Immunology of the Lung Immune - Mediated Lung Diseases

• 1.Immunology of the Lung Immune - Mediated Lung Diseases Interstitial Lung Diseases Dr. Hristina Andreeva, MD Department of Immunology and TransfusionMedicine, Haukeland Hospital -Bergen

2. Disposition

• Classification and Epidemiology

• Pulmonary Immunobiology and Inflammation

• Main Immunological Methods

• serology, cell mediated immunity, Flowcytometry blod, BALF

• Sarcoidosis

• Hypersensitivity Pneumonitis

• Autoimmune Mediated Lang Diseases

• Idiopathic Pulmonary Fibrosis

• Pulmonary EosinophilicSyndromes

1 3. 2 4. Epidemiology of Interstitial Lung Diseases

• Idiopathic pulmonary fibrosis

• Occupational/environmental

• Post inflammatory pulmonary fibrosis

• Sarcoidosis

• Connective tissue disease

• Hypersensitivity pneumonitis

• Drugs and radiation

3 5. Pulmonary Immunobiology and InflammationConsensus 2000 adopted pathwaysofimmune control in processingforeign antigens

• mucociliary clearance

• 10 10particlesper day

• 5x10 8alveoli / 100m 2area

• upper &lowerrespiratory

• tracts-ciliated epithelium

• lymphatic tissues-NALT, BALT, draining lymph nodes

• secretory IgA-immobilizes Ag

• AM - poor APC ,butexcellent cleaners without initiating an inflammation - preventing the alveolarcapil. membrane

• T-cells- residualT - cells

• CD4 - /CD8 -T cells

• CD4+ & CD8+ -hyporesponsive

• B- cells-high%ininterstitium

4 6. Pulmonary Immunobiology and InflammationConsensus 2000

• Neutrophils - undernormal conditions the lung is designed to excludeNeufrom alveolar capillary membrane;

• -transendotheliumtrafficking via CAM

• - phagocytic defence- ingesting and clearing damaged epithelium

• Eos, Ba, Mast cells transvesselsmigration, roleinAsthma, Eosinophilic Pneumonia, Lung Fibrosis, Lung parasitic diseases

• Oxidative stress - reactive oxygen andNO intermediatestissue injury; antioxidants - glutathione (100x) higher than in other tissues, extracellular superoxide dismutase (alveolar type II cells)

pulmonary inflammatory events 5 7. Pulmonary Immunobiology and InflammationConsensus 2000

• type II alveolar cells secreting and dividing cells

• (Surfactant, SOD3, IL-8, MCP-1, MIP12, RANTES)

• bronchiolar epithelial serous cells (Clara cells)-secreting and dividing cells (stem cells for ciliated/not ciliated bronch. epith.)

• (lactoferrin, - defensin, cathelicidins, SP, cyt-p450)

• type II alveolar cells and Clara cells - a potent source of cytokines and variety peptide/protein antibiotics -LL37/ hCAP18, PhosphoLipase - A2, Clara Cell 26kDa protein

unique immune characteristics 6 8. Immunologic Methods for DiagnosisinLung Diseases

• blood ( serology ) C3, C4, C1-IHN,Ig (G, A, M), IgE, CRP, 1-AT ,autoantibodies, infections diseases

• blood ( cells )-CMI- CD3, CD4, CD8, CD19, NK, adhesion molecules CD62L, CD11b, CD54, CD25, CD86

• cutaneous teststest for type 1 allergic reaction;MULTITEST CMI ( Skin Test Antigens for Cell-Mediated Immunity) ;Mantu test

• invasive methods-bronchoscopy, pleural punction - respiratory cells profile in BALF and PF

• biopsy-histological examination, immunohistochemial staining

7 9. BALF normal respiratory cells profile 8 10. Pleural Fluid normal respiratory cells profile 9 11. SARCOIDOSIS

• Definition-a multisystem disorder of unknown origin

• It commonly affects young and middle-aged adultsand frequently presents with bilateral hilar lymphadenopathy, pulmonary infiltration, ocular and skin lesions. The liver, spleen, salivary glands, nervous system, muscles, bones also may be involved.

