Medicine
®
Diagnostic Accuracy Study
OPEN
Hypersensitivity to fluoroquinolones
The expression of basophil activation markers depends on the
clinical entity and the culprit fluoroquinolone
Tahia D. Fernández (PhD)a, Adriana Ariza (PhD)a, Francisca Palomares (PhD)a, María I. Montañez (PhD)a,
María Salas (MD, PhD)b, Angela Martín-Serrano (BS)a, Rubén Fernández (BS)a, Arturo Ruiz (MD)b,
∗
Miguel Blanca (MD, PhD)b, Cristobalina Mayorga (PhD)a,b, , María J. Torres (MD, PhD)b
Abstract
Although fluoroquinolones (FQs) are generally well-tolerated antibiotics, increasing numbers of hypersensitivity reactions have been
reported. These can be evaluated in vitro by basophil activation tests (BATs); however, sensitivity is not optimal. Many factors could
influence sensitivity such as basophil activation markers. The objective of this study was to evaluate the influence of 2 different
activations markers, CD63 and CD203c, on the sensitivity of BAT to FQ. We studied 17 patients with immediate allergic reactions to
FQ. BAT was performed with moxifloxacin and ciprofloxacin using CD193 (CCR3) for basophil selection and CD203c or CD63 as
activation markers. Stimulation with ciprofloxacin induced a significantly higher expression of CD63 in ciprofloxacin-allergic patients
compared to moxifloxacin-allergic patients (P = 0.002). In patients allergic to moxifloxacin with anaphylactic shock, we have observed
an increase in the percentage of cells that upregulate CD203c, whereas patients with anaphylaxis preferentially upregulate CD63. The
best sensitivity–specificity was obtained using a cutoff of 3 and the culprit FQ, using CD203c for moxifloxacin-allergic patients
(sensitivity = 36.4%; specificity = 94.4%), and CD63 for ciprofloxacin-allergic patients (sensitivity = 83.3%; specificity = 88.9%). A
negative correlation was found between the upregulation of CD63 and CD203c and the time interval between the reaction
occurrence and the performance of the test (Spearman r = 0.446; P < 0.001 for CD63 and Spearman r = 0.386; P < 0.001 for
CD203c). The performance of BAT for FQ allergy must be optimized for each drug, taking into account possible differences in the
stimulation mechanism that leads to the upregulation of different activation markers.
Abbreviations: BAT = basophil activation test, CIP = ciprofloxacin, DPT = drug provocation test, FQ = fluoroquinolones, MOX =
moxifloxacin, SI = stimulation index.
Keywords: anaphylactic shock, anaphylaxis, basophils, fluoroquinolones, immediate hypersensitivity reactions
Editor: Shankar Esaki Muthu.
Funding: This work was supported by the Institute of Health “Carlos III” of the
Ministry of Economy and Competitiveness (grants cofounded by European
Regional Development Fund (ERDF): PI12/02529, Red de Reacciones Adversas a
Alergenos y Farmacos (RD12/0013/0001). Andalusian Regional Ministry of
Economy and Knowledge (grants cofounded by European Regional Development
Fund (ERDF): (CTS-06603); Andalusian Regional Ministry Health (grants: PI0545–2010, PI-0699-2011, and PI-0179-2014). AA holds an Andalucía Talent Hub
Fellowship (TAHUB/II-004) cofunded by The Junta de Andalucia and the UE, VII
Framework Programme of the European Commision (Grant Agreement n° 291780).
TDF hold a ‘Ramon y Cajal’ research contract by Ministry of Economy and
Competitiveness (RYC-2013-13138), MIM hold a Miguel Servet I’ research contract
by Institute of Health “Carlos III” of the Ministry of Economy and Competitiveness
(CP15/00103) (grants cofounded by European Social Fund (ESF): CP14/00034
and CP15/00103 respectively) and CM hold a ‘Nicolas Monardes’ research
contract by Andalusian Regional Ministry Health: C-0044-2012.
