Immunologic mechanisms of tissue damage, allergic diseases and autoimmunity

Definition
• Hypersensitivity refers to undesirable reactions produced by the normal immune system.
• Its is an inappropriate or exaggerated response to an antigen or an allergen.
The normally beneficial immune response become the cause of disease

Classification: Gell and Coombs

Hypersensitivity reactions can be classified into four types:
• Type I: IgE mediated hypersensitivity or immediate reaction
• Type II: Antibody-mediated reaction (IgG or IgM antibodies)
• Type III: Immune complex-mediated reaction
• Type IV: Cytotoxic, cell-mediated, or delayed hypersensitivity reaction

Definition of IgE mediated Allergy or Type 1 hypersensitivity

“An allergy is a chronic condition involving an abnormal reaction to an ordinarily harmless
substance called an allergen”.

Allergens
- FOOD MOULDS DUST MITES
- DANDERS
- HYMENOPTERA VENOMS
- POLLENS OCCUPATIONAL DRUGS
• Allergens are proteins or chemicals bound to proteins.
• Typical allergens include proteins in pollen, house dust mites, animal dander, foods, and
drugs.
• Allergy affects about 30% of the population, and its prevalence is increasing worldwide.
• The most common manifestations of IgE mediated allergies are atopic dermatitis, hay fever
(allergic rhinitis), and asthma.
• Genetic factors
• Environmental factors
(pollution, socioeconomic status, geographical distribution)
Predispose for the development of allergies

Overview of IgE-Dependent Allergic Reactions

• Allergy is the prototype 2 inflammatory disease, mediated by the cytokines IL-4, IL-5, and IL-
13, different combinations of which are secreted by Th2 cells.
• Allergic reactions require previous T cell–dependent specific IgE production by B cells and the
binding of the IgE to mast cells.
• Specific IgE produced in response to the allergen binds to Fc receptors on mast cells:
sensitization phase.
• Re-exposure to the allergen then activates the mast cells to release mediators that
cause the harmful reaction.

Mechanism of Action
• Sensitization
➢ Antigen presenting cells present the allergens that enter the body to immune cells,
particularly T cells ( activation of Th0 that will lead to an increase in Th2 cells)
➢ Immune interactions between Th2 cells and B cells leading to the release of Cytokines
including Interleukins IL (4,5,13) resulting in production of IgE allergen-specific antibodies.
➢ In response to CD40 ligand and cytokines, mainly IL-4 and IL-13, produced by these helper T
cells, the B cells undergo heavy chain isotype switching and produce IgE.
➢ IL-5 secreted by Th2 cells enhances eosinophil production in the bone marrow and activates
mature eosinophils in tissues.
➢ Once released into the blood, IgE binds to mast cells as well as other immune cells such as
basophils.
➢ Mast cells and basophils express a high-affinity Fc called FcεRI which binds IgE
Mechanism of Action
• Re-exposure to allergen
➢ Binding of the allergen to specific IgE on mast cells can initiate an aggressive and immediate
immune response.
➢ Activated mast cells secrete a variety of mediators that are responsible for the
manifestations of allergic reactions
➢ These include substances that are stored in granules and rapidly released upon activation
and others that are synthesized upon activation
➢ In addition to early-phase symptoms, a number of symptoms can occur several hours after
exposure to the allergen and can even last upwards of weeks.
➢ Late-phase reactions can result in similar symptoms, but also tissue destruction and
continued immune cell recruitment.

Mast cells activation

• Mast cells are activated by cross-linking of FcεRI molecules, which occurs by binding of
multivalent antigens to the IgE molecules that are ached to the Fc receptors.
• Exposure to the antigen will cross-link sufficient IgE molecules to trigger mast cell activation.
• Activation of mast cells results in three types of biologic responses: secretion of preformed
granule contents by exocytosis (degranulation), synthesis and secretion of lipid mediators, and
synthesis and secretion of cytokines.
Hypersensitivity: Disorders Caused by Immune Responses
Type I Hypersensitivities Response
• Eosinophils play a principal role in the late-phase reaction
✓ ECF released by mast cells during the initial reaction attracts large numbers of eosinophils
✓ Cytokines released at the site, including IL-3, IL-5, and GM-CSF, contribute to eosinophil
growth and differentiation
✓ Eosinophils are activated by the binding of antibody-coated antigen ➔ leads to eosinophil
degranulation ➔ further release of inflammatory mediators ➔ contribute to the extensive
tissue damage typical of the late-phase reaction

Immediate (type I) hypersensitivity

Begins rapidly, within minutes of antigen challenge, in a previously sensitized individual

Allergic Manifestations
Allergic reactions are manifested in different ways, depending on organs affected and Allergen
routes of exposure

