detecção de citocinas em culturas de linfócitos em pacientes

LUIS EDUARDO AGNER MACHADO MARTINS

'HWHFomR�GH�FLWRFLQDV�HP�FXOWXUDV�GH�OLQIyFLWRV�HP�

SDFLHQWHV�DOpUJLFRV�DR�FURPR

Tese�DSUHVHQWDGD�j�)DFXOGDGH�GH�0HGLFLQD

GD�8QLYHUVLGDGH�GH�6mR�3DXOR�SDUD�REWHQomR�

GR�WtWXOR�GH�Doutor em Dematologia

Programa: Dermatologia

Orientador: Dr. Vitor Manoel Silva dos Reis

6mR�3DXOR

2010

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Dados Internacionais de Catalogação na Publicação (CIP)

Preparada pela Biblioteca da Faculdade de Medicina da Universidade de São Paulo

©reprodução autorizada pelo autor

Martins, Luis Eduardo Agner Machado Detecção de citocinas em culturas de linfócitos em pacientes alérgicos ao cromo / Luis Eduardo Agner Machado Martins. -- São Paulo, 2010.

Tese(doutorado)--Faculdade de Medicina da Universidade de São Paulo. Programa de Dermatologia.

Orientador: Vitor Manoel Silva dos Reis.

Descritores: 1.Teste de proliferação linfocitária 2.Hipersensibilidade/diagnóstico 3.Cromo 4.Citocinas 5.Dermatite de contato

USP/FM/DBD-229/10

DEDICATÏRIA


Aos meus pais pelo constante

DX[tOLR��apoio e

incentivo

.


AGRADECIMENTOS


Ao Profo. Dr. Vitor Manoel Silva dos Reis que mais uma vez acreditou no meu

potencial e contribuiu ativamente durante todo o desenvolvimento desse

projeto.

Ao Profo. Dr. Evandro Rivitti e PHPEURV� GD� FRPLVVmR� GD� SyV-JUDGXDomR� GR�

Departamento de Dermatologia que permitiram a continuidade do trabalho.

Ao Profo�'U��$OEHUWR�-RVp�GD�6LOYD�'XDUWH, a Profa. Dra. Mirian Nacagami Sotto e

demais integrantes do LIM-��SRU�DSRLDU�H�IRUQHFHU�RV�PHLRV�SDUD�D�UHDOL]DomR�

da tese.

A Profa. Dra. 9DOpULD�$RNL�e ao Profo. Dr. Paulo Ricardo Criado pela amizade,

DX[tOLR�H�RULHQWDo}HV�SUHVWDGDV�

$R�5LFDUGR�6SLQD�1XQHV�SHOD�GHGLFDomR�H�UHDOL]DomR�GRV�WHVWHV�GH�FRQWDWR�

A todos os demais professores, residentes� H� IXQFLRQiULRV� pela amizade e

carinho.


680È5,2


680È5,2

Lista de abreviaturas/LVWD�GH�VtPERORVLista de tabelas�H�JUiILFRV ResumoSummary ��,1752'8d2.......................................................................................... 012 OBJETIVOS................................................................................................ 06��5(9,62�'$�/,7(5$785$................................................................... 073.1.1 Cromo................................................................................................. 07 3.1.2 0DQLIHVWDo}HV�FOtQLFDV�GD�'&$�SHOR�FURPR....................................... 08 3.1.3 3URJQyVWLFR�GD�'&$�SRU�FURPR.......................................................... 09 3.2 3DWRJrQHVH�GD�GHUPDWLWH�GH�FRQWDWR�DOpUJLFD........................................ 10 3.2.1 Fase aferente ..................................................................................... 12 3.2.2 Fase eferente ,.................................................................................... 153.2.3 &pOXODV�HQYROYLGDV.............................................................................. 16 3.2.3.��&pOXODV�GHQGUtWLFDV........................................................................... 163.2.3.1.1 As &pOXODV�GHQGUtWLFDV�QD�IDVH�DIHUHQWH........................................ 173.2.3.1.2 As FpOXODV�GHQGUtWLFDV�QD�IDVH�HIHUHQWH......................................... 20 3.2.3.2 /LQIyFLWRV ........................................................................................ 213.2.3.2.1 /LQIyFLWRV�HIHWRUHV......................................................................... 21��/LQIyFLWRV�7�UHJXODGRUHV��...................................................... 23��4XHUDWLQyFLWRV.................................................................................. 263.2.3.4 0DVWyFLWRV........................................................................................ 283.2.3.5 /LQIyFLWRV�%�H�FpOulas T NK.............................................................. 28 4 7HVWHV�GLDJQyVWLFRV.................................................................................. 304.1 Teste de contato ................................................................................... 304.2 7HVWH�GH�SUROLIHUDomR�liQIRFLWiULD............................................................ 31 ��0e72'26............................................................................................... 42��6HOHomR�GH�SDFLHQWHV��..................... 424.2 Teste de contato.................................................................................... 43 ��7HVWH�GH�SUROLIHUDomR�OLQIRFLWiULD��..................... 454.3.1 7HVWH�GH�SUROLIHUDomR�OLQIRFLWiULD�SDUD�GHWHFomR�GD�DWLYDomR�FHOXODU�pela taxa GH�FDSWDomR�GH�WLPLGLQD�UDGLRPDUFDGD........................................ 47 4.3.2 7HVWH�GH�SUROLIHUDomR�OLQIRFLWiULD�SDUD�GHWHFomR�GD�DWLYDomR�FHOXODUpela pURGXomR de citocinas ......................................................................... 49 4.4 Dosagem das citocinas no sobrenadante das culturas ........................ 50 4.4.1 ³/XPLQH[�OLTXLFKLS�DUUD\´................................................................... 50 4.4.2 Citocinas testadas ............................................................................ 52 ��0pWRGRV�HVWDWtVWLFRV��.................. 535 RESULTADOS........................................................................................ 545.1 6HOHomR�GRV�JUXSRV.............................................................................. 545.2 Testes de contato................................................................................. 54


5.3�7HVWHV�GH�SUROLIHUDomR�OLQIRFLWiULD��......... 55 5.4 'HWHFomR�GDV�FLWRFLQDV�........................................................................ 575.4.1 Interferon-gama............................................................................... 575.4.2 Interlucina-2..................................................................................... 59 5.4.3 Interlucina-4..................................................................................... 61 5.4.4 Interlucina-5..................................................................................... 63 5.4.5 Interlucina-10................................................................................... 65 5.4.6 Interlucina-12................................................................................... 67 5.4.7 Interlucina-13................................................................................... 69 5.4.8 Interlucina-17................................................................................... 71 5.4.9 RANTES.......................................................................................... 73��7HVWHV�GH�FRSUUHODomR.......................................................................... 75��',6&8662........................................................................................... 767 &21&/86®(6....................................................................................... 868 ANEXOS................................................................................................. 87 ��5()(5Ç1&,$6�%,%/,2*5È),&$6...................................................... 100

LISTAS


Lista de Abreviaturas

Ag = $QWtJHQR C5 = )UDomR�&��GR�FRPSOHPHQWR C5a = )UDomR�&�D�GR�FRPSOHPHQWR CCL1 = Quimiocina CCL1 CCL5 = Quimiocina CCL5 (RANTES)

CCL19 = Quimiocina CCL19 CCL21 = Quimiocina CCL21 CCR4 = Receptor de quimiocina CCR4 CCR7 = Receptor de quimiocina CCR7 CCR8 = Receptor de quimiocina CCR8 CD = &pOXOD�GHQWUtWLFD CD1d = 0HPEUR�GD�IDPtOLD�&'� CD4+ = $QWtJHQR�&'� CD4+CD25+ = &pOXOD�7�UHJXODGRUD�&'�+CD25+

CD8+ = $QWtJHQR�&'� CD25 = $QWtJHQR�&'�� CD28 = $QWtJHQR�&'�� CD80 = $QWtJHQR�&'�� CD86 = $QWtJHQR�&'�� CD205 = $QWtJHQR�&'�� CLA = $QWtJHQR�OLQIRFLWiULR�FXWkQHR CL = &pOXOD�GH�/DQJHUKDQV


Cpm = Contagens por minuto

Cr (III) = Cromo trivalente Cr (VI) = Cromo hexavalente CrCl3 = Cloreto de cromo CTLA-4 = $QWtJHQR��DVVRFLDGR�DR�OLQIyFLWR�7�FLWRWy[LFR DC = Dermatite de contato

DCA = 'HUPDWLWH�GH�FRQWDWR�DOpUJLFD DCI = Dermatite DNA = ÈFLGR�GHVR[LUULERQXFOpLFR DTH = 5HDomR�GH�KLSHUVHQVLELOLGDGH�WDUGLD ELISA = Ensaio imunoenzLPiWLFR ELISpot = EQVDLR�LPXQRHQ]LPiWLFR modificado Fas = 3URWHtQD�)DV FasL = /LJDQWH�GD�SURWHtQD�)DV Fas-FasL = ,QWHUDomR�GD�SURWHtQD�)DV�FRP�VHX�OLJDQWH Foxp3 = )DWRU�GH�WUDQVFULomR�QXFOHDU�)R[S� GM-CSF = Fator estimuladRU�GD�FRO{QLD�GH�PDFUyIDJRV�H�PRQyFLWRV� HC-FMUSP = +RVSLWDO�GH�&OtQLFDV�GD�)DFXOGDGH�GH�0HGLFLQD�GD�

8QLYHUVLGDGH�6mR�3DXOR� ICAM-1 = 0ROpFXOD�GH�DGHVmR�LQWHUFHOXODU IE = ËQGLFH�GH�HVWLPXODomR IgM = Imunoglobulina M IL-1 = Interleucina 1

IL-1 = Interleucina 1 alfa IL-1 = Interleucina 1 beta IL-2 = Interleucina 2 IL-4 = Interleucina 4 IL-5 = Interleucina 5 IL-6 = Interleucina 6

IL-7 = Interleucina 7 IL-8 = Interleucina 8 IL-10 = Interleucina 10 IL-12 = Interleucina 12 IL-13 = Interleucina 13 IL-16 = Interleucina 16 IL-17 = Interleucina 17 IL-23 = Interleucina 23 INF- = Interferon gama K2Cr2O7 = %LFURPDWR�GH�SRWiVVLR LB = /LQIyFLWR�% LFA-1 = 3URWHtQD��DVVRFLDGD�D�IXQomR�OLQIRFLWiULD LT = /LQIyFLWR�7 LT NK = FpOXODV�7�H[WHUPLQDGRUDV�QDWXUDLV M = Molar MHC I = Complexo principal de histocompatibilidade 1 MHC II = Complexo principal de histocompatibilidade 2

NK = &pOXOD�H[WHUPLQDGRUD�QDWXUDl P = 6LJQLILFkQFLD PWM = Pokeweed RANK = Receptor ativador do fator nuclear B RANKL = Ligante do receptor ativador do fator nuclear B RANTES = Quimiocina RANTES (CCL5) RNAm = ÈFLGR�ULERQXFOpLFR�PHQVVDJHLUR Rpm = 5RWDo}HV�SRU�PLQXWR RPMI 1640 = Meio de cultura Rosewell Park Memorial Institute TC = Teste de contato Tc1 = 7�FLWRWy[LFD�WLSR�� TGF- = Fator transformador do crescimento beta Th1 = T auxiliar tipo 1 Th2 = T auxiliar tipo 2 Th17 = T auxiliar tipo 17 TNF- = Fator de necrose tumoral alfa TPL = 7HVWH�GH�SUROLIHUDomR�OLQIRFLWiULD Tr1 = /LQIyFLWR�7�UHJXODGRU�� UVB = 5DGLDomR�XOWUDYLROHWD�% VCAM-1 = 0ROpFXOD�1 GH�DGHVmR�GD�FpOXOD�YDVFXODU VLA-4 = $QWtJHQR�GH�DWLYDomR�PXLWR�WDUGLD�� VLA-5 = $QWtJHQR�GH�DWLYDomR�PXLWR�WDUGLD��

VLA-6 = $QWtJHQR�GH�DWLYDomR�PXLWR�WDUGLD��

/LVWD�GH�6tPERORV

Delta

g Micrograma

g Nanograma

L Microlitro M Molar > Maior que

Maior ou igual a < Menor que % por cento

oC grau Celsius

/LVWD�GH�7DEHODV�H�*UiILFRV

FIGURA 1 0HFDQLVPR�GD�VHQVLELOL]DomR�H�HOLFLWDomR�GD�GHUPDWLWH�GH�FRQWDWR�

DOpUJLFD..........................................................................................11 FIGURA 2 Microesferas de poliestireno coradas de forma singular...............50 FIGURA 3 $�HVIHUD�FRP�R�DQWLFRUSR�p�LQFXEDGD�FRP�D�DPRVWUD�H�VH�OLJD�DR�

VHX�DQWtJHQR��$� DPRVWUD� p� ODYDGD�H� LQFXEDGD� FRP�XP�DQWLFRUSR�biotinilado que se ligD� DR� FRPSOH[R� DQWtJHQR-anticorpo. O resultado p amplificado pela� LQFXEDomR� FRP� R� FRQMXJDGR�estreptavidina-ficoeritrina que emite um sinal fluorescente ..........51

FIGURA 4 2V�IHL[HV�GH�ODVHU�LQFLGHP�VREUH�DV�HVIHUDV�SHUPLWLQGR�D�GHWHFomR�

do ensaio e da intensidade da resposta........................................52 FIGURA 5 Contagens por minuto encontradas nas culturas basais e

estimuladas com PWM do grupo de casos. .................................56 FIGURA 6 Contagens por minuto encontradas nas culturas basais e

estimuladas com PWM do grupo controle.....................................56 FIGURA 7 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QRV� FDVRV� H� FRQWUROHV�

estimulados com PWM. ................................................................56 FIGURA 8 Contagens por minuto encontradas nas culturas basais e

estimuladas com cromo do grupo de casos. ................................56 FIGURA 9 Contagens por minuto encontradas nas culturas basais e

estimuladas com cromo do grupo controle. ..................................56 FIGURA 10 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QRV� FDVRV� H� FRQWUROHV�

estimulados com cromo.................................................................56 FIGURA 11 'HWHFomR�GH�,)1- nas culturas basais dos casos e controles.....58 FIGURA 12 'HWHFomR�GH� ,)1- nas culturas basais e estimuladas com cromo

do grupo de casos.........................................................................58 FIGURA 13 'HWHFomR�GH� ,)1- nas culturas basais e estimuladas com cromo

do grupo controle. .........................................................................58

FIGURA 14 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QDV� FXOWXUDV� GRV� FDVRV� H�controles........................................................................................58

FIGURA 15 'LIHUHQoD� QD� GHWHFomR� GH� ,)1- entre as culturas estimuladas e basais dos grupos de caso e controle...........................................58

FIGURA 16 'HWHFomR�GH�,/-2 nas culturas basais dos casos e controles........60 FIGURA 17 'HWHFomR�GH�,/-2 nas culturas basais e estimuladas com cromo do

grupo de casos. ............................................................................60 FIGURA 18 'HWHFomR�GH�,/-2 nas culturas basais e estimuladas com cromo do

grupo controle. ..............................................................................60 FIGURA 19 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QDV� FXOWXUDV� GRV� FDVRV� H

controles........................................................................................60 FIGURA 20 'LIHUHQoD�QD�GHWHFomR�GH�,/-2 entre as culturas de estimuladas e

basais dos grupos de caso e controle. .........................................60 FIGURA 21 'HWHFomR�GH�,/-4 nas culturas basais dos casos e controles........62 FIGURA 22 'HWHFomR�GH�,/-4 nas culturas basais e estimuladas com cromo do

grupo de casos..............................................................................62 FIGURA 23 'HWHFomR�GH�,/-4 nas culturas basais e estimuladas com cromo do

grupo controle................................................................................62 FIGURA 24 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QDV culturas dos casos e

controles........................................................................................62 FIGURA 25 'LIHUHQoD� QD� GHWHFomR� GH� ,/-4 entre as culturas estimuladas e

basais dos grupos de caso e controle. .........................................62 FIGURA 26 'HWHFomR�GH�,/-5 nas culturas basais dos casos e controles........64 FIGURA 27 'HWHFomR�GH�,/-5 nas culturas basais e estimuladas com cromo do

grupo de casos. ............................................................................64 FIGURA 28 'HWHFomR�GH�,/-5 nas culturas basais e estimuladas com cromo do

grupo controle................................................................................64 FIGURA 29 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QDV� FXOWXUDV� GRV� FDVRV� H�

controles........................................................................................64

FIGURA 30 'LIHUHQoD� QD� GHWHFomR� GH� ,/-5 entre as culturas estimuladas e basais dos grupos de caso e controle. .........................................64

FIGURA 31 DeteFomR�GH�,/-10 nas culturas basais dos casos e controles......66 FIGURA 32 'HWHFomR�GH� ,/-10 nas culturas basais e estimuladas com cromo

do grupo de casos. .......................................................................66 FIGURA 33 'HWHFomR�GH� ,/-10 nas culturas basais e estimuladas com cromo

do grupo controle...........................................................................66 FIGURA 34 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QDV� FXOWXUDV� GRV� FDVRV� H�


basais dos grupos de caso e controle...........................................66 FIGURA 36 'HWHFomR�GH�,/-12 nas culturas basais dos casos e controles......68 FIGURA 37 'HWHFomR�GH� ,/-12 nas culturas basais e estimuladas com cromo

do grupo de casos.........................................................................68 FIGURA 38 'HWHFomR�GH� ,/-12 nas culturas basais e estimuladas com cromo

do grupo controle...........................................................................68 FIGURA 39 ËQGLFHV� GH� HVWLPXODomR� HQFontrados nas culturas dos casos e


basais dos grupos de caso e controle...........................................68 FIGURA 41 'HWHFomR�GH�,/-13 nas culturas basais dos casos e controles......70 FIGURA 42 'HWHFomR�GH� ,/-13 nas culturas basais e estimuladas com cromo


do grupo controle...........................................................................70 FIGURA 44 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QDV� FXOWXUDV� GRV� FDsos e


basais dos grupos de caso e controle...........................................70 FIGURA 46 'HWHFomR�GH�,/-17 nas culturas basais dos casos e controles......72

FIGURA 47 'HWHFomR�GH� ,/-17 nas culturas basais e estimuladas com cromo


do grupo controle...........................................................................72 FIGURA 49 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QDV� FXOWXUDV� GRV� FDVRV� H�


basais dos grupos de caso e controle. .........................................72

FIGURA 51 'HWHFomR� GH RANTES nas culturas basais dos casos e controles........................................................................................74

FIGURA 52 'HWHFomR� GH� 5$17(6� QDV� FXOWXUDV� EDVDLV� H� HVWLPXODGDV� FRP�

cromo do grupo de casos..............................................................74 FIGURA 53 'HWHFomR� GH� 5$17(6� QDV� FXOWXUDV� EDVDLV� H� HVWLPXODGDV� FRP�

cromo do grupo controle................................................................74 FIGURA 54 ËQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QDV� FXOWXUDV dos casos e

controles........................................................................................74 FIGURA 55 'LIHUHQoD�QD�GHWHFomR�GH�5$17(6�HQWUH�DV�FXOWXUDV�HVWLPXODGDV�

e basais dos grupos de caso e controle. ......................................74 QUADRO 1 7UDEDOKRV�VREUH�WHVWH�GH�SUROLIHUDomR�OLQIRFLWiULD�SRU�FURPR�� QUADRO 2 *UXSR� GH� VXEVWkQFLDV� WHVWDGDV� QD� EDWHULD� SDGUmR� EUDVLOHLUD� GH�

dermatite de contato......................................................................87 QUADRO 3 *UXSR�GH�VXEVWkQFLDV�WHVWDGDV�QD�EDWHULD�GH�FRVPpWLFRV............87 QUADRO 4 Resultados dos testes de contato.................................................88 TABELA 1 9DORUHV� PpGLRV� GDV� FRQWDJHQV� SRU� PLQXWR� GDV triplicatas dos

casos e controles........................................................................................89

TABELA 2 'HWHFomR� GH� ,)1-gama em pg/mL nas culturas dos casos e

controles........................................................................................90 TABELA 3 'HWHFomR�GH�,/-2 em pg/mL nas culturas dos casos e controles..91

TABELA 4 'HWHFomR�GH�,/-4 em pg/mL nas culturas dos casos e controles..92 TABELA 5 'HWHFomR�GH�,/-5 em pg/mL nas culturas dos casos e controles..93 TABELA 6 'HWHFomR� GH� ,/-10 em pg/mL nas culturas dos casos e

controles........................................................................................94 TABELA 7 'HWHFomR� GH� ,/-12(p70) em pg/mL nas culturas dos casos e

controles........................................................................................95 TABELA 8 'HWHFomR� GH� ,/-13 em pg/mL nas culturas dos casos e

controles........................................................................................96

TABELA 9 'HWHFomR� GH� ,/-17 em pg/mL nas culturas dos casos e controles........................................................................................97

TABELA 10 'HWHFomR� GH� RANTES em pg/mL nas culturas dos casos e

controles........................................................................................98 TABELA 11 &RUUHODomR� HQWUH� DOHUJLD� H� RV� tQGLFHV� GH� HVWLPXODomR� GHWHFWDGRV�

FRP�R�WHVWH�GH�SUROLIHUDomR�OLQIRFLWiULD�.........................................99 TABELA 12 &RUUHODomR�HQWUH�DOHUJLD�H�RV�tQGLFHV�GH�HVWLPXODomR�HQFRQWrados

com as citocinas detectadas. .......................................................99 TABELA 13 &RUUHODomR� HQWUH� Rs tQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� FRP� R�

TPL e RV�tQGLFHV�REWLGRV�FRP�DV�citocinas. ..................................99

RESUMO


Martins LEAM. 'HWHFomR�GH�FLWRFLQDV�HP�FXOWXUDV�GH�OLQIyFLWRV�HP�SDFLHQWHV�DOpUJLFRV�DR�FURPR. 6mR�3DXOR�� )DFXOGDGH�GH�0HGLFLQD��8QLYHUVLGDGH�6mR�Paulo; 2010.

