Hyperimmunoglobulinemia Abnormally high blood levels of
immunoglobulins. Abnormally high blood levels of immunoglobulins.
Polyclonal immunoglobulins Polyclonal immunoglobulins Monoclonal
immunoglobulins Monoclonal immunoglobulins
Slide 2
Monoclonal immunoglobulins An uncontrolled proliferation of a
single clone of plasma cells. An uncontrolled proliferation of a
single clone of plasma cells. Electrophoresis of serum appears a
narrow band or spike . Electrophoresis of serum appears a narrow
band or spike . This protein is called paraprotein or This protein
is called paraprotein or monoclonal protein M protein . monoclonal
protein M protein . Paraproteinemia Paraproteinemia.
Slide 3
Theory of Monoclonal Detection Immunoglobulins have a broad
range of isoelectric points Immunoglobulins have a broad range of
isoelectric points Results in a very diffuse band when subjected to
electrophoresis Results in a very diffuse band when subjected to
electrophoresis Each monoclonal antibody has a unique isoelectric
point - all molecules of any given monoclonal antibody have the
same isoelectric point Each monoclonal antibody has a unique
isoelectric point - all molecules of any given monoclonal antibody
have the same isoelectric point Results in a sharp distinct band
when subjected to electrophoresis Results in a sharp distinct band
when subjected to electrophoresis
Slide 4
Monoclonal gammopathies A monoclonal serum (or urine) protein
without clinical manifestations of plasma cell dyscrasia. A
monoclonal serum (or urine) protein without clinical manifestations
of plasma cell dyscrasia. Elevated levels of a single class and
type of immunoglobulin. Elevated levels of a single class and type
of immunoglobulin.
Monoclonal gammopathies Multiple myeloma Multiple myeloma
Waldenstrom s macroglobulinemia Waldenstrom s macroglobulinemia
Heavy chain diseases Heavy chain diseases Light chain diseases
Light chain diseases Chronic lymphocytic leukemia ( CLL ) Chronic
lymphocytic leukemia ( CLL )
Slide 7
Multiple myeloma IgG is the most common form. IgG is the most
common form. Between the ages of 40 and 70 years. Between the ages
of 40 and 70 years. The male-to-female ratio is 1.6 1 The
male-to-female ratio is 1.6 1 The causes of death are overwhelming
infection (sepsis) and renal insufficiency. The causes of death are
overwhelming infection (sepsis) and renal insufficiency.
Slide 8
Multiple myeloma Signs and Symptoms Skeletal abnormalities
Skeletal abnormalities --disseminated destruction of the skeleton.
--disseminated destruction of the skeleton. --bone pain, consist of
punched-out lytic --bone pain, consist of punched-out lytic areas,
osteoporosis, and fractures. areas, osteoporosis, and fractures.
Renal disorders Renal disorders --chronic renal failure and
proteinuria are --chronic renal failure and proteinuria are common
developments. common developments. --over half of all patients
excreting abnormal --over half of all patients excreting abnormal
amounts of Bence-Jones (BJ ) protein. amounts of Bence-Jones (BJ )
protein. Anemia or abnormal bleeding. Anemia or abnormal
bleeding.
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Slide 10
Multiple myeloma Immunologic Manifestations IL-6 is the major
growth factor. (also function as osteoclast-activating factors.)
IL-6 is the major growth factor. (also function as
osteoclast-activating factors.) Incessant synthesis of a
dysfunctional single monoclonal protein or of Ig chains of
fragments, with inhibits the synthesis of normal functional
antibody. Incessant synthesis of a dysfunctional single monoclonal
protein or of Ig chains of fragments, with inhibits the synthesis
of normal functional antibody. M component is usually found in
serum, urine or both. M component is usually found in serum, urine
or both.
Slide 11
Multiple myeloma
Slide 12
Bence-Jones proteins Single-peptide chains with a molecular
weight of 20000 or 22000, but dimerization occurs. Single-peptide
chains with a molecular weight of 20000 or 22000, but dimerization
occurs. Monoclonal kappa or lambda Ig light chains. Monoclonal
kappa or lambda Ig light chains. Detected in serum, urine, or both.
Detected in serum, urine, or both. Related to filtration,
resorption, or catabolism of the protein by the kidney. Related to
filtration, resorption, or catabolism of the protein by the kidney.
Insoluble near 60-70 , then resoulubilize at 80 Insoluble near
60-70 , then resoulubilize at 80
Slide 13
Waldenstrom s macroglobulinemia An indolent B-cell disorder
characterized by excess secretion of IgM paraprotein. An indolent
B-cell disorder characterized by excess secretion of IgM
paraprotein. Involvement of the bone marrow by lymphoplasmacytic
cells. Involvement of the bone marrow by lymphoplasmacytic cells.