1. Introduction
Fluoroquinolones (FQs) are generally considered well-tolerated
antibiotics[1] and have been used for over 30 years to treat a wide
range of infections. Their consumption is increasing, particularly
for certain derivatives like ciprofloxacin (CIP) and more recently
moxifloxacin (MOX).[2] This has led to an increase in allergic
reactions and they are now the non-betalactam antibiotics most
frequently involved in allergic drug reactions.[3–6] Most of these
reactions are thought to be IgE-mediated, being anaphylaxis and
urticaria the most frequently reported,[7–12] but since the
introduction of MOX, more severe reactions, such as anaphylactic shock, have been reported.[8,13] This FQ has been shown to
be involved in >60% of severe reactions.[11]
Immediate allergic reactions to FQs are difficult to diagnose,
and the value of skin testing is controversial. Although some
consider the test useful,[6,9,14,15] most studies show that FQs
induce false-positive results,[7,10,16,17] probably because of the
capacity of some FQs to directly induce histamine release.[10,14]
Therefore, the only test available to diagnose these patients is the
drug provocation test (DPT), which is not risk-free[7,11,12]
especially for severe reactions and older patients. There is a
strong need for a biological test with adequate sensitivity.
To this end, the sepharose radioimmunoassay (Sepharose-RIA)
has been assessed by some groups for evaluating immediate
reactions to FQs; however, sensitivity ranges from 30% to
55%,[7,11] results that can be explained by differences in the FQ
The authors report no conflicts of interest.
Supplemental Digital Content is available for this article.
a
Research Unit for Allergic Diseases, IBIMA-Regional University Hospital of
Malaga-UMA, Málaga, Spain., b Allergy Unit, IBIMA-Regional University Hospital
of Malaga-UMA, Málaga, Spain.
∗
Correspondence: Cristobalina Mayorga, Research Unit for Allergic Diseases,
IBIMA-Regional University Hospital of Malaga, Pl. Hospital Civil, 29009 Malaga,
Spain (e-mail: mayorga.lina@gmail.com).
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
This is an open access article distributed under the Creative Commons
Attribution License 4.0, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Medicine (2016) 95:23(e3679)
Received: 28 December 2015 / Received in final form: 23 March 2016 /
Accepted: 21 April 2016
Published online 1 May 2016
http://dx.doi.org/10.1097/MD.0000000000003679
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Fernández et al. Medicine (2016) 95:23
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administration of a FQ derivative, were initially eligible for
inclusion. Different clinical categories were established: anaphylaxis and anaphylactic shock, defined according to the criteria of
Sampson,[34] and urticaria when manifestations were limited to
the skin and consisted of pruritic, erythematous cutaneous
elevations that blanched with pressure at various sites on the
body. In the allergological work-up, skin testing was not
performed because of its low sensitivity and specificity.[35] For
ethical reasons, patients with anaphylaxis and anaphylactic
shock were considered allergic from clinical history, once other
possible causes were ruled out. In those with urticaria, a DPT was
performed to confirm the diagnosis. The controls consisted of
18 cases with confirmed good tolerance to quinolones. None
of the patients or controls received treatment with systemic
corticoids or cyclosporine during the study.
The study was conducted according to the declaration of
Helsinki and all patients and controls participating in the study
gave their informed consent and protocols were approved by
institutional ethical committees (Ethical Committee of Malaga).
