Allergy

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PLASMAPHERESIS IN ALLERGIES
Voinov V.A.
Pulmonology clinic, First Pavlov State Medical University of St. Petersburg, Russia.
Abstract
In recent years there has been a continuous increase in the frequency of allergic diseases
with

damage

of

skin,

mucous

of

the

upper

respiratory

tract

and

bronchi.

The greatest danger is bronchial asthma. Attempts only medical treatment is not always
effective. There is pathogenetically more justificated the use of plasmapheresis.
Key words: allergy, atopic dermatitis, asthma, plasmapheresis.
Increased incidence of allergic diseases (up to 20% of the population) is the result of
human contact with the growing number of allergens: industrial (turpentine, nickel, chromium,
tar, varnishes, resins, tannins, etc.), food (eggs, citrus fruits, tomatoes and chemical additives),
vegetable (ragweed pollen, timothy grass, etc.), household (house dust, perfumes, detergents,
synthetic fabrics), agricultural (insecticides, pesticides, defoliants, fertilizers), medicines
(penicillin, sulfonamides, aspirin, etc.).
Occurrence of allergic diseases there are due to imperfection of the biotransformation
allergens in the microsomal liver unit (appearance of secondary reactive compounds) and with
defects of the immune response (atopic forms), biotransformation and elimination of immune
complexes.
Atopy seems as overreaction of the immune system against common and harmless
environmental substances. Allergic antibodies are immunoglobulin E (IgE). IgE production by
B-lymphocytes is stimulated by cytokines IL-4, IL-5 and IL-13 secreted by T-helper
lymphocytes influenced allergens [1, 2]. Communication IgE-antibodies to allergens (antigens)
generates involving complement persistent immune complexes, the elimination of which is
difficult in allergy. Some of them are still in circulation (circulating immune complexes or CIC),
and the rest are fixed in the interstitium of target organs, stimulating there the immune or allergic
inflammation. Among these target organs occupies the leading place bronchial tree, skin and
mucous membranes of the nasal cavity.
Allergy is a disorder characterized by immune system hypersensitivity as the first
(immediate) type, which develops when the IgE-response is directed against a normally harmless
environmental antigens such as pollen, house dust mites or animal dander. IgE-sensitized mast
cells excreted wherein the bioactive mediators that causes an acute inflammatory reaction with
symptoms of asthma or rhinitis.

2
Triggers or provoking factors of allergic reactions exacerbation, act above allergens, among
which the pollen of trees such as birch, alder, hazel, oak, hornbeam. Leading role among them
belongs to the pollen of white birch (Betula verrucosa), containing the major allergen Bet v 1,
which can be detected in 60% of patients with IgE reactions [3, 4].
In atopic dermatitis and asthma forms can connection IgE-antibodies and autoantigens
with the activation of allergic effector cells – mast cells and basophils. IgE-autoimmunity thus
explains exacerbation for severe atopy even in the absence of exogenous allergens [5]. This may
cause sensitization and against self antigens. Special studies have shown that antigens Aspergillis
fumigatus can be close to the antigenic structure of the human body's own proteins, so if
sensitization to this microorganism, and even in its absence, can be maintained autoreactivity and
allergic reactions [6].
IgE-dependent activation of mast cells plays a leading role in the development of
immediate allergic reaction [7]. Moreover mast cells can produce various mediators, including
tumor necrosis factor (TNF-) and many other cytokines (interleukins IL-1, IL-2, etc.).
Furthermore, mast cells stimulate the formation of a large number of highly active surface
receptors for IgE, and enhance the level of IgE-dependent secretion of neurotransmitters in
response to increasing concentrations of IgE. Mast cells (and in some cases released from them
cytokines) may play an important role in triggering acute, subacute and chronic components of
IgE-dependent allergic inflammation that can affect the development of important functional
consequences of these reactions – airway hyperresponsiveness [8].
In allergic inflammation plays a role also eosinophils which increased release of
stimulatory cytokines IL-4 and IL-5 of T-helper cells [2]. Eosinophils, in turn, release the
enzymes in large amounts, which have high proteolytic activity, and contribute to eosinophil
infiltration. Basic proteins of eosinophils promote to the release of histamine from mast cells,
suggesting their close cooperation [9].
Significant incidence of allergic diseases in infants and even newborns suggests the
possibility of their perinatal sensitization, especially in the presence of allergy in their mothers.
Contributing factors are disorders of pregnancy (toxemia, preterm labor) and used in significant
quantities in this medication. In such cases, increased concentrations of immunoglobulins,
including IgE, found in newborns and even in a few months after birth [10].
In industrialized countries, up to 20% of the population suffered from allergic symptoms of
type I – rhinitis, conjunctivitis, asthma [3]. The earliest manifestations of allergy, often from the
very first days of life, are skin – so-called diathesis, with undulating course, passing at a later
age in common, persistent, recurrent continuously neurodermatitis.

