Medical Microbiology and Immunology for Dentistry

Library of Congress Cataloging-in-Publication Data

Düzgüneş, Nejat, author.

  Medical microbiology and immunology for dentistry / Nejat Düzgüneş.

      p. ; cm.

  Includes bibliographical references and index.

  ISBN 978-0-86715-647-8

  eISBN 978-0-86715-909-7

  I. Title.

  [DNLM: 1. Stomatognathic Diseases--immunology. 2. Stomatognathic Diseases--microbiology. 3. Dentistry--methods. WU 140]

  QR47

  617.5’22--dc23

2015031156

© 2016 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc
4350 Chandler Drive
Hanover Park, IL 60133
www.quintpub.com

5  4  3  2  1

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Leah Huffman
Editorial Intern: Cassidy Olson
Design: Ted Pereda
Production: Angelina Sanchez

Printed in the USA

Contents

Dedication

Preface

Chapter Opener Image Credits

Immunity

  1 The Immune System

  2 Antibodies and Complement

  3 Cellular Immunity

  4 The Immune Response to Pathogens and Immunopathogenesis

  5 Vaccines

Bacteria

  6 Bacterial Structure, Metabolism, and Genetics

  7 Bacterial Pathogenesis

  8 Antibacterial Chemotherapy

  9 Sterilization, Disinfection, and Antisepsis

10 Microbial Identification and Molecular Diagnostics

11 Staphylococcus

12 Streptococcus

13 Miscellaneous Gram-Positive Bacilli

14 Clostridium

15 Bordetella, Legionella, and Miscellaneous Gram-Negative Bacilli

16 Neisseria and Neisseriaceae

17 Spirochetes

18 Enterobacteria, Campylobacter, and Helicobacter

19 Mycoplasma and Ureaplasma

20 Mycobacteria

21 Chlamydia, Rickettsia, and Related Bacteria

22 Vibrio, Pseudomonas, and Related Bacteria

23 Oral Microflora and Caries

24 Periodontal and Endodontic Infections

Fungi

25 Fungal Structure, Replication, and Pathogenesis

26 Fungal Diseases

27 Antifungal Chemotherapy

Viruses

28 Virus Structure, Replication, and Pathogenesis

29 Antiviral Chemotherapy

30 Naked Capsid DNA Viruses

31 Human Immunodeficiency Virus and Other Retroviruses

32 Hepatitis Viruses

33 Herpesviruses

34 Orthomyxoviruses: Influenza Virus

35 Paramyxoviruses: Measles, Mumps, and Respiratory Syncytial Viruses

36 Picornaviruses

37 Arboviruses

38 Rhabdoviruses, Poxviruses, and Coronaviruses

39 Rubella Virus, Filoviruses, Reoviruses, and Noroviruses

Prions and Parasites

40 Prions

41 Pathogenic Parasites

Appendix: Cases in Medical Microbiology

Index

Dedication

To Maxine, Avery, and Diana

for all the wonderful experiences you have brought into my life, for your love, and for asking many, many questions

and

to the memories of my cousin Professor Ferruh Ertürk and my aunt Sevim Uygurer, who were always there for me

Preface

This book is the outcome of my teaching the Microbiology course at the University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco. In my 25 years of teaching this course, I have relied on medical microbiology texts that cover all areas quite extensively, are written by numerous experts, and are excellent reference books; however, all of them are too detailed for instructional purposes. Therefore, I decided to write this textbook and tailor the information specifically for dental students. Practicing dentists and other dental professionals, as well as students in other health professions, may also benefit from the didactic, succinct, yet thorough coverage of the field.

Dentists are “physicians of the mouth” and thus need to have a basic understanding of medical microbiology and immunology. Most of the conditions treated by general dentists and specialists are the result of bacterial infection, including caries, periodontal disease, and endodontic infections. The response of the immune system to these infections may also contribute to their pathology. Caries and periodontal disease are initiated by changes in the oral bacterial ecosystem, and understanding the microbiology of these diseases is essential for their treatment.

Dentists need to be able to diagnose oral infections, such as denture stomatitis caused by Candida species, as well as obvious systemic medical conditions whose medical implications may be lost on patients. They should also understand the nature and complications of any infectious disease their patients may have, including HIV/AIDS, hepatitis, tuberculosis, and emerging diseases such as SARS and MERS. Members of the dental care team as well as other patients must be protected from these infectious diseases, and dentists should be able to answer questions, address patient concerns, and allay their fears about cross infection. Finally, dentists are health care providers who can influence decisions on public health issues such as the importance of vaccinations, fluoridation of water sources, and funding for biomedical research by the National Institutes of Health. Therefore, understanding microbiology and immunology and their roles in the initiation, progression, and treatment of disease is pertinent for any practicing dentist.

