2. Introduction
• Immunodeficiency - state where the defence mechanisms of the body are impaired,
leading to enhanced susceptibility to microbial infections as well as to certain forms of
cancer
• Immunodeficiency diseases are broadly classified as:
Primary immunodeficiency
Secondary immunodeficiency
5. Bruton Disease (X-linked
Agammaglobulinemia)
• Failure of pre-B cells to differentiate into immature B cells in the bone marrow
• Due to absence of an enzyme called Bruton’s tyrosine kinase (transformation of pre-B cell
into immature B cell) Total absence of B cells and plasma cells in the circulation
• Pre-B cells are found in normal numbers in bone marrow and the T-cell-mediated
responses are also normal
• Cytoplasm of pre B cell may have incomplete immunoglobulins
• X linked, primarily in males; nevertheless, sporadic cases have been described in females
6. • Secondary infections are seen after 6 months of age, when maternal antibodies are
depleted
Recurrent bacterial infections (e.g., Haemophilus influenzae, Streptococcus
pneumoniae, or Staphylococcus aureus) leading to acute and chronic pharyngitis,
sinusitis, otitis media, bronchitis, and pneumonia
Viruses that are cleared by neutralizing antibodies- e.g. enteroviruses
Parasites which are usually resisted by secretory IgA- e.g. Giardia lamblia
7. Common Variable Immunodeficiency
• Heterogeneous group of both sporadic and inherited forms of the disease
• Hypogammaglobulinemia, increased susceptibility to infection, autoimmune disorders
(hemolytic anemia, pernicious anemia), as well as lymphoid tumors
• Clinical manifestations are superficially similar to those of Bruton diseases; but differ in
the following aspects:
Both sexes are affected equally
Onset of symptoms is much later - second or third decade of life
B cell development defect
Intrinsic B-cell defects, deficient T-cell help, or excessive T-cell suppressor activity
8. Isolated IgA Deficiency
• Most common, affects about 1 in 700 white individuals
• Weakened mucosal defences due to IgA deficiency predispose patients to recurrent
sinopulmonary infections and diarrhea
• Significant (but unexplained) association with autoimmune diseases
• Pathogenesis:
Block in the terminal differentiation of IgA-secreting B cells to plasma cells (due to altered T-
cell production of cytokines or intrinsic B-cell defect)
The levels of other immunoglobulins are usually normal or even excess
9. Hyper-IgM Syndrome
• X-linked disorder - due to a defect in isotype class switchover of B cells
• Mutations in either CD40L or CD40 genes, leading to prevention of interaction between T and B-cell ; thus
blocking the class switchover
• Block in class switchover results in lack of synthesis of other classes of antibodies - IgG, IgA, and IgE with a
normal or supernormal levels of IgM
• Deficiency of IgG – leads to defect in opsonization and complement activation (predisposes to recurrent
pyogenic infections)
10. Hyper-IgM Syndrome
• IgA deficiency leads to increased recurrent sinopulmonary infections
and diarrhea
• Excess IgM antibodies can react with blood cells, resulting in
autoimmune hemolytic anemia, thrombocytopenia, or neutropenia
• Patients with defect in CD40L are more susceptible to Pneumocystis
jirovecii infection
11. DiGeorge Syndrome (Thymic Aplasia)
• Results from a congenital defect in thymic development leading to defect in T-cell
maturation
• Infants are extremely vulnerable to viral, fungal, intracellular bacterial and protozoan
infections
• Pathogenesis- In 90% of cases, there occurs a deletion affecting chromosome 22q11
which leads to developmental malformation affecting the third and fourth pharyngeal
pouches in embryonic life
• Thymus, parathyroid glands, and portions of the face and aortic arch become defective
12. DiGeorge Syndrome (Thymic Aplasia)
• There may be associated:
Parathyroid gland hypoplasia resulting in neonatal tetany and hypocalcemia
Anomalies of the heart and the great vessels (Fallot's Tetralogy)
Characteristic facial appearance
• Treatment- Thymus transplantation has been found to be successful in restoration of
