M.H.

H ALSHAMRY

Immunity
► Definitions :

⋆ Immunity can be defined as protection from infection , whether this is bacterial , viral , fungal or parasitic.
⋆ Immunology is the study of the immune system & it has 2 parts :
1 - Protective part " immunity " ( which should be finely tuned )
2 - Pathology part : √ Over response : will cause hypersensitivity
√ Under response : will cause immune deficiency

► Ogans : The immune system is composed of cells & molecules organized into special lymphoid tissues ,
which can be classified into :

1 - Central or Primary Lymphoid Tissues :

⋆ These are tissues in which the lymphoid precursor cells mature to a stage at which they are capable of
performing their function in response to an antigen.

⋆ Includes Bone Marrow & Thymus

2 - Peripheral or Secondary Lymphoid Tissues :
⋆ These are tissues in which antigen specific reactions occur.
⋆ Includes L.N , Spleen , Mucosa Associated Lymphoid Tissue ( MALT )
Bronchial Associated Lymphoid Tissue ( BALT )

► Characteristics :
⋆ Duality : innate & acquired immune system.
⋆ Pleiotropy : 1 molecule has ≥ 1 function e.g. immunoglobulins act as phagocytosis , antitoxin & stimulate complement.
⋆ Redundancy : 1 function done by ≥ 1 molecule e.g. receptors activation by ≥ 1 ligand.

► Types : The 2 main types are innate immunity & acquired immunity , although each has own distinctive features ( cells ,
Molecules , interferons , complements ) , they are both recently linked together by either proteins or cells :

Innate Acquired

Begin Since birth After birth

Cells Macrophages , Leukocytes ( Eosinophils , Lymphocytes ( B & T )

Basophils , Neutrophils ) , Mast cells , PMN.
Cells that link them together are NK cells & Innate Lymphoid cells

Specificity Non - specific Specific

Memory Has no memory Has memory

Molecules Defensin , Lysosomes, Lipopolysaccharide Immunoglobulins ( all five isotypes IgG , IgA , IgM , IgE , IgD )
binding protein ( LPS )
Interferons Has alpha & beta interferons ( Type 1 ) Has gamma interferons ( Type 2 )

Complement activated through MBL & alternate pathways. activated through classical pathway.

Molecules that link them together are Interferons & Complements

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B lymphocytes
► Development : they initially develop in the fetal liver till 6 weeks after birth, then they develop in the bone
marrow & in the peripheral lymphoid tissues extramedullary lymphopoiesis.

► Types :

B 1 cells B 2 cells

System Belong innate immunity Belong to acquired immunity

Produced in the fetus ( fast ) Late

Response
Responds only to simple antigens but not haptens Responds to all types of antigens

Type T - cell independent T - cell dependent

Antigen Carbohydrate Ag Protein Ag

Surface markers IgM in greater quantities than IgG IgG more than IgM

Memory No memory Has memory

► Surface markers :
1 - Surface Ig : IgM & IgD.
2 - Class II HLA : ( II DP, II DQ , II DR ).
3 - CD19 , CD20 , CD23 , CD25 , CD32 ( CD 3 negative )
4 - BCR ( B - Cell antigen Receptor ).

T lymphocytes
► Development : lymphohematopoietic progenitor cells ( LPCs ) , produced by bone marrow , migrate to
thymus develop to T lymphocytes :

