Week 33- Skin and Allergy Flashcards
What is an allergic reaction?
It is a hypersensitivity reaction to “harmless” environmental factors (allergens = antigens)
How common is allergic disease within the Australian population?
20% has allergic disease
What are common reactions to allergic disease?
Itch
Runny nose
Rashes
Sneezing
What is a severe reaction during allergic disease?
Anaphylaxis
What are examples of allergen categories?
Food allergens (wheat, dairy products) Inhaled allergens (house dust-mite, pollens) Medications (penicillin)
What determines the response of an allergy?
Determined by the route of exposure and the immune response activated
What are some sites of allergen exposure?
Skin
Injection
Ingestion
Inhalation
What is the mechanism of allergic immune activation?
- Allergen exposure to epithelium causes cytokine release (IL-25, IL-33, TSLP)
- Activation of ILC2s
- Activation of local antigen presenting cells (APCs)
- T cell activation –> TH2 cells generated in presence of IL-4
- B-cell activation –> IgE produced in presence of IL-4/TH2
- Mast cell activation by IgE –> release histamine
- Eosinophil activation by IL-5
What is the early phase of allergic response?
In pre-sensitised individuals:
Early response –> Mast cell activation and release of granular molecules
What is the late-phase response in allergic response?
Activation of APC and TH2 cells
T-cell proliferation
Activation of eosinophils
What does a Type I hypersensitivity reaction require?
Prior exposure and immune sensitisation –> to produce IgE antibody
What is the time of appearance and immune mechanism behind Type I hypersensitivity?
Time = 2-30minutes (very fast) (requires previous exposure)
Allergen binds to IgE antibodies on mast cell surfaces (acute inflammatory response) –> mast cells degranulate and release immune mediators (histamine etc)
E.G = allergic asthma, allergic rhinitis, eczema
What is the time of appearance and immune mechanism behind Type II hypersensitivity?
Time = 5 - 8 hours Mechanism = Humeral IgG binding to cellular antigens (allergen) leads to damage of self cells --> Antibody and complement (cytotoxic result) E.G = some drug allergies eg penicillin
What is the time of appearance and immune mechanism behind Type III hypersensitivity?
Time = 2-8 hours Mechanism = Humeral IgG binds to blood-borne allergen (forms insoluble complex)Complement pathways lead to tissue damage in sites of complex deposition.
What is the time of appearance and the immune mechanism behind type IV hypersensitivity?
Time = 24-72 hours (delayed response)
Mechanism = Immune cell mediated response (T cell) (can be granulonatous) –> no antibody involvement
E.G –> response to large insoluble antigens, contact dermatitis, chronic asthma, graft rejection
Does drug allergy relate to the toxicity or side effects of a drug?
No, it cannot be predicted pharmacologically
No link between dose and response
What are some common symptoms of drug allergies?
- Skin rash/hives
- Itching
- Wheezing/ breathing problems
- Muscle and joint pain
- Swelling/angioedema –> facial swelling typically
- Anaphylaxis
What is anaphylaxis?
Severe, life threatening allergic reaction
What are common drugs that can trigger an allergic reaction?
- Chemotherapy
- Antibiotics containing sulphonamides
- Aspirin, ibuprofen and other NSAIDS
- Anticonvulsants
- Penicillin and related antibiotics
How does the direct presentation mechanism of drug allergy work?
- Drugs are too small to activate the adaptive immune system
- Drugs first can interact with the MHC-peptide complexes on the antigen presenting cells —> interaction can change the normal non reacting self peptides to a reactive structure
- T cells screen for their TCR recognition
- TCR binds to the altered MHC region and activates a T cell response against the drug
What is the Hapten mechanism of drug allergy?
- Drug molecules or metabolites can act as Haptens
- Happens are drugs that irreversibly binds to carrier proteins which are then displayed in the MHC (this mechanism happens in penicillin)
- Adaptive immune response is then initiated through T cell recognition of the drug protein complex
What is the difference between a Hapten and a pro-Hapten?
- Hapten is a drug that irreversibly binds to a carrier protein
- Pro-Haptens are inert drugs that are processed into reactive metabolites which can act as Haptens.
What hypersensitivity reactions can be caused by drug allergy?
All of them
How is a drug allergy diagnosed?
- Skin test
2. Drug challenge –> under carefully controlled conditions
How are drug allergies treated?
- Avoidance where possible
- Antihistamine treatment
- Bronco dilators, adrenaline and oxygen to help deal with respiratory distress
- Desensitisation if possible
What are the three types of adverse drug reactions for eg penicillin? For: common infrequent True anaphylaxis
- Common adverse drug reactions —> eg diarrhoea, nausea, rash
- Infrequent adverse effects —> eg fever, vomiting, erythema dermatitis, angiodema (swelling), seizures.
