Nataliya V. Bychkova

Allergic reactions of the lower genital tract in women cause significant chronic vulvovaginal discomfort and require active diagnosis and treatment. Modern approaches to therapy, which combine allergen elimination and anti-inflammatory therapy, can achieve improvement or cure in most cases. Obstetricians-gynecologists are recommended to involve dermatovenerologists and allergists for joint management of patients in case of non-standard cases of vaginitis. From a scientific point of view, further studies of immune mechanisms in the genital tract and the development of new methods of specific therapy and prevention remain relevant. In the future, the results of such studies will help to develop more accurate clinical guidelines and improve the effectiveness of care for these patients. Successful treatment of allergic diseases of the vulva and vagina significantly improves the quality of life, restores a woman's confidence and comfort in everyday and intimate life. Developing an interdisciplinary approach, education, and a thoughtful method for addressing symptoms can help overcome many difficulties in diagnosing and treating this condition. The identified unresolved issues will serve as the starting point for new research and progress in this field of medicine.

Relevance. Genetic determinants of multifactorial diseases are critical for assessing the risk of genetic diseases and their prevention, especially among the workforce exposed to industry-related dangerous and aggressive occupational factors. Firefighters perform combat service duties in extremely unfavorable industrial environments associated with occupational diseases. Respiratory diseases are among the pathologies with highest incidence rates in firefighters. In addition to environmental factors, the development of these diseases (especially bronchial asthma and chronic obstructive pulmonary disease) is largely driven by impaired immune system – one of the three critical regulatory systems involved in pathogenetic mechanisms of various diseases, including inflammatory diseases. Polymorphic gene variants of inflammatory mediators – in particular cytokine genes and their receptors – mediate the immune system activity and can impact its functionality, susceptibility, or resistance to disease development.The objective is to analyze how interleukin 1β, 4, 6, 13, TNF and interleukin 6 receptor genes, as well as their polymorphic variants are associated with respiratory diseases and changes in the biomarker profiles showing immune response intensity in the employees of the Federal Firefighting Service of the EMERCOM of Russia. Methodology. Molecular genetic profiling and immunology tests were performed in 70 employees of the Federal Firefighting Service of the EMERCOM of Russia to analyze proinflammatory cytokine genes and their polymorphic variants. Real-timePCR was used to analyze the interleukin 1β, 4, 6, 13, TNF and interleukin-6 receptor genes and their polymorphic variants. Immunological examination evaluated the blood monocyte subpopulations and relative count of type 2 T-helper cells; flowcytometry and immunochemiluminescence assays were used to evaluate immune response biomarkers in peripheral blood and total immunoglobulin E (IgE) respectively.Results and discussion. The analysis provides evidence that minor alleles of most polymorphic cytokine genes are associated with a proinflammatory phenotype, which is especially apparent for genotypes comprising several minor alleles. Allele A at rs1 800 629 polymorphic TNF gene exposed a direct correlation with respiratory diseases, as well as with increased monocyte differentiation. Allele T of IL4 rs2243250 gene and allele A of IL1β rs16944 gene were associated with increased proinflammatory monocyte count. Elevated count of type 2 T-helper mediators of humoral response, especially of allergicorigin, was observed in individuals with C/C IL6 rs1 800 795 and G/G IL1β rs16944 genotype.Conclusion. The obtained results suggest that evaluation of cytokine gene polymorphic variants is a promising strategy to predict the risk of respiratory diseases in firefighters. Prompt assessment of genetic predisposition to a proinflammatory phenotype paves the way towards prevention and early detection of inflammatory diseases in this cohort of workers.

The review presents the current understanding of the mechanisms of initiation and development of hypersensitivity reactions triggered by external factors, based on the new 2023 nomenclature of allergic diseases proposed by the European Academy of Allergy and Clinical Immunology. It details the new concept of hypersensitivity, which systematizes previous classifications and summarizes the new data on the etiology and mechanisms of inflammatory reactions in comparison with diverse immune response variants, based on the concept of disease phenotypes and endotypes. The today’s concept of allergic reactions covers several types: those associated with antibody formation (I–III), cell-mediated reactions (IVa–c) and the Pichler concept, tissue-dependent ones caused by the epithelial barrier defects and metabolism-induced immune dysregulation (V–VI), and direct immunoinflammatory reactions to chemicals (VII). In the updated classification, both adaptive and innate immune responses actively participate in initiation and effector phases of the hypersensitivity reactions. The review highlights the role of regulatory and effector lymphocyte subpopulations and innate lymphoid cells in various types of hypersensitivity. It also reports a pivotal role of epithelial barrier dysfunction in many allergic diseases and the effect of viral infections on their courses. The significance of the metabolic dysregulation and its impact on the immune response is emphasized. According to the nomenclature of allergic reactions, several pathophysiological mechanisms may underlie the development of a same disease. Notably, various hypersensitivity mechanisms involve most cellular and humoral factors, reaffirming the universal biological nature of immune response. As awareness of the new concept grows and clinical and experimental data accumulate, the updated classification of the hypersensitivity types will contribute to a theoretically substantiated and practically effective framework for the prevention, accurate diagnosing, and improved treatment of allergic diseases.

