TEXTBOOK MATAKULIAH

IMUNOLOGI
UNTUK FARMASI

DISUSUN OLEH :

NURUL MARFU’AH, S.Si, M.Si

PROGRAM STUDI FARMASI

FAKULTAS ILMU KESEHATAN
UNIVERSITAS DARUSSALAM GONTOR
NGAWI
2020
 BAB I
PENDAHULUAN

Tubuh manusia diciptakan oleh Alloh dengan dibekali sistem pertahanan terhadap zat asing
yang dapat menyebabkan penyakit. Sistem pertahanan tersebut dikenal dengan istilah sistem imun.
Sistem imun adalah sistem pertahanan tubuh dari segala hal yang dapat menyebabkan penyakit.
Ilmu yang mempelajari tentang sistem imun disebut imunologi. Di dalam mempelajari sistem imun,
kita mengenal istilah antigen dan antibodi. Antigen adalah bahan/subtansi yang dihasilkan oleh
jamur, bakteri, protozoa, parasit yang dapat mengaktifkan sistem imun dalam tubuh. Sedangkan
antibodi adalah protein yang dihasilkan oleh sel B sebagai respon adanya antigen dalam tubuh.
Sistem imun dibagi menjadi 2 yaitu (1) sistem imun non-spesifik (innate/bawaan) dan (2) sistem
imun spesifik (adaptif/dapatan).
Antigen adalah bahan/subtansi yang dihasilkan oleh jamur, bakteri, protozoa, parasit yang
dapat mengaktifkan sistem imun dalam tubuh. Secara fungsional antigen dibagi menjadi imunogen
dan hapten. Antigen memiliki bagian disebut epitop/determinan yang berfungsi sebagai tempat
berikatan dengan reseptor antibodi. Berdasarkan epitopnya, antigen dibedakan menjadi:
1. Unideterminan, univalen (terdapat 1 jenis epitop dan jumlahnya juga 1)
2. Unideterminan, multivalen (terdapat 1 jenis epitop tetapi jumlahnya 2 atau lebih)
3. Multidetermianan, univalen (terdapat banyak jenis epitop tetapi jumlahnya 1 pada setiap jenis)
4. Multideterminan, multivalen (terdapat banyak jenis epitop dan jumlahnya juga banyak)
Berdasarkan spesifikasinya, antigen dibedakan menjadi:
1. Heteroantigen (dimiliki oleh banyak spesies)
2. Xenoantigen (hanya dimiliki spesies tertentu)
3. Aloantigen (spesifik untuk individu dalam 1 spesies)
4. Antigen organ spesifik (dimiliki oleh organ tertentu)
5. Autoantigen (dimiliki oleh anggota tubuh sendiri)
Berdasarkan ketergantungan terhadap sel T, antigen dibedakan menjadi:
1. T dependen (memerlukan pengenalan oleh sel T untuk menimbulkan respon antibodi,
kebanyakan antigen protein termasuk dalam golongan ini)
2. T independen (dapat secara langsung merangsang sel B untuk menghasilkan antibodi; antigen
golongan ini adalah lipopolisakarida, ficoll, dekstran, levan dan flagelin polimerik bakteri)
Berdasarkan sifat kimiawinya, antigen dibedakan menjadi hidrat arang (polisakarida), lipid, asam
nukleat dan protein.
 Gambar 1.1 Struktur antigen dengan epitopnya yang berinteraksi dengan antibodi

Sistem Imun Non-Spesifik

Sistem imun non-spesifik adalah sistem imun yang sudah ada sejak lahir, tidak berubah oleh
infeksi, waktu responnya cepat, selalu siap kapan saja, dan efektif untuk semua antigen. Sistem
imun non-spesifik dibagi menjadi:
1. Pertahanan fisik/mekanik (First line defense)
Pertahanan ini meliputi kulit (3 lapisan kulit yaitu epidermis, dermis dan adipose serta adanya
melanin), selaput lendir (saluran pernapasan, saluran pencernaan, saluran reproduksi), silia
(trakea), mekanisme batuk dan bersin.
2. Pertahanan biokimia (Second line defense)
Pertahanan ini meliputi kadar NaCl tinggi pada keringat, sekresi minyak dan asam lemak yang
dihasilkan di kulit. Enzim lisozim yang ada di keringat, air ludah, air mata dan ASI. Enzim
lisozim ini dapat menghancurkan peptidoglikan (penyusun dinding sel bakteri). Asam
hidroklorida di lambung, enzim proteolitik di empedu, pH rendah vagina dan pH asam urine.
3. Pertahanan humoral (cairan) (Second line defense)
Pertahanan ini meliputi komplemen dan sitokin.
4. Pertahanan seluler (sel) (Second line defense)
Pertahanan ini meliputi sel neutrofil, sel eusinofil, sel basofil, sel monosit/makrofag, sel NK
(Natural Killer), sel dendritik, dan sel mast. Sel dendritik adalah sel yang berasal dari sel dalam
sumsum tulang atau dari monosit. Sel makrofag adalah sel monosit yang berada dalam
jaringan. Sel mast adalah sel basofil yang hanya ditemukan dalam jaringan yang berhubungan
dengan pembuluh darah.
Darah manusia terdiri atas plasma darah dan sel darah. Plasma darah terdiri atas air 91%,
protein 8%, mineral 0,9%, dan garam. Sel darah terdiri atas sel darah merah (eritrosit), sel
darah putih (leukosit), dan keping darah (trombosit). Leukosit berfungsi sebagai sistem imun
dalam tubuh. Leukosit terdiri atas (1) granulosit (leukosit bergranula) dan (2) agranulosit
(leukosit tidak bergranula). Leukosit bergranula dibedakan menjadi:
(a) Neutrofil (plasmanya bersifat netral, inti selnya seringkali berjumlah banyak dengan bentuk
bermacam-macam, bersifat fagosit)
(b) Eusinofil (plasmanya bersifat asam sehingga akan berwarna merah tua bila ditetesi eosin,
bersifat fagosit dan jumlahnya akan meningkat jika tubuh terkena infeksi)
(c) Basofil (plasmanya bersifat basa sehingga akan berwarna biru jika ditetesi larutan basa,
jumlahnya bertambah banyak jika terjadi infeksi, bersifat fagosit, mengandung heparin
yaitu zat kimia anti penggumpalan)

Gambar 2.1 Sel darah putih (leukosit)

Sedangkan leukosit tidak bergranula dibedakan menjadi:

(a) Limfosit (tidak dapat bergerak, berinti satu, ukuran ada yang besar dan ada yang kecil)
Limfosit dibedakan menjadi sel B, sel T, dan sel NK. Sel NK adalah sel yang mampu
membunuh berbagai mikroba tanpa bantuan tambahan untuk aktivasinya. Sel ini memiliki 2
reseptor yaitu reseptor inhibitori dan reseptor aktivasi. Reseptor inhibitori berfungsi untuk
mengenali sel sehat, sedangkan reseptor aktivasi untuk mengikat sel yang tidak sehat
(misalnya tumor).
(b) Monosit (dapat bergerak seperti Amoeba, mempunyai inti yang bulat atau bulat panjang,
diproduksi pada jaringan limfa dan bersifat fagosit)
Sistem Imun Spesifik
Sistem imun spesifik adalah sistem imun yang bekerja spesifik pada antigen yang pernah
menyerang tubuh, dapat berubah oleh infeksi, waktu responnya lambat, dan akan siap jika ada
antigen yang menyerang. Sistem imun spesifik dibedakan menjadi:
1. Pertahanan humoral (antibodi atau immunoglobulin yang dihasilkan limfosit sel B)
Types of B Cell are :
a. Plasma Cell
Once activated B cells may differentiate into plasma cells. Plasma cells are large
lymphocytes with large amounts of endoplasmic reticulum, which allows them to produce
antibodies to specific antigens. They respond to signals from T cells during infection and
continue to produce antibodies to the required antigen until the infection is controlled.
Plasma cells are often found within chronic infection and inflammation.
b. Memory B Cell
Other B cells will differentiate into memory B cells when activated. These are long lived
cells which remain within the body and allow the body to respond much more rapidly in
the case of a subsequent infection. If the host is re-exposed to the same antigen these cells
rapidly divide with assistance from T cells and produce more B cells capable of producing
specific antibodies to the pathogen. This often means that the pathogen can be dealt with
before the infection takes hold.
c. T-independent B Cells
Most B cells require T cells to be present in order to produce antibodies, however a small
number are able to function without this. They are found within specialised sites such as
the spleen and peritoneum. They are particularly important for dealing with encapsulated
bacteria, which often have a polysaccharide outer layer as opposed to proteins, which
allows them to evade T cells. T-independent B cells are able to recognise these layers and
produce antibodies to them without the need for T cell help.
2. Pertahanan seluler (limfosit sel T)
There are 3 main types of T cells: cytotoxic, helper, and regulatory. Each of them has a
different role in the immune response.
a. Cytotoxic T cells (CD8+)
Cytotoxic T cells (Tc cells) have a co-receptor called CD8 on their cell surface. CD8
partners with the T cell receptor and with MHC class I molecules, acting as a sort of
bridge. This bridge allows cytotoxic T cells to recognize normal cells that are infected by
a pathogen. When the cytotoxic T cell recognizes the infected cell, it becomes activated
and produces molecules that kill the infected cell, destroying the pathogen in the process.
b. Helper T cells (CD4+)
Helper T cells (Th cells) have a different co-receptor called CD4 on their cell surface. CD4
also partners with the T cell receptor but interacts with MHC class II molecules instead of
MHC class I molecules. This allows helper T cells to recognize pathogen peptides that
have been displayed by antigen presenting cells. When helper T cells recognize a peptide
on an antigen presenting cell, they become activated and begin to produce molecules
called cytokines that signal to other immune cells. There are many subtypes of helper T
cells (ie, Th1, Th2, Th17). Each subtype produces a specialized combination of cytokines
that depends on type of pathogen that the helper T cell has recognized—some cytokines
are more effective than others in the process of eliminating certain invaders.
c. Regulatory T cells
Regulatory T cells (Treg cells) also have CD4 on their surface, but they do not activate the
immune system like helper T cells do. Instead, regulatory T cells play a protective role by
shutting off the immune response when it is no longer needed. This prevents excessive
damage to the normal cells and tissues in the body. Regulatory T cells suppress the
immune response in several ways, including:
 Producing anti-inflammatory cytokines that suppress the immune response
 Releasing molecules that kill activated immune cells
 Changing the way dendritic cells behave so they can't activate T cells
 BAB II
PERKEMBANGAN DAN AKTIVASI SEL T

Proses maturasi (pematangan) sel T terjadi di dalam kelenjar timus. Kelenjar timus
termasuk ke dalam sistem limfatik, berada di rongga dada bagian atas, terletak tepat di atas jantung.
Perkembangan sel T dimulai dari sel induk (stem cell) hematopoietik di dalam sumsum tulang
yang berdiferensiasi menjadi sel limfoid. Sel limfoid kemudian bermigrasi ke kelenjar timus. Di
dalam kelenjar ini, sel limfoid berdiferensiasi menjadi DN kemudian menjadi DP dan berkembang
menjadi sel T yang imatur. Sel T imatur dipersiapkan di dalam kelenjar timus untuk memperoleh
reseptor. Sel T imatur akan menjadi matur jika reseptornya tidak berintegrasi dengan peptida selnya
sendiri (self antigen) yang diikat MHC dan dipresentasikan APC. Proses perolehan reseptor oleh sel
T ini akan menghasilkan Tc, Th dan Treg. Sel T yang tidak aktif/reaktif akan mengalami apoptosis.
Selanjutnya sel T yang sudah matang akan bermigrasi ke kelenjar getah bening (limfe). Di dalam
organ ini, sel T mengalami diferensiasi setelah di stimulasi oleh adanya antigen. Sel T memiliki
reseptor yang disebut TCR (T Cell Receptor). Reseptor ini memiliki sifat diversitas, spesifitas,
memori dan berperan dalam imunitas spesifik. Satu sel T hanya memiliki reseptor untuk satu jenis
antigen saja.

Gambar 2.1 Struktur anatomi kelenjar timus

 Gambar 2.2 Maturasi sel T

Cytokines are small polypeptides that regulate cell function and are predominantly secreted
by immune cells. Numerous cytokines responsible for the modulation of T cell differentiation are
produced by thymocytes and TECs. The ability of thymocytes to produce cytokines is important in
the regulation of thymic cytokine production and the responses to their action. Of these regulators,
IL-7 serves a particular role in thymocyte differentiation; IL-7 has been reported to promote the
rearrangement of TCR genes by enhancing the production and activity of recombinases. The thymic
production of Treg cells requires IL-2, which is also required during T cell development in the
thymus and for the maturation of Treg cells. Recent studies have reported that IL-2 receptor is
functionally active within the thymus; it increases the number of CD4 +Foxp3+ thymocytes and the
expression of Foxp3 and CD25 to normal levels. IL-4 is another cytokine produced by T cells
whose receptor contains a γ(c)-chain. It has previously been demonstrated that IL-4 is synergistic
with IL-2 in the induction of thymocyte proliferation in fetal thymic organ culture. In addition, IL-4
supports thymocytes through successive phases of proliferation, acting alongside stimulatory
agents. Recently, research has been directed at the cytokine IL-10, which is produced by Treg cells,
and other chronically stimulated T helper cells, B cells and APCs. IL-10 is important for
maintaining immune homeostasis at mucosal surfaces and also contributes to immune suppression.
Interferon (IFN)-γ has numerous effects on TECs; it activates TECs and increases surface
expression of MHC classes I and II, and other membrane proteins. Furthermore, IFN-γ stimulates
the secretion of IL-6 by TECs. IFN-γ also supports thymocyte differentiation, through its action on
TEC functions. Tumor necrosis factor (TNF)-α has been reported to have an important role in the
regulation of thymocyte production, inducing apoptosis and the proliferation of immature
CD3−CD4−CD8− T cells in the presence of IL-7. Furthermore, TNF-α and IL-1 participate as
cofactors in the induction of CD4−CD8− thymocyte commitment and differentiation. TNF-α also
stimulates the production of IL-6 and enhances the apoptosis of CD4+CD8+ cells induced by
glucocorticoids.
 BAB III
PERKEMBANGAN DAN AKTIVASI SEL B

Perkembangan sel B dimulai dari sel induk (stem cell) hematopoietik di dalam sumsum
tulang yang berdiferensiasi menjadi menjadi sel limfoid. Sel limfoid kemudian berdiferensiasi
menjadi sel pro-B kemudian menjadi sel pre-B. Sel pre-B kemudian menjadi sel B yang imatur dan
setelah itu menjadi matur. Sel B imatur akan menjadi matur setelah memiliki reseptor. Proses
maturasi (pematangan) sel B ini terjadi di dalam sumsum tulang. Setelah matang, sel B bermigrasi
ke kelenjar getah bening (limfe). Di dalam organ ini, sel B mengalami aktivasi dan diferensiasi
setelah di stimulasi oleh adanya antigen. Sel T yang tidak aktif/reaktif akan mengalami apoptosis.
Setelah itu, sel B akan membentuk (1) sel memori, (2) sel yang mempresentasikan antigen ke sel T
dan (3) sel yang menghasilkan immunoglobulin (Ig).
Sel B memiliki beberapa reseptor di antaranya dalah (1) Ig M (reseptor untuk antigen) (2)
FcR/Fragment crystallizable Receptor (salah satunya dimiliki oleh Ig G yang berperan dalam
melewati membran sel plasenta), (3) C3 (untuk mengikat komplemen) (4) EBV/Epstein Barr Virus
(mengikat virus Epstein Barr). EBV adalah salah satu virus herpes yang menyebabkan penyakit
mononukleosis. Virus ini biasanya berada di dalam air liur dan dapat ditularkan. Gejala penyakit
mononukleosis adalah demam, radang tenggorokan, pembengkakan kelenjar limfe dan tubuh lelah.

Gambar 3.1 Perkembangan sel B

 Gambar 3.2 Aktivasi sel B

Antibody responses to different antigens are classified as T-dependent or T-independent,

based on the requirement for T cell help. B lymphocytes recognize and are activated by a wide
variety of chemically distinct antigens, including proteins, polysaccharides, lipids, nucleic acids,
and small chemicals. Helper T lymphocytes play an important role in B cell activation by protein
antigens. (The designation helper came from the discovery that some T cells stimulate, or help, B
lymphocytes to produce antibodies.) T cells help B cells respond to only protein antigens because T
cells can only recognize peptides derived from proteins presented as peptide–major
histocompatibility complex (MHC) complexes. In the absence of T cell help, most protein antigens
elicit weak or no antibody responses. Therefore, protein antigens and the antibody responses to
these antigens are called T-dependent. Polysaccharides, nucleic acids, lipids, and other multivalent
antigens (which contain the same structural unit repeated multiple times in tandem) can stimulate
antibody production without the involvement of helper T cells. Therefore, these multivalent
nonprotein antigens and the antibody responses to them are called T-independent. The antibodies
produced in response to proteins exhibit more isotype switching and affinity maturation than
antibodies against T-independent antigens because helper T cells stimulate these processes.
Furthermore, T-dependent antigens stimulate the generation of long-lived plasma cells and memory
B cells. Thus, the most specialized and long-lived antibody responses involve protein antigens and
are generated under the influence of helper T cells, whereas T-independent responses are relatively
simple and transient, and involve only the direct activation of B cells by antigens.
 BAB IV
MAJOR HISTOCOMPATIBILITY COMPLEKS (MHC) DAN
ANTIGEN PRESENTING CELL (APC)

Major Histocompatibility Compleks (MHC)

MHC adalah protein yang berfungsi untuk mengenali antigen. Molekul MHC yang ada di
setiap permukaan sel menampilkan fraksi tertentu dari molekul protein yang disebut epitop. Ini
mencegah sistem kekebalan sel dari menargetkan sel-selnya sendiri selama presentasi antigen yang
bisa berupa antigen diri atau non-self. MHC dibagi menjadi 2 yaitu:
1. MHC kelas I
MHC kelas I ditemukan pada semua permukaan sel berinti. Protein ini bertugas
mempresentasikan antigen peptida ke T-cytotoxic (Tc) yang secara langsung akan
menghancurkan sel yang mengandung antigen asing tersebut. MHC kelas I terdiri dari dua
polipeptida, yaitu rantai membrane integrated alfa (α) yang disandikan oleh gen MHC pada
kromosom nomor 6, dan non-covalently associated beta-2 mikroglobulin (β2m). Rantai α akan
melipat dan membentuk alur besar antara domain α1 dan α2 yang menjadi tempat penempelan
molekul MHC dengan antigen protein. Alur tersebut tertutup pada kedua ujungnya dan peptida
yang terikat sekitar 8-10 asam amino. MHC kelas I juga memiliki dua α heliks yang menyebar
di rantai beta sehingga dapat berikatan dan berinteraksi dengan reseptor sel T.
2. MHC kelas II
MHC kelas II terdapat pada permukaan sel B, makrofag, dan sel dendritik. Melalui MHC kelas
II inilah, sel B dapat mempresentasikan antigen ke sel T-helper (Th) yang akan menstimulasi
reaksi inflamatori atau respon antibodi. MHC kelas II ini terdiri dari dua ikatan non kovalen
polipeptida integrated-membrane yang disebut α dan β. Biasanya, protein ini akan berpasangan
untuk memperkuat kemampuannnya untuk berikatan dengan reseptor sel T. Domain α1 dan β1
akan membentuk tempat untuk pengikatan MHC dan antigen.

