IMMUNOLOGY - largest internal organ of immune system

Divided into 2: IF CUT CROSS SECTIONALLLY

Neutrophils
Red Pulp – responsible for filtering and cleansing
Eosinophils Granulocytes
White Pulp – protection
Basophils
Lymphocytes
Agranulocytes SPLEENOMEGALY
Monocytes
- enlargement of spleen ; weighs 1.8kg : 170g (normal)

IMMUNITY : Protection
SPLEENECTOMY
- body’s specific protective response to a foreign agent or
organism - removal of the spleen
IMMUNOPATHOLOGY : Study
- study of disorders resulting in dysfunctions within the BONE
immune system
Compact Bone
- long part ; diaphysis
LYMPHATIC SYSTEM : complementary to circulatory
If cut in half:
system
Yellow Bone Marrow – fats
- drains excessive fluid and proteins and return them back to
the blood stream
- fights infections Spongy Bone
- removes waste products - epiphysis
- ends of the bones
ADENOIDS - site of Hematopoiesis
- located upper back of the nose Red Bone Marrow – contains blood stem cells
- fights infections that enter the nose
Metaphysis
TONSILS - epiphysial plate
- located in the middle of nose, mouth and throat - connects compact bone and spongy bone
- fights infections that enter the mouth
Tonsillectomy Types of Immune Response
- removal of the tonsils Innate Immunity
- first responders
PEYER’s PATCHES - non-specific cannot identify one pathogen to another
pathogen
- located at small intestines (specifically: Ileum)
- fast
- has no memory
KUPFFER’s Cells
- Physical Barriers: Skin
- located in the liver
- Chemical Barriers: Saliva, sweat, tears

