Immunopathogenesis of infectious diseases: lesions

learned from histopathology

Γιώργος Χαμηλός, MD
Ιατρική Σχολή Πανεπιστημίου Κρήτης
[email protected]
 Outline

• Definitions-Classification of Infectious Diseases

• Basic principles of the immune response
• Immunopathogenesis of Infectious Diseases
• Role of histopathology in diagnosis of infections:
Clinical examples
 Terms and Definitions

• Disease-a pathological condition of body parts or tissues

characterized by an identifiable group of signs and
symptoms
• Infectious Diseases-disease caused by an infectious agent
• Infection-occurs when an infection agent enters the body
and begins to reproduce; may not lead to disease
• Pathogen-an infectious agent that causes disease
• Host-an organism infected by another organism
• Virulence-the relative ability of an agent to cause rapid and
severe disease
 Classification of human pathogens

• Commensal: Microbe inducing no damage after

infection
• Pathogen: a microbe capable of causing host damage
• Opportunistic pathogen: Pathogen not able to cause
disease in healthy hosts but only in those with impaired
defense mechanisms
 Chain of Infection

1. PATHOGEN

2. Reservoir or
6. Susceptible host
source

5. Entry portal 3. Exit portal

4. Route of
transmission
 Transmission of Infectious Diseases
Infectious agents can be transmitted by many ways
• The air
• Contaminated food and water
• Body fluids
• Direct contact with contaminated objects
• By animal vectors
 Insects
 Birds
 Bats
 Domestic animals
West Nile Virus
SARS and MERS
 Clinical response to infection

 Colonization-Carrier state: A state of infection

 Chronicity-Persistence: A state of infection in which the
host response does not eliminate the microbe, resulting in
continued damage over time; persistence may evolve into
overt disease
 Latency-Persistence: asymptomatic infection over long
periods of time but can evolve into overt disease
 Symbiosis and mutualism: a state of infection whereby
both the host and the microbe benefit as a consequence of
infection
 Elimination: removal of the microbe
Microbiological Classification of infectious diseases
Taxonomy Size Site of propagation Examples Disease

Prions 30-50 kD Intracellular Prion protein Creutzfeld-Jacob

disease
Viruses 20-300 nm Obligate intracellular Varicella zoster virus Chikenpox, herpes
(DNA vs. RNA) (VZV) zoster
Bacteria 0.2-15 µm Obligate intracellular Chlamydia trachomatis Trachoma, urethritis

extracellular Streptococcus Pneumonia

pneumoniae
Facultative intracellular Mycobacterial Tuberculosis
tuberculosis
Fungi 2-200 µm Extracellular Candida albicans Thrush, vaginitis

Facultative intracellular Cryptococcus neoformans Cryptococcosis

Dimorphic Histopaslma capsulatum Histopasmosis

Parasitic

Protozoa 1-50 µm Extracellular Trypanosoma gambiense Sleeping sickness

Facultative intracellular Trypanosoma cruzi Chagas disease

Obligate intracellular Leishmania donovani Kala-azar

Helminths 3mm-10 m Extracellular Wuchereria bancrofti Filariasis

Intracellular Trichinella spiralis Trichinosis

 Mechanisms of Infectious Disease

• Production of toxins and enzymes that destroy cells

and tissues
• Direct invasion and destruction of host cells
• Triggering of host immune responses leading to
disease
• Derangement of normal physiological functions of
organs or organelles
 Phases of infectious diseases

• Incubation period

• Prodromal phase

• Clinical phase

• Decline phase

• Recovery phase
 Classification of infectious diseases

By Duration
• Acute, Chronic, Latent
By Location
• Local, Systemic
By Timing
• Primary, Secondary (superinfection or reactivation)
 Classification of infections in Clinical Practice

• Acute infections caused by common pathogens

• Opportunistic Infections
• Chronic, granulomatous infections
• Endemic infections
• Mixed (polymicorbial) infections
Acute infections caused by common pathogens
 Affect immunocompetent and immunocompromised hosts
 Caused by common bacteria, viruses*
 Example: UTI, pneumonia, skin abscess, meningitis
 May lead to severe infection (sepsis, septic shock)
 Examples:
 Bacteria: Streptococcus pneumoniae, Staphylococcus aureus,
Escherichia coli, Mycoplasma pneumoniae
 Viruses: Influenza, Varicella Zoster Virus
*Rarely initial infection by protozoa or parasites (e.g. acute toxoplasmosis), localized fungal or
parasitic infections
Opportunistic infections
 Occur exclusively immunocompromised hosts