⋆ They pass from cortex to subcortex to medulla then released to the blood.
⋆ At the cortex and subcortical area of the thymus gland it becomes thymocytes & gains the T cell receptor
( TCR ) & surface markers ( either CD 3 & CD 4 or CD 3 & CD 8 , see later ).
⋆ They pass through 2 killing mechanisms before being released to blood :
1 - Thymic graveyard : in which cells that fail to manufacture functioning T cell receptors are killed.
2 - Thymocytes that can survive the graveyard are then exposed to Hassall's corpuscles ( which is like a huge
library of antigens ) :
√ The T cells that react with these antigens without presence of HLA are killed ( releasing these cells to
blood can cause an autoimmune reaction )
√ The T cells that react with these antigens in presence of HLA are released to blood.
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◊ From Junqueira’s Basic Histology :
⋆ Each T cell recognizes a specific antigen when it is presented in complex with a Human Leukocyte
Antigen ( HLA) molecule by an antigen presenting cell.
⋆ This recognition is accomplished by the T cell receptors expressed on the cell surface.
⋆ T cells receptors are generated by randomly shuffled gene segments which results in a highly diverse population
of T cells - each with a unique antigen specificity. Subsequently , T cells with receptors that recognize the body's
own proteins need to be eliminated while still in the thymus.
⋆ So , during development ( shortly before birth and for a few months after birth ) the thymus makes certain
that any T lymphocytes leaving it will not react against proteins or other antigens that are present in body’s
own tissues ; otherwise , the T lymphocytes would be lethal to the person’s own body in only a few days.
⋆ The thymus selects which T lymphocytes will be released by first mixing them with virtually all the specific
“ self - antigens ” from the body’s own tissues.
⋆ If a T lymphocyte reacts , it is destroyed & phagocytized instead of being released.

► Types : according to surface markers , T cells are classified into :

A - T Helper cells ( with CD 3 & CD 4 ) which can be further subclassified according to cytokines
they secrete into TH1 & TH2 :

TH 1 TH 2

Secrete gamma interferon, IL2 Secrete IL-4

Inhibited by IL-4 Inhibited by gamma interferon

- Stimulate humoral immunity - Stimulate humoral immunity ( Stimulates B - cells into

- ( stimulates T - cells into proliferation ) - Proliferation , to induce B - cell antibody formation )

- Inhibit T Helper 2 - Inhibit T Helper 1

- Stimulate cellular immune response ( maximizes

- the killing efficacy of the macrophages)

N.B. T regulatory lymphocytes are CD 3+ , CD 4+ , & CD 25 + ve or - ve.

B - T Cytotoxic cells ( with CD 3 & CD 8 ).

► discussed some points about Bronchial Asthma :

⋆ BA can be differentiated into types , TH2 increasing type & TH2 deficient type.
⋆ ( Group 2 ) Innate Lymphoid cells ( ILCs ) are similar to TH2 cells & are responsible for respiratory
inflammation (eosinophilic allergic asthma).

⋆ Normally , allergens , after entering the airways , activate TH2 cells which produce cytokines that
stimulate B lymphocytes to produce antibodies ( IgE ) that then leads to release of bronchoconstrictors.
Over stimulation of TH2 cells is inhibited by T regulatory cells.

⋆ In atopic patients, these T regulatory cells are inhibited, so B lymphocytes activation & IgE production
are excessive causing severe bronchoconstriction & wheeze.
N.B. Inflammatory disorders of group 3 innate lymphoid cells on the other hand include obesity induced asthma.
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Clusters of Differentiation (CD)

♦ They are low molecular weight proteins present on the surface of some cells that have 2 functions :

1 - Lineage Identification : a protocol used for the identification & investigation of cell surface molecules
providing targets for immunophenotyping of cells e.g. :

⋆ CD 19 & 20 identifies B cells.

⋆ CD 3 identifies T cells.
⋆ CD 4 identifies TH cells.
⋆ CD 8 identifies TC cells.

N.B. Hematopoietic stem cells that gain CD 34 during development become myeloblastic , while those
that lose CD 34 during development become lymphoblastic.

2 - In terms of physiology :

⋆ CD molecules can act in numerous ways , often acting as receptors or ligands important to the cell.

⋆ A signal cascade is usually initiated ( transports the extracellular stimulus through the cell membrane ) ,
altering the behavior of the cell.

⋆ Some CD proteins do not play a role in cell signaling, but have other functions.

