The lymphocyte transformation test in the diagnosis of drug hypersensitivity

Diagnosis of drug hypersensitivity is difficult, as an enormous amount of different drugs can elicit various immune-mediated diseases with distinct pathomechanism. The lymphocyte transformation test (LTT) measures the proliferation of T cells to a drug in vitro--from which one concludes to a previous in vivo reaction due to a sensitization. This concept of the LTT has been confirmed by the generation of drug-specific T-cell clones and the finding that drugs can directly interact with the T-cell receptor, without previous metabolism or need to bind to proteins. In this review, technical aspects and usefulness of this test for the diagnosis of drug hypersensitivity are discussed. The main advantage of this test is its applicability with many different drugs in different immune reactions, as drug-specific T cell are almost always involved in drug hypersensitivity reactions. Its main disadvantages are that an in vitro proliferation of T cells to a drug is difficult to transfer to the clinical situation and that the test per se is rather cumbersome and technically demanding. In addition, its sensitivity is limited (for beta-lactam allergy it is in the range of 60-70%), - although at least in our hands - it is higher than of other tests for drug hypersensitivity diagnosis. Consequently, drug hypersensitivity diagnosis needs to rely on a combination of history and different tests, as none of the single tests available has per se a sufficiently good sensitivity. Within this setting, the LTT has proven to be a useful test for the diagnosis of drug hypersensitivity reactions and helped to better understand these reactions. Further work on the simplification of this test and systematic evaluation of its sensitivity and specificity in some main groups of drugs are necessary to make this test more widely available.     

Studies of the radioallergosorbent test and the lymphocyte stimulation index in symptomatic ragweed pollenosis

We followed 47 ragweed hay fever patients (not on immunotherapy) through a ragweed season by means of clinical evaluation and symptom scores. The radioallergosorbent test (RAST) and lymphocyte stimulation index (LSI) were done to determine their reliability as predictors of clinical symptomatology. Symptom scores of 10 or above, denoting at least moderate daily symptoms, occurred in 36 patients (80%). Preseasonally, RAST class 2 or above was found in 34 patients (75%), of whom 29 patients (64%) had symptom scores of 10 or above. At that time, LSI was elevated in about 50% of the patients. Patients in RAST class 3 had the highest LSI as a group. Seasonal exposure boosted the LSI in 50% of the patients, whereas 25% were unchanged and 25% showed a decrease. The results suggest that neither RAST nor LSI are reliable predictors of clinical severity in ragweed pollenosis.     

The lymphocyte transformation test for the diagnosis of drug allergy: sensitivity and specificity

Background The diagnosis of a drag allergy is mainly based upon a very detailed history and the clinical findings. In addition, several in vitro or in vivo tests can be performed to demonstrate a sensitization to a certain drug. One of the in vitro tests is the lymphocyte transformation test (LTT), which can reveal a sensitization of T-cells by an enhanced proliferative response of peripheral blood mononuclear cells to a certain drag. Objective To evaluate the sensitivity and specificity of the LTT, 923 case histories of patients with suspected drag allergy in whom a LTT was performed were retrospectively analysed. Methods Based on the history and provocation tests, the probability (P) of a drag allergy was estimated to be >0.9, 0.5–0.9, 0.1–0.5 or <0.1, and was put in relation to a positive or negative LTT. Results Seventy-eight of 100 patients with a very likely drag allergy (P<0.9) had a positive LTT, which indicates a sensitivity of 78%. If allergies to betalactam-antibiotics were analysed separately, the sensitivity was 74.4%. Fifteen of 102 patients where a classical drag allergy could be excluded (P<0.1), had nevertheless a positive LTT (specificity thus 85%). The majority of these cases were classified as so-called pseudoallergic reaction to NSAIDs. Patients with a clear history and clinical findings for a cotrimoxazole-related allergy, all had a positive LTT (6/6), and in patients who reacted to drags containing proteins, sensitization could be demonstrated as well (i.e. hen's egg lysozyme, 7/7). In 632 of the 923 cases, skin tests were also performed (scratch and/or epicutaneous), for which we found a lower sensitivity than for the LTT (64%), while the specificity was the same (85%). Conclusion Although our data are somewhat biased by the high number of penicillin allergies and cannot be generalized to drag allergies caused by other compounds, we conclude that the LTT is a useful diagnostic test in drag allergies, able to support the diagnosis of a drag allergy and to pinpoint the relevant drag.     

