TOLL LIKE RECEPTORS (3m):

●​ These are transmembrane receptors and about 10 types of human TLRs have
been identified.
●​ Each receptor recognizes a unique set of microbial patterns.
●​ For example, TLR2 recognizes various ligands (e.g. lipoteichoic acid)
expressed by gram positive bacteria, TLR4 recognizes lipopolysaccharides
(LPS) of gram negative bacteria.

TYPE I HYPERSENSITIVITY REACTION (5m/3m)

●​ Usually known as allergic or atopic disorders.
●​ Type I hypersensitivity reaction is a type of immunological tissue reaction,
which occurs rapidly (within 5–10 minutes) after the interaction of antigen
(allergen) with IgE antibodies bound to the mast cells in a sensitized
person.
PATHOGENESIS:
 MEDIATORS OF TYPE 1 HYPERSENSITIVITY:
PRIMARY MEDIATORS:
●​ Vasoactive amines: Most important being histamine, which causes:
Vasodilatation– Increased vascular permeability– Smooth muscle
contraction– Increased secretion of mucus.
●​ Enzymes: It includes neutral proteases (chymase, tryptase) and several acid
hydrolases. These enzymes cause tissue damage.
●​ Proteoglycans: It includes heparin (anticoagulant), and chondroitin sulfate.
SECONDARY MEDIATORS:
●​ Lipid mediators: Leukotrienes C4 and D4 causes increased vascular
permeability and bronchial smooth muscle contraction.
●​ Leukotriene B4 is chemotactic for neutrophils, eosinophils and monocytes.
●​ Prostaglandin D2: It causes bronchospasm and increased mucus secretion.
●​ Cytokines: TNF, IL-1 and chemokines promote leukocyte recruitment
●​ IL-4 and IL-5 amplifies the TH2 response and IL 13 stimulates mucus
secretion.
●​ Eg: Localised : Bronchial asthma (extrinsic), Hay fever/allergic rhinitis,
Allergic conjunctivitis, Urticaria
 ●​ Systemic: Anaphylaxis due to: Antibiotics: Most commonly penicillin, Bee
stings, Insect bite, Foreign proteins (e.g. antisera).

TYPE III HYPERSENSITIVITY REACTION (5M):

●​ Type III hypersensitivity reactions are characterized by formation of immune
(antigen and antibody) complexes in the circulation and may get deposited
in blood vessels, leading to complement activation and acute inflammation.
●​ SITES OF ANTIGEN-ANTIBODY PRODUCTION:
●​ Circulating immune complexes: They are formed within the circulation.
●​ In situ immune complex: They formed at extravascular sites where antigen
might have been previously planted.
●​ SITES OF IMMUNE COMPLEX DEPOSITION:
●​ Systemic: Circulating immune complexes may be deposited in many organs.
●​ Localized: Immune complexes may be deposited or formed in particular
organs/tissues: Kidney (glomerulonephritis), joints (arthritis), small blood
vessels of the skin.
Cause of Tissue Damage:
●​ Activation of complement
●​ Inflammation at the sites of deposition.
SERUM SICKNESS:
ARTHUS REACTION (3M):
●​ Arthus reaction is a local area of tissue necrosis usually in the skin,
resulting from acute immune complex vasculitis.
●​ Arthus reaction can be experimentally produced by intracutaneous injection
of an antigen to a previously immunized animal causing immune complex
formation.
●​ Immune complexes deposited in the vessel walls, cause fibrinoid necrosis
and thrombosis leading to ischemic injury.

TYPE IV HYPERSENSITIVITY REACTION (5M):

●​ Type IV hypersensitivity reaction is mediated by T lymphocytes including
CD4+ and CD8+ T-cells.
●​ Reaction is delayed by 48–72 hours after exposure to antigen. Hence also
called delayed-type hypersensitivity (DTH).
●​ This hypersensitivity reaction is involved in several autoimmune diseases
(e.g. rheumatoid arthritis, Hashimoto's thyroiditis), pathological reactions to
environmental chemicals (e.g. poison ivy, nickel) and persistent microbes
(e.g. tuberculosis, leprosy).
CD4+ MEDIATED:

