Allergy to a product(s) of ethylene oxide gas: demonstration of IgE and IgG antibodies and hapten specificity.

Patient D.H., on chronic hemodialysis, developed severe allergic reactions after exposure to articles such as plastic tubing and hemodialysis supplies which had undergone cold sterilization with ethylene oxide (EO) gas. It was shown that human serum albumin (HSA) exposed to EO (EO-HSA) in the usual sterilization procedure selectively elicited positive skin tests and in vitro histamine release. It is now demonstrated that D.H. serum reacts selectively in a radioallergosorbent test (RAST) which utilizes discs coated with HSA and exposed to EO gas. In addition, D.H. serum contained IgG antibodies reactive with EO-HSA. This antibody activity was not detected in the sera of 27 normal subjects and 25 chronic hemodialysis patients. EO-HSA and ragweed RAST inhibition tests with a number of proteins in native form and after exposure to EO demonstrated the EO hapten specificity of the IgE antibody.     

Cytophilic antibodies in bronchopulmonary aspergilloma and cryptogenic pulmonary eosinophilia.

The immunoglobulin class and subclass of cytophilic antibodies have been studied using peripheral leucocytes from twenty-two patients with allergic bronchopulmonary aspergillosis, aspergilloma and cryptogenic pulmonary eosinophilia. In patients with allergic bronchopulmonary aspergillosis, significantly increased histamine liberation occurred following challenge of their leucocytes with antisera to IgE, IgG2, IgG3 and IgG4 as well as with Aspergillus fumigatus antigen. The results were considerably modified if the patient was receiving corticosteroids at the time of the test. The presence of IgG2-specific antibody to A. fumigatus in the serum of one patient, capable of sensitizing donor leucocytes, was demonstrated in passive sensitization experiments. In two patients with uncomplicated aspergillomas no evidence of cytophilic antibody to any class was found although large amounts of precipitating IgG antibody was present in the serum. Two patients with aspergilloma and systemic symptoms of weight loss and fatigue (which have been interpreted by others as 'hypersensitivity' responses) had increased amounts of cytophilic antibody similar to those with allergic bronchopulmonary aspergillosis. Six patients with cryptogenic pulmonary eosinophilia were also studied. No evidence of specific antibody to A. fumigatus was found but, as a group, significantly increased histamine liberation using antisera to IgG2 was demonstrated. Individual patients also showed evidence of other classes of cytophilic antibody, one having IgE, three IgG3 and two IgG4. The relationship between heat-stable short-term sensitizing antibody (IgG STS) inducing immediate skin responses and the pattern of cytophilic antibodies found in our patients with bronchopulmonary aspergillosis having dual (immediate and late reactions) is discussed. Clinically these tests are of diagnostic value and they may be helpful in assessing symptomatic patients with aspergillomas for corticosteroid treatment.     

Anaphylaxis from topical bovine thrombin (Thrombostat®) during haemodialysis and evaluation of sensitization among a dialysis population

BACKGROUND: Topical bovine thrombin (TBT) is used as a topical haemostatic agent in haemodialysis (HD) units and for surgical procedures. It has caused allergic reactions during surgical procedures, but no previous cases have been reported with dialysis usage. OBJECTIVE: A case is reported of anaphylaxis due to TBT in an HD patient. This led to a determination of whether HD patients exposed to TBT develop specific IgE and IgG antibodies to TBT and an assessment of the frequency of allergic symptoms in HD patients as compared with peritoneal dialysis (PD) patients. METHODS: A cross-sectional study of 100 HD and 52 PD patients was performed using a questionnaire to determine allergic symptoms. An ELISA assay was developed to determine TBT-specific IgE and IgG serum antibodies among HD patients. HD patients without TBT exposure and age- and gender-matched blood donors served as controls. RESULTS : Allergic symptoms temporally related to dialysis reported by a questionnaire were significantly more frequent for HD patients than for PD patients: rhinoconjuctivitis 11% vs. 2%, asthma symptoms 20% vs. 6%, urticaria 23% vs. 8% (P values <0.05). Positive TBT-specific IgE and IgG antibodies were more frequent among 65 exposed HD patients (28% for IgE and 26% for IgG) than for controls (4% and 9%), P<0.05. CONCLUSIONS: Results indicate the potential for sensitization and clinical allergic responses to beef thrombin when used for haemostasis in HD and suggest that other haemostatic methods should be considered.     

