Clinical application of measurements of serum levels of bee venom-specific IgE and IgG

Bee venom-specific IgE and IgG antibodies were measured in the serum of beekeepers, bee-allergic persons, and normal persons infrequently stung without adverse effects. Beekeepers, who are stung frequently and relatively “immune” to bee stings, are characterized by high serum levels of IgG- and low serum levels of IgE-specific antibodies. Bee-allergic individuals have high titers of bee venom-specific IgE and generally low titers of bee venom-specific IgG. Following a bee sting, allergic individuals develop a rising titer of IgE antibodies, accompanied occasionally by a rise in IgG antibodies. Therapy with whole bee body extracts fail to effect IgE or IgG antibody titers. During the course of venom immunotherapy IgG-specific antibodies are stimulated and IgE-specific antibodies continue to decline. These observations suggest that: (1) bee sting allergy is a function of bee venom-specific IgE; (2) bee sting immunity is a function of bee venom-specific IgG; and (3) bee venom is an appropriate therapeutic antigen.     

Sensitization to nonvenom contaminants in a venom preparation.

An individual is described who appeared to be sensitive to nonvenom contaminants in a venom preparation. His IgE antibodies, measured by the immediate direct skin test and the radioallergosorbent test (RAST), reacted with a yellow jacket venom preparation obtained by "washing" of venom sacs. With yellow jacket venom obtained by electriral stimulation, there was a skin test reaction of equivocal significance and no serum antibodies were detected by the RAST. Moderate reactions were also found with yellow jacket body extracts. In contrast, sera obtained from patients with yellow jacket sting anaphylaxis showed strong reactions with the electrically stimulated venom preparation and only a few reacted with the body extract. In additional studies, the patient's serum reacted with yellow jacket extracts devoid of venom and a variety of hornet and wasp extracts. Analyses of the two yellow jacket venoms by gel diffusion using rabbit antisera showed the presence of body proteins in the venom obtained by venom sac "washing." Subsequent history revealed the presence of insect nests in the roof of the patient's bedroom, perhaps the source of inhalant exposure and sensitivity. This case history demonstrates the need for venom extracts that do not contain potentially sensitizing extraneous material.     

Clinical and immunologic studies of patients with large local reactions following insect stings

During the summer of 1978, 22 patients who had large local reactions following insect stings were evaluated for the development of potential systemic sensitivity. Approximately half the patients had venom IgE antibodies, detected by either the immediate skin test or radioallergosorbent test (RAST). A control group of 26 patients experiencing normal sting reactions had only a 15% incidence of venom-specific IgE. No correlations could be found between the presence of venom-specific IgE and age, sex, sting location, atopic history, or prior stings. IgE antibodies were found in 13 of 17 patients who had experienced local reactions lasting more than 48 hr. Serum venom-specific IgG was detected in only three of 19 patients. These results suggest that following large local reactions from insect stings patients must be individually assessed for the presence of venom-specific IgE and consideration for specific immunotherapy.     

Immunological studies of the effect of whole body insect extracts in the treatment of stinging insect allergy

Specific IgE antibodies and total antibodies reacting with bee venom and yellow jacket venom were measured in sequential serum samples of insect-sensitive individuals. Venom-specific IgE decreased as a function of time and was not significantly affected by treatment with whole body extracts. There was no stimulation of total antibodies reacting with bee venom or bee venom phospholipase A₂ (PLA) following treatment with whole bee body extracts. These studies suggest that as measured by these parameters, whole body insect extracts used in the usual recommended doses are immunologically ineffective antigens.     

Studies of the antigenicity and allergenicity of phospholipase A2 of bee venom.

