Diagnosis of Sesame Allergy: Analysis of Current Practice and Exploration of Sesame Component Ses i 1

Precision allergy molecular diagnosis applications in food allergy

PURPOSE OF REVIEW

Precision medicine has become important in the diagnosis and management of food allergies. This review summarizes the latest information regarding molecular allergology, an essential component of food allergy managements.

RECENT FINDINGS

Component-resolved diagnostics (CRD) can be used to investigate sensitization to allergens based on symptoms and to reveal co-sensitization and/or cross-sensitization in patients with allergies. The following allergen components are known to be associated with symptoms: ovomucoid from eggs, omega-5 gliadin from wheat, and many storage proteins (Gly m 8 from soy, Ara h 2 from peanut, Cor a 14 from hazelnut, Ana o 3 from cashew nut, Jug r 1 from walnut, and Ses i 1 from sesame). Recent studies on allergens of macadamia nuts (Mac i 1 and Mac i 2), almonds (Pru du 6), fish (parvalbumin and collagen), and shrimp (Pem m 1 and Pem m 14) have provided additional information regarding CRD. In addition, Pru p 7 is a risk factor for systemic reactions to peaches and has recently been found to cross-react with cypress and Japanese cedar pollen.

SUMMARY

CRD provides information of individualized sensitization profiles related to symptoms and severity of allergies in patients. Clinical practice based on CRD offers many benefits, such as higher diagnostic accuracy and improved management of individual patients.

Molecular Allergology and Component-Resolved Diagnosis in Current Clinical Practice

Specific immunoglobulin E immunodiagnostics is becoming a convenient way to identify allergic patients and their specific allergies. These results are comparable to skin testing and may be more accessible for some populations. Each allergen contains thousands of molecules but only a few of these molecules are allergenic to humans. Each allergen has a number of individual components-generally proteins-which have different characteristics that may impact the effects of sensitization. Identification of the specific component allows for differentiation of the true allergies and can help to determine the risk of a significant clinical response.

Comprehensive Diagnosis, Management, and Treatment of Sesame Allergy

Sesame allergy prevalence varies regionally and by age, in the range of 0.1% to 0.9%. Reactions can be severe and potentially fatal. Resolution rates are in the range of 20% to 50%. The diagnosis requires a careful history and the use of tests, such as skin prick tests and serum sesame-specific IgE. The availability of serum IgE testing for the sesame protein Ses i 1 has improved diagnostic accuracy. The emerging potential for sesame basophil activation tests and additional new tests will likely improve diagnosis in coming years, further reducing the need for diagnostic oral food challenges. Although sesame proteins share homology with those in many foods, clinically relevant cross-reactivity appears uncommon. Nevertheless, sesame is a prominent allergen for those with multiple food allergies. Management may include strict avoidance, but sesame products vary dramatically in protein content. Many people with sesame allergy tolerate forms that are low in protein, such as scattered seeds, rather than sesame paste that is protein-dense. Thus, options in the approach to avoidance are possible. Studies suggest that sesame oral immunotherapy may be safe and effective, and this and additional treatment options are emerging. Here, we review the current comprehensive diagnosis, management, and treatment for sesame allergy.

Systematic review and meta-analyses on the accuracy of diagnostic tests for IgE-mediated food allergy

The European Academy of Allergy and Clinical Immunology (EAACI) is updating the Guidelines on Food Allergy Diagnosis. We aimed to undertake a systematic review of the literature with meta-analyses to assess the accuracy of diagnostic tests for IgE-mediated food allergy. We searched three databases (Cochrane CENTRAL (Trials), MEDLINE (OVID) and Embase (OVID)) for diagnostic test accuracy studies published between 1 October 2012 and 30 June 2021 according to a previously published protocol (CRD42021259186). We independently screened abstracts, extracted data from full texts and assessed risk of bias with QUADRAS 2 tool in duplicate. Meta-analyses were undertaken for food-test combinations for which three or more studies were available. A total of 149 studies comprising 24,489 patients met the inclusion criteria and they were generally heterogeneous. 60.4% of studies were in children ≤12 years of age, 54.3% were undertaken in Europe, ≥95% were conducted in a specialized paediatric or allergy clinical setting and all included oral food challenge in at least a percentage of enrolled patients, in 21.5% double-blind placebo-controlled food challenges. Skin prick test (SPT) with fresh cow's milk and raw egg had high sensitivity (90% and 94%) for milk and cooked egg allergies. Specific IgE (sIgE) to individual components had high specificity: Ara h 2-sIgE had 92%, Cor a 14-sIgE 95%, Ana o 3-sIgE 94%, casein-sIgE 93%, ovomucoid-sIgE 92/91% for the diagnosis of peanut, hazelnut, cashew, cow's milk and raw/cooked egg allergies, respectively. The basophil activation test (BAT) was highly specific for the diagnosis of peanut (90%) and sesame (93%) allergies. In conclusion, SPT and specific IgE to extracts had high sensitivity whereas specific IgE to components and BAT had high specificity to support the diagnosis of individual food allergies.

