IMMUNITY TO INFECTION

dr. Arthur E. Mongan, M.Sc., Sp.PK

SEMESTER-7 BLOK-II
MODUL-1 PENYAKIT / INFEKSI TROPIS
FK UNSRAT
2011
 Overview:
Immunity to Microbes
 IMMUNITY TO MICROBES
(A BRIEF OVERVIEW)

The key events during infection :

entry of the microbe,
invasion
colonization of host tissues
evasion of host immunity
tissue injury or functional impairment
 General Features of Immune
Responses to Microbes
Mediated by the effector mechanisms of innate and adaptive
immunity

The immune system responds in distinct and specialized ways to

different types of microbes

The survival and pathogenicity of microbes in a host are critically

influenced by the ability of the microbes to evade or resist the
effector mechanisms of immunity

In many infections, tissue injury and disease may be caused by the

host response to the microbe and its products rather than by the
microbe itself
main features microbes:
extracellular bacteria
intracellular bacteria
fungi
viruses
protozoan
multicellular parasites
Extracellular bacteria
 Extracellular bacteria

capable of replicating outside host cells

the circulation
in connective tissues
tissue spaces (lumens of the airways & gastrointestinal tract)

disease is caused by 2 principal mechanisms:

1. Induce inflammation tissue destruction at the site of infection
2. Produce toxins diverse pathologic effects
Endotoxins: components of bacterial cell walls
Exotoxins: actively secreted by the bacteria
INNATE IMMUNITY to
Extracellular Bacteria

The principal mechanisms:

Complement activation
Phagocytosis
Inflammatory response
 ADAPTIVE IMMUNITY to
Extracellular Bacteria
Humoral immunity is the principal protective
immune response against extracellular bacteria

Functions:
block infection
eliminate the microbes
neutralize their toxins
ADAPTIVE Immune Response to Extracellular Bacteria
(antibody and T-helper response)
Extracellular bacteria Examples of human diseases
Staphylococcus aureus Skin and soft tissue infections,
lung abscess;
systemic: toxic shock syndrome,
food poisoning
Streptococcus Pharyngitis, Skin infection
pyogenes (group A) (impetigo, erysipelas, cellulitis),
Systemic (scarlet fever)
Streptococcus pyogenes Pneumonia, Meningitis
(pneumococcus)
Escherichia coli Urinary tract infections,
gastroenteritis, septic shock
Mechanisms of pathogenicity
Skin infection; acute inflammation
induced by toxins (cell death by
pore-forming toxins)
Systemic: enterotoxin
superantigen - induced cytokine
production by T cells causing skin
necrosis, shock, diarrhea
Acute Inflammation
Acute Inflammation
Toxins act on intestinal epithelium
and cause increased chloride and
water secretion; endotoxin (LPS)
stimulates cytokine secretion by
macrophages
Extracellular bacteria Examples of human diseases Mechanisms of pathogenicity

Vibrio cholerae Diarrhea (cholera) Cholera toxin ADP ribosylates G

protein subunit, which leads to
increased cyclic AMP in intestinal
epithelial cells and results in
chloride secretion and water loss

Clostridium tetani Tetanus Tetanus toxin binds to the motor

endplate at neuromuscular
junctions and causes irreversible
muscle contraction

Neisseria meningitidis Meningitis Acute inflammation and systemic

(meningococcus) disease caused by potent endotoxin

Corynebacterium Diphtheria Diphtheria toxin ADP ribosylates

Diphtheriae elongation factor-2 and inhibits
protein synthesis
Intracellular bacteria
 Immunity to
Intracellular Bacteria
 INNATE IMMUNITY to
Intracellular Bacteria

Initially
neutrophils and later macrophages
ingest and attempt to destroy these microbes

mainly mediated by phagocytes and natural

killer (NK) cells
 ADAPTIVE IMMUNITY to
Intracellular Bacteria

The major protective immune response

against intracellular bacteria is T cell
mediated immunity
 Cooperation of CD4+ and CD8+ T cells
in defense against intracellular bacteria
 Patterns of T cell responses to intracellular microbes
are important determinants of disease progression and
clinical outcome
IMMUNITY TO Dengue Viral
INFECTION
Intro..

DENGUE VIRUS:
A Virion, 50 nm in diameter
having SS-RNA genome
surrounded by an icosahedral nucleocapsid
covered by a lipid envelope
the genome ( 11 kb in length), composed of 3 structural protein
genes encoding the nucleocapsid or core protein (C), a
membrane-associated protein (M), an envelope protein (E), and
7 nonstructural protein genes (NS)
Intro..

