Perfil de sensibilización en pacientes con alergia a melocotón, y estudio de los cambios inmunológicos, eficacia y tolerancia a inmunoterapia específica con melocotón

Aproximadamente el 2% de la población adulta es alérgica a alimentos, fundamentalmente a vegetales, siendo la familia de las Rosaceae la más frecuentemente implicada (1,2,3,4,5,6,7). La alergia a alimentos tiene un gran impacto en la calidad de vida de los pacientes, sufriendo un porcentaje significativo de los mismos reacciones inesperadas debido a la presencia de alérgenos ocultos. Si se considera que las reacciones alérgicas a Rosaceas y concretamente a LTP, pueden ser múltiples, graves y en algunas ocasiones fatales, esto hace que el manejo de los pacientes sea difícil ya que no existe ningún tratamiento específico a excepción de la evitación de la ingestión del alimento, lo cual no siempre es posible por las razones anteriormente mencionadas (8). Además, datos recientes sugieren que la proporción de reacciones graves y fatales producidas por LTP puede incrementarse en los próximos años, especialmente en el área mediterránea (9, 10), donde la proporción de sensibilización a LTP es muy alta (11, 4, 12, 13, 14). El diagnóstico de la alergia a Rosáceas es complejo siendo la prueba diagnóstica “patrón de oro” la PPDCCP (15, 16, 17, 18, 19), procedimiento que entraña riesgos y consume tiempo y recursos (20). Por ello es muy relevante estudiar y conocer el perfil de sensibilización de estos pacientes en la historia clínica, así como obtener la máxima información posible a partir de pruebas complementarias poco invasivas, como las pruebas cutáneas intraepidérmicas (PC), la Inmunoglobulina E específica (IgEe) y el test de activación de basófilos (BAT) (21, 22, 23, 24). Esto ayudará a evitar restricciones innecesarias de alimentos nutricionalmente básicos de la dieta mediterránea (25). En este sentido, la inmunoterapia (IT) es el tratamiento de elección debido a su demostrada capacidad para modificar la historia natural de la enfermedad alérgica (26, 27). La administración de la LTP del melocotón, Pru p 3, por vía sublingual en pacientes con alergia a alimentos sensibilizados a LTP parece segura, efectiva y bien tolerada (28,29, 30). De hecho es un tratamiento que se ha comercializado recientemente en algunos países europeos. Sin embargo, los escasos estudios existentes se centran en pacientes con reacciones leves, no existiendo estudios en situación de vida real, que incluirían pacientes con reacciones graves. Además es de destacar la posible influencia en la respuesta que la IT sobre un alérgeno puede tener en otros alimentos, como cacahuete, que resultaría de gran importancia a nivel clínico. El mecanismo inmunológico subyacente de las respuestas de células T efectoras y reguladoras, a los cambios clínicos que conducen a la eficacia de la IT con alimentos, no se han analizado en profundidad (30, 31), crítico para comprender el funcionamiento de la IT y las circunstancias que conllevan una falta de respuesta a la misma. En el presente estudio planteado en condiciones de práctica clínica habitual sobre un grupo de 48 pacientes, se ha demostrado la eficacia de la inmunoterapia sublingual con extracto enriquecido en Pru p 3 (ITSL-Pru p 3) tras un año de su tratamiento, en más del 90% de los pacientes con alergia a melocotón, y alergia concomitante a cacahuete, demostrada mediante la disminución del tamaño de pápula para LTP por PC, descenso del valor de IgEe frente a Pru p 3 y Ara h 9, aumento de reactividad en el BAT, aumento del valor de IgG4 específica, y cambio en la respuesta celular desde el genotipo Th2 hacia un patrón TH1/Treg, medido por el descenso en la maduración de las células dendríticas (CD) y en las subpoblaciones de linfocitos Th2, Th9, y células plasmáticas productoras de IgEe frente a Pru p 3, junto a un incremento de las subpoblaciones Th1, NKBright. Todo ello con un buen perfil clínico de seguridad

Influence of pore size in protein G'-grafted mesoporous silica nanoparticles as a serum pretreatment system for in vitro allergy diagnosis

