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Jochum C. Histamine Intolerance: Symptoms, Diagnosis, and Beyond. Nutrients 2024; 16:1219. [PMID: 38674909 PMCID: PMC11054089 DOI: 10.3390/nu16081219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Histamine intolerance is a condition characterized by the accumulation of histamine to a point that exceeds the body's capacity to eliminate it. Researchers have attributed several reasons to this condition, such as genetic factors, alcohol, and dietary deficiencies, among other elements. Symptoms of histamine intolerance have been found to extend beyond the gastrointestinal tract and to the whole body, with these symptoms being sporadic and non-specific. This review will explore various aspects related to histamine intolerance, such as its causes, symptoms, diagnosis, and information related to management.
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Affiliation(s)
- Christoph Jochum
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow Klinikum, 10117 Berlin, Germany
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Duelo A, Comas-Basté O, Sánchez-Pérez S, Veciana-Nogués MT, Ruiz-Casares E, Vidal-Carou MC, Latorre-Moratalla ML. Pilot Study on the Prevalence of Diamine Oxidase Gene Variants in Patients with Symptoms of Histamine Intolerance. Nutrients 2024; 16:1142. [PMID: 38674832 PMCID: PMC11054051 DOI: 10.3390/nu16081142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/06/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
A retrospective pilot study was carried out to investigate the prevalence of four variants of the diamine oxidase (DAO) encoding gene (AOC1) in Caucasian adults with symptoms of histamine intolerance. In a cohort of 100 patients and 100 healthy individuals, DAO-encoding gene non-synonymous Single Nucleotide Variations (SNVs) were genotyped by multiplex single-nucleotide primer extension (SNPE) and capillary electrophoresis, and serum DAO activity was analyzed with a radio-extraction assay. The study found that 79% of individuals with symptoms of histamine intolerance harbored one or more of the four SNVs associated with reduced DAO activity. No significant differences were found in the prevalence of any variant between the group of patients and healthy controls. However, when considering the status of the alleles associated with DAO deficiency, more homozygous alleles were observed in histamine-intolerant patients. Moreover, a slightly but statistically higher percentage of patients had a high genetic risk score, reflecting the cumulative effect of carrying multiple DAO deficiency-associated gene variants and a high load of risk alleles (homozygous). A relationship between serum DAO activity and the genetic load of one specific SNV was observed, with DAO activity being significantly lower in patients homozygous for rs2052129. These results potentially support that carrying multiple DAO deficiency-associated gene variants and a high load of risk alleles (homozygous) is more relevant than the mere presence of one or more SNVs. Further studies are needed to determine the predictive value of these DAO-encoding gene variants.
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Affiliation(s)
- Adriana Duelo
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Campus de l’Alimentació de Torribera, Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (A.D.); (S.S.-P.); (M.T.V.-N.); (M.C.V.-C.); (M.L.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
- International Institute of DAO Deficiency, C/Escoles Pies 49, 08017 Barcelona, Spain
| | - Oriol Comas-Basté
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Campus de l’Alimentació de Torribera, Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (A.D.); (S.S.-P.); (M.T.V.-N.); (M.C.V.-C.); (M.L.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
| | - Sònia Sánchez-Pérez
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Campus de l’Alimentació de Torribera, Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (A.D.); (S.S.-P.); (M.T.V.-N.); (M.C.V.-C.); (M.L.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
| | - M. Teresa Veciana-Nogués
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Campus de l’Alimentació de Torribera, Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (A.D.); (S.S.-P.); (M.T.V.-N.); (M.C.V.-C.); (M.L.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
| | - Eva Ruiz-Casares
- Vivolabs, C/Marqués de la Valdavia 106, 28100 Alcobendas, Spain;
| | - M. Carmen Vidal-Carou
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Campus de l’Alimentació de Torribera, Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (A.D.); (S.S.-P.); (M.T.V.-N.); (M.C.V.-C.); (M.L.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
| | - M. Luz Latorre-Moratalla
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Campus de l’Alimentació de Torribera, Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (A.D.); (S.S.-P.); (M.T.V.-N.); (M.C.V.-C.); (M.L.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona (UB), Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
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Tobajas Y, Alemany-Fornés M, Samarra I, Romero-Giménez J, Cuñé-Castellana J, Tintoré M, del Pino A, Canela N, del Bas JM, Ortega-Olivé N, de Lecea C, Escoté X. Exploring the Relationship between Diamine Oxidase and Psychotropic Medications in Fibromyalgia Treatment, Finding No Reduction in Diamine Oxidase Levels and Activity except with Citalopram. J Clin Med 2024; 13:792. [PMID: 38337486 PMCID: PMC10856182 DOI: 10.3390/jcm13030792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/17/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Histamine intolerance manifests when there is an imbalance between the production of histamine and the body's capacity to metabolise it. Within the gastrointestinal tract, diamine oxidase (DAO) plays a pivotal role in breaking down ingested histamine. Insufficient levels of DAO have been linked to various diseases affecting the respiratory, cardiovascular, nervous, muscular, and digestive systems; some of these symptoms are evidenced in fibromyalgia syndrome. This underscores the crucial role of DAO in maintaining the histamine balance and highlights its association with diverse physiological systems and health conditions. The management of fibromyalgia commonly involves the use of psychotropic medications; however, their potential interactions with DAO remain not fully elucidated. Methods: This study delved into the influence of various psychotropic medications on DAO activity through in vitro experiments. Additionally, we explored their impact on the human intestinal cell line Caco-2, examining alterations in DAO expression at both the mRNA and protein levels along with DAO activity. Results: Notably, the examined drugs-sertraline, pregabalin, paroxetine, alprazolam, and lorazepam-did not exhibit inhibitory effects on DAO activity or lead to reductions in DAO levels. In contrast, citalopram demonstrated a decrease in DAO activity in in vitro assays without influencing DAO levels and activity in human enterocytes. Conclusions: These findings imply that a collaborative approach involving psychotropic medications and DAO enzyme supplementation for individuals with fibromyalgia and a DAO deficiency could offer potential benefits for healthcare professionals in their routine clinical practice.
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Affiliation(s)
- Yaiza Tobajas
- Eurecat, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain; (Y.T.); (J.R.-G.); (N.O.-O.)
| | - Marc Alemany-Fornés
- DR Healthcare-AB Biotek HNH, 43204 Reus, Spain; (M.A.-F.); (J.C.-C.); (M.T.); (C.d.L.)
| | - Iris Samarra
- Centre for Omic Sciences (COS), Joint Unit URV-Eurecat, Unique Scientific and Technical Infrastructures (ICTS), Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain; (I.S.); (A.d.P.); (N.C.)
| | - Jordi Romero-Giménez
- Eurecat, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain; (Y.T.); (J.R.-G.); (N.O.-O.)
| | - Jordi Cuñé-Castellana
- DR Healthcare-AB Biotek HNH, 43204 Reus, Spain; (M.A.-F.); (J.C.-C.); (M.T.); (C.d.L.)
| | - Maria Tintoré
- DR Healthcare-AB Biotek HNH, 43204 Reus, Spain; (M.A.-F.); (J.C.-C.); (M.T.); (C.d.L.)
| | - Antoni del Pino
- Centre for Omic Sciences (COS), Joint Unit URV-Eurecat, Unique Scientific and Technical Infrastructures (ICTS), Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain; (I.S.); (A.d.P.); (N.C.)
| | - Núria Canela
- Centre for Omic Sciences (COS), Joint Unit URV-Eurecat, Unique Scientific and Technical Infrastructures (ICTS), Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain; (I.S.); (A.d.P.); (N.C.)
| | - Josep M. del Bas
- Eurecat, Centre Tecnològic de Catalunya, Biotechnology Area, 43204 Reus, Spain;
| | - Nàdia Ortega-Olivé
- Eurecat, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain; (Y.T.); (J.R.-G.); (N.O.-O.)
| | - Carlos de Lecea
- DR Healthcare-AB Biotek HNH, 43204 Reus, Spain; (M.A.-F.); (J.C.-C.); (M.T.); (C.d.L.)
| | - Xavier Escoté
- Eurecat, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain; (Y.T.); (J.R.-G.); (N.O.-O.)
- Department of Biochemistry and Biotechnology, Universitat Rovira i Virgili, Campus Sescelades, 43007 Tarragona, Spain
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Tobajas Y, Alemany-Fornés M, Samarra I, Romero-Giménez J, Tintoré M, del Pino A, Canela N, del Bas JM, Ortega-Olivé N, de Lecea C, Escoté X. Diamine Oxidase Interactions with Anti-Inflammatory and Anti-Migraine Medicines in the Treatment of Migraine. J Clin Med 2023; 12:7502. [PMID: 38068554 PMCID: PMC10707353 DOI: 10.3390/jcm12237502] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/09/2023] [Accepted: 12/01/2023] [Indexed: 07/03/2024] Open
Abstract
Histamine intolerance arises when there is a disparity between the production of histamine and the body's ability to break it down. In the gastrointestinal tract, the primary enzyme responsible for metabolizing ingested histamine is diamine oxidase (DAO), and a shortage of this enzyme has been associated with some diseases related to the respiratory, cardiovascular, nervous, muscular, and digestive systems, in addition to migraines. The treatment of migraines typically revolves around the utilization of both anti-migraine and anti-inflammatory drugs, but their interaction with DAO is not thoroughly understood. In this study, we examined the impact of nonsteroidal anti-inflammatory drugs (NSAIDs) and anti-migraine medications on DAO activity through in vitro experiments. We also investigated their effects on the human intestinal cell line Caco-2, assessing changes in DAO expression (both at the mRNA and protein levels) as well as DAO activity. The tested drugs, including ibuprofen, acetylsalicylic acid, paracetamol, a combination of acetylsalicylic acid with paracetamol and caffeine, zolmitriptan, and sumatriptan, did not inhibit DAO activity or reduce their levels. However, naproxen reduced DAO protein levels in human enterocyte cultures while not affecting DAO activity. These results suggest that combining anti-inflammatory and anti-migraine drugs with DAO enzyme supplementation for migraine patients with DAO deficiency could be beneficial for healthcare professionals in their daily practice.
