THE PLACENTAL TRANSMISSION OF ANTIBODIES IN THE SKIN SENSITIVE TYPE OF HUMAN ALLERGY

Transcription

1 THE PLACENTAL TRANSMISSION OF ANTIBODIES IN THE SKIN SENSITIVE TYPE OF HUMAN ALLERGY BY WILLIAM B. SHERMAN, M.D., STANLEY F. HAMPTON, M.D., ANn ROBERT A. COOKE, M.D. (Frm the Department f Allergy, The Rsevelt Hspital, New Yrk) (Received fr publicatin, August 3, 194) It has been suggested that the transmissin f skin-sensitizing antibdies frm the maternal t the fetal circulatin may be a factr in the develpment f allergic diseases. Certain ther antibdies such as diphtheria antitxin, typhid agglutinin, tetanus antitxin, hemlysins, and bacterilysins, have been shwn t pass thrugh the human placenta frm mther t fetus. Excellent reviews f this subject have been published by Ratner, Jacksn, and Gruehl (1), Bell and Erickksn (2), Lippard and Wheeler (3), and Wiener and Silverman (4) and thers. Placental transmissin f antibdies respnsible fr anaphylactic shck has been demnstrated in the lwer animals by Rsenau and Andersn (5), Ott (6), Wells (7), Schenck (8), Lewis (9), Ratner and his cwrkers (1), and Chen and Wdruff (11). Chen, Chen, and Hawver (12) reprted the presence f skin-sensitlzing antibdies in the bld f a newbrn rhesus mnkey after injectin f a sensitive human serum int the mther within 7 days prir t delivery. Placental transmissin f skin-sensitizing antibdies in the human being has nt been shwn. Bell and Erickksn (2) were unable t demnstrate in the crd sera f 1 allergic mthers the skin-sensitizing antibdies that were shwn t be present in the maternal sera in varius dilutins. Caulfeild (13) als reprted inability t demnstrate skin-sensitizing antibdies in the crd sera f 2 allergic mthers. Walzer (14) in a discussin f Bell's paper supprted Bell's findings. Zhn (15) was unable t shw such antibdies in the crd bld f 11 wmen actively sensitized and skin-reactive t Ascaris lumbricides, althugh the maternal bld f 9 f the wmen was psitive by passive transfer tests. Wiener and Silverman (4), n the basis f titratirr f the hemagglutinin cntent f maternal and crd bld, reprted that "the index f permeability f the human placenta t antibdies r the cefficient f distributin f antibdies between maternal and crd bld" falls between 8 and 16. They suggested that the failure t detect placental transmissin f skin-sensitizing antibdy was due t the small amunts present in the maternal bld and lack f quantitative studies theref. Althugh all the direct evidence has shwn there is n transmissin f skin-sensitizing antibdies thrugh the human placenta, the apparently cntradictry evidence f transmissin f ther human antibdies and f certain anaphylactic antibdies in experimental animals has caused many t dubt that the pint was cmpletely prved. Therefre, it seems wrth 611

