CONTENTS .

Preface
 Introduction (How Summarization Helps) (i)
 E Summarization project (Process of Making it) (ii)
 Coordinating Teams and their Roles (iii)
 Message from Dr. Raza Younus (iii)
 What Next (iv)
 Contributors towards summarization Group (v)
 Task-Based Team Members (vi)

Summary
 Week 1: Anemia 1
 2: Bleeding Disorders 17
 3: Immunity 31

Reference Guide 43 Onwards

SUMMARY
  Supporting framework by reticular connective tissue
consisting of reticular cell and reticular fibers.
Classified into three categories
1. Diffused lymphoid tissue
2. Nodular lymphoid tissue
3. Lymphoid organs
Lymphoid organs
 Contain lymphoid tissue
 Each tissue is covered by a fibrous capsule

Primary Lymphoid Organ

 Production of T lymphocytes
 Thymus
Secondary Lymphoid Organ
HISTOLOGY  Increase lymphocyte in number
Describe the composition of blood  Take part in immune response against antigen
 Lymph nodes, spleen, tonsils
Plasma: 55%
 Water: 1% Lymph nodes
 Proteins (albumin, globulin & fibrinogen): 7 %  Small oval or bean shaped bodies
 Other solutes (electrolytes, nutrients): 2 %  Serve as immunologic filters of lymph
Formed elements: 45% Each node consists of
 Hilum (in which arteries enter while the veins and
 RBCs: Millions
efferent lymphatic vessels leave the node at hilum)
 Platelets: Hundreds of thousands
 Supplied by a large number of afferent lymphatic
 WBCs: Thousands
vessels
1. Neutrophils: 70%
2. Lymphocytes: 20%  Covered by a connective tissue capsule composed of
3. Monocytes: 5% densely packed collagen fibers
4. Eosinophils: 4%  Trabeculae
5. Basophils: 1%  Reticular fibers and reticular cells
 Parenchyma consists of two regions
 Outer darkly staining cortex
 Inner lightly staining medulla
Lymph node cortex
They consist of trabeculae, capsule, sub capsular sinuses,
cortical sinuses. Divided into two regions
1) Nodular Cortex
 Contains primary as well as secondary lymphatic
nodules.
 Primary do not exhibit germinal center while
secondary shows light germinal center and darkly
stained peripheral mantle zone or corona.
 Composed of mainly B lymphocytes and plasma cells.
 Diffused populations of small lymphocytes are also
present.

Discuss lymphoid system

It consists of
1. Lymphoid tissue
2. Lymphoid organs
3. Lymph nodes
Lymphoid tissue
 Also called lymphatic tissue.
 A special type of connective tissue. 2) Germinal Centre:
 Large numbers of lymphocytes are present.
 Antigen reaches central region of nodule

Blood & Immunity Module | 1

  Activation of B-cells 5000 to 10000. Leukocytes further classify into granulocytes
 B cells form plasmoblasts and lymphoblast. (take and a granulocytes.
lighter stain) GRANULOCYTES are further classified into:
 Centre also contains follicular dendrite cells which 1. Neutrophils
are antigen presenting cells. 2. Eosinophils
3) Mantle Zone: 3. Basophils
 Contain dens e accumulation of small lymphocytes and A GRANULOCYTES are classified into:
plasma cells. 1. Lymphocytes
Para cortex 2. Monocytes

It is the region between nodular cortex and medulla Platelets:

containing:
 Loosely aggregated T lymphocytes, so called as thymus-  The platelets are small disc like cytoplasmic fragments
dependent zone about 2 to 4 micrometer in diameter.
 Special type of post capillary venules present called  They appear flat, roughly oval in shape.
high endothelial venules HEVs which plasma lemma  Normally ranges from 200000 to 400000.
contains receptors for antigen primary lymphocytes
which allow migration of lymphocytes from blood
stream to Para cortex region.
Medulla:
 Consists of trabeculae, medullary cords and medullary
sinuses
 Medullary cords consist of B lymphocytes and plasma
cells lying in the network of reticular fibers and reticular
cells.

Histology of blood
The formed elements of blood are:
Erythrocytes
PHYSIOLOGY
 A mature erythrocyte is also called red blood cell is
shaped like a biconcave disc.
Blood composition and function
 It does not contain a nucleus and also no typical cell
organelles. Deduce hematological abnormalities on the basis
 It measures about 7-8 micrometer in diameter and of composition of blood
2.6 micrometer thick.
It is connective tissue in fluid medium that is pumped
through a closed system of blood vessels by the heart to
whole body. It is about 8-9% of total body weight.
Blood is composed of two major parts
1. Plasma
2. Cells
Plasma
 55% of total blood volume
 Water
 Organic and inorganic constituent
 Proteins
 Other solutes
Cells
 45% of total blood volume
 RBCs (erythrocytes)
 WBCs (leukocytes)
 Platelets (thrombocytes)

Blood disorders affecting red blood cells

Leukocytes: Hematological abnormalities of blood include increase or
decrease in the number of RBCs.
Leukocytes possess a nucleus and capable of ameboid
movement and contain no hemoglobin adults it ranges from Anemia

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A decrease in the number of RBCs which can occur due to  Provides immunity
different reasons:  Destroys invading bacteria’s or
 Excessive blood loss viruses(phagocytosis)
 Malabsorption of vitamins  Antibody production
 Absence of intrinsic factor  Forms sensitized lymphocytes.
 Malnutrition Thrombocytes:
 Radiations
 Blood clotting
 Auto immunity
 Viral infections
Relate the physiology of spleen with effect of
Polycythemia: splenectomy and diseases
Increase in the number of red blood cells. When the spleen enlarges up to 40% of the red cell mass
 RBCs may increase up to 7 to 8 million/mm3. may be pooled in the spleen. This functionally excludes a
 Hematocrit increases up to 60 – 70%. large volume of red cells from the circulation and results in
It is caused by: functional anemia.
o Hypoxia or
o Genetic aberrations Erythropoiesis
Blood disorders affecting white blood cells: Associate the structure of RBC with their function
1. Lymphoma
Biconcave disc shape
2. Leukemia
 Increases surface area to volume ratio, therefore rate of
3. Multiple myeloma
diffusion increases.
4. Myelodysplastic syndrome
 Allows rapid diffusion of respiratory gases to and from
Blood disorders affecting platelets: the cell due to its biconcavity.
 Thrombocytopenia  Can easily pass through the small capillaries by squeezing
because it can deform to almost any shape.
Correlate the count of Red blood cells with clinical  A major function of RBCs is to transport hemoglobin,
which, in turn, carries oxygen from the lungs to the
conditions like Anemia and Polycythemia
tissues.
Normal RBCs Count:  They contain a large quantity of carbonic anhydrase, an
 Males : 5.4 million per ml enzyme that catalyzes the reversible reaction between
 Females : 4.8 million per ml carbon dioxide (CO2) and water to form carbonic acid
(H2CO3), increasing the rate of this reaction several
ANEMIA:
thousand fold.
Deficiency in the oxygen carrying capacity of blood due to
Hemoglobin:
decreased erythrocyte mass is known as anemia.
 Its main function is to carry oxygen.
 Abnormally low RBC count
 Flexible deformable cell membrane.
 Erythrocytopenia
 No nucleus or other organelles.
 < 4.5 million/mm RBCs in males
3
 So, the energy (ATP) is produces via HMP-Shunt in
 < 3.9 million/mm RBCs in females
3
cytoplasm.
 < 13.5 gm/dl Hb in males
 < 11.5 gm/dl Hb in females Discuss stages of erythropoiesis
POLYCYTHEMIA:
Increased number of blood cells is known as polycythemia.
 Abnormally high RBC count
 Impeded blood flow
 RBCs : 7 – 8 million/mm
3

 Hematocrit : 60 – 70 %
Highlight the functions of blood cell
Erythrocytes:
 Oxygenation of tissues
 Transport of O2 and CO2.
 Excellent acid – base buffer
 Contributes to the blood viscosity
 Antigens present on RBC membranes forms the
blood group system
 Contains carbonic anhydrase, an enzyme which is
used in catalysis of reactions.
Leukocytes:
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 RBCs are produced in the bone marrow and they have a Higher Altitudes:
limited life span after which they die. Therefore the
 At very high altitudes, where the quantity of oxygen in
body needs to produce new RBC.
the air is greatly decreased.
 Large numbers of these cells are formed from the CFU-E
 Insufficient oxygen is transported to the tissues and RBC
stem cells, which are called proerythroblast.
production is greatly increased.
 They divide multiple times, eventually forming many
 It is because the amount of oxygen transported to the
mature RBCs. The first-generation cells are called
tissues in relation to tissue demand for oxygen is
basophil erythroblasts because they stain with basic
decreased.
dyes; the cell at this time has accumulated very little
 The stimulus for the formation of RBCs in the low oxygen
hemoglobin.
state is the hormone erythropoietin
 In the next generation, the cells become filled with
 It in turn causes a marked increase in the production of
hemoglobin to a concentration of about 34 percent, the
RBCs.
nucleus condenses to a small size, and its final remnant
is absorbed or extruded from the cell. At the same time,  Erythropoietin begins to be formed within minutes to
hours and reaches its maximum production within 24
the endoplasmic reticulum is also reabsorbed. The cell at
hours.
this stage is called a reticulocyte; it still contains a small
amount of basophilic material.  Erythropoietin stimulates the production of
 The remaining basophilic material in the reticulocyte proerythroblast from the hematopoietic stem cells.
normally disappears within 1 to 2 days, and the cell is
then a mature erythrocyte. Because of the short life of
the reticulocytes, their concentration among all the RBCs
is normally slightly less than 1 percent

Elucidate the regulation of erythropoiesis

particularly at High Altitude
Conditions that decrease the quantity of oxygen transported
to the tissues ordinarily increase the rate of RBC production.
Sites of production of erythropoietin in body are:
 Kidney ; 90%
 Liver : 10%
Regulation:
 Renal tissue hypoxia leads to increased tissue levels of Classify anemia on the basis of etiology and
hypoxia-inducible factor–1 (HIF-1)
 It serves as a transcription factor for a large number of
morphology
hypoxia-inducible genes, including the erythropoietin Anemia Classification based on RBC Morphology
gene.  Microcytic Anemia < 76 FL
 HIF-1 binds to a hypoxia response element residing in  Macrocytic Anemia > 100 FL
the erythropoietin gene  Normocytic Anemia 76-95 FL
 It induces transcription of messenger RNA and, Mean corpuscular volume (MCV) and Mean Corpuscular
ultimately, increased erythropoietin synthesis. Hemoglobin (MCH) tests are used to evaluate the wide range
of diseases.
Blood & Immunity Module | 4
Their abnormal values results in following types of anemia: rapidly as it is lost. RBCs that are much smaller than normal
and have too little hemoglobin inside them are then
Decreased MCV and MCH:
produced, giving rise to microcytic, hypochromic anemia.
Microcytic and Hyper-chromic Anemia
 Iron deficiency anemia Aplastic anemia (due to bone marrow dysfunction):
 Anemia of chronic disease Bone marrow aplasia means lack of functioning bone
 Thalassemia marrow. Exposure to high-dose radiations or chemotherapy
 Sideroblastic anemia to cancer patients can damage stem cells of bone marrow,
followed in few weeks by anemia. Likewise, high-doses of
Increased MCV:
certain toxic chemicals, such as insecticides or benzene in
Macrocytic Anemia gasoline may cause the same effect. In autoimmune
 Folate deficiency anemia disorders, such as lupus erythematous, the immune system
 Vitamin B 12 deficiency anemia began attacking healthy cells such as bone marrow stem
 Hemolytic anemia cells, which may lead to Aplastic anemia. In half of Aplastic
 Aplastic anemia anemia cases the cause is unknown called idiopathic aplastic
anemia.
Normal MCV:
 Acute blood loss anemia Megaloblastic anemia:
 Hemolytic anemia The loss of vitamin B-12, folic acid or intrinsic factor from
 Aplastic anemia the stomach mucosa can lead to slow production of
 Anemia of renal disease erythroblasts in bone marrow. As a result the RBCs grow too
large, with odd shapes, and are called megaloblasts. Thus
Anemia atrophy of stomach mucosa, as occurs in pernicious anemia
Designate the causes of different type of anemia or loss of entire stomach after surgical total gastrectomy can
lead to magaloblastic anemia.
Blood loss anemia: These cells rupture easily, leaving the person in dire need of
Caused by either too few RBCs or too little hemoglobin in adequate no. of RBCs.
the cells Hemolytic anemia:
Aplastic anemia: This type anemia occurs when red blood cells are destroyed
Lack of functioning bone marrow, caused by espousing to faster than bone marrow can replace them.
high-dose radiations or chemotherapy for cancer treatment
Heredity spherocytosis:
can damage stem cells of bone marrow high doses of certain
toxic chemicals such as insecticides or benzene in gasoline, In this disease the RBCs are very small and spherical rather
infections autoimmune diseases and medicines may also than being concave discs. Upon passing through the splenic
cause the same effect. pulp and some other tight vascular beds, they are easily
ruptured by even slight compression.
Megaloblastic anemia:
A diet lacking vitamin B-12, folic acid and intrinsic factor Sickle cell anemia:
from stomach mucosa can cause decreased red blood cell It is present in 0.3 to 1 percent of West African and American
production. As a result RBCs grows too large, with odd shapes blacks, the cells have abnormal type of hemoglobin called
and are called megaloblasts. hemoglobin S, containing faulty beta chains in hemoglobin
Some people may consume enough B 12, but their bodies molecule. When this hemoglobin is exposed to low
aren’t able to produce vitamin. This can lead to vitamin concentration of oxygen, it precipitates into long crystals
deficiency anemia, also known as pernicious anemia. inside the RBCs. These crystals elongate the cell and give it
Hemolytic anemia: the appearance of sickle rather than a biconcave disc. The
precipitated hemoglobin also damage cell membrane, so the
This group of anemia develops when red blood cells are cells become highly fragile, leading to serious anemia. Such
destroyed faster than bone marrow can replace them. patients experience a vicious circle of events called a sickle
Certain blood diseases increase red blood destruction. cell disease “crisis”, in which low oxygen tension in the
Sickle cell anemia: tissues causes sickling, which lead to ruptured RBCs, which
It is a type of hemolytic anemia. It is caused by a defective causes a further decrease in oxygen tension and still more
form of hemoglobin that forces red blood cells to assume an sickling and RBC destruction. In some cases it can cause
abnormal crescent (sickle) shape. This shape of cells is death.
formed when hemoglobin is exposed to low concentration of Erythroblastosis fetalis:
oxygen.
In erythroblastosis fetalis, Rh-positive RBCs in the fetus are
Describe the morphology and clinical features of attacked by antibodies from an Rh-negative mother. These
different type of anemia antibodies make the Rh-positive cells fragile, leading to rapid
rupture and causing the child to be born with a serious case
Blood loss anemia: of anemia. The extremely rapid formation of new RBCs to
When chronic blood loss occurs, a person frequently cannot make up for the destroyed cells in erythroblastosis fetalis
absorb enough iron from intestines to form hemoglobin as

