Hypersensitivity reactions are an overreaction of the immune system to an antigen which would not normally trigger an immune response. The antigen may be something in which most people would be ignored, such as peanuts. Alternatively, it may originate from the body. In either case, the damage and clinical symptoms result from the body’s response to the substance rather than by the substance itself.
The vulnerability of an individual to these reactions can have a genetic link. Overreaction to innocuous antigens is linked to changes in the CD regions of T-helper cell membranes, explaining why reactions like peanut allergies can commonly run in families. Overreaction to self-antigens is normally due to a failure in central tolerance which can also have genetic features.
As is the case for many immune reactions, hypersensitivity requires two separate interactions of the immune system with the antigen. The first time an antigen enters the body, it is picked up by antigen-presenting cells (such as macrophages or dendritic cells). It is then taken to the nearest lymph node, where it is presented to naïve T-cells. Cross-linking of the antigen with T-cells, as well as co-stimulatory molecules, can lead to activation of that T-cell. Subsequently, the T-cell differentiates into “primed” Th1, Th2, or Th17 cells. These are specific to that antigen and can stimulate further immune responses if they meet the antigen again. It is this second meeting that could result in a hypersensitivity reaction.
Types of Hypersensitivity Reaction
According to the Coombs and Gell classification, there are four main types of hypersensitivity reaction.
Type 1
In Type 1 hypersensitivity reactions, mast-cell activation is induced by secretion of IgE antibodies. Initial exposure to the antigen causes the priming of Th2 cells. The release of IL-4 by these Th2 cells causes the B cells to switch their production of IgM to IgE antibodies which are antigen-specific. The IgE antibodies bind to mast cells and basophils, sensitising them to the antigen.
When the antigen enters the body again, it cross links the IgE bound to the sensitised cells. This causes the release of preformed mediators including histamine, leukotrienes and prostaglandins. These mediators stimulate widespread vasodilation, bronchoconstriction, and increased permeability of vascular endothelium.
The reaction can be divided into two stages – immediate and late-phase. The immediate phase involves release of pre-formed mediators causing the immune response. The late-phase response 8-12 hours later, where cytokines released in the immediate stage activate basophils, eosinophils, and neutrophils even though the antigen is no longer present.
Fig 1 – Mast Cell Degranulation
Clinical Relevance – Anaphylaxis
Anaphylaxis is a systemic response to an antigen, leading to bronchoconstriction and vasodilation. This causes decline in oxygen transportation and can lead to anaphylactic shock and possibly death. It is usually treated with:
- Adrenaline: to dilate the bronchioles and constrict the blood vessels
- Antihistamines: to reduce the inflammatory effects of histamine
- Corticosteroids: to reduce systemic inflammation
Type 2
Type 2 hypersensitivity reactions are mediated by antibodies targeting cell surface antigens. When these antigens are presented to T-cells, an immune response is started, targeting the cells to which the antigens are attached.
Antibodies binding to cells can activate the complement system, leading to:
- Degranulation of neutrophils
- Release of oxygen radicals
- Formation of membrane attack complex
All of the above leads to destruction of the cell. Parts of the complement activation can also opsonise the target cell, marking it for phagocytosis.
The destruction of host cells in this way can lead to tissue-specific damage. Type 2 hypersensitivity reactions may occur in response to host cells (i.e. autoimmune) or to non-self cells, as occurs in blood transfusion reactions.
Type 2 is distinguished from Type 3 by the location of the antigens. In Type 2, the antigens are cell bound, whereas in Type 3 the antigens are soluble.
Clinical Relevance – Acute Transfusion Reactions
Acute transfusion reactions are when an inappropriate blood transfusion is administered and a patient is given blood not matching their ABO type. This leads to activation of complement and widespread haemolysis by tumour necrosis factor and other interleukins, which can be fatal.
Fig 2 – Summary table of ABO blood groups
Type 3
Type 3 hypersensitivity reactions are mediated by antigen-antibody complexes in the circulation that may be deposited in and damage tissues. The complexes may become lodged in the basement membranes of tissues which have particularly high rates of blood filtration. For example, the kidney and synovial joints being common targets.
Once lodged, the immune complexes rapidly and significantly activate the complement chain. This results in increased vasopermeability, the attraction and degranulation of neutrophils, and the release of oxygen free radicals which can severely damage surrounding cells.
Clinical Relevance – Rheumatoid Arthritis
Rheumatoid arthritis can occur when antigen-antibody complexes circulate in the bloodstream end up lodging in the complex filtration systems responsible for maintaining the levels of synovial fluids at synovial joints. The lodged immune complexes can cause a local inflammatory response, leading to stiffness and pain in affected joints.
Type 4
Type 4 hypersensitivity reactions are mediated by antigen-specific activated T-cells. When the antigen enters the body, it is processed by antigen-presenting cells and presented together with the MHC II to a Th1 cell.
If the T-helper cell has already been primed to that specific antigen, it will become activated. Subsequently, it releases chemokines to recruit macrophages and cytokines such as interferon-γ to activate them.
Activated macrophages release pro-inflammatory factors, leading to local swelling, oedema, warmth, and redness. They also secrete lysosomal elements and reactive oxygen species, again leading to local tissue damage. CD8+ T-cells may be involved in type 4 reactions where a foreign antigen is detected on a cell, such as in organ rejection. This is known as cell mediated cytotoxicity, and results in recruitment and activation of macrophages.
This reaction is also known as delayed-type hypersensitivity due to its characteristic prolonged time to appear following antigen exposure. The reaction takes longer than all other types because of the length of time required to recruit cells to the site of exposure – around 24 to 72 hours.
Clinical Relevance – Contact Dermatitis
Contact dermatitis can result from a wide variety of innocuous substances, such as nickel, poison ivy, or household cleaning products. Because of the delay in transporting Th1 cells to the site of infiltration, symptoms can develop several days after initial exposure. Redness, itching, swelling, and heat are all common.
Fig 3 – Image showing contact dermatitis resulting from a buprenorphine transdermal patch
Summary Table
| Type | Type 1 | Type 2 | Type 3 | Type 4 |
| Reactant | IgE | IgG | IgG | T effector cells |
| Mechanism | Mast-cell activation releases histamines and other mediators | Antigens embedded in host cells cause complement activation and destruction by MAC. | Antibody binds to soluble antigen, forming a circulating immune complex lodge in a vessel wall and causes a local inflammatory response. | APC activates Th1/CTL. T-cells activation macrophages and cause an inflammatory response. |
| Time course | Minutes | Days | ||
| Example | Anaphylaxis | Acute Transfusion Reaction | Rheumatoid Arthritis, Vasculitis, Glomerulonephritis | Contact Dermatitis, Mantoux tuberculin test |
Fig 1 - Mast Cell Degranulation[/caption]