1. External regulation of immune response J. Ochotná

2. Causal treatment a) Stem cell transplantation a) Stem cell transplantation  for serious congenital disorders of the immune system and some lymphoproliferative and myeloproliferative disorders  complications: infectious complications Graft-versus-host  obtaining stem cells - collection from shovel hip bone - from umbilical cord blood - from peripheral blood after stimulation with GM-CSF

3. b) Gene therapy  with a suitable expression vector is introduced functional gene (to replace dysfunctional gen) into the lymphocytes or stem cells  used as a treatment for some cases of SCID

4. Substitution treatment  autologous stem cell transplantation following chemotherapy and radiotherapy  treatment with intravenous immunoglobulin (derived from plasma of blood donors)  substitution of C1 inhibitor for hereditary angioedema  substitution of erythropoietin in patients with chronic renal failure  substitution of G-CSF in agranulocytosis

5. Immunomodulation = medical procedure to adjust the disrupted immune function Non-specific immunosuppressive therapy Non-specific immunosuppressive therapy  nonspecific = affects not only autoreactive and aloreactive lymphocytes, but also other components of immunity (risk of reduction antiinfectious and anti- tumor immunity)  used for treatment of autoimmune diseases, severe allergic conditions and for organ transplantation

6. Non-specific immunosuppressive therapy  corticosteroids - anti-inflammatory, immunosuppressive effects - blocking the activity of transcription factors (AP-1, NF  B) - suppress the expression of genes (IL-2, IL-1, phospholipase A, MHC gp II, adhesion molecules) - inhibition of histamine release from basophils - higher concentrations induce apoptosis of lymfocytes  immunosuppressants affecting the metabolism of DNA - cyclophosphamide - methotrexate - azathioprine

7.  immunosuppressant selectively inhibiting T lymphocytes - immunosuppressive ATB: cyclosporine A, tacrolimus, rapamycin (suppressing the expression of IL-2 and IL-2R in activated T lymphocytes) - monoclonal antibody anti-CD3 (Immunosuppression after transplantation, treatment of rejection crises)  immunoglobulins in the immunosuppressive indication - Polyspecific intravenous immunoglobulins (Inhibition of B lymphocytes, antiidiotype activity, inhibition of cytokines, neutralization of toxins, inhibition of complement activation...)

8. Anti-inflammatory and antiallergic treatment  nonsteroidal anti-inflammatory drugs  antihistamines - blocking H1 receptor - reduce the expression of adhesion molecules - reduce the secretion of histamine...  inhibitors of inflammatory cytokine - receptor antagonist for IL-1 - monoclonal antibodies against TNF - thalidomide (TNF inhibitor)  enzyme therapy - in the enzyme mixture has a major effect trypsin and bromelain - anti-inflammatory and immunomodulatory effects

9. Non-specific immunostimulant therapy  synthetic immunomodulators  Methisoprinol (Isoprinosine) - used in viral infections with more severe or relapsing course  bacterial extracts and lysates  Broncho-Vaxom - prevention of recurrent respiratory tract infections  Ribomunyl  products of the immune system  IL-2 - renal adenocarcinoma  IFN , IFN  - viral hepatitis, some leukemia  Erythropoietin – renal failure  G-CSF, GM-CSF – neutropenia  Transfer factor (blood donors leukocytes undergoing dialysis)  Thymus hormones  Thymus hormones

10. Antigen-specific immunomodulatory therapy  specific immunomodulation = induce an immune response or tolerance against a specific antigen

11. a) active immunization = use of antigen to induce an immune response that can later protect against a pathogen bearing the antigen (or similar antigen)  immunization vaccines are made from inactivated or attenuated microorganisms or their antigens (polysaccharide capsule, toxins)  creates long-term immunity  activate cellular and antibody immunity  administration of antigen injectable, oral  prophylaxis  risk of infection or anaphylactic reactions

12. b) passive immunization natural - transfer of maternal antibodies in fetal blood  natural - transfer of maternal antibodies in fetal blood  therapeutically - the use of animal antibodies against various toxins (snake toxins, tetanus toxin, botulinum toxin)  prophylaxis - the human immunoglobulin from immunized individuals (hepatitis A, rabies, tetanus) - Anti-RhD antibodies - preventing maternal immunization with RhD + fetus  provides a temporary (3 weeks) specific humoral immunity  the risk anaphylactic reactions

