HEMA LEC 2 FINALS Structure of the Immune system

IMMUNOLOGIC NURSING The organs of the immune system are positioned throughout the
body.
TERMINOLOGIES
Lymphoid organs
Antigen
o They are home to lymphocytes
- Include toxins, chemicals, bacteria, viruses, or others
that causes the body to make an immune response. Bone marrow

Antibody o The soft tissues in the hollow center of bones

o Is the ultimate source of all blood cells
- Is a protein component of the immune system that o Release mature B lymphocytes into the blood
circulates in the blood, recognizes foreign substances circulation
like bacteria and viruses, and neutralizes them. o Moving T lymphocytes from bone marrow to the
thymus
Autoimmune disease
Thymus
o Is a condition in which your immune system mistakenly
attacks your body o An organ that lies behind the breastbone
o The primary central gland of the lymphatic system
Memory cell
Spleen
o A cell in the immune system that, when exposed to an
invading pathogen, replicates itself and remains in the o A flattened organ at the upper left of the abdomen
lymph nodes searching for the same antigen, resulting o Removing worn-out erythrocytes from blood
in a more efficient and rapid response to any o Starting blood and platelets
subsequent attack.

The immune system

Lymph nodes (secondary organ)
o Is a network of cells, tissues and organs that work
together to defend the body against attacks by “foreign o Contains specialized compartments where immune
invaders” cells congregate and where they can encounter
 Bacteria antigens
 Viruses o Function as an immunologic filter for the bodily fluid
 Parasites known as lymph
o Filtering and phagocytizing (processing and killing)
Fluid systems of the body antigens
o Generating lymphocytes and monocytes
o Two main fluid systems in the blood
o Blood Immune cells and foreign particles enter the lymph nodes via
o Lymph coming lymphatic vessels or the lymph nodes tiny blood vessels
The blood system The lymph node contains numerous specialized structures. T
cells concentrate in the paracortex B cells in and around the
Blood
germinal centers and plasma cells in the medulla.
o 52-62% liquid plasma
o 38-48% cells
o Lightly alkaline (pH=7.40 + .05) Tonsils, Adenoids, Mucoid tissues
o Heavier than water (density = 1.057 +.009)
o Contain immune cells that defend the body’s mucosal
Lymph system surfaces against microorganisms
o Lymph is an alkaline (pH> 7.0) fluid that is usually clear, Cells of the immune system
transparent, and colorless.
o It flows in the lymphatic vessels and bathes tissues and T-cell
organs in its protective covering.
2 types:
o There are no RBCs in lymph and it has a lower protein
content than blood. 1. T helper subset (CD4+ T cell)
2. T killer/suppressor subset (CD8 + T cell)

B cells

o Are lymphocytes that play a

The human lymphoid system has the ff:
large role in the humoral
Primary organs immune response
o Essential component of the
o Bone marrow adaptive immune system
o Thymus gland

Secondary organs

o Adenoids, tonsils, spleen

o Lymph nodes
o Peyer’s patches
o Appendix

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 o Production of antibodies in response to foreign proteins Specific defense mechanisms
of bacteria, viruses and tumor cells
Humoral immune system
Natural killer cells
o Consist of B-cells which originate in the Bone marrow
o Function as effectors cells that and stay there to develop
directly kill certain tumors such o B-cells can produce antibodies, but need exposure to
as melanomas, lymphomas foreign antigens to do so. These antigens are cell
and viral- infected cells, most surface oligosaccharides and proteins which the cell
notably herpes and used as the “ID tags”
cytomegalovirus-infected
cells. Cell-mediated Immune system

Granulocytes or Polymorphonuclear (PMN) Leukocytes o Consists of T-cells which originate in the bone marrow,
but go to the Thymus to finish their development.
o Composed of three cell o T-cells are highly-specialized cells in the blood and
types identified as lymph to fight bacteria, viruses, fungi, protozoans,
neutrophils, eosinophils cancer, etc. within host cells and react against foreign
and basophils matter such as organ transplants.
o Important in the removal
of bacteria and parasites Three kinds of T-cells
from the body
1. Cytotoxic T-cells
Macrophages 2. Helper T-cells
3. Suppressor T-cells
o Important in the regulation of immune responses
o Referred to as scavengers or antigen-presenting cells
(APC) White Blood Action
o Role is to phagocytes (engulf and then digest) cellular
o Leukocytes- participates in both the natural and the
debris and pathogens either as stationary or mobile cell
acquired immune responses
Dendritic cells
A. Granular leukocytes or granulocytes (granules in
o Main function is to process antigen material and the cytoplasm)
present it on the surface to other cells of the immune o Fight invasion by foreign bodies or toxins by releasing
system, thus functioning as antigen-presenting cells cell mediators, bradykinin, and prostaglandins, and
o Present in small quantities in tissues that are in contact engulfing the foreign bodies or toxins
with the external  Neutrophils
o Also be found in an immature state in the blood  Eosinophils
 Basophils
Immunity

