S.G.O. Johansson

Organization of secondary lymphoid tissue and local IgE formation to Staphylococcus aureus enterotoxins in nasal polyp tissue

Background:  Bilateral nasal polyposis (NP) is characterized by high concentrations of IgE in NP tissue, which show no relation to the atopic status. We aimed to study the relationship between systemic and local IgE formation, nasal carriage of Staphylococcus aureus and nasal polyposis.

IgE to Staphylococcus aureus enterotoxins in serum is related to severity of asthma

To the Editor: Staphylococcus aureus–derived enterotoxins (SAEs) are a group of high-molecular-weight superantigens that possesses an extremely potent stimulatory activity for T lymphocytes by cross-linking the V -chain of the T-cell receptor with MHC class II molecules on accessory or target T cells, outside the peptide-binding groove area.1 The SAEs are a family of structurally related, heat-stable proteins comprising several major serologic types; among these are the 5 prototypic SAEs (types A through E) and toxic shock syndrome toxin 1 (TSST-1). Although S aureus is often found as part of the normal microflora of the upper respiratory tract, especially the vestibulum nasi, there is a marked paucity of studies documenting an association between SAEs and airway disease, particularly rhinitis, sinusitis, and asthma. Studies in animals have shown that SAE-B triggers airway recruitment of several pro-inflammatory cell types, including T cells, eosinophils, neutrophils, and macrophages, and the release of cytokines, associated with increased airway responsiveness in these animals.2 There is circumstantial evidence that SAEs might trigger T-cell activation in poorly controlled asthma in human beings,3 as the expression of corresponding TCR-V 8 on T cells in bronchoalveolar lavage is significantly increased in comparison with controls. We have recently provided evidence that SAEs are related to eosinophilic inflammation in nasal polyposis, a chronic eosinophilic inflammation located in the sinuses, which often is associated with severe asthma and aspirin hypersensitivity.4 In approximately 50% of the polyp homogenates, IgE antibodies specific to SAE-A and/or SAE-B could be demonstrated; these were linked to high total tissue IgE and a local multiclonal IgE antibody formation against various inhalant allergens. In SAE-specific IgE antibody–positive polyp samples versus controls, the eosinophilic inflammation was significantly more pronounced in terms of synthesis of IL-5, eotaxin, eosinophil cationic protein (ECP), and cysteinylleukotrienes, and most of these patients also had asthma and aspirin hypersensitivity.4 It was therefore tempting to investigate the potential role of SAEs in lower airway disease, using IgE antibodies specific to enterotoxins as a marker. To allow screening of sera from asthmatic patients, we characterized the patterns of IgE antibody responses specific to SAEs in nasal polyps and established a mix consisting of 3 SAEs (SAE-A, SAE-C, and TSST-1) coupled to the ImmunoCAP solid phase (Pharmacia Diagnostic, Uppsala, Sweden), which proved to be both more sensitive than the single allergens and highly specific (cutoff, 0.1 kU/L). No nonspecific IgE reactivity to SAE mix/ImmunoCAP was found for non–antibody-active IgE (E myeloma) at concentrations up to 1000 