13. c) specific immunosuppression = induction of tolerance to a specific antigen c) specific immunosuppression = induction of tolerance to a specific antigen  ongoing clinical studies  induction of tolerance by oral administration of antigen (treatment of certain autoimmune diseases)  allergen immunotherapy (pollen, insect poisons) d) vaccination against cancer d) vaccination against cancer  immunization by dendritic cells

14. Defence against extracellular pathogens

15.  bacteria (gram-negative, gram-positive cocci, bacilli), unicellular parasites  for their elimination is necessary opsonization (C3b, lectins, antibodies...)  neutrophilic granulocytes are chemotactic attracting to the site of the infection (C5a, C3a and chemotactic products of bacteria)  absorbed bacteria are destroyed by the microbicidal systems (products of NADP-H oxidase, hydrolytic enzymes and bactericidal substances in lysosomes)

16.  phagocytes produce proinflammatory cytokines (IL-1, IL-6, TNF) that induce an increase in temperature, metabolic response of the organism and synthesis of acute phase proteins  in later stages of infection are stimulated antigen-specific mechanisms  plasma cells initially produce IgM isotype after isotype switching produce IgG1 and IgA (opsonization)  sIgA protect against intestinal and respiratory infections by bacteria  bacteria with a polysaccharide capsule may cause T-independent IgM antibody production (after the establishment to the bacteria activate the classical complement path)

17.  after infection persist IgG, IgA (protective effect) and memory T and B lymphocytes  in the defense against bacterial toxins apply neutralizing antibodies (Clostridium tetani and botulinum...)  "indirect toxins - bacterial Lipopolysaccharide (LPS) stimulates big number of monocytes to release TNF, which can cause septic shock  extracellular bacterial infections are especially at risk individuals with disorders in the function of phagocytes, complement and antibody production

18. Defence against intracellular pathogens

19. Defense against intracellular pathogens  bacteria, fungi and unicellular parasites  intracellular parasites are resistant to the microbicidal mechanisms of phagocytes  macrophages, which absorbed them, produce IL-12 → T H 1 differentiation, production of IFN  and membrane TNF → activation of macrophages and induction of iNOS  plasma cells under the influence of IFN  produce IgG2, immune complexes containing IgG2 bind to Fc receptors on macrophages and thus stimulate them -

20.  in the defense against intracelular parasites, which escape from phagolysosomes apply T C lymphocytes  intracellular microorganisms infections are at risk individuals with certain disorders of phagocytes and defects of T lymphocytes

21. Defense against intracellular pathogens

22. Anti-viral defence

23.  interferons - in infected cells is induced production of IFN  and IFN  (prevents viral replication and in uninfected cells cause the anti-virus status); IFN  stimulates the conversion to activated macrophages (iNOS)  NK cells - ADCC (Antibody-dependent cell-mediated cytotoxicity) = cytotoxic reaction depends on the antibodies; the NK-lymphocyte recognizes cell opsonized with IgG by stimulation Fc receptor CD16 and then activate cytotoxic mechanisms (degranulation)  infected macrophages produce IL-12 (a strong activator of NK cells)

24.  in the defense against cytopathic viruses mostly applied antibodies:  sIgA inhibit mucosal adhesion of viruses (defense against respiratory viruses and enteroviruses)  neutralizing IgG and IgM antibodies activate the classical way of complement, which is capable of some viruses lysis  IgA and IgG derived in viral infection have a preventive effect in secondary infection

25.  effector T C lymphocytes destroy infected cells in direct contact (granzym/perforin; FasL) and by produced cytokines (lymfotoxin)  some viruses after infection integrate into the host genome, where persist for years (varicella zoster, EBV, papillomavirus)  by these infections are at risk individuals with T lymphocyte immunodeficiency and with combined immune disorders  increased susceptibility to herpes infections in individuals with dysfunction of NK cells

