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Lee WI, Lam L, Bacchi S, Jiang M, Inglis JM, Smith W, Hissaria P. Antibiotic prophylaxis in immunosuppressed patients - Missed opportunities from trimethoprim-sulfamethoxazole allergy label. World Allergy Organ J 2024; 17:100856. [PMID: 38235260 PMCID: PMC10793173 DOI: 10.1016/j.waojou.2023.100856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 01/19/2024] Open
Abstract
Trimethoprim-sulfamethoxazole (TMP-SMX) is a broad spectrum antibiotic in use for more than 50 years. It has an important indication as first line agent in the prophylaxis of opportunistic infections, particularly Pneumocystis jirovecii pneumonia (PJP), in immunosuppressed patients. For those who have a history of allergy or severe intolerance to TMP-SMX, pentamidine, dapsone or atovaquone may be substituted; however there is evidence that TMP-SMX offers superior coverage for PJP, toxoplasmosis, and nocardiosis. Compared to pentamidine, it has the added benefit of cost-effectiveness and self-administration as opposed to required hospital attendance for administration. Many patients who report a history of allergy or adverse reaction to TMP-SMX (or "sulfur allergy") will be found not to be allergic; and even those who are allergic may be able to be desensitized. The evaluation and, where appropriate, removal of TMP-SMX allergy label enables the use of TMP-SMX for prophylaxis against opportunistic infections. This is a cost-effective intervention to optimize antimicrobial prescribing and reduce the risk of opportunistic infections in immunosuppressed patients.
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Affiliation(s)
- Wei-I Lee
- Department of Immunology, The Canberra Hospital, Yamba Drive, Garran, ACT, 2605, Australia
- Australian National University, Canberra, ACT, 2601, Australia
| | - Lydia Lam
- University of Adelaide, Adelaide SA 5005, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Melinda Jiang
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Joshua M. Inglis
- University of Adelaide, Adelaide SA 5005, Australia
- Flinders Medical Centre and University, Bedford Park, SA, 5042, Australia
| | - William Smith
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Pravin Hissaria
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Department of Immunopathology, SA Pathology, Frome Rd, Adelaide, 5000, Australia
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In Vitro Assays for Diagnosis of Drug-Induced Nonsevere Exanthemas: A Systematic Review and Meta-Analysis. J Immunol Res 2022; 2022:2386654. [PMID: 36590449 PMCID: PMC9797304 DOI: 10.1155/2022/2386654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/20/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Abstract
Frequent mislabelled causal relationship between drug hypersensitivity reactions and culprit drugs reinforces the need for an accurate diagnosis. The systematic reviews and meta-analyses of in vitro assays published so far focused on immediate reactions and the most severe delayed reactions, while the most frequent drug-induced delayed reactions-nonsevere exanthemas-have been underestimated. We aim to fill this gap. A systematic review of studies on in vitro assays used in the diagnosis of nonsevere drug-induced delayed reactions was conducted following the methodology of Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies Statement. The EMBASE and PubMed databases were searched. We have included 33 studies from which we extracted the data, then performed meta-analysis where possible, or synthesised the evidence narratively. The quality of the analysed studies was assessed with the QUADAS-2 tool. The tests identified the most frequently were lymphocyte transformation test (LTT), ELISpot, and ELISA. In the meta-analysis carried out for LTT in reactions induce by beta-lactams, the pool estimate of sensitivity and specificity amounted to 49.1% (95% CI: 14.0%, 85.0%) and 94.6% (95% CI: 81.7%, 98.6%), respectively. The studies showed heterogeneity in study design and laboratory settings, which resulted in a wide range of specificity and sensitivity of testing.
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Weir C, Li J, Fulton R, Fernando SL. Development and initial validation of a modified lymphocyte transformation test (LTT) assay in patients with DRESS and AGEP. ALLERGY, ASTHMA & CLINICAL IMMUNOLOGY 2022; 18:90. [PMID: 36210462 PMCID: PMC9548132 DOI: 10.1186/s13223-022-00729-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022]
Abstract
Background The lymphocyte transformation test (LTT) is an in vitro assay used to diagnose drug induced hypersensitivity reactions by detecting the activation and expansion of drug-specific memory T cells to the suspected implicated drug. Traditionally radiolabelled thymidine (3H-thymidine) has been used but requires the handling and disposal of radioactive materials. Objective To examine safe alternatives to 3H-thymidine, test assay modifications for improved assay sensitivity and evaluate the modified LTT in patients with DRESS and AGEP. Methods Four proliferation detection assays (BRDU, CyQUANT™, MTT and XTT) were screened for LTT sensitivity. XTT the most sensitive and practical was selected for further evaluation Modifications like autologous serum (AS) and regulatory T cell depletion (T-REG) were tested for improved assay sensitivity. Finally, an initial evaluation of the XTT–LTT was performed in 8 patients with DRESS and 2 with AGEP including cytokine testing. Results Of the non-radioactive alternatives we tested, XTT a colorimetric assay was the most sensitive and practical to move to evaluation. The addition of AS increased background signal. Depletion of T-REGs improved sensitivity but cell sorting time and risk of contamination limited benefit. Of eight patients diagnosed with DRESS and 2 with AGEP tested with XTT–LTT assay results showed our assay matched clinical findings of implicated drugs in 8/10 patients when using a stimulation index (SI) ≥ 2 and 8/10 with analysis by ANOVA. All ten patients were correctly diagnosed by either analysis. Conclusion XTT appears to be a safe, viable alternative to 3H-thymidine, with high sensitivity and allowing direct cytokine quantification on specific patient cells.