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Affiliation(s)
- Yaiza Tobajas
- EURECAT, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain; (Y.T.); (J.R.-G.); (N.O.-O.)
| | - Marc Alemany-Fornés
- DR Healthcare-AB Biotek HNH, 08017 Barcelona, Spain; (M.A.-F.); (M.T.); (C.d.L.)
| | - Iris Samarra
- Centre for Omic Sciences (COS), Joint Unit URV-EURECAT, Unique Scientific and Technical Infrastructures (ICTS), Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain; (I.S.); (A.d.P.); (N.C.)
| | - Jordi Romero-Giménez
- EURECAT, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain; (Y.T.); (J.R.-G.); (N.O.-O.)
| | - Maria Tintoré
- DR Healthcare-AB Biotek HNH, 08017 Barcelona, Spain; (M.A.-F.); (M.T.); (C.d.L.)
| | - Antoni del Pino
- Centre for Omic Sciences (COS), Joint Unit URV-EURECAT, Unique Scientific and Technical Infrastructures (ICTS), Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain; (I.S.); (A.d.P.); (N.C.)
| | - Núria Canela
- Centre for Omic Sciences (COS), Joint Unit URV-EURECAT, Unique Scientific and Technical Infrastructures (ICTS), Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain; (I.S.); (A.d.P.); (N.C.)
| | - Josep M. del Bas
- EURECAT, Centre Tecnològic de Catalunya, Biotechnology Area, 43204 Reus, Spain;
| | - Nàdia Ortega-Olivé
- EURECAT, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain; (Y.T.); (J.R.-G.); (N.O.-O.)
| | - Carlos de Lecea
- DR Healthcare-AB Biotek HNH, 08017 Barcelona, Spain; (M.A.-F.); (M.T.); (C.d.L.)
| | - Xavier Escoté
- EURECAT, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain; (Y.T.); (J.R.-G.); (N.O.-O.)
- Department of Biochemistry and Biotechnology, Universitat Rovira i Virgili, Campus Sescelades, 43007 Tarragona, Spain
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Bent RK, Kugler C, Faihs V, Darsow U, Biedermann T, Brockow K. Placebo-Controlled Histamine Challenge Disproves Suspicion of Histamine Intolerance. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3724-3731.e11. [PMID: 37648152 DOI: 10.1016/j.jaip.2023.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 08/03/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Histamine intolerance (HIT) is frequently diagnosed in patients with polysymptomatic otherwise unexplained symptoms. OBJECTIVES To exclude HIT by a single-blind placebo-controlled histamine challenge (SBPCHC), to study clinical features of patients with positive challenge, and to examine the predictability of HIT by biomarkers. METHODS SBPCHC was performed in 59 patients with suspected HIT. History and clinical data, including serum diamine oxidase (DAO) and histamine skin test wheal size of patients with positive versus negative SBPCHC, were compared. RESULTS Patients were predominantly middle-aged women (84.7%). Three-quarters reported improvement but never resolution of symptoms during a histamine-low diet. Histamine provocation was safe; only 1 patient was treated with antihistamines. Thirty-seven patients (62.7%) displayed symptoms to placebo. HIT was excluded in 50 patients (84.7%). Objective symptoms occurred in 4 of 59 cases (6.8%) after histamine but not after placebo challenge. These were diagnosed with "plausible HIT" because reactions occurring by chance could not be excluded. Another 5 patients (8.5%) were diagnosed with "possible HIT" after case-dependent detailed analysis. Patients with plausible/possible HIT had reported more gastrointestinal symptoms (P = .01), but comparable diet response and equal histamine skin prick test wheal sizes to those without HIT. Serum DAO activity tended to be lower in patients with HIT (P = .08), but was highly variable in those without, limiting its value as a biomarker. CONCLUSIONS SBPCHC disproves HIT in the majority of patients. Placebo-controlled challenges are needed as placebo reactions were frequent. Gastrointestinal symptoms after food intake and reduced DAO levels are markers for HIT; however, specificity is not sufficient enough for making the diagnosis.
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Affiliation(s)
- Rebekka Karolin Bent
- Department of Dermatology and Allergy Biederstein, Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Claudia Kugler
- Department of Dermatology and Allergy Biederstein, Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Valentina Faihs
- Department of Dermatology and Allergy Biederstein, Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Ulf Darsow
- Department of Dermatology and Allergy Biederstein, Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergy Biederstein, Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Faculty of Medicine, Technical University of Munich, Munich, Germany.
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Zingone F, Bertin L, Maniero D, Palo M, Lorenzon G, Barberio B, Ciacci C, Savarino EV. Myths and Facts about Food Intolerance: A Narrative Review. Nutrients 2023; 15:4969. [PMID: 38068827 PMCID: PMC10708184 DOI: 10.3390/nu15234969] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
Most adverse reactions to food are patient self-reported and not based on validated tests but nevertheless lead to dietary restrictions, with patients believing that these restrictions will improve their symptoms and quality of life. We aimed to clarify the myths and reality of common food intolerances, giving clinicians a guide on diagnosing and treating these cases. We performed a narrative review of the latest evidence on the widespread food intolerances reported by our patients, giving indications on the clinical presentations, possible tests, and dietary suggestions, and underlining the myths and reality. While lactose intolerance and hereditary fructose intolerance are based on well-defined mechanisms and have validated diagnostic tests, non-coeliac gluten sensitivity and fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) intolerance are mainly based on patients' reports. Others, like non-hereditary fructose, sorbitol, and histamine intolerance, still need more evidence and often cause unnecessary dietary restrictions. Finally, the main outcome of the present review is that the medical community should work to reduce the spread of unvalidated tests, the leading cause of the problematic management of our patients.
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Affiliation(s)
- Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy; (L.B.); (D.M.); (M.P.); (G.L.); (E.V.S.)
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padua, Italy;
| | - Luisa Bertin
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy; (L.B.); (D.M.); (M.P.); (G.L.); (E.V.S.)
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padua, Italy;
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy; (L.B.); (D.M.); (M.P.); (G.L.); (E.V.S.)
| | - Michela Palo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy; (L.B.); (D.M.); (M.P.); (G.L.); (E.V.S.)
| | - Greta Lorenzon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy; (L.B.); (D.M.); (M.P.); (G.L.); (E.V.S.)
| | - Brigida Barberio
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padua, Italy;
| | - Carolina Ciacci
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Salerno, Italy;
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35124 Padua, Italy; (L.B.); (D.M.); (M.P.); (G.L.); (E.V.S.)
- Gastroenterology Unit, Azienda Ospedale—Università Padova, 35128 Padua, Italy;
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Okutan G, Sánchez Niño GM, Terrén Lora A, López Oliva S, San Mauro Martín I. Exogenous Supplementation with DAO Enzyme in Women with Fibromyalgia: A Double-Blind Placebo-Controlled Clinical Trial. J Clin Med 2023; 12:6449. [PMID: 37892588 PMCID: PMC10607251 DOI: 10.3390/jcm12206449] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Fibromyalgia (FM) is characterized by chronic musculoskeletal pain, muscle tension, joint mobility loss, and several psychological symptoms severely affecting patient well-being. Histamine is naturally degraded in the small intestine by diamine oxidase (DAO). Hereditary or acquired DAO deficiency causes extracellular histamine accumulation, leading to symptoms similar to those of individuals diagnosed with FM. Thus, this study aimed to assess the efficacy of adding DAO supplementation for 8 weeks to their standard therapy. We randomly assigned 100 women with FM (age: 33-61 years) to the supplementation and control groups. The Fibromyalgia Impact Questionnaire (FIQ), the Pain Catastrophizing Scale (PCS), and intensity scales were applied for a series of clinical symptoms together with the Bristol scale to assess the added value of DAO supplementation. Patients in both groups were receiving complete pharmacological support but some differences in the number of subjects receiving analgesics, antidepressants, and anxiolytics was noted. Patients in both study groups experienced favorable changes during the evaluation period as indicated by their final FIQ and PCS scores, particularly in the DAO group in the latter questionnaire. Qualitatively, the patients assigned to the DAO treatment group had lower scores for fatigue, anxiety, depression, burning and for rumination, magnification, and helplessness.
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Affiliation(s)
| | | | | | | | - Ismael San Mauro Martín
- Research Centers in Nutrition and Health (CINUSA Group), Paseo de la Habana 43, 28036 Madrid, Spain; (G.O.); (G.M.S.N.); (A.T.L.); (S.L.O.)
