Allergy/ Overview

David E. Sloane, MD, EdM

Attending Physician Department of Internal Medicine Division of Allergy and Immunology Brigham and Women’s Hospital Dana Farber Cancer Institute West Roxbury VA Medical Center

Instructor in Medicine Harvard Medical School

No Disclosures David Sloane, MD, EdM

• Instructor in Medicine, Harvard Medical School • Attending in Allergy and Immunology, Brigham and Women’s Hospital • Consultant in Allergy and Immunology for the Rapid Drug Desensitization service at Dana Farber Cancer Institute • Medical Director of Allergy and Clinical Immunology, West Roxbury VA Medical Center DISCLOSURES Discussion of an unapproved/ investigational use of a commercial product/ device: None

Disclosed commercial relationship(s): None Allergy/Immunology

• Immunology background • Allergic Rhino-conjunctivitis • Allergic • Angioedema and Urticaria • Anaphylaxis • Drug Hypersensitivity and Desensitization • Food Allergy and Oral Immunotherapy • Mastocytosis and Mast Cell Activation Syndromes • Common Variable Immunodeficiency The Immune System as a Matter Processing Network Where it is from: Inside Outside

How bad it is: Safe

Dangerous The Mast Cell + IgE Paradigm

Slide courtesy of Dr. Tse Wen Chang Allergic Rhino-Conjunctivitis

• Symptoms: • Signs: • Sneezing • Clear bilateral nasal • Nasal congestion discharge • Runny nose • Post nasal discharge • Nasal itching • pale and edematous turbinate mucosa • Ocular itching, • conjunctival injection • Increased tearing • clear to white ocular • Palatal itching, discharge • Ear blockage • hyper-lacrimation • Ear itching Allergic Rhino-Conjunctivitis

• Importance: • Seasonal Allergens: • Prevalence approximately 15-20% • pollens from trees, grass, of the population weeds • Relationship between AR and • Perennial Allergens: asthma • dust mites, cat/dog dander • In one study, 28% of patients with asthma had AR and 17% of • Diagnosis: patients with AR had asthma • prick/epicutaneous and intradermal skin test • DDx: • Infectious rhinitis (PMN’s vs. Eos in smear), cholinergic rhinitis Allergic Rhino-Conjunctivitis: Treatment

• Environmental Control/Allergen Avoidance • Medications: • Intranasal Steroids = fluticasone, budesonide, triamcinolone, et al. • Intranasal Antihistamine = azelastine • Non-sedating antihistamines = Loratidine, Desloratidine, Fexofenadine, Cetirizine, Levocetirizine Decongestants = α-adrenergic agonists • Mast cell Stabilizers = Cromolyn • Ocular Antihistamines = Olpatidine, Ketotifen • Intranasal Anticholinergics = Ipratropium Immunotherapy for Allergic Rhino-Conjunctivitis Immunotherapy: Allergen Specific “Vaccine” beneficial in randomized trials for pollens, Alternaria, dust mites, and cat dander allergens (Durham NEJM 1999, 2008; Ross RN 2000) high affinity and specificity pollen-biding IgG4 with IgE blocking ability (James LK J All Clin Immunol 2012) generation of Th0 and Treg responses.

Sublingual Immunotherapy tablets for grass, ragweed, and dust mites Asthma • A syndrome, not single disease – Allergic – Exercise induced – Cough variant • Endotypes or subtypes may co-occur • Newer biologic therapies – = anti-IgE (for allergic) – Meoplizumab, Reslizumab = anti-IL-5 (for eosinophilic) – Benralizumab = anti-IL-5Ra chain (for eosinophilic) – Dupilumab = anti IL-4/13 receptor alpha chain – (Lebrikizumab = anti-IL-13 in patients with elevated serum periostin concentrations) Asthma and Aspirin Sensitivity AERD = Aspirin Exacerbated Respiratory Disease (Samter’s triad/tetrad): • Asthma (often steroid dependent) • Nasal polyposis (loss of smell) • Aspirin and NSAIDS intolerance (decreased FEV1>12% upon exposure) • Chronic rhino-sinusitis

Pathobiology: NOT IgE mediated, rather insufficient concentrations of PGE2

• LT overproduction because PGE2 inhibition of 5-LO pathway (and thus LT production) is insufficient; COX-1 inhibition further decreases PGE2 generation. LT’s such as LTC4 produced by mast cells and eos;

• In some patients, eos overexpress LTC4 synthase • Platelets aggregate with eos, pmns, monos; Management: - Leukotriene blockade (5-LO, LTR antagonists) - Surgery (polyps, sinuses) - Aspirin desensitization • Anti-IL-4/13 receptor alpha-chain (Dupilumab) Allergic Bronchopulmonary Aspergillosis

Criteria: Asthma Pulmonary infiltrates/central bronchiectasis Elevated total serum IgE >1000 ng/ml (note units!) Peripheral eosinophilia Positive skin test and RAST (IgE) to Aspergillus Precipitins against Aspergillus Treatment: Oral steroids, consider anti-fungals Associations: cystic fibrosis and HLA DR2 . Urticaria and Angioedema