$� GHUPDWLWH� GH� FRQWDWR� DOpUJLFD� GHFRUUH� GH� XPD� UHDomR� LPXQROyJLFD,PHGLDGD� SRU� FpOXODV� 7�� FRQWra um contactante em pessoas previamente VHQVLELOL]DGDV��2�H[DPH�SDGUmR�RXUR�SDUD�R�GLDJQyVWLFR�GD�'&$�p�R�WHVWH�de contato (TC). Infelizmente, o TC demanda tempo, QmR� p� LQyFXR� e tem DOJXPDV� OLPLWDo}HV� 2� WHVWH�GH�SUROLIHUDomR� OLQIRFLWiULD� �73/��convencional, uma alternativa ao TC, apresenta baixa sensibilidade no GLDJQyVWLFR� GH�alergia ao cromo. A fim de aprimorar a sensibilidade o resultado do teste foi REWLGR� SHOD�GHWHFomR� GH�FLWRFLQDV�QR�VREUHQDGDQWH�GDV�FXOWXUDV�H�QmR�SRU�timidina radiomarcada. DezoitR�SDFLHQWHV�DOpUJLFRV�DR�FURPR�H��FRQWUROHV�foram testados com o teste convencional e com as citocinas IFN- , IL-2, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17 e rantes. +RXYH� FRUUHODomR� HQWUH� DOHUJLD� DR�cromo e GHWHFomR�GDV�FLWRFLQDV� ,)1- , IL-2, IL-5, IL-12 e IL-13. Dessas, os melhores resultados foram encontrados com a IL-13. O TPL pode ser utilizado como� H[DPH�DGLFLRQDO�RX� DOWHUQDWLYR� QR� GLDJQyVWLFR� GD�'&$�SHOR�cromo.


SUMMARY


Martins LEAM. Cytokine detection in lymphocyte cultures of chromium allergic patients [thesis]. )DFXOW\� RI�0HGLFLQH�� 8QLYHUVLW\� RI� 6mR� 3DXOR�� 63�(Brazil); 2010. Allergic contact dermatitis (ACD) elapses from an specific T cell immunologic reaction against an allergen in a sensitized individual. The gold standard exam to confirm ACD is the patch test (PT). However, PT demands time, has potential side efects and some limitations. The standard lymphocyte proliferation assay (LPA) has sensitivity in the diagnosis of chromium allergy. To optimize this test the results were obtained by detection of cytokines instead radiolabeled thymidine. Eighteen patients allergic to chromium and 19 controls were tested with the conventional LPA and for the following cytokines: IFN- , IL-2, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17 and rantes. Correlation between allergy to chromium and detection of IFN- , IL-2, IL-5, IL-12 e IL-13 was found. The best results were found with IL-13. LPA can be used as an alternative or additional test in the diagnosis of ACD by chromium.


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GHWHUPLQDP� GRHQoDV�� FRPR� RV� HF]HPDV�� 2V� HF]HPDV� VmR� GHUPDWLWHV�

caracterizadas� SHOD� SUHVHQoD� GH� HULWHPD�� HGHPD�� YHVtFXODV�� VHFUHomR��

HVFDPDV�� FURVWDV� H� OLTXHQLILFDomR� GHSHQGHQGR� GR� HVWiJLR� GD� OHVmR� Os

HF]HPDV� FDXVDGRV� SRU� DJHQWHV� H[yJHQRV� sejam eles contatantes ou

endotantes�VmR�FKDPDGRV�de eczemas de contato ou dermatites de contato

(DC). A DC pode ser cDXVDGD� SRU� LUULWDomR�SULPiULD�� GHUPDWLWH� GH� FRQWDWR�

LUULWDWLYD��'&,��RX�SRU�VHQVLELOL]DomR��GHUPDWLWH�GH�FRQWDWR�DOpUJLFD��'&$��$�

DCI UHVXOWD� GD� H[SRVLomR� D� DJHQWHV� TXH� SURYRFDP� GDQR� WHFLGXDO� GLUHWR��

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sensibilidade de 84% e especificidade de 100%. Outros autores chegaram a

resultados semelhantes, confirmando o valor desse testH�QR�GLDJQyVWLFR�GH�

DOHUJLD�DR�QtTXHO�26

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OBJETIVOS


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proteicos.44

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A figura 1 resume os eventos envolvidos nessas fases.


Fonte: Adaptado de Gober e Gaspari45 e Campos et al.46

Fig 1.� 0HFDQLVPR� GD� VHQVLELOL]DomR� H� HOLFLWDomR� GD� GHUPDWLWH� GH� FRQWDWR�DOpUJLFD�� Na fase aferente os haptenos penetram a pele e se ligam a SURWHtQDV�WHFLGXDLV�WRUQDQGR-VH�DQWtJHQRV��$J��FRPSOHWRV��(VVHV�DQWtJHQRV�VmR�FDSWDGRV� H�SURFHVVDGRV� SHODV�FpOXODV�GHQGUtWLFDV� �&'�� TXH�SDVVDP�D�DSUHVHQWi-ORV� DFRSODGRV� D� PROpFXODV� GR� FRPSOH[R� SULQFLSDO� GH�KLVWRFRPSDWLELOLGDGH� �0+&�� QD� VXSHUItFLH� GD� PHPEUDQD� FHOXODU�� $V� &'�PLJUDP� SDUD� RV� OLQIRQRGRV� UHJLRQDLV� RQGH� DSUHVHQWDP� R� DQWtJHQR� DRV�OLQIyFLWRV� 7� �/7�� 2V� /7� TXH� UHFRQKHFHP� R� DQWtJHQR� DSUHVHQWDGR� VmR�DWLYDGRV��$�SHQHWUDomR�GRV�DQWtJHQRV�QD�SHOH�WDPEpP�GHWHUPLQD�D�OLEHUDomR�GH�JOLFROtSLGHV�HQGyJHQRV�TXH�VmR�DSUHVHQWDGRV�SHODV�&'�SDUD�RV�OLQIyFLWRV�T NK (LT NK). Os LT NK liberam IL-4 que estimula�RV�OLQIyFLWRV�%��/%��WLSR��D� SURGX]LU� ,J0�� )UHQWH� D� XP� QRYR� FRQWDWR� D� LQWHUDomR� GD� ,J0� FRP� R�FRPSOH[R� DQWtJHQR-SURWHLFR� OHYD� D� DWLYDomR� GR� FRPSOHPHQWR� TXH� LQGX]� D�OLEHUDomR� GH� IDWRUHV� TXLPLRWiWLFRV� H� LQIODPDWyULRV� GRV�PDVWyFLWRV� H�FpOXODV�endoteliais. Os LT ativados migram para a pele a interagem com as CD que FDUUHJDP�R�DQWtJHQR�OHYDQGR�D�'&$�


3.2.1 Fase aferente

A fase aferente se desenvolve ao longo do tempo como resultado

GD�H[SRVLomR�UHSHWLGD�D�DJHQWHV�DPELHQWDLV��$�PDLRULD�GRV�FRQWDFWDQWHV�VmR�

JUDQGHV�GHPDLV�SDUD�SDVVDU�R�HVWUDWR�FyUQHR��PDV�RV�KDSWHQRV��GHYLGR�DR�

VHX�EDL[R�SHVR�PROHFXODU�SHQHWUDP�HVVD�FDPDGD�H�VH�GLIXQGHP�HP�GLUHomR�

D�FDPDGD�EDVDO�VHP�VHUHP�UHFRQKHFLGRV�SHOR�VLVWHPD�LPXQROyJLFR��'XUDQWH�

HVVH� SURFHVVR� GH� GLIXVmR� VH� OLJDP� jV� SURWHtQDV� WHFLGXDLV� WRUQDQGR-se

LPXQRJrQLFRV�� (VVDV� SURWHtQDV� SRGHP� VHU� GHULYDGDV� GRV� TXHUDWLQyFLWRV��

FRPSRQHQWHV� GDV� FpOXODV� GH� /DQJHUKDQV� �&/�� RX� SHSWtGHRV� SUHYLDPHQWH�

processados ligados ao MHC.47�$�QDWXUH]D�GR�KDSWHQR��R�WLSR�GH�OLJDomR�GR�

hapteno com sHX� FDUUHDGRU� H� D� FRQILJXUDomR� WULGLPHQVLRQDO� ILQDO� GR�

complexo formado influenciam a imunogenicidade do complexo hapteno-

proteico.48

O complexo hapteno-SURWHLFR� p� FDSWDGR� SHODV� FpOXODV� GHQGUtWLFDV�

�&'�� IUDJPHQWDGR� HP� GLYHUVRV� SHSWtGLRV� H� DFRSODGRV� D� PROpFXODV� GR�

FRPSOH[R�SULQFLSDO�GH�KLVWRFRPSDWLELOLGDGH��0+&��2�FRQMXQWR�SHSWtGLR-MHC

p�H[SUHVVR�QD�VXSHUItFLH�GD�&'�SRVVLELOLWDQGR�D�DSUHVHQWDomR�GR�DQWtJHQR�

DR� OLQIyFLWR�7�KDSWHQR-HVSHFtILFR�QR� OLQIRQRGR� UHJLRQDO�48-50�$�FDSWDomR�GRV�

DQWtJHQRV�SURPRYH�XPD�VpULH�GH� DOWHUDo}HV�PRUIROyJLFDV�H� IXQFLRQDLV� QDV�

CD. Elas tornam-VH�PDLV�GHQGUtWLFDV��DXPHQWDm� R�Q~PHUR�GH�JUkQXORV�GH�

%LUEHFN�� GH� PROpFXODV� FR-HVWLPXODWyULDV� H� SURGX]HP� PDLRU� TXDQWLGDGH� GH�

citocinas. Dentre essas citocinas destacam-VH�DV�FLWRFLQDV�SUy-iQIODPDWyULDV�

IL-1 e TNF- .51,52


A IL-1 e o TNF- WUDQVIRUPDP� DV� &'� TXH� SDVVDP� GH� FpOXODV�

SUHSDUDGDV� SDUD� D� FDSWDomR� H� SURFHVVDPHQWR� GH� DQWtJHQRV� SDUD� FpOXODV�

HVSHFLDOL]DGDV� QD� DSUHVHQWDomR� DQWLJrQLFD�53 A IL-1 beta aumenta a

H[SUHVVmR�GH�PROpFXODV�FR-eVWLPXODWyULDV�FRPR�D�,&$0-1 e o CD86 nas CD,

QHFHVViULDV�SDUD�D�DWLYDomR�GRV�/7�KDSWHQR-HVSHFtILFRV�54,55 O TNF- atua

HP� GLYHUVRV� SRQWRV� QD� PLJUDomR� GDV� CD�� 'LPLQXL� D� H[SUHVVmR� GH� (-

caderinas nas CL�� XPD� PROpFXOD� GH� DGHVmR� DRV� TXHUDWLQyFLWRV�� LQGX]� D�

libeUDomR�GH�PHWDORSURWHLQDVHV��D�LQWHUDomR�GH�PROpFXODV�GH�DGHVmR��FRPR�

a LFA-1, ICAM-1 e VLA-6 das CD�FRP�D�PDWUL]�GpUPLFD��H�D�H[SUHVVmR�GH�

&&5�� XP� UHFHSWRU� TXH� UHVSRQGH� j� TXLPLRFLQDs� GR� WHFLGR� OLQIyLGH�

VHFXQGiULR�47,56-59 EVVDV�DOWHUDo}HV�levam�D�PLJUDomR das CD�HP�GLUHomR�DR�

HQGRWpOLR�GR�YDVR�OLQIiWLFR�DIHUHQWH�HP�UHVSRVWD�DR�JUDGLHQWH�GH�TXLPLRFLQDV�

SURGX]LGDV� SRU�HVVDV�FpOXODV. $V�FLWRFLQDV�SUy-LQIODPDWyULDV�� ,/-1 e TNF- ,

DXPHQWDP� D� H[SUHVVmR� GH� (-selectinas e VCAM-�� QDV� FpOXODV�

endoteliais.60,61 A intHUDomR� HQWUH� R� VLDO\O� /HZLV� ;�� XPD� VHOHFWLQD� FXMa

H[SUHVVmR� HVWD� DXPHQWDGD�QDV�&'�GXUDQWH� DV� UHDo}HV� DOpUJLFDV�� H� R� VHX�

ligante, a E-VHOHFWLQD�GDV�FpOXODV�HQGRWHOLDLV�SURPRYH�D passagem das CD

SDUD�RV�OLQIiWLFRV�42,56,62,63

Dentro de vinte e quatro horaV�DSyV�R�FRQWDWR�FRP�R�DQWtJHQR��DV�

CD�PLJUDP�SDUD�RV�OLQIRQRGRV�UHJLRQDLV�SDUD�D�DSUHVHQWDomR�GR�DQWtJHQR�64

1D� UHJLmR�SDUDFRUWLFDO�GRV� OLQIRQRGRV�UHJLRQDLV��DV�&D encontram e tocam

GLYHUVRV� OLQIyFLWRV� 7� YLUJHQV� TXH� HVWmR� HP� SURFHVVR� GH� UHFLUFXODomR��3DUD

aWLYDU� DV� FpOXODV� 7� YLUJHQV� DV� &' devem passar dois sinais.65 Caso o

OLQIyFLWR� SRVVXD� R� UHFHSWRU� FRPSOHPHQWDU� DR� FRPSOH[R� SHSWtGHR-MHC ele


UHFHEHUi� R� SULPHLUR� VLQDO�� 2� SULPHLUR� VLQDO� GHWHUPLQD� DOWHUDo}HV�

conformacionais nDV�PROpFXODV�FR-HVWLPXODWyULDV�GR�LT virgem tornando-as

mais iYLGDV� SHORV� VHXV� OLJDQWHV� TXH� HVWmR� SUHVHQWHV� QD� &'. Ainda, o

SULPHLUR�VLQDO�OHYD�D�WUDQVFULomR�GR�51$P�GD�,/-��SRUpP�R�51$P�IRUPDGR�p�

LQVWiYHO�66 2� VHJXQGR� VLQDO� p� GDGR� SHOD� OLJDomR� HQWUH� DV� PROpFXODV� FR-

HVWLPXODWyULDV� GDV� &D, ICAM-1, CD80 e CD86, com os seus respectivos

ligantes, LFA-1 e CD28 (que se liga tanto ao CD80 quanto ao CD86), no LT.

O CD86, quando acoplado ao CD28, estabiliza o RNAm da IL-2 induzindo o

/7� D� SURGX]LU� JUDQGH� TXDQWLGDGH� GHVVD� FLWRFLQD�� 2V� OLQIyFLWRV� DWLYados

passam a expressar o receptor completo da IL-2 tornando-VH�VXVFHWtYHLV�D�

esta citocina que� SRU� DomR� DXWyFULQD� OHYD� D� SUROLIHUDomR� FHOXODU�� SURFHVVR�

HVVH� FRQKHFLGR� FRPR� H[SDQVmR� FORQDO�66-68� $� H[SDQVmR� FORQDO� IRUPD� um

JUDQGH� Q~PHUR� GH� FpOXODV� 7� KDSWHQR-HVSHFtILFDV� TXH� UHVSRQGHUmR� HP� XP�

IXWXUR�FRQWDWR�FRP�R�DOpUJHQR. 1D�DWLYDomR�GDV�FpOXODV�7��DOpP�GR�SULPHLUR�H�

segundo sinais, as citocinas produzidas pelas CD e presentes no

PLFURDPELHQWH� RQGH� RFRUUH� D� DSUHVHQWDomR� DQWLJrQLFD� WDPEpP� WrP� XP�

papel essencial. AV� FLWRFLQDV� GHWHUPLQDP� R� WLSR� GH� UHVSRVWD� DR� DQWtJHQR�

apresentado, a IL-��OHYD�D�IRUPDomR�GH�FpOXODV�HIHWRUDV�DR�SDVVR�TXH�D�,/-

��GHWHUPLQD�R�VXUJLPHQWR�GH�FpOXODV�UHJXODGRUDV��FpOXODV�TXH�VXSULPHP�R�

processo.69,70 $SyV� D� H[SDQVmR� FORQDO nos linfonodos regionais, os LT

passam para R� GXFWR� WRUiFLFR e� HQWUDP� QD� FLUFXODomR� VDQJ�tQHD�� Essas

FpOXODV� 7� KDSWHQR-HVSHFtILFDV� H[SUHVVDP� R� DQWtJHQR� OLQIRFLWiULR� FXWkQHR�

�&/$�� TXH� GLUHFLRQD� HVVHV� OLQIyFLWRV� SUHIHUHQFLDOPHQWH� SDUD� RV� SURFHVVRV�

LQIODPDWyULRV�FXWkQHRV.


3.2.2 Fase eferente

3DUD� HQFRQWUDU� R� DOpUJHQR�� DV� FpOXODV� 7� SUHFLVDP� SDVVDU� SHOD�

PLFURYDVFXODWXUD�GpUPLFD��SHOD�PDWUL]�GpUPLFD�H�DOFDQoDU�Rs TXHUDWLQyFLWRV

modificadoV�SHOR�DQWtJHQR� RQGH� DWXDUmR��7RGD�HVVD� SDVVDJHP�p� UHJXODGD�

SRU� TXLPLRFLQDV� H� PROpFXODV� GH� DGHVmR� H[SUHVVDV� QRV� WHFLGRV� H�

reconhecidas pelos LT.

2�/7� DWLYDGR� DSUHVHQWD� R� DQWtJHQR� GH� ³KRPLQJ´� �&/$�� R�9/$-4 e

receptores para quimiocinas.70-74�2�&/$�VH� OLJD� j�(-selectina expressa no

HQGRWpOLR� HVWLPXODGR� SHOD� SUHVHQoD� GR� DQWtJHQR� na pele sobrejacente

LQLFLDQGR� R� SURFHVVR� GH� URODJHP�� 3RUpP�� VRPHQWH� TXDQGR� R� 9/$-4 ou o

LFA-�� GRV� OHXFyFLWRV� VH� OLJDP� UHVSHFWLYDPHQWH� jV� LQWHJULQDV� HQGRWHOLDLV�

VCAM-1 e ICAM-1, forma-VH�XPD�OLJDomR�ILUPH�TXH�FRPELQDGD�DR�HVWtPXOR�

de quimiocinas permite a diapedese.60,75-77 &RPR�D�H[SUHVVmR�GH�,&$0-1 no

HQGRWpOLR�Vy�DXPHQWD��KRUDV�DSyV�R�FRQWDWR�FRP�R�DQWtJHQR��SHUtRGR�QR�

TXDO�JUDQGH�SDUWH�GR�LQIOX[R�GH�OLQIyFLWRV�Mi�RFRUUHX��D�(-selectina e o VCAM-

��SDUHFHP�VHU�SDUWLFXODUPHQWH�LPSRUWDQWHV�QR�LQtFLR�GR�SURFHVVR�e o ICAM-1

QD�VXD�DPSOLILFDomR�77

Uma vez na derme, o VLA-4 e o VLA-5 dos LT se ligam a

ILEURQHFWLQD�� XPD� SURWHtQD� H[WUDFHOXODU� GD� PDWUL]� GpUPLFD�� o que facilita o

WUkQVLWR�GHVVDV�FpOXODV�QHVVH�PHLR�78 $V�TXLPLRFLQDV�GLUHFLRQDP�RV�OLQIyFLWRV�

para o epitpOLR�H�D�OLJDomR�HQWUH�R�,&$0-��H[SUHVVR�QRV�TXHUDWLQyFLWRV��FRP�

o LFA-��GRV� OHXFyFLWRV�SURPRYH�D� LQWHUDomR�GHVVDV�FpOXODV�79�2V� OLQIyFLWRV�

SURGX]HP�XPD�UHVSRVWD�LQIODPDWyULD�YLJRURVD�SDUD�HOLPLQDU�RV�TXHUDWLQyFLWRV�


PRGLILFDGRV� SHOR� DQWtJHQR�� /LEHUDP� JUDQde quantidade de IFN- que

HVWLPXOD� RXWUDV� FpOXODV� 7�� FpOXODV� 1.� H�PDFUyIDJRV� D� DPSOLDU� R� SURFHVVR�

LQIODPDWyULR�H�DXPHQWD�D�H[SUHVVmR�GH�)DV�QRs�TXHUDWLQyFLWRV� WRUQDQGR-os

PDLV� VXVFHWtYHLV� j� FLWRWR[LFLGDGH�PHGLDGD� SRU� )DV/�80,81� $OpP� GD� YLD� )DV-

FasL, foi dHPRQVWUDGR� TXH� DV�SHUIRULQDV� WDPEpP�SDUWLFLSDP�GD� GHVWUXLomR�

celular na dermatite de contato.82� 2V� TXHUDWLQyFLWRV� HQWUDP� HP� DSRSWRVH�

RFRUUHQGR�D�FOLYDJHP�GD�FDGHULQD�(�TXH�UHVXOWD�HP�SHUGD�GD�FRHVmR�FHOXODU�

GHPRQVWUDGD� SHOD� HVSRQJLRVH� H� IRUPDomR� GH� YHVtFXOas.83� $� GHVWUXLomR�

WHFLGXDO� H� D� GHVFDPDomR� UHPRYHm� R� DQWtJHQR� GR� WHFLGR�� GLPLQXLQGR� R�

processo�LQIODPDWyULR.42

3.2.3 &pOXODV�HQYROYLGDV

3.2.3.1 &pOXODV�GHQGUtWLFDV

��$� DSOLFDomR� GH� KDSWHQRV� QD� SHOH� LQGX]� D� H[WHQomR� H� UHWUDomR�

sucessiva dos dendritos dDV�FpOXODV�GH�/DQJHUKDQV��&/��EHP�FRPR�LQGX]�D�

PLJUDomR�GHVVDV�FpOXODV�SDUD�RV� OLQIRQRGRV�UHJLRQDLV�84 Esses movimentos

VmR� HVWLPXODGRV� SHOD� ,/-1 e TNF alfa, citocinas produzidas pelos

TXHUDWLQyFLWRV�H�SHODV�SUySULDV�&/�DSyV�R�FRQWDWR�FRP�R�DQWtJHQR�85 Essas

FLWRFLQDV� WDPEpP� LQGX]HP� D� PDWXUDomR� H� PLJUDomR� GDV� &/�86 Durante o

SURFHVVR�GH�DPDGXUHFLPHQWR�DV�&'�DXPHQWDP�D�H[SUHVVmR�GH�PROpFXODV�

FRHVWLPXODWyULDV�FRPR�R�&'��&'��H�&'��PROpFXODV�GH�DGHVmR�FRPR�D�

ICAM-1 e citocinas, como a IL-12.87-89 O processo de DPDGXUHFLPHQWR� p�


QHFHVViULR� SDUD� D� DWLYDomR� GDV� FpOXODV� 7� KDSWHQR-HVSHFtILFDV� YLUJHQV� QRV�

/)1�UHJLRQDLV�SDUD�/7�HIHWRUHV�H�GH�PHPyULD�90 O amadurecimento descrito

RFRUUH�FRP�D�H[SRVLomR�DRV�KDSWHQRV��RV�LUULWDQWHV�TXDQGR�DSOLFDGRV�j�SHOH�

induzem a miJUDomR�GDV�&/��PDV�QmR�D�PDWXUDomR�� LPSHGLQGR�D�IRUPDomR�

GH� XPD� UHVSRVWD� HVSHFtILFD�89� $V� &'� HVWLPXODGDV� VmR� DWUDtGDV� SDUD� RV�

OLQIiWLFRV� DIHUHQWHV�� SRLV� SDVVDP� D� H[SUHVVDU� R� &&5�� TXH� UHVSRQGH� DV�

TXLPLRFLQDV� GR� WHFLGR� OLQIyLGH� &&/�� H� &&/��91� 2V� OLQIiWLFRV aferentes

expressam CCL21 e a zona paracortical dos linfonodos tanto CCL21 quanto

&&/�� DWUDLQGR� DV� &'� SDUD� HVWD� UHJLmR� Gos linfonodos pelo gradiente de

citocinas.92

Recentemente o papel das CD na DCA vem sendo revisto.