Age-specific incidence (60 to 64 years) Age-specific incidence (60
to 64 years)
Slide 14
Waldenstrom s macroglobulinemia Signs and Symptoms High levels
of IgM macroglobulin. High levels of IgM macroglobulin. IgM is
precipitabled at cold temperatures. (when IgM levels exceed 2 to 3
g/dL) IgM is precipitabled at cold temperatures. (when IgM levels
exceed 2 to 3 g/dL) Hyperviscosity Hyperviscosity Bleeding, weight
loss, and infection. Bleeding, weight loss, and infection.
Hepatomegaly, splenomegaly, and lymphadenopathy. (40%)
Hepatomegaly, splenomegaly, and lymphadenopathy. (40%)
Slide 15
Waldenstrom s macroglobulinemia Signs and Symptoms Hematologic
abnormalities Hematologic abnormalities --forming bruising,
purpura, bleeding --forming bruising, purpura, bleeding
--quantities of platelets is normal, but --quantities of platelets
is normal, but platelet function is abnormal. platelet function is
abnormal. --IgM produces an increased erythrocyte --IgM produces an
increased erythrocyte sedimentation rate. (rouleaux formation)
sedimentation rate. (rouleaux formation) Blurred vision is abnormal
Blurred vision is abnormal Glomerular lesions are the predominant
form of real injury. Glomerular lesions are the predominant form of
real injury. Congestive heart failure. Congestive heart
failure.
Slide 16
Waldenstrom s macroglobulinemia Immunologic Manifestations
Accumulation of monoclonal IgM in the circulationg plasma and of
plasmacytoid lymphocytes in the bone marrow. Accumulation of
monoclonal IgM in the circulationg plasma and of plasmacytoid
lymphocytes in the bone marrow. Cryoglobulin can be detected
Cryoglobulin can be detected --precipitate or gel when cooled to 0c
--precipitate or gel when cooled to 0c --fix complement and
initiate an --fix complement and initiate an inflammatory reaction.
inflammatory reaction. Occasionally, the macroglobulin is
cryoprecipitable and capable of cold-induced, anti-i-mediated
agglutination of red cells. Occasionally, the macroglobulin is
cryoprecipitable and capable of cold-induced, anti-i-mediated
agglutination of red cells.
Slide 17
Heavy-Chain Disease The presence of monoclonal proteins
composed of the heavy-chain portion of the Ig molecule. The
presence of monoclonal proteins composed of the heavy-chain portion
of the Ig molecule. Alpha heavy-chain disease is the most frequent.
Alpha heavy-chain disease is the most frequent.
Slide 18
Light-Chain Disease 10%~15% of monoclonal gammopathies. 10%~15%
of monoclonal gammopathies. Only kappa or lambda monoclonal light
chains or Bence Jones proteins are produced. Only kappa or lambda
monoclonal light chains or Bence Jones proteins are produced.
Serum viscosity Elevated serum viscosity (SV) levels commonly
occur in patients with Waldenstrom s macroglobulinemia (WM )as a
result of excess serum IgM production. Elevated serum viscosity
(SV) levels commonly occur in patients with Waldenstrom s
macroglobulinemia (WM )as a result of excess serum IgM production.
The normal SV ranges from 1.4-1.8 units. The normal SV ranges from
1.4-1.8 units. hyperviscosity : viscosity greater than 5 units.
hyperviscosity : viscosity greater than 5 units.
Serum Electrophoresis (SEP) excellent low cost screen for
initial discovery of gammopathies excellent low cost screen for
initial discovery of gammopathies If Negative, go no further If
Negative, go no further If positive, order Immunoelectrophoresis
(IEP) or Immunofixation (IFE) If positive, order
Immunoelectrophoresis (IEP) or Immunofixation (IFE) Under SEP test
instructions, can state Do IEP if abnormal gamma region detected
Under SEP test instructions, can state Do IEP if abnormal gamma
region detected Good monitoring tool - Can quantitate grams in
monoclonal peak Good monitoring tool - Can quantitate grams in
monoclonal peak
Slide 23
Serum electrophoresis (SEP) Thin layer agarose - High
resolution and Cellulose acetate - 5 zone resolution Thin layer
agarose - High resolution and Cellulose acetate - 5 zone resolution
To trained eye 5 Zone sensitivity equal to IFE To trained eye 5
Zone sensitivity equal to IFE Scaning by densitometry yields
quantitative measure of monoclonal peak relative to total protein
Scaning by densitometry yields quantitative measure of monoclonal
peak relative to total protein
Slide 24
Slide 25
Immunoelectrophoresis 1. Identifies Ig Class: Qualitative not
quantitative 2.Not good monitoring tool 3. Presently, if IEP is
questionable or inconclusive, IFE is automatically performed 4.