3
Atopic dermatitis is often accompanied by bronchial asthma and allergic rhinitis. Studies
indicate activation of cytokines IL-3, IL-4, IL-5, IL-15. Clinical manifestations largely depend
on the reactions to exogenous allergens [11]. However, as antigens there may play a role not only
products of external origin but also bacterial, in particular – Staphylococcus aureus, which can
be identified in 95% of patients with atopic dermatitis. Such bacterial superantigens can activate
both local T-cell mechanisms and produce IgE [12].
Duration course neurodermatitis indirect evidence of the ineffectiveness of traditional
treatments designed usually to local places of skin lesions. Even hormonal ointments cause only
temporary effects.
The most reasonable pathogenetic approach to the treatment of this skin, only to localize
lesions, disease seems efferent therapy aimed at removing allergens from the body,
autoantibodies, immune complexes and other pathological metabolites, create a series of vicious
circles that break neither the body nor any medications not be able to. That is, treatment should
be directed not so much at the local sites of lesions as to eliminate the conditions of their
occurrence and chronicity. And the best way it can be achieved by plasmapheresis. From our
own experience the best results are achieved by adding to the rate of 4 operations plasmapheresis
also hemosorption with simultaneous ultraviolet or laser beams blood irradiation and subsequent
enterosorption [41].
Allergic dermatitis poses also a risk of pregnancy, when many allergy medications pose a
risk to the developing fetus and preferred in such cases are also courses of plasmapheresis [13].
Described the so-called "hyper-IgE syndrome" when needed to conduct 60 (!) sessions of
plasmapheresis for two years to eliminate manifestations of severe dermatitis, which lasted eight
years [14].
Local eczema-like dermatitis also has an allergic nature. In particular, periorbital eczema
and eyelids dermatitis are a variety of allergic contact dermatitis. The reasons could be eye
ointments, creams, eye shadows and makeup, shampoos and even nail polish [15].
Urticaria is episodic and transient allergic skin lesions, although described and chronic
urticaria, in which are found in the blood of patients with IgG-antibodies against highly IgEreceptors. Removing them using plasmapheresis leads to clinical remission [16, 17, 18].
Application of the IgG-antibody immunosorbent provided almost complete disappearance of
autoantibodies with regressive disease within 8 months. X. Jiang et al. [19] have achieved the
considerable success using cascade plasmapheresis in the case of chronic urticaria resistant to
treatment of dexamethasone and gamma globulin.
Given the greater frequency of detection of parasites in these patients (giardiasis,
opistorhosis, toxocariasis), it is advisable to carry out additional inspection and detection of

