Basic Immunology Allergy:!

Highlights in hypersensitivity
reactions, tolerance, and hygiene
hypothesis

UKK Alergi Imunologi

Ikatan Dokter Anak Indonesia
Introduction
 Epidemiology
•  Allergic diseases are affecting the lives of more than one
billion people worldwide. With an epidemic rise during the
last 60 years, their prevalence is expected to reach up to 4
billion in 2050s.
•  Because of immense numbers of affected individuals, the
general public confronts huge direct and indirect costs with
major effects on macroeconomics due to health-care, loss of
productivity and absenteeism of patients.
•  Unfortunately, high number of unmet needs due to missing
scientific knowledge in disease mechanisms, prevention,
patient care, and social determinants remain to be resolved

Akdis CA, Agache I, 2014

 Allergy & Allergology

•  The term “Allergy” was first coined on July 24, 1906 as

“specifically altered reactivity of the organism”
•  Now, we define allergy as an immunologically-mediated and
allergen-specific hypersensitivity
•  Allergies can be seen in almost every organ, most commonly
in the skin and the mucous membranes
•  Allergology is the science regarding allergic diseases and their
differential diagnoses and mechanisms
 Atopy!
(Dorlands Medical Dictionary:atopy” & Mosby's Medical Dictionary:atopy”)

•  Atopy (pron.: / æt pi/; Greek ἀτο - placelessness, out

of place, special, unusual) or atopic syndrome
–  is a predisposition toward developing certain allergic hypersensitivity
reactions.
–  may have a hereditary component, although contact with the allergen
must occur before the hypersensitivity reaction can develop.
•  The term "atopy"
–  by Coca and Cooke in 1923.
•  Many physicians and scientists
–  use the term "atopy" for any IgE-mediated reaction (even those that
are appropriate and proportional to the antigen)
•  Many pediatricians
–  use the term "atopy" for a genetically mediated predisposition to an
excessive IgE reaction..
Ruby Pawankar; Stephen T. Holgate; Lanny J. Rosenwasser (7 April 2009)
Allergy Frontiers: Classification and Pathomechanisms
 Allergy-Allergic Reaction-Allergen!
(Dorlands Medical Dictionary:atopy” & Mosby's Medical Dictionary:atopy”)
•  Allergic reactions
–  occur when a person's immune system reacts to
normally harmless substances in the environment.
–  distinctive because of excessive activation of d
mast cells and basophils by a type of antibody
called Immunoglobulin E (IgE).
–  results in an inflammatory response which can
range from uncomfortable to dangerous.
•  Allergy
–  hypersensitivity disorder of the immune system.
–  is one of four forms of hypersensitivity and is
formally called type I (or immediate) hypersensitivity.
•  Allergen
–  substance that causes a reaction.
“Allergy")at)Dorland's)Medical)Dic5onary))Kay)AB)(2000).)"Overview)of)'allergy)and)allergic)diseases:)
with)a)view)to)the)future'".)Br.)Med.)Bull.)56)(4):)843–64.))
Illustrates the minimum Allergen or
requirements for a
molecule to be Crossreactive Allergen ?
designated as an
allergen: it binds IgE
antibodies
Panel B &
It can C depict
itself act the two
as identities
primary an
sensi- allergen
tizer can have
(orange
in panel
B & C)

It cannot and binds IgE only based on EAACI Global Atlas of Allergy 2014.
cross-reactivity with the primary
sensitizer (blue in panel C). Editors: Cezmi A. Akdis, Ioana Agache.
 Allergic Reaction:!
Mast Cell Degranulation

!
 Allergic inflammation "
Allergic inflammation
•  is an important pathophysiological feature of several
disabilities or medical conditions including
–  allergic asthma,
–  atopic dermatitis,
–  allergic rhinitis
–  and several ocular allergic diseases.

•  Hansen I, Klimek L, Mösges R, Hörmann K (2004).

"Mediators of inflammation in the early and the late phase of allergic rhinitis". Curr Opin Allergy Clin
Immunol 4 (3): 159–63.
•  Fireman P (2003). "Understanding asthma pathophysiology". Allergy Asthma Proc 24 (2): 79–83
•  Katelaris CH (2003). "Ocular allergy: implications for the clinical immunologist". Ann. Allergy Asthma
Immunol. 90 (6 Suppl 3): 23–7.
 Allergic
inflammation

Atopy Allergic Reaction

Hypersensitivity Reactions
What is hypersensitivity?

