Hypersensitivity pneumonitis.

Although the cause and development of most inflammatory and fibrotic interstitial lung diseases are unknown, both the antigenic stimuli and the immunopathogenic mechanisms that produce the syndrome of hypersensitivity pneumonitis have been well described. Hypersensitivity pneumonitis is a group of related inflammatory and fibrotic interstitial lung diseases that result from hypersensitivity immune reactions to the repeated inhalation of antigens derived from fungal, bacterial, animal protein, and reactive chemical sources. Immune complex-induced inflammatory reactions initiate acute lung injury; T cell-mediated hypersensitivity reactions perpetuate it and induce chronic inflammatory, granulomatous, and fibrotic responses in the interstitium of the lungs. Because the natural history of many interstitial lung diseases of unknown causes involves the progressive evolution through these same phases, knowledge about immune pathogenesis gained from studies of hypersensitivity pneumonitis may provide a way to understand the causes and development of other interstitial lung diseases.     

Mechanisms of lung tissue restructuration. A structural analysis of experimental and human materials

Lung tissue restructuration is one of the most important components of chronic pneumopathies. Comparison of experimental and human data regarding the dynamic evolution of variously induced chronic lung processes pointed out as main mechanisms the bronchial and bronchiolar obstructions, the viral and fungal pneumonitic processes, the parenchymatous suppurative processes, the granulomatous organization of cellular reactions, the interlobular cell accumulations, the hypersensitivity reactions, and the lesions of small vessels. Mostly acting in association, these dynamic conditions determine the fibroplastic transformation of lesions, the exclusion of unventilated areas, the destruction of respiratory surfaces, the clear predominance of connective tissue structures, sometimes with ossifications; some microcavities persist within restructuring areas, sometimes delimited by alveolar or bronchiolar epithelia. The honeycomb lung is one of the evolutive possibilities of this restructuration of damaged tissues during chronic lung diseases.     

Morphogenesis and pathogenesis of chronic lung diseases. XX. Effects of repeated hypersensitivity reactions upon experimental immuno-granulomas of the lung

In order to analyse the effects of repeated hypersensitivity reactions upon chronic lung lesions, lung granulomas were experimentally induced in rabbits by an intravenous injection of 1 ml of the complete Freund's adjuvant added with 10 per cent human gammaglobulin. Groups of rabbits with 14- and 21-day-granulomas were intratracheally challenged with 1.000 I.U. human gammaglobulin injected two or three times at 7-9 days interval. The responses of the lung tissue were of the Arthus type with neutrophil granulocytic accumulations and proteasic action; the intensity of cell accumulations was decreasing after the 2nd and 3rd challenge. The lesional evolution after challenge showed intra- and perigranulomatous infiltrations with alkaline-phosphatase positive lymphocytes and plasma cells. The density of the intragranulomatous reticulin network developed after the hypersensitivity reactions increased progressively and was morphometrically assessed as statistically significant. Cellular and fibrillar lesions led to the restructuring of the lung tissue.     

Pathogenetic significance of the immediate and delayed types of hypersensitivity reactions in the dynamics of nephritis]

Complex study of the immunologic status of rats from the first days after the injection of nephrotoxic serum up to formation of chronic renal failure in comparison with functional and morphological characteristics of the disease confirmed the hypothesis on the phasic development and different pathogenetic role of the hypersensitivity reactions of the immediate and delayed types during nephritis. Signs of the immediate hypersensitivity predominated during the initial stages of the disease; realization of this hypersensitivity is indicated both by the liberation of the mediators of the pathochemical phase and by the change of the renal processes. The development of delayed hypersensitivity reactions plays the basic role in the pathogenesis of chronic nephritis.     

