory Tests

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G Myasthenia Gravis
i. Laboratory
ii. Treatment
H Goodpasture’s Syndrome
i. Clinical Presentation
ii. Diagnosis
iii. Treatment
X Immunoproliferative Diseases
A Lymphoma
B Hodgkin’s Lymphoma
i. Etiology
ii. Risk Factors
iii. Clinical Presentation
iv. Staging
v. Diagnosis
vi. Investigations used for Staging
vii. Abnormal Lab Tests
viii. Classification System
ix. Histology
x. Treatment
C Non – Hodgkin’s Lymphoma
i. Definition
ii. Risk Factors
iii. Clinical Presentation
iv. Staging and Diagnosis
v. Grades
vi. Treatment
D Lymphoblastic Leukemia
i. Acute Lymphoblastic Leukemia
ii. Chronic Lymphoid Leukemia / Lymphoid
iii. Hairy Cell Leukemia
XI Hypersensitivity
A Immediate Hypersensitivity
B Type I: IgE – Mediated Hypersensitivity
i. Component of Type I Reactions
ii. Type I Reactions
iii. Mediators in Type I Hypersensitivity
iv. Methods of Detection for Type I Hypersensitivity Reactions
v. Methods for Controlling Type I Hypersensitivities
C Type II: Antibody – Mediated Cytotoxic Hypersensitivity
i. Sensitization Phase
ii. Effector Phase
iii. ADCC Reaction of Dengue
iv. Type II Hypersensitive Reactions
D Type III: Immune Complex – Mediated Hypersensitivity
i. Stimulation Phase
ii. Effector Phase
iii. Examples
E Type IV: Cell – Mediated or Delayed Type Hypersensitivity (DTH)
i. Sensitization Phase
ii. Effector Phase
iii. Examples
XII Transplantation
A Solid Organs for Transplantation
B Hematopoietic Stem Cells
i. HLA Pharmacological Agents
ii. HLA System
C Histocompatibility Systems
D Functions of HLA Proteins
E HLA Genes
F Mendelian Inheritance
G HLA Proteins are Heterodimeric Molecules
H Histocompatibility Systems
i. Minor Histocompatibility Antigen Non HLA
ii. MIC / MICA Antigens (MHC Class I – Related Chain A)
iii. ABO Blood Group Antigens
iv. KIR System (Killer Immunoglobulin – like Receptors)
v. Allorecognition
I Transplant Rejection
J Graft – Versus – Host Disease
i. Acute GVHD
ii. T – cell Reduction
K Immunosuppressive Agents
i. Corticosteroids
ii. Antimetabolic Agents
iii. Calcineurin Inhibitors
iv. Monoclonal Antibodies

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v. Polyclonal Antibodies
L Clinical Histocompatibility Testing
i. HLA Typing
ii. HLA Phenotyping
iii. HLA Genotyping
iv. HLA Antibody Screening and Identification
XIII Serological Tests
A Syphilis
i. Stages in Syphilis
ii. Lab Diagnosis of Syphilis
B Group A Streptococcal Infection
i. Antistreptolysin O Titer (ASO)
ii. Anti – DNase B Testing
iii. Streptozyme Testing
C Hepatitis
i. Hepatitis A
ii. Hepatitis B
iii. Hepatitis C
iv. Hepatitis D
v. Hepatitis E
D Human Immunodeficiency Virus (HIV)
i. Main Structural Genes
ii. Laboratory Testing for HIV Infection
E Systemic Lupus Erythematosus (SLE)
F Rheumatoid Arthritis
i. Laboratory Diagnosis of RA
ii. CRP
G Heterophile Antibodies Associated with Infectious Mononucleosis (IM)
i. Test for Heterophile Antibodies
ii. Serologic Responses of Patients with Epstein – Barr Virus – Associated Diseases

INTRODUCTION o IS will only circulate with these four concepts

• Immunology: inside the body
o What is happening inside the body
o If you want to know if you have good immune system
and immune response, you will test using serological
testing
▪ Vaccines and Antibodies: serological testing

IMMUNITY
Antibodies • Immunology
o The study of host reaction when foreign substance is
introduced in the body
o Processed which all living organisms defend
themselves against infection
▪ Body’s response is to protect
• When bacteria, parasites or other foreign
particles that enters the body they will react
because they are foreign
Test Cards (CRP, RPR, ASO or other precipitation test) o Not only limited to microorganisms
▪ When blood/organ is donated,
injections (Botox) are all foreign,
which means they are also
needed to be tested
• Immunity
o A condition of being resistant to infection
▪ Response of the body
o Used to imply resistance to infectious agent, foreign
RBCs with WBCs that are in the bloodstream particle, toxin, living cells and cancer
o Natural Immunity
▪ Ability of the individual to resist infection by
means of normally present body function
▪ Nonadaptive, Nonspecific, No prior exposure is
required, the response does not change with
subsequent exposures
• Has very limited function
▪ Mechanism are subject to influence by such
factors as nutrition, age, fatigue, stress, and
Machines genetic determinants
• Four photos will give idea of Immunoserology

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• Natural Immunity is fragile due to these ▪ Rabies vaccine, venom snake vaccines
factors • Those are deadly viruses
o Nutrition – if not eating proper food, o Keypoint:
proper nutrients are not harvested ▪ Natural – related to antigen; antigen is given
from the food, which will make the ▪ Acquired – related to antibody; antibody is given
natural immunity low
o Age – as you age, the natural immunity
lowers
o Fatigue – as you abuse your body,
natural immunity lowers
o Stress – can lower natural immunity
▪ These factors can be controlled
by eating correct nutrition, less
stress and fatigue while you are
young
o Genetic determinants – cannot be
controlled; when you have inherited
diseases such as asthma, it is given • Innate: many cells are involved but are nonspecific
and you cannot change but can be • Acquired Adaptive: few cells are involved but very specific
controlled not to be chronic
▪ Without production of protective antibodies NATURAL DEFENSE SYSTEM
• No immunoglobulins present • Has two parts
▪ Present at birth and activated each time individual
is subject to challenge EXTERNAL DEFENSE SYSTEM
• Challenges can be microorganisms or other • SKIN acting as BARRIER
environmental factors • Composed structural barriers that prevent most infectious
o Acquired Immunity agents from entering the body
▪ Adaptive immunity
• Physical membrane (skin, mucous membrane) ex. Lactic
▪ Type of resistance that is characterized by
acid in sweat, Fatty acids from sebaceous glands maintain
specificity for each individual pathogen or
skin pH acid 5.6
microbial agent and the ability to remember a
o Sweat produces lactic acid
prior exposure, which results in an increased
▪ Lactic acid contains fatty acids that makes our
response upon repeated exposure
sweat pH acid, which makes it hard for the
• It has specific immunity to each individual bacteria to propagate
pathogen ▪ Sweat is smelly due to lactic acid; healthy and
o E.g. When one had Chicken Pox fatty people sweat profusely as compared to
(Varicella Zoster) then healed, next those that are slim
time VZV will infect, the patient will
• Respiratory tract, mucous secretions, motion of cilia lining
already have memory
nasopharyngeal passages clear away almost 90% of
▪ Will not be as infectious as the
deposited material
first time
o Respiratory tract contains goblet cells
▪ Only that, you will need exposure
▪ Goblet cells are the mucous producers
so once it is repeated, you will be
• Lactic acid production in female genital tract keep vagina
protected
pH 5
o Both systems are essential to maintain good health, in
o pH care / betadine wash – makes vaginal area acidic,
fact, they operate in concert and are dependent upon
preventing urinary tract infection
one another for maximal effectiveness
o In microbiology, it is said that vaginal area contains
▪ Both should be in good stable status
lactobacillus acidophilus (normal flora for protection)
• When one has problem, the other is affected
▪ However, this normal flora can be washed out
o Natural: present at birth
• When urinating and you wipe with tissue
o Acquired: as you grow old, you
o That is why feminine wash is needed
ACQUIRE this
to maintain acidic vaginal area
▪ Vaccine
o Active Natural / Innate Immunity • Tears – IgA, maintain urine flow, excretion of feces and
▪ Active – Antigen earwax protection of auditory canal
▪ Exposed to antigen in natural o Tears contain IgA2
o Earwax contains IgA
• Exposure to chicken pox
o Stool and urine also contain minimal amount of IgA2
o Active Acquired / Adaptive Immunity
o IgA1 is in serum
▪ Injected vaccines
▪ Given chicken pox vaccines • Hydrochloric acid – acidity of the stomach pH 1 which halt
o Passive Natural / Innate Immunity microbial growth
▪ Antibody is given o Produced by parietal cells of the stomach
▪ Colostrum: IgA2 / Secretory IgA o All bacteria will be controlled except H. pylori (formerly
▪ Mother gave you maternal IgG as protection known as Campylobacter pylori) (infectious agent)
• As you grow old (1 year old), you will • Lysozyme secretion such as tears, saliva which attacks the
develop antibody cell walls of microorganism – gram positive
o Passive Acquired / Adaptive Immunity o Lysozymes will destroy the cell wall
▪ Given antibody through injection

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▪ Cell wall is composed of proteins and

carbohydrates (peptidoglycans) which is
destroyed by the antibiotics
• Some antibiotics destroys nucleus instead
of the cell wall
• Prevents entry, growth, multiplication or reproduction of
bacteria while they go inside the body
o In the event that that some bacteria enter the body,
external defense system will depend now on the
internal defense system

INTERNAL DEFENSE SYSTEM

• Cells and soluble factors CHO – mannose in microorganism
which is not evident in human cells
• Leucocytes – phagocytosis, enhanced by soluble factors
called acute phase reactant IMMUNITY DEFENSES
o Specifically, lymphocytes, monocytes and the most
phagocytic cell, neutrophils NON – SPECIFIC DEFENCES SPECIFIC
▪ Challenges to cells: nonspecific (as they are
(Innate Immunity) DEFENCES
natural immunity) unless lymphocytes are
activated to become T and B cells (which will (Adaptive Immunity)
become the acquired immunity) First line of Second line of Third line of defense
o Once WBCs will respond to the infection, it will also defense (skin) defense
activate and enhance acute phase reactants (internal)
▪ APRs Skin Phagocytic Lymphocytes
• Different cells that will participate as Mucous leukocytes Antibodies
presented in the next bullet points membranes Antimicrobial Memory cells
• Internal Defense Secretions of skin proteins
o Inflammatory Response – pain and swelling that occur and mucous Inflammatory
upon injury or infection membranes response
▪ Cardinal signs Fever
• Rubor, Dolor, Calor, Tumor, Functio laesa • Lymphocytes: has the ability to transform into T cells (can
will be experienced by the cell transform in T helper, T cytotoxic and T suppressor) and B
o Mast cells – hold histamines that cause blood vessels cells (producing antibodies called plasma cells)
to dilate, bringing extra blood which causes swelling in • Memory cells: for life, remembers past infections
the tissues
o This attracts phagocytes to come and help deal with ACUTE PHASE REACTANTS
the infection • Soluble carbohydrates that are enhanced
▪ Wounds where bacteria or pathogen will attract • Normal serum constituents increases rapidly by 25% due to
WBCs together with mast cells (one of fast o Infection: common; there is microorganisms
responders in connective tissues) will produce o Injury: stab, operations
chemicals enhancing APRs
o Trauma of the tissues: car accident, hazing,
• If not all foreign organisms are engulfed =
liposuction
lead to infection or inflammation and
activation and enhancement of acute phase CYTOKINES
reactants
• Cell messenger, most notably IL – 1B, IL – 6 and TNF – a
which are produced by monocytes and macrophages at the
site of the inflammation. Interferon as well
o Monocyte: blood
o Macrophage: tissue
• a. C-Reactive Protein:
o Ab to C-polysaccharide of pneumococci
▪ Reacts to pneumococci infection
o 4 – 6 hours following infection, surgery, trauma to the
1ST LINE: NON – SPECIFIC EXTERNAL DEFENSES body. Increases hundredfold/thousandfold in a peak
• Barrier: skin value within 48 hours
• Traps: mucous membranes, cilia, hair, earwax o Pentraxin family member, capable of opsonization,
• Elimination: coughing, sneezing, urination, diarrhea agglutination, precipitation & activation of complement
• Unfavorable pH: stomach acid, sweat, saliva, urine through classical pathway
• Lysozyme enzyme: digests bacterial cell walls; tears, sweat o Opsonization: makes the bacteria “yummy”, and when
it is “yummy” the WBC will eat them
o Agglutination: mostly antigen – red cell participation
o Precipitation: mostly antibody – serum participation

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• Increase more in bacterial infection rather than viral

infection
o Serological correlation
o If decreased: viral infection
• Facilitates in recycling of TC and phospholipids in cell
membrane for reuse in building new cells required during
acute inflammation
o Cholesterol is used for production of steroid hormone:
clinical chemistry correlation
• Normal circulating level 30 ug/mL

o Macrophage – from monocyte

▪ When monocyte transforms, it becomes
macrophage
▪ Monocyte from blood going to tissue as
macrophage
▪ Macrophage cannot go back to monocyte
• Cells cannot go back
o Predominant producer of cytokine – macrophage and
monocyte • Understand the diagram
o Mast cell – one of the most responsive • Nothing to be waste; only that there is increased amount of
▪ Only in the connective tissue cholesterol
o CRP
COMPLEMENT
• Series of serum CHON – mediation of inflammation
• 9 CHON bound to antibody through classical pathway and
an additioned number involved in alternative pathway
o Most common: Classical Pathway
o Newest: MBL (Mannose – Binding Lectin)
• Function includes opsonization, chemotaxis, and lysis of
cells
o Chemotaxis: movement of WBCs directly to the organ
with the bacteria
▪ Positive: WBC is in the infection area
▪ Product from liver: CRP ▪ Negative: WBC move in different areas before to
• Activates opsonization the infection area
• Activates Complement Classical Pathway ▪ Lysis
o Lyse the target microorganism • Complement has 3 phases
• What if the patient is liver problematic? o Activation
o Fatty liver, cirrhosis o Recognition
▪ CRP production is affected o Membrane Attack Complex: papasabugin yung
▪ More susceptible to have bacteria, virus, red blood cell or organ that is not
infection since the liver has compatible
already problems as it cannot ▪ Crossmatching is important in prior Blood
produce APRs Transfusion
▪ Transplantation should take time (months or
• Intrinsic, Extrinsic and Common Pathway
years) to make major histocompatibility complex
are mostly produced by the liver
as it is very tedious
o If there has liver problem, may lead to
bleeding problems
o Liver will not easily be damaged as it
has a lot of function
o Liver regenerates
o Liver has limits though, and expect for
problems

SERUM AMYLOID A (SAA)

• Apolipoprotein – secrete by LIVER, associated in
metabolism of cholesterol
o Apolipoprotein member
▪ Apolipoproteins: good and bad cholesterol
• Contributes in the cleaning up, by removing TC from • C3 Convertase – C4b2a
cholesterol – filled macrophages in the site of tissue injury. • C5 Convertase – C4b2a3b
MI no CVD history • All happens in the body: picture above
o Clinical Chemistry correlation: Remove total o These 3 pathways have functions for: lysis, respond for
cholesterol that are lodged at the blood vessels (those inflammation and to make opsonization
that are free cholesterol)

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o Classical Pathway: mostly used in virus because it will ▪ Hard to breath

identify antigen – antibody reaction; antibody – ▪ Could lead to infection
dependent ▪ Can manifest chronic problem
o Alternative Pathway: mostly for bacteria; it will identify • Cancer or other forms
glycopeptidoglycan in the cell wall
o Lectin Pathway: in between; can respond in bacterial
or viral but it is better if the other two pathways will be
used in specific situations

MANNOSE – BINDING PROTEIN

• Newest of 3
o Like alternative, recognizing protein
• Mannose – binding lectin
• Acts as opsonin, calcium dependent
• Recognize foreign CHO like mannose found in bacteria,
yeast, viruses, and some parasite
o Activate from bacterial or viral and responds to other
yeasts and parasites
▪ It can only respond to some parasites: protozoans
• Has cyst and trophozoites
• Cannot respond to other parasites • Lungs and Kidneys will be affected to follow liver
• Similar with C1q as binding activates the complement o Why kidney and liver: in Clinical Chemistry 2, there is
cascade and help promote phagocytosis acid base balance
o Does not have C1q from classical pathway ▪ When lungs have problem, the kidney will
• Normal concentration up to 10 ug/mL compensate
• Lack of MBP associated with recurrent yeast infection ▪ Liver producing other ARP: SAA, CRP
o Diabetic patients, if sugar is not controlled can develop • That is why they have individual correlated
candidiasis, “thrush syndrome” problems
▪ Cannot respond to lectin, does not have MBP • Last to give up then following brain
pathway already
▪ Usually type 2 DM HAPTOGLOBIN
• Mentioned in Hematology 1
• Function is to bind irreversibly to free Hgb released by
intravascular hemolysis
o It will capture the free Hgb from intravascular (inside)
hemolysis
▪ Hemolysis due to different factors: malaria,
hazing and other parasite problems
▪ Will bring to liver and recycle since it is not
allowed to lose Hgb
• Hgb will be converted by liver to bilirubin 1
(unconjugated) turning to bilirubin 2
(conjugated) with the help of enzyme
UDGPT so B2 will be excreted as
• Representation of reaction inside the body
urobilinogen in the intestine, turning
urochrome (urine) and stercobilin (feces)
ALPHA 1 - ANTITRYPSIN
• Once bound it is cleared by the Kupffer and parenchymal
• Acts against trypsin, general plasma inhibitor of protease cells in the liver thus preventing the loss of free Hgb
related from leucocytes especially elastase
• Normal plasma concentration: 40 – 290 mg/dL
o Responding to WBC
• Prevent damage of kidney and loss of iron by urinary
• Elastase degrade elastin and collagen
excretion
• During chronic pulmonary inflammation, lung tissue is o Hgb that have escaped will be captured by haptoglobin
damaged because of its activity thus, it acts as mop up or and should not enter the kidney
counteract the effects of neutrophil invasion during an ▪ When it enters kidney, it could damage the
inflammatory response glomerulus (the filtration ability) and will be
o Responds to pulmonary inflammation, can be excreted in the form of iron (Fe)
pneumonia, COPD and other related pulmonary o Common in hazing, they die due to ruptured RBCs
inflammation entering kidney and causing kidney failure
• Lack of AAT lead to emphysema, destruction of • Provide protection against oxidative damage mediated by
parenchymal cells in the lungs in lower RT free Hgb
o Can also have a permanent damage in the right area
• Damaged CHON to prevent them aggregating in blood
of the lungs
vessels
o Lack of AAT: from active or passive smokers
o May also damage capillaries, veins and arteries
(commonly associated), vaping or chemicals (chlorox
and such)
▪ Highly developed emphysema

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CERULOPLASMIN
• One of the important acute phase reactants (APRs)
• Principal copper transporting CHON
o Transports copper
o No one eats copper since it is toxic
o We eat copper in the form of vegetables
▪ Vegetables will sip copper from the soil and
process it in photosynthesis
• We eat copper that are nontoxic
• Acts as ferroxidase, oxidizing from ferrous to ferric means
releasing iron from ferritin for binding to transferrin
• Haptoglobin is part of the body where it will capture the free
o May lose when is not converted
Hgb and this will be presented in the macrophage Kupffer
o When it enters kidney, it will be filtered
cells in the liver and will be recycled by liver cells as B1 and
• Deficient – Wilson’s disease, autosomal, recessive genetic
B2
disorder increase copper in the tissue
o Used and reused
o Hereditary
• In Wilson’s disease, copper accumulates in the liver, brain,
FIBRINOGEN
cornea, kidney and bones
• Discussed in Hematology 2 o In eyes: Kayser – Fleischer eyes
• Most abundant coagulation factor in the plasma thus form a o In hair: Menkes Kinky Hair
fibrin clot
o Other organs: Wilson Disease
o Most common in test of PT and APTT
• Rare disease
• Normal level 100 – 400 mg/dL
o Genetic disorder
• Increases the strength of a wound healing and stimulate
o 1 per 100,000 population
endothelial cell adhesion and proliferation which is critical
in healing process o Rare in Asian but common in Western / European
o One of the important common pathways as it will
promote wound healing
o When fibrinogen is good, the wound healing will be
easy
▪ Wounds due to scratches: 5 days longest
▪ Wounds from surgery: takes time
• Formation of clot creates a barrier that helps prevent spread
of microorganisms
o It will make clot to prevent bacterial spreading
▪ But this clot may be dangerous as it can be a
blockage to veins called “embolism”
• May lead to blood clot to veins
• It also promotes aggregation of erythrocytes
o Countereffect
o Clots and clumps in RBCs may also become
“embolism”
• Increase level contribute to risk for developing coronary
artery disease especially in women • Copper will be absorbed by small intestine, goes to the
o Common in women especially if menopausal women blood, then to the liver
▪ Due to decreased supply of estradiol • Over in liver accumulation – develop hepatoproblem
o Toxic
• Deficient develops Wilson’s disease
• Control of copper is important with the help of ceruloplasmin

CELLULAR DEFENSE MECHANISMS

• Five principal types of LEUCOCYTES that arises in
common precursor in the BM known as MYELOID LINE

NEUTROPHILS (PMN)
• 2 – 5 lobes, granules contain three types:
• Granular type
• Fibrinogen will prevent from bleeding and will make • Primary (Azurophilic granules): enzymes –
temporary clot with the help of platelet first myeloperoxidase, elastase, proteinase 3, lysozyme,
• Coagulation cascade will be activated when platelets are cathepsin G, defensin = antibacterial activity
activated • Secondary: collagenase, lactoferrin, lysozyme, NADPH
o No platelet = no clotting factors oxidase (reduced Nicotinamide Adenine Dinucleotide
o Problem in platelets (function/numbers) – you cannot phosphate oxidase)
call the coagulation cascade as it is important o These granules are important by killing and neutralizing
▪ Platelet – primary hemostasis microorganisms
▪ Blood Coagulation – secondary hemostasis ▪ Contains these enzymes that kills