EAACI 2014
 Hypersensitivity Reaction
•  Soluble •  IgE •  Mast Cell Activation
•  Phagocyte Activation
•  IgG •  NK-Cell Activation
•  Macrophage Activation
•  Th1 •  Eosinophil activation
•  Cytotoxicity
•  Non-soluble •  Th2 •  Antibody signalling
–  Cell/matrix
•  Complement Activation
–  Receptor
–  Antigen cell
•  Tc (CTL) •  IgE production
 Hypersensitivity Reaction
•  IgE •  Mast Cell Activation •  Degranulation
•  Phagocyte Activation •  Phagocytosis
•  IgG •  NK-Cell Activation •  Inflammation
•  Macrophage Activation •  Inflammation
•  Th1 •  Eosinophil activation •  Inflammation
•  Cytotoxicity •  Cell Killing
•  Th2 •  Antibody signalling •  Autoimmunity
•  Complement Activation •  Anaphylatoxine
•  Tc (CTL) •  IgE production •  Degranulation
Allergen
IgEsp-Allergen

Mast Cell
Symptoms & Signs of Allergy
GENETICS !
!
 GENE OVERLAPS
43 gene between AR and asthma,
29 between AD and asthma,
28 between FA and asthma,
Food 27 between AR and AD, Atopic
22 between FA and AD,
Allergy 22 between FA and AR," Dermatitis

Allergic
Rhinitis
Allergic
Asthma

Gupta J et al. J Allergy Clin Immunol 2016;138:676-99

 Ingenuity Pathway Analysis (IPA) network for 16 genes
shared among patients with Atopic Dermatitis (AD), Food Allergy (FA), Allergic
Rhinitis (AR), and Asthma. "
GENE INTERACTIONS

•  Solid lines
representing direct
interactions

•  Dashed lines
representing
Gupta J et al. J Allergy Clin Immunol 2016;138:676-99 indirect
interactions.
Gupta J et al. J Allergy Clin Immunol 2016;138:676-99

Deconstructing atopic disorders using genetic and molecular information.

Complex interplay between functional gene clusters and interpretation based on a model that integrates each atopic
disorder in a central theme are presented. A mechanism through which epidermal barrier dysfunction can lead to
inflammation and allergic sensitization in patients with atopic disorders is shown.
Epigenetics mechanism
Interaction

Neonatal phenotype
Interaction

Intermediate phenotype

22"

Clinical phenotype
 Allergic March"

1.  FA and AD peak in the first years of life and decrease after that time.
2.  Asthma and AR increase over time as sensitization develops further.
3.  Food sensitization can be used as an early indicator for identifying children at risk
for subsequent allergic disease who might benefit from early intervention.

Gupta J, et al. Resolving the etiology of atopic disorders by using genetic analysis of racial ancestry. J Allergy Clin Immunol 2016;138:676-99)
MODIFIERS OF !
ALLERGIC MARCH !
!
 Environmental factors such as
pollution, food, agriculture and
microbiota have been shown to
have significant implications on
early immune programming &
development.

Prenatal exposure to these

elements is postulated to
cause epigenetic changes to
genes and signaling
pathways of fetal immunity
that may have lasting effects
during the child’s life.
Prescott SL. J Allergy Clin Immunol 2013;131:23-30
EAACI Global Atlas of Allergy 2014. Editors: Cezmi A. Akdis, Ioana Agache.
Tolerance
The management of allergic diseases will depend
on three main factors:
(a) how easy it is to avoid the trigger
(b) whether there are multiple triggers
(c) how easy it is to induce tolerance
EAACI Global Atlas of Allergy 2014. Editors: Cezmi A. Akdis, Ioana Agache.
 Immune tolerance
Two major
is the lack of
pathways of
immune
immune tolerance"
responsiveness to "

Prevent immunity
Harmless Prevent immunity to harmless
Self antigens" environmental to self-antigens" environmental
antigens (allergens)"
antigens"
 Immune tolerance is the lack of
immune responsiveness to "

‘Induced or Aquired
‘Natural' or 'self tolerance’"
tolerance', "

Body does not mount an Tolerance to a given antigen

immune response to self (would likely induce cell-
antigens" mediated or humoral immunity)"

Adaptation to Specific non-

Central " Peripheral " external reactivity (of
antigens " the lymphoid
tissues)
Tolerance to external antigens can be created
by manipulating the immune system. "
 By prior
administration of the
antigen
Tolerance
By the oral route of
the antigen "

Oral Cellular immune

tolerance reactivity"

