Biomedicine Course Autumn 2002

Pathology, Immunology and Infection biology

Synopses of lectures
Mon 26/8 10.00 10.45 (Agneta Richter-Dahlfors) Introduction: Introduction to pathogenic microorganisms diseases. and infectious

Objectives: this lecture will: provide an historical overview of the origins of microbiology describe the major types of human pathogens and their major biological features review some of the evolutionary, social and economical implication of microbial diseases review the directions of the microbiological research of today and speculate about future directions.

Section I Molecular Immunobiology

Aims of this section to review the anatomy and cell composition of the immune system to provide an overview of lymphocyte receptors (LR), their structure and function to review the main steps of the assembly process of the LRs to review the principal mechanisms of these receptors in induction of adaptive immune responses to review the regulation of lymphocyte gene expression during development Tue 27/8 09.00-11.30 (Elena Levitskaya) Anatomy and cells of the immune system

The aim of this lecture is to scrutinize the functional role of red and white blood cells for our immune defences. Also, to present the central and peripheral organs in our immune system, the lymphatic circulation as well as the anatomy of peripheral lymphoid tissues. Mucosal associated lymphoid tissues are defined. Keywords: direct cytotoxicity, antibody dependent cell-mediated cytotoxicity (ADCC), phagocytosis, pinocytosis, antigen presentation and processing, antigen presenting cell (APC), costimulation, Langenhans cells (LH), Interdigitating dendritic cells (IDC), Follicular dendritic cells (FDC), cytokines and chemokines, FcR, CR, mediators of inflammation, major basic protein, NK cells and inhibitory (KIR) and activating (KAR) receptor(s), NKT cells, anti-bacterial peptides. Gut-Associated Lymphoid Tissue (GALT), Bronchial-Associated Lymphoid Tissue (BALT), Mucosal-Associated Lymphoid Tissue (MALT). A review article on anti-bacterial peptides will be handed out.
Biomed/overview 1

Tue 27/8

13.00- 14.30 (Benedict Chambers) Innate immunity

The aim of this lecture is to present innate immunity and its major relevance for signalling, orientation and strengthening of adaptive responses. Previously known qualities of innate immunity as absence of memory and specificity, are discussed based on recent knowledge of conserved receptors (pattern of recognition receptors) and conserved patterns associated with the pathogen (pathogen-associated molecular patterns). The inflammatory response leading to the production of pro-inflammatory cytokines and acute-phase proteins are discussed. Acute-phase proteins are introduced as opsonins. Mannan binding protein and its ability to activate complement cascade will be discussed. The three pathways for complement activation are introduced. Biochemical reactions leading to C3 convertase and C5 convertase are presented in detail during this lecture. Keywords: barriers to infection, lyzozyme, lactoferin, anti-bacterial peptides, natural flora, inflammation, increased vascular permeability, cytokines, chemokines, lymphocyte migration, PRR, PAMPS, Toll-like receptors, CRP, SAA. MBP, type I interferons, Il-1, Il-6, TNF-a, IL-8, Il-12, C3 tickover, C3, C5 convertases, Membrane-Attack Complex (MAC). A review article on PRR, PAMPS will be handled out. Thu 29/8 09.00-11.30 (Elena Levitskaya) Basic immunological terminology, immunoglobulin structure and function of B-cells Short historical introduction describing the concepts of cellular and humoral immunity. Humoral immunity as prevailing concept in the early strategies of immunological research. Basic immunological terms which developed during studies on humoral immunity: Antigen; Immnogen; Hapten; Antigenic determinant; Adjuvant; Affinity; Avidity; Specificity; Crossreactivity.

Structure of immunoglobulins, Fab, F(ab)2 and Fc fragments. Antigenic determinants of immunoglobulins, idiotypic networks. Immunoglobulin subclasses and their functional diversity. Monoclonal and polyclonal antibodies.
Biomed/overview 2

Principles of hybridma technology. Major assays based on Ag/Ab reaction. B-cell activation. Immunoglobulins as cell surface signal transducing receptors. Components of the signalling machinery. Immunoglobulin class switch. T-cell dependent and independent antigens Regulation of B-cell activation and maturation by lymphokines and co-stimulatory signals. Anatomy of the process: follicular dendritic cells, lymphnodes, germinal center. B-cells as antigen presenting cells. Thu 29/8 13.00-14.30 (Elena Levitskaya) Generation diversity of B-cell repertoires

The aim of this lecture is to give understanding to the generation of receptor diversity present in the T and B lymphocytes and their relevance to adaptive immune responses. The immunoglobulin receptor (IgR) is used as a model for gene rearrangement. The IgR is quickly introduced as a surface protein and from the protein structure we will go into DNA and understand mechanisms behind rearrangement of immunoglobulin genes. 12/23 rule, generation of P and N nucleotides will be explained. The development of B cells in the bone marrow and its selection process will be introduced. Keywords: IgR (IgM IgD), VL, VH, CL, CH, Variable, Constant, CDR1,2,3, VDJ/VJ gene segments, germline DNA, somatic recombination, heptamer, nonamer, RAG-1, RAG-2 complex, hairpin formation, TdT, allelic exclusion, somatic hypermutation, clonal deletion of B cells. Fri 30/8 09.00-11.30 (Elena Levitskaya) MHC structure and antigen processing and presentation

Antigen processing and presentation machinery, MHC molecules and T-cells as components of the integral system of adoptive immunity. Short history of major discoveries that have unravelled the structure and function of MHC molecules. Basic information about MHC class I and class II molecules. Nomenclature of MHC and MHC encoded molecules in mice and humans. Structure of MHC molecules. Major steps of MHC class I restricted antigen presentation. Major proteases involved in antigen processing. Evolutionary relationship between the proteolyic systems and MHC. Major steps of proteolysis involved in MHC class I restricted presentation. Structure and enzymatic activity of the proteasome. Housekeeping and immunoproteasome. Regulatory complexes (19S, PA28). Other proteases involved in the processing of MHC class I associated peptides.

Biomed/overview 3

Function and selectivity of TAPs. Phenotype of TAP deficient cells. Assembly and trafficking of MHC class I molecules through ER and Goldgi compartments. Role of different chaperones. Assembly and trafficking of MHC class II molecules. Structure and function of invariant chain. Degradation of invariant chain and other proteins transported into the lysosomal/endosomal compartment. Cathepsins. CLIP and HLA-DM. Alternative pathway of MHC class I restricted antigen presentation. Characteristics of the pathway in different cell types. Genetics and structure of TCR. Structural aspects of MHC:TCR interaction. Fri 30/8 13.00-14.00 (Benedict Chambers) Dendritic cells

The aim of this lecture is to describe the biology of dendritic cells and their role in immune responses. Topics will be DC precursors and their relation to other cells in the immune system. Uptake of antigen and trafficking to secondary lymphoid organs, with Langerhans cells in the skin as a model. Signals that induce DC maturation. Interaction between T cells and DC and the molecules involved. Co-stimulation and the danger hypothesis. Peripheral tolerance versus T cell activation. The difference between DC and macrophages and B cells as APC. Tue 3/9 09.00-10.00 (Victor Levitsky) T-cell activation

Role of MHC/TCR interactions in immune regulation. General characteristics of Tcell recognition. Different outcomes of MHC/TCR interaction. Effects of altered peptide ligands on T-cell recognition and activation. TCR serial triggering. Thermodynamic and kinetic characteristics of MHC:TCR interaction. Models of TCR triggering. Schematic overview of TCR signal transduction, short description of major signalling pathways. Role of co-stimulation. CR/MHC interaction in space and time. Supramolecular activation complexes. Tue 3/9 10.30-11.30 (Victor Levitsky) T-cell effector functions

Effector molecules of T-cells. Apoptosis as a major mechanism of CTL killing. Granule exocytosis. Perforine and granzymes. Caspases: nomenclature, enzymatic activity and function.
Biomed/overview 4

TNF-receptor family of apoptotic and co-stimulatory molecules. Signalling through Fas and TNFalfa-receptor. TRAIL and its receptors. Bactericidal molecules produced by T-cells. Lymphokines and inhibition of viral replication. Th1 and Th2 subsets of CD4+ T-cells. Role of effector molecules in regulating homeostasis in the immune system. Phenotype of relevant mutant and gene knock-out mouse strains. Wed 4/9 09.00-11.30 (Victor Levitsky) T-cell selection and tolerance

In this lecture, we will walk through T cell development from the precursors in the bone marrow, via the thymus to the peripheral T cell in secondary lymphoid organs. The role of the thymus will be emphasized and the different steps in thymic selection described in detail, giving experimental evidence for positive and negative selection from work with superantigens and TCR transgenic mice. Generation of T cell receptor diversity will be described. We will then go into tolerance, discuss clonal deletion in T and B cells and then go into mechanisms for peripheral tolerance, such as ignorance, anergy, immunological privileged sites etc. Finally, the development of gamma/delta T cells and thymus-independent T cell maturation in the gut will be discussed. Thu 5/9 09.00-10.00 (Benedict Chambers) NK cells

The origin of NK cells will be described, how they were discovered and what is thought to be their main biological role. We will then go into the recognition mechanisms, focusing on the two step model with an initial positive trigger that is balanced by negative signals, the missing self model. Next, some of the known receptors that mediate positive and negative signals, their signal transduction pathways and how they are balanced in the cell will be discussed. Finally, we will talk about NK-T cells and their proposed biological role. Thu 5/9 10.30-12.00 (Benedict Chambers) Congenital immunodeficiencies

The aim of this lecture is to give a detailed description of congenital immunodeficiency disorders and emphasize how they can shed light on immune functions. At least one disorder for each major component of the immune system, i.e. T cells, B cells, complement, macrophages etc. will be touched upon, but we will not go into details of all known diseases. Some epidemiology will be discussed as well.

Biomed/overview 5

Fri 6/9

09.00-11.30 (Victor Levitsky) Regulation of immune responses

The aim of these lectures is to summarize the role of innate and adaptive immunity in infection. An example of a viral and a bacterial infection will be used. The class should actively participate in the exercise of mounting an adequate eliminating response to both infectious agents, involving effector cells and molecules in the immediate early, early and late phases of infection.

Section II Pathology
Aims of this section Description of basic pathological responses Structural alterations in cells and tissues during cell adaptation, damage and death. Etiological (causative) factors for and pathogenesis of cell adaptation, damage and death. Structure of and mechanisms involved in tissue repair and regeneration. Mon 9/9 09.00-10.15 (Lennart Eriksson) Introduction to concept of disease, cell damage and adaptation 10.45-12.00 (Jerker Olsson) Cell damage and defence mechanisms

Mon 9/9

Objectives: You should be able to describe the tissue reactions at the morphological level during reversible (degeneration) and irreversible (necrosis) cell damage. You should know common etiological factors and pathogenetic mechanisms for cell damage, in particular due to lack of adequate oxygen supply and following exposition of cytotoxic compounds. You should be able to describe the role of free radicals for the development of cell damage, how free radicals are formed and the effects of these radicals on cellular components and functions. Knowledge on the cellular defence mechanisms towards free radicals, and how cells can learn (adapt) to cope with a hostile environment. Tue 10/9 9.00-10.15 & 10.45-12.00 (Gran Andersson) Acute and chronic inflammation

Objectives: Definition of acute and chronic inflammation, innate and adaptive immune response Regulatory and effector inflammatory cells Aetiology of inflammation Local and systemic inflammatory symptoms
Biomed/overview 6

Local vascular and cellular responses during inflammation Leukocyte-endothelial interactions, emigration and chemotaxis Vasoactive and chemotactic mediators Phagocytosis and intracellular destruction of inflammatory agents Histopathology of acute and chronic inflammatory exsudate Composition of exsudate and granulation tissue Dissemination of agens (lymfangitis, lymfadenitis, sepsis) Granulomatous inflammation Healing after inflammation

Wed 11/9 09.00-10.15 (Gran Andersson) Tissue regeneration and repair Objectives: You should be able to describe the structure and composition of granulation (repair) tissue, and the essential features of wound healing. Why do some tissues heal damaged areas with a scar while other tissues completely regenerate? Which are the molecular mechanisms involved in tissue regeneration and repair, particularly the role of growth factors, cell proliferation and cell differentiation. You should know the repair mechanisms of specialized tissues, such as epithelia, muscle, nervous tissue and bone. Fri 13/9 09.00-10.25 (Staffan Strmblad) Cellular ageing and cell death

Objectives: You should be able to describe the mechanisms and characteristics for cellular ageing and different forms of cell death, including necrosis and apoptosis, their regulation, physiological relevance and relation to disease. You should also know the principle for various apoptosis detection methods. Synopsis: Maximal life span, Age-related changes, Progeria, Mechanisms of ageing, Telomeres and telomerase. Necrosis; Characteristics of Necrosis, Pyknosis, Karyorrhexis. Apoptosis; Definition, Physiological relevance, Diseases related to apoptosis regulation, Cellular changes and characteristic morphology during apoptosis, Central Mechanism of apoptosis, Activators and inhibitors of apoptosis, Fas, Caspases, bcl-2 family, Methods for detection of apoptosis, Immune evasion by stimulation of apoptosis.

Section III Clinical Immunology - Autoimmunity

Aims of this section: To provide clinical examples of autoimmune diseases To review the molecular mechanisms of autoimmune reactions To discuss rational approaches of therapy
Biomed/overview 7

To review the present status of research in autoimmunity 08.30-09.15 (Helena Erlandsson Harris) Introduction to autoimmunity and Rheumatoid Arthritis (RA)

Mon 16/9

Objectives: By the end of this lecture you should be able to: Define autoimmunity Define autoimmune disease Define the term autoantigen Define the term autoantibody Define organ-specific autoimmune diseases, and give an example Define systemic autoimmune diseases, and give an example Describe B-cell mediated autoimmunity, and give an example of a disease Describe T-cell mediated autoimmunity, and give an example of a disease Have an idea about these concepts in conjunction with rheumatoid arthritis Lecture synopsis: A definition of autoimmunity is stated and discussed. The existence of autoimmunity in healthy individuals is mentioned and the development from autoimmunity to autoimmune disease, and factors influencing this, is discussed. Briefly, prevalencies and geographical spread of autoimmune diseases are discussed. Division of autoimmunity in B-cell mediated and T-cell mediated is made, and mechanisms involved described. Antagonistic and agonistic autoantibodies and their opposite effects discussed. Examples of AD given for each scenario. Division of autoimmunity in systemic and organ-specific is described with examples of diseases. An introduction of rheumatoid arthritis as an autoimmune disease, and features of RA according to previous part of the lecture, is ending this lecture. Mon 16/9 10.00-10.45 (Tina Trollmo) Autoimmunity evolving to autoimmune disease

Objectives: By the end of this lecture you should be able to: - Discuss possible theoretical explanations to the occurrence of autoimunity and factors that might influence the induction of autoimmune diseases. Lecture synopsis: Errors in central or peripheral tolerance mechanisms, immunoprivilige, molecular mimicry, induction of co-stimulatory signals, inappropriate MHC expression, polyclonal activators as autoantigens, oxidative stress as factors triggering/influencing the development of autoimmunity/autoimmune diseases. For the different concepts discussed, examples will be given from human or experimental systems. Mon 16/9 11.00-11.45 (Tina Trollmo) Environment and genetic factors (RA)

Biomed/overview 8

Objectives: After this lecture you should be able to: Give examples of environmental factors known to influence the development of autoimmune disease, and if known, mechanisms for this. Give examples of genetic factors influencing the development of autoimmune disease (RA). Describe the theory behind The shared epitope hypothesis. Lecture synopsis: Current knowledge in the field of environmental and genetic influence of AD and RA in particular is reviewed. Concerning environmental factors such things as drugs, smoking, diet, sunlight, stress(?), silicone, plastics and solvents are discussed. Concerning genetic factors MHC-linkage and the shared epitope hypothesis will be discussed, as well as other hereditary factors such as sex hormones,TNF-a polymorphisms, Ig-genes, TcR genes, apoptosis genes. Tue 17/9 08.30-09.30 (Vivi Malmstrm) Experimental models of RA

Objectives: After this lecture you should be able to: Name some examples of different experimental arthritis models Define the term adjuvant Name two cartilage antigens that can induce exp arthritis Name two adjuvants that can cause exp arthritis Lecture synopsis: Advantages and disadvantages with animal models of human diseases compared to studies in humans will be discussed, as well as types of studies that are/can be performed in animals. Experimental models will be divided into groups according to way of induction, spontaneous, induced with ag, induced with adjuvant and genetically modified. Examples will be discussed in each group. Collagen-induced arthritis and oil-induced arthritis will then be presented in more detail. Half of the lecture will be used as a discussion with the students how you can investigate various immunological features of these two models, and how it has been done. (T-cell dependence, B-cell dependence, type I or type II cytokine pattern, MHC-restriction etc). The idea is to trigger the researchers in the students. Tue 17/9 10.00-10.45 (Vivi Malmstrm) Future therapeutic strategies for RA

Objectives: After this lecture you should be able to: Discuss oral tolerance as a therapeutic strategy for autoimmune diseases Briefly explain what is meant with bystander suppression Briefly describe the role of TNF-a in RA Lecture synopsis: TNF-a treatment as a therapy for RA will be discussed, from the first animal studies to the latest patient trials. Antibodies, soluble receptors, synthetic substances.
Biomed/overview 9

Feeding with potential autoantigens to induce tolerance as a therapy for autoimmune diseases. Possible tolerance mechanisms (TGF- production or deletion) will be discussed. Ameliorating effect of coupling to cholera toxin B. MBP trials in MS and CII trials in RA. Bystander suppression (tolerance induced to a particular joint-specific antigen will ameliorate any form of arthritis, whether induced by the antigen in question or induced by other means). Tue 17/9 11.00-12.00 (Helena Erlandsson Harris) The hopes and wishes of a RA patient

Objectives: After this lecture you should hopefully feel that you have gained in understanding of how it can be to live with an autoimmune disease, and the restraints it puts on everyday life. It is also my hope that you, after listening to this extraordinary woman, feel filled with enthusiasm to do research about autoimmune diseases (and arthritis in particular!). Lecture synopsis: Margareta Bckskog, 1:e vice chairman in the patients organisation Reumatikerfrbundet, has promised to come and tell us about her Rheumatoid arthritis and how it affects her life. She will also tell us about her hopes of how research might improve her situation.