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• Tertiary (New discovered): gelatinase, plasminogen o Type 2 and 3: Related to IgM and IgG
activator and acid hydrolases found in different ▪ Type 2: For blood transfusions
compartment of lysozymes (from Turgeon) ▪ Type 3: Rare
o Currently under study o Type 4: Lymphocyte
o Gelatinase contains acid hydrolase (ACP) ▪ Cell mediated
• Capable of DIAPEDESIS – movement through blood vessel • HISTAMINE: vasoactive amine contracts smooth muscle
cell wall and HEPARIN – anticoagulant
• Contains selectin which makes them sticky enhance • IgE formed in allergic reaction binds to basophils cell
adherence to endothelial cell in the vessel wall membrane
o Selectin is enzyme • Granules releases when contact with antigen, lack of
• Attracted with CHEMOTAXINS – chemical messenger hydrolytic enzyme but peroxidase is present
cause cell to migrate in a particular direction • Exist only in few hours in the blood stream
o Positive Chemotaxis: They could identify where the
bacteria is located; most are positive chemotaxis
o Negative Chemotaxis: WBCs moved in different areas
first
o Causes of Chemotactic factor
▪ 1. Coagulation cascade
▪ 2. Products from bacteria/virus
▪ 3. Platelet activating factor
▪ 4. Secretions from mast cells MAST CELL
▪ 5. Lymphocyte, macrophage & neutrophils • Resembles basophils but origin in connective tissue of
• Efficient in initiating PHAGOCYTOSIS mesenchymal
• Life span: about 5 days • Longer life span about 9 – 18 months
o Neutrophil is the most populated cell (50 – 70%) • Has more granules which contain (strong granules; can kill
• Increases of circulating neutrophils in the blood occur microorganisms and some parasites)
almost immediately o Acid phosphatase
o Alkaline phosphatase
o Protease
• Role in HYPERSENSITIVITY REACTION BINDING IN IgE
o Type 1: IgE

EOSINOPHILS
• Increases in allergic reaction or in response to many
parasitic infections
• Usually bilobe, red orange granules MONOCYTE (MONONUCLEAR CELL)
• Primary – acid phosphatase and arylsulfatase and other • One of biggest cell
basic protein includes eosinophil cationic CHON, eosinophil • Second that can perform PHAGOCYTOSIS
peroxidase & eosinophil derived neurotoxin • Horseshoe nucleus, grayish – blue, glass ground
• Capable of phagocytosis but less efficient due to small size appearance with dust like granules
and lack of digestive enzyme • Contain two types of granules:
o Cannot kill bacteria as they lack the digestive enzyme o First – contain peroxidase, acid phosphatase and
▪ It will eat but cannot kill arylsulfatase (similar to PMN)
• Role in neutralizing basophil and mast cell and killing o Second – contain B – glucuronidase, lysozyme and
certain parasites lipase but not Alkaline phosphatase
o Mast cell is better to kill; present in connective tissue • Do not remain in the circulation for long up to 70 hrs and
when migrate to the tissue becomes MACROPHAGES
o Life span: up to 3 days
▪ It transforms to MACROPHAGE before it dies
• From blood (monocyte) to tissue
(macrophage)
• Macrophage Life span: about a year
• Small in population; only 8 – 10% in normal blood

BASOPHILS
• Deep bluish granules contain heparin, eosinophil
chemotactic factor A which important function in INDUCING
AND MAINTAINING IMMEDIATE HYPERSENSITIVITY
REACTIONS
o Associated with allergic reactions
o 4 types of Hypersensitivity Reactions TISSUE MACROPHAGE
o Type 1 Hypersensitivity: Related to IgE • Arises from monocyte, differentiation and cell division takes
▪ Where basophil participate place in the tissue

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o Converted from monocyte CHEMOTAXIS, without the influence of chemotactic

o Stays in the tissue substances, cell motion is random
• 25 – 80 um, matures and increases lysozymes, o Most WBCs do positive chemotaxis, as they go
endoplasmic reticulum and mitochondria towards the bacteria
• Not contain peroxidase, some immobile some do amoeboid
action ENGULFMENT
• Not as efficient as neutrophil in phagocytosis and • Eating of bacteria
movement • Once recognize the foreign particle, engulfment occur in
o Disadvantage: slow moving but is still good as a active ameboid motion, phagocyte extend cytoplasmic
defender membrane around the invading microorganism and
• Ex. Lungs – Alveolar macrophage, Liver – Kupffer cells, completely enclosed
Brain – microglial and Connective tissue – histiocytes • Phagosome/Phagocytic vacuole: contain phagocytized
o Specific names particle. Microorganism should be more hydrophobic than
o Main organ where they go phagocyte as physical nature
• Ex. Diplococcus pneumoniae

DIGESTION
• Or Degranulation
• Hydrolytic enzymes and peroxidase approach the
phagosome, fuse, rupture and discharge its contents
o Excreted as discharged content
▪ Digested with their enzymes then destroyed and
DENDRITIC CELL discharged by WBCs
• A special cell; unique • Killed microorganisms will go to spleen
• Cover with long membranous extensions resemble nerve o It will cater all the dead
cell dendrites microorganisms as it is the “graveyard”
• Function to phagocytose antigen and present to T-
lymphocytes to initiate acquired immune response
• Actual development linkage not known
o Debate where it came from
▪ As to appearance, it does not resemble any cell
• Believed descendants of MYELOID LINE
o According to Stevens, it is from lymphocytes as based
on the function
▪ It does not look like it but in terms of function, it
INFLAMMATION
resembles it
• Condition wherein tissue enter as a reaction to injury,
• Called Antigen Presenting Cells (APCs)
classic signs pain, heat, redness and swelling and
• Classified as to their tissue location sometimes loss of function
• Ex. Langerhans cell – skin /mucous membrane, interstitial o Cardinal signs of inflammation
dendritic cell – heart, lung, liver, kidney and GI tract ▪ If one of these have been felt, it means there is
• Looks like octopus, it has projections/extensions, and these inflammation
captures the antigens • Two or more: more severe
• Loss of function: rare to be felt, as it may
lead to amputation of the loss function of a
particular area
• Cellular response most efficient and adaptive of all
mechanism
• In addition to that vascular response aids in preventing the
invasion of bacterial agents beyond the periphery of the
body
• Dilation of capillaries more blood passes on the area of
PHAGOCYTOSIS injury which appears red / inflamed. This termed refer as
• Mechanism of action is presented below HYPEREMIA – increase blood content. Exudate is formed
– infection present
INITIATION o Response of the body
• Initiated by tissue damage, either trauma or microbial ▪ Increase blood supply, more WBCs, cytokines
multiplication. Increase surface receptor (CR3, formyl- and acute phase reactants will enter and will
methionyl-leucyl-phenylalanine) receptors for the control microorganisms
adherence of bacterium to phagocyte o Exudate – when there are bacteria, there is water,
o Bacteria will be identified leading exudate
▪ No bacteria, process inside the body/function and
CHEMOTAXIS there is water leading to transudate
• Seen in AUBF (serous fluids)
• Cells tend to move in a certain direction under stimulation
of chemical substance. Two effects: move toward the • Fluid is clear, no odor – transudate
stimulating substance POSITIVE CHEMOTAXIS or move • Fluid has color, with odor – exudate
away from stimulating substance NEGATIVE
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o Lymphoid system is needed to be studied to appreciate

what happened to lymphocyte after it was released by
bone marrow
▪ Bone Marrow will produce 20 – 40% of
lymphocytes coming from hematopoietic stem
cell myeloid
• These cells are unique they arise from HEMATOPOIETIC
STEM CELL and further DIFFERENTIATED in the primary
lymphoid organ
o Once released by bone marrow, it will be differentiated
into two different classes
• Separated into two main classes:
o Primary – Bone Marrow and Thymus
▪ Lymphocytes that go to thymus becomes T
lymphocytes/T cells
• Lymphocytes that do not go will become B
cells (Bursa cell)
o Secondary – Spleen, Lymph nodes, Tonsils, Appendix
and other Mucosal – Associated Lymphoid Tissue
NONSPECIFIC IMMUNITY OF BODY FLUIDS (MALT)
▪ Once becoming B or T cell, they will enter the
LYSOZYMES secondary lymphoid TWICE per day
• Enzyme seen in cell, tears & saliva with antibacterial • They will check if there will be filtered
activity. It contain mucolytic properties that cleave acetyl- microorganisms
amino sugars, the backbone of gram -/+, destroy the cell • Two main Secondary Organs:
wall and some has large amounts of LYSINE to kill anthrax o SPLEEN – FILTERING MECHANISM FOR ANTIGEN
• Kill gram + mostly and some gram– especially if you have IN THE BLOOD STREAM
good supply of lysine o LYMPHNODES – Filter fluid from the tissue
o Lysine is an amino acid ▪ Both have ability to filter
▪ With this, you can also kill bacillus anthracis • Lymphocyte circulation is complex and regulated by
different cell surface adhesion molecules and by chemical
PROPERDIN messengers called CYTOKINES
• Serum CHON bactericidal/viricidal effects presence of o Lymphocyte is one of the producers of cytokines
Complement C3 and Mg ions ▪ May not be phagocytic cell, but it has the ability to
o Prevent the growth and reproduction of bacteria/virus produce cytokines and transform into T or B cell
with the help of C3 • Lymphocytes are segregated with the secondary organs
▪ Alternative pathway = bactericidal according to their particular functions
▪ Classical pathway = bactericidal/viricidal
▪ MBL = both SPECIFIC LYMPHOCYTES
o To activate complement, we need good supply of • T – lymphocytes – effector cell that serves as regulator cell
electrolyte Mg – 61 – 89%
▪ Mg is just like calcium and phosphorus o Greatest in number
(intracellular) o T cells called as “tiny”
• Most of them are inside the bone cell, some o Catches antigens and presents to B lymphocytes
in the muscle, few in blood stream (antibody producers) forming into plasma cells
• B – lymphocytes – produce antibody – 20%
BETALYSIN o B – “big type”
• Beta lysin • NK cell – role in both innate and adaptive immunity – 22%
• Heat stable, antibacterial activity, release by platelet during in the peripheral blood
coagulation, bactericidal for gram + except streptococci o Special cells
o Has antibacterial activity o Null cell – “do not know”
o Helps in the production of platelets, especially to o Can protect from any infection even cancer, but the
activate coagulation cascade problem is they do not have receptor, unlike B and T
▪ Common in dengue, hemophilia and bleeding cells
disorder patients to activate the coagulation by ▪ Cannot recognize good from bad and therefore
having good supply of platelets/megakaryocytes fights them both
• That will be the last stage in the bone ▪ CD – cluster of differentiations are known to be as
marrow before they will be out in the blood receptors
streams as platelets or thrombocytes • Both T and B lymphocytes recirculate continuously from the
o Good for gram positive except for streptococci blood stream to the secondary lymphoid organ and back, in
an attempt to increase contact with foreign antigen
LYMPHOID ORGAN o T and B cells are important especially in the secondary
lymphoid organ
▪ Once they go out from the bone marrow or
THE LYMPHOID SYSTEM
thymus, they do not go back
• Lymphocyte is the cell that involve in immune response,
• They can only visit secondary organs, unlike
about 20 – 40% represent the circulating leucocytes
the primary

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PRIMARY LYMPHOID ORGAN o Graveyard of the cell

o Very hard to see; hiding at the back of the stomach
BONE MARROW o Inflammation: splenomegaly
• All lymphocytes arise from pluripotential hematopoietic • Splenic tissue main types:
stem cells appear initially at the yolk sac of the developing o 1. RED PULP – TO DESTROY OLD RED BLOOD
embryo and later found in the fetal liver CELLS
o Lymphocytes are produced by liver for fetus o 2. WHITE PULP – WBC
• Bone Marrow assumes this role when the infant is born
• Largest tissue in the body
o Function as the center for antigen – independent
lymphopoiesis. Lymphocyte stem cells are released
from marrow to travel additional primary lymphoid
organs where further maturation takes place
o Produces different cells and releases matures cells
▪ Sometimes, immature cells like reticulocytes are
released (1 – 2%) but are captured by spleen LYMPH NODES
• Located along lymphatic ducts and serve as COLLECTING
POINTS FOR LYMPH FLUID from adjacent tissue.
FILTRATION is the main function
o Filter from tissue
• Specialized dendritic cell – found only in the lymphoid
follicles, have long cytoplasmic processes that radiate out
like tentacles, which exhibit large number of receptors for
antibody and complement and help to capture antigen to
present to T and B cells
o Companion of lymph nodes
o Resembles same function of T lymphocytes but its
origin is not yet known
• Pelvic and humerus are the predominant producers of cells
• Thymus has 2 lobes
o Below thyroid gland and above the heart

THYMUS
• T cell develop their identifying characteristics. As we grow
old it diminishes its size but still capable of producing T-
lymphocytes until the fifth or sixth decade of life
o A unique character
o As thymus diminishes in size, it can still produce T cells
but at a decreased amount
▪ Reason why older people tend to get sick easily
• It is divided into lobes for central role in the differentiation • We have plenty of lymph nodes from neck, armpit, arms,
process groin and legs
o Females that undergo removal of breast will also be
• Surface antigen is acquired as lymphocytes travel from
removed with lymph nodes from breast and
cortex to the medulla for 2 – 3 weeks
arms/shoulder (decreased filtering organ)
• Mature lymphocytes are then released from the medulla
• Progenitor of T cell appears in the fetus as early as 8 weeks
in the gestational period
IMMUNOGEN
• Macromolecules capable of triggering an adaptive immune
response by inducing the formation of ANTIBODIES or
SECONDARY LYMPHOID ORGAN
SENSITIZED T CELLS in an immunocompetent host
• After mature T and B cell leave the BM and Thymus, they
migrate to the secondary lymphoid organ and become part
of a recirculating pool
ANTIGEN
• Substance that reacts with ANTIBODY or SENSITIZED T
• SLO – spleen, lymph nodes, tonsils, appendix, Peyer’s
CELL
patches in the intestine and other MALT – mucosal
associated lymphoid tissue
o Lymphocytes visit SLO once or twice per day FACTORS INFLUENCING IMMUNE RESPONSE
▪ Those that have organs that have been removed • 1. AGE
have reduced secondary lymphoid protectors o Neonates do not have complete vaccines
• Lymphocyte in these organs goes with the blood stream by o Older people have smaller thymus
the way of thoracic duct. The journey of theses occurs one o Ages 12 – 40: best age to respond
or two times per day • 2. OVERALL HEALTH
o Healthy individual with comorbidities may also be
SPLEEN affected with immune response
o Health is not the absence of disease
• Second largest lymphoid organ, a large discriminating filter
• 3. DOSE
that removes old and damaged cells and foreign antigen
o If given with vaccine, how many doses should be given
from the blood
▪ E. g Hepa B shots (3 doses) before internship
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• 4. ROUTE OF INOCULATION RELATIONSHIP OF ANTIGEN TO THE HOST

o Inject, IV, IM, Oral
• 5. GENETIC CAPACITY AUTOANTIGENS
o Complete, Incomplete, Live, Attenuated Vaccines • Ag that belongs to the host, do not evoke an immune
• The older individuals = decrease response Antigenic response under normal circumstances
Stimulation o Do not have immune response
• Neonates do not fully response due to their immune o Personal; from you to you
systems not completely developed
• Actual amount of immunogen needed to generate immune ALLOANTIGENS
response dependent on the route of inoculation • Are from other members of the host species, capable of
o Intravenous: best route; direct to veins eliciting an immune response
▪ Sometimes, could lead to vein inflammation • They are important to consider in tissue transplantation and
o Intradermal blood transfusion
▪ Next best to IV o Challenging
o Subcutaneous o Same species, but different person
▪ Next best to IV o Common in transplantation and transfusion
o Oral Administration
▪ Rare
HETEROANTIGENS
▪ Rotavirus vaccine
▪ May be denatured by stomach except for • From other species, such as animals, plants and
rotavirus microorganisms
• Immunogen enters the body determines which cell o Rare; from other species
population will involve the response and how much needed ▪ Ex. Pig heart transplant to human; human
to trigger the response survived for 3 days only
• Pig heart has only 2 chambers
TRAITS OF IMMUNOGEN
• Immunogen Characteristics to stimulate host response: HETEROPHILE ANTIGENS
o 1. Macromolecular size: Should be big • Heteroantigens that exist in unrelated plants or animals but
o 2. Chemical composition and Molecular complexity: are either identical or close related in structure which Ab
Should be complete cross react with Ag of the other.
o 3. Foreignness: The more foreign, the better o Ex. IM Heterophil Antibody
o 4. Ability to process, present with MHC molecules: • Early stage of IM Heterophile Ab is stimulated of unknown
Should activate MHC Ag which react with sheep RBC as the basis of Paul-Bunnell
• Least molecular weight of immunogens: 10,000 d screening test for Infectious Mononucleosis-Atypical
o Minimum lymphocyte is observed.
o Should be the minimum for vaccines o Causative agent for IM: EBV (“Kissing disease”)
• Best molecular weight of immunogens: > 10,000 d ▪ Sheep RBC + Serum (infected) = Rossette
• But substances with <1000 d MW still induce immune formation of RBC
response • PBS = observe atypical lymphocytes
• Foreignness: immune system normally able to distinguish o Big lymphocytes (same as monocyte)
between self and nonself, and those substances
recognized as nonself are immunogenic ADJUVANTS
• Example: Plant CHON is better immunogen to animal than • Substance administered with an immunogen that increases
material from related animal the immune response, it acts by producing local
o Most of medications are from plants before they are inflammatory response that attracts large number of
made synthetic from laboratories immune system cells to the injection site.
▪ Ex. Lagundi capsules o Added to increase immune response; to become more
activated
HAPTENS • Example:
• Some substances are too small to be recognized by o ALUMINUM SALTS-only approved for clinical use,
themselves, but if they are complexed to larger molecules, used to complex with the immunogen to increase its
they are able to stimulate a response size and prevent rapid escape from the tissue. It must
• HAPTENS – are nonimmunogenic material that when be injected IM to work. Like Нер. В vaccination.
combined with a carrier, create a new antigenic determinant ▪ Common adjuvant; to respond more
o Making the molecules bigger (small immunogen + • FREUD'S ADJUVANT-MINERAL OIL (EMULSIFIER) –
hapten = increased size) killed mycobacteria (0.5mg/ml)
o Ag is mixed with adjuvant then injected, which
produces granulomas or large areas of tissue scar BUT
PRECIPITATION / AGGLUTINATION
not used in humans which increases number of
macrophages, antigen processing and prolonging the
existence of the immunogen in the area
▪ Injected to mice; tb was killed; however, the effect
on mice made large granulomas (scar)
• Reason why it was not already used in
humans as it may impact the proper
functioning

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• AFFINITY = initial force of attraction that exists between a

single Fab site on an Ab molecule and a single epitope or
determinant site on the corresponding Ag
o AF = initial force (Ag – Ab meet)
▪ F comes first before V
o Serum is added to latex then mixed = precipitation
• AVIDITY = sum of all the attractive forces between an
• When you put adjuvants, it will develop increased immune antigen and an antibody. It involves the strength with
response / effective multivalent Ab to multivalent Ag. It measures overall
o Very rare cases of Hepatitis B vaccine will not develop stability of Ag – Ab complexes
antibody production as it has good adjuvants o AV = there is attraction
▪ 1 per population
• But will again be developed during second PRECIPITATION CURVE
and the succeeding doses • Optimum precipitation occurs when the number of Ag and
• The higher titer: the higher immunity Ab approximately EQUAL thus ZONE OF EQUIVALENCE
o Needs booster to increase immunity • Precipitation = random, reversible that each Ab binds with
more than one Ag forming a stable network or LATTICE
MAJOR HISTOCOMPATIBILITY COMPLEX • LATTICE based on Marrack, that Ab has two binding site
and Ag must be multivalent. As they combine,
HUMAN LEUCOCYTE ANTIGEN (HLA) multimolecular lattice that increases in size until it
precipitates the solution
• Old term; renamed as before transplantation is not common
• Heidelberger and Kendall performed Quantitative
• Indicates the genetic capability to mount an immune
precipitation reaction to established proof in this theory
response is linked to a group of molecules.
o Observed precipitation = zone of equivalence / lattice
• MHC molecules
formation
• Dausset (French scientist) gave this name, discovering Ab ▪ Precipitation clumps: reaction of serum and latex
response to circulating WBC, determine whether the o Uses slides
transplanted tissue is HISTOCOMPATIBLE, thus accepted ▪ Now, precipitation tests are using disposable
or recognized as foreign and rejected
• Reusable wells are also used before
o Before, it was thought that when transplanting, it is only
needed that it was compatible to cells (leukocyte must
be compatible to organ to be donated)
PROZONE AND POSTZONE
▪ Dausset found out that it should not only be the • Prozone – excess Ab on the other side (FALSE NEGATIVE
WBC to be considered but the general – HIGH Ab concentration = dilute Ab, retest = positive
histocompatibility result)
• Organs as well must be compatible, so from • Postzone – excess Ag on the other side (FALSE
HLA, it was renamed MHC NEGATIVE – repeat with additional patient specimen –
o No organs will be removed in after 1 week for further Ab production)
transplantation, only adding of organs
o Transplants take time (6 months at MEASUREMENT OF PRECIPITATION BY LIGHT
minimum) unlike in blood transfusions SCATTERING
• Seen in all nucleated cells, play pivotal role in the
development of both humoral and cellular immunity TURBIDIMETRY
o RBCs and platelets are the only cells that are non- • Oldest
nucleated in the body • Measure turbidity or cloudiness of a solution. Precipitates
measured by this, thus precipitation is one of the most
AGGLUTINATION VS PRECIPITATION simplest method of detecting Ag – Ab reaction, due most
Ag are multivalent capable of forming aggregates in the
PRECIPITATION REACTIONS presence of corresponding Ab
• Immunoassays have been developed to detect either o Turbid – positive
Antigen or Antibody, and they vary from easily performed • Measures the reduction in light intensity due to reflection,
manual tests to highly complex automated assays absorption, or scatter. Scattering light occurs I proportion to
• PRECIPITATION- involves combining solution with soluble the size, shape and concentration of the molecules
antibody to produce insoluble complexes that are visible. • Uses spectrophotometer – using absorbance unit, measure
o Mostly in immunology and serology the ratio of incident light to that transmitted light
o Uses antibody – serum / plasma (rare) o Beer’s Law
▪ CRP, RPR, ANA – serum
o Drops in the kit – immunoassay precipitation
• AGGLUTINATION-process by which particulate Antigens
such as cell aggregate to form larger complexes when a
specific antibody is present.
o Mostly in blood bank
o Uses antigen – red blood cell

