Immunogenetics

Professor Varban Ganev, MD, PhD, DSc

Faculty of Medicine
Sofia University “St. Kliment Ohridski”
University Hospital Lozenetz
City Clinic Oncology Center
 Medicinal discovery,
It moves in mighty leaps,
It leapt straight past the common cold
And gave it us for keeps.

PAM AYERS
Immunity
The immune system in all its forms is our defense mechanism against the
armies of microorganisms, insects, and other infectious agents that,
numerically, dwarf the human population. Effective defense mechanisms
are absolutely essential to mankind’s survival; in order to understand the
inherited disorders of immunity, we must first understand the
fundamentals of the genetic basis of immunity.
Immune defense mechanisms can be divided into two main types: innate
immunity, which includes a number of non-specific systems that do not
require or involve prior contact with the infectious agent, and specific
acquired or adaptive immunity, which involves a tailor-made immune
response that occurs after exposure to an infectious agent. Both types can
involve either humoral immunity, which combats extracellular infections,
or cell-mediated immunity, which fights intracellular infections.
Innate Immunity
The first simple defense against infection is a mechanical barrier. The skin
func-tions most of the time as an impermeable barrier, but in addition the
acidic pH of sweat is inhibitory to bacterial growth. The membranes lining
the respiratory and gastrointestinal tracts are protected by mucus. In the
respiratory tract, further protection is provided by ciliary movement,
whereas other bodily fluids contain a variety of bactericidal agents, such as
lysozymes in tears. If an organism succeeds in invading the body, a healthy
immune system reacts immediately by recognizing the alien intruder and a
chain of response is triggered.

Cell-Mediated Innate Immunity

Phagocytosis
Two major cell types go on the offensive when a foreign microorganism
invades—macrophages and neutrophils. Macrophages are the mature form
of circulating monocytes that migrate into tissues and occur primarily
around the basement membrane of blood vessels in connective tissue, lung,
liver, and the lining of the sinusoids of the spleen and the medullary sinuses
They are believed to play a key role in the orchestration of both the innate
and adaptive responses, and can recognise invading microorganisms
through surface receptors able to distinguishing between self and pathogen.
Recognition of the foreign material leads to phagocytosis by the
macrophage, followed rapidly by neutrophils recruited from the circulation
during the inflammatory process. The activation of the macrophage
triggers the inflammatory process through the release of inflammatory
mediators. The invading organism is destroyed by fusion with intracellular
granules of the phagocyte and exposure to the action of hydrogen peroxide,
hydroxyl radicals, and nitrous oxide (Figure 13.1).
The Toll-like Receptor Pathway
A key component of cell-mediated immunity is the Toll-like receptor (TLR)
path-way. TLRs are conserved transmembrane receptors which in fruit fly
embryos play a critical role in dorsal-ventral development. However, their
mammalian homologs function in innate immune responses and microbial
recognition (in adult Droso-phila, the pathway is responsible for the
formation of antimicrobial peptides) and belong to the interleukin-1/TLR
superfamily. The superfamily has two subgroups based on the extracellular
characteristics of the receptor—i.e., whether they possess an
Figure 13.1 Phagocytosis and the pathways involved in intracellular killing
of microorganisms.
There are 10 TLRs in man, each receptor being responsible for recognition
of a specific set of pathogen-associated molecular patterns. TLR2 has been
well characterised and has an essential role in the detection of invading
pathogens, recognizing peptidoglycans and lipoproteins associated with
gram-positive bacteria, as well as a host of other microbial and endogenous
ligands. TLR2’s primary function is therefore lipoprotein-mediated
signaling, and activation of the pathway by recognition of its ligand results
in activation of the transcription factor NF-κB, which in turn results in the
increased expression of co-stimulatory molecules and inflammatory
cytokines (Figure 13.3). These cytokines help mediate migration of
dendritic cells from infected tissue to lymph nodes, where they may
encounter and activate leukocytes involved in the adaptive immune
response. The signaling pathways used by TLRs share many of the same
proteins as the interleukin-1 receptor (IL-1R) pathway (Figure 13.2).
Activation of TLR leads to recruitment of the MyD88 (this is sometimes
known as the MyD88-dependent pathway) which mediates the interaction
between IL-1R associated kinases 1 and 4 (IRAK1 and IRAK4).
Figure 13.2 The Toll-like receptor (TLR) and interleukin-1 receptor (IL-1R)
pathways, which share many of the same proteins. Activation of TLR2 and
other TLRs, via NFκB activation and gene induction, leads to dendritic cell
maturation, upregulation of expression of the major histocompatibility
complex and co-stimulatory molecu-les, and production of immuno-
stimulatory cytokines. IKK, I kappa kinase; IkB, NFκB inhibitor; IRAK, IL-
1R–associated protein kinases; MKK, MAP kinases; MyD88, adapter
molecule; TAB1, TAK1-binding protein 1; TAB2, TAK1-binding protein 2;
TAK1, transforming growth factor-β–activated kinase; TRAF6, tumor
Figure 13.3 The classic and alternative pathways of complement
activation. The main functions of complement are recruitment of
inflammatory cells, opsonization of pathogens, and killing of pathogens.
The activation of the Toll pathway has several important effects in
inducing innate immunity. These effects include the production of
cytokines and chemo-kines, including IL-1, IL-6, and TNF-α (tumor
necrosis factor-alpha), which have local effects in containing infection and
systemic effects with the generation of fever and induction of acute phase
responses, including production of C-reactive protein. One important
medical condition related to the Toll pathway is septic shock, as activation
of the Toll pathway by certain ligands induces systemic release of TNF-α.
There are also important health-related consequences that result from
TLR2 deficiency or mutation. TLR2 deficient mice are susceptible to
infection by Gram(+) bacteria as well as meningitis from Streptococcus
pneumoniae.
Extracellular Killing
Virally infected cells can be killed by large granular lymphocytes, known
as natural killer (NK) cells. These have carbohydrate-binding receptors on
their cell surface that recognize high molecular weight glycoproteins
expressed on the surface of the infected cell as a result of the virus taking
over the cellular replicative functions. NK cells play an early role in viral
infections and are activated by cytokines from macrophages.
They recognise virally infected cells through either changes in
glycoproteins or in the expression of major histocompatibility complex
(MHC) class 1 on virally infected host cells. Attachment to the infected
cells results in the release of a number of agents, which in turn results in
damage to the membrane of the infected cell, leading to cell death.