The book starts with chapters on immunology and proceeds with chapters on bacterial structure, genetics, and diseases, with intervening chapters on microbial identification and control as well as antimicrobial chemotherapy. Oral microbiology is covered in two major chapters, and these are followed by a discussion of fungal structure, pathogenesis and diseases, and antifungal chemotherapy. The book continues with chapters on virus structure, antiviral chemotherapy, and viral diseases, including HIV, hepatitis, and influenza as well as viruses that are much less prevalent. Prions and parasitic diseases conclude the didactic part of the book. The appendix includes cases in medical microbiology that allow readers the opportunity to integrate their knowledge of the field to diagnose cases.

The chapters also highlight some of the exciting discoveries in microbiology, immunology, and molecular biology and pose research questions to stimulate the reader to further inquiry and thinking. Each chapter concludes with take-home messages that will be useful for reviewing the material for an examination. The reader is encouraged to consult some of the references in the bibliography for more detailed information on a given subject. Microbiology affects every aspect of dental practice, so it is paramount that today’s students understand the processes at work in the mouth as well as in the rest of the body.

Acknowledgments

I have benefited greatly from the contributions to the Microbiology course by past and present colleagues Dr Ken Snowdowne, Dr Krystyna Konopka, Dr Taka Chino, Dr Matt Milnes, and Dr Ove Peters.

I am grateful to the staff at Quintessence, particularly Lisa Bywaters for enthusiastically supporting the project and moving it along and Leah Huffman for being a very helpful and competent editor. Jeanne Robertson also did a superb job with the illustrations.

I am fortunate to have a supportive and loving family who are all interested in science and who made sure I was working on the book when I had other obligations.

Chapter Opener Image Credits

1		SEM of a neutrophil engulfing Bacillus anthracis. (Courtesy of PLoS Pathogens and Volker Brinkman.)
2		SEM of HeLa cells stained with antinuclear pore complex antibody and chicken anti-vimentin. (Courtesy of antibodies-online.com.)
3		SEM of a cytotoxic T cell and a somatic cell. (Courtesy of G. Wanner.)
4		Artist rendering of the immune system from “The Body on Fire.” (Courtesy of J. Flaherty.)
5		Photograph of a scientist filling a syringe with a rabies vaccine. (PHIL image 8326, courtesy of the CDC.)
6		SEM of rod-shaped Mycobacterium tuberculosis. (PHIL image 18138, courtesy of the NIAID.)
7		SEM of spherical MRSA interacting with a white blood cell. (PHIL image 18168, courtesy of the NIAID.)
8		Penicillin inhibiting growth of Staphylococcus aureus. (Courtesy of Christine Case, Skyline College.)
9		Chemical structure of chlorhexidine.
10		Petri dish with Streptococcus pyogenes-inoculated trypticase soy agar. (PHIL image 8170, courtesy of Dr Richard Facklam.)
11		SEM of spheroid-shaped MRSA enmeshed within the pseudopodia of a human white blood cell. (PHIL image 18125, courtesy of the NIAID.)
12		Streptococcus. (Courtesy of Tina Carvalho, University of Hawaii at Manoa.)
13		SEM of spores from the Sterne strain of Bacillus anthracis. (PHIL image 10122, courtesy of Janice Haney Carr.)
14		Illustration of Clostridium difficile. (PHIL image 16786, courtesy of Melissa Brower.)
15		SEM of Legionella pneumophila. (PHIL image 11147, courtesy of Janice Haney Carr.)
16		TEM of a diplococcal pair of Neisseria gonorrhoeae. (PHIL image 14493, courtesy of Dr Wiesner at the CDC.)
17		Photomicrograph of Treponema pallidum. (PHIL image 14969, courtesy of Susan Lindsley.)
18		SEM of a human white blood cell interacting with Klebsiella pneumoniae. (PHIL image 18170, courtesy of the NIAID.)
19		SEM of Mycoplasma pneumoniae on the surface of a cell. (Courtesy of Dr David M. Phillips.)
20		SEM of Mycobacterium chelonae. (PHIL image 227, courtesy of Janice Haney Carr.)
21		SEM of Coxiella burnetii undergoing rapid replication in an opened vacuole of a dry-fractured Vero cell. (PHIL image 18164, courtesy of the NIAID.)
22		SEM of Pseudomonas aeruginosa. (PHIL image 10043, courtesy of Janice Haney Carr.)
23		Photomicrograph of Streptococcus mutans with Gram stain. (PHIL image 1070, courtesy of Dr Richard Facklam.)
24		Porphyromonas gingivalis. (Courtesy of Tsute Chen, PhD.)
25		SEM close-up of an asexual Aspergillus species fungal fruiting body. (PHIL image 13367, courtesy of Janice Haney Carr.)
26		Spherule of a Coccidioides fungal organism. (PHIL image 14499, courtesy of the CDC.)
27		Susceptibility testing to the antifungal amphotericin B. (PHIL image 15147, courtesy of James Gathany.)
28		TEM of spherical MERS coronavirus virions. (PHIL image 18113, courtesy of the NIAID.)
29		An HIV-1 protease inhibitor interacting with a mutant protease. (Courtesy of Nature.com and the Protein Data Bank.)
30		A simplified 3D-generated structure of adenovirus. (Courtesy of Thomas Splettstoesser.)
31		Electron micrograph of monocytic THP-1 cells infected with HIV-1 cells. (Reprinted with permission from Konopka et al.*)
32		TEM showing numerous hepatitis virions of an unknown strain. (PHIL image 8153, courtesy of E. H. Cook, Jr.)
33		TEM depicting cytomegalovirus virions. (PHIL image 14429, courtesy of the CDC.)
34		TEM depicting a strain of swine flu (A/New Jersey/76 [Hsw1N1]) virus in a chicken egg. (PHIL image 1246, courtesy of Dr E. Palmer and R. E. Bates.)
35		TEM of parainfluenza virus. (PHIL image 236, courtesy of Dr Erskine Palmer.)
36		TEM of poliovirus. (Courtesy of Graham Beards.)
37		Deceased mosquitos about to undergo laboratory testing. (PHIL image 14887, courtesy of James Stewart.)
38		TEM highlighting the particle envelope of a single MERS coronavirus virion through the process of immunolabeling the envelope proteins. (PHIL image 18108, courtesy of the NIAID.)
39		SEM of numerous Ebola virus particles budding from a chronically infected Vero E6 cell. (PHIL image 17768, courtesy of the NIAID.)
40		Photomicrograph of a neural tissue specimen harvested from a scrapie-affected mouse showing the presence of prion protein. (PHIL image 18131, courtesy of the NIAID.)
41		SEM of an in vitro Giardia lamblia culture. (PHIL image 11636, courtesy of Dr Stan Erlandsen.)

