1. Basic Immunology I Basic Immunology I Ratanavadee Nanagara, M.D. Allergy-Immunology-Rheumatology Unit Department of Medicine KhonKaen University

2. Nature of Immunity Model of Host Immune Response Immunopathogenesis of Autoimmune Dis. Self Tolerance Abnormal immune response Therapeutic implication

3. Part I Nature of Immunity

4. The Nature of Immunity Cardinal features of immune response Recognition and Defense

5. Cardinal Features specificity memory discrimination

6. Recognition & Defense  Innate (non-specific)  Adaptive (specific)

7. Recognition & Defense  Innate (non-specific)  Adaptive (specific) barriers : skin, mucosa cells: macrophages, neutrophils cytokines complements

8. barriers: skin & mucosa lysozyme in saliva acid mucus cilia mucus normal gut flora lysozyme washing action Fatty acids Normal bacterial skin flora washing action of urine

9. Cells : professional phagocytes neutrophil macrophage monocyte NK cells adhearance, chemotaxis, phagocytosis, oxidative burst, degranulation, IC killing attack and eat kill

10. complement bacteria phagocyte bacteria 2. chemotaxis C5a 3. opsonization C3b 1. lysis C9 C5b

11. phagocyteopsoninbinding _ + C3b ++ Ab + Ab + C3b ++++ Y Y

12. Innate Adaptive Mannose binding protein (MBP) Protein binding receptor Cell receptor and cell differentiation

13. Recognition & Defense  Innate (non-specific)  Adaptive (specific)  Innate (non-specific)  Adaptive (specific) Cardinal features Specific memory discrimination Specific memory discrimination CMIR T-cell HIR B-cell

14. Antibody  Neutralized Ag  Complement fixed  (chemotaxis, permeability & lysis)  Opsonization

15. Part II Integrated Model of Host Immune Response Part II Integrated Model of Host Immune Response

16. Innate Immune Response

17. effective IC killing occult (persistent) infection overt infection adhearance chemotaxis phagocytosis oxidative burst degranulation IC killing Professional phagocytes no disease IC killing defect ? Clinical outcome

18. Adaptive Immune Response

19. Antigen

20. Antigen Presenting Cell Antigen processing exogenous endogenous Antigen

21. CD28 LFA-1 CD2 CD4 CD3 HLA-DR Ag TcR VV VV ICAM-1 LFA-3 CD80/86(B7) auxillary molecules CTL-4 Tyrosine kinase Trimolecular complex

22. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6

23. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 chemokines MIF Fibroblast Synoviocyte

24. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 Effector T-cells CMI R Th1 K Tc N K

25. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IL-5 B-lymphocyte IgG HIR Th2 CD40

26. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG Activated macrophage effector T-cells IF-  IL-2 CD25 ® autocrine paracrine

27. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG Blood vessel effector T-cells

28. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1 (CD106 ) ICAM-1 (CD54) effector T-cells L. integrin (CD11/18) VLA integrin (CD49/29) Selectin (CD62) Adhesion molecules

29. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG effector T-cells Stop inflammatory cells

30. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG effector T-cells VEGF BMP TGF-  ETR Facilitate extravasation

31. Recognition & Defense  Innate (non-specific)  Adaptive (specific)  Innate (non-specific)  Adaptive (specific) Cardinal features specific memory discrimination specific memory discrimination

32. Self Tolerance Clonal ignorance Central tolerance Peripheral tolerance

33. autoreactive T-cells blood barrier Clonal ignorance Normal tissue Self Ag

34. educated T-cell autoreactive cell Central Tolerance

35. autoreactive cell host cell Peripheral Tolerance program cell death … or anergy…

36. HLA-DR auto Ag TcR VV VV ICAM-1 LFA-3 1. lack of co-stimulator molecules – “anergy” 2. stimulate fas ligand - program cell death “apoptosis” Autoreactive T-cell fas

37. Abnormal Immune Response immunodeficiency hypersensitivity autoimmune diseases hypersensitivity autoimmune diseases

38. Gel & Coombs Classification of Immune Response (Hypersensitivity)  Type I - IgE mediated  Type II - Ab mediated  Type III - Immune complex  Type IV - Delayed-type  Type I - IgE mediated  Type II - Ab mediated  Type III - Immune complex  Type IV - Delayed-type