3.2.3.1.1 As CpOXODV�GHQGUtWLcas na fase aferente

+i� FRQWURYpUVLDV� TXDQWR� j� IXQomR� GDV� &/� QD� IDVH� GH� LQGXomR da

'&$��$�ODQJHULQD�p�XPD�SURWHtQD�WUDQVPHPEUDQD�TXH�OHYD�D�IRUPDomR�GRV�

JUkQXORV�GH�%LUEHFN��XP�PDUFDGRU�HVSHFtILFR das CL. Utilizando um modelo

PXULQR�RQGH�D�LQMHomR�GH�WR[LQD�GLIWpULFD�OHYD�D�GHSOHomR�VHOHWLYD�GDV�FpOXODV�

que expressam a langerina, Bennett et al.93 demonstraram em maio de 2005

TXH�D�DXVrQFLD�GDV�&/�GLPLQXL�D�FKDQFH�GH�VHQVLELOL]DomR�DRV�KDSWHQRV. Os

autores creditaraP� D� VHQVLELOL]DomR� GH� DOJXQV� GRV� FDPXQGongos expostos

no ensaio DV�&'�GpUPLFDV�H�FRQFOXtUDP�TXH�HVVDV�FpOXODV� trabalham junto

com as CL QR� SURFHVVR� GH� VHQVLELOL]DomR� H� TXH� D� DXVrQFLD� GHVWDV� DIHWD�

esse mecanismo.� 1R� HQWDQWR�� QR� PHVPR� PrV�� .LVVHQSIHQQLJ� et al.94


utilizando um modelo semelhante encontraram uma resposta aos haptenos

VHPHOKDQWH� HQWUH� FDPXQGRQJRV� FRP� GHSOHomR� GDV� &/� H� FRQWUROHV� H�

FRQFOXtUDP�TXH�DV�&/�VmR�GLVSHQViYHLV�SDUD�D�DSUHVHQWDomR�GRV�KDSWHQRV,

ILFDQGR�HVVD�IXQomR�D�FDUJR�DSHQDV�GDV�&'�GpUPLFDV. Em dezembro desse

mesmo ano, Kaplan et al.95 demonstraram que camundongos que

FRQVWLWXFLRQDOPHQWH� QmR� DSUHVHQWDP� &/� WrP� UHVSRVWD� DXPHQWDGD� DRV�

haptenos, ou seja, segundo esse modelo as CL possuem um papel

regulador. $Wp� HQWmR� R� SDSHO� GD� &/� QD� VHQVLELOL]DomR� IRL� GHILQLGR� FRPR�

indutor, indiferente ou supressor. Em 2007, Bennett et al.96 colaboradores

voltaraP� DR� VHX� PRGHOR� H� GHPRQVWUDP� TXH� RV� DQWtJHQRV� QmR� VmR�

DGHTXDGDPHQWH� WUDQVSRUWDGRV� SDUD� RV� OLQIRQRGRV� QD� DXVrQFLD� GDV� &/� H�

concluem que isso diminui a VHQVLELOL]DomR�DRV�DQWtJHQRV��FRQILUPando seus

achados no primeiro ensaio. AtributUDP� jV� GLIHUHQoDV� HQFRQWUDGDV� nos

outros estudos a: 1)� DXVrQFLD� SHUHQH� GDV� &/� QR� PRGHOR� GH� .DSODQ� H�

colaboradores H� �� DR� XVR� GH� FRQFHQWUDo}HV� HOHYDGDV� GRV� DOpUJHQRV� QRV�

demais estudos. As CL em seu estado imaturo carregam auto-DQWtJHQRV�

SDUD� RV� OLQIRQRGRV� JHUDQGR� PHFDQLVPRV� GH� WROHUkQFLD� FRPR� FpOXODV� 7�

reguladoras.97.98� $� DXVrQFLD� GHVVDV� FpOXODV� SRGH� WHU� LPSHGLGR� R�

desenvolvimento desse mecanismo e levado a um estado de

KLSHUUHDWLYLGDGH��UHVSRQViYHO�SHOR�DXPHQWR�GD�VHQVLELOL]DomR�DRV�KDSWHQRV.

&RP� UHODomR� DR� HPSUHJR� GH� FRQFHQWUDo}HV� HOHYDGDV� GRV� DOpUJHQRV os

DXWRUHV� UHIHUHP� TXH� QmR� UHIOHWHP� DV� H[SRVLo}HV� KDELWXDLV�� PDV� VLP� D�

artificialidade dos modelos criados, o que pode ter gerado uma via de

resposta alternativa (Bennett 2007, 34 do Bennett 2007 e os 3 patetas).96,98


Mais tarde Fukunaga et al.99 demonstraram que camundongos com defeito

PLJUDomR� GDV� &/� SDUD� RV� OLQIRQRGRV� UHJLRQDLV��PDV� FRP�PLJUDomR� QRUPDO�

GDV�&'�GpUPLFDV��WHP�UHVSRVWD�QRUPDO�DRV�KDSWHQRV�H�VXJHUHm que as CD

GpUPLFDV� VHMDP� PDLV� LPSRUWDQWHV� QD� JHUDomR� GH� XPD� UHVSRVWD� HIHWRUD�

contra os haptenos do que as CL. Coletivamente, esses dados demonstram

FODUDPHQWH�TXH�DV�&'�GpUPLFDV�VmR�FDSD]HV�GH�GHWHUPLQDU�XPD� UHVSRVWD�

HIHWRUD�DRV�KDSWHQRV��PDV�QmR�SHUPLWHP�XPD�FRQFOXVmR�DGHTXDGD�TXDQWR�

ao papel das CL.

Recentemente um novo subtipo de CD langerina+ foi descrita, a CD

GpUPLFD� ODQJHULQD+.100� (VVDV� FpOXODV� QmR� VmR� &/� HP� WUkQVLWR� SDUD� RV�

OLQIRQRGRV� UHJLRQDLV��SRLV�VmR� RULXQGDV� GH� XPD� OLQKDJHP� FHOXODU�GLIHUHQte,

TXDQGR�GHSOHWDGDV�VmR�FDSD]HV�GH� UHSRYRDU�RV� WHFLGRV�PXLWR�PDLV� UiSLGR�

que as CL e apesar de serem fenotipicamente muito semelhantes

DSUHVHQWDP� PDUFDGRUHV� GH� VXSHUItFLH� SUySULRV.100-102� $V� &'� GpUPLFDV�

langerina+�WDPEpP�FDSWDP�H�DSUHVHQWDP�DQWtJHQRV��8Vando um modelo de

DEODomR� VHOHWLYD� GDV� &/� H� &'� GpUPLFDV� ODQJHULQD+, Wang et al.103

GHPRQVWUDUDP� TXH� D� WHQWDWLYD� GH� VHQVLELOL]DomR� LPHGLDWDPHQWH� DSyV� D�

GHSOHomR��PRPHQWR�TXH�VH�FDUDFWHUL]D�SHOD�DXVrQFLD� WDQWR�GDV�&/�TXDQWR�

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IL-�� HP� UHVSRVWD� D� H[SRVLomR� DRV� KDSWHQRV�145,146� $� H[SRVLomR� DRV�

DOpUJHQRV� WDPEpP� LQGX]� D� SURGXomR� GH� ,/-�� TXH� HVWi� HQYROYLGD� QD�

quimiotaxia de LT CD4+� TXH� VXSULPHP� D� UHVSRVWD� LQIODPDWyULD�147� $OpP�

GLVVR�� RV� TXHUDWLQyFLWRV�� HP� XP� DPELHQWH� LQIODPDWyULR�� H[SUHVVDP� DOWRV�

QtYHLV�GR�OLJDQWH�GR�UHFHSWRU�DWLYDGRU�GR�IDWRU�QXFOHDU� B (RANKL) que induz

D�H[SUHVVmR�GH�&'��H�&'��QDV�&/�TXDQGR�VH�OLJD�DR�UHFHSWRU�DWLYDGRU�

do fator nuclear B (RANK).148� $� H[SUHVVmR� GH� &'�� HVWi� DVVRFLDGD� j�

LQGXomR�GH�Fplulas CD4+CD25+ que suprimem a resposta imune.149

3.2.3.4 0DVWyFLWRV

��-XQWR�FRP�RV�TXHUDWLQyFLWRV�H�FpOXODV�HQGRWHOLDLV�RV�PDVWyFLWRV�VmR�

fonte importante de TNF- e atuam tanto na fase aferente quanto eferente

da hipersensibilidade de contato.150 O TNF- �p�LPSRUWDQWH�QD�PDWXUDomR�GDV�

&'�H�SDVVDJHP�GDV�PHVPDV�SHOR�HQGRWpOLR� 7DPEpP�SURPRYH�D�LQILOWUDomR�

GH� FpOXODV� 7� DXPHQWDQGR� D� UHDomR� LQIODPDWyULD�� $VVLP� FRPR� RV�

TXHUDWLQyFLWRV��RV�PDVWyFLWRV� WrP�IXQomR�GXSOD��SRLV�VXSULPHP�D�'&$�SHOD�

SURGXomR�GH�,/-10.151

3.2.3.5 /LQIyFLWRV�%�H�FpOXODV�7�1.

A DCA foi considerada por muito tempo um processo independente

GD�SDUWLFLSDomR�GDV�FpOXODV�%��PDV�HVWXGRV�UHFHQWHV�DSRQWDP�SDUD�XP�SDSHO�


HVVHQFLDO�GHVVDV�FpOXODV��2V�OLQIyFLWRV�%��/%��DVVRFLDGRV�j�'&$�VmR�GR�WLpo

�� TXH� VmR� FpOXODV� %� LQGHSHQGHQWHV� GDV� FpOXODV� 7�� QmR� IRUPDP� FHQWURV�

JHUPLQDWLYRV��JHUDOPHQWH�QmR�SDVVDP�SHOR�UHDUUDQMR�GR�'1$�H�VmR�IRQWH�GH�

IgM.152�&DPXQGRQJRV�FRP�GHSOHomR�GH�/%�WLSR��DSUHVHQWDP�GLPLQXLomR�GD�

'&$� TXH� p� UHVWDXUDGD� FRP� D� UHSRVLomR� GD� ,J0� PRQRFORQDO� DQWtJHQR-

HVSHFtILFD�� SHOD� WUDQVIHUrQFLD� GH� /%� WLSR� �� GH� GRDGRUHV� DOpUJLFRV� DR�

DQWtJHQR�RX�GH�VRUR�GH�FDPXQGRQJRV��KRUDV�DSyV�D�VHQVLELOL]DomR�GHVWHV�

FRP�R�DQWtJHQR�HP�TXHVWmR�153�(VVD�,J0�FOLYD�D�IUDomR�&��GR�FRPSOHPHQWR�

formando o C5a que DWLYD� RV� PDVWyFLWRV� FRP� FRQVHT�HQWH� OLEHUDomR� GH�

TNF- �H�TXLPLRWD[LD�GRV�OHXFyFLWRV�154�&DPXQGRQJRV�FRP�GHILFLrQFLD�GH�&��

DSUHVHQWDP� GLPLQXLomR� QD� UHVSRVWD� GH� FRQWDWR� DRV� KDSWHQRV�155-157 A IgM

DQWtJHQR-HVSHFtILFD�p�SURGX]LGD�GXUDQWH�D�IDVH�DIHUHQWH�GD�'&$ onde os LB

tipo 1 proliferam rapidamente.153

��2V� /%� WLSR� �� SRU� VXD� YH]� VmR� DWLYDGRV� SHODV� FpOXODV� 7� 1.�� XP�

VXEWLSR� GH� OLQIyFLWR� TXH� ID]� SDUWH� GR� VLVWHPD� LPXQH� LQDWR�� $SHVDU� GH�

DSUHVHQWDUHP�UHFHSWRU�GH�FpOXODV�7�HVVDV�FpOXODV�QmR�SDVVDP�SRU�UHDUUDQMR�

JrQLFR� H� VmR� FDSD]HV� GH� VH� OLJDU�� DWUDYpV� GHVVH� 7&5�� D� JOLFROtSLGHV�

DOWDPHQWH� FRQVHUYDGRV� DFRSODGRV� DV� PROpFXODV� &'�G�� XPD� PROpFXOD�

VHPHOKDQWH� j� PROpFXOD� GR� 0+&� FODVVH� ,�� HQFRQWUDGD� QDV� FpOXODV�

DSUHVHQWDGRUDV�GH�DQWtJHQR�45,158,159�$�QDWXUH]D�GHVVH�JOLFROtSLde permanece

GHVFRQKHFLGD��$SyV�R�FRQWDWR�FRP�HVVH�JOLFROtSLGH�D�FpOXOD�7�1.�VH�SUROLIHUD�

QR�ItJDGR�H�OLEHUD�FLWRFLQDV�FRPR�D�,/-��TXH�p�UHVSRQViYHO�SHOD�DWLYDomR�GRV�

/%�WLSR��QD�SUHVHQoD�GR�DQWtJHQR�46,160


4 7HVWHV�GLDJQyVWLFRV

4.1 Teste de contato

2� GLDJQyVWLFR� HWLROyJLFR� GDV� '&� DOpUJLFDV� p� FRQILUPDGR� SHOR� TC,

considerado H[DPH� SDGUmR� RXUR� SDUD� D� LGHQWLILFDomR� GR� DJHQWH� FDXVDO��

Todavia,� HVVH� WHVWH� WHP� XPD� VpULH� GH� GHVYDQWDJHQV�� 2� WHVWH� HVWi�FRQWUD-

LQGLFDGR�QRV�SDFLHQWHV��FRP�GRHQoD�DWLYD��TXH fizeram uso recente de

FRUWLFRVWHUyLGH�VLVWrPLFR�RX�WySLFR�QR�ORFDO�GR�WHVWH��TXH�IRUDP�H[SRVWRV�j�

UDGLDomR�XOWUDYLROHWD�QR� ORFDO�GR� WHVWH�H��HP�JHVWDomR��+i�D�QHFHVVLGDGH�

GH� PDWHULDO� DGHTXDGR�� FRQKHFLPHQWR� H� H[SHULrQFLD� TXDQWR� j� WpFQLFD� GH�

montagem H�DSOLFDomR��FRPSUHHQVmR�H�FRRSHUDomR�SRU�SDUWH�GR�SDFLHQWH�H�

tempo, tanto do profissional quanto do paciente.21 $LQGD��D� LQWHUSUHWDomR�p�

VXEMHWLYD� H� R� WHVWH� QmR� p� LQyFXR� podendo levar a� FRPSOLFDo}HV� ORFDLV� H�

VLVWrPLFDV� GH� JUDYLGDGH� YDULiYHO�� (QWUH� DV� UHDo}HV� ORFDLV� GHVFULWDV�

encontram-VH�� GHUPDWLWH� GH� FRQWDWR� LUULWDWLYD�� H[DFHUEDomR� GD� GHUPDWLWH�GH�

FRQWDWR�� VtQGURPH� GD� SHOH� H[FLWDGD�� UHDo}HV� SHUVLVWHQWHV�� SLJPHQWDomR� H�

FLFDWUL]HV��'HQWUH�DV�DGYHUVLGDGHV�VLVWrPLFDV�SRGHP�RFRUUHU��VHQVLELOL]DomR�

ativa, absoromR� GH� VXEVWkQFLDV� Wy[LFDV� H�RX� FDUFLQRJrQLFDV� H� UHDo}HV�

DQDILODFWyLGHV�2,21,161,162

Outro problema associado ao TC se refere j� UHSURGXWLELOLGDGH dos

resultados. O maior estudo sobre reprodutibilidade do TC foi feito pelo grupo

DOHPmR� GH� SHVTXLVD� HP� Germatite de contato que encontrou 15,1% de

GLVFRUGkQFLD�HQWUH�RV�UHVXOWDGRV�163


$OpP�GLVVR��R�TC com metais pode levar a respostas falso-positivas,

de natureza irritativa.16�1RV�(VWDGRV�8QLGRV�D�FRQFHQWUDomR�GR�ELFURPDWR�GH�

SRWiVVLR�QR�TC foi reduzida GH��SDUD��SDUD�GLPLQXLU�R�Q~PHUR�GH�

UHVSRVWDV� LUULWDWLYDV��1R�HQWDQWR��DOJXQV�DXWRUHV� UHIHUHP�TXH�D�UHGXomR�GD�

FRQFHQWUDomR� SRGH� OHYDU� D� GLPLQXLomR� GD� VHQVLELOLGDGH� H� SRU� LVVR�

UHFRPHQGDP�WHVWDU�FRP��GH�ELFURPDWR�GH�SRWiVVLR�38 Na Europa esse

agente continua sendo testado a 0,5% tomando-VH� FXLGDGR� TXDQWR� j�

UHOHYkQFLD�GRV�UHVXOWDGRV�11

$� LPSRUWkQFLD� GR� GLDJQyVWLFR� HWLROyJLFR� QR� SURJQyVWLFR� GD� '&$�

DOLDGR� DV� OLPLWDo}HV� H� GLILFXOGDGHV� JHUDGDV� SHOR� 7&� DSRQWDP� SDUD� D�

necessidade do desenvolvimento GH� RXWUR� WHVWH� GLDJQyVWLFR�� $� DOWHUQDWLYD�

PDLV�SURPLVVRUD�p�R�WHVWH�GH�SUROLIHUDomR�OLQIRFLWiULD�27

4.2 Teste de pUROLIHUDomR�lLQIRFLWiULD

2�WHVWH�GH�SUROLIHUDomR�OLQIRFLWiULD��73/��YHP�VHQGR�HVWXGDGR�FRP�

R� SURSyVLWR� GH� FRPSOHPHQWDU� H� HYHQWXDOPHQWH� Vubstituir o TC. O TPL

FRPSDUD� D� UHVSRVWD� GRV� OLQIyFLWRV� HP� FXOWXUD� QD� SUHVHQoD� H� DXVrQFLD� GH�

PLWyJHQRV�RX�DQWtJHQRV��2V�PLWyJHQRV�VmR�DWLYDGRUHV�SROLFORQDLV�DR�SDVVR�

TXH� RV� DQWtJHQRV� DWLYDP� DSHQDV� RV� OLQIyFLWRV� TXH� SRVVXHP� R� UHFHSWRU�

DQWtJHQR� HVSHFtILFR� DGHTXDGR�� 4XDQGR� RV� OLQIyFLWRV� VmR� DWLYDGRV� SDVVDP�

SRU�DOWHUDo}HV�PRUIROyJLFDV��IXQFLRQDLV�H�SUROLIHUDP��Aumentam de tamanho,

DSUHVHQWDP� FLWRSODVPD�DPSOR� H� QXFOpROR�HYLGHQWH� WRUQDQGR-se semelhante

jV�FpOXODV�EOiVWLFDV��(VVH�IHQ{PHQR�p�GHQRPLQDGR�³WUDQVIRUPDomR�EOiVWLFD´�


H� p� DFRPSDQKDGR� GR� DXPHQWR� GD�H[SUHVVmR�GH� FLWRFLQDV� H� GD�VtQWHVH� GR�

iFLGR�GHVR[LUULERQXFOpLFR��'1$��$�DWLYDomR�OLQIRFLWiULD�SRGH�VHU�TXDQWLILFDGD�

SHOD�GHWHUPLQDomR�SRU�PLFURVFRSLD�GD�SRUFHQWDJHP�GH�FpOXODV�EOiVWLFDV�QD�

FXOWXUD��SHOD�VtQWHVH�GH�'1$�GHVVDV�FpOXODV��TXH�SRGH�VHU� LQIHULGD�DWUDYpV�

GD� DGLomR� GH� WLPLGLQD� UDGLRPDUFDGD� QD� FXOWXUD� H� SRVWHULRU� GHWHFomR� GR�

PDWHULDO� UDGLRDWLYR� LQFRUSRUDGR�RX� SHOD� GHWHFomR�GDV�FLWRFLQDV�SURGX]LGDV��

,QGHSHQGHQWH�GR�PpWRGR��DV�FpOXODV�VmR�FXOWLYDGDV�QD�SUHVHQoD�H�DXVrQFLD�

GR�DQWtJHQR�H�D�DIHULomR�p�IHLWD�FRPSDUDQGR�RV�UHVXOWDGRV�HQFRQWUDGRV�HQWUH�

as culturas� HVWLPXODGDV� H� QmR� HVWLPXODGDV�28,66,164 $� GLIHUHQoD� H� D� UD]mR�

HQFRQWUDGDV� HQWUH� DV� FXOWXUDV� HVWLPXODGDV� H� QmR� HVWLPXODGDV�� FRQKHFLGDV�

como delta ( ) e tQGLFH� GH� HVWLPXODomR� �,(� respectivamente, VmR� RV�

SDUkPHWURV�PDLV�XWLOL]DGRV�FRPR�FULWpULR�GH�UHVSRVWD�DR�HVWtPXOR�164

��2�73/� Mi�SURYRX�VHU� ~WLO� QR� GLDJQyVWLFR� GH�'&$�SRU� QtTXHO�e vem

sendo estudado� SDUD� GLDJQyVWLFR� GH� KLSHUVHQVLELOLGDGH� DR� FURPR� GHVGH�

meDGRV�GR�VpFXOR�;; sem o mesmo sucesso. 24,25

Em 1966, Grosfeld et al.165 testaram o TPL em 5 pacientes com

'&$�SRU�FURPR�H��FRQWUROHV��$V�FXOWXUDV� IRUDP� UHDOL]DGDV�FRP� OHXFyFLWRV�

WRWDLV�HVWLPXODGRV�FRP�ELFURPDWR�GH�SRWiVVLR�QD�FRQFHQWUDomR�GH�294, 29,4

e, em um caso, 2,94 g/mL durante 3 a 4 dias. A leitura do teste foi feita pelo

SHUFHQWXDO�GH�FpOXODV�EOiVWLFDV��2�SUySULR�DXWRU�GHILQLX�VHXV�UHVXOWDGRV�FRPR�

QmR�FRQYLQFHQWHV�H�TXHVWLRQD�VH�R�XVR�GH� ILWRKHPDJOXWLQLQD��XP�PLWyJHQR��

SDUD�D�VHSDUDomR�GDV�FpOXlas e/ou o tempo de cultura, possivelmente curto,

WHULDP�VLGR�UHVSRQViYHLV�SHORV�UHVXOWDGRV��


Em 1971, Gerd Lischka166 XVRX� ELFURPDWR� GH� SRWiVVLR� QD�

FRQFHQWUDomR� ILQDO� GH� 0,294 e 2,940 g/mL em culturas de 5 dias de

OHXFyFLWRV� WRWDLV� GH� �� SDFLHQWHV� FRP� 'CA por cromo e 5 controles. Sete

SDFLHQWHV�H��FRQWUROH�UHVSRQGHUDP�DR�WHVWH��2V��SDFLHQWHV�UHVSRQGHUDP�j�

FRQFHQWUDomR�GH�2,940 g/mL H��SDFLHQWHV�H�XP�FRQWUROH�j�FRQFHQWUDomR�GH�

0,294 g/mL. Assim como Grosfeld e colaboradores analisou a resposta pelo

perFHQWXDO�GH�FpOXODV�EOiVWLFDV��XP�PpWRGR�WUDEDOKRVR�H�VXEMHWLYR e por isso

muito pouco utilizado hoje.

