Hypersensitivity Reactions In Humans Research Articles

Fungal Sensitization and Human Allergic Disease.

Fungal sensitizations have been associated with hypersensitivity reactions with variable levels of evidence available to link types of fungi with human disease. We conducted systematic reviews of the literature to identify the strength of evidence linking lesser-studied fungi for which there are commercially available extracts to identify populations in which they were useful in clinical practice. Excluding five fungi for which hundreds of articles were identified, there are 54 articles on the remaining fungi with clinical data. For 12 of the fungi, the prevalence of fungal sensitization varies in different hypersensitivity disorders due to factors related to geographic areas, age, and other underlying medical conditions. There were no studies linking seven genera to human disease. Most of the commercially available fungal extracts are uncommonly associated with hypersensitivity reactions in humans. Specific extracts may be useful in particular disease states such as allergic fungal sinusitis or allergic bronchopulmonary mycosis, or when routine testing fails to identify a cause of uncontrolled disease, such as in asthma.

Immunoglobulin E-specific allergens against leaf in serum of dogs with clinical features of grass leaf allergy.

Grass leaf has been suspected of causing immunoglobulin (Ig)E-mediated immediate hypersensitivity reactions in humans and dogs. However, most studies in this area are case-control studies without in vitro data showing the involvement of IgE in the reaction. Laboratory studies have demonstrated the reactivity to a 50-55 kDa protein with clinical signs immediately after contact with grass leaf material. The clinical findings of dogs with atopic-like dermatitis immediately after contact with grass leaf material suggest the involvement of grass leaves as the allergen source. This study was designed to test the IgE-reactivity of grass leaf proteins in dogs with clinical signs and positive scratch test results against grass leaf material. The serum of 41 patients with a history of allergy and suspected to grass leaf material was immunoblotted against grass leaf extracts from five suspected grass species. The IgE-positive blots were separated with 2D gel electrophoresis and analysed with mass spectrometry (MS). Commercially supplied proteins were used to validate immunoblot activity. The serum of 25 dogs diagnosed with grass dermatitis had positive IgE-specific immunoblot against one or more grass leaf extracts. The MS data indicated a reactive band at 55 kDa to be beta-amylase or RuBisCO (ribulose-1,5-bisphosphate carboxylase/oxygenase) large subunit (RbLS). All tested dog sera showed IgE-reactivity with beta-amylase and some with RbLS. Canines with clinical signs of grass-related dermatitis had IgE-reactivity against grass leaf proteins. Serum IgE-reactivity to beta-amylase and RuBisCO large subunit may indicate that these proteins act as allergens, possibly causing pruritus and skin lesions.

Targeted proteomics and specific immunoassays reveal the presence of shared allergens between the zoonotic nematodes Anisakis simplex and Pseudoterranova decipiens

The family Anisakidae, mainly represented by Anisakis simplex s.l. and Pseudoterranova decipiens, encompasses zoonotic nematodes infecting many marine fish. Both are responsible for gastrointestinal disease in humans after ingestion of a live larva by consumption of undercooked fish, and, in the case of A. simplex, an allergic reaction may occur after consuming or even handling infected fish. Due to its phylogenetic relatedness with A. simplex, few studies investigated the allergenic potential of P. decipiens, yet none of them focused on its excretory/secretory (E/S) proteins that easily get missed when working solely on extracts from crushed nematodes. Moreover, these E/S allergens remain behind even when the larva has been removed during fish quality processing. Therefore, the aim was to investigate if Anisakis-like allergens could also be detected in both crushed and E/S P. decipiens protein extract using targeted mass spectrometry analysis and immunological methods. The results confirmed that at least five A. simplex allergens have homologous proteins in P. decipiens; a result that emphasizes the importance of also including E/S protein extracts in proteomic studies. Not only A. simplex, but also P. decipiens should therefore be considered a potential source of allergens that could lead to hypersensitivity reactions in humans.

