ACAAI

TAO LE BRET HAYMORE
VIVIAN HERNANDEZ-TRUJILLO GERALD LEE
ACAAI REVIEW
THE ALLERGY &
FOR
SECOND EDITION
IMMUNOLOGY
BOARDS
Concise topic summaries
ideal for quick review
Hundreds of color images and
tables that enhance study
Key facts and mnemonics
for easy memorization
test critical concepts

ACAAI REVIEW
ALLERGY &
FOR
THE
IMMUNOLOGY
BOARDS
SECOND EDITION
Tao Le, MD, MHS

Associate Clinical Professor of Medicine and Pediatrics
Chief, Section of Allergy and Immunology
Department of Medicine
University of Louisville School of Medicine, Kentucky
Bret Haymore, MD
Assistant Professor
University of Oklahoma Health Science Center
Medical Director, BreatheAmerica
Tulsa, Oklahoma
Vivian Hernandez-Trujillo, MD
Director, Division of Allergy and Immunology
Miami Children's Hospital
Clinical Assistant Professor
Herbert Wertheim College of Medicine
Miami, Florida
Gerald Lee, MD
Assistant Professor
Section of Allergy and Immunology
Department of Pediatrics
University of Louisville School of Medicine, Kentucky
American College of Allergy, Asthma & Immunology

ACAAI Review for the Allergy and Immunology Boards, Second Edition
Copyright © 2013 by American College of Allergy, Asthma & Immunology. All rights reserved.
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required. The authors and the publisher
of this work have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards accepted at the time of
publication. However, in view of the possibility of human error or changes in medical
sciences, neither the authors nor the publisher nor any other party who has been involved in
the preparation or publication of this work warrants that the information contained herein is in
every respect accurate or complete, and they disclaim all responsibility for any errors or
omissions or for the results obtained from use of the information contained in this work.
Readers are encouraged to confirm the information contained herein with other sources. For
example and in particular, readers are advised to check the product information sheet included
in the package of each drug they plan to administer to be certain that the information
contained in this work is accurate and that changes have not been made in the recommended
dose or in the contraindications for administration. This recommendation is of particular
importance in connection with new or infrequently used drugs.
DEDICATION
To our families, friends, and loved ones, who encouraged and assisted us in the task of
assembling this guide.
v
CONTENTS
Contributing Authors ix
Senior Reviewers xi
Preface xiii
Acknowledgements xv
How to Contribute xvii
SECTION I. BASIC SCIENCE
Chapter 1. Immune Mechanisms 1

Yong Luo MD, PhD & Joon H. Park, MD
Antigens
Major Histocompatibility Complex Cytokines, Chemokines, and Their Receptors
Immunologic Tolerance Cell Adhesion Molecules
Immunogenetics Complements and Kinins
Immunoglobulins Mucosal Immunity
T-Cell Receptors and Signaling Transplantation and Tumor Immunology
B-Cell Receptor Signaling Innate Immunity and Toll-Like Receptors
Chapter 2. Cells Involved in Immune Responses 67

Cindy Salm Bauer, MD & Michelle A Halbrich, MD
Lymphocytes Platelets
Monocytes, Macrophages, and Dendritic Cells Epithelial Cells
Mast Cells Endothelial Cells
Basophils Smooth Muscle
Eosinophils Fibroblasts
Neutrophils
Chapter 3. Specific Immune Responses 93

Cindy Salm Bauer, MD
Immediate Hypersensitivity Reactions Type III Hypersensitivity Reactions
Type I Hypersensitivity Reactions Type IV Hypersensitivity Reactions
Type II Hypersensitivity Reactions
vi
Chapter 4. Laboratory Tests 105

Michelle A Halbrich, MD, Hillary Hernandez-Trujillo, MD, & Ahila Subramanian, MD, MPH
Immunoglobulin Measurement Phagocytosis and Cell Killing
Mediator Detection Hybridoma and Monoclonal Antibodies
Cell Surface Markers and Receptors Immune Complexes
Lymphocyte Function: Cell Proliferation, Complement
Cytokine Production, and Cytotoxicity Molecular Biology Technology
Chemotaxis
Chapter 5. Anatomy, Physiology and Pathology 157

Kusum Ahila Subramanian, MD, MPH
Lymphoid System and Organs Skin
Upper Airway (Nose, Sinuses, and Middle Ear) Gastrointestinal
Remodeling of the Lower Airway
Chapter 6. Research Principles 183

Hillary Hernandez-Trujillo, MD
Experimental Design Informed Consent
Data Analysis and Biostatistics Adverse Event Reporting
Epidemiology
SECTION II. CLINICAL SCIENCE
Chapter 7. Hypersensitivity Disorders 193

Justin C. Greiwe, MD, Michelle A Halbrich, MD, Fatima S. Khan, MD, & Mariam Rasheed, MD
Rhinitis Interstitial Lung Disease
Sinusitis Chronic Obstructive Pulmonary Disease
Otitis Media Food Allergy
Conjunctivitis Anaphylaxis
Atopic Dermatitis (Eczema) Stinging Insect Allergy
Asthma Drug Reactions
Occupational Disease Urticaria
Lung Diseases Contact Hypersensitivity
Allergic Bronchopulmonary Aspergillosis and Vaccine, Principles and Reactions
Allergic Fungal Sinusitis Bronchiolitis
Hypersensitivity Pneumonitis Croup
Chapter 8. Immunological Disorders 297

Neeti Bhardwaj MD, MS, Timothy J. Campbell, MD, Michelle A Halbrich, MD, Fatima S. Khan,
MD, & Pavadee Poowuttikul, MD
Hereditary and Acquired Angioedema Immunologic Rejection and Organ

Congenital (Primary) Immunodeficiencies Transplantation
Acquired (Secondary) Immunodeficiencies Stem Cell Transplantation
Systemic Autoimmune Disease Graft-Versus-Host Reaction
vii
Immune Endocrinopathies (Thyroid, Diabetes, Leukemias, Lymphomas, Myelomas
and Adrenal) Granulomatous Diseases
Immunologic Renal Diseases Amyloidosis
Immunologic Skin Diseases Mastocytosis
Immunologic Eye Diseases Immunohematologic Diseases
Inflammatory Gastrointestinal Diseases Cystic Fibrosis
Immunologic Neuropathies Reproduction and the Immune System
Hypereosinophilic Syndromes Immunologic Aspects of Infectious Diseases
Chapter 9. Pharmacology and Therapeutics 421

Ahmed Butt, MD & Jonathan Romeo, DO
Allergen Avoidance Cytokine and Cytokine Receptor-Mediated

Immunotherapy Therapy
Histamine Antagonists Cellular Immune Reconstitution
Theophylline Immunoprophylaxis Vaccine
β Agonists and Blockers Apheresis
Leukotriene Pathway Modulators Anti-inflammatory Agents
Mast Cell Stabilizers Surgical Intervention With Sinuses and Middle
Anticholinergics Ear
Corticosteroids Controversial Treatments
Immunomodulators and Immunosuppressives Cardiopulmonary Resuscitation
Immunoglobulin Replacement Therapy Dermatologic and Ophthalmic Treatments
Gene Therapy
Chapter 10. Specific Diagnostic Modalities 485

Lisanne P. Newton, MD & Jonathan S. Tam MD
Skin Tests (Immunoassay for Total and Specific Serologic Tests for Autoimmunity
IgE) Molecular Diagnostics and Tissue Typing
Nasal Provocation Imaging
Pulmonary Function Tests Flow Cytometry and Cell Surface Markers
Bronchial Provocation Controversial Tests
Nasal and Sputum Smears Delayed Type Hypersensitivity Tests
Mucociliary Function Food Challenge
Serologic Tests
Chapter 11. Allergens and Antigens 533

Howard C. Crisp, MD & Jonathan S. Tam MD
Aerobiology Standardization & Stability of Antigens

Pollens Autoantigens
Molds and Fungi Infectious Agents
Indoor Allergens Foods
Pollutants Venom Allergen and Antigens
About the Editors 577

ix
CONTRIBUTING AUTHORS
Cindy Salm Bauer, MD Hillary S. Hernandez-Trujillo, MD

Physician, Division of Allergy and Immunology, Attending Physician, Connecticut Asthma &
Department of Pediatric Pulmonology, Phoenix Allergy Center; Clinical Assistant Professor,
Children's Hospital; Clinical Assistant Professor, Department of Pediatrics, University of
Department of Child Health, University of Connecticut School of Medicine, Division of
Arizona College of Medicine, Phoenix, Arizona Infectious Diseases and Immunology,
Connecticut Children's Medical Center, West
Neeti Bhardwaj MD, MS Harford, Connecticut
Assistant Professor of Pediatrics, Division of
Pediatric Allergy and Immunology, Department Fatima S. Khan, MD
of Pediatrics, Penn State Milton S. Hershey Physician, Allergy/Immunology, Grand Forks,
Medical Center, Penn State College of North Dakota
Medicine, Hershey, Pennsylvania
Yong Luo MD, PhD
Ahmed Butt, MD Fellow, Division of Allergy and Immunology,
Allergist/Immunologist, Allergy and Asthma Departments of Medicine and Pediatrics, North
Centers of Fredericksburg and Fairfax, Shore-LIJ Health System, Great Neck, New
Fredericksburg, Virginia York
Timothy J. Campbell, MD Lisanne P. Newton, MD

Fellow, Division of Allergy and Immunology, Fellow, Division of Allergy and Immunology,
Department of Pulmonology, Allergy and Department of Pulmonology, Allergy and
Critical Care Medicine. Respiratory Institute, Critical Care Medicine, Respiratory Institute,
Cleveland Clinic, Ohio Cleveland Clinic, Ohio
Howard C. Crisp, MD Joon H. Park, MD

Fellow-in-Training, Department of Allergy and Allergist and Immunologist, Clinical Allergy
Immunology, Wilford Hall Ambulatory Surgical Center, Fairfax, Virginia
Center, San Antonio, Texas
Pavadee Poowuttikul, MD
Assistant Professor, Assistant Program Director,
Justin C. Greiwe, MD Allergy/Immunology, Children's Hospital of
Fellow, Division of Allergy and Immunology, Michigan, Wayne State University, Detroit,
Department of Pulmonology, Allergy and Michigan
Critical Care Medicine, Respiratory Institute,
Cleveland Clinic, Ohio Mariam Rasheed, MD
Assistant Professor of Pediatrics, Albert Einstein
Michelle A Halbrich, MD College of Medicine, Division of Allergy and
Fellow, Paediatric Clinical Immunology and Immunology, Department of Pediatrics;
Allergy, McGill University, Montreal Children’s Attending Physician, The Children's Hospital at
Hospital, Quebec, Canada Montefiore, New York, New York
x
Jonathan Romeo, DO Jonathan S. Tam MD

Instructor in Internal Medicine and Pediatrics, Assistant Professor of Pediatrics, Division of
Section of Pulmonary, Critical Care, Allergy, Clinical Immunology and Allergy, Children's
and Immunologic Diseases, Wake Forest Hospital Los Angeles, Department of Pediatrics
University School of Medicine, Winston Salem, University of Southern California, Los Angeles,
North Carolina
California
Ahila Subramanian, MD, MPH
Fellow, Division of Allergy and Immunology,
Department of Pulmonology, Allergy and
Critical Care Medicine, Respiratory Institute,
Cleveland Clinic, Ohio
xi
SENIOR REVIEWERS
Matthew Adam, MD Mark Glaum, MD, PhD
Assistant Professor in Pediatrics; Chief, Associate Professor of Medicine and Pediatrics,
Rheumatology Division, Department of Division of Allergy and Immunology,
Pediatrics, Wayne State University, Detroit, Department of Internal Medicine, University of
Michigan South Florida Morsani College of Medicine,
Tampa, Florida
Reza Alizadehfar, BSc. MD FRCPC
Assistant Professor of Pediatrics, Pediatric Fred Hsieh, MD
Allergist Immunologist, Montreal Children’s Staff Physician, Department of Pulmonary,
Hospital, Montreal General Hospital, McGill Allergy and Critical Care Medicine; Staff
University Health Centre, Quebec, Canada Physician, Department of Pathobiology, Lerner
Research Institute, Cleveland Clinic, Ohio
Moshe Ben-Shoshan, Msc, MD,
Assistant Professor, Division of Allergy and Mitchell H. Grayson, MD
Clinical Immunology, Department of Pediatrics, Associate Professor of Medicine and Pediatrics,
Montreal Children's Hospital, Quebec, Canada Division of Allergy and Clinical Immunology,
Medical College of Wisconsin, Milwaukee
Larry Bernstein, MD
Associate Clinical Professor of Pediatrics, Faoud T. Ishmael, MD, PhD
Albert Einstein College of Medicine, New York, Assistant Professor of Medicine and
New York Biochemistry and Molecular Biology, Penn
State College of Medicine, Hershey,
Vincent R. Bonagura, MD Pennsylvania
Associate Chair, Department of Pediatrics;
Chief, Division of Allergy/Immunology; David Lang, MD
Jack Hausman Professor of Pediatrics; Professor Chairman, Department of Allergy and
of Molecular Medicine,Hofstra North Shore-LIJ Immunology; Co-Director, Asthma Center;
School of Medicine, Hempstead, New York; Director, Allergy and Immunology Fellowship
Professor, Elmezzi Graduate School of Program, Cleveland Clinic, Ohio
Molecular Medicine; Investigator, Feinstein
Institute for Medical Research, Manhasset, New Elena E. Perez, MD PhD
York Associate Professor, Chief of Pediatric Allergy
and Immunology, University of Miami Miller
Jason W. Caldwell, DO School of Medicine, Florida
Assistant Professor, Internal Medicine and
Pediatrics, Section on Pulmonary, Critical Care, Roxana Siles, MD
Allergic, and Immunological Diseases, Medical Associate Staff Physician, Department of
Center Boulevard, Winston-Salem, North Pulmonary, Allergy and Critical Care Medicine,
Carolina Cleveland Clinic, Ohio
Jim Fernandez MD PhD

Associate Staff Physician, Department of
Pulmonary, Allergy and Critical Care Medicine,
Cleveland Clinic Foundation, Ohio
xii
Elizabeth Secord, MD Julie Wang, MD

Associate Professor of Pediatrics; Chief and Assistant Professor of Pediatrics, Division of
Program Director, Division of Allergy/ Pediatric Allergy and Immunology, Mount Sinai
Immunology, Department of Pediatrics School of Medicine, New York
Wayne State University, Detroit, Michigan
Kevin M. White, MD
Monica Vasudev, MD Staff Physician, Department of Allergy and
Associate Professor of Medicine and Pediatrics, Immunology, Wilford Hall Ambulatory Surgical
Division of Allergy and Clinical Immunology, Center, San Antonio, Texas
Medical College of Wisconsin, Milwaukee
Frank S. Virant MD
Clinical Professor of Pediatrics, University of
Washington School of Medicine; Division
Chief, Allergy, Seattle Children's Hospital;
Associate Director, Allergy/Immunology
Training Program, Seattle, Washington
xiii
PREFACE
With this second edition of ACAAI Review for the Allergy and Immunology Boards, we continue
our commitment to providing fellows-in-training and A/I physicians with the most useful and up
to-date preparation guide for the ABAI examination. This text was written like other publications
in the First Aid board review series and is designed to fill the need for a high-quality, in-depth,
concept driven study guide for ABAI exam preparation. The second edition features all new
“embedded flashcards” to test your learning as well as revised and expanded high-yield topic
summaries and illustrations.
This book would not have been possible without the help of the many fellows-in-training,
physicians, and faculty members who contributed their feedback and suggestions. We invite you
to share your thoughts and ideas to help us improve ACAAI Review for the Allergy &
Immunology Boards. (See How to Contribute, p. xvii.)
Tao Le, MD, MHS

Louisville, Kentucky
Bret Haymore, MD
Tulsa, Oklahoma
Miami, Florida
Gerald Lee, MD
xv
ACKNOWLEDGMENTS
This has been a collaborative project from the start. We gratefully acknowledge the thoughtful
comments and advice of the fellows-in-training, A/I physicians, and faculty who have supported
the authors in the development of ACAAI Review for the Allergy and Immunology Boards.
Thanks to the ACAAI Board of Regents for their support and the funding necessary to undertake
this project. We thank Mark Frenkel for his contributions to the sections on gene therapy and
infectious agents. We also thank Dr. Luz Fonacier for her image contributions. For outstanding
editorial work, we thank Isabel Nogueira and Linda Davoli. We thank Louise Petersen for her
project editorial support. A special thanks to Thomson Digital for their excellent illustration
work.
Tao Le, MD, MHS

Bret Haymore, MD
Tulsa, Oklahoma
Miami, Florida
Gerald Lee, MD
xvii
HOW TO CONTRIBUTE
To continue to produce a current review source for the ABAI exam, you are invited to submit
any suggestions or corrections. Please send us your suggestions for:
• Study and test-taking strategies

• New facts, mnemonics, diagrams, and illustrations
• Relevant topics that are likely to be tested in the future
For each entry incorporated into the next edition, you will receive a personal acknowledgment in
the next edition. Also let us know about material in this edition that you feel is low yield and
should be deleted.
The preferred way to submit entries, suggestions, or corrections is via our email address:
boardreview@acaai.org
NOTE TO CONTRIBUTORS
All submissions become property of the ACAAI and are subject to editing and reviewing. Please
verify all data and spellings carefully. Include a reference to a standard textbook to facilitate
verification of the fact. Please follow the style, punctuation, and format of this edition if possible.
Section 1. Basic Science
1 Immune Mechanisms
ANTIGENS
The term antigen—a contraction of “antibody generator”—is a molecule that is

recognized by the immune system.
Definitions
Antigen is a molecule that is recognized by the immune system.

Immunogen is a molecule that induces immune responses other than immune
tolerance.
Hapten is a small-molecule antigen that requires covalent linkage to a larger
carrier to stimulate immune response (e.g., penicillin). Once an antibody to
hapten is generated, hapten can be recognized by the antibody itself.
Carrier is a macromolecular substance to which a hapten is coupled in order
to produce an immune response against the hapten.
Adjuvants are molecules that enhance the immune response. Adjuvants
release bound antigens to antigen-presenting cells (APCs) over a prolonged
period, interact with Toll-like receptors (TLRs), and stimulate chemokine and
cytokine release. Examples:
o Alum
o Freund’s adjuvant: Emulsified bacterial products (e.g., bacille Calmette- Flash Card Q1
Guérin [BCGs]) What is the hapten-
carrier effect?
o Incomplete Freund’s adjuvant: Water in oil emulsification
o Ribi adjuvant system: Squalene–Tween80–water and oil emulsification
o Titermax: Copolymers polyoxypropylene (POP) and polyoxyethylene
(POE) Flash Card Q2
Superantigen: Antigens that activate a large number of polyclonal T What are the common
lymphocytes. Examples of microbial toxin superantigens are provided in superantigens and
Table 1-1. related diseases?
2 / CHAPTER 1
Table 1-1. Superantigens

Source Toxin Disease
Staphylococcus aureus SEB Food poisoning
SEC2 Food poisoning
TSST Toxic shock syndrome
Streptococcus pyogenes SPE-C Streptococcal toxic shock syndrome

Abbreviations: SEB, staphylococcal enterotoxin B; SEC, staphylococcal enterotoxin C; TSST, toxic
shock syndrome toxin; SPE-C, streptococcal pyrogenic exotoxins C.
Key Fact
Superantigens bind the
Superantigens bind to a particular family of Vβ chain of the T-cell receptor (TCR),
Vβ region of TCRs bypassing the need for the specific major histocompatibility complex (MHC),
(CDR4) and outside of peptide, or TCR complex required for signal 1 (Figure 1-1). Stimulation of T cells
the peptide-binding by superantigens can lead to “cytokine storm.”
groove on the MHC
molecule.
Flash Card A1
Small-molecule antigen
requires covalent linkage
to a larger carrier to
stimulate adaptive
immune response. The
process is achieved in
collaboration between
hapten-specific B cells
and carrier-specific T
cells. This is the basis of
developing conjugated
vaccines.
Flash Card A2
SEB and SEC cause
food poisoning; TSST
and SPE-C cause toxic
shock syndrome. Figure 1-1. Superantigen.
IMMUNE MECHANISMS / 3
Composition of Antigens
Table 1-2 summarizes the composition of antigens.
Antigen Structure
Epitope (Antigenic Determinant)—Antigenic component identified by a unique
antibody.
Recognized by B lymphocytes:
Linear determinants or tertiary structure
Carbohydrates, amino acids (four to eight residues), and nucleic acids
Recognized by T lymphocyte:
Linear determinants
Amino acid peptides
Eight to 30 amino acids (MHC class I 8–11 aa and MHC class II 10–30 aa).
Key Fact
An understanding of antigen composition and factors influencing immunogenicity Conjugated vaccines
is critical to immunization development and the assessment of response to are T-independent
immunizations. antigens linked to a
carrier protein, which
Table 1-3 reviews factors that influence the immunogenicity of antigens. can trigger a T-
dependent response
Table 1-2. Composition of Antigens and memory. Examples
of conjugated vaccines
Antigen Immune Cell Surface B-Cell Vaccines
include 13-valent
Involved Molecule Response
pneumococcal vaccine
Involved
(Prevnar 13), Hib
Protein T–cell- MHC class I Isotype switch Diphtheria vaccines, and
dependent MHC class II Affinity Tetanus meningococcal vaccines
maturation (MCV4–Menactra and
Induced memory
Menveo).
response
Polysaccharide T–cell- No isotype Meningococcal
independent switch vaccine
Marginal zone B Predominantly (MSPV4—
cells and B1 IgM Menomune)
cells No affinity Pneumococcal
maturation vaccine 23-
Limited memory valent
Nucleic acids T–cell- MHC class I DNA vaccines
dependent/indep MHC class II in clinical trials
endent TLR9 (CpG
CTL and DCs recognization on
DCs)
Flash Card Q3
Lipids NKT cells MHC-like CD1
γδ T cells (NKT) Which type of T cells
Abbreviations: CTL, cytotoxic T lymphocyte; DCs, dendritic cells; MHC, major histocompatibility recognizes lipid antigens
complex; NKT, natural killer T cell.; TLR, Toll-like receptor and what is the
molecule involved?
4 / CHAPTER 1
Table 1-3. Factors Influencing Immunogenicity of Antigens

Non or Less
Factors Immunogenic
Immunogenic
Origin Foreign Self
Size Larger (usually) Smaller (usually)
Chemical Proteins, Nucleic acids
composition polysaccharides Lipids
(less), and lipids
Immunogen (activate NKT via
CD1)
Physical form Particulate and Soluble and native
denatured
Degradability Easily degradable by Not easily degradable
APCs (T-lymphocyte-
dependent)
Genetics Specific HLA-antigen
interactions (e.g.:
Biological system HLA-B* 5701 and
abacavir)
Age Extremes of age
Dose High dose Low dose

Prolonged course Single exposure
Repetitive exposure
Method of Route Parenteral Oral
administration Cutaneous
Adjuvant Use of adjuvant
increases
immunogenicity
Abbreviations: APCs, antigen-presenting cells; HAL, human leukocyte antigen; NKT, natural killer T
cell.
MAJOR HISTOCOMPATIBILITY COMPLEX (MHC)
MHC molecules are also known as human leukocyte antigens (HLA), which are
encoded on the MHC locus.
MHC molecules share certain features:

Each MHC molecule has one binding site.
MHC molecules are bound to cell membranes.
Interaction with T lymphocyte requires direct contact.
MHC molecules are expressed codominantly (MHC from both parents is
Flash Card A3 expressed on cell surfaces).
Natural killer T (NKT)
cells and CD1 molecule.
Structure
Table 1-4 summarizes differences between MHC class I and MHC class II
molecules.
Anchor residues:
Side chains of peptide, which strongly bind to pockets in the peptide-binding
cleft of MHC molecule. This interaction stabilizes the peptide in the cleft.
MHC Distribution
MHC class I is expressed on most nucleated cells. The expression of MHC class
II varies by cell type. Their expression is induced by cytokines produced by innate
and adaptive immune responses. APCs express both MHC class I and MHC class
II.
Features of MHC expression are reviewed in Table 1-5.
Table 1-4. Structure of MHC Class I and Class II Molecules

MHC Class I MHC Class II
Genes HLA-A, -B and -C HLA-DP, -DQ and -DR

Polypeptide chains α chain (α1, α2, α3) α chain (α1, α2)
(domains) β2-microglobulin β chain (β1, β2)
Restriction CD8 CD4
Binding site for TCR α3 binds CD8 β2 binds CD4
(nonpolymorphic)
Binding site for α1 and α2 α1 and β1
peptide (polymorphic) Flash Card Q4
Peptide-binding cleft Peptides 8–11 amino acids Peptides 10–30 amino acids What are the binding
sites for TCR on MHC
Antigenic sampling Intracellular Extracellular class I and class II
molecules, respectively?
6 / CHAPTER 1
Table 1-5. Cells That Express MHC Class I and MHC Class II
MHC Class I MHC Class II
Constitutive Most nucleated cells APC (dendritic cells, macrophages,
and B lymphocytes), thymic epithelia,
and activated T lymphocytes
Inducting Interferon (IFN)α, IFNβ, and IFNγ IFNγ
cytokines
Abbreviation: APC, antigen-presenting cell.
MHC Genome
Genes that encode MHC molecules are encoded on the short arm of chromosome
6, whereas the β2-microglobulin chain is encoded on chromosome 15. A map of
the human MHC is shown in Figure 1-2.
In addition to encoding the MHC polypeptides, the MHC genome encodes

proteins involved in the processing of peptides that occupy the peptide-binding
clefts.
The class III region encodes:

Proteins of the complement system: Factor B, C4a, C4b, and C2
Cytokines: Tumor necrosis factor (TNF)α, and lymphotoxins α and β
Heat shock proteins
The class I-like proteins are highly conserved. They include:

HLA-E: NK cell recognition
HLA-F: Localized to endoplasmic reticulum and Golgi apparatus
HLA-G: On fetal-derived placental cells
HLA-H: Involved in iron metabolism
Antigen Processing and MHC Presentation

Intracellular and extracellular proteins can be processed by specific pathways and
are presented in association with MHC class I or MHC class II molecules.
Summaries of class I and class II antigen-processing pathways can be found in
Figures 1-3 and 1-4, respectively.
Flash Card A4
α3 and β2.
Figure 1-2. Map of the human MHC genome.
MHC I Pathway
Newly synthesized MHC class I polypeptides remain sequestered in the
endoplasmic reticulum by interacting with calnexin, calreticulin, Erp57, and Key Fact
tapasin.
Viruses develop
Cytoplasmic proteins that enter the cytoplasm are degraded to antigenic strategies to evade
peptides by the proteasome: MHC class I
o The proteasome is a multisubunit proteinase. Four seven-membrane rings presentation. Herpes
have catalytic subunits. simplex virus (HSV) can
block TAP
o Examples of subunits are: Low-molecular-mass polypeptide (LMP) 7 and transportation, and
LMP2. cytomegalovirus (CMV)
o LMPs are encoded in MHC class II locus. can remove MHC class I
Antigenic peptides are transported into the endoplasmic reticulum by molecule from ER.
transporter of antigenic-processing (TAP) proteins.
o Energy-dependent transport of peptides.
o Composed of two subunits: TAP1 and TAP2, both of which must be
present for function.
o TAP proteins are encoded in MHC class II locus. Flash Card Q5
Antigenic peptides are loaded onto newly synthesized MHC class I MHC class I molecule
polypeptides. presents which type of
MHC class I and antigenic peptide are transported to cell surface. antigens and where
Stable MHC class I expression requires presence of antigenic peptide. does the antigen-MHC
class I loading happen?
8 / CHAPTER 1
Figure 1-3. MHC class I antigen-processing pathway.
MHC II Pathway
Extracellular antigen is endocytosed and compartmentalized in cytosolic
phagosomes.
Phagosomes fuse with lysosomes. The resulting phagolysosome degrades the
microbe into antigenic peptides by endosomal and lysosomal proteases
(cathepsins).
Key Fact Newly synthesized MHC class II molecules are synthesized in the ER and
HLA-DM is an transported to the phagolysosome, forming the MHC class II vesicle. The
intracellular protein MHC class II-binding cleft is occupied by the invariant chain (Ii) prior to
involved in MHC class II peptide loading.
antigen processing and In the MHC class II vesicle, the Ii is degraded by proteolytic enzymes, leaving
does not present
antigenic peptides nor is
behind a short peptide named class II-associated invariant chain peptide
it a component of MHC (CLIP).
class II. HLA-DM removes CLIP and allows antigenic peptides to be loaded in the
MHC-binding cleft.
MHC class II and peptide are transported to cell surface.
Stable MHC class II expression requires presence of antigenic peptide.
Defect in MHC Expression and Disease
Flash Card A5 Bare Lymphocyte Syndromes (MHC Class I and MHC Class II
Deficiencies)—The bare lymphocyte syndromes are primary immune
Intracellular antigens
(e.g., viral antigen in deficiencies due to a lack of MHC expression. Features of MHC class I and MHC
cytoplasm) and the class II deficiencies are reviewed in Table 1-6.
loading site is
endoplasmic reticulum
(ER).
Figure 1-4. MHC class II antigen-processing pathway.
Table 1-6. Bare Lymphocyte (MHC Deficiency) Syndromes

MHC Class I Deficiency MHC Class II Deficiency
Mutation Genes encoding for TAP— Genes encoding for mutations in several
essential for MHC class I transcription factors required for MHC class
expression. II expression: MHC2TA, RFX5, FRXAP, and
FRXANK
Inheritance Autosomal recessive Autosomal recessive

(rare)
Clinical Sinopulmonary infections, Diarrhea, hepatosplenomegaly,

features granulomatous skin lesions, and transaminitis, sclerosing cholangitis
necrobiosis lipoidica (Cryptosporidium parvum), pulmonary
infections (Pneumocystis jiroveci,
encapsulated bacteria, Herpesviridae, and
RSV), and meningitis
Laboratory CD8 lymphopenia, PBMC on flow CD4 lymphopenia (reversed CD4:CD8)

cytometry lack MHC class I Lack of HLA DR/DP/DQ on lymphocytes,
DTH
Hypogammaglobulinemia
Absent germinal centers from lymph nodes
Treatment Treat pulmonary infections like Hematopoietic stem cell transplantation Flash Card Q6
CF (aggressive toileting and (HSCT)
chest PT) MHC class II molecule
presents which type of
Abbreviations: CF, cystic fibrosis; DTH, delayed-type hypersensitivity test; MHC, major antigens and where
histocompatability complex; PMBC, peripheral blood mononuclear cells; RSV, respiratory syncytial
virus; TAP, . transporter-associated with antigen presentation.
does the antigen-MHC
class II loading happen?
10 / CHAPTER 1
IMMUNOLOGIC TOLERANCE
Definitions
Tolerance is unresponsiveness to an antigen. This can be to self-antigens (i.e.,

self-tolerance) or to foreign antigens. Self-tolerance is part of the normal
function of educating the immune system not to react to itself.
Tolerogens are antigens that induce tolerance. A foreign antigen that becomes
a tolerogen is conditional. The antigen may only induce tolerance under
certain conditions, like age or the amount of antigen being at a very low or
high concentration.
Anergy is a state of unresponsiveness to antigenic stimulation. The antigen is
recognized by the immune cell; but weak signaling, due to a lack of
costimulation, leads to anergy. Other factors include antigen type and antigen
dose.
Key Fact Central Tolerance

Mutation in the AIRE
gene produces disorders Central tolerance occurs in the lymph organs.
such as autoimmune
polyglandular syndrome
(APS). Lymphocytes are
not deleted or tolerized Central T-Lymphocyte Tolerance
to endocrine-related self-
antigens. The endocrine In T-lymphocyte central tolerance, a T-lymphocyte precursor is exposed to a
organs are attacked by self-antigen in the thymus. The T lymphocyte is exposed to a self-antigen, which
autoreactive T
lymphocytes and
yields two fates: apoptosis, which is also known as negative selection, or
autoantibodies. development into a regulatory T (Treg) cell, which will migrate to the periphery.
The two main factors determining tolerance or negative selection are antigen
concentration and affinity to the TCR. High concentration and high affinity
Key Fact promote negative selection.
κ light chains are
rearranged first. If The thymus presents self-antigens through thymic antigen-presenting
receptor editing is lymphocytes that process antigen in the context of HLA class I and II. The
needed, a λ light chain autoimmune regulatory gene (AIRE) is expressed in the thymus. This gene
will be used. promotes expression of nonthymic tissue antigens in the thymus!
Flash Card A6 Central B-Lymphocyte Tolerance

Extracellular antigens
(e.g., antigens from In B-lymphocyte central tolerance, the precursor B lymphocyte is exposed to a
phagocytosed bacteria) self-antigen in the bone marrow during development. The immature B
and loading site is lymphocyte is exposed to self-antigen, which yields three fates: apoptosis (or
phagolysosome.
negative selection), receptor editing, or anergy. Receptor editing involves

reactivation of RAG1 and RAG2 when a high-affinity self-antigen is recognized
by a B-cell receptor (BCR). The RAG enzymes will delete the previously
rearranged VκJκ exon and give the BCR a new light chain. As a result, the self-
reactive immature B cell will have a new specificity. If both recombinations
recognize a self-antigen (failure of editing), the immature B lymphocyte will be
deleted by apoptosis. In low antigen concentration, the B lymphocyte may
become anergic to the self-antigen.
Peripheral Tolerance
In both T and B lymphocytes, peripheral tolerance occurs in peripheral tissues
when a mature lymphocyte encounters a self-antigen. In the case of a T
lymphocyte, if recognition of self-antigen occurs, the T lymphocyte may be
induced to undergo apoptosis, may become anergic, or a Treg cell that confers
suppression. In this situation, a B lymphocyte will either become anergic or be
deleted through apoptosis.
Peripheral T-Lymphocyte Tolerance

Key Fact
Peripheral tolerance has the same outcomes as central tolerance: Anergy, deletion,
or regulation. Lack of a second signal or lack of innate costimulation (e.g., Lack of costimulation, or
lack of an innate immune
microenvironment) produces the anergy of the peripheral T lymphocytes.
system response to the
antigen, blunts the
Anergy in these T lymphocytes is maintained by blockade of TCR signaling, required upregulation to
ubiquitin ligases (which target proteins for degradation), and inhibitor achieve costimulation
costimulatory molecules (e.g., CTLA-4 and PD-1). Dendritic cells may also (i.e., a second signal). T
lymphocytes recognize
present self-antigen without expression of costimulatory molecules.
the antigen, but receive
no support to activate.
After repeated recognition
Maintenance of Tolerance without costimulation, the
lymphocyte becomes
unresponsive to that
Dendritic cells that are not activated or that are immature still present self-antigen
antigen (i.e., anergic).
on their surfaces. These cells in an immature state do not express receptors, thus Once a cell is anergic,
antigen presented to T lymphocytes will not have a second signal, resulting in costimulation will not
tolerance. This presentation of antigen by the dendritic cell is ongoing, which restore activation.
reminds cells not to be self-reactive (Table 1-7.)
Treg cells are a component of the immune system involved in suppressing

immune response of other cells. They are mainly thymic emigrants that respond to Flash Card Q7
self-antigen. Development of Treg cells in thymus depends on the binding affinity Which B-cell-exclusive
between the cells and self-peptide/MHC II complex. T cells with strong binding process is involved in
developing central
will undergo negative selection (apoptosis). T cells with weak binding will
tolerance and which two
undergo positive selection (effector cells). T cells with intermediate binding will enzymes are important
in this process?
12 / CHAPTER 1
Table 1-7. To Be or Not to Be: Tolerance to Self-Protein Antigen

Determinant Immunogenicity Tolerance Comments
Dose Optimal Optimal dose varies.
Exposure Gets tired of seeing
the same thing and
ignores it, until it
becomes
“background.”
Delivery route Cutaneous and Oral Think about where
intradermal the APCs are
located. We have to
eat.
Adjuvant T-lymphocyte help Without an adjuvant Adjuvant can
promote
costimulation. It gets
Key Fact the team involved.
Treg cells play a critical APCs Activated and Inactivated and naïve Without
role in maintaining normal costimulators costimulation, there is
no activation, which
immune function.
yields immune
Classically Treg cells ignorance or
express CD4, CD25 and tolerance.
FoxP3. FoxP3 mutation in Abbreviation: APCs, antigen-presenting cells.
human causes immune
dysregulation,
polyendocrinopathy,
enteropathy X-linked become Treg cells. Despite being self-reactive, they are allowed to escape the
(IPEX) syndrome, which thymus and, instead, help to maintain self-tolerance.
is a fatal autoimmune
disorder characterized by Characteristically, Treg express CD4, CD25 (interleukin [IL-2R] α chain) and
a triad of watery diarrhea, FoxP3 (Foxhead box P3, a master transcription factor of Treg cells). Their
eczema, and
endocrinopathy. survival depends on IL-2 and transforming growth factor beta (TGFβ). Tolerance
or regulation is maintained by secretion of IL-10 and TGFβ. IL-10 targets
macrophages and dendritic cells, and TGFβ inhibits lymphocytes and
macrophages.
Key Fact
Mutations in Fas or Apoptosis is a key regulator of self-reacting T lymphocytes. Self-antigens
caspase 10 manifest as
repeatedly recognized by a T lymphocyte without costimulation can activate Bim,
autoimmune
lymphoproliferative which is a proapoptotic member of the Bcl-2 protein family. Bim leads to cell
syndrome (ALPS). The apoptosis through mitochondrial pathway.
lymphocytes do not
know when to die. They Cells presenting self-antigen without innate response or costimulation have other
accumulate in the lymph
receptors on their surfaces, such as Fas ligand (FasL) (CD95L) on the T
organs. There is a lack
of tolerance, producing lymphocyte. FasL is upregulated on repeatedly activated T lymphocytes. FasL can
autoimmune problems. interact with Fas (CD95) on the same cell or nearby cells, either deleting a self-
reactive T lymphocyte or causing the death of an activated cell, thereby
downregulating the immune response. The Fas:FasL interaction signals through
Flash Card A7 the caspase system.
Receptor editing. RAG1,
RAG2.
Peripheral B-Lymphocyte Tolerance
Because antigens cannot cross-link the BCR on their own, B cells cannot be
activated if there is no help from T cells. B cells will then become anergic or be
induced to apoptosis.
Chronic antigen recognition downregulates CXCR5, inhibiting B-lymphocyte

homing and interaction with T lymphocytes, which yields death.
To summarize, tolerance is a process by which the immune system teaches itself

not to react to self-antigens (Table 1-8). In central tolerance, the T lymphocyte
can be deleted by negative selection of high-affinity self-antigens or apoptosis; or
some “self-recognizers” can be released into the periphery to become regulator
cells to maintain tolerance. B-lymphocyte central tolerance can yield deletion;
but, prior to deletion, receptor editing may save the B lymphocyte from negative
selection. In low concentration of antigen, anergy is also a possibility. Peripheral
tolerance can result in deletion or anergy. Anergy occurs with antigen exposure,
without a second signal and/or inflammation.
Table 1-8. Summary of T- and B-Lymphocyte Tolerance

T Lymphocytes B Lymphocytes
Central Peripheral Central Peripheral
Location of Thymus Bone marrow
tolerance
Educational CD4+CD8+ T CD4+ or CD8+ T IgM+, IgD+ B
phenotype lymphocyte lymphocyte lymphocyte
(double positive) (single positive) (immature)
Why High avidity No co-stimulators Multivalent No T
become No inflammation antigen lymphocyte
tolerant? (innate) help
Repeated Chronic
stimulation stimulation
No
costimulation
Fate of self- Deletion Anergy (no signal) Receptor editing Anergy (no
recognition Become Death (apoptosis) Deletion signal)
regulatory Regulatory Follicular
suppression exclusion
Death
(apoptosis)
14 / CHAPTER 1
IMMUNOGENETICS
DNA
DNA is stored in the nucleus of cells.

Composed of subunits (or bases) called nucleotides, which include adenine
(A), guanine (G), thymine (T), and cytosine (C).
A and G are purines.
T and C are pyrimidines.
Organized into a double helix (the Watson-Crick model), in which A forms a
base pair with T and G forms a base pair with C.
RNA
Protein synthesis occurs via RNA.

Contains the pyrimidine uracil (U), instead of T.
mRNA is copied from DNA and travels to ribosome.
tRNA transports amino acids to ribosome.
rRNA and protein combine to make ribosomes.
Transcription is the synthesis of mRNA from DNA. Translation is the synthesis

of proteins from mRNA.
Genetic Mutations
Mutations result from changes in the nucleotide sequence of genes (Table 1-

9).
Germ-line mutations can be passed down via reproductive cells.
Somatic mutations involve cells outside the reproductive system and generally
do not get passed to subsequent generations.
Table 1-9. Types of Mutations

Mutation Consequence Code Translation
Frameshift Insertion or deletion causes a UUU UAC AAA GAC Phe Tyr Lys Asp
shift in the translational UUU ACA AAG ACA Phe Thr Lys Thr
reading frame. More dramatic
effect on peptide sequence
Missense Single-nucleotide substitution UUU UAC AAA GAC Phe Tyr Lys Asp
causes the translation of a UUG UAC AAA GAC Leu Tyr Lys Asp
different amino acid
Nonsense Single-nucleotide substitution UUU UAC AAA GAC Phe Tyr Lys Asp
causes an early stop (or UUU UAA AAA GAC Phe STOP
termination) codon
Silent Single-nucleotide substitution UUU UAC AAA GAC Phe Tyr Lys Asp
does not cause a change in UUU UAC AAG GAC Phe Tyr Lys Asp
amino acid sequence
Neutral Single-nucleotide substitution UUU UAC AAA GAC Phe Tyr Lys Asp
causes a different but similar UAU UAC AAA GAC Tyr Tyr Lys Asp Key Fact
amino acid to be translated
SNPs, which manifest
human genome
variations across
Single-Nucleotide Polymorphism different geographic and
ethnic groups, are
widely used in GWAS as
A single-nucleotide polymorphism (SNP) is a variation in DNA sequence that gene-mapping tools to
occurs when a single nucleotide in a gene of an individual is different from study the association
that of other individuals. between genes and
SNPs are not mutations. SNPs usually occur more frequently in noncoding diseases.
DNA sequences. Overall, these occur at a higher frequency than mutations.
SNPs occur in varying frequency between different geographic and ethnic
groups. Therefore, they are useful markers of human genetic variations, which Key Fact
sometimes underlie different susceptibilities to diseases.
Histone acetylation
SNPs are used in genome-wide association studies (GWAS) as high- opens the chromatin to
resolution gene-mapping markers related to various diseases. allow transcription.
Several SNPs have been identified that associate a higher risk of atopy or Histone deacetylation
change the response to medications used to treat atopic conditions (Table 1- represses gene
10). expression and is
reduced in chronic
obstructive pulmonary
Table 1-10. Selected SNPs Associated with Development of Atopic disease (COPD).
Disease
Gene Protein Protein Function Relevance in Atopy
Filaggrin Filaggrin Essential for epidermal barrier Increased risk of eczema and
gene asthma
17q12-21 ORMDL3 Unknown Increased risk of asthma
5q22-32 CD14 Lipopolysaccharide (LPS) Both increased as well as
receptor reduced risk of asthma and
atopy
16 / CHAPTER 1
Table 1-10. Selected SNPs Associated with Development of Atopic

Disease, cont.
Gene Protein Protein Function Relevance in Atopy
3p21-22 CCR5 Chemokine receptor Protection against nonatopic asthma
Xp22 TLR 7 and 8 Pattern recognition Increased risk for asthma, rhinitis,
receptor for viral ssRNA atopic dermatitis, and increased
specific IgE
5q31 IL-13 Cytokine that induces IgE Increased risk of asthma, bronchial
secretion, mucus hyper-responsiveness, and skin-test
production, and collagen responsiveness. Linked to response
synthesis to montelukast
ADRB2 β2-Adrenergic Adrenaline and Arg/Arg phenotype with decreased
receptor noradrenaline receptor albuterol response compared with
Gly/Gly phenotype at residue 16
ADAM33 Type 1 Involved in cell-to-cell Increased risk of asthma and
transmembrane interactions bronchial hyperresponsiveness
protein
Abbreviations: Arg, arginine; Gly, glycine; ssRNA, single-stranded RNA; TLR, Toll-like receptor.
Epigenetics
Epigenetics can be described as changes in gene function that occur without a
change in the sequence of DNA. These changes occur as a result of the interaction
of the environment with the genome. DNA methylation and histone
modification likely play a crucial role in the epigenetic regulation of immune
system genes.
IMMUNOGLOBULINS (Ig)
Igs are glycoprotein molecules produced by B lymphocytes and plasma cells in

response to an immunogen. Ig is the key component of humoral immunity. The
earliest cell in B-lymphocyte lineage that produces Ig is the pre-B lymphocyte.
An adult human produces approximately 2–3 g of Ig every day.
Ig Structure
The Ig molecule is a polypeptide heterodimer composed of two identical light
chains and two identical heavy chains connected by disulfide bonds (Figure 1-5).
Each chain consists of two or more Ig domains, which are compact, globular
structures of approximately 110 amino acids containing intrachain disulfide
bonds.
Heavy chains are designated by letters of the Greek alphabet (i.e., γ, α, µ, ε, δ) Key Fact
for Ig classes: G, A, M, E, and D, respectively. Human IgG consists of four
Omalizumab binds to
isotypes: IgG1, IgG2, IgG3, and IgG4. For example, IgG1 contains Cγ1 as its Cε3.
heavy chain. The constant (C) regions of IgG, IgA, and IgD consist of only three
CH domains. In IgM and IgE, the C regions consist of four CH domains.
Key Fact
Light chains κ and λ are identified by their C regions. κ is encoded on
chromosome 2 and λ is encoded on chromosome 22. An Ig molecule has either κκ The ratio of κ-bearing
(60%) or λλ (40%) but never one of each. An individual B lymphocyte will lymphocytes to λ-
bearing lymphocytes
produce only κ or λ chains but never both. can be used as an
indication of clonality
Hinge regions are proline-rich and provide Ig flexibility. Interchain disulfide and is, therefore, useful
bonds exist between the heavy-heavy and heavy-light chains. in diagnosing and typing
B-lymphocyte
lymphomas.
Ig fragments are produced from enzymatic cleavage of the Ig molecule. Papain
cleaves Ig above the hinge (as seen in Figure 1-5) and results in two Fab (antigen-
binding) fragments and one Fc (crystallizable) fragment. Pepsin cleaves Ig below
the hinge at multiple sites and produces F(ab′)2, which contains interchain Key Fact
disulfide bonds, and exhibits two antigen-binding sites. F(ab) can bind but not The most variable part
cross-link; and F(ab′)2 both binds and cross-links. Neither F(ab) nor F(ab′)2 will of Ig molecule is CDR3.
fix complement or bind to the Fc receptor on the cell surface.
Variable regions VL and VH form the antigen-binding sites that consist of

complementarity-determining regions (CDRs) of about 10 amino acids and
account for antibody diversity. There are three CDRs in each V region; CDR3 is
the most variable and, typically, has the most extensive contact with the antigen.
Flash Card Q8
What molecules belong
Figure 1-5. Immunoglobulin structure. to Ig superfamily?
18 / CHAPTER 1
Constant regions CH and CL are located at C-terminals of the Ig molecule. Only

CH mediates effector functions by binding to Fc receptors or binding complement.
Glycosylation of Igs is important in maintaining their structural stability and

effector functions. Human IgG has one conserved glycosylation site in the Cγ2
domain (asparagine-297). Deglycosylated IgG cannot bind FcγRs and C1q
effectively and therefore is unable to trigger antibody-dependent cell-mediated
cytotoxicity (ADCC) and complement activation. Decreased galactosylation has
been associated with many inflammatory and infectious diseases, such as
rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Crohn’s disease,
and tunerculosis (TB). Sialic acid enrichment in intravenous immunoglobulin
(IVIG) preparation significantly increases its anti-inflammatory activity.
Ig Forms
Two forms of Ig exist that differ in the amino acid sequence of the C-terminal end
of the CH.
Membrane-bound Ig (or surface Ig) is attached to the B-lymphocyte surface by

its transmembrane region. Once Ig molecules bind to antigens and are cross-
Key Fact linked, they serve as B-lymphocyte antigen receptors that mediate B-lymphocyte
The shortest half-life of activation.
all IgG subclasses is
IgG3. Secreted Ig molecules lack transmembrane regions and circulate in the plasma,
IgM fixes complement mucosal sites, and interstitial fluids. Secreted Ig can be in the form of monomers
most efficiently of any
(all Ig), dimers (IgA), or pentamers (IgM). Dimers or pentamers are formed by
Ig isotype.
Rheumatoid factor (RF) tail pieces connected by disulfide bonds to joining (J) chain.
is an antibody against
the Fc portion of IgG.
RF is most commonly
IgM, but can also be
Ig Characteristics
any other isotype.
Affinity is the strength of the binding between each molecule of Ig and antigen
epitopes, and is indicated by Kd. A numerically lower Kd indicates higher affinity.
Avidity is determined by the net effect of affinity and valence. It is an estimate of

the overall strength of the binding between Ig and antigen. A low-affinity IgM can
produce a high-avidity interaction by simultaneous binding to multiple antigen
epitopes, through 10 contact sites on each IgM molecule.
Flash Card A8 Ig Superfamily

TCR, MHC molecules,
CD4, CD8, CD19, B7-1, The Ig superfamily is a group of proteins that share similar structure to Ig by
B7-2, Fc receptors, KIR, having one or more domains composed of 70–110 amino acids, most typically
and VCAM-1. containing an intrachain disulfide loop. Examples of Ig superfamily members are
TCR, MHC molecules, CD4, CD8, CD19, B7-1, B7-2, Fc receptors, killer cell
immunoglobulin-like receptor (KIR), and vascular cell adhesion molecule 1
(VCAM-1).
Antigen Recognition
Key Fact
Ig can recognize highly diverse antigens through linear and conformational
determinants found in various macromolecules (i.e., proteins, polysaccharides, The only Ig to cross the
and lipids). TCRs only recognize linear determinants of peptides presented by placenta is IgG.
The Ig class with highest
MHC molecules. plasma concentration
is IgG.
The Ig class with highest
Ig Production total body
concentration and
daily production is IgA.
IgM is the first Ig produced after birth, the first to reach adult level, and the The poly-Ig receptor is
first to be synthesized following antigenic stimulation. synthesized by
Only IgG crosses the placenta. IgG level reaches a nadir around 4–6 months mucosal epithelial
cells and expressed
after birth due to decline in passively transferred maternal IgG. on their basolateral
IgA is produced in the highest quantity daily, and is found in higher surfaces. Once inside
concentrations in the respiratory and GI mucosal surfaces. It may take several the epithelial cell, IgA
years for IgA to reach adult levels. In the gastrointestinal tract, IgA is bound to the poly-Ig
produced by plasma cells in the lamina propria and is transported across the receptor is actively
transported in vesicles
mucosal epithelium by poly-Ig receptor (transcytosis). to the luminal surface.
Ig Isotypes
There are five Ig heavy chain isotypes. The isotypes differ in their biological
properties, functional locations and interactions with different antigens, as
depicted in Table 1-11.
20 / CHAPTER 1
Table 1-11. Immunoglobulin Isotypes

Isotype IgG IgA IgM IgE IgD
Subclasses IgG1 IgG2 IgG3 IgG4 IgA1 IgA2 none none none
Heavy chain γ1 γ2 γ3 γ4 α1 α2 µ ε δ
# Heavy 3 3 4 4 3
chains (CH)
Secreted form Monomer (150) Monomer (170), Monomer (180), Monomer (190) Monomer (180)
(MW in kDa) dimer (390) Pentamer (900)
430–1050 100–300 30–90 15–60 90–325 80– 50–250 0.0015–0.2 0.3–30
Serum level
in adult 290
(mg/dL) Total: 700–1500 Total: 60–450
Half-life 23 23 8 23 6 6 5 2 3
(days)
Cytokines IFNγ, IFNγ, IFNγ IL-4, TGFβ, IL-5 N/A IL-4, N/A
inducing class IL-4 TGFβ IL-13 IL-13
switch
Complement ++ + ++ – – +++ – –
fixation
Placental ++ + ++ ++ – – – –
transport
Properties Th1 Antipolysaccha Shortest half- Antipolysacchari Mucosal immunity Primary Allergic reaction Do not require
response, ride Ab life in IgG de Ab IgA1 in serum and response. (e.g., The only Ig bind to isotype switching
opsonizati Latest to reach subclasses Th2 response respiratory tract isohemagglutinin mast cells Exact function
on Best for adult level of Opsonization Elevated in IgA2 in lower GI and rheumatoid unknown
ADCC all IgG immunotherapy tract factor) B-cell maturation
subclasses marker
Abbreviations: Ab, antibody; ADCC, antibody-dependent cell-mediated cytotoxicity kDa, kilodaltons; MW, molecular weight..
General Functions of Ig
Antigen recognition by Ig initiates a humoral immune response. Ig selectively
captures antigens and microbial pathogens, including bacteria and viruses,
through noncovalent, reversible binding through the Ig V regions.
Key Fact
Ig-mediated effector functions include neutralization of microbes or toxins, Somatic hypermutation
opsonization, ADCC, and immediate hypersensitivity (IgE). These effector leads to changes in the
V but not the C regions.
mechanisms often require interaction of Ig with complement proteins or other
immune cells, such as phagocytes, eosinophils, and mast cells, through Fc Class switch
recombination changes
receptors. The functional features of Ig are summarized in Table 1-12. Some of
the C but not the V
these characteristics are also shared by TCR. regions.
Alternative splicing
changes Ig from
transmembrane to
Table 1-12. Functional Features of Ig secretory form.
Feature Description Results
Specificity Ability of Ig and TCR to Distinct antigens elicit specific
distinguish subtle differences in responses
molecular structures of antigen
Diversity Variability in the structures of the Large structurally distinct
antigen-binding site of Ig and antibody and TCR repertoires
TCR
Germ-line variation Variation in inherited (germ-line) Inherited structural differences
V, D and, J elements in Ig and create different basic structural
TCR frameworks
Combinatorial Result of different V, D, and J Moderate levels of immune
diversity (somatic segment rearrangement in receptor diversity
recombination) developing B and T lymphocytes
Junctional diversity Random (nontemplated) addition Extensive somatic variability in
or removal of nucleotide immune receptors
sequences at junctions between
V, D, and, J regions
Somatic Point mutations in V regions of Ig Selected increase (or
hypermutation in rapidly dividing B lymphocytes decrease) in antibody affinity
Receptor editing Changes in Ig specificity that Elimination of self-reactive Ig
express self-reactive antibody
achieved through secondary
rearrangements
Class switch Change in heavy-chain C regions, Switch in Ig isotype from IgM
recombination with same V region at the gene or IgD to IgG, IgA, or IgE
(Isotype switching) locus
Affinity maturation Process of somatic hypermutation ↑Ig affinity
and selective survival of B Flash Card Q9
lymphocytes that produce high-
Which somatic
affinity antibodies
recombination process
Alternative splicing Splicing at different locations in Production of membrane- introduces the greatest
the 3′ of C region exons bound or secreted Ig forms. diversity in immune
Splicing at different location of the Production of IgD from the receptors and which
C-terminal of the IgM gene same RNA transcript with IgM. enzyme is important in
Not conventional class switch this process?
22 / CHAPTER 1
Fc Receptors (FcRs)
FcRs are members of the Ig superfamily. Each Fc receptor functions as a receptor
specific for the CH region of the Ig molecule (Table 1-13). FcRs contain domains
for Ig-binding and signaling components.
T-CELL RECEPTORS AND SIGNALING
T-Cell Activation
T-lymphocyte progenitors arise in the bone morrow and travel to the thymus as
double-negative (CD4– and CD8–) and CD3+ cells. Once in the thymus, they are
educated and screened for reactivity. Then single-positive CD4+ or CD8+ T
lymphocytes enter the blood and lymph system as naïve T lymphocytes. Naïve T
lymphocytes recirculate through the lymph nodes looking for their unique protein
antigen as displayed in the context of an HLA molecule, class I for CD8+ T cells
and HLA class II for CD4+ T cells.
Table 1-13. Fc Receptors on Leukocytes

FcR CD Affinity Cell Distribution Function
Marker for Ig
For IgG FcγRI CD64 High Macrophages, Phagocytosis
neutrophils
eosinophils
FcγRIIA CD32 Low Macrophages, Phagocytosis (poor)
neutrophils,
eosinophils, platelets
FcγRIIB CD32 Low B lymphocytes Feedback inhibition of
B lymphocytes
FcγRIIIA CD16 Low NK cells, macrophages ADCC
FcγRIIIB CD16 Low Neutrophils, Phagocytosis (poor)

macrophages,
eosinophils
For IgE FcεRI High Mast cells, basophils, Degranulation, ADCC
eosinophils
FcεRII CD23 Low Neutrophils, Unknown
(not 32!) eosinophils,
monocytes
Flash Card A9 Abbreviations: ADCC, antibody-dependent cell-mediated cytotoxicity; NK, natural killer.
Junctional diversity and
TdT.
T-Cell Differentiation
Once the TCR-antigen HLA complex is formed, then activation can occur as
follows:
Activation requires a second signal or costimulation.
The most important cytokine produced during activation is the T-lymphocyte
survival signal, provided by IL-2 and its receptor CD 25.
Proliferation is clonal. It is stimulated by IL-2. Clonal expansion preserves
the specificity of the T lymphocyte for its particular antigen.
Once T lymphocytes are activated, they become either effector or memory T

lymphocytes (Table 1-14). Effector cells react to antigens. In the CD4+ lineage,
they induce differentiation of the T lymphocyte response, Th1, Th2, Treg, and
Th17. In the CD8+ population, the cells become cytolytic.
Effector cells function to eliminate antigen. With the decline in antigen
stimulation, there is a decline in T-lymphocyte activity and achievement of
homeostasis.
Memory cells are a subset of the clonally expanded population. These cells
are long-lived and functionally quiet. They provide a rapid secondary
response.
Costimulation Between Antigen-Presenting Cells and T

Cells
The costimulatory molecules are on the APCs. Their ligands are on the T
lymphocytes. There is no T-lymphocyte response without costimulation. The T
lymphocyte that recognizes the antigen, but is not costimulated, is said to be in a
state of anergy (nonresponsiveness). Key Fact
CD3 deficiency
Costimulators may produce activation or induce negative regulation of the produces severe
immune response (Table 1-15). combined
immunodeficiency
The TCR comes in two forms: αβ and γδ. (SCID).
Table 1-14. T-Cell Differentiation

Cell Clonal
Antigen Recognition Functional Differentiation
Activation Expansion
Effector CD4+ T cells (helper)

Naïve CD4+ T cells IL-2 production Proliferation of
cell with same Memory CD4+ T cells
Dendritic cells Upregulation antigen Effector CD8+ T cells (killer)
IL-2 receptor recognition
Naïve CD8+ T cells Memory CD8+ T cells
24 / CHAPTER 1
Table 1-15. Costimulator Expression and Function

APC DC/Mø/B cells DC/Mø/B cells DC/Mø/B cells DC/Mø/B cells DC/Mø/B cells
Costimulator on APC B7-1 (CD 80), B7-2 B7-1 (CD 80), B7-2 (CD ICOS-L CD40 PD-L1/PD-L2
(CD 86) 86)
APC
T cells
Receptor on T cells CD 28 CTLA4 (CD152) ICOS CD40L PD-1

(Inhibitory through ITIM) (Inhibitory through ITIM)
Expression Constitutive Inducible Inducible Inducible T, B, myeloid
cells/inducible
Effect Activation of naïve cells T-lymphocyte tolerance Costimulation of APC activation, Negative regulation, cell
Induction of CD40L, Th1 development effector T lymphocytes, germinal center death
OX40, CXR5, ICOS, implicated in Ab class development, class
CTLA-4 switching switching
Abbreviations: APC, antigen-presenting cells; CTLA, cytotoxic T-lymphocyte antigen; DC, dendritic cell; ICOS, inducible costimulator; ITIM, immuno-receptor
tyrosine-inhibitory motifs; Mø, macrophage; PD-1, programmed death.
αβ TCR
Structure—It is a heterodimer of an α and β chain, each with two Ig-like
domains. One is the variable domain, antigen contact, and HLA contact. The Key Fact
second Ig-like domain is the constant domain. The particular variable β or Vβ αβ TCRs recognize a
region of the TCR is the binding site for superantigen. single antigen only in
the context of an HLA
molecule. The receptor
Both chains have an extracellular region, constant region, transmembrane region, has no signaling ability
and a short cytoplasmic tail with no signaling molecules. The CDRs of both and requires accessory
chains are the sites of recognition of the peptide-HLA complex. molecules for signal
transduction.
αβ TCR affinity is less than that of antibodies; this, and the lack of signaling
motifs on the αβ receptor, sets the stage for the necessity for accessory molecules
and adhesion molecules to and from the TCR complex. Key Fact
The combination of the
TCR Complex—TCR complex consists of the TCR, CD3 and two zeta (ξ) chains chains and their Ig-like
(Figure 1-6). CD4 recognizes antigens presented in the context of HLA class II, domains are analogous
and CD 8 (not shown in Figure 1-6) recognizes antigens presented in the context to the immunoglobulin
of HLA class I antigens. Fab fragment. These
molecules undergo
recombination for their
In order for antigen-signaling transduction to be initiated, the entire TCR complex diversity. Both chains
is required to be expressed. The accessory molecules contain immunoreceptor have complementarity-
tyrosine-based activation motifs (ITAMs), which are required for signal determining regions
transduction. Antigen recognition is connected to activation through the TCR (CDRs), and like in an
complex. immunoglobulin, the αβ
CDR3 region of the TCR
imparts the most
significant sequence
variability.
Flash Card Q10

Mutation in SAP cause
Figure 1-6. TCR complex with CD4. which disease?
26 / CHAPTER 1
γδ T Lymphocytes
Key Fact
γδ T lymphocytes are similar in structure and association to αβ T lymphocytes. γδ
CD40 ligand: CD40 T lymphocytes require CD3 and the ζ chain for signal transduction. Most do not
stimulates activation-
induced cytosine
have CD4 or CD8. They are not HLA-restricted. Some antigens do not require
deaminase (AID), which processing. Some antigens are presented in MHC-like class I molecules. They are
is crucial for somatic thought to be a bridge between innate and acquired immunity.
mutation and isotype
switching.
Natural Killer T (NKT) Cells
Key Fact These cells express NK cell and T lymphocytes markers.

NKT cells recognize
lipids in the context of
CD1. TCR-Signaling Pathways
Role of CD4 and CD8 Molecules—These molecules dictate HLA restriction.
CD4 binds to HLA II molecules at a nonpolymorphic site. CD8 binds to HLA I
molecules at a nonpolymorphic site. The class II-binding site is the β2 region and
the class I-binding site is the α3 region; both contain Ig-like domains. These
molecules stabilize the immune synapse. They are also involved in signaling
through a Src family tyrosine kinase called lck. Lck is noncovalently associated
with CD4 and CD8, and it is required for T-lymphocyte activation and
maturation (Figure 1-7).
Costimulation—The interaction between CD28 and both CD80 and 86, CD2 and
CD58, and a signaling lymphocytic activation molecule (SLAM) provides signals
of cosimulation for activation, survival, and stability of the immune synapse.
SLAM has an immunoreceptor tyrosine switch motif (ITSM). SLAM binds to

SLAM-associated protein (SAP), which links SLAM to Fyn. Mutations in SAP
Key Fact cause X-linked lymphoproliferative syndrome (XLPS).
ZAP-70 deficiency is a
SCID with no CD8 cells P equals phosphorylation.
and no T-lymphocyte
function, but normal B
Lck is a Src family kinase. It is noncovalently associated with CD4 and CD8.
lymphocytes and NK Fyn is a Src family kinase. It is noncovalently associated with CD3.
cells. ZAP-70 is a Syk family kinase. It has two Src homology domains (SH),
where ZAP-70 binds to the P on the ξ chain, which results in docking.
LAT phosphorylation recruits adapter proteins that mediate different signaling
pathways.
Sos is a GDP/GTP exchanger.
ERK is one of the MAP kinases which activates the transcription factor
activation protein 1 (AP-1).
IP3 is1,4,5-trisphosphate.
Flash Card A10
XLPS
Figure 1-7. T–cell-receptor signaling.
CRAC (calcium release-activated calcium channel) is on the cell

membrane.
Calmodulin is an ubiquitous, calcium-dependent regulatory protein that binds
calcium and interacts with calcineurin.
Calcineurin is an activator of nuclear factor of activated T lymphocytes
(NFAT) by dephosphorylation, allowing it to travel to the nucleus.
NFAT is an antigen-activated transcription factor for cytokines including IL-
2, IL4, and TNF.
Rac-GTP is another molecule activated by another GDP/GTP exchanger that
activates JNK to phosphorylate Jun, which also turns on AP-1. Flash Card Q11
Immunosuppressant
cyclosporine binds to
which molecule in T-cell
signaling pathway?
28 / CHAPTER 1
B-CELL RECEPTOR SIGNALING

(See Figure 1-8.)
B–lymphocyte-receptor complex (BCR)—made up of the surface immuno-

globulin and the associated Igα and Igβ chains.
Cross-linking—Recognition of the antigen by at least two receptors. Activation

will not occur without receptor cross-linking.
Igα and Igβ chains—similar to the CD3 molecules and the ξ chain of the TCR;
they contain the ITAMs, are noncovalently associated, and required for signal
transduction.
Lipid rafts—formed with cross-linking, bringing the BCR and the Src family of
kinases in close proximity. The BCR Src kinases are Lyn, Fyn, and BTK. Like in
the TCR, they phosphorylate the ITAMs, providing a docking site for Syk. These
are, again, Src homology domains.
Flash Card A11

Cyclosporin bind to
proteins called
immunophilins. Then
Figure 1-8. B-lymphocyte signaling.
drug protein complex
inhibits calcineurin and
therefore NFAT
translocation to the
nucleus.
Syk is the ZAP-70 analog, and its phosphorylation of molecules (e.g., PLC
and accessory molecules) is active in the same pathways as for transcription
factor activation.
B-lymphocyte linker protein (BLNK) when phosphorylated by Syk, it will
further activate Ras and Rac, PLC, and Bruton’s tyrosine kinase (BTK).
BTK is unique to B lymphocytes. BTK and Syk activate PLC to break PIP2
down to IP3 and make diacylglycerol (DAG) analogous to the TCR pathway.
Note: BTK is also involved in B-lymphocyte maturation. Mutation in BTK
produces Bruton’s agammaglobulinemia or X-linked agammaglobulinemia.
CD21 (CR2) provides signals that enhance the BCR if the antigen is
opsonized by C3b. On the surface, C3b is covalently bound to the antigen and
degraded to C3d, which is the ligand for CD21.
CD21-CD19-CD81 complex is expressed on the surface of B lymphocytes.
When CD21 interacts with C3d, the complex is brought into the BCR. CD19
has an ITAM that is phosphorylated, thus recruiting Lyn to enhance
phosphorylation of the Igα and Igβ chains; it also activates IP3 kinase, which
helps in BTK and PLC recruitment.
CYTOKINES, CHEMOKINES, AND THEIR

RECEPTORS
CYTOKINES
Cytokines are proteins secreted by the cells of the innate and adaptive immunity
that mediate many of the functions of these cells
Cytokines That Mediate and Regulate Innate Immunity

Cytokines are Produced mainly by mononuclear phagocytes in response to
infectious agents (Table 1-16).
Flash Card Q12

What are the CD
molecules in BCR
coreceptor?
30 / CHAPTER 1
Table 1-16. Cytokines of the Innate Immune System

Cytokine Source Receptor Action
TNF Activated mononuclear Two types: Type I TNF Mediates the acute
Key Fact phagocytes and type II TNF inflammatory
1β is cleaved by Antigen-stimulated T response to infectious
cells Binding to TNF-RII leads microbes (ESP gram
caspase-1, which negative rods)
NK cells to recruitment of
requires activation by a Stimulates the
Mast cells TRAFs to cytoplasmic
complex of proteins, domains, activating recruitment of
including NALP. Gain-of- transcription factors neutrophils and
Most potent stimulus is
function mutations of (NFκB, and AP-1) monocytes to sites of
TLR engagement
NALP lead to with LPS and other Binding of TNF-RI leads infection
uncontrolled IL-1 microbial products to apoptosis via Induces vascular
production and auto- Synthesis augmented by caspase 8 endothelial cells to
inflammatory syndromes. IFNγ express adhesion
IL-1ra is a competitive molecules
inhibitor of IL-1 made by Stimulates endothelial
cells and
mononuclear
macrophages to
phagocytes. It is induce leukocyte
available commercially chemotaxis and
(Anakinra) to treat auto- recruitment
inflammatory syndromes. Acts on mononuclear
phagocytes to
stimulate IL-1
secretion
Key Fact IL-1 Activated mononuclear Binding to type I IL-I R Low concentrations:
Patients with mutations phagocytes leads to Myd88 Mediates local
in the IL-12 Rβ1 are 2 forms: IL- Neutrophils recruitment to the TIR inflammation and acts
1α and Epithelial cells domain and protein on endothelial cells to
susceptible to infections
IL-1β Endothelial cells kinases (IRAK4, increase expression
with intracellular IRAK1 and TRAF6), of surface molecules
bacteria notably leading to activation of that mediate
Salmonella and atypical Production is induced by
NFκB leukocyte adhesion
mycobacteria. bacterial products,
such as LPS and Larger quantities: Induce
other cytokines (TNF) fever and the
synthesis of acute
phase reactants by
Key Fact the liver (via IL-6
IRAK-4 deficiency leads production), and
neutrophil and
to susceptibility to
platelet production by
pyogenic infections, the bone marrow
especially with
Streptococcus IL-12 Activated dendritic cells Type I receptor family, Stimulates production of
pneumoniae. Macrophages composed of β1 and IFNγ by NK cells and
Made of p35 Produced in response to β2 subunits T lymphocytes
and p40 TLR signaling p35 binds to β2 receptor, Promotes
subunits induced by many leading to Jak 2 → differentiation of
microbial stimuli STAT4 CD4 helper T
Stimulated by IFNγ from p40 binds to β1 receptor, lymphocytes into
NK cells or T leading to Tyk 2 → IFNγ producing TH1
lymphocytes STAT 4 cells
CD40L/CD40 Enhances cytotoxicity of
interaction on NK cells and CD8
Flash Card A12 macrophages and cells
dendritic cells
CD21, CD19, and
CD81.
Table 1-16. Cytokines of the Innate Immune System, cont.

Type 1 IFNα: Plasmacytoid Type II cytokine receptor Inhibit viral replication,
interferons dendritic cells and family thereby eradicating
mononuclear IFNAR1/Tyk2 and viral infections
phagocytes IFNAR2/Jak1, leading Increase expression of
IFN β: Produced by to STAT1 and STAT2 class I MHC
many cells, including phosphorylation and molecules;
fibroblasts recruitment of IRF9 Stimulate development
of Th1 cells
Most potent stimulus is Promote sequestration
viral nucleic acids of lymphocytes in
lymph nodes
Inhibit proliferation of
many cell types
IL-10 Macrophages Type II cytokine receptor Inhibits production of IL-
Regulatory T cells family, Jak1 and Tyk2; 12 by activated
Janus family kinases, macrophages and
which induce STAT3 dendritic cells
signaling molecule Inhibits expression on
costimulators, and
class II molecules on
macrophages and
dendritic cells
Inhibits costimulatory
receptors
IL-6 Mononuclear Type I cytokine receptor Stimulates synthesis of

phagocytes family acute phase protein
Vascular endothelial Signaling pathway by hepatocytes
cells involves Jak1 and Stimulates production of
Fibroblasts STAT3 activation neutrophils from bone
Produced in response to marrow progenitors
IL-1 and TNF Stimulates growth of B
lymphocytes that
have differentiated
into antibody
producers
Growth factor for
neoplastic plasma
cells (myelomas)
IL-15 Mononuclear Activates Jak3, STAT5 Survival of memory
phagocytes in and Akt-dependent CD8 T lymphocytes,
response to viral signaling pathways NK cells, and NK-T
infection and LPS cells
Required for NK cell
differentiation and
activation
IL-18 Macrophages; IL-1 or TLR family Enhances IFNγ
Dendritic cells. signals through TIR production by T
domain that recruits lymphocytes
Production is dependent IRAK and TRAF, Promotes differentiation
on caspase-1 leading to activation of of IFNγ, producing
NFκB and AP-1 Th1 CD4 cells
transcription factors Synergistic with IL-12
32 / CHAPTER 1
Table 1-16. Cytokines of the Innate Immune System, cont.

IL-23 Macrophages and On T lymphocytes and Contributes to
dendritic cells in NK cells inflammation in
response to microbial IL-23R is a heterodimer autoimmunity
infection of a unique IL-23R Important for resistance
Production depends on chain and the IL- to Klebsiella
caspase-1 (similar to 12Rβ1 chain pneumoniae
IL-1) Promotes
differentiation and
maintenance of T
lymphocytes that
produce IL-17
IL-27 Macrophages IL-27R composed of IL-6 Promotes ThI
Dendritic cell gp30 subunit and a differentiation
second homologous Promotes IFNγ
chain production by T
Expressed on resting NK lymphocytes
cells and NK-T Role in controlling
lymphocytes, effector ongoing T-
and memory T lymphocyte
lymphocytes, and responses
regulatory T
lymphocytes
Abbreviations: CTL, cytotoxic T lymphocyte; DCs, dendritic cells; IFN, interferon; IL, interleukin;
MHC, major histocompatibility complex; NFκB, nuclear factor kappa B; NK, natural killer; TLR, Toll-
like receptor; TNF, tumor necrosis factor.
Cytokines That Mediate and Regulate Adaptive Immunity

Produced mainly by T lymphocytes in response to specific recognition of foreign
antigens (Table 1-17).
Table 1-17. Cytokines of the Adaptive Immune System

Cytokine Source Receptor Actions
IL-2 Mainly CD4 T IL-2R (composed of 3 Required for survival
lymphocytes (8–12 hr proteins:IL-2Rα, IL- and function of
after activation) 2/15Rβ, γc) Treg cells
Engages Jak3-STAT5 Stimulates the survival,
signal transduction proliferation, and
Key Fact pathways differentiation of
antigen-activated T
Receptors for IL-2, IL-4, lymphocytes
IL-7, IL-9, IL-15, and IL- Promotes the
21 contain γc, which is proliferation and
affected in X-linked differentiation of NK
SCID. cells
Induces expression of
Bcl-2 (anti-apoptotic
protein)
Table 1-17. Cytokines of the Adaptive Immune System, cont.

IL-4 Th2 CD4 T lymphocytes Type I cytokine receptor Th2 differentiation
Activated mast cells family; Inhibition of Th1 and
IL-4Rαγc signals through Th17 cell
the Jak-STAT development
pathway (STAT6).
Key Fact
B lymphocyte
switching to IgE The receptors IL-3, IL-5,
Acts on macrophages and granulocyte
with IL-13 to induce monocyte colony-
arginase induction,
stimulating factor (GM-
leading to collagen
production and CSF) share a common β
increased mannose chain.
receptor expression,
which promotes
phagocytosis of
microbes
IL-5 Th2 CD4 T lymphocytes IL-5Rα and IL-5Rβc Activates immature
Activated mast cells heterodimer induces eosinophils, and
Jak2 and STAT 3 stimulates growth
signaling pathway and differentiation
of eosinophils
Stimulates the
proliferation of B
lymphocytes and
production of IgA
antibodies
IL-13 Th2 CD4 T lymphocytes IL-4Rα and IL-13Rα1 Promotes fibrosis as
CD8 T lymphocytes heterodimer part of the tissue
NK T lymphocytes Binds to IL-4 and IL-13 repair phase of
Basophils with high affinity chronic inflammatory
Eosinophils state
Stimulates mucus
production by lung
epithelial cells
Induces IgE class
switching in B
lymphocytes
Promotes inflammation
by inducing
expression of
endothelial
expression factors
and chemokines
34 / CHAPTER 1

IFNγ NK cells Type II cytokine receptor Promote macrophage-
Th1 CD4 T lymphocytes family, IFNγR1, and rich inflammatory
CD8 T lymphocytes IFNγR2 heterodimer reactions while
IFNγR1 associates with inhibiting IgE-
Jak1 kinase and dependent eosinophil
IFNγR2 associates rich reactions
with Jak2 kinase Activates macrophages
Leads to STAT1 to kill phagocytosed
phosphorylation and microbes
dimerization Promotes the
differentiation of
naïve CD4 T
lymphocytes to the
Th1 subset (via T-
bet)
Inhibits the
differentiation of TH2
cells;
Acts on B lymphocytes
to promote switching
to certain IgG
subclasses
Stimulates expression
of class I and class II
MHC molecules, and
costimulators on
APCs
TGFβ(1) Antigen-stimulated T Serine or threonine Inhibits the
lymphocytes kinase domain that proliferation and
LPS-activated phosphorylates effector functions
mononuclear transcription factors of T lymphocytes,
phagocytes of Smads and the activation
ALK5 phosphorylates of macrophages
Smad2 and Smad3, Regulates the
which, with Smad4, differentiation of T-
translocates to the lymphocyte subsets
nucleus, binds to Stimulates the
promoters of target production of IgA
genes, and regulates antibodies by
their transcription inducing B
lymphocytes to
switch to this isotype
Regulates tissue repair
Lymphotoxin T lymphocytes TNF receptors Activates endothelial

cells and neutrophils

IL-21 Activated CD4 T Type I family receptor Stimulation of
lymphocytes that activates Jak1, proliferation and
Jak2, STAT1, and augmentation of
STAT3 effector CD8 T
lymphocytes
Enhancement of class
switching and Ig
production by B
lymphocytes
Induction of
differentiation and
enhancement of
effector function of
NK cells
BAFF Neutrophils TACI, BCMA, and BAFF-R Up-regulation of anti-
Monocytes apoptotic protein Bcl-
Macrophages 2 activation of NFκB.
Dendritic cells
Follicular dendritic cells
Activated T lymphocytes
APRIL Monocytes TACI and BCMA Up-regulation of anti-
Macrophages apoptotic protein Bcl-
Dendritic cells 2 activation of NFκB.
Activated T lymphocytes
Abbreviations: MHC, major histocompatibility complex; NK, natural killer; NFκB, nuclear factor
kappa B; TNF, tumor necrosis factor
Cytokines and Hematopoiesis
Cytokines that stimulate hematopoiesis are also involved in the differentiation and
expansion of bone marrow progenitor cells (Table 1-18).
Families of Cytokine Receptors

Table 1-19 lists families of cytokine receptors and their signaling pathways.
Flash Card Q13

Which chemokine
receptor is associated
with WHIM (warts,
hypogammaglobulinemi
a, infections,
myelokathexis)
syndrome?
36 / CHAPTER 1
Table 1-18. Cytokines That Stimulate Hematopoiesis

Stem cell Stromal cells of the bone Act on immature stem Enhances response to
factor (c-kit marrow cells with c-kit other colony-
ligand) stimulating factors
(CSFs)
Sustains the viability of
T lymphocytes in
the thymus
Mast cell growth
factor
Mnemonic IL-7 Fibroblasts IL-7Rα chain associated Survival of mature,
Bone marrow stromal with γc chain naïve and memory
Hot T-Bone stEAk
cells Associated with Jak3 T lymphocytes
IL-1: fever (Hot) kinase (especially CD4)
IL-2: stimulates T IL-3 CD4 T lymphocytes Type I cytokine receptor Promotes the growth
lymphocytes family and development of
IL-3: stimulates Bone Signal transduction mast cells from
involves Jak-STAT bone marrow
marrow Basophil-
IL-4: stimulates IgE differentiating
IL-5: stimulates IgA cytokine
Erythropoietin Produced in the kidney Type I cytokine receptor Promotes production of
(Epo) in response to low that signals through RBC from
oxygen tension Jak2-STAT5 and PI-3 committed erythroid
kinase-Akt pathways progenitors
IL-11 Bone marrow stromal gp130 signaling Jak- Megakaryocytopoiesis
cells STAT
Table 1-19. Cytokine Receptor Families

Receptors Pathways
Type I cytokine R (hematopoietin receptors) Engage Jak-STAT signaling pathways
Type II cytokine R Engage Jak-STAT-signaling pathways
IL-1 family R Share Toll-like/IL-1 receptor (TIR) domain.
TNFR Intracellular signaling mechanisms induce
apoptosis and/or stimulate gene expression
Seven transmembrane α-helical R Signaling pathways involve GTP-binding
proteins.
Abbreviations: IL, interleukin; TNFR, tumor necrosis factor receptor.
Flash Card A13

CXCR4
CHEMOKINES
Chemokines are a subgroup of cytokines that are divided into four families, based
on the number and location of terminal cysteine residue.
Source—Leukocytes, endothelial cells, epithelial cells, and fibroblasts stimulated

by microbes via TLR signaling and inflammatory cytokines (TNF and IL-1).
Receptors—Found on leukocytes (greatest number and diversity on T

lymphocytes); and G protein-coupled receptors (GPCRs) with seven-
transmembrane α-helical domains (GTP) modulate cytoskeletal protein
configuration and integrin affinity.
Actions—Recruit cells of host defense to sites of infection; induce migration of

leukocytes toward the chemical gradient of the cytokine by stimulating alternating
polymerization/depolymerization of actin filaments; regulate the traffic of
lymphocytes and other leukocytes through peripheral lymphoid tissues; and
promote angiogenesis and wound healing.
Table 1-20 lists the known chemokines or receptors that are associated with
certain diseases.
Table 1-20. Select Chemokine or Receptor Defects and Their Associated

Diseases
Chemokines or Receptors Associated Disease
CCR5 or CCL3L1 and CXCR4 HIV and/or AIDS
CXCR4 WHIM syndrome
CXCL4 Heparin-induced thrombocytopenia
CX3CR1, CCL5 Atherosclerosis
CCL2, 5, 7, 11 and CXCL8 Asthma or allergies
CXCL12 or CXCR4 Cancer metastases
CCL25 or CCR9 Crohn’s disease

Abbreviations: WHIM., warts, hypogammaglobulinemia, infections, and myelokathexis.
38 / CHAPTER 1
CELL ADHESION MOLECULES
Think of cell adhesion molecules (CAMs) as traffic cops: they aid in directing the
traffic of leukocytes to areas of inflammation.
The following are the major players that are most important to know:
Chemokines
Selectins
Integrins
Immunoglobulin superfamily
Chemokines
Figure 1-9 outlines chemokine pathways and functions.
The following four families of chemokines are the most important to know (see
Table 1-21 for a list of notable chemokine ligands and their receptors):
C
CC → Eo’s, Baso’s, Mono’s → ALLERGY
CXC → PMN’s → INFLAMMATION
o ELR—angiogenic, acts through CXCR2
o Non-ELR—angiostatic, acts via CXCR3B, induced by interferons
CX3
Homeostatic: CCL19/CCL21 → CCR7 → Lymphocyte Homing

Inflammatory: CCL17/CCL22 → CCR4 → pro Th2 response
Figure 1-9. Chemokines signal via G protein-coupled receptors and result in the
activation of several pathways as shown.
Table 1-21. Important Chemokine Ligands and Receptors

Ligand Receptor
CCL5 (RANTES) CCR 1,3,5
CCL11 (Eotaxin) CCR3
CCL17 (TARC) CCR4
CXCL8 (IL-8) CXCR 1,2
Abbreviations: IL, interleuking; RANTES, regulated on activation, normal T expressed and
secreted; TARC, thymus and activation-regulated cytokine.
Decoy Chemokine Receptors

DARC (Duffy): Protects against metastasis; mutation in GATA in DARC
gene confers malaria protection in African Americans.
D6
CCX-CKR: Target for CCL19 or CCL21.
Selectins
All three types of selectins are involved in the rolling of leukocytes, and they bind
carbohydrates (Table 1-22).
In LAD-2, polymorphonuclear neutrophils (PMNs) cannot express carbohydrate

ligands for E and P selectin.
Integrins
All integrins are involved in adhesive interplay between APCs and lymphocytes
as well as lymphocyte homing. There are three families of integrins (Table 1-23).
Table 1-22. Summary of Selectins

Selectin Location Ligand Function
P Selectin Platelets, and PGSL and Sialyl- Binds PMNs, T lymphocytes,
(CD62P) Weibel-Palade Lewis X and monocytes
bodies of the
endothelium
a
E Selectin (ELAM Endothelium ESL-1, CD15, Homing of T lymphocytes to
and CD62E) PGSL, and Sialyl- peripheral sites of
Lewis X inflammation
L Selectin (LAM-1 Lymphocytes and GLYCAM-1, Homing to lymph node HEV Flash Card Q14
and CD62L) leukocytes MADCAM-1, CD34, (GLYCAM) and PMN rolling
and Sialyl-Lewis X (MAdCAM) Which integrin molecule
a
ELAM increases in Kawasaki’s disease. Abbreviations: ELAM, endothelial leukocyte adhesion is important for gut
molecule; MAdCAM, mucosal addressin cell adhesion molecule; PMN, polymorphonuclear homing by binding to
neutrophil. MAdCAM?
40 / CHAPTER 1
Table 1-23. Integrin Families

Name Synonyms Ligand Function
Β1
Α4β1 VLA4 VCAM Important for neuronal
homing; used as treatment
for multiple sclerosis
Β2
Alβ2 LFA1, CD11a/CD18 ICAM-1 Rhinovirus binds here
Amβ2 MAC1, CD11b/CD18 ICAM-1, iC3B (CR3)
Axβ2 CD11c/CD18 ICAM3, C3dg, iC3B
(CR4)
Amβ2 MAC1, CD11b/CD18 ICAM-1, iC3B (CR3)
Β3
Avβ3 Important for platelets and
GIIbIIIa
The fourth β integrins family, α4β7 is also important. This family is a mucosal
addressin that binds to mucosal addressin cell adhesion molecule (MAdCAM) and
it is important for gut homing.
Immunoglobulin Superfamily (IgSF)

All IgSF molecules contain at least one immunoglobulin or immunoglobulin-like
domain. These molecules are involved in cell-to-cell interaction.
ICAM1 (CD54) → binds LFA1, MAC1, and rhinovirus

ICAM2 (CD102) → binds LFA1
ICAM3 (CD50) → binds LFA1 and CD18
ICAM4 (CD242) → binds LFA1 and CD18
VCAM1 (CD106) → binds VLA4 (α4β1); vascular

PECAM (CD31) → binds CD31 and CD38; platelets
MAdCAM → binds mucosal addressin (α4β7); mucosa
NCAM (CD56) → binds VLA4 (α4β1); neuronal
Clinical Implications
Flash Card A14 Chemokines are implicated in a number of clinically relevant disorders. Please see
Table 1-24 for further details.
α4β7
Table 1-24. Chemokines and Associated Conditions

Condition Implicated Chemokines
Heparin-induced thrombocytopenia CXCL4
Asthma and allergies CCL2, 5, 7, 11; CXCL8
HIV CCR5 Homozygotes → No infection

(mono/macro)
Heterozygote → Slow progressors
of infection
CXCR4 T trophic
CCL3L1 Low level → Higher HIV acquisition,
high viral load, worse
disease
Atherosclerosis (also known as CXC3CL1

fractalkine) CX3CR1 V249I → Increased risk of acute
coronary syndrome
T280M → Prevents plaque entry
(confers
protection)
Glanzmann’s thrombasthenia GIIbIIIa defect leading to platelet defect
COMPLEMENTS AND KININS
The complement system is an important effector mechanism of both humoral and

innate immunity. Its functions are to promote phagocytosis of microbes, to
stimulate inflammation, and to induce lysis of these organisms.
Pathways of Complement Activation

Alternative Pathway (AP) (Figure 1-10)
C3 is continuously undergoing small-scale cleavage in the plasma (C3 tick-
over) to C3b → activates an internal thioester bond → covalent binding of
C3b to hydroxyl groups on microbial cell surfaces.
Bound C3b binds factor B to form C3bB.
Factor D cleaves factor B to form the AP C3 convertase (C3bBb), stabilized
by properdin.
Regulation of this pathway occurs through factor I-mediated cleavage of C3b. Flash Card Q15
Factor H, membrane cofactor protein (MCP/CD46) and decay-accelerating Which complement is
factor (DAF/CD55) serve as cofactors (only found on mammalian cells). the most potent
mediator of basophil and
cutaneous mast cell
degranulation?
42 / CHAPTER 1
Figure 1-10. Alternative pathway.
Classical Pathway (CP) (Figure 1-11)

Key Fact C1q binds to the Fc portion of an immunoglobulin cross-linked by antigen.
Binding affinity of C1q
Binding affinity of C1q for IgM > IgG3 > IgG1 > IgG2.
for IgM > IgG3 and IgG1 C1q is associated with C1r serine proteases, which cleave and autoactivate
or IgG2. Factor H C1s proteins.
regulates only the Activated C1s cleave C4 and C2 to yield C4b2a, which is the C3 convertase
alternative pathway.
of the CP.
C1 inhibitor inhibits C1r and C1s, thus regulating the pathway.
C4b deposited on cell surfaces is bound by DAF, complement receptor type 1
(CR1) and C4-binding protein (C4BP), thus blocking further progression of
the cascade.
C4b bound to C4BP is inactivated to C4bi by factor I
Figure 1-11. Classical pathway.

Abbreviation: IC, immune complex.
Flash Card A15

C5a.
Lectin Pathway (LP)—Activated in the absence of antibody. Mannose-binding

lectin (MBL) binds to mannose residues on microbial polysaccharides, and also to
MBL-associated protease-1 (MASP-1) and MBL-associated protease-2 (MASP-
2). MASP-2 cleaves C4 and C2 to form the C3 convertase C4b2a (Figure 1-12).
C3 convertase cleaves C3 to C3b, which binds to the convertase and form C5
convertase: C3bBb3b in the AP, and C4b2a3b in the CP and LP.
C5 convertase cleaves C5 and initiates the formation of the membrane attack
complex (MAC), and C5a is released.
MAC is formed by (C5b-8) polyC9 and it creates pores in the membrane and
induces cell lysis.
C9 is structurally homologous to perforin.
S Protein and CD59 inhibit formation of the MAC.
C5a is the most potent mediator of basophil and cutaneous mast cell
degranulation; C5a > C3a > C4a.
Key Fact
C5a is chemotactic for neutrophils, eosinophils, monocytes, and basophils.
Leukocyte adhesion
C3a is chemotactic for only eosinophils.
deficiency (LAD) type 1
is observed in patients
with CR3 or CR4
Complement Receptors deficiency due to a
rare mutation in the β
chain (CD18) common
Biologic activities of the complement system are performed by binding of to the CD11 or CD18
complement proteins to membrane receptors on various cell types. However, family of integrin
many microorganisms can also bind to these receptors, thus entering human cells molecules.
(Table 1-25). Leukocyte adhesion deficiency (LAD) type 1 is observed in patients
with CR3 or CR4 deficiency and is due to a rare mutation in the β chain (CD18) Key Fact
common to the CD11 or CD18 family of integrin molecules. CR4 is a marker for
dendritic cells.
C3d binds CR2 (CD21)
and provides a second
signal for B-
lymphocyte activation
by antigen.
Flash Card Q16

Which complement
Figure 1-12. Lectin pathway. receptor is implicated in
Abbreviations: MASP, mannose-associated serine protease; MLB, mannose-binding lectin. PNH (paroxysmal
nocturnal
hemoglobinuria)?
44 / CHAPTER 1
Table 1-25. Receptors of the Complement System

Complement
System Used
Receptor
Associated by Micro-
(Alternative Ligand Function
Pathology organisms to
Names)
Enter Human
Cells
CR1 (CD35) C3b, C4b, iC3b Regulates HIV
complement
activation
Phagocytosis of
C3b- and
C4b-coated
particles
Clearance of
immune
complexes
(CR1 on
RBCs)
CR2 (CD21) C3d, iC3b, and Part of B EBV and HIV
C3dg lymphocyte
coreceptor
with CD19
and CD81
(TAPA)
Trapping
antigens in
the germinal
center
CR3 (Mac-1, iC3b and Phagocytosis LAD type I Mycobacterium
CD11b/CD18) ICAM-1 Leukocyte tuberculosis, HIV,
adhesion to and West Nile
endothelial virus.
cells
CR4 (gp 150/95, iC3b Phagocytosis LAD type I
CD11c/CD18)
CD46 (MCP) Measles virus
CD55 (DAF) C4b and capsid Regulates PNH Echovirus and

formation of coxsackie virus
C3 convertase
CD59 (Protectin C5b-8 and Disrupts PNH
monomeric C9 formation of
(C5b-8)polyC9
Abbreviations: DAF, decay-accelerating factor; EBV, Epstein-Barr virus; HIV, human
immunodeficiency virus; LAD, leukocyte adhesion; MCP, membrane cofactor protein; PNH,
paroxysmal nocturnal hemoglobinuria.
Flash Card A16

CD55 (DAF); CD59.
Pathologic Effects of Complement Activation

C3 Nephritic Factor
An autoantibody that binds and stabilizes C3bBb, and protects it from factor
H-mediated dissociation and factor I cleavage, resulting in unregulated
consumption of C3
Found in a few patients with systemic lupus erythematosus (SLE)
Associated with type II membranoproliferative glomerulonephritis (MPGN)
and partial lipodystrophy
MPGN: Mesangial proliferation, capillary wall thickening, and subendothelial
deposits of Ig and C3
Partial lipodystrophy, a disfiguring condition that affects the body from the
waist upward but spares the legs
Adipose cells are the main source of factor D, which completes the formation
of C3bBb
o There is a gradient in the concentration of factor D; more is present in the
upper-half than the lower-half of the body, thus causing the distribution of
fat loss observed in partial lipodystrophy. C3 nephritic factor stabilizes
C3bBb that forms in the vicinity of adipocytes and cleaves C3 to allow
assembly of membrane attack complex, which lyses the adipocytes.
Anti-C1q Antibody
Autoantibody to the collagen-like region of C1q
Found in patients with hypocomplementemic urticarial vasculitis (HUVS)
Results in activation of creatine phosphate pathway with tissue deposition of
immune complexes
HUVS is responsive to treatment with hydroxychloroquine
Complement Deficiencies
Testing (Figure 1-13)
CP: CH50: Assesses ability of serum to lyse sheep RBCs sensitized with
rabbit IgM
AP: AH50: Measures lysis of unsensitized rabbit RBCs
C3 and C4 levels are measured in nephelometric immunoassays
C4a and C4d: markers of CP or LP activation; and Bb: AP activation
C3a, iC3b, C5a, and soluble C5b-9: markers of terminal pathway activation
Flash Card Q17

Which complement
deficiency is inherited as
X-linked?
46 / CHAPTER 1
Figure 1-13. Diagram summarizes deficient complement components based on

the results of CH50 and AH50.
Complement Component Deficiency—Generally autosomal recessive, but

properdin deficiency is the only X-linked deficiency; so, all known cases are
Key Fact male. Patients are predisposed to recurrent infections and autoimmune disorders
SLE is seen much more at an early age (Table 1-26).
frequently with
deficiency of C1q than
any other complement
deficiency. Also caused
Table 1-26. Complement Component Deficiency
by C1r/C1s, C4 (1%
whites C4A), and C2 Complement Component Associated Disease Increased Frequency of
deficiency. Deficiency Infection With
Microorganism
C1q, C1r, C1s, C4, and C2 SLE and MPGN Recurrent pyogenic bacterial
infections: Streptococcus
pneumonia and Haemophilus
influenzae type b.
C3 MPGN Severe, recurrent pyogenic
infections beginning shortly
after birth
MBL SLE Pyogenic infections
C5-C9 Neisseria
Factor D, Factor B, and
Properdin
Factor H HUS, MPGN, and ARMD
Factor I MPGN
CD46 (MCP) MPGN
C1 inhibitor HAE
CD59 (MAC) and CD55 PNH
(DAF)
Flash Card A17 Abbreviations: ARMD, age-related macular degeneration; HAE, hereditary angioedema; HUS,
hemolytic uremic syndrome; MPGN, membranoproliferative glomerulonephritis; PNH, paroxysmal
Properdin. nocturnal hemoglobinuria; SLE, systemic lupus erythematosus.
Kallikrein-Kinin System Activation
There are two pathways of bradykinin generation. In the first, simpler one, tissue
kallikrein cleaves low-molecular-weight kininogen to yield lys-bradykinin, which
is further cleaved by an aminopeptidase to bradykinin. This latter cleaving is the
second pathway.
Contact Activation Pathway—Initiated when circulating factor XII (Hageman

factor) binds to a negatively charged surface and autoactivates (contact activates)
Key Fact
to form factor XIIa. Prekallikrein (PK) circulates as a complex with high-
molecular-weight kininogen (HK), and HK binds to the initiating cell surface. C1 inhibitor is the sole
plasma inhibitor of factor
Factor XIIa then cleaves PK to kallikrein, 10–20% of which dissociates into the XIIa and factor XIIf, a
fluid phase, and kallikrein digests HK to liberate the vasoactive peptide cleavage product
bradykinin (Figure 1-14). A positive feedback loop is shown in which kallikrein derived from factor XIIa
cleaves and activates factor XII at a rate at least 50-fold faster than the factor XII by digestion with
autoactivation. Factor XIIa also cleaves XI to form factor Xia, which initiates the kallikrein or plasmin. C1
inhibitor is also one of
intrinsic coagulation pathway. the major inhibitors of
kallikrein and factor XIa
as well as C1r and C1s.
C1 inhibitor is consumed
by plasmin.
Figure 1-14. Contact activation pathway leading to bradykinin generation.

Abbreviations: HK, high-molecular-weight kininogen; PK, plasma kallikrein; + = activates.
48 / CHAPTER 1
Bradykinin—The mediator of swelling during angioedema episodes, via the B-2

receptor on endothelial cells.
Hereditary angioedema (HAE) is characterized by bradykinin overproduction
caused by lack of C1 inhibitor function; activation is most pronounced at the
site of swelling although enzyme activation is detectable throughout the
plasma.
Angiotensin-converting enzyme (ACE) is identical to kininase II, which is the
major enzyme responsible for bradykinin degradation. Thus treatment with
ACE inhibitors leads to bradykinin accumulation caused by inhibition of
degradation.
The natural surface is likely the endothelial cell membrane (Figure 1-15).
Factor XII and HK bind to cell-surface complexes of urokinase plasminogen
activator receptor (u-PAR), cytokeratin 1, and receptor for the globular head
of C1q (gC1qR), cytokeratin 1, respectively in the presence of zinc.
Although cell-bound factor XII may initiate the cascade, it is also possible that
cell-derived heat shock protein (HSP) 90 or prolylcarboxypeptidase can
activate the PK-HK complex stoichiometrically (but not unbound PK) to
generate kallikrein. The kallikrein formed can activate factor XII.
Figure 1-15. Contact activation pathway: Cell-surface receptors.

Abbreviations: + = activates; B-2 receptor, B2 bradykinin receptor; gC1qR, receptor for the globular
head of C1q; HK, high-molecular-weight kininogen; HSP-90, heat shock protein-90; PK, plasma
kallikrein; u-PAR, urokinase plasminogen activator.
MUCOSAL IMMUNITY
Role of Mucosal Surfaces

The gastrointestinal (GI) mucosal barrier is a complex physical (i.e., mucus,
epithelial cell tight junctions, acid, and enzymes) and immunologic structure. The
mucosal immune system is a barrier between the internal and external
environment; therefore, it is an important site of entry for microbes.
Mucosal surfaces of the GI and respiratory tracts are colonized by
lymphocytes and APCs that initiate immune responses to ingested and inhaled
organisms.
Removal or alterations to this barrier may promote food allergy and
respiratory allergy.
Secretory immunity (IgA) is the major mechanism of protection by oral
vaccines such as oral polio.
Oral vaccines such as the oral polio vaccine use the mucosal immune system to
provide protection.
Pathophysiology
When food is ingested, intestinal and pancreatic enzymes break proteins into
amino acids and small peptides. Figure 1-16 highlights cells of the gastrointestinal
mucosa and their role in immunity.
Figure 1-16. Gastrointestinal tract mucosa.

(Reproduced, with permission, from by Daniel Muller).
50 / CHAPTER 1
It is estimated that 2% of the proteins are absorbed in immunologically active

forms.
Specialized cells in the GI tract selectively absorb peptides.
Mucosa of the GI has lymphocytes in large numbers in three main regions.
Cells in each site have distinct phenotype and functional characteristics (Table
1-27).
Peyer’s patches are organized collections of lymphoid tissue and are most
prominent in the small intestine. They are also the major site of IgA and B-
lymphocyte development that begins from cellular signals from dendritic cells and
T lymphocytes.
Cells Involved in Mucosal Immunity

M Cells—Specialized membranous cells that play a role in delivering antigens to
Peyer’s patches.
M cells are not APCs. M cells within the Peyer’s patch help create an
invaginated subdomain or pocket, where memory T lymphocytes, naïve B
cells, and memory B lymphocytes interact with antigen.
Table 1-27. Three Main Regions of the Gastrointestinal Tract Mucosa

Predominant T Other Cells Function of Various Cells
Lymphocyte
Types
Epithelial CD8+ Paneth cells Participates in innate immunity
layer
Intestinal epithelial Important in nutrient absorption.
cells Transports secretory IgA
Intraepithelial Predominantly effector and effector
lymphs (IELs) memory cells
Lamina Mixed population of Activated B IgA+
propria cells, including lymphocytes and
activated CD4+ T plasma cells
lymphocytes
T lymphocytes Memory phenotypes. Produce
scattered
cytokines IFNγ, IL-4, and IL-5
throughout
Macrophages
Mast cells Fight parasites
Eosinophils Allergic response
Fight parasite
Peyer’s Interfollicular B lymphocytes Central region is B-lymphocyte rich
patches regions with CD4+ area that contains germinal centers
T lymphocytes
M cells Specialized membranous cells that
play a role in delivering antigens to
Peyer’s patches
M cells assist in transport of antigens such as protein, bacteria, virus, and

noninfectious particles from the gut lumen to APCs and lymphoid tissue via
transcytosis.
“Sampling” of these antigens is important in the development of the immune
response and tolerance.
T Lymphocytes—Localize to small intestine due to 4 7 + CCR9.

CD4+ and CD8+ T lymphocytes occur throughout lamina propria. These T
lymphocytes have memory phenotype. CD4+ T lymphocytes produce
cytokines IFNγ, IL-4, and IL-5.
CD8+ T lymphocytes are preferential to epithelium.
Epithelial Cells
Paneth cells: Participate in innate immunity. Located in crypts of Lieberkühn
in small intestine.
Intestinal epithelial cells: Important in nutrient absorption. Transport secretory
IgA. Act as nonprofessional APCs by recognizing bacterial and viral motifs
such as TLRs. Intraepithelial lymphocytes (IELs): Reside above the basement
membrane, between epithelial cells. Migration is influenced by CCR9 or
CCL25 and CD103 or E cadherin. All IEL subunits express CD8 , which is
a characteristic of activated mucosal T lymphocytes. IELs are mostly effector
and effector memory cells with mainly CD8+. See Table 1-28 for phenotype
of IELs.
Regulatory T lymphocytes—Five regulatory T lymphocytes have been

identified in conjunction with intestinal immunity:
Th3 cells, a subset of CD4+ cells that secrete TGFβ
TR1 cells, CD4 cells that secrete IL-10
CD4+CD25+ regulatory T lymphocytes
CD8+ suppressor T lymphocytes
or δ T lymphocytes
Table 1-28. Phenotype of Intraepithelial Lymphocytes
T cells CD8+ –10% of total population
T lymphocytes CD4+ or CD8+
Double-negative T lymphocytes T lymphocytes with no coreceptor

52 / CHAPTER 1
Oral Tolerance
In both children and adults, intact food antigens are ingested and absorbed
through the GI tract. These antigens enter circulation and are transported
throughout the body in an immunologically intact form. These antigens do not
normally cause symptoms because most people develop tolerance.
Mechanisms That Promote Tolerance

ACPs, especially intestinal epithelial cells, dendritic cells, and Treg cells play
central role in oral tolerance.
APCs in the gut lumen and elsewhere in the body present the potentially
allergenic proteins to the T lymphocytes that, in a genetically predisposed
individual, results in Th2 allergic response.
Intestinal epithelial cells process luminal antigens and present it to T
lymphocytes on a MHC class II complex; but these lack a “second signal,”
thus suggesting their potential to play a role in tolerance induction.
Dendritic cells residing within lamina propria and a noninflammatory
environment of Peyer’s patches express IL-10 and IL-4. IL-10 promotes
Tregs.
Commensal gut flora can influence mucosal immune response. Gut flora are
established within 24 hours after birth and depend on both maternal flora and
local environment. Studies feeding lactating moms and their offspring
Lactobacillus GG suggest that probiotics may be of benefit in preventing
atopic dermatitis, possibly by enhancing Th1 cytokine response (IFNγ).
Whether probiotics will be useful to prevent food allergy has yet be
Key Fact determined.
High-dose tolerance
involves deletion of Mechanisms That Hinder Tolerance
effector T Developmental immaturity of components of gut barrier (decreased enzymatic
lymphocytes. activity in newborn period and secretory IgA) accounts for high prevalence of
Low-dose tolerance is food allergy in infancy.
mediated by activation
of regulatory T
Studies show that neutralizing pH (decreased acidity from antacids) can
lymphocytes with promote allergy sensitization by changes to the physiologic barrier.
suppressor functions.
IgA and Mucosal Immunity

IgA is the major class of antibodies produced by the mucosal immune system.
Key Fact
IgA binds to microbes and toxins present in lumen and neutralizes them by
Gut homing lymphocyte blocking entry into the host. Secretory immunity is mechanism of protection by
integrins are 4 7 and oral vaccines such as oral polio. More IgA is produced than any other antibody
MAdCAM-1.
because of the size of the intestinal surface.
Secretion of IgA is shown within the square insert of Figure 1-16 and detailed as
follows:
IgA synthesis occurs primarily in gut mucosal lymphoid tissue (lamina
propria), and transport across mucosal lumen is efficient (i.e., not lost to the
bloodstream). Key Fact
IgA+ B lymphocytes migrate from Peyer’s patches to mesenteric lymph A normal adult secretes
nodes. They circulate in lymphatics, ending up in lamina propria of gut. 2 g of IgA per day. More
Arrival in laminal propria is regulated by site-specific adhesion molecules, IgA is produced than
4 7 + and MAdCAM-1. any other antibody.
Switching to the IgA
Secretory IgA molecules in the gut lumen bind foreign proteins and block isotype is stimulated by
absorption. TGFβ and IL-5.
Switching to IgA isotype is stimulated by TGF and IL-5.
IgA is secreted in dimerized form that is held together by J chain. Serum IgA
is a monomer. IgA is transported across the epithelium by a poly-Ig receptor.
Once the dimerized IgA + poly-Ig receptor is on the luminal surface, the
receptor is proteolytically cleaved, leaving behind its transmembrane and
cytoplasmic forms. The IgA molecule plus extracellular domain of receptor is
Key Fact
released into the intestinal lumen. Poly-Ig receptor transports IgA into bile,
milk, sputum, saliva, and sweat as well as IgM into intestinal secretions. In kidney transplants,
the degree of HLA
compatibility
Breast Feeding—Provides immune protection and decreases incidence of food correlates with long-
allergies. Colostrum has very high levels of IgA in the first 4 days postpartum, term survival. If less
then drops to serum levels. Other components of breast milk include lysozyme, HLA compatibility,
lactoferrin, and TNFα. cyclosporine helps
improve survival.
In bone marrow
transplant, an HLA-
matched sibling is
preferred so as to
TRANSPLANTATION AND TUMOR IMMUNOLOGY avoid rejection, and
lethal graft-versus-
host disease (GVHD).
If using a
TRANSPLANTATION haploidentical match,
depletion of post-
thymic T lymphocytes
helps decrease
Transplantation Antigens GVHD.
There is an increase of
ABO System—ABO incompatibility does not cause stimulation in mixed CD3 HLA-DR cells in
leukocyte cultures, indicating that ABO incompatibility is of much less patients with idiopathic
anaphylaxis.
importance than HLA compatibility in graft survival. ABO incompatibility can
result in hyperacute rejection of primary vascularized solid-organ grafts
such as kidney and heart. This occurs because of the following:
ABO blood group antigens are present on all tissues, including kidney and Flash Card Q18
cardiac grafts.
Which receptor
Preformed, naturally occurring antibodies to blood group substances are facilitates transport of
present in mismatched recipients. IgA across the
epithelium in the gut?
54 / CHAPTER 1
Major Histocompatibility Complex (MHC)—HLA antigens are inherited in a

Mendelian dominant manner, but HLA genes are almost always inherited together
because of the closeness of the different loci of the MHC and the resultant low
cross-over frequency.
The fixed combination of genetic determinants is referred to as a haplotype.
Since chromosome 6 is an autosome, all individuals have two expressed HLA
haplotypes (maternal and paternal).
There are only four possible combinations of haplotypes among the offspring
of any two parents
HLA typing is very useful in organ transplants.
HLA Antibodies—Individuals exposed to non-self-HLA antigens can develop

anti-HLA antibodies. These antibodies, like ABO incompatibility, can cause
hyperacute rejection of a solid organ expressing those HLA antigens.
Methods to Detect Antibody Mismatches Between Donor

and Recipient
Cross-Matching—Serologic cross-matching is of particular importance to
success of highly vascularized grafts such as kidney and heart. Serum from the
prospective recipient is tested against cells from the potential donor for presence
of antibodies to RBC or HLA antigens.
Presence of such antibodies correlates with hyperacute renal graft
rejection.
Positive serologic crossmatch is an absolute contraindication to renal
transplantation.
Donor-Recipient Matching—Two general methods are used to pair donors and

recipients for transplantation:
Detect HLA antigens on donor and recipient leukocytes by either serologic or
DNA typing.
Key Fact Measure response of immunocompetent cells from recipient to antigens
present on donor cells (and vice versa for bone marrow transplantation).
Heart, lung, and liver
transplants are often not
HLA-matched (primarily Antigen Mismatches = disparities that are serologically detected.
due to time Allele Mismatches = differences that can be identified only by DNA-based
considerations). typing.
Flash Card A18

Poly-Ig-receptor.
Mechanisms Involved in Rejection

The mechanisms involved in rejection are summarized in Table 1-29 and include
following:
Hyperacute rejection is often associated with deposits of neutrophils,
endothelial damage, and thrombosis. It is mediated by preformed ABO natural
antibodies, HLA antibodies, and complement (Figure 1-17).
Accelerated rejection results in vascular disruption and hemorrhage. It is
mediated by noncomplement-fixing antibodies, NK cells, and monocytes.
Acute rejection is associated with tubulitis, interstitial inflammation,
parenchymal cell damage, and endovasculitis. It is mediated by T
lymphocytes (CD4+ and CD8+) and antibodies.
Chronic rejection results in vascular onion skinning (fibrosis) on biopsy,
along with delayed-type hypersensitivity (DTH) in vessel wall, intimal
proliferation, and vessel occlusion. It is mediated by antibodies.
Postoperative immunosuppression, using corticosteroids, antithymocyte globulin,

tacrolimus, and cyclosporine, can be used to reduce risk of rejection. (See section
on immunomodulators for more details.)
Figure 1-17. Hyperacute rejection in a transplanted kidney demonstrating acute

tubular necrosis. All of the tubules are necrotic with sloughed pink epithelial cells
and debris, with loss of nuclear detail (examples indicated by yellow arrows). The
glomerulus is indicated by the black arrows.
(Reproduced, with permission, from USMLERx.com.
56 / CHAPTER 1
Table 1-29. Key Features of Mechanisms Involved in Rejection

Key Fact Types Timing Onset
Immune
Component
Chance of rejection of
transplants in order from Hyperacute <24 hours Hours Ab and complement
highest to lowest: Accelerated 3–5 days 1 day Noncomplement-
Mismatched fixing Ab
Matched unrelated Acute 6–90 days Days to weeks T lymphocytes and
Matched 1st-degree Ab
relative
Chronic >60 days Months to years Ab and inflammatory
Syngeneic (identical cytokines
twin)
Abbreviation: Ab, antibody.
Screening for Preformed Antibodies

Screening involves the following:
Key Fact Pretransplant screen for presence of antidonor HLA antibodies to panel of
potential donors
High-risk groups for
hyperacute and
Expressed as percentage of reactive antibodies (PRA)
accelerated rejection are Predicts hyperacute and accelerated rejection
multiparous women and High-risk groups (i.e., previously sensitized) include recipients of multiple
multiple transfusion transfusions and multiparous women
recipients.
Mechanisms of Graft Rejection

Antibodies—Antibodies are involved in hyperacute rejection of a highly
vascularized organ such as kidney and heart. Antidonor antibodies are seen in
recipients undergoing those reactions.
Antibodies combine with HLA antigens on endothelial cells with subsequent
complement fixation and accumulation of polymorphonuclear cells.
Endothelial damage then occurs secondary to enzymes released form
polymorphonuclear (PMN) leukocytes.
Platelets later accumulate, thrombi develop, and the result is renal cortical
necrosis or myocardial infarction.
Innate Immunity—Natural killer cells and monocytes are effector cells of

accelerated rejection via antigen-dependent cell-mediated cytotoxicity (ADCC).
Leukocytes and Cytokines—Allograft rejection results from coordinated

activation of alloreactive T lymphocytes and APCs. Acute rejection is a T–
lymphocyte-dependent process, but destruction of allograft results from a broad
array of effector mechanisms.
Primed helper T lymphocytes release multiple cytokines: IL-2, IL-4, IL-5, IL-
7, IL-10, IL-15, TNFα, and IFNγ.
Cause recruitment of primarily immunocompetent donor-specific CD4+ T

lymphocytes; also CD8+ cytotoxic T lymphocytes, antibody-forming B
lymphocytes, and nonspecific inflammatory cells.
CD4 T Cells—Stimulation of CD4+ T lymphocytes through antigen receptor is

not sufficient to initiate T-lymphocyte activation. Activation of CD4+ T
lymphocytes needs costimulation.
Signaling must occur through one of the costimulators:
o Receptor: Ligand interactions (Table 1-30)
o IL-1 and IL-6 on APCs
o CD4 T lymphocyte anergy
Tolerance induction occurs when T-cell receptor interacts with APCs. As a
result, T–lymphocyte-accessory proteins and ligands on APCs are target
molecules for antirejection therapy.
CD8+ T Lymphocyte—CD8+ T lymphocytes recognize antigenic peptides on

MHC class I molecules and represent a major cytotoxic effector lymphocyte
population in graft rejection.
CD8+ activation requires second signal + IL-2.
CD8+ activation signaling occurs through γ chain of multiple cytokine
receptors.
Activated CD8 cells proliferate and mature into specific alloreactive clones
capable of releasing granzymes, perforin, and toxic cytokines such as TNFα.
T-Lymphocyte Activation—Once T lymphocyte activation occurs:

Autocrine T-lymphocyte proliferation continues secondary to expression of
IL-2R. The IL-2 or IL-2R interactions trigger kinases, leading to Raf-1
activation and expression of DNA binding proteins, Jun, c-Fos, and c-Myc.
This results in graft-specific T lymphocytes.
T-lymphocyte cytokines also activate macrophages, leukocytes, and
upregulate HLA on graft cells.
Activated T lymphocytes stimulate B lymphocytes to make autograft
antibody.
Ultimately, all cellular and humoral factors destroy graft.
Key Fact
Table 1-30. T lymphocyte-Ligand Combinations for Activation of CD4+ T Cyclosporine and
Lymphocytes tacrolimus interfere with
T Lymphocyte Ligand on APC activating process
involving T-cell
CD2 CD58 receptors and
CD11a/CD18 CD54 costimulatory molecule
CD5 CD72 CD28:CD80 or CD86.
CD40L CD40
CD28 CD80 or CD86
Abbreviations: APC: antigen-presenting cell.
58 / CHAPTER 1
Immunosuppressive agents used in the management of graft rejection target some

of these components discussed earlier. See Table 1-31 for specific mechanism of
action for immunosuppression.
TUMOR IMMUNOLOGY
A tumor is a mixture of many individual clones that are all from a single common
precursor. Each clone contains one or more genetic alterations with different
mechanisms to resist the host’s antitumor defense systems.
Tumors develop from a single, transformed cell to a mass of malignant cells

through a progression of genetic changes, which arise over many years in the
descendants of a transformed cell. The genetic changes result in the creation of a
tumor that can grow without restraints.
It is likely that tumors that are discovered by the immune system are destroyed
and that only the tumor cells that evade the immune system can survive. The
growth of a tumor results after a series of interactions between the immune
system and the tumor, in which the immune system tries to limit the expansion of
the tumor and the tumor responds by modifying itself to become impervious to
the immune system.
These interactions are referred to as immune surveillance and immune

selection.
Table 1-31. Immunosuppression in the Management of Graft Rejection

Category Drug Mechanism of Action
Inhibitors of T Cyclosporin (CsA) CsA binds to cyclophilin → inhibition of
lymphocytes and their FK 506 (tacrolimus) calcineurin → blockade of NFAT
activation activation → inhibition of transcription of
IL-2 → inhibition of T-cell differentiation
Rapamycin Rapamycin binds to FKBP → binds to
mTOR → inhibition of mTOR → blockade
of T-cell proliferation
Metabolic toxins Mycophenolate mofetil Inhibition of guanine nucleotide
inhibiting proliferating (MMF) synthesis → T-cell proliferation halted
T cells
Azathioprine Blockade of lymphocyte precursors
(less-specific than MMF → higher toxicity)
Antibodies to T-cell Anti-CD3 Monoclonal Ab binding to CD3 → promote
antigens phagocytosis or complement-mediated
lysis of T cells
Anti-CD25 (α subunit of Blockade of IL-2 binding to activated T
IL2R) cells that express CD25 → prevention of
T-cell activation
Anti-inflammatory Corticosteroids Block synthesis and secretion of cytokines
agents from macrophage
Tumor Progression
Early lesions are infiltrated with hematopoietic cells, including lymphocytes,

Key Fact
macrophages, and occasionally granulocytes.
Late stages of tumor development of colon, breast, and oral carcinomas have The presence of the
TILs with a normal ζ
an abundance of tumor infiltrating lymphocytes (TILs).
chain is associated with
o TILs: Small-to-large lymphocytes that are mostly CD3+ CD95+ TCR-α/β improved patient
+ T lymphocytes. survival. These cells are
typically CD95+ (Fas).
Human tumors produce molecularly defined immunoinhibitory factors:
Tumor necrosis factor (TNF) family ligands: Induce apoptosis through the
TNF family receptors. Include FasL, TRAIL, and TNF.
Cytokines: TGFβ, IL-10, GM-CSF, and ζ-inhibiting protein (ZIP).
Small molecules: Prostaglandin E2, epinephrine, and reactive oxygen
metabolites (ROMs). Inhibit leukocyte functions via increased cyclic
adenosine monophosphate (cAMP) or superoxide generation.
Virally related products: p15E and EBI-3.
Tumor-associated gangliosides: Inhibit IL-2-dependent lymphocyte
proliferation, induce apoptotic signals, suppress NFkB activation, and
interfere with dendritic cell generation.
Tumors are not ignored by the immune system:

Cancer patients have a higher amount of tumor-specific T lymphocytes in
circulation that recognize class I or class II MHC-restricted tumor epitopes.
Tumor-specific T lymphocytes, in the presence of cytokines, can increase and
target tumor cells for destruction.
Tumor-specific T lymphocyte can be used to recognize T–lymphocyte-defined
tumor epitopes.
TILs with normal ζ chain expression (resulting in normal signaling through
the TCR) is associated with improved patient survival.
Antitumor antibodies in patients allow for identification of serologically
defined tumor antigens.
NK cells are important in preventing metastasis of tumors by eliminating
tumor cells in the circulation through perforin-mediated lysis and apoptosis of
tumor cell targets.
Inhibitor receptors on NK cells known as killer cell immunoglobulin-like
receptors (KIR) recognize MHC class I and assist NK cells in sampling
healthy cells to look for abnormal cells that have lost the self-determinants on
their surface.
This evidence is leading researchers to consider new ways to protect immune
cells from the tumor and the factors they release. Flash Card Q19
Cyclosporin inhibits
calcineurin and blocks
NFAT activation by
binding to which
molecule?
60 / CHAPTER 1
INNATE IMMUNITY AND TOLL-LIKE RECEPTORS
INNATE IMMUNITY
Innate immunity is initiated in response to microbial invasion. Recognition of

conserved microbe sequences stimulates immediate host defense mechanisms
(Table 1-32). It differs from adaptive immunity in several ways, which are
summarized in Table 1-33.
Table 1-32. Innate Immune Mechanisms

Microbe Immune Mechanisms
Extracellular Complement activation
Phagocytosis: Recognition by PRR
Bacteria
Intracellular Nucleotide binding oligomerization domain-like receptors
(NLRs)
Fungi Neutrophil phagocytosis
Complement activation
Viruses Phagocytosis: Toll-like receptors (TLRs) and NK cells
Parasites Phagocytosis;
Complement (alternative pathway)
Abbreviations: PRR, pattern recognition receptor.
Table 1-33. Innate Versus Adaptive Immune Mechanisms

Innate Immunity Adaptive Immunity
Genetics Response encoded in host germ line Somatic gene rearrangement
DNA
Recognition Recognize conserved sequences such Recognize unique antigenic
as pathogen-associated molecular determinants:
patterns (PAMPs) TCR and (MHC restricted-)
Ig receptors
Components Complement T lymphocytes, B lymphocytes, and
Pattern recognition receptors (PRRs) on complement
immune cells
Phagocytes
Mast cell or basophils
NK cells
Flash Card A19

Cyclophilin
Components
Antimicrobial Peptides (AMP)—AMP are ubiquitous cationic proteins that play
a role in innate immunity. They provide defense against bacteria and fungi Key Fact
viruses. AMPs are decreased in
a Th2 environment.
Features: Atopic dermatitis
patients are susceptible
Produced by keratinocytes to Staphylococcus
Two families in humans: aureus infection due to a
decrease in AMP.
o Human β defensins: HBD1, 2, 3
o Human cathelicidins: LL37
o Lactoferrins: hLF1-11
o Histatins
Interact with phospholipids of microbial membranes, enter cell and mediate
antiproliferative effects
Complement
Refer to Chapter 4 for a discussion on Complement.
Cells of the Innate Immune System

Cells involved in innate immunity are reviewed in Table 1-34.
Table 1-34. Cells of the Innate Immune System

Cell Function
Neutrophil Phagocytosis and oxidative burst or free radical production
Monocyte or macrophage Phagocytosis and secretion of proinflammatory cytokines
Dendritic cells APCs (conventional) and antiviral (plasmacytoid)
Eosinophil Antihelminthic, antibacterial, and secretion of proinflammatory

mediators or free radicals
Mast cell Antibacterial, antiviral, and secretion of proinflammatory cytokines
Basophil Antibacterial, antiviral, and secretion of proinflammatory cytokines
NK Cell Eliminates virus-infected cells and tumor cells (missing “self”

hypothesis), and secretion of cytokines
Intraepithelial lymphocytes Secretion of proinflammatory cytokines (phagocyte activation and

killing of infected cells)
B-1 B lymphocytes Produce natural serum antibodies

Abbreviation: APCs, antigen-presenting cells.
62 / CHAPTER 1
Innate Response: Recognition

Pathogen-Associated Molecular Patterns (PAMPs)
PAMPs are conserved microbial sequences found on microorganisms.
Their structures are consistent and conserved.
Examples include lipopolysaccharide (gram-negative bacteria) and teichoic
acid (gram-positive bacteria).
They are recognized by receptors of the innate immune system.
Pattern Recognition Receptors (PRRs)

PRRs on APCs (conventional dendritic cells, B lymphocytes, and macro-
phages).
PRRs identify PAMPs on microorganisms to detect infection.
A summary of PRRs is provided in Table 1-35.
Table 1-35. Pattern Recognition Receptors

Receptors Location Class Structure Function
fMLP N-formyl Met-Leu Cell Signaling G protein-coupled Antibacterial
Phe receptors surface 7-transmembrane
domain receptor
CARD Caspase activation Cytoplasm Signaling RNA helicase, and Cytoplasmic
and recruitment caspase virus
domains (e.g., recruitment detection and
retinoic acid- domains to induce
inducible gene-I- type 1 IFN
like receptors) Component of production
inflammasome
CLR C-type lectin Cell Secreted Calcium- Antifungal
receptors: surface or dependent immunity
Mannose-binding endocytic carbohydrate-
lectin and binding domains
macrophage
mannose receptor
NLR or Nucleotide-binding Cytoplasm Signaling C-terminal IL-1β and IL-
NACT- oligomerization leucine-rich repeat 18 secretion
LRR domains (NODs) and nucleotide-
binding domain
NACT-LRR and
pyrin domain- Central proteins of
containing proteins inflammasome
(NALPS)
TLR Toll-like receptors Cell- Signaling Antibacterial,

surface antifungal,
cytoplasm and antiviral
(TLR3) immunity
Inflammasome
The inflammasome is multiprotein complex located in the cytoplasm that
activates caspases 1 and 5, leading to production and secretion of IL-1 and IL-18. Key Fact
NALPs provide a platform to which the adaptor protein ASC and caspases bind.
Activating mutations in
cold-induced auto-
inflammatory syndrome
TOLL-LIKE RECEPTORS (TLRs) 1(CIAS1) is seen in
Muckle-Wells syndrome
(MWS), familial cold
urticaria, and chronic
TLRs are a family of receptors that recognize PAMPs and initiate signaling infantile neurologic,
pathways, which activate innate immunity. The known TLRs and their ligands are cutaneous, and articular
summarized in Table 1-36. autoinflammatory
disease (CINCA).
TLR Ligands
Subcellular Localization and Signaling Pathways of TLRs—TLRs are found
on the cell surface or intracellularly.
TLR 3, 7, 8, and 9 are found in the intracellular compartment and detect
nucleic acids.
TLRs initiate multiple signaling pathways by use of adapter proteins:
o The adapter protein MyD88 plays a role in TLR signaling.
Table 1-36. Toll-Like Receptors and Their Ligands

Toll-Like Ligand Source
Receptor
1 Lipoarabinomannan Mycobacteria
2 Zymosan Fungi
3 dsRNA Virus
4 Lipopolysaccharide, peptidoglycan, RSV Gram-negative bacteria, gram-positive
fusion protein, and HSP 70 and HSP 90 bacteria, RSV, and endogenous acute
phase proteins
5 Flagellin Flagellated bacteria
6 Diacyl lipopeptides Mycoplasma
7 Imidazolquinolones Synthetic
8 ssRNA Virus
9 Unmethylated CpG motifs Bacteria and DNA viruses
10 Unknown
11 Profilin Toxoplasma gondii
Abbreviations: CpG, cytosine-phosphate-guanosine; dsRNA, double-stranded RNA; HSP, heat
shock protein; RSV, respiratory syncytial virus; ssRNA, single-stranded RNA.
64 / CHAPTER 1
o MyD88-dependent pathways are similar to signaling through IL-1

receptors, and are involved in all TLR-signaling pathways except for
TLR 3.
o TLR3 signaling is mediated by the Toll-interleukin-1-receptor domain
containing adapter-inducing interferon β (TRIF) and is MyD88-
independent.
o TLR4 can signal through both MyD88-dependent and -independent
pathways (Figure 1-18).TLR 4 binds to lipopolysaccharide (LPS) via
lipopolysaccharide-binding protein (LBP), MD2 (lymphocyte antigen 96),
and CD14.
Figure 1-18. TLR 4 signaling occurs through MyD88-dependent and -

independent pathways.
TLR and Disease

TLR mutation has been associated with infections and other diseases. Examples
of such diseases are reviewed in Table 1-37.
TLR agonists, such as imiquimod (TLR 7) and resiquimod (TLR 7 and 8), are
used topically for its antiviral and antitumor effects.
TLR function can be measured by flow cytometry, as seen in Figure 1-19.
Once recognition by the innate immune system occurs, phagocytosis, rapid

production of proinflammatory mediators, and engagement of the adaptive
immune system leads to eradication of the foreign organism.
Innate immunity confers a constitutive first line of defense to a myriad of

pathogens. Mutations in innate immunity have implications beyond immune
deficiency.
Table 1-37. Pattern Recognition Receptors and Clinical Disease

Disease TLR, PRR or Signal Pathway Affected
HSV1 encephalitis TLR 3, 7, 8, 9
Aspergillosis TLR4
Adrenal insufficiency TLR 2, 4
Crohn’s disease or Blau’s syndrome NOD2
Leprosy and TB TLR2
IRAK4 or MyD88 deficiency (recurrent IRAK4 or MyD88 (all TLR)

infections with pyogenic bacteria)
Flash Card Q20
Primary immune deficiency with infectious and NEMO
mycobacterial susceptibilities Which TLR binds
Abbreviations: HSV, herpes simplex virus; NEMO, NFκB essential modifier; NOD, nucleotide lipopolysaccharide
oligomerization domain; TLR, Toll-like receptor. (LPS) on gram-negative
bacteria?
Flash Card Q21

Which TLRs are present
in the intracellular
compartment and
implicated in HSV1
encephalitis?
66 / CHAPTER 1
Abnormal
Normal (IRAK-4 Deficiency)
Cell Number
TNFα
Unstimulated
Stimulated
Figure 1-19. Measuring TLR function. Histogram plot shows induction of cytokine
TNFα in lipopolysaccharide (LPS)-stimulated monocytes in normal healthy
controls. Reduced expression of TNFα is indicative of defective TLR4-signaling
pathway.
(Reproduced, with permission, from Dennis W. Schauer, Jr., Trivikram Dasu, PhD, James W.
Verbsky, MD, PhD, Clinical Immunodiagnostic & Research Lab, Medical College of Wisconsin.)
Flash Card A20

TLR 4.
Flash Card A21

TLR 3, 7, 8, 9.
Cells Involved in Immune
2 Responses
LYMPHOCYTES
Lymphocytes function to ward off infection. They are the primary players in
adaptive immunity.
TYPES OF LYMPHOCYTES
The three major types of lymphocytes are B cells, T cells, and natural killer (NK)
cells.
B lymphocytes
Humoral immunity; produce immunoglobulins; derived from and mature in bone

marrow; recognize linear or conformational epitopes; major
ligands/markers/associations: Fc receptors, clusters of differentiation (CD19,
CD20, CD21), and major histocompatibility complex II (MHCII).
T lymphocytes
Cellular immunity; precursors arise in bone marrow, but then mature in thymus;
recognize linear epitopes.
Helper T lymphocytes (Th, CD4+)(Table 2-1): Stimulate B-cell growth;
secrete cytokines to activate macrophages; MHCII-restricted; markers
CD3+/CD4+/CD8–.
o Th1 cells, Th2 cells, Th17 cells: See Table 2-1.
o T regulatory (Treg) cells: Do not make IL-2; use cytotoxic T-lymphocyte
antigen 4 (CTLA4) as a means to suppress other T cells (Tables 2-1 and 2-
2).
o Th9 cells: Induced by transforming growth factor beta (TGFβ) and
interleukin 4 (IL-4); produce IL-9 +/– IL-4; IRF4 and PU.1 required for
their differentiation.
68 / CHAPTER 2
Table 2-1. Major CD4+ Families

T Helper Induced Produce Transcription Major Function Other
Family By Factors
Th1 IL-12; IL-27, IFNγ; IL-2, Tbet, STAT4, Intracellular defense Express CXCR3
Key Fact 18 TNF STAT1 and CCR5; Th1
cells are associated
Know what induces Th1, with type I DM and
Th2, Th17, and Treg cell MS
development. Also, IL-4; IL25,
Th2 IL-4,5,13; GATA3, Humoral immunity;
know what these cells 33; TSLP IL-6, 10, STAT6, STAT5 antiparasitic; allergy
produce and the 21,25,31,33
transcription factors
Th17 IL-6; IL-1, IL-17; RORγT, STAT3 Extracellular defense; Express CCR6;
used.
21, 23; IL1,6,21, 22; neutrophil involved in RA, IBD,
TGFβ TNFα; GM- recruitment; MS, and psoriasis
CSF autoimmunity
Treg TGFβ and IL-10, TGFβ FOXP3, STAT5 Immunosuppression; See Table 2-2
retinoic acid prevents
autoimmunity
Abbreviations: DM, diabetes mellitus; GM-CSF, granulocyte monocyte colony-stimulating factor;
IBD, inflammatory bowel disease; IFN, interferon; IL, interleukin; MS, multiple sclerosis; RA,
rheumatoid arthritis; TGF, transforming growth factor; Th, helper T cell; TNF, tumor necrosis factor.
o Tfh (follicular helper T cells): In the follicles of active germinal centers

and play a major role in helping B cells make antibodies; mediated by
transcription factor Bcl-6 (which causes downregulation of CCR7 and
upregulation of CXCR5); produce IL-21.
Cytolytic T lymphocytes (CTLs and CD8): Kill viral-infected cells and
tumor cells via perforin and granzyme; express IFN , TNF, and lymphotoxin;
harder to activate than CD4s; involved in allograft rejection; use
eomesodermin homologs (EOMES) as a transcription factor; MHCI-
restricted; markers CD3+/CD8+/CD4–.
γδ T cells: These cells use γ and δ chains (instead of α and β chains); they
develop in the thymus and have limited diversity; they can bind lipids and
heat shock proteins; they are not associated with CD4 or CD8, but do require
CD3 and the chain for signal transduction; they do not recognize MHC-
associated peptides and are not MHC-restricted; produce IFN and TNF.
Table 2-2. Regulatory T-Cell Subsets

Natural Treg’s Induced Treg’s
Thymically derived and develop in Peripherally derived and develop in response to
response to thymically presented peripherally expressed self-antigens and
autologous antigens external antigens
Constitutively express IL-2-Rα(CD25+) Inducible IL-2–Rα(CD25) expression
FOXP3+ Include: Tr1(produce IL-10; involved in
Mediate self-tolerance mechanism of immunotherapy), Th3 (produce
TGFβ; in gut; important in IgA production)
Abbreviations: Ig, immunoglobulin; IL, interleukin; TGF, transforming growth factor; T h, helper T
cell.
CELLS INVOLVED IN IMMUNE RESPONSES / 69
Natural Killer (NK) cells

These cells function mostly in innate immunity. They kill viral-infected cells and
tumor cells (due to these cells losing MHCI and gaining danger receptors). IL-15
is very important for NK cell development. Markers include: CD16+ (FC RIII),
CD56+ (NCAM), natural cytotoxicity receptors (NCRs), and killer inhibitory
receptors (KIRs); do not express CD3. NK cell killing is mediated via perforin,
granzymes, serglycine, and Fas. See Table 2-3 for summary of NK cell receptors.
Natural Killer T (NKT) Cells

These are not NK cells; limited T-cell receptor (TCR) repertoire (Vα24/Jα18 and
Vβ11); CD3+, CD16+, CD56+, and usually CD4+; recognize glycolipid antigens
in context of CD1; produce IFN and IL-13 rapidly.
Innate Lymphoid Cells
There are several types of innate lymphoid cells.
Innate lymphoid cells (ILC2; nuocytes) arise from a common lymphoid

progenitor, but lack rearranged antigen receptors; secrete IL-5, IL-9, and IL-13;
proliferate in response to IL-25 and IL-33; play a central role in type-2-mediated
immunity.
Table 2-3. Activating and Inhibitory Receptors for NK Cells

Activating (activate to kill) Inhibitory (inhibit killing)
EBV-infected cell expresses CD48 binds MHCI binds KIR (long tail containing ITIM)
2B4 receptor on NK cell
Stressed cell expresses MICA/B, ULBP

binds NKG2D on NK cell
Viral hemagglutinin on target cell binds

NKp44/46 on NK cell
HLA-E binds NKG2C on NK cell HLA-E binds NKG2A/B
IgG-bound target cell binds Fc RIIIA on

NK cell (ADCC)
Abbreviations: EBV, Epstein-Barr virus; HLA-E, human leukocyte antigen E; Ig, immunoglobulin; IL,
interleukin; ITIM, immunoreceptor tyrosine-based inhibitory motif; KIR, killer cell immunoglobulin-
like receptor; MHC, major histocompatibility complex; NK, natural killer .
Flash Card Q1
Which cytokines induce
development of Th17
cells?
70 / CHAPTER 2
LYMPHOCYTE DEVELOPMENT, MATURATION AND

APOPTOSIS
Anatomic segregation of B and T cells:

T-cell zone (parafollicular zone) T cell expresses CCR7, which binds
CCL19/21 in the T cell/parafollicular zone (as the concentration/gradient of
CCL19/21 is highest there).
B-cell zone (follicles) B cell expresses CXCR5, which binds CXCL13 in
the B-cell zone/follicles (as the concentration/gradient of CXCL13 is highest
there).
This segregation ensures that each subset of lymphocytes is talking to the right
antigen-presenting cell (APC) in the lymph node.
Maturation of B and T lymphocytes is characterized early on by high levels of IL-
7 (lack of this cytokine can lead to X-Linked severe combined immunodeficiency
disease [SCID]); then, somatic recombination of antigen receptor genes and,
finally, positive (active) selection or negative (passive) selection of mature
lymphocyte repertoires.
Positive selection: Interaction between lymphocyte and MHC molecules,
which ensures maturation; for T cells; this ensures that an individual’s T cells
can respond to peptides bound to her/her own MHC molecules.
Negative selection: Interaction between lymphocytes and MHC molecules,
which serves to eliminate self-reactive lymphocytes (and prevent
autoimmunity); important for T and B cells; results in anergy, or elimination
[by apoptosis or receptor editing (for B cells)].
VDJ recombinase is the collective term for the set of enzymes needed to
recombine V, D, and J gene segments; the combining of these gene segments
results in combinatorial diversity; it recognizes DNA sequences called
recombination signal sequences (RSS); recombination occurs between two gene
segments (immunoglobulin or TCR) only if one of the segments is flanked by one
12-nucleotide spacer and by one 23-nucleotide spacer 12/23 rule. Important
enzymes in lymphocyte (immunoglobulin or TCR) gene rearrangement appear in
the following list and are summarized in Figure 2-1.
RAG 1/RAG 2: Expressed in immature lymphocytes (i.e., when antigen
receptors are being assembled); cleaves double-stranded DNA between the
coding segment and its recombination signal sequence.
Ku: Binds DNA ends (hairpin in the case of the coding segment).
DNA-PK (DNA-dependent protein kinase complex) and Artemis: Open DNA
hairpin at a random site.
Terminal deoxynucleotidyl transferase (TdT): Adds nucleotides for
Flash Card A1 junctional diversity (creates the greatest variability for diversity).
IL-6, TGFβ, IL-1, IL-21, Endonuclease: Removes nucleotides for junctional diversity.
and IL-23 DNA ligase IV:XRCC4: Ligates DNA.
Figure 2-1. V(D)J rearrangement.