Em 1979, Christiansen et al. 167 o resultado do TPL para cromo,

QtTXHO�H�FREDOWR�HQWUH��SDFLHQWHV�FRP�SHUGD�DVVpSWLFD�GH�SUyWHVH�PHWiOLFD�

e 11 controOHV�FRP�SUyWHVH�EHP�VXFHGLGD�SRU�SHOR�PHQRV�GRLV�DQRV��3DUD�

WDQWR� HVWLPXODUDP� RV� OLQIyFLWRV� FRP� FORUHWR� GH� FURPR� QDV� FRQFHQWUDo}HV�

finais de 0,2665; 2,665; 26,65 e 266,5 g/mL em culturas de 6 dias. Os

resultados obtidos com o TPL para o cromo foram significativamente

VXSHULRUHV� QR� JUXSR� FRP� SHUGD� GH� SUyWHVH�� 4XLQ]H� FDVRV� H� DSHQDV� um

FRQWUROH� IRUDP� HVWLPXODGRV� �,(!�� VXJHULQGR� D� SDUWLFLSDomR� GD�

KLSHUVHQVLELOLGDGH� GRV� FRPSRQHQWHV� GD� SUyWHVH� QD� SHUGD� GDV� PHVPDV��

Esses autores encontraram os melhores resultados do TPL para o cromo

com�D�FRQFHQWUDomR�GH�� g/mL.

Em 1985, Carando et al.168 utilizaram o TPL em dois pacientes com

SHUGD�DVVpSWLFD�GH�SUyWHVH�PHWiOLFD��2V�DQWtJHQRV�XWLOL]DGRV�IRUDP�R�FORUHWR�

GH� FURPR�� FORUHWR� GH� QtTXHO� H� FORUHWR� GH� FREDOWR�� 2� FUomo foi testado na

FRQFHQWUDomR�GH�� J�PO�HP�FXOWXUDV�GH�OLQIyFLWRV�GH�DSHQDV��KRUDV��2V�

tQGLFHV�GH�HVWLPXODomR�REWLGRV�QR�WHVWH�SDUD�R�FURPR�IRUDP�GH��H��


Em 1981, Al-Tawil et al. 169 compararam os resultados do TPL entre

31 pacientes com TC positivo para FURPR� �� RX� PDLV�� H� �� LQGLYtGXRV�

VDXGiYHLV�� 2V� DXWRUHV� WHVWDUDP� �� VDLV� GH� FURPR� WULYDOHQWHV� �&U&O3 e

Cr4(SO4)5(OH)2) e dois hexavalentes (K2Cr2O7 e Na2CrO4) em diversas

FRQFHQWUDo}HV� HP� FXOWXUDV� GH� OLQIyFLWRV� FRP� GXUDomR� GH� �� D� �� GLDV�� 9LQWH�

pacientes (sensibilidade = 65%) e 2 controles (especificidade = 92%)

UHVSRQGHUDP�DR�WHVWH��2�DXWRU�HVWDEHOHFHX�FRPR�FULWpULR�SDUD�SRVLWLYLGDGH�D�

SUHVHQoD� GH� ,(� PDLRU� TXH� �� H� VXSHULRU� DR� ,(� GH� XP� FRQWUROH� WHVWDGR�

simultaneamente. Os melhores resultados foram obtidos com as culturas de

��D��GLDV�GH�GXUDomR�FRP�FORUHWR�GH�FURPR�QDV�FRQFHQWUDo}HV�ILQDLV�GH��

50 e 100 g/ml (P < 0,001). Os pacientes que responderam ao cromo

KH[DYDOHQWH�WDPEpP�UHVSRQGHUDP�DRV�FRPSRVWRV�WULYDOHQWHV��2�DXWRU�WHVWRX�

a especificidaGH� GR� WHVWH� HP� �� SDFLHQWHV� VHQVLELOL]DGRV� DR� QtTXHO� H�RX�

cobalto sendo os resultados negativos.

(P��5lVlQHQ�et al.27�WHVWDUDP�YiULDV�FRQFHQWUDo}HV�GH�&U&O3,

K2Cr2O7 e Na2CrO4� HP� FXOWXUDV� GH� OLQIyFLWRV� GH� �� D� �� GLDV�� 6HLV� GRV� ��

SDFLHQWHV� DOpUJLFRV� e nenhum dos 8 controles responderam. Os autores

encontraram as melhores respostas nas culturas de 7 e 8 dias com 25 e 50

g/ml de CrCl3 e 0,025; 0,050 e 0,1 g/ml de K2Cr2O7 e Na2CrO4.

(P�VtQWHVH��RV�WUDEDOKRV�XVDUDP�WpFQLFDV�GLIHUHQWHV��GLIHUHQWHV�VDLV

GR� PHWDO�� FRQFHQWUDo}HV� GLYHUVDV�� SHUtRGRV� GH� LQFXEDomR� YDULiYHLV� H� os

FULWpULRV� SDUD� SRVLWLYLGDGH� QmR� foram uniformes. Face aos diferentes

protocolos empregados, Martins et al. 24 compararam os resultados do TPL

entre 20 pacientes com DCA ao cromo e 20 controles utilizando diversos


SDUkPHWURV��)RUDP�UHDOL]DGDV�FXOWXUDV�GH�FXUWD�H�ORQJD�GXUDomR��H��GLDV��

empregando diferentes�FRQFHQWUDo}HV��0,000133 a 133,23 g/mL) de um sal

trivalente (cloreto de cromo) e (0,147 g/mL a 147 g/mL) de outro

hexavalente (biFURPDWR�GH�SRWiVVLR��2V�DXWRUHV�FRQFOXtUDP�TXH�FXOWXUDV�GH�

ORQJD�GXUDomR�HVWLPXODGDV�FRP�333,33 g/mL de cloreto de cromo oferecem

D� PHOKRU� DFXUiFLD� SDUD� R� WHVWH�� Doze casos e apenas um controle

resSRQGHUDP� DR� PpWRGR� XWLOL]DQGR� HVVHV� SDUkPHWURV, determinando uma

sensibilidade de 60% e especificidade de 95%��$SHVDU�GDV�GLIHUHQoDV�QDV�

metodologias empregadas entre os artigos publicados a sensibilidade e

HVSHFLILFLGDGH�GR�PpWRGR�IRL�VHPHOKDQWH�QRV�HVWXGRV�FRP�maior�FDVXtVWLFD��

24,167,169

Os motivos para uma�VHQVLELOLGDGH�DTXpP�GR�GHVHMDGR�QHVVH�WHVWH�

SRGHP� VHU� GHYLGR�� D�� DR� HPSUHJR� GH� PRQyFLWRV� SDUD� D� DSUHVHQWDomR�

DQWLJrQLFD� QR� OXJDU� GDV� FpOXODV� GHQGUtWLFDV� TXH� VmR� PHOKRUHV�

DSUHVHQWDGRUDV�GH�DQWtJHQR��E��EDL[D�VHQVLELOLGDGH�GR�PpWRGR�GH�GHWHFomR�H�

F��DXVrQFLD�GH�XP�JDWLOKR�SDUD�GDU�LQtFLR�D�UHDomR�³LQ�YLWUR´�

5lVlQHQ�et al.27�WHVWDUDP�R�73/�XWLOL]DQGR�FpOXODV�GH�/DQJHUKDQV�HP�

TXDWUR� SDFLHQWHV� H� REWLYHUDP� XP� LQFUHPHQWR� QR� tQGLFH� GH� HVWLPXODomR��

'HQWUH� HVVHV� SDFLHQWHV� VH� HQFRQWUDYD� XP� TXH� QmR� KDYLD� UHVSRQGLGR� Do

WHVWH� FRQYHQFLRQDO�� R� tQGLFH� GH� HVWLPXODomR� VDOWRX� GH� �� SDUD� ��

tornando-se positivo se considerarmos IE>3 como valor de corte. Outros 3

pacientes, que responderam ao teste convencional, apresentaram aumento

GH��D��YH]HV�QR�tQGLFH�GH�HVWLPXODomR�� ,QIHOL]PHQWH�QHQKXP�FRQWUROH�

IRL�WHVWDGR�FRP�HVVH�PpWRGR��p�LPSURYiYHO��SRUpP�SRVVtYHO�TXH�RV�FRQWUROHV�


WDPEpP�DSUHVHQWDVVHP�XP�LQFUHPHQWR�QR�,(��$OpP�GLVVR��R�PpWRGR�p�PXLWR�

WUDEDOKRVR��QmR�SRGHQGR�VHU�XWLOL]DGR�KRMH�SDUD�VXEVWLWXLU�R�WHVWH�GH�FRQWDWo

FRPR�URWLQD�QR�GLDJQyVWLFR�GD�'&$.

Trattner et al. 28 seguiram outro caminho, tentaram aprimorar o

PpWRGR� PHGLQGR por ELISA o INF- no sobrenadante das culturas de 24

horas de��SDFLHQWHV�DOpUJLFRV�DR�FURPR�H��FRQWUROHV��As culturas foram

estimuladDV�FRP�ELFURPDWR�GH�SRWiVVLR��H�� cg/mL) e fitohemaglutinina,

XP� PLWyJHQR� XWLOL]DGR� SDUD� LQLFLDU� D� UHDomR�� Quatorze pacientes e 6

controles responderam, KDYHQGR�GLIHUHQoD�HQWUH�RV�JUXSRV (P = 0,001). Em

FRPSDUDomR� FRP� R� WHVWH� GH� FRQWDWR� D� GHWHFomR� GH� INF- apresentou

sensibilidade e especificidade de 73,7% e 71,4% respectivamente.

Resultados ainda pouco encorajadores.

Em 2005, Moed et al.29 estudaram a resposta proliferativa de 4

pacientes DOpUJLFRV ao cromo em culturas de 6 dias com diferentes

concHQWUDo}HV�GH�&U&O3 (1, 10 e 100 g/ml) e K2Cr2O7 (0,01; 0,1 e 1 g/ml).

Nenhum dos pacientes respondeu. Os autores passaram a estimular as

culturas de 6 dias FRP�DV�FRPELQDo}HV�GH�FLWRFLQDV�,/-7 e IL-12 e IL-7 e IL-4

H�DYDOLDUDP�D�SUROLIHUDomR�H�D�SURGXomR de INF- e IL-5. A IL-7 foi escolhida

SRU�DXPHQWDU�D�DWLYDomR�FHOXODU�H�D�,/-12 e IL-��SRU�HVWLPXODUHP�D�SURGXomR�

de citocinas Th1 (IFN- ) e Th2 (IL-5) respectivamente. (VVH� PpWRGR� IRL�

aplicado em 7 casos e 7 controles. Os resultados variaram de acordo com o

PpWRGR�GH�GHWHFomR�XWLOL]DGR��7UrV�FDVRV�H�QHQKXP�FRQWUROH� UHVSRQGHUDP�

TXDQGR� R� PpWRGR� GH� DIHULomR� IRL� R� tQGLFH� GH� HVWLPXODomR�� FDVRV� H� XP�

FRQWUROH�FRP��D�GHWHFomR�GH�,1)- e os sete casos e um controle quando a


DIHULomR�IRL�IHLWD�SHOD�GHWHFomR�GH�,/-5. O mesmo resultado foi obtido com a

GHWHFomR� GH� ,/-�� HP� VHWH� SDFLHQWHV� DOpUJLFRV� DR� QtTXHO� H� VHWH� FRQWUROHV��

PDV� UHVXOWDGRV� LQIHULRUHV� IRUDP� HQFRQWUDGRV� FRP� R� FREDOWR�� IUDJUkQFLD��

parafenilenodiamina e metilcloroisotiazolinona.

Akerman et al.30 reali]DUDP�D�GHWHFomR�VLPXOWkQHD�GH��FLWRFLQDV�

no sobrenadante das culturas de 6 dias de 20 pacientes DOpUJLFRV ao cromo

XVDQGR� R� NLW� ³/XPLQH[� OLTXLFKLS� DUUD\´�� 7RGDV� DV� citocinas testadas (GM-

CSF, IL- -2, IL-4, IL-5, IL-6, IL-8, IL-10, INF- , e TNF-

TNF-

esses resultados podem levar ao desenvolvimento de testes, baseados na

GHWHFomR� GH� FLWRFLQDV�� SDUD� R� GLDJQyVWLFR� GD� KLSHUVHQVLELOLGDGH� DR� FURPR��

,QIHOL]PHQWH�RV�WHVWHV�QmR�IRUDP�UHDOL]DGRV�HP�XP�JUXSR�FRQWUROH�

Minang et al.31� GHWHFWDUDP� D� SURGXomR� GH� ,/-2, IL-4 e IL-13 por

ELISpot e IFN- , IL-2 e IL-13 por ELISA nas culturas de 20 a 40 horas de

FpOXODV�PRQRQXFOHDUHV�GR�VDQJXH�SHULIpULFR�GH��SDFLHQWHV�FRP�HF]HPD�H�

WHVWH� GH� FRQWDWR� SRVLWLYR� SDUD� RV� PHWDLV� QtTXHO�� FREDOWR�� FURPR�� SDOiGLR� H�

RXUR�H�GH��FRQWUROHV�VDXGiYHLV�FRP�WHVWH�GH�FRQWDWR�QHJDWLYR��$� LQWHQomR�

dos autores era determinaU�VH�D�UHVSRVWD�GRV�GHPDLV�PHWDLV�p�XPD�UHVSRVWD�

PLVWD�� WDQWR� 7K�� TXDQWR� 7K�� FRPR� HVWi� EHP� GHWHUPLQDGR� SDUD� R� QtTXHO��

&RQFOXtUDP�TXH�WRGRV�RV�PHWDLV�WHVWDGRV�OHYDP�D�XPD�UHVSRVWD�PLVWD��FRP�

DXPHQWR�QD�SURGXomR�GH�FLWRFLQDV�SDGUmR�7K��H�7K��'HQWUH�RV�SDFLentes,

QRYH� HUDP� DOpUJLFRV� DR� FURPR�� 3DUD� R� (/,6$� RV� DXWRUHV� DGRWDUDP� FRPR�

FULWpULR�GH�UHVSRVWD�DR�FURPR�XP�LQFUHPHQWR�QR�YDORU�HQFRQWUDGR�QD�FXOWXUD�

HVWLPXODGD� VREUH� D� DIHULomR� GD� FXOWXUD� EDVDO� DOLDGR� D� XPD� UD]mR� HQWUH� D�


cultura estimulada e a cultura basal que deveriam ser respectivamente da

ordem de: - ,

IL-2 e -��3DUD�R�(/,6SRW�RV�FULWpULRV�IRUDP�

os mesmos mas o aumento nas citocinas deveria ser de: ³VSRWV´ e 2

vezes para a IL-2, ³VSRWV´ e 2 vezes para a IL-4 e ³VSRWV´ e 2 vezes

para a IL-13. Seis dos nove pacientes apresentaram resposta a pelo menos

XPD�GDV�FLWRFLQDV�HP�SHOR�PHQRV�XP�GRV�PpWRGRV��(/,6$�RX�(/,6SRW��2V�

WUrV�SDFLHQWHV�TXH� QmR� UHVSRQGHUam foram os que apresentaram resposta

de menor intensidade ao cromo no TC, apenas eritema e edema sem a

IRUPDomR� GH� SiSXODV� RX� YHVtFXODV�� $OpP� GLVVR�� RV� WUrV� DSUHVHQWDUDP�

SRVLWLYLGDGH�LQWHQVD��FRP�IRUPDomR�GH�YHVtFXODV��DR�QtTXHO��XP�DR�FORUHWR�GH�

cobalto H� RXWUR� HULWHPD�H� HGHPD� DR� SDOiGLR� H� RXUR�� $VVLP� D� DXVrQFLD� GH�

positividade nesses pacientes pode se dever a baixa sensibilidade do

PpWRGR�RX�D�UHDo}HV�IDOVR-positivas com os metais.

Em 2008, Lindemann et al.32� WHVWDUDP� RV� PpWRGRV� FHOXODUHV� GH�

GHWHFomR� ³LQ�YLWUR´� GH�DOHUJLD�DR�FURPR�D� ILP� GH� HVWDEHOHFHU� D�FDSDFLGDGH�

GRV� PHVPRV� GLVFHUQLUHP� DOHUJLD� GH� VHQVLELOL]DomR�� HVWDGR� HP� TXH� Ki�

UHDWLYLGDGH�QR�WHVWH�GH�FRQWDWR��PDV�DR�FRQWUiULR�GD�DOHUJLD�QmR�DR�FRQWDWR�

KDELWXDO� FRP� R� DJHQWH� HP� TXHVWmR�� /HPEUDP� TXH� UHDo}HV� LUULWDQWHV� VmR�

FRPXQV� QR� 7&� SDUD� R� FURPR�� DWp� XPD� HP� GXDV� UHDo}HV� VmR� LUULWDQWHV�

TXDQGR� R� FURPR� p� WHVWDGR� QD� IRUPD� GH� ELFURPDWR� GH� SRWiVVLR� D� ��

GLILFXOWDQGR� R� GLDJQyVWLFR�170 Assim um TC positivo para o cromo tem

VLJQLILFDGR� FOtQLFR� OLPLWDGR�� GHYHQGR� VHU� FRUUHODFLRQDGR� j� FOtQLFD� GR�

paciente.171�7RGDYLD��QRV�FDVRV�FU{QLFRV�GH�'&��HYHQWR�EDVWDQWH�FRPXP�QD�


DOHUJLD�DR�FURPR��p�GLItFLO�GLIHUHQFLDU�D�'&,�GD�'&$�SHOR�TXDGUR�FOtQLFR�32,163

(VVHV� GDGRV� OHYDUDP� RV� DXWRUHV� D� EXVFDU� SRU� PpWRGRV� GLDJQyVWLFRV�

aOWHUQDWLYRV� TXH� SRVVDP�SUHIHUHQFLDOPHQWH� GLVWLQJXLU� HQWUH�VHQVLELOL]DomR� H�

alergia. Os autores estudaram o TC, TPL e ELISpot em 37 pacientes

DOpJLFRV�DR�FURPR��VHQVLELOL]DGRV�H��YROXQWiULRV��

��&RP� UHODomR� DR� 73/� GHPRQVWUDUDP� TXH� FXOWXUDV� GH� �� GLDV�

estimuladas com 12,5 g/mL de cloreto de cromo ou 50 ng/mL de bicromato

GH� SRWiVVLR� VmR� FDSD]HV� GH� GLVFHUQLU� HQWUH� DOpUJLFRV� H� VHQVLELOL]DGRV�� D�

SUROLIHUDomR� OLQIRFLWiULD� IRL� HVWLPXODGD� QRV� DOpUJLFRV� PDV� QmR� QRV�

sensibilizados. Todavia, o resultado foi signiILFDWLYR� TXDQGR� R� FULWpULR� GH�

UHVSRVWD�DGRWDGR�HUD�R�YDORU�REWLGR�SHOD�VXEWUDomR�GDTXHOH�HQFRQWUDGR�QDV�

FXOWXUDV�HVWLPXODGDV�PHQRV�R�GDV�FXOWXUDV�QmR�HVWLPXODGDV��PDV�QmR�FRP�R�

YDORU� HQFRQWUDGR� SHOD� UD]mR� HQWUH� DV� FXOWXUDV�� DSHVDU� GRV� DXWRUHV� WHUHP�

encontrDGR� FRUUHODomR� HQWUH� RV� GRLV� FULWpULRV� �r = 0.85 e P < 0,0001). A

positividade nas culturas estimuladas com cloreto de cromo e/ou bicromato

GH� SRWiVVLR� RFRUUHX� HP� �� GH� �� SDFLHQWHV� DOpUJLFRV� �� GH� ��

sensibilizados (31%) e 5 de 25 controles (20%) e se mostrou um fator

SUHGLWLYR� IRUWH� SDUD� DOHUJLD�� WDQWR� QD� FRPSDUDomR� FRP� SDFLHQWHV�

sensibilizados quanto controles, P = 0,004 e < 0,0001 respectivamente.