• The diagnosis isestablished when clinical, radiological findingsaresupportedbyhistologicalevidenceof noncaseatingepitheloidcellgranulomas.

• 1877Jonathon Hutchinson- first described erythema nodosum

• 1899Caesar Boeck -used the term sarcoid- benign sarcoma

• 1941Morten Ansgar Kveim - intra-cutaneous Kveim test

Statement of Sarcoidosis 2000 10 12. SARCOIDOSIS

• age- < 40, peak 20 - 29, second peakinwomenover 50

• rate- 5.9 - men, 6.3-women- 100 000/ year

• race- 0.85% whites - asymptomatic; 2.4% blacks - severe

• overall mortality - 1% - 5%

• transmission- 40% contact way (person to person) exposure to an environmental agents; occupational risk (beryllium, metal dusts, organic Ag); familial 5%

• seasons- winter and early spring

• smoking- more commonly in nonsmokers

• genetic factors - classI-HLA-A1, B8, B22 - Italy, class II-DR3, 17, 15, 16

Epidemiology 11 13. SARCOIDOSIS

• infectious-viruses (EBV, HHV, CMV, CoxBV), B. burg-dorferi, M. tuberculosis (50-80% of cases +), Mycoplasma

• inorganic- aluminum, zirconium, talc, Ro-radiation

• organic- pine tree pollen

• T- Cell Receptor features -existence ofT cells with restricted TCR usage, these TCR have highly restricted TCR - V segment, with special antigen recognition

Etiology 12 14. SARCOIDOSIS

• T-cell-mediated anergy-negative skin tests for CMI

• Th1 activated lymphocytes - cytokine release at foci of disease

• Proliferation- oflocallymphocytes (CD4+), activation ofblood T-cells andMo-Ma

• Granuloma formation - T-cells, Mo-Ma, epitheloid cells, multinucleated giant cells type Langhans

• Peripheral blood - T-lymphopenia, immune complexes, hypergammaglobulinemi

• Pulmonary manifestation-CD4+ lymphocytic alveolitis

Major Immunologic Features 13 15. SARCOIDOSIS

• morphology-noncaseating epitheloid cell granuloma consisting of Mo-Ma (epitheloid & giant cells), lymphocytes- CD4 central, CD8 in peripheral zone; fibrosis - from periphery to center

• location- lymph node (intrathoracic); lung, liver, spleen, skin; CNS, in the lung 75% - close to bronchioles, subpleural, perilobular; 50% - lung vascular involvement

• course of granulomas - either resolve or spontaneous remission; parenchymal fibrosis

• tumor-related sarcoid reactions-regional lymph nodes with noncaseating epitheloid cell granulomas with frequency of4.4%- NHML, Hs D, seminoma

• granulomatous lesions of unknown significance (the GLUS syndrome) -15 - 20% of biopsy samples

Histopathology 14 16. SARCOIDOSIS Clinical presentation and organ involvement

• Lungs - 90%, larynx, trachea, bronchi, pleural effusion

• Lymph nodes -1/3

• Heart - 5%, arrhythmias, block

• Liver - 20% palp., 80% - biopsy

• Skin- 25%, erythema nodosum, lupus pernio

• Ocular- 11-83%, uveitis, KC - sicca, dacryocystitis, ret. vasculitis

• NS- 10%, CNS-cranial nerve 7,hypothalamus, pituitary regions

• Muscular-skeletal - 25-39%

• GI tract- 1%, mimic Crohns D

• Blood- anemia - 4 - 20% leucopenia - 40%

• Parotid glands - 6%

• hyper Ca-emia / uria - 10%

• Reproductive organs - uterus, breast, testis -1/3 orchiectomies

15 17. SARCOIDOSIS Markers ofActivity

• recent progressive dry cough

• progressive dyspnea

• systemic:fatigue, fever, polyathralgia, erythema nodosum, lymphadenopathy

• progressive changes on chest Ro-graphs or lung CT scans

• BALF - CD4+ alveolitis with activated Mo-Ma

• hypercalceuria > hypercalcemia

• high serum levels of ACE

16 18. SARCOIDOSIS ImmunologicDiagnosis

• skin test for CMI

• peripheral blood immunophenotyping

• immunophenotyping of BALF cellsprofile !!!

