Nairn: Immunology for Medical Students, 2nd Edition
Test Bank by Rohit Divekar, MD
MULTIPLE CHOICE
1. A 46-year-old man complaining of an upper respiratory tract infection attends the
outpatient clinic for treatment. After assessment of the patient’s condition the doctor
prescribes him some antibiotics. After 4 days of treatment, the patient notices that
whenever he goes outside the house and it’s very cold, his hands turn blue and white. He
says that he has never had this problem before. If the attending physician suspects that the
person has developed Raynaud’s phenomenon secondary to the drug administration, what
kind of antibodies would be present in this patient causing the symptoms?
a. IgG
b. IgM
c. IgA
d. IgD
e. IgE
ANS: B
Drug-induced Raynaud’s phenomenon is due to cryoglobulins. Cryoglobulins are IgM
antibodies that react at lower temperatures such as those that might be expected when it’s
cold outside (choice b). Cryoglobulins are also formed in many nonspecific viral illnesses
and in mycoplasma infections. IgG antibodies (choice a) are warm agglutinins and will
react at only warm temperatures; hence, they would not be responsible for this kind of
picture. IgA (choice c) is a secreted antibody and is not responsible for cold agglutinin
reaction. IgD (choice d) is membrane-bound antibody seen on B cells; the function of
IgD is not yet clear. IgE (choice e) is important for immunity to parasites and also is the
cause of anaphylactic and type I hypersensitivity reactions.
2. A center for autoimmune diseases in a metropolitan area deals with all kinds of
autoimmune conditions. The research wing of this institution is divided into cell-
mediated autoimmune diseases and antibody-dependent autoimmune diseases. The
research personnel receive their human tissue samples and research material from the
patients admitted to the hospital. There are blood samples of five patients listed below
that need to go to their respective research laboratories.
Which of the patient samples would go to the division of antibody-mediated autoimmune
diseases?
a. Patient A = autoimmune myocarditis
b. Patient B = type 1 diabetes
c. Patient C = insulin-resistant diabetes
d. Patient D = multiple sclerosis
e. Patient E = T-cell–mediated peripheral neuritis
ANS: C
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
,Test Bank by Rohit Divekar, MD 2
Immune diseases can be basically divided in these groups: T cell mediated autoimmune
diseases, immune complex-mediated autoimmune diseases, and antibody-dependent
immune conditions. Autoimmune carditis (choice a) is a result of T cells sensitized to
myosin antigen, and both multiple sclerosis (choice d) and type 1 diabetes (choice b) are
classically CD4 T-cell-mediated autoimmune diseases. T-cell-mediated peripheral neuritis
(e.g., Guillain-Barré syndrome) is again not antibody mediated though there might be an
elevation of immunoglobulin titer. Insulin resistance (choice c) on the other hand is due
to preformed antibodies that react with the insulin receptor and prevent the binding of
insulin to the receptor, reducing the efficacy of insulin, leading to diabetes. Thus, this is
clearly an example of antibody-dependent disease.
3. Experimental autoimmune encephalomyelitis (EAE) is the animal model of human
multiple sclerosis (MS). Injecting myelin antigen along with a strong adjuvant like CFA
can induce the disease in these mice. CFA contains a suspension of mineral oil and killed
mycobacteria. What is the purpose of adding the killed bacteria to the emulsion?
a. Products of killed bacteria retain the antigen better.
b. Killed bacteria stimulate B cells to stimulate antibody.
c. Inflammation produced by bacteria aids in EAE.
d. Bacterial products migrate to the brain producing severe disease.
e. Killed bacteria stimulate antigen-presenting cells.
ANS: E
The entire concept of adjuvant in immunization is related to retention of antigen at the
site long enough so that it will be delivered effectively to the T cells. This is achieved by
the emulsion that is formed because of the mineral oil (choice a). Mycobacteria are added
to the adjuvant to initiate an inflammatory condition that will stimulate the antigen-
presenting cells (APCs), so when they present the antigen, the cells will recognize the
antigen in the presence of the up-regulated co-stimulatory molecules. Bacterial
inflammation has no direct role to play in induction of EAE (choice c), nor do the
antibodies induced by the bacterial products enhance the disease (choice b). In addition,
because the bacterial products are injected with the mineral oil they will be retained at the
site of injections along with the antigen rather than being circulated to the brain; hence,
choice d is wrong.
4. A 6-year-old child complains of sudden onset of breathlessness and becomes very ill.
She is rushed to the emergency department, where the intern attending this patient does a
complete physical examination to evaluate the cause. Patient appears very anxious, is
hyperventilating, and complains of a dull pain substernally. Pulse = 110 beats per minute,
BP = 124/84 mm Hg, and upon auscultation there is a distinct pericardial friction rub.
