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Hypersensitivity

Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

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Page 1: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Hypersensitivity

Page 2: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Hypersensitivity reactions

• An immunological responses not controlled by normal regulatory mechanism.

• Classification- Gell and Coombs system

Page 3: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Gell and Coombs system• Type I – immediate (Ig E)

• Type II – antibody mediated (ADCC)

• Type III – immune complex mediated

• Type IV – T cell mediated (delay type hypersensitivity)

Page 4: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

OUTLINE

• Hypersensitivity-mechanism (Sensitization phase/Effect phase)-clinical manifestation

-lab testing

Page 5: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type I - immediate hypersensitivity IgE-mediated reactions

• Mechanism :

IgE

SolubleAntigen

FcεROn mast cells or basophils

Page 6: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

degranulation

Cross linking of Fab

Page 7: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs
Page 8: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type I - immediate hypersensitivity IgE-mediated reactions

• clinical manifestationAtopy:Genetically linkage-Allergies-Allergic rhinitis-Asthma-Atopic dermatitis

-Allergic gastoenteropathy

Lack genetic linkage and target organ :

-Urticaria -Anaphylaxis-Anaphylacic shock

全身性過敏反應

蕁麻疹

異位性皮膚炎「濕疹」

Page 11: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type I - immediate hypersensitivity IgE-mediated reactions

• allergen

Host dust, arthropod, mold, weeds (ragweed), pollen, tree, animal, food, drug, latex

Inhalant allergenContact allergenFood allergen

Page 12: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type I - immediate hypersensitivity IgE-mediated reactions

• Lab test

Skin test

In vitro tests

Lymphocyte stimulation

Intranasal provocative tests鼻內激發法

Page 13: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Skin test

• Cutaneous test (prick test)pucture small amount to dermis and read after 20 min

• Intradermal testsemiquantitative

皮下過敏注射

扎刺法

Page 14: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

In vitro tests• Total IgE :

IMMULITE Total IgE (serum IgE only)• Allergen specific IgE

RAST : radioallergosorbent testMAST : multiple antigen simultaneous test CAP

Immunoblot (AlaBLOT test) --allergen: Ep strip• Eosinophilia : 114-142 300-500/mm3• ECP (eosinophil cationic protein)

體外敏感試驗

Page 15: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

過敏原檢測

Total IgE Test

CAP( 混合過敏原群 IgE 抗體篩檢 )

Phadiatop, fx5

CAP(特定過敏原 IgE 抗體篩檢 , 自選 )

or

MAST allergy test

Page 16: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

MAST(Multiple Antigen Simultaneous Test)• 同時測定 36 種抗原• 使用 Chemical Luminescent ImmunoAssay • 半定量

Allergen + tested IgE → Allergen-IgE-(Anti-IgE) → CLA-1

• 結果判讀 : 4 : >2423 : 143~2422 : 66~142   1 : 27~65±: 12~26- : 0~11

↑Anti-IgE*Enzyme

( 單位 : LUs)

* Total IgE>500 IU/mL MAST 中的某些 ± 可能為 non-specific binding

Page 17: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Principle

• Chemiluminescence Analysis ( 化學冷光酵素免疫分析法 )

Page 18: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

MAST allergy test• Introduction ─ 同時測定血清中 36 種過敏原的特異性 IgE 抗體 ─ 半定量計量。結果值 (LUs 淨值 ) 以級數表示

• Result ─ 分四級: 0, 0/1, 1, 2, 3, 4 ─ 2 級以上表示有意義

• Clinical significance ─ Atopic allergy 屬第一型過敏反應。 ─常見的臨床症狀有花粉熱、氣喘、皮膚炎、蕁麻疹、過敏

性休克 ─ 得知患者對不同過敏原的 IgE 濃度,是診斷和治療過敏的 重要資訊。

Page 19: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

• MAST 36種過敏原測試

Page 20: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs
Page 21: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs
Page 22: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

CAP

cellulose carriersβ-Galactosidase 的抗 IgE 抗體反應後 , 清洗掉未反應物 ,

加入反應呈色劑於 CAP 機器判讀結果。

β-Galactosidase

Page 23: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

CAP• 吸入性混合過敏篩檢 (23 種 ) 及食物性混合

過敏篩檢 (6 種 )

Page 24: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

CAP• 吸入性混合過敏篩檢 (23 種 ) 及食物性混合

過敏篩檢 (6 種 )

Page 25: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

UniCAP

Page 26: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

UniCAP 原理 : FEIA

• Fluorescence Enzyme Immunoassay (FEIA)

• Enzyme : β-galactocidase• Substrate : 4-MUG → 4-MU• Stop Solution : 4% Sodium Carbonate

Page 27: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

UniCAP• 以 FEIA 的方法,應用於 Autoantibody(Specific IgG) 和過敏免

疫系統 (Total IgE, Specific IgE) 的定量• Total IgE

檢測體內所含 IgE 濃度,作為過敏的指標 ─ 測定範圍 : 2~5000 kU/L• Specific IgE

檢測不同過敏原產生的特異性 IgE 抗體 ─ 吸入性混合過敏篩檢 (23種 ) 及食物性混合過

敏篩檢 (6種 )