• Urticaria Acute < 6 weeks , Chronic > 6 weeks • Urticaria : pruritic geographic macular lesions with central clearing of short duration (<24h) and variable size • Angioedema : swelling ± pain, associated to urticaria in 40-50% of cases Acute Urticaria

A cause is found in 20% of cases:

• Drugs: aspirin and NSAIDS, Abx • Foods: egg, milk, peanut and nuts, seafood, shellfish • Infections (viral/bacterial: HBV and HCV) • Contact Allergies (animal dander and saliva; pollen from trees, grass, weeds) Chronic Urticaria (a cause is found in < 10% of cases) Physical Urticarias •Symptomatic Dermatographism •Pressure (delayed) •Exercise Induced •Cold, solar, aquagenic, vibratory Autoimmune : IgG Anti-IgE Receptor (35-40%) or Anti-IgE (5-10%) autologous serum skin test positive (CIU index) Hashimoto’s Thyroiditis elevated anti-peroxidase (TPO) and anti-microsomal , Graves disease Connective tissue disorders, Malignancy SLE, leukocytoclastic vasculitis, multiple myeloma, plasmocytoma, cryoglobulinemias Urticaria: Treatment

• H1 antagonists nonsedating→sedating • H2 antagonists famotidine, cimetidine • Doxepin (combined H1 and H2 antagonist) • Leukotriene antagonists Montelukast • Corticosteroids (alternate day ≤ 20mg) • Others: Colchicine, Dapsone, Hydroxychloroquine, Sulfasalazine, Cyclosporine, Plasmapheresis, IVIG, Levothyroxine Omalizumab Anti-IgE (Chronic idiopathic urticaria/Cold- induced urticaria, Boyce 2007 JACI, Kaplan 2009, Maurer 2013 NEJM), with on the way (Maurer 2019 NEJM) Angioedema (non mast cell mediated)

Hereditary • C1inh deficiency : Type I decreased level due to point/frame shift mutations of the SERPIN gene • C1inh dysfuntion: Type II normal serum concentration but non-functional protein C1Inh/C1Q Normal Type III: Factor XII mutation Females, familial, menstrual periods (estrogen/progestrogen) Acquired • Inhibitor(s) of C1inh : auto-Abs B cell lymphomas Excessive consumption (malignancies, connective tissue diseases SLE, HIV ) Hereditary and Acquired Angioedema

• Symptoms episodic swelling of the head, face, neck, extremities and GI (abdominal pain, nausea and vomiting responsive to fluids and narcotics) • Diagnosis C4 C1INH C1q C2 Hereditary ↓ nl/↓ nl +/- Acquired ↓ nl/↓ ↓ +/- • Therapy : Purified C1inh: Cinryze, Berinert Kallikrein inhibitor (ecallantide = Kalbitor; lanadelumab flyo = Takhyzyro) Bradykinin receptor 2 antagonist (Icatabant; Cicardi et al. 2010, NEJM) Androgenic steroids (danazol, stanazolol) Epsilon amino-caproic acid, tranexamic acid, Fresh Frozen Plasma Anaphylaxis Clinical Manifestations

1. Acute onset of an illness (min to hrs) with involvement of the skin and/or mucosae (, pruritus, flushing) and at least one of the following 1. Respiratory compromise (dyspnea, wheeze, bronchospasm, stridor, reduced PEF, hypoxemia) 2. Reduced BP or symptoms (syncope) 2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (min to hrs) 1. Skin and/or mucosae 2. Respiratory compromise 3. Reduced BP 4. GI symptoms (colic, diarrhea) 3. Reduced BP after exposure to a known allergen for that patient (min to hrs)

Table I from Sampson et al JACI 2006 117:391-397. Frequency of Manifestations

• Cutaneous 90% – Urticaria and Angioedema 85-90% – Flushing 45-55% – Pruritus 2-5% • Respiratory 40-60% – Dyspnea and Wheeze 45-50% – Laryngeal Angioedema 50-60% – Rhinitis 25-20% • Dizziness, syncope, hypotension 30-35% • Abdominal (n, v, colic, diarrhea) 25-30% • Misc (HA 5-8%, SSCP 4-6%, Sz 1-2%)