ANTIGEN – ANTIBODY BINDING • 7 cuvettes

• Primary union of binding sites on antibody with specific o 1 – 5: could be positive, has particles
epitopes on an antigen depends on two characteristics of o 7: may be clear, but still think there are particles
antibody known as:
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▪ Where spectrophotometer is here, following o Ag diffuses out from the well, Ag – Ab combination in
Beer’s Law changing proportion until ZONE OF EQUIVALENCE is
o Not usually practiced in Serology but in Clinical reached and stable lattice network formed in the gel
Chemistry o Not used anymore in clinical laboratory as it is
expensive and time – consuming
NEPHELOMETRY o Radial immunodiffusion and Passive Immunodiffusion
• Measures light scattered at a particular angel from the are prone to technical errors
incident beam it passes through a suspension ▪ Control is also difficult
• 10 – 90 degrees angle, used in Ig, Complement and CRP
o Similar to Turbidimetry, but in here, you can adjust the
angle unlike up to 10 degrees
o Used serological approach
o Used before for CRP determination
• Used in accurate and precise quantitation of serum CHONs
o But mostly in Clinical Chemistry
• OUCHTERLONY DOUBLE DIFFUSION
o Old, classic immunochemical techniques
o Time consuming
o Ag – Ab diffuse independently through semi sold
medium in two dimensions horizontal and vertical
o 12 – 48 hours incubation time in moist chamber
o PRECIPITIN LINES FORM MOVING FRONT OF
ANTIGEN MEETS ANTIBODY. THE DENSITY OF
LINS REFLECTS THE AMOUNT OF IMMUNE
COMPLEX FORMED
PASSIVE IMMUNODIFFUSION TECHNIQUES o Used to identify fungal Ag such as Aspergillus,
• PASSIVE IMMUNODIFFUSION Blastomyces, Candida and Coccidioides and several
o Ag – Ab complexes using support medium gel autoimmune diseases
o Agar a high molecular weight complex polysaccharide ▪ Became popular just because of these
from seaweeds and agarose, a purified agar o Error = irregular pattern overfilling of well, irregular hole
o An Ag and Ab combination occurs by means of or punching, nonlevel incubation, drying out of gel, time
diffusion, no electric current is used to speed up the of diffusion, weakness of band intensity, fungal or
process bacterial contamination in gel
o 0.3 – 1.5% agar concentration = allows diffusion of ▪ Has common errors and a lot of violation to
most reactants Westgard rules
o Agarose preferred AGAR, because agar has a strong o Better compared to Passive and Radial, however, in
negative charge clinical practice they are not usually used
▪ Very rare, used for researches only as it will take
time
• TAT may be at risk
o Reactions in gels
o Migrate towards each other and where they meet in
optimal proportions form a precipitate

o Use of agar plates

▪ Make holes where to put Ag and Ab
• Precipitin lines: Identical, Nonidentical,
Partial
o Requires visibility

o Ag and Ab is put in agar and allowed to react ELECTROPHORESIS TECHNIQUES

▪ Line of precipitation = more lines, more reaction • Diffusion combined with electrophoresis speed up or
• RADIAL IMMUNODIFFUSION sharpen the result
o One of the oldest as well o Purpose
o Modification of single – diffusion technique (James o Can have result in just 3 hours
Oudin first use gels for precipitation reaction. Use • ELECTROPHORESIS: separates molecules according to
agarose gel in tube) difference in their electric charge when placed in an electric
▪ Passive – plates field (from negative to positive)
▪ Radial – test tubes / tubes o A direct current forced through the gel, causing Ag, Ab
o Ag is layered in the top as it move down into the tube, or both to migrate
precipitation occurred and it move down the tube o Used in Molecular Biology nowadays
proportion to the amount of Ag present ▪ Expensive but is well improved

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o The more curved, the more ag or ab is increased

▪ Radial – curve
▪ Ouchterlony – precipitin line
o Usage of serial pipette to lodge
proteins/antigens/antibodies and submerge to AGGLUTINATION
electrophoresis and will promote electric current that • Mostly done in Blood Bank
will migrate from anode to cathode then will see results • Uses antigen/red blood cell
in impregnation paper or gel (look for band) • Is the visible aggregation of particles caused by
▪ Also done during COVID testing combination with specific antibody
▪ Complex: time consuming, expensive
• AGGLUTININS: Ab that produce such reaction. Ag must be
• Errors must be reduced exposed to Ab
• ROCKET IMMUNOELECTROPHORESIS o For agglutination
o Like typical agarose gel • Types of particles participating:
▪ The more pointed the precipitin line, the more o Erythrocytes: most common
content it has o Bacterial cells
o Used to identify antibodies (quantification) o Inert carrier like latex particles
o End result is a precipitin line that is conical in shape, ▪ Made from laboratories
resembles rocket
• Each particles have antigenic or determinant site that cross
o The height of rocket measured from the well to the apex
– linked to sites and formation of Ab bridge
is directly in proportion to the amount of Ag in the
• Ex. Blood typing
sample
o More rapid than RID, used in quantitating Ig using • GRUBER AND DURHAM
buffer pH 8.6. Ag migrate toward positive anode o First report the ability of Ab to clump cells (bacterial cell
by serum) because of this serology is used a diagnostic
tool and ABO blood group discovery
• WIDAL AND SICARD: detection of Ab occurring in typhoid
fever, brucellosis, and tularemia
• Detection of antigen and antibody – simple to perform and
end point is easily to read visually
• Two step process result the formation of stable lattice
network

STEPS IN AGGLUTINATION
• Two steps/Process
• 1. Sensitization
o Upper: representation o First reaction involve Ag – Ab combination through
o Lower: what you’ll see single antigenic determinants on the particle surface
▪ Highest point = has higher Ab content ▪ Like affinity in precipitation
• IMMUNOELECTROPHORESIS o Rapid and reversible
o Or double – diffusion technique that incorporates • 2. Formation of Cross – Links that Form Visible Aggregates
electrophoresis current to enhance result (Gabar and – Lattice Formation
Williams) o Represents stabilization of Ag – Ab complexes with the
▪ Same as rocket binding together of multiple antigenic determinants
o Ag in serum which is electrophoresed to separate out ▪ Like avidity in precipitation
main proteins fractions
o Gel is incubated in 18 – 24 hours, the DDT occurs in ENHANCEMENT OF LATTICE FORMATION
right angle to electrophoretic separation and precipitin • Visible agglutination – decreasing the buffer ionic strength
lines develop if Ag – Ab combination takes place use of LOW IONIC STRENGTH SALINE RBC:
o Line or arc be compared in shape, intensity and • 1. Addition of Albumin – neutralize surface charge and allow
location of normal serum to detect abnormalities like RBC to approach other more closely
bowing or thickening of the bands and charged mobility o Albumin promotes agglutination
▪ Instead of rocket’s conical • 2. Viscosity – increased by adding agents like dextran and
▪ Like Ouchterlony that do not have holes polyethylene glycol – reduce water hydration around cells
• Combined Ouchterlony with Radial allow to come closer for Ab to join together
o Dextran and PEG will make the sample viscous as it
will reduce water hydration
▪ More viscous = more agglutination
• PEG is expensive, so dextran is mostly used
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• 3. Adding ENZYMES like bromelin, papain, ficin, and • Antigen mixed with coated one before being
trypsin – enhance agglutination, reduced surface charge of submerged in a reaction
the RBC by cleaving, chemical group and decrease o Presence of haptens (ex. Those with
hydration Bombay phenotype)
o Ficin – cleaves siaglycoCHONs from the RBC surface ▪ To have a very good visible and
by reducing the charge and change the external quick reaction
configuration of the membrane to reveal more antigenic
determinant sites
▪ Ficin – good for visibility
• 4. Agitation and Centrifugation – physical means increase
cell – cell contact and heighten agglutination
o Cheapest
• 5. Altering temperature – IgG class agglutinate best 30 –
37c and IgM – 4 – 27c thus natural occurring against ABO
blood group are IgM and best run at room temp. and other o Recommended for those without agglutination viewer
Ab and human blood group are IgG class • 3. REVERSE PASSIVE AGGLUTINATION
o IgG – warm o ANTIBODY rather than Ag is attached to a carrier
o IgM – cold particle
• 6. Alter of pH 6.5 – 7.5 optimal Ag – Ab combination except o Ab must still be reactive and joined in a manner that
human anti – M and anti – P1 react lower Ph active site facing outward
o Not recommended as it will take time and needs more o CARRIER PARTICLE + ANTIBODY = COATED
complex procedure and needs more time to verify if the PARTICLE + ANTIGEN WITH MULTIPLE
blood contains anti – M or anti – P1 minor blood groups DETERMINANTS = VISIBLE AGGLUTINATION
▪ These people carrying these blood groups are not ▪ Separated with direct and indirect because it was
allowed found out that antigen is more fragile than
• Time consuming as you need to identify antibody
these groups and at the moment, we have • Indirect is more prone to hemolysis
very limited testing resources for minor ▪ Looks like indirect but differ on the manner of
blood groups what is added first
o Test to detect microbial Ag Ex. Group B strep., S.
TYPES OF AGGLUTINATION REACTIONS aureus, Strep Group A and B, H. influenzae, Rotavirus,
• 1. DIRECT AGGLUTINATION C. neoformans, V. cholerae and Leptospira
o Common in blood type o Measure test for hormones, therapeutic drug and
▪ Whole Blood + Antisera = sensitization = 2 nd plasma CHON like CRP and Haptoglobin and RF
effect - lattice formation causes false positive it react to any IgG Ab
o Ag are found naturally on a particle, testing, known o Mostly used on microbiology and clinical chemistry
bacterial Ag to test the presence of UNKNOWN Ab. Ex.
WIDAL test = typhoid fever (Ag used Salmonella O
somatic and H flagellar)
▪ Old name – Typhidot
o If RBC involve in agglutination reaction called
HEMAGGLUTINATION – ABO blood group, antisera of
IgM determine presence or absence of A and B Ag
perform in room temperature
o A dark red button in bottom well = NEGATIVE
• 4. AGGLUTINATION INHIBITION
o Spread across bottom well irregular edge = POSITIVE
o LACK of agglutination is an indicator of positive
• 2. PASSIVE/INDIRECT AGGLUTINATION
reaction
o Particles that are coated with Ag not normally found in
o Hapten are involved in the reaction then attached to
their surfaces
carrier particle
o Variety of particles are erythrocytes, latex, gelatin and
▪ Used to detect illicit drug like cocaine and heroine
silicates
• Drug testing (screening)
o Use of synthetic beads or particles provide advantage
o With line = negative for drugs
of consistency, uniformity and stability
▪ Ab + patient sample (incubate) = Patient Ag
o Reactions are easy to read visually and give quick
present + Antigen coated latex particle = NO
results
AGGLUTINATION – POSITIVE
o Used to detect RF, ANA-SLE, Ab to group A strep., T.
spiralis, T. pallidum, CMV, rubella, varicela -zoster, HIV • Looks like reverse typing in Blood Banking
1/2
▪ Detection of autoimmune diseases
o IgG absorbed to the surface of polystyrene latex
particles, while polysaccharide and CHON not naturally
absorb by these particles
o Commercial test contain disposable plastic card or
cardboard cards, with positive and negative control, a
typical screening test
o This was used before for detection of Rubella and
o Carrier particle + Soluble Ag = coated particles + Ab =
Rubeola but now since we have vaccines (MMR) and
visible agglutination
▪ Not directly mixed
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they are self-limiting, the doctors will just advice to take • Remedy: mother is given Rhogam at 26
rest or increase fluids weeks (8 months) or after she gave birth to
o HEMAGGLUTINATION INHIBITION avoid same scenario with the next child
▪ Same principle reaction except RBC are indicator ▪ Sensitization of RBC caused presence of drugs
particles • Clinical chemistry correlation
▪ Detect Abs like rubella, mumps, measles, • There are drugs that causes agglutination
influenza, parainfluenza, HBV, herpesvirus, and rupture of cells
adenovirus and respiratory syncytial virus ▪ Transfusion reaction
▪ Patient serum incubate with viral preparation then • IgG and IgM Ab: Type 2 hypersensitivity
if Ab is present combine with viral particles and o The test called DIRECT because RBC are tested
prevent agglutination directly as they come the body
o RBC from patient is WASHED to remove any Ab that is
not specifically attached
▪ To clear up proteins and unbound RBCs
o Focus on serology
• INDIRECT ANTIGLOBULIN TEST
o Determine the presence of a PARTICULAR
ANTIBODY in a patient or it can be used to type patient
RBC for specific blood group Ag
o TWO STEP PROCESS:
▪ Washed RBC and ANTIBODY are allowed to
combine at 37c and then RBC are washed again
• 5. COAGGLUTINATION to remove any unbound. Then AHG is added, a
o Co = companion visible reaction occur where Ab has been
o Controversial specifically bound
o Using bacteria as the inert particles to which Ab is o Test used to check presence of clinical alloantibody in
attached patient serum when performing compatibility testing for
o S. aureus contain Protein A absorb Fc of Ab, active blood transfusion
sites face outward and capable in reacting, with o Almost the same with direct but must maintain
specific Ag temperature
o Exhibit greater stability than latex particles ▪ Laborious and time consuming
o Use to detect strep., Neisseria meningitidis, N. o Done in Blood Bank
gonorrhoeae, V. cholerae, and H. influenzae
o If bacteria are not colored and equation sometimes
react sometimes difficult to read

IMMUNOGLOBULIN
• Antigen stimulate B lymphocyte and undergo differentiation;
the end product is ANTIBODY OR IMMUNOGLOBULIN
ANTIGLOBULIN – MEDIATED AGGLUTINATION o Product when B cell is stimulated and transformed into
plasma cells
• ANTIHUMAN GLOBULIN TEST = COOMB’S TEST
• Are glycoCHONs found in the serum portion of the blood
o Technique that detects NONAGGLUTINATING
• Composed of 82 to 96% polypeptide and 2 to 14%
ANTIBODY by means of coupling with the second Ab
carbohydrate
o Widely used procedure in blood banking
o Highly protein
o Agglutination takes place the AHG able to bridge the
distance between cells that IgG alone cannot do • In electrophoresis at pH 8.6 appears in gamma y band
o The strength of reaction is proportional to the amount o Can separate the 5 main proteins
of Ab coating the RBC ▪ Albumin
o Done at the later phases of crossmatching ▪ Alpha 1 and 2
▪ Beta and Gamma Globulins
• DIRECT ANTIGLOBULIN TEST
o Demonstrate IN VIVO attachment of Ab or complement • Gamma globulins can be separated in an
to an individual RBC alkaline nature and can identify GMADE
o Test serve an indicator of: o Unique individually but have common
▪ Autoimmune hemolytic anemia feature
• Red cells has 120 days • 5 major classes IgG, IgA, IgM, IgE and IgD = unique
o Once it dies less than this, there is properties but share many common features
possibility of hemolytic anemia (cell o IgG and IgM = high in proteins (96%)
wall problem) o IgA =90%
▪ HDN o IgE and IgD = 82 – 85%
• Rh of mother is not compatible with the fetus • Considered humoral branch of immune response

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o Can cater natural and cellular immunity

▪ Abs are humoral that came from cellular immunity
• Essential role in Ag recognition and biological activities
related to immune response like opsonization and
complement activation
o Ag could be blood cells, tissue cells, other latex
particles or microorganisms that will invite the
activation of opsonization and complement
o Immunoglobulins will follow classical pathway as they
are antibody – dependent
▪ MBL is usually catered as an option
▪ Classical has completes set of protein
complement IMMUNOGLOBULIN G
• Predominant in human, 75 – 80% of total serum
CLEAVAGE WITH PAPAIN o Most powerful
• Porter’s wok use of proteolytic enzyme PAPAIN which • Longest half – life, 23 – 25 days account for predominance
cleave IgG into 3 pieces with equal size, having same • Four subclass: IgG1 - 67% / 4, IgG2 - 22% / 6, IgG3 - 7% /
sedimentation coefficient of 3.5 S and approximately 7 and IgG4 - 4% / 4 (unique to this immunoglobulin)
molecular weight 45,000 – 50,000 d o IgG1 is predominant in terms of quantity but IgG3 has
o Research scientist who tried to challenge IgG (one of the greatest disulfide bonds
the most stable and predominant in high o They differ mainly in number and position of disulfide
temperature/warm environment) by using papain and bridge between the y chain
pepsin o Variability in hinge region affect the ability to reach
▪ When he used papain, he was able to identify 2 antigen and ability to initiate biological function like
products (Fc and 2 Fab fragments)
complement activation
• 1. Fc fragment (fragment crystallizable)
• IgG3 has largest hinge region and number of disulfide
o Where complement will complement (C1qrs)
bonds, hence, more efficient in binding complement
• 2. The remaining two identical fragment were found to have
followed by IgG1, IgG2 and IgG4 have shorter hinge
Ag – Ab binding capacity named Fab fragment (fragment
segments tend make them poor mediators of complement
antigen binding)
activation
o IgG4 is the least to activate the complement

PEPSIN DIGESTION
• This proteolytic enzyme was found to cleave IgG at the
carboxy-terminal side interchain disulfide bonds
IgG Antibody Isotype Comparison
• Yielding single fragment with MW 100,000 d and all the
antigen – binding ability known as F (ab)2 PROPERTY IgG1 IgG2 IgG3 IgG4
• An additional fragment called Fc, similar with Fc except Molecular Weight (kDa) 150 150 170 150
disintegrated into smaller pieces Amino acids in hinge region 15 12 62 12
Inter – H chain disulfide bonds 2 4 11 2
Half life (days) 14 - 14 - 7 14 –
21 21 21
Mean adult serum level (g/l) 6.98 3.8 0.51 0.56
Relative abundance (%) 60 32 4 4

• Function:
HINGE REGION o 1. Providing immunity for newborn since it crosses the
• Located between CH1 and CH2, high content of proline (for placenta
flexibility – ability to bend and let the two antigen – binding ▪ IgG can be transferred from mother to fetus
site operate independently) and hydrophobic residue o 2. Fixing complement
o CH1 – part of Fab ▪ Especially the classical pathway
o CH2 – part of Fc o 3. Coating Ag enhanced phagocytosis (opsonization)
o Proline – amino acid o 4. Neutralizing toxin and viruses
o 5. Participating in agglutination and precipitation
• Flexibility assist in effector functions such as initiation of the
reaction
complement cascade
▪ But if you let IgG choose, it will choose
• G, D, A has hinge region while M and E do not have,
precipitation
however the CH2 domains of these latter two chains are
• All IgG subclass appear to cross placenta, IgG2 is least
repaired in such ways as to confer flexibility of the Fab arms
efficient

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• Fc region of IgG have receptor with macrophages, • Primary response Ab, first to appear after antigenic
monocytes and neutrophils stimulation, first to appear in maturing infant
• Enhance contact between antigen and phagocytic cells and o First to increase in infection
increase efficiency in phagocytosis, IgG1 and IgG3 good in o M – meron
initiating phagocytosis, binding most strongly to Fc receptor ▪ Followed by G – galing, gone
• IgG high diffusion coefficient allows to enter extravascular ▪ IgG and IgM – still in course of infection
spaces, it is distributed almost equally between • Synthesized as long as antigen remain present because
intravascular and extravascular spaces thus it plays major there is no memory cell for IgM
role in neutralizing toxin and viruses • Primary response – IgM = long log phase, secondary
• Agglutination and Precipitation reaction take place in vitro, response – IgG = shortened lag phase and much more
not known significant in vivo rapid increase in antibody titer
• IgG is better in precipitation than agglutination due to
precipitation involve small particle = IgG small while FUNCTION
agglutination clumping large particle like RBC = IgM is • 1. Complement fixation
much more efficient than IgG • 2. Agglutination
o IgG is better in precipitation than agglutination because o IgM wants cold and agglutination is on the cold side
it is small • 3. Opsonization
o IgM is better in agglutination • 4. Toxin neutralization
o No virus neutralization
IMMUNOGLOBULIN M ▪ Only present in IgG
• Known as macroglobulin, sedimentation rate 19S, MW • Efficient triggering classical complement pathway single
970,000 molecule initiate reaction result multiple binding site
o Big o Likes classical pathway
• Half – life 10 days, account 5 - 10% in serum
• If treated with mercaptoethanol, it dissociates into 5 7S IMMUNOGLOBULIN A
units, MW 190,000 • 10 – 15% circulating appear monomer MW 160,000,
o 5 individual units held together and can be dissociated sedimentation rate 7S migrate between mu and beta region
individually in electrophoresis
• MW of H chain is 70,000 with 576 amino acids • H chain called alpha chain MW 55,000 – 60,000 with 472
o Has a lot of protein but few carbohydrate content amino acids
• Pentamer form found in secretions, while monomer form o Unique to this immunoglobulin
occurs in B cell surface o Lesser proteins, more carbohydrate content
o Only extravascular and cannot be found intravascular • Two subclasses: IgA1 and IgA2: they differ in 22 amino acid
• 5 monomer unit held together by J / Joining chain = content, while 13 of it in the hinge region is deleted in IgA2
glycoCHON with cysteine residues. Linkage point of make it more resistant to bacterial proteases that are able
disulfide bonds between to adjacent monomer (carboxy – to cleave IgA1
terminal end) o IgA2 has only 9 amino acids in the hinge region
▪ Reason why it is weaker than IgA2
• IgA2 predominant in secretion at mucosal surface and IgA1
in serum
• Not capable of fixing complement by classical pathway but
aggregation of immune complexes may trigger alternate
pathway
o Only if triggered
o IgA = Alternative
• Lack of complement activation actually assist in clearing
• The picture should only be five units (instead of 6) antigen without triggering inflammatory response thus
o CH4 – where complement binds minimizing tissue damage
o CH3 – in IgG (where complement binds) • IgA receptor for neutrophils, monocytes and macrophage.
Binding to these site trigger respiratory burst and
• J chain may initiate polymerization by stabilizing Fc degranulation, occur in both serum and secretory IgA thus
sulfhydryl group -, J chain MW 15,000 / 1 J chain per capable in acting opsonins
pentamer • Ex. Success in oral Sabin vaccine induces IgA
• IgM assume starlike shape with 10 functional binding site, demonstrates effectiveness as protective role on mucosal
only five is used unless antigen is extremely small but its surfaces
high valency contravenes the fact it tend to have low affinity o Known for rotavirus
for antigen ▪ As this may cause diarrhea
o Bigger chance to attach to antigen • May lead to electrolyte imbalance
o Common in blood typing (5 units with 10 binding sites)
• Large size, it is mainly found in intravascular pool and not
in other body fluid / tissue
o Intact: intravascular
o Separated individually: extravascular
• Cannot cross placenta
o Due to its size