2 612 PLACENTAL TRANSMISSION OF ANTIBODIES IN ALLERGY while t reprt quantitative studies cnfirming the findings f Bell and Erickksn. In the present investigatin, bservatins have als been made n the transmissin frm the mther t the fetus f the "blcking" r "immune" antibdy which is present in the serum f hay fever patients after treatment with injectins f pllen extract. The presence f such an antibdy, distinct frm the skin-sensitizing antibdy, was suggested by Cke, Barnard, Hebald, and Stull (16). Further evidence f its existence was given by Lveless (17), wh demnstrated that the skin-sensitizing antibdy was destryed by heat, while the new antibdy prduced in respnse t treatment was nt destryed. Titratin f Skin-Sensitizing Antibdy Twelve sera frm allergic pregnant wmen, drawn during the latter half f pregnancy, were shwn t cntain skin-sensitizing antibdies t varius antigens. At the time f delivery, bld was btained frm the umbilical crd using sterile precautins. In six cases, samples f clstrum were als btained. The sera were separated frm the cltted blds, passed thrugh Seitz filters, prved sterile by culture, and Kline tests were perfrmed. Passive transfer studies were carried ut in the skin f test subjects nn-reactive t thse aliergen extracts tested. The crrespnding maternal serum, crd serum, and clstrum were studied in the same test subject. Skin sites were prepared with.1 cc. f cncentrated serum and its dilutins 1-1, 1-1, 1-1, and 1-1, in saline, and tested 48 hurs later with.25 cc. f allergen extract cntaining 1 prtein nitrgen units t per cc. Each f the maternal sera reacted in passive transfer sites with ne r mre allergen extracts, including, timthy, plantain, srrel, ash, and birch pllen, cttnseed, kapk, dust, wheat, dg and hrse dander (Table I). Ten f the 12 sera were psitive in a dilutin f 1-1 and 3 sera were still psitive in a dilutin f 1-1. The 12 crrespnding crd sera were tested with the same antigens but nne gave psitive passive transfer reactins. Tw f the 6 clstra tested gave slight reactins in the cncentrated frm but nne reacted in the 1-1 dilutin. The 2 samples f clstrum which reacted were frm mthers whse wn sera in dilutins f 1-1 t 1-1 reacted t the same antigen. Seven f the infants at ages f 3 t 6 mnths were tested directly with extracts cntaining 1 r 1 units f the allergen t which the mther's 1 1 prtein nitrgen unit =.1 rag. prtein nitrgen. Hereafter in this presentatin "unit" refers t prtein nitrgen unit.

3 TABLE I Titratin ~ Skin-Sensitizing A ntibdies ~ Maternal, Crd, and Infant Sera and Clstrum Dilutin tests Infants Cases and age Diagnses Allergen tested 1 prtein nitrgen units per cc. Maternal sera Crd Clssera trum ~8 3hl. 27 yrs., asthma Lw Ean. 35 yrs. Asthma Cttnseed Kapk ~.r. 29 yrs. Timthy Lw [ga. 29 yrs. Timthy Emn. 25 yrs., vasmtr rhinitis Lw Timthy Dust #.dz. 3 yrs. Lw Timthy rff. 27 yrs. Lw 1 Timthy [ Lsn. 24 yrs. Lw Timthy -4- Wheat Sre. 24 yrs. Lw Birch Wheat -4- Pmd., 28 yrs. va~mti rhinitis Lw Dust Film. 34 yrs. Timthy Plantain Srrel -4- Lw Ash Wheat Jpr. 23 yrs. Asthma Dg dander Hrse dander Dust 513

4 614 PLACENTAL TILANSM.ISSION OF ANTIBODIES IN ALLERGY serum reacted in passive transfer, and bld was drawn fr passive transfer studies. In all cases, bth the direct tests and the passive transfer reactins were negative (Table I). Placental Extract.--It has been suggested that the skin-sensitizing antibdies are intercepted in the cells f the placenta separating maternal and fetal circulatin because f the nrmal affinity f these antibdies fr cells. On the basis f this thery, an attempt was made t recver skin-sensitizing antibdies frm the placenta. A whle placenta (case Ar.) was perfused with saline until the perfusate was free f bld. The placenta was then grund in a meat grinder and subsequently in a ball mill with a small amunt f extracting fluid (cntaining.5 per cent NaC1 and.35 per cent NaHCO3) fr 2 hurs at 7 C. The extract was filtered thrugh a Seitz filter and tested in passive transfer sites as were the sera. A secnd placenta (case Jpr.) was treated in the same manner, except that it was extracted with distilled water instead f the saline extracting fluid. A prtin f this material was then frzen with dry ice and allwed t thaw in an attempt t rupture cell membranes. After being filtered thrugh a Seitz filter and prved sterile, the extract was tested by passive transfer as were the sera. Neither the saline extract, nr the water extract, nr the water extract f the frzen placenta shwed evidence f the skin-sensitizing antibdies which were demnstrated in the maternal sera. Titratin f Blcking Antibdies Seven f the crd sera were frm hay fever patients wh had received injectins f pllen extract befre the babies were brn. In these sera, the presence f blcking antibdy was tested by mixing the sera with lw pllen extract and injecting the mixtures int the skin sites which had been passively sensitized t. Table II represents a typical experiment. Six rws each f six identical sites were prepared by the intracutaneus injectin int each site f.1 cc. f a 1-1 dilutin f serum frm an untreated case f hay fever (serum Rr.). The serum chsen reacted strngly in passive transfer sites with the fractin (fractin 1) f lw pllen extract prepared frm whle extract by precipitatin at ph 4 with 5 per cent ammnium sulfate but reacted nly slightly with the fractin (fractin 2) prepared by subsequent precipitatin with cmpletely saturated ammnium sulfate at the same ph (18). Other experiments have indicated that the blcking antibdy f pst treatment hay fever sera ften inactivates fractin 1 but nt fractin 2, s that the blcking effect f serum n whle lw pllen extract is mre apparent when tested n sites prepared with a serum reacting mainly t fractin 1 (19).