Blood & Immunity Module | 5

cause a large number of early blasts forms of RBCs to be
released from the bone marrow into the blood.
Elaborate the effects of Anemia on various
functional systems of body
The blood viscosity depends on concentration of RBCs in
blood. In person with severe anemia, the blood viscosity may
fall as low as 1.5 times that of water rather than the normal
value of about 3. It decreases the resistance to blood flow in
the peripheral blood vessels, it increases the cardiac output.
Hypoxia resulting from diminished transport of oxygen by
the blood cause the peripheral tissue blood vessels to dilate,
allowing a further increase in the return of blood to the heart
and increasing the cardiac output to a still higher level it
results in reduced oxygen carrying effect of anemia because
each unit quantity of blood carries small quantity of oxygen.
When anemic person exercise then it increases the tissue
demand for oxygen, extreme tissue hypoxia results and acute
cardiac failure may ensue.
The major effect of anemia is greatly increased cardiac
output, as well as increased pumping workload on the heart.
Polycythemia
Distinguish different varieties of Polycythemia
Secondary polycythemia:
When tissues become hypoxic such as in cardiac failure, the
blood forming organs automatically produce large quantities
of extra RBCs, this condition is called is secondary
polycythemia, and the RBC count normally rises to 6 to 7
million/mm3,about 30 % above normal.
Physiological Polycythemia:
The common type of secondary polycythemia is called
physiological polycythemia, occurs in natives living at high
altitudes where oxygen is low. The high blood count allows
these people to perform high levels of continuous work even
in rarefied atmosphere.
Polycythemia Vera (erythaemias):
A pathological condition in which RBC count increases up to
may be 7 to 8 million/mm3 and the hematocrit may be 60 to
70 percent instead of the normal 40 to 45 percent.
 It is caused by genetic aberration in the hemocytoblastic
cells that produce the blood cells.
 The excess production of RBCs may also cause excess
production of WBCs and platelets as well.
 The total volume of blood also increases twice of normal
in polycythemia Vera.
 As a result the entire vascular system intensely engorged
and the viscosity of blood increases from the normal of 3
times the viscosity of water to 10 times that of water.
Elaborate the effects of Polycythemia on
Circulatory system
 Increased blood viscosity decreases the rate of venous
return to the heart.
 Increase in blood volume tends to increase the venous
return.
 Arterial pressure is normal in most of the patients but is
elevated in about one third of them.
 It means that the blood pressure regulating mechanisms
can usually off set the tendency for increased blood
viscosity which increases arterial pressure.
 Beyond these limits, these regulations fail and
hypertension develops.
 A polycythemia patient has a ruddy complexion with a
bluish (cyanotic) tint to the skin.
PRACTICAL
Calculate the absolute Corpuscular values and Red
Cell Indices for identifying the type of anemia and
elucidating its etiology
 Erythrocytes that have a normal size or volume (normal
MCV) are called normocytic,
 When the MCV is high, they are called macrocytic.
 When the MCV is low, they are termed microcytic.
 Erythrocytes containing the normal amount of
hemoglobin (normal MCHC) are called normochromic.
 When the MCHC is abnormally low they are called
hypochromic,
 When the MCHC is abnormally high, hyperchromic
To calculate MCV:
To calculate MCHC:
Measure the Osmotic Fragility of Red Blood Cells
in solutions of varying tonicities to diagnose some
hereditary disorders of RBC structure
Osmotic Fragility:
It is a test that measures the resistance to hemolysis of red
blood cells (RBC) exposed to hypotonic solutions.
 RBC are exposed to a series of saline (NaCl) solutions
with increasing dilution
 T Isotonic (physiological) solution – 0.9 % NaCl
 RBC burst in hypotonic (< 0.9 % NaCl), and shrink
(crenate) in hypertonic solutions (> 0.9 % NaCl)
 In hypotonic medium a membrane rupture occurs,
allowing hemoglobin (Hb) to exit from the cells
 By measuring Hb concentration, the % of hemolysis at
different NaCl concentrations can be calculated the
sooner hemolysis occurs, the greater is osmotic fragility
of RBC
Procedure:
Label 5 ends of micro tubes 1–5 and pipette 1 ml of the
following solutions into them:
 Tube 1: physiological solution (non-diluted)
 Tube 2: physiological solution diluted with water in
the ratio 3:1.
 Tube 3: physiological solution diluted with water in
the ratio 2:1.
 Tube 4: physiological solution diluted with water in
the ratio 1:1.
Blood & Immunity Module | 6
  Tube 5: physiological solution diluted with water in BIOCHEMISTRY
the ratio 1:5, containing NH4Cl (NH4Cl disables
remaining membrane pumps).
 Pipette 50 μl erythrocyte suspension into each Explain the Composition and Structure of
microtube, gently mix and let stand for 10 minutes. Then Hemoglobin
centrifuge 3 minutes at 3 000 × g and carefully collect the
Function of hemoglobin:
supernatants for hemoglobin assay
 Prepare five glass test tubes 1–5 with 2 ml Drabkin  Major function of hemoglobin is transport of oxygen.
reagent. Add 50 μl of each supernatant from the  Required for aerobic respiration
previous step into the corresponding glass test tube and  Act as buffer
mix gently. Classification of hemoglobin
 Measure the absorbances of all the samples at 400 nm  Transport  functional
against blank containing the Drabkin reagent only.  Quaternary, Globular  structural
 Due to the fact that the blood sample is not fresh, we  Conjugated, Chromo proteins specialized
observe partial hemolysis even in test tube 1. The
amount of hemoglobin determined in this test tube Structure of hemoglobin
represents the control value and should be subtracted 2 parts:
from the values obtained for all the tubes. The value of  4 globin chains (protein component)
hemoglobin measured in test tube 5 is the maximum  4 Heme groups (prosthetic component)
obtainable amount and we express it as 100% hemolysis.
Structure of heme
On this basis, calculate the percentage of hemolysis in
test tubes 2–4. Heme is a complex of protoporphyrin IX (a complex of 4
pyrole rings) and ferrous iron.
Ascertain the conditions with increased and decreased
RBC fragility associated with decreased RBC function
Normal range:
 Hemolysis onset at: 0.45-0.5 % NaCl
 Hemolysis complete at: 0.3-0.33 % NaCl
Factors affecting osmotic fragility:
 Cell membrane permeability
 Surface-to-volume ratio
Increased osmotic fragility:
1) Hereditary spherocytosis:
 Characterized by a defective RBC membrane and
decreased surface-to-volume ratio CH: Methyl Bridge
 Characteristic round cells (spherocytes) are seen in M: Methyl
blood smear and they are more fragile and break V: Vinyl
 open in less hypotonic solutions than normal red P: Propionic acid
blood cells
 It consists of iron and protoporphyrin IX.
 In hypotonic solutions water enters red blood cells
 The porphyrins are compounds with tetra pyrole
 Therefore, normal RBC with a biconcave shape swell
structure.
and expand their volume
 Four pyrole are combined through –CH= brides called
On the other hand, spherocytes cannot absorb much
methyne bridges referred to as α, β, γ and δ
extracellular liquid and break very easily
respectively.
2) Acquired spherocytosis  Ferrous ion occupy the center of the compound ring
structure and establish linkages with all four nitrogen’s
Decreased osmotic fragility
of all the pyrole rings
 Thalassemia 
th
It’s 5 linkage is linked to the nitrogen of histidine of
 Sickle cell anemia polypeptide chains
 Iron deficiency anemia  It’s 6
th
linkage is linked to molecule of water in
deoxygenated Hb which is displaced by oxygen when Hb
is oxygenated
 The hydrogen is at positions 1 to 8 are substituted by
methyl, vinyl, methyl, vinyl, methyl, propionic acid and
methyl groups respectively
 The propionic acid groups of 6 and 7 positions of heme,
of III and IV pyrole are linked to basic groups of amino
acids Arg and Lys of the polypeptide chains.

TYPES OF HEMOGLOBIN

Blood & Immunity Module | 7

 Embryonic Stage:  Treatment: Methylene blue
 Embryonic Hemoglobin: α2Є2 (epsilon)
OXYGEN DISSOCIATIVE CURVE
Fetal Stage:
Interpret oxygen dissociative curve and evaluate
 HbF: α2 gamma2
the allosteric effects of pH2, 3 BPG and O2 on
Adult: hemoglobin oxygen binding
 HbA1: α2β2 90% T form: The deoxy form of hemoglobin is called the “T,” or
 HbA2: α2δ2<5% taut (tense) form. In the T form, the two αβ dimers interact
 HbF: α2gamma2 through a network of ionic bonds and hydrogen bonds that
 HbA1c: α2β2-glucose < 3-5% constrain the movement of the polypeptide chains. The T
 1-aminodeoxyfructose (fructose attached to amine form is the lowoxygen-affinity form of hemoglobin.High
terminals of globin) (glycosylated) delivery of oxygen
 >5% in diabetics who take sugar
R form: The binding of oxygen to hemoglobin causes the
 Irreversible glycosylation  HbA1c test
rupture of some of the ionic bonds and hydrogen bonds
Structure & Composition of Globin: between the αβ dimers. This leads to a structure called the
“R,” or relaxed form, in which the polypeptide chains have
The major hemoglobin in adults is composed of four
more freedom of movement. The R form is the highoxygen-
polypeptide chains—two α chains and two β chains—held
affinity form of hemoglobin. Low delivery of oxygen
together by non covalent interactions. Each subunit has
stretches of α-helical structure, and a heme-binding pocket. Oxygen dissociation curve:
A plot of Y measured at different partial pressures of oxygen
Composition:
(pO2) is called the oxygen dissociation curve.
Males: 14-16 g / dL  The oxygen dissociation curve for hemoglobin is
Female: 12-14 d / dL sigmoidal in shape, which means that that the binding of
In 5L of blood there is 750g Hb out of which 6.25g is an oxygen molecule at one heme group increases the
destroyed daily. oxygen affinity of the remaining heme groups in the
Differentiate between the structural differences in same hemoglobin molecule. This effect is referred to as
heme-heme interaction.
hemoglobin, myoglobin and met hemoglobin
 Although it is more difficult for the first oxygen molecule
to bind to hemoglobin, the subsequent binding of oxygen
occurs with high affinity.
 The partial pressure of oxygen needed to achieve half
saturation of the binding sites (P50) is approximately 26
mm Hg for hemoglobin.

List out the conditions leading to formation of met

hemoglobin Allosteric effects
Oxidation of heme component of hemoglobin to ferric state o pO2
forms met hemoglobin o pCO2
Causes: o pH
Genetic: o 2, 3-BPG
o Deficiency of NADH-cytochrome b5 reductase, which 1. Heme- heme interaction
keeps iron in ferrous form.
 The affinity of hemoglobin for the last oxygen bound is
Acquired: greater than its affinity for the first oxygen bound.
o Drugs containing Nitrates for cardiac problems,  Increased partial pressure of oxygen i.e. in lungs
which converts ferrous into ferric. facilitates binding of hemoglobin to oxygen whereas
o Oxygen reactive species / superoxide radicals. decreased partial pressure of oxygen i.e. in peripheral
o Aging tissues cause decreased binding.
o Cancer
2. Effect of pH/CO2:
 Signs and Symptoms: chocolate cyanosis
Blood & Immunity Module | 8
 When the pH is lowered (acidosis) or when the
hemoglobin is in the presence of an increased pCO2, the
release of oxygen from hemoglobin is enhanced
(decreased oxygen affinity)/T state is stabilized. A shift to
the right in the oxygen dissociation curve. This change in
oxygen binding is called the Bohr Effect.
 Conversely, raising the pH (alkalosis) or lowering the
concentration of CO2 results in a greater affinity for
oxygen, a shift to the left in the oxygen dissociation
curve, and stabilization of the R state.
3. Effect of 2, 3 BPG: -
 2, 3-BPG decreases the oxygen affinity of hemoglobin by
binding to deoxy -hemoglobin (so that oxygen cannot
bind to it), but not to oxy hemoglobin.
 This stabilizes the taut conformation of deoxy
hemoglobin, as hemoglobin has lesser affinity to
combine with oxygen now.
 High 2, 3-BPG levels shift the oxygen dissociation curve
to the right.
 Less 2, 3-BPG levels shift the oxygen dissociation curve
to the left.
 This reduced affinity enables hemoglobin to release
oxygen efficiently at the partial pressures found in the
tissues.
Binding of CO2:
+
Hb – NH2 + CO2  Hb – NH – COO– + H
The binding of CO2 stabilizes the T (taut) or deoxy form of
hemoglobin, resulting in a decrease in its affinity for oxygen
and a right shift in the oxygen dissociation. In the lungs, CO 2
dissociates from the hemoglobin, and is released in the
breath.
Binding of CO:
Shifts the oxygen dissociation curve to the left, and changes
the normal sigmoidal shape toward a hyperbola. As a result,
the affected hemoglobin is unable to release oxygen to the
tissues. The affinity of hemoglobin for CO is 220 times
greater than for oxygen. Consequently, even minute
concentrations of CO in the environment can produce toxic
concentrations of carbon mono oxy hemoglobin in the blood.
Correlate the role of Glutathione with abnormal
hemoglobin
Glutathione (GSH) is an important antioxidant in animals
preventing damage to important cellular components caused
by reactive oxygen species such as free radicals, peroxides,
lipid peroxides and heavy metals. It is a tripeptide with a
gamma peptide linkage between the carboxyl group of the
glutamate side chain and the amine group of Cystein (which
is attached by normal peptide linkage to a glycine).
Glutathione reverses the Met-hemoglobin to the normal
hemoglobin so that it can carry out its function properly.
Met-hemoglobin is abnormal hemoglobin in which the iron
molecule is in the ferric state Fe+3 rather than ferrous form
Fe+2 which has decreased affinity to bind with oxygen.
Glutathione acts as an antioxidant and prevents the
formation of met-hemoglobin by combining with oxidizing
agents.
Synthesis of heme
Outline the synthesis of hemoglobin highlighting the
defective pathway
Synthesis of heme:
Globin is produced by ribosomes from mRNA.
Globin + Heme in Golgi apparatus  complete Hb  RBCs
Blood & Immunity Module | 9
Factors effecting Heme Synthesis:
 Regulatory step: Globin is responsible for heme
production. If there is no globin then there will be hemin
which will down regulate the production of ALA
synthase.
 Lead poisoning: It inhibits ALA dehydratase and
ferochelatase. Deficiency of these enzymes leads to
anemia.
 Drugs: Antiepileptic drugs decrease the heme
production. So in this case the ALA synthase is up
regulated to produce sufficient heme.
 Antiepileptic (Fenitoin): P450 system metabolizes them
by using Heme enzymes (in liver). On feedback when
heme gets low, it up regulates ALA synthase.
Defects in synthesis of hemoglobin
Porphyrias
Genetic defects in synthesis of Heme
i. Also called Vampire’s disease
ii. Purplish / Brownish urine.
iii. No synthesis of certain enzymes required for heme
synthesis
iv. Defects in enzymes before hydroxy methyl bilane in
heme synthesis chain, the clinical conditions are
abdominal problems and psychic problems.
[Autosomal dominant]
v. Defects in enzymes after hydroxy methyl bilane, the
clinical features are Photosensitivity (itching etc) due
to accumulation of excess HOMB under skin.
[Autosomal dominant]
vi. In case of deficiency of Ferochelatase, anemia occurs.
[Autosomal recessive]
Hemoglobinopathies
(Defects in Globin)
 Might be qualitative (sickle - cell disease) or
 Quantitative (Thalassemia)
Sickle-cell disease
 In β-globin chains, Glutamic acid is replaced by Valine
 (Glu. Val.)
 Most common point mutation
 β-chains fit tightly into their companion α-chains
 Form crystals/fibrous bands inside RBCs
 Sickle shape (crescent moon)
 Lifetime of RBCs reduced to 20 days only
 Most common in African-Americans
 Whenever the patient is at low partial pressure of O 2,
pain in body parts occurs due to ischemia. This is called
sickle-cell crisis.
C-disease
 Glutamic acid replaced with lysine.
 Intensity is less severe than sickle-cell disease
SC disease
 Sickle-cell + C-disease
 Glutamic acid replaced with Valine in some positions
and with lysine in others.
 Intensity of severity: sickle-cell> CS > C-disease
Met hemoglobin
 Chocolate colored blood
 Iron is in oxidized Ferric form instead of Ferrous.
 Can be genetic (due to NADPH reductase deficiency) or
acquired (Nitrates containing drugs for cardiac
problems, oxygen reactive species/superoxide radicals
due to cancers or aging)
 Treatment: methylene blue
Thalassemia
 Homozygous recessive genetic disease
 16th chromosome (4 copies) α-chain
 11th chromosome (2 copies) β-chain

0 0
α , β : No chains (complete gene deletion)

+ +
α , β : Some chains (some genes replaced etc)
 Carrier: Mild hemolysis
0
β Thalassemia:
 α-chains normal, no β-chains.
 α-chains clump together
 Hemoglobin molecule not formed properly
 Rupture of RBCs.
 Diagnosed after birth
 Very difficult / not diagnosed IU.
 Treatment: regular blood transfusions
α Thalassemia:
 Diagnosed intrauterine
 Silent carrier
 Traits
 Hemolytic Hb (severe anemia)
 Hydrophs fetalis (no survival)
Catabolism of heme
Discuss the catabolism of Hemoglobin
Steps of catabolism of hemoglobin are:
1. Senescent red cells are a major source of hemeprotiens.
2. After 120 days they become fragile and break down
occurs.
3. Breakdown of heme to bilirubin occurs in macrophages
of RES (reticuloendothelial system).
4. Degeneration of heme is catalyzed by hemeoxygenase
system of reticulo-endothelial cells.
5. This catalysis results in the opening of cyclic porphyrin
ring, converting it into linear biliverdin which is then
reduced to bilirubin by the action of biliverdin
reductase.
6. As UCB is slightly soluble in plasma so, it is transported to
liver by binding with albumin.
7. Bilirubin dissociates from albumin and enters into liver.
8. In liver, solubility of bilirubin is increased by the addition
of 2 molecules of glucuronic acid producing bilirubin
diglucoronide. The reaction is catalyzed by UDP -
glucuronosyl transferase.
9. This CB is then actively secreted into bile (due to
concentration difference) & then intestine.
10. In the intestine, glucuronic acid is removed by bacteria.
The resulting bilirubin is converted to urobilinogen
(colorless).
11. Some of urobilinogen is reabsorbed from the gut &
enters the portal blood.
12. A portion of this urobilinogen participates in the
enterohepatic urobilinogen cycle.
Blood & Immunity Module | 10
13. Remainder of the urobilinogen is transported by the
blood to kidneys where it is converted to yellow urobilin
& excreted giving urine a characteristic yellow color.
14. Remainder of the urobilinogen in the intestine is oxidized
by intestinal bacteria to brown stercobilin which gives
feces its characteristic color.
Jaundice & LFT
Correlate Jaundice with LFT report
Jaundice refers to yellow color of skin, nail beds and scleras
caused by deposition of bilirubin in hyper-bilirubinuremia.
Normal level of bilirubin is < 1 mg/dL Jaundice is seen at 2-3
mg/dL of serum total bilirubin.
TYPES OF JAUNDICE:
Following are types of jaundice.
 Hemolytic jaundice (pre-hepatic)
 Hepatocellular jaundice (hepatic)
 Obstructive jaundice (post-hepatic)
Hemolytic jaundice:
 No hepatic damage
 Extensive hemolysis occurs
 Due to increased hemolysis more CB is made &
excreted into bile.
 Urobilinogen amount entering the enterohepatic
circulation is increased.
 Urinary urobilinogen increased.
Causes:
 Thalassemia
 Malaria
 Cytotoxic drugs
 Hemolytic Anemia (sickle-cell disease, Hereditary
spherocidosis, Erythroblastosis fetalis)etc
Hepatocellular jaundice:
 Damage to liver cells cause UCB levels to increase in
blood due to decreased conjugation.
 Urobilinogen is increased in the urine because hepatic
damage causes decrease in the enterohepatic
circulation of this compound allowing more to enter
into the blood.
 Urine becomes dark and feces pale clay in color.
Causes:
 Alcohol abuse
 Liver cirrhosis
 Hepatitis
Obstructive jaundice:-
 Caused by obstruction of common bile duct
 Patients suffer from nausea, GIT pain and produces
stools pale clay in color.
 Liver regurgitates CB into blood which is excreted in
urine.
Causes:
 Carcinoma of head of pancrease
 Carcinoma of bile duct
 Gall stones
 Worm infections etc.
A patient with Jaundice has an LFT report showing bilirubin
= >1 mg/dl.
 IRON
Discuss the metabolism of Iron
Absorption:
 Dietary iron is found in haem and ionic (non-haem)
forms.
 About 1-2 mg of iron is absorbed a day mainly from the
apical surfaces of duodenum and upper jejunum where
pH is low.

+3 +3
Dietary non-haem iron exists as Fe . Fe is converted to
+2
Fe by Ferric-reductase enzyme.

2+
Fe is then transported into the cell by a transporter
called divalent metal transporter 1 (DMT1) by a proton
coupled mechanism.
 Haem iron is absorbed into the enterocyte by a different,
as yet unidentified, haem receptor.
 Once internalized in the enterocyte, iron is released from
haem by haem oxygenase and then either stored or
transported out of the enterocyte across the basolateral
membrane.
Transport:
 Iron is exported out of the enterocyte by ferroportin 1

+2 +3
Fe is then oxidized to Fe by hephaestin.

