Passive transfer of cutaneous mosquito-bite hypersensitivity by IgE anti-saliva antibodies

Mosquito allergy: Immunological aspects and clinical management

Mosquito allergy has been conceived as the cutaneous reactions that appears during and after mosquito biting process; a perception that is supported by several scientific research. Additional data have led to conceive that other manifestations of allergic responses may occur as a cause of the exposure to somatic mosquito allergens. Two main phenotypes of mosquito allergy are identifiable: the cutaneous allergic reactions, induced by salivary allergens, and other manifestations of the allergic responses such as asthma and allergic rhino conjunctivitis that are caused by somatic allergens. The cutaneous reactions have kept the focus of attention of the scientific community. It appears as skin lesions that resembles the phenotype of papular urticaria with a defined natural history of the disease. Although these two phenotypes of mosquito allergy seem to be well differentiated in terms of the allergens that are involved and the routes of exposures, other factors such as geographical distribution, may participate. Mosquitoes have adapted to the host immune response against bites, producing immunomodulatory molecules that counteract such defensive response. The role that the immunomodulatory molecules have on the allergic immune response has not been studied yet and it is still not known if affects all mosquito allergy phenotypes. Only a few studies of allergen specific immunotherapy for cutaneous allergic reactions induced by mosquito bites have been done, and none for respiratory allergic responses. The clinical practice focuses on symptom management and avoiding mosquito bites as much as possible. Avoiding mosquitoes, using different well described methods, is still the best option to limit contact with these insects. The lack of knowledge of mosquito allergy have raised several questions that affects the clinical management of this allergic disease, from its diagnosis, prevention and immunotherapy.

IgE response to Aed al 13 and Aed al 14 recombinant allergens from Aedes albopictus saliva in humans

Background

Mosquito bite is normally associated with mild allergic responses, but severe localized or systemic reactions are also possible. Reliable tools for the diagnosis of mosquito allergy are still unavailable. Here, we investigated the IgE response to 3 potential salivary allergens identified in the saliva of the tiger mosquito Aedes albopictus.

Methods

Serum from 55 adult individuals (28 controls and 27 allergic people), were analysed using an in-house Enzyme Linked ImmunoSorbent Assay (ELISA) against the Salivary Gland Extract (SGE) and the recombinant proteins albD7l2 (Aed al 2), albAntigen5-3 (Aed al 13) and albLIPS-2 (Aed al 14).

Results

Fifteen of the 27 (56%) individuals having hypersensitive reactions to mosquito bites had IgE serum levels recognizing SGE. Negative sera did not show detectable levels of IgE targeting the SGE from the most common sympatric mosquito Culex pipiens. Among the positive individuals, 2 subjects displayed IgE targeting Aed al 2 (13%), while IgE recognizing Aed al 13 and Aed al 14 were detected in ten (67%) and seven (47%) individuals, respectively. Two sera from non-hypersensitive subjects had detectable levels of IgE targeting Aed al 13, suggesting possible cross-reaction with the homologue salivary proteins of multiple mosquito species or, more generally, of hematophagous insects.

Conclusions

Our results indicate that Aed al 13 and Aed al 14 hold the potential to be developed as tools for the diagnosis of allergy to Ae. albopictus bites. Such tools would facilitate epidemiological studies on tiger mosquito allergy in humans and might foster the development of further protein-based assays to investigate cross-species allergies.

Hypersensitivity to mosquito bites: A versatile Epstein-Barr virus disease with allergy, inflammation, and malignancy