 Rarely in “immunocompetent” host with subtle immune

defects or metabolic abnormalities
 Subacute infections, characterized by necrosis and tissue
destruction (rarely cause sepsis)
 Difficult to diagnose, atypical presentation at early stages
 Examples:
 Fungi (Candida, Cryptococcus, Aspergillus), Viruses (CMV),
Bacteria (Nocardia, Listeria), Parasites (Toxoplasma reactivation)
Chronic granulomatous infections
 Affect immunocompetent and immunocompromised hosts
 Subacute infections, characterized by granuloma formation with
or without necrosis
 Intracellular bacteria (less frequently fungi, protozoa)
 Difficult to diagnose, reactivation of latent infection, death caused
by disseminated disease
 Examples:
 Fungi (Cryptococcus, Histoplasma), Viruses (CMV), Bacteria
(Mycobacteria, Bartonella), Protozoa (Toxoplasma, Leishmania),
parasites (Schistosoma)
Endemic Infections
• Geographically restricted area
• Zoonotic diseases, frequently vector borne
• Acute or chronic course
• Typically caused by intracellular pathogens
• Examples:
 Viruses (Zika, West Nile, Hepatitis A) Bacteria (Brucella, Coxiella,
Leptospira), fungi (Histoplasma, dimorphic fungi), protozoa
(Leishmania, Plasmodium), most parasitic infections
• Mixed or polymicrobial infections
• Frequent in immunocompromised or debilitated
patients
• Synergistic bacterial infection
 Necrotizing skin infections, aspiration pneumonia, intraabdominal
sepsis
• Sequential infection with different pathogens
 H1N1 followed by bacterial or fungal pneumonia
• Concomitant infection by different classes of pathogens
 Aspergillus, CMV, Pseudomonas pneumonia
Basic Principles of the Immune Response to
Infection
 Sensing of danger (damage)
 Functional Specialization
 Division of Labor-Co-operative activity
 Memory: Adaptive Immunity
 Communication: Cross-Talk
 Redundancy: many effectors
 Plasticity: Epigenetic reprogramming-trained immunity
 Tolerance: Balanced Response Infection Clearance vs.
Resolution of inflammation
Sensing: Pattern Recognition Receptors
(PRR)
The Toll pathway: from Drosophila to mammalian Toll like
Receptors (TLRs)

Lemaitre et al., Cell 1996

Functional Specialization: Recognition of PAMPs from Different
Classes of Pathogens by different PRRs and DC subsets

CLRs

pDC mDC
Stranger Hypothesis Danger Hypothesis
 Sensing of Damage: PAMPs, DAMPs and MAMPs

Infection: PAMPs Tissue Damage: PAMPs Tissue Damage: MAMPs,

PAMPs or DAMPs?
 Sensing of Live vs. Dead bacteria: vita-PAMPs

↑↑Stranger
Hypothesis

↓Danger
Hypothesis

Sander et al., Nature 2011 May 22;474(7351):385-9

Functional Specialization: PRR signaling is shaping Dendritic
Cells (DCs) responses and Th polarization
Memory (Adaptive Immunity) and the Cross-Talk of the
Immune System
 2011 Nobel Prize in Medicine
IMMUNOLOGISTS!!!!!!!

Bruce A. Beutler Jules A. Hoffman Ralph M. Steinman

In 1973 he discovered the
In 1998 Dr. Beutler identified the cell In 1996, Dr. Hoffmann discovered dendritic cell and worked for
receptors in mice that respond to a the cell receptors in laboratory many years defining its role in
substance in the coat of bacteria and fruit flies that are activated by adaptive immunity.
that can set off septic shock if pathogenic bacteria or fungi.
overstimulated.

