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Feature

PATHOGENESIS
ALLERGY
Professor Munir Pirmohamed, PhD

OF PENICILLIN

Professor Pirmohamed presents an expert tutorial on the fascinating complexity of immune responses to -lactam antibiotics. Recent insights may explain why antibiotic allergy varies so widely and is worse in the presence of certain viral infections.
llergic reactions are, by definition, immunologically mediated. It is believed that drugs (which are less than 1000Da in weight) must form stable adducts (drugprotein conjugates) with endogenous proteins to initiate an immune response [1]. This is the basis of the hapten hypothesis of drug hypersensitivity. lactam antibiotics are intrinsically reactive. This is because the -lactam ring is chemically unstable and can open spontaneously to form reactive intermediates which combine with free amino groups on soluble or cell-bound proteins forming several antigens, the commonest of which is the penicilloyl antigen (see Figure 1) [2]. It is important to note, however, that the majority of antibiotics cannot react directly with proteins and require metabolism to produce chemically reactive species, which, once formed, conjugate with proteins [1]. Examples of such drugs include sulfamethoxazole which

undergoes bioactivation to the nitroso metabolite and trimethoprim which can be converted to an iminoquinone methide intermediate [3, 4]. The necessity for a drug to form a drugprotein conjugate before it can induce an immune response lies at the heart of traditional immunological theories which suggest that hapten-protein conjugates are required for the antigen to be taken up and undergo intracellular catabolism

The ability to mount an immune response to the penicillin antigens is under genetic control.
in so-called antigen presenting cells, prior to presentation (in association with major histocompatibility complex (MHC) molecules) of recognisable epitopes on the surface of these cells. However, recently the fundamental concept that protein-conjugation is an obligatory

Figure 1: Structure of the major antigenic determinant from penicillin

step in the process of immune recognition of drugs has been challenged by the observation that T cell clones from patients hypersensitive to a number of drugs undergo proliferation in an antigen-processing-independent (but MHCrestricted) manner [5]. Regardless of the mechanism of antigen presentation, it is clear that the antigenic determinants formed from a single drug vary amongst patients, adding incredible complexity to any type of drug allergy testing. For instance, from penicillin, the major antigenic determinant (the most common antigenic determinant generated) is formed from the penicilloyl configuration (see Figure 1), but minor antigenic determinants formed from penicillenic or penicilloic acid may also be extremely important in penicillin allergy, either in combination with or independent of the major determinant [6]. Moreover, in some patients allergic to semi-synthetic penicillins, the immunogenic determinant may be derived from the side chain of the molecule [7]. Given that the -lactam ring is the predominant source of the penicillin antigens, it explains the cross-reactivity that is witnessed with other antibiotics such as cephalosporins, and newer compounds such as meropenem, in patients with a history of penicillin allergy.

The nature of the immune response may be categorised according to the Gell and Coombs classification of hypersensitivity. While drug-specific IgE and IgG

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Allergy to Antibiotics
antibodies are central to immediate-type hypersensitivity reactions and cytotoxic/immune complex reactions, respectively, there is now increasing laboratory evidence that drug-specific activated T cells play a central role in the pathogenesis of antibiotic allergy. T cells proliferating to -lactam antibiotics have been demonstrated in penicillin-allergic patients [8]. Polarization of the T cells into Th1 and Th2 phenotypes, through mechanisms that are unclear, determines the clinical manifestations. Thus, T cells from individuals with penicillin-induced anaphylaxis have a predominant Th2 phenotype, secreting large amounts of IL-4, while a Th1 phenotype is characteristic of drug-induced exanthematous eruptions [9, 10]. Apart from T cells, the immune response to the penicillinderived antigen may also be characterised by antibodies directed against either the drug (haptenic epitopes), the carrier protein (autoantigenic determinant) or the neoantigen created by the combination of the drug and the protein (new antigenic determinant). The most feared manifestation of penicillin allergy is anaphylaxis. Several factors determine the likelihood that a patient will develop an anaphylactic reaction (and other immunologic reactions) to penicillin. It has been found that in patients on high doses of penicillin, there is little inter-individual variability in circulating penicilloyl groups, yet fewer than 40% show a detectable serological response, suggesting that the ability to mount an immune response to the penicillin antigens is under genetic control. Interestingly, atopic patients, who have high IgE levels, are at greater risk of experiencing anaphylactic reactions to penicillin. Furthermore, the half-life of the IgE antibodies, once formed, is enormously variable ranging from 10 days to >1000 days. Other risk factors include the age and route of administration with adulthood and parenteral drug use increasing the risk of anaphylaxis. The factors responsible for translating the serological response to tissue damage are poorly understood but relate to the ability of the mast cell to release chemical mediators including histamine, serotonin and leukotrienes. These mediators which are released upon cross-linking of the IgE antibodies on the mast cell surface cause vasodilatation and increased permeability of the small blood vessels, and bronchospasm resulting in the clinical syndrome of anaphylaxis. In some instances, the clinical manifestation of penicillin allergy does not involve the skin, but is limited to an internal organ. The best example of this is the occurrence of cholestatic hepatitis that has been reported with co-amoxiclav and flucloxacillin. The reason why the liver is involved with these drugs in some patients is unclear. An emerging concept that may be extremely important in the pathogenesis of antibiotic allergy is the concept, proposed by Matzinger, that drugs may elicit danger signals [11]. The danger model basically states that the immune systems major focus is not on self and non-self, but rather that it responds to alarm signals that are generated by stressed cells or those undergoing injury [12]. T-cell recognition of an antigen in the absence of costimulation (a danger signal) results in tolerance, while recognition in the presence of costimulation leads to T cell activation. According to Matzinger drugs will not elicit an immune response unless there is cellular stress or danger. In drug-induced reactions, there are several ways in which danger signals may be generated. First, drug metabolites may be formed that, in addition to combining with antigen-specific T-cell receptors, also may provide costimulatory factors or danger signals by activating signaling pathways that result in oxidative stress and protein damage [1]. Alternatively, costimulatory factors may be provided by the host, not the drug. Inflammatory cytokines produced in response to an infection may lead to the generation of danger signals that activate drug-specific T cells leading to drug hypersensitivity responses. This latter mechanism may explain the higher frequency of antibiotic allergy in the presence of certain viral infections [13]. For instance, in patients with Epstein-Barr virus (EBV)-induced infectious mononucleosis who are treated with penicillin or tetracycline, the prevalence of druginduced exanthems is 14-23% in adults and approaches 100% in children [14]. A similar mechanism may account for the increased number of antibiotic reactions seen in patients with HIV disease. The reasons for individual susceptibility to penicillins include environmental factors, as outlined above, and genetic factors. The latter however have been poorly defined, with only a limited number of studies having evaluated the role of MHC polymorphisms in predisposing to delayed hypersensitivity responses to aminopenicillins and liver injury with co-amoxiclav [15, 16]. In conclusion, the mechanism by which penicillin causes allergic reactions is not completely understood. Given the importance of this class of agent, it is important that further mechanistic studies are undertaken so that we can better understand, and predict, penicillin allergy.

