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Brasal-Prieto M, Fernández-Prades L, Dakhaoui H, Sobrino F, López-Enríquez S, Palomares F. Update on In Vitro Diagnostic Tools and Treatments for Food Allergies. Nutrients 2023; 15:3744. [PMID: 37686776 PMCID: PMC10489659 DOI: 10.3390/nu15173744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Food allergy (FA) is an adverse immunological reaction to a specific food that can trigger a wide range of symptoms from mild to life-threatening. This adverse reaction is caused by different immunological mechanisms, such as IgE-mediated, non-IgE-mediated and mixed IgE-mediated reactions. Its epidemiology has had a significant increase in the last decade, more so in developed countries. It is estimated that approximately 2 to 10% of the world's population has FA and this number appears to be increasing and also affecting more children. The diagnosis can be complex and requires the combination of different tests to establish an accurate diagnosis. However, the treatment of FA is based on avoiding the intake of the specific allergenic food, thus being very difficult at times and also controlling the symptoms in case of accidental exposure. Currently, there are other immunomodulatory treatments such as specific allergen immunotherapy or more innovative treatments that can induce a tolerance response. It is important to mention that research in this field is ongoing and clinical trials are underway to assess the safety and efficacy of these different immunotherapy approaches, new treatment pathways are being used to target and promote the tolerance response. In this review, we describe the new in vitro diagnostic tools and therapeutic treatments to show the latest advances in FA management. We conclude that although significant advances have been made to improve therapies and diagnostic tools for FA, there is an urgent need to standardize both so that, in their totality, they help to improve the management of FA.
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da Silva ES, de Santana MBR, Silveira EF, Torres RT, Silva RC, Fernandes AMS, Belitardo EMMDA, Garcés LFS, Santiago LF, Urrego JR, Vilas-Bôas DS, de Freitas LAR, Zakzuk J, Pacheco LGC, Cruz ÁA, Ferreira F, Cooper P, Caraballo L, Pinheiro CDS, Alcantara-Neves NM. The hybrid protein BTH2 suppresses allergic airway inflammation in a murine model of HDM-specific immunotherapy. Clin Exp Allergy 2023; 53:821-832. [PMID: 36779555 DOI: 10.1111/cea.14293] [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: 10/21/2022] [Revised: 01/22/2023] [Accepted: 01/28/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Allergen-specific immunotherapy (AIT) is the only disease-modifying treatment approach to change disease-causing allergens. Hypoallergenic derivatives show promise as potential therapeutics, amongst which BTH2 was designed to induce tolerance against Blomia tropicalis allergy. Our aim was to investigate the hypoallergenicity and immunoregulatory activity of BTH2 in vitro and its therapeutic potential in a mouse model of AIT. METHODS Recombinant Blo t 5 and Blo t 21 allergens and their hybrid derivatives (BTH1 and BTH2) were expressed and purified. IgE binding capacity was tested by ELISA using sera from Brazilian, Colombian, and Ecuadorian subjects. Secretion of cytokines in supernatants from human cell cultures was measured following stimulation with the four recombinants and controls. The capacity of BTH2 to ameliorate allergic airway inflammation induced by B. tropicalis extract was evaluated in a murine model of AIT. RESULTS rBlo t 5 and rBlo t 21 were identified as major allergens in Latin American patients, and BTH2 had the lowest IgE binding. In vitro stimulation of human cells induced greater levels of IL-10 and IFN-γ and reduced the secretion of Th2 cytokines. BTH2 ameliorated allergic airway inflammation in B. tropicalis-challenged A/J mice, as evidenced by the histopathological and humoral biomarkers: decreased Th2 cytokines and cellular infiltration (especially eosinophils), lower activity of eosinophil peroxidase, an increase in IgG blocking antibodies and strong reduction of mucus production by goblet cells. CONCLUSIONS Our study shows that BTH2 represents a promising candidate for the treatment of B. tropicalis allergy with hypoallergenic, immune regulatory and therapeutic properties. Further pre-clinical studies are required in murine models of chronic asthma to further address the efficacy and safety of BTH2 as a vaccine against B. tropicalis-induced allergy.