Upon specific questioning, the parent of the child gives a history of an upper respiratory
illness preceding this episode. If the physician considers the possibility of acute viral
myocarditis, which cell is most likely responsible for the pathogenesis?
a. CD4 T cell
b. CD8 T cell
c. Myofibroblast
d. Plasma cells
e. Mast cell
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
,Test Bank by Rohit Divekar, MD 3
ANS: B
CD4 T cells perform the function of regulating and orchestrating the immune system;
they are responsible for production of cytokines. Depending on the nature of the
inflammation, these cytokines are meant to activate specific cells of the immune system
to carry out their functions. CD4 T cells that secrete IL-12 and IFN-gamma are called TH1
cells, and those that produce IL-4, IL-5, and IL-13 are called TH2 cells. CD8 T cells, on
the other hand, are responsible for cytotoxic effector functions that get rid of tumor cells
and virally infected cells. Myofibroblasts are mesenchymal cells that line the wound
during the process of repair; they are modified fibroblasts that have the capacity to
contract. They are responsible for wound contraction. Plasma cells are mature and
differentiated B cells that produce antibody. They are important in antibody-mediated
immune responses. Mast cells are cells of the innate immune system that secrete a variety
of immunomodulatory proteins. Degranulation of mast cells causes release of
proinflammatory products, notably histamine.
5. Neutrophils are isolated from the peripheral blood of a patient suffering from an
immunodeficiency disease. This individual has a recurrent history of severe infections.
Upon analysis it is found that the neutrophils are able to ingest gram-negative organisms
but are unable to kill them. The nitro blue tetrazolium test (NBT), however, is positive.
Which of the following is most likely responsible?
a. Neutrophil elastase
b. NADPH oxidase
c. Nitric oxide synthase
d. Toll-like receptors (TLRs)
e. Perforin
ANS: A
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
, Test Bank by Rohit Divekar, MD 4
One of the mechanisms of microbicidal killing is phagocytosis. The ingested bacteria are
held in a phagosome that fuses with the lysosome, which contains proteolytic enzymes
and a variety of bactericidal molecules. Neutrophil lysosomes are particularly rich in the
enzyme neutrophil elastase (choice a), whose primary targets are probably bacterial
proteins. Incidentally, neutrophil elastase is also implicated in lung damage in patients
who lack the protein to inactivate this elastase, alpha-1 antitrypsin. NK cells such as the
cytotoxic T lymphocytes contain a protein known as perforin (choice e). This protein,
similar in function to the membrane attack complex of the complement pathway, is
inserted into the cell membrane, where it creates pores or channels through which
cytoplasmic content can leak out. It also allows for enzymes produced by these cells,
called granzymes, to get inside and activate the apoptosis pathway. The other mechanism
of bacterial killing is production of reactive oxygen metabolites following a “respiratory
burst.” The principal enzyme involved in generation of these free radical oxy-halide
molecules (e.g., HOCl) is NADPH oxidase (choice b). Deficiency of NADPH oxidase is
one of the causes of chronic granulomatous disease (CGD), in which the neutrophils
ingest bacteria but are unable to kill them because of defective free radical production.
Cells that lack the ability to generate free oxygen radicals give a negative NBT test. A
second method of generating free radicals is by using the nitric oxide synthase enzyme
(choice c). This enzyme is absent from macrophages and neutrophils but is rapidly
induced upon exposure of these cells to bacterial products such as LPS along with IFN-
gamma. The inducible nitric oxide system along with the reactive oxygen system work
together for efficient killing of pathogens. Toll-like receptors (choice d) belong to a
family of innate receptors that are involved in pattern recognition. They don’t have
pathogen-specific recognition motifs but can recognize patterns of molecular structure in
bacteria. For example, TLR 4 can recognize LPS produced by a variety of bacteria, and
TLR 5 bind to bacterial flagellin. TLRs are abundant on macrophages and dendritic cells
and are responsible for activation of these cells upon exposure to bacterial products.
6. Neutrophils are isolated from the peripheral blood of a patient suffering from an
immunodeficiency disease. This individual has a recurrent history of severe infections.