Specific Humoral immune

one forms of suppression" reactivity"
acquired
tolerance (the Cellular"&"Humoral
most important) " immune reactivity"

Food proteins "

Prevent
hypersensitivity
reactions to:" Bacterial"an0gens"
 Play a central role
in peripheral
tolerance" Allergen-specific
Regulatory Th2 & IgE
T cells" responses"
Inhibiting effector
pathways that drive
allergic reactions"
Cells that mediate
Immune Regulatory allergic reactions
(mast cells &
tolerance " B cells " eosinophils)"

Regulatory
subsets of other
cells " Therapies such as allergen
immunotherapy enhance
regulatory T cell function to
restore immune tolerance
 Mechanisms of inhibition !
by regulatory T cells

EAACI Global Atlas of Allergy 2014. Editors: Cezmi A. Akdis, Ioana Agache.
 Treg act at multiple levels of the allergic cascade "
to prevent & control disease"

Induction of Enhanced Ig Suppression activation

Inhibition of Th2 production by B
tolerogenic DC" cytokine secretion" lymphocyes" &degranulation of mast
cell, basophil &
Prevent eosinophil"
Enhanced
allergen- Decreased
specific Teff IgG4
IgE " production "
activation"

Promote
Foxp3+ &
IL-10"

Inhibition of
Teff migration
to tissues"

Suppression of
Teff activation"

Regulatory T cell actions"

 Routes by which intestinally derived antigen
might disseminate and generate
widespread systemic tolerance.

Antigen Free antigen

! !
Peyer ’ s Afferent
patches (PP) or intestinal lymph
lamina propria !
! Mesenteric
Portal vein
! lymph nodes
Bloodstream (mLNs)
! !
Liver Thoracic duct
! !
Circulation" Bloodstream

Pabst O, Mowat AM, 2013. Mucosal Immunol 5, 3: 232-239

Routes by which intestinally derived antigen
might disseminate and generate
widespread systemic tolerance.
Systemic tolerance occur, because of antigen presentation in the liver by:
•  sinusoidal endothelial cells
•  tolerogenic conventional dendritic cells (DCs)
•  plasmacytoid DCs (pDCs)

Systemic tolerance
occur, because of
!
antigen reaching
peripheral lymph
nodes (pLNs)
!
will be presented
by resident DCs in
the absence of
costimulation."

Pabst O, Mowat AM, 2013. Mucosal Immunol 5, 3: 232-239

 Mechanisms of antigen uptake in gut-associated lymphoid
tissue (GALT) and lamina propria.
Soluble antigens" tight junctions (II)
Particulate
material
(including
Soluble antigens!
intestinal transcellular routes (III)
microbiota)
! Exosomes"
transcellular
DCs (IV)  
transport
!
Peyer ’s patches
CX3CR1 high
specialized macrophages
microfold !
(I) Capture
luminal
! antigens
Production of !
by extending
CCL20 processes
Attract further through the
DCs epithelial layer
!
(via their pass this
expression of on to
neighboring
CCR6). CD103 + DCs
(V).  
 Tregs "
RA (in mLNs) induces the
expansion in
expression of gut-homing
LP (under
receptors (a4 b7 integrin &
the influence
CCR9)" on T cells (antigen-
of IL-10
specific) " favors the iTregs (II).
produced by
CX3CR1
Migration of high
antigen- macrophages
loaded (IV)
CD103 +
DCs Tregs home
from the (LP) back to LP
into mLNs (III)
(I).

Tregs "exit
"systemic
oral
tolerance
A multistep model of oral tolerance to soluble antigens (V).
 A multistep model of oral tolerance to
particulate antigens
Food proteins get digested partially or completed.
In intestine either food proteins are
absorbed or degraded into smaller
fragments or remain intact.

The
undigested
food
proteins
are taken
to APCs by
M cells
where fate
of allergic
tolerance
determined A mechanistic outline
of oral tolerance
following dietary
antigens.
Kumar S et al. Immunology Letters 149 (2013) 101– 109
The profiles of immune response
in healthy subject

Orihara et. al. WAO Journal 2008, 9-14

Antigen

41"
Thakur A et al. , Vaccine 30 (2012) 4907– 4920
EAACI Global Atlas of Allergy 2014. Editors: Cezmi A. Akdis, Ioana Agache.
 FOXP3+ & FOXP3-"
•  The FOXP3- cells population divided in to (in the peripheral system)
–  Tr1
–  Th1
–  Th2
–  Th3
–  Th17
•  The FOXP3+ cell population is divided into
–  natural Treg (nTreg)
–  induced (iTreg).