Section III Clinical Immunology - Allergy

Aims of this session - to review the principle mechanisms of the IgE-mediated reaction - to give an overview of the mechanisms of T-cell mediated allergic reactions - to provide an overview of structure and function of IgE - to describe the use of DNA technology in allergy - to review novel strategies for allergy treatment Wed 18/9 8.30-9.15 (Marianne van Hage-Hamsten) Mechanisms in IgE-mediated allergic reactions

Objectives By the end of this lecture you should be able to: - understand the mechanisms of the IgE-mediated reaction give examples of different allergens - indicate the relevant diagnostic tools - briefly discuss some possible reasons for the increase in allergy Lecture synopsis: The aim of this lecture is to present the IgE-mediated allergic reactions and describe their mechanisms. The atopic march will be mentioned. The most common allergens, which are small antigens that provoke an IgE-antibody response, will be summarised and their properties discussed. The different tools for
Biomed/overview 10

diagnosis of allergy will be reviewed as well as their advantages and disadvantages. The increase in allergic diseases and some possible reasons for this will be described and protective mechanisms discussed. Wed 18/9 9.20 10.05 (Magnus Lindberg) Mechanisms of contact dermatitis

Objectives By the end of this lecture you should be able to: - understand the mechanisms of the T-cell mediated allergic reaction - give examples of different haptens/allergens - indicate the relevant diagnostic tools present today and the need of additional ones - discuss preventive strategies Lecture Synopsis The aim of this lecture is to present the T-cell mediated allergic reactions and describe their mechanisms. The most common haptens/allergens, which are causing contact allergy will be presented. The method for diagnosis of allergic contact dermatitis will be reviewed, its advantages and disadvantages, and the need for additional methods will be discussed. In addition, the social and economic problems related to allergic contact dermatitis and different strategies for prevention will be described. Wed 18/9 10.30 - 11.15 (Cecilia Hellman) Airway inflammation

Objectives After this lecture you should be able to: Describe the key events in the early and late phase of an allergic reaction Describe the role of mast cells, Th2-lymphocytes and eosinophils in the initiation and maintenance of airway inflammation Identify some cytokines / chemokines, and explain their specific role in the initiation and maintenance of airway inflammation Lecture synopsis This lecture will focus on the late phase of the allergic reaction. The biology and integrated function of mast cells, Th2-lymphocytes and eosinophils, as well as the importance of different cytokines / chemokines in the initiation and maintenance of airway inflammation will be discussed. Wed 18/9 11.15 - 12.00 (Omid Rasool) Experimental allergy - DNA technology

Lecture synopsis: For the last 100 years, allergists have relied on natural allergenic products (crude extracts) for the diagnosis and treatment of allergic diseases. Although the quality of natural allergen extracts has improved during the last 20 years, allergens prepared from such materials remain heterogeneous products and vary
Biomed/overview 11

in allergen composition and content. Furthermore, natural products may become contaminated with allergens from other sources. Therefore, production of more consistent products, such as recombinant allergens, has become of great importance to improve the quality of allergens used as tools for diagnosis and treatment of type I allergies. Techniques of molecular biology and genetic engineering applied to allergens have enabled the production of recombinant allergens, which can be produced as pure proteins and in large amounts. Several techniques have been used for allergen identification and cloning. Strategies based on PCR (RACE-PCR, also called anchored PCR) offer opportunity to directly select, amplify and isolate a message of interest. This approach needs a small amount of sequence information. Expression cDNA libraries, such as lambda and phage display libraries, prepared from the allergen source, are other tools used for allergen identification. Once the allergen is cloned, it will be necessary to express the protein in order to analyse it further. The expression system of choice, either prokaryotic or eukaryotic, will be very much dependent on the nature and properties of the protein. Mapping of the B- and T-cell epitopes of the allergen together with the study of its three-dimensional structure will give important information regarding the properties of the allergen and its molecular interactions. Wed 18/9 13.00 - 13.45 (Caroline Nilsson) The asthmatic patient

Lecture synopsis The lecture will cover definition, diagnosis and clinical aspects of asthma. The selection and the utility of different direct and indirect challenge models of asthma will be presented as well as the possibilities of sampling biological fluids and tissues. Questions on "The asthmatic patient" 1. Name the most common trigger factors of airway obstruction in asthma. Distinguish between allergens and unspecific trigger factors. 2. Discuss the different levels of action of the allergen bronchoprovocation, the leukotriene bronchoprovocation and the exercise challenge. Briefly explain what is meant by a "biomarker" in the context of asthma and give some examples. Thu 19/9 8.30-9.30 (Mauro DAmato) Susceptibility genes for asthma and allergy

Lecture Synopsis: Asthma and allergy are complex disorders, which are due to the interaction of an unknown number of genes with strong environmental factors. Segregation analysis, twin studies and, more recently, linkage studies suggest the presence of major genes conferring susceptibility to these pathological conditions. Identifying such genetic predisposing factors will improve our understanding of its aetiology and will hopefully lead to a better treatment of patients and the development of prevention strategies.
Biomed/overview 12

A serious impediment to the study of the genetics of asthma and allergy is the difficulty in defining their phenotype, for which a uniform definition still does not exist. Indeed, it has become clear that the choice of the phenotype is of paramount importance in the ability to discover predisposing genes or to replicate previous positive findings. To overcome this problem, there is now a general tendency to dissect these complex phenotypes into their major components, by the analysis of quantitative traits rather than the diseases in their whole manifestation. These include total and specific serum IgE levels, skin prick tests for hypersensitivity, bronchial hyperresponsiveness (BHR), eosinophil count etc., which are more amenable to objective measurement than clinician diagnosed asthma/allergy. As for other complex disorders, the identification of predisposing genes can be assessed by two different approaches: examining candidate genes or by genetic linkage followed by positional cloning. The first approach is generally used when some hypothesis can be made regarding disease pathogenesis and the role of a candidate gene is tested by allele-association (case-control) studies. By genetic linkage and positional cloning, genes are identified based on their position on the genetic map. This approach has the advantage of not requiring any prior knowledge of the pathophysiology of the disease. The prerequisite is the collection of a large number of families and accurate phenotyping of the individuals. Genetic linkage relies on the demonstration of a co-inheritance of the disease with genetic polymorphic markers of known chromosomal localization. This results in the disease gene being mapped to an approximate position on the genome. The power of this approach is such that if an appropriate number of markers are typed in several hundreds of families a whole-genome screen is possible. Several association and linkage studies (three whole-genome screens) have been performed in the last few years and a number of genes have been consistently reported to be involved in the inherited susceptibility to asthma. Moreover, For the sole didactic purpose we will arrange these genes into three major groups comprising genes involved in mechanisms of general inflammation and maintenance of the Th1/Th2 balance, genes contributing to specific responses against allergens, and genes acting at the level of target organs, influencing their reactivity and function. A few examples for each group will be discussed and data from recent literature will be covered. Thu 19/9 10.00 - 11.00 (Guro Gafvelin) Novel strategies for allergy treatment

Objectives: By the end of the lecture you should be able to: describe different general approaches for allergy treatment explain differences between pharmacological treatment, specific immunotherapy and new general treatments of allergy account for advantages and drawbacks with different allergy treatments describe how an allergy vaccine could be designed Lecture Synopsis: There are several efficient pharmacological agents in use today, which relieve the symptoms of allergy. Among these are specific inhibitors of mediators released by mast cells e.g. antihistamins, and general anti-inflammatory agents like corticosteroids. The only curative treatment for allergy in use today is
Biomed/overview 13

specific immunotherapy. Immunotherapy involves administering increasing quantities of allergen over a period of time to induce allergen specific tolerance. During immunotherapy, T-cells are affected and may either become anergic or deviate from a Th2 to a Th0/Th1 response. It has also been shown that allergen specific IgGantibodies are synthesised during immunotherapy, which may act as blocking antibodies. A main interest is to reduce the risks associated with injecting allergens to patients. This may be achieved by the use of recombinant allergens. Modified recombinant allergens with decreased IgE binding but retained T-cell epitopes overcome problems such as sensitisation to new components and anaphylactic side effects and are ideal candidates for specific immunotherapy. Another promising approach in immunotherapy, which has so far only been tested in animal models, is the application of naked DNA vaccination. In this case, DNA encoding the allergen is given as plasmid DNA also containing immunostimulatory sequences that stimulate a cellular immune response. Molecular biology techniques have also been used to develop other new treatments of allergy. A humanised monoclonal anti-IgE antibody blocking the binding of IgE to its high affinity receptor FcRI has been constructed and tested on patients. Another target for allergy treatment is cytokines involved in the allergic response. For example, Th2 cytokines like IL-4 and IL-5 may be inactivated by specific antibodies or receptor fragments and Th1 cytokines like IL-12 may be given to enhance the effect of immunotherapy. Chemokines and costimulatory molecules are other possible targets for treatment of allergic disease. Thu 19/9 11.15 - 12.00 Anne Renstrm Prevention in allergy research

Allergy and asthma may influence quality of life in many ways. Besides personal health, both the lifestyle of the patient and often his family may be affected. The school work of a student, or the career an occupational asthmatic may suffer. The economical consequences of occupational allergy or asthma may affect both the patient (sick leave, medical costs, rehabilitation, change of job/new education (new student loans), unemployment) and the employer (loss of competence and time, recruitment of new staff, costs for/investments in prevention). The costs of allergy and asthma in Western countries are indeed great. Much research has been focused on the development of pharmaceutical approaches to combat allergy and asthma in patients. However, other strategies can be employed both to limit the consequences of disease and to prevent recurrence: screening, early intervention, education, reduction of exposure to the allergen and adjuvants (eg smoking, pollution), rehabilitation etc. Primary prevention: preventing or minimising the development of allergy or asthma by identifying individuals at risk or risk occupations/situations, and by developing prevention strategies, is even more desirable. Such efforts aimed at primary or secondary prevention must be properly evaluated. Several prevention strategies have recently been tested, such as Lactobacilli intake, occupational health activities, or various allergen exposure reduction measures. To study where, in which situations and to what levels subjects are exposed to allergens, and to evaluate the effectiveness of exposure reduction strategies, it is necessary to measure the allergens. A number of methods to sample and assess

Biomed/overview 14

allergen exposure have been developed over the last decade, making it both possible and necessary to choose between methods. Some studies aimed at primary or secondary prevention will be presented.

Section IV Microbiology - Virology

Aims of this section: to provide an overview of virus structures and genome types to review the main steps of the virus cycle to provide an overview of the main strategies of RNA and DNA virus replication and to explain the concept of viral latency to review the principal mechanisms of viral pathogenesis to discuss why and how viruses interfere with the cell cycle to review viral strategies to prevent apoptosis to describe viral functions affecting host immune responses to discuss the origin of new viruses to review the factors contributing to the emergence of new viral diseases and the national and international programs for monitoring disease outbreaks to illustrate the principles and strategies for development of new antiviral drugs

Section IV Microbiology- Epidemiology

Aims of this section to provide an overview of the epidemiology of infectious diseases to review the impact of infectious diseases to review the transmission routes to review the principal types of surveillance Mon 23/9 9.30 11.00 (Karl Ekdahl) Epidemiology of Infectious Diseases

Objectives: by the end of this lecture you should be able to: define the most important concepts used in infectious disease epidemiology describe the different variables needed to understand the transmission of diseases give examples of factors influencing the emergence of new infections Lecture Synopsis: The impact of acute infectious diseases on mortality patterns in Sweden has changed dramatically during the last 100 years: from a situation similar to the one we find in developing countries today to one where the role f infectious diseases seems negligible. A number of factors have contributed to this - many of them outside the medical sphere. However, most of the deadly diseases remain under control only through a never-ending work in many sectors of society to keep them at bay. One of the important components in the combat against infectious diseases has been the establishment of routine
Biomed/overview 15

surveillance systems. The basic Swedish surveillance system will be described as well as the possibilities for intervention it supplies. There are a number of terms that need to be grasped in order to understand infectious disease epidemiology: attack rate, asymptomatic infection, immunity, secondary case, latency period, incubation time, etc. These will be covered. The propensity of a disease to spread in a population depends not only on biological characteristics of the pathogen and the host, but also on contact patterns in society. Models will be discussed for how these factors co-operate. Against this background, it will be underlined that infectious diseases keep evolving and emerging, and that there is every reason to believe that this will never stop. Tue 24/9 9.00-10.00 (Anders Bergqvist) Virus structure and classification

