Body Defences: Immunodeficiency Flashcards
What kind of immunodeficiency defects can arise?
Quantitative Functional (affecting maturation or activation/effector functions)
What is the predicted consequences of immunodeficiency?
Increased susceptibility to newly acquired infections Reactivation of latent infections Increased incidence of some malignancies
What clinical features suggest primary immunodeficiency?
Recurrent +/- severe infections Opportunistic organisms Unusual infections Severe infections with organisms of low pathogenicity Failed response to therapy/recur soon after therapy is ceased Family members with known Primary Immunodeficiency
What are the types of immunodeficiency?
Primary (congenital) Secondary (acquired immunodeficiencies)
What kind of conditions can cause immunodeficiency?
Genetic abnormalities in one or more components of the immune system. Infections Drugs Protein losing states Haematological disorders
When can primary immunodeficiency first show up?
It can occur in infancy or during adulthood.
What kind of diseases affect people with T cell deficiencies?
Viral and intracellular microbial infections
What kind of diseases affect people with B cell deficiencies?
Pyogenic bacterial infections, enteric bacterial infections, and viral infections.
What histopathological abnormalities are seen in people with reduced B cells and T cells?
B cells: reduced or absent follicles and germinal centers in lymphoid organs + reduced serum Ig levels T cells: Reduced T cell zones in lymphoid organs. Reduced DTH reactions to common antigens, defective T cell proliferative responses.
What genetic defects affect lymphocyte maturation?
Severe Combined ImmunoDeficiency (X-SCID due to γc mutations) ADA and PNP deficiencies Defects in maturation of B-lymphocytes (X-linked aγglubulinemia) Defects in maturation of T-lymphocytes (Di George Syndrome)
What functional deficiencies are present in people with X-linked SCID?
Markedly decreased T cells and either normal or increased B cells. This results in reduced serum Ig due to loss of T help.
What is the mechanism of the defect in X-linked SCID?
Cytokine receptor common γ chain gene mutation due to lack of IL-7 signals.
What fucntional deficiencies are present in autosomal recessive SCID?
Progressive decrease in T and B cells (mostly T cells)
What is the mechanism of defect in autosomal recessive SCID?
ADA or PNP deficiency leads to accumulation of toxic metabolites in lymphocytes.
What causes X-linked SCID?
>99% are due to mutations in the common γc chain signalling subunit of receptors for several cytokines - IL-2, 4, 7, 9, 15, 21.
What is the result of the mutation in the γ chain in T lymphocytes?
Immature lymphocytes cannot proliferate in response to IL-7. Reduced maturation and maturation of lymphocyte precursors (mainly affects T cells) Profound decrease in the numbers of mature T cells and deficient CMI.
Why is NK cell activity reduced in response to γc chain mutations?
Due to the importance of IL-15 in NK proliferation and maturation.
Why is the humoral immune system’s activity reduced in response to γc mutations?
Due to absence of T cell help (B cells may mature normally but this is still an issue)
What percentage of SCID disorders are X-linked?
50%
Where does the mutation occur in 99% of X-linked SCID?
In the γ chain (the blue chain)
Where else can mutations occur besides the γ chain?
JAK3, STAT5 and IL-7Rα
What kind of SCID are ADA and PNP deficiencies?
Autosomal recessive
What happens during ADA and PNP deficiencies?
Mutations in autosomal genes that encode proteins involved in nucleic acid metabolism.
ADA deficiency leads to the accumulation of toxic purine metabolites in cells that are actively synthesizing DNA (proliferating cells) such as lymphocytes undergoing maturation.
Deficiency in PNP leads to a similar phenotype.
What do ADA and PNP stand for?
Purine Nucleotide Phosphate
Adenosine DeAminase
What mutations lead to SCID?
X-linked: γc chain -> IL 2, 4, 7, 9, 15, 21 deficiency
Autosomal -> ADA and PNP, JAK3 (similar effect to γc), RAG1 or RAG2 (rare cases)
What are the clinical features of SCID?
Profound susceptibility to infection from early infancy:
Chronic mucocutaneous candidiasis, opportunistic infections, severe/fatal infections with viral pathogens, attenuated live vaccines can cause disease
What kind of pneumonia is common in SCID patients?
PJP pneumonia (aka Pneumocystis pneumonia (PCP))
How is SCID managed?
Aggressive search for and treatment of infections
Protective isolation and no attenuated live or live vaccines
Replacement immunoglobulin
Prophylaxis for bacterial, viral and fungal infections
Haematological stem cell transplant - treatment of choice - source of normal T/B cells
What is X-linked Aγglobulinemia?
The most common syndrome associated with B-cell maturation block.
Failure of expansion of pre-B-cells in bone marrow due to mutations in the gene encoding a kinase called Bruton tyrosine kinase (BTK) leading to defective production or function of the enzyme. This results in decrease or absence of mature B-cells and immunoglobulins.
What happens to people with X-linked Aγglobulinemia?
Maternal IgG supplies antibodies for the first 6 months of life and then when this protection is no longer available the patients start to develop infections.
In 25% of patients there is an autoimmune response. (arthritis)
What are the theories as to why X-linked Aγglobulinemia causes autoimmunity in 25% of people?
BTK contributes to B cell receptor signalling and is required for central B cell tolerance.
Defective BTK may result in the accumulation of autoreactive B cells.
What is Di George syndrome?
The most frequent selective defects in T cell maturation due to incomplete development of thymus and parathyroid glands. This results in failure to develop mature T cells.