immune function. In others (with partial defects), immunity may improve spontaneously
with age
14. Chronic Mucocutaneous Candidiasis
• Represents an impaired cell-mediated immunity against Candida albicans
leads to superficial infections of the skin, mucous membranes, and nails
• Do not show increased susceptibility to other infections but often
associated with endocrinopathies and autoimmune disorders (vitiligo,
malabsorption syndromes)
• Transfer factor therapy, along with fluconazole has been reported to be
effective
15. Severe Combined Immunodeficiencies
(SCID)
• Represents groups of genetically distinct syndromes; all having in common,
defects in both humoral and cell-mediated immune responses
• Severe: implies complete absence of T cell function, death in first year
• Mutation in cytokine receptor - Approximately 50-60% of the cases of SCID
are X-linked (seen in males)
• Results from mutations in the gene encoding the common γ chain shared
by the cytokine receptors for IL-7 and others (IL-2, IL-4, IL-9, and IL-15)
• Defective IL-7 receptor - defect in survival and expansion of immature B-
and T-cell precursors in the bone marrow
• Defect in IL-15 receptor - deficiency of NK cell
16. Types of SCID
• Adenosine deaminase (ADA) deficiency - Most common, ADA deficiency leads to accumulation of
deoxyadenosine which is toxic to rapidly dividing immature T lymphocytes
• RAG Mutation- Recombinase-activating genes (RAG) defect blocks the development of T and B
cells
• Jak3 mutation- Jak3, an intracellular kinase mutation is another way of blocking the cytokine
receptor signalling
• Class II MHC deficiency-Mutations that impair the expression of class II MHC molecules prevent
the development of CD4+ T cells. This condition is also called the bare lymphocyte syndrome
17. SCID
• Affected infants are susceptible to
severe recurrent infections by a wide
array of pathogens, including Candida,
Pneumocystis, cytomegalovirus, and
Pseudomonas
• Bone marrow transplantation. Gene
therapy replacing the mutated genes
has been successful in X linked cases
18. Wiskott–Aldrich Syndrome (WAS)
• X-linked recessive disease
• Characterized by immunodeficiency with thrombocytopenia, eczema(triad)
• Severity of WAS increases with age
• First manifests itself by defective responses to bacterial polysaccharides and by lower IgM levels.
IgG levels are usually normal
Paradoxically the levels of IgA and IgE are often elevated
• Other T and B cell responses are normal initially, but with increase of age, there are recurrent
bacterial infections and a gradual loss of humoral and cellular responses
• Prone to develop non-Hodgkin B-cell lymphomas
• Bloody diarrhea secondary to thrombocytopenia
19. Wiskott–Aldrich Syndrome (WAS)
• Pathogenesis:
Genetic defect is due to a mutation in the gene encoding Wiskott-Aldrich syndrome
protein (WASP) present in precursor lymphoid cells of bone marrow
Cytoskeletal glycoprotein (sialophorin or CD43), required for actin polymerization
20. Ataxia Telangiectasia
• Difficulty in maintaining balance while walking (cerebellar ataxia)
• Appearance of broken capillaries (telangiectasia) in the eyes and
choreoathetoid movements (usually noticed in infancy)
• Deficiency of IgA and sometimes IgE
• Profound sinopulmonary infections
• Primary defect - kinase involved in regulation of the cell cycle
21. Nezelof Syndrome
• Autosomal recessive
• Cellular immunodeficiency resulting from thymus hypoplasia
• In some patients, B cells are normal, whereas in others a B-cell
deficiency is secondary to the T-cell defect
• Affected individuals suffer from chronic diarrhea, viral and fungal
infections, and a general failure to thrive
22. Chronic Granulomatous Disease (CGD)
• Pathogenesis:
Involves inherited defects in the gene encoding components of oxidase
system
E.g. Nicotinamide adenine dinucleotide phosphate (NADP) oxidase of
phagocyte which breaks down hydrogen peroxide to generate free oxygen
radicals (O2
-) that are involved in microbial killing
Decreased oxidative burst which predisposes to recurrent bacterial infections.