4
parasites prescribe appropriate therapy (tiberal, flag, biltritsid, dekaris). Chronic urticaria may be
accompanied by diseases caused by hepatitis B and C, HIV, Epstein- Barr virus, coxsackie A and
B, infectious mononucleosis. While acute urticaria can become chronic. Chronic urticaria often
develops on the background of other autoimmune diseases – chronic hepatitis C, autoimmune
thyroiditis [20].
Same episodic angioedema clearly limited skin and subcutaneous tissue, usually affects
the lips, tongue, throat, tissues of the orbit. Nevertheless, it is sometimes a danger to life in the
propagation of the larynx edema on the development of severe dyspnea. This swelling usually
idiopathic, but may be triggered also some drugs administration, including nonsteroidal antiinflammatory drugs. Pathogenetic mechanism may be the accumulation of bradykinin by
inhibiting its degradation mechanisms [21].
Another factor in the pathogenesis of this edema is the appearance of autoantibodies
against specific protein that inhibits the complement component C1 (C1- inhibitor), the lack of
which contributes to suddenly increased vascular permeability of certain local areas of the
vascular bed, most often on the face, abdomen and extremities. Until recently, such a sudden
edema accompanying upper airway obstruction could be lethal to 50% of patients. Permitting
trigger such a reaction may be an increase in the content of vasoactive peptides of kinin cascade,
in particular the already mentioned above bradykinin at allergic reactions [22].
Extremely difficult course has idiosyncratic system syndrome of Lyell or Stephen-Jones –
toxic epidermal necrolysis toxic-allergic nature with extensive lesions not only the skin but also
the mucous membranes that occur in response to the reception of a number of drugs
(sulfonamides, antibiotics). Sometimes play the role of viral infections and even the graft
rejection. Mortality in this case reaches 25-75%. In particular, it describes death in a patient with
Lyell's syndrome after administration of ciprofloxacin. Most of the hypotheses based on the
autoimmune processes with skin infiltration by cytotoxic T-cells (CD8+), monocytes and
macrophages, the deposition of a number of cytokines (TNF-), contributing to extensive
apoptosis of keratinocytes [23].
Efferent therapy quickly enough, sometimes already after the first session of
plasmapheresis, interrupt such a reaction and lead to permanent cure [24, 25, 26]. G. Bamichas et
al. [27] used a massive membrane plasma exchange remove 4.2 liters of plasma from 2 to 5
sessions carried out every other day or every day, replacing with fresh frozen plasma and
albumin. In Japan, there are successfully used for the treatment of not only conventional, but also
cascade plasmapheresis [28]. Isolated use of corticosteroids is fraught with increased septic
manifestations, but in combination with plasmapheresis provides better results [29, 30, 31].

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Intestinal allergies are characterized by sudden intestinal and biliary tract dyskinesia. In
dentistry, characterized by the so-called prosthetic or medication stomatitis. In a separate form
isolated eosinophilic esophagitis, characterized by the occurrence of transient dysphagias
disorders. At esophagoscopy they find local narrowing of the esophagus, and biopsy in the
mucosa determined high levels of eosinophils. It is often detected in the blood eosinophilia, as
well as other manifestations of allergy, in particular – asthma [32, 33].
Persistent course has vasomotor rhino-sinusopatiya, often accompanied by allergic
conjunctivitis. Allergic rhinitis formed inflammatory infiltrates of various cells with the release
of inflammatory mediators (histamine, leukotrienes, cytokines) that attract cells and promote
their trans-endothelial migration that creates a vicious circle, which break the organism itself is
no longer able. Outwardly innocuous running nose can last for many years, but they often attach
and asthma also. This contributes to the restriction of nasal breathing.

Inspiration of cold dry

air and delay bacteria in the nasal cavity promote to the development and maintenance of catarrh
in the bronchial tree, which also starts and establishes allergic inflammation in the airways.
Therefore, the position to such rhinitis should be no less serious than asthma.
The most serious manifestation of allergy is asthma, which represents the greatest danger
and the greatest difficulties in the treatment.
According to U.S. statistics in the U.S. suffer from asthma for about 15 million people with
the loss of up to 100 million training or working days per year [34]. However, even in such
country with a highly developed medical care, where the overall cost of treatment of patients
with asthma are up to 6.2 billion dollars a year, the death rate from asthma increased from 13.4
per 1 million population in 1982 to 18.8 per 1 million population in 1992. Asthma is also an
important cause of disability in adults and school days loss in children [35]. Occurrence of
asthma there is often long preceded other manifestations of allergy, in particular – allergic
rhinitis [Peters E. et al., 1999]. While 78% of patients with asthma have symptoms of rhinitis,
and 38% of patients suffer both from rhinitis and asthma [34].
In asthma appear and persist clones of activated T-helper (CD4), sensitized allergens –
from environmental antigens or viruses that stay on the lungs. Cytokines of these cells (IL-3, IL5, and granulocyte-colony-stimulating factor) are activated eosinophils, which excite the
eosinophilic inflammation of the mucous membranes and secrete IL-4, stimulates, in turn,
produce IgE. This causes damage to the epithelium, mucus hypersecretion and contraction
muscle of the bronchi (bronchospasm) [36]. In addition, with the development and aggravation
of asthma there are occur and other homeostasis disorders, particularly depleted antioxidant