Gambar 4.1 Struktur MHC-I dan MHC-II

Gen MHC dan Polimorfisme
Gen yang mengkodekan MHC tersebut terdiri dari ± 4 juta bp yang terdapat di kromosom
nomor 6 manusia dan lebih dikenal sebagai kompleks Human Leukosit Antigen (HLA). Kelompok
gen yang termasuk kelas I terdiri dari tiga lokus mayor yang disebut B, C, dan A, serta beberapa
lokus minor yang belum diketahui. Setiap lokus mayor menyandikan satu polipeptida tertentu. Pada
gen pengkode rantai alfa, terdapat banyak alel atau dengan kata lain bersifat polimorfik. Rantai
beta-2-mikroglobulin dikodekan oleh gen yang terletak di luar kompleks gen MHC, namun apabila
terjadi kecacatan pada gen tersebut maka antigen kelas I tidak bisa dihasilkan dan dapat terjadi
defisiensi sel Tc. Kompleks gen kelas II terdiri dari tiga lokus yaitu DP, DQ, dan DR yang masing-
masing mengkodekan satu rantai alfa atau beta. Rantai polipetida yang dihasilkan akan saling
berikatan dan membentuk antigen kelas II. Seperti halnya antigen kelas I, antigen kelas II juga
bersifat polimorfik (unik) karena lokus DR dapat terdiri atas lebih dari satu macam gen penyandi
rantai beta fungsional.

Antigen-Presenting Cell (APC)

APC atau sel aksesori adalah sel yang memiliki major histocompatibility complex (MHC)
pada membran selnya agar dikenali sebagai antigen oleh sistem imun. Sel T dapat mengenali
kompleks ini menggunakan reseptor sel T (TCR). APC memproses antigen dan menyajikannya ke
sel T. Hampir semua jenis sel dapat mempresentasikan diri sebagai antigen dalam beberapa cara.
Mereka ditemukan dalam berbagai jenis jaringan. Sel penyaji antigen profesional, termasuk
makrofag, sel B, dan sel dendritik, mempresentasikan diri sebagai antigen ke sel Th, sementara sel
yang terinfeksi virus (atau sel kanker) dapat mempresentasikan diri sebagai antigen ke sel Tc.
Selain menggunakan MHC, presentasi antigen bergantung pada molekul pensinyalan khusus
lainnya pada permukaan sel APC dan sel T.
Sel penyaji antigen sangat penting untuk respons imun adaptif yang efektif, karena fungsi
sel Tc dan Th bergantung pada APC. Presentasi antigen memungkinkan spesifisitas imunitas adaptif
dan dapat berkontribusi pada respons imun terhadap patogen intraseluler dan ekstraseluler. Itu juga
terlibat dalam pertahanan melawan tumor. Beberapa terapi kanker melibatkan pembuatan APC
buatan untuk memperkuat sistem kekebalan adaptif untuk menargetkan sel-sel ganas.
Sel penyaji antigen terbagi dalam dua kategori yaitu profesional dan non-profesional.
Mereka yang mengekspresikan molekul MHC kelas II bersama dengan molekul ko-stimulator dan
reseptor pengenalan disebut sel penyaji antigen profesional. APC non-profesional mengekspresikan
molekul MHC kelas I. Sel T harus diaktifkan sebelum bisa membelah dan menjalankan fungsinya.
Ini dicapai dengan berinteraksi dengan APC profesional yang menyajikan antigen yang dikenali
oleh reseptor sel T mereka. APC yang terlibat dalam mengaktifkan sel T biasanya merupakan sel
dendritik. Sel T tidak dapat mengenali dan oleh karena itu tidak dapat merespons, antigen 'bebas'
atau terlarut. Mereka hanya dapat mengenali dan merespons antigen yang telah diproses dan
disajikan oleh sel melalui molekul pembawa seperti molekul MHC. Sel Th dapat mengenali antigen
eksogen yang disajikan pada MHC kelas II; Sel Tc dapat mengenali antigen endogen yang terdapat
pada MHC kelas I.
Dalam terapi kanker, APC secara alami memiliki peran dalam melawan tumor, melalui
stimulasi sel B dan Tc untuk masing-masing menghasilkan antibodi melawan antigen terkait tumor
dan membunuh sel ganas. Sel dendritik, menampilkan antigen spesifik tumor ke sel T, adalah kunci
dari proses ini. Terapi kanker termasuk merawat pasien dengan peningkatan jumlah sel dendritik
atau sel T khusus kanker. Namun, terapi terbaru telah beralih ke sel penyaji antigen buatan yang
direkayasa secara genetik yang dirancang untuk memprioritaskan sistem kekebalan untuk
menyerang sel-sel ganas. Beberapa APC buatan berasal dari sel manusia; lainnya adalah aseluler,
mengandung protein MHC, molekul ko-stimulatori, dan peptida yang diperlukan. Aktivator APC
IMP321 sedang diuji dalam uji klinis untuk mempercepat reaksi kekebalan untuk menghilangkan
kanker payudara metastatik atau melanoma.
 BAB V
CARA KERJA LIMFOSIT B DAN LIMFOSIT T

Sel B adalah salah satu limfosit yang dibentuk di dalam sumsum tulang kemudian
mengalami pematangan di sumsum tulang juga. Sel B berfungsi untuk menghasilkan
antibodi/immunoglobulin. Immunoglobulin (Ig) pada manusia terdiri atas Ig G, Ig A, Ig M, Ig E,
dan Ig D. Sedangkan Sel T dibentuk di sumsum tulang dan mengalami pematangan di kelenjar
timus. Sel T dibedakan menjadi (1) Sel T CD8 (Tc-T cytotoxic/CTL-cytotoxic T lymphocyte), (2)
Sel T CD4 (Th/T helper), dan Treg. Sel B dan sel T sebagai salah satu sistem imun memiliki bagian
paratop di membran selnya sebagai tempat untuk mengikat bagian epitop dari antigen.
B-cells recognize solvent exposed antigens through antigen receptors, B-cell
receptor (BCR), consisting of membrane-bound immunoglobulins. Upon activation, B-
cells differentiate and secrete soluble forms of the immunoglobulin, also known as antibodies. A B-
cell epitope or antigenic determinant is the antigen portion binding to the immunoglobulin or
antibody. Antigens recognized by B-cells can be of different chemical nature but most of them are
proteins and here will focus on them.

Gambar 5.1 Antigen-Imunoglobulin interaction

Any solvent exposed region in the antigen can be subject of recognition by antibodies.
Nonetheless, B-cell epitopes can be divided in two main groups: linear and conformational. Linear
B-cell epitopes consist of sequential residues, peptides, whereas conformational B-cell epitopes
consist of patches of solvent exposed atoms from residues that are not necessarily sequential.
Therefore, linear and conformational B-cell epitopes are also known as continuous and
discontinuous B-cell epitopes, respectively. Antibodies recognizing linear B-cell epitopes can
recognize denatured antigens, while denaturing the antigen results in loss of recognition for
conformational B-cell epitopes. Most B-cell epitopes (approximately a 90%) are conformational
and in fact only a minority of native antigens contains linear B-cell epitopes.

Gambar 5.2 Linear and conformational B-cell epitopes

B-cell epitopes are determined by structural studies that require solving the 3D-structure of
antigen-antibody complexes using X-ray crystallography, nucleic magnetic resonance (NMR)
or electron microscopy (EM). Alternatively, B-cell epitopes can be identified by functional assays
in which the antigen is mutated and the interaction antibody–antigen is evaluated and by screening
of peptide libraries for antibody binding (Potocnakova et al., 2016). B-cell epitope prediction aims
to facilitate B-cell epitope identification with the practical purpose of replacing the antigen for
antibody production or for carrying structure-function studies.
Naïve T cells can express one of two different molecules, CD4 or CD8, on their surface, as
shown in Figure 3, and are accordingly classified as CD4 + or CD8+ cells. These molecules are
important because they regulate how a T cell will interact with and respond to an APC. Naïve
CD4+ cells bind APCs via their antigen-embedded MHC II molecules and are stimulated to
become helper T (TH) lymphocytes, cells that go on to stimulate B cells (or cytotoxic T cells)
directly or secrete cytokines to inform more and various target cells about the pathogenic threat. In
contrast, CD8+ cells engage antigen-embedded MHC I molecules on APCs and are stimulated to
become cytotoxic T lymphocytes (CTLs), which directly kill infected cells by apoptosis and emit
cytokines to amplify the immune response. The two populations of T cells have different
mechanisms of immune protection, but both bind MHC molecules via their antigen receptors called
T cell receptors (TCRs). The CD4 or CD8 surface molecules differentiate whether the TCR will
engage an MHC II or an MHC I molecule. Because they assist in binding specificity, the CD4 and
CD8 molecules are described as coreceptors.
Gambar 5.2 Cara kerja sel Tc dan sel Th
 BAB VI
IMUNOGLOBULIN ATAU ANTIBODI

Sel B setelah menjalani proses maturasi, akan mengalami diferensiasi dan akan membentuk
3 macam sel B yaitu sel memori, sel yang mempresentasikan antigen ke sel T serta sel yang
menghasilkan antibodi. Sel B memori akan berperan mengenali antigen yang menyerang tubuh
untuk kedua kali. Sel B yang mempresentasikan antigen ke sel T bertindak sebagai APC.
Sedangkan sel B yang berperan menghasilkan antibodi, akan dihancurkan ketika benda asing yang
masuk dalam tubuh telah dimusnahkan. Antibodi akan dihasilkan jika ada benda asing yang masuk
ke dalam tubuh. Antibodi akan menempel pada antigen yang dihasilkan oleh benda asing tersebut.
Setelah itu, antibodi akan menggumpalkan benda asing tersebut sehingga menjadi tidak aktif atau
berperan sebagai sinyal bagi sel-sel fagosit.
Beberapa cara kerja antibodi yaitu netralisasi, penggumpalan, pengendapan, dan
pengaktifan sistem komplemen. Netralisasi terjadi jika antibodi memblokir beberapa tempat
antigen berikatan dan membuatnya tidak aktif. Antibodi menetralkan virus dengan menempel pada
tempat yang seharusnya berikatan dengan sel inang. Selain itu, antibodi menetralkan bakteri dengan
menyelimuti bagian beracun bakteri dengan antibodi. Hal tersebut menetralkan racun bakteri
sehingga sel fagosit dapat mencerna bakteri tersebut. Penggumpalan (aglutinasi) bakteri, virus,
atau sel patogen lain oleh antibodi merupakan salah satu cara yang cukup efektif. Hal ini dapat
dilakukan karena antibodi memiliki minimal dua daerah ikatan (binding site). Cara ini memudahkan
sel fagosit menangkap sel-sel patogen tersebut. Cara ketiga mirip dengan penggumpalan.
Pengendapan dilakukan pada antigen terlarut oleh antibodi. Hal ini untuk membuat antigen terlarut
tidak bergerak dan memudahkan ditangkap oleh sel fagosit. Cara terakhir merupakan perpaduan
antara antibodi dan sistem komplemen. Antibodi yang berikatan dengan antigen akan
mengaktifkan sistem komplemen untuk membentuk pori pada sel mikroba patogen. Pembentukan
pori ini menyebabkan enzim lisozim dapat masuk dan sel patogen tersebut akan hancur (lisis).
Struktur antobodi/imunoglobulin merupakan rangkaian 4 rantai polipeptida yang terdiri
dari 2 rantai “berat” (Heavy Chain =H) dan 2 rantai “ringan” (Light Chain = L) yang tersusun
secara simetris dan saling berhubungan satu sama lainnya melalui ikatan disulfida (Interchain
Disulfide Bonds).
 Gambar 6.1 Struktur immunoglobulin/antibodi

Beberapa jenis immunoglobulin (Ig) yang dihasilkan oleh sel B adalah:

1. Ig G
Imunoglobulin ini diproduksi terbanyak sebagai antibodi utama dalam proses sekunder dan
merupakan pertahanan tubuh yang penting terhadap bakteri dan virus. Mampu menyebar
dengan mudah ke dalam celah ekstravaskuler dan mempunyai peranan penting menetralisir
toksin mikroba, serta melekat pada mikroba sebagai persiapan fagositosis. Imonoglobulin ini
mampu menembus jaringan plasenta sehingga bertindak sebagai proteksi utama pada bayi
terhadap infeksi selama beberapa minggu pertama setelah lahir. Selain itu, Ig G yang diberada
dalam kolostrum ASI (Air Susu Ibu) dapat menembus mukosa usus bayi dan menambah daya
kekebalan. Ig G mempunyai dua tempat pengikatan antigen yang sama (divalen) dan dikenal
memiliki 4 subkelas yaitu Ig G1, Ig G2, Ig G3 dan Ig G4. Perbedaannya terletak pada rantai-H
dengan beberapa fungsi biologis serta jumlah dan lokasi ikatan disulfida.

Gambar 6.2 Perbedaan struktur Ig G

2. Ig A
Imunoglobulin ini banyak terdapat pada susu, air liur, air mata dan dalam sekresi pernapasan,
saluran genital serta saluran pencernaan atau usus (Corpo Antibodies). Imunoglobulin ini
melindungi selaput mukosa dari serangan bakteri dan virus dengan bekerjasama dengan enzim
lisozim serta komplemen. Ig A terdiri atas dua subkelas yaitu Ig A1 (terletak di serum darah)
dan Ig A2 (terletak di air liur, air mata, kolostrum).
3. Ig M
Imunoglobulin ini pertama kali dibentuk ketika antigen masuk ke dalam tubuh. Ig M terdapat
pada semua permukaan sel B, paling sering bereaksi di antara semua imunoglobulin, sangat
efisien untuk reaksi aglutinasi dan reaksi sitolitik, dan dapat bekerjasama dengan komplemen.
Dikarenakan cepat terbentuk ketika terjadi infeksi dan tetap tinggal dalam darah, maka Ig M
merupakan daya tahan tubuh yang penting untuk bakteri dan virus. Immunoglobulin ini dapat
diproduksi oleh janin yang terinfeksi.
4. Ig E
Imunoglobulin ini di dalam serum ditemukan dalam konsentrasi sangat rendah. Ig E pada
serum darah akan meningkat selama infeksi parasit cacing. Ig E juga berperan dalam proses
alergi. Reaksi alergi setelah terkena zat alergen membutuhkan waktu yang disebut dengan
proses sensitisasi yaitu masa sejak kontak dengan alergen hingga terjadi reaksi alergi. Proses ini
dapat terjadi singkat yaitu beberapa bulan atau dalam waktu lama yaitu hingga tahunan. Reaksi
alergi dapat terjadi jika kadar Ig E sudah cukup banyak. Pada awal kontak dengan alergen
mulai timbul perlawanan dari tubuh yang memiliki bakat atopik, yaitu terbentuknya antibodi
atau imunoglobulin yang spesifik. Jika kontak dengan alergen ini terjadi secara terus menerus,
kadar Ig E yang spesifik terhadap alergen semakin banyak hingga suatu saat dapat
menimbulkan reaksi alergi bila terpapar lagi oleh alergen tersebut. Di dalam jaringan tubuh, Ig
E yang bereaksi pada zat alergen menempel pada sel mast. Jika Ig E bertemu dengan zat
alergen, maka sel mast ini akan mengalami degranulasi (pecah) dan mengeluarkan zat-zat
seperti Interlaukin-4 (IL-4), histamin, kinin, dan bradikinin. IL-4 dapat merangsang sel B untuk
menghasilkan Ig E lebih banyak lagi, sedangkan histamin, kinin, dan bradikinin menyebabkan
timbulnya gejala-gejala alergi seperti gatal-gatal (biduran), asma, diare, muntah, ruam pada
kulit, mata merah, dan sakit kepala.
5. Ig D
Imunoglobulin ini fungsi keseluruhannya belum diketahui secara jelas. Ig D ditemukan dalam
jumlah yang sangat sedikit dalam serum darah. Ig D dapat juga bertindak sebagai reseptor
antigen apabila berada pada permukaan sel B tertentu dalam darah tali pusar janin dan mungkin
merupakan reseptor pertama terhadap antigen sebelum diambil alih fungsinya oleh Ig M dan
imunoglobulin lainnya, setelah sel tubuh berdiferensiasi lebih jauh.

