Immunological

tolerance & Auto

immunity
Learning objectives
At the end of the session, the student should be able to –
• Define tolerance and explain its clinical significance
• Classify and enlist mechanisms of tolerance in the two limbs of
adaptive immunity
• List important immunodeficiency syndromes
• Explain the pathology behind Grave’s disease and Myasthenia gravis
• Immune system attacks foreign antigen • Immunodeficiency

• Does not attack self antigen • Autoimmunity

This phenomenon is called Self tolerance

Does body naturally
produce self reactive
Immune cells
• Immune cells are genetically pre-programmed to
express receptors against a unique antigen

• This process takes place in the central (generative)

lymphoid organs by random gene recombination

• It naturally produces receptors against an infinite

range of antigens – both foreign and self
• TCR & BCR are randomly generated by recombination
in primary (central) lymphoid organs such as the
thymus and bone marrow

• Diversity – protection against an unpredictable number of

pathogens
• Autoreactivity – generates T cells that recognize self-
antigens
Tolerance
Refers to unresponsiveness to an antigen induced by prior
exposure of lymphocytes to that antigen.

1. Unresponsiveness specific for a given antigen

a) Active antigen-dependent process
b) Different from immunosuppression and immunodeficiency,
which are non specific

2. Induced by prior exposure to that antigen

Self tolerance
• Refers to lack of responsiveness to an individual’s own
antigens

• Breach in self tolerance leads to autoimmunity

• While the most important form of tolerance is non-reactivity to self

antigens, it is possible to induce tolerance to non-self antigens. When
an antigen induces tolerance, it is termed tolerogen
Clinical significance
• To prevent the body from attacking
• its own tissues (self tolerance)
• many harmless airborne and food antigens found at mucosal
surfaces

• Therapeutic application: To prevent graft rejection, treat

autoimmune and allergic diseases, and prevent immune
responses in gene therapy, perhaps stem cell transplantation
Mechanisms of Tolerance
Divided on the basis of site where it develops
Central tolerance Peripheral tolerance

Central lymphoid organs (Thymus,

Peripheral lymphoid organs
Bone marrow)
Immature self-reactive T and B Potentially self-reactive T and B cells
lymphocyte clones that recognize self that escape to the peripheral tissues
antigens are killed are eliminated/ suppressed
Clonal deletion, Receptor editing, Clonal deletion, Anergy, Suppression
Formation of Regulatory cells by Regulatory cells
 Rearrangement of
TCR genes

• Positive selection (Cortex) – only T cells

with TCR recognizing self-MHC are
spared
Self MHC restriction

• Negative selection (Medulla) – T cells

that react too strongly with self-MHC or
self-MHC + self-peptides, are eliminated
Self-tolerance
Positive selection
• About 50 million CD4+CD8+ (Double positive or DP) cells
audition everyday

• ~10% cells recognize peptide/ MHC complex presented on

cortical thymic epithelial cells (cTECs) & receive critical
survival signals

• Differentiate into CD4+ and CD8+ single-positive T cells

according to their affinity to MHC class II and I, respectively
 Negative selection - central tolerance

• Positively selected CD4+ or CD8+ T cells

interact with mTECs and dendritic cells

• AIRE (autoimmune regulator) stimulates

expression of “peripheral tissue-restricted
self antigens” (TRA) in the thymus

• Autoreactive T cell clones undergo

apoptosis/ Clonal deletion

A fraction of autoreactive CD4+ T cells differentiate into regulatory T (Treg) cells

mTECs express a great many tissue-restricted antigens (TRAs)
Central B cell tolerance
Receptor editing
• Immature B cells which strongly recognize self-antigens
reactivate RAG1/2

• Receptor gene rearrangement takes place to express new BCR

• ~25-50% of all B cells in the body may have undergone receptor

editing

• If receptor editing does not occur, the self- reactive cells

undergo apoptosis
Peripheral T cell tolerance
 Anergy

• Lymphocytes that recognize self antigens are

rendered functionally unresponsive

• T cell activation requires two signals

oSignal 1: TCR interaction with peptide/MHC
oSignal 2: CD28 interaction with B7 (costimulation)