O ELISpot foi utilizado para dosar as citocinas IFN- , IL-2, IL-4,IL-10

e IL-12 nas culturas de 48� KRUDV�GRV� SDFLHQWHV� DOpUJLFRV�� VHQVLELOL]DGRV�H�

FRQWUROHV�� 1mR� KRXYH� GLIHUHQoD� QD� SURGXomR� GHVVDV� FLWRFLQDV� HQWUH� RV�

JUXSRV� GH� SDFLHQWHV� DOpUJLFRV� H� VHQVLELOL]DGRV�� 2V� SDFLHQWHV� DOpUJLFRV�

DSUHVHQWDUDP� PDLRU� SURGXomR� GH� ,)1- que o os controles (P < 0,05). A


resposta do IFN- ��PDV�QmR�D�GDV�GHPDLV�FLWRFLQDV��VH�FRUUHODFLRQRX�D�FRP�

a intensidade da resposta encontrada no TC (r = 0.49 e P = 0.002). Em

FRQWUDVWH��QmR�KRXYH�FRUUHODomR�HQWUH�DV�UHVSRVWDV�HQFRQWUDGD�QR�7&�H�QR�

TPL. Em conjunto, alergia se correlacionou a resposta no TPL e a resposta

do TC a do IFN- �GHWHFWDGR�SHOR�(/,6SRW��2V�DXWRUHV�FRQFOXHP�TXH�R�73/�p�

PHOKRU�TXH� D�GHWHFomR� GH�FLWRFLQDV� SHOR�(/,6SRW�SDUD� GLVWLQJXLU� SDFLHQWHV�

DOpUJLFRV�GH�VHQVLELOL]DGRV�PDV�DGPLWHP�TXH�QRYRV� WUDEDOKRV�TXH�DYDOLHP

GLIHUHQWHV� FRQGLo}HV� GH� FXOWXUD� SDUD� D� GHWHFomR� GH� FLWRFLQDV� GHYHP� VHU�

IHLWRV�SDUD�GHWHUPLQDU�RV�SDUkPHWURV�PDLV�DGHTXDGRV�SDUD�HVVH� WHVWH��(P�

SDUWLFXODU�GHIHQGHP�R�DXPHQWR�QR�SHUtRGR�GH�LQFXEDomR�TXH�FRPR�FKDPDGR�

D�DWHQomR�SRU�.HDWLQJ�et al.172 pode levaU�D�LGHQWLILFDomR�GH�RXWURV�IHQyWLSRV�

GH�FpOXODV�7��FRPR�DV�FpOXODV�7�GH�PHPyULD�FHQWUDO�

��8P� UHVXPR� GRV� SULQFLSDLV� WUDEDOKRV� VREUH� 73/� FRP� FURPR� HVWi�

GLVSRQtYHO�QR�TXDGUR��


Quadro 1 -�7UDEDOKRV�VREUH�WHVWH�GH�SUROLIHUDomR�OLQIRFLWiUia com cromo

Autores &pOXODV Salutilizado

CRQFHQWUDomR�nas culturas*1

3HUtRGR�GH�cultura*1

0pWRGR�GH�DIHULomR

Resultado

Grosfeld165

(1966)/HXFyFLWRV�

totaisK2Cr2O7 0,0294 a

2,94 g/mL 3-4 dias Blastos I

Lischka166

(1971) /HXFyFLWRV�

totais K2Cr2O7 2,94 g/mL 5 dias Blastos S = 87%

E = 80% Christiansen167

(1979) ³3%01�FHOOV´

CrCl3 26,65 g/mL 6 dias IE > 3 S = 62% E = 91%

Al-Tawil169

(1983) ³3%01�FHOOV´

Diversos 25, 50 e 100 g/mL

(CrCl3)

7 e 8 dias IE>1 e > co

S = 65% E = 92%

Carando168

(1985) ³3%01�FHOOV´

CrCl3 0,5 g/mL 56 horas(2,33 dias)

IE S = 100%E = NT

5lVlQHQ27

(1991) ³3%01�FHOOV´

Diversos 25 e 50 g/mL (CrCl3)

7 e 8 dias IE > 2,5 S = 75% E = 100%

Trattner28

(2003) ³3%01�FHOOV´

K2Cr2O7 0,5 e 1 cg/mL 1 dia IFN- S = 74% E = 71%

Moed29

(2005) ³3%01�FHOOV´

CrCl3 e K2Cr2O7

1, 10 e 100 g/mL (CrCl3)

6 dias IE, IFN- e IL-5

S = 100%E = 86%

Martins24

(2006) ³3%01�FHOOV´

CrCl3 333,33 g/mL 6 dias IE > 3 S = 60% E = 95%

Ackerman30

(2006) ³3%01�FHOOV´

K2Cr2O7 ND ND Diversas citocinas*2

P < 0.05*3 NT

Minang31

(2006) ³3%01�FHOOV´

CrCl3 e K2Cr2O7

100 g/mL

(CrCl3)

20 a 40 horas

IL-2, 4, 13 e IFN- *4

S = 67%*5

E = 100%*5

Lindemann32

(2008) ³3%01�FHOOV´

CrCl3 e K2Cr2O7

12,5 g/mL*6

50 g/mL*7

7 e 8 dias*8 48 horas*9

IE, cpm, citocinas*10

S = 70%*11 E = 80%*11

*1 ±� RV� SDUkPHWURV� TXH� OHYDUDP� DRV� PHOKRUHV� UHVXOWDGRV�� .2Cr2O7 ±� ELFURPDWR� GH� SRWiVVLR�� ,� ±inconclusivo; S ± sensibilidade; E ± especificidade; ³3%01�FHOOV´�±�FpOXODV�PRQRQXFOHDUHV�GR�VDQJXH�SHULIpULFR�� CrCl3 ± cloreto de cromo; IE ±� tQGLFH� GH� HVWLPXODomR�� FR� ± controle testado simultaneamente; NT ±�QmR�WHVWDGD�SHOD�DXVrQFLD�GH�JUXSR�FRQWUROH��1'�±�QmR�GLVSRQtYHO��*2 ± GM-CSF, IL- -2, IL-4, IL-5, IL-6, IL-8, IL-10, INF- , e TNF- ; *3 ± aumento de todas as citocinas, exceto TNF- ; *4 ± o valor de corte foi diferente para cada citocina; *5 ± considerando todas as citocinas testadas; *6 ± melhor valor de CrCl3 para disWLQJXLU�SDFLHQWHV�DOpUJLFRV�GH�VHQVLELOL]DGRV��*7 ±valor de CrCl3�FRP�R�TXDO�KRXYH�GLIHUHQoD�QD�SURGXomR�GH�,)1- �HQWUH�DOpUJLFRV�H�QmR�DOpUJLFRV��*8 ±PHOKRU� SHUtRGR� SDUD� R� WHVWH� GH� SUROLIHUDomR� FRQYHQFLRQDO�� *9 ±� SHUtRGR� XVDGR� SDUD� D� GHWHFomR� GH�citocinas; *10 ±�RV�YDORUHV�GH�FRUWH�QmR�IRUDP�GHVFULWRV�H�DV�FLWRFLQDV�WHVWDGDV�IRUDP��,)1- , IL-2, IL-4, IL-10 e IL-12; *11 ±�YDORU�SDUD�R�WHVWH�GH�SUROLIHUDomR��DV�UHVSRVWD�DV�FLWRFLQDV�QmR�IRUDP�GHVFULWDV�

0e72'26


__________________________________________________________0pWRGRV 42

4 0pWRGRV

4.1 6HOHomR�GH�SDFLHQWHV

37� SDFLHQWHV� IRUDP� VHOHFLRQDGRV� QR� DPEXODWyULR� GH� DOHUJLD� GD�

'LYLVmR�GH�'HUPDWRORJLD�GR�+RVSLWDO�GDV�&OtQLFDV�GD�)DFXOGDGH�GH�0HGLFLQD�

GD� 8QLYHUVLGDGH� GH� 6mR� 3DXOR (HC-FMUSP) entre novembro de 2009 e

janeiro de 2010. Dezoito pacientes apresentavam�KLVWyULD��FOtQLFD e teste de

contato recente, teste realizado a menos de dois anos,� FRPSDWtYHLV� FRP�

DCA por cromo e formaram R�JUXSR�GH�FDVRV��2V�GDGRV�GD�KLVWyULD�OHYDGRV�

HP� FRQVLGHUDomR� IRUDP�� j� H[LVWrQFLD� GH� H[SRVLomR� DR cromo, o tempo

WUDQVFRUULGR� HQWUH� D� H[SRVLomR� H� R� VXUJLPHQWR� GDV� OHV}HV�� D� UHFRUUrQFLD�

IUHQWH�jV�H[SRVLo}HV�UHSHWLGDV�H�D�PHOKRUD��DR�PHQRV�SDUFLDO��QD�DXVrQFLD�

GD� H[SRVLomR�� &RP� UHODomR� DR� H[DPH� ItVLFR� HVSHFLDO� DWHQomR� IRL� GDGD� j�

morfologia, que deveria VHU� FRPSDWtYHO� FRP� HF]HPD� H� D� WRSRJUDILD� GDV�

OHV}HV�� TXH� GHYHULDP� RFRUUHU� QRV� ORFDLV� GD� H[SRVLomR�� 2V� RXWURV� ��

pacientes tinham KLVWyULD�H�FOtQLFD�QmR�FRQGL]HQWHV�FRP�'&$�SRU�FURPR bem

como teste de contato recente negativo para o metal, esses pacientes foram

iQFOXtGRV� QR� JUXSR� GH� FRQWUROHV�� 1HVVH� HVWXGR� IRUDP� H[FOXtGRV� SDFLHQWHV�

menores de 18 anos idade, gestantes ou�TXH�IL]HUDP�XVR�GH�FRUWLFRVWHUyLGH�

VLVWrPLFR�SRU�XP�SHUtRGR�PtQLPR�GH��VHPDQDV�DQWHV�GD�UHDOL]DomR�GR�7&�H�

do TPL.


__________________________________________________________0pWRGRV 43

Antes da coleta do exame todos os pacientes foram informados

quanto ao procedimento e a finalidade do estudo. Receberam e assinaram o

termo de consentimento livre e esclarecido.

&DUDFWHUtVWLFDV�GRV�JUXSRV�

1) Grupo de casos: 18 pacientes, sendo 17 GR� JrQHUR� PDVFXOLQR� e 1

feminino, com idade entre 36 e 65� DQRV� �PpGLD� 50 anos)

DSUHVHQWDQGR� KLVWyULD� H� FOtQLFD� FRPSDWtYHO� FRP� VHQVLELOL]DomR� DR�

cromo confirmada por teste de contato.

2) Grupo controle: 19 pacientes, sendo 11� GR� JrQHUR� PDVFXOLQR e 7

feminino com idade entre 26 e 68 anos �PpGLD�44�DQRV��VHP�KLVWyULD�

RX� FOtQLFD� FRPSDWtYHO� FRP� VHQVLELOL]DomR� DR� FURPR� FRP� WHVWH� GH�

FRQWDWR�QHJDWLYR�SDUD�ELFURPDWR�GH�SRWiVVLR��

4.2 Teste de contato

��7RGRV� RV� WHVWHV� GH� FRQWDWR� IRUDP� UHDOL]DGRV� QR� DPEXODWyULR� GH�

Dermatologia do HC-FMUSP. Os testes foram efetuados utilizando a bateria

brasileira padronizada de teste de contato (IPI-ASAC Brasil , Rio de Janeiro,

Brasil).� (VVD� EDWHULD� p� IRUPDGD� SRU� �� VXEVWkQFLDV� VHQGR� R� ELFURPDWR� GH�

SRWiVVLR� WHVWDGR� D� ��HP� YDVHOLQD�VyOLGD��Dois controles tambpP� IRUDP�

WHVWDGRV� FRP� D� EDWHULD� GH� WHVWH� GH� FRQWDWR� SDUD� FRVPpWLFRV� (IPI-ASAC

Brasil , Rio de Janeiro, Brasil)�H�XP�FRP�R�SUySULR�HVPDOWH.�$V�VXEVWkQFLDV�

TXH� FRPS}HP� HVVDV� EDWHULDV� HVWmR� D� GLVSRVLomR� QRV� TXDGURV� �� H� ��

GLVSRQtYHLV�QRV�DQH[RV�

__________________________________________________________0pWRGRV 44

��2V� DOpUJHQRV� IRUDP� DSOLFDGRV� QR� GRUVR�VXSHULRU� FRP�R� DX[tOLR� GH�

contensores (IPI-ASAC Brasil , Rio de Janeiro, Brasil ± registro no MS-

$19,6$�Q�� ) presos por fita adesiva KLSRDOHUJrQLFDV� (3M )

DSyV� SUHSDUR� GD� SHOH� FRP� VROXomR� GH� pWHU�� 2V� SDFLHQWHV� UHFHberam as

RULHQWDo}HV� QHFHVViULDV� H� DSyV� ��KRUDV�R� WHVWH� HUD� UHWLUDGR� H� D� SULPHLUD�

leitura feita. Em 96 horas o paciente retornava para a segunda leitura e

RULHQWDo}HV�TXDQWR�DRV�UHVXOWDGRV�

��2V�FULWpULRV�XWLOL]DGRV�SDUD�DYDOLDU�RV�UHVXOWDGRV�IRUDP�HVWDEelecidos

SHOR� ³International Contact Dermatitis Research Group´�± ICDRG.173 Dessa

forma os resultados foram divididos em:

negativo (-��VHP�UHDomR�

duvidoso (+?): eritema mal definido;

SRVLWLYR�IUDFR��HULWHPD�GHILQLGR�H�SiSXOD�

positivo forte (++): eriWHPD��SiSXOD�H�YHVtFXODs;

SRVLWLYR�PXLWR�IRUWH��HULWHPD��SiSXOD e�YHVtFXODV�FRQIOXHQWHV�

5,��UHDomR�LUULWDWLYD�

3DUD�VHU�FRQVLGHUDGR�VHQVLELOL]DGR�DR�DOpUJHQR�WHVWDGR�o resultado

deveria ser positivo em 96 horas com intensidade igual ou superior j� GD�

leitura de 48 horas. Nos casos em que houve positividade de 3 ou mais

VXEVWkQFLDV�QmR�UHOacionadas o teste foi repetido.

__________________________________________________________0pWRGRV 45

4.3 Teste de pUROLIHUDomR�lLQIRFLWiULD

��)RUDP�FROKLGRV�TXLQ]H�PLOLOLWURV�GH�VDQJXH�YHQRVR�SHULIpULFR�GH�FDGD�

paciente, em tXER�HVWpULO� KHSDULQL]DGR��QR�DPEXODWyULR�GH�'HUPDWRORJLD�GR�

HC-FMUSP. O sangue foi processado dentro de 2�KRUDV�QR�/DERUDWyULR�GH�

,QYHVWLJDomR� HP� $OHUJLD� H� ,PXQRORJLD� &OtQLFD� H� ([SHULPHQWDO� �/,0� �� GD�

FMUSP.

Em fluxo laminar, o sangue era transferido pDUD�XP�WXER�F{QLFR�GH�

��PO� DR� TXDO� HUD� DGLFLRQDGR� LJXDO� TXDQWLGDGH� GH�VROXomR� VDOLQD� LVRW{QLFD��

��PO��$SyV�KRPRJHQHL]DU�R�FRQWH~GR�R�VDQJXH�HUD�WUDQVIHULGR�OHQWDPHQWH��

DWUDYpV� GH� XPD� SLSHWD� GH� WUDQVIHUrQFLD�� SDUD� RXWUR� WXER� F{QLFR de 50ml

contendo 12,5ml de Ficoll-Hypaque. O Ficoll-+\SDTXH� p� XP� JUDGLHQWH� GH�

GHQVLGDGH�TXH�IDFLOLWD�D�VHSDUDomR�H�FROKHLWD�GDV�FpOXODV�PRQRQXFOHDUHV�GR�

UHVWDQWH�GR�VDQJXH�DSyV�D�FHQWULIXJDomR��

��$� FHQWULIXJDomR� HUD� IHLWD� D� ��USP� SRU� �� PLQXWRV� HP� XPD�

FHQWUtIXJD�UHIULJHUDGD�H�R�FRQWH~GR��VDQJXH�H�)LFROO-Hypaque) separava-se

em fases. A superior era formada pelo plasma, amarelo citrino. Logo abaixo,

D� VHJXQGD� IDVH�� IRUPDGD� SHODV� FpOXODV� PRQRQXFOHDUHV�� DSUHVHQWDYD-se

FRPR� XP� DQHO� HVEUDQTXLoDGR�� $� WHUFHLUD� IDVH� HUD� FRPSRVWD� SHOR� )icoll-

+\SDTXH�� LQFRORU� RX� OLJHLUDPHQWH� HVEUDQTXLoDGR� H� D� TXDUWD�� QD� SRUomR�

LQIHULRU�GR�WXER��HUD�IRUPDGD�SHORV�HULWUyFLWRV�H�JUDQXOyFLWRV�TXH�FRQIHULDP�D�

cor vermelha.

__________________________________________________________0pWRGRV 46

��$SHQDV� R� DQHO� GH� FpOXODV� PRQRQXFOHDUHV� HUD� WUDQVIHULGR�� SHOR�

DX[tOLR� GH� XPD� SLSHWD� GH� WUDQVIHUrQFLD�� SDUD� XP� WXER� F{QLFR� GH� ��PO�

FRQWHQGR��PO�GH�VRUR�ILVLROyJLFR��$SyV�D� WUDQVIHUrQFLD�R�FRQWH~GR�GR� WXER�

era completado para 10ml FRP�VRUR�ILVLROyJLFR�H�FHQWULIXJDGR�D��USP�SRU�

�� PLQXWRV� HP� FHQWUtIXJD� UHIULJHUDGD�� (VVD� HWDSD� YLVD� HOLPLQDU� o Ficoll-

+\SDTXH�UHVLGXDO�GHYLGR�j�VXD�DomR�FLWRWy[LFD�

��$R� WpUPLQR� GD� FHQWULIXJDomR� R� VREUHQDGDQWH� HUD� GHVSUH]DGR� H� R�

ERWmR�GH�FpOXODV�SUHVHQWH�QR� IXQGR�GR� WXER�F{QLFR�HUD�UHVXVSHQVR�HP��PO�

GH� VRUR� ILVLROyJLFR�� 2� YROXPH� HUD� QRYDPHQWH� FRPSOHWDGR� para 10ml e

centrifugado a 1100rpm por 10 minutos em centrifuga refrigerada.

��1RYDPHQWH��R�VREUHQDGDQWH�HUD�GHVSUH]DGR�H�R�ERWmR�UHVXVSHQVR��

SRUpP�QHVVD�HWDSD��HP��PO�GH�530,��Rosewell Park Memorial Institute

FXOWXUH� PpGLXP). O RPMI 1640 foi o meio de cultura empregado nas

culturas.

��$SyV� D� KRPRJHQHL]DomR� GR� FRQWH~GR� �� l� GD� VXVSHQVmR� HUDP�

OHYDGRV�SDUD�D�FRQWDJHP�GH�FpOXODV�QR�DSDUHOKR�Cell Dyn 1400��$V�FpOXODV�

HUDP� WUDQVIHULGDV� SDUD� XP� WXER� F{QLFR contendo RPMI 1640 enriquecido

com 10% de soro humano AB.� $� TXDQWLGDGH� GD� VXVSHQVmR� GH� FpOXODV�

transferida era ajustada para que a VXVSHQVmR� ILQDO� WLYHVVHP� �� [� ��6

FpOXODV�Pl.

__________________________________________________________0pWRGRV 47

4.3.1 7HVWH� GH� SUROLIHUDomR� OLQIRFLWiULD� SDUD� GHWHFomR� GD� DWLYDomR�

FHOXODU�SHOD�WD[D�GH�FDSWDomR�GH�WLPLGLQD�UDGLRPDUFDGD

As cultXUDV�IRUDP�IHLWDV�HP�WULSOLFDWDV�HP�SODFDV�GH��RULItFLRV�FRP�

fundo chato (TPP �� 6ZLW]HUODQG�� (XURSH�� (P� FDGD� RULItFLR� IRUDP�

adicionados 100 O� GD� VXVSHQVmR� GH� FpOXODV� H� �� O� GH� DQWtJHQR� RX�

PLWyJHQR�D�VHU�WHVWDGR�GLOXtGR�HP�530,��8PD�WULSOLFDWD��FKDPDGD�de basal,

era preparada com 100 O�GH�FpOXODV�H�� O�GH�530,��VHP�DQWtJHQR�RX�

PLWyJHQR�� (VVD� FXOWXUD� p� D� FXOWXUD� QmR� HVWLPXODGD�� XVDGD� FRPR�

GHQRPLQDGRU�QR�FiOFXOR�GR�tQGLFH�GH�HVWLPXODomR�

O�PLWyJHQR� WHVWDGR� IRi o Pokeweed ± 5 l/ml (PWM - Sigma ). Os

PLWyJHQRV�VmR�XWLOL]DGRV�SDUD�YHULILFDU�D�LQWHJULGDGH�GR�VLVWHPD�LPXQROyJLFR�

2� DQWtJHQR� WHVWDGR� IRi o cloreto de cromo hexahidratado (CrCl3.6H2O ±

fornecido pela Merck, Darmstadt, Alemanha, com pureza 96%). O sal

trivalente foi� GLOXtGR� QR� PHLR� 530,� �� SDUD� IRUPDU� VROXo}HV� a 10-2 M.

(VVDV� VROXo}HV� IRUDP� KRPRJHQHL]DGDV e estocadas a ±70o&� DWp� R� XVR��

Durante o TPL D� VROXomR� GH� FORUHWR� GH� FURPR� D� ��-2� 0� HUD� GLOXtGD� SDUD�

2,5.10-3 M, equivalente a 666,66 g/mL. $�FRQFHQWUDomR�ILQDO�GDV�FXOWXUDV�HUD�

a metade dessD�FRQFHQWUDomR,�Mi�TXH�DV�FXOWXUDV�HUDP�FRPSRVWDV�SRU�� l

GD�VXVSHQVmR�GH�FpOXODV�H�� O�GD�VROXomR�

��$V� FpOXODV� IRUDP� FXOWLYDGDV� HP� WULSOLFDWDV� SRU� �� GLDV� D� ��oC em

atmosfera de 5% de CO2. O� PLWyJHQR� PWM era testado como controle

positivo.

__________________________________________________________0pWRGRV 48

��'H]RLWR�KRUDV�DQWHV�GR�WpUPLQR�GDV�FXOWXUDV�� l de timidina tritiada

(3H-thymidine, Amershan Pharmacia Biotech, UK; specific activity

25Ci/mmol�� GLOXtGD� HP�530,� �� IRL� DGLFLRQDGD� HP� FDGD� FXOWXUD�

para ser incorporada SHODV�FpOXODV em quantidade diretamente proporcional

DR�VHX�HVWDGR�GH�DWLYDomR.

��&RPSOHWDGR�R�SHUtRGR�GH�LQFXEDomR�DV�FpOXODV�HUDP�DVSLUDGDV�SRU�

XP�FROHWRU�GH�FpOXODV�DXWRPiWLFR��Cell-Harvester, Skatron Instruments, UK) e

passadas para uma membrana de fibra de vidro que era deixada para secar

por 24 horas.

��$SyV� R�SHUtRGR� GH� VHFDJHP�� DV�PHPEUDQDV� HUDP� EDQKDGDV� FRP�

OtTXLGR� GH� FLQWLODomR� H� VHODGDV� HP� HQYHORSHV� SOiVWLFRV�� 3DVVDYDP� SRU� XP�

FRQWDGRU� GH� FLQWLODomR� �%HWDSODWH�� :DOODF�� )LQOkQGLD) que determinava a

FDSWDomR�GH� WLPLGLQD�Uadiomarcada em cada cultura e dava o resultado em

FRQWDJHQV� SRU� PLQXWR� �FSP�� $� PpGLD� GDV� WULSOLFDWDV� HUD� FDOFXODGD� H� RV�

UHVXOWDGRV�H[SUHVVRV�HP�tQGLFH�GH�HVWLPXODomR�(IE) TXH�p�D� UD]mR�HQWUH�D�

PpGLD�GH� FDSWDomR�GH� WLPLGLQD� UDGLRPDUFDGD� GDV�FXOWXUDV� HVWLPXladas e a

PpGLD�HQFRQWUDGD�QDV�FXOWXUDV�QmR�HVWLPXODGDV�

ËQGLFH�GH�HVWLPXODomR (IE) = _PpGLD�GD�FDSWDomR�QDV�FXOWXUDV�HVWLPXODGDV__ �PpGLD�GD�FDSWDomR�QDV�FXOWXUDV�QmR�HVWLPXODGDV

__________________________________________________________0pWRGRV 49

4.3.2 7HVWH� GH� SUROLIHUDomR� OLQIRFLWiULD� SDUD� GHWHFomR da DWLYDomR�

FHOXODU�SHOD�SURGXomR de citocinas

As culturas foram realizadas em monoplicatas em placas de 96

RULItFLRV� FRP� IXQGR� FKDWR� �733 �� 6ZLW]HUODQG�� (XURSH�� (P� FDGD� RULItFLR�

foram adicionados 100 O�GD�VXVSHQVmR�GH�FpOXODV�H�� l de meio RPMI ou

da� VROXomR� GH� FORUHWR� GH� FURPR� a 2,5.10-3� 0�� IRUPDQGR� FXOWXUDV� QmR�

HVWLPXODGDV�� WDPEpP� GHQRPLQDGDV� GH� � FXOWXUDV� EDVDLV� H� HVWLPXODGDV�

UHVSHFWLYDPHQWH��$V�FXOWXUDV�SDUD�D�GHWHFomR�GH�FLWRFLQDV�IRUDP�SUHSDUDGDV�

DR�PHVPR� WHPSR�H�QDV�PHVPDV�FRQGLo}HV�TXH�DV�FXOWXUDV�SDUD�GHWHFomR�

por timidina radiomarcada, mas em placas diferentes.