Gambar 6.3 Perbedaan struktur beberapa jenis immunoglobulin (Ig)

 BAB VII
COVID-19, RAPID TEST DAN SWAB TEST

A novel coronavirus (CoV) is a new strain of coronavirus. The disease caused by the novel
coronavirus first identified in Wuhan, China, has been named coronavirus disease 2019 (COVID-
19) – ‘CO’ stands for corona, ‘VI’ for virus, and ‘D’ for disease. Formerly, this disease was referred
to as ‘2019 novel coronavirus’ or ‘2019-nCoV.’ The COVID-19 virus is a new virus linked to the
same family of viruses as Severe Acute Respiratory Syndrome (SARS) and some types of common
cold.

Gambar 7.1 Struktur tubuh corona virus

The virus is transmitted through direct contact with respiratory droplets of an infected
person (generated through coughing and sneezing), and touching surfaces contaminated with the
virus. The virus may survive on surfaces for several hours, but simple disinfectants can kill it.
Symptoms can include fever, cough, and shortness of breath. In more severe cases, infection can
cause pneumonia or breathing difficulties. More rarely, the disease can be fatal. These symptoms
are similar to the flu (influenza) or the common cold, which are a lot more common than novel
coronavirus. This is why testing is required to confirm if someone has novel coronavirus. It’s
important to remember that key prevention measures are the same – frequent hand washing, and
respiratory hygiene (cover your cough or sneeze with a flexed elbow or tissue, then throw away the
tissue into a closed bin). Also, there is a vaccine for the flu – so remember to keep yourself and your
child up to date with vaccinations. Here are four precautions you and your family can take to avoid
infection:
1. Wash your hands frequently using soap and water or an alcohol-based hand rub
2. Cover mouth and nose with flexed elbow or tissue when coughing or sneezing. Dispose of
used tissue immediately
3. Avoid close contact with anyone who has cold or flu-like symptoms
4. Seek medical care early if you or your child has a fever, cough or difficulty breathing
 Masks help stop the COVID-19 virus from spreading. To help you take the best decisions for
your family, we’ve rounded up the latest expert information on masks and COVID-19, how to wear
and look after masks correctly, and ideas on how to successfully introduce them to your family.
This is a new virus and we do not know enough yet about how it affects children or pregnant
women. We know it is possible for people of any age to be infected with the virus, but so far there
have been relatively few cases of the novel coronavirus reported among children. The virus is fatal
in rare cases, so far mainly among older people with pre-existing medical conditions. At this time,
there is not enough evidence to determine whether the virus is transmitted from a mother to her
baby during pregnancy, or the potential impact this may have on the baby. This is currently being
investigated. Pregnant women should continue to follow appropriate precautions to protect
themselves from exposure to the virus, and seek medical care early, if experiencing symptoms, such
as fever, cough or difficulty breathing.

Perbedaan Rapid Test dan Swab Test

Rapid Test merupakan bentuk skrining awal terhadap infeksi covid-19. Uji ini dilakukan
dengan menggunakan sampel darah dan hanya memerlukan waktu 10-15 menit untuk mengetahui
hasilnya. Uji ini bekerja dengan cara mendeteksi keberadaan antibodi di dalam darah berupa IgM
dan IgG. IgM dan IgG adalah antibodi yang terbentuk di dalam tubuh dikarenakan terdapat
mikroorganisme yang menginfeksi misalnya covid-19. Antibodi ini terbentuk sekitar 2-4 minggu
setelah tubuh terinfeksi mikroorganisme.
Rapid test sejauh ini belum terbukti akurat dalam mendeteksi apakah seseorang terinfeksi
covid-19 atau tidak. Hal ini dikarenakan hasil positif pada rapid test menunjukkan bahwa terdapat
mikroorganisme yang masuk ke dalam tubuh. Mikroorganisme tersebut bisa jadi covid-19 atau bisa
jadi virus lain atau bakteri atau mungkin protozoa. Misalnya saja seseorang terkena malaria
dikarenakan Plasmodium sp., rapid test pun akan menunjukkan hasil yang positif dikarenakan
Plasmodium sp. juga menyebabkan kenaikan antibodi IgM dan IgG dalam tubuh. Sebaliknya,
apabila hasil rapid test menunjukkan negatif bukan berarti orang tersebut terbebas sama sekali dari
covid-19. Hasil negatif tersebut bisa jadi dikarenakan uji rapid yang dilakukan pada saat orang
tersebut baru terinfeksi covid-19 (belum 2 minggu). Antibodi IgM dan IgG belum terbentuk dalam
jumlah banyak sehingga jika di tes rapid akan menunjukkan hasil negatif.
Pada alat rapid test, terdapat beberapa notasi atau tanda yang harus dipahami pula. Notasi C
artinya adalah control yang artinya bahwa apabila setelah ditetesi darah dan tidak terbentuk strip
merah pada tulisan C maka menunjukkan bahwa alat yang digunakan rusak atau jumlah darah yang
diteteskan kurang banyak. Tanda M menunjukkan keberadaan IgM dan tanda G menunjukkan
keberadaan IgG. Apabila terbentuk strip pada tanda M atau tanda G atau pada keduanya, berarti
terdapat indikasi bahwa orang tersebut terkena covid-19 dan perlu dilanjutkan dengan swab test.

Gambar 7.2 Notasi atau tanda pada alat rapid test

Swab test merupakan uji lanjutan terhadap infeksi covid-19. Uji ini dilakukan menggunakan
sampel lendir yang ada di hidung atau tenggorokan. Uji ini memerlukan waktu yang lebih lama
daripada rapid test yaitu beberapa jam sampai beberapa hari. Sampel lendir yang telah didapatkan
akan dianalisis menggunakan metode Polimerase Chain Reaction (PCR) dan dibaca hasilnya
menggunakan elektroforesis. Prinsip kerja PCR adalah menggandakan fragmen-fragmen
DNA/RNA secara cepat dalam waktu singkat. Proses ini dimulai dengan cara sampel lendir yang
sudah didapatkan kemudian di sentrifuse untuk memisahkan antara materi genetik (DNA atau
RNA) dari bagian sel yang lain. setelah itu, sampel DNA/RNA yang sudah didapatkan ditambahkan
buffer, enzim polymerase dan primer. Tiga tahap kerja PCR dalam satu siklus yaitu :
1. Denaturasi. Pada tahap ini, ikatan hidrogen DNA terputus (denaturasi) sehingga membentuk
untai tunggal. Tahap ini berlangsung pada suhu tinggi, yaitu 94–96°C. Pemisahan ini
menyebabkan DNA tidak stabil dan siap menjadi template bagi primer. Tahap ini berlangsung
selama 1–2 menit.
2. Annealing. Primer menempel pada bagian DNA template yang komplementer urutan basanya.
Tahap ini dilakukan pada suhu antara 45–60°C. Penempelan ini bersifat spesifik. Suhu yang
tidak tepat menyebabkan tidak terjadinya penempelan atau primer menempel di sembarang
tempat. Tahap ini berlangsung selama 1–2 menit.
3. Elongasi. Suhu untuk proses ini tergantung dari jenis DNA-Polimerase yang dipakai. Proses ini
biasanya dilakukan pada suhu 76 °C. Tahap ini berlangsung selama 1 menit.
 Gambar 7.3 Hasil elektroforesis

Urutan DNA/RNA hasil PCR sampel kemudian dimasukkan dalam alat bernama
elektroforesis untuk dibaca dan dibandingkan dengan kontrol yang berisi urutan DNA/RNA
organisme yang diinginkan. Apabila pita-pita berpendar yang ada pada sampel memiliki kemiripan
dengan pita-pita yang terbentuk dari DNA/RNA kontrol misalnya diisi covid-19, maka dapat
disimpulkan bahwa orang yang diuji positif terinfeksi covid-19.
Hanya saja, primer yang digunakan dalam PCR covid-19 ini sampai sekarang belum ada
yang spesifik dan masih menggunakan primer untuk menganalisis virus corona secara umum yaitu
primer yang digunakan pula untuk pendeteksian infeksi virus SARS dan MERS. Oleh karena itu,
apabila hasil PCR menunjukkan hasil positif sebenarnya belum bisa menunjukkan 100% bahwa
orang tersebut pasti terkena covid-19. Bisa jadi orang tersebut terkena virus SARS atau MERS atau
virus corona jenis lain.
 BAB VIII
RESPON IMUN SELULER

Neutrophil Cells
Neutrophil granulocytes (frequently designated PMN, for polymorphonuclear leukocytes)
are able to directly recognize and phagocytize many bacteria, but not the most crucial
polysaccharide-capsulated pathogens. These agents are only recognized and phagocytized following
opsonization with complement, via complement receptors on the neutrophil. How do neutrophils
find their way from the blood stream to their site of action? From the site of infection, a host of
molecules diffuse in all directions, eventually reaching endothelial cells of neighboring vessels.
These molecules include LPS (lipopolysaccharide) derived from bacteria, C3a, C4a, C5a and
signaling molecules from the first macrophages on the scene, e.g., the chemokine IL-8, TNFα and
leukotriene B4. Endothelial cells quickly react to these signals with changes in their expression
pattern, exposing new proteins such as ICAM-1 and -2 on their membranes which are then tightly
bound by cell-cell contact proteins of neutrophils and other leukocytes rolling past. Neutrophils are
normally rolling along the endothelium by dynamic contacts between their sialyl-Lewis-x-
carbohydrates and selectin proteins on the endothelial plasma membrane. Binding of the ICAMs by
PMN-integrins brings the neutrophil to a sudden stop. It squeezes through between two endothelial
cells and, along the chemotactic gradient, approaches the focus of infection. There, neutrophils
phagocytize and kill bacteria. In addition, neutrophils can target pathogens outside the cells by
ejecting their DNA —or rather chromatin— in the form of nets laden with toxic granule contents
(neutrophil extracellular traps = NET). Cells either die in the NET-forming process, or they just
eject their nucleus plus enzymes while remaining intact for another short while, continuing to
phagocytize. Once activated, neutrophils quickly die, as the harsh conditions necessary to kill
bacteria also lead to irreparable cell damage. Their remains are picked up by macrophages.

Basophils Cells
Basophils are a type of white blood cell. Basophils are the least common type
of granulocyte, representing about 0.5% to 1% of circulating white blood cells. However, they are
the largest type of granulocyte. They are responsible for inflammatory reactions during immune
response, as well as in the formation of acute and chronic allergic diseases,
including anaphylaxis, asthma, atopic dermatitis and hay fever. They also produce compounds that
co-ordinate immune responses, including histamine and serotonin that induce inflammation, heparin
that prevents blood clotting, although there are less than that found in mast cell granules. Mast cells
were once thought to be basophils that migrated from blood into their resident tissues (connective
tissue), but they are now known to be different types of cells.
Basophils were discovered in 1879 by German physician Paul Ehrlich, who one year earlier
had found a cell type present in tissues that he termed mastzellen (now mast cells). Ehrlich received
the 1908 Nobel Prize in Physiology or Medicine for his discoveries.The name comes from the fact
that these leukocytes are basophilic, i.e., they are susceptible to staining by basic dyes, as shown in
the picture. Basophils contain large cytoplasmic granules which obscure the cell nucleus under
the microscope when stained. However, when unstained, the nucleus is visible and it usually has
two lobes. The mast cell, another granulocyte, is similar in appearance and function. Both cell types
store histamine, a chemical that is secreted by the cells when stimulated. However, they arise from
different branches of hematopoiesis, and mast cells usually do not circulate in the blood stream, but
instead are located in connective tissue. Like all circulating granulocytes, basophils can be recruited
out of the blood into a tissue when needed.
Basophils appear in many specific kinds of inflammatory reactions, particularly those that
cause allergic symptoms. Basophils contain anticoagulant heparin, which prevents blood from
clotting too quickly. They also contain the vasodilator histamine, which promotes blood flow to
tissues. They can be found in unusually high numbers at sites of ectoparasite infection, e.g., ticks.
Like eosinophils, basophils play a role in both parasitic infections and allergies. [10] They are found
in tissues where allergic reactions are occurring and probably contribute to the severity of these
reactions. Basophils have protein receptors on their cell surface that bind IgE,
an immunoglobulin involved in macroparasite defense and allergy. It is the bound IgE antibody that
confers a selective response of these cells to environmental substances, for
example, pollen proteins or helminth antigens. Recent studies in mice suggest that basophils may
also regulate the behavior of T cells and mediate the magnitude of the secondary immune response.

Eosinophils Cells
Eosinophils, sometimes called eosinophiles or, less commonly, acidophils, are a variety
of white blood cells and one of the immune system components responsible for combating
multicellular parasites and certain infections in vertebrates. Along with mast cells and basophils,
they also control mechanisms associated with allergy and asthma. They are granulocytes that
develop during hematopoiesis in the bone marrow before migrating into blood, after which they are
terminally differentiated and do not multiply. These cells are eosinophilic or "acid-loving" due to
their large acidophilic cytoplasmic granules, which show their affinity for acids by their affinity
to coal tar dyes: Normally transparent, it is this affinity that causes them to appear brick-red
after staining with eosin, a red dye, using the Romanowsky method. The staining is concentrated in
small granules within the cellular cytoplasm, which contain many chemical mediators, such
as eosinophil peroxidase, ribonuclease (RNase), deoxyribonucleases (DNase), lipase, plasminogen,
and major basic protein. These mediators are released by a process called degranulation following
activation of the eosinophil, and are toxic to both parasite and host tissues.
In normal individuals, eosinophils make up about 1–3% of white blood cells, and are about
12–17 micrometres in size with bilobed nuclei. While they are released into the bloodstream as
neutrophils, eosinophils reside in tissue, They are found in the medulla and the junction between
the cortex and medulla of the thymus, and, in the lower gastrointestinal tract, ovaries, uterus, spleen,
and lymph nodes, but not in the lungs, skin, esophagus, or some other internal organs under normal
conditions. The presence of eosinophils in these latter organs is associated with disease. For
instance, patients with eosinophilic asthma have high levels of eosinophils that lead to inflammation
and tissue damage, making it more difficult for patients to breathe. Eosinophils persist in the
circulation for 8–12 hours, and can survive in tissue for an additional 8–12 days in the absence of
stimulation. Pioneering work in the 1980s elucidated that eosinophils were unique granulocytes,
having the capacity to survive for extended periods of time after their maturation as demonstrated
by ex-vivo culture experiments. Following activation, eosinophils effector functions include
production of the following:
 Cationic granule proteins and their release by degranulation
 Reactive oxygen species such as hypobromite, superoxide, and peroxide (hypobromous acid,
which is preferentially produced by eosinophil peroxidase)
 Lipid mediators like the eicosanoids from the leukotriene (e.g., LTC4, LTD4, LTE4)
and prostaglandin (e.g., PGE2)
 Enzymes, such as elastase
 Growth factors such as TGF beta, VEGF, and PDGF
 Cytokines such as IL-1, IL-2, IL-4, IL-5, IL-6, IL-8, IL-13, and TNF alpha
There are also eosinophils that play a role in fighting viral infections, which is evident from the
abundance of RNases they contain within their granules, and in fibrin removal during inflammation.
Eosinophils, along with basophils and mast cells, are important mediators of allergic
responses and asthma pathogenesis and are associated with disease severity. They also
fight helminth (worm) colonization and may be slightly elevated in the presence of certain parasites.
Eosinophils are also involved in many other biological processes, including postpubertal mammary
gland development, oestrus cycling, allograft rejection and neoplasia. They have also been
implicated in antigen presentation to T cells.
Eosinophils are responsible for tissue damage and inflammation in many diseases, including
asthma. High levels of interleukin-5 has been observed to up regulate the expression of adhesion
molecules, which then facilitate the adhesion of eosinophils to endothelial cells, thereby causing
inflammation and tissue damage. An accumulation of eosinophils in the nasal mucosa is considered
a major diagnostic criterion for allergic rhinitis (nasal allergies).