Immune response to chemically modified flagellin. IV. Further studies on the relationship between humoral and cell-mediated immunity

Acetoacetylation converts flagellin from an antigen which preferentially induces humoral antibodies to an antigen which exclusively provokes cell-mediated immunity and, under certain circumstances, induces antibody tolerance. Studies reported in this paper revealed that the acetoacetylated flagellins expressed similar immunological properties in flagellin primed rats as in normal rats. Thus, on the one hand, acetoacetylation destroyed the capacity of flagellin to trigger a secondary antibody response, but on the other hand, the acetoacetyl-flagellins very effectively induced delayed-type hypersensitivity reactions in flagellin primed animals. It was concluded from these results that humoral and cell-mediated immunity may be opposing immunological processes in both unprimed and primed animals.Acetoacetylated flagellin induced antibody tolerance in both strain W (low responder) and J (high responder) Wistar rats. Maximum tolerance was induced 12 hr after injection of antigen, but in strain J animals the tolerance had disappeared by 48 hr, whereas in strain W rats tolerance persisted for >28 days. The potential to recover from tolerance in strain J rats appeared to coincide with the level of delayed hypersensitivity at the time of challenge. However, this delayed hypersensitivity disappeared when breaking of tolerance occurred. These results suggest that the T cells which participate in delayed hypersensitivity reactions may also act as “helper” cells in antibody responses. On the other hand, it was found that priming for a secondary antibody response by flagellin appeared to coincide with development of primary antibodies rather than with induction of delayed-type hypersensitivity. The relative importance of specific T and B cells in these phenomena is discussed.     

Lung pathogenesis. V. The stereotype development of bronchial and lobular pathological reactions (a systemic approach)

Taking into account the present data upon the general stereotyping of different pathological processes of various nature challenged by the extremely numerous environmental actions, a structural analysis of the peculiarities presented by such reactions at the lung level, mainly on bronchial and lobular structures, was attempted. It was shown that the first damaged structures and their behaviour impose the peculiarities of the subsequently developed reactions which manifest a certain stereotyping, different when bronchi or lobules are the first lesioned. Relationships between bronchial and lobular lesions were also analysed and pointed out their role in the development of the whole complex process of the lung. This special aspect of lung complex pathogenesis was also emphasized.     

Monoclonal antibodies: Longitudinal prescribing information analysis of hypersensitivity reactions

Monoclonal antibodies (mAbs) are known to cause hypersensitivity reactions (HSRs). The reactions pose a significant challenge to investigators, regulators, and health providers. Because HSRs cannot be predicted through the pharmacological basis of a therapy, clinical data are often relied upon to detect the reactions. Unfortunately, clinical studies are often unable to adequately characterize HSRs especially in therapies for orphan diseases. HSRs can go undetected until post-marketing safety surveillance when a large number of patients have been exposed to the therapy. The presented data demonstrates how hypersensitivity reaction warnings have changed over time in the prescribing information (PI), i.e., the drug package insert, through August 1, 2011 for 28 US-marketed mAbs. Tracking all PI revisions for each mAb over time revealed that hypersensitivity warning statements were expanded to include more severe manifestations. Over the course of a mAb therapy’s life cycle, the hypersensitivity warning is twice more likely to be upgraded than downgraded in priority. Approximately 85% of hypersensitivity-associated fatality warnings were added in PI revisions as a result of post-marketing experience. Over 60% (20/33) of revisions to hypersensitivity warnings occurred within 3–4 y of product approval. While HSRs are generally recognized and described in the initial PI of mAbs, fatal HSRs are most commonly observed in post-marketing surveillance. Results of this study suggest that initial product labeling information may not describe rare but clinically significant occurrences of severe or fatal HSRs, but subsequent label revisions include rare events observed during post-marketed product use.     

Monoclonal antibodies: Longitudinal prescribing information analysis of hypersensitivity reactions

Monoclonal antibodies (mAbs) are known to cause hypersensitivity reactions (HSRs). The reactions pose a significant challenge to investigators, regulators, and health providers. Because HSRs cannot be predicted through the pharmacological basis of a therapy, clinical data are often relied upon to detect the reactions. Unfortunately, clinical studies are often unable to adequately characterize HSRs especially in therapies for orphan diseases. HSRs can go undetected until post-marketing safety surveillance when a large number of patients have been exposed to the therapy. The presented data demonstrates how hypersensitivity reaction warnings have changed over time in the prescribing information (PI), i.e., the drug package insert, through August 1, 2011 for 28 US-marketed mAbs. Tracking all PI revisions for each mAb over time revealed that hypersensitivity warning statements were expanded to include more severe manifestations. Over the course of a mAb therapy’s life cycle, the hypersensitivity warning is twice more likely to be upgraded than downgraded in priority. Approximately 85% of hypersensitivity-associated fatality warnings were added in PI revisions as a result of post-marketing experience. Over 60% (20/33) of revisions to hypersensitivity warnings occurred within 3–4 y of product approval. While HSRs are generally recognized and described in the initial PI of mAbs, fatal HSRs are most commonly observed in post-marketing surveillance. Results of this study suggest that initial product labeling information may not describe rare but clinically significant occurrences of severe or fatal HSRs, but subsequent label revisions include rare events observed during post-marketed product use.     