39. SRSA Ag Y Y Y IgE Mast cell Type I Anaphylaxis

40. IFN-  IL-2 IL-4 IL-6 IL-5 B-lymphocyte Type II Ab-mediated IgG Y Y Y Y Y Y Y Y Y Y Y Y Y Target organ

41. LE cell IFN-  IL-2 IL-4 IL-6 IL-5 B-lymphocyte IgG Type III Immune complex Y Y Y Y Y Y

42. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG effector T-cells Type IV Cell mediated

43. Abnormal Immune Response immunodeficiency hypersensitivity autoimmune diseases hypersensitivity autoimmune diseases

44. Autoimmune Diseases HYPERSENSITIVITYAUTOIMMUNITY T-cell  Persistent foreign Ag  Self Ag

45. Immune Response Target cell Inflammatory process

46.  Th lymphokine mediated cytotoxicity Target cell

47.  Th activated macrophage

48.  Th TcK Cytotoxic NK-cell Effector T-cells NK Ab mediated cytotoxic T

49.   Y Y  Th NK Tc K B Complement

50.  Y  Y  Th protease NK Tc K B

51.  Y  Y  Th NK Tc K B

52. Part III Immunopathogenesis of Autoimmune Diseases

53. Triggering Infection Triggering Infection Abnormal Immune Response Genetic predisposition Genetic predisposition Disease HLA Class I - B27 Class II- DR - DW Non HLA Bacteria Chlamydia Yersinia Salmonella Shigella Campylobactor H. Pyroli Virus

54. How infectious agents induce chronic inflammatory or autoimmune diseases?

55. How infectious agents induce chronic inflammatory or autoimmune diseases? T-cells are central to most model of autoimmunity

56. self reactive T-cell proliferation, cytokines, B-cell activation, cytolysis proliferation, cytokines, B-cell activation, cytolysis

57. self reactive T-cell Molecular mimicry Molecular mimicry Presentation of cryptic cell Presentation of cryptic cell Hypersensitivity to persistent organism or their antigens Hypersensitivity to persistent organism or their antigens Immune activation by superantigen Immune activation by superantigen Antigen activation or disruption by retroviruses Antigen activation or disruption by retroviruses

58. self reactive T-cell Molecular mimicry Molecular mimicry Presentation of cryptic cell Presentation of cryptic cell Hypersensitivity to persistent organism or their antigens Hypersensitivity to persistent organism or their antigens Immune activation by superantigen Immune activation by superantigen Antigen activation or disruption by retroviruses Antigen activation or disruption by retroviruses

59. microbeAPC T-cell effector cells against microbe cross reactivity (molecular mimicry) self antigen

60. self reactive T-cell Molecular mimicry Molecular mimicry Presentation of cryptic cell Presentation of cryptic cell Hypersensitivity to persistent organism or their antigens Hypersensitivity to persistent organism or their antigens Immune activation by superantigen Immune activation by superantigen Antigen activation or disruption by retroviruses Antigen activation or disruption by retroviruses

61. autoreactive T-cells Normal tissue Self Ag

63. self reactive T-cell Molecular mimicry Molecular mimicry Presentation of cryptic cell Presentation of cryptic cell Hypersensitivity to persistent organism or their antigens Hypersensitivity to persistent organism or their antigens Immune activation by superantigen Immune activation by superantigen Antigen activation or disruption by retroviruses Antigen activation or disruption by retroviruses

64. Ineffective intracellular killing inapparent infection overt infection

65. Mechanism

66. H. pylori C. trachomatis C. pneumoniae Salmonella inf. M. tuberculosis Viral hepatitis B, C Retrovirus inf. Herpes zoster Prion

67. C. trachomatis persistent infection in chronic arthritis

69. M. Tuberculosis infection that caused intractable autoimmune disease

70. self reactive T-cell Molecular mimicry Molecular mimicry Presentation of cryptic cell Presentation of cryptic cell Hypersensitivity to persistent organism or their antigens Hypersensitivity to persistent organism or their antigens Immune activation by superantigen Immune activation by superantigen Antigen activation or disruption by retroviruses Antigen activation or disruption by retroviruses

71. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG effector T-cells antigen superantigen