Humoral Innate Immunity

Several soluble factors are involved in innate immunity; they help to
minimize tissue injury by limiting the spread of infectious microorganisms.
These are called the acute-phase proteins and include C-reactive protein,
mannose-binding protein, and serum amyloid P component. The first two
act by facilitating the attachment of one of the components of complement,
C3b, to the surface of the microorganism, which becomes opsonized (made
ready) for adherence to phagocytes, whereas the latter binds lysosomal
enzymes to connective tissues. In addition, cells infected by virus
synthesize and secrete interferon-α and interferon-β, which have a role in
promoting the cellular response to viral infection by NK cell activation and
upregulation of the MHC class I. In addition, interferon interferes with
viral replication by reducing messenger RNA (mRNA) stability and
interfering with translation.
 Complement
The complement system is a complex of 20 or so plasma proteins that
cooperate to attack extracellular pathogens. Although the critical role of
the system is to opsonize pathogens, it also recruits inflammatory cells and
kills pathogens directly through membrane attack complexes. The
complement system can be activated through three pathways: the classical
pathway, the alternative pathway, and the mannose-binding lectin (MBL)
pathway (see Figure 13.3). Complement nomenclature, like much else in
immunology, can be confusing. Each component is designated by the letter
C, followed by a number. But they were numbered in order of their
discovery rather than the sequence of reactions. The reaction sequence is
C1, C4, C3, C5, C6, C7, C8, and C9. The product of each cleavage reaction
is designated by letters, the larger fragment being ‘b’ (b = big), and the
smaller fragment ‘a’. In the lectin pathway, MBL in the blood binds
another protein, a serine protease called MASP (MBL-associated serine
protease). When MBL binds to its target (for example, mannose on the
surface of a bacterium), the MASP protein functions like a convertase to
clip C3 into C3a and C3b. C3 is abundant in the blood, so this happens
very efficiently. The other two comple-ment pathways also converge
toward C3 convertase, which cleaves C3. C3a mediates inflammation while
The effector roles of the major complement proteins can be summarized
according to function as follows (Figure 13.4):
1. Opsonisation: C3b and C4b are opsonins that coat foreign organisms,
greatly enhancing their phagocytosis—phagocytes have receptors that
recognize complement proteins bound to pathogen.
2. Inflammation: C5a, as well as C4a and C3a, are inflammatory activators
that induce vascular permeability, and recruit and activate phagocytes.
3. Lysis: C5b binds and recruits C6 and C7, eventually forming a complex
with C8 Maturity-onset diabetes of the young C5b678—which catalyses
the polymerisation of the final component C9, forming a transmembrane
pore of ∼ 10 nm diameter, and cell lysis. This assembly is known as the
membrane attack complex (MAC).
4. Immune complex clearance: Complement has a critical role in removing
immune complexes from the circulation. The immune complex binds C4b
and C3b, which then binds to receptors on red blood cells and the
complexes are transported to the liver and spleen, where the complexes are
given up to phagocytes for destruction.
Figure 13.4 Overview of the main components and effector actions of
complement. Note that the MBL pathway involves the MBL protein,
MASP-1, MASP-2, C4, and C2. MASP acts as a C3 convertase, creating a
C3b fragment from C3. C3b attaches to the pathogen surface and binds to
receptors on phagocytes, leading to opsonization. C3b can also combine
with other proteins on the pathogen surface and form a membrane attack
There are clinical consequences relating to mutations in the genes of these
pathways. The frequency of mutations of the MBL2 gene in the general
population may be 5% to 10%. Although most individuals with MBL
deficiency from mutations and promoter polymorphisms in MBL2 are
healthy, there is an increased risk, severity, and frequency of infections
and autoimmunity. The deficiency has been reported to be particularly
common in infants with recurrent respiratory tract infection, otitis media,
and chronic diarrhea.

Specific Acquired Immunity

Many infective microorganisms have, through mutation and selective
pressures, developed strategies to overcome or evade the mechanisms
associated with innate immunity. There is a need, therefore, to be able to
generate specific acquired or adaptive immunity. This can, as with innate
immunity, be separated into both humoral and cell-mediated processes.
 Humoral Specific Acquired Immunity
The main mediators of humoral specific acquired immunity are
immunoglobulins or antibodies. Antibodies are able to recognize and bind
to surface antigens of infecting microorganisms, leading to the activation
of phagocytes and the initiation of the classic pathway of complement,
resulting in the generation of the MAC (see Figure 13.4) and availability of
other complement effector functions. Exposure to a specific antigen results
in the clonal proliferation of a small lymphocyte derived from the bone
marrow (hence ‘B’ lymphocytes), resulting in mature antibody-producing
cells or plasma cells.
Lymphocytes capable of producing antibodies express on their surface
copies of the immunoglobulin (Ig) for which they code, which acts as a
surface receptor for antigen. Binding of the antigen, in conjunction with
other MASPs, results in signal transduction leading to the clonal expansion
and production of antibody. In the first instance this results in the primary
response with production of IgM and subsequently IgG. Re-exposure to
the same antigen results in enhanced antibody levels in a shorter period of
time, known as the secondary response, reflecting what is known as
antigen-specific immunological memory.
 Immunoglobulins
The immunoglobulins, or antibodies, are one of the major classes of serum
protein. Their function, both in the recognition of antigenic variability and
in effector activities, was initially revealed by protein studies of their
structure, and later by DNA studies.

Immunoglobulin structure
Papaine, a proteolytic enzyme, splits the immunoglobulin molecule into
three fragments. Two of the fragments are similar, each containing an
antibody site capable of combining with a specific antigen and therefore
referred to as the antigen-binding fragment or Fab. The third fragment
can be crystalized and was therefore called Fc. The Fc fragment
determines the secondary biological functions of antibody molecules,
binding complement and Fc receptors on a number of different cell types
involved in the immune response. The immuno-globulin molecule is made
up of four polypeptide chains—two ‘light’ (L) and two ‘heavy’ (H)—of
approximately 220 and 440 amino acids in length, respectively. They are
held together in a Y-shape by disulfide bonds and non-covalent inter-
actions. Each Fab fragment is composed of L chains linked to the amino-
terminal portion of the H chains, whereas each Fc fragment is composed
Figure 13.5 Model of antibody molecule structure.
 Immunoglobulin isotypes,
subclasses, and idiotypes
There are five different types of heavy chain, designated respectively as γ,
µ, α, δ, and ε, one each for the five major antibody classes—the isotypes:
IgG, IgM, IgA, IgD, and IgE, respectively. The L chains are of two types—
kappa (κ) or lambda (λ), and these occur in all five classes of antibody, but
only one type occurs in each individual antibody. Thus, the molecular
formula for IgG is λ2γ2 or κ2γ2. The characteristics of the various classes
of antibody are outlined in Table 13.1. In addition, there are four IgG
subclasses—IgG1, IgG2, IgG3, and IgG4—and two IgA subclasses—IgA1
and IgA2—that differ in their amino acid sequence and interchain
disulfide bonds. Individual antibody molecules that recognize specific
antigens are known as idiotypes.
Table 13.1 Classes of Human Immunoglobulin (Ig)
 Immunoglobulin allotypes
The five immunoglobulin classes occur in all normal individuals, but allelic
variants, or what are known as antibody allotypes of these classes, have
also been identified. These are the Gm system associated with the heavy
chain of IgG, the Am system associated with the IgA heavy chain, the Km
and Inv systems associated with the κ light chain, the Oz system for the λ
light chain and the Em allotype for the IgE heavy chain. The Gm and Km
systems are independent of each other and are polymorphic, the
frequencies of the different alleles varying in different ethnic groups.

