Lecture Allergy

Blok 2.4 Digestion and Defense II

ITM Medicine
 What we are going to discuss?
• Allergy
• IgE in and outs
• Allergy diagnostics
• Anaphylaxis
• Allergy vaccination
Hayfever
 Allergy
• Summary:
• Immunologic reaction, because of specific
recognition by gammaglobulines (IgE) or
(sometimes) immune cells
• Antigen non-self
• Related with complaints

• Eg: hay fever, astma, urticaria, eczema,

anafylaxis, food allergy
 IgE and Allergy
• Allergy is not related to high total IgE levels.
• There is no relation between IgE and atopy,
high IgE is not automatically atopy (genetic
propensity to develop IgE mediated reactions)
• IgE titer is genetically determined, oa locus on
5q31-32
• Atopy, however, ís defined as high specific IgE
against allergen (except for immune responses
against worms)
 IgE, Allergy and Worms
• In atopy there is high specfic IgE, low irrelevant
IgE, whereas in parasitic infection there is high
bystander (thus irrelevant IgE) and little specific
IgE
• Relevant, because a lot of bystander IgE
“dilutes” specific IgE on mast cells and reduces
IgE-crosslinking
 Common allergens (geograpy!)
• House dust mite (sept-dec)
• Tree pollen (dec-april)
• Grass pollen (mai-july)
• Weed pollen (june-aug
• Funghi (aug-sept)
• Animals (all year long)

• Italy: olive pollen

4 types hypersensitivity reactions,
summerised

Immunologic inducers of infection:

Antibodies (Type I and II), immune complexes (Type III) and effector lymphocytes (Type IV)
 Common food allergens
(prevall data)
• Egg
• Milk
• Kiwi
• Apple
• Hazelnut
• Peanut
• Soy
• Fish
• Shrimps
• Tomato
• Wheat
Immediate type hypersensitivity
 Nature of humane immunoglobulines

Immunoglobuline
IgG1 IgG2 IgG3 IgG4 IgM IgA1 IgA2 IgD IgE
MW (kDa) 146 146 165 146 970 160 160 184 188
-5
Serum (mg/ml) 9 3 1 0.5 1.5 3.0 0.5 0.03 5x10
T½ (dagen) 21 20 7 21 10 6 6 3 2
IgE formation
IgE class switching is rare!
 IgE switching
• B cells leave bone marrow carrying IgM.
• Under influence of Il-4 and Il-13 class switch to
IgE (skipping IgG and IgA ?)
• Plasma and memory cells for IgE

• How about changing to IgG4?

Class switching: role of germinal
center
Modified B-cell response in mature
germical center
IgE class switching!
Effect of protein allergens on IgE-
mast cell
Role of lymf node germinal center (GC)
in IgE generation (source Davies)
 Diagnosis of allergy
• Skin tests : SPT, ICT, epicutaneous test, patch
test
• Plasma analysis with either crude extracts of
natural allergens (Immunocap)or with
recombinants allergens(ISAC)
• Basofil degranulation-assay with FACS of
histamine-measurement
Skin prick testing (SPT) for immediate
type hypersensitivity
 Intracutaneous testing
(ICT)