+3
Fe is then complexed with apoferritin to form ferritin.
 This binds with plasma transferrin.
 Thus bound, iron is transported to the bone marrow or
iron storage sites where it is stored as either ferritin or
hemosiderin.
 The liver is the main storage organ for iron.
 Ferritin may contain small or large amount of iron which
is referred to as Storage Iron.
 Smaller quantities of iron are the storage pool is in an
extremely insoluble form called Hemosiderin.
Assimilation:
 Most cells have transferrin receptors (CD 71) to which
iron ladden transferrin binds.
 The receptor-transferrin-iron complex is then
incorporated into the cytosol by endocytosis.
 In red cells the endocytotic vacuole fuses with a
++
lysozyme, where at an acid pH the iron (Fe ) is released
from transferrin and transported to mitochondria where
it is incorporated into heme, the ferrous iron complex of
protoporphyrin IX.
Blood & Immunity Module | 11
Identify the functions of Iron and relate them with 1. Re-methylation of homocysteine (Hcy) to
deficiency disorders methionine
2. Isomerization of methylmalonyl CoA ( produced
Functions: during the degradation of some amino acids)
 Central atom of heme group of heamoglobin.  Accounts for neurological manifestations
 Helps in the maintenance of structure.  It participates in hematopoiesis
 Helps in the maintenance of the Ph of RBCs.  In nucleic acid synthesis
 Due to the presence of iron RBCs helps in the binding  thyroid activity
and transport of oxygen.  ascorbic acid metabolism
 Helps in heme synthesis: hemoglobin deficiency
(Anemia) Sources of Folic Acid
 Cofactor for cytochromes: decreased energy production o Liver
(lethargy, fatigue, low LBW) o Kidney
o Yeast
Deficiency: o Green vegetables (Spinach)
 Failure of transport of iron to the erythroblasts causes o Meat
severe Hypochromia Anemia i.e RBCs contain much less o Cauliflower
haemoglobin. o Milk
 Due to chronic blood loss enough iron is not absorbed by o Wheat
the intestines to met the loss.This results in smaller Minimum daily requirement
RBC’s, thus causing Microcytic Anemia. o Infants = 25 mg/day
 Deficiency of iron causes Iron Deficiency Anemia. This o Children = 30-60 mg/day
causes less transport of oxygen.
Biochemical functions:
Effect of iron on RBC Synthesis:
As iron is the central atom in the Heme group of hemoglobin.  Its biologically active form is Tetrahydrofolate (reduced
So deficiency of Iron will result in the decreased coenzyme form of folic acid)
Erythropoiesis (synthesis of RBCs). This will make the person  Structure: pteridine nucleus, Para-aminobenzoic acid
Anemic. (PABA), 1-glutamic acid
 Position 5 of pteridine nucleus, position 10 of PABA 
Relate Iron deficiency with their effects on RBCs 1C units attach here
synthesis in humans Shuttles one carbon units
Iron is required for the synthesis of heme. In deficiency of  Formyl (-CHO)
iron (nutritional anemia), heme cannot be synthesized in  Formimino (-CH=NH)
sufficient quantities. This eventually results in hemoglobin  Methyl (-CH3)
deficiency. Therefore, lesser hemoglobin is packed into RBCs  Donors: serine, glycine, histidine, formate and choline
and the RBCs produced are microcytic and hypochromic.  Recipients: intermediates in the synthesis of amino
acids, purines and pyrimidines
Vitamin B12 & Folic Acid  Also used in re-methylation of HCY
 Transfers methyl group from glycine to serine
Identify Sources and functions of Vitamin B12 &  Figlu test (formiminoglutamate)
Folic Acid Folic acid antagonists:
Sources of Vitamin B12  Sulphonamide(antibiotics)  inhibit dihydrofolate
synthase
 Synthesized only by microorganisms  Methotrexate  inhibit dihyrofolate reductase in cancer
 Not present in plants + other rapidly dividing cells  DNA & RNA cannot be
 Animals obtain the vitamin performed from natural synthesized
microflora present in intestines
 Or by eating food derived from other animals (diet) PHARMACOLOGY
It is present in appreciable amounts in
o Liver Identify the role of Hematinics to manage anemia
o Red meat
o Fish IRON:
o Eggs  Microcytic hypochromic anemia caused by inadequate
o Dairy products synthesis of haem due to iron deficiency also known as
o Fortified cereals iron deficiency anemia.
Minimum daily requirement Pharmacokinetics:
 3-5 mg
Absorption:
Biochemical functions  In duodenum and proximal jejunum
 Required in human for two essential enzymatic reactions  Absorbed in ferrous form which is supported in acidic
medium

Blood & Immunity Module | 12

  Ferric iron is converted into ferrous state by enzyme
ferrireductase
 2 methods of absorption
 In the form of heme (hemoglobin or myoglobin from
meat)
 In ionic state (from vegetables, etc.)
 Transport protein ferriportin aids absorption
Transport and Storage:
 Transported by transferrin protein to erythroid cells
 Stored in intestinal epithelium, skin, macrophages of
liver, spleen, bone, hepatocytes and heart
 Stored as ferritin
Elimination:
 No special elimination mechanism present
 Iron is mostly reused
 Eliminated by wearing off of skin and intestinal
epithelial layer
 Also secreted with saliva and sweat
Clinical pharmacology:
Indications:
 In iron deficiency anemia
 People with increased iron requirement eg. In
infants, pregnant women, patients with chronic
kidney disease, lactating women, etc.
 Inadequate absorption can also be a reason for iron
deficiency such as in gastrectomy small bowel
disease. Iron is administered in these cases as well.
 Abnormal blood loss in menstruation, accidents or
any other cause can also increase iron requirement.
Treatment:
Both oral and parentral treatments have almost the same
effects.
1. Oral:
 Ferrous sulphate, ferrous glutamate and ferrous
fumarate are prescribed
 200-400mg/day should be given for 3-6 months
 Patients unable to tolerate such large doses can be
given lower daily doses
 Adverse effects: nausea, epigastric discomfort,
abdominal cramps, constipation, diarrhea and black
stool.
2. Parentral:
 Patients unable to absorb oral iron and patients with
extensive chronic anemia who’s iron requirement
cannot be met orally alone.
 Patients with chronic renal disease requiring
hemodialysis, postgastrectomy, malabsorption
syndromes and other bowel diseases are given
parentrally
 Ferric Iron is toxic so it is given as colloid containing
particle with a core of iron oxyhydroxide surrounded by
a core of carbohydrate
 IRON DEXTRAN: 50mg/ml of solution administered IM
or IV.
IV is better but can cause headache, fever, nausea,
vomiting, flushing, light-headedness, bronchospasm,
rarely anaphylaxis and death.
 Allergic reactions are also expected.
 Sodium ferric gluconate complex and iron sucrose
complex: are also administered as an alternative
intravenously. They are less likely to cause
hypersensitivity reactions.
Clinical toxicity:
1. Acute iron toxicity:
 Accidental ingestion of iron in young children as
many as 10 tablets.
 Children experience necrotizing grastroenteritis with
vomiting, abdominal pain and bloody diharrea
followed by shock, lethargy and dyspnea. This might
be followed by severe metabolic acidosis, coma and
death.
 Urgent treatment: whole bowel irrigation (to flush
out unabsorbed iron) and deferoxamine (iron-
chelating compound) given intravenously.
 Appropriate supportive therapy for gastrointestinal
bleeding, metabolic acidosis and shock must also be
provided.
2. Chronic iron toxicity:
 Hemochromatosis: excess deposition of iron in
organs such as heart, liver, pancreas, etc.
 Can lead to organ failure and death
 Treated by phlebotomy; removal of a unit of blood
every week.
Vitamin B12:
 Vitamin B12 (cobalamin) and folic acid are cofactors
required for transfer of 1 carbon units, an essential
step for DNA synthesis.
 Absence of these results in impairment of SNA
synthesis leading to anemia, neurological defects
and gastrointestinal symptoms.
Pharmacokinetics:
 The chief source is meat, eggs and dairy products.
 It is produced by bacteria only
 Absorbed from GIT in the presence of intrinsic
factor, a .glycoprotein secreted by parietal cells of
gastric mucosa
 It is absorbed in stomach and small intestine
 Deficiency can be due to inadequate absorption and
in rare cases (specially in vegetarians after many
years) due to malnutrition
 Transported by transcobalamin I, II & III
 Stored primarily in the liver
Pharmacodynamics:
 Essential In two reactions:
1. Methylmalonyl-CoA → succinyl-CoA
2. Synthesis of dTMP, a precursor of DNA synthesis

5
VitB12 deficiency; folate accumulation as N -
methylteterahydrofolate; supply of tetrahydrofolate
depleted; production of RBC slows.
 Folic acid is required to fill tetrahydrofolate pool
 Folic acid does not correct neurological defects
Clinical use:
Two available forms are:
1. Hydroxocobalamin
2. Cyanocobalamin
 For the treatment of naturally occurring pernicious
anemia and anemia due to gastric resection.
Blood & Immunity Module | 13
 Usually given through parentral route due to inadequate
absorption (cause of deficiency)
 None of these 2 forms causes toxicity
Folic acid:
 Required for DNA synthesis
 Deficiency in pregnancy leads to neural tube defects and
usually presents as megaloblastic anemia
Pharmacokinetics:
Deficiency is caused by less intake of folic acid within a few
months due to less stores in the body. It is absorbed in GIT.
Pharmacodynamics
 Constitutes the dMTP cycle required for DNA synthesis
 Rapidly dividing cells are most effected by folic acid
deficiency
 Antifolate drugs are used to treat cancers
result of defective blood formation, which may be due to
failure to receive, absorb or utilize vitamin B12 or folic acid,
or an absence of intrinsic factor.
Treatment: Folic acid 15mg daily causes regeneration of
erythrocyte s, and is administered in macrocytic anemia of
pregnancy. Maintenance dose of folic acid: 5mg daily.
Pernicious anemia:
Parentral administration of 50mg of vitamin B12 twice a
week, maintenance dose: 15mg twice a month.
Iron deficiency anemia:
Iron deficiency produces a hypochromic mycrocytic anemia.
There is a deficient intake of iron, blood loss or increased iron
demand, so that the body store of iron is depleted and
anemia occurs.
Symptoms: Pallor, weakness, irritability, fissures of angles of
the mouth, heart murmurs and ingestion.

Clinical use Prevention:

1) Dietary modification
 Deficiency caused by malnutrition and
2) Food fortification
malabsorption
3) Iron supplements
 Folic acid is recommended in anemia and before and
during pregnancy Treatment: Iron salts: 3gm ferrous sulphate 3 times a day
 Folic acid corrects anemia but does not correct after meals
neurological deficits of vitamin B12 deficiency
 No recognized toxicity MICROBIOLOGY

COMMUNITY MEDICINE Sterilization and asepsis

Definitions
Identify the ways for prevention of Nutritional
1. CLEANING:
Deficiency Anemia Is a process which removes visible contamination but does
A Diet that meets the dietary guidelines will ordinarily have not necessarily destroy micro-organisms.
enough iron, folate and vitamin B12 to prevent anemia. 2. ASEPSIS:
Term used to describe methods which prevent contamination
Food rich in folate includes of wounds & other sites, by ensuring that only sterile object
1. Dark green leafy vegetables & fluids come into contact with them.
2. Nuts, enriched grain products such as bread, cereal, 3. ANTISEPSIS:
pasta, and rice It is the procedure or application of an antiseptic solution or
3. Fruits and fruits juices an agent which inhibits the growth of microorganisms, while
Foods rich in vitamin b12 remaining in the contact with them.
4. DISINFECTION:
1. Eggs, fortified foods such as breakfast cereals
It is a process which reduces the number of viable
2. Milk, cheese and yogurt
microorganisms to an acceptable level but may not inactive
3. Red and white meats and shellfish
some viruses and bacterial spores.
Foods rich in iron 5. STERLIZATION:
1. Meats and eggs , sea food It is the process of destruction or removal of all
2. Vegetables , bread and cereals microorganisms from article, surface or medium, including
3. Fruits beans and other foods spores.
4. Most adults need these daily dietary Sanitizing Process that reduces microbial population on
object to a safe level
Amounts should be taken per day
Decontamination Process that removes pathogenic
1. Vitamin B12 2.4 micrograms
microorganisms from an object to make it safe to handle
2. Folate or Folic Acid 400 micrograms
6. DISINFECTANT:
3. Iron 8 milligram
Process that eliminates defined pathogens
4. Pregnant and breast feeding women may require
• Main difference with sterilization = the lack of
more of each vitamin.
sporocidal activity.
Anemia and its treatments
Macrocytic anemia: Sterilization
This group includes macrocytic anemia of pregnancy,
pernicious anemia, sprue, celiac disease. They occur as a

Blood & Immunity Module | 14

 Carried out by autoclaving, which consists of exposure to
steam at 121°C under a pressure of 15 lb/in2 for
15minutes.
 Surgical instruments that can be damaged by moist heat
are sterilized by exposure to ethylene oxide gas.
 Most intravenous solutions are sterilized by filtration.
Chemical agents
Disruption of cell membrane:
Ethanol: Widely used to clean the skin before immunization
or venipuncture. It acts mainly by disorganizing the lipid
structure in membranes, but it denatures proteins as well.
Detergent: Interact with the lipid in the cell membrane
through their hydrophobic chain and with the surrounding
water through their polar group and thus disrupt the
membrane.
Phenol: Chlorinated phenol that is widely used as a hand
disinfectant prior to surgery and in the cleansing of wounds.
Modification of proteins:
Chlorine: Chlorine is used as a disinfectant to purify the
water supply and to treat swimming
Iodine: Used prior to obtaining a blood culture and installing
intravenous catheters.
 Inactivates containing enzymes.
 Binds specifically to tyrosine residues in proteins.
Heavy metals Mercury and silver have the greatest
antibacterial activity. They act by binding to sulfhydryl
groups, thereby blocking enzymatic activity.
Ethylene oxide: Used for the sterilization of heat sensitive
materials such as surgical instruments and plastics. It kills by
alkylating both proteins and nucleic acids.
Hydrogen peroxide: Antiseptic to clean wounds and to
disinfect contact lenses.
Alkali and acid: Weak acids, such as benzoic, propionic, and
citric acids, are frequently used as food preservatives
because they are bacteriostatic.
Formaldehyde:
 A broad-spectrum antimicrobial agent, used for
disinfection, has limited sporicidal activity.
 Hazardous substance, inflammable and irritant to the
eye, skin and respiratory tract.
Glutaraldehyde:
 It is a high level disinfectant
 A solution of 2% glutaraldehyde (Cidex), requires
immersion of 20 minutes for disinfection; and 6 to 10
hours of immersion for sterilization.
Physical agents
Heat energy:
Can be applied in three ways:
1)Moist heat (either boiling or autoclaving):
Autoclaving important to kill spores which are resistant to
boiling (pressure of 15 lb/in2, a temperature of 121°Cand
for 15 to 20 minutes). Bacteria removed: Clostridium
botulinum.
2) Dry heat: 180°C for 2 hours.
3) Pasteurization: heating 62°C for 30 minutes followed by
rapid cooling.
 Heat kills by denaturing proteins, but membrane
damage and enzymatic cleavage of DNA may also be
involved.
 Moist heat sterilizes at a lower temperature than dry
heat, because water aids in the disruption of non-
covalent bonds (e.g., hydrogen bonds).
Radiation/cold sterilization:
1) UV rays:
The greatest antimicrobial activityof UV light occurs at 250
to 260 nm, which is the wavelength region of maximum
absorption by the purine and pyrimidinebases of DNA. The
most significant lesion caused by UV irradiation is the
formationof thymine dimers, but addition of hydroxyl groups
to the bases also occurs. As a result, DNA replication is
inhibited and the organism cannot grow.
USE:
Used in hospitals to kill airborne organisms, especially in
operating rooms
It can damage the cornea and skin.
2) X-rays: Kill mainly by the production of free radicals.
These highly reactive radicals can break covalent bondsin
DNA, thereby killing the organism. Sulfhydryl-containing
compounds, such as the amino acid cysteine, can protect
DNA from free-radical attack. Therefore, another mechanism
is a direct hit on a covalent bond in DNA, resulting in chain
breakage.
USE:
 Sterilization of heat-sensitive items, such as sutures and
surgical gloves, and plastic items, such as syringe
3) Infrared:
It is most commonly used to purify air, as in the operating
room. Infrared is effective, however, it has no penetrating
ability.
4) Filtration:
 Help to remove bacteria from heat labile liquids.
 As viruses pass through ordinary filters, it can be used to
obtain bacteria free filtrates of virus isolation.
TYPES:
 Candle filter
 Asbestos filter
 Sintered glass filter
 Membrane filter
Aseptic storage
 Instruments are kept wrapped until ready for use.
 To reduce the risk of contamination, sterilepacksmust be
handled as little as possible.
 Sterilized packs should be allowed to cool before
storage; otherwise condensation will occur inside the
packs.
 To prevent contamination from rodents, ants, and
cockroaches, the store must be subjected to adequate
pest control.
 Materials should be stored at least 8” off the floor and
18” from the ceiling
Blood & Immunity Module | 15
 Sterile packs must be stored and issued in correct date  Hyperplasia of lymphocytes and macrophages.
order. The packs, preferably, are stored in drums which Malaria caused by P. falciparum is more severe.
can be locked. Preset trays and cassettes, are useful as,  Hemorrhage and necrosis, particularly in the brain
the instruments can be organized as per the procedure. (cerebral malaria).
 Hemolysis and
Fumigation of operation theatre  Kidney damage
Fumigation of the operation theatre is achieved by fumigator  Hemoglobinuria.
and potassium permanganate reaction technique .The  Dark color of the patient’s urine has givenrise to
chemical used is 40% formalin. the term “blackwater fever.”

