45

Case 8
MHC Class II Deficiency

An inherited failure of gene regulation.

The class II molecules of the major histocompatibility complex (MHC) are involved
in presenting antigens to CD4+ T cells. The peptide antigens that they present are
derived from extracellular pathogens and proteins taken up into intracellular vesi-
cles, or from pathogens such as Mycobacterium that persist intracellularly inside Topics bearing
vesicles. MHC class II molecules are expressed constitutively on antigen-present- on this case:
ing cells, including dendritic cells, monocyte/macrophages, and B lymphocytes. In
Role of MHC class II
humans, MHC class II molecules, together with MHC class I molecules (see Case molecules in antigen
12), are known as the HLA antigens. They are also expressed on the epithelial cells presentation to CD4
of the thymus and their expression can be induced on other cells, principally by T cells
the cytokine interferon-γ. T cells also express MHC class II molecules when they
are activated. Role of co-receptor
molecule CD4 in
MHC class II molecules are heterodimers consisting of an α chain and a β chain antigen recognition
(Fig. 8.1). The genes encoding both chains are located in the Human Leukocyte by T cells
Antigen (HLA) locus on the short arm of chromosome 6 in humans (Fig. 8.2). The
Intrathymic
principal MHC class II molecules are designated DP, DQ, and DR, and, like the maturation of CD4
MHC class I molecules, they are highly polymorphic. Peptides bound to MHC class T cells
II molecules can be recognized only by the T-cell receptors of CD4+ T cells and not
by those of CD8+ T cells (Fig. 8.3). MHC class II molecules expressed in the thymus Mixed lymphocyte
also have a vital role in the intrathymic maturation of CD4+ T cells. reaction

Expression of the genes encoding the α and β chains of MHC class II molecules Lymphocyte
must be strictly coordinated and it is under complex regulatory control by a series stimulation by
polyclonal mitogens
of transcription factors. The existence of these transcription factors and a means
of identifying them were first suggested by the study of patients with MHC class II FACS analysis
deficiency.

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 46 Case 8: MHC Class II Deficiency

Fig. 8.1 Structure of an MHC class II

molecule. Panel a shows a computer
graphic representation of the MHC
class II molecule HLA-DR1. Panel b is a
schematic representation of the molecule.
It is composed of two transmembrane peptide-binding
cleft
glycoprotein chains, α and β, each folded
into two protein domains. The antigenic
peptide binds in a cleft between the β1 α1
two chains. Photograph courtesy of
C. Thorpe.

β2 α2

a b
Case Studies in Immunology | Raif Geha
ISBN: 978-0-8153-4512-1 | 7th edition
MHC Class II Deficiency | CS-08.01 | Figure 8-1
© Garland Science design by blink studio limited

The case of Helen Burns: a 6-month-

old child with a mild form of combined
immunodeficiency.
Helen Burns was the second child born to her parents. She thrived until 6 months
of age when she developed pneumonia in both lungs, accompanied by a severe
cough and fever. Blood and sputum cultures for bacteria were negative, but a tra-
cheal aspirate revealed the presence of abundant Pneumocystis jirovecii. She was
h
old girl wit
treated successfully with intravenous administration of high doses of trimethoprim-
6 - m o nt h - sulfamethoxazole, which is very effective against Pneumocystis, and seemed to
m o n i a . S CID? Do recover fully.
pne u .
o c y t e f un ction tests As her pneumonia was caused by the opportunistic pathogen P. jirovecii, Helen was
lymp h suspected to have severe combined immunodeficiency. A blood sample was taken,
and her peripheral blood mononuclear cells were stimulated with phytohemag-
glutinin (PHA) to test for T-cell function by 3H-thymidine incorporation into DNA.
A normal T-cell proliferative response was obtained, with her T cells incorporating
114,050 counts min–1 of 3H-thymidine (normal control 75,000 counts min–1). Helen
had received routine immunizations at 2 months of age. However, in further tests her
T cells failed to respond to tetanus toxoid in vitro, although they responded normally
in the 3H-thymidine incorporation assay when stimulated in a mixed leukocyte reac-
tion (see Fig. 6.3).