*Konopka K, Pretzer E, Plowman B, Düzgüneş N. Long-term noncytopathic productive infection of the human monocytic leukemia cell line THP-1 by human immunodeficiency virus type 1 (HIV-1IIIB). Virology 1993;193:877–887.

CDC, Centers for Disease Control and Prevention; MERS, Middle East respiratory syndrome; MRSA, methicillin-resistant Staphylococcus aureus; NIAID, National Institute of Allergy and Infectious Diseases; PHIL, Public Health Image Library (of the CDC); SEM, scanning electron micrograph; TEM, transmission electron micrograph.

The protective responses of the immune system against invading microorganisms consist of natural barriers (eg, skin, mucosa, tears); nonspecific, innate immunity (eg, response of neutrophils and interferons); and antigen-specific immunity (eg, antibodies and cell-mediated immunity). The soluble mediators of the immune response include cytokines, interferons, and chemokines. All of these components of the immune system work together in harmony, much like a symphony orchestra does.

Organs and Tissues of the Immune System

The immune system functions within all the organs and tissues of the body to protect it from invading microorganisms. The main avenues of the immune system, however, are in the lymphatic system, which consists of the primary and secondary lymphoid organs. The primary lymphoid organs are the bone marrow and the thymus, where B cells and T cells mature, respectively. Cellular and humoral immune responses take place in the secondary lymphoid organs and tissues (Box 1-1). These include bronchus-associated and urogenital lymphoid tissues, bone marrow, the spleen, mesenteric and other lymph nodes, Peyer’s patches, and Waldeyer’s ring (including tonsils and adenoids).

Peyer’s patches are differentiated lymphoid tissues along the intestines that are involved in antigen internalization and that facilitate the encounter of the antigen with lymphocytes, macrophages, and dendritic cells (Fig 1-1). The M cells along the intestinal lumen transcytose antigens from the apical to the basolateral side of the cells. B and T lymphocytes that encounter the antigens migrate to the local lymphoid follicle. Follicular dendritic cells in the lymphoid follicle facilitate the activation of the lymphocytes. Some of the activated lymphocytes enter an afferent lymphatic vessel and a local lymph node. Antigen-presenting cells (APCs)—such as macrophages, dendritic cells, and B cells—and T cells in the lymph node further activate the lymphocytes. These lymphocytes enter the efferent lymphatic vessel, the thoracic duct, and peripheral blood. The lymphocytes can then enter distal sites at postcapillary venules.

Fig 1-1 Trafficking of B cells and T cells following activation at the Peyer’s patch.

In the oral cavity, the lymphoid tissues include lingual tonsils, palatine tonsils, and pharyngeal tonsils (also called adenoids).

Lymph nodes consist of the cortex (the outer layer), the paracortex, and the medulla (the inner layer) (Fig 1-2). In the cortex, B cells and macrophages are arranged in clusters called follicles. In the paracortex, dendritic cells present antigens to T cells to initiate the specific immune response. The medulla contains T cells and B cells and antibody-producing plasma cells. Following activation of lymphocytes by microbial antigens, they alter the expression of their receptors for chemokines (chemoattractant cytokines). This results in the migration of T cells and B cells to meet at the edge of the follicles, with helper T (T_h) cells interacting with B cells to induce the differentiation of the B cells into antibody-producing cells (plasma cells).