• If signal 1 is present in absence of signal 2, it may

result in anergy
CD28 and B7 interact to give second
signal

• If the antigen is presented to T cells without adequate levels

of costimulators, the cells become anergic
CTLA-4
• CTLA-4 is structurally homologous to CD28, and binds to
B7 molecules on APC with higher affinity but causes
inhibition

• CTLA-4 may be preferentially engaged when the levels of

B7 are low, e.g. resting APCs are presenting self antigens

• In contrast, when microbial products elicit innate

immune reactions, B7 levels on APCs increase and are
able to engage the low affinity CD28
 Clonal
expansion
vs
Clonal anergy

• At low levels of expression,

• CD28 on T cell binds to co- costimulators are engaged by
stimulators (CD80/86) to provide Inhibitory receptors like CTLA-4
signal 2 which induce anergy
Blocking CTLA-4 or PD-1 boosts immunity
• Some tumors and viruses may use inhibitory molecules like
CTLA-4 or PD-1 to evade immune attack (Anergy)
• Antibodies that block CTLA-4 and PD-1 are used for tumor
immunotherapy
Blocking costimulatory signals to prevent transplant rejection
Suppression by Treg cells
• T cells called regulatory T cells are important for peripheral
tolerance

• They are CD4+ cells which express high levels of IL-2 receptor α
chain (CD25), & transcription factor FOXP3

• Suppression is antigen specific because it depends upon

activation through the TCR

• Inhibit the development of autoimmune & chronic inflammatory

diseases
eff
Central and
Peripheral Treg
cells
Mechanism
• Express CTLA-4, which may bind to
B7 molecules on APCs and reduce
their ability to activate T cells via
CD28

• Secrete immunosuppressive
cytokines IL-10 and TGF-β, which
inhibit lymphocyte activation
Clonal Deletion / Apoptosis
• Activation induced cell death (AICD)

• Auto reactive T cells undergo apoptosis if their TCR is

engaged by self antigens
May express a pro-apoptotic member of the Bcl family,
called Bim

Fas and FasL are co-expressed, leading to elimination of

the cells via Fas- mediated apoptosis.
AICD
• Engagement of Fas by FasL induces
apoptosis of activated T cells

• Self-reactive B cells may also be deleted by

FasL on T cells engaging Fas on the B cells
Peripheral B cell tolerance
T – dependent antigens
• Auto reactive B cells even after binding to their self antigen require
the help of TH cell to provide –
Signal 2 : CD40L expressed on T cell binds to CD40 on B cell

Other factors for differentiation and proliferation (e.g. IL-4,5)

• Without such help, it undergoes anergy or apoptosis

Immune privilege – Immunologic Ignorance
• Some antigens are sequestered (hidden) from the immune
system because their tissues do not communicate with the
blood and lymph

• Immune privileged sites – Brain, anterior chamber of eye,

testis. Immune system is not normally exposed to such
antigens

• Lymphoid cells remain in a state of immunologic ignorance

(neither activated nor anergized)
• If the antigens of these tissues are released due to trauma or
infection, it leads to prolonged tissue inflammation and injury

Brain - Multiple sclerosis

Eye - Sympathetic ophthalmia

Testis - post-traumatic orchitis

 Summary
Tolerance (unresponsiveness) to self antigens is a fundamental property of
the immune system. Breakdown of tolerance is the basis of autoimmune
diseases
Central tolerance: Immature lymphocytes that recognize self antigens in the
central (generative) lymphoid organs are killed by apoptosis

Central tolerance: In B-cell lineage, some self-reactive immature

lymphocytes switch to new antigen receptors that are not self-reactive

Peripheral tolerance: Mature lymphocytes that recognize self antigens in

peripheral tissues become functionally inactive (anergic), or are suppressed
by regulatory T lymphocytes, or die by apoptosis
Autoimmunity and autoimmune
diseases