kU/L. Samples positive for IgE antibody to SAE mix tested negative to a control ImmunCAP without allergen. Presence of IgE antibody to SAE mix was studied in the following groups: (a) 15 healthy controls (10 female, 5 male; mean age, 33 years), who had no symptoms compatible with asthma; (b) 34 patients with mild asthma (16 female, 18 male; mean age, 27 years), who had a resting FEV1 of >80% predicted and received only the inhaled short-acting -agonist salbutamol as on-demand therapy; and (c) 21 patients with severe asthma (11 females, 10 males; mean age, 45 years), as defined by the need for regular high-dose inhaled corticosteroid therapy and (despite this treatment) persistently impaired lung function (FEV1 < 80%). All of the patients with severe asthma were receiving high-dose inhaled corticosteroid therapy (≥800 g BDP or the equivalent), as well as additional asthma medication (mostly 4 different asthma therapies); 4 of these patients were also receiving long-term oral corticosteroid therapy. None of the asthmatic patients had active disease or could recall having had atopic dermatitis previously. We measured total IgE, IgE antibodies specific to a mixture of inhalant allergens (Phadiatop), IgE antibodies specific to SAE mix, and ECP (Pharmacia Diagnostic) in serum. Severity of asthma was reflected not only in FEV1 percent and medication but also in increased serum ECP concentrations (Table I). IgE antibodies to SAE mix were found more often in serum from asthmatic patients than in serum from controls (49% vs 13%; P = .03) and, within the group of asthmatic patients, more often in those with severe asthma than in those with mild asthma (62% vs 41%; P = .224), with a statistical significant difference between patients with severe asthma and controls (62% vs 13%; P = .01; 2 test). These data suggest a relation between the presence of IgE antibody to SAE mix and the severity of asthma (in terms of spirometry and need for medication) as well as eosinophilic inflammation, as previously identified in nasal polyposis, a disease closely related to asthma. Furthermore, the data support a link between enterotoxins and steroid insensitivity in airway disease, as was demonstrated previously in human mononuclear cells.5 Inasmuch as most of the asthmatic patients—certainly those with severe asthma—also had rhinitis symptoms, we could speculate that the source of SAEs might also be the nose and sinuses and that droplets from the nose containing SAEs would be inhaled. However, further research needs to be done to clarify the pathophysiologic link between SAE-specific IgE and bronchial inflammation. Of the 55 patients with asthma, 31 showed increased concentrations of total IgE in serum (>100 kU/L), and 21 of those had IgE antibodies to SAE mix. Consequently, each of 10 subjects had an increased total IgE but no IgE antibodies to SAE mix. Twelve sera had total IgE levels above 500 kU/L, and 9 were positive and 3 negative for IgE antibodies to SAE. These data confirm the specificity of the assay; furthermore, they suggest that in approximately one third of the patients, superantigens other than the ones tested here might also play a role. In addition, there was a significant though weak correlation between concentrations of total IgE and IgE antibodies to SAE mix (P = .000; r = 0.533), as well as

