Hypersensitivity
Hypersensitivity
reactions are pathologic processes that result from exaggerated specific interactions
between antigens (exogenous or endogenous) and either humoral antibodies or
sensitized lymphocytes, resulting in tissue injury. It occurs only if the host
has had a previous contact with the antigen (allergen). The initial or sensitizing dose sensitizes
the immune system and the subsequent contact (shocking dose) with the same
antigen or allergen causes hypersensitivity.
Hypersensitive reactions are
classified based on
·
Duration
between exposure of antigen and reaction – immediate type and delayed type
hypersensitivity. In immediate hypersensitivity, the symptoms manifest within
minutes or hours after second encounter with antigen. In Delayed-type
hypersensitivity (DTH) the symptoms occur even days after exposure.
·
Immune
component involved in reaction – antibody mediated and cell mediated
hypersensitivity
·
Gell
– Coombs classification- typeI, type II, type III and type IV
Type I -
IgE-Mediated Hypersensitivity
Antigen induces
crosslinking of IgE bound to mast cells and basophils with release of
vasoactive mediators.
Typical
manifestations include systemic anaphylaxis and localized anaphylaxis such as
hay fever, asthma, hives, food allergies, and eczema.
Type II - IgG-Mediated Cytotoxic Hypersensitivity
Antibody directed
against cell surface antigens mediates cell destruction via complement
activation or ADCC (Antibody-dependent cell-mediated cytotoxicity)
Typical
manifestations include blood transfusion reactions, erythroblastosis fetalis,
and autoimmune hemolytic anemia
Type III - Immune Complex-Mediated Hypersensitivity
Antigen - Antibody
complexes deposited in various tissues induce complement activation and an
ensuing inflammatory response mediated by massive infiltration of neutrophils
Typical
manifestations include localized Arthus reaction and generalized reactions such
as serum sickness, necrotizing vasculitis, glomerulnephritis, rheumatoid
arthritis, and systemic lupus erythematosus.
Type IV - Cell-Mediated Hypersensitivity
Sensitized TH1
cells release cytokines that activate macrophages or TC cells which mediate
direct cellular damage
Typical
manifestations include contact dermatitis, tubercular lesions and graft
rejection.
Type I - IgE-Mediated Hypersensitivity
Type I
hypersensitive reaction is induced by certain types of antigens known as
allergens, and is similar to a normal humoral response. That is, an allergen
induces a humoral antibody response resulting in the generation of
antibody-secreting plasma cells and memory cells. But here, the plasma cells
secrete IgE that binds to Fc receptors on the surface of tissue mast cells and
blood basophils. Mast cells and basophils coated by IgE are said to be
sensitized.
A later exposure
to the same allergen cross-links the membrane-bound IgE on sensitized mast
cells and basophils, causing degranulation of these cells. The IgE-antigen
reaction occurring on the surface of basophils and mast cells leads to receptor
cross-linking and degranulation, ie release of vasoactive amines (histamine and
serotonin) and other agents (heparin, eosinophil and neutrophil chemotactic
factors, platelet-activating factor, a variety of cytokines and prostaglandins
and leukotrienes) from the cytoplasmic granules. These molecules cause contraction of smooth
muscle cells, vasodilation, increased vascular permeability and platelet
aggregation and degranulation. These reactions can affect a single tissue or
organ (as in asthma, hay fever or eczema) or multiple ones (as in generalised
anaphylaxis) depending on local or general re-exposure to the allergen.
The clinical
manifestations of type I reactions can range from life-threatening conditions,
such as systemic anaphylaxis and asthma, to hay fever and eczema, which are
merely irritating. So type I reactions are of two types – Anaphylaxis and Atopy
The mediators can
be classified as either primary or secondary.
The primary
mediators are produced before degranulation and are stored in the granules and
these are histamine, serotonin, proteases, eosinophil chemotactic factor,
neutrophil chemotactic factor, and heparin.
The secondary
mediators either are synthesized after target-cell activation or are released
by the breakdown of membrane phospholipids during the degranulation process.
They include platelet-activating factor, leukotrienes, prostaglandins,
bradykinins, and various cytokines.
Histamine, which is formed by decarboxylation of
the amino acid histidine, is a major component of mast-cell granules, and
induces contraction of intestinal and bronchial smooth muscles, increased
permeability of venules, and increased mucus secretion by goblet cells.