CLINICAL FINDINGS
1) Abrupt onset of fever and chills, accompanied by
headache, myalgias, and arthralgias, about 2 weeks after the
mosquito bite. Fever may be continuous early in the disease,
The fever spike, which can reach 41°C,is accompanied by
shaking chills, nausea, vomiting, and abdominal pain. The
fever is followed by drenching sweats.
2) Patients usually feel well between the febrile episodes.
3)Splenomegalyis seen in most patients, and hepatomegaly
 Factors influencing the fumigation of the theatre: occurs in roughly one-third.
1) Relative humidity
Relative humidity plays a major role in fumigation. A DIAGNOSIS
minimum of 70% is essential. Water used in fumigator with 1) Thick smear is used to screen for the presence of
fumigant helps to achieve and maintain humidity. organisms
2) Temperature: temperature for effective fumigation is 300-
2) Thin smearis used for species identification.
400C.
Ring shaped trophozoites can be seen within infected red
3) Formaldehyde levels in the Air in the operation theatre: blood cells The gametocytes of P. falciparum are crescent-
The dose of formaline is usually decided by the size of the shaped (banana-shaped), whereas those of the other
room. As a rule, 180 ml is used for a room of the size 1000 plasmodia are spherical.
cubic feet.
3)ELISA and PCR may also be used.
Malaria TREATMENT:
The vector and definitive host for plasmodia is the female
Anopheles mosquito (only the female takes a blood meal).
There are two phases in the life cycle:
 Sexual cycle, which occurs primarily in mosquitoes,
 Asexual cycle, which occurs in humans, intermediate
hosts.
 Sexual cycle is called sporogony because sporozoites are
produced.
 Asexual cycle is called schizogony because schizonts are
made.
The sexual cycle begins in the human red blood cells when
some merozoites develop into male and others into female
gametocytes.
 The gametocyte-containing red blood cells are ingested
by the female Anopheles mosquito and, within her gut,
produce a female macrogamete and eight sperm like
male microgametes.
 After fertilization, the diploid zygote differentiates into a
motile ookinete that burrows into the gut wall, where It
grows into an oocyst within which many haploid
sporozoites are produced. The sporozoites are released
and migrate to the salivary glands, ready to complete the
cycle when the mosquito takes her next blood meal.
Destruction of red blood cells Red cells are destroyed both
by the release of the merozoites and by the action
of the spleen to first sequester the infected red cells and then
to lyse them.
 Enlarged spleen

Blood & Immunity Module | 16


HISTOLOGY
 Histological features of veins and spleen
Describe the microscopic features of spleen
Histological features of spleen are as follows.
 Spleen is surrounded by capsule of dense connective
tissue.
 Trabecule arise from the capsule to parenchyma of
splenic pulp.
 Kidney is composed of reticular tissue.
 Splenic pulp is divided into two parts. White pulp and
Red pulp.
 White pulp lymph contains lymphoid nodules and peri
arteriolar lymphoid sheaths.
 Red pulp contains sinusoids and splenic cords.
 Stave cells are also present these are unusual long
endothelial cells wrapped by reticular fibers.
Differentiate between red and white pulp
Red pulp:
The red pulp is composed almost entirely of splenic cords (of
Billroth) and splenic sinusoid and is the site where effete
RBCs in blood are removed.
 The splenic cords contain a network of reticular cells and
fibers filled with T and B lymphocytes, macrophages,
other leukocytes, and red blood cells.
 The splenic cords are separated by the sinusoids.
 Unusual elongated endothelial cells called stave cells line
these sinusoids, oriented parallel to the blood flow and
sparsely wrapped in reticular fibers and highly
discontinuous basal lamina.
White pulp:
The small masses of white pulp consist of lymphoid nodules
and the periarteriolar lymphoid sheaths (PALS).
PALS, which consists primarily of T cells with some
macrophages, DCs, and plasma cells as part of the white pulp.
Surrounded by the PALS, these vessels are known as central
arterioles.
B cells located within the PALS may be activated by a trapped
antigen from the blood and form a temporary lymphoid
nodule like those of other secondary lymphoid organs. In
growing nodules, the arteriole is pushed to an eccentric
position but is still called the central arteriole. These
arterioles send capillaries throughout the white pulp and to
small sinuses in a peripheral marginal zone of developing B
cells around each lymphoid nodule.
Differentiate between lymphatic nodule of spleen
and lymph node
 In lymph nodes lymphatic nodules are present only in
Cortex.
 In Spleen lymphatic nodules are present in white pulp.
Describe the blood flow in red pulp of spleen
 In the closed circulation, capillaries branching from the
penicillar arterioles connect directly to the sinusoids and
the blood is always enclosed by endothelium.
 In the open circulation, capillaries from about half of the
penicillar arterioles are uniquely open-ended, dumping
blood into the stroma of the splenic cords. In this route
plasma and all the formed elements of blood must
reenter the vasculature by passing through narrow slits
between the stave cells into the sinusoids. These small
openings present no obstacle to platelets, to the motile
leukocytes, or to thin flexible erythrocytes.
Blood & Immunity Module | 17
 PHYSIOLOGY
ABO blood type
Discriminate blood groups on the basis of diverse
antigenic and immunological properties of blood
Recognize major and minor antigens present on
red blood cells
Major Antigens
Major antigens present on RBCs are of ABO system and Rh
system.
Minor Antigens:
Besides these, there are hundreds of minor antigens
including MNs, Lutheran, Kell, Kid, Duffy etc
Predict the genetic determination of blood group
of offspring based on inheritance
The ABO blood group genetic locus has three alleles which
determines 3 types of blood, these are:
 I ; typically called “A”
A
 I ; typically called “B”
B
 I ; typically called “O”
O
The common symbol is the letter “I,” which stands for
“immunoglobulin.”
 The type O allele is either functionless or almost func-
tionless, so it causes no significant type O agglutinogen
on the cells.
 The type A and type B alleles do cause strong
agglutinogens on the cells.
Thus, the O allele is recessive to both the A and B alleles,
which show co-dominance. Because each person has only
two sets of chromosomes, only one of these alleles is present
on each of the two chromosomes in any individual. However,
the presence of three different alleles means that there are
six possible combinations of alleles. These alleles are known
as genotypes and each person is one of six genotypes; OO,
OA, OB, AA, AB and BB.
Identify the origin, chemical nature and changing
titer of agglutinins in plasma
After birth: the quantity of agglutinins in the plasma is
almost zero.
2 to 8 months after birth, an infant begins to produce
agglutinins; Anti-A agglutinins when type A agglutinogens are
not present in the cells, and anti-B agglutinins when type B
agglutinogens are not in the cells.
8 – 10 years: A maximum titer is usually reached at 8 to 10
years of age, and this titer gradually declines throughout the
remaining years of life.
Origin: The agglutinins are gamma globulins they are
produced by the same bone marrow and lymph gland cells
that produce antibodies to any other antigens.
Most of them are IgM and IgG immunoglobulin molecules.
Small amounts of type A and B antigens enter the body in
food, in bacteria, and in other ways, and these substances
initiate the development of the anti-A and anti-B agglutinins.
For instance, infusion of group A antigen into a recipient
having a non-A blood type causes a typical immune response
with formation of greater quantities of anti-A agglutinins
than ever. Also, the neonate has few, if any, agglutinins,
showing that agglutinin formation occurs almost entirely
after birth.
Elucidate the agglutination process in transfusion
reactions
When bloods are mismatched the RBCs agglutinate as a
result of the agglutinins attaching themselves to the RBCs.
The agglutinins have
 IgG type : 2 binding sites
 IgM type : 10 binding sites
A single agglutinin can attach to two or more RBCs at the
same time, thereby causing the cells to be bound together by
the agglutinin. This binding causes the cells to clump, which is
the process of “agglutination.”
Then these clumps plug small blood vessels throughout the
circulatory system. During ensuing hours to days, either
physical distortion of the cells or attack by phagocytic white
blood cells destroys the membranes of the agglutinated cells,
releasing hemoglobin into the plasma, which is called
hemolysis of the RBCs.
Comprehend the basis of Immediate and delayed
intravascular hemolysis as an outcome of
mismatched blood transfusion
Blood & Immunity Module | 18
Immediate Hemolysis:
 Due to mismatched blood of donor and recipient, the
antibodies cause lysis of the RBCs by activating the
complement system, which releases proteolytic enzymes
(the lytic complex) that rupture the cell membranes.
Delayed hemolysis,
 It is more common than immediate hemolysis because
not only does there have to be a high titer of antibodies
for lysis to occur, but also a different type of antibody
seems to be required, mainly the IgM antibodies; these
antibodies are called hemolysis.
Highlight the significance of blood typing and
blood matching procedures
For giving transfusions, determination of the blood type of
the recipient’s blood and the blood type of the donor blood is
called blood typing and blood matching,
Procedure:
 The RBCs are first separated from the plasma and
diluted with saline solution.
 One portion is then mixed with anti-A agglutinin and
another portion with anti-B agglutinin.
 After several minutes, the mixtures are observed under a
microscope.
 If the RBCs have become clumped (agglutinated) one
knows that an antibody-antigen reaction has resulted.
Type O RBCs have no agglutinogens and therefore do not
react with either the anti-A or the anti-B agglutinins.
Type A blood has A agglutinogens and therefore agglutinates
with anti-A agglutinins.
Type B blood has B agglutinogens and agglutinates with anti-
B agglutinins.
Type AB blood has both A and B agglutinogens and
agglutinates with both types of agglutinins.
Rh blood type
Discriminate between the O-A-B system and the
Rh-system
In the O-A-B system, the plasma agglutinins responsible for
causing transfusion reactions develop spontaneously,
whereas in the Rh system, spontaneous agglutinins almost
never occur.
Instead, the person must first be massively exposed to an Rh
antigen, such as by transfusion of blood containing the Rh
antigen, before enough agglutinins to cause a significant
transfusion reaction will develop.
Categorize the common types of Rh antigens
There are six common types of Rh antigens, each of which is
called an Rh FACTOR.
 The types are C, D, E, c, d, and e.
 Every person has one of each of the three pairs of
antigens.
 A person who has a C antigen does not have the c
antigen, but the person missing the C antigen always has
the c antigen. The same is true for the D-d and E-e
antigens.
 The type D antigen is said to be Rh positive, whereas a
person who does not have type D antigen is said to be Rh
negative.
Illustrate the pattern of Rh immune response
Formation of anti-Rh agglutinins:
Injecting Rh factor containing RBC’s into a Rh-Negative
person there is anti-Rh agglutinins which develop slowly,
reaching maximum concentration of agglutinins about 2 to 4
months later.
Some people are strongly sensitized due to, multiple
exposures to the Rh factor.
Characteristics of Rh transfusion reactions:
 No immediate reaction occurs if a Rh-Negative person is
exposed to Rh-positive blood by transfusion.
 However, anti-Rh antibodies can develop in sufficient
quantities during the next 2 to 4 weeks to cause
agglutination of the transfused cells that are still
circulating in the blood.
 A mild delayed transfusion reaction occurs on hemolysis
by tissue macrophages system
 When already immunized against Rh-factor, transfusion
can be immediate and as severe as a transfusion reaction
caused by mismatched type A or B blood.
Correlate the implication of Rh factor in
Erythroblastosis fetalis
It is a disease in which a Rh-negative mother develops anti-Rh
agglutinins due to placental exposure with a Rh-positive
fetus’s Rh- antigens.
Incidence
 An Rh-negative mother having her first Rh-positive child
usually does not develop sufficient anti-Rh agglutinins to
cause any harm.
 About 3 percent of second Rh-positive babies exhibit
some signs of erythroblastosis fetalis;
 About 10 percent of third babies exhibit the disease; and
the incidence rises progressively with subsequent
pregnancies.
Clinical picture
o Jaundiced erythroblastotic newborn baby is usually
anemic at birth, along with anti-Rh agglutinins from the
mother usually circulating in the infant’s blood for
another 1 to 2 months after birth, destroying more and
more RBCs.
o The hematopoietic tissues of the infant attempt to
replace the hemolyzed RBCs.
o The liver and spleen become greatly enlarged and
produce RBCs.
o Due to, the rapid production of RBCs, many early forms
of RBCs, are passed from the baby’s bone marrow into
the circulatory system.
o Although the severe anemia of erythroblastosis fetalis is
usually the cause of death, many children who barely
survive the anemia exhibit permanent mental
impairment or damage to motor areas of the brain
because of precipitation of bilirubin in the neuronal
cells, causing destruction leading to a condition called
kernicterus.
Prevention
Blood & Immunity Module | 19
 Rh immunoglobulin globin, an anti-D antibody that is
administered to the expectant mother starting at 28 to
30 weeks of gestation.
 The anti-D antibody is also administered to Rh-negative
women who deliver Rh-positive babies to prevent
sensitization of the mothers to the D antigen.
 Due to this risk of developing large amount of D-
antibodies greatly reduces in second pregnancy.
Blood transfusion and its problems
Assume the complications from transfusion of
mismatched blood types
 If mismatched blood types are transfused, a transfusion
reaction occurs.
 Agglutinins’ attach themselves to the red blood cells.
Two binding sites on IgG type &10 binding sites on IgM
type can attach two or more red blood cells at the same
time causing clumping, known as Agglutination.
 Agglutination of the recipient’s cell occurs because
plasma portion of the donor blood is diluted decreasing
concentration of infused agglutinins while recipient’s
agglutinins agglutinate the mismatched donor cells.
 These clumps plug small blood vessels throughout the
circulatory system.
 Hemolysis of the RBCs occurs due to
o Either physical distortion of the cells
o or attack by phagocytic white blood cells
As a result, Hemoglobin is released into the plasma.
 The hemoglobin released is converted by the phagocytes
into bilirubin, excreted in the bile by the liver normally.
If the rate of hemolysis of blood is more than 400ml/day,
it can lead to jaundice.
 Less commonly, immediate hemolysis of red cells occurs
in the circulating blood.
o Antibodies activate complement system which
releases proteolytic enzymes causing rupture of the
cell membranes of RBCs.
o There has to be a high titer of antibodies for lysis to
occur and different type of antibody seems to be
required
o Mainly the IgM antibodies (called hemolysis) are
involved.
Acute kidney shutdown after transfusion reactions
Begins within a few minutes to a few hours and continues
until the person dies of renal failure. The kidney shutdown
seems to result from three causes:
1. Antigen-antibody reaction of the transfusion reaction
releases toxic substances causing powerful renal
vasoconstriction.
2. Loss of circulating red cells & production of toxic
substances cause circulatory shock.
The arterial blood pressure falls very low, and renal
blood flow and urine output decrease.
3. If the free hemoglobin in blood is greater than
hemoglobin binding protein in blood, haptoglobin,
excess hemoglobin leaks through glomerular
membranes into the kidney tubules. Slight amount can
be reabsorbed but large amount isn’t fully reabsorbed
causing the tubular hemoglobin concentration to rise so
high that the hemoglobin precipitates and blocks the
kidney tubules.
Renal vasoconstriction, circulatory shock, and renal tubular
blockage together cause acute renal shutdown.
If the shutdown is complete and fails to resolve, the patient
dies within a week to 12 days, unless treated with an artificial
kidney.
↑amount of hemoglobin in blood → kidney → precipitate
→ blockage of kidney tubules → renal vasoconstriction +
circulatory shock + renal tubular blockage→ acute renal
shut down
Hemostasis
Elaborate the sequential events of Hemostasis
Blood vessel injury leads to a series of events:
1. Vascular constriction – contraction of blood vessel
2. Platelet plug formation
3. Blood coagulation
4. Growth of fibrous tissue for permanent closure.
Discriminate between the terms of “Hemostasis”
and “Homeostasis”
 Homeostasis: maintenance of nearly constant conditions
in the internal environment.
 Hemostasis: prevention of blood loss. (heme → blood,
stasis → stoppage)
Outline the mechanisms of vascular constriction
Smooth muscles of the blood vessel contract resulting from
1. Local myogenic spasm: (myogenic - muscular, spasm –
involuntary contraction) due to direct trauma
2. Local autacoids factors: (chemical substances which act
like hormones)
 Released by traumatized tissue and blood platelets.
 Include serotonin and thromboxane.
3. Nervous reflexes: initiated by pain and sensory receptors
Degree of vasoconstriction depends upon the severity of
trauma. It lasts from several minutes to hours.
Associate the structural and functional features of
platelets with the platelet plug formation
 1-4 µm in diameter
 Formed from megakaryocytes in bone marrow
 Normal concentration: 150,000-300,000/µl
 Lack nuclei and thus, cannot reproduce
 Functional characteristics their cytoplasm has:-
o Actin, myosin & thrombosthenine; cause contraction
o Residuals of Endoplasmic reticulum & golgi
+2
apparatus; enzyme synthesis & Ca storage
o Enzyme system; form prostaglandins (local
hormone)
o Fibrin stabilizing factor
o Growth factor; for growth of vascular endothelium,
smooth muscles & fibroblast
 Glycoprotein layer causes adherence to injured area only
 Phospholipids on cell membrane activate stages in blood
clotting
 Half-life: 8-12 days
 Destroyed by tissue macrophages mostly in spleen
Blood & Immunity Module | 20
 Highlight the importance of platelet-plugging
mechanism for Closing Vascular Holes
Mechanism:
Platelets come in contact with damaged blood vessel
o Swell, take irregular forms and form pseudopods
o Becomes sticky and attach to collagen and von
williboard factor
o Contract forcefully releasing granules with multiple
active factors including thromboxane
o Release ADP which along with thromboxane acts on
nearby platelets
o Increased number of platelets form a lose platelet
plug blocking the blood loss.
Importance:
 Vascular endothelium is ruptured several times daily.
 Platelet plug closes very small blood vessels and
becomes a part of the endothelial cell membrane.
 People with low platelet count develop thousands of
small hemorrhagic areas daily.
Identify the diagram and explain particular coagulation
pathway in specific setting of vessel injury
Clotting takes place in 3 steps:
1. Activation of prothrombin activator:
It is the rate limiting factor.
This is believed to be done in two ways:
Extrinsic pathway; begins with the trauma to vascular
walls and surrounding tissues. 2. Conversion of prothrombin to thrombin

