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2. What are the direct and indirect Coombs tests?

The Coombs test is used to detect antibodies that act against the surface of RBCs. There are two types of Coombs tests: direct and indirect. The direct Coombs test, also known as the direct antiglobulin test, is the test usually used to identify hemolytic anemia. [The indirect Coombs' test is used only in prenatal testing of pregnant women and in testing blood prior to a transfusion.] For the direct Coombs test, blood is drawn from the vein in your arm and then washed to isolate your red blood cells. The red blood cells are then incubated (combined in a controlled environment) with a substance called Coombs reagent. If the red blood cells clump together (a process called agglutination), then the Coombs test is said to be positive. An antibody, also known as an immunoglobulin, is a large Y-shaped protein used by the immune system to identify and neutralize foreign objects such as bacteria and viruses. The antibody recognizes a unique part of the foreign target, termed an antigen.[1][2] Each tip of the "Y" of an antibody contains a paratope (a structure analogous to a lock) that is specific for one particular epitope (similarly analogous to a key) on an antigen, allowing these two structures to bind together with precision. Using this binding mechanism, an antibody can tag a microbe or an infected cell for attack by other parts of the immune system, or can neutralize its target directly (for example, by blocking a part of a microbe that is essential for its invasion and survival). The production of antibodies is the main function of the humoral immune system
4. What are the different antibody isotypes and what is their typical structure? Antibody isotypes of mammals Name Types Description Found in mucosal areas, such as the gut, respiratory tract and urogenital tract, and prevents colonization by IgA 2 pathogens.[13] Also found in saliva, tears, and breast milk. Functions mainly as an antigen receptor on B cells that have not been exposed to antigens.[14] It has been IgD 1 shown to activate basophils and mast cells to produce antimicrobial factors.[15] Binds to allergens and triggers histamine release from IgE 1 mast cells and basophils, and is involved in allergy. Also protects against parasitic worms.[3] In its four forms, provides the majority of antibodybased immunity against invading pathogens.[3] The IgG 4 only antibody capable of crossing the placenta to give passive immunity to fetus. Expressed on the surface of B cells (monomer) and in a secreted form (pentamer) with very high avidity. IgM 1 Eliminates pathogens in the early stages of B cell mediated (humoral) immunity before there is sufficient IgG.[3][14] Antibody Complexes

Antibodies can come in different varieties known as isotypes or classes. In placental mammals there are five antibody isotypes known as IgA, IgD, IgE, IgG and IgM. They are each named with an "Ig" prefix that stands for immunoglobulin, another name for antibody, and differ in their biological properties, functional locations and ability to deal with different antigens, as depicted in the table.[16] The antibody isotype of a B cell changes during cell development and activation. Immature B cells, which have never been exposed to an antigen, are known as nave B cells and express only the IgM isotype in a cell surface bound form. B cells begin to express both IgM and IgD when they reach maturitythe co-expression of both these immunoglobulin isotypes renders the B cell 'mature' and ready to respond to antigen.[17] B cell activation follows engagement of the cell bound antibody molecule with an antigen, causing the cell to divide and differentiate into an antibody producing cell called a plasma cell. In this activated form, the B cell starts to produce antibody in a secreted form rather than a membrane-bound form. Some daughter cells of the activated B cells undergo isotype switching, a mechanism that causes the production of antibodies to change from IgM or IgD to the other antibody isotypes, IgE, IgA or IgG, that have defined roles in the immune system. Structure Antibodies are heavy (~150 kDa) globular plasma proteins. They have sugar chains added to some of their amino acid residues.[18] In other words, antibodies are glycoproteins. The basic functional unit of each antibody is an immunoglobulin (Ig) monomer (containing only one Ig unit); secreted antibodies can also be dimeric with two Ig units as with IgA, tetrameric with four Ig units like teleost fish IgM, or pentameric with five Ig units, like mammalian IgM.[19] Several immunoglobulin domains make up the two heavy chains (red and blue) and the two light chains (green and yellow) of an antibody. The immunoglobulin domains are composed of between 7 (for constant domains) and 9 (for variable domains) -strands. The variable parts of an antibody are its V regions, and the constant part is its C region. Immunoglobulin domains The Ig monomer is a "Y"-shaped molecule that consists of four polypeptide chains; two identical heavy chains and two identical light chains connected by disulfide bonds.[16] Each chain is composed of structural domains called immunoglobulin domains. These domains contain about 70-110 amino acids and are classified into different categories (for example, variable or IgV, and constant or IgC) according to their size and function.[20] They have a characteristic immunoglobulin fold in which two beta sheets create a sandwich shape, held together by interactions between conserved cysteines and other charged amino acids. Heavy chain For more details on this topic, see Immunoglobulin heavy chain. There are five types of mammalian Ig heavy chain denoted by the Greek letters: , , , , and .[1] The type of heavy chain present defines the class of antibody; these chains are found in IgA, IgD, IgE, IgG, and IgM antibodies, respectively.[6] Distinct heavy chains differ in size and composition; and contain approximately 450 amino acids, while and have approximately 550 amino acids.

