it’s nothing to sneeze at – an update in allergy
DESCRIPTION
It’s Nothing to Sneeze At – An Update in Allergy. Virginia Chapter ACP Annual Meeting 2013 Scott P. Commins Division of Allergy and Clinical Immunology. Disclosures. We are grateful for generous support from the Oakey Food Allergy Fund - PowerPoint PPT PresentationTRANSCRIPT
It’s Nothing to Sneeze At – An Update in Allergy
Virginia Chapter ACP Annual Meeting2013
Scott P. ComminsDivision of Allergy and Clinical Immunology
Disclosures
We are grateful for generous support from the Oakey Food Allergy Fund
These studies were carried out with generous support from the NIH-NIAID (K08 AI085190 &
R21 AI087985) Disclosure: Up-to-Date card
I. Background
How oncologists helped uncover a novel food allergy
High incidence of hypersensitivity reactions to cetuximab infusions in mid-Missouri: Association with prior history of atopyR. Owera, A. Gill, S. Haddadin, R. Khozouz and M. C. Perry University of Missouri Columbia, Columbia, MO
Abstract, 2008 ASCO Annual Meeting Proceedings, Vol 26, No 15S, 2008:20747
The story got stranger as O’Neil talked to more oncologists. He heard that a colleague in Nashville, Tennessee, was finding the same problem. But when O’Neil spoke to oncologists from other areas of the country, they didn’t know what he was talking about. A prominent colorectal oncologist in New York “thought we were lying or crazy,” O’Neil recalls.
From “A Mysterious Allergy Afflicts the South” by Sheila Read in Endeavors, 24:2, 2-3, 2008.
Regarding cetuximab HSR:
Measurement of IgE ab to Purified Allergens Using Streptavidin Solid Phase
Streptavidin Solid Phase + Biotinylated “Allergen”
“Allergen” of interest (cetuximab) + Biotin
Solid Phase*
*Routine assay technique in parallel with Phadia standard curve gives results in IU/ml.
Then add serum; wash; add labeled anti-IgE; detect chemilum.
IgE Antibodies Binding to Cetuximab in Sera from 76 Case Subjects and 462 Controls
Cetuximab
* * Site not glycosylated
N-88
N-43
N-299
Qian J, Liu T,…Zhou Q. Analytical Biochem, 2007.
Typical Fc region oligos: core fucosylated
biantennary oligos; no alpha-gal or NGNA
Specificity of the IgE Antibodies that Cross-React with Cetuximab
Chung CH et al. N Engl J Med 2008;358:1109-1117
II. Defining a “new” food allergy
Specificity of the IgE Antibodies That Cross-React with Cetuximab
Chung CH et al. N Engl J Med 2008;358:1109-1117
JACI, February 2009
-24 patients-Virginia & Missouri- Symptoms delayed 3-6 hours after eating mammalian meat- Prick skin test often less than 4mm- Intradermal skin test positive
Skin Testing Results: Often <4mm SPT
IntradermalPrick test
Prick test performed using lancette and intradermal testing with 25 gauge needle in the same patient on a single clinic visit.
Patient data, presentation, symptom delay, and laboratory evaluation
Patient Age /Sex Race Symptoms ANA = Anaphylaxis AE = Angioedema U = Urticaria
Time to Reaction (hours)
Alpha-Gal IgE Titer (IU/mL)
Beef IgE Titer (IU/mL)
Total IgE Titer (IU/mL)
E001 44 / M W ANA 6 67.0 3.48 157
E008 80 / F W AE, U 6 0.52 0.35 45.9
E018 26 / M W ANA 5 59.3 16.6 274
E022 74 / F W AE, U 3 9.03 8.90 66.6
E026 47 / M W ANA 6 >100 32.9 1081
E030 56 / M W U 4-6 80.6 15.8 709
E031 55 / F W U 4 68.9 26.2 243
E036 66 / M W U 4-6 21.1 19.2 262
E054 45 / M W ANA 3 2.42 0.35 244
E076 50 / M W U 4 9.25 3.24 247
E115 58 / F W ANA 2-4 >100 47.8 1622
E128 37 / M W U 4-6 26.8 5.65 886
E162 39 / F W AE, U 6 11.1 1.51 30.5
Alph
a-Ga
l
Beef
Pork
Lam
bCh
icke
n
Turk
ey
Fish Ca
t
Fel d
1
Dog
Dust
Mite
Tim
othy
Gra
ss
0.1
1
10
100
Limit ofdetection
