23. Clinical laboratory assessment of IgE-dependent hypersensitivity

doi:10.1067/mai.2003.123

Journal of Allergy and Clinical Immunology

Volume 111, Issue 2, Supplement 2, February 2003, Pages S687-S701

https://doi.org/10.1067/mai.2003.123 Get rights and content

Abstract

This chapter reviews clinical and laboratory analyses that aid in the diagnosis and management of human allergic (IgE-dependent) diseases. The diagnostic algorithm for immediate-type hypersensitivity begins with a thorough clinical history and physical examination. Once signs and symptoms compatible with an allergic disorder have been identified, a skin test and/or blood test for allergen-specific IgE antibodies may serve as primary confirmation to strengthen the diagnosis. Puncture and intradermal skin testing provide a biologically relevant immediate-type hypersensitivity response in the skin, with resultant wheal and flare reactions within 15 minutes of allergen application. Bleeding, dermatographism, and antihistamines may confound the quality of the skin test. Allergenspecific IgE antibody may also be detected in the blood using a radioallergosorbent test (RAST). Nonisotopic “secondgeneration” RAST-type assays have evolved to provide more quantitative, sensitive, precise IgE antibody results. In vivo provocation tests may serve as secondary confirmatory tests when the clinical history is discordant with a primary IgE antibody test result. The multiallergen screen is a qualitative RAST-type assay that detects specific IgE antibody to approximately 15 allergens that evoke a large majority of aeroallergen or food-related allergic disorders. Other useful serological assays performed in the diagnostic allergy laboratory include total serum IgE, Hymenoptera venom-specific IgG antibody, IgG precipitins for organic dusts, mast cell tryptases, and the venom RAST inhibition test. Above all, in vivo or laboratory confirmatory test results that are inconsistent with the clinical history should be repeated as for any laboratory assessment. (J Allergy Clin Immunol 2003;111:S687-701.)

Section snippets

Ige antibody

IgE was identified in 1967 as the reagin in serum that mediates the immediate-type wheal and flare reaction.1, 2 Human IgE is an immunoglobulin of approximately 190,000 Da that circulates in the blood as a monomer (Table I). Its concentration in serum is highly age dependent, and it constitutes approximately 0.0005% of the total serum immunoglobulins in adults. The level of total serum IgE is commonly reported in kilo international units per liter (kIU/L) based on the 75/502 IgE standard from

Allergens

Allergens are glycoprotein, lipoprotein, or proteins conjugated with chemical or drug haptens that have been extracted from well-defined (usually biological) sources. Allergenic proteins elicit the formation of IgE antibody when introduced into an immunocompetent and genetically predisposed host. The concentration of all the allergenic epitopes within a single protein together produce a defined, measurable biological response in allergic individuals. More than 200 allergens of clinical

Diagnostic algorithm for allergic disease

The diagnosis of allergic disease relies on a complete clinical history and physical examination.⁹ The signs and symptoms associated with the various allergic disorders are extensively discussed in Chapters 6 to 11 , and they are not repeated here. Once the history has been collected, one of several primary confirmatory tests can be performed to detect allergen-specific IgE in the skin or blood. Of the individuals with a clinical history consistent with allergic disease, a subset will have a

Diagnostic skin testing

Skin testing is 1 of 2 primary confirmatory tests for allergen-specific IgE antibody that are used in the diagnosis of human allergic disease. Application of an allergen extract to the skin may be accomplished through either a prick/puncture or an intradermal (ID) injection.¹²

Diagnostic immunology laboratory tests

The presence of allergen-specific IgE antibody supports the diagnosis of allergic disease. Other serological tests that can be useful in selected circumstances for the diagnosis or management of individuals with Type 1 hypersensitivity include total serum IgE, Hymenoptera venom RAST inhibition test, Hymenoptera venom-specific IgG, mast cell tryptase, and precipitins for assessing hypersensitivity pneumonitis (HP). Basophil histamine release (BHR), while rarely offered as a clinical test due to

Comparative performance of ige antibody assays in the skin and blood

Comparison of the diagnostic performance (sensitivity, specificity, and positive and negative predictive value) (Table III) of any 2 in vivo and/or in vitro tests for allergen-specific IgE from peer-reviewed published data is difficult for several reasons. First, various investigators use different clinical and/or test criteria to define cases (individuals with disease). Second, study populations may vary widely within their disease category due to differences in the magnitude and frequency of

Multiallergen ige screening assays

Occasionally, individuals provide a questionable or negative history for atopic disease, or a history from which no one allergen specificity can be pinpointed with a reasonable probability as the cause of allergic symptoms. The multiallergen IgE antibody screen is a qualitative RAST-type test that evaluates a patient's serum for the presence of IgE antibodies specific for a mixture of approximately 15 indoor and outdoor aeroallergens that are believed to account for a large majority of allergic

Total serum ige

Total serum IgE is currently the only diagnostic allergy test that is regulated under the Federal Clinical Laboratory Improvement Act of 1988 (CLIA-88). Nine of more than 30 reported total serum IgE assay configurations are principally used by clinical laboratories.²⁹ These assays are almost exclusively 2-site (capture and detection antibody), noncompetitive immunometric (labeled antibody) assays in which a solid-phase antihuman IgE is used to bind IgE from a human serum. Following removal of

Proficiency testing for total and allergen-specific ige antibody assay

CLIA-88 requires that all federally licensed clinical laboratories that perform diagnostic allergy testing participate in an external proficiency survey. The College of American Pathologists conducts an independent diagnostic allergy laboratory proficiency survey in the United States.²⁹ The survey involves analysis of 5 challenge sera every 17 weeks (3 cycles per year) for total serum IgE and IgE antibody to 5 allergen specificities and a multiallergen screen. Results are collated, and