T lymphocytes of the 2^nd type of immune response contribute to the development and exacerbation of inflammation, mainly allergic. Increased inflammation with prolonged exposure to adverse factors during the work of firefighters can lead to the development of various diseases. Evaluation of the immunity of firefighters is important for the appointment of adequate treatment and prevention of infectious and allergic diseases. This paper aimed to analyze the indicators of immunity in employees of the state fire service of EMERCOM of Russia, depending on the age and intensity of the professional workload. The surveyed were men (n = 79), mean age 31 years, work experience from 1 to 22 years, with different workload intensity. In peripheral blood, flow cytometry (Navios, FC 500, Beckman Coulter) was used to evaluate subpopulations of monocytes, the relative number of T lymphocytes of the 2^nd type of immune response CD3⁺CD294⁺. The concentration of total immunoglobulin E (Immulite) was determined. From nasal secretions, the content of secretory immunoglobulin A (Vector Best) was evaluated (n = 30). Statistical processing of the results was performed using the Statistica 12.0 package (StatSoft). An increase in the number of CD3⁺CD294⁺ cells was observed in 16.5%. A direct correlation was found between the number of T lymphocytes 2 and the age of the examined persons (р < 0.05). In the group of firefighters with a more intense workload, an increase in the number of CD3⁺CD294⁺ cells were 5 times higher (р < 0.05). Among patients who had any disease of the respiratory tract, an increase in this population was observed statistically significantly more often – in 26% of cases versus 11.5%. A strong direct correlation was found between the number of T lymphocytes 2 and the duration of smoking experience (р < 0.05). A direct correlation was established between the number of T lymphocytes 2 and the concentration of total IgE (р < 0.05). A decrease in secretory IgA in the secret from the nasal passages was observed in 23% of firefighters, in 13% of the examined, the indicator went beyond the upper limit of the reference interval. Significantly more often revealed the deviation of this indicator from the reference values in firefighters with a high workload. An increase in the subpopulation of classical monocytes was established in the group of those examined with a high number of CD3⁺CD294⁺ cells (p < 0.05). Thus, with an increase in the professional workload of firefighters in unfavorable conditions of service, inhibition of protection to infection and aggravation of damage to the respiratory tract with an increase in the 2^nd type of immune response are noted. Evaluation of the number of type 2 T lymphocytes in peripheral blood will reveal a predisposition to the T2 profile of immune inflammation, which will contribute to a personalized approach to patient management.

T lymphocytes type 2 immune response protect against helminths and toxins, and also contribute to the development of allergic inflammation. One of the most specific T cell surface markers T lymphocytes 2 is the CRTH2 molecule (CD294), which is an activating receptor for prostaglandin D2. The CD3⁺CD294⁺ population is negligible in the peripheral blood of healthy individuals; an increase occurs in patients with allergic diseases and an autoimmune nature of the response. The aim of the study was to study the quantitative and functional characteristics Т lymphocytes type 2 immune response in patients with rhinoconjunctival symptoms (n = 248) and drug hypersensitivity (n = 184). In 68 patients with an elevated and extremely high number of CD3⁺CD294⁺ cells, a detailed phenotype of this population was characterized by flow cytometry and the functional activity of the studied cell population in relation to the production of interleukin 4 and interferon γ was studied using enzyme immunoassay. The control group consisted of 34 volunteers. The relative number of CD3⁺CD294⁺ cells was significantly higher in the group of patients with drug hypersensitivity – 1.6% and rhinoconjunctival symptoms 1.2% compared to the control group – 1.0%. Elevated (1.6-3.6%) and extremely high (>3.6%) CD3⁺CD294⁺ cell number were significantly more frequently detected in patients with drug hypersensitivity. In both groups, an increase in the number of CD3⁺CD294⁺ cells were observed with severe damage to the skin. The phenotype of the population T lymphocytes type 2 CD45RA-CD3⁺CD294⁺CD2⁺CD5⁺CD7⁺CD27⁺CD28⁺CD57^-CCR7^- was determined, which corresponds to effector memory T lymphocytes. With a moderately increased relative amount of this population, T lymphocytes 2 were usually represented by T helpers 2. A pronounced increase in the population was observed due to T cytotoxic lymphocytes 2. Regardless of the predominance of the Т helper or Т cytotoxic 2 cells in patients revealed an increase in spontaneous production of interleukin 4 at a normal level of interferon. An increase in the peripheral blood T lymphocytes with CD294 expression contributes to the development, maintenance and exacerbation of allergic inflammation with the participation of IgEdependent and IgE-independent mechanisms. The CD3⁺CD294⁺ cell population should be determined as an additional parameter in assessing the presence of sensitization in the basophil activation test in patients with hypersensitivity reactions. The use of this laboratory biomarker to assess the dominant type of immune inflammation will make it possible to personalize the therapy of the examined patients. Identification of pronounced deviations of indicators from the average values of a population will influence the tactics of patient management.

