[Acetylsalicylic acid: hypersensitivity, intolerance, or allergy?]

After a century of therapeutic use of acetyl salicylic acid (ASA), the different mechanisms involved leading to the therapeutic activity and to the various clinical reactions (even life threatening) observed in patients sensitive to ASA or in general to the non steroidal anti-inflammatory drugs (NSAID's) are still to be discovered or confirmed. During the last century a lot of scientific results have been published in favour of a wide panel of mechanism including an humoral (IgE and/or IgG) or a cellular (lymphocytes) immune reaction, inhibition of the cyclooxygenases, a cellular activation (mast cells, basophils, eosinophils and platelets), a competition at the serum albumin level and an activation of the complement cascade. In general the same actors than in the anaphylactic reaction are found (mediators, cellular activation and amplification systems). It is clear today that these reactions for which an accurate diagnosis is mandatory cannot be explained by a single mechanism, which is the case of a lot of other allergens.

Diagnosis of venom allergy by flow cytometry. Correlation with clinical history, skin tests, specific IgE, histamine and leukotriene C4 release

BACKGROUND

Potent allergens such as hymenoptera venoms are capable of inducing severe and life threatening clinical reactions. Percentage of false negative results obtained by the usual diagnostical methods is comprised between 10 and 25%.

OBJECTIVE

Evaluation of the sensitivity and the specificity of cellular tests and particularly evaluation of a new flow cytometric method.

METHODS

Forty-five allergic patients having experienced a local, a systemic reaction or an anaphylactic shock and 10 controls having undergone hymenoptera stings without clinical reactions were selected on the basis of the clinical history, skin tests and specific IgE. Three cellular tests were performed on the same cell suspensions and in the presence of 2 ng/mL of rIL3: histamine release (RIA), leukotriene C4 release (ELISA) and basophil activation test (flow cytometry after double anti-IgE FITC, anti-CD63 PE labelling).

RESULTS

As compared to the clinical history, sensitivities of skin tests, specific IgE, flow cytometry, histamine release and leukotriene release were, respectively; 85%, 88%, 100%, 89% and 100%. Flow cytometric analysis of basophil activation showed a significant decrease of the mean fluorescence density and number of IgE positive cells and a significant increase of the number of CD63 positive cells. The 10 controls tested by flow cytometry were negative.

CONCLUSION

As compared to the clinical history and to the other parameters tested here, flow cytometry showed a high sensitivity and a high specificity. The excellent correlation observed between this method and the other cellular tests such as histamine and leukotriene release are in favour of the specificity of flow cytomery and in favour of the use of this method for venom allergy diagnosis.

[Importance of blood tests for the diagnosis of drug allergies]

This work is devoted to the study of 22 dossiers of persons who have presented with clinical signs following taking a drug. The study was confined to patients in whom the symptoms had as origin a hypersensitivity (true or non-specific by histamine release). This study has allowed analysis of the value of several serological tests (measurement of leukotrienes, activation of basophils and T specific lymphocytes) in diagnosis and so to define the path to take that is best adapted to each case. The conclusion presents an agreement between the suspected diagnosis, after allergy enquiry and prick-tests, and the results of serological tests.

Anaphylactoid and anaphylactic reactions to iodinated contrast material

Some adverse reactions to iodinated contrast material (ICM) are considered allergy-like, with cutaneous, cardiovascular, respiratory, and digestive symptoms. Allergy-like reactions are usually unpredictable. Reactions are more frequent with ionic than with nonionic material, but the frequency of deaths is almost identical. In a recent study, 20 severe unexpected reactions to ICM, including 10 life-threatening reactions and one death, were investigated by measuring mediators in blood, within the first minutes or hours of reaction. The responsible ICMs were mostly ionic materials. Histamine and tryptase release correlated with the severity of the reaction. Specific IgE against the responsible ICM was significantly higher in reactors than in controls. A few patients had positive skin tests to the administered ICM, suggesting type-I allergic reaction. Only 2.4% and 3.1% of the cases yielded a positive IgE-RIA, in a second retrospective study which included 165 patients recruited during a 4-year period. In conclusion, IgE-mediated anaphylaxis is rare, but it may be one of the possible mechanisms of severe adverse reactions to ICM.

