exogenous (originating from outside the body)

pathogen-associated molecular patterns (PAMPs), such as

the carbohydrates typically found in bacterial cell walls but
not found in human cells,

endogenous (originating from

within the body) damage-associated molecular patterns
(DAMPs; also known as alarmins), such as extracellular
adenosine triphosphate (ATP) released from trauma-damaged
cells.

The responding phagocytic cells possess

pattern recognition receptors on their surface membrane
or in their cytosol for detecting the patterns associated with
threatening agents. For example, phagocytes are studded with
plasma membrane proteins known as toll-like receptors
(TLRs), which recognize PAMPs.

A TLR’s recognition of a pathogen triggers the phagocyte to

engulf and destroy the infectious microorganism.

Moreover,activation of the TLR induces the phagocytic cell to secrete

Chemicals, inflammatory cytokines.

As another link between the innate and adaptive branches

of the immune system, foreign particles are deliberately marked
for phagocytic ingestion by being coated with antibodies produced
by the B cells of the adaptive immune system.
These are
but a few examples of how various components of the immune
system are highly interactive and interdependent. The most
significant cooperative relationships among the immune effectors
are pointed out throughout this chapter.
TLRs function at the cell surface to recognize pathogens in
the extracellular fluid (ECF), but most viruses are hidden inside
host cells instead of being free in the ECF. Scientists recently
discovered intracellular pattern recognition receptors, including
several RLRs,1 which recognize viral DNA or RNA within
the cytosol, and multiple NLRs,2 which distinguish intracellular
PAMPs such as bits of bacterial cell wall engulfed by a phagocyte
or parasites that have invaded a nonimmune cell. Appropriately,
activation of RLRs by viral genetic material triggers
synthesis of interferon, an innate mechanism to be described
later that defends against viral invasion. Activated NLRs trigger
formation of cytosolic, multiprotein complexes termed inflammasomes,
of which the NLRs themselves are a part. Inflammasomes
bring about a potent inflammatory response, complementing
the actions triggered by activated TLRs. Thus, the
trinity of pathogen receptors—TLRs, RLRs, and NLRs—
cooperate to ensure efficient innate immune responses against
pathogenic interlopers.
The innate mechanisms give us all a rapid but limited and
nonselective response to unfriendly challenges of all kinds,
much like medieval guardsmen lashing out with brute-force
weapons at any enemy approaching the walls of the castle they
are defending. Innate immunity largely contains and limits the
spread of infection. These nonspecific responses are important
for keeping the foe at bay until the adaptive immune system,
with its highly selective weapons, can be prepared to take over
and mount strategies to eliminate the villain

Roles of Phagocytosis

Earlier we studied the

basics of phagocytosis
using the figure shown
to the right, which
shows the formation of
the phagosome and the
subsequent fusion of
lysosomes to form the
phagolysosome. Now we
want to look at roles
that phagocytosis plays
at various times during
an infection. You will find that it is important in both innate immunity
and specific (adaptive) immunity.

Initial Encounters with Pathogen

There are two types of phagocytic cells normally present in interstitial

spaces throughout the body, and especially under epithelia. These are
the dendritic cells and the resident macrophages, both of which are
the first immunological cells to interact with a pathogen. Both are also
similar in that they do not need an specific immune response in order
to phagocytize a pathogen. You can think of these two types of cells as
sentinels, always out in the tissues waiting to encounter any microbes
that might enter the body. They then alert the immune system so that
the various defense mechanisms begin. But the two types of phagocytes
have quite different roles.

The role of dendritic cells is shown in the figure to the right. It illustrates
that the phagocytosis is not for the purpose of destroying the pathogen,
but rather for collecting antigen(foreign molecules) and carrying it to
lymphocytes in lymph nodes, spleen or MALT. In these locations, the
dendritic cells serve as antigen presenting cells, which "present" the
antigen to helper T cells (lymphocytes). This is an important step in
starting an specific immune response.

As shown, some peptides from the phagocytized protein are put on the
surface of the cell attached to MHC II molecules. You will hear much
more on this soon.

Thus, while the phagocytosis and activation of dendritic cells is innate

(non-specific), the point of the phagocytosis to help promote an specific
immune response. But an specific immune response requires five days or
so in order to have an effect on the pathogens. With this in mind, we are
going to leave dendritic cells until we take up specific immune responses
and concentrate now on macrophages.

Macrophages, on the other hand, start processes in the infected tissue

that can begin within minutes. At this point, no molecules (antibodies or T
cell receptors) are available to specifically identify the pathogen. Thus,
these initial processes are part of an innate immune response. In
addition, macrophages are important in actually destroying pathogens,
especially for infections that are more prolonged and that turn
into chronic problems.

Release of Cytokines

Now let us start to follow the sequence of events as microbes first enter a
tissue in the body. The very first step is the phagocytosis of a few of the
microbes by a few dendritic cells and macrophages. The dendritic cells
scurry off to a lymph node and begin the specific immune response, which
will require about a week to start having an effect on the microbes. For
now, we set aside the dendritic cells and start to following the sequence
of events that the phagocytosis of a few microbes by resident
macrophages sets in motion. All this starts happening within minutes.

