Immu 2: Autoimmune And Auto-inflammatory Disorders 2 Flashcards
Patient presents with nervousness, diarrhoea, heat intolerance and on examination has exophthalmos. What is the most likely auto-immune disease causing this ?
Grave’s disease
What causes hyperthyroidism in Grave’s disease ?
IgG antibodies that stimulate TSH receptors
What type of hypersensitivity reaction is Grave’s disease ?
Type 2
What is a goitre ?
Enlarged thyroid due to T and B cell infiltration
What causes hypothyroidism in Hashimoto’s Thyroiditis ?
How common is this condition as a cause of hypothyroidism?
Anti-thyroid peroxidase antibodies and anti-thyroglobulin antibodies
(most common cause of hypothyroidism in iodine-replete areas)
What type of hypersensitivity reaction is hashimoto’s thyroiditis ? (2 option)
Type 2 and type 4
List 2 of the auto-antigens presented by MHC class 1 molecules to cytotoxic CD8+ T cells that causes destruction of the Beta cells of the pancreas in Type 1 diabetes mellitus
islet antigen 2 (IA2)
Glutamic acid dehydrogenase (GAD)
List the 4 antibodies associated with T1DM ?
Anti-islet cell antibodies
Anti-GAD antibodies
Anti-insulin antibodies
Anti-IA2 antibodies
Which auto- antibodies are associated with pernicious anaemia ?
Anti-IF antibodies (Intrinsic factor)
Pernicious anaemia is an example of a …………. anaemia
Macrocytic
Aetiology of pernicious anaemia
- patients develop antibodies against intrinsic factor, which leads to failure of absorption of vitamin B12
- Vitamin B12 deficiency can also lead to subacute degeneration of the spinal cord
- Other neurological features include peripheral neuropathy and optic neuropathy
Pernicious anaemia can cause subacute …………
Subacute degeneration of the spinal cord
Apart from anti IF antibodies which other auto-antibodies are seen in pernicious anaemia ? (1)
Anti-parietal cell antibodies
Patient presents with drooping eyelids and weakness which is worse at the end of the day. What is the likely diagnosis ?
Myasthenia gravis
Deficiency of which vitamin causes subacute degeneration of the spinal cord ?
Vitamin B12
Seen in pernicious anaemia
Which Autoantibodies cause Myasthenia gravis?
How does this result in the aetiology?
Nicotinic acetylcholine receptor antibodies (nAChR)
- subsequent failure to depolarise the receptors and do NOT get muscle action potential
- get fluctuating weakness
Which test is used to diagnose Myasthenia Gravis ?
Tensilon test - give very short-acting acetylcholinesterase - causes rapid improvement in symptoms
*type II hypersensitivity reaction
What type of hypersensitivity reaction is mysasthenia gravis?
Type 2
Which autoimmune disease causes haematuria, proteinuria and pulmonary haemorrhage ?
Goodpasture’s syndrome
What Histological finding on renal biopsy suggests Goodpasture’s syndrome ?
How does the test work?
Crescentric nephritis
Test works by: detected using fluorescein conjugated anti-human immunoglobulin
Which auto-antibodies are associated with Goodpasture’s syndrome ?
Anti-basement membrane antibodies
Patient presents with Pain and stiffness of multiple joints in the hands. He also has a normocytic anaemia and elevated ESR and CRP. What is the most likely diagnosis ?
Rheumatoid arthritis
Which HLA polymorphisms are associated with Rheumatoid arthritis ?
HLA DR4
HLA DR1
(others = PTPN22, those affecting TNF, IL1, IL6, IL10, PA2 + PD4)
Which bacterial gum infection is associated with Rheumatoid arthritis ?
Porphyromonas gingivalis (expresses PDA)
Is smoking associated with increased or decreased risk of rheumatoid arthritis ?
Increased
Which antibodies are characteristically seen in rheumatoid arthritis ?
Anti-cyclic Citrullinated Peptide Antibodies (anti-CCP) antibodies (95% specific)
Anti-Rheumatoid factor (IgM anti IgG variant)
Which 3 types of hypersensitivity reactions occur in Rheumatoid arthritis ?
Hypersensitivity 2- antibody binds to CCP (peptides) causing complement activation (classical pathway), Macrophage and NK cell activation
Hypersensitivity 3- Immune complexes deposit
Hypersensitivity 4- APCs present peptides (citrulinated, self) to CD4+ T cells causing release of IFN gamma and IL-17 which activate macrophages and fibroblasts. MMPs and TNF-alpha are then released
What is a ‘Pannus’ in Rheumatoid arthritis ?\
Inflammed synovial cartilage which invades the articular cartilage and adjacent bone structures
Increase in synovial fluid volume
What happens to the joint in rheumatoid arhtritis?