Liberman P et al JACI 2005;115(3):S483-S523 Anaphylaxis: Triggers and Diagnosis

Foods: Peanuts, Tree Nuts, Seafood, Acute : Eggs, Milk, Sesame Tryptase : total >11ng/ml, mature > Allergen Extracts, Vaccines, antisera 1 ng/ml Hymenoptera Venom: Bees, Wasps, N-Methyl Histamine in 24h urine Yellow Jackets, Hornets, Fire Ants collection Hormones (Progesterone Autoimmune Prostaglandin D2 metabolites (PG Dermatitis), Enzymes 11-b-F2-a) in urine Monoclonal Abs :anti-TNFa, anti-CD20 Retrospective : Chemotherapy: platins, taxenes -Specific IgE Beta lactams, ASA and other NSAIDS Specific IgE in serum (in vitro) (COX1>COX2), vancomycin (red person Skin Testing (in vivo) syndrome), Radio Contrast Media, Basophil activation FACS: opiates (direct mast cell activators) CD69/CD203 Anesthetics: Curare Derivatives Dialysis membranes Management of Anaphylaxis Epinephrine IM (not SC!) 0.3-0.5cc recumbent position, quadriceps Observation for a minimum of 6 Hours Obtain a serum Tryptase Oxygen Anti-histamines H1 and H2, Steroids: single dose (IV or oral) do they decrease the risk of a late phase reaction? (Not so much = JACI In Pract. 2017, 5(5), pg 1194-1205) Delayed, protracted anaphylaxis may occur 6 to 24 hours; late phase or secondary reaction requires repeat Epi in 16-36% of patients. If ß Blockade: Glucagon 5 - 15 mg/min IV (after trying epi) ACE inhibitors are implicated in severe/refractory Education Allergy evaluation Auto injectable epinephrine Anaphylaxis to COVID-19 Vaccines

• Rates for mRNA vaccines vs. adenovirus viral vector vaccines • Is it polyethylene glycol (PEG)? • Screening we do: – Previous anaphylaxis? – Sensitivity to PEG (colonoscopy)? – Previous vaccine reactions? • Serum Tryptase • Skin testing to PEG • Recommendations: – Premedications: antihistamines – Observation time 30 min not 15 min Sellaturay et al. Clin Exp Aller 2021;51:861-863 Drug Hypersensitivity

Common Drugs: PCN and related Abx: IgE-mediated - Cross reactivity with cephalosporins (10 % first generation, 1-2% 3th -4th generation) aztreonam is non- cross-reactive (except ceftazidime) ASA and NSAID’s: COX-1/COX-2 blockade, universal cross-reactivity ACE-I (Kininase II): Bradykinin Mediated angioedema Sulfonamides: no cross-reactivity with non-antibiotic medications (NEJM 2007) Diagnosis: • Skin test (Pre-Pen for PCN: FDA 2010) • Challenge Management Avoidance, MediAlert Bracelets Desensitization (to Antibiotics, Aspirin, Chemotherapeutics, Monoclonal Antibodies) Non-IgE Hypersensitivity Reactions to Medications • DRESS syndrome: eosinophlia, rash, systemic symptoms, LAN, LFT elevations anti-convulsants: cross-reactivity is high (HLA-B* 1502) phenytoin, phenobarbital, carbamazepine role of HHV6-7 reactivation • Delayed Maculopapular Rashes: Erythema Multiforme, Steven’s Johnson Syndrome, Toxic Epidermal Necrolysis sufonamides, beta-lactams Abacavir: fever, rash, systemic involvement (HLA-B*5701) Quinolones: universal cross-reactivity Systemic Mastocytosis: Diagnostic Criteria

Major Criteria : • Classification of Disease multifocal infiltrates of associated with Mast Cell 15 or more mast cells in Activation (Akin, Metcalf, Valent bone marrow and/or JACI 2010) extracutaneous organs • Non-Clonal Mast Cell Activation Minor Criteria: Syndrome (MCAS: Hamilton et al 1. > 25% spindle shaped JACI 2011) mast cells 2. c-kit mutations (codon D816V) 3. aberrant expression of CD2 and CD25 4. Tryptase >20 ng/ml Common Variable Immunodeficiency

• Sinusitis (>2) , Pneumonia (>2), UTI (>3-4), Deep seated infections • Low IgG, IgA, IgM (– 2 SD) • Poor response to vaccines : Pneumovax, H.Influenza, Hepatitis, Strep pneumo (Prevnar-13) • Gammaglobulin replacement: IVIG or SQ 400mg/kg q 3-4 weeks (TACI defect, association with autoimmune diseases and lymphoma) Board Question 1

An 18 yo patient presents with an episode of angiodema of face and abdominal pain. He has no itching or associated hives. Which test would be most appropriate? a) Serum tryptase b) Serum C4 c) CT abdomen d) CBC Explanation: Correct answer = B. The clinical presentation of angioedema without associated pruritus, in conjunction with this family history, suggests hereditary angioedema (HAE). The best single test for HAE is the serum C4 concentration. Board Question 2 A 50 yo male with CAD presents to the ER with hypotension , tachycardia, SOB and generalized hives after a wasp sting. The most important action in the acute setting is: a) Perform skin test to Hymenoptera venom b) Obtain a serum tryptase c) Administer epinephrine d) Administer venom immunotherapy Explanation: Correct answer = C. While all these measures are appropriate, the most pressing issue acutely is patient safety. Timely administration of epinephrine is life saving, while a delay in administration is the most important risk factor for death from anaphylaxis. References

• Castells et al JACI 2008, 2012 Desensitizations • Boyce et al JACI 2009 • Omalizumab use in Urticaria, Maurer 2013 • Escribano et all 2009 Mastocytosis • Durham et al NEJM 2008 Immunotherapy for AR • Cunningham Rundles 2007 Common Variable Immunodeficiency • Simons FE 2011 : World Allergy Organization anaphylaxis guidelines: J Allergy Clin Immunol • LEAP study NEJM 2015 • Mast Cell Anaphylactoid Receptor Nature 2015