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Cadot R, Gery P, Lenief V, Nicolas JF, Vocanson M, Tauber M. Exploring recent advances in drugs severe cutaneous adverse reactions immunopathology. Allergy 2024. [PMID: 39295209 DOI: 10.1111/all.16316] [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: 06/26/2024] [Revised: 08/13/2024] [Accepted: 09/03/2024] [Indexed: 09/21/2024]
Abstract
Severe cutaneous adverse reactions to drugs (SCARs) are rare but life-threatening delayed allergies. While they primarily affect the skin, they can also affect internal organs. Accordingly, they present with diverse clinical symptoms that vary not only between SCARs subtypes but also among patients. Despite the availability of topical and systemic treatments, these only address the symptoms and not the cause. To develop more effective therapies, it is necessary to elucidate the complexity of the pathophysiology of SCARs in relation to their severity. In line with the new type IV hypersensitivity reactions nomenclature proposed by the European Academy of Allergy and Clinical Immunology (EAACI), this review highlights the current insights into the intricate immune mechanisms engaged, the interplay between the culprit drug and genetic predisposition in drug presentation mechanisms, but also how external factors, such as viruses, are implicated in SCARs. Their relevance to the development of targeted medicine is also discussed.
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Affiliation(s)
- Romane Cadot
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
| | - Perrine Gery
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
| | - Vanina Lenief
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
| | - Jean-François Nicolas
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
- Allergology and Clinical Immunology Department, Lyon Sud University Hospital, Pierre Bénite, France
| | - Marc Vocanson
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
| | - Marie Tauber
- CIRI-Centre International de Recherche en Infectiologie, Lyon, France
- INSERM, U1111, Lyon, France
- École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
- CNRS, UMR 5308, Lyon, France
- Allergology and Clinical Immunology Department, Lyon Sud University Hospital, Pierre Bénite, France
- Reference center for toxic bullous dermatitis and severe cutaneous adverse reactions, Hospices Civils de Lyon, Lyon, France
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2
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Shah H, Parisi R, Mukherjee E, Phillips EJ, Dodiuk-Gad RP. Update on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Diagnosis and Management. Am J Clin Dermatol 2024:10.1007/s40257-024-00889-6. [PMID: 39278968 DOI: 10.1007/s40257-024-00889-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2024] [Indexed: 09/18/2024]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the most severe cutaneous adverse reactions that are typically drug-induced in adults. Both SJS and TEN have high morbidity and mortality rates. SJS/TEN imposes clinical challenges for physicians managing patients suffering from this condition, both because it is rare and because it is a rapidly progressing systemic disease with severe cutaneous, mucosal, and systemic manifestations. Although many cases of SJS/TEN have been reported in the literature, there is no consensus regarding diagnostic criteria or treatment. Significant progress has been made in understanding its genetic predisposition and pathogenesis. This review is intended to provide physicians with a comprehensive but practical SJS/TEN roadmap to guide diagnosis and management. We review data on pathogenesis, reported precipitating factors, presentation, diagnosis, and management SJS/TEN focusing on what is new over the last 5 years.
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Affiliation(s)
- Hemali Shah
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Eric Mukherjee
- Department of Dermatology, Vanderbilt University, Nashville, TN, USA
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Dermatology, Vanderbilt University, Nashville, TN, USA.