Anaphylaxis
Definition
Anaphylaxis is a serious, life-threatening generalized reaction that is rapid in onset and can be
fatal.
- Usually IgE-mediated but not always
Clinically defined by:
- Sudden onset and rapid progression of signs and symptoms
- Reaching at least 2 organs (GI, Respiratory, Skin mucosal tissue)
- Or drop in blood pressure (> 30% of baseline, anaphylactic shock)

Anaphylaxis: symptoms duration

Uniphasic Anaphylaxis – Mostly
-> symptoms appear and disappear within 1-2 hours

Biphasic Anaphylaxis - in 1-20%

-> symptoms disappear after treatment and reappear 30 min to 72 hours after

Refractory anaphylaxis – exceptionally

-> symptoms persist despite a well-conducted treatment (and more than 10 mg of adrenaline
used)

Treatment
EPINEPHRIN
Intramuscularly immediately administeredadrenaline is life-saving for anaphylaxis.
• It relieves the symptoms of anaphylaxis including preventing, and relieving airway obstruction
• It prevents and relieves fall in blood pressure and shock.
• Anti-histamines do not work fast enough
• Corticosteroids do not work fast enough
• Anti-histamines and corticosteroids should NOT be used first-line for the emergency
treatment of anaphylaxis

Skin Testing for Allergy Diagnosis or type 1 hypersensitivity

Skin prick testing (SPT)

• Reliable method to diagnose IgE-mediated allergic disease in patients with:
a) Rhinoconjunctivitis
b) Asthma
c) Anapylaxis
d) Atopic eczema
e) food and drug allergy.
• Safe/ Fast/ Inexpensive/ Sensitive/ Minimally invasive/ Correlates well with nasal and
bronchial challenge
• SPT may be performed in infants as young as 1 month
• It provides evidence for sensitization
• Clinical relevance must be interpreted based on the medical history and clinical symptoms.

General principle in SPT

• When allergens are introduced into the skin
• Specific IgE bound to the receptors on mast cells are cross-linked, mast cells degranulate, and
histamine and other mediators are released.
• Producing a wheal and flare response which can be quantitated.
• The test can be interpreted within 15 to 20 minutes.

Assessment of the SPT

• Positive and negative controls should be measured first.
• The negative control excludes the presence of dermographism.
• The histamine control should be positive to exclude negative results due to potentially
interfering medications taken by the patient.
• The size of the papule: the average of its largest diameter and its perpendicular diameter; a
positive being a wheal of ≥3 mm.

Intradermal skin tests

• More sensitive but less specific than SPT.
• These tests have been occasionally associated with serious systemic allergic reactions from
anaphylaxis.
• They will be done only in the case of negative SPT.
• Intradermal testing are primarily used for sensitization to medications.

Intradermal injection
• Injection is administered just under the epidermis.
• Small volumes, usually 0.02 to 0.05ml of a diluted (10-1000 fold) prick extract concentration
are injected raising a small bleb measuring 3 mm in diameter.
• Circle the Injection site marking the wheal with ink

Interpretation
• After 20 mn the area is examined for a reaction.
• The new wheal should be marked with ink.
• Measure the diameter of the new wheal and compare to the initial one.
• Positivity criteria: the initial wheal increases by 3 mm or greater in
diameter.

What is an IgE blood test?

Measurement of serum levels of IgE by ELISA. An IgE test is a blood test that detects circulating
IgE.
• The test includes two types of test:
a. Testing for total IgE — the total level of IgE in the blood.
b. Testing for specific IgE — the level of specific IgE against a particular allergen.
• Sensitivity of specific IgE tests ranges from 60% to 95% and the specificity from 30% to 95%,
depending upon the type of allergen and the age of the patient. There is a good predictive value
(> 90%) for food (cow’s milk, egg, fish, and peanuts), pollens (grass and trees) and dust mites.
• A positive test result means sensitisation to an allergen.
• The indicated level of IgE may not correlate with the extent or severity of symptoms when
exposed to the allergen.
• A normal level of IgE may not exclude allergic disorders.
• False-positive and false-negative results can be due to cross-reactivity, the age of the patient,
or the type and duration of exposure to the allergen.

Treatment of Type I Hypersensitivity

Desensitization/immunotherapy
• Can reduce or even eliminate symptoms for years after the desensitization course is complete
• Repeated exposure to low doses of allergen induces an increase in regulatory T cells
producing the immunosuppressive cytokines TGF- and/or IL-10 (a form of tolerance)
• Also induces an increase in non-inflammatory IgG (specifically IgG4) antibodies specific for the
allergens

Type II Hypersensitivity
Type II hypersensitivity reaction/ AntibodyMediated Cytotoxic Hypersensitivity
• IgG and/or IgM antibodies against cell surface antigens
• When IgG and IgM antibodies bind to self antigens, they can direct the cytotoxic response
against the host itself and cause potentially extensive damage.
• IgG/IgM binding to cell-surface components causes cytotoxicity via three
main mechanisms:
1. Complement activation
2. Antibody-dependent cell-mediated cytotoxicity (ADCC)
3. Opsonization

1. Complement-dependent cytotoxicity is the primary etiology in autoimmune hemolytic

anemia and autoimmune thrombocytopenic purpura.
- Antigen-antibody complexes on the surface of cells activate the classic complement pathway,
creating the membrane attack complex (C5-C9), which causes lysis of the target cell.