Antigen recognition in delayed-type hypersensitivity.

It is still uncertain if cell-mediated immune reactions are more or less specific than antibody-mediated reactions. Accordingly, hapten and carrier specificity were examined in delayed hypersensitivity in guinea pigs. Hapten specificity was demonstrated with 2,4-dinitrophenyl (DNP)-guinea pig albumin (GPA), 2,6-DNP-GPA, 2,4,6-trinitrophenyl (TNP)-GPA, and dansyl (DNS)-GPA. Guinea pigs immunized with each of these conjugates were tested 7 days later with the immunogen and the other conjugates. Strong delayed skin responses were highly specific for the immunogen; there were some weak cross-reactions among the nitrophenyl conjugates, no crossre-actions between the DNS and nitrophenyl conjugates, and no responses to unconjugated GPA. Conjugates carrying different numbers (1–45) of 2,4-DNP groups per molecule were all able to elicit specific responses to 2,4-DNP.Carrier specificity in delayed hypersensitivity was confirmed by immunizing with 2,4-DNP-GPA, and challenging with the immunogen, with 2,4-DNP coupled to bovine albumin (BSA), rabbit IgG, ovalbumin, and hemocyanin. Strong responses were seen to the immunogen, a weak response to 2,4-DNP-BSA, and no response to the other conjugates. Specific immune recognition of both hapten and carrier determinants is therefore required for expression of delayed hypersensitivity. These cell-mediated reactions thus appear to be more specific than those of antibody-mediated reactions in solution.     

The biological effects in animals in relation to the accident at the Chernobyl Atomic Electric Power Station. 10. Cooperative immune reactions in different generations of mice]

The immune status of mice has been assessed by the whole complex of data. The permanent action of low-level radiation has been shown to suppress considerably the rate of reactions of the delayed-type hypersensitivity and "graft versus host" disease, as well as NK and specific cytolytic T-lymphocyte activity. The dynamics of accumulation and the levels of antiviral antibodies in the serum, lung and trachea extracts are virtually invariable. The resistance of experimental animals to influenza is lower than that of non-irradiated mice of the same line and age. The data obtained indicate that the immune disturbances revealed are connected not only with the alteration of lymphoid cell populations, but also with the alteration of the immune regulation mechanisms.     

Production of tumour necrosis factor by cells exposed to sulphonamide reactive metabolites.

Hypersensitivity reactions are the most common adverse events associated with therapy with the sulphonamide antibiotics. These reactions have been shown to occur among individuals with pharmacogenetically determined differences in the capacity of their cells to detoxify reactive products of oxidative metabolism of the sulphonamides. These reactions appear to be propagated by an inflammatory response by the immune system. To investigate the role of the cytokine tumour necrosis factor (TNF-alpha) in these reactions, we studied the production of TNF-alpha by peripheral blood mononuclear cells (PBMCs) that had been incubated with sulfamethoxazole and murine microsomes in the presence and absence of a microsomal-activating system and TNF-alpha production by PBMCs in the presence and absence of the hydroxylamine derivative of sulfamethoxazole. The PBMCs showed a time-related increase in the production of TNF-alpha. There was no increase in TNF-alpha production seen during incubation with sulphonamide reactive metabolites; rather, there was a decrease in TNF-alpha elaboration that was most marked when PBMCs were incubated with the hydroxylamine of sulfamethoxazole. There is no evidence from these in vitro studies that TNF-alpha is involved as a mediator of the inflammatory response in sulphonamide hypersensitivity adverse drug reactions.     

