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Immunology and autoimmune disease

Immunology and autoimmune disease. Peer Teaching Society Jennifer McMurran and Tori Shanklin (phase 3a students). What we’re going to cover. The classic patient, clinical features, the main antibody, investigations and management of several key autoimmune diseases Quiz!

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Immunology and autoimmune disease

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  1. Immunology and autoimmune disease Peer Teaching Society Jennifer McMurranand Tori Shanklin (phase 3a students)

  2. What we’re going to cover • The classic patient, clinical features, the main antibody, investigations and management of several key autoimmune diseases • Quiz! • And finally…… A handy summary table of the antibody for the major autoimmune diseases We’re not covering: • Innate v adaptive immunity, Immunoglobulins, Complement, hypersensitivity, the immune system and how it reacts to a pathogen, transplant immunology and immunodeficiency disease…sorry! Any questions- please ask in the moment or at the end 

  3. Systemic lupus erythematous (SLE) The Classic Patient: Afro-Carribeanwoman of child-bearing age just had Epstein Barr virus (EBV) Pathology: B cells secrete pathogenic auto-antibodies => immune complex formation and deposition and complement => tissue damage Clinical features: Malar butterfly rash, discoid rash, photosensitivity, oral ulcers, non-erosive arthritis (more than two peripheral joints) etc. etc. everything!

  4. Systemic lupus erythematous (SLE) Antibodies: Antinuclear antibody (ANA), anti double stranded DNA, Anti-Sm Diagnosis: Raised ESR, normal CRP, reduced complement C3 and C4 Management: -Severe flare e.g. haemolytic anaemia => urgent IV cyclophosphamide and high dose prednisolone Maintenance => NSAIDs and hydroxychloroquine -Cutaneous=> topical steroids and high factor sun creams -B cell depletion => rituximab

  5. Sjӧgren’s syndrome DRY!!! • Classic patient: 45 year old woman, HLA DR3 • Pathology: chronic inflammatory autoiummune >> inflammation of exocrine glands (salivary ie dry mouth and lacrimal ie dry eyes) • Clinical features: gritty sore dry eyes(sicca), xerostomia(dry mouth) => dysarthria and dysphasia, vaginal dryness, lack of GI mucus => dry cough and gastritis, polyarthritis

  6. Sjӧgren’s syndrome • Antibodies: Anti-Ro and Anti-La, ANA, Rheumatoid factor • Diagnosis: Schrimer’s test- <5mm after 5 mins- conjunctival dryness, Rose Bengal staining(keratitis) • Management: • Artificial tears • Saliva substitutes • Hydroxychloroquine for polyarthritis • Severe- steroids

  7. Systemic sclerosis Limited cutaneous • Clinical features: Calcinosis – calcium deposits under skin Raynaud’s (o)Esophaegeal/gut dysmotility Sclerodactyly – swollen digits Telangiectasia(capillaries => purple clusters) • Antibody: anticentromere antibodies Diffuse cutaneous • Clinical features: • Diffuse skin involvement • Organ fibrosis- lungs, cardiac, GI and renal • Antibody: anti-topoisomerase 1 Poorer prognosis than limited

  8. Rheumatoid arthritis • Classic patient: 55 year old female smoker, HLA DR4 • Pathology: excess inflammation →cytokines eg TNF- a → cartilage resorption, excess synovial fluid production, ↑B lymphocytes → antibodies → rheumatoid factor • Clinical features: • Early- inflammation of MCP, PIP, MTP, tenosynovitis, bursitis • Late- deformity- ulnar deviation, subluxation, Boutonniere(button pressing 2nd digit), swan neck

  9. Rheumatoid arthritis • Antibody: anti CCP • Diagnosis: rheumatoid factor, anaemia of chronic disease, increased platelets, ESR and CRP. • XR= SOLD Swelling of soft tissues Osteopenia Loss of joint space Deformity of the joint • Management: • Symptom relief: NSAIDS and steroids • Slow progression: DMARDS eg methotrexate (+ folic acid)

  10. Other arthritides- reactive and psoriatic Reactive arthritis Classic patient: 20 year old post chlamydia(1-4 weeks) Pathology: sterile arthritis Clinical features: knee/ankle/feet pain and swelling, iritis, mouth ulcers. Reiter’s syndrome- urethritis, conjunctivitis and arthritis Diagnosis: ↑ESR and CRP. Culture stool if diarrhoea. Sexual health review Management: Splint joint, NSAIDs >6 months – consider methotrexate or sulphalazine Psoriatic arthritis Classic patient: Someone with psoriasis (can occur before though) Clinical types: • Symmetrical polyarthritis - >5 joints • Distal – DIP • Asymmetrical oligoarthritis- 1-4 joints • Psoriatic arthritis mutilans= severe deformity Features: dactylitis, pitting, telescoping, nail changes Diagnosis: XR- erosions, pencil in cup, resorption of terminal phalanges Management: NSAIDs, methotrexate, sulphalazine, ciclosporin, anti TNF agents

