Evaluation of a lymphocyte transformation test and cytokine detection assay to identify phenytoin and carbamazepine provoked DRESS or SJS/TEN in epilepsy patients
Introduction
Drug hypersensitivity reactions (DHRs) are one of the major public health problems [1,2]. DHRs are classified into four types according to Gell-Coombs classification. Type I and type IV hypersensitivity is mediated by drugs that have been reported to cause severe adverse drug reactions [3,4]. The severe manifestation of type I drug hypersensitivity is anaphylaxis, whereas type IV drug hypersensitivity elicits severe cutaneous adverse drug reactions (SCARs). The common clinical manifestations of SCARs are various such as drug rash with eosinophilia and systemic symptoms (DRESS) and Stevens-Johnson syndrome with toxic epidermal necrolysis (SJS/TEN) with mortality rates of up to 70% [[5], [6], [7], [8]].
Anti-epileptic drugs (AEDs) are important medications for epilepsy treatment [9,10]. Unfortunately, these drugs can cause SCARs [11,12]. Phenytoin (PHE) and carbamazepine (CBZ) are common drugs widely prescribed for epilepsy patients. As reviewed elsewhere, PHE and CBZ are the first rank causative drugs provoking SCARs [13]. The prevalence of PHE and CBZ-induced SCARs is 13% and 11%, respectively [14].
To determine drug-induced SCARs in patients, Naranjo's assessment has been employed [15]. This assessment provides four outcomes; doubtful, probable, possible and definite, whereas most outcomes are given as grey zones (probable and possible). To obtain a definite diagnosis, other investigations are required [16,17]. The drug provocation test has been accepted as the gold standard method for diagnosis; however, it has not been recommended for patients suffering from SCARs [18]. Therefore, in vitro tests might be a promising alternative test to define the specific drugs causing SCARs [19]. The utility of common in vitro tests such as the lymphocyte transformation test (LTT) and cytokine detection assays by either enzyme-linked immunosorbent assay or enzyme-linked immunospot have been investigated [16]. Although LTT has been widely used to assess DHRs for more than two decades, its efficacy is variable and depends on many factors [4,[20], [21], [22]]. Detection of cytokine production as a means to assess drug-induced immune responses has recently been proposed [23,24]. However, the sensitivity and specificity of cytokine detection assays was very low. Meanwhile, the use of both LTT and cytokine detection assay for the diagnosis of AEDs-induced hypersensitivity, especially PHE and CBZ, has yet to be evaluated.
Aim of our study was to evaluate the efficacy of LTT and cytokine detection assay in the diagnosis of PHE and CBZ-induced hypersensitivity in epilepsy patients. LTT and cytokine detection assay were performed to assess volunteers. The sensitivity and specificity of these tests were calculated and further analyzed with receiver operator characteristic.
Section snippets
Patient accumulation and sample collection
Twenty well characterized epilepsy patients, with complete medical records, that were allergic to PHE and CBZ were categorized as responders (R). These patients were assessed with Naranjo's criteria (score ≥ 3) and their clinical manifestations were assessed and confirmed by dermatologists. Twenty people, who had never received PHE and CBZ, were classified as healthy donors (N). Thirteen patients that received PHE and CBZ and never developed SCARs were grouped as exposed non-reactive (ENR). N
Donor characteristic
Fifty-three volunteers were recruited from July 2014 to June 2016 as shown in Table 1. The mean age among exposed non-reactive (ENR) and responder (R) groups in this study was not statistically different. Twenty cases were male (37.74%) and thirty-three were female (62.26%). Peripheral blood mononuclear cells (PBMCs) from one volunteer might be incubated with more than one drug, hence, numbers of PBMC cultivation with PHE and CBZ in normal healthy subjects (N), ENR and R were 20, 14, 27 and 11,
Discussion
Definite identification of culprit drugs still remains difficult in practice [2]. Clinical assessment for drug allergy such as Naranjo's algorithm is simple, widely acceptable and takes a short time to assess; however, it requires experience and an understanding of the assessors [15,28]. Another drawback is that the majority of Naranjo's outcomes fall in a grey zone. Therefore, other tools are needed to identify culprit drugs for definite diagnosis. There are many in vivo tests that can give a
Acknowledgments
We gratefully thank all the donors that participated in this project. This study was funded by a research grant from the Research Division of the Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand. P.T. and Y.S. were supported by the Chalermprakiat Fund, Faculty of Medicine, Siriraj Hospital. P·K. was funded by the Post Graduate Study Division, Graduate Study, Mahidol University, Thailand. Critical reading and grammatical correction by Dr. James Dubbs was so appreciated. Last
Author contributions
Y.S. conceived and designed the experiments; P.K., S.U., and T.T. performed the experiments; P.K and Y.S. analyzed the data; P.T. recruited patients; Y.S., P.K., and P.T. wrote the paper.