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Tobajas Y, Alemany-Fornés M, Samarra I, Romero-Giménez J, Tintoré M, Del Pino A, Canela N, Del Bas JM, Ortega-Olivé N, de Lecea C, Escoté X. Interaction of Diamine Oxidase with Psychostimulant Drugs for ADHD Management. J Clin Med 2023; 12:4666. [PMID: 37510782 PMCID: PMC10380856 DOI: 10.3390/jcm12144666] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Histamine intolerance occurs when there is an imbalance between histamine production and the capacity for histamine degradation. Diamine oxidase (DAO) is the main enzyme for the catabolism of ingested histamine degradation in the gastrointestinal tract and its deficiency has been linked to allergy-like symptoms. Psychostimulant drugs are commonly used to treat Attention Deficit Hyperactivity Disorder (ADHD), but their interaction with DAO is not well characterized. In this work, we evaluated the effects of psychostimulant drugs (methylphenidate and lisdexamfetamine) on in vitro DAO activity and in the human cell line of enterocytes (Caco-2), evaluating DAO expression (mRNA and protein) and DAO activity. Methylphenidate and lisdexamfetamine did not repress the in vitro DAO activity. In addition, in Caco-2 cells, lisdexamfetamine promoted a strong upregulation of DAO mRNA levels, whereas methylphenidate tended to induce DAO activity. To sum up, methylphenidate and lisdexamfetamine treatments do not reduce DAO activity. These findings could be useful for physicians prescribing these two drugs to ADHD patients affected by DAO deficiency.
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Affiliation(s)
- Yaiza Tobajas
- Eurecat, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain
| | | | - Iris Samarra
- Centre for Omic Sciences (COS), Joint Unit URV-EURECAT, Unique Scientific and Technical Infrastructures (ICTS), Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain
| | - Jordi Romero-Giménez
- Eurecat, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain
| | | | - Antoni Del Pino
- Centre for Omic Sciences (COS), Joint Unit URV-EURECAT, Unique Scientific and Technical Infrastructures (ICTS), Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain
| | - Núria Canela
- Centre for Omic Sciences (COS), Joint Unit URV-EURECAT, Unique Scientific and Technical Infrastructures (ICTS), Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain
| | - Josep M Del Bas
- Eurecat, Centre Tecnològic de Catalunya, Biotechnology Area, 43204 Reus, Spain
| | - Nàdia Ortega-Olivé
- Eurecat, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain
| | | | - Xavier Escoté
- Eurecat, Centre Tecnològic de Catalunya, Nutrition and Health, 43204 Reus, Spain
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van Odijk J, Weisheit A, Arvidsson M, Miron N, Nwaru B, Ekerljung L. The Use of DAO as a Marker for Histamine Intolerance: Measurements and Determinants in a Large Random Population-Based Survey. Nutrients 2023; 15:2887. [PMID: 37447214 DOI: 10.3390/nu15132887] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Histamine intolerance (HIT) is a common adverse reaction to food where elimination and reintroduction of histamine-rich food is part of the investigation. Analysis of the enzyme diamine oxidase (DAO) is sometimes used as an additional tool for diagnosis. This study aimed to describe the distribution of DAO in a large representative cohort of adults and to determine the association between DAO activity and possible associated factors. The study is based on the population-based West Sweden Asthma Study and includes 1051 subjects. Subjects underwent structured interviews including questions on demography, asthma, allergy symptoms, and lifestyle factors. Subjects were assessed for specific-IgE-antibodies and measurement of DAO activity in serum. Previously suggested cut-off levels for low values (<3 U/mL), normal values (>10 U/mL), and median levels of DAO were used. In the group of 1051 subjects, only a few presented reactions upon histamine intake, whereas 44% presented DAO levels below the suggested normal cut-off levels. BMI and age were shown to have an impact on DAO activity among women with increasing activity of DAO with increasing BMI and age. Among men, only increasing age was seen to have an impact on DAO levels. There was no difference in DAO levels with different sensitization status to common foods or airborne allergens. No association between DAO levels and reported symptoms to histamine-rich foods could be found. In conclusion, the determination of the DAO enzyme needs to be re-evaluated and may not be used as a valuable tool for histamine intolerance using current cut-off values. Further studies are needed to improve the use of DAO as a biomarker for histamine intolerance.
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Affiliation(s)
- Jenny van Odijk
- Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, 413 46 Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Adina Weisheit
- Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, 413 46 Gothenburg, Sweden
| | - Monica Arvidsson
- Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, 413 46 Gothenburg, Sweden
| | - Nicolae Miron
- Department of Clinical Immunology, Sahlgrenska University Hospital, 413 46 Gothenburg, Sweden
| | - Bright Nwaru
- Krefting Research Centre, Institute of Medicine, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Linda Ekerljung
- Krefting Research Centre, Institute of Medicine, University of Gothenburg, 405 30 Gothenburg, Sweden
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10
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Alcohol-Induced Headache with Neuroinflammation: Recent Progress. FERMENTATION-BASEL 2023. [DOI: 10.3390/fermentation9020184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Ethanol and other congeners in alcoholic beverages and foods are known triggers of alcohol-induced headaches (AIHs). Recent studies implicate AIHs as an important underlying factor for neuroinflammation. Studies show the relationship between alcoholic beverages, AIH agents, neuroinflammation, and the pathway they elicit. However, studies elucidating specific AIH agents’ pathways are scarce. Works reviewing their pathways can give invaluable insights into specific substances’ patterns and how they can be controlled. Hence, we reviewed the current understanding of how AIH agents in alcoholic beverages affect neuroinflammation and their specific roles. Ethanol upregulates transient receptor potential cation channel subfamily V member 1 (TRPV1) and Toll-like receptor 4 (TLR4) expression levels; both receptors trigger a neuroinflammation response that promotes AIH manifestation—the most common cause of AIHs. Other congeners such as histamine, 5-HT, and condensed tannins also upregulate TRPV1 and TLR4, neuroinflammatory conditions, and AIHs. Data elucidating AIH agents, associating pathways, and fermentation parameters can help reduce or eliminate AIH inducers and create healthier beverages.
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11
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Megoura M, Ispas-Szabo P, Mateescu MA. Enhanced Stability of Vegetal Diamine Oxidase with Trehalose and Sucrose as Cryoprotectants: Mechanistic Insights. Molecules 2023; 28:molecules28030992. [PMID: 36770661 PMCID: PMC9921882 DOI: 10.3390/molecules28030992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/21/2023] Open
Abstract
Enteric dysfunctions are common for various histamine-related intestinal disorders. Vegetal diamine oxidase (vDAO), an enzyme able to decompose histamine and thus alleviate histamine-related dysfunctions, was formulated in gastro-resistant tablet forms for oral administration as a food supplement and possible therapeutic agent. A major challenge for the use of proteins in the pharmaceutical field is their poor stability. In this study, vDAO was freeze-dried in the absence or in the presence of sucrose or trehalose as cryoprotectants and then formulated as tablets by direct compression. The stability of the obtained preparations was followed during storage at 4 °C and -20 °C for 18 months. In vitro dissolution tests with the vDAO powders formulated as tablets were performed in simulated gastric and in simulated intestinal fluids. The tablets obtained with the powder of the vDAO lyophilized with sucrose or trehalose cryoprotectants offered better protection for enzyme activity. Furthermore, the release of the vDAO lyophilized with the cryoprotectants was around 80% of the total loaded activity (enzyme units) compared to 20% for the control (vDAO powder prepared without cryoprotectants). This report revealed the potential of sucrose and trehalose as cryoprotectants to protect vDAO from freeze-drying stress and during storage, and also to markedly improve the vDAO release performance of tablets obtained with vDAO powders.
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12
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Vander Does A, Ju T, Yosipovitch G. When Foods Cause Itch: Clinical Characteristics, Pathophysiology, and Recommendations for Food-Induced Skin and Mucosal Pruritus. Dermatitis 2023; 34:13-20. [PMID: 36705658 DOI: 10.1089/derm.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Itch occurs in various dermatologic and systemic conditions. Many patients report that certain foods instigate itch, although there is limited published information in dermatology on food-induced pruritus. In addition, itch severity is rarely mentioned. Food can induce pruritus through either ingestion or direct contact with skin or mucosal membranes. The most common type of itch provoked by food is acute urticaria, often through the classical immunoglobulin E (IgE)-mediated pathway. Other mechanisms include non-IgE-mediated, mixed (IgE-mediated and non-IgE-mediated), T-cell-mediated, and nonimmune reactions. For patients presenting with urticaria, generalized pruritus, oral pruritus, or dermatitis, a thorough history is warranted, and possible food associations should be considered and assessed. Although any food seems to have the potential to elicit an immune response, certain foods are especially immunogenic. Treatment includes avoidance of the trigger and symptom management. Careful consideration should be used as to avoid unnecessarily restrictive elimination diets.
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Affiliation(s)
- Ashley Vander Does
- From the Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, FL
| | - Teresa Ju
- From the Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, FL
| | - Gil Yosipovitch
- From the Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, FL
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13
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Advances in the Clinical Application of Histamine and Diamine Oxidase (DAO) Activity: A Review. Catalysts 2022. [DOI: 10.3390/catal13010048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The serum level of diamine oxidase (DAO) reflects the integrity and maturation of the small intestinal mucosa. This measure is important in diagnosing various diseases, including chronic urticaria tachyphylaxis, multiple organ dysfunction syndrome, preterm abortion, and migraine. This review aimed to summarize the findings of previous studies on the changes in DAO levels in diverse diseases and the application of this enzyme in the clinical setting, as well as the roles of this enzyme under physiological and pathological conditions. The advances in the mechanism and clinical application of DAO presented in this review will contribute to a better understanding of this enzyme and open up new and broader perspectives for future basic research and clinical applications.
