IMMUNOTOLERANCE

Immune tolerance is a state of unresponsiveness towards substances or tissues that have the ability
to generate immune responses. It is related to the adaptive immune system, where the receptors are
generated by random processes; therefore, it will be important to make sure that these receptors will not
work against self-antigens, meaning that it will be extremely important to avoid autoreactivity. Three topics
will be discussed: immune tolerance, natural autoimmunity and pathological autoimmunity.

IMMUNOTOLERANCE

Before going on, it is better to repeat the definitions of affinity and avidity:

Affinity: describes the strength of a single interaction between antigens and receptors;
Avidity: its the cumulative strength of affinities of individual non-covalent binding interactions.

Immune tolerance can be distinguished into central and peripheral immune tolerance:

Central tolerance can be divided into central T cell tolerance and central B cell tolerance. In both
cases, T and B cells will have to face negative selection which will be determined by the avidity with
which they bind self-antigens. If the avidity is too high, the cells will be eliminated. Cells that are
allowed to live, normally have an average avidity, while Reg cells will be on the borderline of
deletion.
Peripheral tolerance is achieved through four mechanisms:
o Regulatory T and B cells: Regulatory cells actively suppress activation of the immune
system and prevent pathological self-reactivity, i.e. autoimmune disease.
Treg cells: the critical role regulatory T cells play within the immune system is
evidenced by the severe autoimmune syndrome that results from a genetic
deficiency in regulatory T cells (IPEX syndrome). The molecular mechanism by
which regulatory T cells exert their suppressor/regulatory activity has not been
definitively characterized and is the subject of intense research; what is known is
that they can: use inhibitory cytokines, induce cytolysis (granzymes), disrupt cell
metabolism, and target DCs. The latest research suggests that regulatory T cells are
defined by expression of the forkhead family transcription factor FOXP3 (forkhead
box p3). Expression of FOXP3 is required for regulatory T cell development and
appears to control a genetic program specifying this cell's fate. The Tregs can be:
nTreg
iTreg: they further divide into Treg1 (if a lot IL10 is present) and TH3 (if a lot
TGF-beta is present)
Breg cells: they represent a small population of B cells which participates in
immunomodulations and in suppression of immune responses. These cells regulate
the immune system by different mechanisms. The main mechanism is a production
of anti-inflammatory cytokine interleukin 10 (IL-10). They will inhibit or suppress
inflammatory reactions mediated by T cells, especially Th1 type immune reactions.
They wll also inhibit Th17 cell differentiation, but promote differentiation into Treg
cells.
 o Anergy: T-cells can be made non-responsive to antigens presented if the T-cell engages an
MHC molecule on an antigen presenting cell (signal 1) without engagement of
costimulatory molecules (signal 2). Co-stimulatory molecules are upregulated by cytokines
in the context of acute inflammation. Without pro-inflammatory cytokines, co-stimulatory
molecules will not be expressed on the surface of the antigen presenting cell, and so anergy
will result if there is an MHC-TCR interaction between the T and antigen presenting cell
o Ignorance: there is low autoreactive avidity of TCRs. However, they might be stimulated in
case large amount of autoantigens are present, such as during necrotic phenomena.
o Antigen segregation: some immune privileged organs have this feature (brain, ovary, testis,
etc). In these organs, there is no lymphatic drainage, so immune cells do not get in, and
there are barriers protecting them. Moreover, antigens from these organs are secreted
along with immunosuppressive molecules (e.g. TGF-beta) and their cells will have FasL,
which will induce apoptosis of cells that might get in somehow and recognise them as
dangerous cells.

NATURAL AUTOIMMUNITY

It is a system made of natural autoantibodies. They are mostly IgMs, and these antibodies will
recognise antigens that are shared, between microbes and humans. They have a physiological and
protective role in the system, as they help maintain the immune system homeostasis. Natural
autoantibodies can be found in free form circulating in the body; however, there are also cryptic, or latent,
ones that are not possible to detect under normal circumstances; to detect these cryptical autoantibodies,
particular conditions such as high temperature, low ph, high salt cc., and oxidising agents must be present.

Natural autoantibodies will be produced by B1 B cells, which will differentiate from other B cells,
due to expression of CD43; in addition, B1a B cells will express CD5, as opposed to B1b B Cells, which do
not. These autoantibodies can work with the immune system cells, as there are specific receptors on the
different cells, to bind these Ab. The roles of natural autoantibodies are varied:

They will help in antiviral immunity, as they will bind the virions, forming immune complexes;
activate the complement system (which will remove the immune complexes from circulation, and
put them into lymphatics); and finally they will deliver the antigen to the immune system cells (T
cells).
They are thought to have important roles in elimination of apoptotic bodies, by binding them;
lather phagocytic cells will bind these autoantibodies to phagocytize the apoptotic body
They also help remove oxiLDL (another homeostatic function).

Natural autoantibodies will form a network. This network will be a repertoire of antibodies, specific for
each individual. This network is flexible and may be transiently distorted several times during our life time,
as during pathological conditions, there may be an increase in their ligands, so that many free
autoantibodies will bind these ligands, and their no. will decrease. Later, this network, once the
pathological condition is overcome, will be resumed.

There is an idiotypic antibody network hypothesis, which postulates that the immune response may
be regulated by responses to idiotypes, unique determinants originally described on antibodies. This thesis
is based on the dual characteristics of the antibodies, such that they react with an antigen through their
antigen-binding sites, but may also be recognized by antiidiotypic antibody and anti-idiotypic cells. These
interactions create a network of antibodies that express distinct idiotypic specificities that interact with
each other to regulate the immune response. An idiotope is a site on the antibody that can bind to
complementary structures. The collection of idiotopes on one antibody is called idiotype; all antibodies
from a given cell have the same specific idiotype. A huge diversity of idiotypes is generated by random
somatic rearrangements of genes. Bcells of a given idiotype are stimulated to proliferate if its receptors are
crosslinked by complementary structures; unstimulated cells die. For this network to occur, you will
necessarily need autoantibodies recognising other antibodies.

IMMUNOLOGICAL HOMUNCULUS: it is an abstract term, which refers to the disproportional recognition of

body Ags by autoABs; some autoAGs receive more attention than others.

PATHOLOGICAL AUTOIMMUNITY

There is a homeostatic balance of the immune system. Different factors support the immune
response or immune tolerance. In pathological autoimmunity, the tolerance is shifted to autoimmunity
activating mechanisms, due to failure of immune tolerance mechanisms.

Any of us might be susceptible to manifesting autoimmune disorders, depending on the number of

susceptibility alleles. This is what is stated by the threshold theory of autoimmune diseases; however,
genetics alone are not enough, environmental variations are also important in development of
autoimmune disorders.

ENVIRONMENTAL FACTORS

Several factors can contribute to development of autoimmune diseases:

Drugs and toxins

Infections:
o by secretion of inflammatory mediators: The cells mediating autoimmunity are Th1 and
Th17. These two cells will induce activation of ECs, fibroblasts, epithelial cells, and
Mphages, which will produce cytokines and other substances that will stimulate
granulocytes recruitment and cause chronic inflammation. Other non-conventional T cells,
such as type A and type B T cells are thought to have a role in autoimmunity.
o by increased costimulation: a microbe could activate a resting tissue APC, inducing its
expression of costimulatory molecules, therefore leading to activation of autoreactive T
cells
o by the release of tissue antigens/epitope spreading:
some tissue antigens are not reproduced in the thymus; this could induce
activation of autoreactive T cells that did not encounter the antigen during
development, and that were thought to be non-autoreactive.
Epitope spreading: some auto antigens have epitopes that are hidden inside the
conformational folding of the molecule; because of this, T cells that recognise
those epitopes, but do not come into contact with them (due to the fact that they
are hidden in the antigen), will not be deleted. When these antigens are released
(for any reason) and get processed, these epitopes will be presented to the T cells,
which will see them as harmful, and start immune reactions.
 o by microbial-host cross reactions, molecular mimicry: exogenous antigens have a similar
structure to auto antigens; therefore, when an immune response develops against those
exogenous antigens, a cross-reaction with auto antigens will occur (e.g. VP2/AChR; HPV-
E2/insulin; rheumatic fever).
o superantigen effect: bind the MHC molecules and the TCR from outside of the peptide
binding groove, and thus, may induce the proliferation of a high number of T cells clones
aspecifically.
Alternative RNA maturation in the thymus
Posttranslational modifications of autoantiges

GENETIC FACTORS

Various autoimmune disorders share alleles: IL-23B, IL-12B, and PTPN22.