Hundred to thousand times

more sensitive than skin prick
testing, for immediate type
hypersensitivity
Epicutaneous testing for type IV
reactions
 Positive reaction on
epicutaneous testing
(EPT)
nickel
latex
Colophonium
Methylisothiazoline
perfum
 Eczemateous reaction
(eg. contact allergy after nickel)
 Immunocap testing
• In vitro determination of specific IgE, about 500 allergens or
allergen mixes can be tested
• Allergen is fixed upon paper, patient serum is added and a
second antibody is used to indicate binding of patient serum
• Phadiatop: specific IgE against most relevant inhalation-
allergens for northern Europe, house dust mite, cat, dog, tree
pollen, grass pollen, weed pollen, fungi
• MUMC food allergy mix (fx1 t/m 5) measures sIgE against
egg white, cow’s milk, fish, wheat, peanut, nuts, soy, sea food,
shrimps, sesame seed.
• Phadiatop infant: determines house dust mite, cat, dog, grass
pollen, egg white, milk and peanut
Phad Phadiatop positive
Gx3 Grass positive >100 [kU/L] *
Tx9 Tree positive 3.7 [kU/L] *
Wx3 Herb positive 3.3 [kU/L] *
Mx1 Fungus negative
D1 House dust mite positive 3.5 [kU/L] class: 3
E1 cat hair/scall positive 2.5 [kU/L] class: 2
E5 dog hair/scall positive 10 [kU/L] class: 3
Fx5 food in general positive >100 [kU/L] * class: 6
F1 egg white positive 1.9 [kU/L] class: 2
F2 milk positive >100 [kU/L] class: 6
Fx3 awn positive 4.3 [kU/L] *
F4 wheat positive 3.5 [kU/L] class: 3
F7 oat positive 1.9 [kU/L] class: 2
F8 corn positive 3.6 [kU/L] class: 3
F11 buckwheat positive 3.2 [kU/L] class: 2
F14 Soy positive 4.7 [kU/L] class: 3
F10 Sesame seed positive 4.9 [kU/L] class: 3
Fx1 nuts positive 4.2 [kU/L] * class: 3
F13 peanut positive 4.3 [kU/L] class: 3
F17 hazelnut positive 2.4 [kU/L] class: 2
F18 Para nut positive 0.54 [kU/L] class: 1
F20 almond positive 3.1 [kU/L] class: 2
F36 coconut positive 2.0 [kU/L] class: 2
F202 Cashew nut positive 1.9 [kU/L] class: 2
Fx2 seafood positive 10 [kU/L] * class: 3
F3 kabeljou positive 0.63 [kU/L] class: 1
F24 shrimp positive 13 [kU/L] class: 3
F37 shell positive 1.2 [kU/L] class: 2
F40 tuna positive 0.77 [kU/L] class: 2
F41 salmon negative 0.24 [kU/L]
F27 beef meat positive 7.8 [kU/L] class: 3
F83 chicken meat positive 1.1 [kU/L] class: 2
F92 banana positive 2.7 [kU/L] class: 2
Cross reactivity
 Causes cross reactivity
• Shared allergens (tropomyosin in HSM and
shrimps, storage proteins in nuts, serum
albumen in animals and meat)
• Molecular mimicry (Betv1 homology with Mal
d1 apple, Gly m4 soymilk, etc)

• NEW: also carbohydrate-structures on proteins:

galactose-α-1,3-galactose story
 Two stories
1. cetuximab
• 2006 cetuximab, monoclonal against epidermal
growth factor, used in bladder cancer

• In USA several cases of infusion-related

anaphylaxis
 Two stories
1. cetuximab 2. red meat allergy
• 2006 cetuximab, monoclonal against epidermal
growth factor, used in bladder cancer

• In USA several cases of infusion-related

anaphylaxis

• Same region dr. Platt Mills et all. several patients

with delayed anaphylaxis on red meat
 Red meat-tick- cetuximab
anaphylaxis

anaphylactic reactions to cetuximab in 2006 (A) Rocky Mountain spotted fever (B). patients with delayed anaphylaxis to red meat whose serum
contained IgE antibodies to alpha-gal (C)..
In panel D, distribution of the tick Amblyomma americanum
 Galactose-1,3-galactose
• 2006 tick bites
• 2009 cat IgA