THYMUS
Adaptive Immunity
- a butterfly shaped organ
- back up responders
- located in front of the lungs by the sternum
- highly specific
- one of the most hardworking organs
- takes weeks to be achieved
- largest during childhood and shrinks during puberty
Antigen Presenting Cell
- finds specific match for the antigen
Massively proliferates
SPLEEN
Kills the infection
- located at the left upper abdominal quadrant
- has memory - cytokines
Killer Cells
INNATE IMMUNE RESPONSE : First Responders - cytotoxic t.cells
1. Neutrophils - kills pathogens
- polymorphonuclear cells (PMN) Regulatory T. Cell
- most abundant circulating WBC - suppressor T.Cells
- Phagocytic Cells – eats pathogens - limit strength or the immune response
- short lived
TYPES OF IMMUNOGLOBULINES
2. Eosinophils 1. IgG
- responsible for parasitic infections - most abundant antibody ( 65%)
- only antibody that passes placenta (pregnancy)
3. Basophils : blood - protects body against bacteria, viruses, tonxins
- responsible for allergic responses, secreting histamines, - chronic infection
leukotrienes
2. IgA
“ exclusively found in the blood”
- produced by mucous membranes
- passes in breastmilk; colostrum (lactating mothers)
4. Mast Cells : tissues
- located in sweats, saliva, tears
- secretes histamines, allergic responses
3. IgM
“ exclusively found in the tissues”
- largest antibody
- located in the blood and lymphatic fluids
5. Monocytes & Macrophages
- acute infection
- Phagocytic cells - eats pathogens
4. IgE
Monocytes – blood
- allergic responses
Macrophages – tissues
- Basophils & Mast cells
- mature monocytes
- least abundant antibody (less than 1%)
5. IgA
6. Dendritic Cells ( DCs)
- least understood antibody
- prototypal antigen presenting cells
- involvement happens when B.cells turn into plasma cells
- has fingerlike projections
Mature
HYPERSENSITIVY
7. Natural Killer Cells
- abnormal, overexaggerated immune response
- can identify cancer cells
4 Types:
Adaptive Immune Response
• Type 1 (immediate)
1. B-Cells
- antibody mediated
- humoral response
• Type 2 (immediate)
- located in bones
- produces antibodies - antibody mediated
• Type 3 ( immediate)
2. Plasma Cells - antibody mediated
- mature B-cells • Type 4 (delayed: 3-4 days)
- produce antibodies - cell mediated
3. T.Cells Type 1 Hypersensitivity
Helper T. Cell - allergies
- Coordinates and strengthens immune response - Ige Mediated
- Sensitization: Asymptomatic 1. Rheumatoid Arthritis
IgE binds basophils and mast cells 2. Glumerulonephitis
1. Bronchospasm 3. SLE
- due to inc smooth muscle contraction
2. Hypotension and Hypovolemia Type 4 Hypersensitivity “delayed”
- due to the peripheral vasodilation - T.Cell mediated
3. Erythema - tuberculin skin test
- extravasation of capillary blood - connect dermatitis
4. Pruritus, Hives - transplant rejection – reaction of donated organs
- Graft vs. Host Disease – reaction of donated blood, stem
cell
Diagnostic Test Anaphylaxis – severe
allergic raction (life Allogenic – donation should be allogenic
1. Skin Prick Test
threatening)
- first line test Drug: Epinephrine via IV/IM
DIFFUSE CONNECTIVE TISSUE DISEASES
- upper arm, fore arm, back
Preventative treatment is the RHEUMATOID ARTHRITIS
2. Scratch Test most effective form of
management - inflammation of the joints
3. Intradermal Test
- females are more at risk (aging 80-60’s)
- high risk for false positives
Synovium: Lining of Joints
4. Blood Test
Rheumatoid Arthritis – inflammation of synovium
2nd Generation Anti- Histamines
Autoimmune
- cetirizine, loratadine
Bilateral
1st Generation Anti-Histamines
Systemic
- diphenhydramine (Benadryl)
Cartilage: Bones; shock absorber
Osteoarthritis if cartilage is damaged
Type 2 Hypersensitive “Cytotoxic”
- not an autoimmune
- ABG incompatibility
- unilateral
- means cellular destruction
- localized
- autoimmune diseases
- “wear and tear disease”
- autoantibodies: defective antibodies (IgG/IgM)
STAGES OF RHEUMATOID ARTHRITIS
- Self-antigen: seen in cell surface of the body
First Stage: Synovitis
Autoantibodies – attack self-antigen: causing autoimmune
diseases (organ specific: localized) - earliest
- synovius
1. Hemolytic Anemia Second Stage: Pannus
- RBC’s - Fibrous Tissue Formation(Thick)
2. Thrombocytic Purpura - extensive cartilage loss; exposed and pitted bones
- Platelets Third Stage: Fibrous Ankylosis
3. Myasthenia Gravis - fusion of the joint
- ACH receptors - joint invaded by fibrous connective tissue
4. Grave’s Disease Fourth Stage: Bony Ankylosis
- TSH receptors - most severe
- Bones fused
Type 3 Hypersensitivity “immune complex” RA: Diagnostic Test
- antigen-antibody complex (free floating) 1. ANA – Antinuclear Antibody Testing
- deposited in tissues- inflammation – complement cascade - general screening test for autoimmune
crea – tissue damage
- identifies presence of antibodies
2. RF – Rheumatoid Factor AE – hypertension, hyperglycemia, skin bruising,
immunosuppression
- identifies presence of autoantibodies
3. DMARDS – Disease Modifying Anti- Rheumatic Drugs:
3. ESR – Erythrocyte Sedimentation Rate
Immunosuppressants
- inflammation
Hydroxychloroquine – irreversible retinopathy sulfasalazine
4. CRP – C reactive protein test
Methotrexate – Current standard treatment for RA
- inflammation
5. Anti- CCP test – Anti-cyclic Citrullinated Peptide Test
RA: Surgery Management
- exclusive antibodies located in the joints
Reconstructive Surgery
6. XRAY of the joints- Synovial Fluid Aspiration
- surgery fusion of the joints
- palliative management
RA Signs and Symptoms:
Arthrodesis
“Red, Hot, Swollen, Painful Joints”
- surgery fusion of the joints
• Early morning stiffness of the joints - palliative management
- timed for more than1hr: if <1hr = OA Arthroplasty
• Extra-Articular Signs and Symptoms: - repair & replacement of joints
Fatigue - prosthesis (ceramic, metal, plastic)
Considered as early diagnosis of RA
Anorexia Synovectomy
Anemia - removal of synovial fluid
Weight loss - acute management
Fever
Nursing Management: RA
RA; Complications 1. Promote Comfort and Reduce Pain
PIP DIP - positioning ( turning 2 hours)
- supportive pillows
1. RA
- splints
Boutonneire Flexed Hyperextended - application of heat – relax
- application of cold – reduce swelling
Swan Neck Hyperextended Flexed
- pain meds
Rheumatoid Nodules: Firm, movable lumps under the skin, 2. Decrease Fatigue
chronic, painless, risk for infection
3. Encourage Physical Activity
4. Refer to Physical Therapist
5. Encourage verbalization of feelings
SLE: Systemic Lupus Erythematosus
Ulnar Deviation:
- multi-organ affectation
PIP DIP
- female
1. OA - no cure, period of flare ups
(exacerbations: worsen sx)
Heberdens’s Bony
swelling ( remissions: subside sx)

