immunopathologies

types of immune system diseases / disorders

1. immunodeficiency diseases

2. hypersensitivity disorders

3. autoimmune diseases

4. multisystem diseases

5. isoimmune diseases

immunodeficiency diseases

cannot mount an immune response to take care of an issue

general categories

-primary immunodeficiency

-secondary immunodeficiency

ex: hiv / aids

hypersensitivity disorders

too much of a response

-allergy

-asthma

autoimmune diseases

body starts to attack itself, MHC not functioning properly

-systemic lupus erythematosus (SLE)

-fibromyalgia

-rheumatoid arthritis

multisystem diseases

components of each type

ex: myalgic encephalomyelitis / chronic fatigue syndrome

isoimmune diseases

ex: organ transplants, bone marrow transplants

iatrogenic immunodeficiency

hospital / care provider induced

(secondary immunodeficiency)

-immunosuppressive drugs, radiation therapy, splenectomy, cytotoxic drugs

acquired immunodeficiency syndrome (AIDS)

primary immunodeficiency

potential progressive loss of immune function

increased host susceptibility

******HIV DOES NOT = AIDS******

incidence and prevalance of HIV

1.2 million people living with HIV in the US end of 2021

new infections in US 36,136 in 2021 (7% decrease since 2017)

MSM: 24,107 new infections per year

etiology of HIV

retrovirus

HIV type 1 and type 2

retrovirus

virus gets into cell DNA and uses the DNA to replicate itself

transmission of HIV

exchange of bodily fluids (blood and semen)

direct contact

NOT casual or social contact (not transmitted by sneezing / a surface)

what is the average time between exposure and diagnosis of AIDS

8-10 years

which cells in the immune system should function to kill the HIV virus

T cells

risk factors for HIV

unprotected oral and anal sex

vaginal sex with infected partner

having 6 or more sexual partners in past year

exchanging sex for money or drugs

injecting drugs

pathogenesis of HIV

retrovirus that predominantly infects human T4 lymphocytes (CD4)

3 primary impacts of HIV on immune system

1. immunodeficiency with opportunistic infections and unusual malignancies

2. autoimmunity

3. neurologic dysfunction

****not seen until viral load is very high

CD4 count during asymptomatic stage of HIV

500 cells / mm3

no restriction on activities because no symptoms

CD4 count during early symptomatic to advance disease stages of HIV

200-500 cells / mm3

increasingly more compromised

restriction on activity based on symptoms, still benefit from exercise to boost immune system

CD4 count during advanced stage of HIV

200 cells / mm3 or less

neurologic symptoms and increasing opportunistic infections

what is treatment focused on in the advanced stage of HIV

pain management

what opportunistic infections are possible in the advanced stage of HIV

cytomegalovirus (retinitis / blindess)

pneumocystis pneumonia (fungal infection of lung)

kaposi sarcoma

malignant cancer of blood vessels

red and puffy

not contagious

*****often associated with CD4 counts

central and peripheral nervous system signs associated with CD4 counts

cognition, memory, weakness

burning, tingling, sensory loss, weakness

ability to perform ADLs decreases

medical management of HIV

PREVENTION

-pre exposure prophylaxis (PrEP)

-post exposure prophylaxis (PEP)

TREATMENT

-Treatment as prevention (TasP)

-antiviral therapy (ART): regular use of condoms, use of antiviral meds for rest of their life to reduce viral loads

pre exposure prophylaxis (PrEP)

given to someone with high risk factors

has to be used everyday

expensive

have to visit physician often

post exposure prophylaxis (PEP)

most effective if taken within 72 hours

take for 28 days

diagnosis of AIDS

blood tests

-quick screen: looks for virus

-definitive testing: looks for antibodies and CD4 cell counts

prognosis of HIV

mortality rate has been decreased by 80%

mortality

death rate

morbidity

impact on person

does not necessarily kill person

newer campaign of medical management for HIV

U= undetectable = untransmissable (as long as ART is continued, do not need condoms)

implications for PT for HIV

protect person with HIV

-patient : need to know CD4 count to know risk

prevent spread of infection

-standard precautions (unless coming in contact with blood)

-consider transmission

exercise and activity

-consider limitations based on stage

etiology of allergy

allergen/antigen causes immune response

type I: common form CAN RESULT IN ANAPHYLACTIC SHOCK

type II: autoimmune component

type III: immune complex reaction

type IV: mediated by T cells

pathogenesis of allergy

overactive immune system

*anaphylaxis definition

systemic release of histamine

-systemic vasodilation (may appear red)

