Basic Sciences

Immunology

Complement
Complement pathway
Classic pathway

Mannose

lectin
proteases

from bact cell wall

C1qrs

- C1 inhibitor, +

immune complex

C2,4 C3a, 5 a chemotaxis C3b opsonization

- C4 binding protein

C3

Alternate pathway Properdin, Factor B, D (C3bBb) + bact. Lipopolysac

C3 nephritic factor - Decay accelerating factor (DAF), factor H.

- Membrane inhibitor
of reactive lysis (MIRL)

C5,6,7,8,9 (MAC) cell lysis

Complement deficiency

1. 2. 3. 4.

Def of Complement components;

Congenital def. of C2,4 IC clearance SLE, vasculitis, polymyositis. C3 def Life threatening infection with encapsulated org. e.g. pneumococci. MAC (C5,6,7,8,9) disseminated neisserial infection. Acquired consumption occur in SLE, cryo, IEC, post infectious GN, MPGN.

1. 2. 3. 4. 5. 6.

Def of regulatory proteins;

Def of C1 inhibitor hereditary angioneurotic edema dt vasoactive C2 fragment, ttt with epinephrine in the acute attack & danazole for prevention as it hepatic synthesis of C1 inhibitor & C4, SLE dt consumption of C2, 4. PNH; def of membrane GP (GPI) which bind the inhibitory comp DAF. HUS; familial type dt def of Factor H compl activation & end. Injury. MPGN type 2; C3 nephritic factor, def factor H. ACEI C1 inhibitor def angioedema. Cryo; C4, preserved C3 dt C4 binding protein inact of C3.

Ig G;

- Monomer formed of a divalent molecule ( 2Fab) 2 light and 2 heavy chains. Most abundant. 2ry immune response. The only Ig that cross the placenta. MW; 150.000 dalton (25 for each LC & 50 for HC). 4 subclasses according to Fc. The reference range is 8-20 g/l.

Immunoglobulin
Fab

Ig A;
Monomer in serum, dimeric in secretion. Def chronic diarrhea, respiratory infection, autoimmune dis. IgA1 contain hinge region. Level undetectable at birth, reach adult level at puberty.

Ig M
pentameric. 1ry immune response. Secretion do not need Th2. Include Bl group Ab. Against bacteria. Level undetectable at birth, reach adult level at 1 yr.

Fc

Ig D on B cell surface. Ig E;
produced by plasma cell, attach to mast cell & basophils, responsible for type 1 hypersensitivity reaction.

 Type 1; anaphylactic or immediate - Ag+ Ig E on mast cell - diagnosed by plasma tryptase ( protease released from mast cell). - e.g. asthma, atopy, drugs as latex, peanut. Type 2; Ab-dependent cytotoxicity - cell bound Ag + circulating Ig - e.g. transfusion react, Rh, Goodpasture, ITP, Coomb's positive haemolytic anaemia. Type 3; IC-mediated or arthus reaction - free Ag + free Ig - e.g. excess Ig farmer lung, bird fancier, pulm aspergillosis. excess AgGn, serum sickness. Type4; cell-mediated or delayed hypersensitivity - Ag on APC + T memory cells - tuberculin, contact dermatitis, GVHD, graft rejection. Type 5; stimulatory. - Ab + cell surface receptor e.e. Graves.

Hypersensitivity reactions

Cells of the immune system

1. PMN; Neutrophils phagocytosis, bacteria. - Phagocytes have a role in recognition and elimination of microbes by reactive oxygen species or antigens by opsonisation. 2. basophils & mast cells; type 1 hypersensitivity, parasites. 3. Eosinophils; allergy, helminthes, phagocytose IC. 1. 2. Mononuclear; Lymphocytes, monocytes.

 Chronic granulomatous disease; - It is a defect in the production of NADPH H peroxide phagocytic function of neutrophils (normal phagocytosis but defective intracellular killing) chronic granulomas & microabcesses in skin, bone & liver. - Diagnosed by nitroblue tetrazolium test (screening for reduced phagocytic capacity). - Ttt; INF

blood lymphocytes
1.5-3.5.000 20-40% of WBCs

T-cells 60 to 80 %

B-cells 10 to 20 %

natural killer (NK) 5 to 10 %.

Helper T-cells 60 to 70 % (CD4+ cells) Bind to class 2 MHC Ag on APC as MQ IL1,6, TNF
Active CD4 Th

Suppressor/ cytotoxic T-cells 30 to 40 % (CD8+ cells).

IL2 IFN IL12, 18 Th1 IL4 th2

Bind to class 1 MHC Ag On viral infected cells, cancer cells

th1

(-)

IL10

 T lymphocytes;
- The predominant cell type in the paracortical region of LN. - Role; intracellular infections, tumour surveilance, graft rejection. - Arise in BM, mature in thymus. - Types; Cytotoxic (CD8) T cells recognise MHC class I molecule antigens T helper (CD4) cells recognise MHC class II molecule antigens.

Thymus- independent Ag; theses are mainly carbohydrate Ag e.g. pneumoccocal polysaccarides, activate B lymphocyte without TH cells polyclonal Ab mainly Ig M with poor affinity & no memory.

 B lymphocytes;
- The predominant cell type in the germinal follicle of LN. - Arise in BM, mature in the spleen & LN. NB: - B cells usually require T cell help for full activation. B cells are activated in primary immune response which initially produce IgM. CD40 & CD 40L are required for costimulation of T cells, if either is deficient impair Ig class switching.

 Natural killer cells; - destroy viral infected & tumour cells. - Rather than T cell receptors, natural killer cells express adhesion molecules which allow adhesion to target cells. - CD94 receptor is located in Natural Killer (NK) cells and is bound to the cell membrane. It enables NK cells to discriminate between healthy cells and pathogen infected cells

Major histocompatibility complex

DR/DP Class 2 A, B, C class1 Class 3= C2,4, factor B

MHC is a group of genes on chr 6 that form HLA Ag & some CC.
class1 form on Signal to HLA A,B,C transmemb peptide with B2 microglobulin All cells, allow self recognition. CD8 cytotoxic cells (which are activated when they see foreign class 1 Ag as graft, virally infected cell, tumor cell.) Class 2 HLA DR, DP, DQ Immune cells; B cell, MQ & some endothelial cells CD4 Th, (class2 Ag on APC present foreign Ag to Th cells & protect their cells from T cytot)

 Cytokines are low MW peptides produced by lymphocytes, MQ and fibroblasts & have non enzymatic biological activity,( local or systemic). They include; - Interleukins - interferons - CSFs Certain patterns of Cytokine production; - Acute phase reactants(IL1, 6, TNF ) derived from MQ. - cell-mediated immunity; (IL2,INF) by Th1. Ab-mediated immunity; (IL4,5,6,10) by Th2 & stimulate B lymphocytes, maturation of dendritic cells . - Antiinflammatory; (IL4, 10) by Th2.