Quantitative assessment of sensitizing potency using a dose\u2013response adaptation of GARDskin

Hundreds of chemicals have been identified as skin sensitizers. These are chemicals that possess the ability to induce hypersensitivity reactions in humans, giving rise to a condition termed allergic contact dermatitis. The capacity to limit hazardous exposure to such chemicals depends upon the ability to accurately identify and characterize their skin sensitizing potency. This has traditionally been accomplished using animal models, but their widespread use offers challenges from both an ethical and a scientific perspective. Comprehensive efforts have been made by the scientific community to develop new approach methodologies (NAMs) capable of replacing in vivo assays, which have successfully yielded several methods that can identify skin sensitizers. However, there is still a lack of new approaches that can effectively measure skin sensitizing potency. We present a novel methodology for quantitative assessment of skin sensitizing potency, which is founded on the already established protocols of the GARDskin assay. This approach analyses dose–response relationships in the GARDskin assay to identify chemical-specific concentrations that are sufficient to induce a positive response in the assay. We here compare results for 22 skin sensitizers analyzed using this method with both human and LLNA potency reference data and show that the results correlate strongly and significantly with both metrics (rLLNA = 0.81, p = 9.1 × 10–5; rHuman = 0.74, p = 1.5 × 10–3). In conclusion, the results suggest that the proposed GARDskin dose–response methodology provides a novel non-animal approach for quantitative potency assessment, which could represent an important step towards reducing the need for in vivo experiments.

Sequence-based Identification of Allergen Proteins Developed by Integration of PseAAC and Statistical Moments via 5-Step Rule

Background: Allergens are antigens that can stimulate an atopic type I human hypersensitivity reaction by an immunoglobulin E (IgE) reaction. Some proteins are naturally allergenic than others. The challenge for toxicologists is to identify properties that allow proteins to cause allergic sensitization and allergic diseases. The identification of allergen proteins is a very critical and pivotal task. The experimental identification of protein functions is a hectic, laborious and costly task; therefore, computer scientists have proposed various methods in the field of computational biology and bioinformatics using various data science approaches. Objectives: Herein, we report a novel predictor for the identification of allergen proteins. Methods: For feature extraction, statistical moments and various position-based features have been incorporated into Chou’s pseudo amino acid composition (PseAAC), and are used for training of a neural network. Results: The predictor is validated through 10-fold cross-validation and Jackknife testing, which gave 99.43% and 99.87% accurate results. Conclusions: Thus, the proposed predictor can help in predicting the Allergen proteins in an efficient and accurate way and can provide baseline data for the discovery of new drugs and biomarkers.

Discovery of Alpha-Gal-Containing Antigens in North American Tick Species Believed to Induce Red Meat Allergy.

Development of specific IgE antibodies to the oligosaccharide galactose-α-1, 3-galactose (α-gal) following tick bites has been shown to be the source of red meat allergy. In this study, we investigated the presence of α-gal in four tick species: the lone-star tick (Amblyomma americanum), the Gulf-Coast tick (Amblyomma maculatum), the American dog tick (Dermacentor variabilis), and the black-legged tick (Ixodes scapularis) by using a combination of immunoproteomic approach and, carbohydrate analysis. Anti-α-gal antibodies identified α-gal in the salivary glands of both Am. americanum and Ix. scapularis, while Am. maculatum and De. variabilis appeared to lack the carbohydrate. PNGase F treatment confirmed the deglycosylation of N-linked α-gal-containing proteins in tick salivary glands. Immunolocalization of α-gal moieties to the salivary secretory vesicles of the salivary acini also confirmed the secretory nature of α-gal-containing antigens in ticks. Am. americanum ticks were fed on human blood (lacks α-gal) using a silicone membrane system to determine the source of the α-gal. N-linked glycan analysis revealed that Am. americanum and Ix. scapularis have α-gal in their saliva and salivary glands, but Am. maculatum contains no detectable quantity. Consistent with the glycan analysis, salivary samples from Am. americanum and Ix. scapularis stimulated activation of basophils primed with plasma from α-gal allergic subjects. Together, these data support the idea that bites from certain tick species may specifically create a risk for the development of α-gal-specific IgE and hypersensitivity reactions in humans. Alpha-Gal syndrome challenges the current food allergy paradigm and broadens opportunities for future research.

Identification of MHC Haplotypes Associated with Drug-induced Hypersensitivity Reactions in Cynomolgus Monkeys.