Hypersensitivity to mosquito bites (HMB) is a rare disease characterized by transient intense skin reaction and systemic inflammation. Clinical presentation of HMB resembles other mosquito allergic responses, and it can also be difficult to clinically distinguish HMB from other severe allergic reactions. However, a distinctive pathophysiology underlies HMB. HMB belongs to a category of Epstein-Barr virus (EBV)-associated natural killer (NK) cell lymphoproliferative disorders (LPD). Hence, HMB may progress to systemic diseases, such as hemophagocytic lymphohistiocytosis, chronic active EBV disease, and EBV-associated malignancies. A triad of elevated serum IgE, NK lymphocytosis, and detection of EBV DNA in peripheral blood is commonly observed, and identification of EBV-infected NK cells usually facilitates the diagnosis. However, the effective treatment is limited, and its precise etiology remains unknown. Local CD4+ T cell proliferation triggered by mosquito bites appears to help induce EBV reactivation and EBV-infected NK-cell proliferation. These immunological interactions may explain the transient HMB signs and symptoms and the disease progression toward malignant LPD. Further research to elucidate the mechanism of HMB is warranted for better diagnosis and treatment of HMB and other forms of EBV-associated LPD.

Vector saliva controlled inflammatory response of the host may represent the Achilles heel during pathogen transmission

Infection with vector-borne pathogens starts with the inoculation of these pathogens during blood feeding. In endemic regions, the population is regularly bitten by naive vectors, implicating a permanent stimulation of the immune system by the vector saliva itself (pre-immune context). Comparatively, the number of bites received by exposed individuals from non-infected vectors is much higher than the bites from infected ones. Therefore, vector saliva and the immunological response in the skin may play an important role, so far underestimated, in the establishment of anti-pathogen immunity in endemic areas. Hence, the parasite biology and the disease pathogenesis in “saliva-primed” and “saliva-unprimed” individuals must be different. This integrated view on how the pathogen evolves within the host together with vector salivary components, which are known to be endowed with a variety of pharmacological and immunological properties, must remain the focus of any investigational study dealing with vector-borne diseases.

Considering this three-way partnership, the host skin (immune system), the pathogen, and the vector saliva, the approach that consists in the validation of vector saliva as a source of molecular entities with anti-disease vaccine potential has been recently a subject of active and fruitful investigation. As an example, the vaccination with maxadilan, a potent vasodilator peptide extracted from the saliva of the sand fly Lutzomyia longipalpis, was able to protect against infection with various leishmanial parasites. More interestingly, a universal mosquito saliva vaccine that may potentially protect against a range of mosquito-borne infections including malaria, dengue, Zika, chikungunya and yellow fever. In this review, we highlight the key role played by the immunobiology of vector saliva in shaping the outcome of vector-borne diseases and discuss the value of studying diseases in the light of intimate cross talk among the pathogen, the vector saliva, and the host immune mechanisms.

Novel salivary gland allergens from tropical mosquito species and IgE reactivity in allergic patients

Background

Mosquito allergy is common in tropical countries but remains under-diagnosed. This may be due to the lack of knowledge and diagnostic tools for tropical mosquito allergens.

Objective

We aimed to characterize allergens from tropical mosquito species and investigate IgE reactivity in mosquito-allergic patients to the salivary gland proteins from these mosquitoes.

Methods

Salivary gland extract (SGE) from 4 mosquito species, highly distributed in the tropics, including Aedes aegypti, Aedes albopictus, Culex quinquefasciatus, and Anopheles dirus b, were studied. SGE-specific IgE and IgG ELISA were developed, and serum from 64 mosquito-allergic and 22 non-allergic healthy control subjects was assayed. Further investigations using IgE-immunoblots followed by mass spectrometry analysis were performed to identify and characterize allergens from each species.

Results

Mosquito-allergic subjects have detectable serum IgE to SGE derived from local mosquito species, while the IgE levels to Aedes communis using commercially available ELISA were mostly minimal. IgE-immunoblot analysis and mass spectrometry identified 5 novel mosquito allergens from A. albopictus (Aed al 2, Aed al 3), C. quinquefasciatus (Cul q 2.01, Cul q 3), and A. dirus b (Ano d 2). Interestingly, 4 of the 5 new allergens belong to the D7 protein family.

Conclusions & clinical relevance

Five novel allergens from 3 tropical mosquito species were characterized. The majority of mosquito-allergic subjects who live in the tropics have IgE reactivity to these allergens. Our study paves the way for the development of diagnostic tests, component-resolved diagnostics, and future immunotherapy for mosquito allergy in tropical countries.