• Autoimmunity – presence of antibodies or T lymphocytes that react

with self-antigens

• Autoimmune disease – tissue injury caused by autoimmune reaction

of the organism against its own tissues

• Hypersensitivity – exaggerated or inappropriate immune reaction

resulting in tissue damage, may be against self or foreign antigen
 Hypersensitivity Autoimmunity
Definition Uncontrolled or excessive Abnormal or pathologic
responses to repeated immune reaction that is caused
exposure to an antigen by an immune response to self
antigen

Immune system Normal or abnormal Abnormal (autoreactive)

Antigen Self or foreign Self
Disease progress Acute or chronic Generally chronic, progressive
Examples Hay fever, food allergies, SLE, RA, Grave’s disease,
atopic dermatitis, allergic Multiple sclerosis, Pernicious
asthma, and anaphylaxis anemia
Hypersensitivity may be observed in some autoimmune diseases as part of their
pathophysiology
Mechanisms of
Autoimmunity
Etiology (Cause)
Genetic (Endogenous) factors –
Breakdown of self tolerance
• Tolerance
• Regulation
• Antigen display

Environmental (Exogenous) factors –

Activation of autoreactive lymphocytes
• Infection, Injury
• Molecular mimicry
• Superantigenic stimulation
• Loss of Immunologic privilege
1. Genetic susceptibility
Complex multigenic disorders
Higher incidence observed in twins, especially monozygotic
• MHC genes are most commonly involved; HLA allele polymorphisms are
associated with specific diseases (e,g, HLAB27 – Ankylosing spondylitis)
HLA polymorphisms in Autoimmune disease
2. Altered antigen presentation
• Cryptic Epitopes: altered proteolytic processing of a self-antigen may
lead to presentation of novel peptides not routinely presented to
lymphocytes

• These may be recognised as immunogenic as they were not

previously available to silence the autoreactive lymphocytes

• Epitope spreading: When immunogenicity develops against one

epitope of a self-antigen, with passage of time, there is loss of
tolerance to other epitopes of that antigen or related antigens
A typical immune response focuses on one or two epitopes
within that protein (Dominant epitopes)

Dominant
epitope

Spreading refers to diversification of immune response to include

the subdominant epitopes (Cryptic epitopes) on that protein
 SLE
• APCs present novel self-
peptides (Ro/ HNE-Ro
neoantigen) to TH cells. TH
cells activate autoreactive B
cells

• B cells internalize multiple

proteins & present additional
self-epitopes to naïve T cells

• New autoreactive T cells

assist a diversified B-cell
response.

And the cascade continues

3. Molecular mimicry
• Cross-reactivity between a microbial product and a self-antigen may
lead to activation of autoreactive lymphocytes
• Rheumatic fever - M protein of streptococci cross-react with myosin,
laminin, and other matrix proteins of myocardium, neuronal antigens
 4. Superantigenic stimulation
• Superantigens – Viral or bacterial
proteins e.g. Staphylococcal
enterotoxin, TSS toxin

• Simultaneously bind-
• Vβ domain of TCR and
• α chain of class II MHC

• Crosslinkage of a T-cell receptor and

class II MHC produces an activating
signal & induces T-cell activation and
proliferation
• Polyclonal activation: Superantigens bind outside TCR
antigen-binding cleft. Any T cell expressing Vβ sequence
complemetary to the superantigen is activated irrespective
of its antigen specificity

• ~5% of total TH population may be activated & TH-cell

cytokines overproduction & systemic toxicity result

• If autoreactive T (& corresponding B) cells get activated, it

results in autoimmunity
5. Loss of immunologic privilege
• If the antigens normally sequestered from the immune system are
released due to trauma or infection, it leads to prolonged tissue
inflammation and injury

Brain - Multiple sclerosis

Eye - Sympathetic ophthalmia

Testis - post-traumatic orchitis

Autoimmune disease:
General features
• Chronic – Remissions (decreased symptoms), Relapses
(increased symptoms) …Epitope spreading