Mouchard’s Bony
swelling Types of Lupus:
1. SLE – most common
RA Medications: 2. Cutaneous Lupus – skin
1. NSAIDS – ibuprofen, naproven: AE – GI Ulcers 3. Drug Induced Lupus – drugs
2. Corticosteroids – dexamethasone, prednisone 4. Neonatal Lupus – neonates only
 5. Encourage Physical Activity
6. Encourage Verbalization of Feelings
SLE: DIAGNOSTIC
1. ANA & RF: Autoantibodies SJOGREN’S SYNDROME “dry eyes and mouth”
2 ESR & CRP: Inflammation Xerophthalmia, xerostomia
3. ANTI DSONA, ANTI-SMITH ANTIBODY: Exclusive F: Middle aged woman
SLE
Primary: Genetics
Secondary: RA, SLE, Autoimmune Thyroid Disease
RISK FACTORS:
1. Genetics
Diagnostic Test:
2. Immunologic
1. ANA, RF: antibodies
3. Hormonal: Inc estrogen = Risk for SLE
2. ESR, CRP: inflammation
4. Environmental Factor:
3. ANTI – SSA, ANTI-SSB ANTIBODIES: exclusive
a. sunlight/ fluorescent light bulbs
4. Teat Test: tear production
b. viral infections: EBV, CMV
5. Split Tamp Test:
c. Drugs: Hydralazine, Minocycline, Procainamide
6. Sialogram:
d. Emotional Stress
7. Salivary Gland Biopsy:
e. Stress on the body ( sx, pregnancy )
f. smoking, silica dust exposure
Signs and Symptoms:
1. Dry Eyes: Blepharitis
SLE: Signs and Symptoms
2. Dry Mouth: Dental Caries, Angular Cheilitis
1. Malar Rash: Butterfly rash over cheeks
3. Fatigue, Anorexia, Arthritis, Anemia
2. Discoid Rash: coin shaped rash
4. Sleep disturbances, depression
3. Alopecia: initial clinical manifestation of SLE exacerbation
Management:
- no cure
Pulmonic Symptoms
- meticulous eye care
1. Cough
- artificial eye drops (pizocarpme)
2. Tachypnea
- meticulous dental care ( frequent dental visits_
3. Pleural Inflammation/ Effusion
- decrease fatigue
- refer to psych
SCLERODERMA
- connective tissue disease involving blood vessels and internal
Cardiac SLE Symptom organs
1. Pericaditis – most common - females are more at risk
Localized: cutaneous only
Systemic Symptoms Diffused: Systemic sclerosis
1. Weight Loss Collagen: Responsible for
2. Fatigue - skin elasticity
3. ETC - bone
- muscle health
SLR: MANAGEMENT - overproduction of collagen
1. NSAIDS, Corticosteroids, Immunosuppressants Diagnostic Test:
2. Advise to wear wig: reassure pt hair loss is temporary 1. ANA, RF, ESR, CRP
3. Sunscreen: SPF 15, wide brimmed hats, umbrella 2. SCL 70 ANTIBODY TEST: EXCLUSIVE
4. Decrease Fatigue 3. ECG, ECHO
4. CHEST XRAY, CT SCAN Complications:
5. SKIN BIOPSY • Osteoporosis
• AV Defects
Stone Facies – facial appearance of scleroderma
• Pulmonary Fibrosis (most life threatening)
Sclerodactyly – thinning