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Drugs will not illicit an immune response unless there is cellular stress or "danger".

Author
Professor Munir Pirmohamed, PhD Professor of Clinical Pharmacology The University of Liverpool Ashton Street Liverpool, L69 3GE, UK munirp@liv.ac.uk

References
1. Park BK, Pirmohamed M, Kitteringham NR. The role of drug disposition in drug hyper-

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sensitivity: a chemical, molecular and clinical perspective. Chemical Research in Toxicology 1998;11:969-88. 2. DiPiro JT, Adkinson NF, Jr., Hamilton RG. Facilitation of penicillin haptenation to serum proteins. Antimicrob Agents Chemother 1993;37(7):1463-7. 3. Farrell J, Naisbitt DJ, Drummond NS, et al. Characterization of sulfamethoxazole and sulfamethoxazole metabolite-specific T-cell responses in animals and humans. J Pharmacol Exp Ther 2003;306(1):229-37. 4. Lai WG, Zahid N, Uetrecht JP. Metabolism of trimethoprim to a reactive iminoquinone methide by activated human neutrophils and hepatic microsomes. J Pharmacol Exp Ther 1999;291(1):292-9. 5. Schnyder B, Mauri-Hellweg D, Zanni M, Bettens F, Pichler WJ. Direct, MHC-dependent presentation of the drug sulfamethoxazole to human alpha/beta T cell clones. Journal of Clinical Investigation 1997;100: 136-41. 6. Weltzien HU, Padovan E. Molecular features of penicillin allergy. J Invest Dermatol 1998;110(3):203-6. 7. Mayorga C, Torres MJ, Romano A, et al. Monoclonal antibodies to amoxicillin express different idiotypes determined by anti-idiotype antibodies production. Allergy 2002;57 Suppl 72:45-51. 8. Brander C, Mauri-Hellweg D, Bettens F, Rolli H, Goldman M, Pichler WJ. Heterogeneous T cell responses to beta-lactam-modified selfstructures are observed in penicillin-allergic individuals. J Immunol 1995;155(5):2670-8. 9. Naisbitt DJ, Vilar J, Stalford A, Wilkins EGL, Pirmohamed M, Park BK. Plasma cysteine and decreased reduction of nitroso sulphamethoxazole with HIV infection. AIDS Res Hum Retrov 2000:in press. 10. Pichler WJ. Delayed drug hypersensitivity reactions. Ann Intern Med 2003;139(8): 683-93. 11. Matzinger P. Tolerance, danger, and the extended family. Annu Rev Immunol 1994;12:991-1045. 12. Anderson CC, Matzinger P. Danger: the view from the bottom of the cliff. Semin Immunol 2000;12(3):231-8; discussion 57344. 13. Sullivan JR, Shear NH. The drug hypersensitivity syndrome: what is the pathogenesis? Arch Dermatol 2001;137(3):357-64. 14. Renn CN, Straff W, Dorfmuller A, AlMasaoudi T, Merk HF, Sachs B. Amoxicillininduced exanthema in young adults with infectious mononucleosis: demonstration of drugspecific lymphocyte reactivity. Br J Dermatol 2002;147(6):1166-70. 15. Romano A, De Santis A, Romito A, et al. Delayed hypersensitivity to aminopenicillins is related to major histocompatibility complex genes. Ann Allergy Asthma Immunol 1998;80(5):433-7. 16. O'Donohue J, Oien KA, Donaldson P, et al. Co-amoxiclav jaundice: clinical and histological features and HLA class II association. Gut 2000;47(5):717-20.

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