hypersensitivity reactions dr somesh - microbiology
TRANSCRIPT
HYPERSENSITIVITY REACTIONS
Dr. SOMESHWARAN RAJAMANI, MBBS, MDAssistant professor, Department of Microbiology,
Karpagam Faculty of medical sciences and Research.
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INTRODUCTIONImmunity – protective – overcome infectious agents (antigens) and toxins
Immune response – may also be injurious to host
Sensitised individual respond to specific antigenic stimuli in an inappropriate or exaggerated manner
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In protective part of immunity – antigen is the focus of attention and what happens to it
Example: Bacteriolysis, Toxin neutralization
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In hypersensitivity antigens are of little concern and often innocuous or bland substances such as serum proteins or pollen
Hypersensitivity is concerned with what happens to host as a result of immune reaction
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DEFINITIONInjurious consequences in the sensitized host, following contact with specific antigens.
Deals with injurious aspect of heightened and exaggerated immune response leading to tissue damage, disease or even death
Concerned with what happens to the host rather than what happens to the antigen.
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Essentials for Hypersensitivity
Contact with allergen
Sensitizing/priming dose
Induction of AMI/CMI
Shocking dose
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CLASSIFICATION TRADITIONAL CLASSIFICATION
COOMB AND GELL (1963) CLASSIFICATION
Traditional classification is based on the time required for a sensitized host to develop clinical reactions on re-exposure to the specific antigen
Coomb and Gell classification is based on mechanism of pathogenesis
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TRADITIONAL CLASSIFICATION IMMEDIATE HYPERSENSITIVITY: (B cell or antibody mediated)
Anaphlaxis Atopy Antibody mediated damage Arthus phenomenon Serum sickness DELAYED HYPERSENSITIVITY Infection (Tuberculin) type Contact dermstitis type
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IMMEDIATE HYPERSENSITIVITY DELAYED HYPERSENSITIVITY
Appears and recedes rapidly Appears slowly and lasts longer
Induced by antigens or haptens by any route Antigen or hapten intradermally or with Freund’s adjuvant or by skin contact
Circulating antibodies present and responsible for reaction; ‘antibody mediated’ reaction.
Circulating antibodies may be absent and not responsible for reaction; ‘cell mediated’ reaction
Passive transfer possible with serum Cannot be transferred with serum; but possible with T cells or transfer factor
Desensitisation easy, but short-lived Difficult, but long-lasting
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COOMB AND GELL CLASSIFICATION (4 types)1. Type l : IgE mediated2. Type ll : Cytolytic & Cytotoxic3. Type lll : Immune complex4. Type lV : Delayed hypersensitivity
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AtopyAnaphylaxis
Arthus reactionSerum sickness
Autoimmune anemiaHemolytic disease of
newbornGrave’s disease
Myasthenia gravis
Contact dermatitisTuberculin reaction
Schwartzmann reactionCutaneous basophil
hypersensitivity
I III
II IV
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COOMBS & GELL CLASSIFICATION (1963)Type of reaction
Clinical syndrome Time required for manifestation
Mediators
Type l AnaphylaxisAtopy
Minutes IgE: histamine & other pharmacological agents
Type ll Ab mediated damage- thrombocytopenia, hemolytic anemia
Variable : hours to days
IgG : Igm, C
Type lll Arthus reactionSerum sickness
Variable : hours to days
IgG : Igm, C, leucocytes
Type lV Tuberculin Contact dermatitis
Hours to days T cells; lymphokines; macrophages
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TYPE I REACTIONS IgE dependant/ Reagin , mediated Occur in 2 forms:1. Anaphylaxis – acute, potentially fatal,
systemic form.
2. Atopy – chronic or recurrent, non fatal, localized form.
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ANAPHYLAXISAna- without, Phylaxis-protectionClassical immediate hypersensitivity reactionSensitization
Most effective when Ag is introduced parenterally
Minute quantities are enoughInterval of 2-3 weeks needed between sensitizing & shocking dose
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ANAPHYLAXISOnce sensitized it remains so for long time
Shocking dose most effective by IV route then IP, then SC then ID
The shocking Ag must be same or similar to Sensitizing Ag
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ANAPHYLAXIS Mechanism: Cytotropic IgE – IgE antibodies bound to surface of mast cells and basophils
FcER receptors analogous to TCR is present in these cells
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ANAPHYLAXIS IN VITROSchultz Dale phenomenon:Intestinal or uterine muscle strips – from sensitized guinea pigs – kept in a bath of ringer’s solution – contarct vigorously on addition of specific antiserum
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ANAPHYLAXISPrimary mediators:Histamine, Serotonin, Chemotactic factors
Secondary mediators: Prostaglanins and Leukotrienes, Platelet activating factor (PAF)Others: anaphylatoxins, bradykinin
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Theobald-Smith phenomenon: Guinea pigs - Sublethal load of sea anemones – toxin - immune
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ANAPHYLACTOID REACTIONIntravenous Trypsin or peptone - HS
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B cell
Histamine, tryptase,
kininegenase, ECFA
Leukotriene-B4, C4, D4, prostaglandin D,
PAF
Newly synthesized mediators
TH2IL13
Sensitization against allergens and type-I hypersensitivity
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Type I ReactionsHumans – Itching of scalp & tongue,
flushing of skin, difficulty in breathing, nausea, vomiting, diarrhea, acute hypotension, loss of consciousness, death (rare)
Causes Serum therapy, antibiotics,
insect stings Treatment
Adrenalin 0.5 ml (1 in 1000 solution) SC/IM repeated up to 2 ml in 15 min
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CUTANEOUS (LOCAL) ANAPHYLAXIS Follows I.D. injection (small shocking dose) – a
local wheal & flare response is seen. Wheal – central pale area of puffiness due to
edema Flare - surrounds wheal, caused by hyperemia
and subsequent erythema. Uses : - Testing for hypersensitivity Precaution – Keep adrenalin injection ready to
combat severe fatal reaction.