Being replaced by IFE
Slide 26
Immunofixation Identifies Ig Class Identifies Ig Class
Qualitative not quantitative Qualitative not quantitative Not good
monitoring tool Not good monitoring tool More sensitive than IEP at
identifying monoclonal gammopathie More sensitive than IEP at
identifying monoclonal gammopathie
Slide 27
Immunodeficiency Immunodeficiency
Slide 28
Classification Primary vs. secondary immunodeficiency Primary
vs. secondary immunodeficiency Antibody (B cell) immunodeficiency
diseases Antibody (B cell) immunodeficiency diseases T cell
immunodeficiency diseases T cell immunodeficiency diseases Combined
B cell and T cell immunodeficiency diseases Combined B cell and T
cell immunodeficiency diseases Phagocyte dysfunction diseases
Phagocyte dysfunction diseases Complement abnormalities Complement
abnormalities
Slide 29
Slide 30
Slide 31
B cell immunodeficiency diseases
Slide 32
X-linked agammaglobulinemia Definition: An inherited disorder
characterized by very low levels of protective immunoglobulins;
affected people develop repeated bacterial infections. An inherited
disorder characterized by very low levels of protective
immunoglobulins; affected people develop repeated bacterial
infections. IgG
Slide 33
XLA involves an absence of mature,peripheral B cells.
Slide 34
XLA is now known to be largely due to a defect in a gene
encoding a tyrosine kinase - btk (Brutons tyrosine kinase). 90-95%
of patients with XLA have a mutation in btk. Btk is involved in
activation of PLC during B cell activation (cooperatively with Syk
and BLNK)
Slide 35
X-linked hyper IgM syndrome(CD40L deficiency) Definition:
Definition: Normal to elevated serum levels of IgM Normal to
elevated serum levels of IgM 150~1000mg/dl, reduced IgG and IgA
150~1000mg/dl, reduced IgG and IgA Defective CD154 (CD40L) on T
cells, defective isotype switching to IgG and IgA isotypes
Defective CD154 (CD40L) on T cells, defective isotype switching to
IgG and IgA isotypes Limited IgM responses to antigens Limited IgM
responses to antigens
Slide 36
Slide 37
Selective deficiency of IgA Definition: Low levels of or
complete absence of IgA (
Slide 38
Selective IgG subclasses deficiency Definition: These patients
are susceptible to bacterial infections. These patients are
susceptible to bacterial infections. deficiency of one ore more IgG
subclass deficiency of one ore more IgG subclass IgG1 Response to
protein antigen IgG2 Response to polysaccharide IgG3 Response to
protein antigen IgG4 High in allergic dz;block IgE response
Slide 39
T cell immunodeficiency diseases
Slide 40
Digeorges Syndrome Definition: Absence of T cell function in
peripheral blood due to defective development of 3 rd and 4 th
pharyngeal pouches in Absence of T cell function in peripheral
blood due to defective development of 3 rd and 4 th pharyngeal
pouches in hypoplasia of the thymus hypoplasia of the thymus
Athymic mouse or rat model Athymic mouse or rat model Alternative
Names: catches 22 catches 22
Slide 41
Combined B cell and T cell immunodeficiency diseases
Slide 42
Severe combined immunodeficiency disease Definition: Over half
of all SCID cases are due to a defect in a gene on the X
chromosome. Over half of all SCID cases are due to a defect in a
gene on the X chromosome. The gene involved encodes the gamma
subunit of the IL-2 receptor. The gene involved encodes the gamma
subunit of the IL-2 receptor. This is also the gamma subunit of the
receptors for (at least): This is also the gamma subunit of the
receptors for (at least): - IL-4 - IL-7 - IL-9 - IL-15
Slide 43
Slide 44
Wiskott-Aldrich syndrome (WAS) Definition: 1 in 250,000 births,
1 in 250,000 births, normal T cell numbers with reduced functions,
normal T cell numbers with reduced functions, IgM are reduced but
IgG levels are normal. IgM are reduced but IgG levels are normal.