Cytokines

IL-1; Released by MQ B &T stimulation, acute phase reactant, osteoclastic bone resorption. Involved in; - Rh arthritis IL-1 + collagenase, phospholipase, cyclooxygenese (facilitator of damage). - Atherosclerosis; endo uptake of LDL IL-1 PDGF. - Septic shock IL1 NO, PG, PAF VD. - Infection, acute graft rejection IL1 T & B lymph. IL2; from Th1 growth of activated T cells, NK cells. IL4, IL10; from Th2 inhibit cell mediated immunity, INF (antiinflammatory cytokines), stimulate Ig production. IL-5; from mast cells chemotaxis for esinophils. IL6; from MQ acute phase reactant, stimulate Ig production.

 Tumour necrosis factor (TNF) ; MQ, esinoph, NK. T lymph . TNF is procoagulant & lead to thrombosis. dis associated; Rheumatoid, MS, MOF. So, neutralizing Abs = anti-TNF are used. not used in cancer highly toxic, + tumor growth.

INF,; from WBC, fibroblasts antiviral effects . IFN and IFN (not ) bind to the same receptor known as type I receptors. IFN is used therapeutically in multiple sclerosis.

INF; Th1 activate MQ, inhibit Th2. .

Therapeutic uses;
* INF HBV, HCV, hairy cell Keuk, cut T cell lymphoma, Kaposi sarcoma in AIDs, RCC, condyloma acuminata.

* INF MS.
* INF chronic granulomatous dis.

* IL2 RCC, acute leukemia.

* GM-CSF correction of cytopenias e.g. during chemotherapy.

* interleukin receptor antagonists (IL-1Ra) are useful as disease modifying drugs in rheumatoid arthritis (Anakinra).
* anti- TNF (infliximab, etanercept) are used in Rheumatoid,IBD.

Eicosanoids
Def; are biologically active lipids, derived from the cellular membrane phospholipids by the enzyme phospholipase releasing arachydonic acid (or Omega 3 FA as an exogenous source); Lipooxygenase act upon arachydonic acid leukotrienes; - LTB4 neutrophil chemotaxis, mucous secretion, modulate cell growth. - LTC4,D4,E4 (slow reacting substance of anaphylaxis) vascular permeability, sm contraction, mucous secretion, modulate cell growth.NB; LT receptor antagonists are used in asthma. Cyclooxygenase act upon arachydonic acid PG & thromboxane. - PG I2 (prostacyclin) released from endothelium VD, (-) plat aggregation.used in 1ry pul HTN, HUS, Raynaulds. - PGE2; immunomodulator, (-) lymphocyte proliferation, cytokinr production, neutrophil function. - PGD2; from mast cells anaphylaxis.

Congenital Complement def.; encap org

- C3 life threatening pneumoc inf. - MAC disseminated neisseria.

Immune deficiency

Neutrophil def Bact, candida.

- chronic granulomatous dis. - Chediak Higashi - lazy leukocyte S.

T cell def viral, mycobact, fungal, malig, parasites, fatal BCG & yellow
fever vaccine. - Di George; non familial, def in thymus & 3rd & 4th branchial arches immun def, absent PTH, aortic arch abn., cleft palate

B cell def Bact.

- common variable; non familial, failure of B cell maturation - X linked agammagiardia. - Ig A def. giardia, allergic, autoimmune dis, fatal transfusion react.

Combined B & T def;

- severe combined immune def.; AR. - ataxia telangectasia; AR, ataxia, telangiectasia, malignancy, cell mediated im,Ig A. - Wischott Aldriech; XLR, CMI, IgM, thrombocytopenia, eczema, malignancy.

Acquired;
Causes of neutropenia Causes of acquired hypogammaglob (B cells)
- synthesis; malnutrition, uremia, viral infection, immunosupp drugs. - catabolic dis; thyrotoxicosis, myotonia. - lost; prot loosing enteropathy, nephrotic S, ovarian hyperstimulation. - lymphoproliferative dis; CLL, NHL, MM.

Causes of acquired CMI def (T cells)

- alcohol - drugs; cyclosporin, cyclophosphamide, steroids. - lymphomas, - AIDS, - medical dis; DM, RA.

Passive; (Ig)

Vaccination

- used for post exposure, immunocompromized. - HAV, HBV, ZIG, DT, Rabies, Botulinum.

1.

Active;

Subunit vaccines; - used for patients with CRF, before splenectomy, hypocomplementimics. - e.g. pneumoccoccal, Meningeococcal, H influenza, HBV 2. Killed; - used for patients with chronic illness. - e.g. pertussis, TAB, influenza, cholera. 3. Live attenuated; - used for healthy individual. - contraindicated for HIV, patients taking steroids 40mg/d for one week or long term smaller dose . - given after ; 3 wks of another live v. 3 m of Ig or stopping steroids , 6 mths from chemo. - BCG, Yellow fever, MMR, oral polio.

Genetics

Prokaryotes(microorganisms) circular DNA, no nuclear membrane . Eukaryotes (higher organisms) have multiple chromosomes , nuclear membranes. Histones allow DNA to twirl round it to form stable nucleoprotein complexes.

 The human karyotype consists of 22 pairs of autosomes and 1 pair of sex chromosomes totalling 23 pairs altogether. Telomeres are DNA sequence at distal extremities of chromosomal arms, become progressively shorter with each cell division when it is reduced to a critical length, the cell is not capable of dividing. The enzyme telomerase lengthen it. centromeres provide a point of attachment for the mitotic spindle.

Chromosomes

Lyonization is the process whereby in a cell containing > 1 x chr, only one is active. A Barr body is an inactivated X chromosome. Haploid= cell with 23 chromosome as gametes. Diploid= cell with 46 chromosome Triploid= cell with 3 copies of each chr. Aneupoid= contain a number of chr not a multiple of 23.

Bases are paired with hydrogen bonds In DNA; Deoxyribose sugar A+T by 2 H bonds G + C by 3 H bonds

In RNA, - uracil instead of thymine - Ribose - Single-stranded.

Cell cycle:
G1 phase ; enzymes for the production of RNA and protein, are produced. S phase ; DNA is synthesized by replication of the existing strand. G2 phase ; RNA and protein are synthesized. M phase mitosis occur: Cell division results in 2 daughter cells, each of which can
enter its own G1 phase become an inactive resting (G0) or die (cell loss fraction).

cyclins= are proteins key regulators of cell cycles which can bind to enzymes known as cyclin dependent kinases. These regulate the progression of the cell cycle.

Stages of Mitosis

Prophase:
chromosomes condense

Metaphase:
chromosomes are lined up on cell equator, attached to the spindle at the centromeres

Anaphase:
centromeres divide. the chromosomes are pulled to opposite poles by the spindle.

Telophase:
cytoplasm divided into 2 separate cells

Chromozomal aneuploidy
Turner S (45,X0); -1:2500 live birth females. - Streak ovaries, E, failure of menstruation, 2ry sexual ccc - short stature, normal intelligence. - Associations; - CVS; coarctation - renal; hoarseshoe, agenesis, double ureter. Kleinfelter;47; XXY - Hypergonadotrophic hypogonadism - Male, tall stature. - Azospermia, testosterone, Gn. - Gynecomastia, male breast cancer. - normal intelligence.

 Down syndrome (trisomy 21)

- 2ry to non dysjunction during oogenesis (with increasing maternal age) - 5% Translocation bet. Chr 14 & 21. - 3% mosaism. - Complication; - CVS; VSD - hematologic malig; ALL, AML. - Alzeheimer disease. - Duodenal atresia (Double bubble sign), hirshsprung.

 Edwards (trisomy 18); - overlapping fingers - renal abn - CHD - MR - diaphragmatic hernia -mortality early infancy. Patau S (trisomy 13); - CNS, -scalp defect, microphthalmia, cleft lip & palate.

Genome
= DNA. Only about 5% of DNA codes for proteins. Human genome = 30.000 gene. Each cell express 16.000 gene. Housekeeping genes =genes expressed in all cells to provide basic function for cell survival (constitutive). Southern blotting detects DNA.

Transcriptome
= m RNA. Microarray analysis of transcriptome identify the expressed genes. Northern blotting detects RNA

Proteome
= protein. Analysis of the proteome is better as it detects changes at the protein level, not reflected at transcriptome level dt Post translation processing.(bioinformatics). Western blotting can be used to detect and quantify proteins

Gene
5
RNA polymerase binding site ex in ex in 3

Transforming factor binding sites

TATA box

ATG Translation Starting site

Translation termination code

Promotor elements

Coding sequences (exons) are interspersed with introns. Both coding (exons) and non coding regions (introns) exist on RNA.

 Exons= segment of the gene transcripted into m RNA then translated into proteins. Introns= segment of the gene transcripted then removed by splicing (not translated). Promotor elements = binding sites for initiation of transcription complex at 5. TF can activate any gene that has a TATA box. TATA box= - a promotor element. - at 25-30 base pairs from the start of transcription. - anchor to RNA polymerase II. Enhancers= - present at 5 or 3. - not obligatory for initiation. - but gene expression. TF; - basal = constitutive - Housekeeping genes. - inducible = temporal, spatial expression of genes for tissue phenotype. Application of TF; 1- many cong malformation are dt inherited mutation of TF. 2- can be oncogenic e.g. CMyC, P53. 3- steroids affect TF.

Process of protein synthesis

DNA is transcribed into RNA by mRNA polymerase II mRNA is translated into proteins in the cytoplasm at the ribosomes. mRNA contain codon which bind to anticodons on tRNA. Transfer RNA (tRNA) is a small RNA chain that has sites for amino-acid attachment & transfers a specific amino acid to the growing polypeptide chain according to the RNA codon. the anticodon region of tRNA, contains the complementary bases to the ones encountered on the mRNA.

Reverse transcription involves transcription of RNA to DNA (used by retroviruses). Restriction enzymes cut DNA at nucleotide sequences specific to each restriction enzyme. DNA ligase and polymerase are involved in joining and linking DNA together. Plasmids are circular molecules of bacterial DNA separate from the bacterial chromosome.

DNA analysis

Direct testing; = identify abnormality within a well known specific gene.

- PCR - restriction enzymes digestion - Southern blotting

Indirect testing; (linkage analysis) used when the gene in question has not been identified before. It involves tracing DNA markers in more than generation within a family.

 1. 2.

PCR Def; it is an amplification reaction in which a small amount of target

DNA (template) is amplified to produce enough amount to perform analysis. PCR is powerful (need only one copy). Uses= Detect viral or bact DNA. Detect mutations.

NB; In PCR, two primers are required for a start and stop sequence to amplify the DNA strand. DNA polymerase needs to be stable at high temperatures and hence thermostable enzyme from T. aquaticus is used. The mixture is heated to below 100C. DNA polymerase causes synthesis of DNA between two primers Stages; 1. Mix the specimen with 2 primers & Taq polymerase (thermostable DNA polymerase). 2. Heat & cool primer anneal to template. 3. Heat ( 72 c) polymerization. 4. Repeat & analyse.

 southern blot; electrophoresis of DNA fragment through gel solid memb as nitrocellulose+ labelled probe visualised under x ray film. Northern blot is a mean to detect RNA (uracil instead of thymine in m RNA). Somatic cell hybridization; - method for gene maping. - using 2 diff species, chr from 1 species is selectively lost resulting in clones of certain chr of the another species. FISH; fluorescence in situ hybridization, labeled probes are hybridized to chromosomes, and the hybridized probes are detected with fluorochromes. visualised under florescent microscope, This technique is a rapid and sensitive means of detecting recurring numerical and structural abnormalities. for microdeletions & trisomy. SSCP (single strand conformation polymorphism analysis); is a technique for detecting variation in DNA sequence by running single stranded DNA fragments through a non denaturating gel.