5 W. B. SHERMAN, S. F. HA]~fPTON, AND R. A. COOKE 615 The mixtures fr testing were prepared by mixing.1 cc. f each crd serum with.9 cc. f lw pllen extract cntaining 1 units per cc. Three cntrl mixtures were made, 2 with crd sera frm mthers wh were nt sensitive t and had nt received injectins f pllen extract and ne with nrmal adult serum. The mixtures were kept vernight at 7 C. and each was then diluted 1-3, 1-9, 1-27, 1-81, and The dilutins f each mixture were used t test ne rw f skin sites. The serum- mixtures made with the 3 cntrl sera gave reactins in higher dilutin than the mixtures cntaining the crd sera f -treated mthers. The in the latter mixtures had been TABLE II Inactivatin f Lw Ragweed Extract by Crd r Nrmal Human Serum Thirty skin sites prepared with lw sensitive serum (Rr.) in dilutin f 1-1, tested 48 hurs later with serial dilutins f mixtures f crd r nrmal human serum with lw extract cntaining 1 prtein nitrgen units per cc. Reactin f skin sites Dilutins f serum-lw Ean. crd Wsn. nrmal mixtures Lsn. crd serum Jga. crd serum Bed. crd serum lw lw lw serum lw serum (cnlw (cntrl) (cntrl) trd Cncentrated thus partially inactivated by the blcking antibdy cntained in the crd sera (Table II). In such experiments, the 7 crd sera frm cases treated with pllen extract were cmpared with 2 cntrl crd sera frm cases which had nt received pllen injectins, with serum f a nrmal untreated adult, and with mixtures made with saline instead f serum. The varius cntrl mixtures gave identical results in all cmparisns, shwing that crd serum frm untreated cases did nt cntain any nn-specific inhibiting agent. All 7 crd sera frm treated mthers when cmpared with the cntrl sera shwed evidence f inactivatin f pllen extract. Since different test subjects shw slight variatin in reactivity f skin sites, the reactins f the serum tested must be cmpared with the cntrl serum tested simultaneusly in the same test subject. These 7 crd sera were als cmpared with the crrespnding maternal sera in similar experiments. Since the maternal sera cntained skin-