Fig 1-2 Schematic cross section of a lymph node. Note the cortex (which includes the germinal center and follicle), paracortex, medulla, and the germinal centers.

Lymphocytes enter the node from the circulation through postcapillary venules called high endothelial venules. Lymphocytes and antigens from adjacent tissues or lymph nodes enter the node via the afferent lymphatic vessel. Activated lymphocytes leave the lymph node via the efferent lymphatic vessels and may enter the circulation and travel to the sites of infection.

RESEARCH

Cells of the Immune System

The different types of cells that constitute the immune system are generated by the differentiation of hematopoietic cells. Self-renewing stem cells differentiate into pluripotent stem cells, which can in turn differentiate into either myeloid progenitors or lymphoid progenitors (Fig 1-3). The myeloid progenitors then differentiate to produce erythroid colony-forming units (CFUs), megakaryocytes, basophil CFUs, eosinophil CFUs, and granulocyte-monocyte CFUs. The erythroid CFUs form erythrocytes, megakaryocytes form platelets, basophil CFUs form basophils, and eosinophil CFUs form eosinophils. The granulocyte-monocyte CFUs can differentiate into neutrophils, monocytes, and dendritic cells. Monocytes, in turn, can differentiate into macrophages as well as dendritic cells.

Fig 1-3 Differentiation of self-renewing stem cells into the cells of the immune system. CFU, colony-forming unit (to be distinguished from the CFU of bacteria grown on nutrient agar). Myeloid progenitors can also differentiate into megakaryocytes and erthyroid CFUs (not shown). NC, natural cytotoxic (also known as natural killer).

The lymphoid progenitors can differentiate into B lymphocytes, T lymphocytes, and natural killer cells (the author prefers the term natural cytotoxic cells).

RESEARCH

Macrophages are phagocytotic cells that are derived via the differentiation of circulating monocytes that have entered tissues. They become Kupffer cells in the liver, histiocytes in connective tissue, dendritic cells in various tissues, microglial cells in neural tissue, alveolar macrophages in the lung, osteoclasts in bone, and sinusoidal lining cells in the spleen (Fig 1-4). Macrophages engulf bacteria, fungi, and viruses in endocytotic vesicles called phagosomes and destroy them following the fusion of the phagosomes with lysosomes. Lysosomes contain numerous enzymes (acid hydrolases) that degrade proteins, nucleic acids, polysaccharides, and lipids at acidic pH. Attachment of bacteria to the macrophage membrane is facilitated by the binding of the complement component C3b or specific antibodies to the bacterial membrane. The macrophage, in turn, binds these molecules via its C3b receptor (CR1) and Fc receptor (FcR), respectively. The bacteria are internalized in phagosomes, and the enzyme nicotinamide adenine dinucleotide phosphate (NADPH) oxidase is activated to produce superoxide anion, resulting in the consumption of excess oxygen by the cells, a process called the respiratory burst. The superoxide anion can damage bacterial cell membranes.

Fig 1-4 Resident macrophages in various tissues.

Macrophages can also bind bacteria via their lipopolysaccharide (LPS) receptors, mannose receptors, and glycan receptors. Macrophages can be activated by receptors on their surface for the cytokines tumor necrosis factor-alpha (TNF-α) and interferon gamma (IFN-γ) as well as for pathogen-associated molecular patterns. The receptors for the latter—including lipoarabinomannan (from mycobacteria), flagellin (from bacterial flagella), LPS, heat shock protein (Hsp60), CpG DNA (characteristic of bacterial DNA), lipoteichoic acid, and peptidoglycan—are called pattern-recognition receptors or Toll-like receptors (called as such because of their homology to Toll receptors involved in Drosophila development) (Fig 1-5).

Fig 1-5 Pattern-recognition receptors (Toll-like receptors [TLRs]).

Another major role for macrophages is to be a central part of the specific immune responses. Macrophages present antigens on their surface to helper T lymphocytes to help the immune system select the most appropriate T lymphocytes to be stimulated to proliferate in response to a specific antigen. The antigen is presented to the outside world after it is associated with a major histocompatibility complex class II (MHC II) molecule embedded in the plasma membrane. Other membrane proteins such as B7 act as co-stimulatory molecules, and leukocyte function antigen-3 (LFA-3) and intercellular adhesion molecule-1 (ICAM-1) facilitate adhesion between the macrophage and the T_h cell.