• 2012 gelatin in marsh mallows

 ISAC
component resolved diagnosis
112 molecular allergens tested
 ISAC
component resolved diagnosis
• rApi g 1 Celery Apium graveolens PR-10 protein
• rDau c 1 Carrot Daucus carota PR-10 protein
• rMal d 1 Apple Malus domestica PR-10 protein
• rPru p 1 Peach Prunus persica PR-10 protein
• nPru p 3 Peach Prunus persica Lipid transfer protein (nsLTP)
• rAna o 2 Cashew nut Anacardium occidentale
• nAra h 1 Peanut Arachis hypogaea Storage protein, vicilin
• nAra h 2 Peanut Arachis hypogaea Storage protein, Conglutin
• nAra h 3 Peanut Arachis hypogaea Storage protein, 11S globulin
• rAra h 8 Peanut Arachis hypogaea PR-10 protein
• rBer e 1 Brazil nut Bertholletia excelsa Storage protein, 2S albumin
• rCor a 1.0401 Hazelnut Corylus avellana PR-10 protein
• rCor a 8 Hazelnut Corylus avellana Lipid transfer protein (nsLTP)
• nCor a 9 Hazelnut Corylus avellana Storage protein, 11S globulin
• rGly m 4 Soybean Glycine max PR-10 protein
• nGly m 5 Soybean Glycine max Storage protein, b-conglycinin
• nGly m 6 Soybean Glycine max Storage protein, glycinin
• nSes i 1 Sesame seed Sesamum indicum Storage protein, 2S albumin
• nTri a 18 Wheat Triticum aestivum
• nTri a gliadin Wheat Triticum aestivum Crude gliadin
• rTri a 19.0101 Wheat Triticum aestivum Omega-5 gliadin
• nTri a aA_TI Wheat Triticum aestivum
• rHev b 1 Latex Hevea brasiliensis
• rHev b 3 Latex Hevea brasiliensis
• rHev b 5 Latex Hevea brasiliensis
• rHev b 6 Latex Hevea brasiliensis
 Clinical examples of ISAC vs. ImmunoCAP | De Boer et al. | xxxx xx, xxxx 36
Comparison of ISAC vs. ImmunoCAP
Gx3 Grass positive >100 [kU/L] * F36 coconut positive 2.0 [kU/L] class: 2
Tx9 Tree positive 3.7 [kU/L] * F202 Cashew nut positive 1.9 [kU/L] class: 2
Wx3 Herb positive 3.3 [kU/L] * Fx2 seafood positive 10 [kU/L] * class: 3
Mx1 Fungus negative F3 kabeljou positive 0.63 [kU/L] class: 1
D1 House dust mite positive 3.5 [kU/L] class: 3 F24 shrimp positive 13 [kU/L] class: 3
E1 cat hair/scall positive 2.5 [kU/L] class: 2 F37 shell positive 1.2 [kU/L] class: 2
E5 dog hair/scall positive 10 [kU/L] class: 3 F40 tuna positive 0.77 [kU/L] class: 2
Fx5 food in general positive >100 [kU/L] * class: 6 F41 salmon negative 0.24 [kU/L]
F1 egg white positive 1.9 [kU/L] class: 2 F27 beef meat positive 7.8 [kU/L] class: 3
F2 milk positive >100 [kU/L] class: 6 F83 chicken meat positive 1.1 [kU/L] class: 2
Fx3 awn positive 4.3 [kU/L] * F92 banana positive 2.7 [kU/L] class: 2
F4 wheat positive 3.5 [kU/L] class: 3
F7 oat positive 1.9 [kU/L] class: 2
F8 corn positive 3.6 [kU/L] class: 3
F11 buckwheat positive 3.2 [kU/L] class: 2
F14 Soy positive 4.7 [kU/L] class: 3
F10 Sesame seed positive 4.9 [kU/L] class: 3
Fx1 nuts positive 4.2 [kU/L] * class: 3
F13 peanut positive 4.3 [kU/L] class: 3
F17 hazelnut positive 2.4 [kU/L] class: 2
F18 Para nut positive 0.54 [kU/L] class: 1
F20 almond positive 3.1 [kU/L] class: 2
 Clinical examples of ISAC vs. ImmunoCAP | De Boer et al. | xxxx xx, xxxx 37

Comparison of ISAC vs. ImmunoCAP

ISAC112 profilin panel
ISAC112 tropomyosin panel
ISAC112 storage protein nPen m 1 11 ISU
rPhl p 12 1.7 ISU
panel rDer p 10 8.4 ISU rBet v 2 3.7 ISU
rAna o 2 0.6 ISU nBla g 7 13 ISU
rMer a 1 7.2 ISU
rBer e 1 neg rAni s 3 16 ISU

rPen a 1 ― ISU rHev b 8 12 ISU

nCor a 9 neg
nPen i 1 ― ISU nOle e 2 ― ISU
nJug r 1 neg

nJug r 2 1.6 ISU

ISAC112 egg panel ISAC112 CCD panel
nSes i 1 neg
nGal d 1 neg
nAna c 2 ― ISU
rAra h 1 neg
nGal d 2 neg
rAra h 2 neg nMUXF3 1.6 ISU
nGal d 3 neg
rAra h 3 neg nGal d 5 0.6 ISU
ISAC112 milk panel
nAra h 6 neg

nGly m 5 neg ISAC112 serum albumin nBos d 4 9.3 ISU

panel
nGly m 6 neg nBos d 5 15 ISU
nBos d 6 1.1 ISU
nFag e 2 neg nBos d 6 1.1 ISU
nFel d 2 0.9 ISU

