Hypersensitivity reactions to beta-lactams

Immunological Mechanisms in Cutaneous Adverse Drug Reactions

Adverse drug reactions (ADRs) are an inherent aspect of drug use. While approximately 80% of ADRs are predictable, immune system-mediated ADRs, often unpredictable, are a noteworthy subset. Skin-related ADRs, in particular, are frequently unpredictable. However, the wide spectrum of skin manifestations poses a formidable diagnostic challenge. Comprehending the pathomechanisms underlying ADRs is essential for accurate diagnosis and effective management. The skin, being an active immune organ, plays a pivotal role in ADRs, although the precise cutaneous immunological mechanisms remain elusive. Fortunately, clinical manifestations of skin-related ADRs, irrespective of their severity, are frequently rooted in immunological processes. A comprehensive grasp of ADR morphology can aid in diagnosis. With the continuous development of new pharmaceuticals, it is noteworthy that certain drugs including immune checkpoint inhibitors have gained notoriety for their association with ADRs. This paper offers an overview of immunological mechanisms involved in cutaneous ADRs with a focus on clinical features and frequently implicated drugs.

Clinical Manifestations and Causes of Anaphylaxis. Analysis of 382 Cases from the Anaphylaxis Registry in West Pomerania Province in Poland

Anaphylaxis is most commonly defined as an acute, severe, potentially life-threatening systemic hypersensitivity reaction. Current expert consensus has defined anaphylaxis as a serious reaction that is rapid in onset and can be fatal, and is a severe, potentially life-threatening systemic hypersensitivity reaction that is still rarely diagnosed. For safety reasons, patients should visit an allergologist to identify potential causes of this reaction. There are no data from other health care centres in Poland presenting characteristics of anaphylactic reactions. Clinical manifestations of anaphylaxis should be analysed, because some patients (10-30%) with anaphylaxis can present without cutaneous findings. This lack of skin/mucosa involvement can lead to misdiagnosis or delayed diagnosis of anaphylaxis. Objectives-to gather epidemiological data on anaphylactic reactions, to identify clinical manifestations of anaphylaxis (organ systems involved), to present diagnostic methods useful for the identification of anaphylaxis triggers, and most importantly, to find causes of anaphylaxis. In this retrospective analysis, we used a questionnaire-based survey regarding patients visiting the Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, between 2006 and 2015. The registry comprised patients with grade II (Ring and Messmer classification) or higher anaphylaxis. Patients with grade I anaphylaxis (e.g., urticaria) were not included in the registry. The incidence of anaphylaxis was higher in women. Clinical manifestations included cutaneous and cardiovascular symptoms, but more than 20% of patients did not present with cutaneous symptoms, which may create difficulties for fast and correct diagnosis. Causes of anaphylaxis were identified and confirmed by means of detailed medical interview, skin tests (STs), and measurement of specific immunoglobulin E (sIgE) and tryptase levels. In the analysed group, the most common cause of anaphylaxis (allergic and nonallergic) was Hymenoptera stinging (wasp), drugs (nonsteroidal anti-inflammatory drugs, NSAIDs) and foods (peanuts, tree nuts, celery). The incidence of anaphylaxis is low, but because of its nature and potentially life-threatening consequences it requires a detailed approach. Comprehensive management of patients who have had anaphylaxis can be complex, so partnerships between allergy specialists, emergency medicine and primary care providers are necessary. Monitoring its range is very important to monitor changes in allergy development.

Amoxicillin Inactivation by Thiol-Catalyzed Cyclization Reduces Protein Haptenation and Antibacterial Potency

Serum and cellular proteins are targets for the formation of adducts with the β-lactam antibiotic amoxicillin. This process could be important for the development of adverse, and in particular, allergic reactions to this antibiotic. In studies exploring protein haptenation by amoxicillin, we observed that reducing agents influenced the extent of amoxicillin-protein adducts formation. Consequently, we show that several thiol-containing compounds, including dithiothreitol, N-acetyl-L-cysteine, and glutathione, perform a nucleophilic attack on the amoxicillin molecule that is followed by an internal rearrangement leading to amoxicillin diketopiperazine, a known amoxicillin metabolite with residual activity. Increased diketopiperazine conversion is also observed with human serum albumin but not with L-cysteine, which mainly forms the amoxicilloyl amide. The effect of thiols is catalytic and can render complete amoxicillin conversion. Interestingly, this process is dependent on the presence of an amino group in the antibiotic lateral chain, as in amoxicillin and ampicillin. Furthermore, it does not occur for other β-lactam antibiotics, including cefaclor or benzylpenicillin. Biological consequences of thiol-mediated amoxicillin transformation are exemplified by a reduced bacteriostatic action and a lower capacity of thiol-treated amoxicillin to form protein adducts. Finally, modulation of the intracellular redox status through inhibition of glutathione synthesis influenced the extent of amoxicillin adduct formation with cellular proteins. These results open novel perspectives for the understanding of amoxicillin metabolism and actions, including the formation of adducts involved in allergic reactions.