6 616 PLACENTAL TRANSMISSION" OF ANTIBODIES IN ALLERGY sensitizing antibdies, they were heated fr 4 hurs at 56 C. in rder t destry this activity. The crd and cntrl sera were als heated s as t maintain cmparable cnditins. It is apparent that this heating did nt TABLE III Inactivatin f Lw Ragweed Extract by Heated Crd and Maternal Sera Thirty-six skin sites prepared with lw sensitive serum (Rr.) in dilutin f 1-1, tested 48 hurs later with serial dilutins f mixtures f heated crd r maternal sera with lw extract cntaining 1 prtein nitrgen units per cc. Dilutins f serum-lw mixtures Cncentrated Ghl. crd serum lw Ghl. maternal serum lw Reactin f skin sites Ar. crd Ar. maternal serum -}- lw serum -[- lw Bed. crd serum lw (cntrl) Bed. maternal serum [ lw (cntrl) TABLE IV Inactivatin f Lw Ragweed Extract by Infant r Crd Sera Thirty skin sites prepared with lw sensitive serum (Rr.) in dilutins f 1-1, tested 48 hurs later with serial dilutins f mixtures f infant r crd serum with lw extract cntaining 1 prtein nitrgen units per cc. Dilutins f serum-lw mixtures Lsn. infant serum lw I l Lsn. crd serum lw Reactin f skin sites Adz. infant serum lw Adz. crd serum lw Bed. crd seru~ -[- lw (cntrl) Cncentrated materially affect the blcking activity f the crd sera. All heated maternal sera failed t sensitize nrmal skin. Table III shws typical results. The crd sera used in this experiment shwed mre blcking activity than thse used in Table II, s that the was cmpletely inactivated in the strength used. In every case the crrespnding crd and maternal sera shwed rughly cmparable blcking activity. Exact

7 W. B. SHERMAN~ S. F. HAMPTON, AND R. A. COOKE 617 quantitative cmparisns culd nt be made, as in mst f the cases several weeks elapsed between the drawing f the maternal and crd blds. Sme f the mthers received additinal injectins during this interval, thers allwed the treatment t lapse. Three f the infants' sera taken at 3 t 6 mnths f age were studied fr the presence f blcking antibdy. In Table IV, 2 f these infant sera are cmpared with the crrespnding crd sera and the same cntrl crd serum used in the previus experiment. This experiment shws that the blcking antibdy had practically disappeared within 3 t 6 mnths, althugh in ne case (Adz.) the crrespnding crd serum shwed a large amunt f antibdy. The third infant serum, nt represented in the table, shwed n evidence f any immune antibdy, althugh the crrespnding crd serum did. Titratin f Other Antibdies Fr cmparisn with the skin-sensitizing and blcking antibdies, the placental transmissin f certain ther antibdies present in the same maternal sera was studied. Hemagglutinins.--The hemagglutinin cntent f maternal, crd, and infant sera was determined in the manner similar t that suggested by Wiener (4)..2 cc. f prgressively dubled dilutins f the sera were mixed with equal vlumes f a 2{ per cent suspensin f knwn type A and als with knwn type B human bld cells. The mixtures were incubated at 37 C. fr 2 hurs and read by macrscpic and micrscpic examinatin. Interpretatins were recrded "psitive" t the last dilutin shwing any degree f agglutinatin by micrscpic examinatin. Table V shws the results f titratin f the hemagglutinin cntent f 11 maternal, 1 crd, and 6 infant sera. Fur f the 1 crd sera shwed hemagglutinins, althugh it has been shwn that nne f the crd sera pssessed any skin-sensitizing antibdies. The rati f crd serum hemagglutinins t maternal serum hemagglutinins ranged between 2 and 32 in the fur instances where crd hemagglutinins were present and studied in dilutins. Shick Test.--Schick tests were perfrmed n the mthers during pregnancy and upn 6 f the infants at ages 3 t 6 mnths, using the txin btained frm the New Yrk City Bard f Health. Each infant reacted with the same result (negative r psitive) as the crrespnding mther (Table VI). Typhid Agglutinins.--In ne case, the mther had received three injectins f triple typhid vaccine 3 mnths prir t delivery, The maternal

8 TABLE V Titratin f Hemagglutinins in Maternal and Crd Sera Case Antigen Dilutin where maternal sera were still psitive Re;,ct n ~f cr t s ~ra Dilutin f crd sera Re I~:tin f i Lfants' era Dilutin where infant sera were still psitive Ghl. A cens 1-32 Ean Ar Jga Emn Adz Ttf. 1-4 Lsn Sre q.n.s.* Prd. Jpr * q.n.s. = quantity nt sufficient. TABLE VI Results f Schick Testing n Mthers and Infants Case Mther Infant Age f infant Jga. Emn. Lan. Pmd. Jpr. Adz. 3 ms. 3 ms. 6 ms. 5 ms. 3 ms. 6 ms. 618