Drug-induced hypersensitivity reactions can significantly impact drug development and use. Studies to understand risk factors for drug-induced hypersensitivity reactions have identified genetic association with specific human leukocyte antigen (HLA) alleles. Interestingly, drug-induced hypersensitivity reactions can occur in nonhuman primates; however, association between drug-induced hypersensitivity reactions and major histocompatibility complex (MHC) alleles has not been described. In this study, tissue samples were collected from 62 cynomolgus monkeys from preclinical studies in which 9 animals had evidence of drug-induced hypersensitivity reactions. Microsatellite analysis was used to determine MHC haplotypes for each animal. A total of 7 haplotypes and recombinant MHC haplotypes were observed, with distribution frequency comparable to known MHC I allele frequency in cynomolgus monkeys. Genetic association analysis identified alleles from the M3 haplotype of the MHC I B region (B*011:01, B*075:01, B*079:01, B*070:02, B*098:05, and B*165:01) to be significantly associated (χ2 test for trend, p < 0.05) with occurrence of drug-induced hypersensitivity reactions. Sequence similarity from alignment of alleles in the M3 haplotype B region and HLA alleles associated with drug-induced hypersensitivity reactions in humans was 86% to 93%. These data demonstrate that MHC alleles in cynomolgus monkeys are associated with drug-induced hypersensitivity reactions, similar to HLA alleles in humans.

Identification of IgE-binding peptide and critical amino acids of Jatropha curcas allergen involved in allergenic response.

Increasing energy demand has spurred interest in the use of biofuels. Jatropha curcas (physic nut), an inedible oilseed, is a potential source of bioenergy. The seeds, however, contain allergens such as Jat c 1, a 2S albumin that can induce hypersensitivity reactions in humans and result in allergic diseases. Recent advances in identifying and characterizing plant allergens and, in particular, their immunoglobulin E (IgE)-binding epitopes have produced a wealth of information. We identified IgE-binding regions and the critical amino acids involved in the degranulation of mast cells and the release of histamine, preliminary steps for the prevention and treatment of this allergy. Four IgE-binding regions were identified in the sequence of Jat c 1. We identified and demonstrated the fundamental role of two glutamic acid residues in IgE binding. The sequence LEKQLEEGEVGS produces a random loop on the most exposed part of Jat c 1. This region is important to the stimulation of the allergic response. The possibility of using this information to produce vaccines and other pharmacological agents for allergy treatment is discussed.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-016-2036-5) contains supplementary material, which is available to authorized users.

Estriol strongly inhibits DNCB-induced contact dermatitis: role of antigen-specific antibodies in pathogenesis.

The endogenous estrogens are important modulators of the immune system and its functions. However, their effects are rather complex and many aspects have not been studied. In this study, we used the 1-chloro-2,4-dinitrobenzene (DNCB)-induced contact dermatitis as a disease model and investigated the effect of estriol (E3), along with two other estrogens, 17β-estradiol and estrone, on the pathogenesis of contact hypersensitivity. A series of parameters, such as ear swelling, skin inflammation, antigen-specific immunoglobulins, and lymphocyte compositions in peripheral lymphoid organs, were evaluated in mice following development of contact dermatitis. We found that administration of all three estrogens elicited strong inhibition of DNCB-induced dermatitis, while E3 exerted the strongest suppressive effect. Administration of E3 alleviated dermatitis, and this effect was accompanied by decreases in serum DNCB-specific immunoglobulins, such as IgA, IgG1, IgG2a, and IgG2b. Besides, treatment with E3 reduced B cell population, especially IgG-producing cells in the peripheral lymphoid organs following the induction of dermatitis. These observations consistently suggest that the antibody (Ab)-mediated humoral immune reactions play a critical role in the pathogenesis of DNCB-induced contact dermatitis. The results from this study demonstrate, for the first time, that estrogen administration has a strong suppressive effect on the pathogenesis of contact dermatitis. These findings offer important insights concerning the pathogenic role of antigen-specific Abs in contact dermatitis and the treatment of chemical-induced, Ab-mediated skin hypersensitivity reactions in humans.

Immunoglobulin E-Binding Epitopes of Mite Allergens: From Characterization to Immunotherapy

House dust mites and storage mites produce a number of allergens that can induce hypersensitivity reactions in humans and result in allergic diseases like asthma, rhinitis, and dermatitis. Recent advances in identifying and characterizing these allergens--and, in particular, their immunoglobulin E (IgE)-binding epitopes--have produced a wealth of knowledge. Here, methods for identifying IgE-binding epitopes, from immunoassays to in silico approaches, are summarized and placed in context with the identification of epitopes of mite allergens, particularly from the Dermatophagoides spp. major allergen groups 1 and 2. Finally, the transfer of this information to the clinical development and application of new diagnostic and immunotherapeutic approaches is discussed. While progress in recent years has built on the specific immunotherapies established decades ago, much work remains to be done to mitigate mite allergic disease. Future studies should seek to identify epitopes for mite species beyond Dermatophagoides and for minor allergens. Efforts in translational medicine should use the current epitope data to develop modified allergens for immunotherapy.

