Transcript Alpha-Gal IgE Titer (IU/mL)

It’s Nothing to Sneeze At –
An Update in Allergy
Virginia Chapter ACP Annual Meeting
2013
Scott P. Commins
Division of Allergy and Clinical Immunology
Disclosures
We are grateful for generous support from
the Oakey Food Allergy Fund
These studies were carried out with generous
support from the NIH-NIAID (K08 AI085190 &
R21 AI087985)
Disclosure: Up-to-Date card
I. Background
How oncologists helped uncover a
novel food allergy
High incidence of hypersensitivity reactions to cetuximab
infusions in mid-Missouri:
Association with prior history of atopy
R. Owera, A. Gill, S. Haddadin, R. Khozouz and M. C. Perry
University of Missouri Columbia, Columbia, MO
Abstract, 2008 ASCO Annual Meeting Proceedings, Vol 26, No 15S,
2008:20747
Regarding cetuximab HSR:
The story got stranger as
O’Neil talked to more
oncologists. He heard that a
colleague in Nashville,
Tennessee, was finding the
same problem. But when
O’Neil spoke to oncologists
from other areas of the
country, they didn’t know what
he was talking about. A
prominent colorectal oncologist
in New York “thought we were
lying or crazy,” O’Neil recalls.
From “A Mysterious Allergy Afflicts the
South” by Sheila Read in Endeavors, 24:2,
2-3, 2008.
Measurement of IgE ab to Purified Allergens
Using Streptavidin Solid Phase
“Allergen” of interest (cetuximab)
+ Biotin
Streptavidin Solid Phase + Biotinylated “Allergen”
Solid Phase*
Then add serum; wash; add labeled anti-IgE; detect chemilum.
*Routine assay technique in parallel with Phadia standard curve gives results in IU/ml.
IgE Antibodies Binding to Cetuximab in Sera
from 76 Case Subjects and 462 Controls
Cetuximab
N-88
N-43
*
*
Site not
glycosylated
N-299
Typical Fc region oligos:
core fucosylated
biantennary oligos;
no alpha-gal or NGNA
Qian J, Liu T,…Zhou Q.
Analytical Biochem, 2007.
Specificity of the IgE Antibodies that Cross-React
with Cetuximab
Chung CH et al. N Engl J Med 2008;358:1109-1117
II. Defining a “new” food allergy
Specificity of the IgE Antibodies That Cross-React with Cetuximab
Chung CH et al. N Engl J Med 2008;358:1109-1117
JACI, February 2009
-24 patients
-Virginia & Missouri
- Symptoms delayed 3-6 hours after eating mammalian meat
- Prick skin test often less than 4mm
- Intradermal skin test positive
Skin Testing Results: Often <4mm SPT
Prick test
Intradermal
Prick test performed using lancette and intradermal testing with
25 gauge needle in the same patient on a single clinic visit.
Patient data, presentation, symptom delay,
and laboratory evaluation
Symptoms Time to Alpha-Gal Beef IgE Total IgE
ANA = Anaphylaxis Reaction IgE Titer
Titer
Titer
AE = Angioedema
U = Urticaria
(hours)
(IU/mL)
(IU/mL) (IU/mL)
ANA
6
67.0
3.48
157
Patient
Age /Sex
Race
E001
44 / M
W
E008
80 / F
W
AE, U
6
0.52
0.35
45.9
E018
26 / M
W
ANA
5
59.3
16.6
274
E022
74 / F
W
AE, U
3
9.03
8.90
66.6
E026
47 / M
W
ANA
6
>100
32.9
1081
E030
56 / M
W
U
4-6
80.6
15.8
709
E031
55 / F
W
U
4
68.9
26.2
243
E036
66 / M
W
U
4-6
21.1
19.2
262
E054
45 / M
W
ANA
3
2.42
0.35
244
E076
50 / M
W
U
4
9.25
3.24
247
E115
58 / F
W
ANA
2-4
>100
47.8
1622
E128
37 / M
W
U
4-6
26.8
5.65
886
E162
39 / F
W
AE, U
6
11.1
1.51
30.5
CAP-RAST of Specific IgE Abs in Patients with anti-Gal IgE
Foods
Inhalants
r =0.81
r =0.98
10
1
▼x1
♦x1
Be
ef
Po
Limit of
detection
x3 x12 x11 x12
x1 x7
♦x4
x1 x9
s
yG
ras
ite
tM
Tim
oth
Du
s
Do
g
1
Fe
ld
Ca
t
Fis
h
rke
y
Tu
ke
n
Ch
ic
mb
La
rk
a-G
a
l
0.1
Alp
h
Specific IgE Abs (IU/mL)