N.B. CD for humans is numbered up to 371

N.B. Antibody dependent cell mediated cytotoxicity ( ADCC ) function of CD 16 as an example of CD

signaling function :

√ CD 16 , present on macrophages & NK cells , bind ( by dynamic contraction ) FC receptors of immunoglobulins ,

as a result , a change happens in the structure of the receptor , then intracellular translocation of some enzymes
occur e.g. protein kinase C → activate tyrosine → activate signal transduction activating motives → till reach
the genes inside the nucleus which produces the killing product

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Toll Like Receptors

► Definition :

⋆ They are a class of proteins that play a key role in the innate immune system that are expressed on
the membranes of leukocytes including : macrophages , natural killer cells , T & B lymphocytes &
non - immune cells ( epithelial & endothelial cells , & fibroblasts ).

► Functions :

⋆ TLRs are locations to “ stop & check ” , they remove unwanted residuals of bacterial & virus breakdown
( pathogen associated molecular patterns ; PAMP ) ( so TLR are also called Scavenger receptors ).

⋆ They have intra & extra cellular extensions forming links between intracellular organism & IL1.

► Types :

⋆ According to their location , they are classified into :

√ Extracellular : on the surface of reticuloendothelial cells ( especially macrophages ). Include TL1 , 2 , 4 , 5 , 6.
√ Intracellular : include TL 3 , 7 , 8 , 9.

⋆ According to the specific cell ( bacteria or virus ) product that they bind , they are classified into :

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TLR Recognizes TLR Recognizes

Lipopeptides , HSP70 , PNG , HCV core ,

TLR 1 Triacyl lipoproteins / soluble factors TLR 2
Non - structural 3 protein

Zymosan , leukotriene A ( LTA ) , Diacyl

Lipopolysaccharides ( LPS )
TLR 6 Lipopeptides , Lipo - arabino - mannan ( LAM ) TLR 4
( present in gram - ve bacteria )
“ Virulence Factor of Mycobacterium TB”

TLR 5 & TLR 10 Flagellin TLR 3 Double stranded RNA

TLR 7 SsRNA ( viral RNA ) Imidazo - quinoline TLR 9 CpG containing DNA ( bacterial DNA )

◊ Nota Benes :

⋆ TLR 1 , 2 , 4 , 6 recognize bacterial lipids.

⋆ TLR 5, 10 recognize bacterial proteins.
⋆ The 70 kilodalton heat shock proteins Hsp70s ( recognized by TLR 2 ) are linked to familial Mediterranean fever.
⋆ TLR 4 binds lipopolysaccharides which is the cause of sepsis in cases of gram - negative septicemia.
⋆ Flagellin , present on flagellate bacteria and chlamydia , is a protein that works as a virulence factor.
⋆ Patients that have TLR 7 deficiency are prone to acquire fatal COVID
⋆ TLR 9 recognizes CpG which is shorthand for 5 '— C — phosphate — G — 3 ' , that is , cytosine & guanine
separated by only one phosphate group.
CpG oligodeoxynucleotides ( ODNs ) bind to & activate TLR9 ( potentiate immune responses ). More than
100 clinical trials utilizing CpG ODNs have been conducted that evaluated their utility in preventing or
treating allergy , infectious diseases , & cancer.

Toll - like receptor signaling : https://www.cellsignal.com/pathways/toll-like-receptor-signaling-pathway

⋆ According to Dr.Serag , TLR Signaling activates Enzymes known as “ Caspases ” which stimulate
the formation of TNF to destroy the infective agents
According to Various Online Papers , TLR Signaling activates Caspases which in turn activate
a pathway leading to Cell Apoptosis
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Human Leukocyte Antigen ( HLA )

► Def. : These are cell - surface proteins encoded by gene on chromosome 6.
⋆ HLA genes are highly pleomorphic ( the most pleomorphic inheritance system in humans ) , which means that they
have many different alleles ( an allele is a variant form of a given gene ) , allowing them to fine - tune the adaptive
immune system. This gene is inherited by haplotype ( co - dominant genes ).
⋆ As a result of this , each human has his own almost unique HLA on his cells.

N.B. The main difference between HLA & MHC is that the HLA is a form of MHC antigens in humans whereas the
MHC is a group of antigens that occur in other vertebrates.