The Transcription Factor MAZR Preferentially Acts as a Transcriptional Repressor in Mast Cells and Plays a Minor Role in the Regulation of Effector Functions in Response to FcεRI Stimulation

Mast cells are key players in type I hypersensitivity reactions in humans and mice and their activity has to be tightly controlled. Previous studies implicated the transcription factor MAZR in the regulation of mast cell function. To study the role of MAZR in mast cells, we generated a conditional Mazr allele and crossed Mazr F/F mice with the Vav-iCre deleter strain, which is active in all hematopoietic cells. MAZR-null BM-derived mast cells (BMMC) were phenotypically indistinguishable from wild-type BMMCs, although the numbers of IL-3 generated Mazr F/F Vav-iCre BMMCs were reduced in comparison to Mazr F/F BMMCs, showing that MAZR is required for the efficient generation of BMMC in vitro. A gene expression analysis revealed that MAZR-deficiency resulted in the dysregulation of 128 genes, with more genes up- than down-regulated in the absence of MAZR, indicating that MAZR acts as a transcriptional repressor in mast cells. Among the up-regulated genes were the chemokines Ccl5, Cxcl10, Cxcl12, the chemokine receptor Ccr5 and the cytokine IL18, suggesting an immunoregulatory role for MAZR in mast cells. Enforced expression of MAZR in mature Mazr-deficient BMMCs rescued the altered expression pattern of some genes tested, suggesting direct regulation of these genes by MAZR. Upon FcεRI stimulation, Mazr expression was transiently down-regulated in BMMCs. However, early and late effector functions in response to FcεRI-mediated stimulation were not impaired in the absence of MAZR, with the exception of IL-6, which was slightly decreased. Taken together, out data indicate that MAZR preferentially acts as a transcriptional repressor in mast cells, however MAZR plays only a minor role in the transcriptional networks that regulate early and late effector functions in mast cells in response to FcεRI stimulation.

Occupational Exposure to Aspergillus by Swine and Poultry Farm Workers in Portugal

Aspergillus is among a growing list of allergens that aggravate asthmatic responses. Significant pulmonary pathology is associated with Aspergillus-induced allergic and asthmatic lung disease. Environments with high levels of exposure to fungi are found in animal production facilities such as for swine and poultry, and farmers working with these are at increased risk for occupational respiratory diseases. Seven Portuguese poultry and seven swine farms were analyzed in order to estimate the prevalence, amount, and distribution of Aspergillus species, as well as to determine the presence of clinical symptoms associated with asthma and other allergy diseases in these highly contaminated settings. From the collected fungal isolates (699), an average incidence of 22% Aspergillus was detected in poultry farms, while the prevalence at swine farms was 14%. The most frequently isolated Aspergillus species were A. versicolor, A. flavus, and A. fumigatus. In poultry farms, A. flavus presented the highest level of airborne spores (>2000 CFU/m3), whereas in swine farms the highest was A. versicolor, with an incidence fourfold greater higher than the other mentioned species. Eighty workers in these settings were analyzed, ranging in age from 17 to 93 yr. The potentially hazardous exposure of poultry workers to mold allergens using sensitization markers was evaluated. Although no significant positive association was found between fungal contamination and sensitization to fungal antigens, a high incidence of respiratory symptoms in professionals without asthma was observed, namely, wheezing associated with dyspnea (23.8%) and dyspnea after strenuous activities (12.3%), suggesting underdiagnosed respiratory disturbances. Further, 32.5% of all exposed workers noted an improvement of respiratory ability during resting and holidays. From all the analyzed workers, seven were previously diagnosed with asthma and four reported the first attack after the age of 40 yr, which may be associated with their occupational exposure. Some of the fungi, namely, the Aspergillus species detected in this study, are known to induce hypersensitivity reactions in humans. This study confirmed the presence and distribution of Aspergillus in Portuguese poultry and swine farms, suggesting a possible occupational health problem and raising the need for preventive and protective measures to apply to avoid exposure in both occupational settings.