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14
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Safety Considerations for Natural Products Commonly Used By Patients with Allergic Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3131-3138. [PMID: 36174919 DOI: 10.1016/j.jaip.2022.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 12/14/2022]
Abstract
Natural products are a category of Complementary and Alternative Medicine that includes medicinal plants, vitamins, and dietary supplements. These products are often utilized by patients with allergies in conjunction with, or as an alternative to, their conventional medical therapies. Despite the wide use of these modalities, many clinicians often have limited knowledge and training in their use. It is important for health care providers to know the safety and risks of these products that their patients may use. This Clinical Commentary reviews the side effects and adverse reactions of several natural products commonly used by patients with allergies and gives an overview of the U.S. Food and Drug Administration requirements for manufacturing, advertising and distribution.
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15
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Sánchez-Pérez S, Celorio-Sardà R, Veciana-Nogués MT, Latorre-Moratalla ML, Comas-Basté O, Vidal-Carou MC. 1-methylhistamine as a potential biomarker of food histamine intolerance. A pilot study. Front Nutr 2022; 9:973682. [PMID: 36313101 PMCID: PMC9597364 DOI: 10.3389/fnut.2022.973682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
Efforts are currently being directed to identify a non-invasive marker that can serve as a solid and clinically irrefutable diagnostic criterion for histamine intolerance associated with diamine oxidase (DAO) deficiency. Accordingly, the identification of biomarkers of histamine (HA) metabolism in urine is proposed as a possible new diagnostic strategy. It is hypothesized that individuals with histamine intolerance could have a different urinary profile of HA and its metabolites in comparison with the healthy population. Thus, the aim of this study was to assess the urinary excretion of HA and 1-methylhistamine (MHA) in individuals diagnosed with histamine intolerance and in a control group. Levels of HA and MHA were compared between 24 h and first morning spot urine in a subgroup of 14 control individuals. Then, HA and MHA concentrations in spot urine of 32 histamine intolerant and 55 control individuals were determined by ultra-high performance liquid chromatography and fluorometric detection (UHPLC-FL) and normalized by creatinine. No differences were found between HA and MHA levels in 24 h and first morning samples. Overall, histamine intolerant patients presented a distinct urinary excretion profile compared to the control group due to lower levels of MHA. No differences in urinary MHA were observed related to serum DAO activity. Spot urine samples were thus validated as a reliable tool to determine the urinary excretion of HA and MHA. These results constitute a starting point for the study of HA metabolomics as a suitable and non-invasive approach to histamine intolerance diagnosis.
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Affiliation(s)
- Sònia Sánchez-Pérez
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA-UB), Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Xarxa d’Innovació Alimentària, Barcelona, Spain
| | - Ricard Celorio-Sardà
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA-UB), Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Xarxa d’Innovació Alimentària, Barcelona, Spain
| | - M. Teresa Veciana-Nogués
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA-UB), Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Xarxa d’Innovació Alimentària, Barcelona, Spain
| | - M. Luz Latorre-Moratalla
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA-UB), Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Xarxa d’Innovació Alimentària, Barcelona, Spain
| | - Oriol Comas-Basté
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA-UB), Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Xarxa d’Innovació Alimentària, Barcelona, Spain
| | - M. Carmen Vidal-Carou
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA-UB), Universitat de Barcelona, Santa Coloma de Gramenet, Spain
- Xarxa d’Innovació Alimentària, Barcelona, Spain
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16
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Recent advances in the application of microbial diamine oxidases and other histamine-oxidizing enzymes. World J Microbiol Biotechnol 2022; 38:232. [PMID: 36208352 PMCID: PMC9547800 DOI: 10.1007/s11274-022-03421-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/23/2022] [Indexed: 11/25/2022]
Abstract
The consumption of foods fraught with histamine can lead to various allergy-like symptoms if the histamine is not sufficiently degraded in the human body. The degradation occurs primarily in the small intestine, naturally catalyzed by the human diamine oxidase (DAO). An inherent or acquired deficiency in human DAO function causes the accumulation of histamine and subsequent intrusion of histamine into the bloodstream. The histamine exerts its effects acting on different histamine receptors all over the body but also directly in the intestinal lumen. The inability to degrade sufficient amounts of dietary histamine is known as the ‘histamine intolerance’. It would be preferable to solve this problem initially by the production of histamine-free or -reduced foods and by the oral supplementation of exogenous DAO supporting the human DAO in the small intestine. For the latter, DAOs from mammalian, herbal and microbial sources may be applicable. Microbial DAOs seem to be the most promising choice due to their possibility of an efficient biotechnological production in suitable microbial hosts. However, their biochemical properties, such as activity and stability under process conditions and substrate selectivity, play important roles for their successful application. This review deals with the advances and challenges of DAOs and other histamine-oxidizing enzymes for their potential application as processing aids for the production of histamine-reduced foods or as orally administered adjuvants to humans who have been eating food fraught with histamine.
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17
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Moniente M, García-Gonzalo D, Llamas-Arriba MG, Virto R, Ontañón I, Pagán R, Botello-Morte L. Potential of histamine-degrading microorganisms and diamine oxidase (DAO) for the reduction of histamine accumulation along the cheese ripening process. Food Res Int 2022; 160:111735. [DOI: 10.1016/j.foodres.2022.111735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/04/2022]
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18
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Matysiak J. Histamine intolerance (HIT). JOURNAL OF MEDICAL SCIENCE 2022. [DOI: 10.20883/medical.e727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Histamine intolerance (HIT) is food intolerance of non-immunological origin, and it results from an imbalance between the consumption of histamine with food and the organism ability to metabolize it. The patients with HIT were found to have a significantly reduced concentration of histamine-degrading enzymes, diamine oxidase (DAO) and histamine N-methyltransferase (HNMT). Factors which have been identified that are conducive to histamine intolerance are: genetic factors, dysbacteriosis, chronic diseases – especially allergic and intestinal diseases, chronic infections, mastocytosis and some drug use. Clinical symptoms of histamine excess may affect various organs and systems - the most common are skin symptoms (pruritis, erythema) nausea, vomiting, abdominal pain, diarrhea, headaches and sometimes severe reactions with shortness of breath, arrhythmias, blood pressure drop, and even cardiac arrest.
Diagnostic methods in HIT utilize determination of serum DAO, determination of histamine metabolites in urine, measurement of the histamine wheal in the 50th minute of the skin prick test (SPT), gastroscopy with intestinal biopsy, diagnostic and therapeutic test, oral histamine-challenge test and genetic tests.
The mainstay of histamine intolerance treatment if a low-histamine diet. Patients should avoid products belonging to the three groups of food: containing large amounts of histamine, histamine liberators, and products inhibiting the activity of DAO. Additionally, supplements containing DAO and antihistamines can be used.
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19
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Vander Does A, Ju T, Yosipovitch G. When Foods Cause Itch: Clinical Characteristics, Pathophysiology, and Recommendations for Food-Induced Skin and Mucosal Pruritus. Dermatitis 2022; Publish Ahead of Print:01206501-990000000-00036. [PMID: 35839419 DOI: 10.1097/der.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Itch occurs in various dermatologic and systemic conditions. Many patients report that certain foods instigate itch, although there is limited published information in dermatology on food-induced pruritus. In addition, itch severity is rarely mentioned. Food can induce pruritus through either ingestion or direct contact with skin or mucosal membranes. The most common type of itch provoked by food is acute urticaria, often through the classical immunoglobulin E (IgE)-mediated pathway. Other mechanisms include non-IgE-mediated, mixed (IgE-mediated and non-IgE-mediated), T-cell-mediated, and nonimmune reactions. For patients presenting with urticaria, generalized pruritus, oral pruritus, or dermatitis, a thorough history is warranted, and possible food associations should be considered and assessed. Although any food seems to have the potential to elicit an immune response, certain foods are especially immunogenic. Treatment includes avoidance of the trigger and symptom management. Careful consideration should be used as to avoid unnecessarily restrictive elimination diets.
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Affiliation(s)
- Ashley Vander Does
- From the Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, FL
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20
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Kettner L, Seitl I, Fischer L. Toward Oral Supplementation of Diamine Oxidase for the Treatment of Histamine Intolerance. Nutrients 2022; 14:nu14132621. [PMID: 35807806 PMCID: PMC9268349 DOI: 10.3390/nu14132621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/16/2022] [Accepted: 06/22/2022] [Indexed: 02/07/2023] Open
Abstract
A new diamine oxidase (DAO-1) was discovered recently in the yeast Yarrowia lipolytica PO1f and investigated for its histamine degradation capability under simulated intestinal conditions. DAO-1 was formulated together with catalase as a sucrose-based tablet. The latter (9 × 7 mm; 400 mg) contained 690 nkat of DAO-1 activity, which was obtained from a bioreactor cultivation of a genetically modified Y. lipolytica with optimized downstream processing. The DAO-1 tablet was tested in a histamine bioconversion experiment under simulated intestinal conditions in the presence of food constituents, whereby about 30% of the histamine was degraded in 90 min. This amount might already be sufficient to help people with histamine intolerance. Furthermore, it was found that the stability of DAO-1 in a simulated intestinal fluid is influenced distinctively by the presence of a food matrix, indicating that the amount and type of food consumed affect the oral supplementation with DAO. This study showed for the first time that a microbial DAO could have the potential for the treatment of histamine intolerance by oral supplementation.