Venom rast competitive inhibition assay

Of the medically important Hymenoptera, there is known structural similarity between vespid and Polistes wasp phospholipase A1/B (Ves g I; Pol a I) and Hyaluronidase (Ves g II; Pol a II) that leads to IgE antibody cross-reactivity. A competitive inhibition format of the RAST is used to better define the appropriate therapeutic composition of venoms for insect sting allergic patients who have multiple potentially cross-reactive sensitivities and have elected to receive immunotherapy.³² This test

Hymenoptera venom-specific igg

Allergen injections during immunotherapy are known to enhance the production of specific IgG “blocking” antibodies (Table I).³³ As a general rule, quantitative measurements of allergen-specific IgG (or IgG subclass) antibodies in studies of allergic rhinitis have not correlated well with improvement in clinical symptoms of individual patients on immunotherapy. However, clinically successful immunotherapy is almost always accompanied by high serum levels of allergen-specific IgG. In contrast,

Precipitating igg antibodies (precipitins)

HP, also referred to as extrinsic allergic alveolitis, is an inflammatory reaction in the lung interstitum and terminal bronchioles induced by chronic exposure antigenic organic dusts (eg molds, bird droppings). While the lung lesion histology indicates a cell-mediated pathology, most patients with HP develop high levels of IgG antibody to the offending antigen in their blood.³⁵ Clinical laboratories still perform the classic double diffusion (Ouchterlony) to detect precipitating antibodies.

Mast cell tryptase

Mast cells that have been activated during an IgEmediated hypersensitivity reaction release proteases as well as prestored histamine and newly generated vasoactive mediators (Table IV) into surrounding soft tissue. Mast cell tryptase (MW 134,000) is a serine esterase with 4 subunits, each with an enzymatically active site. When dissociated from heparin, tryptase rapidly degrades into its monomers and loses enzymatic activity. Human basophils also contain tryptase, but their levels are 300- to

Bhr test

BHR assay has been a useful assay for defining the potency of allergen extracts. Alternatively, it has been used to detect the presence of allergen-specific IgE on the surface basophils by direct challenge or passive sensitization. This later test can be used as an alternative diagnostic test for allergen-specific IgE antibody since BHR test results are highly correlated with results from skin testing and bronchoprovocation.³⁹

In the direct challenge assay, peripheral blood leukocytes are

In vivo diagnostic provocation testing

When there is discordance between the clinical history and the results of primary diagnostic confirmatory tests, one of several provocation tests may be performed. Bronchial and nasal provocation challenges are tools used to identify a relationship between an inhaled substance and a change in the patient's bronchial or nasal physiology. A DBPCFC is used to evaluate patients who have experienced food-induced gastrointestinal reactions (eg, nausea, colic, vomiting, and diarrhea) that occur within

Dbpcfc

The DBPCFC involves the controlled ingestion of frequently eaten foods that are known to contain potent allergens including cow's milk (caseins, β-lactoglobulin, α-lactalbumin), chicken egg white (ovalbumin, ovomucoid, ovotransferrin), cereal grains (wheat, rye, barley, oats), legumes (peanut, soybean, white bean), and fish and seafood (shrimp, crabs, lobsters, oysters). The DBPCFC generally begins with strict elimination of the suspect foods for 7 to 14 days before the challenge. An equal

Indoor aeroallergen testing

A new area of diagnostic testing has developed during this past decade as a result of research on indoor aeroallergens that induce sensitization and allergic symptoms leading to rhinitis and asthma. Since individuals spend from 30% to 60% of their lives eating, sleeping, working, and relaxing in an indoor environment,⁴³ it has become a target for allergen control and avoidance. A number of clinical laboratories perform environmental testing in which a surface dust specimen is collected with a

Outdoor aeroallergen testing

Aerobiology monitoring stations have been established in most major cities across the United States. These stations typically involve the installation of a collection device on a platform or roof top, typically 1 story off the ground (eg, 13 feet). Ideally it is in an open space distant from trees, which can bias results. One device is a rotating arm cascade impactor called a rotorod. It contains a pair of 1.59-mm wide plastic rods that extend during rotation on a central arm at defined time

Concluding statement

A number of analytical measurements are used to promote more accurate diagnosis and better management of allergic individuals. The clinician should remember, however, that all in vivo and in vitro analyses are subject to variation and interference. Thus, it is prudent to question the validity of any in vivo or laboratory test that is inconsistent with a carefully collected history. Often, repeat in vivo testing on a different day or in vitro testing with a new blood specimen and/or using a

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^☆: Reprint requests: Robert G. Hamilton, PhD, DABMLI, Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Cir, Room 1A20, Baltimore, MD 21224.

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Assessment And Modulation Of The Immune Response23. Clinical laboratory assessment of IgE-dependent hypersensitivity☆

Abstract

Section snippets

Ige antibody

Allergens

Diagnostic algorithm for allergic disease

Diagnostic skin testing

Diagnostic immunology laboratory tests

Comparative performance of ige antibody assays in the skin and blood

Multiallergen ige screening assays

Total serum ige

Proficiency testing for total and allergen-specific ige antibody assay

Venom rast competitive inhibition assay

Hymenoptera venom-specific igg

Precipitating igg antibodies (precipitins)

Mast cell tryptase

Bhr test

In vivo diagnostic provocation testing

Dbpcfc

Indoor aeroallergen testing

Outdoor aeroallergen testing

Concluding statement

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

Methods

J Allergy Clin Immunol

Physiochemical properties of reaginic antibody. I. Association of reaginic activity with an immunoglobulin other than gamma A or gamma G globulin

J Allergy

Assessment And Modulation Of The Immune Response
23. Clinical laboratory assessment of IgE-dependent hypersensitivity☆