Objectives: Part I - by the end of this lecture you should be able to: define a virus describe the basic components of a virus list the different types of viral genomes giving examples for each type describe the basic principles of virion assembly and architecture name the main criteria for classification of viruses Lecture Synopsis: A virus is a subcellular organism with a parasitic intracellular life cycle that, unlike cells, contains either DNA or RNA and multiply by assembly of preformed components rather than division. A virus particle (virion) consist of a nucleic acid genome surrounded by a proteinaceous shell (capsid). In some viruses this core structure is covered by a lipid membrane of cellular origin (envelope). Viruses may be subdivided by genome type into: 1. double stranded (ds) DNA genomes, typically large viruses; 2. single stranded (ss) DNA genomes, typically small viruses; 3. ds RNA genomes that consist of between 2 and 12 different molecules of RNA (segmented genomes); 4. ssRNA genomes of positive sense and 5. SsRNA genomes of negative sense genomes; 6. Viruses with RNA genomes that use a DNA (retroviruses); 7. viruses with DNA genomes that used a RNA intermediate (hepadnaviruses). Virions are assembled to protect the nucleic acids from physical chemical or enzymatic damage. The outer surface is also responsible for recognition and interaction with the host cells. The capsid is made up of multiple protein subunits that are held together by hydrophobic and electrostatic interactions resulting in energetically stable ordered structures with helical or icosahedral symmetry. Helical capsids are formed by basic nuclocapsid proteins (N) regularly spaced around the nucleic acid. All animal viruses with helical symmetries are enveloped with single stranded, negative sense RNA genomes. Icosahedral capsids are composed of triangular faces arranged around the surface of a sphere. Each face is built by three subunits (protomers). The five subunits around each vertex form the capsomers. Complex capsids use scaffolding proteins as a mold for assembly. Very large viruses like poxviruses have a more complex structure. The classification of viruses into families and genera is bases on structural properties such as size, nucleocapsid symmetry, and presence of an envelope membrane and type of genome. Other classifications are based on epidemiological and clinical criteria. Sequencing of viral genomes has revealed phylogenetic relationships between viruses based on genome
Biomed/overview 16

organisation and gene arrangement. Many viruses have gained functional genes from their hosts. Objectives: Part II - By the end of this lecture you should be able to: define the concept of cell tropism describe the different phases of the virus cycle give examples of viral receptors list different modes of virus entry and uncoating describe how viruses inhibit cellular protein synthesis describe the general strategies of viral replication describe the basic principles of virus maturation and exit explain the main differences between productive/lytic, persistent, transforming and latent infection. Lecture Synopsis: Animal cells show restricted susceptibility to virus infection. In resistant cells the infection is blocked due to lack of surface receptors or specific factors required for viral replication. The replication of viruses in susceptible cells can be divided into eight stages: attachment, penetration, uncoating, gene expression and genome replication, assembly, maturation and exit. Many examples of surface proteins, carbohydrate residues on glycoproteins or glycolipids that serves as virus receptors are know. Penetration of the virus is an energy-dependent process that may occur via: 1. translocation of the entire virus particle across the cytoplasmic membrane; 2. endocytosis into intracellular vacuoles; 3. fusion of the virus envelope with the cell membrane. The product and intracellular site of uncoating depends on the structure of the virus nuleocapsid. The nature of the viral genome determines the strategy of replication. Shut off cellular protein synthesis is achieved: i. a cleavage of a 200 kD cap-binding protein, ii. elongation block of the initiation complex, iii. blocks transcription initiation. The site of virus assembly depends on the site of replication and on the mechanism of release. The maturation of naked viruses involves assembly of the empty procapsid, its association with the nucleic acid and further processing of the capsid proteins to prevent exit of the viral genome. The virus envelope is formed by budding of cellular membranes (plasma membrane, ER or Golgi). Envelope proteins displace host proteins. Matrix proteins connect the cytoplasmic side of the nucleocapsid with the cytoplasmic domain of the envelope protein and direct virion assembly. The rapid release of large numbers of mature non enveloped virus particles causes cell lysis. Naked DNA viruses that mature in the nucleus tend to accumulate and are released when the cell undergo autolysis. Budding from the cell surface or in cytoplasmic vesicles is compatible with cell survival. The outcome of infection depends on the virus and on the type of infected cells. Infection of permissive cells results in high levels of virus production followed by cell lysis. In less permissive cells virus production may persist at low levels without causing cell death. In transformed cells the infection is abortive, only few viral genes are expressed and their products induce cell growth. The viral genome is not expressed or only very few viral products are expressed in latently infected cells.

Biomed/overview 17

Tue 24/9 Wed 25/9

10.15-11.15 (Anders Bergqvist) 10.15-11.00 (Anders Bergqvist) Viral replication strategies I & II

Objectives: Part I - By the end of this section you should be able to: Understand the main differences between RNA and DNA viruses List two problems with animal cells that an RNA virus has to solve List two differences between +RNA viruses and the other RNA viruses (- and ds) List three basic strategies that RNA viruses use to produce their proteins. Name two RNA viruses, which produce more structural proteins than ns proteins, and one that does not. Illustrate how this is done. Lecture Synopsis: RNA is much more mutable than DNA. It follows that RNA viruses tend to be smaller and more compact than DNA viruses (smaller target size for mutation). Most RNA viruses do not require the nucleus of the cell, and no RNA viruses (except retroviruses) integrate into the genome of the host; RNA viruses can cause acute or persistent infections, but are never latent. Animal cells only have a DNA dependent RNA polymerase function; RNA viruses must carry their own polymerase (RDRP). Animal cells also use monocystronic messages. The RNA virus must find a way to produce individual proteins from their genome. They can do this by using subgenomic messages, polyprotein processing, or segmentation of the genome. RNA viruses produce either a single or multiple subgenomic messages, or nested set transcripts. Some RNA viruses have devised strategies for producing more of the structural proteins than non-structural proteins. In general +RNA viruses begin the infectious cycle with translation, while - and ds RNA viruses begin with transcription. Naked +RNA virus genome is often infectious. The lecture will cover in more detail the replication strategy of poliovirus, rabdovirus, influenza virus, and rotavirus. Objectives: Part II - By the end of this section you should be able to: explain the molecular basis of permissive and non-permissive infection define the various steps of temporally organised transcription (immediate early, early, late) describe different strategies of DNA virus replication Lecture Synopsis: Not all virus infections result in virus replication and production of progeny virus. Progression of the virus cycle may be limited by lack of specific cellular factors that are not expressed in the particular cell type or are expressed in a differentiation-dependent fashion (Papillomavirus). Transcriptions of viral genes occurs in the nucleous of the infected cells, except in Poxviruses that encode their own RNA polymerase, and is temporally organised. Only a fraction of the genome is transcribed into early genes that are required for initiation the synthesis of viral DNA. Late genes encode for structural components of the virus. Complex viruses have immediate early genes, which are expressed in the presence of inhibitors of protein synthesis. and delayed early genes (Herpesviruses). Regulation is carried out by proteins present in the virion or specified by viral or cellular genes, interacting with regulatory sequences in the 5end of the genes. Adenovirus, Herpesvirus, Papovavirus, Parvovirus, Poxvirus and Hepatitis B virus use different strategies for viral DNA replication. These strategies depend on the type of viral genome (linear,
Biomed/overview 18

circular, single stranded, double stranded, partially double stranded) and on the amount of genetic information carried by the virus (parvovirus, poxvirus). Objectives: Part III - By the end of this section you should be able to: define the concept of latency and give examples of DNA viruses that establish latency explain how latency may be established explain why viruses that establish latency can cause disease long after primary infection Lecture Synopsis: Certain viruses can persist in the host organism by latent infection in which no infectious virus is produced. Latent DNA viruses hide in specific cell types where they express very few or no viral products (neuronal cells, hematopoyetic stem cells, and lymphoid cells). Different forms of latent Epstein-Barr virus infection are discussed to illustrate the molecular events involved (downregulation of viral promoters, use of alternative promoters). Latently infected cells that still express viral proteins must evade recognition by the host immune system. Latency may occur at immunologically privileged sites (nervous system, non immunogenic cells). Certain viral proteins are protected from recognition (EBNA1). Various types of stimuli (UV light, hormonal changes etc.) induce the reactivation of latent viral infections by largely unknown mechanisms. Reactivation that occurs in immunocompetent hosts is usually limited and may be asymptomatic. Massive reactivation may occur in immunosuppressed patients with consequent reappearance of clinical symptoms. Wed 25/9 11.15-12.30 (Anneka Ehrnst) Viral pathogenesis

Objectives: - By the end of this lecture you should be able to: list the possible routes of virus entry and give examples of viruses using these routes describe different routes of virus spread explain various mechanisms of viral pathogenesis (cytopathic effect, cell damage associated with chronic inflammation, transformation) Lecture Synopsis: Viral pathogenesis is an abnormal situation of no value to the virus. The first factor that influences the course of infection is the mechanisms and site of entry into the body. Few viruses enter through the skin (herpes simplex, papilloma viruses) and this probably still requires some form of disruption. The mucosal membranes of the eye and genitourinary tract are more favourable route of access, thus many viruses are sexually transmitted. Transmission through the alimentary channel requires survival through the stomach, many of these viruses are naked. Transmission through the respiratory tract occurs via aerosol or exchange of saliva. Some viruses use insect or arthropod vectors to avoid environmental stress. Following primary replication at the site of infection the virus may spread through the infected host. This occurs via cell-cell contact (localised infections Papillomavirus, Rhinovirus, Rotavirus), via the blood stream (as free virus or in association with red cells, platelets, lymphocytes or monocytes) or via the nervous system. After entry via the synaptic junctions the virus spread by axonal transport. Some viruses use different
Biomed/overview 19

pathways of spread at different stages of the infections (Varicella zoster). Virus infection causes phenotypic changes in the infected cells including: altered shape, membrane permeability, detachment from the substrate, membrane fusion, inclusion bodies, lysis, apoptosis. Cell lysis causes inflammation that may result in additional damage of the infected tissue (Hepatitis viruses). Immune responses to viral antigens may favour virus infection (Dengue) or initiate autoimmune responses (Measles, CMV, Coxackie). Cell transformation is a risk factor for tumor development. Innate and adaptive immunity contribute to the control of virus infections. Cell mediate responses play a predominant role in the control of most virus infections. Innate immune responses involve cytokines (interferon) natural killer cells (NK) and complement responses. Adaptive cellular immune responses are directed to viral antigens expressed in infected cells by cells and result in cell lysis and production of regulatory or antiviral cytokines (CTL and TH cells). Neutralising antibody directed to surface structures prevent infection or target the virus to other elements of the immune system (phagocytosis, ADCC, complement system). Antibodies directed to viral antigens may serve as markers of disease progression. Fri 27/9 08.30-10.00 (Elisabeth Aurelius, Annika Linde) Herpes viruses: classification and principles of diagnosis

Objectives: by the end of this lecture you should be able to: name and describe the eight human herpes-viruses describe the transmission, sites for primary infection and latency of the human herpes-viruses describe the clinical outcome of primary and reactivated infection in previously healthy and in immune-compromised hosts name some principles for diagnosis and treatment Lecture synopsis: The herpes-viruses are large enveloped DNA viruses, characterised by their ability to establish latency, with more or less frequent reactivations. These reactivations are often asymptomatic, and an efficient means for viral spread. All human herpes-viruses apart from VZV are spread by close contact. The herpes-viruses are divided into three subfamilies, a, b and g herpes-viruses. The division is based on biological properties and genomic organisation. So far eight herpes-viruses with humans as their main host have been identified: Herpes simplex type 1 (HSV1); Herpes simplex type 2 (HSV2); Varicella-zoster virus (VZV); Epstein-Barr virus (EBV); Cytomegalovirus (CMV); Human herpesvirus-6 (HHV-6); Human herpesvirus-7 (HHV-7); Human herpesvirus-8 (HHV-8). HSV1, 2 and VZV belong to the -herpesvirus group. They primarily infect the skin and mucous membranes, and establish latency in the sensory neural ganglia. More than 70% of the adult Swedish population have antibodies against HSV as a sign of infection. Primary infection with HSV1 and 2 may be asymptomatic or cause painful blisters in the skin and mucous membranes. HSV1 is mainly associated with labial and HSV2 with genital lesions. Twenty-30% of infected persons will experience recurrent blisters. Infection of the nervous system may occur in primary as well as in reactivated infections. HSV1 then preferably causes encephalitis and HSV2 meningitis. In newborn and other immunecompromised hosts HSV may cause life-threatening, disseminated disease. VZV is spread airborne and is one of the most contagious viruses existing today. At 30 years
Biomed/overview 20

of age practically everyone in Sweden has experienced primary VZV infection. The primary infection causes chickenpox with fever and generalised blisters. The severity of the symptoms varies. Neonates infected by their mothers in utero and immunecompromised patients frequently contract severe disease. When the cellular immune control of the latent virus diminishes, with age or with immune-suppression for other reasons reactivation may occur. This results in localised, painful blisters; herpes zoster. Demonstration of virus in lesions by virus isolation, antigen detection or PCR is the most efficient means for diagnosis, but serology may also be used. CMV, human herpesvirus-6 and -7 (HHV-6 and HHV-7) belong to the -herpesviruses. They primarily infect lymphoid tissue, but may infect a variety of cells throughout the body. Latency is probably established in monocytes. Primary infection with CMV in early childhood is mainly transferred via breast-milk, and does normally not cause any symptoms. A second wave of infections occurs with the onset of sexual activity, and also these infections are often asymptomatic, but fever and inflammation of lymphoid glands and liver may occur. CMV infects 0.5% of foetuses in Sweden, and is the main viral cause of congenital defects, mainly hearing loss and various CNS defects. CMV is also a main infectious complication in immune-compromised patients. HHV-6 and HHV-7 infect via saliva, and almost everyone is infected by three years of age. HHV6 infection causes exanthema subitum, characterised by three days of high fever followed by a rash. Neurological complications are sometimes seen. Also HHV-7 may cause exanthema subitum, but the clinical importance of this virus is otherwise still unclear. Diagnosis is made mainly by serology and PCR. The human -herpesviruses are Epstein-Barr virus (EBV) and human herpesvirus-8 (HHV-8). EBV replicates in epithelial cells, and has its latency in B-lymphocytes. HHV-8 has been identified in B-cells, but whether this is the site of latency is not known. EBV infects via saliva and sexually, and >95% of the population is infected at the age of 30. The clinical outcome of primary EBV infection becomes more severe with increasing age. EBV is the main cause of mononucleosis; long standing fever, tonsillitis and inflammation of other lymph glands as well the liver. EBV is involved in the development of lymphatic and nasopharyngeal carcinomas. Diagnosis of primary EBV infection is made serologically, In atypical cases PCR may be useful. HHV-8 was recently detected and is associated with a skin cancer of mainly AIDS patients, Kaposis sarcoma. It is spread sexually in Western countries, but reports concerning seroprevalence vary considerably, and the true rate of infection is unknown. Diagnosis is made by serology and PCR on blood cells or tumour material. There are antiviral drugs effective against all herpesviruses. They target either the virus specific thymidine kinase and/or the DNA. The effect of treatment varies, and it is most successful against the a-herpesviruses. Fri 27/9 10.30-12.30 (Marie Henriksson) Subversion of cellular functions: cell cycle and apoptosis

Objectives: - by the end of this lecture students should: know the major effector mechanisms of antiviral adoptive immunity understand the relationship between the life-stile of the virus and the effective mechanisms of antiviral immune response understand the difference between immune responses to persistent and nonpersistent viruses
Biomed/overview 21

 understand that the mechanisms used for viral immune subversion are determined by the life-stile of the virus give examples of different mechanisms used by viruses to suppress or subvert the immune system Lecture synopsis: Short overview of major effector mechanisms used by the immune system to combat viral infections. Effects of the immune response on the pathogenesis of viral infection and spread of the virus will be illustrated by describing various ways of virus-host interaction: influenza, EBV and HIV. Persistent and non-persistent viruses. Viral latency as a major mechanism of immune escape of persistent viruses. Role of the immune system in controlling viral reactivation. Viral interference with antibody responses. Antigenic drift and antigenic shift. Proteins interfering with complement activation. Cytotoxic T-cell responses. The pathway of MHC class I restricted antigen presentation: short overview. Viral proteins interfering with the pathway. Discussion in the context of the viral life-cycle. Effects of mutations in CTL peptide epitopes MHC class I presentation and T-cell recognition. Viral interference with lymphokine networks: example of pox viruses. Blocking apoptotic pathways in infected cells: importance in the context of immune recognition. Mon 30/9 08.30-10.00 (Maria Rotzen-stlund) Respiratory viruses: classification and principles of diagnosis 10.30-12.00 (Victor Levitsky) Viral subversion of cellular functions: modulation of immune responses

Mon 30/9

Objectives: By the end of this section you should be able to: explain why viruses interfere with the cell cycle and apoptosis describe the G1-S transition of the cell cycle briefly and name the key regulators give examples on how DNA viruses interfere with the cell cycle machinery describe the mechanism of apoptosis schematically give examples of viral strategies for interference with apoptosis discuss why studying viruses have helped understanding normal cellular functions Lecture synopsis: After infection of a host cell the sole purpose of the DNA virus is to ensure replication and spread of its genome. In order to do this the virus needs to activate the cellular cell cycle machinery. The host have evolved two different mechanisms to control viral infections, one is the immune response and the other is
Biomed/overview 22

induction of apoptosis. DNA tumour viruses have virus specific proteins, i.e. there are no cellular homologues, that activate the host cell replication. The strategy used is to attack, bind to and thereby inhibiting the function of the key players in cell cycle regulation, pRb and p53. The binding of viral proteins to Rb releases the transcription factor E2F from Rb which than can activate S-phase genes. Binding of viral proteins to p53 has a dual effect, no G1 arrest and no induction of apoptosis. Different forms of apoptosis can be distinguished, e.g. Fas induced apoptosis. The mechanism is the following: the death stimuli, Fas ligand (FasL), binds to the Fas receptor (FasR) leading to a trimerisation of receptors. Adaptor proteins (FADDs) then bind to the cytoplasmic part of the R, the so called the death domain (DD). The adaptor in turn recruits and binds FLICE (caspase8) which results in self activation of the protease domain. Caspases are cystein proteases that need to be cleaved in order to be active. The active FLICE then cleaves another pro-protease and starts a chain reaction leading to apoptosis of the cell. Damage of mitochondria is a central co-ordination factor in apoptosis. The Bcl-2 family of proteins are located in the mitochondria. There is a balance of activating and inhibiting proteins where the Bcl-2 is the prototype for the inhibition and Bax for the induction of apoptosis, respectively. The exact mechanism for Bcl-2 function is not known. Viruses have established strategies to interfere with almost all stages of apoptosis. Mon 30/9 13.00 14.00 (ke Lundqvist) Emerging viruses