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Roni P Dodiuk-Gad
- Department of Dermatology, Emek Medical Center, Afula, Israel
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, M5S 1A1, Canada
- Department of Dermatology, Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, 3525433, Haifa, Israel
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3
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Barbaud A, Goncalo M, Mockenhaupt M, Copaescu A, Phillips EJ. Delayed Skin Testing for Systemic Medications: Helpful or Not? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2268-2277. [PMID: 38977212 DOI: 10.1016/j.jaip.2024.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/13/2024] [Accepted: 06/23/2024] [Indexed: 07/10/2024]
Abstract
Cutaneous adverse drug reactions collectively are delayed drug reactions such as morbilliform drug eruption and severe cutaneous adverse reactions (SCARs). Morbilliform drug eruption may wane over time, be the result of drug viral interactions, and be amenable to slow reintroduction or rechallenge, whereas SCARs are HLA class I restricted, T-cell-mediated reactions that demonstrate durable immunity and warrant lifelong avoidance. SCARs such as drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome and toxic epidermal necrolysis, acute generalized exanthematous pustulosis, and generalized bullous fixed drug eruption often occur in the setting of multiple drugs dosed together. Collectively, they lead to significant morbidity, mortality, and drug safety concerns that could severely limit future treatment options. Currently, no single or combination of diagnostic tests for SCARs such as ex vivo or in vitro testing, in vivo (skin) testing, or other adjunctive tests such as HLA typing have 100% negative predictive value. In this "Controversies in Allergy Review" article, we review the current literature on delayed skin testing (patch and delayed prick/intradermal test) and critically assess the evidence base of its utility across different drugs and clinical phenotypes of delayed hypersensitivity reactions.
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Affiliation(s)
- Annick Barbaud
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP.Sorbonne Université, Hôpital Tenon, Département de dermatologie et allergologie, Paris, France
| | - Margarida Goncalo
- Department of Dermatology, University Hospital, Coimbra Local Health Unit, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Maja Mockenhaupt
- Dokumentationszentriúm schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Ana Copaescu
- The Research Institute of McGill University Health Center, McGill University, Montreal, Canada; Center for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia.
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Liu G, Wang Z, Li S. Heterogeneity and plasticity of tissue-resident memory T cells in skin diseases and homeostasis: a review. Front Immunol 2024; 15:1378359. [PMID: 38779662 PMCID: PMC11109409 DOI: 10.3389/fimmu.2024.1378359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
Skin tissue-resident memory T (Trm) cells are produced by antigenic stimulation and remain in the skin for a long time without entering the peripheral circulation. In the healthy state Trm cells can play a patrolling and surveillance role, but in the disease state Trm cells differentiate into various phenotypes associated with different diseases, exhibit different localizations, and consequently have local protective or pathogenic roles, such as disease recurrence in vitiligo and maintenance of immune homeostasis in melanoma. The most common surface marker of Trm cells is CD69/CD103. However, the plasticity of tissue-resident memory T cells after colonization remains somewhat uncertain. This ambiguity is largely due to the variation in the functionality and ultimate destination of Trm cells produced from memory cells differentiated from diverse precursors. Notably, the presence of Trm cells is not stationary across numerous non-lymphoid tissues, most notably in the skin. These cells may reenter the blood and distant tissue sites during the recall response, revealing the recycling and migration potential of the Trm cell progeny. This review focuses on the origin and function of skin Trm cells, and provides new insights into the role of skin Trm cells in the treatment of autoimmune skin diseases, infectious skin diseases, and tumors.
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Affiliation(s)
- Guomu Liu
- Department of Dermatology and Venereology, The First Hospital of Jilin University, Changchun, China
| | - Ziyue Wang
- Key Laboratory of Organ Regeneration & Transplantation of Ministry of Education, The First Hospital of Jilin University, Changchun, China
| | - Shanshan Li
- Department of Dermatology and Venereology, The First Hospital of Jilin University, Changchun, China
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Long B, Zhou S, Gao Y, Fan K, Lai J, Yao C, Li J, Xu X, Yu S. Tissue-Resident Memory T Cells in Allergy. Clin Rev Allergy Immunol 2024; 66:64-75. [PMID: 38381299 DOI: 10.1007/s12016-024-08982-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
Tissue-resident memory T (TRM) cells constitute a distinct subset within the memory T cell population, serving as the vanguard against invading pathogens and antigens in peripheral non-lymphoid tissues, including the respiratory tract, intestines, and skin. Notably, TRM cells adapt to the specific microenvironment of each tissue, predominantly maintaining a sessile state with distinctive phenotypic and functional attributes. Their role is to ensure continuous immunological surveillance and protection. Recent findings have highlighted the pivotal contribution of TRM cells to the modulation of adaptive immune responses in allergic disorders such as allergic rhinitis, asthma, and dermatitis. A comprehensive understanding of the involvement of TRM cells in allergic diseases bears profound implications for allergy prevention and treatment. This review comprehensively explores the phenotypic characteristics, developmental mechanisms, and functional roles of TRM cells, focusing on their intricate relationship with allergic diseases.