Immunological aspects of the immune response induced by mosquito allergens

Allergies caused by mosquito bites may produce local or systemic reactions. The inhalation of mosquito allergens may also cause asthma and/or allergic rhinoconjunctivitis in sensitized individuals. The mechanisms implicated in the development of these immune responses involve IgE antibodies, different subtypes of IgG and proinflammatory cytokines as well as basophils, eosinophils and mast cells. Several allergenic components have been identified in the saliva and bodies of mosquitoes and some of these are present in different mosquito species. The most common species implicated in allergic reactions belong to the genera Aedes, Culex and Anopheles. Several Aedes aegypti allergens have been cloned and sequenced. The recombinant molecules show IgE reactivity similar to that of the native allergens, making them good candidates for the diagnosis of mosquito allergies. Allergen-specific immunotherapy with mosquito extracts induces a protective response characterized by a decreased production of IgE antibodies, increased IgG levels, a reduction in the severity of cutaneous and respiratory symptoms and the need for medication. The aims of this review are to summarize the progress made in the characterization of mosquito allergens and discuss the types of immune responses induced by mosquito bites and the inhalation of mosquito allergens in atopic individuals.

Impact of mosquito bites on asexual parasite density and gametocyte prevalence in asymptomatic chronic Plasmodium falciparum infections and correlation with IgE and IgG titers

An immunomodulatory role of arthropod saliva has been well documented, but evidence for an effect on Plasmodium sp. infectiousness remains controversial. Mosquito saliva may orient the immune response toward a Th2 profile, thereby priming a Th2 response against subsequent antigens, including Plasmodium. Orientation toward a Th1 versus a Th2 profile promotes IgG and IgE proliferation, respectively, where the former is crucial for the development of an efficient antiparasite immune response. Here we assessed the direct effect of mosquito bites on the density of Plasmodium falciparum asexual parasites and the prevalence of gametocytes in chronic, asymptomatic infections in a longitudinal cohort study of seasonal transmission. We additionally correlated these parasitological measures with IgE and IgG antiparasite and anti-salivary gland extract titers. The mosquito biting density was positively correlated with the asexual parasite density but not asexual parasite prevalence and was negatively correlated with gametocyte prevalence. Individual anti-salivary gland IgE titers were also negatively correlated with gametocyte carriage and were strongly positively correlated with antiparasite IgE titers, consistent with the hypothesis that mosquito bites predispose individuals to develop an IgE antiparasite response. We provide evidence that mosquito bites have an impact on asymptomatic infections and differentially so for the production of asexual and sexual parasites. An increased research focus on the immunological impact of mosquito bites during asymptomatic infections is warranted, to establish whether strategies targeting the immune response to saliva can reduce the duration of infection and the onward transmission of the parasite.

A randomised, double-blind pilot study of enzyme-potentiated desensitisation for prophylaxis of large local reactions to mosquito bites

Primary Objective. To test the hypothesis that two injections of enzyme-potentiated mosquito antigen significantly reduce the size of experimental mosquito bites in participants with LLR-MB. Design. Randomised, double-blind, placebo-controlled, parallel group comparison over 3 months. Setting. Hospital outpatient clinic. Participants. Fifty adult participants of both sexes. Interventions. Two injections of mosquito antigen or matching placebo, 6 weeks apart. Main Outcome Measures. Early (1 hour) and late (24 hours) mean square root of erythema area (SREA) following controlled mosquito bite with the second bite given at least 6 weeks following the final injection. Results. At 1 hour, mean SREA was slightly higher in the EPD group compared to placebo after adjusting for baseline values (0.46, 95% CI -6.11 to 7.03), but this was not statistically significant (P = 0.89, ANCOVA analysis); neither were the results at 24 hours (-2.58, 95% CI -11.73 to 6.57) (P = 0.57). The proportion of participants experiencing a decrease in wheal size at 1 or 24 hours was similar between groups. Conclusions. EPD was not demonstrated to be effective for immediate or delayed LLR-MB. Methodological problems included a high variability in LLR-MB between subjects, suggesting that a crossover design should be used in future.