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21
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Schnedl WJ, Meier-Allard N, Michaelis S, Lackner S, Enko D, Mangge H, Holasek SJ. Serum Diamine Oxidase Values, Indicating Histamine Intolerance, Influence Lactose Tolerance Breath Test Results. Nutrients 2022; 14:nu14102026. [PMID: 35631167 PMCID: PMC9146026 DOI: 10.3390/nu14102026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/12/2022] [Accepted: 05/09/2022] [Indexed: 12/12/2022] Open
Abstract
Lactose intolerance (LIT) is one of the major causes of irritable bowel syndrome (IBS) spectrum complaints. Differences in inadequate lactose digestion are described as various LIT phenotypes with basically unknown pathophysiology. In LIT patients, we retrospectively assessed the effect of histamine intolerance (HIT) on expiratory hydrogen (H2) during H2 lactose breath tests. In a retrospective evaluation of charts from 402 LIT patients, 200 patients were identified as having only LIT. The other 202 LIT patients were found to additionally have diamine oxidase (DAO) values of <10 U/mL, which indicates histamine intolerance (HIT). To identify HIT, standardized questionnaires, low serum DAO values and responses to a histamine-reduced diet were used. Patients were separated into three diagnostic groups according to the result of H2 breath tests: (1) LIT, with an H2 increase of >20 parts per million (ppm), but a blood glucose (BG) increase of >20 mg/dL, (2) LIT with an H2 increase of 20 ppm in combination with a BG increase of <20 mg/dL, and (3) LIT with an exhaled H2 increase of <20 ppm and BG increase of <20 mg/dL. Pairwise comparison with the Kruskal Wallis test was used to compare the areas under the curve (AUC) of LIT and LIT with HIT patients. Exhaled H2 values were significantly higher in H2 > 20 ppm and BG < 20 mg/dL patients with LIT and HIT (p = 0.007). This diagnostic group also showed a significant higher number of patients (p = 0.012) and a significant higher number of patients with gastrointestinal (GI) symptoms during H2 breath tests (p < 0.001). Therefore, low serum DAO values, indicating HIT, influence results of lactose tolerance breath tests.
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Affiliation(s)
- Wolfgang J. Schnedl
- Practice for General Internal Medicine, Dr. Theodor Körnerstrasse 19b, 8600 Bruck an der Mur, Austria
- Correspondence: ; Tel.: +43-3612-55833; Fax: +43-3612-55833-22
| | - Nathalie Meier-Allard
- Division of Immunology and Pathophysiology, Otto Loewi Research Center, Medical University of Graz, Heinrichstrasse 31a, 8010 Graz, Austria; (N.M.-A.); (S.L.); (S.J.H.)
| | - Simon Michaelis
- Institute of Clinical Chemistry, Laboratory Medicine, Hospital Hochsteiermark, Vordernberger Straße 42, 8700 Leoben, Austria; (S.M.); (D.E.)
| | - Sonja Lackner
- Division of Immunology and Pathophysiology, Otto Loewi Research Center, Medical University of Graz, Heinrichstrasse 31a, 8010 Graz, Austria; (N.M.-A.); (S.L.); (S.J.H.)
| | - Dietmar Enko
- Institute of Clinical Chemistry, Laboratory Medicine, Hospital Hochsteiermark, Vordernberger Straße 42, 8700 Leoben, Austria; (S.M.); (D.E.)
- Clinical Institute of Medical, Chemical Laboratory Diagnosis, Medical University of Graz, Auenbruggerplatz 30, 8036 Graz, Austria;
| | - Harald Mangge
- Clinical Institute of Medical, Chemical Laboratory Diagnosis, Medical University of Graz, Auenbruggerplatz 30, 8036 Graz, Austria;
| | - Sandra J. Holasek
- Division of Immunology and Pathophysiology, Otto Loewi Research Center, Medical University of Graz, Heinrichstrasse 31a, 8010 Graz, Austria; (N.M.-A.); (S.L.); (S.J.H.)
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22
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Cucca V, Ramirez GA, Pignatti P, Asperti C, Russo M, Della-Torre E, Breda D, Burastero SE, Dagna L, Yacoub MR. Basal Serum Diamine Oxidase Levels as a Biomarker of Histamine Intolerance: A Retrospective Cohort Study. Nutrients 2022; 14:nu14071513. [PMID: 35406126 PMCID: PMC9003468 DOI: 10.3390/nu14071513] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/25/2022] [Accepted: 04/01/2022] [Indexed: 12/13/2022] Open
Abstract
Background: Histamine Intolerance (HIT) is a multifaceted pseudoallergic disorder possibly due to defective histamine metabolism. Diamine oxidase (DAO) contributes to histamine degradation and can be measured in the serum. The role of DAO measurement in the diagnostic work-up of HIT still remains unclear, and conflicting results have been reported in the literature. Therefore, we aimed to evaluate the possible clinical usefulness and consistency of DAO value ranges as provided by the assay manufacturer and verify whether they could predict the response to treatment. Methods: We retrospectively analyzed 192 outpatients with HIT symptoms and measured serum DAO values at baseline. Patients were prescribed either with low-histamine diet and/or enzymatic supplementation according to symptom severity and re-evaluated six to eight months later. Patients were stratified into three groups according to DAO levels: <3 U/mL, 3−10 U/mL, and >10 U/mL. HIT severity was assessed on a scale of 1 to 5 before and after treatment. Results: A total of 146 patients completed the study. Gastrointestinal and cutaneous symptoms, often associated with headache, were more frequent in subjects with DAO < 10 U/mL. Symptom severity and DAO ranges were correlated. Patients with intermediate DAO levels (3−10 U/mL) showed a more complex clinical phenotype but also a more significant improvement in symptom severity (score reduction 50%, interquartile range (IQR) = 33−60%) when compared to patients with low DAO (40%, IQR = 20−60%; p = 0.045) or high DAO (33%, IQR = 0−50%; p < 0.001). Complex clinical phenotypes were also more frequent in patients with intermediate DAO levels. Conclusions: HIT is characterized by typical symptoms and low levels of DAO activity. Symptom severity was associated with the degree of DAO deficiency. Patients with DAO values between 3 and 10 U/mL show the best response to treatment (low-histamine diet and/or DAO supplementation). DAO value could arguably be considered as a predictor of clinical response to treatment. Prospective studies are needed to confirm these data.
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Affiliation(s)
- Valentina Cucca
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, 20132 Milan, Italy; (V.C.); (G.A.R.); (C.A.); (M.R.); (E.D.-T.); (L.D.)
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Giuseppe A. Ramirez
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, 20132 Milan, Italy; (V.C.); (G.A.R.); (C.A.); (M.R.); (E.D.-T.); (L.D.)
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Patrizia Pignatti
- Allergy and Immunology Unit, Istituti Clinici Scientifici Maugeri IRCCS Pavia, 27100 Pavia, Italy;
| | - Chiara Asperti
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, 20132 Milan, Italy; (V.C.); (G.A.R.); (C.A.); (M.R.); (E.D.-T.); (L.D.)
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Marco Russo
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, 20132 Milan, Italy; (V.C.); (G.A.R.); (C.A.); (M.R.); (E.D.-T.); (L.D.)
| | - Emanuel Della-Torre
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, 20132 Milan, Italy; (V.C.); (G.A.R.); (C.A.); (M.R.); (E.D.-T.); (L.D.)
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Daniela Breda
- Laboratory of Cellular and Molecular Allergology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Samuele E. Burastero
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
- Laboratory of Cellular and Molecular Allergology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Lorenzo Dagna
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, 20132 Milan, Italy; (V.C.); (G.A.R.); (C.A.); (M.R.); (E.D.-T.); (L.D.)
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Mona-Rita Yacoub
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, 20132 Milan, Italy; (V.C.); (G.A.R.); (C.A.); (M.R.); (E.D.-T.); (L.D.)
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
- Correspondence: ; Tel.: +39-02-2643-6895
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Zhao Y, Zhang X, Jin H, Chen L, Ji J, Zhang Z. Histamine Intolerance-A Kind of Pseudoallergic Reaction. Biomolecules 2022; 12:454. [PMID: 35327646 PMCID: PMC8945898 DOI: 10.3390/biom12030454] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 02/04/2023] Open
Abstract
Histamine intolerance (HIT) is a common disorder associated with impaired histamine metabolism. Notwithstanding, it is often misdiagnosed as other diseases because of its lack of specific clinical manifestations. HIT did not gain traction until the early 21st century. In this review, we will focus on the latest research and elaborate on the clinical manifestations of HIT, including its manifestations in special populations such as atopic dermatitis (AD) and chronic urticaria (CU), as well as the latest understanding of its etiology and pathogenesis. In addition, we will explore the latest treatment strategies for HIT and the treatment of specific cases.
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Affiliation(s)
- Ying Zhao
- Department of Dermatology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.Z.); (X.Z.); (L.C.)
- Department of Dermatology and Venereology, Suzhou Medical College of Soochow University, Suzhou 215000, China;
| | - Xiaoyan Zhang
- Department of Dermatology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.Z.); (X.Z.); (L.C.)
- Department of Dermatology and Venereology, Suzhou Medical College of Soochow University, Suzhou 215000, China;
| | - Hengxi Jin
- Department of Dermatology and Venereology, Suzhou Medical College of Soochow University, Suzhou 215000, China;
| | - Lu Chen
- Department of Dermatology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.Z.); (X.Z.); (L.C.)