•  Treg (nTreg & iTreg)have ability to

–  suppress allergic reactions
–  induce oral tolerance
 •  HEALTHY
Treg >> •  ASYMTOMATIC

Treg >Th2

Treg<Th2

Treg<Th17

Treg>Th17
Orihara et. al. WAO Journal 2008, 9-14
Oral tolerance in Allergy: !
is CD4+Treg have a role?

45"
 Food induced allergic sensitization
Kumar S et al. Immunology Letters 149 (2013) 101– 109

CD28 CTLA4

Tcell response " Allergic Reactions No Tcell response " No Allergic Reactions
 Possible mechanisms Prebiotics & probiotics
!
of prenatal and postnatal influence the mother’s gut
microbiome
induction of tolerance !
by microbial components inducing regulatory cytokines
!
pass the placenta
!
prime the fetal immune
system
!
tolerance

Vaginal birth
!
newborn’s gut acquires the
maternal vaginal
microbiome.

Prebiotics/probiotics
oral
!
homeostatic
Pfefferle PI et.al, J Allergy Clin Immunol 2013 ;131:1453-63 colonization
of the infant’s gut.
+Alergen
+ Placebo

+Alergen
+Lactobacillus
plantarum IS

Probiotics induce :
1.  high circle transcripts to alpha
2.  low circle transcripts to epsilon
Study on animal model (Endaryanto A, et.al., 2006)
 Induction"

Desensitization " Tolerance "

Protection from life- Refers to active modulation

threatening anaphylaxis of the immune response to

Possible mechanisms of Promote Treg Skewing away

from a Th2
desensitization: development response

Decreased activation & release of

Increased Reduced inflammatory mediators
IgG IgE
(by mast cells and basophils)

Scurlock AM, BP Vickery BP, Hourihane JO, AW Burks AW. Mucosal Immunology 3, 345-354 (2010)
 IgG4"

IgE #

Desensitization " Skin prick test (SPT) wheal

size #
Mechanism

Basophil reactivity #

Mean relative binding # "

Increased numbers of
FOXP3-expressing Tregs "

Tolerance " Skewing away from a Th2

response
Scurlock AM, BP Vickery BP, Hourihane Downregulation of genes in
JO, AW Burks AW. Mucosal Immunology 3, apoptosis pathways "
345-354 (2010)
During
desensitization:
1. Mast cell &
basophil
activation
decreased
2. Shift from TH2
to Treg
3. Shift from IgE
to IgG4
4. IgG4 may
compete with
IgE, further
dampening the
TH2 CMI
response
 A randomized, double-blind, placebo-controlled
study of milk oral immunotherapy for cow’s milk allergy.

•  In randomized, double-blind, placebo-controlled study of

cow’s milk oral immunotherapy (OIT) in children
•  Investigators treated 19 children (6–17 years of age) with
cow’s milk allergy
–  desensitization protocol !(a modified rush “build-up day”)
–  dose increases up to 500 mg, followed by daily maintenance dosing
•  Laboratory evaluation of the subjects showed:
–  milk-specific IgE levels
•  no significant difference in the treated vs. untreated groups
–  milk-specific IgG4 levels,
•  significantly increased in the treated vs. untreated groups

Skripak,"J.M."et)al."J.)Allergy)Clin.)Immunol.122,"1154–1160"(2008)"
 Clinical efficacy & immune regulation !
Peanut oral immunotherapy
•  In a cohort study, clinical responsiveness
–  skin prick test reactivity#
–  basophil activation#
•  In patients undergoing OIT
–  peanut-specific IgE levels
•  increased initially
•  then decreased at 12 and 18 months
–  peanut-specific IgG4 levels
•  increased significantly throughout the study.
–  FOXP3 + Tregs
•  increased 1.5-fold in peanut-stimulated cells at 6 and 12 months on therapy
•  decreased thereafter, returning to baseline by 20 months

Jones, S.M. et al 2009. J. Allergy Clin. Immunol. 124, 292–300 (2009).