Evidence for natural desensitization to mosquito salivary allergens: mosquito saliva specific IgE and IgG levels in children

BACKGROUND

There are few epidemiologic data on the prevalence of mosquito allergy, although local reactions to mosquito bites are common.

OBJECTIVE

To investigate the prevalence of mosquito allergy in children by measuring serum levels of mosquito saliva specific IgE and IgG antibodies that correlate well with the size of mosquito bite local reactions.

METHODS

Using enzyme-linked immunosorbent assays to measure mosquito (Aedes vexans) saliva-specific antibodies, we investigated sensitization to mosquito bites in 402 children aged 1 month to 18 years and correlated mosquito saliva specific IgE and IgG levels with age and sex. Twenty-three serum samples from infants who had never been exposed to mosquitos were used as negative controls.

RESULTS

Mean levels of mosquito saliva specific IgE and IgG were lowest in the 23 negative control serum samples. In the 402 samples from children who may have been exposed to mosquitos, mean saliva specific IgG levels were higher in boys than in girls (P < .008). Levels of IgE and IgG correlated with each other (P < .001). A significant inverse correlation was found between age and both IgE and IgG levels. IgE levels peaked at the age of 6 to 12 months of age, and IgG levels peaked at 1 to 6 months of age. Levels of IgE and IgG antibodies gradually declined after the age of 5 years.

CONCLUSIONS

Based on the presence of mosquito saliva specific antibodies, exposed infants and young children are at increased risk of having allergic reactions to mosquito bites. Antibody levels decline throughout childhood and adolescence, suggesting that natural desensitization may occur.

Comparison of cetirizine, ebastine and loratadine in the treatment of immediate mosquito-bite allergy

BACKGROUND

People frequently experience whealing and delayed papules from mosquito bites. Whealing is mediated by antisaliva immunoglobulin (Ig)E antibodies and histamine. Cetirizine, ebastine and loratadine have earlier shown effects on mosquito-bite reactions but no comparative studies exist.

METHODS

A double-blind, placebo-controlled, cross-over study was performed with cetirizine 10 mg, ebastine 10 mg and loratadine 10 mg in 29 mosquito-bite-sensitive adults exposed to Aedes aegypti mosquito-bites. The size of the bite lesion and the intensity of pruritus (visual analog scale) were measured at 15 min and 2, 6 and 24 h.

RESULTS

Cetirizine and ebastine, but not loratadine, decreased significantly the size of whealing (P < 0.01) and accompanying pruritus (P < 0.001) compared to placebo. Cetirizine was most effective on pruritus but caused more often sedation than ebastine or loratadine. The delayed bite symptoms remained too faint for any statistical comparison.

CONCLUSION

This comparative study in mosquito-bite-sensitive adults shows that cetirizine and ebastine decrease significantly whealing and accompanying pruritus, and that cetirizine seems to be the most effective against pruritus.

Roles of mast cells and histamine in mosquito bite-induced allergic itch-associated responses in mice