Particles with the capacity to bind to immunoglobulin G (IgG) can be used for the purification of IgG or to process clinical samples for diagnostic purposes. For in vitro allergy diagnosis, the high IgG levels in serum can interfere with the detection of allergen-specific IgE, the main diagnostic biomarker. Although commercially available, current materials present a low IgG capture capacity at large IgG concentrations or require complex protocols, preventing their use in the clinic. In this work, mesoporous silica nanoparticles are prepared with different pore sizes, to which IgG-binding protein G’ is grafted. It is found that for one particular optimal pore size, the IgG capture capacity of the material is greatly enhanced. The capacity of this material to efficiently capture human IgG in a selective way (compared to IgE) is demonstrated in both solutions of known IgG concentrations as well as in complex samples, like serum, from healthy controls and allergic patients using a simple and fast incubation protocol. Interestingly, IgG removal using the best-performing material enhances in vitro IgE detection in sera from patients allergic to amoxicillin. These results highlight the great translation potential of this strategy to the clinic in the context of in vitro allergy diagnosis.Funding for Open Access charge: Universidad de Málaga/CBUA. TEM experiments were performed in the ICTS “NANBIOSIS,” more specifically in the U28 Unit at IBIMA Plataforma BIONAND

Resensitization in suspected penicillin allergy

Background The diagnosis of allergic reactions to penicillins (AR-PEN) is very complex as there is a loss of sensitization over time, which leads to negative skin tests (STs) and specific IgE in serum, and even to tolerance to the drug involved. However, STs may become positive after subsequent exposure to the culprit drug (resensitization), with the risk of inducing potentially severe reactions. The exact rate of resensitization to penicillins is unknown, ranging from 0% to 27.9% in published studies. Objectives To analyze the rate of resensitization in patients with suggestive AR-PEN by repeating STs (retest) after an initial evaluation (IE). Material and Methods Patients with suspected AR-PEN were prospectively evaluated between 2017 and 2020. They underwent STs, and a randomized group also underwent a drug provocation test (DPT) with the culprit. Only patients with negative STs and/or DPT were included. All included cases were retested by STs at 2–8 weeks. Results A total of 545 patients were included: 296 reporting immediate reactions (IRs) and 249 non-immediate reactions (NIRs). Eighty (14.7%) cases had positive results in retest (RT+): 63 (21.3%) IRs and 17 (6.8%) NIRs (p < 0.0001). The rate of RT+ was higher in anaphylaxis compared with all other reactions (45.8% vs 9.1%, p < 0.0001). The risk of RT+ was higher from the fifth week after IE (OR: 4.64, CI: 2.1–11.6; p < 0.001) and increased with the patient's age (OR: 1.02; CI: 1.01–1.04; p = 0.009). Conclusions Due to the high rate of resensitization, retest should be included in the diagnostic algorithm of IRs to penicillins after an initial negative study, especially in anaphylaxis, to avoid potentially severe reactions after subsequent prescriptions of these drugs.he present study has been supported by Institute of Health “Carlos III” of the Ministry of Economy and Competitiveness (grants cofunded by European Regional Development Fund (ERDF): PI18/00095, RETIC ARADYAL RD16/0006/0001). Andalusian Regional Ministry of Economy and Knowledge (grants cofunded by European Regional Development Fund (ERDF): CTS-06603); Andalusian Regional Ministry Health (grants PI-0241-2016 and PE-0172-2018). GB holds a “Juan Rodes” (JR18/00054), Institute of Health “Carlos III” of the Ministry of Economy and Competitiveness (grants cofunded by European Social Fund [ESF]). ID is a Clinical Investigator (B-0001-2017), Andalusian Regional Ministry Health

Usefulness of myeloid dendritic cells in cellular in vitro assays for evaluating immediate hypersensitivity reactions to betalactams.