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Affiliation(s)
- Eduardo Santos da Silva
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Post-Graduate Program in Biotechnology of the Northeast Biotechnology Network (RENORBIO), Maceió, Brazil
| | - Marina Borges Rabelo de Santana
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Post-Graduate Program in Immunology, Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
| | - Elisânia Fontes Silveira
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
| | - Rogério Tanan Torres
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
| | - Raphael Chagas Silva
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Post-Graduate Program in Immunology, Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
| | | | - Emília Maria Medeiros de Andrade Belitardo
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Post-Graduate Program in Immunology, Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FioCruz), Salvador, Brazil
| | - Luis Fabián Salazar Garcés
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Post-Graduate Program in Immunology, Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Faculty of Health Sciences, Technical University of Ambato, Ambato, Ecuador
| | - Leonardo Freire Santiago
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
| | | | - Deise Souza Vilas-Bôas
- Post-Graduate Program in Immunology, Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Laboratory of Histotechnology, Department of Biomorphology, Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
| | - Luiz Antônio Rodrigues de Freitas
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FioCruz), Salvador, Brazil
- Department of Pathology of the School of Medicine, Federal University of Bahia, Salvador, Brazil
| | - Josefina Zakzuk
- Institute of Immunological Research, University of Cartagena, Cartagena, Colombia
| | - Luis Gustavo Carvalho Pacheco
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
| | | | - Fatima Ferreira
- Department of Biosciences, Paris-Lodron University of Salzburg, Salzburg, Austria
| | - Philip Cooper
- Institute of Infection and Immunity, St George's University of London, London, UK
- School of Medicine, International University of Ecuador, Quito, Ecuador
| | - Luis Caraballo
- Institute of Immunological Research, University of Cartagena, Cartagena, Colombia
| | - Carina da Silva Pinheiro
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Post-Graduate Program in Immunology, Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
| | - Neuza Maria Alcantara-Neves
- Laboratory of Allergology and Acarology (LAA), Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
- Post-Graduate Program in Biotechnology of the Northeast Biotechnology Network (RENORBIO), Maceió, Brazil
- Post-Graduate Program in Immunology, Institute of Health Sciences, Federal University of Bahia, Salvador, Brazil
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Zhang Y, Che H, Li C, Jin T. Food Allergens of Plant Origin. Foods 2023; 12:foods12112232. [PMID: 37297475 DOI: 10.3390/foods12112232] [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: 04/15/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
This review presents an update on the physical, chemical, and biological properties of food allergens in plant sources, focusing on the few protein families that contribute to multiple food allergens from different species and protein families recently found to contain food allergens. The structures and structural components of the food allergens in the allergen families may provide further directions for discovering new food allergens. Answers as to what makes some food proteins allergens are still elusive. Factors to be considered in mitigating food allergens include the abundance of the protein in a food, the property of short stretches of the sequence of the protein that may constitute linear IgE binding epitopes, the structural properties of the protein, its stability to heat and digestion, the food matrix the protein is in, and the antimicrobial activity to the microbial flora of the human gastrointestinal tract. Additionally, recent data suggest that widely used techniques for mapping linear IgE binding epitopes need to be improved by incorporating positive controls, and methodologies for mapping conformational IgE binding epitopes need to be developed.