Granulocytes consist of neutrophils, basophils, and eosinophils. Between 50% and 70% of white blood cells (leukocytes) are neutrophils, 1% to 3% are eosinophils, and less than 1% are basophils. During infection, the number of circulating neutrophils increases, a condition termed leukocytosis. Neutrophils are the initial phagocytotic defense against bacterial infection. Their primary (azurophilic) granules contain myeloperoxidase, elastase, and cathepsin G. The secondary (specific) granules contain lysozyme and lactoferrin. Neutrophils can migrate from the circulation into tissues by squeezing in between vascular endothelial cells in a process termed diapedesis. They recognize endothelial cells that have been activated by TNF-α and histamine produced as a result of the infection of the tissue. Activation of the endothelial cells involves the expression of ICAM-1 and E-selectin molecules on the cell surface. In response to TNF-α and histamine, neutrophils express integrins, L-selectin, and LFA-1 on their cell membrane. The initial binding of the neutrophil to the endothelial cell is facilitated by its mucin-like cell adhesion molecule (CAM), or selectin ligand, to the E-selectin on the endothelial cell. The chemokine/chemoattractant receptor on the neutrophil responds to chemokines like interleukin-8 (IL-8; also termed CXCL8 because it acts as a chemokine) secreted by the endothelial cell. This results in the conformational change of the integrin on the neutrophil to a high-affinity state, facilitating strong binding to the integrin ligand on the endothelial cells. This is followed by migration through the endothelium (Fig 1-6).

Fig 1-6 Leukocyte recruitment to and migration through the endothelium. (Adapted from Abbas et al.)

Eosinophils are involved in defense against parasitic infections. Basophils are not phagocytotic but release pharmacologically active molecules.

T lymphocytes are generated from T-cell progenitors that can differentiate into CD4⁺ T_hcells, CD8⁺ cytotoxic T cells, and CD8 suppressor T cells (CD8⁺ T_reg cells). The CD4⁺ cells can differentiate further into T_h1, T_h2, T_h3, T_h17, and regulatory T_reg cells. The designation CD refers to cluster of differentiation and is used to identify specific molecules on the surface of immune cells that are characteristic of the state of differentiation of the cells. For example, T cells have the CD3 molecule as part of the T-cell receptor complex, the set of molecules that recognize foreign antigens.

T-cell differentiation takes place in the thymus. If a developing T cell reacts with a protein made by its host before it matures, it will die via apoptosis (programmed cell death), thereby eliminating many T cells that have the potential to attack the body.

RESEARCH

T_h1 cells promote local initial defenses and delayed-type hypersensitivity responses (as in the tuberculin skin test for tuberculosis). T_h2 cells promote antibody production, whereas T_h3 cells facilitate immunoglobulin A (IgA) production. T_h17 cells are involved in inflammation. They produce IL-17, which induces chemokine and cytokine production in other cells, resulting in the recruitment of neutrophils. Their numbers increase in multiple sclerosis, inflammatory bowel disease, and rheumatoid arthritis. T_reg (T-regulator) cells control the immune response.

Lymphocytes differentiate into B cells in the bone marrow and gut-associated lymphoid tissue. In the antigen-independent phase, progenitor B cells (with the CD45R surface marker) undergo Ig gene rearrangement and selection and become mature (but still naïve) B cells with IgM and IgD on their surface. They express MHC II molecules on their surface and thus are also APCs. Following exposure to a particular antigen and to T_h cells that have been presented to the antigen by APCs, the naïve B cells become activated to differentiate into plasma cells that secrete antibodies that recognize the antigen (in the peripheral lymphoid tissues) (Fig 1-7). If the naïve B cells do not encounter antigen and T_h cells, they undergo apoptosis. Antibody class switching also occurs at this stage, where the plasma cells switch from producing IgM antibodies (the type of antibodies that are produced initially) to producing IgG antibodies. A subset of the B cells differentiate into memory cells that facilitate the anamnestic response (the rapid response upon re-exposure to the antigen).

Fig 1-7 Differentiation of B cells. CD, cluster of differentiation; Ag, antigen; Ab, antibody.

RESEARCH

Lymphocyte progenitors can also differentiate into large granular lymphocytes, known as natural killer (NK) cells. Because of the anthropomorphic connotation of violence of the term killer, this monograph introduces the designation natural cytotoxic (NC) cells. These cells can also act as antibody-dependent cellular cytotoxicity cells by means of the Fc receptors that bind the Fc regions of antibodies that recognize antigens on foreign cells.

The common myeloid progenitor cells can differentiate into Langerhans cells and interstitial dendritic cells. The progenitor cells can also differentiate into monocytes, which in turn differentiate into myeloid dendritic cells. The common lymphoid progenitor can also be transformed into lymphoid dendritic cells. Long ignored, dendritic cells are now recognized as the most potent APC. They are found in very small numbers in blood (less than 0.1% of leukocytes). Dendritic cells are also called veiled cells because of their ruffled membrane. Langerhans cells are the dendritic cells in the skin. In draining lymph nodes, dendritic cells become interdigitating cells, carrying antigen to the T-cell regions of the node.