  11. Pencil in cup erosion in reactive arthritis

  12. Multiple sclerosis • Classic patient: 30 year old woman from the UK(temperate areas) • Pathology: discrete plaques of demyelination at multiple CNS sites. Unknown trigger →T cell mediated immune response → demyelination → heals poorly → relapse/remitting → axonal loss(progression) • Clinical features: unilateral optic neuritis, numbness/tingling in limb, leg weakness, brainstem/cerebellar symptoms – may worsen with heat(Uhthoff’s phenomenon-vision)

  13. Multiple sclerosis • Diagnosis: clinical – requires lesions disseminated in time and space. MRI= sensitive but not specific • Management: • Happy stress-free life! • Vit D supplement if poor diet or lack of sunlight • Steroids- shortens acute relapses but doesn’t alter prognosis • Interferons- decrease relapses and number of lesions (seen on MRI)- loads of SEs! • Monoclonal antibody- alemtuzumab (mab-monoclonal antibody) acts against T cells

  14. Motor neuron disease • Collection of diseases- most common type is amyotrophic lateral sclerosis(ALS- think ice bucket challenge!) • Pathology: selective loss of neurons, genetic element • Clinical features: UMN and LMN signs but no sensory loss, sphincter disturbance or eye movement disturbance (distinguishing it from MS) • Diagnosis: of exclusion • Management: MDT approach, antiglutamergic drugs eg Riluzole – prolongs life by 3 months, symptom management eg amitriptyline for drooling • NOT GOOD PROGNOSIS

  15. Myaesthenia gravis • Classic patient: < 50 female or >50 male • Pathology: antibodies to nicotinic ACh receptors (anti ACh R) • Clinical features: increasing muscular fatigue(extraocular, bulbar, face and neck, limb girdle, trunk), ptosis, diplopia, voice fades on extending speaking eg counting to 50 • Diagnosis: antibodies, neurophysiology- reduced muscle function • Management: symptom control, anticholinesterase – pyridostigmine

  16. Myaesthenia gravis

  17. GuillainBarré syndrome • Classic patient: 2 weeks after CMV • Pathology: acute inflammatory demyelinating polyneuropathy – infection → antibodies → attacks nerves • Clinical features: few weeks after infection(Campylobacter jejuni, CMV, EBV) symmetrical ascending muscle weakness – proximal > distal. Autonomic dysfunction- sweating, BP, arrhythmia. Big danger= respiratory involvement- FVC every 4 hrs, ventilate. Progresses for 4 weeks then recovers. Good prognosis • Diagnosis: nerve conduction studies • Management: IV immunoglobulin, plasma exchange *No steroids!

  18. Coeliac disease • Classic patient: Irish 55 year old female • Pathology: T cell mediated – prolaminintolerance → villous atrophy and malabsorption inc of bile acids and crypt hyperplasia • Clinical features: diarrhoea that smells offensive, bloating, abdo pain, nausea and vomiting, apthous ulcers, weight loss, angular stomatitis, fatigue • Antibody: anti TTG, anti-endomysialand anti-alpha gliadin. • Diagnosis: gold standard: jejunal and duodenal biopsies • Management: gluten free diet (if not then increases risk of lymphomas)

  19. Villous atrophy Crypt hyperplasia

  20. Diabetes Mellitus Type 1 • Classic patient: 14 year old male, HLA DR 3 • Pathology: destruction of pancreatic β cells(insulin secreting) in Islets of Langerhans • Clinical features: polyuria(weeing lots), polydipsia(thirst), tired, blurred vision, weight loss • Diagnosis: fasting glucose > 7mmol/L or random > 11.1, HbA1c(glycosatedHb over last 3 months) > 6.5% • Management: insulin

  21. Antibody table

  22. Quiz time!!! • A 45 year old lady comes in to your clinic. She has been complaining of dry sore eyes. You do a Schrimer’s test and it comes back as less than 5mm in 5 minutes. • What is Schrimer’s test? • What is the autoimmune disease? Test for conjunctival dryness- uses filter paper Sjogren’s syndrome

  23. Question number 2 • A patient’s XR was reported to have ‘pencil in cup erosions’- what disease does this indicate? Psoriatic arthritis

  24. Question number 3 3. 55 year old lady presents with noticeable changes to her hands. You send her for an X- Ray. Name 4 XR changes with RA Swelling of soft tissues Osteopenia Loss of joint space Deformity of the joint

  25. Question number 4 • A 55 year old presents with offensive smelling diarrhoea that is sometimes hard to flush away. She is also experiencing bloating and abdominal pain. You suspect coeliac disease. What are the antibodies found in coeliac disease patients? Anti TTG, anti endomysial, anti-alpha gliadin

  26. Question number 5 • What is Uhthoff’s phenomenon? And what autoimmune disease is it associated with? Blurry vision worse in heat/ exercise Multiple sclerosis

  27. KEY POINTS • Autoimmune conditions lead to more autoimmune conditions • Acute flare up? STEROIDS • Learn the antibodies …. Its an easy mark!

  28. And finally…. The end! Thank you for listening Any questions?

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