Serotonin is derived by decarboxylation of
tryptophan and cause smooth muscle contraction, increased vascular permeability
and vasoconstriction.
Leukotrienes and prostaglandin are formed during
the mast cell degranulation and the enzymatic breakdown of phospholipids in the
plasma membrane. Their effects are more pronounced and long lasting. The
leukotrienes are formed through lipooxygenase pathway and mediate
bronchoconstriction, increased vascular permeability, and mucus production.
Prostaglandin are formed through cyclooxygenase
pathway causes bronchoconstriction.
Slow reacting
substance of anaphylaxis (SRS-A) are a family of leukotrienes (LTC4, D4, E4).
Platelet activating Factor (PAF) is release from
basophils and causes aggregation of platelets.
Anaphylaxis (Ana
– without and Phylaxis - protection)
is a shock-like and often fatal state whose onset occurs within minutes of a
type I hypersensitive reaction. This is due to the systemic vasodilation and
smooth-muscle contraction brought on by mediators released in the course of the
reaction. The symptoms include edema, decreased coagulability of blood,
decrease in blood pressure and temperature, leucopenia and
thrombocytopenia. Tissues or organs
involved are known as shock organ or target organs.
A wide range of antigens
have been shown to trigger this reaction in susceptible humans, including the
venom from bee, wasp, hornet, and ant stings; drugs, such as penicillin,
insulin, and antitoxins; and seafood and nuts. If not treated quickly, these
reactions can be fatal.
Epinephrine is the
drug of choice for systemic anaphylactic reactions. Epinephrine counteracts the
effects of mediators such as histamine and the leukotrienes.
Cutaneous anaphylaxis – This is a skin
test for type I hypersensitivity. When small dose of antigen is
administered intradermally to a sensitized host, localized wheal and flare
effect occurs with a central puffi area surrounded by area having hyperemia and
erythema.
Passive Cutaneous anaphylaxis – when small volume
of antibody or serum is intradermally injected to normal animal followed by
intravenous injection of antigen along with Evans Blue 4-24 hour later, bluing
at the intradermal site occurs due to vasodilation and increased vascular
permeability.
In vitro anaphylaxis – when intestinal or
uterine muscle strip from a sensitized animal is place in Rogers solution in
presence of antigen, the muscle strip contract vigorously. This is known as Schultz-Dale phenomenan.
Anaphylactoid reaction – intravenous
injection of peptone or trypsin provoke a reaction resembling anaphylactic
shock.
In Localized anaphylaxis (atopy), (atopy
means out of place / strangeness) the reaction is limited to a specific target
tissue or organ, often involving epithelial surfaces at the site of allergen
entry. The localized anaphylactic reactions is inherited and is called atopy.
Atopic Allergies include allergic rhinitis (hay fever), asthma, atopic dermatitis
(eczema), and food allergies.
Allergic Rhinitis, commonly known as hay fever results
from the reaction of airborne allergens with sensitized mast cells in the
conjunctivae and nasal mucosa to induce the release of pharmacologically active
mediators from mast cells; these mediators then cause localized vasodilation
and increased capillary permeability.
The symptoms
include watery exudation of the conjunctivae, nasal mucosa, and upper
respiratory tract, as well as sneezing and coughing.
Asthma -In some cases, airborne or blood-borne allergens,
such as pollens, dust, fumes, insect products, or viral antigens, trigger an
asthmatic attack (allergic asthma);
In other cases, an
asthmatic attack can be induced by exercise or cold, apparently independently
of allergen stimulation (intrinsic asthma).
Like hay fever,
asthma is triggered by degranulation of mast cells with release of mediators,
but instead of occurring in the nasal mucosa, the reaction develops in the
lower respiratory tract. The resulting contraction of the bronchial smooth
muscles leads to bronchoconstriction. Airway edema, mucus secretion, and
inflammation contribute to the bronchial constriction and to airway
obstruction.
Food allergies – Food allergen crosslinking of IgE on
mast cells along the upper or lower gastrointestinal tract can induce localized
smooth-muscle contraction and vasodilation and thus such symptoms as vomiting
or diarrhea.
Mast-cell
degranulation along the gut can increase the permeability of mucous membranes,
so that the allergen enters the bloodstream.