Objectives: By the end of this lecture you should be able to: Understand the concept emerging viruses, and what the main viral threats are at present Understand the influence of the modern life-style on entry and spread of new viruses into the human population. Understand the concept species specificity, and its limiting effect on viral spread Briefly describe some methods by which unknown viruses have been identified Briefly describe some surveillance programmes Briefly describe existing means for prevention of spread Lecture Synopsis: The term emerging viruses is used to describe viruses that represent a new epidemiological threat to humans. It may refer to the causative agents of diseases that have not previously been described in humans, as HIV in the beginning of the 80-ies, old viruses that spread in new regions, like dengue fever in the 90-ies, or old viruses that have changed immunogenicity and pathogenicity, like influenza has done a few times during this century. In a wider sense it can also include viruses which are detected by chance, until the role and pathogenicity of the agent is defined. An example of this is human herpesvirus- 6, detected in the 80-ies and initially thought to be a rare infection but later verified to be the cause of a common childhood disease. The appearance of a completely new virus is probably an extremely rare event. Re-assortment of duck and human influenza virus genes in pigs, giving rise to new influenza variants is probably the closest we will come to a new virus in our times. In most instances an emerging virus is an animal virus that has for some reasons managed to infect the human host. Many of these viruses are monkey viruses, mainly emerging in the African continent, such as Ebola and HIV. There are,
Biomed/overview 23

however examples of other natural hosts such as sin nombre virus spread from the deer mouse in the US, pneumonia in Australia caused by a morbilli-virus in horses and a chicken influenza infecting humans in Hong-Kong. Fortunately, these emerging viruses seldom get truly adapted to the human host. HIV is a remarkable exception. The fact that it probably has emerged from monkeys, genetically closely related to humans, and that it only kills its infected host after many years from primary infection may explain its success. In old ages poor hygienic conditions, crowded living and lack of epidemiological and medical control measures may have facilitated the spread of some emerging viruses. In modern times the increased population, urbanisation, rapid global contacts, environmental destruction possibly affecting our immune systems and changes in natural habits may facilitate virus spread. The rapid spread of HIV is one example, the spread of Dengue to new regions in the world another. New viruses may be identified as a result of continuos surveillance of regions where threats are expected. The isolation and typing of the chicken flu in Hong-Kong is one example. The appearance of an unknown disease usually initiates the search for the agent. A variety of conventional and modern methods are used, including electron microscopy, virus isolation, genome detection and serology. Electron microscopy is the only method that can be used without any prior knowledge of the nature of the infectious agent. All other methods are more specific, and lots of various antigens, primers and cell cultures may have to be tried before the agent is identified. By restriction difference analysis (RDA) foreign genetic material can be deduced from the normal cellular background. This method was used to identify the probable agent causing Kaposis sarcoma (HHV-8), and may be developed to be used in other conditions suspected to be caused by unidentified agents. The identification of emerging viruses is primarily under national control. Centres such as Center for Disease Control (CDC) in the USA, Collindale in the UK and Swedish Institute for Infectious Disease Control are initiating investigations as soon as something unexpected is reported in their countries. CDC is also helping a lot internationally, and has teams that can travel anywhere for investigations on short notice. The EU is trying to build up improved facilities for Paneuropean epidemiological control. In the developing countries the national organisations often have very limited resources and WHO is working hard to strengthen the epidemiological surveillance in such countries. WHO also spreads information to all its collaborating centres as soon as something unexpected happens. Internet has become a source of information, for good and for bad, which often spreads information more effectively than WHO. One good source of information is Promed where mostly serious information on most emerging infections can be found. The first measure to prevent a serious viral threat is epidemiological control measures, such as isolation of an area where a potentially dangerous agent is detected. In modern societies this is a very difficult measure, since world-wide travel is part of our daily life and our societies and economies are therefore extremely vulnerable. Decision with major effects on society life must be taken by our political leaders, but few other means to protect large populations groups are available even today. Antiviral and preventive hyperimmune-globulins effective against various viruses exist only to a limited extent. They can possibly be given to special risk groups, but are at present not available in amounts sufficient to meet the needs of a large epidemic. The most effective measure against viral spread is vaccination, though this approach has failed so far for many viruses such as HIV and RSV. Live vaccines are today given against a variety of viruses. Such vaccines demand strict controls for safety, and will probably never be the first line vaccines against newly emerging viruses. Killed purified virus
Biomed/overview 24

preparations are still the most suitable first line vaccine. However, the rapid production of large amounts of virus is restricted to those viruses that can grow in eggs. Recombinant proteins could be another source of vaccine, but demands that the gene product giving protective immune response is identified, and often good adjuvants are necessary to elicit a sufficient immune response. Much hope is give today to DNA-vaccines. Viral genes inserted into plasmids and administered by various routes are taken up by cells. Proteins are produced and presented to the immune system in such a way that both cellular and humoral immune responses are elicited. There is still a long way to go concerning the efficacy and safety of these new methods, but they may represent our main future hope for the rapid production of an effective vaccine that may protect a whole population from a serious viral threat. Tue 1/10 08.30-10.00 (Olle Reichard/Madeleine von Sdow) Hepatitis viruses: - classification and principles of diagnosis

Objectives - by the end of this lecture you should be able to: describe the overall structure and classification of hepatitis A,B, and C viruses describe different diagnostic methods for hepatitis A, B, and C in general terms describe the clinical picture and the natural course of acute and chronic viral hepatitis discuss possible explanations for chronicity in hepatitis discuss treatment possibilities of chronic hepatitis Lecture synopsis: Hepatitis A, B, and C viruses (HAV, HBV, and HCV) all cause inflammation in the liver, but the viruses are not related virologically. HAV is a RNA virus within the picornavirus family, and is spread by the faecal-oral route. HAV cause acute infections, usually subclinical in children and clinical in adults, that always resolve. Thus, there is no carrier state. Acute and resolved infections are diagnosed by anti-IgM and anti-IgG antibodies, respectively. No antiviral treatment is available. A vaccine exist. HBV is a DNA virus within the hepadnavirus family and is spread by the parenteral route, mostly by blood. The acute infection resolves in approximately 95% of the cases, and thus becomes chronic in 5%. Chronicity is more common in new-borns and in immunocompromised persons. The chronic hepatis B carrier state is characterised by 3 phases; the immunotolerant- (highly replicative), immunoactive- (diminished viral replication) or low-replicative phases. Chronic carriers risk liver cirrhosis and hepatocellular carcinoma over time. HBV infections are diagnosed by serology (HBsAg and HBeAg with their corresponding antibodies, and anti-HBc) and by detection of HBV DNA by PCR or dot-blot methods. Antiviral treatment (alfa-interferons and nucleoside analogues) of chronic HBV infection is possible. A HBsAg based vaccine has been developed. HCV is a RNA virus within the flavi/pesti virus family. It is transmitted mainly by blood, and causes chronic infections in approximately 85% of the cases. The reason for the high chronicity rate is not fully known but depends at least in part to escape mutations within the hypervariable region of the virus. Approximately 20% of the chronic carriers will develop liver cirrhosis or hepatocellular carcinoma within 20-25 years. Treatment with a combination of Alfa-interferon and the nucleoside analogue ribavirin eradicate HCV in a proportion of patients, and approximately 50% of treated patients seem to be cured by the treatment. The reason why some patients respond to treatment, while
Biomed/overview 25

others do not, is not known. Probably both viral and host factors are important. No vaccine is available. Tue 1/10 13.00-14.00 (Monica Grandien) Prions

Objectives: - The biology of prions. - Mechanisms of spread of prions to and within the infected host - Prion diseases : transmissible spongiform encephalopathies (TSE) - Neurohistopathological correlates of prioninfections in man and animals - Genetics: mutation and polymorphism of the gene for normal prion protein Lecture synopsis: Definition of prions: small proteinaceous infectious particles that resist inactivation by procedures modifying nucleic acids and that contain an abnormal isoform of a cellular protein which is a major and necessary component ( S. B..Prusiner ). The presence of normal prion protein, its size and structure. Conformational change of isoform from normal (PrPcell) to the disease-causing (PrPsc or PrPres) prion protein. Prion strains and the possibilities to differentiate between them. The species barrier. The prion diseases or TSEs have the following characteristics: 1. they are progressive fatal brain diseases with long incubation periods 2. there is no detectable immune response 3. the brain shows a spongiform picture caused by neuronal vacuolisation and astocytic gliosis. Amyloid plaques occur in the brain in a varying degree. Prion diseases in humans: a. sporadic : Creutzfeldt - Jakob disease (CJD) b. inherited : familial CJD., Gerstmann-Strussler-Scheinkers syndrom, (GSS) fatal familial insomnia (FFI) c. transmitted : iatrogen CJD Kuru variant CJD ( v CJD) Prion diseases in animals: a. scrapie, in sheep and goats b. bovine spongiform encephalopathy ( BSE ) in cattle c. mink encephalopathy d. chronic wasting disease in mule deer and elk in USA. Wed 2/10 09.00-9.45 (Britta Wahren) Chemotherapy of viral infections

Targets for antiviral effects can be specific molecules or can be quite general. In the lecture you will learn about clinical useful antiviral drugs for retroviruses, herpes
Biomed/overview 26

viruses and influenza. The properties of antiviral compounds that affect distinct targets as well as the influence of dosing and ad routes will be described. Antiviral resistance and the phenomena of synergy and antagonism between antivirals are other important factors. The field develops rapidly due to new methodology for identifying molecules that cause inhibition of viral replication. Specific molecules consist of viral-specific enzymes such as polymerases, reverse transcriptases, proteases, and other enzymes that are unique for the virus type, for the virus family or for several viral families. They should be distinct enough for the host enzymes so that inhibitory molecules cause little or no damage to the host metabolism. Such molecules can be used as monotherapy or in combination with one another. By combination of compounds one can obtain synergistic effects, which benefit the host both by the effectiveness and by less side effects. Other important issues are bolus doses and repeated therapy. A danger in treatment is the induction or selection of resistant virus. The most common phenomenon with viral specific drugs is a selection among many replicating quasispecies. Toxic drugs that affect also host enzymes or host DNA/RNA can cause new mutations that form a drug resistant virus population. Resistant viral populations have begun to spread through patient patient contact or by transmission from mother to the newborn child. General antivirals affect host cell DNA or RNA as well as viral nucleotides and can be mutagenic. They induce or can constitute interferons, cytokines or chemokines and indirectly affect the immune system. Direct resistance is uncommon but may occur through escape mechanisms in effector molecules. Wed 2/10 10.00 - 10.45 (Britta Wahren) Antiviral vaccines

Objectives: by the end of this lecture you should have understood the following concepts Passive/active vaccination. Live/attenuated vaccines. Adjuvants. Side effects. Vaccination of children. Vaccination of adults/travel vaccinations.

Section IV Microbiology - Bacteriology

Aims of this section to define the general, outermost host anatomical and physical defence barriers to define the role of these barriers in preventing infections to describe innate defence mechanisms, phagocytic cells, the complement system and antibacterial peptides
Biomed/overview 27

to describe how bacteria may overcome the effects of host defences to provide an overview of adhesion mechanisms to understand the cross-talk between bacteria and host cells upon adherence to review bacterial invasion of epithelial cells and uptake of phagocytic cells to define the global and domestic impact of bacterial gastrointestinal infections to define routes and sources of these infections to define the infection pathogenesis of a toxigenic gastrointestinal infection to define the infection pathogenesis of an invasive gastrointestinal infection 09.00-10.00 & 10.00-11.00 (Staffan Arvidson) Bacteria-host interaction

Thu 3/10

Objectives: Part I - by the end of this lecture you should be able to: list the components of our innate defence list different antimicrobial strategies and effectors understand the how these substances may act and function describe the initial phases of an inflammatory response

Lecture synopsis: The anatomical linings of our bodies consists of the skin and, for example in the nasopharynx, lungs and gastrointestinal tract, mucosal surfaces. The skin is protective much due to its rigid structure and antibacterial substances. The mucosal surface is thin as thus apparently more vulnerable. To be protective, mucosal membranes are equipped with additional defence systems. These include a persistent arrangement of flow out from the host, e.g. through peristalsis and the action of ciliated cells. The secretions covering mucous membranes are themselves antimicrobial (due to lysozyme, secretory IgA, low pH, bile acids, antibacterial peptides, lactoferrin) and prevents colonisation (due to adhesion receptor analogues). A pathogen successful enough to penetrate the mucosal barrier will have to face innate defence mechanisms operating in the parenteral space or in conjunction with epithelial linings. These include the action of the complement system, phagocytic cells (macrophages), and initiation of inflammation and neutrofil infiltration. Objectives: Part II - by the end of this lecture you should be able to: understand what strategies bacteria use to overcome host defence barriers name virulence factors of bacteria name some important bacterial pathogens, and link them to a particular disease Lecture synopsis: Interference with mucous membrane function may be achieved by intoxication of ciliated cells (Bordetella pertussis). Peristalsis can be coped with through strong bacterial motility, enabling penetration of the mucin layer, and through subsequent adhesion to mucosal cells (Vibrio cholerae). Bacteria may adapt to low pH through so called acid tolerance responses (Shigella sp., Salmonella sp.). Penetration of the epithelial cells can be achieved through expression of bacterial invasion functions enabling bacteria to enter the parenteral space (Listeria monocytogenes, Salmonella sp., Yersinia sp.). In the parenteral space, expression of particular surface antigens may prevent complement activation (Streptococcus pyogenes M proteins)
Biomed/overview 28

which may interfere with normal complement regulation. Special bacterial toxins or effector molecules interfere with macrophage functions preventing phagocytosis (Yersinia pseudotuberculosis) or enabling bacterial growth within macrophages. Fri 4/10 09.00-10.45 (Roland Mllby) Bacterial microecology

Objectives: By the end of this lecture you will understand the origin of life, the evolutionary relations between all life on earth, including bacteria and man as well as the complexity of the human microecology in relation to health and disease. The message is that bacteria were here first and that every other living creature has to adapt to this fact. Content Following areas will be covered: The origin of life, the development of an oxygenated atmosphere, the development of multicellular organisms up to man. The relations between micro-organisms and life in general. The relations between micro-organisms and host organisms, including symbiosis, commensalism and parasitism. The composition and complex ecology of microbial populations, specially the normal flora of man. How to measure this flora, its development and composition during a human life. Relations between the intestinal flora and the development of the intestinal functions Positive and negative effects of the normal flora in health and in disease. Examples of diseases related to the microecology of the normal flora. Examples of pre- and probiotic drugs and effects thereof. Questions How can the normal flora be disturbed ? Restored ? Do you know anyone that regularly uses probiotics ? Positive effects ? Is it true that a good defecation is the best sleeping pillow* ?
*Elvira Krank in Krlek och lavemang, 2001

Fri 4/10 Mon 7/10

11.00-11.45 (Staffan Arvidson) 13.00-14.45 (Staffan Arvidson) Antibiotics and antibiotic resistance

When we have an infection, antibiotic treatment may be needed to supplement the bodys natural defences. This was not possible before the 1940ies when the antibiotic era started. Antibiotics have saved many lives but in the past decades an increasing number of bacteria have become resistant to one or several antibiotics. This is a

