Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2008

Exposures to humidifier disinfectant and various health conditions in Korean based on personal exposure assessment data of claimants for compensation

BACKGROUND

Humidifier disinfectants (HDs) were commonly used household chemicals to prevent microbial growth in a humidifier water tank in South Korea. A growing body of evidence has indicated that its airborne exposure can induce severe lung injury. However, there has been low awareness of other health outcomes in HD users. This study aimed to evaluate health conditions appealed by claimants for compensation in relation with an increased exposure to HD.

METHODS

From survey data of personal HD exposure assessment of claimants for compensation in Korea, we included a total of 4,179 subjects [cases in each dataset were defined by nine reported health conditions, i.e., pneumonia, asthma, cardiovascular disease, respiratory disease, otorhinolaryngologic disease, brain disease (including cerebrovascular disease), dermatological disease, lung cancer, and all cancers]. HD exposures was considered as the following exposure criteria: exposure duration, exposure proximity, exposure direction, chemical type, cumulative exposure time, indoor air concentration, and cumulative exposure level. Logistic regression models were used to evaluate the associations between HD exposure and health conditions.

RESULTS

After adjusting for sociodemographic and health behavioral factors and other chemical exposures (households, environmental, and occupational exposures), an increase in cumulative HD exposure time was significantly associated with risks of all nine diseases (all p-trends < 0.05). An increase in HD exposure duration was associated with asthma, respiratory disease, otorhinolaryngologic disease, dermatological disease, all cancers, and lung cancer (p-trends < 0.05). Indoor HD concentration was associated with only pneumonia (p-trend = 0.015).

CONCLUSIONS

Our findings suggest that cumulative exposures to airborne HD might potentially increase the risk of various reported health outcomes.

A Probiotic Preparation Alleviates Atopic Dermatitis-Like Skin Lesions in Murine Models

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a complex etiology that encompasses immunologic responses. AD is frequently associated with elevated immunoglobulin (Ig) E levels, and common environmental factors contribute to its pathogenesis. Several recent studies have documented the role of specific lactic acid bacteria in the treatment and prevention of AD in humans and mice. In this study, the efficacy of Duolac ATP, a probiotic preparation, was determined in a mouse model with AD-like skin lesions. Alterations in the cytokine levels and histological staining suggested the alleviation of AD. The in vivo test showed that T helper (Th)2 cytokines, IgE, interleukin (IL)-4, and IL-5, were significantly downregulated, whereas Th1 cytokines, IL-12p40 and interferon (IFN)-γ, were upregulated in all groups of mice treated with Duolac ATP compared to that observed in the group of mice treated with 1-chloro-2,4-dinitrobenzene (DNCB) alone. Moreover, the scratch score decreased in all mice treated with Duolac ATP. Staining of the dorsal area of the mice in each group with hematoxylin and eosin and toluidine blue further confirmed the alleviation of AD in mice orally treated with Duolac ATP. These results suggest that Duolac ATP inhibits the development of AD-like skin lesions in NC/Nga mice by suppressing the Th2 cell response and increasing the Th1 cell response. Thus, Duolac ATP is beneficial and effective for the treatment of AD-like skin lesions.

Case Study of Intrapartum Antibiotic Prophylaxis and Subsequent Postpartum Beta-Lactam Anaphylaxis

Universal screening for maternal group B Streptococcus (GBS) in the prenatal period has led to administration of intrapartum antibiotic prophylaxis (IAP). Although IAP decreased the rate of early neonatal GBS disease, exposure of childbearing women to penicillin and other beta-lactam antibiotics has increased. Beta-lactam-induced anaphylaxis in the breastfeeding woman during the postpartum period illustrates risk factors for beta-lactam allergy and anaphylaxis. Treatment and nursing implications for this adverse reaction are suggested.

The role of food allergy in otolaryngology disorders

PURPOSE OF REVIEW

Food allergy is often an unrecognized clinical entity that has been implicated as a cause in many types of chronic inflammatory conditions. This review serves to provide an update on how food allergy plays a role in otolaryngology disorders.