2. IgG antibodies can induce damage via antibody-dependent cellmediated cytotoxicity (ADCC)
- IgG on target cells binds to Fc gamma receptor IIb on natural killer cells and macrophages,
which causes them to release granules that contain perforin and granzyme to directly kill cells.

3. IgG and IgM can bind to Fc receptors on phagocytes to activate them and initiate
phagocytosis.

Examples of type II hypersensitivity

Transfusion reactions: ABO and Rh blood group reactions
• Transfusion reaction: Incompatible donor cells are lysed (complement-mediated) as they
enter bloodstream  intravascular hemolysis  release of hemoglobin  degradation and
metabolism of hemoglobin  bilirubin, which at high levels is toxic
• Symptoms: fever, chills, nasuea, clotting within blood vessels, pain in the lower back and
hemoglobin in urine

Autoimmune diseases:
• Rheumatic fever where antibodies result in joint and heart valve damage
• Idiopathic thrombocytopenic purpura where antibodies result in the destruction of platelets
• Goodpasture's syndrome where antibodies lead to destruction of cells in the kidney
• Graves' disease where antibodies are made against thyroid stimulating hormone receptors of
thyroid cells leading to defective thyroid function

Type III hypersensitivity

• IgG and IgM antibodies bind to antigens to form immune complexes.
• These complexes deposit in tissues and activate complement, which then causes organ
damage.
• Common sites of complex deposition include small arteries, renal glomeruli, and synovial
capsules of joints.
• Symptoms associated with type III reactions are determined by the site of immune complex
deposition and not by the source of the antigen.
• The resulting inflammatory lesion is referred to as:
a) Vasculitis if it occurs in a blood vessel
b) Glomerulonephritis if it occurs in the kidney
c) Arthritis if it occurs in the joints

• The antigen may be exogenous (chronic bacterial, viral or parasitic infections),

or endogenous (non-organ specific autoimmunity: e.g., Systemic Lupus Erythematosus-SLE).
• The location of the immune complexes is largely determined by the route by which antigen
enters the body:
– Inhaled antigens give rise to a pneumonitis
– antigens that enter through the skin cause local skin lesions: Insect bite (skin): Arthurs
reaction
– antigens that access the bloodstream form immune complexes that are deposited in renal
glomeruli or joints.

An Arthus reaction is a localized type III hypersensitivity reaction characterized by small vessel
vasculitis associated with deposition of immune complexes and activation of complement, and
consequent organ damage

Type IV hypersensitivity
• Are delayed reactions and involve T cells as the major effector cells.
• Reaction takes more than 12 hours to develop; between 48 to 72 hours
• This reaction to exogenous antigens involves T cells and also antigenpresenting cells
(monocytes/ macrophages), all produce cytokines that stimulate a local inflammatory response
in a sensitized individual.

Type IV Hypersensitivity Reactions

• Development undergoes two major phases

(1) Sensitization phase

• After primary antigen contact; 1-2 Wk duration
• TH cells are activated and clonally expanded
• Mainly CD4+ TH1 cells

(2) Effector phase

• Induced by subsequent exposure to antigen
• Becomes apparent 24 hours after contact with antigen
• Peaks 48-72 hours after antigen contact
• TH cells secrete cytokines ➔ recruit and activate macrophages and other inflammatory cells
• Macrophages compromise about 95% of participating cells

Contact dermatitis
• The most common type IV hypersensitivity
• Chemicals complex with skin proteins ➔ internalized by APCs (E.g. skin’s Langerhans cells) ➔
processed and presented via MHC II ➔ sensitization and later activation of sensitized TH1 cells
➔ recruitment and activation CD8+ T cells and NK cells cytotoxic cells ➔ induce death of
keratinocytes and sloughing of the skin or mucus membrane

• Type IV hypersensitivity is involved in the pathogenesis of many autoimmune and infectious

diseases (tuberculosis, leprosy, toxoplasmosis, leishmaniasis etc.) and granulomas due to
infections and foreign antigens.

