Epicutaneous sensitization results in IgE-dependent intestinal mast cell expansion and food-induced anaphylaxis Lisa M. Bartnikas, MD, Michael F. Gurish,

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Epicutaneous sensitization results in IgE-dependent intestinal mast cell expansion and food-induced anaphylaxis Lisa M. Bartnikas, MD, Michael F. Gurish, PhD, Oliver T. Burton, PhD, Sabine Leisten, MS, Erin Janssen, MD, PhD, Hans C. Oettgen, MD, PhD, Jacqueline Beaupré, BA, Christopher N. Lewis, BA, K. Frank Austen, MD, Stephanie Schulte, MD, Jason L. Hornick, MD, PhD, Raif S. Geha, MD, Michiko K. Oyoshi, PhD Journal of Allergy and Clinical Immunology Volume 131, Issue 2, Pages 451-460.e6 (February 2013) DOI: 10.1016/j.jaci.2012.11.032 Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 1 Epicutaneous (EC) sensitization with OVA results in anaphylaxis after oral OVA challenge. A, Experimental protocol. B, OVA-specific IgE and IgG1 levels. C, Core body temperature after challenge. D, Serum mMCP-1 levels before and 60 minutes after challenge. Columns and bars represent means and SEMs (n = 8-20 mice per group). *P < .05 and ***P < .001. ns, Not significant. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 2 Anaphylaxis after oral OVA challenge in epicutaneously (EC) sensitized mice is IgE dependent. A, OVA-specific IgG1 in epicutaneously sensitized IgE−/− mice and WT control animals. B, Core body temperature after oral OVA challenge. C, Serum mMCP-1 level before and 60 minutes after challenge. Columns and bars represent means and SEMs (n = 4-10 mice per group). ***P < .001. ns, Not significant. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 3 Response of orally immunized mice to antigen challenge. A, Experimental protocol. B, OVA-specific IgE and IgG1. C, Core body temperature after oral challenge. D, Serum mMCP-1. E and F, Core body temperature after intravenous challenge. Columns and bars represent means and SEMs (n = 10-12 per group in Fig 3, A-D, and 4 in Fig 3, E and F). **P < .01 and ***P < .001. EC, Epicutaneous; ns, not significant; PO, per oral. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 4 Increased IL-4 serum levels in epicutaneously (EC) sensitized mice. A, Serum levels of IL-4 determined by using the in vivo cytokine capture assay. B, Il4 mRNA levels in MLNs determined by using quantitative PCR. Columns and bars represent means and SEMs. *P < .05 and ***P < .001. ns, Not significant; PO, per oral. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 5 Expansion of submucosal MCs in the jejunum of epicutaneously (EC) sensitized mice. A, CAE staining of jejunum from epicutaneously sensitized and orally immunized mice (magnification ×200, inset magnification ×400). B-D, Total (Fig 5, B), mucosal (Fig 5, C), and submucosal (Fig 5, D) MCs in jejunum of epicutaneously sensitized, orally immunized, and unmanipulated mice. Columns and bars represent means and SEMs (n = 5-10 mice per group). Statistical significance was calculated relative to the unmanipulated group. *P < .05 and ** P < .01. HPF, High-power field; PO, per oral. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 6 A-D, Expansion of intestinal MCs in epicutaneously (EC) sensitized mice is IgE dependent. Quantitation of MCs in CAE-stained jejunal tissue sections from epicutaneously sensitized IgE−/− mice and unmanipulated IgE−/− control animals. Columns and bars represent means and SEMs (n = 5 mice per group). HPF, High-power field. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E1 Epicutaneous (EC) sensitization with peanut extract results in anaphylaxis after oral antigen challenge. A, Core body temperature of WT BALB/c mice epicutaneously sensitized with peanut extract or saline and orally challenged with peanut flour. B, Serum mMCP-1 levels before and 60 minutes after challenge. Columns and bars represent means and SEMs (n = 7 mice per group). *P < .05 and ***P < .001. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E2 Production of TH1 and TH2 cytokines and proliferation by OVA-stimulated splenocytes from epicutaneously (EC) sensitized and orally immunized mice. A, Proliferation measured by incorporation of tritiated thymidine into DNA (n = 3-9 mice per group). B-D, Secretion of IL-4 (Fig E2, B), IL-13 (Fig E2, C), and IFN-γ (Fig E2, D). *P < .05, **P < .01, and ***P < .001. PO, Per oral. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E3 Effect of epicutaneous (EC) sensitization on MC numbers in different tissues. B, Quantitation of MCs in tissue sections. Ear sections (n = 5-12 mice per group) were stained with Giemsa. A and C-E, All others (n = 2-5 mice per group) were stained for CAE. Columns and bars represent means and SEMs. Statistical significance was calculated relative to the unmanipulated (unmanip) group. **P < .01. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E4 Administration of OVA-specific IgE did not induce oral anaphylaxis in mice epicutaneously (EC) sensitized with saline. A, Effect of oral OVA challenge on core body temperature of unmanipulated BALB/c mice and BALB/c mice epicutaneously sensitized with saline that had received 4 μg of intravenous (i.v.) anti-OVA IgE 24 hours before challenge. Mice epicutaneously sensitized with saline received anti-OVA IgE and intravenously challenged with 100 μg of OVA were used as positive controls. B, Serum mMCP-1 levels before and 60 minutes after challenge. Columns and bars represent means and SEMs (n = 5 mice per group). ***P < .001. ns, Not significant; p.o., per oral; unmanip, unmanipulated. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E5 Upregulation of TSLP levels in mouse skin epicutaneously (EC) sensitized with OVA. Skin TSLP levels in BALB/c mice that were unmanipulated (unmanip) or epicutaneously (EC) sensitized with saline or OVA were measured by using ELISA. Columns and bars represent means and SEM (n = 7 mice per group). *P < .05 and **P < .01. ns, Not significant. Journal of Allergy and Clinical Immunology 2013 131, 451-460.e6DOI: (10.1016/j.jaci.2012.11.032) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions