ALLERGY

AND
HYPERSENSITIVITY

Mr. Binu Babu Mrs. Jincy Ealias

M.Sc. Nursing M.Sc. Nursing
 Allergy
A disorder of the immune system often also referred to as
atopy.
Strictly, allergy is one of four forms of hypersensitivity
and is called type I (or immediate) hypersensitivity.
Allergic reactions occur to normally harmless
environmental substances known as allergens.
Reactions are acquired, predictable, and rapid Include
eczema, hives, hay fever, asthma attacks, food allergy, and
reactions to drugs and the venom of stinging insect such
as wasp and bees
 Hypersensitivity Reactions

• Excessive, undesirable (damaging, discomfort-

producing and sometimes fatal) reactions
produced by the normal immune system.
• Require a pre-sensitized (immune) state of the
host
• Gell-Coombs Classified the reactions into four
types based on the mechanisms involved and time
taken for the reaction
• Type I, type II, type III and type IV
• Produce tissue injury
 Hypersensitivity types and Immune
Reactant
• 3 involve antibody-
– Type I (immediate): mediated by IgE (Mast Cells)
– Type II: mediated by IgG or IgM
– Type III (immune complex disease): IgG &
complement
• One involves antigen specific cells-
– Type IV: Delayed type hypersensitivity, cell- mediated
immune memory response.
 Type I Hypersensitivity
• Known as immediate or anaphylactic hypersensitivity
• Sudden, widespread, potentially severe and life-
threatening allergic reactions.
• Involve skin, eyes, nasopharynx bronchopulmonary
tissues and gastrointestinal tract
• The reaction usually takes 15 - 30 minutes from the time
of exposure to the antigen
• Begin with a feeling of uneasiness, followed by tingling
sensations and dizziness.
• Rapidly develop severe symptoms, including generalized
itching and hives, wheezing and difficulty breathing,
fainting, or a combination of these and other allerav
symptoms.
 Anaphylaxis
Most commonly caused by
• Drugs (such as penicillin)
• Insect stings
• Certain foods (particularly eggs, seafood,
and nuts)
• Allergy injections (allergen
immunotherapy)
• Latex
 Type I Hypersensitivity Reactions
Systemic anaphylaxis:
• An acute multi-system severe type I hypersensitivity reaction that can
cause shock, or even death Injection Ingestion->blood stream
Inhaled/Airborne Allergic runny nose:
• Irritation and inflammation of some internal areas of the nose Asthma -
lower airways
Insect bite
• Wheal and flare allergy: skin reaction which occurs in response to
exposure to an allergen. This distinctive reaction is often used in
testing for allergies to determine which allergens trigger a reaction in a
patient.
Hives-ingestion skin
• A rash that is caused by an adverse reaction to certain substances. In
most cases, allergy hives can be traced to certain foods or injections
 Type I Hypersensitivity
• Mediated by IgE
• The primary cellular component is the mast
cell or basophils
• The reaction is amplified and/or modified
by platelets, neutrophils and eosinophils
• The reaction site is mainly mast cells and
eosinophils.
 Mechanism of Reaction
• Involves preferential production of IgE, in response
to certain antigens (allergens).
• IgE has high affinity for its receptor on mast cells
and basophils.
• A subsequent exposure to the same allergen cross
links the cell-bound IgE and triggers the release of
various pharmacologically active substances
• Produce IgE from B-cells
• Cross-linking of IgE Fc-receptor to mast cells
increases Calcium influx in Mast cells and trigger
degranulation of mast cells
Induction and effector mechanisms in
type I hypersensitivity
 T-helper cells

Antigen presentation stimulates T cells to become either "cytotoxic" CD8+

cells or "helper" CD4+ cells. TCR: T-cell receptor
MHC proteins are only found on the surface of specialised antigen-
presenting cells (APCs).
 Type I hypersensitivity
• Response to innocuous
antigen (allergen) IgE
bound to mast cells is
cross-linked
• Mast cell
degranulation -
localized or systemic.
• On blood vessels
• Increase blood flow
and permeability
• Increase fluid, cells
protein in tissues
• Increase flow to lymph
node
• On airway
• Decrease diameter,
increase mucus
congestion, blockage
• On GI increase fluid
secretion, increase
peristalsis Expulsion-
diarrhea
 Type II hypersensitivity
• Known as cytotoxic hypersensitivity
• The antigens are normally endogenous, although
exogenous chemicals can also lead to type II
hypersensitivity.
• Autoimmune thrombocytopenia, autoimmune hemolytic
anemia, Rh disease of the newborn
• The lesion contains antibody, complement and
neutrophils
• The reaction time is minutes to hours.
• Primarily mediated by antibodies of the IgM or IgG
classes and complement
• Antibody IgG mediates cell death.
IgG and clearance of immune
complexes
 Antibody-Dependent Cell-
Mediated Cytotoxicity (ADCC)
• Another form of type II hypersensitivity
• Cells exhibiting the foreign antigen are
tagged with antibodies (IgG or IgM).
• The tagged cells are then recognized by
natural killer (NK) cells and macrophages
(recognized via IgG bound (via the Fc
region) to the effector cell surface receptor
(FcΥRIII)), which in turn kill these tagged
cells
Type II cytotoxicity mechanism
• Diagnostic tests include
– Detection of circulating antibody against the
tissues involved
– The presence of antibody and complement in
the lesion (biopsy) by immunofluorescence.
– Treatment involves anti-inflammatory and
immunosuppressive agents
 Type III hypersensitivity
• Immune complex hypersensitivity
– The reaction may be general or may involve
individual organs including skin, kidneys, lungs,
blood vessels, joints (e,g. rheumatoid arthritis)
or other organs
– This reaction may be the pathogenic mechanism
of diseases caused by many microorganisms
– The reaction may take 3 - 10 hours after
exposure to the antigen
 Type III hypersensitivity
• Mediated by soluble immune complexes -
mostly of the IgG class and sometimes IgM
– Both exogenous (chronic bacterial, viral or parasitic
infections) and endogenous (non-organ specific
autoimmunity) antigens can cause it.
– The antigen is soluble and not attached to the organ
involved.
– Primary components are soluble immune
complexes and complement (C3a, 4a and Sa).
– The damage is caused by platelets and neutrophils
Immune complex hypersensitivity
 Type III hypersensitivity
• Small immune
complexes formed
antigen excess, not
cleared efficiently
• Deposit in vascular wall
(vasculitis)
• Deposit in kidney
(glomerulonephritis)
• Deposit in joints
(arthritis)
• Hall mark is
inflammatory response
 Type III hypersensitivity
• The affinity of antibody and size of immune
complexes are important in production of
disease and determining the tissue involved,
Diagnosis involves
• Tissue biopsies for deposits of Ig and
complement by immunofluorescence.
• The presence of immune complexes in serum
and depletion in the level of complement
• Polyethylene glycol-mediated turbidity to
detect immune complexes.
• Treatment includes anti-inflammatory agents
 Systemic Type III response
• Serum sickness from
passive immunity-
systemic
• Self-limiting as clears
antigen
 Type IV Hypersensitivity
• Known as cell mediated or delayed type hypersensitivity
– The reaction takes two to three days to develop.
– The classical example is tuberculin reaction
• Involved in the pathogenesis of many autoimmune and
infectious diseases
– tuberculosis, leprosy, blastomycosis (fungal infection),
toxoplasmosis (a parasitic disease).
– garanulomas due to infections and foreign antigens.
– contact dermatitis (poison ivy, chemicals, heavy metals, etc.)
• Can be classified into three categories depending on the
time of onset and clinical and histological presentation
 Classifications of hypersensitivity
Type Reaction Clinical Histology Antigen and site
time appearance
Contact 48-72 hr eczema lympocytes Epidermal (organic
followed chemicals, poisons
bymacrophage ivy, heavy metals
edema of etc.
epidermis
Tuberculin 48-72 hr local lympocytes, intradermaI
induration monocytes, (tuberculin
macrophages lepromin, etc
Granuloma 21-28 Hardening macrophages, persistent antigen
days epitheoid or foreign body
and giant cells, presence
fibrosis (tuberculosis,
leprosy, etc.)
Mechanisms of damage in delayed
hypersensitivity
• TH1 release cytokines to activate vascular
endothelium
• Cytokines activate macrophages and cause
release of cytokines and chemokines
• Activated macrophages to produce chemotactic
factor, interleukin-2, interferon-gamma (IFN-
y), Tumor necrosis factor (TNF), cytotoxin etc.
• Transform macrophages into multinucleated
giant multinucleated cell, which eventually
becomes necrotic.
Release of cytokines
Mechanism
 Diagnostic tests for immediate
hypersensitivity
• Skin (prick and intradermal) tests
• Measurement of total IgE and specific IgE
antibodies against the suspected allergens.
• Total IgE and specific IgE antibodies are
measured by a enzyme immunoassay
(ELISA).
• Increased IgE levels are indicative of an
atopic condition
• A genetic predisposition for atopic diseases
 Diagnostic techniques
• Diagnostic tests in vivo include delayed
cutaneous reaction (e.g. Montoux test) and
patch test (for contact dermatitis).
• In vitro tests for delayed hypersensitivity
include mitogenic response, lympho-
cytotoxicity and IL-2 production.
 Treatments
• Antihistamines which block histamine receptors.
• Chromolyn sodium inhibits mast cell degranulation by inhibiting
Ca++ influx.
• Leukotriene receptor blockers or inhibitors of the
cyclooxygenase pathway
• Bronchodilators (inhalants) for bronchoconstriction
• Inhinbitors for cAMP-phosphodiesterase
• Use of IgG antibodies against the Fc portions of IgE that binds to
mast cells - block mast cell sensitization.
• Hyposensitization (immunotherapy or desensitization) to insect
venoms and pollens
• Corticosteroids and other immunosuppressive agents are used
in treatment
 Nursing Assessment
• Physical examination
• History collection
• Assess any kind of allergy. The nurse must assess all
patients for allergies or previous reactions to antigens.
• Assess patient’s knowledge. The nurse must also
assess the patient’s understanding of previous reactions
and steps taken by the patient and the family to prevent
further exposure to antigens.
• New allergies. When new allergies are identified, the
nurse advises the patient to wear or carry identification
that names the specific allergen or antigen.
 Nursing Diagnosis
• Based on the assessment data, the nursing
diagnoses appropriate for the patient are:
• Impaired gas exchange related to ventilation
perfusion imbalance.
• Altered tissue perfusion related to decreased blood
flow secondary to vascular disorders due to
anaphylactic reactions.
• Ineffective breathing pattern related to the swelling
of the nasal mucosa wall.
• Acute pain related to gastric irritation.
• Impaired skin integrity related to changes in
circulation.
THANK YOU