Anaphylactic reaction after artificial insemination

Albumins represent highly cross-reactive animal allergens

Albumins from animals are highly cross-reactive allergens for patients suffering from immunoglobulin E (IgE)-mediated allergy. Approximately 20-30% of cat and dog allergic patients show IgE reactivity and mount IgE-mediated allergic reactions to cat and dog albumin. It is astonishing that allergic patients can develop specific IgE responses against animal albumins because these proteins exhibit a more than 70% sequence identity to human serum albumin (HSA) which is the most abundant protein in the blood of the human body. The sequence identity of cat albumin (Fel d 2) and dog albumin (Can f 3) and HSA are 82% and 80%, respectively. Given the high degree of sequence identity between the latter two allergens and HSA one would expect that immunological tolerance would prohibit IgE sensitization to Fel d 2 and Can f 3. Here we discuss two possibilities for how IgE sensitization to Fel d 2 and Can f 3 may develop. One possibility is the failed development of immune tolerance in albumin-allergic patients whereas the other possibility is highly selective immune tolerance to HSA but not to Fel d 2 and Can f 3. If the first assumption is correct it should be possible to detect HSA-specific T cell responses and HSA-containing immune complexes in sensitized patients. In the latter scenario few differences in the sequences of Fel d 2 and Can f 3 as compared to HSA would be responsible for the development of selective T cell and B cell responses towards Fel d 2 as well as Can f 3. However, the immunological mechanisms of albumin sensitization have not yet been investigated in detail although this will be important for the development of allergen-specific prevention and allergen-specific immunotherapy (AIT) strategies for allergy to albumin.

Anaphylaxis to additives in vaccines

Anaphylaxis in connection with the administration of vaccines occurs only very rarely. Triggers of immunoglobulin IgE-mediated and non-IgE-mediated anaphylaxis—in addition to the active ingredient itself—may be excipients contained in the vaccine due to their special properties. Some of the excipients in medicinal products are the same compounds used as additives in food. Furthermore, residues from the manufacturing process (e.g., chicken egg white, casein, antibiotics, formaldehyde) or contaminants (e.g., from the primary packaging material) may be potential triggers of anaphylaxis in vaccines. This review article provides an overview of ingredients in vaccines that pose an allergenic risk potential. The components of COVID-19 vaccines approved and marketed in Germany are discussed with regard to their potential for triggering anaphylaxis and possible pathophysiological mechanisms involved.

Anaphylaxie auf Zusatzstoffe in Impfstoffen

Anaphylaxien im zeitlichen Zusammenhang mit der Verabreichung von Impfstoffen treten nur sehr selten auf. Auslöser von IgE-vermittelten und nicht IgE-vermittelten Anaphylaxien können neben dem Wirkstoff selbst Hilfsstoffe sein, die aufgrund spezieller Eigenschaften im Impfstoff enthalten sind. Bei den Hilfsstoffen in Arzneimitteln handelt es sich teilweise um dieselben Verbindungen, die als Zusatzstoffe in Lebensmitteln eingesetzt werden. Weiterhin kommen in Impfstoffen Rückstände aus dem Herstellungsprozess (z. B. Hühnereiweiß, Kasein, Antibiotika, Formaldehyd) oder Kontaminationen (z. B. aus dem Primärpackmittel) als potenzielle Auslöser von Anaphylaxien in Frage. Der vorliegende Review gibt einen Überblick über Bestandteile in Impfstoffen, von denen ein allergenes Risikopotenzial ausgeht. Die Bestandteile der in Deutschland zugelassenen COVID-19-Impfstoffe als potenzielle Auslöser von Anaphylaxien und mögliche pathophysiologische Mechanismen werden diskutiert.

Zitierweise: Mahler V, Junker AC. Anaphylaxis to additives in vaccines. Allergo J Int 2022;31: 123-36

https://doi.org/10.1007/s40629-022-00215-8

Dermatological Manifestations in Patients Undergoing In Vitro Fertilisation: A Prospective Study

BACKGROUND

Changing sociodemographic patterns with an increase in the age of childbirth have affected fertility rates worldwide. With advancing reproductive medicine, assisted reproductive techniques (ARTs) are becoming common. While dermatological manifestations in normal pregnancies have been well documented, there is a paucity of data regarding cutaneous manifestations in patients undergoing ART.