1. Fab region 2. Fc region 3. Heavy chain (blue) with one variable (VH) domain followed by a constant domain (CH1), a hinge region, and two more constant (CH2 and CH3) domains. 4. Light chain (green) with one variable (VL) and one constant (CL) domain 5. Antigen binding site (paratope) 6. Hinge regions. In birds, the major serum antibody, also found in yolk, is called IgY. It is quite different from mammalian IgG. However, in some older literature and even on some commercial life sciences product websites it is still called "IgG", which is incorrect and can be confusing. Each heavy chain has two regions, the constant region and the variable region. The constant region is identical in all antibodies of the same isotype, but differs in antibodies of different isotypes. Heavy chains , and have a constant region composed of three tandem (in a line) Ig domains, and a hinge region for added flexibility;[16] heavy chains and have a constant region composed of four immunoglobulin domains.[1] The variable region of the heavy chain differs in antibodies produced by different B cells, but is the same for all antibodies produced by a single B cell or B cell clone. The variable region of each heavy chain is approximately 110 amino acids long and is composed of a single Ig domain.

Light chain
For more details on this topic, see Immunoglobulin light chain. In mammals there are two types of immunoglobulin light chain, which are called lambda () and kappa ().[1] A light chain has two successive domains: one constant domain and one variable domain. The approximate length of a light chain is 211 to 217 amino acids.[1] Each antibody contains two light chains that are always identical; only one type of light chain, or , is present per antibody in mammals.

CDRs, Fv, Fab and Fc Regions


Some parts of an antibody have unique functions. The arms of the Y, for example, contain the sites that can bind two antigens (in general identical) and, therefore, recognize specific foreign objects. This region of the antibody is called the Fab (fragment, antigen binding) region. It is composed of one constant and one variable domain from each heavy and light chain of the antibody.[21] The paratope is shaped at the amino terminal end of the antibody monomer by the variable domains from the heavy and light chains. The variable domain is also referred to as the FV region and is the most important region for binding to antigens. More specifically, variable loops of -strands, three each on the light (VL) and heavy (VH) chains are responsible for binding to the antigen. These loops are referred to as the complementarity determining regions (CDRs). The structures of these CDRs have been clustered and classified by Chothia et al. [22] and more recently by North et al.[23] In the framework of the immune network theory, CDRs are also called idiotypes. According to immune network theory, the adaptive immune system is regulated by interactions between idiotypes. The base of the Y plays a role in modulating immune cell activity. This region is called the Fc (Fragment, crystallizable) region, and is composed of two heavy chains that contribute two or three constant domains depending on the class of the antibody.[1] Thus, the Fc region ensures that each antibody generates an appropriate immune response for a given antigen, by binding to a specific class of Fc receptors, and other immune molecules, such as complement proteins. By doing this, it mediates different physiological effects including recognition of opsonized particles, lysis of cells, and degranulation of mast cells, basophils and eosinophils.[16][24] 9. What is allergic fungal sinusitis and how is it treated? AFRS was first described in 1976 by Sarfistein. Now thought to account for 5-10% of CRS cases, pts mean age 21.9, mostly in warm, humid climates. Presentation: gradual nasal airway obstruciton with semi-solid nasal crusting, extensive nasal polyposis, sinusitus- Unilateral in half of patients. Rarely do they complain of pain , and disease is often recalcitrant despite maximal medical therapy. Pts are often unresponsive to anithisamines, intranasal steroids, immunotherapy, Systemic steroids often provide temporary relief. 75% of patients desribe expelling dark colored rubbery nasal casts. Allergic mucin can accumulate and act like a mucocele where bony remodeling and decalcification can mimic invasion on CT scan. Can go so far as to see proptosis, telecanthus, and intracranial extension. To diagnose: Bent Kuhn criteria (1994) 1) Type 1 hypersensitivity confirmed by history, skin tests, serology 2) nasal polyposis 3) Fungal hyphea on stain in OR/ culture, charcot leiden crystal (negative culture does not rule out AFRS) 4) CT findings: areas of high attenuation within expanding sinuses and hyperdense areas thought to represent accumulation of heavy metals and calcium salts, bony erosion is very common- up to 98% of scans. but does not incvade dura or peri-orbital elements. Tx: 1) immunotherapy 2) FESS +/- antifungal therapy, cotrticosteroids - goal of surgery to remove all polyps to the BM, extirpation of the allergic mucin and fungal debri, create permanent drainage and ventilation for the affected sinuses while maintaining intact mucosa, and create post-operative acess to previously diseased areas Immunotherapy has really not shown to be effective in the long-term and certainly not without FESS. There is less agreement about anti-fungals, they are toxic in large doses, there are no well studied topical antifungals with good track records. Ponikau et all found that boht CRS and normal controls grew fungus from nasal mucosal cultures,

concluded that 93% of CRS had AFRS, and they disregarded atopy as a contributing factor. Argue that arfs is not caused directly by a fungus in an immunocompromised host but by an otherwise harmless fungus in an immunologically "hypercompetent" host.