9 W. B. SHERMAN, S. F. HAMPTON, AND R. A. COOKE 619 and crd sera each agglutinated a suspensin f frmalized typhid rganisms at a dilutin f 1-1. The infant serum, hwever, taken at 3 mnths, failed t shw agglutinins. This finding is in accrdance with previus investigatins. DISCUSSION The findings supprt thse f Bell and Erickksn, in that the naturally ccurring skin-sensitizing antibdies f human allergy are nt transmitted thrugh the human placenta. It was impssible by quantitative dilutin tests t establish an index f permeability f the placenta t these antibdies such as was suggested by Wiener and Silverman (4). In this study, even when skin-sensitizing antibdies were demnstrated in the maternal sera when diluted I r 1 times, the same antibdies culd nt be demnstrated in the crrespnding undiluted crd sera. Fur f the 1 crd sera studied cntained hemagglutinins and 4 infants and their mthers shwed negative reactins by the Schick test (indicating immunity r placental permeability fr diphtheria antibdy) yet the crd sera f these same cases did nt shw skin-sensitizing antibdies. The demnstratin that crd serum f hay fever patients, wh had received injectins f pllen extract, inactivates the pllen extract but des nt sensitize nrmal skin is further evidence f cexistence f tw distinct antibdies fr pllen in the bld f treated cases. It might be suppsed that the presence f blcking antibdy in the crd serum was due t active immunizatin f the fetus by pllen antigen passing thrugh the placenta and nt t transmissin f blcking antibdy. In all f the eases, the mthers had received injectins f pllen extract during pregnancy. There is n direct evidence cncerning the passage f this antigen thrugh the placenta r f the ability f the fetus t frm blcking antibdy, but Cke, Lveless, and Stull (2) have shwn that such an antibdy can be fund in the sera f nn-sensitive adults wh received pllen injectins. Hwever, quantitative cnsideratins make it seem unlikely that the blcking antibdy in the crd serum was prduced by the nn-sensitive fetus. The nrmal adults described by these authrs shwed evidence f blcking antibdy nly after ttal dses f 2, t 1,, units f pllen extract, dses much greater than thse required by hay fever patients sensitive t ; such as, the sensitive mther (case Ar.) wh had received a ttal f nly 414 units f extract, but whse wn serum and the crd serum f her nn-sensitive infant shwed marked blcking antibdy. Furthermre, the degree f blcking activity f the maternal and crd sera in each case was as nearly cmparable as culd be expected cnsidering the time in-

10 62 PLACENTAL TRANSMISSION OF ANTIBODIES IN ALLERGY terval and further treatment that intervened between the taking f the 2 sera. This was better shwn in sme f the ther cases where the blcking activity f the maternal and crd sera was less than that f the sera shwn in Table III and in which the extract was nly partially inactivated in the range f dilutins used. The disappearance f the blcking antibdy frm the infants' sera within 3 t 6 mnths after birth crrespnds with the knwn facts regarding certain antibdies, such as typhid agglutinin, knwn t be passively transmitted t the fetus thrugh the placenta. The disappearance f blcking antibdy frm the serum f actively immunized hay fever patients is slwer. Fr example, the maternal serum (case Ar.) was taken 4 mnths after the last injectin f pllen extract, yet it shwed active blcking antibdy. Fr all f these reasns, althugh the pssibility f passage f the antigen thrugh the placenta cannt be definitely excluded, it seems mst prbable that the fetus acquires the blcking antibdy passively and nt by active immunizatin. The skin-sensitizing antibdy which ccurs spntaneusly in the serum f allergic human beings differs frm mst induced antibdies nt nly in being thermlabile but als in its failure t pass thrugh the placenta. The blcking antibdy, which is develped in respnse t injectins f pllen extract, resembles the antibdy prduced by injectins f ther antigens in thermstability and in readily passing thrugh the placenta. The separatin f the tw antibdies withut heating the serum definitely establishes that the blcking antibdy is nt frmed frm the skin-sensitizing antibdy by heat. The fact that 2 f the 6 clstra shwed a small amunt f skin-sensitizing antibdy suggested that these antibdies may pass thrugh sme cell membranes. This cnflicts with the hypthesis that failure f these antibdies t permeate the placenta is due t affinity fr cells preventing it frm passing thrugh membranes. The cncentratin f antibdy, hwever, was nly ne-hundredth t ne-thusandth that f the crrespnding maternal sera, and in view f the small vlume f clstrum btainable frm these wmen, the actual amunt f antibdy s secreted must have been small. SUMMARY 1. Quantitative studies f the skin-sensitizing antibdies, blcking antibdies, and hemagglutinins in sera f allergic human beings have been made. 2. A cmparisn f 12 maternal and the 12 crrespnding crd sera by