- In rheumatoid arthritis, the synovium becomes very inflamed forming a pannus
- This invades the articular cartilage and adjacent bone
- There is also an increase in synovial fluid volume
Which auto-antibodies are characteristic of connective tissue diseases ?
ANA
Antibody found in each condition:
- Goodpasture’s disease
- Myasthenia gravis
- Graves’ disease
- Pernicious anaemia
- Diabetes Mellitus
- Hashimoto’s thyroiditis
- Rheumatoid arthritis
- Goodpasture’s disease – Anti-basement membrane antibody
- Myasthenia gravis – Anti-AChR antibody
- Graves’ disease – Anti-TSHR antibody
- Pernicious anaemia – Anti-IF antibody
- Diabetes Mellitus – Anti-GAD antibody
- Hashimoto’s thyroiditis – Anti-thyroglobulin antibody
- Rheumatoid arthritis – Anti-cyclic citrullinated antibody
What is the role of anti-nuclear antibodies (ANA)?
- These are a group of antibodies that bind to nuclear proteins
- They are tested by staining Hep-2 (Human epidermoid cancer line) cells
List 6 pathologies seen in SLE ?
SOAP BRAIN MD
Serositis
Oral or nasal ulcers
Arthritis in > 2 joints
Photosensitivity
Blood disorders
Renal
ANA
Immunologic
Neurologic symptoms
Malar rash
Discoid rash
(abnormalities in clearing apoptotic cells. Antibodies bind to antigens forming immune complexes, deposit in tissues eg skin, joints, kidneys)
Aetiology of SLE
- Abnormalities in clearing apoptotic cells
- Abnormalities in cellular activation
- B cell hyperactivity and loss of tolerance occurs
- Antibodies directed particularly at intracellular proteins
- Antibodies bind to antigens forming immune complexes, which deposit into small blood vessels of tissues (e.g. kidneys, skin, joint)
- Immune complexes can activate complement via the classical pathway
Histology of the kidney shows “Lumpy bumpy” pattern of immunoflourescence.
Which disease is more likely:
A) SLE
B) Goodpasture’s disease
A- SLE
causes lumpy bumpy pattern due to immune complex deposition (type 3 hypersensitivity reaction)
Which Auto-antibody is useful for monitoring disease severity in SLE ?
Which antibody is used for diagnosis?
Anti- dsDNA - disease monitoring
ANA used in diagnosis
Which of these Auto-antibodies is not often seen in SLE ?
A) ANA
B) dsDNA
C) topoisomerase (Scl70)
D)smith
E)Ro
D)La
C- Anti- topoisomerase (Scl70) is seen in Diffuse Cutaneous Systemic Sclerosis and not in SLE
All the other antibodies can be seen in SLE
Ro and La are more present in Sjögren’s syndrome
SLE (type 3) vs Goodpasture’s (type 2) presentation
- GP: get antibody binding in a linear fashion at the basement membrane
- SLE: immune complex deposition leads to a lumpy-bumpy distribution of antibody formation
Association between SLE and complement + how does this link to disease activity?
- Formation of antibody-antigen immune complexes will activate complement via the classical pathway (expose the binding site for C1q)
- Complement components (C3 and C4) become depleted if constantly consumed
- Quantification of C3 and C4 acts as a surrogate marker for DISEASE ACTIVITY
What is the Triad for Antiphospholipid syndrome ?
Recurrent venous or arterial thrombosis
Recurrent miscarriage
Thrombocytopenia
List the 2 main antibody tests in antiphospholipid syndrome?
Anti-Cardiolipin antibody
Lupus anticoagulant test- coagulation dependent on phospholipids is prolonged
List the 6 pathologies seen in Limited Cutaneous Systemic Sclerosis (NB think about the mnemonic) ?
CREST-P
Calcinosis
Raynauds
Esophageal dysmotility
Sclerodactyly
Telangectasia
Primary pulmonary hypertension
Which features of LIMITED cutaneous Systemic Sclerosis are different to DIFFUSE cutaneous Systemic Sclerosis?
Skin involvement goes beyond forearm
Renal involvement: scleroderma kidney/renal cysts
more extensive GI disease
Interstitial pulmonary disease
Also has all the other features of CREST
ANA staining is an important prognostic indicator in SS
Which 2 antibodies allows differentiation of LIMITED cutaneous Systemic Sclerosis from Diffuse cutaneous Systemic Sclerosis ?