Respiratory allergy takes a significant place among allergic diseases. Similar clinical manifestations occur in sensitized patients in response to various airborne allergens. Accordingly, the allergen testing by means of in vivo and in vitro techniques is necessary to identify a causally significant allergen. The main laboratory assay to estimate sensitization to the airborne allergens is based on detection of specific immunoglobulin E (sIgE). However, clinical manifestations cannot be always confirmed by this test. The aim of this work was to evaluate the potential of basophil activation test (BAT) using flow cytometry, in order to confirm sensitization to house dust mite allergens. The BAT was carried out with allergens from Dermatofagoides in 34 volunteers, 130 patients were examined at the Russian Centre of Emergency and Radiation Medicine (33 people with household and 97 people with polysensitization), and 10 patients with allergy to house dust mites confirmed by skin testing. The sensitization was assessed using two laboratory kits (Allergenicity and BD FastImmune). The total IgE and sIgE to house dust mites, as well as concentrations of eosinophilic cationic protein, were determined. Specificity of the BAT with Allergenicity kit for the house dust mites was 94%. The sensitivity was 88% in the patients with household sensitization, thus being comparable with skin testing results available from the literature. An absolute correlation was found between positive results of skin testing and the BAT. In patients with household sensitization, sIgE levels > 0.35 UA/mL were detected in 39% of cases. A positive correlation was shown between the indices of basophil activation in response to testing allergens, and total immunoglobulin E and sIgE concentrations. High degree of correlation was found between the results of Dermatofagoides sensitization testing with both BAT kits. It was shown that the use of H1 histamine receptor blockers had no effect on BAT results. A decrease in sensitivity assay for airborne allergens was revealed upon therapy with glucocorticosteroids. Due to the proven clinical significance of the basophil activation test for diagnosing sensitization to inhaled allergens, one may require to supplement the range of approved assays in Russian Clinical Guidelines with BAT testing to prove sensitization in patients with allergic rhinitis and bronchial asthma, thus contributing to better diagnosis of causally significant allergens and, accordingly, administration of proper therapy.

Permanently increased frequency of drug hypersensitivity is observed throughout the world and continues to be of concern to clinicians of either discipline. Diagnostic problems with prevention and treatment of hypersensitivity reactions are due to different pathogenetic mechanisms that may underly similar clinical manifestations. On the other hand, clinical symptoms, response to therapy and the outcome of the disease significantly depend on clinical state of the patient. The phenotypes which are determined by clinical manifestations, and endotypes dependent on the pathogenetic mechanisms of hypersensitivity reactions were specified to the purpose of personalized therapy. Two kinds of phenotypes are described: with immediate (1-6 hours) and delayed (more than 6 hours) onset of the response. Four types of hypersensitivity according to Gell and Coombs with the presence of primary sensitization are discerned between the endotypes. Moreover, interaction of drugs with immune receptors of lymphocytes, according to the Pichler’s pharmaco-immune concept, has been identified, along with quick impact of drugs directly upon receptors of effector cells and signaling cascades without primary sensitization, which was previously termed as “pseudo-allergy”. To optimize therapy and prevent repeated reactions in the patients with drug hypersensitivity, high-quality diagnostics with detection of the causal allergen is required. This strategy currently includes analysis of medical history, physical examination as well as in vivo and in vitro testing. Provocation tests are rarely used, due to the significant risk of severe adverse reactions. Skin tests are a reliable and cost-effective tool, if the case history infers possibility of IgE-dependent reactions. Among nonspecific laboratory markers, the greatest clinical value is shown for determining serum tryptase levels, especially in anaphylactic reactions. In addition to genetic testing, several specific laboratory methods are used, i.e., measuring levels of drug-specific IgE, assessment of antigen-induced activation and proliferation of lymphocytes as well as basophil activation test, which has a number of advantages and allows us to identify a causally significant allergen for the hypersensitivity reactions proceeding by various mechanisms. Due to dysregulation which is a key factor of allergic inflammation, the mechanisms of normalization for impaired immune regulation should be understood, thus offering new strategies for personalized treatment, e.c., modulating the regulatory cell functions, aiming for control of the drug hypersensitivity reactions.