Evaluation of the immunoenzyme test (Elisa) in detecting Clostiridium difficile toxin A in fecal samples]

Currently, the method of choice in diagnosis of Clostridium difficile-associated intestinal diseases is the detection of toxin B in fecal specimens. This method is long (72 h) and can be realized in laboratories which have tissue culture facilities. Commercial agglutination test have been evaluated but they lack in specificity. An immunoenzymatic test has been recently commercialized for detection of toxin A. We have compared the results of this assay on 275 fecal specimens from patients suspected of having Clostridium difficile-associated intestinal diseases with the results obtained with the cytotoxicity test and the culture. Of the 275 fecal specimens, 58 were positive in cytotoxicity and 53 in Elisa. The overall sensitivity and specificity of the Elisa compared with cytotoxicity were 89.5% and 99.0% respectively. The immunoenzymatic test detecting Clostridium difficile toxin A is an easy test to perform in 2 h 15; it displays a good correlation with detection of toxin B and can be very useful in daily laboratory diagnosis.     

Evaluation of the mutagenicity of the anti-inflammatory drug salicylazosulfapyridine (SASP)

Salicylazosulfapyridine, commonly known as sulfasalazine or SASP, is an anti-inflammatory drug that is widely used in the treatment of diseases such as ulcerative colitis and Crohn's disease. Increases in sister chromatid exchanges (SCE) and micronuclei (MN) frequencies have been reported in lymphocytes of patients maintained on SASP therapy for up to 21 months. We have tested SASP for its ability to induce chromosome aberrations (ABS) and SCE in cultured Chinese hamster ovary (CHO) cells, ABS in mouse bone marrow cells, and MN in erythrocytes from both bone marrow and peripheral blood of mice. In vitro assays for ABS and SCE were negative. In vivo, SASP administered by single gavage at doses up to 1000 mg/kg did not increase ABS in bone marrow cells of male B6C3F1 mice; however, increases in MN were observed in the peripheral blood erythrocytes of male and female B6C3F1 mice administered 675, 1350 or 2700 mg/kg SASP by gavage for 90 days. Weak but significant dose-related increases in MN were also observed in the bone marrow cells of male B6C3F1 mice administered 500, 1000 and 2000 mg/kg SASP for 3 days. These positive findings in mice support the role of SASP in the induction of MN and SCE in humans, and suggest the need for further evaluation of possible adverse human health effects associated with SASP therapy.     

Experience with the written examination (multiple choice test) in the teaching of anatomy]

All students (400 each winter-term) receive extensive information at the beginning of the course "anatomical propedeutics": a timetable with recommendations for learning, a list of instructional objectives and of terminology and an instruction for that type of test, the students never had experienced before. Feed-back is given by computer-output containing comments on the objective related to a wrong answer and indicating sub-test scores. Correlation of scores with results in the following dissection course seems to be acceptable. Questions of the multiple-choice test were compared by pairs with questions asked for in confrontation with the anatomical object. A strong coherence was found in answering correctly the multiple choice questions and the related oral exam. Over-all experience with a multiple choice test administered in Austria for the first time was rather encouraging.     

Cysteinyl-leukotriene release test (CAST) in the diagnosis of immediate drug reactions

BACKGROUND: The diagnosis of allergic reactions to drugs is difficult. Most skin tests are not standardized, and in vitro tests are needed to avoid provocation tests. Cross-linking of IgE on basophils is known to cause the release of both cysteinyl leukotriene (Cys-LT) and histamine. We aimed to evaluate the diagnostic utility (sensitivity, specificity, and efficiency) of measurement of sulfidoleukotrienes in drug allergy. METHODS: We performed a prospective study in 55 patients with proven immediate adverse reactions to drugs (30 to beta-lactams, six to acetaminophen, and 19 to aspirin) and 64 drug-exposed nonallergic controls. Positive diagnosis was established by history, skin tests, and, if needed, oral provocation tests. Cys-LT release was determined after drug-allergen stimulation by the cellular antigen stimulation test (CAST(R)) technique. Histamine release was also assessed on the same samples by enzyme immunoassay. Spontaneous and anti-FcepsilonRIalpha-induced mediator release was also studied in all subjects. Sensitivity, specificity, and efficiency were calculated. RESULTS: Net Cys-LT release was over the maximal threshold given by the manufacturer in 19/55 patients and in 9/64 controls. Net histamine release was over 5% of total histamine content in 28/55 patients and 34/64 controls. The efficiency of both tests was low. CONCLUSION: Thus, in most cases, the in vitro Cys-LT test has little or no diagnostic utility and is not superior to histamine release.     