(Reproduced, with permission, from Cindy Salm Bauer, MD, Medical College of Wisconsin.)
B-Cell Development
B-cell maturation is presented in Table 2-4 and Figure 2-2.
Table 2-4. B-Cell Maturation

Flash Card Q2
Pro Immature Mature Memory B Cell
B Cell
Pre B Cell
Naïve B Cell Naïve B Cell or Plasma Cell Which enzyme is
responsible for adding
CD 19+, Cytoplasmic µ Light-chain Express δ heavy Memory cell: nucleotides during
CD20+; chain produced product (κ or λ) chain (as well as Isotype switch and junctional diversity?
Heavy- here; signaling binds μ heavy μ) via alternative somatic
chain D-J through pre-B–cell chain to make splicing so that hypermutation
then V-DJ receptor and then IgM; receptor IgM and IgD are occurs
rearrange light-chain V-J editing occurs expressed on the Flash Card Q3
ment rearrangement cell surface Plasma cell:
Alternative splicing At which stage does
yields membrane signaling through the
and secreted Ig pre-B–cell receptor
occur?
72 / CHAPTER 2
Figure 2-2. B-cell maturation.

(Reproduced, with permission, from Marie-Paule Lefranc, IMGT, the International
ImMunoGeneTics Information System/Wikimedia Commons.)
Alternative splicing yields membrane versus secretory Ig.

Differential splicing produces different immunoglobulin isotypes. IgD is the
only Ig without a switch region; so, class switching will never apply to it.
o AID, UNG, CD40, CD40L if lacking, cannot class switch Ig
gets ‘stuck’ at IgM Hyper IgM phenotype ensues.
Transcription Factors associated with commitment to the B cell include: PU.1,

IKAROS, E2A, EBF, PAX5, and IRF8.
B-cell survival in the periphery depends on survival signals such as BLYSS,

BAFF, and APRIL. The receptors for these on the B cells are BR3 and TACI
(early on) and BCMA (later on). No TACI CVID risk factor.
Mature B Cells—There are three types of mature B cells:

B1 cells: Innate; limited diversity; analogous to γδ cells; make up 5–10% of
total B lymphocytes; self-renewing; produce natural antibodies (low-affinity
polyreactive immunoglobulins) that respond to microbes and lipids; found in
Flash Card A2 peritoneal cavity and fetus; T-cell-independent.
TdT Marginal zone B cells: Developed by 2 years of age (which explains why
infants have poor polysaccharide responses); first responders (especially to
polysaccharide antigens); T–cell-independent.
B2 cells (conventional B cells or follicular B cells): includes memory B cells
Flash Card A3 and plasma cells; adaptive; respond to protein antigens; T–cell-dependent.
Pre B cell
T-Cell Development
T-cell maturation is presented in Table 2-5.
When T cells are immature (DN; CD4–/CD8–), they are located in the
subcapsular cortex. As they undergo positive selection, they move to the cortex.
As they undergo negative selection, they move to the medulla.
T cells leave lymphoid organs by expressing sphingosine-1-phosphate (S1P)

receptors. After activation, expansion, and differentiation, memory or effector T
cells form:
Central memory T cells: CD45RA–, CD27+, CCR7+, CD62L+ (L-
selectin).
Effector memory T cells: CD45RA–, CD27–, CCR7–, CD62L– (L-
selectin).
Expression of a molecule called Notch commits T cells to develop.
Lymphocyte Apoptosis
Key Fact
There are two types of lymphocyte apoptosis: Mutations in Fas(CD95)
are the most common
Passive/Intrinsic Pathway: Programmed death by neglect; mitochondrial defect seen in
pathways; mediated by caspase 9; bcl-2 and bcl-XL (antiapoptotic); bid/bim autoimmune
(proapoptotic). lymphoproliferative
Active/Extrinsic Pathway: Repeated lymphocyte activation causes increased syndrome (ALPS), which
results in defective
Fas (CD95)/FasL(CD178) expression, which causes increased Fas-associated lymphocyte apoptosis.
protein with Death Domain (FADD); mediated by caspase 8.
Both pathways converge on caspase 3.
Table 2-5. T-Cell Maturation

Double Negative (DN) Double Positive Single-Positive
(DP) Thymocyte
Does not express T-cell receptor; stages: DN1, CD4+/CD8+; positive Cells undergo
DN2 (β chain D-J then V-DJ rearranges; and negative selection to become
analogous to pro B cell), DN3 (signaling selection occurs; α CD4+ or CD8+
through pre-T–cell receptor; analogous to pre chain V-J rearranges
B cell), and DN4 (proliferation)
Flash Card Q4
Where does negative
selection occur for T
cells?
74 / CHAPTER 2
MONOCYTES, MACROPHAGES, AND DENDRITIC CELLS
Monocytes are white blood cells that replenish macrophages and dendritic cells in
the periphery. In tissue, macrophages and dendritic cells engulf invaders and
cellular debris; they also initiate the adaptive immune system as APCs.
Monocyte Morphology
Monocytes are cells with one, kidney-shaped nucleus and are 10–15 μm in
size.
Express surface receptors for IgG, IgA, and IgE.
Monocyte Growth and Differentiation
Originate from monoblasts (Figure 2-3).

Highly express CD14 and CD16 after further maturation.
Migrate to peripheral tissue and become macrophages and dendritic cells.
Monocyte Function
Can act as phagocytes and present antigen.
Macrophage Morphology
Mononuclear cells with a diameter of 21 μm (Figure 2-4).

Move in tissue via amoeboid movement and capture particles with
pseudopodia.
Express CD14, CD11b/CD18 (Mac-1), and CD36.
Have several subtypes named by location, including Kupffer cells (liver),
histiocytes (tissue), osteoclasts (bone), mesangial cells (kidney), and alveolar
macrophages (lung).
Macrophage Growth and Differentiation
Flash Card A4 Develop in response to granulocyte monocyte colony-stimulating factor

(GM-CSF) and macrophage colony-stimulating factor (M-CSF).
The medulla, which is
also where the AIRE Can survive weeks in tissue.
protein functions
Figure 2-3. Blood cell lineage.

(Adapted, with permission, from Wikimedia Commons.)
Macrophage Function Key Fact

CD14 is a highly
Clear cellular debris as well as bacterial invaders. expressed receptor on
Can be activated by signals, such as IFN and LPS (which binds CD14). monocytes and
Present pathogens to helper T cells via MHCII molecules. macrophages, which
binds lipopolysaccharide
Secrete cytokines, such as TNFα, IL-12, IL-18, IL-1, IL-6 (CXCL-8). and activates an
immune response. It is a
component of Toll-like
receptor 4 (TLR4).
Diseases Associated with Macrophages
Many macrophages (see Figure 2-4) fuse to form granulomas in order to wall off
a pathogen when they are unable to clear it. Granulomas are characteristic of Key Fact
many infectious and noninfectious inflammatory reactions, including sarcoidosis HLH is often a fatal
(noncaseating granulomas) and tuberculosis (caseating granulomas). TNFα, which consequence of
is secreted by macrophages, promotes granuloma formation. Epstein-Barr virus (EBV)
infection in boys with X-
linked
Uncontrolled activation of macrophages with a marked increase in circulating lymphoproliferative
cytokines is called hemophagocytic lymphohistiocytosis (HLH) or macrophage (XLP) syndrome, which
activation syndrome, when secondary to chronic rheumatoid disease. This is due to mutations in
potentially life-threatening syndrome is characterized by high fever, the SH2D1A gene
hepatosplenomegaly, high ferritin and triglyceride levels, and low fibrinogen and (encodes SAP protein).
76 / CHAPTER 2
Figure 2-4. Gaucher cell. Macrophage with "crumpled tissue" appearance.

(Reproduced, with permission, from the National Institutes of Health.)
circulating NK levels. Hemophagocytosis can often be seen on bone marrow

biopsy. The diagnosis is made when five of the eight following criteria are met:
fever, splenomegaly, cytopenia involving two or more cell lines,
hypertriglyceridemia or hypofibrinogenemia, hemophagocytosis, hepatitis, low or
absent NK cell activity, ferritin level >500 µg/L, and soluble CD25 (sIL-2
receptor) >2400 U/mL.
Dendritic Cell Morphology
Mononuclear cells with multiple projections, called dendrites (Figure 2-5).

Classified into subsets (Table 2-6).
Figure 2-5. Dendritic cell.

(Reproduced, with permission, from Wikimedia Commons.)
Table 2-6. Dendritic Cell (DC) Subsets

Subset Markers Precursor Key Points
Myeloid CD1, CD11b/c, Myeloid Primarily act in phagocytosis and
(DC1)(Conventional CD13, CD14 antigen presentation
DCs)
Plasmacytoid Lymphoid Secrete large amounts of IFNα

(DC2) and associated with viral
infections
Langerhans CD11c, CD207 Myeloid (CLA+) Prime CD8 T cells

Birbeck
granules
Interstitial CD2, CD9, Myeloid (CLA–) Activate B cells

CD68
Dendritic Cell Growth and Differentiation
Develop in response to GM-CSF and IL-4 from the common myeloid or

lymphoid progenitor.
Key Fact
Dendritic Cell Function
CD1 isoforms (CD1a–
CD1e) are class I MHC
Are the major antigen presenting cells (APCs) and are critical in starting
like molecules that
germinal center reaction. present nonpeptide (lipid
o Are immature in the tissue (where they specialize in antigen uptake) and and glycolipid) antigens
mature in the lymphoid organs (where they specialize in antigen to T cells. CD1 maps
presentation; increased MHC II expression). outside the MHC locus
on chromosome 15.
Express B7.1 and B7.2 (CD80/CD86) which interacts with CD28 on T cells to
provide costimulation.
Flash Card Q5
Which subset of
dendritic cells produces
type I IFN during viral
infections?
78 / CHAPTER 2
MAST CELLS
Mast cells (MC) are ubiquitous granulocytes found in skin and mucosal
membranes; known primarily for their role in immediate hypersensitivity, but
now better known as a regulator of innate immunity.
Mast Cell Morphology
Metachromatically staining cell; mast means “feeding” or “fattening.”

Contain large cytoplasmic granules, which are filled with preformed
mediators (e.g., histamine) that can be released quickly.
Have peripheral, unsegmented nuclei and are 9–14 μm in size (Figure 2-6).
Mast Cell Growth and Differentiation
Derived from pluripotent, kit+ (CD117+), CD34+ stem cells in the bone
marrow.
Key Fact Develop phenotype after arrival in the tissue (Table 2-7)—mature in the tissue
(unlike basophils and eosinophils).
Kit is the receptor for the
cytokine stem cell factor,
the critical growth factor
of mast cells and a
target of imatinib. The
gene that encodes the
receptor kit, c-kit, is a
proto-oncogene.
Figure 2-6. Mast cell.

Flash Card A5
Plasmacytoid dendritic
cells
Table 2-7. Mast Cells Phenotypes

Phenotype Mediators Location Other
MCT Tryptase Respiratory tract and Do not express C5aR
intestinal mucosa (CD88); scroll-like
appearance; require T cells Mnemonic
for their development; do For MCT, think Tissue.
not respond to opiates,
For MCTC, think
C5a, C3a, and vancomycin
Connective Tissue.
MCTC Tryptase, Skin, blood vessels, eyes, Express C5aR (CD88);
chymase, synovium, intestinal, and whorled appearance; do not
carboxypeptidase, respiratory submucosa require T cells for their
cathepsin G development; respond to
opiates, C5a, C3a, and
vancomycin
MCC Chymase Lymph nodes, intestinal
submucosa, and salivary
glands
IgE Receptor/FcεR
Key Fact
High-Affinity IgE Receptor/FcεRI: Some CIU patients have
IgG directed against the
o Tetrameric form: Composed of one α chain, one β chain, and two α chain of FcεRI, though
chains; it is found on mast cells and basophils (Figure 2-7). this is also seen in
patients without
The α chain contains two immunoglobulin domains that bind with urticaria. There is no
high affinity to IgE. evidence that these
The β chain contains four transmembrane domains and one antibodies are
pathogenic in urticaria.
immunoreceptor tyrosine-based activation motif (ITAM).
The chains are covalently linked, and each contains one ITAM.
This is the main signaling component.
o Trimeric form: Composed of one α chain and two γ chains; it is found on
dendritic cells, monocytes, and eosinophils.
Low-Affinity IgE Receptor/ FcεRII/CD23: C-type lectin; it is found on mature Key Fact
B cells, activated macrophages, eosinophils, dendritic cells, and platelets; the IgE binds to FcεRI via
allergen responsible in dust mite allergy (Der-p-1) is known to cleave CD23 the α chain. Signaling of
mast cells is similar to
from the cell surface, increasing the production of allergen-specific IgE. that in B cells with Lyn,
Fyn, and Syk.
Mast Cell Activation
Allergens activate MC via cross-linking IgE receptor (Figure 2-7).

80 / CHAPTER 2
Figure 2-7. Mast cell activation and signaling.

Mast cells can also be activated by: IgG via Fc RI; bacterial antigens via TLR
2/6 or 4; C3a or C5a (anaphylatoxins)(MCTC only); cytokines; neuropeptides;
physical stimuli (e.g., heat, pressure); substance P; and drugs [radiocontrast
media; opioids (MCTC only); muscle relaxants].
Mast Cell Mediators
Release preformed mediators (<15 minutes) (e.g., histamine, tryptase,

chymase, TNF, and heparin).
Produce and release lipid-derived mediators (~10–30 minutes) after
activation via the arachidonic acid pathway; responsible for late allergic
reactions (e.g., PGD2, LTC4, LTB4, PAF).
Produce and release cytokines and chemokines (hours to days) after activation
(eg, IL-3, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, GM-CSF, TNFα, MCP-1, MIP-
1α, and RANTES [CCL-5]).
Table 2-8 lists selected mast cell mediators.

Table 2-8. Select Mast Cell Mediators

Lipid-
Mediator Function Preformed
Derived
Histamine Smooth muscle contraction; mucus X
production; vasodilation; gastric acid
secretion; and wakefulness
Tryptase Serine (protease) endopeptidase X
Key Fact
Carboxypeptidase Peptidase for C-terminal end of peptide X
Chymase Serine (protease) endopeptidase X
Both α- (mostly
immature) and β-
Heparin Anticoagulant X (mostly mature) tryptase
Prostaglandin D2 Increases vascular permeability; X are elevated in
bronchoconstriction; inhibits platelet mastocytosis, but only
aggregation; chemoattraction β-tryptase (i.e., mature
Leukotriene C4 Increase vascular permeability; X tryptase) is elevated in
and B4 bronchoconstriction anaphylaxis. Mast cells
are the major producers
Platelet-activating Bronchoconstriction; vasodilation; and X
factor platelet aggregation of tryptase.
BASOPHILS
Basophils are the least common circulating granulocytes that appear in many
inflammatory reactions (especially allergic diseases) and share many
characteristics of mast cells. They are important in the late phase of IgE-mediated
disease.
Basophil Morphology
Contain large cytoplasmic granules, which are filled with preformed
mediators (e.g., histamine) that can be released quickly.
Have bilobed nuclei and are 10–14μm in size (Figure 2-8).
Basophil Growth and Differentiation
Derived from bone marrow progenitors distinct from those of mast cells.
Mature in bone marrow.
Found primarily circulating in blood; also in bronchoalveolar lavage (BAL)
from late-phase reactions. Flash Card Q6
Have CD123 (IL-3 receptor) and IL-3 is important for their Which mast cell
expansion/differentiation. mediator is both
preformed and produced
in the late phase?
82 / CHAPTER 2
Figure 2-8. Basophil.

(Reproduced, with permission, from Wikipedia Commons.)
Basophil Mediators
Release preformed mediators (<15 minutes) that cause symptoms of

immediate allergic reactions (e.g., histamine, chondroitin, MBP, and Charcot-
Leyden protein).
Key Fact Produce and release lipid-derived mediators (~10–30 minutes) after
activation via the arachidonic acid pathway responsible for late allergic
Unlike mast cells,
basophils do not produce
reactions (e.g. LTC4).
(or produce very little) Produce and release cytokines and chemokines (minutes to days) (e.g. IL-3,
tryptase, chymase, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, GM-CSF, TNFα, MCP-1, MIP-1α,
carboxypeptidase, RANTES (CCL-5), and PAF).
heparin, PGD2, and
LTB4.
Table 2-9 compares mast cells and basophils.
Table 2-9. Comparison of Mast Cells and Basophils

Mediator/Characteristic Mast Cell Basophil
Location Tissue Circulation/blood
Nucleus Unsegmented Multilobed
Granules More, smaller Fewer, larger
Histamine + +
Tryptase +++ +
Chymase + –
Carboxypeptidase + –
LTC4 + +
LTB4 + –
PGD2 + –
FCεRI + +
IL-3 receptor (CD123) – +
Flash Card A6 C5a receptor + –

Abbreviations: IL, interleukin; LT, leukotriene; PGD, prostaglandin.
TNF
EOSINOPHILS
Eosinophils are granulocytic leukocytes that combat infection (namely, helminth)

and mediate allergic responses.
Eosinophil Morphology
Have a bilobed nucleus and are 12–14 μm in size (Figure 2-9).

Primary granules contain Charcot-Leyden crystals
Specific/secondary granules contain preformed mediators that include major
basic protein, eosinophil cationic protein, eosinophil peroxidase, and
eosinophil-derived neurotoxin, which are all toxic to surrounding tissue and
are released during cytolysis.
Express Fc receptors for immunoglobulins, β2-integrins (CD11a-cCD18), β1-
integrin (VLA-4), β4-integrin (α4β7), and PSGl-1.
Eosinophil Growth and Differentiation
Derived from myeloid precursor (Figure 2-3). Key Fact

Differentiation, maturation, and activation stimulated by GM-CSF, IL-3, and Major basic protein can
IL-5. be used to detect the
o Mature in the bone marrow. recent presence of
o GATA1 transcription factor eosinophils in tissue,
even when eosinophils
Migrate to tissue in response to RANTES (CCL-5) and eotaxin (eotaxin-1,
cannot be seen on
CCL-11; eotaxin-2, CCL-24). biopsy.
o Most eosinophils reside in the tissue (lower GI tract, mammary gland,
female reproductive tract, lymph tissue).
o 1–2% in peripheral blood.
Half-life of approximately 18 hours.
o Levels vary throughout the day (diurnal variation).
Flash Card Q7
Figure 2-9. Eosinophil. What is contained in
(Reproduced, with permission, from Wikimedia Commons.) eosinophil primary
granules?
84 / CHAPTER 2
Eosinophil Function
Modulate immune response, fight helminthic infections, and has antitumor

effects:
o Release of toxic granule proteins.
o Produce reactive oxygen species.
o Release leukotrienes and prostaglandins.
o Release cytokines, including IL-1, IL-2, IL-4, IL-5, IL-6, IL-8, IL-13, and
TNF.
Mammary gland development.
Wound repair and tissue remodeling.
Associated Disorders
Hypereosinophilia (>450 cells/μL) the following causes:

Mnemonic
Malignancy (Hodgkin’s lymphoma)
Causes for eosinophilia:
NAACP
Adrenal insufficiency (Addison’s disease)
Neoplasm
Allergic disease and asthma (usually only mild to moderate eosinophila in
Atopy asthma)
Addison’s disease Collagen vascular disorders
Collagen vascular
disease Drug reactions (antiepileptics, NSAIDs, fluoroquinolones, tetracycline,
Parasites penicillin, nitrofurantoin, others)
Hematologic disorders:
o Hypereosinophilic syndrome
o Mastocytosis
Eosinophilic esophagitis
Skin disease (eczema and pemphigoid)
Kimura’s disease
Key Fact Lung disease:
Drug reactions are the
o Allergic bronchopulmonary aspergillosis (ABPA)
#1 cause of marked o Loeffler’s syndrome
eosinophilia in the U.S., o Eosinophilic pneumonia
whereas parasitic
infections are the #1 o Churg-Strauss vasculitis
cause worldwide. Infectious diseases:
o HIV (secondary to adrenal insufficiency, HIV medications, or HIV virus
itself)
o Parasitic infections, especially those that invade tissue (strongyloidiasis)
o Isospora belli and Sarcocystis, but not other protozoa
Flash Card A7 o Chronic TB
Charcot-Leyden crystals
Suppression of eosinophil levels occurs by:

Most bacterial/viral infections (note the exceptions listed earlier, such as
HIV).
Fever
Steroids
NEUTROPHILS
Neutrophils are the most abundant white blood cells in the adult human body and
an essential component of the innate immune system. Key Fact
Neutrophils are attracted
to tissue by IL-8
(CXCL8) and LTB4.
Neutrophil Morphology
Have a multilobulated nucleus and are 12–15 μm in size (Figure 2-10).

Contain granules of preformed mediators (Table 2-10).
Express surface receptors for IgG, IgA.
Neutrophil Growth and Differentiation
Derived from myeloid precursor (Figure 2-3).

Survival, differentiation, and proliferation stimulated by IL-3, GM-CSF and
G-CSF.
Approximately 1 × 1011 is made per day in a healthy individual.
Circulate for only 4–10 hours (mostly in the bone marrow).
Migrate into tissues via IL-8 (CXCL-8), IFN , f-met-leu-phe (fMLP), MIP-1,
LTB4, and C5a as well as interactions between Sialyl-Lewis X, E-/P-
selectins, and LFA-1/ICAM-1. Key Fact
Neutrophils, eosinophils,
and basophils are each
considered polymorpho-
nuclear cells because of
the multilobulated
appearance of their
respective nuclei. They
are named for their
characteristic appearance
after H&E stain. Basophils
stain a basic blue.
Eosinophils stain an
acidic, bright red.
Figure 2-10. Neutrophil. Neutrophils stain a neutral
(Reproduced, with permission, from Wikimedia Commons.) pink.
86 / CHAPTER 2
Table 2-10. Neutrophil Granules

Key Fact Granule Type Mediators
Primary granules are Azurophilic (1 granules) Myeloperoxidase, defensins, elastase, lysozyme, and
cathepsin
enlarged in Chediak-
Higashi syndrome, but Specific (2 granules) Lactoferrin, cathelicidin, fMLP, and CD11b
secondary granules are Gelatinase fMLP, CD11b, lysozyme, and gelatinase
absent in specific
Secretory fMLP, CD11b, and alkaline phosphatase
granule deficiency. The
exact mediators in each
are less important.
Neutrophil Function
Function primarily as phagocytes.

Phagosomes fuse to lysosomal granules (see Table 2-10) and kill invaders via
Key Fact
respiratory burst.
Neutrophils are Also secrete detectable amounts of cytokines.
activated by cytokines
secreted by Th17 cells.
Undergo apoptosis in tissue and can “feed” surrounding cells.
Neutropenia causes a predisposition to severe bacterial infections, ulcerations,

abscess formation, and gingivitis.
o Mild: ANCA < 1500 cells/μL
o Moderate: ANCA < 1000 cells/μL
o Severe: ANCA < 500 cells/μL
Several congenital causes of neutropenia as well as defects in migration and
effective killing have been identified. See section in Chapter 8, Congenital
(Primary) Immunodeficiencies.
PLATELETS
Platelets are small, anuclear cells in the blood circulation whose primary role is in
homeostasis.
Morphology, Growth, and Differentiation
Anucleated cells that are 2–3 μm in diameter (Figure 2-11).

Derived from megakaryocyte precursor (Figure 2-3).
Average life span is 8–12 days.
Figure 2-11. Two Platelets (purple).

Formation regulated by thrombopoietin secreted by the liver and kidney.

Express surface receptors for IgG and CD23.
Function
Thrombus formation (Figure 2-12).

o After endothelial damage, platelets are activated by exposed collagen and
von Willebrand factor (vWF).
o Activated platelets release contents of granules (ADP/ATP, calcium,
serotonin, TGFβ, platelet factor 4 (PF4), platelet-derived growth factor
(PDGF), vWF, and fibrinogen).
o Arachidonic acid pathway initiated to produce thromboxane A2, which
activates more platelets.
o Platelets clump together via fibrinogen and vWF interaction with the
GPIIb/IIIa receptor
Cytokine release
In general, thrombocytopenia increases bleeding risk (however, heparin-

induced thrombocytopenia may lead to thrombus formation), and
thrombocytosis leads to increased coagulation.
88 / CHAPTER 2
Figure 2-12. Thrombus formation (and inhibitors).
Diseases with reduced platelet counts (thrombocytopenia) or function:

Key Fact o Aplastic anemia o Idiopathic thrombocytopenic
o Bernard-Soulier syndrome purpura (ITP) (due to antibodies
Wiskott-Aldrich
syndrome is an X-linked
o Drug-induced to platelet’s GP2b3a)
disorder characterized thrombocytopenia o Thrombotic thrombocytopenic
by eczema, infections, o Gaucher’s disease purpura (TTP) (due to
and thrombocytopenia o Glanzmann’s thrombasthenia antibodies to ADAMTS13)
(as well as small platelet o HELLP syndrome o Von Willebrand disease
volume). The defective
gene encodes for the
o Hemophilia o Heparin-induced
Wiskott-Aldrich o Hermansky-Pudlak syndrome thrombocytopenia (due to
syndrome protein o Wiskott-Aldrich syndrome antibodies to PF4)
(WASp) used in cell
signaling.
EPITHELIAL CELLS
Mnemonic
Layers of the epidermis: Epithelial cells form a type of tissue that lines the surface of structures throughout
Before Signing Get the body, serving in innate and acquired host defense as both a barrier and an
Legal Counsel effector (secretory) tissue.
Stratum Basale
Stratum Spinosum
Stratum Granulosum Epithelial Cell Morphology
Stratum Lucidum
Stratum Corneum
Classified by structure into four distinct types.
Layers of keratinized epithelial cells make up the skin epidermis and contain
an extensively cross-linked protein called transglutaminase.
Key Fact
Defined by the expression of certain adhesion molecules called e-cadherins.
Attached to adjacent epithelial cells by tight junctions, intermediate junctions, Oligomeric IgA binds to
a polymeric
and desmosomes (which contain e-cadherins). immunoglobulin receptor
Attached to extracellular matrix via hemidesmosomes (which use integrins on epithelial cells, is
for adhesion instead of cadherins). transported through the
Contain filament-associated proteins, which bind keratin fibers called cell, and secreted, while
still attached to part of
filaggrins. the receptor called the
secretory component.
Epithelial Cell Function

Key Fact
Forms primary barrier against pathogens.
Intestinal epithelial cells
Secretes numerous mediators used in defense, including cytokines, can process antigens
chemokines, growth factors, mucous, and antimicrobials. from the gut lumen and
Removes potential pathogens via beating motion of cilia. present them to T cells
Also functions in absorption and diffusion of liquids and gases. via MHCII.
Epithelial Cells in Disease
Pathogens exploit epithelial receptors to initiate infection:

o Rhinovirus/ICAM-1
o Influenza/Glycans
o Adenovirus/Integrins and CD80/CD86
Filaggrin mutations are associated with the development of eczema, allergic
rhinitis, and asthma.
Autoantibodies against components of epithelial cells cause several bullous
Flash Card Q8
skin disorders (Table 2-11).
The innate immune function of the human airway epithelium is to orchestrate In which platelet
disorder are platelets
key inflammatory events following insult (virus, fungus, allergen, pollution) abnormally large?
which may be important in allergic disease such as asthma and atopic Hint: Antibodies to
dermatitis. platelet’s GP2b3a are
o Airway epithelial cells produce CCL2 and CCL20 in response to house also seen.
dust mite inhalation, which attracts monocytes and immature DCs to
the lung.
o Produce thymic stromal lymphopoietin (TSLP), GM-CSF, IL-25 and
IL-33, which share the propensity to activate DCs that prime Th2 and Flash Card Q9
coordinate the subsequent immune response. Which chemokines
o IL-33 and other members of the IL-1 family of cytokines, such as IL- produced by
1α, IL-1β and IL-36γ (IL-1F9), are released from bronchial epithelial keratinocytes are
cells in response to allergen exposure. responsible for homing
T cells to the skin? What
o Suppression of β defensins and cathelicidin due to the expression of are the corresponding
IL-4 and IL-13 may contribute in the pathogenesis of atopic dermatitis. receptors on the T cells?
90 / CHAPTER 2
Table 2-11. Bullous Skin Disorders

Disease Direct IF Target Antigen Location
Pemphigus vulgaris Intercellular IgG and Desmoglein 3 Desmosome
IgM
Pemphigus Intercellular IgG Desmoglein 1 Desmosome
foliaceous
Bullous pemphigoid Linear IgG at BMZ BP 230 (BPAg1) or Hemidesmosome
BP180 (BPAg2)
Pemphigoid Linear IgG at BMZ BP 230 (BPAg1) or Hemidesmosome
gestationis BP180 (BPAg2)
(formerly herpes
gestationis)
Dermatitis Granular IgA in dermis Transglutaminase Subepidermal
herpetiformis
Linear IgA Linear IgA at BMZ BP 180 (BPAg2) Hemidesmosome
dermatosis
Abbreviations: BMZ, basement membrane zone; Ig, immunoglobulin.
Study note: Be able to look at an immunofluorescence and know the most likely
bullous skin disorder and target antigen.
ENDOTHELIAL CELLS
Endothelial cells are specialized, mesenchymally derived cells related to

epithelium; they are found on the inside line of blood vessels throughout the body.
Endothelial Cell Function
Flash Card A8 Maintains homeostasis via vasodilation and vasoconstriction, coagulation and
fibrinolysis, wound healing, inflammation, and immunity.
ITP
Mediates adhesion and transmigration of circulating leukocytes via selectins
and integrins (Table 2-12).
Certain chemokines can increase the affinity of integrins for their ligands.
Flash Card A9 Endothelial cells in the high endothelial vessels display adhesion molecules
and chemokines that are responsible for the homing of naive T cells to the
Keratinocytes produce
lymph nodes.
CCL17 (TARC) and
CCL22 (MDC). Skin-
homing T cells express
cutaneous lymphocyte
antigen (CLA) and
CCR4 and CCR10.
Table 2-12. Adhesion Molecules on Endothelium Used for Transmigration

of Leukocytes
Adhesion Adhesion
Mnemonic
Ligand Ligand Location
Molecule Molecule Location "P" selectin: think
E-Selectin Endothelium Sialyl-Lewis X Leukocytes "P"reformed (actually
named after platelets)
P-Selectin Endothelium Sialyl-Lewis X Leukocytes
L-Selectin Leukocytes Sialyl-Lewis X on High endothelial
(not endothelium) GlyCAM-1/ MadCAM-1 venules
Integrins Leukocytes ICAM and VCAM Endothelium
Abbreviations: GlyCAM, glycosylation-dependent adhesion molecule; ICAM, intercellular adhesion
molecule; MadCAM, mucosal addressin cell adhesion molecule, VCAM, vascular cell adhesion
molecule.
Endothelial Cells in Disease
Activation and deposition of inflammatory cells can lead to endothelial

disruption and endothelial death, both locally and systemically.
Antineutrophil cytoplasmic antibodies (ANCA) can lead to widespread
endothelial inflammation.
Deposition of inflammatory cells (in particular, eosinophils) in lung
endothelium correlates with airway hyperresponsiveness in asthma.
Flash Card Q10

SMOOTH MUSCLE
Which selectin is not
found on endothelium?
Smooth muscle is an involuntary, nonstriated muscle found in vessels walls. An
IgG autoantibody (anti-SMA) is directed against smooth muscle in type I
autoimmune hepatitis.
Flash Card Q11
What surface markers
on the high endothelial
FIBROBLASTS venules and naive T
cells are responsible for
homing to the lymph
nodes?
Fibroblasts are a type of cell that makes collagen and other components of the
extracellular matrix. Fibroblasts secrete growth factors, including stem cell factor,
which is essential for mast cell differentiation and survival. Fibroblasts are
particularly important in wound healing.
Flash Card Q12
What integrin ligands
are found on the surface
of activated
endothelium?
92 / CHAPTER 2
Flash Card A10

L-selectin (this is found
on leukocytes. E-selectin
and P-selectin are found
on endothelium)
Flash Card A11

CCL19 and CCL21 by
the high endothelial
venule, and CCR7 on
the naive T cell
Flash Card A12

ICAM-1, ICAM-2,
VCAM-1
3 Specific Immune Responses
OVERVIEW OF HYPERSENSITIVITY REACTIONS
Hypersensitivity reactions have been grouped into four types (types I–IV) based
primarily on the mechanisms involved. This has been summarized in Table 3-1. A
particular disease may however involve more than one type of reaction.
TYPE I HYPERSENSITIVITY REACTIONS
Mast cells and basophils are the primary cells in immediate hypersensitivity or
type I hypersensitivity reactions. The reaction is amplified or modified by
platelets, neutrophils and eosinophils. IgE is the primary immunoglobulin.
Examples include: allergic asthma, allergic conjunctivitis, allergic rhinitis ("hay
fever"), anaphylaxis, drug allergy, and food allergy.
Table 3-1. Overview of Hypersensitivity Reactions

Type of
Hypersensitivity Key Players Antigen Example(s)
Reactions
Type I Mast cells Soluble Allergic asthma
Basophils Allergic rhinitis
IgE Anaphylaxis
Food allergy
Type II IgG Cell/matrix Hemolytic anemia
IgM associated Goodpasture’s
Complement syndrome
Phagocytes Graves’ disease
Type III Complement Soluble SLE
IgG Glomerulonephritis
Serum sickness
Type IV T cells Contact dermatitis
Psoriasis
Celiac disease
Abbreviations: Ig, immunoglobulin; SLE, systemic lupus erythematosus.
94 / CHAPTER 3
Pathophysiology
IgE Production—Upon initial exposure, allergen/antigen is presented by antigen-
presenting cells (APCs) to CD4+ Th2 cells specific to the antigen. These Th2 cells
then drive B cells to produce IgE specific for the antigen (which is called
sensitization) through cytokines such as interleukin 4 (IL-4) (which binds IL-
4Rα/γc and IL-4Rα/IL-13Rα1) and IL-13 (which binds IL-4Rα/IL-13Rα1). This
process occurs primarily in the peripheral lymphoid organs.
The specific IgE (sIgE) binds high-affinity IgE receptors (FcεRI) on mast cells
and basophils.
Degranulation—Upon re-exposure, allergen binds the surface-bound sIgE on

mast cells or basophils. When the receptors are cross-linked, intracellular
signaling occurs and leads to cell degranulation (see Figure 2-6). This releases
preformed mediators, enzymes, and cytokines (Table 2-8). These mediators act
directly on tissues and recruit and activate additional inflammatory cells
(eosinophils among others) which release more mediators and propagate the
reaction.
Immediate reaction—results from the release of preformed mediators

Late reaction—results from the influx of inflammatory cells and generation of
cysteinyl leukotrienes (lipid-derived mediators)
For mediators, mast cell kininogenase and basophil kallikrein activate the contact
system; tryptase has kallikrein activity [which can activate the contact system,
complement cascade, and clotting cascade (via cleaving fibrinogen, which is a
chemoattractant for neutrophils and eosinophils)]; platelet-activating factor
(PAF) from tumor necrosis factor (TNF) activation of nuclear factor kappa B
(NFκB) induces clotting and disseminated intravascular coagulation; PAF also
activates mast cells; heparin inhibits clotting; and, chymase can convert
angiotensin I to angiotensin II, which modulates hypotension.
The process is summarized in Figure 3-1.
Anaphylaxis
IgE-mediated immunologic anaphylaxis (sometimes called allergic anaphylaxis)
is a key example of a type I hypersensitivity reaction.
SPECIFIC IMMUNE RESPONSES / 95
Subtypes of Anaphylaxis
Immunologic anaphylaxis—IgE-mediated reactions; non-IgE-mediated (i.e.,

not type I reactions), which include IgG-mediated reactions (which have not
been identified in humans) and immune complex/complement-mediated
reactions
Nonimmunologic anaphylaxis—IgE-independent mast cell or basophil
degranulation. This is also known as nonallergic anaphylaxis.
Pathophysiology of Immunologic/IgE-mediated Anaphylaxis—As described

earlier in detail, these reactions consist of allergens reacting with IgE antibodies
bound to Fc receptors on mast cells and basophils, leading to activation of the
cells and mediator release.
Figure 3-1. Steps in a type I hypersensitivity reaction.

Abbreviations: APC = antigen-presenting cell, ECP, EDN, MBP = eosinophil granule proteins, IgE =
immunoglobulin E, IL = interleukin, PGD2 = prostaglandin 2, Th2 = type 2 helper T cell.
(Reproduced, with permission, from Mitchell Grayson, MD, Medical College of Wisconsin.)
Flash Card Q1
What are the steps that
occur during primary
exposure to antigen?
96 / CHAPTER 3
TYPE II HYPERSENSITIVITY REACTIONS
IgG and IgM are the primary immunoglobulins in type II hypersensitivity

reactions with complement or phagocytes also frequently being involved.
Examples include: hemolytic anemia, hemolytic disease of the newborn,
Goodpasture’s syndrome, myasthenia gravis, and Graves’ disease.
Pathophysiology
The effector function of antibodies is to eliminate microbes and toxins (Table

3-2).
This antibody-mediated elimination of antigens requires the involvement of
other effector mechanisms, such as complement and phagocytes.
In summary, type II reactions occur when antibodies bind antigens on a target
Key Fact cell (e.g., for example, penicillin bound to red blood cells); target cell damage
Know all of the effector then occurs through:
functions of o Cellular neutralization/blocking (i.e., myasthenia gravis),
immunoglobulins listed o Cytotoxicity (i.e., hemolytic anemia), or
in Table 3-2 as well as o Cellular stimulation (i.e., Graves’ disease)
the how the processes
are carried out.
Neutralization of Microbes and Toxins
Antibodies block the binding of microbes and toxins to cellular receptors.
o Example: Influenza virus uses its envelope hemagglutinin to infect
respiratory epithelial cells. An antibody will bind the hemagglutinin
and “neutralize” the microbe so it does not interact with cellular
receptors. This is an example of steric hindrance.
Flash Card A1
Table 3-2. Effector Functions of Antibody Isotypes
(1) Allergen/antigen is
presented by APCs to Antibody Isotype Effector Functions
CD4+ Th2 cells specific IgG Opsonization (namely, IgG1 and IgG3)
to the antigen; (2) these Activation of classical pathway of complement (namely, IgG1 and IgG3)
Th2 cells then drive B Antibody-dependent cell-mediated immunity (ADCC)
cells to produce IgE Neonatal immunity as a result of placental transport
specific for the antigen
(which is sensitization) IgM Activation of classical pathway of complement
through cytokines such IgA Mucosal immunity
as IL4 and IL-13; (3) the Neonatal immunity provided by breast milk
specific IgE (sIgE) binds
high-affinity IgE IgE Mucosal immunity
receptors (FcεRI) on
mast cells and
basophils.
Cytotoxicity by Opsonization and Phagocytosis

IgG antibodies coat or opsonize microbes and promote phagocytosis (Figure
3-2).
Mononuclear phagocytes and neutrophils have receptors for the Fc portions of
the antibodies that specifically bind the opsonized microbes for intracellular
killing.
The phagocyte Fc receptors:
o Promote phagocytosis of opsonized particles.
o Deliver signals that promote killing of the microbes by the phagocyte.
FcγRI (CD64) is a high-affinity phagocyte receptor that strongly binds IgG1
and IgG3 (two of the most efficient opsonins).
Cytotoxicity by Complement Fixation
Out of the three major pathways of complement activation, the classical
pathway is the only one activated by an antibody (IgG or IgM).
The alternative pathway is activated by microbial cell surfaces and the lectin
pathway is activated by plasma lectins, which bind to microbe mannose
residues, both in the absence of antibody.
All three pathways result in the generation of C3, the most abundant
complement protein.
With complement activation, C3 is proteolyzed to produce an active product
C3b that attaches to microbes.
As a result, microbes can be opsonized by complement particles, specifically
C3b, and engulfed by phagocytes expressing receptors (CR1=CD35) specific
for C3b.
Figure 3-2. Antibody-mediated opsonization and phagocytosis of a microbe. Flash Card Q2

Which immunoglobulin(s)
is/are involved in
opsonization?
98 / CHAPTER 3
Cytotoxicity by Antibody-Dependent Cell-Mediated Cytotoxicity (ADCC)

A process whereby natural killer (NK) cells (and other leukocytes) bind to
antibody-coated microbes to destroy them.
NK cells express the FcγRIII receptor (a low-affinity Fc receptor; CD16) that
binds to clustered IgG molecules (not to monomeric-circulating IgG) (Figure
3-3)
An antibody-coated particle engages the FcγRIII receptor on the NK cell,
which subsequently activates the NK cell to:
o Produce and secrete cytokines such as IFNγ.
o Discharge its granules.
o Kill the infected cell.
Antibody-Mediated Immune Regulation

IgA and Mucosal Immunity: Gut/Oral―The gastrointestinal and pulmonary
tracts are the most common entry point for microbes. The major defense against
microbes on those mucosal surfaces is provided by IgA antibody.
IgA binds microbes and toxins in the gut and respiratory lumen, neutralizing
Key Fact them and preventing infection.
Isotype switching to IgA occurs most efficiently in the mucosal lymphoid
Although it constitutes
less than one quarter of tissue and is stimulated by transforming growth factor (TGFβ) and IL-5.
antibody in plasma, the Secreted IgA is a dimer that is transported into lumen via an IgA-specific
amount of IgA produced receptor called the poly-Ig receptor (Figure 3-4).
in the body is greater o Note: Poly-Ig receptor can also transport IgM into intestinal
than that of any other
secretions; thus, the use of the prefix “poly” in its name.
antibody isotype (60–
70% of total antibody The poly-Ig receptor is responsible for secreting IgA into milk, bile, saliva,
output), with most of the and sweat.
antibody located in or
near the mucosal
tissues.
Flash Card A2
Figure 3-3. Antibody-dependent cell-mediated cytotoxicity.
IgG (Reproduced, with permission, from Wikipedia.)
Figure 3-4. IgA dimer. 1 = H chain; 2 = L chain; 3 = J chain; 4 = secretory

component.
IgG and Neonatal Immunity—Neonates are not capable of producing an

effective immune response and, for the first several months after birth, they are
protected passively by maternal antibodies.
IgG is transported across the placenta from mother to infant.
Maternal IgA more than IgG are ingested from the breast milk by the infant.
IgG is transported across the placenta and infant gut lumen by an IgG-specific
Fc receptor called neonatal Fc receptor (FcRn), which resembles the major
histocompatibility complex (MHC) class I molecule.
TYPE III HYPERSENSITIVITY REACTIONS
Immune complexes, hence antigen, antibody, and complement, are the major
players in immune complex-mediated or type III hypersensitivity reactions.
Examples include systemic lupus erythematosus (SLE), glomerulonephritis,
serum sickness, and vasculitis.
Pathophysiology
Immune complexes are clusters of antigens and antibodies that are typically
cleared by the spleen and liver. Under some circumstances, immune complexes
are deposited in the blood vessels or tissues where they can cause disease.
Damage is caused by formation or deposition of antigen-antibody complexes in
vessels or tissue. The deposition of immune complexes causes complement
100 / CHAPTER 3
activation and recruitment of neutrophils by interaction of immune complexes

with Fc IgG receptors
Immune Complex Clearance—The relative concentration of antigen to antibody

and their charge (amongst other factors) determine whether immune complexes
will be cleared or deposited in the tissue.
Immune complexes formed at equivalence (antibody number = antigen number)

form a lattice and are rapidly removed from the circulation by mononuclear
phagocytes, such as Kupffer cells in the liver.
Immune complexes that are formed when either the antibody or the antigen are in
excess are smaller and not removed efficiently from the circulation. It is thought
that the most pathogenic state (i.e., the case of many pathological syndromes in
vivo) occurs when immune complexes are created in a state of moderate antigen
excess. Immune complexes in this state are soluble (and hence difficult to
phagocytose) and can easily fix complement and generate potent cleavage
products (contributing to increased vascular permeability and extravascular
movement of inflammatory cells)
Precipitin curves illustrate immune complex formation (Figure 3-5).
3.5
3
2.5
Amount of 2
precipitate 1.5
1
0.5
0
0 1 2 3 4 5
Amount of antigen
Figure 3-5. Precipitin curve. As antigen is added to serum with a fixed amount of
antibody, small immune complexes are first formed in a state of antibody excess
(left side of curve). As equivalence is reached, immune complexes begin to
precipitate (middle of curve). With antigen excess, immune complexes again
become smaller and do not precipitate (right side of curve). The most pathogenic
state is thought to be moderate antigen excess (arrow). This is a representative
curve of an Ouchterlony plate with the visible precipitate graphed against the
increasing antigen concentration using a serum with a fixed antibody
concentration (x-axis = amount of antigen added; y-axis = concentration of
precipitate in serum.)
The basement membrane is negatively charged. Positively charged immune

complexes tend to deposit in the basement membrane of skin and kidneys (Figure
3-6), whereas neutral or negatively charged complexes do not. Hemodynamics
also influence immune complex deposition.
Immune Response―In general, early in an immune response, immune

complexes that form with a low amount of antibody (antigen excess) tend to elicit
further responses to antigen. Late in the immune response, complexes formed in
antibody excess tend to suppress the response.
Exposure to a large amount of antigen tends to be more immunogenic.

The longer the duration of exposure to an antigen, the more potent the
immunologic stimulus.
Example: SQ immunization offers better antibody production than a brief IV
exposure to antigen
Immune complex injury in tissues is associated with the release of
inflammatory cytokines, such as IL-1β, TNF, IL-2, and IFN-γ.
Examples
Arthus Reaction―When antigen is injected into the skin or tissue of an
immunized individual, local edema, neutrophil migration, hemorrhage, and
necrosis occur. This is called an Arthus reaction. This cutaneous inflammation is
caused by local vasculitis due to immune complex deposition in vessel walls, with
peak intensity occurring at 4–10 hours. It is a local type III hypersensitivity
reaction as the target organs is the blood vessels of the dermis.
Figure 3-6. Immune complexes deposited in the kidney.

102 / CHAPTER 3
Serum Sickness—Exposure to foreign proteins or haptens in unimmunized

persons leads to antibody production and formation of soluble immune complexes
in the circulation. This typically develops in 4–10 days (due to time needed to
class switch). Pathogenesis is related to (1) immune complex deposition in blood
vessels of the skin, joints, kidneys, and/or lungs and (2) immune complex fixing
and activating of complement. Symptoms include: fever, rash, joint pain, and
lymphadenopathy (all which are all self-limited once the foreign antigen is
removed). Common causes of serum sickness are hypersensitivity reaction to
medications (antibiotics) and foreign proteins. In contrast to the Arthus reaction,
serum sickness is a systemic type III hypersensitivity reaction since the target
organs are the blood vessels of the skin, joints, kidneys, lungs, etc.
Upon re-exposure (i.e., previously immunized person), the amnestic IgG response
is much more rapid. Thus, the symptoms of serum sickness may occur in 12–36
hours and be more severe.
Vasculitis—Inflammation of small or large blood vessels can result in tissue

damage. Immune complex deposition in endothelial basement membrane usually
occurs in this disease. Inflammation can vary from necrosis and granulomatous
change to fibrosis and scarring. In some individuals bacterial, viral and
mycobacterial antigens have been detected in vessel walls.
Systemic Lupus Erythematosus (SLE)—SLE is a systemic autoimmune disease

characterized by autoantibody production (against DNA), low levels of
complement, hypergammaglobulinemia, and the presence of circulating immune
complexes. In patients with SLE, high levels of circulating immune complexes
correlate with disease activity. Immunoglobulin and complement deposits can be
found in blood vessel walls and kidney glomeruli of SLE patients.
Glomerulonephritis—Immune-mediated glomerular disease with many sub-

types mediated by antigen-antibody complexes, including post-streptococcal
glomerulonephritis, lupus nephritis, and membranoproliferative glomerulo-
nephritis. In these diseases, immunoglobulin and complement deposits are seen in
the glomeruli.
TYPE IV HYPERSENSITIVITY REACTIONS
The major player of cell-mediated or delayed hypersensitivity (also called type IV

hypersensitivity) reactions is the T-cell (CD4+ or CD8+); other cells involved
depends on the subtype. Examples include: contact dermatitis, psoriasis, celiac
disease, etc.
Pathophysiology
T Cells—T cells originate from hematopoietic stem cells in the bone marrow and
mature in the thymus.
Th0 (Naïve T cells)—Naïve T cells migrate from blood to peripheral lymphoid
organs in search of antigen they recognize. Naïve T cells express L-selectin
(CD-62L). After seeing their antigen, they become activated, proliferate, and
differentiate into effector T cells or memory T cells.
CD4+ T cells (Helper T Cells)—Subsets are listed in Chapter 2. CD4+ T cells
respond to antigens that are internalized by APCs in association with MHC
class II molecules.
CD8+ T Cells (Cytotoxic T Cells)—Naïve CD8+ T cells differentiate into
effector T cells (CTLs) that recognize and kill cells expressing foreign
peptides (specifically intracellular peptides, such as viruses) in association
with class I MHC molecules. Refer to Chapter 1.
o CD8+ T cells contain membrane-bound cytotoxic granules that contain
perforin and granzymes. Like Th1 cells, CTLs are able to secrete
cytokines: IFN-γ, TNF, and lymphotoxin. CTL killing is antigen-specific
and contact-dependent. Lysis of target cells can occur via two
mechanisms: perforin and granzyme released from the CTL that enters
target cell and induces apoptosis; and, Fas ligand (FasL) expressed on
CTL that binds target cell Fas, leading to apoptosis.
Subtypes—Type IV reactions have been subdivided in IVa, IVb, IVc, and IVd.
Certain diseases may fit into more than one subtype (i.e., contact dermatitis).
Type IVc and IVd are less well-characterized. These are summarized in Table 3-
3.
Table 3-3. Subtypes of Type IV Hypersensitivity Reactions

T-Cell
Reaction Type Other Cells Target Organs Example
Involved
CD4+ Th1 cells Contact
Macrophages
IVa (IFN , TNFα, Skin, lung, GI dermatitis
NK cells
IL2) TB
CD4+ Th2 cells Eosinophils B Chronic allergic
IVb Skin, lung, GI
(IL4, IL5, IL13) cells disease
CD4+ T17 cells

IVc Neutrophils Skin, lung, GI Psoriasis
(IL17, IL21, IL22)
Flash Card Q3
Contact
IVd CD8+ cells Skin, systemic Upon first exposure to a
dermatitis
medication, when might
Abbreviations: IFN, interferon; IL, interleukin; NK, natural killer; Th, helper T cell; TNF, tumor a patient develop
necrosis factor.
symptoms of serum
sickness?
104 / CHAPTER 3
Delayed-type Hypersensitivity (DTH)—These reactions occur by contact

sensitization to chemicals or subQ/ID injection of protein antigen (e.g., PPD).
Chemicals can bind and modify self-proteins, creating new antigens that are
presented to CD4+ or CD8+ T cells. This is a type IV delayed hypersensitivity
reaction involving an induction/sensitization phase (priming of the immune
system) and elicitation phase (triggering of the reaction) and involves a cell-
mediated response. An example of DTH is allergic contact dermatitis. Agents
implicated in allergic contact dermatitis include: nickel, Quaternium-15 in
cosmetics, bacitracin, poison ivy (urushiol, which is a hapten) and resin.
Evidenced by the name, these reactions are “delayed” (i.e., 48–72 hours).
Flash Card A3
4–10 days
4 Laboratory Tests
IMMUNOGLOBULIN MEASUREMENT
Methods for Determining Immunoglobulin Levels

Immunoassays detect specific antibody-antigen interactions. Due to the bivalent
binding properties of immunoglobulins, the resulting antibody-antigen interaction
is dependent upon the ratio of antigen to antibody. Complexes that form are
classified into three classes, based upon the immunoprecipitin curve (Figure 4-1).
Zone of Antibody Excess: Complexes exist as single antibody to single

antigen.
Zone of Equivalence: Single antibody bind to two antigens, forming large
insoluble lattices (i.e., can increase turbidity of solution, appear as precipitin
lines).
Zone of Antigen Excess: Binding sites on the antibodies are saturated, and
antibodies exist as single antibody to two antigens.
Immunoassays can be classified based on the immunoprecipitin curve (Table 4-1).
Figure 4-1. Immunoprecipitin curve.

106 / CHAPTER 4
Table 4-1. Immunoassays

Antibody excess Immunoblotting
Enzyme-Linked Immunosorbent Assay
(ELISA)
Antigen-antibody equivalence Radial Immunodiffusion (RID)
Double Immunodiffusion (Ouchterlony)
Nephelometry
Antigen excess Radioimmunoassay (RIA)
ELISA
Serum immunoglobulins (Ig) IgG, IgG subclasses, IgM, and IgA are usually
measured by automated nephelometry or immunoturbidimetric assay systems.
Nephelometry—Nephelometry is a method by which the turbidity of a solution is

determined by a pattern of scattered light (Figure 4-2). In the determination of Ig
levels, Ig are injected into a reaction chamber with antigen-specific antibody. As
antibody-antigen complexes form, light is applied and the extent of light scatter is
measured by a nephelometer. Photons are reflected from the immune complexes
at an angle and measured with a photomultiplier tube.
Figure 4-2. Nephelometry determination of serum immunoglobulin levels.

LABORATORY TESTS / 107
The amount of light detected is quantified as a function of time and the

concentrations of antibody and antigen. This automated technique allows
laboratories to process a high volume of samples. Nephelometry is considered to
be more sensitive than RID and can measure quantities of protein from 1–10
µg/mL.
Radial Immunodiffusion (RID)—Antiserum is mixed into a warm gel matrix

while it is still in liquid form, then poured into a flat plate and allowed to cool.
Antigen (IgG) is then placed into wells that have been cut into the gel and diffuses
into the gel matrix. At the zone of equivalence, a precipitin line is seen (Figure 4-
3). The amount of antigen is determined by the diameter of the precipitin ring,
which is compared with a standard curve, created by known serially diluted
concentrations of the antigen (see Figure 4-3). This is a quantitative method.
Limitations include the inability to accurately measure serum protein
concentrations less than 10 µg/mL.
Laurell Rocket—The Laurell rocket method is considered to be less time-

consuming and more accurate than RID. This method incorporates features of
immunoelectrophoresis and the immunodiffusion technique. The addition of
immunoelectrophoresis decreases the time involved considerably, from up to 48
hours in RID to several minutes for the Laurell rocket technique. Samples are
added to gel plates containing antiserum in holes made throughout the gel layer. A
voltage is applied for a predetermined length of time. A precipitin line is seen at
the zone of equivalence, which adopts the shape of a “rocket” (Figure 4-4). The
height of the precipitin line is used to determine the amount of antigen
concentration, compared against a standard curve. This represents both a
qualitative and quantitative method of the antigen placed in the gel.
Figure 4-3. Radial Immunodiffusion (RID).

108 / CHAPTER 4
Figure 4-4. Laurell rocket electroimmunoassay.

(Reproduced, with permission, from Nancy Elms and Jordan N Fink, MD, Medical College of
Wisconsin.)
A summary of immunoassays used to determine immunoglobulin levels are found

in Table 4-2.
Table 4-2. Methods for Determining Immunoglobulin Levels

Method Features
Nephelometry Scatter light to determine Automated
turbidity Method of choice
Turbidity created by immune
complexes in solution
Zone of equivalence
Radial immunodiffusion (RID) Antiserum mixed in gel Time-consuming
Study Ig placed in well, 48 hr to process a sample
looking for ring of precipitin Insensitive, semiquantitative
Zone of equivalence
Laurel Rocket Immunodiffusion + Minutes to perform
electrophoresis. Insensitive, semiquantitative
Precipitin appears rocket-
shaped, need to measure
height of peak
Zone of equivalence
Methods for Characterizing Immunoglobulins

Immunodiffusion (Ouchterlony)—The Ouchterlony method utilizes a double-
immunodiffusion (DID) technique. Holes are punched into an agarose gel.
Antigens are placed in wells, and serum is placed in adjacent wells. Antigen and
antibodies diffuse into the gel, and complexes form at the zone of equivalence,
which is seen as a white precipitin line (Figure 4-5). The Wadsworth method
simplifies the Ouchterlony method and utilizes agar on glass slides. Diffusion
occurs within hours and requires fewer reagents.
Enzyme-Linked Immunosorbent Assay (ELISA)—ELISA refers to assays

performed on a microtiter plate in either a zone of antigen excess or zone of
antibody excess. Antigens and reagents are immobilized by adsorption onto
microtiter plates
ELISAs can be performed in many different ways by modifying the basic

principle of identifying the bound protein by an antibody, which is conjugated to a
label (e.g., enzymes such as horseradish peroxidase, alkaline phosphatase,
streptavidin, and fluorescent tags). Figure 4-6 illustrates common ELISA formats.
The appropriate substrate is added, and the signal is detected by use of a
spectrophotometer, fluorometer, or luminometer.
ELISAs have been used to diagnose a variety of clinical conditions. It is used to

determine the presence of allergen-specific IgE (see later discussion), B-
natriuretic peptide, complement, toxins, histamine, leukotriene C4, and tumor
markers.
Flash Card Q1
Figure 4-5. Ouchterlony’s double-immunodiffusion method. Which test can be used
to detect both excess
antibody and excess
antigen?
110 / CHAPTER 4
Figure 4-6. ELISA formats.
Western Blot (Protein Immunoblot)—The Western blot represents an antibody

excess assay for recognizing specific proteins within soluble tissue or cell
samples. The method is summarized in Figure 4-7 and a Western blot is shown in
Figure 4-8.
Proteins are separated by sodium dodecyl sulphate polyacrylamide gel
electrophoresis (SDS-PAGE). SDS is a detergent that unfolds a protein’s
tertiary structure and provides a negative charge. Immunoglobulins separate
by migrating to a positive pole when placed under an electric field. Shorter,
denatured immunoglobulins will migrate further in the polyacrylamide gel.
Separated immunoglobulins are then transferred to a nitrocellulose sheet or
polyvinylidene difluoride (PVDF) membrane while maintaining the same
separation pattern created in the polyacrylamide gel.
Labeled specific immunoglobulin antibody is added, binding to the separated
immunoglobulins. A secondary antibody is added and then conjugated to an
enzyme, such as horseradish peroxidase or alkaline phosphatase.
Flash Card A1
Enzyme substrate is added to provide a colorimetric reaction (see Figure 4-8).
ELISA
Figure 4-7. Western blot method of protein detection.

(Reproduced, with permission, from Stephen B. Gauld, PhD, Medical College of Wisconsin.)
Clinically, the Western blot has been used to determine infection by:
Borrelia burgdorferi
HHV6 and HHV7
HIV (confirmatory test after positive ELISA)
Human T-lymphocyte leukemia virus
Prion diseases
Respiratory syncytial virus
Severe acute respiratory syndrome (SARS) coronavirus
Varicella-zoster virus
Confirmatory test for hepatitis B
Lyme disease
It can also be used to determine the presence of antiglomerular basement

antibodies, antinuclear antibodies, and antiretinal antibodies. Western blotting can
essentially be used to detect expression of virtually any protein as long as a
detection antibody exists.
112 / CHAPTER 4
- + - +
Stimulation Stimulation
- -
Ser473 Thr202/Tyr204
Phospho- pAkt pErk
-
tyrosine actin actin
Erk
Figure: 4-8. Western blot. Phosphorylated proteins separated by one-

dimensional SDS-PAGE and analyzed by Western blot.
(Reproduced, with permission, from Stephen B. Gauld, PhD, Medical College of Wisconsin.)
Immunofixation Electrophoresis (IFE)—IFE determines levels of serum

immunoglobulins by electrophoresis by measuring immunodiffusion against an
antiserum. The test replaces the less sensitive and slower immunoelectrophoresis
method and is used to confirm monoclonal gammopathy and determine heavy- or
light-chain class type.
Serum proteins are separated by high-resolution agarose gel electrophoresis.

Proteins are separated by size and charge. Once separated, immunoglobulins are
exposed to specific antisera and the immunoprecipitate is visualized with a
protein stain.
Clinical Applications of Immunoglobulin Measurement

Immunoglobulin levels vary with age. Maternal IgG levels contribute to the high
IgG seen at birth. A nadir is seen at 6 months of age, when maternal IgG levels
wane, and before the child synthesizes its own IgG (Figure 4-9). Serum IgG and
IgA also increase with age (Figure 4-10).
Figure 4-9. IgG versus age in months.
Figure 4-10. Serum IgM and IgA (mg/mL) and IgE (IU/mL) with age (months)
.
114 / CHAPTER 4
Specific Ig Levels Determine Prior Immunization, Infection,

Exposure, or Autoimmune Disease
Specific immunoglobulins are routinely measured in the evaluation of clinical
disease. Examples of the use of specific immunoglobulins are summarized in
Table 4-3.
Specific IgE Testing

HyCor Turbo-RAST: Radioallergosorbent Test—The first-generation method
for determining allergen-specific IgE was the radioallergosorbent test. Paper discs
(allergosorbent material) coated with allergens were incubated with a patient’s
serum. Antigen would bind specific immunoglobulins of all classes (IgG, IgM,
IgA, IgE), and unbound immunoglobulins were washed away. Radiolabeled
antihuman IgE was used to detect antiallergen IgE. Results were then compared
with a reference curve.
Currently, Phadia ImmunoCAP (cellulose sponge as allergosorbent) and DPC

Immulite 2000 (allergen conjugated to biotin) are used due to their excellent
degree of quantification and automation.
ImmunoCAP or FEIA (Fully Automated Fluroroenzyme Immunoassay)—

ImmunoCAP was developed by Phadia and is the technique employed by both
Phadia and Quest. It utilizes a basic “sandwich” ELISA technique (Figure 4-11).
The anti-IgE conjugate has a fluorescent enzymatic tag. Fluorescence quantifies
the amount of sIgE captured in this process.
Table 4-3. Examples of Clinical Disease and Methods to Determine

Specific Ig Levels
Clinical Disease Method
Bacterial polysaccharide ELISA
(Pneumococcus, Meningococcus, Hib)
Tetanus ELISA
Escherichia coli O157 LPS/HUS infection ELISA (IgG, IgM, IgA)
Helicobacter pylori infection ELISA (IgG, IgM, IgA)
Sm autoantibody DID (Ouchterlony)
Alport’s syndrome (anti GBM antibody) Western blot
Abbreviations: DID, double immunodiffusion; ELISHA, enzyme-linked immunosorbent assay; Hib.
Haemophilus influenzae type B.
Figure 4-11. ImmunoCAP.
DPC Immulite 2000—This is a chemiluminescent enzyme-labeled immunoassay

(Figure 4-12).
Specific egg, milk, peanut, cat, birch, and Dermatophagoides farinae IgE levels
were obtained by ImmunoCAP and compared with specific IgE levels obtained by
Turbo-MP (Aglient Technologies Co, Santa Clara, CA); and Immulite 2000
(Siemens Medical Solutions Diagnostics, Tarrytown, NY) assay systems by Dr.
Julie Wang (Mount Sinai School of Medicine, New York, NY) and her
colleagues. She found that allergen-specific IgE levels were not comparable
across the different testing modalities. She highlighted that predictive values of
specific IgE levels, which exist for the management of food allergies, is based on
studies using the ImmunoCAP assay; and that these predictive values should not
be applied to specific IgE levels from other assay systems.
Flash Card Q2
Figure 4-12. DPC Immulite 2000. What test(s) would you
use to diagnose Lyme
disease?
116 / CHAPTER 4
MEDIATOR DETECTION
Immediate hypersensitivity reactions are associated with the release of mediators,

including proteases, biologic amines, proteoglycans, prostaglandins, leukotrienes,
and cytokines.
Leukotrienes
Basophils are the main source of LTC4, LTD4, and LTE4 during IgE-
mediated reactions, as well as during some non-IgE-mediated reactions (e.g.,
nonsteroidal anti-inflammatory drug [NSAID] hypersensitivity).
Basophil activation test uses IL-3-primed basophils that are stimulated by
allergens in vitro. The release of LTC4, LTD4, and LTE4 is measured by
ELISA.
Cellular Allergen Stimulation Test (CAST)
This test became available commercially in 1993 and provides a quantitative

measurement of leukotriene release.
May be used in conjunction with the flow cytometric basophil activation test
(FAST), which analyzes surface expression of CD63 on basophils following
allergen stimulation.
CAST demonstrates high sensitivity but low specificity for diagnosis of IgE-
mediated allergy to inhalant allergens.
Studies have shown a correlation between the results from food-specific
basophil activation studies and food-specific IgE levels. Prediction of clinical
sensitivity has not been shown to be increased. Further studies are needed.
Up to 33% of patients with stinging insect allergy proven by provocation have
negative skin tests. The combined CAST and FAST test appears to have high
diagnostic efficiency in this scenario.
Technical issues: The mixed results found in various studies may be due to the
lack of standardized allergens used and the varying dose of allergen used to
perform the CAST assay. The future use of recombinant allergens may
overcome these problems.
Although the histamine release test (HRT) has been used as a research tool for
40 years, it has not been applied routinely in laboratory diagnosis, mainly
because it is relatively cumbersome and not very sensitive. In principle, it is
very similar to CAST and shows good correlation with it; however, it has been
Flash Card A2 found to be less sensitive than CAST. An additional drawback is that
histamine release may be nonspecifically high (often observed in food allergy)
ELISA as a screen and
Western blot to confirm
and lead to false positives in cases of allergen cytotoxicity and/or following

recent in vivo allergen exposure.
Interleukins and TNF
Measured using commercially available sandwich ELISA.
Prostaglandins
Measured using radioimmunoassay (RIA).
Toll-Like Receptor (TLR)
Real-time reverse transcription polymerase chain reaction (RT-PCR) can be

performed on ribonucleic acid (RNA) samples using commercially available
TaqMan assays for TLR1 through TLR10.
Flow cytometry can also be performed to analyze cell surface and intracellular
expression of TLR1 through TLR10.
Functional Study: The responsiveness of cells to TLR stimulation can be
assessed using incubation with a panel of ligands for TLR1 through TLR9,
followed by measurement of inflammatory molecule production by real time
RT-PCR, ELISA, and flow cytometry.
Fas (CD95 or Apo 1)
Fas and FasL expression on the cell surface can be measured using flow
cytometry.
sFas and sFasL can be measured via sandwich ELISA using monoclonal
human antibodies.
Several assays quantify apoptosis. Labeling of DNA strand breaks by the
terminal deoxynucleotidyl transferase dUTP nick end-labeling (TUNEL)
reaction is the most specific of all the methods tested.
Bradykinin
RIA may be used for the measurement of plasma bradykinin levels.
Study note: ELISA or RIA assays are available for many cytokines and
mediators, but they are used primarily in research settings.
118 / CHAPTER 4
CELL SURFACE MARKERS AND RECEPTORS
Function
Cell surface makers play a role in the following:
Recognition
Adhesion
Signal transduction
Cell recognition in research
Cell Surface Markers

Cluster of differentiation (CD) markers signal the presence of cell surface
proteins, which leads to the identification and characterization of leukocytes.
CD markers have multiple roles:

Cell identification
Antigen or cytokine receptors
Table 4-4 offers a summary of CD markers.
Table 4-4. Cell Surface CD Markers

CD Other
Expression Structure Function
Marker Names
CD1 Five subsets APCs Member of Ig Presents autologous and
CD1a– e superfamily, bacterial lipid antigen to T
CD1a (Leu6) binds to β2- lymphocytes
microglobulin
CD2 LFA 2 Early T and NK Ig superfamily Binds LFA3 (CD58) on APC
E rosette cells Activates T lymphocytes
receptor
Induces cytokine production
Mediates adhesion between
T lymphocytes and APCs
Inhibits apoptosis of
activated T lymphocytes
Table 4-4. Cell Surface CD Markers, cont.

CD Other
Expression Structure Function
Marker Names
CD3 T lymphocytes Ig superfamily Required for TCR expression
(plasma cells, δ, ε, γ, and ζ and signal transduction
macrophage) chains δ, ε, γ, and ζ defects causes
Not found on NK T-B+NK+ SCID
cells OKT3—monoclonal antibody
clone, which recognizes
human CD3 in the treatment
of solid-organ transplant
rejection and acute T-
lymphocyte ALL. Leads to
activation then apoptosis of
T-cells causing immuno-
suppression
CD14 LPS receptor Macrophage and Pattern Detects lipoteichoic acid on

monocytes recognition GPB, and LPS on GNB,
receptor mycobacteria, and fungi
Mediates IL-12 and IFNγ
production
FcγRIIIA NK cells, ADCC
Low-affinity IgGR granulocytes, and
macrophages
CD16
FcγRIIIB Neutrophils Most common Phagocytosis
Low-affinity IgGR IgG FcR
CD18 β2 chain Neutrophils, Combines with Adhesion and signaling

macrophages αL: LFA1, Defect in common β chain
monocytes, and NK (CD11aCD18), responsible for LAD1
cells αM: MAC-1 and
CR3
(CD11bCD18),
αX: p150,95
and CR4
(CD11cCD18)
CD19 Pre B lymphocytes, Coreceptor B-lymphocyte ontogeny and
B lymphocytes, and with CD21 activation
follicular dendritic
cells
CD20 L26 On B lymphocytes Transmembra B lymphocyte activation and
MS4A1 after CD19 ne signaling
expression phosphoprotei
Follicular dendritic n—forms
cells structure like
ion channel—
Ca influx
CD21 CR2 Mature B Binds EBV, HHV8, C3d, and
C3d receptor lymphocytes and CD23
follicular dendritic
Flash Card Q3
EBV receptor High levels of CD21lo B cells
cells are associated with CVID Which cell marker of the
class Ia following is not found on
NK cells: CD3, CD16,
CD56?
120 / CHAPTER 4

CD Other Expression Structure Function
Marker Names
CD22 B-lymphocyte B lymphocytes Inhibits B signaling
cell adhesion
molecule (BL-
CAM)
CD23 Low-affinity IgE Activated, mature B Type C lectin B-lymphocyte ontogeny and
receptor lymphocytes and activation
FCεRII follicular dendritic
cells
CD25 IL-2 Rα chain Activated B and T Suppress self-reactive T
lymphocytes lymphocytes.
prevent CTL cytolysis, and
suppress NK cells.
Elevated in HLH
CD27 TNFRSF7 Memory B TNF receptor B-lymphocyte activation and
lymphocytes superfamily Ig production
Memory B lymphocytes:
CD27+
Memory T lymphocytes:
CD27-
CD31 PECAM-1 Endothelial cells, Ig superfamily Cell adhesion and binds
platelets, CD38
monocytes, and
macrophage
CD32 FcγRII (types a, WBCs Binds Fc of IgG immune
b, and c) complexes to remove
foreign antigens
Binding of FcγRIIb proposed
mechanism of IVIG
CD34 Adult Adhesion molecule and
hematopoietic stem binds CD62L (L selectin)
cells
CD35 CR1 WBCs Binds immune complexes
C3b and C4b coated with C3b and C4b
receptor Cofactor for factor I-
mediated cleavage
CD40 TNFRSF5 APCs T–lymphocyte-dependent Ig
switching
Expressed on B cells
Defective in HIGM3
CD44 Activated B and T Surface Cell adhesion
lymphocytes glycoprotein
CD45 Leukocyte CD45RA naïve T Protein tyrosine Defective in T-B+NK- SCID
common lymphocytes and phosphatase
antigen (LCA) CD45RO memory
or activated T
lymphocytes
Flash Card A3
CD3

CD Other Expression Structure Function
Marker Names
CD46 Membrane All cells (no Cofactor for factor I-mediated
cofactor protein RBC) cleavage
(MCP) Adenovirus receptor
CD49 Very late WBCs Receptors for fibronectin,
antigen (VLA VCAM, and others in cell
a–f) adhesion
CD52 CAMPATH-1 Mature Target for alemtuzumab
antigen lymphocytes (Campath)—monoclonal
antibody used in the
treatment of CLL
CD54 ICAM-1 WBCs Binds LFA-1 (CD50)
Receptor for rhinovirus
CD55 Decay- Hematopoietic Binds C3bBb and C4b2a to
accelerating cells, epithelial accelerate decay of C3
factor (DAF) cells, and cell convertase
matrix Deficient in paroxysmal
nocturnal hemoglobinuria
CD58 LFA-3 WBCs Binds CD2 and adhesion
CD59 Protectin All cells Inhibits MAC formation by

Complement binding to C8 or C9
regulatory
molecule
CD62E Endothelium Ligand for CD15s, CD44,
E selectin and CD162
ELAM1 Leukocyte rolling
SELE Defective in LAD2
CD62L B and T Lymphocyte homing to HEV

LECAM-1 lymphocytes, of LN
and NK cells Binds CD34, CD15s,and
SELL
CD62 MAdCAM-1
L Selectin
CD62P Platelets Binds CD162, rolling on
PADGEM Activated activated endothelial cells
SELP endothelial Defective in LAD2
cells
P Selectin (membranes of
Weibel-Palade Flash Card Q4
bodies) What is the CD marker
CD64 FcγRI APC ADCC for FcγRII?
High affinity IgG (macrophages,
receptor neutrophils,
eos)
Flash Card Q5
What is the CD marker
for CD40L expressed on
T-cells?
122 / CHAPTER 4

CD Other Names Expression Structure Function
Marker
CD95 Fas Activated B Apoptosis when ligated by
Apo-1 and T FasL
lymphocytes Defective in ALPS
TNFRSF6
CD106 VCAM-1 Endothelium, VLA-4 (α4:β1)
fibroblasts, and α4β7 (act-1, LPAM-1)
respiratory
epithelium
CD154 CD40L T lymphocytes Regulates B lymphocyte
TRAP function
Expressed on T-cells
Defective in XHIGM
CD158 KIR NK and T Binds HLA class I and inhibits
(KIR2DL, NK or T cell cytotoxicity
NKG2A, and
others)
CD159 NKG2A NK Modulates NK killing
CD162 P-selectin Myeloid cells Adhesion with endothelial

glycoprotein Activated T cells
ligand-1 lymphocytes
(PSGL-1)
CD178 CD95 ligand Activated, Apoptosis Fas-expressing

FasL cytotoxic T cells
lymphocytes
Abbreviations: ADCC, antibody-dependent cell-mediated cytotoxicity; ALL, acute lymphoblastic
leukemia; ALPS, autoimmune lymphoproliferative syndrome; APC, antigen-presenting cell; CIVD,
common variable immunodeficiency; CLL, chronic lymphocytic leukemia; EBV, Epstein-Barr virus;
GNB, gram-negative bacillus; GPB, gram-positive bacillus; HEV, high endothelial venule; HIGM,
hyper-IgM; HHV, human herpesvirus; HLA, human leukocyte antigen; HLH, hemophagocytic
lymphohistiocytosis; IVIG, intravenous immunoglobulin; LAD, leukocyte-adhesion deficiency; LFA,
leukocyte function-associated antigen; LN, lymph node; LPS, lipopolysaccharide; MAC, membrane
attack complex; MAdCam, mucosal addressin cell adhesion molecule; NK, natural killer; SCID,
severe combined immunodeficiency disease; TCR, T-cell receptor; TNF, tumor necrosis factor;
XHIGM, X-linked hyper-IgM.
CD4 and CD8 are T–cell-receptor coreceptors. A comparison between CD4 and
CD8 is summarized in Table 4-5.
Flash Card A4
CD32
Flash Card A5
CD154
Table 4-5. CD4 versus CD8

CD4 CD8
Other names OKT4 OKT8
CD223
MHC restriction MHC class II MHC class I
Cell expression T Helper cells Cytotoxic T lymphocytes
Monocytes Cortical thymocytes
Phagocytes NK cells
Dendritic cells Dendritic cells
Langerhans cells
Thymocytes
% T-lymphocyte expression 65% 35%
Structure Ig Superfamily Ig Superfamily
Monomer Heterodimer
CD8α CDβ
Domain-binding MHC β2 α3
Function or biological MHC-restricted antigen- MHC-restricted antigen-
properties induced T-lymphocyte induced cytolysis
activation
HIV receptor on T lymphocytes
Downregulated by HIV nef

protein during infection
Abbreviations: MHC, major histocompatibility complex; NK, natural killer,
CD28 Family
Costimulation provides signal 2, which leads to proliferation of T lymphocytes.

The CD28 family of receptors plays an important role in signal 2 and is
Table 4-6. CD28 Family of Receptors, Their Ligands, and Functions

CD28 Receptors B-7 Family Ligand Function
CD28 T lymphocytes CD80 (B71) Costimulation or activation
CD86 (B72)
(APCs)
CTLA4 Activated T CD80 (B71) DC Costimulation or inhibition
(CD152) lymphocytes CD86 (B72) Macrophage
B lymphocytes
ICOS T lymphocytes ICOS-L Costimulation
B7-H1 (PD- DCs PD 1 B lymphocytes Inhibition

L1) Macrophages T lymphocytes
B lymphocytes Flash Card Q6
B7-DC
What is the MHC class
Abbreviations: APCs, antigen-presenting cells; DC, dendritic cells. restriction for CD4 and
CD8?
124 / CHAPTER 4
Cell Surface Receptors

Cell surface receptors have been classified by function and structure. A summary
of commonly encountered receptors are found in Tables 4-7, 4-8, and 4-9.
Table 4-7. FcγR Family

Other Names Cell Function Ligand
CD16 FcγRIIIA NK cells ADCC IgG–low affinity
FcγRIIIB Neutrophils Phagocytosis IgG–low affinity
CD32 FcγRIIB B lymphocytes, Feedback IgG–low affinity

dendritic cells, inhibition of B
macrophages cells, dendritic
cells,
macrophages
FcγRIIA Macrophage Phagocytosis IgG–low affinity

Neutrophils
Eosinophils
Platelets
FcγRI Macrophage Phagocytosis High-affinity

Neutrophils IgG (IgG1, IgG3
CD64
and monomeric
Eosinophils IgG)
Abbreviation: ADCC, antibody-dependent cell-mediated cytotoxicity.
Table 4-8. FcεR Family

Receptor Cell Function Ligand
FcεRI Mast cells Degranulation Monomeric IgE high
Basophils Antigen uptake affinity
Eosinophils
Dendritic cells
FcεRII (CD23) B lymphocytes Unknown IgE

Eosinophils Low affinity
Flash Card A6
CD4 = MHC II and CD8
= MHC I
Tumor Necrosis Family Receptor Family (TNFR Family)

The TNFR family includes the following cell surface receptors, which have a role
in cellular apoptosis. They are reviewed in Table 4-9.
Complement Receptors
Complement receptors have an important role in bridging innate immunity with Key Fact
cell-mediated immunity. Innate responses generate complement components, Activating mutation of
which bind to receptors on WBCs. Ligand-receptor interaction leads to signaling CXCR4 causes the
pathways, cytokine release, and engagement of cell-mediated immunity. phagocytic defect,
Complement receptors have also been utilized by microbes as the mechanism of WHIM (or wart,
entry into host cells. A summary of complement receptors is provided in Table 4- hypogammaglobulinemi
a, infection, and
10. myelokathexis)
syndrome.
CR3 is the most potent complement receptor and binds iC3b, which is an opsonin
like Ig.
A hereditary deficiency of C3 will lead to defective phagocytosis of encapsulated

bacteria and will present with autoimmune disease and repeated infections. Key Fact
CCR5 and CXCR4 are
Chemokine receptors are G-coupled, seven-transmembrane proteins that play a HIV coreceptors
role in lymphocyte trafficking. A summary of chemokine receptors is found on
Table 4-11.
Table 4-9. TNFR Family

Receptor Cell Function Ligand
TNF RI/p55 Most cells Apoptosis TNF (membrane
bound and trimeric
soluble forms)
TNFR2/p75 Immune cells TNF (membrane-
bound homotrimer
form)
LT-βR Epithelial cell Apoptosis TRAF
Myeloid cells IL-8 release Lymphotoxin
(Not B and T
lymphocytes)
Fas Activated B and T Apoptosis FasL
lymphocytes
CD40/CD134 Activated T Second signal CD40L
lymphocytes TRAF
OX40 Ligand Activated T Implicated in cytokine TRAF
lymphocytes storm of H1N1
Flash Card Q7
RANK Osteoclasts Activation of RANK ligand
Dendritic cells osteoclasts TRAF Which PID is associated
Some macrophages with defective CD40 and
Abbreviations: RANK, receptor activator of nuclear factor κ-B; TNF, tumor necrosis factor; TRAF, which is associated with
TNF receptor-associated factor. defective CD40L?
126 / CHAPTER 4
Table 4-10. Complement Receptors

Complement
Other Names Cell Function Ligand
Receptor
CR1 CD35 Monocytes Phagocytosis C3b
Neutrophils Cofactor for C4b
T and B cleavage of C3b, iC3b
lymphocytes c4b
Eosinophils Clears immune
RBCs complexes
CR2 CD21 B lymphocytes B-lymphocytes C3d
FDC activation iC3b
EBV receptor c3dg
CR3 Mac-1 Monocytes Phagocytosis iC3b
CD11b/CD18 Neutrophils Adhesion ICAM-1
NK cells bacteria
CR4 p150.95 Monocytes Phagocytosis iC3b, ICAM-3
CD11c/CD18 Neutrophils
NK cells
CRIg Complement Macrophage in Phagocytosis C3b
receptor of the liver (Kupffer iC3b
immunoglobulin cells) Inhibits
family alternative
pathway
convertases
Abbreviations: EBV, Epstein-Barr virus; FDC, follicular dendritic cell.
Table 4-11. Chemokine Receptors

Chemokine Chemokine
Cell Function Ligand
Receptor Receptor
CCR3 Macrophage Implicated in allergic CCL11 (eotaxin-1)
Eosinophils disease CCL5 (RANTES)
Basophils CCL7 (MCP-3)
Th1 CCL8 (MCP2)
Th2 CCL13 (MCP4)
Airway epithelial CCL26 (eotaxin-3)
cells
CCR4 CD4 T lymphocytes T-lymphocyte CCL17 (TARC)
DCs trafficking CCL22 (MDC)
Basophil
CC Macrophage
Platelets
CCR5 T lymphocytes Cell trafficking. CCL3 (MIP 1α)
Monocytes HIV coreceptor CCL4 (MIP 1β)
CCL5 (RANTES)
CCL11 (eotaxin-1)
CCL14 (HHC-1)
CCL16 (HHC-4)
Flash Card A7 CCR7 T lymphocytes Naïve T lymphocyte CCL19 (MIP-

DCs (EBV-infected and DC trafficking to 3β/ELC)
Defective CD40 = B lymphocytes) LN CCL21 (SLC)
HIGM3 and defective
CD40L = XHIGM
Table 4-11. Chemokine Receptors, cont.

Chemokine Chemokine
Cell Function Ligand
Receptor Receptor
CXCR4 Mature blood cells, B lymphocyte CXCL12 (SDF-1)
blood progenitor development
CXC cells, epithelial cells HIV co-receptor
CXCR5 B lymphocytes Home to B-T CXCL13 (BCA-1)
junction in LN
XCR XCR1 T and NK cells XCL1 (lymphotactin)
recruitment
CX3CRI CX3CRI Recruits T, NK, and CX3CL1(factalkine)
Macrophages
Activates CTL and
NK
Abbreviations: DCs, dendritic cells; EBV, Epstein-Barr virus; LN, lymph node; RANTES, regulated
on activation, normal T expressed and secreted.
Cell Surface Markers on Specific Cell Types

Cell surface markers on lymphocytes are expressed differentially, based on the
maturity of the cell. For example, some of these markers allow lymphocytes to
follow a restricted pattern of circulation. Naïve lymphocytes home in
preferentially on secondary lymphoid organs such as lymph nodes, spleen, and
Peyer’s patches. This ensures a maximal probability of a diverse TCR repertoire
coming in contact with unique antigens. Once activated, lymphocytes enter the
circulation, whereby they encounter antigen residing in different tissues to elicit a
strong memory response.
A summary of cell surface makers and activating and inhibitory receptors is

shown in Table 4-12. Key Fact
NK cells lack expression
All nucleated cells express MHC I. of CD3 and TCR.
B lymphocytes express MHC I and MHC II.
CD4 T-cells express MHC II.
Switched memory B lymphocytes lose expression of surface IgD.
Flash Card Q8
CLA-1 on T lymphocytes mediates homing to skin.
Α4β7 on T lymphocytes mediate homing in on colonic tissue by binding to Which complement
receptor is also known
MAdCAM-1.
as CD11c/CD18?
In addition, key cell surface markers of other cell types are reviewed in Table 4-
13. Flash Card Q9
What lymphocyte cell
surface marker is
present on memory B
cells and absent on
memory T cells?
128 / CHAPTER 4
Table 4-12. Lymphocyte Cell Surface Markers

B lymphocyte T lymphocyte NK Cells
Naïve IgM/IgD L Selectin CD2
CXCR5 CCR7
CD45RA
Activated IgA CD40L (CD154)
IgE CD28
IgG CTLA4
CD27 CD 25
CD44
CD45RO
CXCR3
CCR5
HLADR
Memory IgG CCR7
IgA L-Selectin
IgE (CD62L)
CD27+ IL-7R
IL-15 (CD8 only)
CD44
CD45RO
MHCI
CD27-
Receptors
Inhibitory CD22 NKG2A (CD94)
ILT-2
KIR
Activating IL-12 Rβ CD16
IL-18 R NCR
KIR2DS
CD92/NKG2C
NKG2D
Abbreviation: NK, natural killer.
Table 4-13. Cell Surface Markers

Cell Surface Markers
Monocyte or macrophage FcγR
Endothelial cell Selectins (CD62E)
NKT cell Vα24-Jα18

Vβ11
Flash Card A8
Mast cell CD117 (c-KIT)
CR4
Abbreviations: KKT, natural killer T cell.
Flash Card A9
CD27
Dendritic cells are divided into:

Conventional dendritic cells (myeloid, lymphoid)
o Act as antigen-presenting cells
Plasmacytoid dendritic cells
o Produce IFNα
Surface markers differentiate between the subsets of dendritic cells, as shown in
Table 4-14.
Cell surface markers play an important role in cell function and survival. Clinical
disease results as a defect in expression or in function, or by opportunistic use by
a pathogenic organism. Further evaluation of cell surface markers will provide
greater insight into the normal physiology and disease manifestation using cells of
the immune system.
Table 4-14. Human Dendritic Cell Surface Markers

Conventional Dendritic Plasmacytoid Dendritic
Cells Cells
CD1a-3 High Negative
CD11c High Negative
CD11b Variable Negative
TLR TLR 4 TLR 7
TLR5
TLR8
CD80/CD86 Inducible
ILT7 (CD85g) Negative High
CD33 (Siglec - 3) High
CD209 (DC SIGN) High
CMKLR1 High In vitro expression
TCL1 Negative High
Abbreviations: DC SIGN: dendritic dell-sp
LYMPHOCYTE FUNCTION: CELL PROLIFERATION,

CYTOKINE PRODUCTION, AND CYTOTOXICITY
Adaptive immunity reflects the function of T lymphocytes, B lymphocytes, and

NK cells. The first step performed in an immunologic evaluation is a complete
blood count (CBC) that provides an absolute lymphocyte count (ALC). The ALC
reflects the sum of all lymphocyte populations in the given peripheral blood
specimen. The ALC is normal or decreased in most of the cellular primary
130 / CHAPTER 4
immunodeficiency disorders; however, it is profoundly decreased in most forms

of severe combined immune deficiency (SCID), and increased ALC does not rule
out these disorders. Flow cytometry enables the quantitative enumeration of
lymphocyte subsets (T and B lymphocytes, and NK cells) in peripheral blood.
Measuring T-Cell Number and Function

Enumeration of T Lymphocyte Subsets—Flow cytometric analysis of lympho-
cytes enumerates the T-lymphocyte compartment. T lymphocyte subsets are
identified by their cell surface molecules (Table 4-15).
Measuring in Vitro T-Cell Function

In Vitro T-Cell Proliferation Assay by 3H Thymidine Incorporation—The lym-
phocyte proliferation assay (LPA) is an in vitro method of assessing lymphocyte-
mediated immunity. T lymphocytes undergo clonal proliferation when stimulated
in vitro by a mitogen (polyclonal) or recall antigen. (Table 4-16).
Table 4-15. Cell Surface Markers on T Lymphocyte Subsets

Cell Surface Marker T-Cell Subset
CD3 T cells
CD3 CD4 CD4 T lymphocytes (helper)
CD3 CD8 CD8 T lymphocytes (cytotoxic)
CD4 HLA-DR Activated CD4 cells
CD8 HLA-DR Activated CD8 cells
CD45RA Naïve T lymphocytes
CD45RO Activated T lymphocytes
CD4-CD8- Double-negative T lymphocytes
CD4-CD8-γδ γδ T lymphocytes
CD3 CD25 T regulatory cells (highly expressed); activated

T cells
Table 4-16. T Cell Proliferation in Response to Recall Antigens or Mitogens

Antigen-Specific Polyclonal T Lymphocyte
T-Lymphocyte Proliferation (Mitogen)
Proliferation
(Recall Antigen)
T cells Activated and memory Naïve, activated, and memory
Prior exposure Yes No
required
Antigens CMV Cell surface signaling Bypass proximal
Tetanus Phytohemagglutinin signaling
VZV antigens (PHA) Phorbol ester (PMA)
HIV antigens gp 120, Pokeweed mitogen Calcium ionophore
p24 (PWM) (Ionomycin)
Candida Concanavalin A (ConA)
anti-CD3 antibody
Costimulation No (but requires antigen No No
needed presenting cells)
Abbreviation: VZV, varicella-zoster virus.
Lymphocyte Proliferation Assay (LPA) Stimulation Index
Cells are incubated in culture for a week. On day 3 after mitogen stimulation,
and on day 6 for antigens specific T lymphocyte-specific stimulation,
radioactive [3H] (tritiated) thymidine is added and is incorporated into the
newly synthesized DNA of the dividing cells.
The amount of radioactivity incorporated into the DNA of each culture well is
measured in a scintillation counter and is proportional to the number of
proliferating cells. In the absence of proliferation of defective lymphocytes,
less radioactivity is detected.
The readout is measured in counts per minute (cpm).
Note that pokeweed mitogen also has B-cell proliferation activity along the T-
cell proliferation capacity.
Stimulation Index (SI) = (cpm Mitogen / cpm background Unstimulated)

Net counts or cpm = (cpm Mitogen – cpm background Unstimulated)
In Vitro T-Lymphocyte Proliferation Assay by Flow

Cytometry
Peripheral blood mononuclear cells (PBMCs) are labeled with a proliferation

tracking fluorescent dye (carboxyfluorescein diacetate succinimidyl ester, CFSE)
and stimulated with appropriate mitogens for 4 days. Flow cytometric evaluation
of T-cell proliferation is shown in Figure 4-13.
132 / CHAPTER 4
Normal Abnormal proliferation

Unstimulated Unstimulated
Cell Number
ConA / IL-2 stimulated ConA / IL-2 stimulated
PHA / IL-2 stimulated PHA / IL-2 stimulated
CFSE
Figure 4-13. T-Lymphocyte proliferation assay (LPA). Lymphocyte proliferative
response is demonstrated by a progressive twofold reduction in the fluorescence
intensity of CFSE (read from right to left, in the graphs above) as measured by
flow cytometry.
(Reproduced, with permission, from Dennis W. Schauer, Jr., Trivikram Dasu, PhD, and James W.
Upon stimulation and following proliferation of dividing T cells, there is a

dilution of CFSC. This will lead to its decreased concentration. In the absence of
proliferation of defective lymphocytes, there will be no decrease of fluorescence
detected by the machine given the absence of dilutional effect.
Cytokine Production
Measuring cytokine production by activated T lymphocytes is more often done in
experimental laboratories and is often not used routinely in clinical evaluation.
In Vivo T-Lymphocyte Function

Delayed-type hypersensitivity (DTH) is a cost-effective and widely available
method to screen for cell-mediated immunity. Clinically, it is used most
commonly to determine prior tuberculosis exposure (purified protein derivative,
PPD), although the test can be done with a number of other recall antigens
(Candida, tetanus, Tricophyton, etc.).
DTH assesses the integrity of cell-mediated immunity. Patients who have a lack
of response to ubiquitous antigens are susceptible to intracellular pathogens, such
as viruses, fungi, protozoa, and parasites. In acquired immunodeficiency due to
HIV, DTH could used to clinically monitor the progression of disease. Anergy
(i.e., lack of DTH response) indicates the likelihood of disease progression.
Anergy can be seen in < 5% of the general healthy population who have been
exposed to a antigen. In this case, an in vitro T-lymphocyte function assay should
be employed. However, a lack of exposure, as well as a number of other
conditions, could explain a negative DTH response.
Caution should also be advised if a patient has had repeat DTH testing. A booster
effect can be seen by testing that occurs within 3 months between tests.
The DTH test can be used to determine the presence or history of exposure to an
infectious agent. Tuberculosis, histoplasmosis, blastomycosis, and leishmaniasis
can be diagnosed with DTH testing. DTH testing employs the Mantoux skin
testing method as described in Figure 4-14.
Figure 4-14. Mantoux test and interpretation.

134 / CHAPTER 4
Measuring B-Lymphocyte Function

Enumeration of B-Lymphocyte Subsets—Enumeration of B lymphocytes
in the peripheral blood is accomplished with flow cytometry. B-lymphocyte
numbers are characterized by their hallmark cell surface markers, CD19 and
CD20.
CD19 is part of the CD19, CD21, CD81 coreceptor complex and functions to
amplify B-lymphocyte receptor-generated signals. CD19 is expressed on early
B-lymphocyte progenitors up until the B-lymphocyte plasmablast stage of
differentiation.
CD20 is expressed on pre-B lymphocytes and B-lymphocyte blasts, but are
not seen in early B lymphocytes or plasma cells.
In patients with X-linked agammaglobulinemia (XLA), Bruton agamma-

globulinemia tyrosine kinase (BTK) is absent in B lymphocytes and monocytes.
CD19+ B lymphocytes are absent.
For examples of flow cytometric patterns for XLA, see Figures 4-15; for patterns
in common variable immunodeficiency (CVID), see Figure 4-16.
Normal Abnormal (XLA) Abnormal (XLA-carrier)
BTK+ B cells
CD19 (B Cells)
CD14 (Monocytes)
BTK+ Monocytes
BTK
Figure 4-15. Flow cytometric assessment of B lymphocytes: XLA. Bruton’s

tyrosine kinase (BTK) is expressed in normal B lymphocytes and monocytes. In
patients with X-linked agammaglobulinemia (XLA), CD19 B lymphocytes and
BTK expression in monocytes are absent. Carrier status is determined by
reduced CD19 B lymphocytes and BTK expression.
IgD+CD27+
IgD-CD27+ (unswitched memory)
(switched memory)
IgD+CD27-
(naïve)
Normal Abnormal (CVID) B

11% 19% 0% 2%
CD27
68% 98%
IgD
B
Figure 4-16. Flow cytometric assessment of memory B lymphocytes: CVID.

Abnormal populations of naïve and memory B lymphocytes in patients with
common variable immune deficiency (CVID): (A) Arrow demonstrates normal B-
lymphocyte maturation. (B) Case scenarios of normal and abnormal B-
lymphocyte maturation.
B-Lymphocyte Proliferation
B-lymphocyte proliferation can also be measured by the lymphocyte proliferation
assay. Whole blood or peripheral blood mononuclear cells (PBMCs) are cultured
with mitogens [i.e., Staphylococcus aureus Cowan I (SAC), anti-IgM, pokeweed
mitogen (PWM), and tetanus toxoid] for up to a week.
Flash Card Q10
3
A stimulation index is generated by measuring the amount of [H] thymidine Which mitogens
incorporated into DNA and expressed as: stimulate T cells?
[counts per minute of stimulated wells] / [counts per minute of control wells]
[counts per minute of stimulated wells] – [counts per minute of control wells]
Flash Card Q11
Alternatively, flow cytometry can be used.
Which mitogens
stimulate B cells?
136 / CHAPTER 4
B-lymphocyte secretion of immunoglobulins in cell culture supernatants after

stimulation can be determined by ELISA or ELISPOT.
Immunoglobulin Measurement
Total serum immunoglobulin measurement (IgM, IgG, IgA, and IgE) is the
best screening test for B-lymphocyte function.
Response to immunizations can be evaluated by serology.
Controversy still exists around what constitutes an adequate response to

immunization. Table 4-17 provides a summary of immunizations and their role in
assessing B-lymphocyte function.
Measuring NK Cell Function

In Vitro NK or CD8 T Lymphocyte Cytotoxicity—Perforin and granzyme B
expression in NK and CD8 T lymphocyte can be used to determine cytotoxic cell
function (Figure 4-17).
Key Fact The granules of NK cells coat in the interior with CD107a. Expression of CD107a
Protein vaccines and on the surface of an NK cell is indicative of degranulation. Absence of CD107a
conjugated vaccines on the surface suggests failure of degranulation.
enlist T-cell help.
The assessment of lymphocyte function is a useful clinical tool in the assessment
of some primary immune deficiencies.
Table 4-17. Immunizations Assess B-Lymphocyte Function with or

Without T-Lymphocyte Help
Conjugated Unconjugated
Protein
Polysaccharide Polysaccharide
Immunizations Diphtheria Haemophiuls Neisseria
Flash Card A10 Tetanus influenzae meningitides
Prevnar Pneumovax
Pokeweed,
phytohemagglutinin, and T-lymphocyte Yes Yes No
concanavalin A help?
Age All ages All ages Only >2 years of age

can induce response
Flash Card A11

Pokeweed, LPS, and
SAC
Normal Abnormal (HLH)

Natural killer cells Natural killer cells
Granzyme B
T cytotoxic cells T cytotoxic cells
Perforin
Figure 4-17. Perforin and granzyme B expression in cytotoxic lymphocytes and

NK cells. Deficient expression can be seen in patients with hemophocytic
lymphohistiocytosis (HLH).
CHEMOTAXIS
Chemotaxis is the ability of a protein to direct the traffic and migration patterns of
a specific cell. Basically, an assay creates a gradient of the chemotactic agent and
allows cells to migrate through a membrane toward said agent. If the agent is not
chemotactic for the cell, then the cells will remain on the membrane. If the agent
is chemotactic, then the cells will move through the membrane and settle on the
chemotaxis plate.
Flash Card Q12

Which surface markers
are not present in
leukocyte adhesion
deficiency 1?
138 / CHAPTER 4
This type of test is used generally for testing neutrophils, and it can reveal specific
defects in this molecule. It is important for diagnosing neutrophilic disorders,
such as the following:
Chédiak-Higashi syndrome: Neutropenia, recurrent skin, sinus, pulmonary
infections, oculocutaneous albinism, mitral regurgitation (MR), neuropathy.
Diagnosis made with detection of giant granules seen on a manual smear, and
mutations in LYST 1q42
Leukocyte adhesion deficiency 1 (LAD1): Missing CD18 protein;
chemotaxis and adhesion of leukocyte to wall of endothelium and diapedesis
impaired; recurrent necrotizing infections of lung, GI tract and skin; umbilical
stump separation delayed beyond 1 month of age; poor wound healing;
cigarette paper scarring. Diagnosis made through impaired chemotaxis, but
can also be made with flow cytometry that shows abnormal CD18
Ras-related C3 botulinum toxin substrate 2 (RAC2) deficiency: RAC
facilitates actin cytoskeleton regulation; therefore deficiency causes adhesion
problems and impaired chemotaxis. Clinically resembles LAD 1.
Transmission autosomal dominant.
Another area of chemotactic importance is in the complement system. Active

metabolites C4a, C3a, and C5a are potent anaphylatoxins.
PHAGOCYTOSIS AND CELL KILLING
Phagocytosis is an active process by which solid material (i.e., >500 nm in

diameter), such as microbes and apoptotic cells, are engulfed within a cell and
killed. Classic examples of phagocytic cells include neutrophils and macrophages.
PHAGOCYTOSIS
Phagocytic cells express various receptors, such as mannose receptors,

scavenger receptors, and Toll-like receptors, that can recognize pathogens.
They also express opsonin receptors, which increase phagocytosis of bacteria
coated with IgG antibodies or with complement.
Flash Card A12
Bound pathogen is surrounded by the phagocyte cell membrane and then
CD18, which is part of
CD11a/CD18 (LFA-1), internalized in a membrane-bound vesicle known as a phagosome (Figure 4-
CD11b/CD18 (Mac-1), 18).
and CD11c/CD18
(p150/95)
Figure 4-18. Phagosome.
KILLING
The phagosome becomes acidified, killing most pathogens.

Macrophages and neutrophils have lysosomal granules that contain
microbicidal enzymes, proteins, and peptides.
The phagosome fuses with the lysosome, producing the phagolysosome, in
which lysosomal contents are released to destroy the ingested pathogen.
Ingestion of microorganisms activates the phagocyte to assemble the
multisubunit enzyme NADPH oxidase from its components. The enzyme
consists of several subunits and converts molecular oxygen to oxygen free
radicals, which are toxic to bacteria (Figure 4-19).
Myeloperoxidase (MPO) uses hydrogen peroxide to convert normally
unreactive halide ions (Cl– and Br–) into reactive hypohalous acids [i.e.,
hypochlorite (HOCL) and hybromite] that are toxic to bacteria.
o MPO deficiency is a phagocytic disorder that is asymptomatic in most
individuals. Recurrent candida infections (skin, bones, blood) have been
described rarely in patients with diabetes mellitus and partial/complete
MPO deficiency.
140 / CHAPTER 4
Figure 4-19. Respiratory burst and intracellular killing.
Macrophages produce reactive nitrogen intermediates, mainly nitric oxide,

by the action of inducible nitric oxide synthase (iNOS), which can combine
with hydrogen peroxide to form peroxynitrite radicals, which are toxic to
bacteria.
Key Fact
The importance of the Bactericidal Killing Assay
respiratory burst is
highlighted in patients
with chronic granulo- This assay measures the respiratory burst, which is responsible for the generation
matous disease (CGD), of reactive oxygen species and intracellular microbial killing. Respiratory burst
which is caused by activity can be measured by several methods, including nitro blue tetrazolium
mutations in the genes
encoding the NADPH
(NBT) reduction test, dihydrorhodamine 123 (DHR) oxidation test, and
oxidase system. chemiluminescence assay.
Individuals with CGD
have defective NBT Reduction Test—The oldest and best-known laboratory test for CGD is the
intracellular killing of NBT test. This provides a simple and rapid (but largely qualitative)
bacteria and fungi that
predispose them to
determination of phagocyte NADPH oxidase activity. Neutrophils are mixed with
infections with catalase- NBT and stimulated with phorbol myristate acetate. Normal neutrophils reduce
positive organisms the NBT to formazan, which changes color from yellow to blue. (PAM) Patients
(e.g., Staphylococcus with CGD lack a component of the oxidase system that produces superoxide
aureus, Serratia anion and, thus, cannot reduce NBT to formazan. Figure 4-20 depicts a visual
marcescens,
Pseudomonas, and
representation of normal and abnormal NBT test results.
Salmonella spp.).
This test is no longer the gold standard for the diagnosis of CGD.
Normal (positive test) Abnormal (negative test)

Large cells with an orange-red Small cells with an orange-red
nucleus and blue nucleus and colorless
cytoplasm cytoplasm
Figure 4-20. Interpreting NBT reduction test results.
Most patients with X-linked CGD will have nearly absent reduction of the
NBT, so mostly negative cells (yellow).
Patients with autosomal recessive CGD may have some positive cells,
leading to a missed diagnosis.
Carriers of the autosomal recessive form of CGD usually have normal
NBT results.
In the X-linked carrier state, usually between 30–80% of the cells will be
negative (yellow). The results are variable and can range between 10–90%
negative cells.
Dihydrorhodamine 123 (DHR) Oxidation Test—In this test, the nonfluorescent

rhodamine derivative, DHR, is taken up by phagocytes and oxidized to a
green fluorescent compound by products of the NADPH oxidase. The
fluorescence emitted is detected by flow cytometry. The DHR test is preferred
because it is a quantitative assay, offers relative ease of use, enables distinction
between X-linked and autosomal forms of CGD, as well as providing the
ability to detect gp91phox carriers. Other tests can provide reliable diagnosis of
CGD, but cannot distinguish carrier status or they require significant operator
experience. Figure 4-21 shows the normal and abnormal results with a DHR
assay.
Chemiluminescence Assay—In this assay, light is generated from the

interaction of reactive oxygen species (generated during respiratory burst) with
ingested microorganisms. The light can be detected using a scintillation counter,
with the amount released reflecting the respiratory burst activity of the cells. It is
more sensitive than the NBT test.
Interpretation:
Patients with CGD lack a chemiluminescence response. Flash Card Q13
Maternal carriers of X-linked CGD have intermediate values. Which test can distinguish
among X-linked,
autosomal, AND X-linked
carrier forms of CGD?
142 / CHAPTER 4
Figure 4-21: DHR assay results.

(Reproduced, with permission, from Thomas A. Fleisher, MD, National Institutes of Health, DHHS
Bethesda, MD.)
Patients with CD11 or CD18 surface glycoprotein deficiency may have

normal chemiluminescence after stimulation with soluble stimulators, such as
PMA; but, they may have delayed and diminished chemiluminescence after
stimulation with opsonized particles.
HYBRIDOMA AND MONOCLONAL ANTIBODIES
HYBRIDOMA
A hybridoma is product of cell fusion between a normal antibody producing B

lymphocyte and a myeloma cell, followed by selection of fused cells that secrete
Flash Card A13 antibody of the desired specificity.
Dihydrorhodamine 123
assay (DHR)
Synthesis
Spleen cells from an immunized mouse are fused with myeloma cells by using
polyethylene glycol (PEG) to produce a hybrid cell line called a hybridoma.
Myeloma cells lacking both antibody production and the enzyme
hypoxanthine-guanine phosphoribosyl transferase (HGPRT) are selected
out. Absence of this enzyme prevents growth in hypoxanthine-aminopterin-
thymidine (HAT) medium.
After fusion, cells are transferred to HAT medium, where unfused spleen and
myeloma cells die. Only hybrid cells with HGPRT enzyme (i.e., gene
contributed by spleen cells) can grow in this medium and are, thus, selected.
Hybridomas are screened for antibody production, and cells that make
antibody of desired specificity are cloned by growing them from a single cell
(Figure 4-22).
Figure 4-22. Production of monoclonal antibodies.