involved and the severity of the reaction. More recently, studies
have shown the utility of the basophil activation test (BAT) for
evaluating FQ-allergic reactions[6,10,11,18,19] with sensitivity
ranging from 50% to 100%,[11,18] which can be explained by
different factors. One of these factors is the type of reaction that,
as occurs with Sepharose-RIA, could influence the results, being
in some studies mainly anaphylactic shock,[18] whereas in others,
the reactions were less severe such as anaphylaxis and
urticaria.[6,11] Sensitivity is also affected by both the FQs
involved in the reaction and the FQs used for the test. It has
been observed that basophil activation is higher with CIP than
with MOX,[11] which was in part explained by the FQs that
originally sensitized the patients.[11] However, it can also be
explained by other intrinsic technical issues such as patient
treatment, that is, systemic steroids and cyclosporin A.[20,21] In
addition, it can be influenced by the fast photodegradation of
MOX, even in laboratory conditions, which influences the
formation of drug–protein conjugates interfering with basophil
activation.[22] Finally, another factor that can influence the
FQ BAT results could be the choice of activation markers,
CD203c[18] and CD63,[10,11,22] as has been demonstrated for
amoxicillin[23] and neuromuscular blocking agents.[24]
Of the different basophil activation markers identified, CD63, a
member of the transmembrane-4 superfamily anchored in the
intracellular granules that are exposed in cellular surface after the
degranulation process,[25] is the most highly validated,[25,26]
although CD203c, constitutively expressed on the surface of resting
basophils[27] and upregulated after stimulation,[28] has been also
shown to be reliable.[23,29] Both markers are related with
degranulation and histamine release, but with 2 different mechanisms proposed, anaphylactic and piecemeal. The former is
characterized by the fusion of the granules to the plasma membrane
to expel their contents and leads to the exposition of CD63[30]; in
piecemeal degranulation, small vesicles are formed from the
histamine-containing granules and gradually shuttled to the plasma
membrane. This is associated with the upregulation of CD203c.[31]
It is also possible that different drugs interact with basophils in
different ways, activating 1 of these 2 pathways specifically. Another
difference between these 2 markers is that CD203c is constitutively
expressed in basophils and increases in expression after activation,
whereas CD63 is expressed only after activation.[32] Both markers
have advantages and disadvantages: CD203c is specific to basophils;
however, the increase in its expression is sometimes difficult
to assess, owing to low changes mainly when evaluating drug
hypersensitivity, or the induction of nonspecific increases when
using interleukin-3 for priming basophils,[33] as well as aspects of
cells manipulation during the testing procedure.[30]
On the contrary, CD63 shows a bimodal expression, making it
easier to measure; however, it is expressed not only in basophils
but also in platelets.
In this study, we evaluated basophil response for 17 patients
with confirmed immediate allergic reactions to FQs using 2
different activation markers CD63 and CD203c. We find that the
upregulation of these markers depends on both the FQs used and
the severity of the reaction.
2.2. DPT
Single-blind placebo-controlled DPT was carried out using CIP
(Ciprofloxacino Normon, Madrid, Spain) or MOX (Actira,
Bayer, Barcelona, Spain) under strict hospital surveillance, as
described.[11] The suspected quinolone was administered at
30-minute intervals in increasing doses until reaching the full
therapeutic dose or symptoms of a drug reaction occurred. For
CIP, the doses administered were 5, 50, 100, 150, and 200 mg
(cumulative dose of 505 mg), followed by ambulatory therapeutical doses for 2 days and for MOX 5, 50, 100, 100, and 150
mg (cumulative dose of 405 mg), and followed by ambulatory
therapeutical doses for 2 days.