- Department of Dermatology and Venereology, Suzhou Medical College of Soochow University, Suzhou 215000, China;
| | - Jiang Ji
- Department of Dermatology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.Z.); (X.Z.); (L.C.)
- Department of Dermatology and Venereology, Suzhou Medical College of Soochow University, Suzhou 215000, China;
| | - Zhongwei Zhang
- Department of Biochemistry and Molecular Biology, School of Medicine, Nantong University, Nantong 226001, China
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24
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Tedner SG, Asarnoj A, Thulin H, Westman M, Konradsen JR, Nilsson C. Food allergy and hypersensitivity reactions in children and adults-A review. J Intern Med 2022; 291:283-302. [PMID: 34875122 DOI: 10.1111/joim.13422] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Adverse reactions after food intake are commonly reported and a cause of concern and anxiety that can lead to a very strict diet. The severity of the reaction can vary depending on the type of food and mechanism, and it is not always easy to disentangle different hypersensitivity diagnoses, which sometimes can exist simultaneously. After a carefully taken medical history, hypersensitivity to food can often be ruled out or suspected. The most common type of allergic reaction is immunoglobulin E (IgE)-mediated food allergy (prevalence 5-10%). Symptoms vary from mild itching, stomach pain, and rash to severe anaphylaxis. The definition of IgE-mediated food allergy is allergic symptoms combined with specific IgE-antibodies, and therefore only IgE-antibodies to suspected allergens should be analyzed. Nowadays, methods of molecular allergology can help with the diagnostic process. The most common allergens are milk and egg in infants, peanut and tree nuts in children, and fish and shellfish in adults. In young children, milk/egg allergy has a good chance to remit, making it important to follow up and reintroduce the food when possible. Other diseases triggered by food are non-IgE-mediated food allergy, for example, eosinophilic esophagitis, celiac disease, food protein-induced enterocolitis syndrome, and hypersensitivity to milk and biogenic amines. Some of the food hypersensitivities dominate in childhood, others are more common in adults. Interesting studies are ongoing regarding the possibilities of treating food hypersensitivity, such as through oral immunotherapy. The purpose of this review was to provide an overview of the most common types of food hypersensitivity reactions.
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Affiliation(s)
- Sandra G Tedner
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Asarnoj
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Thulin
- Allergy and Lung Department, Sachs' Children and Youth Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Marit Westman
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Asthma and Allergy Clinic S:t Göran, Stockholm, Sweden
| | - Jon R Konradsen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Nilsson
- Allergy and Lung Department, Sachs' Children and Youth Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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25
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Parfenov AI. Food intolerances and the small intestine. TERAPEVT ARKH 2022; 94:153-159. [DOI: 10.26442/00403660.2022.02.201364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 03/27/2022] [Indexed: 11/22/2022]
Abstract
The article presents an analysis of the literature on food intolerance (FS) associated with the presence in the diet of fermentable oligodimosaccharides and polyols FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols), histamine and food additives. The relationship between FS and insufficient activity of enzymes of the small intestine mucosa, in particular, in patients with irritable bowel syndrome, is discussed. FS often noted in them forces them to strictly adhere to the elimination diet and significantly impair the quality of life due to dissatisfaction with the results of treatment. Analysis of the literature has confirmed in many patients with irritable bowel syndrome an etiotropic relationship with poor food tolerance and dictates the need for randomized studies to further study the pathogenetic mechanisms of increasing food tolerance under the influence of cytoprotective therapy.
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26
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Supplementation with Exogenous Catalase from Penicillium notatum in the Diet Ameliorates Lipopolysaccharide-Induced Intestinal Oxidative Damage through Affecting Intestinal Antioxidant Capacity and Microbiota in Weaned Pigs. Microbiol Spectr 2021; 9:e0065421. [PMID: 34908474 PMCID: PMC8672903 DOI: 10.1128/spectrum.00654-21] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The present study aimed to explore the protective effects of exogenous catalase (CAT) from microorganisms against lipopolysaccharide (LPS)-induced intestinal injury and its molecular mechanism in weaned pigs. Fifty-four weaned pigs (21 days of age) were randomly allocated to CON, LPS, and LPS+CAT groups. The pigs in CON and LPS groups were fed a basal diet, whereas the pigs in LPS+CAT group fed the basal diet with 2,000 mg/kg CAT supplementation for 35 days. On day 36, six pigs were selected from each group, and LPS and LPS+CAT groups were administered with LPS (50 μg/kg body weight). Meanwhile, CON group was injected with an equivalent amount of sterile saline. Results showed that LPS administration damaged intestinal mucosa morphology and barrier. However, CAT supplementation alleviated the deleterious effects caused by LPS challenge through enhancing intestinal antioxidant capacity which was benefited to decrease proinflammatory cytokines concentrations and suppress enterocyte apoptosis. Besides, LPS-induced gut microbiota dysbiosis was significantly shifted by CAT through decreasing mainly Streptococcus and Escherichia-Shigella. Our study suggested that dietary supplemented with 2,000 mg/kg catalase was conducive to improve intestinal development and protect against LPS-induced intestinal mucosa injury via enhancing intestinal antioxidant capacity and altering microbiota composition in weaned pigs. IMPORTANCE Exogenous CAT derived from microorganisms has been widely used in food, medicine, and other industries. Recent study also found that exogenous CAT supplementation could improve growth performance and antioxidant capacity of weaned pigs. However, it is still unknown that whether dietary exogenous CAT supplementation can provide a defense against the oxidative stress-induced intestinal damage in weaned pigs. Our current study suggested that dietary supplemented with 2,000 mg/kg CAT was conducive to improve intestinal development and protect against LPS-induced intestinal mucosa injury via enhancing intestinal antioxidant capacity and altering microbiota composition in weaned pigs. Moreover, this study will also assist in developing of CAT produced by microorganisms to attenuate various oxidative stress-induced injury or diseases.
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27
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Kettner L, Braun C, Seitl I, Pross E, Fischer L. Production and characterization of a new diamine oxidase from Yarrowia lipolytica. J Biotechnol 2021; 340:39-46. [PMID: 34474093 DOI: 10.1016/j.jbiotec.2021.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/26/2021] [Accepted: 08/28/2021] [Indexed: 10/20/2022]
Abstract
A putative diamine oxidase (DAO) from Yarrowia lipolytica PO1f (DAO-1) was homologously recombinantly integrated into the genome of Y. lipolytica PO1f using the CRISPR-Cas9 system for the subsequent DAO production in a bioreactor. Thereby, it was proven that the DAO-1 produced was indeed a functional DAO. The cultivation yielded 2343 ± 98 nkat/Lculture with a specific DAO activity of 1301 ± 54.2 nkat/gprotein, which was a 93-fold increase of specific DAO activity compared to the native Y. lipolytica PO1f DAO-1 production. The DAO-1 showed a broad substrate selectivity with tyramine, histamine, putrescine and cadaverine being the most favored substrates. It was most active at 40 °C, pH 7.2 in Tris-HCl buffer (50 mM) (with histamine as substrate), which is comparable to human and porcine DAOs. The affinity of DAO-1 towards histamine was lower compared to mammalian DAOs (Km = 2.3 ± 0.2 mM). Nevertheless, DAO-1 degraded around 75% of the histamine used in a bioconversion experiment with a food-relevant concentration of 150 mg/L. With its broad selectivity for the most relevant biogenic amines in foods, DAO-1 from Y. lipolytica PO1f is an interesting enzyme for application in the food industry for the degradation of biogenic amines.
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Affiliation(s)
- Lucas Kettner
- University of Hohenheim, Institute of Food Science and Biotechnology, Department of Biotechnology and Enzyme Science, Garbenstr. 25, 70599 Stuttgart, Germany
| | - Carina Braun
- University of Hohenheim, Institute of Food Science and Biotechnology, Department of Biotechnology and Enzyme Science, Garbenstr. 25, 70599 Stuttgart, Germany
| | - Ines Seitl
- University of Hohenheim, Institute of Food Science and Biotechnology, Department of Biotechnology and Enzyme Science, Garbenstr. 25, 70599 Stuttgart, Germany
| | - Eva Pross
- University of Hohenheim, Institute of Food Science and Biotechnology, Department of Biotechnology and Enzyme Science, Garbenstr. 25, 70599 Stuttgart, Germany
| | - Lutz Fischer
- University of Hohenheim, Institute of Food Science and Biotechnology, Department of Biotechnology and Enzyme Science, Garbenstr. 25, 70599 Stuttgart, Germany.
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28
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Guideline on management of suspected adverse reactions to ingested histamine: Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergology and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA) as well as the Swiss Society for Allergology and Immunology (SGAI) and the Austrian Society for Allergology and Immunology (ÖGAI). Allergol Select 2021; 5:305-314. [PMID: 34651098 PMCID: PMC8511827 DOI: 10.5414/alx02269e] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/06/2021] [Indexed: 12/20/2022] Open
Abstract
Adverse reactions to food or food ingredients are more often perceived than objectively verifiable. However, reliable laboratory tests are often lacking. As a result, people with perceived adverse reactions to food often follow extensive elimination diets for years and unnecessarily restrict their diet, as in the case of the frequently suspected histamine intolerance. In this condition, laboratory parameters such as the determination of diamine oxidase in serum have been shown to be inconclusive. The lack of symptom reproducibility calls into question the clinical picture of adverse reactions to ingested histamine. In order to approach persons with perceived histamine intolerance and to support them in moving from blanket restrictions, which are often unnecessarily strict, to effective personalized therapeutic strategies, the present guideline of the Working Group on Food Allergy of the German Society of Allergology and Clinical Immunology (DGAKI) in cooperation with the Medical Association of German Allergists (AeDA), the Pediatric Allergology and Environmental Medicine (GPA) as well as the Swiss Society of Allergology and Immunology (SGAI) and the Austrian Society of Allergology and Immunology (ÖGAI) recommends a practicable diagnostic and therapeutic approach.