► Functions :

1 - They are responsible for the regulation of the immune system in humans.
2 - If the cell is infected by a virus, the HLA system brings fragments of the virus to the surface of the
cell so that the cell can be destroyed by the immune system.
3 - They are the major cause of organ transplant rejections.
4 - They may protect against cancers.

► Types :

◊ HLA Class 1 :

⋆ Present in all nucleated cells whether immune or non - immune

⋆ Classified into A , B , C ( also G , F , E but they have no role in immunity )
⋆ Each composed of 2 peptides on its membrane alpha ( α 3 ) & β2 macroglobulin
( β2m ) which are bound to each other non covalently
⋆ The antigen binding cleft is made of α1 & α2
⋆ It acts with killer T cells ( TC cells )
⋆ They are called transplantation antigen ( related to tissue rejection ).
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So , before organ transplantation, identifying donor & recipient HLA haplotypes is a must.
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◊ From Junqueira’s Basic Histology :

⋆ Before being exposed to the cell surface , HLA class I proteins bind a wide variety of peptide fragments
representing the range of all proteins synthesized in that cell.

⋆ All nucleated cells produce & expose on their surfaces HLA class I molecules presenting such “ self - antigens ”
which T cells recognize as a signal to ignore those cells. By this same mechanism , some virally infected cells ,
cells of a transplanted organ , or cells with proteins altered by gene mutation also have HLA class I proteins
displaying peptides ( antigens ) that T cells do not recognize as “ self ” helping lead to the elimination of such cells.

◊ HLA Class 2 :

⋆ Present in immune cells only ( macrophages , B lymphocytes )

⋆ Classified into II DP , II DQ , II DR
⋆ Each composed of 2 peptides on its membrane alpha ( α1 , α2 ) & beta ( β1 , β2 )
⋆ The antigen binding cleft is made of α1 & β1
⋆ They are called immune response antigens
⋆ It acts with T helper cells

◊ HLA Class 3 :
⋆ Gene coding for common components ( e.g Complements ) & certain enzymes ( e.g Lysozymes )

◊ From Junqueira’s Basic Histology :

⋆ HLA class II proteins are synthesized & transported to the cell surface similarly but only in antigen presenting
cells ( APCs - mainly macrophages & dendritic cells ).

⋆ Before joining the cell membrane , the Golgi - derived vesicles with the HLA class II complexes first fuse with
endolysosomal vesicles containing antigens ingested by endocytosis , pinocytosis , or phagocytosis.

⋆ This allows the class II proteins to bind fragments of whatever proteins the cells had ingested , including those
from dead , infected , or abnormal cells & atypical proteins of all kinds.

⋆ At the surface of these cells, the class II complexes display the antigens from these potentially pathogenic cells ,
signaling T lymphocytes & activating their responses against sources of these antigens.

► HLA class I related diseases ( V.V.I )

Disease HLA antigen Disease HLA antigen

Acute Anterior Uveitis B 27 Chronic active hepatitis B8

Ankylosing Spondylitis B 27 Coeliac disease B8

Reiter’s disease B 27 Dermatitis herpetiformis B8

Acute lymphatic leukaemia A2 Graves’ disease B8

Behcet’s Syndrome B 5 , B 51 , B 53 Hodgkin’s disease B8

Ragweed hay-fever B7 Juvenile diabetes B8

Multiple Sclerosis A 3 , B 7 , DW 2 Myasthenia gravis A 1 , B 8 , DW 3

Addisnian adrenalitis B8 Psoriasis B7

Dermatomyositis B8 Systemic lupus erythematosus BW 15

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N.B. Behcet’s syndrome is an autoinflammatory disease ( not autoimmune ) that presents with recurrent arterial
& venous thromboses + recurrent buccal ulcerations + anterior uveitis + anal fistula :

Autoinflammation Autoimmunity

Inflammasome + ve - ve
Autoantibodies - ve + ve

Behcet’s syndrome Autoimmune pancreatitis

Examples Mikulickz Syndrome ( Enlargement of the glandular tissue
IgG4 mediated diseases
of the head & neck : Parotid , lacrimal , etc.)