6
activity system with accretion of lipid peroxidation products and a high level of free radicals.
This further supports allergic chronic inflammation and also requires special measures to correct
such disorders.
Unfortunately, conventional therapeutic measures in these various manifestations of allergy
are mainly symptomatic – various ointments to relieve the intolerable itching in skin
manifestations, the vasoconstrictors used in the form of droplets (galazolin, sanorin) with
rhinitis, mucolytics and bronchodilators in asthma. At best, the effect sought appointment of
hormonal preparations. It should be borne in mind and the potential dangers of hormone
replacement therapy. Even seemingly innocuous with betamethasone nasal drops can, even
before clinical manifestations of Cushing's syndrome, lead to stunted growth of children [37].
For a long time been practiced specific immunotherapy increasing doses of allergens
administered subcutaneously, orally, sublingually or intranasally. This process is also called
hyposensitization or desensitization, because it is aimed at reducing the sensitivity of the target
organ to these allergens. Typically, this is the inhaled allergens – house dust mites or minute
Hymenoptera. Although this therapy has been used for about 80 years, but still not quite clear
mechanisms of its action and its effectiveness is not constant [38].
Raise doubts and possibility of selective extracorporeal immunoadsorption, particularly to
house dust antigen. And not just because of the risk of causing anaphylactic reactions as a result
of massive basophil degranulation, carrier specific IgE, with the release of serotonin, histamine,
slow reacting substance A, until the development of anaphylactic shock. Major objections cause
allergy facts polyvalence. There are virtually no patients with asthma who were sensitized to one
allergen only. Over time, their circle extends to several tens.
Despite the fact that the work of numerous researchers have proved the effectiveness of the
introduction of efferent therapy in the range of therapeutic interventions, this tactic is still not
widely used. In some cases, the diagnosis of asthma is set only after a few years of the disease
under the guise of asthmatic bronchitis, bronchitis with asthmatic components, then preastma,
and the final diagnosis is made only before the start of hormone therapy. Occurrence of asthma
often occurs against a background of long flowing rhinosinusopathy or cutaneous manifestations
Nevertheless, when all these listed types of allergies as pathogenetic treatment are present
efferent therapy is aimed at removing from the body of antibodies – allergens blocking
antibodies receptors, inhibitors, tissue degradation products, inflammatory mediators,
leukotrienes and immune complexes. Reducing the concentration of biologically active
substances leads to the restoration of -adrenergic reception, reduces resistance to
bronchodilators [39]. Deblocady and removal of inhibitors of receptors of T-suppressor activity

7
in plasmapheresis leads to the restoration of T-lymphocyte activation and which promotes
alveolar macrophages. Deblokady of phagocyte receptors promotes more effective natural
elimination of allergens. Overall, this provides a more stable remission. Related
photohemotherapy also helps to normalize the processes of differentiation of T-lymphocytes with
increased activity of T-suppressor and decreased production of IgE, the elimination of
biochemical disorders. Using photohemotherapy of red light even in monotherapy has a
favorable effect on bronchial asthma [40].
Removing plasma at plasmapheresis stimulates the release into the circulation of fresh
ingredients and helps to normalize metabolism, particularly lipid peroxidation with increased
activity of the antioxidant system. Reducing the level of biologically active substances helps
normalize membrane phospholipids metabolism. All this leads to the elimination of
immunoallergic inflammation with restoration of sensitivity and bronchial reactivity and
elimination of bronchial obstruction. Action efferent therapy continues in the longer-term. All
newly arriving in circulation components homeostasis, young cell shape, which replaced the old,
in refreshed environment for the more longer period retain their genetically predetermined
properties and functions that helps break many pathological formed circles, enter the more stable
remission. Positive effect after a course of plasmapheresis comes 5-7 days after the start of
treatment and lasts from a few months to two years.

This is also confirmed in our clinical

practice [41].
Hemosorbtion in recent years, increasingly gives way to plasmapheresis, as the most
effective method of removing all pathological products, regardless of their ability to adhere and
be adsorbed on the surface of activated sorbents. An exception is the so-called "aspirin" or
"prostacyclin" form of bronchial asthma, in which sorption methods are quite efficient, as well as
in cases of concomitant allergodermatitis [41].
Plasmapheresis, helps to eliminate pathological products, and also could eliminate the
reasons which cause immune disorders, and create conditions for their gradual regression [42].
Bronchial asthma has an adverse effect on pregnancy also, promoting to toxicity, with the
threat of termination of pregnancy and premature birth, abnormalities of labor, fetal hypoxia. All
this makes the plasmapheresis necessary in these patients too [13].
Study of biochemical homeostasis disorders showed significant violations of lipid
peroxidation with the accumulation of toxic end products and suppression of antioxidant
protection; determined elevated concentrations of histamine, serotonin, medium weight
oligopeptides. It is therefore important not only to the removal of pathological immunoglobulins,
antibodies and immune complexes, but also normalization of biochemical homeostasis.