●​ Granuloma formation: Granuloma is a microscopic aggregate of epithelioid

cells, surrounded by a rim of lymphocytes. Older granulomas are enclosed by a
rim of fibroblasts and connective tissue.
 ●​ CD8+ MEDIATED:
●​ Acts through 2 mechanisms:
●​ Perforin - Granzyme system: CTLs have lysosome-like granules containing
preformed mediators, perforins and granzymes.
●​ Perforin is a transmembrane pore-forming molecule, which allows the entry
of granzymes into the cytoplasm of target cells.
●​ Granzymes are proteases, which cleave and activate cellular caspases
(effector pathway of apoptosis).
●​ Fas ligand pathway: Activated CTLs also express Fas ligand (a molecule with
homology to TNF), which can bind to Fas expressed on target cells and cause
apoptosis by extrinsic pathway.

SYSTEMIC LUPUS ERYTHEMATOSUS (5m):

●​ Systemic lupus erythematosus (SLE) is a chronic autoimmune disease having
following characteristics:
●​ Protean manifestation and variable behavior.
●​ Remission and relapses.
●​ Multisystemic involvement: Mainly affects skin, kidneys, joints, serous
membranes and heart.
●​ Broad spectrum of autoantibodies.
ETIOLOGY:
 GENETIC FACTORS:
●​ Family association: Family members of SLE patients have an increased risk of
SLE.
●​ High rate of concordance (>25%) in monozygotic twins when compared with
dizygotic twins (1–3%).
●​ HLA association: Risk is more with HLA-DR2 or HLA DR3.
●​ Other genetic factors: Genetic deficiencies of early complement
components (such as C2, C4 or C1q).
ENVIRONMENTAL FACTORS:
●​ Ultraviolet (UV) radiation: Exposure to sunlight exacerbates the lesions of
the disease.
●​ Cigarette smoking
●​ Sex hormones: SLE is 10 times greater during the reproductive period (17
through 55 years) in women than in men.
●​ Drugs: Examples include hydralazine, procainamide, isoniazid and
D-penicillamine can produce SLE–like disease.
IMMUNOLOGICAL ABNORMALITIES:
●​ Type I interferons: INF- α is a type I interferon produced by plasmacytoid
dendritic cells and large amounts are produced in SLE. It may indirectly
produce autoantibodies.
●​ Toll-like receptor (TLR) signals: In SLE, nuclear DNA and RNA within the
immune complexes may activate B lymphocytes by engaging with TLRs.
●​ Failure of B-cell tolerance: Occurs due to defects in both central (i.e. bone
marrow) and peripheral tolerance → higher autoreactive B-cells.
PATHOGENESIS (Fig)
AUTOANTIBODIES IN SLE (3m):
●​ SLE is characterized by the production of several diverse autoantibodies.
●​ Importance of autoantibodies: (1) diagnosis and management of patients
with SLE and (2) responsible for pathogenesis of tissue damage.
●​ ANTINUCLEAR ANTIBODIES (ANA):
●​ They are directed against various nuclear antigens including DNA, RNA and
proteins (all together called generic ANAs).
●​ Types of ANA:

●​ Autoantibodies against blood cells, namely (1) red cells, (2) platelets, (3)
neutrophils and (4) lymphocytes.
●​ Antiphospholipid antibodies (aPL) are detected in 40–50% of SLE patients
but they are not specific for SLE.
●​ Antiphospholipid antibody includes lupus anticoagulant antibody,
anticardiolipin antibody and anti-β2 glycoprotein antibody.
●​ These autoantibodies can lead to increased venous and arterial thrombosis
and thrombocytopenia → recurrent spontaneous miscarriages and focal
cerebral or ocular ischemia.
●​ Anticardiolipin antibodies in SLE may produce false +ve VDRL test for
syphilis.
LE CELLS (5M):
●​ It is related to LE bodies and can be demonstrated in vitro.
●​ The nuclei of damaged cells react with ANAs to form a homogenous
denatured nuclear material.
●​ The LE cell is any phagocytic leukocyte (blood neutrophil or macrophage)
that has engulfed this denatured nucleus of an injured cell.
●​ With the advent of new techniques for detection of ANAs, this test is of only
historical interest.