OBJECTIVES

The objectives of our study were to estimate the incidence and types of dermatological manifestations in patients undergoing in vitro fertilisation (IVF) and to study their associations with age, type of infertility, and outcome of the procedure.

METHODS

A prospective cohort of 200 patients undergoing IVF in a tertiary care centre was observed for occurrence of any dermatological manifestations from initiation of the IVF protocol to the outcome of the procedure at 3 weeks after embryo transfer.

RESULTS

Dermatological manifestations were seen in 27% of the study group, with urticaria being the most common cutaneous finding seen in 13.5%, followed by acneform eruptions (3%). Twenty-six (96.3%) of patients who manifested with urticaria were on progesterone. No statistically significant association was found between the occurrence of dermatological manifestations and the outcome of IVF, type of infertility, history of ART, and ovum donation in our study. Association between the age of the patient and the outcome of IVF cycle was statistically significant.

CONCLUSION

Dermatological manifestations are seen in almost one-quarter of patients undergoing IVF, with progesterone-induced urticaria being the most common. Occurrence of cutaneous manifestations has no significant association with the outcome of IVF.

Flow-assisted basophil activation tests in immediate drug hypersensitivity: two decades of Antwerp experience

The last two decades have witnessed that flow-assisted analysis of in vitro-activated basophils can constitute a valuable adjunct in the in vitro diagnostic approach of immediate drug hypersensitivity reactions (IDHR). This article summarises the current experience with the basophil activation test in the diagnosis of IDHR, with particular focus on allergy to curarising neuromuscular blocking agents, antibiotics (β-lactams and fluoroquinolones), iodinated radiocontrast media and opiates.

Testing for hypersensitivity to seminal fluid-free spermatozoa

Hypersensitivity to human semen (HHS) is an increasingly reported condition with symptoms manifested locally and systemically, which in some cases may result in anaphylaxis. This report describes four cases of HHS all with positive allergy skin prick tests to partner's whole semen. None of the patients elicited a response to seminal fluid-free washed spermatozoa. In cases of high risk of anaphylaxis, we recommend avoiding exposure to semen. By carrying out an allergy skin prick test on seminal fluid-free washed spermatozoa, the risk of immunogenic reaction to the spermatozoa could be eliminated.

Role of sensitization to mammalian serum albumin in allergic disease

Serum albumin (SA) constitutes an intriguing puzzle that is involved in allergic sensitizations from different sources and induces different clinical manifestations. In this article, we describe the role of sensitization to SAs in inducing allergic diseases and the complex interactions and cross-reactivity between SA resulting from its presence in various mammalian tissues and fluids. SAs alone are an uncommon cause of allergic sensitization in airways, but these allergenic proteins likely play a significant role as cross-reacting allergens in individuals sensitized to several types of animal dander. SAs are a minor allergen in milk but a major allergen in meats. Recently, bovine SA has been added to the culture medium of spermatozoids used for artificial insemination. As a consequence, some case reports have shown that bovine SA may be a causative agent in severe anaphylaxis after standard intrauterine insemination or in vitro fertilization.

Inhibition of cation channels in human erythrocytes by spermine

In erythrocytes, spermine concentration decreases gradually with age, which is paralleled by increases of cytosolic Ca²+ concentration, with subsequent cell shrinkage and cell membrane scrambling. Cytosolic Ca²+ was estimated from fluo-3 fluorescence, cell volume from forward scatter, cell membrane scrambling from annexin V binding and cation channel activity with whole-cell patch-clamp in human erythrocytes. Extracellular spermine exerted a dual effect on erythrocyte survival. At 200 μM spermine blunted the increase of intracellular Ca²+, cell shrinkage and annexin V binding following 48 h exposure of cells at +37 °C. In contrast, short exposure (10-30 min) of cells to 2 mM spermine was accompanied by increased cytosolic Ca²+ and annexin binding. Intracellular addition of spermine at subphysiological concentration (0.2 μM) significantly decreased the conductance of monovalent cations (Na+, K+, NMDG+) and of Ca²+. Moreover, spermine (0.2 μM) blunted the stimulation of voltage-independent cation channels by Cl⁻ removal. Spermine (0.2 and 200 μM) added to the extracellular bath solution similarly inhibited the cation conductance in Cl⁻-containing bath solution. The effect of 0.2 μM spermine, but not the effect of 200 μM, was rapidly reversible. Acute addition (250 μM) of a naphthyl acetyl derivative of spermine (200 μM) again significantly decreased basal cation conductance in NaCl bath solution and inhibited voltage-independent cation channels. Spermine is a powerful regulator of erythrocyte cation channel cytosolic Ca²+ activity and, thus, cell survival.