Fast and simple epidemiological typing of Pseudomonas aeruginosa using the double-locus sequence typing (DLST) method

Although the molecular typing of Pseudomonas aeruginosa is important to understand the local epidemiology of this opportunistic pathogen, it remains challenging. Our aim was to develop a simple typing method based on the sequencing of two highly variable loci. Single-strand sequencing of three highly variable loci (ms172, ms217, and oprD) was performed on a collection of 282 isolates recovered between 1994 and 2007 (from patients and the environment). As expected, the resolution of each locus alone [number of types (N_T)?=?35–64; index of discrimination (ID)?=?0.816–0.964] was lower than the combination of two loci (N_T?=?78–97; ID?=?0.966–0.971). As each pairwise combination of loci gave similar results, we selected the most robust combination with ms172 [reverse; R] and ms217 [R] to constitute the double-locus sequence typing (DLST) scheme for P. aeruginosa. This combination gave: (i) a complete genotype for 276/282 isolates (typability of 98 %), (ii) 86 different types, and (iii) an ID of 0.968. Analysis of multiple isolates from the same patients or taps showed that DLST genotypes are generally stable over a period of several months. The high typability, discriminatory power, and ease of use of the proposed DLST scheme makes it a method of choice for local epidemiological analyses of P. aeruginosa. Moreover, the possibility to give unambiguous definition of types allowed to develop an Internet database (http://www.dlst.org) accessible by all.     

Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption

BACKGROUND: Lymphocyte transformation test (LTT) is a safety and reproducible test to assess activation of drug-specific T cells in vitro; however, there are several practical concerns such as the time of testing and the influence of treatment. Our aim was to define the right timing to perform LTT for determining the causative agent in various types of drug reactions. METHODS: Lymphocyte transformation test was performed at different time points during the evolution of three types of drug reactions, maculo-papular type of drug eruptions (MP), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), and drug-induced hypersensitivity syndrome/drug rash and eosinophilia with systemic symptoms (DIHS/DRESS). RESULTS: Positive LTT reactions were obtained when the test was performed at the acute stage but not the recovery stage in MP and SJS/TEN, while positive LTT reactions were obtained at the recovery stage but not the acute stage in DIHS/DRESS, regardless of treatment with systemic prednisolone. CONCLUSIONS: Lymphocyte transformation test is a reliable method to define the causative agent, when LTT is performed at the right timing depending on the type of drug reactions. Lymphocyte transformation test should be performed within 1 week after the onset of skin rashes in patients with MP and SJS/TEN; and 5-8 weeks after in patients with DIHS/DRESS, respectively.     

Electrophoretic mobility test (EMT): studies on lymphocyte response and mechanism of the test using a rat tumor model

After incubation with an encephalitogenic factor from human (HEF) or rat (REF) brain, lymphocytes of Fischer 344 rats bearing a spontaneous mammary adenocarcinoma produced a soluble substance which reduced the mobility of tanned sheep red blood cells in the electrophoretic mobility test (EMT). For studying the kinetics of this lymphocyte response, 6 X 10(5) tumor cells were injected into the hind footpad. In correlation with time and tumor size, one was able to influence the appearance of metastases by amputation of the leg. As early as 16 hours after inoculation of tumor cells, sensitivity of lymphocytes against HEF and a KCl-extract of the tumor could be shown in the EMT. It decreased on days 2 and 5, but was still seen until the day of amputation. Rats without metastases showed sensitivity up to four weeks after amputation and then returned to normal levels. Rats with metastases showed sensitivity until death at about seven weeks later. With the use of Amicon membranes, Sephadex G-50, and ion-exchange chromatography, a protein could be isolated from human basic myelin extract with a molecular weight of about 16,000-20,000 daltons. It had no direct influence on the EIC by itself, but after incubation with lymphocytes from tumor-bearing rats it evoked the production of a slowing substance. Using Sephadex G-100, the slowing substance appeared in the region in front of BSA indicating a molecular weight of greater than 80,000 daltons. It was heat-stable for 30 min at 56 degrees C and was sensitive to trypsin.     

The macrophage electrophoretic migration (MEM) test for lymphocyte sensitization. A study of the kinetics

The macrophage electrophoretic migration (MEM) test for lymphocyte sensitization (Field & Caspary, 1971; Caspary & Field, 1971) has been used to study a number of problems (reviewed by Field, 1972) and seems widely applicable in clincial immunology. Whilst the conditions of the test have been established empirically and it is known to involve protein synthesis by both lymphocytes (Caspary, 1971) and the indicator macrophages (Caspary, 1972) the kinetics of the test have not previously been investigated. Some observations of the effects of variation in antigen dosage and in number of lymphocytes employed, `avidity' of antigen and dilution of macrophage slowing factor (MSF) are here presented.