Immunotherapy of allergic diseases by bacterial products

Allergic diseases are characterized by excessive immunoglobulin E (IgE) production, mast cell degranulation, tissue eosinophilia and mucus hypersecretion. These responses also take place during infection with multicellular parasites, and are linked to the production of a characteristic set of cytokines by T helper (Th)2 cells. By contrast, many other microbial infections are associated with cytokine production by Th1 or Th17 cells. There have been extensive efforts to subvert the Th2 responses of allergic diseases by treatment with microbial products.

Successful expression and purification of dppd, using a codon optimized synthetic gene

DPPD (Rv0061) is a difficult to express protein of Mycobacterium tuberculosis that elicits strong and specific delayed type hypersensitivity reactions in humans infected with M. tuberculosis. Therefore e DPPD is a molecule that can improve the specificity of the tuberculin skin test, which is widely used as an aid for the diagnosis of tuberculosis. However, a pitfall of our initial studies was that the DPPD molecule used to perform the skin tests was engineered as fusion molecule with another Mycobacterium protein. This approach was used because no expression of DPPD could be achieved either as a single molecule or as a fusion protein using a variety of commercially available expression systems. Here, we report the production and purification of rDPPD using a synthetic gene engineered to contain E. coli codon bias. The gene was cloned into pET14b expression vector, which was subsequently used to transform Rosetta 2(DE3) pLysS or BL-21(DE3)pLysS host cells. The recombinant protein was over-expressed after induction with IPTG and its purification was easily achieved at levels of 5 - 10 mg/l of bacterial broth cultures. The purified protein was confirmed to be DPPD by Mass Spectroscopy sequencing analysis. Moreover, purified rDPPD stimulated peripheral blood mononuclear cells of PPD positive blood donors to produce high levels of IFN-γ, thus confirming that this molecule is biologically active. Because of the DPPD gene is restricted to the tuberculosis-complex organisms of Mycobacterium genus, this highly purified molecule should be useful for the identification of individuals sensitized with tubercle bacilli.

Surface-modified magnetic colloids for affinity adsorption of immunoglobulins

This work describes the preparation, characterization and in vitro adsorption tests of surface-modified magnetoliposomes for affinity binding of (i) anticardiolipin (isotype G) antibodies and (ii) specific isotype E antibodies generated by hypersensitivity reactions in humans with respiratory allergy. In the first case, cardiolipin embedded in the bilayer of magnetoliposomes was used as specific ligand. In the second case, antigenic proteins present in an extract of Dermatophagoids pteronyssinus and Blomia tropicalis mites were covalently coupled on the surface of magnetoliposomes via a diglycolic spacer arm, and used as specific ligands for IgE. Antibody adsorption was performed in a high-gradient magnetophoresis system, using either sera of healthy individuals or a pool of sera from autoimmune or allergic patients. The selectivity and capacity of the system were quantified by a frontal analysis in a capillary column, and by constructing breakthrough curves. The results show that the highest yield and selectivity were obtained if the ligand was extended into the aqueous layer surrounding the magnetoliposome surface. A 100% selectivity was obtained for adsorption of specific IgE, and 8% for IgG. These results demonstrate the potentialities of both types of surface-modified magnetic biocolloids in the field of in vitro diagnosis tests for allergic or autoimmune conditions.

Cutaneous Contact Urticaria to Pyrethrum–Real?, Common?, or Not Documented?: An Evidence-Based Approach

Reports suggest that pyrethrum, the insecticidally active extract from Chrysanthemum cinerariifolium, can induce Type I hypersensitivity reactions in humans. Using knowledge of pyrethrum chemistry and an evidence-based analysis of literature, whether current refined pyrethrum induces and/or elicits skin manifestations of contact urticaria was assessed. Current extraction and refinement techniques suggest that refined pyrethrum lacks the presence of significant, if any, proteins speculated to induce Type I hypersensitivity. Our interpretation suggests that no reports of Type I reactions presented in the literature fulfill the criteria for immunologic contact urticaria. Future patient testing with current commercial material should clarify its Type I immunologic potential, if any.

