Allergy march from atopic dermatitis to lifelong allergy

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Presented at The MSD Standing Alone: "From Atopic Dermatitis to Allergic Rhinitis: The Rational Management in Pediatrics".
Surabaya June, 23, 2013.

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  • Presented at The MSD Standing Alone: 'From Atopic Dermatitis to Allergic Rhinitis: The Rational Management in Pediatrics'. Surabaya June 23 2013 Shangrilla Hotel, Surabaya.
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Allergy march from atopic dermatitis to lifelong allergy

  1. 1. Allergy March: from AtopicDermatitis to Lifelong AllergyProf DR Dr Ariyanto Harsono SpA(K)
  2. 2. INTRODUCTIONProf DR Dr Ariyanto Harsono SpA(K)The term “allergic march” refers to the natural history ofatopic manifestations, which is characterized by a typical se­quence of IgE antibody responses and clinical symptoms thatappear early in life, persist over years or decades,even lifelong.1. Once IgE mediated allergy occurs, theprocess continues in a babys life2. Sensitization to another food proteins thatwould otherwise occur2Usually the first sensitization to cows milk
  3. 3. Food Allergens• Fruits• Cow’s Milk• Egg• Fish• NutsProf DR Dr Ariyanto Harsono SpA(K)3
  4. 4. 4 Sorts of allergensProf DR Dr Ariyanto Harsono SpA(K)4
  5. 5. SensitizSensitizaattiionon in Uteroin UteroT cells has been responding to the fetus at22 weeks.T cells have been responding navel atbirth: mite ~ 47% eggs, cow’s milk ~ 75% Low level of IFN­γ and high level of IL­4& 10 IgE at birth to Cows milk, wheat, eggs.Prof DR Dr Ariyanto Harsono SpA(K)5
  6. 6. Aktivasisel­selImuno­kompeten•Sel T•Sel B•Sel Mast•SelLanger­hansAktivasisel­selstruk­tural•Selendotel•SelepitelAktivasi danRekruitmen•Sel Mast•Eosinofil•Neutrofil•BasofilPelepasanmediatorKerusakanepitelStimulasineuralDilatasi &peningkatanpermeabilitasvaskulerlBronkokonstriksiPerbaikanepitel•Proliferasifibroblast•Deposisikolagen•Hipertropi/hiperplasia otot polos•EkspansivaskulerPenyempitansaluran nafasbawahSymptomalergiBronkushiper-reaktifALERGENA B C D EImunopathology of allergyAirwayremodelling6Trigger
  7. 7. Prof DR Dr Ariyanto Harsono SpA(K)7
  8. 8. SususapiAPC MHC-II Th0IL-1Th-2Th.1IL-12 IL-2, IFN-γB-CellIL-4IL-5SEL PLASMASEL MEMORIIL-6IL-10AMemory CellsProf DR Dr Ariyanto Harsono SpA(K)8ACTIVATION of IMMUNOCOMPETENCE CELLS ByANTIGEN
  9. 9. Prof DR Dr Ariyanto Harsono SpA(K)9(J Allergy Clin Immunol 1999;118:124-6)Th1Dendritic cellEosinophileNeutrophile
  10. 10. Prof DR Dr Ariyanto HarsonoSpA(K)1011Ariyanto Harsono MD PhDProf DR.dr. Ariyanto Harsono SpAK
  11. 11. VACCINATIONACTIVATIONANTIGENSPECIFICB CELLGENERATION OFMEMORYACTIVATEDCD4+Th-2 CELL IL-4DIFFERENTIATION& AFFINITYMATURATIONANTIBODY SECRETINGPLASMA CELLSANTIGENPROCESSING &PRESENTATIONMHC Class II B CELL IMMUNOGLOBULINET CELL RECEPTOR ANTIGENB CELLIL-5,IL-13Cow’s Milk ProteinCow’s Milk epitopeIgE mediated: Asthma, Rhinitis, Dermatitis Atopic, Urticaria, Abdominal colic11
  12. 12. Mast Cells and basophiles involve in allergicreaction in the context of antigen-IgE Prof DR Dr Ariyanto Harsono SpA(K)12
  13. 13. IgGIgG mediated:Protein loosing enteropathy, Gastro-intestinal haemorrhage, Abdominal ColicProf DR Dr Ariyanto Harsono SpA(K)113