▼x1 ♦x1 x3 x12 x11 x12 x1 x7 x1 x9 ♦x4
Foods InhalantsS
peci
fic Ig
E A
bs (I
U/m
L)
r =0.81 r =0.98
CAP-RAST of Specific IgE Abs in Patients with anti-Gal IgE
Asthma(N = 68)
Clinic controls(N = 59)
No cat in home(N = 112)
0.35
0.1
1
10
100
1000
0.35
Alph
a-ga
l spe
cific
IgE
(IU/m
L)
Limit ofdetection
• x 8 • x 13 • x 58 • x 55Number <0.35
Cat in home(N = 96)
Anaphylaxis/ urticaria subjects
Alpha-gal specific IgE is associated with anaphylaxis but not asthma (Figure adapted from Commins, Kelly…Platts-Mills, AJRCCM, 2012)
= Reactions include anaphylaxis
r = 0.60, p<0.001
30% 10%
Sex (% male) 69%
Mean age at presentation(Range)
12 (4-17)
Geometric Mean of Total IgE (95% CI) 147 IU/mL (105-206 IU/mL)
Symptoms at presentationAnaphylaxis* 44%
Gastrointestinal/Oral
64%
Urticaria 92%Angioedema 31%
Average time to symptoms (Range) 4.68 hrs (10 mins to 24 hrs)
Tick exposure 100%
Redness and Itching at site of
Tick bite
87%
Tick borne illness# 10%
Emergency Department (ED) visits 46%**
Medications administered in ED Epinephrine (19%)Antihistamines (35%)Oral Steroids (19%)
Parenteral Steroids (17%)IV Fluids (17%)
Hospital Admissions 8%
IgE Ab to alpha-gal in kids (n=45)
IgE Ab to alpha-gal in kids (n=45)
Delayed symptoms induced by oral exposure to mammalian proteins in patients with IgE ab to alpha-gal.
• Despite high titer IgE antibodies that bind epitopes on a range of mammalian proteins including beef, pork and lamb:– No awareness of immediate response in the mouth
(i.e. no lip swelling or tingling).– Anaphylaxis occurring after eating beef starts with
skin itching 3-6 hours later.– Skin prick tests generally <4mm in diameter while
intradermals often ≥8mm.
‘Delayed’ food allergy?
• Food allergy symptoms classically occur immediately (OAS), up to 2 hours after eating
• No mention of ‘delayed’ symptoms that can be attributed to food in common allergy texts
III. Ticks. Really?
Geographical distribution of cetuximab hypersensitivity reactions
As reported by O’Neil et al, JCO 2007
Distribution of known cases of delayed anaphylaxis to mammalian meat
Dots = single casesSmaller stars = 5 to 24 cases within a stateLarger stars = states with 25 or more cases
Geographical Incidence of Rocky Mountain Spotted Fever
Data from CDC website for 2009; accessed 2/2011
Original image: CDC; modified by D.N. Gaines for Virginia Department of Health
Geographical range of Amblyomma americanum population
Data from CDC website; accessed 10/2010
Geographical range of Amblyomma americanum population
Data from CDC website; accessed 9/2012
welcome to the party
Bites from the larvae of Amblyomma or Dermacentor ticks and IgE ab to alpha-Gal.
Test 10/26/06 5/21/07 10/9/07 11/6/07*
Cetuximab(alphaGal) 0.49 16.9 48.3 130
Total IgE 127 199 350 532
•Multiple bites by seed ticks are not uncommon in the Southeast.
Photograph: August 23, 2007.
*Titers:Total 262, Beef 19.2 Pork 10.1,Cat 17.5,Dog 19.8, IU/ml. Chicken, Turkey, Roach, Dust Mite and Ragweed all <0.35 IU/ml.
*
Subject #1
Time course of IgE antibodies to alpha-gal and total IgE following episodes of multiple tick bites (red arrows)
Subject #2
Time course of IgE antibodies to alpha-gal and total IgE following episodes of multiple tick bites (red arrows)
* Subject #3
Time course of IgE antibodies to alpha-gal and total IgE following episodes of multiple tick bites (red arrows)
1 10 100 1000 100000.1
1
10
100
1000
Total IgE versus IgE to Alpha-Gal
Total IgE (IU / mL)
IgE
to A
lpha
-Gal
(IU
/ m
L)
Report tick or chigger bite(s)
No history obtained for tick bite(s)
Specifically deny tick bite(s)
R= 0.78P <0.001
R amblyommii?