Generation of Antibody Diversity

It could seem paradoxical for a single protein molecule to exhibit sufficient
structural heterogeneity to have specificity for a large number of different
antigens. Different combinations of H and L chains could, to some extent,
account for this diversity. It would, however, require thousands of
structural genes for each chain type to provide sufficient variability for the
large number of antibodies produced in response to the equally large
number of antigens to which individuals can be exposed. Our initial
understanding of how this could occur came from persons with a
malignancy of antibody-producing cells—multiple myeloma.
 Multiple myeloma
People with multiple myeloma make a single or monoclonal antibody
species in large abundance, which in a proportion of patients is detected in
their urine. This is known as Bence Jones protein and consists of antibody
L chains. The amino-terminal ends of this protein molecule in different
patients are quite variable in sequence, whereas the carboxy-terminal ends
are relatively constant. These are called the variable, or V, and constant, or
C, regions, respectively. However, the V regions of different myeloma
proteins show four regions that vary little from one antibody to another,
known as framework regions (FR 1–4), and three markedly variable
regions interspersed between these, known as hypervariable regions (HV
I–III) (Figure 13.5).

DNA studies of antibody diversity

In 1965 Dreyer and Bennett proposed that an antibody could be encoded
by separate ‘genes’ in germline cells that undergo rearrangement or, as
they termed it, ‘scrambling’, in lymphocyte development. Comparison of
the restriction maps of the DNA segments coding for the C and V regions
of the immunoglobulin λ light chains in embryonic and antibody-
producing cells revealed that they were far apart in the former but close
together in the latter.
Detailed analysis revealed that the DNA segments coding for the V and C
regions of the light chain are separated by some 1500 base-pairs (bp) in
antibody-producing cells. The intervening DNA segment was found to code
for a joining, or J, region immediately adjacent to the V region of the light
chain. The κ L-chain was shown to have the same structure. Cloning and
DNA sequencing of H-chain genes in germline cells revealed that they have
a fourth region, called diversity, or D, between the V and J regions.
There are estimated to be some 60 different DNA segments coding for the
V region of the H-chain, 40 for the V region of the κ L-chain, and 30 for
the λ L-chain V region. Six functional DNA segments code for the J region
of the H-chain, five for the J region of the κ L-chain, and four for the J
region of the λ L-chain. A single DNA segment codes for the C region of the
κ L-chain, seven for the C region of the λ L-chain and 11 functional DNA
segments code for the C region of the different classes of H-chain. There
are also 27 functional DNA segments coding for the D region of the H-
chain (Figure 13.6).
Figure 13.6 Estimated number of the various DNA segments coding for the
κ, λ, and various heavy chains.
The genomic regions in question also contain a large number of
unexpressed DNA sequences or pseudogenes. Although the coding DNA
segments for the various regions of the antibody molecule can be referred
to as ‘genes’, use of this term in regard to antibodies has deliberately been
avoided because they could be considered an exception to the general rule
of ‘one gene–one enzyme (or protein)’.