• There are three variants of delayed hypersensitivity :

– Contact (48 to 72 hours)
– Tuberculin (48 to 72 hours)
– Granulomatous (21 to 28 days)
Autoimmunity
• Autoimmunity is defined as a phenomenon in which antibodies or T cells react with
autoantigens leading to autoimmune diseases.
• Autoimmunity results from some failure of the host’s immune system to distinguish self from
non-self, causing destruction of self cells and organs.
• There are over 80 autoimmune diseases currently identified.
• Some are organ-specific whereas others are systemic.
• Autoimmune disease is estimated to affect between 3% and 8% of individuals in the
industrialized world, making this a rising problem in terms of morbidity and mortality

Pathogenesis of Autoimmunity
Genetic factors/predisposition
• Multiple genes are associated with autoimmunity
– Most human autoimmune diseases are multigenic

MHC genes
• Major genetic association with autoimmune diseases (relative risk of disease in individuals
with particular HLA haplotypes)
– HLA-DR2 ➔ SLE and MS
– HLA-DR3 ➔ Myasthenia gravis and Type I DM
– HLA-DR4 ➔ RA

Non-MHC genetic mutations causing autoimmune diseases

• Mutations in Fas or FasL genes
– Autoimmune lymphoproliferative syndrome
• Mutations in AIRE gene
– Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED)
• Mutations in Foxp3 gene
– Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX)
• Another potential issue that contributes to the breakdown of tolerance
seen in autoimmunity is an imbalance between Th17 and Treg cells.
• The following autoimmune diseases are known to be related to Th17/IL-17
production:
o Rheumatoid Arthritis
o Inflammatory Bowel Disease
o Multiple Sclerosis
o Psoriasis
o Ankylosing Spondylitis
o Sjӧgren’s Syndrome
Autoimmune diseases are divided into two groups:
▪ Organ-specific autoimmune diseases, in which the target antigens and the tissue disorders
are localized in one organ
▪ Systemic autoimmune diseases, in which the response to a certain type of antigens that are
expressed widely in the body and multiple organs are involved, such as an intranuclear antigen.

Examples of localized autoimmune diseases

• Addison’s disease – this disease results from damage to the outer layer of the adrenal gland
(the adrenal cortex). As a result the adrenal gland does not produce enough steroid hormones
resulting in symptoms which include fatigue, muscle weakness, and a loss of appetite.
• Type 1 diabetes – diabetes mellitus type 1 is a consequence of the autoimmune destruction of
cells in the pancreas producing insulin.

Examples of systemic autoimmune diseases

• Lupus – systemic lupus erythematosus is a complex condition affecting many parts of the
body, including the skin, joints, heart, lungs and nervous system. It occurs as a result of a
widespread systemic autoimmune reaction and results in symptoms including fever, weakness,
arthritis, skin rashes and kidney dysfunction
• Autoimmunity against multiple tissue antigens: auto-antibodies specific for DNA, histones,
RBCs, platelets, leukocytes, and clotting factors
• ANA: antinuclear antibodies
– Laboratory diagnosis of SLE involves detection of ANA directed against doublestranded or
single-stranded DNA, nucleoprotein, histones, and nucleolar RNA
Systemic Autoimmune Diseases
Rheumatoid arthritis
• Autoimmunity mostly against the joints, eventually leading to damage of the joint itself.
• The major symptom is chronic inflammation of the joints, although the hematologic,
cardiovascular, and respiratory systems are also frequently affected
• RA patients produce auto-antibodies called Rheumatoid Factors ➔ complexes deposits in
joints ➔ activate the complement cascade ➔ result in a type III hypersensitivity reaction ➔
chronic inflammation
Lecture Notes:

Anaphylaxis vs anaphylactic shock

- Anaphylaxis: involvement of 2 organs
- Shock: systolic blood pressure level 90, or decrease more than 30% of baseline blood
pressure

Treatment: epinephrine - fast acting, vasoconstriction

- Beta 1: adrenergic receptor (increase cardiac contraction forced and heart rate)
- Beta 2: adrenergic receptor (high bronchodilation, low mediator release)
- Alpha 1: adrenergic receptor (high vasoconstriction, high blood pressure, low mucosal
edema)

Delayed type hypersensitivity: Type IV

- Tuberculin skin test  antigen tuberculin is injected  recognized by APC  activates
already preformed TH1 effector cells  recruitment of phagocytes and plasma to site of
antigen injection (24-72 hours)

Type I: rash is 2 hours and hives (papules that are migratory, no scars, itchy)
Type IV: Vesicular, red, itchy, linear pattern
Contact dermatitis: in contact with plant  hapten binds to protein
Histamine release: mediator in type I  insect bite releases histamine either by secondary
mosquito saliva contact, or activation mast cells by IgE or IgE independent pathway
IgE

The more we are exposed to antigen, more at risk to develop allergies

Atopy: genetic predisposition to developing allergic conditions

Individuals with one atopic condition are at higher risk of developing another atopic condition

Serum sickness: type III hypersensitivity reaction  result of immune complex disposition in
various tissues of the body  activate/consume C3 and result in decreased serum levels of C3
- It can be a vaccine reaction