IV. Delayed food allergy
-FC02 - sIgE to alpha-gal = 22.4 IU/mL; Total IgE = 109-4:22 after consuming meat, symptoms began as itching & hive on hand; second hive appeared on arm-Given AH and observed
-FC02 - sIgE to alpha-gal = 17.6 IU/mL; Total IgE = 184-Whole blood was collected, fixed & stained-3:54 after consuming meat, symptoms began as itching, flushing and progressed: ultimately requiring epinephrine
-Subject #FC-07: sIgE to alpha-gal = 9.3 IU/mL; Total IgE = 204-Whole blood was collected, fixed & stained-6 hours after consuming 56g of pork prosciutto, subject released with (disappointing) mild itch and single hive
Subject calls from car 30 minutes after being released to report progression of itching and
“warmth to skin”
Initial picture upon arriving home
(approximately 7.5 hours after eating pork prosciutto)
Approximately 8.25 hours after eating prosciutto
Mammalian meat challengeSubject #FC-08: sIgE to alpha-gal = 30.3 IU/mL ; total IgE = 146
Before 3hrs 45min after eating meat
Subject #FC-08: Mammalian meat challenge
Diffuse urticaria appeared at4hrs 15min after eating meat
(left arm shown here)
Mammalian meat challengeSubject #FC-10: sIgE to alpha-gal = 29.1 IU/mL ; total IgE = 201
4hrs 25min after eating mammalian
meat: pruritus followed by urticaria
on right flank
UrticariaTime to
symptoms (hrs:min)
Treatment required
Tryptase elevation
Allergics (n=10) 7*/10 3:50 – 6:00 7/10 1**/9
Summary of Mammalian Meat Challenge Results in Subjects with IgE to alpha-gal
*Two subjects received epinephrine (i.e., these reactions are probably better defined as delayed anaphylaxis to mammalian meat)
**Tryptase: -Subject FC-08: 4.2ng/mL (baseline) → 18.2ng/mL (4 hrs) → 20.1 ng/mL (5 hrs) -Subject FC-10: 4.9 (baseline) → 6.2 (4 hrs) → 9.9 (5 hrs) → 10.7 (6 hrs) -No tryptase measurements were performed in subject FC-06
Gating StrategyGating Strategy
HLA-
DR/l
inea
ge 1
FIT
C
CD63
APC
CD123 PerCP-Cy5.5
CD 123
% o
f max
BasophilsNegative for • Lineage Cocktail 1 (CD3, CD14, CD16, CD19,CD20, and CD56) • HLA-DR
Positive for • CD123 (IL-3Ra)• FcεRI (IgE receptor)• IgE
FACS Detection of CD63, a marker of Basophil Activation
nuclear membrane
Histamine
CD63-APC
-APC
APC-linked anti-CD63 ab
IL-3 Rα
PerCP-Cy5.5-linked anti-CD123 ab
1 hr0.72%
2 hrs0.54%
3 hrs0.87%
CD63
CD123
In vivo Basophil Activation during Mammalian Meat Challenge
#FC-02
4 hrs - 16.11% 5 hrs - 14.12% 6 hrs - 5.12%
In vivo Basophil Activation during Mammalian Meat Challenge
Baseline1.96%
2 hrs3.08%
4 hrs1.8%
5 hrs8.74%CD63
IgE
-FC07 - sIgE to alpha-gal = 9.3 IU/mL; Total IgE = 204-Whole blood was collected, fixed & stained
Delayed anaphylaxis Urticaria
Time to symptoms (hrs:min)
Treatment required
Allergics 2/10 7/10 3:50 – 6:00 7/10
Controls 0/10 0/10 n/a 0/10
Summary of Mammalian Meat Challenge Results in Subjects with or without IgE to alpha-gal
Delayed anaphylaxis Urticaria
Time to symptoms (hrs:min)
Treatment required
Basophil activation
Allergics 2/10 6/10 3:50 – 6:00 7/10 8/10
• The answer could be fat. Recall that fat is absorbed differently from protein or carbohydrates in a process that takes 3-4 hrs to enter the blood stream
Why the delay?
Thoracic duct blood stream
The delivery of lipid to the circulation takes time (about 4 hours)
VLDL IDL LDL HDL
=Alpha-gal moiety,as a glycolipid
Further conversion
• The answer could be long-chain triglycerides associated with chylomicrons. Studies suggest LCT enhance dietary antigen absorption into the circulation via chylomicron formation.
• The answer could be the nature of a carbohydrate-based food allergy.
Why the delay?
• The report of delayed reactions occurring 3-6 hours after eating mammalian meat has been confirmed on multiple occasions and at two medical centers
• In subjects with IgE to alpha-gal, basophil activation in vivo coincides with the appearance of clinical symptoms
• Lack of basophil activation before 4 hours suggests that there is delayed appearance of the antigen into the bloodstream
Conclusions
UvaHayley JamesSusan MozzicatoLisa WorkmanAlicia ClarkJudith WoodfolkWalter OliveiraWhitney StevensShama SatinoverLibby KellyPeter HeymannAmy StallingsJulia WisniewskiJosh KennedyAnubha TripathiJonathon Posthumus
ContributorsBarrett LewisMichael LandJoey LaneHeather GütekünstJane PurserGary RakesMadeline DillonTina HatleyLuis MatosSaju Eapen Dane McBrideJoseph BelleauHarold MoessnerMarty FiserEddie Shields