​ ​ ​ ​
●​ Interpretation: LE cell is positive in about 70% of SLE. It may also be
positive in conditions such as rheumatoid arthritis, lupoid hepatitis.
CLINICAL FEATURES AND LAB DIAGNOSIS:
●​ SLE is a multisystem disease with variable clinical presentation.
●​ Age: It usually occurs in young women between 20 and 30 years.
●​ Sex: It predominantly affects women.
●​ Onset: Acute or insidious with fever
●​ Typical presentation: Butterfly rash over the face, fever, pain in one or more
peripheral joints, pleuritic chest pain and photosensitivity.
●​ SLE patients are susceptible to infections.
●​ LAB FINDINGS:
 ●​ Tests for autoantibodies : By Indirect Immunofluorescence assay (IFA) for
ANA.
●​ Multiplex flow cytometry immunoassay
●​ ELISA (for smith antigen).
●​ Standard tests for diagnosis: Includes complete blood count, platelet count,
ESR (raised) and urinalysis.
●​ Tests for following disease course:
●​ Renal involvement: Urinalysis
●​ Hematologic changes: Hemoglobin levels (anemia) or platelet counts
(thrombocytopenia) and ESR.
●​ Serum levels of creatinine or albumin
●​ Decreased complement component levels in serum such as C3 and C4

TRANSPLANT REJECTION (5M):

●​ Transplantation is a procedure for replacement of irreparably damaged tissue
or organ to restore their lost function.
MECHANISMS:
T-CELL MEDIATED:
●​ Direct pathway: During this pathway MHC antigens on graft APCs are
directly recognized by host CD8+ cytotoxic cells (class I MHC) and CD4+
helper T-cell (class II MHC), followed by their activation.
●​ Consequences: Killing of graft cells by CTLs: Host CD8+ T-cells which
recognize class I MHC antigen on the APCs in the graft differentiate into
cytotoxic T-cells (CTLs) kills parenchymal and endothelial cells in the graft
tissue.
●​ Inflammatory reaction: Host CD4+ helper T-cells which recognize class II
MHC antigens proliferate produce cytokines (e.g. INF-ɣ) stimulate delayed
type hypersensitivity inflammatory reaction.
●​ Indirect pathway: MHC molecules and antigen of the graft cell may be taken
up and processed by the host’s APCs.
●​ Recognition of APCs with graft antigen by the host’s CD4+ T-cells activates
CD4+ T-cells. This causes:
 ●​ Stimulation of B lymphocytes which transform into plasma cells and
produce alloantibodies.
●​ Stimulation of delayed hypersensitivity reaction in the tissue and blood
vessel by producing cytokines.
ANTIBODY MEDIATED:
●​ Antibodies produced against alloantigens in the graft also mediate rejection
and this is called humoral rejection.
●​ It can develop in two forms: Hyperacute rejection and Acute humoral
rejection sometimes referred to as rejection vasculitis.

GRAFT VS HOST DISEASE (GVHD):

●​ It is the major complication that follows allogeneic HSC transplant.
●​ Three conditions are necessary for the development of GVHD:
●​ An immunocompetent graft (i.e. one containing T-cells).
●​ HLA mismatch (minor or major) between donor and recipient.
●​ An immunosuppressed recipient who cannot mount an immune response to
the graft.
●​ When immunosuppressed recipients receive normal bone marrow cells from
allogeneic donors, the immunocompetent T-cells present in the donor HSCs
recognize the recipient’s HLA antigens as foreign and react against them.
●​ Acute GVH disease: It occurs before 100 days. Affects three primary target
organs simultaneously, namely skin, gastrointestinal (GI) tract and liver.
 ●​ Chronic GVH disease: It occurs after day 100 and can affect the skin, GI tract,
liver, eyes, lungs and joints.