Conflicts of interest
The authors declare no conflict of interest. The funding sponsors had no role in the design of the study; in the collection, analysis and interpretation of the data; in the writing of the manuscript or in the decision to publish the results.
References (42)
- et al.
Adverse drug reactions: definitions, diagnosis, and management
Lancet
(2000) - et al.
Anticonvulsant hypersensitivity syndrome: cross-reactivity with tricyclic antidepressant agents
Ann. Allergy. Asthma. Immunol.
(2006) - et al.
Antiepileptic drugs and adverse skin reactions: an update
Pharmacol. Rep.
(2015) - et al.
In vitro rapid diagnostic tests for severe drug hypersensitivity reactions in children
Ann. Allergy. Asthma. Immunol.
(2016) - et al.
Allergen-specific T-cell response in patients with phenytoin hypersensitivity; simultaneous analysis of proliferation and cytokine production by carboxyfluorescein succinimidyl ester (CFSE) dilution assay
Allergol. Int.
(2007) - et al.
Long-lasting reactivity and high frequency of drug-specific T cells after severe systemic drug hypersensitivity reactions
J. Allergy Clin. Immunol.
(2006) - et al.
Pathogenesis and diagnosis of delayed-type drug hypersensitivity reactions, from bedside to bench and back
Clin. Transl. Allergy
(2015) - et al.
Drug hypersensitivity reactions: response patterns, drug involved, and temporal variations in a large series of patients
J. Investig. Allergol. Clin. Immunol.
(2012) - et al.
In vitro drug causality assessment in Stevens-Johnson syndrome - alternatives for lymphocyte transformation test
Clin. Exp. Allergy
(2013) - et al.
Severe cutaneous adverse drug reactions
J. Dermatol.
(2016)
T-cell-mediated drug hypersensitivity: immune mechanisms and their clinical relevance
Asia Pac. Allergy
T cell involvement in cutaneous drug eruptions
Clin. Exp. Allergy
T cell-mediated hypersensitivity reactions to drugs
Annu. Rev. Med.
Antiepileptic drug interactions - principles and clinical implications
Curr. Neuropharmacol.
Antiepileptic drugs: indications other than epilepsy
Epileptic Disord.
Drug hypersensitivity reactions involving skin
Handb. Exp. Pharmacol.
In vitro diagnostic assays are effective during the acute phase of delayed-type drug hypersensitivity reactions
Br. J. Dermatol.
A method for estimating the probability of adverse drug reactions
Clin. Pharmacol. Ther.
In vitro models to evaluate drug-induced hypersensitivity: potential test based on activation of dendritic cells
Front. Pharmacol.
In vivo diagnosis of allergic diseases—allergen provocation tests
Allergy
Drug provocation testing in the diagnosis of drug hypersensitivity reactions: general considerations
Allergy
Cited by (15)
Differential cytokine profiles produced by anti-epileptic drug re-exposure of peripheral blood mononuclear cells derived from severe anti-epileptic drug patients and non-allergic controls
2022, CytokineCitation Excerpt :A p-value < 0.05 was considered to be significant. Many medications have been reported to cause SCARs, and AEDs are among the most common SCARs causative drugs [24–29]. Three percent of epilepsy patients have cutaneous reactions, and the incidence of epilepsy patients suffering from SCARs could be up to 4 of every 10,000 patients [30].
Lymphocyte transformation test and cytokine detection assays: Determination of read out parameters for delayed-type drug hypersensitivity reactions
2021, Journal of Immunological MethodsCitation Excerpt :Gaspard et al., 2000; Tsuge et al., 2007; Halevy and Grossman, 2008; Khalil et al., 2008). In our study, production of IFN-γ, detected by multiplex bead immunoassay, provided comparable sensitivity (75.0%) consistent with the aforementioned studies suggesting that IFN-γ could be used as a diagnostic marker to identify culprit drugs in delayed DHRs (Kumkamthornkul et al., 2018). Interestingly, the sensitivity of the IFN-γ detection (75.0%) was comparable to the sensitivity of LTT (75.0%); however, its specificity (100%) was higher than that of LTT (91.2%).
Phenytoin – An anti-seizure drug: Overview of its chemistry, pharmacology and toxicology
2020, Food and Chemical ToxicologyCitation Excerpt :Allergic reactions to phenytoin present themselves as a rash. They can sometimes, if rarely, take up more severe forms, e.g. anaphylaxis or DRESS (drug reaction with eosinophilia and systemic symptoms) (Kumkamthornkul et al., 2018). A side effect linked to DRESS syndrome is the drug-induced hypersensitivity syndrome (amongst other names).
Post-acute phase and sequelae management of epidermal necrolysis: an international, multidisciplinary DELPHI-based consensus
2023, Orphanet Journal of Rare Diseases