• Progressive – damage often increases with time

• Clinical features depend on the nature of the underlying

immune response
 1. Grave’s disease

• Stimulating Ab that binds to

TSH-R: Long acting Thyroid
stimulator (LATS)

• Results in Thyrotoxicosis that

cannot be suppressed by
negative feedback
Thyrotoxicosis
• Ophthalmopathy – Exophthalmos
• Goitre
• Weight loss, fatigue
• Heat intolerance, sweating
• Insomnia, irritability
• Palpitations – tachycardia, Arrhythmia
 Auto-antibodies bind TSH receptor on thyroid cells &
activate adenylate cyclase

Stimulates the synthesis of two thyroid hormones,

thyroxine (T4) and triiodothyronine (T3)

T3, T4 do not have negative feedback effect on TSH

R-Ab

Overstimulation of Thyroid

Hence TSH R-Ab are referred to as Long acting Thyroid stimulator (LATS)
2. Myasthenia Gravis
Blocking Autoantibodies against post-synaptic acetylcholine receptors
Auto-antibodies bind acetylcholine receptors on motor end-
plates of muscles

Block the normal binding of acetylcholine

Impaired N-M transmission &

Progressive weakening of the skeletal muscles

Complement mediated lysis: Ultimately, the antibodies

destroy the cells bearing the receptors
• Muscle weakness as the day progresses
• Eye: Ptosis, diplopia
• Oropharynx: Dysphagia, dysarthria,
dyspnea
• Emergency: May require endotracheal
intubation
 3. Rheumatic fever (RF)
& Rheumatic heart disease (RHD)
• Acute, immunologically mediated, multisystem inflammatory
disease following group A streptococcal pharyngitis (or skin
infection)

• Antibodies and CD4+ T cells against streptococcal M proteins

recognize cardiac and neuronal self-antigens
Acute rheumatic carditis, may progress to chronic rheumatic heart
disease (RHD), mainly valvular abnormalities e.g. Mitral stenosis
Immunological injury in brain – Sydenham’s chorea
Molecular mimicry in Acute Rheumatic fever
Systemic autoimmune
diseases
• Autoimmune reactions are against widespread antigens, resulting in
systemic or generalized disease
• Dysfunction in immune regulation
• Antibodies to a vast array of antigens – DNA, histones etc.
• Blood vessels & connective tissue involved – also called
Collagen vascular diseases (CVD) , Connective tissue diseases
(CTD)
• Multiple organ systems involved
• May be fatal
Rheumatoid arthritis
• Common systemic autoimmune
disorder
• Women: 40 - 60 years
• Chronic inflammation of the joints
• Hematologic, cardiovascular, and
respiratory systems are also
frequently affected
Etiology
• Susceptibility genes
HLA DRB1 alleles
PTPN22

• Environmental triggers
Cigarette smoking
Viruses – EBV
Pathogenesis
Individuals have auto-antibodies called rheumatoid factors
(RF) that are reactive with Fc region of IgG (anti-IgG)

Auto-antibodies (IgM) bind to normal circulating IgG,

forming IgM-IgG complexes that are deposited in the joints

Immune complexes can activate the complement cascade,

resulting in a type III hypersensitive reaction

Chronic inflammation of the joints (symmetric polyarthritis)

Extra-articular
manifestations
• Subcutaneous nodules
• Lung nodules
• Anemia
Lab diagnosis
• Rheumatoid factor (RF) also called RA factor – anti-IgG
• Anti-CCP (antibodies to cyclic citrullinated peptides)

Imaging
• Xray, MRI, USG
Summary
• A variety of mechanisms are proposed for autoimmunity
✓release of sequestered antigens
✓molecular mimicry,
✓inappropriate class II MHC expression on cells
✓polyclonal B-cell activation

• Organ-specific autoimmune diseases involve an autoimmune

response directed primarily against a single organ or gland

• Systemic autoimmune diseases are directed against a broad spectrum

of tissues and have manifestations in a variety of organs resulting
from cell-mediated responses, auto-antibodies or immune complexes.