PREFACE

Bismillahirrahmanirrahim

Assalamu’alaikum warahmatullahi wa barakatuh

First of all thanks to Allah the almighty who has giving as marching and
blessing so we can write this paper. Sholawat and salam be with our prophet
Muhammad SAW, who has guide us from darkness to the lightness. So we can
write this paper.

Only a word of gratitude that the author can convey so that the paper that
becomes the task of plenary discussion is well resolved. On the other hand, we say
those who have assisted in the process of composing this paper. We also thank to
Mrs Mega Octavia for guide us during the tutorial, and give us critism and
suggestion to be better. So we can convey hopefully this paper can give a good
impression. Critism and suggestion we always hope that this paper can be better in
the future.

So we can convey hopefully this paper can give a good impression. So we

can convey, hopefully this paper can give a good impression. Critism and
suggestion we always hope that this paper can be better in the future.

Wassalamu’alaikum wa rahmatullahi wa barakatuh

Yogyakarta, March 11, 2019

writer

All of member gorup 6 tutorial

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 TABLE OF CONTENTS
PREFACE .................................................................................................................................................... 1

Table of Contents ...................................................................................................................................... 2

Scenario ......................................................................................................................................................... 3

Chapter I : Discussion ...............................................................................................................................

1.1 Hypersensitivity types ............................................................................................................................. 4

1.2 Mechanism of food allergy .................................................................................................................... 4

1.3 How does a person become allergic? ..................................................................................................... 5

1.4 Definition of antihistamin ................................................................................................................. 6

1.5 Antihistamin types .............................................................................................................................. 6

1.6 How an allergist diagnoses allergies ............................................................................................... 7

1.7 Treatment for allergic reaction ......................................................................................................... 8

1.8 Mechanism of immunotherapy ......................................................................................................... 9

1.9 Artificial immune system and natural immune system ............................................................... 11

Chapter II : Conclusion........................................................................................................................ 14

2.1 Conclusion ......................................................................................................................................... 14

2.2 Reference ................................................................................................................. .............15

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 SCENARIO

Mr. N came to a pharmacy to buy some drug because he felt itching all over his body
after eating shrimp.Mr. N has taken supplements that can increase endurance.
Therefore, Mr. N thought he had recovered from the allergies he suffered so he
wanted to eat, when he was offered a shrimp by his friend. Mr. N asked for a drug
that did not cause drowsiness because of his job as a bus driver.

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 CHAPTER I : DISCUSSION

1.1 HYPERSENSITIVITY TYPES

Type I: Mastocytes bind Ig E through Fc receptor. Bond between antigen and The
Ig E will cause degranulation of the releasing mastocytes mediator.
Type II: Antibodies formed against antigen which is part of the cell host.
Antigen complex and the antibodies formed will give rise to cytotoxic responses
of K cells (as an ADCC effector) and or cell through complementary activity.
Type III: Immune complex deposited on the network. Complement activated,
polymorphonuclear cells are sent to a complex place.
Type IV: Sensitized T cells release lymphokine due to exposure reset with the
same antigen. Lymphokine exerts and activates subsequent marcrophages remove
the mediator and cause inflammatory response.

Hypersensitivity reactions are categorized into four major types: type I, type
II, type III, and type IV. Type I, II, and III reactions are the result
of antibody actions, while type IV reactions involve T cell lymphocytes and cell-
mediated immune responses.

1.2 MECHANISM OF FOOD ALLERGY

Limfoepiteal intestinal structure known as GALT (Gut-Associated Lymphoid
Tissue) consists of tonsils, patch payers, appendices, patches and patches of
colonies. In circumstances specifically GALT has the ability to develop local
responses together with the ability to suppress the induction of a systemic
response to the same antigen.
Under normal conditions of food absorption, it is a natural everyday event inside
human digestive system. Factors in the intestinal lumen (intestine), epithelial
surface(intestinal wall) and in the lamina propia work together to limit the entry of
objects foreign into the body through the digestive tract. A number of non-
immunological mechanisms andimmunologists work to prevent penetration of
foreign objects such as bacteria, viruses, parasites and protein causing food
allergies to the walls of the intestine (intestinal barrier).
At initial exposure, the allergen allergen will be recognized by the antigen
presenting cell for the nextexpress to T-cells directly or through cytokines. T cells
are sensitized and will stimulate B cells produce antibodies from various subtypes.
Intensive allergens will be absorbed by the intestine in considerable amounts and
reach antibody-forming cells in the intestinal mucosa and intestinal orgalimfoid.
In general, children forming antibodies with IgG, IgA and IgM subtypes. In atopic

