HYPERSENSITIVITY REACTIONS

HYPERSENSITIVITY REACTIONS

Innocous materials can cause hypersensitivity in certain

individuals

unwanted inflammationdamaged cells and tissues

Non-proper reaction of the immune system to foreign substances

Mainly harmless substances – after second or multiple times

TYPES OF HYPERSENSITIVITY REACTIONS

Type I„immediate”

Type II Type III Type IV„delayed”

Antibody mediatedT cell

mediatedspecific IgE cell surface antigen

specifically reacting with antibody

aspecifically

deposited soluble immuncomplex

MHC restricted T cell activation

mediators produced by mast cells

FcR mediated inflammation, inhibition of cell functions

FcR mediated complement activation, inflammation

cytokines, cytotoxicity

„classical allergy” newborn haemolytic anaemia, penicillin sensitivity, M. gravis

Serum sickness, SLE Contact dermatitis

mostly appear together with autoimmune diseases

ANTIBODY MEDIATED HYPERSENSITIVITY REACTIONS

HYPERSENSITIVITY REACTIONS

TYPE I ALLERGY

TYPE II TYPE III

Soluble antigenCell surface or matrix

antigen Soluble antigen

IgEMast cell

IgG – immune complexFcγR+ cells

NK, macrophage

IgG – immune complexFcγR+ cells

Complement

Hay feverAsthma

Systemic anaphylaxis

Certain drug allergies(penicillin)

Serum sicknessArthus reaction

TYPE I HYPERSENSITIVITY REACTION

ALLERGY

DIFFERENCES OF IMMUNE RESPONSES INDUCED BY ALLERGENS AND PATHOGENS

• ALLERGEN– Non deviding– Act together with other

environmental effects

• DANGER SIGNAL– Ni, Mn, Co, Sn chlorides

• Ion channel inhibitors• Energy homeostasis

• DC/TISSUE DEMAGE– TNCB, DNCB– Der p1 – cisztein proteáz

• papain – meat processing • CD25, CD23 cleavage• Structure of epithelial „tight

junction” is demaged

– Bee bite (toxin)– Substilyzin – washing powder

• PATHOGEN– Deviving– Escape mechanism

• DANGER SIGNAL– Microbial DNS, CpG-ODN– dsRNS IFN– LPS (Gram-), PG (Gram+)– HSP– Inflammatory cytokin

• TNF-, IL-1

• DC/TISSUE DEMAGE– Activation of innate immunity– Inflammation,

neurotransmitters (VIP)

allergy response

Th2

B cell

Th2

DC

ALLERGENS USUALLY ENTER THE BODY VIA MUCOSAL SURFACES AND THEY ARE PRESENT AT A LOW DOSE

antigen presentation

T cell priming and polarization

soluble proteins on te surface of small particles (pollen, dust mite „drops”) small molecular weight, soluble trans-mucosal entry, enzymatic activity low dose (ragweed: 1µg/year)