Immunity Innate Acquired

Cells Neutrophils, macrophage T & B Lymphocytes
Cytokines + ve - ve
TTT Anti - cytokines. Anti - lymphocytes

► HLA class II related diseases :

⋆ Multiple sclerosis : DR2

⋆ SLE : DR2 , DR3
⋆ Diabetes mellitus ( type 1 insulin dependent ) : DR3 , DR4
( if only one of them is present , there is 50 % susceptibility , if both then it is 100 % ).

⋆ Resistant to DM : DRs
⋆ Nephrotic syndrome : DR7
⋆ Parkinsonism , Hashimoto’s , & pernicious anemia : DR5

◊ Very important :

⋆ A large case - control study of malaria in West African children shows that a human leukocyte class I antigen
( HLA - Bw53 ) & an HLA class II haplotype ( DRB1 * 1302 - DQB1 * 0501 ) , common in Western Africans but
rare in other racial groups, are independently associated with protection from severe malaria.
⋆ HLA A * 32 is associated to HIV acquisition while B * 44 & B * 53 are associated with protection
against HIV acquisition in perinatally exposed infants.

The highlight of this part of this article is :

⋆ Thus , relative resistance to Nef - mediated
downregulation by the cytoplasmic domains of
HLA - B might be a contributing factor for better
disease outcome in HLA - B + individuals with HIV

https://www.frontiersin.org/articles/10.3389/fi
mmu.2017.00832/full?fbclid=IwAR1Wdm12
MmdwmTkOgCQuEGnLwnequUapKO-
XwHY_9q5j2zh3iAe_DemhkUI
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Macrophages
♦ They are tissue resident cells that develop from peripheral blood monocytes.

⋆ They are crucial unique cells as they can produce the molecule ( enzyme ) & its opposite ( anti - enzyme )
e.g. they secrete coagulation factors and tissue plasminogen activators.
N.B. Microphages = polymorphs

♦ The name of the macrophage is acquired from the tissue it resides , as :

⋆ Macrophages of brain : Microglia. ⋆ Macrophages of bone : Osteoclasts.
⋆ Macrophages of liver : Von Kupffer cells. ⋆ Macrophages of skin : Langerhans.
⋆ Macrophages of circulation : Dendritic. ⋆ Macrophages of lung : Alveolar macrophages.
⋆ Macrophages of spleen : Red bulb macrophages.

⋆ They are controlled by T lymphocytes & according to type of activating T cell , macrophages produce certain
Properties , e.g. in granuloma , macrophages lose their phagocytic activity & turn into epithelioid cells ( secretory
Cells ) , So , in TB & HIV , organisms engulfed by the macrophages have multiple mechanisms to avoid being
destroyed , so they multiply repeatedly till the engulfing macrophage ruptures infecting other macrophages.

◊ Macrophages are classically polarized into one of four phenotypes ( M1 / M2 / TAMs / ATMs ).

◊ Each phenotype of macrophages has a relatively specific expression of some cytokines , chemokines ,
Toll - like receptors ( TLRs ) , & matrix metalloproteinases ( MMPs ) :

A - Pro - inflammatory macrophages ( M1 ) induced by LPS ( lipopolysaccharides ) / LPS plus IFN - γ

( under effect of TH1 ). M1 cells characterized by : ( V.V.I MCQ )
1 – Inos : Inducible nitric oxide synthase.
2 - IL - 1 β & IL - 6 ( & IL - 12 which is the most important neutrophils-chemotactic IL & stimulates natural
killer cells ) : they have paracrine , autocrine , & endocrine effects.
3 - TNF-α
4 - CD11c & CD80
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5 - MHC-II
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6 - CCL - 2 : chemokine ( C - C motif ) ligand 2 ( contain 2 cysteine ) which binds CCR ( chemokine receptor )
7 - CXCL - 9 & CXCL - 10 : chemokine ( C -X-C motif ) ligand (9 & 10) (contain 2 cysteine + a different amino acid X )
N.B. Chemokines : cytokines which have the ability to attract other cells against concentration
gradient ( chemotaxis ).
8 - TLR2 & TLR4

B - Anti-inflammatory macrophages ( M2 ) induced by IL - 4 / IL - 13 ( under effect of TH2 ). M2 cells characterized

By : Arg - 1, IL - 4, IL - 10 , IL - 13 , TGF - β , CD 163 , CD 204 , CD 206 , CXCR 1 , CXCR 2 ,& CCR 2.