Cyclic cirtullinared peptide(CCP) AbExtractable Nuclear Antigen Ab(ENA)

Page 28: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Eosinophil cationic protein(ECP)

將 Anti-ECP 固定於 cellulose carriers( 固相 ) 中 , 加入待測血清反應後 , 清洗掉未反應物 , 再加入 β-Galactosidase 的抗 ECP 抗體反應後 , 清洗掉 未反應物 , 加入反應呈色劑於 CAP 機器判讀結果。

檢驗活化的 eosinophil 及其產物 ECP 可追蹤病程 , 並在發炎期 (ex. 急性氣喘 ) 給予抗發炎藥劑 , 降低發炎 , 故檢驗血清中的 ECP 值是治療成效的指標。

Anti-ECP

Page 29: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type I - immediate hypersensitivity IgE-mediated reactions

Therapy• Environmental measures : avoid allergen• pharmacological therapies -antihistamine -corticosteroids -cromolyn sodium• Desensitization treatment -Allergen shots (blocking antibody, IgG) • Antibody against free and membrane IgE • Antibody to CD23 (low affinity IgE receptor)• Cytokine intervention

Page 30: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type II – antibody mediated

• Mechanism :

1.Cell surface antigen Transplanted cell

Host cell (autoimmune)

Foreign antigen bind to host cells

2.IgM IgG production (dep. on cytokine)

Sensitization phase

1.Complement activation

chemoattractant C5a C3a Anaphylatoxin C5a Opsonin

MAC 2.ADCC by NK3.Opsonin mediated

phagocytosis

Effect phase

Ag dose not clear from system

Destory cells

IgG

IgM

Page 31: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

IgG IgM

Page 32: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type II – antibody mediated

• clinical manifestation (dep. on cell type)

-Hemolytic disease of newborn

-Transfusion reactions

-Autoimmune disorders

-Drug induced reactions

-Transplantation

Page 33: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Hemolytic disease of newborn

RBC-Rh antigen

Page 34: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Autoimmune disorder• Goodpasture’s syndrome Ab against kidney and lung basement membranes Antiglomerular basement membrane antibody (Anti-GBM)

renal biopsy

even layer on the glomerular basement membrane

Page 35: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

• Myasthenia gravis Ab against acetylcholine receptor in neuromuscular junctions

down regulation of receptors by endocytosis muscle weakness

Page 36: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Drug induced reactions

ex : penicillin

Drug (hapten) Bind to cell surface

Type II hypersensitivity

Cell destruction

Page 37: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type III-immune complex mediated

Sensitization phase

1.Chronic Ag (soluble) exposureautoimmue disorders or persistent infection

2.IgM IgG production

(dep. on cytokine)

Too many immune complexesfor phagocytesto remove

Immune complex formationand

deposition in the capillary walls

IgG

IgM

• Mechanism :

Page 38: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs
Page 39: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs
Page 40: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

1.Complement Anaphylatoxin C5a Opsonin C3b CR1 chemoattractant C5a C3a

2.Neutrophil phagocytosis

damage capillary walls (proteolytic enzyme)

3.Coagulation Vascular permeability PLA aggregation blood clot formation *4.Immune complexes penetrate and lodged in capillary

walls 5.Vascular occlusion

Effect phase

Type III-immune complex mediatedIgG

IgM

Page 41: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type III-immune complex mediated• clinical manifestation -SLE

autoantibody, immune complexes deposit in various tissues

-Post streptococccal glomerulonephritisS. pyogenes, kidney, “captured antigen”

-Serum sicknesspassive immunization of non human IgGhuman antibody – non human IgG

(ex:horse serum:anti-diphtheria antibodies, antiserum administered following a snakebite )

-Farmer’s lungAg = spore of Thermophilic actnomycetes

-Arthus Reaction

Non human

IgG

Page 42: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Serum sickness

Page 43: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Arthus Reaction• Ag inject into immunized body• Local inflammatory response due to deposition of immune

complexes in tissues. • vaccine boosting( 第 2 劑 )

Page 44: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Detection of Immune Complex

• C1q binding assay

• Raji cell assay

• Detection of Cryoglobulins

Page 45: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

C1q binding assay

Page 46: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

C1q binding assay

False (-)Small immune complex 、 IgE, IgA, IgG4 immune complex

False (+)Fibrinogen 、 fibronectin 、 DNA 、endotoxin 、 heparin

Page 47: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Raji cell assay• Lymphoblastoid cell line from Burkitt’s lymphoma• C1q C3b C3d and Fcreceptor

• Normal:<15.0 μgEq/mL • positive: 20.0μg Eq/mL

Page 48: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Raji cell assay

• False-positives occur when antilymphocyte antibodies are present.