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Srinoulprasert Y, Kumkamthornkul P, Tuchinda P, Wongwiangjunt S, Sathornsumetee S, Jongjaroenprasert K, Kulthanan K. Differential cytokine profiles produced by anti-epileptic drug re-exposure of peripheral blood mononuclear cells derived from severe anti-epileptic drug patients and non-allergic controls. Cytokine 2022; 157:155951. [DOI: 10.1016/j.cyto.2022.155951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/01/2022] [Accepted: 06/20/2022] [Indexed: 12/01/2022]
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Saito T, Usui T, Inada H, Miyawaki I, Mizuno K, Ikeda M, Iwata N. Clozapine-specific proliferative response of peripheral blood-derived mononuclear cells in Japanese patients with clozapine-induced agranulocytosis. J Psychopharmacol 2022; 36:1087-1094. [PMID: 35861221 DOI: 10.1177/02698811221112937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although clozapine-induced granulocytopenia (CIG) is less severe than clozapine-induced agranulocytosis (CIA), and some patients with CIG may not go on to develop serious complications, clozapine is discontinued in cases of both CIA and CIG. Understanding the pathogenic mechanisms of CIA/CIG could provide better management of clozapine therapy. Recently, as a mechanistic insight into adaptive immune systems, European groups reported clozapine-specific proliferative responses and clozapine-specific T cells using blood taken from patients with CIA and/or CIG. AIMS The aims of our study are to support this mechanistic evidence and to investigate the difference in the lymphocyte response to clozapine between patients with CIG and those with CIA. METHODS Lymphocyte stimulation tests (LSTs) were conducted using CD25-positive cell-depleted peripheral blood-derived mononuclear cells (PBMCs) isolated from blood of four Japanese patients with CIA, four patients with CIG, and nine clozapine-tolerant subjects. RESULTS Three of four patients with CIA and one of four patients with CIG showed proliferative responses to clozapine with a stimulation index of greater than 2. In contrast, none of the nine clozapine-tolerant subjects showed any response to clozapine. Olanzapine did not stimulate PBMCs of patients with CIA, patients with CIG, or clozapine-tolerant subjects. CONCLUSIONS Clozapine- and CIA-specific lymphocyte reactions in a Japanese population provided supportive evidence that the pathogenesis of CIA is based on adaptive immune reactions. In addition, patients with CIG who show a positive response to an LST may at the very least not be chosen for clozapine-rechallenge and further prospective studies are desirable to verify this hypothesis.
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Affiliation(s)
- Takeo Saito
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Toru Usui
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Hiroshi Inada
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Izuru Miyawaki
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | | | - Masashi Ikeda
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Nakao Iwata
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
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Antibiotic Allergy De-Labeling: A Pathway against Antibiotic Resistance. Antibiotics (Basel) 2022; 11:antibiotics11081055. [PMID: 36009924 PMCID: PMC9404790 DOI: 10.3390/antibiotics11081055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 12/10/2022] Open
Abstract
Antibiotics are one of the most frequently prescribed drugs. Unfortunately, they also are the most common cause for self-reported drug allergy, limiting the use of effective therapies. However, evidence shows that more than 90% of patients labeled as allergic to antibiotics are not allergic. Importantly, the label of antibiotic allergy, whether real or not, constitutes a major public health problem as it directly impacts antimicrobial stewardship: it has been associated with broad-spectrum antibiotic use, often resulting in the emergence of bacterial resistance. Therefore, an accurate diagnosis is crucial for de-labeling patients who claim to be allergic but are not really allergic. This review presents allergy methods for achieving successful antibiotic allergy de-labeling. Patient clinical history is often inaccurately reported, thus not being able to de-label most patients. In vitro testing offers a complementary approach but it shows limitations. Immunoassay for quantifying specific IgE is the most used one, although it gives low sensitivity and is limited to few betalactams. Basophil activation test is not validated and not available in all centers. Therefore, true de-labeling still relies on in vivo tests including drug provocation and/or skin tests, which are not risk-exempt and require specialized healthcare professionals for results interpretation and patient management. Moreover, differences on the pattern of antibiotic consumption cause differences in the diagnostic approach among different countries. A multidisciplinary approach is recommended to reduce the risks associated with the reported penicillin allergy label.