 Gene mutations; - mismatch = change in the nucleotide. - inversion= nucleotide base removed, reverse directed & reinserted. - point mutation; single base pair substitution.

Dominant vs. Recessive

A dominant allele is expressed even if it is paired with a recessive allele. A recessive allele is only visible when paired with another recessive allele.
Recessive alleles are not expressed in the presence of a dominant allele

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Expression
Homozygous
Both alleles alike AA or aa

Heterozygous
Alleles are different Aa

Codominant
Two different alleles are both dominant A = allele for type A blood B = allele for type B blood AB = results in type AB blood

Autosomal dominant
Musculoskeletal; achondroplasia, Ehlers-Danlos syndrome, Marfan's syndrome , osteogenesis imperfecta Neuro; Huntington's disease, neurofibromatosis, tuberous sclerosis, AIP, benign essential tremors. GIT; intestinal polyposis, Peutz Jeghers syndrome, Gilbert's disease, hereditary haemorrhagic telangiectasia Blood; protein C , antithrombin III deficiency, Von Willebrand's disease, elliptocysis, spherocytosis, C1 esterase inhibitor deficiency CVS; Familial hypercholesterolaemia idiopathic hypoparathyroidism polycystic kidney disease (adult) Noonan S

Marfan's syndrome AD associated with; 1. ocular abnormalities ; upwards lens dislocation and retinal detachment. 2. Aortic regurgitation due to aneurysmal dilatation, MVP. 3. Upper to lower body ratio is decreased , arachnodactyly, high arched palate. 4. Spontanoeus pneumothorax.

As if a male Turner

Autosomal recessive
Metabolic; alkaptonuria, galactosaemia, glycogen storage disease , homocystinuria, phenylketonuria, mucopolysaccharidoses except Hunter, oculocutaneous albinism, G6 phosphatase dedficiency (Von gierkes), Liver; crigler, DJS, Rotor, hemochromatosis, Wilson's disease, Gaucher's disease Blood; B thalathemia, Fanconi anemia, Sickle cell disease, pyruvate kinase def. Neuro; ataxia telangiectasia, spinal ms atrophy, Renal; Bartter's syndrome, Endocrine; congenital adrenal hyperplasia , endemic goitrous cretinism cystic fibrosis xeroderma pigmentosa

 Most metabolic disorders are AR except; 1. XLR; MPS 2 (Hunter), G6PD def , adrenoleuckodystrophy. 2. AD; AIP, Familial hypercholesterolaemia

X linked recessive
The features of X linked inheritance; Males are all affected Females only occasionally show mild signs of disease Each son of a carrier a 1:2 chance of being affected Each daughter of a carrier has a 1:2 risk of being a carrier Daughters of affected males will all be carriers Sons of affected males will not be affected Renal; Alport, Fabrys disease Neuro; Beckers, Duchennes muscular dystrophy Bl; G6PD deficiency, haemophilia A and B Endocrine; Testicular feminisation syndrome. Eye; ocular albinism, red-green colour blindness Hunters syndrome, leishnehan, Wiskott Aldrich syndrome

X linked dominant (rare)

Daughters of affected males will all be affected. All offsprings of an affected female have a 50% chance of being affected. e.g. X linked Hypophosphataemic VDR rickets . Fragile X syndrome

Fragile X syndrome XLD delayed mental and motor development seizures. prognathism, long face, high arched palate, large ears, cryptorchidism, hypotonia and mitral valve prolapse.

Codominant inheritance
Two different versions (alleles) of a gene can be expressed, and each version makes a slightly different protein. E.g. ABO locus

53

Non Mendelian inheritance; Polygenic; 2 or more genes influence phenotype. Multifactorial; gene + enviroment e.g. DM, HTN, obesity, CAD, schizophrenia, parkinson, Alzeheimer. Mitochondrial inheritance. Genomic imprinting

mitochondrial inheritance
Mitochondria contain certain genes & are exclusively maternally inherited (from oval cytoplasm). Mitochondrial DNA codes for proteins in the oxidative phosphorylation . In Mitochondrial Diseases , all offsprings of affected women but no offsprings of affected men. Kearn Sayre's MELAS (mitochondrial encephalopathy, lactic acidosis, stroke) MERRF (myoclonic epilepsy, ragged red fibres) progressive external opthalmoplegia Leber's optic atrophy

Genomic imprinting refers to the difference in phenotypic presentation depending on the origin of the diseased chromosome from either maternal or paternal. Conditions with genomic imprinting: Albright hereditary osteodystrophy Prader Willi syndrome Angelman syndrome

Trinucleotide repeat
Affected pts has increased number of repeated units of 3 nucleotides in affected gene (expansion), become more severe over successive generations (anticipation). Myotonic dystrophy (AD) Huntington dis (AD) Fragile X S (XLR) Freidreich ataxia (AR) Spinocerebellar ataxia (AD) Anticipation refers to increase in the number of trinucleotide repeats

Enzyme deficiencies
Gauchers disease Glucocerebrosidase deficiency Niemann Pick disease - Sphingomyelinase deficiency Alkaptonuria homogentisic acid oxidase Homocystinuria cystathionine B synthase.

 AR Dt deficiency of homogentisic acid oxidase accumulation of homogentisic acidpolymerize to alkapton deposit in different tissues. C/P; pigmentation of ear, arthritis, intervertebral disc calcification, dark sweat-stained clothes, urine darken on standing,renal stone, ocular comp. TTT; symptomatic non specific.

Ochronosis; (Alkaptinuria)

cong hyperhomocysteinemia AR Reduced activity of cystathionine synthase. accumulation of homocysteine & methionine. C/P; Marfanoid + Mental Ret. + thrombosis ( downward dislocation of the lens, high arched palate, Osteoporosis , livido reticularis, atherogenic, thrombogenic). Diagnosis; Na cyanide/nitroprusside test Ttt; vit B6, B12, folic acid, methionine restriction, cystine supplemented diet.