Antibody gene rearrangement

The genes for the κ and λ L-chains and the H-chains are located on
chromo-somes 2, 22, and 14, respectively. Only one of each of the relevant
types of DNA segment is expressed in any single antibody molecule. The
DNA coding seg-ments for the various portions of the antibody chains on
these chromosomes are separated by DNA that is non-coding. Somatic
recombinational events involved in antibody production involve short
conserved recombination signal sequences that flank each germline DNA
segment (Figure 13.7). Further diversity occurs by variable mRNA splicing
at the V–J junction in RNA processing and by somatic mutation of the
antibody genes. These mechanisms readily account for the anti-body
diversity seen in nature, even though it is still not entirely clear how parti-
cular DNA segments are selected to produce an antibody to a specific
antigen.
Figure 13.7 Immunoglobulin heavy-chain gene rearrangement and class
switching.
 Class Switching of Antibodies
There is a normal switch of antibody class produced by B cells on
continued, or further, exposure to antigen—from IgM, the initial class of
antibody produced in response to exposure to an antigen, to IgA or IgG.
This class switching involves retention of the specificity of the antibody to
the same antigen. Analysis of class switching in a population of cells
derived from a single B cell has shown that both classes of antibody have
the same antigen-binding sites, having the same V region but differing only
in their C region. Class switching occurs by a somatic recombination event
that involves DNA segments designated S (for switching) that lead to
looping out and deletion of the intervening DNA. The result is to eliminate
the DNA segment coding for the C region of the H-chain of the IgM
molecule, and to bring the gene segment encoding the C region of the new
class of H-chain adjacent to the segment encoding the V region (Figure
13.7).
The Immunoglobulin Gene Superfamily
Several other molecules involved in the immune response have been shown
to have structural and DNA sequence homology to the immunoglobulins.
This involves a 110 -amino acid sequence characterized by a centrally
placed disulfide bridge that stabilizes a series of antiparallel bb-strands into
This group of structurally similar molecules has been called the
immunoglobulin superfamily. It consists of eight multigene families that, in
addition to the k and ll L-chains and different classes of H-chain, include
the chains of the T-cell receptor, the class I and II MHC, or human
leukocyte antigens (HLA). Other molecules in this group include the T-cell
CD4 and CD8 cell surface receptors, which cooperate with T-cell receptors
in antigen recognition, and the intercellular adhesion molecules-1, -2, and
-3, which are involved in leukocyte-endothelial adhesion and
extravasation, T-cell activation, and T-cell homing.
Antibody Engineering
At the beginning of the 20th century, Paul Ehrlich proposed the idea of the
'magic bullet'—the hope that one day there might be a compound that
would selectively target a disease-causing organism. Today we have
monoclonal antibodies (mAb) and, for almost any substance, it is possible
to create a specific antibody that binds that substance. Monoclonal
antibodies are the same because they are made by one type of immune cell
which are all clones of a unique parent cell.
In the 1970s it was understood that the B-cell cancer multiple myeloma
produced a single type of antibody—a paraprotein. The structure of
antibodies was studied from this but it was not possible to produce
identical antibodies specific to a given antigen. Myeloma cells cannot grow
because they lack hypoxanthine-guanine-phosphoribosyl transferase,
which is necessary for DNA replication. Typically, mAb are made by fusing
myeloma cells with spleen cells from a mouse (or rabbit) that has been
immunized with the desired antigen. They are then grown in medium
which is selective for these hybrids—the spleen cell partner supplies
hypoxanthine-guanine-phosphoribosyl transferase and the myeloma has
immortal properties because it is a cancer cell. The cell mixture is diluted
and clones grown from single parent cells. The antibodies secreted by
different clones are assayed for their ability to bind to the antigen in
question, with the healthiest clone selected for future use. The hybrids can
also be injected into the peritoneal cavity of mice to produce tumors
containing antibody-rich ascitic fluid, and the mAb then has to be
extracted and purified.
To overcome the problem of purification, recombinant DNA technologies
have been used since the 1980s. DNA that encodes the binding portion of
mouse mAb is merged with human antibody-producing DNA. Mammalian
cell culture is then used to express this DNA, producing chimeric
antibodies. The goal, of course, is to create 'fully human' mAb, which has
met with success in “phage display-generated” antibodies and mice that
have been genetically modified to produce more human-like antibodies.
Specific mAb have now been developed and approved for the treatment of
cancer, cardiovascular disease, inflammatory diseases, macular
degeneration, and transplant rejection, among others. A mAb that inhibits
TNF-aa has applications in rheumatoid arthritis, Crohn disease, and
ulcerative colitis; one that inhibits IL-2 on activated T cells is used in
preventing rejection of transplanted kidneys; and one that inhibits
vascular endothelial growth factor (VEGF) has a role in antiangiogenic
cancer therapy.
Cell-Mediated Specific Acquired Immunity
Certain microorganisms, viruses, and parasites live inside host cells. As a
result, a separate form of specific acquired immunity has developed to
combat intracellular infections involving lymphocytes differentiated and
mature in the thymus—hence T cells. T lymphocytes have specialized
receptors on the cell surface, known as T-cell surface antigen receptors,
which in conjunction with the MHC on the cell surface of the infected cell
result in the involvement of different subsets of T cells, each with a distinct
function—T helper cells and cytotoxic T cells. The battle against
intracellular infections is a cooperative, coordinated response from these
separate components of the immune system, leading to death of the
infected cell (Figure 13.8).
Figure 13.8 T cells and the cooperative response resulting in death of an
infected cell. MHC, Major histocompatibility complex.
 T-Cell Surface Antigen Receptor
T cells express on their surface an antigen receptor, which distinguishes
them from other lymphocyte types, such as B cells and NK cells. The
antigen consists of two different polypeptide chains, linked by a disulfide
bridge, that both contain two immunoglobulin-like domains, one that is
relatively invariant in structure, the other highly variable like the Fab
portion of an immunoglobulin. The diversity in T-cell receptors required
for recognition of the range of antigenic variation that can occur is
generated, by a process similar to that seen with immunoglobulins.
Rearrangement of variable (V), diversity (D), junctional (J), and constant
(C) DNA segments during T-cell maturation, through a similar
recombination mechanism as occurs in B cells, results in a contiguous VDJ
sequence. Binding of antigen to the T-cell receptor, in conjunction with an
associated complex of transmembrane peptides, results in signaling the cell
to differentiate and divide.
The Major Histocompatibility Complex
The MHC plays a central role in the immune system. Its role is to bind
antigen peptides processed intracellularly and present this material on the
cell surface, with co-stimulatory molecules, where it can be recognised by
T cells. MHC molecules occur in three classes: class I occur on virtually all
cells and are responsible for presenting cytotoxic T cells; class II occur on
B cells and macrophages and are involved in signaling T-helper cells to
present further B cells and macrophages; and the non-classic class III
molecules include a number of other proteins with a variety of other
immunological functions. The latter include inflammatory mediators such
as the TNF, heat-shock proteins, and the various components of
complement.
Structural analysis of class I and II MHC molecules reveal them to be
heterodimers with. homology to immunoglobulin. The genes coding for the
class I (A, B, C, E, F, and G), class II (DR, DQ, and DP) and class III MHC
molecules, or what is also known as the human leukocyte antigen (HLA)
system, are located on chromosome 6.
Transplantation Genetics
Organ transplantation has become routine in clinical medicine and, with
the exception of corneal and bone grafts, success depends on the degree of
antigenic similarity between donor and recipient. The closer the similarity,
the greater the likelihood that the transplanted organ or tissue (the
homograft), will be accepted rather than rejected. Homograft rejection
does not occur between identical twins or between non-identical twins
where there has been mixing of the placental circulations before birth. In
all other instances, the antigenic similarity of donor and recipient has to be
assessed by testing them with suitable antisera or monoclonal antibodies
for antigens on donor and recipient tissues. These were originally known
as transplantation antigens but are now known to be a result of the MHC.
As a general rule, a recipient will reject a graft from any person who has
antigens that the recipient lacks. HLA typing of an individual is carried
out using PCR-based techniques.
The HLA system is highly polymorphic (Table 13.2). A virtually infinite
number of phenotypes resulting from different combinations of the various
alleles at these loci is theoretically possible. Two unrelated individuals are
therefore very unlikely to have identical HLA phenotypes. The close
linkage of the HLA loci means that they tend to be inherited en bloc, the
term haplotype being used to indicate the particular HLA alleles that an
individual carries on each of the two copies of chromosome 6. Thus, any
individual will have a 25% chance of having identical HLA antigens with a
sibling, as there are only four possible combinations of the two paternal
haplotypes (say P and Q) and the two maternal haplotypes (say R and S),
i.e., PR, PS, QR and QS. The siblings of a particular recipient are more
likely to be antigenically similar than either of his or her parents, and the
latter more than a non-relative. Therefore, a sibling is frequently selected
as a potential donor.
Although recombination occurs within the HLA region, certain alleles tend
to occur together more frequently than would be expected by chance, i.e.
they tend to exhibit linkage disequilibrium. An example is the association
of the HLA antigens A1 and B8 in populations of western European origin.
Table 13.2 Alleles at the HLA Loci.
H-Y antigen
In a number of different animal species, it was noted that tissue grafts from
males were rejected by females of the same inbred strain. These
incompatibilities were found to be due to a histocompatibility antigen known
as H-Y. However, H-Y seems to play little part in transplantation in humans.
The H-Y antigen (not the same as the SRY gene) is important for testicular
differentiation and function but its expression does not correlate with the
presence or absence of testicular tissue.