o Refers to the body’s specific protective response to an

invading foreign agent or organism

Immunopathology

o Refers to the study of diseases

o Resulting from dysfunctions within the immune system

o Neutrophils (polymorphonuclear leukocytes or

PMN) – are first cells to arrive at the site where
inflammation occurs

o Eosinophils and Basophils – increase in number

during allergic reactions and stress response.

B. Non- granular leukocytes

o Monocytes or macrophages – functions as
phagocytic cells – engulfing, ingesting, and destroying
greater numbers and quantities foreign bodies or toxins
than granulocytes.

Physical Barriers o Lymphocytes – consist of B cells and T cells – play

major roles in humoral and cell-mediated immune
o Intact skin and mucous membrane responses
o Prevent pathogens from gaining access to the body o About 60% - 70% of lymphocytes in the blood are T
o Cilia of the respiratory tract cells

Inflammatory response

Chemical Barriers - Is a major function of the natural immune system

elicited in response to tissue injury or invading
o Acidic gastric secretions organisms
o Mucus enzymes in tears and saliva - Chemical mediators assist this response by:
o Substances in sebaceous and sweat secretions o Minimizing blood loss
o Walling of the invading organism
o Activating phagocytes
o Promoting formation of fibrous scar tissue

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 o Regeneration of injured tissue 4. IgE (Epsilon) less than 8 mg/dL (5-30 micrograms per
liter (mcg/L)
Response to Invasion - Found in the lungs, skin, and mucous membranes
- They cause the body to react against foreign
- Phagocytic immune response
substances such as pollen, fungus, spores, and animal
- Humoral or antibody immune system
dander
- Cellular immune response
- They may occur in allergic reactions to milk, some
Phagocytic immune response meds, and some poisons
- Antibody levels are often high in people w allergies.
- Involves the WBCs (granulocytes and macrophages)
- Phagocytes also remove the body’s own dying or dead 5. IgD (Delta) – 700- 1600 mg/Dl
cells - Are found in small amounts in the tissues that line the
- Apoptosis (programmed cell death) belly or chest
- How they work is not clear
Humoral immune response

- Begins with the B lymphocytes, which can transform

themselves into plasma cells that manufacture
antibodies

Stages of Specific response

1. Recognition stage
- The body must first recognize invaders as foreign
before it can react to them

2. Proliferation stage
- The circulating lymphocyte containing the antigenic
message returns to the nearest lymph nodes

3. Response stage
- The changed lymphocytes function either in a humoral
or a cellular fashion Why it is done?
- The production of the antibodies by the lymphocyte in
A test for immunoglobulins (antibodies) in the blood is
a response to antigen begins the humoral response
done to:
4. Effector stage - Find certain autoimmune diseases or allergies
- Either the antibody of the humoral response or the - Find certain types of cancer
cytotoxic (killer) T cells of the cellular response reaches - See whether recurring infections are caused by a low
and couples w the antigen on the surface of the invader level of immunoglobulins (especially IgG)
o Results in the total destruction of the invading - Check the treatment for certain types of cancer
microbes or the complete neutralization of the affecting the bone marrow
toxin - Check the treatment for Helicobacter pylori (H. pylori)
bacteria
Immunoglobulins (GAMDE)
- Check the response to immunizations to see if you are
- Antibodies are glycoproteins, termed as immune to the disease
immunoglobulins (Igs), which are produced in
response to an immune reaction and specifically bind
to antigens responsible for initiating the reaction.