D penicillamine uses; RA, scleroderma Cystinurea wilson

COAL

-Hexagonal crystals in urine analysis -Colorimetric qualitative test with Na cyanide/nitroprusside test -quantitative

Liver transplantation before renal

Fabry's disease is an X-linked lysosomal storage disorder. It is caused by a deficiency of alphagalactosidase A. Ceramide accumulation occurs in various organs including the heart, skin and nerves. The skin lesion is known as angiokeratoma corporis diffusum. Gaucher's disease is associated with the enzyme glucocerebrosidase. As a result, glucocerebroside accumulates, principally in the phagocytic cells of the body but also sometimes in the central nervous system neurones.

Molecular

Apoptosis
Def; is the morphological changes that accompagny the programmed cell death e.g. cell shrinkage, compaction of chromatin, nuclear & cytoplasmic apoptotic bodies phagocytosed by MQ, laddering of DNA on electrophoresis gel by activation of intracellular nucleases. programmed cell death= naturally occurring cell death dt activation of a set of genes in response to ext signals e.g. from neighbour or extracellular matrix.

P53 Fas, CD 95 +

+ _ Signals for cell death + bcl2

TF +

caspases

endonucleases

 Cancer resists apoptosis by; - Mutation of P53. - Causing apoptosis of cytotoxic T cells (TNF like + Fas). - Over-expression of Bcl2.

 Apoptosis; - non-inflammatory process. - no proteolytic enzymes. - no free radicals. - no damage of neighbouring cells. E.g. apopt of finger web, selection of neurons ( normal apopt in embrio). - apopt of excess or autoreactive T lymphocytes ( normal apopt in adult). - neurodegenerative dis, HIV (dis). - insufficient apoptosis e.g. cancer, autoimmune dis, viral dis. Factors that + apoptosis; P53, P27, Fas or CD95 (receptor for TNF), withdrawal of GF. Factors that - apoptosis; bcl2 (survival signals), B catenin accumulation adenoma. Apoptosis occur through proteases called caspases (e.g. ICE= IL-1B converting enzyme) that + endonuleases. Caspases = cysteine aspartate specific proteases.

Molecular pathogenesis of cancer

Oncogenes
Proto-oncogenes and oncogenes encode growth factors. A single aa mutation is enough to change the proto-oncogene into an oncogene. Mutated proto-oncogenes that cause cancer are called oncogenes. Examples of oncogenes are: Ras is the commonest oncogene is involved in sporadic tumours (colon and lung) and rhabdomyosarcomas. c-myc translocation occurs in Burkitt's lymphoma. N-myc proto-oncogene is seen in neuroblastoma. SRC oncogene is associated with sarcoma. Mutations of protein kinasesTF (Fos & Jun)+ Myc tumor. Philadelphia chr bcr + abl (9;22) fusion protein tumor growth. Bcl-2 inhibits apoptosis, preventing p53 mediated cell destruction and prevent cell death. Fas ligands and caspases trigger apoptosis. Bax, Bad and Bak are members of the oncogenes which promote cell death (of immune cell).

Tumour suppressor genes ;

NF-1 gene in neurofibromatosis BRCA-1 in breast and ovarian cancer Rb gene in retinoblastoma VHL gene in von Hippel Lindau P53 Li Fraumeni syndrome p53 : The p53 Gene is a tumor suppressor gene. If a person inherits only one functional copy of the p53 gene from their parents, they are predisposed to cancer and usually develop several independent tumors in a variety of tissues in early adulthood. This condition is rare, and is known as Li-Fraumeni syndrome. Li Fraumeni syndrome predisposes patients to breast cancer and sarcoma. p53 is also a transcription factor and is not found only in malignant cells. It has a role in downregulating cell division and apoptosis. P27 Tumor suppressor gene through down regulation of cell cycle (cyclin dependent kinase inhibitor), if downregulated sporadic Cancer colon.

Nitric oxide (NO)

1. 2. Endothelial derived relaxation factor Produced from L arginine by oxidation of Nitrogen NO + citrulin. C GMP (2ry mess) in neighboring cells. Produced in; Constitutive..Vascular end & Nervous system VD, sm hyperplasia, plat agg. new memory. Inducible.. in MQ, PNL, plat, hepatocytecytotoxic.

Clinical application;
- So used as nitrates or inhaled NO in pulm HTN. - endothelial dysf in DM, HTN, smokers & hypercholestrolemia is dt loss of NO bioavailability. - NO in atherosclerosis, HTN dt CRF, HRS, Alzeheimer. - NO in septic shock, ARDS, acute inflammation.

Endothelin I (VC)
ET-1 (end, sm, coronary, GIT). Related to dis; - HTN, HRS, ARF, CHF, Raynaulds. (VC) - VC following subarachnoid Hge. ET1 receptor blockers & CEI used as anti HTN.

Pro-inflammatory cytokines Il-1, TNF, TGF-B, Heat shock protein, free radicals.
TGF- action; - tissue repair. - extracellular matrix. - fibrosis. tissue injury + plat release of TGF-B chemotaxis monocytes (+ fibroblast GF, TNF, IL-1) involved in glomerulosclerosis, hep fibrosis, pulm fibrosis, bleomycin lung. NB;

HSPs (Heat shock proteins)

heat, chemicals, free radicals damage of intracellular proteins HSP cell resistance to stress through; - prot folding & unfolding. - degrad of prot ( by ubiquitination). dis associated; if mutated cataract, motor neuron deg. bact HSP + immune syst.

Free radicals Any molecule with 1or more unpaired electron (more reactive); peroxide, super, hydroxyl, NO. NB; hydroxyl is the most reactive. action; - lysosomes. - lipid peroxidation of memb. - mutations (by attaching purines & pyrimidine). Diseases athero, cancer, neurodeg ( MND). Free radical scavengers; - tocopherol (Vit E). - ascorbate (Vit C). - glutathione. - Beta carotene. - Flavenoids.

Adhesion Molecules
Def; Molecules that interact as receptors & ligand. 4 groups; Ig ( CD2, CD3, NCA (neural cell adh), ICAM (intercellular) bind to LFA ( lymph funct ass)to recruit lymphocytes. - integrin ( cell to matrix) Integrins are surface receptors by which cells are attached to extracellular matrix.. - Cadherins (Nerve & Muscle ). - selectins ( leukocytes to endoth in inflam, over expressed in autoimmune viral hepatitis, organ rejection). Clinical application; 1. leuk adhesions deficiency recc bact sepsis. 2. integrin IIb IIIa ( plat receptor to fibrinogen) deficiency Glansman thrombathenia. Ab (abciximab) antithrombotic in coronary Ht.

