Immune Function, Deficiency, and Disorders

Immune Function and Dysfunction

• Immunocompetence refers to the ability of the immune system to respond appropriately to an antigen.
• Immune deficiency is a state in which the immune system's ability to fight infectious disease and cancer is compromised or entirely absent.
• Autoimmune disorders occur when the immune system mistakenly attacks the body's own tissues.

Immune Deficiency Conditions

• Primary immune deficiency is due to an inherited genetic mutation.
• Acquired immune deficiency includes human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS).

Therapeutic Immunosuppression

• Drug-induced immunosuppression needs a delicate balance between immune response control and side effects,
• It is used for organ transplant recipients and management of autoimmune disorders,
• It is also used for non-Hodgkin lymphoma, rheumatoid arthritis, and neoplastic growths.

Diagnostic Tests and Treatment of Immune Deficiencies

• A health history, current complaints or symptoms, and physical examination findings are required for diagnosis.
• Treatments consist of immune globulin (Ig), bone marrow transplant, granulocyte colony-stimulating factor (filgrastim [Neupogen]), and/or antimicrobial agents.

Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS)

• HIV-1 and HIV-2 are retroviruses that cause immunosuppression.
• Pathophysiology includes the processes of retroviruses and reverse transcriptase.

HIV Transmission

• The three highest risks for becoming infected with HIV include unprotected sex (oral, vaginal, or anal) with an HIV-positive person
• The other risks are sharing needles/syringes with an HIV-infected person, and maternal-fetal exposure.

HIV Exposure Prophylaxis

• Pre-exposure prophylaxis (PrEP) includes Truvada (tenofovir disoproxil fumarate and emtricitabine) combined with safer sexual practices.
• Postexposure prophylaxis (PEP) PEP should be initiated less than 72 hours after exposure and is more effective when the exposure is a single episode involving an HIV-positive partner.

HIV Prevention

• Safe sexual practices include barrier protection and touch, as well as various forms of intimacy.
• The current risk of contracting HIV from a blood transfusion, blood products, or a donated organ/tissue is very small, about 1 in 2 million.
• Clinical trials are showing promise for an HIV vaccine, according to a July 2018 report published in "The Lancet".
• Education is key, and it is important to obtain accurate facts and educate others.

HIV Signs and Symptoms

• Individuals can be asymptomatic or have flu-like symptoms.
• Sentinel infections include oral thrush, recurrent infections, skin disorders, night sweats, swollen lymph glands, and significant unintended weight loss.

HIV Diagnosis

• Diagnostic tools include the HIV-1 Test System, OraQuick In-Home HIV test, enzyme-linked immunosorbent assay (ELISA), and HIV-1 nucleic acid (NAT) test.

Management of HIV Infection

• Initiate antiretroviral therapy (ART) if CD4 lymphocyte count is less than 350 cell/mm³.
• The World Health Organization (WHO) uses staging to manage HIV.
• Antiretroviral drugs are one method of management.

HIV Stages

• First stage (Acute HIV infection) develops within 2 to 4 weeks with flu-like symptoms, a high HIV level, and negative antibody testing for approximately 1 1/2 months, and the person can transmit it to others.
• Second stage (Chronic HIV infection) is asymptomatic and can be transmitted to others; without treatment, it usually advances to AIDS.
• Third stage (AIDS: Terminal stage) severely damages the immune system, results in opportunistic infections and cancer, and has a life expectancy of about 3 years without treatment.

Opportunistic Infections

• Viral infections commonly seen are herpes simplex virus types 1 and 2, varicella-zoster virus, cytomegalovirus, and hepatitis.
• Bacterial infections include Mycobacterium tuberculosis and Mycobacterium avium complex.
• Fungal infections: cryptococcosis, histoplasmosis, coccidiomycosis, candidiasis, and pneumocystis jiroveci.
• Parasitic infections: toxoplasmosis and cryptosporidiosis.

Other Complications of HIV

• Wasting syndrome.
• Neoplasms consist of Kaposi sarcoma and lymphomas.
• Neurologic complications.

Other Health Issues

• Consider HIV risk in the over 50 population.
• Community education and care are important.
• Maintain HIV confidentiality and disclosure.
• Understand considerations when a nurse is HIV positive.
• Understand bloodborne pathogen exposure and health care workers.

Autoimmune and Autoinflammatory Disorders

• The immune system reacts against the body’s own cells.
• This can be local, systemic, and mixed.
• General signs and symptoms include fever, fatigue, abdominal pain or digestive issues, swollen glands, joint pain, and swelling.
• Diagnosis includes health history, complete physical examination, and blood tests.
• Treatment and nursing management include replacement or support of lost body function, and therapies targeted to halt destructive processes.