CGD is a genetic disease that runs in family in two forms
• X linked form (more common, 70%) - membrane component of phagocyte
oxidase is defective
• Autosomal recessive form- cytoplasmic component of phagocyte oxidase is
defective
23. Chronic Granulomatous Disease (CGD)
• Manifestations-
Bacteria involved in the recurrent infections are catalase positive; pyogenic
pathogens such as staphylococci, Pseudomonas and coliforms
Excessive inflammatory reactions that result in gingivitis, swollen lymph nodes, and
non-malignant granulomas (lumpy subcutaneous cell masses)
Nitroblue tetrazolium reduction test (NBT) is used for screening to detect deficiency
of NADPH oxidase activity
24. Myeloperoxidase Deficiency
• Common genetic disorder characterized by deficiency in either
quantity or function, of myeloperoxidase, an enzyme produced by
neutrophils
• Patients present with immune deficiency and recurrent infections,
especially with Candida albicans
25. Chediak–Higashi Syndrome
• Autosomal recessive disease
• Defective fusion of phagosomes and lysosomes in phagocytes which leads to
increased susceptibility to recurrent and severe pyogenic infections
• Abnormalities in melanocytes leading to albinism (lack of skin and eye pigment)
• Abnormalities in cells of the nervous system (associated with nerve defects), and
• Platelets abnormalities, causing bleeding disorders
• Aggressive but non-malignant infiltration of organs by lymphoid cells
26. Chediak–Higashi Syndrome
• Pathogenesis:
Mutation in a protein called LYST (regulate lysosomal trafficking)
Impairs the targeting of proteins to secretory lysosomes, which makes them unable
to lyse bacteria
Phagocytes from patients with this immune defect contain giant granules but do not
have the ability to kill bacteria
27. Leukocyte Adhesion Deficiency (LAD)
• Rare autosomal recessive disorder, characterized by a defect in the
adhesion of leukocytes which results in poor leukocyte chemotaxis
particularly of neutrophils
• Predisposes to various bacterial and fungal infections
• Due to mutations in β2 integrin subunit (CD18) of the leukocyte cell
adhesion molecule or fucosyltransferase enzyme
28. Lazy Leukocyte Syndrome
• Idiopathic condition due to defect in neutrophil chemotaxis
• Increased pyogenic infections such as gingivitis, abscess formation,
pneumonia and neutropenia
29. Job’s Syndrome (Hyper-IgE Syndrome)
• Hyper-IgE syndrome - rare primary immunodeficiency disease
characterized by eczema, recurrent staphylococcal skin abscesses,
recurrent lung infections (pneumatocele), eosinophilia and high
serum levels of IgE
• Underlying mechanism - defect in neutrophil chemotaxis; due to
mutations in STAT3 or DOCK8 genes
30. SECONDARY IMMUNODEFICIENCIES
• Secondary effects of other diseases such as-
Malnutrition (due to inadequate immunoglobulin synthesis)
Aging (suppression of immune system with age)
Patients with several infections that supresses immune system causing lymphocyte
depletion, e.g. HIV (human immunodeficiency virus) infection.
Underlying cancers (particularly those of the bone marrow and blood cells (leukemia,
lymphoma, multiple myeloma)
Underlying proteinuric renal diseases– leads to loss of immunoglobulins
Sarcoidosis
Patients on immunosuppressive medications
Patients receiving chemotherapy or radiation therapy for malignancy
31.
32.