Mature & Immature flaviviruses

An envelope protein, responsible for fusion and interaction virus receptors

Source: ftt://purdue.edu/pub/uns/kuhn.dengue1.jpeg.
Intro..

The HOST
Dengue virus infection:

1. incubation period of 3 14 days

2. the acute phase of infection lasts about 5 7 days

3. followed by an immune response

Intro..

Affected blood cells components

Reactive lymphocytes

Lymphocytes
Monocytes

Thrombocytes (Platelets)
Intro..
DENGUE VIRUS INFECTION

Asymptomatic Symptomatic

DHF
Undifferentiated D F syndrome (plasma leakage)
Fever
(viral syndrome)
No shock DSS
Without With unusual
haemorrhage haemorrhage

DF DHF
WHO 95629
Intro..
THE SPECTRUM OF DHF

GRADE
Positive Increased
Fever tourniquet test vascular permeability Hepatomegaly Thrombocytopenia I

Other haemorrhagic
manifestation
- rising haematocrit
- hypoproteinemia Leakage of plasma
- serous effusion II
Hypovolaemia
Coagulopathy
III
Shock DIC

Severe bleeding IV

Death
WHO 95630
 Laboratory findings: (1)
DHF
THROMBOCYTOPENIA and
HAEMOCONCENTRATION are constant findings
THROMBOCYTOPENIA (count: 100.000 u/L,
blood smear: 3 platelets per oil-immersion field)
HAEMOCONCENTRATION (a rise in the
HAEMATOCRIT level, indicating plasma leakage;
definitive evidence: an increase of 20%)
Haematocrit level may be affected by early early
volume replacement or by bleeding
 Laboratory findings: (2)
DHF
LEUKOCYTE COUNT:
at the onset of illness: variable (ranging from leukopenia
to mild leukocytosis at near the end of the febrile phase:
neutropenia, relative lymphocytosis and the PRESENT
of ATYPICAL LYMPHOCYTES (limfosit plasma
biru)
A transient mild ALBUMINURIA
A positive fecal OCCULT BLOOD
Signs of COAGULOPATHY: a reduction in
FIBRINOGEN, PROTHROMBIN, FVIII, FXII, AT III
Normal lymphocyte Infectious lymphocytes

Peripheral blood lymphocytes

 Laboratory findings: (3)
DHF/DSS
when marked liver dysfunction occurred: abnormal
profile of AST, ALT, and serum proteins, reduction of
prothrombin group factors that are vitamin K dependent
factors: prothrombin, F VII, F IX, F X; prolonged PT, PTT,
TT
impaired platelet function
reduced C3 and C5 levels
HYPONATREMIA
elevated BUN level
Metabolic ACIDOSIS
 Supporting laboratory work:
Depends on the course of illness:
Essential Laboratory Tests:
Haematocrit
Serum electrolytes and blood gas studies
Platelet count, PT, PTT, and TT
Liver function tests: serum AST, ALT, proteins
 Laboratory Diagnosis (1)

TWO BASIC METHODS for establishing the

Diagnosis of Dengue Infection:
CULTURE / other recent techniques
(detection of virus)
SEROLOGY (detection anti-dengue antibody)
 Laboratory Diagnosis (2)

DETECTION OF DENGUE VIRUS (ANTIGEN)

CULTURE (laborious, experienced and skillful)
RT- PCR faster
in situ HYBRIDITATION more sensitive
IMMUNOCHEMISTRY simpler
 Laboratory Diagnosis (3)
LABORATORY CRITERIA FOR CONFIRMATION:
Isolation of the dengue virus (serum or autopsy)
Demonstration of a fourfold or > change in
reciprocal IgG or IgM Ab titres to one or more
dengue antigens in paired serum sample
Demonstration of dengue virus antigen in
specimens by immunohistochemistry,
immunofluorescence, ELISA
Detection of virus genomic sequences by PCR
 Laboratory Diagnosis (4)

SEROLOGY
DETECTION OF ANTIBODY TO DENGUE
METHODS of:
EIA/ELISA, Haemagglutination-inhibition test (HI /
HAI test), Neutralization test, Complement-fixation test,
Dot-blot immunoassay.
Basic serological tests:

antibody + antigen + detector

enzyme
radioactive
particle
colloidal gold

Serum is used for antigen or antibody detection

 Laboratory Diagnosis (5)
SEROLOGY
Persons never previously infected with a flavivirus, nor
immunized with a flavivirus vaccine mount a PRIMARY
IMMUNE RESPONSE with dengue virus
Anti-dengue Ig M detectable by qualitative or quantitative
ELISA by day 5 of illness, rise quickly to peak about 2
weeks after the onset of symptoms, then decline to
undeteactable levels over 2 3 months
Anti-dengue antibodies inhibit the haemagglutination of
gander RBC by dengue virus (the principle of HI test)
 Laboratory Diagnosis (6)