Some individuals
develop asthmatic attacks after ingesting certain foods. Others develop atopic
urticaria, commonly known as hives, when a food allergen is carried to
sensitized mast cells in the skin, causing swollen (edematous) red
(erythematous) eruptions; this is the wheal and flare response, or P-K reaction
(Prausnitz – Kustner reaction). It
includes swelling, produced by the release of serum into the tissues (wheal),
and redness of the skin, resulting from the dilation of blood vessels (flare).
Atopic dermatitis (allergic eczema) is an
inflammatory disease of skin. The allergic individual develops skin eruptions
that are erythematous and filled with pus.
Type II
Hypersensitivity Antibody-Mediated Cytotoxic Hypersensitivity
Type II
hypersensitive reactions involve antibody-mediated destruction of cells. Antibody
can activate the complement system, creating pores in the membrane of a foreign
cell or it can mediate cell destruction
by antibody dependent cell-mediated cytotoxicity (ADCC).
Transfusion Reactions
An individual possessing
one type of blood-group antigen recognize other type on transfused blood as
foreign and mount an antibody response. In some cases, the antibodies have
already been induced by natural exposure to similar antigenic determinants on a
variety of microorganisms present in the normal flora of the gut. Antibodies to the A, B, and O antigens, called
isohemagglutinins, are usually of the IgM class. Antibodies to other blood-group antigens may also
result from repeated blood transfusions and these antibodies are usually of the
IgG class.
If a type A
individual is transfused with blood containing type B cells, a transfusion
reaction occurs in which the anti-B isohemagglutinins bind to the B blood cells
and mediate their destruction by means of complement-mediated lysis.
The clinical manifestations of transfusion reactions
result from massive intravascular hemolysis of the transfused red blood cells
by antibody plus complement. These manifestations may be either immediate or
delayed.
In the immediate type, symptoms include fever, chills,
nausea, clotting within blood vessels, pain in the lower back, and hemoglobin
in the urine.
Delayed hemolytic transfusion reactions generally
occur in individuals who have received repeated transfusions of ABO-compatible
blood that is incompatible for other antigens. The reactions develop between 2
and 6 days after transfusion. Symptoms
include fever, low hemoglobin, increased bilirubin, mild jaundice, and anemia.
Hemolytic
Disease of the Newborn
Hemolytic disease of the newborn develops when maternal
IgG antibodies specific for fetal blood-group antigens cross the placenta and
destroy fetal red blood cells. The consequences of such transfer can be minor,
serious, or lethal.
Severe hemolytic disease
of the newborn, called erythroblastosis fetalis, most commonly develops when an
Rh+ fetus expresses an Rh antigen on its blood cells that the Rh– mother does
not express. During pregnancy, fetal red blood cells are separated from the
mother’s circulation by a layer of cells in the placenta called the trophoblast.
During her first pregnancy with an Rh+ fetus, an Rh– woman is usually not
exposed to enough fetal red blood cells to activate her Rh-specific B cells. At
the time of delivery, larger amounts of fetal umbilical-cord blood enter the
mother’s circulation. These fetal red blood cells activate Rh-specific B cells,
resulting in production of Rh-specific plasma cells and memory B cells in the
mother.
Activation of the memory
cells in a subsequent pregnancy results in the formation of IgG anti-Rh antibodies,
which cross the placenta and damage the fetal red blood cells. Mild to severe
anemia can develop in the fetus and conversion of hemoglobin to bilirubin cause
brain damage with fatal consequences.
Hemolytic disease of the
newborn can be prevented by administering antibodies against the Rh antigen to
the mother within 24–48 h after the first delivery. These antibodies, called
Rhogam, bind to any fetal red blood cells that enter the mother’s circulation
at the time of delivery and facilitate their clearance before B-cell activation
and ensuing memory-cell production can take place.
Drug-Induced
Hemolytic Anemia
Certain antibiotics (e.g., penicillin, cephalosporin,
and streptomycin) can adsorb nonspecifically to proteins on RBC membranes,
forming a complex similar to a hapten-carrier complex. In some patients, such
drug-protein complexes induce formation of antibodies, which then bind to the adsorbed
drug on red blood cells, inducing complement mediated lysis and thus
progressive anemia. When the drug is withdrawn, the hemolytic anemia
disappears.