+2
Prothrombin activator & Ca convert prothrombin into
thrombin
Prothrombin: α-globulin plasma protein produced in the liver
which requires vit K for activation. It is deficient In cases of
vitamin K deficiency and liver diseases which can result in
bleeding tendency
3. Conversion of fibrinogen into fibrin
 Thrombin removes 4 low molecular weight polypeptides
from fibrinogen and converts it into fibrin.
 Fibrin starts forming polypeptides due to its automatic
polymerization property
 Fibrin-stabilizing factor is activated by thrombin. This
factor induces conversion of weak hydrogen bonds of the
polypeptide chain into covalent bond and induces cross-
link formation.
Blood clot:
Blood cells, platelets and plasma entrapped by fibrin
which adheres to the damaged surface of the blood vessel
Contraction of clot: Clot contracts several minutes after
contraction. Serum, a fluid different from plasma is released.
Clotting factors are absent in serum.
Platelets induce contraction by:
o Bonding different fibers together during clot formation
o Releasing pro coagulant substances specially fibrin-
stabilizing factor which causes formation of more cross-
bridges
o Activating its contractile proteins
+2
o Releasing Ca which acts with thrombin to activate and
Intrinsic pathway: begins in blood accelerate contraction

Blood & Immunity Module | 21

 Categorize various clotting factors and ascertain
their roles in coagulation cascade
>50 substances in our blood effect blood coagulation:
 Pro-coagulants: promote coagulation
 Anti-coagulants: inhibit coagulation
Normally anticoagulant predominate pro coagulants while
pro coagulants activate in case of an injury to the vessel.
Find out the interaction and dissimilarities
between intrinsic or extrinsic pathways
Clotting occurs by both pathways simultaneously.
Natural anticoagulants
Explore the factors & mechanisms that prevent
blood clotting in the normal vascular system
 Endothelial Surface Factors: Probably the most impor-
tant factors for preventing clotting in the normal vascular
system are
 The smoothness of the endothelial cell surface, which
prevents contact activation of the intrinsic clotting
system.
 A layer of glycocalyx on the endothelium which repels
clotting factors and platelets, thereby preventing
activation of clotting.
 A protein bound with the endothelial membrane,
thrombomodulin, which binds thrombin. Not only does
the binding of thrombin with thrombomodulin slow the
clotting process by removing thrombin, but the
thrombomodulin-thrombin complex also activates a
plasma protein, protein C, that acts as an anticoagulant
by inactivating activated Factors V and VIII.
 When the endothelial wall is damaged, its smoothness
and its glycocalyx thrombomodulin layer are lost, which
activates both Factor XII and the platelets, thus setting
off the intrinsic pathway of clotting. If Factor XII and
platelets come in contact with the sub endothelial
collagen, the activation is even more powerful.
Determine the blood clot lytic mechanisms
The plasma proteins contain a euglobulin called
plasminogen, its activated form is called plasmin.
Plasmin is a proteolytic enzyme. It digests fibrin fibers and
some other protein coagulants such as fibrinogen, Factor V,
Factor VIII, prothrombin, and Factor XII. Therefore,
whenever plasmin is formed, it can cause lysis of a clot by
destroying many of the clotting factors, thereby sometimes
even causing hypocoagulability of the blood.
Mechanism:
 When a clot is formed, a large amount of plasminogen is
trapped in the clot along with other plasma proteins.
 Tissue plasminogen activator (t-PA)is released by the
injured tissue and vascular endothelium.
 A few days later, t-PA converts plasminogen to plasmin,
which in turn removes the unnecessary blood clot.
Many small blood vessels in which blood flow has been
blocked by clots are reopened by this mechanism.
 Thus, an especially important function of the plasmin
system is to remove minute clots from millions of tiny
peripheral vessels that eventually would become
occluded were there no way to clear them.
Discriminate between Thrombi and Emboli
 An abnormal clot that develops in a blood vessel is called
a thrombus.
 If the clot is broken by the continued blood flow and flow
with the blood, it is known as emboli.
 Cause of Thromboembolic Conditions:
 The causes of thromboembolic conditions in the human
being are usually twofold:
 (1) Aroughened endothelial surface of a vessel : as may
be caused by arteriosclerosis, infection, or trauma, is
likely to initiate the clotting process.
 (2) Blood often clots when it flows very slowlythrough
blood vessels, where small quantities of thrombin and
other pro coagulants are always being formed.
Blood & Immunity Module | 22
Associate failed anticoagulant and clot lytic mechanisms
with clinical thromboembolic conditions
 Clotting almost always occurs when blood flow is blocked
for many hours in any vessel of the body, the immobility
of patients confined to bed plus the practice of propping
the knees with pillows often causes intravascular
clotting because of blood stasis in one or more of the leg
veins for hours at a time.
 Then the clot grows, mainly in the direction of the slowly
moving venous blood, sometimes growing the entire
length of the leg veins and occasionally even up into the
common iliac vein and inferior vena cava.
 Then, about 1 out of every 10 times, a large part of the
clot disengages from its attachments to the vessel wall
and flows freely with the venous blood through the right
side of the heart and into the pulmonary arteries to
cause massive blockage of the pulmonary arteries, called
massive pulmonary embolism.
 If the clot is large enough to occlude both pulmonary
arteries at the same time, immediate death ensues. If
only one pulmonary artery is blocked, death may not
occur, or the embolism may lead to death a few hours to
several days later because of further growth of the clot
within the pulmonary vessels. T-PA therapy can be a
lifesaver.
Practical
Determine the role of RBC antigens and plasma
agglutinins in identifying the blood group
Landsteiner’s law:
 If particular antigens (agglutinogens) are present on the
RBCs of a person, then its corresponding antibodies
(agglutinins) must be absent in the plasma of that
person, and vice versa.
 In blood grouping, 3 sera are used:
 Blue  contains antigen A
 Yellow  contains antigen B
 Clear  contains antigen D
 Agglutination of an individual’s blood in any of these sera
determines his/her blood type.

Mode of inheritance of different blood groups
Blood groups are inherited from parents.
 I and I are codominant allele
A B
 I id recessive allele
O
Analyze the role of blood group antigens in
pregnancy in context of Erythroblastosis fetalis
o In Erythroblastosis fetalis, mother is Rh –ve, fetus Rh +ve
(because father is Rh +ve).
o Due to mixing of blood in complications during
pregnancy or during parturition, D antigens get into
mother’s blood from fetus’s blood. Mother’s body gets
sensitized and produces anti-D antibodies.
st
o The condition is usually not severe in 1 pregnancy but
severity increases with successive pregnancies.
Identify the role of Blood Compatibility through the
process of Cross Matching & acquire the pre-and
post-knowledge of Blood Transfusion Reactions
Blood transfusion reactions are of two types: Incompatible
and compatible
Incompatible: major antigen-antibody reactions (A-B-O, Rh),
acute, can be checked by cross matching
Compatible: minor antigen-antibody reactions, delayed
(after 24hrs of transfusion), cannot be checked by cross-
matching
Relate in particular the role of Platelets with normal BT.
Identify the Level of Defect in the process of
Hemostasis
 Normal bleeding time = 1-5 minutes.
 Damaged wall activates increasing number of platelets
that attract more and more platelets and forms the
platelet plug.
 The platelet plug mechanism is very important in closing
the ruptured tissues and blood vessel walls by forming
loose primary clot thus maintaining the bleeding time.
 Thus normal level of platelets is very important in
hemostasis.
 Normal level of platelets = 1.50000 and 300000 per
micro liter.

st
The 1 step in hemostasis is the aggregation of platelets
to form loose plug at the site of rupture. Thus if the
number of platelets falls, blood’ ability to clot is reduced.
Discriminate various Bleeding Disorders as well as
Thromboembolic Conditions (CT) through simple
laboratory technique
 In Hemophilia the person bleeds for a longer time after
an injury due to the reduced ability of a body to make a
clot caused by the abnormality or deficiency of clotting
factor VII or IX.
Blood & Immunity Module | 23
 Purpura is a bleeding disorder in which there is an
internal bleeding of blood vessels occurs due to the
defect of blood clotting factor.
 Both disorders mentioned above can be caused due to
the low level of platelets in their blood. So normal
platelet count is the characteristic of these disorders.
Discuss specific clotting factor defects:
Hemophilia, Christmas disease, Vitamin K
deficiency
 Hemophilia is the bleeding disorder in which blood
clotting ability is reduced due the abnormality or
deficiency of clotting factor VII (Hemophilia A )or factor
IX.
 Hemophilia caused by the deficiency of blood clotting
factor IX is known as Christmas disease
 Vitamin K Deficiency
 All blood clotting factors are synthesized in liver but
some factors i-e II, VII , IX and Xrequire vitamin k for
their active forms. In the absence of active vitamin K,
subsequent insufficiency of these clotting factors can
lead to the serious bleeding disorders.
Explain the role of anticoagulants in vivo
Anti-coagulants delay the coagulation process. Natural anti-
coagulants in the blood prevent the formation of abnormal
and unusual clot in blood vessels. These anticoagulants also
prevent excessive clot formation during coagulation
process. Thus a balance is maintained between bleeding and
clotting by these anti-coagulants.
BIOCHEMISTRY
VITAMIN K
Identify the sources of Vitamin K
 Plants as phyllo quinone(or vitamin K1)
 Intestinal bacterial flora as menaquinone(or vitamin K2).
 Synthetic form of vitamin K, menadione
 Vitamin K is found in cabbage, kale, spinach, egg yolk,
and liver.AI for vitamin K is 120 μg/day for adult
 Males and 90 μg for adult females
 Vitamin K is found in cabbage, kale, spinach, egg yolk,
and liver.AI for vitamin K is 120 μg/day for adult
 Males and 90 μg for adult females
Discuss vitamin K role in RBCs
1) Post Transcriptional modification of various blood clotting
factors, (a coenzyme in the carboxylation of certain Glutamic
acid residues)
2) Formation of carboxyglutamate (Gla):
 Hepatic synthesisof prothrombin and blood clotting
factors II, VII, IX, and X(inactive precursor molecules.).
 Formation of the clotting factors requires the vitamin K–
dependent carboxylation of glutamic acid residuesto
Gla residues (gives activated clotting factors).
 The reaction requires O2, CO2, and the hydroquinone
form of vitamin K.
Inhibitors:
 Dicumarol, (anticoagulant in sweet clover)
 Warfarin, (synthetic analog of vitamin K).
3) Interaction of prothrombin with platelets:
 The Gla residues of prothrombin chelates positively
charged calcium ions, because of the two, negatively
charged carboxylate groups.
 Prothrombin–calcium complexformed.
 It binds to phospholipids on the surface of platelets.
 Increases the rate of conversion of prothrombin to
thrombin
4) Gla in protein C (involved in limiting the formation of
blood clots).
Relate vitamin K deficiency with defective
coagulation mechanism
Vitamin K deficiency is unusual as produced by intestinal
bacteria or from the diet.
Bacteria population destroyed (antibiotics)
 Hypoprothrombinemia
Treatment:
Supplementation with vitamin K to correct the bleeding
tendency
In addition, certain second-generation cephalos porins, for
example, cefoperazone, cefamandole, and moxalactam cause
Hypoprothrombinemia (warfarin-like mechanism).
Supplemented with vitamin K
Deficiency of vitamin K in the newborn:
Newborns have sterile intestinesand so initially lack the
bacteria that synthesize vitamin K. (human milk provides only
about one fifth of the daily)
Asingle intramuscular dose of vitamin Kto prevent
hemorrhagic disease
Toxicity of vitamin K:
Prolonged administration of large doses of synthetic vitamin
K (menadione) can produce hemolytic anemia and jaundice.
(effect membrane of RBCs)
Plasma proteins
Outline the components of blood and plasma
Components of blood:
 Plasma 55%
 Formed elements 45%
Components of plasma:
 Water 91%
 Plasma proteins (Albumins, Globulins, Fibrinogen)
7%
 Other solutes (electrolytes, nutrients, gases, wastes,
vitamins, regulatory substances e.g. hormones) 2%
Differentiate between serum and plasma
Serum= plasma - fibrinogen
Plasma: liquid cell-free part of the blood, which has been
treated with anti-coagulants
Serum: liquid part of the blood AFTER coagulation, therefore
devoid of clotting factors such as fibrinogen
Blood & Immunity Module | 24
 Mutant α1 –antitrypsin accumulates to cause liver damage
followed by accumulation of collagen resulting in fibrosis
(cirrhosis).
ii. α1–Fetoproteins
 Present in high amount in fetal blood
 The fetal form of serum albumin.
 Copper, nickel, fattyacids and bilirubin.
 Raised in hepatocellular carcinoma/teratoma
(derived from germ cells in the testes and ovaries)
tumor marker
iii. α1–Acid glycoproteins (Oroso-mucoids)
 1-3% plasma protein
 Reliable indicator of acute inflammation

B.α2-Globulin
i. Heptoglobin (Hp)
 Can bind with the free hemoglobin (extra-
corpuscular Hb) during hemolysis.
 Prevent the loss of free Hb into urine.
Identify the functions of individual plasma proteins  Decreases in hemolytic anemia
with the mechanism ii. Ceruloplasmin (CER)
Albumin  A blue-colored, copper-containing
Functions:  Carries copper (6 atoms)
1. Transport of ions, fatty acids, bilirubin and hormones  Ferroxidase enzyme (copper-dependent oxidase
2. Maintenance of intravascular pressure activity)

2+ 3+
Albumin does not readily move through normal capillary Fe (ferrous iron)fe (ferric iron)
pores, while water and smaller biologic structures move  For transport in transferrin mol.
freely. Sodium is highly attracted to albumin and together  Ceruloplasmin too much copper in the body's
help maintain colloidal osmotic pressure by attracting water tissues.
into the intravascular space.  Damages the liver and nervous system
Wilson’s disease (hepatolenticular degeneration)
Low albumin  edema
Because excess water will accumulate in interstitial spaces
1. Acid-base balance
2. Anti-oxidant effect
3. Anti-coagulant effect
4. Drug transport
5. Micro vascular integrity
Globulins:
 A family of globular proteins that include a set of sixty
proteins
 Weight 90--1300 kDa
 Produced by the liver and the immune system.
 2.3-3.5 gm/dL
A.α1-Globulin
i. α1–Antitrypsin/Antiproteinase
 1.5 - 3.5 gram/liter
 plasma proteinase inhibitor
 Can combine with elastase, trypsin and other
proteases and inhibit them.
 Clinical Significance: C. β–Globulins
Emphysema: a disease of the lungs (COPD)
(shortness of breath, wheezing, rhonchi, and rales) ii. Transferrin (Tf)

3+
 α1–antitrypsin deficiency liver disease Transports iron in ferric ions (Fe ) and protects the
body against the toxic effects of free iron.
 Each molecule carries two iron ions

Blood & Immunity Module | 25

  Increase cause anemia  It is the most abundant class in serum~80%
 IgG is the only class of Ig that crosses the placenta.
iii. C-reactive Proteins
 Macrophages, monocytes, PMNs
 Activates the complement system promoting (polymorphonuclear leukocyte), and some
phagocytosis by macrophages, thus lymphocytes
 Clears necrotic and apoptotic cells and bacteria.
 Involved in the promotion of immune system. Ig A
 A major component of acute phase protein  Major Secretory Ig
<10 mg/l,  Found in the body secretions: tears, breast milk,
 Crp rises up to 50,000-fold in acute inflammation saliva, mucus of the bronchial, genitourinary, and
 Rises within 6 hours, and peaks at 48 hours. digestive tract
 Antibody in the colostrums (The initial secretion
d. γ-Globulins from the mother’ breast after a baby is born).
Ig M
 It is restricted to the blood stream.
 B cell-mediated (humoral) immunity before there is
sufficient igg
 Serve as first line of defense.
 The most effective in leading to the lysis of
microorganisms.
IgD
 An antigen receptor on B cells that have not been
exposed to antigens
 Activate basophils and mast cells to
Produce antimicrobial factors.
Ig E
 Least common serum Ig
 Allergic Reactions
Immunoglobulin (Ig) /antibody (Ab): Binds to basophils and mast cells (Does not require
 Type of γ-globulin Ag binding)
 Produced by plasma cells in response to an  Parasitic infections (Helminths)
immunogen and function as antibodies Binds to Fc receptor on eosinophils
 No complement activation.
 Ferritin---intracellular globular protein consisting of 24
protein subunits
 Stores iron
 Releases it in a controlled fashion
 Small amounts-secreted into the serum where it
functions as an iron carrier
Fibrinogen:

 Immunoglobulin Classes and Subclasses

 Differences in amino acid sequence of constant
region of heavy chain
 Immunglobulin molecules are divided into 5 classes:
IgG, IgA, IgM, IgD and IgE
IgG

Blood & Immunity Module | 26

 Comprises 7% of blood proteins
 Blood level 200-300mg/dl
 complex glycoprotein, 340 kDa
 Is converted by thrombin into insoluble fibrin during
blood clot formation.

AST:

Correlate the clinical aspects of plasma proteins

Albumin
Hypoalbuminemia (lowered plasma albumin)
In malnutrition, nephrotic syndrome and cirrhosis ofliver
Albuminuria (albumin in urine)
In nephrotic syndrome and certain inflammatory conditions Observation:
of urinary tract
Therapeutic uses
For the treatment of burns and hemorrhage

Practical
Correlate serum ALT & AST different clinical disorders Change in A1: A1- A2
Change in A2: A2- A3
Liver function tests: Change in A3: A3- A4
Reagent:
1. R1: Phosphate buffers L- Alanine and ketogluterate,
Mean= change in A1+change in a2 + change in a3
L- aspartate. 3
2. R2: 2,4 DNPH Concentration of ALT/AST= mean absorbance multiplied by
3. R3: NaOH and Pyruvate standard factor.