Systemic Lupus Erythematosus (SLE)

• It is an autoimmune disease where the body produces abnormal antibodies that attack the target tissues instead of foreign agents.
• Forms of SLE consist of discoid, systemic, and drug-induced.
• SLE is caused by an abnormal reaction against proteins found in the nucleus of body cells.
• Prolonged exposure to sunlight and drugs can exacerbate SLE.
• Symptoms: painful or swollen joints and muscle pain, extreme fatigue, unexplained fever, red rash (malar/butterfly rash), hair loss, sensitivity to the sun, weakness/profound fatigue, mouth ulcers, poor appetite, weight loss, abnormal menses, and edema/swollen glands.
• Diagnosing SLE requires at least 4 of the 11 clinical presentations or laboratory test results.
• There is no cure, but treatment focuses on symptom control/management to prevent exacerbations.
• Nursing care should focus on patients with a low immune response.
• Assess the ability for patients to participate in ADLs.
• Provide pain management, and assistance with mobility.
• The nurse should educate the patient about the disease and review appropriate skin care.

Hodgkin Lymphoma

• Etiology consists of a genetic, environmental, or combination of factors.
• Pathophysiology consists of Reed-Sternberg cells.
• Symptoms: lymphadenopathy, abdominal fullness, fatigue, night sweats, weight loss, and pruritus.
• Nursing care focuses on symptoms a patient is currently experiencing and the side effects of prescribed therapies.
• Diagnosis, treatment, and nursing management are impacted by the presence of R-S cells, which is a definitive diagnosis.
• Treatment depends on the stage; chemotherapy can be given in all stages.
• Radiation therapy.
• Remission is present when the disease is under control.

Non-Hodgkin’s Lymphoma (NHL)

• NHL is the seventh most common cancer in men and women and incidence is higher in men.
• It is less predictable and spreads to other body sites much more rapidly than HL.
• A sign is unilateral, painless enlargement of a lymph node that may progress to generalized, painless lymphadenopathy.
• Other symptoms: high fevers, chills, night sweats, weight loss, cough, dyspnea, chest pain, nausea, vomiting, a sense of fullness in the abdomen, and constipation, and hepatomegaly or splenomegaly.
• To aid in diagnosis and staging, CT, magnetic resonance imaging (MRI), PET, or ultrasound can be used.

Primary Lymphedema

• Is an inherited condition caused by a congenital issue with deficient growth of the lymphatic system (in a lower extremity, especially).
• It chiefly affects females and often becomes apparent during the middle teens to early 20s.

Secondary Lymphedema

• Is an acquired condition caused by an obstruction of the lymph vessels and nodes after trauma.
• It may be caused by mastectomy with lymph nodes removed, extensive soft-tissue injury, and/or scar formation.
• Parasites can enter and block lymph channels.
• Patients present with symptoms: restricted range of motion, heavy feeling, aching discomfort, recurrent infections, and thick, hard skin.
• Regardless of the etiology, treatment goals are to minimize the impact of the disease process on the individual.

Fibromyalgia

• Is characterized by chronic systemic pain and multiple symptoms not caused by another source or disease.
• It affects women 10 times more than men and is commonly seen in women 25-60 years of age.
• Stressors, like infection, trauma, drugs, hormonal influences, and psychological distress can trigger fibromyalgia symptoms.
• The most common feature is musculoskeletal pain along with hyperalgesia and allodynia.

Allergy

• Allergy is an abnormal response to certain substances and is a systemic immune disorder.
• Hypersensitivity reaction is the body’s excessive response to a normally harmless substance.
• Allergens can enter the body in several ways and have either a local or a systemic effect.
• Manifestations include itchy, red, watery eyes, soft palate pruritus, clear rhinorrhea, sneezing, erythema, edema and dyspnea and wheezing.
• Diagnosis is determined from a patient history of reactions.
• Other methods consists of the radioallergosorbent test (RAST), a skin scratch test, or a patch test.
• Anaphylactic reactions may be IgE-mediated immune responses.
• Non-IgE allergen responses include iodine-based dyes for select radiologic studies.
• Some narcotics can cause this as well such as morphine and vancomycin in particular, especially if administered too rapidly.

Anaphylactic Reaction and Anaphylactic Shock

• Symptoms: urticaria (hives), angioedema, wheals, tachycardia, decreased pulses, rapid drop in blood pressure, dyspnea, accumulation of mucus, and wheezing.
• Treatment of anaphylaxis involves five steps.
• Establish a patent airway.
• Administer oxygen.
• Administer intravenous epinephrine.
• Administer antihistamine.
• Institute supportive measures.