Sesame eliciting and safe doses in a large sesame allergic population

BACKGROUND

Sesame is a significant food allergen causing severe and even fatal reactions. Given its increasing prevalence in western diet, sesame is listed as an allergenic food requiring labeling in the United States and EU. However, data on the population reaction doses to sesame are limited.

METHODS

All sesame oral food challenges (OFCs), performed either for diagnosis or for threshold identification before the beginning of sesame oral immunotherapy (OIT) between November 2011 and July 2021 in Shamir medical center were analyzed for reaction threshold distribution. Safe-dose challenges with 90-120 min intervals were also analyzed.

RESULTS

Two hundred and fifty patients underwent 338 positive OFCs, and additional 158 safe-dose OFCs were performed. The discrete and cumulative protein amounts estimated to elicit an objective reaction in 1% (ED01) of the entire cohort (n = 250) were 0.8 mg (range 0.3-6.3) and 0.7 mg (range 0.1-7.1), respectively, and those for 5% of the population (ED05) were 3.4 mg (range 1.2-20.6) and 4.5 mg (range 1.2-28.8), respectively. Safe-dose OFCs showed similar values of ED01 (0.8, 0.4-7.5 mg) and ED05 (3.4, 1.2-22.9 mg). While doses of ≤1 mg sesame protein elicited oral pruritus in 11.6% of the patients, no objective reaction was documented to this amount in any of the challenges, including safe-dose OFCs.

CONCLUSIONS

This study provides data on sesame reaction threshold distribution in the largest population of allergic patients studied, with no right or left censored data, and with validation using a safe-dose OFC. It further supports the current methods for ED determination as appropriate for establishing safety precautions for the food industry.

Sesame allergy in children: New insights into diagnosis and management

Sesame is a potentially potent allergen that can trigger skin, gastrointestinal, and respiratory tract symptoms, and anaphylaxis. Only 20% to 30% of sesame-allergic children develop tolerance. The prevalence of sesame allergy depends on local diets and ranges from 0.1% to 0.9%. A high risk of accidental exposure to sesame has resulted in mandatory food labeling in many countries. More than half of patients with sesame allergy are also allergic to peanut/tree nuts. Serum-specific IgE testing with a quantitative Ses i 1 component can be performed safely and has higher clinical specificity and better positive predictive value for oral food challenge (OFC) than whole sesame extract or skin prick testing (SPT). Compared with SPT or OFC, in vitro Ses i 1 testing requires no special techniques and carries no risk of reactions. Diagnosis of suspected sesame allergy begins with a thorough history and physical examination. A positive sesame extract test (≥0.1 kUA /L) should prompt further testing. In patients with a high probability of reacting, results of component testing may facilitate a decision about performing an OFC. In a Japanese study of OFC and Ses i 1, there was a 5% probability of a positive OFC with Ses i 1 sIgE levels <0.13 kUA /L, and a 50% probability of a positive OFC with levels >32.0 kUA /L. Most patients could safely consume sesame if sIgE levels were <0.13 kUA /L. Ses i 1 testing can be used to guide appropriate management (avoidance, emergency medication, and oral immunotherapy).