Stem cells
progenitor cells. present in certain tissues e.g. BM, embrionic. embryonic totipotent (any tissue). BM Bl. cells only, can be recruited by Ag sorting with CD34 Ab & undergo transdifferentiation to non hematologic cells.

Physiology

O2-Hb dissociation curve

is shifted to the right when there is: - an increase in CO2 - increase in hydrogen ions (fall in pH) - increase in temperature - increase in lactate The curve is shifted to the left by - increased carboxyhaemoglobin - methaemoglobin - fetal haemoglobin.

Receptors
A) Cell membrane surface receptors;
1- ligand gated Ion channel; - e.g. neurotransmitter open ion channel - Nicotinic Na. - GABA, Glycine Cl. 2- receptors with protein tyrosine kinase - phosphorylation of tyrosine residue of receptors cascade of cytoplasmic prot. e.g. insulin, PDGF, prolactin, IGF1, MQ CSF, NGF, EGF. 3- G protein coupled - is a protein that bind to guanine nucleotide). - G protein receptors are 7 transmembrane spanning receptors. - Examples are: Muscarinic Ach receptor, Adrenergic receptor (adrenaline), Retinal rhodopsin receptor, FSH, TSH, ACTH,GABA - Dis associated with G protein abn e.g. cholera, Albright HOD, MeCune Albright S, pit adenoma. NB; prot kinases add phosphate group to serine, threonine, tyrosine residue (# phosphatase)

B) Intracellular receptors; - cytoplasmic= steroids. - Nuclear= thyroid. - no 2 ry mess. - intracytoplasmic receptors. - the complex travel to the nucleus & bind to hormone responsive elements.

Stimulation of receptors leads to: - Vasoconstriction - decrease in gut motility - uterus contraction - decrease in pancreatic exocrine secretion
Cholera toxin: activates G protein, which activates adenylate cyclase. Elevated cAMP results in unrestricted chloride secretion from villous crypts.

GIT
Stomach; - 3 litres HCL - parietal cell HCL, intrinsic factor - chief cell pepsin - surface cells mucous, HCO3. - parasymp & symp via Meissner, Aurbach plexus. - Bl sully celiac trunk. H pylori

H pylori
1. Campylobacter pyloridis, is a gram-negative microaerophilic rod Pathologic mech; produce urease. Urease produces ammonia from urea, an essential step in alkalinizing the surrounding pH epithelial damage. Produce protease, lipase damage of mucosal gel. Increase HCl directly or indirectly through cytokines on G, D, parietal cells resulting in gastrin & somatostatin. Chemotactic factors PNL. Incidence; 80% in developing countries, 20% in industrialized. Complications; Chronic active gastritis. PUD MALT lymphomas Adenocarcinoma Extragastric; IsHD, enteropathic arthropathy, hep enceph, acne rosesea, alopecia, urticaria, Raynaulds.

2. 3.
4. 1. 2. 3. 4. 5.

Gut Hormones
Gastrin; - is secreted by the G cells of gastric antrum. - It stimulates parietal cells produce hydrochloric acid. - Its production is stimulated by; - gastric distension, certain aa (phenylalanine, tryptophan). HCL. - vagal stimulation - S.Ca - epinephrine. - Its production is inhibited by; - HCL - secretin, GIP, VIP - glucagon, calcitonin - effects; gastric motility & secretion mucosal growth pancreatic secretion; insulin, glucagon, bicarbonate.

 Cholecystokinin. - is produced by the duodenum & jejunum. - Its production is stimulated by fat, aa, peptides. - stimulates GB contraction, pancreatic enzyme secretion, delay gastric empting.
Secretin ; - is produced by the jejunum. - Its production is stimulated by HCL - stimulates pancreatic enzyme secretion(HCO3). - It relaxes the oesophageal sphincter , delay gastric empting. Motilin; - is produced by the duodenum & jejunum. - Its production is stimulated by acid - increase motility.

 Vasoactive intestinal peptide (VIP) - is produced by SI - Its production is under neural stimulation - promotes intestinal & pancreatic water and electrolyte secretion. Gastric inhibitory peptide; - produced by duodenum & jej. - Its production is stimulated by glucose, fat &aa - inhibit gastric acid secretion, stimulate insulin secretion, motility.

Somatostatin; - produced by D cells of pancreas. - stimulated by vagal & B adrenergic stimulation. - stimulate gastric empting & inhibit everything else (gastric & panc secretion).
Pancreatic polypeptide; - produced by PP cells in pancreas. - stimulated by protein rich diet - inhibit pancreatic & biliary secretion.

Q
The following statements regarding gastrointestinal hormones are correct: A gastrin increases gastric motility. B somatostatin decreases gastric motility. C pancreatic polypeptide stimulates pancreatic bicarbonate secretion. D enteroglucagon decreases the small bowel transit time. E secretin maintains mucosal growth. True= abd Comments: Pancreatic Polypeptide inhibits exocrine pancreatic secretions. Secretin is important in stimulating pancreatic secretion. The role of enteroglucagon is not well defined but includes villous hypertrophy and hence reduction in transit time. Somatostatin inhibits many many GI functions including gastric motility.

Vitamins deficiencies
Nutrient Vitamin A Clinical Finding Xerophthalmia, nightblindness, Bitot's spots, follicular hyperkeratosis, impaired embryonic development, immune dysfunction Rickets: skeletal deformation, rachitic rosary, bowed legs; osteomalacia Contributing Factors to Deficiency Fat malabsorption, infection, measles, alcoholism, proteinenergy malnutrition Aging, lack of sunlight exposure, fat malabsorption, deeply pigmented skin Occurs only with fat malabsorption, or genetic abnormalities of vitamin E metabolism/transport Fat malabsorption, liver disease, antibiotic use

Vitamin D

Vitamin E

Peripheral neuropathy, spinocerebellar ataxia, skeletal muscle atrophy, retinopathy

Vitamin K

Elevated prothrombin time, bleeding

Nutrient Thiamine Riboflavin Niacin

Clinical Finding Beriberi: neuropathy, muscle weakness and wasting, cardiomegaly, edema, ophthalmoplegia, confabulation Magenta tongue, angular stomatitis, seborrhea, cheilosis

