IMMUNOLOGY AND SEROLOGY
Lecture| finals: Immunodeficiencies
IMMUNODEFICIENCY DISEASES
If autoimmune disorders are disorders were the
immune system attacks itself. In
immunodeficiency disease these are the
disorders in which body’s immune system is not
functioning well because there is something
missing or there is a component that is
dysfunctional. People with this condition will
have a decrease ability to defend themselves
against infectious organisms and are more
susceptible to developing certain types of
cancer.
Evaluating Immunoglobulin Deficiency States
In evaluating immunoglobulin deficiency states,
it is important to remember that blood levels of
immunoglobulins change with age.
 Age
 Blood level of IgG at birth = adult level
o The blood level of IgG at birth
is about the same as the adult
level, reflecting transfer of
maternal IgG across the
placenta.
 IgG level declines over the first 6
months of life
o The IgG level drops as maternal
antibody is catabolized.
 Levels of IgA and IgM are low at birth
o The concentrations of all
immunoglobulins gradually rise
when the infant begins to
produce antibodies at a few
months of age, in response to
environmental stimuli.
 IgM (1 yr) → Igg (5-6 yrs) → IgA
(adolescence)
o IgM reaches normal adult levels
first, around 1 year of age,
followed by IgG at about 5 to 6
years of age. In some normal
children, IgA levels do not reach
normal adult values until
adolescence. Therefore, it is
important to compare a child’s
immunoglobulin levels to age-
matched reference ranges.
The Nine Categories of Primary
Immunodeficiencies
Category 1: Combined Immunodeficiencies
Category 2: Combined Immunodeficiencies
With Associate or Syndromic Features
Category 3: Predominantly Antibody
Deficiencies
Category 4: Diseases of Immune Dysregulation
Category 5: Congenital Defects of Phagocyte
Number, Function, or Both
Category 6: Defects in Innate Immunity –
sometimes they overlap because the complement
deficiencies are also part of the innate immune
system
Category 7: Autoinflammatory Disorders
Category 8: Complement Deficiencies
Category 9: Phenocopies of Primary
Immunodeficiencies
Category 1: Combined Immunodeficiencies
- Contains diseases in which there are
defects in both humoral which mean
there are problems with the B cells and a
problem with the T cells as well
consequently affecting the cell-mediated
immunity. This deficiencies result from
a mutation that develop that affects the
development of both types of
lymphocytes or cause defective
interaction between the two antigen
specific claims of the adaptive immune
sysrem.
Severe Combined Immunodeficiency (SCID)
 The most serious of the congenital
immune
 a group of related diseases that all affect
T- and B-cell function but with differing
causes.
 Interleukim-2 receptor gamma
(IL2RG) gene
o Mutation of this, IL2RG is
located on the X chromosome
and considered as the most
common form of the disease
approximately accounting for 46
of the cases in the United States.
o Patients with SCID generally
present early in infancy with
infection by nearly any type of
organism. Oral candidal
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infections, pneumonia, and
diarrhea are the most common
manifestations.
o Babies with Severe SCID
should not be given live
vaccines because their immune
system is defective, live
vaccines can actually cause
them severe illness unless
immune reconstitution can be
achieved by bone marrow
transplantation or by
specifically replacing a deficient
enzyme, patients with SCID die
before they reach 2 years of age.
 Adenosine deaminase (ADA)
deficiency
o About 15 to 20 percent of the
patients with SCID
o leads to T-negative which mean
there is no/negative T cell, B cell,
no NK phenotype ; no antiseptic, it
doesn’t have any lymphocytes
o Located in chromosome 1 region
of the long arm of the acute 21
o Will affect an enzyme involved in
the metabolism of purines, it is
actually had similarities with PNP
deficiency. There will be toxic
metabolites of the purines that will
accumulate in lymphoid cells and
impair their proliferation of Both B
and T cells. It is not produce rather
these cells are unable to proliferate
because they’re being killed by
toxic metabolites.
 Purine-nucleoside phosphorylase
(PNP) deficiency
o Produces moderate to severe defect
in the cell mediated so it is more on
the T cells with a normal or mildly
impaired humoral immunity.
o The number of T cells
progressively decreases because of
the accumulation of
deoxyguanosine triphosphate, a
toxic purine metabolite.
o The levels of immunoglobulins are
generally normal or increased.
