Presentation on theme: "It’s Nothing to Sneeze At – An Update in Allergy"— Presentation transcript:
1It’s Nothing to Sneeze At – An Update in Allergy Virginia Chapter ACP Annual Meeting2013Scott P. ComminsDivision of Allergy and Clinical ImmunologyCetuximab:Marketed under ErbituxChimeric monoclonal IgG1 antibody against the epidermal growth factor receptor (EGFR)Used primarily in treatment of metastatic colorectal cancer and head and neck cancerDiscovered by ImClone, distributed by BMS, and costs ~$30K per 8 wks of txDisproportionate HSR in parts of the South
2Disclosures We are grateful for generous support from the Oakey Food Allergy FundThese studies were carried out with generous support from the NIH-NIAID (K08 AI & R21 AI087985)Disclosure: Up-to-Date card
3How oncologists helped uncover a novel food allergy I. BackgroundHow oncologists helped uncover a novel food allergy
4High incidence of hypersensitivity reactions to cetuximab infusions in mid-Missouri:Association with prior history of atopyR. Owera, A. Gill, S. Haddadin, R. Khozouz and M. C. PerryUniversity of Missouri Columbia, Columbia, MOAbstract, 2008 ASCO Annual Meeting Proceedings, Vol 26, No 15S, 2008:20747UNC clinical trial data for 88 patients,22% had grade 3 to 4 HSRData at that time from 400 patients in EPIC trial:any infusion reaction = 4%, grade 3 to 4 = 0.5%All reactions occurred with the first doseAssessment ToolsTable 1. Common Toxicity Criteria (ver 3.0) of the National Cancer InstituteGrade 1 Transient flushing or rash; Drug fever <100.4°FGrade 2 Rash; urticaria; dyspnea; Drug fever >100.4°F and/or asymptomatic bronchospasmGrade 3 Symptomatic bronchospasm with or without urticaria; parenteral medication(s) indicated; allergy-related edema/anigiodemaGrade 4 AnaphylaxisGrade 5 DeathData from National Cancer Institute Cancer Therapy Evaluation Program.8
5Regarding 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.
6Measurement of IgE ab to Purified Allergens Using Streptavidin Solid Phase“Allergen” of interest (cetuximab)+ BiotinStreptavidin 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.
7IgE Antibodies Binding to Cetuximab in Sera from 76 Case Subjects and 462 ControlsFigure 1. IgE Antibodies Binding to Cetuximab in Serum Samples from 76 Case Subjects and 462 Control Subjects. Results are shown according to whether the treating physician reported a hypersensitivity reaction (HSR) to cetuximab or no HSR reaction. Results are also shown for pretreatment serum samples from control subjects and from subjects who had not received cetuximab. The horizontal lines indicate geometric mean values for the positive results. Values with multiplication signs indicate the number of negative values for each symbol.
8Typical Fc region oligos: core fucosylated biantennary oligos; Cetuximab*Site not glycosylatedN-88N-43N-299Qian J, Liu T,…Zhou Q.Analytical Biochem, 2007.Typical Fc region oligos: core fucosylated biantennary oligos;no alpha-gal or NGNAC’tux is an IgG1, human/mouse chimeric monoclonal ab against the EGFR and is produced in the SP2/0 mammalian (murine myeloma) cell line.Variable domain is glycosylated in approx 20% of human IgGs.21 distinct oligosaccharide structures in c’tux. These oligos differ mainly in degree of sialylation with N-glycolyl neuraminic acid and extent of galactosylation. Of the 21 oligos identified, approx 30% have one or more alpha-1,3 linked galactosyl residues as measured by peak area on TOF-MS spectra. Approx 12% have an NGNA residue and a very small amount of high mannose. Both alpha-gal and NGNA were found only in the Fab portion.Unique among therapeutic mAbs, c’tux has 2 occupied N-linked glycosylation sites on the heavy chain: Asn88 & Asn299 (usually 297)
9Specificity of the IgE Antibodies that Cross-React with Cetuximab Table 3. Specificity of the IgE Antibodies That Cross-React with Cetuximab.Chung CH et al. N Engl J Med 2008;358:
11Specificity of the IgE Antibodies That Cross-React with Cetuximab Chung CH et al. N Engl J Med 2008;358:Specificity of the IgE Antibodies That Cross-React with CetuximabTable 3. Specificity of the IgE Antibodies That Cross-React with Cetuximab.Contained w/n nejm publication is sera results from 6 patients with recurrent anaphylaxis not related to cetuximab.