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• IgA1 has only 1 unit, while IgA2 has two unit (called it as • Incapable of crossing placenta
dimer) connected by J chain • Shortly after synthesis it attaches to basophils and tissue
o IgA2 cannot be transmitted from placenta mast cell means high-affinity Fc RI receptor which is only
found in this cells
IMMUNOGLOBULIN A2 o For allergic reaction
• Keep antigen from penetrating in the body since mucosal
surface major point of entry of pathogen
• Has J chain MW 15000
• Secretory IgA synthesized in plasma cell in MALT and
released in dimeric form
o MALT has many IgA2 known as secretory IgA
• Synthesized much greater than IgG by 3 grams per day in
average adult in secretory form, serum concentration is
lower
• IgA2 as dimer along respiratory, urogenital and intestinal • Like IgM
mucosa appear in milk, saliva, tears, and sweat o No hinge region, it flexes through CH2 like IgM
• Binds in the CH3 domain on the Fc region. Leaves the
IMMUNOGLOBULIN D antigen – binding site free to interact with specific antigen
• 1965, found in patient with multiple myeloma • Plasma cell produce IgE located primarily in lungs and skin
o Accidentally • Mast cell found in skin, respiratory and alimentary tract bind
o MM: Bence Jones Protein specific antigen cascade event initiated results to
▪ Protein that does not agglutinate at 100c degranulation of mast cell release vasoactive amines like
▪ Related to bone; ALP is affected heparin and histamine induce type 1 immediate
hypersensitivity or allergic reaction like hay fever, asthma,
• Isoenzymes: Regan and Nagao ALP
vomiting, diarrhea, hives, and life – threatening
• Extremely scarce less than 0.001%, synthesized low level anaphylactic shock
• Half – life 2 – 3 days, MW 180,000 migrate as fast as y o Anaphylactic shock could distort normal function
immunoglobulin
• Appear to be nuisance antibody, may serve as protective
• Delta H chain MW 62,000 appears extended hinge region role by triggering an acute inflammation reaction that
consisting 58 amino acids – more susceptible to proteolysis recruits neutrophil and eosinophil in area to help destroy
reason for short half-life invading antigen that have penetrated IgA defense
o In between heavy chain of IgA and IgM
• Play major part in the destruction of large antigen such as
o Hinge region has a lot of amino acid (proline) parasitic worm that cannot be easily phagocytized
• Found in the surface of immunocompetent but o It cannot phagocytize these parasites; needs help of
unstimulated B lymphocytes IgG
• Second to appear after IgM ▪ They can only phagocytize protozoans
o Appears shortly
▪ For those that cannot really be phagocytized,
• Play role in B-cell activation, maturation and differentiation anthelminthic drugs may be needed
o Function: trigger antibody production
• Does not appear a protective function, not bind
complement, neutrophil, macrophage, cross placenta
o Does not complement, no receptor on neutrophil,
macrophage, monocyte

CYTOKINES
• A cell
• Small soluble CHON that regulate immune system in both
innate and adaptive response to infection
o Natural and adaptive immunity are still linked to
cytokines
• Chemical messenger, produced by different cells
IMMUNOGLOBULIN E (leucocytes)
• Least abundant in serum 0.0005%, 8S, MW 190,000 o Mostly the monocytes and macrophage produce it
▪ Some are neutrophils and other cells
• H chain composed of 550 amino acid
• Induced in response to specific stimuli: flagellin, bacterial
• Disulfide bond 1H-L chain and 2 H-H chain
lipopolysaccharides and other bacterial products
• Most heat labile, heating 56c 30 min – 3 hour
o Flagellin: bacteria and parasites
conformational changes and loss of ability to bind at target
cells o Other bacterial products: like glycopeptidoglycan
o The more heated, the more it loses its ability to target ▪ Cytokines will respond quickly with these stimuli
cells • Do not act alone but in conjunction with many other
• Not participate in complement fixation, agglutination, and cytokines that induced during the process of immune
opsonization activation

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o Since it will regulate the function o IL – 1a and IL – 1B: proinflammatory cytokines

• Regulates leucocytes activity and leads to the elimination of produced by monocytes and macrophages
the infection o IL – 1a
▪ Remains intracellular within monocytes and
CYTOKINE STORM macrophages, rarely found outside in these cells
• Extreme circumstances, massive overproduction and • Phagocytic cell eating function
dysregulation produces / leads to shock, multiorgan failure ▪ Released after cell death and help attract
or death inflammatory cells to areas where cells and
o Should only be at a specific amount as excess will tissues are being killed or damaged
lead to this • Abundant outside the cell
▪ Most potent among the two
o IL – 1B
AUTOCRINE STIMULATION
▪ Responsible for most of the systemic activity
• Affecting the same cell that is secreted attributed to IL – 1, including fever, activation of
• B cell to stimulate another B cell phagocytes and production of acute phase CHON
• Mostly used for fever
PARACRINE STIMULATION ▪ Cleaved intracellularly to an active form that is
• Affecting a target cell in close proximity secreted by monocytes
• Liver has problem, and will stimulate gallbladder to release o IL – 1RA (receptor antagonist)
cytokines ▪ Produced by monocytes and macrophages
▪ Acts as antagonist to IL -1 by blocking IL – 1
PLEIOTROPIC receptor and limiting the availability of receptor for
• Having many different effects: Cytokines ability to alter IL – 1
expression of numerous genes ▪ Helps regulate the physiologic response to IL – 1
• Liver has problem and any of the organs present in your and turn off the response when no longer needed
body could also stimulate cytokine ▪ Acts as regulator aside from chemokines and IL –
• Best to have 6
o But it depends on the stages of infection • To avoid cytokine storm
▪ Usually starts with autocrine to paracrine to o Increased fever up to 40c: may lead to
pleiotropic anaphylactic shock
▪ Avoid this as it is damaging to the
CYTOKINES IN THE INNATE IMMUNE RESPONSE brain
• Physical symptoms attributed to: fever, swelling, pain,
cellular infiltrates into damaged tissue TUMOR NECROSIS FACTOR
• Non-specific but occurs within hours of first attack with • Isolated in tumor cells, induced lysis in the cells
microorganisms o Kill gram negative bacteria and lyse tumor cells
o But unsure if it will succeed because it is nonspecific ▪ Prevents increase of size or content
• Plays a crucial part in recovery from infection o TNF – a
• Function is to recruit effector cells to the area ▪ Production presence of lipopolysaccharide found
in gram negative bacteria
• CYTOKINES INVOLVE ARE:
▪ Secreted by monocytes and macrophages –
activate T-cells ability to induce MHC class II.
INTERLEUKIN – 1 (IL – 1) Vascular adhesion molecules and chemokines
• Endogenous pyrogen, induces fever in acute phase • Controlled by chemokines
response through its action on the hypothalamus – acts as ▪ In higher levels – TNF leads to: SEPTIC SHOCK
thermostat, sets for higher level • Cytokine storm
o Promotes fever ▪ And large amounts due to gram negative bacteria
o Pyrogen promoter leads to:
• Altered body temperature, may serve to inhibit the growth • 1. Decreased blood pressure
of pathogenic bacteria, viruses and increased lymphocyte • 2. Reduced tissue perfusion
activity o Fluids
• Induces the production of vascular cell-adhesion molecules • 3. Disseminated Intravascular Coagulation
as well as chemokines and IL – 6 (DIC)
o Chemokines and IL – 6 will signal IL – 1 when to stop o Clots
o Selectins – makes the WBCs stick to the area of
• 4. Uncontrolled bleeding
infection
o Vit. K and coagulation cascade will be
• Chemokines and cell – adhesion molecules: attract and affected
assist leucocytes to enter the inflamed area by diapedesis ▪ Prominent, consist of 19 peptides
o Diapedesis: movement of WBCs from one area to ▪ Exist in both membrane bound and soluble forms
another = causes vasodilation and increased
▪ Can cross cell wall/vascular wall vasopermeability
▪ Penetrate from vascular wall lining ▪ Soluble Form of TNF – a
• Induces the production of CSF (e.g., for meningitidis, • Derived from membrane bound proteolytic
bacterial, viral infections) in the bone marrow, increased cleavage with TNF – a converting enzyme
available number of phagocytic cells that respond to
• Unstable, short half – life
damaged tissue
o Mixed in the fluid
• Types of Interleukin – 1 (IL – 1)

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▪ Membrane Bound TNF – a: mediate all cytotoxic o Autoimmune inflammation

and inflammatory effects though cell to cell o Cancer
contact o Homing of lymphocytes to all lymphoid tissues
• Much effective ▪ If lymphocytes visit secondary lymphoid organ
• Additional Information once or twice, sometimes they do not go out,
o TNF – a and IL – 1: present in RA = Rheumatoid thus, this cytokine will tell it is time to go out
synovial fluid and synovial membrane of the patient • Classified according to N-terminal cysteine residues (the
▪ Patients with autoimmune diseases more cysteine, the faster is its motility; faster chemotaxis)
▪ Patients will be collected with synovial fluid and o Alpha / CXC: single amino acid between first and
will check for the rheumatoid factor second cysteine
o TNF – R1 (receptor 1) o Beta / CC: has adjacent cysteine residues
▪ Most of the tissue binds with the THF – a o C chemokines: lacks one of the cysteine
▪ Mediator of TNF – a signal in most cells o CX3C: has 3 amino acid between cysteine
▪ All cells have this
• Initiation and development of inflammatory response in
o TNF – R2 (receptor 2): most in epithelial cells and cells
numerous disease process
of immune system, activated by membrane bound form
• 40 chemokines and 30 chemokine receptor are currently
of TNF – a
identified
▪ Only for epithelial cells (squamous, columnar,
o Receptors will control to avoid overproduction that may
cuboidal)
lead to cytokine storm
• Facilitates leucocytes and activation chemokine receptor, in
INTERLEUKIN – 6 (IL – 6)
turn integrins or cell adhesion is activated leads to adhesion
• CHON produced by lymphoid and nonlymphoid cell types to endothelial cells
• Released in response to lipopolysaccharide and play and o Selectins will help this
important role in acute phase reaction and adaptive • TNF – a and IL – 6 induce chemokine production in
immune response inflammatory response
• Pleiotropic cytokines affect inflammation, acute phase • Chemokine receptor
reaction, immunoglobulin synthesis and activation of B and o CXCR4 and CCR5 utilized by HIV as coreceptors for
T cells infection of CD4+ T lymphocytes and macrophage
• Related to all general cells o Addition of SDFI (ligand for CXCR4) and Rantes
• Expressed in variety of normal and transformed cells: (ligand for CCR5) can block the virus ability to bind and
o T cells enter T cells and delay the progression to full blown
o B cells AIDS
o Monocyte cells ▪ TX for HIV
o Macrophages
o Fibroblasts TRANSFORMING GROWTH FACTOR BETA (TGF – B)
o Hepatocytes • 3 isoforms: TGF – B1, B2, and B3
o Keratinocytes • Induced growth arrest in tumor cells
o Astrocytes • Induced antiproliferative activity in variety of cells
o Vascular endothelial • Active TGF – B
o Various tumor cells o Regulator of cell growth, differentiation, apoptosis,
• IL – 6 stimulates: migration and inflammatory response
o B cells to proliferate and differentiate into plasma cells o Acts as a control to help regulate down the
and induce CD4+ (T helper cells) inflammatory response when no longer needed
o T cells to produce greater quantities of both pro and • Function – depending on developmental stage of affected
anti – inflammatory cytokines (T cytotoxic and T cells
suppressor cells) o Activator – acts as autocrine inhibitory factor for
• IL – 6 receptor consists of: immature thymocytes
o IL – 6Ra (specific receptor) o Inhibitor – inhibits the activation of macrophages and
o gp 130 (common signal – trans during receptor subunit growth of types of somatic cells and functions of
utilized by several cytokines) mature T cells as anti-inflammatory
▪ To avoid cytokine storm
▪ Control to avoid cytokine storm
• IL – 6 binds with IL – 6RA
• Production of TGF – B by T Helper Cells: Recognize its
o Dimerization of gp 130 – causing conformational
important role in the establishment of oral tolerance to
changes that expose tyrosine residues in intracellular
bacteria normally found in the mouth
portion, series of phosphorylation reaction, genes
o Infections found in mouth can be controlled by T helper
acute phase CHON: CRP, C3 and fibrinogen is
(T. tenax, E. gingivalis, Herpes)
activated as well as interferon regulatory factor (IRF –
1) and T-cell / B-cell are turned on activated
INTERFERONS
CHEMOKINES • Interferes viral replication
o Type 1 interferon (IFN – a and IFN – B)
• Enhance motility and promote migration of WBCs towards
the source of chemotaxis • Produced by dendritic cells and induce production of
o We want positive chemotaxis CHONs and pathways – directly interfere with viral
replication and cell division – this helps limits the infection
• Leucocytes is regulated by activities of chemokines
to one relatively area of the body
including
o Response to infection • IFN – 1

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o Activates NATURAL KILLER CELLS and enhances • 2. Cytokine stimulation by IL – 12 and IL –

expression of MHC class I CHONS 18 or even without number 1. How? CD8+
▪ Purpose: increased recognition and killing of virus lymphocytes activate IFN – y
– infected cells ▪ Stimulate Ag presentation by MHC I and MHC II
o Active against certain malignancies and other • Activated during tissue compatibility
inflammatory processes. FOR INSTANCE: o MHC I – A, B, C (Main)
▪ IFN – B: effective in treating multiple sclerosis o MHC II – DP, DQ, DR (Secondary)
▪ IFN – a: treat Hep. C, Kaposi’s sarcoma and ▪ Matched during tissue typing to
certain leukemias and lymphomas check compatibility
• Part of natural innate immunity ▪ Strong stimulator of macrophage and boost
tumoricidal activity
CYTOKINES IN THE ADAPTIVE IMMUNE RESPONSE • Like TNF and TGF – B but these are innate
• MAINLY SECRETED BY T cells (Th cells) and affect T and as compared to IFN – y
B cell function more directly o IL – 2 (T cell Growth Factor)
• 3 subclasses of Th cells: T cell receptor + Ag ▪ Produced by Th 1 cell
• Protects from intracellular bacteria
INFLUENCED ▪ Drives the growth and differentiation of T and B
BY SPECTRUM cells and induces lytic activity of NK cells
OF CYTOKINE ▪ Same as IFN – y – induces macrophage
activation and delayed type hypersensitivity
1. Th 1 IL – 12 By dendritic cells, IFN – ▪ Help generate IgG1 and IgE producing cells
responsible for cell y
• IgG1 – most predominant
mediated immunity
• When you ate something that is toxic, this is
2. Th 2 IL – 4 Antibody – mediated IL – 4
also activated
immunity
▪ Transcription of gene for IL – 2 and IL – 2R begin
3. T reg IL – 10 Regulate the activity IL – 10 within hour of TcR ligation (problem in
(regulatory of Th1 and Th2 cells transcriptions/mutations)
cells) • IL – 2R consist of a, B, y, or B and y subunits
• B and y subunit = increased affinity of
TH 1 CYTOKINES receptor IL -2, 7 responsible most signal
• Stimulated production of IgG1 and IgG3 transduction through receptor
• Opsonizing and complement fixing Ab by Ag – activated B • y subunit
cells o Shared by IL – 7, 9, 15, and 21
o Complement cascade ▪ IL that can have autoimmune,
• Examples are the following: immunoproliferative problems
o IL – 12 o Demonstrate by individuals with
▪ Produce by dendritic cells (when damaged) mutation X – linked combined
response to mycobacterium, intracellular bacteria immunodeficiency syndrome, lack of T
and viruses and B cells
• IL – 12 will always interact to foreign
particles entering the body TH 2 CYTOKINES
▪ Produced by macrophages and B cells, multiple • Regulate immune response
effector for T cells and natural killer cells (NK) • Ex. Allergies, Autoimmune disease, Fighting off parasites
▪ Increased cytotoxic ability of NK cells • Main: IL – 4
• IL – 12 is produced because of this because • IL – 4
they want to destroy intracellular o Cytokines regulating Th 2 immune activities and helps
microorganisms driven Ab response to disease
▪ Activation of Th 1 cell induce high level o Express on lymphocytes and nonhematopoietic cell
expression of IFN – y ▪ Nonhematopoetic – lungs, liver are IL – 4
• IFN – y and IL – 12 are co working to fight producers
off these intracellular organisms o IL – 4 activity to T cell turns on to generate Th 2 cell
▪ Adaptive – needs to acquire a disease first before ▪ 7 turns off the gene to promote Th 1
harboring this cytokine • Enhance by chemokine MCP - 1
o IFN – y o Promotes production of IgG2 and IgE, activation of
▪ Produced by Th 1 cell (mature) affects RNA = > eosinophils – response to allergy and parasite
200 genes – needed for the activation of o IL – 13 same properties with IL – 4 – induce worm
• 1. CD4 + Th 1 cells expulsion and favor IgE class switching
• 2. CD8+ cytotoxic lymphocytes ▪ Work together
• 3. NK o Induced MHC – I, IL – 5, 13 and costimulatory molecule
• 4. Bactericidal activity B7.1 and B7.2
o Betalysin, Properdin – nonspecific • IL – 10
• 5. IL – 12R and IL – 18R o Has anti – inflammatory and suppression effects of
▪ 2 means by: the Th 1 cells
• 1. Litigation of TCR (T cell receptor) by MHC o Produced by monocytes, macrophages, CD8+ T cells
peptide Ag and Th 2 CD4+ T cells
o Inhibit Ag presentation by macrophage 7 dendritic
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o Induces production of MHC II on B cells o Drives developmental of basophils and masts cells
o Inhibition of IFN – y production via suppression of IL – while addition of IL – 5 to IL – 3 and GM – CSF drives
12 synthesis and promote Th2 cytokine developmental of eosinophils
o IL – 10 serve as an antagonist to IFN – y – down ▪ Especially in cases of allergies and parasitic
regulator of immune response infections
o T regulator cells
ERYTHOPOIETIN
CYTOKINE ASSOCIATED WITH T REGULATORY • Regulates production of RBC in the BM but is primarily
CELLS produced in the kidneys
o When a patient has problem in kidney, EPO production
• T regulatory cells (T reg) = (CD4+ T cells) = CD4+, CD25+
is also affected
T cells secreted in the thymus establish peripheral
▪ Expect fewer RBCs produced
tolerance to wide variety of self Ag like allergies, tumor Ag,
transplant Ag and infectious agents • CHON with 34 KD monomer with high CHO content
• T reg affect T cell activity by suppressing its activity and • Glycosylation of CHON required for:
o EPO – B – same in both amino acid sequence
other T cell
o How? Through the action of TGF – B, it suppressing o EPO – a – clinical use in FDA, prescribed to improve
RBC count for individual with anemia and those with
the activity of T cells
cancer undergone radiation and chemotherapy
o T reg is produced by thymus ▪ Also same in both amino acid sequence
• T reg found in transplanted tissue and help establish • RBC proliferation induced by EPO, it improves oxygenation
tolerance to the graft by host immune system through of the tissues and eventually switches off the EPO
alteration of Ag presentation • NV of EPO: 5 – 28 U/L but interpreted with the relation to
o Prevent GVHD hematocrit
▪ But should not depend on this only but rather o Associate it with hematocrit
have tissue compatibility done with effort as it is ▪ Hematocrit is much lower in females
the most important as cytokines are controlled • EPO increased on thousand fold during anemia
with medications
• T reg (CD4+) exert their activities suppressive on both Th1 ANTI-CYTOKINE THERAPIES
and Th2 by producing IL – 10, TGF – B or IL – 5 • DNA techniques production of humanized monoclonal Ab =
• MODE OF ACTION: HOW? less immunogenic and function as cytokine antagonists
o IL – 10 inhibit costimulatory molecule by Ag presenting • Example:
cells (APCs) and suppression / inhibition of
proinflammatory cytokines INFLIXIMAB (REMICADE)
▪ Promote organ attack • Blocks the activity of TNF – a and Crohn’s disease
o TGF – B or IL – 5 down regulate the APCs and blocks o Crohn’s disease – problem in the intestine
proliferation and cytokine production by CD4+ T cells =
• Single dose alleviates symptoms and reduce swollen joints
prevent chronic inflammation immune response
in RA patients up to 4 weeks
▪ Done in transplanted organ as they are vulnerable
o RA is different from gouty arthritis
to the recipient’s body
• Transplanted organs are still foreign which
ETANERCEPT (ENBREL)
is why the patients are given
immunosuppressive drugs • Bind with TNF – a and blocks its activity
o Downgrade the immune system to • Lasts for 4 – 8 days
avoid attack to transplanted organ • Binds at the HC constant region of IgG1
• Less effect compare with Remicade
COLONY STIMULATING FACTORS • This is given if you have side effects with Remicade
• Acts on the bone marrow cells at different developmental o Adverse effect may be lesser with days compared with
stage and promote specific colony formation for cell Remicade
lineages
ZENAPAX
IL – 3 • Studies used in the mice
• Induces CD34++ bone marrow stem cell to form T and B • Under 3rd clinical trial
cells o No brand name yet
• Direct immature bone marrow stem cell to develop into • Directed to IL – 2Ra
RBC, platelets and other WBCs • Ab with low affinity, extend half life but reduced
immunogenicity change to Ab with high affinity, long half life
GM – CSF (GRANULOCYTE – MACROPHAGE CSF) and not immunogenic
• Drives differentiation toward other WBCs
• If M – CSF is activated, cell becomes macrophages and COMPLEMENT
also increased phagocytosis, chemotaxis and production of • Heat labile
monocytes • Enhance host defense mechanism against foreign cells
• If G – CSF is activated, cell becomes neutrophils, enhance • Action of antibody in destroying microorganism
function of mature neutrophils, affects survival, proliferation • Promote opsonization
and differentiation of all cell type in neutrophil lineage • Lysis of foreign cells
o Granulocytes: NEB • Immune complexes
• IL – 3 IN CONJUNCTION WITH GM – CSF • Complement activation is regulated because activation lead
to inflammation and tissue damage

