PRIMARY
IMMUNODEFICIENCIES
DISORDERS OF SPECIFIC IMMUNITY
Classification
A. Humoral immunodeficiencies (B
cell defects)
1. X –
linked agammaglobulinemia
2. Common
variable immunodeficiency
3. Hyper
IgM syndrome
B. Cellular immunodeficiency
1. Chronic
mucocutaneous candidiasis
2. (DiGeorge’s
syndrome) Thymic hypoplasia
C. Combined immunodeficiencies (B
and T cell defects)--SWAIN
1. Severe
combined immunodeficiency
2. Wiskott-Aldrich
syndrome
3 Ataxia telangiectasia
4 Immunodeficiency with thymoma.
X-Linked Agammaglobulinemia (Bruton Disease)
1.
Cause:
Mutation in tyrosine
kinase.
2.
Inheritance:
X-linked recessive.
3.
Clinical
feature: Recurrent bacterial
infection in childhood, chronic giardiasis.
4.
Diagnosis:
Absent or decreased B
cells, absent
plasma cells, decreased Ig in serum.
5.
Treatment:
IV gammaglobulin.
Common Variable Immunodeficiency
·
Defective
humoral immunity due to lack
of differentiation of B cells.
·
Clinical
feature: Same as Bruton disease, onset is late, chronic giardiasis.
·
Diagnosis: Normal B cells but absent plasma cells.
·
Others:
Increased chance of
autoimmune diseases (hemolytic anemia, pernicious anemia) and lymphoid tumors.
Isolated IgA Deficiency
·
Most common of all the primary immunodeficiencies.
·
Clinical
feature: Usually
asymptomatic, chronic sinopulmonary
infection and diarrhea.
Hyper-IgM Syndrome
·
Cause: Mutations in CD40L or CD40,
resulting in defective isotype
switching.
·
Inheritance:
Usually X-linked.
·
Diagnosis:
Normal or increased IgM but lack of IgG, IgA or IgE isotypes.
Severe Combined Immunodeficiency
·
Defects in
both humoral and cell-mediated immunity.
·
Cause: X-linked – cytokine (IL-7) receptor
mutation
·
Autosomal recessive – adenosine
deaminase deficiency–the most common enzyme deficiency.
·
Clinical
feature: Recurrent infection.
·
Treatment:
Bone marrow transplantation.
Wiskott-Aldrich Syndrome
1.
There is
loss of cellular as well as humoral immunity.
2. Clinical feature: Characterized by thrombocytopenia, eczema and
recurrent infection.
3.
Inheritance:
X-linked.
4.
Diagnosis:
a.
Decreased T
cell and defective cellular immunity,
b.
Defective
antibody formation to polysaccharide (encapsulated organisms),
c.
Decreased
IgM but IgG, IgA are normal or increased,
d. IgE is also
increased,
e.
Decreased ratio of
CD4:CD8 cells,
f.
Small platelets in peripheral smear.
5.
Treatment:
Bone marrow transplantation.
Thymic Hypoplasia
(DiGeorge’s Syndrome)
1.
Cause:
Deletion of chromosome 22q11.
2.
Clinical
feature: Thymic hypoplasia leads to deficient T cell maturation → increased
viral, fungal and protozoal infection.
3.
Parathyroid
hypoplasia → hypocalcemic tetany.
4.
It is
associated with Fallot’s tetralogy and other congenital anomalies and a
characteristic facial appearance.
Nezelof Syndrome
1.
Depressed
cell mediated immunity is associated with selectively elevated, decreased or
normal levels of immunoglobulin.
Immunodeficiency with Thymoma Spindle
cell thymoma
associated with hypogammaglobulinemia,
impaired cell mediated immunity and aplastic anemia.
Classification
a.
Defective adhesion – leukocyte adhesion deficiency
b.
Defective chemotaxis –
1.
Shwachman’s
disease,
2.
Lazy
leukocyteyndrome,
3.
Job’s
syndrome,
c.
Defective microbicidal activity –
1.
Chronic granulomatous
disease,
2.
Myeloperoxidase
deficiency,
3.
Chediac-Higashi
syndrome.
Leukocyte Adhesion Deficiency
Defect:
• Type 1 –
defective synthesis of CD18 β-subunit of
leukocyte
integrins LFA-1 and Mac-1.
• Type 2 –
absence of Sialyl-Lewis X (selectin receptor
on
endothelium).
Clinical
feature:
• Type 1 – delayed separation of umbilical cord,
recurrent
infection.
• Type 2 – severe mental retardation, short stature, Bombay blood group,
recurrent infection.
Hyper IgE-recurrent Infection (HIE) or Job’s Syndrome
·
Clinical
feature: Eczema, cold abscess,
recurrent staphylococcal pneumonia,
·
coarse
facies,
·
bony abnormalities,
·
serum IgE
> 2000 IU/ml.
Myeloperoxidase Deficiency
• Most common neutrophil defect.
• Usually
asymptomatic.
Chediac-Higashi Syndrome
1.
Defect:
Reduced chemotaxis and phagolysosome fusion.
2.
Clinical
feature: Recurrent pyogenic infections specially with Staphylococcus aureus.
3. Oculocutaneous
albinism, nystagmus, peripheral neuropathy, mental retardation.
4.
Diagnosis: Giant primary granules in
neutrophils.
Chronic Granulomatous Disease
1.
60 percent
X-linked, 40 percent autosomal recessive.
2.
Defect:
Lack of one of four NADPH oxidase subunit → absent respiratory burst →
decreased production of H 2 O 2 .
3.
Clinical
feature: Recurrent infection with catalase positive pyogenic organisms like
Staphylococcus aureus.
4.
Lymph node
suppuration, granuloma
formation which may obstruct GI tract or genitourinary tract.
5.
Diagnosis:
a.
NBT test
(screening test)
b.
Absent
superoxide and H 2 O 2 production by
neutrophils.
Shwachman’s Disease
1.
Decreased neutrophil mobility,
2.
pancreatic malfunction,
3.
bone abnormalities.
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