AIDS (5M):
●​ Acquired immunodeficiency syndrome (AIDS) is caused by the retrovirus
human immunodeficiency virus (HIV)
Characteristic features:
●​ Infection and depletion of CD4+ T lymphocytes
●​ Severe immunosuppression leads to opportunistic infections, secondary
neoplasms and neurologic manifestations.
ROUTES OF TRANSMISSION (3M):
●​ Three major routes:
●​ Sexual route: It is the main route of infection in more than 75% of cases of
HIV.
●​ Homosexual or bisexual men or heterosexual contacts
●​ HIV is present in genital fluids
●​ Viral transmission can occur in two ways: – Direct inoculation of virus or
infected cells into the blood vessels at the site of breach caused by trauma,
and– By uptake into the mucosal dendritic cells (DCs).
●​ Parenteral route: Intravenous drug abusers: Transmission occurs by sharing
of needles and syringes contaminated with HIV-containing blood.
●​ Transfusion of blood or blood components: Recipients of blood transfusion
of HIV-infected whole blood or components (e.g. platelets, plasma) was one of
the modes of transmission. Screening of donor blood and plasma for
antibodies to HIV has reduced the risk of this mode of transmission.
●​ Perinatal transmission: Major mode of transmission of AIDS in children.
●​ In utero: It is transmitted by transplacental spread.
●​ Perinatal spread: During normal vaginal delivery or child birth (intrapartum)
through an infected birth canal
●​ After birth: It is transmitted by ingestion of breast milk
STRUCTURE OF HIV:
●​ HIV-1 is spherical enveloped virus which is about 90–120 nm in diameter.
Viral core:
●​ Major capsid protein p24: This viral antigen and the antibodies against this
are used for the diagnosis of HIV infection in enzyme-linked immunosorbent
assay (ELISA).
●​ Nucleocapsid protein p7/p9
●​ Two identical copies of single stranded RNA genome
●​ Three viral enzymes: 1) Protease, 2) reverse transcriptase (RNA-dependent
DNA polymerase), and 3) integrase.
Nucleocapsid:
●​ The viral core is surrounded by a matrix protein p24 and p17, which lies
underneath the lipid envelope of the virion.
Lipid envelope:
●​ The virus contains a lipoprotein enve lope, which consist of lipid derived from
the host cell and two viral glycoproteins.
●​ These glycoproteins are: 1) gp120, project as a knob-like spikes on the
surface and 2) gp41, anchoring transmembrane pedicle.
HIV GENOME:
●​ Standard genes: HIV-1 RNA genome contains three standard retroviral genes,
which are typical of retroviruses. These include: gag, pol, and env genes.
●​ Accessory genes: HIV contains accessory genes: E.g. tat, rev, vif, nef, vpr, and
vpu. They regulate the synthesis and assembly of infectious viral particles
LIFE CYCLE:
●​ Infection of cells by HIV:
​
●​ Integration of the proviral DNA into the genome of the host cell: After the
internalization of the virus core, the RNA genome of the virus undergoes
reverse transcription → leading to the synthesis of double-stranded
complementary DNA (cDNA/proviral DNA).
●​ In quiescent T-cells, HIV cDNA may remain as a linear episomal form in
the cytoplasm of infected cell.
●​ In dividing T-cells, HIV cDNA enters the nucleus, and becomes integrated
into the genome.
●​ Viral replication: Latent infection: During this, the provirus remains silent
for months or years.
●​ Productive infection: In this, the proviral DNA is transcribed leading to viral
replication → formation of complete viral particles.
●​ Production and release of infectious virus: The complete virus particle
formed, buds from the cell membrane and release new infectious virus.
PROGRESSION OF HIV INFECTION:
ACUTE INFECTION:
●​ Primary infection: HIV first infects memory CD4+ T-cells (express CCR5),
which are present in the mucosal lymphoid tissue.
●​ Spread to lymphoid tissue: Dendritic cells at the primary site of infection
capture the virus and migrate to lymphoid tissue such as lymph nodes and
spleen.
●​ Acute HIV syndrome: Virus replicates and causes viremia, accompanied by
acute HIV syndrome (nonspecific signs and symptoms similar to many viral
diseases).
●​ Host immune response against HIV: Virus spreads throughout the body and
infects helper T-cells, macrophages and DCs in the peripheral lymphoid
tissues. Host produces anti-HIV antibodies and HIV specific cytotoxic
T-cells.
CHRONIC INFECTION:
●​ Minimal/no symptoms: In this phase, virus continuously replicates in the
lymph nodes and spleen. The host immune response can handle most
infections with opportunistic microbes
●​ Progressive decrease of CD4+ T-cells: There is continuous destruction of
CD4+ T-cells in the lymphoid tissue.
●​ Mechanism of T-cell depletion: Direct killing of T-cells by the virus is the
major cause.
NATURAL HISTORY OF HIV INFECTION:
●​ Early acute phase: It may present as an acute (refer above), usually self-limited
nonspecific illness. These symptoms include sore throat, myalgias, fever,
weight loss and fatigue.
●​ Middle chronic phase: It may have few or no clinical manifestations and is
called the clinical latency period.
●​ Final crisis phase: It is the final phase of HIV with progression to AIDS. It
presents with fever, weight loss, diarrhea, generalized lymphadenopathy,
multiple opportunistic infections, neurologic disease and secondary
neoplasms.
DIAGNOSIS:
●​ ELISA: Detects antibodies against viral proteins.
●​ Western blot: Most specific or the confirmatory test