Introduction Dendritic cells (DCs) are the most potent antigen presenting cells (APCs) with an important role detecting, processing, and presenting antigens to T cells. The analysis of maturation after in vitro stimulation with the culprit drug, and their ability to trigger the proliferation of specific T cell populations in patients with immediate drug hypersensitivity reactions (IDHRs) could serve to prove the sensitization to a drug. Most approaches used monocyte-derived DCs (moDCs), although their sensitivity is not optimal. The different nature of moDCs and myeloid DCs (mDCs), main DC population involved during the in vivo development of IDHRs, could influence the sensitivity of these in vitro tests. Therefore, we evaluated the effect of two betalactams (BLs), amoxicillin (AX) and clavulanic acid (CLV) in moDCs and mDCs from selective-allergic patients (AP) to each BL, as well as to assess their capacity to stimulate different T cell populations. Methods mDCs and moDCs were obtained from 14 AX-AP, 14 CLV-AP and 10 Healthy controls (HC). After stimulating with the culprit BL, maturation and their capacity to stimulate different T cell populations was assessed by flow cytometry. Results Higher maturation was observed in both AX- and CLV-AP compared with HC when using BL-stimulated-mDCs, whereas with moDCs, only higher was observed in AX-AP, but not in CLV-AP. The % of positive maturation cases was higher with mDCs than moDCs, with higher % with AX compared to CLV. The most relevant T cell population proliferative response was obtained in CD4+Th2 cells, reaching to 67% of positivity when using mDCs, followed by 50% with the traditional LTT, and only of 22% with moDCs from AX-AP. The specificity was higher than 80% in all cases. Conclusions mDCs from selective AP efficiently recognised the culprit drug and triggered the proliferation of T-cells, mainly those with a Th2 cytokine pattern, although these responses depended on the drug.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Diagnosis of immediate reactions to amoxicillin: Comparison of basophil activation markers CD63 and CD203c in a prospective study

Amoxicillin (AX) combined or not with clavulanic acid (CLV) is frequently involved in IgE-mediated reactions. Drug provocation test (DPT) is considered as the gold standard for diagnosis, although contraindicated in high-risk patients. Basophil activation test (BAT) can help diagnose immediate reactions to beta-lactams, although controversy exists regarding the best activation marker. We have performed a real-life study in a prospective cohort to analyze the real value of BAT as diagnostic tool and the best activation marker, CD63 and CD203c, for the evaluation of immediate reactions to these drugs.We thank Claudia Corazza for her invaluable English language support; Verónica Prados and Ana Molina for their help in technical support in flow cytometry methods. This work has been supported by Institute of Health “Carlos III” (ISCIII) of the Ministry of Economy and Competitiveness (MINECO; grants co-funded by European Regional Development Fund: PI15/01206, PI17/01237, PI18/00095, PI20/01734, RETICS ARADYAL RD16/0006/0001, and RICORS REI (RD21/0002/0008); Andalusian Regional Ministry of Health (grants PI-0241-2016, PE-0172-2018, and PI-0127-2020); Spanish Ministerio de Ciencia e Innovación Proyectos de I + D + I «Programación Conjunta Internacional», EuroNanoMed 2019 (PCI2019-111825-2)). AA holds a Senior Postdoctoral Contract (RH-0099-2020) with the Andalusian Regional Ministry of Health (cofunded by European Social Fund (ESF): "Andalucía se mueve con Europa". GB holds a “Juan Rodes” contract (JR18/00054) by ISCIII of MINECO (cofounded by ESF). ID holds a clinical research stabilization contract by Andalusian Regional Ministry of Health (RB-0001-2022). ML holds a “Rio Hortega” contract (CM20/00210) by ISCIII of MINECO (cofounded by ESF). CF holds a Marie Skłodowska-Curie Individual Fellowship by the European Union's Horizon 2020 research and innovation program (agreement n° PI-0241-2016101027955). CM holds a “Nicolas Monardes” research contract by Andalusian Regional Ministry of Health (RC-0004-2021). // Funding for open access charge: Universidad de Málaga / CBUA

Detection of Serum-Specific IgE by Fluoro-Enzyme Immunoassay for Diagnosing Type I Hypersensitivity Reactions to Penicillins