100
Alpha-gal specific IgE is associated with anaphylaxis but not asthma
1000
(Figure adapted from Commins, Kelly…Platts-Mills, AJRCCM, 2012)
Alpha-gal specific IgE (IU/mL)
= Reactions include anaphylaxis
100
10
1
Limit of
detection
0.35
Number <0.35
•x8
• x 13
• x 58
• x 55
Asthma
(N = 68)
Clinic controls
(N = 59)
0.1
Cat in home
No cat in home
(N = 96)
(N = 112)
Anaphylaxis/ urticaria subjects
30%
r = 0.60, p<0.001
10%
IgE Ab to alpha-gal in kids (n=45)
Sex (% male)
69%
Mean age at presentation
(Range)
Geometric Mean of Total IgE (95% CI)
12 (4-17)
147 IU/mL (105-206 IU/mL)
Symptoms at presentation
Anaphylaxis*
44%
Gastrointestinal/
Oral
Urticaria
64%
Angioedema
31%
92%
Average time to symptoms (Range)
4.68 hrs (10 mins to 24 hrs)
Tick exposure
100%
Redness and
Itching at site of
Tick bite
Tick borne illness#
Emergency Department (ED) visits
Medications administered in ED
Hospital Admissions
87%
10%
46%**
Epinephrine (19%)
Antihistamines (35%)
Oral Steroids (19%)
Parenteral Steroids (17%)
IV Fluids (17%)
8%
IgE Ab to alpha-gal in kids (n=45)
Delayed symptoms induced by oral exposure to
mammalian proteins in patients with IgE ab to alpha-gal.
• Despite high titer IgE antibodies that bind
epitopes on a range of mammalian proteins
including beef, pork and lamb:
– No awareness of immediate response in the mouth
(i.e. no lip swelling or tingling).
– Anaphylaxis occurring after eating beef starts with
skin itching 3-6 hours later.
– Skin prick tests generally <4mm in diameter while
intradermals often ≥8mm.
‘Delayed’ food allergy?
• Food allergy symptoms classically occur
immediately (OAS), up to 2 hours after eating
• No mention of ‘delayed’ symptoms that can be
attributed to food in common allergy texts
III. Ticks.
Really?
Geographical distribution of cetuximab hypersensitivity reactions
As reported by O’Neil et al, JCO 2007
Distribution of known cases of
delayed anaphylaxis to mammalian meat
Dots = single cases
Smaller stars = 5 to 24 cases
within a state
Larger stars = states with 25
or more cases
Geographical Incidence of Rocky Mountain Spotted Fever
Data from CDC
website for 2009;
accessed 2/2011
Original image: CDC; modified by D.N. Gaines for Virginia Department of Health
Geographical range of Amblyomma americanum population
Data from CDC website; accessed 10/2010
Geographical range of Amblyomma americanum population
welcome to the party
Data from CDC website; accessed 9/2012
Bites from the larvae of Amblyomma or
Dermacentor ticks and IgE ab to alpha-Gal.
Photograph: August 23, 2007.
Test
10/26/06
5/21/07
10/9/07
11/6/07*
Cetuximab
(alphaGal)
0.49
16.9
48.3
130
Total IgE
127
199
350
532
•Multiple bites by seed ticks are
not uncommon in the Southeast.
*Titers:Total 262, Beef 19.2 Pork 10.1,Cat 17.5,Dog 19.8,
IU/ml. Chicken, Turkey, Roach, Dust Mite and Ragweed
all <0.35 IU/ml.
Time course of IgE antibodies to alpha-gal and total IgE
following episodes of multiple tick bites (red arrows)
Subject #1
*
Time course of IgE antibodies to alpha-gal and total IgE
following episodes of multiple tick bites (red arrows)
Subject #2
Time course of IgE antibodies to alpha-gal and total IgE
following episodes of multiple tick bites (red arrows)
*
Subject #3
Total IgE versus IgE to Alpha-Gal
Report tick or
chigger bite(s)
IgE to Alpha-Gal (IU / mL)
1000
R= 0.78
P <0.001
100
No history
obtained for
tick bite(s)
10
Specifically deny
tick bite(s)
1
0.1
1
10
100
Total IgE (IU / mL)
1000
10000
R amblyommii?
