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Chen CB, Hung WK, Wang CW, Lee CC, Hung SI, Chung WH. Advances in understanding of the pathogenesis and therapeutic implications of drug reaction with eosinophilia and systemic symptoms: an updated review. Front Med (Lausanne) 2023; 10:1187937. [PMID: 37457584 PMCID: PMC10338933 DOI: 10.3389/fmed.2023.1187937] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/05/2023] [Indexed: 07/18/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms or drug-induced hypersensitivity syndrome (DRESS/DIHS) is one type of severe cutaneous adverse reaction (SCAR). It is featured by fever, widespread skin lesions, protracted clinical course, internal organ involvement, and possibly long-term autoimmune sequelae. The presence of high-risk human leukocyte antigen (HLA) alleles, hypersensitivity reaction after culprit drug ingestion, and human herpesvirus reactivation may all contribute to its complex clinical manifestations. Some recent studies focusing on the roles of involved cytokines/chemokines and T cells co-signaling pathways in DRESS/DIHS were conducted. In addition, some predictors of disease severity and prognosis were also reported. In this review, we provided an update on the current understanding of the pathogenesis, potential biomarkers, and the relevant therapeutic rationales of DRESS/DIHS.
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Affiliation(s)
- Chun-Bing Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wei-Kai Hung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
| | - Chih-Chun Lee
- Department of Medical Education, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
- Department of Dermatology, Beijing Tsinghua Chang Gung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
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Gibson A, Deshpande P, Campbell CN, Krantz MS, Mukherjee E, Mockenhaupt M, Pirmohamed M, Palubinsky AM, Phillips EJ. Updates on the immunopathology and genomics of severe cutaneous adverse drug reactions. J Allergy Clin Immunol 2023; 151:289-300.e4. [PMID: 36740326 PMCID: PMC9976545 DOI: 10.1016/j.jaci.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 02/05/2023]
Abstract
Severe cutaneous adverse reactions (SCARs) such as Stevens-Johnson syndrome, toxic epidermal necrolysis (SJS/TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS)/drug-induced hypersensitivity syndrome (DIHS) cause significant morbidity and mortality and impede new drug development. HLA class I associations with SJS/TEN and drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome have aided preventive efforts and provided insights into immunopathogenesis. In SJS/TEN, HLA class I-restricted oligoclonal CD8+ T-cell responses occur at the tissue level. However, specific HLA risk allele(s) and antigens driving this response have not been identified for most drugs. HLA risk alleles also have incomplete positive and negative predictive values, making truly comprehensive screening currently challenging. Although, there have been key paradigm shifts in knowledge regarding drug hypersensitivity, there are still many open and unanswered questions about SCAR immunopathogenesis, as well as genetic and environmental risk. In addition to understanding the cellular and molecular basis of SCAR at the single-cell level, identification of the MHC-restricted drug-reactive self- or viral peptides driving the hypersensitivity reaction will also be critical to advancing premarketing strategies to predict risk at an individual and drug level. This will also enable identification of biologic markers for earlier diagnosis and accurate prognosis, as well as drug causality and targeted therapeutics.
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Affiliation(s)
- Andrew Gibson
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Pooja Deshpande
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Chelsea N Campbell
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Matthew S Krantz
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Eric Mukherjee
- Department of Dermatology, Vanderbilt University Medical Center, Nashville; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen Department of Dermatologie, Medical Center and Medical Faculty, University of Freiburg, Freiberg, Germany
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Amy M Palubinsky
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia; Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tenn; Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn; Department of Dermatology, Vanderbilt University Medical Center, Nashville; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn.