Upon analysis it is found that the neutrophils are able to ingest organisms but are unable
to kill them. The nitro blue tetrazolium test (NBT), however, is negative. A defect in
which of the following is most likely to be responsible for this presentation?
a. Neutrophil elastase
b. NADPH oxidase
c. Nitric oxide synthase
d. Toll-like receptors (TLRs)
e. Perforin
ANS: B
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank by Rohit Divekar, MD
MULTIPLE CHOICE
1. A 46-year-old man complaining of an upper respiratory tract infection attends the
outpatient clinic for treatment. After assessment of the patient’s condition the doctor
prescribes him some antibiotics. After 4 days of treatment, the patient notices that
whenever he goes outside the house and it’s very cold, his hands turn blue and white. He
says that he has never had this problem before. If the attending physician suspects that the
person has developed Raynaud’s phenomenon secondary to the drug administration, what
kind of antibodies would be present in this patient causing the symptoms?
a. IgG
b. IgM
c. IgA
d. IgD
e. IgE
ANS: B
Drug-induced Raynaud’s phenomenon is due to cryoglobulins. Cryoglobulins are IgM
antibodies that react at lower temperatures such as those that might be expected when it’s
cold outside (choice b). Cryoglobulins are also formed in many nonspecific viral illnesses
and in mycoplasma infections. IgG antibodies (choice a) are warm agglutinins and will
react at only warm temperatures; hence, they would not be responsible for this kind of
picture. IgA (choice c) is a secreted antibody and is not responsible for cold agglutinin
reaction. IgD (choice d) is membrane-bound antibody seen on B cells; the function of
IgD is not yet clear. IgE (choice e) is important for immunity to parasites and also is the
cause of anaphylactic and type I hypersensitivity reactions.
2. A center for autoimmune diseases in a metropolitan area deals with all kinds of
autoimmune conditions. The research wing of this institution is divided into cell-
mediated autoimmune diseases and antibody-dependent autoimmune diseases. The
research personnel receive their human tissue samples and research material from the
patients admitted to the hospital. There are blood samples of five patients listed below
that need to go to their respective research laboratories.
Which of the patient samples would go to the division of antibody-mediated autoimmune
diseases?
a. Patient A = autoimmune myocarditis
b. Patient B = type 1 diabetes
c. Patient C = insulin-resistant diabetes
d. Patient D = multiple sclerosis
e. Patient E = T-cell–mediated peripheral neuritis
ANS: C
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
,Test Bank by Rohit Divekar, MD 2
Immune diseases can be basically divided in these groups: T cell mediated autoimmune
diseases, immune complex-mediated autoimmune diseases, and antibody-dependent
immune conditions. Autoimmune carditis (choice a) is a result of T cells sensitized to
myosin antigen, and both multiple sclerosis (choice d) and type 1 diabetes (choice b) are
classically CD4 T-cell-mediated autoimmune diseases. T-cell-mediated peripheral neuritis
(e.g., Guillain-Barré syndrome) is again not antibody mediated though there might be an
elevation of immunoglobulin titer. Insulin resistance (choice c) on the other hand is due
to preformed antibodies that react with the insulin receptor and prevent the binding of
insulin to the receptor, reducing the efficacy of insulin, leading to diabetes. Thus, this is
clearly an example of antibody-dependent disease.
3. Experimental autoimmune encephalomyelitis (EAE) is the animal model of human
multiple sclerosis (MS). Injecting myelin antigen along with a strong adjuvant like CFA
can induce the disease in these mice. CFA contains a suspension of mineral oil and killed
mycobacteria. What is the purpose of adding the killed bacteria to the emulsion?
a. Products of killed bacteria retain the antigen better.
b. Killed bacteria stimulate B cells to stimulate antibody.
c. Inflammation produced by bacteria aids in EAE.
d. Bacterial products migrate to the brain producing severe disease.
e. Killed bacteria stimulate antigen-presenting cells.
ANS: E
The entire concept of adjuvant in immunization is related to retention of antigen at the
site long enough so that it will be delivered effectively to the T cells. This is achieved by
the emulsion that is formed because of the mineral oil (choice a). Mycobacteria are added
to the adjuvant to initiate an inflammatory condition that will stimulate the antigen-
presenting cells (APCs), so when they present the antigen, the cells will recognize the
antigen in the presence of the up-regulated co-stimulatory molecules. Bacterial
inflammation has no direct role to play in induction of EAE (choice c), nor do the
antibodies induced by the bacterial products enhance the disease (choice b). In addition,
because the bacterial products are injected with the mineral oil they will be retained at the
site of injections along with the antigen rather than being circulated to the brain; hence,
choice d is wrong.
4. A 6-year-old child complains of sudden onset of breathlessness and becomes very ill.
She is rushed to the emergency department, where the intern attending this patient does a
complete physical examination to evaluate the cause. Patient appears very anxious, is
hyperventilating, and complains of a dull pain substernally. Pulse = 110 beats per minute,
BP = 124/84 mm Hg, and upon auscultation there is a distinct pericardial friction rub.