nyá lka -há rtya

ALLE RG ÉN

CD40L

Th2

DC

C 40D

IgE

BMHCII B

C 40D

CD40L

Th2

IL-4

IL-4

IL-10

Mucosa

Allergen

Mechanism of the initiation of Th2 response

CD4+ T

chromosome 11q

FcεRβ chain gene

chromosome 11q

IL-3-5 IL-9, IL-13 GMCSF

HLAII DRB1*015

allergy Inproper

immunregulation Th1/Th2 inbalance

regulation of IgE synthesis

immunodeficiency

high eosinophil counts

Environmental factors

lack of tolerance

GENETIC/ENVIRONMENTAL PREDISPOSITION TO ALLERGY

Genetic factors

Mast cell degranulation, wheel and flare reaction

Ragweed

Saline

Histamine

IgE

Fc RIea

bg

foszfatidil-kolin

PGD2

PGD2

PAF

LTC4

PIP2

IP3

DAG

Ca2+Ca2+

Ca2+foszfolipid

PKC

LTC4

LTD4LTE4

LYSO-PC arachidonsav

szekretorosgranulum

mediátorokcitokinekIL-3, IL-4,IL-5, IL-6

TNFa

endoplazmásretikulum

PI-PLCg

Ca2+

Ca2+

szekréció

MAP-kináz

proteinek(miozin-

könnyűlánc)foszforilációja

PLA2

ciklooxigenáz

5-lipoxigenáz

ITAM

ITAM

ITAM

ITAM

ITA

M

ITA

M

citokin génektranszkripciója

SykLyn

NFATAP-1 NF- Bk

MAST CELL RESPONSE TO SURFACE FcRεI CROSSLINKING

EARLY MEDIATORS

Biogenic amins – histamin

Enzymes – triptase, chymase, carboxypeptidase

LATE MEDIATORS

The effect of mast cell degranulation varies with the tissue exposed to allergen

Systemic anaphylaxis is caused by allergens that reach the blood stream

Types of IgE-derived allergic response

SYNDROME ALLERGENS ROUTE OF ENTRY RESPONSE

systemic anaphylaxis

drugsanti-serum

peanuts

intravenousperoral

edema, increased vascular permeabilitytracheal occlusion

circulatory collapse, death

acuteurticaria

bug biteallergy test

subcutan local increase in blood flow and vascular

permeability

allergicrhynitis

pollendust mite

drops

inhaled irritation and edema of nasal mucosa

airway inflammation

asthma animal furpollen

dust mite drops

inhaled bronchial constriction, increased mucus

production

food allergy nut, peanuts,fish, shellfish

milk, eggs

peroral vomiting, diarrheapruritis (itching)urticaria (hives)

anaphylaxia (rare)

Short/Common ragweed (Ambrosia artemisiifolia)

Short/Common ragweed (Ambrosia artemisiifolia) Mugwort (Artemisia vulgaris)

Green leaf back White leaf back

Mugwort (Artemisia vulgaris)

Mugwort (Artemisia vulgaris) – ?

Wormwood (Arthemisia absinthium) – Absinthe (thujone: max 35 mg/l)

Type II hypersensitivityIgG tpye antibodies bound to the cell surface or to tissue

antigens

• cells expressing the antigen become sensitive to complement mediated lysis or to opsonized phagocytosis

• frustrated phagocytosiss tissue demage

• the antibody inhibits or stimulates target cell function – no tissue damage (e.g. M. gravis – receptor blocker

antibodies)

HYPERSENSITIVITY REACTIONS INDUCED BY

IMMUNE COMPLEXES

TYPES II and III

MECHANISMS OF TYPE II HYPERSENSITIVITY REACTIONS

Hemolytic anemia of newbornsErythroblastosis fetalis

Drug induced Hemolytic anemiaTrombocytopeniaAgranulocytosisPenicillin-based antibiotics Anti-arythmic quinidin

Goodpasture syndrome (type IV collagen)Pemphigus vulgaris(desmosomal antigens)Damage of epidermal and mucosal junctions, acantholysis

Killing of target cell by effector-macrophage orNK-cell

Killing of targetcell by complement-mediated lysis

complement activation

IgG

IgG

Receptor-specific autoantibodyinterferes withsignal transduction

NKMf

C '

ADCC

Healthy cell Drug-modified cell surface protein

Th

B

IgG type antibodies

DEVELOPMENT OF DRUG SENSITIVITY

The tissue, which can not be

phagocytosed, is damaged

Internal or absorbed antigen

(drug)

FcR

C3R

C3b C3b

C3b

C3b C3b C3b

FRUSTRATED PHAGOCYTOSIS MEDIATED BY IgG TYPE ANTIBODIES

Binding Opsonization Internalization Enzyme release

Opsonized surface Binding Frustrated Enzyme release phagocytosis

Examples - Type II hypersensitivity

Newborn haemolytic anaemiaTransfusion reactionHyperacut allograft rejection

Drug-derived • Haemolitic anaemia• Thrombocytopenia• Agranulocitosis

• Penicillin-based antibiotics• Anti-arithmic quinidin

Goodpasture syndrome (kidney, membrane basalis, collagen type IV)

Myasthaenia gravis (anti-acetyl-choline receptor antibodies)

Basedow-disease (anti-TSH-receptor antibodies)

Pemphigus vulgaris (mucosal bubbles) against desmosomal antigens, interruption of epidermal and mucosal connections, acantolysis (desintegration into single cells)