  14. 14. IgMProf DR Dr Ariyanto Harsono SpA(K)1IgM mediated:Protein loosing enteropathy, Gastro-intestinal haemorrhage, Abdominal Colic 14
  15. 15. BAKTIVASI SEL-SEL STRUKTURALNature Rev Immunol 2003; 3: 867-78NeutrophilEosinophilProf DR Dr Ariyanto Harsono SpA(K)15
  16. 16. CMEDIATOR RELEASEProf DR Dr Ariyanto HarsonoSpA(K)16
  17. 17. Granule contents:Histamine,TNF-α,Proteases,Heparin, ECF, NCFLipid mediators:ProstaglandinsLeukotrienesCytokine production:Specifically IL-4, IL-13Prof DR Dr Ariyanto Harsono SpA(K) 17
  18. 18. D EFFECTS of MEDIATOR RELEASE on TARGET ORGANNature Rev Immunol 2004: 3:234-237Prof DR Dr Ariyanto HarsonoSpA(K)18
  19. 19. TargetOrganIgE-mediated disorder Non IgE-mediateddisorderSkinGastro-intestinalRespiratoryTractMulti-systemUrticaria and angioedemaAtopic DermatitisOral Allergy SyndromeGastrointestinal anaphylaxisAllergic eosinophilic gastroenteritisAsthma; Allergic RhinitisFood-induced anaphylaxisFood associated, exercise-inducedanaphylaxisAtopic DrmatitisDermatitis HerpetiformisProctocolitisEnterocolitisAllergic eosinophilic-gastroenteritisEnteropathy syndromeCeliac DiseaseHeiner SyndromeClinical ManifestationE SymptomsProf DR Dr Ariyanto Harsono SpA(K)19
  20. 20. Prof DR Dr Ariyanto HarsonoSpA(K)20Prof DR Dr Ariyanto Harsono SpA(K)Atopic Dermatitis
  21. 21. Prof DR Dr Ariyanto HarsonoSpA(K)21Prof DR Dr Ariyanto Harsono SpA(K)Urtikaria
  22. 22. Prof DR Dr Ariyanto Harsono SpA(K)22Udema Quinke
  23. 23. Prof DR Dr Ariyanto Harsono SpA(K)23Oral Allergi sindrome
  24. 24. Prof DR Dr Ariyanto Harsono SpA(K) 24Asma bronkial
  25. 25. Prof DR Dr Ariyanto Harsono SpA(K)25Rinitis Alergika
  26. 26. Prof DR Dr Ariyanto Harsono SpA(K)26Rinitis Alergika
  27. 27. Target organ Unusual Clinical manifestation•Skin•ENT•Respiratory•Gastrointestinal•Multi systemVasculitis; Fixed Skin EruptionChronic Serous Otitis MediaChronic Pulmonary disease (Heiner Syndrome)Hypersensitivity pneumonitisConstipation; Gastroesophageal refluxIrritability/Sleeplessness in infants; colic, Arthropathy;Nephropathy; ThrombocytopeniaUnusual Clinical ManifestationProf DR Dr Ariyanto Harsono SpA(K)27
  28. 28. Unusual ManifestationProf DR Dr Ariyanto Harsono SpA(K)28
  29. 29. Unusual ManifestationProf DR Dr Ariyanto Harsono SpA(K)29
  30. 30. Unusual ManifestationProf DR Dr Ariyanto Harsono SpA(K)30Fixed Skin Eruption
  31. 31. CEProf DR Dr Ariyanto HarsonoSpA(K)31Unusual ManifestationAbdominal Colic
  32. 32. Prof DR Dr Ariyanto Harsono SpA(K)Unusual Manifestation32Abdominal Colic
  33. 33. Sensitization to environmentalallergens from indoor andoutdoor sources requires moretime and is generally observedbetween the first and tenthyears of life.Prof DR Dr Ariyanto Harsono SpA(K) 33
  34. 34. THE FIRST STEP OF THE ATOPICMARCH: ATOPIC DERMATITISProf DR Dr Ariyanto Harsono SpA(K) 34AD starts early in the first few years in life. Of theaffected children,45% of them had the condition during the first 6months of life,60% during the first year of life andup to 85% suffered AD before 5 years of age.Less than half of the patients with AD have completeresolution by 7 years of age andonly 60% of them have resolution by adulthood,indicating the chronic nature of AD.