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Glässner A, Dubrall D, Weinhold L, Schmid M, Sachs B. Lymphocyte Transformation Test for drug allergy detection: when does it work? Ann Allergy Asthma Immunol 2022; 129:497-506.e3. [PMID: 35732204 DOI: 10.1016/j.anai.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The lymphocyte transformation test (LTT) is an in vitro test system for the detection of a sensitization in the context of allergies to drugs. Its reported sensitivity varies largely and seems to be affected by different parameters. In review articles, the average LTT performance was often calculated by combining overall mean sensitivities of various published studies, but without considering different patient characteristics or varying patient numbers per publication. OBJECTIVE This meta-analysis aims to investigate the impact of different patient-specific and methodical parameters on the sensitivity of the LTT based on data on the level of the individual patient extracted from single studies. METHODS We performed an advanced literature search in Pubmed and screened the identified publications according to previously defined inclusion criteria. In total, individual patient data from 721 patients were extracted from 30 studies. Random-effects meta-regression analyses were performed. RESULTS The analysis indicate that the ELISA-based read-out is more sensitive compared to the classical radioactivity method (ELISA: 80% vs. radioactivity: 66%;p=0.084). Interestingly, DRESS/DHISS is associated with a higher probability of a positive LTT test result compared to other investigated clinical phenotypes ("DRESS/DHISS" vs. "bullous reaction"; OR: 2.52;p-value=0.003). Our analysis also revealed an impact of the time to testing period after the occurrence of the allergic event ("<2 weeks" vs. "2 weeks-2 months"; OR: 2.12;p-value=0.034). CONCLUSION The read-out method and relevant clinical parameters affect the sensitivity of the LTT. These findings are based on a meta-analysis providing a higher level of evidence than a single study or previous reviews not considering individual patient data.
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Affiliation(s)
- Andreas Glässner
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany.
| | - Diana Dubrall
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany; Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Leonie Weinhold
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Bernhardt Sachs
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany; Department for Dermatology and Allergy, University Hospital Aachen, Aachen, Germany
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Srinoulprasert Y. Lymphocyte transformation test and cytokine detection assays: Determination of read out parameters for delayed-type drug hypersensitivity reactions. J Immunol Methods 2021; 496:113098. [PMID: 34216607 DOI: 10.1016/j.jim.2021.113098] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 06/23/2021] [Accepted: 06/29/2021] [Indexed: 12/15/2022]
Abstract
Drug hypersensitivity reactions (DHRs) occur in certain people and are often not predictable. DHRs can be classified as immediate and delayed reactions regarding to onset of clinical manifestations. Both reactions are considered to be an important public health problem because they can lead to life-threatening conditions; however, this review article will focus on delayed DHRs. The most important points for diagnosis of delayed DHRs are the recognition of drug hypersensitivity characteristics and culprit drug identification. While it is usually difficult to identify a culprit drug; clinical evaluation using the causality assessment method, a non-invasive process, can identify the culprit drug without the need for intensive investigation. Delayed DHRs can cause life-threatening conditions; therefore, in vivo skin tests, as well as drug provocation tests, have to be cautiously performed by a drug allergist and have not been recommended in uncontrolled conditions. ENDA/EAACI has recommended that in vitro tests (if available) be performed prior to any in vivo tests. Therefore, in vitro diagnostic tests can be alternative methods to identify a culprit drug for delayed DHR diagnosis as there is no or very low risk for patients under investigation. There are many testing approaches to identify causative agents for delayed DHRs such as: the lymphocyte transformation test (LTT), cytokine/mediator detection assays (i.e. ELISA and flow cytometry-based bead assays), multiplex bead-based immunoassay and ELISpot. The LTT is the most standardized method whereas it has been available in medical schools affiliated with university hospitals. Other in vitro tests, like cytokine detection assays, have also been used, even though they are still being evaluated. They could supplement LTT results that would provide drug allergist's with documentary evidence and prevent risk to patients by avoiding in vivo or drug provocation testing. Hence, the in vitro tests have been promising tests contributing to the management of the delayed DHR work-up process in clinical practice.
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Affiliation(s)
- Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand.
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Fatangare A, Glässner A, Sachs B, Sickmann A. Future perspectives on in-vitro diagnosis of drug allergy by the lymphocyte transformation test. J Immunol Methods 2021; 495:113072. [PMID: 34000289 DOI: 10.1016/j.jim.2021.113072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/22/2021] [Accepted: 05/12/2021] [Indexed: 11/26/2022]
Abstract
This article aims to envisage future perspectives of the lymphocyte transformation test (LTT). We describe the select innovative techniques, which can be integrated at different stages of the LTT to potentially improve the sensitivity, specificity, or practicability of the LTT. We first focus upon the cell sorting techniques comprising immunomagnetic cell separation and flow cytometry, which can be implemented prior and after the LTT culturing step to concentrate and quantify specific immune cell types. Further, we elaborate upon three important omics techniques such as transcriptomics, proteomics, and metabolomics, which can be integrated downstream of the LTT to analyze molecular changes in specific immune cells following drug induced activation and proliferation. We also develop visions, how state of the art techniques used in other scientific fields, can be transferred and applied in the context of in-vitro detection of drug allergy.