2.3. Basophil activation by flow cytometry
BAT was a in-house-made test performed as previously described[36] with different concentrations of quinolones: MOX at
0.2 and 0.1 mg/mL, and CIP at 2 and 0.2 mg/mL (all from Sigma
Aldrich, Saint Louis, MO). The optimal concentrations for each
drug were chosen based on dose–response curves and cytotoxicity.[11] The samples were incubated while protected from light for
30 minutes at 37°C in a water bath to prevent FQ photodegradation.[22] Cells were stained with monoclonal antibodies,
anti-CD63-FITC, CD203c-PE, CCR3-APC (Caltag Laboratories,
Burlingame, CA) and acquired in a FACSCalibur flow cytometer
(Becton-Dickinson Bioscience, San Jose, CA) by acquiring at least
500 to 1000 basophils per sample, selected as CCR3+ cells (Fig S1,
http://links.lww.com/MD/B14). Results were analyzed at blind by 2
independent well-trained researchers with FlowJo software
(FlowJo LLC, Ashland, OR) and activation expressed as percentage
of CD63 or percentage of CD203c and as stimulation index (SI). SI
was calculated as the ratio between the percentage of activated
basophils (CD63+ or CD203c+ cells) in samples stimulated with the
different haptens and the unstimulated sample. The percentage of
spontaneously activated basophils (unstimulated sample) was
required to be ≥5% to calculate the SI, as previously described.[36]
2. Methods
2.4. Statistical analysis
2.1. Patients and controls
Comparisons of quantitative variables without a normal distribution were done by the Mann–Whitney and Kruskall–Wallis
tests. Comparisons of qualitative variables were done by means
of the x2 test. Correlation was measured using Spearman rank
In this retrospective study, all patients referred to the Allergy
Service of Regional University Hospital of Malaga, over a 3-year
period (2013–2015) with an immediate allergic reaction after
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Table 1
Clinical characteristics of patients included in the study.
P1
P2
P3
P4
P5
P6
P7
P8
P9
P10
P11
P12
P13
P14
P15
P16
P17
Sex
Age (y)
Culprit drug
F
F
F
F
F
F
F
M
F
M
F
M
M
F
F
F
F
54
66
56
79
50
68
48
71
51
80
77
74
75
60
79
59
57
MOX
MOX
MOX
MOX
MOX
MOX
MOX
MOX
MOX
MOX
MOX
CIP
CIP
CIP
CIP
CIP
CIP
Reaction
Anaphylactic
Anaphylactic
Anaphylactic
Anaphylactic
Anaphylactic
Anaphylaxis
Anaphylaxis
Anaphylaxis
Anaphylaxis
Urticaria
Urticaria
Anaphylaxis
Anaphylaxis
Anaphylaxis
Urticaria
Urticaria
Urticaria
Time interval (mo)
shock
shock
shock
shock
shock
24
2
4
3
3
1
2
3
1
84
19
1
1
4
10
2
2
CIP, ciprofloxacin; F, female; M, male; MOX, moxifloxacin.
correlation coefficient. All reported P values represent 2-tailed
tests, with values <0.05 considered statistically significant. The R
Project software 3.1.2 was used for the analysis.
(IR: 1–84) months. The drugs involved were MOX for 11 (64.7%)
and CIP for 6 (35.3%) patients. The clinical entities observed were
anaphylactic shock in 5 (29.4%), anaphylaxis in 7 (41.2%), and
urticaria in 5 cases (29.4%). Significant differences in clinical
manifestation were found in different groups depending on the culprit
FQ (P= 0.006) as in all patients with anaphylactic shocks the culprit
FQ was MOX (45.5%). In those cases with urticaria, the diagnosis
was confirmed by a DPT. A control group of 18 sex- and age-matched
tolerant subjects was also included.
3. Results
The study included 17 patients with confirmed immediate allergic
reactions to FQ (Table 1). Thirteen were women (76.5%) and the
median age was 65 (interquartile range [IR]: 48–80) years. The
median time interval between the reaction and the study was 11.12
Figure 1. Basophil activation test (BAT) results in fluoroquinolone (FQ)-allergic patients and controls. Comparison of expression levels for CD63 and CD203c as (A)
percentage of activated cells in controls; (B) stimulation index (SI) in controls; (C) percentage of activated cells in FQ-allergic patients; (D) SI in FQ-allergic patients,
represented as individual data points. Lines represent the mean of all data. Wilcoxon matched-pair tests were performed.