Identification of Novel Biomarkers for Drug Hypersensitivity After Sequencing of the Promoter Area in 16 Genes of the Vitamin D Pathway and the High-Affinity IgE Receptor

The prevalence of allergic diseases and drug hypersensitivity reactions (DHRs) during recent years is increasing. Both, allergic diseases and DHRs seem to be related to an interplay between environmental factors and genetic susceptibility. In recent years, a large effort in the elucidation of the genetic mechanisms involved in these disorders has been made, mostly based on case-control studies, and typically focusing on isolated SNPs. These studies provide a limited amount of information, which now can be greatly expanded by the complete coverage that Next Generation Sequencing techniques offer. In this study, we analyzed the promoters of sixteen genes related to the Vitamin D pathway and the high-affinity IgE receptor, including FCER1A, MS4A2, FCER1G, VDR, GC, CYP2R1, CYP27A1, CYP27B1, CYP24A1, RXRA, RXRB, RXRG, IL4, IL4R, IL13, and IL13RA1. The study group was composed of patients with allergic rhinitis plus asthma (AR+A), patients with hypersensitivity to beta-lactams (BLs), to NSAIDs including selective hypersensitivity (SH) and cross-reactivity (CR), and healthy controls without antecedents of atopy or adverse drug reactions. We identified 148 gene variations, 43 of which were novel. Multinomial analyses revealed that three SNPs corresponding to the genes FCER1G (rs36233990 and rs2070901), and GC (rs3733359), displayed significant associations and, therefore, were selected for a combined dataset study in a cohort of 2,476 individuals. The strongest association was found with the promoter FCER1G rs36233990 SNP that alters a transcription factor binding site. This SNP was over-represented among AR+A patients and among patients with IgE-mediated diseases, as compared with control individuals or with the rest of patients in this study. Classification models based on the above-mentioned SNPs were able to predict correct clinical group allocations in patients with DHRs, and patients with IgE-mediated DHRs. Our findings reveal gene promoter SNPs that are significant predictors of drug hypersensitivity, thus reinforcing the hypothesis of a genetic predisposition for these diseases.

An unusual dual hypersensitivity reaction to moxifloxacin in a patient

Both immediate and nonimmediate type hypersensitivity reactions (HRs) with a single dose of quinolone in the same patient have not been previously reported. A 47-year-old female patient referred to us because of the history of a nonimmediate type HR to radio contrast agent and immediate type HR to clarithromycin. She experienced anaphylaxis in minutes after the second dose of 50 mg when she was provocated with moxifloxacin. She was treated immediately with epinephrine, fluid replacement and methylprednisole and pheniramine. On the following day she came with macular eruptions, and she was treated with methylprednisolone. The positive patch test performed with moxifloxacin as well as the lymphocyte transformation test proved the T-cell mediated HR. In order to prove the immediate type HR, basophil activation test was performed but was found negative. This case report presents for the first time the 2 different types of HRs in a patient with a test dose of quinolone.

Drug desensitization in 17-year-old male with Mast Cell Activation Syndrome, pneumonia, and antibiotic hypersensitivities

Rapid desensitization (RD) is utilized in order to provide necessary medications to patients with drug hypersensitivity. RD is performed in a closely monitored setting to protect patients from severe anaphylactic or anaphylactoid reactions. A recently classified syndrome, mast cell activation syndrome (MCAS), has been defined by episodic symptoms caused by mast cell mediators and is associated with specific laboratory markers. Patient with MCAS and history of systemic reactions to ceftriaxone and azithromycin presented with pneumonia requiring treatment with ceftriaxone and azithromycin, both provided via desensitization protocols. Desensitization for drug hypersensitivities in the setting of MCAS presents several controversial issues as mechanism of hypersensitivity may not be related to IgE-mediated but rather non-specific mast-cell degranulation. The controversies of diagnosis and management of antibiotic hypersensitivity in patients with MCAS discussed. Our case demonstrates that desensitization protocols can be used in MCAS patients with noted hypersensitivities. The intricacies of desensitization in the setting of MCAS are not fully understood and will require further research and characterization.