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Affiliation(s)
- Yuzhu Zhang
- US Department of Agriculture, Agricultural Research Service, Pacific West Area, Western Regional Research Center, 800 Buchanan Street, Albany, CA 94710, USA
| | - Huilian Che
- Key Laboratory of Precision Nutrition and Food Quality, Key Laboratory of Functional Dairy, Ministry of Education, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing 100083, China
| | - Caiming Li
- US Department of Agriculture, Agricultural Research Service, Pacific West Area, Western Regional Research Center, 800 Buchanan Street, Albany, CA 94710, USA
- School of Food Science and Technology, Jiangnan University, Wuxi 214122, China
- Collaborative Innovation Center of Food Safety and Quality Control, Jiangnan University, Wuxi 214122, China
| | - Tengchuan Jin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
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Gao H, Jorgensen R, Raghunath R, Nagisetty S, Ng PKW, Gangur V. Creating hypo-/nonallergenic wheat products using processing methods: Fact or fiction? Compr Rev Food Sci Food Saf 2021; 20:6089-6115. [PMID: 34455695 DOI: 10.1111/1541-4337.12830] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/14/2021] [Accepted: 07/29/2021] [Indexed: 12/29/2022]
Abstract
Wheat allergy is a potentiallylife-threatening disease that affects millions of people around the world. Food processing has been shown to influence the allergenicity of wheat and other major foods. However, a comprehensive review evaluating whether or not food processing can be used to develop hypo-/nonallergenic wheat products is unavailable. There were three objectives for this study: (1) to critically evaluate the evidence on the effect of fermentation, thermal processing, and enzyme or acid hydrolysis on wheat allergenicity so as to identify the potential for and challenges of using these methods to produce hypo-/nonallergenic wheat products; (2) to identify the molecular effects of food processing needed to create such products; and (3) to map the concept questions for future research and development to produce hypo-/nonallergenic wheat products. We performed literature research using PubMed and Google Scholar databases with various combinations of keywords to generate the data to accomplish these objectives. We found that: (1) food processing significantly modulates wheat allergenicity; while some methods can reduce or even abolish the allergenicity, others can create mega allergens; and (2) fermentation and enzymatic hydrolysis hold the most potential to create novel hypo-/nonallergenic wheat products; however, preclinical validation and human clinical trials are currently lacking. We also identify five specific research concepts to advance the research to enable the creation of hypo-/nonallergenic wheat products for application in food, medical, and cosmetic industries.
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Affiliation(s)
- Haoran Gao
- Food Allergy and Immunology Laboratory, Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, USA
| | - Rick Jorgensen
- Food Allergy and Immunology Laboratory, Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, USA
| | - Rajsri Raghunath
- Food Allergy and Immunology Laboratory, Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, USA
| | - Siddharth Nagisetty
- Food Allergy and Immunology Laboratory, Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, USA
| | - Perry K W Ng
- Cereal Science Laboratory, Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, USA
| | - Venu Gangur
- Food Allergy and Immunology Laboratory, Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, USA
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Landers JJ, O'Konek JJ. Vaccines as therapies for food allergies. ADVANCES IN PHARMACOLOGY 2021; 91:229-258. [PMID: 34099110 DOI: 10.1016/bs.apha.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Food allergy is a growing public health epidemic with few available treatments beyond allergen avoidance and rescue medications for accidental exposures. A major focus of therapeutic development for food allergies is allergen-specific immunotherapy (AIT) in which patients are exposed to increasing amounts of allergen in controlled dosing to induce desensitization or tolerance. The work of the past few decades has culminated in the recent FDA approval of a peanut product for oral AIT for peanut allergies. Despite these advances, current AIT protocols are cumbersome, take a long time to reach clinical benefit and often have significant side effects. Therefore, there is a great need to develop new therapeutics for food allergy. One area of research aims to improve AIT through the use of adjuvants which are substances traditionally added to vaccines to stimulate or direct a specific immune response. Adjuvants that induce Th1-polarized and regulatory immune responses while suppressing Th2 immunity have shown the most promise in animal models. The addition of adjuvants to AIT may reduce the amount and frequency of allergen required to achieve clinical benefit and may induce more long-lasting immune responses. In this chapter, we highlight examples of adjuvanted AIT and vaccines in development to treat food allergies.
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Affiliation(s)
- Jeffrey J Landers
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, MI, United States
| | - Jessica J O'Konek
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, MI, United States.