DISCOVERY

Take-Home Messages

Bibliography

Abbas AK, Lichtman AH. Basic Immunology: Functions and Disorders of the Immune System, ed 3. Philadelphia: Saunders/Elsevier, 2011.

Abbas AK, Lightman AH, Pillai S. Cellular and Molecular Immunology, ed 6. Philadelphia: Saunders/Elsevier, 2010.

Coico R, Sunshine G. Immunology: A Short Course, ed 6. Hoboken, NJ: John Wiley & Sons, 2009.

Goldsby RA, Kindt TJ, Osborne BA, Kuby J. Immunology, ed 5. New York: WH Freeman and Company, 2003.

Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology, ed 6. Philadelphia: Mosby/Elsevier, 2009.

Pier GB, Lyczak JB, Wetzler LM. Immunology, Infection and Immunity. Washington: ASM Press, 2004.

Rockefeller University/International Society for Dendritic Cell and Vaccine Science. Introduction to Dendritic Cells. lab.rockefeller.edu/steinman/dendritic_intro/discovery. Accessed 14 April 2015.

Roitt I, Brostoff J, Male D. Immunology, ed 5. London: Mosby, 2008.

Antibodies are produced by the humoral immune system. This system comprises stem cells, B lymphocyte precursors, immature B lymphocytes that undergo gene rearrangement to produce mature B cells, B cells that proliferate upon interaction with a particular antigen that they are programmed to recognize, plasma cells that differentiate from the latter cells and start producing large amounts of antibody, and memory B cells that facilitate the anamnestic response.

The Clonal Selection Theory

The Australian immunologist Frank Macfarlane Burnet proposed the clonal selection theory to explain the proliferation of B lymphocytes specific for an invading antigen or a vaccine. According to this theory, each set of lymphocytes (a clone) arises from a single precursor and can recognize a particular epitope, or antigenic determinant, via specific antibodies on the B-cell surface. This B cell is thus activated to proliferate, and the proliferating cells differentiate into plasma cells that produce antibodies with the same specificity as that of the antibodies on the particular B cell. Some of the proliferating cells differentiate into memory B cells.

A similar clonal selection takes place for T cells. Stem cells differentiate into a pre–T cell, which then forms cells that are both CD4⁺ and CD8⁺. If these cells interact weakly with major histocompatibility complex class II (MHC II) molecules, they differentiate into CD4⁺ cells, which will eventually have to recognize MHC II molecules during antigen presentation by antigen-presenting cells. If the cells weakly recognize the MHC I molecules, they become CD8⁺ cells, which will eventually have to recognize MHC I molecules during antigen presentation by infected cells. The strong recognition of MHC I or MHC II molecules by the CD4⁺ and CD8⁺ cells results in the apoptosis of the cells, thereby providing tolerance for self-antigens. If the cells do not recognize the MHC molecules together with the peptides they present, this also results in apoptosis, providing the basis for clonal deletion.

DISCOVERY

Antibody Structure

Antibodies are the main elements of the humoral immune response and belong to the immunoglobulin (Ig) superfamily of proteins. They neutralize toxins and microorganisms, or “opsonize” microorganisms to help their efficient internalization by phagocytes. An antibody “monomer” consists of four polypeptide chains: two light chains, which are designated kappa (k) and lambda (l), and two heavy chains (Fig 2-1).

Fig 2-1 The schematic structures of IgG and membrane-bound IgM. The heavy chains are in blue, and the light chains are in red. Disulfide bonds are shown as dotted lines. The approximate binding sites for complement and the Fc receptor within the Fc region are also indicated. (Adapted from Abbas and Lichtman.)

The structure generated by the N termini of one light chain and one heavy chain constitutes the variable region of the antibody and recognizes an epitope (a molecular structure recognized by an antibody) on an antigen (a molecule that interacts with the products of a specific immune response). Epitopes can be linear (ie, a continuous sequence of amino acids on a protein) or conformational (ie, a three-dimensional structure consisting of different linear regions of the protein). The paratope is the region of the antibody that interacts with an epitope.

The region of the heavy chain that is invariant is termed the constant region (Fc, for the “crystallizable” fragment that could be used for determining the partial x-ray diffraction structure of the antibody molecule). There are five types of heavy chains that define the class of the antibody: IgG, IgM, IgA, IgE, and IgD. These heavy chains are known as γ, μ, α, ∈, and δ, respectively, and constitute isotypes. These five classes of antibodies can be identified by antibodies directed against the Fc segment of the molecule. Allotypes are additional genetic features of immunoglobulins that vary among individuals. Idiotypes are antigenic determinants formed by the specific protein sequence in the variable region of an immunoglobulin that generate the large number of antigen-binding regions.