SEROLOGY
In PRIMARY INFECTION, serological test may yield
results indicating a specific dengue serotype with
specimens obtained early in the disease. In other cases,
cross-reactive antibodies, may confound
determination of the serotype
 Laboratory Diagnosis (7)

SUPPORTIVE SEROLOGY
METHODS of :
Haemagglutination-inhibition test (HI / HAI test
(titre 1280)
a comparable IgG ELISA
a positive Ig M on a late acute or convalescent phase
serum specimen
 Laboratory Diagnosis (8)
conclusive diagnosis of acute-dengue infection only when
rising levels of anti-dengue Ig are detected in paired sera
(serological diagnoses)
 Primary and Secondary Immune Response in DHF

WHO 95631
 Laboratory Diagnosis (9)
COLLECTION AND HANDLING OF
SPECIMENS: (serological diagnoses)
TUBES
VIALS
FILTER PAPERS
DO NOT SEND FROZEN WHOLE BLOOD (hemolysis)
 Laboratory Diagnosis (10)
COLLECTION AND HANDLING OF
SPECIMENS: (serological diagnoses)
As soon as possible after the onset of illness, hospitala dmission,
or attendance at a clinic (ACUTE SERUM, S1)

Shortly before discharge from the hospital or in the event of a

fatality, at the time of death (CONVALESCENT SERUM, S2)
In the event hospital discharge occurs within 1-2 days of
the subsidence of fever, 7-21 days after the acute serum
was drawn (LATE CONVALESCENT SERUM, S3)
 Laboratory Diagnosis (11)
SEROGICAL TESTS
EIA / ELISA (MAC-ELISA, Dengue Combo IgM/IgG)
HI (the test is based on the ability of dengue virus antibodies to
inhibit agglutination reaction between the virus and the RBC):
simple, sensitive, reproducible; however, requires:
- pretreated RBC (gander or type O human)
- paired sera (S1 and S2)
Neutralization test (able to distinguish between the immune
responses in primary infections to different dengue serotypes) e.g.
the plaque-reduction test
Complement-fixation test (CF); (the least sensitive serological
assay, useful for a secondary seroresponse pattern)
 Laboratory Diagnosis (12)
Example of a SIMPLE SEROGICAL TEST (Dengue
COMBO (IgM/IgG) Card Test for screening of dengue
infection in Lab PK):
- specific human IgM/IgG binding proteins
immobilized on the nitrocellulose membrane
- highly purified recombinant dengue viral
proteins are conjugated to colloidal gold
particles in the sample path
- patient serum is added to the sample well; if
specific antibodies (IgM/IgG) to dengue virus
present, a gold-conjugated IC is formed on the
test zone (colored IgM or IgG test line)
Dengue COMBO (IgM/IgG) Card Test
(immunochromatography)
IMMUNITY TO SPECIFIC
(Mycobacterium tbc)
INFECTION
 INTRODUCTION
Mycobacterium tuberculosis infection
One-third of the world population
.. Indonesia?
But only 5-10% a lifetime risk of
developing active tuberculosis, either within 1 or
2 years after infection (PRIMARY TBC) or thereafter (POSTPRIMARY TBC)
ACTIVE TUBERCULOSIS
Variation in:
Localization
Severity
Outcome
 ACTIVE TUBERCULOSIS
Variation in:
Localization any where in the
body (usually pulmonary infection, ranging from
mild infiltration to chronic, cavitary, and severely
destructive disease)

Severity (milliary tbc / the most serious disease

manifestation to tuberculous pleuritis / self limiting)

Outcome (the quality of host defense determines

outcome)
 THE PATHOGENESIS OF
TUBERCULOSIS
STAGES (Luries fundamental studies in rabbit) :
1. Inhalation of tubercle bacilli (die or
escape)
2. the blood monocyte and other
inflammatory cells are attracted to the lungs
3. symbiotic stage
4. chronicity
Phagocytosis and immune recognition of M. tuberculosis
INFLAMMATORY RESPONSE of phagocytic
cells upon activation with M. tuberculosis
M. tbc chronicity
ADAPTIVE Cellular Mediated Immunity
(antigen presentation, costimulation, cytokine
production)
COSTIMULATION

COSTIMULATORY MOLECULES for T stimulation

(B7.1 or CD80 and B7.2 or CD86 on macrohages or dendritic

cells respectively bind to CD28 and CTLA-4 on T cells)