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Hrubisko M, Danis R, Huorka M, Wawruch M. Histamine Intolerance-The More We Know the Less We Know. A Review. Nutrients 2021; 13:2228. [PMID: 34209583 PMCID: PMC8308327 DOI: 10.3390/nu13072228] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/16/2022] Open
Abstract
The intake of food may be an initiator of adverse reactions. Food intolerance is an abnormal non-immunological response of the organism to the ingestion of food or its components in a dosage normally tolerated. Despite the fact that food intolerance is spread throughout the world, its diagnosing is still difficult. Histamine intolerance (HIT) is the term for that type of food intolerance which includes a set of undesirable reactions as a result of accumulated or ingested histamine. Manifestations may be caused by various pathophysiological mechanisms or a combination of them. The problem with a "diagnosis" of HIT is precisely the inconstancy and variety of the manifestations in the same individual following similar stimuli. The diagnosing of HIT therefore requires a complex time-demanding multidisciplinary approach, including the systematic elimination of disorders with a similar manifestation of symptoms. Among therapeutic approaches, the gold standard is a low-histamine diet. A good response to such a diet is considered to be confirmation of HIT. Alongside the dietary measures, DAO supplementation supporting the degradation of ingested histamine may be considered as subsidiary treatment for individuals with intestinal DAO deficiency. If antihistamines are indicated, the treatment should be conscious and time-limited, while 2nd or 3rd generation of H1 antihistamines should take precedence.
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Affiliation(s)
- Martin Hrubisko
- Department of Clinical Allergology and Immunology, Oncological Institute of St. Elizabeth, Heydukova 2157/10, 812 50 Bratislava, Slovakia;
- Institute of Immunology and Allergology, Slovak Medical University, Limbová 12, 833 03 Bratislava, Slovakia
| | - Radoslav Danis
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine at Comenius University of Bratislava, Špitálska 24, 831 72 Bratislava, Slovakia;
| | - Martin Huorka
- Department of Gastroenterology and Hepatology, University Hospital Bratislava, Ružinovská 6, 821 01 Bratislava, Slovakia;
| | - Martin Wawruch
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine at Comenius University of Bratislava, Špitálska 24, 831 72 Bratislava, Slovakia;
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30
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Histamine Intolerance in Children: A Narrative Review. Nutrients 2021; 13:nu13051486. [PMID: 33924863 PMCID: PMC8144954 DOI: 10.3390/nu13051486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022] Open
Abstract
Histamine intolerance is defined as a disequilibrium of accumulated histamine and the capacity for histamine degradation. This clinical term addresses a non-immunologically mediated pathology when histamine ingested with food is not particularly high, however its degradation is decreased. This paper aims to provide a narrative review on etiopathology, epidemiology, possible diagnostic algorithms and diagnostic challenges of histamine intolerance in children. The clinical picture of histamine intolerance in children is similar to that observed in adults apart from male predominance found in paediatric patients. Both in children and adults, a histamine-reduced diet is typically the treatment of choice. Diamine oxidase supplementation offers another treatment option. There is no symptom or test pathognomonic for histamine intolerance. Nevertheless, manifestations of chronic gastrointestinal symptoms, measurements of diamine oxidase deficits, positive results of histamine provocation tests and improvement in symptoms with histamine-reduced diet considerably increase the probability of histamine intolerance diagnosis. These factors have been included in the proposed diagnostic algorithm for histamine intolerance. In children histamine intolerance most likely co-occurs with allergies and bowel diseases, which creates an additional diagnostic challenge. As the evidence for children is poor further research is needed the determine epidemiology, validate diagnostic algorithms and establish possible treatment options regarding histamine intolerance.
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31
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Schnedl WJ, Enko D. Histamine Intolerance Originates in the Gut. Nutrients 2021; 13:1262. [PMID: 33921522 PMCID: PMC8069563 DOI: 10.3390/nu13041262] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/05/2021] [Accepted: 04/09/2021] [Indexed: 12/13/2022] Open
Abstract
Histamine intolerance (HIT) is assumed to be due to a deficiency of the gastrointestinal (GI) enzyme diamine oxidase (DAO) and, therefore, the food component histamine not being degraded and/or absorbed properly within the GI tract. Involvement of the GI mucosa in various disorders and diseases, several with unknown origin, and the effects of some medications seem to reduce gastrointestinal DAO activity. HIT causes variable, functional, nonspecific, non-allergic GI and extra-intestinal complaints. Usually, evaluation for HIT is not included in differential diagnoses of patients with unexplained, functional GI complaints or in the here-listed disorders and diseases. The clinical diagnosis of HIT is challenging, and the thorough anamnesis of all HIT-linked complaints, using a standardized questionnaire, is the mainstay of HIT diagnosis. So far, DAO values in serum have not been established to correlate with DAO activity in the gut, but the diagnosis of HIT may be supported with determination of a low serum DAO value. A targeted dietary intervention, consisting of a histamine-reduced diet and/or supplementation with oral DAO capsules, is helpful to reduce HIT-related symptoms. This manuscript will present why histamine should also be taken into account in the differential diagnoses of patients with various diseases and disorders of unknown origin, but with association to functional gastrointestinal complaints. In this review, we discuss currently increasing evidence that HIT is primarily a gastrointestinal disorder and that it originates in the gut.
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Affiliation(s)
- Wolfgang J. Schnedl
- General Internal Medicine Practice, Dr. Theodor Körnerstrasse 19b, A-8600 Bruck, Austria
| | - Dietmar Enko
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Auenbruggerplatz 15, A-8036 Graz, Austria;
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Schnedl WJ, Meier-Allard N, Lackner S, Enko D, Mangge H, Holasek SJ. Increasing Expiratory Hydrogen in Lactose Intolerance Is Associated with Additional Food Intolerance/Malabsorption. Nutrients 2020; 12:E3690. [PMID: 33265924 PMCID: PMC7761160 DOI: 10.3390/nu12123690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 12/12/2022] Open
Abstract
Single and/or combined food intolerance/malabsorption may cause nonspecific, functional gastrointestinal (GI) complaints. In lactose-intolerant patients we evaluated the influence of additional food intolerance/malabsorption with hydrogen (H2) breath tests. In a retrospective analysis of charts from 279 lactose-intolerant patients, we found 128 patients with only lactose intolerance (LIT). Then, we identified 106 LIT patients with additional histamine intolerance (HIT). Additionally, 45 LIT and HIT patients also had fructose malabsorption (FM). A hydrogen (H2) breath test was performed to evaluate LIT and FM. A serum diamine oxidase value of <10 U/mL and a response to a histamine-reduced diet was used to identify HIT. Using pairwise comparison with the Kruskal-Wallis test to associate the area under the curve (AUC) of LIT patients and, LIT with HIT, to LIT with HIT and FM it was found, that the exhaled hydrogen values were significantly higher in patients with two-fold and triple combined food intolerance/malabsorption (p < 0.004 and p < 0.001, respectively). Within the pool of 170 LIT patients with >20 ppm increase of expiratory H2 from baseline, there were 74 LIT-only patients, 60 LIT with HIT patients, and 36 LIT patients with additional HIT and FM. With the Kruskal-Wallis test AUCs demonstrated a significant difference between all three groups (p = 0.024). In patients with LIT, the presence of additional food intolerance/malabsorption, significantly increases expiratory H2 values. We demonstrate evidence, which may suggest HIT to embody an own GI disorder as food intolerance/malabsorption.
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Affiliation(s)
- Wolfgang J. Schnedl
- General Internal Medicine Practice, Theodor Körnerstrasse 19b, A-8600 Bruck, Austria
| | - Nathalie Meier-Allard
- Division of Immunology and Pathophysiology, Otto Loewi Research Center, Medical University of Graz, Heinrichstrasse 31a, A-8010 Graz, Austria; (N.M.-A.); (S.L.); (S.J.H.)
| | - Sonja Lackner
- Division of Immunology and Pathophysiology, Otto Loewi Research Center, Medical University of Graz, Heinrichstrasse 31a, A-8010 Graz, Austria; (N.M.-A.); (S.L.); (S.J.H.)
| | - Dietmar Enko
- Clinical Institute of Medical and Chemical Laboratory Diagnosis, Medical University of Graz, Auenbruggerplatz 30, A-8036 Graz, Austria; (D.E.); (H.M.)
| | - Harald Mangge
- Clinical Institute of Medical and Chemical Laboratory Diagnosis, Medical University of Graz, Auenbruggerplatz 30, A-8036 Graz, Austria; (D.E.); (H.M.)
| | - Sandra J. Holasek
- Division of Immunology and Pathophysiology, Otto Loewi Research Center, Medical University of Graz, Heinrichstrasse 31a, A-8010 Graz, Austria; (N.M.-A.); (S.L.); (S.J.H.)