-bronchospasm

-increased mucus secretion

-edema (local or systemic)

*initial symptoms of anaphylaxis

itching, edema, sneezing

*progressive symptoms of anaphylaxis

wheezing

dyspnea: difficulty breathing

cyanosis: turning blue

circulatory shock

****which symptoms raise your level of worry to anaphylaxis

dyspnea (all of a sudden)

cyanosis

****other progression symptoms

initial symptoms starting suddenly

known contact with allergen

type I allergy

immediate

-wheezing

-hypotension

-swelling

-anaphylaxis possible

type II allergy (autoimmune)

multiple body systems

malaise

weakness

cardiovascular

upper/lower respiratory

GI

CNS

type III (immune complex)

headache/backache/chest pain

nausea & vomiting

tachycardia / hypotension

hematuria

urticaria

type IV (t cell mediated)

fever

arthralgias

lymphadenopathy

urticaria (rash)

anemia

allergy prevention

avoid stimulus

carry epi-pen

suppress immune system prophylactically (steroids)

allergy treatment

suppress immune system response

emergency management with anaphylaxis

allergy implications for the PT

****know signs of anaphylaxis

potential for reaction to products used in PT

may not see a reaction on first exposure

asthma

chronic disease involving inflammation of the bronchioles

triggered by allergen or other stimulus

what are the several types of asthma

exercised induced bronchoconstriction

allergic asthma response to allergen

occupational allergen

childhood asthma

2 kinds of medical management for asthma

relievers

preventors

relievers (asthma)

quick relief

taken after onset

before exercise

rescue medications often bronchodilators

inhaler or nebulizer

preventors (asthma)

long term controllers

taken daily

inhaled corticosteroids common

what are some important questions to ask a patient with a comorbidity of asthma

ask if they take a reliever or a preventer

ask if it is taken daily

long term management of asthma

avoid triggers

medications

knowing when to use meds and when to seek help

asthma implications for PT

know patient’s ability to manage it

encourage preventative reliever prior to exercise

single organ autoimmune disorders

thyroiditis

addison’s disease

graves disease

chronic active hepatitis

pernicious anemia

ulcerative colitis

insulin-dependent diabetes

systemic autoimmune disorders

fibromyalgia

rheumatoid arthritis

SLE

treatments of autoimmune disorders

“healthy” suppression of immune response

corticosteroids

salicylates

systemic lupus erythematosus (SLE) (Lupus)

systemic autoimmune disorder

can change over time

incidence of systemic lupus erythmatosus

most common in young women but can occur infancy to old age

etiology of systemic lupus erythmatosus

combo of immunologic, environmental, hormonal and genetic factors

risk factors of systemic lupus erythmatosus

appears to be a hereditary predisposition

physical or mental stress

streptococcal or viral infection

exposure to UV / sunlight

immunization

pregnancy

pathogenesis of systemic lupus erythmatosus

immune disregulation

early symptoms of SLE

fever, malaise, weight loss, fatigue

****hallmark: butterfly rash (only in about 50% of cases)

what is hallmark of systemic lupus erythmatosus

butterfly rash

medical management of SLE

clinical signs: synovitis or tenderness in at least 2 joints

30 minutes of morning stiffness

antinuclear antibody presence

antinuclear antibody presence in SLE

most people who have lupus have positive ANA test

*BUT you can have a positive ANA test without having lupus

test is sensitive but not specific

treatment of SLE

reverse autoimmune and inflammatory process

prevent exacerbations and complications

non-steroidal anti-inflammatory drugs (NSAIDs): relieve muscle and joint pain and inflammation

prognosis for SLE

better with early detection

poor when associated with cardiovascular, renal, neuro, or severe bacterial infections