NK Cells
Natural killer (NK) cells are similar in appearance and function to cytotoxic T lymphocytes,
but lack the receptor T cells are using to identify virus-infected cells (the T cell receptor): they are
counted among the innate lymphoid cells. So how do they recognize cells that should be killed?
One of the cellular properties activating NK cells may be characterized by the catch phrase missing
or altered self. NK cells are important in the early phases of defense against certain viruses, but also
against other infectious agents, as well as for the elimination of rogue cells to prevent tumor
formation. They express two types of receptors: activating and inhibiting. The inhibiting receptors
sense the presence of normal MHC-I molecules on cells probed by the NK cell. A cell with normal
MHC-I will be left alone. A cell lacking MHC-I or expressing altered MHC-I (missing or altered
self, MHC-I=self), however, is only recognized by the activating NK receptors and will be killed by
induction of apoptosis. Many viruses, especially herpes viruses, inhibit MHC-I expression in
infected cells. Viruses using this trick have a selective advantage later on, as these cells cannot be
identified as infected by cytotoxic T cells. Yet, with this strategy they make themselves vulnerable
to attack by NK cells. In addition, NK cells may be activated by alternative mechanisms. Under
conditions of cellular stress, many cells express proteins like MICA (MHC I-chain-related A),
which act as ligands for an activating NK receptor, NKG2D (natural killer group 2, member D).
In some cells, this happens as the result of oncogenic transformation. High expression levels
of MICA cause NK cells to axe these questionable cells: better safe than sorry! Except by direct
cell-cell contact, NK cells may be activated by cytokines, especially IL-12. In turn, NK cells
respond by secreting cytokines, primarily IFNγ, which acts as a spur to effort on macrophages. The
importance of this mechanism has been shown in the early defense against the protozoon
Leishmania, which is spread by sand flies. Leishmania species are taken up into macrophages, but
manage to lull them into an inactive state. In defense, dendritic cells, which also recognise
Leishmania, activate NK cells via IL-12. Via IFNγ, NK cells then try to incite the macrophages to
kill off the intracellular parasites. 16 Although NK cells are part of the non-adaptive immune
system, they can also be directed to target structures by antibodies, in a mechanism termed
antibody-dependent cellular cytotoxicity (ADCC).
 Gambar 8.1 Structure mast cells, dendritic cells, macrophage cells, NK cells, Basophil cells, Eosinophil cells and
Neutrophil cells

Dendritic cells
What is the difference between macrophages and dendritic cells? Macrophages are more on
the non-adaptive side of defense. They are "heavy earth moving equipment", as their name implies,
able to phagocytize large amounts of particulate matter. Dendritic cells are mainly on the adaptive
side of defense: their main goal is to gather all kinds of antigenic materials, take it to the lymph
node and show it to T cells. They are able to phagocytize, but don't do the heavy lifting. Many
antigens are taken up by macropinocytosis ("drinking a whole lot"), a mechanism of taking up large
gulps of surrounding fluids with all soluble antigens. A third way for dendritic cells to take up
antigens is by being infected with viruses, which, as we shall see later, is important to start an
adaptive antiviral immune response. Many of our dendritic cells are quite long-lived, having
originated during developmental stages before birth from hematopoietic cells in the wall of the yolk
sac or the fetal liver. Later, dendritic cells are also produced in the bone marrow.
Dendritic cells have two stages of life: while functionally young and immature, they roam
the periphery, eagerly collecting stuff but lacking the tools to activate T cells. Where they go is
determined by chemokine receptors, with which they follow the chemokine trail into peripheral
tissues. When everything is quiet, some (like Langerhans cells) may sit in their target tissues for
years on end, others for just a few days, but any "traumatic" infection with heavy TLR signaling
induces them to mature and to rush to the lymph node, now following chemokines that are
recognized by newly expressed chemokine receptor 7 (CCR7). Mature dendritic cells have lost the
ability to take up antigen, but have everything needed for a productive relation with T cells, most
prominently lots of MHC and B7 molecules. By secreting chemokine CCL18, these battle-
hardened, worldly-wise dendritic cells are especially attractive to young, naive T cells, the
implications of which will only become clear later).
Macrophages are specialised cells involved in the detection, phagocytosis and destruction of
bacteria and other harmful organisms. In addition, they can also present antigens to T cells and
initiate inflammation by releasing molecules (known as cytokines) that activate other cells.
Macrophages originate from blood monocytes that leave the circulation to differentiate in different
tissues. There is a substantial heterogeneity among each macrophage population, which most
probably reflects the required level of specialisation within the environment of any given tissue.
This heterogeneity is reflected in their morphology, the type of pathogens they can recognise, as
well as the levels of inflammatory cytokines they produce (i.e. IL-1, IL-6, tumour necrosis factor
alpha). In addition, macrophages produce reactive oxygen species, such as nitric oxide, that can kill
phagocytosed bacteria.The heterogeneous nature of these cells may not solely be the result of their
differentiation process, but it is likely to be inherited from their monocyte precursors.
Macrophages migrate to and circulate within almost every tissue, patrolling for pathogens or
eliminating dead cells. The table below describes the location and function of a few different
macrophage populations.

Type of macrophage Location Function

Phagocytosis of small particles, dead cells or bacteria.

Alveolar macrophage Lung alveoli Initiation and control of immunity to respiratory
pathogens

Initiate immune responses and hepatic tissue

Kupffer cells Liver
remodelling.

Elimination of old or dead neurons and control of

Microglia Central nervous system
immunity in the brain.

Splenic macrophages
Spleen marginal zone,
(marginal zone, metallophilic Elimination of dysfunctional or old red blood cells.
red and white pulp
and red pulp macrophages)

Macrophages are able to detect products of bacteria and other microorganisms using a system of
recognition receptors such as Toll-like receptors (TLRs). These receptors can bind specifically to
different pathogen components like sugars (LPS), RNA, DNA or extracellular proteins (for
example, flagellin from bacterial flagella).
Mast cells
Mast cells are important cells of the immune system and are of the hematopoietic lineage.
Mast cells are originated from pluripotent progenitor cells of the bone marrow, and mature under
the influence of the c-kit ligand and stem cell factor in the presence of other distinct growth factors
provided by the microenvironment of the tissue where they are destined to reside. Under normal
conditions, mature mast cells do not circulate in the bloodstream. However, mast cell progenitors
migrate into tissues and differentiate into mast cells under the influence of stem cell factor and
various cytokines. Mast cells are present throughout the body and they play important roles in the
maintenance of many physiological functions as well as in the pathophysiology of diseases.
Accordingly, this review is focused on the role of mast cells in a wide range of physiological
functions and pathogenesis of a variety of disease states.
Mast cells are found in mucosal and epithelial tissues throughout the body. In rodents, mast
cells also reside in peritoneal and thoracic cavities. Mast cells are found in all vascularized tissues
except for the central nervous system and the retina. Mast cells are located at the junction point of
the host and external environment at places of entry of antigen (gastrointestinal tract, skin,
respiratory epithelium). Mast cells are located in areas below the epithelium in connective tissue
surrounding blood cells, smooth muscle, mucous, and hair follicles.
The cytoplasm of the mast cell contains 50–200 large granules that store inflammatory
mediators, including histamine, heparin, a variety of cytokines, chondroitin sulfate, and neutral
proteases. In order for mast cells to migrate to their target locations, the co-ordinated effects of
integrins, adhesion molecules, chemokines, cytokines, and growth factors are necessary. Mast cell
progenitors are found in high numbers in the small intestine. CXCR2 expressed on mast cell
progenitors directs their migration to the small intestine. Binding of α4β7 integrins (expressed on
mast cells) to adhesion molecule VCAM-1 on the endothelium initiates the transit of mast cell
precursors out of the circulation.
The lungs do not have many mast cell progenitors in a normal physiological state. Upon
antigen-induced inflammation of the respiratory endothelium, mast cell progenitors are recruited by
engaging α4β7 integrins, VCAM-1, and CXCR2. Additionally, CCR-2 and CCL-2 are involved in
the recruitment of mast cell progenitors to the respiratory endothelium. When mature mast cells are
activated and degranulated, more mast cell progenitors are recruited to the site of inflammation.
There are two phenotypes of human mast cells: mucosal mast cells that produce only
tryptase and connective tissue mast cells that produce chymase, tryptase, and carboxypeptidases.
Mast cell activation and mediator release have different effects in various tissues and organs. Most
common sites in the body exposed to antigens are the mucosa of the respiratory tract (airborne),
gastrointestinal tract (food borne), blood (wounds, absorption from respiratory tract/gastrointestinal
tract), and connective tissues.
When the gastrointestinal tract is exposed to an antigen, its response is to increase fluid
secretion, increase smooth muscle contraction, and increase peristalsis. Proteins derived from
different plants and animals can act as antigens and activate the immune system in vulnerable
subjects. The antigen (peptide) permeates through the epithelial layer of the mucosa of the gut and
binds to IgE on mucosal mast cells. These peptides are presented to Th2 cells, and if there is an IgE
antibody against the peptide present, it will cause activation of the mast cell resulting in an immune
response. This causes mast cells to degranulate and release a variety of inflammatory mediators.
These mediators increase vascular permeability, causing edema in the gut epithelium and smooth
muscle contraction, which lead to vomiting and diarrhea. This type of reaction can occur in
response to peptides found in certain medications. Food allergens can also cause skin reactions.
Uptake from the gastrointestinal tract can introduce antigens into the blood, which are transported
throughout the body where they bind to IgE on mast cells in the connective tissue in the deep layers
of the skin. This results in urticarial reaction and angioedema.
In the respiratory tract, the immune response to mast cell activation results in airway
constriction, increased mucous production, and cough. The most common introduction of antigens
to the respiratory tract is via inhalation. Mucosal mast cells in the nasal epithelium are activated by
antigens that diffuse across the mucosa after being inhaled. In the respiratory tract, mast cell
degranulation increases vascular permeability and local edema, which can obstruct nasal airways
and lead to congestion. There is increased production of mucus and its accumulation can block off
the sinuses and result in a bacterial infection. Mast cells also play a pivotal role in the
pathophysiology of allergic asthma. This is caused by an inflammatory response in the airways,
which results from inhaled antigens that get into the lower respiratory tract and cause mast cell
degranulation and local inflammation. These events lead to increased vascular permeability, fluid
accumulation, and edema, which can obstruct the airways. Bronchial constriction can occur due to
smooth muscle contraction, which can lead to airway obstruction that is seen in asthma. Air is,
therefore, trapped and total lung capacity is increased while forced expiratory volume in 1 s (FEV1)
and forced vital capacity (FVC) are decreased. In the blood vessels, increased vascular permeability
leads to edema and local inflammation, which results in antigen transport to the lymph nodes.
In the skin, antigens, via IgE, activate mast cells in the deep layers of connective tissue.
Mast cells release histamine as well as other vasoactive molecules, which cause urticaria (hives). If
the antigen activates mast cells in deeper tissue, this can lead to angioedema. If the response is
prolonged, atopic dermatitis or eczema may occur. Eczema is seen clinically as a chronic itching
skin rash with raised lesions and fluid discharge. Eczema is more commonly seen in childhood
while allergic rhinitis and asthma are seen throughout life.
Mast cells are known for their main mechanism of action: IgE-mediated allergic reactions
through the FcϵRI receptor. IgE antibodies are produced by mature B cells in response to CD4+ Th2
cells. Naïve mature B cells produce IgM and IgD antibodies. Once they become activated by an
antigen, B cells will proliferate. If these B cells interact with cytokines, such as IL-4 (which is
modulated by CD4+ Th2 cells), the antibody class switches from IgM to IgE (12). IgE is mostly
found bound to FcϵRI receptors on the mast cell, and very little IgE is found as a soluble antibody
in circulation. When an antigen comes in contact with the mast cell, it crosslinks two or more FcϵRI
molecules and activates the release of granules from the mast cell. IgE is found in the connective
tissue under epithelial layers of the skin, in the respiratory tract, and also in the gastrointestinal
tract. In addition to FcϵRI, mast cells also express Fc receptors for IgA and IgG, receptors for
adenosine, C3a, chemokines, cytokines, and pathogen-associated molecular patterns (PAMPs), as
well as toll-like receptors (TLRs), all of which are involved in mast cell activation and immune
response.
The most common physiological pathway for mast cell activation is via antigen/IgE/FcϵRI
cross linking. FcϵRI consists of an α-chain that binds to IgE, a β-chain, which spans the membrane,
and γ chains, which are a disulfide-linked homodimer. FcϵRI interacts with LYN tyrosine kinase,
which phosphorylates the tyrosine in its immunoreceptor tyrosine bases activation motifs (ITAMs)
on the B and γ chains of the FcϵRI (15). Lyn activates Syk tyrosine kinases, which phosphorylates
signaling proteins, such as LAT1 and LAT2 (linkers for activation of T cells) (16). Phosphorylated
PLCγ hydrolyzes phosphatidylinositol-4,5-bisphosphate to make inositol-1,4,5-triphosphate (IP3)
and diacylglycerol (DAG). IP3 and DAG are second messengers and IP3 causes calcium
mobilization from the endoplasmic reticulum. Calcium release activates and causes NFκB to
translocate to the nucleus of the cell, which results in transcription of cytokines, such as IL-6,
TNFα, and IL-13. Zeb2 is involved in regulation of degranulation upon stimulation via FcϵRI.
Activation of FcϵRI activates Fyn (Src kinase).
Fyn regulates mast cell degranulation, which is complementary to the Lyn signaling
pathway. Fyn activates PI3K, which activates Akt and produces PIP3. This activates mTOR, which
is involved in mast cell chemotaxis and cytokine production. There are also receptors for IgG called
FcγR. The y-chain homodimer is the same in FcγRI as in FcϵRI so the signal sent from FcγR can
crosstalk with FcϵRI. Repeated and controlled exposure of mast cells to antigen can desensitize a
patient’s sensitivity. Although the mechanisms are not clearly understood, the slow and persistent
degranulation of mast cells is thought to be one of the mechanisms. The desensitization protocol is
used in patients who are allergic to certain drugs (e.g., penicillin) but need treatment for a life-
threatening bacterial infection that can only be treated with this drug.
Mast cell desensitization can occur from exposure to increasing doses of antigen. This
technique can be used if a patient is allergic to a necessary drug and prevention of anaphylactic
reactions to food. By desensitizing the receptors, this can decrease the number of FcϵRI molecules
available on the mast cell surface.
 BAB IX
SITOKIN

Sitokin adalah protein yang dihasilkan oleh sel B, sel T, sel makrofag, sel eusinofil, dan sel
mast yang dapat memicu aktivitas sistem imun non-spesifik maupun spesifik. Sampai saat ini telah
diketahui 200 protein yang berfungsi sebagai sitokin. Berdasarkan manfaatnya, sitokin dibedakan
menjadi:
1. Sitokin yang berperan dalam proses hematopoiesis yaitu SCF (Stem Cell Factor), IL-3
(Interleukin-3), IL-7, GM-CSF (Granulocyte Monocyte Colony Stimulating Factor), G-CSF
(Granulocyte Colony Stimulating Factor), dan M-CSF (Monocyte Colony Stimulating
Facto).

Gambar 9.1 Sitokin yang berperan dalam proses hematopoiesis

 SCF = fungsinya memicu stem cell menjadi progenitor myeloid dan limfoid
IL-3 = fungsinya proliferasi dan diferensiasi sel progenitor myeloid menjadi sel spesifik
yaitu eritrosit, trombosit, granulosit dan monosit
IL-7 = fungsinya proliferasi dan diferensiasi sel progenitor limfoid menjadi sel spesifik yaitu
sel B, sel T dan sel NK
GM-CSF = fungsinya memicu sel progenitor myeloid berubah menjadi sel granulosit
(eusinofil, basofil dan neutrofil) dan monosit
G-CSF = fungsinya memicu sel progenitor myeloid berubah menjadi sel granulosit
M-CSF = fungsinya memicu sel progenitor myeloid berubah menjadi sel monosit
2. Sitokin yang berperan dalam sistem imun non-spesifik yaitu IL-1, IL-6, IL-10, IL-12, IL-
15, IL-18, IL-33, IFN-α (Interferon-α), IFN-β, IFN-γ, kemokin, dan TNF (Tumor Necrosis
Factor).
IL-1 = fungsinya sebagai mediator inflamasi yang merupakan respon terhadap infeksi
IL-6 = fungsinya memicu pembentukan neutrofil dan memicu pertumbuhan serta
diferensiasi sel B menjadi sel mast yang memproduksi antibodi.
IL-10 = fungsinya mencegah produksi IL-12 sehingga dapat mencegah ekspresi
konstimulatori molekul MHC-II pada makrofag dan sel dendritik
IL-12 = fungsinya memicu produksi IFN-γ oleh sel NK dan sel T, diferensiasi sel Th
menjadi sel Th1 yang memproduksi IFN-γ, dan meningkatkan fungsi sitolitik sel NK serta
sel Tc.

Gambar 9.2 Beberapa sitokin yang berperan dalam sistem imun non-spesifik
 IL-15 = fungsinya memicu sel NK ketika terjadi infeksi karena virus
IL-18 = fungsinya memicu sel NK dan sel T memproduksi IFN-γ
IL-33 = fungsinya memicu aktivasi sel mast
IFN = fungsinya proteksi terhadap virus (IFN terdiri atas 2 yaitu IFN tipe I terdiri atas IFN-α
dan IFN-β serta IFN tipe II terdiri atas IFN-γ)
Kemokin = fungsinya sebagai kemoatraktan (pemandu) dan aktivasi sel limfosit
TNF = fungsinya menimbulkan respon inflamasi terhadap bakteri gram negatif, memicu dan
mengaktifkan neutrofil serta monosit untuk menghancurkan mikroba, dan memicu makrofag
untuk menghasilkan kemokin.
3. Sitokin yang berperan dalam sistem imun spesifik yaitu IL-2, IL-4, IL-5, IL-9, IL-13, IL-16,
IL-17, IL-23, IL-25, IL-31, IFN-γ, TGF-β (Tumor Growth Factor-β), dan limfotoksin.
IL-2 = fungsinya memicu proliferasi dan diferensiasi sel T, sel B, dan sel NK
IL-4 = fungsinya memicu sel B menghasilkan Ig G dan Ig E, serta diferensiasi sel Th
menjadi Th2
IL-5 = fungsinya mengaktifkan proses pematangan dan diferensiasi sel eusinofil, dan
aktivasi sel T
IL-9 = fungsinya memicu proliferasi sel T, maturasi sel eusinofil, proliferasi dan
pematangan sel mast sehingga memproduksi IL-6
IL-13 = fungsinya mencegah aktivasi IFN-γ
IL-16 = fungsinya multipel (mengaktifkan banyak sel misalnya sel Th, monosit, eusinofil,
dan sel dendritik)

Gambar 9.3 Beberapa sitokin yang berperan dalam sistem imun spesifik
 IL-17 = fungsinya memicu produksi TNF, IL-1 dan kemokin
IL-23 = fungsinya memicu sel Th menghasilkan IL-17
IL-25 = fungsinya memicu sel Th2 memproduksi IL-4, IL-5 dan IL-13
IL-31 = fungsinya memicu sel monosit dan keratinosit
IFN-γ = fungsinya mengaktifkan komplemen, mengaktifkan APC, mengaktifkan neutrofil,
dan memicu efek sitolitik sel NK
TGF-β = fungsinya mencegah proliferasi dan aktivasi limfosit, serta memicu sel B
memproduksi Ig A
Lomfotoksin (Leukotrin) = fungsinya mengaktifkan sel neutrofil dan berperan dalam proses
inflamasi yang dilakukan oleh sel T
4. Sitokin jenis lain yaitu IL-19, IL-21, IL-23, IL-26, IL-27, IL-28, IL-29, IL-30, IL-32, dan
BCAF (B-Cell Activating Factor).
IL-19 = belum diketahui fungsinya
IL-21 = fungsinya homolog dengan IL-15 (memicu proliferasi sel NK)
IL-23 = fungsinya homolog dengan IL-12 (memicu respon imun seluler)
IL-26 = fungsinya homolog dengan IL-10
IL-27 = fungsinya mengatur aktifitas sel B dan sel T
IL-28 = fungsinya berperan dalam proses inflamasi terhadap virus
IL-29 = fungsinya berperan dalam proses inflamasi terhadap mikroba
IL-30 = fungsinya homolog dengan IL-27
IL-32 = fungsinya memicu monosit dan makrofag menghasilkan TNF-α dan IL-8
BCAF = fungsinya memicu proliferasi sel B dan berperan dalam proses apoptosis
 BAB X
KOMPLEMEN