- True anaphylaxis (drug allergy) —> eg hypotension, angiodema, broncospasm.
What are cytokines?
Signalling molecules that orchestrate inflammatory response and ramp up the immune systems response to pathogens.
What are some ways cytokines ramp up the immune response?
- Activates cells of the immune system
- Acts on blood vessels to allow proteins, fluid and cellular blood elements to leave the circulation and get to the affected tissue
What happens to cytokines numbers when the amount of pathogen decreases?
They decrease as the level of secreted cytokines reduces —> the response subsides.
What happens when there is no subsiding of cytokines?
Cytokines storm —> uncontrolled inflammation within tissue and key organs
What are some key cytokines in allergic response?
IL-4 –> released by TH2 to stimulate clonal expansion
IL-4 and IL13 –> drive B-cell antibody production
In asthma –> IL3,4,9,13 important
What are some certain infection types that increase the risk of cytokine storm?
- systemic infection
- septic shock
- SARS
- bird flu (H5N1)
- Hanta virus infection
- Ebola
How is atopic (allergenic) asthma induced?
Allergen induced activation of submucosal mast cells leading to TH2 mediated chronic inflammation
After initial exposure is the presence of the allergen required to give an effect in chronic atopic asthma?
Not necessarily as the response may be perpetuated even in the absence of the allergen and can be triggered by other factors as well.
What are the 4 clinical levels of asthma and what is the difference in each?
Step 1 —> less than once a week and brief symptoms
Step 2 —> more than once a week but less than once every day
Step 3 —> daily FEV1 between 80 and 60% predicted
Step 4 —>daily, loss of ability for physical activity FEV1 less than 60% predicted
Are x-rays useful in people with asthma?
Not really in 75% of cases x-rays appear normal
What are some X-ray features that may be present in asthmatics?
- Pulmonary hyperinflation
- Bronchial wall thickening
- Pulmonary wall oedema
What are some factors that contribute to virus induced wheezing illness?
- Genetics —> history of asthma or atopy, poor antiviral immunity, risk genes and SNP
- Preexisting airway inflammation —> TH2 polarised inflammation, airway damage/remodelling
- Virus infection —> Rhinovirus A and C, Respiratory syncytial virus
- Treatment —> corticosteroid use, monoclonal antibody use for virus treatment
- Environment —> exposure to allergens —> smoke, tobacco, pollen
- Microbiome —> loss of diversity
What are some clinical features of Atopic dermatitis?
Onset is 3-6months of age
May appear in childhood or adolescence but normally clears by the age of 2
Persistence into later life is normally frequent cycles of remission and exacerbation.
What are the signs of atopic dermatitis?
Dry and scaly skin
Active lesions intensely pruritic (itchy)
Chronic lesions thickened and lichenified
Commonly accompanied by atopic respiratory allergy
Symptoms commonly independent of allergen exposure
Very high IgE possible
What is the pathology of atopic dermatitis?
Mononuclear cell infiltration and CD4 cells
What is the common bacteria or virus for atopic dermatitis?
Rarely viral
Commonly staph aureus Or strep pyrogenes
How common are auto immune diseases and which gender is impacted more?
5-10% of the population with 2/3 of cases being in females
Is B or T cell tolerance more important to avoid autoimmunity?
T-cell tolerance
What are some thymic tolerances to reduce autoimmunity?
- +/- selection leading to deletion
2. Weakly self reacting lymphocytes rendered unresponsive (anergy)
What are some peripheral tolerances to reduce autoimmunity?
- Ignorance (self antigens are invisible)
- Separation of autoreactive T cells and Ag
- Anergy and lack of self stimulation
- Suppression induced by regulatory T reg cells
What is anergy?
absence of the normal immune response to a particular antigen or allergen.
What is the causative agent in Hep B?
DNA virus
What is poly arthritis nodosa (PAN)?
It is a necrotising vasculitis of medium sized muscular arteries.
How does PAN relate to Hep B?
It is mostly observed in patients with Hepatitis B
It is caused by circulating immune complexes
Immunoglobulin and complement deposit on the walls of the involved vessels and cause vascular infiltration of neutrophils and mononuclear cells.
How does poly arthritis nodosa normally present?
Myalgia --> muscle pain Arthralgia --> joint pain Fever Weight loss Multisystem disorders --> reflective multiorgan involvement
How is PAN treated?
Removal of hepatitis B antigens (antiviral therapy)
What is the causative agent of Hepatitis C?