Longitudinal study of specific IgE and IgG antibodies in a patient sensitized to ethylene oxide through dialysis

IgE and IgG antibodies to ethylene oxide (EO) were monitored by RAST and by ELISA in serum from a patient with hypersensitivity reactions during hemodialysis. Serum samples from the patient covering a 7-year period were analyzed. The changes in titers of IgE and IgG antibodies correlated to the time of EO exposure as well as to clinical symptoms. EO-specific IgG antibodies were, however, also found in sera from hemodialysis patients without any hypersensitivity symptoms. Assay of specific IgG antibodies will only indicate whether a patient has been exposed to, and immunostimulated by, EO, whereas specific IgE antibodies appear to be clearly related to hypersensitivity symptoms. The hapten and carrier specificity of EO-induced IgE antibodies was studied. The antibodies were found to be solely hapten specific because carriers of different types could be used in RAST without changing the outcome of the test. The existence of new antigenic determinants related to the carrier could not be demonstrated.     

Some immunological aspects of patients with rhinitis in Lebanon

Background: Hitherto immunological determinates in Lebanese patients with rhinitis have not been investigated.

Objective: To identify causative allergens in Lebanese patients with allergic rhinitis and determine possible correlation's among serum allergen specific antibody, polyclonal IgE, IL-4, IL-5 and peripheral eosinophil levels.

Methods: One hundred and thirteen patients with a long lasting history of nasal obstruction, rhinorrhea, sneezing and nasal itching were investigated. Serum allergen specific antibodies using a panel of 10 potential allergens, IL-4 and IL-5 levels were determined by enzyme immunoassays. Polyclonal IgE levels were estimated by an immunochromatographic assay and eosinophil counts by a Coulter STKS counter.

Results: Based on the presence of serum allergen-specific IgE antibodies, 74 patients were considered to have an allergic etiology. Polyclonal IgE levels were elevated in 41 of the 74 allergic rhinitis patients while the other 33 patients had normal serum levels. In the remaining 39 specific IgE antibody-negative patients, 32 had normal, and 7 had elevated, polyclonal IgE levels. IgE specific antibodies to more than one allergen were detected in 59 of 74 patients. The most common causative allergens were mite, Dermatophagoides pteronyssinus, Dpt (83.8%) and Dermatophagoides farinae, Df (78.4%). Analysis of the data indicated that elevated polyclonal IgE levels correlated with the concentration of serum specific IgE antibodies and the number of the detected causative allergens per patient. Fifty-nine of 74 allergic rhinitis patients had elevated IL-4 levels and 44 had elevated IL-5 levels. The number of allergic patients with both elevated IL-4 and IL-5 levels was 24. Finally, only 9 allergic rhinitis patients had peripheral eosinophilia.

Conclusion: Mite Dpt and Df were the most common causative agents of allergic rhinitis in the Lebanese group studied. A prerequisite for Specific Immunotherapy is the identification of the causative allergen. Determinations of polyclonal IgE level and peripheral eosinophil count alone, as an aid to diagnosis are insufficient and may be misleading. On the other hand, determination of all the parameters studied in conjunction appears to be of diagnostic value.     

Experience with daily immunotherapy in 59 adult allergic patients

Fifty-nine adult men with seasonal allergic rhinitis received immunotherapy that was administered five to six times per week until maintenance doses were achieved. Immunologic response was monitored with titrated prick skin tests, which revealed increased sensitivity at 2 wk, followed by progressive decline coinciding with a rise in IgG blocking antibody. Specific serum IgE (RAST) did not change. When compared with a group receiving conventional weekly injections, these subjects required the same number of injections to reach maintenance and had the same incidence of adverse reactions.     

SOME IMMUNOLOGICAL ASPECTS OF PATIENTS WITH RHINITIS IN LEBANON

ABSTRACT

Background: Hitherto immunological determinates in Lebanese patients with rhinitis have not been investigated.

Objective: To identify causative allergens in Lebanese patients with allergic rhinitis and determine possible correlation's among serum allergen specific antibody, polyclonal IgE, IL-4, IL-5 and peripheral eosinophil levels.

Methods: One hundred and thirteen patients with a long lasting history of nasal obstruction, rhinorrhea, sneezing and nasal itching were investigated. Serum allergen specific antibodies using a panel of 10 potential allergens, IL-4 and IL-5 levels were determined by enzyme immunoassays. Polyclonal IgE levels were estimated by an immunochromatographic assay and eosinophil counts by a Coulter STKS counter.