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PLASMA COMPLEMENT CHON ▪ Trigger by bacterial cell wall

• Synthesized in the liver except C1, which is produced by (lipopolysaccharides), fungal wall, yeast and
intestinal epithelial cells virus
• Monocytes and macrophages by C1, C2, C3, and C4 o C3 – not stable, once activated binds with Factor B
93,000 d
THREE PATHWAY REACTION o C3b or iC3 – causes conformational changes
• 1. Classical pathway – involve 9 CHON Ag – Ab reaction susceptible to cleavage of serine proteases
• 2. Alternative pathway or Properdin pathway o C5 convertase to C3bBb3b to MAC
• 3. Lectin pathway – Antibody independent
LECTIN PATHWAY
CLASSICAL PATHWAY • LECTIN – CHON bind with CHO – innate and acquired
• RECOGNITION UNIT immune response
o C1 – mw 740,000 d (C1r and C1s) o MBL (mannose – binding or mannan binding lectin)
▪ C1q (1 subunit – bind with Ab), mw 40,000d – 6 ▪ Binds to mannose and related sugar and Ca
strands with 6 globular head dependent
• Strand = composed of homogenous ▪ Found in glycoprotein or CHO – microorganism:
polypeptide “Alanine” allow the stem to bacteria, yeast, viruses, and parasites
bend ▪ Acute Phase – produce in liver, normal in serum
▪ C1r and C1s – generate substrate enzyme, and increase initial inflammatory response
serine protease proenzyme “zymogen,” complex ▪ Important role during infancy defense, loss of
S – shaped maternal Ab and acquisition of full pledge Ab
▪ C1s-C1r-C1r-C1s, figure of 8 wrap around C1q response to pathogen
o C1q binding occur (conformational change) recognize o MBL (similar to C1q) associated with 3 MBL - serine
Fc region (2 globular head attached protease (MASPS) 1, 2, and 3
▪ IgG2 – CH2 ▪ MBL binds to cell surface
▪ IgM – CH3 ▪ MASPS 2 – autoactivate – cleavage of C4 and
o C1S AND C1r – convert to active enzyme but C1r C2
result to autoactivation • While, MASPS 1 and 3 function is unclear
o C1s – cleaves with C4 -> C4a process open thioester ▪ C1s to C4 to C2 to Activation Unit
active site
o C4b binds with C1 Ag cluster 40 nm radius C1:C4 AUTOIMMUNITY
1:30 attached • Auto – you/host
• ACTIVATION UNIT • Immunity – making of antibody
o C2 combine with C4b with Mg ion and cleaved by C1s o Autoimmunity – you make an antibody against yourself
60 nm radius C2a 70,000 d and C2b 34,000 resulting ▪ One of the rare scenarios and one of the crucial
to C4b + C2 = fluid phase phases as your body knows your strong and weak
o C4b + C2a = C3 convertase C4b2a combine, not links
stable half life of 3 min and 15 secs very quick ▪ Two problems: control antibody production and
o C3a removed by cleavage thioester is exposed suppress the immunity
o C3b most significant step complement activation
capable binding hydroxyl, CHO, CHON hydrolyzed AUTOIMMUNE DISEASES
with H2O, shelf life 60 sec if not bond with antigen • Are conditions in which damage to organs or tissues results
from the presence of autoantibody or autoreactive cells
• MEMBRANE ATTACK COMPLEX (MAC)
o Because it damages self and its own organ/s
o C3b -> C5 convertase C4b2a3b
▪ Organ – specific
▪ C5b labile rapid inactivate unless bind with C6
• Much better as it is only specific to that
o C5a attach to cell membrane
organ
▪ Splitting of C3 and C5 – most significant
▪ Organs – systemic
biological in complement system
▪ C6789 • Thought to be caused by the loss or breakdown of self –
tolerance
• C6 – 110,000 d C56
• In the early 1900s, Ehrlich described this phenomenon as
• C7 – 110,000 d trimolecular complex “horror autotoxicus,” literally meaning “fear of self-
increase affinity in lipid constitute poisoning”
• C8 – 150,000 d attaches and make a small • Several other mechanisms are thought to contribute to
hole in membrane = LYSIS and loss of autoimmunity
potassium in the cell o Release of sequestered antigens
• C9 – accelerates the process o Molecular mimicry
o C5b678 = capable of lysing RBC o Polyclonal B cell activation
o MAC completed • Besides the factors mentioned previously, several others
must be taken into account in the etiology of autoimmune
ALTERNATIVE PATHWAY diseases. Some of these are defects in the immune system,
• Pathogen can be destroyed in absence of antibody by the influence of hormones, and environmental conditions.
innate or natural immunity Defects in natural killer cells, in the secretion of cytokines,
o Properdin (CHON) 5 – 15 ng/ml in serum in apoptosis (or killing of cells), and in complement
components all may contribute to the loss of self – tolerance
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o Actively producing antibodies to the point that it • Joint involvement

cannot be controlled by the body damaging NK cells o Most frequently reported manifestation; patients with
o Destroying complement leading to self – tolerance SLE are subject to arthritis
• Autoimmune diseases can be classified as systemic or • Skin manifestation
organ – specific. There is often a good bit of overlap o An erythematous rash may appear on any area of the
between the two, because some diseases that start out as body exposed to UV light
organ – specific later affect other organs o Appearance of the butterfly rash across the nose and
cheeks
SPECIFICITY DISEASE TARGET TISSUE ▪ When exposed to sunlight
▪ Erythematous rash
Organ - Hashimoto’s Thyroid
• Renal Involvement (SLE usually targets kidney)
Specific thyroiditis
o Diffuse Proliferative Glomerulonephritis (DPGN)
Grave’s disease Thyroid
o Most dangerous lesion
Pernicious Gastric parietal o Cellular proliferation in at least 50% of the glomeruli
anemia cells ▪ Glomerulus’ important function in the body:
Addison’s Adrenal glands filtration
disease • It is very deadly when SLE attacks it
Type I Diabetes Pancreas o 20% of individuals with DPGN will die or develop end –
Mellitus stage renal disease within 10 years of diagnosis
Myasthenia Nerve – muscle • Cardiac Involvement (very rare)
gravis synapses o Pericarditis
Multiple sclerosis Myelin sheath of nerves ▪ Inflammation
o Tachycardia
Autoimmune Red blood cells o Ventricular enlargement
Hemolytic ▪ Either right or left
Anemia o Pleuritis with chest pain
Idiopathic Platelets ▪ Thought it could only be angina pectoris but is not
thrombocytopenic
purpura CLINICAL DIAGNOSIS
Goodpasture’s Kidneys, lungs
• Unique to SLE is this clinical diagnosis
syndrome
• Malar rash
Rheumatoid Joints, lungs, skin
Arthritis • Discoid rash
Scleroderma Skin, gut, lungs, kidneys • Photosensitivity
• Oral ulcers
Systemic Systemic Lupus Skin, joints, kidneys,
• Arthritis
Erythematosus brain, heart, lungs
• Serositis
SYSTEMIC LUPUS ERYTHEMATOSUS • Renal disorders
• Fact: Marcos Sr. died due to this • Neurological disorders
• Represents the prototype of human autoimmune disease • Presence of antinuclear antibodies
chronic inflammatory disease o Screening test for lupus: ANA
• The immune response is directed against a broad range of
target antigens, as the typical patient has an average of IMMUNOLOGIC FINDINGS
three circulating autoantibodies • LE Cell (hematology; done by smearing)
o Has a lot of target organs o A neutrophil that has engulfed the antibody – coated
▪ Resulting in body suffering nucleus of another neutrophil
• The peak age of onset is usually between 20 – 40 years ▪ Abnormal function
o Just common but does not mean you cannot acquire o Appears in vitro, occurs when cells are damaged and
younger than 20 or older than 40 release nuclear material
• Women are much more likely to have SLE than men o HLA antigens play a role in presentation of foreign or
• More common in African Americans and Hispanics that in self-antigens to T and B cells
Whites o Associated with inherited deficiencies of complement
components C1q, C2, and C4
CLINICAL SIGNS ▪ Leading to just use Lectin pathway
• Environmental factors • Drug – induced lupus
o Exposure to UV light o Move chronic form of the disease in that symptoms
▪ UVA usually disappear once the drug is discontinued
▪ UVB ▪ Recurrence will be much invasive; leading to
o Certain medications lifetime medications
o Infectious agents
• First symptoms to appear (very common; general) LABORATORY DIAGNOSIS
o Fatigue
• Antinuclear Antibodies (ANA): are a group of
o Weight loss
autoantibodies that target substances found in the nucleus
o Malaise
of the cell
o Fever o Screening
o Anorexia
o Targets nucleus of cells that are infected

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• Fluorescent Antinuclear Antibodies (FANA) CLINICAL FINDINGS

o The most common and gold-standard method used to • Key symptoms
detect antinuclear antibodies (ANA) in the blood. It is o Morning stiffness lasting at last 1 hour
widely used in diagnosing autoimmune diseases like o Swelling in soft tissue around 3+ joints
systemic lupus erythematosus (SLE) and others o Symmetric arthritis
▪ Like ANA but uses fluorescence dye
o Subcutaneous nodules
▪ Much definitive; highly sensitive and specific
o Positive rheumatoid factor (RF) test
o Radiographic evidence of joint erosions in hands or
wrists
• Systemic symptoms
o Anemia, pericarditis, lymphadenopathy, interstitial
lung disease or vasculitis
o Symptoms start in small joints and progress
symmetrically to larger joints
o Diagnosis requires at least 4 symptoms for 6 weeks or
more
• Once these dots acquire color, they will be a definitive for ▪ 3 days: could be just gouty arthritis
SLE
o No color = negative
• Homogenous and speckled are worse as they have high
infected and target organ/s
• Immunodiffusion: this method is used to determine the
immunologic specificity of a positive FANA test
• Enzyme Immunoassay: use for detection of anti-ds-DNA,
anti-histone antibodies and anti-SS-A and anti-SS-B
o Enzyme markers: peroxidase (most commonly used)
o Four antibodies that are specific to SLE: ds-DNA, anti-
histone, anti-SS-A and anti-SS-B
• Antiphospholipid Antibodies: are a heterogenous group of • Felty’s Syndrome: involves chronic RA with neutropenia,
antibodies that bind to phospholipid alone or are complexed splenomegaly, and possibly thrombocytopenia
with protein o Neutropenia: below 10,000
• Possible infectious Agents: Mycoplasma, rubella,
TREATMENT cytomegalovirus, EBV and parvovirus
• For control and not as a complete drug to heal with it o CMV resides in WBC
• If fever or arthritis is the primary symptom, a high dose of ▪ Common for blood transfusion
aspirin or other anti-inflammatory drug may bring relief o EBV “kissing disease”
• Topical steroids ▪ Self limiting
• Systemic corticosteroids o Rubella: MMR (Measles Mumps Rubella)
• Other drug used include cyclophosphamide, azathioprine,
methotrexate, and chlorambucil
o Methotrexate – has less adverse effect so it is the most
commonly used

RHEUMATOID ARTHRITIS
• Systemic autoimmune disorder, it is a chronic, symmetric
and erosive arthritis of peripheral joints, potentially affecting
organs like the heart and lungs
o Symmetric: present on left and right
o Rare to affect heart but mostly affects lungs
• Women are three times more likely to be affected than men IMMUNOLOGIC FINDINGS
o Due to menopausal stage • Early Rheumatoid Arthritis
▪ Potent female estrogen will go low o Increased synovial cells and infiltration of CD4+ T
• Occurs between ages 35 – 50 but can occur at any age lymphocytes, CD8+ T cells, B cells and plasma cells
• It results in decreased functional ability and reduced life o Macrophages and neutrophils form a pannus, which
expectancy invades joint spaces and cartilage
• Disease progression: spontaneous remissions / rapid • Cytokines involved
progression to joint deformity and disability o IL – 1, IL – 6, IL – 8, IL – 15, IL – 18, TNF -a = causes
• Associated with certain MHC class II genes, particularly DR sustained inflammation
4 alleles, found in 70% of RA patients ▪ TNF – a is key in the inflammatory process,
o These alleles share a specific amino acid sequence promoting secretion of other cytokines and white
(positions 67 – 74) in HLA class II B chain blood cell transport
▪ More on cytogenetics • Collagenase and enzymes from synoviocytes and
o The shared epitope may facilitate antigen chondrocytes degrade connective tissue, cartilage and
bone
presentation to Th and B cells
o Collagen and enzymes are decreased
▪ Earlier treatment prevents decrease
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• 75% of RA patients have rheumatoid factor (RF), typically • Anti-Cyclic Citrulinated Peptides Assay (Anti – CCP Assay)
IgM targeting IgG’s Fc portion, but RF is not specific to RA – more reliable indicator of RA than the RF test
• IgM and IgG form immune complexes that deposit in joints, o A new rapid anti – CCP 2 test – valid and reliable and
causing type III hypersensitivity and complement activation may help to simplify testing
o C3a and C5a attract neutrophils and macrophages, o Anti – CCP with IgA RF testing – appear to be the best
resulting in chronic inflammation predicators for future development of RA
▪ C3a and C5a are part of complement system
• Other autoantibodies: antikeratin, antiperinuclear, anti TREATMENT
flaggrin, anti – • Rituximab – targets the CD20 antigen on B cells
o Sa, anti – CCP Anti – CCP is more specific than RF for o Also, a cytokine drugs; will last for 4 weeks
RA diagnosis o Severe RA injuries
▪ Main autoantibody markers for RA • Salicylates and Ibuprofen – these are anti-inflammatory
▪ Best marker drugs and traditional therapy to control local swelling and
▪ CCP = Citrate Citrulated Peptide Protein pain
• About 40% of RA patients have low titers of antinuclear o Ibuprofen may damage kidney if too much
antibodies, often showing a speckled pattern o Aspirin may also damage certain organ
• Prednisone (Corticosteroids) – halt the inflammatory
LABORATORY DIAGNOSIS OF RHEUMATOID response and slow the progression of joint erosion
ARTHRITIS o May develop edematous problems
• Diagnosis of RA is made on the basis of a combination of • Disease modifying antirheumatic drugs (DMARDS) – are
clinical manifestations, radiographic findings, and now prescribed if disease activity persists after 4 to 6 weeks
laboratory testing of treatment with nonsteroidal anti-inflammatory drugs
• RHEUMATOID FACTOR (RF) TESTING: RF – antibody • Methotrexate, hydroxychloroquine, sulfasalazine,
that is most often tested to aid in making the initial diagnosis leflunomide, penicillamine
• Once diagnosis is made, however, the most helpful tests • Biological agents that block the activity of TNF – a
used to following progress of disease are general indicators o Agents that act against TNF – a are classified into two
of inflammation, such as measurement of ESR, C-reactive categories
protein (CRP), and complement components ▪ 1. Infliximab and Adalinumab – monoclonal
o CRP is an acute phase reaction antibody to TNF – a
▪ Will increase during inflammation ▪ 2. Etanercept – TNF – a receptors fused to an IgG
molecule
RHEUMATOID FACTOR TESTING • 5 days effectivity
• A. Agglutination Test
o Detect only the IgM isotype AUTOIMMUNE THYROID DISEASES
o Negative result does not rule out the presence of RA • Affecting thyroids
o Positive test result is not specific for RA, because RF o Correlation to CC: T3, T4, TSH
can be found in other diseases such as: • Most notable: Hashimoto’s syndrome and Grave’s disease
▪ Syphilis o Grave being most important to take note
▪ SLE • These are examples of organ – specific autoimmune
▪ Chronic active hepatitis diseases
▪ Tuberculosis • It is believed that the autoimmune response to the thyroid
▪ Leprosy seen in these diseases is based on a combination of genetic
▪ Infectious mononucleosis susceptibility genes coupled with environmental triggers
▪ Malaria • In case of Hashimoto’s disease, one environmental trigger
▪ Sjorgren’s syndrome is a high iodine intake
o Two types of Agglutination Tests for RF • GENETIC PREDISPOSITION (study nowadays also
▪ A. One using sheep red blood cells coated with consider genes as a factor for thyroid diseases)
IgG o Immune – modulating genes
▪ B. Using latex particles coated with the same ▪ HLA antigens
antigen – predominant agglutination test used
▪ Cytotoxic T lymphocyte associated factor 4
• B. Testing for IgG and IgA (in serum) Isotype
(CTLA – 4)
o Testing in these antibody classes of RF, tend to be
▪ Protein Tyrosine Phosphatase – 22 (PTPN – 22)
more specific
o The elevation of IgA early in the disease appears to be o Thyroid – specific genes
associated with a poorer prognosis, such as ▪ Thyroglobulin Gene
development of bone erosions and systemic ▪ Thyroid Stimulating Hormone Receptor (TSHR)
manifestations, so this can be used to predict the
disease outcome CLINICAL SIGNS AND IMMUNOLOGIC FINDINGS
o Sensitivity of this testing is not that high FOR HASHIMOTO’S THYROIDITIS
▪ Generally, anti – CCP is better • Or chronic autoimmune thyroiditis
o Inflammation
TESTING TECHNIQUES • Often seen in middle – aged women
• EIA Techniques and Nephelometric Assays – testing for o As early as 25, it can be detected
IgG and IgA isotypes and IgM can be performed • Women are 5 to 10 times more likely to develop the disease
o Nephelometric Assays – increases in light scattering as • Thyroid shows hyperplasia with an increased number of
immune complexes accumulate, and the sensitivity is lymphocytes
better than manual agglutination methods

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• Antibodies to thyroglobulin predominate, or progressively ▪ Passive hemagglutination – most commonly used

destroying thyroglobulin and producing the symptoms test
associated with hypothyroidism ▪ Indirect immunofluorescent test – less sensitive
o Decreased thyroglobulin = hypothyroidism than passive hemagglutination but it can detect
▪ May be experienced by obese patients non agglutinating antibody
▪ Hyperthyroidism may be experienced by fit o Antibody to thyroid peroxidase
patients ▪ They are found in approximately 90 to 95 percent
• Patients develop a combination of of patients with the disease
o Goiter ▪ Commonly measured by EIA, IIF, and particle
▪ Or enlarged thyroid agglutination assays
• Self-confidence may be decreased o Antibodies to TSH receptors
▪ Irregular and rubbery ▪ Associated with Grave’s disease
▪ Immune destruction of the thyroid gland ▪ Hormone test: elevation of free triiodothyronine
o Hypothyroidism (T3) and thyroxine (T4)
▪ Dry skin • If there is a blockage
▪ Decreased sweating ▪ Measurement of thyroid receptor antibodies is
▪ Puffy face with edematous eyelids done when results of these assays are unclear
▪ Pallor with yellow tinge • Bioassays – require tissue culture
▪ Weight gain • Binding assays – based on competition
▪ Dry and brittle hair between radiolabeled TSH and patient
• Hair Fall autoantibodies for binding to thyrotropin
o Thyroid autoantibodies receptors
• But, usually, it is the clinical chemistry section first that
CLINICAL SIGNS AND IMMUNOLOGIC FINDINGS initiates the test when there is thyroid problem (endocrine)
FOR GRAVE’S DISEASE and if there is a problem, it is where serological tests would
• Common cause of HYPERTHYROIDISM enter
• Most prevalent autoimmune disorder in the United States
(they eat more iodized food and seafoods) TREATMENT FOR AUTOIMMUNE THYROID
• Manifests as: DISEASES
o 1. THYROTOXICOSIS • Thyroid Hormone Replacement Therapy
o 2. EXOPHTHALMUS o Uses natural hormones to raise abnormally low levels
• Seen in multiorgan autoimmune disorder T3 and T4
• Major antibodies found: o Can be delivered in pill form and the most common
o 1. Thyroid Stimulating Hormone Receptor Antibody prescribed is pure thyroxine T4
(TSHRab) ▪ T4 can stay in the body for 7 days unlike for T3
o 2. Antibodies to thyroid peroxidase that is just staying for 1 day (24 hours)
• Additional Autoantibody found: o Half – life: T4 (7 days) versus T3 (24 hours) The blood
o 1. Thyrotropin Receptor Blocking Antibody results also reveal thyroid – stimulating hormone (TSH)
▪ Blocks conversion of free T3 to T3 and free T4 to levels released by the pituitary gland
T4 o Can be given to those with thyroid in decreased
amounts and those whose thyroid are already absent