After phagocytizing microbes, macrophages (and dendritic cells) release

regulatory moleculess. These serve mainly as paracrines that set in
motion many of the further immunological processes during an infection.
The term cytokine refers to any small protein that is released to help
coordinate an immune response. Most cytokines are released by white
blood cells.

Two important cytokines released by macrophages when they encounter a

pathogen are TNF-alpha and interleukin-1 (IL-1). The effects of both
are similar, except that when TNF-alpha is released in pathological
excess, it can trigger dramatic, life-threatening responses. In addition,
macrophages, as well as other nearby cells, release cytokines
called chemokines.

Roles of Cell Adhesion Molecules

The initial phagocytosis of microbes by resident macrophages is not going

to end the infection unless there are just a few, stray microbes present.
Any significant infection is going to require reinforcements, and recruiting
these is perhaps the most important role of the cytokines released by the
resident macrophages. The first cells recruited are neutrophils, which
are present in substantial quantity in the blood and rapidly enter the
infected tissue in order to start phagocytizing microbes. Unlike
macrophages, neutrophils are short-lived, lasting only hours to days.

The first step in the migration of neutrophils into the tissues is necessarily
the binding of the neutrophils to the endothelium of the blood vessels.
Without this step, of course, the neutrophils would simply continue to
tumble through and out the vessels serving the region. The binding
begins when TNF-alpha and IL-1 from the macrophages cause endothelial
cells to begin expressing two types of cell adhesion molecules that
promote the binding of neutrophils to endothelial cells. These molecules
allow the binding to occur in two steps. In the first, adhesion molecules
called selectins lightly tether the neutrophil to the endothelium, so that it
begins rolling along the surface. In a second step, a much tighter binding
occurs through another class of newly expressed adhesion molecules on
endothelial cells called ICAMs. These cause a tight adhesion of the
neutrophils by binding molecules on the neutrophils called integrins.

Diapedesis and Chemotaxis

Once bound to the endothelium, neutrophils squeeze through gaps

between adjacent endothelial cells into the interstitial fluid, a process
called diapedesis. Aiding this, an endothelium activated by the cytokines
also becomes more permeable than normal. Even blood proteins can
now cross.
Once outside the blood vessel, a neutrophil is guided towards an infection
by various diffusing chemotactic factors. The chemokines released by
macrophages and other cells are especially important. Another example is
the complement peptide C5a, which is released when the complement
system, as discussed on the next page. Certain bacterial molecules are
also directly chemotactic.

With time, monocytes in the blood also begin adhering to the

endothelium and moving into the infected tissue. Once in the tissues
these are called macrophages. While the short-lived neutrophils
predominate in an acute response to an infection, the long-lived
macrophages are important for chronic infections.

Another process going on while all of the above are occurring is dilation
of the small arteries serving the infected area. This is caused by the
cytokines and also various other inflammatory paracrines. This, of course,
makes available more substances in the blood to fight the infection and is
the reason infected tissue turns red.

Recognition of Pathogen

A dendritic cell or macrophage must recognize that it has encountered a

microorganism and not a normal cell of the body. Basically, these
phagocytes have certain proteins in their membranes that either directly
or indirectly recognize various molecules that could not be found on
human cells. Reflect that microbes have structures such as cell walls that
are never a part of a human cell. Thus certain molecules are present on
microbes that are quite different than those on a human cell.

But the recognition molecules on dendritic cells and macrophages are not
nearly as precise as the molecules created by an specific immune
response (antibodies and T cell receptors). The innate recognition
molecules only recognize general classes of microbes rather than specific
microbes. The resulting phagocytosis is enough to get the immunological
processes started, but is restrained, so that it will not get rid of a
significant pathogen. For that, an specific immune response with
antibodies and/or T cell receptors is required.

The first and most important of these recognition molecules are the toll-
like receptors. There are 11 different molecules in this category, and
they recognize a wide variety of molecules found only on microbes. The
binding of a ligand to a toll-like receptor sets in motion of sequence of
events inside the cell that activates various genes important for
orchestrating a innate immune response.

Another example of a recognition molecule is the mannose receptor.

Some microbes have molecules on their surfaces that contain mannose
 spaced at specific intervals. (Mannose is a sugar.) Human cells would
never have molecules of this type.

In addition, there are three or four more types of known recognition

molecules on macrophages. But the total number is not large and they
are all coded by typical genes. These are normally expressed; the
macrophage does not need to be exposed to the microbe to begin making
these innate recognition molecules (unlike for antibodies or T cell
receptors).

A few of the recognition molecules are not on the surface of

macrophages, but rather found in the blood plasma. One especially
important molecule of this sort is C-reactive protein. This is made by
the liver and only binds to microbes. Another protein of this type is
called mannose binding lectin. Macrophages in turn have molecules on
their surface that bind to C-reactive protein or mannose binding lectin.
This binding promotes phagocytosis.

