RU2609839C1 - Method of differential diagnostics of hypersensitivity to bee poison (apis mellifera) - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to allergology and immunology, and can be applied in differential diagnostics of hyper-reactivity (HR) to bee poison. For this purpose in medical history of patients contact with bee Apis mellifera is detected. Level of general lgE, level of specific lgE to bee poison, histamine, leukotrienes, basal tryptase, expression of CD63+ and CD203c in contact of blood basophils with allergens of bee poison, histamine, leukotrienes are determined. In case of presence in medical history of contact with bee Apis mellifera with the following reactions of different severity degree, level of general IgE higher than 100 IU/ml, level of specific IgE higher than 0.7 IU/ml, CD63+ higher than 10%, CD203c higher than 10%, level of leukotrienes higher than 200 pcg/ml, level of histamine liberation from 50±5.3%, increased level of basal tryptase, IgE- mediated reaction is diagnosed. In case of presence in medical history of contact with bee Apis mellifera with the following reactions of different severity degree, level of general IgE lower than 100 IU/ml, level of specific IgE lower than -0.7 IU/ml, CD 63+ lower than 10%, CD203c higher than 10%, level of leukotrienes lower than 200 pcg/ml, level of histamine liberation to 15%, normal level of basal tryptase non-IgE-mediated reaction is diagnosed.

EFFECT: developed complex method makes it possible to realise differentiated diagnostics of true and pseudo-allergic reactions to bee poison, which further makes it possible to prescribe adequate treatment with account of formation of blocking (protective) antibodies.

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Description

The invention relates to medicine, namely to allergology and immunology, and can be used in the diagnosis of hypersensitivity (MS) of patients with allergic diseases (AZ) to bee venom, which will subsequently allow the development of adequate preventive measures and a strategy for choosing a therapy, including allergen-specific immunotherapy (hyposensitization) for allergies to the poison of these insects.

Morbidity is the basis of most allergic diseases that are widespread and pose a serious social, economic and medical problem [Khaitov P.M. Clinical Allergology. Guide for practitioners. M .: Medpress-inform, 2002, 623 p.]. There is a lot of evidence in the literature that insects, like most representatives of the Arthropod type, are sources of allergens that contribute to the formation of sensitization in humans [Golden D.B., Marsh D.G., Kwiterovich K.A. et al. Natural history of Hymenoptera venom sensitivity in adults. // Allergy and Clin. Immunol. 1998. V. 102. P. 702-731; Fedoskova T.G. Allergy to non-stinging insects (prevalence, clinical characteristics, specific diagnostics and allergen-specific immunotherapy). Diss. ... doctor. honey. Sciences, M .: FSBI “SSC Institute of Immunology” FMBA of Russia, 2008, 317 pp.].

Hypersensitivity - objectively reproducible manifestations and symptoms that develop when exposed to certain environmental factors in doses that do not cause these manifestations in normal individuals - is an important criterion for allergic conditions. The concept of hypersensitivity unites all types of manifestations of hyperreactivity (GR) of the body, including mediated by the synthesis of specific IgE (true allergy). As a result of the direct action of bee venom toxins on the membrane of the mast cell and other target cells (basophils, etc.), in contrast to the true (IgE-mediated) allergic reaction, body GR can be formed to the acting factor as a false or pseudo-allergic reaction (non- IgE mediated), followed by the liberalization of histamine and other mediators of inflammation and, as a consequence, the manifestation of GH in the form of clinical signs of the pathophysiological stage of the body’s response [Fedoseeva V.N., Rakhmanin Yu.A. Ecological aspects of the body's hyperreactivity to environmental factors: Monograph. M .: MAX Press, 2012, 190 pp.].

Thus, HH reactions in patients with AZ arise when stinging bees not only by the type of true allergy with the formation of specific IgE, but also by the type of formation of pseudo-allergic reactions. The latter are characterized by the absence of high levels of specific IgE and the involvement of target cells (mainly mast cells and basophils) in the process of HH with the liberalization of mediators (histamine, leukotrienes, etc.) and the subsequent implementation of their action on target organs [Ado A.D. General allergology. 2nd edition, revised and supplemented. - M .: Medicine, 1978, 464 p.]. An important role in the pathogenesis of HH in this case is played by the state of the cell membrane of target cells. At the same time, the processes of degranulation and liberalization of mediators causing a state of hypersensitivity when exposed to bee venom are of great importance.