TYPE 1 DIABETES MELLITUS

• One of the most intriguing
• Inborn
• Is a chronic autoimmune disease that occurs in a
genetically susceptible individual as a result of
environmental factors
• It is characterized by insufficient insulin production caused
by selective destruction of beta cells
LABORATORY TESTING FOR AUTOIMMUNE o Insulin – dependent
THYROID DISEASE • Family studies indicate that there is an inherited genetic
susceptibility to the disease, probably attributable to
• Three major autoantibodies
multiple genes
o Antibodies to thyroglobulin: for Grave’s
o Sometimes it can skip one or more generation before
o Antibodies to thyroid peroxidase: for Hashimoto
o Antibodies to TSH receptors: for Grave’s the disease will manifest again
▪ Grave’s is what is monitored
• Antibody Tests IMMUNOPATHOLOGY
o Antibodies to thyroglobulin • Progressive inflammation of the islet of Langerhans in the
pancreas leads to fibrosis and destruction of most beta cells

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• The generalized inflammation that results is responsible for • Other immunosuppressive drugs:
the destruction of beta cells. Although islet autoantibodies o Azathioprine
trigger the immune response, it is not known what role they o Methotrexate
play in cell destruction o Cyclophospham
o Hard to identify
▪ It could be diagnosed at late stage, when there is LABORATORY TESTS
increased damage to the pancreas • Common test for diagnosis of Multiple Sclerosis
• Either medication or candidate for o Oligoclonal banding
transplantation ▪ Highest is Gamma globulin, alpha 1 and alpha 2
o Transplantation of pancreas is rare but • IgG is the highest
it happens o CSF IgG index
• There is increasing evidence that autoimmunity to insulin • Specimen: CSF
itself may be central to disease pathogenesis o Lumbar puncture: 4th to 5th disc: for fit patients; 3rd to 4th
• Autoantibodies are present in prediabetic individuals and in disc: obese
newly diagnosed patients
MYASTHENIA GRAVIS
LABORATORY TESTING • Looks like MS because it affects the nerve but is different
• CAs have been reported in the sera of greater than 80 • Autoimmune disease that affects neuromuscular junction
percent of patients newly diagnosed with type I diabetes • Characterized by weakness and fatigability of skeletal
mellitus muscles
• Antibodies to insulin can be detected using RIA or EIA o Targets skeletal muscle instead of brain
methods ▪ Though, it is still controlled by brain
• RIA and EIA are also used to detect anti – GAD antibodies • Antibody – mediated damage to the acetylcholine receptors
and anti – IA – 2 antibodies in skeletal muscles leads to progressive muscle weakness
o Positive marker for Type I Autoimmune DM o No contractions
▪ Only type I can be autoimmune o Progressive weakness
o Glutamic Acid Decarboxylase: GAD
o Early onset disease, which is usually defined as
• Type I diabetes mellitus is usually diagnosed by the prime
occurring before the age of 40, appears to be linked to
characteristics of hyperglycemia
several HLA antigens, A1, B8, and DR3
• Antibodies to islet cells have traditionally been detected by
IF using frozen sections of human pancreas o Late – onset MG, presenting in patients older than 40,
is linked to HLA antigens B7 and DR2 and is more
TREATMENT likely to appear in men between the ages of 30 and 60
• 1. Growth factors or transplantation of beta islet cells may ▪ More common in men
also be of use in the future • Acetylcholine (ACH)
o Last to consider: Transplantation o Main contributor to the pathogenesis of the disease
• 2. Cyclosporin A, azathioprine, and prednisone have all o Released from nerve endings to generate an action
been used to inhibit the immune response potential that causes the muscle fiber to contract
• 3. Use of injected insulin
LABORATORY
MULTIPLE SCLEROSIS • Procedures RIA: used to detect antibody, based on assays
• An inflammatory autoimmune disorder of the central that block the binding of receptors by anti – ACH receptor
nervous system (ACHR) antibody
• Characterized by the formation of lesions called plaques in o A – bungarotoxin: a radio – labeled snake venom used
the white matter of the brain and spinal cord to irreversibly bind to ACHRs precipitation of receptors
o Plaques – hard caused by combination with antibody is then measured
• Rare and specific ▪ Rare nowadays
o Targets only nerves • Because we do not use animals for testing
SYMPTOMS nowadays
• Visual disturbances o Radioisotopes (RIA) are highly carcinogenic
▪ Iodine – 125: mostly used isotope
• Weakness or diminished dexterity in one or more limbs
• Locomotor incoordination
• Dizziness
TREATMENT
• Facial palsy • Anticholinesterase agents: used as the main treatment
• Tingling or “pins and needles” that run down therapy
• Thymectomy: beneficial to some patients, especially those
younger than 60 with early onset disease
TREATMENT
• Corticosteroids: effective, as is etanercept, which inhibits
• There is no one specific therapy (mixed), but newer
the action of TNF – a
treatment for relapsing – remitting MS centers around three o For those diagnosed long ago
drugs:
o IFN – B1a (Avonex, Rebif)
o IFN – B1b (Betaseron)
GOODPASTURE’S SYNDROME
o Glatiramer acetate • Specific but systemic because it targets kidney
▪ For three way o But can target lungs, glomerulus and other anti-
• Acute exacerbations are treated with methylprednisolone, glomerular basement membranes
but this cannot be used on a long term basis • Goodpasture syndrome characteristically has:

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o 1. Pulmonary hemorrhage – hemoptysis • Main types:

o 2. Glomerulonephritis – hematuria o Hodgkin Lymphoma: lesser abnormality compared to
o 3. Circulating anti – glomerular basement membrane NHL
antibodies o Non-Hodgkin Lymphoma: dangerous
▪ B – cell lymphoma
CLINICAL PRESENTATION ▪ T – cell lymphoma
• 1. Cough
HODGKIN’S LYMPHOMA
• 2. Dyspnea
• Definition: a neoplastic transformation of lymphocytes
• 3. Hemoptysis
particularly in lymph nodes
• 4. Hematuria
• Characterized by:
• 5. Advanced cases might present with oliguria and
o 1. The presence of Reed – Sternberg cells on histology
symptoms of uremia
▪ Marker
▪ Lymphocyte eating another
DIAGNOSIS o 2. Spreading in an orderly fashion to contagious lymph
• 1. Blood test – anti – GBM, antibodies are seen nodes
• 2. Urine analysis – microscopic hematuria (dysmorphic ▪ For example, Hodgkin lymphoma that starts in the
RBC s in urine microscopy), RBC casts or gross hematuria cervical lymph nodes may spread first to the
• 3. Renal biopsy – proliferative, crescentic, supraclavicular nodes then to the axillary nodes
glomerulonephritis, renal biopsy is preferred because it is • Reed – Sternberg Cells: cells with mirror image nuclei and
more yielding prominent, eosinophilic, inclusion – like nuclei
• 4. Pulmonary biopsy – alveolar necrosis, alveolar o Seen in PBS (Hematology)
hemorrhage and hemosiderin – laden macrophages
o Alveolar damage
▪ Alveoli is important in the exchange of oxygen
and carbon dioxide
• 5. Immunofluorescence – the immunofluorescent studies of
renal or lung tissue shows linear deposits of
immunoglobulins at glomerular

ETIOLOGY
• Hodgkin disease has bimodal age distribution – one peak
in the 20s and 60s
o Current in Philippines: Mostly in 60s

RISK FACTORS
• 1. Certain viruses
o Epstein – Barr Virus (EBV)
o Human Immunodeficiency Virus (HIV)
• GS is a Type II Hypersensitivity • 2. Weakened immune system
o Covers IgG and IgM antibodies o Inherited condition
o Certain drugs used after an organ transplant
TREATMENT ▪ Immunosuppressive drugs taken for
• Anti – GB removing antibodies using plasmapheresis transplantation will be a factor
o Costly • 3. Age
o Cleansing of plasma by removing antibodies (Anti – o Hodgkin lymphoma is most common among teens and
adults aged 15 to 35 years and adults aged 55 years
GBM)
and older
• Corticosteroid treatment ▪ Bimodal age: teens (lifestyle factors)
o Reduction of antibodies formed
• 4. Family history:
▪ Side effect: inflammation leading to edematous o Family members, especially brothers and sisters, of a
kidneys person with Hodgkin lymphoma or other lymphomas
may have an increased chance of developing this
IMMUNOPROLIFERATIVE DISEASES disease
• Body has problem in controlling the proliferation
• Proliferate in terms of number (quantitative) and size CLINICAL PRESENTATION
(qualitative) • Enlarged, painless, rubbery, non – erythematous,
nontender lymph nodes are the hallmark of the disease
LYMPHOMA o Lymphadenopathy – effective marker
• Leukemia – lymphoid neoplasm presenting with wide • May become painful after drinking alcohol
spread involvement of the bone marrow, usually • Patients may develop “B” symptoms which are:
accompanied by large number of tumor cells in the o Drenching night sweats
peripheral blood o 10% weight loss
• Lymphoma – neoplastic proliferation arising as discrete o Fever
tissue masses ▪ Looks like you have malaria but you don’t have it

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• 25% have “B” symptoms o Chemotherapy – generalized but will make you weak
• Although pruritis is common in the disease it is not one of due to the drugs used
the “B” symptoms • Highly treatable as compared NHL
• Cervical, supraclavicular and axillary lymphadenopathy
• Extra lymphatic sites may be involved such as: INVESTIGATIONS USED FOR STAGING
o Spleen • Chest X – ray: X – ray pictures may show swollen lymph
o Liver nodes or other signs of disease in the chest
o Bone marrow • CT: Chest, abdomen and pelvis (CT is sensitive enough to
o Lung detect any abnormal nodes)
o CNS • MRI
• Extra lymphatic involvement is more common with non – • PET scan
Hodgkin lymphoma • LP for CSF cytology if any CNS signs
o Check lymphoid organs • Lymphangiography and laparotomy are no longer used for
staging
STAGING o Obese patients are not benefited with this
• The doctor considers the following to determine the stage ▪ Some lymph nodes may not be seen
of Hodgkin lymphoma: • A bone marrow biopsy is used when:
o The number of lymph nodes affected o 1. B symptoms
o Whether these lymph nodes are on one or both sides o 2. Stage 3 or 4
of the diaphragm
o Whether the disease has spread to the bone marrow, ABNORMAL LAB TESTS
spleen, liver or lung • Don’t alter the stage of the disease
o Each stage is divided into A or B symptoms according • CBC: anemia and high WBC (Eosinophilia is common)
to the presence of systemic symptoms o Hematology
o Good marker for staging
• LDH: high (poor prognostic factor)
o Chemistry
• ESR: high (poor prognostic factor)
o Hematology
• LFTs: help determine the need for liver biopsy
o Chemistry

• After lymphoma is diagnosed, a variety of tests may be

carried out to look for specific features characteristic of
different types of lymphoma
o 1. Immunophenotyping
▪ Costly
STAGE DESCRIPTION ▪ Long process
Stage I Involvement of a single lymph node region or of a single o 2. Flow cytometry
extralymphatic organ or site ▪ Fastest
Stage II Involvement of > two lymph node regions or lymphatic o 3. FISH testing
structures on the same side of the diaphragm o with ▪ Currently used
involvement of limited, contiguous extralymphatic organ ▪ Long preparation time
or tissue ▪ Not available to all of the tests
▪ Fluorescence Interface In Situ Hybridization
Stage III Involvement of lymph node regions on both sides of the
diaphragm which may include the spleen or limited, • Used to check malignancy
contiguous extralymphatic organ or site or both ▪ Much costly compared to Immunophenotyping
Stage IV Diffuse or disseminated foci of involvement of > one
extralymphatic organ or tissue with o without associated CLASSIFICATION SYSTEM
lymphatic involvement • The classification of lymphoma can affect treatment and
prognosis
DIAGNOSIS • Classification systems generally classify lymphoma
according to:
• An excisional lymph node biopsy is the essential first step
o 1. Whether or not it is a Hodgkin lymphoma
in diagnosis
o 2. Whether the cell that is replicating is a T cell or B cell
• A biopsy is the only sure way to diagnose Hodgkin o 3. The site that the cell arises from
lymphoma. The biopsy can be:
o 1. Excisional biopsy
HISTOLOGY
o 2. Incisional biopsy
o 3. Fine needle aspiration usually cannot remove a large • Hodgkin has several histological subtypes
enough sample for the pathologist to diagnose Hodgkin o Lymphocyte – predominant has the best prognosis
lymphoma ▪ Lymphocytes normal
▪ Done in histopathology o Lymphocyte – depleted has the worst prognosis
• After that the most important step is to determine the extent ▪ Lymphocytes abnormal
of the disease because the stage will determine the nature
of the therapy, that is, radiation vs. chemotherapy TREATMENT
o Radiation – only the target • Therapy is entirely based on the stage

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• Localized disease (stage IA and IIA) is managed GRADES

predominantly with radiation • NHL divided into low or high grade
• All patients with evidence of “B” symptoms as well as stage • A high grade lymphoma has cells which look quite different
III and IV are managed with chemotherapy from normal cells. They tend to grow fast (aggressive),
• The most effective combination chemotherapeutic regimen usually look follicular. Incurable and wider dissemination at
for Hodgkin lymphoma is ABVD (Adriamycin, Bleomycin, presentation
Vinblastin, Dacarbazine) • Low grade lymphomas have cells which look much like
• ABVD is superior to MOP (Meclorethamine, Yincristin normal cells and multiply slowly (indolent), usually look
(Oncovin), prednisolone and procarbazine) because ABVD diffuse. Long term treatment maybe achievable
has fewer side effects such as: • Low – grade lymphomas
o 1. Permanent sterility o Many low – grade lymphomas remain indolent for many
o 2. Secondary cancer formation years
o 3. Aplastic anemia o Treatment of the non – symptomatic patient is often
▪ Problem in Bone Marrow avoided
o 4. Peripheral neuropathy o In this case watchful waiting is often the initial course
▪ Problem in the veins of action. This is carried out because the harms and
risks of treatment outweigh the benefits
NON – HODGKIN’S LYMPHOMA o If a low – grade lymphoma is becoming symptomatic,
radiotherapy or chemotherapy are the treatments of
DEFINITION choice
• The neoplastic transformation of either B or T cell lineages ▪ Chemotherapy is much preferred as it may
of lymphatic cells progress to high – grade which is incurable
• NHL causes the accumulation of neoplastic cells in both the o They don’t cure the lymphoma, they can alleviate the
lymph nodes as well as more often diffusely in symptoms
extralymphatic organs and the bloodstream o Patients with these types of lymphoma can live near –
o Angioplastic cancer for lymph nodes normal lifespan, but the disease is incurable
• Absent Reed – Sternberg cells • High – grade lymphomas
o Treatment of the aggressive, forms of lymphoma can
RISK FACTORS result in a cure in the majority of cases
o However, the prognosis for patients with a poor
• Infections
response to therapy is worse
o Human Immunodeficiency Virus (HIV)
o Treatment for these types of lymphoma typically
o Epstein – Barr Virus (EBV): linked to Burkitt consists of aggressive chemotherapy, including the
lymphoma CHOP or RCHOP regimen
o Helicobacter pylori: extranodal tissues generating ▪ Bone marrow therapy will also be considered but
lymphoma include MALT (mucosa associated they need first to check the medication and
lymphoid tissue) treatment
o Human T-cell leukemia/lymphoma virus (HTLV-1)
▪ Hairy cell leukemia TREATMENT
o Hepatitis C virus • Same principle of treating Hodgkin lymphoma
• Age: most people with non – Hodgkin lymphoma are older • The initial chemotherapeutic regimen is CHOP
than 60 (cyclophosphamide, hydroxy – adriamycine, oncovin, and
prednisolone)
CLINICAL PRESENTATION • CNS lymphoma is often treated with radiation in addition to
• Clinical presentation is the same as for Hodgkin lymphoma CHOP
• The difference is that Hodgkin is localized to cervical and • Relapses can be controlled with BM transplantation
supraclavicular nodes 80% - 90% of the time. Whereas NHL • Some pts express CD – 20 antigen in greater amount. In
is localized 10 – 20% of the time this case, monoclonal antibody Rituximab should be used
• CNS involvement is more common with NHL • Rituximab is an anti – CD20 antibody that has limited
o Reason why it is deadly toxicity and add survival benefit to the use of CHOP
• HIV positive patients often have CNS involvement
LYMPHOBLASTIC LEUKEMIA
STAGING AND DIAGNOSIS • Leukemias are generally classified as either acute or
• Staging and diagnosis are the same as for Hodgkin chronic
lymphoma o Acute – young
• Differences ▪ Highly responsive to therapy
o Bone marrow biopsy is more central in the initial o Chronic - old
staging of NHL • Chronic leukemias are usually slowly progressive and
▪ Because it is thought that it is already stage III/IV compatible with extended survival. However, they are
of Hodgkin’s Lymphoma generally not curable with chemotherapy
o Because the presence of bone marrow involvement • By contrast, acute leukemias are generally much more
means the patient has stage IV disease and therefore rapidly progressive but have a higher response rate to
needs combination chemotherapy, further invasive therapy
testing such as laparotomy is not required
ACUTE LYMPHOBLASTIC LEUKEMIA
• Childhood acute lymphoblastic leukemia (also called acute
lymphocytic leukemia or ALL)

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• Is a disease in which too many underdeveloped infection – • Lymph node enlargement is prominent early in the disease
fighting white blood cells, called lymphocytes, are found in • CLL is compatible with a long survival
a child’s blood and bone marrow • Palliative therapy – treatment that helps control or reduce
• These abnormal cells reproduce very quickly and do not symptoms but is not curative – is used
function as healthy white blood cells to help fight infection
• The most common form of leukemia HAIRY CELL LEUKEMIA
• The most common kind of childhood cancer • Rare, slowly progressive disease
• Peak incidence occurs from 3 to 5 years of age • Infiltration of the bone marrow and spleen by leukemic cells,
o Treatment would last 5 years without involvement of lymph nodes
▪ Then if successful, monitoring for after 10 years • 4:1 male predominance, seen in individuals over 20 years
and so on of age
• The most common symptoms of leukemia: fever, anemia, • Patients usually present with cytopenias because of bone
bleeding and/or bruising, persistent weakness or tiredness, marrow infiltration, but the blood lymphocyte count is
achiness in the bones or joints, recurrent infections, usually not very high. Splenomegaly may be striking
difficulty breathing (dyspnea) or swollen lymph nodes o TRAP test is performed for diagnosis
• CLINICAL MANIFESTATIONS ▪ Lavender top must be hemolyzed and smeared
o Protean as the more it is hemolyzed, it would be much
▪ Variable changes (confusions, changes in more definitive
learning activity)
▪ Hanging drop technique / wet mount
• But could go back to normal activity once
▪ In hematology
ALL is treated
o Bone marrow and organ infiltration • Round with a “bland” cytological appearance
o Common symptoms fever (60%), malaise (50%), pallor • Irregular hairy cytoplasmic projections from their surfaces
(40%) • Visible on wet – mount preparation
• ETIOLOGY • Express B – cell markers CD19, CD20, and CD22
o Unknown (usually) • Contain tartrate – resistant acid phosphatase (TRAP) in
▪ Idiopathic their cytoplasm – histochemical staining
o Hereditary
▪ Down’s syndrome HYPERSENSITIVITY
▪ Leukemia in siblings • “Allergy” or allergic reaction
o Chemicals • Has happened to all of us
▪ Chronic benzene exposure o Type I: common
▪ Alkylating agents o Type IV: super rare
o Ionizing Radiation • Implies an increased response; not always heightened, but
o Predisposing hematological disease (MPD, AA) instead be an inappropriate immune response to an antigen
o Viruses (HTLV – 1) • May be developed in humoral or cell – mediated responses
• ALL is treatable disease, with a remission rate of 90% and • Requires a pre-sensitized host
a cure rate of 60 – 70% in children • We avoid anaphylactic shock in hypersensitivity
o That is why the treatment should be continuing to avoid o C4a and C3a are anaphylactic shock promoters
remissions ▪ We drink allergic medications to have it removed
• The remission and cure rate are lower in adults
• Immunologically, ALL is divided into four types: IMMEDIATE HYPERSENSITIVITY
o CALLa (CD – 10) – expressing immature B – cell ALL • Anaphylactic reactions within the humoral branch initiated
(MOST COMMON) by antibody or antigen-antibody complexes
o Pre – B cell wall without CALLa (CD – 10) (SECOND • Symptoms manifest within minutes or hours after a
MOST COMMON) sensitized recipient encounters the antigen
o T – cell ALL
o B – cell ALL (RARE) TYPE I: IGE – MEDIATED HYPERSENSITIVITY
• Induced by certain types of antigens referred to as allergens
CHRONIC LYMPHOID LEUKEMIA / LYMPHOID • Has the hallmarks of a normal humoral response
• Most common leukemia, classified as a type of NHL by • Allergen induces a humoral antibody response by the same
WHO mechanisms as for other soluble antigens
• Affects B lymphocytes • Resulting in the generation of antibody-secreting plasma
o Common cells and memory cells
• Incidence increases with age
o Common in adults COMPONENTS OF TYPE I REACTIONS
• Mostly detected incidentally, based on lymphocytosis on • Allergen can be;
CBC o Exogenous: microbes, pollen, foreign cells and
o Above 40% lymphocytes proteins
• AIHA and frequent infections are seen o Endogenous: self-tissues
• Flow cytometry confirms clonality, based on presence of ▪ Nonparasitic antigens capable of stimulating type
CD19/20/5 and CD23 I hypersensitive responses in allergic individuals
• As the malignant lymphocytes continue to increase the
number, replacement of normal elements in the bone TYPE I REACTIONS
marrow leads to anemia and thrombocytopenia • Systemic Anaphylaxis
o Bleeding problems