RECENT FINDINGS

The incidence of food allergy has been on the rise over the last decade. Currently, about 6% of children and 3-4% of adults are thought to be affected by food allergy. The middle and inner ear are immunologically responsive and this includes responsiveness to food hypersenstivities. Both chronic otitis media with effusion and Meniere's disease can improve with treatment of food allergies. Some evidence supports a link between rhinitis and nasal polyps and food allergies. Finally, there is increasing literature about eosinophilic esophagitis, which is a relatively newly recognized disease with many otolaryngologic associations. Many of these patients may have food allergy, and treatment of their food allergy may be effective in treating the disease.

SUMMARY

In chronic inflammatory disorders of the head and neck, especially those involving the upper aerodigestive tract, food allergy must be considered in the differential. Patients with food allergy often do not respond to conventional treatments, and it can often be a challenge to arrive at the proper diagnosis. Further research is warranted to improve our understanding of the role of food allergy in otolaryngology disorders, as well as our diagnostic and treatment methods.

Improvement of atopic dermatitis-like skin lesions by IL-4 inhibition of P14 protein isolated from Lactobacillus casei in NC/Nga mice

Atopic dermatitis (AD) is a chronic inflammatory skin disease, with a complex etiology encompassing immunologic responses. AD is frequently associated with elevated serum immunoglobulin (Ig) E levels and is exacerbated by a variety of environmental factors, which contribute to its pathogenesis. However, the etiology of AD remains unknown. Recently, reports have documented the role of lactic acid bacteria (LAB) in the treatment and prevention of AD in humans and mice. The LAB, Lactobacillus casei (LC), is frequently used in the treatment of AD. To identify the active component of LC, we screened fractions obtained from the ion exchange chromatography of LC extracts. Using this approach, we identified the candidate protein, P14. We examined whether the P14 protein has anti-atopic properties, using both in vitro and in vivo models. Our results showed that the P14 protein selectively downregulated serum IgE and interleukin-4 cytokine levels, as well as the AD index and scratching score in AD-like NC/Nga mice. In addition, histological examination was also effective in mice. These results suggest that the P14 protein has potential therapeutic effects and that it may also serve as an effective immunomodulatory agent for treating patients with AD.

Intestinal epithelial cell-derived integrin αVβ6 affects the function of dendritic cells

AIM: To investigate the effect of intestinal epithelial cell (IEC)-derived integrin αVβ6 on the biological characteristics of bone marrow-derived dendritic cells (BMDCs).

METHODS: IECs and BMDCs were separated from BALB/c mice and cultured. After IECs were stimulated with ovalbumin (OVA), exosomes were prepared by multiple-step centrifugation. The expression of integrin αVβ6 in exosomes was examined by using the immune colloidal gold technique. Dendritic cells (DCs) were separated using immunomagnetic beads, and the concentration of DCs was determined by flow cytometry. DCs were then divided into five groups: blank group, OVA group, exosomes group, exosomes plus anti-αVβ6 antibody group, and exosomes plus goat anti-mouse IgG group. After these groups of DCs were treated with LPS, the expression of IL-12p70 was detected. In addition, the expression of active and total TGF-β1 was detected before LPS stimulation.

RESULTS: Compared to the blank group, the expression levels of total TGF-β1 increased (both P < 0.05) and those of active TGF-β1 showed no significant changes (both P > 0.05) in the OVA group and exosomes plus anti-αVβ6 antibody group; and the expression levels of both active and total TGF-β1 increased in the exosomes group and exosomes plus goat anti-mouse IgG group (both P < 0.05). Compared to the blank group, the expression of IL-12p70 was significantly reduced (both P < 0.05) in the exosomes group and exosomes plus goat anti-mouse IgG group, but showed no significant changes in the OVA group and exosomes plus anti-αVβ6 antibody group (both P > 0.05) 48 h after stimulation with LPS.

CONCLUSION: Intestinal epithelial cell-derived integrin αVβ6 can increase the expression of active TGF-β1 and total TGF-β1 in DCs and antagonize LPS-induced BMDC maturation.

Factors associated with shock in anaphylaxis

BACKGROUND

The aim of this study was to investigate the clinical characteristics of anaphylactic shock and the factors associated with anaphylactic shock in anaphylaxis.

METHODS

Data were retrospectively collected from patients with anaphylaxis for 10 years. Study subjects were searched with broad disease codes including anaphyla-, adverse, angioedema, allergy, insect bite, bee, and hypersensitivity to prevent omission. All the 294 study subjects were divided into shock and nonshock groups.