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ATOPY Refers to naturally occurring familial
hypersensitivities of human beings : - Hay fever - Asthma Antigens involved in atopy can be 1. Inhalants – pollen, house dust 2. Ingestants – eggs, milk3. Contact allergens.
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Type-I hypersensitivity
The common allergy
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DIAGNOSIS1. Skin tests (ID injection ) - with allergens like pollen, cat or dust mite Children - 3x3 mm wheal Adults – 4x4 mm wheal +ve test takes 5 -15 mins to develop, persist for 30 mins or
more – IMMEDIATE RESPONSE.
2. Radioallergosorbent test (RAST) - to measure the levels of Ig E in serum.
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TYPE II (CYTOTOXIC) REACTIONS
Involve activation of complement by IgG or IgM binding to an antigenic cell.
Antigenic cell is lysed.
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Type II Hypersensitivity
Role of complement and phagocytes
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TYPE II HYPERSENSITIVITY REACTIONS
Reactions against blood cells & platelets1. Incompatible blood transfusion. 2. Hemolytic disease of the newborn.3. Autoimmune hemolytic anemias,
thrombocytopenia.
• Reactions against Tissue Antigens1. Myasthenia gravis & LATS in Grave’s
disease2. Pemphigus vulgaris
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Type II hypersensitivity induced by exogenous agents
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Involve reactions against soluble antigens circulating in serum.
Usually involve IgA antibodies.Antibody-Antigen immune complexes are
deposited in organs, activate complement, and cause inflammatory damage.
Glomerulonephritis: Inflammatory kidney damage.Occurs when slightly high antigen-antibody ratio
is present.
TYPE III (IMMUNE COMPLEX) REACTIONS
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APC
TH2
B cell
Sensitization for Type III hypersensitivity
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Immune Complex Mediated Hypersensitivity
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SERUM SICKNESSSystemic form of type lll HS. Appears 7-12 days following the injection of large doses of foreign serum (Diphtheria antitoxin).
ICs are deposited on the endothelial lining of blood vessels in various parts of the body.
Features – fever, LN pathy, splenomegaly, arhthritis, glomerulonephritis, endocarditis, rashes, abdominal pain, nausea & vomiting.
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Serum sickness
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ARTHUS REACTIONLocal reaction consisting of edema, induration & hemorrhage.
Followed by repeated SC injection with a foreign serum/ normal horse serum.
Intense local reaction – edema, induration, hemorrhagic necrosis
Reaches peak after 4 - 10 hrs, disappears by 48 hrs.
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TYPE 4: DELAYED HYPERSENSITIVITY
Takes more than 12 hrs to develop. Involve CMI reactions. Provoked by intracellular microbial infections
or haptens like simple chemicals Varieties of Delayed HS :1. Contact 48-72 hrs2. Tuberculin 48-72 hrs3. Granulomatous 21-28 days
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CONTACT DERMATITIS Eczematous reaction at the point
of contact with an allergen, like1. Metals – nickel, chromium2. Simple chemicals – dyes3. Drugs – Penicillin
• Cells involved in Contact HS1. Langerhans cells2. Keratinocytes
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CONTACT DERMATITISLesions – vary from macules & papules to vesicles that break down leaving behind raw weeping areas
Detected by ‘Skin Patch Test’ * Allergen is applied to the skin under an adherent dressing. * Itching appears in 4- 5 hrs. * Local reaction after 24- 48 hrs: Erythema to vesicle or blister formation
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Clinical & Patch test appearance of contact hypersensitivity
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Tuberculin Type HypersensitivityTuberculin type – ID inoculation of PPD in sensitized
individual leads to induration & inflammation in 48-72 hrs. This is not the same as skin test done for Type I hypersensitivity.
Used for diagnosis / exclusion of diagnosis of many bacterial / fungal / parasitic / viral and autoimmune diseases.
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DISEASES MANIFESTING GRANULOMATOUS HS
LeprosyTuberculosisSchistosomiasisSarcoidosisCrohn’s disease
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SCWARTZMANN REACTION
Not an immune reactionPertubation in factors affecting intravascular coagulation
Ex: Waterhouse Freiderichsen syndromeMeningococcal septicemia
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Type-IVType-IIIType-IIType-Icharacteristic
Comparison of hypersensitivity reactions
TB test, poison ivy, granuloma
farmers’ lung, SLE
pemphigus, Goodpasture
hay fever, asthma
examples
antibody IgE IgG, IgM IgG, IgM noneantigen exogenous cell surface intracellularsoluble
response time
15-30 min. Min.-hrs 3-8 hours 48-72 hoursor longer
appearance Weal & flare Lysis & necrosis
Erythema & edema
Erythema & induration
baso- and eosinophils
Ab and complement
histology PMN andcomplement
Monocytes & lymphocytes
T-cellsantibodyantibodyantibodytransfer with
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SUMMARYHypersensitivity – injurious4 types – Type I, II, III, IVI, II, III – ImmediateIV- DelayedDifferences between immediate and delayed HS
Examples for Type I, II, III and IV HS
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THANK YOU