Without proper COSTIMULATION

Antigen presentation leads to apoptosis of T cells

 CONCLUDING REMARK

IMMUNITY to M. tbc infection:

INNATE the role of MACROPHAGES,

DENDRITIC CELLS

ADAPTIVE CMI (antigen presentation,

costimulation, cytokine production)
Masih ingatkah anda ..
pada kuliah demam
(immunity of fever)
dulu. ?
 IMMUNITY

NATURAL (INNATE, NON-SPECIFIC)

ACQUIRED (ADAPTIVE, SPECIFIC)
NATURAL AND ACQUIRED
IMMUNE DEFENSE
NATURAL and ACQUIRED
(immune defenses against
bacterial agents)
 NATURAL
BARRIERS TO INFECTION
CELLS
SERUM PROTEINS and THE
COMPLEMENT SYSTEM
NATURAL IMMUNITY
BARRIERS TO INFECTION
NATURAL IMMUNITY
CELLS
PHAGOCYTES
(PMN, MN phagocyte
system: monocytes,
macrophages)
NATURAL KILLER
CELLS (NK cells)
DEGRANULATING
CELLS (Mast cells,
Basophils)
NATURAL IMMUNITY
SERUM PROTEINS
inflammatory cytokines
(IL-1, IL-6, TNF)
acute phase proteins
(C-reactive protein, Serum
amyloid A, complement
components, fibrinogen,
a1-antitrypsin, ceruloplasmin,
haptoglobulin)
NATURAL and ACQUIRED
(inflammatory response)
NATURAL phagocytosis by
macrophages
 NATURAL and ACQUIRED
antibody-dependent cell-
mediated cytotoxicity (ADCC)
NATURAL complement
cascade
 ACQUIRED
HUMORAL IMMUNITY (B
cells and antibody production)
CELL-MEDIATED IMMUNITY
(CTL)
ACQUIRED IMMUNITY
HUMORAL (Ab class)
COMPLEMENT ACTIVATION
ADCC
NEUTRALIZATION (of bacterial
toxins and viruses)
MUCOSAL IMMUNITY (Ig A-
mediated)
ACQUIRED IMMUNITY
CELL MEDIATED (mainly T-cells)
Cytotoxic T lymphocytes (CTL)
Purpose to eliminate of:
- intracellular pathogens and infected
cells
- tumour cells
- foreign grafts
ACQUIRED development T
helper cell phenotypes
ACQUIRED CTL (effector
response)
ACQUIRED DTH response
(mycobacterial infections)
 INFECTIONS
TYPE OF INFECTIOUS AGENTS:
BACTERIAL
MYCOBACTERIAL
VIRAL
PARASITIC (PROTOZOAL,
HELMINTHS)
FUNGAL
MAJOR IMMUNE DEFENSE
MECHANISMS AGAINST
PATHOGENS
BACTERIAL : Antibody,
immunocomplex, and cytotoxicity
MYCOBACTERIAL : DTH and
granulomatous reactions
VIRAL : Antibody
(neutralization), CTL, and TDTH
PROTOZOAL : DTH and antibody
PARASITIC WORMS : Antibody (atopic,
ADCC) and granulomatous reactions
FUNGAL : DTH and
granulomatous reactions
 YOU LEARN ! ..
Antibody, immunocomplex, ADCC
(adaptive immunity)
DTH, granulomatous reactions
(adaptive immunity)
NEUTRALIZATION Ab, CTL, and
TDTH (adaptive immunity)
MECHANISMS OF INFECTIOUS
ORGANISMS TO AVOID IMMUNE
DEFENSES
1. Inhibit chemotaxis
2. Secrete toxins
3. Block complement-mediated pathways
4. Have outer capsules to block attachment,
phagocytosis
5. Inhibit lysosomal fusion
6. Have outer coat resistant to degradative
enzymes
7. Escape from phagosome
8. Turn off cytokine activation
9. Activate cytokine inappropriately
 YOU LEARN
CHEMOTAXIS ! ..
(innate immunity)
BACTERIAL TOXINS
COMPLEMENT PATHWAYS (innate
immunity)
PHAGOCYTOSIS (innate immunity)
DEGRADATIVE ENZYMES (innate
immunity)
CYTOKINES (innate immunity)
 REFERENCES:
1. Actor JK. Immunology and Microbiology.
1st ed., Mosby Elsevier. Philadelphia USA,
2007.
2. Van Crevel R, Ottenhoff T.H.M, van der
Meer J.W.M. Innate immunity to
Mycobacterium Tuberculosis. Clinical
Microbiology Reviews. 2002, vol. 15 no.2,
pp.294-309
3. Immunology Textbook, Abdul Abbas, ed.
6th. 2010