 Development of natural oral tolerance and
desensitization in cow’s milk allergy
Development of tolerance in CMA
•  Shift from Th2 dominant response toward Th1 type responses.
•  Tregs "numbers# and/or activity# "Th2 responses$
•  Majority of infants develop oral tolerance

Development of desensitization during CM Oral Immunotherapy

•  Similar changes in specific antibody levels with tolerance in CMA.
•  Tregs express IL-10 & TGF-b " induce in B cells "IgG4 & IgA
•  Specific IgG4 & IgA antibodies " tolerance to allergens
•  Specific IgE levels # gradually "as tolerance develops

Savilahti EM, Savilahti E, 2013. Pediatr Allergy Immunol 24, 114–121

 A mechanistic outline of desensitization
following immunotherapy

Allergy Asthma Immunol Res. EAACI Global Atlas of Allergy 2014.

2011;3(1):11-20. Editors: Cezmi A. Akdis, Ioana Agache.
 What is the mechanism of
Oral tolerance in Allergy?

Scurlock AM, BP Vickery BP, Hourihane JO, AW Burks AW. Mucosal Immunology 3, 345-354 (2010)
Hygiene Hypothesis
Original
Hygiene Hypothesis
Microbe Infection"Th1# " Th2$" IgE$"Allergy$

Th1#"

IgE$"

Microbe"
Infec0on" Th2$" Allergy$"

Nat Rev Immunol. 2001;1(1):69-75.

Infectious diseases # " Allergic diseases $
Nat Rev Immunol. 2001;1(1):69-75.
Th1$ " Th2#"IgE#"Allergy# Th1# " Th2$"IgE$"Allergy$

Atopic + Allergen Atopic + Allergen + TB Infection

Th1 Th1

Th0 Th0

Th2 Th2

Allergy
Alergy !!!!
Immunology 2004 112 352–363
 “Original Hygiene Hypothesis”
Allergy = f [Atopic]. [Allergen]. [Th1]. [Th2].

Th0

Th1 Th2
PROTECTION
PROTECTION FOR EC INFECTION
FOR IC INFECTION

Biomed Res Int. 2015;2015:327470. Epub

Modified
Hygiene Hypothesis
(I): by Treg
 Modified Hygiene Hypothesis

NORMAL SUBJECTS PROBIOTICS MECHANISM

TH1 Treg TH2 Probiotics Probiotics Allergen

Allergen TLR2&4
Mast Cell Degranulation(-)
? ? ?
TH1
ALLERGIC SUBJECTS TH1 Treg TH2
Treg
Alergen
TH2
TH1 BL1

Treg Mast Cell Degranulation ? TH1 Treg TH2

Allergic Reaction ?
TH2 BL2

Mast Cell Degranulation(+) Mast Cell Degranulation

Allergic Reaction(+) Allergic Reaction
Endaryanto A et al.WAO Journal 2007;11: S306
 “Hygiene Hypothesis Revisited”
Allergy = f [Atopic]. [Allergen]. [Microbe]. [Th1]. [Th2]. [Treg]

Th0

TOLERANCE

T
reg

Th1 Th2
Micro- PROTECTION
PROTECTION
FOR EC INFECTION
biota FOR IC INFECTION

Biomed Res Int. 2015;2015:327470. Epub

Modified
Hygiene Hypothesis
(II): by Th17
Mycoplasma & Clamidia Infection
!
Th2#
!
IgE #
Allergy 2007: 62: 579–90
Orihara et. al. WAO Journal 2008, 9-14
 •  HEALTHY
Treg >Th17 •  ASYMTOMATIC

>Th17
Treg

Treg<Th17

Treg<Th17

Treg >Th17
Orihara et. al. WAO Journal 2008, 9-14
 “Hygiene Hypothesis Revisited”
Allergy = f [Atopic]. [Allergen]. [Microbe]. [Th1]. [Th2]. [Treg]. [Th17]

Th0

TOLERANCE PROTECTION
FUNGI & BACT
T INFECTION Th
reg 17

Th1 Th2
PROTECTION
PROTECTION FOR EC INFECTION
FOR IC INFECTION

Biomed Res Int. 2015;2015:327470. Epub

Revisited
Hygiene Hypothesis
By Th9 & Th22
 “Hygiene Hypothesis Revisited”
Allergy = f [Atopic]. [Allergen]. [Microbe]. [Th1]. [Th2]. [Treg]. [Th17]. [Th9]. [Th22].

Th0
PROTECTION
FOR INVASIVE
TOLERANCE PROTECTION PATHOGEN
FUNGI & BACT
T INFECTION Th Th
reg 17 22
PRORIASIS
& AD

Th1 Th2 Th9

PROTECTION
PROTECTION FOR EC INFECTION AUTOIMMUNE &
FOR IC INFECTION ALLERGY
(T Cells survival)

Biomed Res Int. 2015;2015:327470. Epub

Thank you