33. Pathogen Type T-Cell Defect B-Cell Defect Granulocyte
Defect
Complement
Defect
Bacteria Bacterial sepsis Streptococci,
Staphylococci,
Haemophilus
influenzae
Staphylococci,
Pseudomonas
Nocardia
Neisseria,
Other pyogenic
infections
Viruses Cytomegalovirus,
Epstein-Barr virus,
Severe varicella,
Chronic infections
with respiratory
and intestinal
viruses
Enterovirus
encephalitis
-
Fungi Candida,
Pneumocystis
- Candida,
Aspergillus
34. Pathogen Type T-Cell Defect B-Cell Defect Granulocyte Defect Complement Defect
Parasites - Giardiasis -
Special features Aggressive disease
with opportunistic
pathogens, failure to
clear infections
Recurrent
sinopulmonary
infections,
Sepsis, chronic
meningitis
-
35. Case1
• 42 / male from Balrampur, Uttar Pradesh was cough and breathlessness since 6 months
• He had a history of taking anti tubercular therapy 15 years ago but there was no documentation
• He had no history of COVID-19 illness
• There was no history of diabetes,hypertension, ischaemic heart disease
• Patient was smoker for 20 years,quit smoking 5 years ago
• He is farmer by occupation
• CT guided biopsy of the mass lesion (done on 1/7/22) was done outside and was suggestive of
fungal granuloma , while work up for TB was negative
• Patent was initiated on empirical anti-fungals (Fluconazole 400mg/day); which he has taken for 4
months- however there is no clinic-radiological improvement. He was thus referred to Dept. of
Pulmonary Medicine at our hospital
36. Figure showing CT Thorax- homogenous soft tissue
lesion in the right upper lobe, right middle lobe, and
superior segment of RLL with non enhancing
necrotic component
Figure showing Chest Xray with lobulated
spiculated mass covering upper and middle lobe
37. Work up
• Repeat CT guided biopsy was done and the biopsy sample was sent to microbiology department for further
confirmation
• Mycobacterium tuberculosis complex was not detected by GeneXpert Assay. ZN stain was negative for acid
fast bacilli. Culture for tuberculosis was also negative
• 10% KOH wet shows plenty of tissue debris and plenty capsulated round budding yeast suggestive of
Cryptococcus spp
• Grams’s stain also showed 5-10 micrometer round double walled spherical structures with gram positive
stippling suggestive of Cryptococcus spp
• However culture was negative after 6 weeks of incubation
40. Further Work up
• HIV 1 and 2- Not detected
• HbsAg- Not detected
• Anti HCV-Not detected
• Serum IgA-324 mg/dl (Normal range 90-450 mg/dl)
• Serum IgE- 1799 iu/ml
• Serum IgM- 82.3 mg/dl (Normal range 60-280 mg/dl)
• Serum IgG= 1630 mg/dl (Normal range 800-1800 mg/dl)
41.
42. • His absolute CD4 count was 173 per cmm. Suggestive of CD4
lymphopenia
• Final Diagnosis- Lung mass caused by Cryptococcus spp in a patient
of isolated CD4 lymphopenia.
43. • Total Duration of Illness – 2 years
• Dec 2020: Fever, cough for 1 week
• Jan 2021: Fever, cough, shoertness of breath treated
as pneumonia with IV antibiotic for 1 month(Needed
hospital admission)
• Oct 2021: Fever, cough – admitted and treated 1 week
• Dec 2021: Petechial rash over bilateral hands, chest,
abdomen, no h/o mucosal lesions, reduced platelet. No
platelet transfusion was given. Symptoms resolved in 4
days
• April 2022: Fever, with raised TLC around 24000,
Treated for 2 days. Hb 7. Platelet – 33k. 1 PRBC was
transfused
• June 2022: 3 platelets transfused. BMA – Congenital
amegakaryocytic thrombocytopenia
• Aug-Sept 2022: On oral folate,
• Oct 2022: Thrombocytopenia, PLT – 33k. TLC 50,000.