IV. Delayed food allergy
-FC02 - sIgE to alpha-gal = 22.4
IU/mL; Total IgE = 109
-4:22 after consuming meat,
symptoms began as itching &
hive on hand; second hive
appeared on arm
-Given AH and observed
-FC02 - sIgE to alpha-gal = 17.6
IU/mL; Total IgE = 184
-Whole blood was collected, fixed &
stained
-3:54 after consuming meat,
symptoms began as itching, flushing
and progressed: ultimately requiring
epinephrine
-Subject #FC-07: sIgE to alpha-gal = 9.3 IU/mL; Total IgE = 204
-Whole blood was collected, fixed & stained
-6 hours after consuming 56g of pork prosciutto, subject released with
(disappointing) mild itch and single hive
Subject calls from car 30 minutes after being
released to report progression of itching and
“warmth to skin”
Initial picture upon
arriving home
(approximately 7.5
hours after eating
pork prosciutto)
Approximately 8.25 hours after eating prosciutto
Mammalian meat challenge
Subject #FC-08: sIgE to alpha-gal = 30.3 IU/mL ; total IgE = 146
Before
3hrs 45min after eating meat
Subject #FC-08: Mammalian meat challenge
Diffuse urticaria appeared at
4hrs 15min after eating meat
(left arm shown here)
Mammalian meat challenge
Subject #FC-10: sIgE to alpha-gal = 29.1 IU/mL ; total IgE = 201
4hrs 25min after
eating mammalian
meat: pruritus
followed by urticaria
on right flank
Summary of Mammalian Meat Challenge
Results in Subjects with IgE to alpha-gal
Allergics
(n=10)
Urticaria
Time to
symptoms
(hrs:min)
Treatment
required
Tryptase
elevation
7*/10
3:50 – 6:00
7/10
1**/9
*Two subjects received epinephrine (i.e., these reactions are probably better
defined as delayed anaphylaxis to mammalian meat)
**Tryptase:
-Subject FC-08: 4.2ng/mL (baseline) → 18.2ng/mL (4 hrs) → 20.1 ng/mL (5 hrs)
-Subject FC-10: 4.9 (baseline) → 6.2 (4 hrs) → 9.9 (5 hrs) → 10.7 (6 hrs)
-No tryptase measurements were performed in subject FC-06
CD63 APC
HLA-DR/lineage 1 FITC
Gating
Strategy
Gating
Strategy
CD123 PerCP-Cy5.5
Negative for
• Lineage Cocktail 1 (CD3, CD14,
CD16, CD19,CD20, and CD56)
• HLA-DR
Positive for
• CD123 (IL-3Ra)
• FcεRI (IgE receptor)
• IgE
% of max
Basophils
CD 123
FACS Detection of CD63, a marker of Basophil Activation
PerCP-Cy5.5-linked antiCD123 ab
APC-linked
anti-CD63 ab
CD63
-APC
IL-3 Rα
Histamine
nuclear membrane
In vivo Basophil Activation during Mammalian Meat Challenge
1 hr
0.72%
2 hrs
0.54%
3 hrs
0.87%
CD63
CD123
4 hrs - 16.11%
5 hrs - 14.12%
6 hrs - 5.12%
#FC-02
In vivo Basophil Activation during Mammalian Meat Challenge
Baseline
1.96%
CD63
IgE
2 hrs
3.08%
5 hrs
8.74%
4 hrs
1.8%
-FC07 - sIgE to alpha-gal = 9.3
IU/mL; Total IgE = 204
-Whole blood was collected,
fixed & stained
Summary of Mammalian Meat Challenge
Results in Subjects with or without IgE to alpha-gal
Urticaria
Time to
symptoms
(hrs:min)
Treatment
required
2/10
7/10
3:50 – 6:00
7/10
0/10
0/10
n/a
0/10
Delayed
anaphylaxis
Allergics
Controls
Allergics
Delayed
anaphylaxis
2/10
Urticaria
Time to
symptoms
(hrs:min)
Treatment
required
Basophil
activation
6/10
3:50 – 6:00
7/10
8/10
Why the delay?
• The answer could be fat. Recall that fat is
absorbed differently from protein or
carbohydrates in a process that takes 3-4 hrs to
enter the blood stream
The delivery of lipid to the circulation takes time (about 4 hours)
VLDL
IDL LDL HDL
Further conversion
Thoracic duct
blood stream
=Alpha-gal moiety,
as a glycolipid
Why the delay?
• The answer could be long-chain triglycerides
associated with chylomicrons. Studies suggest
LCT enhance dietary antigen absorption into the
circulation via chylomicron formation.
• The answer could be the nature of a
carbohydrate-based food allergy.
Conclusions
• The report of delayed reactions occurring 3-6
hours after eating mammalian meat has been
confirmed on multiple occasions and at two
medical centers
• In subjects with IgE to alpha-gal, basophil
activation in vivo coincides with the appearance
of clinical symptoms
• Lack of basophil activation before 4 hours
suggests that there is delayed appearance of
the antigen into the bloodstream
Uva
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