HLA Polymorphisms and Disease Associations

The association of certain diseases with certain HLA types (Table 13.3)
should shed light on the pathogenesis of the disease, but in reality this not
well understood. The best documented is between ankylosing spondylitis and
HLA-B27. Narcolepsy, a condition of unknown etiology characterized by a
periodic uncontrollable tendency to fall asleep, is almost invariably
associated with HLA-DR2. The possession of a particular HLA antigen does
not mean that an individual will necessarily develop the associated disease,
only that the relative risk of being affected is greater than the general
population. In that the relative risk of being affected is greater than the
general population. In a family, the risks to first-degree relatives of those
Table 13.3 Some HLA-Associated Diseases.
Explanations for the various HLA-associated disease susceptibilities
include close linkage to a susceptibility gene near the HLA complex, cross-
reactivity of antibodies to environmental antigens or pathogens with
specific HLA antigens, and abnormal recognition of self antigens through
defects in T-cell receptors or antigen processing. These conditions are
known as autoimmune diseases. An example of close linkage is congenital
adrenal hyperplasia from a 21-hydroxylase deficiency from mutated
CYP21, which lies within the HLA major histocompati-bility locus. This
form of congenital adrenal hyperplasia is strongly associated HLA-
A3/Bw47/DR7 in northern European populations. Non-classical 21-
hydroxy-lase deficiency is associated with HLA-B14/DR1, and HLA-
A1/B8/DR3 is nega-tively associated with 21-hydroxylase deficiency.

Inherited Immunodeficiency Disorders

Inherited immunodeficiency disorders are uncommon and sometimes
severe but, with early diagnosis and optimum management many patients
with primary immune deficiency (PID) can remain very well. Prompt
diagnosis is very important in order that treatment, for example
antimicrobials, immunoglobulin, or bone marrow transplant, be instituted
before significant irreversible end-organ damage takes place.
Presentation is variable but often in childhood for more severe immune
defects, especially after the benefits of maternal transplacental immunity
have declined. New diagnoses of PID are sometimes made in adults.
Investigation of immune function should be considered in all patients with
recurrent infections and in children with failure to thrive. Failure to
thrive, diarrhea, and hepatosplenomegaly may also be features.

Primary Inherited Disorders of Immunity

The manifestations of at least some of the PID diseases in humans can be
understood by considering whether they are disorders of innate immunity
or of specific acquired immunity. Abnormalities of humoral immunity are
associated with reduced resistance to bacterial infections and may be lethal
in infancy. Abnormalities of cell-mediated specific acquired immunity are
associated with increased susceptibility to viral infections and are manifest
experimentally in animals by prolonged survival of skin homografts.
Disorders of Innate Immunity
Primary disorders of innate immunity are considered under humoral and
cell-mediated immunity categories.
 Disorders of innate humoral immunity
A variety of defects of complement can lead to disordered innate
immunity.
Disorders of complement. If a complement defect is suspected,
investigation of the integrity of the classical and alternative pathways
should begin with functional assays looking at the entire pathway. If
functional abnormalities are found, measurement of the individual
components of that pathway can be undertaken.
The clinical effects of MBL deficiency have been described previously.
Defects of the third component of complement, C3, lead to abnormalities
of opsonization of bacteria, resulting in difficulties in combating pyogenic
infections. Defects in the later components of complement—those involved
in the formation of the MAC—also result in susceptibility to bacterial
infection, though in particular Neisseria (meningococcal infections). This
includes deficiency of properdin (factor P), a plasma protein active in the
alternative complement pathway.
C1 inhibitor deficiency follows autosomal dominant inheritance and there
are two forms—type 1 due to low levels, and type 2 resulting from non-
functioning protein. Inappropriate activation and poor control of the
complement pathway occurs with breakdown of C2 and C4, and
production of inflammatory mediators. C1 inhibitor also controls the
kinin-bradykinin pathway and when deficient an accumulation of
bradykininin the tissues occurs, and is believed to be the main cause of
oedema, triggered by episodes of surgery, dental work, trauma, and some
drugs. Attacks vary in severity from mild cutaneous to abdominal pain
and swelling, which can be severe—laryngeal oedema is potentially fatal.
This is known as hereditary angioedema. Acute attacks are treated with
C1 inhibitor concentrate, a blood product, which has superseded fresh
frozen plasma when available. In due course, a recombinant C1 inhibitor
may become the treatment of choice. The drug Danazol, an androgen, is
the mainstay of long-term prevention.
Other associations with disease include homozygous C2 deficiency. There
are various case reports of individuals who developed cutaneous vasculitis,
Henoch-Schonlein purpura, seropositive rheumatoid arthritis,
polyarteritis, membranoproliferative glomerulonephritis, and an
association with systemic lupus erythematosus (SLE). Similarly, C4 is
The copy number of C4 genes in a diploid human genome varies from two
to six in the white population. Each of these genes encodes either a G4A or
C4B protein. Subjects with only two copies of total C4 are at significantly
increased risk of SLE, whereas those with five copies or more are at
decreased risk.