DISCOVERY

The immunogenicity of a molecule is its ability to induce a humoral and/or cell-mediated immune response. Proteins are the strongest immunogens. Pure polysaccharides and lipopolysaccharides are good immunogens. Nucleic acids are not effective in eliciting an immune response, except when they are single stranded or associated with proteins. The antigenicity of a molecule is its ability to combine specifically with the final products of the immune response (ie, antibodies and/or T-cell receptors specific for the molecule). Small molecules like penicillin, called haptens, are antigenic, but they are incapable of inducing a specific immune response by themselves; they become immunogenic if they are bound to peptides or proteins. Penicillin allergies are mediated by recognition by IgE antibodies as well as by T cells.

Antibody Diversity

Antibody diversity is generated by the rearrangement of DNA by recombinases and by RNA splicing. The light chain is encoded by V (variable region) and J (joining segment) genes (Fig 2-2). The heavy chain is encoded by V, D (diversity segment), and J genes. The DNA segments rearrange to make genes for chains that are different in each B cell. Thus, only a limited number of gene segments can generate the estimated 100 million distinct antibodies that the body can produce.

Fig 2-2 Recombination and expression of immunoglobulin genes.

The κ light chain gene clusters on chromosome 2, the λ light chain genes on chromosome 22, and the heavy chain genes (α, δ, ∈, γ, μ) on chromosome 14 encode the different components of antibodies. Certain nucleotide segments are removed at both the DNA and RNA levels, enabling the apposition of genes that were previously separated. A light chain gene is generated in a pre–B cell by combining one of 35 V_Lκ genes (or one of 30 V_Lλ genes) with one of 4 J_Lκ (or one of 5 J_Lλ) light chain–joining segment genes and one constant segment gene (C_Lκ or C_Lλ) (see Fig 2-2). An antibody can have either a κ chain or a λ chain.

A heavy chain gene is generated by the combination of one of about 100 variable segment genes (V_H), one of 23 diversity segment genes (D_H), one of 6 joining segment genes (J_H), and one constant region gene among the 5 genes encoding the different classes of antibody (C_Hα, C_Hδ, C_H∈, C_Hγ, and C_Hμ; IgA, IgD, IgE, IgG, and IgM antibodies, respectively). This recombination process can generate:

35 V_Lκ genes × 4 J_Lκ genes = 140 κ chain variable region genes

and

30 V_Lλ genes × 5 J_Lλ genes = 150 λ chain variable region genes

Because antibodies contain either a κ chain or a λ chain, and not both, there is the potential to generate 140 + 150 = 290 different light chains.

Recombination of the heavy chain genes can generate:

100 V_H genes × 23 D_H genes × 6 J_H genes = 13,800 heavy chain variable regions

Because the light chain and heavy chain variable regions together comprise the antigen-recognition site on the antibody, a B cell has the potential to create:

13,800 heavy chain variable regions × 290 light chains = 4,002,000 binding specificities.

Further specificities are added to the antibody genes by terminal deoxyribonucleotidyl transferase, an enzyme that adds or removes nucleotides between the different gene segments to create junctional diversity that increases the specificity of the variable region up to 10¹⁰.

Immunoglobulin Isotypes

Immunoglobulin G (IgG) constitutes between 75% and 85% of antibodies in blood and has the longest half-life (23 days) among the immunoglobulins. It can opsonize antigens, activate complement, and cross the placenta during pregnancy. It also mediates antibody-dependent cellular cytotoxicity, where a cell coated with specific antibodies is killed by natural cytotoxic cells (also known as natural killer cells). There are four types of IgG, namely IgG₁, IgG₂, IgG₃, and IgG₄, with IgG₁ being the most abundant (about 9 mg/ mL in serum).

IgA makes up between 5% and 15% of blood antibodies and has a half-life of 6 days. It is found in blood, tears, colostrum, intestinal and respiratory secretions, and saliva. Secretory IgA consists of two antibodies joined by a J chain and the secretory component that helps the transport of the dimer through epithelial cells. Monomers of IgA are of two types: IgA₁ and IgA₂. The concentration of IgA in serum is about 3 mg/mL.

IgM antibodies have a unique, pentameric structure, with five immunoglobulin units connected via sulfhydryl bonds and a J chain. They constitute about 5% to 10% of blood antibodies (1.5 mg/mL in serum), have a half-life of 5 days, and are the first class of antibodies produced during the primary immune response following the introduction of an immunogen into the host. They are found on the plasma membrane of B cells, are the most efficient antibodies for binding complement, and are effective against polysaccharide antigens.

IgE antibodies are present at very low concentrations, constitute less than 1% of blood antibodies (0.00005 mg/mL in serum), and mediate anaphylactic, Type I hypersensitivity by binding to basophils and mast cells. Antigen-antibody binding and the clustering of Fc receptors on the cells results in cell activation and histamine secretion, giving rise to allergy symptoms. IgE antibodies also protect against parasitic infections.

IgD antibodies are found on B-cell membranes and, together with IgM, function as antigen receptors and activate B-cell growth.