About two-thirds of PNP-deficient
patients also have neurological
disorders, but no characteristic
physical abnormalities have been
described. Because of the relatively
selective defect in cell-mediated
immunity, PNP deficiency can be
confused with neonatal HIV
infection. The two conditions can
usually be distinguished by specific
tests for anti-HIV antibody (if the
infant is old enough to be producing
antibody) and by assays for PNP
activity.
o One immunodeficiency state for
which a specific enzymatic basis.
o PNP deficiency is a rare autosomal
recessive trait. The condition
presents in infancy with recurrent
or chronic pulmonary infections,
oral or cutaneous candidiasis,
diarrhea, skin infections, urinary
tract infections, and failure to
thrive.
o PNP deficiency affects an enzyme
involved in the metabolism of
purines.
Category 2: Combined Immunodeficiencies
With Associate or Syndromic Features
- Differs from the category 1 in that the
diseases in category 2 are characterized
by non-immunologic features in addition
to the combined immunodeficiency.
Diseases in this category are typically
caused by defects in cell mediated
immunity which will indirectly lead to
problems with other branches of the
immune responses. Oftentimes, diseases
can result from abnormalities at
different stages of T-cell development.
Wiskott-Aldrich Syndrome (WAS)
 These are abnormalities in both the
cellular and humoral branches of the
immune system, related to a general
defect in antigen processing.
 triad of immunodeficiency, eczema
(inflammation of the skin), and
thrombocytopenia (low platelet count)
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o Patient will display severe
deficiency also of naturally
occurring IgM antibodies to
ABO blood group or
isohemagglutinins which means
you cannot do a reverse blood
typing for the patient with WAS
because their anti-A and anti-B
antibodies are very low or
almost zero.
 Absence of isohemagglutinins
o Absence of isohemagglutinins
(IgM antibodies against ABO
blood group antigens) is the
most consistent laboratory
finding in WAS and is often
used diagnostically.
o In addition, these patients have
persistently increased levels of
serum alpha-fetoprotein, which
can also be a useful diagnostic
feature.
 Low levels of IgM, normal levels of IgA
and IgG, and increased levels of IgE
o The antibody against the ABO
blood group which is called
isohemagglutinins are naturally
occurring antibodies against
antibodies which are IgM in
nature are severely decrease.
o The gene responsible for the
defect is called the WASp gene,
and it is located on the X
chromosome, region p11. It
actually affects the:
 integral membrane protein CD43
DiGeorge Anomaly
 developmental abnormality of the
thymus
o The thymus will fail to develop.
Thymus is the exclusive primary
lymphoid organ for the
production, education, and
differentiation of the T-cells
 is a developmental abnormality of the
third and fourth pharyngeal pouches that
affects thymic development or
consequently leading to the impaired
development of thymus in the embryo.
 The defect in the third and fourth
pharyngeal pouches will have a severe
and persistent decrease in T cell
numbers.
o about 20 percent of children
 decrease in T-cell numbers
 Severely affected children usually
present in the neonatal period with
tetany (caused by hypocalcemia
resulting from hypoparathyroidism) or
manifestations of cardiac defects.
 The immunodeficiency associated with
the DiGeorge anomaly is a quantitative
defect in thymocytes. Not enough
mature T cells are made, but those that
are present are functionally normal. The
immunodeficiency of DiGeorge
syndrome can be treated with fetal
thymus transplantation. Bone marrow
transplantation has also been successful
in some patients, as has administration
of thymic hormones.
Ataxia-Telangiectasia
 A rare autosomal recessive syndrome
characterized by cerebellar ataxia which
is involuntary muscle movements and
telangiectasias where the blood vessels
are so fragile, it usually involves
capillary swelling resulting in red
patches on the skin especially on the
earlobes and conjunctiva.
 Combined defect of both humoral and
cellular immunity. Antibody response to
antigens, especially polysaccharides, is
blunted.
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 The levels of IgG2, IgA, and IgE are
often low or absent, although the pattern
can be quite variable.
 Number of circulating T cells is often
decreased.
Category 3: Predominantly Antibody
Deficiencies
- This category encompasses conditions in
which the main characteristic is low
levels of serum immunoglobulins term
agammaglobulinemia. The
mechanisms of agammaglobulinemia
include genetic defects and B-cell
maturation or mutations leading to
defective interactions between B and T
cells. The conditions in this category are
the most common immune deficiencies
representing about 50% of the primary
Immunodeficiencies.