Sistem komplemen adalah protein dalam serum darah yang bereaksi berjenjang
sebagai enzim untuk membantu sistem kekebalan seluler dan sistem kekebalan humoral untuk
melindungi tubuh dari infeksi. Protein komplemen tidak secara khusus bereaksi
terhadap antigen tertentu, dan segera teraktivasi pada proses infeksi awal dari patogen. Oleh karena
itu sistem komplemen dianggap merupakan bagian dari sistem imun bawaan. Walaupun demikian,
beberapa antibodi dapat memicu beberapa protein komplemen, sehingga aktivasi sistem komplemen
juga merupakan bagian dari sistem kekebalan humoral. Protein komplemen di dalam serum darah
merupakan prekursor enzim yang disebut zimogen. Zimogen pertama kali ditemukan pada saluran
pencernaan, sebuah protease yang disebut pepsinogen dan bersifat proteolitik. Saat ini diketahui
sekitar 20 jenis protein yang berperan sebagai komplemen. Dalam keadaan normal komponen-
komponen komplemen terdapat dalam serum dalam keadaan inaktif, dan dinyatakan dengan huruf
C (C = complement) diikuti dengan angka misalnya C1, C2, C3, C4, C5, C6, C7, C8 dan C9. Tetapi
disamping itu ke dalam system komplemen juga termasuk subkomponen C1 yang terdiri dari C1q,
C1r dan C1s faktor B, faktor D dan protein-protein regulator yang terdiri atas C1 inhibitor,
C4b binding protein, karboksipeptidase N, faktor H, faktor I, properdin dan protein-S. Pada reaksi
komplemen setiap komponen diaktivasi secara berurutan sehingga terjadi reaksi berupa cascade.
Komponen komplemen yang aktif diberi tanda bar atau garis diatas huruf masing-masing misalnya
C1s, faktor B, sedangkan fragmen-fragmen komplemen yang terbentuk akibat pemecahan enzimatik
diberi tanda huruf dibelakang angka yang menunjukkan komponen komplemen bersangkutan,
misalnya C3a, C3b, C4a, C4b dan seterusnya.
Aktivasi komplemen terdapat 3 jalur yaitu (1) jalur klasik (2) jalur alternatif dan (3) jalur
lektin. Jalur klasik dimulai ketika C1 teraktivasi saat berikatan dengan kompleks antigen-antibodi.
C1 yang telah teraktivasi akan merangsang pembelahan C2 menjadi C2a dan C2b, serta pembelahan
C4 menjadi C4a dan C4b. C2b dan C4b bergabung dan membentuk senyawa protease yang dikenal
sebagai C3-convertase. C3-convertase ini kemudian berperan dalam pembelahan C3 menjadi C3a
dan C3b. C3a berperan dalam reaksi inflamasi karena C3a mampu berikatan dengan membrane sel
mast dan merangsang pelepasan histamin. C3b dapat menjadi C3-convertase dengan bantuan faktor
D dan faktor B ataupun C3b berikatan dengan dinding sel bakteri, dimana sel fagosit memiliki
kemampuan pengenalan terhadap situs C3b, hal ini disebut opsonisasi.
 Gambar 10.1 Aktivasi komplemen jalur klasik

Mekanisme aktivasi komplemen melalui jalur alternatif biasanya terpicu oleh adanya
polisakarida berupa endotoksin. Endotoksin mengaktifkan C3-convertase yang akan mengaktifkan
C3 melalui rangakaian proses yaitu endotoksin mengaktifkan properdin, properdin akan
mengaktifkan faktor D, faktor D bersama dengan ion Mg2+ akan mengaktifkan aktivator C3, yaitu
C3b. C3 adalah molekul yang tidak stabil dan terus menerus ada dalam aktivasi spontan derajat
rendah dan klinis yang tidak berarti.

Gambar 10.2 Aktivasi komplemen jalur alternatif

Aktivasi jalur lektin diawali dengan terjadinya ikatan antara polisakarida mikroba dengan
lektin dalam sirkulasi darah. Lektin adalah protein larut yang mengenal dan mengikat residu
manosa dari hidrat arang yang merupakan bagian dinding sel mikroba. Sesudah itu, semua tahap
jalur lektin adalah sama dengan jalur klasik.
 Peran komplemen antara lain (1) memicu proses opsonisasi dan inflamasi, (2) dapat
membunuh mikroorganisme secara langsung dengan sistem membran attack complex (MAC) yang
dapat melisiskan bakteri dan virus. Mekanisme sistem MAC dimulai dengan C5b yang baru
diaktifkan mengikat C6 untuk membentuk kompleks C5b-6, kemudian ke C7 membentuk kompleks
C5b-6-7. Kompleks C5b-6-7 berikatan dengan C8, yang terdiri dari tiga rantai (alfa, beta, dan
gamma), sehingga membentuk kompleks C5b-6-7-8. C5b-6-7-8 selanjutnya mengikat C9 dan
bertindak sebagai katalis dalam polimerisasi C9.

Gambar 10.3 Sistem Membrane Attack Complex (MAC)

 BAB XI
IMUNOMODULATOR

Immunology is one of the most rapidly developing area of medical biotechnology research
and has great promises with regard to the prevention and treatment of a wide range of disorders
such as the inflammatory diseases of skin, gut, respiratory tract, joints and central organs. In
addition infectious diseases are now primarily considered immunological disorders while neoplastic
diseases, organ transplantation and several autoimmune diseases may involve in an
immunosuppressive state. The immune system is one of our most complex biological systems in the
body. The basic role of the immune system is to distinguish self from non-self. This non-self could
be an infectious organism, a transplanted organ or an endogenous cell that can be mistaken as a
foreign. The immune responses of the human body against any non-self are of two types: (a) innate
(or natural or non-specific) and (b) adaptive (or acquired or specific).
Both these responses have two components each, viz. cellular and humoral. Innate immunity
lacks specificity as there is no involvement of memory cells. Acquired immunity on other hand is
specifically adapted for the inducing pathogens and response improves with subsequent exposures
to the same pathogen due to the presence of memory cell line. In the innate cellular immunity there
is involvement of monocytesmacrophage system, while in innate humoral immunity there is
activation of component system. On the other hand the cellular component of acquired immunity
consists of T-lymphocytes while the humoral component of this immunity involves the role of
Blymphocytes. Normally in innate and acquired immune responses act in concerted manner to
contain or eradicate infection. In some cases innate responses are enough to neutralise the offending
agent. However in many other cases, certain cells of innate immune system, such as antigen
presenting cells (APC), can also process the offending agent into smaller fragments which then
activate adaptive immune system to neutralise or kill these pathogens.
The elements formed in the blood are erythrocytes (RBC), leukocytes (WBC) and
thrombocytes (platelets). The leukocytes are of two types: granulocytes (neutrophils, eosinophils
and basophils) and agranulocytes (T-lymphocytes, Blymphocytes and monocytes). The process by
which blood cells are formed is called haemopoiesis. All such cells are involved in exerting immune
response develops from pluripotent haemotopoietic stem cells which resides in bone marrow. These
stem cell gives rise to lymphoid stem cell, trilineage myeloid stem cell, megakaryocytes (from
platelets) and erythroblasts (from erythrocytes). The lymphoid stem cells through their progenitors,
gives rise to mature lymphocytes (T-lymphocytes and Blymphocytes) and natural killer cells (NK
cells).
 T- and B lymphocytes are involved in mediating adaptive immune responses while NK cells
exert innate immune response along with mature cells originating from trilineage myeloid stem
cells. When exposed to specific antigens, B-lymphocytes differentiate into antibody producing
plasma cells in the bone marrow. Simultaneously, t-cells, under the influence of thymic hormones,
migrate to the thymus and on appropriate stimulus by antigen presenting cells (APC) acquire T-cell
receptor (TCR) and get differentiated to helper T-cells (with specific protein cluster of
differentiation- CD4+) and cytotoxic T-cells (with specific protein cluster of differentiation-
CD8+). The CD4+ (TH cell) subtypes of T-cells differentiate further outside the thymus into several
phenotypes: TH1, TH2 and TH3 which are distinguished by the different cytokines (IL-2 and IFN-
γ) they synthesize. TH1 T-cells produce cytokines that stimulate proliferation and differentiation of
T-lymphocytes and NK cells. These cytokine play an important role in cell mediated immunity
(CMI). TG2 T-cells release cytokine (IL-4, IL-5, IL-10 and IL-13) that stimulate B-lymphocytes
production for humoral immunity.
TH3 T-cells play an important role in resting phases of immune response and in the
production of anti-inflammatory immunoglobin-A (IgA) antibodies that are important in secretory
immunity 4. The benefits of immunomodulators stem from their ability to stimulate natural and
adaptive defense mechanisms, such as cytokines, which enables the body to help itself. The natural
immunomodulators act to strengthen weak immune systems and to moderate immune systems that
are overactive. Plant sterols and sterolins are natural immunomodulators found in some raw fruits
and vegetables and in the alga, spirulina. Spreads and yoghurttype foods containing high levels of
plant sterols are commonly to be found on sale as ‘cholesterol-reducing’ agents. These compounds
are destroyed when vegetables and fruits are cooked. Other natural immunomodulators include aloe
vera, plumbago indica, aegle marmalos, ginseng root, chamomile tea, reishi mushroom extract,
olive leaf extract, N. sativa oil, polysaccharides isolated from Juniperus scopolorum, Isodon serra
extract, ficus carica leaf extract. In children, immunomodulators are less likely to cause growth
failure than corticosteroids. Topical immunomodulators are well tolerated even in infants.
Recent research carried out in Russia has identified extracts of certain Siberian plant species
(Aconitum baikalense, Cirsium setosum and Saussurea controversa) as potent natural
immunomodulators. The extracts are dissimilar chemically but have similar immune system
enhancing effects. They have successfully been used for the treatment of benign and malignant
tumors, antibiotic-resistant infections, allergies, polyarthrites, thyroid diseases, psoriasis and other
pathologies which can be treated with medicines only with difficulty, if at all. The synthetic
immunomodulator capsaicinanandamide (hybrid arvanil) has been found to ameliorate symptoms in
autoimmune encephalomyelitis in mice. The relevance of these findings suggests that arvanil and
related compounds may offer benefits in the treatment of multiple sclerosis. A series of triptolide
analogs have been successfully synthesized one of them is 5(R)-5-hydroxytriptolide showed low
cytotoxicity and relatively high immunosuppressive activities as compaired with its parent
compound triptolide. Patent immunomodulator preparations containing naturally-derived
ingredients include Immunoferon™, Licopid™, Biobran™, AHCC, Noxylane4™, Leucomeal™
and MGN. Drugs used for Immunomodulation All drugs which modify immune response generally
categorized as immunomodulators. These can either function as:
1. Immunosuppressants
2. Immunostimulants.
Some of these can have both the properties depending on which component of immune response
they affect. There is also an upcoming generation of immunosuppressants called tolerogens.

Inhibitors of Lymphocyte Gene Expression to Reduce Inflammatory Responsee

1. Glucocorticoids:
Mechanism of Action: Multiple mechanisms are involved in the suppression of inflammation
by glucocorticoids. Glucocorticoids inhibit the production by multiple cells of factors that are
critical in generating the inflammatory response. As a result there is decreased release of
vasoactive and chemoattractive factors diminished secretion of lipolytic and proteolytic
enzymes decreased extravasation of leukocytes to areas of injury and ultimately decreased
fibrosis. Glucocorticoids can also reduce expression of proinflammatory cytokines such as
COX-2 and NOS2. The influence of stressful conditions on immune defense mechanisms is
well documented as is the contribution of the HPA axis to the stress response. Stresses such as
injury, infection and disease result in the increased production of cytokines a network of
signaling molecules that integrate actions of macrophages/monocytes, T lymphocytes and B
lymphocytes in mounting immune responses. Among these cytokines interleukin (IL)-1, IL-6,
and tumor necrosis factor-a (TNF-a) stimulate the HPA axis with IL-1 having the broadest
range of actions. IL-1 stimulates the release of CRH by hypothalamic neurons, interacts
directly with the pituitary to increase the release of ACTH and may directly stimulate the
adrenal gland to produce glucocorticoids. Factors that are inhibited include components of the
cytokine network, including interferon-g (IFN-g), granulocytemacrophage colony-stimulating
factor (GM-CSF), interleukins (IL-1, IL2, IL-3, IL-6, IL-8, and IL-12), and TNF-a.
Therapeutic Uses: Acute transplant rejection, graft-versus-host disease in bonemarrow
transplantation, rheumatoid and other arthritides, systemic lupus erythematosus, systemic
dermatomyositis, psoriasis and other skin conditions, asthma and other allergic disorders,
inflammatory bowel disease, inflammatory ophthalmic diseases.
Adverse Effects: Growth retardation in children, avascular necrosis of bone, osteopenia, increased
risk of infection, poor wound healing, cataracts, hyperglycemia, and hypertension

Inhibitors of Lymphocyte Signaling to Prevent Immune Cell Activation and Proliferationa)

Calcineurin Inhibitors Cyclosporine:
1. Cyclosporine (cyclosporin A), a cyclic polypeptide consisting of 11 amino acids is produced by
the fungus species Beauveria nivea.
Mechanism of Action: Cyclosporine suppresses T-cell-dependent immune mechanisms such
as those underlying transplant rejection and some forms of autoimmunity. It preferentially
inhibits antigen-triggered signal transduction in T lymphocytes, blunting expression of many
lymphokines including IL-2 and the expression of antiapoptotic proteins. Cyclosporine forms a
complex with cyclophilin, a cytoplasmic receptor protein present in target cells. This complex
binds to calcineurin, inhibiting Ca2+-stimulated dephosphorylation of the cytosolic component
of nuclear factor for activated T-cells (NFAT). When cytoplasmic NFAT is dephosphorylated
and translocates to the nucleus and complexes with nuclear components required for complete
T-cell activation including transactivation of IL-2 and other lymphokine genes. Calcineurin
phosphatase activity is inhibited after physical interaction with the cyclosporine/cyclophilin
complex. This prevents NFAT dephosphorylation such that NFAT does not enter the nucleus
gene transcription is not activated and the T lymphocyte fails to respond to specific antigenic
stimulation. Cyclosporine also increases expression of transforming growth factor-b (TGF-b), a
potent inhibitor of IL-2-stimulated T-cell proliferation and generation of cytotoxic T
lymphocytes (CTL).
Therapeutic Uses: Kidney, liver, heart, and other organ transplantation, rheumatoid arthritis
and psoriasis, early engraftment, extending kidney graft survival, cardiac and liver
transplantation, Behcet's acute ocular syndrome, endogenous uveitis, atopic dermatitis. •
Adverse effects: Renal dysfunction, tremor, hirsutism, hypertension, hyperlipidemia, gum
hyperplasia, hyperuricemia, hyper-cholesterolemia, nephrotoxicity, hypertension, diabetogenic,
Elevated LDL cholesterol. Tacrolimus: Tacrolimus (PROGRAF, FK506) is a macrolide
antibiotic produced by Streptomyces tsukubaensis. • Mechanism of Action: Like cyclosporine,
tacrolimus inhibits Tcell activation by inhibiting calcineurin. Tacrolimus binds to an
intracellular protein FK506-binding protein-12 (FKBP-12) an immunophilin structurally related
to cyclophilin. A complex of tacrolimus-FKBP-12, Ca2+, calmodulin, and calcineurin then
forms, and calcineurin phosphatase activity is inhibited. As described for cyclosporine the
inhibition of phosphatase activity prevents dephosphorylation and nuclear translocation of
NFAT and inhibits T-cell activation.
Pharmacokinetics: Tacrolimus can be given orally or I.V. It is 99% metabolized in liver by
CYP3A and has a plasma half life of 7-8 hrs.
Therapeutic Uses: Prophylaxis of solid-organ allograft rejection, kidney transplantation,
pediatric liver transplantation.
Adverse effects: Nephrotoxicity, neurotoxicity (tremor, headache, motor disturbances and
seizures), GI complaints, hypertension, hyperkalemia, hyperglycemia, and diabetes
 BAB XII
TOLERANSI DAN AUTOIMUN

Tolerance
Tolerance is best defined as a state of antigen-specific immunological unresponsiveness. This
definition has several important implications. When tolerance is experimentally induced it does not
affect the immune response to antigens other than the one used to induce tolerance. This is a very
important characteristic which differentiates tolerance from generalized immunosuppression, in
which there is a depression of the immune response to a wide array of different antigens. Tolerance
may be transient or permanent, while immunosuppression is usually transient. Tolerance Must Be
Established at the Clonal Level. In other words, if tolerance is antigen-specific, it must involve the
T- and/or a B-lymphocyte clone(s) specific for the antigen in question and not affect any other
clones. Tolerance Can Result from Clonal Deletion or Clonal Anergy
3. Clonal deletion involves different processes for T and B lymphocytes.
a. Clonal deletion of T lymphocytes. T lymphocytes are massively produced in the thymus
and, once generated, will not rearrange their receptors. Memory T cells are very long lived,
and there is no clear evidence that new ones are generated after the thymus ceases to
function in early adulthood. Therefore, elimination of autoreactive T cells must occur at the
production site (thymus), at the time the cells are differentiating their TcR repertoire. Once
a T-cell clone has been eliminated, there is no risk of reemergence of that particular clone.
b. B-cell clonal deletion involves different mechanisms than T-cell clonal deletion. B cells are
continuously produced by the bone marrow and initially express low-affinity IgM on their
membranes. In most instances, interaction of these resting B cells with circulating self
molecules neither activates them nor causes their elimination. Selection and deletion of
autoreactive clones seem to take place in the peripheral lymphoid organs during the onset of
the immune response. At that time, activated B cells can modify the structure of their
membrane immunoglobulin as a consequence of somatic mutations in their germ-line Ig
genes. B cells expressing self-reactive immunoglobulins of high affinity can emerge from
this process and their elimination takes place in the germinal centers of the peripheral
lymphoid tissues.
4. Clonal anergy. Both T-cell and B-cell clonal deletion fail to eliminate all autoreactive cells. In
the case of T cells, those that recognize self-antigens not expressed in the thymus will
eventually be released and will reach the peripheral lymphoid tissues. The causes of B-cell
escape from clonal deletion are not as well defined, but they exist nonetheless. Thus, peripheral
tolerance mechanisms must exist to ensure that autoreactive clones of T and B cells are
 neutralized after their migration to the peripheral lymphoid tissues. Clonal anergy is one such
mechanism.
a. Clonal anergy can be defined as the process that incapacitates or disables autoreactive
clones that escape selection by clonal deletion. Anergic clones lack the ability to respond
to stimulation with the corresponding antigen.
b. The most obvious manifestation of clonal anergy is the inability to respond to proper
stimulation. Anergic B cells carry IgM autoreactive antibody in their membrane but are not
activated as a result of an antigenic encounter. Anergic T cells express TcR for the
tolerizing antigen, but fail to properly express the IL-2 and IL-2 receptor genes and to
proliferate in response to it. c. Anergy results from either an internal block of the
intracellular signaling pathways, or from downregulating effects exerted by suppressor
cells, and it can be experimentally induced after the ontogenic differentiation of
immunocompetent cells has reached a stage in which clonal deletion is no longer possible.
3. There is now ample evidence suggesting that tolerance results from a combination of clonal
deletion and clonal anergy. Both processes must coexist and complement each other under
normal conditions so that autoreactive clones that escape deletion during embryonic
development may be down-regulated and become anergic. The failure of either one of these
mechanisms may result in the development of an autoimmune disease.