STANDARD: Serum
PHARMACOLOGY
Reactions:
ALT: Identify the drugs used for coagulation disorders
Alpha-ketogluterate + L-Alanine L-gluterate pyruvate Classes of drugs:-
1. Prevent coagulation
AST:
2. Dissolve clots
Alpha-ketoluterate + L-Aspartate L-glutamate +
3. Prevent hemorrhage (Bleeding)
oxaloacetate
4. Replacement therapies
Procedure:
ALT:

Blood & Immunity Module | 27


Explain clinical uses with major adverse effects of
these drugs
Heparins:
 Prevent blood clotting and thrombosis of vessels
 Parenteral
 Cannot cross placenta and is safe in pregnancy
 I/M infusion can cause hematoma
 Action: Inactivates prothrombin by activating anti-
thrombin III
Use: To prevent blood clot in angioplasty, by-pass, dialysis,
etc. Major role is in myocardial infarction treatment as it
prevents clotting.
Adverse effects: Bleeding, osteoporosis, hypersensitivity, etc.
Antitode: Protamine sulphate
Warfarin
 Prevent or decreases the synthesis of clotting factors
 Oral
 Can cross placenta and can cause bone defects and
hemorrhage in fetus.
 4 (Factor II, VII, IX AND X) out of 13 factors are
dependent upon Vitamin K. Warfarin affects these
factors.
 Prothrombin is activated by Vitamin K. Warfarin stops
the reduction of Vitamin K which in turn stops the
activation of prothrombin
Antitode: Intake of Vitamin K containing products and Fresh
Frozen Plasma (in emergency).
Side effects: Severe bleeding, hyper coagulability, fatigue,
pale skin, hair loss, etc.
Adverse effects: Cutaneous necrosis, allergic reactions,
microcephaly, abnormal bone formation,etc.
Thrombolytic drugs:
 Clot is broken down by plasmin (activated by
plasminogen).
 Antitode: Amino carporic acid and tranexamic acid
Anti platelets drugs:
 Blocks platelet formation by destroying fibrin and
separating platelets.
Aspirin
 Decreases platelet aggregation (inhibitor of COX 1 and
COX2)
 Prevent the thrombosis of vessels (arteries mostly)
COMMUNITY MEDICINE
Describe the blood transfusion hazards and their
prevention
Hazards of blood transfusion
 Dose, age of product, and immunomodulation.
 Transfusion-associated circulatory overload.
 Transfusion-related acute lung injury. Hemolytic
transfusion reactions
 Acute transfusion reactions.
 Transfusion-associated dyspnea.
 Post-transfusion purpura.
Preventions:
 Check patient`s blood group
 Cross match patient`s and donor blood group
 Test that the donor is not suffering from any disease
which is transferred to patient via blood transfusion.
 Check history of donor i.e.; he is not suffering from any
disease or have hereditary disease
Determine the importance of screening of blood
 It is important because we can check that the donor is
not suffering from five major blood diseases i.e; HIV, Hep
B, Hepatitus C, Malaria ,SYPHILLIS
 These diseases are transferred through blood.
Identify that blood act as a vehicle for transmission of
diseases like HIV/ AIDS, Hepatitis C and B
As we know the virus lives in the blood of human being and
specifically in the cells and take control of the synthetic
machinery of the human cell and start replicating and
Blood & Immunity Module | 28
producing new viruses. When we transfer blood to the 2) Neurotic- stable
person he takes cells also. The cells have viruses that start to
replicate in that person`s blood and producing the symptoms FIVE FACTORS AND ASSOCIATE ADJECTIVES
of that disease. HIV, plasmodium, hepatitus virus, syphillis
virus lives in blood and their corresponding disease will
transfer also.
Relate the social factors affecting blood
transfusion behavior
 Use of elevator and exercise should be avoided
after blood donation
 Patients on insulin cannot donate blood

BEHAVIORAL SCIENCES
Personality
1) Characteristic patterns of behavior and modes of thinking
that determine a person’s adjustment to the environment.
(bolander)
2) Personality is a dynamic organization, inside the person, of
psychophysical system that creates persons characteristic
patterns of behavior, thoughts, and feelings. (Carver &
Scheier)
 Temporary changes being tired or taking medicines etc
does not alter personality
 Personality help make predictions on behavior

Synthesize the various determinants of personality

development
Body types: Piagets theory of cognitive development:
Greek theory: Initially Determined personality of a person Sensory motor stage:
relating to the various substances in the body, Later related  0 to 2 yrs of age
the physical appearance to personality. (e.g.; Short/plum:  Non verbal development
called endomorphs, sociable, relaxed even tempered)  Learning purposeful movements
Roman: Believed in the influence of air, water, fire and earth.  After 18 month concept of object permanence develops
Psychoanalytic theory: Preoperational stage:
 Reservoir of unconscious impulse called ID.  2 to 7 yrs
 Conscious mind: ego  Ability to think and use language( not sophisticated)
 Rules of society and those inculcated in upbringing:  Egocentric and unable to take point of view of others
superego Concreteoperational stage:
 As growing from early childhood; basic impulses
 Ego and super ego.  7 TO 11 yrs of age
 Hence come’s psychosexual development.  Mastery of concept of conversation
 Some of the mental energy blocked in early childhood at  Grasp concept of time, space and number
a stage. Depending on when that occurs give us a Formal operational stage:
personality characteristic:  11 yrs onwards
 Early stage: miserly grabby nature Thinking based on abstract ideas
 Later stage: sarcastic and biting  Less egocentric
 Even later stage: concerned with attention  Full adult intellectual ability
Trait theory:  Capable of reasoning

 Relies on mathematical calculations Psychodynamic theory of personality

 Large no of information collected from a large group of Development:
people. Sigmund freud proposed personality develops in 5 stages.
 Factor analysis: tells what information tends to go
Oral stage:
together.
 Supported by Eysenck  Pleasure seeking behavior focusing on baby mouth
 When oral needs not fulfilled , personality becomes
 Categorize in
fixated or arrested
1) Introversion- extroversion

Blood & Immunity Module | 29

 In adults it is shown by behavior such as chewing pencils, Write the influence of personality types on common
smoking cigar, over reacting. In personality it clinical conditions
dependency, optimism and gullibility are shown
Personality types and heart disease:
Anal stage:
 18 months to 3 yrs.
 Muscular control develops
 Derives pleasure from retention and expulsion of faeces
 Strict and demanding parents at this stage can cause
fixation. As a result person develops rigid, obsessional.
They are perfectionists, become distresses and anxious
easily with timetables disturbed.
Phallic stage:
 4 to 5 yrs. of age
 Pleasure derived from fondling their genitals
 Fixation results in disturbed relation with both or any of
the genders
Latency and genital stage:
 6 yrs. of age to adolescence
 Sexual interest reawaken at puberty
 Sexual pleasure derived from heterosexual relationship
 At beginning narsissistic qualities seen , but as mature
greater ability to establish relationship is achieved
Eriksson stage of psychosocial development:

Blood & Immunity Module | 30


PHYSIOLOGY
Introduction to lymphoid system
Differentiate between different types of MALT
The immune cells located diffusely in the digestive,
respiratory, or urogenital mucosae comprise what is
collectively known as Mucosa-associated lymphoid tissue
(MALT). It is the largest lymphoid organ, containing up to
70% of all the body’s immune cells. These surfaces protect
the body from an enormous quantity and variety of antigens.
Following are the types of MALT:
 TONSILS: These are clusters of lymphatic tissue under
the mucous membrane lining of the nose, mouth, and
throat. Lymphocytes and macrophages in the tonsils
provide protection against foreign substances and
pathogens that enter the body through the nose or
mouth.
 ADENOIDS: A cluster of lymphatic tissue that hangs from
the upper part of the back of the nasal cavity. Adenoids
get bigger after birth but usually stop growing by the age
of 7. Like the Tonsils, they can be removed without
significantly increased risk of infections.
 PEYER'S PATCHES: These are clusters of lymphatic
nodules in the mucosa that lines the ileum of the small
intestine. They play an important role in defending
against the large number of pathogens that enter the
gastrointestinal system.
Describe the light microscopic features of
pharyngeal tonsils
The pharyngeal tonsil is situated in the posterior wall of the
nasopharynx and is usually covered by ciliated
pseudostratified columnar, ciliated epithelium interspersed
with patches of stratified squamous non keratinized
epithelium.
Lymph node
Define lymph node
 Lymph nodes are bean shaped, encapsulated structures,
distributed throughout the body along the lymphatic
vessels.
 Lymph nodes are major sites of B, T, and other immune
cells. Lymph nodes are important for the proper
functioning of the immune system, acting as filters for
foreign particles and cancer cells.
 These also facilitate the production of plasma cells
secreting non-IgA antibodies.
Differentiate between primary and secondary
lymph node
Primary lymph nodules do not exhibit germinal centersand it
consists of lymphocytes only secondary lymph nodules
exhibit a light staining germinal center and darkly stained
peripheral mantle zone or corona(B and T lymphocytes) that
surrounds the germinal center. (Plasma cells, dendritic cells,
lymphoblast and macrophages).
Correlate the histological structure of lymph node with
its immune function
The lymph node is an important site of lymphocyte
proliferation (especially of B cells in the germinal centers) as
well as of transformation of B lymphocytes into plasma cells.
Because of this, the lymph that leaves a lymph node may be
enriched in antibodies. When the lymph is returned to the
blood circulation, these antibodies will be delivered to the
entire body.
Differentiate between red and white pulp of
spleen and lymphatic nodule of lymph node
The white pulp is densely packed with immune cells, and is
the site of antigen specific differentiation in the spleen. It is
separated into the T-zone (otherwise known as the peri-
arteriolar lymphoid sheath or PALS) that surrounds the
arteriole, the B-Cell-rich lymphoid follicles which surround
the T-zone, and the marginal zone (this basically “wraps” the
lump of white pulp together) that surrounds the follicles and
connects the white pulp to the surrounding red pulp.There
are several parts of white pulp with distinct functions:
 Periarteriolar lymphoid sheaths (PALS)are typically
associated with the arteriole supply of the spleen;
contain T lymphocytes.
 Lymph follicles with dividing B lymphocytes are located
between PALS and marginal zone. IgM and IgG2 are
produced in this zone. These molecules play a role in
opsonization of extracellular organisms, encapsulated
bacteria in particular.
 Marginal zone is located further away from the central
arteriole (in proximity to red pulp), it contains Antigen
presenting cells (APCs).
The RED PULP is responsible for recycling red blood cells and
removing foreign material There are also lymphocytes in the
red pulp. The red pulp can also act as a storage place for iron
and platelets.Red pulp consists of a dense network of
fine reticular fiber, continuous with those of the splenic
trabeculae, to which are applied flat, branching cells. The
meshes of the reticulum are filled with blood:
 White corpuscles are found to be in larger proportion
than they are in ordinary blood.
 Large rounded cells, termed splenic cells, are also seen;
these are capable of ameboid movement, and often
contain pigment and red-blood corpuscles in their
interior.
 The cells of the reticulum each possess a round or oval
nucleus, and like the splenic cells, they may contain
pigment granules in their cytoplasm
Blood & Immunity Module | 31
 Spleen
Describe the blood flow in red pulp of spleen
 The splenic red pulp is composed of splenic venous
sinusoids and splenic cords, both of which contain blood
cells of all types.
 The cords, often called cords of Bilroth, are reticular
tissue rich in lymphocytes. The sinuses are lined by
unusual, non-squamous endothelial cells.
Blood flow through the splenic red pulp can take two routes:
o In the closed circulation, the penicillar arterioles or
capillaries branching from them connect directly to the
sinusoids, so that blood is always enclosed by the
vascular endothelium.
o In open ended circulation, plasma and formed
elements of blood reenter the vasculature by passing
between the stave cells of sinusoids. From the
sinusoids, blood proceeds to the red pulp veins that
join together and enter the trabeculae, forming the
trabecular veins. The splenic vein originates from
these vessels and emerges from the hilum of the
spleen. The trabecular veins do not have muscle in
their wall and resemble channels hollowed out in the
trabecular connective tissue and lined by endothelium.
Reticuloendothelial system
Enumerate the components of Reticuloendothelial
system
It is a generalized phagocytic system located in all tissues,
especially in those tissues areas where large quantities of
particles, toxins and other unwanted substances must be
destroyed.
Components of reticuloendothelial system:
 Tissue macrophages in skin and subcutaneous tissues.
 Microglia in brain.
 Macrophage in lymph nodes.
 Macrophages in the liver sinuses.
 Alveolar macrophages in the lungs.
 Macrophages in the spleen and bone marrow.
Explain function of each components of
reticuloendothelial system
Macrophages in the skin and subcutaneous tissues
 Skin is mainly impregnable to infectious agents.
 Broken and injured skin is exposed to infectious agents.
 These histocytes attack and destroy the infectious
agents.
Macrophages in the lymph nodes
 Macrophages line the lymph sinuses
 Bacteria enter the lymph sinuses.
 Macrophages phagocytize and destroy
microorganism.
Alveolar macrophages in the lungs
 Macrophages are present as integral components of
the alveolar walls.
 Infectious agents enter through air and blood in the
alveoli.
 These particles phagocytize and destroy.
 If particles are not digestible, macrophages form a
giant cell capsule around the particles.
 Capsules form around tuberculosis bacilli, silica dust
particle and carbon particle.
Macrophage (kupffer cell) in the liver sinuses
 Another route by which bacteria invade the body is
through the gastrointestinal tract.
 Large numbers of bacteria from ingested food
constantly pass through the gastrointestinal mucosa
into the portal blood.
 Liver sinusoid, which are lined by tissue
macrophages called Kupffer cells. These cells form
such an effective particulate filtration system.
 Prevents entry of bacteria from gastrointestinal
tract from the portal blood into the general
systemic circulation.
Macrophages of the Spleen and Bone Marrow
 Macrophages become entrapped by the reticular
meshwork of the two organs.
 When foreign particles come in contact with these
macrophages, they are phagocytized
 The trabeculae of the red pulp and the venous
sinuses are lined with vast numbers of macrophages.
 This peculiar passage of blood through the cords of
the red pulp provides an exceptional means of
phagocytizing unwanted debris in the blood,
including especially old and abnormal RBCs.
Classification and function of wbc
Classify different types of WBC
There are two types of WBCs.
GRANULOCYTES:
 Neutrophils.
 Eosinophils.
 Basophils.
AGRANULOCYTES:
 Monocytes.
 Lymphocytes
Describe function of WBC
Blood & Immunity Module | 32
 i. Neutrophils: Phagocytize the infectious agents.
ii. Eosinophils: combat the effect of histamine in
Inflammation
allergic reaction.
iii. Basophils: develop into mast cells that liberate Specify the role of Neutrophils and Macrophages in
heparin. inflammation
iv. B lymphocytes: produces antibodies in response to When tissue injury occurs, whether caused by bacteria,
the foreign particles. trauma, chemicals, heat, or any other phenomenon, multiple
v. T lymphocytes: Destroy foreign invaders directly. substances are released by the injured tissues and cause
vi. Monocytes: also help in phagocytosis via dramatic secondary changes in the surrounding uninjured
macrophages. tissues. This entire complex of tissue changes is called
inflammation.
Role of Neutrophils and macrophages:
 Neutrophils are mature cells that can attack and destroy
bacteria.
 Margination: Wall-off the area of injury.
 Diapedesis: can squeeze through the pores of blood
capillaries.
 Ameboid motion: move through the tissue spaces.
 Pusformation: engulfment of bacteria, necrotic cells.
 Chemotaxis: chemical substances in tissues cause
neutrophils to move towards source of chemical.
 Phagocytosis: cellular ingestion of offending agents.
 Bacteriocidial action: agents that kill most bacteria even
lysosomal enzymes fail to digest.

Elaborate the Lines of Defense

Tissue Macrophages Provide a First Line of Defense Against
Infection.
Highlight Leucopoiesis  By histiocytes in the subcutaneous tissues, alveolar
macrophages in the lungs, microglia in the brain.
 When activated by the products of infection and
inflammation, the first effect is rapid enlargement of
each of these cells and become mobile.
 Start within minutes and lasts for an hour or so.
Neutrophil Invasion of the Inflamed Area Is a Second Line of
Defense.
 Within the first hour or so
 They cause increased expression of adhesion
molecules, cause the neutrophils to stick to the
capillary. This effect is called margination
 Passage of neutrophils to crawl through directly
from the blood into the tissue spaces by diapedesis.
 Within several hours of injury neutrophils are ready
to begin their scavenger function.
Second Macrophage Invasion into the Inflamed Tissue Is a
Third Line of Defense.
 Several days to several weeks.
 Along neutrophils, monocytes from the blood enter
the inflamed tissue.
 Monocytes are still immature cells, requiring 8 hours
or more to swell to much larger size by lysosomes.
 Macrophages phagocytize 5 times more than
neutrophils.
Increased Production of Granulocytes and Monocytes by the
Bone Marrow Is a Fourth Line of Defense.
 This action results from stimulation of the
granulocytic and monocytic progenitor cells of the
marrow.
 It takes 3-4 days to months-years.

Blood & Immunity Module | 33


Appraise the sequential response of body to
Inflammation
Sequential response to inflammation:
 Wall-off the area of injury from the remaining tissue
by fibrinogen clot.
 Tissue macrophage is the first line of defense against
infection.
 Neutrophils invasion of the inflamed area is the
second line of defense.
 Second macrophage invasion into inflamed tissue is
the third line of defense.
 Increased production of granulocytes and
monocytes by the bone marrow is the fourth
defense of line.
Leucopenia and leukemia
Classify leukemia
Differentiate leukemia, leucopenia, and leukocytosis
LEUKEMIAS:
 Uncontrolled production of WBCs in the circulating blood
is called leukemia.
 Cancerous production of lymphoid or myelogenous cells.
LEUCOPENIA:
 A condition in which the bone marrow produces very
WBCs is called leucopenia.
 This condition leaves the body unprotected against many
bacteria.
LEUKOCYTOSIS:
 Increase in the number of leucocytes count above 11,000
mm3, irrespective of the cell type is involved.
Immunity
To categorize acquired or adaptive immunity and
elaborate special immune mechanisms that comprises
antibodies and activated lymphocytes

Uncontrolled production of WBCs can be caused by

cancerous mutation is called leukemia.
There are two types of leukemia.
 Lymphocytic leukemia.
 Myelogenous leukemia.
Lymphocytic leukemia:
 Are caused by cancerous production of lymphoid cells.
Myelogenous leukemia:
 Are caused by cancerous production of young
myelogenous cells in the bone marrow.
 Resulting in neutrophilic leukemia, eosinophilic
leukemia, basophilic leukemia, monocytic leukemia.