��$R� WpUPLQR� GR� SHUtRGR� GH� LQFXEDomR� DV� FXOWXUDV� IRUDP�

FHQWULIXJDGDV�� SDUD� VHSDUDU� DV�FpOXODV� GR� VREUHQDGDQWH� H� R�VREUHQDGDQWH�

WUDQVIHULGR�SDUD� WXERV�SOiVWLFRV� LGHQWLILFDGRV�H�DUPD]HQDdos a -70o&�DWp�D�

dosagem das citocinas.

Os resultados da GHWHFomR�GH�FLWRFLQDV�IRUDP�H[SUHVVRV�HP�SJ�P/��

2V� FULWpULRV� XVDGRV� SDUD� SRVLWLYLGDGH� GRV� WHVWHV� IRUDP�� R� DXPHQWR� QD�

SURGXomR� GH� FLWRFLQDV� GHWHUPLQDGR� SHOD� GLIHUHQoD� HQWUH� D� SURGXomR�

encontrada nDV� FXOWXUDV� HVWLPXODGDV� PHQRV� D� SURGXomR� GD� FXOWXUD� EDVDO��

GLIHUHQoD� HVVD� DTXL� GHQRPLQDGD� GH� GHOWD� � ) e pelD� UD]mR� HQWUH� o valor

encontrado nas culturas estimuladas e as culturas basais, denominada de

tQGLFH�GH�HVWLPXODomR��,(��

Delta ( ) = valor encontrado nas culturas estimuladas valor encontrado nas culturas basais

__________________________________________________________0pWRGRV 50

ËQGLFH�GH�HVWLPXODomR�(IE) = valor encontrado nas culturas estimuladas valor encontrado nas culturas basais

4.4 Dosagem das citocinas no sobrenadante das culturas

4.4.1 ³/XPLQH[�OLTXLFKLS�DUUD\´

��$�GRVDJHP�GDV�FLWRFLQDV�IRL�UHDOL]DGD�XWLOL]DQGR�R�VLVWHPD�³OXPLQH[�

OLTXLFKLS� DUUD\´�� (VVH� VLVWHPD� SHUPLWH� D� GRVDJHP� VLPXOWkQHD� GH� P~OWLSODV�

citocinas no sobrenadante de culturas. Nesse PpWRGR� PLFURHVIHUDV� GH�

poliestireno VmR�FRUDGDV�com dois fluorocromos espectrais distintos (figura

2). 8WLOL]DQGR�XPD�SURSRUomR�SUHFLVD�GHVWHV�GRLV�fluorocromos foram criadas

100 microesferas diferenciadas pela sua cor. &DGD�HVIHUD�p�FRQMXJDGD�D�XP�

anticorpo GH� FDSWXUD� HVSHFtILFR� TXH� VH� OLJDUi� DR� VHX� DQWtJHQR� TXDQGR�

encontra-OR�� $� YDQWDJHP� GHVVH�PpWRGR� UHVLGH� QD� XWLOL]DomR� GH� HVIHUDV� GH�

HVSHFLILFLGDGHV� GLIHUHQWHV�SDUD� D�GHWHFomR�VLPXOWkQHD� GH�YiULRV�DQWtJHQRV�

em uma amostra.

Fig 2. Microesferas de poliestireno coradas de forma singular.

__________________________________________________________0pWRGRV 51

As microsferas foram incubadas com o sobrenadante das culturas.

$SyV� D� LQFXEDomR� D� DPRVWUD� foi lavada para remover as microesferas que

QmR�VH�OLJDUDP�DRs seus respectivos�DQWtJHQRs. Em seguida um anticorpo de

GHWHFomR� ELRWLQLODGR,� TXH� VH� OLJD� DR� FRPSOH[R� DQWtJHQR-anticorpo preso a

microesfera de poliestireno, foi incubado com a amostra. O resultado final

era� DPSOLILFDGR� DWUDYpV� Ga� LQFXEDomR� FRP� R� FRQMXJDGR� HVWUHSWDYLGLQD-

ficoeritrina que emite um sinal fluorescente (figura 3). As microesferas foram

lidas no equipamento Luminex 100 �DWUDYpV�GH�um sistema duplo de lasers

que incide nDV�PLFURHVIHUDV� j�PHGLGD� TXH�HVWDV�passavam pelo aparelho.

Um feixe de laser detectava a cor da microesfera e portanto o ensaio

relacionado a sua cor e o outro laser quantificava o sinal em cada

microesfera (figura 4).

)LJ��$�HVIHUD�FRP�R�DQWLFRUSR�p�LQFXEDGD�FRP�D�DPRVWUD�H�VH�OLJD�DR�VHX�DQWtJHQR��$�DPRVWUD�p� ODYDGD�H�LQFXEDGD�FRP�XP�DQWLFRUSR�ELRWLQLODGR�TXH�se ligD� DR� FRPSOH[R� DQWtJHQR-anticorpo. O resultado p amplificado pela

__________________________________________________________0pWRGRV 52

LQFXEDomR� FRP� R� FRQMXJDGR� HVWUHSWDYLGLQD-ficoeritrina que emite um sinal fluorescente.

)LJ��2V�IHL[HV�GH�ODVHU�LQFLGHP�VREUH�DV�HVIHUDV�SHUPLWLQGR�D�GHWHFomR�GR�ensaio e da intensidade da resposta.

4.4.2 Citocinas testadas

As citocinas escolhidas para estudo foram o IFN- , IL-2, IL-4, IL-5,

IL-10, IL-12, IL-13, IL-�� H� 5$17(6�� 2V� YDORUHV� PpGLRV� PtQLPRV� GH�

GHWHFomR�GHVVDV�FLWRFLQDV�FRP�R�PpWRGR�VmR��4;

0,2 e 1,0 J�P/� UHVSHFWLYDPHQWH�� 3DUD� RV� FiOFXORV� HVWDWtVWLFRV� WRGRV� RV�

YDORUHV� HQFRQWUDGRV� DEDL[R� GD� FDSDFLGDGH� GH� GHWHFomR� GR� PpWRGR� IRUDP�

WURFDGRV�SDUD�R�YDORU�PpGLR�PtQLPR�GH�GHWHFomR�GH�FDGD�FLWRFLQD�

__________________________________________________________0pWRGRV 53

4.4 0pWRGRV�HVWDWtVWLFRV

�3DUD� D� DYDOLDomR� HVWDWtVWLFD� IRUDP utilizados os testes� QmR�

SDUDPpWULFRs de Mann-Whitney U H� R� WHVWH� GH� FRUUHODomR� GH� 6SHDUPDQ�

(software GraphPad Prism �YHUVmR��H�RV�UHVXOWDGRV�IRUDP�FRQVLGHUDGRV�

significantes quando P <0,05. A sensibilidade, especificidade�H�DFXUiFLa dos

PpWRGRV foram calculadas.

RESULTADOS


________________________________________________________Resultados 54

5 RESULTADOS

5.1 6HOHomR�GRV�JUXSRV

O grupo de casos foi formado por 18 pacientes, sendo 17 GR�JrQHUR�

masculino e 1 feminino e o grupo controle por 19 pacientes, 11� GR�JrQHUR�

masculino e 7 feminino. A idade do grupo de casos variou entre 36 e 65

anoV��PpGLD�50 anos) e do grupo controle de 26 a 68�DQRV��PpGLD�44 anos),

QmR�KDYHQGR�GLIHUHQoD�HVWDWtVWLFD�VLJQLILFDWLYD��P = 0.1913).

5.2 Testes de contato

Todos os casos apresentaram teste de contato positivo (+, ++ ou

+++) para cromo. Em um paciente o teste foi positivo fraco (+), em treze

positivo forte (++) e em quatro�SRVLWLYR�PXLWR�IRUWH��$OpP�GR�FURPR��oito

pacientes eram sensibilizados ao carba-mix, cinco ao tiuram-mix e ao sulfato

GH� QtTXHO, WUrV� DR� FREDOWR� H� XP�ao PPD-PL[�� IRUPDOGHtGR� nitrofurasona e

quinolina.

Todos os controles apresentaram teste de contato negativo para

ELFURPDWR� GH� SRWiVVLR��Cinco pacientes eram sensibilizados ao sulfato de

QtTXHO, dois DR� FREDOWR�� FRORI{QLR�� QHRPLFLQD� H� SHUIXPH-PL[� H� XP� j�


________________________________________________________Resultados 55

EHQ]RFDtQD��FORUH[LGLQH��HWLOHQRGLDPLQD��HVPDOWH��IRUPDOGHtGR��QLWURIXUD]RQD��

WLPHURVDO��WLRJOLFRODWR�GH�DP{QLD�H�WLXUDP-mix.

2V� UHVXOWDGRV� GRV� WHVWHV� GH� FRQWDWR� GRV� FDVRV� H� FRQWUROHV� HVWmR�

GLVSRQtYHLV�no quadro ��SUHVHQWH�QD�VHVVmR�GH�DQH[RV�

5.3 Testes de pUROLIHUDomR lLQIRFLWiULD

��7DQWR�FRQWUROHV�TXDQWR�FDVRV�DSUHVHQWDUDP�SUROLIHUDomR�DGHTXDGD�

DR� VHUHP� HVWLPXODGRV� FRP� R� PLWyJHQR� pokeweed, P < 0.0001 nos dois

JUXSRV�� QmR� H[LVWLQGR� GLIHUHQoD� QRV� tQGLFHV� GH� HVWLPXODomR� HQWUH� FDVRV� H�

controles, P = 0.2185 (Figuras 5 a 7).

1R�HQWDQWR��DSHQDV�R�JUXSR�GH�FDVRV� UHVSRQGHX�DR�HVWtPXOR�FRP�

cromo, P < 0.0001 e 0.2202 para casos e controles respectivamente (figuras

�� H� �� 2V� tQGLFHV� GH� HVWLPXODomR� HQFRQWUDGRV� QRV� JUXSRV� GH� FDVRV� H�

FRQWUROHV� HVWLPXODGRV� FRP� FURPR� WDPEpP� IRUDP diferentes, P = 0.0014

(figura 10).

��6HLV� GRV� �� FDVRV� H� QHQKXP� FRQWUROH� DSUHVHQWDUDP� tQGLFH� GH�

HVWLPXODomR� VXSHULRU� D� �� DSUHVHQWDQGR� R� WHVWH� GH� SUROLIHUDomR� OLQIRFLWiULD�

uma sensibilidade, especificidade� H� DFXUiFLD� de 33%, 100% e 68%,

respectivamente. Os valores encontrados nas culturas basais e estimuladas

FRP�FURPR��EHP�FRPR�RV�tQGLFHV�GH�HVWLPXODomR�H�RV�YDORUHV�GHOWD�REWLGRV��

HVWmR�GLVSRQtYHLV�QD�WDEHOD��SUHVHQWH�QRV�DQH[RV�

________________________________________________________Resultados 56

Fig 5. Contagens por minutoencontradas nas culturas

basais e estimuladas com PWMdo grupo de casos.

Basal casos PWM casos0

1000

2000

3000

4000

P < 0.0001

Fig 6. Contagens por minutoencontradas nas culturas

basais e estimuladas com PWMdo grupo controle.

Basal controles PWM controles0

2500

5000

7500

10000

P < 0.0001

)LJ��ËQGLFHV�GH�HVWLPXODomRencontrados nos casos e

controles estimulados comPWM.

IE PWM casos IE PWM controls0

10

20

30

P = 0.2185

Fig 8. Contagens por minutoencontradas nas culturasbasais e estimuladas comcromo do grupo de casos.

Basal casos Cromo casos0

250

500

750

P < 0.0001

Fig 9. Contagens por minutoencontradas nas culturasbasais e estimuladas comcromo do grupo controle.

Basal controles Cromo controles0

500

1000

1500

P = 0.2202

)LJ��ËQGLFHV�GH�HVWLPXODomRencontrados nos casos e

controles estimulados comcromo.

IE cromo controles IE cromo casos0

1

2

3

4

5

P = 0.0014

________________________________________________________Resultados 57

5.4 'HWHFomR�GDV�FLWRFLQDV

5.4.1 Interferon-gama

��1mR�IRL�HQFRQWUDGR�GLIHUHQoD�QD�SURGXomR�GH�,1)- entre as culturas

basais de casos e controles, P = 0.1406 (figuras 11).

��+RXYH�DXPHQWR�GD�SURGXomR�GH� ,)1- nas culturas estimuladas no

JUXSR� GH� FDVRV�� PDV� QmR� QR� JUXSR� FRQWUROH� - P = 0.0005 e 0.1290

respectivamente (figuras 12 e 13).

��2V�tQGLFHV�REWLGRV�SHOD�UD]mR�HQWUH�D�SURGXomR�GH�,)1- encontrada

QDV� FXOWXUDV� HVWLPXODGDV� FRP� FURPR� H� QDV� QmR� HVWLPXODGDV� QR� JUXSR� GH�

casos foram superiores aos vistos no grupo controle, P = 0.0186 (figura 14).

Da mesma forma os vDORUHV� HQFRQWUDGRV� SHOD� GLIHUHQoD� QD�

SURGXomR� GH� ,)1- � HQWUH� DV� FXOWXUDV� HVWLPXODGDV� H� QmR� HVWLPXODGDV� FRP�

cromo no grupo de casos foram maiores do que os obtidos no grupo

controle, P = 0.0186 (figura 15).

��2V� YDORUHV� GRV� tQGLFHV� GLDJQyVWLFRV� TXH� DSUHVHQtaram a melhor

DFXUiFLD� IRUDP�� ,(� VXSHULRU� D� �� H� maior que 50. Com esses valores de

corte, a sensibilidade e especificidade do teste com o IE foi de 83% e 63%

�DFXUiFLD�GH��H�FRP�R� �GH��H��DFXUiFLD�GH��7RGRV�RV�

valores de INF- detectadoV� H� GRV� tQGLFHV� XWLOL]DGRV� HVWmR� GLVSRQtYHLV� QD�

tabela 2, presente nos anexos.

________________________________________________________Resultados 58

)LJ��'HWHFomR�GH�,)1� nasculturas basais dos casos e

controles.

Basal casos Basal controles0

100

200

300

400

500

P = 0.1406

Fig 12. 'HWHFomR�GH�,)1� nasculturas basais e estimuladas

com cromo do grupo de casos.


2500

5000

7500

P = 0.0005

Fig 13. 'HWHFomR�GH�,)1� nasculturas basais e estimuladascom cromo do grupo controle.


500

1000

1500

P = 0.1290

)LJ��ËQGLFHV�GH�HVWLPXODomRencontrados nas culturas dos

casos e controles.

IE casos IE controles0

100

200

300

400

500

P = 0.0186

)LJ��'LIHUHQoD�QD�GHWHFomRde IFN- entre as culturasestimuladas e basais dos

grupos de caso e controle.

casos controles-2500

0

2500

5000

7500

P = 0.0186

________________________________________________________Resultados 59

5.4.2 Interlucina-2

1mR�IRL�HQFRQWUDGR�GLIHUHQoD�QD�SURGXomR�GH�,/-2 entre as culturas

basais de casos e controles e nem entre as culturas basais e estimuladas do

grupos, P = 1, 0.2110 e 0.1567, respectivamente (figuras 16 a 18).

��2V� YDORUHV� REWLGRV� SHOD� UD]mR� HQWUH� DV� FXOWXUDV� HVWLPXODGDV� FRP�

cromo e as basais no grupo de casos foram superiores aos vistos no grupo

controle, P = 0.0465 (figura 19).

No entanto, os valorHV�HQFRQWUDGRV�SHOD�GLIHUHQoD�HQWUH�DV�FXOWXUDV�

HVWLPXODGDV� H� QmR� HVWLPXODGDV� QR� JUXSR� GH� FDVRV� QmR� IRUDP� GLIHUHQWHV�

daqueles encontrados no grupo controle, P = 0.0705 (figura 20).

��2V�YDORUHV�yWLPRV�HQFRQWUDGRV� IRUDP�FRP�XP� ,(�VXSHULRU�D��$�

sensibilidade e especificidade do teste com esse IE foram de 61% e 84%

UHVSHFWLYDPHQWH�� DFXUiFLD� GH��7RGRV� RV�YDORUHV�GH� ,/-2 detectados e

GRV�tQGLFHV�XWLOL]DGRV�HVWmR�GLVSRQtYHLV�QD�WDEHOD��SUHVHQWH�QRV�DQH[RV�

________________________________________________________Resultados 60

Fig 16. 'HWHFomR�GH�,L-2 nasculturas basais dos casos e

controles.


5

10

15

P = 1

)LJ��'HWHFomR�GH�,/��QDVculturas basais e estimuladas



10

20

P = 0.2110

)LJ��'HWHFomR�GH�,/��QDVculturas basais e estimuladascom cromo do grupo controle.


5

10

15

P = 0.1567


casos e controles.


10

20

30

40

P = 0.0465

Fig 20. 'LIHUHQoD�QD�GHWHFomRde IL-2 entre as culturas deestimuladas e basais dos


-20

-10

0

10

20

casos controles

P = 0.0705

________________________________________________________Resultados 61

5.4.3 Interleucina-4

Foi encontrado maior pURGXomR�GH�,/-4 nas culturas basais do grupo

GH�FDVRV�HP�UHODomR�DV�FXOWXUDV�EDVDLV�GR�JUXSR�FRQWUROH��P = 0.0164 (figura

21).

��1mR� KRXYH� GLIHUHQoD� HQWUH� RV� YDORUHV� GH� ,/-4 detectados nas

culturas basais e estimuladas no grupo de casos, mas houve aumento nas

FXOWXUDV�HVWLPXODGDV�HP�UHODomR�DV�EDVDLV�QR�JUXSR�FRQWUROH�± P = 0.2114 e

0.0265 respectivamente (figuras 22 e 23).

��2V�YDORUHV�REWLGRV� WDQWR�SHOD�UD]mR�TXDQWR�SHOD�GLIHUHQoD�HQWUH�DV�

FXOWXUDV�HVWLPXODGDV�FRP�FURPR�H�DV�EDVDLV�QR�JUXSR�GH�FDVRV�QmR foram

diferentes daqueles encontrados no grupo controle, P = 0.6268 e 0.7962

respectivamente (figuras 24 e 25). Todos os valores de IL-4 detectados e

GRV�tQGLFHV�XWLOL]DGRV�HVWmR�GLVSRQtYHLV�QD�WDEHOD��SUHVHQWH�QRV�DQH[RV�

________________________________________________________Resultados 62

Fig 21. 'HWHFomR�GH IL-4 nasculturas basais dos casos e

controles.


25

50

75

100

P = 0.0164




25

50

75

100

P = 0.2114



50

100

150

P = 0.0265


casos e controles.


1

2

P = 0.6268

Fig 25. 'LIHUHQoD�QD�GHWHFomRde IL-4 entre as culturas

estimuladas e basais dosgrupos de caso e controle.

casos controles-25

0

25

50

P =0.7962

________________________________________________________Resultados 63



basais dos casos e controles, P = 0.069 (figuras 26).

��+RXYH� DXPHQWR� GD� SURGXomR� GH� ,/-5 nas culturas estimuladas no

JUXSR� GH� FDVRV�� PDV� QmR� QR� JUXSR� FRQWUROH� ± P = 0.0006 e 0.7588


��2V�YDORUHV�REWLGRV� WDQWR�SHOD�UD]mR�TXDQWR�SHOD�GLIHUHQoD�HQWUH�DV�

culturas estimuladas e as basais no grupo de casos foram superiores aos

vistos no grupo controle, P = 0.0032 e 0.0102 respectivamente (figuras 29 e

30).

Os valRUHV�yWLPRV�GH�FRUWH�IRUDP��,(�VXSHULRU��H� maior que 0,2. A

VHQVLELOLGDGH�� HVSHFLILFLGDGH� H� DFXUiFLD� GR� WHVWH� FRP� HVVHV� SDUkPHWURV�

foram de 72%, 79% e 76% com esse IE e 56%, 89% e 73% com o . Todos

os valores de IL-��GHWHFWDGRV�H�GRV�tQGLFHV�XWLOL]DGRV�HVWmR�GLVSRQtYHLV�QD�

tabela 5, presente nos anexos.

________________________________________________________Resultados 64


controles.


5

10

15

P = 0.0609



Basal casos Cromo casos0.0

2.5

5.0

7.5

10.0

P = 0.0006



5

10

15

P = 0.7588


casos e controles.


25

50

75

100

P = 0.0032

Fig 30. 'LIHUHQoD�QD�GHWHFomRde IL-5 entre as culturas


-10

0

10

casos controles

P = 0.0102

________________________________________________________Resultados 65



basais dos casos e controles, P = 0.6595 (figuras 31).

��7RGDYLD�� KRXYH� UHGXomR� QRV� YDORUHV� GHWHFWDGRV� QDV� FXlturas

estimuladas com cromo tanto no grupo de casos quanto no grupo controle, P

< 0.0001 e 0.0001 respectivamente (figuras 32 e 33).

��2V� YDORUHV� REWLGRV� SHOD� UD]mR� H� SHOD� GLIHUHQoD� HQWUH� DV� FXOWXUDV�

HVWLPXODGDV�FRP�FURPR�H�DV�EDVDLV�QR�JUXSR�GH�FDVRV�Qmo foram diferentes

daqueles obtidos no grupo controle, P = 0.2019 e 0.7962 respectivamente

(figuras 34 e 35). Todos os valores de IL-�� GHWHFWDGRV� H� GRV� tQGLFHV�

XWLOL]DGRV�HVWmR�GLVSRQtYHLV�QD�WDEHOD��SUHVHQWH�QRV�DQH[RV�

________________________________________________________Resultados 66


controles.


1000

2000

3000

P = 0.6595




1000

2000

P < 0.0001



1000

2000

3000

P = 0.0001


casos e controles.

IE casos IE controles0.00

0.25

0.50

0.75

1.00

P = 0.2019

Fig 35. 'LIHUHQoD�QD�GHWHFomRde IL-10 entre as culturasestimuladas e basais dos



-2000

-1000

0

P = 0.7962

________________________________________________________Resultados 67



basais de casos e controles, P = 0.0946 (figura 36).