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Non-responsive celiac disease may coincide with additional food intolerance/malabsorption, including histamine intolerance. Med Hypotheses 2020; 146:110404. [PMID: 33268003 DOI: 10.1016/j.mehy.2020.110404] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/24/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PILOT STUDY Celiac disease (CD) or gluten malabsorption is a well-defined autoimmune disorder characterized by mucosal gastrointestinal reaction to ingested gluten proteins. The necessary treatment for CD is a gluten-free diet. However, up to 30% of celiac patients experience persistent or recurring abdominal complaints despite following an exact gluten-free diet. This condition was named refractory, non-responsive celiac disease. Other food ingredients, such as carbohydrates and biogenic amines, also influence and impair digestion, and may cause these abdominal symptoms. In this retrospective pilot study, we have reported on 20 non-responsive, celiac disease patients, with persistent abdominal complaints, for longer than 6 months. These patients were evaluated for extra food intolerance/malabsorption, including fructose malabsorption, histamine-, lactose intolerance, and Helicobacter pylori (H.p.) infection. RESULTS AND CONCLUSIONS The results demonstrate that 18 of the 20 refractory, non-responsive celiac disease patients presented various, additional food intolerance/malabsorption and/or H.p. infection. Seven NRCD patients demonstrated lactose intolerance, 7 showed fructose malabsorption, 11 had additional histamine intolerance and 6 had signs of H.p. infection or combinations thereof. If present, then eradication of H.p. was performed. Histamine intolerance, was found in more than 50% of patients, and it seems to play an important role in non-responsive celiac disease. A registered dietician continued to help with, and to improve, the patients' gluten-free diet. Furthermore, additional food intolerance/malabsorption considerations were included in the individual, dietary recommendations.
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Comas-Basté O, Sánchez-Pérez S, Veciana-Nogués MT, Latorre-Moratalla M, Vidal-Carou MDC. Histamine Intolerance: The Current State of the Art. Biomolecules 2020; 10:E1181. [PMID: 32824107 PMCID: PMC7463562 DOI: 10.3390/biom10081181] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/18/2022] Open
Abstract
Histamine intolerance, also referred to as enteral histaminosis or sensitivity to dietary histamine, is a disorder associated with an impaired ability to metabolize ingested histamine that was described at the beginning of the 21st century. Although interest in histamine intolerance has considerably grown in recent years, more scientific evidence is still required to help define, diagnose and clinically manage this condition. This article will provide an updated review on histamine intolerance, mainly focusing on its etiology and the existing diagnostic and treatment strategies. In this work, a glance on histamine intoxication will also be provided, as well as the analysis of some uncertainties historically associated to histamine intoxication outbreaks that may be better explained by the existence of interindividual susceptibility to ingested histamine.
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Affiliation(s)
- Oriol Comas-Basté
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (O.C.-B.); (S.S.-P.); (M.T.V.-N.); (M.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
- Xarxa de Referència en Tecnologia dels Aliments de la Generalitat de Catalunya (XaRTA), C/Baldiri Reixac 4, 08028 Barcelona, Spain
| | - Sònia Sánchez-Pérez
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (O.C.-B.); (S.S.-P.); (M.T.V.-N.); (M.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
- Xarxa de Referència en Tecnologia dels Aliments de la Generalitat de Catalunya (XaRTA), C/Baldiri Reixac 4, 08028 Barcelona, Spain
| | - Maria Teresa Veciana-Nogués
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (O.C.-B.); (S.S.-P.); (M.T.V.-N.); (M.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
- Xarxa de Referència en Tecnologia dels Aliments de la Generalitat de Catalunya (XaRTA), C/Baldiri Reixac 4, 08028 Barcelona, Spain
| | - Mariluz Latorre-Moratalla
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (O.C.-B.); (S.S.-P.); (M.T.V.-N.); (M.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
- Xarxa de Referència en Tecnologia dels Aliments de la Generalitat de Catalunya (XaRTA), C/Baldiri Reixac 4, 08028 Barcelona, Spain
| | - María del Carmen Vidal-Carou
- Departament de Nutrició, Ciències de l’Alimentació i Gastronomia, Facultat de Farmàcia i Ciències de l’Alimentació, Campus de l’Alimentació de Torribera, Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain; (O.C.-B.); (S.S.-P.); (M.T.V.-N.); (M.L.-M.)
- Institut de Recerca en Nutrició i Seguretat Alimentària (INSA·UB), Universitat de Barcelona, Av. Prat de la Riba 171, 08921 Santa Coloma de Gramenet, Spain
- Xarxa de Referència en Tecnologia dels Aliments de la Generalitat de Catalunya (XaRTA), C/Baldiri Reixac 4, 08028 Barcelona, Spain
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35
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Abstract
In westernized countries, adverse reactions to ingested foods are reported to affect up to 20% of the population. Functional, nonspecific, non-allergic gastrointestinal complaints are mainly due to the intolerance/malabsorption of carbohydrates (lactose and fructose), proteins (gluten), and biogenic amines (histamine). Food intolerance/malabsorption is defined by one or several of the above mentioned food components not being degraded and/or absorbed properly within the gastrointestinal tract. Food intolerance/malabsorption causes variable, functional, nonspecific, non-allergic gastrointestinal and extra-intestinal complaints, and a detailed diagnostic workup for all possible etiologic factors in individual patients is essential. Usually, evaluation for histamine intolerance is not included in differential diagnoses of patients with functional, nonspecific, non-allergic gastrointestinal complaints. A targeted dietary intervention for single or possibly combined intolerance/malabsorption is required. In this article, we review currently discussed differential diagnoses and available tests for intolerance/malabsorption. Accordingly, we aim to outline why including histamine and, histamine intolerance, should be considered in differential diagnoses of patients with functional, nonspecific, non-allergic gastrointestinal complaints.
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Affiliation(s)
| | - Dietmar Enko
- Clinical Institute of Medical and Chemical Laboratory Diagnosis, Medical University of Graz, Graz, Austria
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36
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Lyophilised legume sprouts as a functional ingredient for diamine oxidase enzyme supplementation in histamine intolerance. Lebensm Wiss Technol 2020. [DOI: 10.1016/j.lwt.2020.109201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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37
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Kettner L, Seitl I, Fischer L. Evaluation of porcine diamine oxidase for the conversion of histamine in food-relevant amounts. J Food Sci 2020; 85:843-852. [PMID: 32090335 DOI: 10.1111/1750-3841.15069] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 11/29/2022]
Abstract
Histamine exists in a multitude of foods and displays an emerging role within food intolerances. Our aim was to identify the activity of porcine diamine oxidase (DAO) required for the in vitro degradation of histamine amounts that are found in typical meals containing histamine (75 mg, equaled 150 mg/L). Furthermore, we investigated an actual dietary supplement that is commercially available for histamine intolerant individuals for its histamine reduction capability. Kinetic investigations of porcine DAO showed a substrate inhibition by histamine concentrations greater than 56 mg/L (0.5 mM). The stability of free porcine DAO was tested in a fed state simulated intestinal fluid and exhibited a half-life period of around 19 min. A total of 50 nanokatal (nkat) free porcine DAO, which equaled the amount of enzyme isolated from around 100 g pig kidney, were necessary for the in vitro reduction of around 90% of the histamine. The dietary supplement that contains a pig kidney extract did not show DAO activity. Instead, the used histamine (0.75 mg) was apparently reduced due to the adsorption of histamine onto a capsule component by 18.9 ± 2.3% within 5 hr. Although the capsule preparation retained its overall structure and shape for at least 90 min in simulated gastric fluid, the apparent histamine reduction was significantly reduced to 12.1 ± 2.3% (P ≤ 0.05). In conclusion, an alternative to the pig kidney DAO or an improved capsule preparation is needed to ensure an adequate supplementation for histamine-intolerant humans. PRACTICAL APPLICATION: Histamine intolerance is an emerging issue in our society and the intolerance-related physiological symptoms are currently not reliably treatable due to a lack of scientific investigation. A commercially available dietary supplement for histamine intolerance does not fulfil the requirements for a satisfactory histamine reduction in intolerant humans. The activity of the histamine degrading enzyme diamine oxidase, required for a satisfactory histamine degradation, is by far higher than the theoretical amount apparently given in the dietary supplement. With this knowledge, it is obvious that improved food supplements must be developed to help histamine intolerant humans.
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Affiliation(s)
- Lucas Kettner
- Dept. of Biotechnology and Enzyme Science, Inst. of Food Science and Biotechnology, Univ. of Hohenheim, Garbenstr. 25, 70599, Stuttgart, Germany
| | - Ines Seitl
- Dept. of Biotechnology and Enzyme Science, Inst. of Food Science and Biotechnology, Univ. of Hohenheim, Garbenstr. 25, 70599, Stuttgart, Germany
| | - Lutz Fischer
- Dept. of Biotechnology and Enzyme Science, Inst. of Food Science and Biotechnology, Univ. of Hohenheim, Garbenstr. 25, 70599, Stuttgart, Germany
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38
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Schnedl WJ, Queissner R. Migraines appear more likely to be caused by histamine than ethanol. Eur J Neurol 2019; 26:e79. [DOI: 10.1111/ene.14003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/14/2019] [Indexed: 01/16/2023]
Affiliation(s)
| | - R. Queissner
- Department of Psychiatry and Psychotherapeutic Medicine Medical University of Graz Graz Austria
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