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Bellón T, Lerma V, Guijarro J, Ramírez E, Martínez C, Escudero C, Fiandor AM, Barranco R, de Barrio M, de Abajo F, Cabañas R. LTT and HLA testing as diagnostic tools in Spanish vancomycin-induced DRESS cases: A case-control study. Front Pharmacol 2022; 13:959321. [PMID: 36339612 PMCID: PMC9631441 DOI: 10.3389/fphar.2022.959321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/03/2022] [Indexed: 11/23/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe T-cell-mediated off-target adverse reaction. DRESS cases caused by vancomycin have often been reported. The HLA-A*32:01 allele has been associated with genetic susceptibility to vancomycin-induced DRESS in US citizens of European descent. We have analyzed the association of the HLA-A*32:01 allele in 14 Spanish DRESS cases in which vancomycin was suspected as the culprit drug, and the lymphocyte transformation test (LTT) as an in vitro assay to evaluate vancomycin sensitization. The results were compared to vancomycin-tolerant control donors. LTT was performed in 12 DRESS cases with PBMCs from resolution samples available and in a group of 12 tolerant donors. ROC curves determined that LTT is a suitable tool to identify patients sensitized to vancomycin (AUC = 0.9646; p < 0.0001). When a stimulation index >3 was regarded as a positive result, contingency tables determined 91% sensitivity, 91.67% specificity, 91% positive predictive value, and 91.67% negative predictive value (p = 0.0001, Fisher’s exact test). The HLA A*32:01 allele was determined by an allele-specific PCR assay in 14 cases and 25 tolerant controls. Among the DRESS cases, five carriers were identified (35.7%), while it was detected in only one (4%) of the tolerant donors, [odds ratio (OR) = 13.33; 95% CI: 1.364–130.3; p = 0.016]. The strength of the association increased when only cases with positive LTT to vancomycin were considered (OR = 24.0; 95% CI: 2.28–252.6; p = 4.0 × 10−3). Our results confirm the association of the risk allele HLA-A*32:01 with vancomycin-induced DRESS in Spanish cases, and support LTT as a reliable tool to determine vancomycin sensitization.
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Affiliation(s)
- Teresa Bellón
- Drug Hypersensitivity Laboratory, Institute for Health Research Hospital Universitario La Paz (IdiPaz), Madrid, Spain
- *Correspondence: Teresa Bellón,
| | - Victoria Lerma
- Clinical Pharmacology Unit, Hospital Universitario Príncipe de Asturias, Madrid, Spain
- Department of Biomedical Sciences, University of Alcalá (IRYCIS), Madrid, Spain
| | - Javier Guijarro
- Clinical Pharmacology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, IdiPAZ, School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Elena Ramírez
- Clinical Pharmacology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, IdiPAZ, School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Celia Martínez
- Drug Hypersensitivity Laboratory, Institute for Health Research Hospital Universitario La Paz (IdiPaz), Madrid, Spain
| | - Carmelo Escudero
- Allergy Department, Hospital Universitario Niño Jesús, Madrid, Spain
| | - Ana M. Fiandor
- Allergy Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
| | - Ruth Barranco
- Allergy Department, Hospital Universitario Doce de Octubre, Madrid, Spain
| | | | - Francisco de Abajo
- Clinical Pharmacology Unit, Hospital Universitario Príncipe de Asturias, Madrid, Spain
- Department of Biomedical Sciences, University of Alcalá (IRYCIS), Madrid, Spain
| | - Rosario Cabañas
- Allergy Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
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Mixed T Helper1/T Helper2/T Cytotoxic Profile in Subjects with Chronic Chagas Disease with Hypersensitivity Reactions to Benznidazole. Microbiol Spectr 2022; 10:e0135722. [PMID: 35938810 PMCID: PMC9430713 DOI: 10.1128/spectrum.01357-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Dermatitis is the most common adverse event during treatment with benznidazole in chronic Chagas disease and is probably mediated by T cells. A set of molecules representative of the different type IV hypersensitivity reactions was evaluated in the circulation and skin biopsies of Trypanosoma cruzi-infected subjects presenting dermatitis during benznidazole administration. Through cytometric bead assays and enzyme-linked immunosorbent assay capture techniques, the serum levels of cytokines, chemokines, proapoptotic molecules, and mediators of the activation and migration of eosinophils and T cells were measured in subjects infected with Trypanosoma cruzi who exhibited skin adverse events (n = 22) and compared with those without adverse events (n = 37) during benznidazole therapy. Serum levels of interleukin- 5 (IL-5), soluble Fas cell surface death receptor ligand (FAS-L), and interferon γ-induced protein (IP-10) significantly increased at 7 to 30 days posttreatment with benznidazole and decreased thereafter in subjects with dermatitis but not in those without dermatitis. Circulating eotaxin levels were lower in subjects with dermatitis than in those without. Two patterns emerged in the skin biopsies: a T helper 1/T cytotoxic profile and a T helper 2/T cytotoxic profile with the presence of CD4+ and CD8+ T cells. Increased low-density lipoprotein (LDL), glutamic-oxaloacetic transaminase (GOT), uremia, and T cell activation emerged as risk factors for the development of dermatitis during benznidazole administration. These results support a delayed-type hypersensitivity reaction to benznidazole, involving CD4+ and CD8+ T cells and eosinophils, and a mixed cytokine profile. This study provides new insights for better management of adverse drug reactions to benznidazole. IMPORTANCE This study identified the risk factors for the development of adverse reactions to benznidazole and identified a set molecule to monitor the appearance of these reactions. This knowledge might improve the safety of benznidazole administration.