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Affiliation(s)
- Bojin Long
- Department of Otorhinolaryngology-Head and Neck Surgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Shican Zhou
- Department of Otorhinolaryngology-Head and Neck Surgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Yawen Gao
- Department of Otorhinolaryngology-Head and Neck Surgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Kai Fan
- Department of Otorhinolaryngology-Head and Neck Surgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Ju Lai
- Department of Otorhinolaryngology-Head and Neck Surgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Chunyan Yao
- Department of Otorhinolaryngology-Head and Neck Surgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Jingwen Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Xiayue Xu
- Department of Otorhinolaryngology-Head and Neck Surgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Shaoqing Yu
- Department of Otorhinolaryngology-Head and Neck Surgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China.
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China.
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Line J, Saville E, Meng X, Naisbitt D. Why drug exposure is frequently associated with T-cell mediated cutaneous hypersensitivity reactions. FRONTIERS IN TOXICOLOGY 2023; 5:1268107. [PMID: 37795379 PMCID: PMC10546197 DOI: 10.3389/ftox.2023.1268107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
Cutaneous hypersensitivity reactions represent the most common manifestation of drug allergy seen in the clinic, with 25% of all adverse drug reactions appearing in the skin. The severity of cutaneous eruptions can vastly differ depending on the cellular mechanisms involved from a minor, self-resolving maculopapular rash to major, life-threatening pathologies such as the T-cell mediated bullous eruptions, i.e., Stevens Johnson syndrome/toxic epidermal necrolysis. It remains a significant question as to why these reactions are so frequently associated with the skin and what factors polarise these reactions towards more serious disease states. The barrier function which the skin performs means it is constantly subject to a barrage of danger signals, creating an environment that favors elicitation. Therefore, a critical question is what drives the expansion of cutaneous lymphocyte antigen positive, skin homing, T-cell sub-populations in draining lymph nodes. One answer could be the heterologous immunity hypothesis whereby tissue resident memory T-cells that express T-cell receptors (TCRs) for pathogen derived antigens cross-react with drug antigen. A significant amount of research has been conducted on skin immunity in the context of contact allergy and the role of tissue specific antigen presenting cells in presenting drug antigen to T-cells, but it is unclear how this relates to epitopes derived from circulation. Studies have shown that the skin is a metabolically active organ, capable of generating reactive drug metabolites. However, we know that drug antigens are displayed systemically so what factors permit tolerance in one part of the body, but reactivity in the skin. Most adverse drug reactions are mild, and skin eruptions tend to be visible to the patient, whereas minor organ injury such as transient transaminase elevation is often not apparent. Systemic hypersensitivity reactions tend to have early cutaneous manifestations, the progression of which is halted by early diagnosis and treatment. It is apparent that the preference for cutaneous involvement of drug hypersensitivity reactions is multi-faceted, therefore this review aims to abridge the findings from literature on the current state of the field and provide insight into the cellular and metabolic mechanisms which may contribute to severe cutaneous adverse reactions.
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Affiliation(s)
| | | | | | - Dean Naisbitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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Villafán H, Gutiérrez-Ospina G. Looking beyond Self-Protection: The Eyes Instruct Systemic Immune Tolerance Early in Life. Brain Sci 2023; 13:1261. [PMID: 37759864 PMCID: PMC10526493 DOI: 10.3390/brainsci13091261] [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: 05/28/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023] Open
Abstract
The eyes provide themselves with immune tolerance. Frequent skin inflammatory diseases in young blind people suggest, nonetheless, that the eyes instruct a systemic immune tolerance that benefits the whole body. We tested this premise by using delayed skin contact hypersensitivity (DSCH) as a tool to compare the inflammatory response developed by sighted (S) and birth-enucleated (BE) mice against oxazolone or dinitrofluorobenzene at the ages of 10, 30 and 60 days of life. Adult mice enucleated (AE) at 60 days of age were also assessed when they reached 120 days of life. BE mice displayed exacerbated DSCH at 60 but not at 10 or 30 days of age. AE mice, in contrast, show no exacerbated DSCH. Skin inflammation in 60-day-old BE mice was hapten exclusive and supported by distinct CD8+ lymphocytes. The number of intraepidermal T lymphocytes and migrating Langerhans cells was, however, similar between S and BE mice by the age of 60 days. Our observations support the idea that the eyes instruct systemic immune tolerance that benefits organs outside the eyes from an early age. The higher prevalence of inflammatory skin disorders reported in young people might then reflect reduced immune tolerance associated with the impaired functional morphology of the eyes.