TYPE III HYPERSENSITIVITY

Antibodies binding to soluble antigensSmall circulating immune complexes

Depends on:Size of immune complexes

Antigen-antibody ratio Affinity of antibodyIsotype of antibody

PATHOGENICITY OF IMMUNE COMPLEXES

• Pathogenic immune complexes – Formed in the blood and than are deposited in tissues – Formed in situ at the site of antigen localization

• Mechanisms of tissue demage is independent on the site of deposition• Steps of tissue demage

– Formation immune complexes in the blood – Deposition depends on the size, composition and cytophylic properties of the antibody

(IgM, IgG, IgA)– FcγRIII has a pivotal role – expressed by basophylic granulocytes, NK cells– Permeability of endothelium – Tissue demage

• Increased permeability of blood vessels • Reqruitment of neutrophils – enzymes, chemoattractans, dilatators, prostaglandins• fibrosis

• Consequences of tissue demage depends on the site of deposition – Arthus reaction – local reaction in skin– Infectious diseases – morbilli – erythema, vasculitis– Acute serum disease – 7 – 10 days

• Polyclonal antibodies against snake venom produced in horses (anti-streptococcal)• Immune suppresszive anti-lymphocyte globulin • Bacterial trombolytic streptokinase – treatment of miocardial infarction• Subacute bacterial endocarditis – pathogens are not eliminated• Chronic viral hepatitis

– SLE – small vessels, kidney, joints, skin, heart, serosal surfaces

THE PROCESS OF TISSUE DAMAGE CAUSED BY IMMUNE COMPLEXES

Immune complexes activate the complement system, neutrophils, bazophil granulocytes and thrombocytes

Blood vessel wall

permeability

Frustrated phagocytosis

Antig e n

Antib o d y

Va so a c tivea m ine s

Ba so p hilg ra nulo c yte

Thro m b o c yte s

PM NC he m o ta xis

Im m une c o m p le x

C om p le m e nt-a c tiva tion(C 3a , C 5a )

De p ositio n

End othe liumBa sa l m e m b ra neVe sse l wa ll

C '

C '

Arthus-reaction• Localized Type III hypersensitivity

• Local vasculitis develops as a result of immune complex deposition

• Inhaled antigens (fungi, animal feces) may induce similar reaction in the lung

• IgG type antibody

• ‘Farmer lung’ and ‘piegeon breeder lung’

Facial, malar "butterfly" rash with characteristic shape across the cheeks. Discoid lupus erythematosus (DLE) involves mainly the skin, it is relatively benign compared to systemic lupus erythematosus (SLE). In either case, sunlight exposure accentuates this erythematous rash. A small number (5 to 10%) of DLE patients go on to develop SLE (usually the DLE patients with a positive ANA).

                                 

Here is a more severe inflammatory skin infiltrate in the upper dermis of a patient with SLE in which the basal layer is undergoing vacuolization and dissolution, and there is purpura with RBC's in the upper dermis (which are the reason for the rash).

MANIFESTATION OF TYPE III HYPERSENSITIVITY IN SLE

When immunofluorescence staining with an antibody to complement or immunoglobulin is performed, a brightly fluorescent signal staining the dermal epidermal junction is visable indicating immune complex deposition.

Immunofluorescence staining pattern with antibody to IgG staining immune complexes at the dermal-epidermal junction. If such a pattern is seen only in skin involved by a rash, then the diagnosis is probably DLE, but if this pattern appears even in skin uninvolved by a rash, then the diagnosis is SLE.

DEPOSITION OF IMMUNE COMPLEXES IN THE SKIN OF SLE PATIENTS

One of the feared complications of the rheumatic diseases is renal failure. This is most likely to occur in SLE. Here is a glomerulus in which the capillary loops are markedly pink and thickened such that capillary lumens are hard to see. This is lupus nephritis.

Here is a glomerulus with thickened pink capillary loops, the so-called "wire loops", in a patient with lupus nephritis. The surrounding renal tubules are unremarkable.

RENAL FAILURE IN IMMUNECOMPLEX DISEASES

This is the so-called "rim" pattern that is more characteristic of SLE.

This is the so-called "speckled" pattern of staining which is more characteristic of the presence of autoantibodies to extractable nuclear antigens, particularly ribonucleoprotein. This pattern is not very specific, but may be seen with an entity called "mixed connective tissue disease" which is a mix between SLE, scleroderma, and polymyositis, but without serious renal or pulmonary disease. The autoimmune diseases are very hard to classify, even for the experts.