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children there is more tendency forming IgE, then sensitizing mast cells to the
gastrointestinal tract, airways, skin and many other body organs. Intestinal
epithelial cells play an important role in determining speed and pattern ingested
antigen .
During the reaction the IgE is delivered to the digestive tract, speed and the
amount of foreign matter absorbed increases. Foreign objects dissolved in the
intestinal lumen are taken and offered primarily by gastrointestinal epithelial cells
with the result of suppression of the immune system or known as tolerance.
Insoluble antigens, intestinal bacteria, viruses and intact parasites taken by M cells
(cells) special epithelium that lines the vaginal patch) with the result of active
immunity and IgA formation. Protein ingestion the diet normally activates TCD8
+ suppressor cells located in the intestinal lymphoid tissue and after ingestion of
the antigen lasts a long time. The cell is located in the spleen. The initial
activation of these cells depends on the nature, dosage and frequent antigen
exposure, host age and the possibility of lipopolysaccharide produced by intestinal
flora from the host. Factors that cause absorption of pathological antigens are
decreased intraluminal digestion, barrier the mucosa is disrupted and the
production of IgA decreases by plasma cells in the lamina propia.

1.3 HOW DOES A PERSON BECOME ALLERGIC ?

Allergens can be inhaled, ingested, or enter through the skin. Common allergic
reactions, such as hay fever, certain types of asthma, and hives are linked to an
antibody produced by the body called immunoglobulin E (IgE). Each IgE
antibody can be very specific, reacting against certain pollens and other allergens.
In other words, a person can be allergic to one type of pollen, but not another.
When a susceptible person is exposed to an allergen, the body starts producing a
large quantity of similar IgE antibodies. The next exposure to the same allergen
may result in an allergic reaction. Symptoms of an allergic reaction will vary
depending on the type and amount of allergen encountered and the manner in
which the body's immune system reacts to that allergen.
Allergies can affect anyone, regardless of age, gender, race, or socioeconomic
status. Generally, allergies are more common in children. However, a first-time
occurrence can happen at any age, or recur after many years of remission.
Hormones, stress, smoke, perfume, or environmental irritants may also play a role
in the development or severity of allergies

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1.4 DEFINITION OF ANTIHISTAMIN

Histamine is a biologically active substance that potentiates the inflammatory and

immune responses of the body, regulates physiological function in the gut, and
acts as a neurotransmitter. Drugs that antagonize these effects by blocking or
inhibiting histaminereceptors (H receptors) are called antihistamines.
Antihistamines are divided into two classes (H1 antihistamines and H2
antihistamines), based on the type of H receptor targeted. H1 antihistamines are
mostly used to treat allergic reactions and mast cell-mediateddisorders. This
subtype is further divided into two generations. While the first-generationH1
antihistamines have a central effect and, thus, are also used as sedatives, second-
generation H1 antihistamines have less central effects and are used primarily as
antiallergenic drugs. H2 antihistamines are indicated primarily for gastric reflux
disease because they reduce the production of stomach acid by reversibly
blocking the H2 histaminereceptors in the parietal cells of the gastric mucosa. Use
of most H1 and H2 antihistamines is contraindicated during pregnancy and
childhood. First-generation H1 antihistamines are specifically contraindicated
in angle-closure glaucoma and pyloric stenosis.