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Affiliation(s)
- Horacio Villafán
- Programa de Doctorado en Ciencias Biológicas, Unidad de Posgrado, Circuito de Posgrados, Ciudad Universitaria, Edificio D, 1piso, Coyoacán, Ciudad de México 04510, Mexico
- Departamento de Biología Celular y Fisiología, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Ciudad de México 04510, Mexico
| | - Gabriel Gutiérrez-Ospina
- Departamento de Biología Celular y Fisiología, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Ciudad de México 04510, Mexico
- Coordinación de Psicobiología y Neurociencias, Facultad de Psicología, Universidad Nacional Autónoma de México, Ciudad de México 04510, Mexico
- Department of Zoology and Physiology and Wyoming Sensory Biology Center of Biomedical Research Excellence, University of Wyoming, Laramie, WY 82071, USA
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Strobl J, Haniffa M. Functional heterogeneity of human skin-resident memory T cells in health and disease. Immunol Rev 2023; 316:104-119. [PMID: 37144705 PMCID: PMC10952320 DOI: 10.1111/imr.13213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/06/2023]
Abstract
The human skin is populated by a diverse pool of memory T cells, which can act rapidly in response to pathogens and cancer antigens. Tissue-resident memory T cells (TRM ) have been implicated in range of allergic, autoimmune and inflammatory skin diseases. Clonal expansion of cells with TRM properties is also known to contribute to cutaneous T-cell lymphoma. Here, we review the heterogeneous phenotypes, transcriptional programs, and effector functions of skin TRM . We summarize recent studies on TRM formation, longevity, plasticity, and retrograde migration and contextualize the findings to skin TRM and their role in maintaining skin homeostasis and altered functions in skin disease.
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Affiliation(s)
- Johanna Strobl
- Department of DermatologyMedical University of ViennaViennaAustria
- CeMM Research Center for Molecular MedicineViennaAustria
| | - Muzlifah Haniffa
- Wellcome Sanger InstituteCambridgeUK
- Department of Dermatology and NIHR Newcastle Biomedical Research CentreNewcastle Hospitals NHS Foundation TrustNewcastle upon TyneUK
- Biosciences InstituteNewcastle UniversityNewcastle upon TyneUK
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Chimbetete T, Choshi P, Pedretti S, Porter M, Roberts R, Lehloenya R, Peter J. Skin infiltrating T-cell profile of drug reaction with eosinophilia and systemic symptoms (DRESS) reactions among HIV-infected patients. Front Med (Lausanne) 2023; 10:1118527. [PMID: 37215719 PMCID: PMC10196146 DOI: 10.3389/fmed.2023.1118527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Drug Reaction with Eosinophilia Systemic Symptoms (DRESS) is more common in persons living with HIV (PLHIV), and first-line anti-TB drugs (FLTDs) and cotrimoxazole are the commonest offending drugs. Limited data is available on the skin infiltrating T-cell profile among DRESS patients with systemic CD4 T-cell depletion associated with HIV. Materials and methods HIV cases with validated DRESS phenotypes (possible, probable, or definite) and confirmed reactions to either one or multiple FLTDs and/or cotrimoxazole were chosen (n = 14). These cases were matched against controls of HIV-negative patients who developed DRESS (n = 5). Immunohistochemistry assays were carried out with the following antibodies: CD3, CD4, CD8, CD45RO and FoxP3. Positive cells were normalized to the number of CD3+ cells present. Results Skin infiltrating T-cells were mainly found in the dermis. Dermal and epidermal CD4+ T-cells (and CD4+/CD8+ ratios) were lower in HIV-positive vs. negative DRESS; p < 0.001 and p = 0.004, respectively; without correlation to whole blood CD4 cell counts. In contrast, no difference in dermal CD4+FoxP3+ T-cells was found in HIV-positive vs. negative DRESS, median (IQR) CD4+FoxP3+ T-cells: [10 (0-30) cells/mm2 vs. 4 (3-8) cells/mm2, p = 0.325]. HIV-positive DRESS patients reacting to more than one drug had no difference in CD8+ T-cell infiltrates, but higher epidermal and dermal CD4+FoxP3+ T-cell infiltrates compared to single drug reactors. Conclusion DRESS, irrespective of HIV status, was associated with an increased skin infiltration of CD8+ T-cells, while CD4+ T-cells were lower in HIV-positive DRESS compared to HIV-negative DRESS skin. While inter-individual variation was high, the frequency of dermal CD4+FoxP3+ T-cells was higher in HIV-positive DRESS cases reacting to more than one drug. Further research is warranted to understand the clinical impact of these changes.