SLE implications for PT

may treat arthritis symptoms, fatigue, generalized deconditioning

red flags related to SLE

pain in one joint (septic arthritis)

sudden onset pain with weight bearing (avascular necrosis)

constant pain

signs of renal failure

fibromyalgia

possible systemic autoimmune disorder

“migraine of the muscles”

diffuse pain, multiple tender points

no known cause or cure

incidence of fibromyalgia

more common in females

ages 20-55 years

etiology of fibromyalgia

possible genetic link

risk factors for fibromyalgia

prolonged anxiety and emotional stress or trauma

rapid steroid withdrawal

hyperthyroidism

viral and non viral infections

pathogenesis / hallmarks of fibromyalgia

increased activity (exercise level responses) of skeletal muscles, heart, stomach, intestines, blood vessels, and sweat glands during daily activities

increased substance P

decreased pain inhibiting neurotransmitters

diagnosis of fibromyalgia

*takes a long time

clinical manifestations

must rule out other medical causes

increased substance P

clinical manifestations of fibromyalgia

migraine of muscles, tender but not inflamed

diffuse pain / multiple tender points (11/18 tender points with 4kg of pressure bilaterally)

sleep disturbances with exhaustion, fatigue not relieved by rest

visual disturbances, morning stiffness >30min, anxiety/depression, headache, IBS, TMJ pain, swelling in feet

treatment for fibromyalgia

stress management

cognitive behavioral therapy

nutrition

support (support groups, etc)

meds for symptom management

prognosis for fibromyalgia

life long symptoms

mild: may manage without intervention

moderate or severe: early treatment improves outcomes

fibromyalgia implications for the PT

lessen pain and fatigue

exercise when tolerated

aquatic therapy

aerobic fitness

education and support

stress management

work simplification

psychotherapy

myalgic encephalomyelitis / chronic fatigue syndrome

multisystem condition

immunodeficiency

incidence of myalgic encephalomyelitis / chronic fatigue syndrome

75% women, middle class, white

onset 40-50 years old

etiology of myalgic encephalomyelitis / chronic fatigue syndrome

unsure exactly what causes it

viruses, bacteria, toxins, mold, genetics

may have increase epstein barr virus levels

immune system biomarkers of myalgic encephalomyelitis / chronic fatigue syndrome

low natural killer cell function

abnormal increase in pro inflammatory cytokines

nervous system biomarkers of myalgic encephalomyelitis / chronic fatigue syndrome

reduced white and gray matter in the brain (can cause headaches, mild memory impairment, sensitive to light)

reduced blood flow to brain

neuroinflammation

endocrine system biomarkers of myalgic encephalomyelitis / chronic fatigue syndrome

dysfunctional communication between endocrine glands (flight vs fight)

decreased cortisol and dysfunction of other hormones

low growth hormone (associated with sleep disturbance)

what disease is associated with mitochondrial impairment

myalgic encephalomyelitis / chronic fatigue syndrome

mitochondrial impairment (myalgic encephalomyelitis / chronic fatigue syndrome)

leads to reliance on anaerobic metabolism for energy

abnormal fatigability

may be associated with viral infection

will impact cardiac function

will impact blood flow to brain

high lactate levels (causes pain in muscle)

five cardinal symptoms of myalgic encephalomyelitis / chronic fatigue syndrome

1. fatigue: profound energy loss, not relieved by rest (limits ADLs, may end up bedridden)

2. post-exertional malaise: onset 12-24 hrs after exertion, extended recovery, can be tested with 2 day consecutive cardiopulmonary exercise test (CPET)

3. cognitive impairment: brain fog, impaired attention / decision making

4. pain: not always present, may include hypersensitivity to heat, cold, touch, etc

5. sleep disorder: hypersomnia, insomnia, etc

what is the hallmark for myalgic encephalomyelitis / chronic fatigue syndrome

sudden onset of symptoms is most common and a hallmark that distinguishes it from other diseases

****disabling fatigue and post-exertional malaise unrelieved by rest

diagnosis of myalgic encephalomyelitis / chronic fatigue syndrome

signs: BP often low, orthostatic

fluctuating temp throughout day

tachycardia

irritated throat

screening tests, exclusionary tests, confirmatory tests (2 day CPET, low NK cells)

treatment for myalgic encephalomyelitis / chronic fatigue syndrome

herbal remedies

pharmaceutical managements

nutritional supplements

massage, chiropractic, PT, biofeedback

cognitive behavior therapy

prognosis for myalgic encephalomyelitis / chronic fatigue syndrome

varies from minimal impact to severely debilitated

8-63% show improvement

5-10% total remission

an individual with HIV is referred to PT for evaluation and treatment. what are some key questions you need / want to know

what differentiates myalgic encephalomyelitis / chronic fatigue syndrome from fibromyalgia? how do patients with these present similarly?