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Hypersensitivity Reaction
DefinisiReaksi imunologik (humoral atau diperantarai seluler) terhadap antigen, baik yang bersumber endogen maupun eksogen, dapat menyebabkan beberapa reaksi perusakan jaringan.
Classification
The four-group classification was expounded by P. H. G. Gell and Robin Coombs in 1963.
Additional Type V
Comparison
Hypersensitivity Reactions Gell and Coombs classification:
Type I – IgE mediated (allergy) Type II – Antibody-mediated cytotoxic Type III – Immune Complex mediated Type IV – Delayed-Type Hypersensitivity (DTH) Type V – Autoimmune Disseases
Types I, II and III are “immediate” Type IV is delayed
Type I Hypersensitivity
Antigens are called “allergens” Unknown why people get allergies, but there
is a strong genetic predisposition (called atopy)
Hallmark is inappropriate production of IgE against allergens that cause mast cell degranulation
Normally IgE/mast cell activity should be directed against parasitic infections
Type I Hypersensitivity
Mediators of Type I hypersensitivites Mast cell granule contents (early effects)
Histamine and Heparin - ↑ vascular permeability, smooth muscle contraction (intestines, bronchi), mucus secretion
Chemotactic factors – attract eosinophils and neutrophils Proteases – mucus secretion, complement activation,
degradation of blood vessel basement membrane Later Effects
Leukotrienes and prostaglandins – secreted after tissue disruption caused by mast cell degranulation, effects are similar to histamine
Arrival of proinflammatory eosinophils and neutrophils
Reaksi Hipersensitivitas Tipe I ( Tipe Anafilaksis )
Rx hipersensitivitas tipe cepat IgE
Co : asma, rinitis, dermatitis atopi, urtikaria,
anafilaksis.
Ag sel B untuk membentuk Ig E dengan
bantuan sel Th. Ig E diikat oleh mastosit pd
reseptor Fc.
Bila terpajan ulang, maka Ag tersebut IgE
yang sudah ada pada permukaan mastosit
degranulasi mastosit histamin.
Clinical Manifestations of Type I Systemic anaphylaxis
Allergen gets into the blood stream Dyspnea, ↓BP, bronchole constriction, GI and
bladder smooth muscle contration, shock, death within minutes if untreated
Treatment - epinephrine Allergic rhinitis (hay fever)
Inhaled allergen triggers reaction in nasal mucosa Watery exudate from nose, eyes, upper
respiratory tract, sneeezing and coughing
Clinical Manifestations of Type I Asthma
Allergic asthma – due to inhaled airborne allergens (pollens, dust, fumes, etc)
Intrinsic asthma – triggered by cold, exercise Reaction develops in lower respiratory tract Bronchoconstriction, airway edema, mucus secretion,
inflammation Food allergies
Ingestion of allergen Vomiting and diarrhea If allergens are absorbed into bloodstream, reactions can occur
where allergen deposits asthma-like symptoms Urticaria (hives, wheal & flare response)
Triad asma Hipertrofi muscularis bronchial (1)
spasme bronchial Produksi mukus berlebihan (2)
obstruksi alveoli tertutup emphysema
Edema membran mukus (3) infiltrasi eosinofil mediator inflamasi membran edema kristalisasi enzym eosinofil diamond-shaped Charcot-Leyden crystals (4)
Clinical Manifestations of Type I Atopic Dermatitis (allergic eczema)
Often occurs in young children Red skin rash Strong hereditary predisposition
Type I Hypersensitivity
Treatment Avoid allergen if possible Antihistamines, or anti-prostaglandins Hyposensitization – injections of low doses of
allergen may cause a shift from IgE to IgG as the dominant antibody formed.
Type II Hypersensitivity
Antibody-mediated Cytotoxic HS Antibodies (IgM or IgG) bind to cell surface
antigens. Antigen/antibody complex may lead to: Complement activation lysis ADCC Opsonization phagocytosis
These are normal reactions, but when they cause unwarranted tissue damage, they are considered a hypersensitivity.
Reaksi Hipersensitivitas Tipe II ( Tipe Sitotoksik)
Antigen terikat pada sel sasaran.
Antibodi IgG dan IgM dengan adanya komplemen akan berikatan dengan antigen, sehingga dapat mengakibatkan hancurnya sel tersebut.
Reaksi ini merupakan reaksi yang cepat.