1.5 ANTIHISTAMIN TYPES antihistamin types

 H1 antihistamines
Target: histamine H1 receptors
Location of H1 receptors
 Smooth muscles (esp. bronchial and nasopharyngeal lining)
 Vascular endothelial cell surfaces
 Heart
 Central nervous system

Effect of histamine on target

↑ Capillary dilation and permeability → hypotension and edema
↑ Bronchiolar smooth muscle contraction (via IP3 and DAG release) →
bronchoconstriction
↑ Nasal and bronchial mucus production
↑ Activation of peripheral nociceptive receptors → ↑ pain and pruritus
↓ Conduction in AV node

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Effects
 Competitive, reversible antagonism of histamine H1 receptors
 Inhibition of increased vascular permeability
 Inhibition of allergic bronchial constriction

 H2 antihistamines
Target receptors
Target: histamine H2 receptors
Location of H2 receptors
 Gastric parietal cells (oxyntic cells)
 Vascular smooth muscle
 Neutrophils
 Central nervous system
 Heart
 Uterus

Effect of histamine on target

↑ Gastric acid secretion
Positive inotropism and ↑ automaticity
Smooth muscle relaxation → vasodilatation
Effects
 Competitive, reversible antagonism of histamine H2 receptors → reduced
production of stomach acid
 Side effects

1.6 HOW AN ALLERGIST DIAGNOSES ALLERGIES

1. Allergy skin tests and testing standards

When you visit an allergist, the doctor will :

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a. take a medical history. You will be asked about your health, your symptomps
and whether members of your family have allergies such as hay fever, hives or
skin rashes.
b. ask you about your symptoms. The doctor will want to know when symptoms
occur, how often they happen and what seems to bring them on. The allergies will
also ask about your work, home and eating habits to see if these can provide clues
to help pinpoint your allergy.
There are 2 types of skin tests :
a. the prick test pricks the surface of the skin with a tiny amount of the allergen.
The test is done on your back or the inside of your arms with several allergens
tested at once. If you’re allergic, redness and swelling appear at the site of the
pick.
b. the intradermal test injects the allergen with a very fine needle under the first
few layers of the skin. This type of skin test may be used when the result of a
prick test is not clear.
2. allergy blood tests
Skin tests are more sensitive than blood tests, but an allergiest might use a blood
test to diagnose allergies if:
a. you are taking a medicine that could interfere with allergy result.
b. you have very sensitive skin or a serious skin condition.
c. you had a previous reaction to an allergen that suggested you were very
sensitive and should avoid more exposure.

1.7 TREATMENT FOR ALLERGIC REACTION

Over the counter (OTC) antihistamines and decongestants may relieve minor
symptoms of an allergic reaction. Antihistamines prevent symptoms such as hives
by blocking histamine receptors so your body doesn’t react to the allergens.
Decongestants help clear your nose and are especially effective for seasonal
allergies. But don’t take them for more than three days.
These medications are available in tablets, eye drops, and nasal sprays. Many
OTC drugs also cause drowsiness, so avoid taking them before driving or doing
work that requires a lot of concentrations.
Swelling, redness, and itching may be reduced with ice and topical creams that
contain corticosteroids.

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Make an appointment with your doctor if OTC drug doesn’t work. Call your
doctor right away if you have an allergic reaction to the medication.
Treatments for food allergies
The best remedies for food allergies usually entail avoiding foods that trigger an
allergic reaction. If you accidentally come in contact or eat the food you’re
allergic to, OTC drugs can temper the reaction. However, these drugs only help
relieve hives or itching.