Diagnosis of type I hypersensitivity reactions (IgE-mediated reactions) to penicillins is based on clinical history, skin tests (STs), and drug provocation tests (DPTs). Among in vitro complementary tests, the fluoro-enzyme immunoassay (FEIA) ImmunoCAP® (Thermo-Fisher, Waltham, MA, USA) is the most widely used commercial method for detecting drug-specific IgE (sIgE). In this study, we aimed to analyze the utility of ImmunoCAP® for detecting sIgE to penicillin G (PG) and amoxicillin (AX) in patients with confirmed penicillin allergy. The study includes 139 and 250 patients evaluated in Spain and Italy, respectively. All had experienced type I hypersensitivity reactions to penicillins confirmed by positive STs. Additionally, selective or cross-reactive reactions were confirmed by DPTs in a subgroup of patients for further analysis. Positive ImmunoCAP® results were 39.6% for PG and/or AX in Spanish subjects and 52.4% in Italian subjects. When only PG or AX sIgE where analyzed, the percentages were 15.1% and 30.4%, respectively, in Spanish patients; and 38.9% and 46% in Italian ones. The analysis of positive STs showed a statistically significant higher percentage of positive STs to PG determinants in Italian patients. False-positive results to PG (16%) were detected in selective AX patients with confirmed PG tolerance. Low and variable sensitivity values observed in a well-defined population with confirmed allergy diagnosis, as well as false-positive results to PG, suggest that ImmunoCAP® is a diagnostic tool with relevant limitations in the evaluation of subjects with type I hypersensitivity reactions to penicillinsThis research was funded by the Institute of Health ‘Carlos III’ (ISCIII) of the Ministry of Economy and Competitiveness (MINECO) (grants cofunded by European Regional Development Fund: PI15/01206, PI17/01237, PI18/00095, RETICS ARADYAL RD16/0006/0001). Andalusian Regional Ministry of Health (grants PE-0172-2018, PI-0127-2020). DrNanoDall project by ISCIII thorough AES 2019 within the ERANET-EuroNanoMed-III framework (AC19/00082). AA holds a Senior Postdoctoral Contract (RH-0099-2020) with the Andalusian Regional Ministry of Health (cofunded by European Social Fund (ESF): “Andalucía se mueve con Europa”). ML holds a “Rio Hortega” contract (CM20/00210), GB and N.P.-S. hold a “Juan Rodés” (JR18/00054 and JR21/00024, respectively) with ISCIII of MINECO (cofunded by ESF). CM holds a ‘Nicolas Monardes’ research contract with the Andalusian Regional Ministry Health (RC-0004-2021). Partial funding for open access charge: Universidad de Málag

NSAIDs-hypersensitivity often induces a blended reaction pattern involving multiple organs