Autoimmune Diseases
Failure of the immune system to “tolerate” self tissues may result in pathological processes
known as autoimmune diseases. At the clinical level, autoimmunity is apparently involved in a
variety of apparently unrelated diseases such as systemic lupus erythematosus (SLE), insulin-
dependent diabetes mellitus, myasthenia gravis, rheumatoid arthritis, multiple sclerosis, and
hemolytic anemias. There are at least 40 diseases known or considered to be autoimmune in nature,
affecting about 5% of the general population. Their distribution by sex and age is not uniform. As a
rule, autoimmune diseases predominate in females and have a bimodal age distribution. A first peak
of incidence is around puberty, whereas the second peak is in the forties and fifties.
Classification of the Autoimmune Diseases. There are several different ways to classify
autoimmune diseases. Because several autoimmune diseases are strongly linked with MHC
antigens, one of the most recently proposed classifications, shown in Table 18.5, groups
autoimmune diseases according to their association with class I or with class II MHC markers. It is
interesting to notice that although both sexes may be afflicted by autoimmune diseases, there is
female preponderance for the class II-associated diseases and a definite increase in the prevalence
of class I-associated diseases among males.
 The autoimmune pathological process may be initiated and/or perpetuated by
autoantibodies, immune complexes (IC) containing autoantigens, and autoreactive T lymphocytes.
Each of these immune processes plays a preponderant role in certain diseases or may be
synergistically associated, particularly in multiorgan, systemic autoimmune diseases. The role of
autoantibodies in autoimmune diseases. B lymphocytes with autoreactive specificities remain
nondeleted in the adult individuals of many species. In mice, polyclonal activation with
lipopolysaccharide leads. Classification of Autoimmune Diseases
1. MHC class II-associated
a. Organ-specific (autoantibody directed against a single organ or closely related organs)
b. Systemic (systemic lupus erythematosus—variety of autoantibodies to DNA, cytoplasmic
antigens, etc.)
2. MHC class I-associated
a. HLA-B27-related spondyloarthropathies (ankylosing spondylitis, Reiter's syndrome, etc.)
b. Psoriasis vulgaris (which is associated with HLA-B13, B16, and B17) to production of
autoantibodies. In humans, bacterial and viral infections (particularly chronic) may lead to
the production of anti-immunoglobulin and antinuclear antibodies. In general, it is accepted
that polyclonal B-cell activation may be associated with the activation of autoreactive B
lymphocytes.
Autoantibody-associated diseases are characterized by the presence of autoantibodies in the
individual's serum and by the deposition of autoantibodies in tissues. The pathogenic role of
autoantibodies is not always obvious and depends on several factors, such as the availability and
valence of the autoantigen and the affinity and charge of the antibody.
a. Antibodies with high affinity for the antigen are considered to be more pathogenic because they
form stable IC, which can activate complement more effectively.
b. Anti-DNA antibodies of high isoelectric point, very prevalent in SLE, have a weak positive
charge at physiological pH, bind to the negatively charged glomerular basement membrane,
which also binds DNA. Such affinity of antigens and antibodies for the glomerular basement
membrane creates the ideal conditions for in situ IC formation and deposition, which is usually
followed by glomerular inflammation.
Autoantibodies may be directly involved in the pathogenesis of the disease, while in others,
they may serve simply as disease markers without a known pathogenic role. For example, the anti-
Sm antibodies that are found exclusively in patients with systemic lupus erythematosus (SLE) are
not known to play a pathogenic role. However, in may other situations, autoantibodies can trigger
various pathogenic mechanisms leading to cell or tissue destruction.
a. Complement-fixing antibodies to red cells (IgG and IgM) may cause intravascular red cell
lysis, if the complement activation sequence proceeds all the way to the formation of the
membrane attack complex, or may induce phagocytosis and extravascular lysis if the sequence
is stopped at the C3 level, due to the accumulation of C3b fragments on the red cell membrane.
b. If the antigen-antibody reaction takes place in tissues, pro-inflammatory complement fragments
(C3a, C5a) are generated and attract granulocytes and mononuclear cells that can release
proteolytic enzymes and toxic radicals in the area of IC deposition, causing tissue damage.
c. Other autoantibodies may have a pathogenic role dependent not on causing cell or tissue
damage, but on the interference with cell functions resulting from their binding to
physiologically important cell receptors.
Representative human autoimmune diseases in which autoantibodies are believed to play a
major pathogenic role are listed in Table 18.7. It must be noted in some of these diseases there is
also a cellmediated immunity component. For example, in myasthenia gravis, autoreac- tive T
lymphocytes have been described, and both autoreactive cell lines and clones have been
successfully established from patients' lymphocytes. These T lymphocytes may provide help to
autoreactive B lymphocytes producing antiacetylcholine receptor antibodies. In such cases,
autoreactive T lymphocytes could be more central in the pathogenesis of the disease than
autoantibody-producing B lymphocytes. However, the pathogenic role of autoantibodies is evident
from the fact that newborns to mothers with myasthenia gravis develop myasthenia-like symptoms
for as long as they have maternal autoantibodies in circulation. The pathogenic role of immune
complexes (IC) in autoimmune diseases. In autoimmune diseases, there is ample opportunity for the
formation of IC involving autoantibodies and self antigens. However, not all IC are pathogenic.
1. Several factors determine the pathogenicity of IC.
a. Size (intermediate size IC are the most pathogenic).
b. The ability of the host to clear IC (individuals with low complement levels or deficient Fc
receptor and/or complement receptor function have delayed IC clearance rates and are
prone to develop autoimmune diseases).
c. Physicochemical properties of IC (i.e., charge, affinity, and isotype of the antibody moiety)
which determine the ability to activate complement and/or the deposition in specific tissues
as discussed earlier in this chapter.
2. On many occasions, IC are formed in situ, activate the complement system, complement split
products are formed, and neutrophils are attracted to the area of IC deposition where they will
mediate the IC-mediated tissue destruction.
3. SLE and polyarteritis nodosa are two classic examples of autoimmune diseases in which IC
play a major pathogenic role. In SLE, DNA and other nuclear antigens are predominantly
 involved in the formation of IC, while in polyarteritis nodosa, the most frequently identified
antigen is hepatitis B surface antigen.
The role of activated T lymphocytes in the pathogenesis of autoimmune diseases. T
lymphocytes that are involved in the pathogenesis of such autoimmune diseases may be
autoreactive and recognize self antigens; recognize foreign antigen associated with self
determinants (modified self); or respond to foreign antigens but still induce self tissue destruction.
1. Cytotoxic CD8+ lymphocytes play a pathogenic role in some autoimmune diseases, usually
involving the recognition of non-self peptides expressed in the context of self MHC and
destroying the cell expressing such “modified” self. For example, coxsackie B virus-
determined antigens expressed on the surface of myocardial cells may induce CD8+- mediated
tissue destruction, causing a viral-induced autoimmune myocarditis.
2. Activated CD4+ helper cells appear to be frequently involved in cell-mediated autoimmune
reactions. Their pathogenic effects are mediated by the release of cytokines (IFN-g, IL-1, L-2,
IL-4, etc.) that can either trigger inflammatory reactions (if TH1 cells are predominantly
involved) or activate autoantibody-producing B lymphocytes (if TH2 cells are predominantly
involved). As a rule, TH1 cells appear to play a dominant role in many organ-specific
autoimmune diseases, and TH2 cells are predominantly involved in systemic autoimmune
diseases, such as SLE or rheumatoid arthritis.
Pathogenic Factors Involved in the Onset of Autoimmune Diseases. Multiple factors have been
proposed as participating in the pathogenesis of autoimmune diseases. These factors can be
classified as immunological, genetic, environmental, and hormonal. Each group of factors is
believed to contribute in different ways to the pathogenesis of different diseases.
1. Abnormal immunoregulation. Multiple lymphocyte abnormalities have been described in
patients with autoimmune diseases. Prominent among them are B-lymphocyte hyperactivity,
presence of spontaneously activated T and B lymphocytes, and decreased suppressor T-cell
function.
2. Anti-idiotypic antibodies. It has been postulated that anti-idiotypic immune responses may play
an important role in autoimmunity.
a. For example, during a normal immune response to a virus, an immune response directed
against the viral structures mediating attachment to its target cell is likely to be triggered.
As the immune response evolves, anti-idiotypic antibodies reacting with the antigen
binding site of the antiviral antibodies may develop. These anti-idiotypes, by recognizing
the “internal image of the antigen” (which is the configuration of the binding site of the
first antibody), may be able to combine with the virus receptor protein in the cell. If the
membrane protein used as binding site by the virus happens to be a receptor with important
 physiological functions, the synthesis of anti-idiotypic antibodies may have adverse effects
by either activating or blocking the physiological activation of these functions.
b. Such a mechanism could explain the origin of antibodies against the acetylcholine and the
TSH receptors detected in myasthenia gravis and Graves disease, respectively. A
hypothetical viral infection would trigger the synthesis of anti-idiotypic antibodies cross-
reacting with the acetylcholine receptor at the neuromuscular junction or with the TSH
receptor on thyroid cells; these antibodies could interfere with normal functions, cause cell
death, or induce cell stimulation depending upon their isotype and the receptor epitopes to
which they would bind.
c. An alternative theory linking anti-idiotypic responses to autoimmunity postulates that
autoreactive cells are stimulated by anti-idiotypic antibodies emerging in the wake of an
anti-infectious response, due to the crossreactivity of these anti-idiotypic antibodies with
the membrane immunoglobulins of autoreactive B lymphocytes. In other words, the anti-
infectious antibody that stimulated the anti-idiotypic response and the antigen receptors of
B lymphocytes would share cross-reactive idiotypes.
Genetic factors. Clinical observations have documented increased frequency of autoimmune
diseases in families, and increased rates of clinical concordance in monozygotic twins. Several
studies have also documented associations between HLA antigens and various diseases. As
stated earlier in this chapter, autoimmune diseases can be classified into two groups, one
apparently associated with MHC-I genetic markers, and the other associated with MHC-II
genetic markers.
1. Linkage with MHC-I markers. The classic example is the association between HLA-B27
and inflammatory spondyloarthropathies (ankylosing spondylitis, Reiter's syndrome, etc).
a. The link between HLA-B27 and these diseases has been strengthened by experiments
in which transgenic mice carrying the gene for HLA-B27 were observed to
spontaneously develop inflammatory disease involving the gastrointestinal tract,
peripheral and vertebral joints, skin, nails, and heart. The disease induced in transgenic
mice resembled strikingly the B27-associated disorders that afflict humans with that
gene.
b. It has been postulated that the autoimmune reaction is triggered by an infectious
peptide presented by HLA-B27 and followed by cross-reactive lymphocyte activation
by an endogenous collagen-derived peptide, equally associated with HLA-B27.
2. Linkage with MHC-II markers. In recent years the definition of MHC-II alleles has
undergone a rapid expansion, due to the development of antisera and DNA probes, as well
as to the successful sequencing of the genes coding for the constitutive polypeptide chains
 of MHC-II molecules. For example, insulin-dependent diabetes mellitus (IDDM) is
strongly associated with serologically defined MHC-II markers (HLA-DR3 and HLA-
DR4), but is even more strongly correlated with the presence of uncharged amino acids at
position 57 of the b chain of DQ (DQb).
3. Mechanisms explaining the association between HLA alleles and disease susceptibility.
Although the exact mechanisms are unknown, two have been hypothesized, both based on
the persistence and later activation of autoreactive clones.
a. Molecular mimicry, i.e., cross-reactivity between peptides derived from infectious
agents and peptides derived from autologous proteins that are expressed by most
normal resting cells in the organism. Anergic autoreactive T-cell clones would be
activated by an immune response against an infectious agent due to this type of cross-
reactivity.
b. Lack of expression of MHC alleles able to bind critical endogenous peptides. Under
those circumstances, potentially autoreactive T-lymphocyte clones would not be
eliminated and would remain available for later activation due to an unrelated immune
response or by the presentation of a crossreactive peptide.
4. Associations with specific TcR variable region types. The specific recognition of different
oligopeptides by different T lymphocytes depends on the diversity of the TcR. The TcR
repertoire and, particularly, the TcR Vb gene polymorphism may determine autoimmune
disease susceptibility. In other words, if the genome of an individual includes a particular V-
region gene that encodes a TcR that can combine with an autologous peptide, and the clones
expressing such receptors are not eliminated during embryonic differentiation, the individual
could be susceptible to a given autoimmune disease.
a. Immunogenetic studies in different animals and humans with different manifestations of
autoimmunity suggest that linkages between specific TcR V-region genes and specific
autoimmune diseases may exist (for example, insulin-dependent diabetes mellitus,
multiple sclerosis, and SLE). But, even in identical twins, concordance for a particular
autoimmune disease never exceeds 40%, suggesting that the presence of these TcR V-
region genes is not sufficient to cause disease by itself.
b. Experimental corollaries of the postulated positive association between specific TcR V-
region genes and disease are found in experimental allergic encephalomyelitis and
murine collagen-induced arthritis. The lymphocytes obtained from arthritic joints of
mice susceptible to collagen-induced arthritis have a very limited repertoire of Vb genes.
In mouse strains that do not develop collagen-induced arthritis, there are extensive
deletion of Vb genes, including those preferentially expressed by susceptible mice.
 Environmental factors. Autoimmunity can result from exposure to foreign antigens sharing
structural similarity with self determinants. The term molecular mimicry is used to describe identity
or similarity of either amino acid sequences or structural epitopes between foreign and self antigens.
1. The cardiomyopathy that complicates many cases of acute rheumatic fever is one of the best-
known examples of autoimmunity resulting from this mechanism. Group A b-hemolytic
streptococci have several epitopes cross-reactive with tissue antigens. One of them cross-reacts
with an antigen found in cardiac myosin. The normal immune response to such a cross-reactive
strain of Streptococcus will generate lymphocyte clones that will react with myosin and induce
myocardial damage long after the infection has been eliminated.
2. For example, molecular mimicry between the envelope glycolipids of Gram-negative bacteria
and the myelin of the peripheral nerves may explain the association of the Guillain-Barré
syndrome with Campylobacter jejuni infections.
3. Viruses can precipitate autoimmunity by inducing the release of sequestered antigens. In
autoimmune myocarditis associated with coxsackie B3 virus, the role of the virus is to cause
the release of normally sequestered intracellular antigens as a consequence of virus-induced
myocardial cell necrosis. Autoantibodies and T lymphocytes reactive with sarcolemma and
myofibril antigens or peptides derived from these antigens emerge and the autoreactive T
lymphocytes are believed to be responsible for the development of persistent myocarditis.
4. Physical trauma can also lead to immune responses to sequestered antigens. The classic
example is sympathetic ophthalmia, an inflammatory process of apparent autoimmune etiology
affecting the normal eye after a penetrating injury to the other.
5. Latent viral infections are believed to be responsible for the development of many autoimmune
disorders. Latent infection is commonly associated with integration of the viral genome into the
host chromosomes, and while integrated viruses very seldom enter a full replicative cycle and
do not cause cytotoxicity, they can interfere, directly or indirectly, with several functions of the
infected cell. For example, T-cell activation by an unknown nonlytic virus has been proposed to
explain the onset of autoimmune thyroiditis. The infection would lead to T-lymphocyte
activation and, as a consequence, to the release of interferon-g and TNF-a, both known to be
potent inducers of MHC-II antigen expression. The increased expression of class II MHC
antigens in the thyroid gland would create optimal conditions for the onset of an autoimmune
response directed against MHC-II self peptide complexes.
Treatment of Autoimmune Diseases Standard therapeutic approaches to autoimmune disease
usually involve symptomatic palliation with anti-inflammatory drugs and attempts to down-regulate
the immune response. Corticosteroids, which have both anti-inflammatory and immunosuppressive
effects, have been widely used, as well as immunosuppressive and cytotoxic drugs. However, the
use of these drugs is often associated with severe side effects and are not always efficient. Other
therapeutic approaches that have been tried include:
1. Plasmapheresis, which consists of pumping the patient's blood through a special centrifuge in
which plasma and red cells are separated. The red cells and plasma substitutes are pumped back
into the patient, while the plasma is discarded. The rationale of plasmapheresis in autoimmune
diseases is to remove pathogenic autoantibodies and immune complexes from the circulation.
This is an expensive therapeutic modality, but when it is coupled with immunosuppression to
prevent or reduce production of new autoantibodies, it is an efficient therapeutic measure in a
number of diseases.
2. Injection of a normal pool of immunoglobulin (IVIG) has been tried in a number of human
autoimmune diseases and proved to be of definite help in a form of pediatric vasculitis
(Kawasaki's syndrome) as well as in many cases of idiopathic thrombocytopenic purpura. The
mechanism of action is not clear, but it is believed that IVIG administration has
immunomodulating effects that result in the down-regulation of the synthesis of autoantibodies.
3. Elimination of T cells by injection of monoclonal anti-T-cell antibodies has been shown to be
therapeutic in a number of animal models. However, this approach is riddled with difficulties
when it comes to its application to humans, including the immunogenicity of murine
monoclonals, the adverse effects of generalized T-cell elimination (see Chaps. 26 and 27), and
unexpected results, such as generalized T-cell activation.
4. Immunotoxins have been prepared by combining either monoclonal antibodies or IL-2 with
cytotoxins, hoping to increase the destruction rate of the cells responsible for the autoimmune
process. These approaches have not met with great success. It is hoped that better definition of
cell markers for lymphocytic subsets that are involved in the pathogenesis of autoimmune
diseases may lead to the introduction of more specific and more effective antibodies or
immunotoxins.
5. Blocking of Co-Stimulatory Signals. The knowledge that co-stimulatory signals are essential
for T-cell activation has led to attempts to induce anergy by disrupting co-stimulatory
interactions, with variable but promising results in animal models.
6. Induction of Tolerance to the responsible antigen is a logical approach that is hampered by the
fact that the identity of the antigen is not known with certainty in many diseases. However, this
may not be an insurmountable obstacle, due to the phenomenon of bystander tolerance,
discussed on an earlier section of this chapter. There is great interest in protocols of oral
tolerization because of the encouraging results observed in experimental allergic
encephalomyelitis with oral administration of basic myelin protein and in rheumatoid arthritis
with oral administration of collagen type II. In addition, oral tolerization is devoid of side
effects.
 BAB XIII
ALERGI DAN REAKSI HIPERSENSITIVITAS