1.8 MECHANISM OF IMMUNOTHERAPY

The exact mechanism and way of working of immunotherapy is not yet known
clearly. Several mechanisms of immunotherapy have been proposed to explain the
success of immunotherapy, namely induction of IgG formation (blocking
antibodies), decreased IgE production, decrease in effector cell mobilization,
changes in cytokine balance (shift from Th2 to Th1), T cell anergy and induction
of regulator T cells.
Atopy is an increase in sensitivity as a result of increasing specific IgE antibodies
to common environmental allergens such as mites, pollen or animal hair.
Repeated exposure to allergens will significantly increase the prevalence of
asthma. Ninety percent of children with asthma and eighty percent of adult asthma
have a history of atopy. Allergic / atopic asthma is characterized by infiltration of
eosinophils and 2 (Th-2) T helper cells to the bronchial mucosa, increased
circulation of specific IgE antibodies, positive skin testing using common
allergens and bronchial hyperactivity. Through Interleukin-4 (IL-4) and IL-13, B
cells will be stimulated to produce IgE and through IL-5 growth, differentiation
and mobilization of eosinophils will occur in the respiratory tract on repeated
exposure to allergens. Interleukin-13 acts as a regulator of inflammatory response
by inhibiting the activation and release of inflammatory cytokines.
Immunotherapy works on specific antibodies to allergens. Specific IgE increases
temporarily at the start of immunotherapy, but decreases after maintenance dose.
Rapid skin reaction decreases after immunotherapy but has very little role in
clinical improvement. On the other hand, the slow reaction in the skin test
decreases markedly after immunotherapy. Immunotherapy also induces specific
IgG for allergens, serves to negate allergic responses even though there is a weak
correlation with clinical improvement. Increased IgG levels correlate with
increasing doses.
T cells also play a role in immunotherapy. Both the skin and the nasal mucosa the
amount of T cell and eosinophil infiltration decreases at the end of
immunotherapy. Along with that, there is a shift in the balance of Th-1 and Th-2

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cytokines, an increase in IL-2, IFN-12 and IL-12.5. In immunotherapy by giving
bee stings, regulator T cell induction produces IL-10 and cytokine shifts towards
Th-1. IL-10 has a complex role including the production of IgG4 as an indicator
of the success of immunotherapy. Research in Surabaya showed that
immunotherapy with house dust extract in children with asthma caused a decrease
in IL-4, IL-5, increases in IFN-γ and IL2. In this study also reported that the
addition of inhaled corticosteroids for 3 months led to a greater emphasis on the
reduction of IL-5, inducing modulation of the immune response resulting in
clinical improvement as indicated by improved reversibility of FEV-1.

Immunotherapy has a modulation effect on T cells, this explains why clinical

symptoms and slow reactions are greatly suppressed even though the decrease in
antibodies does not decrease significantly. Based on this, several new formulas for
immunotherapy have been designed using T cell peptides or allergen conjugation
to shift the cyrokin to the Th-1 pattern. The immunological effects that occur after
administration of immunotherapy are as follows: 8 a). Immunotherapy will induce
allergen-specific IgG (IgG4) which acts as a barrier antibody that competes with
IgE to bind to allergens. A number of studies have suggested that there is a proven
relationship between a reduction in allergy symptoms and the amount of serum
IgG. b). A gradual decrease in allergen-specific IgE in immunotherapy, although
initially there was an increase. Th 2 responses to allergens will be inhibited and
induce Th 1 responses with increased interferon (IFN--) and IL-12. Changes in
this function will affect IgE production, maturation of cell populations, release of
mediators by mast cells and basophils. Finally a decrease in IgE will reduce

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allergic response. c). Immunotherapy modulates the function of mast cells and
basophils so there is a decrease in mediator release even though there is specific
IgE on the surface. This effect is indicated by a decrease in histamine release post-
immunotherapy after exposure to specific allergens preceded by a decrease in
specific IgE or specific IgG enhancement. d). Immunotherapy will change the
working network of cell regulation due to increased suppressor T lymphocyte
activity. IgE production, mast cell maturation, macrophage activation and the
release of mediators by mast cells and basophils will decrease and affect the
mechanism of allergies.

1.9 ARTIFICIAL IMMUNE SYSTEM AND NATURAL IMMUNE SYSTEM

The immune system is all the mechanisms used by the body to maintain its
integrity as a protection against danger caused by various substances in the
environment that are considered foreign to the body (Baratawidjaja, 2000;
Benjamini et al., 2000).
The mechanism involves a combination of cells, molecules, and tissues that play
a role in resistance to infections caused by various pathogenic elements found in
our environment such as viruses, bacteria, fungus, protozoa and parasites (Kresno,
1996; Baratawidjaja & Rengganis, 2009).
The immune system has three functions, namely the defense function (against
pathogens, homeostasis function (maintaining the balance of the body's condition
by eliminating cells that are already useless) and surveillance. In the function of
early surveillance the immunesystem will recognize cells abnormal arising in the