A molecule that promotes phagocytosis by binding to a microbe, such as

C-reactive protein and mannose binding lectin, is called an opsonin.
Another example of an opsonin is C3b, which is discussed on the next
webpage. (The best opsonins, however, are antibodies, which are made in
a specific immune response.)

The Complement System

The complement system (also called the complement cascade) is a mechanism

that complements other aspects of the immune response. Typically, the complement system

acts as a part of the innate immune system, but it can work with the adaptive immune system

if necessary.

The complement system is made of a variety of proteins that, when inactive, circulate in the

blood. When activated, these proteins come together to initiate the complement cascade,

which starts the following steps:

1. Opsonization: Opsonization is a process in which foreign particles are marked for

phagocytosis. All of the pathways require an antigen to signal that there is a threat present.

Opsonization tags infected cells and identifies circulating pathogens expressing the same

antigens.
2. Chemotaxis: Chemotaxis is the attraction and movement of macrophages to a chemical

signal. Chemotaxis uses cytokines and chemokines to attract macrophages and neutrophils to

the site of infection, ensuring that pathogens in the area will be destroyed. By bringing

immune cells to an area with identified pathogens, it improves the likelihood that the threats

will be destroyed and the infection will be treated.

3. Cell Lysis: Lysis is the breaking down or destruction of the membrane of a cell. The proteins

of the complement system puncture the membranes of foreign cells, destroying the integrity

of the pathogen. Destroying the membrane of foreign cells or pathogens weakens their ability

to proliferate, and helps to stop the spread of infection.

4. Agglutination: Agglutination uses antibodies to cluster and bind pathogens together, much

like a cowboy rounds up his cattle. By bringing as many pathogens together in the same area,

the cells of the immune system can mount an attack and weaken the infection. Other innate

immune system cells continue to circulate throughout the body in order to track down any

other pathogens that have not been clustered and bound for destruction.

Complement cascade diagram

The steps of the complement cascade facilitate the search for and removal of antigens by

placing them in large clumps, making it easier for other aspects of the immune system to do

their jobs. Remember that the complement system is a supplemental cascade of proteins that

assists, or “complements” the other aspects of the innate immune system.

The innate immune system works to fight off pathogens before they can start an active

infection. For some cases, the innate immune response is not enough, or the pathogen is able

to exploit the innate immune response for a way into the host cells. In such situations, the

innate immune system works with the adaptive immune system to reduce the severity of
infection, and to fight off any additional invaders while the adaptive immune system is busy

destroying the initial infection.

Neutrophil Invasion of the Inflamed Area Is a Second

Line of Defense. Within the first hour or so after inflammation
begins, large numbers of neutrophils begin to
invade the inflamed area from the blood. This invasion is
caused by inflammatory cytokines (e.g., tumor necrosis
factor and interleukin-1) and other biochemical products
produced by the inflamed tissues that initiate the following
reactions:
1. They cause increased expression of adhesion molecules,
such as selectins and intercellular adhesion
molecule–1 (ICAM-1) on the surface of endothelial
cells in the capillaries and venules. These adhesion
molecules, reacting with complementary integrin
molecules on the neutrophils, cause the neutrophils
to stick to the capillary and venule walls in the
inflamed area. This effect is called margination and
is shown in Figure 34-2 and in more detail in
Figure 34-6.
2. They also cause the intercellular attachments
between the endothelial cells of the capillaries
and small venules to loosen, allowing openings
large enough for neutrophils to crawl through
directly from the blood into the tissue spaces by
diapedesis.

Neutrophil Invasion of the Inflamed Area Is a Second

Line of Defense. Within the first hour or so after inflammation
begins, large numbers of neutrophils begin to
invade the inflamed area from the blood. This invasion is
caused by inflammatory cytokines (e.g., tumor necrosis
factor and interleukin-1) and other biochemical products
produced by the inflamed tissues that initiate the following
reactions:
1. They cause increased expression of adhesion molecules,
such as selectins and intercellular adhesion
molecule–1 (ICAM-1) on the surface of endothelial
cells in the capillaries and venules. These adhesion
molecules, reacting with complementary integrin
molecules on the neutrophils, cause the neutrophils
to stick to the capillary and venule walls in the
inflamed area. This effect is called margination and
is shown in Figure 34-2 and in more detail in
Figure 34-6.
2. They also cause the intercellular attachments
between the endothelial cells of the capillaries
and small venules to loosen, allowing openings
large enough for neutrophils to crawl through
directly from the blood into the tissue spaces by
diapedesis.

3. They then cause chemotaxis of the neutrophils

toward the injured tissues, as explained earlier.
Thus, within several hours after tissue damage begins,
the area becomes well supplied with neutrophils. Because
the blood neutrophils are already mature cells, they are
ready to immediately begin their scavenger functions of
killing bacteria and removing foreign matter.