Transient Hypogammaglobulinemia
All infants experience low levels of
immunoglobulins at approximately 5 to 6
months of age, but in some babies, the low
levels persist for a longer time.
 Low levels of immunoglobulins at
infancy with normal numbers of B cells
 Severe pyogenic sinopulmonary and
skin infections
o Because these children do not
begin synthesizing
immunoglobulin promptly, they
can experience this as protective
maternal IgG is cleared.
 9 to 15 months of age
o Immunoglobulin levels usually
normalize spontaneously
*The mechanism of this transient
hypogammaglobulinemia is not known. These
patients have normal numbers of circulating
CD19 positive B cells. This condition does not
appear to be X-linked, although it is more
common in males. The cause may be related to a
delayed maturation of one or more components
of the immune system, possibly T helper cells.
X-linked Bruton’s Tyrosine Kinase (Btk)
Deficiency
 lack circulating mature CD19 positive B
cells and exhibit a deficiency
 lack of immunoglobulins of all classes.
 Males exclusive
 Arrested differentiation at the pre-B
cell stage
o No pre-B cells no plasma cells
in their lymphoid tissues but
they will still have the T-cells
both in normal quantity and
normal quality
o About half of the patients have a
family history of the syndrome.
They develop recurrent bacterial
infections beginning in infancy,
as maternal antibody is cleared.
 The underlying genetic mechanism is a
deficiency of an enzyme called the
Bruton tyrosine kinase (Btk) in B-cell
progenitor cells. Lack of the enzyme
apparently causes a failure in the
immunoglobulin variable and heavy
(Vh) gene rearrangement. The syndrome
can be differentiated from transient
hypogammaglobulinemia of infancy by
the absence of CD19 positive B cells in
the peripheral blood, by the abnormal
histology of lymphoid tissues, and by its
persistence beyond 2 years of age.
*In transient you have low antibodies yet you
have normal number of B cells. In X-Linked you
have decrease antibody but you don’t have B
cells.
Selective IgA Deficiency
 Most common congenital
immunodeficiency
 Asymptomatic
o But those with symptoms
usually have infections of the
respiratory and gastrointestinal
tract and an increased tendency
to autoimmune diseases
(because we know IgA is mostly
found in bodily secretion so the
cause of selective IgA
deficiency is impaired
differentiation of lymphocytes
to become IgA producing
plasma cells ) such as systemic
lupus erythematosus,
rheumatoid arthritis, celiac
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disease, and thyroiditis. Allergic
disorders and malignancy are
also more common.
 < 5 mg/mL : severe
 IgA antibodies in severe state
o Anti-IgA antibodies are
produced by 30 to 40 percent of
patients with severe IgA
deficiency. These antibodies can
cause anaphylactic reactions
when blood products containing
IgA are transfused. Because
many patients with severe IgA
deficiency have no other
symptoms, the IgA deficiency
may not be detected until the
patient experiences a transfusion
reaction resulting from the
presence of anti-IgA antibodies.
Products for transfusion to
known IgA-deficient patients
should be collected from IgA-
deficient donors, or cellular
products should be washed to
remove as much donor plasma
as possible
Common Variable Immunodeficiency (CVI)
 most common primary immune
deficiency (PID) with a severe clinical
syndrome
 Is a heterogeneous group of disorders
with a prevalence of about 1 in 25,000.
 Patients usually begin to have symptoms
in their 20s and 30s, but age at onset
ranges from 7 to 71 years of age.
 hypogammaglobulinemia that leads to
recurrent bacterial infections,
particularly sinusitis and pneumonia.
 low serum IgG level IN patients with
recurrent bacterial infections
 In contrast to X-linked
agammaglobulinemia, most patients
with CVI have normal numbers of
mature B cells. However, these B cells
do not differentiate normally into
immunoglobulin-producing plasma
cells.
o That is why transient after 9-15
months of age will be gone; the
antibody will arise. In CVI, it
will reach 71 years old that has
no immunoglobulins because B-
cells although present they will
not differentiate into the
immunoglobulin producing
plasma cells.
 CVI is often a diagnosis of exclusion,
where an immunodeficiency is present
with no specific genetic defect defined
Isolated IgG Subclass Deficiency
 Usually diagnosed by having level of
one or more of the IgG subclasses is
more than two standard deviations
below the mean age-appropriate level.
 The most common subclass deficiency
is IgG4, with IgG1 deficiency being the
least common yet more clinical
significant, although IgG4 subclass
deficiency may have the least clinical
significance.