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body due to viruses or chemicals.Theimmune system will recognize these
abnormal cells and destroy them.The most important physiological function of the
immune system is to prevent infection and eradicate existing infections (Abbas et
al., 2014).
There are two immune responses, namely natural or nonspecific / natural / innate
/ native / nonadaptive immunity and acquired or specific / acquired immunity.
a. Nonspecific immune response
The nonspecific immune response is innate immunity where the immune response
to foreign substances can occur even though the body was never previously
exposed to the substance (Kresno, 1996).
Nonspecific immunity plays the earliest role in the body's defense against
microbial pathogens by blocking the entry of microbes and immediately
eliminating microbes that enter the body's tissues (Abbas et al., 2014).
This type of immune response will always provide the same response to all types
of infective agents and do not have the ability to recognize infective agents even
though they have been previously exposed. Included in the nonspecific immune
response are physical, biochemical, humoral and cellular defense (Baratawidjaja
& Rengganis, 2009).
b. Specific immune response
Specific immune responses are responses obtained from stimulation by infective
agent (antigen / immunogen) and can increase in subsequent exposure. The target
of a specific immune response is an antigen, which is a foreign substance (for
hosts) that can induce specific immune responses (Benjamini et al., 2000).
Antigens react with T-cell Receptor (TCR) and antibodies. Antigens can be
molecules that are on the surface of pathogenic elements or toxins produced by
the antigen in question.There are three types of cells involved in specific immune
responses, namely T cells, B cells and APC (macrophages and dendritic cells)
(Benjamini et al., 2000).
7 response specifics include activation and maturation of cells, mediator cells and
B cells to produce sufficient antibodies to fight antigens (Kresno, 1996). In
essence the specific immune response is an interaction between various
components in the immune system together. Specific immune responses consist of
cellular immune responses and humoral immune responses. The second difference
in the immune response lies in the molecules that play a role in fighting infective
agents, but the main goal is the same, namely to eliminate antigens (Benjamini et
al., 2000).

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 Cellular immune responses are needed to fight microbes inside cells
(intracellular) such as viruses and bacteria. This response is mediated by T
lymphocytes (T cells) and plays a role in supporting the destruction of microbes
inside phagocytes and killing infected cells. Some T cells also contribute to
eradication of extracellular microbes by recruiting leukocytes which destroy
pathogens and help B cells make effective antibodies (Abbas et al., 2015).
The humoral immune response is in the blood and secretions such as mucosa,
saliva, tears and breast milk. Another element that plays an important role in the
humoral immune response is the complement system. The complement system is
activated by the reaction between antigen and antibody. When the complement
system is active it will lyse target cells or increase the phagocytosis ability of
phagocytic cells (Benjamini et al., 2000).

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 CONCLUSION

So in this case Mr. N asked for an allergy medicine that did not cause
drowsiness, and the most appropriate drug given was the 2nd generation anti
histamine drug. Second-generation oral antihistamines are a type of drug
developed to target their action on more specific receptors. This helps reduce
side effects, including drowsy side effects. This second generation medicine also
works longer in the body. examples of the drugs are cetirizine, loratadine and
Fexofenadin.

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Reference :

Baratawidjaja, K.G. & Rengganis, I., 2000, Imunologi Dasar, Edisi IV, FKUI, Jakarta.

Abbas, A.K., Lichtman, A.H., & Pillai, S., 2014, Basic Immunology, Fourth Edition, Elsevier,
Saunders,

Philadelphia.

Benjamini, E., Coico, R., Sunshine, G., 2000, Immunology A Short Course, Forth Edition,
Wiley-Liss, A John Wiley & Sons, Inc., New York.

Kresno, S.B., 1996, Imunologi: Diagnosis dan Prosedur Laboratorium, Edisi III, Fakultas
Kedokteran Universitas Indonesia, Jakarta

Brockow K, Przybilla B, Aberer W, Bircher AJ, Brehler R, Dickel H, et al. Guideline for the
diagnosis of drug hypersensitivity reactions. Allergo J Int.2015;24:94-105.

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