144 / CHAPTER 4
MONOCLONAL ANTIBODY
As each hybridoma is descended from a single cell, all the antibodies it produces
are identical in structure, including their antigen-binding site and isotype. These
antibodies are called monoclonal antibodies (mAbs).
The initial mAbs produced were all composed of mouse protein; but, when used
in humans, they elicited production of human antimouse antibodies with resultant
side effects. A number of techniques have been developed to make the murine
mAbs less immunogenic. The different types of mAbs and their proposed
nomenclature are detailed in Table 4-18. Nomenclature for product source
identifiers is listed in Table 4-19. Sketches of the various types of monoclonal
antibodies are depicted in Figure 4-23.
Uses—Monoclonal antibodies are used in serologic assays, as diagnostic probes,

and as therapeutic agents (Table 4-20).
Table 4-18. Monoclonal Antibodies and Fusion Protein

a
Nomenclature Type Means of Synthesis Murine
Mnemonic Component
(%)
XImab: miXing human
-omab Mouse Murine-variable and constant antibody 100
and mouse makes regions
Chimeric
-ximab Chimera Combines murine mAb variable regions 30–35
Umab: hUman with the constant region of human antibody
Zumab: humans at the -zumab Humanized Combines murine mAb hypervariable or CD <10
Zoo are humaniZed regions to remaining portion of human IgG
Omab: mOuse molecule
-umab Human Human heavy- and light-chain variable (V) None
region genes are cloned into a
bacteriophage—V region is expressed as a
fusion protein on phage cell surface →
phage-display library—multiplied in
bacteria-select phage with desired antigen
specificity. May replace hybridoma
technology for production of mAbs
-cept Fusion proteins created by joining two or
more genes that were originally coded for
separate proteins
a
All mAbs end in the suffix -mab. These identifiers are used as infixes preceding the -mab suffix
stem.
Table 4-19. Nomenclature of Product Source Identifiers

Protein
u Human
o Mouse
a Rat
e Hamster
i Primate
xi Chimeric
axo Rat/mouse
xizu Combination of humanized and chimeric chains
Figure 4-23: Monoclonal antibody figures. Mouse (top left), chimeric (top right),
humanized (bottom left). Human parts are shown in brown, nonhuman parts in
blue.
146 / CHAPTER 4
Table 4-20. Examples of Monoclonal Antibodies Used as Medications

Antibody Target Antigen Molecule Application
Abciximab Integrin αIIβ3 Cardiac ischemic complications
Adalimumab TNFα Rheumatoid arthritis
Alemtuzumab CD52 Chronic lymphocytic leukemia
Basiliximab IL-2 receptor α chain (CD25) Transplant rejection
Belimumab B-cell activating factor Systemic lupus erythematosus (SLE)
Bevacizumab Vascular endothelial growth factor Colorectal cancer
(VEGF)
Brentuximab vedotin CD30 Anaplastic large-cell lymphoma
(ALCL), Hodgkin’s lymphoma
Canakinumab IL-1β Cyropyrin-associated periodic
syndrome (CAPS)
Cetuximab Epidermal growth factor receptor Colorectal cancer, head and neck
cancer
Certolizumab pegol TNFα Crohn’s disease
Daclizumab IL-2 receptor α chain (CD25) Transplant rejection
Denosumab RANK ligand Postmenopausal osteoporosis, solid
tumor’s bony metasteses
Eculizumab Complement system protein C5 Paroxysmal nocturnal hemoglobinuria
Efalizumab CD11a Psoriasis
Gemtuzumab CD33 Acute myelogenous leukemia
Golimumab TNF-α Rheumatoid arthritis, psoriatic arthritis,
Ankylosing spondylitis
Ibritumomab tiuxetan CD20 Non-Hodgkin’s lymphoma
Infliximab TNFα Several autoimmune disorders
Ipilimumab (MDX-101) CTLA-4 Melanoma
Keliximab CD4 Multiple sclerosis
Mepolizumab IL-5 Hypereosinophilic syndrome
Muromonab-CD3 (OKT3) T cell CD3 receptor Transplant rejection
Natalizumab α 4 chain of integrin molecule Multiple sclerosis
Ofatumumab CD20 Chronic lymphocytic leukemia
Omalizumab FcεRI (cε3) Asthma
Palivizumab RSV F-protein Infants with bronchopulmonary
dysplasia
Panitumumab Epidermal growth factor receptor Colorectal cancer
Ranibizumab Vascular endothelial growth factor A Macular degeneration
(VEGF-A)
Rituximab CD20 Autoimmune diseases, B-lymphocyte
lymphomas
Tocilizumab Anti-IL6R Rheumatoid arthritis
Tositumomab CD20 Non-Hodgkin’s lymphoma
Trastuzumab ErbB2 Breast cancer
Limitations—There is a risk of hypersensitivity reactions, ranging from mild

allergic reaction to anaphylaxis. However, with the development of humanized
and human mAbs, the risk of hypersensitivity has decreased significantly by
reducing exposure to murine antibody immunogenicity.
Fusion Proteins
Fusion proteins are created by joining two or more genes that originally coded
for separate proteins.
Translation of the fusion gene results in a single polypeptide with functional
properties derived from each original protein.
Recombinant fusion proteins are created artificially using recombinant DNA
technology for use in research and therapeutics.
One example is etanercept, a TNFα antagonist created through the
combination of a tumor necrosis factor receptor (TNFR) with the
immunoglobulin G1 Fc segment. TNFR provides specificity for the drug
target, and the antibody Fc segment adds stability and deliverability of the
drug. It is used for treatment of autoimmune conditions, including rheumatoid
arthritis, psoriatic arthritis, ankylosing spondylitis, plaque psoriasis, and
juvenile idiopathic arthritis.
IMMUNE COMPLEXES
Synthesis
IgM or IgG antibodies specific for a soluble antigen bind to it, forming
Key Fact
circulating immune complexes (ICs).
If IgM or IgG binds to an antigen on a normal host cell, regulatory Degree of complement
activation by immuno-
complement proteins, such as factor H and I, inactivate C3b to iC3b, globulin in descending
thereby inhibiting IC formation. Thus, IC formation normally occurs only order:
on foreign cells. IgM → IgG3 → IgG1 →
C3b binds CR1 on RBCs, thus allowing transport of ICs to the liver and IgG2.
spleen, where they are eliminated by macrophages.
ICs only cause disease if produced in excessive amounts, are not cleared
efficiently, and are deposited in tissues.
Large circulating ICs are formed at the zone of equivalence (Figure 4-24).
Small circulating ICs are formed at the zone of antigen or antibody excess.
(see Figure 4-24).
Flash Card Q14
IgM and IgG (subclass IgG1, IgG2, and IgG3) can activate the classical
complement pathway. What is the target antigen
for omalizumab?
148 / CHAPTER 4
Figure 4-24. Immune complex formation.
IC-Mediated Diseases
Key Fact Circulating ICs are deposited in vascular beds and complement, which leads to
Serum sickness is a type complement consumption and reduced levels of C3 and C4. This produces a
III hypersensitivity neutrophilic inflammation, usually affecting small arteries, glomeruli, and
reaction in which excess synovial of joints, which results in clinical symptoms of vasculitis, nephritis,
immune complex
formation leads to clinical and arthritis. (See Table 4-21 for specific IC-mediated diseases).
symptoms of fever, rash
(urticarial), joint pain, and Serum sickness is a type III hypersensitivity reaction in which excess immune
lymphadenopathy. complex formation leads to clinical symptoms of fever, rash (urticarial), joint
pain, and lymphadenopathy.
Laboratory Testing for Detection of Circulating IC

IC formation leads to the activation of the classical complement pathway.
Key Fact
C1q, C4b, and C3b coat the IC, maintain its solubility, and act as ligands for
ICs that are not properly receptors on WBCs and RBCs.
eliminated can cause
inflammation, resulting in
Conglutinin: Binds iC3b, which can then be detected in an assay. Does not
tissue injury. Excessive IC detect C3dg. iC3b is converted to C3dg within 1–8 hours of its generation.
formation also results in
complement consumption.
Measuring, IC formation
via complement Table 4-21. Examples of Immune Complex-Mediated Diseases
consumption, allows for Disease Antigen Involved
estimation of disease
burden. Thus, C3 and C4 Systemic lupus erythematosus DNA, nucleoproteins, and others
levels can be used to
Serum sickness Various antigens
monitor disease activity
(e.g., in SLE). Poststreptococcal glomerulonephritis Streptococcal cell wall antigen
Polyarteritis nodosa Hepatitis B virus surface antigen
Flash Card A14 Cryoglobulinemia Hepatitis C virus or rheumatoid factor
FcεRI
Raji cell: Burkitt’s cell line with receptors for C1q, C3b, C3bi, and C3d. ICs
bind to Raji cells, which are detected by antihuman IgG (IgA or M). False
positive with warm reactive antilymphocyte Abs (e.g., SLE).
C1q-binding assay: Radiolabeled C1q binds to circulating ICs and is then
detected. False positives may occur with autoantibody to C1q, aggregated
immunoglobulins, or heparin in test samples. C1q will also bind to
polyanionic substances in serum, such as bacterial endotoxin or DNA, giving
false positive results.
COMPLEMENT
Complement deficiency may manifest with increased susceptibility to infection,

autoimmune or IC-mediated diseases, or with angioedema. The specific illness
depends upon which complement component is involved.
Key Fact
The most common cause
DIAGNOSTIC TESTS FOR COMPLEMENT DEFICIENCY of low complement level
is a poorly handled
specimen. Complement
assays are very sensitive
Functional Screening Tests to breakdown at room
temperature.
Consequently, when
AH50: Measures lysis of unsensitized rabbit RBCs. Screens the alternative abnormal results are
pathway. obtained, the test should
be repeated to confirm
CH50: Assesses ability of serum to lyse sheep RBCs sensitized with rabbit true low/absent
IgM. Screens the classical pathway. Best single screen for complement complement.
abnormalities. Low CH50 implies that at least one of the components is
missing or low.
C1 inhibitor levels and function: Several assays available. Evaluates for Mnemonic
presence of type II hereditary angioedema. rAbbit — AH50 —
Function of MBL pathway: Measured by an ELISA assay. Wells coated with Alternative pathway
mannan are incubated with patient’s serum-activation of MBL pathway, Classic image to sleep
which results in production of C4b and C4d that are measured by using → sheep jumping over
enzyme conjugated monoclonal antibodies. Clouds — CH50 —
Classical
See Table 4-22 for a summary of screening test results for complement
deficiency.
Flash Card Q15

Type III hypersensitivity
occurs with antigen or
antibody excess?
150 / CHAPTER 4
Table 4-22. Interpretation of Laboratory Results for Complement

Deficiency
CH50 AH50 Missing Factors
Absent OK C1q, C1r, C1s, C2, or C4
B or D (very rare), or
OK Absent
Properdin
Absent Absent C3, C5, C6, C7, C8, or C9
Absent Absent, and C3 absent Factor H or I
Distinguishing Hereditary from Acquired Complement

Deficiency
In an acquired complement deficiency, CH50 and/or AH50 will be low, as

opposed to a hereditary defect, in which case CH50 and/or AH50 will be absent.
Also, an acquired defect will manifest with multiple low complement
components; whereas, a hereditary deficiency will manifest with only one
component low or absent (Table 4-23).
Quantitative Tests for Component Concentrations

Individual complement components are measured using immunoprecipitation
assays, including nephelometry, RIA, RID, and ELISA techniques. The most
definitive method for evaluating complement activation is quantitation of the
fragments formed during the enzymatic cleavage steps. Because many of the
complement components are acute-phase reactants, decreases due to activation
might be masked by increases in the synthesis rates during an inflammatory
episode. The split products can be used to determine whether activation has
occurred, because their increase occurs only when the complement enzymes are
formed and active.
C4a and C4d: Markers of classical pathway or lectin pathway activation
Bb: Marker of alternative pathway activation
C3a, iC3b, C5a, and soluble C5b-9: Markers of terminal pathway activation
SLE: C3 and C4:
o Reduced levels in the setting of lupus nephritis is an important
Flash Card A15 predictor of more severe disease and poor outcome.
Antigen excess results in o Total deficiency of C3 is associated with development of
the formation of small membranoproliferative glomerulonephritis.
immune complexes that
do not fix complement
Hereditary versus acquired angioedema (see Table 4-23)
and are not cleared from
circulation, leading to
deposition in glomeruli,
vessels, and joints.
Table 4-23. Hereditary Versus Acquired Angioedema

a C1 Inhibitor C1 Inhibitor C1q
C4
Level Function
HAE type I Low Low Low Normal
HAE type II Low Normal or Low Normal

elevated
AAE Low Low Low Low
HAE type III Normal Normal Normal Normal
a
Note: C4 is a sufficient screening test to evaluate patients with angioedema. Further testing is not
necessary if C4 is normal.
Abbreviations: AAE, acquired angioedema HAE, hereditary angioedema.
Complement Autoantibody Tests
C1q autoantibody: Found in patients with hypocomplementemic vasculitis

C1 inhibitor autoantibody: Found in some patients with acquired
angioedema
C3 nephritic factor: Found in a few patients with SLE, associated with dense
deposit disease (membranoproliferative glomerulonephritis type II) and partial
lipodystrophy
Very few complement assays have been standardized and validated for FDA
clearance. However, it is fairly easy to measure individual complement
component, especially C3 and C4 levels, which can be used as screening tests for
various disorders.
MOLECULAR BIOLOGY TECHNOLOGY Flash Card Q16

What complement defect
would be expected in an
The following techniques are used to characterize, isolate, and manipulate the individual with frequent
molecular components of cells and organisms. Neisseria infections?
T-Cell Receptor Excision Circles (TRECs)

Methods—T lymphocytes develop in the bone marrow and undergo maturation Flash Card Q17
in the thymus. During T-cell receptor rearrangement, extrachromosomal DNA Various mutations in
byproducts, called T-cell receptor excision circles (TRECs) are generated. which gene have been
Measurement of TRECs via PCR allows monitoring of the development of associated with type III
HAE?
152 / CHAPTER 4
naïve T lymphocytes that have recently emigrated from the thymus. In

healthy individuals, the number of TRECs declines with increasing age.
Disadvantages—TREC concentration can be affected by T-lymphocyte division

and T-lymphocyte death.
Uses
Diagnosis of SCID and 22q11 deletion syndromes.
HIV-1 infection causes decreased levels of TRECs in peripheral blood T
lymphocytes. Successful treatment with highly active antiretroviral therapy
(HAART) increases TREC levels in peripheral blood T lymphocytes, possibly
by decreasing T-lymphocyte turnover.
Downs syndrome can present with low TREC levels in a newborn.
Monitoring of immune reconstitution after bone marrow transplant.
See Figure 4-25 for an illustration of TRECs.
Reverse Transcriptase Polymerase Chain Reaction

(RT-PCR)
Methods—RT-PCR is a sensitive method for detecting mRNA expression levels.
RNA is first reverse transcribed into cDNA using a reverse transcriptase. The
resulting cDNA is used as templates for subsequent PCR amplification with
primers specific for one or more genes.
Advantages—Most sensitive technique for mRNA detection and quantitation. It

can be used to quantify mRNA levels from much smaller samples and is sensitive
enough to enable quantitation of RNA from a single cell.
Flash Card A16

Terminal complement
complex (C5, C6, C7, C8,
C9)
Flash Card A17

Factor 12 mutation
(Hageman Factor). The
most common mutation
involves a gain of function
resulting in abnormal
generation of bradykinin. Figure 4-25. T–cell-receptor excision circles.
Disadvantages—Accuracy is dependent on variations during amplification.
Uses—Widely used in the diagnosis of genetic diseases and commonly used in

studying the genomes of viruses whose genomes are composed of RNA, such as
influenza A and retroviruses like HIV.
Figure 4-26 illustrates the RT-PCR.
In Situ Hybridization (ISH)

Methods—A method of localizing and detecting specific mRNA sequences in
morphologically preserved tissue sections or cell preparations by hybridizing the
complementary strand of a nucleotide probe to the sequence of interest.
Fluorescent in situ hybridization (FISH) uses fluorescence microscopy to find

where the fluorescent probe binds to the chromosomes (Figure 4-27).
Advantages—Does not require living cells and can be quantified automatically.

Can be used to determine the structure of chromosomes. ISH can also use two or
more probes, labeled with a radioactive label or the other nonradioactive labels, to
simultaneously detect two or more transcripts.
Uses
FISH is often used for finding specific features in DNA for use in genetic
counseling, medicine, and species identification.
FISH can also be used to detect and localize specific mRNAs within tissue
samples.
Diseases that can be diagnosed using FISH include acute lymphoblastic
leukemia (ALL); DiGeorge syndrome [Deletion 22q11 or velocardiofacial
syndrome (VCSF)]; and Down syndrome.
Flash Card Q18
Figure 4-26. Reverse transcriptase PCR. TREC assay has been

introduced in the newborn
screens of several states
for diagnosis of which
disease?
154 / CHAPTER 4
Figure 4-27. Fluorescent in situ hybridization.
Gene Chips
Methods—Gene chips are glass substrate wafers containing many tiny cells, each
of which holds DNA from a different human gene; the genetic material and a
fluorescent probe react. Hybridization of the added nucleic acid and a piece of the
tethered DNA will occur if the sequences complement one another. The
development of fluorescence on the chip's surface identifies regions of binding,
and the known pattern of the tethered DNA can be used to deduce the identity of
the added sample (Figure 4-28).
Advantages—Possible to carry out a very large number of genetic tests on one

sample simultaneously (e.g., up to 260,000 genes can be probed on a single chip).
This is useful when one wants to survey a large number of genes quickly or
when the sample to be studied is small.
Flash Card A18
SCID. The absence of
Uses
TRECs in a newborn To genotype or resequence mutant genomes
reflects T-cell To identify single-nucleotide polymorphism (SNP) among alleles
lymphocytopenia. The
assay can also detect
22q11 deletion syndromes
and trisomy 21.
Figure 4-28. Gene chips.
DNA Sequencing
Methods—Technique for determining the precise order of nucleotides within a

DNA molecule. Several different techniques have been developed to sequence
DNA.
Developed in 1977, the Sanger method is based on the concept of the
“chain-terminating” technique. It became the method of choice for its relative
ease and reliability. This was the most commonly used method until the
advent of next generation of techniques in early 2000.
Second-generation techniques (Next-gen) utilize a variety of methods,
including fluorescent labeling, capillary electrophoresis, and general
automation. Examples include pyrosequencing, sequencing by synthesis, ion
semiconductor, and sequencing by ligation. Goals of next-gen sequencing
include lowering the cost of DNA sequencing while increasing productivity
by replicating thousands or millions of sequences concurrently.
Advantages
Sanger method: Simple and sensitive. Long individual reads useful for many
applications.
Next-generation methods: Variable. Overall lower cost per base in DNA
sequence with potential for higher sequence yield.
Uses—Identification of specific mutations in genes associated with disease can

aid in diagnosis, prognosis, and possible use of therapeutic gene therapy in the
future.
156 / CHAPTER 4
For example, the location (exon) and type of mutation (loss of /gain of
function) in the WAS protein determines clinical phenotype of disease.
Anatomy, Physiology, and
5 Pathology
LYMPHOID SYSTEM AND ORGANS
Lymphoid organs are organized aggregations of lymphocytic cells in a framework

of nonlymphoid cells.
PRIMARY (CENTRAL) LYMPHOID ORGANS
Bone marrow and thymus are the central lymphoid organs. They are the site for
generation and maturation of lymphocytes.
Bone Marrow
Bone marrow generates both B- and T-lymphocyte precursors.
Mnemonic
B-lymphocyte precursors complete most of their development in bone marrow. BONE
However, B lymphocytes also originate in the fetal liver and neonatal spleen.
B-lymphocyte
education and
Interleukin 7 (IL-7) is a hematopoietic growth factor produced by stromal cells
development occur in
in the bone marrow and thymus that is required for development of B and T
BOne marrow.
lymphocytes.
NEgative selection
occurs during B-
B-lymphocyte precursors in contact with bone marrow stromal cells undergo lymphocyte
successive cell divisions: development.
Autoreactive or nonfunctional B-cell–receptor-bearing B lymphocytes

undergo apoptosis and are removed by marrow macrophages by negative
selection.
Functional IgM-bearing B lymphocytes migrate from the periphery of bone to
the central sinusoid along reticulum processes. They then enter central sinus
and blood vessels to migrate to secondary lymphoid tissues.
158 / CHAPTER 5
Thymus
Once generated in bone marrow, T-lymphocyte precursors migrate to the thymus
Mnemonic for maturation. The thymus is formed of the endoderm and mesoderm of third
THYMUS and fourth pharyngeal pouches. It grows in size from birth, peaks at puberty,
T-lymphocyte and then undergoes gradual atrophy with age by thymic involution caused by
maturation occurs in circulating hormone levels.
the thymus.
Hassall’s corpuscles The thymus is composed of two identical lobes and located in the anterior
are in the thymus superior mediastinum. Thymic histology and architecture is detailed in Figure 5-1.
(cortex).
Young individuals
have a thymus that The thymic epithelium is divided into the subcapsular zone, the cortex, and the
is relatively large in medulla:
childhood, peaks
during puberty, and The subcapsular zone contains the most primitive lymphocyte progenitors
decreases in size derived from bone marrow.
thereafter with age. The cortex contains small lymphocytes engaged in the division, expression,
Medulla, cortex, and
subcapsular zone.
and selection process of T-cell receptors.
U should remember The medulla contains lymphocytes that are undergoing their final stages of
both positive selection and maturation. It also contains Hassall’s corpuscles, which are
(cortex) and small bodies of granular cells surrounded by concentric layers of modified
negative (medulla) epithelial cells.
selection occur in
thymus.
Subcapsular Within the cortex:
epithelium provides
blood-thymus Positive selection: T-cell receptor gene rearrangement in immature
barrier. thymocytes creates T-cell receptors compatible with self-MHC molecules
displayed on the thymic epithelium or stroma. The functional T-cell receptors
transmit a survival signal for positive selection.
Limited negative selection begins in the cortex where autoreactive or
nonfunctional T-cell receptor–bearing T lymphocytes undergo apoptosis.
By way of the medulla:

Negative selection: Thymocytes undergo further rounds of negative selection
to remove autoreactive T cells and contribute to central tolerance.
Mature T lymphocytes leave the thymus to circulate at the periphery or go to
secondary lymphoid tissues.
It should also be noted that, other than migrating to the thymus for maturation,
some T-lymphocyte precursors from bone marrow migrate to cryptopatches
(CPs), tiny mucosal lymphoid aggregates found just under the intestinal
epithelium, to form specialized T-lymphocyte populations.
ANATOMY, PHYSIOLOGY, AND PATHOLOGY / 159
B C Flash Card Q1
Figure 5-1. (A) Thymus architecture showing Hassall’s corpuscle. (B, C) What diseases are
Histologic images of human thymic tissue. associated with
(Figure A adapted, with permission, from Ankita Nair and Nikita Nair; Figures B and C reproduced, congenital thymic
with permission, from USMLERx.com.) aplasia in humans?
SECONDARY (PERIPHERAL) LYMPHOID ORGANS Flash Card Q2

In which condition is
immunodeficiency
The secondary or peripheral lymphoid glands are the sites for mature lymphocyte
(hypogammaglobulinemi
activation and the initiation of adaptive immune responses. They also provide a) associated with a
signals that sustain recirculating lymphocytes. thymoma in adults?
160 / CHAPTER 5
Lymph Node
Lymph nodes (LN) are located along the course of lymphatic vessels. They are
small, oval- or kidney-shaped, with hilum that contains the blood vessels and
efferent lymphatic vessel. Figure 5-2 shows the structure of the lymph node:
The outermost layer is the capsule with several afferent lymphatics that drain
in the subcapsular or marginal sinus (Figure 5-2A).
The cortex contains B-lymphocyte-rich follicles and T-lymphocyte-rich
parafollicular areas. Dendritic cells and macrophages are interspersed (Figures
5-2B and 5-2C, respectively).
The medulla has less densely packed lymphocytes, forming medullary cords,
macrophages, plasma cells, and few granulocytes.
Postcapillary venules are lined by high cuboidal endothelium and are called
high endothelial venules (HEV), which are designed for lymphocyte cell
adhesion and exit.
Structures:
o Lymph: Extracellular fluid collected from tissues, which is filtered by the
LNs, then returned to blood
o Follicle: Site of B-lymphocyte localization within the LN
o Primary follicle: Site of resting B lymphocytes
o Secondary follicle: Has germinal-center area of B-cell proliferation in
response to antigen stimulation or T-lymphocyte help.
o Ratio of primary and secondary follicles defines LN activity
o Parafollicular cortex: T-lymphocyte zone surrounding B-lymphocyte
follicle
Lymph node size is generally larger in adolescence than later in life. Normal
lymph nodes are typically less than 1 cm in diameter. Enlarged peripheral lymph
nodes, or peripheral lymphadenopathy, can result from a variety of diseases and
drugs. See Table 5-1 for common causes of peripheral lymphadopathy.
Table 5-1. Differential Diagnosis of Peripheral Lymphadenopathy

Etiology Examples
Infections Bacterial, viral , fungal, parasitic
Flash Card A1 Malignancy Lymphoma, SSC head/neck, metastatic, leukemia
DiGeorge syndrome, Lymphoproliferative ALPS, hemophagocytic lymphohistiocytosis
SCID
Immunologic Serum sickness, drug reactions
Endocrine Hypothyroidism, Addison’s disease
Miscellaneous Sarcoidosis, amyloidosis, Churg-Strauss syndrome

Flash Card A2
Abbreviations: ALPS, autoimmune lymphoproliferative syndrome; SSC, squamous cell carcinoma.
Good’s syndrome
Capsule
Cortex
(T Cells) Follicle
(B Cells)
Cortex
Follicle
Capsule
Trabeculae
Figure 5-2. Lymph node. (A) Lymph node architecture; (B, C) histologic images
of lymph node.
(Figures B and C reproduced, with permission, from Dr. Harpreet Chopra.)
162 / CHAPTER 5
Spleen
The spleen is the largest specialized lymph organ. It contains 25% of total blood
lymphocytes and consists primarily of red pulp with only a relatively small
amount of white pulp (20%).
Red pulp is the site of senescent RBC collection and disposal (Figure 5-3).
White pulp includes the areas rich in lymphocytes that surround arterioles
entering the spleen.
The spleen does not have afferent lymphatic supply, but it receives
lymphocytes and antigen from the vasculature via the splenic artery. It also has
efferent lymphatic vessels that carry lymphocytes out:
Periarteriolar lymphoid sheath (PALS) has an inner region of white pulp
with T lymphocytes.
B-lymphocyte corona surround PALS and B-lymphocyte follicles.
Splenic artery branches along invaginations of capsule (trabeculae).
Figure 5-3. Spleen architecture.

Mucosa-Associated Lymphoid Tissue
Mucosa-associated lymphoid tissue (MALT) is unencapsulated lymphoid tissue

found in the walls of the gut-associated lymphoid tissue (GALT), respiratory Key Fact
epithelium (bronchus-associated lymphoid tissue, BALT), reproductive tract,
Remember: B
urinary tract, and skin. lymphocytes undergo
only negative selection,
Most MALT presents as microscopic populations of lymphocytes, located in the whereas T
lamina propria and submucosa, where they are discrete follicles as well as lymphocytes undergo
dispersed in the base of the epithelium. both positive and
negative selection.
Some MALT presents as macroscopic masses, such as peripharyngeal lymphoid

ring (i.e., Waldeyer’s ring containing tonsils and adenoids) and Peyer’s patches.
Similar to lymph nodes, MALT serves as a center for activation of B and T

lymphocytes after antigen presentation.
UPPER AIRWAY
(NOSE, SINUSES, AND MIDDLE EAR)
NOSE
Anatomy
The lateral walls of nose are rigid bony structures with bony conchae that
protrude into the nasal cavity (Figures 5-4A and 5-4B, respectively).
The concha bullosa is the pneumatization of the concha and is one of the most
common variations of the sinonasal anatomy (Figure 5-5). Flash Card Q3
The absence of a spleen
The nasal septum has bony and cartilaginous components. Trauma or other leads to increased
factors can cause septal deviation, leading to blockage and sometimes formation susceptibility to which
organisms?
of nasal spurs that can cause facial pain syndromes.
Conchae are covered by an erectile mucosa with a rich blood supply, forming
turbinates.
Flash Card Q4
The nasal valve, or internal ostium, is the narrowest point of the whole airway. It What pathogen is
is located at the junction between the nasal vestibule and the main nasal cavity, frequently associated
with gastric MALT
just anterior to the tip of the inferior turbinate. lymphoma?
164 / CHAPTER 5
Flash Card A3
Encapsulated bacteria
(Neisseria meningitidis,
Haemophilus influenzae,
and Streptococcus B
pneumoniae)
Figure 5-4. Nasal structures. (A) Sagittal section and (B) coronal section.
Flash Card A4
Helicobacter pylori.
Gastric MALT lymphoma
is frequently associated
(72–98%) with chronic
inflammation from H.
pylori.
Figure 5-5. CT scan shows concha bullosa (arrow).

Function
The primary function of the nose is to provide filtration of foreign particles,
humidification, and thermal regulation of inspired air as well as olfaction.
The turbinates increase the surface area of the nasal cavity, thereby providing
turbulence to the airflow. Airflow is essential for the humidification and thermal
regulation of all inspired air, not just the portion in contact with nasal mucosa.
Nasal airway resistance is regulated at the level of the nasal valve, which is
controlled by the swelling of the inferior turbinate. Dilator naris muscles
voluntarily increase patency of the nasal vestibule.
Nasal Epithelium
The nasal epithelium is the stratified squamous membranous tissue in the nasal
vestibule and nasopharynx.
Pseudostratified ciliated columnar epithelia are found in the lines of the
trachea and the respiratory area of the nasal cavity.
Specialized olfactory epithelium is found in the olfactory area.
Submucosa contains serous and mucous glands, fibroblasts, inflammatory cells,

nerves, and blood vessels. Smooth muscle is not present in the submucosa.
166 / CHAPTER 5
Nasal polyps are nontender, mobile masses of mucosal overgrowth occurring in

the nose and paranasal sinuses (Figure 5-6).
Differential diagnosis for nasal polyps includes chronic rhinosinusitis, cystic

fibrosis, NSAID sensitivity (with coexisting asthma), and tumors.
A B
Figure 5-6. Example of diffuse nasal polyposis. (A) Right nasal cavity illustrating
nasal polyps in the middle meatus and olfactory cleft (on both sides of the middle
turbinate). (B) Lower left nasal cavity, showing polyps extending beneath the left
middle turbinate and touching the inferior turbinate. (C) Upper left nasal cavity
showing the middle turbinate enveloped by polyps in the middle meatus and
olfactory cleft.
(Reproduced, with permission, from Dr. Daniel Hamilos, Massachusetts General
Hospital, Allergy and Immunology, Department of Medicine)
Nasal Fluid and Mucociliary Clearance

The adult nose makes approximately a quart of thin mucus each day.
Nasal fluid contains immunoglobulins (IgA) and other serum proteins, enzymes,
antioxidants (glutathione, uric acid and vitamin C), and cellular mediators.
Mucus is normally swallowed via mucociliary clearance, subconsciously, along

with trapped particles, potentially infectious agents, and other debris.
Conditions that increase mucus production or thicken it, such as inflammation

(viral, bacterial, or allergic), irritation, altered ciliary clearance, and autonomic
dysregulation, etc., will produce postnasal drip.
Seromucous glands in nasal epithelium have parasympathetic cholinergic

innervations, causing watery nasal secretion; hence, an anticholinergic is used to
decrease rhinorrhea.
Mucociliary clearance can be tested by placing saccharin on the anterior end

of an inferior turbinate and timing the onset of sweet taste in the mouth.
(The normal range is 7–11 minutes.)
Primary ciliary dyskinesia (PCD) is a disease that results in decreased

mucociliary clearance. PCD is a rare autosomal recessive genetic disorder that
causes a defect in the function of cilia lining in the respiratory tract, fallopian
tubes, and flagella of sperm. This causes reduced/absent mucous clearing from the
lungs, leading to chronic recurrent respiratory infections (sinusitis, bronchitis,
pneumonia, otits media), bronchiectasis, infertility, and in some cases hearing
loss.
Blood Vessels
Resistance vessels (i.e., small arteries and arterioles) control nasal blood flow
via local mediators and sympathetic stimulation, which causes
vasoconstriction.
Capacitance vessels, or venous erectile tissue located primarily over inferior
and middle turbinates and nasal septum, have sympathetic adrenergic
innervation, which controls nasal airway resistance.
Subepithelial capillaries and veins are fenestrated, leading to the high
permeability-increased absorption of intranasal drugs.
Flash Card Q5
What syndrome is
characterized by ciliary
dyskinesia, situs
inversus, bronchiectasis,
and chronic sinusitis?
168 / CHAPTER 5
Nerve Supply
The olfactory nerve is a chemoreceptor that governs the sense of smell.
Ophthalmic and maxillary branches of the trigeminal nerve are responsible for
sensory innervation.
The nasal epithelium has both a parasympathetic and sympathetic supply.

Parasympathetic innervation to nasal glands controls glandular secretion and
is mediated primarily by acetylcholine.
Sympathetic innervation of arterial vessels controls nasal blood flow (i.e.,
nasal patency), and venous erectile tissue controls airflow resistance.
Nasal Airflow
With nasal airflow there is normal asymmetry of nasal mucosal swelling, in
Key Fact
which one side of the nose is swollen as a result of dilatation of venous sinuses in
The nasal airflow is the inferior turbinate and the other side is open.
usually asymmetrical
due to the “nasal cycle”
of alternating congestion Table 5-2 shows dynamic factors that affect nasal airflow. Static factors like
and decongestion of septal deviation and adenoids also affect nasal flow.
nasal venous sinuses.
About 80% of the
population exhibits a
nasal cycle, with
reciprocal changes in Table 5-2. Factors Affecting Nasal Airflow
airflow over time as Factors Affecting Nasal Mechanism Effect on Airflow
controlled by the Flow
sympathetic nervous
system. Sympathetic activity Vasoconstriction Increased flow
Posture, sitting to supine Increased venous filling Decreased flow
Lateral recumbent position Reflex vasomotor activity Increased flow in upper nostril
Decreased flow in lower
nostril
Mild to moderate exercise Increased sympathetic activity Increased flow
Increase in blood carbon Sympathetic supply to blood Increased flow
dioxide levels vessels
Epinephrine Vasoconstriction Increased flow
Puberty, menstruation, and Vasodilatation and glandular Decreased flow
pregnancy hypersecretion
Flash Card A5
Kartagener’s
syndrome—50% of
individuals with PCD
have Kartagener’s
syndrome
SINUSES
Sinus is a Latin word meaning “fold” or “pocket.”
Paranasal sinuses develop in the embryo as an excavation of bone by air-filled Mnemonic

sacs (pneumatic diverticula) from the nasal cavity. They are rudimentary at birth
Sinuses listen to the
and slowly grow to be well developed by about 8 years of age. They are lined following radio channels:
with ciliated pseudostratified columnar epithelia with goblet cells, which secrete FM AM PS SS
mucus.
Frontal sinus, Maxillary
sinus, and Anterior
Ostia are 2–6 mm wide sinus openings into the nose. Ciliary action sweeps mucus ethmoids all drain into
produced in the sinus through the ostium into the nose. An open ostium allows Middle meatus.
ventilation of the sinus. A blocked ostium contributes to development of Posterior ethmoids and
sinusitis. Sphenoid sinus drain
into Sphenoethmoidal
recess above Superior
turbinate.
Function of Sinuses
The function of the sinuses is debatable. The following have been proposed:
Decreasing the relative weight of the front of the skull
Increasing resonance of the voice
Insulating intracranial structures
Humidifying and heating of inhaled air
Source of nitric oxide
Opening of Sinuses
Inferior meatus: Opening of nasolacrimal duct

Middle meatus: Frontal, maxillary and anterior ethmoids open into hiatus
semilunaris
Superior turbinate: Has sphenoethmoidal recess above it where posteth-
moids and sphenoid sinuses drain
Flash Card Q6
Identify the structures
labeled (A–F) in the
sinus CT images (Figure
5-7).
Flash Card Q7
Which paranasal sinus
cavity is absent at birth?
170 / CHAPTER 5
B
F
C E
A D
A B
Figure 5-7. CT scan images with coronal (A) and sagittal (B) views of the
sinuses.
(Reproduced, with permission, from Dr. Ahila Subramanian)
MIDDLE EAR
The tympanic cavity, or middle ear, is an irregular space in the petrous part of the
temporal bone. It is lined by mucous membrane and filled with air that reaches it
from the nasopharynx via the eustachian tube (ET), which is also known as
either the auditory or pharyngotympanic tube.
The middle ear contains the three auditory ossicles that transmit vibrations of
the tympanic membrane to the cochlea.
Infection to the middle ear usually spreads from the nasopharynx via the
Flash Card A6
pharyngeal ostium of the ET (Figure 5-8).
(A) maxillary sinus; (B)
ethmoid sinus; (C)
concha bullosa; (D)
inferior turbinate; (E)
sphenoid sinus; (F)
posterior ethmoid sinus
Flash Card A7
Frontal sinus. It is
generally well developed
by 7–8 years of age and
reaches full size after
puberty.
Key Fact
ET blockage in children
can occur due to
. mucosal swelling caused
by infection, allergic
Figure 5-8. Endoscopic view of nasopharynx. inflammation, or
enlarged adenoids. Fluid
unable to drain from
Posterior to the middle ear are the mastoid antrum and mastoid air cells. middle ear causes
middle ear effusion,
The tympanic membrane is innervated by the auriculotemporal nerve, which which is prone to
can perceive only pain. infection.
REMODELING OF THE LOWER AIRWAY
Lower airway changes are seen in both asthma and chronic obstructive pulmonary
disease (COPD).
REMODELING
Remodeling is defined as structural change evident in asthmatic airways
compared with normal airways. With remodeling, the airway wall is thickened by
cellular infiltration, extracellular matrix deposition, and expansion of airways
smooth muscle. There is also pronounced neovascularization.
172 / CHAPTER 5
Sputum Characteristics in Asthma
Curschmann’s spirals: Corkscrew-shaped twists of condensed mucus

(Figure 5-9)
Creola bodies: Clusters of surface epithelial cells (Figure 5-9)
Charcot-Leyden crystals: Eosinophil cell and granule membrane
lysophospholipase (Figure 5-9)
Eosinophils
Metachromatic cells
Sputum Characteristics in COPD
Though eosinophils may be present, eosinophilia is NOT predominant in

sputum of patients with COPD.
Sputum macrophages and neutrophils during exacerbations are caused by
infections.
LOWER AIRWAY CHANGES SEEN IN ASTHMA AND COPD

Table 5-3 illustrates the changes seen in lower airways in cases of asthma and
COPD.
Figure 5-9. Sputum findings seen in asthma.

Table 5-3. Lower Airway Changes in Asthma and COPD

Characteristic Asthma COPD
Surface epithelium Fragile or denuded Usually not fragile
Reticular basement Thickened and hyaline Variable or normal
membrane
Bronchiolar mucous cells Possible mucous metaplasia Metaplasia or hyperplasia
Bronchial smooth muscle Enlarged in large airways Enlarged in small airways
Mucus histochemistry No change Increased acidic glycoprotein
Cellular infiltrate Predominantly CD3, CD4, Predominantly CD3, CD8,
CD25 (IL-2R) positive, marked CD68, CD25, VLA-1 positive,
eosinophilia, and increase in HLA-DR positive, mild
mast cells eosinophilia, and mast cell
increase
Cytokines Increase in IL-4 and IL-5 gene GM-CSF protein, ±IL-4;
expression No increase in IL-5
Airflow obstruction Variable, reversible; Usually progressive
Nonreversible after remodeling deterioration of lung function
Postmortem findings Hyperinflation, airway plugs; Excessive mucus, more small
Usually no emphysema airway involvement;
Emphysema prominent
SKIN
The skin is the largest organ in the body. The structure of the skin is depicted in
Figure 5-10.
Functions of the skin include thermoregulation, sensation, metabolism (vitamin-D

synthesis), physical barrier to external environment, and active participation in
host defense with ability to generate and support local immune and inflammatory
reactions
Epidermis
Principal cell populations in the epidermis include the following:
Keratinocytes and melanocytes do not appear to be important mediators of
adaptive immunity. However, keratinocytes do express major
histocompatability complex (MHC)-type II proteins and produce several
molecules (IL-1, antimicrobial peptides, thymic stromal lymphopoietin Flash Card Q8
[TSLP], and receptor activator of nuclear factor κ-B ligand [RANKL]) that What are the pathologic
contribute to both the adaptive and innate immune response, respectively. features of airway
These cytokines also mediate cutaneous inflammation. remodeling?
174 / CHAPTER 5
Figure 5-10. Skin structure.
Langerhans’ cells are immature dendritic cells of the cutaneous immune

system located in the suprabasal portion of the epidermis.
o They have dendritic processes that enable them to capture antigens
entering through the skin.
o On stimulation by proinflammatory cytokines, Langerhans’ cells
retract their processes, lose their adhesiveness for epidermal cells, and
migrate to the dermis.
o They subsequently migrate to lymph nodes through afferent lymphatic
vessels.
Epidermal lymphocytes constitute only about 2% of skin-associated
lymphocytes (the rest reside in dermis), and the majority are CD8+ T
lymphocytes.
o Express a more restricted set of antigen receptors than T lymphocytes
Flash Card A8 in most extracutaneous tissues.
Airway wall thickening
o The majority express an effector or memory phenotype.
with increased collagen Langerhans’ cell histiocytosis (LCH) is a rare disease caused by clonal
deposition and airway proliferation of Langerhans’ cells. Clinical presentation involves a nonspecific
smooth muscle, goblet
cell hyperplasia,
inflammatory response (fever, lethargy, weight loss) and multifocal organ
subepithelial fibrosis, involvement, including bone, skin, bone marrow, lymph nodes, endocrine
and angiogenesis glands, and lungs.
Dermoepidermal Junction
The dermoepidermal junction joins the epidermis to the dermis. Its function is to
protect against mechanical shear and to serve as a semipermeable barrier.
The basement membrane has three main layers:

Lamina lucida: Includes the extracellular portion of the hemidesmosomes
and anchoring filaments
Lamina densa: Includes collagen IV and laminin network
Sublamina densa: Includes anchoring fibrils (collagen VII)
Dermis
Principal cell populations in the dermis include the following and their related
Key Fact
functions:
Connective tissue mast
Fibroblasts synthesize and degrade extracellular matrix proteins, collagen, cells with tryptase and
and elastic fibers. They also secrete soluble mediators (e.g., eotaxin when chymase (MCTC) are
stimulated by IL-4, as well as IL-1 and IL-6). present in skin,
conjunctiva, heart, and
Mast cells have granules containing both tryptase and chymase. Their intestinal submucosa
development depends on c-kit receptor and its ligand stem cell factor (SCF). (and have the CD88
receptor for C5a
Macrophages in dermis have several functions, including phagocytosis,
anaphylatoxin).
antigen presentation, wound healing, and secretory functions. They express
Mucosal mast cells with
CD68. tryptase (MCT) present in
Dermal dendritic cells can be labeled by factor XIIIa, and can express DC- the surface of the
SIGN/CD 209+, CD1b, CD1c, and CD11c. They play a role in antigen alveolar wall, the
respiratory epithelium,
presentation. and the small intestinal
Dermal T lymphocytes (both CD4+ and CD8+ cells) are located mucosa.
predominantly in perivascular locations. They express phenotypic markers
typical of activated or memory T lymphocytes. Many dermal T lymphocytes
also express a carbohydrate epitope called cutaneous lymphocyte antigen
(CLA)-1, which may play a role in homing to the skin.
Specialized Structures
Specialized structures of the skin include: hair follicles, sebaceous glands,
Meissner’s and Pacinian corpuscles, and apocrine and eccrine sweat glands.
176 / CHAPTER 5
Role in Immunity
Key Fact Skin homing of memory, effector, and regulatory T-cell subtypes (CLA+) are
programmed by skin-derived dendritic cells via cytokines, such as CCR4/CCL17
Filaggrin (FLG) serves
as the matrix protein
and CCR10/CCL27.
promoting aggregation
and disulfide bonding of
keratin filaments. Immunobullous Skin Diseases
Mutations in the FLG
gene have been linked
to ichthyosis vulgaris Table 5-4 lists immunobullous skin diseases.
and atopic eczema.
Some of these Table 5-4. Immunobullous Skin Diseases
mutations have also
been associated with Immunobullous Clinical Serum Tissue Immuno-
the propensity to Disease Presentation Autoantibodies fluorescence
develop asthma in Pemphigus vulgaris Flaccid>tense bullae IgG autoantibodies to Epidermal IgG and C3
eczema patients and (Figure 5-11A) Crusting desmoglein 1 and 3 cell surface staining of
asthma severity that is Nikolsky’s sign present the suprabasal layers
independent of eczema. Affects scalp, chest,
intertriginous areas,
and oral mucosa
Pemphigus foliaceous Superficial bullae IgG autoantibodies to Epidermal IgG and C3
Erosions desmoglein 1 cell surface staining of
Key Fact Scale with crusting the granular layer
Nikolsky’s sign present
In all suspected
immunobullous diseases, Paraneoplastic Flaccid bullae IgG autoantibodies to Epidermal IgG and C3
it is best to obtain two pemphigus Lichenoid or erythema plakin proteins and cell surface and
multiforme-like desmoglein 1 and 3 basement membrane
biopsies for diagnosis.
lesions zone staining
One shave biopsy of an Affects mucosa
intact vesicle or bulla for Nikolsky’s sign present
routine hematoxylin and
IgA pemphigus Pustules, erythema, IgA autoantibodies to Epidermal IgA cell
eosin (H&E) stain; and a
and flaccid lakes of pus desmoglein 3, surface staining
second biopsy of desmocollin 1
perilesional tissue for
direct Bullous pemphigoid Tense > flaccid bullae IgG autoantibodies to Linear basement
(Figure 5-11B) Prominent pruritus BP180 and BP 230 membrane zone IgG
immunofluorescence.
Nikolsky’s sign in some and C3
(Note: Immunoreactants (~10%)
may not be present in
lesional tissue.) Cicatricial pemphigoid Erosions, rare vesicles IgG autoantibodies to Linear basement
or bullae integrins, BP180, and membrane zone IgG
Scarring sequelae laminins and C3
Herpes gestationis Tense bullae Complement fixing, Linear basement
Onset in second basement membrane membrane zone C3
trimester pregnancy zone, and epidermal;
Key Fact Pruritus Autoantibody to BP180
Nikolsky's sign is the Epidermolysis bullosa Tense bullae, erosions, IgG autoantibody to Linear basement
formation of erosion from acquisita and scarring collagen VII membrane zone IgG
shearing pressure Sites of trauma and and C3
oral mucosa
applied on normal-
appearing skin. Linear IgA bullous Tense bullae IgA autoantibody Linear basement
dermatosis Oral involvement LABD97, LAD-1, and membrane zone IgA
common others
Table 5-4. Immunobullous Skin Diseases, cont.

Immunobullous Clinical Serum Tissue Immuno-
Disease Presentation Autoantibodies fluorescence
Dermatitis Small bullae on elbows IgA autoantibody to Granular basement
herpetiformis and knees epidermal membrane zone IgA
(Figure 5-11C) Markedly pruritic transglutaminase with stippling in dermal Key Fact
Associated with papillae
intestinal gluten Pemphigus vulgaris (PV),
sensitivity (celiac bullous pemphigoid (BP),
disease) and dermatitis
Bullous lupus Tense bullae IgG autoantibody to Linear basement herpetiformis (DH) must
erythematosus Photo distributed collagen VII membrane zone IgG; be known for the boards!
May show granular IgM (Figure 5-11.)
and C3 basement
membrane zone
Flash Card Q9
Which condition, PV,
A B BP, or DH, is most likely
to show a positive
Nikolsky’s sign?
Flash Card Q10

Which condition(s), PV,
BP, and DH, is(are)
extremely pruritic?
C
Figure 5-11. (A) Pemphigus vulgaris lesions on the mucosal surface of the lower
lip. (B) Bullous pemphigoid. (C) Dermatitis herpetiformis on a four-year-old child
with a vesiculo-papular skin eruption due to dermatitis herpetiformis. Flash Card Q11
(Figure A reproduced, with permission, from the Public Health Image Library, Centers for Disease
Control and Prevention, Atlanta, Georgia, courtesy of Dr. J. Lieberman; Dr. Freideen Farzin, Univ. In PV and BP, what two
of Tehran;Figure B reproduced, with permission, from USMLERx.com; Figure C reproduced, with molecules react with
permission, from the Public Health Image Library, Centers for Disease Control and Prevention, antigens in the
Atlanta, Georgia.)
basement membrane
zone?
178 / CHAPTER 5
Autoimmune Skin Diseases
Table 5-5 lists autoimmune skin diseases.
Table 5-5. Autoimmune Skin Diseases

Indirect
Nuclear Antigens to
Autoimmune Immuno- Direct Immuno-
Which Autoantibodies
Disease fluorescence fluorescence of Tissue
Are Directed
Pattern (Serum)
Systemic lupus Peripheral nDNA or dsDNA, ssDNA, Two or more granular
erythematosus Homogeneous histones, nucleolar RNA, immunoglobulin and
(SLE) Nucleolar various ribonucleo- complement deposits at
Speckled proteins, cardiolipin, Sm BMZ, IgG, IgM, and/or IgA
(Smith), U1-snRNP, and with C3 in involved and
HMG-17 uninvolved skin (lupus
band)
Discoid lupus No circulating Usually none detected Two or more granular
erythematosus antibodies immunoglobulin and
(DLE) complement deposits at
BMZ, IgG, IgM, and/or IgA
with C3 in involved skin
Subacute cutaneous Speckled SS-A/Ro and SS-B/La Particulate intercellular
lupus erythematosus staining with or without
(SCLE) granular immune deposits
at BMZ or lichenoid
changes
Neonatal lupus Speckled SS-A/Ro and SS-B/La Granular IgG
erythematosus (transplacental) at BMZ
Drug-induced lupus Peripheral Histones Granular immune deposits
erythematosus Homogeneous at the BMZ
Cutaneous Peripheral Scl-70, SS-A/Ro, and SS- No characteristic changes;
scleroderma B/La vascular staining may be
observed
Flash Card A9
Limited scleroderma Centromere Centromere, Scl-70, U1- No characteristic changes;
Pemphigus vulgaris (PV). (CREST) snRNP, and HMG-17 vascular staining may be
Only approximately 10% observed
of individuals with BP will Progressive Nucleolar Scl-70, U1- and U3- No characteristic changes;
have a positive systemic sclerosis Speckled snRNP, fibrillarin, and vascular staining may be
Nikolsky’s sign. RNA pol I, II, and III observed
Dermatomyositis, Speckled Jo-1, PM-Scl, Mi-2, U1- No characteristic changes;
polymyositis Nucleolar snRNP and SS-A/Ro s lichenoid features and
vascular staining may be
observed
Flash Card A10
Sjögren's syndrome Fine speckled SS-A/Ro, SS-B/La, No characteristic changes;
Dermatitis herpetiformis Nucleolar histones, and U1-snRNP vascular staining may be
(DH) and bullous observed
pemphigoid (BP) Mixed connective Speckled U1-snRNP and PM-scl No characteristic changes;
tissue disease granular immune deposits
(MCTD) at the BMZ lichenoid
features and vascular
Flash Card A11 staining may be observed
Abbreviations: BMZ, basement membrane zone; ds, doubled-stranded; ss, single-stranded.
Immunoglobulin G and
C3 complement
Antimicrobial Peptides (AMPs) in the Skin

Defensins are cysteine-rich peptides made up of 29–34 amino acids that are
present in skin. They are abundant in neutrophil granules and constitute about 5%
of all cellular proteins of human neutrophils.
Defensins are broad in spectrum, and kill a wide variety of bacteria and fungi.
Synthesis of defensins is increased in response to inflammatory cytokines
such as IL-1 and tumor necrosis factor (TNF), which are produced by
macrophages and other cells in response to microbes.
GASTROINTESTINAL
Gut-Associated Lymphoid Tissue (GALT)
Samples antigens from the gut.

Peyer’s patches are located in small and large intestine (Figure 5-12). Key Fact
Microfold (M) cells are overlying specialized epithelial cells with microvilli
Peyer’s patches follicles
that help in antigen sampling. differ from LN in that
Follicles located within lamina propria of intestinal mucosa have B there is never a resting
lymphocytes. appearance due to a
constant response to gut
Parafollicular area have T lymphocytes. flora.
No afferent lymphatics, lymphocytes reach here via high endothelial
venules (HEV) and leave via efferent lymphatics.
Flash Card Q12

What is a diagnostic
Figure 5-12. Peyer’s patches lymphoid follicle. biopsy characteristic for
(Reproduced, with permission, from Uniformed Services University of the Health Sciences, Huck eosinophilic esophagitis
Finne.) (EoE)?
180 / CHAPTER 5
Allergic Eosinophilic Esophagitis and Gastroenteritis
Eosinophil-associated gastrointestinal disorders (EGID) comprise a range of

Key Fact disorders, including eosinophilic esophagitis (EoE), eosinophilic gastritis,
Eosinophils are present eosinophilic enteritis, eosinophilic colitis, and eosinophilic gastroenteritis
in all segments of (involves more than one gastrointestinal segment).
gastrointestinal tract EGID are believed to be primarily a Th type 2 lymphocyte-mediated process
mucosa at baseline
EXCEPT for the driven by food allergens.
esophagus. Characterized by eosinophilic infiltrates in the mucosal, vascular, and/or
serosal layers of the gut (Figure 5-13).
IL-5 and Eotaxin-3 are implicated in the pathogenesis of EoE.
Therapy for EGID involves a combination of interventions including allergen
avoidance, elemental diets, and anti-inflammatory agents.
Allergic proctocolitis, or eosinophilic proctocolitis, typically presents with
bloody stools in an otherwise well-appearing infant. The condition occurs in
infants, is strongly associated with breast-fed infants, and has a benign and
limited course. Dietary proteins, most commonly cow’s milk protein, excreted
in the mother’s milk are responsible for the majority of cases. There is no
association with atopy or specific IgE, and greater than 90% will tolerate an
unrestricted diet by 1 year of age.
On endoscopy, linear furrows, white papules or plaques, or concentric rings may

be found (Figure 5-14).
Flash Card A12

Figure 5-13. Esophageal mucosa infiltrated by eosinophils.
Greater than 15 (Reproduced, with permission, from Dr. Douglas Field).
eosinophils per high
powered field while on a
proton pump inhibitor
(PPI) for at least 4–8
weeks.
Key Fact
Figure 5-14. Linear furrows and white plaques in esophagus. Diagnostic screening for
(Reproduced, with permission, from Dr. Douglas Field). celiac disease with anti-
tTG IgA should always
be accompanied by a
serum IgA level. IgA
Celiac Disease deficiency is often
undiagnosed as it can
Celiac disease is an autoimmune disorder of the small intestine that presents in commonly occur without
genetically predisposed people of all ages, from infancy onward. It occurs due to clinical symptoms.
sensitivity to gliadin, the alcohol-soluble portion of gluten. Therefore low Anti-tTG
IgA levels can be a
false-negative result in
With celiac disease, there is loss of intestinal villi and hyperplasia of the crypts the setting of IgA
along with lymphocytic infiltrate (Figure 5-15). deficiency and warrants
screening for total IgA in
Clinical presentation involves malabsorption, chronic diarrhea, steatorrhea, conjunction with anti-
tTG IgA.
abdominal distension, flatulence, weight loss, or failure to thrive. Oral ulcers or
dermatitis herpetiformis may occur in the absence of GI symptoms.
Celiac disease is screened with IgA antibodies to tissue transglutaminase (tTG)

and confirmed with intestinal biopsy when patient is consuming gluten.
Flash Card Q13

What mediator is
important in the
pathogenesis of EoE?
Flash Card Q14

What skin manifestation
of celiac disease can
present in absence of GI
symptoms?
182 / CHAPTER 5
Villous blunting
Figure 5-15.Small-bowel biopsy specimen in celiac disease.

Flash Card A13

Eotaxin-3.
Flash Card A14

Dermatitis herpetiformis
6 Research Principles
EXPERIMENTAL DESIGN
TYPES OF STUDIES
There are six main types of experimental design studies: cross-sectional, case
series, case control, cohort studies, and randomized control studies.
Cross-Sectional
Defined: Subjects sampled from a population and data regarding presence or

absence of exposure and disease are collected at the same time
Example: In a specific group, is there a relationship between smoking and
lung cancer?
Strengths: Inexpensive and quick to perform; population-based; and provides
a timely “snapshot”
Weaknesses: Recall bias; lacks time sequence (i.e., it is not always possible
to discern whether the exposure preceded or followed the disease)
Case Series
Defined: Tracks patients with a known exposure who have been given similar
treatment, or examines their records for exposure and outcome
Example: A clinical report on a series of patients
Strengths: Provides a method of investigating uncommon diseases;
inexpensive; and can be hypothesis-generating
Weaknesses: No control group with which to compare outcomes; no
statistical validity; and may be confounded by selection bias Flash Card Q1
If cost and time were
unlimited, which two
studies would yield the
most robust data?
184 / CHAPTER 6
Case Control
Defined: Compare subjects who have a condition (the “cases”) with patients
who do not have the condition but are otherwise similar (the “controls”),
examining how frequently the risk factor is present in each group
Example: Do women who use hormone replacement therapy (HRT) have
reductions in the incidence of heart disease?
Strengths: Inexpensive and quick study of (several) risk factors; useful in
studying infrequent events or when populations would have to be tracked for
long periods of time (e.g., development of cancer); and useful for generating
odds ratio (OR)
Weaknesses: Do not indicate the absolute risk of factor in question; suffer
from confounders since it can be difficult to separate the “chooser” from the
“choice” (e.g., those who wear bike helmets vs. those who choose not to wear
bike helmets); and do not show cause and effect; recall bias
Cohort Study
Defined: Form of longitudinal study comparing a group of people who share a

common characteristic or experience within a defined period with another
group. Importantly, cohort identified before appearance of the disease or
condition under investigation
Examples: Framingham Heart Study and Nurses’ Health Study
Strengths: Longitudinal observations over time; collection of data at regular
intervals; reduced recall error; considered gold standard in observational
epidemiology; and useful for generating relative risk (RR)
Weaknesses: Expensive to conduct, sensitive to attrition, and requires lengthy
follow-up time to generate useful data
Randomized Controlled Trial (RCT)
Defined: Random allocation of different interventions to subjects

Example: Comparison of a standard drug therapy with a new experimental
medication regimen; comparison of a new drug with placebo group
Strengths: Consistent selection of subjects and randomization removes most
forms of bias
Flash Card A1 Weaknesses: Expensive; attrition to or loss of follow-up occurs; and treated
Cohort and RCT individuals may not be fully compliant with treatment
RESEARCH PRINCIPLES / 185
DATA ANALYSIS AND BIOSTATISTICS
Types of Data
Variable Defined—When the variable is defined, three main types of categorical
data are collected: nominal, ordinal, and interval. Table 6-1 provides a summary
of these types of categorical data.
Parametric statistical tests are used if the dependent variable is reasonably

symmetric or of normal distribution (i.e., not skewed) or if variances of the group
seem close. Table 6-2 provides a summary of parametric statistical tests and
analogous nonparametric tests.
Table 6-1. Three Main Types of Categorical Data
Nominal Ordinal (Ranked) Interval
Data in the form of Measures of physical Differences between the

frequencies fitting discrete, quantities that can be ranked values correspond to real
distinct categories differences between the
physical quantities that the
scale measures
Example: Race; gender; Example: Small, medium, Example: Differences in
counting a class, where large; responses on a Likert height correspond to actual
each individual is either a scale physical differences
male or a female, and they
cannot be ranked
numerically by this data
Table 6-2. Parametric Statistical Tests and Analogous Nonparametric

Parametric Tests Analogous Nonparametric Tests
Student’s t-test Wilcoxon rank-sum test
Analysis of variance (ANOVA) Kruskal-Wallis test
Paired t-test Wilcoxon signed-rank test (or sign test)
Least square correlation Spearman rank-order correlation

186 / CHAPTER 6
Error and Power

Type I Error—Occurs when the null hypothesis is falsely rejected. A p value
indicates the chance that an error is made by accepting the difference between
treatments when, in reality, there was no true difference.
Example: The null hypothesis states no difference exists between the
response to drug A and the response to drug B.
o Drug A increased (forced expiratory volume in 1 second) (FEV1) by 0.41
L
o Drug B increased FEV1 by 0.05 L
o p < 0.05
Conclusion: Drug A is “significantly” better than drug B, p <0.05. This
means that there is less than a 5% chance that no difference exists between
drug A and drug B. The risk of type I error is less than 5%.
Type II Error—Occurs when the null hypothesis when the null hypothesis is not
rejected when it is false. In other words, the study fails to find a true difference
when one is actually present. A common reason for a type II error is that the
sample size is too small.
Example: The null hypothesis states that there is no difference between the
response to drug A and drug B.
o Drug A increased FEV1 by 0.26 L
o Drug B increased FEV1 by 0.09 L
o p = 0.25
Conclusion: Drug A is “not significantly” better than drug B.
Statistical Power—The percentage chance that a difference will be detected if a

difference does exist.
Calculation: 1 minus the probability of a type II error. For example, if the
probability of a type II error in a study is 5%, the statistical power of the study
is 95%.
Probability
Normal Distribution—Produces a bell-shaped curve, where 68% of observations
are within one standard deviation (1 SD), and 95% of observations are within 2
SD. Thus, 2.5% of observations are greater than 2 SD above the 95% level, and
2.5% are less than the 95% level. These two populations of 2.5% of observations
represent the “two tails” of the bell-shaped curve.
p Values—Express the probability of rejecting the null hypothesis due to chance,

when the null hypothesis is true (type I error).
Example: If p = 0.05, there is a 5% chance that the observed results are due to
chance alone.
Odds Ratio—The probability of occurrence of an event over the probability of

nonoccurrence. For example, OR = odds that a case was exposed / odds that a
control was exposed. Here, however, the term odds can be defined differently,
according to the situation.
Relative Risk—The ratio of the risk of disease (or death) among people who are
exposed to the risk factor compared with the risk among people who are not
exposed. Alternatively, relative risk can be defined as the ratio of the cumulative
incidence rate among those exposed compared with the rate among those not
exposed. In either case, the term relative risk is synonymous with risk ratio.
Prevalence—The percentage of the population with existing disease (at one time
point or during one time period) and, as such, is a measure of present disease
(prevalence = present).
Incidence—The number of new disease cases in the population over an interval

of observation (incidence = new).
Sensitivity—The fraction of all true cases the test detects (i.e., among those who
have the disease, it refers to how many test positive).
Defined as true-positive tests or number with disease
Sensitivity is associated with the false-negative rate of a test; and, therefore,
can be used to rule out disease. For tests with a low false-negative rate, a
negative result rules out disease. (Recall tip: SNout.)
Calculation: Sensitivity = true positive / (true positive + false negative) or
a/(a +c)
Specificity—The fraction of all negative cases the test detects (i.e., among those
who do not have the disease, it refers to how many test negative).
Defined as true-negative tests / number without the disease
Tests with high specificity are associated with a low number of false positives
and can be used to rule in disease. (Recall tip: SPin.)
Calculation: Specificity = true negative / (false positive + true negative) or
d/(b + d)
Flash Card Q2
What type of error
Positive Predictive Value (PPV)—Describes the probability that a positive test
occurs when the null
indicates disease. hypothesis is falsely
rejected?
188 / CHAPTER 6
Calculation: PPV = True positive / (true positive + false positive) or a/(a + b)

PPV determines how many actually have the disease from among those who
test positive. This information is found on the first row of a 2 × 2 table (Table
6-3).
Negative Predictive Value (NPV) —Describes the probability that a negative test
indicates no disease
Calculation: NPV = True negative / (true negative + false negative) or c/(c +
d).
Values for NPV calculation are found on the second row of a 2 × 2 table
(Table 6-3).
Example: A new allergy test finds that, in patients with the disease, 80 are
positive (true positives), whereas 5 without the disease tested positive (false
positives). Of those testing negative, 95 do not have the disease (true
negatives); but 20 that had the disease tested negative (false negatives). Table
6-4 shows details of the constructed 2 × 2 table in this scenario.
Table 6-3. Mechanics of a 2 × 2 Table

Disease Status
Positive (+) Negative (–)
Test Positive (+) True positive (a) False positive (b)
Result Negative (–) False negative (c) True negative (d)
Flash Card A2
Type I error
Table 6-4. Example With Detailed Calculations for Mechanics of a 2 × 2

Disease Status
Positive (+) Negative (–)
Positive (+) 80 5 85
Test
Negative (–) 20 95 115
result
100 100
Sensitivity = a/(a + c) = 80/100 = 80%
Specificity = d/(b + d) = 95/100 = 95%
PPV = a/(a + b) = 80/85 = 94%
NPV = d/(c + d) = 95/115 = 82.6%
Additional formulas:
Odds ratio = a × d / b × c
This measure is used for case control studies because persons are selected based on
disease status so one cannot calculate the risk of getting disease.
Relative risk = Incidence rate among exposed = a/(a + b)

Incidence rate among unexposed c/(c + d)
Where:
1 = No association between exposure and disease
>1 = Positive association, and
<1 = Negative association or protective effect
Absolute risk (AR) = number of events in treated or control groups
number of people in that group
ARC = the AR of events in the control group
ART = the AR of events in the treatment group
Absolute risk reduction (ARR) = ARC – ART
Relative risk (RR) = ART/ARC
Relative risk reduction (RRR) = (ARC – ART)/ARC
RRR = 1 – RR
Number needed to treat (NNT) = 1/ARR
EPIDEMIOLOGY
Validity
The validity of a study is dependent on the degree of the systematic error. Validity
is usually separated into two components:
Internal validity is dependent on the amount of error in measurements,
including exposure, disease, and the associations between these variables.
High internal validity implies a lack of error in measurement and suggests that
inferences may be drawn at least as they pertain to the subjects under study.
External validity pertains to the process of generalizing the findings of the
study to the population from which the sample was drawn (or, even beyond
190 / CHAPTER 6
that population, to a more universal statement). Internal validity is a

prerequisite for external validity.
Bias is any deviation of results or inferences that results in an erroneous estimate

of effect of an exposure on the risk of disease. This can be due to flaws in study
design, conduct, or analysis of the study. Examples of bias include selection bias
or information bias (e.g., recall bias, surveillance bias, misclassification bias, wish
bias).
Precision in epidemiologic variables is a measure of random error. Precision is

also inversely related to random error, such that a reduction in random error
increases precision. Confidence intervals are computed to demonstrate the
precision of relative risk estimates. The narrower the confidence interval, the
more precise the relative risk estimate.
Clinical Evidence
Evidence classes are used to stratify evidence by quality, such as this one by the
US Preventive Services Task Force (USPSTF) for ranking evidence about the
effectiveness of treatments or screening:
Level I: Evidence obtained from at least one properly designed randomized
controlled trial
Level II-1: Evidence obtained from well-designed controlled trials without
randomization
Level II-2: Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research group
Level II-3: Evidence obtained from multiple time series with or without the
intervention. Dramatic results in uncontrolled trials might also be regarded as
this type of evidence
Level III: Opinions of respected authorities, based on clinical experience,
descriptive studies, or reports of expert committees
Recommendations for a clinical service are classified by the balance of risk

versus the benefit of the service and the level of evidence on which this
information is based. The USPSTF uses the following recommendations:
Level A: Good scientific evidence suggests that the benefits of the clinical
service substantially outweigh the potential risks. Clinicians should discuss
the service with eligible patients.
Level B: At least fair scientific evidence suggests that the benefits of the
clinical intervention outweigh the potential risks. Clinicians should discuss the
treatment with eligible patients.
Level C: At least fair scientific evidence suggests that the clinical treatment
does provide benefits, but the balance between benefits and risks are too close
for making general recommendations. Clinicians need not offer it unless there
are individual considerations.
Level D: At least fair scientific evidence suggests that the risks of the clinical
intervention outweigh the potential benefits. Clinicians should not routinely
offer the treatment to asymptomatic patients.
Level I: Scientific evidence is lacking; it is of poor quality, or conflicting,
such that the risk versus the benefit balance cannot be assessed. Clinicians
should help patients understand the uncertainty surrounding the clinical
treatment.
INFORMED CONSENT
The Belmont Report was issued in 1979. It explains the unifying ethical
principles that form the basis for the National Commission’s topic-specific reports
and the regulations that incorporate its recommendations.
The three fundamental ethical principles for using any human subjects for
research are:
Respect for persons: Protecting the autonomy of all people and treating them
with courtesy and respect, and allowing for informed consent
Beneficence: Maximizing the benefits for the research project while
minimizing the risks to the research subjects
Justice: Ensuring that reasonable, nonexploitative, and well-considered
procedures are administered fairly (e.g., the fair distribution of costs and
benefits to potential research participants)
These principles remain the basis for the Health and Human Service’s (HHS)
human subject protection regulations.
Elements of informed consent include: (1) competence; (2) disclosure; (3)

understanding; (4) voluntariness; and (5) consent. In addition, the patient should Flash Card Q3
have an opportunity to ask questions to elicit a better understanding of the Name the three
treatment or procedure. This communication process (or any variation thereof) is fundamental ethical
both an ethical obligation and a legal requirement as spelled out in statutes and principles of human
case law in all 50 states. research?
192 / CHAPTER 6
If a patient is competent to act, receives thorough disclosure, has an understanding,

and is voluntary in his or her consent, then informed consent is viable. For
informed consent to be legally recognized in medical practice, the following steps
need to be clearly articulated:
Preconditions: These include competence (to understand and decide) and
voluntariness (in deciding).
Information elements: These include disclosure (of risks/benefits),
recommendation (plan), and understanding (of information and plan).
Consent elements: These include authorization (based on patient autonomy).
ADVERSE EVENT REPORTING
The Adverse Event Reporting System (AERS) is a computerized information

database designed to support the Food and Drug Administration’s (FDA)
postmarketing safety surveillance program for all approved drug and therapeutic
biologic products. The FDA uses AERS to monitor for new adverse events and
medication errors that might occur with these marketed products.
Reporting of adverse events from the point of care is voluntary in the United
States. The FDA receives some adverse event and medication error reports
directly from health care professionals and consumers. Health care professionals
and consumers may also report these events to the products’ manufacturers. If a
manufacturer receives an adverse event report, it is required to send the report to
the FDA as specified by regulations. However, AERS data do have limitations:
There is no certainty that the reported event was actually due to the product.
(The FDA does not require that a causal relationship between a product and
event be proven.)
The FDA does not receive all adverse event reports that occur with a product.
Therefore, AERS cannot be used to calculate the incidence of an adverse
event in the US population.
Mandatory reporting is required for the following areas:

Over-the-counter products and dietary supplements
Drug, biologic, or human cell tissues, and cellular and tissue-based product
manufacturers, distributors, and packers
Flash Card A3
Adverse reactions (ARs) relating to human cell and tissue products (HCT/P)
Respect for persons,
beneficence, and justice
Section 2. Clinical Science
7 Hypersensitivity Disorders
RHINITIS
The nose knows that not all that sneezes are allergic. The nose also knows that
this is too routine a topic and far too “bread and butter” to be high yield for the
boards.
ALLERGIC RHINITIS (AR)
Epidemiology
Prevalence 15–25%
Uncommon in patients younger than 2 years old (especially rare for seasonal
AR younger than 2 years old)
Most common chronic disease of childhood. Male predominance in childhood
with no gender disparity by adulthood
Mean age of onset is 10 years
80% of cases develop before 20 years of age
20% of AR is seasonal, 40% is perennial, and 40% is mixed (i.e., perennial
with seasonal exacerbation)
About half of chronic rhinitis allergic in nature
Risk Factors
Although the prevalence is generally increasing, this trend varies markedly from
country to country by up to 10-fold. Generally, industrialized countries are
showing a more pronounced increase; however, even this trend varies among
countries.
194 / CHAPTER 7
The prevalence rate is increasing at a faster pace in younger age groups than in
adults.
Decreased exposure to infections in childhood (i.e., the hygiene hypothesis) is one

posited mechanism of the increase. This is broadly supported by data showing a
decrease in the risk of allergen sensitization and clinical allergy with:
The protective effect of the number of siblings
A rural upbringing, with exposure to farmyard animals early in life (with
higher endotoxin),
Day care attendance
Large family size
Exposure to household pets
Morbidity
As shown in the 2010 National Allergy Survey Assessing Limitations study,
significant differences between those with AR and the general population include:
Those with AR rate their health significantly lower
Significant effect on sleep: Difficulty getting to sleep and/or waking up during
the night
Significant effect on daily life for more than 50% of patients with AR
More of a limitation with work, with an estimated 20% decrease in
productivity
Pathophysiology
AR is usually due to aeroallergen sensitivity to dust mites, pets, pollens, mold,
and cockroaches. Allergens cross-link the allergen-specific IgE receptor (FcεRI)
on previously sensitized mast cells, which leads to degranulation. More recent
evidence suggests that IgE may be made in nasal tissues and upper airway
lymphatics even in the absence of systemic production.
Immediate Allergic Response—Occurs within 15 minutes. Mast cells release

preformed mediators: histamine, proteases such as tryptase, and kinins such as
kallidin and bradykinin. Mast cells also release newly formed mediators:
prostaglandin-2 (PGD2) and leukotrienes (LT) LTC4, LTD4, and LTE4.
Acute symptoms are influenced by specific mediators:

Histamine: Itch, sneeze, rhinorrhea
PGD2: Nasal congestion
Leukotrienes: Nasal congestion
Kinins: Nasal congestion and/or blockage
HYPERSENSITIVITY DISORDERS / 195
Late Allergic Response—Begins within 4–8 hours and can last for more than 24
hours. Cellular infiltrates occur with basophils, eosinophils, and infiltrating
lymphocytes, especially Th2 CD4 T lymphocytes. Since the mast cell is less
important, there is no increase in tryptase. Th2 cells release cytokines, such as IL-
3 and IL-5 (eosinophil factors), as well as IL-4 and IL-13 (IgE class switch).
Nasal mucosal epithelial cells have been shown to generate granulocyte
monocyte colony-stimulating factor (GM-CSF, an eosinophil growth factor) and
stem cell factor (i.e., mast cell growth factor), as well as eotaxin and regulated on
activation, normal T expressed and secreted (RANTES, also known as chemokine
(C-C motif) ligand 5, or CCL5). Predominant symptoms include nasal congestion
and mucus production.
Nasal hyperresponsiveness to both allergic and nonallergic triggers may be

observed. AR is a risk factor for asthma, and most asthmatics (80%) have AR. AR
may be associated with lower airway abnormalities, such as basement membrane
Key Fact
thickening, even in the absence of asthma.
30–50% of patients with
chronic rhinitis have
Exhaled nitric oxide (eNO) is a sensitive marker of inflammation that is increased
nonallergic triggers
in AR and decreased in sinusitis.
Priming is the effect by which progressively lower doses of allergen are needed
to trigger subsequent symptoms, perhaps due to the recruitment of inflammatory
cells such as eosinophils and mast cells that cause progressive inflammation and
increased mucosal sensitivity. Clinically, residence in a geographic location is
required for at least 1 year, and usually longer for sensitization to take place.
Signs and Symptoms

Classically, symptoms of AR include rhinorrhea, nasal pruritus, nasal congestion,
and sneezing.
Signs of AR include:
Allergic shiners
The “allergic crease”
Dennie-Morgan lines (linear creases or furrows underneath the lower eyelids)
Pale nasal mucosa
Turbinate hypertrophy
Mouth breathing
Cobblestoning of the oropharynx
Common comorbid conditions are allergic conjunctivitis, rhinosinusitis, asthma Flash Card Q1
(up to 40% of AR patients have asthma) and pharyngeal lymphoid hyperplasia What symptom is
with resultant obstructive sleep apnea (OSA) and disordered sleep. particularly prominent in
the late-phase response
of allergic rhinitis?
196 / CHAPTER 7
Diagnosis
Diagnosis of AR requires skin testing (prick or intradermal) or serum-specific IgE
in the appropriate clinical context. Although both methods generally have good
agreement, skin tests are more sensitive but less specific than in vitro allergen-
specific IgE tests. History has a reasonable positive predictive value (PPV) of
about 70% in patients with symptoms.
Less useful clinically is the seasonal-versus-perennial distinction. AR may be

classified based on symptom severity (i.e., mild, moderate, or severe) and
frequency (i.e., intermittent vs. persistent) as defined by allergic rhinitis and its
impact on asthma (ARIA) guidelines.
Treatment
Treatment of choice is allergen avoidance, but this is not always practical (i.e.,
pollen allergy). Intranasal steroids are the most effective medication for AR
and, therefore, the medication of choice. They work by causing
vasoconstriction, reducing mucosal edema, and inhibiting the expression of
cytokines and mediators. First-generation antihistamines are also effective but
limited by side effects due to their relative lack of selectivity for the histamine
(H1) receptor and their ability to cross the blood-brain barrier. Nonsedating
(second-generation) oral antihistamines are also effective but have fewer side
effects as they are more selective for peripheral H1 receptors. They are often used
in combination with intranasal steroids despite the fact that the addition of an oral
antihistamine to daily intranasal steroid therapy has not clearly demonstrated any
added efficacy in controlled clinical trials. Additional medications may include:
Nasal antihistamines
Antileukotriene therapy
Oral and intranasal decongestants (short-term use only)
Cromoglycolates
Allergen immunotherapy
The best treatment for patients with inadequately controlled AR, who have failed
avoidance and standard medications, is allergen immunotherapy. Allergen
immunotherapy improves AR symptoms, decreases the risk of developing new
sensitizations, and helps decrease the risk of developing asthma in children.
Flash Card A1
Nasal congestion
NONALLERGIC RHINITIS
Table 7-1 provides a summary of differential diagnosis of nonallergic rhinitis.
Table 7-1. Summary of Differential Diagnosis of Nonallergic Rhinitis

Type of Rhinitis Associations
a
NARES Eosinophilia on nasal smear
Vasomotor Irritant, gustatory, cold- or temperature-induced
Medications ASA, NSAIDs, topical decongestants, antagonists, β blockers, other
antihypertensives
Hormonal OCPs, pregnancy, menstrual associations, hypothyroidism
Atrophic Elderly
Infectious Common cold viruses
Occupational Flour (bakers), latex (health care workers), pet dander (animal handlers)
Miscellaneous Anatomic, tumor, systemic disease, CSF rhinorrhea
a
NARES: Nonallergic rhinitis with eosinophilic syndrome.
ASA, aspirin; CSF, cerebrospinal fluid; NSAIDs, nonsteroidal anti-inflammatory drugs; OCPs, oral
contraceptive pills.
Vasomotor or Irritant Rhinitis

Vasomotor or irritant rhinitis indicates noninflammatory nasal hyper-
responsiveness with sympathetic and parasympathetic nerve imbalance. Common
triggers are:
Cold air
Dry air
Barometric pressure or temperature shifts
Strong scents (i.e., tobacco, perfume, or cleaning materials)
Other respiratory irritants
Rhinorrhea may be the only presenting symptom. Treatment usually consists of

intranasal antihistamines such as azelastine. Gustatory rhinitis, a common
subtype of vasomotor or irritant rhinitis, is triggered by eating, possibly by
stimulation of vagal (parasympathetic) innervation. A common treatment option is
an anticholinergic medication—intranasal ipratropium.
Nonallergic Rhinitis with Eosinophilia Flash Card Q2

Intranasal
Nonallergic rhinitis with eosinophilia syndrome (NARES) is a poorly understood
corticosteroids block
condition with typical symptoms of AR and documented eosinophilia on nasal which phase(s) of the
smear cytology in the absence of increased total or specific IgE. It typically allergic response?
198 / CHAPTER 7
occurs in middle-aged adults. These patients are prone to nasal polyps, and this
condition may represent a prodrome to aspirin-exacerbated respiratory disease
(AERD). NARES responds well to intranasal corticosteroids.
Atrophic Rhinitis
Atrophic rhinitis is a noninflammatory condition associated with loss of the
normal secretory/humidifying function of the nose. It occurs more frequently in
young to middle-aged patients, especially females at onset of puberty. The
primary (idiopathic) form is more predominant in developing countries with a
warm climate and is generally associated with microbial colonization (e.g.,
Klebsiella ozaenae). Secondary causes are frequent in the developed world and
occur in those with a history extensive nasal and sinus surgeries, chronic
granulomatous nasal infection, or irradiation). Symptoms of atrophic rhinitis
include:
Nasal congestion
Nasal pain upon inspiration from excess mucosal dryness
Nasal crusting
A foul smell in the nasal vault (fetor)
Treatment may include nasal saline irrigation and topical antibiotics.
Medication-Induced Rhinitis
Some common medications and drugs that can cause medication-induced rhinitis
include:
ASA and NSAIDs (as a feature of AERD)
β blockers and various other antihypertensive medications
Rhinitis medicamentosa: Prolonged use of intranasal decongestants (rebound
congestion)
Angiotensin-converting enzyme (ACE) inhibitors
Key Fact OCPs
Intranasal Sildenafil
corticosteroids are Intranasal cocaine or methamphetamine.
ineffective in rhinitis of
pregnancy.
Hormone-Induced Rhinitis
Rhinitis may occur due to fluctuations in estrogen or progesterone and may thus
Flash Card A2 occur perimenstrually or during OCP use, puberty, or pregnancy. Hormone-
They block both the
induced rhinitis may be associated with hypothyroidism. Any of the causes of
early- and late-phase rhinitis may occur during pregnancy. True pregnancy-induced rhinitis occurs in 1
responses
in 5 pregnant patients, is not present prior to pregnancy, does not present before
the second trimester, and usually resolves within 2 weeks postpartum.
Infectious Rhinitis
This is the most common cause of pediatric nonallergic rhinitis. It is distinguished
from AR by a lack of pruritus and limited duration. More than 200 different
viruses may cause infectious rhinitis, but common culprits are:
Rhinovirus
Parainfluenza
Adenovirus
Coronavirus
Influenza virus
Miscellaneous Rhinitis
Common miscellaneous causes include:
Rhinitis triggered by emotion
Occupational rhinitis
Anatomic or mechanical factors (e.g., foreign body or septal deviation)
Systemic disease (e.g., Wegener’s granulomatosis)
Tumor (e.g., nasopharyngeal carcinoma)
Diseases of ciliary dysfunction
Persistent unexplained rhinorrhea, particularly with a history of trauma and/or if

unilateral, should trigger a search for CSF rhinorrhea (e.g., check β2-transferrin).
SINUSITIS
Flash Card Q3
What is the most
ACUTE RHINOSINUSITIS common cause of
rhinitis during
pregnancy?
Acute rhinosinusitis (ARS) is defined as inflammation of the mucosal lining of

the nasal and sinus cavities lasting up to 4 weeks. (Subacute rhinosinusitis: >4
weeks, chronic rhinosinusitis: >8–12 weeks).
Flash Card Q4
Why can nasal
congestion or rhinorrhea
develop in
hypothyroidism?
200 / CHAPTER 7
Epidemiology
Rhinitis and sinusitis usually coexist in most patients as the nasal mucosa is
connected to that of the paranasal sinuses, hence the term rhinosinusitis.
Annually, nearly 1 in 7 adults older than 18 years are diagnosed with
rhinosinusitis; adults between 45–75 years old are most commonly affected.
Incidence is higher in females.
Pathogenesis
The vast majority of ARS cases are viral (>90%), including:
Rhinovirus
Coronavirus
Influenza virus
Parainfluenza
Respiratory syncytial virus (RSV)
Adenovirus
Enterovirus and others
Anatomic obstruction is the usual inciting event (e.g., blocked ostiomeatal

complex). For bacterial sinusitis, the most common pathogens are the same that
cause otitis media: Streptococcus pneumoniae, Moraxella catarrhalis, and
Haemophilus influenzae. Less frequent but also common etiologies include
group A strep, Staphylococcus aureus, and anaerobes. Resistant strains of S.
pneumoniae occur due to altered penicillin-binding proteins which can be
compensated for by increasing the dose of amoxicillin. Up to 50% of H.
influenzae is β-lactamase-positive, as is nearly 100% of M. catarrhalis; therefore
the addition of a β-lactamase inhibitor is useful.
Flash Card A3 Predisposing factors of ARS include:

Pre-existing allergic Allergy
rhinitis: About 1/3 of Nasal polyps
females with AR Anatomic variations (e.g., nasal septal deviation)
experience symptom
exacerbation during Preceding upper respiratory infection (URI)
gestation. Conditions that impair mucociliary clearance (e.g., cystic fibrosis [CF] or
smoke exposure)
Immunodeficiency
Flash Card A4
Release of thyroid-
stimulating hormone
(TSH) results in
increased edema in the
turbinates
Signs and Symptoms

There are both major and minor symptoms for rhinosinusitis.
Major symptoms include:

Purulent anterior or posterior (postnasal drip) rhinorrhea
Nasal congestion and/or obstruction
Facial congestion and/or “fullness”
Facial pain/ pressure
Fever
Hyposmia and/or anosmia
Minor symptoms include:

Headache
Ear pain and/or pressure and/or fullness
Bad breath
Dental pain
Fatigue
Cough
Diagnosis for ARS requires at least 2 major symptoms or 1 major and at least 2
minor symptoms.
Differential Diagnosis
It can be difficult to distinguish acute bacterial rhinosinusitis (ABRS) from viral
rhinosinusitis. The following clinical scenarios best identify patients with ABRS:
Persistent signs/symptoms compatible with ARS for more than 10 days, no
sign of clinical improvement
Severe signs/symptoms (fever >102oF) and either purulent rhinorrhea or facial
pain lasting for at least 3–4 consecutive days (at start of illness)
URI symptoms for 5–6 days followed by worsening signs/symptoms (new
fever onset, headache or increase in rhinorrhea)—this is known as “double
sickening.”
Work-up
During uncomplicated URI, patients may have significant radiographic
abnormalities; the presence of these positive findings can’t confirm the presence
of rhinosinusitis. CT scans should be performed in ABRS with suspected
suppurative complications. Recurrent ARS or sinusitis with complications Flash Card Q5
warrants a search for predisposing conditions (e.g., allergy, anatomic abnormality, Gravity cannot drain
or immunodeficiency). Cases refractory to standard treatment may warrant ENT which sinus?
202 / CHAPTER 7
consultation for culture of the organism via direct sinus aspiration (recommended)
or endoscopically guided cultures of middle meatus (adults only). Note: A nasal
swab culture is unreliable for diagnosis of ABRS.
Treatment
Most cases of ARS (viral) may be treated supportively and with reassurance.
Empiric treatment should be started as soon as ABRS has been diagnosed (refer to
the three earlier scenarios). Children should be treated for 10–14 days, whereas
adults can be treated for 5–7 days.
The initial antibiotic treatment of choice for children and adults with ABRS is
amoxicillin-clavulanate, rather than amoxicillin alone. High-dose amoxicillin-
clavulanate should be given to patients living in areas with high endemic rates of
invasive resistant S. pneumoniae, fever >102oF, threat of suppurative
complications, participating in day care, younger than 2 years or older than 65
years of age, recently hospitalized, treated with antibiotics in preceding month, or
those who are immunocompromised.
Penicillin (PCN)-allergic adults may be treated with a fluoroquinolone or

doxycycline. Children with a history of type I reaction to PCN may be treated
with levofloxacin, and children with other types of allergic reactions to PCN can
be treated with clindamycin in combination with a third-generation cephalosporin.
Levofloxacin is not licensed by the FDA for routine use in children.
Empiric therapy with macrolides or trimethoprim-sulfamethoxyzole (TMP-SMX)

is not recommended due to high resistance rates. Coverage should be broadened
in those who do not improve or worsen after 3–5 days.
RECURRENT SINUSITIS
Recurrent sinusitis is defined as repeated (typically >4 episodes in 1 year)

occurrences of acute sinusitis. Patients with chronic or recurrent sinusitis should
be evaluated for underlying inflammation, allergy, immunodeficiency, and
anatomic abnormalities. The majority of immunodeficient patients with recurrent
sinusitis have defects in humoral immunity. However, other types of
immunodeficiencies might present with recurrent sinusitis as one of their clinical
Flash Card A5 features, including AIDS.
Because of the position
of the maxillary ostia,
gravity cannot drain the
contents of the maxillary
sinus when the head is
upright.
CHRONIC RHINOSINUSITIS
Chronic rhinosinusitis (CRS) is an inflammatory (rather than infectious) condition

that is defined by radiographic evidence of sinusitis with symptoms persisting >8–
12 weeks. The presence of >2 symptoms (i.e., nasal obstruction/congestion, facial
pain/pressure/fullness, purulent anterior/posterior rhinorrhea, hyponosmia
/anosmia) for >12 weeks in conjunction with documented inflammation (i.e.,
purulence or edema in middle meatus or ethmoid region, polyps in middle meatus
or nasal passages, and/or imaging documenting paranasal sinus inflammation) is
highly sensitive for diagnosing CRS. There is less evidence to support the use of
antibiotics in CRS than in ABRS because microorganisms (typically anaerobes)
are thought to be secondary to the inflammatory mechanisms causing CRS or
suggestive of colonization only. However, acute exacerbations of CRS are
commonly treated with antibiotics.
The differential diagnosis of CRS is similar to that of AR and includes:
Infectious rhinitis
AR
Nonallergic rhinitis (e.g., vasomotor, eosinophilic, etc.)
AERD
Rhinitis medicamentosa
Anatomic abnormalities (e.g., nasal septum deformity)
Tumors (e.g., inverted papillomas)
Granulomatosis with polyangiitis (Wegener’s)
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
Asthma
Fungal sinus disease
Nonrhinogenic causes of facial pain (e.g., migraine, trigeminal neuralgia,
etc.)
Flash Card Q6
Which inflammatory
Work-up mediators are elevated
in ARS?
Work-up for CRS is likely to include sinus imaging (i.e., CT scan), allergy
testing, and rhinoscopy in refractory or persistent cases. Depending on the clinical
context, work-up may also include:
Quantitative immunoglobulins, pneumococcal titers Flash Card Q7
Ciliary function tests Which of the following is
a risk factor for the
Sweat test (to rule out cystic fibrosis, CF)
development of sinusitis:
HIV testing concha bullosa or Haller
Sinus puncture with cultures. cell?
204 / CHAPTER 7
Treatment
Treatment for CRS may include:
Antibiotics for acute exacerbations
Treatment of underlying or exacerbating conditions (e.g., AR, gastroesopha-
geal reflux disease [GERD], AERD, CF)
Topical nasal steroids or short courses of systemic steroids
Surgical consultation (e.g., for functional endoscopic sinus surgery [FESS]).
Surgery is indicated in sinusitis with complications or in cases of medical

treatment failure. Note: Antifungals are indicated in invasive fungal disease
(usually only seen in diabetics or immunodeficient patients).
Complications of Sinusitis
Complications of sinusitis are rare in general. However, these are seen in greater
frequency with sphenoid and frontal sinusitis, which include:
Orbital cellulitis
Subperiosteal abscess
Cavernous sinus thrombosis
Meningitis
Subdural or epidural brain abscess
Osteomyelitis
Mucocele
CRS with Nasal Polyps

CRS with nasal polyps (NPs), also known as hyperplastic eosinophilic sinusitis,
Flash Card A6 represents about one third of CRS cases. Polyps most commonly arise from the
ethmoid sinuses. Compared with CRS without NPs, CRS with NPs has an
IL-1 , IL-6, and increased incidence of:
especially IL-8
Anosmia
Dust mite sensitization
Eosinophils on biopsy
Flash Card A7 Asthma
Haller cell—a AERD
pneumatized ethmoid Allergic fungal rhinosinusitis (AFRS)
cell that blocks the
ostiomeatal complex.
CRS with NPs is not usually associated with bacterial causes, except in cases of
Concha bullosa, an
aerated middle local production of staphylococcal enterotoxins in NPs, which may increase local
turbinate, is not a risk IgE production and eosinophilic inflammation via Th2 skewing.
factor.
Both CRS with and without NPs have significant nasal obstruction/congestion and
rhinorrhea. In CRS without NPs there is a higher rate of facial pain. Patient with
CRS with NPs tend to have more problems with hyponosmia/anosmia, whereas
these is rare in CRS without NPs.
Nasal steroids or short courses of systemic steroids are of clear benefit, and
surgery may be indicated for treatment failures.
CRS Without Nasal Polyps
A summary of inflammatory mediators in CRS with and without NPs is given in

Table 7-2.
Table 7-2. Summary of Inflammatory Mediators in CRS with and Without

Nasal Polyps
CRS Without NP CRS with NP
IL-3 ↑↑ –
GM-CSF ↑ –
Eosinophil cationic protein ↑ ↑↑
IL-5 – ↑↑
IgE – ↑↑
Eotaxin – ↑↑
LTC4/D4/E4 ↑ ↑↑
LTB4 ↑ ↑
PGE2 ↑↑ ↓
Lipoxin A4 ↑ ↑↑
Ig, immunoglobulin; IL, interleukin; LT, leukotriene; PG, prostaglandin.
206 / CHAPTER 7
OTITIS MEDIA
ACUTE OTITIS MEDIA
Epidemiology and Risk Factors

Acute otitis media (AOM) typically follows URI. Peak incidence occurs in
children 6–18 months old. Risk factors include:
Key Fact Male gender
Children younger than 3 Day care attendance or older sibling in home
years of age are at Low socioeconomic status
increased risk for AOM
because of a lack of Bottle propping (i.e., feeding while supine)
pneumococcal Passive smoke exposure
antibodies and the Craniofacial abnormalities such as cleft lip or palate
horizontal position of the
Factors affecting immunity (e.g., immunodeficiency, prematurity, altered host
eustachian tube
interferes with drainage. defenses such as allergic rhinitis or age younger than 3 years)
Recurrent AOM is defined as >3 episodes within 6 months or >4 episodes within
1 year with at least 1 episode in the past 6 months. A blocked eustachian tube,
which drains from the middle ear into the nasopharynx, causes an effusion; and,
when the effusion becomes infected, AOM results. Sixty percent to 80% of
children have an episode by the age of 1 year, and 80–90% have at least one
episode by age 2–3 years. Breast feeding is protective.
Key Fact
Microbiology
Conjunctivitis with otitis AOM is 50–90% bacterial in different series. The microorganisms most
(otitis-conjunctivitis) is
more likely caused by
commonly involved are the same as those for acute sinusitis: Streptococcus
nontypeable H. pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.
influenzae and suggests Traditionally, S. pneumoniae was more common. Since the introduction of
that a broader-spectrum pneumococcal vaccination, S. pneumoniae = H. influenzae, and M. catarrhalis is
antibiotic like amoxicillin- third. In neonates, otitis may be caused by group B Strep. Viral causes can
clavulanate may be
indicated.
typically occur secondarily to RSV or rhinovirus.
Signs and Symptoms

Signs of AOM include:
Fever
Fussiness
Tugging at ear
Otalgia
The physician should assess for bulging of the tympanic membrane (TM),
quintessential sign distinguishing AOM from OM with effusion, decreased TM
mobility on pneumatic otoscopy, or intense TM erythema. AOM can be
diagnosed in children who present with:
Moderate to severe bulging of the TM or new onset of otorrhea not due to
acute otitis externa
Mild bulging of TM and recent (<48 hours) onset of ear pain (holding,
tugging, rubbing of ear in the nonverbal child) or intense erythema of the TM
Treatment
Table 7-3 shows treatment guidelines for AOM.
Table 7-3. Criteria for Therapy

Age Presentation Decision
<6 months of age Unilateral or bilateral Treat × 10 days
involvement with severe
signs/symptoms:
Moderate-to-severe otalgia
Otalgia for at least 48 hr
o
Fever >102.2 F)
6–23 months of age Bilateral involvement without Treat × 10 days
severe signs/symptoms:
Mild otalgia for < 48 hr
o
Temperature <102.2 F
6–23 months of age Unilateral involvement without Joint decision making with
severe signs/symptoms parent(s)/caregiver regarding:
Treatment × 10 days or
Observation with close
follow-up
>24 months of age Unilateral or bilateral Joint decision making with
involvement without severe parent(s)/caregiver regarding:
signs/symptoms Treat (2–5 years: 7 days;
>6 years 5–7 days) or
Observation with close
follow-up
208 / CHAPTER 7
If a patient has not received amoxicillin in the past 30 days or does not have
concurrent purulent conjunctivitis, then high-dose amoxicillin can be prescribed.
Otherwise another antibiotic with additional -lactamase coverage (e.g.,
amoxicillin/clavulanate) should be prescribed. A patient history of recurrent AOM
unresponsive to amoxicillin is also an indication to prescribe additional -
lactamase coverage. During the close follow-up period, if a patient’s symptoms
have worsened or failed to respond within 48–72 hours, reevaluation and
consideration for a different coverage is necessary. Patients with type I PCN
allergy and negative testing/challenge to cephalosporins may be treated with
cefdinir, cefuroxime, cefpodoxime, or ceftriaxone. Patients with AOM that fails
treatment with amoxicillin should be given amoxicillin-clavulanate. Amoxicillin-
clavulanate treatment failures should be treated with 3 days of ceftriaxone.
Bactrim (TMP-SMX) is not useful due to substantial resistance rates. Consider
ENT referral for tympanocentesis and culture, and possible tympanostomy tubes
in patients with refractory or recurrent AOM. Don’t forget to assess for pain and
give treatment to reduce it.
OTITIS MEDIA WITH EFFUSION
Unlike AOM, otitis media with effusion (OME) is a condition that does not
warrant antibiotic treatment, as the effusion in this case is sterile. Most
commonly, it occurs in children younger than 2 years of age, may occur in some
children from 2–6 years of age, and very rarely occurs after the age of 6. The only
symptoms may be subtly decreased hearing and the sensation of fullness in the
ear. Pneumatic otoscopy is sensitive (nearly 90%), but not as specific (50–88%),
whereas a tympanogram may be helpful for confirming uncertain cases or
documenting hearing loss (Figure 7-1). This is a common, potentially incidental
finding in children; but, a persistent effusion in adults could indicate a structural
abnormality such as a tumor. The most common cause is recent AOM with
lingering eustachian tube dysfunction. There is insufficient evidence to suggest a
causal link between atopy and OME, although there is a strong increased relative
risk of OME in atopic patients.
After AOM, the majority will have an effusion at 2 weeks, nearly 50% at 1
month, 10–25% at 3 months, and 5–10% will last 1 year or longer. OME is the
leading cause of hearing loss in children (usually conductive), and it may be
associated with language delay in children younger than 10 years of age. The
average hearing loss from OME is 25 dB (mild = 21–39 dB loss; moderate ≥ 40
dB).
Figure 7-1. Tympanograms. (A) Type A is normal and resembles a symmetrical

upside down “V”. (B) Type B is seen in effusion or perforation and appears
relatively flat. (C) Type C represents eustachian tube dysfunction and is shifted to
the left.
Treatment
Medical—Examination 3 months after onset of OME with baseline hearing test;
then serial evaluation every 3–6 months. These evaluations should continue until
the effusion resolves, hearing loss is documented, or structural changes of the TM
or middle ear are noted. Antihistamines, decongestants, antibiotics, or intranasal
steroids have no proven benefit. Identify at-risk children (i.e., those at greater risk
for developmental or language delay), who may require more aggressive
management.
Surgical—May be indicated in cases of OME with structural damage, recurrent

OME, hearing loss of 40 dB or higher, or hearing loss 21–39 dB in at-risk
children. (Note: Both thresholds apply to the better ear.) Surgery may include
myringotomy (incision of TM) with or without tympanostomy tubes,
adenoidectomy, or both. Any repeat surgery should include an adenoidectomy,
which results in improved eustachian tube drainage with less of a local nidus for
infection.
210 / CHAPTER 7
Complications
AOM complications may be extracranial or intracranial.
Extracranial complications include:
TM perforation
Chronic AOM
Labyrinthitis or vestibular disturbance (secondary to fistula formation)
Mastoiditis
Facial paralysis
Subperiosteal abscess
Intracranial complications of AOM include:

Meningitis
Brain abscess
Sinus thrombosis
Epidural abscess
Subdural empyema
OME complications may include hearing loss, TM retraction, or cholesteatoma

(Figure 7-2). A cholesteatoma is a destructive, expanding accumulation of
keratinized squamous epithelium in the middle ear or mastoid (see arrow in
Figure 7-2), which usually occurs as a result of chronic or recurrent infection.
Figure 7-2. Cholesteatoma.

CONJUNCTIVITIS
ALLERGIC CONJUNCTIVITIS (SEASONAL AND

PERENNIAL)
Allergic conjunctivitis (AC) is such a basic topic that it is not high yield for the
boards. A few key points, however, are worth remembering. AC is a self-limited,
bilateral inflammation of the conjunctiva with limbal sparing (lack of or less
injection around the limbus, where the cornea fuses with the conjunctiva) (Figure
7-3). This is considered under-reported, with an estimated 20% of the general
population being affected, 60% of whom present with allergic rhinitis. Vision,
pupil shape, and ocular movement remain normal in AC. Allergic shiners are a
transient increase in periorbital pigmentation from decreased venous return to skin
and tissue. The best treatment for AC includes dual-acting topical medications
with combination of H1-receptor antagonist and mast cell stabilizers (e.g.,
olopatadine, ketotifen, and azelastine).
VERNAL KERATOCONJUNCTIVITIS

Vernal keratoconjunctivitis (VKC) is a sight-threatening, bilateral chronic
inflammation of the conjunctiva. It occurs more in young atopic males (ages 3–20
years) residing in warm and dry climates.
Flash Card Q8
What is ciliary flushing,
Figure 7-3. Edema of the conjunctiva due to hay fever allergy. and in which conditions
(Reproduced, with permission, from Wikimedia Commons.) is it found?
212 / CHAPTER 7
Pathology
The exact mechanism is incompletely understood, but mast cells and eosinophils
are increased in conjunctival epithelium and substantia propria.
Clinical Features
VKC presents with a severe photophobia and intense ocular itching. Key features
include papillary hypertrophy (>1 mm), resulting in possible ptosis of the upper
eyelid, thick, ropey discharge, and Horner-Trantas dots.
Differential diagnosis of VKC
Atopic keratoconjunctivitis (AKC)
Giant papillary conjunctivitis (GPC)
AC
Infective conjunctivitis
Blepharitis
Treatment
Treatment of VKC includes allergen avoidance (i.e., alternate occlusive eye
therapy) and high-dose pulse topical corticosteroids. Mast cell stabilizers (i.e.,
cromolyn) have shown to be effective. Other treatments include dual-acting
medications (i.e., H1-receptor antagonist and mast cell stabilizers) oral
antihistamines, and antibiotic and steroid ointments (for shield ulcers).
ATOPIC KERATOCONJUNCTIVITIS

Flash Card A8
Ciliary flushing is an Atopic keratoconjunctivitis (AKC) is a sight-threatening, bilateral chronic
injection of the deep inflammation of the conjunctiva and eyelids. It occurs mostly in teenagers or
episcleral vessels, young adults in their twenties with a personal or family history of atopic
causing redness around
the cornea. It is seen in dermatitis. The conjunctival activity parallels the skin involvement and can occur
corneal inflammation, perennially (no seasonal predisposition).
iridocyclitis, and acute
glaucoma.
Pathology
Similarly to AC, AKC involves IgE, mast cells, and eosinophils.
Clinical Features
The key feature of AKC is chronic ocular pruritus/burning with findings of
atopic dermatitis. Loss of vision can occur from corneal pathology, which
includes:
Superficial punctuate keratitis Key Fact
Corneal infiltrates
Steroid administration
Scarring results in formation of
Keratoconus posterior subcapsular
Anterior subcapsular cataracts (Figure 7-4) cataracts.
(Prednisone = posterior)
Differential diagnosis of AKC includes:
Contact dermatitis
Blepharitis
Pemphigoid
VKC
AC
GPC
Figure 7-4. Anterior subcapsular cataract.

214 / CHAPTER 7
Treatment
Treatment of AKC usually involves environmental allergen controls and a
transient topical corticosteroid. Mast cells stabilizers (i.e., cromolyn) or dual-
acting medications (e.g., H1-receptor antagonist and mast-cell stabilizers) are
effective. Other treatments include systemic antihistamines, cyclosporine A (oral
or topical), and topical tacrolimus.
GIANT PAPILLARY CONJUNCTIVITIS

GPC is accompanied by a chronic, bilateral inflammation associated with foreign
body intolerance (e.g., ocular prostheses, sutures), which may affect 20% of
contact-lens wearers (Figure 7-5). Extended-wear soft contact lens > hard contact
lens > soft contact lens (daily disposables). This condition can be aggravated by
concomitant allergy.
Pathology
Mechanical trauma with irritation of the upper lid and protein buildup on the lens
causes an allergic reaction. Tear deficiency may also be a contributing factor of
GPC.
Figure 7-5. Contact lenses are a risk for GPC.

Clinical Features
Key features of GPC are:
Ocular itching after lens removal
Morning mucus discharge
Photophobia or blurred vision
Contact lens intolerance
Tarsal papillary hypertrophy is smaller than in VKC (i.e., >0.3mm).
Differential diagnosis of GPC includes:
Irritant or toxin conjunctivitis
AC
AKC
VKC
Treatment
The most effective treatment of GPC involves the reduction in contact lens
wearing and/or a change in lens style, plus “artificial tears.”
Several eye diseases may threaten sight and need to be considered when
examining patients with ophthalmic concerns (Table 7-4).
Table 7-4. Sight-Threatening Conditions and Signs

Sight-Threatening Conditions Red Eye Danger Signs
Acute glaucoma Photophobia
Scleritis Blurry vision
Iritis Severe pain
Uveitis Seeing colored halos
Herpes simplex keratitis Abnormal pupil size (sluggish or fixed)
Ciliary flush
216 / CHAPTER 7
ATOPIC DERMATITIS (ECZEMA)
Atopic dermatitis (AD) is a chronic, relapsing skin disorder that starts in

childhood and, generally, improves with age. It can be associated with allergic
rhinitis and asthma. AD manifests in adults as relapsing. Note that environmental
and bacterial stimuli cause Th2 bias.
Epidemiology
Key Fact AD is the most common chronic skin disease of young children, but can affect
In an adult patient
patients of any age. Its prevalence (8–18%) has continued to increase, paralleling
presenting with new- respiratory allergies and asthma.
onset dermatitis and no
history of childhood Atopic March—More than 50% of patients with AD will develop asthma, and a
eczema, asthma, or higher percentage will develop allergies. Increased numbers of IgE+ Langerhans
allergic rhinitis, the
physician should
cells present in both active AD and asthma (as opposed to inactive AD or asthma)
consider other causes, suggests the active allergic disease may be controlled systemically.
such as cutaneous T-
cell lymphoma (CTCL), Natural History—AD presents in early childhood, often by 2–6 months of age.
which may require a Onset is usually before 5 years of age in approximately 90% of patients. Other
skin biopsy for
diagnosis.
disease causes need to be considered in adults with new-onset dermatitis,
especially without a history of childhood eczema, asthma, or allergic rhinitis.
Basic Science
Key Advances
High levels of Fc RI-expressing IgE+ Langerhans cells in active AD, asthma,
and allergic rhinitis.
IgE to Staphylococcus aureus toxins is produced in both extrinsic and intrinsic
forms of AD.
Two distinct Ag-presenting dendritic cells in atopic skin, Langerhans cells and
inflammatory dendritic epidermal cells (IDECs), upregulate surface Fc RI to
catch allergens that have infiltrated the injured skin.
Cutaneous T–lymphocyte-attracting chemokine (CTACK and CCL27) and
thymus and activatation-regulated chemokine (TARC) levels have been found
to be specific for AD, increasing with acute symptoms and decreasing with
improvement of symptoms.
Superantigen stimulation causes CD4+CD25+ Treg cells to lose their immune
suppressive activity.
A decrease or absence of antimicrobial peptides, human β defensins (hBD-2

and hBD-3) and human cathelicidin (LL-37) in keratinocytes place patients at
risk for infections with bacteria, fungi, and viruses. Deficiency in hBD-3
Mnemonic
expression results in impaired killing of S. aureus. Downregulation of
antimicrobial genes, due to local upregulation of Th2 cytokines, could explain Cytokines involved in
the susceptibility of atopic dermatitis skin to bacterial, viral, and fungal acute and chronic atopic
infections. dermatitis:
A TLR2-gene polymorphism that results in an impaired TLR2 expression has Acute: IL-4, IL-13:“4
been linked to severe AD with frequent bacterial infections. Suits with 13 cards
each in a deck,
Loss of function variants of the epidermal barrier protein filaggrin can including the aces.”
predispose patients to have earlier onset, more severe, and persistent AD. Chronic: IL-5, IL-12,
Loss-of-function mutations in filaggrin (FLG) are associated with increased IFNγ: “Education is
risk for asthma when it occurs with atopic dermatitis. chronic starting at 5
through Grade 12.”
TSLP (thymic stromal lymphopoietin) is expressed by keratinocytes in both
acute and chronic lesions of atopic dermatitis.
Cells Involved in Atopic Dermatitis

T lymphocytes: Predominantly CD3, CD4, CD45RO memory T lymphocytes
that also express CD25 and human leukocyte antigen (HLA) DR on their Mnemonic
surface. Most memory T lymphocytes express high levels of the homing You beta remember that
receptor cutaneous lymphocyte-associated antigen (CLA), a ligand for the Fc RI of Langerhans
vascular adhesion molecule, E selectin. cells lack the classic
Langerhans cells: Express Fc RI that bind IgE. Fc RI on Langerhans cells beta chain
lack the classic β chain. Langerhans cells contain Birbeck granules.
Inflammatory Dendritic Epidermal Cells (IDECs): Fc RI-activated IDECs
stimulate naïve T lymphocytes to become IFNγ-producing T lymphocytes. In
combination with IL-12 and IL-18, this leads to switch from Th1 to Th2. Flash Card Q9
IDECs do not contain Birbeck granules. Where is filaggrin
Eosinophils: Activated eosinophils are present in significantly greater expressed?
numbers in chronic than in acute lesions. Deposition of eosinophil, a major A. Anterior vestibulum
of nose
basic protein, can be detected throughout the dermis of involved areas. Serum B. Transitional nasal
levels of eosinophil cationic protein are elevated and correlate with disease epithelium
severity. C. Respiratory nasal
epithelium
D. Human bronchial
Table 7-5 highlights the differences between extrinsic and intrinsic AD as well as epithelium
the cells and cytokines involved.
Flash Card Q10

Which cell type
expresses higher levels
of Fc RI: Langerhans
cells or IDECs?
218 / CHAPTER 7
Table 7-5. Extrinsic Versus Intrinsic Atopic Dermatitis

Extrinsic = Atopic Eczema Intrinsic = Nonatopic Eczema
70–80% 20–30%
IgE IgE-mediated sensitization No IgE-mediated sensitization
Eosinophils Eosinophilia Eosinophilia
IL-4 and IL-13 Increased production Less production
Cause increased IL-5 production
IL-10 Plays immune-modulating role Plays immune-modulating role
Clinical Features
Presentation—Initially, patients with AD have intense itching accompanied by
red macules and papules. Scratching leads to excoriation with crusting and
formation of exudates.
Distribution
Involvement of face and extensor surfaces of extremities occurs in children
younger than 2 years old (Figure 7-6).
Flexural involvement occurs in children older than 2 years of age and in
adults.
Flash Card A9
A. Anterior vestibulum of
nose
Flash Card A10 Figure 7-6. Severe atopic dermatitis.

(Reproduced, with permission, from USMLERx.com).
IDECs
Major Clinical Features

Pruritus
Chronic or relapsing course
Personal or family history of atopy
Other Characteristic Features

Early age of onset (i.e., 2–6 months of age)
Dry skin
Hand and/or food dermatitis
Cheilitis
Nipple eczema
Immediate hypersensitivity skin test responses
Anergy
Diagnosis
Diagnosis of AD is based on itching and characteristic rash, with specific
distribution and history.
Major Diagnostic Criteria—Criteria include pruritus, chronic or chronically

relapsing dermatitis, personal or family history of atopy (asthma, allergic
rhinoconjunctivitis, or atopic dermatitis).
Specific distribution and appearance based on age:

Older children and adults have lichenification of flexor surfaces, including
hands, feet, face, antecubital and popliteal fossae.
Infants have involvement of extensor surfaces, neck, trunk, and face.
Spares nasolabial skin.
Laboratory Tests—Diagnostic tests for AD are primarily supportive. Elevated

serum total IgE supports diagnosis of AD. Prick skin tests or in vitro testing of
suspected allergens can help identify specific triggers of AD. Negative tests can
help exclude triggers.
Skin biopsy can be useful in patients who do not respond well to
corticosteroids.
Patch testing is useful in patients with suspected contact allergen such as
nickel or cosmetics. It has also been used to identify aeroallergen triggers such
as: Flash Card Q11
Which cytokine is
primarily associated with
pruritus in atopic
dermatitis?
220 / CHAPTER 7
o Dust mites
o Animal dander
o Weeds
o Molds
Complications
AD is accompanied by an increased susceptibility to infections or colonization
with a variety of organisms: S. aureus, herpes simplex, molluscum contagiosum,
Pityrosporum orbiculare (formerly known as Malassezia furfur), and
Pityrosporum ovale.
Mnemonic AKC presents with bilateral intense ocular pruritus, burning, tearing, and
copious mucoid discharge. Horner-Trantas dots may be seen. Activity
Anterior cataracts are parallels that of the skin and may result in visual loss from corneal scarring.
associated with atopic Can be complicated by herpes infection, keratoconus (noninflammatory
keratoconjunctivitis.
thinning of cornea), and anterior subcapsular cataracts.
Posterior cataracts are
associated with Nonspecific hand dermatitis is aggravated by repeated wetting, especially in
Prednisone. the work environment, leading to occupational disability.
Eczema vaccinatum is a rare, severe reaction to smallpox vaccination in
patients with history of AD.
Triggers of AD
Food—Double-blind, placebo-controlled food challenges have demonstrated that
food allergens can trigger flares in some AD patients (e.g., 25–33% of those with
moderate to severe disease).
Seven foods (milk, egg, soy, wheat, fish, peanuts, and tree nuts) account for
nearly 90% of positive challenges.
Elimination of the causative food allergens results in the improvement of skin
disease and a decrease in spontaneous basophil histamine release.
Aeroallergens—Evidence supporting a role for aeroallergens includes finding of

both allergen-specific IgE antibodies and antigen-specific T lymphocytes.
Environmental control measures, such as dust mite avoidance, resulted in clinical
improvement in AD.
Autoantigens—Sera from some patients with severe AD have been found to

have IgE antibodies directed against human protein. The release of allergens
against self from damaged tissues triggers IgE- or T–lymphocyte-mediated
responses and maintains chronic allergic inflammation in severe AD.
Microbial Agents and Toxins—Patients with AD are colonized with high

numbers of S. aureus. Exotoxins secreted by S. aureus can act as superantigens,
contributing to persistent inflammation or inflammation of AD.
Flash Card A11
IL-31
Increased colonization may be associated with decreased antimicrobial

peptides, H- defensin (H D-2 and 3), and human cathelicidin (LL-37) by
keratinocytes.
AD patients can make specific IgE antibodies against the toxins on their skin,
and their disease severity appears to correlate with the presence of these
antibodies.
Table 7-6 lists the differential diagnosis of AD.
Table 7-6. Differential Diagnosis of Atopic Dermatitis

Disorder Specific Diseases Distinguishing Features
Chronic Netherton syndrome Congenitally acquired scaly dermatitis with
dermatoses short, spiky, brittle hair, called “bamboo hair”
Seborrheic dermatitis Greasy, scaly rash with well-defined edges in
areas with sebaceous glands (i.e., scalp,
face, and periauricular)
Contact dermatitis (allergic History of exposure
or irritant) Erythema, papules, and vesicles
Nummular eczema Clearly demarcated edge
Lesions on limbs more so than on trunk
Variable intermittent course
Lichen simplex chronicus Cutaneous response to repeated rubbing or
scratching
Common in neck or fold behind ear (areas
commonly reached)
Accentuation of surface marking (e.g.,
resembles tree bark)
Infections and Scabies Eczematous vesicles on hands and feet
infestations Pityriasis that is rosea-like
HIV-associated dermatitis
Malignancy Cutaneous T-cell Adult without history of eczema
lymphoma (CTCL) Diagnosis by biopsy
(mycosis fungoides)
Immune Wiskott-Aldrich syndrome Child with dermatitis, low platelets, and recurrent
deficiencies (WAS) infection
Severe combined Dermatitis, failure to thrive, diarrhea, and life-
immunodeficiency (SCID) threatening infections
Hyper-IgE syndrome Chronic eczema with impetigo
Flash Card Q12

Deficiency of which
antimicrobial peptide in
atopic skin may
contribute to eczema
vaccinatum?
222 / CHAPTER 7
Table 7-6. Differential Diagnosis of Atopic Dermatitis, cont.

Disorder Specific Diseases Distinguishing Features
a
Immune IPEX syndrome Infant with dermatitis, intractable diarrhea,
deficiencies diabetes, and hypothyroid
FOXP3 mutation
Dock8 deficiency Respiratory tract infections, difficult to treat viral

skin infections (HPV-associated warts,
orolabial/anogenital/corneal HSV, molluscum,
severe varicella or herpes zoster), bacterial
skin infections and/or mucocutaneous
candidiasis. High incidence of malignancy
Metabolic Zinc deficiency; Infant with eczema that does not respond to
disorders acrodermatitis steroids
enteropathica Periorificial rash
Necrotic areas around nose
Pyridoxine (vitamin B6 and Seizures, irritability, and cheilitis
niacin deficiency)
Multiple carboxylase Infant with skin rash, alopecia, and lethargy
deficiency
Phenylketonuria Pale pigmentation, blue eyes, and scleroderma
If untreated, leads to mental retardation
Proliferative Letterer-Siwe disease Infants with anemia, thrombocytopenia,
disorder lymphadenopathy, and histiocytic infiltration
of liver, spleen, and lymph nodes
a
Immunodysregulation, polyendocrinopathy, enteropathy, X-linked.
Treatment
Cutaneous hydration and emollients: Lukewarm soaking baths, followed by

emollient application, can control itching and hydrate dry skin. Effective
hydration and emollient therapy may reduce need for topical corticosteroids.
Topical corticosteroids: Mainstay of treatment. Careful patient instruction
essential to minimize side effects.
Topical calcineurin inhibitors: Early treatment with topical calcineurin
inhibitors might prevent relapses and decrease need for steroid rescue. Black
box warning has raised concerns about long-term use.
Avoidance of triggers of AD:
o Antibiotics, antivirals, and antifungals: Helpful in reducing secondary
infections that can complicate AD such as S. aureus, herpes simplex, P.
ovale, Candida, or scabies
o Antihistamines to control itching
o Vitamin D, which has been shown to enhance innate immune responses in
patients with AD. Especially helpful in patients with house dust mite
sensitization
Flash Card A12 o Bleach baths: Decreases bacterial infection and reduces symptoms
LL-37
ASTHMA
Asthma can be defined as a complex disorder with variable and recurring

respiratory symptoms, airflow obstruction, bronchial hyperresponsiveness, and
underlying inflammation.
Pathogenesis
Infiltration of the airways with inflammatory cells is a hallmark of asthma. These
are mainly eosinophils; however, neutrophils, lymphocytes, and other cells are
also typical. In contrast to neutrophils, eosinophils, and T lymphocytes that are
recruited from the circulation, airway mast cells are primarily longstanding tissue-
dwelling cells. In asthma, the number of mast cells is not increased, but they are
activated and show frequent degranulation. Neutrophilic accumulation is a
hallmark of fatal asthma.
Airway cellular recruitment involves several proinflammatory processes,

including:
Upregulation of adhesion molecule expression
Arachidonic acid metabolite production (including LTB4)
Chemokine synthesis (including IL-8, monocyte chemotactic protein 1 (MCP-
1), and RANTES)
Cytokine secretion (IL-1 , 4, 5, 9, 10, 13, 16, TNF IL-6, GM-CSF, and
transforming growth factor beta [TGF ).
In particular, Th2 cytokines (IL-4, 5, 13) induce isotype switching of B

lymphocytes to IgE-producing plasma cells and support eosinophil survival,
whereas others promote mast cell (stem cell factor, SCF) and basophil (IL-3) Flash Card Q13
development. A 3-year-old boy
presents to the
Airway smooth muscle is hypertrophied in the smaller airways and hyperplastic pediatrician with bloody
in the larger airways. Asthmatics have increased airway wall thickness (50–300% stools, draining ears,
and eczema. What
in fatal asthma and 10–100% in nonfatal asthma compared with nonasthmatics).
primary
Thickening occurs in smooth muscle, epithelium, submucosa, adventitia, and immunodeficiency
mucosal glands. Angiogenesis also occurs. Thickening of the lamina reticularis should be considered?
occurs below the basement membrane, composed largely of collagen types III and
V, likely produced by myofibroblasts beneath the epithelium. Mucus plugs
worsen airway obstruction. These plugs are composed of mucus, serum proteins,
inflammatory cells, and cellular debris. Excess mucus is due to hypertrophy and Flash Card Q14
hyperplasia of submucosal glands, promoted by IL-9. Damaged epithelia are a
Oral vitamin D induces
characteristic feature of chronic asthma. Damage to the epithelial cells may be production of which
due to eosinophil-derived products, active radicals of oxygen, or proteins from antimicrobial peptide in
neutrophils or mast cells (e.g., tryptase, chymase). When these cells are repaired atopic individuals?
224 / CHAPTER 7
or regenerated, instead of pseudostratified, ciliated columnar cells, the regenerated

cells are simple, stratified, nonciliated epithelium or goblet cells. Characteristic
features in asthmatic sputum are:
Curschmann’s spirals: Associated with excess mucus production (see Figure
5-9).
Creola bodies: Clusters of surface airway epithelial cells (Figure 5-9).
Charcot-Leyden crystals (CLC): A classic finding. The CLC protein is
produced in eosinophils and released in eosinophilic disorders, including
asthma. These appear as colorless, needle-shaped structures (Figure 5-9).)
Development of Asthma
Both genetic predisposition and environmental interactions are thought to
determine the asthma phenotype. Atopy is the strongest identifiable predisposing
factor. Allergen exposure plays a complex role, both in the onset and triggering of
asthma. Early life exposure to pets and farm animals may exert a protective
effect on the development of allergy but not asthma. Epidemiologic studies have
found that a child’s sensitization to Alternaria by 6 years of age is associated with
persistent asthma by 11-years-old. In older children, exposure to higher levels of
dust mites correlates with wheezing and airway hyperresponsiveness. Gender
differences are seen (e.g., boys have a higher prevalence than girls until the ages
of 15–17; the opposite is seen after that age). The hygiene hypothesis suggests
that some types of microbial exposure may decrease the development of asthma.
Viruses and other infections are associated with asthma in several ways:
Viruses such as RSV may produce symptoms of asthma in infants (see
Bronchiolitis section).
In asthmatics, viral infections are a common trigger.
Genetic factors may contribute to the heritability of asthma. On chromosome

5q, the genes 5q31-33, known as the interleukin-4 (IL-4) gene cluster, may play
an important role in inflammation in atopy and asthma. IL-4 plays a key role in
inducing synthesis of IgE and Th2 differentiation. A polymorphism in the IL-4
promoter was identified that increased transcription of IL-4 with resultant high
serum levels of IgE. The β2-adrenoreceptor gene, also in this region, is highly
polymorphic. Polymorphisms including Arg-16 → Gly and Gln 27 → Glu are
associated with decreased responses to β2 agonists. CD14, is a recognition
coreceptor with TLR4 for endotoxin (bacterial lipopolysaccharide) and is
Flash Card A13 important for innate responses to bacterial infection, leading to a shift towards Th1
Wiskott-Aldrich cell responses. A polymorphism in a soluble form of CD14 (sCD14) was
syndrome associated with high levels of sCD14 and low levels of IgE. Lastly, on a genome-
wide scan, chromosome 20p13 was found to contain a locus that was linked to
asthma. On the locus, the disintegrin and metalloproteinase (ADAM 33) gene was
associated with asthma. It may play a role in the function of airway smooth
Flash Card A14 muscle leading to airway hyperreactivity or remodeling. Chitinase-like proteins
Cathelicidin
(including chitotriosidase [CHIT 1] and YKL-40) are also an area of research as

susceptibility genes for asthma.
Diagnosis
Features of asthma include recurrent episodes of airflow obstruction (i.e.,
obstruction is at least partially reversible; an increase in forced expiratory volume
in 1 second (FEV1) >200 mL and > 12% from baseline after inhaling short-acting
β2 agonist [SABA] is specified in the American Thoracic Society definition of
reversibility) or airway hyperresponsiveness (the airways react too readily and
too much; demonstrated by methacholine challenge). Declining and irreversible
loss of lung function over time is generally attributed to airway remodeling,
which is thought to be a tissue response to recurrent injury or inflammation.
Features of remodeling include:
Subepithelial fibrosis
Increase in thickness of the small airways
Angiogenesis
Mucosal gland hypertrophy
All that wheezes is not asthma. A differential diagnosis of adult asthma
includes:
Chronic obstructive pulmonary disease (COPD)
Congestive heart failure
Pulmonary embolism
Mechanical obstruction of airways (e.g., tumor)
GERD
Bronchiectasis
Lower respiratory tract infection Flash Card Q15
Vocal cord dysfunction (VCD). What is the most
frequent infectious
Table 7-7 shows the differential diagnosis for asthma in infants and children. cause of asthma
exacerbations?
Table 7-7. Differential Diagnoses of Asthma in Infants and Children
Upper Airway Obstruction of Obstruction of Other
Disease Large Airways Small Airways
Flash Card Q16
Allergic rhinitis Foreign body in trachea Viral or obliterative Aspiration
Sinusitis or bronchus bronchiolitis Gastroesophageal What percentage of
Vocal cord dysfunction Cystic fibrosis reflux children will have
Vascular ring or Bronchopulmonary Tracheoesophageal episodes of wheezing in
laryngeal web dysplasia fistula the first 3 years of life
Laryngotracheomalacia, Heart disease
attributable to viral
tracheal stenosis, and
bronchostenosis
respiratory tract
infections?
226 / CHAPTER 7
Infants and Children

Epidemiology—About 50–80% of children who have asthma developed
symptoms before their fifth birthday. Lung function declines very early in
childhood, but this may be irreversible. Approximately 50% of children under
the age of 3 years have wheezing episodes with viral respiratory infections, with
many responding to asthma therapy even though the diagnosis of asthma is not
clearly established. Longitudinal studies looking at the natural history of asthma
in young children have defined three different phenotypes among children who
wheeze:
Transient early wheezers, children who wheezed when they were younger
than 3 years old and resolved by the time they were 6 years old, the most
prevalent type
Persistent wheezers, children whose wheezing began when they were
younger than 3 years old and continued through 6 years old
Late-onset wheezers, children whose onset of wheezing was at 6 years old
The asthma predictive index (Table 7-8) was developed to estimate which
children with wheezing would have persistent asthma. Roughly, two thirds of
children with frequent wheezing and a positive asthma predictive index will have
asthma during school years; by contrast, > 95% of wheezing toddlers with a
negative index did not have asthma during school years. In addition, the 2007
National Heart Lung and Blood Institute (NHLBI) guidelines suggest the use of
the asthma predictive index as a tool to help determine when to initiate long-term
control therapy. In children younger than 4 years of age, long-term control
therapy can be initiated for any of the following scenarios:
At least four episodes of wheezing in the past year that lasted more than 1 day
and affected sleep, and that had a positive asthma predictive index (see Table
7-8)
Consider for patients who require symptomatic treatment more than 2 days
per week for more than 4 weeks
Consider in patients requiring oral steroids twice in 6 months
Consider during periods or seasons of previously documented risk (e.g.,
during seasons of viral respiratory infections)
Table 7-8. Asthma Predictive Index

Any One of the Following Any Two of the Following
Major Criteria Or Minor Criteria
Flash Card A15 Parental asthma Sensitization to foods
Physician diagnosis of >4% eosinophils
Rhinovirus atopic dermatitis
Sensitization to aeroallergens Wheezing apart from colds
Flash Card A16

Fifty percent
National Heart, Lung, and Blood Institute (NHLBI)

Guidelines
It is very important to memorize the summary tables of the NHLBI guideline

for the boards (Tables 7-9 through 7-15). The long-term management of asthma
is divided into four components as follows:
Assessing and monitoring asthma severity and asthma control.
Impairment is the frequency and intensity of symptoms and the functional
limitation of the patient. Risk is the likelihood of exacerbation, decline in lung
function, or adverse effects of medication. Severity is the intrinsic intensity of
disease and should be assessed prior to a patient being on long-term control
medications. Control is the degree to which asthma is controlled by treatment
and the goals of treatment are met. For patients on long term-control
medications, access control and step-up therapy if asthma is not well
controlled. Be sure to check adherence, inhaler technique, and environmental
control measures prior to stepping up.
Education for a partnership in care, including the importance of giving all
patients a written asthma action plan.
Control of environmental factors and comorbid conditions that affect
asthma.
o Allergens: Common trigger. Major contributor to both acute symptoms
and chronic inflammation. Immunotherapy can reduce incidence of
additional aeroallergen sensitization and the subsequent development
of asthma in children.
o Allergic bronchopulmonary aspergillosis (ABPA) (discussed later). GERD
treatment may be beneficial for patients with frequent nighttime asthma
symptoms, even in absence of GERD symptoms. Up to 45–65% of
asthmatics have GERD. Possible mechanisms include bronchospasm due
to esophageal irritation and vagal reflex, or microaspiration.
Nonsteroidal antiinflammatory drugs (NSAIDs): 5–10% of adults may have
asthma episodes triggered by NSAIDs. Some have Samter’s triad, consisting
of asthma, nasal polyps, and aspirin sensitivity. Symptoms to aspirin (and
NSAIDs that inhibit COX-1) occur within 1–2 hours or ingestion and include Flash Card Q17
rhinorrhea, nasal congestion, tearing of the eyes, and bronchospasm. These
Which of the following is
reactions are mediated by eicosanoid metabolism with leukotriene production, the biggest risk factor for
not IgE. The onset of NSAID sensitivity can occur years after asthma and persistent asthma at age
nasal polyps. 6 in a 3-year-old with
recurrent wheezing?
For asthma medications, see Tables 7-9 through 7-15 for steps of care. A. Asthma in a parent
B. Asthma in a sibling
C. Wheezing apart
from colds
D. Allergic rhinitis in a
sibling
228 / CHAPTER 7
Exercise
Exercise is a common trigger in uncontrolled asthma; however, some patients
experience bronchospasm, which is only triggered by exercise. Classically,
symptoms have their onset after 10 minutes of aerobic activity and usually resolve
15–30 minutes after exercise. Exercise-induced bronchospasm is diagnosed by
an FEV1 decrease > 15% after exercise challenge test or history and an
appropriate bronchodilator response. SABA used shortly before exercise may
last for 2–3 hours and be helpful in 80% of patients. A daily leukotriene receptor
antagonist can help in 50% of patients.
Pregnancy
The classic rule of thumb is that, during pregnancy, approximately one third of
asthmatic women improve, one third worsen, and one third remain the same.
Uncontrolled asthma increases perinatal mortality, preeclampsia, preterm birth,
and the likelihood of a low-birth-weight infant. It is generally safer for pregnant
women to be treated with asthma medications than to risk asthma exacerbations.
Albuterol is the preferred SABA. Budesonide is the preferred inhaled
corticosteroid.
Flash Card A17

A. Asthma in a parent.
Table 7-9. Classifying Asthma Severity in Children 0–4 Years of Age
Moderate Severe
Intermittent Mild Persistent
Persistent Persistent
Impairment Symptoms <2 days/week >2 days/week Daily Throughout the
day
Nighttime 0 1-2×/month 3-4×/month >1×/week
awakenings
Short-acting β <2 days/week >2 days/week Daily Several times
agonist (SABA) use per day
Interference with None Minor limitation Some limitation Extremely limited
normal activity
Risk Exacerbations
>2 exacerbations in 6 months, or >4 wheezing episodes/1
requiring oral 0–1/year year lasting >1 day AND risk factors for persistent asthma
steroids
Recommended step for initiating Step 1 Step 2 Step 3 and Step 4 and
therapy consider short consider short
course of oral course of oral
steroids. steroids.
Table 7-10. Assessing Asthma Control in Children 0–4 Years of Age

Very Poorly
Well Controlled Not Well Controlled
Controlled
Impairment Symptoms <2 days/week >2 days/week or multiple Throughout the day
times on <2 days/week
Nighttime <1/month >1/month >1×/week
awakenings
Interference with None Some Extremely limited
normal activity
SABA use <2 days/week >2 days/week Several times per day
Risk Exacerbations 0–1/year 2–3×/year >3×/year

requiring oral
steroids
Treatment-related Side effects can vary in intensity. Level of intensity should be considered in overall
adverse effects assessment of risk.
Recommended action for treatment Maintain current step. Step up one step. Step up one to two
Follow up every 1–6 steps. Consider short
months. Consider step- course of oral steroids.
down if well controlled >3
months.
230 / CHAPTER 7
Table 7-11 Classifying Asthma Severity in Children 5–11 Years of Age

Mild Moderate Severe
Intermittent
Persistent Persistent Persistent
Impairment Symptoms <2 days/week >2 days/week Daily Throughout the
day
Nighttime <2/month 3-4 × /month >1×/week Often nightly

awakenings
SABA use <2 days/week >2 days/week Daily Several times per
day
Interference with None Minor limitation Some limitation Extremely limited

normal activity
Lung function Normal FEV1 FEV1 >80% FEV1 60–80% FEV1 < 60%
between predicted predicted; predicted;
exacerbations FEV1/FVC > FEV1/FVC < 75%
FEV1/FVC 75–
FEV1 > 80% 80% 80%
predicted; FEV1/FVC
> 85%
Risk Exacerbations 0–1/year >2/year

requiring oral
steroids
Recommended step for initiating therapy Step 1 Step 2 Step 3 and Step 3 or 4 and
consider short consider short
steroids steroids
Abbreviations: FEV1, forced expiratory volume in 1 second; FEV1/FVC, forced expiratory volume in
1 second/ forced vital capacity; SABA, short-acting β2 agonist.
Table 7-12. Assessing Asthma Control in Children 5–11 Years of Age

Very Poorly
Well Controlled Not Well Controlled
Controlled
Impairment Symptoms <2 days/week >2 days/week or multiple Throughout the day
times on <2 days/week
Nighttime < 1/month >1/month >1×/week

awakenings
Interference with None Some Extremely limited

normal activity
Lung function FEV1>80% predicted FEV1 60–80% predicted; FEV1 <60% predicted;
FEV1/FVC <75%
FEV1/FVC > 80% FEV1/FVC 75–80%
Risk Exacerbations 0–1/year 2-3×/year >3×/year

requiring oral
steroids
Treatment-related Side effects can vary in intensity. Level of intensity should be considered in overall
adverse effects assessment of risk.
Progressive loss of Evaluation requires long-term follow-up care.

lung function
Recommended action for treatment Maintain current step. Step up one step. Step up one to two steps.
Follow up every 1–6 Consider short course of
months. Consider step- oral steroids.
down if well controlled >3
months.
Abbreviations: FEV1, forced expiratory volume in 1 second; FEV1/FVC, forced expiratory volume in
1 second/ forced vital capacity; SABA, short-acting β2 agonist.
232 / CHAPTER 7
Table 7-13. Classifying Asthma Severity in Adults and Children > 12 Years of Age
Mild Moderate Severe
Intermittent
Persistent Persistent Persistent
Impairment Symptoms <2 days/week >2 days/week Daily Throughout the day
Nighttime <2×/month 3–4×/month >1×/week Often nightly

awakenings
SABA use <2 days/week >2 days/week Daily Several times per
day
Interference with None Minor limitation Some Extremely limited
normal activity limitation
Normal FEV1/FVC: Lung function Normal FEV1 FEV1 >80% FEV1 60–80% FEV1 <60%
8–19 yr 85% between predicted; predicted predicted
exacerbations FEV1/FVC FEV1/FVC FEV1/FVC reduced
20–39 yr 80%
FEV1 >80% normal reduced 5% >5%
40–59 yr 75% predicted
60–80 yr 70% FEV1/FVC normal
requiring oral
steroids
Recommended step for initiating therapy Step 1 Step 2 Step 3 and Step 4 or 5 and
consider short consider short
steroids. steroids.
Abbreviations: FEV1, forced expiratory volume in 1 second; FEV1/FVC, forced expiratory volume in 1 second/
forced vital capacity; SABA, short-acting β2 agonist.
Table 7-14. Assessing Asthma Control in Adults and Children > 12 Years of Age
Not Well
Well Controlled Very Poorly Controlled
Controlled
Impairment Symptoms <2 days/week >2 days/week or Throughout the day
multiple times on < 2
days/week
Nighttime >2/month 1–3×/week >4×/week
awakenings
Interference with None Some limitation Extremely limited
normal activity
FEV1 or peak flow >80% 60–80% <60% predicted/personal best
predicted/personal predicted/personal
best best
Validated
questionnaires
ATAQ 0 1–2 3-4
ACQ <0.75 >1.5 n/a
ACT >20 16–19 <15
requiring oral
steroids
Treatment-related Side effects can vary in intensity. Level of intensity should be considered in
adverse effects overall assessment of risk.
Progressive loss of Evaluation requires long-term follow-up care
lung function
Recommended action for treatment Maintain current step. Step up one step. Step up one to two steps.
Follow up every 1–6 Consider short course of oral
months. Consider steroids.
step-down if well
controlled >3 months.
Abbreviations: ACT, Asthma Control Test; ACQ, Asthma Control Questionnaire; ATAQ, Asthma
Therapy Assessment Questionnaire; FEV1, forced expiratory volume in 1 second; FEV1/FVC,
forced expiratory volume in 1 second/ forced vital capacity; SABA, short-acting β2 agonist.
234 / CHAPTER 7
Table 7-15. Stepwise Approach for Managing Asthma
Step1 Step 2 Step 3 Step 4 Step 5 Step 6
Children 0–4 Preferred SABA Low-dose ICS Medium-dose Medium-dose High-dose ICS High-dose ICS +
prn ICS ICS + LABA or + LABA or LABA or
montelukast montelukast montelukast +
oral
corticosteroids
Alternative Cromolyn or
montelukast
Children 5–11 Preferred SABA Low-dose ICS Low-dose ICS Medium-dose High-dose ICS High-dose ICS +
prn + LABA, ICS + LABA + LABA LABA + oral
LTRA, or corticosteroids
theophylline or
Alternative Cromolyn, Medium-dose High-dose ICS High-dose ICS +
medium-dose
LTRA,nedo- ICS + LTRA or + LTRA or LTRA or
ICS
cromil, or theophylline theophylline theophylline +
theophylline oral
corticosteroids
Consider subcutaneous immunotherapy for
persistent allergic asthma.
Children >12 and Preferred SABA Low-dose ICS Low-dose ICS Medium-dose High-dose ICS High-dose ICS +
Adults prn + LABA or ICS + LABA + LABA and LABA + oral
Medium-dose consider corticosteroids
ICS omalizumab and consider
omalizumab
Alternative Cromolyn, Low-dose ICS Medium-dose
LTRA, + LTRA, ICS + LTRA or
nedocromil, or theophylline, theophylline,
theophylline or zileuton or zileuton
Consider subcutaneous immunotherapy for
persistent allergic asthma
Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting β agonist, LTRA, leukotriene receptor antagonist; SABA, short-
acting β agonist.
OCCUPATIONAL DISEASE
Occupational Asthma (OA)
Form of work-related asthma characterized by bronchial hyperresponsiveness,

airway inflammation and obstruction related to specific exposure only in the
workplace
10–25% of adult asthma due to OA
Variable latency period that is dependent on duration of exposure, dose, agent,
host susceptibility factors. Refer to Table 7-16.
Methacholine challenge performed when patient symptomatic and at work if
negative excludes OA
Table 7-16. Mechanisms of OA

Key Fact
Immunologic Nonimmunologic
*
Animal laboratory
Mechanism IgE Haptens with protein Irritant—RADS/IrIA workers take 2 years to
Can be polyimmunogenic (albumin)
sensitize; in contrast,
(IgE/IgG)
flour workers take
Agents High molecular weight Low molecular weight Gases/fumes significantly longer.
(HMW) (LMW)
Allergic rhinitis usually
precedes OA for HMW
Protein/polysaccharide Chemical agents, not LMW
agents.
Timing of Latency period, variable Immediate no latency
symptoms onset
Abbreviations: IrIA; irritant-induced asthma; RADS, reactive airways dysfunction syndrome..
Epidemiology—It is reported in up to 30% of animal workers, 10% of snow crab

workers, 10% of bakers, and 10% of isocyanate handlers (Table 7-17).
Different means of sensitization can lead to the same clinical outcome. Symptoms
generally get worse as the work week goes on.
Flash Card Q18
What agents are the
Natural Progression—The natural progression of OA leads to variable airflow most common causes of
limitation and/or airway hyper-responsiveness. The diagnosis is confirmed by OA?
objective testing as well as the relation between asthma symptoms and work. OA
should be considered in any adult with new-onset asthma. The treatment is similar
to any other asthmatic. Early diagnosis and removal of the patient from exposure
prevents permanent loss of lung function. Flash Card Q19
Smoking is a risk factor
for sensitization to which
agent?
236 / CHAPTER 7
Table 7-17. Common Associations for Occupational Asthma

Industry Agent
Low molecular weight:
Western red cedar mill, carpenters, Plicatic acid
woodworkers
Body shop, spray paint, and insulation, roofers, Isocyanates
auto industry
Key Fact Nail salon workers Acrylates
Plicatic acid activates Welder, metal/chemical workers Platinum salts, potassium dichromate
complement. Hairdressers Ammonium persulfate
Diisocyanates can Adhesives and epoxy resin, paint/plastics Phthalic anhydride
induce reactions via
Plastics, paint Trimellitic anhydride
immunologic and
nonimmunologic Shellac and lacquer, plastics/cleaners Amines
mechanisms. Hospital workers, laboratories Formaldehyde
Drug industry workers β-Lactam agents
High molecular weight:
Lab workers, vets Animal proteins
Seafood handlers Crab/lobster
Baker Flour (wheat, soya dust)
Baker/textiles Wheat, coffee, tobacco dust, psyllium, latex
Baker/pharmaceuticals Enzymes (amylase, lipase, pectinase)
Risk Factors
History of atopy (especially cat/dog in laboratory workers/vets)
Smoking
HLA DQB1*0503/0201/0301 increase risk of TDI OA
HLA DR3, DR7 increases risk for OA in general
Glutamine S transferase (GSTP1) enzyme defects (increased diisocyanate
OA)
Diagnosis
Obtain thorough history, especially of exposures/timing/pattern of symptoms,
atopy history, current occupation and past work exposures
Flash Card A18 Skin prick test (SPT)/sIgE testing to occupational allergens, correlate with
Plicatic acid, symptoms and airflow obstruction via spirometry on exposure
isocyanates, wheat Pulmonary function test at baseline and serially, may need to check after
flour, latex exposure to agent if normal initially
Methacholine challenge
Radiograph of the chest
Gold standard is inhalational challenge but false-positive and -negative results
Flash Card A19 can occur and has limited availability; only at specific centers
Platinum
Treatment
Change work environmental exposures if can’t change jobs
o Protective equipment
Inhaled corticosteroids and other standard asthma therapies
Smoking cessation
Reactive Airway Dysfunction Syndrome (RADS)
Also called irritant induced asthma (IrIA); nonimmunologic process secondary to

high-dose single exposure to irritant agent. Symptoms are immediate, there is no
latency period, and can last a long time.
Lung Diseases
Vocal Cord Dysfunction (VCD)

VCD is known as “the asthma imitator.” It is the paradoxical adduction of vocal
cords during inspiration; however, it can happen in expiration as well.
Clinical Features
Wheezing
Stridor
Hoarseness
Dysphonia
Chest tightness
Cough
There is a high preponderance of VCD found in treatment-resistant asthma.