The antigenic and allergenic properties of phospholipase A2 (PLA2) and whole bee venom were compared by measuring the IgG and IgE antibody responses in animals and man. Precipitating antibodies raised in rabbits and reaginic and other antibodies raised in mice reacted about equally with both bee venom and PLA. The majority of human sera containing bee venom-specific IgE also contained PLA-specific IgE, although in somewhat lower titers. Similarly, most human sera with significant amounts of total antibodies reacting with bee venom also had antibodies reacting with PLA. Histamine and SRS-a release from leukocytes of sensitive patients followed challenge with whole bee venom and PLA in the majority of instances. However, mediator release from several patients' cells was obtained with bee venom only. These studies suggest that although PLA is a major allergen and antigen in bee venom, significant exceptions in patients' reactivity may limit its potential diagnostic and therapeutic usefulness.     

Reactions during hemodialysis caused by allergy to ethylene oxide gas sterilization

In patients receiving long-term hemodialysis (HD), we have examined the presence of IgE-dependent sensitization to ethylene oxide (EO) gas, which is used for sterilization of disposable medical products including dialyzers. Serum was obtained from 25 patients who experienced acute allergic reactions during HD, five patients receiving HD with isolated eosinophilia, and 37 unselected patients receiving HD. Sera from 22 of 25 of the allergic reaction group and from five of 35 of the unselected group were demonstrated to contain IgE antibodies with specificity for EO. Corresponding IgG antibodies were also present. No such antibodies were detected in serum from normal controls or ragweed-allergic patients. The serum from one patient with isolated eosinophilia had a borderline elevated IgE antibody level. These results demonstrate a close relationship between the presence of IgE antibodies to EO and HD-related allergic reactions in this patient population.     

Antigenemia in paracoccidioidomycosis.

Severe forms of paracoccidioidomycosis (Pcm) are accompanied by intense immunological involvement characterized by depression of the cell-mediated immune response and by high levels of antibodies in serum with no protective function. These changes can be reversed by antifungal treatment. It has been suggested that antigens of Paracoccidioides brasiliensis released into the circulation during the active phase of the disease may be involved in the genesis of the changes in the immune response. In the present study, we evaluated the antigenemia of patients with Pcm using a competitive enzyme-linked immunosorbent assay (ELISA-c) capable of detecting 6 ng of antigen per ml of serum. Twenty-seven of 88 serum samples tested gave positive results, with the highest frequency of positivity being detected in patients with the severe acute form of the disease; these patients had the highest antigen levels (0.03 to 3.4 micrograms/ml). Follow-up of one case showed a correlation between antigen levels in serum and evolution of the disease. False-positive reactions were observed in sera from patients with histoplasmosis, aspergillosis, and cryptococcosis. The results indicate that the described method has potential for clinical application, especially with respect to the evaluation of disease activity. Quantification of fungal antigens in the serum of patients with active Pcm represents an objective parameter for the study of the physiopathology of the disease.     

Immunologic mechanisms in hypersensitivity pneumonitis: I. Evidence for cell-mediated immunity and complement fixation in pigeon breeders' disease

Immunologic studies were performed on 5 patients with pigeon breeders' disease. Intradermal injection of pigeon serum produced an immediate wheal-and-flare reaction within 15 minutes and a secondary Arthus-type reaction within 4 to 8 hours. Immunofluorescent studies of the secondary reaction site showed IgG, C3, and C4 in 2 patients. Patients' sera produced multiple precipitin bands with pigeon serum when reacted by double diffusion in gel. IgG antibody isolated from each of the patients' serum formed precipitating immune complexes that fixed large amounts of complement (C4) when added to fresh human serum. Peripheral blood lymphocytes from 4 of the 5 patients produced macrophage migration inhibitory factor (MIF) when challenged with dilute pigeon serum. These studies are the first to show complement fixing antibodies and macrophage MIF production by lymphocytes from patients with hypersensitivity lung disease and suggest that both humoral and cellular immunity may be important in the pathogenesis of these disorders.     