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Figure 2. Comparisons of BAT results in CIP and MOX allergic patients as (A) percentage of cells expressing CD63 or upregulating CD203c and (B) stimulation
index (SI) calculated with %CD63 and %CD203c. Box plots represent the median and IQR. Statistical Mann-Whitney U tests were performed. (C) Differences in
activation marker up-regulation in BAT positive MOX allergic patients. Bars represent the mean and SEM of the percentage of cells expressing CD63 or CD203c
in MOX allergic patients with positive BAT, discriminating between the types of reaction: Anaphylactic Shock or Anaphylaxis.
3.1. CD63 and CD203c upregulation
laxis, and urticaria. We observed an increase in the percentage of
cells that upregulate CD203c in the patients with anaphylactic
shock and in the percentage of cells that upregulate CD63 in patients
with anaphylaxis (Table 2), although these differences were not
significant. However, when the same analysis was done including
only positive patients, we observed a higher increase in CD203c in
the anaphylactic shock patients compared with CD63, whereas in
patients suffering from anaphylaxis, we observed an increase in
CD63 cells (Fig. 2C). No positive BAT was found in urticaria
patients. Moreover, we compared the expression of activation
markers, CD63 and CD203c, in the 2 most frequent clinical entities,
anaphylaxis and urticaria, obtained after incubation with their
respective culprit FQ. Data showed a higher expression of CD63
independently of the clinical entities and the FQ involved in the
reaction (Fig. S2, http://links.lww.com/MD/B14).
Higher expression of CD63 was observed for all FQs and
concentrations tested, although differences were only significant
at 0.2 mg/mL for CIP and MOX when data were analyzed in
terms of percentage (P = 0.04 for MOX; P = 0.01 for CIP)
(Fig. 1A) and SI (P = 0.03 for MOX; P = 0.04 for CIP) (Fig. 1C). In
allergic patients, CIP could upregulate both CD63 and CD203c,
although the percentage of cells expressing CD63hi was
significantly higher compared to CD203chi (P = 0.005). These
differences were not detected with MOX (Fig. 1B). Equivalent
results were observed for SI (P = 0.01) (Fig. 1D).
Classifying the patients according to the culprit FQ, we observed
a significantly higher basophil expression of CD63 after CIP
stimulation in patients allergic to this FQ (P = 0.002) compared with
MOX-allergic patients (Fig. 2A), with similar results found using SI
(P = 0.002) (Fig. 2B). Regarding CD203c, the highest values were
obtained for MOX-allergic patients using the same FQ for the test,
although the differences were not significant (Fig. 2A and B).
In terms of the relation between the upregulated marker and the
clinical entity, we analyzed MOX-allergic patients, the only group
that included patients suffering from anaphylactic shock, anaphy-
3.2. Sensitivity and specificity
We assessed 2 different SI cutoff points, 2 and 3, with results
showing a better sensitivity–specificity with a cutoff of 3 and
using the culprit FQ. Using CD203c as activation marker for
MOX-allergic patients gave sensitivity = 36.4%; specificity =
Table 2
BAT results in moxifloxacin and ciprofloxacin allergic patients. Data represent means ± SEM.
MOX (n = 11) tested with MOX
Shock (N = 5)
Anaphylaxis (N = 4)
Urticaria (N = 2)
CIP (n = 6) tested with CIP
Shock (N = 0)
Anaphylaxis (N = 3)
Urticaria (N = 3)
%CD63
%CD203c
SI CD63
SI CD203c
4.54 (±0.39)
16.43 (±7.25)
2.90 (±0.70)
6.90 (±1.84)
11.89 (±3.40)
3.34 (±0.75)
0.84 (±0.07)
2.42 (±0.86)
0.51 (±0.13)
1.34 (±0.31)
2.35 (±0.71)
0.57 (±0.13)
—
14.78 (±7.03)
24.25 (±7.85)
—
4.61 (±0.63)
9.67 (±1.99)
—
2.74 (±1.34)
4.59 (±1.53)
—
0.85 (±0.11)
1.84 (±0.38)
CIP, ciprofloxacin; MOX, moxifloxacin; SI, stimulation Index.