TLC 26000, L 88, N8
• Two of his sibling died
44. Further Work up
• HIV 1 and 2- Not detected
• HbsAg- Not detected
• Anti HCV-Not detected
• Serum IgA-6.67 mg/dl (Normal range 90-450 mg/dl)
• Serum IgE- 5 iu/ml
• Serum IgM- 4.17 mg/dl (Normal range 60-280 mg/dl)
• Serum IgG= 33.3 mg/dl (Normal range 800-1800 mg/dl)
45. • Total lymphocytes: 68%,
• T cell- 97%, B cell - 0.01%, NK cell - 2%,
• Of the CD3+ T Cells:- CD4 positive T cells: 3%, CD8 Pos T Cells:
86%, DNTs- 11%.
CD4:CD8 ratio is 1:29
46.
47. Case 3
• 27/ M from a site manager of fertilizer unit
• TDI – 2 yrs
• Aug 2020: Weight loss 1 yr – 13 kg, fever low grade 3 months, night
sweats, abdominal pain
• Started on emperical ATT (outside)
• ill defines hypodense lesions in spleen, minimal ascites,
retroperitoneal lymphadenopathy
• Patient started feeling well on ATT , fever resolved, there was weight
gain
• July 2021: Completed ATT for 1 yr
48. Present illness
• Nov 2022: 1 month history of cough with expectoration, myalgia,
fever low grade with loose stool for for 15 days
• CT thorax – multilobar bronchial wall thickening and mild dilatation
with clusters of branching centrilobular nodules in bilateral lower
lobes
• Multiple mediastinal, para tracheal and mesenteric nodes present
49. Course in SGPGIMS
• Admitted in SGPGIMS as a case of pneumonia
• He had leukopenia of 1900, ANC – 900
• Emperically started on cefoperazone- sulbactum and Teicoplanin
• He was afebrile after 3 days
• His sputum revealed Pseudomonas aeruninosa
• Gene Xpert sputum negative
• His lungs were clear. No active sputum or fever
• Hence Bone marrow analysis was done – BMA & Biopsy normal
• Stool examination- Giardia sp
51. Further Work up
• HIV 1 and 2- Not detected
• HbsAg- Not detected
• Anti HCV-Not detected
• Serum IgA-6.67 mg/dl (Normal range 90-450 mg/dl)
• Serum IgE- 5 iu/ml
• Serum IgM- 8.08 mg/dl (Normal range 60-280 mg/dl)
• Serum IgG= 33.3 mg/dl (Normal range 800-1800 mg/dl)
Mutations in the BTK gene are implicated in the primary immunodeficiency disease X-linked agammaglobulinemia (Bruton's agammaglobulinemia); sometimes abbreviated to XLA and selective IgM deficiency.[8] Patients with XLA have normal pre-B cell populations in their bone marrow but these cells fail to mature and enter the circulation. The Btk gene is located on the X chromosome (Xq21.3-q22).[9] At least 400 mutations of the BTK gene have been identified. Of these, at least 212 are considered to be disease-causing mutations.[
It is not recommended and dangerous for XLA patients to receive live attenuated vaccines such as live polio, or the measles, mumps, rubella (MMR vaccine).[3] Special emphasis is given to avoiding the oral live attenuated SABIN-type polio vaccine that has been reported to cause polio to XLA patients. Furthermore, it is not known if active vaccines in general have any beneficial effect on XLA patients as they lack normal ability to maintain immune memory.
A normal CD4/CD8 ratio is greater than 1.0, with CD4 lymphocytes ranging from 500 to 1200/mm 3 and CD8 lymphocytes ranging from 150 to 1000/mm 3
Immunoglobulin class switching, also known as isotype switching, isotypic commutation or class-switch recombination (CSR), is a biological mechanism that changes a B cell's production of immunoglobulin from one type to another, such as from the isotype IgM to the isotype IgG
During this process, the constant-region portion of the antibody heavy chain is changed, but the variable region of the heavy chain stays the same (the terms variable and constant refer to changes or lack thereof between antibodies that target different epitopes). Since the variable region does not change, class switching does not affect antigen specificity. Instead, the antibody retains affinity for the same antigens, but can interact with different effector molecules.
