Chronic recurrent infections and immunopathy

308
Review Article
Chronic recurrent infections and
immunopathy
A. Miller
Fachärztin für Dermatologie und Venerologie Allergologie – Phlebologie/Lymphologie, die hautexperten, Berlin,
Germany
Keywords
Schlüsselwörter
Lymphatic system, infection, immunopathology, lymhoedema
Lymphgefäßsystem, Infektion, Immunopathie, Lymphödem
Summary
Zusammenfassung
In the immune system the lymphatic system
has a central function. Starting with absorption and transport of the antigen to the lymphatic nodes it initiates the production of
antibodies. Many substances like fat, proteins and cell detritus can only be absorbed
and transported by the lymphatic system. A
defect of this systems reduces defence and
increase the risk of infection. Any inflammation includes and intensifies lymphoedema. Therefore early and sufficient therapy is
important.
Das Lymphgefäßsystem hat eine zentrale
Funktion im Immunsystem des Menschen.
Nach Antigenaufnahme und Transport zu
dem Lymphknoten wird die Antikörperproduktion initiiert. Viele Substanzen, wie Fette,
Proteine und Zellbestanteile werden ausschließlich über das Lymphgefäßsystem aufgenommen und transportiert. Ein Defekt dieses Systems für zu einer Reduktion der Abwehr und erhöht das Risiko für Infektionen.
Mit jeder Entzündung wird auch ein Lymphödem induziert oder verstärkt. Eine frühzeitige und ausreichende Therapie ist deshalb
wichtig.
Correspondence to
Dr. Anya Miller
die hautexperten
Wilmersdorfer Straße 62, 10627 Berlin, Germany
Tel. +49-30/31997836
E-mail: [email protected]
Chronisch rezidivierende Infektionen und Immunopathien
Phlebologie 2016; 45: 308–309
http://dx.doi.org/10.12687/phleb2334-5-2016
Received: August 10, 2016
Accepted: August 16, 2016
The human lymphatic system, with its network of vessels and 600–700 lymph nodes,
plays an important role in the body’s defence system and immunological interaction with foreign matter.
The microfiltrate in the capillaries is almost completely reabsorbed by the lymphatic system (1) and partially transported
to the veins via the lymph nodes. Proteins,
fats, cells, chemical, organic and non-organic cell products, cell residues and, in
particular, bacteria and viruses are disposed of exclusively by the lymphatic system.
Penetration of the skin barrier by
microorganisms triggers, on the one hand,
an unspecific defence through phagocytosis by neutrophilic granulocytes and activation of the complement cascade and, on
the other, phagocytosis by Langerhans
cells. These are transported to the lymph
nodes via the lymphatic collectors. On the
way, the Langerhans cells mature to highly
efficient antigen-presenting cells (APC). In
the process, their phagocytic ability is lost
in favour of the synthesis of major histocompatibility complex (MHC) molecules.
In the lymph nodes, they encounter T cells
and if a naive or memory T cell with their
T cell receptor matches the presented
antigen peptide receptor, an immunological synapse occurs and a specific (acquired)
immune response is initiated. This ultimately results in the production of more T
effector cells. These can specifically destroy
infected cells (2).
In diseases of the lymphatic system, this
defence mechanism is markedly reduced. If
initial lymphatic vessels and lymph collectors are aplastic, neither the absorption nor
the transport and maturation of the Langerhans cells can function. Fibrosis as a result of chronic oedema is another condition in which absorption is impaired. Infections are therefore the most common
complications of lymphatic malformations
(3). Whilst the frequency of erysipelas in
the healthy population is quoted as
0.001 %, in Stage III lymphoedema it is
50–70 % (4).
Infection by bacterial pathogens leads to
the release of TNF-a and interleukin-1b
from macrophages, which causes vasodilation and extravasation of plasma into the
tissues and, as a result, an oedema.
Group A streptococci in erysipelas induce a cleavage of bradykinin precursors
that cause activation of the epithelial complement system and likewise increase vascular permeability (5). This oedema is generally accompanied by fever and pain. In
addition, the propulsive muscles of the
lymphatic collectors are paralysed by prostaglandins, nitric oxide and histamine. The
result is an intrinsic pump failure of the
lymphatic vessels and further oedema.
The resulting fibrosis of the tissue seen
with every erysipelas causes the already
impaired lymphatic drainage to deteriorate. However, contact of the immune system in the lymph nodes with the antigen is
essential for an adequate immune response. Lymph nodes situated above zones
of prolonged congestion become atrophied
and, with it, reduce the ability of the body
to defend itself. Erysipelas can be the first
clinical manifestation of a pre-existing im-
© Schattauer 2016
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309
A. Miller: Chronic recurrent infections and immune disorders
pairment of lymphatic drainage. Erysipelas
must be treated at an early stage. The basic
treatment is systemic antibiotics (6),
whereby penicillin is still first-line therapy
(e.g. penicillin G 3 mill. IU daily for 14
days). Alternatively, erythromycin, other
macrolide antibiotics, clindamycin or amoxicillin can be given. Depending on the
response to antibiotics, complex physical
therapy (CPT), especially manual lymphatic drainage (MLD) and compression
should generally be resumed after two
days. Skin changes should be appropriately
treated and the limb should generally be
elevated and cooled.
Recurrent erysipelas requires prophylaxis with azithromycin (3 days/month).
Alternatively, penicillin IV for 10 days
every 3 months or IM 2.4 mega units every
2 weeks (caution: injection site abscess).
Careful skin care, e.g. with urea-containing external preparations (urea 10 %),
is needed to avoid infections. Attention
should also be paid to prevent the
formation of moist pockets in the folds of
skin dressings and, if appropriate, consider
long-term local antifungal treatment. Any
trauma to the skin should be immediately
and adequately disinfected.
In addition to the prophylaxis of local
infections, thorough and consistent complex physical therapy is an important support for the immune system in patients
with chronic lymphoedema.
Conflict of interests
The author declares that there is no conflict
of interests.
Ethical guidelines
References
1. Levick JR, Michel CC. Microvascular fluid exchange and the revised Starling principle. Cardiovascular Research 2010; 87(2); 198–210.
doi:10.1093/cvr/cvq062
2. Schmolke K. Immunabwehr im Lymphsystem der
Haut. Phlebologie 2015; 44 (3): 118–120.
3. Wojcicki P, Woicicka K. Epidemiology, Diagnostics and Treatment of Vascular Tumors and
Malformations. Adv Clin Exp Med 2014, 23:
475–484.
4. Chakraborty S, Gurusamy M, Zawieja DC, Muthuchamy M, Lymphatic filariasis: perspectives on
lymphatic remodeling and contractile dysfunktion
in filarial disease pathogenesis. Microcirculation
2013; 20: 349–364.
5. Schmolke .: Erysipel und Immunsystem. LymphForsch 2010; 14 (2): 65–68.
6. Heine-Varias U, Miller A. In: Leitfaden Lymphologie. Hrsg. von Gültig O, Miller A, Zötzer T.
München: Elsevier/Urban & Fischer 2015;
169–176.
No studies in humans or animals were
undertaken for this manuscript.
Phlebologie 5/2016
© Schattauer 2016
Downloaded from www.phlebologieonline.de on 2017-06-03 | IP: 88.99.70.242
For personal or educational use only. No other uses without permission. All rights reserved.