●​ Direct detection of viral infection: p24 antigen capture assay. Reverse
transcriptase polymerase chain reaction (RT-PCR). DNA-PCR. Culture of
virus from the monocytes and CD4+T cells.
AMYLOIDOSIS (10 M):
●​ Definition: Amyloid is a pathologic fibrillar protein deposited in the
extracellular space in various tissues and organs of the body in a variety of
clinical conditions.
GENERAL FEATURES:
●​ Associated with number of inherited and inflammatory disorders.
●​ Extracellular deposits cause structural and functional damage to involved
tissue.
●​ Usually a systemic (sometimes localized) disease.
PHYSICAL NATURE OF AMYLOID:
●​ All types of amyloid are composed of nonbranching fibrils of 7–10 nm
diameter.
●​ Each fibril consists of β -pleated sheet polypeptide chains
●​ Congo red dye binds to these fibrils and produces classic apple-green
birefringence
CHEMICAL NATURE OF AMYLOID:
Major forms:
●​ AL form (Amyloid Light chain):Consists of complete immunoglobulin (Ig)
light chains or the amino-terminal fragments of light chains, or both.
●​ Seen in plasma cell tumors.
●​ AA (amyloid-associated) protein: Non-immunoglobulin.
●​ Derived from a larger precursor in the serum called SAA (serum
amyloid-associated) protein synthesized by the liver.
●​ Associated with chronic inflammation (called as secondary amyloidosis).
●​ Aβ protein: Derived from transmembrane glycoprotein called amyloid
precursor protein (APP).
●​ Found in the cerebral lesions of Alzheimer disease.
Minor forms:
●​ Transthyretin (TTR): It is a normal serum protein that transports thyroxine
and retinol.
●​ Mutations in gene encoding TTR alter its structure → misfolds.
●​ Found in a familial amyloid polyneuropathies, heart of aged individuals
●​ β2 microglobulin: Amyloid fibril subunit namely Aβ2m is derived from
β2-microglobulin and is found in amyloidosis of patients on long-term
hemodialysis.
PATHOGENESIS: (fig)
CLASSIFICATION OF AMYLOIDOSIS:
Systemic amyloidosis:
●​ Primary amyloidosis:
●​ Immunocyte dyscrasias with amyloidosis: Usually systemic and is of AL
type.
●​ Multiple myeloma:
●​ 5–15% of patients develop amyloidosis
●​ Tumor synthesize abnormal amounts of a single specific Ig (monoclonal
gammopathy) appears as an M (myeloma) protein spike on serum
electrophoresis.
​ ​
●​ Tumor also synthesizes the light chains (known as Bence-Jones protein) of
either the or the type which are found in the serum.
●​ All the myeloma patients with amyloidosis invariably have Bence-Jones
proteins in the serum or urine, or both.
●​ Primary amyloidosis without plasma cell dyscrasia: Majority of patients
with AL amyloid do not have multiple myeloma or any other overt plasma cell
neoplasm.
●​ But almost all these patients have monoclonal immunoglobulins or free light
chains, or both, in the serum or urine.
Secondary amyloidosis:
●​ Systemic in distribution and is of AA type.
●​ Chronic inflammatory conditions: E.g. tuberculosis, bronchiectasis and
chronic osteomyelitis.
●​ Autoimmune states: E.g. rheumatoid arthritis, ankylosing spondylitis,
inflammatory bowel disease
●​ Non-immunocyte–derived tumors: E.g. renal cell carcinoma and Hodgkin
lymphoma.
●​ Hemodialysis associated amyloidosis:
 Patients with chronic renal failure on long-term hemodialysis have high levels
of β2-microglobulin in the serum which deposits as Aβ2.
Familial amyloidosis:
●​ Familial Mediterranean Fever: Autosomal recessive disorder
●​ Characterized by recurrent attacks of fever accompanied with inflammation
of serosal surfaces. Gene codes for pyrin.
●​ The amyloid fibril proteins are of AA type probably produced due to recurrent
bouts of inflammation.
●​ Familal Amyloidotic neuropathy: It is characterized by deposition of amyloid
in peripheral and autonomic nerves and the fibrils are made up of mutant
TTRs.
Localised amyloidosis:
●​ Amyloid deposits are limited to a single organ (e.g. heart) or tissue.
●​ Either grossly visible as nodular masses or detected only by microscopic
examination.
●​ Sites: Lung, larynx, skin, urinary bladder and tongue
STAINING PROPERTIES OF AMYLOID (3m):
●​ Congo red stain: It is the special stain used for the diagnosis of amyloidosis.
Amyloid stains pink or red with the Congo red dye under ordinary light.
●​ But more specific when viewed under polarizing microscope; amyloid gives
apple-green birefringence.
●​ Van Gieson stains: It takes up khaki color
●​ Alcian blue: It imparts blue color to glycosaminoglycans in amyloid.
●​ Periodic acid Schiff reaction (PAS): It stains pink
●​ Methyl violet and cresyl violet: These metachromatic stains give rose pink
color
●​ Immunohistochemical staining: It can distinguish AA, AL and ATTR types.
MORPHOLOGY OF MAJOR ORGANS INVOLVED:
KIDNEY:
●​ Gross: It may be of normal size and color during early stages. In advanced
stages, it may be shrunken due to ischemia, which is caused by vascular
narrowing.
●​ Microscopy: Most commonly renal amyloid is of light-chain (AL) or AA type.
●​ Glomeruli: It is the main site of amyloid deposition
●​ First, focal deposits within the mesangial matrix, accompanied by diffuse or
nodular thickening of the glomerular basement membranes.
●​ Later, both the mesangial and basement membrane deposits cause capillary
narrowing and obliteration of the capillary lumen.
●​ Amyloid may also be deposited in the peritubular interstitial tissue, arteries
and arterioles.