8
Practically all of these types of allergies – as if not outwardly expressed rhinitis or skin
forms, and in severe asthma, it is advisable to conduct a full course of efferent therapy and
immune correction because there is never a guarantee that the lighter allergy can not be
transformed into heavy. From this perspective, the unjustified delay in recognition that the
diagnosis of asthma, registering only asthmatic bronchitis components and preasthma not allow
timely eliminate background homeostasis disorders, helps to perpetuate pathological allergic
reactions. There is much easier to prevent the progression of primary, yet functional disorders,
than to achieve regression of organic disorders – severe obstructive suppurative endobronchitis,
emphysema with destruction of the elastic framework of the lung parenchyma [41].
Use of plasmapheresis in the initial phases of formation of asthma often meets objections
clinicians considering ample drugs prescriptions. However, A.K. Samotolkin [43] has made quite
good results in patients with "Preasthma" using plasmapheresis, considering that the elimination
of mediators of inflammation and bronchoconstriction stimulates macrophage system and
complement.
For all invasive techniques, plasmapheresis in these patients may well be applied even on
an outpatient basis. This was confirmed by our own experience in the use of plasmapheresis in
the early stages of asthma, including children, when they could almost completely interrupt the
pathological process. In addition, the irradiation of blood in the extracorporeal circuit with laser
beams on a helium-neon SHUTTLE device with the power density at the end of the fiber to 1520 mW, quite sufficient for penetration through the wall of plastic tubes with blood flowing in
them, located in a special spherical chamber [41].
Given the often concomitant allergic rhinosinusopathy, performed also an additional
exposure of the nasal cavities in the same waveguide device SHUTTLE, as well as the maxillary,
frontal sinuses and infrared laser penetrating the tissues up to 8 cm. Expediency due to the need
to eliminate the last points of chronic infection as one of the possible triggers excitation allergic
reactions. Even in the absence of any symptoms of the rhino-sinus area, it can be considered one
of the most influential reflex zones, promoting sensitization, area first contact with inhaled
allergens. Therefore healing of the nasal cavities and sinuses pathogenetically justified, as well
as the possible impact on reflex this sensitive zone. Furthermore, the improvement of the upper
respiratory tract and promotes greater warming of inspirable air and humidification, delay
allergens and blockade of nasal-bronchial reflex [34]. Moreover, given the significant risk of
asthma in connection with allergic rhinitis patients, more intensive treatment of the latter may be
one of the methods for the prevention of asthma.
Complete this complex of efferent therapy by enterosorption allowing to limits the entrance
of enterogenous toxins that can support the allergic reactions, as well as for removal from

9
circulation of middle weight endotoxins. Courses enterosorption can be repeated periodically
also after plasmapheresis every 2-3 months for 2 weeks.
Unfortunately we must admit that completely cure patients with allergies is almost
impossible and such patients will need later in life for repeated courses of efferent therapy, which
is confirmed by clinical practice.
Several stands out quite a rare disease – subsepsis Wissler-Fanconi ("allergosepsis"),
characterized by articular syndrome (swelling, stiffness), hectic fever, ephemeral roseolous rash
on the body, high leukocytosis with a left shift,

thrombocytosis (from 400-600x10 9 /l to

1000x109 /l), headaches and increased IgE levels by 3-4 times. It also helps the frequent repeat
plasmapheresis sessions over time. At the patient with this disease who were treated in our
department, it was observed the pattern of the lung spread infiltrates with the rapid development
of refluence during the course of plasmapheresis .
There is in the same row also the Churg-Straus syndrome – allergic vasculitis and
granulomatosis. Often develops on the background of steroid therapy for bronchial asthma.
Eosinophilic lymphadenopathy occurs on a background of blood eosinophilia with severe
vasculitis, up to a fatal outcome. The use of high doses of steroids, and sometimes of
cyclophosphamide are not always successful. This underlines the need for vigilance when steroid
administration to patients with bronchial asthma [44]. In our practice in such cases helps
plasmapheresis too.
Conclusion
Thus, the materials of the present study clearly show the need for efferent therapy, mainly
plasmapheresis, for all forms of allergy, and particularly of bronchial asthma. Just using
plasmapheresis we can remove allergens, autoantibodies and immune complexes from the body,
which allows for more stable remission with less medication.

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