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Table 3
Sensitivity and specificity of BAT using 2 different stimulation index cutoffs.
Sensitivity SI >2
Specificity SI >2
Patients allergic to:
MOX
Marker
Drug tested
MOX
CIP
CIP
Controls
CD63
CD203c
CD63
CD203c
CD63
CD203c
18.2%
63.6%
36.4%
54,5%
0%
83.3%
0%
33.3%
55.6%
55.6%
72.2%
83.3%
Sensitivity SI >3
Specificity SI >3
Patients allergic to:
Marker
Drug tested
MOX
MOX
CIP
CD63
9.1%
36.4%
CIP
CD203c
36.4%
9.1%
CD63
0%
83.3%
Controls
CD203c
0%
0%
CD63
77.8%
88.9%
CD203c
94.4%
94.4%
Sensitivity is expressed as percentage of positive patients. Specificity is expressed as the percentage of negative controls. CIP, ciprofloxacin; MOX, moxifloxacin; SI, stimulation index.
94.4%; using CD63 for CIP-allergic patients gave sensitivity =
83.3%; specificity = 88.9% (Table 3).
We have also analyzed the effect of the time interval between
the reaction occurrence and the performance of the test in the
upregulation of basophil activation markers, finding a negative
correlation for both markers (Spearman r = 0.446; P < 0.001
for CD63 and Spearman r = 0.386; P < 0.001 for CD203c) (Fig.
S4A and S4B, http://links.lww.com/MD/B14). This seems to be
more important for MOX-allergic patients, and their best marker
CD203c, with a higher negative correlation with the time interval
(Spearman r = 0.646; P < 0.001) (Fig. S4C, http://links.lww.
com/MD/B14).
3.3. Correlation between CD63 and CD203c activation
markers
Expression of both markers, CD63 and CD203c, showed a
positive correlation (Spearman r = 0.671; P < 0.001) in the whole
group of FQ-allergic patients, indicating that both are valid
markers in BAT (Fig. 3). Significant correlations between the 2
markers were also obtained for MOX-allergic patients (Spearman r = 0.725; P < 0.001) (Fig. S3A, http://links.lww.com/MD/
B14) for anaphylactic shock (Spearman r = 0.661; P = 0.007) (Fig.
S3B, http://links.lww.com/MD/B14) and anaphylaxis (Spearman
r = 0.923; P < 0.001) (Fig. S3C, http://links.lww.com/MD/B14).
The slope was more pronounced in the anaphylactic shock
patients showing the relevance of CD203c in this diagnosis.
4. Discussion
In the last decade, increased consumption of FQs has led to more
allergic reactions to these drugs and increased severity.[3,8,11]
Diagnosis is difficult owing to the low value of skin
testing,[6,7,9,10,14–17] as some FQs have the capacity to induce
direct histamine release.[17] In fact, it has been described that a
mast cell receptor, MRGPRX2, can be activated nonspecifically
by FQs, inducing degranulation and release of histamine,
b-hexosaminidase, tumor necrosis factor, and PGD2 among
others, being probably one of the reason for false-positive results
in skin tests.[37] BAT with FQ[6,10,11,18] has been used for
diagnosis with sensitivity ranging from 50%[19] to 100%[18] and
specificity from 80%[11] to 100%.[6,18] These differences may be
because of the number of patients,[10,18] culprit FQ, the clinical
manifestations, with only 2 studies including patients with
anaphylactic shock,[11,18] and the activation markers used. In this
work, we have analyzed 2 different basophil activation markers,
CD63 and CD203c, to diagnose immediate reactions to MOX
and CIP in a well-characterized population with a high
proportion of severe reactions, including anaphylaxis and
anaphylactic shock (70.6% of cases). As reported in previous
studies,[8,11,12] we have detected that anaphylactic shock only
occurred in MOX-allergic patients (45.5% of these reactions).