The extravasation of phagocytes into the area requires 4 sequential, overlapping

steps:
Step 1: Rolling
Phagocytes attach loosely to the endothelium by low-affinity, selectin-carbohydrate
interactions. E-selectin molecules on the endothelium bind to mucin-like
adhesion molecules on the phagocyte membrane and bind the cell briefly, but
the force of blood flow into the area causes the cell to detach and reattach repeatedly,
rolling along the endothelial surface until stronger binding forces can
be elicited.
Step 2: Activation by chemo-attractants
Chemokines released in the area during inflammation, such as interleukin 8
(IL-8), complement split product C5a, and N-formyl peptides produced by
bacteria bind to receptors on the phagocyte surface and trigger a G-protein–
mediated activating signal. This signal induces a conformational change in integrin
molecules in the phagocyte membrane that increases their affinity for
immunoglobulin-superfamily adhesion molecules on the endothelium.
Step 3: Arrest and adhesion
Interaction between integrins and Ig-superfamily cellular adhesion molecules
(Ig-CAMs) mediates the tight binding of the phagocyte to the endothelial cell.
These integrin-IgCAM interactions also mediate the tight binding of phagocytes
and their movement through the extracellular matrix.
Step 4: Transendothelial migration
The phagocyte extends pseudopodia through the vessel wall and extravasates
into the tissues.

The human body regularly encounters and combats many pathogenic organisms and toxic
molecules. Its ensuing responses to these disease-causing agents involve two interrelated
systems: innate immunity and adaptive (or acquired) immunity. Innate immunity is active at
several levels, both at potential points of entry and inside the body (see figure). For example,
the skin represents a physical barrier preventing pathogens from invading internal tissues.
Digestive enzymes destroy microbes that enter the stomach with food. Macrophages
and lymphocytes, equipped with molecular detectors, such as Toll-like receptors (TLRs),
which latch onto foreign structures and activate cellular defenses, patrol the inside of the
body. These immune cells sense and devour microbes, damaged cells, and other foreign
materials in the body. Certain proteins in the blood (such as proteins of the complement
system and those released by natural killer cells, along with antimicrobial host-defense
peptides) attach toforeign organisms and toxins to initiate their destruction.

When a pathogenic organism or toxin does gain a foothold in the body, the defenses
furnished by the innate immune system are reinforced by those of the adaptive immune
system. Compared with innate immunity, adaptive immunity is a more evolved and complex
system consisting of both cells and proteins. These adaptive immunity agents specifically
target and destroy the invading pathogen. Within days or weeks, the adaptive immune
system manufactures antibodies tailored to the pathogenic invader to halt its spread. This
process, known as the humoral response or antibody- mediated immune response, relies on
specific cell types, called B cells, which produce antibodies. In parallel, this response
activates lymphocytes, including T cells, programmed with information to detect surface
molecules specific to the invader—a second type of adaptive immunity called cellular
immunity. A hallmark of adaptive immunity is that it can store—via production of specialized
T and B cells—a memory of the pathogen’s unique molecular structures allowing for a more
rapid response to future invasions by the same pathogen.

The expanded glossary below presents the main features of and mechanisms and players in
the innate and adaptive immune systems that are relevant to this special issue
of Alcohol Research: Current Reviews.

The Innate Immune System

Responses of the innate immune system to acute or persistent infection or injury typically
manifest as inflammation. The primary purpose of the inflammation is to contain the
infection, enable rapid access of immune cells and proteins to the infection site, and promote
healing once the pathogen(s) has been cleared. This process involves multiple cytokines
and types of immune cells. Many of the cells of the innate immune system are phagocytes:
cells that ingest other cells or cellular debris through a processcalled
phagocytosis, which neutralizes harmful agents. In phagocytosis, the immune cells
engulfmicroorganisms or foreign particles and inactivate them in an intense chemical shower
of reactive oxygen species called the respiratory burst.

Innate immune cells have various functions, including the following.

Granulocytes are white blood cells (i.e., leukocytes) characterized by the presence of
granules in their cytoplasm. Granulocytes include the following cell types:

Neutrophils are the most abundant granulocytes and also the most abundant type of white
blood cell, reaching concentrations of up to 5 million cells per milliliter in the blood.
Neutrophils normally circulate in the blood and, upon injury or infection, quickly move to the
affected site. They thereby follow chemical signals consisting
of cytokines and chemokines to the site where they are among the first immune cells to
arrive. Neutrophils detect pathogens via TLRs and directly attack them, for example, through
phagocytosis. Neutrophils also release extracellular traps composed of DNA and
antimicrobial peptides that ensnare and kill microbes. Thus, neutrophils represent an
important first-line defense against invading microbes.

Basophils originate from bone marrow and circulate in the blood; they are the least abundant
white blood cells. Upon activation by proteins, they move to an injured or infected site.
Similar to mast cells, basophils also sometimes cause inflammatory responses such as
allergic reactions. Basophils release the anticoagulant heparin and the vasoactive
compounds histamine and serotonin, which reduce blood clotting and contribute to wound
swelling typical of inflammations, respectively.

Eosinophils develop and mature in bone marrow and then also circulate in the blood. They
are activated, for example, by lymphocytes of the adaptive immune systems, and they are
crucial for combating larger parasites that cannot be phagocytosed, such as protozoans.
Eosinophils also help fight other types of infections.