Antiallergic/antiasthmatic effect of novel antiallergic hexapeptide-95/220 in various experimental models

The effects of newly synthesized antiallergic hexapeptide 95/220 was investigated on various allergic and asthmatic test models. This newly developed peptide was found to be more potent than clinically used drug disodium cromoglycate (DSCG). Hexapeptide 95/220 inhibited immediate hypersensitivity reactions such as passive cutaneous anaphylaxis (PCA) and mast cell degranulation in rats, antigen-induced bronchoconstriction in actively sensitized guinea pigs in dose dependent manner like DSCG. Antigen-induced contraction of guinea pig ileum was also markedly inhibited by this newly developed hexapeptide in the same fashion as ketotifen and DSCG did but at comparatively lower dose. Egg albumin-induced histamine release was also blocked by this hexapeptide from chopped lung tissues of sensitized guinea pigs. These results suggest that hexapeptide' 95/220 has potent inhibitory effect on immediate hypersensitivity reactions thereby inhibiting mediator release from mast cell. Moreover, this newly synthesized peptide is orally active and effective at lower doses as compared to standard drugs.     

Biochemical pathology of lung damage produced by chemicals.

Damage to the lung may be caused by chemicals that gain access to the alveolar zone by inhalation or via the pulmonary circulation. Several agents toxic to the lung have recently been found to bind covalently to pulmonary macromolecules or to disrupt certain metabolic reactions. However, it has also been observed that extensive chemical lung injury is not necessarily preceded by a depression of pulmonary metabolic reactions. One possible explanation for this might be that biochemical changes due to cell death are often masked and/or compensated for by changes associated with lung tissue repair. Substantial cell proliferation as a response to toxic lung damage is a common phenomenon in lung pathology. This makes it necessary to develop models that permit analysis of the biochemical events triggering and accompanying cell growth in lung. We have recently examined some aspects of cell proliferation in mouse lung. Intraperitoneal injection of the antioxidant butylated hydroxytoluene (BHT) produces within 3-5 days extensive hypertrophy, hyperplasia, and general disorganization of the cellular components of the lung. Total lung weight and total DNA per lung almost double within this time and are accompanied by proportional increases in protein and lipids. RNA accumulates at a faster rate than DNA. The changes in lung composition are accompanied by dose-dependent increases in the in vivo incorporation of thymidine into DNA and of leucine into protein. The activities of several enzymes (thymidine kinase, DNA polymerase, uridine kinase, glucose-6-phosphate dehydrogenase, and 5'-nucleotidase) increase substantially after BHT. Administration of BHT to mice seems to offer a convenient tool to study cell growth in the lungs of mice.     

Failure of delayed hypersensitivity skin testing to predict postoperative sepsis and mortality.

Delayed hypersensitivity skin reactions to a battery of recall antigens, haemoglobin and albumin concentrations, arm-muscle circumference, and percentage of ideal weight were determined before operation in 244 patients undergoing elective major surgery. Depressed skin reactions were found in 70 patients (28%), but this group did not have significantly higher sepsis or mortality rates when compared with patients with normal reactions. Significant associations were found between depressed skin reactions and increasing age, anaemia, hypoalbuminaemia, low arm-muscle circumference, and low weight. Patients with benign and malignant disease had similar distributions of skin reactions. Hypoalbuminaemia was associated with a higher rate of serious postoperative sepsis, and hypoalbuminaemia, low arm-muscle circumference, and low weight were all associated with a higher mortality. These results suggest that the routine use of delayed hypersensitivity skin testing in the preoperative assessment of surgical patients is not justified.     

In situ pulmonary responses of T cell and macrophage subpopulations to a challenge infection in mice vaccinated with irradiated cercariae of Schistosoma mansoni

Cellular events related to the resistance induced by radiation-attenuated cercariae of Schistosoma mansoni were determined immunocytochemically in the lung tissues of mice. Thy-1, CD4, CD8, Mac-1 MOMA-1, MOMA-2, and Ia antigens were identified on cryostat sections by the immunogold-silver staining technique with specific monoclonal antibodies. In mice vaccinated with irradiated cercariae and challenged with normal cercariae, the number of Thy-1+ and CD4+ lymphocytes was increased dramatically relative to the normal numbers both in perivascular tissues and in focal cellular aggregates in the parenchyma of the lungs. A high ratio of CD4+/CD8+ T cells was noted in the aggregates, both in perivascular tissues and in the foci. Macrophages showing positive reactions for Mac-1, MOMA-1, MOMA-2, and Ia also infiltrated the foci. In control mice that were unvaccinated and challenged, foci showing positive reactions for the lymphocyte subpopulations barely were detectable in the lungs by day 14. The numbers of Thy-1+, CD4+, and CD8+ cells and the CD4+/CD8+ ratio in controls were considerably less than those in vaccinated/challenged mice over the period of observation. In conclusion, pulmonary cellular aggregates in vaccinated and challenged mice were composed mainly of Thy-1+ and CD4+ cell populations characteristic of delayed-type hypersensitivity (DTH) reactions. Thus, Thy-1+ and CD4+ cells in the lungs of vaccinated mice may be involved in the elimination of challenge parasites through DTH reactions.     