This is the so-called "nucleolar pattern" of staining in which the bright fluorescence is seen within the nucleoli of the Hep2 cells. This pattern is more suggestive of progressive systemic sclerosis.

ANA

Anti -nuclear antibody

TYPE IV HYPERSENSITIVITY REACTION

T CELL MEDIATED PROCESS

MACROPHAGES ARE INVOLVED

Type IV hypersensitivity reaction

Chemokines, cytokines,cytotoxins

Delayed-type (TYPE IV) HypersensitivityDelayed-type (TYPE IV) Hypersensitivity

Delayed-type (Type IV) HypersensitivityDelayed-type (Type IV) Hypersensitivity

Delayed-type hypersensitivity (DTH) (e.g., tuberculin skin test)

TH1 from a previous immunization (memory)

Tuberculin skin test

Ag = antigen

Mycobacterium protein (PPD) Introduction of Ag

Chemical Mediators of DTH

*a contact-sensitizing agent is usually a small molecule that penetrates the skin then binds to self-proteins, making them “look” foreign

Contact Dermatitis

Poison ivy Anacardiaceae (family), Toxicodendron (genus)Toxicodendron radicans or Rhus toxicodendron

Delayed-type hypersensitivity is mediated by T cells

Delayed-type Hypersensitivity

A positive tuberculin skin test is a DTH reaction

PRACTICAL ASPECTS OF TRANSPLANTATION IMMUNOLOGY

• Hyperacut rejection

Causes: previous immunization against alloantigens, preformed anti-HLA-antibodies, blood group incompatibility, xenotransplantation

antibodies bound to endothel

activation of the complement systemthrombosis in venules

vascularis necrosis

Therapy resistent

• REJECTION• HLA-A, B, C, DR, DQ, DP, minor

histocompatibility antigens

• foreign MHC-antigens recognized by T cells

Direct: self T cells - donor APCs CD8+ T cells

Indirect: self APC presents donor MHC-derived peptidesCD4+ T cells

inflammatory cytokine release

Transplantation reactions

HLA typingHLA typing

- used for transplantations Most important is the most polymorphic HLA-B and HLA-DR, HLA-C does not matter)

- diagnostical value Connections between the HLA alleles and diseases

MHC I: HLA-A, HLA-B, HLA-CMHC II: HLA-DP, HLA-DQ, HLA-DR

Serotyping - microcitotoxicity tests (1)Based on the serological reaction between the TARGET cells and the typing serum.Complement-mediated lysis induced by antibodies recognizing MHC I and/or MHC II cell surface molecules as antigens

There is NO reaction in the case of serotype identity(dead cells can be visualized by specific dye)

Typing sera containing antibodies to Class I and II proteins are collected from multiparous women, or individuals who had received multiple blood transfusions (immunized against multiple HLA alleles). The specificity of thes polyclonal test sera has been validated by international workshops.The procedure is carried out in Terasaki microtiter plates (with 10µl working aliquots) due to the limited quantity of typing sera. Polyclonal typing sera have been replaced by monoclonal antibodies with unlimited availability.

HLA-D (MHC II) antigens are also studied on nylon column separated B cells

Serotyping - technology

The polymorphism of HLA-D antigens could be studied by mixed lymphocyte reactions (MLR)

1. Bidirectional MLR – lymphocytes of both donors are responding2. Unidirectional MLR – lymphocyte proliferation of one donor is blocked (irradiation,

Mitomycin treatment) THE RATIO OF ALLOREACTIVE LYMPHOCYTES IS AN INDIVIDUAL IS 1 – 10 %

Microtiter plates

Serotyping have some limits: – crossreactions (HLA-B27 – HLA-B7)– there are no sera available against HLA-C because of its low immunogenicity– some subtypes cannot be discriminated

Genomic DNA based examinationsGenomic DNA based examinations

- PCR-SSP is using the PCR amplification reaction directly to detect HLA polymorphisms. Primers can be constructed specifically to complement HLA polymorphisms; if the primers bind the complementary polymorphism and amplify the gene segment, then the PCR product can be detected by standard techniques. It has been constructed an array of PCR primers complementary to the range of HLA polymorphisms