Results: Based on the presence of serum allergen-specific IgE antibodies, 74 patients were considered to have an allergic etiology. Polyclonal IgE levels were elevated in 41 of the 74 allergic rhinitis patients while the other 33 patients had normal serum levels. In the remaining 39 specific IgE antibody-negative patients, 32 had normal, and 7 had elevated, polyclonal IgE levels. IgE specific antibodies to more than one allergen were detected in 59 of 74 patients. The most common causative allergens were mite, Dermatophagoides pteronyssinus, Dpt (83.8%) and Dermatophagoides farinae, Df (78.4%). Analysis of the data indicated that elevated polyclonal IgE levels correlated with the concentration of serum specific IgE antibodies and the number of the detected causative allergens per patient. Fifty-nine of 74 allergic rhinitis patients had elevated IL-4 levels and 44 had elevated IL-5 levels. The number of allergic patients with both elevated IL-4 and IL-5 levels was 24. Finally, only 9 allergic rhinitis patients had peripheral eosinophilia.

Conclusion: Mite Dpt and Df were the most common causative agents of allergic rhinitis in the Lebanese group studied. A prerequisite for Specific Immunotherapy is the identification of the causative allergen. Determinations of polyclonal IgE level and peripheral eosinophil count alone, as an aid to diagnosis are insufficient and may be misleading. On the other hand, determination of all the parameters studied in conjunction appears to be of diagnostic value.     

Identification of IgG antibody as a carrier of reaginic activity in asthmatic patients

In a previous study it was reported that a group of asthmatic patients, in whom cromolyn sodium did not inhibit bronchial immediate allergic reactions, had reaginic antibodies that did not appear to belong to the IgE class. This study was designed to extend these observations, and it was shown that the IgG fractions from these patients' sera, purified by ion exchange chromatography and specific immunosorbents, had skin-sensitizing activity to the antigen studied, while the IgE fractions did not. The skin-sensitizing activity in the IgG fractions was not removed by anti-IgE antiserum and was not inactivated by heating at 56 °C or by reduction/alkylation. It is proposed that IgG antibodies may mediate immediate allergic reactions in some asthmatic patients, that these patients can be detected by means of serum total IgE and allergen-specific IgE estimation, and that cromolyn sodium is not an effective inhibitor of bronchial immediate allergic reactions in these patients.     

In vitro studies of human seminal plasma allergy

A 23-yr-old woman experienced generalized urticaria, angioedema, and respiratory obstruction after intercourse. Reactions increased in frequency and severity over a 2-yr period; sexual exposures were limited to her husband. Fresh, centrifuged seminal plasma samples from four donors, including her husband, evoked positive immediate puncture skin-test reactions in dilutions of 1:100 or 1:1,000; no reactions were seen in normal control males. A borderline elevation in serum IgE antibodies to seminal plasma was noted by the radioallergosorbent test (RAST). However, the patient had elevated IgE antibodies to a partially purified seminal plasma fraction (IV) obtained by Sephadex G-200 gel filtration. Seminal plasma from all four donors showed similar allergenic activity when tested in fraction IV RAST inhibition experiments. Further in vitro studies have characterized the allergenic components infraction IV. Allergenic components (pool III) (1) are distinct from acid phosphatase; (2) have an apparent molecular weight range from 20,000 to 30,000 daltons; (3) by isoelectrofocusing produced multiple bands with pi of 6.6, 7.0, and 7.5; and (4) produced multiple bands in polyacrylamide gel electrophoresis, indicating a heterogeneous group of antigens. Comparison of pool III with seminal vesicle secretions and prostatic homogenate via thin-layer isoelectrofocusing revealed protein bands which appeared to be common to all three materials. Thus, it remains uncertain as to whether allergenic proteins are derived from seminal vesicle or prostatic secretions. Condom usage by the patient's husband has essentially prevented subsequent allergic reactions. However, serum IgE antibodies to fraction IV remained consistently elevated during a 28-mo follow-up period.     

Immune responses to nematode exoantigens: sensitizing antibodies and basophil histamine release

Windelborg Nielsen B, Lind P, Hansen B, Reimert CM, Nansen P, Schiotz PO. Immune responses to nematode exoantigens: sensitizing antibodies and basophil histamine release.
High levels of IgE and eosinophilia are found in both allergy and helminth infections, but allergic symptoms are rare in naturally acquired helminth infections. The interrelation of specific IgE antibodies and in vitro basophil histamine release (HR) induced by exoantigens from the larval stages (L-₂/L₃) of the nematodes Toxocara canis and Ascaris suum was examined in 148 patients visiting an outpatient clinic for parasitic diseases. The antigen sensitivity of the basophils was found to be dependent not only on the absolute amount of antigen-specific IgE present in patient plasma, but also on the ratio between specific and total IgE. Thus, large HR was observed in some patients in response to helminth antigens despite low levels of both specific and total IgE content in plasma. Patients with eosinophilia showed greater IgE-mediated HR than the other patients examined. In contrast, only five patients showed HR after challenge with anti-IgG4, despite the presence of high levels of antigen-specific IgG4 and IgGl in all patients showing specific IgE antibodies.     