Relationships between prednisone therapy, disease activity, and the total serum IgE level in allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is an unusual syndrome caused by hypersensitivity to Aspergillus spores growing in the bronchii. Previous investigators have suggested that the IgE levels and precipitating antibodies may vary according to disease activity. We have been able to closely follow 12 out of a group of 40 ABPA patients with IgE and serum precipitating antibody measurements. Our results confirm that both the total serum IgE and the precipitin response vary according to ABPA disease activity. In particular the IgE trend appears to mirror the disease activity in that a rising level may portend a flare, while a stable or declining value implies disease remission.     

Antibodies to purified bee venom proteins and peptides. II. A detailed study of changes in IgE and IgG antibodies to individual bee venom antigens

Antibodies to individual bee venom antigens were studied in detail in nine bee sting-allergic patients who received venom immunotherapy without side effects, in two patients who failed to reach maintenance, and in two whose sensitivity returned. The study was confined to patients who had IgE antibodies to at least one of four purified bee venom antigens at the start of treatment. IgE and IgG antibodies to phospholipase A2 (PLA2), hyaluronidase (HYAL), and acid phosphatase (ACID P) and IgE antibodies to melittin (MEL) were measured, and changes in the antibody levels were followed during bee venom immunotherapy. Two contrasting patterns of antibody response were seen in the nine successfully treated patients. In five patients there was a rise in serum IgG antibodies to the same antigens as the IgE antibodies. In two patients' serum IgE antibody to HYAL or ACID P fell without a marked IgG antibody response to these antigens, although high levels of IgG antibody to PLA2 were present in both. Although the first pattern is consistent with a "blocking" role for IgG antibody, clearly the second is not. Not all patients can be conveniently divided into these two categories, and two patients did not show any significant change in either IgG or IgE antibody but were nevertheless able to tolerate the maintenance dose of 100 micrograms of venom. Two patients who failed to reach the maintenance dose of 100 micrograms because of their allergic reactions to the injections of venom were distinguished by (1) very high serum IgE antibody and (2) a low ratio of IgG/IgE antibody. Passive immunization with IgG antibody from a hyperimmune beekeeper was, however, protective in these patients, although it did not raise their overall serum IgG antibody level very much. We are unable to explain either the failure of conventional therapy or the beneficial effect of passive immunization in these two patients. Two bee sting--allergic beekeepers lost their sensitivity to stings, but later, when their sera contained IgE antibody to another bee venom antigen, they reacted to stings and inhalation of beehive dander. These data suggest that either falling IgE antibody or IgG- "blocking" antibody could be responsible for providing clinical protection to bee venom--allergic subjects. Renewed clinical sensitivity was observed when the IgE response was modulated, with patients making IgE antibody first to one antigen and then to another.     

Detection of allergy to nuts by the radioallergosorbent test.

The diagnosis of food allergy is often difficult to make by conventional means. Histories are frequently ambiguous, and skin testing is of dubious reliability because of the number of false-positive and false-negative reactions. We have evaluated the radioallergosorbent test (RAST) for the in vitro measurement of the specific IgE antibodies to nuts, including Brazil nut, almond, walnut, pecan, cashew, and the legume, peanut. Serums were obtained from 18 patients with a history of nut allergy and IgE level and specific IgE antibodies were measured. Thirteen of the 18 patients had significantly elevated IgE antibody (greater than twice control) to one or more of the allergens. Prausnitz-Küstner tests on selected serums in general corroborated the results of the in vitro studies. Five patients had RAST elevations to 2 or more nuts. As a group RAST-positive patients had elevated mean serum IgE levels and more severe clinical symptoms (p less than 0.01). The specificity and cross-reactivity of IgE antibodies to different nut antigens was investigated by RAST inhibition with serums from 5 patients having high levels of IgE antibody. In 4 patients no cross-reactivity between Brazil nut and peanut was found. In contrast, several nut extracts inhibited the reaction of pecan allergen with IgE antibodies. These results indicate that specific IgE antibodies can be measured by RAST in patients with nut allergy and the cross-reactivity of nut antigens can be investigated. RAST would appear to be most useful in confirming the diagnosis of nut hypersensitivity in children or in highly allergic patients in whom skin testing poses a risk of anaphylaxis.     