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Affiliation(s)
- Tafadzwa Chimbetete
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phuti Choshi
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sarah Pedretti
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Mireille Porter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Riyaadh Roberts
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Rannakoe Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Jonathan Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
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Chimbetete T, Buck C, Choshi P, Selim R, Pedretti S, Divito SJ, Phillips EJ, Lehloenya R, Peter J. HIV-Associated Immune Dysregulation in the Skin: A Crucible for Exaggerated Inflammation and Hypersensitivity. J Invest Dermatol 2023; 143:362-373. [PMID: 36549954 PMCID: PMC9974923 DOI: 10.1016/j.jid.2022.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 12/24/2022]
Abstract
Skin diseases are hallmarks of progressive HIV-related immunosuppression, with severe noninfectious inflammatory and hypersensitivity conditions as common as opportunistic infections. Conditions such as papular pruritic eruption are AIDS defining, whereas delayed immune-mediated adverse reactions, mostly cutaneous, occur up to 100-fold more during HIV infection. The skin, constantly in contact with the external environment, has a complex immunity. A dense, tightly junctioned barrier with basal keratinocytes and epidermal Langerhans cells with antimicrobial, innate-activating, and antigen-presenting functions form the frontline. Resident dermal dendritic, mast, macrophage, and innate lymphoid cells play pivotal roles in directing and polarizing appropriate adaptive immune responses and directing effector immune cell trafficking. Sustained viral replication leads to progressive declines in CD4 T cells, whereas Langerhans and dermal dendritic cells serve as viral reservoirs and points of first viral contact in the mucosa. Cutaneous cytokine responses and diminished lymphoid populations create a crucible for exaggerated inflammation and hypersensitivity. However, beyond histopathological description, these manifestations are poorly characterized. This review details normal skin immunology, changes associated with progressive HIV-related immunosuppression, and the characteristic conditions of immune dysregulation increased with HIV. We highlight the main research gaps and several novel tissue-directed strategies to define mechanisms that will provide targeted approaches to prevention or treatment.
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Affiliation(s)
- Tafadzwa Chimbetete
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Chloe Buck
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Phuti Choshi
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Rose Selim
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sarah Pedretti
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Sherrie Jill Divito
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Rannakoe Lehloenya
- Division of Dermatology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Jonny Peter
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa.