• high CD4/ CD8 Ratio

• lymphocyte > 16%

• noncaseating granulomas

• serum levels of immunoglobulin subclasses

17 19. Active & Non ActiveSarcoidosis

• Monocyte like Macrophages

• CD14 bright /CD11b bright

• HLA-DR dim/CD16 dim

• intermediaryphenotype in NS

• correlation- %CD4+/CD25+

• and CD14 onMo ~ Main BALF from patients with AS

• (r=0.94, p=0.001)

* p ARDS

• Immunologic diagnosis-ACA,GPI, lupus anticoagulant, ANA positive in 30%-40%, platelet activation status

33 35. Diffuse Alveolar Hemorrhage

• etiology-SLE, APS, Behcet, Goodpasture, Henoch-Schonlein,IgA nephropathy, microscopic polyarteritis, WG, Churg-Strauss

• clinical features -nose hemorrhage,hemoptysis,mucosal hemorrhagic ulcerations,diffuse alveolar infiltrates onX-ray, anemia ,adequate platelets number & function

• immunologic pathogenesis-immune complexes

• -ANCA associated pathogenesis -activation of circulating neutrophils and Mo;

• in situ -formation of immune complexes; adhesion of activated neutrophils; oxidative burst, degranulation - endothelial cell injury / increasedvascular permeability- development of capillaritis

34 36. Diffuse Alveolar Hemorrhage

• association WG - 43% capillaritis, 7% DAH

• Microscopic polyarteritis -30%SLE - 7%

• Goodpasture - 75%

• Beh et, H-S Purpura -6.5%

• IgA nephropathy 1%-3%

• APS - 1% - 3%

35 37. Flowcytometric BALF analysis DAHerythrocytes are lysed elevated activated neutrophilsAdditional findings: hemoptysis, mucosal/skinhemorrhagic ulcerations and arthritis MPO -ANCA + serum chest-CT-diffuse pulmonary infiltrates Diclofenac - induced small vessel vasculitis rather than an idiopathic 36 38. Autoimmune - Mediated Lung Disease in conclusion

• serology - autoantibodies

• immunologic diagnosis-BALF- hemorrhagic alveolitis - over 80% of the cellsare activated, peripheral blood neutrophils

• immunofluorescence -linear or granular deposition of immune complexesalongglomerular / alveolar basementmembrane, pulmonary arteries, veins

• treatment -immune suppression(corticosteroid, cyclophosphamide),plasmapheresis

• Add IVIG - 250 - 400mg/kg/d - no relapse!

37 39. Interstitial Lung Disease withBALFNeutrophilia

• Idiopathic pulmonary fibrosis(15-40 %)

• Cryptogenic organizing pneumonia(40-70 %)

• Inorganic dust diseasesAsbestosisSilicosis

• Cigarette smoking(500 Eos/mm 3 )

• BAL should be performed

• Increased eosinophils in BALF:

• a cut-off of 25% for the diagnosis of AEP

• a cut-off of40 percent for the diagnosis of CEP

• Radiographically or tomographically identified pulmonary abnormalities- need to be combined with other diagnostic methods

• Lung tissue eosinophilia demonstrated in transbronchial or open lung biopsies

• Serology - CRP, IgE levels, ELISA for coccidioidomycosis, ABPA, helminthes infections can help to support diagnoses

47 49. Interstitial lung disease associated withBALF Eosinophilia

• High count (>30%)

• Tropical pulmonary eosinophilia (40%-70%)

• Eosinophilic pneumonia (>40%)

• Mild to moderate counts (