11. Tell us about congenital immunodeficiency syndromes I. Epidemiology: Normal children have recurrent infections A. Average child has 5-6 Upper Respiratory Infections/year 1. Unlucky children (5%) have 11-12 URIs per year 2. Otitis Media complicates URIs in 30-50% of cases Causes: Primary Immunodeficiency A. Antibody or humoral (B-Cell Disorder): 50% of cases 1. General a. Onset after 6 months of age b. Recurrent respiratory encapsulated infections 2. X-Linked Agammaglobulinemia (XLA; Btk gene related) a. Very low serum IgG, IgA and IgM b. Severe infections with encapsulated organisms c. Chronic Diarrhea, recurrent varicella 3. IgA Deficiency 4. Transient hypogammaglobulinemia of infancy a. Increased bacterial respiratory infections b. Normal nadir that corrects by age 2-4 years 5. Common variable Immunodeficiency (CVID) a. Bimodal onset in preschool and in young adults b. Low total IgG c. Similar to XLA, but more mild B. T-Cell disorder: DiGeorge Syndrome (Velocardiofacial) 1. Deletion at 22q11.2 results in thymus hypoplasia 2. T Lymphocyte deficiency a. Severe viral infection or from live vaccine b. Thrush persists >12 months 3. Hypoparathyroidism with Hypocalcemia 4. Cardiac abnormalities and altered facial features C. Mixed T-Cell and Antibody Disorders 1. Severe combined Immunodeficiency (SCID) a. Severe T cell deficiency causes B Cell dysfunction b. X-Linked deficiency or Autosomal recessive trait c. Presents with Diarrhea or Failure to Thrive 2. Ataxia telangiectasia 3. Wiscott-Aldrich Syndrome 4. Common variable Immunodeficiency 5. Hyper-IgM Syndrome D. Phagocytic Disorders: 15-20% of cases 1. General a. Fungal Lung Infections b. Recurrent abscesses or delayed Wound Healing 2. Decreased Absolute Neutrophil Count (ANC<500/ul) a. Chemotherapy-related Neutropenia b. Other causes: Congenital, autoimmune, cyclic

II.

III.

IV.

V.

Decreased Neutrophil function a. Chronic Granulomatous Disease (CGD) i. Inherited NADPH oxidase abnormality ii. Results in defect of PMN intracellular killing iii. Catalase positive infections i. Staphylococcus aureus ii. Pseudomonas iii. Aspergillus b. Leukocyte adhesion deficiency c. Chediak-Higashi Syndrome E. Complement Disorders: 2% of cases 1. Autoimmune condition 2. Recurrent encapsulated organism infections a. Neisseria infections are most common b. Infection types related to missing complement type Red Flags for Primary Immunodeficiency A. Recurrent and persistent infections 1. Otitis Media (>8 episodes/year) a. Or complicated by Mastoiditis 2. Severe bacterial Sinusitis (>1 episode/year) 3. Pneumonia (>1 episode/year) 4. Enteric infections (e.g. Giardia, Cryptosporidium) 5. Skin Abscesses 6. Unusual sites of infection (e.g. liver, spleen) 7. Opportunistic infections (e.g. Aspergillus, Nocardia) 8. Persistant Thrush after age 1 year 9. Infection despite >2 months of antibiotic use 10. Infection clears only with parenteral antibiotics B. Physical findings 1. Failure to Thrive C. Miscellaneous 1. Family History of Primary Immunodeficiency 2. Autoimmune disease (e.g. ITP or Hemolytic Anemia) Differential Diagnosis A. Asthma or atopic condition B. Cystic Fibrosis C. Secondary Immunodeficiency 1. HIV Infection 2. Asplenism Labs A. Initial Screening 1. Complete Blood Count with manual differential 2. Erythrocyte Sedimentation Rate (ESR) a. Chronic infection unlikely with normal ESR 3. Peripheral Smear a. Howell-Jolly bodies suggests Asplenism B. Other tests to consider 1. B-Cell function Tests a. Quantitative serum IgG, IgM and IgA levels i. IgG subclasses are usually not helpful b. Antibody test to vaccines patient recieved

3.

2.

3.

4. VI.

i. Tetanus Antibody titers ii. Streptococcus Pneumoniae titers (in over age 2) T-Cell Function tests (Delayed-Type Hypersensitivity) a. Absolute Lymphocyte Count (ALC, done in CBC) i. Unlikely if normal Lymphocyte Count b. Candida albicans intradermal skin test i. Positive test rules-out T-Cell defects ii. Most cost-effective test for T-Cell dysfunction c. HIV Test Phagocytosis function tests a. Absolute Neutrophil Count (ANC) b. Flow cytometry for Neutrophil oxidative burst Complement function tests a. Total complement or CH50 (test when well)

Precautions A. Vaccines to avoid in patients and their close contacts 1. Oral Polio Vaccine (live vaccine) 2. Varicella Vaccine (live vaccine) 3. BCG vaccine 4. Measles Vaccine B. Blood Products 1. Specific precautions depending on condition

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