The use of iodinated radiocontrast media is necessary for visualization. A number of patients have adverse effects of various nature and severity when these drugs are administered. Routine allergy tests do not provide adequate diagnosis of reactions to drugs in this group. The aim of this work is to assess the capabilities of the basophil activation test to confirm sensitization to non-ionic iodinated radiocontrast media, as well as to select a safe alternative drug in patients with a burdened history. Basophil activation test by flow cytometry was performed in 184 patients The Nikiforov Russian Centre of Emergency and Radiation Medicine» EMERCOM of Russia and 32 volunteers using ultravist, omnipack, and optiray. The presence of sensitization was assessed based on the basophil activation index, as well as spontaneous and anti-IgE antibody-induced activation of basophils and the population of T-lymphocytes type 2 immune response. The volunteers showed no sensitization to iodinated radiocontrast media. In patients with a medium degree of hypersensitivity reaction in vivo, in vitro sensitization to drugs was detected 4 times more often than in patients with a mild degree (51% versus 13.5%). In patients with systemic reactions to the administration of a known drug, in vitro sensitization was confirmed in 86% of cases, while the frequency of detection of sensitization to drugs did not differ. Spontaneous activation of basophils in patients and type 2 T-lymphocytes were 2 times higher than in volunteers. Patients were more likely to have low (less than 30%) activation of basophils for anti-IgE antibodies. The specificity of the basophil activation test with iodinated radiocontrast media was 100% with a sensitivity of 94.1%. Most patients were able to select a non-sensitizing contrast. Inclusion in the algorithm of spontaneous and anti-IgE antibody-induced activation of basophils and a population of T-lymphocytes type 2 immune response will allow the doctor to carry out a personalized approach to the management of patients with a burdened history.

Diagnostics of allergic diseases is a difficult issue, which requires distinct solutions, since this disorder is very common among the population. The overview focuses on complex diagnostics, including various methods that are most in demand at the present stage. The allergy diagnostics primarily include taking anamnesis, physical examination, instrumental and functional tests. Less often, the provocative tests are used, due to risk of severe adverse reactions. At the present stage, the role of laboratory diagnostics of allergies is growing, since, firstly, there is an increase in difficult-to-diagnose cases that require involvement of the entire medical armamentarium, and, secondly, the sensitivity and specificity of laboratory tests are improving. Among laboratory methods, the most significant are the assessment of the level of specific IgE, and the relatively new basophile activation test. The latter test is the main focus of the present review. It is functional and combines the advantages of provocative tests, during which conditions are created for the interaction of a potential allergen and effector cells of allergic inflammation, keeping safety for the patient. The data on the life cycle of basophils, their expression of membrane receptors, the content of granules, and ability to produce additional inflammatory mediators by the cells are presented. Participation of these cells in pathogenesis of allergic inflammation is being considered. Various mechanisms of basophil activation are discussed, both IgE-mediated and IgE-independent, which are similar in vivo and in vitro. Theoretical aspects of using the in vitro basophil activation test to estimate the hypersensitivity to a wide range of allergens are discussed. High sensitivity and specificity of the test for diagnosing allergies to food, household, pollen, insect and drug allergens are presented. Specific features of the basophil activation test related to the preanalytical, analytical and postanalytical stages of the study are highlighted. The factors influencing evaluation of this method are known. For example, difficulties in interpreting the test may arise while taking glucocorticosteroid hormones, in acute period of inflammation, with severe edema. The possibility of using this test to assess effectiveness of allergen-specific and anti-IgE therapy is being considered. A comparison of the basophil activation test, measurement of specific IgE and skin tests by various parameters related to performance and interpretation of results is carried out. Comprehensive diagnostics of allergic diseases, including usage of pathogenetically determined laboratory methods, will contribute to adequate treatment and, as a result, improve the health of the population.