��7DPEpP� QmR� KRXYH� GLIHUHQoD� HQWUH� RV� YDORUHV� GHWHFWDGRV� QDV�

FXOWXUDV� HVWLPXODGDV� H� QmR� HVWLPXODGDV� QRV� GRLV� JUXSRV�� P = 0.1940 e

0.2999 respectivamente (figuras 37 e 38).

��1R� HQWDQWR�� RV� YDORUHV� REWLGRV� WDQWR� SHOD� UD]mR� TXDQWR� SHOD�

GLIHUHQoD�HQWUH�DV�FXOWXUDV�HVWLPXODGDV�H�DV�EDVDLV�QR�JUXSR�GH�FDVRV�IRUDP�

superiores aos vistos no grupo controle, P = 0.0024 e 0.0050 (figuras 39 e

40).

Os melhores valores encontrados para o IE e o foram: superior a

1,5 e 0,3 respectivamente. Com esses, a sensibilidade, especificidade e

DFXUiFLD� GR� WHVWH� IRUDP�GH�� H� ��SDUD�R� ,(�H� GH� �� H�

70% para o . Todos os valores de IL-12 detectados e GRV�tQGLFHV�XWLOL]DGRV�

HVWmR�GLVSRQtYHLV�QD�WDEHOD��SUHVHQWH�QRV�DQH[RV�

________________________________________________________Resultados 68


controles.


10

20

30

P = 0.0946

Fig 37. 'HWHFomR�GH IL-12 nasculturas basais e estimuladas



10

20

P = 0.1940



10

20

30

P = 0.2999


casos e controles.

IE casos IE controles0.0

2.5

5.0

7.5

P = 0.0024



-30

-20

-10

0

10

20

30

casos controles

P = 0.0050

________________________________________________________Resultados 69



basais de casos e controles, P = 0.0945 (figuras 41).

��2� FURPR�HVWLPXORX� D� SURGXomR�de IL-13 nas culturas do grupo de

FDVRV�� PDV� QmR� QDV� FXOWXUDV� GR� JUXSR� FRQWUROH�� P < 0.0001 e 0.9186


��2V�YDORUHV�HQFRQWUDGRV�WDQWR�SHOD�UD]mR�TXDQWR�SHOD�GLIHUHQoD�HQWUH�

as culturas estimuladas com cromo e as basais no grupo de casos foram

superiores aos obtidos no grupo controle, P� �� QDV� GXDV�FRQGLo}HV�

(figuras 44 e 45).

Utilizando os valores superiores a 3 para o IE e superior a 2 para o

��D�VHQVLELOLGDGH��HVSHFLILFLGDGH�H�DFXUiFLD�GR�WHVWH�IRUDP�GH��% e

89% para o IE e 94%, 89% e 92% para o . Todos os valores de IL-13

GHWHFWDGRV�H�GRV� tQGLFHV�XWLOL]DGRV�HVWmR�GLVSRQtYHLV�QD� WDEHOD��SUHVHQWH�

nos anexos.

________________________________________________________Resultados 70


controles.


100

200

300

P = 0.0945




25

50

75

P < 0.0001



100

200

300

P < 0.9186


casos e controles.


100

200

P < 0.0001



-100

-50

0

50

100

casos controles

P < 0.0001

________________________________________________________Resultados 71



basais dos grupos, P = 0.4459 (figura 46).

��7DPEpP�QmR�KRXYH�GLIHUHQoD�QRV�YDORUHV�GHWHFWDGRV�QDV�FXOWXUDV�

HVWLPXODGDV�H�QmR�HVWLPXODGDV�QR�JUXSR�GH�FDVRV�H�QR�JUXSR�FRQWUROH��P =

0.3101 e 0.1547 respectivamente (figuras 47 e 48).

Os valores obtidos pela rD]mR� H� SHOD� GLIHUHQoD� HQWUH� DV� FXOWXUDV�

HVWLPXODGDV�H�DV�QmR�HVWLPXODGDV�QR�JUXSR�GH�FDVRV�QmR� IRUDP�GLIHUHQWHV�

daqueles obtidos no grupo controle, P = 0.0698 e 0.0910 respectivamente

(figuras 49 e 50). Todos os valores de IL-�� GHWHFWDGRV� H� GRV� tQGLFHV�

utLOL]DGRV�HVWmR�GLVSRQtYHLV�QD�WDEHOD��SUHVHQWH�QRV�DQH[RV�

________________________________________________________Resultados 72


controles.

Basal casos Basal controles0.0

2.5

5.0

7.5

10.0

P = 0.4459



Basal casos Cromo casos0.0

2.5

5.0

7.5

P = 0.3101


Basal controles Cromo controles0.0

2.5

5.0

7.5

10.0

P = 0.1547


casos e controles.


10

20

30

P = 0.0698



-10

-5

0

5

10

casos controles

P = 0.0910

________________________________________________________Resultados 73

5.4.9 RANTES

��1mR� IRL� HQFRQWUDGR� GLIHUHQoD� QD� SURGXomR� GH� RANTES entre as

culturas basais de casos e controles, P� ��ILJXUD��-i�DV�FXOWXUDV�

de casos e controles realizadas com cromo aXPHQWDUDP� D� SURGXomR� GH�

RANTES, P < 0,0001 (figuras 52 e 53).

��-i�RV�YDORUHV�REWLGRV�SHOD�UD]mR�H�SHOD�GLIHUHQoD�HQWUH�DV�FXOWXUDV�

estimuladas com cromo e as basais no grupo de casos foram iguais aos

encontrados no grupo controle, P = 0.5535 e 0.6595 respectivamente

�ILJXUDV�� H� ��7RGRV� RV�YDORUHV�GH�5$17(6�GHWHFWDGRV�H� GRV� tQGLFHV�

XWLOL]DGRV�HVWmR�GLVSRQtYHLV�QD�WDEHOD��SUHVHQWH�QRV�DQH[RV�

________________________________________________________Resultados 74

)LJ��'HWHFomR�GH�5$17(6nas culturas basais dos casos

e controles.


2500

5000

7500

P = 0.6161

)LJ��'HWHFomR�GH�5$17(6nas culturas basais e

estimuladas com cromo dogrupo de casos.


5000

10000

P < 0.0001

)LJ��'HWHFomR�GH�5$17(6nas culturas basais e

estimuladas com cromo dogrupo controle.


2500

5000

7500

P < 0.0001


casos e controles.


5

10

15

P = 0.5535

Fig 55. 'LIHUHQoD�QD�GHWHFomRde RANTES entre as culturas



0

2500

5000

7500

10000

P = 0.6595

________________________________________________________Resultados 75

5.5 7HVWHV�GH�FRUUHODomR

��2� tQGLFH� GH� FRUUHODomR� HQWUH� DV� YDULiYHLV� DOHUJLD� H� RV� tQGLFHV� GH�

HVWLPXODomR� HQFRQWUDGRV� FRP� R� WHVWH� GH� SUROLIHUDomR� FRQYHQFLRQDO� IRL� GH�

0,55 (P ��WDEHOD��QRV�DQH[RV��$�WDEHOD��DSUHVHQWD�RV�tQGLFHV�

GH�FRUUHODomR�HQFRQWUDGRV�HQWUH�DOHUJLD�H�RV�tQGLFHV�GH�HVWLPXODomR�REWLGRV�

com cada citocina testada. A tabela 13, disSRQtYHO�QRV�DQH[RV��PRVWUD�TXH�

QmR�KRXYH�FRUUHODomR�HQWUH�RV�UHVXOWDGRV�GRV�tQGLFHV�GH�HVWLPXODomR�REWLGRV�

FRP� R� 73/� H� FRP� DV� GLYHUVDV� FLWRFLQDV�� 3DUD� WRGDV� DV� DQiOLVHV� GH�

FRUUHODomR�D�YDULiYHO�DOHUJLD�IRL�JUDGXDGD�SHOR�WHVWH�GH�FRQWDWR�HP��H�

3 que FRUUHVSRQGHUDP�D�SDFLHQWHV��VHP�DOHUJLD��DOpUJLFRV�FRP�XPD�FUX]�QR�

TC, duas cruzes e 3 cruzes, respectivamente.

',6&8662


________________________________________________________'LVFXVVmR 76

6 ',6&8662

Apesar de existirem poucos estudos sobre o TPL em pacientes

VHQVLELOL]DGRV� DR� FURPR� HVWi� FODUR� TXH� HVVH� WHVWH�� QD� VXD� IRUPD�

FRQYHQFLRQDO��QmR�DSUHVHQWD�VHQVLELOLGDGH�VXILFLHQWH�SDUD�VXEVWLWXLU�R�7&�24

��)RUPDV�DOWHUQDWLYDV�GHVVH�PpWRGR, como o uso de CD no lugar dos

PRQyFLWRV�RX�D�LQGXomR�H�D�GHWHFomR�GD�UHVSRVWD�SRU�FLWRFLQDV�FRP�R�LQWXLWR�

GH�PHOKRUDU�D�VHQVLELOLGDGH��UHDEULUDP�DV�SRUWDV�SDUD�QRYDV� LQYHVWLJDo}HV��

Os poucos estudos que seguiram esses protocolos alternativos apresentam

dLIHUHQoDV� FRQVLGHUiYHLV� TXDQWR� D� VXD� PHWRGRORJLD�� GLILFXOWDQGR� D�

FRPSDUDomR� GRV� UHVXOWDGRV�27-32 Mesmo assim, todos apresentaram algum

UHVXOWDGR� HVWLPXODQGR� R� UHILQDPHQWR� GHVVHV� SURWRFRORV� DWUDYpV� GH� QRYDV�

pesquisas.

��'HQWUH�DV�GLIHUHQoDV�HQFRQWUDGDV�QRV�PpWRGRV�DOWHUQDWLYRV� WHPRV��

D� LQGXomR� GD� UHVSRVWD� SRU� PLWyJHQR� RX� FLWRFLQDV�� SHUtRGRV� GLIHUHQWHV� GH�

FXOWXUD��SRXFDV�H�GLIHUHQWHV�FLWRFLQDV�WHVWDGDV�SDUD�GHWHFomR�GR�UHVXOWDGR�H��

HP� XP� WUDEDOKR�� DXVrQFLD� GH� JUXSR� FRQWUROH�� 3DUD� VDQDU� DOJXPDV� GHVVDV�

TXHVW}Hs esse estudo foi realizado comparando a resposta do TPL

FRQYHQFLRQDO� j� GHWHFomR� GH� QRYH� FLWRFLQDV� QDV� FXOWXUDV� GH� �� GLDV� GH� ��

SDFLHQWHV�DOpUJLFRV�DR�FURPR�H��FRQWUROHV�

O IFN- �IRL�HVFROKLGR�SRU�VHU�SURGX]LGR�SHORV�/7F��H�/7K��DQWtJHQR-

HVSHItFLIRV��SULQFLSDLV�FpOXODV�HIHWRUDV�GD�GHUPDWLWH�GH�FRQWDWR�DOpUJLFD.108,111

(VVDV� FpOXODV� Oiberam IFN- � TXH� HVWLPXOD� RXWUDV� FpOXODV� 7�� FpOXODV� 1.� H�


________________________________________________________'LVFXVVmR 77

PDFUyIDJRV�D�DPSOLDU�R�SURFHVVR�LQIODPDWyULR�H�DXPHQWD�D�H[SUHVVmR�ICAM-

1 e GH�)DV�QR�TXHUDWLQyFLWRV� WRUQDQGR-os maLV�VXVFHWtYHLV�j�FLWRWR[LFLGDGH�

mediada por FasL.80,81,111,140,141

A IL-��p�XP�IDWRU�GH�FUHVFLPHQWR�SDUD�DV�FpOXODV�7�DWLYDGDV��(OD�p��

SURGX]LGD� SHORV� SUySULRV� /7� KDSWHQR-HVSHFtILFRV� DWLYDGRV� H� DWXD� SRU�DomR�

DXWyFULQD� OHYDQGR� D� SUROLIHUDomR� FHOXODU�� SURcesso esse conhecido como

H[SDQVmR�FORQDO�66-68

A IL-��SURGX]LGD�SHOD�FpOXOD�7�1.�LQYDULDQWH��p�QHFHVViULD�SDUD�D�

DWLYDomR� GRV� OLQIyFLWRV� %-�� H� FRQVHT�HQWH� SURGXomR� GD� ,J0� DQWtJHQR-

HVSHFtILFD�� $� DXVrQFLD� GH� ,/-4 diminui a resposta do contato em

camundoQJRV�³knock-out´�SDUD�R�JHQH�GHVVD�LQWHUOHXFLQD�46,160

A IL-�� p� SURGX]LGD� HP� PRGHUDGD� TXDQWLGDGH� SHODV� FpOXODV� 7�

UHJXODGRUDV� DQWtJHQR-HVSHFtILFDV�70 A IL-�� WDPEpP� p� QHFHVViULD� SDUD� D�

PDQXWHQomR�GD�SURGXomR�GD� ,J0��&DPXQGRQJRV�FRP�³knock-out´�GR�JHQH�

da IL-��DSUHVHQWDP�GLPLQXLomR�GD�UHVSRVWD�GH�FRQWDWR�45

A IL-10 foi escolhida por ser produzida em grande quantidade pelas

FpOXODV�7�UHJXODGRUDV�SDUD�VXSULPLU�D�UHVSRVWD�GH�FRQWDWR�70

A IL-1�� p� H[SUHVVD� SHODV� &'� DSyV� D� PDWXUDomR� FRPSOHWD� GDV�

PHVPDV� H� p� QHFHVViULD� SDUD GLIHUHQFLDomR� H�PDWXUDomR� GRV� /7� KDSWHQR-

HVSHFtILFRV�HP�FpOXODV�HIHWRUDV�H�GH�PHPyULD.112

Minang et al.� GHPRQVWUDUDP� TXH� RV� PHWDLV� OHYDP� D� SURGXomR� GH�

FLWRFLQDV�SDGUmR�WDQWR�7K��FRPR�R�,1)- e a IL-2, quanto Th2, como a IL-4 e

IL-13, naV� FXOWXUDV� GRV� SDFLHQWHV� DOpUJLFRV�� $� ,/-13 foi a citocina que

apresentou a melhor resposta em seus ensaios com o cromo, sugerindo

________________________________________________________'LVFXVVmR 78

XPD�PHOKRU�DYDOLDomR�TXDQWR�DR�VHX�SDSHO�QR�GLDJQyVWLFR�GH�DOHUJLD�D�HVVH�

metal.

A IL-17, produzida pelos LTh17 estimula a� SURGXomR� GH� FLWRFLQDV�

SUy-LQIODPDWyULDV��PRGXOD�D�OLEHUDomR�GH�TXLPLRFLQDV�H�DXPHQWD�D�H[SUHVVmR�

de ICAM-�� QRV� TXHUDWLQyFLWRV�� R� TXH� IDYRUHFH� D� LQWHUDomR� FRP� RV�

OLQIyFLWRV�115-117

A quimiocina RANTES�� WDPEpP� FKDPDGD� GH� &&/�� p� SURGX]LGD�

SHOR� HQGRWpOLR�� SODTXHWDV� H� FpOXODV� 7�� (OD� DWUDL� PRQyFLWRV�� &'�� EDVyILORV��

HRVLQyILORV��FpOXODV�1.�H�FpOXODV�7�H�HVWi�HQYROYLGD�QD�DWLYDomR�GRV�/7�66

��&RP� UHODomR� DR� 73/� FRQYHQFLRQDO�� D� UHVSRVWD� DR� ³SRNHZHHG´ foi

adequada e de igual intensidade nos casos e controles; confirmando que as

FRQGLo}HV�GH�FXOWXUD�IRUDP�DGHTXDGDV�H�TXH�FDVRV�H�FRQWUROHV�UHVSRQGHP�

GH�IRUPD�VHPHOKDQWH�D�XP�HVWtPXOR�DRV�TXDLV�DPERV�VmR�VHQVtYHLV��ILJXUDV�

5 a 7).

��&RPR� HVSHUDGR�� DSHQDV� RV� OLQIyFLWRV� GR� JUXSR� GH� SDFLHQWHV�

DOpUJLFRV� IRUDP� HVWLPXODGRV� FRP� R� FURPR� �ILJXUDV� �� H� �� $� GLIHUHQoD�

HQFRQWUDGD� QD� UHVSRVWD� HQWUH� RV� JUXSRV� OHYRX� D� GLIHUHQoD� QRV� ,(�

encontrados entre os grupos (figura 10).

��&RQVLGHUDQGR� XP� ,(� VXSHULRU� D� �� FRPR� FULWpULR� GH� SRVLWLYLGDGH�� D�

resposta ao teste foi encontrada em apenas 6 dos 18 casos e nenhum

controle, o que corresponde a uma sensibilidade de 33% e especificidade de

100% (tabela 1, nos anexos). Esse valor de corte foi determinado como o

LGHDO� SDUD� GLVWLQJXLU� FDVRV� GH� FRQWUROHV� HP� XP� HVWXGR� SUpYLR� IHLWR� SHORV�

mesmos DXWRUHV�VHJXLQGR�DV�PHVPDV�FRQGLo}HV�GH�FXOWXUD�24

________________________________________________________'LVFXVVmR 79

��$� VHQVLELOLGDGH� DTXpP� GR� GHVHMDGR� p� XPD� FDUDFWHUtVWLFD� SUySULD�

desse teste, quando realizado para detectar alergia ao cromo.24 Todavia, a

VHQVLELOLGDGH�ILFRX�DEDL[R�GR�HQFRQWUDGR�QR�QRVVR�HVWXGR�SUpYLR�(60%) e em

RXWUR�HVWXGR�GH�PHVPD�DXWRULD��FXMRV�GDGRV�QmR�IRUDP�SXEOLFDGRV��HQWUH��

casos e 14 controles onde a sensibilidade foi de 53%.24

��-i�D�HVSHFLILFLGDGH�GR�WHVWH�VH�PRVWURX�H[FHOHQWH��FRPR�QR�QRVVR�

HVWXGR�SUpYLR��H�VXSHULRU�jTXHOD�HQFRQWUDGD�QR�HVWXGR�QmR�SXEOLFDGR��

que foi de 79%.24� &RPR� RV� FULWpULRV� GH� VHOHomR� IRUDP� RV� PHVPRV�� DV�

culturas foram realizadas seguindo a mesma metodologia e preparadas pela

PHVPD� SHVVRD� HP� WRGRV� RV� FDVRV�� HVVDV� GLIHUHQoDV� GHYHP� VH� GHYHU� DR�

acaso.

��2� tQGLFH� GH� FRUUHODomR� GH� 6SHDUPDQ� PRVWURX� H[LVWLU� FRUUHODomR�

PRGHUDGD�HQWUH�DV�YDULiYHLV�DOHUJLD�H�tQGLFH�GH�HVWLPXODomR�REWLGR�SHOR�73/�

convencional, como visto no estudo de Lindemann et al.32

��2� HVWtPXOR� FRP� FURPR� LQGX]LX� D� SURGXomR� GH� ,1)- , IL-5 e IL-13

apenas no grupo de casos (figuras 12, 13, 27, 28, 42 e 43), determinando

GLIHUHQoD�QRV�,(�H� entre casos e controles (figuras 14, 15, 29, 30, 44 e 45).

��$� VHQVLELOLGDGH� H� HVSHFLILFLGDGH� REWLGDV� FRP� D� GHWHFomR� GH� ,)1-

nesse trabalho foram semelhantes as encontradas nos estudos de Trattner

et al.28 (73,7% e 71,4%) e Moed et al.29 (57% e 86%). Esses pesquisadores

adicionaram fitohemaglutinina e citocinas a fim de melhorar a sensibilidade

GR� WHVWH�� &RPR� RV� UHVXOWDGRV� IRUDP� VHPHOKDQWHV� QRYRV� HVWXGRV� VHUmR�

QHFHVViULRV�SDUD�MXVWLILFDU�R�XVR�GHVVHV�PpWRGRV��DR�PHQRV�SDUD�D�GHWHFomR�

de IFN nas culturas estimuladas com cromo. No entanto, duas ressalvas

________________________________________________________'LVFXVVmR 80

GHYHP�VHU� IHLWDV��R�Q~PHUR�GH�FDVRV�HVWXGDGRV�SRU�0RHG�Ht al.29 foi muito

SHTXHQR�H�R�SHUtRGR�GH�LQFXEDomR�GH�7UDWWQHU�et al.28 foi sensivelmente mais

FXUWR��3DUD�XPD�PHOKRU�FRPSDUDomR�FRP�R�WUDEDOKR�GH�7UDWWQHU�et al.28 um

QRYR� HVWXGR� FRP� XP� SHUtRGR� GH� LQFXEDomR� PDLV� FXUWR� p� QHFHVViULR��

Ackerman et al.30 e Lindemann et al.32� WDPEpP� HQFRQWUDUDP� DXPHQWR� QD�

SURGXomR� GH� ,)1- � QRV� SDFLHQWHV� DOpUJLFRV�� PDV� QmR� FDOFXODUDP� D�

VHQVLELOLGDGH� H� HVSHFLILFLGDGH� GR� PpWRGR�� $SHQDV� 0LQDQJ� et al.31� QmR�

GHWHFWDUDP�GLIHUHQoD� QD� SURGXomR� GHVVD� FLWRFLQD� HQWUH� FDVRV� H� FRQWUROHV��

WDOYH]�SHOD�EDL[D�FDVXtVWLFD�

��$� DFXUiFLD� REWLGD� FRP� D� GHWHFomR� Ge IFN- � QmR� SHUPLWH� D�

VXEVWLWXLomR�URWLQHLUD�GR�7&�SRU�HVVH�WHVWH��0DV��D�GRVDJHP�GH�,)1- pode

VHU�~WLO�FRPR�DOWHUQDWLYD��TXDQGR�R�7&�QmR�SXGHU�VHU� IHLWR�RX�FRPR�H[DPH�

complementar.

��2� WHVWH� GH� FRUUHODomR� GH� 6SHDUPDQ� PRVWURX� H[LVWLU� FRUUHODomR�

moderada entre alergia e a resposta do INF- nas culturas, tabela 12 nos

anexos.

Ackerman et al.,30 demonstraram que as culturas de pacientes

DOpUJLFRV� D� FURPR� SURGX]HP� ,/-5 quando estimuladas com esse metal.