Interestingly, we have found that the use of each FQ, MOX, or
CIP in the BAT mainly induces the upregulation of a specific
activation marker, CD63 or CD203c, which could be related to
the severity of the reaction; however, further analysis with larger
number of patients should be carried out to confirm this
observation.
Although mast cells have been considered the primary effector
cells in IgE-mediated reactions, basophils also play an important
role in the development of an early immune response[38,39] and
constitute an important target for the in vitro evaluation of these
reactions. CD63, the most widely used activation marker,[25] is
Figure 3. Correlation between CD63 and CD203c expression in FQ-allergic
patients. Each point represents an individual patient for a given drug
concentration.
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Acknowledgements
exposed at the cellular surface after the degranulation processes,[25] whereas CD203c is constitutively expressed on the surface
of resting basophils[27] and upregulated after stimulation.[28]
Although both markers were correlated in expression when
considering all patients, our results showed differences related to
the FQs used in the test. We found that CIP induced a greater
upregulation of CD63, whereas MOX preferentially upregulated
CD203c. A similar pattern can be found for other drugs: Abuaf
et al[23] (2008) found that CD203c seems to have more sensitivity
for the detection of amoxicillin-activated basophils, but CD63
had more sensitivity in patients with anaphylaxis to muscle
relaxants.[24] Differences have also been described for allergens:
CD203c is a better marker for latex allergy[40]; CD63 is more
specific but CD203c more sensitive for bee or wasp allergy[32];
and both can be reliable markers for cat allergy diagnosis.[29]
These studies suggest that different basophil activation pathways
exist depending on the culprit.
Other explanations for these differences could be based on the
existence of different activation mechanisms related to the clinical
entity. Analyzing MOX-allergic patients, the only group containing
patients suffering from all 3 clinical entities, we have observed
differences in the upregulated marker: in patients who suffered
anaphylactic shock, an upregulation of CD203c was found, whereas
patients with anaphylaxis showed a CD63 upregulation. These
markers are differentially located in the cell, CD203c molecules in
vesicles near the membrane, whereas CD63 is stored in granules.[32]
These molecules might be related to the 2 potential degranulation
pathways, piecemeal and anaphylactic. In piecemeal degranulation,
small vesicles from the histamine-containing granules are formed
and rapidly shuttled to the plasma membrane.[30,31] This process
could lead to the upregulation of CD203c, present in other small
vesicles distinct from histamine-containing granules,[33] and may be
linked to stimulation by certain drugs and the development of severe
reactions like anaphylactic shock.[18] In the second mechanism,
anaphylactic degranulation, the main granules are fused to the
plasma membrane, releasing the entire contents to the extracellular
space. CD63, present in the membrane of these granules, is thus
exposed on the surface of basophils.[33] This process is slower than
piecemeal degranulation and could be related to the development of
anaphylaxis or urticaria.[8]
The time interval between reaction occurrence and the BAT
performance should also be considered. We have found negative
correlations between the 2 markers, CD63 and CD203c, and the
time interval. This agrees with results for other drugs, wherein a
rapid negativization of the test has been found several months
after the reaction occurred, owing to the loss of drug-specific IgE
in non-reexposed patients,[41,42] and highlights the importance of
performing BAT soon after the reaction.
Finally, we found better results for sensitivity and specificity
using an SI cutoff of 3 and using the culprit drug for the test.
However, the activation marker must be different for each drug:
CD203c for MOX- and CD63 for CIP-allergic patients.
Moreover, it is important to take into account the type of
reaction: it is important to include CD203c in addition to CD63
when evaluating anaphylactic shock, whereas CD63 seems to be
more related to anaphylactic reactions, as has been previously
reported.[11]
In conclusion, the performance of BAT for drug allergy must be
optimized for each drug, taking into account the possible
differences in the stimulation mechanism that leads to the
upregulation of different activation markers, influencing BAT
results.
The authors thank James R Perkins for help with English
language, Ana Molina for help with the laboratory work and
IBIMA major statistics service for help with statistical analysis.
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