Toll Receptors Dendritic cells

 Redundancy: Many effector mechanisms

• Epithelia: sensing, secretion of cytokines/chemokines, AMPs, cross-

talk with immune cells, programmed cell death
• Microbiome: Competition for growth, natural antibiotics, metabolites
• Soluble PRRs: collectins, pentraxins
• Serum: complement, Abs, nutritional immunity
• Phagocytes: oxidative and non-oxidative mechanisms of killing
 PMNs: NETosis, sequestration of essential nutrients
• Other immune cells (NK cells, pDCs, CTL): direct cytotoxicity
(granulysin, perforins), cross talk with adaptive and innate effectors
• Cytokines/chemokines: orchestrate immune response, direct
antimicrobial action
Multi-layered immune response
Tolerance: Balancing protective immunity and
immunopathology (granuloma)
Failure of immune homeostatic mechanisms

Chronic inflammation

Primary Immunodeficiency

Autoimmune
and
Cancer
Inflammatory
Diseases

Chronic infections
Defective phagocyte function is the common cause of
chronic inflammation

Martinez J, Nature. 2016 May 5;533(7601):115-9

Martinez J, Nat Cell Biol. 2015 Jul;17(7):893-906
Akoumianaki T, Cell Host Microbe. 2016 Jan 13;19(1):79-90
Chu H, Science. 2016 May 27;352(6289):1116-20
Failure of immune homeostatic mechanisms: Chronic
Inflammation
Lupus erythematosous Secondary syphilis

Chronic granulomatous disease Lymphoma of the skin

Immunopathogenesis of infectious diseases
 HOST

DISEASE
TRIAD

PATHOGEN ENVIRONMENT
(e.g. nutrients)
Microbial Interactions
OTHER MICROBES
 The Damage-Response Framework of Microbial
Pathogenesis

Ευκαιριακές λοιμώξεις
Ευκαιριακές λοιμώξεις

Casadevall A, Pirofski LA, Nat Rev Microbiol 2003; 1:17-24

Aspergillus diseases as a function of the host's immune response

CGD

Stacy J. Park, and Borna Mehrad Clin. Microbiol. Rev. 2009;22:535-551

 HUMORAL IMMUNITY (Complement, Abs)

Neutralization
Lysis (complement)
Phagocytosis (PMNs, Macrophages)
Phagosome maturation

Immune deficit Predisposing condition Related Pathogens

B lymphocyte MM, leukemia, anti-CD20, Encapsulated bacteria, Giardia,

deficiency c/steroids Sallmonela, Camplylobacter,
Enteroviruses
Spleen Splenectomy, SCD, SLE Encapsulated bacteria,
Capnocytophaga
Complement Congenital, acquired (SLE) Encapsulated bacteria, S.aureus
 CELLULAR IMMUNITY: Adaptive Immunity

Immune deficit Predisposing Related Pathogens

condition

T lymphocyte AIDS, lymphoma, Latent viruses: CMV

deficiency chemotherapy, Intracellular bacteria: Listeria,
transplantation, TB,NTBM
c/steroids Nocardia
Fungi: PCP, Cryptococcus
Parasites: Toxoplasma, Leishmania
 CELLULAR IMMUNITY: Innate Immunity

Immune deficit Predisposing condition Related Pathogens

Neutropenia Chemotherapy, leukemia Gram negative, S. aureus,

Streptococci,
Fungi: Candida, molds
Neutrophil DM, cirrhosis, alcoholism, S. aureus, Streptococci,
chemotaxis uremia, trauma, burn, Fungi: Candida, Mucorales?
c/steroids
Neutrophil killing CGD, MPO deficiency, S. aureus, E. coli,
c/steroids Fungi: Candida, molds
Role of pathology in diagnosis of infectious disease?

• Microbial culture alone cannot distinguish between colonization and tissue

invasion (commensal bacteria, fungi)
• Molecular techniques (PCR) cannot distinguish between asymptomatic viral
shedding and tissue invasion (latent virus, CMV)
• Often the pattern of histopathologic damage, the host response, and the
cultivated organism have a long-established association: TB granuloma
• Diagnosis of non-cultivable organisms: Mycobacterium leprae, Pneumocystis
carinii, Treponema pallidum, Tropheryma whipplei
• Diagnosis of difficult to culture organisms: intracellular bacteria including
mycobacteria, bartonella
• Timely diagnosis: frozen biopsy for invasive fungal disease (mucormycosis)
 Multidisciplinary approach

Primary
Physician

Surgery
Radiologist
team

Diagnosis
PharmD and Immunologist
Treatment

Microbiologist Pathologist

Infectious
Disease
specialist
 Diagnostic Steps
Primary Physician
• Clinical Syndrome
• Epidemiology-Exposures
• Underlying immunodeficiency

Radiologist
• X-ray, CT scan, MRI

Microbiologist
• Smear, culture, serology

Pathologist
• Direct exam, Immunohistochemistry

Diagnosis not reached

• Molecular Diagnostics?
• Repeat Biopsy?
ΔΙΑΓΝΩΣΤΙΚΗ ΠΡΟΣΕΓΓΙΣΗ ΚΛΙΝΙΚΩΝ ΠΕΡΙΣΤΑΤΙΚΩΝ