Allergic and nonallergic rhinitis: their characterization with attention to the meaning of nasal eosinophilia

We examined the differences between allergic and nonallergic rhinitis. One hundred forty-two patients were evaluated. Forty-eight patients were diagnosed as having allergic rhinitis (AR) on the basis of histories correlating with skin tests and markedly elevated total serum IgE levels. Forty-two percent of these patients had nasal eosinophilia (greater than or equal to 25%) and 58% had histories or findings consistent with asthma. Fifty-two individuals had no evidence for immunologic nasal disease, incriminated physical agents as precipitants, and demonstrated no associated respiratory pathology. These patients were classified as having vasomotor rhinitis (VMR). Twenty-one patients had symptoms similar to those of patients with VMR but they demonstrated nasal eosinophilia and were classified as having eosinophilic nonallergic rhinitis (ENR). These patients had a high prevalence of nasal polyps and were significantly more responsive to medical therapy than any group studied. It is concluded that nasal eosinophilia is of little value in the evaluation of AR but provides significant information regarding the therapy and prognosis in nonallergic rhinitis.     

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.     

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.     

Sensitization following Hymenoptera whole body extract therapy

Treatment of an insect sensitive patient with Hymenoptera whole body extracts (WBE) led, on five occasions, to a serum sickness-like syndrome which did not recur after therapy was stopped. The patient was found to be sensitive by skin test, histamine release, and radioallergosorbent test (RAST) to both venom and WBE as well as to venomless bee body preparations. Subsequent therapy with honeybee and yellow jacket venoms was without sequelae, and after treatment the patient did not react to a sting. In order to assess the frequency of sensitivity to irrelevant body proteins in patients treated with WBE we carried out WBE RASTs on sera from 15 such patients and compared them with those from 15 nontreated insect-allergic patients who had similar venom-specific IgE antibody levels. None of the patients allergic to insects who had not been treated with WBE had detectable IgE anti-WBE antibodies, while about 50% of those treated with WBE had developed IgE antibodies against these proteins. It appears that sensitization to nonvenom WBE proteins in terms of the development of IgE antibody is a common result of this therapy, and, rarely, repeated challenge with this complex antigenic mixture can also lead to clinical illness.     

An Analysis of the Role of IgE in Intolerance to Aspirin and Tartrazine

Total serum IgE and eosinophil count were determined for 30 patients with intolerance to aspirin. Total IgE levels in the aspirin intolerant patients were similar to those expected in a non-atopic population. In contrast, total eosinophil count (TEC) tended to be elevated in the aspirin intolerant group. Elevated TEC was observed both in bronchospastic (57%) and in urticarial (25%) aspirin intolerance. Specific anti-aspiryl and anti-tartrazyl antibodies of the IgE class were assayed by the galactosidase immunosorbent test (GIST). IgE anti-aspiryl antibodies were possibly detected in one patient, but did not correlate with clinical intolerance to aspirin. It is unlikely that the clinical symptoms and the eosinophilia of intolerance to aspirin and tartrazine are mediated by antibodies of the IgE class.     

Melittin: An allergen of honeybee venom

The presence of serum IgE antibodies to melittin was tested by the radioallergosorbent test (RAST). Melittin, the principal protein of honeybee venom, was isolated by gel filtration on Sephadex G-75 and covalently bound to cyanogen bromide-activated microcrystalline cellulose. The melittin preparation was homogenous by immunoelectrophoresis with the use of rabbit antiserum to whole honeybee venom and by polyacrylamide electrophoresis in gels containing 1% sodium dodecyl sulfate. Elevated serum IgE antibodies to melittin (three times greater than binding by normal sera) were found in 7 of 24 honeybee venom-sensitive persons and in 5 of 20 nonsensitive beekeepers. In one venom-sensitive patient a particularly high titer of IgE antibody was found. The reaction between solid-phase melittin and IgE antibody could be inhibited by fluid-phase melittin but not by phospholipase A (PLA). Similarly, the reaction of IgE antibody with solid-phase PLA was inhibited by PLA but not by melittin. In passive transfer skin tests with the sensitive patient's serum, positive wheal-and-flare reactions were obtained in 3 nonallergic recipients following melittin challenge; appropriate controls were negative. These results indicate that melittin is an allergen in some honeybee venom-sensitive patients and in an occasional patient melittin may be a major allergen.     