Salient features can be summarized using the mnemonic CATCH-22 to describe 22q11.2DS, with the 22 signifying the chromosomal abnormality is found on the 22nd chromosome, as below:[17]
Cardiac abnormality (commonly interrupted aortic arch, truncus arteriosus and tetralogy of Fallot)
Abnormal facies
Thymic aplasia or hypoplasia
Cleft palate
Hypocalcemia/hypoparathyroidism early in life
Transfer factors are essentially small immune messenger molecules that are produced by all higher organisms.[1] Transfer factors were originally described as immune molecules that are derived from blood or spleen cells that cause antigen-specific cell-mediated immunity, primarily delayed hypersensitivity and the production of lymphokines, as well as binding to the antigens themselves. They have a molecular weight of approximately 5000 Daltons and are composed entirely of amino acids.
The mechanism the human immune system has is normally to fight an infection (like Candida). Initially, Th17 cells are made by the immune system, which in turn produces interleukin-17 (IL-17). This induces inflammation and white blood cells confront infection.[9]
Chronic mucocutaneous candidiasis mutations affect IL-17 by inhibiting its pathway. This in turn affects the human immune system's ability to fight infection, in total there are 9 possible types of this condition
Most common SCID Is X linked SCID 40-50% of SCID
Adenosine deaminase (also known as adenosine aminohydrolase, or ADA) is an enzyme involved in purine metabolism. It is needed for the breakdown of adenosine from food and for the turnover of nucleic acids in tissues.
ADA irreversibly deaminates adenosine, converting it to the related nucleoside inosine by the substitution of the amino group by a keto group.
Adenosine
Inosine
Inosine can then be deribosylated (removed from ribose) by another enzyme called purine nucleoside phosphorylase (PNP), converting it to hypoxanthine.
WASP protein is expressed exclusively in cytoplasm of hematopoetic cell Required for actin cytoskeleton remodelling
In the absence, cause defective formation of immunological synapse (required for lipid rafts
Nezelof syndrome is an autosomal recessive[6] congenital immunodeficiency condition due to underdevelopment of the thymus. The defect is a type of purine nucleoside phosphorylase deficiency with inactive phosphorylase, this results in an accumulation of deoxy-GTP which inhibits ribonucleotide reductase. Ribonucleotide reductase catalyzes the formation of deoxyribonucleotides from ribonucleotides, thus, DNA replication is inhibited.
The nitroblue-tetrazolium (NBT) test i-It is negative in CGD, meaning that it does not turn blue. The higher the blue score, the better the cell is at producing reactive oxygen species. This test depends upon the direct reduction of NBT to the insoluble blue compound formazan by superoxide which is produced by normal peripheral blood neutrophils stimulated in vitro; NADPH oxidase catalyzes the aforementioned reaction and NADPH is oxidized in the same reaction. This test is simple to perform and gives rapid results but only tells whether or not there is a problem with the PHOX enzymes, not how much they are affected.[citation needed]
Phagocytes (i.e. neutrophils and macrophages) require an enzyme to produce reactive oxygen species to destroy bacteria after they are ingested (phagocytosis), a process known as the respiratory burst. This enzyme is termed "phagocyte NADPH oxidase" (PHOX). This enzyme oxidizes NADPH and reduces molecular oxygen to produce superoxide anions, a reactive oxygen species. Superoxide is then disproportionated into peroxide and molecular oxygen by superoxide dismutase. Finally, peroxide is used by myeloperoxidase to oxidize chloride ions into hypochlorite (the active component of bleach), which is toxic to bacteria. Thus, NADPH oxidase is critical for phagocyte killing of bacteria through reactive oxygen species.[citation needed]
(Two other mechanisms are used by phagocytes to kill bacteria: nitric oxide and proteases, but the loss of ROS-mediated killing alone is sufficient to cause chronic granulomatous disease.)[