Type II Hypersensitivity
Examples of Type II HS: Transfusion reactions
To ABO blood groups To other RBC blood groups
Hemolytic disease of the newborn (erythroblastosis fetalis)
Drug-induced hemolytic anemia (penicillin)
Reaksi Hipersensitivitas Tipe III (diperantarai kompleks imun)
Antibodi berikatan dengan antigen dan komplemen membentuk kompleks imun.
Keadaan ini menimbulkan neuro-trophic chemotactic factor yang dapat menyebabkan terjadinya peradangan atau kerusakan lokal.
Pada umumnya terjadi pada pembuluh darah kecil. Pengejawantahannya di kornea dapat berupa keratitis herpes simpleks, keratitis karena bakteri (stafilokok, pseudomonas) dan jamur.
Type III Hypersensitivity
Immune Complex Disease Antibody (IgG) / attaching to soluble antigen leads
to complex formation Immune complexes may deposit in:
Blood vessel walls (vasculitis) Synovial joints (arthritis) Glomerular basement membrane (glomerulonephritis) Choroid plexus
Type III Hypersensitivity
Damage occurs due to: Anaphylatoxin release due to complement
activation (C3a, C5a) which then attracts neutrophils, and causes mast cell degranulation
Neutrophils have trouble phagocytosing “stuck” immune complexes so they release their granule contents leading to more inflammation
Platelet aggregation also results from complement activation
These effects are also known as the Arthus reaction
Type III Hypersensitivity
Localized reactions edema and redness (erythema) and tissue
necrosis of the affected tissue Can occur in the skin following insect bites Can occur in the lungs
E.g. “farmer’s lung” from inhaling particles from moldy hay
Type III Hypersenstivity
Generalized reactions: Serum sickness (following treatment with
antiserum to a toxin) Autoimmune diseases
SLE Rheumatoid arthritis
Drug reactions (penicillin) Infectious diseases
Meningitis, hepatitis, malaria, mono etc.
Reaksi Hipersensitivitas Tipe IV (diperantarai sel)
Reaksi terjadi melalui sel ketimbang melalui antobodi.
Terdapat reaksi yang termasuk ke dalam hipersensitivitas IV ini, yaitu hipersensitivitas lambat dan sitotoksisitas diperantarai sel.
Type IV Hypersensitivity
Delayed type hypersensitivity (DTH) TH cells that have been “sensitized” by an antigen
develop a TH1 and (sometimes a TC response) leading to macrophage recruitment and activation.
First noticed with reaction to tuberculosis bacteria (tuberculin reaction)
Hallmarks of type IV is the large number of macrophages at the reaction site, and that it takes an average of 24 hrs to manifest after repeat exposure.
Type V : Hypersensitivity
Inflammation
Inflamasi
Reaksi lokal pada jaringan karena adanya injuri.
Reaksi proteksi komples Penyebab : berbagai stimulus exogen /
endogen Agen penyebab : dihancurkan oleh tubuh
Mechanisme local systemic 3 major:
1. alteration2. exsudation - inflammatory exsudate
liquid (exsudate)cellular (infiltrate)
3. proliferation (pembentukan granulasi dan jaringan fibrosa)
Classification several points of view length:
acute × chronic (+ subacute, hyperacute)
according to predominant component 1. alterative (predominance of necrosis - diphtheria) 2. exsudative (pleuritis) 3. proliferative (cholecystitis - thickening of the wall by
fibrous tissue)
Classification
according to histological features nonspecific (not possible to trace the etiology) - vast
majority specific (e.g. TB)
according to causative agent aseptic (sterile) - chemical substances, congelation,
radiation - inflammation has a reparative character septic (caused by living organisms) - inflammation has
a protective character
Acute inflammation important role in inflammation has
microcirculation! supply of white blood cells, interleukins, fibrin,
etc.