 IgG1 or IgG3 : reduced response
capability to protein antigens such as
toxins, while selective deficiencies of
 IgG2: impaired responses to
polysaccharide antigens, which cause
recurrent infections with
polysaccharide-encapsulated bacteria
such as Streptococcus pneumoniae and
Haemophilus influenza. These include
heavy chain gene deletions and
transcriptional defects.
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Category 4: Diseases of Immune
Dysregulation
- These are diseases with normal numbers
of T or B cells but we just control over
their functions; less on quantitative but
more on qualitative and they would have
usually normal numbers of T and B
cells.
 Autoimmune lymphoproliferative
syndrome
o Many of the diseases in this
category will also have features of
autoimmunity the outlet of
autoimmune lymphoproliferative
syndrome which involves mutation
in genes coding for caspases that is
involved in apoptosis. Once there is
defective apoptosis in the thymus
this will lead to autoreactive cells in
the circulation so that will cause
autoimmune lymphoproliferative
syndrome
 Defective apoptosis
 CD25 deficiency
o Manifested by a lack of T-reg cells.
No T-reg cells which leads to
reparation and autoimmunity
because T-reg cells are like the
regulatory cells they control the
length or the duration of the
immune response, without them
there is a tendency of hyper
proliferation and eventually
autoimmunity will happen.
Mutation in the fox53 gene is
required for direct differentiation so
they may show a similar clinical
presentation.
 Chediak-Higashi syndrome
o Immune deficiency that is
associated that has
hypopigmentation (albino) that
is caused by mutation in the IST
gene. There is a reduced number
of NK cells and neutrophils but
an increased production of
inflammatory proteins.
Category 5: Congenital Defects of Phagocyte
Number, Function, or Both
- These are primary immune deficiencies
where there is an abnormality in the
phagocytic cell.
Chronic Granulomatous Disease (CGD)
The most common and the best characterized of
all the neutrophil abnormalities, this is a genetic
defect in any of the several components of
NADPH oxidative system that can result in
CGD phenotype by making the neutrophil
incapable of generating an oxidative burst.
Remember: For phagocyte, part of the process
of phagocytosis is bacterial killing through the
production of reactive oxygen species- hydrogen
peroxide that will kill the bacteria. This
phenomenon is called as the oxidative burst. If
the oxidative burst does not happen the bacteria
will not be killed and thus they will be choke,
can’t digest eventually that will kill also the
neutrophils if it was from the inside. Typically
catalyst positive organisms such as
Staphylococcus aureus, Burkholderia cepacia
Chromobacterium violaceum are involved in
addition to fungi such as aspergillus and
nocardia. The infection would usually begin
before 1 year of age and the syndrome is often
fatal in childhood.
 Inability of the patient’s neutrophils to
produce the reactive forms of oxygen
necessary for normal bacterial killing
 Nitroblue tetrazolium (NBT) reaction
o Before, to diagnose CGD we
employed this. The neutrophil
of the patients are evaluated on
their ability to reduce the natural
blue tetrazolium dye. NBT
reduction is caused by the
production of hydrogen
peroxide and other reactive
forms of oxygen. In other
words, the NBT dye will be
used by the neutrophil. The
neutrophil will reduce NBT dye
into a blue precipitate. The
reduction will supposed to
produce H2O (WATER) they
will reduce the NBT. The
reduction will cause the NBT to
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happen and there will be no
color. If it reduce because no
H2O production it will become
blue and it is a positive.
 Dihydrorhodamine (DHR)
o The methodology is more of a free
flow cytometric assay which involves
the labeling of the neutrophils with
DHR .DHR will fluoresce when it is
reduced. The neutrophils are then
activated using PHORBOL
MYRISTATE ACETATE OR
PMA which is mitogenic for
neutrophils. The resultant oxidative
burst will reduce the DHR resulting
in fluorescence that may be
quantitated on the flow cytometer.
Neutrophils from CGD patients will
be unable to undergo the oxidative
burst and will show less
fluorescence, less confusing than
normal neutrophils. This technique is
more objective and quantitative than
the traditional NBT technique. The
fluorescence us directly proportional
to the amount/ ability of the
neutrophil to do and to produce an
oxidative burst so low fluorescence
means no sedative burst. High
fluorescence means normal and
functional killing of neutrophil.