Defects in NFkB signaling

Inappropriate activation of nuclear factor kappa-B (NFkB) has been
linked to inflammation associated with autoimmune arthritis, asthma,
septic shock, lung fibrosis, glomerulonephritis, atherosclerosis, and AIDS.
Conversely, persistent inhibition of NFkB has been linked directly to
apoptosis, abnormal immune cell development, and delayed cell growth.
Since 2000, mutations have occasionally been found in the X-linked IKK-
gamma gene, part of the TLR pathway, in children demonstrating failure
to thrive, recurrent digestive tract infections, often with intractable
diarrhea, and recurrent ulcerations, respiratory tract infections with
bronchiectasis, and recurrent skin infections, presenting in infancy,
suggesting susceptibility to various gram-positive and gram-negative
bacteria. Sparse scalp hair is sometimes a feature and in older children
oligodontia and conical-shaped maxillary lateral incisors have been noted.
Survival ranged from 9 months to 17 years in one study. IgG is low and
However, in this condition of the immune system mutations occur in exon
10 of the gene. IRAK4 is another component of the TLR pathway and
deficiency leads to recurrent infections, mainly from gram-positive
microorganisms, though also fungi. There is a reduced inflammatory
response. Infections begin early in life but become less frequent with age,
some patients requiring no treatment by late childhood. It follows
autosomal recessive inheritance.
Disorders of innate cell-mediated immunity
An important mechanism in innate cell-mediated immunity is
phagocytosis, as previously discussed, which results in subsequent cell-
mediated killing of microorganisms.
Chronic granulomatous disease. Chronic granulomatous disease (CGD) is
the best known example of a disorder of phagocytic function, and follows
either an X-linked or an autosomal recessive inheritance. It results from an
inability of phagocytes to kill ingested microbes, because of any of several
defects in the NADPH oxidase enzyme complex which generates the so-
called microbicidal 'respiratory burst' (Figure 13.1).
Hypergammaglobrilinemia may be present. CGD is therefore associated
with recurrent bacterial or fungal infections, and may present as
Childhood mortality was high until the advent of supportive treatment and
prophylactic antibiotics. Bone marrow transplant has been successful, as
well as transplantation of peripheral blood stem cells from an HLA-
identical sibling. The X-linked gene mutated in CGD, CYBB was the first
human disease gene cloned by positional cloning.
The neutropenias. The neutropenias are a heterogeneous group of
disorders of varying severity, following different patterns of inheritance,
and characterised by very low neutrophil counts. Autosomal dominant or
sporadic congenital neutropenia (SCN1) is caused by mutation in the
neutrophil elastase gene (ELA2), and mutation in the protooncogene GFJl,
which targets ELA2, also causes dominantly inherited neutropenia (SCN2).
Mutation in the HAX1 gene causes autosomal recessive SCN3 ('classical'
SCN-Kostmann disease), whereas autosomal recessive SCN4 is caused by
mutation in the G6PC3 gene. SCN patients with acquired mutations in the
granulocyte colony-stimulating factor receptor (CSF3R) gene in
hematopoietic cells are at high risk for developing acute myeloid leukemia.
In SCN, hematopoiesis is characterized by a maturation arrest of
granulopoiesis at the promyelocyte level; peripheral absolute neutrophil
counts are below 0.5 x 109/l and there is early onset of severe bacterial
infections. As well as dominantly inherited SCN1, there is an X-linked
form caused by a constitutively activating mutation in the WAS gene,
mutated in Wiskott-Aldrich syndrome. Cyclic neutropenia rare,
characterized by regular 21-day fluctuations in the numbers of blood
neutrophils, monocytes, eosinophils, lymphocytes, platelets, and
reticulocytes. This results in patients experiencing periodic symptoms of
fever, malaise, mucosal ulcers, and occasionally life-threatening infections.
As with SCN1, it is due to mutated ELA2.
Leukocyte adhesion deficiency. Individuals affected with leukocyte
adhesion deficiency (LAD) present with life-threatening bacterial
infections of the skin and mucous membranes and impaired pus
formation. The increased susceptibility to infections occurs because of
defective migration of phagocytes from abnormal adhesion-related
functions of chemotaxis and phagocytosis. This disorder is fatal unless
antibiotics are given, both for infection and prophylactically, until bone
marrow transplantation can be offered. Three different forms of LAD are
recognised, each with unique clinical features, though leukocytosis is a
LAD I is characterized by delayed separation of the umbilical cord,
omphalitis, and severe recurrent infections with no pus formation. It is due
to mutated ITGB2, located on chromosome 21, and encodes the bb2 subunit
of the integrin molecule. LAD II patients have the rare Bombay blood group
and suffer from psychomotor retardation and growth delay. It is caused by
mutations in the gene encoding the Golgi-specific GDP-fucose transporter.
LAD III is similar to LAD I but includes severe neonatal bleeding tendency.
Various defects in leukocyte chemotaxis and adhesion to endothelial cells
have been found and the definitive diagnosis is reached by the showing
defects in the integrin activation process, whereas the CD18 molecule is
structurally intact. The genetic defect in LAD III is not known.