12Symptoms delayed 3-6 hours after eating mammalian meat JACI, February 200924 patientsVirginia & MissouriSymptoms delayed 3-6 hours after eating mammalian meatPrick skin test often less than 4mmIntradermal skin test positive
13Skin Testing Results: Often <4mm SPT Prick testIntradermalPrick test performed using lancette and intradermal testing with 25 gauge needle in the same patient on a single clinic visit.
15CAP-RAST of Specific IgE Abs in Patients with anti-Gal IgE FoodsInhalantsr =0.81r =0.98Specific IgE Abs (IU/mL)Limit ofdetection▼x1♦x1x3x12x11x12x1x7x1x9♦x4
16Anaphylaxis/ urticaria subjects Alpha-gal specific IgE is associated with anaphylaxis but not asthma (Figure adapted from Commins, Kelly…Platts-Mills, AJRCCM, 2012)0.350.11101001000= Reactions include anaphylaxisAlpha-gal specific IgE (IU/mL)We are exceedingly grateful to allergists and colleagues throughout the US and beyond for finding cases and sending samples. This is truly a team effort and we appreciate the support.Limit ofdetection• x 8• x 13• x 58• x 55Number <0.35Cat in home(N = 96)No cat in home(N = 112)Asthma(N = 68)Clinic controls(N = 59)Anaphylaxis/ urticaria subjects16
18IgE Ab to alpha-gal in kids (n=45) Sex (% male)69%Mean age at presentation(Range)12 (4-17)Geometric Mean of Total IgE (95% CI)147 IU/mL ( IU/mL)Symptoms at presentationAnaphylaxis*44%Gastrointestinal/Oral64%Urticaria92%Angioedema31%Average time to symptoms (Range)4.68 hrs (10 mins to 24 hrs)Tick exposure100%Redness andItching at site ofTick bite87%Tick borne illness#10%Emergency Department (ED) visits46%**Medications administered in EDEpinephrine (19%)Antihistamines (35%)Oral Steroids (19%)Parenteral Steroids (17%)IV Fluids (17%)Hospital Admissions8%
20Delayed 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.
21‘Delayed’ food allergy? Food allergy symptoms classically occur immediately (OAS), up to 2 hours after eatingNo mention of ‘delayed’ symptoms that can be attributed to food in common allergy texts
23Geographical distribution of cetuximab hypersensitivity reactions As reported by O’Neil et al, JCO 2007
24Distribution of known cases of delayed anaphylaxis to mammalian meat Dots = single casesSmaller stars = 5 to 24 cases within a stateLarger stars = states with 25 or more cases
25Geographical Incidence of Rocky Mountain Spotted Fever Data from CDC website for 2009; accessed 2/2011
26Original image: CDC; modified by D. N Original image: CDC; modified by D.N. Gaines for Virginia Department of Health
27Geographical range of Amblyomma americanum population Data from CDC website; accessed 10/2010
28Geographical range of Amblyomma americanum population welcome to the partyData from CDC website; accessed 9/2012
29Bites from the larvae of Amblyomma or Dermacentor ticks and IgE ab to alpha-Gal. Test10/26/065/21/0710/9/0711/6/07*Cetuximab(alphaGal)0.4916.948.3130Total IgE127199350532Multiple 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.Photograph: August 23, 2007.
30Time course of IgE antibodies to alpha-gal and total IgE following episodes of multiple tick bites (red arrows)*Subject #1Fig 1, Panel 1
31Time course of IgE antibodies to alpha-gal and total IgE following episodes of multiple tick bites (red arrows)Subject #2Fig 1, Panel 2
32Time course of IgE antibodies to alpha-gal and total IgE following episodes of multiple tick bites (red arrows)*Subject #3Fig 1, Panel 3
33Total IgE versus IgE to Alpha-Gal Report tick or chigger bite(s)No history obtained for tick bite(s)Specifically deny tick bite(s)1000IgE to Alpha-Gal (IU / mL)R= 0.78P <0.0011001010.1110100100010000Total IgE (IU / mL)
34R amblyommii?Overall infection prevalences were 4.7% for E. chaffeensis (range, 0Ð27%), 3.5% for E. ewingii (range, 0Ð18.6%), 2.5% for B. lonestari (range, 0Ð12.2%), and 41.2% for R. amblyommii (range, 0Ð84.0%).