Neutrophil Glucose-6-Phosphate
Dehydrogenase Deficiency
 An inability to generate enough NADPH
to supply reducing equivalents to the
NADPH oxidase system.
o This leads to a defect in
hydrogen peroxide production
and a clinical picture similar to
that of CGD.
Myeloperoxidase deficiency
 Recurrent candidal infections.
o Is relatively common, occurring
in about 1 in 3000 persons in the
United States. Deficient patients
may have this.
o Defects of neutrophil secondary
granules have also been
described. However, the
molecular nature of the defects
is unknown.
Leukocyte Adhesion Deficiency (LAD)
Not on phagocyte killing but on the problem in
the adhesion of neutrophils and even on your
monocytes
 CD18- LAD is a deficiency in this
protein.
o Component of adhesion
receptors on neutrophils and
monocytes (with CD11b or
CD11c) and on T cells (with
CD11a) is defective.
o The CD18 deficiency is
transmitted with autosomal
recessive inheritance and has
variable expression. This defect
leads to abnormal adhesion,
motility, aggregation,
chemotaxis, and endocytosis by
the affected leukocytes.
 Delayed wound healing, chronic skin
infections, intestinal and respiratory
tract infections, and periodontitis.
 Decreased amount of the CD11/18
antigen on patient leukocytes by flow
cytometry
o defect in CD18 can be
diagnosed by detecting this
Category 6: Defects in Innate Immunity
 mutations in Toll-like receptors (TLRs)
o TLR 3 specific deficiency will
result in herpes simplex
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encephalitis, defect in TLRs
signaling pathways example is
IRAK4 deficiency can also
happen and cause herpes
encephalitis.
o The diagnosis for category 6
involves more on clinical
presentation and would lead to
molecular analysis to identify
the specific gene mutation.
Category 7: Autoinflammatory Disorders
Can be subdivided into two classifications those
involving the inflammasome and non-
inflammasome.
 Inflammasome
o Is a protein oligomer that contains
caspase enzymes and other proteins
associated with apoptosis. Caspase
= apoptosis. Located primarily in
myeloid cells and may be activated
by various microbial substances.
Once activated the inflammasome
stimulates the production of the
pro-inflammatory cytokines IL-1
and IL-18. Basically it is called
inflammatory because you are
producing a protein that will
activate stimulation of production
of the pro-inflammatory cytokines
that is harmful to your immune
system that is like
autoinflammatory. It is like an
autoimmune disease for the
immune system that leads to an
immunodeficiency
o Hyper IgD syndrome- caused by a
deficiency of mevalonate kinase an
enzyme that involved in steroid
synthesis pathway which is the
syndrome has been seen primarily
in Northern European population
o Muckle-Wells syndrome – caused by
mutation in CIAS1 gene coding for
cryopyrin a component of the
inflammasome. The patients here
will present with urticarial (sige
pangatol) and amyloidosis.
 Non-inflammasome
o Tumor necrosis factor (TNF)
receptor-associated periodic
syndrome (TRAPS) – Is caused by a
mutation in TNF -Tumor Necrosis
Factor receptor associated is TNFR-
SF1A gene. TNFRSF1A gene codes
for the TNF receptor and my result in
recurrent fevers as well as ocular
endpoint inflammation in the ;
o Early onset inflammatory bowel
disease – another non-inflammatory
disorder under the category 7 is
caused by imitation in genes coding
for IL-10 and its receptor.
Category 8: Complement Deficiencies
 C1q, C4 and C2: lupuslike syndrome
o C2 is most common but least
important
 C3: lupuslike syndrome but recurrent
infectionwith encapsulated organisms
 C5-C9 : Neisseria meningitides
infections
 C1 esterase inhibitor: hereditary
neuroangioedema
Category 9: Phenocopies of Primary
Immunodeficiencies
 Chronic mucocutaneous candidiasis – a
disease that was classifies as a cell
mediated deficiency now transferred to
category 9. This disease is induced by a
genetic mutation in the AIRE gene a
gene involved in the production of the
antibodies or either IL-17 and IL-22.
Screening Tests
Before you all these tests always bear in mind
that you always have to start with patient
history. Why? Think about it and answer this
question on the exam.
 Complete blood count (CBC) and white
blood cell (WBC) differentials
 Levels of serum IgG, IgM, and IgA and
levels of the subclasses of IgG
 Assay for isohemagglutinins
 CH50 assay
 Flow cytometric assay – esp. for more
problem on the quantitative defect
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