Autoimmune-Polyendocrinopathy-
Candidosis-Ectodermal Dysplasia Syndrome
Autoimmune polyendocrinopathy syndrome type I is characterized by the
presence of two of three major clinical symptoms: Addison disease,
hypoparathyroidism, chronic mucocutaneous candidiasis, and is caused by
mutations in the autoim-mune regulator gene. Malabsorption and diarrhea
can be striking and dominate the clinical picture, and immune disorders
may be present, though diabetes mellitus and thyroid disease are infrequent.
The onset of Addison disease is mostly in child-hood or early adulthood, and
frequently accompanied by chronic active hepatitis, malabsorption, juvenile
Disorders of Specific Acquired Immunity
Again, these can be considered under the categories of disorders of
humoral and cell-mediated specific acquired immunity.
Disorders of humoral acquired immunity
Abnormalities of immunoglobulin function lead to an increased tendency
to develop bacterial infections.
Bruton-type agammaglobulinemia. Boys with this X-linked
immunodeficiency usually develop multiple recurrent bacterial infections
of the respiratory tract and skin after the first few months of life, having
been protected initially by placentally transferred maternal IgG. Features
similar to rheumatoid arthritis develop in many and they are not prone to
viral infection. Treatment of life-threatening infections with antibiotics and
the use of prophylactic intravenous immunoglobulins have improved
survival prospects, but children with this disorder can still die from
respiratory failure through complications of repeated lung infections. The
diagnosis of this type of immunodeficiency is confirmed by demonstration
of immunoglobulin deficiency and absence of B lymphocytes.
The disorder has been shown to result from mutations in a tyrosine kinase
specific to B cells (Btk) that result in loss of the signal for B cells to
differentiate to mature antibody-producing plasma cells. A rarer,
autosomal recessive, form of agammaglobulinemia shows marked
depression of the circulating lymphocytes, and lymphocytes are absent
from the lymphoid tissue.
Hyper-IgM syndrome (HIGM). HIGM is another genetically
heterogeneous condition that includes increased levels of IgM, and also
usually of IgD, with levels of the other imunoglobulins being decreased or
virtually absent. Patients are susceptible to recurrent pyogenic infections,,
as well as opportunistic infections such as Pneumocystis and
Cryptosporidium, because of primary T-cell abnormality. In the X-linked
form (HIGM1) the mutated gene encodes a cell surface molecule on
activated T cells called CD40 ligand (renamed TNFSF5). When the gene is
not functioning, immunoglobulin class switches are inefficient, so that IgM
production cannot be readily switched to IgA or IgG. IgM levels are
therefore high, and IgG levels reduced. At least four other types are
recognised, including autosomal recessive forms HIGM2 (CD40
deficiency) and HIGM3 (activation-induced cytidine deaminase, AICDA)
deficiency.
Hyper-IgE syndrome. Again heterogeneous, this condition is sometimes
known as Job syndrome and is a PID characterized by chronic eczema,
recurrent staphylococcal infections, increased serum IgE, and eosinophilia.
Abscesses maybe 'cold', i.e. they lack of surrounding warmth, erythema, or
tenderness. Patients have a distinctive coarse facial appearance, abnormal
dentition, hyperextensibility of the joints, and bone fractures. Autosomal
dominant HIES is caused by mutation in the STAT3 gene and autosomal
recessive by mutation in DOCKS.
Common variable immunodeficiency (CVID). CVID constitutes the most
common group of B-cell deficiencies but is very heterogeneous and the
causes are basically unknown. The presentation is similar to that for other
forms of immune deficiency, including nodular lymphoid hyperplasia. The
sexes are equally affected and presentation can begin at any age. Affecting
approximately 1:800 Caucasians, selective IgA deficiency is the most
frequently recognized PID. Many affected people have no obvious health
problems, but others may have recurrent infections, gastrointestinal
disorders, autoimmune diseases, allergies, or malignancies. The
pathogenesis is arrest of B-cell differentiation, giving rise to a normal
number of IgA-bearing B-cell precursors but a profound deficit in IgA-
producing plasma cells. The response to immunization with protein and
CVID is regarded as a 'wastebasket' category that includes a number of
immune disorders; however, most individuals with CVID show a
distinctive phenotype characterized by normal numbers of
immunoglobulin-bearing B-cell precursors and a. broad deficiency of
immunoglobulin isotypes. CD40 ligand deficiency has been found in some
patients in this group.
Disorders of cell-mediated specific acquired immunity
The most common inherited disorder of cell-mediated specific acquired
immunity is severe combined immunodeficiency (SCID).
Severe combined immunodeficiency. SCID, as the name indicates, is
associated with an increased susceptibility to both viral and bacterial
infections because of profoundly abnormal humoral and cell-mediated
immunity. Common to all forms of SCID is the absence of T cell-mediated
cellular immunity from defective T-cell development. Presentation is in its
infancy with recurrent, persistent, opportu-nistic infections by many
organisms, including Candida albicans, Pneumocystis carinii, and
cytomegalovirus. The incidence of all types of SCID is approximately
1:75,000. Death usually occurs in infancy because of overwhelming
infection, unless a bone marrow transplant is performed. SCID is
genetically hetero-geneous and can be inherited as either an X-linked or
The X-linked form (SCIDX1) is the most common form of SCID in males,
accounting for 50% to 60% overall, and has been shown to be due to
mutations in the y chain of the cytokine receptor for IL-2 (IL2RG). In
approximately one-third to one-half of children with SCID that is not X-
linked, inheritance is autosomal recessive (SCID1) and the different forms
are classified according to whether they are B-cell negative (T-B-) or B-cell
positive (T-B+). The presence or absence of NK cells is variable.
T-B+ SCID, apart from SCIDX1, includes deficiency of the protein
tyrosine phosphatase receptor type C (or CD45) deficiency. CD45
suppresses Janus kinases (JAK), and there is a specific B-cell-positive
SCID due to JAK3 deficiency, which can be very variable—from
subclinical to life threatening in early childhood. Other rare autosomal
recessive forms of SCID include mutation in the IL7R gene—IL2RG is
dependent on a functional interleukin-7 receptor.
T-B- SCID includes adenosine deaminase deficiency, which accounts for
approximately 15% of all SCID and one-third of autosomal recessive
SCID. The phenotypic spectrum is variable, the most severe being SCID
presenting in infancy and usually resulting in early death. Ten to 15% of
patients have a 'delayed' clinical onset by age 6 to 24 months, and a
smaller percentage of patients have 'later' onset, diagnosed from ages 4
years to adulthood, showing less severe infections and gradual
immunologic deterioration. The immune system is affected through the
accumulation of purine degradation products that are selectively toxic to T
cells. Rare forms of B-cell negative SCID include mutated RAG1/RAG2
(recombination activating genes), which are normally responsible for VDJ
recombinations that lead to mature immunoglobulin chains and T-cell
receptors. In addition, cases occur due to mutation in the Artemis gene
(DNA cross-link repair protein 1c—DCLRE1C). The latter forms are both
sensitive to ionizing radiation. Lastly, reticular dysgenesis is a rare and
very severe form of SCID characterized by congenital agranulocytosis,
lymphopenia, and lymphoid and thymic hypoplasia with absent cellular
and humoral immunity functions. It is due to mutation in the
mitochondrial Adenylate kinase-2 gene (AK2).
Secondary or Associated Immunodeficiency
There are a number of hereditary disorders in which immunological
abnormalities occur as one of a number of associated features as part of a
syndrome.
DiGeorge/Sedlagkova Syndrome
Children with the DiGeorge syndrome (also well described by Sedlagkova,
10 years earlier than DiGeorge) present with recurrent viral illnesses and
are found to have abnormal cellular immunity as characterized by reduced
numbers of T lymphocytes, as well as abnormal antibody production. This
has been found to be associated with partial absence of the thymus gland,
leading to defects in cell-mediated immunity and T cell -dependent
antibody production. Usually these defects are relatively mild and improve
with age, as the immune system matures, but occasionally the immune
deficiency is very severe because no T cells are produced and bone marrow
transplantation is indicated. It is important for all patients diagnosed to be
investigated by taking a full blood count with differential CD3, CD4, and
CD8 counts, and immunoglobulins. The levels of diphtheria and tetanus
antibodies can indicate the ability of the immune system to respond. These
patients usually also have a number of characteristic congenital
The latter finding can result in affected individuals presenting in the
newborn period with tetany due to low serum calcium levels secondary to
low parathyroid hormone levels. This syndrome has been recognized to be
part of the spectrum of phenotypes caused by abnormalities of the third
and fourth pharyngeal pouches as a consequence of a microdeletion of
chromosome band 22q11.2.
Ataxia Telangiectasia
Ataxia telangiectasia is an autosomal recessive disorder in which children
present in early childhood with signs of cerebellar ataxia, dilated blood
vessels on the sclerae of the eyes, ears, and face (oculocutaneous
telangiectasia), and a susceptibility to sinus and pulmonary infections. Low
serum IgA levels occur and a hypoplastic thymus as a result of a defect in
the cellular response to DNA damage. The diagnosis is made by the
demonstration of low or absent serum IgA and IgG as well as
characteristic chromosome abnormalities on culture of peripheral blood
lymphocytes—a form of chromosome instability. Patients have an
increased risk of developing leukemia or lymphoid malignancies.
 Wiskott-Aldrich Syndrome
Wiskott-Aldrich syndrome is an X-linked recessive disorder in which
affected boys have eczema, diarrhea, recurrent infections,
thrombocytopenia, and, usually, low serum IgM levels and impaired T-cell
function and numbers. Mutations in the gene responsible have been shown
to result in loss of cytotoxic T-cell responses and T-cell help for B-cell
response, leading to an impaired response to bacterial infections. Until the
advent of bone marrow transplantation, the majority of affected boys died
by raid-adolescence from hemorrhage or B-cell malignancy.