Las reacciones de hipersensibilidad inducidas por medicamentos antiinflamatorios no esteroideos (AINE) están clasificadas por la Red Europea de Alergia a los Medicamentos (ENDA) como reacciones cruzadas o selectivas. La primera es el tipo más frecuente e incluye a los pacientes con síntomas exclusivamente respiratorios (AINE - enfermedad respiratoria exacerbada, ENDA) o exclusivamente cutáneos: urticaria/angioedema inducido por AINEs (NIUA); y enfermedad cutánea exacerbada por AINEs (NECD). Sin embargo, aunque no se refleja en el esquema de clasificación actual (ENDA), en la práctica clínica se observa con frecuencia una combinación de síntomas tanto cutáneos como respiratorios o incluso de otros órganos, como los síntomas del tracto gastrointestinal (reacciones mixtas o combinadas). Esta entidad no ha sido suficientemente caracterizada. Nuestro objetivo era caracterizar clínicamente las reacciones mixtas a los AINEs, comparando sus características clínicas con las del NERD y la NIUA. Evaluamos a los pacientes con síntomas que sugerían hipersensibilidad a los AINEs que acudieron a la Unidad de Alergia del Hospital Universitario Regional de Málaga (Málaga, España) entre 2008 y 2015. Se incluyeron 880 pacientes con reacción cruzada confirmada en base a la historia clínica, prueba de provocación nasal positiva con acetilsalicilato de lisina (NPT-LASA) y/o prueba de provocación de drogas positiva (DPT) con ácido acetilsalicílico (ASA), que se clasificaron como mezclados (261; 29,6%), NERD (108; 12,3%) o NIUA (511; 58,1%). Se compararon los síntomas, los medicamentos, las enfermedades subyacentes y los métodos de diagnóstico dentro de los grupos y entre ellos. Entre los pacientes mezclados, el subgrupo más común comprendía aquellos que desarrollaban urticaria/angioedema más rinitis/asma (n = 138), que tenían un mayor porcentaje de rinitis subyacente (p < 0,0001) y asma (p < 0,0001) que los pacientes de NIUA, mostrando similitudes con la NERD. Estas diferencias no se encontraron en el subgrupo de pacientes mezclados que desarrollaron síntomas respiratorios como el edema de la glotis; estos eran más similares a la NIUA. El porcentaje de NPT-LASA positivo fue similar para los grupos de mezcla (77%) y NERD (78,7%). Concluimos que las reacciones mixtas son reacciones de hipersensibilidad a los AINEs que afectan al menos a dos órganos. Además de la clásica afectación cutánea y respiratoria, en nuestra población algunos pacientes también desarrollan síntomas gastrointestinales. Dada la alta tasa de respuestas positivas al NPT-LASA en el NERD así como las reacciones mixtas, sugerimos que todos los pacientes que reporten síntomas respiratorios, independientemente de si tienen otros síntomas asociados, deben ser evaluados inicialmente usando el NPT-LASA, lo cual representa menos riesgo que el DPT.Non-steroidal anti-inflammatory drugs (NSAIDs)-induced hypersensitivity reactions are classified by the European Network on Drug Allergy (ENDA) as either cross-reactive or selective. The former is the most frequent type and includes patients with exclusively respiratory symptoms (NSAIDs-exacerbated respiratory disease, NERD) or exclusively cutaneous symptoms: NSAIDs-induced urticaria/angioedema (NIUA); and NSAIDs-exacerbated cutaneous disease (NECD). However, although not reflected in the current classification scheme (ENDA), in clinical practice a combination of both skin and respiratory symptoms or even other organs such as gastrointestinal tract symptoms (mixed or blended reactions) is frequently observed. This entity has not been sufficiently characterised. Our aim was to clinically characterize blended reactions to NSAIDs, comparing their clinical features with NERD and NIUA. We evaluated patients with symptoms suggestive of hypersensitivity to NSAIDs who attended the Allergy Unit of the Regional University Hospital of Malaga (Malaga, Spain) between 2008 and 2015. We included 880 patients confirmed as cross-reactive based on clinical history, positive nasal provocation test with lysine acetylsalicylate (NPT-LASA), and/or positive drug provocation test (DPT) with acetylsalicylic acid (ASA), who were classified as blended (261; 29.6%), NERD (108; 12.3%) or NIUA (511; 58.1%). We compared symptoms, drugs, underlying diseases and diagnostic methods within and between groups. Among blended patients the most common sub-group comprised those developing urticaria/angioedema plus rhinitis/asthma (n = 138), who had a higher percentage of underlying rhinitis (p < 0.0001) and asthma (p < 0.0001) than NIUA patients, showing similarities to NERD. These differences were not found in the sub-group of blended patients who developed such respiratory symptoms as glottis oedema; these were more similar to NIUA. The percentage of positive NPT-LASA was similar for blended (77%) and NERD groups (78.7%). We conclude that blended reactions are hypersensitivity reactions to NSAIDs affecting at least two organs. In addition to classical skin and respiratory involvement, in our population a number of patients also develop gastrointestinal symptoms. Given the high rate of positive responses to NPT-LASA in NERD as well as blended reactions, we suggest that all patients reporting respiratory symptoms, regardless of whether they have other associated symptoms, should be initially evaluated using NPT-LASA, which poses less risk than DPT.• Gobierno de Andalucía. Ayuda PI-0463-2013 • Instituto de Salud Carlos III y Fondo Europeo Regional de Desarrollo. Ayuda RETIC ARADyAL RD16/0006/0001 y PI17/1253 • Sociedad Española de Alergología. Fondo de Investigación de la Fundación de la SEAIC 2016 • Instituto de Salud Carlos III, Ministerio de Economía y Competitividad y Fondo Europeo Social. Contrato de investigación Juan Rodes JR15/00036, para Inmaculada Doña Díaz. Contrato Río Hortega CM16/0067, para Gádor Bogas Herrera. Programa Miguel Servet CP14/00034, para José Antonio Cornejo García. Programa Sara Borrell CD14/00242, para James Richard Perkins.peerReviewe

How to Diagnose and Treat Local Allergic Rhinitis: A Challenge for Clinicians.