Biomed/overview 29

serious problem. Will the antibiotic era come to an end? This, and other questions will be discussed in this lecture After attending this lecture you should be able to: Describe the principles for antibiotic action Describe different mechanisms of antibiotic resistance Specify how bacteria become resistant to antibiotics. Suggest means to limit the development of antibiotic resistance Antibiotics are synthesized and secreted by both procaryotic and eucaryotic microorganisms, e.g., Streptomyces, Bacillus,Cephalosporium, and Penicillium . Todays antibiotics are manufactured as semi-synthetic or completely synthetic products. Most antibiotics have 4-6 membered hydrocarbon ring structures, sometimes with nitrogen and sulphur, in various arrangements and with various side chains. Examples: beta-lactams, tetracyclines, aminoglycosides, glycopeptides. The following definitions will be discussed: Antibiotic sensitivity and resistance. Bacteriostatic and bactericidal effect. Minimal inhibitory concentration (MIC). Minimal bactericidal activity (MBC). Antibacterial spectrum. The principles of antibiotic sensitivity testing will be described. Which are the cellular targets attacked by antibiotics? For obvious reasons antibiotics must attack essential structures and functions. The major targets for the antibiotics used today are: the cell wall biosynthesis, protein synthesis, and synthesis of nucleic acids. The mechanisms of action of some major antibiotics will be described. The emergence of antibiotic resistant super bugs such as multi-resistant Mycobacterium tuberculosis, vancomycin resistant pneumococci and staphylococci, and penicillin resistant pneumococci has prompted alarming headlines in both lay and scientific press. However, antibiotic resistance is not a new phenomenon. For example, penicillin resistant S. aureus developed soon after penicillin was introduced in the mid 1940s, and by the 1960s penicillin resistance had become the rule rather than the exception in hospital isolates of S.aureus. For a long time antibiotic discovery kept ahead of bacterial resistance and there was little concern about the problem that whenever antibiotics are used it means a selection of resistant clones. However, today antibiotic resistance has become a major medical and economical problem. Resistance can be due to enzymes that inactivate antibiotics, pumps that remove antibiotics from the bacteria, alterations of bacterial target molecules leading to decreased affinity for antibiotics, or a decreased uptake of antibiotics. Bacteria may acquire antibiotic resistance through spontaneous mutations that alters the target of the drug, or by the uptake of DNA coding for specific proteins that mediate resistance. Tue 8/10 13.00 14.45 (Ann-Beth Jonsson) Bacterial adhesion

Objectives: Part I - by the end of this lecture you should be able to: describe a pilus adhesin and a non-pilus adhesin give examples of bacterial receptors define the two-component system in bacteria
Biomed/overview 30

Lecture synopsis: A necessary step in successful colonisation and production of disease by bacterial pathogens is the ability to adhere to host cell surfaces. The bacterial adhesin binds to a specific target molecule - the receptor. Both cell surface molecules and/or extracellular matrix protein may act as receptors of bacterial adhesins. The adhesion-receptor interaction is specific. Adherence occurs in two steps: - Step 1: initial adherence to host cell surfaces. - Step 2: tight adherence to host cells, - this may lead to invasion. Adhesins: Pili (or fimbriae) extend from the bacterial surface in order to reach the host cell pilus receptor. There are different types of pili, for example type-1 pili, P-pili, type-IV pili. Non-pilus adhesins are usually involved in tight binding. The two component system in bacteria: - Sensor = transmembrane protein that responds to an extracellular signal. - Transducer = cytoplasmic protein that is activated by the sensor (by phosphorylation). The activated form of the transducer activates gene expression. Objectives: Part II - by the end of this lecture you should be able to: describe how the bacteria can manipulate the host cell describe the use of type III secretion systems in bacterial adherence describe molecular mechanisms for modulation of adherence and invasion Lecture synopsis: The contact between bacteria and host cells leads to a sophisticated cross-talk. Bacteria induce signal transduction pathways, stimulate production of inflammatory cytokines, and trigger changes of the host cell surface, etc. Invasion is a directed uptake of bacteria by nonphagocytic cells. The process involves rearrangements of the actin cytoskeleton. Inside the cell the bacteria are in a protected cellular niche to replicate and persist. Bacteria enter first in a membrane bound vacuole. After entry they may stay in the vacuole and prevent fusion with lysozomes or escape from the vacuole. Phagocytic cells: bacteria may survive in macrophages, or escape. - EPEC: Bundle forming pili mediate the initial attachment. Type III secretion machinery: insertion of its own receptor into the host cell. Cause pedestals = actin rearrangements. - Neisseria: Type-IV pili mediate the initial attachment. The pili induce signal transduction pathways in the host cell that lead to stable and tight adherence. Outer membrane proteins such as Opa mediate efficient invasion. Opa proteins bind to heparan sulphate proteoglucans or to CD66 molecules on epithelial and endothelial cells. - Uropathogenic E. coli: P pili mediate the initial attachment to target cells. The PapG adhesin binds to Gal1-4 )Gal. Pilus retraction is a possible mechanism of tight binding. Tue 8/10 Wed 9/10 15.00 15.45 (Staffan Arvidson) 13.00 13.45 (Staffan Arvidson) Bacterial toxins

Biomed/overview 31

Objectives: By the end of the lectures you should be able to list the various types of toxins and give examples of bacteria that produce them describe the molecular mechanism of action of representatives of each type of toxin explain the specific symptoms related to the toxins Lecture synopsis: Many bacteria secrete protein (exo)toxins which can kill or alter the function of specific host cells, tissues or organs, at the site of infection or far away from it. Depending on their biological effects exotoxins are divided in cytolysins (hemolysins), enterotoxins , neurotoxins, cytotoxins, superantigens and others. Cytolysins damage or kill cells by forming pores in the cell membrane, or by degrading membrane phospholipids. Depending on the kind of target cells, cytolysins may cause local tissue damages, specific organ failure, or protection of the bacteria from the immunsystem. Enterotoxins, neurotoxins and cytotoxins act inside target cells. They consist of two parts , or domains, one which is necessary for internalisation and an other which is toxic. The toxic part has enzymatic activity, which inactivates specific intracellular target proteins by ADP-ribosylation, glycosylation or proteolysis. Depending on which cells are attacked and which target protein is affected different effects are seen, such as increased synthesis of cAMP leading altered ion transport (diarrhoea), impaired release of neurotransmittors (tetanus or paralysis), inhibition of protein synthesis (cell death), or disruption of the cytoskeleton (immobilisation of cells and cell death). A number of bacterial toxins act as superantigens, which non-specifically activate large subsets of T-cells and induce cytokine production that may produce the signs septic shock. Examples of cytolysins: Alpha-toxin from Staphylococcus aureus, alpha-toxin from Clostridium perfringens and Escherichia coli hemolysin A. Enterotoxins: Cholera toxin and cholera-like toxins from enteric bacteria. Neurotoxins: Tetanus toxin and botulinus toxin. Cytotoxins: Diphtheria toxin, Clostridium dificille toxin A, shiga toxin , pertussis toxin. Superantigens: S. aureus TSST-1 and enterotoxins, Streptococcus pyogenes pyrogenic toxin. Wed 9/10 14.00 14.45 (Staffan Arvidson) Skin and soft tissue infections 15.00 15.45 (Staffan Arvidson) Sepsis

Wed 9/10

Objectives: by the end of this lecture you should be able to: Describe the major routes of invasion Define bacteremia, septicemia and septic shock Give examples of the most prominent bacterial pathogens causing systemic infection Describe the major bacterial components causing septic shock Describe the major host cells and effector molecules leading to septic shock

Biomed/overview 32

Lecture synopsis: Systemic bacterial infections are caused by bacteria entering the blood stream. The bacteria usually have their origin in a localised infection, eg in the gastrointestinal tract (gastroenteritis), the urinary tract (pyelonephritis), the respiratory tract (pneumonia, otitis media), skin (wounds, surgical instrumentation, catheters). Septicemia is defined as an infection in the blood (bacteremia) in association with more than one of following symptoms: temperature >38C or < 36C, tachycardia, tachypnea or hyperventilation, altered white blood cell count. Septicemia may be caused by a wide variety of pathogens, such as E. coli, Klebsiella, Proteus, Pseudomonas, Bacteroides, N. meningitides, Haemophilus influenzae, Staphylococcus aureus, coagulase negative staphylococci, Enterobacter, Streptococcus pneumoniae, Streptococcus pyogenses. Septicemia may lead to septic shock, which is a severe, life threatening condition, with symptoms including hypotension, perfusion abnormalities and unresponsiveness to fluid resuscitation. Septic shock is induced by various microbial components, such as cell wall constituents endotoxin/lipopolysaccharide (LPS) of Gram-negative bacteria (causing so called endotoxin shock), peptidoglycans and teichoic acids in Gram-positive bacteria) or exotoxins/superantigens (enterotoxin B in Staphylococcus aureus, causing Staphylococcal toxic shock syndrome, exotoxin A and/or B in Group A streptococcus, causing Streptococcal toxic shock syndrome). The clinical manifestations of septic shock are considered to be due to an imbalance in the cytokine network of pro-inflammatory cytokines (such as IL-1, TNF-alfa) and anti-inflammatory cytokines (such as IL-10). Thu 10/10 9.00 11.45 (Mikael Rhen) Invasion and intracellular survival. Gastrointestinal infections

Objectives: by the end of this lecture you should be able to: list the names of most important bacterial gastrointestinal pathogens to describe how a gastrointestinal pathogen can cause symptoms to define the infection pathogenesis of a noninvasive vs. invasive infection to describe the molecular function of some central bacterial virulence functions Lecture synopsis: It is estimated that gastrointestinal infections are directly or indirectly responsible for 3 to 5 million deaths yearly. Though most incidences occur in the third world, we register annually some 5500 cases each of Salmonella and Campylobacter infections of in Sweden, the real number presumably being much higher. Gastrointestinal infections are acquired through contaminated food, water or beverages. The infection dose varies depending on the pathogen in question. In all cases, the bacteria have to pass the acidic barrier of the stomach, and at some stage to reach the epithelial cell lining. Adhesion to epithelial cells, adsorptive cells or M-cells seem to be a general requirement, although the specific adhesins are not always known. In some cases, adhesion is accompanied by toxin production causing functional disturbances in the absorptive function of the intestine. A prime example is cholera (V.choleare), the infection pathogenesis of which is described. In contrast to V.cholerae, other bacteria tend to be invasive, penetrating the epithelial cell barrier. Shigella sp. provides an illustrative example in this context, and consequently the cellular and molecular events occurring during a shigella infections are described. Other examples of important gastrointestinal pathogens include Salmonella enterica, Campylobacter jejuni and various Escherichia coli strains.
Biomed/overview 33

Wed 10/10

13.00 14.45 (Birgitta Henriques-Normark Respiratory tract infections

Objectives: Part I - by the end of this lecture you should be able to: List bacteria most commonly found in respiratory tract infections Describe how a respiratory pathogen can cause symptoms Differentiate between upper and lower tract infections Describe the pathogenesis of pneumococcal infections Lecture synopsis: (Henriques) Major bacterial causes of upper respiratory tract infections (tonsillitis, sinusitis, otitis media) and lower respiratory tract infections (pneumonia) are S. pneumoniae, H. influenzae, and S. pyogenes. These pathogens colonise the respiratory tract in humans and cause acute respiratory infections which may be associated with a spread to the blood and the meninges, causing invasive disease. Previously encapsulated H. influenzae type b was the leading cause of bacterial meningitis in children, but since the widespread use of Hib conjugate vaccines the incidence of disease has declined remarkably in immunised populations. Immunisation appears to also reduce the nasopharyngeal carriage rate of the organism. Pneumococci and H. influenzae are found in high frequencies among healthy carriers, for example pneumococci can be found in high frequencies in the nasopharynx in up to 50% of pre-school children. S. pyogenes or group A streptococci are found in much lower frequencies in the upper respiratory tract and they cause pharyngitis and pneumonia, but also invasive, sometimes fatal disease. Other bacterial causes of respiratory infections include B. pertussis, M. cattarhalis, S. aureus, C. diphtheriae, L. pneumophila, K. pneumoniae and F. tularensis. Two examples of respiratory infections will be described in more detail, pneumococcal infections and tuberculosis. Pneumococci are an important cause of morbidity and mortality in developed and developing countries. A significant portion of healthy individuals carries pneumococci in the nasopharynx. An asymptomatic carrier state may persist for several weeks and in a few individuals the bacteria spread from the nasopharynx and gain access to the ear, lung and/or blood stream, causing otitis, pneumonia and meningitis. Pneumococci are the most common cause of otitis media in children and of community acquired pneumonia and meningitis in adults. Pneumococcal pathogenesis will be discussed with regard to factors supposed to be involved in adherence, invasion and virulence. The capsular polysaccharide of pneumococci is a major virulence factor, dividing pneumococci into 90 different serotypes. The chemical composition and the size of the capsule are major factors in determining virulence in pneumococci. Some serotypes, like type 3, are associated with high virulence and non-capsulated pneumococci with less virulence. The capsule protects pneumococci from phagocytosis by polymorphonuclear leukocytes and therefore contributes to the progression of the infection. The components of the cell wall, released when the bacteria lyse when exposed to antibiotics, contributes to host defence responses associated with acute inflammation. The host defence against pneumococcal infection is mainly dependent on the humoral immune response. Patients with immunodeficiencies, splecectomized individuals, and alcoholics are risk groups for acquiring pneumococcal infections. Prophylaxis today depends on a 23valent polysaccharide vaccine, not efficient enough in age groups most prone to get an infection, the infants and the elderly. Efforts are made to make a new conjugate
Biomed/overview 34

vaccine with a better efficacy. A threatening problem worldwide is also the increasing rate of antibiotic resistance, making these common infections even more difficult to treat. Resistant pneumococci do not elaborate -lactamases and the mechanism for resistance towards penicillin, which has been the drug of choice, is a decreased binding to altered penicillin binding penicillins (PBPs). Resistance to penicillin in more than 50% has been reported from different parts of the world. Objectives: Part II - by the end of this lecture you should be able to: Describe the time-course of tuberculosis (TB) Describe the major lesions caused by tubercle bacilli Describe the spectrum of disease caused by TB Describe the main mechanisms believed to be important in the protection against TB Lecture synopsis: (Pavlowski) Tuberculosis (TB) is a major cause of morbidity and mortality, with most cases occurring in developing countries. One third of the worlds population is infected with organisms of the Mycobacterium tuberculosis complex, with about ten million cases of active tuberculosis disease reported each year, leading to three million deaths annually. An increased morbidity and mortality in TB patients is associated with the ongoing HIV pandemic. TB usually presents itself as an infection of the lungs but it can affect virtually any organ system in the body. Mycobacterium tuberculosis is a facultative intracellular pathogen which has the ability to survive and multiply inside cells of the monocyte/macrophage cell lineage. Its cell envelope is composed of a plasma membrane, a complex wall consisting of a variety of covalently linked and non-covalently linked carbohydrates and lipids, and a capsule of polysaccharides and proteins. The mycobacterial cell wall and capsule contribute to the resistance to many therapeutic agents. TB is primarily spread by bacteria present in aerosols generated by coughing. Infection with TB triggers a broad spectrum of immune responses, which can contribute both to elimination of the pathogen, and to disease-associated pathology. The pathology is mainly an expression of a misdirected immune response evoked by the bacteria. The alveolar macrophages are normally the primary target of infection, and mycobacteria survive intracellularly by preventing phagolysosomal fusion. Macrophages also play an important role in the presentation of mycobacterial antigens to T cells. Mycobacteria are very effective in inducing responses by a variety of T cell subsets that are stimulated by presentation of antigens via MHC class I, class II or CD1 molecules. The cellular elements involve both CD4 and CD8 T lymphocytes as well as subsets of lymphocytes expressing T-cell receptor, double-negative CD1-restricted T cells and NK cells. Antigen recognition by CD4 T cells represents a key element in the immune response to mycobacteria. Protection against TB is believed to be due mainly to cellular immunity in which a type 1 T-cell-mediated immune response (characterised by the production of macrophage-activating cytokines such as IFN gamma) has been suggested to be the most important. Fri 11/10 13.00 14.30 ( ) Urinary tract infections. Sexually transmitted infections

Biomed/overview 35

Section IV Microbiology - Parasitology

Aims of this section: explain the concept of parasitism provide an overview of selected representatives from the major groups of parasites describe unusual molecular mechanisms discovered in these parasites and how the parasites interact with the host Mon 14/10 9.00-10.00 (Staffan Svrd) Introduction to parasitology and intestinal protozoa