Types of Immunoglobulins

1. IgA (Alpha) - 0.85-3.85 grams per liter (g/L) DISORDERS OF THE IMMUNE SYSTEM
- Are found in areas of the body such the nose, breathing Disorders of the immune system fall into four main
passages, digestive tract, ears, eyes, and vagina, also categories:
found in saliva
2. IgG (Gamma) - 5.65- 17.65 g/L
- are found in all body fluids
- they are the smallest but most common antibody (75%
to 80%) of all the antibodies in the body)
- important in fighting bacterial and viral infections
- are the only type of antibody that can cross the
placenta in a pregnant woman to help protect her baby
(fetus)
3. IgM (Mu) – 0.55 – 3.75 g/L
- are the largest antibody
- they are found in blood and lymph fluid and are the first A. Immunodeficiency disorders
type of antibody made in response to an infection - Primary
- they also cause other immune system cells to destroy - Acquired
foreign substances
- IgM antibodies are about 5% to 10% of all the
antibodies in the body
M. FAR 
 o HIV (Human Immunodeficiency Virus) Clinical manifestations of systemic anaphylactic reaction
infection/AIDS (Acquired immunodeficiency
syndrome)
o Immunodeficiencies caused by meds

B. Autoimmune disorders
- SLE

C. Allergic disorders
- Asthma
- Eczema
- Allergies

D. Concerns of the immune system

- Leukemia
- Lymphoma

An overactive immune system/ hypersensitivity

- If you are born w certain genes, your immune system

may react to substances in the environment that are
normally harmless.

Hypersensitivity

- Refers to the undesirable reactions produced by the

normal immune system, including allergies and
autoimmunity Localized Reactions
- These reactions may be damaging, uncomfortable, or
A. Allergic Rhinitis (Hay Fever)
occasionally fatal
- It is an inflammation of the nasal mucosa by an allergen
-
Pathophysiology – atopic reactions to inhaled allergens
Classification/ Types of Hypersensitivity reactions
Characteristic – localized in the nasal mucosa and conjunction
Type I- Immediate, Atopic, Anaphylactic reaction
of the eye
Type II- Cytotoxic Reaction
Clinical manifestations
Type III- Immune Complex Reaction
- Nasal congestion
Type IV – Cell Mediated Reaction - Clear to greenish rhinorrhea
- Intermittent sneezing and nasal itching
- Headache
- Fatigue, lack of sleep and poor coordination
Type I - Immediate, Atopic, Anaphylactic reaction
Medical management
- Characterized by vasodilation, increased permeability,
and smooth muscle contraction and eosinophilia - Oral anti-histamines
- Nasal decongestant
- Mast cell stabilizer
- Analgesic and antipyretic

Localized Reactions

B. Atopic Dermatitis (Eczema)

- Inflammation of the skin

Pathophysiology – contact w irritants to which a person has

specific sensitivity

Characteristics

- Acute or chronic
- Noncontagious inflammatory condition
- Causes the typical wheal and flare reaction

Clinical manifestations

- Red oozing crusting rash

- Dry thick brownish-grey and scaly skin
- Pruritus
- Lesion are mostly found:
o Hand, foot
o Back of the knees, neck, face, eyelids and
Anaphylactic responses can be… elbow bands

Localized reactions Medical Management

- Hay fever, asthma, hives - Moisturizers

- Antibiotics
Systemic reactions - Antihistamines
- Shock and breathing difficulties
C. Asthma
- Is a chronic inflammatory disease of the airways that
causes airway hyper-responsiveness, mucosal edema,
and mucus production

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Predisposing factors: Clinical manifestation

- Allergy Mild Moderate Severe

- Chronic exposure to airway irritants or allergens
Occurs within first Same Same
3 major signs 2 hrs. of exposure
Peripheral tingling Flushing Bronchospasm
- Airway blockage Sensation of Itching Laryngeal edema
- Inflammation warmth
- Airway irritability Fullness in mouth Bronchospasm Severe dyspnea,
& throat cyanosis
Clinical Manifestations/ Symptoms
Nasal congestion Edema of larynx Hypotension
- Cough Periorbital Dyspnea Cardiac arrest &
- Dyspnea swelling coma may follow
- Wheezing Pruritus Cough
Sneezing Wheezing
Classification

- Mild intermittent asthma Prevention and treatment of anaphylaxis

- Mild persistent asthma
- Avoidance of potential allergens
- Moderate persistent asthma
- Avoid areas populated by insects
- Severe persistent asthma
- Use appropriate clothing & insect repellent
Risk factors - Auto injection system: EpiPen
- May follow w IV epinephrine
- Genes - IV fluids
- Race - Screening for allegies before med administration
- Lung infection, allergies or obesity

Diagnostic test

- Spirometry
- Peak flow
- Methacholine challenge
- Chest x-ray
- Allergy test

Medical management

- Long-acting beta-agonists
- Combination inhaler
- Theophylline

Pathophysiology of an Allergic Reaction

Antigen (foreign substance)