Chronic rhinitis is a very common disease that can be divided in various phenotypes. Historically, the condition has been classified into the allergic rhinitis (AR) and non-allergic non-infectious rhinitis (NAR) forms, based on the results of the classical biomarkers of atopy: skin prick test and serum allergen-specific IgE However, this classification does not reflect the complexity of the rhinitis syndrome, as illustrated by the existence of non-atopic rhinitis patients who display a nasal reactivity to environmental allergens. This new phenotype has been termed local allergic rhinitis (LAR) and can be only recognized if an additional test such as the nasal allergen challenge (NAC) is integrated in the diagnostic algorithm for chronic rhinitis. Recent data shows that the NAC is a very safe and reliable technique ready for the clinical practice. LAR is a differentiated rhinitis phenotype which often commences during childhood and quickly progresses towards a clinical worsening and the association of comorbidities in other mucosal organs. Recent evidence supports the existence of a bronchial counterpart of LAR (local allergic asthma), which highlights the pathophysiological links between the upper and lower airways and reinforces the united airways concept. Importantly, several controlled studies have demonstrated the ability of allergen immunotherapy to control LAR symptoms while the therapy is being administered. This review emphasizes the need to implement the NAC in the clinical practice in order to facilitate the recognition of LAR patients, allowing for an early prescription of specific therapies with disease-modifying potential

Hypersensitivity Reactions to Multiple Iodinated Contrast Media.

The incidence of hypersensitivity reactions (HSRs) to iodinated contrast media (ICM) has risen over last years, representing an important health problem. HSRs to ICMs are classified into immediate reactions (IRs) and non-immediate reactions (NIRs) according to if they occur within 1 h or longer after ICM administration. The diagnosis of HSRs to ICM is complex as skin test (ST) sensitivity ranges widely, and drug provocation test (DPT) protocols are heterogeneous. In this manuscript, we describe the clinical characteristics of a series of patients confirmed as HSR to ICM and the diagnosis procedure carried out, looking into those cases confirmed as HSRs to multiple ICMs. For this purpose, we prospectively evaluated patients suggestive of HSRs to ICMs and classified them as IRs or NIRs. STs were carried out using a wide panel of ICMs, and in those with a negative ST, a single-blind placebo controlled DPT was performed with the culprit. If ST or DPT were positive, then tolerance was assessed with an alternative negative ST ICM. We included 101 cases (12 IRs and 89 NIRs) confirmed as allergic. Among them, 36 (35.64%) cases were allergic to more than one ICM (8 IRs and 28 NIRs). The most common ICM involved were iomeprol and iodixanol. Although not statistically significant, the percentage of patients reporting anaphylaxis was higher in patients allergic to multiple ICMs compared with patients allergic to a single ICM (50 vs. 25%). Likewise, the percentage of positive results in STs was higher in patients allergic to multiple ICMs compared with those allergic to a single ICM (for IR 62.5 vs. 25%, p > 0.05; and for NIR, 85.71 vs. 24.59%, p 0.05; and for NIR, 85.71 vs. 24.59%,

Antibiotic Allergy De-Labeling: A Pathway against Antibiotic Resistance

Antibiotics are one of the most frequently prescribed drugs. Unfortunately, they also are the most common cause for self-reported drug allergy, limiting the use of effective therapies. However, evidence shows that more than 90% of patients labeled as allergic to antibiotics are not allergic. Importantly, the label of antibiotic allergy, whether real or not, constitutes a major public health problem as it directly impacts antimicrobial stewardship: it has been associated with broad-spectrum antibiotic use, often resulting in the emergence of bacterial resistance. Therefore, an accurate diagnosis is crucial for de-labeling patients who claim to be allergic but are not really allergic. This review presents allergy methods for achieving successful antibiotic allergy de-labeling. Patient clinical history is often inaccurately reported, thus not being able to de-label most patients. In vitro testing offers a complementary approach but it shows limitations. Immunoassay for quantifying specific IgE is the most used one, although it gives low sensitivity and is limited to few betalactams. Basophil activation test is not validated and not available in all centers. Therefore, true de-labeling still relies on in vivo tests including drug provocation and/or skin tests, which are not risk-exempt and require specialized healthcare professionals for results interpretation and patient management. Moreover, differences on the pattern of antibiotic consumption cause differences in the diagnostic approach among different countries. A multidisciplinary approach is recommended to reduce the risks associated with the reported penicillin allergy label