Gene structure of the human MHC

HLA

Fig. 8.2 The organization of the major DP DN DM DO DQ DR

histocompatibility complex (MHC) on
TAPBP β α α α β LMP/ TAP β β α β β α B C A
chromosome 6 in humans. There are
separate regions of class I and class II
genes. The class I genes encode for the
HLA-A, HLA-B, and HLA-C proteins. The
class II class III class I
class II genes are shown in yellow.
Case Studies in Immunology | Raif Geha
ISBN: 978-0-8153-4512-1 | 7th edition
MHC Class II Deficiency | CS-08.02 | Figure 8-2
© Garland Science design by blink studio limited

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 Case 8: MHC Class II Deficiency 47

Fig. 8.3 Effector CD4+ cells recognize

CD4 T cells: peptide + MHC class II antigens bound to MHC class II
molecules. CD4+ T cells carry the co-
TH1 cells TH2 cells receptor molecule CD4, which binds to
MHC class II molecules on the antigen-
intra- presenting cell and helps to stabilize
cellular the binding of T-cell receptor to antigen.
bacteria
Effector CD4 T cells fall into several
bacterial
toxin different subclasses: TH1 and TH2 are
CD4 shown here. TH1 cells are involved mainly
TH1 TH 2 in responding to antigens presented
TCR by macrophages, which activates the
macrophages causing destruction of the
MHC
class II bacteria within the macrophage vesicles.
TH2 cells respond to antigen presented by
macrophage antigen-specific B cells, stimulating the differentiation of
B cell
B cells to plasma cells and the production
of antibodies.
Macrophage activation and B-cell proliferation and differentiation
destruction of intravesicular pathogens to plasma cells. Antibody production

Case Studies in Immunology | Raif Geha

ISBN: 978-0-8153-4512-1 | 7th edition
MHC Class II Deficiency | CS-08.03 | Figure 8-3
When it was found that Helen’s T cells could not respond to a specific antigenic
© Garland Science design by blink studio limited

stimulus, her serum immunoglobulins were measured and found to be very low.
IgG levels were 96 mg dl–1 (normal 600–1400 mg dl–1), IgA was 6 mg dl–1 (normal
60–380 mg dl–1), and IgM 30 mg dl–1 (normal 40–345 mg dl–1).
Helen’s white blood cell count was elevated at 20,000 cells μl–1 (normal range 4000–
7000 μl–1). Of these, 82% were neutrophils, 10% lymphocytes, 6% monocytes, and
2% eosinophils. The calculated number of 2000 lymphocytes μl–1 was low for her
age (normal >2500 μl–1). Of her lymphocytes, 27% were B cells as determined by ls, deficie ncy of CD4
an antibody against CD20 (normal 10–12%), and 47% reacted with antibody to the Low Ig leve
T-cell marker CD3. In particular, 41% of Helen’s lymphocytes were positive for CD8, T cells.
and 6% were positive for CD4. Thus, at 810 cells μl–1 her number of CD8+ T cells was
within the normal range, but the number of CD4+ T cells (120 μl–1) was much lower
than normal (her CD4+ T-cell count would be expected to be twice her CD8+ T-cell
count). The presence of substantial numbers of T cells, and thus a normal response
to PHA, ruled out a diagnosis of severe combined immunodeficiency (see Case 5).
Helen’s pediatrician referred her to the Children’s Hospital for consideration for
t y p e av ailable. Do
R
No HLA-D s.
a bone marrow transplant, despite the lack of a diagnosis. When an attempt was
made to HLA-type Helen, her parents, and her healthy 4-year-old brother by serol-
lysi
ogy, a DR type could not be obtained from Helen’s white blood cells. Her circulat- FACS ana
ing B lymphocytes and her monocytes did not express HLA-DR molecules. Hence,
a diagnosis of MHC class II deficiency was established (Fig. 8.4). Ultimately, HLA
typing was performed by molecular DNA techniques.
Her brother was found to have the same HLA type as Helen, and therefore was cho-
sen as a bone marrow donor. Helen was given 1 mg kg–1 of body weight of the cyto-
toxic drug busulfan every 6 hours for 4 days and then 50 mg kg–1 cyclophosphamide s II d e fic i e ncy. Bone
each day for 4 days to ablate her bone marrow. The brother’s bone marrow was MHC clas plant advisable,
ans
administered to Helen by transfusion without any in vitro manipulation. The graft marrow tr u n satisfactor
y.
was successful and immune function was restored. s ofte n
but result

MHC class II deficiency.

MHC class II deficiency is inherited as an autosomal recessive trait. Health prob-
lems show up early in infancy. Affected babies present the physician with com-
bined immunodeficiency as they have increased susceptibility to pyogenic and

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 48 Case 8: MHC Class II Deficiency

Fig. 8.4 Detection of MHC class II

molecules by fluorescent antibody. Cells from a patient with class II Immunofluorescence of normal
histocompatibility deficiency EBV-transformed cells
Helen’s transformed B-cell line was
examined by using a fluorescent antibody
against HLA-DQ and HLA-DR. Helen (left HLA-DQ
panels) expressed approximately 1% of
160 160
the amount of MHC class II molecules
compared with a transformed B-cell line
from a normal control (right panels).