Mast cells reside in connective tissues and mucous membranes and aid in wound healing
and also in defending against pathogens. When activated by pathogens or allergens such as
pollen, mast cells rapidly release protein-carrying granules rich in both histamine and
heparin, molecules involved in inflammation. Mast cell activation often underlies adverse
immune responses such as allergies, arthritis, and anaphylactic shock.

Monocytes are the largest cells of the innate immune system. They mature in bone
marrow and then circulate through the blood. Half of them are stored in the spleen and the
other half in other locations throughout the body. Monocytes are precursors for two other
innate immune system cells: macrophages and dendritic cells.

Macrophages are cells that search for and phagocytose pathogens. Upon exiting blood and
entering tissues, monocytes develop into macrophages. They help remove excess,
damaged, or dead cells marked by surface proteins for elimination. “Resident” macrophages
inhabit specific locations or organs that are prone to infections, such as the lungs and liver,
or serve in hubs, such as the spleen, for rapid deployment to injured or infected sites.
Examples include Kupffer cells, macrophages residing in the liver, and microglia, residing in
the central nervous system. Macrophages carry on their surface several TLRs that are
activated by pathogen- or damage-associated molecular patterns—this activation stimulates
the macrophages to phagocytose pathogens or damaged cells or to secrete cytokines to
activate and recruit additional immune cells. Macrophages contribute to wound healing, help
control immune responses and other cells of the innate immune system, and also stimulate
adaptive immunity (see below).

Dendritic cells act as messengers between the innate and adaptive immune systems. They
reside in tissues exposed to the external environment, including the skin and the linings of
the nose, lungs, stomach, and colon. Like neutrophils and macrophages, they detect foreign
invaders via TLRs. Upon encountering a pathogen, dendritic cells ingest (i.e., endocytose) it
or its products and attach pieces of the pathogen (i.e., antigens) to their cell surface on a
protein assembly called the major histocompatibility complex II (MHC II). The dendritic cells
then migrate to the lymph nodes where they activate T cells and B cells by presenting the
pathogen’s antigens to them. Dendritic cells are the most potent of several types of antigen-
presenting cells, which effectively jumpstart the adaptive immune response.

Natural killer cells (NK cells) rapidly respond to the presence of virus-infected and tumor
cells and destroy them with proteolytic enzymes and cytotoxic proteins that destabilize the
cells’ membranes and induce apoptosis. NK cells recognize stressed cells in the absence of
the chemical triggers other immune cells need to mount an immune response. Although
traditionally classified along with innate immune cells, some evidence of immunological
memory in NK cells (see table) suggests that these cells are also affiliated with adaptive
immunity.

The complement system consists of more than 30 blood-borne proteins produced in the
liver. These proteins help or “complement” the killing of pathogens by antibodies. The
complement system triggers a biochemical cascade in which foreign cells are first opsonized
(i.e., coated) with complement proteins, weakening or rupturing (i.e., lysing) their cell walls.
The action of complement also attracts other immune cells such
as macrophages and neutrophils, along with antibodies, to the site of infection.
Table Components of the Immune System

Innate Immunity Adaptive Immunity

Immune responses specifically target

Immune responses are largely non-specific,
pathogens via its antigens detected by
e.g., via Toll-like receptors (TLRs)
specific immune cell receptors

Comprises a variety of defense mechanisms,

i.e., physical/physiological barriers, lytic
Involves mainly cell- and protein-
enzymes, reactive oxygen species, isolation of
mediated immunity
diseased tissues, and cell- and protein-
mediated immunity

Lag time between pathogen detection

Immediate response to pathogenic challenge
and response

No immunological memory (with some Activation leads to immunological

evidence for immune memory in NK cells) memory

Often underlying autoimmune diseases

Often underlying chronic inflammation in in which self/nonself recognition is
allergies and degenerative diseases (e.g., impaired, causing adaptive immune cells
Alzheimer’s disease, rheumatoid arthritis) to attack the body’s own cells (e.g., in
type I diabetes, autoimmune hepatitis)

Present in jawed vertebrates with

Present in all eukaryotes (including plants,
emerging evidence of related immune
which, however, use different mechanisms and
mechanisms in jawless vertebrates and
molecules in innate immunity)
some invertebrates

The Adaptive Immune System

The cells and structures of all organisms display unique antigens, which are molecules
characteristic only to them. During the development of the immune system, adaptive
immune cells originating from lymphocytes differentiate to recognize specific antigens, and
the entire complement of this antigen specificity enables recognition of all possible antigens.
As rearrangements within the genes in the immune cells occur during this developmental
process, antigens present in the host (self-antigens) interact with the emerging cell
population to eliminate those adaptive immune cells that would attack the host, while
retaining only those cells that will target any non–self-antigens.

The functions of cells of the adaptive immune system are as follows.

B lymphocyte cells display an enormous variation in the cells they target—the blood and
lymphatic systems contain millions of B cells, produced early in the body’s development,
which differ in the type of antibody they produce in response to the antigens they recognize.
Each B cell carries a cell-surface receptor designed to fit a specific antigen on the pathogen.
B cells scan for pathogens (such as viruses and bacterial toxins), and on encountering a
pathogen whose antigen fits its receptor, a B cell will start to make copies of itself (i.e.,
proliferate). The proliferating B cells grow into a colony of plasma cells producing and
secreting antibodies that block the pathogen from gaining access to healthy cells. After the
infection has resolved, some of these plasma cells may persist for 50 years or longer as
memory B cells, which contribute to immunological memory and can respond quickly by
producing antibodies if they encounter the same pathogen again.