Describe the etiology, morphology and clinical features

of acute and chronic leukemia
 Acute Lymphocytic Leukemia (ALL)is the most common
type of leukemia in young children. Acute lymphocytic
leukemia also affects adults, especially the age 65 and
older.
 Acute Myeloid Leukemia (AML)occurs in both adults and
children. This type of leukemia is sometimes called acute
non-lymphocytic leukemia (ANLL).
 Chronic Lymphocytic Leukemia (CLL)most often affects
adults over the age of 55. Chronic lymphocytic leukemia
sometimes occurs in younger adults, but it almost never
affects children.
To elaborate the preprocessing of T and B lymphocytes
 Chronic Myeloid Leukemia (CML) occurs mainly in
adults. A very small number of children also develop The Thymus Gland Preprocesses the T Lymphocytes.
chronic myeloid leukemia. The T lymphocytes, after origination in the bone marrow, first
Associate the effects of Leukemia on body migrate to the thymus gland. Here they divide rapidly and at
the same time develop extreme diversity for reacting against
 Metastatic growth of leukemic cells in abnormal areas of different specific antigens. That is, one thymic lymphocyte
the body. develops specific reactivity against one antigen, and then the
 Tendency for bones to fractures easily. next lymphocyte develops specificity against another antigen.
 Causes severe anemia and thrombocytopenia. This process continues until there are thousands of different
 Excessive use of metabolic substrate by the growing types of thymic lymphocytes with specific reactivities against
cancerous cells. many thousands of different antigens. These different types
 The leukemic tissue grows, other tissues become of preprocessed T lymphocytes now leave the thymus and
debilitated. spread by way of the blood throughout the body to lodge in
lymphoid tissue everywhere.

Blood & Immunity Module | 34

Liver and Bone Marrow Preprocess the B Lymphocytes.
In humans, B lymphocytes are preprocessed in the liver
during mid fetal life and in the bone marrow during late fetal
life and after birth
After reprocessing the T lymphocytes, migrate to lymphoid
tissue throughout the body, where they lodge near but
slightly removed from the T-lymphocyte areas.
To highlight the role of lymphocytes in acquired
immunity
Acquired immunity is the product of the body’s lympho-
cytes. In people who have a genetic lack of lymphocytes or
whose lymphocytes have been destroyed by radiation or
chemicals, no acquired immunity can develop. Within days
after birth, such a person dies of fulminating bacterial
infection unless he or she is treated by heroic measures.
Therefore, it is clear that the lymphocytes are essential to the
survival of the human being. The lymphoid tissue in the
lymph nodes is exposed to antigens that invade peripheral
tissues of the body, and the lymphoid tissue of the spleen,
thymus, and bone marrow plays the specific role of
intercepting antigenic agents that have succeeded in reaching
the circulating blood.
Discuss the origin and role of lymphocyte clones
Origin of lymphocyte clone:
The whole gene for forming each type of T cell or B cell is
never present in the original stem cells from which the
functional immune cells are formed. Instead, there are only
“gene segments”—actually, hundreds of such segments—but
not whole genes. During preprocessing of the respective T-
and B-cell lymphocytes, these gene segments become mixed
with one another in random combinations, in this way finally
forming whole genes.
Because there are several hundred types of gene segments,
as well as millions of different combinations in which the
segments can be arranged in single cells, one can understand
the millions of different cell gene types that can occur. For
each functional T or B lymphocyte that is finally formed, the
gene structure codes for only a single antigen specificity.
These mature cells then become the highly specific T and B
cells that spread to and populate the lymphoid tissue.
Role of lymphocyte clones:
Each clone of lymphocytes is responsive to only a single type
of antigen (or to several similar antigens that have almost
exactly the same stereochemical characteristics). The reason
for this is the following: In the case of the B lymphocytes,
each of these has on its cell surface membrane about
100,000 antibody molecules that will react highly specifically
with only one type of antigen. Therefore, when the
appropriate antigen comes along, it immediately attaches to
the antibody in the cell membrane; this leads to the
activation process, which is described in more detail
subsequently. In the case of the T lymphocytes, molecules
similar to antibodies, called surface receptor proteins (or T-
cell markers), are on the surface of the T-cell membrane, and
these are also highly specific for one specified activating
antigen. An antigen therefore stimulates only those cells that
have complementary receptors for the antigen and are
already committed to respond to it.
Clarify the function of B-lymphocyte system based
humoral immunity
Formation of Antibodies by Plasma Cells
Before exposure to a specific antigen, the clones of B lympho-
cytes remain dormant in the lymphoid tissue. Upon entry of a
foreign antigen, macrophages in lymphoid tissue phagocytize
the antigen and then present it to adjacent B lymphocytes. In
addition, the antigen is presented to T cells at the same time,
and activated T-helper cells are formed. These helper cells
also contribute to extreme activation of the B lymphocytes,
as discussed later.
The B lymphocytes specific for the antigen immediately
enlarge and take on the appearance of lymphoblast. Some of
the lymphoblast further differentiates to form plasmoblasts,
which are precursors of plasma cells. In the plasmoblasts, the
cytoplasm expands and the rough endoplasmic reticulum
vastly proliferates. The plasmoblasts then begin to divide at a
rate of about once every 10 hours for about nine divisions,
giving in 4 days a total population of about 500 cells for each
original plasmoblasts. The mature plasma cell then produces
gamma globulin antibodies at an extremely rapid rate—about
2000 molecules per second for each plasma cell. In turn, the
antibodies are secreted into the lymph and carried to the
circulating blood. This process continues for several days or
weeks until finally exhaustion and death of the plasma cells
occur.
To justify the production, structure, specificity, classes
and function of Antibodies
Special immune mechanism that comprises antibodies and
activated lymphocytes the body develops circulating
antibodies, which are globulin molecules in the blood plasma
capable of attacking the invading agent. This type of
immunity is called humoral immunity or B-cell immunity
(because B lymphocytes produce the antibodies). The second
type of acquired immunity is achieved through formation of
large numbers of activated T lymphocytes that are specifically
crafted in the lymph nodes to destroy the foreign agent. This
type of immunity is called cell-mediated immunity or T-cell
immunity (because the activated lymphocytes are T
lymphocytes). The activated lymphocytes are formed in the
lymphoid tissues of the body
To elaborate the role of Complement System for
antibody action
Complement system for antibody action
“Complement” is a collective term that describes a system of
about 20 proteins, many of which are enzyme precursors.
The principal actors in this system are 11 proteins designated
C1 through C9, B, and D. All these are present normally
among the plasma proteins in the blood, as well as among
the proteins that leak out of the capillaries into the tissue
spaces. The enzyme precursors are normally inactive, but
they can be activated by the so-called classical pathway.
Classical Pathway: The classical pathway is initiated by an
antigen-antibody reaction. That is, when an antibody binds
with an antigen, a specific reactive site on the “constant”
portion of the antibody becomes uncovered, or “activated,”
and this in turn binds directly with the C1 molecule of the
complement system, setting into motion a “cascade” of
sequential reactions beginning with activation of the
Blood & Immunity Module | 35
proenzyme C1. The C1 enzymes that are formed then activate
successively increasing quantities of enzymes in the later
stages of the system so that from a small beginning, an
extremely large “amplified” reaction occurs. Multiple end
products are formed, and several of these cause important
effects that help to prevent damage to the body’s tissues
caused by the invading organism or toxin. Among the more
important effects are the following:
Opsonization and phagocytosis:
One of the products of the complement cascade, C3b,
strongly activates phagocytosis by both neutrophils and
macrophages, causing these cells to engulf the bacteria to
which the antigen-antibody complexes are attached. This
process is called opsonization. It often enhances the number
of bacteria that can be destroyed by many hundredfold.
Lysis:
One of the most important of all the products of the
complement cascade is the lytic complex, which is a
combination of multiple complement factors and is
designated C5b6789. This has a direct effect of rupturing the
cell membranes of bacteria or other invading organisms.
Agglutination:
The complement products also change the surfaces of the
invading organisms, causing them to adhere to one another,
thus promoting agglutination.
Neutralization of Viruses:
The complement enzymes and other complement products
can attack the structures of some viruses and thereby render
them non virulent.
Chemotaxis:
Fragment C5a initiates chemotaxis of neutrophils and
macrophages, thus causing large numbers of these
phagocytes to migrate into the tissue area adjacent to the
antigenic agent.
Activation of Mast Cells and Basophils:
Fragments C3a, C4a, and C5a activate mast cells and
basophils, causing them to release histamine, heparin, and
several other substances into the local fluids. These
substances in turn cause increased local blood flow,
increased leakage of fluid and plasma protein into the tissue,
and other local tissue reactions that help inactivate or
immobilize the antigenic agent. The same factors play a
major role in inflammation
Inflammatory Effects:
In addition to inflammatory effects caused by activation of
the mast cells and basophils, several other complement
products contribute to local inflammation. These products
cause
(1) The already increased blood flow to increase still further,
(2) The capillary leakage of proteins to be increased, and
(3) The interstitial fluid proteins to coagulate in the tissue
spaces, thus preventing movement of the invading organism
through the tissues
To highlight the function of Activated T- lymphocytes in
Cell Mediated Immunity
Special attributes of the t-lymphocyte system—activated t
cells and cell-mediated immunity
The release of Activated T Cells from Lymphoid Tissue and
formation of Memory Cells, Upon exposure to the proper
antigen, as presented by adjacent macrophages, the T
lymphocytes of a specific lymphocyte clone proliferate and
release large numbers of activated, specifically reacting T
cells in ways that parallel antibody release by activated B
cells. The principal difference is that instead of releasing
antibodies, whole activated T cells are formed and released
into the lymph. These T cells then pass into the circulation
and are distributed throughout the body, passing through the
capillary walls into the tissue spaces, back into the lymph and
blood once again, and circulating again and again throughout
the body, sometimes lasting for months or even years.
Also, T-lymphocyte memory cells are formed in the same way
that B memory cells are formed in the antibody system. That
is, when a clone of T lymphocytes is activated by an antigen,
many of the newly formed lymphocytes are preserved in the
lymphoid tissue to become additional T lymphocytes of that
specific clone; in fact, these memory cells even spread
throughout the lymphoid tissue of the entire body.
Therefore, on subsequent exposure to the same antigen
anywhere in the body, release of activated T cell occurs far
more rapidly and much more powerfully than during first
exposure.
To categorize various T- lymphocytes and identify their
specific functions
Following are the types of T lymphocytes and their functions:
T HELPER CELLS:
o Growth stimulation
o Proliferation of cytotoxic T cells and suppressor T
cells
o Activation of macrophage system
o Feedback stimulatory effect on helper T cells
themselves
CYTOTOXIC T CELLS:
o Destroy cancer cells, heart transplant cells or other
type of foreign cells
SUPPRESSOR T CELLS:
o Prevent cytotoxic cells from causing excessive
immune reactions
o Probably play a role on immune tolerance
To discuss the basis of Immune Tolerance
Most Tolerance Results from Clone Selection During
Preprocessing.
Most tolerance is believed to develop during preprocessing of
T lymphocytes in the thymus and of B lymphocytes in the
bone marrow. The reason for this belief is that injecting a
strong antigen into a fetus while the lymphocytes are being
preprocessed in these two areas prevents development of
clones of lymphocytes in the lymphoid tissue that are specific
for the injected antigen. Experiments have shown that
specific immature lymphocytes in the thymus, when exposed
to a strong antigen, become lymphoblastic, proliferate
considerably, and then combine with the stimulating
antigen—an effect that is believed to cause the cells to be
destroyed by the thymic epithelial cells before they can
migrate to and colonize the total body lymphoid tissue.
Blood & Immunity Module | 36
It is believed that during the preprocessing of lymphocytes in IgE
the thymus and bone marrow, all or most of the clones of  Least common serum Ig
lymphocytes that are specific to damage the body’s own  Allergic Reactions:
tissues are self-destroyed because of their continual o Binds to basophils and mast cells (does not require
exposure to the body’s antigens. Ag binding)
 Parasitic infections (Helminths)
BIOCHEMISTRY o Binds to Fc receptor on eosinophils
o No complement activation
Immunoglobulin
Discuss the biochemical role of immunoglobulin PATHOLOGY
Immunoglobulin (Ig)/Antibody (Ab): Discuss the hypersensitivity reactions
 Type of γ-globulin
 Produced by plasma cells in response to an immunogen  A state of altered reactivity in which the body reacts with
 Function as antibodies an exaggerated immune response to foreign agent.
 Hypersensitivity reflects an imbalance between the
Structure effector mechanisms of immune responses and the
4 chains: 2 heavy chains, 2 light chains. control mechanisms that serve to normally limit such
responses.
One carbohydrate chain attached to each heavy chain  Both exogenous and endogenous antigens may elicit
Variable region and constant region hypersensitivity reactions
 Exogenous antigens include:
• Dust
• Pollens
• Foods
• Drugs
• Microbes
• Chemicals
• Blood products
 Immune responses against self, or autologous antigens,
cause the important group of auto immune diseases.

Types:
TYPE 1

Types  Rapid immunologic reaction occurring within minutes

after the combination of an antigen with antibody bound
IgG to mast cells in individuals previously sensitized to the
 Most abundant – 80% antigen
 Only class that can cross placenta  These reactions are often called allergy, and the antigens
 Macrophages, monocytes, PMNs (polymorphonuclear that elicit them are allergens
leukocytes) and some lymphocytes  Occur within minutes of exposure to antigens
 Antigens combine with IgE antibodies
IgA  IgE binds to mast cells and basophils
 Secretory Ig  Degranulation occurs with release of mediators
o Found in tears, breast milk, saliva, mucus of the  Histamine
bronchial, genitourinary and digestive tract • Increases vascular permeability
o Antibody in the colostrum (the initial secretion from • Increases smooth muscle contraction
the mother’s breast after a baby is born) • Increases mucus secretion
 Prostaglandins
IgM
• Increases smooth muscle contraction and
 Restricted to the blood stream mucus secretion
 B cell-mediated (humoral) immunity before there is  Leukotrienes
sufficient IgG • Bronchial spasm
 First line of defense
 Most effective in leading to lysis of microorganisms PATHOGENESIS:
Three phases
IgD
• Sensitization
 An antigen receptor on B cells that have not been exposed • Activation
to antigens • Tissue phase
 Activate basophils and mast cells to produce – Immediate or initial reaction
antimicrobial factors. – Late-phase reaction

Blood & Immunity Module | 37

Immediate reactions Localized Anaphylaxis:
– Vasodilation • Cutaneous anaphylaxis– wheal &flare
– Vascular leakage • Urticaria
– Smooth muscle spasm • Allergic rhinitis
– Glandular secretions • Food allergies
• Become evident within 5 to 30 minutes after • Atopic dermatitis (allergic eczema)
exposure to an allergen. • Asthma
Late-phase reaction Systemic Anaphylaxis
• Sets in 2 to 24 hours later • Characterized by:
• Without additional exposure to antigen – Vascular shock
• May last for several days (e.g in bronchial asthma , – Widespread edema
allergic rhinitis) – Difficulty in breathing
• In hospitals after administration of foreign proteins,
Characterized by:
hormones, enzymes, and drugs (such as the
• Infiltration of tissues with: antibiotic penicillin).
– Eosinophils • In the community setting following exposure to food
– Neutrophils allergens (e.g. peanuts, shellfish) or insect toxins
– Basophils (e.g. those in bee venom).
– Monocytes
– CD4+ T cells TYPE 2
– Tissue destruction
• Mediated by IgG and IgM
• In type II hypersensitivity, secreted IgG and IgM
antibodies participate directly in:
– Injury to cells by promoting their
phagocytosis or lysis
– Injury to tissues by inducing inflammation
– Interfere cellular functions and cause
disease without tissue injury
Opsonization and Phagocytosis
• Phagocytosis is largely responsible for:
– Depletion of cells coated with antibodies
• Cells opsonized by IgG antibodies are recognized by:
– Phagocyte Fc receptors
• The net result is:
– Phagocytosis of the opsonized cells and
their destruction

ADCC may be mediated by:

Atopy – Monocytes
 Refers to genetic predisposition to develop localized – Neutrophils
immediate hypersensitivity reactions to a variety of – Eosinophils
inhaled and ingested allergens. – NK cells
 Atopic individuals tend to have higher serum IgE levels,
and more IL-4–producing TH2 cells.
Important examples of type 1 hypersensitivity reactions

Blood & Immunity Module | 38

 Endogenous
• If the individual produces antibody against self-
components (autoimmunity)

EXAMPLES:
• Transfusion reactions, in which cells from an
incompatible donor react with and are opsonized by
preformed antibody in the host.
• Hemolytic disease of the newborn (erythroblastosis
fetalis), in which there is an antigenic difference between
the mother and the fetus, and antibodies (of the IgG
class) from the mother cross the placenta and cause
destruction of fetal red cells Clinical condition of Type III hypersensitivity
• Autoimmune hemolytic anemia: in which individuals • Diseases produced by immune complexes are those in
produce antibodies to their own blood cells which antigen persists without being eliminated as:
– Repeated exposure to extrinsic antigen
Cellular Dysfunction – Injection of large amounts of antigen
• In some cases, antibodies directed against cell – Persistent infections
surface receptors, impair or dysregulate function – Autoimmunity to self-components
without causing cell injury or inflammation.
Myasthenia gravis Arthus reaction
• Antibodies reactive with acetylcholine receptors in • Localized immune complex deposition phenomenon
the motor end plates of skeletal muscles, block • Local reactions in the form of:
neuromuscular transmission and therefore cause – Edema
muscle weakness. – Erythema
Graves’ disease – Necrosis
• In this disorder, antibodies against the thyroid- • Immune complexes deposited in small vessels leads to:
stimulating hormone receptor on thyroid epithelial – Vasculitis
cells stimulate the cells, resulting in – Microthrombi formation
hyperthyroidism. – Vascular occlusion
– Necrosis
TYPE 3
• Antigen-antibody complexes produce tissue damage
mainly by eliciting inflammation at the sites of
deposition.
• When antibodies (IgG and IgM) and antigens coexist,
immune complexes are formed
• Immune complexes are removed by
reticuloendothelial system
• Some immune complexes escape phagocyosis
• Immune complexes deposited in tissues on the
basement membrane of blood vessels and cause
tissue injury
• Deposited typically in vessel walls
• The antigens that form immune complexes may be:
Exogenous
• Such as a foreign protein that is injected or
produced by an infectious microbe