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Affiliation(s)
- Amol Fatangare
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany
| | - Andreas Glässner
- Federal Institute for Drugs and Medical Devices, Research Division, Bonn, Germany
| | - Bernhardt Sachs
- Federal Institute for Drugs and Medical Devices, Research Division, Bonn, Germany; Department for Dermatology and Allergology, University Hospital Aachen, Germany
| | - Albert Sickmann
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany; Medizinische Fakultät, Medizinisches Proteom-Center (MPC), Ruhr-Universität Bochum, 44801 Bochum, Germany; Department of Chemistry, College of Physical Sciences, University of Aberdeen, Aberdeen, AB243FX, Scotland, UK.
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Sachs B, Fatangare A, Sickmann A, Glässner A. Lymphocyte transformation test: History and current approaches. J Immunol Methods 2021; 493:113036. [PMID: 33745950 DOI: 10.1016/j.jim.2021.113036] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 02/07/2023]
Abstract
Drug-induced hypersensitivity reactions encompass a variety of different clinical phenotypes ranging from harmless rashes to fatal reactions. They can be classified into allergic (i.e. drug allergy) and non-allergic reactions (i.e. non-allergic hypersensitivity). Drug allergies in turn can either be antibody (e.g. IgE) or T cell-mediated. One of the diagnostic tools for the in vitro detection of drug allergy is the lymphocyte transformation test (LTT) which is based on the activation and expansion of the drug-specific memory T cells following co-incubation of the patient's peripheral mononuclear cells (PMBC) with the suspected drug in vitro. The read-out parameter in the classical LTT is T cell proliferation which can be measured as counts per minute following the addition of radiolabeled thymidine to the cell culture. However, in the course of time different modifications of the classical LTT with regard to the read-out parameters and methods have been proposed. Likewise, variations of the LTT platform itself have been described in the literature. This review article describes the development of the classical LTT and its use in the context of drug allergy detection and summarizes the modifications which have been published over time.
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Affiliation(s)
- Bernhardt Sachs
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany; Department for Dermatology and Allergology, University Hospital Aachen, Germany.
| | - Amol Fatangare
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany
| | - Albert Sickmann
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany; Medizinische Fakultät, Medizinisches Proteom-Center (MPC), Ruhr-Universität Bochum, 44801 Bochum, Germany; Department of Chemistry, College of Physical Sciences, University of Aberdeen, Aberdeen AB243FX, UK
| | - Andreas Glässner
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
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Goh SJR, Tuomisto JEE, Purcell AW, Mifsud NA, Illing PT. The complexity of T cell-mediated penicillin hypersensitivity reactions. Allergy 2021; 76:150-167. [PMID: 32383256 DOI: 10.1111/all.14355] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 04/16/2020] [Accepted: 04/30/2020] [Indexed: 12/20/2022]
Abstract
Penicillin refers to a group of beta-lactam antibiotics that are the first-line treatment for a range of infections. However, they also possess the ability to form novel antigens, or neoantigens, through haptenation of proteins and can stimulate a range of immune-mediated adverse reactions-collectively known as drug hypersensitivity reactions (DHRs). IgE-mediated reactions towards these neoantigens are well studied; however, IgE-independent reactions are less well understood. These reactions usually manifest in a delayed manner as different forms of cutaneous eruptions or liver injury consistent with priming of an immune response. Ex vivo studies have confirmed the infiltration of T cells into the site of inflammation, and the subsets of T cells involved appear dependent on the nature of the reaction. Here, we review the evidence that has led to our current understanding of these immune-mediated reactions, discussing the nature of the lesional T cells, the characterization of drug-responsive T cells isolated from patient blood, and the potential mechanisms by which penicillins enter the antigen processing and presentation pathway to stimulate these deleterious responses. Thus, we highlight the need for a more comprehensive understanding of the underlying genetic and molecular basis of penicillin-induced DHRs.
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Affiliation(s)
- Shawn J. R. Goh
- Infection and Immunity Program Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology Monash University Clayton Vic. Australia
| | - Johanna E. E. Tuomisto
- Infection and Immunity Program Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology Monash University Clayton Vic. Australia
| | - Anthony W. Purcell
- Infection and Immunity Program Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology Monash University Clayton Vic. Australia
| | - Nicole A. Mifsud
- Infection and Immunity Program Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology Monash University Clayton Vic. Australia
| | - Patricia T. Illing
- Infection and Immunity Program Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology Monash University Clayton Vic. Australia
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Gelincik A, Cavkaytar O, Kuyucu S. An Update on the Management of Severe Cutaneous Drug Hypersensitivity Reactions. Curr Pharm Des 2019; 25:3881-3901. [DOI: 10.2174/1381612825666191106115556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022]
Abstract
Severe cutaneous drug hypersensitivity reactions involve of different mechanisms , some of which are
life-threatening, such as Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia
and systemic symptoms, acute generalized exanthematous pustulosis, generalized bullous fixed drug eruptions,
serum sickness and serum sickness-like reaction and drug-induced vasculitis. These reactions may have substantial
morbidity and mortality. In the past years, successive studies have provided new evidence regarding the
pathogenesis of some of these severe reactions and revealed that underlying mechanisms are highly variable.