Pholcodine exposure raises serum IgE in patients with previous anaphylaxis to neuromuscular blocking agents

Background:  Neuromuscular blocking agents (NMBAs) can cause anaphylaxis through immunoglobulin E (IgE) antibodies that bind quaternary ammonium ion epitopes. These epitopes are present in numerous common chemicals and drugs, exposure to which, theoretically, could be of importance in the development and maintenance of the IgE sensitization promoting allergic reactions. Pholcodine is one such drug, which in a recent pilot study was shown to induce a remarkable increase in serum IgE levels in two IgE‐sensitized individuals. The present study explores the effect of pholcodine exposure on IgE in a population with previously diagnosed IgE‐mediated anaphylaxis towards NMBAs.

National pholcodine consumption and prevalence of IgE-sensitization: a multicentre study

To cite this article: Johansson SGO, Florvaag E, Öman H, Poulsen LK, Mertes PM, Harper NJN, Garvey LH, Gerth van Wijk R, Metso T, Irgens A, Dybendal T, Halsey J, Seneviratne SL, Guttormsen AB. National pholcodine consumption and prevalence of IgE‐sensitization: a multicentre study. Allergy 2010; 65: 498–502.

False-positive penicillin immunoassay: An unnoticed common problem

range of IL-31 levels between 23.1 and 111.3 pg/mL, levels in patients with mastocytosis ranged between 24.5 and 781.0 pg/mL (Fig 1, A). Interestingly, within the group of 38 adult patients, thosewith advanced disease categories, such as smoldering systemic mastocytosis and aggressive systemic mastocytosis with associated clonal hematologic non-MC lineage disease, exhibited significantly increased IL-31 levels compared with those with nonadvanced disease categories, including CM or ISM and ISM with associated clonal hematologic non-MC lineage disease (P5 .0006 [Fig 1, A] and P5 .0005 [Fig 1, B]). All IL-31 values of greater than 313.9 pg/mL were measured in patients with advanced disease categories, and none of the patients with advanced disease categories were found to exhibit IL-31 values of less than 81.9 pg/mL (Fig 1, A). As anticipated, tryptase levels increased along with disease severity (see Fig E1, A, in this article’s Online Repository at www.jacionline.org), and consistently, IL-31 was found to also correlate with tryptase in the subgroup of adult patients (P5 .0093; Fig 1, C). Furthermore, IL-31 levels correlated with the percentage of MC infiltrates in bone marrow (P5 .0404; see Fig E2, E, in this article’s Online Repository at www. jacionline.org), and patients with MC infiltrates of greater than 15% showed significantly increased IL-31 levels compared with patients with infiltrates of 15% or less (P 5 .0306; see Fig E2, F). Surprisingly, when we compared the group of 12 pediatric patients, who all had CM, with the group of 28 adult patients with CM or ISM, we observed significantly increased IL-31 levels in pediatric patients (P5 .0279; Fig 1,A). Because pediatric patients typically show lower tryptase levels than adult patients, which was also confirmed in our study (see Fig E1, A), this finding was unexpected. Analyzing different clinical parameters, we detected significantly increased IL-31 levels in male compared with female patients, which might be due to increased body weight associated with increased MC numbers in male patients (P5 .0338; see Fig E2, A). There was also a trend toward increased IL-31 expression in patients with osteosclerosis compared with that seen in patients with normal bone density, osteopenia, or osteoporosis, reflecting again the association between advanced categories of mastocytosis and high IL-31 levels because all 3 patients with osteosclerosis had either smoldering systemic mastocytosis (n 5 1) or ASMAHMND (n 5 2; not significant; see Fig E2, H). A relationship between increased bone density and increased tryptase levels has already been described. In contrast, other clinical parameters, including age, disease duration, presence of a KitD816Vmutation or skin lesions, presence of MC activation symptoms (eg, pruritus, anaphylaxis, flushing, and diarrhea), and intake of H1 antihistamines, did not affect IL-31 levels (see Fig E2,B,G, and I-P). To determine the cellular source of IL-31, we next analyzed skin and bone marrow biopsy specimens of patients with mastocytosis by using immunohistochemistry with specific antibodies against tryptase and IL-31 (Fig 2). In both tissues expression of IL-31 clearly colocalized with tryptase-positive MCs, demonstrating that MCs represent a major source of IL-31 in mastocytosis. In conclusion, our results show, for the first time, that patients withmastocytosis express increased serum IL-31 levels. In adults, IL-31 levels correlate with disease severity, tryptase levels, and percentages of bone marrow infiltration. MCs in skin and bone marrow of patients with mastocytosis are able to produce IL-31. Our data suggest exploiting IL-31 levels as a potential diagnostic marker in adult patients, particularly in patients with mastocytosis-associated osteosclerosis, which might indicate disease progression. Furthermore, to our knowledge, this is the first report on expression of IL-31 in bone marrow.

Allergens of the imported fire ant

A whole body extact (WBE) was prepared by saline extraction of ground imported fire ants (IFA). A serum pool from rabbits immunized with the WBE elicited 31 precipitates on crossed immunoelectrophoresis. Crossed radioimmunoelectrophoresis was performed with sera from 26 RAST IFA-positive subjects, 24 of whom were known for clinical hypersensitivity to IFA and two subjects, known to be hypersensitive to yellow jacket. Radiostaining was obtained to 14 precipitates, some of which were judged to be partially identical. Thus, six apparently different allergen groups could be identified. Two of these fulfilled arbitrary criteria of major allergens. Three of the IFA WBE allergens were easily identified in crossed immunoelectrophoresis of a commercially obtained IFA-venom preparation. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the IFA WBE demonstrated protein bands with molecular weight ranging from 10,000 to 200,000 daltons. An immunoblotting technique with nitrocellulose paper strips revealed binding of human IgE from hypersensitive subjects to four different bands (either single bands or clusters of proteins of similar molecular weight) with molecular weights ranging from 13,000 to 42,000 daltons. It is a notable finding that these insect allergens thus were of a similar size as important aeroallergens.