Comparison of immunodiffusion and enzyme linked immunosorbent assay in the detection of abnormal antibodies in pigeon breeder''s disease.

AIMS: To compare the sensitivity of two methods for the detection of serum antibodies to pigeon faecal antigens in patients with pigeon breeder's disease. METHODS: Serum samples stored at -20 degrees C from 50 patients with pigeon breeder's disease, 50 control samples from patients with other respiratory diseases, and 50 healthy blood donors were examined for the precipitating antibodies and IgG antibodies to antigens present in extract of pigeon droppings by immunodiffusion and enzyme linked immunosorbent assay (ELISA), respectively. RESULTS: Both antigen preparations of pigeon dropping extract were equally effective. A positive immunodiffusion reaction gave one or more precipitin lines and these antibodies were detected only in undiluted sera from 80% of the patients with pigeon breeder's disease. In the ELISA the sera were tested at a starting dilution of 1 in 100 because positive reactions were observed with sera from healthy blood donors at lower dilutions. All sera which gave optical density readings above 3 SD of the control value were considered to have IgG antibodies. These antibodies were detected in sera from all the patients with pigeon breeder's disease. The antibody titres were much higher in those patients who had precipitating antibodies (range 800-51,200) than those without (range 100-800). The antibodies were not detected in the sera of patients with respiratory diseases or healthy blood donors by either method. CONCLUSIONS: Antibodies to pigeon dropping antigens were detected by immunodiffusion and ELISA in sera from patients with pigeon breeder's disease but not in control sera. ELISA was a more sensitive method for detecting antibodies and therefore seems to have considerable potential as a routine technique in the serological diagnosis of pigeon breeder's disease.     

Insect venom allergy: a prospective case study showing lack of correlation between immunologic reactivity and clinical sensitivity

This case report demonstrates the lack of correlation between clinical sensitivity to insect venoms and immunologic reactivity as indicated by the presence of venom-specific IgE. A 20-yr-old venom collector was monitored over a 3-yr period with measurements of venom-specific IgE (skin test and RAST) and venom-specific IgG. In the first year of venom collection, multiple stings were tolerated with no reaction. In the second season, she had an anaphylactic reaction after a yellow jacket sting. Subsequently, there was a rising titer of serum yellow jacket and bee venom-specific IgE and positive skin-test reactions. In the third season, yellow jacket, hornet, and bee venom skin tests remained positive and serum IgE antibody titers remained elevated. Stings from all three insects were tolerated with no reaction. Throughout the 3-yr course, serum venom-specific IgG remained low and unchanged. The factors other than IgE-modulating clinical anaphylaxis, perhaps responsible for this clinical and immunologic dichotomy, are unknown. These observations add a further complication to the choice of patients for venom immunotherapy.     

Comparison of idiotypes of rabbit antibodies against Salmonella abortusequi and tobacco mosaic virus. Study of cross reactions between antibody idiotypes against these 2 antigenic materials

Idiotypic determinants of anti-tabacco mosaic virus (TMV) antibodies produced by different rabbits can sometimes show a very strong similarity. The frequency of precipitin reactions between sera against anti-TMV idiotypes and anti-TMV sera which are not used for their preparation (heterologous reactions) is about 4 %. We have compared idiotypy of anti-TMV antibodies and idiotypy of anti-Salmonella abortus-equi (Sae) antibodies produced by different rabbits. We have observed precipitin reactions between anti-Sae sera and sera against anti-TMV idiotypes and vice versa. However, anti-Sae antibodies do not combine with TMV and vice versa. Anti-idiotypic sera which precipitate anti-TMV antibodies in the homologous anti-TMV serum can also precipitate anti-Sae antibodies in a heterologous anti-Sae serum. In the same way, anti-idiotypic sera which precipitate anti-Sae antibodies in the homologous serum can also precipitate anti-TMV antibodies in a heterologous anti-TMV serum. We have observed 3 heterologous reactions during the study of 1260 reactions in which anti-TMV sera and sera against anti-Sae idiotypes are involved. We have observed 3 heterologous reactions during the study of 436 reactions in which anti-Sae sera and sera against anti-TMV idiotypes are involved. Previous absorption of anti-idiotypic serum by the homologous serum causes these heterologous reactions to disappear. We have observed, in the case of two of these heterologous reactions, that addition to the anti-idiotypic serum of an excess of the heterologous serum IgG could cause the homologous reaction to disappear. These heterologous reactions between sera against different antigens do not seem to imply the rabbit rheumatoid factor-like substance. These reactions imply idiotypy of anti-Sae antibodies and idiotypy of anti-TMV antibodies.     