ΕΠΙΔΗΜΙΟΛΟΓΙΚΕΣ
ΕΚΘΕΣΕΙΣ

ΥΠΟΚΕΙΜΕΝΗ ΚΥΡΙΑ ΚΛΙΝΙΚΗ

ΑΝΟΣΟΚΑΤΑΣΤΟΛΗ ΕΙΚΟΝΑ
 Case#1
• 60 y/o Diabetes mellitus, peripheral vascular disease, chronic
kidney injury, recent diabetic foot infection on clindamycin
• One month later, fever, watery diarrhea
• C. difficile toxin negative
• Worsening on ciprofloxacin, develops ileus
• What is next?
 Repeat C. difficile toxin assay?
 CT abdomen?
 Colonoscopy?
 Abdominal X-Ray?
 All the above?
Colonoscopy
 Case#2
• 40 y/o male with rheumatoid arthritis on corticosteroids and TNF
inhibitors
• Bloody diarrhea, weight loss and abdominal pain
• No response to ciprofloxacin and metronidazole
• C. difficile toxin negative
• What is next?
 Repeat C. difficile toxin assay?
 CT abdomen?
 Colonoscopy?
 Abdominal X-Ray?
 All the above?
Colonoscopy
 Case#3
• 50 y/o male with chronic diarrhea, severe weight loss, fever,
diffuse arthritic pain
• Dementia and seizures
• On clinical exam diffuse lymphadenopathy
• Severe hypoalbuminemia (protein loosing enteropathy)
 Case#4

• 67 y/o female poorly controlled Diabetes mellitus

• Admitted with fever, orbital pain, necrotic eschar in the nose and
bloody exudate
• Glucose: 600 mg/dl, pH: 6.9
• What is next?
 Start empirical antibiotics
 Obtain cultures
 Call ENT for tissue biopsy
 Call pathologist
 Autopsied lung with multifocal irregular hemorrhagic infarcts, seen
after chemotherapy for acute leukemia

Massive hemorrhagic necrosis of the stomach in systemic

mucormycosis seen in a hemodialysis case (gross findings)
 Case#5

• 50 y/o female with acute leukemia

• Pancytopenia following chemotherapy
• Construction in the hospital
• Low-grade fever, cough
• After a week bloody sputum production and chest pain
• What is next?
 Start empirical antibiotics
 Obtain sputum, cultures
 BAL
 Chest CT
D. Necrotizing pneumonia
Airborne opportunistic fungi (molds)

Aspergillus Rhizopus
 Histopathology features of IMI

• Aspergillosis • Zygomycosis
 Branching, dichotomous hyphae – Non septate, ribbon-like hyphae
Invasive mold infections: Manifestations

A. Sino-orbital B. CNS abscess C. Cutaneous infection

D. Necrotizing pneumonia
 Invasive fusariosis

Εξέλιξη δερματικών βλαβών σε ασθενή με γενικευμένη φουσαρίωση

Ονυχομυκητίαση
 INVASIVE MOLD INFECTIONS

Dagenais TRT, Keller NP. Clin Microbiol Rev 2009; 447-65

 Invasive fungal infections
Quantitative or
Barrier qualitative neutrophil
disruption dysfunction
Candida
Candida
Aspergillus and other moulds
Aspergillus (lung tx)

Exposures Deficits in cell-mediated

immunity
Endemic mycoses Cryptococcus, PCP
Aspergillus and other moulds Endemic mycoses

Metabolic
Candida
Zygomycetes
Consensus of Front-Line Faculty.
 Case#6

• 50 y/o female with RA

• High doses of corticosteroids
• High-grade fever, shortness of breath
• Severe hypoxia, bilateral pulmonary inflitrates
• What is next?
 Start empirical antibiotics
 Obtain sputum, cultures
 BAL
 Chest CT
 Classic radiographic presentation
D0 D5
Life Cycle of Pneumocystis
 PCP: Morphology

• Spherical, Elliptical
4- 6 microns, contains 4 to 8 nuclei
Stained with
Silver stain, toludine blue, Calcoflour
white
Trophozites present in a tight mass
P.Jiroveci is an extracellular pathogen
 Atypical clinical presentation: role of histopathology