72. HLA-DR Antigen Presentation LFA-3 ICAM -1

73. Trimolecular complex HLA-DR CD3 CD4 CD2 LFA-1 VV TcR LFA-3 ICAM -1

74. Trimolecular complex HLA-DR VV TcR Normal T-cell activation

75. Kawasaki’s Disease

76. SUPERANTIGEN HLA-DR VV TcR VV Activate T-cell without Ag processing CD4 CD5 ICAM -1

77. VV HLA-DR TcR CD4 CD5 ICAM -1

78. Treatment of Kawasaki’s disease by giving intravenous immunoglobulin (IVIG) VV HLA-DR TcR Y Y Y Y Y Y Y Y Y CD4 CD5 ICAM -1 Y Y

79. self reactive T-cell Molecular mimicry Molecular mimicry Presentation of cryptic cell Presentation of cryptic cell Hypersensitivity to persistent organism or their antigens Hypersensitivity to persistent organism or their antigens Immune activation by superantigen Immune activation by superantigen Antigen activation or disruption by retroviruses Antigen activation or disruption by retroviruses

82. Signal Transduction

83. CD28 LFA-1 CD2 CD4 CD3 HLA-DR Ag TcR VV VV ICAM-1 LFA-3 CD80/86(B7) auxillary molecules Tyrosine kinase Trimolecular complex

84. Model of TNF-  - receptors - down regulation - signal transduction

85. TNFR-I (p55, CD120a) TNFR-II (p75, CD120b) 2 types of TNF receptor Dead signal → apoptosis Down regulation mechanism TNF-  -TNFR complex endocytosis  soluble TNFRs production LPS Location of TNFR in steady state express constitutively Inducible TNF-  overproduction → cytokines production TNFR cleaved into soluble TNFRs

86. Kinase cascade (MAPK, NIK, caspase) Transcription factors (AP-1, NF-  B) TNFR II TNFR I TNFR associated factors (TRAF 1-6) caspase NIK MAPK RIP: R. interacting protein TRADD- TNFR I asso death domain FADD: factor asso death domain NF-  B AP-1 IL-1, IL-6, IL-8, IL-10, GM-CSF Adhesion molecules PGE2, collagenase Signal Transduction Protein transcription TNF- , IL-1 , IL-6, IL-8, COX2, INOS Transcription associated protein Protein kinase cascade Transcription factors Rx target

87. TNF family proteins fas TRAIL dead R 4 TRAIL = TNF related apoptosis-inducing ligand TRAIL dead R 5 BAFF-R BLyS APRIL TACI BCMA Lymphocyte Therapeutic implication Humanized mAb anti fas mAb Ig BAFF-R = B-cell activating factor receptor TACI = transmembrane activator and calcium modulator and cyclophilin ligand-interactor BCMA = B-cell maturation BLyS = B-lymphocyte stimulator (increase serum level in SLE) differentiation, activation, survival APRIL = a proliferation inducing ligand Belimumab Lymphostat RA, SLE

88. HLA-DR stimulus specific receptor signal transductiontranscription translation proteins Receptor associating proteins Protein kinease pathways Translocation of transcription factors mRNA post- transcription

89. Nature of Immunity Model of Host Immune Response Immunopathogenesis of Autoimmune Dis. Self Tolerance Abnormal immune response ?????

90. To be continued Basic Immunology II Targeted Therapy Biologic response modification

92. Therapeutic Implication

93. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8

94. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8 avoid Ag exposure antimicrobial

95. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8

96. Antimalarial drug change pH in phagosome

97. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8

98. HLA-DR TcR  TcR CD3 CD4 CD2 LFA-3 ICAM-1 Ag TRIMOLECULAR COMPLEX & COSTIMULATORY PATHWAY APC THTH CD80/86 (B7) CD28 CTLA4 (CD154) CTLA4 (CD154) Cytotoxic T lymphcyte-associated antigen 4 = immunoregulatory protein ? RA refractory to TNF-  inhibitor ? RA subset ? SLE mice CD40 CTLA4-Ig - CTLA4-Fc - LEA29Y CTLA4-Ig - CTLA4-Fc - LEA29Y LFA-1 (CD11a/CD18) CD40L

99. B CD40 HLA-DR TcR  TcR CD3 CD4 CD2 LFA-3 ICAM-1 Ag APC THTH CD80/86 (B7) CD28 CTLA4 (CD154) CTLA4 (CD154) CD40 CD40L CD40L TRIMOLECULAR COMPLEX & COSTIMULATORY PATHWAY Anti CD40L mAb ( IDEC-131, hu5c8, BG9588, Biogen ) Anti CD40L mAb ( IDEC-131, hu5c8, BG9588, Biogen ) RA T B CD40 SLE B CD40 B B LFA-1 (CD11a/CD18)