Interleukin-4 and interferon-γ are possible allergic markers in pediatric patients with β-lactam hypersensitivity

Background:

β-lactam agents are known to elicit T-cell-mediated immune responses that play a central role in the onset of allergic reactions, but the involvement of specific type of cytokines in drug allergy remains largely unexplored in humans.

Objectives:

This study was undertaken to investigate the role of cytokines involvement in pediatric patients with β-lactam hypersensitivity and to determine whether involvement of cytokines in drug-mediated reactions are important for the perspective of allergic patient's management.

Methods:

β-lactam-induced hypersensitivity reactions in eighty pediatric patients were determined by clinical manifestations and skin prick or intradermal testing. Production of T-helper (Th) type-1 cytokine interferon (INF)-γ, Th-2 cytokine interleukin (IL)-4, regulatory T-cell cytokine IL-10, and other cytokines IL-6 and IL-12 were determined by sandwich ELISAs.

Results:

Diagnosis of β-lactam allergy was confirmed in 53 pediatric patients. IL-4 secretion in patients' sera was significantly higher as compared with healthy controls (P < 0.05). However, INF-γ level in patients' sera was significantly lower as compared with controls (P < 0.05). No significant alterations were found in the protein secretion of IL-10, IL-12, and IL-6 in allergic patients as compared with controls (P > 0.05).

Conclusion:

We conclude that IL-4 is specific marker for the diagnosis of β-lactam-induced hypersensitivity. Moreover, IL-4 in combination with INF-γ is more sensitive for the diagnosis of these reactions. This study also concludes that both IL-4 and INF-γ may play an active role in the onset of allergic reactions against β-lactam antibiotics.

New approaches for predicting T cell-mediated drug reactions: A role for inducible and potentially preventable autoimmunity

Adverse drug reactions (ADRs) are commonplace and occur when a drug binds to its intended pharmacologic target (type A ADR) or an unintended target (type B ADR). Immunologically mediated type B ADRs, such as drug hypersensitivity syndrome, drug reaction with eosinophilia and systemic symptoms syndrome, and Stevens-Johnson syndrome/toxic epidermal necrolysis, can be severe and result in a diverse set of clinical manifestations that include fever and rash, as well as multiple organ failure (liver, kidney, lungs, and/or heart) in the case of drug hypersensitivity syndrome. There is increasing evidence that specific HLA alleles influence the risk of drug reactions. Several features of T cell-mediated ADRs are strikingly similar to those displayed by patients with autoimmune diseases like type I diabetes, such as strong HLA association, organ-specific adaptive immune responses, viral involvement, and activation of innate immunity. There is a need to better predict patient populations at risk for immunologically mediated type B ADRs. Because methods to predict type 1 diabetes by using genetic and immunologic biomarkers have been developed to a high level of accuracy (predicting 100% of subjects likely to progress), new research strategies based on these methods might also improve the ability to predict drug hypersensitivity.

Correlation analysis of gene polymorphisms and β-lactam allergy

A total of 64 patients with β-lactam allergy and 30 control subjects were enrolled in a case-control study. This study is aimed to analyze the relationship between β-lactam allergy and 10 single nucleotide polymorphisms (SNPs) in interleukin-10 (IL-10), IL-13, IL-4Rα, high-affinity immunoglobulin E-receptor β chain (FcεRIβ), interferon γ receptor 2 (IFNGR2), and CYP3A4, and within the Han Chinese population of Northwest China. Genotyping for the SNPs was conducted using the Sequenom MassARRAY(®) platform. SPSS 17.0 was employed to analyze the statistical data and SHEsis was used to perform the haplotype reconstruction and analyze linkage disequilibrium of SNPs of IL-10 and IL-13. The results showed that the genotype distribution of CYP3A4 rs2242480/CT differed significantly between case and control groups of males (P=0.022; odds ratio (OR)=0.167, 95% confidence interval (CI): 0.032-0.867). Further analysis showed that CCA, CCG, and TAA haplotypes of IL-10 had no significant correlation in patients with β-lactam allergy. The correlation between CCT and CAC haplotypes of IL-13 and β-lactam allergy needs to be further studied. The analysis did not reveal any differences in the distribution of others gene polymorphisms between cases and controls.