[Evaluation of allergic-type reactions to antibiotics and rapid immunotherapy]

Adverse effects of medications, most notably antimicrobials, are becoming increasingly common and raise difficult challenges in the area of clinical pattern definition (wide variety of symptoms, polypharmacy in many cases), diagnosis, and methodology (need for a rapid diagnosis, frequent obscurity of causative mechanisms, and less than ideal reliability of laboratory techniques). Sixty patients were treated by rush immunotherapy to one or more antimicrobials. The pretreatment evaluation included oriented history taking, skin tests, blood cell counts, IgE assays, and cell activation tests (basophils and lymphocytes). The results of this study confirm the usefulness of skin tests (intradermal, prick, or patch tests), which provided etiological orientation in 54 of the 60 cases. They also provide additional evidence of the lack of reliability of currently available in vitro tests (only 29 of the 60 tests were positive).

[Biological assays in allergology: constraints, concepts, criteria, and methods of evaluation]

The in vitro diagnosis of allergies is submitted to several constraints some shared by all the in vitro methods and some which are specific of immuno-allergology. The in vitro diagnosis of allergies involves various parameters among which the allergen by itself is far the most complex. On the basis of a studied population having an optimal size, the most powerful statistical parameters are the positive predictive value, the negative predictive value and the efficiency. The bio-clinical correlations lead to the involvement of another parameter which is the prevalence of the clinical reaction which may be corrected by a clear clinical history. Finally, the absence of absolute gold standard in allergology lead to the conclusion that allergy diagnosis is still based on the synthesis of various clinical and biological arguments.

Human basophil activation measured by CD63 expression and LTC4 release in IgE-mediated food allergy

BACKGROUND

IgE-dependent basophil activation induced by an allergen elicit the release of LTC4 and the expression of the CD63 membrane marker.

OBJECTIVE

The aim of this study was to check if flow cytometric analysis of basophil activation could be applied to food allergy diagnosis and if this method paralleled LTC4 release.

METHODS

Patients were selected by the clinical history, skin tests, and provocation tests. Basophil activation induced by food extracts was studied in 24 control subjects and in 27 patients having a food allergy by LTC4 release test (LRT) and by flow cytometric anti-IgE+, CD63 + cell counting (BAT = basophil activation test). In case of negative anti-IgE response a passive blood donor basophil passive sensitization step was added to LRT and BAT. Leucocyte histamine release test was performed in 11 patients.

RESULTS

Basophil activation test was positive in 18/31 cases and LRT in 22/34 cases for food-allergic patients and, respectively, in 1/33 and 1/35 cases for the controls. A correlation was observed between specific IgE, BAT, and LRT. Basophil activation test and LRT performed after passive sensitization had an excellent sensitivity only for specific IgE levels ranging between 3.5 and 35 KU/L.

CONCLUSION

The present study shows that allergen-induced LTC4 release and anti-IgE, antiCD63 bicolor flow cytometric analysis of basophil activation may be used for food allergy diagnosis. Both tests have a good sensitivity and specificity. Basophil activation test and LRT are more efficient than histamine release test in case of high spontaneous histamine release, frequently observed in case of food allergy.

Analysis of anti-IgE and allergen induced human basophil activation by flow cytometry. Comparison with histamine release

OBJECTIVE AND DESIGN

On the basis of flow cytometric methods previously described for the analysis of human basophil activation, we present here a bi-color anti-IgE FITC, anti CD63 PE method and the correlation with histamine release.

MATERIALS AND SUBJECTS

Subjects allergic to grass pollen were selected by their clinical history, skin tests and specific IgE.

METHODS

Basophils gated in the lymphocyte region of the side scatter (SSC)/forward scatter (FSC) pattern were selected by their high IgE epitope density. Percentage of cells expressing CD63 marker, upregulated on activated basophil membrane, was calculated by the cytometer. Histamine released into the supernatants was measured by RIA.