Objectives: by the end of this lecture you should be able to: describe the major groups of organisms that are studied in parasitology explain and understand the terms symbiosis, commensalism, phoresis, parasitism, mutualism, vector, parasite life-cycles describe the effects of the most common parasites on the host describe ways used by parasites to evade the immune system describe different ways of entry into the host used by parasites Lecture synopsis: Many bacteria, fungi and all viruses can be called parasites but parasitology has been limited to parasitic protozoa (one celled eukaryotes), helminths (flatworms and roundworms) and arthropods (insects, ticks and mites). Any organism that spend a portion of its life intimately associated with another living organism of a different species is known as a symbiont and the relationship is designated as symbiosis. Four categories of symbiosis are commonly recognized: commensalism, phoresis, parasitism and mutualism. Commensialism does not involve physiologic interaction or dependency between two partners, they can survive independently but they share nutrients. In phoresis one organism is carried by another but the food is not shared. In parasitism the parasite is physiologically dependent on the host. Endoparasites live within the body and ectoparasites are attached to the outer surface. Parasites usually have complex life cycles and these can often explain the behaviour of the parasites. Arthropods that serve as a carrier for a parasite is called a vector. Infective animals that serve as sources of infective organisms are called reservoir hosts. A disease of humans that is caused by a pathogenic parasite normally found in wild or domestic animals is called zoonotic disease. In mutualism the host and the mutualist depend on each other physiologically. Parasitic diseases are usually known as tropical diseases and a variety of conditions contribute to the prevalence of parasitic diseases in the tropics, among them unsanitary living conditions, inadequate funding for disease control and treatment, poor nutrition, lack of health education, climatic conditions and compromised immune systems. Parasites trigger varying degrees of change within their hosts. Parasitic diseases are usually functions of parasite density. Three major types of histopathological cell damage occur in parasite-injured tissues: parenchymatous or albuminous degeneration, fatty degeneration and necrosis. Tissue changes of parasitic origin are of four major types: hyperplasia, hypertrophy, metaplasia and neoplasia. The most common modes of entry are by oral ingestion or penetration of the skin. Many parasites evade the immune system, some cover themself with host proteins and some have developed mechanisms for antigenic variation.
Biomed/overview 36

The agent of amoebiasis is Entamoeba histolytica. As its name indicates, it may cause lysis of host tissue, especially in the colon. The organism may also spread through the blood stream to produce abcesses in the liver, the brain and other organs. The clinical manifestations are bloody diarrhea (dysentery) or abcesses. Often infection by Entamoeba is asymptomatic which is due to infection by the non-pathogenic, morphologically identical variant E. dispar. E. histolytica is transmitted from person to person via the fecal-oral route. It has a simple life cycle, with two forms-the actively growing, uninucleate trophozoite and the dormant but highly resistant cyst. The trophozoite moves with pseudopodia. Cysts are formed in encystation in the lower part of the colon and cysts excyst in the upper part of the small intestine to start infection but the processes are poorly understood. Giardia lamblia is the agent of giardiasis. The clinical manifestation are watery diarrhea and malabsorption. Humans aquire giardiasis by ingesting the cyst form of the parasite. As in amebiasis, the parasite excysts and transforms to a trophozoite in the upper GI tract, where it replicates asexually by binary fission. Trophozoites cause disease by attaching to the epithelium of the small intestine via a ventral sucking disk. However, it is not clear what causes the disease. Giardia has two nuclei and 4 pairs of flagella. It is one of the earliest diverging eukaryotes known and it is lacking mitochondria. The metabolism is anaerobic and many enzymes are related to bacterial enzymes. The trophozoite is covered by a cysteine rich surface protein and antigenic variation has been detected. Mon 14/10 10.15 11.15 (Staffan Svrd) Blood and tissue protozoa

Objectives: By the end of this lecture you should be able to: describe the major characteristics of leishmania, trypanosoma and the plasmodium life cycle explain how plasmodium and trypanosome species evade the immune system describe protozoan flagella, kinetoplasts, apical complex and glycosomes Lecture synopsis: Leishmania are small protozoa that belong to the flagellates. There are several species of leishmania, each of which has different tissue tropism and clinical manifestations. The diseases they cause include localized skin ulcer, mucutaneous lesions, disseminated cutaneous leishmaniasis, and disseminated visceral leishmaniasis. The flagellum is a highly structured, filamentous organelle used to propel the parasite forward in liquid. In the cytoplasm the flagellum is anchored by a basal body and the basal body interacts with a DNA containing organelle called kinetoplast. The kinetoplast is related to mitochondria and RNA editing is used to change the coding capacity of typical mitochondrial mRNAs. Leishmania are transmitted by the bite of sandflies. After internalization by macrophages they differentiate into nonflagellated amastigotes. This form is better prepared to evade the immune system since it elicts little hydrogen peroxide production. The promastigote occurs only in the insect vector and it is more elongated with a longer flagella that is used for locomotion and attachment. Members of the genus trypanosoma that infect humans can be divided into two groups. The African varieties (Trypanosoma brucei) cause African sleeping sickness and the other variety (Trypanosoma cruzi) cause Chaga's disease. In African sleeping sickness the tsetse fly inoculates infectious trypomastigotes under the skin. In the blood the parasite replicates as a trypomastigote. The African trypanosomes do not have promastigote or
Biomed/overview 37

amastigote forms. Antigenic variation of variable surface glycoproteins is used to evade the immune system. Glycolysis occurs in a specialized organell called glycosomes. Circulating trypomastigotes are taken up by tsetse flies. In the fly the parasite develop into an epimastigote. The organisms that cause human malaria and toxoplasmosis belongto the phylum Apicomplexa. The apical complex is found in the merozoite and sporozoite forms. Malaria is one of the most prevalent and debilitating diseases afflicting humans. The main manifestations of malaria are fever, chills, and anemia. Four species of Plasmodium cause malaria in humans, P. vivax, P. malariae, P. falciparum and P. ovale. P. falciparum accounts for 80% of human malaria. The life cycle is complicated with two hosts: the female mosquito belonging to the genus Anopheles and the human host. A significant feature of the life cycle is alternation of sexual and asexual phases in the two hosts. One asexual phase (schizogony) occurs in the human. The sexual phase (gamogony) occurs in the mosquito as does a second asexual phase (sporogony). The infective form is the sporozoite and the parasite subsequently actively invade hepatocytes and develop into trophozoites. After 1-2 weeks the trophozoites divide several times to generate merozoites. Merozoites erupt from the hepatocytes and invade red blood cells. Inside the red blood cell the merozoite grows to the early trophozoite stage (ring stage). This early form develops into the mature trophozoite form and to new merozoites that invade red blood cells or develop into the sexual gametocyte stage. The sexual phase occurs in the mosquito and DNA recombination creates new variants of the parasite. Antibodies against plasmodial proteins on the surface of the infected red blood cell protect against severe malaria but it does not block infection. Antigenic variation of plasmodial erythrocyte membrane proteins (PfEMP1 and riffins) has been characterized. Tue 15/10 09.00-10.00 (Staffan Svrd) Helminths-worms

Objectives: By the end of this lecture you should be able to: describe the major characteristics of nematodes, trematodes and cestodes - describe the major characteristics of Wuchereria bancrofti, Echinococcus - granulos,and Schistosoma mansoni Lecture synopsis:The helminths or worms are multicellular animals. Many are able to carry out their life cycle within the human body, but others have complex life cycles that include insect vectors and animal reservoirs. Helminths falls into three major groups, roundworms (nematodes), tapeworms (Cestodes) and flukes (Trematodes), generally distinguished by their shape. The most important factors that determine the severity of helminthic infections are the number of worms and the immune state of the patient. Helminths cause disease by a variety of mechanisms, the main ones being mechanical tissue invasion, chronic inflammation, and nutritional effects. The type of clinical manifestation usually depends on the organ or tissue where the damage occurs. Tapeworms can cause intestinal infections. Diphyllobothrium latum is a broadfish tapeworm that parasitizes several larger mammals, including humans, throughout the world. Humans aquire the typical poork tapeworms (Taenia solium) by ingesting the tissue stage of the parasite (cysticercus) in adequately cooked meat. The parasite then hatches in the intestine and matures to an adult intestinal tapeworm that can be up to 10 meters in length. This tapeworm causes human cysticercosis. When human feces containing viable
Biomed/overview 38

eggs are ingested by pigs, the eggs hatch and produce the tissue stage of the infection to complete the cycle. The trematoda (Flukes) are dorsoventrally flattened animals commonly known as flatworms. The digestive tract, if present, is incomplete. The mouth serves both for ingestion and egestion. They parasitize a wide range of invertebrate and vertebrate hosts. Within human hosts, these worms are found in numerous organs, including the intestine. Trichinella spiralis, Enterobius vermicularis and Ascaris lumbricoides are well-known intestinal nematodes. Nematodes (roundworms) are generally elongate, cylindrical, and tapered at both ends. The basic body design is a tube within a tube, the other tube being the body wall and the underlying muscles and the inner tube being the digestive tract. Nematodes undergo four molts and larval stages are referred to as first-, second-, third-, and fourth-stage larvae. Symbiotic bacteria are important for differentiation of several nematodes. Tue 15/10 10.15 11.15 (Staffan Svrd) Diagnosis and summary

Objectives: By the end of this lecture you should be able to: describe the major ways of diagnosis of medically important parasitic infections Lecture synopsis: Diagnosis of parasitic infections are ususally done by direct identification of the parasite by microscopy of blood, faeces and tissue samples. Serology and PCR is also used to detect certain parasites.Toxoplasma can be detected by serology, PCR or histology by examination of Giemsa stainedbiopsy specimen or spinal fluid. Plasmodium and trypanosomes are detected in thick or thin blood smears after Giemsa staining. Serology is also used. Leishmania is diagnosed by serology or direct demonstration of the parasite in the bone marrow, liver, lymphnodes, spleen and scrapings from skin lesions. Intestinal parasites (Giardia, Entamoeba, Cryptosporidium, Microsporidium and Cyclospora) are diagnosed by identification of the parasites in faeces. Fresh samples are used to detect trophozoites and fixed samples are used to detect cysts. Concentration techniques are often used to enrich for the parasites. Serology is used to detect invasive forms of Entamoeba. Worm infections are usually detected by serology and/or detection of eggs in fixed faeces. Skin snips and biopsies are used to detect certain worms. Wed 16/10 9.00 9.45 (Ulf Bronner) Principles of therapy

Objectives: by the end of this lecture you should be able to: understand major general characteristics for successful therapy of parasitic diseases describe current drug therapies of blood/tissue protozoal infections including malaria, intestinal protozoal infections, intestinal worms and blood/tissue helminths describe the mechanism of action of drugs used for therapy of parasitic diseases

Biomed/overview 39

Lecture synopsis: Successful drug therapy of parasitic diseases rely on several important factors. Complex parasite life cycles must be understood and the way parasites are transmitted. Antiparasitic drugs are targeted against specific development stages of the parasites. The response to drug therapy is greatly influenced by the immune status of the human host. Severe immunological reactions can be elicited by the drug-induced parasite killing due to release of parasite antigens. The aim of antihelminthic drug therapy differs between high-endemic areas and areas where only imported cases are treated. Major drugs for therapy of malaria, intestinal roundworms, tapeworms, filarial infections, schistosomiasis, amoebiasis, African trypanosomiasis, Chagas disease and leishmaniasis will be presented as well as their mechanism of action. Wed 16/10 10.00 - 11.30 (Annelie Brauner/Ulf Bronner) Clinical parasitology

Synopsis of lecture: Authentic clinical cases of protozoal and helminthic infections will be presented. Important aspects on epidemiology, pathogenesis, clinical picture, drug therapy and disease prevention will be discussed. Lecture synopsis: Many bacteria, fungi and all viruses can be called parasites but parasitology has been limited to parasitic protozoa (one celled eukaryotes), helminths (flatworms and roundworms) and arthropods (insects, ticks and mites). Any organism that spend a portion of its life intimately associated with another living organism of a different species is known as a symbiont and the relationship is designated as symbiosis. Four categories of symbiosis are commonly recognized: commensalism, phoresis, parasitism and mutualism. Commensialism does not involve physiologic interaction or dependency between two partners, they can survive independently but they share nutrients. In phoresis one organism is carried by another but the food is not shared. In parasitism the parasite is physiologically dependent on the host. Endoparasites live within the body and ectoparasites are attached to the outer surface. Parasites usually have complex life cycles and these can often explain the behaviour of the parasites. Arthropods that serve as a carrier for a parasite is called a vector. Infective animals that serve as sources of infective organisms are called reservoir hosts. A disease of humans that is caused by a pathogenic parasite normally found in wild or domestic animals is called zoonotic disease. In mutualism the host and the mutualist depend on each other physiologically. Parasitic diseases are usually known as tropical diseases and a variety of conditions contribute to the prevalence of parasitic diseases in the tropics, among them unsanitary living conditions, inadequate funding for disease control and treatment, poor nutrition, lack of health education, climatic conditions and compromised immune systems. Parasites trigger varying degrees of change within their hosts. Parasitic diseases are usually functions of parasite density. Three major types of histopathological cell damage occur in parasite-injured tissues: parenchymatous or albuminous degeneration, fatty degeneration and necrosis. Tissue changes of parasitic origin are of four major types: hyperplasia, hypertrophy, metaplasia and neoplasia. The most common modes of entry are by oral ingestion or penetration of the skin. Many parasites evade the immune system, some cover

Biomed/overview 40

themselves with host proteins and some have developed mechanisms for antigenic variation.

Section V Theme Day "HIV and AIDS"

Mon 21/10 09.00-10.30 (Sven Britton) Clinical and therapeutic aspects of HIV infection

Lecture synopsis: HIV omfattas sedan 1987 av Smittskyddslagen. Det yttersta syftet med denna lagstiftning r att skydda samhllet frn vidare spridning av olika sjukdomar men reglerar ocks samhllets skyldigheter att tillhandahlla konfidentialitet och behandling. Lkaren r skyldig att - Anmla HIV - och AIDS-fall. - Ansvara fr att kontaktuppfljning sker. - Utfrda freskrifter fr att frhindra vidare smittspridning. - Anmla till Smittskyddslkare om givna freskrifter ej fljs. Patienten r skyldig att flja givna freskrifter vilka i sin standardform omfattar - Att upplysa sexualpartner om sin HIV-infektion. - Att vid sexuellt umgnge skydda sexualpartners genom t ex kondomanvndning. Att vid intravenst missbruk inte anvnda samma nlar och sprutor som andra personer. - Att inte ge blod eller donera organ. - Att uppge sig ha blodsmitta vid kontakt med tand- eller sjukvrd. - Att g p regelbundna lkarkontroller. Fr samtliga medborgare gller att man r skyldig att testa sig vid misstanke om HIVinfektion vilket framfr allt gller namngivna sexualpartners till HIV-infekterade. Sjukdomslra Hos ca 50% av de infekterade upptrder ca tv veckor efter smittotillfllet en akut primr HIV-infektion som kliniskt domineras av halsont med rodnade och svullna tonsiller, enantem med afteliknande sr i munnen. De flesta har ett makulst icke konfluerande exantem fr a p vre blen, halsen som frsvinner inom 5-7 dygn. S gott som alla har lymfkrtelsvullnad p hals och i axiller som debuterar under andra sjukdomsveckan. Samtliga dessa patienter har feber. Mnga har dessutom huvudvrk, muskelvrk och rethosta. Det r ocks vanligt med krkningar, illamende och diarreer. Sers meningit encefalit och gastrointesinala besvr kan frekomma. HIVtesten r initialt negativ men blir positiv 3-10 dagar efter insjuknandet. Virus kan pvisas med HIV-antigentester eller med kvantitativ HIV-RNA-test. Patienter som utvecklar denna sjukdomsbild har en smre klinisk prognos n om man inte gjort det. Med modern testmetodik berknas de flesta ha serokonverterat inom 6 veckor efter smittillfllet och alla inom tre mnader. HIV-sjukdomen gr sedan in i en kronisk, kliniskt tyst, fas. Virologiskt har dock virus frkat sig mycket snabbt under den akuta infektionen fr att sedan stabilisera sig p en niv som kommer att karaktrisera individen under mnga r. Denna niv r karaktristisk fr virusomsttningen och bestmmer den takt med vilken immunbristen utvecklas. En niv p ca 10 000 kopior per ml motsvarar mediantid p 8-10 r frn smitta till svr sjukdom och dd. Vid hgre virusmngd progredierar sjukdomen fortare. Immunologiskt motsvarar detta en
Biomed/overview 41