LIMITED cutaneous Systemic Sclerosis - Anti-centromere antibodies
Diffuse cutaneous systemic sclerosis - Anti-Topoisomerase antibodies (Scl70)
Which disease causes weakness, malaise, peri-orbital heliotrope rash and gottron’s papules ?
Dermatomyositis
How is polymyositis different to dermatomyositis ?
There is no rash in Polymyositis
Name 1 autoantibody seen in dermatomyositis ?
Anti-aminoacyl tRNA synthetase antibody (anti-Jo1)
Anti- Mi2 is more common in DM than PM
Name 1 autoantibody seen in Polymyositis ?
anti-signal recognition peptide antibody
Patient presents with recurrent nosebleeds and breathlessness. Examination reveals collapse of the nose bridge. X ray shows cavitation get lesions. What is the likely cause ?
ANCA (Anti-neutrophil cytoplasmic antibodies) associated vasculitis (small vessel)
List 3 types of small vessel vasculitis (ANCA associated vasculitis) ?
Microscopic polyangitis (MPA)
Granulomatosis with polyangitis (GPA) (aka wegener’s)
Eosinophilic granulomatosis with polyangitis (eGPA) (Churg-Strauss syndrome)
Which type of ANCA is associated with granulomatosis with polyangitis ?
A) cANCA
B) pANCA
A (cANCA) - suggests Granulomatosis with polyangitis with renal involvement
(pANCA suggests MPA or eGPA)
Which auto-antibodies can be seen in Primary sclerosis cholangitis / Autoimmune hepatitis ?
Anti- SMA
(Autoimmune hepatitis can also have anti-LMK-1)
Which type of ANCA is associated with eosinophilic granulomatosis with polyangitis (Churg-strauss syndrome) ?
What is presentation of this syndrome?
P-ANCA
Which antibodies are associated with Primary billiard cirrhosis ?
Anti-mitochondrial antibodies
Patient presents with blurry vision and weakness in her legs. CSF shows Oligoclonal bands of IgG on electrophoresis.
Most likely diagnosis ?
What type of hypersensitivity reaction is this ?
Multiple sclerosis (MS)
Optic neuritis and demyelination.
Type 4 hypersensitivity reaction targeting oligodendrocyte and myelin proteins.
Which antibody is characteristic of Pemphigus vulgaris ?
Anti- Demoglein 3
Which disease is suggested by a +ve Nikolsky’s sign ?
Pemphigus vulgaris
Bullae rupture easily
Skin histology shows acantholytic cells (separation of keratinocytes caused by loss of intercellular cadherin connections). Leading to blistering.
Most likely diagnosis ?
Pemphigus vulgaris
Immunofluorescence shows A linear pattern of IgG and C3 at the basement membrane. Causes blistering.
Most likely diagnosis ?
Bullous pemphigoid.
List 2 diseases for which interferon Beta is a treatment ?
- Relapsing MS
- Bechets
for which disease is inteferon gamma used as a treatment ?
Chronic granulomatous disease
Describe complement profiles in SLE
formation of antibody-antigen immune complexes will activate the classical pathway
complement becomes depleted
active disease - low C4
severe active disease - low C3 + C4
features of systemic sclerosis
inflammation with Th2 and Th17 cells
cytokines lead to activation of fibroblasts and the development of fibrosis
loss of B cell tolerance to nuclear antigens
list 3 idiopathic inflammatory myopathies
dermatomyositis - within muscle, immune complex mediated vasculitis (type III response)
polymyositis - within muscle, type IV response
list 2 large vessel vascilituses
Takayasu’s arteritis
Giant cell arteritis/ polymyalgia rheumatica
list 2 medium vessel vasculituses
anti-GBM disease
IgA disease
Cryoglobulinaemia
ANA+ve, Anti-dsDNA +ve, Low C3 and C4, High ESR. Negative results for:
Ro, La, Sm, RNP, Scl70, Centromere, Jo1. What is the diagnosis?
SLE
What are Anti-neutrophil cytoplasmic antibody (ANCA)?
- Antibodies specific for antigens located in primary granules within the cytoplasm of neutrophils
- Inflammation may lead to expression of these antigens on the cell surface of neutrophils
c-ANCA (Anti-neutrophil cytoplasmic antibodies) vs p-ANCA in terms of where in the cell they stain
c-ANCA: cytoplasm
p-ANCA: Perinuclear staining
c-ANCA vs p-ANCA in terms of which antibody they are associated with
- c-ANCA: antibodies to the enzyme proteinase 3
- p-ANCA: antibodies to myeloperoxidase
ANA vs ANCA in terms of what they screen for
- ANA= Screening test for a connective tissue disease
- ANCA= associated with a small subset of small vessel vasculitides including MPA, GPA and eGPA
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