Celiac disease and hypoparathyroidism: cross-reaction of endomysial antibodies with parathyroid tissue.

Celiac disease (CD) is a gluten-sensitive enteropathy characterized by the presence of serum antibodies to endomysial reticulin and gliadin antigens. CD has been associated with various autoimmune endocrine disorders, such as diabetes. We report a rare case of idiopathic hypoparathyroidism with coexistent CD characterized by the presence of serum autoantibodies. Studies were conducted to determine the specificities of these autoantibodies and to localize the antibody binding sites by indirect immunofluorescence and immunoelectron microscopy. Sera from a patient with idiopathic hypoparathyroidism and CD and from two patients with CD alone were tested by indirect immunofluorescence for autoantibodies to parathyroid and endomysial antigens. The specificities of the antibody reactions were determined by testing the sera before and after absorption with monkey stomach tissue. In addition, immunoelectron microscopic studies were performed to determine the localization of the endomysial antigen. Indirect-immunofluorescence studies on the patient's serum were positive with the parathyroid as well as the endomysial substrate. Similar reactions were also observed with the sera of endomysial antibody-positive patients with CD. Absorption of the sera with monkey stomach powder, which is known to have the endomysial antigen, abolished the antibody activities on both the endomysial substrate and the parathyroid tissue. Immunoelectron microscopic studies showed that endomysial antibody activity was associated with antigens localized on the myocyte plasma membrane and in the intercellular spaces. Thus, reactions of the patient's serum with the parathyroid tissue were due to endomysial antibodies and were not parathyroid specific as in patients with idiopathic hypoparathyroidism who did not have coexistent CD. In conclusion, indirect-immunofluorescence tests on parathyroid tissue detect not only tissue-specific antibodies but also cross-reactive antibodies, and this should be taken into consideration when these tests are performed.     

Evaluation of immune parameters in HIV+ subjects reporting adverse reactions to sulfamethoxazole

Trimethoprim-sulfamethoxazole (TMP-SMX) is frequently used in human immunodeficiency virus (HIV)-infected patients (HIV+) for treatment or prophylaxis of Pneumocystis carinii pneumonia (PCP). Up to 80% of those patients report adverse reactions to that drug combination. To test the hypothesis that these reactions are immunologically mediated, we quantitated specific IgG and IgE SMX-human serum albumin (HSA) antibodies and immune complexes (IC) in HIV+ patients and in HIV controls. Patients with mild HIV disease had elevated specific SMX-HSA IgG and IC levels compared with those having severe disease or with controls. Conversely, patients with severe HIV disease had statistically elevated levels of specific IgE when compared with patients having milder disease or with controls. There were no differences in either specific antibody or IC levels between patients reporting adverse reactions and those who did not. Results suggest that there are increased levels of SMX-HSA-specific antibodies in some HIV+ patients. The presence of these antibodies appears to be related to severity of disease, rather than clinically significant drug sensitivity.     