frlust mellan 3-5 T-hjlparlymfocyter x 106/l och mnad. Lttare komplikationer upptrder p niver under 350 celler medan risken fr svrare komplikationer (och drmed indikation fr profylax mot dessa) intrder vid ca 200 T-hjlparlymfocyter x 106/l. Mnga patienter har under denna period frstorade lymfkrtlar som i sig inte har ett prognostiskt vrde. Grnsen mellan lindrigare komplikationer och AIDSdefinierande tillstnd r flytande, och har allt mindre betydelse nr nu effektiv behandling finns att tillg. T ex spontanlker herpes simplex recidiv lngsammare vid svr immunbrist men svarar fortfarande bra p medicinering. Har recidivet varat mer n 4 veckor klassificeras det som AIDS, medan om behandling insatts och lkning skett tidigare det inte klassificeras som AIDS. P motsvarande stt kan avsaknad av adekvat vrd leda till att oral candida sprider sig till matstrupen och drmed blir AIDS-definierande. Tidiga symtom som skall leda tanken till att pbrja antiretroviral behandling r t ex upprepade bltrosattacker, besvrliga herpes simplex recediv, svrare luftvgsinfektioner, hrig leukoplaki p tungans kanter, torsk i munnen, besvrlig seborroisk dermatit eller allmnsymptom som det r svrt att f en etiologisk diagnos till ssom nattsvettningar, periodisk diarre, viktnedgng, perioder med feber eller uttalad trtthet. Diskussion om insttning av antiretroviral terapi pbrjas i allmnhet nr T-hjlparcellslymfocyttalen faller under 500, RNA-nivn ligger ver 10 000 eller symptom freligger. Med tanke p de stora besvr som patienten kan ha med lkemedelsfljsamhet r det dock av yttersta vikt att patienten r mogen att flja den komplicerade behandlingen och frstr de konsekvenser de kan leda till i vederbrandes liv. Det r sllan ngon brdska att inleda antiretroviral behandling. AIDS har mindre aktualitet idag men det r viktigt att knna till de viktigaste behandlingsbara sjukdomarna och de som ltt kan frebyggas. Lunginflammation orsakad av Pneumocystis carinii (PCP): PCP upptrder vanligen inte vid CD4-tal ver 200. De knnetecknas av ett lngsamt progredierande frlopp med lggradig feber, rethosta och tilltagande andfddhet vid ltt anstrngning. Lungrntgendiagnostik kan vara besvrlig under den tidiga fasen. Sjukdomen diagnostiseras genom pvisande av cystor i upphostningsprov vilket kan kompletteras med bronkoalveolrt lavage. Behandlingen r vid tidig upptckt enkel med trimetoprim-sulfa i hgdos eller pentamidin. Primrprofylax rekommenderas till alla patienter vars T-hjlparlymfocyttal gr under 200 x 106/l, vanligtvis med hgdos trimetroprim-sulfa 1 tabl 3 gnger i veckan. (Varje dag om patienten r serologiskt positiv fr toxoplasma). Cerebral toxoplasmos: Ungefr 20% av svenskar har serologiska tecken till att vara infekterade av toxoplasma. Vid CD4-vrden under 100 kan toxoplasman aktiveras i hjrnan vilket leder till en fokal tillvxt med olika typer av fokalneurologi beroende p var hrden finns. Detta r ofta kombinerat med feber, huvudvrk och mental pverkan. Diagnosen stlls i allmnhet via datortomografi men den kan vara svr att differentialdiagnosticera mot cerbrala lymfom. Ex juvantibus-terapi ges i dessa fall. Behandlingen sker med pyrimetamin, sulfadiasin och folinsyra och drefter livslng supressionsbehandling. Fr primrprofylax se ovan. Candida oesofagit: Svampinfektion i munnen r vanligt vid CD4-tal under 350. Korta kurer med antimykotika r ofta tillrckliga fr att hantera detta. Kronisk supressionsbehandling leder ofta till resistens varfr noggrann vervakning och intermittent behandling r att fredra fr att undvika infektioner i matstrupen. Cytomegalovirus (CMV)-infektion: CMV aktiveras framfr allt i retina men ven i CNS vid mycket lga CD4-tal under 50. CMV kan ven ge srbildningar i esofagus
Biomed/overview 42

och colon och hos svrt sjuka patienter angripa binjurarna. Behandlingen r intravens med foscavir eller gancyklovir i kurer med underhllsbehandling under remissionerna. Tuberkulos: Tuberkulos r i utvecklingslnderna en av de tidigaste AIDS-definierande tillstnden och kan drabba patienter med relativt bibehllet immunsvar. Det r dock ovanligt i vstvrlden utom hos intravensa missbrukare i t ex Sydeuropa. PPD r ofta negativ p.g.a. immunbristen. Behandlingen r konventionell TB-behandling som ofta sker med sk DOT-teknik, dvs given under vervakning fr att undvika behandlingssvikt och resistenutveckling. Infektion med atypiska mycobakterier: Denna mycobakterieinfektion ses sent i frloppet med CD4-tal under 50. Den knnetecknas av lngdragen feber, viktnedgng, diarr, rethosta och kan ha en diagnostisk lymfkrtelfrstoring. Diagnostiken sker vanligen genom att pvisa mycobakterier i odling frn blod eller benmrg. Behandlingen kan inte ske med vanliga tuberkulostatika pga resistens utan istllet ges vanligtvis etambutol, rifabutin och claritromycin +/- t ex amikasin. Behandlingen blir ofta livslng. Lymfom: Primra B-cellslymfom i hjrnan r vanligast men det finns ven en kad frekomst av non Hodgkin-lymfom. ven denna komplikation intrder vid lga CD4tal under 50. De cerebrala lymfomen r EBV-relaterade. Symptomen r ofta karaktriserade av feberperioder, avmagring, nattsvettningar och vid CNS-lymfom fokal neurologi. Diagnostiken sker vanligtvis med datortomografi och konfirmeras med punktion, biopsi i lymfkrtlar eller pvisande av EBV i CSF. Behandlingen sker med cytostatika eller strlning men prognosen r i allmnhet dlig. Kaposis sarkom: Mnga av de homosexuellt infekterade patienterna r ocks infekterade med herpesvirus HHV-8. Hos dessa kan hudtumrer uppst uppbyggda av prolifierande endotel och fibroblast-liknande celler. Frndringarna r lokaliserade fr a till huden p blen och ansikte, men frekommer ocks vanligt i hrda gommen, vriga munnen och mag- tarmkanalen. Kaposisfrndringar kan ocks stta sig i lungorna och lymfkrtlar d ge svrbehandlade tillstnd. Diagnostiken sker med biopsi men det kan primrt vara svrt fr patologen att skilja frn en ytlig rrbildning. Behandlingen begrnsas ofta till symtomgivande eller kosmetiskt strande frndringar. I ansikte har upprepad lgdosradioterapi givit goda kosmetiska resultat. Smrre frndringar p huden kan behandlas med frysningar eller laser. Vid lungfrndringar eller lymfstas har cytostatika tmligen god effekt. Anti-retroviral terapi Det finns idag ett 15-tal lkemedel tillgngliga i Sverige fr HIV-terapi. De indelas i tre olika klasser varav de frsta tv r verksamma mot det omvnda transkriptaset och det tredje omfattar proteashmmarna. Nucleosidanaloger. Dessa hmmar det omvnda transkriptaset. De r alla pro-droger som mste metaboliseras av den infekterade cellen till sitt trifosfat som sedan kompetetivt hmmar nybildningen av provirus RNA med de naturliga nucleotiderna. Resistensutvecklingen r mycket olika frn att nstan vara obefintlig mot D4T och ddI, stegvis fr AZT och mycket snabb 3TC. Icke nucleosidanaloger. Detta r en kemiskt mycket heterogen grupp av molekyler som alla har en snarlik verkningsmekanism genom att hmma det omvnda transkriptaset. Det krver ingen metabolisering och r hgaktiva mot HIV-1 men utan aktivitet mot HIV-2. De kan i nrvaro av resterande HIV-replikation ge upphov till mycket snabb resistensutveckling (veckor).
Biomed/overview 43

Proteashmmare. Denna kemiskt heterogena klass av molekyler sker alla att s noga som mjligt blockera den aktiva sajten p proteaset. De krver ingen metabolisering fr att bli aktiva. Resistensutvecklingen r stegvis och relativt lngsam men ger tyvrr korsresistens. Som grupp tycks de vara behftade med lngtidsstrningar p socker och fettmetabolismen som kan bli terapibegrnsande. Mlet vid insatt behandling r att kombinera tre eller flera lkemedel som patienten kan klara av att ta p freskrivet stt och drmed uppn icke detekterbara niver, idag under 50 kopior per ml, och vidmakthlla supressionen p denna lga niv fr resten av patientens liv. Detta krver noggrann monitorering med virusmngdsmtningar och snabba byten till nya kombinationer om misstanke fr resistens freligger. Hos patienter med tidigare suboptimal antiretroviral behandling och/eller tidigare biverkningar kan detta leda till mycket komplicerade individualiserade behandlingsregimer. Hos de patienter dr framgngsrik antiretroviral suppression av olika skl inte kan uppns ses dock ett kliniskt positivt vrde ven av suboptimal behandling. Framgngsrik virussuppression har dock ej vistats leda till att smittspridningsriskerna har upphrt. Spridning av resistent virus kommer att bli ett problem som krver fortsatt hg uppmrksamhet. Mon 21/10 10.45-12.00 (Thomas Leitner) The HIV virus

Objectives: by the end of this lecture you should be able to: describe the major characteristics of the replication cycle of HIV including receptors, reverse transcription, integration, production and release of new virus particles. describe the mechanisms for and consequences of genetic variation of HIV. describe what is known about the pathogenesis of AIDS Lecture synopsis: The lecture will shortly present the retroviruses and lentiviruses. The characteristics of the different steps in the replication cycle of HIV will discussed in more detail focussing on the events which are critical for cell tropism, generation of genetic variation, biological properties and pathogenic consequences. HIV is characterised by a very high degree of genetic variation; the underlying mechanisms for this genetic variation will be discussed as well as its biological consequences for cell tropism, immune escape and development of drug resistance. The rate of disease progression in HIV infected individuals correlates closely with plasma levels of free virions. Factors which influence plasma virus load will be discussed as well as the current knowledge about the mechanisms by which HIV induces immunodeficiency. Finally, similarities and differences between HIV and related viruses in African monkeys (SIVs) will be presented and used to discuss the probable origins of HIV. Mon 21/10 13.00-14.30 (Hans Wigzell) Immunology of HIV infection

Biomed/overview 44

Section VI Transplantation
Tue 22/10 09.00-9.45 (Henrik Gjertsen) Clinical organ transplantation

Objectives: By the end of this lecture the student should be able to: give a short overview over the history of organ transplantation. to be able to describe common clinical procedures and problems related to organ transplantation Lecture synopsis: This lecture will give an introduction to the clinics on solid organ transplantation. The modern era of transplantation surgery began in the beginning of the 20th century when Alexis Carrel developed the basical surgical technique of vascular suture. During the 1930th the first attempts of renal transplantation between humans was performed in Kiev, the transplantation was technically successful but failed due to immunological reasons. The first successful human renal transplantation was performed in Boston 1954 when Murrey documented the permanent survival of identical twin donor kidney transplants. Based on sir Peter Medawars work on transplantation immunology, immuno-suppressive protocols could be developed to be used in organ transplantation. During the late 1960s the first successful kidney transplant programs were started using the combination of azathioprine and steroides. In 1963 the first human liver transplant was performed and one year later Dr Barnard performed the first successful heart transplant. The first pancreas transplant was performed in 1966 followed by intestinal transplants in 1970 and cluster transplantations 1990. Cell transplantation in the form of bone marrow was tried sporadic before the turn of the century and in the early 1940, but it was first in the 1970s that successful transplantations were reported. Regarding islet cell transplantation attempts started in the late 1970s but the first successful insulin independent patient series was first reported in the year 2000. As of today, transplantation of kidneys, liver, pancreas, heart, lung, small intestines, islet cell and hematological stemcells transplants are clinical established and common treatment forms. But it was first with the introduction of modern immunosuppressive agents like cyclosporine in the beginning of the 1980s that made transplantation to become a successful treatment modality. The indications for transplantation are numerous and both acute as well as chronic diseases may make a patient in need of a transplant. Donors can both be deceased patients as well as living donors, where we have both unrelated and related donations of kidneys, livers and cell transplants. All the different organs have different complications and risks. However, all transplant recipients have in common that they are immunocompromised to a greater or lesser extent secondary to the immunosuppressive treatment. Thus recipients of transplants have a higher incidence of infections, especially opportunistic infections and an increased risk to develop malignancies.

Biomed/overview 45

Tue 22/10

09.45-10.30 (Henrik Gjertsen). Clinical organ transplantation

Objectives: By the end of this lecture the students should be able to: give a short overview of the present problems of organ transplantation to describe some of the measures taken to overcome these problems Lecture synopsis: This lecture will give a summary of the present problems in organ transplantation. Main problems: The lack of suitable organs Acute rejections Chronic rejections Which immunosuppressive protocol to use Long term adverse events of immunosuppression Patients waiting for a solid organ transplantation is increasing. One of the major problem is the lack of suitable donors. The majority of donors are patients dying in intracerebral haemorrhagies, and with the improvements in modern medicine, many of these patients can today be saved. To overcome the shortage of donors, active programs to find and approach all possible donors have been developed in several countries. Other approaches to improve donations are to use more and more living related donors, both relatives as well as non-related persons willing to donate one kidney, part of the liver or the gut. One of the most fascinating and thrilling aspects of the future is xenotransplantation, i e transplantation between different species. At present attempts is made to be able to use organs from pigs for transplantation. However, we still see some obstacles both immunological, infectious and physiological in this area. Non vascularized organs can be transplanted, but vascularized organs will succumb to hyperacute rejection due to preformed antibodies directed against other species. Furthermore we have physiological barriers as well as the risk of transferring species specific infections, that previously did not affect mankind. Rejection is still one of the major barriers to transplant success and its prevention and treatment is still not solved. Also chronic rejection is a major problem regarding the long term function of all the different organs, as of today very little can be done to prevent or treat chronic rejection. Thus the optimal immunosuppression is not known, with more effective protocols we will probably run into more problems with toxicity, infections and secondary malignancies. The ultimate goal of achieving transplant tolerance is now being attempted in clinical studies and remain the major challenge for the coming years. Tue 22/10 11.00 11.45 (Johan Aschan) Hematopoietic stem cell transplantation

Objectives: By the end of these lectures the student should be able to: (part 1) give a overview of the development and current status of allogeneic hematopoietic stem cell transplantation (HSCT)
Biomed/overview 46

 describe the general procedure of how a HSCT is performed describe future applications of molecular biology techniques in HSCT Lecture synopsis (1): Allogeneic (from another individual) hematopoietical stem cell transplantation (HSCT) was pionered in the clinical setting during late 1950s after research during the World War II concerning effects of irradiation on the human body and in particular the hematopoietic system. HSCT is today a well accepted curative treatment for patients with life-treathening hematological disorders, mainly leukemias. The basic theory of dose escalation of cytotoxic drugs and irradiation followed by infusion of stemcells to resque the patient from the subsequent myeloaplasia has recently been challenged by the graft-versus-leukemia (GVL) effect, the anti-tumour effect mediated by the new immune system. Stemcells can be harvested from bone marrow, peripheral blood or cord blood. An increasing number of HSCT are performed with peripheral stem cells. Also unrelated donors are increasingly used since only approx 30 % of the patients have a suitable donor in the family. After conditioning treatment the stemcells are infused iv and the patient kept in an isolation room. After approx 2 weeks the new bloodcells appear and the patient can shortly thereafter leave the hospital. Main complications are infections, graft-versus-host disease (GVHD) and relapse of the underlying disease. To reduce the relapse incidence after HSCT hematopoietic chimerism and minimal residual disease can be monitored by highly sensitive PCR methods and treatment instituted early. Tue 22/10 11.45-12.30 (Johan Aschan) GvHD/GvL-pathogenic mechanisms