If a patient experiences a reaction of HH to bee stings, the practitioner needs to conduct a differential diagnosis between true allergy and non-allergic hypersensitivity in order to determine a treatment strategy - either allergen-specific immunotherapy with IgE - caused by true allergy, or conducting therapy aimed at stabilizing the target cell membrane and reduction of intoxication and liberalization of inflammatory mediators (sanitation of foci of chronic infection, use of antileukotriene preparations Ratov and other drugs). Differential diagnostics requires the development and application of a system of methods for diagnosing the state of MS in patients with AZ with stinging with a bee. Diagnosis of reactions in this case requires in vitro conditions due to the high reactivity of bee venom.

State of the art

In the 80-90 years. XX century, the diagnosis of HC in patients with stings by bees was mainly aimed at identifying specific IgE, using the method of enzyme-linked immunosorbent assay (ELISA). To date, the determination of specific IgE in the blood serum of patients in clinical laboratories is carried out in most cases using water-salt extracts of allergens. The study (test setting) is based on the use of a mixture of purified allergens and allergen extracts, in the presence of which class E antibodies bind to them and form “antigen-antibody” complexes, the amount of which is subsequently measured and recorded. The sensitivity of these tests is from 60% to 95%, and their specificity is from 30% to 95% [Siles R.I., Hsien F.Y. Allergy blood testing: A practical guide for clinicians // Cleveland Clinic Journal of Medicine. 2011.V. 78 (9). P. 585-592].

These tests are cheap to use, but have their drawbacks. The use of extracts can lead to an increase in both false-positive results due to the presence of components with high cross-reactivity or contamination by allergens from other sources, and false-negative due to the absence or degradation of the main allergenic proteins in the extract.

Diagnostic methods for AZ using not allergen extracts from natural raw materials, but individual allergenic molecules purified or obtained recombinantly, which is commonly called molecular allergy diagnostics. The first commercial in vitro system for such an analysis of ImmunoCAP ISAC (Phadia AB, Sweden) - a biochip containing 103 components from more than 50 natural sources of allergens and including the main clinically significant species-specific and cross-reactive markers, appeared in 2007 [ Mokronosova M.A., Korovkina E.S. Component diagnostics - a new era in clinical allergology // Therapeutic Archive. 2013. No. 10. S. 4-8 - prototype].

Currently, twelve different allergens have been identified in bee venom, and commercial forms of allergens have been developed only for the two main allergens Api m1 (phospholipase A2) and Api m4 (melittin), which significantly limits the use of this method to detect hypersensitivity to everything in patients with AZ the spectrum of sensitizing components that make up the bee venom. A significant drawback of this method is the impossibility of detecting a pseudo-allergic response to the formation of hyperreactivity in a patient with bee venom, which makes it difficult to reduce the body's reactivity under conditions of bee sting, preventive measures in the face of acute sting reactions, and determine the prognosis of severe systemic hyperergic reactions. The identification of pseudo-allergic reactions in patients with differential diagnosis in these cases makes it possible to recommend methods of therapy aimed at stabilizing the membranes of target cells (basophils) and reducing the body’s hyperreactivity to bee venom.

A drawback of all existing methods for diagnosing bee venom hyperreactivity based on IgE-specific reactions is the complete exclusion of the possibility of detecting another type of allergic reactivity to bee venom in the context of clinical and laboratory diagnostics, requiring other therapeutic approaches to therapy. Among the disadvantages of methods for determining specific IgE should also include their high cost.

We used the determination of specific IgE for bee venom as a screening test for the diagnosis of allergic reactivity in a patient during the differential diagnosis of true and pseudo-allergic reactions to bee venom.

Achievable technical result is the differential diagnosis of true and pseudo-allergic reactions to bee venom, which subsequently allows you to assign an adequate specific treatment, taking into account the formation of blocking (protective) antibodies, the effect of stabilizing the membranes of target cells of allergic reactions.

Disclosure of invention

We have developed a comprehensive method for the diagnosis of hypersensitivity to bee venom (intolerance to stinging bees), which includes the identification of the following data set (for the implementation of our diagnostic method, it is necessary to determine the entire set of data below, since the definition of this particular complex will allow us to differentiate between true and pseudo-allergic reactions on bee venom):

- data of a “positive” medical history, i.e. the presence of a mandatory fact of stinging a patient in the history of a bee (Apis mellifera), with subsequent undesirable pathological reactions of varying severity.

The most dangerous manifestation of GR is anaphylactic shock, which is often accompanied by a fatal outcome for the patient. The risk of developing anaphylactic reactions increases in patients with a true allergy to bee venom, complicated by the presence of an increased content of histamine in tissues (including mastocytosis), with a high level of serum tryptase due to the severe manifestation of anaphylactic reactions and high values of total IgE (for patients with allergic reactions from 200 to 500 IU / ml and above);

- data on the level of specific IgE to bee venom according to assessing the quality of stability to the affecting factor of target cells, namely: determination of the expression of CD63 +, CD203c upon contact of blood basophils with allergens of bee venom;

- data on the reaction of cells - targets of allergies (basophils, eosinophils) with the release of inflammatory mediators (histamine, leukotrienes, basal tryptase) under the action of specific bee venom allergens.