Monogenic autoimmune diseases exist, where mutation of a single gene generates huge autoimmune
disorders. One of these genes is AIRE, which will result in APECED syndrome (APS) if mutated; another one
is FOXP3, which manifests in IPEX syndrome when mutation occurs. We only know these two monogenic
diseases, which are just the tip of the iceberg; most diseases are multifactorial with very complex genetics.

APS-1: it will cause candisiasis, hypoparathyreosis, and Addisons.

IPEX: it is X-linked and will cause immune dysregulation, polyendocrinopathy, and enteropathy.

IPEX and APS are, however, rare disorders. In all the other (normal) cases, the diseases are affected with
different extent by different genes:

E.g. HLA will have a variable effect on development of different autoimmune diseases: The relative risk' for
an HLA allele in an autoimmune disease is calculated by comparing the observed number of patients
carrying the HLA allele with the number that would be expected, given the prevalence of the HLA allele in
the general population.E.g.: for type I insulin-dependent diabetes mellitus (IDDM), the association is in fact
with the HLA-DQ gene, which is tightly linked to the DR genes but is not detectable by serotyping; The HLA-
DQ1 chain contains an aspartic acid (Asp) at position 57 in most people; in Caucasoid populations,
patients with IDDM more often have valine, serine, or alanine at this position instead, as well as other
differences. Asp 57, shown in red on the backbone structure of the DQ chain, forms a salt bridge to an
arginine residue in the adjacent chain. The change to an uncharged residue (for example, alanine)
disrupts this salt bridge, altering the stability of the DQ molecule. The nonobese diabetic (NOD) strain of
mice, which develops spontaneous diabetes, shows a similar replacement of serine for aspartic acid at
position 57 of the homologous I-A chain, and NOD mice transgenic for chains with Asp 57 have a
marked reduction in diabetes incidence. Some diseases show a significant bias in the sex ratio; this is
taken to imply that sex hormones are involved in pathogenesis. Consistent with this, the difference in the
sex ratio in these diseases is greatest between the menarche and the menopause, when levels of such
hormones are highest.

DISEASES

There are several diseases that are caused by autoimmunity:

SLE
RHEUMATOID ARTHRITIS infections will increase risk of developing RA, by causing production of
citrullinated proteins; the B cells will produce antibodies against these proteins, which will form
 immune complexes that will perpetuate inflammation, leading to chronic RA. Tobacco smoking will
also increase risk of developing RA, if there is a susceptible individual. Therapy includes TNF-alpha
antagonist, IL-1 antagonists, Suppressors of T cell activation, Anti-B cell monoclonal antibody
MYASTHENIA GRAVIS the autoantibodies will react against AChRs, leading to impaired muscle
contraction.
AUTOIMMUNE THYROIDITIS
o HASHIMOTOS they cause necrosis or apoptosis of thyroid cells, leading to
hypothyroidism
o GRAVES they cause overstimulation of thyroid cells, leading to hyperthyroidism
MULTIPLE SCLEROSIS demyelination of nerve cells occurs
INFLAMMATORY BOWEL DISEASE (IBD) - ROLE OF GUT MICROBIOTA IN AUTOIMMUNITY
o ULCERATIVE COLITIS it is a continuous (in its distribution) inflammation of the colonic
mucosa, where the mucosa becomes hyperaemic and oedematous, often associated with
crypt abscesses
o CHRONS DISEASE it is a discontinuous, transmural, granulomatous inflammation, that
can affect the whole GI tract.
AUTOINFLAMMATORY DISEASES if IL1-beta production increases, there might be induction of
inflammasomopathies, which means, inflammasomes generate IL1-beta, which will cause
inflammation.