Blood & Immunity Module | 39

Serum sickness
• A systemic immune complex phenomenon
• Injection of large doses of foreign antigen
• Antigen is slowly cleared from the circulation
• Immune complexes are deposited in the circulation
• After 10 days following reactions occur:
– Fever
– Urticaria
– Arthralgia
– Lymphadenopathy
– Splenomegaly
– Glomerulonephritis
Examples:
• Post-streptococcal glomerulonephritis
– Glomerulitis associated with infective
endocarditis
• Hypersensitivity pneumonitis (farmer lung)
– Immune complex deposition in lung after
repeated exposure to dust, mold spores
• Endogenous antigen antibody comlexes
– Autoimmune diseases- SLE, rhemuatoid arthritis
 Discuss the mechanism involved in graft rejection.
TYPE 4
• Rejection is a complex process in which “recipient
• The cell-mediated type of hypersensitivity is initiated by immune system recognizes the graft as foreign and
antigen-activated (sensitized) T lymphocytes, including attacks it.”
CD4+ and CD8+ T cells.. It involves:
• CD4+ T cell–mediated hypersensitivity can be a cause of – Cell mediated immunity
chronic inflammatory disease. – Circulating antibodies
• In certain forms of T cell–mediated reactions that follow
viral infections, CD8+ cells may be the dominant effector TYPES
cells. AUTOGRAFT
• T cells cause Tissue is transplanted from one site to another on the same
• Triggers delayed type hypersensitivity by TH1 patient, it is termed an autograft
cells
• Directly kills target cells by CD8 cells Example:
Reactions of CD4+ T Cells (DTH) – Transplantation of blood vessel from leg to heart of same
• The reactions can be divided into the following person during cardiac bypass surgery.
stages – Skin grafting in burns, destructive injuries
 Proliferation and Differentiation of CD4+ T • This type of graft does not require
Cells immunosuppressive therapy
 Responses of Differentiated Effector T Cells
Reactions of CD8+ T Cells: Cell-Mediated Cytotoxicity ISOGRAFT
• In this type of T cell–mediated reaction, CD8+ CTLs • A transplanted organ or tissue from a genetically
kill antigen-bearing target cells identical donor, i.e., an identical twins.
• Also called homograft
• CTLs directed against cell surface histocompatibility XENOGRAFT
antigens play an important role in
• A transplant from another species is called a
– Graft rejection
xenograft
– Reactions against viruses
• Also called heterograft
– Tumor rejection
Example
• In a virus-infected cell, viral peptides are displayed
• Transplanting a heart from baboon to human
by class I MHC molecules and the complex is
• Have very poor prognosis
recognized by the TCR of CD8+ T lymphocytes.
• Cross reactivity between different species antibodies
ALLOGRAFT
• Transplanted cells, tissues or organs are sourced
from a genetically non-identical member of the
same species.
Example
• Kidney transplant from one person to another person

TISSUE TYPING

Blood & Immunity Module | 40

 • Microcytotoxicity assay
• Known antibody to MHC of blood cells of donor
COMMUNITY MEDICINE
• Complement mediated lysis if antibody recognizes Give a brief account of immunization agent, mode of
epitopes on MHC administration and scheduling in EPI
 Immunization:
“It is a process of induction of immunity”
 Components:
• Policy
Strategy (immunization & surveillance)
Schedule
• Logistics
Vaccines
Vaccine storage and vaccine carriers boxes
Syringes
• Trained manpower
• EPI center

HYPER ACUTE
• Occurs within minutes or hours after transplantation
• A hyperacutely rejecting kidney rapidly becomes
cyanotic, mottled, and flaccid
• May excrete a mere few drops of bloody urine
ACUTE
• May occur within days of transplantation in the
untreated recipient.
Acute cellular rejection:
• Seen within the initial months after transplantation
and is heralded by signs of renal failure. MICROBIOLOGY
• Histologically, extensive interstitial mononuclear cell
infiltration and edema as well as mild interstitial Hemoparasites
hemorrhage Define parasitism, symbiosis and commensalism
Acute humoral rejection (rejection vasculitis)  Parasitism: A non-mutual symbiotic relationship
• Mediated by antidonor antibodies, and hence it is between species, where one species, the parasite,
manifested mainly by damage to the blood vessels benefits at the expense of the other, the host.
associated with extensive necrosis of the renal  Symbiosis:A close and often long-term interaction
parenchyma. between two different biological species.
CHRONIC  Commensalism: a relationship between two
organisms whereone is benefited and the other is
• Progressive renal failure manifested by a rise in neither benefited nor harmed.
serum creatinine over a period of 4 to 6 months
• Dominated by vascular changes, interstitial fibrosis, Differentiate between hemoparasites and anemia
and tubular atrophy with loss of renal parenchyma causing parasites
o Hemoparasites
Formulate the steps that can be taken to combat  Transmitted By :
Blood transfusion andNeedle Sharing
graft rejection
 Factors influenced :
 HLA matching between donor & recipient Life cycle of parasite in blood
 Immunosuppressive therapy Concentration of parasite in blood
 Prevention of host T cells to receive costimulatory signals Duration of stay of parasite in blood
from dendritic cells o Anemia causing parasites
 Donor-specific tolerance in graft recipients

Blood & Immunity Module | 41

 Enlist hemoparasites
 African Tryponosomiasis
 Babesiosis
 Chagas disease
 Leishmaniasis
 Malaria
 Toxoplasmosis

Plasmodium (hemolytic anemia)

Enlist types of Plasmodium
 Plasmodium Falciparum
 Plasmodium vivax
 Plasmodium ovale
 Plasmodium malariae

Describe pathogenesis of Plasmodium

 Most of the pathologic findings of malaria result
from the destruction of RBCs
 Red cells are destroyed both by the release of
merozoites and by the action of spleen.

Draw life cycle of Plasmodium

Ancylostoma duodenale
Describe pathogenesis of A.doudenale
 Hookworm infections
 Humans shed eggs in the feces, which hatch into
filariform larvae and burrow in the skin of the lower
legs.
 Larvae travel from blood to lungs, proceed up
bronchi and throat and are swallowed.
 Worms mature and reproduce in small intestine and
complete the cycle.
 May cause pneumonia,nausea,vomiting,cramps and
bloody diarrhea.
 There’s significant blood loss leading to anemia.

Draw life cycle of A.duodenale

Diphylobothrium latum (Pernicious anemia)

Describe pathogenesis of D. latum

 In upper part of the jejunum and duodenum, the

infection impairs intrinsic factor and causes the
deficiency of Vitamin B 12, causing pernicious anemia.
 Megaloblastic anemia occurs as a result of Vitamin B 12
deficiency caused by preferential uptake of the vitamin
by the worm.

Draw life cycle of D. latum

Blood & Immunity Module | 42

REFERENCE
GUIDE
 BLOOD & IMMUNITY MODULE
Reference Guide
Theme: Anemia (Week 1)
Subject Topic Learning Outcomes Reference
Describe the composition of blood
Blood
Histology Discuss blood and lymphoidal system (Chapter # 9 & 14 )
Histology of blood
Medical Histology
by Laiq Hussain Identify the tissue under microscope (Lymph node)
Volume 2
Practical Draw and label.
(Experiment # 1)
Give two points of identification
Deduce hematological abnormalities on the basis of
composition of blood. Chapter # 33
Blood composition Correlate the count of Red blood cells with clinical (Pg # 445, 452,
conditions like Anemia and Polycythemia. 453)
Highlight the functions of blood cell

Associate the structure of RBC with their function

Discuss stages of erythropoiesis Chapter # 33
Erythropoiesis Elucidate the regulation of erythropoiesis particularly at (Pg # 445 – 447)
high Altitude
Classify anemia on the basis of etiology and morphology
Physiology
Designate the causes of different type of anemia
Medical Physiology Describe the morphology and clinical features of
by Guyton & Hall different type of anemia. Chapter # 33
Anemia
th
13 Edition (Page # 452, 453)
Elaborate the effects of Anemia on various functional
(Volume 1) systems of body.
Distinguish different varieties of Polycythemia
Chapter # 33
Polycythemia Elaborate the effects of Polycythemia on Circulatory
system (Page # 453)

Calculate the absolute Corpuscular values and Red Cell

Indices for identifying the type of anemia and elucidating
its etiology.
Measure the Osmotic Fragility of Red Blood Cells in Section 2
Practical solutions of varying tonicities as a tool to diagnose some Experiment # 6 & 7
hereditary disorders of RBC structure.
Ascertain the conditions with Increased and decreased
RBC fragility associated with decreased RBC function.

Biochemistry Explain the Composition and Structure of Hemoglobin.

Differentiate between the structural differences in Chapter # 3
Lippincott’s Heme Structure hemoglobin, myoglobin and met hemoglobin. (Page # 25-27 & 38
Illustrated )
Reviews List out the conditions leading to formation of met
hemoglobin.
Biochemistry
Interpret oxygen dissociative curve and evaluate the
(6th Edition) allosteric effects of pH2,3 BPG and O2 on hemoglobin
Oxygen Dissociation oxygen binding. Chapter # 3
Curve (Page # 29-33)
Correlate the role of Glutathione with abnormal
hemoglobin
 Outline the synthesis of hemoglobin highlighting the Chapter # 21
Synthesis Of Heme
defective pathway. (Page # 278 – 279)
Chapter # 21
Catabolism of Heme Discuss the catabolism of Hemoglobin
(Page # 282 – 284)
Jaundice & LFT Correlate Jaundice with LFT report
Discuss the metabolism of Iron.
Identify the functions of Iron and relate them with
Chapter # 28
Iron deficiency disorders.
(Page # 374 – 375)
Relate Iron deficiency with their effects on RBCs
synthesis in humans.
Identify sources and functions of vitamin B12 and folic
Vitamin B12 & Folic acid. Chapter # 28
Acid Relate their deficiency effects on structural abnormalities (Page # 374 – 377)
of RBCs.
Estimate the levels of
 Bilirubin
Practical  ALT
 AST in blood
Pharmacology
Katzung &
Chapter # 33 & 34
Trevor’s (Board Identify the role of Hematinics to manage anemia
Review)
Community Identify the ways for prevention of Nutritional Deficiency
Medicine Anemia

Theme: Bleeding Disorders (Week 2)

Subject Topic Learning Outcome References
Describe the microscopic features of spleen
Differentiate between red and white pulp
Chapter # 14
Spleen Differentiate between lymphatic nodule of spleen and
lymph node (Page # 158 – 162)
Histology
Describe the blood flow in red pulp of spleen
Medical Histology by
Identify the tissue under microscope (Spleen)
Laiq Hussain
Draw and label the light microscopic appearance of Volume 2
Practical spleen. (Experiment # 1)
Give two points of identification.
Discriminate different blood group on the basis of diverse
Physiology antigenic and immunological properties of blood.
Medical Physiology Recognize major and minor antigens present on red blood
by Guyton & Hall cells.
Predict the genetic determination of blood group of
13th edition
offspring based on inheritance.
(Volume 1)
Identify the origin, chemical nature and changing titer of Chapter # 36
ABO Blood type agglutinins in plasma.
(Page # 477 –
Elucidate the agglutination process in transfusion 479)
reactions.
Comprehend the basis of Immediate and delayed
intravascular hemolysis as an outcome of mismatched
blood transfusion.
Highlight the significance of blood typing and blood
matching procedures
Rh Blood Type Discriminate between the O-A-B system and the Rh- Chapter # 36
 system. (Page # 479, 480)
Categorize the common types of Rh antigens/ Rh-factors.
Illustrate the pattern of Rh immune response
Correlate the implication of Rh factorin
Erythroblastosisfetalis (Hemolytic Disease of the
Newborn).
Blood transfusion Chapter # 36
Assume the complications from transfusion of mismatched
and its problems
blood types (Page # 480)
Elaborate the sequential events of Hemostasis.
Discriminate between the terms of “Hemostasis” and
“Homeostasis”.
Outline the mechanisms of vascular constriction.
Associate the structural and functional features of
platelets with the platelet plug formation.
Chapter # 37
Highlight the importance of platelet-plugging mechanism (Page # 483 –
Hemostasis for Closing Vascular Holes. 492)
Identify the diagram and explain particular coagulation
pathway (intrinsic or extrinsic) in specific setting of vessel
injury.
Categorize various clotting factors and ascertain their roles
in coagulation cascade.es
Find out the interaction and dissimilarities between
intrinsic or extrinsic pathways.
Explore the factors (Intravascular Anticoagulants) and
mechanisms that prevent blood clotting in the normal
vascular system.
Determine the blood clot lytic mechanisms.
Natural Discriminate between Thrombi and Emboli. Chapter # 36
Anticoagulants Associate the failed anticoagulant and clot lytic (Page # 480, 481)
mechanisms with clinical thromboembolc conditions
(femoral vein thrombosis, pulmonary embolism and DIC).
Assume the complications from transfusion of mismatched
blood types
Determine the role of RBC antigens and plasma agglutinins
in identifying the blood group of an individual.
Deduce the mode of inheritance of different blood groups.
Analyze the role of blood group antigens in pregnancy in
context of Erythroblastosisfetalis.
Identify the role of Blood Compatibility through the
process of cross Matching and acquire the pre-and post
knowledge of Blood transfusion Reactions.
Display the Bleeding Time (BT) through simple laboratory
Section 2
technique.
Practical Experiment # 9 –
Relate in particular the role of Platelets (number and 14
function) with normal BT. Identify the Level of Defect in
the process of hemostasis.
Discriminate various Bleeding Disorders i.e. purpura and
hemophilia as well as Thromboembolic Conditions.e (CT)
through simple laboratory technique.
Discuss specific clotting factor defects i.e. Hemophilia,
Christmas disease, Vitamin K deficiency etc.
Explain the role of anticoagulants in vivo

Lippincott
Biochemistry Vitamin K Identify the sources of Vitamin K.
Chapter # 38
Lippincott’s Discuss its role in RBCs (Page # 389 – 391)
Illustrated Reviews Relate its deficiency with defective coagulation
Biochemistry mechanism.
(6th Edition)
Describe the features of various types of plasma proteins. Mushtaq
Mushtaq’s Plasma proteins Relate their functions with blood disorders.
Chapter # 11
Biochemistry (Page # 158 – 160)
(Volume 2) Estimate
Practical  Serum ALT &AST
 Correlate with different clinical disorders
Identify the drugs used for coagulation disorders.
Pharmacology Differentiate between anticoagulants, thrombolytic and
Chapter # 21
anti-platelet drugs.
Lippincott’s (Page # 381 – 394)
Pharmacology Explain clinical uses with major adverse effects of these
drugs.
Describe the blood transfusion hazards and their
prevention.
Determine the importance of screening of blood.
Community
Identify that blood act as a vehicle for transmission of
Medicine diseases like HIV/ AIDS, Hepatitis C. Hepatitis B etc.
Relate the social factors affecting blood transfusion
behavior.

Theme: Immunity (Week 3)

Subject Topics Learning Outcomes References
Reticuloendothelial Enumerate the components of reticuloendothelial system Chapter # 34
system Explain function of each components (Page # 455, 458)
Classify different types of WBC
Classification and Chapter # 34
Describe function of WBC
function of WBC (Page # 455, 456)
Highlight Leucopoiesis
Specify the role of Neutrophils and Macrophages in
Inflammation Chapter # 34
Inflammation Elaborate the Lines of Defense (Page # 460, 461,
462)
Appraise the sequential response of body to
Inflammation
Classify leukemia
Leucopenia and Describe the etiology, morphology and clinical features of
Physiology acute and chronic leukemia
Chapter # 34
leukemia
Medical Physiology Associate the effects of Leukemia on body. (Page # 463)
by Guyton & Hall Differentiate leukemia, leucopenia, leukocytosis
th Classify immunity into its basic varieties.
13 edition
(Volume 1) Categorize further the acquired or adaptive immunity and
elaborate a special immune mechanism that comprises
antibodies and activated lymphocytes.
Elaborate the preprocessing of T and B lymphocytes.
Highlight the role of lymphocytes in acquired immunity.
Chapter # 35
Discuss the origin and role of lymphocyte clones.
Immunity (Page # 465 –
Clarify the function of B-lymphocyte system based
474)
humoral immunity.
Justify the production, structure, specificity, classes and
function of Antibodies.
Elaborate the role of Complement System for antibody
action.
Highlight the function of Activated T- lymphocytes in Cell
 Mediated Immunity.
To categorize various T- lymphocytes and identify their
specific functions.
To discuss the basis of Immune Tolerance.

Biochemistry
Mushtaq’s Discuss the biochemical role of immunoglobulin Chapter # 11
Immunoglubin
Biochemistry (Page # 160 – 163)
(Volume 2)
Pathology Discuss the hypersensitivity reactions. Chapter # 4
Robbins basic Discuss the mechanism involved in graft rejection. (Page # 109, 110,
Pathology Formulate the steps that can be taken to combat graft 135 – 138)
(Medium) rejection
Define parasitism, symbiosis, commensalism
Hemoparasites Differentiate between hemoparasites and anemia causing
parasites
Enlist hemoparasites

Microbiology Enlist types of Plasmodium

Plasmodium
Medical (hemolytic anemia) Describe pathogenesis of Plasmodium
Microbiology by Draw life cycle of Plasmodium
Warren Levinson Diphylobothrium Describe pathogenesis of D. latum
Latum (Pernicious Draw life cycle of D. latum
anemia)
Ancylostoma Describe pathogenesis of Ancylostoma duodenale
duodenale (iron
Draw life cycle of A. duodenale
deficiency anemia)
Describe the mode of action of two types of vaccination,
Community active and passive. Chapter # 6
Medicine Give a brief account of immunization agent, mode of (Page # 132 -
Excel community Immunization
administration and scheduling in the national 136, 141 & 142)
medicine by Dr. immunization program(EPI)
Naveed Alam Describe the other vaccine than EPI
Pharmacology Identify drugs used for the treatment of allergic reactions
Anaphylaxis & Explain their mechanism of action Chapter # 16
Katzung & Trevor’s Allergic Reactions (Page # 144 – 146)
(Board Review) Discuss major adverse effects of these drugs
Histology Identify the tissue under microscope
Thymic & Palatine
Practical copy Draw and label the light microscopic appearance Experiment # 1
Tonsils
(Volume 2) Give two points of identification
Behavioral Synthesize the various determinants of personality
Sciences Section C;
development.
Personality Personality
Mowadat Rana Write the influence of personality types on common
(Page # 63 – 67)
clinical conditions.