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11
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Novack DE, Braskett M, Worswick SD, Adler BL. Drug patch testing in Stevens-Johnson syndrome and toxic epidermal necrolysis: A systematic review. Ann Allergy Asthma Immunol 2023; 130:628-636. [PMID: 36649833 DOI: 10.1016/j.anai.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND The data on patch testing (PT) to identify culprit medications in Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are limited to scattered case reports and small case series, without analysis of overall trends to inform clinicians of its utility, methodology, and safety. OBJECTIVE To conduct a systematic review of the practice of PT in SJS/TEN, quantify the positivity rate of common drug classes, and assess safety during testing. METHODS PubMed was searched from inception to 2021. Search terms included "patch testing" AND "SJS" OR "TEN" OR "Stevens-Johnson syndrome" OR "toxic epidermal necrolysis" OR "Lyell's syndrome." RESULTS There were 58 articles that met the inclusion criteria. In total, 82 patients underwent patch testing for SJS/TEN, resulting in 104 positive reactions to 49 unique medications. Antiepileptic drugs were responsible for 48.1% of the positive reactions; antibiotics, 28.8%; and nonsteroidal anti-inflammatory drugs, 6.7%. The positivity rates of antiepileptics, antibiotics, and nonsteroidal anti-inflammatory drugs were 33.1%, 13.1%, and 21.9%, respectively. When accounting for suspected causality, these rates increased to 54.3%, 78.4%, and 54.5%, respectively. Three patients (3.7%), 2 of whom had human immunodeficiency virus infection and active tuberculosis, experienced systemic reactions during PT, which required only conservative treatment. CONCLUSION Published reports suggest that PT in SJS/TEN is useful and safe. Antiepileptic drugs have been tested most frequently and found to have the highest positivity rate. There is a critical need for large-scale studies with standardized methodology to obtain reproducible data on PT in SJS/TEN.
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Affiliation(s)
| | - Melinda Braskett
- Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Scott D Worswick
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Brandon L Adler
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, California.
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12
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van der Valk H, Pleijhuis RG, Voorbij-Vierstra CL, Schuttelaar MLA. Case report: Recall dermatitis at patch-test sites after oral provocation with mesalazine. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3323-3324.e1. [PMID: 36184024 DOI: 10.1016/j.jaip.2022.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/21/2022] [Accepted: 08/28/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Hester van der Valk
- Department of Internal Medicine and Allergology, University Medical Center Groningen, Groningen, the Netherlands.
| | - Rick G Pleijhuis
- Department of Internal Medicine and Allergology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Marie L A Schuttelaar
- Department of Dermatology, University Medical Center Groningen, Groningen, the Netherlands
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13
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Advancements in the characterization of tissue resident memory T cells in skin disease. Clin Immunol 2022; 245:109183. [DOI: 10.1016/j.clim.2022.109183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
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14
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Deshpande P, Li Y, Thorne M, Palubinsky AM, Phillips EJ, Gibson A. Practical Implementation of Genetics: New Concepts in Immunogenomics to Predict, Prevent, and Diagnose Drug Hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1689-1700. [PMID: 35526777 PMCID: PMC9948495 DOI: 10.1016/j.jaip.2022.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/26/2022] [Accepted: 04/26/2022] [Indexed: 02/05/2023]
Abstract
Delayed drug hypersensitivities are CD8+ T cell-mediated reactions associated with up to 50% mortality. Human leukocyte antigen (HLA) alleles are known to predispose disease and are specific to drug, reaction, and patient ethnicity. Pretreatment screening is recommended for a handful of the strongest associations to identify and prevent drug use in high-risk patients. However, an incomplete predictive value implicates other HLA-imposed risk factors, and low carriage of many identified HLA-risk alleles combined with the high cost of sequence-based typing has limited economic viability for similar recommendation of screening across drugs and health care systems. For mitigation, an expanding armory of low-cost polymerase chain reaction-based screens is being developed, and HLA-imposed risk factors are being discovered. These include (1) polymorphic variants of metabolic and endoplasmic reticulum aminopeptidase enzymes toward multiallelic screening with increased predictivity; (2) regulation by immune checkpoint inhibitors, enabling detolerized animal models of human disease; and (3) immunodominant T cell receptors (TCR) on clonally expanded CD8+ T cells. For the latter, HLA risk-restricted TCR provides immunogenomic strategies and samples from a single patient to identify novel HLA-risk associations in underserved minority populations, tissue-relevant effector biomarkers toward earlier diagnosis and treatment, and HLA-TCR-presented immunogenic structures to aid future drug development.
