Drug-specific in vitro release of IL-2, IL-5, IL-13 and IFN-γ in patients with delayed-type drug hypersensitivity

Speaker: Jui-Yun Weng

Advisor: Ching-Tsan Huang PhD

Date: 2009-11-30

P. Lochmatter, A. Beeler, T. T. Kawabata, B. O. Gerber, and W. J. Pichler

Allergy 64(9): 1269-1278, 2009.

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93.6.20 蘋果日報A16版

http://www.cgmh.org.tw/intr/intr6/c5c010/%E8%97%A5%E7%89%A9%E4%B8%8D%E8%89%AF%E5%

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SJSTEN

(http://adr.doh.gov.tw/default.asp)

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(http://www.who.int/medicines/areas/quality_safety/safety_efficacy/advdrugreactions/en/)

Adverse drug reactions (ADR)

Harmful, unintended reactions to medicines that occur at doses normally used for treatment are called adverse drug reactions (ADRs). --according to WHO

Type A: augmented pharmacologic effects

- dose dependent and predictable

Type B: bizarre effects (or idiosyncratic)

- dose independent and unpredictable

hypersensitivity:

immunological mechanisms involved

*History and testing

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75~80%

General problems of diagnosing drug hypersensitivity

Is it a drug hypersensitivity reaction?

Which type of immune reaction is involved?

What is the eliciting drug?

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Allergy/hypersensitivity testing

Skin test Food allergy

Mold, pollen, animal, and other allergies that cause allergic rhinitis and asthma

Penicillin allergy

Venom allergy

Allergic contact dermatitis

Elimination test Allergens from food

Blood test Level of IgE to a specific allergen

Provocation (challenge test)

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Hypersensitivity

Type Alternative names Mediators

I Allergy (immediate) •IgE

IIAntibody-dependent cell-mediated

cytotoxicity

•IgM or IgG

•(Complement)

III Immune complex disease•IgG

•(Complement)

IV

Delayed-type hypersensitivity

(DTH), cell-mediated immune

memory response, antibody-

independent

•T-cells

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Coombs and Gell classification

(http://en.wikipedia.org/wiki/Hypersensitivity)

Drug hypersensitivity

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IgE IgM, IgG

•Atopy

•Anaphylaxis

•Asthma

•Autoimmune

hemolytic

anemia

•Thrombocytope

nia

•Erythroblastosis

fetalis

Drug hypersensitivity

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IgGT cell

•Serum sickness

•Contact dermatitis

•Chronic transplant rejection

•Multiple sclerosis

Th1/Th2

10http://en.wikipedia.org/wiki/T_helper_cell

Cell-mediated immunity— T-cell–mediated defense

mechanism

Contact hypersensitivity

– immunogen:

hapten + host proteins

24 - 72 hours to developed

Protein

carrier

Delayed-type hypersensitivity (DTH)

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Drug-induced DTH

Culprit drugs (hapten):

Penicillin (b-lactam)

Sulfonamides

Symptoms: Maculopapular exanthema (MPE)

Drug reaction with eosinophilia and systemic symptom (DRESS)

Erythema exsudativum multiforme (EEM)

Stevens-Johnson syndrome(SJS)

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The symptoms DTH patients might have

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(http://tray.dermatology.uiowa.edu/EMult003.htm)

Erythema multiforme

Maculopapular exanthema

(http://www.phac-aspc.gc.ca/publicat/uvpd-mjmepv/vol6-1/index-eng.php)

(http://dilantininjury.com/)

Previous studies

Lymphocyte transformation test, LTT

T cell proliferation and activation test in vitro

3H-thymidine

CD69

Express while CD4+/CD8+ T cell activated

Flowcytomerty

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This study

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monocyte

Peripheral Blood Mononuclear Cell(PBMC)

~75%

(+)

Tetanus toxoid(TT)

Sulfonamides:

Sulfamethoxazole (SMX)

Sulfapyridine (SPD)

b-lactam:

Ampicillin (AMP)

Amoxicillin (AMX)

Cytokines/chemokinesexpression detection

From patients and healthy donors

Stimulatory drugs:

IL-5, IL-13, IFN-g, IL-2,

IL-4, IL-17, IL-6, IL-10,

TNF-a, GM-CSF,

CCL4,

G-CSF, CXCL8, CCL2,

IL-1b, IL-12, IL-7

Screen for the guidelines to diagnose DTH

Patient no. Age/sex Culprit drug Disease Skin test LTT CD69 Time interval

(months)

32 64/m AMX MPE - + + 19

249 26/f AMX MPE + + n.d. 2

31 35/m AMX MPE - + + 8

244 35/f AMX MPE - + n.d. 5

358 41/f AMX EEM + + + 6

DTH patients

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Patient

no.

Age/sex Culprit drug Disease Skin test LTT CD69 Time interval

(months)

11 45/m SMX MPE/Malaise + + + 144

38 48/m SPD DRESS - + + 13

245 71/m SMX SJS - + + 2

32 64/m SMX Erythroderma - + + 19

295 41/f SPD DRESS - + + 6

Sulfonamides-allergic

b-lactam-allergic

Baseline cytokine secretion

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pg/mL

Healthy donors’ PMBC stimulated

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Fold increase

TNF-a

Secreted by leukocytes , epithelia, fibroblasts

Stimulate IL-12 production and Th1 cells

IL-12: induction of Th1 cell

Stimulation of NK cells

MHC I induction

Antivirus

19*P<0.05; **P<0.01; ***P<0.001

INF-g

Secreted by T cell, NK cell, epithelia, fibroblasts

Macrophage activation

Antivirus

20*P<0.05; **P<0.01; ***P<0.001

c

IL-2

Secreted by Th0 and Th1 cell

T cell proliferation and differentiation

Activate CTL and macrophage

21*P<0.05; **P<0.01; ***P<0.001

IL-5

Secreted by Th2 cell

B cell growth and differentiation

Eosinophil activation

*P<0.05; **P<0.01; ***P<0.00122

IL-13

Secreted by activated T cell

B cell growth and differentiation

Inhibits proinflammatorycytokine production

23*P<0.05; **P<0.01; ***P<0.001

T-cell dependent cytokine secretion

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Sulfonamides:

b-lactam:

Summary

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monocyte

~75%

Cytokines/chemokinesexpression detection

Allergic drugs

IL-5, IFN-g, IL-2, IL-13Sulfonamides

b-lactam

Need more patients and controls to determine the exact

sensitivity and specificity

ADRs Drug-induced DTH

Thank you all~

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