Patients are usually either:
Young female overachievers and athletes
Middle-aged women with psychiatric history or health care association
Diagnosis—Physical examination reveals inspiratory wheezing over larynx.

Bronchodilators can worsen the condition. Spirometry shows reduced FEV1 and
FVC with a preserved ratio as well as a blunted inspiratory loop. Refer to Chapter
10, Figure 10-2 for pulmonary function test (PFT). Diagnosis is confirmed with
fiberoptic laryngoscopy while patient is symptomatic.
Treatment—(Refer to Table 7-18).

238 / CHAPTER 7
Table 7-18. VCD Treatment

Long Term Short Term
Panting Heliox inhalation
Speech therapy Topical lidocaine spray
Botox injections into the vocal cords Intermittent positive pressure ventilation
ALLERGIC BRONCHOPULMONARY
ASPERGILLOSIS (ABPA) AND ALLERGIC
FUNGAL SINUSITIS
Allergic Bronchopulmonary Aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is an inflammatory disease of
lungs and airways, occurring as an immune response to Aspergillus fumigatus
colonization. Other fungi are rarely implicated.
Pathophysiology—Aspergillus colonization in the bronchi leads to an

inflammatory and immune response to Aspergillus antigens, resulting in poor
Key Fact
mucus clearance and recurrent bronchial obstruction. The chronic mucoid
ABPA is due to fungal impaction of bronchi leads to the development of bronchiectasis, pulmonary
colonization not local
invasion.
fibrosis, and pulmonary function compromise. The dectin-1 receptor on alveolar
macrophages plays a critical role in defense against Aspergillus. -1,3-glucan in
fungal cell walls binds dectin-1, which leads to production of various cytokines,
including, TNF , IL-1 , IL-1 , IL-6, IL-10, and IFN leading to Th1 response
critical in host defense against this pathogen.
Clinical Features
Asthmatics:
o Exacerbation of asthma symptoms (shortness of breath, cough, and
wheezing), brown/tan sputum production, and systemic symptoms
(fever and malaise)
o Pulmonary infiltrates on radiograph of the chest mid/upper lung fields
(tram line, parallel lines, hilar adenopathy)
o Central- or upper-lobe bronchiectasis, pulmonary nodules and/or air
trapping on CT of the chest.
Cystic Fibrosis: Similar to symptoms and radiographic findings seen in primary
disease.
Diagnosis—Table 7-19 provides a diagnostic overview of APBA in patients with

asthma versus those with cystic fibrosis.
Key Fact
See Figures 11-3, 11-5 through 11-24 for micrographs of various pollens. See In cases with ABPA, the
Figure 11-27A for a micrograph of Aspergillus. treatment goal is to
prevent the
development or
progression of
Treatment—Treat with long-term corticosteroids. Daily prednisone (0.5–1
bronchiectasis and any
mg/kg) for at least 14 days; taper and continue for 3–6 months. Steroid therapy worsening of pulmonary
can be combined with itraconazole for at least 16 weeks. Voriconazole can be function.
used as it has better absorption and requires less frequent dosing. Antifungal
therapy decreases antigenic stimulus for bronchial inflammation and decreases
Aspergillus IgG. It may also affect steroid levels, thus allowing decreased doses
of steroid with concomitant use. Monitor response to steroid therapy with monthly Key Fact
total serum IgE. Rising IgE levels can
Omalizumab and immunotherapy have been discussed for treatment of ABPA in help predict an ABPA
children with CF but there is insufficient evidence at this time to support their use recurrence, with a
doubling of the baseline
in this patient population. IgE often indicating a
flare of ABPA.
Allergic Fungal Sinusitis (AFS)

Fungal sinusitis is divided into acute/fulminant (invasive form), chronic/indolent
(also invasive), fungus ball, and AFS categories. AFS is the most common form
of fungal sinusitis. It is more prevalent in southern US than in northern states.
AFS is a noninvasive hypersensitivity reaction to fungi affecting the nasal cavity

and paranasal sinuses, resulting in the formation of thick fungal debris, mucin,
and polyposis. Causative fungi are from the dematiaceous family (i.e., genera
Bipolaris, Curvularia, Alternaria, Rhizopus, Drechslera, Helminthosporium, Flash Card Q20
Fusarium, and Aspergillus). Approximately 5–10% of patients with chronic
A 15-year-old soccer
rhinosinusitis requiring surgery have AFS. Refer to Figures 11-25 through 11-32 player complains of
for fungal images. chest tightness that is
worsening despite high-
dose ICS/LABA
combination therapy and
Table 7-19. Commonly Used Diagnostic Criteria frequent albuterol use.
Patients with Asthma Patients with Cystic Fibrosis What alternative
diagnosis should be
Positive immediate skin test to Aspergillus Clinical deterioration not due to other causes
fumigatus
considered?
Total serum IgE >1200 ng/mL (500 IU/mL)
Total serum IgE >1000 ng/mL (417 IU/mL)
Positive immediate skin test to A. fumigatus
Elevated A. fumigatus specific IgG and IgE
Serum IgE or IgG antibodies to A. fumigatus
a
Central bronchiectasis
Fixed chest film abnormalities (e.g., infiltrates
3
Peripheral eosinophilia (>1000/mm ) or mucus plugging) Flash Card Q21
a
Absence of bronchiectasis with presence of other criteria is seropositive ABPA (ABPA-S). In the setting of which
two lung diseases does
ABPA typically occur?
240 / CHAPTER 7
Pathophysiology—AFS is due to an exaggerated immunologic reaction

Key Fact following exposure to a fungus to which the patient is sensitized. This results in
Charcot-Leyden crystals the development of chronic edema and obstruction, leading to the obstruction of
are composed of the sinuses, mucosal stasis, and fungal proliferation. The fungal proliferation
eosinophil-degradation
products.
further contributes to the hypersensitivity response and worsening of nasal
symptoms.
Clinical Features—Refer to Table 7-20.
Imaging—CT shows hyperattenuation, heterogeneous opacification, and

calcification in affected sinus(es).
Laboratory Findings—Allergic mucin (gross): thick, tenacious, highly viscous,

Key Fact
light tan to brown colored; (histologically) branching noninvasive fungal hyphae,
sheets of eosinophils, and Charcot-Leyden crystals. Positive fungal skin testing,
Positive fungal culture elevated IgE and fungal IgG may be seen.
does not confirm the
diagnosis of AFS, nor
does a negative culture Diagnosis—Table 7-21 provides a summary of diagnostic criteria for AFS.
exclude it.
Treatment—Courses of treatment include:
Endoscopic sinus surgery: Surgical debridement of fungal debris and polyps
Nasal saline irrigations: Provides mild symptomatic relief
Oral corticosteroids: Usually initiated before surgery and most often
continued 3–4 weeks postoperatively delayed the need for repeat surgery
Topical nasal steroids: Most effective when begun postoperatively and
chronically continued for control of inflammation
Immunotherapy: Effectiveness is controversial, but this is frequently used as
an adjuvant treatment
Antifungals: Have not been shown to significantly modify clinical course
Prognosis—Chronic condition that requires life-long therapy, with recurrence of

disease varying from 10–100%.
Table 7-20. Symptoms and Signs AFS

Acute Chronic
Flash Card A20 Fever Vision changes/loss due to ophthalmic nerve
compression
VCD Nasal congestion Proptosis
Acute facial pain Sinus tenderness to palpation/pressure
Headache Malaise
Diplopia Fatigue
Flash Card A21
Acute loss of sense of smell
Asthma and cystic
fibrosis
Table 7-21. Most Commonly Accepted Diagnostic Criteria for AFS

Type I hypersensitivity to fungi confirmed on skin testing or by specific IgE
Nasal polyposis
Positive fungal stain of sinus contents
Characteristic histology: Eosinophil-rich allergic mucin and fungal elements with no invasion of
respiratory mucosa
HYPERSENSITIVITY PNEUMONITIS (HP)
This is an important topic, key elements are discussed in Tables 7-22, 7-23, and 7-
24.
Table 7-22. Immunologic Lung Disease

TH1 TH2
CD8: HP and COPD Asthma, ABPA, pulmonary eosinophilia, HIV,
and Graves’ disease
CD4: granulomatous TB, sarcoid, and
berylliosis
Abbreviations: ABPA, allergic bronchopulmonary aspergellosis; COPD, chronic obstructive
pulmonary disease; HIV, human immunodeficiency virus; HP, hypersensitivity pneumonitis; TB,
tuberculosis.
Table 7-23. Three Types of HP

Acute Subacute Chronic
Explosive respiratory Progressive No explosive symptoms
symptoms Slow No fever
Takes 4–6 hours Productive cough Fibrotic lung
Nonproductive cough No systemic symptoms Anorexia
Fever present HRCT: Diffuse micronodules, Weight loss
Recovery spontaneous air trapping, mild fibrosis Permanent damage likely
On HRCT: Normal or fleeting HRCT: Ground-glass
ground glass opacities opacities, emphysema,
seen honeycombing, and
parenchymal micronodules
Abbreviations: HRCT, high-resolution computed tomography.
Flash Card Q22

What treatment(s) are
recommended for AFS?
242 / CHAPTER 7
Table 7-24. Important HP Associations

Antigen Source
Faenia rectivirgula or Micropolyspora faeni Farmer’s lung (moldy hay and compost)
Thermoactinomyces vulgaris Bagassosis (moldy sugar cane)
Thermoactinomyces sacchari, Naegleria Ventilation pneumonitis (humidifier and A/C)
gruberi, or Acanthamoeba
Bacillus cereus or Klebsiella oxytoca Humidifier’s lung (cool mist humidifier)
Mycobacterium avium intracellulare (MAI) Hot tub lung
Aspergillus species Malt worker’s lung (malt, tobacco, and soy)
Penicillium casei or P. roqueforti Cheese worker’s lung (moldy cheese)
Pseudomonas, Acinetobacter, or Mycobacter Machine operator’s lung
Avian proteins or Aspergillus species Bird fancier’s lung (kids have good prognosis)
Bacillus subtilis Detergent worker’s lung
Alternaria species Woodworker’s lung
Stachybotrys Winegrower’s lung
Aureobasidium Air-conditioner lung
Trichosporum cutaneum Summer-type HP (Japan)
Pezizia El Niño lung
Candida albicans Saxophonist’s lung
Epicoccum nigricans Basement shower lung
Sitophilus Wheat weevil lung
Toluene or toluene diisocyanate (TDI) Paint finisher’s lung
Diphenylmethane diisocyanate (MDI) Chemical worker’s lung
Phthalic acid Epoxy resin worker’s lung
Trimellitic anhydride Plastic worker’s lung
Diagnosis—The major criteria for diagnosis are:

HP symptoms
Evidence of exposure (history and +IgG)
+ Radiograph of chest or high-resolution computed tomography (HRCT,
reticular, nodular, or ground-glass opacities)
Bronchoalveolar lavage (BAL) lymphocytosis > 20% (low CD4:CD8 ratio
<1)
Symptoms on re-exposure
Flash Card A22 Additional criteria include bibasilar dry rales, decrease in diffusion lung capacity
Systemic and topical for carbon monoxide (DLCO), and decrease in partial arterial pressure of oxygen
steroids with surgical (PaO2) with exercise.
intervention. IgE level
increase can predict Laboratory Findings—(See Table 7-25).
recurrence when
following these patients.
Table 7-25. Laboratory Findings in HP

Laboratory Test Result
BAL ↑CD8 (CD4:CD8 <1)
Lymphocytosis >20%
↑ neutrophils
↑ eosinophils
>1% of WBCs in BAL are mast cells
↑ IgG, IgA, IgM
↑ hyaluronic acid
Lung biopsy Noncaseating granulomas

Mononuclear cell infiltrates of alveolar walls
(lymphocytes, plasma cells)
Foamy histiocytes in alveoli
Giant cells, peribronchiolar fibrosis
PFT findings ↓FEV1 after 4–6 hr of exposure

↓FVC after 4–6 hr of exposure
↓DLCO after 4–6 hr of exposure
Abbreviations: BAL, bronchoalveolar lavage DLCO, diffusion lung capacity for carbon monoxide;
FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; PFT, pulmonary function
test; WBCs, white blood cell count.
For a summary of laboratory studies for asymptomatic versus symptomatic HP,

see Table 7-26.
Table 7-26. Laboratory Studies for Asymptomatic Versus Symptomatic HP

Asymptomatic Symptomatic
CD4 > CD8 CD8 > CD4
Normal CD8 numbers Low CD8
Normal IgM High IgM
Organic dust toxic syndrome (ODTS, pulmonary mycotoxicosis):
Noninfectious, febrile illness that occurs in workers after exposure to dust
contaminated by bacterial and/or fungal spores (from inhalation of toxin-
producing fungi-contaminated aerosols [i.e., grain, hay])
30 to 50 times more common than HP; young patients; usually contracted in
the summer months; complete recovery.
244 / CHAPTER 7
Fire-eater’s lung: Choking, coughing, respiratory symptoms from aspiration

of the flammable petrochemicals used during the fire-eating demonstration.
Fever and pleuritic chest pain also seen
Humidifier fever: Toxic alveolitis, recirculated water with endotoxin, chest
Mnemonic tightness occurs 4–8 hours after exposure; resolves in hours
Drugs that can cause Silo unloaders disease: Acute exposure to NO2, leading to asphyxia (i.e., a
HP farmer entering a silo).
A Boy Came From a Byssinosis: Dust inhalation of cotton, flax, and hemp; bronchoconstriction
Good Home to Make Nice first day of exposure; tends to improve as the week goes on
Purple Sweets Histiocytosis: Pneumothorax in 10% of cases
Amiodarone Usual interstitial pneumonia (UIP): Clubbing present and neutrophil
Beta Blockers
Chlorambucil, clozapine,
predominant
cyclosporine Occasional interstitial lung disease (ILD): Secondary to flock or nylon;
Fluoxetine lifeguarding at the pool, with endotoxin as the culprit
Gold
Heroin, HMG Co-A Clinical History and Findings—Farmer’s lung is the most common form of
reductase inhibitors
Methotrexate, HP. But, far more common, in farmers is ODTS (nonimmunologic) up to 50
minocycline times more common; thus it is important to distinguish between the two. Farmer’s
Nitrofurantoin lung occurs after prolonged exposure, whereas ODTS occurs after a single high-
Procarbazine dose exposure.
Sulfasalazine
HP seen with contamination of water and ventilation systems. MAI
(Mycobacterium avium intracellulare) most common pathogen
Smoking is protective in HP, thought to be due to decreased antibody
response to antigen in the lung
Key Fact The particle size of the inciting agent must be <5 μm to enter to smaller
ODTS is 50 times more airways
common in farmers than Timing of cells involved: Eosinophils and PMNs after a few hours,
farmer’s lung. lymphocytes infiltrate after a few days and macrophages over months
Treatment—Avoidance of offending agent. Glucocorticoids in severe or

persistent symptoms accelerate recovery. Use daily for 1–2 weeks and taper over
next 2–4 weeks.
INTERSTITIAL LUNG DISEASE (ILD)
ILD refers to a group of lung diseases affecting the interstitium.
Interstitial Pneumonitis
The acute injury pattern of interstitial pneumonitis is characterized by fibroblastic

foci. IL-1, -6, -8, and TNF are important cytokines involved via macrophages.
“Ground-glass” appearance on early radiography versus “honeycombing” in the
late phases. (Note: It is synonymous with usual interstitial pneumonitis.).
Usual Interstitial Pneumonitis (UIP)

UIP is the most common of the interstitial pneumonias and is also known as
idiopathic pulmonary fibrosis (IPF). Males have poorer prognosis. It is a
chronic, progressive fibrotic disease. Symptoms include:
Dyspnea and/or nonproductive cough
Diffuse interstitial infiltrates on chest radiographs
Honeycombing on HRCT
Restrictive pattern with low DLCO on spirometry
The etiology of UIP is unknown and it has a poor prognosis. Although steroids
are used in treatment, lung transplant is definitive.
Desquamative Interstitial Pneumonitis (DIP)

DIP is an uncommon ILD. Ninety percent of these patients have a smoking
history and present with “smoker’s bronchiolitis.” DIP has a better prognosis than
UIP.
Acute Interstitial Pneumonitis (AIP)

AIP is another uncommon ILD. It is also called Hamman-Rich syndrome and
has a pathologic pattern of diffuse alveolar damage. It is characterized by:
High fever
Severe dyspnea over 1 day
Flu-like symptoms Flash Card Q23
Rapid respiratory decompensation What are typical
laboratory findings in HP?
Nonspecific Interstitial Pneumonia (NSIP) or Fibrosis

NSIP is yet another uncommon ILD, which is based on a diagnosis of exclusion. Flash Card Q24
One must rule out collagen vascular disorders, organic dust inhalation, drug Usual interstitial
reactions, etc. Overall, NSIP has a good prognosis. pneumonia is the typical
pathologic pattern in
patients with which clinical
condition?
246 / CHAPTER 7
CHRONIC OBSTRUCTIVE PULMONARY

DISEASE (COPD)
Characteristics—COPD has the following characteristics:

Progressive airflow limitation characterized by FEV1/FVC < 70%
Spirometric severity is based on postbronchodilator FEV1 percent predicted
Spirometry is essential for test of COPD staging. GOLD criteria are used for
staging purposes as follows:
GOLD 1: FEV1 ≥ 80% predicted = Mild
GOLD 2: 50% to < 80% predicted FEV1 = Moderate
GOLD 3: 30 % to < 50% predicted FEV1 = Severe
GOLD 4: FEV1 < 30% predicted, or <50% normal with chronic
respiratory failure present
COPD is caused by chronic inflammation of the airways and lung parenchyma.

The primary risk factor is tobacco smoke exposure (current or former). In severe
COPD, an inverse relationship between body mass and respiratory mortality has
been described.
Airway Inflammation—Neutrophils and macrophages play a major role in

COPD. Activated macrophages and neutrophils release matrix-degrading enzymes
(including matrix metallo-, serine, and cysteine proteases) that cause the
parenchymal lung destruction that underlies emphysema. Nicotine in cigarette
smoke may also enhance tissue destruction by inhibiting tissue inhibitors of
matrix metalloproteinases (TIMPs). Sputum eosinophils are a marker of viral
exacerbation, whereas sputum neutrophils are seen in both bacterial and viral
exacerbations.
Clinical Phenotypes—Chronic bronchitis involves inflammation of small- and

medium-sized airways, with symptoms of dyspnea, chronic cough, and sputum
production. Emphysema involves destruction of elastic tissue in terminal
airspaces, loss of lung elastic recoil, and parenchymal loss. Signs and symptoms
include dyspnea and hypoxemia.
Flash Card A23 Centrilobular emphysema: Involves upper lobes; associated with cigarette
Increased CD8 in BAL smoke
fluid with decreased Panlobular emphysema: Involves lower lobes; seen with α1-antitrypsin
CD4:CD8 <1 deficiency
Flash Card A24

Idiopathic pulmonary
fibrosis
Lung Function—There is an accelerated loss of lung function in smokers with a

decline in FEV1 of almost 60 mL/year (compared with a normal loss of 30
mL/year typical of nonsmokers). Hyperinflation is seen in moderate-to-severe
COPD. Destruction of the alveolar-capillary interface (particularly with
emphysema) and alveolar hypoventilation leads to a reduced diffusing capacity
for carbon monoxide along with hypoxemia.
Treatment Considerations in COPD Compared with Asthma—Medications

useful for COPD include short- and long-acting anticholinergics, which improve
symptoms and airflow while decreasing hyperinflation in COPD. Long-acting β
agonists, which are used only with inhaled corticosteroids for asthma, can be used
as isolated agents for COPD.
Although inhaled corticosteroids (ICS) are a mainstay of treatment for persistent

asthma, ICSs are considered only for moderate-to-severe COPD with symptoms
despite bronchodilators. A proposed mechanism explaining why COPD may be
less steroid-responsive than asthma includes the following:
Histone acetyltransferase acetylates (unwinds) the DNA-histone complex,
leading to the generation of nuclear factor kappa B (NFκB) and activator
protein 1 (AP-1), which are proinflammatory transcription factors.
Histone deacetylases (HDACs) deacetylate (compacts) DNA, which
suppresses gene transcription of NFκB and AP-1 (thus less inflammation).
Corticosteroids increase HDACs in asthma, but not in COPD.
Smoking cessation is critical and returns rate of loss of lung function almost to
normal. Supplemental oxygen decreases mortality. There is a role for pulmonary
rehabilitation, lung volume reduction surgery, and/or lung transplant for some Flash Card Q25
patients. Use of anticholinergic therapy as adjunct to ICS has been shown to What is the only treatment
preserve lung function. that prolongs life in
COPD?
FOOD ALLERGY
Flash Card Q26
On a vacation in Florida,
a 39-year-old man
Adverse Food Reactions orders mahi mahi in a
restaurant and, within 20
Nonimmune-mediated adverse food reactions include the following categories: minutes of eating it,
develops abdominal
Metabolic: Lactose intolerance, galactosemia, alcohol intolerance cramps, vomiting,
swelling of the tongue,
Pharmacologic: Caffeine (makes you jittery), tyramine in aged cheeses and trouble breathing.
(headaches and migraines), Scombroid fish poisoning (releases histamine- He has eaten fish all of
like chemicals) his life. Skin testing to all
Toxins (not host-specific): Food poisoning white fish is negative.
What is the cause of this
Psychologic: Food aversion, anorexia nervosa patient’s illness?
248 / CHAPTER 7
Other: Auriculotemporal syndrome (vasodilatation), gustatory rhinitis

(runny nose from spicy or hot foods), Frey’s syndrome (transient,
unilateral and bilateral facial flushing or sweating after ingestion of spicy
or flavored foods; due to damage to auriculotemporal nerve)
IgE-Mediated and Non-IgE-Mediated Food Allergy

Reactions to foods can be mediated by the immune system. These can be IgE- or
non-IgE-mediated.
IgE-mediated food allergy is acute in onset (within 2 hours of exposure) and

includes skin symptoms (e.g., hives), gastrointestinal symptoms (e.g., vomiting) ,
respiratory (e.g., wheezing) or cardiovascular symptoms (e.g., hypotension). The
most severe clinical manifestation of an IgE-mediated reaction is defined as
anaphylaxis.
Non-IgE-mediated reactions involve mainly T-cell mediated mechanisms.

Typically, these reactions are not immediate and involve primarily the
gastrointestinal system.
Finally, some reactions to food are considered to be mixed IgE- and cell-mediated
(Figure 7-7).
IgE-mediated Non-IgE-mediated
Flash Card A25

Use of supplemental
oxygen
Figure 7-7. Types of food allergy showing spectrum of IgE-mediated, non-IgE-

mediated, and mixed reactions.
Flash Card A26
Scombroid fish poisoning
Prevalence of Food Allergy

Public perception is that 20–25% of the population has food allergies. Actually,
about 6% of young children and 3–4% of adults have food allergies (Table 7-27).
Reactions to fruits and vegetables are approximately 5%, but usually are not
severe.
Soy or wheat each cause reactions in up to 0.4% of young children.
Food is the most common cause of outpatient anaphylaxis; and peanut
accounts for the most common trigger of fatal reactions in North America.
Sensitization to one food may increase risk of sensitization to other foods.
Pathophysiology
Class 1 Allergens—These allergens result primarily from food that is ingested
(i.e., GI sensitization). Such a breach in oral tolerance typically occurs when
food proteins stable to digestion are encountered by sensitive individuals. Class I
allergens such as egg or peanut may invade through the skin. Type 1 allergens are
usually characterized by the following:
10–70 kD glycoproteins; heat resistant, acid stable, and water soluble
Examples include cow’s milk protein (casein and whey), egg (ovalbumin and
ovomucoid), peanut (vicilin, conglutin, and glycinin), fish (parvalbumin), and
shellfish (tropomyosin)
This class of allergens also includes nonspecific lipid-transfer proteins in
apple and corn. (See the food section within Chapter 11 on allergens for more
details and nomenclature.)
Table 7-27. Prevalence of Food Allergy in the U.S.

Food Young Children (%) Adults (%)
Milk 2.5 0.3
Egg 1.3 0.2
Peanut 0.8 0.6
Tree nuts 0.2 0.5
Fish 0.1 0.4
Shellfish 0.1 2.0
Overall 6 3.7
250 / CHAPTER 7
Class 2 Allergens—These allergens are formed primarily from respiratory

sensitization. Sensitization to labile proteins encountered via the respiratory
route, such as pollens, results in IgE antibodies that recognize homologous
epitopes on food proteins from plants. Some patients exhibit symptoms of pruritus
limited to the oral mucosa when eating fresh fruits and vegetables, termed pollen-
food allergy syndrome. Type 2 allergens are characterized by the following:
Plant-derived and labile
Key Fact
Predominantly in superfamilies of cupin and prolamin, and the protein families
Linear epitope = more of the plant defense system
prolonged allergy,
allergen is “stable” and
persistent Linear vs. Conformational Epitopes—A single food is composed of many
Conformational epitope =
proteins, and these proteins have multiple areas, termed epitopes, to which the
mild, transient allergy. immune system can respond. Epitopes that are dependent upon the folding of the
proteins are termed conformational epitopes; those that are not dependent upon
folding are termed linear epitopes.
Clinical Syndromes
Specific syndromes that are associated with food allergy are listed in Table 7-28.
A few are highlighted here.
Anaphylaxis—Rapid-onset organ response involving at least two body systems

or hypotension in response to a potential allergen that is potentially fatal. Reaction
may be biphasic (i.e., symptoms may recur after initial resolution) . Tryptase
levels (a mast cell mediator) may be increased. Any food can cause a reaction, but
the main culprits are peanuts, tree nuts, and seafood.
Factors associated with increased risk for fatal reaction include delayed
epinephrine administration, young adult or teen, underlying asthma, and
absence of skin symptoms.
Food-Associated, Exercise-Induced—Often associated with particular foods

such as celery and wheat (omega-5 gliadin) in the context of physical activity.
Pollen-Food Allergy Syndrome—Sensitization to allergens such as Bet v 1

(birch) through the respiratory route may result in cross-reactivity to type 2
allergens such as Mal d 1 (apple, peach), and present with oral pruritus when
eating fresh fruit. This is IgE-mediated, rarely progresses to more severe
symptoms, and certain forms of fruit/vegetables may be tolerated. Symptoms may
vary by season.
Plant food allergens can be divided into a number of categories:
PR-10: Bet v 1 homologues in the pulp of the fruit; sensitive to heat,
therefore, no reaction to cooked/processed fruit; symptoms usually restricted
to the mouth
Nonspecific lipid transfer proteins: Located primarily in the peel; stable to

heat and digestion, therefore reacts to cooked/processed fruit as well; reaction
may be more severe
Profilin: Bet v 2 homologues, sensitive to heat, therefore, no reaction to
cooked/processed fruit; symptoms usually restricted to the mouth
Storage proteins: Located in the fruit stone (seed/nut/kernel); stable to heat
and proteases, therefore, react to cooked/processed foods
Cross-reacting carbohydrate determinants: Found in plants and
invertebrates (not mammals); may cause no reaction, or anaphylaxis;
examples include latex, bee/wasp, cockroach, mite, and shellfish
Table 7-28. Important Disorders Associated with Food Hypersensitivities

Disorder Mechanism Symptoms Diagnosis
Gastrointestinal
Pollen-food allergy IgE-mediated Pruritus, tingling, Hx and +SPT to pollens
syndrome angioedema of lips, palate, and/or fresh fruit
tongue, or oropharynx
Anaphylaxis IgE-mediated Hives, cough, dyspnea, Hx, SPT, specific IgE levels,
wheezing, abdominal pain, and +/– oral challenge
vomiting, and/or diarrhea
Eosinophilic IgE-mediated Reflux, dysphagia, Hx, SPTs, and endoscopy
esophagitis and/or cell- abdominal pain, and failure or biopsy, and elimination
mediated to respond to reflux meds; diet
sensation of food impaction
Eosinophilic IgE-mediated Recurrent abdominal pain, Hx, SPTs endoscopy or
gastroenteritis and/or cell- vomiting, early satiety, FTT, biopsy and elimination diet
mediated and peripheral eosinophilia
Food protein- Cell- Blood in stool, first few SPTs, elimination diet,
induced mediated months of life, and no FTT challenge results in sx in 72
proctocolitis hr
Food protein- Cell- Vomiting and diarrhea, +/- SPTs, elimination diet,
induced mediated blood, FTT, vomiting one to challenge results in sx in 1–
enterocolitis three hours after eating, 2 hr
and hypotension
Food protein- Cell- Diarrhea, steatorrhea, Endoscopy and biopsy, IgA,
induced mediated abdominal distension, celiac abs, and elimination
enteropathy; celiac flatulence, oral ulcers, and diet
disease weight loss
Cutaneous
Urticaria and IgE-mediated Itching, hives, and/or Hx, SPT, specific IgE levels,
angioedema swelling and food challenge
Atopic dermatitis IgE- and cell- Itching and eczematous Hx, SPT, specific IgE levels,
mediated rash in “classic distribution” elimination diet, and food
challenges
Dermatitis Cell- Itching, papulovesicular Skin biopsy (IgA
herpetiformis mediated rash over extensor surfaces deposition), IgA antigliadin
and buttocks; associated and antitransglutaminase
with celiac disease antibodies, and endoscopy
Respiratory
Heiner’s syndrome Uncertain Recurrent pneumonia, Hx, peripheral eosinophilia,
pulmonary infiltrates, milk precipitins, lung biopsy,
hemosiderosis, iron and elimination diet
deficiency anemia, and FTT
Abbreviations: FTT, failure to thrive; Hx, history; SPT, skin prick test; Sx, symptoms.
252 / CHAPTER 7
Specific food and fruit associations can be found in the Foods section of Chapter
11.
Dermatitis Herpetiformis—An example of non-IgE-associated syndromes that

Key Fact affect the skin. Associated with celiac disease. Patients are gluten-sensitive.
Antibodies often positive Symptoms include vesicular, pruritic eruption (usually in acral distribution) on
in patients with celiac sun-exposed areas of arms and/or legs
disease include IgA-
antigliadin antibodies Celiac disease antibodies: IgA-antigliadin antibodies and antitransglutaminase
and tissue antibodies
transglutaminase
antibodies. If IgA is Galactose-α-1,3-galactose—urticaria, angioedema, or anaphylaxis 3–6 hours
absent, serology for after ingesting beef, lamb, or pork. May have a history of a tick bite. Unlike
celiac disease can be
falsely negative. common allergens, which are usually proteins, this allergen is a carbohydrate
found as part of the glycoproteins, including the chemotherapeutic monoclonal
antibody cetuximab.
Diagnosis
Key Fact History: Consider symptoms, timing, reproducibility, quantity ingested, and
Most children who are ancillary factors, such as exercise, aspirin, and alcohol. Must consider if cause
unable to consume acute vs. chronic disease.
nonbaked forms of egg Diet details and/or symptom diary: Allows identification of specific causal
and milk are able to food(s) and “hidden” ingredient(s).
tolerate baked egg and
milk. Physical examination: Allows evaluation of disease severity. Look for failure
to thrive.
General approach: Consider whether reaction is allergy vs. intolerance and
IgE- vs. non-IgE-associated.
Laboratory Evaluation
Suspect IgE-Associated—SPTs (consider fresh food if oral allergy); also
consider serum food-specific IgE antibodies. Selection of foods for testing should
be guided by the history, given the high level of false-positive tests in the absence
of suggestive history.
Suspect Non-IgE-Associated—Consider biopsy of gut and skin in appropriate

clinical setting (e.g., suspected celiac disease). The role of atopy patch test in
detecting delayed-type hypersensitivity reactions is not established yet.
Suspect Nonallergic—Consider the following:

Breath hydrogen for lactose intolerance
Sweat test, especially if malabsorption
Endoscopy
Interpretation of Tests
Positive SPT and elevated food-specific serum IgE indicate presence of
specific IgE antibody (sensitization), but not necessarily clinical reactivity
(PPV < 50%). With increasing size of the skin test and beyond certain cut off
levels of specific IgE, especially in the context of a suggestive history of
allergic reaction, the likelihood of clinical allergy or reaction is increased.
Commercially prepared extracts may be inadequate for fruits and vegetables,
especially for the diagnosis of the pollen-fruit syndrome, so fresh food for
testing is often required.
Intradermal skin tests with food have a higher risk of systemic reactions and
are not used.
Increasing serum-specific IgE correlates with increasing likelihood of reaction.
Not useful in predicting the type or severity of the reaction. Ten percent to
25% of those with negative serum-specific IgE may have clinical reactions.
Component-resolved diagnostics can identify IgE specific for conformational
epitopes, or specific epitopes that may help predict whether a reaction may be
systemic (i.e., Ara h 2) or oral (i.e., Ara h 8) in individuals with peanut
allergy.
Unproven and/or experimental tests and likely useless tests include
provocation and/or neutralization, cytotoxic tests, applied kinesiology, hair
analysis, and IgG4.
Treatment
Dietary Elimination—Teach patients about hidden ingredients, reading labels,
cross-contamination (e.g., shared equipment), emergency ID bracelet, and seeking
assistance from registered dietitian as well as Food Allergy Research & Education
(FARE).
Emergency Medications
Epinephrine is the drug of choice for reactions. Self-administered epinephrine
should be readily available. Epinephrine should be administered through the
IM route. Train patients on indications and technique.
Antihistamines are secondary therapy; they help to manage hives and pruritus.
Emergency plan in writing for schools, spouses, caregivers, and mature
siblings or friends.
254 / CHAPTER 7
Oral Food Immunotherapy—: Exposing patients to gradually increased amounts

of food allergen under medical supervision is currently done on a research basis
only.
Follow-Up—Reevaluate periodically for tolerance. Interval and decision to

rechallenge is based on type of food allergy, severity of previous symptoms,
confirmatory tests (i.e., SPT and /or specific IgE levels), and the specific
allergens.
Ancillary testing: Repeat SPT and serum IgE. Reduced concentration of
specific IgE and smaller SPTs suggest outgrowing food allergy.
See Contact Hypersensitivity section for specific IgE and SPT size for when
to challenge.
Natural History
Natural history is dependent on food and pathogenesis of food allergy.
IgE-mediated reaction to cow’s milk, egg, wheat, and soy: Approximately
Key Fact 85% remit by 5 years, although recent studies suggest lower rates of
Approximately 85% of resolution. Declining and/or low levels of specific IgE are predictive of
cow’s milk, egg, wheat, tolerance development as well as the extent of IgE binding to conformational
and soy allergies remit epitopes.
by 5 years of age.
Twenty percent of young IgE-mediated reaction to peanut, nuts, and seafood allergies typically persist
children “outgrow” their into adulthood. Over a 2-year period 20% of young children “outgrow” peanut
peanut allergy allergy (approximately 9% for tree nut). Some (i.e., 7–9%) may redevelop the
(approximately 9% for allergy (increased risk if avoided).
tree nut).
Non-IgE-associated GI allergy: Infant form resolves by 1–3 years of age.
Toddler and adult forms are more persistent.
Some evidence suggests that consumption of baked milk/egg may expedite
resolution of IgE-mediated allergy to nonbaked milk/egg
Food Allergy Prevention

There are limited data for the prevention of food allergy. This is an area of intense
study and significant controversy, and it is currently being assessed through
randomized controlled trials. Several pediatric and allergy organizations have
suggested guidelines that require further study.
Insufficient evidence to suggest maternal avoidance of allergens for atopic
dermatitis (AD).
Exclusive breast feeding for the first 4 months of life may decrease the risk of
AD and cow’s milk protein allergy in the first 2 years of life.
Avoidance of solid food in the first 4 months of life may decrease risk of AD.
Vitamin D, antioxidants, fats; antacids may play a role in exposure to intact

proteins.
Recently it was suggested that delayed introduction of allergens via the oral
route (promoting tolerance) may increase risk of sensitization via other routes
such as the skin, which may be more likely to produce clinical allergy.
However, randomized controlled trials exploring this hypothesis are currently
underway.
ANAPHYLAXIS
Anaphylaxis is an acute-onset, potentially fatal, systemic allergic reaction.

Lifetime prevalence 0.05–2%
Largest number of cases in children and/or adolescents
Food and drug reactions the most common cause of anaphylaxis
Risk has been established for several characteristics (Table 7-29)
Table 7-29. Risk Factors of Anaphylaxis

Risk Factors
Atopy: Increased risk for idiopathic anaphylaxis, exercise-induced anaphylaxis,
radiocontrast material and latex-induced reactions
Note: Atopy is not a risk factor for anaphylactic reactions to medications (PCN, insulin, or
muscle relaxants)
Gender: More common in males until age 15 years; more common in females for those
older than age 15 years
Age: More cases in children and/or adolescents
Route of administration: More severe reactions with IV or IM versus oral
Intermittent admin: If start and stop, then more likely to sensitize (e.g., DM of pregnancy
where patients take insulin intermittently)
Length of admin: Prolonged antibiotic courses more likely to sensitize than single doses
Time since reaction: The longer the time between administrations, the lower likelihood of
an event
Geography: Epinephrine autoinjector prescriptions in the US are found to have a north-
south gradient, with more in the northern portion of the country
Socioeconomic status: Higher-income groups prescribed epinephrine more
frequently
256 / CHAPTER 7
Pathogenesis
Terminology has changed to favor immunologic vs. nonimmunologic (previously
anaphylactoid) anaphylaxis.
Immunologic Anaphylaxis
IgE-mediated: Most common; initiated by antigen interacting with allergen-
specific IgE bound to high-affinity IgE receptors (FcεRI) on mast cells and/or
basophils. Aggregation leads to cell activation, mediator release, and
immediate hypersensitivity response. Examples include foods, venoms, latex,
and drugs
IgG-mediated: Animal models only
Immune complex/complement-mediated reactions
Nonimmunologic Anaphylaxis—Initiated by certain drugs or events that induce

a sudden release of mast cell or basophil mediators in the absence of IgE or other
immunoglobulins. Examples include vancomycin, opiates, radiocontrast media, or
cold urticaria.
Idiopathic Anaphylaxis— Diagnosis of exclusion where no specific trigger can

be identified and all other diseases have been ruled out including mast cell
disorders. Women more commonly affected than men; long-term management
with oral prednisone and a nonsedating H1 antihistamines for patients with
frequent episodes.
Table 7-30 lists the mediators involved in anaphylaxis.
Table 7-30. Mediators Involved in Anaphylaxis

Mediators Pathophysiologic Activity Clinical Signs
Histamine, leukotrienes, Smooth muscle spasm, mucus Wheezing, urticaria,
thromboxane, prostaglandins, secretion, increased vascular angioedema, flush, itch,
and platelet activating factor permeability, eosinophil diarrhea, abdominal pain,
chemotaxis, and activation hypotension, rhinorrhea
Neutral proteases: Tryptase, Cleaves complement Recruits complement,
chymase, carboxypeptides, components, chemoattractants increases blood pressure via
and cathepsin-G for eosinophils and neutrophils, conversion to angiotensin II
and converts angiotensin I to II
Proteoglycans: Heparin and Anticoagulation, inhibits Can prevent intravascular
chondroitin sulfate complement, binds coagulation, complement
phospholipase A2, activation, recruits kinins
chemoattractant for eosinophils
Chemoattractants: Attracts cells to the site Late-phase reaction
Chemokines, eosinophils symptoms, or protraction of
chemotactic factors symptoms
Tumor necrosis factor (TNF) Promotes platelet-activating Vascular permeability and
factor production vasodilation, and late-phase
reactions
Clinical Features
Anaphylaxis is likely when any one of the criteria in Table 7-31 is fulfilled.
Target Organs (and Percentage of Time Involved)

Cutaneous (90%)
Respiratory (70%)
Gastrointestinal (30–45%)
Cardiovascular (10–45%)
Central nervous system (10–15%)
Patients who do not experience skin manifestations may experience profound

shock immediately. Most common organs involved in shock include the heart,
vasculature, and lungs with fatalities caused by circulatory collapse or respiratory
failure.
Note: The severity of a reaction is not predictable, but a history of anaphylaxis to

an allergen is more likely to be associated with severe systemic reactions to the
same allergen in the future.
Table 7-31. Diagnostic Criteria for Anaphylaxis

Criterion 1 Criterion 2 Criterion 3
Acute onset of symptoms Acute onset of symptoms Acute decrease in BP (minutes
(minutes to hours) with skin (minutes to hours) after to hours) after exposure to a
and/or mucosal involvement exposure to a likely allergen known allergen for that
Generalized hives for that patient patient
pruritus
Angioedema
flushing
plus at least 1 of the plus 2 or more of the defining reduced BP
following following
Respiratory compromise Skin/mucosal involvement Adults: Systolic < 90 mmHg or
(dyspnea, wheeze, Respiratory compromise >30% decrease from baseline
hypoxemia) Infants/children: Age-specific
Decreased BP
Decrease in BP or end-organ low systolic BP or >30%
dysfunction (hypotonia, Gastrointestinal symptoms decrease from baseline
syncope) (abdominal pain, vomiting)
Skin findings most common Skin findings absent or Criterion 3 is used to detect
presenting symptom of unrecognized in ~20% of anaphylactic reactions in
anaphylaxis (~90%). Therefore anaphylactic episodes. patients exposed to a known
criterion 1 is the most useful Therefore criterion 2 includes allergen when only one organ
for diagnosis. symptoms from other organ system is involved.
systems in patients with
exposure to a likely allergen.
258 / CHAPTER 7
Biphasic Anaphylaxis—Biphasic or late-phase reactions are a recurrence of

anaphylactic signs and symptoms several hours after the apparent resolution of
the initial anaphylactic episode. These reactions occur in roughly 20% of
anaphylactic episodes, with symptoms occurring as late as 72 hours (most within
10 hr) after resolution of the primary event. Observation for as long as 24 hours
has been advocated, although 8 hours is sufficient for most reactions. Foods
appear to be the most likely to induce this reaction.
Protracted Anaphylaxis—Anaphylactic reaction that lasts for hours, days, or

even weeks in extreme cases
Compensatory Mechanisms
Physiological attempts to correct the hypotension that can occur during
anaphylactic events include the synthesis and release of epinephrine (adrenal
gland) and endothelin (endothelium), activation of the renin-angiotensin axis, and
the release of norepinephrine (ganglia). Drugs that interfere or block these
compensatory mechanisms may predispose to severe or protracted episodes:
β-Adrenergic blockers: Interfere with normal compensatory tachycardia and
blunt the effect of epinephrine. Relative contraindication to immunotherapy
Angiotensin-converting enzyme inhibitors (ACEIs): Theoretical increased risk
in venom immunotherapy, because it acts at two sites (no data supports its
cessation in pollen immunotherapy):
o Blocks conversion of angiotensin I to angiotensin II
o Inhibits the same enzyme that destroys kinins, which are known to be
active in anaphylactic episodes
Angiotensin II receptor blockers (ARBs): No data
Key Fact Tricyclics: Exaggerate the response to epinephrine by preventing the reuptake
of catecholamines at ganglionic sites
Recall that the ratio of
total tryptase (pro-
Monoamine oxidase inhibitors (MAOIs): Prevent degradation of epinephrine
β+mature) to mature systemically
tryptase is helpful in
distinguishing
anaphylaxis in
Diagnosis
mastocytosis from other
forms: Total/mature >20 Clinical History—More than one target organ is involved, and history often
= mastocytosis; <10 = involves provocation by known food, drug, or insect allergen exposure.
other cause.
Tryptase may not be Laboratory Findings
elevated in food-induced
anaphylaxis. Check serum histamine 15–60 minutes: Levels begin to rise by 5 minutes but
remain elevated only 30–60 minutes.
Check urinary histamine: Metabolites may remain elevated as long as 24
hours.
Check serum tryptase 15–180 minutes: Peaks 60–90 minutes after the onset of
symptoms and can remain elevated as long as 5 hours.
Platelet-activating factor (PAF): Recent studies suggest that PAF levels more
accurately correlate with anaphylaxis severity scores than either histamine or
tryptase levels.
Evaluation
Investigate suspected allergens or triggers for specific IgE by SPT or in vitro
methods. SPT is often performed at least 4–6 weeks after the episode due to
refractory period of mast cells that can create false negatives. Selection of foods
for testing should be guided by the history.
Management
Short term:
Epinephrine at dose of 0.01 mg/kg intramuscularly (often as 0.3–0.5 mL of
1:1000)
ABCs, supine positioning, and establishment of an airway
Skin inspection
Supplemental oxygen, insertion of one or more large-bore IVs for fluids
Even if on β blockers, administer epinephrine first but consider glucagon.
(Also, recall IV fluids are particularly important for patients unresponsive to
epinephrine)
Long term:
Epinephrine autoinjector
Emergency action plan and medical alert bracelet
Relevant and specific preventive treatment (e.g., avoidance of confirmed
triggers and/or immunomodulation)
Pretreatment is effective for radiocontrast, cold, and fluorescein-related

anaphylaxis. A common protocol consists of 50 mg prednisone 13, 7, and, 1 hour
before the procedure, with 50 mg of diphenhydramineone 1 hour before the
procedure, along with the use of low osmolar contrast material. This intervention
has been shown to lower the risk for reaction to less than 1%. Histamine receptor
roles are shown in Table 7-32.
260 / CHAPTER 7
Table 7-32. Histamine Receptors in Anaphylaxisa

b b
H1 H2 H3
Coronary artery constriction, Coronary artery vasodilation, Autonomic receptor
bronchoconstriction, systemic increase force and rate of downregulator (prevents
vasodilation, increased atrial and ventricular release of additional
capillary permeability, contractions, increased epinephrine from autonomic
tachycardia, pruritus, capillary permeability, increase ganglion, leads to heightened
rhinorrhea secretion of mucus hypotension)
a
The histamine H4 receptor is the most recently identified in the histamine receptor family and in
murine models may be involved in pruritus, chemotaxis, and mast cell cytokine release.
b
Need activation of both receptors for maximal changes in hypotension, headache, and flushing.
PERIOPERATIVE ANAPHYLAXIS
Etiology
Neuromuscular blocking agents (NMBAs)
Hypotonic induction agents (barbiturates)
Antibiotics
Opioids
Latex
Colloids
Risk factors: Asthma, female sex, atopy, multiple past surgeries, mast cell
disorders
Perioperative anaphylaxis has a higher mortality rate than other forms of

anaphylaxis, likely secondary to impaired early recognition (surgical drapes
obscuring view, inability of patient to report symptoms), additional stress of
surgery/illness, and IV administration of medications.
Diagnosis
Diagnosis is mainly clinical. Develop timeline of reaction with all medications,
including NMBAs, latex, and skin prep used during procedure (local anesthetics
like lidocaine or disinfectants like povidone-idoine, chlorhexidine). Elevated
serum total tryptase, plasma histamine, or histamine metabolites in the urine
obtained appropriately suggest anaphylaxis. Wait 4–6 weeks after reaction to skin
test to suspected agents; if negative; consider a nonimmunologic cause.
LATEX ALLERGY
Features
Natural rubber latex (NRL) is a cytoplasmic exudate of the Hevea brasiliensis

tree.
Although there are over 250 NRL proteins, 13 protein allergens from
nonammoniated latex have been characterized and designated as Hev b
allergens (Table 7-33). Key Fact
At-risk populations include health care workers and patients who use latex- Hev b 1 and 3 are less
water-soluble and are more
containing medical devices. Risk is directly related to duration of exposure commonly identified as
and cumulative use of latex-containing products. allergens in sensitized
Some latex proteins cross-react with proteins found in certain fruits and patients with spina bifida,
but are minor in vivo
vegetables (bananas, kiwi, avocado, chestnut). allergens in health care
Cornstarch powder in latex gloves absorbs allergens and acts as an airborne workers.
vehicle to sensitize nearby people by inhalation.
Dipped rubber products (gloves, condoms, balloons) cause most reactions
because these are heat-vulcanized at lower temperatures and have more
proteins intact.
Key Fact
Health care workers react
most frequently to Hev b 5,
Table 7-33. Protein Allergens in Natural Rubber Latex-Isolated and 6, and 7.
Associated Foods
Antigen Trivial Name Predicted Associated Food
Physiologic Roles
Hev b 1 Rubber elongation Rubber biosynthesis
factor
Hev b 2 β-1 and 3-glucosidase Defense-related protein Bell pepper, olive
Hev b 3 Prenyltransferase Rubber biosynthesis
Hev b 4 Microhelix component Defense-related protein
Hev b 5 Acidic protein Kiwi, potato, and sugar
beet
Hev b 6 Hevein and prohevein Defense-related protein Avocado, banana,
proteins (latex coagulation) chestnut, sweet pepper
Hev b 7 Patatin-like proteins Defense-related protein Potato and tomato
or inhibitor of
biosynthesis
Hev b 8 Profilin Structural protein
Hev b 9 Enolase
Hev b 10 Manganese superoxide
dismutase
Hev b 11 Class I endochitinase
Hev b 12 Lipid transfer protein Defense-related protein
Hev b 13 Latex esterase Potato
262 / CHAPTER 7
Diagnosis
Identification of NRL-specific IgE associated with symptoms that are consistent

with IgE-mediated reactions to latex protein allergens. There are no standardized
skin test extracts. The in vitro assays have wide ranges of sensitivity (73–92%)
and specificity (73–97%).
FOOD-DEPENDENT EXERCISE-INDUCED ANAPHYLAXIS
Features
Exercise-induced anaphylaxis (EIA): Symptoms occur after physical activity.
Food-dependent exercise-induced anaphylaxis: Variant of EIA that requires

ingestion of certain foods within minutes to a few hours prior to vigorous physical
activity . The culprit food can be ingested without symptoms if there is no
associated exercise, and these patients can exercise as long as they have not eaten
the offending food.
Associated foods include:

Crustaceans
Cephalopods
Celery
Grapes
Chicken
Wheat
Buckwheat
Tomato
Key Fact Dairy product
Celery and wheat are the
Mushrooms
most common foods
associated with food- Clinically, there are two subsets of patients with food-dependent EIA:
dependent EIA.
Rarely patients develop anaphylaxis when exercising within a short time after
ingestion of any type of food (usually solids rather than liquids).
More commonly patients have anaphylaxis with exercise only after ingestion
of a specific food.
Management of food-dependent EIA includes avoiding exercising in proximity

(4–6 hr) to food consumption, carrying self-injectable epinephrine, exercising
with a partner, and wearing a medical alert bracelet.
STINGING INSECT ALLERGY
STINGING INSECTS (ORDER HYMENOPTERA)
Family Apidae
Apis Mellifera (Honeybee)—Used commercially for honey production and
pollination; beeswax nest with numerous vertical combs (Figure 7-8A); not
aggressive, and only females will sting when provoked; barbed stinger that
remains in victim’s skin, killing the insect.
African–European Hybrid Bees (Killer Bee—Escaped from a lab in Brazil in

1957 and have gradually migrated into the southern US. Similar to domestic
honeybees and deliver identical allergen protein when it stings; however, they
have a tendency to swarm with little provocation and sting in large numbers,
causing a toxic reaction that can be fatal. Their aggressive nature has earned them
the title "killer bees."
Bombus Spp (Bumblebee)—Subterranean or concealed nests made up of loose

fibrous material; not aggressive but will sting when nests are disturbed; attack is
loud, and slow so avoidance is fairly easy.
Family Vespidae
Subfamily Vespinae—Multilayered paper nests made of masticated wood. Can Key Fact
sting repeatedly without losing sting apparatus. Think yellow jacket!
Flying hymenoptera are
Vespula spp. (yellow jacket): Picnic and trash can scavengers; highly found around garbage
aggressive, especially in summer and autumn when larger populations cans or food.
compete for food supplies; often sting for no apparent reason; nests found in
concealed locations, either underground, in wall cavities, or decaying logs
(Figure 7-8B); responsible for most human stings.
Dolichovespula arenaria and D. maculata (yellow hornet and white-faced
hornets): Aerial-nesting yellow hornets found in North America but not
Europe; nests found around human dwellings; sensitivity to vibrations sets off
their defensive sting behavior.
Subfamily Polistinae—Polistes spp. (paper wasp): Nest constructed of a single

layer of open cells (or comb) that are found on eaves or window sills of homes
(Figure 7-8C). Narrow “wasp waist” and dangling legs when in flight; less
aggressive, but can sting repeatedly without losing sting apparatus.
264 / CHAPTER 7
A B
Figure 7-8. (A) Honeybee nest; (B) yellow jacket nest; (C) paper wasp nest.
(Images courtesy of Wikipedia.)
Family Formicidae
Solenopsis invicta (Imported Fire Ant). Large subterranean nests. Widespread
in the southeastern US. Are aggressive and have a true sting apparatus; they
anchor by their mandibles and pivot to administer multiple stings that develop
into characteristic sterile pustule at site within 24 hours after sting. Arrived in
Mobile, Alabama, in the 1940s and have slowly spread, adapting to colder
climates, with nests found as far north as Maryland.
Epidemiology
Systemic reactions reported in 3% of adults and 1% of children; approximately
30–50 fatal stings occur per year in the US, with half of those occurring in people
with no prior history of allergic reaction to sting.
Presentation
Table 7-34 is a summary of clinical presentation of stings from insects.
Table 7-34. Clinical Presentation of Insect Stings Key Fact

Normal Immediate, local, and transient erythema, also edema and tenderness Whole-body extracts
at site (WBE) for flying
Large local Pronounced erythema, edema, and tenderness extending over a large hymenoptera contain
area, peaking at 48 hr after sting, and lasting up to 1 week little or no venom and
are ineffective for
Systemic Immediate, generalized IgE-mediated anaphylactic reaction diagnosis or treatment
Other Toxic, serum sickness, neuropathy, and rhabdomyolysis of venom allergy, unlike
imported fire ant venom,
in which WBE is
routinely used for
diagnosis and treatment
of imported fire ant
Diagnosis allergy
Clinical History—The most important diagnostic tool is the clinical history; it

should include the nature and timing of stings, the temporal relation between sting Key Fact
and development of reaction as well as all associated symptoms and treatments. Degree of skin test
sensitivity does not
Laboratory Tests correlate with the
degree of sting reaction.
Skin tests: Unlike testing for other allergies, the venom skin prick testing is
not always done prior to intradermal testing, although it is reasonable in
patients with a history of severe anaphylaxis who may be extremely sensitive
to venom (1.0–100 μg/mL). Intradermal technique begins with concentrations
between 0.001–0.01 μg/mL and proceeds by 10-fold increments until a Key Fact
postive result or a maximum concentration of 1 μg/mL is reached. At Diagnosis of insect sting
concentrations > 1 μg/mL venom can cause false positives due to irritant allergy must include a
effects. Negative skin testing in the days or weeks after a sting reaction may clear clinical history and
be attributed to a refractory period of “anergy.” For these patients, the skin positive-specific IgE to
hymenoptera venom.
test should be repeated after 4–6 weeks.
In vitro tests: For patients whose skin tests are negative, but who have a
history of a severe systemic reaction to an insect sting, serologic testing
should be performed before concluding that venom immunotherapy (VIT) is
unnecessary. Serologic testing is negative in up to 20% of skin test-positive Flash Card Q27
patients, and skin tests are negative in up to 10% of persons found to have If severe hypotension
venom-specific IgE. If in vitro testing is negative and suspicion is still high, occurs after a
then repeat skin testing may be considered. A baseline serum tryptase level hymenoptera sting, what
can be drawn to evaluate for a possible mast cell disorder. key blood test should be
done?
Sting challenge tests: Thirty percent to 60% risk of systemic reaction to
subsequent stings in patients with a prior history of systemic reaction and with
evidence of serum-specific IgE; therefore, a lack of reaction on sting
challenge has limited clinical significance. It is also the gold standard for
Flash Card Q28
assessing efficacy of VIT in research studies.
False-positive (irritant)
results to intradermal
testing are more likely
above what venom
concentration?
266 / CHAPTER 7
Treatment and Prevention
Acute Reactions
Large local: Symptomatic treatment with ice, NSAIDs, and H1
antihistamines. Topical steroids or oral steroid bursts can be used for more
bothersome local reactions.
Systemic: Immediate administration of IM epinephrine with additional
observation, systemic steroids, and antihistamines. With severe reactions,
consider obtaining baseline tryptase to rile out mast cell disease.
Venom Immunotherapy—Treatment of choice for prevention of further systemic

reactions to insect stings. It is indicated for patients with clinical history of
anaphylaxis to insect sting and evidence of venom-specific IgE with skin test or
serologic testing (Table 7-35).
VIT Safety—Fifty percent of patients have large local reactions and 5–15% have
systemic symptoms during the build-up phase. The majority of reactions are mild,
and < 5% require treatment with epinephrine.
VIT Efficacy—Seventy-five percent to 95% efficacy rate with maintenance dose

of 100 μg of venom (for single antigen) or 300 μg of venom (for mixed vespids).
Table 7-35. Recommendations Based on Sting History and Results of

Testing
Risk of
Reaction to Skin Test or in
Systemic Clinical Advice
Previous Sting Vitro Test
Reaction (%)
No reaction 1–3
Large local Not indicated 5–10 No VIT
Urticaria/angioedema Positive—Child < 16 yr 10 No VIT

Positive—Adult ≥ 16 yr 20 VIT
Flash Card A27
Anaphylaxis Positive—Child 40 VIT
Tryptase
Positive—Adult 60 VIT
Negative Repeat ST/in vitro
test
Abbreviations: ST, sting test; VIT, venom immunotherapy.
Flash Card A28
Concentrations > 1
μg/mL, therefore not
recommended for
diagnostic purposes
Doses and Schedules—Standard maintenance dose is 100 μg of venom (for Key Fact
single antigen), but can be increased to a 200 μg maintenance dose if treatment
Patients who have
fails. For mixed vespids, a standard maintenance dose of 300 μg is used. received VIT for at least
Schedules are highly variable, and risk of systemic reactions with rush regimens 5 years have ~10%
are not much higher than traditional regimens. Imported fire ant extract is chance of systemic
composed of WBE and has a maintenance dose of 0.5 mL of a 1:10 to 1:200 reaction with each sting
wt/vol extract given monthly. after stopping treatment.
Patients should
therefore continue to
Discontinuation—General recommendation is to continue VIT for at least 3–5 have epinephrine
years. Those patients with a very severe initial reaction, patients with systemic available even after
reactions to injection or sting while on therapy, or those with honeybee allergy discontinuing VIT
might need to continue VIT indefinitely. (general population risk
~3%).
BITING INSECT ALLERGY
Kissing Bug (Triatoma)—Most common cause of systemic reactions to biting Key Fact
insects. Most often a nocturnal painless bite that causes an erythematous urticarial
The allergens in biting
nodule or plaque. Relevant allergens are salivary gland proteins; small studies
insects are found in the
have shown benefit with immunotherapy with salivary gland extracts. saliva.
Mosquito (Culicidae)—Anaphylaxis to mosquito bites is rarely reported. Large

local reactions are more common in children, may be accompanied by fever
(skeeter syndrome), and are due to sensitization to mosquito salivary secretions;
mosquito extracts are not approved for therapeutic use. Antihistamines can be
used to relieve large local reactions from mosquito bites.
Horsefly and Deerfly (Tabanidae)—Large, blood-sucking flies that inflict

painful bites; anaphylaxis following bites has rarely been reported.
Asian Lady Beetle (Harmonia Axyridis)—Bites in sensitized individuals have

been associated with rhinitis, urticaria, and asthma symptoms; considered an
indoor allergen and has cross-reactivity with cockroach on skin testing.
DRUG REACTIONS Flash Card Q29

A 6-year-old boy
camping in Texas
The term adverse drug reaction is broadly used to cover a variety of reactions, awakens with diffuse
hives, shortness of
including expected side effects (e.g., sedation with antihistamines), intolerances breath, and wheezing
(AERD), allergic reactions (PCN-induced anaphylaxis), or pseudoallergic after a painless bug bite.
reactions (radiocontrast media). Only about 10% of adverse drug reactions are What biting insect would
allergic. you be most concerned
about?
268 / CHAPTER 7
Physicians must know the Gell-Coombs classification of drug reactions:

Type I: Immediate IgE-mediated hypersensitivity (e.g., PCN-induced
anaphylaxis).
Type II: Antibody-dependent cytotoxic reactions.
Type III: Immune complex reactions (i.e., secondary to an antibiotic)
Type IV: Cell-mediated or delayed hypersensitivity reactions (e.g., to purified
protein derivative [PPD]).
Many drug reactions do not fit neatly into this pattern, and some actually involve
multiple components of the Gell-Coombs classification. It is also valuable to
Key Fact know the subclassification of type IV reactions (Table 7-36).
The hapten hypothesis
states that small drugs,
which are not by
Pathophysiology
themselves
immunogenic (haptens), The prohapten hypothesis recognizes that most drugs by themselves are not
become immunogenic or immunogenic until they are metabolized to a reactive metabolite. More recently
allergenic after binding described, the pharmacologic interaction of drugs with immune receptors (p-i
to a self-carrier protein.
concept of drug allergy) states that once a drug binds to a T-cell receptor (TCR)
So, PCN is not
allergenic until it is with sufficient affinity, especially in context of the TCR interacting with major
haptenized; however, histocompatibility complex (MHC), then it may become immunogenic. This latter
one must remember that concept may explain hypersensitivity reactions that can occur even when
the hapten refers to receiving a medication for the first time.
PCN, not to the carrier
protein.
Table 7-36. Subclassification of Type IV Reactions

Reaction Cytokines Cells Involved Clinical
Manifestations
Type IVa Th1 (IFNγ) Monocyte Eczema
Type IVb Th2 (IL-4 and IL-5) Eosinophil Maculopapular or bullous
Type IVc CTL (perforin and CD4 and CD8 Maculopapular or bullous
granzyme) to pustular and
increased CD8 T
lymphocytes in skin
Type IVd T lymphocytes and IL-8 PMNs Pustular

Abbreviations: IFNγ, interferon gamma; PMNs, polymorphonuclear neutrophils.
Flash Card A29

Triatoma
Risk Factors
Risk factors for drug allergy include:
Higher dose
IV route
Large-molecular-weight agents
Frequent or repetitive courses
Duration of previous courses
Female gender
Reactions are less frequently noted in infants and the elderly. HLA-DR3 is an
MHC marker associated with increased reactions to insulin, gold, and
penicillamine. HLA-B*5701 is strongly associated with reactions to abacavir and
should be checked for prior to starting this drug. Atopy is not a risk factor for
most drug allergy, but is for reactions to latex or radiocontrast reactions.
Common Drug Reactions

Penicillin
Major determinants = Benzylpenicilloyl polylysine (Pre-Pen)
Minor determinants = Penicillin G; penicilloate and penilloate if available Key Fact
Ampicillin and/or amoxicillin (3–25 mg/mL) if relevant to the patient’s care
PCN-specific IgE
antibodies decrease
Most PCN allergy (80%) is related to the major determinant. Approximately 10% over time (~10% per
of patients report a history of PCN allergy; however, ~90% of these patients will year). Therefore, ~50%
tolerate PCN. of patients who had
immediate reactions to
PCN will have a
The predictive value of negative skin tests to PCN’s major determinants (i.e., negative skin test after 5
PrePen) and minor determinants is ~97% for ruling out anaphylactic years, and ~80% will be
potential. The predictive value of positive skin test to PCN is about 60%. Ten negative at 10 years.
percent to 20% of PCN allergic patients only react to minor determinants,
therefore they should be included in any PCN skin test to have adequate
predictive value. After losing PCN allergy, resensitization is rare with oral
medications, but more common with subsequent exposure to high-dose IV PCN Mnemonic
(e.g., ~16%).
AZtreonam cross-reacts
with ceftaZidime.
Ampicillin/Amoxicillin (AMP/AMOX)
Patients may have IgE antibodies against side chains (R-group) rather than the
core PCN determinants. Such patients are negative for the PCN skin test and able
to tolerate other PCN compounds. Approximately 10% of patients have a
delayed maculopapular rash with AMP/AMOX, which is not IgE-mediated.
270 / CHAPTER 7
If patients have Epstein-Barr virus and get AMP/AMOX, ~80% will develop
such a rash.
PCN has moderate cross-reactivity with carbapenems (e.g., imipenem or

meropenem) based on skin testing, but clinically important cross-reactivity is
much rarer (0–11%), and there are no reactions in patients with negative PCN
skin tests to imipenem or meropenem. A monobactam, aztreonam, does not cross-
react with other β-lactams, except for ceftazidime.
Cephalosporins
Cross-reactivity with PCN is rare (~2%), but some reactions can be fatal. The low
cross-reactivity may be because some cephalosporin allergy can occur due to the
R-group side chain and not the β-lactam ring. In general, first- and second-
generation cephalosporins cause more allergic reactions than do third- and fourth-
generations cephalosporins.
To determine if a patient with a history of PCN allergy may safely receive a

cephalosporin, you should perform PCN skin testing. Patient who are negative
on the PCN skin test may safely receive cephalosporins. Cephalosporin skin
testing does not have sufficient negative predictive value to rule out anaphylactic
risk in a patient with a convincing history. If PCN skin testing is unavailable, risk
stratify the reaction and then either directly administer the drug, perform a graded
challenge, or desensitize the patient
Sulfonamides
Prototype here is TMP/SMX. Contains SO2NH2 moiety. Most clinically important

sulfonamide allergy is due to sulfa antibiotics. The typical reaction is a delayed
maculopapular rash, likely T-lymphocyte-mediated. This is a very common
reaction to TMP/SMX in patients with HIV (40–70%). Type I reactions, which
are much rarer, are due to the N4 sulfonamidoyl hapten acting as the major
determinant. There is little clinically relevant cross-reactivity between
sulfonamide antibiotics and sulfonamide nonantibiotics (e.g., furosemide),
because nonantibiotic sulfonamides lack the aromatic amine at the N4 position.
Pseudoallergic Reactions
These reactions include “anaphylactoid” reactions (a term that is falling out of

favor), which indicates that they are non-IgE-mediated. This includes reactions to
radiocontrast dye, ASA and/or NSAIDs, and opiate-induced urticaria. These
reactions are typically mediated by basophil and mast cell activation.
Radiocontrast adverse reactions are increased in women, asthma and/or
atopy, cardiovascular disease, and prior history of reaction. Reactions to

radiocontrast media may be attenuated or prevented by the use of lower ionic
contrast media (or nonionic), and premedication with steroids and antihistamines.
(Note that true anaphylactic reactions are not preventable in this manner.)
Blistering Drug Reactions (SJS and TEN)
Stevens-Johnson syndrome (SJS) is defined by less than 10% epidermal

detachment. In SJS, patients present with confluent, purpuric macules on face
and/or trunk, mucosal involvement, and often systemic symptoms and fever.
Other organ involvement may include ocular, liver, kidney, and lung. By contrast,
toxic epidermal necrolysis (TEN) is more severe (>30% involvement).
Although steroids may be helpful in early SJS, they are contraindicated in TEN.
High-risk agents include PCN and sulfonamides, anticonvulsants, NSAIDs, and
allopurinol. Mechanisms of action include reactive metabolites causing Fas/FasL-
mediated apoptosis of epidermal cells as well as cytotoxic T-lymphocyte
activation and perforin release.
Treatment is supportive, although intravenous immunoglobulin (IVIG) can be

helpful due to the presence of Fas-blocking antibodies.
Vancomycin
“Red man syndrome” is a rate-related infusion reaction characterized by flushing, Mnemonic
erythema, and pruritus caused by direct activation of mast cells. May respond to Remember VAncomycin
decreased rate, premedication with antihistamine, and stopping concurrent may cause IgA bullous
narcotic medications. Vancomycin may also cause linear IgA bullous dermatitis dermatitis.
with tense blisters. Less commonly, this reaction may occur due to captopril,
furosemide, lithium, or TMP-SMX (Bactrim).
ACE I Reactions
Cough may occur in up to 20% of patients. ACE I-induced angioedema is usually

observed in the first week after starting the medication; however, up to 30% of
patients present months or even years afterward. Interferes with degradation of
bradykinin and therefore rarely responds to antihistamines or steroids. May occur
in up to 0.7% of the population and is increased in African Americans.
Intermittent angioedema can develop for up to a month after the patient is off the
medication, and around 2% of patients continue to have episodes when switched
to another antihypertensive. The risk of recurrent angioedema with use of
angiotensin receptor blockers (ARBs) is quite low.
272 / CHAPTER 7
Drug Rash with Eosinophilia and Systemic Symptoms

(DRESS)
Common offending agents are anticonvulsants, sulfonamides, allopurinol, and
minocycline. May be accompanied by fever, lymphadenopathy, and hepatitis.
Facial edema is characteristic. This reaction occurs weeks after therapy, develops
over days, and, unlike most drug reactions, symptoms may worsen even after drug
discontinuation and last for weeks afterwards. Initial treatment is with systemic
corticosteroids. IVIG has been reported to be helpful in patients who did not
respond to systemic steroids.
Fixed Drug Eruption

Typically, fixed drug eruption appears as a purple-blue macule that occurs at
same location upon each subsequent exposure to the drug but may take any
dermatologic manifestation. Due classically to Bactrim or phenolphthalein.
Local Anesthetic Agents

Although lidocaine and other “-caine” medications are commonly blamed for
“allergic reactions,” these rarely cause any actual hypersensitivity; rather, these
are associated most commonly with vagal reactions (e.g., a clinical clue is
bradycardia as opposed to the usual tachycardia that would accompany
anaphylaxis). Positive skin tests do not necessarily indicate actual allergy;
therefore, graded challenges are more predictive of allergic reactions.
Perioperative Agents
Perioperative drug reactions are most commonly due to quaternary ammonium
muscle relaxants such as succinylcholine. These agents do not require
haptenation since they act as bivalent antigens able to directly bind adjacent IgE
antibodies on cell surfaces. Skin testing has been shown to be helpful in such
cases if positive; if negative, the predictive value is uncertain. Other IgE-mediated
perioperative reactions can be due to latex, antibiotics, barbiturates, or propofol
(contains sulfites).
Insulin
Up to 50% of patients receiving insulin may develop anti-insulin antibodies, but

these patients often tolerate insulin without clinical reactions. HLA-DR3 confers
increased risk. Allergenicity of insulin preparations = bovine > porcine > human.
Most patients can tolerate continuing insulin treatment despite local reactions;
however, if needed, antihistamines or splitting doses may help. Patients receiving
NPH insulin may have allergy to the protamine component rather than the insulin,
and switching to nonprotamine-containing insulin can be helpful. Anaphylactic
reactions are rare but may occur; insulin desensitization has been successfully
performed.
Biologics
This wide class of drugs may be associated with a variety of adverse reactions.
Many are prone to cytokine release syndrome with resultant fever, rash,
bronchospasm, capillary leak syndrome, GI symptoms, meningoencephalopathy
with abnormal liver functions tests (LFTs), uric acid, lactate dehydrogenase
(LDH), IL-6, and TNFα. Inciting agents may include rituximab (anti-CD20) or
muromonab (anti-CD3).
Sirolimus (rapamycin), which antagonizes IL-2 signaling in particular, is known

to cause capillary leak syndrome with resultant hypotension. Interestingly, high-
dose monoclonal antibody therapy with IL-2, used in the treatment of metastatic
melanoma, is also known to cause this syndrome (cytokine storm).
Interferon therapy may cause:

Flu-like symptoms
Urticaria
Dermatitis
Vasculitis
Idiopathic thrombocytopenic purpura (ITP)
Autoimmunity
Depression
TNF inhibitors may cause serum sickness reactions. Etanercept causes injection-
site and local reactions. Epoetin may paradoxically provoke pure red cell aplasia.
Alteplase and tissue plasminogen activator (tPA) may cause anaphylactoid
reactions. Any of the anti-TNF drugs (e.g., infliximab, etanercept) may cause
disseminated mycobacterial infection and/or TB, so checking a PPD prior to
therapy and annually thereafter is recommended.
More recently, a novel mechanism of anaphylaxis to cetuximab has been

described. Cetuximab is a monoclonal antibody against the epidermal growth
factor receptor and is used in certain colorectal and head and neck cancers. The
rate of hypersensitivity reactions to cetuximab varies by geographic region.
Molecular analyses have found that this is predicted by the presence of IgE
antibodies against naturally occurring galactose-α-1,3-galactose (i.e.,
oligosaccharides related to the ABO blood group) even prior to exposure to
274 / CHAPTER 7
cetuximab. These pre-existing IgE antibodies appear to put such patients at risk
for anaphylaxis to cetuximab, which also contains galactose-α-1,3-galactose.
Drug-Induced Cytopenias
Immune-induced hemolytic anemia may classically be due to quinidine,
methyldopa, or PCN. Immune-induced thrombocytopenia may classically be due
to:
Quinidine
Propylthiouracil
Gold
Sulfonamides
Vancomycin
Heparin (i.e., specific IgG to heparin-platelet factor 4 forms immune
complexes)
Pulmonary Drug Hypersensitivity

Pulmonary drug hypersensitivity presents with:
Cough
Migratory infiltrates
Peripheral eosinophilia
Pulmonary fibrosis
May be seen with bleomycin, methotrexate, and nitrofurantoin. Nitrofurantoin

may also be associated with pleural effusion or interstitial pneumonitis and/or
fibrosis. NSAIDs may be associated with eosinophilic pneumonia.
Serum Sickness
Serum sickness occurs most readily or efficiently in the setting of slight antigen
excess. It may occur with PCN, sulfonamides, and phenytoin. It is secondary to
formation of immune complexes. Classic findings include:
Fever
Erythema multiforme or urticaria
Arthralgias
Lymphadenopathy (typically appearing 1–3 weeks after starting treatment)
Symptoms may last weeks. Best treatment is to stop the offending medication,
steroids, and antihistamines, which cannot be desensitized.
Drug-Induced Lupus
Drug-induced cutaneous lupus is associated with anti-Ro (SSA) antibodies.
Typically, physicians will see photodistributed erythema or scaly, annular plaques
weeks after starting a drug. Common agents are
Hydrochlorothiazide (HCTZ)
Calcium channel blockers
ACE inhibitors
Antifungals
This is not to be confused with drug-induced lupus (systemic) in which you see
antihistone antibodies and which is commonly secondary to procainamide,
hydralazine, phenytoin, and isoniazid.
Chemotherapeutics
Taxanes (e.g., paclitaxel, docetaxel) cause anaphylactoid reactions, which may be
treated or prevented with steroids and antihistamines. Platinum compounds (e.g.,
cisplatin, carboplatin, and oxiplaten) can cause IgE-mediated, classic allergic
reactions; thus, patients may be desensitized if necessary. Asparaginase may
cause either anaphylactoid or anaphylactic reactions; however, some patients only
react to asparaginase produced from Escherichia coli, so substituting formulations
from other sources may avoid future reactions. Skin testing to asparaginase may
help identify some at-risk patients.
DIAGNOSIS
Choosing an alternative, non-cross-reactive drug is not always feasible for certain

clinical scenarios. Unfortunately, the relevant epitopes are not known for most
drugs, making predictions based on testing challenging. Since benzylpenicilloyl
polylysine (PrePen) is now available commercially again, skin testing can be
performed for PCN. Using major and minor determinants, PCN skin testing has a
negative predictive value for serious reactions approaching 100%. For
medications other than PCN, unstandardized skin testing to liquid or solution
forms of the drug may be pursued, and the known irritant concentrations are
published for several antibiotics. Positive skin tests to a nonirritating
concentration of the drug, especially in the context of a convincing history,
suggests that drug-specific IgE may be present.
276 / CHAPTER 7
TREATMENT
If drug allergy is suspected based on history and/or testing, an equally efficacious
non-cross-reacting alternative is indicated. If the suspected allergen is absolutely
required have the patient undergoes desensitization. Negative skin tests are not
sufficient proof that drug allergy (i.e., drug-specific IgE) is absent since the drug
metabolite that is the relevant allergen may not be present in the testing reagent.
Negative skin tests may be helpful in choosing the initial dose for desensitization
or prior to a graded oral challenge, but only if the history suggests a mild reaction.
GRADED CHALLENGES
Drug provocation tests may be pursued in patients with a low pretest probability
of being allergic to a given drug. These may consist of two or more doses given in
incrementally increasing doses every 30–60 minutes. Generally, these are
completed in five or fewer doses and, therefore, this procedure in itself is not
designed to induce desensitization or tolerance. The starting doses used are
generally higher than those used during drug desensitization.
DRUG DESENSITIZATION
Higher-risk situations may warrant drug desensitization rather than graded
challenge. Risk factors would include a concerning clinical history (i.e., initial
reaction was anaphylactic or urticarial), recent rather than remote reactions, and
certain comorbid conditions (e.g., heart disease). Patients receive progressively
increasing doses of the drug every 15–20 minutes for IV medications or every 20–
30 minutes for oral dosing until a full therapeutic dose is tolerated. Using this
technique, tolerance may be induced in almost all drug-allergic patients. Skin
testing may help identify acceptable starting doses. Mild-to-moderate reactions do
not necessarily preclude continuing desensitization but do warrant repeating the
dose at which the reaction occurred or decreasing the dose after the reaction
subsides. Using modern protocols, the success rate for tolerance induction is
extremely high, and serious systemic reactions are rare. Acute desensitization is
drug-specific. After desensitization, the drug needs to be continued at regular
intervals, or resensitization will occur. Therefore, repeat desensitization is usually
required for future courses of the drug should therapy be interrupted.
Contraindications to desensitization include exfoliative or blistering skin
reactions and immune complex-mediated reactions, which include:
TEN/SJS
DRESS
Serum sickness
Hepatitis
Hemolytic anemia
Nephritis
Urticaria
Urticaria lesions are raised, pruritic, erythematous, and transient (i.e., lasting <
24 hr at the same location), and are also known as “hives” (Figure 7-9).
Pathologically, urticaria results from the activation of vasoactive mediators,
including histamine, leukotriene, and others that lead to dilation and increased
permeability of blood vessels and edema in the superficial dermis. Angioedema
occurs when these mediators are released in the deep dermis and subcutaneous
tissue.
Acute Urticaria
Acute urticaria is defined as the presence of urticaria for less than 6 weeks. It
occurs in up to 20% of the population and is often associated with drug, food, or
other allergy, or with infection.
Figure 7-9. Urticaria.

278 / CHAPTER 7
Chronic Urticaria
Chronic urticaria is defined as the presence of urticaria for more than 6 weeks. It
occurs in about 1% of the population and is self-limited in most patients; typically
presenting in the third to fifth decades of life, with an average duration of 2–5
years. Around 40% have associated angioedema. Chronic urticaria is usually
subdivided into two general categories:
Chronic autoimmune urticaria (40–45%)
Chronic idiopathic urticaria (55–60%)
Mnemonic
Imagine that urticaria is Chronic Idiopathic Urticaria (CIU)
like raised maps on Diagnosis of exclusion after ruling out acute urticaria and physical urticarias;
different parts of skin, identifiable etiologies may be found in less than 2% of cases.
Itching Maps:
Pathogenesis of CIU still unclear. More recent studies point to histamine-
Infections: Bacterial releasing factors and defects in basophile signaling and/or function.
(including Helicobacter Thyroid autoantibodies (antithyroglobulin or antimicrosomal) are present in
pylori), fungal, viral, and more than 20% of patients with CIU. Their presence does not necessarily
helminthic
Transfusion reactions
correlate with abnormal thyroid function. The role of these autoantibodies is
Chronic idiopathic unknown but may signify a predilection for autoimmunity.
urticaria
Hereditary diseases:
Hereditary angioedema,
familial cold urticaria,
Mediators
(amyloidosis with Mast cell: Histamine, prostaglandin D, leukotrienes LTC4 and LTD4, and
deafness and urticaria) PAF
Inhalation or contact with
Complement system: Anaphylatoxins C3a, C4a, and C5a; histamine
allergens
NSAIDs and/or drug Hageman factor-dependent pathway: Bradykinin
reactions Mononuclear cells: Histamine-releasing factors and chemokines
Gut: Foods or food
additives
Mastocytosis (systemic): Etiologies

Urticaria pigmentosa
and Malignancy Refer to the mnemonic “Itching Maps” for a listing of etiologies.
Autoimmune urticaria
Physical urticarias:
Different types
Systemic lupus Physical Urticaria
erythematosus and
other collagen vascular
diseases Table 7-37 summarizes the various types of physical urticarias.
Table 7-37. Types of Physical Urticarias

Physical Urticarias Triggers Tests
Dermatographism: very common, 2– Stroking of skin results Stroke skin with a blunt,
5% of population in linear wheals smooth object (e.g., tongue
depressor)
a
Cold urticaria Occurs on cold- Ice cube test: Place ice cube
exposed areas of on skin for 5 min, treat with Key Fact
body, systemic cyproheptadine (C for cold) Cold urticaria
reaction can occur
syndromes that have a
with immersion in
lakes or pools negative ice cube test:
Cold-induced cholinergic
Local heat urticaria Occurs on warm- Apply water heated to 45°C in urticaria, systemic cold
exposed areas of body a test tube on skin for 5 min, urticaria, and cold-
treat with hydroxyzine (H for dependent
heat) dermographism.
Cholinergic urticaria or Generalized Elevation of body Various Testing Methods:
Heat Urticaria: temperature (e.g., Intradermal injection of
~30% of all cases of physical heat, exercise, methacholine
urticaria, characterized by numerous emotional stress, spicy Have patient ride stationary
small punctate wheals foods) bike or run on treadmill until
Autologous sweat sensitivity: Sweat point of sweating, then
Key Fact
may cause basophil degranulation in continue for 15 min Cholinergic urticaria can
sensitive subjects who have positive Nonexertional elevation of also present with
skin test to own sweat core body temperature by hypotension and look
submerging arm of patient clinically similar to
in 42ºC hot water bath until
exercise-induced
core temp increases ≥1°C
anaphylaxis (EIA). The
key difference is that
Solar urticaria Exposure of skin to Simple exposure of patient’s patients with EIA will not
sunlight (triggering skin to natural sunlight react with passive
wavelengths vary) Phototesting: Skin is exposed heating.
to UVA and UVB of varying
wavelengths using a
monochromatic light source
Aquagenic urticaria Small wheals result Apply 35°C water compress to

from contact with upper body for 30 min
water, independent of
temperature; salinity of
water important in
some cases
Delayed-pressure Symptoms can Sling attached to a 10–15 lb

Urticaria/angioedema develop 30 min to 12 weight is placed over arm or
hr after pressure has shoulder for 15 min. Patient
been applied to skin reports response over next 4–
24 hr
a
Other cold urticaria syndromes include cold-dependent immunoglobulin diseases
(cryoglobulinemia and cold agglutinin disease), delayed cold urticaria, localized cold urticaria, and
localized cold reflex urticaria.
280 / CHAPTER 7
Laboratory Tests
Blood Tests—Blood tests are usually not helpful for determining the cause of
acute urticaria. For chronic urticaria without identified etiology, limited or
targeted testing may be done for patients who have an otherwise unremarkable
history and physical exam. Skin biopsy only if history or physical exam is
suggestive of vasculitic process.
Treatment
Goal of therapy is to achieve a level of symptom control that is acceptable to
patient while minimizing side effects:
Acute Urticaria
Elimination of trigger factors when identified
Second-generation H1-antihistamines and first-generation H1-antihistamine at
bedtime
Chronic Urticaria: Antihistamine monotherapy first line

Second-generation H1-antihistamines
H2 receptor antagonist
Doxepin (tricyclic antidepressant: Both H1 and H2 receptor antagonists)
Leukotriene antagonists: Not great evidence but inexpensive, safe
Refractory cases may need corticosteroid therapy
Examples of third-line agents used when high-dose antihistamines are ineffective:

Cyclosporine
Tacrolimus
Methotrexate
Sulfasalazine
Dapsone
Hydroxychloroquine
Omalizumab
Colchicine
IVIG
Urticarial Vasculitis and Hypocomplementemic Urticarial

Vasculitis Syndrome
Urticarial Vasculitis (UV)—Lesions are less pruritic and described as painful or

burning, individual hives last >24 hours, leave residual purpura or
hyperpigmentation. Elevated erythrocyte sedimentation rate (ESR), arthralgias,
myalgias, fever, leukocytosis are common associated abnormalities.

Histopathology shows leukocytoclasis and vessel wall damage.
Hypocomplementemic Urticarial Vasculitis Syndrome (HUVS)—Urticaria

with hypocomplementemia, includes systemic findings such as
arthralgias/arthritis, obstructive lung disease, glomerulonephritis, uveitis,
angioedema, and recurrent abdominal pain. Laboratory findings include low C3,
C4, and C1q, anti-C1q antibodies, and elevated ESR.
CONTACT HYPERSENSITIVITY
Pathogenesis—Contact hypersensitivity (CHS) is a type IV hypersensitivity that

is mediated by CD4 and CD8 lymphocytes stimulated by epidermal antigen-
presenting cells (Langerhans cells). Once sensitized, dermatitis is delayed 12–48
hours upon re-exposure to the triggering antigen.
Diagnosis—Made by patch testing: Place patches on day 1, read and remove on

day 3, read again on day 5 (Figure 7-10). Defining the clinical relevance of
positive patch test reactions is of central importance (Table 7-38 and Figure 7-
11).CHS can be divided into four categories based on etiology. Differentiating
allergic versus irritant reactions can be difficult as both ACD and ICD are
indistinguishable clinically and histologically. Lymphocytic infiltration and
spongiosis are the predominant histologic features of contact dermatitis.
Figure 7-10. Patch test applied in Finn Chambers to a patient’s back.

(Reproduced, with permission, from The National Institute for Occupational Safety and Health
[NIOSH] of the CDC.)
282 / CHAPTER 7
Table 7-38. Scoring System for Patch Test Reactions

Score Interpretation Final Read
- No evidence of skin changes Negative reaction
? or +/- Limited to faint macular erythema; use caution when Doubtful reaction
interpreting, especially with less common allergens
+ Erythema and edema that is palpable with slight Weak reaction
infiltration that occupies >50% of patch test site
++ Microvesicles and erythema that occupy at least 50% of Strong reaction
patch test site
+++ Confluent vesicles or bullae, ulcerative Extreme reaction
IR Mild: glazed appearance Irritant reactions
Moderate: follicular (pustular in atopics)
Extreme: can be ulcerative
Allergic Contact Dermatitis (ACD)—Delayed type of induced sensitivity

(allergy), characterized by an antigen-specific T–lymphocyte-mediated
hypersensitivity reaction.
Location: Hands 27%, generalized 18%, face 16%, eyelids 5%, trunk 5%, and
feet 3%
“Crescendo” phenomenon, where positive reactions to patch test become more
marked between first and second readings
Characterized by severe pruritus, reactions usually take 12–48 hours to
develop
+++ ++
+ +/–
Figure 7-11. Positive patch test reactions. (+++, extreme positive reaction; ++,
strong positive reaction; +, weak positive reaction; +/–, equivocal/uncertain
reaction.)
(Reproduced, with permission, from Luz Fonacier, MD, State University of New York at Stony
Brook)
Irritant Contact Dermatitis (ICD)—Most prevalent form (~80%), irritants cause

inflammation of the skin induced by chemicals, oxidants, or alkali, surfactants,
and solvents that directly damage the skin. No previous sensitization is required;
it reflects nonspecific toxicity of the antigen.
Characterized by stinging and less pruritic than ACD, reaction almost
immediate. “Decrescendo” is typical as reactions tend to decrease in severity
between readings.
Photocontact Dermatitis—A photoallergic or phototoxic chemical requires

light-induced excitation in the ultraviolet spectrum to cause dermatitis.
Photoallergic (requires prior sensitization): para-Aminobenzoic acid (PABA),
chlorhexidine, thiourea, NSAIDs, thiazide diuretics, dapsone, and
sulfonylureas
Phototoxic (no prior sensitization): Psoralens, furocoumarins, tar, lime, celery,
parsnip, tetracyclines, amiodarone, diuretics, quinine, and NSAIDs
Contact Urticaria—Can be either immunologic or nonimmunologic.

IgE-dependent: Dairy products, seafood, various fruits, grains, topical
antibiotics, metals, preservatives, and plants
IgE-independent: Fragrances, arthropods, jellyfish, and coral
Common Allergens for Contact Dermatitis

Ten most common contact allergens in the US:
Nickel sulfate
Neomycin
Myroxylon pereirae (balsam of Peru)
Fragrance mix
Thimerosal
Sodium gold thiosulfate
Quaternium-15
Formaldehyde
Bacitracin
Cobalt chloride
Metals
Potassium dichromate: Stainless steel, chrome plating other metals, and
tanned leather
Chromates: Textile, leather tanners, and construction workers using wet
cement
Cobalt dichloride: (Uncommon) dental implants, artificial joints, and
engines or rockets
284 / CHAPTER 7
Nickel: Nonoccupational exposure, jewelry; dimethylglyoxime test of

nickel-containing material (pink = positive).
Plants—Toxicodendron dermatitis (aka poison ivy, poison oak, and poison

sumac) is the most common form of ACD (Figure 7-12). It is caused by urushiol,
an oleoresin that is found in the sap and oozes readily from any crushed part of
the plant.
Sensitivity to Toxicodendron usually develops after several encounters with the

plants, which, in some cases, may occur after many years of exposure. Studies
suggest that ~85% of the population will develop a clinical reaction when
exposed; however, 10–15% of the population is believed to be highly susceptible
to poison ivy and poison oak. These people develop systemic symptoms, which
include rashes with swelling of the face, arms, and genitalia. There is also cross-
reactivity with mango peels.
Although the poison ivy group of plants (Anacardiaceae) causes most cases of
plant dermatitis, other plants that are common sensitizers are listed in Table 7-39.
Figure 7-12. Linear papulovesicular presentation of poison oak contact

dermatitis.
(Reproduced, with permission, from the CDC’s Public Health Image Library)
Table 7-39. Common Non-Rhus Plant Contactants

Family Common Names Antigen
a
Ambrosia Giant and dwarf ragweed Sesquiterpene lactones
Compositae Chrysanthemums and daisies Sesquiterpene
a
Liliaceae Tulips, hyacinth, asparagus, Tuliposide
and garlic
Amaryllidaceae Daffodil and narcissus Unknown
b
Primrose Primula Primin
Umbelliferae Carrots, celery, and parsnips Unknown
Urticaceae Nettles Unknown
Rutaceae Oranges, lemons, and Unknown
grapefruits
a
Sesquiterpene lactones and tuliposides are large, diverse groups of chemicals found in several
plant families that cause ACD in florists and bulb growers. Test the actual chrysanthemum (petal,
leaf, and stem) as no single sesquiterpene is sufficient to screen for sensitivity to chrysanthemums.
b
Primin is the most common ACD in Europe.
The sensitizing substances in most plants are present mainly in the oleoresin
fraction; in some plants, the allergens are water-soluble glucosides. Most plants
must be crushed to release the antigenic chemicals.
In the US, Alstroemeria, also called Peruvian lily, is the most frequent cause of
hand eczema in flower workers. This classic dermatitis is an intensely pruritic
eruption that affects the first three fingers and exposed areas of dorsal hands,
forearms, the V-region of the neck, and the face.
Cosmetics—Cosmetics and personal hygiene products contain a variety of

potential allergens. Typical contact allergens include:
Fragrances
Preservatives
Formulation excipients
Glues
Sunblocks
Fragrances—Fragrances are among the most common causes of CD in the US.

Balsam of Peru has a spicy scent and is used in the manufacture of perfumes, but
it is also used as a flavoring agent. Balsam of Peru has wide cross-reactivity, but
most prominent are cinnamon and vanillin.
Preservatives—Preservatives tend to be grouped into two broad categories:

formaldehyde donors (i.e., products that emit formaldehyde) and
nonformaldehyde donors (Table 7-40). There is a high prevalence of positive
patch tests (approximately 8%) to formaldehyde, and most fabrics, especially
cotton and rayon, contain formaldehyde.
286 / CHAPTER 7
Table 7-40. Preservative Agents Classified According to Formaldehyde

Releasing
Formaldehyde Releasers Nonformaldehyde Donors
a
Diazolinidinyl urea Parabens
Imidazolindinyl urea Methylisothiazolinone
b
Quaternium-15 Phenoxyethanol
DMDM hydantoin PCMX and/or PCMC
Bromonitropropane Benzalkonium chloride
Thimerosal
a
Parabens are the most commonly used preservative in cosmetics; however they are an
uncommon cause of ACD.
b
Quaternium-15 is the preservative that most frequently causes ACD in the US.
Abbreviations: DMDM, dimethylol dimethyl hydantoin; PCMC, parachlorometacresol; PCMX,
parachlorometaxylenol.
Formulation excipients—Defined as inert substances that serve to solubilize,

emulsify, sequester, thicken foam, lubricate, or color the active component in a
product (Table 7-41).
Hair Products—Second only to skin care products as the most common cause of
cosmetic allergy. Important causes of CD include:
Cocamidopropyl betaine: Shampoos, eye and/or facial cleaners, and bath
products
Paraphenylenediamine: Most common cause of contact hypersensitivity
(CHS) in hair dressers
Glycerol thioglycolate: Permanent wave solution
Acrylics—In nails can present locally at the distal digit or ectopically on the
eyelids and face. Patch testing to a variety of acrylates and nail polish resins may
be necessary to delineate the causative agent. Ethylacrylate has been
demonstrated to detect a higher number of acrylate-allergic patients.
Formaldehyde-based nail resins should also be suspected and tested when ectopic
facial dermatitis is present.
Table 7-41. Excipient Chemicals that Cause Allergic Contact Dermatitis

Antioxidants (sulfites) Propylene glycol Benzylalkonium chloride
EDTA Ethylenediamine Cetrimide
Butylene glycol Vegetable gums Lanolin
Polyethylene glycol Chlorocresol Chloramine-T
Triethanolamine Thimerosal Butyl alcohol
Abbreviations: EDTA, ethylenediamine tetraacetic acid.
Sunblocks or Sunscreens—Common causes of photoallergic ACD. These are

frequently present in cosmetics such as moisturizers, “facial” creams, lip and hair
preparations, and foundations. “Chemical-free” sunblocks use physical-blocking
agents (micronized titanium dioxide and zinc oxide) and are rare sensitizers.
Photoallergic CD is diagnosed with photopatch testing. This combines patch
testing with ultraviolet type A (UVA) exposure (320–400 nm of ultraviolet light).
Pure photoallergens only cause a skin hypersensitivity reaction with both UVA
light and chemical exposure.
Topical Corticosteroids—Can cause ACD in up to 5% of patients with

suspected CD. Risk factors include treatment of refractory eczema, leg ulcers, and
stasis dermatitis. The patient usually notes a failure to improve or experiences a
flare-up of the underlying dermatitis being treated with the steroid.
Patch test readings should also be done 7 days after application because of the
immunosuppressant nature of the test reagent itself (false negatives are
common).
The most commonly used screening agents in patch testing for topical
corticosteroid allergy are budesonide and tixocortol pivalate 1%.
There are four major chemical classes of sensitizing corticosteroids
(designated A–D):
o Group A: Hydrocortisone type
o Group B: Triamcinolone type
o Group C: Betamethasone type
o Group D: Hydrocortisone-17-butyrate type
Patients do not usually react to all four classes, so there are safe
corticosteroids. It is important to distinguish among the four classes.
Resins
Epoxy, when cured, is nonsensitizing; ACD occurs with uncured resin (90%)
or to hardener.
Colophony is made from pine trees and appears in cosmetics, topical
medications, and industrial products. Different pine trees mean different forms
of colophony (testing is difficult), and Balsam of Peru may cross-react.
Ethylenediamine dihydrochloride appears in topical creams,
aminophylline, and generic nystatin. EDTA does not appear to cross-react
with ethylenediamine. If sensitive, avoid nystatin, aminophylline, and
piperazine-based antihistamines (e.g., meclizine and cyclizine).
Paraphenylenediamine is a derivative of benzene and common, epidemic
with “henna” tattoos. Patients are not allergic to the henna, but to the
contaminating paraphenylenediamine.
Topical antibiotics such as bacitracin (or Neomycin) are common and
iatrogenic with risk of anaphylaxis that can be delayed. Neomycin is the most
commonly used antibiotic and is an aminoglycoside that cross-reacts with
gentamicin, kanamycin, streptomycin, and tobramycin. There is cross-
reactivity with bacitracin. If patient is sensitive, the physician should avoid
prescribing all of these antibiotics.
288 / CHAPTER 7
Allergic Contact Cheilitis (ACC)—A common form of ACD, because the

epithelium of the lips is similar to that of the skin. Common ACC contactants
include:
Dental devices
Lipsticks
Lip balms
Nail polish
Cigarette paper
Various essential oils
Surgical Implant Dermatitis—The four criteria for diagnosis of a cutaneous

implant-induced reaction are:
Dermatitis (localized or generalized), appearing after implant surgery
Persistent dermatitis that is resistant to appropriate therapies
A positive patch test result to a metallic component of the implant or to acrylic
glues
Resolution of the dermatitis after removal of the implant
Systemic contact dermatitis (SCD) is a generalized ACD rash from systemic

administration of a drug, chemical, or food to which the patient previously
experienced ACD. Patients allergic to topical antihistamines (e.g., Benadryl
cream) may develop systemic CD after systemic administration of
Mnemonic
diphenhydramine. This has been termed the “baboon syndrome” because of the
The seven Ts of passive indurated erythema that may be observed in the groin area of afflicted patients.
immunity: Reactions have also occurred after systemic and intra-articular use of
corticosteroids to which a patient had been topically sensitized.
Transferred protection
from human or animal
Temporary
Examples include: VACCINE PRINCIPLES AND REACTIONS

Transfusion (blood)
Transplacental passage
of IgG PRINCIPLES OF VACCINATION
Tetanus hyperimmune
globulin (IG) (also
rabies, hepatitis B, and
varicella Ig) Passive immunity is the transfer of preformed antibodies produced by one human
AntiToxins (botulism or animal to another that provides temporary protection.
and diphtheria); cause
serum sickness
Monoclonal anTibodies Active (or adaptive) immunity is the stimulation of the immune system by an
(Synagis) for RSV antigen to produce humoral and cellular immunity. It occurs from natural
prevention.
infection or vaccination and is more permanent.
Classification of Vaccines
Live Attenuated—This is a weakened form of “wild” virus or bacterium that Mnemonic
replicates. It is similar to natural infection and usually protective after one dose;
IVIG and Ig interferes. The LMNOP and RSV
of live vaccines.
Inactivated—These vaccines are produced by growing the virus or bacterium in Live vaccines include:
culture media and then inactivating it with hear and chemicals (formalin). MMR
Inactivated vaccines cannot replicate, require multiple (booster) doses, and are Nasal flu
less affected by IVIG or intravenous gamma globulin (IgG). The immune Oral Polio
response is mostly humoral, and antibodies decline with time. The following are
Rotavirus
examples of inactivated vaccines: Smallpox (Vaccinia),
Whole cell: Polio (IPV), hepatitis A, and rabies Shingles (Zoster)
Fractional: Subunit (hepatitis B, trivalent inactivated influenza virus vaccine Varicella
(TIV), pertussis, and human papillomavirus [HPV]) or toxoid (tetanus and
diphtheria)
Polysaccharide:
Key Fact
o Typically T–lymphocyte-independent (i.e., stimulates B lymphocytes
without help from T lymphocytes) The live, attenuated
o IgM is greater than IgG response influenza vaccine is
contraindicated in
o Does not work well in patients younger than 2 years of age immunocompromised
o No booster response patients, patient with a
o Pneumococcal (23-valent and Pneumovax) history of Guillain-Barré
o Meningococcal (Menomune) syndrome, and in
Conjugated vaccine: Immunogenicity improved with conjugation of patients with a history of
recurrent wheezing or
polysaccharide to protein and is T–lymphocyte-dependent; Hib, severe asthma.
pneumococcal (13 serotype, Prevnar), and meningococcal (Menactra)
General Recommendations
Timing and Spacing—All vaccines can be administered at the same visit as for
all other vaccines; however, live vaccines must be separated by 28 days if not
given same day.
Minimum Intervals—Never give earlier than minimum age or interval; if late,

never restart series for missed dose.
Vaccine-Antibody Interactions
Passively acquired antibody (IVIG and RBC transfusion) can interfere with
the response to live vaccines for more than 3 months. Wait before giving live
vaccine (i.e., for tetanus IG, wait 3 months; for IVIG replacement therapy
(400 mg/kg), wait 8 months; and for packed RBCs, wait 6 months); if live
vaccine is given too soon, then repeat the dose.
If live vaccine given first, wait more than 2 weeks to give antibody-containing
product.
290 / CHAPTER 7
Not a problem with monoclonal antibodies (i.e., palivizumab) and live

vaccine.
ADVERSE REACTIONS
Local reactions are common adverse reactions, which occur with 80% of
doses. They are more common with inactivated vaccines.
Arthus reactions are severe, local reactions due to high antibody titers. They
are most common after the fourth or fifth dose of diphtheria, tetanus, and
pertussis (DTaP) vaccine or with frequent boosters. They are type III
hypersensitivity reactions with immune complex deposition.
Systemic reactions are common adverse reactions that include fever, malaise,
Mnemonic and headache. They can later onset with live vaccines (e.g., 7–21 days).
Vaccines containing egg Allergic (IgE) are rare (i.e., < 1 one in 500,000) due to vaccine component
protein: Egg in Your used more commonly than vaccine antigen itself.
Face
o Gelatin: Used as stabilizer; measles, mumps and rubella (MMR),
Egg varicella-zoster, rabies, and yellow fever all contain gelatin; MMR is
Influenza most commonly reported.
Yellow Fever o Egg: Influenza, yellow fever prepared with embryonated chicken eggs;
MMR is not contraindicated in egg allergy (grown in chick
fibroblasts).
o Latex: In patients with anaphylaxis to latex, do not administer vaccine
supplied in vials containing natural rubber unless benefits greater than
risks; very small risk in reality.
o Yeast: Hepatitis B vaccine contains yeast, which causes rare problems.
o Specific vaccines: Japanese encephalitis virus (JEV) vaccine causes
delayed urticaria and angioedema.
Influenza Vaccine and Egg-Allergic Patients

No need to divide and administer vaccine by a two-step approach
No need to skin test with vaccine, unless patient had reaction to vaccine itself
Allergy with hives only: give influenza vaccine at primary care provider’s
office and observe for 30 minutes
Allergy reaction more severe than only hives: Give influenza vaccine at
allergist’s office and observe for 30 minutes
Non-IgE-Mediated Reactions
Thimerosal: Preservative; there are no data to support the contention that
thimerosal causes risk in vaccines, precautionary removal from many
vaccines; delayed local reactions to thimerosal are not a contraindication to
vaccination.
Neomycin: Delayed-type reactions to neomycin are not a contraindication to

vaccination; only neomycin causes anaphylaxis.
Unique side effects of specific vaccines:
o MMR: Transient rash (5%), thrombocytopenia, and late fever (i.e.,
within 5–12 days)
o Tetanus: Brachial neuritis and Arthus reaction
o Pertussis: Febrile seizures, inconsolable crying, and hypotonic
hyporesponsive event
o Varicella: Varicella (chickenpox)-like rash
o Yellow fever: Encephalitis.
o Smallpox (Vaccinia): Myopericarditis, eczema vaccinatum
Invalid Contraindications
Mild illness
Antibiotics
Lactation
Preterm birth
Immunosuppressed contact (exception: Smallpox)
Family history of adverse events
Multiple vaccines
Disease exposure
TB skin test (exception: MMR should be given same day or space 4 weeks
apart)
Contraindications
Severe allergic reaction (anaphylaxis) to prior dose
Encephalopathy less than 7 days after pertussis-containing vaccine
History of Guillain-Barré syndrome: Flu, meningococcal infection
Live vaccine contraindications: Pregnancy and immunosuppression
Precaution—Might increase chance of adverse reaction; includes prolonged

crying or high fever (>105°F) or seizure within 3 days after pertussis vaccination;
and moderate or severe illness.
Flash Card Q30
Vaccine Adverse Event Reporting System (VAERS)—This is a passive, A 16-month-old boy is
national reporting system, to which anyone can send a report. It was created to scheduled to receive
help detect rare or new adverse events and patient risk factors for events. both the MMR and
varicella vaccines during
a health maintenance
visit but parents only
allow him to receive
MMR. What is the
minimum period of time
that must elapse before
the varicella vaccine
may be administered to
this patient?
292 / CHAPTER 7
BRONCHIOLITIS
General Considerations
In infants, bronchiolitis is a lower respiratory tract infection characterized by
wheezing and airway obstruction in children <2 years of age that primarily affects
the small airways (bronchioles). Respiratory syncytial virus (RSV) is the most
common cause of bronchiolitis.
Etiology
Pediatric bronchiolitis: Adult bronchiolitis:
RSV Inhalation injury
Rhinovirus Infection (mycoplasma pneumonia)
Parainfluenza virus Drug reaction
Human metapneumovirus Hypersensitivity pneumonitis
Influenza Connective tissue disease
Epidemiology
Infants 3–6 months of age are the most prone to symptoms during peak RSV
season, from October through May. Approximately 50–65% infants have been
infected with RSV during their first year, and nearly 100% infants have been
infected by 2 years of age.
Pathophysiology
Necrosis of respiratory epithelium occurs along with ciliary disruption and
peribronchiolar lymphocytic infiltration. Obstruction of the small airways is
caused by excessive mucus and edema.
Signs and Symptoms

With RSV bronchiolitis, there is a wide spectrum of illness including:
Cough
Wheezing
Flash Card A30
Fever
Twenty-eight days Rhinorrhea
Nasal congestion
Dehydration
Symptoms typically peak at 3–5 days and resolve in 2 weeks, although wheezing
can persist. Some children with severe illness experience hypoxia, tachypnea, and
apnea.
Infants at higher risk for severe disease include those with:

Congenital heart disease
Immunodeficiency
Bronchopulmonary dysplasia
Prematurity
Diagnosis
Bronchiolitis is a clinical diagnosis. Virologic tests and radiographs can be used
to support the diagnosis, but they rarely alter management or outcomes and are
not routinely required.
Treatment and Prevention

Bronchiolitis is usually a self-limited, mild disease, and treatment is primarily
supportive. Patients in moderate-to-severe respiratory distress may require
hospitalization. In the inpatient setting a trial of albuterol is appropriate with
assessment for bronchodilator response. Ribavirin can be considered for severely
ill infants or those at risk for complications. Palivizumab is a monoclonal
antibody directed against an epitope of the RSV virus and can be given monthly
to high-risk infants younger than 2 years of age as a preventive measure
(bronchopulmonary dysplasia, cyanotic congenital heart disease, and
prematurity).
Association with Asthma

Recurrent wheezing is a common problem in pediatrics, with around 40% of
children developing a wheeze in their first year of life. RSV bronchiolitis is
thought to be an independent risk factor for the development of frequent
wheezing, occurring in patients until the age of 10 years. It is not known why this
occurs in some children but not others; however, there may be a possible role for
genetic disposition, gender, lung size, tobacco exposure, or immune response.
Differentiating bronchiolitis from other causes of wheezing, including asthma, is
often difficult. The Asthma Predictive Index is a helpful tool that allows
294 / CHAPTER 7
physicians to discern infants who wheeze and eventually develop asthma from
those with recurrent wheezing whose symptoms are transient.
CROUP
Laryngotracheitis (croup) is a respiratory illness that results in inflammation of

the larynx and subglottic airway. It is the most common etiology for stridor in
febrile children and is characterized by a barking cough.
Definitions
Laryngitis: Inflammation limited to the larynx; manifests itself as hoarseness;
usually occurs in older children and adults; and is frequently caused by viral
infections.
Laryngotracheobronchitis: Inflammation extending into the lower airways;
symptoms include wheezing, rales, air trapping, and tachypnea.
Bacterial tracheitis: Bacterial infection of the subglottic trachea; thick and
purulent exudates; symptoms of upper-airway obstruction; and may occur as a
complication of viral respiratory infections or as a primary bacterial infection.
Spasmodic croup: Sudden onset of inspiratory stridor at night often
associated with mild URI. Symptoms last several hours with sudden cessation
and condition is recurrent. There is evidence that spasmodic croup may be
more common in atopic children and is often referred to as “allergic croup.”
Etiology
Croup is most often caused by viruses with bacterial infections occurring
secondarily. Approximately 80% of croup is secondary to parainfluenza virus
Key Fact
infection (type one most common).
Influenza A is
associated with more
severe disease and
Parainfluenza virus Rhinovirus
seen in those with RSV Influenza virus
respiratory compromise. Adenovirus Measles
The most common secondary bacterial pathogens include Staphylococcus aureus,

Streptococcus pyogenes, and Streptococcus pneumoniae
Epidemiology
Croup is most common between 6–36 months of age. Most common in late fall
and early winter.
Pathogenesis Key Fact
Viral infection leads to inflammation and edema of the subglottic larynx and In cases of severe
respiratory distress, a
trachea, especially near the cricoid cartilage (i.e., narrowest part of the pediatric tracheal tube that is 0.5–
airway). Narrowing results in the turbulent airflow, stridor, and chest retractions. 1 mm smaller than
Decreased mobility of the vocal cords due to edema leads to the associated would typically be used
hoarseness. may be required
secondary to laryngeal
edema.
Clinical Presentation
The onset of symptoms of croup is usually gradual, beginning with nasal
irritation, congestion, and coryza. Symptoms generally progress over 12–48 hours
to include fever, hoarseness, barking cough, and stridor. Symptoms can persist for
3–7 days. Identifying patients with severe respiratory distress and/or impending Key Fact
respiratory failure is paramount. Infants and young
children will frequently
Symptoms of significant upper-airway obstruction include: present with a barking
cough, whereas older
Stridor at rest children and adults will
Retractions present with
hoarseness.
Diminished breath sounds
Hypoxia and cyanosis
Imaging—Posteroanterior chest radiograph reveals subglottic narrowing;

commonly called the “steeple sign.”
Laboratory Findings—CBC is usually nonspecific. WBC and differential may

reveal a viral pattern with leukocytosis and lymphocytosis.
When evaluating a patient with signs of croup it is important to assess severity

and exclude any other causes of upper-airway obstruction, which can include:
Epiglottitis
Foreign body aspiration
Peritonsillar/retropharyngeal abscesses
Upper-airway injury
Congenital anomalies of upper airway
296 / CHAPTER 7
Diagnosis
Clinical diagnosis of croup is based on symptoms, specifically barking cough and
stridor, and is more common during an epidemic. Radiographs and laboratory
tests are not necessary to make the diagnosis. Viral culture of secretions from
the nasopharynx or throat can be obtained if etiologic diagnosis is desired,
antiviral therapy is indicated, or in patients being admitted, whether isolation is
required.
Treatment
Providing a sense of comfort and reassurance to both the patient and parents is
paramount. A single dose of PO or IM dexamethasone 0.6 mg/kg (maximum dose
10 mg) has been shown to be the most efficacious treatment of croup. Unlike
steroids, nebulized epinephrine provides rapid clinical improvement. Exposure to
cold air and humidified air mist therapy are often utilized both at home and in the
emergency department setting with mixed results. No studies to date have
supported its efficacy in reducing symptoms.
8 Immunologic Disorders
HEREDITARY AND ACQUIRED ANGIOEDEMA
Hereditary angioedema (HAE) is a disease characterized by recurrent episodes of

angioedema, without urticaria or pruritus, which most often affect the skin or mucosal
tissues of the upper respiratory and gastrointestinal tracts.
Acquired angioedema (AAE) is clinically quite similar to HAE but most commonly
develops in patients over the age of 40 years, some of whom have associated
lymphoproliferative disorders. HAE usually presents in younger patients who are
otherwise healthy.
Hereditary Angioedema (HAE)

Autosomal dominant inheritance
C1 inhibitor (C1-INH) gene on chromosome 11
C1esterase inhibitor mutations cause decreased protein (type I) or dysfunctional
protein (type II)
Bradykinin is the major mediator of swelling, and the lack of C1-INH leads to
bradykinin overproduction (See Chapter 1,).
Presentation
Swelling episodes may be spontaneous or precipitated by trauma or stress.
Swelling usually lasts 2–4 days.
Gastrointestinal swelling leads to severe abdominal pain and third spacing.
Laryngeal angioedema may lead to respiratory arrest, occurring in 50% of patients
with HAE type I.
Family history may exist, but 15% mutations are new.
Nonpruritic rash, erythema marginatum, may precede swelling episodes.
Classification
HAE type I: A mutation of one of the C1-INH gene alleles, leading to low or absent
protein; 85% of patients present with HAE
HAE type II: A mutation of one of the two gene alleles, leading to normal or high
levels of a nonfunctioning C1 inhibitor protein; 15% of patients with HAE
HAE type III: Normal C1-INH. Estrogen-dependent, seen primarily in women, and
often triggered by pregnancy or exogenous estrogen administration. Inheritance is
dominant, which may be due to a mutation in factor XII that augments its activity as
an initiator of bradykinin formation
298 / CHAPTER 8
Diagnosis
Laboratory Tests:
Decreased C4, which is often undetectable during an attack, is the best
screening test for diagnosing HAE (Table 8-1). A decreased or absent C1-INH
confirms the diagnosis (type I). 15–20% patients have a normal, even
increased C1-INH but a decreased functional C1 assay (type II). C2 is usually
normal when asymptomatic, but it is decreased in all types during attacks. To
date, no complement abnormality has been discovered in type 3 HAE.
Treatment
Acute attacks:
Airway management
Hydration
Pain control
HAE-specific therapies: C1-INH concentrate, kallikrein inhibitor (ecallantide),
bradykinin receptor antagonist (icatibant)
Fresh frozen plasma has been historically used, but may lead to paradoxical
worsening
Attacks usually abate in 3–4 days, even if no medication is given; however, they
can be lethal (e.g., laryngeal edema).
Long-term therapy:
Attenuated androgens: Androgen derivatives, such as danazol and stanozolol, help
prevent attacks by inducing hepatic synthesis of C1-INH. Common adverse effects of
this type of long-term therapy include hepatotoxicity, dyslipidemia,
masculinization, and headaches.
Plasma-derived C1-INH: See Table 8-2.
Table 8-1. Complement Levels in Diagnosis of HAE

C1-INH C1 INH
Type C1q C4 C3
level Function
HAE type I ↓ ↓ N ↓ N
HAE type II N or ↑ ↓ N ↓ N
HAE type III N N N N N
AAE type I ↓ ↓ ↓ ↓ N or ↓
AAE type II ↓ or N ↓ ↓ or N ↓ N or ↓
Abbreviations: HAE, hereditary angioedema; C1-INH, C1 inhibitor.
IMMUNOLOGIC DISORDERS / 299
Table 8-2. Medications Available for HAE in United States

Therapy Indication Dose Adverse Effect
Plasma-derived C1- Long-term 1000 U Thrombotic events
INH Cinryze prophylaxis IV q 3–4 days (rare)
Plasma-derived C1- Acute attacks 20 Units/kg IV Thrombotic events
INH Berinert (rare)
Kallikrein inhibitor Acute attacks 30 mg SQ Anaphylaxis
ecallantide (~3–4% risk; black
(Kalbitor) box warning)
Bradykinin receptor Acute attacks 30 mg SQ Injection site
antagonist icatibant May repeat q6h (max reactions
(Firazyr) 3 doses/24 h)
Abbreviations: HAE, hereditary angioedema; C1-INH, C1 inhibitor; SQ, subcutaneous.
Short-term prophylaxis:
Indicated prior to oral or general surgical procedures. Angioedema episodes
typically happen within 48 hours of trauma or surgery.
Androgens: High dose, 3–5 days prior to planned procedure
C1 esterase inhibitor, infused 1–2 hours prior to procedure
OB/Gyn Considerations in HAE patients:

Contraception: Estrogens should be avoided. Progestins can be used
Pregnancy:
o Attenuated androgens are contraindicated
o Plasma-derived C1-INH is preferred for acute treatment, short-term and
long-term prophylaxis
Parturition:
o Complications during vaginal delivery are rare
o Plasma-derived C1-INH prophylaxis is advised before caesarian section,
and forceps or vacuum extraction
Flash Card Q1
Which complement
Acquired Angioedema component is decreased
in acquired, but not
hereditary,
Classification angioedema?
Type I (paraneoplastic)
o Associated with B-cell lymphoproliferative diseases
o Monoclonal gammopathy of uncertain significance (MGUS)
o Consumption of C1-INH by neoplastic lymphatic tissue
Type II (autoimmune) Flash Card Q2
o Autoantibody to C1-INH always present. Impairs enzyme function Which medication
o C1-INH levels are normal approved for treatment
of acute attacks of HAE
carries a black box
warning for
anaphylaxis?
300 / CHAPTER 8
Other clinical features include:

Late onset, after fourth decade
Overproduction of bradykinin
The low C1q level distinguishes this condition from the hereditary disorder
C4, C2, and C3 may also be depleted
Low C1-INH level caused by C1 activation.
Idiopathic Angioedema
Key Fact
Warning Signs of PIDs.
Recurrent angioedema may be due to medications, allergen-induced, or physically
1. ≥4 new ear induced. In about 50% of cases, urticaria and pruritus are associated.
infections within 1 Angiotensin-converting enzyme inhibitor (ACEI) use is the most common
year cause of acute angioedema in the emergency room. The mechanism is thought to
2. ≥2 serious sinus involve impaired bradykinin degradation. Icatibant, which is a bradykinin
infections within 1 receptor antagonist, is being investigated for potential use in ACEI-induced
year angioedema. When no underlying etiology is identified for the angioedema (truly
3. ≥2 months on idiopathic), the therapy is similar to that for chronic urticaria, with antihistamines
antibiotics with little
effect being the mainstay of therapy.
4. ≥2 pneumonias
within 1 year
5. Failure of an infant
to gain weight or
grow normally CONGENITAL (PRIMARY) IMMUNODEFICIENCIES
6 Recurrent, deep skin
or organ abscesses
7. Persistent thrush in
mouth or fungal Overview of Primary Immune Disorders
infection of skin
8. Need for IV Primary immune disorders or deficiencies (PIDs) manifest as increased
antibiotics to clear
infections
susceptibility to infections and can occur/present with autoimmune diseases
9. ≥2 deep-seated and/or malignancy. An underlying genetic basis has been determined for many
infections, including PIDs. PID can be diagnosed at any age, but most are diagnosed in childhood.
septicemia Commonly related microbial organisms and PIDs are shown in Table 8-3.
10. A family history of
PIDs
Flash Card A1
C1q
Flash Card A2
Ecallantide (Kalbitor)
Table 8-3. Commonly Related Microbial Organisms and PIDs

Combined
Antibody Phagocyte Complement
Organism Immune
Deficiency Defects Deficiency
Deficiencies
Viruses Enterovirus All, esp CMV, No No
(XLA) RSV, EBV
Bacteria Streptococcus Also: Staphylococcus Also:
pneumoniae, Salmonella aureus, Neisseria
typhi, Listeria meningitidis
Haemophilus Burkholderia
monocytogenes, (late component)
influenzae, cepacia,
enteric flora
Moraxella Nocardia,
catarrhalis, Serratia
Pseudomonas
aeruginosa
Mycobacteria No Nontuberculous Nontuberculous No
including BCG including BCG
Fungi No Candida, Candida, No
Aspergillus, Aspergillus
Cryptococcus,
Histoplasma
capsulatum
Protozoa Giardia Pneumocystis No No
jiroveci,
Toxoplasma,
Cryptosporidium
parvum
Abbreviations: BCG, bacille Calmette-Guérin; CMV, cytomegalovirus; EBV, Epstein-Barr virus;
RSV, respiratory syncytial virus; XLA, X-linked agammaglobulinemia.
Initial Screening Tests in Suspected Immune Deficiencies

Initial screening tests for immune deficiencies assess distinct compartments of the
immune system in a quantitative and qualitative manner. Table 8-4 is a summary
of screening tests.
Second-Tier Evaluation of Primary Immune Deficiencies
Abnormalities in screening tests should be followed by specific studies to further

characterize the immune deficiency. A review of second-tier evaluation are
highlighted under the specific immune deficiencies.
302 / CHAPTER 8
Table 8-4. Initial Work-Up for Suspected Immune Deficiencies

Humoral Cellular Phagocytosis
Complement
Immunity Immunity (Macrophage and
Systems
(B Cell) (T and NK Cell) Monocyte)
Quantitative Flow cytometry: Absolute Absolute neutrophil C3 and C4
assessment CD19 and CD20 lymphocyte count count (CBC with
IgG, IgA, and IgM (CBC with differential counts)
differential counts) Flow cytometry:
Exclude HIV CD11 and CD18
Flow cytometry: (LAD type1) and
CD3CD4, CD15a (LAD type2)
CD3CD8, and
CD16CD56
Qualitative or Isohemagglutinin Delayed-type Oxidative function CH50 (classical
functional titer hypersensitivity (DHR, NBT, or pathway)
assessment Specific antibody Enzyme assays chemiluminescence) AH50 (alternative
titers to: Protein (ADA and PNP) Enzyme assays pathway)
antigens (MPO and G6PD)
NK cytolysis assay
(diphtheria and Phagocyte function
tetanus) and Mitogen or antigen
stimulation Antineutrophil
Polysaccharide antibodies
antigens Cytokine
(Pneumococcus production
and
Cytotoxic assays
Meningococcus)
Abbreviations: ADA, adenosine deaminase; CBC, complete blood clot; DHR, dihydrorhodamine;
G6PD, glucose-6-phosphate dehydrogenase; Ig, immunoglobulin; LAD, leukocyte adhesion
deficiency; MPO, myeloperoxidase; NBT, nitroblue tetrazolium; PNP, purine nucleoside
phosphorylase.
(Adapted, with permission, from Dr. John M Routes, Medical College of Wisconsin.)
COMBINED ANTIBODY AND CELLULAR IMMUNITY

DEFICIENCIES
Severe Combined Immune Deficiencies: Defect in T

Lymphocytes
Severe combined immune deficiencies (SCIDs) represent a heterogeneous group

of disorders characterized by T-cell lymphopenia. The most common form of
SCID is X-linked SCID (γc chain defect) and, therefore, most cases will be
diagnosed in male infants. The etiology of SCID is summarized in Table 8-5.
Table 8-5. Etiology of SCID

Lymphocyte
Type SCID Infections, Clinical Findings Defect Gene
Phenotype
X- X-linked SCID FTT, rash, chronic diarrhea, GVHD Cytokine signaling IL-2RG T– B+ NK–
Linked (γc chain) (maternal T lymphocytes), and
(γc chain involves in IL-2, 4, 7, 9,
absent lymphoid tissue;
SCID 15, 21 receptor signaling)
Opportunistic and live vaccine
(IL-7Rα is specific for only T-cell
AR SCID JAK-3 deficiency infections JAK-3 T– B+ NK–
development, therefore B+ NK+)
IL-7Rα (CD127) (JAK-3 is a signaling protein of γc IL-7RA T– B+ NK+

chain, therefore both have the
IL-2Rα (CD25) same phenotype) IL-2RA B+ NK+
T–
CD45 CD45 tyrosine phosphatase and CD45 T– B+ NK+

CD3 subunits involve in only TCR
CD3δεζ signaling, therefore B+ NK+ CD3δεζ T– B+ NK+
RAG1/2 RAG1/2 involves in VDR RAG1/2 T– B– NK+

rearrangement of T- and B-cell Ag
receptor formation, therefore NK+.
(Proteins are unique to immune
cells, no radiation sensitivity)
a
AR SCID Omenn’s syndrome Erythroderma, increased lymphoid Hypomorphic defects in RAG1/2. RAG1/2 T B– NK+
tissues, alopecia, recurrent Also IL-7RA, ADA, Artemis, RNA
infections, eosinophilia, high IgE component of RNAse
mitochondrial RNA, and leaky
phenotypes
ADA deficiency Skeletal abnormalities: “rachitic Premature lymphoid progenitor cell ADA T– B– NK–
rosary” ribcage and abnormal iliac death from accumulating toxic
bone, deafness metabolites, therefore all negative
phenotypes
PNP deficiency Lymphoreticular disease and PNP T– B+ NK+/–
autoimmune disease (Defective nucleotide salvage
pathway)
Reticular dysgenesis Severe neutropenia and Adenylate T– B– NK–
sensorineural deafness (Defective purine nucleotide kinase 2
metabolism) (AK2)
(Defective hematopoietic energy
metabolism)
304 / CHAPTER 8
Table 8-5. Etiology of SCID, cont.

