Diagnostic in vitro tests.
Immunoassays and cellular tests
The appropriate test for diagnosing allergic diseases depends on the
suspected mechanism involved: specific immunoglobulin E (sIgE)-mediated
or T cell-mediated, especially in DHRs.22,32-36
IgE-mediated allergic reactions can be induced by aeroallergens, food
allergens, and drugs.32,37 Additionally, for the
latter, the drug structure coupled to a carrier protein of sufficient
size may be involved in the sIgE recognition.38,39 The
major issue is the low blood concentration of sIgE, which is
approximately 25% of total IgE for aeroallergens; and even lower for
drug-sIgE (0.2% for betalactam).40 Thus, extremely
high sensitive methods are required.
The best validated and used in vitro approaches are based on the
quantification of sIgE, either in serum by immunoassays
(radioimmunoassay, enzyme-linked immunosorbent assay, or fluorescent
enzyme immunoassay) or on basophil surface by functional basophil
activation test (BAT).41-44 The latter is quite
specific, but complex to perform, and therefore limited to research
laboratories.
Serum sIgE assays against allergen sources/molecules are the most
commonly used and can be performed by singleplexed (which use single
allergens) or multiplexed strategy.37 In general, they
are sensitive but show low specificity due to potential antigenic
competition and isotype (IgG) inhibition.45 There are
several market leaders of singleplexed assays, whose main advantages are
the automation, with increased precision and shorter turnaround times;
the miniaturisation chip technology that reduces serum volumes, and the
adaptability for use with purified native and recombinant
allergens.45 Multiplexed arrays offer the advantage of
providing information on the sensitisation pattern of a patient for a
large number of molecules with a small amount of serum. However, it can
be difficult to differentiate clinically relevant from irrelevant
sensitisations.46 Moreover, allergen specificities on
multiallergen screen are not defined and differ among various
manufacturers.45 Currently, the available multiplex
platforms can provide up to 112 allergens (allergen sources and protein
groups).46 However, the clinical relevance of many of
these epitopes is not known and there is a higher degree of variability
in low IgE levels,47,48 cases in which singleplex
platforms may be more sensitive.37
In the case of DHRs, solid-phase immunoassays have to include
drug-carrier conjugates to detect
serum-drug-sIgE.42,49 Due to the extremely low levels
of drug-sIgE, they generally have low sensitivity, although this depends
on the clinical manifestations, the drug involved, and the time interval
between reaction and diagnostic assay.50,51 The
carrier molecule can also affect the sensitivity, poly-L-lysine is the
most used artificial carrier due to its multivalency, which allows a
high hapten density,52 although its polydispersity
impedes adequate characterisation, reproducibility, and conjugate
control.53 Moreover nonspecific interactions and
immobilisation on solid-phase can reduce immunological capture. Both
commercial and in-house radioimmunoassays are used, although enhanced
sensitivity is needed.54
The use of BAT has increased in the last years, being seen in the
overall context of molecular diagnostics in food and aeroallergen
allergy.37,43,55 A major issue is the allergen source,37 since results differ according to the variety
employed.
In the case of DHRs, BAT has overcome the immunoassay limitations of
amount of drugs available and has been mainly studied for neuromuscular
blocking agents, betalactams, and iodinated contrast media, with a
sensitivity ranging between 50% and 60%, and a specificity of
80%.32 Moreover, BAT has a complementary role for
skin test for many drugs to which no other approaches are
available.39,56-60 Both commercial BAT and in-house
protocols are rarely thoroughly validated and require additional
investigation before they can enter mainstream
application.37,41
Nanotechnology in biomedicine
The famous conference of Richard Feynman in 1959 and the mythical phrase
“there is plenty of room at the bottom” is considered as the starting
point of nanotechnology. Nanotechnology is the development of materials
with nanometric size for searching new properties at this scale, which
could be used for different applications. Some of these materials have
been considered as ideal platforms for their functionalisation with
ligands with applications in biomedicine.61
Metallic and non-metallic nanoparticles (NPs), carbon nanoforms such as
single- or multiple-walls carbon nanotubes (CNTs) and graphene,
liposomes, polymers, dendrimers, nanogels, etc. are popular
representatives (Figure 1). They show different physical and chemical
properties that depend mainly on the size, shape, composition, and
functionalisation of the system. Nanomaterial engineering provides the
tools to control all these parameters and to achieve the desired
requirements for health applications.62 In fact, the
functionalisation of these scaffolds is the way to modulate their
physical, chemical, and biological properties at will. Their
applications in biomedicine include therapeutics, diagnostics, and
theranostics 63,64 for drug
delivery,65 bioimaging and
biosensing,66 as implants,67 cancer
immunotherapy,68 gene therapy,69etc. Besides their potential and the expectative in the biomedical area,
nowadays not many nanodrugs are approved for medical use, although some
promising compounds are still under clinical trials.70Issues related to their nanotoxicity, reproducibility, and homogeneity
have impeded a rapid development of this field in health
applications.71
There is a plethora of examples, in which these nanomaterials have
demonstrated very promising and interesting properties at in
vitro level, for which they were decorated with ligands for specific
receptors expressed or over-expressed in target cells or tissues. On one
hand, these nanosystems behave as selective drugs carriers reducing the
toxicity, being selective for specific targets and decreasing side
effects. On the other hand, nanostructures can provide the means to
protect their cargo, improving their stability against degradation,
their solubility, and their drug availability.