Lymphocytes will respond to the Antigen
Immune system
Chemical mediators
Allergic reaction
Anaphylaxis – is an immediate life threatening systemic
reaction that can occur exposure to a particular substances.
* Inject the medicine into the fleshy
outer portion of the thigh. Do not
inject into a vein or the buttocks. Hold
the leg firmly in place before & during
the injection. You can give the
injection through clothes or on bare
skin.
Medical management:

Causes: For cardiac arrest:

- Food 1. CPR
- Medication insect stings 2. O2 therapy
3. Epinephrine
Pathophysiology
Additional management:
Interaction of foreign antigen w IgE antibodies
1. Antihistamine
Release of histamine 2. Corticosteroids
3. Aminophylline
Activation of platelets, eosinophils & neutrophils

Smooth muscle spasm, bronchospasm, mucosal edema and

inflammation Systemic anaphylaxis

- Due to widespread degranulation of mast cells after

crosslinking of IgE on the mast cell surface.

Severe manifestations:

- Airway obstruction and hypotension

Other signs:

- Urticarial, angioedema

Type II: Cytotoxic reaction (antibody-dependent)

- These allergic reactions are systemic or localized, as

in allergic dermatitis.

M. FAR 
Cytotoxic hypersensitivity Clinical manifestations

- Antibodies involved: IgG & IgM - Expressionless face

- Antigens: Cellular or Cell-bound - Nasal timbre
- Reactions involved antibodies directed to antigen on - Ptosis
surface of specific cells or tissues resulting to cytolysis - Diplopia
(complement activation) - Dysphagia
- Dysarthria
Clinical states - Dysphonia
- Weakness of all extremities
- Hemolytic transfusion reactions (HTRs)
- Hemolytic disease of the newborn (HDN) Diagnostic test
- Myasthenia Gravis
- Acetylcholine receptor antibody
- Tensilon test (edrophonium chloride)
- Anti- muSK antibody testing
Hemolytic transfusion reaction (HTR)
Therapeutic management
- Transfusion of ABO group-incompatible blood
- The most common cause is clerical error - Pyridostismine bromide
o Person who are transfused w the wrong blood - Azathioprine
type will produce anti-hemagglutinins causing - Prednisone
complement mediated lysis

Type III- Immune complex reaction

Hemolytic disease of the newborn (HDN) - An abnormal immune response is mediated by the
formation of antigen-antibody aggregates called
Erythroblastosis fetalis
“immune complexes.”
- A severe hemolytic disease of a fetus or newborn
Clinical state:
caused by production of maternal antibodies for Fetal
RBC - Serum sickness
- Most commonly develops when an Rh+ fetus - Systemic lupus erythematosus
expresses an Rh antigen on ots blood that an Rh - Rheumatoid arthritis
mother
Serum sickness

- Is caused by drugs containing a protein moiety of other

species (heterologous protein) such as:

 Antivenins, vaccines, antitoxin, and

streptokinase
 The heterologous protein can act as
an antigen triggering the immune
response
o Stings from insects, ticks, and mosquito bites
may cause serum sickness

Three main symptoms of serum sickness

Myasthenia Gravis
- Fever
- Is a rare chronic - Rash
autoimmune - Painful swollen joints/
neuromuscular peripheral edema
disorder that causes
weakness in the
Therapeutic management:
skeletal muscles,
which are the - Nonsteroidal anti-inflammatory drugs
muscles your body - Antihistamines
uses for movement - Steroids
- Marked by muscular
weakness without Systemic lupus erythematosus (SLE)
atrophy, and caused
by a defect in the action of acetylcholine at - An autoimmune disease in
neuromuscular junctions. which the body’s immune
mistakenly attacks healthy
Predisposing Factor tissue
- Involves major organ
Age – incidence of myasthenia Gravis occurs between ages 15- systems
35 for women - Exacerbations, remissions
Gender- myasthenia Gravis is three times more common in Causes:
women than men
- Sunlight
Hereditary- a person born into family with history of certain - infections
autoimmune disease is at risk of developing such autoimmune - Medications
disease
Risk factors:
Poor environment – constant exposure to dust or chemical
substances can weaken the immune system of every individual - Sex
that lead to infection - Age

Stress- stress can weaken the immune system

M. FAR 
 - Race Rheumatoid Arthritis

- is an autoimmune
chronic, systemic,
inflammatory
disease
predominantly
affecting joints &
periarticular tissues