C - In addition , macrophages can adapt special tissue microenvironments to polarize specific phenotypes
such as tumor-associated macrophages ( TAMs ) & adipose tissue macrophages ( ATMs ).
⋆ TAMs produce : IL - 10 , TGF - β , TNF - α , CD 163 , CD 204 , CXCL - 8 , CCL 2 , CCL 5 , CD 24 & CD 47
( much similar to M2 cells ).

► Functions of macrophages :
1 - Phagocytosis of foreign & dead bacteria.
2 - Antigen presenting cells.
3 - Form the epithelioid cells in tubercle granuloma ( TB ).
4 - Anti-tumor activity.
5 - Phagocytosis of microorganism
◊ Steps of a macrophage ingesting a pathogen :

A - Ingestion through phagocytosis , so microorganism becomes in cytoplasm surrounded by cell

membrane ( i.e. a phagosome is formed )
B - The fusion of lysosomes with the phagosome creates a phagolysosome ; & the pathogen is broken
down by enzymes
C - Killing through : ⋆ O2 dependent " respiratory burst " : using O2 free radicals as : H2O2 , OH , NO2
⋆ O2 independent : production of lysosomes destroys the microbe
⋆ Cationic proteins : + ve charged protein as : Arginine
6 - Secrete several products :
A - LMW mediators : Reactive O2 intermediates ( ROI ) , Reactive Nitrogen intermediates ( RNI ).
B - All components of complement
C - M1 Macrophages secrete inflammatory cytokines ( IL - 6 & IL 1 ) .
D - M2 Macrophages secrete anti - inflammatory cytokines ( IL - 10 & Transforming growth factor ß ).
E - Leukotrienes.
F - Prostaglandins.
G - Prothrombin.
H - TPA ( Tissue Plasminogen Activator ).
I - Enzymes ( Esterase & Collagenase ).
J - Anti - enzymes ( alpha - 1 - antitrypsin ).
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Macrophage Activation Syndrome ( MAS )

♦ Life threatening condition that develops as a complication of a systemic inflammatory disorder
( e.g. Systemic juvenile idiopathic arthritis , SLE , Kawasaki disease ) d.t over - activation of the
macrophages that cause cytokines storm

► Laboratory findings :

⋆ Thrombocytopenia ( ≤ 262 , 000 / µL )

⋆ Glutamic oxaloacetic transaminase ( > 59 U / L )
⋆ Leukocytopenia ( ≤ 4 , 000 / µL )
⋆ Hypofibrinogenemia ( ≤ 2.5 g / L)

► Clinical findings

⋆ Central nervous system symptoms ( seizures , coma , pain , irritability )

⋆ Hemorrhagia ( purpura , hematoma , mucosa bleeding )
⋆ Hepatomegaly

► Histopathology :

⋆ Hemophagocytosis in bone marrow ( Diagnostic )

► Diagnosis :

⋆ MAS needs at least two laboratory criteria or two clinical &/or laboratory criteria
⋆ Bone marrow puncture is necessary in uncertain cases only

► What is the difference between macrophage activation syndrome and HLH ?

⋆ MAS is classically associated with rheumatologic conditions such as systemic juvenile

idiopathic arthritis ( sJIA ) & adult - onset Still's disease ( AOSD ) [ 1 , 2 ].
⋆ Contrarily , HLH is typically associated with viral infections , malignancy & certain chemotherapies

► Can macrophage activation syndrome be cured ?

⋆ Despite aggressive treatment , long - term disease - free survival in patients with FHLH can be reached
only after stem cell transplantation.
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