Contributing Factors to Deficiency Alcoholism, chronic diuretic use, hyperemesis

Pellagra: pigmented rash of sun-exposed areas, bright Alcoholism, red tongue, diarrhea, apathy, memory loss, vitamin B 6deficiency, disorientation riboflavin deficiency, tryptophan deficiency Seborrhea, glossitis convulsions, neuropathy, depression, confusion, microcytic anemia Alcoholism, isoniazid

Vitamin B6

Folate
Vitamin B12

Megaloblastic anemia, atrophic glossitis, depression , homocysteine

Megaloblastic anemia, loss of vibratory and position sense, abnormal gait, dementia, impotence, loss of bladder and bowel control, homocysteine , methylmalonic acid

Alcoholism, sulfasalazine, pyrimethamine, triamterene

Gastric atrophy (pernicious anemia), terminal ileal disease, strict vegetarianism, acid reducing drugs (e.g., H 2 blockers) Smoking, alcoholism

Vitamin C

Scurvy: petechiae, ecchymosis, coiled hairs, inflamed and bleeding gums, joint effusion, poor wound healing, fatigue

Element Calcium Copper

Deficiency Reduced bone mass, osteoporosis Anemia, growth retardation, defective keratinization and pigmentation of hair, hypothermia, degenerative changes in aortic elastin, osteopenia, mental deterioration Dental caries Thyroid enlargement ,cretinism kilonychia, pica, anemia,, impaired cognitive development, Impaired growth and skeletal development, reproduction, lipid and carbohydrate metabolism; upper body rash Cardiomyopathy, heart failure, striated muscle degeneration

Toxicity Renal insufficiency (milk-alkalai syndrome), nephrolithiasis, impaired iron absorption Nausea, vomiting, diarrhea, hepatic failure, tremor, mental deterioration, hemolytic anemia, renal dysfunction Dental and skeletal fluorosis, osteosclerosis Thyroid dysfunction, acne-like eruptions Gastrointestinal effects (nausea, vomiting, diarrhea, constipation), iron overload with organ damage, acute systemic toxicity Neurotoxicity, Parkinson-like symptoms Encephalitis-like syndrome, Parkinson-like syndrome, psychosis, pneumoconiosis Alopecia, nausea, vomiting, abnormal nails, emotional lability, peripheral neuropathy, lassitude, garlic odor to breath, dermatitis Lung and nasal carcinomas, liver necrosis, pulmonary inflammation Hyperphosphatemia

Fluoride Iodine Iron

Manganese

Selenium

Phosphorou s Zinc

osteomalacia, proximal muscle weakness, rhabdomyolysis, paresthesia, ataxia, seizure, confusion, heart failure, hemolysis, acidosis Growth retardation, taste and smell, alopecia, dermatitis, diarrhea, immune dysfunction, gonadal atrophy, congenital malformations

Reduced copper absorption, gastritis, sweating, fever, nausea, vomiting, Respiratory distress, pulmonary fibrosis

 Iron is absorbed in upper small intestine. Iron absorption is increased with ascorbic acid. The sulfate form contains more elemental iron per dosage unit than gluconate.

Q
The following may be found in the event of a prolonged bout of vomiting except A tetany B hypochlorhydria C megaloblastic anaemia D hypokalaemia E high serum aldosterone . C

Renal physiology

The glomerular filtration barrier; 1. Fenestrated endothelial cells. 2. Glom BM 3. Visceral epith cells (podocytes) & filtration slit diaphragm. GBM is composed of 3, 4, 5 type IV collagen.
Juxta glomerular apparatus; 1. Modified aff arteriolar cells. 2. Macula densa in DCT 3. Lacis cells in extraglom. Mesangium. Stimuli for renin secretion; 1. RBF Na delivery to the macula densa 2. BP (baroreceptor mech) renin from aff cells. 3. B adrenergic stimulation.

 Renin catalyse the conversion of angiotensinogen into Ang I.

Angiotensin II; - thirst sensation - systemic VC - VC of efferent arteriole mainly GFR. - stimulate aldosterone secretion - stimulate ADH - direct stimulation of Na reabsorption from PCT by stimulation of Na/H exchanger. Andosterone; - stimulate Na-K ATPase, - luminal memb permeab to K - H secretion by collecting duct

ADH; Stimulated by plasma osmolarity > 285, plasma volume. V1 receptor VC V2 water permeability in the collecting ducts by stimulation of adenylate cyclase CAMPStimulate memb fusion of vesicle containing water channels.
ANP; Inhibit Na reab in the collecting duct GFR Inhibit ADH & Ald secretion

Tubular function
PCT; Absorption of all glucose, aa. 90% of HCO3 60% Na, Cl, K, Ca Phophate absorption inhibitesd by PTH.

LOH; - countercurrent multiplier (NaK2Cl in thick ascending limb) # frusemide. - 70% of Mg absorption DCT; Na/Cl cotransport # thiazide. CD; principle cells amiloride sensitive channels aldosterone on NaK ATPase ADH on aquaporins intercalated cells H or HCO3 secretion

 In pre renal failure / Acute Tubular Necrosis (hypovolaemia, dehydration), the kidney attempts to retain sodium, hence urine sodium is <20mmol/l. The anion gap is normal (Na + K - Cl Bicarb) - normal range is 10 - 16. Serum osmolality is estimated by the formula : [2 (Na) + urea + glucose].

Sweat chloride test

False +ve conc of sweat electrolytes; 1. Endocrine; hypo-adrenal, parath, thyr, cong nephr DI. 2. Metabolic; G6PD, MPS 3. Ectodermal dysplasia, familial cholestasis, pancreatitis, malnutrition. False ve; nephrotic S.

Q
Atrial natriuretic peptide A inhibits distal tubular reabsorption of sodium B promotes excretion of potassium in the urine C levels in the blood are independent of left ventricular function D inhibits vasoconstriction mediated by angiotensin II E is a vasodilator without causing reflex tachycardia

Neuro
Myosin is involved in striated muscle contraction. It forms filaments in a hexameric array of 2 heavy chains and 2 pairs of light chains. Myosin heavy chain mutation is implicated in familial hypertrophic cardiomyopathy. HOCM and Carney complex are forms of myosin chain disorders.