0 0
0 1 2 3 4 0 1 2 3 4
10 10 10 10 10 10 10 10 10 10
Transformed B cells Transformed B cells

HLA-DR

160 160

0 0
0 1 2 3 4 0 1 2 3 4
10 10 10 10 10 10 10 10 10 10
Transformed B cells Transformed B cells

Case Studies in Immunology | Raif Geha

ISBN: 978-0-8153-4512-1 | 7th edition
MHC Class II Deficiency | CS-08.04 | Figure 8-4
opportunistic infections. However, they differ from infants with severe combined
© Garland Science design by blink studio limited
immunodeficiency (SCID; see Case 5) in that they have T cells, which can respond
to nonspecific T-cell mitogens such as PHA and to allogeneic stimuli. Unlike in
some other types of immunodeficiency, progressive infection with the attenuated
live vaccine strain Bacillus Calmette–Guérin (BCG) has not been observed in MHC
class II-deficient patients after BCG vaccination against tuberculosis (most cases of
MHC class II deficiency have been observed in North African migrants in Europe,
where BCG vaccination is routine). This is because mycobacterial antigens derived
from BCG can be presented on MHC class I molecules and infected cells can be
destroyed by cytotoxic T cells. In contrast, and for reasons that are unclear so far,
patients with MHC class II deficiency are highly prone to severe viral infections.
Patients with MHC class II deficiency are deficient in CD4+ T cells, in contrast with
MHC class I deficiency, in which CD8+ T-cell numbers are very low and the levels
of CD4+ T cells are normal (see Case 12). Typically, patients with MHC class II defi-
ciency also have moderate to severe hypogammaglobulinemia.
Hematopoietic stem cell transplantation (HSCT) is the treatment of choice for
patients with MHC class II deficiency. Helen Burns was cured after a bone mar-
row transplant from her HLA-identical brother. However, the results of HSCT in
patients with MHC class II deficiency, even when transplanted from HLA-identical
donors, are often not satisfactory, and the number of circulating CD4+ T cells fre-
quently remains low. This is likely because positive selection of donor-derived
CD4+ thymocytes is compromised, owing to a lack of MHC class II molecules on
the surface of the patient’s thymic epithelial cells.
Genetic linkage analysis in large extended families with MHC class II deficiency
has shown that this condition is not linked to the MHC locus on the short arm of
chromosome 6 and that the genes encoding the MHC class II molecules at this
locus are normal. Interferon-γ induces the expression of MHC class II molecules
on antigen-presenting cells from normal people but fails to induce their expres-
sion on the antigen-presenting cells of patients with MHC class II deficiency. This
suggested that the defect might lie in the regulation of expression of the MHC class
II genes.
The search for the cause of the defect was complicated further by the discovery
that MHC class II deficiency in different patients seems to have different causes.
Epstein-Barr virus (EBV)-transformed B cells isolated from class II-deficient
patients do not express MHC class II molecules. However, when B cells from two

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 Case 8: MHC Class II Deficiency 49

different patients are fused, MHC class II expression is often observed. The fusion
of the two cell lines has corrected the defect. This means that one cell must be able A B C D
to replace whatever is lacking in the other, and thus the two cells must carry dif-
ferent genetic defects causing the MHC class II deficiency. Pairwise fusions were A
performed on a large number of cell lines from different patients, and four comple-
mentation groups were found (Fig. 8.5).
These experiments provided clues that led eventually to the identification of the B
defect. The lack of MHC class II molecules turns out to result from defects in the
transcription factors required to regulate their coordinated expression. All four of
C
these transcription factors, which bind to the 5ʹ regulatory region of the MHC class
II genes, have been identified. The transcription factors whose mutations account
for MHC class II deficiency are Class II Transactivator (CIITA), RFXANK, RFX5,
D
and RFXAP. The last three bind directly to the promoter of all MHC class II genes,
whereas CIITA is a master transcription factor that binds the RFX complex and
Case Studies in Immunology | Raif Geha
activates transcription of the MHC class II genes. Fig.978-0-8153-4512-1
ISBN: 8.5 Complementation | 7th edition groups of
MHC
MHC Classclass
II Deficiency | CS-08.05 | Figure
II deficiency. 8-5 lines
B-cell
© Garland Science design by blink studio limited
isolated from different patients were
fused in all pairwise combinations to
Questions. determine whether they could correct
each other’s defect. If two cell lines do
not correct each other (–), they are in the
  1 Why did Helen lack CD4 T cells in her blood? same complementation group and have
the same genetic defect. However, if the
defect is corrected (+), the two cell lines
  2 Why did Helen have a low level of immunoglobulins in her blood? belong to two different complementation
groups and have two different defects.
  3 In SCID, lymphocytes fail to respond to mitogenic stimuli. Although Helen was Four complementation groups, A, B, C,
and D, were discovered by this technique.
first thought to have SCID, this diagnosis was eliminated by her normal response
to PHA and an allogeneic stimulus. How do you explain these findings?

  4 If a skin graft were to be placed on Helen’s forearm do you think she would
reject the graft?

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