Since these reactions have unique presentations and distinct pathomechanisms, the treatment methods and response
rates might be different among various entities. Although supportive and local therapies are sufficient in
some of these reactions, targeted immunosuppressive treatments and even mechanistic therapies such as plasmapheresis
may be required in severe ones. However, there is still insufficient evidence to support the best treatment
options for these patients since number of patients and large-scale studies are limited. In this review, conventional
and new treatment options for severe cutaneous drug hypersensitivity reactions are presented in detail in
order to provide the contemporary approaches to lessen the morbidity and mortality relevant to these severe iatrogenic
diseases.
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Affiliation(s)
- Aslı Gelincik
- Division of Immunology and Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Mersin University, Faculty of Medicine, Mersin, Turkey
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Making a diagnosis in severe cutaneous drug hypersensitivity reactions. Curr Opin Allergy Clin Immunol 2019; 19:283-293. [DOI: 10.1097/aci.0000000000000546] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
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Suthumchai N, Srinoulprasert Y, Thantiworasit P, Rerknimitr P, Tuchinda P, Chularojanamontri L, Rerkpattanapipat T, Chanprapaph K, Disphanurat W, Chakkavittumrong P, Tovanabutra N, Srisuttiyakorn C, Sukasem C, Klaewsongkram J. The measurement of drug-induced interferon γ-releasing cells and lymphocyte proliferation in severe cutaneous adverse reactions. J Eur Acad Dermatol Venereol 2018; 32:992-998. [PMID: 29478292 DOI: 10.1111/jdv.14890] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/30/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The lymphocyte transformation test (LTT) is a standard laboratory method to identify culprit drugs in patients with a history of drug-induced non-immediate hypersensitivity and is mainly performed during the recovery phase. The measurement of drug-specific interferon γ (IFN-γ)-releasing cells has been introduced to confirm culprit drugs, even during the acute phase of drug allergy. OBJECTIVES This study aimed to evaluate the capability of the enzyme-linked immunospot assay (ELISpot) to detect drug-specific IFN-γ-releasing cells during the acute phase and the capability of LTT to identify culprit drugs during the recovery phase in patients presenting with severe cutaneous adverse reactions (SCARs). METHODS Peripheral blood mononuclear cells (PBMCs) from 23 SCAR patients were collected during the acute and recovery phases and assayed for drug-specific IFN-γ-releasing cells and lymphocyte proliferation, respectively. RESULTS Drug-specific IFN-γ-releasing cells were detectable in 73.9% of SCAR subjects (55.6% and 85.7% in patients who were and were not taking systemic steroids, respectively), whereas LTT results were positive in 52.2% of SCAR subjects. The frequencies of drug-specific IFN-γ-releasing cells were significantly higher in patients with positive LTT than in those with negative LTT (260.1 ± 110.0 and 46.6 ± 20.7 cells/106 PBMCs, P = 0.01). A significant correlation between the results of the IFN-γ ELISpot assay and LTT was demonstrated (r = 0.65, P value <0.01). CONCLUSION The IFN-γ ELISpot assay could be a useful tool to identify culprit drugs in SCAR patients when culprit drug identification is urgently needed during the acute phase of drug allergy.
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Affiliation(s)
- N Suthumchai
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Y Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P Thantiworasit
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - P Rerknimitr
- King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of Dermatology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - P Tuchinda
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - L Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - T Rerkpattanapipat
- Allergy Immunology and Rheumatology Division, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - K Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - W Disphanurat
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - P Chakkavittumrong
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - N Tovanabutra
- Dermatologic Division, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - C Srisuttiyakorn
- Division of Dermatology, Department of Medicine, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - C Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - J Klaewsongkram
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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16
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An Updated Review of the Molecular Mechanisms in Drug Hypersensitivity. J Immunol Res 2018; 2018:6431694. [PMID: 29651444 PMCID: PMC5830968 DOI: 10.1155/2018/6431694] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/09/2017] [Indexed: 02/07/2023] Open
Abstract
Drug hypersensitivity may manifest ranging from milder skin reactions (e.g., maculopapular exanthema and urticaria) to severe systemic reactions, such as anaphylaxis, drug reactions with eosinophilia and systemic symptoms (DRESS)/drug-induced hypersensitivity syndrome (DIHS), or Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). Current pharmacogenomic studies have made important strides in the prevention of some drug hypersensitivity through the identification of relevant genetic variants, particularly for genes encoding drug-metabolizing enzymes and human leukocyte antigens (HLAs). The associations identified by these studies are usually drug, phenotype, and ethnic specific. The drug presentation models that explain how small drug antigens might interact with HLA and T cell receptor (TCR) molecules in drug hypersensitivity include the hapten theory, the p-i concept, the altered peptide repertoire model, and the altered TCR repertoire model. The broad spectrum of clinical manifestations of drug hypersensitivity involving different drugs, as well as the various pathomechanisms involved, makes the diagnosis and management of it more challenging. This review highlights recent advances in our understanding of the predisposing factors, immune mechanisms, pathogenesis, diagnostic tools, and therapeutic approaches for drug hypersensitivity.