SPLEEN:
●​ Gross: It may be normal in size or may cause moderate to marked
splenomegaly (200–800 g).
●​ Sago spleen: Amyloid deposits are limited to the splenic follicles, which
grossly appear like tapioca/sago granule; hence known as sago spleen.
Microscopically, the amyloid is deposited in the wall of arterioles in the white
pulp.
●​ Lardaceous spleen: Amyloid is deposited in the walls of the splenic sinuses
and connective tissue framework in the red pulp.
●​ Fusion of the early deposits give rise to large, map-like areas of reddish color
on the cut surface. This resembles pig fat (lardaceous) and hence called
lardaceous spleen. Microscopically, it shows amyloid deposits in the wall of
the sinuses.
●​ Light microscopy: These deposits appear homogeneous pink, which when
stained with Congo red and viewed under polarizing microscope, give rise to
characteristic green birefringence.
 CLINICAL FEATURES AND DIAGNOSIS:
●​ Amyloidosis may not produce any clinical manifestations, or it may produce
symptoms related to the sites or organs affected.
●​ Renal involvement: It gives rise to proteinuria sometimes massive enough to
cause nephrotic syndrome.
●​ Cardiac amyloidosis: It may present as congestive heart failure, conduction
disturbances and arrhythmias.
●​ Gastrointestinal amyloidosis: It may be asymptomatic, or present as
malabsorption, diarrhea and digestive disturbances.
●​ Diagnosis: It depends on the histologic demonstration of amyloid deposits in
tissues.
●​ Biopsy: The most common sites are the kidney, rectum or gingival tissues
●​ In immunocyte-associated amyloidosis, serum and urine protein
electrophoresis and immunoelectrophoresis should be done.
●​ Scintigraphy with radiolabeled serum amyloid P (SAP) component is a rapid
and specific test.

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