Qualitative and quantitative evaluation of bird specific IgG antibodies

Background: Exposure to organic dust produced by birds often gives rise to an immune response, e.g. IgG antibodies, but intense exposure can lead to high concentrations of IgG antibodies and the development of allergic alveolitis, often known as ‘bird fancier’s lung’. The aim of this study was to establish the distribution of bird-specific IgG antibodies in exposed and nonexposed individuals and compare a nonquantitative and quantitative method in evaluating raised levels of IgG antibodies. Methods: Sera were collected in Sweden and South Africa and levels of IgG antibodies specific to pigeon, budgerigar and parrot antigens were quantified using the UniCAP system. Results were compared to the precipitation in gel assay. The IgG antibody values of symptomatic patients without precipitating antibodies (non-PP group; n = 51) and patients with precipitating antibodies (PP group; n = 34) were analyzed and compared to nonexposed asymptomatic blood donors (BD group; n = 73) and environmentally exposed pigeon breeders (n = 11). Results: The IgG antibody response of the analyzed groups in Sweden and South Africa did not vary significantly from each other. IgG antibody responses were the strongest to pigeon antigens with clear increased IgG antibody levels in the PP group [geometric mean (GM) 603 mg/l] compared to the non-PP (GM 6.9 mg/l) and BD group (GM 5.0 mg/l). Threshold values, calculated as the GM value from the BD group plus 3 standard deviations (99% confidence interval), were 9.8, 10.8 and 10.0 mg/l for pigeons, budgerigars and parrots, respectively. Comparison of the two methods resulted in a good concordance with a level of agreement of 94.1% (kappa statistic = 0.83). Conclusions: The UniCAP system for the detection of bird-specific IgG antibodies is a highly reproducible, generally available, quantitative method for routine diagnostic testing and monitoring of exposed subjects with a very high level of agreement to the precipitating gel assay.

Mites Living in Hay: An Important Allergen Source?

Fifty‐two farmers and 21 non‐farmers with symptoms related to hay contact were investigated. Skin prick tests (SPT) and RAST were performed with an extract made of barn dust (BDE) consisting of remnants. At microscopy, the barn dust was found to contain large amounts of dead mites, most of them identified as Lepidoglyphus destructor and Acarus siro. Twenty‐one patients (9 farmers and 12 non‐farmers) had positive R. ST to BDE, with a good correlation to the case histories. Other allergies, especially to Dermatophagoides pteronyssinus, pollens, and animal danders were also common among patients. However, there was no correlation between positive SPT and RAST to BDE and any other allergen tested. This indicates that BDE contains distinct allergens, most likely of mite origin.

New diagnostic classification of allergic skin disorders.

Purpose of reviewTo highlight the importance of one common nomenclature for allergic skin disorders. Recent findingsDiseases are best defined on the pathophysiological mechanisms underlying the symptoms. Although the mechanisms behind what is sometimes unfortunately referred to as ‘atopic eczema’ or ‘atopic dermatitis’ have been quite well understood for 30 years the present terms used are confusing. Over the years more than 20 different names have been used. SummaryDoctors, scientists and patients in the field of allergy must use one and the same terminology for allergic diseases or the result will be confusion. Diagnosis, prevention, treatment, patient advice, environmental relations, and the search for genetic markers are examples of areas that will be hampered by conflicting results. Strong efforts should be invested into broadly implementing the European Academy of Allergology and Clinical Immunology (EAACI) revised nomenclature for allergy.

Reactivity of mast-cell-bound IgE idiotypes with anti-idiotypic antibody : mediator release or inhibition of antigen-induced mediator release ?

When anti-idiotypic antibodies specific for idiotopes on IgE antibodies react with mast-cell-bound IgE antibody, the reaction may be expected to lead either to mediator release or to inhibition of allergen-induced release. This study was carried out to determine which would occur. Anti-idiotype antiserum (anti-Ids) was raised in syngeneic mice by immunisation with affinity-purified DNP-specific mouse monoclonal IgE. Sera from these immunised mice and from a similarly immunised rabbit inhibited the binding of the monoclonal IgE to radio-iodinated dinitrophenylated (DNP) ovalbumin, whereas a high concentration of affinity-purified rabbit antimouse epsilon-chain-specific antibody was unable to inhibit even though it was shown to bind to the monoclonal IgE. The mouse anti-Ids did not give a positive passive cutaneous anaphylactic reaction in rats sensitised with high-titre grass-pollen-specific IgE-containing antiserum, whereas it gave a positive result in rats sensitised with the DNP-specific monoclonal IgE. Rabbit antimonoclonal antiserum and rabbit anti-epsilon-chain antibody both gave positive results in these two assays. The results indicated that anti-idiotypic antibodies specific for idiotopes on IgE antibody can react and release mediators from IgE-sensitised mast cells. The significance of this in view of the increased levels of anti-idiotypes that can occur during immunotherapy is discussed.