100. HLA-DR TcR  TcR CD3 CD4 CD2 LFA-3 ICAM-1 Ag APC THTH CD80/86 (B7) CD28 CTLA4 (CD154) CTLA4 (CD154) CD40 TRIMOLECULAR COMPLEX & COSTIMULATORY PATHWAY efalizumab : humanized mAb CD11a psoriasis LFA-1 (CD11a/CD18) LFA-1 (CD11a/CD18) CD40L CD40L

101. HLA-DR TcR  TcR CD3 CD4 CD2 LFA-3 ICAM-1 Ag APC THTH CD80/86 (B7) CD28 CTLA4 (CD154) CTLA4 (CD154) CD40 TRIMOLECULAR COMPLEX & COSTIMULATORY PATHWAY LFA-1 (CD11a/CD18) CD40L Anti-CD3 : HuOKT3  1 (Ala-Ala)

102. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8 CAMPATH-1H Profound peripheral lymphopenia

103. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8 IL-2 DAB IL-2

104. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8 Rituximeb anti-CD20 Rituximeb anti-CD20

105. B CD20 immature mature naive B CD20 memory B CD20 P Plasma cell Rituximeb anti-CD20 Rituximeb anti-CD20 B-cell depletion Autoimmune with antibody production refractory Wegener granulomatosis, SLE with AIHA, ITP essential mixed cryoglobulinemia, RA (? RF+ve)

106. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8 IVIG

107. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8 Biologic response modifier

108. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8 ET-1® TGF- 

109. TNF-  soluble p75-TNFR type II (etanercept) chimeric human: mouse mAb (infliximab) humanized mAb (adalimumab) converting enzyme inhibitors (GW3333) IL-1 recombinant IL-1R antagonist (anakinra) soluble IL-1R type II IL-1 Trap (recomb.IL-1R I – IgG Fc) IL-1 converting enzyme inhibitor (caspase-1) IFN  recombinant IFN-   recombinant IFN-  IL-6 IL-6 mAb soluble IL-6R Biologic response modifier

110. Signal vx-745 (inh. p38 MAPK pathway) transduction c-Jun-N terminal kinase inhibitor calcineurin inhibition (post R signaling) CIS3/SOCS3 (signaling repressor) Chemokines recombinant human IL-18 binding protein humanized CXCL8/IL-8 Ab oral CCR1-antagonist ET-1 ET-1 receptor antagonist TGF-  anti-TGF-  VEGF  soluble VEGFR1-Fc Alternative targets of cytokine modifying Rx

111. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8 block adhesion molecules

112. HLA DR+ CD 44 LFA-1 CLA P & E Slectin (CD62) ICAM-1 ICAM-2 VCAM-1 ( CD106) VLA-4 (CD49/29) Anti-human-ICAM-1 Ab (enlimomab) ADHESION MOLECULES anti VCAM-1 mAb E-selectin humanized anti–  v  3 (integrin mAb) humanized anti–  v  3 (integrin mAb) Humanized 4-1, 4-7 mAb (Natalizumab) 2ME2 (2 methoxyextradiol) antiangiogenesis

113. IL-1 TNF-  GM-CSF IL-6 IFN-  IL-2 IL-4 IL-6 IgG VCAM-1ICAM-1 effector T-cells 1 2 3 4 Collagenase MMP PGs 5 6 7 8 Anti-inflammatory agents NO synthetase Superoxide dismutase

115. Physiological uptake of apoptotic cells

116. Complement Deficiency in SLE

117. “Waste-disposal hypothesis” Complement deficiency caused SLE because of impairment of the clearance of apoptotic or necrotic cells and/or immne complexes which cause inflammation and provide a source of autoantigens

118. Pathological uptake of dying cells

119. How dose C1q contribute to the clearance of apoptotic cells? C1q binds to apoptotic cells C1q bound to apoptotic cells in conjuction with CD91 this stimulates their uptake by pinocytosis C1q bound to apoptotic cells also causes activation of the classical pathway C3 bound to apoptotic cells stimunlates their uptake through C3 receptors

120. SLE -dying cells as source of autoantigen

121. Effector Activity of Complement