RESULTS

The mean age of the subjects was 43 years old, and males comprised 162 patients (55%). There were 119 patients (41%) in the shock group and 175 patients in the nonshock group. Age was older in the shock group than in the nonshock group; however, there was no difference in sex between 2 groups. Frequent causes of anaphylaxis were drugs in the shock group and food in the nonshock group. Nonsteroidal anti-inflammatory drugs and radiocontrast media were the most common cause of drug-induced anaphylaxis in the nonshock group and shock group, respectively. Cardiovascular symptoms were the most frequent symptoms in the shock group. Factors associated with the shock in cases with anaphylaxis were old age, emergency department (ED) arrival by emergency medical services use, radiocontrast material, symptoms with cyanosis, syncope, and dizziness.

CONCLUSION

Elderly anaphylactic patients with symptoms of cyanosis, syncope, and dizziness were at increased risk for the development of shock. Physicians in the ED have to be alert to the possibility of progression to shock in patients with anaphylaxis, and early recognition of anaphylactic shock is critical for adequate treatment.

Immunological approaches for tolerance induction in allergy

Allergy is the consequence of an inappropriate inflammatory immune response generated against harmless environmental antigens. In allergic disorders such as asthma and rhinitis, the Th2 mediated phenotype is a result of loss of peripheral tolerance mechanisms. In cases such as these, approaches such as immunotherapy attempt to treat the underlying cause of allergic disease by restoring tolerance. Immunotherapy initiates many complex mechanisms within the immune system that result in initiation of innate immunity, activation of both cellular and humoral B cell immunity, as well as triggering T regulatory subsets which are major players in the establishment of peripheral tolerance. Though studies clearly demonstrate immunotherapy to be efficacious, research to improve this treatment is ongoing. Investigation of allergenicity versus immunogenicity, native versus modified allergens, and the use of adjuvant and modality of dosing are all current strategies for immunotherapy advancement that will be reviewed in this article.

Proteomic Approach to Evaluate Mechanisms That Contribute to Food Allergenicity: Comparative 2D-DIGE Analysis of Radioallergosorbent Test Positive and Negative Patients

Proteomic profiles of RAST⁺ subjects with severe food allergies and RAST⁻ subjects were compared using 2D-DIGE analysis to obtain candidate biomarkers specific to food allergies. Our analysis highlighted 52 proteins that were differentially expressed between the RAST⁺ and RAST⁻ groups of which 37 were successfully identified that include chondroitin sulfates, zinc finger proteins, C-type lectins, retinoic acid binding proteins, heat shock proteins, myosin, cytokines, mast cell expressed proteins, and MAP kinases. Biological network analysis tool Metacore revealed that most of these regulated proteins play a role in immune tolerance, hypersensitivity and modulate cytokine patterns inducing a Th2 response that typically results in IgE-mediated allergic response which has a direct or indirect biological link to food allergy. Identifying unique biomarkers associated with certain allergic phenotypes and potentially cross-reactive proteins through bioinformatics analyses will provide enormous insight into the mechanisms that underlie allergic response in patients with food allergies.

Electrophysiological and structural aspects in the frontal cortex after the bee (Apis mellifera) venom experimental treatment

The aim of this study is to evaluate the bioelectrical and structural-functional changes in frontal cortex after the bee venom (BV) experimental treatments simulating both an acute envenomation and a subchronic BV therapy. Wistar rats were subcutaneously injected once with three different BV doses: 700 μg/kg (T(1) group), 2100 μg/kg (T(3) group), and 62 mg/kg (sublethal dose-in T(SL) group), and repeated for 30 days with the lowest dose (700 μg/kg-in T(S) group). BV effects were assessed by electrophysiological, histological, histochemical, and ultrastructural methods. Single BV doses produced discharges of negative and biphasic sharp waves, and epileptiform spike-wave complexes. The increasing frequency of these elements suggested a dose-dependent neuronal hyperexcitation or irritation. As compared to the lower doses, the sublethal dose was responsible for a pronounced toxic effect, confirmed by ultrastructural data in both neurons and glial cells that underwent extensive, irreversible changes, triggering the cellular death. Subchronic BV treatment in T(S) group resulted in a slower frequency and increased amplitude of cortical activity suggesting neuronal loss. However, neurons were still stimulated by the last BV dose. Structural-functional data showed a reduced cellular density in frontal cortex of animals in this group, while the remaining neurons displayed both specific (stimulation of neuronal activity) and unspecific modifications (moderate alterations to necrotic phenomena). Molecular mechanisms involved in BV interactions with the nervous tissue are also discussed. We consider all these data very important for clinicians who manage patients with multiple bee stings, or who intend to set an appropriate BV therapy.