The developed method makes it possible to verify the nature of the allergic reaction in patients with intolerance to stinging bees, to evaluate the activation reactions of the receptor type of target cells (basophils), the liberalization of inflammatory mediators, and to diagnose specific IgE-mediated allergic reactions and non-IgE-mediated HC reactions to bee venom allergen .

The developed diagnostic method will allow in the future to choose an adequate strategy for specific (or non-specific) therapy, thereby eliminating the risk of complications during treatment, as well as to determine a strategy for the prevention and treatment of intolerance to bee venom intolerance.

The developed method is based on the correlation between the data of a positive insect allergy history and specific in vitro allergy examination if the patient has reliable anamnestic data on the hypersensitivity reaction after stinging with a bee.

Diagnostic criteria are shown in table 1.

The level of IgE was determined using a kit to determine the specific IgE and allergen of bee venom Dr. Fooke (Germany). According to the manufacturer, indicated in the instructions for use for the kit, the concentration of specific IgE, expressed in international units per ml (IU / ml), has the following ratios with the reaction class for IgE binding: 0 class - <0.35, 1 class - 0.35-0.7 IU / ml, class 2 - 0.7-3.5 IU / ml, class 3 - 3.5-17.5 IU / ml, class 4 - 17.5-50 IU / ml

Clinical examples:

No. 1. IgE-mediated reaction.

Patient K., 32 years old. Since childhood, suffers from allergic rhinitis with household sensitization. Within five years, she twice suffered acute systemic reactions after being stung by a bee.

For the first time after stinging, pronounced angioedema, weakness, and moderate symptoms of intoxication arose. The condition was verified as a moderate-severe systemic reaction after being stung by a bee, and was not examined further.

Repeatedly after stinging the bee, an increase in the severity of symptoms was noted. There was a sharp decrease in blood pressure, tinnitus, headache, shortness of breath, pain in the epigastric region, angioedema of the face and collar zone. The patient is placed in the intensive care unit of the hospital.

The results of the survey are presented in table 2.

Based on the obtained data, the presence of an IgE-mediated reaction was diagnosed.

Prescribed: epinephrine, systemic glucocorticosteroids, beta 2 agonists. Against the background of the use of these drugs, positive dynamics were noted.

No. 2. Non IgE-mediated reaction

Patient Sh. 58 years old. From the age of 20, suffers from chronic recurrent urticaria. Over the past 10 years, it has been stung five times by a bee. There was a development of a moderately pronounced angioedema in the sting area, which was stopped by taking antihistamines. At the last sting, headache, nausea, weakness, moderate decrease in blood pressure, single symptoms of a blister rash, moderate swelling in the sting area were observed. The patient was hospitalized.

The results of the survey are presented in table 3.

Based on the obtained data, the presence of a non-IgE-mediated reaction was diagnosed.

Appointed: systemic glucocorticosteroid drugs. Against the background of the use of these drugs, positive dynamics were noted.

Differential diagnosis is usually hampered by a similar clinical picture of symptoms of true insect allergy and pseudoallergy when stinging, because their development is due to the release of the same inflammatory mediators with different pathogenesis of the disease. Our studies have shown that only a diagnosis using all of the above methods in combination provides accurate verification of the diagnosis. The exclusion of at least one of the examination methods significantly reduces the accuracy of diagnostic measures.

Claims (4)

A method for the differential diagnosis of hypersensitivity to Apis mellifera bee venom, comprising identification of the patient’s history of contact with the Apis mellifera bee, determination of the level of total IgE, the level of specific IgE for bee venom, histamine, leukotrienes, basal tryptase, expression of CD63 + and CD203c upon contact of blood basophils with allergens of bee venom, histamine, leukotrienes, and if there is a history of contact with Apis mellifera bee, with subsequent reactions of varying severity, total IgE level more than 100 IU / ml, specific IgE level more than 0.7 IU / ml, CD63 + more than 10%, CD203c more than 10%, leukotrienes more than 200 pkg / ml, histamine liberation from 10 ± 3.2% to 50 ± 5.3%, elevated basal tryptase, diagnosed with IgE-mediated reaction; and if there is a history of contact with Apis mellifera bee, with subsequent reactions of varying severity, total IgE level less than 100 IU / ml, specific IgE level less than 0.7 IU / ml, CD63 + less than 10%, CD203c more than 10%, leukotriene level less than 200 pg / ml, histamine lobe up to 15%, normal basal tryptase level, a non-IgE-mediated reaction is diagnosed.