Pathophysiology

- inflammation
- synovial
- proliferation
- joint tissue
destruction

Symptoms:

- Fatigue
- Fever
- Joint pain, stiffness and swelling
- Butterfly-shaped rash on the face
- Skin lesions that appear or worsen w sun exposure Risk factors:
Assessment:
- Female gender: age 20-50 yrs.
- Erythematous rash: - genetic predisposition
o Face, neck, extremities - stress
- Butterfly rash
- Alopecia
- Oral, nasopharyngeal lesions Assessment: symmetrical
- Joint pain and morning stiffness
o (fingers, hands, wrists, knees) JOINTS

Diagnostic test: - painful, warm, swollen,

limited motion
- Complete blood count - morning joint stiffness
- Erythrocyte sedimentation rate - slight fever
- Kidney and liver assessment - fatigue
- Antinuclear antibody (ANA) test - weight loss
Imaging Tests:

- Chest x-ray Diagnostic criteria

- Echocardiogram
- morning stiffness lasting more than 1 hr
Medical management - arthritis of 3 of more than joint areas
- arthritis of hand joints
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- symmetric arthritis
- Antimalarial drugs (hydroxychloroquine Plaquenil)
- rheumatoid nodules over extensor surfaces or bony
- Corticosteroids (Prednisone)
prominences
- Immunosuppresants (azathioprine and methotrexate)
- serum rheumatoid factor
- Biologics (belimumab)
- radiologic changes
- Rituximab (Rituxan)
* The presence of 4 or more criteria is diagnostic of RA
Interventions:
* Criteria 1-4 w joint s/sx must be present for 6 weeks
Prevent EXACERBATIONS:

- maintain good nutrition

- avoid exposure:
o infections
o sunlight (heavy sun screen)
o stress
o fatigue

Complications:

- heart (Pericarditis)
- kidneys (Renal failure)
- brain and CNS
- lungs (Pleurisy)

Having lupus also increases your risk of…

- infection
- cancer
- bone tissue death (avascular necrosis)
- pregnancy complications

M. FAR 
 - Transplant rejection

Contact dermatitis

- Is an allergic or irritant
reaction that causes a
painful or itchy skin rash

Transplantation rejection

- Occurs when transplanted tissue is rejected by the

recipients immune system, which destroys the
transplanted tissue

Major types of grafts

1. Autografts – tissue transplanted from one site to

another on the same person
2. Isografts – tissue grafts from an identical person
(identical twin)
3. Allografts – tissue from an unrelated person
4. Xenografts – tissue taken from a different animal
species

Diagnostic test Three types of rejection

- rheumatoid factor (RF) 1. Hyperacute rejection – occurs few mins after the
- increase C-reactive protein transplant when the amtigens are completely
o 1.0 mg/L – 3.0 mg/L unmatched
- Arthrocentesis 2. Acute rejection – may occur any time from the first
o Increase WBC week after the transplant to 3 months afterward
o RF present 3. Chronic rejection – can take over many years

Arthrocentesis

Medical management: Chronic rejection

NSAID’s T lymphocytes (Type IV reaction) causes a relentless

destruction of parenchymal cells
- Aspirin
- Ibuprofen (Motrin)
- Indomethacin (Indocin) Cardinal features:
Principles of management
- Obliteration of the lumen of blood vessels by prolifering
- Rest to acutely inflamed joints smooth muscle cells and interstitial fibrosis
- Relief of pain and stiffness
Graft versus Host disease
- Reduction of inflammation
- Prevention of articular damage - GVHD happens when T cells in the donated bone
- Preservation of joint function and muscle strength marrow or stem cells attacked host body cells
- Improve general wellbeing of patient - It is difficult to day who will develop GVHD but 1 and 4
out of every 6 people (20-80%) will develop some
Nursing intervention
degree of GVHD.
Relieve pain - Some may have mild form, but others may have severe
form which is a life threatening
- Cold compress (acute episode) - Some people may have GVHD over months or even
- Warm compress (chronic pain) years.
- Immobilize (splints)
- Bed rest (acute) * GVHD develops because the transplant affects the immune
- Firm mattress system

Maintain joint mobility

- ROM exercise
- Swimming – to maintain muscle movement and ROM

Type IV: Cell-mediated (delayed hypersensitivity)

- Results from specifically

sensitized T lymphocytes
without the participation of
antibodies
- Typically occur 24-72 hrs. after
exposure to an antigen

Clinical state:

- Contact dermatitis
- Tuberculin test

M. FAR 