Immune
Complex–Mediated (Type III) Hypersensitivity
The reaction of
antibody with antigen generates immune complexes and these complexes are
cleared by phagocytic cells.
Type III
hypersensitive reactions develop when immune complexes activate the complement
system and the C3a, C4a, and C5a complement products cause localized mast-cell
degranulation and consequent increase in local vascular permeability. C3a, C5a,
and C5b67 are chemotactic factors for neutrophils and attract neutrophils to
the complex deposition site and the tissue is then injured due to granular
release from the neutrophil.
Generally, complex
deposition is observed on blood-vessel walls, in the synovial membrane of
joints, on the glomerular basement membrane of the kidney, and on the choroid plexus
of the brain. Larger immune complexes are
deposited on the basement membrane of blood vessel walls or kidney glomeruli,
whereas smaller complexes may pass through the basement membrane and be
deposited in the subepithelium.
·
Much
of the tissue damage is due to release of lytic enzymes by neutrophils as they
attempt to phagocytose immune complexes. During the process, the C3b complement
component acts as an opsonin and coat immune complexes. A neutrophil binds to a C3b-coated immune
complex and since the complex is deposited on the basement membrane surface,
phagocytosis is impeded, and the lytic enzymes are released during the
unsuccessful attempts.
·
The membrane-attack mechanism of the complement system
also contribute to the destruction of tissue.
·
The
activation of complement induce aggregation of platelets, and the resulting
release of clotting factors lead to microthrombi formation.
When the complexes
are deposited in tissue very near the site of antigen entry, a localized
reaction develops. When the complexes
are formed in the blood, a generalized reaction develop.
Localized Type III Hypersensitivity
This is known as
Arthus reaction. When the antigen enter
for the second time, at the site of antigen entry, localized tissue and
vascular damage results in accumulation of fluid (edema) and red blood cells
(erythema) at the site. The severity of
the reaction can vary from mild swelling and redness to tissue necrosis.
After an insect
bite, a sensitive individual may have a rapid, localized type I reaction at the
site. Some 4–8 h later, a typical Arthus
reaction develops at the site, with pronounced erythema and edema.
Intrapulmonary
Arthus-type reactions induced by bacterial spores, fungi, or dried fecal
proteins can also cause pneumonitis or alveolitis. These reactions are known as,
“farmer’s lung” after inhalation of thermophilic actinomycetes from moldy hay, and
“pigeon fancier’s disease” resulting from inhalation of dried pigeon feces.
Generalized Type III Hypersensitivity
This is a systemic
form and occurs 7-12 days after injection of foreign serum and is known as
serum sickness. Serum sickness differs
from other hypersensitivities in that a single injection can serve both as
sensitizing dose and shocking dose.
When large amounts
of antigen enter the bloodstream and bind to antibody, circulating immune
complexes can form and they can cause tissue- damaging type III reactions at
various sites.
Historically, generalized
type III reactions were often observed after the administration of antitoxins
containing foreign serum, such as horse antitetanus or antidiphtheria serum. In
such cases, the recipient develops antibodies specific for the foreign serum
protein antigens which then form circulating immune complexes with the antigens. Within days or weeks after exposure,
individual begins to manifest a combination of symptoms that are called serum
sickness. These symptoms include fever, weakness, generalized vasculitis
(rashes) with edema and erythema, lymphadenopathy, arthritis, and sometimes
glomerulonephritis, endocarditis, vasculitis, abdominal pain, nausea, vomiting,
etc.
The precise
manifestations of serum sickness depend on the quantity of immune complexes
formed as well as the size of the complexes and the site of their deposition.
Formation of
circulating immune complexes contributes to the pathogenesis of a number of
conditions other than serum sickness. These include the following:
Autoimmune
Diseases
Systemic
lupus erythematosus, Rheumatoid arthritis, Goodpasture’s syndrome
Drug Reactions
Allergies
to penicillin and sulfonamides
Infectious
Diseases
Poststreptococcal
glomerulonephritis, Meningitis, Hepatitis, Mononucleosis, Malaria, Trypanosomiasis
Type IV or
Delayed-Type Hypersensitivity (DTH)
When some subpopulations
of activated TH cells encounter certain types of antigens, they secrete
cytokines that induce a localized inflammatory reaction called delayed-type
hypersensitivity (DTH). The hallmarks of a type IV reaction are the delay in
time required for the reaction to develop and the recruitment of macrophages.