Clinical relevance of preclinical testing for allergic side effects

Immune-mediated hypersensitivity reactions include exaggerated humoral or cell mediated responses to specific antigens and may culminate in adverse, potentially life threatening effects. The immune status of the host and presence of infections or other disorders can alter the kind and extent of immune mediated side effects in individuals. Such variability in the immune status may influence the type of idiosyncratic reaction(s) that patients manifest. The issues typically encountered from a drug development standpoint include the potential for contact hypersensitivity, respiratory sensitivity, systemic hypersensitivity, photoallergy, and pseudoallergy. There are no accepted in vitro or in vivo models available to measure and predict all types of hypersensitivity reactions in humans. There is a need for the development of preclinical models to predict all types of hypersensitivity reactions in humans. The FDA immunotoxicology guidance document recommends doing preclinical testing in animal models for topical and inhalational drugs before initiation of multiple dose studies in humans. Any signs of potential immune related drug hypersensitivity should be further evaluated in an attempt to further understand the potential for hypersensitivity reactions in humans. In summary, existing preclinical models have limited capability for prediction of drug allergy in humans except for topical and inhalational drugs. Additional tools are needed to evaluate drugs in early development and improve performance of existing assays.

Resin Monomer 2-Hydroxyethyl Methacrylate (HEMA) is a Potent Inducer of Apoptotic Cell Death in Human and Mouse Cells

Mechanisms by which the resin monomer 2-hydroxyethyl methacrylate (HEMA) induces hypersensitivity reactions in humans are not well-established, nor have the direct effects of HEMA on cell death been fully characterized. The objective of this study was to establish whether HEMA is capable of inducing apoptotic cell death, and whether differences exist in the levels of apoptotic death induced by HEMA in cells obtained from healthy individuals and from patients with established HEMA hypersensitivity. HEMA induced apoptotic death in Peripheral Blood Mononuclear Cells (PBMCs) obtained from both healthy and HEMA-sensitized patients and in the murine RAW cells in a dose-dependent manner. However, induction of cell death by HEMA was lower in PBMCs obtained from patients in comparison with healthy individuals. Studies reported in this paper demonstrate that HEMA induces apoptotic death, and that decreased susceptibility of lymphocytes to HEMA-mediated death might be an important mechanism for the generation and persistence of hypersensitivity reactions in patients.

P73 The magnitude of contact allergy responses can be quantified with imaged perfusion

Objective: The objective of this study was to determine whether the magnitude of the perfusion of the contact hypersensitivity response as measured by the laser Doppler perfusion imaging (LDPI) technique was associated with immunological parameters implicated in the pathogenesis of the disease.Methods: Urushiol was applied on one of the forearms of volunteers for 48 hours while the other forearm served as a control. Twenty‐four hours later, measurements of perfusion of the patch test sites were performed with the LDPI technique. To determine whether there was a correlation with immunological parameters associated with human contact hypersensitivity, suction blisters were produced at the test sites. Blister fluid was removed and examined for the cytokine interleukin‐8 (IL‐8).Results: There was an extremely close correlation between the magnitude of the contact hypersensitivity response as measured by the imaged perfusion and the level of IL‐8 in the blister fluid (r = 1.00). Compared to subjects with visually positive urushiol reactions, patients who failed to develop urushiol contact hypersensitivity despite repeated exposures to that substance had both greatly diminished perfusion and blister fluid IL‐8 levels.Conclusion: The results indicate that LDPI is a sensitive method of quantifying contact hypersensitivity reactions in humans and that the magnitude of the measurements with this technique correlates extremely well with cutaneous cytokine levels that have been implicated in the immunopathogenesis of contact hypersensitivity.

Delayed Hypersensitivity Skin Testing

Many substances, both natural and manufactured, cause inflammation when introduced into living tissue. Some compounds cause a local inflammatory reaction in all exposed individuals and often are called toxic or irritant reactions. Skin testing with other compounds causes an inflammatory response in a limited number of subjects. Those reactions that occur on the basis of specific immune responses are termed hypersensitivity reactions, and the responding individuals are said to be hypersensitive to that antigen. Intradermal skin testing may induce four or more types of cutaneous hypersensitivity reactions in humans 35 : (1) an immediate wheal and flare reaction related to the presence of antigen-specific immunoglobulin E (IgE) in the skin; (2) an IgE-mediated late-phase reaction that follows the wheal and flare, begins several hours after injection, and peaks at 12 to 24 hours; (3) a local vasculitic reaction peaking at 12 to 24 hours that results from the interaction of complement-fixing antibody and antigen at the injection site (Arthus reaction); and (4) a lymphocyte and macrophage-dependent delayed hypersensitivity reaction (DHR). Erythema and induration at the injection site peaks at 48 hours after the injection. The latter reaction is the subject of this article.