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Abstract
During the past decade, major advances have been made in the accurate diagnosis of severe cutaneous adverse reactions (SCARs) to drugs, management of their manifestations, and identification of their pathogenetic mechanisms and at-risk populations. Early recognition and diagnosis of SCARs are key in the identification of culprit drugs. SCARS are potentially life threatening, and associated with various clinical patterns and morbidity during the acute stage of Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reactions with eosinophilia and systemic symptoms, and acute generalised exanthematous pustulosis. Early drug withdrawal is mandatory in all SCARs. Physicians' knowledge is essential to the improvement of diagnosis and management, and in the limitation and prevention of long-term sequelae. This Seminar provides the tools to help physicians in their clinical approach and investigations of SCARs.
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Affiliation(s)
- Tu Anh Duong
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France.
| | - Laurence Valeyrie-Allanore
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France
| | - Pierre Wolkenstein
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France
| | - Olivier Chosidow
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France; French Satellite of the Cochrane Skin Group, Créteil, France; INSERM, Centre d'Investigation Clinique 1430, Créteil, France
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18
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Porebski G. In Vitro Assays in Severe Cutaneous Adverse Drug Reactions: Are They Still Research Tools or Diagnostic Tests Already? Int J Mol Sci 2017; 18:E1737. [PMID: 28796198 PMCID: PMC5578127 DOI: 10.3390/ijms18081737] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/07/2017] [Accepted: 08/04/2017] [Indexed: 12/25/2022] Open
Abstract
Severe cutaneous adverse drug reactions (SCARs) represent life-threatening medical conditions and an appropriate causative diagnosis of these conditions is of the highest importance. Existing in vivo diagnostic methods are risky or are just contraindicated in these patients. Therefore, in vitro tests take on greater significance. In this survey, the studies on in vitro assays in SCARs were identified with a defined searching strategy and strict eligibility criteria. Different methods in the particular clinical manifestations and the groups of drugs were compared in respect to the diagnostic parameters obtained. The lymphocyte transformation test and IFNg-ELISpot (Interferon γ-Enzyme-linked immunospot assay) appeared to have the best evidence currently available. Further diagnostic assays, which are based mostly on distinct mechanisms of SCARs, may outdo previous assays but they still need confirmation in a larger group of patients and in more research centers. Data from pediatric populations and acute generalized exanthematous pustulosis (AGEP) patients are scarce. Some technical issues, limitations, and modifications of routine laboratory methods are also discussed.
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Affiliation(s)
- Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Sniadeckich 10, 31-531 Krakow, Poland.
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19
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Multiple drug sensitization syndrome: A distinct phenotype associated with unrecognized Mycoplasma pneumonia infection. JAAD Case Rep 2017; 3:301-305. [PMID: 28752116 PMCID: PMC5517838 DOI: 10.1016/j.jdcr.2017.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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20
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Karami Z, Mesdaghi M, Karimzadeh P, Mansouri M, Taghdiri MM, Kayhanidoost Z, Jebelli B, Shekarriz Foumani R, Babaie D, Chavoshzadeh Z. Evaluation of Lymphocyte Transformation Test Results in Patients with Delayed Hypersensitivity Reactions following the Use of Anticonvulsant Drugs. Int Arch Allergy Immunol 2016; 170:158-62. [PMID: 27560351 DOI: 10.1159/000448284] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/11/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM Administration of the anticonvulsant drugs phenobarbital, phenytoin, carbamazepine and lamotrigine can be associated with severe hypersensitivity reactions. The lymphocyte transformation test (LTT) is a method to determine which drug has caused the hypersensitivity reaction. This study was done to evaluate the results of LTT in patients with delayed hypersensitivity reactions following the administration of anticonvulsants. METHODS Twenty-four patients with hypersensitivity reactions, e.g. drug-induced hypersensitivity syndrome/drug rash and eosinophilia with systemic symptoms (DIHS/DRESS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN), following the administration of anticonvulsant drugs, and 24 patients who had used anticonvulsant drugs but did not have hypersensitivity reactions (the control group) were included in this study. Peripheral blood mononuclear cells were isolated. The cells were stimulated with the drugs, phytohemagglutinin as a mitogen and Candida as an antigen (positive controls). Lymphocyte proliferation was measured using the BrdU proliferation assay kit (Roche, Germany). The stimulation index was calculated as the mean ratio of the OD of stimulated cells divided by the OD of unstimulated cells. The results in the case and control groups were compared. RESULTS Of 24 patients in the test group, 14 (58.3%) had positive LTT results and 10 (41.7%) had negative results. Among patients in the control group, 1 (4.2%) had a positive LTT result and 23 (95.8%) had negative results. Among the patients who had received carbamazepine and phenytoin, there was a significant difference between the results of LTT in the case and control groups (p = 0.002 and p = 0.028, respectively). Although patients receiving lamotrigine and phenobarbital had more positive LTT results in the case group than in the control group, these differences were not statistically significant. The sensitivity, specificity, positive predictive value and negative predictive value of LTT were 58.4, 95.8, 93.3 and 69.9%, respectively. CONCLUSIONS Considering the significant difference in LTT results between the case and control groups in patients receiving carbamazepine and phenytoin, and not observing such a difference in patients receiving phenobarbital and lamotrigine, LTT results are more valuable for the diagnosis of hypersensitivity reactions following the administration of carbamazepine and phenytoin. The LTT has good specificity but low sensitivity for the diagnosis of drug hypersensitivity reactions.