RESULTS

In these conditions, flow cytometric analysis of blood leukocytes showed that the selected cells had the phenotype CD14-, CD19-, CD45+, IgE++ and CD63- or + which is related to human basophil phenotype, the isotype controls being negative. The use of an anti-CD41 FITC antibody also showed the presence of aggregated platelets on the basophil membrane, CD63 antigen being, however, expressed by basophils themselves and not by platelets. Moreover, no statistical difference was observed between histamine release and flow cytometry after passive sensitization of blood donor leukocytes.

CONCLUSION

Flow cytometry, as a popular method often used in the immunology and haematology departments of clinical laboratories may represent a new alternative for allergy diagnosis and basophil pharmacology.

[Comparison of the levels of histamine, tryptase, and interleukin-6 for the investigation of anaphylactoid drug reactions]

The biological exploration of the anaphylactoid reaction is based on tryptase and plasma histamine determinations. As this reaction may be considered as a particular case of the acute inflammatory reaction, we have compared, on 25 subjects having presented a drug induces anaphylactoid reaction grade 1 to 3 the plasma level of tryptase, histamine and interleukin 6 (IL6) at 30 and 90 min. On a population of patients having presented an increase of plasma histamine and/or tryptase (n = 14), we have shown that the concentrations of tryptase, histamine and IL6 respectively plateaued (63.9 +/- 70 micrograms/l et 74 +/- 102 micrograms/l), decreased (82.5 +/- 102 mmole/l et 20.5 +/- 27 mmole/l), or greatly increased (19.5 +/- 25.3 ng/l et 320 +/- 745 ng/l) at 30 and 90 min. Correlation between IL6 and the two parameters was only significant for tryptase at 30 and 90 min. Due to the longer lasting kinetic of IL6 (48 h) as compared to histamine and tryptase, IL6 could have a place in the immediate exploration of the anaphylactoid reactions, these results having to be completed by studies on a longer delay and on groups of well defined clinical reactions.

[Allergic immunobiology and anesthesiology]

A protocol has been produced for the study of anaphylactic accidents that occur post-operatively that allows definition of the anaphylactic origin, and so reactions that are mediated by IgE in post-operative accidents. This protocol occurs in two stages, the first is done in the minutes and hours that follow the anaphylactic accident, and the second a month or 6 weeks afterwards. At first, we evaluate the sequential study of the liberation of the mediators of anaphylaxis, plasma histamine, serum tryptase, urinary methylhistamine and, more recently, leucotriene E4. The second study is devoted to reactions that are mediated by IgE, essentially, specific serum IgE, tests of activation of basophils by flow cytometry, measurement of leucotriene C4 and skin tests. A study on 16 subjects has evaluated and validated the protocol and shown a significant level of correspondence of results between the sequential measurement of mediators on one hand and on the other the search for IgE-mediated reactions every time that there was an anaphylactic reaction.

[Application of flow cytometry to the analysis of activation of human basophils. Immunologic validation of the method]

Among the different methods used for the analysis of human basophil activation as histamine and leukotriene release, flow cytometry presents several methodological advantages. Moreover, preliminary results obtained for a wide allergen panel have demonstrated its high sensitivity and specificity. We present here the results of the methods used to validate the flow cytometric analysis of human basophil activation by double anti-IgE FITC/anti-CD63 PE labelling of human leucocytes. The use of multiple labelling by monoclonals having different specificities have shown that the selected cells express the phenotype CD14-, CD19-, CD41- or +/-, CD45+, CD63- or +. This phenotype is related to human basophils. We have also demonstrated that the expression of CD63 is related to basophil activation and not to aggregated platelets which are also able to express this marker.