Lymphocyte
Type SCID Infections, Clinical Findings Defect Gene
Phenotype
Radiose Artemis Diarrhea and candidiasis Recombinase DNA repair protein Artemis T– B– NK+
nsitive defect
Athebascan-speaking
SCID
Navajo/Apache Defective receptor formation
Cernunnos Developmental delay, growth failure, Recombinase DNA repair protein Cernunnos T– B– NK+
and bird-like facies defect
Microcephaly Hypogammaglobulinemia
Ligase IV Developmental delay, FTT, Bird-like Recombinase DNA repair protein Ligase IV T– B– NK+
facies defect
Microcephaly, photosensitivity Pancytopenia
Pancytopenia and malignancy ↓CD4/CD8
Nijmegen breakage Microcephaly, recurrent infections, Class switching recombination NBS1 T– B– NK+
syndrome bird-like facies, developmental delay, defect (substrate for
lymphoma, short stature, ATM)
↓CD4/CD8
clinodactyly,syndactyly, and
radiatiosensitive ↓proliferation
Can have
hypogammaglobulinemia and IgA
deficiency.
Elevated IgM
Defect in specific antibody
response
Absence of Hassel’s corpuscles on
thymic biopsy
a
T lymphocytes in Omenn’s are oligoclonal, CD45RO+, and TREC–.
Abbreviations: ATM, ataxia-telangiectasia mutated (kinase); FTT, failure to thrive; GVHD, graft-versus-host disease; Ig, immunoglobulin; NBS, Nijmegen breakage
syndrome; NK, natural killer; PNP, purine nucleoside phosphorylase..
While reviewing this table, focus on the B and NK phenotype. T cells are absent
with the following exceptions:
CD 8 lymphopenia can be caused by MHC class I deficiency (TAP1/2
deficiencies, tapasin deficiency) and ZAP70 deficiency (lack of blood CD8
lymphocyte).
CD4 lymphopenia can be caused by bare lymphocyte syndrome (MHC class
II deficiency), LCK deficiency, and HIV infection.
Lymphocyte proliferation to mitogens is markedly reduced as well.
Treatment is geared to:

Preventing infections with intravenous immunoglobulin (IVIG), prophylactic
antibiotics (sulfamethoxazole/trimethoprim), antifungals, withholding live
immunizations, and isolation in the sterile environment
Improving nutritional status
Hematopoietic stem cell transplantation
Gene therapy
Enzyme replacement; pegdemase bovine ADA (ADA-PEG)
Avoid breast feeding
CMV negative, irradiated blood products
Deficiency in Cellular Immunity (or Complex

Immunodeficiencies)
Cellular immune deficiencies present with opportunistic infections, chronic

diarrhea, and failure to thrive (FTT). An approach to the evaluation of cellular
immune deficiencies is provided in Table 8-4 and a review of clinical diseases is
found in Table 8-6.
Flash Card Q3
What is the lymphocyte
phenotype in X-linked
SCID caused by the
mutation in the γc
chain?
Flash Card Q4
Which type of SCID can
most easily be missed
by newborn TRECs (T-
cell receptor excision
circles) screening?
306 / CHAPTER 8
Table 8-6. Cellular or Complex Immune Deficiencies

Cellular Inheritance or Infections or Laboratory
Notes Therapy
Deficiency Mutation Clinical Findings Values
Ataxia-telangiectasia ATM; Ataxia- Progressive Naïve T-lymphocyte Class- Treatment and
telangiectasia, neuronal loss— (CD45RA) switching prophylactic
mutated normal at birth, lymphopenia; poor recombination antibiotics, IVIG,
ataxia begins ~2 mitogen responses defect and chemo-
years old, later in therapy
Can have ATM is PI3
some patients,
hypogammaglobulinemi kinase, Avoid radiation
wheelchair-bound
a and poor response to responsible for from imaging.
~10 years old.
immunizations; repair in DNA
Oculomotor apraxia, ds breaks; as
IgA deficiency (80%) a result,
dysarthria, and
choreoathetosis Elevated AFP and patients
decrease CSA to radiosensitive
Telangiectasia
assess radiosensitivity
(appears years after
ataxia)
Sterility
Risk of leukemia or
lymphoma
Immune
deficiency—
sinopulmonary
infections
Chronic AR and AIRE Recurrent ↓ T proliferation to Antifungal;
mucocutaneous gene noninvasive thrush, mitogens and recall
candidiasis (CMC); candidal dermatitis, antigens Treat
dystrophic nails, autoimmune
Autoimmune enamel hypoplasia Some IgA deficiency disease
polyglandular
syndrome (APS-1); Endocrinopathies:
Autoimmune Hypoparathyroid
polyendocrinopathy- (most common)
candidiasis-
ectodermal Hypoadrenalism,
dystrophy (APECED) pernicious anemia,
DM, vitiligo,
alopecia, and
hepatitis
CD40L deficiency X linked Opportunistic ↓ IgG, IgA, and IgE, Ig class switch IVIG, PCP
infection, fungal, levels. Variable recombination prophylaxis
(HIGM1, hyper-IgM CD40L/CD154 bacterial, and viral; deficiencies GCSF, and
high/normal IgM;
type1) mutation from defect in HSCT
(TNFS5) Autoimmune Neutropenia CD40-CD40L
hemolytic anemia interaction
CD40 deficiency AR and neutropenia Absent germinal IVIG, PCP
centers prophylaxis, and
(HIGM3, hyper-IgM CD40 absent GCSF
type3)
Flash Card A3
T–B+NK–
Flash Card A4
ADA deficiency
Table 8-6. Cellular or Complex Immune Deficiencies, cont.

Notes Therapy
DiGeorge’s 22q11.2 deletion 1. Cellular immune Complete: naive T CATCH 22 Complete DGS:
3
syndrome (~90%) deficiency cell < 50/mm + no (cardiac treat like SCID with
infections. +/- mitogen proliferation defects, thymus
10p13-14 deletion absence of part or all abnormal transplantation and
(Renal/GU defect) of the thymus Partial: +/– decrease facies, thymic IVIG
T cell, usually normal hypoplasia,
2. Hypocalcemia mitogen proliferation cleft palate, Antibiotic
parathyroid hypocalcemia, prophylaxis—
Can have low Ig if
deficiency chromosome depend on T-cell
severe T-cell defect
tetany/seizures 22) counts and recall
US: kidney agenesis;
3. Congenital heart Live vaccines for
disease (tetralogy of Autoimmune patients who have
Fallot—most antibodies, TUPLE1 normal T recall
common (FISH),
Neuropsychiatric
Type B interrupted low-copy repeat, and therapy, and
nd
aortic arch—2 TBX1. surgery of
common) congenital defects
Other features: low-
set or posteriorly
rotated ears, short
philtrum,
micrognathia,
developmental
delay, B-cell
lymphoma, and
autoimmune disease
Defects in X-linked Lethal in utero Hypogammaglobuline Ectodysplasin IVIG and IFNγ
NFκB inconginentia (male) mia and poor A receptor
regulation pigmenti antibody response to cannot induce HSCT: under
(NEMO) Scarring, alopecia, polysaccharide activation of investigation—prior
(Null mutation of and hypodontia NFκB + attempts resulted in
NEMO) (female) TLR defect (NFκB is engraftment
central in TLR Defect in CD40 difficulties and post
activation) activation transplant
pathway complications
Can have decreased
NK cytotoxicity
X-linked anhydrotic Male—reduced
ectodermal sweat, hyperthermia, Normal T cell-count
dysplasia with hypotrichosis, and and function
immunodeficiency
hypodontia, conical
(Hypomorhic incisors, nail
mutation in NEMO) abnormality
Severe bacterial
infections but poor
inflammatory
responses,
opportunistic
infections including
mycobacteria
Female—usually
normal
308 / CHAPTER 8

Notes Therapy
Defects in LZ-NEMO Normal ectoderm; Impaired Mycobacteria
NFκB mutation Mycobacterium avium production of should be
regulation (X-linked MSMD intracellulare is cause IL-12 and IFNγ typified and
(NEMO), cont. of infection. in response to treated
Disseminated BCG CD40L
Antimycobacteri
al prophylaxis in
some patients
Immune Normal ectoderm; HIGM1/3 phenotype Defect in class
deficiency (combined immune switch
Infections: defect) recombination
bacteria, viral, and due to altered
opportunistic CD40 signaling
AD-STAT-3 Recurrent Infections: IgE > 2000 IU/mL; Triad of: Prophylactic
Hyper-IgE abscesses, Eosinophilia recurrent skin antibiotics
syndrome mucocutaneous and lung (covering staph)
(HIES) candidiasis Normal IgM infections, and antifungal
Pneumonia with Th17 levels severe
Job’s
pneumatoceles decreased eczema, and IVIG in case of
syndrome
elevated IgE poor antibody
Severe eczema and response
eosinophilic pustular Has
folliculitis characteristic
infection
Characteristic facies: profile:
coarse features, Staphylococcu
prominent mandible, s aureus,
hypertelorism, and Streptococcus
broad nose pneumonia,
Skeletal Haemophilus
abnormalities: influenzae, and
retained primary Candida;
dentition and scoliosis
Secondary
Connective tissue infection by:
disease: Pseudomonas
hyperextensibility and aeruginosa and
aortic aneurysms Aspergillus sp
AR-DOCK8 Viral skin infections Low IgM
severe difficult to
treat: HPV, HSV, More prominent
VZV, molluscum eosinophilia
Mucocutaneous Lymphopenia
candidiasis
Eczema and allergies
Risks of malignancies
Pneumonias but no
pneumatoceles
AR-Tyk2 As DOCK8 + Tyk-2 involves
disseminated BCG in Il-12
Vasculitis signaling
pathway to
produce IFN-γ

Notes Therapy
Immune X-linked recessive Severe diarrhea and Villous atrophy with FOXP3 codes IVIG
dysregulation, FTT (enteropathy) lymphocytic infiltrates protein involved
FOXP3 mutation Rx autoimmune
polyendocrinopat in small bowel in Treg
(not found in every Early-onset type 1 DM and endocrine
hy, enteropathy, (CD4+CD25+)
cases) thyroid disease, Autoimmune disease
and X-linked cell
autoimmune cytopenia antibodies
inheritance development HSCT
(IPEX) Variable skin lesions: Cytopenia
Impair Treg Parenteral
erythroderma,exfoliativ
Eosinophilia autoimmune nutrition
e dermatitis, eczema,
psoriasis-like High IgE, normal IgG
(↓enteropathy), IgM
Severe infections
Normal B/T number
Coronary artery
and function exp. no
disease
Treg
X-linked XLP-1: mutation in 1. Fulminant EBV HLH on BM biopsy XLP-1: IVIG, HSCT, and
lymphoproliferativ SH2D1A gene mononucleosis chemo-therapy
Low IgG, high IgM Failure to
e disease (XLP) encodes SAP
2. Dysgamma- eliminate EBV-
↓ CD4 but high CD8.
globulinemia— infected B
Impair T-cell function.
combined cells
immunodeficiency with ↓ NK cell number and
prolonged Ag
severe infections function Absent NKT
presentation +
cell
3. Lymphoma: B hyperactivation
cell/Burkitt’s, Anemia of CTL and
splenomegaly macrophages
HLH
XLP-2: XLP-2: Colitis, XLP-2:
predisposition to increased
XIAP
hemophagocytic susceptibility to
lymphohistiocytosis apoptotic stimuli
Wiskott-Aldrich WASp Triad: ↑ IgE, IgA; PET WASP: HSCT treatment
syndrome of choice
X-linked 1. Thrombocytopenia + ↓ IgM; and pyogenic
bleeding diathesis, 2. infection, Treatment of
Normal IgG but
eczema, 3. recurrent eczema, infections, IVIG,
impaired Ab
infections. thrombocytopeni and splenectomy
responses.
a, and WASp
Risk for: autoimmunity
Impair T-cell mutation
and malignancy (EBV-
proliferation
related lymphoma) HOT ITCH
↓ Platelet size THROM;
↓ Platelet function Wiskott-hot
Aldrich-itch
Syndrome
Thrombo-
cytopenia
Abbreviations: Ab, antibody; AFP, α-fetoprotein; BCG, bacille Calmette-Guérin; CSA, colony survival assay; CTL, cytotoxic T
lymphocyte; DM, diabetes mellitus; EBV, Epstein-Barr virus; ds, double-stranded; G-CSF, granulocyte colony-stimulating
factor; HLH, hemophagocytic lymphohistiocytosis; HPV, human papillomavirus; HSV, herpes simplex virus; HSCT,
hematopoietic stem cell transplantation; MSMD, Mendelian susceptibility to mycobacterial diseases; NEMO, NFκB essential
modifier; PCP, Pneumocystis jiroveci pneumonia; PI3, phosphatidylinositol 3; SAP, SLAM-associated protein; TLR, Toll-like
receptor; VZV, varicella-zoster virus; WASp, Wiskott-Aldrich syndrome protein; XIAP, X-linked inhibitor of apoptosis.
310 / CHAPTER 8
Antibody Deficiencies
Antibody deficiencies should be considered when a patient has:

Recurrent sinopulmonary infections
Enteroviral infections (XLA)
Giardiasis
Autoimmune phenomenon
Immunoglobulin levels, pre- and postimmunization with protein-based (diphtheria,

and tetanus), carbohydrate-based (Pneumovax, Haemophilus and meningococcus),
or conjugate (pneumococcal 7-valent conjugate vaccine, Prevnar) vaccines are
easily obtained from laboratories performing serology. Tables 8-7 and 8-8
summarize laboratory findings in humoral deficiencies.
Table 8-7. Evaluating Antibody Deficiencies

CD19/ Postimmunization
Condition IgG IgA IgM
CD20 Titers
sIgAD Normal Normal <10 mg/dL Normal Normal
XLA Very <200 Low Low Undetectable

low/absent
a
CVID Normal or <450 Low Low Low or undetectable
low
HIGM Normal <400 Low Normal or Small IgM response
High
(Reproduced, with permission, from Dr. John M. Routes, Medical College of Wisconsin.)
a
For CVID, in order to meet the criteria for diagnosis, you need IgG AND IgA OR IgM to be less
than 2 SD below the lower limit for age AND impaired antibody responses.
Abbreviations: CVID, common-variable immunodeficiency; HIGM, hyper-IgM syndrome sIgAD,
selective IgA deficiency; XLA, X-linked agammaglobulinemia.
Table 8-8. Antibody Deficiencies

Infections/
Antibody Inheritance/ Laboratory
Clinical Notes Therapy
Deficiency Mutation Findings
Findings
Transient Unknown Sinopulmonary IgG < 2 SD Prolonged Mostly no Rx,
hypogamma GI, thrush, (95th physiologic may need
globulinemi meningitis percentile), hypogammagl prophylactic
a of infancy (usually not which persists obulinemic antibiotics, but
(THI) severe) older than 6 phase after
months of age. disappearance rarely IVIG
May be
asymptomatic Usually normal of maternal Usually resolved
Ab responses IgG by 2–4 years old
Selective Unknown Majority IgA < 7 mg/dL 2° IgA Treatment and

IgA Some sIgAD + asymptomatic; (Age ≥ 4 years deficiency: prophylactic
deficiency CVID has Sinopulmonary old) Antiepileptics antibiotics; and
(SIgAD) TACI mutation , GI infections; Normal IgG, IVIG if
Sulphasalazin
Most common Autoimmune IgM, and ecaptopril, concomitant
primary and atopic vaccine titers thyroxin specific
immunodeficie disease; FP serum β- Can be part of antibody defect
ncy disorder Rare: anti-IgA HCG tests due AT, IgG2 Monitor
Ab to presence of subclass def, progression to
transfusion heterophile Ab. CMC CVID
reactions
Specific Unknown Sinopulmonary Normal Age ≥ 2 years Prophylactic ABx

antibody infections IgG, A, M old and IVIG
deficiency Allergic rhinitis Poor Monitor
(SAD) progression to
polysaccharide
response CVID
despite
pneumovax
X Linked BTK Sinopulmonary Low IgG, A, M Maturational IVIG treatment

aggamaglob infections, (<2 SD); arrest at the and ABx Rx
ulinemia atypical CD19+ B pre-B Live
(XLA) bacteria, GI lymphocytes lymphocyte immunizations
infections, <2%; stage contraindicated
enteroviral Do not use
encephalitis, Most have
absent BTK serologic
septic arthritis, assays to
lymphoreticula (monocytes, Flash Card Q5
platelets) diagnose
r and infectious
colorectal BTK mutation
What mutation causes
diseases—ex. APECED and what is
malignancies, on gene ELISA for HIV
bronchiectasis sequencing the most common
Use PCR
Small/absent assays or endocrinopathy seen in
lymphoid cultures the disease?
tissue, no instead
germinal
center
Flash Card Q6
What mutation causes
IPEX and what cell is
affected by the disease?
312 / CHAPTER 8
Table 8-8. Antibody Deficiencies, cont.

Infections/
Antibody Inheritance/ Laboratory
Clinical Notes Therapy
Deficiency Mutation Findings
Findings
Autosomal Surrogate light Same as XLA IgG, A, M (<2 μ IgM heavy Same as XLA
recessive chain (V pre-B; SD). chain—most
Can be more
agamma- λ5), μ IgM common of AR
severe and CD19+ B
globulinemia heavy chain agamma-
earlier onset than lymphocytes
(Cμ), Igα, Igβ, globulinemia
XLA <2%
BLNK
Common- Mostly Age >2 years old, IgG (<2 SD), CVID + IVIG
variable unknown; sinopulmonary, and ↓ IgA or thymoma = treatment and
immuno- ICOS, TACI; GI infections, IgM, or both (<2 Good’s ABx Rx
deficiency BAFF-R, CD19 meningitis SD) and syndrome
No live
(CVID) complex, CD20 impaired
Bronchiectasis, Reduced # of vaccine
response
BOOP, switched
immunizations Pulmonary
autoimmune memory B cells
hygiene for
disease, GI/liver Variable T-cell shown to be
bronchiectasis
disease, counts and associated with
granulomatous function certain Excise
disease, non- noninfectious thymoma if
Hodgkin’s complications present
lymphoma, and (hematologic
gastric carcinoma autoimmunity)
IgG subclass Unknown Most Normal IgG and Controversial if Rx as SAD in
deficiency asymptomatic low level of ≥1 true PIDD—20% case of poor
(IGGSD) subclasses of population polysaccharid
e response
IgG2 deficiency have subnormal
can occur with of ≥1
SIgAD with subclasses
(esp. IgG4)
impaired Ab
response to
polysaccharide
Hyper-IgM AR Sinopulmonary ↓IgG, IgA, IgE, AID and UNG IVIG
type2 and GI infections; and normal or ↑ are required for
AIDdeficiency ABx Rx
(HIGM 2) IgM; class switch
Lymphoid
recombination No live
Hyper-IgM AR hyperplasia and Normal T-cell
and somatic vaccines
type4 adenopathy function
UNG deficiency hypermutation
(HIGM4)
CVID-like, but -↑LN and giant of B cell
have increased germinal
No T-cell defect
autoimmune centers.
less severe
disease
than HIGM1, 3
and NEMO
Flash Card A5 defect
Abbreviations: ABx Rx, antibiotic prescription; AFP, α-fetoprotein; AID, activation-induced cytidine
AIRE mutation, deaminase; AR, autosomal recessive; β-HCG, beta human chorionic gonadotropin; BLNK, B-cell linker;
hypoparathyroidism BOOP, bronchiolitis obliterans organizing pneumonia; BTK, Bruton’s tyrosine kinase; CMC, chronic
mucocutaneous candidiasis ELISHA, enzyme-linked immunosorbent assay; IVIG, intravenous
immunoglobulin; LN, lymph nodes; PCR, polymerase chain reaction; PIDD, primary immune disorder or
deficiency; UNG, uracil-DNA glycosylane.
Flash Card A6 An example of flow cytometry used to detect Bruton's tyrosine kinase (BTK)
expression in monocytes in the diagnosis of X-linked agammaglobulinemia is seen in
FOXP3 mutation, Treg
cell
Figure 8-1.
Normal Abnormal (XLA) Abnormal (XLA-Carrier)

CD19 (B Cells)
BTK+ B cells
BTK+
Monocytes
CD14 (Monocytes)
BTK
Figure 8-1. Flow cytometry-detected BTK expression in B lymphocytes and monocytes in
XLA. Abbreviations: BTK, Bruton tyrosine kinase; XLA, X-linked agammaglobulinemia.
Verbsky, MD, PhD, Clinical Immunodiagnostic & Research Laboratory, Medical College of
Wisconsin.)
Phagocytic Cell Disorders

Phagocytes defend against bacteria and fungi. Patients with defects of
phagocytic cell number, function, or both experience recurrent and severe
infections of fungal (especially Candida and Aspergillus species) and bacterial
origin.
Respiratory tract and cutaneous infections predominate, but deep-seated
abscesses are also common. Recurrent oral stomatitis is present in most cases.
Suspicion should be raised if infections are associated with neutropenia or
lack of neutrophilia.
Flash Card Q7
Suspected primary phagocyte deficiencies can be evaluated by functional assays, What stage of B-cell
which are included in Table 8-9. development is affected
by BTK mutation?
Defects intrinsic to the phagocyte are due to:
Abnormal bone marrow production or release
Defect in adhesion or chemotaxis
Leukocyte granule formation Flash Card Q8
Oxidative killing What are the differences
A summary of clinical disorders associated with primary phagocyte cell disorders between HIGM1/3 and
are found in Table 8-10. HIGM2/4?
314 / CHAPTER 8
Table 8-9. Evaluating Phagocyte Deficiencies

Disease
CBC LAD 1, 2 and 3
Cyclic neutropenia
SCN
AIN (classical)
SDS
NBT CGD
DHR CGD
MPO Primary MPO deficiency and secondary MPO deficiency ex. Candida
albicans or C. tropicalis infection in patient with diabetes mellitus
Chemotaxis SDS
Chediak-Higashi syndrome
LAD
Rac2 mutation
Bacteriocidal Neutrophil-specific granule deficiency
CGD
CD18 LAD1
CD15a LAD2
Abbreviations: AIN, autoimmune neutropenia; CGD, chronic granulomatous disease; DHR,
dihydrorhodamine flow cytometric assay; LAD,, leukocyte-adhesion deficiency; MPO,
myeloperoxidase; NBT, nitroblue tetrazolium chloride; SCN, severe congenital neutropenia; SDS,
Shwachman-Diamond syndrome.
Flash Card A7
Arrest in pre-B–cell
stage
Flash Card A8
HIGM1/3 are combined
immune deficiencies
with more severe/wide
spectrum of infections
with absent LN and
germinal centers due to
defects in CD40L-CD40
interactions.
HIGM2/4 are antibody
deficiencies with less
severe infections.
Lymphoid hyperplasia
and adenopathy are
noted. Defects are in B-
cell class switching and
somatic hypermutation
Table 8-10. Clinical Features, Supporting Laboratory Findings, and Molecular Defects of
Phagocytic Cell Disorders
Clinical Molecular
Disorder Laboratory Findings
Presentation & Rx Defect
WHIM Sinopulmonary infections Neutropenia (ANC 100– Activating mutation
3
syndrome Papillomavirus infection 500/mm ) due to retention in CXCR4
Warts with risk of malignant of mature granulocytes in (important in bone
transformation bone marrow marrow homing
No other viral/opportunistic (myelokathexis) and trafficking of
infections Normal phagocyte functions progenitor cells)
3
Rx: G-CSF, IVIG, Rx warts, ALC <1500/mm , +/–↓
CXCR4 inhibitor (in trial) mitogen responses
↓ IgG, ↓ CD19+ B
lymphocytes ↓ CD27+
switched memory B cells
a
Defects in Bone SCN Early onset, severe bacterial Persistent neutropenia ANC AR- HAX 1
3
Marrow infections: Omphalitis, URTI < 200/mm (Kostmann
Production or or LRTI, oral ulcer, skin and syndrome)
Release liver abscess, cellulitis, BM maturation arrest
meningitis. of neutrophil precursors at AD-Elastase (ELA-
promyelocyte-myelocyte 2), GFI1, GCSF-R
Rx: G-CSF (not working for stage XL- WASP
G-CSF-R mutation), HSCT,
monitor for myelodysplasia,
AML
Cyclic Oral ulcers, fever, skin ↓ Neutrophils, platelets, ELA-2- AD
Neutropenia infection/abscess during monocytes, reticulocytes in
periods of neutropenia 21-day cycle; last for 3–6
days
Rx: prophylactic ABx or G-
CSF during the cycling nadir CBC with differential 2–3
times weekly for 6 weeks
Defects in LAD 1 Recurrent pyogenic Leukocytosis; Common chain of
Adhesion and (most common infections, delayed wound β2-intergrin family
Chemotaxis form of LAD) healing, necrotic skin, ↓ CD18 on neutrophils by (CD18) from
infections, impaired pus flow cytometry: ITGB2 gene
formation, Severe: <1-2% mutation
gingivoperiodontitis, Mild-moderate: 2–30%
omphalitis, delayed umbilical Carrier:40–60% Defect in WBC
cord separation adhesion (arrest)
Note:
Rx: ABx Rx and prophylaxis, CD18 binds to variable α-
G-CSF, HSCT chains: LFA-1 (CD11a);
Mac-1 (CD11b);
P150,95 (CD11c)
316 / CHAPTER 8
Table 8-10. Clinical Features, Supporting Laboratory Findings, and Molecular Defects of
Phagocytic Cell Disorders, cont.
Clinical Presentation &
Disorder Laboratory Findings Molecular Defect
Rx
Defects in LAD 2 Less severe skin/lung Leukocytosis Mutation in FUCT1
Adhesion and infections, no delayed Absence of CD15a absence of fucosylation
Chemotaxis, cont. umbilical cord separation, no Sialyl-LewisX
pus formation is impaired Bombay blood phenotype (CD15a)
but not absent (hh) Defect in WBC rolling
Developmental delay, Sequence analysis of
microcephaly, and short GDPfucose transporter
stature
Rx: Abx prophylaxis, fucose
suplementation
LAD 3 LAD 1 + bleeding Leukocytosis CalDAG-GEF1
diathesis. Normal expression of CD18 mutation failure of
Abnormality of Rap1 cytokine activation of
Rx: as LAD 1 GTPase function integrins
Defect in Leukocyte Chediak- Oculocutaneous albinism, Enlarged primary granules CHS1 or LYST
Granule formation Higashi hypopigmented skin, iris, in neutrophils, eosinophils,
syndrome hair, recurrent infections, neutropenia, decreased
bleeding tendency, neutrophil chemotaxis, and
neurologic defects, absent NK cytotoxicity.
lymphoma-like syndrome,
risk of HLH Evenly distributed larger
melanin granules on hair
shaft examination
Defect in Oxidative CGD Infections with catalase- Abnormal NBT and pattern PHOX (phagocytic
Killing positive organisms of DHR NADPH oxidase
DHR is a fluorescent dye system);
Bacteria: S. aureus, that is reduced by >50% g91phox (X-
Burkholderia cepacia, superoxide radicals linked form); and
Serratia marcescens, (produced by phagocytes
Nocardia sp. Aspergillus stimulated with PMA). AR-p22, p47, and p67.
fumigatus This leads to a change in
Aspergillus nidulans flow cytometry-detected
Fungi: fluorescence(see Fig.8-2)
Not associated with
Streptococcus pneumoniae Rx:
or Pneumocystis jiroveci TMP-SMZ and itraconazole
infections prophylaxis
IFNγ
Granuloma formation (GI Systemic corticosteroids for
and GU tract outflow granuloma formation
obstruction), poor wound HSCT
healing, and autoimmune
disease
a
A mitochondrial protein that protects against apoptosis of myeloid cells.
Abbreviations: ABx, antibiotics; AD, autosomal dominant; ALC, absolute lymphocyte count; AML, acute myelogenous
leukemia; ANC, absolute neutrophil count; AR, autosomal recessive; CGD, chronic granulomatus disease; DHR,
dihydrorhodamine; G-CSF, granulocyte colony-stimulating factor; HLH, hemophagocytic lymphohistiocytosis; HSCT,
hematopoietic stem cell transplantation; IFNγ, interferon gamma; LAD, leukocyte-adhesion deficiency; LRTI, lower respiratory
tract infection; NADPH, reduced form of nicotinamide adenine dinucleotide phosphate; NBT, nitrozolium blue test; PAM,
phorbol myristic acetate; SCN, severe congenital neutropenia; TMP-SMZ, trimethoprim-sulfamethoxazole; URTI, upper
respiratory tract infection; WHIM syndrome, warts, hypogammaglobulinemia, recurrent bacterial infections, and
myelokathexis.
The dihydrorhodamine (DHR) test detects the generation of superoxide free

radicals. DHR is a fluorescent dye that is reduced by superoxide radicals, which
are produced by phagocytes stimulated with phorbol myristic acetate (PMA). This
leads to a change in flow cytometry-detected fluorescence (see Figure 8-2).
Figure 8-2. Neutrophil oxidative burst patterns on flow cytometry. The

inheritance pattern can be determined by the DHR fluorescence pattern.
Abbreviations: CGD, chronic granulomatous disease; DHR, dihydrorhodamine.
Verbsky, MD, PhD, Clinical Immunodiagnostic & Research Laboratory, Medical College of
Wisconsin.)
Deficiency in Innate Immunity

See Table 8-11.
Table 8-11. Clinical Features, Supporting Laboratory Findings, and Gene

Defect of IRAK4/MyD88 Deficiency
Clinical Laboratory Gene Defect Therapy
Presentation Findings
Severe/early-onset Normal Ig levels, IRAK4 IVIG therapeutic and
recurrent pyogenic impaired IgG MyD88 prophylactic
bacterial infections response to antibiotics (TMP-
(e.g., polysaccharide Involve in signaling of SMZ + PenV)
Pneumococcus, antigens, normal B- TLRs to the activation
Staphylococcus). and T-lymphocyte of NFκB and AP-1
numbers (may have
Meningitis completely normal
Septicemia screen)
Liver abscess
Diagnose with
Low/absent decreased PBMC
fever/inflammatory cytokine production
responses when stimulated by
TLR agonists (except Flash Card Q9
TLR 3 agonists)
Abbreviations: IRAK4, interleukin 1 receptor-associated kinase 4; NFκB, nuclear factor kappa B; What molecular defects
MyD88, myeloid differentiation primary factor 88- adaptor protein; PBMC; peripheral blood occur in LAD type 1 and
mononuclear cells TLR, Toll-like receptor; TMP-SMZ, trimethoprim-sulfamethoxazole. 2?
318 / CHAPTER 8
Defect in IFN γ/IL-12/IL-23 Axis

Interferon gamma (IFNγ) is produced by Th1 cells, dendritic cells, and NK cells;
it is essential for both innate and adaptive immune responses to viral and
intracellular infections. Th1-produced IFNγ induces IL-12 production by dendritic
cells and macrophages; and, in turn, IL-12 induces further IFNγ production by
NK and T lymphocytes. See Figure 8-3 for IFN γ/IL-12/IL-23 axis.
IL-12 and IL-23, and their receptors are heterodimeric proteins. The
IFNγ/1L12/IL23 axis depends on IFNγ and subunits listed in Table 8-12.
Figure 8-3. IFNγ/IL-12/IL-23 axis between macrophage and T/NK cell.

Abbreviations::IFN, interferon; IL, interleukin; STAT, signal transduction and activation of
transcription; T/NK,, natural killer T cell.
Table 8-12 Heterodimeric Components of IL-12 and IL-23 and Their

Receptors
Cytokine IL-12 IL-23
p35 p19
Subunits
p40 p40
Cytokine Receptors IL-12R IL-23R
IL-12β1 IL-12β1
Subunits
IL-12β2 IL-23R
Abbreviation: IL, interleukin.
Flash Card A9 (Reproduced, with permission, from Dr. John M Routes, Medical College of Wisconsin.)
CD18 and CD 15a
NK Cell Deficiency
Table 8-13 summarizes the clinical features, laboratory findings, and genetic
defect of NK cell deficiency.
NK deficiency is also seen in:

All causes of hemophagocytic lymphohistiocytosis (HLH):
o Primary HLH: XLP, familial, Chediak-Higashi syndrome, and Wiskott-
Aldrich syndrome (WAS)
o Secondary HLH (reactive hemophagocytic syndrome)
NEMO
LAD-1
Defect in IL-12/IFNγ axis
HIV infection
Malignancies
Complement deficiencies are inherited in an autosomal dominant manner except
for properdin deficiency, which is inherited in an X-linked manner. Complement
deficiency versus consumption can be determined by levels of CH50, AH50,
individual complement levels, and complement-split products as outlined in Table
8-14.
Primary complement deficiencies are characterized by recurrent infections and

autoimmune diseases. A summary of clinical features appears in Table 8-15.
Hereditary angioedema is an autosomal dominant condition caused by a

deficiency of functional C1 esterase inhibitor. (Details discussed in Chapter 8).
Table 8-13. Clinical Features, Supporting Laboratory Findings, and Gene

Defect of NK Cell Deficiency
Clinical Presentation Laboratory Findings Gene Defect Flash Card Q10
Recurrent infections with ↓ CD16 by flow cytometry Classical NK cell Patients with a mutation
herpes viruses, and deficiency: in the IFNγR (IFNγR1
papillomavirus and ↓ NK function (cytotoxicity) GATA2, MCM4 mutation and IFNγR2), p40
mycobacteria subunit, IL-12β1, NFκB
Recurrent infections with Normal CD16 by flow Functional NK cell essential modifier
herpes viruses cytometry but ↓ NK function deficiency: (NEMO), or signal
(cytotoxicity) FCRG3A (CD16) mutation transducers and
CD16 = Low-affinity IgG activator of transcription
receptor (STAT) 1 are
susceptible to infections
Abbreviations: IgG, immunoglobulin G; NK, natural killer.
with which organism(s)?
320 / CHAPTER 8
Table 8-14. Evaluating Complement Deficiencies Versus Consumption

Complement
Test Complement Deficiency
Consumption
CH50 or AH50 or both Low Low
Individual complement level Low Low
(e.g., C3)
Two or more individual Low of individual complement only Low
complement levels of CH50
or AH50
Complement split products Normal High
(Reproduced, with permission, from Dr. John M. Routes, Medical College of Wisconsin.)
Abbreviations: AH50, alternate pathway test; CH50, classical pathway test.
Table 8-15. Clinical Features and Characteristic Infections of

Clinical Infectious Laboratory Gene Defect
Features Organisms Findings
Early Sinopulmonary S. Pneumoniae ↓CH50
component infections Haemophilus
(C1q, C1s, C2, Autoimmune Influenzae
and C4) disease (SLE-like) (encapsulated
organisms)
C3 Severe infections Encapsulated ↓CH50 C3
(same as antibody organisms (e.g., ↓AH50
deficiency) Neisseria sp.) ↓C3
Glomerulonephritis C3 NeF: IgG
anti-C3
autoantibodies
MBL Many Neisseria ↓ MBL MASP2
asymptomatic;
Autoimmune
disease and
respiratory
infections
Late Infections Neisseria ↓CH50
component (meningitis, meningitidis ↓specific
arthritis, sepsis) (W135 and Y complement
and C5-7- serotypes) and ↓AH50
associated with Neisseria
autoimmunity gonorrhoeae
Alternative Infections Neisseria ↓AH50
pathway
(factor B, D
and
properdin)
Abbreviations: AH50, alternate pathway test; CH50, classical pathway test; MASP2, mannose-
binding lectin-associated protease 2
Flash Card A10
Atypical mycobacteria
and Salmonella
Acquired (Secondary) Immunodeficiencies
Acquired (secondary) immunodeficiencies are far more common than PID. The
conditions can be divided into HIV-related or due to other causes (Table 8-16).
Treatment focuses on the underlying disorder.
HIV AND/OR AIDS
HIV Group and Subgroup—2 types of HIV that infect humans:

HIV-1: More virulent, more infective, the majority of HIV infections
globally
HIV-2: Largely confined to West Africa, lower infectivity
Virus Structure—HIV structure consists of:

Two identical ssRNAs
Several enzymes packaged in a core; composed of nucleocapsid p24 and
outer membrane p17
All are surrounded by a host-derived lipid bilayer membrane with two
glycoprotein projections: gp120 and gp41 (Figure 8-4)
HIV Life Cycle—HIV crosses mucosal surfaces to infect susceptible cells (CD4–
+T cells, monocytes/macrophages, dendritic cells, and neurons). The sequential
steps of the HIV life cycle are shown in Figure 8-4 and Table 8-17.
Table 8-16. Non-HIV Causes of Secondary Immunodeficiency

Etiology Conditions
Host factor Prematurity, malnutrition, metabolic, chromosomal or genetic Flash Card Q11
disorders, and malignancy
Disruptive barrier Severe eczema and burns. Factor H deficiency is
associated with which
Defective Cystic fibrosis, ciliary dyskinesia, and removal of spleen or
microorganism autosplectomy diseases?
clearance
Protein loss Protein-losing enteropathy, intestinal lymphangiectasia, nephrotic
syndrome, and severe burn
Bone marrow disease Leukemia, myelodysplastic syndromes, and histiocytic disorder Flash Card Q12
Medication-induced Immunosuppressive therapy, radiation, and systemic corticosteroid
DAF (decay-
therapy
accelerating factor) and
Stress-related Trauma, surgery, and exercise CD59 deficiency are
associated with which
disease?
322 / CHAPTER 8
Key Fact
During latency period,
the integrated proviral
DNA may remain
transcriptionally inactive
for months or years.
Figure 8-4. Structure and life cycle of HIV.

(Modified, with permission, from Wikimedia Commons.)
Flash Card A11
Atypical hemolytic-
uremic syndrome (not
associated with
diarrhea) or Table 8-17. HIV Life Cycle
glomerulonephritis and
recurrent pyogenic Steps of Infection Key Events
infections due to Viral entry HIV gp120 binds to CD4 and chemokine coreceptor CCR5 or
secondary C3 CXCR4 on the host cell surface
deficiency. Coreceptor binding conformational change in gp41 fusion
Polymorphism is of HIV membrane with host cell membrane entry of viral
genome into cytoplasm
associated with age-
related macular Reverse transcription Activation of enzymes within viral nucleoprotein complex
degeneration and Viral reproductive cycle begins
HELLP syndrome HIV ssRNA dsDNA by reverse transcriptase
(hemolytic anemia, Integration Proviral DNA enters nucleus and is integrated into the host DNA by
elevated liver enzymes enzyme integrase
and low platelets, Transcription Proviral DNA transcribes into genomic RNA or mRNA; then
occurring during translated into viral proteins in the cytoplasm
pregnancy.
Maturation HIV protease cleaves the viral polyprotein into functional peptides
and becomes infectious
Viral packaging and Packaging RNA transcripts within a nucleoprotein complex.
budding Enclosing within the host’s membrane envelope and released from
Flash Card A12 the cell
Paroxysmal nocturnal Abbreviations: dsDNA, double-stranded DNA; mRNA, memory RNA; ssRNA, single-stranded RNA.
hemoglobinuria
Viral Tropism
HIV coreceptor tropism refers to whichever chemokine coreceptor that a strain
of HIV uses to enter cells. Some viruses can enter cells using either of the
coreceptors (Table 8-18).
Key Fact
Immune Responses to HIV
The most immunogenic
Acute Viremia HIV molecules are
gp120 and gp40. The
HIV infects CD4+ T lymphocytes, macrophages, and dendritic cells. virus can attach to
Infected cells migrate to the regional lymphoid tissues in 3–5 days. dendritic cells through
Direct cell-to-cell contact between virus-harboring cells and susceptible cells the binding of gp120 to
within germinal centers leads to a brisk increase in viral replication within 14 the adhesion molecule
DC-SIGN (dendritic
days after exposure. cell-specific
intercellular adhesion
HIV-Specific Immunity molecule-grabbing
The most effective, adaptive immune response to HIV infection during the nonintegrin).
acute phase is the expansion of HIV-specific cytotoxic T lymphocytes
(CTLs).
Antibody responses to HIV antigens are detectable within a few weeks after
infection Key Fact
Neutralizing antibodies against gp120 develop 2–3 months after infection, but Although the
are not effective. hypergammaglobulinemi
a is partly due to
antibody against the HIV
CD4+ T-Cell Lymphopenia Caused by HIV itself, it is also in part
attributable to polyclonal
activation of B cells.
There are three main mechanisms:
Direct viral killing of infected cells (cytopathic effect)
Increased apoptosis of infected cells
Killing of infected cells by HIV-specific CTLs.
Clinical Features
See Figure 8-5 and Tables 8-19 and 8-20.
Table 8-18. HIV Coreceptor Tropism

Coreceptor Host Cells and HIV Strain Stage of Infection
CCR5 Monocytes/macrophages Acute infection
M-tropic (monocytotropic) or R5 strain of virus
CXCR4 T cells Advanced HIV disease Flash Card Q13
T-tropic (T-cell lymphotropic) or X4 strain of virus What is the significance
Abbreviations: CCR5, CXCR4, chemokine receptors. of CCR5Δ32 mutation?
324 / CHAPTER 8
Figure 8-5. Clinical course of HIV disease.

(Modified, with permission, from Wikimedia Commons.)
Table 8-19. Clinical Feature of HIV Disease

Phase of HIV Disease Clinical Feature
Acute HIV syndrome: Flu-like symptoms for several weeks (fever, headaches, pharyngitis,
maculopapular rash, generalized lymphadenopathy, arthralgia,
Period of viremia (spike of nausea, vomiting, and diarrhea)
viral load) and most
reduction in CD4+ T-cell
counts
Clinical latency period CD4+ T-cell counts returns to normal shortly after the acute phase.
Patient enters the chronic latent period. Declining CD4+ T-
Flash Card A13 lymphocyte counts occurs through several years.
Double-allelic mutations AIDS HIV disease progresses to the final phase, or AIDS, when CD4+ T-
confer resistance to the 3
cell counts drops < 200 cells/mm or patients develop AIDS-
CCR5 strain of HIV defining conditions (category C) see Table 8-20
(resistant to infection
despite being repeatedly
exposed to HIV through
sexual contact).
Single allelic mutations
are long-term
nonprogressors (slow
disease).
Table 8-20. Classification System for HIV Infection

Category B Symptomatic Conditions Category C AIDS-Indicator Conditions
Bacillary angiomatosis Bacterial pneumonia, recurrent (≥2/12 months)
Oropharyngeal candidiasis (thrush) Candidiasis of the bronchi, trachea, or lungs
Vulvovaginal candidiasis, persistent or Candidiasis, esophageal
resistant
Cervical carcinoma, invasive, confirmed by
Pelvic inflammatory disease (PID) biopsy
Cervical dysplasia (moderate or Coccidioidomycosis,
severe)/cervical Carcinoma in situ disseminated/extrapulmonary
Hairy leukoplakia, oral Cryptococcosis, extrapulmonary
Herpes zoster (shingles): Cryptosporidiosis, chronic intestinal (>1 month)
involving ≥ 2 episodes or ≥ 1dermatome Cytomegalovirus disease(other than
liver/spleen/LN)
Idiopathic thrombocytopenic purpura
Encephalopathy, HIV-related
Constitutional symptoms:
Herpes simplex: Chronic ulcers (>1 month) or
fever > 38.5ºC or diarrhea > 1 month
bronchitis, pneumonitis, or esophagitis
Peripheral neuropathy
Histoplasmosis, disseminated or extrapulmonary
Isosporiasis, chronic intestinal (>1 month)
Kaposi’s sarcoma
Lymphoma, Burkitt’s, immunoblastic, or primary
central nervous system
Mycobacterium avium complex (MAC) or
Mycobacterium kansasii, disseminated or
extrapulmonary
Mycobacterium tuberculosis,
pulmonary/extrapulmonary
Mycobacterium, other species or unidentified
species, disseminated or extrapulmonary
Pneumocystis jiroveci pneumonia
Progressive multifocal leukoencephalopathy
(PML)
Salmonella septicemia, recurrent (nontyphoid)
Toxoplasmosis of brain
Wasting syndrome caused by HIV (involuntary
weight loss >10% of baseline body weight) with
either chronic diarrhea (≥2 loose stools /day for
≥1 month) or chronic weakness and documented
fever for ≥1 month
326 / CHAPTER 8
Diagnosis
Table 8-21 summarizes the diagnostic tests for HIV infection.
Table 8-21. Diagnostic Tests for HIV Infection

Antibody Tests Comments
ELISA or EIA High sensitivity, moderate specificity; therefore require a
confirmatory test.
Used as a screening tool for both HIV-1 and 2
False-positive: Autoimmune diseases, multiple pregnancies,
multiple blood transfusions, following immunizations
False-negative: Window period (can be up to 6 months after
infection)
Rapid HIV test High sensitivity, moderate specificity; therefore require a
confirmatory test
Detect anti-HIV antibody in blood/oral fluid.
Turnaround time < 20 minutes
False-positive results possible
Western blot (WB) Confirmatory test (high sensitivity, high specificity)
Expensive and labor intensive.
Used to confirm a reactive EIA/ELISA test or rapid HIV test
A positive WB test requires two of three major bands: anti-p24,
anti-gp41, and anti-gp160/gp120
Follow-up indeterminate or negative test by repeating WB in 4
weeks or considering WB for HIV-2. If results continue to be
indeterminate, then virologic testing recommended
Indirect immunofluorescent Confirmatory test
antibody assays (IFAs) Specimens evaluated by fluorescence microscopy
Antigen-based Tests Comments
HIV DNA by PCR Moderate sensitivity, high specificity
Detects HIV-1 DNA within the PBMC
Used mainly in acute viral syndrome when antibody test is
negative and in exposed infants
HIV RNA by PCR Moderate sensitivity, high specificity
Quantifies viral load; reported as RNA copies/mL
Provides indication for treatment and gauges therapeutic
response
HIV p24 antigen May be used in neonates or as a marker of disease progression
and response to treatment
Now, replaced by PCR assays
Fourth-generation HIV test = test for p24 antigen + ELISA
antibodies;
(Another screening test, can detect infection sooner than
ELISA because p24 antigen appear sooner in serum)
HIV culture Can be diagnostic but not routinely used in clinical practice
because the test more expensive, labor-intensive, and takes
longer than other diagnostic assays
Abbreviations: EIA, enzyme-linked immunoassay; ELISHA, enzyme-linked immunosorbent assay
PCR; polymerase chain reaction; PBMC, peripheral blood mononuclear cells.
HIV-Exposed Infants
HIV-1-exposed infants should be tested by HIV-1 DNA PCR
At birth, within 14–21 days of age; 1–2 months of age and 4–6 months of age
to identify or exclude HIV-1 infection.
An antibody test by ELISA between 12–18 months should be performed to
definitively exclude HIV-1 infection.
Antibody tests in infants younger than 18 months old are not routinely
recommended due to the presence of passively acquired maternal antibody.
Umbilical cord blood sample is not recommended due to high false positive
rate.
Pneumocystis jiroveci pneumonia (PJP) prophylaxis beginning at 4–6 weeks
of age is recommended for infants determined to be infected with HIV-1 until
at least 1 year old.
HIV Prevention
Table 8-22 represents HIV prevention strategies via mode of transmission.
Treatment
Current U.S. Department of Health and Human Services (DHHS) guidelines
(revised Feb 2013 from http://www.cdc.gov/hiv/resources/guidelines) recommend
the initiation of highly active antiretroviral therapy (HAART) in:
All symptomatic persons
Asymptomatic persons
o To initiate HAART at any CD4+ T-cell count
<350 cells/µL (AI*)
350–500 cells/µL (AII*)
>500 cells/µL (BIII*)
o HIV RNA may influence decision to start antiretroviral therapy (ART) and
help determine frequency of CD4 monitoring.
Initial therapy preferably contains a combination of non-nucleoside reverse
transcriptase inhibitor (NNRTI), protease inhibitors (PI), or integrase inhibitor
(II) + 2 nucleoside reverse transcriptase inhibitors (NRTIs). Currently
available antiretroviral drugs are listed in Table 8-23.
(*Strength of recommendation: A. Strong, B: Moderate, C: Optional. Quality of

evidence: I: ≥1 randomized controlled trials, II: ≥1 well-designed nonrandomized
trials or observational cohort studies with long-term clinical outcomes, III: Expert
opinion.)
Table 8-23 summarized the antiretroviral medications, the mechanism of action

and phase of inhibition.
328 / CHAPTER 8
Table 8-22. HIV Prevention

Mode of
Strategies
Transmission
Mother to child Antepartum and intrapartum zidovudine-based prophylaxis
Elective cesarean section or vaginal delivery without invasive procedures
Breastfeeding avoidance
Sexual contact Condoms, male circumcision, and safe sex practice
Sexual/occupation Two to three drugs postexposure, with prophylactic regimens
al exposure Initiate as soon as possible after exposure and continue for 4 weeks
Pre-exposure prophylaxis recently FDA-approved
Table 8-23. Antiretroviral Medications

Mechanism of
Class Phase of Inhibition Examples
Action
Key Fact Entry inhibitors Binding, fusion, and entry Block one of several Maraviroc (binds
(fusion inhibitors) of virion targets to CCR5) and
It is recommended to
enfuvirtide (binds
screen for HLA-B*5701 to gp41).
before starting a patient
with abacavir. Integrase inhibitors Integration of viral DNA Inhibit enzyme Raltegravir
(II) into the DNA of the integrase
Abacavir challenge is
infected cell
absolutely
contraindicated if there is Reverse
a history of transcriptase
hypersensitivity reaction inhibitor
or positive HLA-B*5701 Nucleoside or Reverse transcription Incorporated into the Zidovudine,
testing, since it can nucleotide newly synthesized didanosine,
result in a severe and reverse viral DNA to abacavir, and
potentially life- transcriptase terminate the DNA tenofovir
inhibitors (NRTI strand
threatening reaction. or NtRTI)
Nonnucleoside Reverse transcription Bind directly to Efavirenz,
reverse enzyme reverse nevirapine
transcriptase transcriptase and delavirdine and
inhibitors inhibit its function etravirine
(NNRTI)
Non-nucleoside Reverse transcription Bind directly to Efavirenz,
reverse enzyme reverse nevirapine
transcriptase transcriptase and delavirdine and
inhibitors inhibit its function etravirine
(NNRTI)
Protease inhibitors Viral assembly Inhibit activity of Ritonavir,
(PIs) protease indinavir,
nelfinavir,
lopinavir, and
atazanavir
Immune Reconstitution Inflammatory Syndrome (IRIS)
A paradoxical deterioration in clinical status, usually 4–8 weeks after HAART

initiation.
Attributed to the reactivation of the immune response (cytokine storm) to an
existing opportunistic infection (OI) when the CD4 count rapidly increases.
Most common OIs associated with IRIS include TB and Pneumocystis jiroveci
pneumonia (PJP), although CMV, herpes zoster, and Mycobacterium avium
complex (MAC) can be associated with IRIS.
Patients resent with new or worsening systemic manifestations, such as fever
and malaise or local reactions in organs (e.g., lungs/CNS) depending on the Key Fact
location of the OI.
If patients have a low
initial CD4+ T-
Subjects at high risk for IRIS include: lymphocyte count and OI
Those starting HAART for the first time at the time of HIV
CD4+ T lymphocytes > 50 /mm3 before starting HAART diagnosis, they should
receive treatment to
Have recently been treated for OIs control the OI before
HAART is initiated.
Treatment is mainly limited to supportive measures and anti-inflammatory
medications such as NSAIDS or corticosteroids.
Table 8-24 reviews the prophylaxis for HIV-related opportunistic infections.
Table 8-24. Prophylaxis for HIV-Related Opportunistic Infections

Indication Pathogen Prophylactic Medications
3
CD4 < 200 cells/mm or Pneumocystis jiroveci TMP-SMX
CD4 % < 14, thrush, history Dapsone ± pyrimethamine
of AIDS-defining illness or Atovaquone
FUO
3
CD4 < 100 cells/mm and Toxoplasma gondii TMP-SMX
positive Toxoplasma IgG Dapsone + pyrimethamine +
leucovorin
Atovaquone ± pyrimethamine
3
CD4 < 150 cells/mm and Histoplasma capsulatum Itraconazole
a
living in endemic area for
histoplasmosis
CD4 counts are ≤ 250 Coccidioides species Fluconazole
3
cells/mm and living in Itraconazole
b
endemic area for
Coccidioides sp. and positive
IgM or IgG serologies
3
CD4 < 50 cells/mm Mycobacterium avium complex Azithromycin
(MAC) Clarithromycin
Rifabutin Flash Card Q14
a
Ohio and Mississippi River Valleys, central and south America, Asia, and Africa
b Which HLA allele is
Sonoran Desert in Arizona and the San Joaquin "Central" Valley in California, New
associated with an
Mexico, western Texas, Nevada, and Utah
Abbreviations: FUO, fever of unknown origin; TMP-SMZ, trimethoprim-sulfamethoxazole.
increase risk in abacavir
hypersensitivity?
330 / CHAPTER 8
HIV Vaccine
Candidate HIV vaccines aim at inducing neutralizing antibodies, CTLs, and
strong mucosal responses.
SYSTEMIC AUTOIMMUNE DISEASE
Overview of Systemic Autoimmunity

Autoimmunity can result from one of the following:
Loss of tolerance to host constituents, leading to self-Ag driving immune
Key Fact dysregulation and possible organ damage
Th17 cells may be Exposure of genetically susceptible host to inciting antigen(s) in appropriate
pathogenic in rheumatoid setting (i.e., innate immunity, inflammation, hormones, or environment, etc.),
arthritis (RA) and other
leading to the development of autoantibodies
autoimmune disorders:
Distinct subset from
In some systemic autoimmune diseases, certain autoantibodies are common and
Th1 and Th2
some may even be pathogenic, whereas others serve as markers of disease activity
Induces inflammation
or clinical subsets of disease.
by producing IL-17A,
IL-17F and IL-22 and
synergizes with TNF A summary of high-yield autoimmune diseases is presented in Table 8-25.
and IL-1
Induced by IL-6 and
Factors that contribute to the failure to prevent autoimmunity include the
TGF-ß following:
Survival enhanced by Infection: Viral and bacterial
IL-23 Tissue injury
Environmental stress
Advancing age
General immune dysregulation in predisposed individuals (i.e., HIV infection)
A variety of infection factors are relevant for organ-specific autoimmunity,

including the following:
Self-modification or loss of sequestration (i.e., eye infection)
Superantigen immune dysregulation (i.e., Staphylococcal enterotoxin)
Molecular mimicry:
o Glutamic decarboxylase: Coxsackie B
o Major basic protein: Hepatitis B virus (HBV)
o Acetylcholine receptor: Herpes simplex virus (HSV)
Adjuvant effects (i.e., Toll receptor stimulation by endotoxins)
Flash Card A14
HLA-B*5701
Specific Systemic Autoimmune Diseases

Table 8-25 summarizes the systemic autoimmune diseases.
Table 8-25. Summary of Systemic Autoimmune Diseases

Condition Clinical Findings Autoantibody Treatment
Sjögren’s syndrome Xerophthalmia, ANA, SS-A, SS-B, Symptomatic
xerostomia (sicca and RF (muscarinic agonists,
symptoms), arthritis, cyclosporine
interstitial nephritis, ophthalmic drops, and
renal tubular acidosis, artificial tears); and
and pulmonary immunosuppressives
involvement for severe
extraglandular features
Progressive Fibrosis of skin, ANA and Scl-70 Symptomatic: ACE
systemic sclerosis or vasculopathy, inhibitor for renal crisis;
diffuse systemic hypertensive renal various immune
sclerosis disease, interstitial suppressive therapies
lung disease, and with varying response
CREST symptoms
Progressive Calcinosis, Anticentromere Ab Symptomatic (Ca
systemic sclerosis; Raynaud’s, channel blockers, PPI,
and limited (CREST esophageal motility, metoclopramide); and
syndrome) sclerodactyly, PAH = oral
telangiectasia, and anticoagulation, Ca
PAH channel blockers,
endothelin receptor
antagonist,
prostanoids, and
epoprostenol in
refractory cases
Polymyositis Idiopathic myositis, ANA, Anti-Jo-1, anti Corticosteroids and
weakness of proximal SRP, and anti-PL-7 immunosuppressives
skeletal muscle, (antithreonyl-tRNA (azathioprine and MTX)
increased CPK, and synthetase)
aldolase
Dermatomyositis Similar to polymyositis ANA, Anti-Jo-1, and Corticosteroids and
but also with Anti-PL-7, immunosuppressives
dermatologic features; (antithreonyl tRNA (azathioprine, and
Gottron’s papules, synthetase); MTX)
heliotrope rash, andAnti-Mi2 Ab
“mechanic hands”, (helicase)
and association with
malignancy
Abbreviations: ACE, angiotensin-converting enzyme; ANA, antinuclear antibody; CPK, creatine Flash Card Q15
phosphokinase; MTX, methotrexate; PAH, pulmonary arterial hypertension; PPI, proton pump
inhibitor; RF, rheumatoid factor; SRP, single recognition particle. What autoantibody is
associated with CREST
syndrome?
Flash Card Q16

What is Felty’s
syndrome?
332 / CHAPTER 8
Rheumatoid Arthritis (RA)
Epidemiology—Female-to-male ratio is 3:1, onset during fourth or fifth decade,

but the disease can occur at any age.
Clinical Features— Includes the following:

Common prodrome of weakness and fatigue
Initial presentation with multiple symmetrical joints usually involved, most
often hands and feet (i.e., metacarpophalangeal [MCP], metatarsophalangeal
[MTP], and proximal interphalangeal [PIP] joints). Joint effusions and
restricted motion usually present early
Eventual joint deformities due to chronic inflammation
Other findings include rheumatoid nodules over bony prominences,
splenomegaly, pericarditis, vasculitis, eye disease, and renal amyloidosis
Diagnosis—See Table 8-26 for diagnostic criteria of RA.
Immunologic Features—Features include the following:

Increase in rheumatoid factor (RF) in 80% of patients. RF is the Ig that binds
IgG Fc. Usually IgM isotype. Higher = worse prognosis.
Elevated acute-phase reactants (ESR and CRP).
Anti-cyclic citrullinated peptide (CCP) or ACPA: As sensitive as RF, but
more specific:
o May precede onset of symptoms and is associated with worsening
prognosis.
Treatment—Options include:
NSAIDS
Steroids
Intrasynovial joint injections
Disease-modifying antirheumatic drugs (DMARDs) and
TNFα blocker, α-IL-6R mAb (tocilizumab), CTLA-4-Ig (abatacept), anti-
CD20 mAb (rituximab)
Prognosis—RA is a progressive disease. Treatment helps relieve symptoms and

slow progression.
Flash Card A15

Anticentomere antibody
Flash Card A16

Triad of RA,
neutropenia, and
splenomegaly
Table 8-26. American College of Rhematology Criteria for

Diagnosis of RA
Joint Distribution Score
RA can be classified or diagnosed with a score ≥6.
1 large joint 0
2–10 large joints 1
1–3 small joints 2
4–10 small joints 3
>10 joints with at least 1 small joint 5
Serology
Negative RF and anti-CCP 0
Low positive RF or anti-CCP 2
High positive RF or anti-CCP 3
Symptoms Duration
<6 weeks 0
≥6 weeks 1
Acute-Phase Reactants
Normal CRP and ESR 0
Abnormal CRP and ESR 1

Abbreviations: CCP, cyclic citrullinated peptide; CRP, C-reactive protein; ESR, erythrocyte
sedimentation rate; RA, rheumatoid arthritis; RF, rheumatoid factor.
Juvenile Idiopathic Arthritis (JIA)

Definition:
Age of onset < 16 years of age
Arthritis
Duration of symptoms > 6 weeks
It can be divided into four subtypes, each distinguishable by both clinical and
demographic factors. An important clinical distinction is the location and number
of joints involved. These distinctions are outlined and compared further in Table
8-27.
Treatment—Treatment for JIA is similar to that for RA.

334 / CHAPTER 8
Table 8-27. Comparison of the Four Presentations of JIA

Pauciarticular Polyarticular Juvenile Systemic Onset
Onset Onset Spondyloarthropathy (Still’s Disease)
Frequency 50–60%. Most 30–35% 10–5% 10–15%
common type.
Common 18–36 months 18–36 months Late childhood/adolescent No definite peak
age of (range 2.8–17.6 years) age of onset
onset
Male : 1:5 1:4 4:1 1:1
Female
Arthritis Mono- or Symmetrical Axial arthritis, sacroiliitis, Polyarticular
pattern oligoarticular and polyarticular. ≥5 can be oligoarthritis or
usually involves cumulative joints polyarthritis
larger joints
Extra- Systemic features Intermediate risk for Enthesopathy, uveitis Fever, rash,
articular are often minimal; uveitis (20% in adult, less serositis,
pattern Highest uveitis risk common in children), lymphadenopathy,
(20% patients) aortic insufficiency myopericarditis,
and Köbner’s
a
phenomenon
Relevant RF almost always 15% RF+ 90% HLA B27+ (children) Polyclonal
laboratory negative 80% ANA+ in RF+ RF— absent elevation of
tests 65–85% ANA+ patients, 57% ANA+ immunoglobulin
in RF-negative levels
patients RF, ANA are
uncommon and not
useful for
diagnosis.
Increased LFTs,
ESR/CRP and
ferritin
Prognosis Variable Variable, RF + Usually chronic Chronic arthritis in
more disability 50%, remission
~1/3 and severe in
20%
a
Köbner’s phenomenon: Still’s rash (i.e., faint, evanescent, salmon-colored eruption that occurs with fever) can be
triggered by stroking the skin.
Abbreviations: ANA, antinuclear antibody; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; HLA,
human leukocyte antigen; LFT, liver function test; RA, rheumatoid arthritis; RF, rheumatoid factor.
Systemic Lupus Erythematosus (SLE)
SLE is a disease seen most often in young women of childbearing age and in
cases of drug-induced lupus.
Diagnosis—The clinical features of SLE are listed in Table 8-28.

Table 8-28. Diagnostic Criteria for Systemic Lupus Erythematosus (SLE)
Four or more criteria are needed to make the diagnosis of SLE.

Malar rash = fixed malar erythema, flat or raised (Figure 8-6)
Discoid rash = erythematous raised patches, with keratotic scaling and follicular plugging
Photosensitivity = skin rash as an unusual reaction to sunlight
Oral or nasopharyngeal ulcers
Arthritis = nonerosive
Serositis = pleuritis or pericarditis
Renal disorder (nephritis): Proteinuria ≥0.5 g or 3+; and cellular casts
Neurologic disorder: Seizures, and psychosis
Hematologic disorder: Hemolytic anemia, leukopenia < 4000, lymphopenia < 1500, and
thrombocytopenia < 100,000
Immunologic disorder: Anti-DNA, anti-Sm, positive test for IgM or IgG to anticardiolipin Ab
or lupus anticoagulant or false + RPR
Antinuclear antibody (in absence of drugs known to cause drug-induced lupus syndrome)
Abbreviation: RPR, rapid plasma regain.
Immunologic Features—The mechanism is not completely clear. It is

characterized by immune complex deposition. The best example is seen in
glomerulonephritis. Genetic factors include HLA-DR2, 3, early complement
component deficiencies (C1, 2, 4) and FcγRII, III polymorphisms (Table 8-29).
Figure 8-6. Malar rash of systemic lupus erythematosus. Flash Card Q17
(Reproduced, with permission, from USMLERx.com)
Which type of JIA has
the highest risk for
uveitis?
336 / CHAPTER 8
Table 8-29. Immunologic Markers in SLE

Antibody Frequency in SLE Comments
ANA 99% Negative test essentially rules out SLE
Very sensitive but specificity Seen in many other connective tissue
~67% diseases
Anti ds-DNA 50–60% Correlates with active disease and
Very specific but less sensitive lupus nephritis
Very uncommon in other diseases
Anti-Smith 30–40% Correlates with interstitial lung disease
Very specific but less sensitive Very uncommon in other diseases
Anti-Ro (SS-A) 25–30% Seen in subacute cutaneous lupus,
But see in 60–75% of Sjögren’s neonatal lupus syndrome (congenital
syndrome heart block, thrombocytopenia, and
annular rash; “Anti-Ro makes baby’s
heart GO”)
Antihistone 50–70% Drug-induced lupus
Abbreviation: SLE, systemic lupus erythematosus.
C3 and C4: Decreased in chronic disease because of complement consumption

by immune complexes, especially in the setting of glomerulonephritis. Levels
return to normal with clinical improvement.
Treatment—Corticosteroids are generally used to treat SLE, but milder forms of

the disease can be treated with less potent medications such as NSAIDS. Rash can
be treated with topical steroids. Hydroxychloroquine can be used for control of
skin disease and arthritis. For kidney disease that threatens kidney function,
treatment should involve:
High-dose corticosteroids
IV cyclophosphamide
Mycophenolate mofetil
Azathioprine
Methotrexate
Type I interferons
Antiphospholipid syndrome is commonly seen in patients with SLE, especially

in setting of thromboembolic disease, spontaneous abortion, thrombocytopenia,
and neuropsychiatric events. Treat with anticoagulants.
Flash Card A17

Pauciarticular JIA
Sjögren’s Syndrome (SS)

SS is a chronic inflammatory disorder and lymphoproliferative disease with
autoimmune features characterized by a progressive mononuclear cell infiltration
of exocrine glands, particularly the lacrimal and salivary glands (autoimmune
exocrinopathy).
There are two types of SS:

Primary: Isolated autoimmune disorder. Dry mouth (xerostomia) and dry
eyes (xerophthalmia) develop as isolated entities.
Secondary: Complication of connective tissue disorder include RA, SLE,
polymyositis (PM), or scleroderma.
Presentation—The most common symptoms of SS are related to xerostomia and

xerophthalmia (keratitis sicca). Swelling of parotid gland can be unilateral or
symmetrical, and recurrent. Physical findings include:
Dry skin
Palpable purpura
Urticaria
Arthralgias without arthritis
Frequent sinus infections
Obstructive airway disease
Interstitial pneumonitis (may progress to pulmonary fibrosis)
Dysphagia
CNS involvement, including immune-mediated hearing loss, vasculitis,
neuropsychiatric manifestations, and mononeuritis multiplex, especially in
association with cutaneous vasculitis
SS is also associated with primary biliary cirrhosis, HIV I, and hepatitis C.
Immunologic Markers
Ro/SS-A and La/SS-B: Most clinically significant in primary SS
Anti-Ro: 60–75%; Anti-La: 40% in primary SS
ANA + / RF + = 60–80% patients with primary SS
Treatment—In cases of SS, treatment with artificial tears and pilocarpine can
improve dryness. Cholinergic agents should be administered for dry mouth.
Encourage patients to practice good dental hygiene to prevent dental caries.
338 / CHAPTER 8
Polymyositis, Dermatomyositis, and Inclusion Body

Myositis
Inflammatory myopathies are idiopathic diseases of muscle, characterized
clinically by muscle weakness and pathologically by inflammation and muscle
fiber breakdown. A comparison of the clinical, immunologic, and diagnostic
differences can be seen in Table 8-30.
Presentation—Cutaneous signs:
Key Fact Heliotrope rash on the upper eyelids (Figure 8-7A)
Classic clinical Erythematous rash on the face
manifestations for May also involve the back and shoulders (shawl sign), neck and chest (V-
polymyositis/dermatomy shape), and knees and elbows
ositis is a difficulty
getting up from a chair, Gottron's papules (i.e., violaceous papules overlying dorsal interphalangeal or
climbing stairs, reaching metacarpophalangeal areas, elbow, or knee joints) (Figure 8-7B)
above the head, or the Photosensitivity
combing hair. Distal Nail cracking, thickening, and irregularity with periungual telangiectasia
muscle and ocular
involvement are Mechanic's hand: Fissured, hyperpigmented, scaly, and hyperkeratotic; also
uncommon associated with increased risk of interstitial lung disease
(distinguished from
myasthenia gravis).
Sensation and reflexes
are preserved.
A B
Figure 8-7. (A) Heliotrope rash. (B) Gottron’s papules.

(Figure A reproduced, with permission from Dugan, Elizabeth M; Huber, Adam M; Miller, Frederick
W; Rider, Lisa G; & the International Myositis Assessment and Clinical Studies (IMACS) Group;
Figure B reproduced, with permission, from Wikimedia Commons.)
Table 8-30. Comparison of Autoimmune Myositis

Polymyositis Dermatomyositis Inclusion Body
(PM) (DM) Myositis
Epidemiology Females > Males Females > Males Males > Females
18 years of age and Children & adults 50 years of age and
older older
Immune markers Anti-Jo-1 associated Anti-Jo-1
with interstitial lung Anti-Mi-2 associated
disease with rash, good
Anti-SRP associated outcome. Antibodies
with acute onset, rare in children
refractory to treatment
Pathophysiology Cell-mediated Perifascicular atrophy CD8 T cells
endomysial due to microvascular
inflammatory infiltrate damage. Ab-
with primarily CD8 T mediated
cells. Not Ab-mediated complement attack
Clinical Subacute onset of Subacute onset of Proximal muscle
presentation proximal muscle proximal muscle weakness and
weakness; systemic weakness; atrophy that may
autoimmune disease esophageal involve distal spread;
occurs more dysmotility often progresses over
commonly; and seen; ECG changes; months to years; and
respiratory problems skin findings (see dysphagia
below); and
respiratory problems
Diagnosis Biopsy, CPK, and EMG and nerve conduction Biopsy may reveal
studies basophilic-rimmed
vacuoles as well as
characteristic
filamentous
inclusions and
vacuoles (i.e.,
ragged red fibers on
EM); muscle
enzymes normal-to-
mildly elevated; and
no assoc. with ANA
Treatment Steroids; consider IVIG and cyclophosphamide Resistant to therapy;
Hydroxychloroquine for skin lesions of DM but, consider
steroids, IVIG, and
immune suppression
Other associations May be seen in Associated with Possible association
patients with cancer in patients with viral etiology
scleroderma, SLE, older than 50 years of
and MCTD age
Prognosis 50% of patients will go into remission and stop The older the age at
therapy within 5 years. Poor prognostic onset of the disease,
indicators include delay in diagnosis, older the more rapid is the
age, recalcitrant disease, malignancy, loss of strength and
interstitial pulmonary fibrosis, dysphagia, function
leukocytosis, fever, and anorexia
Abbreviations: ANA, antinuclear antibody; CPK, creatinine kinase, DM, diabetes mellitus; ECG,
electrocardiography; EM, electromicroscopy; EMG, electromyelography; IVIG, intravenous
immunoglobulin; MCTD, mixed connective tissue disease; SLE, systemic lupus erythematosus.
340 / CHAPTER 8
Scleroderma or Progressive Systemic Sclerosis
This systemic disorder is characterized by excess collagen deposition in skin and

viscera. Vascular abnormalities are also present, including vasospasm and
microvascular occlusion.
Clinical Features
Thickening of skin
Calcinosis and telangiectasias occur later in disease
Raynaud’s phenomenon: Universal among patients with systemic sclerosis
Esophageal dysmotility: Most common GI manifestation and may be
accompanied by dysphagia, reflux, and strictures. Decreased motility results
in bacterial overgrowth, diarrhea, and malabsorption
Pulmonary parenchymal fibrosis common but often asymptomatic
Cardiac involvement
Renal crisis, especially in diffuse variant, which can lead to hypertension,
microangiopathy, and renal insufficiency. Treatment of choice is ACE
inhibitors
CREST syndrome:
o Calcinosis
o Raynaud's syndrome
o Esophageal dysmotility
o Sclerodactyly
o Telangiectasias (in CREST scleroderma, is limited to distal extremities)
Immunologic Features
Pathogenesis unknown
Polyclonal hypergammaglobulinemia common, plus presence of ANA and
antiendothelial Abs
ANA: 80% of patients have ANA in centromere or nucleolar pattern
Antiendothelial Ab
Anticentromere antibody (good prognosis if positive)
Antiscleroderma-70 antibody more common with diffuse disease
Diagnosis—Anticardiolipin antibody or antiscleroderma-70 antibody Ab testing

may be used to confirm the clinical suspicion. Skin biopsy is rarely needed.
Treatment—Symptomatic and problem-oriented. Raynaud’s phenomenon may

respond to a calcium channel blocker. Corticosteroids are reserved for resistant
symptoms. Esophageal symptoms are useful for protein pump inhibitors, H2
blockers, and promotility agents. Inflammatory interstitial lung disease (ILD) is
treated with cyclophosphamide.
IMMUNE REJECTION AND ORGAN TRANSPLANTATION
Immune rejection occurs depending on the level of matching and disease.

Solid organ transplantation:
Rejection revolves around the donor’s immune reaction to the vasculature of
the transplanted organ.
GVHD can occur due to harbored, competent immune cells in the donor graft
attaching the immunosuppressed host.
Bone marrow transplantation:

Require human leukocyte antigen (HLA) compatibility, or matching
Major complication tends to be graft-versus-host disease (GVHD)
Rejection occurs when the host immune system remains competent. It will
recognize the donor cells as foreign and kill them mainly through T-
lymphocyte- and natural killer (NK) cell-mediated reactions
IMMUNE REJECTION
Getting to Know HLA (Figure 8-8)

Key Fact
The class I region has
both classical (A, B, C)
and nonclassical HLA
genes. The nonclassical
genes (E, G, F) have
unique properties. HLA-
G and F are expressed
on the extra villous
trophoblast. Their key
role is to protect the
fetus from maternal
immune rejection. They
have a more limited
polymorphic profile.
Figure 8-8 MHC Complex. Peptide presentation on cell surface to discriminate

self- versus non–self-antigens. Three regions on chromosome 6 with large
number of highly polymorphic genes: class I, class II, and class III.
Abbreviations: HLA, human leukocyte antigen; MHC, major histocompatibility complex.
342 / CHAPTER 8
HLA Nomenclature
The HLA is designated by a letter and a single- or a two-digit number.
Class I antigens = A, B, or C + digit
o Example: HLA*A0201
Class II antigens = D + M, O, P, Q, or R + A or B (for α or β chain) + digit
o Example: HLA-DRB1*0401
The antigenic designation is what the antibody sees. One antigen may be coded
by numerous alleles.
Alleles are designated first by two-digit numbers, indicating a group of alleles that
encode a particular antigen at the serologic level. The allele is further subtyped by
a two-digit number, signifying the specific allele at the sequence level.
The difference between the serologic level and the sequence level is that an
antigen that the antibody recognizes may be encoded by different polymorphisms.
The antibody might not be able to tell the difference between these polymorphic
sequences; however, T-lymphocyte epitopes that are linear and presented in the
context of the HLA molecules might induce rejection to a polymorphism that was
serologically indistinguishable. Thus sequencing gives the so called high
resolution typing.
HLA is expressed in a codominant fashion. Each locus has two alleles; and, as
individuals, we each receive one from our mother and one from our father.
Seeing the Alloantigen

Figure 8-9 represents the direct and indirect allorecognition.
Figure 8-9. Direct and indirect allorecognition. The figure on the left represents
the direct allorecognition, the figure in the right represents the indirect
allorecognition. Notice that the recipient APC is used in the indirect
allorecognition instead of the donor antigen-presenting cell (APC) as in the direct
allorecognition.
ORGAN TRANSPLANTATION
Types of Transplants
Syngeneic: Genetically identical, twins

Allogeneic: Nongenetically identical. The reactive antigens are different
within the same species (e.g., HLA or other polymorphic gene products):
These antigens are alloantigens.
Xenogeneic: Graft across species
Allogeneic Transplants
Solid-Organ Transplantation—Kidney, liver, lung, pancreas, cornea, and bone.
Cornea, bone, and joint tissues do not require immunosuppression. The solid
organs require, and survival depends on, immune suppression. Reasons for solid-
organ rejection are mediator-specific, which also affects the timing of the
rejection from very early to late (Table 8-31).
344 / CHAPTER 8
Table 8-31. Solid-Organ Rejection

Type of Mediator Timing Pathophysiology Comments
Reaction
Hyperacute Preexisting Ab On the table Ab to antigen Black organ, ABO-
after compliment incompatible
anastomosis activation and (natural IgM).
Minutes to endothelial damage Big issue in
hours thrombosis, PMN xenotransplantatio
n: Remove!
Accelerated Preexisting Ab Within 2–5 IgG non- Try
but minor days compliment–fixing immunosuppressi
antigens not in Ab, endothelial on
typical damage,
screening thrombosis, and
vasculitis
Acute Alloreactive T- After 7 days to Direct killing by T CD8+ cell and
lymphocyte +/– 3 months lymphocyte, cell steroids
Ab infiltrations, and
endovasculitis
Chronic DTH-like Months to Vessel smooth Alloreactive CD4+
reaction years muscle proliferation, graft
T cells, fibrosis, and vasculopathy, or
cytokines occlusion accelerated graft
arteriosclerosis
Abbreviations: Ab, antibody; PMN, polymorphonuclear neutrophil.
Testing for Transplantation

A test that is rarely administered today, but is still testable, is the mixed
leukocyte reaction (MLR).
Donor A’s mononuclear cells are cultured with donor B’s mononuclear cells.
There will be proliferation; however, this will result in a mess since both donors
are reacting to each other. Their HLA types are different.
If donor A’s cells are irradiated or drug-treated to make them incapable of

proliferation. Donor A’s cells serve as a stimulatory source. Donor B’s cells are
mixed with the non-HLA identical stimulator cells. Since they are foreign to
donor B, the donor B cells will clonally expand in both CD4+ and CD8+ effector
cells.
The proliferation can be measured by incorporation of radioactive material in the

media. If there was no proliferation, the donor A cells would be seen as self and,
thus, ignored.
The other concerns and risks besides HLA associated with transplantation are
reviewed in Table 8-32.
Table 8-32. Testing for Transplantation

Test Target Method Outcome
ABO Natural IgM antibodies Patients’ RBCs with If A or B is present,
α-A or α-B sera the RBCs
agglutinate;
agglutination to both
means AB type
HLA typing Polymorphic HLA Past = serologic HLA type
alleles (standard sera banks) Class I or II, loci;
Present = PCR Numbers
Antibody screening Antibodies of allogenic Complement- Percent reactive
*Risks: HLA mediated lyses or antibodies;
Transfusion flow cytometry of percentage of donor
Pregnancy recipient to donor pool with which
Transplantation pool patients react
Cross matching Ab of recipient to the Same as above Risk of rejection
actual donor
Abbreviations: HLA, human leukocyte antigen; PCR, polymerase chain reaction.
Bone Marrow Transplantation

Bone marrow transplantation can be used to treat:
Malignancy
Inborn errors of metabolism
Hematopoietic disorders
Primary immune deficiency
A full match is considered six out of six, at A, B, and DRB1 alleles. A match
does not have to go out to the four digits and an allele group; the first two
numbers will suffice. Trends are changing, and sequence-based four-digit allele
typing is being used in some types of BMT transplants. Ten-allele matches are
also becoming more common, adding C and DQ to the search.
STEM CELL TRANSPLANTATION
In the technique of stem cell transplantation (SCT) a donor’s stem cells,

designated by being CD 34+, are harvested and given to a recipient or host. These
hematopoietic stem cells are pluripotent and can replace the host’s stem cells
either completely, creating a chimera, or with a partial engraftment of the stem Flash Card Q18
Which tissues can be
transplanted across
ABO?
346 / CHAPTER 8
cell, creating a mixed chimera to provide a cure for many diseases. The type of
donor and level of engraftment depends on many factors, including:
Disease
Host
Age of donor
Amount of chimerism required for cure
Immunologic status of the host.
SCT is by far most widely used to treat malignancy; however, with recent
advances, more diseases, particularly immunodeficiency, are being treated by this
method. SCT is the only definitive cure for many immunodeficiencies. SCT is
also being used to treat aplastic anemia and certain genetic disorders.
Syngeneic, Allogeneic, and Haploidentical SCT

There are two main types of SCT: syngeneic and allogeneic. The “s” in
syngeneic stands for the same. The source can be autologous, or from an identical
twin. Allogeneic transplants are from a nonidentical donor, and are much more
common. Allogeneic SCT relies on HLA matching for success and can come
from different sources (Table 8-33). Haploidentical (i.e., exactly matching half of
another person's HLAs) transplants may also be an option.
Table 8-33. Sources of Stem Cell Transplantation

Advantages Disadvantages Pearls
Bone Marrow Large doses and low Anesthesia, possible Larger number of
drop in blood counts injury, and pain CD34+ cells
Peripheral Blood No anesthesia and Lower number of Mobilization for
leukophoresis CD34+ cells and enrichment of stem
larger volume must cells and 15 mL/kg
be extracted of donor for harvest
Cord Blood Immunologically Small dose of CD34+ Multiple cords have
immature and cells, and slower been used
enriched naturally engraftment
with CD34+ cells;
ease of collection
and less stringent
HLA matching
Abbreviation: HLA, human leukocyte antigen.
Flash Card A18
Cornea, bone, joint
tissues, and
hematopoietic stem cells
Risk of Nonengraftment
The order of risk of nonengraftment is shown in Table 8-34.
Table 8-34. Risk for Allogeneic Transplant Rejection
High Risk Low Risk
Matched
Mismatched Mismatched Matched Matched
First-Degree Syngeneic
Unrelated Cord Unrelated Cord Mnemonic
Relative
Class II Mismatch > Class I Mismatch

Other risks for
nonengraftment include:
LORD NIC
Low stem cell dose
Infection and recipient age are related. The older the patients, the more likely they Older age of donor
are to be infected chronically with a virus such as Epstein-Barr virus (EBV), Recipient T-
cytomegalovirus (CMV), or adenovirus, which can be difficult to control during lymphocyte function
conditioning. Risk of infection is cause for significant morbidity and mortality. Degree of HLA
mismatch
Natural killer cell
Indications function
Infection
Malignancies such as leukemia are the most common reasons for SCT. Solid Conditioning
tumors such as neuroblastoma are treated medically, and the patient is rescued regimen
with a previously harvested autologous SCT.
Hematopoietic disorders such as aplastic anemia, myelodysplasia, and

hemoglobinopathies have been treated with SCT.
Inborn errors of metabolism, such as Hurler’s syndrome and osteopetrosis, have

been treated using SCT.
In cases of primary immunodeficiency, SCT has been used to cure the

immunologic defects in the following diseases:
Severe combined immunodeficiency (SCID)
Chronic granulomatous disease
X-linked hyper IgM syndrome
Wiskott-Aldrich syndrome
Immune dysregulation, polyendocrinopathy, enteropathy, and X-linked
inheritance (IPEX) Flash Card Q19
Familial hemophagocytic lymphohistiocytosis To which HLA loci does
Griscelli’s syndrome a 6/6 HLA match refer?
348 / CHAPTER 8
Severe Combined Immunodeficiency (SCID)

SCID deserves some special attention because not all SCIDs are alike. Genotype
or phenotype predicts the outcome. The presence or absence of T and B
Key Fact lymphocytes and NK cells help define the particular type of SCID and are also
SCID is an immunologic very important in SCT treatment. Patients with T–, B+, and NK– SCID tend to do
emergency. Survival best. These patients, without matched siblings, have traditionally undergone
outcomes are linked to haploidentical transplant with graft T-lymphocyte depletion and no conditioning.
age. Prior to 2 months of
Patients with ADA (T–, B–, and NK–) tend to have the worst prognosis. The
age, stem cell transplant
in SCID has a survival presence of NK cells with activity might make conditioning necessary. X-linked
rate of 95%. After 6 SCID (with B-lymphocytes present, but not functional) transplants have been
months of age, the attempted without conditioning; however, the B-lymphocyte engraftment is low
survival rate declines and may require lifelong Ig replacement. Conditioning improves B-lymphocyte
rapidly.
engraftment, but the agents used for host conditioning have other adverse effects
to consider. Graft-versus-host disease (GVHD) is the most common adverse
effect.
SCID is unique in the use of haploidentical transplants due to the almost total lack
of host immunity. Most other types of immune deficiency disease that require
Key Fact SCT necessitate some kind of conditioning protocol that is disease specific. SCID
conditioning may be nonmyeloablative.
In the graft-versus-
leukemia effect the graft
T lymphocytes
contribute to the Conditioning
eradication of the tumor.
These same T
lymphocytes can cause In primary immunodeficiency, conditioning regimens vary from ablative, to
GVHD. reduced intensity, to no conditioning. If T-lymphocyte function is intact, an
The inhibitory killer ablative conditioning regimen is usually required. This can include medication
immunoglobulin-like and/or total body irradiation. In reduced intensity, a combination of monoclonal
receptors, also called antibodies and chemotherapeutic drugs is used sometimes at a lower dosage.
killer inhibitory receptors Conditioning affects outcomes such as GVHD and engraftment. The following
(KIRs), on donor NK
cells are inhibited by
drugs are used:
cells that display HLA I
markers that they
Myaloablative regimen: Destroys the host hematopoietic cells. Bone marrow
recognize. Recipient
leukemia cells express needs to be replaced. Includes total body irradiation, busulfan, etoposide,
HLA I that is different cytarabine, cyclophosphamide, cytosine arabinoside, anti-CD45, anti-CD66, anti-
from donor HLA I and CD20 antibodies.
results in donor NK-
mediated cellular killing
Nonmyeloablative Regimen: Causes minimal cytopenia with significant
of leukemic cells.
lymphopenia. Includes fludarabine, cyclophosphamide, antimyocyte globulin
(ATG), low-dose total body irradiation, anti-CD52 Ab. Good if graft-versus-
Flash Card A19 tumor effect is desired, minimizes GVHD, minimizes graft rejection, minimizes
opportunistic infections. Donor T cells will eliminate host hematopoietic cells
The donor and recipient
have been matched at
with time.
HLA-A, HLA-B, and
HLA-DRB1
Reduced-Intensity Regimen: Doesn't fit either of the previous categories, causes

cytopenia. Includes low-dose busulfan, low-dose melphalan.
Patients with severe organ toxicity, DNA repair defects, or telomere repair defects
require minimal-intensity conditioning (cannot tolerate myeloablative or
nonmyeloablative regiments).
Toxicities include mucositis, nausea, emesis, alopecia, diarrhea, rash, peripheral

neuropathy, infertility, interstitial lung disease, sinusoidal obstruction syndrome.
Total body irradiation complications include abnormal pulmonary function,
cataracts, sicca syndrome, and thyroid dysfunction.
GRAFT-VERSUS-HOST REACTION
Graft-versus-host (GVH) reaction is the recognition of the host tissues by mature

donor T lymphocytes as being foreign through the recognition of host
alloantigens.
Pathophysiology
Traditional HLA matching is based on A, B, and DR alleles. Mismatch at any
allele increases the risk of GVH reaction. Even in a six-out-of-six matched
transplant, GVH can happen due to the other mismatched HLA alleles or to minor
HLA antigens and non-HLA-encoded antigens.
Other important non-HLA factors are polymorphisms in innate immunity

components, such as nucleotide oligomerization domain (NOD) and Toll-like
receptors (TLRs). The important cytokines in GVH reaction are IL-10, TNFα,
and IFNγ.
TYPES OF GVH REACTION
Acute and Chronic GVH Reaction
GVH can manifest in multiple organ systems. Acute and chronic GVH differ in
timing, immune mechanism, prophylaxis, and treatment (Table 8-35). Acute and
chronic reactions may affect the same organ in different ways (Table 8-36).
350 / CHAPTER 8
Table 8-35. Comparison of Acute and Chronic Graft-Versus-Host

Reaction
Acute GVH Reaction Chronic GVH Reaction
Timing First 100 days >100 days
Cells CD45RO+ T-lymphocyte and CD4+ helper T lymphocytes
neutrophil engraftment
(important)
Prophylaxis Methotrexate, cyclosporine, T-lymphocyte depletion
tacrolimus, corticosteroids,
antithymocyte globulin, and T-
lymphocyte depletion
Treatment Corticosteroids; alternatives Corticosteroids, corticosteroids
include cyclosporine, tacrolimus, plus cyclosporine, thalidomide,
antithymocyte globulin, and and ursodeoxycholic acid
mycophenolate
Table 8-36. Clinical Manifestation of Graft-Versus-Host (GVH) Reaction

Clinical Manifestations
Acute GVH Reaction Chronic GVH Reaction
Key Fact Skin Maculopapular rash Dyspigmentation, alopecia, sclerotic
Chronic GVH reaction is features, and nail dystrophy loss
the major factor in long- Mouth Ulcers, xerostomia
term survival in SCT.
Eyes Dry and sicca syndrome
Musculoskeletal Fasciitis, myositis, and contractures
Gastrointestinal Watery diarrhea, severe abdominal Weight loss, webs, and strictures
pain, bloody diarrhea, and ileus
Liver Cholestatic hyperbilirubinemia Jaundice transaminitis
Lung Restrictive or obstructive defects
and bronchiolitis obliterans
Heart Pericarditis
Marrow Cytopenias
Other Fever
Sinusiodal Obstruction Syndrome

Sinusoidal Obstruction Syndrome (SOS) (formerly known as hepatic
sinusoidal veno-occlusive disease [VOD]) is associated with conditioning therapy
and drug toxicity. Single-dose radiation, alkaloids (e.g., busulfan, cyclosporine,
and methotrexate) for prophylaxis, and sirolimus.
Diagnostic criteria for SOS After SCT:

Seattle Criteria. Two of the three symptoms within 20 days of SCT:
bilirubin > 2 mg/dL, hepatomegaly or right upper quadrant pain, >2% weight
gain due to fluid retention
Baltimore Criteria. Bilirubin >2 mg/dL plus two of the three symptoms:
tender hepatomegaly, >5% weight gain, ascites
Graft Manipulation
T-lymphocyte depletion is the major way of preventing or reducing the risk of Key Fact
both acute and chronic GVH reactions. Mature T lymphocytes from the graft are
implicated in the disease. Eliminating them might represent an advantage from Complete depletion of
graft T lymphocytes
this perspective; however, if all mature T lymphocytes are purged, engraftment leads to
would be severely affected, as would immune reconstitution, graft-versus-tumor nonengraftment.
effect, and infection complications.
These methods involve ex vivo manipulation of the donor cells with methods such
as soybean lectin and E-rosetting, as well as E-rosetting and CD34+ selection, and
monoclonal antibodies like anti-CD3, anti-CD2, anti-CD6, anti-CD25, or anti-
CD52.
Special Conditions
SCID: During birth a maternal-fetal transfusion of blood and immune cells
can occur. When mature, maternal T lymphocytes engraft the baby, a maternal
GVH reaction may occur with the infant’s tissue as a target. In this case, the
cells are likely CD8+ and clonal.
Blood transfusions: In an immunocompromised host, blood transfusion with
a nonirradiated or nonleukoreduced product can result in competent donor
T lymphocytes, which are transfusion-derived, causing GVH reaction. Very
uncommonly, this can even happen in an immunocompetent host when whole
blood is given.
Engraftment
Neutrophil engraftment is defined as 3 consecutive days with an ANC ≥ 0.5 ×
109/L, or one day with a count of ≥1.0 × 109/L.
Platelet engraftment is defined as the first day when the platelet count is >20 ×
109/L on 3 consecutive measurements within 7 days, with no transfusions in the
preceding 7 days
Umbilical cord cells take the longest of the stem cells to engraft. Flash Card Q20
What are the clinical
features of SOS?
352 / CHAPTER 8
IMMUNE ENDOCRINOPATHIES
(THYROID, DIABETES, AND ADRENAL)
Immune endocrinopathies are autoimmune pathological changes of endocrine

organs in predisposed individuals, induced by infection, tissue injury, or other
environmental factors.
Graves’ Disease
Immune Mechanisms—Antibodies to thyryoid-stimulating hormone (TSH)
receptor that stimulate the thyroid gland, are specific for the disease. Thyroid
peroxidase and thyroglobulin antibodies are frequently found, but they are not
disease-specific. B lymphocytes and CD4 and CD8 T lymphocytes are involved
(i.e., intrathyroid T lymphocytes with B lymphocytes organized in germinal
centers), and Th2 cells are primarily responsible for the disease.
Clinical Features—Hyperthyroidism (palpitations, tremor, heat intolerance,

sweating, anxiety, emotional lability, weight loss with increased appetite) with
diffusely enlarged goiter and exophthalmopathy as well as pretibial myxedema
may occur. The disease occurs more often in women than men, with a ratio of 7:1.
Genetic Association
Monozygotic twins 20–40%
10% occurrence in siblings
HLA-DR3 (whites)
CTLA-4 alleles
HLA-DR expression by thyroid epithelium
Prognosis—Fifty percent of patients with hyperthyroid Graves’ disease will

relapse after 1 year of treatment with antithyroid drugs. The level of autoantibody
to TSH receptor is a useful predictor for relapse and remission.
Hashimoto’s Thyroiditis
Immune Mechanisms—Antibodies exist for thyroid peroxidase and
thyroglobulin, as well as TSH receptor, correlating with lymphocyte infiltration
Flash Card A20 and decrease with treatment. Immune mechanisms involved include IgG1/IgG3
Tender hepatomegaly, complement fixation. There is FAS expression on the thyroid with cytotoxic
weight gain due to fluid destruction. Thyroid germinal centers with antibody production are noticed.
retention, and Epithelial cells are enlarged with distinctive eosinophilic cytoplasm due to
hyperbilirubinemia increased mitochondria (Hürthle cells).
Clinical Features—Patient usually presents with an atrophic thyroid but may

have goiter. The disease is defined by chronic progressive autoimmune
thyroiditis. Clinical features of hypothyroidism (fatigue, weakness, cold
intolerance, weight gain, constipation, dry skin, depression, growth failure,
delayed puberty). Prevalence increases with age, with more women afflicted
than men (7:1).
Genetic Association—Monozygotic twins 30–60%, HLA-DR3 and CTLA-4 are

often involved.
Diagnosis—Most hypothyroid patients are thought to have Hashimoto’s disease,

although thyroid antibodies are sent for confirmation. High-titer thyroid Abs are
present, with clinical presentation of pyogenic thyroiditis that is characterized by
thyroid area pain and fever. Other causes of thyroiditis (postpartum, acute,
subacute, and silent) need to be ruled out.
Autoimmune Polyendocrine Syndromes

Autoimmune Polyendocrine Syndromes-1 (APS-1)—Also known as
autoimmune polyendocrinopathy, candidiasis-ectodermal dysplasia
(APECED). This rare disorder is characterized by chronic mucocutaneous
candidiasis of the mouth and nails (this is postulated to be mediated by anti- IL-
17 or IL-22 antibodies), hypoparathyroidism, and autoimmune adrenal
insufficiency. Usually, the disease first manifests in childhood, and the patient
then develops these three diseases in the first 20 years of life. The other
autoimmune endocrinopathies include:
GI disease
Chronic hepatitis
Autoimmune skin disorders
Ectodermal dystrophy
Keratoconjunctivitis
Immunologic defects
Asplenia
Cholelithiasis
Mucosal cancer Flash Card Q21
What is the function of
APS-1 is associated with autoimmune regulator (AIRE) gene mutation on AIRE?
chromosome 21q22.3. In this pathology, autoreactive T cells in the thymus escape
negative selection by not being exposed to self-antigen in the thymus. Antibodies
are formed to 21-hydroxylase (adrenal), IL-17 and IL-22 (candidiasis), islet cells
(DM), IFNω. Autoimmunity affects parathyroid (onset in 20s) > adrenal > Flash Card Q22
gonadal > gut. APS-1 does not usually involve DM or the pituitary gland. APS-1 Which of the following
affects more women than men. Autoantibody to calcium-sensing receptor, glands is not involved in
CYP1A1, CYP17, CYP21 A2, and tryptophan hydroxylase could also be present. APS-2: adrenal, thyroid,
parathyroid, or gonads?
354 / CHAPTER 8
Diagnosis is made by having any two autoimmune conditions, or one

autoimmune condition plus a mutation in the AIRE gene.
Autoimmune Polyendocrine Syndrome-2 (APS-2)—This is also known as

Schmidt’s syndrome. It is more common than APS-1. Adrenal > type I diabetes
= thyroid > gonadal. It is the most common of the autoimmune
endocrinopathies and occurs more often in women than in men (3:1). There is no
evidence of hypothyroidism. APS-2 is associated with:
Celiac disease
Vitiligo
Pernicious anemia
Myasthenia gravis
Stiff-person syndrome
Alopecia
Sjögren’s syndrome
Antiphospholipid antibodies
Rheumatoid arthritis
Autoantibodies are to cytochrome enzymes, which include CYP21A2, CYP17,

and CYP11A1. Antibodies to 21-hydroxylase, tissue transglutaminase (IgA) may
be present.
Genetics: Fifty-percent familial (autosomal dominant and polygenic recessive)

and HLA DRB0404. CTLA-4 gene polymorphism is associated with APS-2
component disorders.
APS-2 is commonly diagnosed between 20 and 40 years of age.
Immune Dysregulation, Polyendocrinopathy, Enteropathy,

X-Linked Syndrome
Flash Card A21 Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX)
AIRE is a transcription syndrome is a form of autoimmune enteropathy. This life-threatening disorder
factor expressed in typically presents during infancy and is characterized by dermatitis, intractable
medullary thymic diarrhea, and recurrent infections, and is associated with autoimmune
epithelial cells that is
responsible for the
endocrinopathy.
expression of antigens
found elsewhere in the Clinical Features—Dermatitis is a key feature of this condition. Diarrhea is
body, and thus guides severe and a biopsy of the small bowel shows partial or complete villous atrophy,
T-cell–negative a mononuclear cell infiltration in the lamina propria, and increased expression of
selection.
MHC class II antigens. This autoimmune disease is diverse and includes:
Insulin-dependent diabetes often at infancy
Membranous glomerulonephritis
Flash Card A22 Autoimmune cytopenias: Hemolytic anemia, idiopathic thrombocytopenic
Parathyroid purpura (ITP), autoimmune neutropenia
Autoimmune hepatitis
Hypothyroidism
50% of patients have antienterocyte antibodies.
Genetics—Maps to the X-chromosome in the region of the WAS gene (Wiskott-

Aldrich), but is distinct from that gene—Xp11.23-Xq21.1. FOXP3 is a
transcription factor responsible for the production of T regulatory cells
inside the thymus. Mutation of FOXP3 results in depletion of Tregs. CD25
(IPEX-like syndrome) and STAT5B (autosomal recessive) mutations can also
cause an IPEX-like presentation.
Treatment—Without early recognition and treatment, children with IPEX usually die
in the first 2 years of life from sepsis or failure to thrive. Treatment of IPEX
involves bone marrow transplant. There has also been clinical response to
cyclosporine, tacrolimus, and sirolimus, which support the role of T lymphocytes.
Autoimmune Lymphoproliferative Syndrome (ALPS)
Autoimmune lymphoproliferative syndrome (ALPS) is characterized by

autoimmunity (typically autoimmune cytopenias) and lymphoproliferation
(lymphadenopathy and splenomegaly). There is also an increased risk of
lymphoma. This disorder is caused by a defect in lymphocyte apoptosis.
Clinical Features
Lymphoadenopathy and/or splenomegaly
Elevated α/β double-negative T cells
Defective lymphocyte apoptosis
Elevated IL-10, vitamin B12, or IL-18 levels
Autoimmune cytopenias with hypergammaglobulinemia
Positive family history
Genetics
Type I—FAS mutation (can be somatic or germline)
Type Ib—FAS ligand mutation
Type IIa—Caspase-10 mutation
Treatment—Cytopenias and lymphoproliferation are treated with immunosuppressives,

such as corticosteroids, mycophenolate mofetil, cyclosporine, tacrolimus, or sirolimus.
Bone marrow transplantation is curative.
356 / CHAPTER 8
Addison’s Disease
Addison’s disease is a chronic disorder of adrenal cortex characterized by
deficient production of glucocorticoids, mineralocorticoids, and androgens, with
an increased secretion of adrenocorticotropic hormone (ACTH). In developed
countries, the most common cause is autoimmunity, accounting for 75–80% of
adrenal insufficiency. In developing countries endemic with TB, TB is the main
cause (10–20%) of adrenal insufficiency.
Classification—APS-1, APS-2, and primary adrenal failure. The implicated

autoantibody is to the adrenal cortex enzyme 21-hydroxylase, and it is found in
90% of recent-onset patients.
Genetics—HLA B8 and DR3.
Clinical Features—Weakness, fatigue, anorexia, orthostasis, nausea, myalgias,

salt cravings, hyperpigmentation, shock, fever, abdominal tenderness,
neuropsychiatric symptoms.
Diagnosis—Failure of serum cortisol to rise after ACTH stimulation in presence

of elevated basal ACTH levels.
Treatment—Addison’s disease patients require a lifetime treatment with oral

mineralocorticoids and glucocorticoid replacement. Stress doses of steroids are
needed for illnesses and surgeries. Monitor for the development of other
autoimmune disorders.
Primary Adrenal Failure
Clinical Features—Occurs more often in males than females in the first two
decades of life; thereafter, it is seen more often in women than men. Decreased
aldosterone with increased renin. Associated with other endocrine diseases such
as APS-1 and APS-2.
Immune Mechanisms—Autoantibody to CYP21A2 (enzyme is necessary to

make cortisol), involving both cellular and humoral injury.
Genetic Association—HLA DRB*0404, DQ8, and MICA.5.1.
Diabetes Mellitus
Type IA—Immune Mechanisms or Immunopathology: Immune-mediated
destruction of islet beta cells in the pancreas. Associated with autoantibodies to
glutamic acid dehydrogenase (anti-GAD65), insulin, tyrosine phosphatase, and
zinc T8 transporter. Destruction of beta cells probably requires T lymphocytes.

May be related to infections from coxsackievirus B4 and enterovirus. Ninety
percent of white children with DM have this disorder. Thirty percent of black and
Hispanic children with diabetes do not have anti-islet autoantibody or high-risk
HLA alleles. Type 1A is characterized by low insulin level and normal weight.
Genetic: Family history of autoimmune diseases, monozygotic twins 30%.

Ninety percent of patients will have the following haplotypes: DR3,DQ2 (DQ2 =
DQA1*0501 and DQB1*0201) and DR4, DQ8 (DQA1*0301 and DQB1*0302).
Type IB—Anti-insulin receptor antibodies block the ability of insulin to bind to

its receptor. Thus, insulin levels are high. It is associated with SLE and
scleroderma. Patients can present with hyperglycemia, euglycemia, and
hypoglycemia.
Type II—Noninsulin-dependent, with anti-islet cell autoantibody. The majority of

adults with DM have this type. Incidence increases with age and 5–20% express
anti-islet cell autoantibody with accelerated loss of insulin secretion.
Insulin Autoimmune Syndrome—Autoantibody that reacts with insulin, which

can be monoclonal or polyclonal. The monoclonal antibody is associated with B-
lymphocyte tumors. Polyclonal antibody follows therapy with sulfhydryl-
containing medications such as methimazole (i.e., treatment for Graves’ disease).
Patients present with recurrent hypoglycemia.
Other Immune Endocrinopathies
Idiopathic Hypoparathyroidism
Part of APS-1 in children

Parathyroid deficiency causes hypocalcemia
Premature Ovarian Failure
Defined as amenorrhea, increased gonadotropin levels, hypoestrogenism

before 40 years of age
Can be idiopathic and isolated; or also associated with adrenal insufficiency
(has antibodies to 21-hydroxylase, 17-hydroxylase that cross-react with theca
interna/granulosa layers of ovarian follicles) or only idiopathic
358 / CHAPTER 8
Lymphocytic Hypophysis
Inflammation of the pituitary gland

Occurs with pregnancy, postpartum, anti-CTLA-4 Ab (ipilimumab)
Antipituitary antibodies have been found in some patients
Fatigue, headache, visual field deficits
Diagnose with pituitary biopsy
Treat by replacing anterior pituitary hormones
POEMS Syndrome
Polyneuropathy, organomegaly, endocrinopathies, M-protein, skin

(hyperpigmentation, hypertrichosis)
IMMUNOLOGIC RENAL DISEASES
Multiple renal diseases are mediated by renal or nonrenal antigens, either in the
form of self- (autoimmune) or foreign antigens, resulting in renal pathologic
changes.
There are two main distinctions: nephrotic and nephritic syndromes (Table 8-37).
Table 8-37. Renal Syndromes

Nephrotic Syndrome Nephritic Syndrome
Symptoms >3.5 g/day proteinuria Hematuria
Edema Edema
Hyperlipidemia Hypertension
Hypoalbuminemia
Increased infections due to low IgG
secondary protein losses
Diseases Minimal change Poststreptococcal GN
Membranous nephropathy IgA nephropathy
Focal segmental glomerulosclerosis Henoch-Schönlein purpura
Membranoproliferative GN
Rapidly progressive GN
Abbreviation: GN, glomerulonephritis.
NEPHROTIC SYNDROME
Minimal-Change Nephrotic Syndrome

This is the most common nephrotic syndrome in children, and 10–15% of
nephroses present in adults.
No abnormalities on light microscopy of renal biopsy specimens, usually with

preserved renal function. Immunoglobulin and complement are absent on
immunofluorescence studies.
Biopsy—Effacement of visceral foot processes identified by electron microscopy

(EM).
Treatment—Treatment of this disorder involves prednisone. Typically, remission

is achieved in 4–6 weeks. For relapses or steroid-resistant cases, administer
cyclophosphamide or chlorambucil.
Membranous Nephropathy
This is the most common nephrotic syndrome in adults. It can occur secondarily
to:
Hepatitis B
Malaria
Syphilis
Neoplasms
Drugs
SLE
Environmental toxins
Both humoral and cellular immunity are implicated as causes as well as the
activated complement.
Clinical Features—Variable. Classic nephrotic syndrome with unremarkable

urinalysis. Preserved renal function.
Biopsy—Diffuse thickening of glomerular basement membrane (GBM) with

immunofluorescence revealing prominent granular staining of IgG and C3
along GBM. EM studies show epithelial foot process effacement with electron-
dense (i.e., immune complex deposits) distributed over the GBM.
Treatment—Courses of treatment for membranous nephropathy are controversial.

360 / CHAPTER 8
Complications and Prognosis—Predictors of clinical expression for end-stage

renal disease (ESRD) include:
High levels of proteinuria or renal insufficiency at presentation
Older age
Male gender
Histologic findings of glomerulosclerosis
Tubulointerstitial inflammation
Focal Segmental Glomerulosclerosis
Focal segmental glomerulosclerosis (FSGS) is the final common pathway of

many forms of glomerular injury. This is a primary or secondary process to
another disease such as:
HIV
Infection
Hypertension
Vesicoureteral reflux
Obesity
Sickle cell disease
Heroin abuse
Nephrotic syndrome is also present with microscopic hematuria, hypertension,

and progressive renal failure.
Biopsy—Segmental glomerular collapse with some focal glomeruli involved.
Treatment—FSGS is treated with a course of prednisone for 3–4 months. ACE

inhibitors are renal protective and reduce proteinuria.
Complications and Prognosis—Dictated by degree of proteinuria and serum

creatinine at presentation, as well as extent of interstitial fibrosis on biopsy. More
than 50% of patients who present with nephrotic-range proteinuria will reach
ESRD in 6–8 years. Those who achieve remission usually do well.
NEPHRITIC SYNDROME
Postinfectious Glomerulonephritis
This includes poststreptococcal (PSGN) but also other infections. This is,
typically, a disease of childhood, especially PSGN. Alcoholics, diabetics, and IV
drug users are also commonly affected.
Clinical Features—PSGN occurs 10–14 days after infection with group A

hemolytic streptococcal pharyngitis or impetigo. Symptoms include hematuria,
edema, and hypertension. Proteinuria can also occur. Antibody and antigen
complexes are deposited in the glomeruli, leading to complement activation,
and recruitment of neutrophils and monocyte or macrophages, leading to
inflammation.
Nephritogenic antigens responsible for PSGN:

Nephritis-associated plasmin receptor (NAPir)
o Glycolytic enzyme with GADPH activity
Streptococcal pyogenic exotoxin B (SPEB)
o Cationic cysteine proteinase
Diagnosis—Low C3 with evidence of circulating immune complexes as well as

cryoglobulins, rheumatoid factor, and elevated IgG. Based on combination of
antecedent streptococcal infection or positive antistreptolysin O or anti-
DNAse B titers. Biopsy is only recommended when diagnosis is in question.
Treatment—In adult cases of postinfectious glomerulonephritis, antibiotics and

supportive therapy are prescribed. In children, treatment is self-limited.
IgA Nephropathy
This is the most common GN in the world. It may also be the renal-limited form
of Henoch-Schönlein purpura.
Clinical Features—Presents with asymptomatic microscopic or macroscopic

hematuria. Nephrotic presentation and acute renal failure is uncommon. Renal
biopsies are only recommended for patients with progressive renal insufficiency
or in cases where protein is greater than 1 g/day.
Biopsy—Mesangial IgA staining on immunofluorescence. Elevated circulating

polymeric IgA and complexes with IgA in the serum.
Treatment—Treatment of IgA nephropathy is limited to patients with abnormal

renal function. In those with mild renal disease, the physician should monitor
closely and control BP with ACE inhibitor or ARB (angiotensin receptor blocker).
If more than 1 g/day of proteinuria, then prednisone is indicated. Fish oil may be
of some benefit. If there is hyperlipidemia and renal disease statins may be
beneficial.
Complications and Prognosis—ESRD in 20–30% of patients after 20 years of

age. Predictors of poor outcome are hypertension, early age of onset, proteinuria >
1 g/day, and renal insufficiency at diagnosis.
362 / CHAPTER 8
Henoch-Schönlein Purpura
Henoch-Schönlein purpura (HSP) is a multisystem disorder that is characterized

by deposition of IgA immune complexes in affected organs. It is associated
with drug sensitivities. Typically, the disorder affects children younger than 10
years of age, with male predominance, following an upper respiratory tract
infection. Manifestations include:
Abdominal pain
Arthralgias
Purpuric, lower-extremity rash (Figure 8-10)
Hematuria
Renal biopsy findings are indistinguishable from IgA nephropathy. Renal

manifestations are generally self-limiting. Progressive renal disease (as evidenced
by crescent changes) and renal failure should be treated with IVIG.
Figure 8-10. Purpura. Note the classic lower extremity distribution of purpura
seen in HSP.
Membranoproliferative Glomerulonephritis (MPGN)

This kidney disorder can occur in conjunction with other diseases or it is a renal-
limited, idiopathic disease. It can also occur after viral upper respiratory
infections.
Secondary MPGN: The most common cause of secondary MPGN is

essential mixed cryoglobulinemia, which is associated with hepatitis C.
Monoclonal IgM, possessing RF activity, is a cryoglobulin. Pathogenesis
related to deposits of circulating immune complexes with complement
activation or monoclonal IgM recognizing endogenous glomerular proteins.
Primary MPGN: Variable amounts of microscopic hematuria, proteinuria,
hypertension, hypocomplementemia, and renal insufficiency.
Treatment—For primary MPGN, corticosteroids are given; treatment is more

successful in children than adults. Long-term treatment with antiplatelet agents
slows progression of the disease in adults. For secondary MPGN, IFNα is given;
and, ribavirin is used for hepatitis C. Note: Do not use ribavirin if creatinine
clearance is less than 50 mL/minute. (See Chapter 9.)
Complications and Prognosis—Fifty percent of patients will progress to ESRD

within 10 years of diagnosis. Risk factors for progression are hypertension and
nephrotic syndrome.
Rapidly Progressive Glomerulonephritis (RPGN)

RPGN is characterized by crescentic GN associated with focal necrotizing lesions
in the glomeruli and small vessels. Clinically, there is rapidly deteriorating renal
function (i.e., days to weeks) that can be caused by a number of conditions.
Pauci-immune GN is the most common cause of RPGN in adults. Immune-
complex–mediated GN is the most common cause in children.
Antiglomerular Basement Membrane (Anti-GBM) Disease
Anti-GBM disease presents as a disease limited to RPGN or the classic

pulmonary-renal vasculitic syndrome known as Goodpasture’s syndrome. It has
a bimodal incidence:
First peak preferentially affects young men who smoke (classic
Goodpasture syndrome).
Second peak affects women in their sixth or seventh decade and is
characterized by renal-limited disease. Flash Card Q23
What key immunologic
process causes MPGN?
364 / CHAPTER 8
Presentation—Acute nephritis with crescent formation and rapid renal failure.