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The impact of provider training on patient education for pediatric early food introduction. J Am Assoc Nurse Pract 2021; 33:1282-1289. [PMID: 33463983 DOI: 10.1097/jxx.0000000000000524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/02/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric food allergies (FAs) present significant health and economic problems. Currently, there are no cures for FAs. Recent studies suggest that early introduction (EI), between 4 and 6 months of age, of commonly allergenic foods (CAFs) may reduce the risk of developing FAs. This contradicts the current standard of care, food avoidance. LOCAL PROBLEM A federally qualified health center saw 894 patients aged 0-24 months during a 12-month period with only 18.9% receiving nutrition education. New dietary recommendations to prevent FA were not in place. METHODS A retrospective chart review was used to evaluate use of an order set with patient education on EI to CAFs in the electronic medical record (EMR). INTERVENTIONS Providers attended training on EI to CAFs and use of the EMR order set. Data were collected on the use of the order set over a 3-month period. RESULTS Provider training significantly improved knowledge of FA as well as EI guidelines. After 3 months of implementation, 25.95% of eligible encounters contained the EI order set; 52% of patients received the order set during the measurement period. In the impact population, patients 4-12 months of age, 74.55% of patients received the order set. CONCLUSIONS Evidence-based clinical content in EMR order sets coupled with provider training ensure clinical decision support in identifying, monitoring, and optimizing quality care standards.
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Han X, Krempski JW, Nadeau K. Advances and novel developments in mechanisms of allergic inflammation. Allergy 2020; 75:3100-3111. [PMID: 33068299 DOI: 10.1111/all.14632] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023]
Abstract
In the past decade, research in the molecular and cellular underpinnings of basic and clinical immunology has significantly advanced our understanding of allergic disorders, allowing scientists and clinicians to diagnose and treat disorders such as asthma, allergic and nonallergic rhinitis, and food allergy. In this review, we discuss several significant recent developments in basic and clinical research as well as important future research directions in allergic inflammation. Certain key regulatory cytokines, genes and molecules have recently been shown to play key roles in allergic disorders. For example, interleukin-33 (IL-33) plays an important role in refractory disorders such as asthma, allergic rhinitis and food allergy, mainly by inducing T helper (Th) 2 immune responses and clinical trials with IL-33 inhibitors are underway in food allergy. We discuss interleukin 4 receptor pathways, which recently have been shown to play a critical role among the allergic inflammatory pathways that drive allergic disorders and pathogenesis. Further, the cytokine thymic stromal lymphopoietin (TSLP) has recently been shown as a factor in maintaining immune homeostasis and regulating type 2 inflammatory responses at mucosal barriers in allergic inflammation and targeting TSLP-mediated signalling is considered an attractive therapeutic strategy. In addition, new findings establish an important T cell-intrinsic role of mucosa-associated lymphoid tissue lymphoma translocation protein 1 (MALT1) proteolytic activity in the suppression of autoimmune responses. We have seen how mutations in the filaggrin gene are a significant risk factor for allergic diseases such as atopic dermatitis, asthma, allergic rhinitis, food allergy, contact allergy, and hand eczema. We are only beginning to understand the mechanisms by which the human microbiota may be regulating the immune system, and how sudden changes in the composition of the microbiota may have profound effects, linked with an increased risk of developing chronic inflammatory disorders, including allergies. New research has shown the important but complex role monocytes play in disorders such as food allergies. Finally, we discuss some of the new directions of research in this area, particularly the important use of biologicals in oral immunotherapy, advances in gene therapy, multifood therapy, novel diagnostics in diagnosing allergic disorders and the central role that omics play in creating molecular signatures and biomarkers of allergic disorders such as food allergy. Such exciting new developments and advances have significantly moved forth our ability to understand the mechanisms underlying allergic diseases for improved patient care.