The basophil activation test in immediate-type drug allergy

Diagnosis of drug allergy involves first the recognition of sometimes unusual symptoms as drug allergy and, second, the identification of the eliciting drug. This is an often difficult task, as the clinical picture and underlying pathomechanisms are heterogeneous. In clinical routine, physicians frequently have to rely upon a suggestive history and eventual provocation tests, both having their specific limitations. For this reason both in vivo (skin tests) and in vitro tests are investigated intensively as tools to identify the disease-eliciting drug. One of the tests evaluated in drug allergy is the basophil activation test (BAT). Basophils with their high-affinity IgE receptors are easily accessible and therefore can be used as indicator cells for IgE-mediated reactions. Upon allergen challenge and cross-linking of membrane-bound IgE antibodies (via Fc-epsilon-RI) basophils up-regulate certain activation markers on their surface such as CD63 and CD203c, as well as intracellular markers (eg, phosphorylated p38MAPK). In BAT, these alterations can be detected rapidly on a single-cell basis by multicolor flow cytometry using specific monoclonal antibodies. Combining this technique with in vitro passive sensitization of donor basophils with patients' serum, one can prove the IgE dependence of a drug reaction. This article summarizes the authors' current experience with the BAT in the diagnostic management of immediate-type drug allergy mediated by drug-specific IgE antibodies.

Wound healing and the immune response in swine treated with a hemostatic bandage composed of salmon thrombin and fibrinogen

We investigated the inflammatory response in pigs exposed to salmon fibrinogen/thrombin dressings. Animals were exposed to the material in 3 ways: (a) thrombin and fibrinogen were injected intravenously, (b) dual full-thickness skin lesions were surgically created on the dorsal aspect of the swine and treated with the fibrinogen/thrombin bandage and a commercial bandage or (c) a fibrinogen/thrombin bandage was inserted through an abdominal incision into the peritoneal cavity. Blood was collected twice weekly and animals were sacrificed at 7, 10 or 28 days. Animals in the 28-day dermal lesion group were given an injection of salmon fibrinogen/thrombin at the 10 day point to simulate a second bandage application. The immune response manifested itself as induction of germinal centers in mesenteric lymph nodes and in the white pulp of the spleen. Examination of the histology of the skin and organs showed a cellular inflammatory response with granulation tissue and signs of edema that resolved by the 28-day stage. Antibodies reactive to salmon and human thrombin and fibrinogen were detected, but fibrinogen levels and coagulation processes were not affected. In conclusion, animals treated with salmon fibrinogen/thrombin bandages demonstrated a smooth recovery course in terms of both tissue healing and the immune response without adverse effects from the exposure to the fish proteins.

The basophil activation test in immediate drug allergy

Diagnosis of drug allergy is not always straight forward for several reasons. First, a broad spectrum of drugs can elicit various immune-mediated diseases with distinct pathomechanism, secondly, although exact epitope identification is not mandatory for clinical diagnosis, the epitope that causes the reaction is frequently unknown, thirdly in vitro or in vivo test results might not be predictive of a clinical situation, and finally the gold standard or reference test for diagnosis, the drug challenge, is a complicated and sometimes dangerous endeavour. Upon challenge with specific allergens that cross-link membrane-bound IgE antibodies, basophils upregulate the expression of different activation markers such as CD63 and CD203c. These immunophenotypic alterations can be detected on a single-cell basis by multicolour flow cytometry using specific monoclonal antibodies in the basophil activation test (BAT). This review intends to summarise our current experience with the BAT in the diagnostic management of immediate-type allergy to drugs and related compounds that are generally (but not always) mediated by drug-specific IgE antibodies.

Bovine serum albumin contained in culture medium used in artificial insemination is an important anaphylaxis risk factor

OBJECTIVE

To analyze the cause of the anaphylactic reaction after a standard artificial insemination process in a patient diagnosed with asthma.

DESIGN

Case report.