Abrupt onset of oliguria or anuria as well as hematuria and anemia. Pulmonary
hemorrhage occurs in some patients with smoking or lung injury.
Renal Biopsy—Crescents over more than 50% of glomeruli and

immunofluorescence of diseased glomeruli reveals staining of IgG along GBM
(linear distribution).
Diagnosis—Confirmed by detection of circulating antibodies directed against

α3 chain of type IV collagen. One third of patients have positive perinuclear
antineutrophil cytoplasmic antibodies (pANCA) and cytoplasmic antineutrophil
cytoplasmic antibodies (cANCA). Patients with these circulating Abs have milder
disease.
Pauci-Immune Crescentic GN
This is the most common cause of RPGN in adults. Pauci-immune indicates the
lack of binding of antibody or complement to the affected glomeruli.
Classification—Primary pauci-immune crescentic GN is secondary to vasculitis,

including Wegener’s granulomatosis, microscopic polyangiitis, and Churg-Strauss
syndrome. Related to activated T lymphocytes and autoantibodies.
Pauci-immune crescentic GN is associated with the use of:
Propylthiouracil
Hydralazine
Penicillamine
Minocycline
One third of patients will have renal-limited disease and the rest will have
associated systemic small-vessel vasculitis symptoms. The disease is often
preceded by nonspecific symptoms of a flu-like prodrome followed by myalgias,
arthralgias, and fatigue. Relapsing disease is common.
Diagnosis—Based on clinical presentation, renal pathology, and serologic

findings. Biopsy characterized by crescent-shaped GN with focal necrotizing
lesions in glomeruli and small vessels.
80–85% of patients present positive ANCA, especially in patients who are
older than 50 years of age and white.
Flash Card A23

IgM immune complexes
deposit on glomerular
proteins and activate
complement or via direct
monoclonal IgM binding
to glomerular proteins.
Immune-Complex–Mediated RPGN
This accounts for most cases of RPGN in children. Hemolytic-uremic syndrome

(HUS) is the primary cause, characterized by microangiopathic hemolytic anemia,
thrombocytopenia, and renal failure.
Immunologic Skin Disease
Immunologic skin diseases are groups of skin conditions induced by

autoantibodies to different parts of unique skin structures. Important target skin
structures include the following (Figure 8-11):
Desmogleins-1 and -3 in desmosome for pemphigus
BP Ags (BP180 and BP230) in hemidesmosome/lamina lucida for
pemphigoid and linear IgA bullous dermatosis
Type VII collagen or anchoring fibrils for epidermolysis bullosa acquisita
Flash Card Q24

A 10-year-old girl
presents to the
emergency department
with petechial rash on
her extremities, bloody
diarrhea, and
decreasing urine output
after consuming
undercooked
Figure 8-11. Skin structures.
(Abbreviations: Dsg1, Desmoglein-1; Dsg3; Desmoglein-3; BPAG, bullous pemphigoid antigen.)
hamburger. Preliminary
lab findings reveal Hgb
7, platelets 40,000, and
schistocytes on
peripheral smear. What
is the most likely
diagnosis?
366 / CHAPTER 8
Table 8-38. Immunologic Skin Diseases

Disease Type Clinical Signs Target Immunopathology Treatment
Pemphigus Pemphigus Flaccid bullae on noninflamed skin IgG epithelial surface Epidermal IgG/C3 Prednisone
vulgaris Nikolsky’s sign Desmoglein-3 Immuno-suppressives +/–
Found on scalp, chest, oral mucosa, +/– desmosome
Pemphigus intertriginous areas Desmoglein-1 Epidermal IgG/C3 Steroids
foliaceous +/– desmosome
IgA IgA epith surface Epidermal IgA Steroids
pemphigus Desmocollin-1
Pemphigoid Bullous Tense bullae on urticarial base IgG basement membrane IgG/C3 (BMZ) Steroids
pemphigoid Pruritus zone (BMZ) Immuno-suppressives +/–
Flexural areas BP180
Elderly BP230
Herpes Urticaria IgG BP180 BMZ Linear BMZ C3 Steroids

gestationis Blistering Antihistamines
Periumbilical area
During or immediately postpartum
May flare w OCP/menses
Others Epidermo- Areas of trauma Type VII collagen Linear BMZ IgG/C3 Colchicine or dapsone + steroids
lysis bullosa Oral mucosa Linear IgA/IgM Immuno-suppressives +/ – for
acquisita refractory cases
Dermatitis Small grouped vesicles Endomysial IgA Granular BMZ IgA Eliminate gluten from diet
herpetiformis LE/buttocks Transglutaminase IgA
Intense pruritus Epidermal transglutaminase
Associated with celiac disease
Abbreviation: BMZ, basement membrane zone; Ig, immunoglobulin; LE, lower extremity; OCP, oral contraceptive pills.
Flash Card A24

Hemolytic-uremic
syndrome
PEMPHIGUS
Pemphigus Vulgaris
Presentation
Flaccid bullae on noninflamed skin
Crusting Mnemonic
Nikolsky’s sign—application of pressure along one edge of the blister will The key features of
extend it further to uninvolved skin pemphigus:
Commonly found on: DEsMO
o Scalp (Desmosome) =
DEMO.
o Chest
o Intertriginous areas DEMO is on the
o Oral mucosa surface (of skin); so,
when DEMO is
Severe morbidity and death as a result of skin loss, oropharyngeal affected, the surface
ulcerations, and sepsis of skin is damaged,
leading to flaccid
Serum Autoantibodies—IgG on epithelial surface. Target protein and structure: bullae.
Desmoglein-3 and/or desmosome.
Tissue Immunofluorescence—Epidermal IgG and C3 cell surface staining

(Figure 8-12).
Treatment—Pemphigus vulgaris is treated with prednisone, with or without other

immunosuppressives.
Flash Card Q25

A 70-year-old woman
presents with a pruritic
rash over her upper
extremities with what
Figure 8-12. Pemphigus vulgaris. appear to be tense,
(Reproduced, with permission, from Wikimedia Commons.) fluid-filled blisters. What
is the diagnosis?
368 / CHAPTER 8
PEMPHIGOID
Bullous Pemphigoid
Clinical Presentations—Tense bullae, often on urticarial base and on flexural
areas, with prominent pruritus (Figure 8-13). Affects elderly patients.
Serum Autoantibodies—IgG BMZ and epidermal. IgE antibody to BP180

present in 86% patients and total IgE levels correlate with disease activity. Target
protein and structure: BP180, BP230 or hemidesmosome, and lamina lucida.
Tissue Immunofluorescence—Linear BMZ IgG and C3.
Figure 8-13. Bullous pemphigoid.

(Reproduced, with permission, from USMLERx.com.)
LUPUS ERYTHEMATOSUS (LE)
Tissue Immunofluorescence—Granular immune deposits at BMZ in both

involved and uninvolved skin (lupus band), IgM = C3 >IgG >IgA, where two or
more required. Refer to Tables 8-25 and 8-29 for antigen testing in these
conditions.
Flash Card A25
Bullous pemphigoid.
Tends to occur in the
elderly, is pruritic, and
occurs in flexural areas
IMMUNOLOGIC EYE DISEASES
Ocular Cicatricial Pemphigoid
Clinical Features—This is a sight-threatening, chronic inflammation and/or

scarring of the conjunctiva that occurs in systemic pemphigoid. It occurs mostly
in older women (i.e., 60–70 years of age). Refer to ophthalmologist.
Symptoms and Signs—Relapsing conjunctivitis with:

Severe conjunctival redness
Mucus discharge
Eyelid and eyelash in-turning
Breakdown of corneal and conjunctival epithelium
Fornix is characteristically shortened.
Treatment—Diagnosis requires conjunctival biopsy. Mild disease responds to

dapsone, and severe disease usually requires systemic steroids or cytotoxic
therapy.
Peripheral Ulcerative Keratitis

Clinical Features—Peripheral ulcerative keratitis involves any part of the limbal
structure and is divided into two types: mild and necrotizing (Mooren’s ulcer). Its
mild form is non-sight-threatening and occurs in both genders at any age (i.e.,
Staphylococcal blepharitis). Mooren’s ulcer is idiopathic, vision-threatening,
and occurs in adults unilaterally (worldwide) or bilaterally (i.e., in African men).
Refer to ophthalmologist ASAP.
Symptoms and Signs

Mild: Flash Card Q26
Worsening pain What skin condition is
Photophobia caused by IgG to
desmoglein-3?
Redness
Tearing
Necrotizing:
Flash Card Q27
As above, plus circumferential destruction of cornea
The typical course of
Treatment—For mild cases of peripheral ulcerative keratis: Topical antibiotics which skin condition
follows the disease
and topical steroids. For necrotizing cases (i.e., Mooren’s ulcer): exclude infection activity?
370 / CHAPTER 8
(i.e., HSV) and systemic disease (i.e., RA), and treat with immunosuppression
(i.e., steroids); however, surgery may be needed. Table 8-39 summarizes the key
features of episcleritis and scleritis (Figure 8-14).
Table 8-39. Episcleritis Versus Scleritis

Episcleritis Scleritis
Clinical features Benign inflammation superficial Sight-threatening
episcleral/conjunctival vascular inflammation of sclera
plexus
Predominantly occurs in
Predominantly occurs in women women
Key Fact Peak age 40s Peak age: 40s
Just one drop of 10% 40% associated with RA
phenylephrine will
blanch episcleral Signs/symptoms Rapid onset conjunctival redness Anterior: Eye redness,
redness within 20 tearing, photophobia,
May persist months/days
boring pain
minutes, but true Minimal pain
scleritis will persist. Posterior: Pain on eye
movement; decreased
vision
Treatment Cool compresses NSAIDs

Natural tears Steroids
Topical NSAIDs/steroids MTX,immunosuppressants
Ophthalmologic No Yes
emergency
Abbreviations: MTX, methotrexate; RA, rheumatoid arthritis
Flash Card A26

Pemphigus vulgaris
Flash Card A27

Dermatitis herpetiformis.
The rash typically
flares/remits with celiac Figure 8-14. Scleritis. Note the injection of scleral vessels and violaceous hue
disease activity. Strict (can be seen better with natural sunlight).
gluten elimination from (Reproduced, with permission, from USMLERx.com.)
the diet alleviates the
rash and symptoms.
Uveitis
Clinical Features—A broad term for intraocular inflammation, in which 60% is

idiopathic and 40% is associated with a systemic disease. It is classified by
location: (1) anterior uveitis is in front of the lens (70%); (2) posterior uveitis
involves the retina, choroid, or vasculature (10%); and (3) intermediate uveitis is
in the remaining, middle portion of the eye (20%) (Table 8-40).
Table 8-40. Uveitis

Anterior Intermediate Posterior
Clinical Features In front of lens Middle of eye Retina, choroid,
vessels
Signs/ Sudden pain Bilateral blurry vision Pain
Symptoms Redness Floaters Redness
Photophobia Photophobia
Vision change Vision loss
variable
Miotic pupil
Treatment Topical steroid Periocular steroid Oral steroid or
Immunosuppressives
INFLAMMATORY GASTROINTESTINAL DISEASES
Autoimmune Gastritis (Pernicious Anemia)

Presentation—Autoimmune gastritis is associated with other autoimmune
diseases (e.g., autoimmune thyroid disease, vitiligo, type I DM, and Graves’
Flash Card Q28
disease).
This eye condition
Epidemiology—This disease occurs in more women than men (3:1). It is the results in inflammation
of the eye, photophobia,
most common cause of vitamin B12 deficiency. tearing, and boring eye
pain. Which condition
does this occur in?
Flash Card Q29

Eye pain, redness, and
miosis of the pupil is
seen in which condition?
372 / CHAPTER 8
Pathogenesis—Gastric atrophy and metaplasia are the main pathologic findings.

Autoantibodies to parietal cell and intrinsic factor are involved in the disease
process. Major molecular target of antibodies are the H+ and K+ATPase. CD4+
T lymphocytes, which recognize a subunit of the ATPase, mediate the disease;
this process is usually suppressed by Tr1 cells. Lymphoid infiltration of mucosa
from the gastric body eventually leads to atrophy of the gastric parietal cell and
loss of intrinsic factor production by zygomatic cells. This further leads to B12
malabsorption. Intrinsic factor (IF) antibody may also block the binding of B12.
Genetics—HLA-B8 or -DR3. Autosomal dominant.
Diagnosis—Low serum B12 during evaluation for anemia or neurologic

symptoms. Antiparietal cell antibody is suggestive but not specific. Multipart
Schilling test can confirm diagnosis.
Treatment—The treatment course for autoimmune gastritis is lifelong vitamin

B12 replacement, typically given as an intramuscular injection.
Prognosis—Left untreated, autoimmune gastritis leads to neurologic damage.
Celiac Disease
Celiac disease is a disorder of the small intestine with chronic inflammation of mucosa; it
leads to atrophy of the intestinal villi with sensitivity to gliadin found in wheat, barley,
and rye, with or without oat.
Genetics—Most common in patients of northern European descent (0.3%

incidence); and, absent among Asian and African populations. Strong genetic
linkage with HLA DQ2 (95% patients) and DQ8; however, most people with
DQ2 and DQ8 do not develop celiac disease.
Presentation—Symptoms, when present, include:

Diarrhea
Flatulence
Abdominal cramping
Bloating
Weight loss (this and the preceding all attributable to malabsorption)
Flash Card A28 Fatigue
Scleritis. This is a sight Nutritional deficiency
threatening condition Anemia
Osteoporosis
Diagnosis—Diagnosed by biopsy evidence of small-bowel villous atrophy, with

Flash Card A29 resolution on gluten-free diet.
Anterior uveitis
The detection of IgA autoantibodies to either endomysium or tissue

transglutaminase (tTG) are most sensitive and specific methods. Currently,
IgA anti-tTG is the test of choice, because it is more cost-effective, with high
sensitivity and specificity.
IgA deficiency can lead to false-negative results.
Serum IgA antigliadin antibodies have 80–90% sensitivity, but low specificity
(high false-positive). In patients with known IgA deficiency, the IgG anti-tTG
test should be used.
IgA endomysial antibodies (EMA), IgA tTG, and IgA anti-gliadin antibodies
(AGA) levels fall with treatment and may be used as noninvasive markers of
response to gluten-free diet.
IgG antibodies against deamidated gliadin peptides (IgG-anti-dGli) have been
shown to be sensitive for diagnosis of celiac disease in IgA-deficient patients.
Biopsies—Characteristic histopathology of small intestine that includes blunting

of villi with crypt hyperplasia and expansion of lamina propria mononuclear cells
(i.e., villous atrophy). Granular IgA and complement deposits can be seen at the
dermal-epidermal junction.
Associations—Celiac disease is associated with dermatitis herpetiformis, IgA

deficiency, autoimmune disorders, and malignant disease.
Dermatitis Herpetiformis—Characterized by pruritic, vesicular (excoriated)

lesions on the extensor surfaces of the extremities, trunk, buttocks, scalp, and
neck. Flash Card Q30
Which HLA type is
Treatment—Dermatitis herpetiformis responds slowly to withdrawal of gluten from strongly associated with
the diet. It is also treated with dapsone. celiac disease?
Eosinophilic Gastrointestinal Diseases (EGID, Primary)

Flash Card Q31
A group of gastrointestinal diseases characterized by abnormal infiltration of
eosinophils in the absence of known causes of eosinophilia (e.g., drug reaction, Which eye condition
parasitic infection, and malignancy, etc.), including: results in inflammation
of the eye, photophobia,
Eosinophilic esophagitis tearing, and boring eye
Eosinophilic gastritis pain?
Eosinophilic enteritis
Eosinophilic colitis
Eosinophilic gastroenteritis (involving a combination of gastrointestinal
segments) Flash Card Q32
Which antibody test has
been shown to be
sensitive for diagnosis of
celiac disease in IgA-
deficient patients?
374 / CHAPTER 8
Eosinophilic Esophagitis (EoE)

Genetics—The condition appears to arise from the interplay of genetic and
environmental factors. Familial form is seen in 10% patients, with a sibling risk
ratio of 50-fold.
Pathogenesis—Primarily Th2-mediated mechanism.

Studies strongly implicate eotaxin-3 in the pathophysiology of EoE, and the
overexpression of eotaxin-3 could be a biological marker for this condition.
IL-5 is required for eosinophilic infiltration of esophagus, whereas IL-13
induces eotaxin-3 expression.
Presentation—Most common symptoms include:

Failure to thrive, feeding disorders in children
Abdominal pain
Irritability
Gastric dysmotility
Vomiting
Diarrhea
Dysphagia
Food impaction
Symptoms typically occur independently of peripheral blood eosinophilia (more

than 50% of the time). But, some patients with EGID (typically those with
eosinophilic gastritis) have substantial peripheral blood eosinophilia, meeting the
diagnostic criteria for the idiopathic hypereosinophilic syndrome (HES).
Diagnosis—EoE is a clinicopathologic disease. Clinically, EoE is characterized

by symptoms related to esophageal dysfunction. Pathologically, 1 or more biopsy
specimens must show eosinophil-predominant inflammation. With few
Flash Card A30 exceptions, 15 eosinophils/hpf (peak value) is considered a minimum threshold
HLA DQ2 for a diagnosis of EoE. For optimal pathologic evaluation, multiple biopsy
specimens from the proximal and distal esophagus should be obtained and
evaluated for a variety of pathologic features:
Strictures
Flash Card A31
Mucosal rings
Furrowing
Scleritis. This is a sight-
threatening condition.
Ulcerations
Whitish papules
Polyps
Gastroesophageal reflux disease (GERD) and EoE may overlap. The presence of
Flash Card A32 GERD does not exclude the diagnosis of EoE. The majority of EoE patients
IgG antibodies against have evidence of food and aeroallergen hypersensitivity as defined by skin prick
deamidated gliadin and/or measurement of allergen-specific IgE antibodies. A subgroup of patients
peptides
has been recognized to have (1) a typical EoE symptom presentation, (2) have had
GERD diagnostically excluded, and (3) demonstrated a clinicopathologic
response to proton pump inhibitors (PPIs). Terms used to describe these patients
include PPI-responsive esophageal eosinophilia and PPI-responsive EoE.
Treatment—A trial of specific food antigen and, perhaps, aeroallergen avoidance

is often indicated for patients with atopic EoE, and, if unsatisfactory or practically
difficult (e.g., when patients are sensitized to many allergens), a diet consisting of
an elemental formula is advocated.
A recent study showed that an elimination diet based on skin prick test/atopy
patch test (SPT/APT) results leads to resolution of esophageal eosinophilia in a
similar proportion of patients to empiric removal of foods but required that fewer
foods be removed. The most common definitive foods identified were milk, egg,
wheat, and soy. Another study recently showed that an empiric six-food (cereals,
milk, eggs, fish/seafood, legumes/peanuts, and soy) elimination diet effectively
induced remission of active adult EoE, which was maintained for up to 3 years.
Systemic steroids are used for acute exacerbations, whereas topical steroids are
used to provide long-term control. Swallowed fluticasone and viscous budesonide
have been shown in studies to be effective in inducing clinicopathologic
remission in EoE. The patient is instructed to swallow the dose to promote
deposition on the esophageal mucosa. Even if GERD is not present, neutralization
of gastric acidity, with PPIs, may improve symptoms and the degree of
esophageal pathology.
Autoimmune Hepatitis
Autoimmune hepatitis occurs in greater numbers of women than in men.
Incidence is 17/100,000 in Northern European and/or North American white
populations.
Autoantibody Specificity Flash Card Q33

Type I (Classic): Presents at any age and is the most common type. What is the antibody
Autoantibodies are for: most specific for
ANA diagnosis of
autoimmune hepatitis
ss- or ds-DNA type I?
Saccharomyces cerevisiae
p-ANCA (myeloid 50-kD nuclear envelope antigen)
Smooth muscle
Actin Flash Card Q34
Soluble liver or pancreas Ag
What is the antibody
specific for diagnosis of
Antismooth-muscle antibodies higher than 1:320 are reflective of the more autoimmune hepatitis
specific antiactin antibodies. type II?
376 / CHAPTER 8
Type II: Presents at any age. Autoantibodies are for:

Antiliver-kidney-microsomes-1, (ALKM-1)
Liver-cytosol antigen (ALC-1 or LC1)
Rare ANA
+/– Soluble liver or pancreas Ag
Autoantibody to cytochrome p450D6 (CYP2D6)
There is some overlap with primary biliary cirrhosis (e.g., mitochondria).
Genetics—
HLA DR3: Early-onset disease
HLA DR4: Late-onset disease
Autoantibodies against asialoglycoprotein receptor (ASPGR) protein seen in
periportal hepatocytes
Presentation
Easy fatigability
Jaundice
Dark urine
Abdominal pain
Anorexia
Amenorrhea
Delayed menarche
Hepatosplenomegaly (HSM)
Spider nevi
Cushingoid features
Laboratory Findings—Aminotransferase elevations more striking than those of

bilirubin and alkaline phosphatase. Hypergammaglobulinemia may reflect high
autoantibody levels.
Treatment—Treatment of autoimmune hepatitis includes corticosteroids and

immunosuppressive drugs.
Primary Biliary Cirrhosis (PBC)
Flash Card A33 PBC is the chronic inflammation of intrahepatic ducts, which progresses,
Antibody against soluble ultimately, to the disappearance of ducts. This autoimmune disease leads to:
liver antigen. Chronic cholestasis
Hepatic fibrosis
Cirrhosis
Liver failure
Flash Card A34

ALKM-1
Epidemiology—PBC is more prevalent in women than men. Patients experience

severe pruritus. Middle-aged women (90% of patients) in their fifth and sixth
decades of life are most commonly affected. Prevalence 2.3–14.4 / 100,000
worldwide.
Genetics—HLA-A*0201 and HLA-DR8. Increased HLA-DR on hepatocytes.
Immune Mechanism—A triggering event initiates autoimmune attack against

bile duct cells in the setting of genetic susceptibility. Appears to be a CD4+ and
CD8+ T-cell mediated process, against specific epitopes on bile duct cells.
Specificity—Antimitochondrial antibody (four subtypes and pyruvate

dehydrogenase); 95% of patients have increased titer, which can be IgG, IgM, or
IgA, although IgG is primary. Antibody titers do not correlate with severity or
progression of disease.
Presentation—Insidious onset, with:

Pruritus
Fatigue
Increased skin pigmentation (secondary to melanin deposits)
Excoriations
Xanthomata
Xanthelasma
Spider telangiectasias
Late in disease course, the following are also found:

Jaundice
Petechia
Purpura
Hepatic encephalopathy
Treatment—Supportive. Treat vitamin deficiencies and symptoms of pruritus.

Steroids exacerbate metabolic bone disease. Ursodeoxycholic acid can be very
helpful. Liver transplant may be required in severe cases.
Flash Card Q35

Primary Sclerosing Cholangitis (PSC) What autoantibodies are
seen in type 1 and type
PSC is characterized by inflammation, fibrosis, and the stricture of bile ducts, 2 autoimmune hepatitis?
which affect the intrahepatic and extrahepatic ducts. PSC is more prevalent in
men than women (2:1). Ulcerative colitis (UC) presents in 50–90% patients
(closer to 90%).
Flash Card Q36
Genetics—HLA-B8 and/or HLA-DR3, and DRw52 (infrequent in UC without
Which HLA type is
PSC). associated with primary
biliary cirrhosis?
378 / CHAPTER 8
Immune Mechanism—Fibrous, obliterative process in bile ducts, and CD8 T

cells predominate. Increased CD4 T cells in liver and bile duct epithelium
expresses aberrant MHC class II and intercellular adhesion molecule (ICAM-1).
Autoantibody Specificity—The most common are antismooth-muscle

antibodies and ANA, which are found in approximately 75% of patients.
Presentation
Fatigue
Pruritus
Hyperpigmentation
Xanthelasma
Jaundice
Recurrent fever
Pain
Liver disease is progressive and leads to cirrhosis; then, risk of

cholangiocarcinoma increases.
Diagnosis—Endoscopic retrograde cholangiopancreatography (ERCP).
Treatment—Includes immunosuppressive and anti-inflammatory agents.

Endoscopic therapy and liver transplant is the treatment of choice for the
advanced disease.
Inflammatory Bowel Disease (IBD)

IBD is an idiopathic inflammatory condition of the intestine, which has three
presentations: ulcerative colitis (UC), Crohn’s disease, and indeterminate colitis.
Epidemiology—Five to 10 per 100,000, with the peak age of onset between 15–
30 years of age. The highest rates are in Europe, North America, and other parts
of the developed world. Rates are particularly high among Ashkenazi Jews and
African Americans. Smoking is associated with an increased risk of Crohn’s
Flash Card A35 disease. Smoking cessation in patients with ulcerative colitis is associated with an
Antibodies in type 1: increase in the disease activity and hospitalization. The basis for this difference is
Antiactin, antiliver (most unknown.
specific), antismooth-
muscle.
Autoantibodies in type 2: Genetics—More important in Crohn’s disease than in ulcerative colitis.
ALKM-1, CYP2D6 Mutation of the NOD gene, which is involved in bacterial recognition, is a
representative defect (NOD2/CARD15); this gene presents in 20–50% of patients
with Crohn’s disease. This mutation is also associated with Blau’s syndrome. A
gene associated with autophagy, ATG16L1, has also been associated with
Flash Card A36 Crohn’s disease. Recent studies have linked IL-10 mutations with IBD.
HLA-A*0201
Presentation—Abdominal pain, diarrhea, and weight loss are most common.

Also present are:
Mouth ulcers
Skin lesions
Perianal lesions
Fever
Additional GI features include arthralgias and arthritis, including sacroiliitis (UC

+ HLA B27).
Diagnosis—Determine disease activity with CBC and ESR. Rule out enteric
infection with stool ova and parasite exam, culture, and Clostridium difficile toxin.
Confirm the diagnosis with biopsy. IBD panel can also be useful.
IBD Panel for ulcerative colitis: ANCA-positive and ASCA-negative = 60%

sensitive and 95% specific.
IBD Panel for Crohn’s disease: ANCA-negative and anti-Saccharomyces
cerevisiae assay (ASCA)-positive = 50% sensitive and 95% specific.
Biopsy
Ulcerative colitis: Mucosal inflammation and superficial cryptitis, intestinal
involvement limited to the colon.
Crohn’s disease: Mucosal inflammation anywhere along the GI tract, with
preponderance of ileum. Evidence of noncaseating granulomas, skip lesions,
transmural involvement, terminal ileal narrowing.
Complications
Intestinal: Obstruction, fistula, and abscess
Extraintestinal:
o Eye: Uveitis and episcleritis
o Arthritis: Large joints more than small joints
o Liver: Sclerosing cholangitis
Treatment—Anti-TNFα antibodies (infliximab and adalimumab) are approved

for treatment.
Flash Card Q37

Fingolimod is a drug
recently approved for
treating multiple
sclerosis. What is its
mechanism of action?
380 / CHAPTER 8
IMMUNOLOGIC NEUROPATHIES
See Tables 8-41, 8-42, and 8-43 for discussions of immunologic neuropathies.
Table 8-41. Immunologic Neuropathies of CNS

Clinical Other
Disorder Epidemiology AutoAb Pathogenesis Diagnosis Treatment
Presentation Associations
MS F > M; NONE Immune-mediated Limb weakness, Neurologic Steroids, IFNβ, HLA-DR2-
20–40 years of destruction of optic neuritis, deficits with ≥2 glatiramer, and associated; not
age; CNS myelin ophthalmoplegia, MRI findings natalizumab autoimmune
White ; sheath (MBP) by sensory (lesions in white (anti-VLA4 mAb). disease, but it is
Colder temps T lymphocytes, symptoms, and matter) Fingolimod, a immune-
with increased gait disturbance sphingosine-1 mediated attack
IL-12, IL-18, IFNγ phosphate by myelin-
receptor specific T
modulator is lymphocytes
approved for use
in MS
ADEM Children and Clinically similar Fever HA, and No specific None, but Clinically similar
adults affected; to MS meningeal signs diagnostic steroids may to MS, but
Seasonal peak in may be seen first testing. help monophasic or
winter nonprogressive
Can be
associated with
measles
infection
Stiff-person F>M Anti-GAD and Excessive firing of Lumbar and EMG shows Diazepam, IVIG; Anti-GAD 100-
syndrome anti-amphiphysin the motor unit thoracic muscle continuous motor and steroids not 500× greater
Association with spasms, unit activity after shown to be than in type I
thymoma, vitiligo, progressive axial benzodiazepine effective DM.
DM type 1 stiffness, and administration Antiamphiphysin
rigidity associated with
malignancy
Abbreviations: ADEM, acute disseminated encephalomyelitis; AutoAb, autoantibodies; DM, diabetes mellitus; EMG, electromyelography; GAD, glutamic acid
decarboxylase; HA, hypersensitivity angiitis; HLA, human leukocyte antigen; IFN, interferon; IL, interleukin; IVIG, intravenous immunoglobulin; MBS, myelin basic
protein; MS, multiple sclerosis;
Flash Card A37

Sphingosine-1-
phosphate receptor
modulator
Table 8-42. Immunologic Neuropathies of Peripheral Nerves

Disorder Epidemiology AutoAb Pathogenesis Clinical Diagnosis Treatment Other
a
GBS Incidence Anti-GM1, Molecular mimicry Symptoms are Increase in CSF Steroids are not May be associated
increases with GD1a, GD1b, causes formation symmetrical and start protein, with beneficial in GBS with autonomic
age GT1a, and of AutoAb to peripherally in all forms normal cellularity dysfunction
GaINAc-GD1a myelin
AIDP M>F Acute flaccid weakness IVIG and 97% of GBS cases
glycoproteins
and sensory loss plasmapheresis are AIDP; 60%
Demyelination due
preceded by illness
to complement
AMAN/ activation Acute flaccid IVIG and Association with
AMSAN weakness, but no plasmapheresis preceding
sensory loss in AMAN Campylobacter
jejuni infection
More frequent in
China, Japan,
Mexico, Korea, and
India
Miller- Anti-GQ1b Acute ataxia, IVIG and Cranial nerve
Fisher ophthalmoparesis, and plasmapheresis involvement; nerve
syndrome areflexia conduction
velocities usually
normal
CIDP F > M; Antiganglioside Macrophage- Slow onset of Steroids; Antecedents are
30–50 years of (LM1, GM1), mediated weakness, Consider IVIG and much less common
age. IgM, and IgG segmental hyporeflexia, and plasmapheresis than GBS
demyelination sensory loss “Onion-bulb”
formation suggests
repeated
myelination and
demyelination
Abbreviations: AIDP, acute inflammatory demyelinating polyneuropathy; AMAN/AMSAN, acute motor axonal neuropathy / acute motor and sensory axonal
neuropathy; AutoAb, autoantibodies; CIDP, chronic inflammatory polyradiculoneuropathy; CSF, cerebrospinal fluid; GBS, Guillain-Barré syndrome;
a
Guillain-Barré syndrome is an acquired inflammatory peripheral neuropathy that can be further subdivided into AIDP, AMAN/AMSAN, and Miller-Fisher syndrome.
Flash Card Q38

A 33-year-old man
presents with diplopia
and balance problems.
Exam reveals absent
reflexes, ataxia, and
ophthalmoplegia. What
autoantibody would
confirm your suspicion
of Miller-Fisher
syndrome?
382 / CHAPTER 8
Table 8-43. Immunologic Neuropathies of the Neuromuscular Junction

Clinical Other
Disorder Epidemiology AutoAb Pathogenesis Diagnosis Treatment
MG F; 20–40 years of Anti-AChR T–lymphocyte- Weakness of AChR–antibody- Acetylcholine HLA-B8/DR3
age; and, older dependent, ocular, bulbar, positive and esterase association
patients (M = F). antibody- limb, and decremental EMG inhibitors Associated with
mediated respiratory (pyridostigmine); thymoma /
damage of AChR muscles; also consider thymic
HLA-B8, DRw3, fatigue thymectomy hyperplasia in
DQw2 younger patients
Thymectomy
often associated
with improved of
disease
Symptoms
worsen at end of
day
Lambert-Eaton Anti-VGCC Crosslinking Difficulty walking; Positive anti- IVIG and Paraneoplastic
syndrome VGCC on the weakness affects VGCC plasmapheresis form can be seen
surface of the mostly proximal with lung cancer
presynapse leads muscles; and, and lymphoma
to clustering, autonomic Nonparaneoplasti
internalization, symptoms c form associates
and reduced with HLA-A1, -B8,
number of ACh and -DR3, as in
vesicles released MG, and
by each nerve improved strength
impulse with repetitive
muscle
contraction
Abbreviations: AutoAb, autoantibodies; Ach, acetylcholine; AChR, acetylcholine receptor; EMG, electromyelography; IVIG, intravenous immunoglobulin; MG,
myasthenia gravis; VGCC, voltage-gated calcium channel.
Flash Card A38

Anti-GQ1b
383 / CHAPTER 8
Hypereosinophilic Syndromes (HES)
These consist of a group of leukoproliferative disorders, which are characterized

by the following:
Marked peripheral eosinophilia (>1500/mm3)
Evidence of end-organ dysfunction
Absence of other causes of eosinophilia, including parasitic, drug reaction,
neoplasm, or allergic disorders
Epidemiology—HES are more prevalent in men than women (9:1), often occur
between 20–50 years of age, but may also develop in children.
Presentation—The onset is often insidious, eosinophilia may be detected

incidentally, or initial manifestations may be due to sudden cardiac or neurologic
complications.
Based on the findings of a recent retrospective multicenter trial the incidence of
organ involvement at presentation was dermatologic (37%), pulmonary (25%),
gastrointestinal (14%), and cardiac (5%).
Cardiac disease is a major cause of morbidity and mortality in these patients. It

can occur whether eosinophilia is due to HES or another etiology. For example,
Loeffler’s endocarditis is a form of HES; however, it can also be induced by
parasitic infection (usually ascariasis).
Flash Card Q39
Subtypes Prior to initiating
systemic corticosteroids
Myeloproliferative—Display features of myeloproliferative disorders such as for suspected HES,
what condition should
elevated B12 level (>1000 pg/mL), splenomegaly, cytogenic abnormality, be ruled out, especially
myelofibrosis, anemia, myeloid dysplasia. in individuals from
developing countries?
May be prone to develop cardiac endomyocardial fibrosis and thrombosis.
There are three myeloproliferative HES variants:

Flash Card Q40
FIP1L1/PDGFRA-associated HES; FIP1L1 or PDGFRA mutation positive
Name two primary
by reverse transcriptase polymerase chain reaction (RT-PCR) or fluorescent in immunodeficiencies
situ hybridization (FISH); serum tryptase increased (≥12 ng/mL); almost associated with
exclusively in men, 20–40 years of age; most responsive to imatinib, a hypereosinophilia.
tyrosine kinase inhibitor). FIP1L1 mutations (in chromosome 4) lead to a
constitutively activated fusion tyrosine kinase
Myeloproliferative with negative FIP1L1/PDGFRA mutations Flash Card Q41
Chronic eosinophilic leukemia
What mutation in HES
patients predicts good
response to imatinib?
384 / CHAPTER 8
Lymphocytic—Clonal expansions of lymphocyte populations with aberrant

phenotypes (like CD4+CD3– Th2-like lymphocytes), and skin manifestations
predominate. No response to imatinib. May progress to lymphoma. Less risk for
cardiac disease; however, more prone to associated cutaneous manifestations,
such as angioedema or urticarial lesions, or erythematous, pruritic papules, and
nodules.
Familial—Autosomal dominant transmittal with family history of persistent

eosinophilia and unknown causes.
Other Subtypes
Primary EGID
Eosinophilic pneumonia
Churg-Strauss syndrome
Systemic mastocytosis
IBD
Adrenal insufficiency
Atheroembolic disease and HIV. Primary immunodeficiencies associated with
eosinophilia: Omenn’s syndrome and HIES. Gleich’s syndrome: Episodic
angioedema with eosinopholia
Treatment—No therapy is indicated for patients with eosinophilia without organ

involvement, which usually has a benign course.
Monitoring for end-organ damage with blood chemistries, echocardiogram
and pulmonary function tests (PFTs)
All patients with aggressive disease should undergo HLA typing in
preparation for possible hematopoietic cell transplantation.
Prednisone: Usual initial therapy (1 mg/kg/day)
Treatment is urgently indicated in myeloproliferative variant with
FIPL1/PDGFRA mutation with tyrosine kinase inhibitor: Imatinib.
Patients with cardiac disease should receive glucocorticoids along with
imatinib to prevent cardiac disease.
Other options include: Hydroxyurea, IFNα, anti-IL5 monoclonal antibodies,
Flash Card A39 cyclosporine A, vincristine.
Strongyloidosis
Prognosis—Better prognosis predictors:
Prolonged eosinopenia with prednisone
Absence of myeloproliferative findings (i.e., elevated serum B12 levels,
Flash Card A40 elevated leukocyte alkaline phosphatase [LAP] scores, splenomegaly)
Omenn’s syndrome, Presence of angioedema
HIES
Flash Card A41

FIP1L1/PDGFRA fusion
gene
LEUKEMIA, LYMPHOMA, AND MYELOMAS
Table 8-44 shows the epidemiologic, pathologic, and most common features
associated with hematologic cancers.
Table 8-44. Most Common Features of Hematologic Cancers

Associated
Leukemias Epidemiology Pathology
Features
Acute lymphocytic Most common Lymphoid Increased risk seen in
leukemia malignancy progenitors undergo patients with Down
diagnosed in dysregulated syndrome and
childhood proliferation Wiskott-Aldrich
Peaks at 2–5 years syndrome
of age
Acute myeloid Prevalence increases Myeloblast Increased risk seen in
leukemia with age, with proliferation (>20% patients with
median age of in bone marrow) Bloom’s syndrome,
onset70 years Down’s syndrome,
M > F. congenital
neutropenia, and
Fanconi’s anemia
Chronic lymphocytic Most common adult Clonal B Associated with
leukemia leukemia in US lymphocytes are overexpression of
Usually affects arrested in the B- proto-oncogene Bcl-
patients 60 years of lymphocyte 2
age differentiation Hypogammaglobuline
M>F pathway mia can be treated
Cells express low with IVIG; and
levels of surface More than 50% of
immunoglobulins cases associated
with 13q deletion
HODGKIN’S LYMPHOMA
Epidemiology
Greater prevalence in men than women
Bimodal distribution ages (1) between 15–34 years of age, and (2) older than
55 years of age
Pathology—Reed-Sternberg cell (B-lymphocyte origin) derived from lymph

node germinal centers, but no longer able to express antibodies (Figure 8-15). Flash Card Q42
The incidence of which
Associated Features lymphoma is very high
May be associated with HIV or EBV infections in patients with X-linked
lymphoproliferative
Positive family history in 1% of cases syndrome (XLP)?
386 / CHAPTER 8
Presentation
Asymptomatic lymphadenopathy
Mediastinal mass
Systemic (B) symptoms: Fever, night sweats, weight loss
Pruritus may be an early symptom, sometimes preceding diagnosis by
weeks, or even a year
NON-HODGKIN’s LYMPHOMA (NHL)
NHLs are a diverse group of blood cancers that include any kind of lymphoma
except Hodgkin's lymphoma. Types of NHL vary significantly in their severity
from indolent to very aggressive (Table 8-45).
Presentation
Clinical presentation of NHL varies tremendously depending on the type of
lymphoma and the areas of involvement.
Aggressive lymphomas commonly present acutely or subacutely with a
rapidly growing mass, systemic B symptoms, elevated levels of serum LDH
and uric acid.
Indolent lymphomas are often insidious, presenting only with slow-growing
lymphadenopathy, hepatomegaly, splenomegaly, or cytopenias.
Exaggerated (hypersensitivity) reactions to insect stings or bites, especially
mosquito bites, may be noted in some patients with NHL.
There is an association between acquired angioedema (AAE), and NHL and
lymphoproliferative disorders.
Flash Card A42

Figure 8-15. Reed-Sternberg cell.
Ileocecal B-cell (Reproduced, with permission, from the National Cancer Institute.)
lymphoma
Table 8-45. Comparison of NHL types

Non-Hodgkin’s Associated
Pathology Genetics
Lymphomas Infections
Burkitt’s lymphoma Highly aggressive EBV (sporadic) Associated with c-
type of B-cell myc gene
lymphoma translocation, found
at 8q24
Splenic marginal Postgerminal center Hepatitis C Deletion of 7q21-32
zone B-cell B lymphocyte with is seen in 40% of
lymphoma an unknown degree cases.
of differentiation
Represents <1% of
all NHL
MALToma Extranodal 70% of gastric Associated with
manifestations of MALTomas trisomy 3 or t(11;18)
marginal-zone associated with
lymphomas Helicobacter pylori
infection
Abbreviations: EBV, Epstein-Barr virus; MALToma, mucosa-associated lymphoid tissue lymphoma.
MYELOMAS
Serum protein electrophoresis (SPEP) and immunofixation are critical to the

diagnosis and management of myelomas (Figure 8-16). A brief overview of these
diagnostic modalities is presented as follows.
Indications for SPEP:

Unexplained anemia, back pain, weakness, or fatigue
Osteopenia, osteolytic lesions, or spontaneous fractures
Renal insufficiency with a bland urine sediment
Heavy proteinuria in a patient older than age 40
Hypercalcemia
Hypergammaglobulinemia
Immunoglobulin deficiency
Bence Jones proteinuria
Unexplained peripheral neuropathy
Recurrent infections
Elevated ESR or serum viscosity
Drawbacks of SPEP:
Not as sensitive when M-proteins are small
If an M-protein is present, the immunoglobulin heavy- and light-chain class
cannot be determined from the SPEP
388 / CHAPTER 8
Figure 8-16. Normal pattern for serum protein electrophoresis.
Serum immunofixation must be performed in order to ascertain the presence of

an M-protein and to determine its type.
Serum immunofixation determines the heavy- and light-chain type of the

monoclonal protein. Immunofixation will detect a serum M-protein at a
concentration of at least 0.02 g/dL and a urine M-protein at a concentration of at a
cog/dL . It should be done in conjunction with electrophoresis.
Α-1 globulin= α1-antitrypsin, thyroid-binding globulin, transcortin

Α-2 globulin= haptoglobin, ceruloplasmin
Β-1= transferrin
Β-2= β-lipoprotein, some IgGAM, complement
Between Β and γ= C-reactive protein, fibrinogen
Γ= immunoglobulins
Monoclonal Gammopathy of Unknown Significance

(MGUS)
MGUS involves the proliferation of bone marrow plasma cells derived from a
single abnormal clone that involves less than 10% of the bone marrow. MGUS is
believed to be a premyeloma condition; 30–40% of cases may progress to
myeloma at a rate of 1–2% per year. The incidence of MGUS increases with age,
with mean diagnosis at 70 years of age. There are no specific findings on physical
examination; and, the disease is often diagnosed during evaluation for an
unrelated problem.
Diagnosis is made by observing <3 g/dL of monoclonal paraprotein spike on

SPEP; <10% of bone marrow involvement; and, no myeloma-related organ or
tissue impairment (Figure 8-17).
Figure 8-17. SPEP seen in MGUS.
Multiple Myeloma (MM)

MM is the proliferation of bone marrow plasma cells derived from a single,
abnormal clone that involves >10% of the bone marrow and the large bones of the Mnemonic
body (e.g., skull, vertebrae, and hips). Symptoms of Multiple
Myeloma: CRAB
Genetics—Fifty-percent are associated with Cs 14 abnormality.
Calcium (↑)
Renal failure
Epidemiology—Affects more men than women (3:2), and usually patients older
Anemia
than 65 years of age. Bone lesions
Presentation—Tetrad of symptoms: Hypercalcemia, renal failure, anemia, and

bone lesions.
Diagnosis—Observation of >3g/dL monoclonal paraprotein spike on SPEP; >10%

of clonal plasma cells on bone marrow biopsy; and, evidence of myeloma-related
organ or tissue impairment.
Waldenström’s Macroglobulinemia
Malignant proliferation of terminally differentiated B lymphocytes resulting in
high levels of IgM. Associated with chromosome 6 abnormalities. Associated
with history of autoimmune diseases with:
Autoantibodies
Hepatitis
HIV
Rickettsiosis
390 / CHAPTER 8
Epidemiology—Waldenström’s macroglobulinemia affects more men than

women, with the median age at diagnosis 64 years.
Presentation
Pallor
Oronasal bleeding
Organomegaly
Constitutional symptoms
Hyperviscosity
Abnormal coagulation
Sensorimotor peripheral neuropathy
Diagnosis—SPEP showing an M component with β-to-γ mobility is highly

suggestive of Waldenström’s macroglobulinemia. High-resolution electrophoresis
and immunofixation to characterize the monoclonal IgM paraprotein; the light
chain of the monoclonal protein is usually the κ light chain. Bone marrow biopsy
shows malignant cells.
Solitary Plasmacytoma
Discrete solitary mass of neoplastic monoclonal plasma cells in bone (medullary)
or soft tissue (extramedullary). Increased risk of progression to multiple myeloma;
more prevalent in men than women; median age at diagnosis is 55 years.
Presentation—Pain at the site of the skeletal lesion is secondary to bone

destruction by infiltrating plasma cells. Monoclonal paraprotein spike on SPEP
and lytic lesions seen on radiograph.
Polyneuropathy, Organomegaly, Endocrinopathy,

Monoclonal Protein, Skin Abnormalities (POEMS)
Syndrome
Monoclonal plasma cell disorder, peripheral neuropathy, and one or more of the
following seven features:
Osteosclerotic myeloma
Castleman's disease (giant cell lymph node hyperplasia, angiofollicular lymph
node hyperplasia. HHV-8 is implicated in the pathogenesis of Castleman’s
disease))
Organomegaly
Endocrinopathy (excluding DM or hypothyroidism)
Edema
Typical skin changes
Papilledema
Almost all patients with POEMS syndrome have either osteosclerotic myeloma or
Castleman's disease. Chronic overproduction of proinflammatory and other
cytokines appear to be a major feature of this disorder (IL-1β, TNFα, IL-6, and
vascular endothelial growth factor [VEGF]). Median age at diagnosis is 51 years.
Affects more men than women.
Diagnosis—Monoclonal paraprotein spike on SPEP; immunohistochemical

staining of biopsy specimens almost always shows the λ chain; and bone marrow
examination is most often nondiagnostic.
Heavy-Chain Disease (α, γ, and μ)

Heavy-chain disease is a rare B-lymphocyte proliferative disorder. It is
characterized by the secretion of incomplete immunoglobulin heavy chains, in
which the deletion in an amino acid sequence results in the inability of the heavy
chain to form disulfide bonds with the light chains.
Alpha (α)—This is the most commonly reported heavy-chain disease. Median age
at diagnosis is 30–40 years, and patients are mostly of Middle Eastern or
Mediterranean ancestry.
Presentation: Severe diarrhea and weight loss from second-degree infiltration
of the intestinal tract wall by cancerous plasma cells, which can lead to
malabsorption.
Gamma (γ)—Median age at onset is 60 years; more prevalent in men than women.
Up to one third of patients with γ heavy-chain disease have an associated
autoimmune disorder (e.g., rheumatoid arthritis, Sjögren’s syndrome, lupus
erythematosus, or autoimmune hemolytic anemia).
Presentation: lymphoma-like illness with lymphadenopathy,
hepatosplenomegaly, and sometimes B symptoms.
Diagnosis: SPEP shows a broad-based band that migrates to the β region.
Immunoselection combined with immunophoresis is the most reliable test in
the detection of γ heavy-chain disease. Bone marrow biopsy and aspirate
findings may be normal; however, they often reveal increased numbers of
plasma cells, lymphocytes, and large immunoblasts. Eosinophilia is also
common.
Mu (μ) —This is the rarest of the heavy-chain diseases. No age or gender

predilection.
Presentation:
o Splenomegaly
o Hepatomegaly Flash Card Q43
o Pallor (if significant anemia is present) Which viral infection is
o Lymphadenopathy. associated with
cryoglobulinemia, and
with what types?
392 / CHAPTER 8
o Most distinctive symptom is palatal edema that is secondary to nodal

involvement of Waldeyer's ring.
Diagnosis: Anomalous serum M component that reacts with anti-IgG but not
antilight-chain reagents. Bone marrow examination is usually nondiagnostic.
Cryoglobulinemia
Cryoglobulins are single or mixed immunoglobulins that undergo reversible
precipitation at low temperatures. It occurs more often in women than men (3:1).
The mean age reported is 42–52 years.
Types
Type I: Results of a monoclonal immunoglobulin IgM > IgG, IgA, or light
Key Fact chains
With cryoglobulins, RF
Types II and III: Contain rheumatoid factors (RFs) usually IgM, and which
is positive in types II and form complexes with the fragmented, crystallizable (Fc) portion of the
III. polyclonal IgG
o Monoclonal RF in type II
o Polyclonal RF in type III
o Types II and III represent 80% of all cryoglobulins
Presentation
Type I:
o Related to hyperviscosity and thrombosis (acrocyanosis, retinal
hemorrhage, severe Raynaud’s phenomenon with digital ulceration, livedo
reticularis purpura, and arterial thrombosis).
Type II and III:
o Joint involvement (usually, arthralgias in the proximal interphalangeal PIP
joints, metacarpophalangeal MCP joints, knees, and ankles)
o Fatigue
Key Fact o Myalgias
Type I cryoglobulinemia o Renal immune-complex disease
is associated with o Cutaneous vasculitis
plasma cell dyscrasias o Peripheral neuropathy
and multiple myeloma.
Type II and III
cryoglobulinemias are
associated with hepatitis Diagnosis
C infection. Evaluation of serum cryoglobulins: Blood specimen must be obtained in
warm tubes (37°C, 98.6°F) in the absence of anticoagulants. Allow the blood
sample to clot before removal of serum with centrifugation at 37°C (98.6°F).
Type I tends to precipitate within the first 24 hours (at concentrations >5
Flash Card A43 mg/mL).
Hepatitis C virus, with Type III cryoglobulins may require seven days to precipitate a small sample
types II and III <1 mg/mL).
GRANULOMATOUS DISEASES
GRANULOMA
Granulomas form either in response to persistent antigen exposure or from the
presence of undigestible particulate antigen. Most consist of organized T and B
lymphocytes surrounded by histiocytes (macrophages with indistinct boundaries).
And, if caused by infectious etiology, large, multinucleated giant cells are usually
present at the granuloma center. One way to categorize granulomatous disease is
by the T-lymphocyte phenotype (i.e., Th1 versus Th2; see Table 8-46).
After activation, macrophages secrete molecules that promote granuloma

formation, including ACE, 1, 25-dihydroxyvitamin D3 (1, 25-[OH]2D3),
osteoporin, and TNFα.
Laboratory Findings—ACE is a marker for the presence of granulomatous

disease and its activity; however, it lacks disease specificity and has limited
diagnostic and therapeutic utility. High serum levels of 1,25(OH)2D3 are a
common feature. Osteopontin is secreted by many granuloma cells that are
implicated in the regulation of chemotaxis, T-lymphocyte development, and cell
adhesion, which are all essential elements to granuloma formation. TNFα is also
critical to granuloma development and plays an important role in containing the
prototypical granuloma-inducing infectious agent, Mycobacterium tuberculosis.
Table 8-46. Granulomatous Diseases: Th1-Dominated and Th2-Dominated

Th1-Dominated Th2-Dominated
Flash Card Q44
Tuberculosis Churg-Strauss syndrome
Sarcoidosis Lepromatous leprosy
What is Lofgren’s
syndrome?
Berylliosis
Hypersensitivity pneumonitis
Wegener’s granulomatosis
Tuberculoid leprosy Flash Card Q45
What is the key
difference between
sarcoidosis and
hypersensitivity
pneumonitis, in terms of
T-cell counts on BAL?
394 / CHAPTER 8
Causes of Granulomatous Diseases

Infectious: Tuberculosis and atypical mycobacterium, fungal infections such
as histoplasmosis, blastomycosis, coccidioidomycosis
Immune dysregulation:
o Wegener’s granulomatosis
o Churg-Strauss syndrome
o Sarcoidosis
o Chronic granulomatous disease (CGD)
o Takayasu’s arteritis
o Crohn’s disease
o Primary biliary cirrhosis
o Patients with common-variable immune deficiency (CVID) may develop
noncaseating granulomas in the lymphoid or solid organs
Environmental exposures: Hypersensitivity pneumonitis, berylliosis, and
silicosis
Sarcoidosis
Sarcoidosis is a disease of unknown etiology. It is characterized by the presence
of multiple, noncaseating granulomas that results in multiple organ dysfunction; it
involves the lung, especially. The high prevalence of hilar lymphadenopathy and
asymptomatic disease in the African-American population clearly suggests a
genetic basis.
Pulmonary function testing usually shows restriction. However, sarcoidosis is

one of a handful of lung diseases that can have mixed-obstructive and restrictive
physiology.
Sarcoidosis is characterized histologically by the presence of perilymphatic,

noncaseating granulomas, with an abundant rim of perigranulomatous
lymphocytes. The perigranulomatous lymphocyte population contains both CD4+
and CD8+ T lymphocytes; and, intracellular cytokine-staining profiles
Flash Card A44 demonstrate a Th1 (IFNγ)-predominant cytokine pattern.
Triad of hilar
adenopathy, acute Diagnosis—Diagnosis is made based on finding this characteristic pathology in
polyarthritis and the lung, or perhaps other tissues, in the absence of known granuloma-inducing
erythema nodosum
agents. Increased serum ACE and vitamin D levels are often detected, although
they are not specific. Bronchoalveolar lavage (BAL) fluid shows elevated CD4 to
CD8 ratio (compare that with hypersensitivity pneumonitis in which the ratio is
Flash Card A45 decreased).
CD4/CD8 count is
elevated in sarcoidosis, Treatment—Oral corticosteroids are typically given for symptomatic disease, but
decreased in probably do not improve long-term outcome. Infliximab (anti-TNFα mAb) has
hypersensitivity
pneumonitis
been used successfully as a treatment for refractory sarcoidosis, but serious

adverse effects might preclude its widespread use.
Berylliosis
Berylliosis is clinically identical to sarcoidosis; however, it results from
environmental exposure to beryllium, often in an occupational setting. Like
sarcoidosis, berylliosis is associated with a broad spectrum of lung abnormalities,
ranging from patchy radiographic opacities to diffuse interstitial lung disease.
Clustering of cases of hypersensitivity pneumonitis and berylliosis within patients
bearing certain MHC and TNFα polymorphisms suggests a common pathogenetic
link between these distinct lung diseases.
Treatment—Treatment of berylliosis centers on removal of the patient from

exposure to the offending metal. Corticosteroids are commonly used as adjunctive
therapy; but, randomized efficacy studies have been inconclusive. Their use
remains controversial.
Wegener’s Granulomatosis (Granulomatosis with

Polyangiitis)
A form of vasculitis that affects small to medium blood vessels. Granulomatous

inflammation of the respiratory tract. It affects women as much as men
Presentation
Sinuses are involved in 95% of patients.
Lungs are affected in 85% of patients with nodules, cavitary lesions, and
pulmonary hemorrhage.
Kidneys are affected in 80% cases and are affected at the time of diagnosis in
20% cases. Typically asymptomatic, but can lead to rapidly progressive renal
failure. Detected by active urine segment.
But other organs such as the eye and skin are also frequently involved.
Diagnosis—Presence of c-ANCA (by immunofluorescence) with proteinase-3

(PR3) specificity by ELISA is most specific, although p-ANCA can also be seen.
In the absence of classic organ involvement in c-ANCA-positive patients, the
diagnosis of Wegener’s granulomatosis is established by tissue biopsy. Kidney
biopsy specimens show pauci-immune glomerulonephritis (focal, segmental,
crescentic).
Flash Card Q46
Treatment—For severe disease, prednisone + cyclophosphamide or prednisone + What type of ANCA
rituximab, transition to azathioprine or mycophenolate, once controlled. For antibody is found in 75–
90% of patients with
nonsevere disease, prednisone + methotrexate. granulomatosis with
polyangiitis?
396 / CHAPTER 8
Mortality is usually from pulmonary or renal failure.
Eosinophilic Granuloma of the Lung (Histiocytosis X)
Associated with pulmonary interstitial fibrosis, the most common symptom is

nonproductive cough.
Diagnosis—The diagnosis is made by lung biopsy and high-resolution CT

scanning with pathognomonic cysts and nodules. The major cells in lesions are
histiocytosis X cells, which are of Langerhans cell origin, and are positive for
CD1 and HLA-DR.
AMYLOIDOSIS
Amyloidosis is a group of disorders associated with deposits of amyloid proteins

in various organs. Symptoms vary widely depending on where in the body
amyloid deposits accumulate, with most commonly affected organs being the
kidneys, heart, and liver (Table 8-47).
Table 8-47. Common Clinical Manifestations of Amyloidosis

System Clinical Manifestations
Renal Proteinuria, nephrotic syndrome
Cardiac Cardiomyopathy leading to heart failure
Hepatic and splenic Hepatosplenomegaly
Neurologic Mixed sensory and motor peripheral
neuropathy, autonomic neuropathy, or stroke
Musculoskeletal Macroglossia (pseudohypertrophy)
Hematologic Bleeding diathesis
Pulmonary Tracheobronchial infiltration, persistent pleural
effusions, parenchymal nodules
Skin Waxy thickening, easy bruising (ecchymoses),
subcutaneous nodules or plaques
Flash Card A46

c-ANCA (anti-proteinase 3)
Primary Amyloidosis (AL)

This plasma cell dyscrasia is the most common form in developed countries and
involves deposits of immunoglobulin light chains. It may occur alone or
associated with multiple myeloma, Waldenström’s macroglobulinemia or non-
Hodgkin’s lymphoma. Immunoglobulin is detectable in the serum or monoclonal
light chains in the urine in approximately 80% of cases. Patients tend to be 60
years of age or older with nonspecific symptoms such as fatigue and weight loss.
Secondary Amyloidosis (AA)

This may occur at any age in patients with chronic inflammatory or infectious
conditions, including RA, IBD, and various periodic fever syndromes (including
familial Mediterranean fever [FMF] and cryopyrin-associated periodic syndromes
[CAPS, i.e., familial cold autoinflammatory syndrome [FCAS] and Muckle-Wells
Flash Card Q47
syndrome ]MWS]) and involves deposits of the acute-phase reactant and serum
amyloid A (AA) protein in tissues. A 16-year-old woman
with a history of
progressive hearing loss
Definitive Diagnosis—Congo-red-positive deposits in tissue/fat pad biopsy as presents with recurrent
seen in Figure 8-18. The sensitivity of the abdominal fat pad aspiration technique episodes of fever,
is around 80%, but its specificity is near 100%. diffuse urticaria, and
diffuse joint pains that
Treatment—Treatment for primary amyloidosis involves melphalan and have occurred every 3
weeks for the past year,
prednisone and may include stem cell transplantation. Treatment for patients with
triggered by cold
secondary amyloidosis should focus on resolving the chronic inflammatory state. temperatures.
Colchicine helps treat amyloidosis in patients with FMF. Liver transplantation Laboratory studies
may be effective in certain cases of the hereditary amyloidoses. reveal proteinuria and
kidney biopsy reveals
AA deposits. What is the
diagnosis?
Flash Card Q48

An 8-year-old boy of
Ashkenazi Jewish
descent presents with
intermittent fevers,
recurrent attacks of
abdominal pain, and
arthritis in the right knee.
An extensive work-up
ruled out infectious
sources and showed
proteinuria on urinalysis.
Figure 8-18. Cardiac amyloidosis. Micrograph showing amyloid deposition (red Subsequent bone
fluffy material) in cardiac tissue. Amyloid will show "apple-green" birefringence marrow biopsy revealed
when stained with Congo red and viewed under polarized light. AA deposits. What is the
(Reproduced, with permission, from Wikimedia Commons.) diagnosis?
398 / CHAPTER 8
MASTOCYTOSIS
Key Fact
Darier’s sign is urticaria
and erythema observed Disease caused by clonal proliferation of mast cells within tissues that can occur
on and around a macule at any age. The true prevalence is unknown, and familial occurrence is unusual. It
after stroking the lesion. is classified into disease variants based on clinical presentation, pathologic
Diffuse cutaneous finding, and prognosis (see Tables 8-48 and 8-49).
mastocytosis (DCM)
typically is a pediatric
skin mastocytosis
variant and usually Table 8-48. Cutaneous Mastocytosis (CM)
resolves without Classification Clinical Presentation
progression to systemic
mastocytosis. Urticaria pigmentosa (UP) Discrete yellow-brown macular-papular or nodular
plaque-like lesions with characteristic Darier’s sign
Diffuse cutaneous mastocytosis Diffuse yellow-brown thickened skin; no discrete lesions;
(DCM) usually occurs in patients younger than 3 years of age
Mastocytoma of skin Solitary reddish brown skin lesion that usually presents in
Flash Card A47 first 3 months of life and frequently resolves
spontaneously
Telangiectasia macularis eruptiva Macular telangiectasias characterized by increased mast
is a rare autosomal
perstans cells around dilated capillaries and venules. Typically
dominant disease that occurs in adults.
causes sensorineural
deafness, recurrent
hives, and can lead to
secondary amyloidosis
with nephropathy. Cold
temperatures may
precipitate attacks. Table 8-49. Classification of Systemic Mastocytosis (SM)
Patients have a Indolent systemic mastocytosis (ISM): most common form of SM; slow progression and good
mutation in NLRP3. prognosis
Rare provisional subvariants of ISM:
Smoldering SM: high mast cell burden ( >30% bone marrow space are MC,
High tryptase >200 ng/mL)
Flash Card A48 Isolated bone marrow mastocytosis—bone marrow involvement without skin involvement
Familial Mediterranean Systemic mastocytosis with associated hematologic nonmast cell lineage disease (SM-AHNMD)
fever. 90% of patients Aggressive systemic mastocytosis (ASM): Aggressive tissue infiltration causing hepatic fibrosis,
with FMF, which is portal hypertension, malabsorption, or cytopenia
common in individuals
off Turkish or Ashkenazi Mast cell leukemia (MCL): Rare; >10% immature MC in peripheral blood or >20% immature MC
Jewish descent, present in marrow
before age 20 with
Mast cell sarcoma (MCS): Reported in tibia, skull, and other bones
symptoms of intermittent
fevers, serositis causing Extracutaneous mastocytoma
abdominal pain or
pleuritis, monoarthritis,
and AA deposition in the
kidney, spleen, liver,
and gut. Symptoms
typically respond to
colchicine.
Pathogenesis
Molecular Pathogenesis of Systemic Mastocytosis–Activating Mutations in Key Fact
c-kit—Activating mutations in c-kit (e.g., KIT D816V) can lead to increased
number of mast cells due to constitutive activation of KIT tyrosine kinase Stem cell factor (SCF)
is required for mast cell
signaling and aberrant expression of antiapoptotic proteins (e.g., Bcl-XL & Bcl-2). survival and is the ligand
for c-KIT (CD117).
Clinical Features
Symptoms (Table 8-50) are caused by infiltration of mast cells in the target
organs and/or the release of mast cell mediators during mast cell activation (e.g.,
Key Fact
histamine, tryptase, chymase, and other mediators).
The following
Bone Marrow—The most common site of mast cell infiltration and most useful medications may induce
symptoms in patients
biopsy site for making diagnosis. Mast cells are identified by with mastocytosis and
immunohistochemical staining for CD117 (c-kit) and coexpression of CD2 and/or should be avoided
CD25. (unless specifically
tolerated by any
individual patient):
Diagnostic Criteria Alcohol, amphotericin B,

dextran,
dextromethorphan, IV
Cutaneous Mastocytosis (CM)—Requires presence of at least one of the vancomycin, α-blocker,
following: β-blockers, quinine,
Focal dense mast cell infiltrates (>15 mast cells per cluster) or diffuse mast polymyxin B, opioids
cell infiltrates (>20 mast cells per high-powered field) on skin biopsy (fentanyl and tramadol
usually tolerated),
c-KIT D816V mutation aspirin and NSAIDs,
muscle relaxants
Systemic Mastocytosis (SM)—See Table 8-51. (succinylcholine and
atracurium;
pancuronium, and
vecuronium usually
tolerated), and local
anesthetics (benzocaine
and procaine).
Table 8-50. Other Symptoms of Mastocytosis
System Clinical Manifestations
Cutaneous Urticaria pigmentosa, flushing, pruritis Key Fact
Gastrointestinal Abdominal pain, diarrhea, nausea, vomiting, Obtain baseline tryptase
and peptic ulcer disease values for a patient who
Musculoskeletal Musculoskeletal and bone pain, osteopenia, presents with severe
osteoporosis, and pathologic fractures anaphylaxis following a
Cardiovascular Anaphylaxis Hymenoptera sting to
screen for mastocytosis.
Neuropsychiatric Decreased attention span, memory impairment,
and irritability reported
400 / CHAPTER 8
Table 8-51. Systemic Mastocytosis—World Health Organization (WHO)

Diagnostic Criteria
Major Criteria
a
Biopsy with multifocal, dense infiltrates of mast cells (>15 mast cells in aggregates)
Minor Criteria
Key Fact a
Biopsy with more than 25% of mast cells having spindle-shaped or atypical morphology
One major and one Detection of c-kit D816V mutation
a
minor, or three minor

Expression of CD2 and/or CD25 on CD117+ mast cells
criteria are required to
diagnose systemic Total serum tryptase > 20 ng/mL
mastocytosis. a
In bone marrow or other extracutaneous organ.
Mast Cell Activation Syndrome (MCAS)—This is a proposed diagnosis

describing patients who have a variety of symptoms suggestive of mast cell
activation, but fail to meet the WHO criteria for diagnosis of SM, and for
whom all other relevant differential diagnoses have been excluded. Patients may
have recurrent episodes of mast cell activation symptoms, such as recurrent
flushing, gastrointestinal cramping, and hypotension, and may exhibit
hypotensive reactions to Hymenoptera stings similar to patients with systemic
mastocytosis. However, they lack urticaria pigmentosa and may demonstrate
baseline serum tryptase values that are normal or mildly increased. This diagnosis
may be suggested when serum tryptase or other laboratory tests for mast cell
mediators are elevated from baseline in conjunction with a “flare” of symptoms.
Monoclonal Mast Cell Activation Syndrome (MMAS)—Distinguished from

MCAS by the presence of the D816V c-KIT mutation, but does not meet full
WHO criteria for SM.
Treatment
Symptomatic treatment includes the following:
Avoidance of triggers, which may include alcohol, NSAIDs, narcotics, intense
exercise, and stinging insects
First- and second-generation antihistamines: Reduce pruritus flushing, and
headaches
H2 antagonist: Add-on therapy for pruritus, flushing, and headaches
Disodium cromoglycate: May be useful in alleviating GI complaints
Epinephrine: Used to treat episodes of hypotension
Topical steroids: Used to treat urticaria pigmentosa (UP) or DCM
Cytoreductive treatment: imatinib mesylate (Gleevec)—tyrosine kinase
inhibitor used in patients with aggressive systemic mastocytosis without
D816V c-KIT mutation
DEXA scanning and calcium supplementation: Monitoring and treatment

of osteoporosis
Associated hematologic disorders existing concomitantly with SM:
Managed according to their specific hematologic abnormalities
Prognosis
Variables associated with poor prognosis include:
Male gender
Absence of cutaneous symptoms
Presence of constitutional symptoms
Anemia or thrombocytopenia
Abnormal liver function tests (LFTs)
Bilobed mast cell nuclei
Low percentage of fat cells in bone marrow biopsy, or
An associated hematologic malignancy
IMMUNOHEMATOLOGIC DISEASE
The predominant antibody involved in immunohematologic disease is IgG, which
opsonizes blood cells, resulting in extravascular clearance by Fc receptors mainly
in the spleen. Two IgG molecules can also activate complement, enhancing cell
clearance via complement receptors. Hemolytic reactions affecting IgM also
involve complement fixation; only one IgM molecule is required to fix
complement. Reticuloendothelial cells (in spleen) lack IgM receptors.
Transfusion Reactions
Acute Hemolytic Transfusion Reactions (HTRs)—HTRs are most commonly

due to transfusion of ABO-incompatible blood. This leads to the formation of
IgM antibody:RBC antigen complexes, which induce complement-mediated lysis,
activate the coagulation cascade, and release proinflammatory cytokines (i.e.,
TNFα). Clinically, the classic presentation includes fever, flank pain, and red-
brown urine (hemoglobinuria), and if the problem is unrecognized, the patient
may progress to disseminated intravascular coagulation (DIC) and a shock-like
state. Laboratory findings include hemoglobinuria, elevated plasma free Flash Card Q49
hemoglobin, and a positive direct antiglobulin test (DAT). What is most common
activating point mutation
in c-kit associated with
systemic mastocytosis?
402 / CHAPTER 8
Delayed HTRs—Delayed HTRs result from exposure to minor blood group

antigens such as Rh, Kell, Kidd, or Duffy blood groups. These are clinically
milder reactions than acute HTRs, and present 5–10 days after transfusion with
fever, jaundice, and a gradual decline in hemoglobin. Additional laboratory
findings include an increased lactate dehydrogenase (LDH), elevated indirect
bilirubin, and a positive DAT.
Nonhemolytic Febrile Reactions—The most common cause of fever after blood

transfusion. They are more commonly seen after platelet transfusions and are
more common in women secondary to pregnancy-related allosensitization. They
are diagnosed after a temperature increase of more than 1 ○C (33.8○F). Cytokines
(TNFα and IL-1β) play a role in the etiology, and cytokine levels increase over
time during storage. Reactions can be prevented by prestorage removal of
leukocytes (leukoreduction).
Urticarial (Allergic) Reactions—Urticarial reactions occur during 1–3% of fresh

frozen plasma and platelet transfusions and are due to IgE-mediated
hypersensitivity to plasma proteins. Patients present with urticaria and pruritus.
Treatment includes temporarily stopping the transfusion and administering
antihistamines. Prevention includes washing future blood products.
Anaphylactic Reactions—Occur rarely in IgA-deficient patients who have anti-

IgA antibodies. Prevent using twice-washed RBCs or products from known IgA-
deficient donors. May also occur via an IgE-mediated mechanism.
Graft-Versus-Host Disease (GVHD)—A highly lethal complication of

transfusion after bone marrow transplantation. Donor T lymphocytes react against
host histoincompatible tissues (e.g., skin, GI, liver, and bone marrow). There is a
high fatality rate secondary to marrow aplasia. GVHD prevention includes γ
irradiation of cellular blood products.
Transfusion-Related Acute Lung Injury (TRALI)—Should be suspected when

patients present with severe respiratory distress 1–4 hours after transfusion.
TRALI results when donor leukocyte antibodies are directed at recipient
neutrophil antigens or HLA determinants. C5a is released, resulting in pulmonary
leukosequestration. Neutrophil sequestration and priming is followed by
neutrophil activation and release of a variety of neutrophil mediators. Treatment
includes intensive respiratory support (ventilation) and high-dose corticosteroids,
Flash Card A49 leading to resolution in 24–48 hours.
The most common
mutation in c-kit is at
codon 816 with a
substitution of valine for
Autoimmune Hemolytic Anemia
aspartic acid
(Asp816Val or D816V). Criteria for Autoimmune Hemolytic Anemia (AIHA)—Criteria for AIHA
Other mutations have consist of the following:
been identified but are
uncommon.
Positive DAT or indirect antiglobulin test (IAT)
Evidence of hemolysis (i.e., anemia with reticulocytosis, jaundice,

hyperbilirubinemia (indirect), high levels of low-density lipoprotein (LDH), or
a low haptoglobin)
Warm-Reactive AIHA—Caused by polyclonal IgG against RBCs. The RBCs

attach to Fc receptors on macrophages in the spleen and are removed by
phagocytosis. There are primary (idiopathic) or secondary (SLE or chronic
lymphocytic leukemia, CLL) causes, and patients have a positive DAT.
Cold-Reactive AIHA—Occurs when IgM binds to I antigen (polysaccharide on

all RBCs) at temperatures less than 37°C or 98.6°F (i.e., not at room temperature).
This activates complement. Idiopathic cases are seen in the elderly, who present
with acrocyanosis and have a monoclonal spike. Cold AIHA can also present
secondary to Mycoplasma infection or mononucleosis. Disease is worsened by
cold exposure.
Paroxysmal Cold Hemoglobinuria—A cold-reacting biphasic, anti-RBC IgG

antibody (also known as Donath-Landsteiner antibody) that is usually against the
P antigen on RBC.
Paroxysmal Nocturnal Hemoglobinuria—Loss of phosphatidyl-inositol-

glycerol (PIG)-linkage proteins on surface of RBCs, including CD59 and CD55
(DAF, decay-accelerating factor). Patients present with hepatic vein thrombosis;
and, diagnosis is made via flow cytometry.
Hemolytic Disease of the Newborn

Rh disease is the most common. Prophylaxis of RhD– women with anti-D
immune globulin at 28 weeks’ gestation and within 72 hours after delivery
prevents sensitization
ABO incompatibility: Mom is O and baby is A, B, or AB; 10% of pregnancies
are a “set up” for this
Minor blood group incompatibilities, which include D, Kell, and Duffy
Immune Neutropenia
Neonatal Alloimmune Neutropenia—Occurs when fetal neutrophil antigens

(NA1 and NB1) provoke formation of maternal IgG that crosses the placenta to
destroy fetal neutrophils. Firstborns are commonly affected.
Primary Autoimmune Neutropenia—Occurs in six-to 24-month-olds and is

usually benign, presenting with minor infections (e.g., skin abscesses, URIs, and
otitis media). Remission is typically seen by age of two to four years (90%).
Diagnosis is clinical; can order antineutrophil antibodies. Neutropenia is severe,
and neutrophil percentage is generally less than 5%.
404 / CHAPTER 8
Immune Thrombocytopenia
Neonatal Alloimmune Thrombocytopenia (NAIT)—NAIT occurs when

Key Fact maternal antibodies against an inherited fetal platelet antigen from the father (e.g.,
Evans’ syndrome is the P1A1 (HPA-1) – the most common antigen in whites) cross the placenta and
simultaneous or destroy fetal platelets. The typical presentation is of a first born child with
sequential development neonatal thrombocytopenia; infant may develop intracranial hemorrhage.
of ITP and AIHA with a
positive DAT in the
Postnatal treatment involves maternal (platelet antigen-negative) platelet
absence of a known transfusion to infant.
underlying etiology.
Some patients may also Immune Thrombocytopenic Purpura (ITP)—ITP is a clinical diagnosis.
have autoimmune Patients present with petechiae, purpura, and ecchymoses, with isolated severe
neutropenia. A majority
of patients with Evans’
thrombocytopenia; otherwise, normal CBC. Treatment indicated under platelet
syndrome have a counts of 20,000–30,000/μL with IVIG 0.5–1 g/kg, anti-D 50–75 μg/kg and/or
chronic relapsing course prednisone 1–2 mg/kg; 80% improve within 1 year. The most severe complication
despite treatment with is intracranial hemorrhage.
steroids, IVIG, and/or
other immuno-
suppressive agents.
Evans’ syndrome has Drug-Induced Immune Thrombocytopenia
been associated with
primary immune
Heparin-Induced Thrombocytopenia (HIT)—Occurs when IgG Fab binds to the
deficiencies such as
CVID or ALPS. complex between heparin and platelet factor 4. The IgG Fc binds to platelet FcIIa,
triggering platelet activation and consumption. Five percent of patients treated
with unfractionated heparin for 5–14 days are affected, and they present with
thrombocytopenia and/or thrombosis. Lower incidence with low-molecular-
weight heparin, but crossreactivity is possible.
Mnemonic Quinine-Induced—Thrombocytopenia occurs when IgG Fab binds to drug-

Clinical features of TTP: dependent antigens localized to glycoproteins IIb/IIIa and Ib/IX on platelets.
FAT RN
A1-
Posttransfusion Purpura—Occurs 7–10 days after RBC transfusion. P1
Fever women develop antibodies to transfused P1A1+ cells.
Anemia,
microangiopathic
hemolytic Thrombotic Thrombocytopenic Purpura (TTP)—Involves an autoantibody
Thrombocytopenia against von Willebrand factor-cleaving protease (ADAMTS13).
Renal failure
Neurologic changes
Autoantibodies Versus Clotting Factors
Lupus Anticoagulant or Antiphospholipid Antibody—Can be primary

(antiphospholipid syndrome (APS) or secondary to autoimmune diseases such as
SLE. In these cases, it is associated with a high risk of thrombosis (30–40%) and
recurrent, spontaneous abortions. The lupus anticoagulant is an IgG or IgM
antibody that binds to anionic phospholipids that have formed complexes with
proteins, leading to prolongation of the activated partial thromboplastin time
(aPTT).
Factor VIII Antibodies—Inhibitory IgG antibody to factor VIII are found in 15–
35% of severe hemophilia patients and can prevent hemostasis, leading to major
bleeding complications. Why some patients develop inhibitors is poorly
understood. Immune tolerance can be achieved in approximately 70% of patients
who receive regular and prolonged infusions of fVIII with or without immune
modulation.
CYSTIC FIBROSIS
Epidemiology
Table 8-52 lists the incidence of cystic fibrosis (CS) across some US ethnic
groups.
Genetics
Develops from a mutation in cystic fibrosis transmembrane conductance
regulator (CFTR), an apical membrane-bound protein; there may be complete or
partial loss of CFTR protein. Phenylalanine 508 (ΔF508) is absent from CFTR in
73% of patients. The end result is a decrease in chloride transport and thickening
of all secretions; partial CFTR mutations exhibit milder disease.
Clinical Features
Sinuses—Chronic sinusitis: bilateral, can be associated with hypoplasia of
frontal and sphenoid sinuses. Flash Card Q50
Pathogens include Pseudomonas aeruginosa, Staphylococcus aureus, Name three
Haemophilus influenzae, and anaerobes. autoantibodies
associated with SLE.
Allergic fungal sinusitis: Most commonly Aspergillus, Curvularia sp.
Nasal polyps: Incidence up to 48% of children with CF (compared with 0.1%
in healthy children).
Flash Card Q51

Table 8-52. Incidences of Cystic Fibrosis in Whites, African-Americans, What are two treatment
and Native Americans options besides
Whites African Native desmopressin or
Americans Americans aminocaproic acid for a
Incidence 1/2000 1/17,000 1/80,000
hemophilia patient with
factor VIII antibody who
Median survival is 32 years in all groups does not respond to
factor VIII replacement?
406 / CHAPTER 8
Pulmonary
Recurrent pneumonias: Particularly P. aeruginosa, S. aureus pathogens.
Allergic bronchopulmonary aspergillosis (ABPA): Up to 15% prevalence in
CF patients. Pathogens include Aspergillus fumigatus, A. flavus, Candida,
Penicillium, Curvularia.
Diagnostic criteria for ABPA in CF include the following:

Acute or subacute clinical deterioration
Total serum IgE > 2400 ng/mL (or >1000 IU/mL)
Skin test reactivity or specific IgE for A. fumigatus
Precipitating or IgG antibodies to A. fumigatus
New infiltrates on chest radiograph or CT findings (bronchiectasis)
Bronchiectasis
Gastrointestinal
Failure to thrive
Flash Card A50 Malabsorption
anti-dsDNA—specific for Diarrhea
SLE; associated with Meconium ileus
glomerulonephritis; may
fall to normal when Small-bowel obstruction
disease is quiescent Focal biliary cirrhosis
anti-Smith (anti-Sm)— Pancreatic exocrine insufficiency
high specificity, remains Pancreatitis
high in remission
anti-U1 RNP—common Reproductive—Obstructive azoospermia.
in all mixed connective
tissue disorders; low Skin—Dehydration due to excessive salt loss.
specificity
Musculoskeletal—Reduced bone mineral content, digital clubbing, and
hypertrophic osteoarthropathy.
Flash Card A51
Renal—Nephrolithiasis and nephrocalcinosis.
Recombinant activated
factor VII (rfVIIa;
Novoseven) is produced
using baby hamster Diagnosis
kidney (BHK) cells
expressing the cloned
The diagnosis of CF requires symptoms consistent with CF in at least one organ
human factor VII gene
and facilitates (or positive newborn screen) and evidence of CFTR dysfunction (via elevated
hemostasis by activating sweat chloride, presence of two mutations in CFTR, or abnormal nasal potential
factor X directly on the difference).
platelet surface. FEIBA
VH is a plasma-derived Laboratory Tests
vapor-heated
concentrate of vitamin Newborn screening program: Measures immunoreactive trypsinogen, which
K-dependent clotting can be falsely positive
factors (factors II, VII, Sweat chloride test
IX, X)
o Normal: <40 mEq/L

o Borderline: 40–60 mEq/L (repeat)
o Elevated: >60 Eq/L (Note: Diagnostic in children)
o Sometimes false-negatives, if patient presents with edema or
hypoproteinemia; false-positives if there is malnutrition and eczema
Molecular diagnosis: CFTR gene mutation
Nasal potential difference measurement
Treatment
Sinuses—Functional endoscopic sinus surgery (FESS), if severe sinusitis and/or
nasal polyps or before lung transplant.
Pulmonary
Chest physiotherapy
Physical training
Recombinant human deoxyribonuclease (dornase alfa-inhaled): Reduces
sputum viscosity and need for antibiotics
Nebulized hypertonic saline: Improves mucociliary clearance
Antibiotics for pneumonia:
o Inpatient: Combination of β-lactam and aminoglycoside given IV
o Outpatient: Oral quinolones
o Prophylactic nebulized tobramycin to reduce colonization with P.
aeruginosa
Oxygen therapy, if advanced disease
Lung transplant: Double-lung or heart-lung transplantation; 2-year survival
rate at 50–60%.
Gastrointestinal
Supplemental pancreatic enzymes
Fat-soluble vitamins
High-calorie diet and/or tube feedings
Flash Card Q52

REPRODUCTION AND THE IMMUNE SYSTEM
Nasal polyps associated
with CF are distinct from
nasal polyps associated
Fertilization with asthma due to
increased numbers of
which of the following?
Achieved following successful fusion of gametes that forms embryo. Despite A. Mast cells
repetitive exposure to “foreign” spermatozoa, the majority of women do not B. Monocytes
mount an immune response to sperm antigen. C. Eosinophils
D. Neutrophils
408 / CHAPTER 8
Pregnancy
Women develop a tolerance to fetal tissue expressing maternal (self) and paternal
(nonself) genes. An immunologically safe environment is created by diminishing
adaptive immune responses while preserving innate immunity.
Placental and Extraplacental Membranes

Fetal Trophoblast Cells—Cells that surround the embryo throughout pregnancy;
Key Fact they seclude and protect it from the maternal immune system.
Placental and fetal
membranes are directly Placental Membranes—Protect themselves from maternal immune cell attack
exposed to maternal through various mechanisms, including unique expression of HLA molecules that
blood and tissues. are thought to interact with LIRs (leukocyte inhibitory receptors) on NK cells
(Table 8-53).
Immune System and the Pregnant Uterus

Lymphocyte Populations—T and B lymphocytes decrease in the pregnant
uterus, whereas the number of maternal NK cells and macrophages increases.
Uterine macrophages help prevent uterine infections in pregnant women, and
uterine NK cells (u-NK) have a higher CD56 expression than peripheral NK cells
and are critical in remodeling spiral arteries for normal placentation. The presence
of γ/Δ T lymphocytes and double-negative T lymphocytes is also seen, but their
roles are unclear.
Table 8-53. Placental Membrane-Specific Protective Mechanisms

Immune Molecule Altered Expression
HLA molecules Class I Absence of HLA-A and HLA-B class Ia
Flash Card A52 antigens
Predominate expression of HLA class Ib
D. Neutrophils. Among molecules (HLA-E, HLA-F, and HLA-G)
inflammatory cells,
EG2+ (activated) Class II Repressed expression of MHC class II genes
eosinophils are a that encode paternally derived foreign MHC
prominent and Soluble Synthesis of immunosuppressive molecules
characteristic feature in immunomodulators and anti-inflammatory cytokines (e.g.,
about 80% of polyps prostaglandin E2, IL-10, and IL-4)
with asthma and allergic
inflammation, whereas Complement proteins Increased expression of complement
lymphocytes and regulatory proteins (CD46 and DAF)
neutrophils are the that prevent activation of complement
predominant cells in CF by maternal antipaternal antibodies
and in primary ciliary Abbreviations: DAF, decay-accelerating factor; HLA, human leukocyte antigen; MHC, major
dyskinesia. histocompatibility class.
Soluble Agents—Induction of progesterone, prostaglandins, and cytokines is Key Fact

seen in the pregnant uterus. Progesterone alters the Th1/Th2 balance and inhibits
Maternal IgG is transferred
production of TNFα in macrophages. PGE2 contributes to poor lymphocyte transplacentally to the
proliferation, and the production of Th2-type cytokines drives antibody-mediated fetus during the third
responses in preference to cell-mediated immune responses. trimester. Full-term infants
often have IgG levels equal
or greater to maternal IgG
level. After birth, levels of
Neonatal Immunity maternally derived IgG
rapidly decline, reaching a
Humoral Immunity—Consists of maternally produced IgG antibodies that are nadir of approximately 400
transported across the placenta into fetal circulation, as well as of maternal IgA mg/dL at 3–6 months. At
the same time, the infant's
and IgG antibodies in breast milk transported across the neonatal intestinal own production of IgG is
epithelium after ingestion. not fully developed. This
sequence of events
Cell-Mediated Immunity (CMI)—Neonates have both qualitative and quantitative represents normal
differences in CMI compared with adults. In general, they have lower numbers of “physiologic” hypogamma-
globulinemia.
antigen-specific T-lymphocyte precursor and T-lymphocyte subsets as well as a
decreased cytokine response to mitogen exposure. Key Fact
Adults can also express
FcRn, which functions to
Maternal Immune Response protect IgG antibodies
from catabolism; this
Humoral Immunity—B-lymphocyte immunity is maintained and explains the long half-life
immunoglobulin levels are unchanged throughout pregnancy. of this class of antibody in
the serum.
Regulatory T Cells—Enhanced tolerance has been seen in pregnancy due to
Key Fact
increased numbers of IL-10-producing Treg cells, which are made in response to
the exposure of fetal cells expressing paternal antigens. There is little to no
depression of the maternal
immune response during
pregnancy.
Infertility and Spontaneous Abortions
Key Fact
Antisperm Antibodies—Can occur in males following disruption of blood-testis
Between 1–12% of
barrier (e.g., trauma) and in women following oral-genital intercourse, and, more
fertile women make
rarely, through vaginal inoculation. Infertility secondary to this can be treated antisperm antibodies.
with intrauterine insemination, steroid treatments, or in vitro fertilization (IVF).
Flash Card Q53
Allergic reactions to homologous proteins in seminal plasma (HSP) are seen
exclusively in women and present as systemic or localized vaginal reactions Which neonatal receptor
allows the transfer of
during or following vaginal sexual intercourse. Condom use can prevent reactions. maternal IgG across the
Skin testing to HSP can be performed once the partner has been evaluated for placenta and neonatal
infectious disease. Desensitization through vaginal or subcutaneous intestinal epithelium?
immunotherapy has been successful.
Flash Card Q54
Autoimmune Disease of Testis or Ovaries—A known cause of infertility that
What treatment options
can be due to ovarian antibodies that cause premature ovarian failure, or by
are available for pregnant
women with APS?
410 / CHAPTER 8
autoimmune orchitis and oophoritis as components of human polyendocrine

autoimmune syndromes.
Antiphospholipid Syndrome (APS)—Characterized by:

Recurrent pregnancy losses
Prolonged bleeding times
History of hypercoagulability
False-positive Venereal Disease Research Laboratory (VDRL) test
Diagnosis: The previous symptoms in a patient with laboratory evidence of

antiphospholipid antibodies (aPL) is necessary for diagnosis. aPL are directed
Key Fact
against serum proteins bound to anionic phospholipids and may be detected as:
Two percent of women IgG or IgM antibodies to anticardiolipin (aCL), anti-ß2-glycoprotein I (anti-
test positive for aPL; β2GPI) or lupus anticoagulant (LA) testing (↑aPTT, ↑ dilute Russell viper venom
however, this is not
clinically significant in time (dRVVT)). The antibodies interfere with the synthesis of prostaglandins and
women with no history prostacyclins that predispose a woman to placental insufficiency and pregnancy
of recurrent pregnancy loss. Confirmatory aPL testing after at least 12 weeks from initial testing to
losses. confirm persistence of the aCL, anti-β2GPI, or LA test is required to satisfy
laboratory criteria for APS.
IMMUNOLOGIC ASPECTS OF INFECTIOUS

DISEASES
LYME DISEASE
Lyme disease is the most common vector-borne disease in the United States and
Flash Card A53
may be classified into acute localized, acute disseminated, and late disease.
The FcRn receptor is an Laboratory testing is usually performed in patients with confusing presentations.
IgG-specific receptor, Cultivation of Borrelia burgdorferi is definitive, but 2–8 weeks is required to
resembling a class I
MHC molecule, which
grow the organism and it is not available in many clinical laboratories. Therefore,
allows transfer of serologic tests are important to validate the presence of B. burgdorferi.
maternal IgG across the
placenta and neonatal
intestinal epithelium.
Serologic Testing
In asymptomatic patients and patients with nonpecific symptoms, serologic

screening (ELISA or immunofluorescence assay [IFA]) is not useful because of
Flash Card A54
low-positive and low-negative predictive values, which are not helpful in guiding
Low-dose aspirin, therapy. In endemic regions, erythema migrans (with or without a history of tick
unfractionated heparin,
bite) is sufficient to treat empirically without laboratory confirmation. In
or low-molecular-weight
heparin (LMWH) symptomatic patients, a two-tier serologic diagnosis is commonly utilized; ELISA
or IFA is initially performed to support the diagnosis. In patients with an

indeterminate or positive ELISA or IFA, a Western blot is performed on the same
serum to look for IgM and IgG in early disease and IgG in late disease. If ELISA
or IFA are negative, no further work-up is indicated.
Within 1–2 weeks of onset of infection, IgM antibodies to B. burgdorferi appear,

and in 4–6 weeks, IgG antibodies are present. Seroreactivity, however, may
persist for months after antibiotic treatment of early infection and for years after
treatment of late infection.
The variable major protein-like sequence-expressed (VlsE) sixth invariant

region (C6) peptide ELISA, a one-step test that measures IgG, has been shown to
be as sensitive and nearly as specific as two-tier serologic testing for the diagnosis
of Lyme disease.
Polymerase Chain Reaction (PCR)

PCR may be used to identify B. burgdorferi DNA in CSF and synovial fluid, but
it has many limitations; it has low sensitivity, false-positive results are common,
and the test does not differentiate between active infection and the presence of
remnant DNA.
IgM Capture Assay

During the initial phase of localized disease, serologic tests may be negative
because specific serum antibodies to B. burgdorferi may be trapped in immune
complexes that render them undetectable by standard assays. An IgM capture
assay (EMIBA), which measures immune complex-derived IgM antibodies, is a
promising new assay for serologic confirmation of early and active Lyme disease;
however, this technique needs to be standardized.
T-Lymphocyte Assays
T-lymphocyte proliferative responses to borrelial antigens have been detected in
blood, synovial, fluid, and CSF samples; however, the test remains difficult to
perform and interpret, thus it is not recommended. Although, detection of B-
lymphocyte chemokine chemoattractant (CXCL13) in CSF as a marker for Lyme
neuroborreliosis appears promising, it requires validation and standardization
before it is recommended as a diagnostic technique.
412 / CHAPTER 8
TUBERCULOSIS
The innate and adaptive arms of the immune system are known to work in concert
to prevent tuberculosis (TB) infection.
Innate Immunity
Upon entry into the body, the bacilli (Mycobacterium tuberculosis) are
phagocytosed by macrophages and neutrophils; however, the organism has
evolved mechanisms to evade intracellular killing. These mechanisms include
resistance to reactive oxygen species (ROS), inhibition of phagosome-lysosome
fusion, and inhibition of phagosome acidification. The mechanisms that lead to
mycobacterial resistance to ROS include:
Scavenging of oxygen intermediates by lipoarabinomannan (LAM)
Reactive oxygen intermediates not being stimulated in macrophages when the
bacilli are phagocytosed via complement receptors, CR1 and CR3
Cyclopropanated mycolic acids in bacterial cell walls, which assist in resisting
the actions of hydrogen peroxide
The bacilli prevent acidification by selectively excluding the proton ATPase from
the phagosome.
Adaptive Immunity
Humoral immunity has not been conclusively proven to provide defense from M.
tuberculosis, where cell-mediated immune responses play a more critical role.
CD4+ and CD8+ T lymphocytes have been shown to play a protective role. CD4+
T lymphocytes produce IFNγ, which activates macrophages. This plays an
important role in preventing infection during the early phase of M. tuberculosis
infection. The mycobacterial killing by CD8+ T lymphocytes and NK cells has
also been reported and is caused by granulysin, a protein present in the granules
of human CTLs and NK cells.
Interferon gamma release assay (IGRA) T lymphocytes that specifically recognize

mycobacterial antigens appear within 2–6 weeks of infection, around the same
time that the tuberculin skin test (TST) becomes positive. IGRAs may detect the
presence of TB. This is an ELISA-based assay that measures the amount of IFNγ
released from T lymphocytes when they are stimulated by tuberculin antigens,
such as early secretory antigenic target 6 (ESAT-6) and culture filtrate protein
(CFP-10). These antigens are absent in the vaccine strain bacille Calmette-Guérin
(BCG) and in Mycobacterium bovis. Peripheral blood samples for this testing
must be processed within 12 hours to ensure the viability of the leukocytes. Such
IGRAs, unlike the TST, are not affected by prior BCG vaccination and, thus, do
not give false-positive results. This test may also be useful for those who receive
serial examination for TB, such as health care workers. However, the assay has
limited data in certain populations such as those younger than 17 years of age,
persons recently exposed to TB, immunocompromised populations, and those
with other disorders (e.g., diabetes and chronic renal failure).
Natural human immunity to the mycobacteria group, including Mycobacterium
tuberculosis, BCG (and/or Salmonella sp.), relies on the functional IL-12/23-IFNγ
integrity of macrophages (monocyte/dendritic cell) connecting to T-
lymphocyte/NK cells.
Increased mycobacterial infections are a characteristic of these primary immune
deficiencies:
IL-12p40, IL-12R-β1, and IL-23 β chain receptor deficiencies
IFNγR1, IFNγR2 receptor deficiency
STAT-1 deficiency
CYBB mutation
AR-Hyper IgE (TYK 2 deficiency)
NEMO mutations (which impair CD40-dependent IL-12 production)
Interferon regulatory factor 8 (IRF8)
Granuloma Formation
Granuloma formation plays an important role in controlling infection, and TNFα
plays an essential role in the formation of a granuloma. The reactivation of latent
TB in individuals treated with anti-TNFα antibody (e.g., infliximab) and TNFα
receptor antibody (e.g., etanercept) provides evidence that TNFα plays a role in
controlling mycobacterial infection.
LEPROSY
Leprosy Classification
The World Health Organization (WHO) has based its classification of leprosy on
the number of skin lesions and smears of skin lesions (Table 8-54). Skin smears
were originally used to distinguish between paucibacillary (PB) and
multibacillary (MB) leprosy. However, skin smears are not always available, and
their reliability is often doubtful, so most leprosy programs classify and choose
the appropriate regimen for a particular patient using clinical criteria. In between
the two ends of the spectrum of M. leprae infection, PB and MB, exist borderline
diseases such as borderline tuberculoid (BT), midborderline (BB), and borderline
lepromatous (BL), which are often referred to as “unstable diseases.”
414 / CHAPTER 8
Table 8-54. Leprosy Classification—World Health Organization

Number of Skin Lesions/
Classification Treatment (Adult)
Nerves Involved
Paucibacillary single-lesion 1 One-time dose:
leprosy Rifampicin 600 mg +
Ofloxacin 400 mg +
Minocycline 100 mg
Paucibacillary leprosy (PB) 2-5 12-month treatment regimen:

Dapsone 100 mg/day
Rifampicin 600 mg q month
Multibacillary leprosy (MB) >5 12-month treatment regimen:

Dapsone 100 mg/day
Rifampicin 600 mg/month
Clofazimine 50mg/day and
300 mg/month
Children: Age 5–14 years of age receive adjusted doses of treatment regimen.
Genetics and Leprosy

Familial clustering and high concordance rates in identical twins support the role
of genetic predisposition. PB is often linked to HLA-DR3, and MB is associated
with HLA-DQ1. Studies have shown that the NRAMP1 gene is a leprosy
susceptibility locus. (Murine homologue Nramp1 controls innate resistance to
Mycobacterium lepraemurium.)
Immunologic Reactions
Type I, or Reversal Reaction—Borderline leprosy cases may be
immunologically unstable; the disease may shift from BT to BL without treatment
and may oscillate from BL back to BT with treatment. The reversal of the disease
toward BT with treatment may result in a delayed-type hypersensitivity reaction,
the reversal, or type 1, reaction. This reaction leads to additional motor and
sensory loss, along with erythema and edema of preexisting skin lesions. The type
I reaction is commonly associated with neuritis and, occasionally, with skin
ulceration.
Type II, or Erythema Nodosum Leprosum (ENL)—Type II, or ENL, an

immune complex disorder, may occur during treatment of MB or BT; it may also
occur before or after completion of therapy. The disorder is characterized by fever
and erythematous tender nodules; and, it may be associated with:
Neuritis
Edema
Arthralgias
Leukocytosis
Iridocyclitis
Pretibial periostitis
Orchitis
Nephritis
TNFα may contribute to the pathogenesis.
Alterations in immune responses have been shown to occur during pregnancy.

Women with leprosy who get pregnant are more prone to develop type I and type
II reactions, and a relapse of their disease. A type II reaction may occur during
pregnancy, especially during the third trimester; type I reactions are known to
occur during puerperium.
It is commonly reported that treatment of rheumatologic diseases with TNF

antagonists may lead to TB. Though uncommon, it has been documented in case
reports that leprosy may develop during treatment with infliximab, a chimeric
IgG1 monoclonal antibody to TNF; in these reports, discontinuation of infliximab
resulted in type 1 reactions.
HEPATITIS
Hepatitis A Virus (HAV)

HAV infection is usually subclinical in children, and infection in adults may
varies from a mild flu-like illness to fulminant hepatitis.
The typical clinical presentation of HAV infection may be confirmed by detection

of serum anti-HAV antibodies. Serum IgM HAV antibodies are usually detected
at the onset of symptoms and remain positive for 4–6 months after exposure. The
antibodies may persist for 12–14 months in individuals with a relapsing or
protracted disease course. Serum IgG HAV antibodies may be detected in early
convalescence and may remain positive for decades. The HAV and HAV RNA
may also be detected to confirm the diagnosis, but serologic detection of
antibodies is simple and easier.
Hepatitis B Virus (HBV)

Surface Antigen and Antibody—Radioimmunoassay (RIA) and enzyme-linked
immunoassay (EIA) are generally used to detect serum hepatitis B surface antigen
(HBsAg), the serologic hallmark of an HBV infection. It may be detected 1–10
weeks after exposure. In the subset, those who recover from infection, HBsAg is
usually undetectable in 4–6 months. Detection of HBsAg after 6 months usually
denotes chronic infection. HBsAg usually disappears over time and is followed by
416 / CHAPTER 8
the appearance of hepatitis B surface antibody (HBsAb), which persists for life in
most patients. In a subset, for a short time (“the window period”), neither the
surface antigen nor antibody may be detectable; during this period, serologic
diagnosis is made by detecting IgM antibodies against the hepatitis B core antigen
(HBcAg). A small number of individuals may have detectable HBsAg and
HBsAb at the same time and are termed “carriers” of the hepatitis B virus.
Core Antigen and Antibody—HBcAg is an intracellular protein, which is

expressed in infected hepatocytes and is undetectable in serum. The detection of
IgM HBcAb suggests an acute HBV infection. In a small number of cases,
HBcAb may remain detectable for up to 2 years following an acute infection. It
may also be detected during acute exacerbations of chronic hepatitis B infection.
In those who recover from the acute infection, IgG anti-HBcAb and anti-HBsAb
anti-HBs may be detected; individuals with chronic HBV infection usually have
detectable HBsAg and IgG HBcAb. The isolated detection of HBcAb may occur
during the “window period,” or after many years of recovery from an acute HBV
infection, or after many years of ongoing chronic HBV infection.
E Antigen and Antibody—The presence of serum HBeAg HeAg usually denotes

active liver disease and ongoing HBV replication. It is associated with high levels
of serum HBV DNA and signifies increased infectivity. In most, the
seroconversion from HBeAg to anti-HBeAb is usually associated with remission
of active liver disease and a decrease in serum HBV DNA.
Acute, Past, and Chronic HBV Infection, Carrier, and

Vaccination
Acute HBV Infection—HBsAg and IgM HBcAB are usually detected in serum.
HBeAg and HBV DNA, the markers of active HBV replication, are present.
Recovery is accompanied by disappearance of HBV DNA, HBeAg to HBeAb
seroconversion, and, finally, HBsAg to HBsA seroconversion.
Past HBV Infection—Serologic diagnosis may be made by detection of HBsAb

and IgG HBcAb.
Chronic HBV Infection—Detection of HBsAg after 6 months of an acute

infection denotes chronic HBV infection. All patients with chronic HBV must be
monitored closely for progression of liver disease with HBV DNA titers and ALT
levels.
Undetectable HBeAg with normal serum ALT levels and low or undetectable
HBV DNA titers denote an inactive HBV carrier. Vaccination is evidenced by the
presence of HBsAb only.
Table 8-55 offers a summary of the spectrum of antigen and antibodies in HBV
infection.
Table 8-55. Spectrum of Antigen and Antibodies in Acute and Chronic

Hepatitis B Virus (HBV) Infection and in a Vaccinated Individual
HBsAg HBeAg IgM IgG HBsAb HBeAb HBV
HBcAb HBcAb DNA
Acute infection
Early period + + + ++
Window period
+ +
Recovery
+ + + ±
period
Chronic infection
Early replicative
+ + + +++
period
Nonreplicative
+ + + ±
period
Acute
+ ± + + +
exacerbation
Vaccinated
+
individual
Hepatitis C (HCV)
Diagnostic tests for HCV infection may be serologic assays, which detect
antibody to HCV, and molecular assays, which detect or quantify HCV RNA.
Testing for HCV infection must be routinely undertaken in individuals who have:
History of illicit injection drug use
Received clotting factors that were manufactured prior to 1987
Received blood/organ transplant before July 1992
Received chronic hemodialysis
HIV infection
Children born to mothers with HCV
The commonly used screening assay for HCV infection utilizes a second-
generation EIA that detects antibodies to recombinant antigens from the core
(C22) and nonstructural regions 3 (C33), and 4 (C100) of HCV. A third-
generation EIA, which detects antibodies to an additional antigen from the
nonstructural region (NS5), is being used in some institutions.
Molecular Testing and HCV Genotyping

Molecular-testing methods consist of nucleic acid tests (NAT), which detect HCV
RNA and may be divided into qualitative and quantitative assays.
418 / CHAPTER 8
Qualitative Assays—Must have a lower limit of detection of less than 50 IU/mL

of HCV RNA. They provide confirmation of HCV infection and may be used to
evaluate sustained virologic responses (SVR) in patients undergoing antiviral
therapy.
Quantitative Assays—Consist of real-time PCR-based methods. Pretreatment

quantitative assays are utilized to measure baseline HCV viral load; and, during
therapy, to evaluate for early virologic response (EVR). EVR is defined as ≥ a 2-
log decline in HCV RNA from baseline to week 12 of treatment. If the patient
does not achieve EVR, it most likely represents failure of therapy and treatment is
stopped. Rapid virologic response (RVR), which is defined as an undetectable
HCV RNA by week 4 of treatment is predictive of SVR. Genotyping is essential
prior to therapy since duration of therapy and dose of ribavarin is dictated by the
HCV genotype. The commonly used method of genotyping is the line probe assay.
SYPHILIS
Testing for syphilis (Treponema pallidum infection) is usually performed when

the disease is suspected clinically, for screening in a high-risk population, and
routinely during antenatal visits. Laboratory diagnosis of syphilis may be done by
the commonly used serologic methods, or by direct visualization techniques,
which are less commonly used.
Serologic Tests
These test commonly involve an initial nonspecific nontreponemal antibody test
for primary screening, which is followed by a more specific treponemal test for
diagnostic confirmation. A clinical suspicion with positive serology provides
presumptive diagnosis. Direct visualization techniques via darkfield microscopy
and direct fluorescent antibody (DFA) provide definitive diagnosis.
Nontreponemal tests evaluate the reactivity of the patient’s serum to a cardiolipin-

cholesterol-lecithin antigen. Nontreponemal tests include the Venereal Disease
Research Laboratory (VDRL), rapid plasma reagin (RPR), and toluidine red
unheated serum test (TRUST). These tests are semiquantitative and reported as a
titer. For example a result of 1:40 indicates the most dilute serum at which the
antibody was detectable. A reactive nontreponemal test must be confirmed by a
treponemal test, which includes:
The fluorescent treponemal antibody absorption (FTA-ABS)
Microhemagglutination test for antibodies to T. pallidum (MHA-TP)
Treponema pallidum particle agglutination assay (TP-PA)
Treponema pallidum enzyme immunoassay (TP-EIA), which is most favored
These tests are based on the detection of antibodies directed against specific
treponemal antigens and are qualitative (i.e., reported as positive or negative).
Interpretation of Serologic Tests

A reactive nontreponemal and treponemal test denotes active syphilis infection,
unless the patient has a history of prior treatment for syphilis. An asymptomatic
person with reactive nontreponemal and treponemal tests denotes "latent" syphilis.
Diagnosis of a new infection in a patient treated in the past for syphilis infection
is made by quantitative testing on a RPR test, which reveals a fourfold or greater
increase in antibody titer than that present during the past treated infection.
False-positive nontreponemal tests may occur during:

Pregnancy
Intravenous drug use
Tuberculosis and rickettsial infection
Nonsyphilis treponemal infection
Endocarditis
HIV infection
False-negative tests are usually encountered in two situations: (1) when the test is
performed prior to the formation of antibodies to syphilis or (2) due to a prozone
reaction. The latter instance is seen in situations such as secondary syphilis or
HIV coinfection, when very high antibody titers (antibody excess) are present that
interfere with the formation and thus visualization of antigen-antibody complexes.
If this situation is suspected, further dilutions of the sample should be done, which
allows for the zone of equivalence to be reached.
Flash Card Q55

What are the key clinical
symptoms of a patient
with primary, secondary,
tertiary syphilis?
420 / CHAPTER 8
Flash Card A55

Primary: Small painless
chancre (ulcer) on
genitals, mouth, skin or
rectum which resolves in
3–6 weeks.
Secondary: Skin rash on
palms and soles,
condylomata lata (moist
warty patches) in
genitals or skin folds.
Other symptoms, such
as fever, general ill
feeling, loss of appetite,
muscle aches, joint pain,
enlarged lymph nodes,
vision changes, and hair
loss may occur.
Tertiary: Symptoms vary
widely depending on
organ system involved.
May include
cardiovascular syphilis
(aortic aneurysm or
valve disease),
neurosyphilis, or tumors
of skin, bones or liver
(gumma).
Pharmacology and
9 Therapeutics
ALLERGEN AVOIDANCE
Outdoor Allergens
Grass, tree, and weed pollens are difficult to avoid during pollen season. Some
recommendations for avoiding outdoor pollen include the following:
Avoid outdoor activities in early morning (pollination peaks from 5–10 AM.).
Stay indoors during humid and/or windy days.
Do not mow grass (grass or mold) or rake leaves (mold).
Do not hang sheets or clothing outside to dry.
Wear protective masks.
Indoor Allergens
Dust Mite (Der p1, Der f1)—Highest exposure to dust mites (Dermatophagoides
spp.) occurs in the bedroom (i.e., mattresses, stuffed animals, carpeting). Higher
contamination is found in areas with high humidity (≥ 55%) and low altitude. A
significant decrease in allergen levels of less than 6 months improves bronchial
hyper-responsiveness and symptoms of atopic dermatitis.
Methods of avoidance:
Impermeable covers (i.e., pore size ≤ 10 μm) for mattress, pillows, and box
springs
Weekly washing of bed and pillow coverings in hot water (54.4°C, or 130°F),
and dry bedding on high heat
Remove stuffed animals or periodically place them in plastic bags in the
freezer overnight
Remove carpet removal and replace with hard flooring
o Alternative is benzyl benzoate or tannic acid applied to carpet
(temporary) Flash Card Q1
o Vacuuming weekly using high-efficiency particulate air (HEPA) filter
Which type of allergen is
or double-thickness bag
most likely to be found
Remove upholstered furniture or change to vinyl or leather in undisturbed air in
Decrease indoor humidity levels to less than 50% (unproven) homes?
422 / CHAPTER 9
Cat (Fel d 1) and Dog (Can f 1) Allergens—Generally, removal of pet from

home followed by thoroughly vacuuming, cleaning, and/or washing all surfaces is
best.
Alternatives to elimination (all unproven):
Restrict pet from bedroom
Use allergen-proof bed covers
Use HEPA filter
Wash animal at least twice weekly
Remove carpet from bedroom and remove upholstered furniture
For cats, higher Fel d1 in males of the species; allergen remains for up to 4–
6 months after cat removal
Other pets known to cause symptoms include:

Rodents (rats, mice, guinea pigs, gerbils and/or hamsters, and rabbits)
Rats and/or mice can be problems for laboratory workers and in the inner city
Birds and other exotic pets
Cockroach (Bla g 1-4, Per a 1)—Methods of avoidance:

Poison baits with hydramethylnon or boric acid (avoid organophosphates),
with second application in 1–2 weeks
Comprehensive housecleaning, focusing on countertops or surfaces and
carpeting
Eliminating food sources in kitchen and/or dining areas
Sealing access points to the house
Takes 6 months for 80–90% reduction
Insecticides and HEPA filters generally ineffective
Fungal Proteins (Various)—Generally, damp environments carry more mold

and bacteria, but there is no clear relationship of indoor spore counts to
symptoms.
Methods of avoidance:
Eliminate excess moisture (e.g., water leaks from plumbing, dishwashers,
and/or hot water heaters)
Limit relative humidity to less than or equal to 40%
Increase ventilation and/or exhaust fans
Replace carpet
Use HEPA filters
Flash Card A1 Table 9-1 provides an overview of common indoor allergens.
Cat, dog
PHARMACOLOGY AND THERAPEUTICS / 423
Table 9-1. Common Indoor Allergens

Allergenic Avoidance
Allergen Location Risk Factors
Protein Methods
Dust mite Der f 1 and Der p Carpet, bedding Humidity, older Impermeable
1 (mattress/pillow/ homes, single covers, hot-water
box springs), family dwelling washing of
and upholstery and absence of linens, and
AC carpet removal
Dog Can f 1 and Carpet and Depends on the Removal,
albumin bedding breed and/or impermeable
animal covers, HEPA
filter, and carpet
removal
Cat Fel d 1 Carpet and Depends on the Removal,
bedding breed and/or impermeable
animal covers, HEPA
filter, and carpet
removal
Cockroach Bla g 1-4 and Kitchen and Humidity and Extermination and
Per a 1 dining open food gel baits.
sources
Fungus Various Bathrooms and/or Humidity, water Eliminate water
kitchens, and damage, and source, roof
areas of water leaky plumbing inspection, and
damage carpet removal
Abbreviations: AC, air-conditioning; HEPA, high-efficiency particulate air.
IMMUNOTHERAPY
General Principles
Allergen immunotherapy (AIT) is an effective treatment for allergic

rhinitis/conjunctivitis, allergic asthma, atopic dermatitis, and stinging-insect
hypersensitivity. Patients selected for such therapy should demonstrate specific
IgE antibodies to relevant allergens to which they are allergic, either by skin
testing or appropriate in vitro tests. AIT is not for food, latex, or drug allergy and
is not usually prescribed for very young or elderly patients. Aeroallergen
immunotherapy can usually be stopped after 3–5 years of successful therapy; but,
with severe stinging-insect hypersensitivity, AIT may be used indefinitely.
Studies Demonstrating Efficacy of AIT
Efficacy has been demonstrated in double-blind placebo-controlled clinical

(DBPC) trials for allergic rhinitis and/or conjunctivitis, atopic dermatitis (AD)
424 / CHAPTER 9
and allergic asthma, in both adults and children; and, for allergy caused by
pollens, certain molds (Alternaria, Cladosporium), animal allergens (dog, cat),
dust mites, cockroaches. Efficacy has also been demonstrated in stinging-insect
hypersensitivity caused by Hymenoptera and imported fire ant. AIT has been
shown to reduce symptoms of allergic rhinoconjunctivitis AD and asthma, and
large meta-analyses have shown a decreased need for medication after AIT.
Regarding asthma, AIT also decreases bronchial responsiveness, but does not
affect pulmonary function results. It can prevent or delay the onset of asthma in
patients with allergic rhinitis. It is best to measure clinical outcomes to monitor
patient response to AIT; repeated in vivo or in vitro testing is unnecessary.
Potential Mechanisms and Immunologic Changes

Associated with Immunotherapy
Modified allergic response to allergens over time

Increase in IgG blocking antibody (initially IgG1, later IgG4)
Increased numbers of CD4+CD25+ regulatory T lymphocytes and % of CD8+
T cells
Initial increase (months), then a steady decrease (years) in allergen-specific
IgE
Blunted seasonal rise in allergen-specific IgE
Decrease in low-affinity FcεRI and FcεRII (CD23)
Increased IgA in respiratory secretions
Reduction in basophil hyper-reactivity
Increased interferon (IFN)-γ/interleukin (IL)-4 ratio and secretion of IL-10
and transforming growth factor (TGF)-β
Decreased number of eosinophils, basophils, and mast cells in nose/lung
Shift of Th2 cytokines (IL-4, IL-5, and IL-13) to Th1 cytokines (IFNγ, TGF ,
and IL-10)
Clinical Aspects of Allergen Immunotherapy
Selection of Allergens and Nomenclature—Selection of allergens for a

particular patient depends on the patient’s history, the local aerobiology in the
patient’s indoor and/or outdoor environment, and the patient’s serum-specific
IgE and/or skin tests results. The highest concentration of an extract, termed
maintenance vial, is represented by 1:1 vol/vol and labeled “red vial” (see Table
9-2 for further dilutions). The starting dose for build-up is usually a 1000– or
10,000-fold dilution of the maintenance concentrate.
Table 9-2. Nomenclature for Labeling Dilutions from the Maintenance

Concentrate
Dilution from Volume/Volume Weight/Volume
Vial Color
Maintenance Ratio Ratio
10,000-fold 1:10,000 1:1,000,000 Silver
1000-fold 1:1000 1:100,000 Green
100-fold 1:100 1:10,000 Blue
10-fold 1:10 1:1000 Yellow
Maintenance
1:1 1:100 Red
concentrate
Cross Reactivity—Selecting the most locally prevalent allergen from cross-

reacting families of allergens permits the addition of optimal doses of clinically
relevant allergens to a vaccine (Table 9-3).
Mixing of Allergens Containing Proteolytic Enzymes—Mold and cockroach

extracts contain proteolytic enzymes that degrade pollen, reducing IgE-
binding affinity. Therefore, these extracts should remain in separate vials; but,
they can be mixed. Dust mite (in 50% glycerin) is safe to mix with pollen, dog or
cat, cockroach, and mold extracts. Ragweed and cat extracts in 50% glycerin
resist degradation when mixed with high-protease extracts.
Table 9-3. Cross-Reactivity of Allergen Extracts

Weeds Grasses Trees
Ambrosia sp. Festuca sp. (meadow fescue, Cupressaceae family (juniper,
(short/giant/false/western timothy, rye, Kentucky blue, cedar, and cypress)
ragweed) orchard, and red top)
Artemisia sp. Betulaceae family (birch,
(sage/wormwood/mugwort) alder, hazel, and hornbeam)
Chenopod sp. (Russian Fagaceae sp. (oak, beech,
thistle/lambs quarter/burning and chestnut)
bush)
Amaranthus sp. (pigweed/red Oleaceae family (ash, olive,
root pigweed) and privet)
Flash Card Q2
Atriplex sp. Populus sp. (cottonwood,
(saltbush/wingscale) poplar, and aspen) Which allergen extracts
are standardized?
426 / CHAPTER 9
Venoms contain proteases that may degrade each other and, therefore, should be
separated. An exception are vespid venoms (hornets or yellow jackets), which can
be mixed.
Doses and Dosing Schedules—Effective maintenance doses for most
inhalant allergens are between 5-20 μg of the major allergen per 0.5 mL
maintenance dose. Effective doses in biologic allergy units (BAU) or arbitrary
units (AU) are 1000–4000, depending on the allergen. Table 9-4 includes
clinically effective maintenance doses for standardized aeroallergens, based on
efficacy studies.
Adverse Reactions
Local Reactions—Consist of redness and/or swelling (dime- to quarter-sized),

which may cause local discomfort. They do not appear to increase risk for
systemic reactions. Frequent large local reactions (i.e., larger in diameter than 25
mm) may increase risk for future systemic reaction.
Systemic Reactions—Risk in approximately 1/2000 injections; most reactions

begin within 30 minutes. There is a greater risk of fatal reactions in patients
taking blockers. Risk of fatal reaction is 1 in 2.5 million.
Table 9-4. Probable Effective Maintenance Doses for Allergen

Immunotherapy
Effective Biologic
Labeled Extract Effective Dose of
Allergen (BAU) Allergy
Potency Major Allergen
Units (AU)
Grass 10,000–100,000 15 μg of various 1000–4000 BAU
BAU/mL
Short ragweed 1:10–1:20 w/v; 6–12 μg 1000–4000 AU
100,000 AU/mL
Cat 5000–10,000 11–17μg 1000–4000 BAU
BAU/mL
Dog, 1:10–1:100 w/v 15 μg
nonstandardized
Dust mite (Der f1 and 3000, 5000, 10,000, 7–12 μg 500–2000 AU
Der p1) and 30,000 AU/mL
Other 1:10–1:40 w/v or Highest tolerated
nonstandardized 10,000–40,000 dose
extracts PNU/mL
Flash Card A2
Bermuda 10,000 BAU/mL 300–1500 BAU
Grass (i.e., northern
grasses and Bermuda),
ragweed, cat, dust mites
Greater risk of systemic reactions in the following:

Taking β-blocker medications may increase risk for more serious reactions
During “priming” of pollen season
During build-up phase
During accelerated or rushed protocols
First injection from new vials
Unstable asthma
Dosing error
History of previous systemic reaction
Contraindications
Relative contraindications to starting immunotherapy:

Pregnancy (OK to continue without increasing dose if patient becomes
pregnant after starting)
Serious immunodeficiency
Malignancy
Uncontrolled asthma
Significant cardiovascular disease
Children younger than age 5 years
Systemic mastocytosis
Sublingual Immunotherapy
Sublingual immunotherapy (SLIT) is currently undergoing clinical trials in US. It

has been used clinically in Europe for years with no fatalities; and, there is an
improved rate of systemic reactions versus in subcutaneous immunotherapy
(SCIT). SLIT is shown to be clinically effective in monotherapy with grass,
ragweed, birch, cat, Parietaria, and dust mite; however, is has less robust efficacy
than SCIT. Efficacy data in polysensitized individuals is lacking.
HISTAMINE ANTAGONISTS
Flash Card Q3
What is the probable
Histamine is formed by histidine decarboxylase (an enzyme expressed in cells effective dose in biologic
allergy units (BAU) for
throughout the body) acting on L-histidine. Histamine is released by mast cells
cat immunotherapy?
428 / CHAPTER 9
and basophils as a preformed mediator (typically, after cross-linkage of surface

IgE bound to FcεR1 in allergic individuals) along with other mediators (i.e.,
preformed: tryptase; newly generated: leukotrienes and prostaglandins). See Table
9-5 for different types of histamine receptors.
Table 9-5. Four Types of Histamine Receptors

H1 H2 H3 H4
Receptor Widespread: Widespread: Histaminergic Bone marrow and

expression Nerve cells, Same as H1 neurons peripheral
airway smooth except not on (presynaptic), hematopoietic
muscle, vascular macrophages eosinophils, cells, eosinophils,
smooth muscle, dendritic cells, neutrophils,
endothelial cells, and monocytes dendritic cells, T
epithelial cells, lymphocytes,
neutrophils, basophils, and
eosinophils, mast cells
monocytes,
macrophages,
dendritic cells, T
lymphocytes, B
lymphocytes,
hepatocytes, and
chondrocytes
General Increase pruritus, Increases gastric Increased pruritus Increased pruritus

function pain, acid secretion, and nasal and nasal
vasodilation, vascular congestion. congestion, and
vascular permeability, Prevent differentiation of
permeability, hypotension, excessive myeloblasts and
hypotension, flushing, bronchocon- promyelocytes
flushing, headache, striction
headache, tachycardia,
tachycardia, chronotropic and
bronchoconstricti inotropic activity,
on, airway vagal bronchodilation,
afferent nerve and airway
and cough mucus production
receptor
stimulation, and
decreased
atrioventricular
node conduction
time
Function in Sleep or wake, Neuroendocrine Decreased Not completely

central food intake, histamine, defined at this
nervous thermal dopamine, time
system regulation, serotonin,
memory, and norepinephrine,
learning and
acetylcholine
Flash Card A3 release
1000–4000 BAU
Antihistamines as Inverse Agonists
Histamine receptors are G protein-coupled, seven-helical, transmembrane mole-

cules with constitutive activity. Equilibrium exists between the active and inactive
states of the receptor. When histamine binds to its receptor, it stabilizes the
receptor in its active form; thus, shifting the equilibrium to the active state. By
contrast, when an H1-antihistamine binds to this receptor, it stabilizes the inactive
form of the receptor; thereby, shifting the equilibrium to the inactive state (Figure
9-1).
Antiallergic and Anti-Inflammatory Effects of H1-

Antihistamines
Antiallergic: Inhibit release of mast cell and basophil mediators (mediated

through inhibition of calcium ion channels). Pretreatment of an allergen
challenge with an oral H1-antihistamine reduces the early response in the nose,
conjunctiva, skin, and lower airways (fewer adhesion molecules, eosinophils,
neutrophils, cytokines, histamine, leukotrienes, and prostaglandins in lavage
fluid).
Anti-inflammatory: Inhibit expression of cell adhesion molecules and
eosinophil chemotaxis (via downregulation of nuclear factor-κB). The anti-
inflammatory effects are weak compared with those of corticosteroids.
Metabolism and Pharmacokinetics/Pharmacodynamics

First-generation antihistamines and some second-generation antihistamines are
metabolized in the liver by the cytochrome P450 system. (Be familiar with Table
9-6).Greater than 97% of histamine is metabolized by two major pathways before
excretion: (1) histamine N-methyltransferase and (2) diamine oxidase.
Figure 9-1. Histamine receptor.

430 / CHAPTER 9
Table 9-6. Antihistamines in Adults

Onset of Action
Conditions That
Based on Wheal- Half-Life (t ½, in
May Require
and-Flare Hr)
Dose Adjustment
Studies(n Hr)
First-generation antihistamines
Chlorpheniramine 3 27.9 ± 8.7
Diphenhydramine 2 9.2 ±2.5 Hepatic impairment
Doxepin 13 Hepatic impairment
Hydroxyzine 2 20 ± 4.1 Hepatic impairment
Second-generation antihistamines
Cetirizine (a 1 6.5–10 Renal and hepatic
metabolite of impairment
hydroxyzine)
cleared through
urine
Desloratadine 2 27 Renal and hepatic
(metabolite of impairment
loratadine)
Fexofenadine 2 14.4 Renal impairment
*cleared through
feces.
Levocetirizine 1 7 + 1.5 Renal and hepatic
(enantiomer of impairment
cetirizine)
Loratadine 2 7.8 + 4.2 Hepatic impairment
Topical antihistamines
Azelastine 0.5 22–27.6
Emedastine 0.25 7
Epinastine 0.1 6.5
N/A
Ketotifen 0.25 20–22
Levocabastine 0.25 35–40
Olopatadine 0.25 7.1–9.4
Adverse Effects
Central Nervous System—First-generation H1-antihistamines block histamine’s

effects in the central nervous system because they can cross the blood-brain
barrier, accounting for increased sedation. Second-generation antihistamines
penetrate the blood-brain barrier poorly.
Cardiac—Although uncommon, first-generation H1-antihistamines may cause a
dose-related prolonged QT interval via antimuscarinic and anti-α-adrenergic
effects. Blockade of the rapid component of the delayed rectifier potassium
current (IKr) and prolongation of the QT interval may result in torsades de

pointes.
Potential adverse effects of H1 antihistamines due to effects on receptors and

ion channels:
H1 receptor: Increased sedation, increased appetite, decreased cognitive

and psychomotor performance, and decreased central nervous system
neurotransmission
Muscarinic receptor: Dry mouth, urinary retention, sinus tachycardia
α-Adrenergic receptor: Hypotension, dizziness, and reflex tachycardia
Serotonin receptor: Increased appetite
Ion channels: Prolonged QT intervals
Efficacy of H1 Antihistamines
Allergic Rhinoconjunctivitis—Relieve nasal itching, sneezing, rhinorrhea,

conjunctival itching, watering, redness, and itching of the palate throat and ears.
Topical administration to the nose or eyes has more rapid onset of action but
requires multiple doses per day.
Other Airway Disorders—Published evidence does not support efficacy in

respiratory tract infections, otitis media, sinusitis, or asthma. However, according
to the “united airway hypothesis,” treatment of rhinitis may reduce symptoms in
lower respiratory tract.
Urticaria—H1-antihistamines decrease itching and reduce wheal size, number,
and duration. May be effective for physical urticarias, but not urticarial vasculitis
or hereditary angioedema.
Other Allergic Conditions—Ancillary treatment for anaphylaxis, but they do not
replace epinephrine.
Flash Card Q4
Which second-generation
antihistamines are safest
to use in pregnancy?
THEOPHYLLINE
Flash Card Q5
Which of the following
Theophylline is a member of methylxanthine family (caffeine is also in this antihistamines has the
family) with a narrow therapeutic range. It is used for treatment of asthma and longest half-life:
chronic obstructive pulmonary disease. Since β2 agonists are more effective as loratadine, cetirizine,
fexofenadine,
hydroxyzine?
432 / CHAPTER 9
bronchodilators and inhaled corticosteroids have a superior anti-inflammatory

effect, the use of theophylline has decreased.
Asthma: 2007 NHLBI guidelines list theophylline as an alternative agent to be

considered when asthma in patients (younger than 5 years old only) is not
controlled with low-dose inhaled corticosteroids. Slow-release theophylline
may be helpful for nocturnal asthma symptoms.
COPD: Theophylline is still used, although inhaled anticholinergics and β2
agonists are preferred.
Mechanism
Theophylline inhibits phosphodiesterase (PDE), resulting in elevated cyclic

adenosine momophosphate (cAMP) (Figure 9-2), and also acts as an adenosine
receptor antagonist. Adenosine is thought to cause histamine and leukotriene
release from mast cells, resulting in bronchoconstriction. Adenosine antagonism
is responsible for the toxic effects of theophylline at high concentrations (i.e.,
cardiac arrhythmias, seizures)
Clinical Effects
Bronchodilation—Produces acute bronchodilator response above plasma

concentration of 10 mg/L (therapeutic range 5–15 mg/L). Directly relaxes airway
smooth muscle and reverses effects of bronchoconstrictor agonists. The degree of
PDE inhibition is very small (i.e., 5–10%) at concentrations of theophylline that
are therapeutically relevant and may account for the frequent side effects of
nausea, vomiting, and headache.
Flash Card A4
Cetirizine, levocetirizine,
and loratadine (category
B)
Figure 9-2. Theophylline inhibits phosphodiesterase resulting in elevated cAMP.