Reactive Arthritis
Raynaud’s Phenomenon
- “Reiter’s Syndrome”
- constriction of a small blood vessels
- young adult males
White – lack of blood flow
- occurs after an infection ( GI, GU Infection)
Blue – lack of oxygen
Red – blood flow returns
• Conjunctivitis – can’t see
• Urethritis – can’t pee Classic TRIAD
Telangiectasis
Crest Syndrome – limited symptoms of sclerosis • Arthritis – can’t bend the knee

Calcinosis
Raynauld’s PSORIATIC ARTHRITIS

Esophageal Psoriasis – “ chronic skin and nail disease”

Sclerodactyly Enthesis – where the tendons and ligaments attach

Telangiectasis
• Synovitis

Scle: Management • Spondylitis Classic TRIAD

- no cure • Polyarthritis
- NSAIDS, corticosteroids, immunosuppressants Common Affected Areas
- meticulous, Skin care,: Lotion, avoid extreme temps • Nail Pitting
- protect against infection
• Joint swelling and stiffness
- sx management
• Bone erosion and collapse

SPONDYLOARTHROPATIES SPONDYLOARTHRITIS: Management

- inflammatory disorders - NSAIDS, Corticosteroids, Immunosuppressants

ANKYLOSING SPONDYLITIS (1st example)
- spine: most affected
- Male > F: 17-45 years old
- HLA – B27 Gene: Correlative, not causative
Sacroiliac Joint
- base of the spine by the pelvis
- promote comfort and reduce pain
- maintain optimal functional ability
- good posture
- encourage physical activity
- encourage verbal feelings
- osteomy of the spine (surgical reshaping of bones)
Arthroplasty

Kyphosis: stooped posture GOUT: common location – BIG TOE

- common symptom of ankylosing spondylitis - best example for metabolic autoimmune disease
- “back pain” (subside upon activity) - most common inflammatory arthritis
- fatigue
Risk Factor:
- M > F 30-50’s
- Obesity
- Dehydration Nursing Management
1. Promote comfort and reduce pain
- Comorbidities (cancer, hypertension, DM, kidney disease)
2. Ensure Hydration (2-3L/ day unless contraindicated)
- diet high in purines, fructose
3. Lifestyle Modification ( diet, alcohol, obesity)
- alcohol
4. Encourage verbalization of feelings
5. Decrease Fatigue
Purines uric acid uric acid crystals
1. Internal organ meats ( liver, gizzard, isaw, bopis, sisig, FIBROMYALGIA
papaitan) - “chronic pain syndrome”
2. Red meats (beef, pork, lamb, samgyup) - Neurogenic in origin: overapplication of pain signal
3. seafoods (anchovies, sardines, scallops, shrimp) - Females are more at risk than Males
4. vegetable purines ( legumes, beans) - Signs and Symptoms:

5. beer • Chronic Muscle Aching

• Chronic Fatigue
GOUT: DX TEST • Sleep disturbances
1. Arthrocentesis: synovial fluid aspiration • cognitive disturbances
2. Serum Uric Acid: F: 2.5-7.5 mg/dl M: 4.0-8.5 mg/dl
• depression
3. Xray of joints:

FIB: MANAGEMENT
Primary Hyperuricemia: genetics, diet
1. Reassure pt pain is real
Secondary Hyperuricemia: co- morbidities, diuretics,
2. NSAIDS, Corticosteroids, Immunosuppressants
(thiazide furosemide, aspirin, ethanol)
3. SSRI, TCA
4. Good sleep Hygiene
5. Physical Activity (cardiovascular)

STAGES:
1. Asymptomatic Hyperuricemia
2. Acute Gout/ Gout Flare: first attack; sharp pain
3. Intercortical Gout: Asymptomatic until 2 years; preventive
management
4. Chronic Gout / Tophaceous Gout: Recurrent Attack:
Painful; Tophi: Firm lumps secondary to deposition of uric
acid crystal: Painless; toes, fingers, scars

Medical Management:
Uricosuric Agents: Probenecid
Colchicine (acute, chronic)
Watch out for:
Nausea/ Vomiting, Diarrhea, Grayish color lips
- toxicity
Xantine Oxidase Inhibitors: Allopurinol (chronic),
Febuxostat
IL 1 Receptor Antagonist
Interleukin Inflammation