Modular antigen-translocation as a novel vaccine strategy for allergen-specific immunotherapy

PURPOSE OF REVIEW

The purpose of the present review is to describe recent approaches aimed at improving the treatment of allergic diseases through allergen-specific immunotherapy (SIT). Special emphasis will be given to the approach based on specific targeting of the major histocompatibility complex (MHC) class-II antigen-presentation pathway.

RECENT FINDINGS

It is well recognized that IgE-mediated allergic diseases including rhinitis, atopic eczema and allergic asthma are increasing worldwide to a pandemic dimension. The only curative treatment remains allergen-SIT, which, however, requires a long treatment time of 3-5 years with up to 80 injections to confer protection. Recent findings strongly indicate that the treatment time and the number of injections could be drastically reduced by turning immunotherapy to a true vaccination. Direct injection of allergen extracts into the inguinal lymph nodes and targeting the MHC class-II antigen-presentation pathway by recombinant modular antigen-translocating vaccines have the potential to cure allergic diseases in a very short time.

SUMMARY

The mechanisms of allergic inflammation can be divided into four distinct stages: T cell activation, organ-selective homing, survival/reactivation and effector functions. On the basis of this new knowledge several novel concepts aimed at treating allergic diseases have been developed. The area of allergen-SIT is experiencing exciting developments. Reciprocal regulation of effector and regulatory T cell subsets is being more and more used to develop novel strategies for immunomodulation.

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2009

This review highlights some of the research advances in anaphylaxis and hypersensitivity reactions to foods, drugs, and insects, as well as advances in allergic skin disease that were reported in the Journal in 2009. Among key epidemiologic observations, several westernized countries report that more than 1% of children have peanut allergy, and there is some evidence that environmental exposure to peanut is a risk factor. The role of regulatory T cells, complement, platelet-activating factor, and effector cells in the development and expression of food allergy were explored in several murine models and human studies. Delayed anaphylaxis to mammalian meats appears to be related to IgE binding to the carbohydrate moiety galactose-alpha-1,3-galactose, which also has implications for hypersensitivity to murine mAb therapeutics containing this oligosaccharide. Oral immunotherapy studies continue to show promise for the treatment of food allergy, but determining whether the treatment causes tolerance (cure) or temporary desensitization remains to be explored. Increased baseline serum tryptase levels might inform the risk of venom anaphylaxis and might indicate a risk for mast cell disorders in persons who have experienced such episodes. Reduced structural and immune barrier function contribute to local and systemic allergen sensitization in patients with atopic dermatitis, as well as increased propensity of skin infections in these patients. The use of increased doses of nonsedating antihistamines and potential usefulness of omalizumab for chronic urticaria was highlighted. These exciting advances reported in the Journal can improve patient care today and provide insights on how we can improve the diagnosis and treatment of these allergic diseases in the future.

Beyond the black box: drug- and device-associated hypersensitivity events

Background:

Drug- and device-associated hypersensitivity reactions are serious toxicities that can result in respiratory failure or acute cardiac ischemic events, or even severe hypersensitivity syndromes such as Stevens–Johnson syndrome. These toxicities are usually poorly described in the “black box” warnings section of the product labels.

Methods:

Adverse event reports contained in databases maintained by the Project on Medical Research on Adverse Drug Events and Reports (Med-RADAR), product labels, safety advisories disseminated by pharmaceutical manufacturers, the Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC) were reviewed.

Results:

Adverse event reports identified three health care workers who developed nevirapine-associated Stevens–Johnson syndrome following occupational exposure to HIV-infected blood or blood products; four persons with localized hypersensitivity and fatal cardiac events associated with rapamycin- or paclitaxel-coated coronary artery stent placements; and six persons with breast cancer who developed severe or fatal anaphylaxis after receiving adjuvant chemotherapy with Cremophor-EL containing paclitaxel. Safety advisories from the FDA, CDC, and the relevant pharmaceutical manufacturers were ambiguous in their description in “black box” warning sections of package inserts describing these serious and potentially fatal toxicities.