We investigated itch-associated responses (scratching) to mosquito bites and the role of histamine and mast cells in mosquito-induced itching in mice. Although the first bites of mosquito Aedes albopictus did not increase scratching, repeated bites increased scratching. The response was not diminished even after an interval of 2 months. Similarly, repeated intradermal (i.d.) injections of salivary gland extract (SGE) from Aedes albopictus increased scratching after SGE injection itself and mosquito bites. The scratching peaked within 10 min and almost subsided by 60 min. The opioid antagonist naloxone (1 mg/kg, s.c.) inhibited scratching following SGE injection. Although the non-sedative H1-histamine-receptor antagonist terfenadine (30 mg/kg, p.o.) significantly suppressed scratching induced by histamine (100 nmol/site, i.d.) in either naive or mosquito-sensitized mice, it did not affect mosquito-induced scratching in mosquito-sensitized mice. Repeated injections of SGE increased scratching in mast cell-deficient (WBB6F1-W/Wv) mice as well as in normal (WBB6F1-+/+) littermates. Repeated exposure to mosquito bites roughly doubled serum concentrations of total IgE and IgG1, but not IgG2a. Repeated injections of SGE markedly increased plasma extravasation induced by mosquito bites and such an increase was almost completely suppressed by terfenadine (30 mg/kg, p.o.). The results show the presence of histamine-mediated and histamine-independent mechanisms in cutaneous itching and suggest that histamine probably released from mast cells does not play an important role in itching in immediate allergic reaction. Our murine model of mosquito itching may be useful for studying the mechanisms of immediate allergic itching.

Loratadine in the treatment of mosquito-bite-sensitive children

BACKGROUND

Children frequently experience harmful whealing and delayed papules from mosquito bites. Whealing is mediated by antisaliva IgE antibodies and histamine, but the effect of antihistamines on mosquito-bite symptoms has not been evaluated in children.

METHODS

The effect of loratadine (0.3 mg/kg) was examined in 28 mosquito-bite-sensitive children (aged 2-11 years). The double-blind, placebo-controlled, crossover study was performed with exposure to Aedes aegypti laboratory mosquitoes. The size of the bite lesion and the intensity of pruritus (visual analog scale) were measured at 15 min and at 2, 6, and 24 h.

RESULTS

Loratadine decreased the size of the wheals by 45% (P < 0.001, 25 children) and accompanying pruritus by 78% (P = 0.011, 12 children) at 15 min compared to placebo. The size of the 24-h delayed bite lesion also decreased significantly (P = 0.004), but there was no change at 2 or 6 h. Loratadine was well tolerated and no marked side-effects were recorded.

CONCLUSIONS

This study in children shows that prophylactically given loratadine decreases significantly the whealing and pruritus caused by mosquito bites and also reduces the size of the 24-h bite lesions. Therefore, the therapeutic profile of loratadine extends from immediate to delayed allergic symptoms in mosquito-bite-sensitive children.

Immunoblot analysis of salivary allergens in 10 mosquito species with worldwide distribution and the human IgE responses to these allergens

BACKGROUND

Most people develop skin reactions to mosquito bites, however, little is known about mosquito salivary allergens and the IgE responses to them.

OBJECTIVES

We sought to identify these allergens and the specific IgE responses they elicit.

METHODS

Saliva or salivary gland extracts were prepared from 10 mosquito species, including seven species with worldwide distribution: Aedes (Ae.) aegypti, Ae. vexans, Ae. albopictus, Ae. togoi, Ae. triseriatus, Culex (Cx.) quinquefasciatus, Cx. pipiens, Cx. tarsalis, Anopheles (An.) sinensis, and Culiseta (Cs.) inornata. Proteins from these preparations were separated by sodium dodecylsulfate-polyacrylamide gel electrophoresis and transferred to nitrocellulose membranes, which were immunoblotted by sequential incubations with human serum, monoclonal anti-human IgE, and enzyme-conjugated goat anti-mouse IgG. Salivary allergens were analyzed by using a pooled serum from subjects allergic to mosquitos. Individual IgE responses to each allergen were evaluated in 12 subjects allergic to mosquitos living in Canada, the United States, and China, as well as in five subjects not allergic to mosquito bites. To study species-shared allergens, the membranes were immunoblotted with two rabbit antibodies specific to recombinant mosquito salivary proteins.

RESULTS

Three to sixteen salivary allergens with molecular masses ranging from 16 to 95 kd were found in each species. Both species-shared and species-specific allergens were identified by molecular masses, binding to the two rabbit antibodies, and individual IgE responses to species indigenous to and absent from the regions where the subjects lived. Salivary allergens, especially from Ae. aegypti, Ae. vexans, and Ae. albopictus, elicited higher IgE responses in subjects allergic to mosquitos than in nonallergic subjects.