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Affiliation(s)
- Zahra Karami
- Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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21
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Mayorga C, Celik G, Rouzaire P, Whitaker P, Bonadonna P, Rodrigues-Cernadas J, Vultaggio A, Brockow K, Caubet JC, Makowska J, Nakonechna A, Romano A, Montañez MI, Laguna JJ, Zanoni G, Gueant JL, Oude Elberink H, Fernandez J, Viel S, Demoly P, Torres MJ. In vitro tests for drug hypersensitivity reactions: an ENDA/EAACI Drug Allergy Interest Group position paper. Allergy 2016; 71:1103-34. [PMID: 26991315 DOI: 10.1111/all.12886] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2016] [Indexed: 12/15/2022]
Abstract
Drug hypersensitivity reactions (DHRs) are a matter of great concern, both for outpatient and in hospital care. The evaluation of these patients is complex, because in vivo tests have a suboptimal sensitivity and can be time-consuming, expensive and potentially risky, especially drug provocation tests. There are several currently available in vitro methods that can be classified into two main groups: those that help to characterize the active phase of the reaction and those that help to identify the culprit drug. The utility of these in vitro methods depends on the mechanisms involved, meaning that they cannot be used for the evaluation of all types of DHRs. Moreover, their effectiveness has not been defined by a consensus agreement between experts in the field. Thus, the European Network on Drug Allergy and Drug Allergy Interest Group of the European Academy of Allergy and Clinical Immunology has organized a task force to provide data and recommendations regarding the available in vitro methods for DHR diagnosis. We have found that although there are many in vitro tests, few of them can be given a recommendation of grade B or above mainly because there is a lack of well-controlled studies, most information comes from small studies with few subjects and results are not always confirmed in later studies. Therefore, it is necessary to validate the currently available in vitro tests in a large series of well-characterized patients with DHR and to develop new tests for diagnosis.
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Affiliation(s)
- C. Mayorga
- Research Laboratory; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
- Allergy Unit; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
| | - G. Celik
- Division of Immunology and Allergy; Department of Chest Diseases; Ankara University School of Medicine; Ankara Turkey
| | - P. Rouzaire
- Department of Immunology and ERTICa Research Group; University Hospital of Clermont-Ferrand and Auvergne University; Clermont-Ferrand France
| | - P. Whitaker
- Regional Adult Cystic Fibrosis Unit; St James's Hospital; Leeds UK
| | - P. Bonadonna
- Allergy Unit; Azienda Ospedaliera Universitaria Intergata of Verona; Verona Italy
| | - J. Rodrigues-Cernadas
- Immunoallergology Department; Faculty of Medicine; Centro Hospitalar São João; Porto Portugal
| | - A. Vultaggio
- Immunoallergology Unit; Department of Biomedicine; Careggi Hospital; Florence Italy
| | - K. Brockow
- Department of Dermatology and Allergology Biederstein; Technische Universität München; Munich Germany
| | - J. C. Caubet
- Pediatric Allergy Unit; Department of Child and Adolescent; University Hospitals of Geneva; Geneva Switzerland
| | - J. Makowska
- Department of Immunology, Rheumatology and Allergy; Healthy Ageing Research Center; Medical University of Łódź; Łódź Poland
| | - A. Nakonechna
- Allergy and Immunology Clinic; Royal Liverpool and Broadgreen University Hospital; Liverpool UK
| | - A. Romano
- Allergy Unit Complesso Integrato Columbus; Rome and IRCCS Oasi Maria S.S.; Troina Italy
| | - M. I. Montañez
- BIONAND-Andalusian Centre for Nanomedicine and Biotechnology; Malaga Spain
| | - J. J. Laguna
- Allergy Unit; Hospital de la Cruz Roja; Madrid Spain
| | - G. Zanoni
- Section of Immunology; Department of Pathology and Diagnostics; University of Verona; Verona Italy
| | - J. L. Gueant
- Department of Molecular Medicine and Personalized Therapeutics and Inserm UMRS 954N-GERE (Nutrition-Genetics-Environmental Risks); University Hospital of Nancy and University of Lorraine; Nancy France
| | - H. Oude Elberink
- Department of Allergology; GRIAC Research Institute; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - J. Fernandez
- Allergy Section; Alicante University Hospital; UMH; Alicante Spain
| | - S. Viel
- Laboratory of Immunology; Centre Hospitalier Lyon Sud; Hospices Civils de Lyon; Lyon France
| | - P. Demoly
- Hôpital Arnaud de Villeneuve; University Hospital of Montpellier, and Sorbonne Universités; UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR; Paris France
| | - M. J. Torres
- Allergy Unit; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
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Kratzer B, Pickl WF. Years in Review: Recent Progress in Cellular Allergology. Int Arch Allergy Immunol 2016; 169:1-12. [PMID: 26953825 PMCID: PMC7058417 DOI: 10.1159/000444753] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
This review highlights the recent key advances in the biology of CD4+ effector T cells, antigen-presenting cells, Th17 and T regulatory cells, as well as immediate effector cells, such as mast cells, basophils and eosinophils, which are critically contributing to the better understanding of the pathophysiology of allergic diseases and are helping to improve their diagnosis and therapy. Some of the key advances with a direct impact on allergic asthma research and treatment are summarized.