RNA virus
What is cryoglobinaemic vasculitis?
Palpable purpura (rash of purple spots due to small blood vessels leaking blood into skin) over lower extremities, arthralgia (joint pain) and neuropathy.
How does cryoglobinaemic vasculitis involve Hep C?
Molecular mimicry HCV E2 protein is antigenically similar to human Igs and this stimulates anti Ig antibodies that can in turn stimulate the complement cascade, forming immune complex that deposit in vessels.
What are the Cryoglobin molecules formed by?
The Cryoglobulin (CG) molecules formed are of a mixture of polyclonal IgG and monoclonal Igs usually of IgM type CG deposit in blood vessels
What are the two infection types in HIV?
HIV1 and HIV2
What are the key differences between HIV1 and HIV2?
HIV 1 —> worldwide, higher mother-offspring infection rate, 7-10years till AIDS
HIV 2 —> west Africa, lower mother-offspring infection rate, 10-25 years till AIDS
How does HIV infection start and progress?
- Primary infection asymptomatic/ influenza like
- Acute viremia is followed by antibody production (seroconversion)
- Period of clinical latency (2-15 years)
- HIV virus is an envelope RNA virus (retrovirus) enters cells by means of gp120 binding to CD4 (on T cells. DC and Mf) and co-receptors CCR5 (DC, Mf) or CXCR4 (T cells)
- Antibodies and CD8 cytotoxic responses directed against the HIV remain high during the asymptomatic phase
- Following progressive loss of CD4 T cells there is increase in HIV number and decrease in antibody and CTL responses leading to opportunistic infections and malignancies(due to immunodeficiency)
- Causes immune dysregulation –hypergammaglobulinaemia and autoimmune diseases
What are some HIV driven autoimmune complications?
- HIV associated Immune Thrombocytopenic Purpura (ITP)
- In 5-30% of pts with HIV and may be the 1 st manifestation
- Treatment strategies: steroids, IV immunoglobulins, plasmapheresis, interferon-alpha therapy, splenectomy with retroviral therapy
- Autoimmune Haemolytic Anemia in HIV (AHA)
- AHA is very rare in pts with HIV Usually occurs in very advanced stages
- Direct antiglobulin test can sometimes give false positive results
What are the two mechanisms by which HIV drives Thrombocytopenic purpura (ITP)?
Mechanism 1: Peripheral platelet destruction with anti-GpIIIa antibodies & activation of immune complexes
Mechanism II: defect in platelet production due to infection of megakaryocytes
What is Guillain-Barre Syndrome (GBS)?
An acute inflammatory or post-infective demyelinating polyneuropathy:
- 70% history of respiratory infection of diarrhoea 1-4 weeks pre onset
- Some cases occur following surgery or post immunisation
Symptoms of GBS?
- Weakness in legs
- “Pins and needles” feeling in extremities
- Difficulty with eye or facial movements
- Body aches
- Bowel or bladder issues
- Rapid heart rate
- Low/high BP
- Difficulty breathing
What is one of the major exposures that can lead to GBS Guillain barre syndrome?
Approximately 25-50% of patients with GBS have been exposed to Campylobacter jejuni
What virus’ have also been implicated GBS?
Viruses such as Epstein-virus, HIV, cytomegalovirus (Zika and chikungunya)
What is the immunological mechanism that leads to infection causing GBS?
Molecular mimicry
Why are nerve cells demyelinated in GBS?
- Antibody-mediated effector pathways, including complement activation, cause glial or axonal membrane injury with consequent conduction failure
- Acute inflammatory demyelinating polyneuropathy (demyelinating): molecular mimicry between glycans in LPS generating antibodies that bind to GM1 and GD1a gangliosides –leading to nerve conduction blockade
What is GAS?
Group A streptococcus pyogenes
What are some examples of superficial and deep tissue infections caused by GAS?
- Impetigo —> superficial —> minor trauma predisposes —> observed in children in hot an humid conditions —> superficial, intraepidermal, unilocular, vesicopustule
- Erysipelas —> superficial cellulitis —> occurs in areas of preexisting lymphatic obstruction or oedema —> painful lesions with bright red oedematous appearance
- Cellulitis and Fasciitis —> involve deeper structures —> requires immediate therapy/ surgery
What is Scarlett fever caused by?
Streptococcal pyrogenic Exotoxins
What are the symptoms of Scarlett fever?
Diffuse erythematous rash, blanching with pressure (7-10days)
Swollen tongue (strawberry)
Usually associated with GAS pharyngitis or tonsillitis
How does toxic shock syndrome cause death?
Cytokines storm and multi organ failure