Objectives: By the end of these lectures the student should be able to: (part 2) understand the criteria for GVHD now the pathogenesis and clinical presentation of GVHD understand risk factors, prevention and treatment of GVHD understand the correlation between GVHD and GVL understand the clinical application of GVL incl. mini-transplants Lecture synopsis (2): GVHD is the attack of the new immune system from the donor against the recipient. Already in the -60s the basic criteria was postulated: the graft must contain immunologically competent cells, the host must possess important antigens lacking in the donor and the host must be incapable of rejecting the infused cells. There are both an acute and a chronic form. Main target organs are skin, liver and gut. The pathogenesis of acute GVHD is currently understood as a combination of tissue damage from the conditioning, donor T cells, which play a central role, antigen presenting cells and cytokines mainly IL-1, IL-2, Interferon-gamma and Tumour necrosis factor-alpha. GVHD has also been described after autologous SCT, blood transfusions and solid organ transplantation, i.e. small bowel transplantation. Riskfactors are HLA-disparities between the donor and the recipient, age, sex mismatch, ie an immunised female donor to a male recipient, intensive conditioning and possibly positivity for herpes viruses. Both prevention and treatment consists of immunsuppressive drugs mainly cyclosporin, methotrexate, steroids and antithymocyte globlin. If a severe form of acute GVHD develops the mortaity is high. Patients with GVHD have a reduced risk of relapse of their hematological malignancy
Biomed/overview 47

since the new immune system can attack not only the patient but also remaining tumour cells, GVL. The best relapse-free survival is observed in patients with a mild GVHD. This GVL effect can be used clinically to treat patients with relapse after HSCT either by abruptly discontinue the immunosuppressive drugs or by donor lymphocyte infusion (DLI). DLI can eliminate recurrence of chronic myeloid leukemia in approx 80% of the patients. However, DLI may cause life-threatening GVHD. To reduce the risk for GVHD the T cells can be gene-modified in the lab by so called suicide-genes. This makes it possible to efficiently and selectively eliminate the T cells with an atoxic drug if GVHD develops. Non-myeloablative HSCT (minitransplantation) is based on the GVL effect. The conditioning is immunosuppressive rather than cytotoxic and thereby less toxic. After infusion of a high number of stemcells a mixed or complete hematopoietical chimerism is established and forms the fundamental base for subsequent DLI. Preliminary data is encouraging and makes it possible to treat older and sicker patients otherwise not eligible for a standard HSCT. New disease that theorethical can be cured by a minitransplant are a variety of solid tumours and auto-immune disorders. Tue 22/10 13.15-14.00 (Gunnar Tydn) Paediatric renal transplantation

Synopsis: Although the number of infants and children accepted for active treatment of end-stage renal failure has increased in recent years the number of transplantations performed annually at the individual centres remains small. At the same time children with renal failure have special problems not encountered in adults such as retarded growth, renal osteodystrophy and problems related to pediatric dialysis. Underlying congenital diseases make it necessary to modify surgical transplant procedures. Furthermore immunosuppressive protocols must be specially designed because of the vigorous immune response in children. The pediatric renal transplant program at Huddinge Hospital is presented at this lecture and all the above mentioned aspects are elucidated. Wed 23/10 9.00-9.45, 9.45-10.30, 11.00-11.45 (D. Hauzenberger) Transplantation immunology

Synopsis: HLA-specific humoral immunity, as a result of recipient allosensitization, induces hyperacute rejection of allogeneic kidney grafts. Cross-match tests are performed to avoid this complication. However, present techniques do not allow determination of HLA specificity of donor-reactive antibodies in the acute necrodonor situation. New methods will be described and discussed as well as the alloantibody specificities which are of clinical importance. Wed 23/10 11.45-12.30 (Gunnar Tydn/Annika Wernersson) Acute/Chron rejection signs & pathology

Synopsis: The various rejection types seen following transplantation will be defined from a mechanistic as well as histopathologic point of view. The different stages of
Biomed/overview 48

acute rejection will be described on a molecular level: initiation of graft rejection by antigen presenting cells, migration of APCs from graft to regional lymph node, direct and indirect antigen presentation, T cell activation by APCs, re-circulation and infiltration of T cells in the graft, and effector functions causing graft destruction. Wed 23/10 13.15-14.00 (Cecilia Sderberg-Nauclr) Chronic rejection & vascular biology 09.00-09.45 (Ann-Christin Croon) Legal aspects on transplantation

Fri 25/10

Objectives: By the end of this lecture the student should be able to: give a short overview over the legal aspects concerning organ donation and transplantation The first Swedish Transplantation Act came into force in 1975. It has since been amended a few times. The present Transplantation Act came into force on 1st July 1996 (SFS 1995:831). The Act is partly concerned with matters relating to the donation of organs or other biological material 1) from a living or deceased human being for transplantation or other medical purposes 2). Regulations on the confirmation of death are contained in the Human Death (Criteria of Determination) Act (1987:269), which lays down that a person is dead when the functions of the brain have totally and irreversibly ceased. If respiration and circulation are being maintained artificially, the occurrence of death shall instead be confirmed if examination of the brain reliably shows all functions of the brain to have totally and irreversibly ceased This examination can be performed in two ways. If the cause of death is known (e.g. intracranial bleeding), a clinical neurological examination will be performed. This examination should be repeated once with an interval of at least 2 hours. If the cause of death is unknown or if the persons temperature is below 33O C, an aortocranial angiogram has to be performed. This X-ray examination should also be performed twice. After the second examination, the person will be declared dead. The Act states that medical measures pending a donation action may not as a general rule continue for more than 24 hours after a person has been pronounced dead Biological material from deceased persons Biological material (organ and tissue) intended for transplantation or some other medical purpose may be taken from a deceased person if he has consented thereto or if it can otherwise be ascertained that this would accord to his wishes. Consent may be general or it may refer solely to actions for a certain purpose or be otherwise restricted. Written consent can take the form of a donor card. Consent does not necessarily be put down in writing. The deceased person may, for example, have clearly indicated his attitude to the next-of-kin. He may also have registered his opinion in the Swedish Donor Registry. Permission or consent can be revoked or altered at any time. If the deceaseds attitude is unclear, action may not be taken if a person who was closely connected to the deceased objects to it (veto). This right, however, can only be
Biomed/overview 49

exercised if the attitude of the deceased is unknown. Accordingly, the next-of-kin are likely to be more important as informants than as independent decision-makers. Biological material from living persons Section 6: biological material intended for transplantation or some other medical purpose may be taken from a living person only if he or she has consented thereto. If the organ or material to be taken is not regenerative or if the action can otherwise entail considerable inconvenience to the donor, the consent shall be in writing There are special regulations concerning minors and mentally disturbed persons Ban on commercialisation. Trading in biological material is prohibited under the Transplant Act. A person who deliberately and for the purpose of gain takes, delivers, receives or procures biological material from a living or deceased person is fined or sentenced to up to two years imprisonment. 1. Other biological material = tissues like heart valves, cornea, skin 2. Other medical purpose = e.g. medical research Fri 25/10 09.45-10.30 (Henryk Wilczek) Immunosuppressive drugs

Objectives: By the end of the lecture you should understand the necessity of immunosuppressive medication after organ transplantation have acquired some basic knowledge of the immunosuppressive drugs used clinically in the prevention of rejection episodes after transplantation have a basic knowledge of the most common hazards associated with immunosuppressive medication after transplantation, and you will know some of the toxic side-effects connected to the individual immunosuppressive agents understand the basic principles in the treatment of ongoing rejection episodes after transplantation Lecture synopsis: This lecture aims to give you a basic understanding in the clinical use of immunosuppressive agents after transplantation. Immunosuppressive medication is necessary after organ transplantation in order to prevent the harmful immunologic reactions to the graft that otherwise occur. If not prevented or treated when occurring, these reactions will ultimately kill the transplanted organ (rejection). Prophylactic immunosuppressive treatment in the clinical setting began in the 50-is, and the first agents to be used were azathioprine (imurel) and steroids (prednisolone, prednisone). These drugs had a rather unspecific mechanism of action and results were generally rather poor. With the introduction of cyclosporine (sandimmun) in the late 70-is results improved dramatically and an era with more effective agents having a more specific mechanism started. For many years most immunosuppressive protocols consisted of cyclosporine in combination with steroids with or without azathioprine. However, during the last decade several other agents have appeared expanding our immunosuppressive armamentarium. The most important of these are FK506 (prograf) and Rapamycin (sirolimus). While immunosuppressive therapy is
Biomed/overview 50

necessary after transplantation for the function and survival of the transplant, it also carries a risk of more or less serious undesired side-effects, in addition to direct toxic effects to the graft. Such side-effects are, e.g. increased risk for infections, increased risk for developing malignancy, weight increase, skin atrophy, osteoporosis, diabetes, gingival hyperplasia, hirsutism, nephro- and hepatotoxicity and hematologic disturbances. Despite the prophylactic use of immunosuppressive agents, rejection still occurs in about 30-50% with most currently used protocols. When rejection episodes occur, they are usually treated with high i.v. bolus doses of steroids, usually methylprednisolone. If the rejection does not respond to steroid treatment, polyclonal or monoclonal agents are used. With the use of these drugs it is possible to reverse more than 90% of the rejection episodes. Fri 25/10 11.00-11.45 (Jan Andersson) Infections in the immunocompromised host

Lecture synopsis: Definition of the different classes of immunosuppressive drugs, including novel antibody- and fusion protein-based therapeutics. The signal transduction pathways from the T cell and IL-2 receptors will be reviewed with emphasis on the targets for the immunosuppressive drugs CsA, FK-506 and rapamycin. Pathways for purine and pyrimidine synthesis will be described focussing on targets for the immunosuppressive drugs mycophenolate mofetil and brequinar. Novel strategies for immunosuppression including IL-2 receptor, costimulatory pathway and adhesion molecule blockade will be reviewed. Fri 25/10 11.45-12.30 (Jan Holgersson) Cell transplantation

Synopsis: The use of cell-based therapy to treat human disease will be reviewed, focussing on pancreatic islet transplantation to treat diabetes and nerve cell transplantation to treat neurodegenerative diseases. Problems involved: lack of donor material, recurrence of autoimmune disease and rejections, will be discussed. The future use of cell xenotransplantation and stem cells for transplantation Fri 25/10 13.15-14.00 (Pontus Blomberg) Gene therapy in transplantation

Lecture synopsis: The lecture will give an introduction to gene therapy with focus on applications within the area of transplantation. Principles for gene therapy and the vectors that are used for gene transfer will be discussed. Transplantation in combination with gene therapy will most probably become a common treatment in the future. Applications within this area will be described. Mon 28/10 9.00-9.45, 9.45-10.30 (Suchitra Sumitran-Holgersson) Tolerance

Biomed/overview 51

Lecture synopsis: Despite improved immunosuppression, chronic rejection is still a major problem and leads to a constant attrition of many types of organ allografts. Induction of donor-specific tolerance with preservation of otherwise normal immune responses is therefore a major goal of research in the field of transplantation. A second impetus for the induction of tolerance arises from the current shortage of allogeneic organs, which has increased interest in the use of other species as xenograft donors. However, immune barriers to xenografts may be even greater than those to allografts and the induction of both B cell and T-cell tolerance may be essential to the ultimate success of xenotransplantation. Mechanisms by which tolerance may be induced in solid organ and cell transplantation will be reviewed. Mon 28/10 09.45-10.30 (Jan Holgersson) Xenotransplantation

Synopsis: Why xenotransplantation? The driving force behind research on xenotransplantation will be outlined, as will the choice of species. Molecular mechanisms behind hyperacute organ xenograft rejection will be explained, and strategies to prevent this will be reviewed. The mechanisms, as we know them today, behind other types of rejections, such as delayed xenograft rejection and acute rejection, will be explained. The special features of the interaction between human immune and cascade (complement and coagulation factors) systems with pig, as opposed to human, cells will be exemplified. Physiological incompatibilities as well as the risk of microbial transmission from pig to man will be reviewed.

Section VII Theme Day "Vaccines"

Tue 29/10 9.15-10.15 (Mikael Jondal) The immunology of vaccines

Objectives: By the end of this lecture you should be able to: 1/ Discuss the need for humoral and cellular immunity against extra- and inracellular microbes during different stages of the infectious process. 2/ Describe the most important antigen presenting cells (APC) and how these may internalize vaccine derived antigens for the induction of B and T cell responses. 3/ Discuss the importance of cytokines in regulating humoral and cellular immune responses to vaccines. 4/ Explain the functions of adjuvants in vaccines. 5/ Outline features of effective vaccines 6/ Outline the difficulties involved in developing effective vaccines against parasites and HIV virus. Lecture synopsis: The aim of prophylactic vaccination is to induce a long-term state of immunity against a pathogen and thereby protect the host from infectious disease caused by later contact with the same microbe. Efforts are also being made to develop therapeutic vaccines against chronic infections and tumors which is considerably more difficult as it involves the reorientation of an already established balance between the
Biomed/overview 52

host and the microbe/tumor. Early vaccines were derived from attenuated, or killed, microorganisms. More recently purified microbial component, conjugate, vector based and genetic vaccines have been developed, all of which aim at targeting antigens to APC for the induction of protective B and T cell responses A successful vaccination requires the induction of humoral immunity against extracellular microbes (or toxins) and cellular immunity against intracellular pathogens. For this purpose the formulation of the vaccine should be such that the antigen is taken up, and processed, efficiently in dendritic cells (DC) which present short peptides bound either to MHC class I or II, for the generation of CD4 positive helper T cells and CD8 positive cytotoxic T cells (CTL), respectively. Vaccine induced antibody responses should optimally opsonize microbes, for destruction by phagocytes, and/or be directed against key epitopes, leading to neutralization of the infectious process. Vaccine induced cellular immune responses should optimally be be directed against nonvariant, immunodominant peptide epitopes. Major B and T cell epitopes can be defined and combined in sub-unit vaccines which, in combination with adjuvants, can trigger the desired immune responses. In this way vaccines can be engineered to be non-toxic and free from components with negative immunological effects such as induction of tolerance and auto-immunity. Tue 29/10 10.45-11.45 (Kari Johansen) The current vaccine programmes and the need for new vaccines

Virus vectors appear to be a promising vehicle to deliver vaccine antigens. Modern vaccines of this type can be useful against infectious diseases for which traditional vaccines are not fully effective. These vectors can be engineered from genomes of DNA or RNA viruses. In this seminar vectors derived from RNA viruses will be described. The features of the currently available vectors will be described, including different ways to improve the safety and effectiveness in this type of vaccination approach. Candidate vaccines based on this type of approach will be presented. Tue 29/10 13.00-14.00 (Margaret Chen/Christina Barnfield) New vaccine strategies. 14.00-15.00 (Gran Hansson) Vaccine for atherosclerosis

Tue 29/10

Atherosclerosis is a focal blood vessel disease characterized by lipid accumulation and inflammation. It causes myocardial infarction and stroke, is the main cause of death in Western societies, and expected to be the dominating lethal disease globally in 20 years. Atherosclerosis is accompanied by local and systemic immune responses to several antigens including oxidized low density lipoprotein (LDL). Studies of human plaques and of lesion formation in a knockout mouse model (apoE KO) show that CD4+ T cells and macrophages form an inflammatory infiltrate. Both cell types are activated and secrete proinflammatory cytokines. CD4+ cells respond immunospecifically to oxidized LDL, suggesting that oxidation induces antigenic epitopes on LDL and converts it to an autoantigen. The pathophysiological
Biomed/overview 53

consequences of this response are probably mediated largely via cytokine secretion. Th1 cytokines dominate and promote vascular inflammation. The net effect of such activity appears to be proatherogenic as can be deduced by cell transfer into immunodeficient apoE KO x SCID mice. However, this is regulated by systemic immune activities involving B cells and probably also T cells. Spleen B cells develop atheroprotective immunity during the course of disease in the mouse model. Interestingly, immunization of apoE KO mice with oxidized LDL leads to a substantial reduction in lesion formation. All these data suggest that vaccination and/or immunomodulation might be used to treat or prevent atherosclerosis.

Biomed/overview 54