T lymphocyte cells mainly target cells of the body that have been invaded by pathogens
such as viruses, or that show abnormal molecular patterns on their surface associated with
cancerous growth or necrosis. T cells do not produce antibodies and they mature in the
thymus. They may be broadly divided into three groups: helper T cells, cytotoxic T cells, and
regulatory T cells.

Helper T cells (also known as CD4+ cells) represent a key cell type in adaptive immunity and
consist of four groups. Th1 and Th2 cells are involved in defenses against intra- and
extracellular pathogens and in autoimmune and allergic responses, respectively; a recently
identified helper T cell, Th17, represents another CD4+ cell group involved in neutralizing
extracellular microbes and also has been shown to be involved in chronic inflammation and
autoimmune disease. Regulatory T (Treg) cells represent a fourth group that helps to check
responses of effector T cells and suppress pro-inflammatory pathways—for example, when
an infection has resolved. These cells also keep the immune system in check when there is
no infection, preventing immune cells from attacking the normal cells of the body.

The T helper cells do not attack pathogens directly, but activate other immune system cells,
includingB cells, killer T cells, and macrophages. They are activated by antigens presented
on, for example, dendritic cells and B cells. Each helper T cell, derived from cells produced
early in the body’s development by the above-mentioned differentiation mechanism, has T-
cell receptors on its surface that recognize a specific antigen attached to MHC II of the
presenting cells. On encountering an immune cell that presents an MHC II–bound antigen
that matches the helper T cell’s receptor, the helper T cell is activated and begins to
proliferate. Some of these proliferating cells become memory helper T cells that contribute to
immunological memory and respond quickly to future infections by the same pathogen. The
others become effector helper T cells, which release cytokines to attract other immune cells,
such as macrophages, B cells, and cytotoxic T cells, or regulate the activity of these cells.

Cytotoxic or killer T cells (also known as CD8+ cells) search for and destroy cells infected
with viruses or other pathogens or for cells that are damaged or abnormal such as cancer
cells. Like helper T cells, cytotoxic T cells have T-cell receptors. These receptors bind to
MHC I, a protein complex that is present on the surface of all cells in the body. When a
microbe or virus infects a cell or a cell becomes cancerous, fragments of damaged proteins
are transported to the cell surface and are presented on MHC I. A cytotoxic T cell whose
receptor fits an antigen presented on MHC I binds to the antigen, resulting in activation of
the T cell. Activated cytotoxic T cells begin to proliferate into memory cytotoxic T cells or
effector cytotoxic T cells. The latter cells bind to MHC I on the antigen-presenting cells and
destroy them, whereas the former contribute to immunological memory of the activation
event.

Signaling in Innate and Adaptive Immunity

Cytokines are small proteins that help immune cells to communicate; they are secreted
from immune cells on contact with a pathogen- or damage-associated molecular pattern or
with an antigen. Many cells of the innate and adaptive immune systems release cytokines,
which activate or suppress the activity of other immune cells by binding to specific receptors
on these cells. Cytokines help regulate virtually all immune processes, affect the balance
between humoral and cellular immunity, and help control the growth and maturation of many
immune cells. They include chemokines, interferons, interleukins, and tumor necrosis factor.

Chemokines represent cytokines whose action on the receptors of immune cells (i.e.,
leukocytes) promotes movement (i.e., chemotaxis) toward the source of the
chemokines; chemokines thus attract the immune cells to, for example, sites of inflammation
or injury.

Interferons are cytokines released by cells (especially leukocytes) interacting with viruses,
other pathogens, or toxic proteins; they bind to and activate specific receptors on
neighboring cells. This activation leads to increased transcription of genes for proteins that
increase the cells’ resistance to viral infection. Interferons also inhibit activation of B
cells and increase the cytotoxicity of NK cells. Interferons are represented by three distinct
classes (α, β, and γ), each of which is characterized by specific functions and is produced by
specific cells (e.g., by leukocytes, fibroblasts, and lymphocytes).

Interleukins (ILs) are produced by leukocytes, lymphocytes, and even non-immune cells (in
some circumstances). ILs include both cytokines and chemokines. Low concentrations of
these proteins mainly facilitate localized communication among leukocytes in inflammation,
such as promoting the production of chemokines to recruit additional immune cells. At higher
concentrations, some ILs (e.g., IL-1) enter the blood stream and act as endocrine hormones,
producing fever and stimulating production of immune proteins in the liver.

Tumor necrosis factor a (TNFα) is a major pro-inflammatory cytokine. It primarily is produced

by macrophages and promotes inflammation both during infection and in dysregulated
immune responses, such as those active in degenerative diseases (e.g., arthritis). By
binding to and activating its specific cell receptor, TNFR (i.e., cluster of differentiation 120
[CD120]), TNFα activates severaltranscription factors such as nuclear factor κΒ, which
upregulates expression of pro-inflammatory genes. TNFα also induces cell death (i.e.,
apoptosis) and necrosis in some cell types.