Abbreviations: AMP, adenosine monophosphate; ATP, adenosine triphosphate; cAMP, cyclic
Flash Card A5 adenosine monophosphate.
Hydroxyzine
Anti-inflammatory Effects—Intravenous theophylline inhibits the late response

to allergen challenge, and airway influx of neutrophils and eosinophils. Other
anti-inflammatory actions of theophylline include: increase in IL-10, increased
histone deacetylase activity (suppressing inflammatory cytokine gene expression),
prevents nuclear translocation of nuclear factor kappa B (NFκβ), and increased
apoptosis of inflammatory cells
Other—May help with mucociliary clearance and improve respiratory muscle

strength.
Factors That Affect Clearance

Theophylline is metabolized in the liver by cytochrome P450 microsomal
enzymes, and other medications affecting this enzyme may alter theophylline
levels. See Table 9-7 for factors affecting clearance of theophylline.
Adverse Effects
Most common adverse effects are headache, nausea, vomiting, abdominal
discomfort, and restlessness. Patient may also have increased gastric acid
secretion, reflux, and diuresis. There is potential for significant toxicity (e.g.,
convulsions, cardiac arrhythmias, and death) at high concentrations. Adverse
effects tend to occur at plasma levels greater than 20 mg/L.
Table 9-7. Factors That Lead to Increased and Decreased Clearance of

Theophylline
Decreased Clearance Increased Clearance
(↑ Serum Level) (↓ Serum Level)
Macrolide antibiotics Carbamazepine, phenobarbital, and phenytoin
Cimetidine (but not ranitidine) Rifampin
Ciprofloxacin Ethanol
Verapamil Smoking tobacco and marijuana
Zileuton High-protein and low-carbohydrate diet
Allopurinol Younger children have greater metabolism
than older children
Congestive heart failure
Liver disease
Viral infection Flash Card Q6
High-carbohydrate diet
A high-protein, low-
Older age carbohydrate diet has
what effect on
theophylline clearance?
434 / CHAPTER 9
Dosage
Based on body weight. Check serum level after 3 days of maximum dose. Peak
serum level occurs 8–13 hours after sustained-release preparations. Target level of
5–15 μL/mL.
β AGONISTS AND BLOCKERS
β AGONISTS
Mechanism
Key Fact β Agonists bind to G protein-coupled receptors (GPCR) and activate adenylyl
cyclase, resulting in increased cAMP. This activates protein kinase A, leading to
Albuterol binds to GPCR
and increases cAMP. phosphorylation and muscle relaxation.
There are three types of β receptors:
B1: Heart
B2: Lung (smooth muscle, epithelium, and alveoli), inflammatory cells (mast
cells, eosinophils, lymphocytes, and neutrophils)
B3: Adipose tissue
Modifications of β-agonist structure affect its function. Increasing the bulk of the
side chain results in more selectivity for the β2-receptor, prolongs bronchodilator
action and protects from catechol-O-methyltransferase (COMT). Also, increasing
the size of the terminal amino group protects the drug from degradation by
monoamine oxidase (MAO). Salmeterol and formoterol have long lipophilic side
chains that allow entry into the plasma membrane and slow release (Table 9-8).
Beta agonists have the following multiple nonbronchodilator actions:
Increased mucociliary clearance (increased chloride ion and H2O secretion,

and increased ciliary beat frequency)
Protect epithelium against bacteria
Flash Card A6 Suppress microvascular permeability
Inhibit cholinergic neurotransmission
Increased clearance
(↓ level)
Table 9-8. Comparing the Onset and Duration of Action of β2 Agonists

Types of β Agonists Onset of Action (min) Duration of Action (hr)
SABAs (i.e., albuterol,
terbutaline, pirbuterol, 2–4 4–6
levalbuterol)
LABAs (i.e., formoterol, Formoterol (2–3) ˃ 12
salmaterol) Salmeterol (30)
Ultra long-acting β
agonists (i.e., <5 ≥24
carmoterol, indacaterol)
Abbreviations: LABA, long-acting β agonist; SABA, short-acting β2 agonist.
Inhibit mediator release from mast cells and basophils

Inhibit function of eosinophils, antigen-presenting cells, T lymphocytes, and
epithelial cells
Prime glucocorticoid receptor by mitogen-activated protein (MAP) kinases,
leading to enhanced nuclear translocation
BAGS study: Regular β agonist use was found to be neither harmful nor
beneficial compared with prn use
SOCS study: Salmeterol monotherapy ineffective
SLIC study: Patients with moderate asthma achieving control with addition of
long-acting β agonist (LABA) to inhaled corticosteroid (ICS) could have 50%
ICS dose reduction but not ICS removal.
LABA versus theophylline: Salmeterol with increased morning peak
expiratory flow (PEF), symptom improvement, and rescue-free days.
LABA versus leukotriene modifiers: Adding LABA to ICS shows greater
improvement in lung function and symptoms versus adding LTRA to ICS.
A maximum of 12–14% of a measured-dose inhaler (MDI) dose is deposited
in the lungs.
IM epinephrine has quicker onset than SQ; vastus lateralis is quicker than
deltoid.
Adverse Effects
Pharmacologically-mediated adverse effects include: Flash Card Q7
Tremor (stimulation of β2 in skeletal muscles) Long lipophilic side chains

Tachycardia of β agonists, have what
effect on bronchodilation?
436 / CHAPTER 9
Prolonged QTc /arrhythmias

Hyperglycemia
Hypokalemia
Hypomagnesemia. Transient increased hypoxia
Paradoxical bronchoconstriction can occur with first use of new MDI. The
Salmeterol Multicenter Asthma Research Trial (SMART) suggested that
asthmatic patients receiving salmeterol were at an increase for fatal asthma
events. However, the risk appears to be limited to asthmatics taking salmeterol
alone and does not apply to the concurrent use of an inhalational corticosteroid.
Findings from the study discourage the use of LABAs as monotherapy in
asthmatics. Polymorphisms of the β2-adrenergic receptor (ADRB2) results in
agonist receptor downregulation, which induces resistance to the smooth-muscle
relaxing effect of β2 agonists. Regular use of albuterol is associated with
worsening lung function in patients with this mutation.
β2-Receptor Desensitization Versus Tachyphylaxis
Desensitization (autoregulatory and safety valves), decrease duration of broncho-

dilation (not peak), prevents overstimulation, and occurs over days to weeks.
There are three mechanisms for this: (1) receptors uncouple from adenylate
cyclase, then (2) internalize, and then (3) become phosphorylated. Systemic
steroids can reverse downregulation.
Tachyphylaxis occurs rapidly. Ephedrine displaces norepinephrine from

sympathetic nerve endings.
Loss of bronchoprotection to stimuli may occur with chronic use (i.e., exercise),
as the protection by the first dose of a β agonist will not be replicated during the
course of regular β-agonist therapy (protection reduced but not lost).
β-BLOCKERS
Nonselective β blockers (β1 = β2) include propranolol, timolol, pindolol, nadolol,

and labetalol (also blocks α1-receptors). They are associated with a blunted
response to β2-agonists and thus may increase the patient’s risk during an asthma
Flash Card A7 exacerbation.
Prolongs bronchodilation
Cardioselective β blockers (β1 > β2), including metoprolol and atenolol, have
greater than 20 times more affinity for β1-receptors and pose less risk for
bronchoconstriction or loss of asthma control.
Inhalant allergen immunotherapy is a relative contraindication for patients on a β

blocker.
Venom immunotherapy is not an absolute contraindication if taking a β blocker.
In anaphylaxis, use glucagon to overcome β blockade if the patient is

unresponsive to epinephrine.
LEUKOTRIENE PATHWAY MODULATORS
Leukotriene Pathway
Leukotrienes are formed by arachidonic acid metabolism through lipoxy-

genase (LO) pathway (Figure 9-3).
Two major enzymes, 5-lipoxygenase (5-LO) and 15-lipoxygenase (15-LO) are
involved. 5-LO catalyzes the formation of an unstable intermediate
leukotriene, A4 (LTA4). LTA4 hydrolase, expressed mostly by neutrophils,
converts LTA4 to the leukocyte chemoattractant substance LTB4, which
upregulates CD11b/CD18 and enhances neutrophil chemotaxis.
The enzyme leukotriene C4 synthase converts LTA4 to cysteinyl leukotrienes
(cysLTs) LTC4, LTD4, and LTE4. This enzyme is expressed in eosinophils,
basophils, macrophages, and mast cells.
The other major enzyme, 15-LO, leads to the formation of lipoxins, a group of
mediators with anti-inflammatory functions.
Pharmacologic Targets
Antileukotrienes include the following:

5-Lipoxygenase inhibitor
CysLT receptor antagonists
There are two types of leukotriene receptors: cysLT1 and cysLT2.

438 / CHAPTER 9
Figure 9-3. Metabolism of arachidonic acid by the cyclooxygenase and

lipoxygenase (LO) enzymatic pathways.
Abbreviations: COX, cyclooxygenase; 5-HETE, 5-hydroxyeicosatetraenoic acid; 5-HPETE, 5-
hydroperoxyeicosatetraenoic acid; LT, leukotriene; PG, prostaglandin; PGI2, prostacyclin; TX,
thromboxane.
CysLT1 receptors are expressed on inflammatory cells, including

eosinophils, mast cells, lymphocytes, macrophages and neutrophils as well as
on bronchial epithelium and muscles. These receptors mediate proasthmatic
actions such as sustained bronchoconstriction, mucus secretion, and increased
vascular permeability. (Receptor affinity: LTD4 > LTC4 > LTE4.)
CysLT2 receptors do not have a known role in bronchoconstriction, although
they may contribute to edema formation. They appear important in activation
of endothelial cells. (Receptor affinity: LTC4 = LTD4 > LTE4.)
CysLT1 Receptor Antagonist—Leukotriene receptor antagonists block the

cysLT1 receptor only. They include montelukast (has highest binding affinity),
pranlukast, and zafirlukast.
Leukotrienes in Asthma Pathogenesis
Cys-LTs are produced within minutes of exposure to an allergen, and these

cytokines further upregulate expression of enzymes involved in their synthesis.
Asthmatics produce higher baseline levels of cys-LTs, and levels of sputum cys-
LTs correlate with asthma severity in adults. High levels of cys-LTs are present in
patients with aspirin-sensitive asthma.
Effects of cys-LTs include smooth muscle contraction and bronchoconstriction

(much more potent than histamine); they increase permeability that leads to
bronchovascular leakage and mucous gland secretion, leukocyte chemotaxis,
stimulation of airway smooth muscle cells, and fibroblasts proliferation,
suggesting a possible role in airway remodeling.
Clinical Uses of Leukotriene Modulators

Exercise-induced bronchospasm
Allergic asthma and allergic rhinitis
Aspirin-exacerbated respiratory disease
o Leukotriene antagonists attenuate both early- and late-phase
bronchoconstrictor responses. Antileukotriene therapy leads to (1)
improvement in forced expiratory volume in the first second (FEV1), (2)
less need for rescue β-agonist therapy, and (3) a decrease in asthma
exacerbations. However, antileukotrienes are generally less efficacious
than corticosteroids.
o Leukotriene antagonists are recommended prior to aspirin desensitization.
Leukotriene modifiers have some anti-inflammatory effects, including
reduced numbers of circulating and sputum eosinophils, exhaled nitric oxide,
and bronchial hyper-responsiveness
No reports of tolerance (tachyphylaxis) to antileukotrienes
Montelukast and Zafirlukast

Montelukast and zafirlukast are selective leukotriene-receptor antagonists that
inhibit the cysLT1 receptor. Pregnancy class B.
Adverse Effects—Anaphylaxis, angioedema, dizziness, dyspepsia, muscle
weakness, and elevated transaminases. Few instances of suicidal thinking,
suicide, and behavioral or mood changes have been noticed among patients taking
montelukast. Montelukast generally has no significant drug interactions.
Zafirlukast absorption is decreased by food. It can also interact with warfarin,
leading to an increased prothrombin time. Rare association with onset of Churg-
Strauss vasculitis; although, this could be due to unmasking with corticosteroid
taper.
Zileuton
A 5-LO inhibitor that blocks the formation of LTB4 and cys-LTs. It is approved
Flash Card Q8
for prophylaxis and treatment of asthma. Pregnancy class C.
LTB4 is a potent
chemoattractant for
which types of cells?
440 / CHAPTER 9
Adverse Effects—Headache, dyspepsia, myalgias, leukopenia, and elevated

transaminases. Use in patients with a history of liver disease or substantial
alcohol consumption should be avoided. ALT should be monitored every 3
months. Zileuton inhibits cytochrome CYP1A2 and, therefore, affects the levels
of certain coadministered drugs. For example it can lead to decreased clearance
(i.e., increased serum levels) of theophylline, warfarin, and propranolol; therefore,
decrease dose of these medications while on zileuton.
MAST CELL STABILIZERS
Physiochemical Properties
Mast cell stabilizers have negligible fat solubility and are totally ionized at
physiologic pH, making them unable to enter the cell. They are well absorbed in
the lung, are not metabolized, and are excreted unchanged in bile and urine. They
are available in many different preparations.
Pharmacokinetics
Cromolyn Sodium—Approximately 8% of each inhaled dose reaches the lungs

and is absorbed, while more than 1% of each oral dose is absorbed. Half-life
elimination of the drug is 1.5 hours, and peak serum concentrations are reached in
about 15 minutes.
Nedocromil Sodium—Inhaled formulation therapeutic effect is seen in 2 hours,

but full therapeutic effect may not occur until 1 week or more of therapy. The
drug has very low systemic absorption rates and has a half-life of 1.5–3.0 hours.
Mechanism of Action
Inhibits IgE-mediated calcium channel activation, which functions to maintain

elevated intracellular calcium necessary for degranulation of mast cells. Inhibits
chloride transport and Cl– channels, which indirectly lower intracellular calcium
levels. Prevents the mast cell release of histamine and leukotrienes. Blocks
activation of eosinophils. Inhibits neutrophil activation, chemotaxis, and mediator
release. Inhibits IgE production.
Flash Card A8
Neutrophils and
eosinophils
Bronchoprotection
Prevents or attenuates the early- and late-asthmatic reaction to bronchial
challenges. Provides protection against exercise and cold air challenges as well as
irritants (i.e., sulfur dioxide and bradykinin). Provides protection against
adenosine, saline, and mannitol challenges. Does not offer protection for
methacholine or histamine challenges.
Common Clinical Applications

Asthma—Effective asthma treatment in both adults and children. Optimal effects
seen in patients using bronchodilators alone and corticosteroid-sparing effect can
be seen. Not effective for immediate relief of symptoms in acute asthma attacks.
Must be used at regular interval for 2–4 weeks to be effective. No longer
available.
Allergic Eye Disease—Effective in relieving eye symptoms in acute or chronic

allergic conjunctivitis, vernal keratoconjuctivitis, and giant papillary
conjunctivitis.
Nasal Disease—Effective in relieving nasal symptoms in allergic and nonallergic

rhinitis.
Systemic Mastocytosis—Useful in symptomatic treatment of GI symptoms.
Safety and Toxicity

Excellent safety profile. Little to no systemic absorption. Most common adverse
effect is unpleasant taste in mouth. Can be used in pregnancy (category B).
Flash Card Q9
Mast cell stabilizers
ANTICHOLINERGICS attenuate which phase of
an allergic response?
Increased parasympathetic tone in asthma or chronic obstructive pulmonary

disease (COPD) releases acetylcholine, which triggers bronchoconstriction,
mucus secretion, and bronchial vasodilation. Acetylcholine induces Flash Card Q10
bronchoconstriction by stimulating muscarinic receptors.
Smooth muscle
contraction and
bronchoconstriction are
primarily mediated by
which M receptors?
442 / CHAPTER 9
Muscarinic Receptors
G protein-coupled acetylcholine receptors found in the cell membranes of neurons
and other cells.
Three Types
M1: Present on eosinophils from sputum of COPD patients
M2: Inhibitory receptor on parasympathetic nerves. Decreases
acetylcholine release; dysfunctional M2 causes increased acetylcholine
M3: Primary mediator of smooth muscle contraction in human airways
o Density greatest in smooth muscle of bronchi > trachea > alveoli >>
airway epithelium
o Increases intracellular Ca2+, causing bronchoconstriction
o Linked to smooth muscle proliferation
o Many antihistamines also have anticholinergic effects, through M3
receptor
Causes of Vagally Mediated Bronchoconstriction
Irritants: Sulfur dioxide, dust, citric acid, exercise, and cold air
Viruses: Cause loss of inhibitory M2 receptors on parasympathetic nerves,
leading to hyperreactivity
Allergen exposure: Blocked by anticholinergic drugs (in mice)
Anticholinergic Drugs
Atropine—Hallucinogenic, with numerous adverse effects. Toxicity limits its use
for airway disease.
Ipratropium Bromide (18 μg/puff)—Quaternary ammonium, first anticholinergic

bronchodilator for COPD. Provides equal bronchodilation to β agonists in COPD
patients. 7.6 minutes to 50% max bronchodilation. Blocks M2 = M3. May cause
paradoxical bronchoconstriction (blocking M2 receptors leads to ↑ acetylcholine
release from vagus which may ↑ bronchoconstriction).
Role in asthma: Recommended in 2007 Expert Panel Report 3 in combi-

Flash Card A9 nation with β agonists in moderate-to-severe asthma exacerbations; synergistic
with β agonists, and decreases hospitalization rate. Recommended for
Early and late phase patients with β-agonist adverse effects (e.g., palpitations or tachycardia), and
drug of choice for β-agonist-induced bronchospasm.
Role in COPD: Seventy-three percent fewer hospital days, and fewer and
Flash Card A10 shorter exacerbations when treated with combined therapy (compared with a β
agonist alone).
M3 receptors
Role in rhinitis: Effective inallergic, nonallergic, gustatory, and infectious;

decreases contralateral responses in unilateral histamine or cold air nasal
challenges.
Tiotropium bromide (18 μg/cap DPI)—Structurally related to ipratropium, it is a

potent inhibitor of M3 = M2; but, it dissociates from M2 10 times faster than M3.
Dissociates from M1 and M3 100 times more slowly than ipratropium. Long
duration of action, 9 hours; 34.8 minutes to 50% maximum bronchodilation.
Role in asthma: May have a role in patients with β-agonist-resistance.

Tiotropium shown to improve asthma when added to ICS alone or
ICS/LABA.
Role in COPD: Greater improvement in trough FEV1 versus ipratropium;
reduced dyspnea scores, use of β agonist, and decreased airway resistance; no
clear benefit in acute exacerbations.
CORTICOSTEROIDS
Key Fact
CORTISOL
Steroids inhibit the late-
Cortisol peak levels are in the early morning, whereas the lowest levels are in phase response of an
antigen challenge, but
early evening. The levels are increased by stress, IL-1, IL-2, IL-6, and tumor NOT the early phase.
necrosis factor alpha (TNFα). Ninety percent of cortisol is protein-bound; cortisol
binds to transcortin with high affinity and to albumin with low affinity.
Mechanism
Steroids bind to a glucocorticoid (GC) receptor. There are two types of GC
receptors, GRα and GRβ. Free steroid (i.e., unbound) binds to the GC receptor in
cytoplasm. After binding with the receptor, heat shock proteins dissociate from
the receptor, the receptor is phosphorylated, and then the steroid-receptor complex
translocates into the nucleus.
Once in the nucleus, the steroid has the following multiple effects on gene
regulation:
Target gene activation via binding to a positive glucocorticoid response
element (GRE)
Target gene repression via binding to a negative GRE Flash Card Q11
Indirect gene repression via interference with transcription activating factors Which medications
(NFκB). There is also competition between GC receptor and transcription decrease glucocorticoid
metabolism?
444 / CHAPTER 9
Mnemonic factors on the surface of integrator proteins, such as CREB-binding protein

(CBP/p300). CBP has associated histone acetyltransferase (HAT) activity,
Adverse effects of which leads to DNA unwinding and access to transcription factors. Steroids
steroids: STEROID inhibit HAT activity and recruit histone deacetylases (HDACs), which oppose
Stunt growth, subcapsular HAT activity.
posterior cataracts, and Induction of transcription factor inhibitors (i.e., GILZ, IκBα) which interfere
steroid myopathy
Thrush
with NFκB
Eyes (increased Destabilize target gene mRNA
intraocular pressure,
cataracts, and Oral steroids cause the following changes in inflammatory cells:
glaucoma), endocrine
(diabetes) T and B lymphocytes: Decreases T lymphocytes > B lymphocytes; decreases
Rage (psychiatric CD4+ > CD8+ cells; upregulates CXCR4; and slight decrease in IgG and IgM
changes), raises blood
pressure (hypertension)
Increases neutrophils
Osteopenia or Decrease eosinophils, basophils, and monocytes
osteoporosis and Spares innate immunity (Toll-like receptor [TLR], complement, and
obesity collectins)
Immunosuppression and
increased weight
Dysphonia, diabetes, and Steroids reverse reduced β-adrenergic responsiveness and increase β-receptor
dermatologic effects numbers.
Adverse Effects
Steroids can adversely affect virtually any organ in the body, including the bone
(osteopenia and osteoporosis), skin (acne), eyes (posterior cataracts), and central
nervous system (rage and depression). This necessitates constant monitoring for
adverse effects and consideration of periodic dual-energy X-ray absorptiometry
(DEXA) scans and ophthalmologic examinations for those on high daily doses
(oral or inhaled).
Drug Interactions—Barbiturates increase steroid metabolism. Troleandomycin

prolongs steroid metabolism and half-life. Protease inhibitors (particularly
ritonavir) may result in high systemic concentrations when coadministered with
inhaled corticosteroids (particularly fluticasone), causing Cushing’s syndrome and
adrenal suppression.
Clinical Uses
Asthma—Most newer inhaled corticosteroid (ICS) products have low oral
bioavailability due to extensive hepatic first-pass metabolism. ICS have not been
Flash Card A11 shown to prevent progressive loss of lung function, affect natural history, or to
Ketoconazole, oral work well during exacerbations. Relative binding affinity for GC receptor:
contraceptives, and mometasone > fluticasone > budesonide > triaminoclone. Relative anti-
macrolides (i.e., inflammatory potency: mometasone = fluticasone > budesonide =
troleandomycin)
beclomethasone > triamcinolone. Multiple GC receptor isoforms exist, but steroid

resistance is mediated by overexpression of GC receptor β. It does not bind to
GC; rather, it inhibits the glucocorticoid response elements (responsible for
synthesis of anti-inflammatory proteins) via a dominant negative effect. Increased
GC receptor β expression associated with fatal asthma and nocturnal asthma.
IMMUNOMODULATORS AND
IMMUNOSUPPRESSIVES
BIOLOGIC IMMUNOMODULATORS
Anti-IgE Therapy (Omalizumab [Xolair])

Mechanism of Action—Omalizumab is a humanized monoclonal antibody that
binds to the CH3 domain (FC portion) of the IgE molecule. This prevents free
IgE from binding to the FcεRI on mast cells and basophils. It is an IgG1 molecule
composed of 95% human and 5% murine sequence. It binds to IgE, typically
Key Fact
forming trimers (i.e., two IgE molecules and one omalizumab) that are cleared by
the reticuloendothelial system. It only binds soluble IgE; therefore, it cannot cause FcεRI on mast cells and
degranulation of effector cells. Omalizumab increases total IgE (as complexes basophils has four
are eliminated slowly), but decreases free IgE. chains: αβγ2 versus
other cells that have
only three chains: αγ2
Omalizumab will decrease: (Note: No β chain). IgE
binds to the α chain of
Free serum IgE and eosinophils (serum, sputum and bronchial biopsies)
the receptor.
Expression of FcεRI on effector cells (mast cells, basophils, dendritic cells,
monocytes)
Circulating IL-13 and fractional exhaled nitric oxide (FeNO)
Mediator release from mast cells and basophils
B lymphocytes
Dosing—Dose is dependent on patient’s body weight and total IgE (between 30–
700 IU). It is administered every 2–4 weeks subcutaneously and is approved for
individuals 12 years of age and older with moderate-to-severe allergic asthma.
Trial of at least 12 weeks is needed to assess clinical improvement.
Safety—Most common adverse events include local reaction at the injection site,
upper respiratory infection, headache. Anaphylaxis (0.2% incidence) can occur Flash Card Q12
within 2 hours of injection, though delayed reactions (2–24 hr later) have been
reported. What is the incidence of
anaphylaxis associated
with omalizumab?
446 / CHAPTER 9
Omalizumab and Allergic Disease
Asthma: Compared with placebo, omalizumab was able to reduce asthma

exacerbations, decrease systemic steroid use, decrease rescue medication use,
decease hospitalizations and emergency department visits, and improve
quality of life.
Allergic Rhinitis: Compared with placebo, omalizumab decreased daily
symptoms, decreased rescue medication use, decreased missed school or work
days, and improved quality of life.
Food Allergy: Study of a different humanized IgG1 monoclonal antibody
(TNX-901) against IgE was studied in patients allergic to peanuts. It was able
to increase the threshold of peanut tolerability from 0.5–1.5 peanuts to 9
peanuts in some patients. However, 25% of patients had no improvement.
This has not been evaluated with omalizumab.
Atopic Dermatitis: Omalizumab may be effective for atopic dermatitis, but
high baseline IgE levels may be a limiting factor.
Chronic Urticaria: Omalizumab has shown to improve symptoms and signs
of chronic idiopathic urticaria in patients who had remained sympto-
matic despite the use of approved doses of H antihistamines.
Many biologic immunomodulators, including monoclonal antibodies and fusion

proteins, are used in the treatment of cancers and autoimmune diseases (Tables 9-
9 and 9-10).
Table 9-9. Other Therapeutic Antibodies

Generic Brand Molecular
Molecular Target Indication
Name Name Structure
Alemtuzumab Campath CD52 (cell surface Humanized IgG1κ Chronic B-lympho-
glycoprotein) and recombinant cyte leukemia (B-
CLL)
Cetuximab Erbitux EGF (epidermal Chimeric monoclonal Metastatic colorectal
growth factor) antibody cancer, and head and
receptor neck cancer
Eculizumab Soliris Complement protein Humanized Paroxysmal nocturnal
C5 hemoglobinuria
Efalizumab Raptiva CD11a (α-subunit of Humanized IgG1κ Chronic and
leukocyte function and recombinant moderate to severe
antigen-1 [LFA-1]) plaque psoriasis
Palivizumab Synagis respiratory syncytial Humanized IgG1κ Prevention of serious
virus fusion (RSV F) lower respiratory tract
protein disease caused by
RSV in pediatric
patients at high risk
Canakinumab Ilaris IL-1 beta Humanized IgG1κ Cryopyrin-associated
and recombinant periodic syndromes
Flash Card A12 (CAPS)
0.2%
Table 9-10. Therapeutic Fusion Proteins

Molecular Molecular
Generic Name Brand Name Indication
Target Structure
Abatacept Orencia B7-1 (CD80), CTLA4-human Rheumatoid
B7-2 (CD86) IgG1 fusion arthritis and
protein juvenile
rheumatoid
arthritis
Alefacept Amevive CD2 LFA-3-IgG1 Fc Moderate-to-
fusion protein severe, and
chronic plaque
psoriasis
Abbreviations: CTLA, cytotoxic T-lymphocyte antigen LFA, leukocyte function-associated antigen.
IMMUNOSUPPRESSIVES
Methotrexate (MTX)
Pharmacology/Metabolism—MTX is a drug and prodrug that is structurally
similar to folic acid. It is administered orally or parenterally with a half-life of 8
hours and elimination via renal clearance. Widely used in rheumatoid arthritis and
other autoimmune diseases.
Immunologic Effects—Inhibits cell replication (i.e., lymphocyte division).
Adverse Effects—MTX is a teratogen and contraindicated in pregnancy. Many

of its adverse effects can be reduced by decreasing the dose or supplementing
with folic acid. Common adverse effects include oral ulcerations, nausea or
diarrhea and postdose arthralgia, and fatigue. Less common effects include
abnormal liver function tests (LFTs), myelosuppression, and skin rash. Rare
events: Myelosuppression, hepatic fibrosis, pulmonary toxicity, Epstein-Barr
virus (EBV)-associated lymphoma, alopecia, and increased risk of infections.
Use in Allergic Disease—In corticosteroid-dependent asthma, there have been

conflicting reports of MTX having modest corticosteroid-sparing effect.
Azathioprine (Imuran, Azasan)

Pharmacology/Metabolism—A systemic immunosuppressive prodrug that
inhibits purine nucleotide synthesis and metabolism. Available in oral form. Flash Card Q13
Adverse Effects—Myelosuppression, GI disturbance, hepatotoxicity, Cyclosporine (CsA) and
susceptibility to infection and, risk of skin cancer. tacrolimus function by
binding to which type of
protein(s)?
448 / CHAPTER 9
Use in Allergic Disease—Shown to be effective in severe atopic dermatitis. Has

slow onset of action and needs a trial for several months to see improvement.
Mycophenolate Mofetil (CellCept)

Pharmacology/Metabolism—A systemic immunosuppressive agent that affects
purine nucleotide synthesis and metabolism. Used in organ transplantation.
Adverse Effects—Diarrhea, vomiting, hepatotoxicity, and myleosuppression (↑

risk of sepsis and opportunistic infections).
Use in Allergic Disease—Shown to be effective in severe/recalcitrant atopic

dermatitis, with responders showing lasting remission. Onset of action slow and
benefit may not be apparent for several months.
Immunophilin-Binding Agents and Calcineurin Inhibitors

(Cyclosporine, Tacrolimus, and Pimecrolimus)
Pharmacology/Metabolism—Cyclosporine A(CsA) has immunosuppressive
properties of inhibiting Th-lymphocyte function. Tacrolimus and pimecrolimus,
though structurally different, have the same mechanism of action. Cyclosporine
and tacrolimus are both used in organ transplantation and for autoimmune
disease; they are eliminated via P450 system. Topical tacrolimus and
pimecrolimus approved for treatment of atopic dermatitis for patients 2 years of
age and older.
Immunologic Effect—These agents bind to cytosolic proteins called

immunophilins: CsA binds to cyclophilin, and tacrolimus binds FK-binding
protein. This results in inhibition of various transcriptional regulatory factors,
such as nuclear factor of activated T lymphocytes (NFAT), which encodes
cytokines that are critical for T lymphocyte function, such as IL-2.
Adverse Effects—Common adverse effects include nephrotoxicity (most

common to CsA and tacrolimus), hypertension (less frequent tacrolimus),
headache, hypertrichosis, and gingival hypertrophy. Rare events include increased
risk of infection and lymphoproliferative disease. Topical agents may cause local
burning on application.
Use in Allergic Disease—Cyclosporin A remains an investigational treatment in

Flash Card A13 asthma and has been used in refractory cases of chronic urticaria. Cyclosporine A
Immunophilins (CsA
has not been effective topically for atopic dermatitis (AD), but studies of oral
binds to cyclophilin and formulations have shown improvement in the extent and severity of AD, although
tacrolimus binds FK- toxicity remains a concern.
binding protein)
DNA-BASED THERAPIES
DNA Vaccines
Immune Response—DNA vaccines are circular extrachromosomal pieces of
plasmid DNA that can be modified to carry genes of interest in antigen-coding
region, such as dust mite allergen for allergen immunotherapy. The subcutaneous
injected DNA vaccine is taken up by dendritic or somatic cells to mediate
immune responses. Somatic cells (i.e., muscle cells) serve as reservoirs of antigen
and function in cross priming (transfer of protein to professional antigen-
presenting cells).
Potential in Allergic Disease—DNA vaccines were studied extensively in mice

and showed protection against specific allergen challenge and prevention of
anaphylactic reaction to peanut. DNA vaccines possibly generate humoral and
cellular immune responses to allergens. There are safety concerns regarding risk
of malignancy and risk of triggering autoimmune response.
CpG DNA Therapy

Immune Response—Cytosine phosphorothioate-linked guanosine (CpG)-rich
immunostimulatory DNA was shown to inhibit Th2 cytokine responses to antigen
in the mouse model via TLR9. Linking of protein antigen to CpG DNA increases
the likelihood of its delivery to the same antigen-presenting cell (APC),
amplifying Th1 response.
Potential in Allergic Disease—The advantage of using conjugated CpG DNA

therapy versus traditional IT is the ability to reach the target dose faster without
inducing a systemic allergic reaction. Human pilot studies with ragweed protein
CpG DNA conjugates showed that only six weekly injections reduced rhinitis
scores in individuals with AR to ragweed, even through the patient had no
additional IT in the second season. However, the results of a large multicenter
study were less encouraging.
Oligodeoxynucleotide
Immune Response—Antisense oligodeoxynucleotide (ODN) therapy prevents
the translation of messenger RNA into protein.
Potential in Allergic Disease—ODN therapy can be targeted against gene

products important in asthma and allergy, such as adenosine-1, IL-5 receptor, IL-
4, or GATA-3. Examples in mouse models demonstrate that GATA-3 antisense
450 / CHAPTER 9
inhibits eosinophilic inflammation, airway hyperreactivity, and cytokine

expression.
Small Interfering RNAs

Immune Response—Small interfering RNAs (siRNAs) are small double-
stranded RNAs that are complementary to specific single-stranded RNAs, which
act to destroy the specific target RNA (gene silencing). May lead to a new class of
drugs that switch off unwanted gene expression in disease.
Potential in Allergic Disease—Fomivirsen (Vitravene) has been approved in the

treatment of cytomegalovirus (CMV) retinitis in patients with AIDS. No antisense
therapy is approved for the treatment of allergic disease at this time.
IMMUNOGLOBULIN REPLACEMENT THERAPY
Immunoglobulin products contain pooled IgG from plasma of approximately

15,000–60,000 donors. These large donor numbers create a significant amount of
antibody diversity for uses as passive immunization and immunomodulation in
various conditions (Table 9-11).
Indications
FDA approved indications include:
Primary immunodeficiencies
B-lymphocyte chronic lymphocytic leukemia (CLL)
Kawasaki’s disease
Following stem cell transplantation with B-lymphocyte nonengraftment
Pediatric HIV infection (recurrent bacterial infections)
Immune thrombocytopenic purpura (ITP)
Chronic inflammatory demyelinating polyneuropathy (CIDP)
Bone marrow transplantation
Off-label uses include toxic epidermal necrolysis (TEN), autoimmune, and

neurologic diseases.
Table 9-11. Uses of Immunoglobulin Therapy

Definitely Probably Might Be Unlikely to Be
Condition
Beneficial Beneficial Beneficial Beneficial
Immune PID Pediatric HIV Isolated IgA
deficiency B lymphocyte deficiency
CLL Isolated IgG4
Specific Ab deficiency
deficiency
Autoimmune ITP Dermatomyositis SLE Inclusion body
Graves’ Polymyositis Severe RA myositis
ophthalmopathy Autoimmune Vasculitis APS in
uveitis Autoimmune pregnancy
diabetes
Autoimmune
cytopenias
Neurologic CIDP Myasthenia MS ALS
Guillain-Barré gravis PANDAS Autism
syndrome Lambert-Eaton Childhood
Multifocal motor syndrome epilepsy
neuropathy
Infectious CMV Neonatal sepsis RSV Acute rheumatic
a b
pneumonitis Staph TSS pneumonitis fever
Rotaviral entero- Pseudomembran
b
colotis ous colitis
Dermatologic TEN and SJS Autoimmune Atopic dermatitis
bullous
diseases
Chronic urticaria
Other Kawasaki’s HSCT HSCT (chronic
disease Severe GVHD
persistent prevention)
steroid- Nonsteroid-
dependent dependent
asthma asthma
Miscarriage
Dilated
cardiomyopath
y
a b
In immunosuppressed patients, Orally administered Igs.
Abbreviations: AB, antibody; ALS, amyotrophic lateral sclerosis; CIDP, chronic inflammatory
demyelinating polyneuropathy; CLL, chronic lymphocytic leukemia; GVHD, graft-versus-host
disease; HSCT, hematopoietic stem cell transplant; ITP, idiopathic thrombocytopenic purpura; MS,
multiple sclerosis; PANDAS, pediatric autoimmune neuropsychiatric disorder associated with
streptococcal infections; PID, primary immunodeficiency; RA, rheumatoid arthritis; SJS, Stevens-
Johnson syndrome; TSS, toxic shock syndrome; TEN, toxic epidermal necrolysis..
Immunoglobulin Replacement Manufacturing

Isolation of immunoglobulin (Ig) from plasma by ethanol fractionation. Most
commonly used method is modified Cohn-Oncley cold ethanol fractionation.
This step is also effective for removal of prion proteins. Bacteria are usually
removed through filtration during final steps of plasma preparation.
452 / CHAPTER 9
Filtration of antibody aggregates and viruses. Commonly used methods are

nanofiltration, treatment with pepsin, ultracentrifugation, and low pH.
Nanofiltration removes particles and viruses as small as 20 nm.
Stabilization to prevent aggregation of Ig molecules. Commonly used stabilizers

are albumin, glycine, proline, polyethylene glycol, D-mannitol, D-sorbitol,
sucrose, glucose, or maltose. Lower pH (range = 4.5–5.0); also preserves the
therapeutic activity of Ig and minimizes formation of aggregates, dimers, and
fragments.
Viral Inactivation. Many enveloped viruses can be inactivated with chemical

methods, such as treatment with solvent or detergent, caprylate precipitation, or
incubation at low pH. Physical methods are required to remove nonenveloped
viruses. Samples are pasteurization, column chromatography, and nanofiltration.
Ingredients and Physicochemical Characteristics
Commercial Ig products contain monomeric IgG (>95%) and small amounts of

IgM and IgA. Products containing low amounts of IgA may be beneficial in
patients with IgA deficiency Serum half-life is 3–4 weeks, but when changing the
dose, several infusions may be needed to equilibrate to a new trough.
Dosing
The starting dose of intravenous immunoglobulin (IVIG) replacement therapy in
primary immune deficiency (PID) management is 400–600 mg/kg every 3–4
weeks. For subcutaneous immunoglobulin (SCIG) it is 100 mg/kg/week.
Although guidelines for dosing are available, for select patients continuing to
have recurrent infections, the dose of IVIG may need to be increased above the
recommended therapeutic range. For immunomodulation, as in management of
Kawasaki’s disease, and various autoimmune and neurologic diseases, higher
dosing (2 g/kg) is recommended every 3–4 weeks.
Forms
Ig products are available in lyophilized powder or liquid from 3–20% and can be
administered via IV, IM, or subcutaneous (SC) infusions. SCIG can be used as an
alternative for IVIG, and is done by the patient as a self-infusion at home. It
provides a more stable trough Ig level since it is given weekly. However, it is
difficult to give large amounts of Ig by this route. SCIG appears to have fewer
systemic adverse events, perhaps due to slower administration and absorption.
Specific (hyperimmune) globulins are prepared from select donors who have
high titers of the desired antibody, either naturally acquired or stimulated by
immunization. They are used to transfer passive immunity for postexposure

prophylaxis. Available hyperimmune globulins include Ig to hepatitis B, rabies,
tetanus, varicella-zoster, vaccinia, CMV, and RSV.
Immunomodulating Effects of Ig Therapy
Fc Receptor Blockade
o Antibody-dependent cell-mediated cytotoxicity (ADCC) inhibition by
blockade of FcγRIII (CD16) on natural killer (NK) cells
o Inhibition of antibody production by blockade of FcγRIIb (CD32) on
B lymphocyte
o In ITP, IVIG blocks membrane Fc receptors on phagocytic cells in
spleen and liver
Sialyated IgG fraction mediates immunosuppressive activity
o Terminal α-2,6-linked sialic acid residues on the N-linked glycans of
the IgG Fc domain have been shown to confer immunosuppressive
properties
Neutralization of superantigens, toxins, and autoantibodies by anti-idiotype
antibodies
Key Fact
Inhibition of cytokine production or action
Inhibition of complement uptake and elimination of immune complexes, Most reactions from IVIG
which deposit in tissues are mild and self-
limited. Systemic
Other unknown mechanism: In toxic epidermal necrolysis (TEN), IVIG reactions are less
inhibits Fas-mediated apoptosis on keratinocytes common with SCIG
than with IVIG.
IVIG not indicated for:
selective IgA
Safety deficiency, IgG due to
protein-losing states,
The capacity for viral and prion elimination during IVIG production over the past IgG subclass
decade is considered sufficient to prevent pathogen transmission. Since the mid- deficiency (unless Ab
1990s, no transmission of the infectious disease has been reported from US deficiency coexists) or
transient
licensed Ig products. hypogammaglobuline
mia of infancy.
Adverse Reactions
Mild reactions during or after infusion are common and usually self-limited.
Headache, fatigue, fever, chills, nausea, vomiting, and myalgias can occur from
IgG aggregates or immune complex formation of Ig and antigens. Reactions
usually are infusion rate-dependent and occur during initial doses of treatment and Flash Card Q14
improve over time. Adverse events from SCIG are milder and mostly involve What is a potential
injection-site reactions. cause of renal
insufficiency when
treating patients with
IVIG?
454 / CHAPTER 9
Aseptic meningitis (history of migraine is predisposing factor) is less common

and associated with large doses, rapid infusions, and the treatment of patients with
autoimmune disorders or inflammatory disease.
Anaphylaxis may occur in patients with IgE antibodies to IgA, such as in

selective IgA deficiency. Preventive measures include using products with lowest
IgA content and premedication with antihistamines or corticosteroids.
Acute renal failure is rare; use of sucrose as a stabilizer has been most strongly
associated. Those receiving higher (immunomodulatory) doses are at greater risk.
Other rare adverse effects include thrombotic events, stroke, myocardial

infarction, hemolytic anemia, osmotic nephrosis, and transfusion-related acute
lung injury (TRALI). These could be secondary to high osmolality or in patients
with underlying cardiovascular or renal disease.
Management of Infusion Reactions

Mild reactions can be prevented by pretreatment with aspirin, acetaminophen,
diphenhydramine or hydrocortisone, and slow infusion rate.
If severe reactions occur, consider reducing rate or volume, using different

product, or changing to SCIG. Epinephrine and other means of treating acute
reactions should be available.
Precaution
Live vaccines may have diminished immunogenicity when given shortly before
or during several months after receipt of Ig products. Suggested intervals of live
vaccines vary from 3–11 months after Ig, depending on Ig doses, products, and
indications for use.
Use low IgA-containing products in patients with low IgA level.
CYTOKINE AND CYTOKINE

Flash Card A14 RECEPTOR-MEDIATED THERAPY
Hyperosmolar renal
damage induced by
breakdown of sucrose The therapeutic administration of purified recombinant cytokines and the
(used as stabilizer in modulation of cytokine action are being used in a wide range of infectious and
IVIG preparations)
autoimmune diseases, acquired immunodeficiency syndrome, and neoplasia.

Given the large number of cytokines, relatively few have been used clinically to
date.
CYTOKINES AS THERAPEUTIC AGENTS
Interferons
The term “interferon” is derived from their ability to interfere with viral infection.
Interferons exert their effects by binding to membrane receptors, which initiates
the activation of Janus kinase (JAK)-signal transducer and activator of
transcription (STAT)-signaling pathways leading to gene transcription. The gene
products formed are responsible for the antiviral, antiproliferative, and
immunomodulatory effects of interferons. There are several type I interferon
products (IFNα, IFNβ) currently approved for the treatment of chronic viral
infections, autoimmune disease, and several malignancies. IFNγ, the only type II
interferon, has significantly fewer antiviral properties than the type I interferons.
It is currently approved for use in chronic granulomatous disease and malignant
osteopetrosis.
A summary of the various interferon products currently available for use are
presented in Table 9-12.
Interleukin-2
Interleukin-2 (IL-2), also known as T-lymphocyte growth factor, is an

immunomodulator whose major function is activation of T lymphocytes and NK
cells, enhancing their antitumor activity. IL-2 also stimulates the differentiation of
regulatory T lymphocytes, which are of significance to the control of
inflammatory responses. A recombinant form of IL-2 has been approved for
clinical use (Table 9-13).
Interleukin-11
Interleukin-11 (IL-11), also known as thrombopoietic growth factor, directly

stimulates the proliferation of hematopoietic stem cells and megakaryocyte
progenitor cells and induces megakaryocyte maturation, resulting in increased
platelet production. A recombinant form of IL-11 has been approved for clinical
use (Table 9-12).
456 / CHAPTER 9
Table 9-12. Summary of Cytokine Therapies Approved for Clinical Use

Drug Approved
Adverse Effects Precautions
Generic Trade Indication
Recombinant Roferon-A Chronic hepatitis C Fever and “flu-like” Caution in those
IFNα-2a Hairy cell leukemia symptoms using α-interferons
Chronic myeloid Cytopenias with cardiovascular
leukemia Hepatic dysfunction disease, thyroid
Recombinant Intron-A Hairy cell leukemia Neuropsychiatric dysfunction,
IFNα-2b Kaposi’s sarcoma symptoms coagulation
Chronic hepatitis B Cerebrovascular disorders or severe
or C events myelosuppression
Malignant Hypersensitivity Patients should
melanoma reactions receive an eye
Follicular lymphoma GI hemorrhage exam at baseline
Condylomata Hyperglycemia and periodic exams
acuminate Pulmonary disorders for those with
Ophthalmologic preexisting
IFNα con-1 Infergen Hepatitis C disorders ophthalmologic
Pancreatitis disorders
IFNα-n3 Alferon-N HPV genital warts Peripheral
leukocyte neuropathy
derived
Pegylated Pegasys Chronic hepatitis B
IFNα-2a or C
Pegylated PEG Intron Hepatitis C
recombinant
IFNα-2b
IFNβ-1a Avonex/ Rebif Relapsing multiple “Flu-like” symptoms Caution in patients
sclerosis Headache with pre-existing:
Depression Seizure disorders
Hepatotoxicity Cardiac disease
↑ Risk of seizures Monitor for auto-
immune disorders
(ITP, hepatitis)
IFNβ-1b Betaseron Early or relapsing Injection site necrosis
multiple sclerosis reported
Bioengineered Actimmune Chronic Fever Caution in those with
IFN -1b granulomatous Headache pre-existing cardiac
disease and Hepatotoxicity conditions, seizure
malignant disorders, and
osteopetrosis myelosuppression.
Recombinant Proleukin Metastatic renal cell Hypotension Caution in those who
IL-2 or carcinoma and Diarrhea have a history of
Aldesleukin metastatic Oliguria cardiac or pulmonary
melanoma Chills disease.
Vomiting Discontinue in
Cytopenias patients developing
BLACK BOX lethargy and
WARNING somnolence
Capillary leak Patients should have
syndrome normal cardiac,
Impaired neutrophil pulmonary, hepatic,
function (↑ risk and CNS function at
infection) the start of therapy
Coma (see warning)
Table 9-12. Summary of Cytokine Therapies Approved for Clinical Use,

cont.
Drug Approved
Generic Trade Indication
Recombinant Neumega Chemotherapy- Vomiting Increased toxicity
IL-11 or induced Edema following
Oprelvekin thrombocytopenia Neutropenic fever myeloablative
in adult patients Hypersensitivity therapy.
with nonmyeloid reactions Anemia (will resolve
malignancies CV abnormalities after treatment)
(Afib)
Pleural effusion
Papilledema
Abbreviation: Afib, atrial fibrillation; CV, cardiovascular; ITP, idiopathic thrombocytopenic purpura.
Hematopoietic Cytokines
Hematopoietic cytokines stimulate growth and differentiation of various elements

of bone marrow. Three cytokines: erythropoietin, granulocyte colony-stimulating
factor (G-CSF), and granulocyte-macrophage colony-stimulating factor (GM-
CSF), have now been in routine clinical use to stimulate cell production (Table 9-
13). A trial of recombinant GM-CSF for use in pulmonary alveolar proteinosis is
currently in progress.
Table 9-13. Summary of Hematopoietic Cytokine Therapies Approved for

Clinical Use
Drug
Approved Indication Adverse Effects
Generic Trade
Sargramostim Leukine Acute myelogenous leukemia Bone pain, malaise, fever,
(Recombinant and bone marrow or stem cell diarrhea, edema, and rash
GM-CSF) transplants
Filgrastim Neupogen Acute myelogenous leukemia, Skeletal muscle pain, bone
(GM-CSF) bone marrow or stem cell pain, alopecia, fever, rash,
transplants, and severe chronic and injection site reaction
neutropenia
Pegfilgrastim Neulasta Nonmyeloid malignancies Bone pain, myalgia,
(Pegylated alopecia, fever, rash, and
GM-CSF) edema
Epoetin alpha Epogen, Anemia due to chronic renal Hypertension, thrombotic
Procrit failure, HIV-infected patients, complication, and allergic
chemotherapy, and primary bone reactions
marrow disorders
Darbepoetin Aranesp Anemia due to chronic renal Mild transient injection site
alpha failure, HIV-infected patients, pain, and hypertension,
chemotherapy, and primary bone thrombotic complication,
marrow disorders and allergic reactions
Abbreviation: GM-CSF, granulocyte monocyte colony-stimulating factor.
458 / CHAPTER 9
ANTICYTOKINES AS THERAPEUTIC AGENTS
Tumor Necrosis Factor-Alpha Inhibitors
Tumor necrosis factor-alpha (TNFα) plays a central role in inflammatory

arthritides, including rheumatoid arthritis (RA), psoriatic arthritis (PsA), and
ankylosing spondylitis (AS). Currently available anti-TNFα strategies involve
either administration of anti-TNFα antibody or soluble TNF receptor to bind
circulating TNFα before it binds to receptors on nearby cells, thus preventing
initiation of apoptosis or an inflammatory response. There are five currently
available TNF inhibitors (Table 9-14).
Table 9-14. Comparison of Tumor Necrosis Factor-Alpha Inhibitors

Infliximab Etanercept Adalimumab Certolizumab pegol Golimumab
Trade name Remicade Enbrel Humira Cimzia Simponi
Structure Chimeric (25% mouse/ Recombinant dimeric Fully human anti-TNFα Polyethylene-glycolated Human IgG1κ monoclonal
75% human) fusion protein made of two monoclonal IgG1 antibody humanized Fab' fragment antibody specific for human
IgG1κ monoclonal antibody soluble p75 TNF receptors of a human anti-TNF α TNFα
(CD120b) and constant Fc antibody
portion of human IgG1
Binds To TNFα TNFα and TNFβ TNFα TNFα TNFα. (Binds both soluble
(lymphotoxin α) and transmembrane
bioactive forms)
Approved RA, AS, Crohn's disease, RA, AS, PsA, plaque RA, AS, Crohn's disease, RA and Crohn’s disease RA, AS, and PsA.
Indications ulcerative colitis, PsA, and psoriasis, and juvenile PsA, severe plaque
plaque psoriasis idiopathic arthritis psoriasis, juvenile
idiopathic arthritis
Adverse Acute infusion reactions: Mild injection site reactions, Injection site reactions, Serious infections, Upper respiratory
Effects fever, chills, pruritus, chest serious infections, TB, upper respiratory infections malignancies, and heart infections, nasopharyngitis,
pain, dyspnea, flushing, sepsis, neurologic events, (sinus infections), failure serious infections, TB,
urticaria, hypersensitivity hematologic events, and headache, rash, nausea, invasive fungal infections,
reactions, serious malignancies serious infections, TB, hepatitis B virus
infections, TB, sepsis, and sepsis, malignancies, reactivation, malignancies
hepatosplenic T-cell anaphylaxis, hepatitis B (lymphoma), heart failure,
lymphomas virus reactivation, demyelinating disease, and
demyelinating disease, cytopenias
cytopenias, heart failure,
and “lupus-like” syndrome
Precautions Perform purified protein derivative (TB) testing prior to initiation of therapy and annually (risk of reactivation)
Safety measures should also be taken in monitoring those with heart failure using this class of medication. Monitor for the development of
autoantibodies and increases in liver function test results. Vaccination with live vaccines is not recommended while patients are receiving TNF
inhibitors.
Abbreviations: AS, ankylosing spondylitis; PsA, psoriatic arthritis; RA, rheumatoid arthritis; TB, tuberculosis.
Flash Card Q15

What TNF antagonist
binds both TNFα and
TNFβ?
460 / CHAPTER 9
Interleukin-1 Inhibitors
IL-1 production is induced by a variety of agents that stimulate molecular pattern
receptors, and it activates T lymphocytes by enhancing the production of IL-2 and
the expression of IL-2 receptors. IL-1 receptor antagonist (IL-1Ra) is a
glycoprotein produced by macrophages that competitively inhibits IL-1α and IL-
1β binding to IL-1 receptors (IL-1R). A biologically active engineered product of
IL-1Ra has been developed for clinical use in autoimmune disease and infection.
Another product, IL-1 Trap, is a long-acting IL-1 inhibitor that is a fully dimeric
fusion molecule. It comprises the extracellular component of the IL-1 receptor
(IL-1 receptor type I and IL-1 receptor accessory protein) and the Fc portion of
IgG1, which binds circulating IL-1β and IL-1α with very high affinity and
prevents its interaction with cell surface receptors. Recently, a human monoclonal
antibody has been produced that targets IL-1β. These different products are
Interleukin-2 receptor (IL-2R) is expressed on the surface of activated T
lymphocytes and B lymphocytes, and it is involved in their proliferation.
Therapies have evolved to curb IL-2Rα (CD25) over activity through monoclonal
antibody directed against the alpha chain of IL-2 receptor (Table 9-15). Other
approaches to IL-2R-targeted treatment of various cancers are under study and
include use of ligand-toxin fusion protein and immunotoxins.
Interleukin-6 (IL-6) has the ability to activate T lymphocytes, B lymphocytes,

macrophages, and osteoclasts and is a mediator of the hepatic acute-phase
response. A recombinant humanized IL-6 receptor monoclonal antibody of the
IgG1 subclass is currently pending approval in the US. The approved forms of
this product are listed in Table 9-15.
Interleukin-12 and -23 Inhibitor
Interleukin 12 has the ability to activate IFNγ production by NK cells and T cells.
It also enhances NK cell and cytotoxic T-lymphocyte (CTL)-mediated toxicity as
well as Th1 cell differentiation. It is secreted by both dendritic cells and
macrophages. IL-23 is involved in the development of Th17 cells. Recently, a new
human IgG1k monoclonal antibody against the p40 subunit of IL-12 and IL-23
Flash Card A15 has been developed, and is listed in Table 9-15.
Etanercept (Enbrel)
Janus Kinase 3 (JAK3) Inhibitors

JAK3 is a tyrosine kinase that belongs to the Janus family of kinases. Also in this
family are JAK1, JAK2, and TYK2. JAK3 is located in the cytosol and is
associated with cytokine receptors. Cytokine receptors lack signaling ability and
rely on JAKs to initiate signaling upon binding of their ligands. JAK3 is
predominately expressed in hematopoietic cells (NK, T, and B cells) and interacts
with members of the signal transduction and activators of transcription (STAT)
family in order to propagate signals. Recently, an inhibitor of JAK3 has been
approved for use in RA (Table 9-15).
Table 9-15. Anticytokines as Therapeutic Agents

Generic Drug Trade Approved
Name Indication
Anakinra Kineret Rheumatoid Injection site reactions, Live vaccines should
(recombinant arthritis and sepsis pneumonia, serious not be given while on
IL-1Ra) infections, hyper- therapy
sensitivity reactions
Rilonacept (IL-1 Arcalyst Cryopyrin- Injection-site reactions, Evaluate for latent TB
Trap) associated increased risk of before initiating
Canakinumab Ilaris periodic infection infections, therapy. Live
(human IgG1/κ syndromes hypersensitivity vaccines should not
against IL-1β) (CAPS): familial reactions, risk of be given concurrently
cold autoinflam- reactivation of TB or Taking with TNF
matory syndrome, new opportunistic inhibitors not
Muckle-Wells infections, and may recommended (may
syndrome, NOMID result in an increase increase the risk of
in the risk of serious infections)
malignancies Monitor lipid profile
Basiliximab Simulect Prophylaxis of Nausea, constipation,
(chimeric acute organ abdominal pain,
IL-2Rα) rejection in renal urinary tract infection,
transplant patients upper respiratory tract
infection, and
hypersensitivity
including anaphylaxis.
Daclizumab Zenapax Prophylaxis of Nausea, constipation,
(humanized acute organ headache,
IL-2Rα) rejection in renal hypersensitivity
transplant patients including anaphylaxis,
and hyperglycemia.
462 / CHAPTER 9
Table 9-15. Anticytokines as Therapeutic Agents, cont.

Generic Drug Trade Approved
Name Indication
Tocilizumab Actemra Rheumatoid Infusion reactions, Careful administration
(humanized arthritis, serious infections, in those with
IL-6Rα) Castleman’s anaphylactic shock or concurrent active
disease an anaphylactoid infection or suspected
reaction, pleurisy, infection, previous
abnormal lipid tuberculosis, patients
parameters, and in an immune
cardiac abnormalities compromised state,
or patients with an
intestinal diverticulum
No live vaccines
during treatment
Lipid tests, LFTs, and
cardiac function
should be monitored
periodically
Ustekinumab Stelara Plaque psoriasis Increased infections Evaluate for TB prior
(human IgG1/κ Increased risk of to starting therapy
against p40 malignancy No live vaccines
subunit of IL-12 during treatment
and IL-23)
Tofacitinib Xeljanz Rheumatoid Increased infections Evaluate for TB prior
(inhibitor of arthritis Abnormal lipid to starting therapy
JAK3) parameters Monitor neutrophil and
Increased risk of lymphocyte counts,
malignancy hemoglobin level,
LFTs, and lipid levels
Abbreviations: LFTs, liver functions tests; NOMID, neonatal onset multisystem inflammatory
disease; TB, tuberculosis; TNF, tumor necrosis factor.
Chemokines
Chemokines function as regulatory molecules in leukocyte maturation, traffic,
homing of lymphocytes, and in the development of lymphoid tissues. In addition
to these roles, they are also critical in the pathogenesis of allergic responses,
infectious and autoimmune diseases, angiogenesis, inflammation, tumor growth,
and hematopoietic development. Specific therapies for several diseases, based on
chemokine receptor antagonists, are being developed.
Other Cytokines of Possible Importance

A number of cytokine therapies are in clinical development. Many cytokines,
including IL-5, IL-6, IL-7, IL-8, IL-10, IL-13, IL-15, IL-18, and IL-21 have been
used experimentally in animals; these are in clinical trials for various conditions,
but have not yet reached routine clinical use. A registry of clinical trials using
cytokine and cytokine receptor-mediated therapies can be found on the National
Institutes of Health clinical trials website.
CELLULAR IMMUNE RECONSTITUTION

Key Fact
Stem cell transplantation (SCT) is used to replace defective, absent, or malignant Factors associated with
cells in an affected host, with pluripotent hematopoietic stem cells from a healthy improved survival after
donor (see sections on PID and stem cell transplantation in Chapter 8). Cellular SCT include the following:
immune reconstitution is a complex process that is influenced by many variables. Younger age (<3.5
This section reviews the most generally accepted aspects of immune months for SCID, < 5
reconstitution, with a focus on immune reconstitution after SCT for PID. years for chronic
granulomatous disease
(CGD), Wiskott-Aldrich
syndrome (WAS)
Factors That Affect Cellular Immune Reconstitution SCID phenotype with
absent NK cells (i.e.,
XL-SCID, ADA
Numerous elements contribute to success following hematopoietic stem cell
deficiency, Jak3)
transplant (HSCT), as shown in the following lists. HLA-identical stem cell
donor
HSC Factors No pretransplant
Human leukocyte antigen (HLA) compatibility conditioning for SCID
Related vs. unrelated donor Larger dose of CD34+
stem cells, and a lower
Source: Cord, peripheral, bone marrow dose of mature T
T-cell depletion vs. CD34+ selection lymphocytes
Absence of viral or
Patient Factors fungal infections at the
Age time of transplantation
Type of gene defect
Pretransplant infection (CMV, EBV) Key Fact
Organ function damage The defects related to
+/– Myeloablative conditioning Wiskott-Aldrich
Use of lineage-specific mAbs syndrome protein
(WASP) expression (i.e.,
+/– GVHD prophylaxis cell migration, immune
synapse stability, and
Post-Transplant Factors susceptibility to
Degree of chimerism infection) may be
overcome by partial
Use of booster HSCT chimera in immune cell
Persistence of immune reconstitution lines. However, in order
Effects of myeloablative chemotherapy (early/late) to achieve resolution of
Chronic infections the autoimmune
manifestation of the
Chronic GVHD disease, a full donor
Autoimmunity chimera is necessary.
Malignancies Post-transplant function
Neuropsychological development and quality of life of B cells is more likely
when the patient has
genetically normal B cells
Donor type and HLA matching have a profound effect on immune reconstitution prior to transplant (i.e., IL-
and engraftment. (See section on stem cell transplantation in Chapter 8). Although 7R mutations).
464 / CHAPTER 9
inconceivable in an immunocompetent host, such as a patient with cancer or a

non-T–lymphocyte primary immunodeficiency, T–lymphocyte-depleted haploid-
identical related (parental) donors can be used in patients with no innate T-
lymphocyte function, such as SCID. Successful SCT has been reported using a
wide variety of related and unrelated donor types, including HLA-identical
siblings, T–lymphocyte-depleted haploidentical related, matched unrelated, and
matched related and unrelated cord blood transplants. Survival after transplant is
dependent on both HLA matching and source of the donor. HLA-identical related
donation has the highest survival, followed by HLA-identical unrelated, and then
HLA-mismatched related. Marrow from a matched related sibling confers
immune function to the patient within 2 weeks since both stem cells and activated
mature immune cells are transferred to the patient and are the best tolerated by the
host. Table 9-16 differentiates between the various sources of HCST and some of
the primary differences associated with them.
Conditioning regimes, prior to bone marrow transplantation in PID, range from

full myeloablation to no pretransplant conditioning. Although the intensity of the
pretransplant conditioning is directed by the underlying immune defect, the type
of conditioning can affect post-transplantation immune reconstitution (Table
9.17).
For many PIDs, the use of “reduced” or “minimal” intensity regimens are being
employed to reduce the adverse complications associated with myeloablative
regimens. Some examples of myeloablative versus newer reduced and minimal
intensity regimens are the following:
Myeloablative
o Total body irradiation (TBI) + cyclophosphamide
o Busulfan (high dose) + cyclophosphamide
o Treosulfan + cyclophosphamide
Reduced Intensity (can be given with or without a donor lymphocyte infusion)
o Fludarabine + treosulfan
o Fludarabine + melphalan
o Fludarabine or cyclophosphamide + busulfan (low dose)
Minimal Intensity (+/– alemtuzumab [Campath] or antithymocyte globulin
[ATG])
o Fludarabine + cyclophosphamide
Many adverse effects are associated with myeloablative therapies. Some of the
primary organs affected by select drugs are the following:
Radiation: Lungs, heart
Cyclophosphamide: Heart
Busulfan/treosulfan: Lungs, gastrointestinal
Fludarabine: Lungs, gastrointestinal
Melphalan: Lungs, gastrointestinal
Table 9.16. Hematopoietic Cell Sources for Stem Cell Transplant
Peripheral Blood Umbilical Cord

Characteristic Bone Marrow (BM)
Stem Cells (PBSC) Blood
Sources (donor) Matched related Mismatched related Matched related or

Mismatched related unrelated Key Fact
Matched unrelated
The alleles used in typical
eight-allele HLA matching
How/where From large bone of Given hematopoietic From UC blood (~ 50
are HLA A, -B, -C, and -
obtained donor (i.e., pelvis) growth factors (G-CSF, mL)
under general GM-CSF) to allow DRB1. For umbilical cord
anesthesia release of stem cells transplants (six vs. eight
into peripheral blood. alleles used), they are
Collected through HLA-A, -B, and -DRB1.
apheresis
The target dose of
CD34+ stem cells is
HLA matching: Higher match = better outcomes More permissive approximately 2 × 108
matching than marrow or
cells/kg.
PBSC
Minimum 6 of 8 HLA match 4 of 6 HLA match

requirements for
unrelated donors
(NMDP)
Time to Medium Fastest Slowest

neutrophil
engraftment
CD34+ cell dose Adequate Good Low
T-cell content Low High Low, functionally

immature
Flash Card Q16
Time to identify ~2 months ~1 month
and collect cells What type of donor can
from unrelated be used in immune
donors deficiencies with no T
cell function (i.e., SCID)
Risk of acute Medium Highest Lowest that can NOT be used in
GVHD in any other type of
recipient immune deficiency?
Risk of chronic Medium Highest Lowest

GVHD in
recipient
Flash Card Q17
Second donation Potentially available (donor availability) Not available (though
(to salvage graft may obtain second unit) What type of
failure or relapse) conditioning regimen(s)
will lead to mixed-
chimerism of donor and
host cells?
466 / CHAPTER 9
Table 9.17: Need for Conditioning in Select Primary Immunodeficiencies

Based on Donor Type
Unrelated/
Matched Related
PID Mismatched
Donor
Donor
B+ SCID (XL-SCID, Jak3, IL-7Rα, CD3 No Possibly
chain, CD45)
B- SCID (ADA, reticular dysgenesis) No Yes
Omenn’s syndrome Yes Yes
PNP Yes Yes
Artemis Reduced intensity Reduced intensity

Other SCID variants
DNA ligase IV Reduced intensity Reduced intensity

deficiency
ZAP-70 No No
Complete DiGeorge syndrome No No
Chronic granulomatous disease Yes Yes
Hyper-IgM syndrome (CD40L or CD40) Yes Yes
Other: Yes Yes

Wiskott-Aldrich syndrome (<5 years old)
X-linked proliferative disease (XLP)
Leukocyte adhesion deficiency (LAD)
MHC II deficiency
Griscelli’s syndrome
Hemophagocytic lymphohistiocytosis (HLH)
Flash Card A16

T–lymphocyte-depleted
haploidentical related Graft-Versus-Host Disease (GVHD) can affect the overall survival of the graft
(i.e., parental donors) and the morbidity and mortality of the host.
Factors reducing the risk of GVHD include:
Prophylaxis with immune suppressive drugs (i.e., steroids and calcineurin
inhibitors)
Flash Card A17
Selective depletion of alloreactive T lymphocytes from donor grafts
Nonmyeloablative or Using umbilical cord blood as a source
reduced-intensity Choosing more closely related HLA-matched donors
conditioning.
(Myeloablative
conditioning leads to When GVHD develops, the patient must be treated with immunosuppressive
higher rate of donor T-cell therapy. Although they suppress the pathologic activated donor T lymphocytes,
and B-cell engraftment)
these drugs also theoretically suppress the development of the therapeutic donor
stem cells in the host. Standard treatment regimens make use of corticosteroids in
addition to cyclosporin or tacrolimus, though patients only have a 50% response
rate. Newer agents being used include:
Monoclonal antibodies (anti-CD3, anti-CD5, and anti-IL-2)
Mycophenolate mofetil (CellCept)
Alemtuzumab (Campath)
ATG
Sirolimus
Time to Engraftment
After HSCT:
T lymphocytes will be of donor origin (chimerism can occur in patients with
pretransplant T-cell function)
Other cell lines (B cells, dendritic cells (DCs), neutrophils, platelets, RBCs)
can be of donor origin (if myeloablative regimen) or chimeric (if reduced
intensity regimen).
Key times in immune reconstitution (Innate T lymphocytes B lymphocytes):

Innate immunity recovers quickly (unless GVHD)
o Neutrophils in first few weeks
o NK cells by 1 month
o Donor DCs seen later (host DCs can persist up to 1 year)
By 3 months: T lymphocytes should be present in circulation, some B Flash Card Q18
lymphocytes
What two SCID types
o Patients vulnerable to opportunistic infections prior to this should NOT undergo
o CD8 cells recover prior to CD4 cells (leads to CD4:CD8 ratio of <1) myeloablative
conditioning, regardless
Between 1–2 years: Peak thymic T-cell output of donor type?
Between 2–3 years: B-lymphocyte function (if at all)
Functional reconstitution can take up to 24 months
Monitoring should include various studies (Table 9-18). Flash Card Q19
Which mitogen
assesses both T and B
lymphocyte function?
Flash Card Q20

What mitogen bypasses
the T-cell receptor?
468 / CHAPTER 9
Table 9-18. Monitoring Reconstitution: Quality Not Quantity

Cell Type Assay Measure
T lymphocytes Flow cytometry Quantification of T-
Key Fact lymphocyte numbers and
phenotypes (e.g., CD3, CD4,
Children with SCID CD8, CD45RA/RO)
should never receive live CDR3 spectratyping TCR repertoire diversity,
viral vaccinations, even clonality, thymic recovery
after SCT because there
TREC Naïve T-lymphocyte
have been reports of production, thymic output
SCID patients with
apparently normal T- Mitogen or antigen stimulation Qualitative T-lymphocyte
lymphocyte function (PHA, ConA, PWM, tetanus, function
Candida)
succumbing to varicella
after vaccination. Tetramers HLA class I or II antigen-
Instead, acyclovir specific function
prophylaxis should be DTH T lymphocyte function
given after exposure or
Cytotoxic assays Cytotoxic T-lymphocyte lytic
the patient should be function
admitted for IV acyclovir
treatment if symptomatic. Mixed lymph proliferation Donor/recipient in vitro
reactivity
Flow cytometry CD19, CD21, CD27 (memory)
B-lymphocyte excision circles Class switching
B lymphocytes
Serology Quantitative antibodies and
functional responses
Flash Card A18 Flow cytometry CD16, CD56
NK cells
Cytotoxic assay Lytic function
Artemis and DNA ligase 4
deficiency. A full Neutrophil DHR Oxidative burst (CGD)
myeloablative regimen Flow cytometry CD18 (LAD Type I)
would kill these patients Abbreviations: CDG, chronic granulomatous disease; CDR3, compliment determining region 3;
as they lack DNA repair DHR, dihydrorhodamine; DTH, delayed type hypersensitivity; HLA, human leukocyte antigen; MLR,
capabilities. In some mixed leukocyte reaction; PHA, phytohemagglutinin; PWM, pokeweed mitogen;. TREC, T
circumstances a reduced- lymphocyte receptor excision circle.
intensity conditioning
regimen can help increase
survival of transplant
Special Considerations: Vaccinations Post-SCT

Flash Card A19
Patients who receive stem cell transplantation after myeloablative treatment for
Pokeweed mitogen malignancy should be reimmunized as though they had a naïve immune system
(PWM)
post-transplantation. Table 9-19 gives an example of a reimmunization schedule
following SCT for otherwise healthy individuals.
Vaccines that are NOT recommended for use in post-HCT patients include bacille
Flash Card A20 Calmette-Guérin (BCG), oral polio, intranasal influenza, cholera, typhoid (oral or
Phorbol myristate acetate intramuscular), rotavirus, yellow fever, or varicella-zoster.
(PMA)
Table 9-19. Vaccination Recommendations After HCT (Autologous and

Allogenic)
Immunization Time After Doses* Notes
HCT (months)
Tetanus, diphtheria, 6–12 3 May consider additional dose for
acellular pertussis older children/adults
DTaP preferred (use Tdap in
adults)
Inactivated polio 6–12 3
Pneumococcal 3–6 3–4 Give three PCV13 doses, consider
PPSV23 to broaden immune
response
Haemophilus influenzae B 6–12 3
Influenza (seasonal) 4–6 1–2 For children < 9 years old, two
doses yearly between transplant
and 9 years of age
Hepatitis B 6–12 3
Hepatitis A 12 2 6 months between doses
Meningococcal 6–12 1
Measles, mumps, rubella 24 1 Contraindicated in those with active
(MMR) graft-vs.-host disease (GVHD) or
who are immunosuppressed
Varicella N/A N/A Contraindicated at this time
a
No specific recommendation on intervals between doses (at least 1 month).
Adapted from Centers for Disease Control and Prevention vaccines website. See hemato cell
transplants.
IMMUNOPROPHYLAXIS VACCINE
Primary and secondary immunodeficiencies have specific vaccine

contraindications and risk-specific recommendations (Table 9-20).
470 / CHAPTER 9
Table 9-20. Vaccine Contraindications and Recommendations for Primary

and Secondary Immunodeficiencies
Specific Risk-Specific
Category Contraindicated
Immunodeficiency Recommendations
Primary immunodeficiencies
B lymphocyte Severe (XLA and Most live vaccines Pneumococcal
CVID) (OPV, smallpox, live Influenza
influenza, BCG, and
live oral typhoid) Consider measles and
varicella
IVIG can interfere with
response to measles
Less severe (IgA and None Pneumococcal
IgG subclass) Influenza
All vaccines probably
effective
T lymphocyte Complete defects All live vaccines Vaccines may be
(SCID) ineffective
Partial defects (AT, All live vaccines Vaccine effectiveness
WAS, and majority of dependent upon degree
DiGeorge of immunosuppression
abnormalities)
Complement Early or late None Pneumococcal
Meningococcal
Influenza
(All effective)
Phagocyte CGD and LAD Live bacterial Pneumococcal
Influenza
Inactivated and live viral
vaccines likely safe and
effective
Secondary immunodeficiencies
HIV OPV, Smallpox, BCG, Influenza
LAIV, Pneumococcal
Withhold MMR and Hib
varicella if severely
immunocompromised Meningococcal
MMR okay if
asymptomatic or mildly
symptomatic and
CD4+>15% for age
Malignancy Live vaccines contraindicated depending on level

of immunosuppression; inactivated may not be
as effective
Steroids If <2 weeks; okay to give all vaccines
If > 20 mg/day for ≥ 2 weeks: wait one month
after stopping steroid
Table 9-20. Vaccine Contraindications and Recommendations for Primary

and Secondary Immunodeficiencies, cont.
Specific Risk-Specific
Category Contraindicated
Immunodeficiency Recommendations
Secondary immunodeficiencies
Other immunosuppressive drugs Inactivated: okay to give vaccine (may not be

effective)
Live: avoidance
Anti-TNF agents may re-activate latent TB
Inactivated: may be ineffective (need
readministration)
Chemotherapy
Live: wait three months after chemotherapy
stopped
Transplant (hematopoietic stem cell transplant) Antibody titers decline one to four years after
transplant;
Should be revaccinated routinely after
transplant;
(see individual recommendations in Table 9-19)
IVIG HIV patients on IVIG: Give live vaccine two
weeks before next scheduled IVIG dose,
although optimal response may not occur
Patients may not respond to MMR and Varicella
if on IVIG due to passively-acquired antibody;
Regarding live vaccines (MMR, Varicella) and
IVIG:
If IVIG given first, wait 8 to 11 months to give
live vaccine (depends on IVIG dose and
indication);
If live vaccine given first, wait two weeks to give
IVIG
Pregnancy Contraindicated: live vaccines
Okay: Td/Tdap, influenza (inactivated), IPV,
HepB, HepA, and meningococcal
Breast feeding Only contraindication is smallpox
Immunosuppression in household Only contraindication is smallpox
Preterm birth Vaccinate on same schedule as full term Flash Card Q21
children;
Only exception: HepB at birth has decreased How long after
seroconversion if weight is ,< 2 kg administering a live
vaccine should you wait
Asplenia None contraindicated; to give a patient an IVIG
Vaccinate against encapsulated bacteria infusion?
(Pneumococcal, meningococcal, and Hib);
Try to give 2 weeks before elective splenectomy
Chronic renal failure LAIV contraindicated (should get inactivated
influenza);
Recommended: Pneumococcal and HepB Flash Card Q22
Abbreviations: AT, ataxia telangiectasia; Hib, Haemophilus influenzae type B; HepA, hepatitis A; What two vaccines
HepB, hepatitis B; IPV, inactivated polio vaccine; IVIG, intravenous immunoglobulin; LAIV, live should be administered
attenuated intranasal vaccine; MMR, measles, mumps, rubella; OPV, oral polio vaccine; Td/Tdap, during pregnancy, if
tetanus, diphtheria, pertussis WAS, Wiskott-Aldrich syndrome.
patient is not up to date?
472 / CHAPTER 9
APHERESIS
Apheresis can be defined as the act of running donor blood through a filtering
machine that removes a particular constituent and returns the rest of the unfiltered
segment back to the donor. It is invasive, must be performed often, and can result
in minor volume losses that would need to be replaced. The following are the four
different types of apheresis:
Plasmapheresis: Useful for collecting fresh frozen plasma (FFP), immune
globulin, WBC and RBC antibodies. Used to treat Guillain-Barré syndrome,
lupus, hyperviscosity syndromes (cryoglobulinemia, paraproteinemia,
Waldenström’s macroglobulinemia), and thrombotic thrombocytopenic
purpura.
o Intravenous Immunoglobulin (IVIG): Pooled IgG that is collected
from various donors via plasmapheresis, used to treat a whole host of
immune deficiency states, confers passive immunity, and reduces
infection by trying to maintain a steady state of antibody in the patient.
It will be discussed fully in another section.
Thrombapheresis: Useful for collecting platelets, which can be used to treat
thrombocytopenia.
Leukapheresis: Useful for collecting neutrophils, eosinophils, and basophils.
Commonly used to treat leukemia, as well as autoimmune diseases, such as
ulcerative colitis and rheumatoid arthritis. Granulocyte infusions can be used
in the treatment of severe infections in CGD (i.e., aspergillosis).
Stem Cell Harvesting: Useful for collecting bone marrow stem cells to be
used in stem cell transplantation.
ANTI-INFLAMMATORY AGENTS
CYCLOOXYGENASE (COX) PATHWAY
Flash Card A21 Cycloxygenase-1 (COX-1) is constitutively expressed in most tissues and
involved in regulating normal cellular processes, such as gastric cytoprotection,
2 weeks
vascular homeostasis, platelet aggregation, and kidney function.
Cycloxygenase-2 (COX-2) is usually undetectable in most tissues and is inducible

during inflammatory states. COX-2 expression is inhibited by glucocorticoids,
Flash Card A22 which may contribute to their significant anti-inflammatory effects.
Tdap, and influenza
(inactivated)
A splice variant derived from the COX-1 gene has been described as COX-3,
which appears to be expressed at a high level in the central nervous system.
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)
The primary effect of NSAIDs is to inhibit cyclooxygenase, thereby impairing the

ultimate transformation of arachidonic acid to prostaglandins, prostacyclin, and Key Fact
thromboxanes (Figure 9-3). COX-2 inhibition: Anti-
inflammatory effects of
Nonselective NSAIDS include the following: NSAIDS
Propionic acid derivatives (ibuprofen, naproxen, and ketoprofen) COX-1 inhibition:
Undesirable adverse
Acetic acid derivatives (indomethacin and diclofenac) effects (see under
Enolic acid derivatives (piroxicam and meloxicam) Pathogenesis)
Fenamic acid derivatives (mefenamic acid) AERD patients typically
tolerate acetaminophen
Weak inhibitors of COX-1 (usually well tolerated in aspirin hypersensitivity) at doses < 1000 mg
include: acetaminophen, salsalate, azapropazone, choline magnesium trisalicylate,
and diflunisal.
Selective COX-2 inhibitors include celecoxib, etoricoxib, lumiracoxib, parecoxib,

rofecoxib, and valdecoxib. These are generally well tolerated in patients with
aspirin sensitivity.
NSAIDS have also been demonstrated in vitro to inhibit NFκB-dependent

transcription, leading to inhibition of inducible nitric oxide synthetase (iNOS).
Induced nitric oxide synthetase produces large amounts of NO, leading to
increased inflammation, including vasocongestion, cytotoxicity, and vascular
permeability.
Adverse Effects
All NSAIDs are absorbed completely, have negligible first-pass hepatic

metabolism, and are tightly bound to albumin. The patients with low albumin
(liver disease) have higher free serum concentration of the drug. Common adverse
effects include gastrointestinal toxicity, including dyspepsia, peptic ulcer disease,
and bleeding. Other adverse effects can include acute renal failure due to renal
vasoconstriction or interstitial nephritis, worsening of underlying hypertension,
increased liver transaminases, anaphylaxis (IgE-mediated reaction), TEN or
Stevens-Johnson syndrome, and aspirin-exacerbated respiratory disease (AERD).
474 / CHAPTER 9
HYPERSENSITIVITY TO ASPIRIN AND NSAIDS
The classic aspirin triad (aspirin sensitivity, asthma, and nasal polyps) was
described by Samter and Beers in 1968 (a.k.a “Samter’s triad”). The prevalence of
AERD, a tetrad consisting of Samter’s triad in addition to chronic rhinosinusitis,
is approximately 5–10% in asthma patients.
Pathogenesis
This is a non-IgE-mediated reaction. There is an increased expression of
leukotriene C4 synthase as well as enhanced expression of cysLT1 receptor in
patients with ASA and/or NSAID hypersensitivity. Blocking the cyclooxygenase
pathway by COX-1 inhibitors leads to the overproduction of leukotrienes by the
lipoxygenase pathway. Increased LTD4 causes acute bronchoconstriction and
increased vascular permeability. Urine LTE4 can be measured to reflect the
increased production of cysLTs. Levels of prostaglandin E2 (PGE2) is decreased
by COX-1 inhibition. PGE2 is an inhibitor of 5-lipoxygenase pathway; thus,
selective COX-2 inhibitors are generally tolerated in these patients.
Presentation
Age of presentation is usually between second and forth decade. Majority of
patients initially develop refractory rhinitis, followed by anosmia and nasal
polyposis. The “classic” adverse reaction to aspirin includes bronchospasm of
varying severity, usually accompanied by profuse rhinorrhea, and nasal
congestion. Some patients experience skin rash, and erythema of the head and
neck.
Diagnosis and Treatment

The definite diagnosis of AERD or aspirin-induced asthma can only be
established through aspirin provocation challenges. There are four types of aspirin
provocations: oral, inhalation (bronchial), nasal, and intravenous. Certain asthma
medications, such as SABAs, should be withdrawn before the aspirin challenge.
Oral Aspirin Challenge/Desensitization

Assessment (1 week prior to procedure): FEV1 > 70% predicted (if low, consider
systemic steroid burst); continue treatment with ICS and/or LABA. Start
leukotriene inhibitor (e.g., 10 mg montelukast).
Procedure: Should be done in a monitored environment. Several protocols are

available; two of which are outlined in Table 9-21. When performing the
Table 9-21. Aspirin Oral Challenge/Desensitization Protocols for AERD

Protocol 1 Protocol 2
Time (hr) Aspirin Dose (mg) Time (min) Aspirin Dose (mg)
Day 1: Onset 30 0 20.25
Day 1: 3 60 90 40.5
Day 1: 6 100 180 81
Day 2: Onset 150 270 162.5
Day 2: 3 325 360 325.00
Day 2: 6 650
challenge, reactions typically will occur with low doses (20–101 mg). These Key Fact
reactions should be treated before continuing protocol. After patient is stabilized,
Reactions to aspirin
the provoking dose should be repeated. A persistent decrease in FEV1 ≥ 15% for during an oral
more than 3 hours is an indication to discontinue desensitization for the day. desensitization protocol
Typical protocol will take 2 days (even with protocol 2). typically occur at lower
doses (e.g., ~40 mg).
Postprocedure: The patient will take the daily dose (usually 650 mg twice daily)
indefinitely, though the patient can sometimes be weaned to as low as 325 mg
once or twice daily, based on control of symptoms. Patients should not be weaned
to lower than 325 mg, however, as they may lose desensitized state against
respiratory symptoms. This procedure can have beneficial effects on asthma
(decreased hospitalizations and need for systemic steroids), sinusitis, and the
recurrence of nasal polyps (though NOT the size). The desensitized state only
lasts as long as daily administration is continued. If a dose is missed, the
refractory period may last 48–72 hours.
SURGICAL INTERVENTIONS
WITH SINUSES OR MIDDLE EAR Flash Card Q23
What arachidonic acid
derivatives contribute to
Sinus Interventions the clinical
manifestations of AERD?
Indications
Complications of sinusitis (meningitis, brain abscess, cavernous sinus
thrombosis, and Pott’s tumor)
Flash Card Q24
Recurrent or persistent infectious sinusitis refractory to medical management
after failing multiple rounds of antibiotics with adequate antimicrobial What treatment should
coverage be initiated prior to
performing aspirin
desensitization?
476 / CHAPTER 9
Obstructive nasal polyps despite an adequate trial of medical management

(surgical cure is an exception; usually combined medical and surgical
approaches are required)
Anatomic blockage thought to contribute to infection, such as ostiomeatal unit
blockage, adenoidal hypertrophy (especially in children), and nasal septal
deviation thought to contribute to nasal blockage or recurrent sinusitis
Biopsy for evaluation of possible Wegener’s granulomatosis, tumor, ciliary
dyskinesia, and fungal infection
Maxillary antral puncture required for culture and guiding antibiotic treatment
Functional endoscopic sinus surgery (FESS) is now the surgical standard of care.
FESS restores adequate sinus drainage by establishing patency of the ostiomeatal
complex and provides at least moderate improvement of symptoms in up to 90%
of properly selected patients.
FESS typically involves maxillary antrostomies, opening of the sinus ostia, and
removing the uncinate process. Radical ethmoidectomy may be done to eradicate
severe nasal polyps. Complications of FESS include bleeding, orbital trauma,
cerebrospinal fluid rhinorrhea, secondary infections, and mucoceles. Frontal and
sphenoid sinus surgeries are associated with an increased complication rate due to
their locations.
Middle Ear Interventions

Tympanocentesis: May provide rapid relief from pain in severe acute otitis
media (AOM). May serve as a means of obtaining cultures in chronic or recurrent
otitis.
Tympanostomy tubes result in a 62% relative decrease in otitis media with
effusion (OME) in the subsequent year (absolute decrease of 128 effusion days
per child in the subsequent year).
Indications
OME with structural damage
Recurrent OME (three or more episodes in 6 months or four or more in a year)
or persistent OME for at least 3 months (bilateral) or at least 6 months
Flash Card A23
(unilateral)
Decreased PGE2 (inhibits Hearing loss of 40 dB or greater in better ear (moderate hearing loss)
the 5-LPO pathway), and Hearing loss of 21–39 dB (mild hearing loss) in better ear if comorbidities
increased LTD4
(bronchoconstriction)
increase risk of developmental delay (e.g., mental retardation or cleft palate)
Repeat tympanostomy tubes should include adenoidectomy and myringotomy
in children older than 4 years of age according to American Academy of
Pediatrics
Flash Card A24
Antileukotriene therapy
CONTROVERSIAL TREATMENTS
Neutralization Therapy
After test doses of various agents (chemicals, allergens, food extracts, or other)
are administered by various routes (intradermal, subcutaneous, or sublingual),
patients self-administer these “neutralizing” substances for a variety of atopic and
nonatopic conditions. This is not standardized, has no established protocols, and
no convincing ramdomized controlled trials (RCTs) support this therapy.
Enzyme-Potentiated Desensitization (EPD)

A very low dose of allergen (equivalent to that used in prick testing) is
administered in combination with β-glucuronidase to treat a variety of atopic and
nonatopic conditions. Beta-glucuronidase is theorized to activate CD8
lymphocytes, thereby suppressing the immunogenicity of the allergen. Some
small trials have suggested some clinical improvements, but this is still
experimental.
Detoxification
Detoxification procedures, including but not limited to exercise, sauna/ or sweat
spas, vitamins, minerals, oils, nutritional therapy, and colon cleansing or enemas,
eliminate “toxic chemicals” from the body. Methods are anecdotal with no sound
evidence for “immunotoxicity” as a plausible cause of atopic disease.
Autogenous Urine Therapy

The ingestion of one’s own urine for supposed health benefits has occurred
throughout various cultures and times. Proposed presence of a substance known
as “proteose” in urine is supposed to have allergen-specific properties. The
patient’s own urine is prepared then injected SC for treatment of a variety of
allergic diseases. There is no rational basis for efficacy and, theoretically, it has
potential for harm (autoantibody production).
Homeopathy
Plant or animal extract ingestion (e.g., bee-transported pollen in honey) of very
small doses of allergens are claimed to promote tolerance. Not standardized.
478 / CHAPTER 9
There are both positive and negative trials, but meta-analysis failed to support any
benefit.
Acupuncture, Relaxation, Hypnosis, and Biofeedback

Although there are mixed reports of the efficacy of acupuncture for allergy
symptoms, most of the positive trials are methodologically flawed. Rigorous trials
have failed to support any of these methods over placebo.
Candida Hypersensitivity Syndrome (Yeast

Hypersensitivity Syndrome)
Various allergic and nonallergic ailments are hypothesized to be secondary to
sensitivity to a toxin released from Candida albicans. Diagnosis is based on
history. Treatment is based on dietary changes, possibly antifungal therapy. There
are no RCTs, and some elements of treatment have the potential for harm (e.g.,
liver or kidney toxicity from antifungals).
CARDIOPULMONARY RESUSCITATION
Basic “Code” Approach: Remember CAB
In 2010, the American Heart Associated recommended a change from the

previous A-B-C stepwise progression, to that of C-A-B. This places an emphasis
on performing chest compressions first. The new recommendations are as
follows:
Call 911 or ask someone else to do so; have them get automated external
defibrillator (AED) (if available). If you are the sole rescuer, do not leave to
call 911 and get AED initially. Wait until after five cycles of CPR (or 2
minutes).
Try to get the person to respond; if they don't, roll the person on his or her
back.
C = Start chest compressions. The proper technique involves placing the heel
of your hand on the center of the victim's chest with the other hand on top of
the first with fingers interlaced. Each press should compress the chest at least
2 inches in adults and children and 1.5 inches in infants. Rate should be 100
compressions per minutes (same rhythm as “Stayin’ Alive,” by the Bee Gees)
A = if trained in CPR, may proceed to open airway after first 30 compressions
(head tilt-chin lift; use jaw thrust if suspect cervical trauma).
B = assess breathing; if inadequate effort or no spontaneous respirations, start

rescue breathing with two, 1-second rescue breaths while watching for chest
to rise.
D = disability; useful to remember defibrillator (this should be part of initial
response if person unconscious).
Continue compressions and breaths (30 compressions, 2 breaths for all
persons) until help arrives (see differences for children below).
Differences Between Adult Versus Child or Infant CPR
Child victim (≤8 years old), two rescuers = use 15:2 compression to breath
ratio. Pediatric arrests are much more commonly pulmonary in nature.
AED use not recommended for infants (<1 year of age).
When a Secure Airway is Obtained (i.e., Intubation)
No longer cycle chest compressions and breaths. Instead, give 12 breaths per
minute and 100 chest compressions per minute simultaneously.
Choking in a Responsive Patient
Adults and children: Abdominal thrusts (Heimlich maneuver)

Infants (< 1 year of age): alternate five back blows and five chest thrusts
Choking in an unresponsive patient signals need to start CPR
Defibrillation
The most effective treatment for ventricular fibrillation and the most common
cardiac arrest rhythms
The probability of successful defibrillation decreases rapidly over time
Code Situations and Anaphylaxis
Do not forget that, in cases of anaphylaxis, epinephrine is both the drug of

choice and the initial medication. Even if the patient is on a β blocker, the
first drug given is epinephrine (0.01 mg/kg SC/IM of 1:1000 or 0.01 mg/kg Flash Card Q25
IV of 1:10,000 concentration).
What is the rate of
Glucagon may be given if patient is on a β blocker and does not respond to
compression when
epinephrine. performing CPR?
480 / CHAPTER 9
Do not forget adequate volume resuscitation and supplemental oxygen.

May also use H1 and H2 blockade and steroids.
Place patient supine to facilitate passive venous return to heart.
DERMATOLOGIC AND OPTHALMIC TREATMENTS
ATOPIC DERMATITIS
Prevention
Identify triggers and avoid irritants such as detergents, soaps, chemicals,
pollutants, abrasive materials, extreme temperatures, and humidity.
Treatment
Hydration—Soak skin in warm water for 10 minutes. This is important because
of decreased water-binding capacity secondary to decreased ceramide levels in
AD skin.
Moisturizers—Emollients restore and preserve stratum corneum layer. Water

content: lotions > creams > ointments.
Corticosteroids—Topical: Use most effective lowest potency formulation (Table

9-22). Ointments are the most occlusive and, therefore, provide better delivery of
medication. Thirty grams is needed to cover the entire body of an average adult.
Adverse effects: Thinning of the skin, telangiectasias, bruising,
hypopigmentation, acne, striae, and secondary infections. Use only low-potency
steroids on the face or groin. Oral steroids should be avoided when possible; if
necessary, can give a short course with taper.
Topical Calcineurin Inhibitors—Available preparations: Tacrolimus 0.03% and

0.1%, and pimecrolimus 1%. Black box warning for lack of long-term safety data;
therefore, used as second-line treatment only for those older than 2 years of age.
Avoid topical calcineurin inhibitors with occlusive dressings. Adverse effects:
Burning or stinging sensation.
Tar Preparations—Inhibit the influx of proinflammatory cells and expression of

Flash Card A25 adhesion molecules in response to allergen. Avoid use on acutely inflamed skin.
Adverse effects: Rare, but include photosensitivity and pustular folliculitis.
100/min
Table 9-22. Topical Steroids Arranged by Potency

Potency (Class) Topical Steroid
Very low (VII) Hydrocortisone 1%, 2.5%
Low (VI) Alclometasone dipropionate, desonide, fluocinolone, hydrocortisone

butyrate 0.1% (C)
Medium (IV-V) Betamethasone valerate, Desoximetasone 0.05% (C), fluocinolone
acetonide, fluticasone propionate 0.05% (C), hydrocortisone butyrate,
hydrocortisone valerate, mometasone furoate, triamcinolone acetonide
0.25–0.1%
Med-high (III) Amcinonide (C), fluticasone propionate 0.005% (O), Triamcinolone
acetonide 0.5% (C, O)
High (II) Amcinonide (O), betamethasone dipropionate, desoximetasone,
fluocinonide, halcinonide
Very high (I) Clobetasol propionate, diflorasone diacetate, halobetasol propionate
Abbreviations: C, cream, O, ointment. As a general rule, potency is as follows: ointment > cream >
lotion.
Wet Dressings—Cool the skin and act as a barrier to trauma; improve

penetration of topical corticosteroids. Adverse effects: Chilling, maceration of the
skin, and secondary infections.
Anti-Infective Therapy—May be indicated for secondary infections.

Semisynthetic penicillins or first- and second-generation cephalosporins. Avoid
maintenance antibiotic therapy. Topical antibiotic may be effective for treating
localized areas of infection. Can use mupirocin intranasally to reduce nasal
carriage of Staphylococcus aureus. Oral acyclovir for disseminated eczema
herpeticum. Recurrent cutaneous herpetic infections can be treated with daily
prophylactic acyclovir.
Antipruritic Agents—Antihistamines (first and second generations). Doxepin has

both H1- and H2-receptor-binding affinity and a long half-life. Avoid topical
antihistamines and anesthetics because of potential for sensitization.
Treatment of Recalcitrant Disease

Hospitalization—Removes patient from environmental allergens or stressors;
may be necessary for those with severe disseminated disease.
Cyclosporin A—Results in decreased transcription of a number or

proinflammatory cytokines; long-term treatment resulted in improvements in
disease activity. There is concern for irreversible nephrotoxicity with extended
treatment.
482 / CHAPTER 9
Phototherapy or Photochemotherapy—Decreases expression of activation

markers on CLA+ T cells. Available forms: UVB, narrow-band UVB, and high-
dose UVA1. High-dose UVA1 decreases dermal IgE-binding cells, including
mast cells and dendritic cells; also downregulates proinflammatory cytokines and
induces apoptosis of skin infiltrating CD4 T lymphocytes.
Recombinant Human Interferon-γ—Suppresses IgE synthesis and inhibits Th2

cell differentiation; results in reduced clinical severity and decreased total
circulating eosinophil counts in patient with AD.
Azathioprine—Systemic immunosuppressive agent affecting purine nucleotide

synthesis and metabolism. Adverse effects include myelosuppression,
hepatotoxicity, GI disturbances, increased susceptibility for infections, and risk of
developing skin cancer
Ophthalmic Treatments
Many different medications/combinations can be used in the treatment of ocular
allergies. They are listed in Table 9-23.
Table 9-23. Ophthalmic Treatments

Drug Available Mechanism of Side Effects
Preparations Action
Vasoconstrictors Tetrahydrozoline α Agonist: Constrict Rebound hyperemia if
Naphazoline conjunctival blood discontinued after
vessels prolonged or excessive
use
H1- First-generation: H1-receptor First-generation: CNS
antihistamines Pheniramine, antagonists; do not Second-generation:
antazoline, prevent histamine Headache and dry eye
levocabastine release
Second-generation:
Emedastine
Mast cell Cromolyn, lodoxamide Inhibit degranulation of Burning, dry eyes, and
stabilizers Nedocromil activated mast cells; eye swelling
Pemirolast most effective when
instituted before or
soon after the onset of
clinical symptoms
Vasoconstrictor Naphazoline + Constrict blood vessels Rebound hyperemia
or antihistamines antazoline and inhibit binding of
Naphazoline + circulating histamine
pheniramine
Antihistamine Olopatadine, ketotifen, Antagonize H1 Headaches and eye
and mast cell azelastine, alcaftadine, receptors, inhibit swelling
stabilizers and epinastine histamine release from
mast cells
Table 9-23. Ophthalmic Treatments, cont.

Drug Available Mechanism of Side Effects
Preparations Action
NSAIDs Ketorolac Inhibit prostaglandin Ocular burning,
and thromboxane stinging, conjunctival
synthesis hyperemia, and
corneal infiltrates
Corticosteroids Loteprednol etabonate Induce lipocortins, Glaucoma, cataracts;
Dexamethasone which inhibit the check IOP 3 months
sodium phosphate release of arachidonic after starting treatment,
acid (precursor to PGs then annually
and leukotrienes).
Abbreviations: CNS, central nervous system; IOP, intraocular pressure; PGs, prostaglandins.
GENE THERAPY IN PID
Refers to treatment resulting from insertion of a gene into somatic cells. The
transferred normal gene will express a normal product, thus correcting the
previously manifested defect.
Current technology, regulation, and predictable success are focused on lethal
single-gene defects.
Primary immune deficiency encompasses many disorders, and the
hematopoietic origin of the immune system provides an attractive platform for
gene therapy.
Gene therapy targeting hematopoietically immature cells allows the gene
copies to be carried throughout the cell lineages and passed to subsequent
generations.
Gene therapy has been used successfully in correcting the genetic defect in X-
linked, adenosine deaminase (ADA) deficiency SCID, and Wiskott-Aldrich
syndrome.
Active areas of research for future use of gene therapy in PIDs include other
forms of single-gene defect: SCID, CGD, LAD, and others.
Obstacles:
The major obstacle to widespread use of gene therapy is insertional
mutagenesis. Of particular concern is variant vector/gene integration into
unintended areas of DNA. In the case of X-linked SCID and WAS gene
therapy trials, development of leukemia has occurred. The concept of gene
therapy has been proven, and now the obstacle lies in vector engineering and
the safety of gene therapy. Examples of viral vectors are listed in Table 9-24.
Isolation of appropriate and specific cell populations.
Efficiency of transducing genes into target cells
484 / CHAPTER 9
Correction of defects in which proper regulation of gene expression is

required.
Viral Vectors
Table 9-24 summarizes the advantages and disadvantages of viral vectors.
RNA Interference (RNAi)/Post Transcriptional Gene

Silencing (PTGS)
RNAi uses antisense oligonucleotides to downregulate the expression of specific
mRNA molecules. This is mediated through the endogenous enzyme “Dicer,”
which cleaves long double-stranded RNA (dsRNA) molecules into short double-
stranded fragments called small interfering RNAS (siRNA). The siRNAs are
unwound into guide ssRNA molecules (a guide strand and passenger strand). The
guide strand is incorporated into the RNA-induced silencing complex (RISC),
which leads to gene silencing.
Table 9-24. Use of Viral Vectors

Viral Family Advantages Disadvantages
Retroviruses (gamma- Integrated genes are Potential for insertional
retroviruses) transferred to progeny cells mutagenesis, only shows
expression in actively dividing
cells
Lentiviruses (subclass of Can integrate into genome of Theoretical potential for
retrovirus) nondividing cells insertional mutagenesis
Lower tendency to integrate
into places than gamma-
retroviruses
Adenoviruses Generates high levels of Immune response to viral
transgene expression antigens may lead to
destruction of infected cells
Adenoassociated viruses Does not induce immune Can only carry transgenes of
(Parvoviridae) responses against infected small sizes; large-scale
cells production difficult
HSV Can carry large transgenes Residual neuronal cytotoxicity
and infects broad range of
cell types
Abbreviation: HSV, herpes simplex virus.
Specific Diagnostic
10 Modalities
SKIN TESTS
(IMMUNOASSAY FOR TOTAL AND SPECIFIC IgE)
TOTAL IgE
Measurement of total IgE has limited value in the diagnosis of atopy. IgE is
elevated in some immunodeficiencies and other disease states (Table 10-1).
Hyper IgE Conditions
T able 10-1 summarizes the conditions associated with a high total IgE.
Table 10-1. Disease States Associated with a High Total IgE Level and
Immunodeficiencies Associated with an Elevated Total IgE Level
Conditions with High Total IgE Immunodeficiency Plus Increased
Total IgE
Atopy (atopic dermatitis, AR, asthma, and Wiskott-Aldrich syndrome
allergic fungal sinusitis)
Hyper IgE syndrome
Infections (parasites, ABPA, HIV, TB, EBV,
CMV, viral respiratory infections) Omenn’s syndrome
Cutaneous (alopecia areata, bullous Di George’s syndrome

pemphigoid, chronic acral dermatitis, Netherton’s syndrome
streptococcal erythema nodosum)
Nezelof’s syndrome (cellular immunodeficiency
Oncologic (IgE myeloma and Hodgkin’s with immunoglobulins)
lymphoma)
Selective IgA deficiency
Kimura’s disease (Asian men in third decade,
and lymphadenopathy or adenitis of face and DOCK8 deficiency
neck)
AIDS
Churg-Strauss syndrome
GVHD and bone marrow transplantation
Other: Drug-induced interstitial nephritis, cystic
fibrosis, Kawasaki’s disease, burns, cigarette
smoking
Flash Card Q1
Abbreviations: ABPA, allergic bronchopulmonary aspergillosis; AR, allergic rhinitis; CMV,
cytomegalovirus; EBV, Epstein-Barr virus; GVHD, graft-versus-host disease; TB, tuberculosis. Where are the highest
concentrations of IgE-
producing plasma cells?
486 / CHAPTER 10
Measurement of Total IgE
Nephelometry or immunoassay
1 IU/mL = 2.44 ng/mL Standardized vs. World Health Organization reference
IgE serum
Clinical Features Regarding Total IgE
Generally nondiagnostic of allergic disease due to wide ranges (Atopic

diseases: Atopic dermatitis: mean 978 IU/L; range 1.3–65,208) and wide
overlap in the IgE distribution of atopic and nonatopic populations
Can be utilized as a screen for allergic bronchopulmonary aspergillosis
(ABPA) (>417 IU/mL) or to evaluate a patient for omalizumab candidacy
Key Fact
(indicated for moderate-to-severe persistent allergic asthma not controlled
Polymorphisms of with standard therapy if total IgE 30–700 IU/L)
CCL11 (eotaxin) are Hyper-IgE syndrome (ranges ~1000–50,000 IU/mL)
associated with serum IgE does not cross the placenta; undetectable at birth. Reaches a peak between
total IgE; increased in 10–15 years of age and then declines through adulthood. Rises at a rate slower
blacks, decreased in than IgG and comparable to IgA
whites.
Total IgE levels tend to be higher in men than women (not in children), higher
in blacks than whites, and higher 4–6 weeks after the pollen season
Decreased IgE seen in familial IgE deficiency and recurrent sinopulmonary
infections, HTLV-1 infections, primary biliary cirrhosis
SPECIFIC IgE TESTING
Detection of serum-specific IgE—sensitization—does not equal allergic disease.

Sensitization occurs in 8–30% of the population when using a standard panel of
aeroallergens. Thirty percent to 60% of sensitized individuals may develop future
clinically relevant allergic symptoms.
Skin Testing
Skin Prick Testing (SPT)—See Table 10-2 for skin test for early- and late-phase
mediators.
Flash Card A1
Tonsils and adenoids
SPECIFIC DIAGNOSTIC MODALITIES / 487
Table 10-2. Early- and Late-Phase Mediators

Early-phase Mediators: Late-phase Mediators: 1–2 hr,
a
Immediate Reaction Peaks 6–12 hr, Resolves 24–48 hr
Histamine CD4+ T cells
Tryptase Eosinophils
Substance P
Calcitonin gene-related peptide
a
Late-phase reaction does not predict symptoms on exposure and is not used in the diagnosis of
IgE-mediated disease.
See Table 10-3 for factors that affect skin tests.
Table 10-3. Factors Affecting Skin Tests

Factor Affect
Skin reactivity of test site (Figure 10-1) Mid (1) and upper back (1) > lower back (2) >
forearm (antecubital fossa [3] > wrist [4])
Place tests at least >2 cm apart
Age Infants have a flare but smaller wheal
The elderly have smaller wheal and flare;

highest in second and third decade of life
Race Wheal is greater in nonatopic blacks
Gender No difference
Season variations Increase peaks after pollen season
Some chronic conditions Eczema, chronic renal failure, hemodialysis,

cancer, spinal cord injuries, peripheral nerve
abnormalities may diminish skin reactivity
Presence of dermatographism RSV infection can increase reactivity
Use of medications Antihistamines (1st-generation H1
antihistamines have a greater suppressive
effect than 2nd-generation; H2 blockers and
nasal antihistamines have more limited effects
on skin testing)
Tricyclic antidepressants, phenothiazines, and

omalizumab (for up to 6 months) also
suppress skin tests
(Medications not affecting the skin test include

oral (short-term use), nasal, or inhaled
corticosteroids; β agonists; theophylline; Flash Card Q2
leukotriene antagonists; and cromolyn.
Which part of the back
Type of device Multiheaded devices produce more false
negatives than single-headed devices
(upper or lower) has
greater skin reactivity for
Abbreviation: RSV, respiratory syncytial virus.
skin testing?
488 / CHAPTER 10
Figure 10-1. Skin reactivity of test sites: Mid (1) and upper back (1) > lower back
(2) > forearm (antecubital fossa) (3) > wrist (4).
Diagnostic Characteristics—For inhalant allergy, the sensitivity and specificity

of the SPT are approximately 80–85% compared with nasal provocation
challenges, lower for molds. For food allergy, the SPT is generally sensitive (30–
70%), with high rates of false positives (30–70% specific). When skin testing for
allergies to fruits and vegetables, use of fresh foods increases sensitivity to 90%.
Limitations of Skin Prick Tests. False-positive SPT results to tree pollen can be
seen in patients allergic to honeybee stings due to cross-reactive carbohydrate
determinants in honeybee venom.
False-negative SPT can be seen if there has been an episode of anaphylaxis in the
previous month. False-negative skin tests can also be caused by low potency of
extracts, reduced reactivity of skin in children and elderly, improper technique,
and UV exposure.
Patients at higher risk for systemic reaction to skin testing include those with
poorly controlled asthma and reduced lung function, and clinical histories of
severe reactions to minute amounts of allergen.
Intradermal Tests (IDST)
IDST should be performed with a 100- to 1000-fold dilution of the SPT

concentration. IDST involves injection of 0.02–0.1 mL of allergen with a 26-
or 27-gauge needle.
IDST are more sensitive but less specific than the SPT (high false-positive
rate).
Flash Card A2
Upper back
SPTs need to be performed before IDSTs for safety reasons since fatalities
have been reported when intradermals are performed without a preceding
SPT.
IDSTs are utilized to perform the IDEAL50 (intradermal dilution equals 50
mm), which is used for the standardization of extracts. In the IDEAL50,
erythema (not wheal) is measured.
Any reaction larger than the negative control may indicate the presence of
specific IgE antibody, though small positive reactions may not be clinically
significant.
Clinical Utility
Venom hypersensitivity: Testing done up to 1 µg/mL. False-positive rates
increase above this concentration.
o Intradermals especially important for diagnosing venom hypersensitivity
as failure to identify can lead to life-threatening consequences.
Key Fact
Drug hypersensitivity: IDST is useful for penicillin, chemotherapeutic
agents, muscle relaxants, insulin, and heparin skin testing. Value of drug skin Venom intradermal skin
tests are performed up to
testing to other agents is variable as (1) patients may be allergic to a 1 µg/mL. Do not include
metabolite (2) lack of standardization, (3) non-IgE mediated mechanism may any positive flying
be involved Hymenoptera skin tests
Specific inhalant allergens: IDST is not typically beneficial for cat or grass; at 10 µg/mL in venom
but, may be more helpful for weaker nonstandardized inhalant allergens. immunotherapy
prescriptions.
Intradermal testing is not used in the diagnosis of food or latex allergy due to
a high rate of systemic reactions
Systemic reaction rate: <0.02–3.6% in prospective studies, fatality
exceedingly rare, nearly always with intradermal without prior SPT
For occupational sensitizers, skin tests are often unreliable with the exception
of high-molecular-weight (HMW) compounds such as latex, enzymes, and
flour.
Serum-Specific IgE
Methods
RAST: Cyanogen bromide-activated paper disc allergosorbent, bound IgE
detected with radiolabeled antihuman IgE Fc, semiquantitative, four to six
classes
ELISA, chemiluminescence, or fluoroenzymatic detection systems:
o Quantitative, more sensitive than RAST
o ImmunoCAP system uses encapsulated hydrophilic carrier polymer that is
configured into the shape of a small cup (and called a CAP); it has
allergen covalently coupled
o Another third-generation assay (DPC) labels allergenic protein with biotin
o Combine this improved binding with fluoroenzymatic or
chemiluminescence detection systems
o Calibrated against WHO human-IgE reference, reported in units (kIU/L)
490 / CHAPTER 10
Performance characteristics versus SPT: Generally less sensitive
Benefits
Use in severe AD and dermatographism
Use in highly sensitive patient/recent anaphylaxis (no risk for reaction)
Use in patients with poor pulmonary function
Use in patients unable to be weaned from antihistamines
High positive predictive values in children can be achieved for some of the
major food allergens
Limitations
Overall, sensitivity ranges 60–95% and specificity 30–95%
Greater than 90% sensitivity, specificity, and predictive values have been
obtained with pollens of common grasses and trees, dust mites, and cat allergens.
Less for venoms, foods, weed pollens, latex, drugs, dogs and molds.
False positives
o Nonspecific binding to glycoepitopes
o 20–30% of patients allergic to pollen will have positive food-specific IgE
without reporting symptoms to foods
o Wheat epitopes cross-react with grass epitopes
o Use bromelain (protein digestive enzyme) to evaluate and clarify
False negatives
o Food: Approximately 20% of patients with egg- or peanut-specific IgE <
0.35 kIU/L have clinical reactions (most have positive skin tests)
o Venom: Insect allergic patients with negative skin test have serum-specific
IgE in 15–20% of cases
o Latex: Sensitivity of only 80% and specificity of 95%
o Penicillin G, penicillin V, penicilloyl, amoxicillin, and ampicillin are
commercially available; sensitivity of penicillin-specific IgE only ~45%
Component-resolved diagnostics utilize purified native or recombinant
allergens to detect IgE sensitivity to individual allergen molecules. Can
identify patients with clinical allergy as opposed to patients who are
merely sensitized but tolerant. Best studied for peanut: Ara h 8 peanut—
Bet V 1 family (birch)—labile—oropharyngeal symptoms
Ara h 9 peanut and Pru p 3 peach—lipid transfer protein—stable—
mixed—can have severe reactions (more in Europe)
Ara h 2 > 3 and 1 peanut—seed storage proteins—stable—anaphylaxis
Ara h 6 is homologous to Ara h 2
NASAL PROVOCATION
Nasal provocation is accepted as a generic model for the human allergic response
and is used to study the pathophysiology of allergic and nonallergic rhinitis.
Indications
Used mainly as a research tool in USA and Great Britain

Study early- and late-phase changes in mucosa and nasal secretions
Look at response to individual mediators or cytokines, assess the relationship
between allergic rhinitis and other illnesses (asthma, conjunctivitis, and otitis
media)
Test therapeutic agents
Also can be clinically diagnostic for the following:

Identify relevant allergens and confirm nasal reactivity (e.g., strong history
despite negative skin testing and serum IgE testing)
Induction of ocular or bronchial symptoms (may be safer than bronchial
challenge for allergic asthma)
Diagnosis of aspirin-exacerbated respiratory disease with nasal ketorolac
Occupational allergens (e.g., baker’s yeast, carpenter’s saw dusts, or latex)
Food induced rhinorrhea
Methods
Note the overlap with bronchial provocation methods.
Table 10-4 shows details about necessary washout periods of drugs that may
interfere with nasal provocation testing. This should be compared with drugs that
interfere with bronchoprovocation (see Bronchial Provocation section and Table
10-5).
492 / CHAPTER 10
Table 10-4. Drugs That Inhibit the Nasal Response and Washout Periods
Medication Washout Period (Days) Inhibits Early or Late
Response
α-Adrenergic agonist, nasal 1 Neither
and oral
Anticholinergics ? Early
Antihistamine, nasal 3 Early
Antihistamine, oral 3–10 Early
Chromones, nasal 3 Early and late

Corticosteroid, nasal 7 Early (with prolonged
treatment) and late
Corticosteroid, oral 7 Early and late
Leukotriene receptor 7 Inconsistent results (zileuton)
antagonists
Allergen Provocation
Produces early and late responses. Only aqueous allergen extracts should be used
because glycerinated extracts can cause significant irritant effects.
Techniques:
o Application to the entire nasal cavity (metered-dose pump spray, spray
bottle, nasal pool device, or dropper)
o Application to a very small area of the mucosa (paper disc or cotton
swab)
o Allergen exposure chamber (more natural level of exposure)
o Unilateral provocation, allows distinction between the direct and
indirect effects of exposure. Nasal secretions increase bilaterally, but
nasal airway resistance increases only in the challenged nostril.
Unilateral allergen challenge results in acute increase of prostaglandin
D2 and histamine in the contralateral side (reflex activation of mast
cells)
Physical and Irritant Stimuli
Cold and dry air: Symptoms associated with sensorineural activation and
with mast cell mediator release. Can help differentiate nonallergic,
noninfectious rhinitis from healthy controls.
Hyperosmolar solutions: Either sodium chloride or mannitol activate mast
cells in a nonantigenic fashion that can mimic effects of cold air.
Capsaicin: Acts on the vanilloid receptor TRPV1 located on unmyelinated,
slow-conducting sensory nerve fibers. Unilateral provocation results in
bilateral secretory response. Nasal responsiveness is increased in allergic

rhinitis, but not in nonallergic rhinitis.
Air pollutants and other irritants (e.g., tobacco, volatile organic
compounds, cleaning products): Provocation agent is in gaseous form;
however, the settings to generate various dosages can be complicated. Passive
tobacco exposure has been shown to potentiate the inflammatory response of
nasal allergen provocation.
Biochemical Stimuli
Biochemical stimuli have limited utility due to considerable overlap in response

between allergic and nonallergic rhinitis.
Histamine: The most common stimulus used. It mimics symptoms of an acute
allergic response to an allergen challenge; however, it does not induce late
inflammatory events. Most effects are mediated by the H1 receptor, but the H2
receptor plays a role in vascular congestion.
Methacholine: Stimulates nasal muscarinic receptors and induces a secretory
response. Unlike histamine, methacholine does not induce nasal reflexes,
therefore it is useful to assess responsiveness of secretory glands. Unilateral
challenge produces only ipsilateral response.
Adenosine: Causes mast cell degranulation and sensory nerve stimulus.
Neuropeptide: Looks at the role of the nervous system in the dysfunction of
the nose (substance P, neurokinin A, serotonin, calcitonin gene-related
peptide, bombesin, and neuropeptide Y).
Outcomes Measured
Symptoms include lacrimation, sneezing, pruritus, rhinorrhea, posterior nasal
drainage, congestion.
Except for sneezing, the other measures are very subjective.
Changes in nasal patency include the following:

Nasal peak flow: Quick and inexpensive, but effort-dependent.
Nasal airway resistance:
o Rhinomanometry is the standard technique for measuring nasal airway
resistance. Nasal airway resistance does not correlate well with subjective
sense of nasal congestion. This may be due to effect of nasal valve on
determining airway resistance but not contributing as much to sensation of
congestion.
o Location of greatest nasal resistance is the nasal valve.
494 / CHAPTER 10
Refer to section on “nasal smears” (Chapter 7, Hypersensitivity Disorders) for

further details on analysis of nasal secretions.
Mucosal tissue changes should only be performed by experienced physicians due

to possible complications.
Contraindications to Nasal Provocation

Relevant contraindications are as follows:
Acute inflammatory conditions in the nose or the paranasal sinuses
Poorly controlled asthma
History of systemic allergic reactions to immunotherapy or to skin testing
History of oral or oropharyngeal angioedema
Receiving medications that could theoretically increase the risk of lower
airway or systemic reactions, or that could interfere with their treatment (e.g.,
ACE-inhibitors or β-adrenergic blockers)
Pregnancy
PULMONARY FUNCTION TESTS (PFT)
Airflow limitation is measured by spirometry. Expiratory flow is affected by

airway caliber, airway wall compliance, and elastic recoil. The forced expiratory
volume in 1 second (FEV1) is the most reproducible pulmonary function test.
Lung volume is related to body size, with standing height being the most
important correlating variable. Reference equations compare patient data to
reference subjects of similar sex, age, height, and ethnicity.
Figure 10-2 shows typical spirometric flow-volume patterns.
Figure 10-2. Types of ventilatory defects. (A) Normal. (B) Obstructive

abnormalities. Reduced FEV1 /FVC. May also see a reduction in mean expiratory
flow between 25% and 75% (FEF 25–75), although this is considered a less
specific indication of obstruction. (C) Restrictive abnormalities. Defined by
reduced TLC. May have normal or increased FEV1/FVC. Restrictive lung disease
cannot be diagnosed by spirometry alone as FVC and TLC may be poorly
correlated. Lung volume measurement is required for confirmation with
plethysmography or other such method. (D) Vocal cord dysfunction. A variable
extrathoracic obstruction with truncation of inspiratory loop seen when patient is
symptomatic. (E) Fixed upper airway obstruction. Flattening of both inspiratory
and expiratory loop. Examples include tracheal stenosis and goiters. (F) Variable
intrathoracic obstruction. Flattening of expiratory loop; an example is
tracheomalacia.
Abbreviations: FEF, forced expiratory flow; FEV, forced expiratory volume; FVC, forced vital
capacity; TLC, total lung capacity.)
Interpretation of PFTs
Was it a good test? Look at effort. Exhalation for at least 6 seconds in adults
[3 seconds in children] or reached plateau for at least 1 second on the volume-
time curve.
Must have three reproducible efforts with the largest volumes of FEV1 and
FVC within 150 mL of each other.
Look at flow-volume loop.
496 / CHAPTER 10
Assess FEV1, FVC, and FEV1/FVC for airflow limitation (also TLC and
diffusion lung capacity for carbon monoxide [DLCO] if needed). See Figure
Key Fact
10-3.
A significant response to For FEV1/FVC ratio, normal ratio varies by age: 8–19 years old: 85%; 20–39
a bronchodilator in
adults is an increase in
years old: 80%; 40–59 years old: 75%; and, 60–80 years old: 70%.
FEV1 of 12% and at Patients should withhold short-acting β agonist (SABA) × 4 hours, long-acting
least 200 mL. β agonist (LABA) × 12 hours, tiotropium × 24 hours.
PFTs in infants and young children:

Spirometry recommended for children older than 4 years old; most can
perform by age 6 years
Other options for young children: whole-body plethysmography (respiratory
system resistance [Rrs]), interrupter technique (Rint), or forced oscillation
technique (measures resistance and reactance)
For infants: Partial flow volume curves, resistance, compliance, functional
residual capacity (FRC); require sedation
Figure 10-3. Algorithm for interpretation of PFTs.

Abbreviations: DLCO, diffusing capacity of carbon monoxide; FEV 1, forced expiratory volume in 1
second; FVC, forced vital capacity; TLC, total lung capacity.
BRONCHIAL PROVOCATION
Key Fact
Bronchial Provocation Challenge Methods Severity of airway
hyper-responsiveness
(AHR) does not
Bronchial provocation is accomplished using the following methods: correlate with severity of
asthma.
Dosimeter: Five inspiratory (TLC) breaths from a breath-activated dosimeter
Tidal breathing: Two-minute tidal breathing from a jet nebulizer. Preferred
method in children
These methods are considered equivalent; however, tidal breathing exposes Key Fact
patient to twice the volume of aerosol at each concentration. Nonselective or
nonallergic versus
selective or allergic
agents: Nonselective
agents have the potential
Table 10-5. Bronchoprovocation Testing Categories to produce
Nonselective Selective bronchoconstriction in all
asthmatics, and they do
Direct Immunologic
Histamine Allergen not purge any specific
Methacholine Occupational triggers. Selective testing
Prostaglandins looks at specific triggers
Leukotrienes in susceptible
Indirect (osmotic) Nonimmunologic asthmatics.
Exercise ASA
EVH NSAIDs Direct versus indirect
Cold air Food additives testing: Direct testing
Nonisotonic aerosols (hypertonic saline) acts on the airway
Mannitol smooth muscle receptors
(muscarinic and
Indirect (nonosmotic) histamine) directly, but
AMP not by inducing mediator
Propranolol
Bradykinin
release. If mediator
release is necessary,
Abbreviations: ASA, aspirin; EVH, eucapnic voluntary hyperpnea (hyperventilation); NSAIDs,
then it is an indirect test
nonsteroidal anti-inflammatory drugs.
(see Table 10-5).
Direct Testing
Direct testing causes bronchoconstriction by directly activating contraction of

smooth muscle cells after binding to receptors. It is highly sensitive and functions
best when trying to exclude asthma with reasonable certainty. Direct testing has
low specificity.
Methacholine Challenge Test (MCT)—analog of acetylcholine.
Flash Card Q3
Important caveats for interpretation: What conditions can
Requires normal expiratory flow rates (such as FEV1). cause a false-positive
Symptoms must be clinically current (in past few days). AHR?
498 / CHAPTER 10
Five percent to 15% of normal population can have a false-positive MCT.