The immune response is basically a mechanism used by vertebrates to eradicate infectious

agents that succeed in penetrating the natural barriers. However, in some instances the immune
response can be the cause of disease, both as an undesirable effect of an immune response directed
against an exogenous antigen, or as a consequence of an autoimmune reaction.
Hypersensitivity can be defined as an abnormal state of immune reactivity that has
deleterious effects for the host. A patient with hypersensitivity to a given compound suffers
pathological reactions as a consequence of exposure to the antigen to which he or she is
hypersensitive. The term “allergy” is often used to designate a pathological condition resulting from
hypersensitivity, particularly when the symptoms occur shortly after exposure.
Classification of Hypersensitivity Reactions. Hypersensitivity reactions can be classified as
immediate or as delayed, depending on the time elapsed between the exposure to the antigen and
the appearance of clinical symptoms. They can also be classified as humoral or cell-mediated,
depending on the arm of the immune system predominantly involved. A classification combining
these two elements was proposed in the 1960s by Gell and Coombs, and although many
hypersensitivity disorders may not fit well into their classification, it remains popular because of its
simplicity and obvious relevance to the most common hypersensitivity disorders.
Gell and Coombs' Classification of Hypersensitivity Reactions. This classification considers
four types of hypersensitivity reactions. Type I, II, and III reactions are basically mediated by
antibodies with or without participation of the complement system; type IV reactions are cell-
mediated (see Table 22.1). While in many pathological processes mechanisms classified in more
than one of these types of hypersensitivity reactions may be operative, the subdivision of
hypersensitivity states into four broad types aids considerably in the understanding of their
pathogenesis.
1. Type I Hypersensitivity Reactions (IgE-Mediated Hypersensitivity, Immediate
Hypersensitivity)
Experimental Models and Historical Background. Much of our early knowledge about
immediate hypersensitivity reactions was derived from studies in guinea pigs. Guinea pigs
immunized with egg albumin, frequently suffer from an acute allergic reaction upon challenge
with this same antigen. This reaction is very rapid (observed within a few minutes after the
challenge) and is known as an anaphylactic reaction. It often results in the death of the animal
in anaphylactic shock.
 a. Passive transfer of anaphylactic reactions. If serum from a guinea pig sensitized 7 to
10 days earlier with a single injection of egg albumin and adjuvant is transferred to a
nonimmunized animal which is challenged 48 hours later with egg albumin, this
animal develops an anaphylactic reaction and may die in anaphylactic shock. Because
hypersensitivity was transferred with serum, this observation suggested that antibodies
play a critical pathogenic role in this type of hypersensitivity.
b. Passive Cutaneous Anaphylaxis. The passive transfer of hypersensitivity can take less
dramatic aspects if the reaction is limited to the skin.
- In these experiments, nonsensitized animals are injected intradermally with the
serum from a sensitized donor.
- The serum from the sensitized donor contained homocytotropic antibodies which
became bound to the mast cells in and around the area where serum was injected.
- After 24 to 72 hours the antigen in question is injected intravenously, mixed with
Evans blue dye. When the antigen reaches the area of the skin where antibodies
were injected and became bound to mast cells, a localized type I reaction takes
place, characterized by a small area of vascular hyperpermeability that results in
edema and redness. When Evans blue is injected with the antigen, the area of
vascular hyper- permeability will have a blue discoloration due to the transudation
of the dye.
c. The Prausnitz-Kustner reaction is a reaction with a similar principle that was practiced
in humans and helped our understanding of the immediate hypersensitivity reaction.
Serum from an allergic patient was injected intradermally into a nonallergic recipient.
After 24 to 48 hours, the area of skin where the serum was injected was challenged
with the antigen that was suspected to cause the symptoms in the patient. A positive
reaction consisted of a wheal and flare appearing a few minutes after injection of the
antigen. The reaction can also be performed in primates, which are injected
intravenously with serum of an allergic individual and challenged later with
intradermal injections of a battery of antigens that could be implicated as the cause of
the allergic reaction. Both of these reactions are no longer used for any clinical
purpose.
Clinical Expression. A wide variety of hypersensitivity states can be classified as immediate
hypersensitivity reactions. Some have a predominantly cutaneous expression (hives or
urticaria), others affect the airways (hay fever, asthma), while others still are of a systemic
nature. The latter are often designated as anaphylactic reactions, of which anaphylactic shock is
the most severe form.
a. The expression of anaphylaxis is species specific. The guinea pig usually has
bronchoconstriction and bronchial edema as predominant expression, leading to death in
acute asphyxiation. In the rabbit, on the contrary, the most affected organ is the heart, and
the animals die of right heart failure. In humans, bronchial asthma in its most severe forms
closely resembles the reaction in the guinea pig.
b. Most frequently, human type I hypersensitivity has a localized expression, such as the
bronchoconstriction and bronchial edema that characterize bronchial asthma, the mucosal
edema in hay fever, and the skin rash and subcutaneous edema that defines urticaria (hives).
The factor(s) involved in determining the target organs that will be affected in different
types of immediate hypersensitivity reactions are not well defined, but the route of exposure
to the challenging antigen seems to be an important factor.
- Systemic anaphylaxis is usually associated with antigens that are directly introduced
into the systemic circulation, such as in the case of hypersensitivity to insect venoms
or to systemically administered drugs.
- Allergic (extrinsic) asthma and hay fever are usually associated with inhaled antigens
- Urticaria is seen as a frequent manifestation of food allergy.
c. Systemic anaphylactic reactions in humans usually present with itching, erythema,
vomiting, abdominal cramps, diarrhea, respiratory distress, and in severe cases, laryngeal
edema and vascular collapse leading to shock that may be irreversible.
Pathogenesis. Immediate hypersensitivity reactions are a consequence of the predominant
synthesis of specific IgE antibodies by the allergic individual; these IgE antibodies bind with
high affinity to the membranes of basophils and mast cells. When exposed to the sensitizing
antigen, the reaction with cell-bound IgE triggers the release of histamine through
degranulation, and the synthesis of leukotrienes C4, D4, and E4 (this mixture constitutes what
was formerly known as slow reacting substance of anaphylaxis or SRS-A). These substances
are potent constrictors of smooth muscle and vasodilators and are responsible for the clinical
symptoms associated with anaphylactic reactions (see Chap. 23).
Atopy. In medicine, the term atopy is used to designate the tendency of some individuals to
become sensitized to a variety of allergens (antigens involved in allergic reactions) including
pollens, spores, animal danders, house dust, and foods. These individuals, when skin tested, are
positive to several allergens and successful therapy must take this multiple reactivity into
account. A genetic background for atopy is suggested by the fact that this condition shows
familial prevalence.
2. Cytotoxic Reactions (Type II Hypersensitivity) In its most common forms, this second type
of hypersensitivity involves complement-fixing antibodies (IgM or IgG) directed against
cellular or tissue antigens.
a. Autoimmune Hemolytic Anemia and Other Autoimmune Cytopenias. Autoimmune
hemolytic anemia, autoimmune thrombocytopenia, and autoimmune neutropenia (are clear
examples of type II (cytotoxic) hypersensitivity reactions. Autoimmune hemolytic anemia
is the best understood of these conditions. Patients with autoimmune hemolytic anemia
synthesize antibodies directed to their own red cells. Those antibodies may cause hemolysis
by two main mechanisms:
- If the antibodies are of the IgM isotype, complement is activated up to C9, and the red
cells can be directly hemolysed (intravascular hemolysis).
- If, for a variety of reasons, the antibodies (usually IgG) fail to activate the full
complement cascade, the red cells will be opsonized with antibody (and possibly C3b)
and are taken up and destroyed by phagocytic cells expressing Fcg and C3b receptors
(extravascular hemolysis).
- When rapid and massive, intravascular hemolysis is associated with release of free
hemoglobin into the circulation (hemoglobinemia), which eventually is excreted in the
urine (hemoglobinuria). Hemoglobinuria can induce acute tubular damage and kidney
failure, usually reversible.
- Extravascular hemolysis is usually associated with increased levels of bilirubin,
derived from cellular catabolism of hemoglobin.
- All hemolytic reactions usually lead to the mobilization of erythrocyte precursors from
the bone marrow to compensate for the acute loss. This is reflected by reticulocytosis
and, in severe cases, by erythroblastosis (see Chap. 24).
b. Goodpasture's Syndrome. The reactions of circulating antibodies with tissue antigens have
been traditionally classified as cytotoxic or type II reactions. The classic example is
Goodpasture's syndrome.
- The pathogenesis of Goodpasture's syndrome involves the spontaneous emergence of
basement membrane autoantibodies that bind to antigens of the glomerular and
alveolar basement membranes. Those antibodies are predominantly of the IgG isotype.
- Using fluorescein-conjugated antisera, the deposition of IgG and complement in
patients with Goodpasture's syndrome usually follows a linear, very regular pattern,
corresponding to the outline of the glomerular or alveolar basement membranes.
- The pathogenic role of antibasement membrane antibodies is supported by two types
of observations: a. Elution studies yield immunoglobulin-rich preparations that, when
 injected into primates, can induce a disease similar to human Goodpasture's syndrome.
b. Goodpasture's syndrome recurs in patients who receive a kidney transplant and the
transplanted kidney shows identical patterns of IgG and complement deposition along
the glomerular basement membrane.
- Once antigen-antibody complexes are formed in the kidney glomeruli or in the lungs,
complement will be activated and, as a result, C5a and C3a will be generated. These
complement components are chemotactic for PMN leukocytes; C5a also increases
vascular permeability directly or indirectly (by inducing the degranulation of basophils
and mast cells) (see Chap. 9).
- Furthermore, C5a can up-regulate the expression of cell adhesion molecules of the
CD11b/CD18 family (see Chap. 17) in PMN leukocytes and monocytes, promoting
their interaction with ICAM-1 expressed by endothelial cells, the first step leading to
the eventual migration to the extravascular space. The combination of increased
vascular permeability and of induction of cell adhesion molecules is believed to be
responsible for the accumulation of neutrophils and monocytes in areas where antigens
and antibodies have reacted.
- Once in the tissues, the PMN will recognize the Fc regions of tissue-bound antibodies,
as well as C3b bound to the corresponding immune complexes, and will release their
enzymatic contents, which include proteases and collagenase. These enzymes split
complement components and generate bioactive fragments, enhancing the
inflammatory reaction, and cause tissue damage (i.e., destruction of the basement
membrane), which eventually may compromise the function of the affected organ.
- The pathological sequence of events after the reaction of antibasement membrane
antibodies with their corresponding antigens is indistinguishable from the reactions
triggered by the deposition of soluble immune complexes or by the reaction of
circulating antibodies with antigens passively fixed to a tissue, considered as type III
hypersensitivity reactions.
c. Nephrotoxic (Masugi) Nephritis. This experimental model of immunologically mediated
nephritis, named after the scientist who developed it, is induced by injection of
heterologous antibasement membrane antibodies into healthy animals. Those antibodies
combine with basement membrane antigens, particularly at the glomerular level, and trigger
the development of glomerulonephritis. This experimental model has been extremely useful
to demonstrate the pathogenic importance of complement activation and of neutrophil
accumulation.
 - If, instead of complete antibodies, one injects Fab or F(ab')2 fragments that do not
activate complement, the accumulation of neutrophils in the glomeruli fails to take
place, and tissue damage will be minimal to non-existent.
- Similar protection against the development of glomerulonephritis is observed when
animals are rendered C3 deficient by injection of cobra venom factor prior to the
administration of antibasement membrane antibodies, or when those antibodies are
administered to animals rendered neutropenic by administration of cytotoxic drugs or
of antineutrophil antibodies.
3. Immune Complex-Induced Hypersensitivity Reactions (Type III Hypersensitivity) In the
course of acute or chronic infections, or as a consequence of the production of autoantibodies,
antigen-antibody complexes (also known as immune complexes) are likely to be formed in
circulation or in tissues to which the pertinent microbial or self-antigens have been adsorbed.
Both scenarios can lead to inflammatory changes that are characteristic of the so-called
immune complex diseases (see Chap. 25).
a. The Fate of Circulating Immune Complexes. Circulating immune complexes are usually
adsorbed to red cells and cleared by the phagocytic system. In most cases, this will be an
inconsequential sequence of events, but, in other cases, when the clearance capacity of the
phagocytic system is exceed, inflammatory reactions can be triggered by the deposition of
those immune complexes in tissues. A simplified sequence of events leading to immune
complex-induced inflammation is shown in Figure 22.1.
b. In Situ Formation of Immune Complexes. The adsorption of circulating antigens of
microbial origin or released by dying cells to a variety of tissues seems to be a relatively
common event. If the same antigens trigger a humoral immune response, immune complex
formation may take place in the tissues where the antigens are adsorbed, in which case
clearance by the phagocytic system may become impossible. In fact, tissue-bound immune
complexes are very strong activators of the complement system and of phagocytic cells,
triggering a sequence of events leading to tissue inflammation virtually identical to that
observed in cases of in situ immune reactions involving tissue antigens and the
corresponding antibodies.
c. The Arthus Reaction. This reaction was first described at the turn of the century by Arthus,
who observed that the intradermal injection of antigen into an animal previously sensitized
results in a local inflammatory reaction. This reaction is edematous in the early stages, but
later can become hemorrhagic, and, eventually, necrotic. A human equivalent of this
reaction can be observed in some reactions to immunization boosters in individuals who
have already reached high levels of immunity.
 - Pathogenesis and general characteristics a. The reaction is due to the combination of
complement-fixing IgG anti- bodies (characteristically predominating in hyperimmune
states in most species) and tissue-fixed antigens. b. The lag time between antigen
challenge and the reaction is usually 6 hours, which is considerably longer than the lag
time of an immediate hypersensitivity reaction, but considerably shorter than that of a
delayed hypersensitivity reaction. c. Although Arthus reactions are typically elicited in
the skin, the same pathogenic mechanisms can lead to organ lesions whenever the
antigen, although intrinsically soluble, is unable to diffuse freely and remains retained
in or around its penetration point (e.g., the perialveolar spaces for inhaled antigens).
4. Delayed (Type IV) Hypersensitivity Reactions In contrast to the other types of
hypersensitivity reactions discussed above, type IV or delayed hypersensitivity is a
manifestation of cell-mediated immunity. In other words, this type of hypersensitivity reaction
is due to the activation of specifically sensitized T lymphocytes rather than to an antigen-
antibody reaction.
a. The Tuberculin Test as a Prototype Type IV Reaction. Intradermal injection of tuberculin or
PPD into an individual that has been previously sensitized (by exposure to Mycobacterium
tuberculosis or by BCG vaccination) is followed, 24 hours after the injection, by a skin
reaction at the site of injection characterized by redness and induration. Histologically, the
reaction is characterized by perivenular mononuclear cell infiltration, often described as
“perivascular cuffing.” Macrophages can be seen infiltrating the dermis. If the reaction is
intense, a central necrotic area may develop. The cellular nature of the perivascular
infiltrate, which contrasts with the predominantly edematous reaction in a cutaneous type I
hypersensitivity reaction, is responsible for the induration.
b. Experimental Studies
- Transfer of delayed hypersensitivity. When guinea pigs are immunized with egg
albumin and adjuvant, not only do they become allergic, as discussed earlier, but they
develop cell-mediated hypersensitivity to the antigen. This duality can be demonstrated
by passively transferring serum and lymphocytes from a sensitized animal to different
unsensitized recipients of the same strain and challenging the passively immunized
animals with egg albumin. The animals that received serum will develop an
anaphylactic response immediately after challenge, while those that received
lymphocytes will only show signs of a considerably less severe reaction after at least 24
hours have elapsed from the time of challenge.
- Experimental contact hypersensitivity. Most of our knowledge about the pathogenesis
of delayed hypersensitivity reactions derives from experimental studies involving
 contact hypersensitivity. Experimental sensitization through the skin is relatively easy to
induce by percutaneous application of low-molecular-weight substances such as picric
acid or dinitrochlorobenzene (DNCB). The initial application leads to sensitization, and
a second application will elicit a delayed hypersensitivity reaction in the area where the
antigen is applied. a. Induction. The compounds used to induce contact hypersensitivity
are not immunogenic by themselves. It is believed that these compounds couple
spontaneously to an endogenous carrier protein, and as a result of this coupling, the
small molecule will act as a hapten, while the endogenous protein will play the role of a
carrier.
i. A common denominator of the sensitizing compounds is the expression of reactive
groups, such as Cl, F, Br, and SO3H, which enables them to bind covalently to the
carrier protein.
ii. Spontaneous sensitization to drugs, chemicals, or metals is believed to involve
diffusion of the haptenic substance into the dermis, mostly through the sweat glands
(hydrophobic substances appear to penetrate the skin more easily than hydrophilic
substances). Once in the dermis, the haptenic groups will react spontaneously with
“carrier” proteins and trigger an immune reaction.
iii. By a pathway that has not been defined, the hapten carrier conjugates are taken up
by the Langerhans cells of the epidermis, and a sensitizing peptide is presented in
association with MHC-II molecules. Since the carrier protein is self, it would be
expected that the sensitizing peptide contained the covalently associated sensitizing
compound.
iv. A unique feature of delayed hypersensitivity is that T lymphocytes are mostly
involved in the antihapten response, while in most experimentally induced hapten-
carrier responses, the hapten is recognized by B lymphocytes. This may be
explained, at least in part, by the fact that Langerhans cells migrate to regional
lymphnodes, where they become interdigitating cells and predominantly populate
the paracortical areas, where they are in optimal conditions to present antigens to
CD4+ T lymphocytes (see Chap. 2).
- Effector mechanisms. The initial sensitization results in the acquisition of
immunological memory. Later, when the sensitized individual is challenged with the
same chemical, sensitized T cells will be stimulated into functionally active cells,
releasing a variety of cytokines, which include chemotactic and activating chemokines
for monocyte/macrophages, basophils, eosinophils, and neutrophils.
 i. The release of chemotactic chemokines such as IL-8, RANTES, macrophage
chemotactic proteins, and migration inhibitory factor is a key factor in attracting
and “fixing” lymphocytes, monocytes, and granulocytes into the area.
ii. Other cytokines released by activated lymphocytes, particularly TNF-a and IL-1
up-regulate the expression of cell adhesion molecules (CAMs) in endothelial cells,
facilitating the adhesion of leukocytes to the endothelium, a key step in the
extravascular migration of inflammatory cells.
iii. As a result of the release of chemokines and of the up-regulation of CAMs, a
cellular infiltrate predominantly constituted by mononuclear cells forms in the area
where the sensitizing compound has been reintroduced 24 to 48 hours after
exposure.
iv. The tissue damage that takes place in this type of reaction is likely to be due to the
effects of active oxygen radicals and enzymes (particularly proteases, collagenase,
and cathepsins) released by the infiltrating leukocytes, activated by the chemokines
and other cytokines.
v. In severe cases, a contact hypersensitivity reaction may take an exudative,
edematous, highly inflammatory character. The release of proteases from
monocytes and macrophages may trigger the complement-dependent inflammatory
pathways by directly splitting C3 and C5; C5a will add its chemotactic effects to
those of chemokines released by activated mononuclear cells, and will also cause
increased vascular permeability, a constant feature of complement-dependent
inflammatory processes. It is not surprising, therefore, that a reaction which at the
onset is cell mediated and associated to a mononuclear cell infiltrate may, in time,
evolve into a more classical inflammatory process with predominance of
neutrophils and a more edematous character, less characteristic of a cell-mediated
reaction.
- Contact Hypersensitivity in Humans. Contact hypersensitivity reactions are observed with
some frequency in humans due to spontaneous sensitization to a variety of substances.
i. Plant cathecols are apparently responsible for the hypersensitivity reactions to
poison ivy and poison oak.
ii. A variety of chemicals can be implicated in hypersensitivity reactions to cosmetics
and leather.
iii. Topically used drugs, particularly sulfonamides, often cause contact
hypersensitivity.
 iv. Metals such as nickel can be involved in reactions triggered by the use of
bracelets, earrings, or thimbles. The diagnosis is usually based on a careful history
of exposure to potential sensitizing agents and on the observation of the
distribution of lesions that can be very informative about the source of
sensitization. Patch tests using small pieces of filter paper impregnated with
suspected sensitizing agents that are taped to the back of the patient can be used to
identify the sensitizing substance.
- The Jones-Mote Reaction. Following challenge with an intradermal injection of a small dose
of a protein to which an individual has been previously sensitized, a delayed reaction (with a
lag of 24 hours), somewhat different from a classic delayed hypersensitivity reaction, may
be seen. The skin appears more erythematous and less indurated, and the infiltrating cells are
mostly lympho- cytes and basophils, the last sometimes predominating. The reaction has
also been described, for this reason, as cutaneous basophilic hypersensitivity.
Experimentally, it has been demonstrated that this reaction is triggered as a consequence of
the antigenic stimulation of sensitized T lymphocytes.
- Homograft Rejection. A most striking clinical manifestation of a delayed hypersensitivity
reaction is the rejection of a graft. In classic chronic rejection, the graft recipient's immune
system is first sensitized to tissue antigens of the donor. After clonal expansion, activated T
lymphocytes will reach the target organ, recognize the foreign antigen, and initiate a
sequence of events that leads to inflammation and eventual necrosis of the organ.
- Systemic Consequences of Cell-Mediated Hypersensitivity Reactions. While type IV
hypersensitivity reactions with cutaneous expression usually have no systemic
repercussions, cell-mediated hypersensitivity reactions localized to internal organs, such as
the formation of granulomatous lesions caused by chronic infections with Mycobacteria,
may be associated with systemic reactions. Cytokines released by activated lymphocytes and
inflammatory cells play a major pathogenic role in such reactions.
i. Proinflammatory cytokines, particularly IL-1, activate the hypothalamic temperature
regulating center and cause fever, thus acting as a central pyrogenic factor.
ii. TNF-a is also pyrogenic, both directly and by inducing the release of IL-1 by
endothelial cells and monocytes. In addition, these cytokines activate the synthesis of
acute phase proteins (e.g., C-reactive protein) by the liver.
iii. Prolonged release of TNF-a, on the other hand, may have deleterious effects since this
factor contributes to the development of cachexia. The way in which TNF-a causes
cachexia has been recently elucidated: the factor inhibits lipoprotein lipase and, as a
consequence, there is an accumulation of triglyceride-rich particles in the serum and a
lack of the break-down of triglycerides into glycerol and free fatty acids. This results
in decreased incorporation of triglycerides into the adipose tissue, and, consequently,
in a negative metabolic balance. The cells continue to break down stored triglycerides
by other pathways to generate energy, and the used triglycerides are not replaced.
Cachexia is often a preterminal development in patients with severe chronic infections.
 BAB XIV
PENYAKIT DEFISIENSI IMUNITAS