nCan f 3 0.7 ISU nBos d 8 2.8 ISU

nEqu c 3 0.6 ISU nBos d lactoferrin neg
 Immunocap versus ISAC
• Soy immunocap contains rGly m5 and rGly m6,
but no rGly m4
• ISAC soy contains all three proteins
• rGly m5 and nGlym6 are storage proteins,
present in fermented soy products and related to
severe soy allergy.
• rGly m4 is present in soy milk, not in fermented
soy products and related to anaphylaxis due to
soy milk
Anaphylaxis
 What is anaphylaxis?
• Brown FA, JACI, 2004
• 1. Acute allergic reaction: diffuse erythema, itching,
rhinoconjunctivitis, urticaria, angioedema
• 2a. Mild/moderate anaphylaxis; 1. plus dyspnea,
wheezing, hoarseness, nausea, vomitting
• 2b. Severe anaphylaxis: 2a plus collaps, dizzyness,
loss of conciousness, < 90 mm Hg, GCS < 15. Or
resp. symptoms with stridor, cyanosis, larynx
edema (hoarseness), tachypnoe > 25.
 Causes of anaphylaxis
• Age dependent:
• under 5 years of age frequently milk, egg, soy,
wheat, nuts, peanut
• Young adults nuts, peanut, sea food, milk often
tolerated
• Adults: NSAIDs, latex, antibiotics, contrast media,
cytostatica, blood products, biologicals, insect
stings, etc: (food-associated, exercise-induced
anaphylaxis), idiopathic anaphylaxis .etc
 Case material
• Case 1. 73 year old woman, drinking coffee with her
cousin, with a biscuit, within 20 minutes itching in
palms of the hands, red skin, dyspnea and collaps.
Specific history revealed: lots of pain in her
arthrotic hip recently.

• Case 2. 50 year old man, for years after a meal red

skin rash and frequently palpitations with diarrhea.
Eight years ago consultation of a gastroenterologist
because of diarrhea, no explanation found
 Case material
• Case 3. 27 year old Chinese woman, medical doctor-in-
training, previously, while living in China, diagnosed with
asthma. Indonesion week in the hospital restaurant:
almost daily nausea, vomitting, more asthma complaints
and sometimes red skin rash.

• Case 4. Erasmus hospital Rotterdam, after lunch thirteen

health care workers reported at the first aid ward with
diffuse redness, itching, nausea, diarrhea and palpitations.
The menu mentioned thuna fish.
 Diagnosis
• Case 1 : NSAIDs-induced anaphylaxis
 diagnosis

• Case 1 : NSAIDs-induced anaphylaxis

• Case 2 : small intestin carcinoïd (hormonally
active tumor in the intestins secreting
serotine-like substances)
 diagnosis
• Case 1 : NSAIDs-induced anaphylaxis
• Case 2 : small intestin carcinoïd (hormonally
active tumor in the intestins secreting serotine-
like substances)
• Case 3 : fish allergy in astmatic patient
 diagnosis
• Case 1 : NSAIDs-induced anaphylaxis
• Case 2 : small intestin carcinoïd (hormonally
active tumor in the intestins secreting serotine-
like substances)
• Case 3 : fish allergy in astmatic patient
• Case 4 : scrombroidosis (food poisoning
where fish contain high amounts of
histamine, due to degradetion of fish
proteins (histidine)
 Treatment of anaphylaxis
and allergy
• Anaphylaxis: epinefrine (adrenalin) intramuscularly,
(epipen) and AFTER adrenaline, antihistaminics
and steroids
• Hayfever: antihistaminics, nasal steroid spray
• Asthma: inhalation steroids, beta mimetics,
antileukotriens, oral, anti IgE-treatment, etc.
steroids
• Food allergy: ……avoidance or recently: oral
desensibilisation reported in peanut, not for severe
anafylaxis.
• How about Allergy vaccination?
 Allergy vaccination
• When ?:
• In proven IgE mediated hypersensitivity leading
to anaphylaxis upon wasp or bee stings
• In hay fever and asthma upon exposure to cat,
tree pollen, grass pollen, house dust mite,
alternaria alternata (fungus), ambrosia (weed
pollen)
 Allergy vaccination
will never let you down!
 How allergy vaccination?
• With injections:
• Natural allergen extracts
• Recombinant allergen extracts
• Allergoiden

• (With droplets or) tablets

• Sublingualy
 Mechanism of protection by allergy
vaccination
• Change of immune response:
• Increase of specific IgG4,interfering with
crosslinking of IgE on mast cells
• Increase in (inducible)T reg cells
• Downregulation in APC presentation through
the Fcepsilon receptor, decreasing Th2
induction of T-cells
• ….?
Questions?