[Testing basophil activation by flow cytometry in the diagnosis of allergy to hymenopteran venom]

Diagnosis of allergy to hymenoptera venom must be precise and depends on indisputable bio-clinical criteria, because of specific immunotherapy for indications such as systemic and/or anaphylactic reactions. Until nowadays, diagnosis was by specific IgE, histamine release and skin tests, most often done for the venoms of wasp, honey bee and hornet at the same time since, in 7-8 cases in 10 the patients had not identified the responsible insect. Basophil activation test (TAB) by Flux cytometry and measurement of leukotriene C4 (LTC4) are new techniques of great reliability. The work shows the correlations between the different immunobiological parameters by reference to TAB by CAF and measurement of LTC4. When the overall results for mixed venoms or those for single venoms are considered, the correlations between TAB, LTC4 and the other parameters are highly significant. It can now be considered objectively that TAB by CTF and measurement of LCT4 are the two highest-performing techniques for diagnosis of hymenoptera venom allergy and so validates them.

Recognition of an extensive range of IgE-reactive proteins in cod extract

Allergy to fish is one of the most common food allergies. Gad c 1 is the only fish allergen which has been purified and characterized. Other allergens have been detected by Western blot in cod extracts. We have now improved the Western-blot procedure in order to characterize fish IgE-reactive proteins from extracts prepared under different conditions: pre-rigor mortis and post-rigor mortis, EDTA addition or not, and DEAE ion-exchange chromatography. Several IgE-reactive protein bands have been identified over a wide molecular-weight range. In particular, the 104- and 130-kDa IgE-reactive protein bands were detected. These new bands may correspond to aggregates, as EDTA increased the relative amount of the 60-, 67-, 104-, and 130-kDa IgE-reactive protein bands in Western blot. All these bands were also detected by antiparvalbumin monoclonal antibody, specific to the first calcium-binding site. The longer period of storage increased the relative amounts of the 41-, 80-, 104-, and 130-kDa IgE-reactive protein bands. The 18-kDa band was detected only in fish stored for several days. In conclusion, we have described IgE-reactive protein bands over a wide molecular-weight range (12-130 kDa) in Western blot of cod extract, and shown that EDTA and storage conditions may influence the relative distribution of IgE-reactive protein bands.

[Diagnostic contribution of abnormal delayed-type hypersensitivity to Candida albicans. Characterization test by activation of cells sensitized to successive dilutions of Candida]

By measuring the activation of different cell models (lymphocytes and lymphocytic subsets) in the presence of Candida albicans with flow cytometry reading, it is possible to show that successive dilutions of Candida albicans can lead to lymphocyte activation in abnormally-sensitized subjects. In a first trial, 10 subjects were tested in duplicate. The decrease of activity of the dilutions does not appear to be regular in relation to the progression of the dilutions. The activity of the dilutions wanes relatively rapidly with the first dilutions, then recurs later very distinctly, at the 6th dilution, then ebbs, then reappears in similar manner at the 9th, the 14th, and finally, the 19th dilution. Cell reactivity appears to differ depending on the subject. It can be represented through the calculated slope of the regression line, for each series of data. It therefore appears feasible to determine a threshold of reactivity and a scale of sensitivity, to make it possible to specify the degree of abnormal reactivity existing at a given time for a given subject. The constancy of the activity of the different dilutions tested, on 10 cultures of a single cell suspension, is especially well demonstrated in the second trial, showing unusually small standard deviations. Thus, the question arises as to the exact nature of the observed phenomenon and of its analysis from a physical-chemical point of view, with regard to the pharmacological effect of successive dilutions of Candida albicans.

[Immuno-biological diagnosis of food allergy]

Food allergy is becoming more frequent, with 6% of asthmatics reporting an isolated food allergy, and 5 to 6% of atopic dermatitis patients also have either a single or multiple true food allergy. There is value in immuno-biological diagnosis by: Measurement of total serum IgE. Measurement of mono-allergen-specific IgE, following a measurement by a multi-allergen of the Trophatope type. A study of elimination of foods for 2 or 3 months followed by their re-introduction. Oral provocation tests in a hospital environment under clinical control and subsequent measurement of the mediators:-Plasma histamine, tryptase, and urinary methylhistamine to give proof of responsibility of the food allergen. Nowadays, it is perfectly possible to include in diagnosis the new technologies of the test of activation of basophils/or lymphocytes by means of flow cytometry.