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Affiliation(s)
- Bernhard Kratzer
- Institute of Immunology, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
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Schrijvers R, Gilissen L, Chiriac AM, Demoly P. Pathogenesis and diagnosis of delayed-type drug hypersensitivity reactions, from bedside to bench and back. Clin Transl Allergy 2015; 5:31. [PMID: 26339470 PMCID: PMC4558726 DOI: 10.1186/s13601-015-0073-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/29/2015] [Indexed: 01/11/2023] Open
Abstract
Drug hypersensitivity reactions (DHR) have been present since the advent of drugs. In particular T-cell mediated delayed-type hypersensitivity reactions represent a heterogeneous clinical entity with a diverse pathogenesis and result in a considerable burden of morbidity and mortality not only driven by the reactions themselves but also by the use of alternatives which are sometimes less effective or even more dangerous. Diagnostic procedures rely on clinical history, skin testing and potential provocation testing, whereas validated in vitro diagnostic procedures are still lacking for most of them. Recent work in the field of pharmacogenomics combined with basic scientific research has provided insights in the pathogenesis of abacavir and carbamazepine hypersensitivities linked with certain human leucocyte antigen risk alleles. Nevertheless, important scientific questions on how other DHR arise and how host-drug interactions occur, remain unanswered. Recent work indicates an intricate relation between host, drug and pathogens in severe cutaneous and systemic reactions and provides more insights in the role of regulatory T-cells and viral reactivation in these reactions. In this review we focus on type IV delayed-type DHR, and address recent advances in the pathogenesis, pharmacogenomics, and diagnosis of these reactions with an emphasis on the understandings arising from basic research.
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Affiliation(s)
- Rik Schrijvers
- Laboratory of Clinical Immunology, KU Leuven, Leuven, Belgium ; Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Liesbeth Gilissen
- Department of Dermatology, University Hospitals Leuven, Leuven, Belgium
| | - Anca Mirela Chiriac
- Exploration des Allergies, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Paris, France ; Sorbonne Universités, UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, 75013 Paris, France
| | - Pascal Demoly
- Exploration des Allergies, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Paris, France ; Sorbonne Universités, UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, 75013 Paris, France
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Trautmann A, Seitz CS, Stoevesandt J, Kerstan A. Aminopenicillin-associated exanthem: lymphocyte transformation testing revisited. Clin Exp Allergy 2015; 44:1531-8. [PMID: 25323308 DOI: 10.1111/cea.12437] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/19/2014] [Accepted: 10/13/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The lymphocyte transformation test (LTT) has been promoted as in-vitro test for diagnosis of drug hypersensitivity. For determination of statistical LTT sensitivity, series of patients with clinically uniform reactions followed by complete drug hypersensitivity work-up are mandatory. Assessment of LTT specificity requires control patients who tolerated exposure to the drug studied. OBJECTIVE To prospectively determine the diagnostic value of the LTT in a clinically and diagnostically well-defined series of patients. METHODS Patients with exanthematous skin eruptions after ampicillin (AMP) intake were included in this study. After exclusion or confirmation of delayed-onset allergic AMP hypersensitivity by skin and provocation testing, two independent LTTs were performed: one standard LTT and a modified LTT with additional anti-CD3/anti-CD28 monoclonal antibody stimulation. RESULTS By testing, delayed-onset allergic AMP hypersensitivity was diagnosed in 11 patients and definitely ruled out in 26. The standard LTT reached a diagnostic sensitivity of 54.5% while the modified LTT yielded 72.7%. However, the methodical test modification resulted in a decline of specificity from 92.3% (standard LTT) to 76.9%. CONCLUSIONS AND CLINICAL RELEVANCE In cases of AMP-associated exanthems, the diagnostic value of the LTT compared with routine allergy testing is limited. When evaluating such exanthems, provocation testing remains the gold standard. Delayed reading of intradermal skin tests remains most useful to avoid positive provocation reactions.
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Affiliation(s)
- A Trautmann
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
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