26. Defense against multicellular parasites

27.  contact of mast cells, basophils and eosinophils with parasite antigens  T H 2 stimulation under the influence of IL-4 (mast cells and other APC stimulated by parasite)  T H 2 stimulate B cells with BCR-specific parasite antigens  isotype switching under the influence of IL-4 to IgE  IgE bind to Fc  RI on mast cells and basophils („antigen- specific receptors“)

28.  establish of multivalent antigen (multicellular parasite) using the IgE to highafinity Fc receptor for IgE (Fc  RI) aggregation of several molecules Fc  RI  initiate mast cell degranulation (cytoplasmic granules mergers with the surface membrane and release their contents)  activation of arachidonic acid metabolism (leukotriene C4, prostaglandin PGD2) - amplification of inflammatory responses  cytokine production by mast cell (TNF, TGF , IL-4, 5,6...)

29.  in later stages are activated T H 1 and are produced antibodies of other classes  eosinophils fagocyte complexes of parasitic particles with IgE via their receptors for IgE  eosinophils use against parasites extracellular bactericidal substances released from granules (eosinophil cationic protein, protease)

30. Activation of mast cell

31. Anti-tumour immunology

32. Malignant transformation  failure of regulation of cell division and regulation of "social" behavior of the cells  the uncontrollable proliferation, dissemination to other tissues  mutations in protoonkogenes and antionkogenes Tumor cells  unlimited growth  growth without stimulating growth factors  immortality  often altered number of chromosomes as frequent chromosomal alteration  TSA...

33. Tumor antigens a)Antigens specific for tumors (TSA)  complexes of MHCgp I with abnormal fragments of cellular proteins - chemically induced tumors - leukemia with chromosomal translocation  complexes of MHC gp with fragments of proteins of oncogenic viruses - tumors caused by viruses (EBV, SV40, polyomavirus)  abnormal forms of glycoproteins - sialylation of tumor cells surface proteins  idiotypes of myeloma and lymphoma - clonotyping TCR and BCR

34. b) Antigens associated with tumors (TAA)  present also on normal cells  differences in quantity, time and local expression  auxiliary diagnostic markers 1) onkofetal antigens 1) onkofetal antigens  on normal embryonic cells and some tumor cells   -fetoprotein (AFP) - hepatom  carcinoembryonic antigen (CEA) - colon cancer 2) melanoma antigens 2) melanoma antigens  MAGE-1, Melan-A

35. 3) antigen HER2/neu 3) antigen HER2/neu  receptor for epithelial growth factor  mammary carcinoma 4) EPCAM 4) EPCAM  epithelial adhesion molecule  metastases 5) differentiation antigens of leukemic cells 5) differentiation antigens of leukemic cells  present on normal cells of leukocytes linage  CALLA -acute lymphoblastic leukemia (CD10 pre-B cells)

36. Anti-tumor immune mechanisms Immune control Immune control  tumor cells normally arise in tissues and are eliminated by T lymphocytes and are eliminated by T lymphocytes  probably wrong hypothesis Defensive immune response Defensive immune response  tumor cells are weakly immunogenic  occurs when tumor antigens are presented to T lymphocytes by dendritic cells activated in the inflammatory environment  if tumor cells are detected, in defense may be involved non- specific mechanisms (neutrophilic granulocytes, macrophages, NK cells) and antigen-specific mechanisms (complement activating antibodies or ADCC, T H 1 and T C )

37.  cancer-associated antigens are processed by APC and recognized by T lymphocytes in complex with HLA I. and II. class with providing costimulus signals  predominance of T H 1 (IFN , TNF  )  specific cell-mediated cytotoxic reactivity – T C  activation of T H 2 → support B lymphocytes → tumor specific antibodies (involved in the ADCC)  tumor cells are destroyed by cytotoxic NK cells (ADCC)

38. Anti-tumor immune mechanisms

40. Mechanisms of tumor resistance to the immune system -  high variability of tumor cells  low expression of tumor antigens  sialylation  tumor cells signals do not provide costimulus → T lymphocyte anergy  some anticancer substances have a stimulating effect  production of factors inactivating T lymphocytes  expression of FasL → T lymphocyte apoptosis  inhibition of the function or durability dendritic cells (NO, IL-10, TGF-  )