Immunodeficiency diseases and syndromes are the cause of significant mortality and
morbidity, as well as a source of extremely valuable information about the physiology of the human
immune system. Most immunodeficient patients have secondary forms of immunodeficiency,
caused by either pathological conditions that affect the immune system or the administration of
therapeutic compounds with immunosuppressive effects. A functional defect of the immune system
is suspected when a patient has: unusual frequency of infections with common or opportunistic
microorganisms; unusually severe infections; and failure to eradicate infections with antibiotics to
which the microorganisms are sensitive. A good history, a careful workup of the infectious
episodes, and a thorough physical examination are essential for the initial evaluation of a suspected
immunodeficiency, providing useful clues about the type of immunodeficiency (Table 30.1). A
good family history is very important. Early death of older siblings suffering from repeated
infectious episodes is often the only way to document the hereditary character of a congenital
immunodeficiency. Once an immunodeficiency is suspected, investigations need to be undertaken
with the purpose of documenting and characterizing the immunodeficiency state. Known causes of
secondary immunodeficiency need to be ruled out and, if present, therapy will be directed at
eliminating them. If a diagnosis of primary immunodeficiency is made, it will be important to
define the degree of compromise of the different mechanisms of immunological defense—cellular
immunity, humoral immunity, phagocytosis, and complement—in order to select the most effective
type of therapy.
In the following pages, a brief outline of the main features of representative primary
immunodeficiency diseases (with the exception of phagocytic deficiencies, is presented. Humoral
Immunodeficiencies are those in which antibody synthesis is pre dominantly impaired.
1. Infantile agammaglobulinemia (Bruton-Janeway syndrome). Infantile agammaglobulinemia is
the prototype of “pure” B-cell deficiency.
a. Genetic transmission and molecular basis.
- In the majority of cases, the disease is transmitted as a sex-linked trait. The defective
gene is located on Xq21.2-22, the locus coding for the B-cell progenitor kinase or
Bruton's tyrosine kinase (Btk). Agammaglobulinemic patients have mutations at
different sites, which result either in the lack of synthesis of the kinase or in the
synthesis of an inactive kinase.
- Btk plays an important role in B-cell differentiation and maturation, and is also part of
the group of tyrosine kinases involved in B-cell signaling in adult life. Most cases of
 infantile agammaglobulinemia are associated with mutations affecting Btk, but some
patients with similar mutations have very mild forms of immunodeficiency with
variable levels of immunoglobulins, suggesting that B-cell differentiation may depend
on additional co-factors, not yet identified.
c. Clinical presentation. Infectious symptoms usually begin early in infancy (8 months to 3
years).
- Patients suffer from repeated infections caused by common pyogenic organisms (S.
pneumoniae, N. meningitidis, H. influenzae, S. aureus)—pyoderma, purulent
conjunctivitis, pharyngitis, otitis media, sinusitis, bronchitis, pneumonia, empyema,
purulent arthritis, meningitis, and septicemia.
- Chronic obstructive lung disease and bronchiectasis develop as a consequence of
repeated bronchopulmonary infections.
- Infections with Giardia lamblia are diagnosed with increased frequency in these
patients and may lead to chronic diarrhea and malabsorption.
- Agammaglobulinemic patients are at risk of developing paralytic polio after
vaccination with the attenuated virus; they also are at risk of developing chronic viral
meningoencephalitis, usually caused by an echovirus.
- Arthritis of the large joints develops in about 30–35% of the cases and is believed to
be infectious, caused by Ureaplasma urealyticum.
d. Laboratory studies
- Very low immunoglobulin levels (usually less than 100 mg/dL for the sum of the three
major isotypes)
- Undetectable isohemagglutinins
- Failure to produce antibodies in response to active immunization with toxoids,
polysaccharides, and bacteriophage øX174.
- Peripheral blood lymphocyte counts are usually normal, T-lymphocyte counts are
normal or elevated, T-lymphocyte subsets are normal, and T-lymphocyte function is
also normal. B lymphocytes, on the contrary, are absent or greatly reduced in the
peripheral blood.
- Histological examination of a peripheral lymph node draining the site of an antigenic
challenge (often difficult to localize) shows lack of germinal centers and secondary
follicles. Peri-intestinal lymphoid tissues are also abnormal, showing lack of
development of germinal centers. Plasma cells are absent both from peripheral
lymphoid tissues and from bone marrow. Adenoids, tonsils, and peripheral lymph
nodes are hypoplastic. In contrast, the thymus has normal structure, and the T-cell-
 dependent areas in peripheral lymphoid organs are normally populated. Normal
numbers of B-cell precursors can be demonstrated in the bone marrow suggesting that
the basic defect is a maturation block.
e. Therapy. This condition is best treated with replacement therapy using gamma globulin (a
plasma fraction containing predominantly IgG, obtained from normal healthy donors)
administered intravenously.
2. Transient hypogammaglobulinemia of infancy. As a consequence of a delay in the infant's B-
cell functional maturation, the hypogammaglobulinemia normally occurring during the second
and third months of life, because of progressive catabolism of maternal IgG, may persist until
2–3 years of age and become progressively more accentuated (relative to age-matched
controls).
a. Clinical presentation. Most patients are referred because of an increased frequency and/or
severity of bacterial infections.
b. Laboratory findings. Low-for-age circulating immunoglobulin levels is the diagnostic
hallmark. Differentiation with more severe forms of humoral immunodeficiencies is usually
based on functional tests and enumeration of B cells.
- Lymphocyte mitogenic responses and antibody response to challenge with toxoids are
usually normal.
- Peripheral blood B lymphocytes are usually normal in number; in most cases, a
deficiency of helper T-cell function appears to be responsible for the delay in
immunoglobulin synthesis.
c. Therapy. Intravenous gamma globulin is indicated until the child's immunoglobulin levels
normalize. With time, most children will develop normal immune function.
4. Common, variable, unclassified immunodeficiency (“acquired” hypogammaglobulinemia).
This designation includes a large number of cases of primary immunodeficiency,
heterogeneous in presentation, with variable age of onset and patterns of inheritance, whose
clinical picture is similar to X-linked agammaglobulinemia, but usually with a less severe
course.
a. Physiopathology. Several variants of common variable immunodeficiency were recognized
by a panel of experts who met under the auspices of the W.H.O. in 1983. i. Most variants of
“acquired hypogammaglobulinemia” have normal or increased numbers of B lymphocytes
in peripheral blood, but the B cells remain immature and do not respond adequately to in
vivo stimulation. ii. T-cell function appears deficient in most cases, with abnormally low
proliferative responses to T-cell mitogens. Thus, lack of proper T-cell help seems
 responsible for the lack of B-lymphocyte responses. iii. In some patients the defect seems to
result from excessive suppressor T-lymphocyte activity.
b. Clinical presentation. Sinusitis and bacterial pneumonia are the predominant infections.
Intestinal giardiasis is common, and in some patients can lead to malabsorption.
Opportunistic infections involving P. carinii, mycobacteria, viruses, and other fungi are also
more frequent in these patients.
c. Laboratory findings
- Serum immunoglobulin levels are variably depressed, and, as a rule, the patients fail to
respond to produce antibodies after proper antigenic stimulation.
- Normal or increased numbers of B lymphocytes in peripheral blood, which can be
stimulated in vitro to produce immunoglobulins.
- Tonsils, lymph nodes, and spleen may be enlarged. Lymph node biopsies show
morphological changes including necrobiosis of the follicles (also seen in the spleen)
and/or reticulum cell hyperplasia (which may be the major contributing factor for the
development of lymphadenopathy and splenomegaly, and, in some patients seem to
evolve into lymphoreticular malignancies).
d. Treatment usually involves administration of intravenous gamma globulin.
5. Immunoglobulin A deficiency. IgA deficiency is the most common immunodeficiency
(detected in 1 out of 500–800 normal Caucasian individuals).
a. Physiopathology
- Phenotypic studies of circulating B cells show patterns similar to those of cord blood
B lymphocytes, suggesting a differentiation abnormality, sometimes reflected by a
defect in secretion of intracytoplasmic IgA.
- In other cases, there is evidence for immunoregulatory defects: • Predominant
synthesis of IgG1 and IgG3 antibodies to pneumococcal polysaccharides, even when
their serum levels of IgG2 are normal (IgG2 is usually the immunoglobulin isotype of
antipolysaccharide antibodies). • Longitudinal variations in IgA levels. In children, a
delayed increase of IgA to normal levels is the most frequently observed variation; in
adults, IgA levels may fluctuate widely, from very low to normal and back to very
low. iii. Anti-IgA antibodies reacting with isotypic or allotypic determinants of IgA
can be detected in about one-third of the patients, usually in low titers. • When present
in high titers, anti-IgA antibodies can cause hypersensitivity reactions (which may be
fatal) upon transfusion of IgA-containing blood products. • Anti-IgA antibodies may
contribute to accentuate and perpetuate the state of IgA deficiency. The administration
of radio-labeled IgA to patients with anti-IgA antibodies is followed by its rapid
 elimination from the circulation (in a matter of hours). More significantly, a
comparison of the levels of residual IgA in patients with and without anti-IgA
antibodies demonstrated that those with antibodies have the lowest levels.
b. Clinical presentation
- Most cases of IgA deficiency are asymptomatic.
- Patients with combined IgA and IgG2 deficiency have frequent infections caused by
bacteria with polysaccharidic capsules.
- Many IgA-deficient individuals have antibodies to food proteins, which, in most cases,
appear to be of no consequence.
- Infections with Giardia lamblia are more frequent in patients with IgA deficiency than
in individuals with normal IgA levels. As in patients with agammaglobulinemia this
parasitic infection may lead to chronic diarrhea and malabsorption.
- IgA deficiency can be associated with “autoimmune” disorders (especially pernicious
anemia) and with a complex syndrome of lymphoid hyperplasia of the intestine,
diarrhea, and malabsorption (Crabbé's syndrome).
c. Therapy
- Treatment is usually symptomatic, using antibiotics as needed if patients are infected.
- Replacement therapy for IgA deficiency is questionable, because the IgA content of
commercial gamma globulins is variable, and the short half-life of IgA (5–6 days)
would require very frequent administration of replacement IgA. To complicate matters
further, there is always the possibility that administration of IgA-containing gamma
globulin may trigger a hypersensitivity reaction in a patient with high levels of anti-
IgA antibodies.
- Administration of intravenous gamma globulin is indicated in patients with combined
IgA and IgG2 deficiency, or in IgA-deficient patients who fail to produce antibodies to
bacterial polysaccharides.
d. Prevention of hypersensitivity reactions due to anti-IgA antibodies. Anti-IgA antibodies
should be assayed in any known IgA-deficient patient considered for transfusion, gamma
globulin administration, or elective surgery. If high titers of such antibodies are found, the
blood bank needs to be notified so that steps can be taken to make sure that any blood
transfused to the patient is IgA-depleted or a gamma globulin preparation lacking IgA
should be selected. Transfusion of IgA-depleted blood can be achieved by obtaining
compatible blood from a healthy IgA-deficient donor, or by using extensively washed red
cells.