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Affiliation(s)
- Xiaorui Han
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
| | - James W. Krempski
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
| | - Kari Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
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The Global Rise and the Complexity of Sesame Allergy: Prime Time to Regulate Sesame in the United States of America? ALLERGIES 2020. [DOI: 10.3390/allergies1010001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Sesame allergy is a life-threatening disease that has been growing globally with poorly understood mechanisms. To protect sensitive consumers, sesame is regulated in many countries. There were four research goals for this work on sesame allergy: (i) to map the timeline, and the extent of its global rise; (ii) to dissect the complexity of the disease, and its mechanisms; (iii) to analyze the global regulation of sesame; and (iv) to map the directions for future research and regulation. We performed a literature search on PubMed and Google Scholar, using combinations of key words and analyzed the output. Regulatory information was obtained from the government agencies. Information relevant to the above goals was used to make interpretations. We found that: (i) the reports appeared first in 1950s, and then rapidly rose globally from 1990s; (ii) sesame contains protein and lipid allergens, a unique feature not found in other allergenic foods; (iii) it is linked to five types of diseases with understudied mechanisms; and (iv) it is a regulated allergen in 32 advanced countries excluding the USA. We also provide directions for filling gaps in the research and identify implications of possible regulation of sesame in the USA.
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Wang N, Zhou Y, Wu M, Zhu H, Cui Y. Expression, epitope prediction and IgE-binding of the Tyrophagus putrescentiae group 13 allergen. Exp Ther Med 2020; 20:21. [PMID: 32934686 PMCID: PMC7471918 DOI: 10.3892/etm.2020.9149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/22/2020] [Indexed: 12/02/2022] Open
Abstract
Storage mites, such as Tyrophagus putrescentiae, are an important source of allergens that cause allergic diseases in humans. It has previously been indicated that T. putrescentiae has a high sensitization rate as an allergen in some Asian and European countries. Identifying and cloning the allergens in this species may enable improved diagnostic and therapeutic approaches. The aim of the present study was to clone and sequence the T. putrescentiae group 13 allergen (Tyr p 13) isolated from storage mites in China, to use bioinformatics tools to model its biophysical characteristics and to induce protein expression to test its IgE-binding activity. The full-length cDNA comprised 486 bp and was predicted to include a signal peptide of 22 amino acids. Its secondary structure was shown to comprise an α-helix (10.79%), extended strand (33.81%) and random coils (55.40%). Using homology modeling, the present study constructed a reasonable tertiary structure of Tyr p 13. Linear Bcell epitopes at amino acids 47-53, 70-76, 81-86, 101-105 and 112120 were predicted. Three discontinuous B-cell epitopes were also predicted: i) 47, 48, 49, 50, 51, 52, 53, 70, 71, 72 and 73; ii) 91, 92, 93, 94, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121 and 138; and iii) 74, 76, 79, 81, 82, 83, 84, 86, 101, 102, 103, 104 and 105. SDS-PAGE identified a specific band at the predicted molecular weight of the recombinant Tyr p 13 (rTyr p 13), demonstrating its successful expression. The rTyr p 13 bound to IgE in the serum of 13.2% (5/38) of patients allergic to T. putrescentiae, according to ELISA. The successful cloning of Tyr p 13 and basic bioinformatics analysis of the protein provided a foundation for the further study of this allergen with regards to the diagnosis and treatment of patients allergic to storage mites. These results provided a theoretical basis for the design of rTyr p 13 with modified B-cell epitopes.
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Affiliation(s)
- Nan Wang
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, Jiangsu 224005, P.R. China
| | - Ying Zhou
- Department of Pediatrics Laboratory, Wuxi Children's Hospital, Wuxi, Jiangsu 214023, P.R. China
| | - Meili Wu
- Department of Pediatrics Laboratory, Wuxi Children's Hospital, Wuxi, Jiangsu 214023, P.R. China
| | - Hanting Zhu
- Department of Clinical Laboratory, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, P.R. China
| | - Yubao Cui
- Department of Clinical Laboratory, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, P.R. China
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