Primary and Secondary Immune Responses

The primary immune response is generated as the production of antibodies by plasma cells after a 5- to 10-day lag period (Fig 2-3). The first class of antibodies produced are IgM antibodies. Immediately after this step, IgG antibodies are produced. After a few days of increased production, antibody levels decline. The primary immune response also leads to the production of memory cells in lymphoid tissues.

Fig 2-3 Primary and secondary antibody responses. (Adapted from Edgar.)

The secondary immune response is initiated when the antigen enters the blood or tissues again. Memory cells facilitate a quicker response to the antigen (3 to 5 days) than that in the primary immune response. The IgM response takes place over a shorter period, and IgG is produced sooner. During this anamnestic response, the antibodies are predominantly IgG, and the antibody levels, measured as the antibody titer, persist for a longer period compared with that in the primary immune response.

Antibody Class Switching

One V_H gene can associate sequentially with different C_H genes during the immune response to produce different classes of immunoglobulins. Whereas the initial antibodies produced are IgM, class switching generates IgG antibodies and eventually IgA antibodies. Class switching occurs only by the change in the heavy chains and not the light chains. The control of class switching depends on the concentration of interleukins. For example, interleukin-4 (IL-4) enhances the production of IgE, whereas IL-5 enhances IgA production.

Monoclonal Antibodies

Monoclonal antibodies recognize a single epitope on an antigen. They were first generated by Georges Köhler and César Milstein, who took lymphocytes from the spleen of mice immunized with a particular antigen and fused them with myeloma cells to produce hybridomas that could divide indefinitely, thus constituting an unlimited reservoir of antibody-producing cells. They could select a particular hybridoma by screening for its antibody product that would recognize the epitope of interest. Such antibodies would be of particular use in the construction of enzyme-linked immunosorbent assays (ELISAs) to detect or quantify particular antigens, since antibodies to different epitopes would be required: one to capture the antigen onto the plastic surface of the well of a microtiter plate and another to recognize the bound antibody. Monoclonal antibodies can also be used in therapeutics; for example, monoclonal antibodies against the epidermal growth factor receptor are used in the treatment of colorectal cancer and head and neck cancer. For this purpose, monoclonal antibodies are genetically engineered to produce chimeric antibodies with a murine variable region and a human constant region to reduce the immunogenicity of murine antibodies.

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The Complement System

The complement system enhances phagocytosis, facilitates inflammation, and can directly lyse certain microorganisms. There are three complement pathways: the classical, alternative, and lectin pathways (Fig 2-4). The three activation pathways of complement converge on a common point, which is the activation of the C3 component of complement by the enzyme C3 convertase.

Fig 2-4 The three pathways of the complement system. (a) Classical pathway. (b) Alternative pathway. (c) Lectin pathway.

In the classical complement pathway, two IgG antibody molecules or a single IgM antibody bound to the surface of a microorganism activates the first component of complement, the protein C1. Activated C1 splits the C2 component into C2a and C2b and the C4 component into C4a and C4b. C4b and C2b form C3 convertase, which cleaves the C3 component of complement into C3a and C3b. C3a is an inflammatory mediator that facilitates chemotaxis and histamine release (see Fig 2-4a). C3b participates in the formation of C5 convertase, which is composed of C4b, C2a, and C3b. C5 convertase splits the C5 component of complement into C5a and C5b. Like C3a, C5a causes chemotaxis and histamine release. C5b combines with C6, C7, C8, and eventually C9 to form a pore, called the membrane attack complex, in certain bacterial membranes, such as Neisseria species, resulting in cell lysis (see Fig 2-4a).

In the alternative pathway, spontaneously formed C3b binds components of the microbial cell surface (endotoxin or polysaccharides). Factor D (a serine protease) cleaves factor B (also a serine protease) bound to C3b, forming Bb (and Ba). The complexation of C3b and Bb forms C3 convertase, which produces C3b. C3b then binds to the membrane-bound C3b/Bb complex, resulting in the formation of C5 convertase (see Fig 2-4b). In the lectin pathway, the host’s mannan-binding protein (MBP), also known as mannose-binding lectin, binds to various sugar residues on bacterial surfaces. This binding activates MBP-associated serine protease, which then cleaves C4 and C2 to form C3 convertase (composed of C4b and C2b) (see Fig 2-4c).

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In its role as a stimulator of immune adherence, C3b also acts as an opsonin that facilitates the clearance of bacteria by the immune system. It binds to the bacterial cell membrane and stimulates phagocytosis by binding to CR1 (complement receptor 1) receptors on macrophages. The two components of the complement system that facilitate inflammation are C3a and C5a, which stimulate neutrophil and macrophage chemotaxis to the tissue of infection. These components also bind to mast cells and platelets, stimulating histamine release and enhancing vascular permeability and smooth muscle contraction.

Take-Home Messages