Local symptomatology classical 5 symptoms (Celsus 1st c. B.C.,
Virchow 19th c. A.D.) 1. calor - heat 2. rubor - redness 3. tumor - swelling 4. dolor - pain 5. functio laesa - loss (or impairment) of
function
Systemic symptomatology fever (irritation of centre of thermoregulation)
TNF, IL-1 IL-6 – high erythrocyte sedimentation rate
leucocytosis - increased number of WBC bacteria – neutrophils parasites – eosinophils viruses - lymphocytosis
leucopenia viral infections, salmonella infections, rickettsiosis
immunologic reactions - increased level of some substances (C-reactive protein)
Vascular changes vasodilation
increased permeability of vessels due to widened intercell. junctions and contraction of endothelial cells (histamin, VEGF, bradykinin)
protein poor transudate (edema) protein rich exsudate
leukocyte-dependent endothelial injury proteolysis – protein leakage
platelet adhesion thrombosis
Cellular events
leukocytes margination rolling adhesion transmigration
emigration of: neutrophils (1-2 days) monocytes (2-3 days)
chemotaxis endogenous signaling molecules - lymphokines exogenous - toxins
phagocytosis - lysosomal enzymes, free radicals, oxidative burst
passive emigration of RBC - no active role in inflamm. - hemorrhagic inflammation
Phagocytosis adhesion and invagination into cytoplasm engulfment lysosomes - destruction in highly virulent microorganisms can die
leucocyte and not the microbe in highly resistant microorganisms -
persistence within macrophage - activation after many years
Outcomes of acute inflammation 1. resolution - restoration to normal, limited injury
chemical substances neutralization normalization of vasc. permeability apoptosis of inflammatory cells lymphatic drainage
2. healing by scar tissue destruction fibrinous inflammtion purulent infl. abscess formation (pus, pyogenic
membrane, resorption - pseudoxanthoma cells - weeks to months)
3. progression into chronic inflammation
Chronic inflammation reasons:
persisting infection or prolonged exposure to irritants (intracell. surviving of agents - TBC)
repeated acute inflamations (otitis, rhinitis) primary chronic inflammation - low virulence,
sterile inflammations (silicosis) autoimmune reactions (rheumatoid arthritis,
glomerulonephritis, multiple sclerosis)
Chronic inflammation
chronic inflammatory cells ("round cell" infiltrate) lymphocytes plasma cells monocytes/macrophages activation of macrophages by
various mediators - fight against invaders lymphocytes plasma cells, cytotoxic (NK) cells,
coordination with other parts of immune system plasma cells - production of Ig monocytes-macrophages-specialized cells
(siderophages, gitter cells, mucophages)
Morphologic patterns of inflammation 1. alterative 2. exsudative
2a. serous 2b. fibrinous 2c. suppurative 2d. pseudomembranous 2e. necrotizing, gangrenous
3. proliferative primary (rare) x secondary (cholecystitis)
Morphologic patterns of inflammation 2a. serous - excessive accumulation of fluid, few
proteins - skin blister, serous membranes - initial phases of inflamm.
modification - catarrhal - accumulation of mucus
2b. fibrinous - higher vascular permeability - exsudation of fibrinogen -> fibrin - e.g. pericarditis (cor villosum, cor hirsutum - "hairy" heart
fibrinolysis resolution; organization fibrosis scar
2c. suppurative (purulent) - accumulation of neutrophillic leucocytes - formation of pus (pyogenic bacteria)
interstitial phlegmone – diffuse soft tissue abscess - localized collection
acute – border – surrounding tissue chronic – border - pyogenic membrane Pseudoabscess – pus in lumen of hollow organ
formation of suppurative fistule accumulation of pus in preformed cavities - empyema
(gallbladder, thoracic)
complications of suppurative inflamm.: bacteremia (no clinical symptoms!; danger of formation
of secondary foci of inflamm. (endocarditis, meningitis) sepsis (= massive bacteremia) - septic fever, activation
of spleen, septic shock thrombophlebitis - secondary inflammation of wall of the
vein with subsequent thrombosis - embolization - pyemia - hematogenous abscesses (infected infarctions)
lymphangiitis, lymphadenitis
2d. pseudomembranous - fibrinous pseudomembrane (diphtheria - Corynebacterium, dysentery - Shigella) - fibrin, necrotic mucosa, etiologic agens, leucocytes
2e. necrotizing - inflammatory necrosis of the surface - ulcer (skin, gastric) gangrenous - secondary modification by bacteria - wet
gangrene - apendicitis, cholecystitis - risk of perforation - peritonitis
Granulomatous inflammation
distinctive chronic inflammation type cell mediated immune reaction (delayed) aggregates of activated macrophages
epithelioid cell multinucleated giant cells (of Langhans type x of foreign body type)
NO agent elimination but walling off intracellulary agents (TBC)
Granulomatous inflammation
1. Bacteria TBC leprosy syphilis (3rd stage)
2. Parasites + Fungi 3. Inorganic metals or dust
silicosis berylliosis
4. Foreign body suture (Schloffer „tumor“), breast prosthesis
5. Unknown - sarcoidosis