11/96: Dx of WG (DAH) 10/97: Cough/SOB, BAL: (-) VATS: Granulomatous PCP

CTX
C/steroids

• Granulomatous PCP: 3% of non-HIV immunocompromised patients

• All patients had negative BAL findings
• Mortality rates: > 60%

Eur Respir J 2000;15:213-216

 Case#6

• 50 y/o female with ulcerative colitis

• High doses of corticosteroids
• Low-grade fever, productive cough and chest pain
• What is next?
 Start empirical antibiotics
 Obtain sputum, cultures
 BAL
 Chest CT

D. Necrotizing pneumonia
Nocardia infection
25 y/o AIDS patient with severe headache, low grade
fever, altered mental status, seizures
 Cryptococcosis
Κύκλος Ζωής Κλινικές εκδηλώσεις

Διάγνωση
25 y/o AIDS patient with odynophagia and oral thrush
 NET STATE OF IMMUNOSUPPRESION:
Risk for Invasive Candidiasis is a Continuum

High-risk patients Exposures If invasive candidiasis develops..

• Abdominal Surgery • ICU >7 days • <50% + Bcx
• Leukopenia • CVCs • ~40% die
• ~60% survive
• Immunosuppresants • Antibiotics
Antifungal Prophylaxis:
• Dialysis • TPN
Yes, if incidence > 10%
• Burns • Colonization Empirical antifungal therapy :
Yes, if incidence > 2.5%
• Neonates
Consider if risk factors + FUO
CVCs=central venous catheters; TPN=total parenteral nutrition.
Rex JH, et al. Adv Intern Med. 1998;43:321-369; Pappas PG, et al. Clin Infect Dis. 2003;37:634-643.; Golan Y et al., Ann Intern Med 2006; 144: 534-535;
Pappas PG et al., Clin Infect Dis 2009; 48:503-535
 Candidiasis
Spectrum of Infection
A. Cutaneous fungemia Deeply Invasive
C. Disseminated

B. Mucosal

D. Chorioretinitis
 Clinical Case

• 70 y/o M, hx of SLE, prosthetic AV,

cholangitis s/p stent placement 6 months
ago
• Intermittent, low grade fever for weeks
• L-sided pleuritic chest pain
• Initial Response on low dose prednisone
• Relapse of fever

C/steroids
Prosthetic
valve

N/A FUO
 Clinical Case
n 41 y/o Indian M, psoriatic arthropathy on
infliximab
n FUO, severe weight loss
n Extensive workup : CTs, Bcx, sputum Cx,
endoscopy (-)
n 5 months later: persistent fever, (+) cough
n CT chest : cavitary RUL mass, numerous
bilateral nodules
n mediastinal and supraclavicular LAD
n multiple splenic, liver, kidneys lesions

a-TNFa

Origin FUO
FDA Registry
Study Period: 1998-2001
• 70 cases of TB
• 40 extra-pulmonary TB
• 17 disseminated TB
• Within 12 wks of Rx
• Countries with low TB
incidence
Βιβλιογραφία με αντικείμενο λοιμώξεις
και βιολογικές θεραπείες
Number of Publications 300

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Scopus search: 29-9-2014
 Κυτταρικοί στόχοι βιολογικών παραγόντων

Golimumab

J Allergy Clin Immunol 2016; 137: 19-27

 Παθογένεση λοιμώξεων: παράγοντες
αναστολείς ΤΝF και φυματίωση
Αναστολή σχηματισμού CD8+ T-λεμφοκύτταρα
κοκκιώματος?? (Granulysin)

Immunity 2008; 29:175-177 J Clin Invest 2009; 119:1079-1082

84
45 y/o Indian Male with scaly nodular lesions,
discoloration, dysesthesias
Leprosy

86
 Clinical Case
• 45 y/o fisherman develops skin lesions in forearm
after fishing in a lake
• Treatment with amoxicillin/clavulanic acid
• Non-healing old lesions that begin to ulcerate
• Eruption of new lesions

87
Fish tank granuloma (fish “tuberculosis”)

Mycobacterium marinum

88
Biopsied axillary lymph node, swollen
2 weeks after bite by a suckling cat

89
Sporotrichosis
 Clinical Case

• 70 y/o F from Crete, hx of RA

• On Infliximab 18 months and
prednisone
• FUO/negative workup
• Persistent fever, worsening
pancytopenia
• Bone Marrow Biopsy (+++)

a-TNFa

Origin FUO/pancytopenia
 Ευχαριστώ πολύ!

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