11 W. B. SHERMAN~ S. F. HAMPTON~ AND R. A. COOKE 621 the methd f passive transfer shwed the human placenta t be impermeable t skin-sensitizing antibdies. 3. Direct skin tests and passive transfer studies f 6 infants at the ages f 3 t 6 mnths shwed negative reactins t the antigens t which their mthers were sensitive. 4. The blcking antibdy present in the sera f hay fever patients after treatment with pllen extract injectins was als demnstrated in the crd sera. The apparent placental transmissin f this antibdy gave further evidence that it was distinct frm the skin-sensitizing antibdy. Infant sera btained at the ages f 3 t 6 mnths shwed n evidence f this immune antibdy. 5. The crd sera frm 4 f these cases were shwn t cntain the same isagglutinins as the maternal sera, shwing that the placentas were permeable t these antibdies. The mthers and their ffspring reacted alike t Schick testing. 6. Typhid agglutinins were demnstrated in maternal and crd sera f an adult wh previusly received injectins f triple typhid vaccine, whereas the serum f the crrespnding infant at the age f 3 mnths failed t shw agglutinins. BIBLIOGRAPHY 1. Ratner, B., Jacksn, H. C., and Gruehl, H. L., J. Immunl., 1927, 14,, Bell, S. D., and Erickksn, Z., J. Immunl., 1931, 2, Lippard, V. W., and Wheeler, G. W., Am. Y. Dis. Child., 1936, 52, Wiener, A. S., and Silverman, I. J., J. Exp. Med., 194, 71, Rsenau, M. J., and Andersn, J. F., Bull. Hyg. Lab., U. S. P. H. S., 196, 29, Ott, R., Mi2nch. reed. Wch., 197, 54, Wells, H. G., J. Infect. Dis., 1911, 9, Schenck, F., Miinch. reed. Wch., 191, 57, Lewis, P. A., f. Exp. Med., 198, 1, (a) Rather, B., Jacksn, H. C., and Gruehl, H. L., J. Immunl., 1927, 14, 291,33. (b) Ratner, B., and Gruehl, H. L., J. Exp. Med., 1929, 49, 833. (c) Rather, B., and Gruehl, H. L., Y. Exp. Med., 1931, 53, Chen, M. B., and Wdruff, B. H., Y. Allergy, 1937, 8, Chen, M. B., Chen, S., and Hawver, K., Prc. Sc. Exp. Bil. and Med., 1939, 41, Caulfeild, A. H. W., Tr. Am. Clin. and Climatl. Assn., 1936, 52, Walzer, M., J. Allergy, 1931, 2, Zhn, B., Am. Y. Dis. Child., 1939, 57, Cke, R. A., Barnard, J. H., Hebald, S., and StuU, A., J. Exp. Med., 1935, 62, Lveless, M. H., J. Immunl., 194, 38, Stull, A., Sherman, W. B., and Hamptn, S. F., f. Allergy, in press. 19. Sherman, W. B., unpublished experiments. 2. Cke, R. A., Lveless, M. H., and Stull, A., J. Exp. Med., 1937, 66, 689.