CONCLUSIONS

Species-shared and species-specific allergens that cause IgE responses in subjects allergic to mosquitos are immunologically identified. Species-shared allergens are the most important for potential use in diagnosis and immunotherapy.

Detection of mosquito saliva-specific IgE antibodies by capture ELISA

We developed an IgE-capture ELISA and measured mosquito saliva-specific IgE antibodies in 27 children sensitive to mosquito bites. Children with large 15-min bite wheals had significantly higher (P < 0.0005) mosquito saliva-specific IgE levels than children with small wheals. In the latter group, the saliva-specific IgE level was significantly higher (P = 0.031) than the levels of six infants never exposed to mosquitoes. A positive correlation (r = 0.65; P = 0.0002) was found between the size of the 15-min wheal and the mosquito saliva-specific IgE antibody levels. These results further support the role of mosquito saliva-specific IgE antibodies in the pathogenesis of mosquito-bite whealing. Compared to immunoblotting, IgE-capture ELISA provides a quantitative method to measure mosquito saliva-specific IgE antibodies.

Immunologic mechanisms in mosquito allergy: correlation of skin reactions with specific IgE and IgG antibodies and lymphocyte proliferation response to mosquito antigens

BACKGROUND

Allergic reactions to mosquito bites are a common problem. Although IgE-mediated hypersensitivity has been reported, other immunologic mechanisms may be involved.

OBJECTIVES

To study the relationship between skin bite reactions and immunologic parameters.

METHODS

Forty-one subjects were experimentally exposed to mosquito (Aedes vexans) bites. Immediate and delayed skin reactions were traced at 20 minutes and 24 hours, respectively, after the bites. Sera were analyzed for mosquito salivary gland-specific IgE (mosquito-IgE) and IgG (mosquito-IgG) by ELISA. Lymphocyte proliferation assays with mosquito extract were also performed.

RESULTS

One of 41 subjects had only a delayed skin reaction to the bite, 23 had both immediate and delayed reactions, 6 had only immediate reactions, and 11 had no reaction. The mean mosquito-IgE and -IgG concentrations were higher in the subjects with immediate reactions than in those without immediate reactions (P < .007). The mean lymphocyte proliferation stimulation index was higher in the subjects with delayed reactions than in those without delayed reactions (P < .015). Further, both mosquito-IgE and -IgG levels correlated with skin immediate and delayed reactions (P < .04), while lymphocyte proliferation indices only correlated with skin delayed reactions (P < .006). Inverse correlations were found between the size of skin reactions and the number of years lived in Canada (P < .04), but not with age.

CONCLUSION

These results indicate that IgE-, lymphocyte- and, probably, local IgG immune-complex-mediated hypersensitivities are involved in mosquito allergy. Naturally acquired desensitization to mosquito bites occurs during long-term exposure.

Histamine and leukotriene C4 release in cutaneous mosquito-bite reactions

BACKGROUND

Mosquito bites are known to sensitize persons, and the most common cutaneous reactions are immediate wheals and delayed bite papules. Anti-saliva IgE and IgG4 antibodies are common in mosquito-sensitive subjects, but mediator release in bite reactions is not known.

METHODS

We used the microdialysis technique to measure in vivo histamine and leukotriene C4 release after bite challenges in six mosquito-sensitive subjects. One individual who was not sensitive to bites volunteered as a control subject.

RESULTS

Three of the six mosquito-sensitive subjects had large wheals and showed clearly increased histamine concentrations 30 to 45 minutes after the bites. The histamine levels declined to baseline value within 2 hours; thereafter, one subject showed a second increase in histamine concentration. Four of the six mosquito-sensitive subjects showed increased leukotriene C4 concentrations, and this mediator seemed to be released somewhat later than histamine.

CONCLUSIONS

The increased histamine and leukotriene C4 release observed in this study suggests that both mediators are involved in the early allergic response caused by mosquito bites.