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Hama N, Abe R, Gibson A, Phillips EJ. Drug-Induced Hypersensitivity Syndrome (DIHS)/Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS): Clinical Features and Pathogenesis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1155-1167.e5. [PMID: 35176506 PMCID: PMC9201940 DOI: 10.1016/j.jaip.2022.02.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 05/16/2023]
Abstract
Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) is one example of a severe delayed T-cell-mediated adverse drug reaction. DIHS/DRESS presents with fever, widespread rash and facial edema, organ involvement, and hematological abnormalities, including eosinophilia and atypical lymphocytosis. DIHS/DRESS is associated with relapse 2 to 4 weeks after acute symptoms, often coinciding with reactivation of prevalent chronic persistent human herpesviruses such as human herpesvirus 6, EBV, and cytomegalovirus. The mortality of DIHS/DRESS is up to 10% and often related to unrecognized myocarditis and cytomegalovirus complications, with longer-term consequences that contribute to morbidity including autoimmune diseases such as thyroiditis. It is essential that all potential drug causes, including all new drugs introduced within the 8 weeks preceding onset of DIHS/DRESS symptoms, are identified. All potential drug culprits, as well as drugs that are closely related structurally to the culprit drug, should be avoided in the future. Systemic corticosteroids have remained the mainstay for the treatment of DIHS/DRESS with internal organ involvement. Steroid-sparing agents, such as cyclosporine, mycophenolate mofetil, and monthly intravenous immune globulin, have been successfully used for treatment, and careful follow-up for cytomegalovirus reactivation is recommended. Strong associations between HLA class I alleles and DIHS/DRESS predisposition include HLA-B∗13:01 and dapsone, HLA-B∗58:01 and allopurinol, and HLA-B∗32:01 and vancomycin. These have opened a pathway for prevention, risk stratification, and earlier diagnosis. Single-cell sequencing and other studies of immunopathogenesis promise to identify targeted treatment approaches.
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Affiliation(s)
- Natsumi Hama
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Andrew Gibson
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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Bosch-Nicolau P, Salvador F, Sánchez-Montalvá A, Franco-Jarava C, Arrese-Muñoz I, Sulleiro E, Roure S, Valerio L, Oliveira-Souto I, Serre-Delcor N, Pou D, Treviño B, Aznar ML, Espinosa-Pereiro J, Molina I. Association of HLA-B*35 and moderate or severe cutaneous reactions secondary to benznidazole treatment in chronic Chagas disease patients. Clin Microbiol Infect 2021; 28:881.e1-881.e5. [PMID: 34863919 DOI: 10.1016/j.cmi.2021.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/09/2021] [Accepted: 11/18/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Benznidazole is the first line treatment for Chagas disease. Adverse events appear in more than 50% of patients, leading to discontinuation in approximately 15%. Cutaneous reactions are one of the most frequent adverse events. HLA-genotyping previous studies identified an association between cutaneous reactions to benznidazole and carrying the specific allele HLA-B*35:05. We designed the present study to prospectively confirm this association. METHODS This is a prospective observational study including Chagas disease patients aged 18 years or more who accepted to receive benznidazole treatment following current guidelines. Allele genotyping of HLA-B was determined in all patients. Clinical and analytical follow-up was performed at days 0, 7, 14, 30 and 60 of treatment. RESULTS Two-hundred and seven patients were included. Seventy percent were female with a mean age of 45.1 (SD ±9.86) years mainly from Bolivia (92.8%). In 102 (49.3%) cases a cutaneous reaction was diagnosed. Forty-eight (46.6%) were classified as mild, 37 (35.9%) as moderate and 18 (17.5%) as severe. Thirty-two (15.4%) patients had to definitively interrupt the treatment due to a cutaneous reaction. Female sex (OR 4.49; 95%CI 1.62-12.47), new-onset eosinophilia prior to cutaneous symptoms (OR 2.55; 95%CI 1.2-5.43) and carrying the HLA-B*35 allelic group (OR 2.58; 95%CI 1.2-5.51) were all predictors of moderate to severe cutaneous reactions. No statistical significance was found when the specific allele HLA-B*35:05 was analyzed. CONCLUSIONS Patients carrying the HLA-B*35 allelic group are at higher risk of moderate to severe reactions when taking benznidazole treatment.