7DPEpP�HQFRQWUDPRV�DXPHQWR�GD�,/-5 e determinamos que esse aumento

p�HVSHFtILFR�SRLV�QmR�IRL�YLVWR�QR�JUXSR�FRQWUROH��ILJXUDV��H��7RGDYLD��D�

VHQVLELOLGDGH� H� HVSHFLILFLGDGH� HQFRQWUDGDV� ILFDUDP� DTXpP� GR� GHVHMDGR�

restringindo o uso isolado da IL-�� FRPR�PpWRGR� GLDJQyVWLFR� GH� DOHUJLD� DR�

cromo. Moed et al.,29�FRQVHJXLUDP�tQGLFHV�GH�VHQVLELOLGDGH�H�HVSHFLILFLGDGH�

PHOKRUHV�� H� �� UHVSHFWLYDPHQWH�� e� SRVVtYHO� TXH� R� HVWtPXOR� FRP�

________________________________________________________'LVFXVVmR 81

FLWRFLQDV� WHQKD� LQGX]LGR� XPD� PHOKRUD� QRV� UHVXOWDGRV��PDV� D� FDVXtVWLFD� p�

muito baixa podendo esse efeito se dever ao acaso. Assim como com o IFN-

�� KRXYH� FRUUHODomR� PRGHUDGD� HQWUH� DOHUJLD� H� RV� QtYHLV� GH� ,/-5 no

sobrenadante das culturas, r = 0,49 (P = 0,0019).

O desempenho do teste com a IL-13 nesse trabalho foi

surpreendente. Como visto por Minang et al.31�HVWD�FLWRFLQD�HVWi�DXPHQWDda

QRV�SDFLHQWHV�DOpUJLFRV�DR�FURPR�H�SDUD�HVVHV�DXWRUHV�� WDPEpP� IRL�D�TXH�

DSUHVHQWRX� RV� PHOKRUHV� UHVXOWDGRV�� $SHQDV� GRLV� SDFLHQWHV� QmR�

UHVSRQGHUDP� DR� WHVWH� XVDQGR� R� ,(� VHQGR� TXH� XP� GHOHV� WDPEpP� QmR�

UHVSRQGHX�DR� tQGLFH� . Os dois pacientes tiveram resposta de duas cruzes

no TC. No estudo de Minang et al.,31 os 3 pacientes que apresentaram

HULWHPD� H� HGHPD� VHP� D� IRUPDomR� GH� SiSXODV� QR� 7&� - resultado positivo

IUDFR� SDUD� RV� DXWRUHV� H� GXYLGRVR� VHJXQGR� D� QRVVD� LQWHUSUHWDomR� -� QmR�

responderam ao teste. Acreditamos�TXH�D�VHQVLELOLGDGH�GR�WHVWH�ILFRX�DTXpP�

GD� VXD� SRVVLELOLGDGH� SHOD� LQFOXVmR� GH� FDVRV� GXYLGRVRV� Qesse estudo. A

GHWHFomR�GH�,/-��WDPEpP�SDUHFH�SURPLVVRUD�FRPR�PpWRGR�GLDJQyVWLFR�HP�

RXWURV�DQWtJHQRV174,175

��&RQVLGHUDQGR�TXH�DWp�XPD�HP�GXDV�UHDo}HV�SRVLWLvas no TC para o

ELFURPDWR�GH�SRWiVVLR� WHVWDGR�D��VmR�IDOVR-positivas, podemos afirmar

que a especificidade do resultado encontrado com a IL-��p�VXSHULRU�D�GR�

TC.170� $� UHGXomR� GHVVD� FRQFHQWUDomR� SDUD� �� SRGH� FRUULJLU� HVVH�

problema com o TC, mas leva a uma perda na sensibilidade.12,32,38 Dessa

IRUPD��D�GHWHFomR�GH�,/-13 pode ser considerada adequada para substituir o

________________________________________________________'LVFXVVmR 82

7&�QR�GLDJQyVWLFR�GH�'&$�SRU�FURPR��2� WHVWH�GH�6SHDUPDQ�PRVWURX� IRUWH�

FRUUHODomR�HQWUH�DOHUJLD�H�D�GHWHFomR�GH�,/-13, r = 0,82 e P < 0.0001.

��1mR� KRXYH� GLIHUHQoD� HVWDWtVWLFD� QD� SURGXomR� GH� ,/-2 entre as

culturas basais e estimuladas tanto de casos quanto controles (figuras 16 a

��$SHVDU�GLVVR�IRL�HQFRQWUDGR�GLIHUHQoD�QRV�,(��PDV�QmR�QR� , de casos e

controles (figuras 19 e 20). Isso SRGH�VHU�H[SOLFDGR�SHOR�DXPHQWR�GD�PpGLD�H�

GD�PHGLDQD�YLVWR� QDV�FXOWXUDV� HVWLPXODGDV��HP� UHODomR�jV�FXOWXUDV�EDVDLV��

GRV�FDVRV�DOLDGR�D�GLPLQXLomR�GD�PpGLD�H�PHGLDQD�GDV�FXOWXUDV�HVWLPXODGDV�

GRV�FRQWUROHV�HP�UHODomR�DV�EDVDLV� �WDEHOD��QR�DQH[R��(VVDV�PXGDQoDV�

QD�SURGXomR�GH�,/-��QmR�IRUDP�GHWHFWDGDV�QD�FRPSDUDomR�HQWUH�DV�FXOWXUDV�

basais com as culturas estimuladas dos dois grupos. No entanto, o discreto

aumento nas culturas estimuladas de casos levou a um aumento equivalente

nos IE desse grupo e a discrHWD� GLPLQXLomR�YLVWD� QDV�FXOWXUDV� HVWLPXODGDV�

GRV� FRQWUROHV� GLPLQXLX� RV� ,(� GRV� FRQWUROHV�JHUDQGR� D� GLIHUHQoD� HVWDWtVWLFD�

encontrada entre os IE dos grupos.

Ackerman et al.30� HQFRQWUDUDP� DXPHQWR� QD� SURGXomR� GH� ,/-2 nas

culturas dos casos quando estimuladRV�FRP�ELFURPDWR�GH�SRWiVVLR��0LQDQJ�

et al.31� WDPEpP� HQFRQWUDUDP� DXPHQWR� GD� ,/-�� FRP�(/,6SRW�PDV� QmR� FRP�

(/,6$��-i�/LQGHPDQQ�et al.,32�XWLOL]DQGR�(/,6SRW��QmR�REVHUYDUDP�DXPHQWR�

QD� SURGXomR�GH� ,/-��$SHVDU� GH� QmR� GHWHFWDGR�QHVVH� HVWXGR� p� SRVVtYHO� H�

OyJLFR�TXH�RFRUUD�XP�DXPHQWR�QD�SURGXomR�GH�,/-2, mas esse aumento, se

H[LVWLU�� p� LQVXILFLHQWH� SDUD� VHSDUD� FDVRV� GH� FRQWUROHV�� SHOR� PHQRV� QDV�

culturas de 6 dias.

________________________________________________________'LVFXVVmR 83

��$�DFXUiFLD�GR�WHVWH�FRP�R�,(�QmR�HQFRUDMD�R�VHX�XVR�QR�OXJDU�GR�7&�

SDUD�R�GLDJQyVWLFR�GH�DOHUJLD�Do cromo, especialmente devido a sua baixa

sensibilidade (61%). No estudo de Minang et al.31�D�VHQVLELOLGDGH�WDPEpP�IRL�

um problema, apenas 2 dos 9 pacientes - seis se excluirmos os 3 pacientes

com apenas eritema e edema no TC - responderam com aumento da IL-2.

Como QmR�KRXYH�GLIHUHQoD�HQWUH�RV� de casos e controles a sensibilidade e

D� HVSHFLILFLGDGH� SDUD� HVVH� tQGLFH� QmR� IRUDP� FDOFXODGas. Foi encontrado

FRUUHODomR� PRGHUDGD� HQWUH� DOHUJLD� H� RV� QtYHLV� GH� ,/-2 produzidos nas

culturas, r = 0,34 e P = 0,0410.

2V�FDVRV�H�FRQWUROHV�DSUHVHQWDUDP�GLIHUHQoD�QD�SURGXomR�EDVDO�GH�

IL-�� R� TXH� LPSHGH� TXDOTXHU� FRPSDUDomR� HQWUH� RV� JUXSRV� �ILJXUD� �� 2�

PRWLYR� GHVVD� GLIHUHQoD� QmR� HVWi� FODUR�� 1R� HVWXGR� GH� $FNHUPDQ� et al.30 o

FURPR� LQGX]LX� D� SURGXomR� GH� ,/-4 nos pacientes alpUJLFRV�� R� TXH� QmR� IRL�

encontrado nesse estudo. Percebemos aumento da IL-4 no grupo controle,

PDV�QmR�QRV�FDVRV��ILJXUDV��H��/LQGHPDQQ�et al.32 e Minang et al.31

QmR�HQFRQWUDUDP�GLIHUHQoD�QD�SURGXomR�GH�,/-��HQWUH�SDFLHQWHV�DOpUJLFRV�H�

QmR�DOpUJLFRV�

��6HJXQGR� QRVVRV� DFKDGRV�� SRGHUtDPRV� LPDJLQDU� TXH� D� ,/-4

DSUHVHQWD�XP�HIHLWR�VXSUHVVRU�QD�'&$�SHOR�FURPR��HIHLWR�HVVH�TXH�QmR�HVWi�

SUHVHQWH�QRV�LQGLYtGXRV�DOpUJLFRV�RX�TXH�HOD�VHMD�SURGX]LGD�FRPR�UHVSRVWD�D�

RXWUR� IDWRU� JHUDGR� SHOD� SUHVHQoD� GR� FURPR� QD� FXltura. Os outros estudos

DSUHVHQWDUDP� UHVXOWDGRV� GLIHUHQWHV�� PDV� R� SHUtRGR� GH� FXOWXUD� GHVVHV�

WUDEDOKRV� IRUDP� PDLV� FXUWRV�� YDULDQGR� GH� �� D� �� KRUDV�� D� H[FHomR� GR�

estudo de Ackerman et al.,30 QR�TXDO� WDO� LQIRUPDomR�QmR�HVWD�GLVSRQtYHO��$�

________________________________________________________'LVFXVVmR 84

GLQkPLFD� GDV� FLWRFLQDV� QHVVDV� FXOWXUDV� GLILFXOWD� D� FRPSDUDomR� HQWUH� RV�

resultados.175

��2�HVWtPXOR�FRP�FURPR�GHWHUPLQRX�XPD�UHGXomR�QD�SURGXomR�GH�,/-

�� QRV� GRLV� JUXSRV� �ILJXUD� ��H�� $� UHGXomR�GH� ,/-10 ocorreu nos dois

JUXSRV� ID]HQGR� FRP� TXH� QmR� H[LVWD� GLIHUHQoD� QRV� FULWpULRV� GLDJQyVWLFRV�

entre eles (figuras 34 e 35). Lindemann et al.32� QmR�HQFRQWUDUDP�GLIHUHQoD�

QD�SURGXomR�GH�,/-��HQWUH�SDFLHQWHV�DOpUJLFRV�H�QmR�DOpUJLFRV��Mi�$FNHUPDQ�

et al.,30� HQFRQWUDUDP� DXPHQWR�� 3RVVLYHOPHQWH� HVVDV� GLIHUHQoDV� VH� GHYHP�

DRV�SHUtRGRV�GH�FXOWXUD�HPSUHJDGRV�RX�D�GLIHUHQoD�QDV�FRQFHQWUDo}HV�H�QD�

IRUPD�GR�FURPR�XWLOL]DGD��1HVVH�HVWXGR�D�FRQFHQWUDomR�GH�FURPR�XVDGD�IRL�

superior aos dos demais estudos o que pode ter gerado dano celular e esse

VLQDO�GH�SHULJR�VXSULPLGR�D�DomR�GDV�FpOXODV�UHJXOadoras, diminuindo assim

D�OLEHUDomR�GH�,/-10.

��1mR� KRXYH� GLIHUHQoD� HVWDWtVWLFD� QD� SURGXomR� GH� ,/-12 entre as

culturas basais e estimuladas tanto de casos quanto controles (figuras 36 a

38). Lindemann et al.32� WDPEpP�QmR�HQFRQWUDUDP�GLIHUHQoD�QD�SURGXomR de

IL-��HQWUH�SDFLHQWHV�DOpUJLFRV�H�QmR�DOpUJLFRV��7RGDYLD��$FNHUPDQ�et al.,30

GHWHFWDUDP�DXPHQWR�QD�SURGXomR�GH�,/-12 em suas culturas.

$SHVDU�GH�QmR�WHUPRV�REVHUYDGR�DXPHQWR�QD�SURGXomR�GH�,/-12 nos

FDVRV� IRL� HQFRQWUDGR� GLIHUHQoD� QRV� tQGLFHV� GH� HVWLPXODomR� H� QR� GHOWD� GH�

casos e controles (figuras 39 e 40). De forma semelhante ao discutido com a

IL-�� LVVR� VH� GHYH� DR� DXPHQWR� GD� PpGLD� H� GD� PHGLDQD� HQFRQWUDGDV� QDV�

FXOWXUDV� HVWLPXODGDV�� HP� UHODomR� jV� FXOWXUDV� EDVDLV�� GRV� FDVRV� DOLDGR� D�

GLPLQXLomR�GD�PpGLD�H mediana das culturas estimuladas dos controles em

________________________________________________________'LVFXVVmR 85

UHODomR� DV� EDVDLV� �WDEHOD� ��QR�DQH[R��$V�RVFLODo}HV�RSRVWDV� GRV� tQGLFHV�

GLDJQyVWLFRV�WRUQDUDP�HVVHV�YDORUHV�HVWDWLVWLFDPHQWH�GLIHUHQWHV��$�DFXUiFLD�

do teste encontrada tanto com o IE quanto com o �QmR�Ioi adequada para

que ele substitua o TC, mas pode ser usado como alternativa.

��1mR�KRXYH�GLIHUHQoD�QD�SURGXomR�GH�,/-17 entre as culturas basais

e estimuladas de casos e controles (figuras 46 a 48) nem nos valores

REWLGRV�FRP�RV�FULWpULRV�GLDJQyVWLFRV��ILJXUDV��H��,VVR�QmR�GHVFDUWD�XP�

SRVVtYHO� SDSHO� GHVVDV� FLWRFLQDV� QR� GLDJQyVWLFR� GD� '&$� SRU� FURPR�� R� TXH�

GHYH�VHU�PHOKRU�LQYHVWLJDGR�HP�RXWURV�SHUtRGRV�GH�FXOWXUD�

��7DQWR�RV� OLQIyFLWRV�GH�FDVRV�TXDQWR�FRQWUROHV� IRUDP�HVWLPXODGRV�D�

produzir RANTES quando cultivados com cromo (figuras 52 e 53). A

UHVSRVWD� IRL� GH� PDJQLWXGH� VHPHOKDQWH�� LQH[LVWLQGR� GLIHUHQoD� QRV� tQGLFHV�

GLDJQyVWLFRV�GRV�JUXSRV�

��1mR�KRXYH�FRUUHODomR�HQWUH�RV�,(�HQFRQWUDGRV�FRP�R�73/�H�FRP�DV�

FLWRFLQDV��SHODV�LPSHUIHLo}HV�VRPDGDV�GH�FDGD�teste.

&21&/86®(6


________________________________________________________ConcluV}HV 86

7 &21&/86®(6

A IL-13 apresenta adequada sensibilidade e especificidade para o

GLDJQyVWLFR� GH� '&$� SHOR� FURPR�� &DVR� RXWURV� HVWXGRV� FRPSURYHP� HVVHV�

DFKDGRV�HVVH�PpWRGR�SRGHUi�VXEVWLWXLU�R�7&�SDUD�HVVH�GLDJQyVWLFR�

��$�GHWHFomR�GH�,)1- , IL-5 e IL-12 tanto pelo IE quanto pelo e de

IL-��SHOR� ,(�QR�VREUHQDGDQWH� GH�FXOWXUDV� GH� SDFLHQWHV� DOpUJLFRV� DR�FURPR�

VmR�DOWHUQDWLYDV�DR�7&��3RGHP�VHU�XVDGRV�TXDQGR�R�7&�HVWi�FRQWUD-indicado

RX�SDUD�FRPSOHPHQWDU�D�LQYHVWLJDomR�HP�FDVRV�HVSHFtILFRV��PDV�D�DFXUiFLD�

desses�H[DPHV�QmR�p�VXSHULRU�D�GR�73/�FRQYHQFLRQDO�

As citocinas IL-4, IL10, IL-17 e RANTES�QmR�VmR�DGHTXDGDV�SDUD�

GLVWLQJXLU�FDVRV�GH�FRQWUROHV�QDV�FRQGLo}HV�HP�TXH�IRUDP�WHVWDGDV�

��2�SDSHO�GHVVDV�FLWRFLQDV�H�GH�RXWUDV��QmR�DYDOLDGDV�QHVVH�HVWXGR��

no diagnyVWLFR� GH� '&$� SDUD� R� FURPR� GHYH� VHU� PHOKRU� LQYHVWLJDGR� FRP�

RXWURV�SHUtRGRV�GH�FXOWXUD�H�FRP�H�VHP�HVWtPXOR�DGLFLRQDO��SDUD�RWLPL]DU�D�

capacidade desse teste.


ANEXOS


___________________________________________________________Anexos 87

8 ANEXOS

Quadro 2 ±�*UXSR�GH�VXEVWkQFLDV�WHVWDGDV�QD�EDWHULD�SDGUmR� brasileira de dermatite de contato.1 Antraquinona 16 Neomicina2 %iOVDPR-do-peru 17 Nitrofurazona 3 %HQ]RFDtQD 18 Parabeno-mix4 %LFURPDWR�GH�SRWiVVLR 19 Parafenilenodiamina5 Butilfenol-SDUDWHUFLiULR 20 Perfume-mix6 Carba-mix 21 PPD-mix 7 Cloreto de cobalto 22 Prometazina 8 &RORI{QLR 23 Propilenoglicol9 Etilenodiamina 24 Quartenium 15

10 )RUPDOGHtGR 25 Quinolina-mix11 Hidroquinona 26 Resina-HSy[L 12 Irgasan 27 6XOIDWR�GH�QtTXHO 13 Kathon CG 28 Terebintina 14 Lanolina 29 Timerosal15 Mercapto-mix 30 Tiuram-mixFONTE: Grupo brasileiro de estudo em dermatite de contato (GBEDC). (VWXGR�PXOWLFrQWULFR�SDUD�D�HODERUDomR�GH�XPD�EDWHULD-SDGUmR�EUDVLOHLUD�GH�teste de contato. An Bras Dermatol. 2000; 75:147-56.9

Quadro 3 ±�*UXSR�GH�VXEVWkQFLDV�WHVWDGDV�QD�EDWHULD�GH�FRVPpWLFRV�

1 *HUPDOO��,PLGD]ROLGLQLOXUpLD�

2 BHT (Butil hidroxi-tolueno)

3 5HVLQD�WRQVLODPLGD�IRUPDOGHtGR

4 Trietanolamina

5 Bronopol (Bromo-2-nitropropano-1,3-diol 2)

6 Cloracetamida

7 ÈFLGR�6yUELFR

8 7LRJOLFRODWR�GH�DP{QLR

9 Amerchol L-101

10 Clorhexidine

FONTE: %DWHULD� SDGUmR� GD IPI-ASAC Brasil , Rio de Janeiro, Brasil. Em: http://www.ipibrasil.com.br/v2/pages/parcerias_endoderme_contatoCosmeticos.asp?catProdAtual=1.


http://www.ipibrasil.com.br/v2/pages/parcerias_endoderme_contatoCosmetic

___________________________________________________________Anexos 88

Quadro 4 - Resultados dos testes de contato Casos Teste de contato Controles Teste de contato 1 4 (++), 6, 27 e 30 1 Negativo 2 4 (++) e 6 2 Negativo 3 4 (++), 6 e 30 3 Negativo 4 4 (++), 6 e 7 4 Negativo 5 4 (++) e 6 5 8, 20 e 306 4 (++) e 25 6 27 e 10c7 4 (++), 6 e 30 7 20, 27 e 8c8 4 (++) e 27 8 27 e esmalte 9 4 (++) 9 9 e 1610 4 (+++), 7, 17 e 30 10 8 e 1011 4 (+) e 6 11 Negativo 12 4 (+++) e 27 12 2713 4 (++) 13 17 e 2914 4 (+++), 7, 27 e 30 14 3 15 4 (++) 15 1616 4 (+++), 10 e 27 16 7, 22 e 2717 4 (++) e 6 17 Negativo 18 4 (++) e 21 18 Negativo 19 7 FONTE: Dermatologia do HC-FMUSP NOTA:� 2V� Q~PHURV� DSUHVHQWDGRV� QDV� FROXQDV� GRV� WHVWHV� GH� FRQWDWR�correspondem aos utilizados pelas baterias de teste de contato SDGUmR�H�GH�FRVPpWLFRV� H� HVWmR� GLVSRQtYHLV� QR� DQH[R�� TXDGURs 2 e 3. Quando os Q~PHURV� IRUHP� VHJXLGRV� GD� OHWUD� ³F´� LQGLFD� TXH� SHUWHQFHP� D� EDWHULD� GH�FRVPpWLFRV�$�LQWHQVLGDGH�GD�UHDomR�DR�ELFURPDWR�GH�SRWiVVLR�QDV��KRUDV�IRL�GHVFUita como(+) ± positivo fraco; (++) ± positivo forte; (+++) ± positivo muito forte (+++).

5()(5Ç1&,$6�%,%/,2*5È),&$6


____________________________________________5HIHUrQFLDV�ELEOLRJUiILFDV100

9 5()(5Ç1&,$6�%,%/,2*5È),&$6

1. Sampaio SAP, Rivitti, EA. Dermatologia��D�HG��6mR�3DXOR��$UWHV�0pGLFDV�

��&DStWXOR��S��-��(UXSo}HV�HF]HPDWRVDV�

2. Fischer T, Maibach HI. Easier patch testing with TRUE Test. J Am Acad

Dermatol. 1989; 20:447-53.

3. Duarte I, Buense R, Kobata C, Lazzarini R. Dermatite de contato�� 6mR�

Paulo: Sgmento farma; 2005.

4. Carvalho LP. $OHUJLD� &OtQLFD. Rio de Janeiro: Guanabara Koogan S.A.;

1982.

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costs, severity, and work-related factors of occupational dermatitis: a

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RevinteR Ltda; 1995.

8. Negreiros B. $OHUJRORJLD�&OtQLFD��6mR�3DXOR��$WKHQHX��

9. Anderson RT, Rajagopalan R. Effects of allergic dermatosis on health-

related quality of life. Curr Allergy Asthma Rep. 2001 Jul;1(4):309-15.

10. Thomson KF, Wilknson SM, Sommer S, Pollock B. Eczema: quality of life

by body site and the effect of patch testing. Br J Dermatol. 2002 Apr;

146(4):627-30.

��5LHWVFKHO�5/�� )RZOHU� -)�� )LVFKHU�V�FRQWDFW�GHUPDWLWLV��a ed. Lippincott

Williams & Wilkins; 2001.

�� )URVFK� 3-�� 0HQQp� 7�� /HSRLWWHYLQ� -3�� Contact dermatitis. 4th ed.

Springer:Berlim; 2006.

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