Conclusion

The innate and adaptive immune systems have distinct roles in combating infections and
pathogenic cells, and both systems have some modest functional overlap. Whereas innate
immunity represents a relatively non-specific and first-line defense against microbes and
parasites, adaptive immunity encompasses a highly evolved assemblage of sophisticated
defense mechanisms that specifically target groups of related or individual pathogens. The
innate immune system blocks entry of pathogens by physical (e.g., skin) and physiological
(e.g., pH, nucleases, proteases, and host-defense peptides) means. If a pathogen succeeds
in breaching these initial barriers, detection of the pathogen by innate immune cells
stimulates inflammation that attempts to isolate infected cells and tissues and to inactivate
the invading pathogen. If this initial inflammatory response does not eliminate the pathogen,
the adaptive immune system comes into play.

The cells of the adaptive immune system translocate to the site of infection and begin to
inactivate, for example, free virus particles (by way of B cells) and to destroy virus-
infected or damaged cells (by way of T cells), or help eliminate other pathogens such as
bacteria, fungi, or larger parasites. Formation of B and T memory cells then guards against
future attack by the same pathogen.

Inflammation and Fever

LEARNING OBJECTIVES

 Identify the signs of inflammation and fever and explain why they
occur
 Explain the advantages and risks posed by inflammatory responses

The inflammatory response, or inflammation, is triggered by a cascade of

chemical mediators and cellular responses that may occur when cells are
damaged and stressed or when pathogens successfully breach the
physical barriers of the innate immune system. Although inflammation is
typically associated with negative consequences of injury or disease, it is a
necessary process insofar as it allows for recruitment of the cellular
defenses needed to eliminate pathogens, remove damaged and dead cells,
and initiate repair mechanisms. Excessive inflammation, however, can
result in local tissue damage and, in severe cases, may even become
deadly.

Acute Inflammation
An early, if not immediate, response to tissue injury is acute inflammation.
Immediately following an injury, vasoconstriction of blood vessels will occur
to minimize blood loss. The amount of vasoconstriction is related to the
amount of vascular injury, but it is usually brief. Vasoconstriction is followed
by vasodilation and increased vascular permeability, as a direct result of
the release of histamine from resident mast cells. Increased blood flow and
vascular permeability can dilute toxins and bacterial products at the site of
injury or infection. They also contribute to the five observable signs
associated with the inflammatory
response: erythema (redness), edema(swelling), heat, pain, and altered
function. Vasodilation and increased vascular permeability are also
associated with an influx of phagocytes at the site of injury and/or infection.
This can enhance the inflammatory response because phagocytes may
release proinflammatory chemicals when they are activated by cellular
distress signals released from damaged cells, by PAMPs, or
by opsoninson the surface of pathogens. Activation of the complement
system can further enhance the inflammatory response through the
production of the anaphylatoxin C5a. Figure 1 illustrates a typical case of
acute inflammation at the site of a skin wound.
Figure 1. (a) Mast cells detect injury to nearby cells and release histamine, initiating an
inflammatory response. (b) Histamine increases blood flow to the wound site, and increased
vascular permeability allows fluid, proteins, phagocytes, and other immune cells to enter
infected tissue. These events result in the swelling and reddening of the injured site, and the
increased blood flow to the injured site causes it to feel warm. Inflammation is also
associated with pain due to these events stimulating nerve pain receptors in the tissue. The
interaction of phagocyte PRRs with cellular distress signals and PAMPs and opsonins on the
surface of pathogens leads to the release of more proinflammatory chemicals, enhancing the
inflammatory response.

During the period of inflammation, the release of bradykinin causes

capillaries to remain dilated, flooding tissues with fluids and leading to
edema. Increasing numbers of neutrophils are recruited to the area to fight
pathogens. As the fight rages on, pus forms from the accumulation of
neutrophils, dead cells, tissue fluids, and lymph. Typically, after a few days,
macrophages will help to clear out this pus. Eventually, tissue repair can
begin in the wounded area.
Chronic Inflammation

Figure 2. A tubercle is a granuloma in the lung tissue of a patient with tuberculosis. In this
micrograph, white blood cells (stained purple) have walled off a pocket of tissue infected with
Mycobacterium tuberculosis. Granulomas also occur in many other forms of disease. (credit:
modification of work by Piotrowski WJ, Górski P, Duda-Szymańska J, Kwiatkowska S)

When acute inflammation is unable to clear an infectious

pathogen, chronic inflammation may occur. This often results in an
ongoing (and sometimes futile) lower-level battle between the host
organism and the pathogen. The wounded area may heal at a superficial
level, but pathogens may still be present in deeper tissues, stimulating
ongoing inflammation. Additionally, chronic inflammation may be involved
in the progression of degenerative neurological diseases such as
Alzheimer’s and Parkinson’s, heart disease, and metastatic cancer.