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Affiliation(s)
- P Bosch-Nicolau
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain; Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - F Salvador
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain
| | - A Sánchez-Montalvá
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain
| | - C Franco-Jarava
- Immunology Department. University Hospital Vall d'Hebron, Barcelona, Spain
| | - I Arrese-Muñoz
- Immunology Department. University Hospital Vall d'Hebron, Barcelona, Spain
| | - E Sulleiro
- Microbiology Department. University Hospital Vall d'Hebron, Barcelona, Spain
| | - S Roure
- North Metropolitan International Health Unit, PROSICS Metropolitana Nord, Badalona, Spain; Infectious Diseases Department, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Ll Valerio
- North Metropolitan International Health Unit, PROSICS Metropolitana Nord, Badalona, Spain
| | - I Oliveira-Souto
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain
| | - N Serre-Delcor
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain
| | - D Pou
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain
| | - B Treviño
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain
| | - M L Aznar
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain
| | - J Espinosa-Pereiro
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain; Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - I Molina
- Tropical Medicine & International Health Unit Vall d'Hebron - Drassanes, Infectious Diseases Department. PROSICS Barcelona, University Hospital Vall d'Hebron, Barcelona, Spain; Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Li Y, Deshpande P, Hertzman RJ, Palubinsky AM, Gibson A, Phillips EJ. Genomic Risk Factors Driving Immune-Mediated Delayed Drug Hypersensitivity Reactions. Front Genet 2021; 12:641905. [PMID: 33936169 PMCID: PMC8085493 DOI: 10.3389/fgene.2021.641905] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/08/2021] [Indexed: 12/19/2022] Open
Abstract
Adverse drug reactions (ADRs) remain associated with significant mortality. Delayed hypersensitivity reactions (DHRs) that occur greater than 6 h following drug administration are T-cell mediated with many severe DHRs now associated with human leukocyte antigen (HLA) risk alleles, opening pathways for clinical prediction and prevention. However, incomplete negative predictive value (NPV), low positive predictive value (PPV), and a large number needed to test (NNT) to prevent one case have practically prevented large-scale and cost-effective screening implementation. Additional factors outside of HLA contributing to risk of severe T-cell-mediated DHRs include variation in drug metabolism, T-cell receptor (TCR) specificity, and, most recently, HLA-presented immunopeptidome-processing efficiencies via endoplasmic reticulum aminopeptidase (ERAP). Active research continues toward identification of other highly polymorphic factors likely to impose risk. These include those previously associated with T-cell-mediated HLA-associated infectious or auto-immune disease such as Killer cell immunoglobulin-like receptors (KIR), epistatically linked with HLA class I to regulate NK- and T-cell-mediated cytotoxic degranulation, and co-inhibitory signaling pathways for which therapeutic blockade in cancer immunotherapy is now associated with an increased incidence of DHRs. As such, the field now recognizes that susceptibility is not simply a static product of genetics but that individuals may experience dynamic risk, skewed toward immune activation through therapeutic interventions and epigenetic modifications driven by ecological exposures. This review provides an updated overview of current and proposed genetic factors thought to predispose risk for severe T-cell-mediated DHRs.
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Affiliation(s)
- Yueran Li
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Pooja Deshpande
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Rebecca J. Hertzman
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Amy M. Palubinsky
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, TN, United States
| | - Andrew Gibson
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Elizabeth J. Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, TN, United States
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