  35. 35. Several studies have demonstrated the allergicmarch from atopic eczema to the developmentof asthma and allergic rhinitis.• In general, atopic dermatitis is the firstclinical manifestation of the IgE response,with the highest incidence during the firstthree months of life and the highest periodprevalence during the first three years oflife.Prof DR Dr Ariyanto HarsonoSpA(K)35
  36. 36. Factrors Influencing AllergyMarchExpsure to EndotoxinePollutants and Tobacco Smoke asAdjuvant FactorsBowel flora, vaccinations, antibioticsand allergyLifestyle and the Development ofAtopic DiseaseProf DR Dr Ariyanto HarsonoSpA(K)36
  37. 37. Exposure to endotoxinProf DR Dr Ariyanto Harsono SpA(K) 37Endotoxin exposure is another possible protectivefactor against allergy in early life. Endotoxins consist ofa family of molecules called lipopolysaccharides (LPS)and are an intrinsic part of the outer membrane ofGram-negative bacteria. It has been suggested thatincreased exposure to endotoxins on farms or inhomes with animals could modify immune responsesto reduce the prevalence of atopic diseases.
  38. 38. Pollutants and TobaccoSmoke as Adjuvant FactorsProf DR Dr Ariyanto Harsono SpA(K) 38Pollutants and Tobacco smoke, though notserving as allergens, are capable ofupregulating existing IgE responses, leadingeither to disease manifestation or to anaggravation of symptoms.
  39. 39. Bowel flora, vaccinations,antibiotics and allergyProf DR Dr Ariyanto Harsono SpA(K) 39The intestinal microflora might well be the major source ofmicrobial stimulation of the immune system in early childhood.The intestinal microflora can enhance Th1-type responses.Observations from Japan have suggested that positivetuberculin responses in children predict a lower incidence ofasthma, lower serum IgE levels and a cytokine profile biasedtoward the Th1 type.A few reports have described an association between the useof antibiotics during the first two years of life and an increasedrisk of asthma.
  40. 40. Lifestyle and the Development of AtopicDiseaseProf DR Dr Ariyanto Harsono SpA(K) 40Observations from Germany suggest that within the populationof an industrialized country with a Western lifestyle, highsocioeconomic status is a risk factor for early sensitization andsymptomatic manifestation of atopic dermatitis and allergicairway disease.
  41. 41. Prof DR Dr Ariyanto HarsonoSpA(K)41
  42. 42. Prof DR Dr Ariyanto Harsono SpA(K) 42
  43. 43. Prof DR Dr Ariyanto HarsonoSpA(K)43
  44. 44. Prof DR Dr Ariyanto Harsono SpA(K) 44
  45. 45. Prof DR Dr Ariyanto Harsono SpA(K) 45THE END POINTS (PROGRESSION) OF THEATOPIC MARCH: ALLERGIC RHINITIS ANDASTHMAIt is important to identify infants at risk for developinglifelong chronic atopic diseases to provide a criticalwindow of opportunity early in life for therapeuticintervention.
  46. 46. Early markers of increased risk for allergicdiseaseProf DR Dr Ariyanto Harsono SpA(K) 46A number of early markers for atopy indicating anincreased risk for the development of subsequentallergy have been identified.elevated cord-blood IgE level (high specificity but lowsensitivity),a positive skin-prick test to egg or to house-dust mitein the first year of life andthe detection of specific IgE to common food andinhalant allergens during early infancy.
  47. 47. Natural History of Food Allergy• Most children with allergies become tolerant tocows milk, soy, and eggs in a few years.• Older children (15 years old) and adultsgenerally do not experience immune tolerance.• Peanut allergy, fish, and shellfish morepersistent.• Food hypersensitivity at an early age (ie cowsmilk, eggs, peanuts) is a risk factor for additionalfood allergies, Atopic Dermatitis, and asthma.Prof DR Dr Ariyanto Harsono SpA(K)47
  48. 48. Conclusion Allergy is a hypersensitivity type I Cows Milk is usually the first sensitization thenother foods. Allergy March begins with Atopic Dermatitis,continues to Gasrointestinal Allergy, AllergicRhinitis and Bronchial Asthma.Prof DR Dr Ariyanto Harsono SpA(K) 48
  49. 49. Prof DR Dr Ariyanto HarsonoSpA(K)49Thank You

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