Carrier Tests for X-Linked Immunodeficiencies

Before it was possible to sequence the genes responsible for Wiskott-
Aldrich syndrome, Bruton-type hypogammaglobulinemia, and X-linked
SCID, the availability of closely linked DNA markers allowed female
carrier testing by studies of the pattern of X-inactivation in the
lymphocytes of females at risk. A female relative of a sporadically affected
male with an X-linked immunodeficiency would be confirmed as a carrier
by the demonstration of a non- random pattern of X-inactivation in the T-
lymphocyte population, indicating that all her peripheral blood T
lymphocytes had the same chromosome inactivated (Figure 13.9).
The carrier (C) and non-carrier (XC) are both heterozygous for an
HpaII/MspI restriction site polymorphism. Hpnll and Mspl recognize the
same nucleotide recognition sequence, but Mspl cuts double-stranded DNA
whether it is methylated or not, whereas Hpall cuts only unmethylated
DNA (i.e. only the active X chromosome). In the carrier female the
mutation in the SCID gene is on the X chromosome on which the
Hpall/Mspl restriction site is present. EcoRI/Mspl double digests of T
lymphocytes result in 6, 4, and 2-kilobase (kb) DNA fragments on gel
analysis of the restriction fragments for both the carrier and non-carrier
females. EcoRl/Hpall double digests of T-lymphocyte DNA result however,
in a single 6-kb fragment in the carrier female. This is because in a carrier
the only T cells to survive will be those in which the normal gene is on the
active unmethylated X chromosome. Thus, inactivation appears to be non-
random in a carrier although, strictly speaking, it is cell population
survival that is non-random.
Blood Groups
Blood groups reflect the antigenic determinants on red cells and were one
of the first areas in which an understanding of basic biology led to
significant advances in clinical medicine. Our knowledge of the ABO and
Rhesus blood groups has resulted in safe blood transfusion and the
prevention of Rhesus hemolytic disease of the newborn.
The ABO Blood Groups
The ABO blood groups were discovered by Landsteiner early in the
twentieth century. In some cases blood transfusion resulted in rapid
hemolysis because of incompatibility. Four major ABO blood groups were
discovered: A, B, AB, and O. Those with blood group A possess the antigen
A on the surface of their red blood cells, blood group E has antigen B, AB
has both antigens, and those with blood group O have neither. People of
blood group A have naturally occurring anti-E antibodies, and blood
group E have anti-A, whereas blood group O have both. The alleles at the
ABO blood group locus are inherited in a co-dominant manner but are
both dominant to the gene for the O antigen. There are, therefore, six
possible genotypes (Table 13.4).
Table 13.4 ABO Blood Group Phenotypes and Genotypes.
Blood group AB individuals do not produce A or B antibodies, so they can
receive a blood transfusion from people of all other ABO blood groups,
and are therefore referred to as universal recipients. On the other hand,
because individuals of group O do not express either A or B antigens on
their red cells, they are referred to as universal donors. Antisera can
differentiate two subgroups of blood group A, A1, and A2, but this is of
little practical importance as far as blood transfusions are concerned.
Individuals with blood groups A, B, and AB possess enzymes with
glycosyltransferase activity that convert the basic blood group, which is
known as the “H” antigen, into the oligosaccharide antigens "A" or “B”.
The alleles for blood groups A and B differ in seven single base
substitutions that result in different A and B transferase activities, the A
allele being associated with the addition of N-acetylgalactosaminyl groups
and the B allele with the addition of D-galactosyl groups. The O allele
results from a critical single base-pair deletion that results in an inactive
protein incapable of modifying the H antigen.
 Rhesus Blood Group
The Rhesus (Rh) blood group system involves three sets of closely linked
antigens, Cc, Dd, and Ee. D is very strongly antigenic and persons are, for
practical purposes, either Rh positive (possessing the D antigen) or Rh
negative (lacking the D antigen).

Rhesus Hemolytic Disease of the Newborn

A proportion of women who are Rh-negative have an increased chance of
having a child who will either die in utero or be born severely anemic
because of hemolysis, unless transfused in utero. This occurs because if
Rh-positive blood is given to persons who are Rh-negative, the majority
will develop anti-Rh antibodies. Such sensitization occurs with exposure to
very small quantities of blood and, once a person is sensitized, further
exposure results in the production of very high antibody titers.
En the case of an Rh-negative mother carrying an Rh-positive fetus, fetal
red cells that cross to the mother's circulation can induce the formation of
maternal Rh antibodies. In a subsequent pregnancy, these antibodies can
cross the placenta from the mother to the fetus, leading to hemolysis and
severe anemia. In its most severe form, this is known as erythroblastosis
fetalis, or hemolytic disease of the newborn. After a woman has been
sensitized, there is a significantly greater risk that a child in a subsequent
pregnancy, if Rh-positive, will be more severely affected.
To avoid sensitizing an Rh-negative woman Rh-compatible blood must
always be used in any blood transfusion. Furthermore, the development of
sensitization, and therefore Rh incompatibility after delivery, can be
prevented by giving the mother an injection of Rh antibodies—anti-E—so
that fetal cells in the maternal circulation are destroyed before the mother
can become sensitized.
It is routine to screen all Rh-negative women during pregnancy for the
development of Rh antibodies. Despite these measures, a small proportion
of women do become sensitized. If Rh antibodies appear, tests are carried
out to see whether the fetus is affected. If so, there is a delicate balance
between the choice of early delivery, with the risks of prematurity and
exchange transfusion, and treating the fetus in utero with blood
 Molecular Basis of the Rh Blood Group
There are two types of Rh red cell membrane polypeptide. One
corresponds to the D antigen and the other to the C and E series of
antigens. We now know that two genes code for the Rh system: one for D
and d, and a second for both C and c and E and e. The D locus is present in
most persons and codes for the major D antigen present in those who are
Rh-positive. Rh-negative individuals are homozygous for a deletion of the
D gene. Therefore, an antibody has never been raised to d!
Analysis of complementary DNA from reticulocytes in Rh-negative
persons who were homozygous for dCe, dcE, and dee allowed
identification of the genomic DNA sequences responsible for the different
antigenic variants at the second locus, revealing that they are produced by
alternative splicing of the mRNA transcript. The Ee polypeptide is a full-
length product of the CcEe gene, very similar in sequence to the D
polypeptide. The E and e antigens differ by a point mutation in exon 5.
The Cc polypeptides are, in contrast, products of a shorter transcript of
the same gene through splicing. The difference between C and c is four
amino-acid substitutions in exons 1 and 2.
 Other Blood Groups
There are approximately a further 12 'common' blood group systems of
clinical importance in humans, including Duffy, Lewis, MN, and S. These
are usually of concern only when cross-matching blood for persons who,
because of repeated transfusions, have developed antibodies to one of these
other blood group antigens. Until the advent of DNA fingerprinting, they
were used in linkage studies and paternity testing.
Further Reading
Bell JI, Todd JA, McDevitt HO: The molecular basis of HLA-disease
association. Adv Hum Genet 18: 1-41 1989
Good review of the HLA-disease associations.
Dreyer WJ, Rennet JC: The molecular basis of antibody formation: a
paiados. Proc Natl Acad Sci US 54: 364-369 1965
The proposal of the generation of antibody diversity.
Hunkapiller T, Hood L: Diversity of the immunoglobulin gene
superfamily. Adv Immunol 44: 1-63 1989
Good review of the structure of the immunoglobulin gene superfamily.
Further Reading

Lachmann PJ, Peters K, Rosen FS, Walport MJ: Clinical aspects of

immunology. 5 edn 1993 Blackwell Oxford
A comprehensive three-volume multiauthor text covering both basic and
clinical immunology*
Murphy KM, TraversP, Walport M: Janeway's immunobiology. 7 adn 2
Science Oxford
Good, well-illustrated, textbook of the biology of immunology.
Roitt I: Essential immunology. 9th edn 1997 Blackwell Oxford
Excellent basic immunology textbook.