37-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
38-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
39-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
40Subject 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)
41Approximately 8.25 hours after eating prosciutto Samantha let’s the reaction proceed = they are not afraid. Others are b/c of ana
42Mammalian meat challenge Subject #FC-08: sIgE to alpha-gal = 30.3 IU/mL ; total IgE = 146Before3hrs 45min after eating meat
43Diffuse urticaria appeared at 4hrs 15min after eating meat Subject #FC-08: Mammalian meat challengeDiffuse urticaria appeared at4hrs 15min after eating meat(left arm shown here)
44Mammalian meat challenge Subject #FC-10: sIgE to alpha-gal = 29.1 IU/mL ; total IgE = 2014:25 in4hrs 25min after eating mammalian meat: pruritus followed by urticaria on right flank
45Summary of Mammalian Meat Challenge Results in Subjects with IgE to alpha-galUrticariaTime to symptoms (hrs:min)Treatment requiredTryptase elevationAllergics (n=10)7*/103:50 – 6:007/101**/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
46Gating Strategy Gating Strategy Basophils % of max CD 123 Negative for HLA-DR/lineage 1 FITCCD63 APCCD123 PerCP-Cy5.5BasophilsNegative forLineage Cocktail 1 (CD3, CD14, CD16, CD19,CD20, and CD56)HLA-DRPositive forCD123 (IL-3Ra)FcεRI (IgE receptor)IgECD 123% of max
47-APC -APC FACS Detection of CD63, a marker of Basophil Activation CD63 PerCP-Cy5.5-linked anti-CD123 abAPC-linkedanti-CD63 ab-APCCD63IL-3 Rα-APCHistamineShift to discuss flownuclear membrane
48In vivo Basophil Activation during Mammalian Meat Challenge 1 hr0.72%2 hrs0.54%3 hrs0.87%CD63CD123In vivo Basophil Activation during Mammalian Meat Challenge#FC-024 hrs %5 hrs %6 hrs %
49In vivo Basophil Activation during Mammalian Meat Challenge Baseline1.96%2 hrs3.08%4 hrs1.8%5 hrs8.74%-FC07 - sIgE to alpha-gal = 9.3 IU/mL; Total IgE = 204-Whole blood was collected, fixed & stainedCD63IgE
50Summary of Mammalian Meat Challenge Results in Subjects with or without IgE to alpha-galDelayed anaphylaxisUrticariaTime to symptoms (hrs:min)Treatment requiredAllergics2/107/103:50 – 6:00Controls0/10n/aDelayed anaphylaxisUrticariaTime to symptoms (hrs:min)Treatment requiredBasophil activationAllergics2/106/103:50 – 6:007/108/10
51Why 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
52The delivery of lipid to the circulation takes time (about 4 hours) VLDLIDLLDLHDLFurther conversion=Alpha-gal moiety,as a glycolipidThoracic duct blood stream
53Why 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.
54ConclusionsThe report of delayed reactions occurring 3-6 hours after eating mammalian meat has been confirmed on multiple occasions and at two medical centersIn subjects with IgE to alpha-gal, basophil activation in vivo coincides with the appearance of clinical symptomsLack of basophil activation before 4 hours suggests that there is delayed appearance of the antigen into the bloodstream
55Contributors Uva Hayley James Barrett Lewis Susan Mozzicato Lisa WorkmanAlicia ClarkJudith WoodfolkWalter OliveiraWhitney StevensShama SatinoverLibby KellyPeter HeymannAmy StallingsJulia WisniewskiJosh KennedyAnubha TripathiJonathon PosthumusBarrett LewisMichael LandJoey LaneHeather GütekünstJane PurserGary RakesMadeline DillonTina HatleyLuis MatosSaju EapenDane McBrideJoseph BelleauHarold MoessnerMarty FiserEddie Shields