 Weakness of small ms of the hand; lower trunk of Br plexus injury all small ms of the hand (T1) + long flex & ext of fingers (C8).

T1 root e.g. cervical rib, pancoat, sub art aneurysm. all small ms of the hand. ulnar n all small ms of the hand except 2 lateral lumbricals & thenar group (T1 through median n).

Dermatomes

Cord compression
Upper 4 cervical; - neck pain - quadriplegia, wasting UL. - cr n 5 spinal root; dissociated sensory loss of face. C5,6; - pain in shoulder, outer arm, FA, thumb - wasting of romboids, deltoid, biceps, supinator, brakioradialis. - lost biceps, exagerated triceps, inverted supinator reflexes. C8,T1; - pain medial side - wasting of flexors of wrist, hand. - horner L3,4; - medial side of LL pain. - wasting of quadriceps, abductors - lost knee, extensor planter reflexes.

Epiconus= L4,5, S1,2 segments of SC. lesions; - lost anckle, preserved knee reflexes - motor;extension of hip, flexor of knee, dorsi & planter flexion of foot, toes. - sensory; most of leg - micturition disturbance.
Conus medullaris= S3,4,5 segments of SC. lesions; - no motor or sensory of LL. - dissociated sensory loss of saddle area. - early urinary incontinence. - impotence. Cauda equina= all lumbar & sacral roots. lesions; - early radical pain. - sphincters late (retension then autonomic) - LMNL in LL.

NB; siatica= roots of epiconus (L4,5, S1,2,3)

Root compression
C5; deltoid C6; biceps & brakioradialis C7; wrist extensor, triceps C8; finger flexors, thumb abductors T1; small ms of the hand L1,2; iliopsoas (flexion of hip) L3; quadriceps (knee exten L4; ant. Tibial (dorsiflexion & inversion) L5; ant. Tibial & glutei. S1; calf ms, glutei S2; hamstring S3-5; saddle area.

Biceps reflexes= C5,6 Triceps reflexes; C7,8 Supinator reflexes;C6 Knee reflexes L3,4 Anckle reflexes; S1,2.

Symptoms Carpal tunnel syndrome Ulnar nerve entrapment at the elbow Ulnar nerve entrapment at the wrist

Ppitating Acts

Examination - Sensory loss in thumb, 2nd,3rd fingers - Weakness in thenar muscles; -Tinel and Phalen signs Sensory loss in the little finger and ulnar half of ring finger Weakness of the interossei and thumb adductor; claw-hand Like UNE but sensory examination spares dorsum of the hand, and selected hand muscles affected

Numbness, pain Sleep or repetitive or paresthesias in hand activity fingers Numbness or paresthesias in ulnar aspect of hand Numbness or weakness in the ulnar distribution in the hand Elbow flexion during sleep; elbow resting on desk Unusual hand activities with tools, bicycling

Radial neuropathy at the spiral groove Thoracic outlet syndrome

Wrist drop

Sleeping on arm after inebriation with alcohol "Saturday night palsy" Lifting heavy objects with the hand

Wrist drop with sparing of elbow extension (triceps sparing); finger and thumb extensors paralyzed; sensory loss in radial region of wrist Sensory loss resembles ulnar nerve and motor loss resembles median nerve

Numbness, paresthesias in medial arm, forearm, hand, and fingers

Symptoms Femoral neuropathy Buckling of knee, numbness or tingling in thigh/medial leg Weakness of the leg, thigh numbness

Precipitating Activities Abdominal hysterectomy; lithotomy position; hematoma, DM Stretch during hip surgery; pelvic fracture; childbirth

Examination Wasting and weakness of quadriceps; absent knee jerk; sensory loss in medial thigh and lower leg Weakness of hip adductors; sensory loss in upper medial thigh

Obturator neuropathy Meralgia paresthetica

Pain or numbness - Standing /walking Sensory loss in the pocket of the in the anterior -Recent weight pant distribution lateral thigh gain Usually an acute compressive episode identifiable; wt loss Injection injury; fracture/dislocation / prolonged pressure on hip (comatose patient) Weak dorsiflexion, eversion of the foot Sensory loss in the anterolateral leg and dorsum of the foot Weakness of hamstring, plantar and dorsiflexion of foot; sensory loss in tibial and peroneal nerve distribution

Peroneal n. Foot drop entrapment at the fibular head Sciatic neuropathy Flail foot and numbness in foot

Q
A lesion of the facial nerve in the internal auditory meatus will affect A taste B sensation over cheek C lacrimation D sweating over cheek E blinking True=ace Comments: The extent of dysfunction depends on the level of injury. If it is proximal to geniculate ganglion eg internal auditory meatus, taste is lost in the anterior 2/3 of tongue. Also secretion from submandibular, sublingual and lacrimal glands is impaired. Hyperacusis is due to paralysis of stapedius. Orbicularis oculi is affected causing inability to blink/close eyelids. Sensation over face supplied by trigeminal nerve, and sweat glands controlled by sympathetic nervous system eg anhydriosis in Horner's syndrome.

Q
The following associations of muscles and nerve supply are true except A triceps and C7 B deltoid and C5 C gastroenemius and S1 D quadriceps and L3 E long flexors of fingers and C6 E Comments: Finger flexors and extensors are supplied by C8.

Q
The following are true of lipoprotein metabolism: A Large LDL particles are most atherogenic B LDL concentrations can be calculated from total cholesterol, triglyceride and HDL concentrations C VLDL is secreted by the liver D hyperchylomicronaemia may cause pancreatitis E dietary lipid is absorbed into the blood as chylomicrons The true= bcd Comments: LDL concentrations can be calculated from HDL, total cholesterol and triglyceride using the Friedwald equation. Small, high density LDL particles are the most atherogenic. Cholesterol and triglycerides that are absorbed from the gut are transported on chylomicrons into the blood through the lymphatic system and thoracic duct. Hyperchylomicronaemia, associated with type I hyperlipidaemia is rare and is associated with hypertriglyceridaemia and pancreatitis. VLDL is secreted by the liver.

Causes of Retinitis pigmentosa are: Kearn Sayre's syndrome Usher's disease Refsum's disease Lawrence Moon Biedl syndrome Alports's syndrome Friedrich's ataxia