Bee venom anti-idiotypic antibody is associated with protection in beekeepers and bee sting-sensitive patients receiving immunotherapy against allergic reactions

Bee venom (BV) anti-idiotypic (anti-Id) antibodies (Abs) were studied in nonreactive beekeepers, patients receiving BV immunotherapy (IT), and in patients with bee-sting hypersensitivity. Detection of serum anti-BV was determined either by the Phadebas RAST test for IgE and IgG concentrations or by isoelectric focusing followed by capillary blotting onto nitrocellulose membranes. Clonotypic analyses of Ab were made with specific probes for BV or BV anti-Id; 13/14 nonreactive multiple-sting beekeepers (93%; p = 0.00006) and 3/3 patients receiving BV IT (100%; p = 0.0026) had detectable amounts of BV anti-Id in serum, whereas five BV-sensitive patients (0%) and four ragweed-sensitive control patients (0%) did not. Beekeeper's serum containing BV anti-Id was found to recognize and bind to IgE anti-BV idiotype from two different patient sources and inhibit their reactions in a Phadebas RAST test in a dose-dependent manner. Nonreactive beekeepers generally had BV-specific IgE levels less than 0.35 PRU/ml in serum with detectable BV anti-Id. BV-allergic patients before IT had elevated BV-specific serum IgE levels, even in the presence of BV-specific IgG greater than 136 U/ml with no BV anti-Id present. These findings provide strong support for a protective role of BV anti-Id against bee sting--allergic reactions.     

The presence of IgE on the surface of lymphocytes in nasal polyps

The presence of IgE-bearing lymphocytes in nasal polyps was correlated with the patients' atopic status. Following surgical removal, the polyp tissue was treated with hyaluronidase and a single-cell suspension was obtained. Lymphocytes were isolated by gradient centrifugation, and the fluorescent antibody technique was used to study the presence of various immunoglobulin markers on the surface of lymphocytes. The presence of IgE-bearing cells was correlated with serum IgE levels, history of allergy, and skin test reactions. Patients with a positive atopic history had intermediate to high serum IgE levels. There was no correlation between IgE level and skin reactivity in these patients. Good correlation was obtained between the number of IgE-bearing cells in nasal polyps and serum IgE levels in atopic patients. The IgE-bearing cells represented 10 to 40 per cent of total immunoglobulin-bearing lymphocytes. No IgE-bearing cells were detected in five of six patients with a negative atopicf history and negative skin tests. Thus IgE may be synthesized within nasal polyps of atopic patients, and the polyps in atopic patients may have a different etiology from those in nonatopic patients.     

Drugs as allergens: the molecular basis of IgE binding to thiopentone

Using an immunoassay developed for the detection of thiopentone-reactive IgE antibodies, the combining site specificities of such antibodies found in sera of patients who experienced life-threatening anaphylactic reactions to the drug were studied. The antibody combining sites from one patient were complementary to the region of the thiopentone molecule containing a thio group at position 2 of the barbiturate ring. The allergenic determinant recognized by IgE antibodies from another patient encompassed a secondary pentyl group and an ethyl group attached to position 5 on the other side of the barbiturate ring. Thus, it is already clear that there is more than one allergenic determinant on the thiopentone molecule with the capacity to provoke IgE formation and drug-induced allergic reactions.     

Specific immunoglobulin E antibodies in tear secretions of patients with vernal conjunctivitis

Twenty-two patients with vernal conjunctivitis (VC) were studied by radioallergosorbent test (RAST) for specific IgE antibodies to the inhalant pollen allergens in tear secretions. Specific IgE antibodies were detected in the tear secretions of 12 (54.5%) patients with VC. Six patients had a positive tear RAST, but the corresponding serum RAST and immediate skin test reactivity were negative. The specific tear IgE antibodies appeared to correlate with the seasonal prevalence of the pollen in the environment and the period of maximal symptomatology. Six patients had both positive serum and tear RAST determinations. A double ratio formula with transferrin as a marker for the leakage of plasma proteins into tear secretions and the “specific activity” ratios of IgE antibody to total IgE between the tear secretions and the serum indicated that almost all (79% to 99%) of the tear IgE antibodies were locally produced. IgE antibodies were also detected in the tears of four of 10 patients with allergic conjunctivitis (AC) and of three with allergic rhinitis (AR). However, the “specific activity” ratio in the patients with AC and AR with measurable tear IgE suggested that the IgE antibodies were derived from the leakage of serum proteins into the tear secretions. These findings suggest that the pathogenesis of VC may be IgE mediated in some patients and lends support to the concept that specific IgE antibodies can be produced locally by the target organ, i.e., conjunctival tissues.