Both IgA and IgE levels are elevated. Both IgA and IgE levels are
elevated. Syndrome develop severe eczema, petechia (due to platelet
defect and thrombocytopenia). Syndrome develop severe eczema,
petechia (due to platelet defect and thrombocytopenia). They
respond poorly to polysaccharide antigens and are prone to pyogenic
infection. They respond poorly to polysaccharide antigens and are
prone to pyogenic infection. defect in WAS protein (WASP) which
binds Cdc42, a GTP binding protein known to regulate cytoskeletal
reorganization and important for collaboration of T and B cells
defect in WAS protein (WASP) which binds Cdc42, a GTP binding
protein known to regulate cytoskeletal reorganization and important
for collaboration of T and B cells
Slide 45
Slide 46
Initial Screening evaluation
Slide 47
Antibody-mediated immunity IgG IgM IgA level IgG IgM IgA level
Anti-A anti-B antibody titer Anti-A anti-B antibody titer Specific
antibody titer Specific antibody titer
Slide 48
Cell-mediated immunity Complete blood count (CBC) Complete
blood count (CBC) Different count Different count Total T cells and
T cell subsets Total T cells and T cell subsets Skin test Skin
test
Slide 49
Therapy Intravenous immunoglobulin (IVIG) Intravenous
immunoglobulin (IVIG) Bone marrow transplantation Bone marrow
transplantation Gene therapy Gene therapy
Slide 50
Phagocytic dysfunction diseases susceptible to bacterial but
not viral infection susceptible to bacterial but not viral
infection extrinsic defects: deficiency of antibody and complement,
or immunosuppression extrinsic defects: deficiency of antibody and
complement, or immunosuppression intrinsic defects: enzyme or
adhesion molecules defect. intrinsic defects: enzyme or adhesion
molecules defect. Acquired vs. congenital phagocytic defect
Acquired vs. congenital phagocytic defect
Slide 51
Phagocytic dysfunction diseases Neutropenia Neutropenia
Disorders of adhesion (Leukocyte adhesion deficiency, LAD)
Disorders of adhesion (Leukocyte adhesion deficiency, LAD)
inherited deficiency of CR3 receptor and LFA-1 (integrin) inherited
deficiency of CR3 receptor and LFA-1 (integrin) Disordrs of
mobility Disordrs of mobility Lazy leukocyte syndrome Lazy
leukocyte syndrome Disorders of chemotaxis Disorders of chemotaxis
Chediak-Higashi syndrome (CHS) Chediak-Higashi syndrome (CHS)
Pelger-Huet anomaly Pelger-Huet anomaly Hyper IgE (Jobs) syndrome
Hyper IgE (Jobs) syndrome
Slide 52
Disorder of adhesion : CR3 deficiency Complement receptor 3
deficiency Complement receptor 3 deficiency Autosomal recessive
trait Autosomal recessive trait Present as a leukocyte adhesion
deficiency Present as a leukocyte adhesion deficiency Marked
abnormalities of adherence related functions Marked abnormalities
of adherence related functions Lack an intravascular marginating
pool Lack an intravascular marginating pool
Granular disorders Chediak Higashi Syndrome Chediak Higashi
Syndrome Myeloperoxidase Deficiency Myeloperoxidase Deficiency
Specific Granule Deficiency Specific Granule Deficiency
Slide 55
Chediak Higashi Syndrome Autosomal recessive Autosomal
recessive Have giant granules display delay killing of ingested
bacteria Have giant granules display delay killing of ingested
bacteria Mutation in a protein involved in the regulation of
intracellular trafficking Mutation in a protein involved in the
regulation of intracellular trafficking
Slide 56
Chediak Higashi Syndrome
Slide 57
Myeloperoxidase Deficiency Autosomal recessive trait on
chromosome 17 Autosomal recessive trait on chromosome 17 MPO
negative MPO negative Not usually associated with increased
infection Not usually associated with increased infection Mild to
marked defect in bacteria-killing ability of neutrophils Mild to
marked defect in bacteria-killing ability of neutrophils
G6PD deficiency Glucose-6-phosphate dehydrogenase deficiency
Glucose-6-phosphate dehydrogenase deficiency X-linked X-linked
Unable to generate enough NADPH Unable to generate enough
NADPH
Slide 61
Nitro blue tetrazolium test (NBT) Principle: Fresh heparinized
blood incubated with NBT dye, allowing phagocytosis to occur.
Following ingestion, NBT reacts with superoxide and is reduced to a
black substance called formazan. Principle: Fresh heparinized blood
incubated with NBT dye, allowing phagocytosis to occur. Following
ingestion, NBT reacts with superoxide and is reduced to a black
substance called formazan. Interpretation: normal > 14%.
Stimulated (add latex particles) results are usually 2 to 3 times
the normal range. Interpretation: normal > 14%. Stimulated (add
latex particles) results are usually 2 to 3 times the normal range.
Chemiluminescence, and Flow cytometry have been used to replace NBT
Chemiluminescence, and Flow cytometry have been used to replace
NBT
Slide 62
Positive Reduced NBT is seen as dark-blue crystals Negative
Unstimulated neutrophils, or stimulated neutrophils from patients
who have CGD fail to reduce NBT
http://www.immunologyclinic.com/figure.asp?chap=03&fig=6-12a