SETTING

Residencia Sanitaria Virgen de la Arrixaca (Murcia, Spain) and University of the Basque Country (Vitoria, Spain).

PATIENT(S)

A 30-year-old woman with a previous medical history compatible with respiratory allergy who suffered an anaphylactic reaction after an artificial insemination with spermatozoids in capable medium (Upgraded B2 INRA medium; Laboratories CCD, Paris, France).

INTERVENTION(S)

Cutaneous tests and specific IgE levels to inhalant allergens, grass and Olea pollens, and insemination medium were performed.

MAIN OUTCOME MEASURE(S)

Specific IgE levels to mammal epithelia and bovine serum albumin (BSA).

RESULT(S)

Skin prick tests were positive for inhalant allergens such as mites, cat, dog, horse, and rabbit epithelia, grasses and Olea pollens, and the insemination medium. The beta-lactamic tests were negative. The determination of specific IgE demonstrated positive values to mammal epithelia and mammal serum albumins including BSA.

CONCLUSION(S)

We report a case of an anaphylactic reaction to the BSA included in the insemination culture medium induced by a subclinical sensitivity to serum albumins of mammal epithelia. A previous testing with the medium is recommended and specific testing might be needed in women who have a history of animal epithelium allergies.

Flow-assisted allergy diagnosis: current applications and future perspectives

Physicians predominantly rely upon quantification of serum-specific immunoglobulin E (IgE) and/or skin test to confirm clinically suspected IgE-mediated allergy. However, for various reasons, identification of the offending allergen(s) and potentially cross-reactive structures is not always straightforward. Flow-assisted allergy diagnosis relies upon quantification of alterations in the expression of particular basophilic activation markers. Actually, upon challenge with a specific allergen, basophils not only secrete quantifiable bioactive mediators but also upregulate the expression of different markers which can be detected efficiently by flow cytometry using specific monoclonal antibodies. Currently, the technique has been applied in the investigation of IgE-mediated allergy caused by classical inhalant allergens, food, Hevea latex, hymenoptera venoms and drugs. It is also appreciated; the technique proves valuable in the diagnosis of non-IgE-mediated (anaphylactoid) reactions such drug hypersensitivity and the detection of autoantibodies in certain forms of chronic urticaria. This review will not address immunologic features, characteristics and general pitfalls of flow-assisted analysis of in vitro-activated basophils as summarized elsewhere. After a recapitulation of the principles and some specific technical issues of flow-assisted analysis of in vitro-activated basophils, we principally focus on the current clinical and research applications of the basophil activation tests. Personal experience of both research groups is provided, where appropriate. Finally, a viewpoint on how the field might evolve in the following years is provided.

Epidemiology of life-threatening and lethal anaphylaxis: a review

Severe anaphylaxis is a systemic reaction affecting two or more organs or systems and is due to the release of active mediators from mast cells and basophils. A four-grade classification routinely places 'severe' anaphylaxis in grades 3 and 4 (death could be graded as grade 5). Studies are underway to determine the prevalence of severe and lethal anaphylaxis in different populations and the relative frequencies of food, drug, latex and Hymenoptera anaphylaxis. These studies will also analyse the risk arising from the lack of preventive measures applied in schools (personalized management protocols) and from the insufficient use of self-injected adrenalin. Allergy-related conditions may account for 0.2-1% of emergency consultations. Severe anaphylaxis affects 1-3 per 10 000 people, but for the United States and Australia figures are even higher. It is estimated to cause death in 0.65-2% of patients, i.e. 1-3 per million people. An increased prevalence has been revealed by monitoring hospitalized populations by reference to the international classification of disease (ICD) codes. The relative frequency of aetiological factors of allergy (food, drugs, insects and latex) varies in different studies. Food, drug and Hymenoptera allergies are potentially lethal. The risk of food-mediated anaphylaxis can be assessed from the number of personalized management protocols in French schools: 0.065%. Another means of assessment may be the rate of adrenalin prescriptions. However, an overestimation of the anaphylaxis risk may result from this method (0.95% of Canadian children). Data from the literature leads to several possibilities. First, a definition of severe anaphylaxis should be agreed. Secondly, prospective, multicentre enquiries, using ICD codes, should be implemented. Moreover, the high number of anaphylaxis cases for which the aetiology is not identified, and the variation in aetiology in the published series, indicate that a closer cooperation between emergency specialists and allergists is essential.