Local intranasal immunotherapy for ragweed allergic rhinitis I. Clinical response

Local nasal immunotherapy (LNIT) of ragweed allergic rhinitis was studied in a double-blind controlled trial. Sixty-seven subjects were divided into three groups. Twenty-one received unmodified ragweed extract (RW), 24 received a glutaraldehyde polymer of ragweed extract (PRW), and 22 received placebo. Mean symptom/medication scores during the season were 2.12, 2.76, and 3.93 for the RW, PRW, and placebo groups, respectively. Both the RW- and the PRW-treated group scores were significantly lower than those of the placebo group (p < 0.01, and p < 0.025, respectively). The results of the patients' self-evaluations indicated that therapy was effective in 71%, 59%, and 41 %for the RW-, PRW-, and placebo-treated groups, respectively. Adverse reactions to treatment were limited to the upper respiratory tract and were noted by all patients. They were significantly more severe in the RW-treated patients than those in the PRW- or placebo-treated groups. We conclude that LNIT is an effective therapy for ragweed allergic rhinitis. The use of a PRW decreased adverse reactions significantly while slightly decreasing the therapeutic benefit.     

Stinging insect allergy: Natural history and modification with venom immunotherapy

The natural history of stinging insect allergy and its modification by venom immunotherapy was investigated by follow-up observations of patients with histories of venom anaphylaxis and detectable venom-specific IgE. The patients were divided into three categories: (1) receiving venom immunotherapy, (2) declined venom immunotherapy, and (3) terminated venom immunotherapy. One hundred twenty-seven patients were evaluated after 6 mo to 9 yr of venom immunotherapy. Most received top venom doses of 50 μg of yellow jacket and/or honeybee venoms every 4 wk. There were 87 restings in 48 patients resulting in two systemic reactions, only one of which could be considered a treatment failure (1%). Fifty-six patients never received venom immunotherapy. In this group there were 40 restings in 28 patients with 14 systemic reactions (35%). In 88 patients who stopped venom immunotherapy, 61 restings in 41 patients led to 11 systemic reactions (17%). Patients with cardiovascular/or respiratory symptoms with initial sting anaphylaxis were at risk for subsequent reactions. With one exception, patients with hives and edema only as the initial reaction either had a similar or no reaction when they were restung. These results confirm the efficacy of venom immunotherapy but also suggest that there are factors other than the presence of venom-specific IgE modulating the occurrence of clinical anaphylaxis.     

T lymphocytes bearing complement receptors in a patient with chronic lymphocytic leukaemia.

A patient is described who presented with a disease clinically resembling chronic lymphocytic leukaemia, characterized by generalized lymphadenopathy, pleural and peritoneal effusions, a blood lymphocyte count of 700,000/mul and failure to respond to conventional therapy. At least 95% of these cells formed rosettes with sheep erythrocytes (E) and with erythrocytes coated with 19S antibodies and complement (EAC). All of these cells bound rabbit anti-human thymocyte serum; this serum bound to 0--22% of the lymphocytes from twenty other patients with chronic lymphocytic leukaemia. These unusual cells did not bear surface immunoglobulin detectable by immunofluorescence. The clinical and cellular features of this malignancy are compared to previously reported cases of T cell chronic lymphocytic leukaemia. As this case illustrates, T-cell chronic lymphocytic leukaemia may present without skin lesions and may be a more aggressive disease than the more common B-cell neoplasm.     

An iatrogenic autoantibody: immunological responses to `pituitary snuff'' in patients with diabetes insipidus

In the treatment of patients with diabetes insipidus, due to a variety of causes, by nasal insufflation of `pituitary snuff' (porcine or bovine, acetone-dried posterior pituitary), asthma may develop and immediate reactions are given on skin testing with the treatment material, In addition, in patients with or without asthma, precipitating antibodies have been found in the serum capable of reacting with heterologous serum protein constituents of the pituitary snuff, and also with antigens of homologous and heterologous pituitary gland. Immunofluorescence studies have shown that antibodies are present not only to heterologous tissues (bovine and porcine) but also to human tissue—in particular to antigens in the pituitary. Inhalation of the heterologous pituitary antigens has thus led to the appearance of `hetero-stimulated', `autoreactive' antibodies against the homologous pituitary. These antibodies are related to the treatment and not to the original causation of the disease.