HLA-A 0201 0202 0203 …

-PCR-SSOP (sequence specific oligonucleotid probe)

The examined HLA genes are amplified by PCR with non allele specific primer pairs. The amplicons are immobilized to nitrocellulose membranes or microtiter plates and are hybridized by HLA allele specific labeled oligonucleotides.The label can be enzimatic, fluorescent or radioactive

-SBT (sequence based typing)

allotypes can be evaluated by sequencing the MHC region of the genomic DNA(minor mutations can be examined)

ref: Klinikai immunológia (II. klinikum) (OHVI 1990 szerk.: Szegedi, Gergely, Sipka, Szemere)

Stenszky Valéria: Autoimmun betegségek genetikai vonatkozásai

Diseases(autoimmune)

HLA

frequency

concerned control

SLEDR3 55 20

B8 50 20

Hydralazine(?) induced lupus erythematosus

DR4 73 32

Basedow-diseaseDR3 56 25

B8 43 20

Active chronic hepatitis DR3 55 21

Sclerosis multiplexDR2 60 30

B7 37 24

Myasthenia gravis B8 44 20

Autoimmune IgA glomerulonephritis

DR4 53 19

Type I diabetes

DR3 72 24

DR3 49 22

B8 40 21

Addison-disease (idiotopic, autoimmune)