Conclusion:

Improvements are needed in pharmacovigilance and subsequent dissemination of safety advisories for drug/device-associated hypersensitivity reactions.

Demonstrating the safety of manuka honey UMF® 20+in a human clinical trial with healthy individuals

Honey is an established traditional medicine with a variety of putative nutritional and health effects, including antibacterial, antioxidant, anti-inflammatory and prebiotic. The aim of the present study was to investigate the safety of consuming manuka honey, UMF® 20+, on healthy individuals by establishing whether UMF® 20+caused an allergic response (as measured by IgE levels), changed major commensal and beneficial microbial groups in the gut and/or affected levels of one of the most common advanced glycation endpoints, Nɛ-(carboxymethyl)-lysine (CML). The study had a randomised, double-blind cross-over design. A total of twenty healthy individuals aged 42–64 years were recruited. We tested two different honeys– a multiflora honey and UMF® 20+, both produced by Comvita New Zealand Ltd (Te Puke, New Zealand). Multiflora honey or UMF® 20+(20 g) was consumed daily for 4 weeks, with a 2-week ‘washout’ period in between. Blood samples were collected every week for each intervention period and used to measure total IgE levels in serum and advanced glycation endproducts – a consequence of methyglyoxal accumulation. Faecal samples were collected at the beginning and end of each 4-week period. DNA was extracted from faecal samples and the levels of a number of microbial groups in the gut, both beneficial and commensal, were analysed. Neither product changed the levels of IgE or CML or altered gut microbial profiles during the trial, confirming that UMF® 20+is safe for healthy individuals to consume. Despite anecdotal evidence suggesting that manuka honey is good for digestive health, we observed no beneficial effects on lower gut bacterial levels with either honey in this healthy population.

TIM4 and TIM1 modulate the function of CD4+CD25+ T regulatory cells in mice with food allergy

AIM: To evaluate the function of T regulatory (Treg) cells and determine the role of T cell immunoglobulin and mucin domain-containing protein 4 (TIM4) and TIM1 in modulating the function of Treg cells in mice with food allergy.

METHODS: Thirty-two BALB/c mice fed an ovalbumin (OVA)-free diet were randomly and equally divided into four groups: normal saline (NS) group, staphylococcal enterotoxin B (SEB) plus OVA group, anti-TIM1 antibody plus SEB and OVA group, and anti-TIM4 antibody plus SEB and OVA group. Mice in the four groups were sensitized by intraperitoneal injections of NS, SEB/OVA, anti-TIM1/SEB/OVA, and anti-TIM4/SEB/OVA on days 0, 3 and 9, respectively. All mice (except the NS group) were challenged by intraperitoneal injections of SEB/OVA on days 7 and 14, respectively. The expression of forkhead box P3 (FOXP3) mRNA in the jejunum and spleen and TIM4 mRNA in the jejunum was measured by reverse transcription-polymerase chain reaction (RT-PCR). The levels of transforming growth factor β1 (TGF-β1) and interleukin-10 (IL-10) in the serum were analyzed by enzyme-linked immunosorbent assay (ELISA). The expression of TGF-β1 and IL-10 proteins in the jejunum was detected by immunohistochemistry.

RESULTS: Compared with the NS group, the expression levels of FOXP3 mRNA in the jejunum and spleen significantly decreased (0.401 ± 0.145 vs 0.732 ± 0.162 and 0.407 ± 0.082 vs 0.691 ± 0.145, respectively; both P < 0.05), the expression level of TIM4 mRNA increased significantly (P < 0.05), and the levels of TGF-β1 in the serum and jejunum decreased significantly (7859.853 ± 126.704 ng/L vs 8342.814 ± 488.461 ng/L and 108.834 ± 9.634 ng/L vs 156.298 ± 12.002 ng/L, respectively; both P < 0.05) in the SEB/OVA group. In contrast, the expression levels of FOXP3 mRNA in the jejunum and spleen and TGF-β1 in the serum and jejunum were significantly higher in the anti-TIM1/SEB/OVA and anti-TIM4/SEB/OVA groups than in the SEB/OVA group (all P < 0.05).

CONCLUSION: Treg cells in SEB/OVA-sensitized mice are dysfunctional. Pretreatment with anti-TIM1 or anti-TIM4 can restore the function of Treg cells, suggesting that the TIM4-TIM1 pathway may play a key role in the development of food allergy.