Immunity to the T1699 murine mammary tumor. I. Thymic influence and long-term effect of irradiation on the humoral response.

The thymus dependency of humoral immunity to syngeneic tumor antigens was investigated in T cell-deficient DBA/2 mice. ATXBM animals bearing the T1699 mammary tumor in the subcutaneous abdominal area displayed normal immediate but not delayed hypersensitivity reactions (DHR) to 3 M KCl-extracted T1699 antigens injected into the footpad. Sera from ATXBM tumor-bearers passively transferred immediate hypersensitivity but failed to support tumor-specific macrophage-mediated ADCC reactions. The synthesis of macrophage-mediated ADCC antibody was greatly reduced in the CXBM animals when compared to nonirradiated tumor-bearers. The CXBM mice, however, showed normal T cell function as measured by allograft rejection, antibody response to sheep erythrocytes, and DHR to T1699 antigens. Of all antibody classes and subclasses tested by indirect membrane fluorescence, only IgG2b was found to be produced at normal levels by either ATXBM or CXBM tumor-bearers. The results show that IgG2b antibody production in response to T1699 syngeneic tumor antigens is thymus independent and suggest that this antibody is the mediator of immediate hypersensitivity. The synthesis of macrophage-mediated ADCC antibody (IgG2a) was found to be not only thymus dependent but also sensitive to the long-term effects of irradiation and bone marrow repopulation.     

The relation between skin histamine concentration, histamine sensitivity, and the resistance of cattle to the tick, Boophilus microplus.

Cattle with different degrees of resistance to Boophilus microplus have responses to tick allergen which correlate with their resistance level. The total amount of histamine in the skin also correlates with both resistance and the immediate hypersensitivity reactions, but the sensitivity to injected histamine does not. Treatment with the antihistamine drug mepyramine maleate suppresses the cutaneous hypersensitivity reactions. The results suggest that the main pharmacologically active agent in these reactions is histamine, and that the total amount of it available locally in the skin may have a role in the resistance to this parasite.     

Cross-protection against Salmonella enteritidis infection in mice. III. Delayed hypersensitivity reaction and clearance of the challenge organism.

Mice were immunized with live vaccines and with live vaccines with complete adjuvant incorporating Salmonella enteritidis, Salmonella typhi-murium, Salmonella gallinarum or Salmonella pullorum. On the 21st day after vacination, the hypersensitivity reactions elicited by the mice to extracts of the challenge organism (S. enteritidis 5694 SMR) were assessed. The degree of delayed hypersensitivity reaction was compared with the level of protection induced by the vaccine. The role in protection of delayed hypersensitivity is discussed. Clearance of the challenge organism from the liver of previously vaccinated and unvaccinated mice was assessed quantitatively.     

Physiologic concentrations of cortisol suppress cell-mediated immune events in the domestic pig

Mild restraint of the domestic pig (Sus scrofa) caused activation of the hypothalamic-pituitary-adrenal axis, atrophy of the thymus gland, and a significant reduction in cell-mediated, delayed-type hypersensitivity reactions. Physiologic concentrations of cortisol suppressed, in vitro, phytohemagglutinin- and concanavalin A-induced proliferation of porcine thymocytes, splenocytes, and peripheral blood mononuclear cells, even though cortisol was only mildly cytolytic. These results extend the concept of an endocrine influence on regulation of cell-mediated immune events to species other than humans and rodents.     

Studies on delayed hypersensitivity of patients with Hodgkin's disease during remission.

The studies of skin sensitivity, the reactivity to intradermally transferred lymphocytes and lymphocytic transformation in vitro showed that delayed hypersensitivity had been slightly impaired in patients with Hodgkin's disease during long time remission. The regression of the disease favoured the recovery of the lymphocytic functions and the delayed type immune reactions associated with them. These data suggest that the enhancement of the delayed hypersensitivity of the tumour defence respectively could promote the treatment or prevention of the disease.