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o Shock-like and often fatal state whose onset occurs Proteases Bronchial mucus secretion;
within minutes blood-vessel degradation of
o May cause massive edema, shock, and bronchiole basement membrane;
constriction generation of complement split
o Can be cause by stings, drugs, seafood, nuts products
o If not treated quickly, reactions can be fatal
o Epinephrine counteracts the effects of mediators such Secondary
as histamine and the leukotrienes MEDIATOR EFFECTS
o Body may also cause to shut down wind pipe when Platelet- Platelet aggregation and degranulation;
there is systemic anaphylaxis activating contraction of pulmonary smooth muscles
• Localized Anaphylaxis (Atopy) factor (lipid)
o Limited to a specific target tissue or organ, often Leukotrienes: Increased vascular permeability; contraction
involving epithelial surfaces at the site of allergen slow reacting of pulmonary smooth muscles; prolonged
substance of bronchospasm
entry
anaphylaxis
o Atopy: inherited tendency to manifest localized
Prostaglandins contraction of pulmonary smooth muscles;
anaphylactic reactions
Vasodilation platelet aggregation; increase sensitivity to
▪ Hereditary predisposition to the development of
pain
immediate hypersensitivity reactions against
Bradykinin Increased vascular permeability; smooth-
common environmental antigens muscle contraction
▪ Afflict at least 20% of the population in Cytokines Systemic anaphylaxis; increased expression
developed countries of CAMs on venular endothelial cells
▪ Risk: both parents = 75%, one parent = 50%,
none = 15% METHODS OF DETECTION FOR TYPE I
• Allergic rhinitis or hay fever HYPERSENSITIVITY REACTIONS
o Most common atopic disorder
• Skin Testing
o Results from the reaction of airborne allergens with
o Inexpensive and allows screening of many allergens in
sensitized mast cells in the conjunctivae and nasal one sitting
mucosa to induce the release of pharmacologically o May sensitize the allergic individual to new allergens,
active mediators from mast cells o mediators cause and in rare cases, may induce systemic anaphylactic
localized vasodilation and increased capillary shock
permeability o Small amounts of potential allergens are introduced at
o Mostly those with odors (downy, albatross) should be specific skin sites either by intradermal injection or by
avoided superficial scratching
• Asthma o May be applied to sites on the forearm or back of an
o Allergic asthma: airborne or blood-borne allergens individual
(pollens, dust, fumes, insect products, viral antigens) o Radioimmunosorbent test (RIST)
trigger an asthmatic attack ▪ Determine the serum level of total IgE antibody
▪ Highly sensitive technique based on
o Intrinsic asthma: exercise or cold, independent of
radioimmunoassay
allergen stimulation, trigger an asthmatic attack o
▪ Can detect nanomolar level of total IgE
triggered by degranulation of mast cells with release o Radioallergosorbent test (RAST): detects the serum
of mediators, developing in the lower respiratory tract level of IgE specific for a given allergen
- Atopic dermatitis o allergic eczema ▪ (+) = positive for allergy
o Inflammatory disease of skin associated with family
history of atopy observed most frequently in young METHODS FOR CONTROLLING TYPE I
children o serum IgE levels are often elevated HYPERSENSITIVITIES
o “Cat whistle” • First step is to avoid contact with known allergens
o Emergency case: drink coffee without sugar • Immunotherapy
▪ Drink slowly o Hyposensitization
▪ Then, drink medications right after wards ▪ Repeated injections of increasing doses of
▪ Coffee will promote opening of alveolars allergens
▪ Reduce the severity, or even eliminate type I
MEDIATORS IN TYPE I HYPERSENSITIVITY reactions completely
Primary ▪ Causes a shift toward IgG production or to induce
MEDIATOR EFFECTS T-cell-mediated suppression that turns off the IgE
response
Histamine (also exerts Increased vascular ▪ IgG: blocking antibody
negative-feedback control permeability; smooth-muscle • Competes for the allergens, binds to it, and
on mediator release) contraction forms a complex for phagocytosis
Heparin • Allergen is not available to crosslink the
Serotonin fixed IgE on the mast-cell membranes =
Eosinophil Chemotactic Eosinophil chemotaxis allergic symptoms decrease
Factor ▪ Should not be done without doctors guidance as
Neutrophil Chemotactic Neutrophil chemotaxis there are people who surpassed their
Factor hyposensitization phase

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o Drug therapy ▪ Immediate transfusion reactions o donor cells will

▪ Interfere with degranulation of cells and blocks be destroyed by complement fixation of IgG and
the receptors of histamine. IgM on ABO antigen sites
▪ Ex. antihistamine, steroids, anti-inflammatory ▪ Antibodies to other blood-group antigens may
drugs - desensitization result from repeated blood transfusions because
• Antihistamine – common medications minor allelic differences in these antigens can
▪ Prevents reaction between allergen, IgE and stimulate antibody production (IgG)
mast cells ▪ Clinical manifestations: massive intravascular
hemolysis of the transfuse RBCs by antibody plus
TYPE II: ANTIBODY – MEDIATED CYTOTOXIC complement
ACTIVITY ▪ Incompatible blood
• IgG and IgM • Hemolytic Disease of the Newborn
• Rare o Develops when maternal IgG antibodies specific for
• Involve antibody-mediated destruction of cells fetal blood-group antigens cross the placenta and
destroy fetal RBCs
• Antigen-antibody mediated cytotoxicity (Lota)
o Erythroblastosis fetalis: Rh+ fetus expresses an Rh
• Can activate the complement system = creating pores in the
antigen on its blood cells that the Rh
membrane of a foreign cells
▪ In the Philippines, majority are Rh positive and if
• Can mediate cell destruction by antibody-dependent cell you are Rh negative, you need to be part of Rh
mediated cytotoxicity (ADCC) (crucial type) negative association of the Philippines so when
o Cytotoxic cells with Fc receptors bind to the Fc region you need blood, you have a group where to ask
of antibodies on target cells and promote killing of the donation
cells ▪ In Europe and Middle East, majority are Rh
• Antibody bound to a foreign cell also can serve as an negative
opsonin, enabling phagocytic cells with Fc or C3b receptors o Mother does not express
to bind and phagocytose the antibody-coated cell o Rh factor o from Rhesus monkey
• Involve a complex of group of syndromes that include the o Present in 85% of humans o Filipinos: usually Rh+
complement system activated by the antibodies IgM and o Caucasian: typically Rho developed through placental
IgG, which are directed against self-surface antigens sensitization or transfusion
(antigens found on cells like RBCs), not free-floating o Because of this you should know the blood type of your
antigens future spouse
▪ Trophoblast: a layer of cells in the placenta that
SENSITIZATION PHASE separates the fetal RBCs form the mother’s
• Immunological response to the cell surface circulation - IgG: only antibody that traverses the
• Production of IgM and IgG because of the activation of B- placenta
cells and T-helper cells ▪ First pregnancy: (Rh+ fetus, Rh- mother)
o HDN-Erythroblastosis fetalis
EFFECTOR PHASE ▪ First pregnancy will have no problem since
• Cytotoxic cells have the Fc receptors mother have yet to differentiate Rh pos from Rh
o Antibodies have Fab and Fc (crystallizable portion) neg but for the succeeding pregnancies, they can
found in the heavy chain differentiate it already
• Fc receptors will bind to Fc region of antibodies on target ▪ Rare cases of HDN
cells and promote the killing o Rhogam: antibodies to avoid hemolytic disease
• IgG and IgM activate complement system which causes ▪ Given 28-32 weeks / 7 – 8th month into pregnancy
lysis, inflammation and destruction of tissue and just after delivery
▪ After delivery: bind to any fetal RBCs that enter
• Promotion of killing by NK – antibody dependent cell
the mother’s circulation and facilitate their
cytotoxicity
clearance before B-cell activation and ensuing
memory-cell production can take place
ADCC REACTION OF DENGUE ▪ Subsequent pregnancy: unlikely to produce IgG
• Dengue 1 – produces antibodies for dengue 1 anti-Rh antibodies = fetus is protected
• Subsequent exposure = dengue 2 o Can be detected by testing maternal serum at intervals
• Antibodies produced for dengue 1 will attack dengue 2 (not during pregnancy for antibodies to the Rh antigen
neutralizing) • Drug-Induced Hemolytic Anemia
• NK will attach to antibody = cause vascular permeability o Certain antibiotics can adsorb nonspecifically to
(severe dengue, circulatory shock) proteins on RBC membranes, forming a complex
• 2014: dengue vaccine! similar to a hapten-carrier complex = drug-protein
o Dengvaxia is only covering Type 1 strain only complex
• IgG effector molecules whose interaction with cell surface ▪ Formation of antibodies => bind to adsorbed drug
antigens result in destruction; activates ADCC on RBCs => complement-mediated lysis =>
consequences: complement activation and recruitment of progressive anemia
inflammatory cells through Fc interaction o Drug is withdrawn = anemia disappears
o Penicillin can induce all four types of hypersensitivity
TYPE II HYPERSENSITIVE REACTIONS ▪ Cefalexin and chloramphenicol can also induce
• Transfusion Reactions hypersensitivity
o Transfusions: preformed antibodies

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TYPE III: IMMUNE COMPLEX – MEDIATED o Main cell concern: T helper

HYPERSENSITIVITY • The symptoms will arise several days after the second
• Almost the same with type 2 but it is rare contact with the antigen
o Since the scenarios rarely happen and we don’t want it • Mediating cells: T-helper 1 cells generally; CD8 cells
• Antigens are not attached to the surface (antigens are occasionally
soluble) • Principal effector cells: macrophages
• Free floating antigen and antibody complexes deposited in
tissues or tissue surfaces SENSITIZATION PHASE
• Deposition of complexes on the tissues activates the • Stimulus: Activation of naive CD4 T-cells, particularly the T-
complement systems helper 1
• Release of anaphylatoxins degranulates mast cells o Can also occasionally activate the CD8 T-cells but
• Inflammatory reactions are characteristic of type III mainly CD4+
• Basically, has the same principles with type II but the • Produce memory T-cells
antigens involved are soluble o Important in immunosurveillance; inspect if there is the
presence of antigens
STIMULATION PHASE • Antigen-presenting cell with MHC class II will stimulate the
• IgG & IgM T-helper cells
• 2 Types of Stimulus: o Possible antigen-presenting cells for this type:
o Exogenous antigens- antigens that have entered the Langerhans cells
body from the outside, for example by inhalation, • Dendritic cells found in the skin; macrophages, and
ingestion, or injection vascular endothelial cells
o Endogenous antigens- antigens that have been
generated within previously-normal cells as a result of EFFECTOR PHASE
normal cell metabolism, or because of viral or • Sensitized T-helper cells produce cytokines (such as
intracellular bacterial infection interferon gamma, tissue necrosis factor, interleukins,
granulocyte-monocyte colony-stimulating factor, etc.) and
EFFECTOR PHASE chemokines, which will activate the macrophages
• Complement activation o Sensitized – the cell already knows the antigen that it
• Neutrophil activation will attack
• Large population and size of immune complex deposit in • Takes about 24 hours; increase about 48 to 72 hours
capillary walls causing inflammatory response • Length of time depends on how long the recruitment and
the activation of macrophages into the area will be
EXAMPLES • During the full-blown of this delayed type hypersensitivity:
only 5% of the T-helper cells or the delayed type
• Arthus Reaction –deposition of Ig & activation of C3 results
hypersensitivity cells (TDTH) will be activated; everything
to local vasculitis
else/all the reactions will be caused by inflammatory cells
o Self-limiting
o Usually found in vaccines and insect bites (macrophages, neutrophils, etc.)
▪ Vaccines are already free from skin testing
▪ Before skin testing are done to prevent arthus EXAMPLES
reaction • Tuberculin reaction (PPD reaction)
• Snake venoms and rabies still have skin o Acute skin inflammation
testing, may be ▪ 24-48 hours
o Localized dermal injury due to inflamed blood vessels ▪ PPD – protein derived from the cell wall of
• Serum sickness-using non-human protein/antigen from Mycobacterium Tuberculosis, which is injected
animal intradermally
o Inflammation of joints, lymph nodes and kidneys • Before, it is skin testing for M. TB
o Due to administration of non-human gamma globulins ▪ Red, slightly swollen, firm lesion between 48-72
for passive immunization hours – later indicates previous exposure
• Arthus & Serum sickness vs. Anaphylaxis • Contact dermatitis
o Dependent on IgG, IgM or IgA - large dose of antigen o From poison ivy, etc.; most common delayed allergic
o Delayed onset of symptoms reaction
• Autoimmune disease ▪ Small molecules that can complex with skin
o Individual develop hypersensitivity to himself protein and internalized by antigen-presenting
▪ Autoantibodies cells in skin, such as Langerhans cells
▪ T-cells mount abnormal attacks to self • Graft rejection
o Inappropriate response against self o Tendency of T-cells to act on foreign tissue and cause
• Myasthenia gravis* rejection
• Goodpasture’s syndrome* ▪ Host rejection of the graft; or graft rejection of the
• Systemic Lupus Erythematosus – can cross over to type II host
o Type II and III have shared immunoglobulins ▪ Minimized by tissue matching and
immunosuppressive drugs
TYPE IV: CELL – MEDIATED OR DELAYED TYPE
TRANSPLANTATION
HYPERSENSITIVITY
• One of the options for autoimmune and immunoproliferative
• Sensitized T-helper 1 cells release cytokines that activate
in terms that if medication and treatment is not successful,
macrophages or the cytotoxic T-cells which mediate direct
so the option for this is reconsidered
cellular damage

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• Done in several years HLA GENES

• Kidney is the most transplanted solid organ and bone • Inherited as haplotype from parental chromosomes (1
marrow is the most transplanted semi solid organ in the maternal and 1 paternal HLA haplotype)
Philippines o 46 chromosomes complete
o Cornea transplant is also mostly done but is not as
invasive as the other two MENDELIAN INHERITANCE
• Lifesaving treatment for the end-stage of the following:
o 1. Organ Failure AB CD
o 2. Cancer
AC AD BC BD
o 3. Autoimmune Disease
o 4. Variety of other Diseases
• Main goal: both donor and recipient should survive HLA HLA HLA NON –
o Sometimes, it is noted that transplant is done when the IDENTICAL HAPLOIDENTICAL IDENTICAL
donor is about to die, that is a different case CHANCE 25% 50% 25%
DESCRIPTION Any two Share on two No haplotype
SOLID ORGANS FOR TRANSPLANTATION siblings will haplotypes inherited
• Kidney inherit same
• Pancreas 2 haplotypes
o In the case of T1DM EXAMPLE A and B A and C NO
• Liver C and D A and D INHERITED
o Most successful transplantation HAPLOTYPE
B and C
o Regenerate 3 – 4 years after transplantation
B and D
• Heart
o Rare; donor at the end stage • Recombination (1% chance) – results in inheritance of
o Also depends on patient – donor age unexpected haplotypic combinations
• Lung
o Rare HLA PROTEINS ARE HETERODIMERIC MOLECULES
• Small Intestine
o Rare PRODUCED BY EXPRESSED IN
CLASS I HLA–A antigen • The cell surface
HEMATOPOIETIC STEM CELLS PROTEINS HLA–B antigen • All nucleated cells
• In cases of Bone Marrow transplants HLA–C antigen
CLASS II HLA-DRB1+DRA1 genes • Antigen presenting
HLA PHARMACOLOGICAL AGENTS PROTEINS HLA-DQB1+DQA1 genes cells
• Interference in promoting sustained graft survival HLA DPB1+DPA1 genes • Dendritic cells
• Monocytes
HLA SYSTEMS • Macrophages
• Is the largest immunologic barrier to successful allogeneic • B lymphocytes
organ transplantation.
• Consists of cell surface proteins that play a central role in HISTOCOMPATIBILITY SYSTEMS
immune recognition and initiation of immune responses
MINOR HISTOCOMPATIBILITY ANTIGEN NON HLA
HISTOCOMPATIBILITY SYSTEMS • Proteins that demonstrate polymorphism in amino acid
• The classical (transplant) HLA antigens, also known as sequence within species.
major histocompatibility antigens, include the: o Both X-linked and autosomally encoded MHAs have
been identifies
CLASS I CLASS II o “Slower” rejection pace
HLA – A HLA – DR ▪ Looks the same
o Mediated by CD4 and or CD8 T cells –its response is
HLA – B HLA – DQ analogous to the reaction to a foreign microbial antigen
HLA – C HLA – DP • Types:
o Proteins encoded by Y chromosome
o Proteins that are autosomally encoded
FUNCTIONS OF HLA PROTEINS
o Proteins that are mitochondrial DNA encoded
o Proteins for which recipient has a homozygous gene
detection.

MIC / MICA ANTIGENS (MHC CLASS I – RELATED

CHAIN A)
• Related to T cells
• Encodes a cell surface protein that is involved in
gamma/delta T-cell responses
• Polymorphic
• 50 allelic variants
• Expressed on endothelial cells, keratinocytes, fibroblasts,
epithelial cells, dendritic cells and monocytes.

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• NOT expressed on T or B lymphocytes TRANSPLANT REJECTION

• Serves as targets for allograft immune responses
• 11% of kidney transplant patients have antibodies to MICA HYPERACUTE ACUTE CHRONIC
antigens REJECTION REJECTION REJECTION
o Challenge to kidney transplants DURATION Minutes to Days to weeks Weeks to
• MICA antibodies are associated with reject episodes and hours after loss after transplant years result
decreased graft survival of vascular from graft
supply to arteriosclerosis
ABO BLOOD GROUP ANTIGENS transplanted
• ABO system is the only blood group system that impacts organ.
clinical transplantation. (ischemia,
• ABO antibodies bind to corresponding antigens that are necrosis)
expressed on vascular epithelium -> Activated compliment CAUSE ABO CD8 Prolonged cold
cascade -> Hyperacute rejection of the transplanted organ HLA –cytotoxic Ischemia
• Incompatible Donors Endothelial reactions to –Reperfusion
o It lowers the ABO antibody levels that allow antigens foreign MHC –Acute
transplantation to proceed without risk of hyrperacute expressing rejection
rejection cells. episodes –
▪ Rejection will happen causing harm to the body CD4 –produce Toxicity from
cytokines and immunosupp
KIR (KILLER IMMUNOGLOBULIN – LIKE induce delayed ressive drugs
RECEPTORS) type –CD4 T cells
• Cell surface molecules that regulates NK lymphocyte hypersensitivity/ –B cells
activity DTH antibody –Cytokines
• 1. NK cell with occupied inhibitory receptors –Growth
• 2. Encounters a cell or decreased class-I expression Factors
• 3. Unoccupied inhibitory receptors CHARACTER Ischemia Parenchymal -Progressive
• 4. Lost of inhibitory signal IZATION Necrosis injury Vascular fibrosis
• 5. Activation injury –Scarring
• 2 types of receptor –Narrowing of
o 1. Activating receptors vessel lumen
o 2. Inhibitory receptors
GRAFT – VERSUS – HOST DISEASE
o The activity of the NK cell depends on the balance of • Less common in lungs and liver
signals received by the KIR receptors. • Common for bone marrow
• Stem cell transplants (less commonly lung and liver
ALLORECOGNITION transplants) are complicated by a unique allogeneic
• Autograft: transfer of tissue from one are of the body to response—graft-versus-host disease (GVHD).
another of the same individual. • Recipients of stem cell transplants for hematologic
o Better malignancies have depleted bone marrow prior to
• Syngeneic graft: of cell or tissue between two identical transplantation as a result of the chemotherapy used to
twins. treat the malignancy.
o Chances of incompatibility is still there • Donor bone marrow or, more commonly, peripheral blood
• Allograft: transfer of cell or tissue between two individuals stem cells are infused. The infused products often contain
of the same species; Mostly performed some mature T cells. These cells have several beneficial
o Most commonly done effects, including promotion of engraftment, reconstitution
• Xenograft: transfer of cell or tissue between two individuals of immunity, and mediation of a graft-versus-leukemia
of different species. effect.
• Two distinct mechanisms • Note: these mature T cells may also mediate GVHD.
o Direct allorecognition: Cytotoxic T cells bind directly to
foreign HLA proteins on graft cells ACUTE GVHD
▪ Must be compatible • Occurs during the first 100 days post-infusion and targets
o Indirect allorecognition: foreign MCH antigen are the skin, gastrointestinal tract, and liver.
presented by phagocytic cells, and CD4+ T cells o Includes:
respond (Uptake, Processing, Presentation) ▪ Mismatched allogeneic stem cell transplantation
▪ Must be specific ▪ Matched stem cell transplantation
o Note: Mixed Lymphocyte Response (MLR) is an invitro • Mismatched allogeneic stem cell transplantation: the
correlate of indirect allorecognition. targets of GVHD are the mismatched HLA proteins.
• Effector response against transplanted allogeneic tissue • Matched stem cell transplantation: minor histocompatibility
o 1. Direct cytotoxicity antigens are targeted.
o 2. Delayed-type hypersensitivity • To reduce the incidence and severity of GVHD, includes:
o 3. Antibody-mediated mechanisms o Immunosuppressive therapy in the early post-
▪ Destroys organ transplanted; necrosis transplant period
o Removal of T lymphocytes from the graft

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T – CELL REDUCTION • Several monoclonal antibodies that bind to cell surface

• Done to avoid GVHD especially in cases of leukemia molecules on lymphocytes are used as induction agents
o Some are through radiation (common) or washing (less and to treat severe rejection episodes.
common) • Administered through injection
• Is very effective in lowering the incidence of GVHD, but it o Doctors are the only allowed to perform such
can also reduce the graft-versus-leukemia (GVL) effect of
the infused cells and increase the incidence of graft failure POLYCLONAL ANTIBODIES
o Beyond 100 days post-transplant, patients may • Two polyclonal anti-T-cell antibody preparations are used
experience chronic GVHD. This condition resembles to treat severe rejection.
autoimmune disease, with fibrosis affecting the skin, • Done as if there is already a potential for rejection (e.g.
eyes, mouth, and other mucosal surfaces organ transplanted is within its survival limits)