·
The
development of the DTH response begins with an initial sensitization phase of
1–2 weeks after primary contact with an antigen. During this period, TH cells
are activated by antigen presented together with the class II MHC molecule on
an appropriate antigen presenting cell including Langerhans cells and
macrophages.
·
A
subsequent exposure to the antigen induces the effector phase of the DTH
response. In the effector phase, TH1 cells secrete a variety of cytokines that
recruit and activate macrophages and other nonspecific inflammatory cells.
·
A
DTH response generally peaks 48–72 h after second contact. The delayed onset of
this response is due to the time required for the cytokines to induce localized
influxes of macrophages and their activation.
·
Macrophages
are the principal effector cells of the DTH response. Cytokines released by TH1
cells induce blood monocytes to migrate from the blood into the surrounding
tissues. During this process the monocytes differentiate into activated
macrophages.
·
The
heightened phagocytic activity and the buildup of lytic enzymes from
macrophages cause nonspecific
destruction of cells. This intense inflammatory response develops into a
visible granulomatous reaction.
·
A
granuloma develops when macrophages adhere closely to one another and fuse to
form epitheloid cells and then multinucleated giant cells. These giant cells
displace the normal tissue cells, forming palpable nodules, and release high
concentrations of lytic enzymes, which destroy surrounding tissue and blood
vessels and lead to extensive tissue necrosis.
The response to Mycobacterium tuberculosis is an example
for the double-edged nature of the DTH response. Immunity to this intracellular
bacterium involves a DTH response in which activated macrophages wall off the organism
in the lung and contain it within a granuloma-type lesion called a
tubercle. However, the concentrated
release of lytic enzymes from the activated macrophages within tubercles
damages lung tissue.
Tuberculin type - The presence of a DTH reaction can
be measured experimentally by injecting small dose of tuberculin antigen
intradermally into an animal and observing whether a characteristic skin lesion
develops at the injection site. Development
of a red, slightly swollen, firm lesion at the site between 48 and 72 h later
indicates previous exposure. The skin lesion results from intense infiltration
of cells to the site of injection during a DTH reaction; 80%–90% of these cells
are macrophages. Similar
hypersensitivity is observed against fungi, viruses, parasites, allograft,
etc.
Cutaneous basophil hypersensitivity – this resembles tuberculin
reaction, but it is a delayed type hypersensitivity. Here the intradermal injection site will be
infiltered with basophils.
Contact Dermatitis – contact with a allergen in a
sensitized individual leads to contact dermatitis. The allergens include formaldehyde,
trinitrophenol, nickel, turpentine, and active agents in various cosmetics and
hair dyes, poison oak, poison ivy, etc. Most of these substances are small
molecules that can complex with skin proteins. This complex is internalized by
antigen-presenting cells in the skin (e.g., Langerhans cells), then processed
and presented together with class II MHC molecules, causing activation of
sensitized TH1 cells. The immune reaction results in formation of macules and
papules that develops to vesicles that break down resulting in raw weeping
areas.
In the reaction to
poison oak, a pentadecacatechol compound from the leaves of the plant forms a
complex with skin proteins. When TH
cells react with this compound displayed by local antigen-presenting cells,
they differentiate into sensitized TH1 cells. A subsequent exposure to
pentadecacatechol will elicit activation of TH1 cells and induce cytokine
production. Approximately 48–72 h after the second exposure, the secreted
cytokines cause macrophages to accumulate at the site. Activation of these
macrophages and release of lytic enzymes result in the redness and pustules that
characterize a reaction to poison oak.
Shwartzman reaction – this is not an
immune reaction. But resembles
hypersensitivity.
If Salmonella typhi culture filterate is
injected intradermally followed 24 hours later by intravenous injection of same
or any other endotoxin, lesion develops at the intradermal site. There is no specificity in the reaction. If both injections are intravenous, then the
animal dies 12-24 hours after the second dose.
The initial or
preparatory dose causes accumulation of leucocytes that damage capillary
walls. The second dose or provocative
dose cause intravascular clotting due to necrosis of vessel walls and
hemorrhage.