Failure to detect circulating immune complexes in allergic patients on injection therapy

Systemic reactions and fatalities associated with allergen immunotherapy

OBJECTIVE

The primary objective of this review is to discuss systemic allergic reactions and risk factors associated with the injection of allergen vaccines.

DATA SOURCES

A review of the literature on anaphylactic reaction, adverse effects, and fatalities associated with allergen immunotherapy (IT) was conducted.

STUDY SELECTION

The expert opinion of the author was used to select relevant data.

RESULTS

Systemic allergic reactions associated with the injection of allergen vaccines usually begin within 20 minutes. However, on occasion, they begin 20 to 30 minutes or longer after an injection. Such reactions can also occur after allergen skin testing. Most reactions associated with skin testing and allergen IT are mild and readily respond to appropriate treatment. However, severe and even fatal reactions have been reported with both skin testing and IT.

CONCLUSIONS

Risk factors for skin testing and allergen IT include: 1) patients, particularly asthmatic patients, suffering with seasonal exacerbation of their symptoms; 2) patients who demonstrate exquisite sensitivity to particular allergen(s); 3) patients on beta-blockers; 4) patients with asthma, especially if their asthma is unstable; 5) patients in whom rush IT is used; and 6) patients in whom high doses of potent standardized allergen vaccines are used. It is essential that strict attention be paid to the risk factors for systemic reactions, and that techniques and management be initiated both before and after skin testing or IT to minimize these risks. Done properly, the risk of skin testing and IT is minimal.

A prospective study on the safety of immunotherapy in children with severe asthma

One hundred and six of 503 (21%) consecutive children with asthma, who from 1979 to 1983 commenced hyposensitization therapy, were prospectively studied on the safety of immunotherapy. More than 80% of the patients completed therapy without side effects. Thirteen patients were withdrawn from hyposensitization due to moderate and predictable, but intolerable, side effects such as asthma/rhinitis, urticaria and subcutaneous nodules and hypersensitivity to aluminium. However, more alarming was the outcome in six children, who after an uneventful course of immunotherapy and after several months on maintenance therapy, suddenly, 5 to 20 min (mean 10 min) following an earlier tolerable allergen injection, developed severe, anaphylactic reactions, in three of them nearly fatal. Mould extracts were responsible for the most frequent and serious side effects (Alternaria iridis/alternata, 3 patients, Cladosporium herbarum, 8 patients). Furthermore, serious, but not immediately life-threatening, anaphylactic reactions occurred in two children treated with Phleum pratense. On the other hand, hyposensitization with Dermatophagoides pteronyssinus was very well tolerated.

[Dermatopolymyositis during desensitization with candidin]

A dermatopolymyositis observation is reported. An urticaria has preceded the dermatopolymyositis and has been treated by a desensitivity procedure. The possible connection between this treatment and the dermatopolymyositis occurring is debated. This observation gives the opportunity to point out the importance of a thorough knowledge of the phenomena involved by such a treatment.

Circulating immune complexes in patients with house-dust-mite-sensitive bronchial asthma

Sera from forty patients with house-dust-mite-sensitive bronchial asthma were examined for the presence of circulating immune complexes (CIC) by the sensitive and quantitative Clq solid-phase radioimmunoassay (Clq-SP) and a monoclonal rheumatoid factor solid-phase radioimmunoassay (mRF-SP). Compared to fifteen normal individuals, the asthmatic patients showed significantly higher mean values of Clq-reactive materials; however, there was no difference between the results from the patients treated by immunotherapy using Dermatophagoides farinae extract and those not so treated. Moreover, immune complexes in eight patients before and after immunotherapy showed that the amount of the complexes tend to decrease during immunotherapy. Furthermore, the presence of complexes had no relationship with the amounts of mite-specific IgG antibody. Similar results were also obtained in tests using mRF-SP. These data suggest that complexes in the sera of the house-dust-mite-sensitive asthmatic patients are not necessarily associated either with immunotherapy or with the mite-specific IgG antibodies.

IgG-containing and IgE-containing circulating immune complexes in patients with asthma and rhinitis

In looking for an additional mechanism that could cause inflammation and therefore be important in the pathogenesis of asthma and rhinitis, IgG- and IgE-CIC were determined in a number of patients that were suffering from asthma and/or rhinitis. Patients were further subdivided into allergic (type I allergy) and nonallergic patients on the basis of history, skin testing with common inhalant allergens, RAST, and, if necessary, allergen provocation. In addition, a control group and patients that were undergoing allergen-specific hyposensitization were studied also. The mean level and frequency of elevated IgG-CIC were significantly increased in all three patient groups as compared to controls. The frequency of IgE-CIC was only significantly elevated in both allergic groups, and the difference between allergic and nonallergic patients was highly significant. IgG- and IgE-CIC did not increase during long-term allergen hyposensitization. Since there was no significant increase of IgE-CIC 10 min after bronchial allergen challenge nor at the moment that symptoms such as urticaria, bronchial obstruction, or rhinorrhea appeared during rush hyposensitization in asthmatic patients, we think that CIC are not involved in classic type I allergic reactions. The possible role of IgG- and IgE-CIC in inducing inflammatory, mediator release from eosinophils and macrophages via binding of Fc receptors on these cells is discussed.

The hazard of mould hyposensitization in children with asthma

Of thirty-eight children, who were immunized with mould extracts, seven (19%) were withdrawn from hyposensitization due to serious side-effects clinically consistent with a type III reaction. These seven children exhibited a two- to four-fold increase in circulating precipitating-antibodies to the injected extracts, and had shown a slight increase in precipitating antibodies to the mould extracts used before hyposensitization. A further fourteen patients, also hyposensitized with mould extracts but without side effects did not develop precipitating antibodies. It is suggested that hyposensitization with mould extracts may be hazardous in children who may have a primary "immune imbalance' with a risk of provoking type III reactions.

Inflammatory bowel disease associated circulating immune complexes

Circulating immune complexes have been detected in patients with inflammatory bowel disease (IBD). To determine if these complexes are related specificially to IBD or more generally to loss of intestinal mucosal integrity, we compared circulating immune complex levels in the sera of 86 IBD patients, nine pseudomembranous and nine bacterial colitis patients, and 42 healthy controls. Immune complexes were measured by a Raji cell radioimmunoassay. Raji detectable circulating immune complex levels were significantly higher in the IBD group than in the healthy controls (P<0.001). Circulating immune complex levels in the pseudomembranous-bacterial colitis group and the healthy controls were essentially identical. While nearly 20% of the IBD patients (16 of 86) had abnormally high levels, none of the patients with the other forms of intestinal inflammation (0 of 18) had abnormal levels. These data suggest that the circulating immune complexes present in inflammatory bowel disease patients are related to the IBD process rather than to non-specific mucosal cell (barrier) damage. Patients with intestinal inflammation and normal peripheral immune complex levels also had normal mesenteric vein levels. These data suggest that lack of formation, rather than more efficient hepatic reticuloendothelial clearance, was primarily responsible for the absence of detectable complexes in Raji negative individuals. Circulating immune complex levels did not correlate with type, location, severity, or extraintestinal manifestations of inflammatory bowel disease. The absence of Raji detectable circulating immune complexes in the majority of patients, even in those with extraintestinal manifestations, raises serious doubts about the pathogenic significance of such complexes. Nevertheless, as the circulating immune complexes appear to be disease related, they may be used to isolate and identify disease specific antigen(s) of possible aetiological importance.