IMMUNOSUPPRESIVE AGENTS CLINICAL HISTOCOMPATIBILITY TESTING

• Maintain organs transplanted • Histocompatibility laboratories provide specialized testing
• Susceptibility infections could be present for both solid-organ and stem cell transplantation programs.
• Taken as long as the transplanted organ is present within • Two main activities in support of transplantation:
the body o HLA typing
• Agents that suppress antigraft immune responses in solid- o HLA antibody screening/identification
organ and stem cell transplantation.
• Immunosuppressive agents are used in several ways, HLA TYPING
including: • The phenotypic or genotypic definition of the HLA antigens
o Induction and maintenance of immune suppression or genes in a transplant candidate or donor.
o Treatment of rejection • Information is used to find the most suitable donor–recipient
o Are frequently used to prevent graft rejection combination from an immunologic standpoint.
• Immunosuppressed state may result to:
o Malignancies HLA PHENOTYPING
o Increased susceptibility to infection
• The classic procedure for determining the HLA phenotype
o Other associated toxic side effects
is the complement dependent cytotoxicity (CDC) test.
• Immunosuppressive agents are:
• Panels of antisera or monoclonal antibodies that define
o Corticoid
individual or groups of immunologically related HLA
o Antimetabolic Agents: mostly used
antigens are incubated with lymphocytes from the individual
o Calcineurin Inhibitors
to be HLA typed
o Monoclonal Antibodies
o Polyclonal Antibodies
HLA GENOTYPING
CORTICOSTEROIDS • Molecular-based HLA genotyping methods use polymerase
chain reaction (PCR)–based amplification of HLA genes
• Potent anti-inflammatory and immunosuppressive agents
followed by analysis of the amplified DNA to identify the
• Used for immunosuppression maintenance. specific HLA allele or group of alleles.
• Higher doses, they are used to treat acute rejection • The most common approaches for analysis is PCR
episodes amplification of HLA genes with panels of primer pairs, each
o Steroids act by blocking production and secretion of of which amplifies specific alleles or related allele groups.
cytokines, inflammatory mediators, chemo attractants,
• Amplification is detected by agarose gel electrophoresis.
and adhesion molecules.
• Decrease macrophage function and alter leukocyte-
HLA ANTIBODY SCREENING AND IDENTIFICATION
trafficking patterns
• Long-term use is associated with hypertension and • Antibodies to HLA antigens can be detected in candidates
diabetes mellitus and recipients of solid-organ transplants.
• These antibodies develop in response to multiple blood
ANTIMETABOLIC AGENTS transfusions;
o 1. To prior HLA-mismatched transplants
• Agents that interfere with the maturation of lymphocytes o 2. In women, to multiple pregnancies
and kill proliferating cells.
• Antibody screening and identification is also performed
• Azathioprine was the first such agent employed post-transplantation to aid in the diagnosis of antibody-
o It has been replaced in large part by mycophenolate mediated rejection and to assess the effectiveness of
mofetil, which has a more selective effect on therapy for antibody-mediated rejection.
lymphocytes compared to azathioprine and thus fewer
• The methods used for antibody detection and identification
side effects.
have changed significantly in recent years. The CDC
method used for HLA typing is also used for HLA antibody
CALCINEURIN INHIBITORS detection and identification.
• Cyclosporine and FK-506 (tacrolimus) are compounds that • Once a donor has been identified for a particular patient, a
block signal transduction in T lymphocytes, resulting in donor–recipient cross match test is performed to confirm
impairment of cytokine syntheses, including IL-2, 3, 4, and the absence of donor-specific antibody
interferon-gamma
SEROLOGICAL TESTS
MONOCLONAL ANTIBODIES • Could be screening or confirmatory
• Done in vitro

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SYPHILIS • A. NON-TREPONEMAL SEROLOGIC TEST- non specific;

• Great Pox / Evil Pox / French Disease / Italian Disease determine the presence of reagin antibody to cardiolipin
• Caused by Treponema pallidum (originally called (subject to false positive eg: SLE)
Spirochaeta pallida) o Eg of non-treponemal tests: based on principle
• Transmitted by sexual contact, direct blood transmission or FLOCCULATION- special type of precipitation involves
transplacental route fine particles
o → Congenital Syphilis (Hutchinsonian Triad: notched o Venereal Disease Research Laboratories Test (VDRL)
teeth, keratitis, deafness) o Rapid Plasma Reagin (RPR)
• First diagnostic test blood test, the Wasserman Test was o Toluidine Red Unheated Serum Test (TRUST)
developed in 1906 o Unheated Serum Reagin (USR)
• In treatment of syphilis, heavy metals such as arsenic, were o Reagin Screen Test (RST)
replaced by penicillin in the 1940s o VDRL- both a qualitative slide flocculation test for
o Arsenic used during WW2 serum and spinal fluid. Antigen consist of 0.03%
• T. pallidum dies in cold temperature: refrigerated for 3 days cardiolipin, 0.9% cholesterol, and 0.21% lecithin
▪ Specimen: 0.05 mL or 50uL serum, heat for 56C
for 30mins (inactivate complement)→
flocculation, microscopically at LPO (100x)-
check
▪ CSF VDRL→ Ring 16mm, Depth 1.75mm
(Rotation)
• Serum: 180 rpm for 4 mins
• CSF: 180 rpm for 8 mins
• Results:
o Non-Reactive- No Clumps
o Weak Reactive- Small Clumps
o Reactive- Medium to Large Clumps
▪ EIA
• → Test for Congenital Syphilis; look for the
STAGES IN SYPHILIS presence of IgM
• PRIMARY SYPHILIS: hard chancre (painless and firm)-
dark field
o You thought to be healed but rather you developed
secondary syphilis
o Microbiology
• SECONDARY SYPHILIS: condylomata lata- wart-like
lesions in moist areas of the body; highly infectious,
systemic dissemination (Dark Field and serological tests)
o Serology
• LATENT SYPHILIS: absence of clinical symptoms (do NOT
use dark field)
o Asymptomatic carrier
• TERTIARY SYPHILIS: gummas (granulomatous lesion),
neurosyphilis
o Gummas: painful lesions o Ag Delivery Needles
o Passed by BBB ▪ Qualitative Serum VDRL: 18 gauge needle
without bevel that will deliver 60 drops of antigen
suspension per mL; Ring= 14mm in diameter
▪ Quantitative Serum VDRL: 19 gauge needle
without bevel that will deliver 75 drops of antigen
suspension per mL, 23 gauge needle with or
without bevel that will deliver 100 drops of saline
per mL
▪ CSF VDRL: 21 or 22 gauge needle that will
deliver 100 drops per mL
▪ Reagent (VDRL)
• Cardiolipin- main reacting
• Cholesterol- enhance reacting surface of
cardiolipin
LAB DIAGNOSIS OF SYPHILIS • Lecithin- removes anti-complement activity
of cardiolipin
• 1. Direct Detection of Spirochetes
o Dark- Field Microscopy
o Fluorescent Antibody Testing of a Specimen
o (+) Coiled organism with cork-screw motility
▪ Looks like C. mesnili (parasitology)
• 2. Serologic Tests
o Wasserman Test- based on complement fixation test

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o Rapid Plasma Reagin (RPR)- principle is agglutination ▪ Transmission: mouth to mouth by utensils
▪ Specimen: 0.05 or 50 uL serum o T. carateuum
▪ Antigen is similar to the VDRL antigen with the ▪ Pinta- ulcerative skin disease
addition of the following: ▪ Transmission: traumatized skin comes in contact
▪ Reagin→modification of VDRL reagent with an infected lesion
▪ Charcoal→ which makes the test easier to read
▪ EDTA→ prevents oxidation of lipid
▪ Thimerosal→ preservative
▪ Choline Chloride→ inactivates complement
▪ Rotation: 100 rpm for 8 mins (Ring of RPR is
18mm in diameter) YAWS BEJEL
▪ Ag Delivery Needle: 20 gauge disposable needle
without bevel; 60 drops are obtained in 1 Ml

PINTA
• B. Treponemal Serologic Tests- specific; detects
treponemal antibodies GROUP A STREPTOCOCCAL INFECTION
o Treponema pallidum immobilization Test (TPI)- • Caused by Strep. pyogenes.
considered as the standard test to which other o Produces M protein
treponemal test are evaluated. Involves mixing of a • Major sites of infection are the upper respiratory tract and
patient with live, actively motile T. pallidum extracted skin with pharyngitis and impetigo being the most common
from testicular chancre of a rabbit and complement o Rheumatoid Fever, Acute Glomerulonephritis, Scarlet
▪ Test is considered positive if >50% treponemes Fever, Erysipelas
are immobilized.
▪ If fewer than 20% are immobilized, the test is ANTISTREPTOLYSIN O TITER (ASO)
negative. • Precipitation test
▪ The range of 20-50% represents an area of • No hemolysis is positive result
“doubtful” result • Based on neutralization of the haemolytic activity of
▪ Needs rabbit tissue streptolysin O
o Fluorescent Treponemal Antibody Absorption Test • Titer of 166 Todd units or below is considered normal;
(FTA-ABS)- for 2nd and latent stage; 100% Reactive moderately elevated if the titre is at least 240 Todd units in
▪ Patient serum is heat-inactivated and made with an adult and 320 in child
a sorbent consisting of non-pathogenic o Positive for strep infection tonsilitis
treponemes (Reiter strain; functions as sorbent)
which removes cross-reactivity with treponemes ANTI – DNASE B TESTING
other than T.pallidum
▪ Nichols strain (virulence strain) of T.pallidum • Sometimes appear earlier than ASO in streptococcal
pharyngitis
have been fixed to slides used for the test
• Deadly • Sensitivity is increased for the detection of
glomerulonephritis preceded by streptococcal skin
• Not heated
infections as ASO antibodies are not stimulated by this type
• NOTE: CONGENITAL INFECTION
of disease
• TORCH TEST
• Measurement is based on a neutralization methodology; if
o Toxoplasmosis
anti- Dnase B antibodies are present, they will neutralize
o Rubella
reagent DNAse B, preventing it from depolymerizing DNA.
o CMV- common cause of congenital
Presence of DNAse is measured by its effect on DNA
o Herpes
methyl green conjugate. This complex is green in its contact
o Syphilis
form, but when hydrolysed by DNAse, the methyl green is
• HEMAGGLUTINATION TESTS reduced and becomes colourless
o Hemagglutination Treponemal test for Syphilis
• An overnight incubation at 37C is required in some testing
(HATTS)
methodologies to permit antibodies to inactivate the
o T.pallidum Hemagglutination Assay (TPHA)
enzyme. Tubes are graded for color, with a 4+ indicating
o Microhemagglutination Assay for Antibodies to
that the intensity of colour is unchanged, and a 0 indicating
T.pallidum (MHA-TP)
a total loss of color
• OTHER TREPONEMA-ASSOCIATED DISEASES IN
HUMANS
STREPTOZYME TESTING
o T. pallidum subspecie pertunue
▪ Yaws (chronic nonvenereal disease of skin and • Slide agglutination screening test for detection of antibodies
bones) to several streptococcal antigens
▪ Transmission: traumatized skin comes in contact • Sheep RBCs are coated with streptolyzin, streptokinase,
with an infected lesion hyaluronidase, DNAse and NADase so that antibodies to
o T. pallidum subspecie endemicum any of the streptococcal antigens can be detected.
▪ Bejel- lesions in oral cavity, oral mucosa, skin, o Uses type O human blood as alternative
bones, and nasopharynx)

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HEPATITIS ▪ Marker of past infection and immune state

HEPATITIS A PROBLEM HBSAG ANTI – HBC ANTI – HBS

• Member of the family Picornaviridae No HBV NEGATIVE NEGATIVE NEGATIVE
• Transmission by fecal-oral route Early HBV POSITIVE NEGATIVE NEGATIVE
• Virus has an average incubation of 28 days
Acute HBV POSITIVE POSITIVE NEGATIVE
• 1. HAV ANTIGENS
o Shed in the feces of infected individuals during the Window NEGATIVE POSITIVE NEGATIVE
incubation period and early acute stage of infection; Past Infection NEGATIVE POSITIVE POSITIVE
decline to low levels by the time the symptoms appear Vaccination NEGATIVE NEGATIVE POSITIVE
o Not clinically useful indicator of disease
• 2. HAV ANTIBODIES IgM Anti-HAV
o Marker of acute hepatitis A
HEPATITIS C
o Peak during first month of illness and decline to • Major cause of post-transfusional HEPA historically
undetectable levels within 6-12 months • Previously classified as “nonA-nonB” hepatitis
o Routinely detected by a solid-phase antibody capture • Member of the family Flaviviridae
ELISA • Average incubation period of 7-8 weeks
o IgG Anti-HAV • MOT: Sexual, Parenteral, Perinatal
▪ Produced as a result of natural infection or •
immunization
▪ Indicate immunity to HAV HEPATITIS D
▪ Detected by competitive inhibition ELISA tests • Incomplete virus
• Self-limiting disease o Does not cause virus
▪ Requires another (e.g. Hep B)
HEPATITIS B o Hep B + Hep C = coinfection leading to
• Member of the family Hepadnaviridae superinfection
• Dane Particle complete HBV that causes infection • Unclassified, single-stranded RNA virus
• Average incubation period of 60-90 days • Parentally transmitted infection that can only occur in the
• 1. HBV Antigens- Hepatitis B Surface Antigen (HBsAg) presence of hepatitis B
o First marker to appear • Infection with the two viruses occur either simultaneously
o Indicator of active infection as a coinfection or sequentially as a superinfection in
o Important marker in screening of blood donors chronic HBV carriers
• 2. Hepatitis B Envelope Antigen (HBeAg) • Routinely indicted by the presence of anti-HDV in the
o Present during periods of active replication of the virus patients’ serum, which is most often detected by ELISA
o Indicates a high degree of infectivity when present • IgM anti-HDV
o High vertical transmission (baby to mother)
• 3. Hepatitis B Core Antigen (HBcAg) HEPATITIS E
o Not detectable in serum because of the viral envelope • Caliciviridae reclassified to Hepeviridae
that masks it • Fecal-oral route, water-borne
o Detected only through biopsy of the infected liver • Usually presents as an acute, self-limiting hepatitis without
▪ May require operation progression to a chronic carrier state
• HBV Antibodies • Associated with a high rate of mortality of pregnant women
o 1. IgM Anti- HBc • HEV Antibodies
▪ Indicator of current or recent infection o IgM anti-HEV is typically present during the acute
▪ Useful in detecting infection during the “core infection but rapidly declines in the early recovery
window” period only period
▪ First antibody to appear; acute hepatitis B o ELISA, Western blot and fluorescent antibody blocking
o 2. IgG Anti-HBc (Total IgM and IgG) assay
▪ Persists for the lifetime of the individual
• HEV RNA
▪ Acute or chronic HBV
o Detected in feces of most patients for about 2 weeks
o 3. Anti- Hbe
after the onset of illness but may persist longer in some
▪ Indicates that the patient is recovering from HBV
cases
infection, convalescence/ favourable prognosis
o Identified by means of PCR
• Good prognosis
• Poses risk for pregnant women
• Done for those without vaccines
o 4. Anti-HBs
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
▪ Appears during the recovery period of acute
• Etiologic agent of the acquired immunodeficiency syndrome
hepatitis B, weeks to months after HBsAg
(AIDS)
disappears
▪ Persists for years and provide protective • RNA, Retroviridae
immunity • Blot in nitrocellulose paper; reverse transcriptase-
▪ Also produced after immunization with the transcribe RNA to DNA
hepatitis B vaccine, which consists of o Characteristic
recombinant HBsAg produced from genetically • HIV-1→ Aids in US and Europe
engineered yeasts (Protective titer >10mIU/mL of o Formerly called human T-cell lymphotropic virus-type
serum) III (HTLV-III), lymphadenopathy- associated virus
• The higher, the better the immunity (LAV) and AIDS-associated retrovirus (ARV)

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• HIV-2→ Endemic in West Africa • Associated with SLE in

o Less pathogenic and has a lower rate of transmission the active stage of the
disease and in Sjogren’s
MAIN STRUCTURAL GENES Syndrome
• 1. ENV (ENVELOPE) • Associated with ds-
DNA→ most specific
antibody in SLE
3. SPECKLED (MOTTLED) • Occurs in the presence
PEPPER DOT of antibody to any
• 2. Gag (Group antigen) gene extractable nuclear
o P55- P15, 17, 24 (first antibody→ p24) antigen devoid of DNA or
o Location: On Nucleocapsid histone; Anti- ENA
• 3.Pol (Polymerase)- all are located to core near nucleic acid • Anti-Sm antibodies have
o Reverse Transcriptase- transcribe RNA to DNA been shown to be
o Integrase- insert viral DNA to host DNA specific for patients with
o Rnase SLE
o Protease- cleaves structural protein • Anti-RNP
• 2 and 3 for confirmatory 4. NUCLEOLAR • Reflects an antibody to
nucleolar RNA
LABORATORY TESTING FOR HIV INFECTION • Present in about 50% of
• Antibody Detection patients with
• A. Screening Tests scleroderma, Sjogrens,
o ELISA- Standard Screening test and in SLE
o Agglutination Tests- uses gel or latex particles
o Dot- Blot Testing 5. ANTI-CENTROMERE • Antibody reacts with the
• B. Confirmatory Tests ANTIBODY (ACA) centromeric chromatin of
o Western Blot Testing- Standard Confirmatory Test metaphase and
o Immunofluorescence Assay interphase cells
• **CDC Criteria for (+) Western Blot • Appears to be highly
o Present at least 2 out of possible 3 antibodies and to selective for the CREST
p24, gp41 and gp 120, and gp160 variant of progressive
systemic sclerosis
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) (CREST→ Calcinosis,
• SLE-connective tissue disorder; HLA DR3. Chronic Raynau’ds Phenomenon,
inflammatory autoimmune disease characterized by the Esophageal motility,
presence of antinuclear antibodies Sclerodactyly,
• Laboratory Diagnosis of SLE Telangiectasis)
o 1. Diagnosis of LE Cell- neutrophil that has engulfed 6. NO STAIN / NO • Ruled out for SLE
the antibody-coated nucleus of another neutrophil FLUORESCENCE
o 2. Detection of ANA
RHEUMATOID ARTHRITIS
• Associated with HLA DR4; autoimmune disease that affects
the synovial membrane of multiple joints. Characterized by
presence of an autoantibody called Rheumatoid Factor→
IgM reacting against Fc portion of IgG

LABORATORY DIAGNOSIS OF RA
• Sheep cell agglutination test (Rose et al)
• Latex fixation test (Singer and Plotz)
PATTERNS DESCRIPTIONS
• Sensitized alligator erythrocyte test (Cohen et al)
1. HOMOLOGOUS (SOLID, • Characterizes anti- • Bentonite flocculation test (Bloch and Bunim)
DIFFUSE) deoxyribonucleoprotein
antibodies (antibodies to CRP
nDNA, dsDNA, ssDNA,
• Non-specific
DNP, or histones
• APR
• This pattern is typically
• CRP is a trace constituent of serum originally thought to be
seen in rheumatoid
antibody to the c-polysaccharide of the pneumococci
disorders
• Increased rapidly within 4-6 hours following infection,
• High titers of
surgery or other trauma to the body
homogenous ANA are
suggestive of SLE; low • Levels increase dramatically as much as 100-1000 fold
titers may be found in reaching a peak value of within 24-72 hours (average of 48
SLE, RA, Sjogren’s hours)
syndrome, and MCTD • Elevated in: bacterial, RF, viral, malignant diseases, TB,
2. PERIPHERAL (RING, • Pattern results from and after heart attack
MEMBRANOUS, SHAGGY, antibodies to DNA
OR THREAD)

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TRANS: IMMUNOLOGY AND SEROLOGY

HETEROPHILE ANTIBODIES ASSOCIATED WITH HETEROPHILE AB ABSORBED BY ABSORBED BY

INFECTIOUS MONONUCLEOSIS GUINEA PIG BEEF
• Heterophile Antibodies- are antibodies capable of reacting KIDNEY CELLS ERYTHROCYTES
with similar antigens from two or more unrelated species Ab to Forssman Ag Adsorbed (+) Not adsorbed (-)
Abs in Serum Sickness (+) (+)
TEST FOR HETEROPHILE ANTIBODIES
• 1. Paul Bunnell Screening Test- general screening test for Abs in IM (-) Not adsorbed (+) Adsorbed
heterophile Abs
o Ab to Forsmann Ag HETEROPHILE AGGLUTINATION AGGLUTINATION
▪ Sheep RBC AB AFTER ABSORPTION AFTER
o Abs in serum sickness
WITH GUINEA PIG ABSORPTION WITH
▪ Type III hypersensitivity
o Ab in IM KIDNEY CELLS BEEF
o Reagent: sheep RBC; positive result= agglutination ERYTHROCYTES
• 2. Davidsohn Differential test (Tube)- based on Ab to Forssman Ag (-) Not adsorbed (+) Agglutination
“adsorption”- removal by antibody in serum using sheep rbc Abs in Serum (-) (-)
as indicator Sickness
Abs in IM (+) (-)

• 3. MONOSPOT- rapid differential slide test

o Indicator Cells: horse RBCs
o More sensitized indicator of Ab found in IM

SEROLOGIC RESPONSES OF PATIENTS WITH EPSTEIN – BARR VIRUS – ASSOCIATED DISEASES

HETEROPHILE ANTI – VCA ANTI – EA ANTI - HETEROPHILE

CONDITION IgM IgG IgA DIFFUSE EA RESTRICTED EA EBNA (IgM)
Uninfected - - - - - - -
IM + ++ + + - - +
Convalescent IM - + - - + + +
Past infection IM - + - - - + -
Chronic Active Infection IM - +++ + + ++ + -
Post transplant lymphoproliferative - ++ + + + + -
disease
Burkitt’s lymphoma - +++ - + ++ + -
Nasopharyngeal carcinoma - +++ + ++ + + -
VCA = Viral capsid antigen; EA = early antigen; EBNA = EBV nuclear antigen; IM = infectious mononucleosis

REFERENCES

Notes from Patrick Silagon, RMT

Compiled by Medical Technology Peers represented by
Renz Louie Galanto

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