Key Fact
A negative MCT or Ipratropium bromide blocks methacholine secondary to anticholinergic
histamine challenge in
the winter does not
mechanism of action. Effects of nonrespiratory medication with anticholinergic
exclude seasonal include β2 agonists, antimuscarinics, some antidepressants, and antipsychotics.
pollen-induced asthma.
Histamine—Correlates significantly with MCT results (Table 10-6). Exercise
symptoms correlate better with MCT than histamine challenge.
Indirect Testing
Challenge of choice when exercise-induced bronchospasm (EIB) is suggested, or

when attempting to differentiate asthma from chronic obstructive pulmonary
disease (COPD). The response to inhaled corticosteroids is assessed with indirect
tests. Also see Table 10-7.
Table 10-6. Interpretation of Methacholine Challenge Test Results

PC20 or Dose Results
>16 mg/mL Normal
4–16 mg/mL Borderline
1–4 mg/mL Mild AHR
0.25-1 mg/mL Moderate AHR
< 0.25 mg/mL Severe AHR

Abbreviations: AHR, airway hyper-responsiveness PC 20, provocation concentration (or dose)
producing a 20% fall in FEV1.
Flash Card A3
Allergic rhinitis, chronic
obstructive pulmonary
disease (COPD),
congestive heart failure
(CHF), cystic fibrosis
(CF), siblings of
asthmatics, upper
respiratory infection
(URI), and smoking
Table 10-7. Comparison of Methods

Method Advantage Disadvantage
Methacholine or histamine Universally accepted Not specific for asthma
Exercise Highly specific for asthma Lacks sensitivity; equipment
Cold air Highly specific for asthma Lacks sensitivity; equipment
Hypotonic Highly specific for asthma Lacks sensitivity
Hypertonic Can do a dose response Lacks sensitivity
EVH or hyperventilation Highly specific for asthma Lacks sensitivity

Abbreviation: EVH, eucapnic voluntary hyperpnea (hyperventilation);
Methods of Indirect Testing
In general, these testing methods have high specificity and low sensitivity.
Exercise
o Near-maximal exercise for 6 minutes breathing dry cool air, relative
humidity less than 50% and less than 25°C through the mouth
o Looking for fall in FEV1 of 15%
EVH or hyperventilation
o Inhale dry air with 5% CO2 for 6 minutes
o Ten percent reduction considered positive
o Similar to exercise challenge and requires less equipment. Can also be
done when patient unable to exercise
Nonisotonic aerosols
o Hypertonic saline (4.5%) most common, but distilled water can also be
used
o Doubling dose achieved by doubling amount of time
o Can also be used to induce sputum for inflammatory analysis. Pretreat
asthmatic patients with bronchodilator (if only using for this purpose) and
not to measure AHR.
Cold air
o Considered a modified-EVH challenge using cold, dry air
Mannitol (dry powder)
o Provides osmotic challenge to the airway mucosa, causing release of mast
cell mediators
o Mast cell mediators (e.g., prostaglandin 2 [PDG2], leukotriene E4) cause
bronchoconstriction
o Rapidly inhaled in progressively increasing doses (0, 5, 10, 20, 40, 80,
160, 160, 160 mg). FEV1 measured at baseline and 1 minute after each
dose. If the FEV1 decreases by 10% after a dose then that dose is repeated.
500 / CHAPTER 10
o Fifteen percent fall in FEV1 at a total cumulative dose of ≤ 635 mg

(known as the provocative dose, or PD 15) is considered a positive
response
o Premeasured doses more convenient
o Cough common side effect
Adenosine or AMP
o Causes bronchoconstriction through release of mediators from mast cells
o AMP constriction 80% inhibited by terfenadine and astemizole
o AMP constriction attenuated by cromolyn and nedocromil
o Allergen avoidance reduces bronchial hyper-responsiveness (BHR) to
Key Fact
AMP but not MCT
MethachOline has a Allergen
high sensitivity so is
most useful to rule Out o Induces bronchial smooth muscle constriction indirectly as a direct result
asthma. MannItol has a of mast cell activation in the lung.
high specificity, so if o The best quality and best standardized allergen extracts should be used;
positive helps to rule-In and allergens for inhalation should be aqueous and not glycerinated (due
asthma, particularly to irritant effect).
exercise-induced.
o Just as is seen in nasal provocation testing, some medications can interfere
with the early and late airway response and have variable washout periods
(Table 10-8).
Airway Responses to Allergen
Table 10-8. Drugs That Inhibit the Early and Late Asthmatic
Response(LAR) to Allergens
Medication Washout Period Inhibits EAR Inhibits LAR
(Hours)
β2-Adrenergic agonist 6–8 Yes No
LABA 24 Yes Masks
Anticholinergics 8–48 Yes Yes
Antihistamine 48 Yes No
Chromones 48 Yes Yes
Inhaled corticosteroid, 0 No Yes (single dose
single dose after EAR)
Inhaled corticosteroid, 7 Yes Yes
regular use
Leukotriene receptor 7 Yes Yes
antagonists
Xanthenes Yes (dose-related)
Anti-IgE ? Yes Yes
Furosemide Yes Yes
Tricyclics Yes ??
Abbreviations: EAR, early asthmatic response, LABA, long-acting β agonist; LAR, late asthmatic
response.
Allergen-Induced AHR
Correlates with both late asthmatic response (LAR) and allergen-induced sputum
eosinophilia. Direct AHR testing (MCT and histamine) is increased after allergen
exposure.
Allergen-Induced Increase in (Eosinophilic) Airway

Inflammation Key Fact
The late sequelae are
Correlated to LAR and suspected to be causally related to AHR. Eosinophils, clinically more important
mast cells, and basophils are increased in sputum after allergen exposure. than the early asthmatic
response (EAR).
NASAL AND SPUTUM SMEARS
Nasal Smears (Table 10-9)
Used for detection of nasal eosinophilia

Most useful when the diagnosis of allergic rhinitis is in question (e.g., positive
history, negative skin test)
Collecting methods: Blown secretions, nasal lavage, nasal swab, nasal
brushing
Sputum Smears
A sputum sample is material expelled from the respiratory passages (lungs,

bronchi, and trachea) taken for laboratory analysis. It is not saliva. Bad sputum
smears can lead to false results. See Table 10-10.
Table 10-9. Nasal Smears: The Quick and Dirty

If the dominant cell type seen is: Then think of these:
Eosinophil Allergic (>10% eosinophils) if skin test negative,
may prompt nasal or conjunctival challenge
ASA-induced
Nonallergic eosinophilic rhinitis (NARES) (>5–>20%
eosinophils) negative allergen challenge
Neutrophil Irritant and nasopharyngitis or sinusitis (infectious—
bacterial > viral) (low specificity)
Abbreviation: ASA, aspirin.
502 / CHAPTER 10
Table 10-10. Comparison of Asthma and Bronchitis Sputum

Possible
Sputum Description Asthma Bronchitis
Findings
Charcot-Leyden Abnormal bipyramidal crystals of Yes No
crystals eosinophil lysophospholipase and
metachromatic cells
Curschmann’s Corkscrew-shaped twists of Yes No
spirals condensed mucus
Creola bodies Multiple clumps of sloughed Yes No
surface epithelial cells
Eosinophilia Yes—mild and No
severe
Neutrophilia Yes (more likely Yes
during
exacerbation
following viral
URI or in severe
asthmatics)
ECP and MBP Yes No
Abbreviations: ECP, eosinophilic cationic protein; MBP, major basic protein; URI, upper respiratory
infection.
Sputum eosinophilia: Can be seen in absence of AHR, but is also associated

with development of persistent airflow limitation in adult asthmatics.
o Eosinophil counts are increased in sputum of both mild and severe asthma;
IL-5 is highest in mild asthma, but eosinophilic cationic protein (ECP) is
highest in severe asthma.
MUCOCILIARY FUNCTION
Airway Mucus
Airway mucus is an important component of the innate immune system and

consists of the following:
“Sol” layer: Watery mixture in direct contact with airway epithelial cells. The
cilia beat freely in the sol layer.
”Gel” layer: Elastic layer in direct contact with inhaled air.
Protein constituents: Mucin glycoproteins, proteoglycans, and a variety of
other proteins important for host airway defenses.
o Mucin glycoproteins are encoded by the mucin (MUC) genes. Their
carbohydrate components bind surface adhesins or hemagglutinins on
microorganisms, making it an important part of host defense and
clearance. The mucin gene (MUC5AC) expression is increased in
asthmatics compared to normal controls.
Mucociliary Clearance
Coordinated activity of ciliated airway epithelial cells, resulting in movement

of lung secretions toward the head
Key cells:
o Goblet cell mucus secretion appears to occur in response to environmental
stimuli (e.g., smoke, ammonia, and nitric oxide) and inflammatory
mediators (i.e., histamine, leukotrienes, and neutrophil elastase).
Hyperplasia and metaplasia of goblet cells play important role in mucus
hypersecretion.
o Clara cells are nonciliated secretory cells, which are abundant in terminal
bronchioles. May be precursor to goblet cell.
o Submucosal glands contain short ciliated duct, a nonciliated collecting
duct and secretory tubules lined by mucous and serous cells. Mucous cells
produce more viscous secretion than serous cells. In response to sulfur
dioxide or tobacco smoke, mucous cells form from serous cells.
Requires optimal properties of mucus and normal functioning cilia
Nasal Mucociliary Clearance
Measures of mucociliary clearance:

o Aerosol of colloid albumin tagged with technetium-99m (99mTc),
radioactivity within lungs measured for 2 hours and again at 24 hours
o Saccharin deposited in inferior turbinate, measure time for taste (more
simple, rapid, less reliable)
If abnormal: Nasal brushing from inferior turbinate, microscope attached to a
photometric cell to detect frequency of beating cilia (normal range 12–15 Hz)
Ciliary Structure (Figure10-4)
Shaft anchored to the cytoplasm containing longitudinal fibrils composed of

nine outer pairs of microtubules (doublets) and two central microtubules
Microtubules composed of tubulin
Dynein arms join adjacent doublets. Normal cilium shows an inner
microtubule pair connected by radial spokes to nine outer microtubule
doublets, which are connected by nexin. Outer doublets each carry an outer
and inner dynein arm
Flash Card Q4
What is the name given
to multiple clumps of
sloughed surface
epithelial cells that may
be seen in asthmatics?
504 / CHAPTER 10
Figure 10-4. Ciliary structure.
DISORDERS OF MUCOCILIARY FUNCTION
Mucociliary Clearance and the Immune System
Infection and irritants can increase both mucus production and mucociliary
clearance to augment airway defenses. When either is disturbed, such as in cases
of recurrent otitis, sinusitis, rhinitis, bronchitis, and bronchiectasis, infections and
irritants can have more significant effects. A comparison of mucus production and
ciliary clearance is seen in Table 10-11.
Flash Card A4
Creola bodies
Table 10-11. Effects of Impaired Mucus Production or Ciliary Clearance

Mucus Ciliary
Results in: Example Notes
Production Clearance
High Normal Expectoration Asthma Expression mucin gene
(overflow) MUC5AC Key Fact
Mucus accumulation Primary ciliary
contributes to fatal attacks
dyskinesia (PCD)
Mucin glycoproteins patients have fewer
predominant proteins;
airway infections than
albumin and DNA
those with cystic fibrosis
Normal Impaired/Low Sludging Primary ciliary Lack of dynein arms, (CF). This suggests that,
dyskinesia defective ciliary spokes in mucus hypersecretory
(Kartagener’s (loss of synchronized states with chronic
syndrome: Situs ciliary movement) bacterial infections, the
inversus in 50% of altered mucus plays a
patients) larger role in disease
progression than ciliary
Abnormal Normal Accumulation Cystic fibrosis CFTR gene defect causes movement.
quality serous cell secretion of
water, producing thick
immobile mucus
SEROLOGIC TESTS
MEASUREMENT OF ANTIGENS AND ANTIBODIES
Serum Immunoglobulins (Igs)

Methods include radial immunodiffusion (RID), nephelometry, and turbidimetry.
Rate nephelometry is the most common method used for quantifying IgG, IgA,
IgM, and inflammatory markers in serum (e.g., C-reactive protein [CRP],
haptoglobin, C3, and C4). It is based on light-scatter measurement, which
depends on the formation of antibody-antigen complexes in the test solution. It is
done by adding variable concentrations of antigen to a fixed amount of antibody
in a spectrophotometric reaction cell.
Turbidimetry measures the decrease in amount of light penetrance, which
correlates with analyte (Ig) concentration. Its application is similar to
nephelometry.
Flash Card Q5
Due to the small serum concentrations of IgE and IgD, they are measured using In which condition is
an enzyme-linked immunosorbent assay (ELISA) or radioimmunoassay (RIA). there a lack of dynein
arms and loss of ciliary
spokes?
506 / CHAPTER 10
ELISA—Method of detecting antibody (Ab) or antigen (Ag). Sandwich ELISA is

a type of ELISA technique in which the antigen or antibody in question is
sandwiched between two proteins, either an Ag and Ab or an Ab and Ab. The
steps of a sandwich ELISA (Figure 10-5) are as follows:
Plate is coated with a capture Ab.
Sample is added, and any Ag present binds to capture Ab.
Detecting Ab is added and binds to Ag.
Enzyme-linked secondary Ab is added and binds to detecting Ab.
Substrate is added, and it is converted by enzyme to detectable form that is
measured with spectrophotometry for quantification.
Examples of a sandwich ELISA include ELISA screening test for anti-HIV

antibodies, total IgE measurement, and C1q and C1 inhibitor levels.
Serum Protein Electrophoresis (SPEP)—Separates proteins using an electric

field on agarose gel. SPEP measures the general distribution of serum proteins
(Figure 10-6). The two main fractions of serum proteins are albumin and
globulins. These are further subdivided as follows:
Albumin: The major fraction, comprising more than half of serum proteins
Α fraction: These bands can be increased by acute-phase reactants:
o Α-1 globulin fraction includes α1-antitrypsin, thyroid-binding globulin,
transcortin, and HDL cholesterol.
o Α-2 globulin fraction includes ceruloplasmin, α2-macroglobulin, and
haptoglobulin.
Β fraction: IgA, IgM, sometimes IgG, and complement proteins can be
identified in the β fraction. CRP is found between the β and γ components.
o Β-1 fraction composed mostly of transferrin
o Β-2 fraction contains β-lipoproteins
Flash Card A5
Primary ciliary Figure 10-5. Sandwich ELISA.
dyskinesia (PCD) (Reproduced, with permission, from Wikimedia Commons.)
Figure 10-6. Normal serum protein electrophoresis.
γ Fraction: Much of the clinical interest is focused in this since

immunoglobulins migrate to this region. Thus, SPEPs (and electrophoresis of
urine samples [UPEPs]) are often used to screen for conditions such as
multiple myeloma (MM), Waldenström’s macroglobulinemia, and
amyloidosis, which cause abnormalities in this region (Figures 10-7 and 10-8).
Immunofixation Electrophoresis (IFE)—Useful for the identification and

quantification of monoclonal paraproteins seen on an SPEP. This procedure
identifies which immunoglobulin isotype causes an “M” spike when it is present.
It can also determine which light chain (i.e., κ or λ) is present. After the SPEP is
run and the monoclonal bands are identified, they are exposed to specific
antiserum to detect specific antibodies (Figure10-9).
Western Blot—Modified ELISA. Proteins to be assayed are separated by

electrophoresis and then transferred to nitrocellulose membrane. Serum with
antibodies is added, and excess antibody is washed off. Enzyme-conjugated
antiantibody is added, and again excess antibody is washed off. Finally, a
substrate to the enzyme is added, and the color or chemiluminescence is detected.
One use of this test is to confirm HIV infection.
Figure 10-7. M-shaped spike serum protein electrophoresis.

508 / CHAPTER 10
Figure 10-8. Serum protein electrophoresis showing γ- and α2 spike.
Key Fact
Allergen-Specific IgE Measurement—Most often done as an automated
Antinuclear antibody
(ANA) is a sensitive but
fluoroenzyme immunoassay (indirect ELISA). Allergen is bound covalently to a
not specific test. It is not solid phase, which binds all allergen-specific IgE. An enzyme labeled “anti-IgE”
a good screening test in is added and incubated with developing agent, and the fluorescence is then
the absence of measured.
significant clinical
suspicion (high false-
positive rate). But, in
Radioallergosorbent test (RAST)—Radioimmunoassay for detecting antibodies
high titers, ANA may against antigens (allergens) adsorbed on solid-phase support. Note: This is an
point toward an older method, using radioisotopes to detect specific IgE. It is no longer in
autoimmune disorder. common clinical use; thus, the term “RAST” is obsolete.
Figure 10-9. Immunofixation electrophoresis showing IgG and κ bands.

Functional Complement Tests
CH50—Function of classical pathway is measured using sheep erythrocytes (E)

plus rabbit antibody (A). A serial dilution of patient serum is mixed with EA
suspension, which results in lysis of RBC and release of hemoglobin. This is
measured by spectrophotometer. The dilution of serum to lyse 50% of RBCs of
EA cells is the quantitative CH50 unit.
CH50 measures functional activity of the components of the classical

complement pathway. This includes C1qrs, C2, C4, C3, C5, C6, C7, C8, and C9.
AH50—Measures functional activity of the alternative complement pathway.

Thus is a screen for deficiencies in factors D, B, C3 properdin, C5, C6, C7, C8,
and C9.
SEROLOGIC TESTS FOR AUTOIMMUNITY
Serologic tests are an important tool in the diagnosis of autoimmune conditions

(Table 10-12).
Table 10-12. Serologic Tests in the Diagnosis of

Autoimmune Conditions
Disease Autoantibody
Systemic autoimmune disorders
Neonatal lupus Anti-SSA or Ro and anti-SSB or La
Systemic lupus erythematosus (SLE) ANA, anti-dsDNA, and anti-Smith
Drug-induced lupus Antihistone
Rheumatoid arthritis RF and anti-CCP
Juvenile inflammatory arthritis RF and ANA
Antiphospholipid syndrome Lupus anticoagulant, anticardiolipin IgG IgM,
anti-b2GPI, and ANA
Sjögren’s syndrome ANA, anti-SSA, and anti-SSB
Systemic sclerosis (diffuse) Anticentromere, antitopoisomerase I, anti-
RNA polymerase I or III, and antifibrillarin
CREST (limited scleroderma) Anticentromere
Polymyositis ANA, anti-Jo 1, antisignal-recognition particle
antibodies, and anti-PM-Scl antibodies
Flash Card Q6
Dermatomyositis ANA, anti-Jo 1, antisignal-recognition particle
antibodies, and anti-PM-Scl antibodies The disease
granulomatosis with
polyangiitis is also
known as what?
510 / CHAPTER 10
Table 10-12. Serologic Tests in the Diagnosis of

Autoimmune Conditions, cont.
Immunologic GI disorders
Autoimmune hepatitis-1 (AIH) ANA, SMA(anti-actin), and ANCA(p-ANCA)
Autoimmune hepatitis-2 Anti-LKM-1(liver kidney microsomes)
Primary biliary cirrhosis (PBC) Antimitochondrial antibodies (AMA, very
specific), anti-M2-subset of AMA, anti-sp100,
and anti-PML(promyelocytic leukemia)
Primary sclerosing cholangitis p-ANCA, SMA, AMA, and ANA
Crohn's disease Anti-Saccharomyces cerevisiae (ASCA)
Ulcerative colitis p-ANCA
Immunologic renal disease
Granulomatosis with polyangiitis (GPA) c-ANCA (proteinase 3 = PR3 and sensitivity
(Wegener's granulomatosis) 90%), p-ANCA (myeloperoxidase = MPO) can
also be positive
Goodpasture’s syndrome Antiglomerular basement membrane (GBM)
and ANCA
Immunologic neuropathies
Guillain-Barré syndrome Antiganglioside antibodies
Myasthenia gravis Antiacetylcholine receptor
Chronic inflammatory demyelinating Antiganglioside antibodies
polyneuropathy
Vasculitis
Hypocomplementemic urticarial vasculitis ANA (low c3 and c4)
Hemolytic uremic syndrome Factor H autoantibodies
Polyarteritis nodosa No identified autoantibody. Presence of
increased immunoglobulins.
Eosinophilic granulomatosis with polyangiitis p-ANCA (MPO)
(EGPA) ( Churg-Strauss syndrome)
Microscopic polyangiitis p-ANCA (MPO) in 60% of patients and
c-ANCA (PR3) in 40%
Autoimmune endocrine disorders
Diabetes mellitus type 1 Islet cell antibodies, insulin autoantibodies,
and anti-glutamic acid decarboxylase (GAD)
Grave's disease Thyroid peroxidase antibody (TPO), thyroid
receptor antibody (TRSAb), and thyroid-
stimulating immunoglobulin (TSI)
Hashimoto's thyroiditis TPO and anti-thyroglobulin antibody
Addison's disease (chronic adrenal Antiadrenal cytoplasmic antibodies(CYP21)-
insufficiency) cytoplasmic antibody
Flash Card A6
Wegener's
granulomatosis
Table 10-12. Serologic Tests in the Diagnosis of Autoimmune

Conditions, cont.
Immune hematologic disorders
Autoimmune hemolytic anemia Positive direct antiglobulin (Coombs’ test)
Paroxysmal cold hemoglobinuria (PCH) Ig antibody against P antigen (anti-P)
Autoimmune thrombocytopenia Antiplatelet antibodies
Autoimmune neutropenia Antineutrophil antibody-HNA-1 or HNA-2
Neonatal autoimmune neutropenia (NAIN) Anti-HNA-1a and anti-HNA-1b-antineutrophil
antibody
Immune skin disorders
Pemphigus vulgaris Antidesmoglein-3 antibodies
Pemphigus foliaceous Antidesmoglein-1 antibodies
Linear IgA disease IgA antibody against basement membrane
zone (BMZ)
Pemphigoid IgG antibody against BMZ—
BP230 and BP180, and hemidesmosomal
antigens
Dermatitis herpetiformis BMZ IgA autoantibodies
Epidermolysis bullosa acquisita Anticollagen type VII
Abbreviations: ANA, antinuclear antibody; c-ANCA, cytoplasmic antineutrophil cytoplasmic
antibodies; p-ANCA, perinuclear antineutrophil cytoplasmic antibodies.
MOLECULAR DIAGNOSTICS AND TISSUE TYPING
MOLECULAR TECHNIQUES
Polymerase Chain Reaction (PCR)
PCR is an enzyme-driven technique for rapidly amplifying short regions of DNA

in vitro. It relies on knowing at least partial sequences of the target DNA and uses
this knowledge to design oligonucleotide primers that hybridize to the target DNA
sequence.
Flash Card Q7
What autoantibody is
associated with
pemphigus vulgaris?
512 / CHAPTER 10
Key Fact Examples of PCR assays used for pathogen detection approved by the FDA:
In patients with defects Human immunodeficiency virus (HIV)
in antibody production Hepatitis C virus (HCV)
(e.g., common variable
Cytomegalovirus (CMV)
immunodeficiency
[CVID], X-linked Groups A and B Streptococcus
agammaglobulinemia Mycobacterium tuberculosis
[XLA]) or on intravenous Chlamydia trachomatis
immunoglobulin (IVIG)
replacement, antibody
Neisseria gonorrhoeae
testing for infections is
unreliable, and direct Over the past two decades, variations in the PCR technique have been developed
PCR methods are that have increased its versatility, including the following.
preferred.
Reverse Transcriptase PCR (RT-PCR)—Used to generate copies of RNA
sequences. The RNA sequence is first converted to a double-stranded
complementary DNA (cDNA) utilizing a viral reverse transcriptase enzyme. A
large number of copies of the newly formed DNA are then generated as described
earlier. RT-PCR may be used for detection of RNA viruses such as HIV and
hepatitis C.
Quantitative PCR (qPCR) or Real-Time PCR—qPCR may be used to quantify

residual disease following bone marrow transplantation or after therapy for
chronic myelogenous leukemia (CML).
Sequencing-Based Technologies
The original goal of DNA-sequencing technology was genomic sequencing. It has

also been used to identify organisms that cannot be cultured or those that are
difficult to identify using conventional lab techniques. The Sanger technique was
the most often used DNA-sequencing technique. However, in recent years, there
has been a shift from the automated Sanger technique, now considered first
generation, to newer methods that are often referred to as next-generation
sequencing. Next-generation sequencing technologies may be utilized for:
Genome-wide characterization and profiling of mRNAs

Transcription factor regions
Structure of chromatin
DNA methylation patterns
Metagenetics
Flash Card A7
Antidesmoglein-3
antibodies
Direct Hybridization Assays
Table 10-13 summarizes the four direct hybridization assays.

Southern Blot—Technique used to detect translocations, deletions and dup-
lications of relatively large areas of the genome such as whole chromosome arms.
DNA is extracted from tissue, purified and enzymatically fragmented by
appropriate restriction endonucleases.
The fragmented strands are electrophoresed on an agarose gel according to
size.
DNA fragments are blotted onto a nylon filter and immobilized/fixed on the
membrane.
DNA sequences are then hybridized with a probe (radiolabeled), single-
stranded DNA sequence complimentary to the blot-transferred DNA
sequence.
The pattern of hybridization is then visualized on radiographic film.
Northern Blot—Technique used to detect specific RNA sequences and their size,
and the expression profiles of tissue-specific genes. Although highly specific, the
Northern blot is semiquantitative and rarely used in clinical applications. The
technique may be divided into three steps:
Electrophoresis of RNA under denaturing conditions in an agarose or
formaldehyde gel
Transfer of RNA from the gel to a nylon or nitrocellulose membrane
Hybridization and analysis of the RNA sequences of interest using a labeled
DNA or RNA probe
Table 10-13. Direct Hybridization Assays

Technique Mechanism Example
Southern blot DNA/DNA analysis Gold standard for T-cell
clonally in detection of
lymphoma and leukemia
Northern blot RNA/DNA analysis Observe a particular gene's

expression pattern between
tissues, other techniques
often used more often
clinically
Western blot Gel electrophoresis of proteins Diagnosis of HIV infection and

Lyme disease
Fluorescent in situ Fluorescence-labeled DiGeorge’s syndrome

hybridization oligonucleotide (DNA) probes (22q11.2)
514 / CHAPTER 10
Fluorescent in Situ Hybridization (FISH)—FISH is used to detect the presence

or absence of specific DNA sequences (duplications, deletions, and
translocations). FISH uses fluorescence-labeled oligonucleotide probes that attach
to their complementary sequences in the DNA strand contained within the cells.
The three most commonly used types of probes are (1) painting probes that
identify an entire chromosome, (2) centromeric probes that recognize the
centromeric regions, and (3) the allele-specific probe that adheres to a specific
target allele sequence. The oligonucleotide-labeled DNA region may then be
visualized under a florescence microscope.
FISH has advantages over conventional cytogenetics in the evaluation of

individuals with chromosomal deletions and translocations, and in gene
amplifications. Unlike conventional cytogenetic techniques, FISH may be
performed on cells that are dividing (in metaphase) or resting (in interphase).
Another advantage is that FISH may be performed on fresh frozen specimens,
archival smears, and paraffin-embedded tissue sections. Diseases that may be
diagnosed using FISH include:
Prader-Willi syndrome (PWS)
Angelman syndrome (AS)
22q11.2 deletion
Cri-du-chat
Down syndrome
Acute lymphoblastic leukemia (ALL)
Array-Based Technologies
Array-based technologies may be macro- or microarrays. Microarrays are

miniaturized versions of macroarrays, with spot sizes less than 200–300 μm in
diameter. Microarray has evolved from RNA and DNA blot assays and ELISA.
The principle behind microarrays is the hybridization of complementary
nucleotides base pairs contained in two DNA strands. The first strand, the probe,
of known DNA sequences is fixed to a support (e.g., glass, silicone, or
polystyrene beads). The second DNA strand contains sequences that are labeled
with fluorescent molecules or dyes for generation of a detectable signal.
Microarrays may detect DNA or RNA, the latter usually as cDNA produced by
reverse transcription.
Microarrays may be employed for gene expression profiling, such as finding the
relative difference in gene expression between normal and cancer cells.
Microarrays may be used to detect:
Single-nucleotide polymorphisms (SNPs)

Chromosomal abnormalities such as in Down syndrome
Genotype mutations, which result in monogenetic diseases such as ataxic
telangiectasia
TISSUE TYPING
Serologic, Cellular, and DNA Techniques in HLA Typing
A variety of techniques may be used for human leukocyte antigen (HLA) typing
with the goal of increasing the success of human transplant. Thus far, three
techniques have been used for HLA typing: serologic, cellular, and the currently
more popular DNA techniques.
Serologic techniques consist of variations of complement-dependent cytotoxicity

(CDC) assays. They are easy to perform, do not require expensive equipment, and
produce reliable results. However, they require viable lymphocytes and a
relatively large volume of blood.
Cellular typing methods such as mixed lymphocyte reaction (MLR) are labor-
intensive, take a long time to perform, and usually employ radioactive isotopes
with the consequent problems of radioactivity.
DNA techniques have superseded serologic and cellular techniques. They are
more time-efficient and robust and have become the technique of choice in most
laboratories. The currently used DNA technique for HLA typing has an element
of PCR technique within it. The technique allows for more precise HLA typing
than serologic or cellular methods. The reagents, the primers, probes, and
thermostable DNA polymerases utilized in PCR-based HLA typing are usually
standardized. Unlike serologic methods, PCR amplification allows for HLA
typing of minute samples; and, viability of the cell or expression of relevant HLA
antigen is not required.
Histocompatibility Testing (HCT)
Approximately 70% of individuals who require hematopoietic stem cell transplant

(HSCT) may not have an available HLA-identical sibling donor. Current evidence
validates the importance of matching an unrelated donor to the recipient for HLA
alleles. The accepted criteria for a HCT from an unrelated donor are based on
compatibility of class I HLA A, B and, C, and class II DRB1 and DQB1
alleles. Matched alleles at all five loci (10/10 matched “perfect match”) appear to
reduce the risk of clinically severe acute graft-versus-host disease (GVHD).
Amongst the classic major histocompatibilty complex (MHC) genes, HLA-DQB1
mismatching is usually considered permissible. Therefore, HCT outcome from
8/8 matched donor at HLA A, B, and C and DRB1 is associated with an equally
good outcome as 10/10 matched.
516 / CHAPTER 10
Optimal matching criteria for solid-organ grafts differ from HCT. Matching for
solid-organ grafts usually includes HLA-A, -B, and -DR. Donors and recipients
matched at all three loci are termed 6/6. In renal grafts, the majority of HLA
alloantibodies formed by renal graft recipients are directed toward cross-reactive
antigen groups (CREGs), which are shared determinants between class I HLA
antigens. Therefore, rather than matching for a unique variant of an allele, which
is infrequently identified, the HLA class I molecules may be matched for CREGs.
Donors of heart, liver, lung, and pancreatic grafts are not usually matched for
HLA type. However, HLA -A, -B, and -DR matching has a significant influence
on the outcome of patients receiving their first heart transplant. Serum antibody
screens may be performed to identify patients at risk for graft rejection.
HLA typing may also be used to monitor chimerism following allogenic stem cell
transplantation, to determine clonality and characterize neoplastic disorders, and
to establish gene mutation.
Panel Reactive Antibody
Preformed antibodies present in recipients against donor HLA antigens lead to

hyperacute or accelerated acute antibody-mediated rejection. Therefore, it is
essential to exclude these antibodies. These antibodies result from prior blood
transfusions, previous grafts, or from sensitization during pregnancy. Their
presence may be detected by testing the recipient’s serum against cells that
contain a panel of well-defined HLA antigens (direct complement-dependent
cytotoxicity or antiglobulin-augmented cytotoxicity assays) or against solubilized
HLA antigens attached to solid support (ELISA and microparticle-based flow
cytometric assays). These tests estimate the panel reactive antibodies or the
percentage of likely crossmatched incompatible donors (Table 10-14.)
Detection of these HLA antibodies is essential in renal transplant and is widely

practiced in lung or heart transplant. However, they do not appear to be involved
in the rejection of liver grafts. Their role in allogenic HCT is less clear.
Mixed Lymphocyte Reaction (MLR)
MLR is used to predict T-lymphocyte-mediated graft rejection of tissue allografts.

It is an in vitro technique utilized to assay T-lymphocyte proliferation in response
to foreign MHC molecules. The mononuclear leukocytes (T lymphocytes, B
lymphocytes, natural killer (NK) cells, dendritic cells, and mononuclear
phagocytes) obtained from peripheral blood of one individual are cultured with
mononuclear leukocytes obtained from peripheral blood of another individual. In
this culture, cells from both individuals may proliferate in response to each
other’s’ HLA molecules. To circumvent this, a one-way mixed-lymphocyte
Table 10-14. The Perfect Donor

HLA-
HLA-A HLA-B HLA-C HLA-DRB1
DQB1
Recipient 2501 1801 0308 0407 0301
6801 4002 1203 0411 0302
Donor 1 2501 1801 0304 0407 0602
6801 4002 1203 1501 0302
Donor 2 2501 1801 0304 0407 0602
6801 4002 1203 1501 0302
Donor 3 2501 1801 0306 0407 0602
6801 4002 1203 1501 0302
Donor 4 2501 1801 0308 0407 0301
6801 4002 1203 0411 0302
Each four-digit number represents a locus. For example, the numbers 2501 and 6801
represent the two loci for HLA A. Donor 4 is a perfect match for the recipient because
HLA-A, -B, -C, -DRB1, and -DQB1 are matched (i.e., 10/10). Donor 1, 2, and 3 are each
matched at 7/10.
Abbreviation: HLA, human leukocyte antigen.
reaction is employed. In this technique, mononuclear leukocyte population from

one individual is rendered mitotically inactive by γ-irradiation or mitomycin C
treatment. These irradiated or treated cells now function as stimulators, and the
unirradiated or untreated cells serve as the responder cell population. If the
unirradiated cells contain alloreactive T lymphocytes, these will proliferate and
differentiate into effector cells. The proliferated cells are mainly CD4+ T
lymphocytes, which recognize differences in MHC class II molecules.
IMAGING
SINUSES
Radiographs
Fast, relatively cheap

Not reliable
Can only reliably evaluate lower third of nasal cavity, maxillary, front,
sphenoid, and posterior ethmoid sinuses
Often obscured: Anterior ethmoid cells, upper two thirds of nasal cavity,
middle meatus, frontal recess
518 / CHAPTER 10
Computed Tomography (CT)
CT allows for coronal, sagittal, and axial views

Sphenoid sinus: Close proximity to carotid artery and optic nerve
The CT scans in Figures 10-10 and 10-11 show anatomic variants or

abnormalities.
B
Figure 10-10. (A) CT scan of the Haller cell (arrow). Ethmoid cell that migrates to
superior roof of maxillary sinus. (B) CT scan of concha bullosa (arrow). Ethmoid
cell migrates into middle turbinate.
(Figure A reproduced, with permission, from Radswiki.Net.; Figure B reproduced, with permission,
from Radiopaedia)
B
Flash Card Q8
Figure 10-11. (A) CT scan shows mucous retention cysts (arrow). (B) CT scan What is the commonly
shows nasal polyps (arrow). used term for a
(Reproduced, with permission, from Radswiki.net.) pneumatized middle
turbinate?
520 / CHAPTER 10
Magnetic Resonance Imaging (MRI)

MRI have the advantage of having no radiation and providing improved soft
tissue contrast.
Lung Diseases—Table 10-15 describes common immunologic lung diseases and

their classic chest CT appearance.
Table 10-15. Immunologic Lung Diseases

Immunologic Lung Disease Classic Chest CT Appearance
Wegener’s granulomatosis Multiple nodules without cavitation; peripheral

wedge-shaped consolidation
Asthma Bronchial wall thickening; air trapping on

expiratory HRCT
Allergic bronchopulmonary aspergillosis Central bronchiectasis (Figure 10-12)

(ABPA)
Chronic eosinophilic pneumonia Peripheral consolidation, ground-glass

attenuation in middle and upper lung zones
Acute hypersensitivity pneumonitis Centrilobular ground-glass and nodular

opacities
Churg-Strauss syndrome Peripheral consolidation or ground-glass

attenuation; 30% pleural effusions
Granulomatous and lymphocytic interstitial Nodular opacities, linear and/or irregular

lung disease (GLILD) in patients with CVID opacities, pulmonary consolidations, ground-
glass opacities, honeycombing, and
bronchiectasis
Abbreviations: CVID, common variable immunodeficiency. HRCT, hematopoietic stem cell
transplantation.
Flash Card A8
Concha bullosa
Figure 10-12. Allergic bronchopulmonary aspergillosis (ABPA) and central

bronchiectasis.
(Reproduced, with permission , from Radswiki.net)
Miscellaneous Imaging Findings
Complete DiGeorge’s syndrome thymic shadow on chest film

Hyper-IgE syndrome characteristic pneumatocele on chest film
Flash Card Q9
What radiographic
finding is a diagnostic
feature of ABPA?
Flash Card Q10

What characteristic
radiographic finding
might be seen in a
patient with autosomal
dominant hyper-IgE
syndrome?
522 / CHAPTER 10
FLOW CYTOMETRY AND CELL SURFACE

MARKERS
Flow cytometry is widely used as an important screening tool for the enumeration
of cells expressing distinct cell surface molecules. These markers can identify the
presence or absence of cellular populations and subpopulations through the
binding of specific monoclonal antibodies carrying a fluorescent tag.
FLOW CYTOMETRY
Principle
After being incubated with fluorochrome-labeled monoclonal antibodies, cells are
Key Fact suspended in a stream of fluid and passed one at a time though the light source,
Forward scatter: Size generating nonfluorescent scatter and fluorescent light emissions (Figure 10-13).
All data from each cell can be collected simultaneously, both physical and
Side scatter : Granularity
and complexity chemical characteristics, up to several thousand particles per second. Two types
of scatter—forward scatter (FSC), which detects size, and side scatter (SSC),
which determines granularity and structural complexity of the cells—allow
discrimination of lymphocytes, monocytes, and granulocyte (Figure 10-14).
Fluorescent emissions are used to identify the subpopulation of interest based on
expression of cellular markers or proteins.
Flash Card A9
Central bronchiectasis
Flash Card A10

Pneumatocele Figure 10-13. Flow cytometry schematic.
Figure 10-14. Flow cytometry pattern of peripheral whole blood.
Detection
Most extracellular surface proteins can be detected by flow cytometry (e.g.,
cluster of differentiation (CD) markers, Toll-like receptor (TLR) ligands, cell
receptors). Intracellular flow cytometry can also be used to assess other cellular
functions, such as neutrophil oxidative burst, calcium reflux, phosphorylation and
cytokine production.
Data Display
Software collates and displays the aggregated data for analysis. Each cell, or
event, is plotted based on scatter and fluorescent intensity. Data are commonly
presented as dot plot, contour plot, and histogram and reported in percentages.
Clinical Applications
Flow cytometry is commonly used for diagnosing primary immunodeficiency
disease (PID) and hematologic malignancies by studying blood or tissue samples.
Examples include assessing cellular activation and intracellular cytokine
production and for studying cell cycle and DNA ploidy. Although data from flow
cytometry can be highly suggestive of the disease, most PIDs still require a
molecular analysis to confirm the diagnosis.
524 / CHAPTER 10
CELL SURFACE MARKERS

The CD system is commonly used as cell markers; this allows cells to be defined
Key Fact based on what molecules are present on their surface. These CD molecules often
B cells and NK cells are serve as functional receptors, ligands, or are involved in cell adhesion. We can
CD3–. identify each immune cell type using the combination of their CD markers.
Commonly used markers are shown in Table 10-16.
Table 10-16. Commonly Used Lymphocyte Surface Markers

Cell Subpopulation Surface Markers
Stem cell CD34+
WBC CD45+
Granulocyte CD45+ CD15+
Monocyte CD45+ CD14+
T cell CD45+ CD2+ or CD3+
T helper CD3+ CD4+
CTL CD3+ CD8+
Treg CD3+ CD25+ Foxp3+
B cell CD45+ CD3– CD19+ or CD20+
Naïve mature B cell CD19+ CD27– surface IgM (sIgM)+
Mature B cell CD19+ CD20– sIgG+
Memory B cell CD19+ CD27+ sIgM+
Switched memory B cell CD19+ CD27+ sIgM–
Note: Majority of B cells in CLL are CD5+
NK cell CD45+ CD3– CD16+ or CD56+
NKT cell CD45+ CD3+ CD16+ or CD56+
Platelet CD45+ CD61+

Abbreviations: CLL, chronic lymphocytic leukemia; CTL, cytotoxic T lymphocyte; NK, natural
killer cell; NKT, natural killer T cell.
Flow Cytometry Study in PID

Applications of flow cytometry for the study of PID are shown in these following
samples (Figures 10-15 through 10-18).
Figure 10-15. X-linked agammaglobulinemia (XLA). Low or absent of peripheral

B cell and intracellular Bruton agammaglobulinemia tyrosine kinase (BTK) protein
in a boy with panhypogammaglobulinemia suggests XLA. The definitive
diagnosis is made by molecular analysis of BTK gene.
Figure 10-16 X-linked hyper-IgM syndrome. CD40L is normally present on the

Flash Card Q11
surface of activated CD4+ T lymphocytes and is absent in patients with X-linked
hyper-IgM. The carrier has bimodal CD40L expression following stimulation. What is a characteristic
(Reproduced, with permission, from Dennis W. Schauer, Jr., Trivikram Dasu, PhD, James W. cell surface marker of
Verbsky, MD, PhD, Clinical Immunodiagnostic & Research Lab, Medical College of Wisconsin.) memory B cells?
526 / CHAPTER 10
Figure 10-17. Autoimmune lymphoproliferative syndrome (ALPS). The flow

cytometry study demonstrates a marked increase in αβ-double-negative (CD4–
CD8–) T cells (DNT). Elevated αβ-DNT cells (≥1%) in blood or lymph node is one
of the diagnostic features for ALPS.
Figure 10-18. Chronic granulomatous disease (CGD). The activated phagocytes

from the patient with gp91phox-deficient CGD (X-linked) cannot undergo an
oxidative burst to generate superoxide radicals measured by dihydrorhodamine
(DHR) 123 assay. Female carriers of this form of CGD will display a mosaicism
with a bimodal DHR pattern of normal and abnormal oxidizing cells.
Flash Card A11 (Reproduced, with permission, from Dennis W. Schauer, Jr., Trivikram Dasu, PhD, James W.
CD27
CONTROVERSIAL TESTS
Skin End-Point Titration (Rinkel Method)

Employed for allergic rhinitis, the Rinkel method establishes a safe dose for
starting immunotherapy (IT) by using increasing serial allergen concentrations
injected intradermally, then measuring the wheal. “End-point” is the dose that
causes ≥ 2 mm increase in wheal diameter that occurs with increasing five-fold
concentrations (up to nine injections). This establishes the starting dose of IT; the
maintenance dose is estimated to be between 25–50 times the end-point dose.
May underestimate the safe starting doses and maintenance dose. Supported by
case reports only, randomized controlled trial (RCT) show that IT using this
method is no more effective than placebo.
Provocation-Neutralization
Similar to skin end-point titration, this uses test doses of various agents
(chemicals, allergens, food extracts, or other), administered ID, SC, or SL.
Subjective symptoms are recorded for 10 minutes following each dose. If there
are no symptoms, increasing doses are given. If symptoms (provocation) occur,
then lower doses are given until no symptoms (neutralization) occur. That dose is
given as therapy/treatment. Not standardized and a double-blind placebo-
controlled trial (DBPCT) found this method to be equivalent to placebo.
Cytotoxic Test and Antigen Leukocyte Cellular Antibody

Test (ALCAT)
Based on claim that morphologic changes in leukocytes exposed to an allergen in
vitro indicates allergy to that allergen. The ALCAT test is similar but measures
changes in leukocyte cell volume. There are anecdotal reports regarding the utility
of this test for guiding elimination diets in suspected food allergy. Not supported
by any DBPCT.
Electrodermal Testing
Flash Card Q12
Measures electrical impedance of the skin at designated acupuncture points in What X-linked immune
response to an electric current while foods or inhalant extracts are placed in deficiency, along with
carriers of the defect,
contact with the circuit. A change in electrical impedance would be considered to can be identified by a
have detected an allergy. DBPCT has shown that this method cannot dihydrorhodamine flow
independently distinguish atopic from nonatopic patients. cytometric assay?
528 / CHAPTER 10
Applied Kinesiology
Allergens are placed in patient’s hand while a technician assesses subjective
muscle strength in the opposite arm. A decrease in muscle power purportedly
indicates allergy. Not supported.
Controversial Uses for Immunologic Laboratory Tests

Total Serum IgE—This test can helpful in certain conditions (Job’s
syndrome/ABPA), but not in diagnosis of allergic rhinitis/food allergy/
Hymenoptera stings, because a normal IgE does not necessarily exclude
significant allergy, and somewhat high levels may also be seen in nonatopic
patients.
Serum-Specific IgG—Merely indicative of exposure and not causation, serum-

specific IgG levels have no utility in diagnosing food or inhalant allergy.
Food Immune Complex Assay

Based on belief that food antigen-immune complexes may potentiate delayed
symptoms of food intolerance (i.e., more than 2 hours after ingestion), this test
assesses the presence of IgE or IgG immune complexes with food antigen.
However, these complexes have never been clearly associated with allergy.
Considered experimental.
DELAYED-TYPE HYPERSENSITIVITY (DTH)

TESTING
DTH (type IV) testing serves as a screening functional assessment of the cellular
immune system. DTH depends upon a T-cell response to an antigen previously
encountered through ubiquitous exposure or vaccination (Table 10-17). These
“recall antigens” are usually Candida, tetanus toxoid, or mumps. The tuberculin
skin test (TST) is another standardized DTH test. However, currently the only
FDA-approved tests for measuring DTH are the TST and Candida. Trichophyton
may be used, and in endemic areas coccidioidin and histoplasmin may also be
used.
Flash Card A12 DTH testing is performed by injecting a small amount of antigen intradermally
Chronic granulomatous and recording the amount of induration 48–72 hours later.
disease
Table 10-17. Advantages and Disadvantages of Delayed-Type

Hypersensitivity Testing
Advantage Disadvantage
b
Quick Not sensitive
a
Inexpensive Not specific
Simple Qualitative
a
DTH would not be expected to be positive in unvaccinated patients (i.e., patients who have not
yet received tetanus or mumps vaccines) or very young patients who haven’t been sufficiently
exposed to the antigen in the environment (i.e., Candida).
b
Other conditions that may cause abnormal DTH test results by adversely affecting cellular
immunity include malnutrition or uremia.
A negative reaction (absence of induration) may simply reflect a lack of exposure

to the antigen, relatively weak nature of the antigen (e.g., Candida), or anergy.
Anergy may be associated with primary or acquired cellular immuno-

deficiency, cancer, sarcoidosis, cytotoxic immunosuppressive therapy (e.g.,
steroids), severe atopic dermatitis, or recent/concurrent infection.
Anergy also correlates with severity of cellular immunodeficiency; anergy is
present in advanced HIV but not seropositive HIV with adequate CD4+
counts.
Anergy without apparent clinical sequelae will be observed to DTH testing for
a period of time after receiving the measles, mumps, rubella (MMR) vaccine,
because a vigorous immune response to one antigen such as measles can
temporarily suppress other DTH responses.
Pathophysiology
DTH results from the activation of specific T cells by antigen-presenting

Langerhans cells in the skin. This T-cell activation leads to cellular infiltration
with macrophages, monocytes, and lymphocyte in a nonspecific fashion. These
cells then secrete inflammatory cytokines, tumor necrosis factor alpha (TNFα)
and interferon gamma (IFNγ). Histamine and serotonin release result in increased
vascular permeability; the leaky vasculature in combination with an upregulation
in adhesion molecules results in additional cellular influx into the site of antigen
exposure, which increases induration and erythema.
530 / CHAPTER 10
Clinical Use of DTH Testing

Testing is typically done with 0.1 mL of a 1:10 to 1:100 concentration antigens on
Key Fact the volar surface of the forearm; several antigens may be placed at the same time.
A positive DTH test Positive tests are usually 5 mm or greater in induration when read at 48 or 72
reflects prior exposure to hours.
the antigen in question
and is typically
reassuring if the DTH A negative test to a recall antigen, which a patient is expected to have because of
test is being done to adequate exposure, should prompt further evaluation. Negative tests may also
assess competence of reflect antigen potency, or concentration, and technique of application. Seventy-
cellular immunity. A five percent of healthy children from 1–3 years of age have a positive Candida
negative DRH test may DTH test results, and some infants as young as 3 months old have positive
simply reflect lack of
exposure to the antigen Candida DTH test results. Positive tetanus DTH usually requires the completion
or it may reflect anergy of several separate tetanus vaccinations in the series (three or more); about a third
as a result of either of patients have a positive DTH to tetanus after the first injection in the series
primary or secondary only. Prior bacille Calmette-Guérin (BCG) vaccination can temporarily result in a
cellular positive TST, but this somewhat weak reaction fades after a few years.
immunodeficiency.
Excessive DTH reactions may be seen in patients with rare mutations in IL-12,
IL-12R, IFNγ, or IFNγR.
FOOD CHALLENGES
Definition
Controlled ingestion of certain foods known to contain allergens. Strict

elimination of suspected food for 7–14 days is recommended before challenge.
Food challenges are the gold standard for the diagnosis of food allergies in both
IgE- and non-IgE-mediated food allergies, especially double-blind placebo-
controlled food challenges (DBPCFC).
Due to the risk of anaphylaxis in IgE-mediated allergy, food challenges are
usually conducted in a physician’s office or hospital.
Blind food challenges involve masking the suspected allergen in a vehicle,
giving it to the patient, and observing the patient for signs or symptoms of an
allergic reaction.
Types of Challenges
Double-Blind, Placebo-Controlled Food Challenges (DBPCFC)—Both the

patient and the tester are unaware of food being used in challenge. A negative
DBPCFC must be confirmed by open feeding challenge under observation. Must
do equal number of randomly alternating food allergens and placebo challenges.
Start with 125–500 mg of lyophilized food (give in fasting state)
Increase the dose every 15–60 minutes
Clinical reactivity ruled out once 10 g of dry food ingested
Single Blind Challenges—The patient is unaware of food being used in the

challenge, but the tester is aware. It may be useful to screen for suspected food
allergies.
Open Challenges—Both the patient and tester are aware of food being used in
the challenge. Most commonly performed in practice.
Diagnostic Decision Points

Indicate the likelihood that patient will “outgrow” the food allergy. As IgE
increases, so does the risk of clinical reactions but the curve is distinct for each
food and may vary with age and atopic disorder.
Ten percent to 25% of those with negative serum-specific IgE may have
clinical reactions. Therefore, if the in vitro test is negative but there is a high
clinical suspicion for food allergy then an SPT and/or food challenge must be
done.
SPTs are generally more sensitive and may be positive despite undetectable
specific serum IgE.
Serum levels of food-specific IgE antibodies and SPT wheal sizes are not
absolute indications or contraindications to performing an oral food challenge
(OFC) and must be interpreted in the context of clinical history.
Specific Diagnostic Decision Points

All decision points in Table 10-18 indicate there is a >95% chance of a reaction
upon food challenge, except for soy and wheat, for which there is a 75% chance.
Table 10-19 shows levels for which there is a 50% chance of experiencing a
negative challenge. These patients are thought to be the optimal candidates for an
office-based OFC.
532 / CHAPTER 10
Table 10-18. Specific Diagnostic Decision Points for Food Challenges ~

95% PPV
Allergen Age (years) Serum IgE (kUa/L)
2 7
Egg
2 2
2 15
Milk
2 5
Peanut 14
Fish 20
Soybean 30*
Wheat 26*
Tree nuts ~15

* 75% predictive value
Abbreviation: PPV, positive predicted value.
Table 10-19. Specific Diagnostic Decision Points for Food Challenges

~50% Negative
Allergen SPT wheal (mm) Serum Food IgE (kUa/L)
Egg ≤3 ≤2
Milk ≤2
Peanut ≤3 ≤ 2 with history of peanut reaction
≤ 5 without history of peanut reaction

11 Allergens and Antigens
AEROBIOLOGY
Factors Influencing Clinical Significance of Aeroallergens

Thommen’s Postulates of Allergenicity outline the following characteristics of
clinically important pollen types:
Pollen must be capable of eliciting an allergenic response (proteins and
glycoproteins).
Pollen must be anemophilous (wind-pollinated) and sufficiently buoyant to
be carried long distances (e.g., hundreds of miles).
Pollen must be produced in abundance, and the plant producing the pollen
must be widely distributed.
Particle Size
Pollens can range from 10 to >200 μm in size, with most significant
aeroallergens ranging between 10–60 μm.
Mold spores may be extremely small at about 1–2 μm or quite large at close to
100 μm.
Aeroallergen Occurrence
Seasonal or occurring at predictable times of the year: tree, weed, and grass
pollen
Perennial or prevalent year round: dust mite, dog, cat, and mold spore
aeroallergens
Dispersal of Pollen Aeroallergens

Anemophilous (wind-pollinated)
o Ten percent of all flowering plants, usually those with small,
inconspicuous flowers
o Usually plants with high pollen production
Entomophilous (insect-pollinated)
o Most common form of pollination; plants often have “flashy” flowers, Flash Card Q1
with scent and nectar
What are the three
o Large sticky pollen grains; usually smaller amounts of pollen produced requirements of an
aeroallergen (derived
from Thommen’s
Postulates)?
534 / CHAPTER 11
Pollination and Plant Flower Characteristics

Pollen is the male gametophyte and analogous to sperm in humans. Pollination is
the transfer of pollen from the anther sac (male portion) to the stigma (female
portion) of the same or another flower.
Monoecious: Plant species that have both male and female flowers on the
same plant
o These include monoclinous (perfect) flowers, which contain both male
and female parts within the same flower, and diclinous flowers, in which
male and female flowers are separate, but located on the same plant.
Dioecious: Species that have male and female flowers on different plants.
Thus, separate male and female plants
Sampling Methods and Detection of Aeroallergens

Sedimentation and gravitational sampling is the most elementary sampling
method, relying on gravity; however, quantitative data for this method are
difficult to obtain.
Durham Sampler—Microslides are thinly coated with adhesive and exposed for a
24-hour period.
Cons: Biased toward larger particles. Cannot determine airborne
concentration. Open culture plates can be exposed to weather
Pros: Low cost, durable, and independent of power source
Settle Plates—Particles are allowed to settle onto an agar medium for a period of
time, then incubated at the required temperature and examined or counted (e.g.,
bacteria and molds).
Cons: Biased toward larger particles. Cannot determine airborne
concentration. Generally for indoor use only
Pros: Identifies viable airborne organisms (molds)
Impaction Volumetric Samplers

Rotorod—Employs rods that sweep through the air to collect particles on surfaces
coated with an adhesive; then, a volumetric count is determined by dividing the
number of particles collected by the volume of air sampled (Figure 11-1A).
Cons: Not efficient for smaller particles (i.e., <10 μm) as the smaller particles
seem to air-stream around the collecting rods
Pros: Not significantly affected by wind; good for particles in the range of
Flash Card A1
most airborne pollen; enables calculation of airborne particle concentration
Must be allergenic,
buoyant, and present in
significant concentration
ALLERGENS AND ANTIGENS / 535
Suction Samplers and Spore Traps—These samplers inhale air and particles at
specific rates of flow through slits, vents, or holes.
Burkard Spore Trap (Hirst-Like)—Known amounts of air are drawn in through a

sampling orifice, and a “tail” keeps the device oriented to the wind (Figure 11-
1B.)
Pros: More efficient than the Rotorod for collecting particles that are less than
10 μm; consistent flow speed of 10 L/min; samples can be taken over 7 days
or over 24 hours
Cons: More expensive than most other samplers. Affected by wind speed
Anderson Sieve Impinger (Multistage Cascade Sampler)—The sampler

comprises a series of sieves or stages, each with up to 400 perforations, through
which air is drawn at 1 ft3/min. As air passes through stages, particles pass
through progressively smaller holes and are separated into size-specific fractions.
Used primarily for culture-based sampling of airborne fungi.
Pros: Separates particles based on size; good for brief collection periods
Cons: Expensive
Allergenco Air Sampler—Nonwind-oriented “grab type” suction sampler that

collects samples on laboratory slides, according to a programmed cycle. Can
sample over an entire weekend period. Primarily for indoor use.
Flash Card Q2
Define monoecious and
dioecious.
A B
Figure 11-1. (A) Rotorod sampler and (B) Burkard spore trap. Flash Card Q3
(Reproduced, with permission, from Sue Kosisky, United States Army Centralized Allergen Extract
Laboratory.) Name an advantage and
disadvantage of the
Rotorod.
536 / CHAPTER 11
Other Sampling Devices

Liquid impingers draw air into liquid and particles become suspended in
circulating fluid. They are used to collect bioaerosols that can be examined
immunochemically. Cyclonic collectors are used for dust collection and
separation. Particles are counted visually and may also be cultured for fungi.
Filtration samplers are used to detect dust levels, endotoxins, antigens, fungi,
and microorganisms. They basically suck particles through a filter, with a wide
range of sampling rates from 2–1000 L/min.
Pollen and Mold Spore Counting and Identification

Basic Technique
Sampling rod or slide surfaces are stained with Calberla’s solution—a basic
fuschin stain—then examined microscopically at 400× for pollen and 1000×
for fungi
Pollen is counted manually for the “raw count,” then converted to grains per
cubic meter, using a formula dependent on sampling methodology (i.e.,
sampler used, exposure time, volume of air sampled, etc.)
Pollen and Spore Identification

Size and shape (most pollens are between 20–60 μm in size, with various
shapes)
Surface texture and sculpturing (i.e., smooth, spiny, warty or granular)
Apertures (pores and furrows)
Staining (characteristically, light pink to darker red)
Unique exine (outer layer) or intine (inner layer) characteristics
Flash Card A2
Monoecious: Having See Figure 11-2 for pollen grain structure.
both male and female
flowers on the same
plant
Dioecious: Having
separate male and
female plants
Flash Card A3
Advantages include
ability to obtain
quantitative results and
this method is not
significantly affected by
wind
Disadvantage is its poor
collection efficiency for Figure 11-2. Pollen grain structure. (Reproduced, with permission, from Sue Kosisky,
particles <10 μm United States Army Centralized Allergen Extract Laboratory.)
POLLENS
GRASS POLLEN
Grass pollen looks the same, regardless of species: monoporate, relatively large
(i.e., 20–45 μm), round pollen grain (Figure 11-3). It is slightly granular in Mnemonic
appearance. The pore is surrounded by a thickened ring (annulus) and may have a To recall the three main
cap (operculum). allergenic southern
grasses, remember
Grass tends to pollinate during the late spring and summer months; but, in Bahia is a coastal
southern climates, may pollinate year-round. region of Brazil and,
along with Bermuda,
should conjure up
images of the beach.
For the third one, think
of American blues great
Robert Johnson, who
hailed from the
Mississippi delta.
Figure 11-3. Grass pollen.

Laboratory.)
Southern Grasses
Chloridoideae: Bermuda, lovegrass, and prairie grasses (e.g., salt, buffalo,

and grama)
Panicoideae: Bahia, Johnson, corn, and sugarcane
(Reproduced, with
permission, from
Wikimedia Commons.)
Northern Grasses (Pooideae)
Northern grasses include timothy, orchard, rye, fescue, bluegrass, redtop, sweet
vernal, brome, velvet, and canary.
Table 11-1 lists southern and norther grasses and their allergens. Flash Card Q4
Which of these grasses
are most cross-reactive
with timothy: bahia,
Bermuda, bluegrass,
Johnson, rye, fescue?
538 / CHAPTER 11
Table 11-1. Grass Pollen Allergens

Type of Grass Common Name Scientific Name Allergen(s)
Key Fact Bahia Paspalum notatum Pas n 1, 13
Fourteen grass allergen Southern grasses Bermuda Cynodon dactylon Cyn d 1-14
groups have been
characterized, with as Johnson Sorghum halepense Sor h 1-14
many as five of those Timothy Phleum pratense Phl p 1-14
being major allergens
(Table 11-1). Bermuda is Northern grasses Rye Lolium perenne Lol p 1-14
cross-reactive with other
members of the subfamily Bluegrass Poa pratensis Poa p 1-14
Chloridoideae, but not
with the other subfamilies.
Bahia and Johnson
grasses have limited
cross-reactivity. Members WEED POLLEN
of the subfamily Pooideae
showed strong cross-
allergenicity based on
homology of three major This category of weeds refers to invasive plants that are neither trees nor grasses,
allergens with possible which pollinate generally in the late summer and fall (Table 11-2). See Figure 11-
unique allergens in 4 for an overview of weed taxonomy, which may prove helpful for remembering
timothy and sweet cross-reactivity; however, it is not meant for memorization. The genus names are
vernal.
the most important.
Note: In a question about
cross-reactivity of
allergens, if two northern Table 11-2. Weed Pollen Allergens
grasses are among the
answer choices, those Common Name Scientific Name Allergen(s)
(e.g., timothy and sweet Ragweed Ambrosia artemisiifolia
Amb a 1-10, profilin, and
vernal) would be a good cystatin
bet! Mugwort Artemisia vulgaris Art v 1-3 and profilin
Pellitory (Urticaceae) Parietaria spp. Par o 1 and 2
Flash Card A4
Bluegrass, rye, and
fescue. The northern
grasses are strongly
cross-reactive with each
other. Figure 11-4. Weed taxonomy.
Chenopod and Amaranth

Pollen grains are 20–35 μm, spherical and periporate (like a golf ball), with a
slightly granular-to-smooth surface (Figure 11-5). Chenopods and amaranths may
have significant cross-allergenicity. Pigweed or careless (Amaranthus): Includes
Palmer amaranth (careless weed), rough pigweed, and western water hemp.
Lambsquarter (Chenopodium): Also known as “goosefoot” (chenopod) due
to the shape of its leaves
Wingscale or saltbush (Atriplex): Mostly found in the western US; seed pods
use “wings” for dispersal
Burning bush (Kochia scoparia): Named for its red leaves
Russian thistle (Salsola): Probably the most important cause of hay fever
among the chenopods
Figure 11-5. Chenopod pollen.

Laboratory.)
Composites (Asteraceae)
Ragweed (Ambrosia)
Pollen grains are 15–25 μm and either tricolporate or tetracolporate, but this is
overshadowed by the spiny exine. Furrows are short, only slightly longer than
the pore (Figure 11-6).
Allergenic species include giant (Ambrosia trifida), short (Ambrosia
artemisiifolia), western (Ambrosia psilotachya), and false (Ambrosia
acanthicarpa); strong cross-reactivity between species.
Pollen-food associations include banana, cantaloupe, and watermelon.
Prolific pollen producers, accounting for 75–90% of all pollen captured
between August and October in some regions. (Its reputation is well
deserved!)
Ragweed season ends typically when frost prevents plants from flowering.
540 / CHAPTER 11
Figure 11-6. Ragweed pollen.

Laboratory.)
Sage and Mugwort (Artemisia)

Grain is 20–30 μm, round to triangular in shape, and has three prominent
furrows (Figure 11-7).
Pollen food associations include mugwort-celery spice, mugwort-peach, and
mugwort-mustard.
Figure 11-7. Sage pollen.

Laboratory.)
Cockleburs (Xanthium)—Grain is 25–30 μm, spheroidal, and similar to

ragweed; however, it is larger in size with smaller, blunter spines (Figure 11-8).
Figure 11-8. Cocklebur pollen.

Laboratory.)
Marshelder (Iva)
Rivals ragweed as an allergen in some parts of the Mississippi River Basin
Differs from ragweed pollen due to long furrows
Nettle (Urticaceae)
Species include the stinging nettle, common in North America, and wall
pellitory (Parietaria), a similar weed that is an important aeroallergen in
Europe.
One of the smallest pollens (12–16 μm) with three to four pores (Figure 11-9).
Figure 11-9. Nettle pollen.

Laboratory.)
Plantain (Plantago)—Pollen is large (i.e., 20–40 μm) and periporate (6–10 pores),
with a distinctive pore cap (operculum) that gives it a “doughnut” appearance
(Figure 11-10).
Figure 11-10. Plantain pollen.

Laboratory.)
Dock or Sorrel (Rumex)

This buckwheat genus includes curly dock and sheep sorrel.
Pollen is round, 20–30 μm, and tricolporate, with characteristic starch
inclusion granules. Furrows are long, almost reaching the poles (Figure 11-
11).
542 / CHAPTER 11
Figure 11-11. Dock or sorrel pollen.

Laboratory.)
TREE POLLEN
In general, trees pollinate in the spring. A few exceptions include three species
of elm, which pollinate in the fall, and the mountain cedar, which pollinates in
midwinter.
Table 11-3 lists the common tree pollen allergens.
Ash, Olive, Privet, and Russian Olive (Oleaceae)

The pollen of the ash family usually includes four- or five-sided grains, with
furrows that suggest a square or pentagonal appearance (Figure 11-12).
Ash trees are allergenically important in eastern and central North America;
whereas, olives are found primarily in western North America and Europe
(particularly, the Mediterranean).
Strong cross-reactivity exists among family members.
Table 11-3. Tree Pollen Allergens

Common Name Scientific Name Allergen(s)
(genera in italics)
Ash Fraxinus Fra a 1
Birch Betulaceae Bet v 1-7
Mountain cedar Juniperus Jun a 1-3
Oak Quercus Que a 1
Olive Oleaceae Ole e 1-8
Sycamore or plane tree Platanus Pla a 1
Exine has net-like (reticulate) pattern. In ash, the net pattern is fine; but, in
olive and privet, the net pattern is coarse and quite apparent.
Olive and privet have three furrows.
Figure 11-12. Ash pollen.

Laboratory.)
Birch, Alder, Hazelnut, and Hornbeam (Betulaceae)

Three pores (triporate) protruding from the surface, each of which contains a
collar (oncus). May appear like a lemon, if only two pores are visible (Figure
11-13).
Alder is slightly different in appearance, with four to six pores.
Pores protrude (aspidate).
Foods known to cross-react with birch and cause oral allergy syndrome,
include apple, almond, apricot, carrot, celery, cherry, coriander fennel,
hazelnut, kiwi, nectarine, parsley, parsnip, pear, pepper, plum, potato, and
walnut.
Strong cross-reactivity within family, extending to the family Fagaceae.
Figure 11-13. Birch pollen.

Laboratory.)
Flash Card Q5
Which pollen has been
most implicated in
pollen-food syndrome?
What are the major
allergens involved?
544 / CHAPTER 11
Cypress, Juniper, and Cedar (Cupressaceae)

Thick intine with stellate cytoplasmic contents and an exine, which can break
and look like Pac-Man (Figure 11-14).
Mountain cedar (Juniperus ashei) pollinates midwinter in Texas, causing
“cedar fever”; Eastern red cedar (Juniperus virginiana) is common in the
eastern US and pollinates in the spring.
Strong cross-reactivity within family; one member should suffice for
treatment.
A B
Figure 11-14. (A) Mountain cedar pollen with disrupted exine; (B) intact mountain
cedar pollen. (Reproduced, with permission, from Sue Kosisky, United States Army Centralized
Allergen Extract Laboratory.)
Oak, Beech, and Chestnut (Fagaceae)

Oak pollen is triangular-shaped with three germinal furrows that appear as
white “pie slices” slightly protruding from the surface. Size, 25–35 μm
(Figure 11-15).
Common spring pollinator and major allergen throughout most of the US.
In addition to cross-reactivity within Fagaceae, oak is also cross-reactive with
birch and other members of the Betulaceae family.
Figure 11-15. Oak pollen.

Laboratory.)
Flash Card A5
Betula (Birch). Bet v 1
and Bet v 2
Sycamore (Platanaceae)—Round grains, with three furrows and a thin exine

that is finely reticulate (Figure 11-16).
Figure 11-16. Sycamore pollen.

Laboratory.)
Pine (Pinaceae)
Bladders give the impression of a child’s Mickey Mouse cap (Figure 11-17).
Large size (i.e., 50–100 μm) means that they are rarely implicated in allergy.
Figure 11-17. Pine pollen.

Laboratory.) Flash Card Q6
A 21-year-old man in
San Antonio, Texas, has
Maple and Box Elder (Aceraceae) rhinorrhea, nasal
congestion, and
Grains contain three furrows, like oak; but, are generally round and may have conjunctivitis for several
a “beach ball” appearance (Figure 11-18). weeks each January for
Box elder is wind-pollinated; maple is primarily insect-pollinated 3 years. He is
asymptomatic the rest of
the year. What is the
most likely allergen?
Flash Card Q7
Lolium, Pinus, Platanus,
Quercus, Urtica. Which
has the smallest pollen?
The largest pollen?
546 / CHAPTER 11
Figure 11-18. Maple pollen.

Laboratory.)
Elm (Ulmaceae)
American elm pollinates in the spring, whereas several other elms pollinate in
the fall.
Four to seven (usually five) oval-shaped pores and may appear pentagonal.
Outer surface appears wavy or undulating (Figure 11-19).
Figure 11-19. Elm pollen.

Laboratory.)
Flash Card A6 Poplar, Willow, and Cottonwood (Salicaceae)

Juniperus ashei Poplar and cottonwood have round grains, each with an outer surface that is
(mountain cedar) pollen granular and often appears “cracked” or “flaky” (Figure 11-20); but, there are
no furrows. By contrast, willow has three furrows and a reticulate pattern on
the pollen wall.
Willows are entomophilous and not considered allergenically important;
Flash Card A7 however, they are medically important since aspirin is made from their bark.
Smallest: Urtica (nettle) Poplars are anemophilous and produce significant allergenic pollen
12–14 μm; Largest: throughout North America.
Pinus (pine) 50–100 μm.
Figure 11-20. Cottonwood pollen. Smallest: Urtica (nettle) 12–14 μm; Largest: Pinus
(pine) 50–100 μm.
Laboratory.)
Sweetgum (Hamamelidaceae)
Periporate, with 12–20 pores per grain that often bulges, suggesting a “soccer
ball” appearance.
Sweetgum is the only species of allergenic importance in this family, which
also includes witch hazel, and is found generally south of the Mason-Dixon
line in the US (Figure 11-21).
Figure 11-21. Sweetgum pollen.

Laboratory.)
Mulberry (Moraceae)
Grains are small (i.e., 11–20 μm), thin-walled, and usually diporate with onci,
giving the appearance of a light, pinkish lemon (Figure 11-22).
Pores are slightly raised or aspirated (“shield-shaped”).
Flash Card Q8
Which of these trees is
entomophilous?
A. Ash (Fraxinus)
B. Oak (Quercus)
Figure 11-22. Mulberry pollen.
C. Poplar (Populus)
Laboratory.) D. Willow (Salix)
548 / CHAPTER 11
Walnut, Hickory, and Pecan (Juglandaceae)

Walnut is periporate, with 9–15 slightly raised germinal pores; hickory and
pecan are indistinguishable, with each containing three nonprotruding pores
(Figure 11-23).
The family Juglandaceae, derived from Latin meaning “Jove’s nuts,” contains
both Juglans (walnut) and Carya (hickory) species. Allergenically important
walnut species exist on both the west and east coasts of North America; but,
the hickories are limited to the eastern US.
Cross-reactivity exists between members.
A B
Figure 11-23. (A) Walnut pollen; (B) Hickory pollen.

Laboratory.)
Mimosa, Acacia, Locust, and Mesquite (Leguminosae)

Pollen grains may exist as monads or polyads, with the polyads usually having
either 4 or 16 quadrangular grains in a group (Figure 11-24).
These four are exceptions among leguminous plant species, which are usually
nonallergenic. Mimosa and Acacia are cultivated as ornamental trees in
tropical and subtropical regions. Mesquite is found primarily in the southwest
US, where it was an important food source for early Native Americans.
Flash Card Q8
D. Willow (Salix) is Figure 11-24. Acacia pollen.
entomophilous (insect- (Reproduced, with permission, from Sue Kosisky, United States Army Centralized Allergen Extract
Laboratory.)
pollinated)
Environmental Control of Pollen
Limit outdoor exposure during high pollen counts.

Keep windows and doors closed.
Use air conditioning with outdoor vents closed.
Consider bathing following outdoor activity to reduce indoor
contamination.
Wash pets after they have been outdoors.
MOLDS AND FUNGI
Medical Importance of Fungi

Fungi can be saprophytic or exist as parasites to both humans and plants. They are
implicated in a number of allergic diseases in humans, including allergic asthma,
hypersensitivity pneumonitis (HP), rhinoconjunctivitis, and bronchopulmonary
mycoses.
Immune Response: Both conidia and spores are associated with IgE
immediate-type hypersensitivity. Smaller spores that penetrate the smaller
airways have been associated with delayed-type hypersensitivity. Respiratory
allergy and atopic asthma may be caused by the inhalation of mold spores.
Allergic fungal sinusitis is also due to mold spores.
Infection: Includes cutaneous and respiratory infections. Important
consideration in the immunocompromised patient. Aspergilla, Candida, and
Mucor (in diabetics) are common agents.
Toxic Irritant: Fungal metabolites and mycotoxins have numerous health
effects for humans. Aflatoxins from Aspergillus flavus, for example, are
known to be carcinogenic and mutagenic. The mycotoxin tenuazonic acid
produced by Alternaria alternata has hepatotoxic and nephrotoxic health
effects. Volatile organic compounds (VOCs) are released by various fungi
growing on different substrates.
Spore Structure and Development
Fungal organisms can be unicellular or multicellular (single-celled yeast

forms to considerably branched hyphae).
Fungal reproduction occurs by many forms, including budding, fission,
fragmentation, and the production of spores.
The size, shape, color, and characteristics of mold spores are important for the
taxonomic classification of fungi.
550 / CHAPTER 11
Fungal Taxonomy
Fungi consist of a large group of complex and diverse organisms, making
classification and identification very difficult. Fungi reproduce both sexually and
asexually. Five major divisions include:
Ascomycota: The largest phylum of fungi. Ascomycota produce sexual
spores (ascospores) in “sacs” known as an ascus. It has multiple classes and
includes most of the allergenic fungi.
Zygomycota: Asexual spores are produced within sacs called sporangia.
Found on soils and leaves, and damp interiors. Mucor and Rhizopus are
prominent genera in this group.
Basidiomycota: Includes puffballs, mushrooms, rust, and smuts. Produce
basidiospores on the ends of protruding “pegs” or finger-like structures called
basidia.
Deuteromycetes: Also known as the fungi imperfecti and asexual spores.
Conidial fungi with no identified sexual stage that constitutes the second
largest group of fungi. Spores vary considerably in size, shape, color, and
structure.
Oomycota: Rarely reported as allergens. Water molds; the downy mildews
are included.
Airborne Fungi of Allergenic Importance

Alternaria
In air samples occur singularly or in chains.
Club-shaped with multicellular beak, 20–75 μm (Figure 11-25).
Prevalent outdoors as dry day mold spore.
Alternaria sensitivity has been associated with severe asthma and life-
threatening exacerbations as well as hay fever.
Likes decaying plants; high prevalence in grain-growing areas.
Figure 11-25. Alternaria.

Laboratory.)
Cladosporium
The most abundant spores in temperate areas of the world
Asexual spore often noted in air sample in chains
Individual conidia range from 6–25 μm in length
Variations in shape, including hot dog, cylindrical, and spherical (Figure 11-
26)
Dry day spore; also prevalent indoors (due to high outdoor concentrations)
Mnemonic
Figure 11-26. Cladosporium. Aspergillus and

(Reproduced, with permission, from Sue Kosisky, United States Army Centralized Allergen Extract Penicillium are often
Laboratory.) indistinguishable.
However, Aspergillus
was discovered by an
Italian priest, who
Aspergillus named it after the
Common, indoor mold spore; asexual aspergillum, the
Spherical to oval spores, which can be single or in chains (Figure 11-27A) implement used by
clergy to sprinkle holy
May produce mycotoxins and cause allergic bronchopulmonary water (Figure 11-27B).
aspergillosis (ABPA) Penicillium comes from
the Latin penicillus,
Penicillium which means
Common, indoor mold spore “paintbrush.”
Distinctive structure (conidiophore) looks like a paint brush, but only visible
in culture (Figure 11-27C)
May produce mycotoxins and cause hypersensitivity pneumonitis (HP), also
called extrinsic allergic alveolitis (EAA), in cheese workers
Flash Card Q9
What is the defining
characteristic of the
largest phylum of fungi,
Ascomycota?
Flash Card Q10

A B C Near-fatal asthma is
Figure 11-27. (A) Aspergillus; (B) aspergillum; and (C) Penicillium. associated with
(Images A and C reproduced, with permission, from Sue Kosisky, United States Army Centralized sensitivity to which
Allergen Extract Laboratory ; image B reproduced, with permission, from Wikimedia Commons.) mold?
552 / CHAPTER 11
Helminthosporium, Drechslera, Bipolaris, and Exserohilum Group

Single, dry, day spores, with thick cell walls
Variable in size: 15–180 μm long by 14–22 μm at broadest part, width-wise
(Figure 11-28)
Light to dark brown in color
Implicated in allergic fungal sinusitis
Figure 11-28. Helminthosporium.

Laboratory.)
Epicoccum
Asexual, round, multicellular, and dry day spores
Usually 15–25 μm, but can be as much as 50 μm (Figure 11-29)
Dark, golden brown with warts on the surface
Figure 11-29. Epicoccum.

Laboratory.)
Flash Card A9
Fusarium
The production of an
ascus (saclike structure Colorless, wet, day spore with three to seven transverse septa
containing sexual Spindle-shaped and curved, with tapered ends (Figure 11-30)
spores) Size: 20–50 μm by 3–5 μm.
Flash Card A10

Alternaria
Figure 11-30. Fusarium.

Laboratory.)
Ascomycota
Rainy day sexual spore, with wide range of shape and size that forms in an
ascus or sac; usually eight ascospores to an ascus (Figure 11-31)
Single or multicelled; colorless to deeply pigmented
Figure 11-31. Ascomycota.

Laboratory.)
Basidiomycota
Common mushroom, bracket fungi, and puffball spores
Rainy day spores with wide range of shape, size, and color
Always single-celled
Range of 2–18 μm in size (Figure 11-32)
Smut spores and rust spores are two groups of plant pathogenic fungi in this
phylum.
Smut spores are especially abundant in agricultural areas; single-celled,
globose to subglobose, 6–15 μm in diameter, and golden brown to dark
brown; and, they may have a smooth, spiny, or reticulate wall.
Rust spores are larger than smut spores (i.e., 20–30 μm), oval to diamond-
shaped, and pale to deeply pigmented, with a smooth or spiny wall.
554 / CHAPTER 11
A B
Figure 11-32. (A) Basidiomycota and (B) smut spores.
Laboratory, and Estelle Levetin, University of Tulsa.)
Aureobasidium
Common, indoor mold spore found on damp surfaces (e.g., in kitchens and
bathrooms)
Difficult to identify in outdoor air samples
Colonizes paper and lumber
Zygomycetes
Class of lower fungi with nonseptate hyphae; found indoors, in damp interiors
Genera include Mucor and Rhizopus
Abundant on leaf litter and decaying vegetation
Stachybotrys—“Black mold”; a toxin-producing mold that can be present

indoors after water damage.
Yeasts
Unicellular fungi that can be opportunistic pathogens (Candida)
Found in water, soil, plants, and air
Indoor Versus Outdoor Mold

Common Indoor Spores
Mnemonic Aspergillus and Penicillium (also Rhizopus and Mucor)
Outdoor spores move readily indoors (Cladosporium)
The most important
indoor molds are
Aspergillus and Outdoor Spores
Penicillium. Abundant Dry, day mold spores; prevalent on dry, sunny, windy days: Alternaria,
outdoor molds Cladosporium, Epicoccum (ACE); also Curvularia, Drechslera, Pithomyces,
(Cladosporium) can also
Botrytis, and smut spores
be found at high
concentrations indoors. Rainy day mold spores: Ascospores, basidiospores, Fusarium
Prevalent at night and in high humidity: Ascospores, basidiospores
Outdoor molds usually present year-round, except with snow cover
Table 11-4. Mold Allergens

Alternaria Alternaria alternata Alt a 1-12
Cladosporium Cladosporium herbarum Cla h 1-12
Aspergillus Aspergillus fumigates Asp f 1-22
Penicillium Penicillium chrysogenum Pen ch 13, 18,20
See Table 11-4 for common molds and their allergens.
Environmental Control of Mold
Dehumidify and eliminate dampness (relative humidity <50%).

Avoid or use a mask while raking, mowing, and mulching.
Disinfect bathroom and use fungicides (e.g., Lysol, Clorox, X14).
Treat directly with bleach and clean with soapy water.
Remove/replace contaminated porous materials (e.g., carpets).
INDOOR ALLERGENS
House dust is a combination of multiple allergens, including animal dander,
insects, fungi, and even human proteins. House dust extracts have largely been
replaced by more specific allergen extracts.
ANIMAL PROTEINS
Dust Mite
Species include the following:
The pyroglyphid mites: Dermatophagoides pteronyssinus,
Dermatophagoides farinae, and Euroglyphus maynei. Flash Card Q11
o The “Dermatophagoides twins” are the most common offenders in the US. What is usually the most
Blomia tropicalis in tropical locales (e.g., Florida, Puerto Rico, and Brazil). abundant outdoor mold
spore?
Storage mites: Lepidoglyphus destructor and Tyrophagus putrescentiae.
Dust mites are not capable of drinking liquids, so they are dependent entirely on
ambient humidity for survival (i.e., they like relative humidity that is greater than
50%). Optimal growth temperatures are between 18–27oC (65–80oF). Flash Card Q12
Which mold spores are
higher during periods of
rain?
556 / CHAPTER 11
Two major allergens have been identified:

Group 1 allergens (Der p 1, Der f 1):
o Show homology with cysteine proteases and are highly cross-reactive
o Present on fecal particles, which are similar in size to pollen grains (i.e.,
10–35 μm)
Group 2 allergens (Der p 2, Der f 2):
o Also highly cross-reactive
o Der p 10 is a tropomyosin and cross-reactive with other invertebrate
tropomyosins (e.g., shrimp and limpet)
o Individuals predisposed to atopy may be sensitized at mite levels of 2 g/g
of dust
Environmental control measures for dust mite include the following:

Dehumidifier (set at <45% relative humidity)
Impermeable mattress and pillow covers
Hardwood floors instead of carpets
Vacuum weekly
Wash bedding in hot water (i.e., >54oC or >130oF), and remove stuffed
animals and similar toys
Vinyl or leather furniture
Key Fact Acaricides (benzyl benzoate, tannic acid)
It can take 4–to 6
months after cat Isolated use of dust mite covers without other interventions is unlikely to be
removal to significantly
effective. Multiple interventions may be needed.
reduce cat allergen
levels in the home.
Additional aggressive
control measures may Cat
reduce the allergen
levels more quickly.
Fel d 1 is the only major allergen, primarily made in the skin, and homologous to
uteroglobin. (About 80% of cat-sensitive individuals react to Fel d 1.) A level of
Fel d 1 that is greater than 2 μg/g is associated with risk of sensitization; greater
than 10 μg/g is a risk factor for asthma in sensitive individuals. Fel d 2 (albumin)
and Fel d 3 are minor allergens.
Cat allergen is ubiquitous! It was found in over 90% of US homes, over half of
which did not even have a resident cat, presumed to be carried on the clothing of
Flash Card A11 cat owners who visit the home. It is carried by small vectors (e.g., <25 μm and
some even <2.5 μm!) and remains airborne, even in undisturbed conditions.
Cladosporium
Environmental control measures for cat include the following:

Cat removal is the only clearly effective avoidance or solution.
Flash Card A12
Washing the cat once or twice weekly reduces allergen temporarily.
Fusarium species as
well as Ascomycota and
Basidiomycota.
Aggressive cleaning of the home can reduce allergen levels more quickly.
(The vacuum cleaner must be equipped with a good filter, provide increased
ventilation or use high-efficiency particulate-absorbing (HEPA) to remove
small airborne particles.)
Dog
Over 28 dog allergens have been detected, at least 5 of which are significant:
Key Fact
Can f 1: Lipocalin and major allergen; found in saliva and hair/dander
Can f 2: Lipocalin and minor allergen In addition to the dog
allergens, the lipocalin
Can f 3: Dog serum albumin; cross-reactive with other mammalian albumins (also known as calycin)
Can f 4: Lipocalin family of proteins
Can f 5: Kallikrein and major allergen; cross-reactive with human prostate- includes rat (Rat n 1),
specific antigen (i.e., sensitization could increase risk of reacting to human mouse (Mus m 1), horse
(Equ c 1, Equ c 2), cow
seminal fluid) (Bos d 2, Bos d 5),
cow’s milk (β-
Dog allergen is carried on larger vectors than those for a cat, so is not as easily lactoglobulin), rabbit
airborne. Like cat allergen, it is also ubiquitous and can be found in public (Ory c 1), and cockroach
buildings as well as homes without dogs. (Bla g 4). (But, not cat!)
Environmental control measures for dog include the following:

Avoidance
Washing the dog twice a week
Wiping the dog down with a wet towel (water just as effective as
commercially available “allergen removers”)
HEPA filtration may be effective
Cockroach
Species include the following:
Blattella germanica (German cockroach): Most common in crowded North
American cities
Periplaneta americana (American cockroach) Flash Card Q13
Blatta orientalis (Oriental cockroach): Associated with water, especially What dust mite is unique
leaking pipes (relatively) to Florida
and Puerto Rico?
Allergens are from feces, saliva, or debris (frass) and include Bla g 1 and Bla g 2,
which are aspartic proteases. Blag g 4 is a lipocalin family protein. Per a 1 is
cross-reactive with Bla g 1, and Per a 7 is a tropomysin. Bla g 2 is typically
measured in house dust and concentrations greater than 10 μg/g are associated Flash Card Q14
with sensitization and disease (i.e., these levels are uncommon in suburban What is the source of
households). Allergens are not easily detected in undisturbed air; they are carried Fel d 1 and Can f 1?
558 / CHAPTER 11
on large particles (e.g., dog and dust mites). Highest levels are detected in
kitchens.
Environmental controls include:

Poison bait
Careful housekeeping to enclose all sources of food for the insects
Cleaning to remove accumulated cockroach allergens
Sealing all possible access points to the house.
Rodents (Mice, Rats, Gerbils, Hamsters)

Rodent infestation occurs in a wide range of environments, including homes,
schools, and restaurants. Exposure to rodent allergens at concentrations greater
than1.6 μg/g of dust is associated with sensitization, and may contribute to the
development of asthma. The major allergens from the mouse and rat are Mus m 1
and Rat n 1. These are cross-reactive lipocalins excreted in the urine of male
rodents. Rodent allergens are carried on small particles (like cat); so can remain
airborne for some time.
Environmental controls should focus on sealing rodent entry points and removing
their sources of food, water, and shelter.
Laboratory animal workers are at high risk of developing sensitization, especially

in the first 3 years. Risk factors include an atopic background and the intensity of
exposure.
Other Animals
Birds are not particularly allergenic, but IgE-mediated sensitivity can occur.
Pigeon breeders and bird fanciers can develop hypersensitivity pneumonitis (HP),
also called extrinsic allergic alveolitis (EAA), which is an IgG-mediated response
to avian serum γ-globulin.
Horses, cows, and rabbits have all had both major and minor allergens
Flash Card A13 characterized, and the major allergens all belong to the lipocalin family.
Blomia tropicalis, found
in tropical locales Table 11-5 lists of common indoor allergens.
Flash Card A14

Fel d 1—cat skin. Can f
1—dog saliva and
hair/dander
Table 11-5. Indoor Allergens

Dust mites Dermatophagoides farinae Der f 1,2,3,7,10,11,14,15-
17,18w
Dermatophagoides Der p 1-11, 14, 20
pteronyssinus
Euroglyphus maynei Eur m 2,14
Blomia tropicalis Blo t 1-9, 13, 21
Storage mites Lepidoglyphus destructor Lep d 2,5,7,10,13
Glycyphagus domesticus Gly d 2
Tyrophagus putrescentia Tyr p 2,13
Animals
Dog Canis familiaris Can f 1-4
Cat Felis domesticus Fel d 1-4, 5w-7w
Horse Equus caballus Equ ca 1-5
Guinea pig Cavia porcellus Cav p 1,2
Mouse urine Mus musculus Mus m 1
Rat urine Rattus norvegius Rat n 1
Insects
German cockroach Blattella germanica Bla g 1-6
American cockroach Periplaneta americana Per a 1,3,7
POLLUTANTS
Air Quality Index (AQI)

The Air Quality Index (AQI) is an index for reporting air quality data to the
general public. Values are standardized for ozone and particulate matter (PM),
among others. Symptoms or disease correlate with exposure. The AQI is also
known as the Air Pollution Index (API) and individual countries set their own
relative values.
The United States Environmental Protection Agency (EPA) uses the AQI values
shown in Table 11-6, which are relative to health concerns and categorized by
color.
Flash Card Q15

What is the major
mouse allergen and its
source?
560 / CHAPTER 11
Table 11-6. Air Quality Index

Level of
Value Color Health Meaning
Concern
0–50 Green Good Air quality is considered satisfactory and poses
little or no risk
51–100 Yellow Moderate Air quality is acceptable; health concern for few
people who are unusually sensitive to air pollution.
101–150 Orange Unhealthy for General public is likely fine, but members of
Sensitive sensitive groups may experience ill effects.
Groups
151–200 Red Unhealthy Everyone may experience adverse health effects;
sensitive groups may experience more serious
health effects.
201–300 Purple Very Unhealthy Health warnings of emergency conditions.
Everyone is likely to be affected.
301–500 Maroon Hazardous Health alert: may cause serious adverse effects in
anyone.
Outdoor Pollutants
Nitrogen Dioxide (NO2)—Precursor to photochemical smog, and found in urban
and industrial regions. Is produced from the combustion of fossil fuels or natural
gas. Associated with decreases in lung function, increased airway neutrophils, and
proinflammatory cytokines. Increased allergen response is at 0.4 ppm.
Ozone (O3)—Byproduct of atmospheric reactions using nitric oxide (NO), VOCs,

UV light; increased during summer and peaks in the afternoon. Increases
symptoms, hospitalization, and agonist use in asthmatics. Major outdoor
pollutant involved in asthma exacerbations. Decreases lung function acutely
and chronically; increases airway neutrophils, IL-6, IL-8, leukotrienes or
prostaglandins, and potentiates allergen challenges.
Sulfur Dioxide (SO2)—Has been shown to decrease lung function in children;

causes bronchospasm in asthmatics at 0.5 ppm, and reverses with agonists.
Particulate Matter (PM)—Composed of mineral dust, organic matter, and

aerosolized byproducts of fossil fuel combustion; these are less than 10 μm in size.
Diesel Exhaust—Contains both particulates and gases. Skews immune responses

toward a Th2 response.
Flash Card A15

Mus m 1, a lipocalin
from male mouse urine
Indoor Pollutants
Environmental Tobacco Smoke (ETS)—Increases indoor PM; associated with
recurrent otitis media, URI, LRI, wheezing, and cancer. Increases Th2
cytokines (IL-4, IL-10) and eosinophils as well as allergen sensitization.
Endotoxin—Originates from gram-negative bacteria. Living with animals

increases exposure. It is also increased in areas where tobacco smoking occurs.
Key Fact
Nitrogen Dioxide (NO2)—Effects as described earlier; comes from indoor natural Nitrogen dioxide is both
gas appliances an indoor and outdoor
pollutant from burning
Other Irritants—Include agents from biomass burning (i.e., tobacco, wood and fossil fuels, including
natural gas.
other biologic plant fuels), household chemicals, and dirty ventilation systems.
Oxidant and Antioxidant Balance

Pollutants exert oxidant stress on airways; reactive oxygen species (ROS) activate
nuclear factor kappa B (NFκB), AP-1 and other pathways. Studies show that
asthmatics have decreased antioxidant levels at baseline (superoxide dismutases
and glutathiones, predominantly). Antioxidant response element (ARE) genes
neutralize ROS; genetic susceptibility data shows that some individuals have less
ARE, less glutathione stores, and may be more susceptible to developing asthma.
STANDARDIZATION AND STABILITY OF

ANTIGENS
Units of Potency
Key Fact
In the United States, allergen extracts can be licensed by the Food and Drug
There is no
Administration (FDA), Center for Biologics Evaluation and Research (CBER) as bioequivalent
either standardized or nonstandardized products. relationship between
W/V, PNU/mL, allergy
Nonstandardized Units of Potency unit (AU) or
Weight per Volume (W/V): Based on the weight of raw source material bioequivalent allergy
extracted with a given volume of extracting fluid (e.g., 1 g of raw pollen and unit (BAU) products. For
example, a 1:10 W/V
10 mL of extracting fluid). extract product is not
Protein Nitrogen Units/milliliter (PNU/mL): Based on a determination of necessarily the same as
the protein nitrogen content per milliliter of the final product. One protein a 20,000 PNU/mL or a
nitrogen unit equals 0.00001 mg of phosphotungstic acid precipitable protein 10,000 BAU/mL extract
nitrogen dissolved in 1 mL of antigen extract. product.
562 / CHAPTER 11
Standardized Units of Potency—Standardization means that the potency of an

allergen extract has been compared with an FDA reference standard.
Allergy unit per milliliter (AU/mL) and bioequivalent allergy unit per
milliliter (BAU/mL): Initiated by FDA to reflect allergenic activity more
Key Fact accurately. FDA reference preparations are assigned BAU/mL units based on
Five types of results of a direct test of allergenic activity, which is derived from an
standardized extracts intradermal skin test endpoint titration in humans measuring erythema;
are currently available in namely, the ID50EAL method developed by CBER, FDA. It can also be
the US: Hymenoptera
venom (labeled in µg of determined by radioallergosorbent test (RAST) or enzyme-linked
protein: hyaluronidase immunosorbent assay (ELISA-inhibition in comparison with an FDA
and phospholipase), reference standard. The dust mite extract AU, originally defined by inhibition
dust mite (labeled in assay, is equivalent to its BAU.
AU), cat, grass (both
labeled in BAU), and
Major allergen content: Ragweed extract products are labeled with the
short ragweed (labeled amount of major allergen content (Amb a 1). 350 Amb a 1 units = 100,000
by major allergen: Amb BAU.
a 1). Venom products (freeze-dried): Standardized on the basis of venom protein
content (enzymes hyaluronidase and phospholipase). Individual species: 100
µg/mL and mixed vespid 300 µg/mL. (Note: Available fire ant extracts are
nonstandardized whole-body extracts).
Extract Forms
Aqueous Extracts—Raw source material (i.e., pollen, dander, mold or fungi
cultures, and dust) is added to an extracting fluid and prepared in saline or buffer
solutions, with less than 50% glycerin. 0.4% phenol is added to prevent microbial
growth.
Glycerinated—Raw material is extracted in 50% glycerin or the glycerin is added

after extraction. Fifty percent glycerin inhibits microbial growth and is more
stable than aqueous allergen extract products. 0.4% phenol is added to prevent
microbial growth.
Alum Precipitated—Allergenic proteins are precipitated with a solution of

aluminum hydroxide (alum), forming a complex that results in slower release of
the allergen. Used for treatment (but, not skin test diagnosis) due to their slow
release nature. Larger doses of extract can be given at less frequent intervals, and
they are reported to have a lower incidence of systemic reactions.
Lyophilized—Freeze-dried preparations existing in powder or dry cake form that

need to be reconstituted. It is recommended that human serum albumin (HSA)
diluent be used. Venom products are lyophilized.
Acetone Precipitated (AP)—The AP extraction process involves a specially

developed technique designed to concentrate the proteins and remove lower-
molecular-weight nonspecific irritant materials. This process requires up to 50

times as much raw material as other extracts.
Stability of Allergen Extracts

Temperature—Loss of potency occurs when stored at higher temperatures for
extended periods of time. To maintain potency, allergen extract products should
be stored at 2–8°C (or 36–46°F).
Loss of potency when exposed to high temperatures may be due to heat-labile

proteins and loss of potency due to extended periods of time at room temperature
or may be due to protease activity in the extract solution. Fifth percent glycerin
may protect against the effects of extended exposure to room temperature. Less is
known about the effect of freezing on allergen extract solutions; however,
numerous freeze-thaw cycles may contribute to loss of potency.
Concentration—Dilute extracts have lower protein content and lose their potency
more rapidly than concentrated extract forms.
Vial Volume—Loss of potency is related to protein content. Thus, lower volume

in a storage vial may increase loss of potency due to greater surface volume
relative to volume of solution, as well as enhanced adsorption of proteins to the
container wall.
Proteolytic Enzymes—Allergens with protease enzymes include cockroach, Flash Card Q16
molds, and dust mite. Though dust mite products in the US do not seem to have
adverse effects on pollen extracts. Consideration should be given to keeping Which of the following
describes a
extracts that have high proteolytic activity, such as fungi and cockroach, separate nonstandardized extract:
from pollen extracts. Grass pollen extracts are particularly susceptible to AU/mL, BAU/mL,
proteolytic enzymes. PNU/mL?
Presence of Stabilizers and Preservatives (Diluents)

Flash Card Q17
Glycerin—At 50%, glycerin is the diluent best known to maximize the stability of
Which extracts most
an allergen extract product; it also inhibits bacterial growth. It appears to inhibit consistently
proteolytic enzymes, and its effectiveness decreases with a decreasing percentage demonstrate proteolytic
of glycerin (e.g., 50% > 25% > 10%). activity?
Human Serum Albumin (HSA)—This diluent has a preservative effect due to its
reducing adsorption of allergenic proteins to vial surface. It is more effective than
glycerin in protecting products from phenol denaturation.
Flash Card Q18
What diluent reduces
allergen adsorption to
vial surfaces?
564 / CHAPTER 11
Phenol—A 0.4% solution of phenol is the preservative added to the allergen

extract solution to prevent microbial growth; but, it can break down allergenic
proteins in allergen extract products containing 50% glycerin.
AUTOANTIGENS
The major factors that contribute to the development of autoimmunity are genetic
susceptibility and environmental triggers.
Infections and tissue injury may alter the way in which self-antigens are displayed
to the immune system, leading to a failure of self-tolerance.
Molecular mimicry: Antigens associated with a microbe may cross-react

with autologous antigens that involve normally dormant cells, which have
escaped thymic deletion and can react with self-antigens.
In a phenomenon known as epitope spreading, autoimmune reactions initiated

against one antigen that injures tissues may result in the release and alterations of
other tissue antigens, activation of lymphocytes specific for these other antigens,
and exacerbation of the disease.
In systemic autoimmunity, most of the autoantibodies do not appear to be directly

pathogenic, yet they are often highly specific for a particular disease. There are
also a number of models that indicate roles of various autoantigens in disease
pathogenesis.
Although thousands of molecules are potential target autoantigens, the number of

Flash Card A16
frequently targeted molecules is extremely restricted. This restriction has led to
PNU/mL (protein the proposal that the targeted autoantigens may have properties that make them
nitrogen units/mL)
immunogenic.
Disease-Associated Self-Antigens
Flash Card A17
Mold, cockroach Self-antigens include autoantigens that are associated with autoimmune disease
(organ-specific or systemic) and tumor antigens. A common feature of these
disease-linked self-antigens is the appearance of antibodies against them as the
disease progresses. A list of human diseases associated with specific autoantigens
can be seen in Tables 11-7, 11-8, and 11-9.
Flash Card A18
Human serum albumin
(HSA)
Table 11-7. Examples of Autoantigens Associated with Cell- or Organ-

Specific Autoimmunity
Autoantigen Clinical Association
Acetylcholine receptor Myasthenia gravis
Actin Chronic active hepatitis and primary biliary
cirrhosis
Adenine nucleotide translocator (ANT) Dilated cardiomyopathy and myocarditis
Aromatic L-amino acid decarboxylase Autoimmune polyendocrine syndrome type I
(APS-I)
Asialoglycoprotein receptor Autoimmune hepatitis
Bactericidal/permeability-increasing protein Cystic fibrosis vasculitides
(Bpi)
Calcium-sensing receptor Acquired hypoparathyroidism
Cholesterol side-chain-cleavage enzyme APS-I
CYPlla)
Collagen-type IV α3-chain Goodpasture’s syndrome
Cytochrome P450 2D6 (CYP2D6) Autoimmune hepatitis
Desmin Crohn’s disease and coronary artery disease
Desmoglein 1 Pemphigus foliaceus
Desmoglein 3 Pemphigus vulgaris
F-actin Autoimmune hepatitis
GM gangliosides Guillain-Barré syndrome (GBS)
Glutamate decarboxylase (GAD65) Type 1 diabetes and stiff person syndrome (SPS)
Glutamate receptor (GLUR) Rasmussen’s encephalitis
H/K ATPase Autoimmune gastritis
17-α-Hydroxylase (CYP17) APS-I
21-Hydroxylase (CYP21) Addison’s disease
IA-2 (ICA512) Type 1 diabetes
Insulin Insulin Type 1 diabetes and insulin hypoglycemic
syndrome (Hirata disease)
Insulin receptor Type B insulin resistance, acanthosis, and
systemic lupus erythematosus (SLE)
Interphotoreceptor retinoid-binding protein Uveitis
(IRBP)
Intrinsic factor type 1 Pernicious anemia
Leukocyte function-associated antigen (LFA-1) Treatment-resistant Lyme arthritis
Myelin-associated glycoprotein (MAG) Polyneuropathy
Myelin basic protein Multiple sclerosis and demyelinating diseases
Myelin oligodendrocyte glycoprotein (MOG) Multiple sclerosis
Myosin Rheumatic fever
p-80-Coilin Atopic dermatitis
Pyruvate dehydrogenase complex-E2 (PDC- Primary biliary cirrhosis
E2)
Sodium iodide symporter (NIS) Graves’ disease and autoimmune
hypothyroidism
566 / CHAPTER 11
Table 11-7. Examples of Autoantigens Associated with Cell- or Organ-

Specific Autoimmunity, cont.
SOX-10 Vitiligo
Thyroid and eye muscle-shared protein Thyroid associated ophthalmopathy
Thyroglobulin Autoimmune thyroiditis
Thyroid peroxidase Autoimmune Hashimoto’s thyroiditis
Thyrotropin receptor Graves’ disease
Tissue transglutaminase Celiac disease (CD)
Transcription coactivator p75 Atopic dermatitis
Tryptophan hydroxylase APS-I
Tyrosinase Vitiligo and metastatic melanoma
Tyrosine hydroxylase APS-I
Table 11-8. Examples of Autoantigens Associated with Systemic

Autoimmunity
Adrenocorticotropic hormone (ACTH) ACTH deficiency
Aminoacyl-tRNA histidyl synthetase Myositis and dermatomyositis
Aminoacyl-tRNA synthetase (several) Polymyositis and dermatomyositis
C1 inhibitor Autoimmune C1 deficiency
C1q Systemic lupus erythematosus (SLE) and
membrane proliferative glomerulonephritis
(MPGN)
Cardiolipin SLE
Carbonic anhydrase II SLE, Sjögren’s syndrome, and systemic
sclerosis
Collagen (multiple types) Rheumatoid arthritis (RA), SLE, and
progressive systemic sclerosis
Centromere-associated proteins Systemic sclerosis
Cytokines (IL-1α, IL-1β, IL-6, IL-10, LIF) RA, systemic sclerosis, and normal subjects
DNA-dependent nucleosome-stimulated Dermatomyositis
ATPase
Fibrillarin Scleroderma
Fibronectin SLE, RA, and morphea
Glucose-6-phosphate isomerase RA
β2-Glycoprotein I (β2-GPI) Primary antiphospholipid syndrome
Glycoprotein IIb/IIIg and Ib/IX Autoimmune thrombocytopenia purpura
Golgin (95, 97, 160, 180) Sjögren’s syndrome, SLE, and RA
Heat shock protein Various immune-related disorders
Hemidesmosomal protein 180 Bullous pemphigoid, herpes gestationis, and
cicatricial pemphigoid
Histone H2A-H2B-DNA SLE
Table 11-8. Examples of Autoantigens Associated with Systemic

Autoimmunity, cont.
IgA Immunodeficiency
IgE receptor Chronic idiopathic urticaria
Keratin RA
Ku-DNA-protein kinase SLE
Ku-nucleoprotein Connective tissue syndromes
La phosphoprotein (La 55-B) Sjögren’s syndrome
Myeloperoxidase Necrotizing and crescentic glomerulonephritis
(NCGN) and systemic vasculitis
Oxidized LDL (OxLDL) Atherosclerosis
Proteinase 3 (PR3) Wegener granulomatosis and Churg-Strauss
syndrome
Ro52 Sjögren’s syndrome, rheumatoid arthritis, and
systemic lupus erythematosus
RNA polymerase I-III (RNP) Systemic sclerosis and SLE
Signal recognition protein (SRP54) Polymyositis
Topoisomerase-I (Scl-70) Scleroderma, Raynaud’s syndrome or
phenomenon (RP)
Tubulin Chronic liver disease and visceral
leishmaniasis
U1 ribonucleoprotein complex Mixed connective tissue disease
Vimentin Systemic autoimmune disease
Table 11-9. Examples of Autoantigens Associated with Cancer and

Paraneoplastic Autoimmunity
Autoantigen Clinical association
Amphiphysin neuronopathy Small lung cell cancer
Cyclin B1 Hepatocellular carcinoma
DNA topoisomerase II Liver cancer
Desmoplakin Paraneoplastic pemphigus
Gephyrin Paraneoplastic stiff man syndrome
Hu proteins Paraneoplastic encephalomyelitis
Neuronal nicotinic acetylcholine receptor Subacute autonomic neuropathy and cancer
p53 Cancer and systemic lupus erythematosus (SLE)
p62 (IGF-II mRNA-binding protein) Hepatocellular carcinoma
Recoverin Cancer-associated retinopathy
Ri protein Paraneoplastic opsoclonus myoclonus ataxia
β IV spectrin Lower motor neuron syndrome
Synaptotagmin Lambert-Eaton myasthenic syndrome (LEMS)
Voltage-gated calcium channels LEMS
Yo protein Paraneoplastic cerebellar degeneration
568 / CHAPTER 11
Conclusion
A number of autoantigens have been either cloned and sequenced, or purified.
Many of these are commercially available as recombinant proteins and can be
used in immunoassays to detect autoantibodies in patients’ sera.
INFECTIOUS AGENTS
Human Immunodeficiency Virus (HIV)

HIV is a member of the lentivirus group of retroviruses. It is an enveloped virus
with a diploid single-stranded ribonucleic acid (ssRNA) genome. Notable proteins
are discussed in Table 11-10.
Table 11-10. Notable Proteins

Proteins
Gene Function
Encoded
env gp41 Hydrophobic portion mediates viral fusion with cell membrane. Target of
fusion inhibitor drugs (e.g., enfuvirtide).
gp120 Mediates virion binding to CD4 receptor. Rapid mutation rates in this
gene have hampered the development of effective vaccines.
gag p24 Main component of the viral capsid. Because its structure is reasonably
well-conserved, it is one of three proteins tested for in a diagnostic
Western blot.
p6, p7 Nucleocapsid
p17 Matrix
pol Reverse RNA-dependent DNA polymerase. Also possesses ribonuclease and
transcriptase DNA-dependent DNA polymerase activity. Low-fidelity polymerase with
high mutation rate. Target of reverse transcriptase inhibitors (e.g.,
nucleoside or nucleotide analog, and non-nucleoside inhibitors).
Integrase Responsible for viral integration into host genome. Target of raltegravir
(integrase inhibitor).
Protease Aspartic protease necessary for viral protein production. Target of
protease inhibitors
tat Tat Regulation of viral transcription. Diffusible action may be responsible for
cell death of uninfected T-cells.
rev Rev Facilitates nuclear export of viral messenger ribonucleic acids
(mRNAs). Plays role in late-phase gene expression.
nef Nef Reduces expression of major histocompatibility complex (MHC) class I
molecules, inhibiting destruction of infected cells by CD8+ cytotoxic T-
cells.
vif Vif Causes ubiquitinization and destruction of APOBEC3G, an antiviral
protein that would otherwise cause hypermutation and destruction of
viral genome.
vpr Vpr Facilitates nuclear import of HIV preintegration complex.
vpu Vpu Facilitates viral budding from infected cells.
Staphylococcus aureus
Staphylococcus aureus is clinically relevant bacterium as it produces a number of
unique virulence factors. In addition, S. aureus may acquire resistance to
methicillin by acquisition of mecA gene location on the staphylococcal cassette
chromosome mec (SCCmec). Table 11-11 shows the virulence factors and
functions of S. aureus.
Molecular Mimicry
Molecular mimicry describes when an environmental agent triggers the
development of an immune response against an antigen that is similar enough to a
self-antigen to cause autoimmunity. Several examples of molecular mimicry have
been observed in disease processes:
Reiter’s syndrome (RS), following infections with Chlamydia or Shigella
Guillain-Barré syndrome (GBS) following Campylobacter infections
Rheumatic fever caused by the resemblance of the Streptococcus pyogenes M
protein with cardiac myosin
Table 11-11. Virulence Factors and Functions of Staphylococcus aureus

Virulence Function
Factor
Protein A Binds Fc region of IgG1, IgG2, and IgG4, inhibiting antibody-mediated
clearance.
Clumping factor Activates fibrinogen to insoluble fibrin, causing aggregation of bacteria.
Capsule Acts to inhibit phagocytosis of bacteria by covering bound opsonins.
Cytotoxins A group of five cytolytic toxins (α, β, γ, and δ toxins and P-V leukocidin).
Exfoliative toxins Two serine proteases that cleave desmoglein 1 in the stratum granulosum of
(ETA, ETB) the epidermis, resulting in staphylococcal scalded skin syndrome (SSSS),
which is also known as Ritter von Ritterschein disease (in newborns), Ritter
disease, and staphylococcal epidermal necrolysis.
Toxic shock Superantigen that elicits its response by binding to major histocompatibility
syndrome toxin- complex (MHC) class II molecules outside of the peptide-binding groove and to
1 (TSST-1) the variable region of the TCR β chain. This leads to a massive release of
cytokines (most notably TNFa, IL-1, and IL-6) and the ensuing capillary leakage
syndrome.
Of note, a disproportionately large number of superantigen-activated T cells
express the skin-homing cutaneous lymphocyte antigen (CLA), which explains
the propensity of bullous manifestations in toxic shock and also likely
contributes to S. aureus colonization in atopic dermatitis.
Enterotoxins C Enterotoxins C and D are found in contaminated food as preformed toxins.

and D These both function as superantigens.
Abbreviations: Il, interleukin; TCR, T-cell receptor; TNF, tumor necrosis factor.
570 / CHAPTER 11
FOODS
Food allergens belong to a limited number of protein families with different

molecular properties, which may mean routes of sensitization differ for different
allergen families. For example, food allergens that sensitize through the
gastrointestinal tract have features that enhance their stability to thermal and
proteolytic denaturation. Table 11-12 gives a few examples of these protein
families.
Table 11-12. Examples of Food Allergen Protein Families

Allergen
Function/Clinical Implication Source (Allergen)
Family
Food Allergens of Animal Origin
Tropomyosins Bind to actin in muscle, increasing thin filament Brown shrimp (Pen a 1),
stability and rigidity. Invertebrate tropomyosins Crab (Cha f 1), Oyster
are highly homologous and tend to be ( Cra g 1, Cra g)
allergenic—those from crustaceans (e.g., shrimp,
crab, crawfish, and lobster), arachnids (house
dust mites), insects (cockroaches), and mollusks
(squid, snails)—whereas vertebrate tropomyosin
tends to be nonallergenic.
Parvalbumin Control the flow of calcium from troponin C back Salmon (Sal s 1.01), Tuna
to membrane-bound pumps after a muscle (Thu o 1.01), Carp (Cyp c
contraction 1.01), Frog (Ran e 1)
Caseins Form stable micellar calcium phosphate protein Cow (Bos d 8)
complexes in mammalian milk. Explains some of
the cross-reactivities amongst mammalian milks.
Food Allergens of Plant Origin
11S (legumin Seed storage protein Peanut (Ara h3, Ara h4),
Key Fact like) globulins Soy (Glycinin), Buckwheat
Multiple families of food (Fag e 1), Cashew (Ana o
allergy proteins may 2)
present similarly, but Bet v 1 Pathogen-related protein 10, comprises many of Apple (Mal d 1), Cherry
superfamily the class 2 proteins that cause OAS/PFAS (Pru av 1), Pear (Pyr c 1),
may infer different Carrot (Dau c 1)
prognosis on the food Nonspecific Function unknown, maybe involved in transport Apricot (Pru ar 3), Cherry
allergy. Bet v 1 lipid transfer of suberin monomers. Highly resistant to heat (Pru av 3), Peach (Pru p
superfamily pathogen- proteins and proteolytic digestion. While a class I allergen, 3), Strawberry (Fra a 3),
related protein (PRP), it is concentrated in the peel of fruits and explains Grape (Vit v 1), Walnut
nonspecific lipid transfer why some patients with true allergy to fruits can (Jug r 3), Lettuce (Lac s
proteins and profilins all tolerated the peeled flesh. 1), Corn (Zea m 14),
involve similar families Chitinases Enzymes catalyze the hydrolysis of chitin Avocado (Pers a 1),
(apple, pitted fruits etc). polymers. Class I chitinases contain hevein Banana (Mus xp
Profilins and Bet v 1 domain which shares high sequence identity with Chitinase)
Hevea brasiliensis (latex)
superfamily PRP both
Profilins Regulates actin polymerization and Pear (Pyr c 4), Cherry
may present as OFAS depolymerization during cell movement and (Pru av 4), Celery (Api g
and are class 2 signaling. Present in some form in all eukaryotic 4), Latex (Hev b 8),
allergens. Lipid transfer cells. Heat labile. Risk factor for allergic reactions
proteins, however, are to multiple pollens and for oral allergy
class 1 allergens that syndrome/pollen-food allergy syndrome
cover a similar spectrum (OAS/PFAS).
of foods.
Food allergens can be categorized as follows:

Class 1: Traditional food allergens (Table 11-13)
Class : Consequence of an allergic sensitization to inhalant allergens (i.e.
associated with oral allergy syndrome [OAS]) (Table 11-14)
Having a basic understanding of allergens families helps to explain cross-

reactivity amongst allergens and phenomenon such as oral allergy
syndrome/pollen-food allergy syndrome (OAS-PFAS)
Most Common Food Allergens

Cow’s Milk
Prevalence: Most common food allergy in children
Allergens: Casein and whey. Pasteurization does not denature these proteins.
Cross-reactivity: Among various types of milk (i.e., cow, goat, and sheep).
Cow’s milk has a cross-reactivity of 10% with beef, 92% with goat’s milk,
and 4% with mare’s (or horse’s) milk.
Egg
Prevalence: Allergy is typically to the egg white; the yolk is less allergenic.
Allergens:
o Egg white has 23 glycoproteins. The major ones are ovomucoid (heat-
stable), ovalbumin (heat-labile), and ovotransferrin.
o The common egg yolk proteins are apovitellin livetin, and vosvetin.
Wheat
Prevalence: Allergy has a prevalence of 0.4% in children.
Allergens: Globulin and glutenin are the major allergenic fractions in IgE-
mediated reactions, gliadin in celiac disease, and albumins in baker’s asthma.
Cross-reactivity: The grains have a 20% cross-reactivity with each other.
Peanuts—In the legume family.

Prevalence: The major food allergen beyond 4 years of age. Flash Card Q19
Allergens: The major allergens that cause severe clinical reactions are Ara h1,
What is the dominant
Ara h2, and Ara h3.
peanut allergen
o Ara h8 is associated more with oral allergy syndrome (OAS). detected in 90–100% of
o Ara h 2 is the dominant peanut allergen detected in 90–100% of patients patients with peanut
with peanut allergy. anaphylaxis?
o Ara h 2 plasma sIgE test levels provide higher diagnostic accuracy than
whole-peanut plasma sIgE levels.
Cross reactivity: 5% cross-reactivity with other legumes (e.g., as peas).
Flash Card Q20
Soybeans—A second legume also an important player in food allergens.
Allergy to which peanut
Prevalence: 0.4% in children. allergen confers the best
prognosis?
572 / CHAPTER 11
Cross-reactivity: 5% cross-reactivity with peanuts. The soy proteins are Gly

m3.
Tree Nuts
Key Fact
Prevalence: 0.6% of Americans.
Within the tree nut Cross-reactivity: Major cross-reactivity among the tree nuts. About 35–50%
family, the strongest
probability of cross-
of peanut-allergic patients can also be allergic to at least one tree nut.
reactivity is between
pistachio and cashew, Fish
and also walnut and Allergens: Very susceptible to heat processing. The major allergen is Gad c 1
pecan. in codfish and Sal s1 in salmon. In finned fish, parvalbumin is the
dominant allergen.
Mnemonic Shellfish—Divided into two families: mollusks (e.g., clams, oysters, and
To recall common food mussels) and crustaceans (shrimp, crab, and lobster).
allergens, remember: Allergen: The major allergen is tropomyosin, which is also found in other
Milk proteins are the invertebrates (e.g., cockroach and dust mite).
boss, especially in kids Cross-reactivity: 75% with other shellfish. Cross-reactivity between shellfish
under 1 year of age. and mollusks is not well defined.
The chicken gallantly
defends his eggs. Table 11-13 provides an overview of the most common food allergens.
The arrogant peanut
scares parents.
Fish gadda swim Table 11-13. Major Class I Food Allergens
upstream.
Foods Proteins Food Allergen
Soy glydes into many
Caseins
recipes. s1-Casein
A bad Apple is mal. s2-Casein
-Casein Bos d 8
Jughead hits his head -Casein
Cow’s milk
on walnuts.
Whey
Most people are -Lactoglobulin Bos d 5
prudent about their -Lactalbumin Bos d 4
fruit, only picking the Serum albumin Bos d 6
freshest plums, Ovalbumin Gal d 1
peaches, and cherries. Chicken egg white Ovomucoid Gal d 2
Ovotransferrin Gal d 3
Ella eats corn with
Globulin
zeal. Wheat
Glutenin
Vicilin Ara h 1
Peanut Conglutin Ara h 2
Flash Card A19 Glycinin Ara h 3
Glycinin G1 acidic chain
Ara h 2 Soybean
Profilin Gly m 3
Codfish—Parvalbumin Gad c 1
Fish
Salmon Sal s 1
Flash Card A20 Shrimp Tropomyosin Pen a 1
Ara h 8
Homology of Food Proteins

Many foods are related botanically or by a high degree of homologous proteins
(Table 11-14).
Table 11-14. Major Class II Food Allergens: Major Plant-Derived Allergens

Plant Allergen Protein Food Food Allergen
Avocado, chestnut,
Class I chitinases
banana
Latex-fruit cross
reactivity Cherry Pru A2
Thaumatin-like
Apple Mal d2
Apple Mal d 1
Cherry Pru a1
Bet v1 homologues = Pear Pyr a1
Birch pathogen-related
proteins 10 Celery Api g1
Carrot Dau c1
Potato
Latex Hev b 8
Celery Api g 4
Potato
Cherry Pru av 4
Celery-mugwort spice Bet v2 homologues =
syndrome Profilin Pear Pyr c 4
Peanut Ara h 5
Soybean Gly m 3
Apple, tomato, and
carrot
Peach Pru p
Lipid-transfer proteins Apple Mal d3
Soy
Mustard Sin a1
English walnut Jug r1
2S albumin
Rapeseed and Brazil
nut
Peanut Ara h1
Seed Storage Vicilin
Proteins Walnut Jug r1
Conglutin Peanut Ara h2
Peanut Ara h3
Glycinin
Soy
β-Glycinin Soy
Table 11-15 highlights the interactions between pollens and foods in pollen-food
allergy syndrome.
574 / CHAPTER 11
Table 11-15. Cross-Reacting Pollens and Foods

Pollen Foods
Birch = Bet v1 Apple, apricot, carrot, cherries, plums, potato, kiwi, celery, hazelnuts,
almonds, and walnuts
Ragweed = Amb Banana, cucumber, melon (i.e., watermelon, cantaloupe, honeydew),
a1 zucchini, dandelions, and chamomile tea
Grass Peaches, celery, melons, tomatoes, and oranges
Mugwort Celery, apple, kiwi, peanut, carrots, and sunflower
Alder Celery, pears, apples, almonds, cherries, hazelnuts, peaches, and parsley
Latex Bananas, avocado, kiwi, chestnut, papaya, tomato, and potato
VENOM ALLERGEN AND ANTIGENS
Venom Composition
Key Fact
Alkaloids in fire ant The major allergen of honeybee venom is phospholipase A2. Melittin is a unique
venom cause the sterile honeybee allergen and makes up 50% of the venom protein. The major allergen of
pustule, but do not vespid venoms is antigen 5, unique to this group. Vespid phospholipase A1 is
contribute to its allergic also a major allergen. Both apids and vespids contain hyaluronidase. Imported
potential.
fire ant (IFA) venom is primarily composed of alkaloids, with a small amount of
aqueous proteins that are similar to other venoms and are responsible for allergic
reactions (Table 11-16).
Key Fact Cross-Reactivity of Venoms

Imported fire ant (IFA)
venoms are not Phospholipase A2, hyaluronidase, and acid phosphatase are similar in patients
commercially available; who are allergic to either honeybee and bumblebee stings; and sera from many
whole-body extract
(WBE) is used for
honeybee-allergic patients shows cross-reactivity with bumblebee venoms.
diagnosis and treatment
of fire ant allergy. Venoms among the vespids and Polistes wasp demonstrate extensive cross-
reactivity. Hyaluronidases show some cross-reactivity among families, but
phospholipases do not cross-react between families. The venom of Solenopsis
invicta (S. invicta, also known as the red imported fire ant) and Solenopsis richteri
(S. richteri, also known as the black imported fire ant and as its own species) have
extensive cross-reactivity.
Table 11-16. Stinging Insect Allergens

Venom Name/
Family Subfamily Other
Allergen Function
The major allergen; cross-
Phospholipase
Api m 1 reactive with Bom p1
A2
•Used to standardize extracts
Honeybee Api m 2 Hyaluronidase A major allergen
Api m 3 Acid phosphatase
Apidae
Api m 4 Melittin Unique antigen to this group
Bom p 1 Phospholipase A2 Cross-reactive with Api m1

Bumblebee
Bom p 4 Protease
A major allergen; not cross-
Grp 1 Phospholipase A1 reactive with phospholipase A2
in Apidae
A major allergen; similar to
Vespinae Grp 2 Hyaluronidase hyaluronidase of Apidae
Vespidae and •Used to standardize extracts
Polistinae Grp 3 Acid phosphatase
Grp 4 Protease
The major allergen; unique
Grp 5 Antigen 5
antigen to this group
Cross-reacts with sera from
Sol i 1 Phospholipase A1
vespid-allergic patients Flash Card Q21
Sol i 2 Unknown protein
What is the major
Formicidae Fire ants Has homology with vespid allergen for honeybee?
Antigen 5 protein
Sol i 3
family
antigen 5, but no cross- What is the major
reactivity allergen for yellow
Has homology with Sol i 2 but jacket?
Sol i 4 Unknown protein
no cross-reactivity
Flash Card Q22

Standardization What venom protein is
most cross-reactive
Honeybee venoms are standardized for their content of phospholipase A and between honeybee and
Vespula venoms are standardized for their content of hyaluronidase. The most yellow jacket?
common source for venom proteins in stinging insects are from the venom sacs of
bees, wasps, and hornets. Fire ant venom proteins have been found to be present
in sufficient concentration in nonstandardized WBE to be suitable for use as
diagnostic allergens and therapeutic vaccine Flash Card Q23
What venom protein is
used to standardize
honeybee extract? What
is used to standardize
yellow jacket and wasp
extracts?
576 / CHAPTER 11
Stability
Proteins in concentrated venom solutions are relatively stable and will remain
constant through the manufacturer’s expiration date, whereas diluted reconstituted
vaccines are less stable. Smaller proteins in venoms are not as stable; so,
processed venoms are not as potent as venom from a natural sting. Extracts should
be stored at 4°C (or 36°F) to decrease rate of potency loss. Proteases in venoms
can decrease stability, which can be attenuated by mixing with solutions of
glycerin or human serum albumin. Human serum albumin also helps decrease
adsorption of allergenic proteins to storage vials.
Flash Card A21

Phospholipase A2 for
honeybee. Antigen 5 for
yellow jacket
Flash Card Q22

Hyaluronidase
Flash Card Q23

Phospholipase A2 for
honeybee.
Hyaluronidase for yellow
jacket and wasp
ABOUT THE EDITORS / 577
ABOUT THE EDITORS

Tao Le, MD, MHS
Dr. Le developed a passion for medical education as a medical student. He currently edits more
than 15 titles in the First Aid series. In addition, he is the founder of the USMLE-Rx online
video and test bank series as well as a cofounder of the Underground Clinical Vignettes series.
As a medical student, he was editor-in-chief of the University of California, San Francisco
(UCSF) Synapse, a university newspaper with a weekly circulation of 9000. Dr. Le earned his
medical degree from UCSF in 1996 and completed his residency training in internal medicine at
Yale University and fellowship training at Johns Hopkins University. At Yale, he was a regular
guest lecturer on the USMLE review courses and an adviser to the Yale University School of
Medicine curriculum committee. Dr. Le subsequently went on to cofound Medsn, a medical
education technology venture, and served as its chief medical officer. He currently has an
interest in medical education and education research at the University of Louisville.
Bret Haymore, MD
Dr. Haymore received his medical degree from the Penn State College of Medicine in 2002
where he was also elected to the AOA. He completed residency training in internal medicine at
William Beaumont Army Medical Center where he remained as chief medical resident. He
completed his allergy-immunology fellowship at Walter Reed Army Medical Center and
remained as the clinical service chief until July 2011. Currently he is medical director at
BreatheAmerica Tulsa and assistant professor in the Department of Medicine at the University
of Oklahoma College of Medicine-Tulsa. He has received numerous teaching and research
awards along with having served as chair of the FIT section on the ACAAI Board of Regents
from 2007-2008. He enjoys many activities with his wife and five children including sports and
outdoor activities.
Dr. Hernandez-Trujillo has had an interest in medical education since 1999. She earned her
medical degree from Albany Medical College in 1999 and completed her residency training in
pediatrics at Miami Children's Hospital and allergy and immunology fellowship training at the
University of Tennessee-Memphis. Dr. Hernandez-Trujillo has received teaching awards for her
work with pediatric residents. She has written textbook chapters and peer-reviewed articles and
lectures regularly, both nationally and internationally, on allergy and immunology topics. She is
involved in national and international education on the topics of anaphylaxis, food allergy,
allergic rhinitis, and primary immunodeficiency diseases. She is the director of the Division of
Allergy and Immunology at Miami Children's Hospital, and Clinical Assistant Professor at the
Herbert Wertheim College of Medicine in Miami, Florida. She enjoys dancing, music, spending
time with her family, and traveling.
Gerald Lee, MD
Dr. Lee received his medical degree from Case Western Reserve University in 2003. He
completed residency training in a combined Internal Medicine/Pediatrics residency at St.
Vincent’s Hospital in New York, NY where he also was the pediatric chief resident. He
completed his fellowship in allergy/immunology at Cincinnati Children’s Hospital Medical
Center in 2011 and is currently an assistant professor at the University of Louisville. He is
currently pursing a Master of Education for medical educators and sits on the Educational
Policy Committee for the medical school. He is also vice-chair of the ACAAI continuing
medical education committee. In his spare time he enjoys marathon running and fiddling with
technology.
85 West Algonquin Road, Suite 550
Arlington Heights, IL 60005-4460
Education@ACAAI.org • 847-427-1200
www.acaai.org

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TAO LE BRET HAYMORE

VIVIAN HERNANDEZ-TRUJILLO GERALD LEE

test critical concepts

Tao Le, MD, MHS

American College of Allergy, Asthma & Immunology

How to Contribute xvii

SECTION I. BASIC SCIENCE

Chapter 1. Immune Mechanisms 1

Chapter 2. Cells Involved in Immune Responses 67

Chapter 3. Specific Immune Responses 93

Chapter 4. Laboratory Tests 105

Chapter 5. Anatomy, Physiology and Pathology 157

Chapter 6. Research Principles 183

SECTION II. CLINICAL SCIENCE

Chapter 7. Hypersensitivity Disorders 193

Chapter 8. Immunological Disorders 297

Hereditary and Acquired Angioedema Immunologic Rejection and Organ

Chapter 9. Pharmacology and Therapeutics 421

Allergen Avoidance Cytokine and Cytokine Receptor-Mediated

Chapter 10. Specific Diagnostic Modalities 485

Chapter 11. Allergens and Antigens 533

Aerobiology Standardization & Stability of Antigens

About the Editors 577

Cindy Salm Bauer, MD Hillary S. Hernandez-Trujillo, MD

Timothy J. Campbell, MD Lisanne P. Newton, MD

Howard C. Crisp, MD Joon H. Park, MD

Jonathan Romeo, DO Jonathan S. Tam MD

Jim Fernandez MD PhD

Elizabeth Secord, MD Julie Wang, MD

Tao Le, MD, MHS

Tao Le, MD, MHS

• Study and test-taking strategies

The term antigen—a contraction of “antibody generator”—is a molecule that is

Antigen is a molecule that is recognized by the immune system.

Table 1-1. Superantigens

SEC2 Food poisoning

TSST Toxic shock syndrome

Streptococcus pyogenes SPE-C Streptococcal toxic shock syndrome

Table 1-3. Factors Influencing Immunogenicity of Antigens

Dose High dose Low dose

MAJOR HISTOCOMPATIBILITY COMPLEX (MHC)

MHC molecules share certain features:

Features of MHC expression are reviewed in Table 1-5.

Table 1-4. Structure of MHC Class I and Class II Molecules

Genes HLA-A, -B and -C HLA-DP, -DQ and -DR

In addition to encoding the MHC polypeptides, the MHC genome encodes

The class III region encodes:

The class I-like proteins are highly conserved. They include:

Antigen Processing and MHC Presentation

Figure 1-2. Map of the human MHC genome.

Figure 1-3. MHC class I antigen-processing pathway.

Defect in MHC Expression and Disease

Figure 1-4. MHC class II antigen-processing pathway.

Table 1-6. Bare Lymphocyte (MHC Deficiency) Syndromes

Inheritance Autosomal recessive Autosomal recessive

Clinical Sinopulmonary infections, Diarrhea, hepatosplenomegaly,

Laboratory CD8 lymphopenia, PBMC on flow CD4 lymphopenia (reversed CD4:CD8)

Tolerance is unresponsiveness to an antigen. This can be to self-antigens (i.e.,

Key Fact Central Tolerance

Flash Card A6 Central B-Lymphocyte Tolerance