DR3 70 20

B8 46 23

Sjörgen-syndromeDR3 70 20

B8 50 22

Coeliaca

DR3 79 22

DR7 60 15

B8 68 22

Goodpasture-syndrome DR2 88 29

IgA loss DR3 81 20

Dermatitis herpetiformisDR3 82 20

B8 75 22

De Qervain-thyreoiditis B35 70 15

Reiter-syndrome B27 79 9

Felty-syndrome DR4 95 20

Diseases HLAfrequency

concerned control

Narcolepsia DR2 100 22

Bechterew-disease B27 89 9

Adrenogenitális syndrome

salt lost

late

virilizing

Bw47 36 1

B14 57 4

B5 48 10

Psoriasis vulgaris

Cw6 56 15

B13 24 8

B17 27 8

DR7 48 23

Idiophatic haemochromatosis A3 76 28

Bechet-disease B51 50 11

Gold induced thrombocytopenia DR3 50 13

Gold induced leucopenia DR3 47 13

HLA allotypes and diseases

HLA-A A*01010101A*0214 A*0263 A*0309 A*2301 A*2428 A*2603 A*300102 A*3306 A*6824A*01010102NA*0215N A*0264 A*0310 A*2302 A*2429 A*2604 A*300201 A*3307 A*6825A*010102 A*0216 A*0265 A*0311N A*2303 A*2430 A*2605 A*300202 A*3308 A*6826A*010103 A*021701 A*0266 A*0312 A*2304 A*2431 A*2606 A*300203 A*3401 A*6827A*010104 A*021702 A*0267 A*0313 A*2305 A*2432 A*260701 A*3003 A*3402 A*6828A*0102 A*0218 A*0268 A*0314 A*2306 A*2433 A*260702 A*3004 A*3403 A*6829A*0103 A*0219 A*0269 A*0315 A*2307N A*2434 A*2608 A*3006 A*3404 A*6830A*0104N A*022001 A*0270 A*0316 A*2308N A*2435 A*2609 A*3007 A*3405 A*6831A*0106 A*022002 A*0271 A*0317 A*2309 A*2436N A*2610 A*3008 A*3406 A*6832A*0107 A*0221 A*0272 A*0318 A*2310 A*2437 A*2611N A*3009 A*3407 A*6833A*0108 A*0222 A*0273 A*0319 A*2311N A*2438 A*2612 A*3010 A*3408 A*6834A*0109 A*0224 A*027401 A*0320 A*2312 A*2439 A*2613 A*3011 A*3601 A*6835A*0110 A*0225 A*027402 A*0321N A*2313 A*2440N A*2614 A*3012 A*3602 A*6901A*0111N A*0226 A*0275 A*0322 A*2314 A*2441 A*2615 A*3013 A*3603 A*7401A*0112 A*0227 A*0276 A*0323 A*24020101A*2442 A*2616 A*3014L A*3604 A*7402A*0113 A*0228 A*0277 A*0324 A*24020102LA*2443 A*2617 A*3015 A*4301 A*7403A*0114 A*0229 A*0278 A*0325 A*240202 A*2444 A*2618 A*3016 A*6601 A*7404A*0115N A*0230 A*0279 A*110101 A*240203 A*2445N A*2619 A*3017 A*6602 A*7405A*0116N A*0231 A*0280 A*110102 A*240204 A*2446 A*2620 A*3018 A*6603 A*7406A*0117 A*0232N A*0281 A*110103 A*240205 A*2447 A*2621 A*310102 A*6604 A*7407A*0118N A*0233 A*0282N A*110104 A*240206 A*2448N A*2622 A*3102 A*6605 A*7408A*0119 A*0234 A*0283N A*110105 A*240207 A*2449 A*2623 A*3103 A*6606 A*7409A*0120 A*023501 A*0284 A*110201 A*240208 A*2450 A*2624 A*3104 A*680101 A*7410A*02010101A*023502 A*0285 A*110202 A*240209 A*2451 A*2625N A*3105 A*680102 A*7411A*02010102LA*0236 A*0286 A*1103 A*240210 A*2452 A*2626 A*3106 A*680103 A*7412NA*020102 A*0237 A*0287 A*1104 A*240211 A*2453 A*2627 A*3107 A*680104 A*8001A*020103 A*0238 A*0288N A*1105 A*240212 A*2454 A*2628 A*3108 A*680105 A*9201A*020104 A*0239 A*0289 A*1106 A*240301 A*2455 A*2629 A*3109 A*68020101A*9202A*020105 A*0240 A*0290 A*1107 A*240302 A*2456 A*2630 A*3110 A*68020102A*9203A*020106 A*0241 A*0291 A*1108 A*2404 A*2457 A*2631 A*3111 A*680301 A*9204A*020107 A*0242 A*0292 A*1109 A*2405 A*2458 A*2632 A*3112 A*680302A*020108 A*0243N A*0293 A*1110 A*2406 A*2459 A*2633 A*3113 A*6804A*020109 A*0244 A*0294N A*1111 A*2407 A*2460N A*29010101A*3114N A*6805A*020110 A*0245 A*0295 A*1112 A*2408 A*2461 A*29010102NA*3201 A*6806A*020111 A*0246 A*0296 A*1113 A*2409N A*2462 A*290201 A*3202 A*6807A*020112 A*0247 A*0297 A*1114 A*2410 A*2463 A*290202 A*3203 A*6808A*0202 A*0248 A*0299 A*1115 A*2411N A*2464 A*290203 A*3204 A*6809A*020301 A*0249 A*03010101A*1116 A*2413 A*2465 A*2903 A*3205 A*6810A*020302 A*0250 A*03010102NA*1117 A*2414 A*2466 A*2904 A*3206 A*6811NA*0204 A*0251 A*03010103A*1118 A*2415 A*250101 A*2905 A*3207 A*6812A*0205 A*0252 A*030102 A*1119 A*2417 A*250102 A*2906 A*3208 A*6813A*020601 A*0253N A*030103 A*1120 A*2418 A*2502 A*2907 A*3209 A*6814A*020602 A*0254 A*030104 A*1121N A*2419 A*2503 A*2908N A*3210 A*6815A*020603 A*0255 A*030105 A*1122 A*2420 A*2504 A*2909 A*3211Q A*6816A*0207 A*0256 A*0302 A*1123 A*2421 A*2505 A*2910 A*3212 A*6817A*0208 A*0257 A*0303N A*1124 A*2422 A*2506 A*2911 A*3213 A*6818NA*0209 A*0258 A*0304 A*1125 A*2423 A*260101 A*2912 A*3301 A*6819A*0210 A*0259 A*0305 A*1126 A*2424 A*260102 A*2913 A*330301 A*6820A*0211 A*0260 A*0306 A*1127 A*2425 A*260103 A*2914 A*330302 A*6821A*0212 A*0261 A*0307 A*1128 A*2426 A*260104 A*2915 A*3304 A*6822

HLA-A alleles described until october 2006

498

http://www.ebi.ac.uk/imgt/hla/allele.html