• Especially in SLE, positive results often reflect the presence of lymphocyte antibodies.

• Raji assay are commonly found in systemic necrotizing vasculitis and might be useful for monitoring sarcoidosis( 肉狀瘤病 ).

Page 49: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Detection of Cryoglobulins

• Cryoglobulins are abnormal immunoglobulins which form complexes and precipitate out of serum at low temperatures and resolubilise on warming.

• 4oC 沉澱,加溫溶解• responsible for specific symptoms,such as

Raynaud’s phenomenon, vascular purpura, bleeding tendencies, cold-induced urticaria

http://www.labcorp.com/datasets/labcorp/html/chapter/mono/sc029100.htm

Page 50: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Detection of Cryoglobulins

Type of Cryoglobulin Immunochemical

Composition

Type 1 : Single monoclonal immunoglobulins

• IgM • IgG • IgA • Monoclonal light-chains

Type II : Mixed monoclonal immunoglobulins

• IgM-IgG • IgG-IgG • IgA-IgG

Type III : Mixed polyclonal immunoglobulins

• IgM-IgG • IgM-IgG-IgA

Page 51: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Detection of CryoglobulinsType 1 : Single monoclonal

immunoglobulins • Myeloma • Waldenstrom’s • Chronic Lymphocytic

Type II : Mixed monoclonal immunoglobulins

• Myeloma • Waldenstrom’s • Macroglobulinaemia • Chronic Lymphatic Leukaemia

Type III : Mixed polyclonal immunoglobulins

• Autoimmune Disease: • Lupus (SLE) • Rheumatoid arthritis • Scleroderma • Sjogren’s Syndrome • Chronic active hepatitis • Active Hepatitis. • Post streptococcal nephritis. • Vasculitis • Infections:

Page 52: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type IV – T cell mediateddelayed-type hypersensitivity, DTH

Sensitization phase Effect phase

Page 53: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs
Page 54: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type IV – T cell mediated macrophage activation

• clinical manifestation

chronic DTH

-Mycobacterium tuberculosis

acute DTH (24-48 hr.)

-Mantoux skin test (PPD= purified protein derivative)

Page 55: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Contact dermatitis

Page 56: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Mycobacterium tuberculosisTB prevent fusion of lysosomes and phagosomes TB live in macrophage

macrophage destruction chemotatic factors release chemotasis 聚集形成肉芽( Tubercle ,結核)

乾酪樣壞死

Page 57: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Type IV – T cell mediated

• Lab

patch test (read after 48 hr.):

PPD or tuberculin skin test (Koch phenomena)

Candida albicans Streptokinase Mumps Trichophyton

Page 58: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

The DTH skin test: Mantoux test

• Determine the infection of Mycobacterium tuberculosis

PPD24-48 hr.

(PPD= purified protein derivative)

Page 59: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Sensitization phase

Effect

phaseClinical

Type I Immediate

Soluble

AntigenIgE

IgE cross-linked with Ag

Mast cells and basophils degranulation

Allergies Rhinitis Asthma

Anaphylaxis Anaphylacic shock Urticaria

Type IIAb mediated

Cell surface

Antigen

IgM IgG

Ab bind to surface Ag

*Complement

*ADCC by NK

*phagocytosis

(Opsonin)

cell destruction

Hemolytic disease of newborn

Goodpasture’s syndrome Myasthenia gravis

Drug induced reaction

Transfusion reaction

Transplantation

Type IIIImmune complex mediated

Soluble

Antigen

(many)

IgM IgG

Ab bind to free Ag immune complex

Immune complex deposited in

capillary wall localized destruction

SLE Post streptococccal glomerulonephritis Serum sickness

Persistent infection

Farmer’s lung

Type IVCell

mediated

Naïve CD4 T cell activation

Macrophage

DTH

Contact sensitivity

Delay hypersensitivity

Immunity to viral and fungal antigens and intracellular organisms

Rejection of foreign tissue grafts

Elimination of tumor cells bearing neoantigens

Formation of chronic granulomas

summary

Page 60: Hypersensitivity. Hypersensitivity reactions An immunological responses not controlled by normal regulatory mechanism. Classification - Gell and Coombs

Comparison of Different Types of hypersensitivity

characteristicstype-I(anaphylactic)

type-II(cytotoxic)

type-III(immune complex)

type-IV(delayed type)

antibody IgE IgG, IgM IgG, IgM None

antigen exogenous cell surface soluble tissues & organs

response time 15-30 minutes minutes-hours 3-8 hours 48-72 hours

appearance weal & flare lysis and necrosis erythema and edema, necrosis

erythema and induration

histology basophils and eosinophil

antibody and complement

complement and neutrophils

monocytes and lymphocytes

transferred with antibody antibody antibody T-cells

examples allergic asthma, hay fever

erythroblastosisfetalis, Goodpasture's nephritis

SLE, farmer's lung disease 

tuberculin test, poison ivy, granuloma