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Affiliation(s)
- Pooja Deshpande
- Institute for Immunology and Infectious Disease (IIID), Murdoch University, Perth, WA, Australia
| | - Yueran Li
- Institute for Immunology and Infectious Disease (IIID), Murdoch University, Perth, WA, Australia
| | - Michael Thorne
- Institute for Immunology and Infectious Disease (IIID), Murdoch University, Perth, WA, Australia
| | | | - Elizabeth J Phillips
- Institute for Immunology and Infectious Disease (IIID), Murdoch University, Perth, WA, Australia,Vanderbilt University Medical Centre (VUMC), Nashville, TN, USA
| | - Andrew Gibson
- Institute for Immunology and Infectious Disease, Murdoch University, Perth, Western Australia, Australia.
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15
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Aparicio-Soto M, Curato C, Riedel F, Thierse HJ, Luch A, Siewert K. In Vitro Monitoring of Human T Cell Responses to Skin Sensitizing Chemicals-A Systematic Review. Cells 2021; 11:cells11010083. [PMID: 35011644 PMCID: PMC8750770 DOI: 10.3390/cells11010083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Chemical allergies are T cell-mediated diseases that often manifest in the skin as allergic contact dermatitis (ACD). To prevent ACD on a public health scale and avoid elicitation reactions at the individual patient level, predictive and diagnostic tests, respectively, are indispensable. Currently, there is no validated in vitro T cell assay available. The main bottlenecks concern the inefficient generation of T cell epitopes and the detection of rare antigen-specific T cells. Methods: Here, we systematically review original experimental research papers describing T cell activation to chemical skin sensitizers. We focus our search on studies published in the PubMed and Scopus databases on non-metallic allergens in the last 20 years. Results: We identified 37 papers, among them 32 (86%) describing antigen-specific human T cell activation to 31 different chemical allergens. The remaining studies measured the general effects of chemical allergens on T cell function (five studies, 14%). Most antigen-specific studies used peripheral blood mononuclear cells (PBMC) as antigen-presenting cells (APC, 75%) and interrogated the blood T cell pool (91%). Depending on the individual chemical properties, T cell epitopes were generated either by direct administration into the culture medium (72%), separate modification of autologous APC (29%) or by use of hapten-modified model proteins (13%). Read-outs were mainly based on proliferation (91%), often combined with cytokine secretion (53%). The analysis of T cell clones offers additional opportunities to elucidate the mechanisms of epitope formation and cross-reactivity (13%). The best researched allergen was p-phenylenediamine (PPD, 12 studies, 38%). For this and some other allergens, stronger immune responses were observed in some allergic patients (15/31 chemicals, 48%), illustrating the in vivo relevance of the identified T cells while detection limits remain challenging in many cases. Interpretation: Our results illustrate current hardships and possible solutions to monitoring T cell responses to individual chemical skin sensitizers. The provided data can guide the further development of T cell assays to unfold their full predictive and diagnostic potential, including cross-reactivity assessments.
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Affiliation(s)
- Marina Aparicio-Soto
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment, 10589 Berlin, Germany; (M.A.-S.); (C.C.); (F.R.); (H.-J.T.); (A.L.)
| | - Caterina Curato
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment, 10589 Berlin, Germany; (M.A.-S.); (C.C.); (F.R.); (H.-J.T.); (A.L.)
| | - Franziska Riedel
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment, 10589 Berlin, Germany; (M.A.-S.); (C.C.); (F.R.); (H.-J.T.); (A.L.)
- Institute of Pharmacy, Freie Universität Berlin, 14195 Berlin, Germany
| | - Hermann-Josef Thierse
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment, 10589 Berlin, Germany; (M.A.-S.); (C.C.); (F.R.); (H.-J.T.); (A.L.)
| | - Andreas Luch
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment, 10589 Berlin, Germany; (M.A.-S.); (C.C.); (F.R.); (H.-J.T.); (A.L.)
- Institute of Pharmacy, Freie Universität Berlin, 14195 Berlin, Germany
| | - Katherina Siewert
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment, 10589 Berlin, Germany; (M.A.-S.); (C.C.); (F.R.); (H.-J.T.); (A.L.)
- Correspondence: ; Tel.: +49-(0)30-18412-57001
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