Chronic inflammation may lead to the formation of granulomas, pockets of

infected tissue walled off and surrounded by WBCs. Macrophages and
other phagocytes wage an unsuccessful battle to eliminate the pathogens
and dead cellular materials within a granuloma. One example of a disease
that produces chronic inflammation is tuberculosis, which results in the
formation of granulomas in lung tissues. A tubercular granuloma is called a
tubercle (Figure 2). Tuberculosis will be covered in more detail in Bacterial
Infections of the Respiratory Tract.

Chronic inflammation is not just associated with bacterial infections.

Chronic inflammation can be an important cause of tissue damage from
viral infections. The extensive scarring observed with hepatitis C infections
and liver cirrhosis is the result of chronic inflammation.

THINK ABOUT IT
  Name the five signs of inflammation.
 Is a granuloma an acute or chronic form of inflammation? Explain.
CHRONIC EDEMA

Figure 3. Elephantiasis (chronic edema) of the legs due to filariasis. (credit: modification of work by Centers
for Disease Control and Prevention)
In addition to granulomas, chronic inflammation can also result in long-term edema.
A condition known as lymphatic filariasis (also known as elephantiasis)
provides an extreme example. Lymphatic filariasis is caused by microscopic
nematodes (parasitic worms) whose larvae are transmitted between human hosts by
mosquitoes. Adult worms live in the lymphatic vessels, where their presence
stimulates infiltration by lymphocytes, plasma cells, eosinophils, and thrombocytes (a
condition known as lymphangitis). Because of the chronic nature of the illness,
granulomas, fibrosis, and blocking of the lymphatic system may eventually occur.
Over time, these blockages may worsen with repeated infections over decades,
leading to skin thickened with edema and fibrosis. Lymph (extracellular tissue fluid)
may spill out of the lymphatic areas and back into tissues, causing extreme swelling
(Figure 3). Secondary bacterial infections commonly follow. Because it is a disease
caused by a parasite, eosinophilia (a dramatic rise in the number of eosinophils in
the blood) is characteristic of acute infection. However, this increase in antiparasite
granulocytes is not sufficient to clear the infection in many cases.
Lymphatic filariasis affects an estimated 120 million people worldwide, mostly
concentrated in Africa and Asia.[1] Improved sanitation and mosquito control can
reduce transmission rates.

Fever
A fever is an inflammatory response that extends beyond the site of
infection and affects the entire body, resulting in an overall increase in body
temperature. Body temperature is normally regulated and maintained by
the hypothalamus, an anatomical section of the brain that functions to
maintain homeostasis in the body. However, certain bacterial or viral
infections can result in the production of pyrogens, chemicals that
effectively alter the “thermostat setting” of the hypothalamus to elevate
body temperature and cause fever. Pyrogens may be exogenous or
endogenous. For example, the endotoxin lipopolysaccharide (LPS),
produced by gram-negative bacteria, is an exogenous pyrogen that may
induce the leukocytes to release endogenous pyrogens such as interleukin-
1 (IL-1), IL-6, interferon-γ (IFN-γ), and tumor necrosis factor (TNF). In a
cascading effect, these molecules can then lead to the release of
prostaglandin E2 (PGE2) from other cells, resetting the hypothalamus to
initiate fever (Figure 4).
Figure 4. The role of the hypothalamus in the inflammatory response. Macrophages
recognize pathogens in an area and release cytokines that trigger inflammation. The
cytokines also send a signal up the vagus nerve to the hypothalamus.

Like other forms of inflammation, a fever enhances the innate immune

defenses by stimulating leukocytes to kill pathogens. The rise in body
temperature also may inhibit the growth of many pathogens since human
pathogens are mesophiles with optimum growth occurring around 35 °C
(95 °F). In addition, some studies suggest that fever may also stimulate
release of iron-sequestering compounds from the liver, thereby starving out
microbes that rely on iron for growth.[2]

During fever, the skin may appear pale due to vasoconstriction of the
blood vessels in the skin, which is mediated by the hypothalamus to divert
blood flow away from extremities, minimizing the loss of heat and raising
the core temperature. The hypothalamus will also stimulate shivering of
muscles, another effective mechanism of generating heat and raising the
core temperature.

The crisis phase occurs when the fever breaks. The hypothalamus
stimulates vasodilation, resulting in a return of blood flow to the skin and a
subsequent release of heat from the body. The hypothalamus also
stimulates sweating, which cools the skin as the sweat evaporates.

Although a low-level fever may help an individual overcome an illness, in

some instances, this immune response can be too strong, causing tissue
and organ damage and, in severe cases, even death. The inflammatory
response to bacterial superantigens is one scenario in which a life-
threatening fever may develop. Superantigens are bacterial or viral proteins
that can cause an excessive activation of T cells from the specific adaptive
immune defense, as well as an excessive release of cytokines that
overstimulates the inflammatory response. For example, Staphylococcus
aureus and Streptococcus pyogenes are capable of producing
superantigens that cause toxic shock syndrome and scarlet fever,
respectively. Both of these conditions can be associated with very high, life-
threatening fevers in excess of 42 °C (108 °F).