Upon specific questioning, the parent of the child gives a history of an upper respiratory
illness preceding this episode. If the physician considers the possibility of acute viral
myocarditis, which cell is most likely responsible for the pathogenesis?
a. CD4 T cell
b. CD8 T cell
c. Myofibroblast
d. Plasma cells
e. Mast cell
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
,Test Bank by Rohit Divekar, MD 3
ANS: B
CD4 T cells perform the function of regulating and orchestrating the immune system;
they are responsible for production of cytokines. Depending on the nature of the
inflammation, these cytokines are meant to activate specific cells of the immune system
to carry out their functions. CD4 T cells that secrete IL-12 and IFN-gamma are called TH1
cells, and those that produce IL-4, IL-5, and IL-13 are called TH2 cells. CD8 T cells, on
the other hand, are responsible for cytotoxic effector functions that get rid of tumor cells
and virally infected cells. Myofibroblasts are mesenchymal cells that line the wound
during the process of repair; they are modified fibroblasts that have the capacity to
contract. They are responsible for wound contraction. Plasma cells are mature and
differentiated B cells that produce antibody. They are important in antibody-mediated
immune responses. Mast cells are cells of the innate immune system that secrete a variety
of immunomodulatory proteins. Degranulation of mast cells causes release of
proinflammatory products, notably histamine.
5. Neutrophils are isolated from the peripheral blood of a patient suffering from an
immunodeficiency disease. This individual has a recurrent history of severe infections.
Upon analysis it is found that the neutrophils are able to ingest gram-negative organisms
but are unable to kill them. The nitro blue tetrazolium test (NBT), however, is positive.
Which of the following is most likely responsible?
a. Neutrophil elastase
b. NADPH oxidase
c. Nitric oxide synthase
d. Toll-like receptors (TLRs)
e. Perforin
ANS: A
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
, Test Bank by Rohit Divekar, MD 4
One of the mechanisms of microbicidal killing is phagocytosis. The ingested bacteria are
held in a phagosome that fuses with the lysosome, which contains proteolytic enzymes
and a variety of bactericidal molecules. Neutrophil lysosomes are particularly rich in the
enzyme neutrophil elastase (choice a), whose primary targets are probably bacterial
proteins. Incidentally, neutrophil elastase is also implicated in lung damage in patients
who lack the protein to inactivate this elastase, alpha-1 antitrypsin. NK cells such as the
cytotoxic T lymphocytes contain a protein known as perforin (choice e). This protein,
similar in function to the membrane attack complex of the complement pathway, is
inserted into the cell membrane, where it creates pores or channels through which
cytoplasmic content can leak out. It also allows for enzymes produced by these cells,
called granzymes, to get inside and activate the apoptosis pathway. The other mechanism
of bacterial killing is production of reactive oxygen metabolites following a “respiratory
burst.” The principal enzyme involved in generation of these free radical oxy-halide
molecules (e.g., HOCl) is NADPH oxidase (choice b). Deficiency of NADPH oxidase is
one of the causes of chronic granulomatous disease (CGD), in which the neutrophils
ingest bacteria but are unable to kill them because of defective free radical production.
Cells that lack the ability to generate free oxygen radicals give a negative NBT test. A
second method of generating free radicals is by using the nitric oxide synthase enzyme
(choice c). This enzyme is absent from macrophages and neutrophils but is rapidly
induced upon exposure of these cells to bacterial products such as LPS along with IFN-
gamma. The inducible nitric oxide system along with the reactive oxygen system work
together for efficient killing of pathogens. Toll-like receptors (choice d) belong to a
family of innate receptors that are involved in pattern recognition. They don’t have
pathogen-specific recognition motifs but can recognize patterns of molecular structure in
bacteria. For example, TLR 4 can recognize LPS produced by a variety of bacteria, and
TLR 5 bind to bacterial flagellin. TLRs are abundant on macrophages and dendritic cells
and are responsible for activation of these cells upon exposure to bacterial products.
6. Neutrophils are isolated from the peripheral blood of a patient suffering from an
immunodeficiency disease. This individual has a recurrent history of severe infections.
Upon analysis it is found that the neutrophils are able to ingest organisms but are unable
to kill them. The nitro blue tetrazolium test (NBT), however, is negative. A defect in
which of the following is most likely to be responsible for this presentation?
a. Neutrophil elastase
b. NADPH oxidase
c. Nitric oxide synthase
d. Toll-like receptors (TLRs)
e. Perforin
ANS: B
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