Open sesame: Shedding light on an emerging global allergen

BACKGROUND

Sesame allergy has been characterized in the Middle East for some time. However, it has become more widely recognized as foods containing sesame and sesame seeds have become increasingly available in Australia, Europe, and North America. With the passage of the Food Allergy Safety, Treatment, Education, and Research Act in 2021, the United States will join other countries in identifying sesame as a major food allergen and require sesame to be labeled as a food allergen beginning in 2023.

OBJECTIVE

To review the literature related to sesame allergy as an increasingly recognized food allergen around the world.

DATA SOURCES

English-language articles retrieved by PubMed searches with relevance to sesame allergy.

STUDY SELECTIONS

Articles were included using the search terms "sesame allergy" and "sesame seed allergy."

RESULTS

A total of 69 relevant articles regarding sesame allergy, relating to its prevalence, clinical presentation, natural history, allergenic epitopes, diagnosis, and treatment, were selected.

CONCLUSION

In recent decades, considerable gains have been made in determining prevalence and natural history of sesame allergy. With increased recognition and prevalence come the need for reliable methods of identification of sesame allergy and approaches for management.

Sesame as a source of food allergens: clinical relevance, molecular characterization, cross-reactivity, stability toward processing and detection strategies

Sesame is an allergenic food with an increasing allergy prevalence among the European/USA population. Sesame allergy is generally life-persisting, being the cause of severe/systemic adverse immune responses in sesame-allergic individuals. Herein, clinical data about sesame allergy, including prevalence, diagnosis, relevance, and treatments are described, with focus on the molecular characterization of sesame allergens, their cross-reactivity and co-sensitization phenomena. The influence of food processing and digestibility on the stability/immunoreactivity of sesame allergens is critically discussed and the analytical approaches available for their detection in foodstuffs. Cross-reactivity between sesame and tree nuts or peanuts is frequent because of the high similarities among proteins of the same family. However, cross-reactivity phenomena are not always correlated with true clinical allergy in sensitized patients. Data suggest that sesame allergens are resistant to heat treatments and digestibility, with little effect on their immunoreactivity. Nevertheless, data are scarce, evidencing the need for more research to understand the effect of food processing on sesame allergenicity modulation. The demands for identifying trace amounts of sesame in foods have prompted the development of analytical methods, which have targeted both protein and DNA markers, providing reliable, specific, and sensitive tools, crucial for the effective management of sesame as an allergenic food.

Sesame allergy: mechanisms, prevalence, allergens, residue detection, effects of processing and cross-reactivity

Sesame allergy is a serious public health problem and is mainly induced by IgE-mediated reactions, whose prevalence is distributed all over the world. Sesame has been included on the priority allergic food list in many countries. This review summarizes the mechanism and prevalence of sesame allergy. The characteristics, structures and epitopes of sesame allergens (Ses i 1 to Ses i 7) are included. Moreover, the detection methods for sesame allergens are evaluated, including nucleic-acid, immunoassays, mass spectrometry, and biosensors. Various processing techniques for reducing sesame allergenicity are discussed. Additionally, the potential cross-reactivity of sesame with other plant foods is assessed. It is found that the allergenicity of sesame is related to the structures and epitopes of sesame allergens. Immunoassays and mass spectrometry are the major analytical tools for detecting and quantifying sesame allergens in food. Limited technologies have been successfully used to reduce the antigenicity of sesame, involving microwave heating, high hydrostatic pressure, salt and pH treatment. More technologies for reducing the allergenicity of sesame should be widely investigated in future studies. The reduction of allergenicity in processed sesames should be ultimately confirmed by clinical studies. What's more, sesame may exhibit cross-reactivity with peanut and tree nuts.

The role of diagnostic tests and oral food challenge results to predict sesame allergy

BACKGROUND

The presence of sesame allergy and its importance are increasing.

OBJECTIVE

To determine the results of sesame and tahini oral food challenges (OFCs) and whether sesame-specific immunoglobulin E and skin prick tests (SPTs) accurately predicted sesame allergy in children.

METHODS

Patients with suspected sesame allergy between June 1, 2018, and June 1, 2020, were examined.

RESULTS

Of 92 patients (n = 65, 70.7% of the patients were boys) with a median age of 2 years (interquartile range, 1.2-3.8 years), 64 were reactive to tahini. Of 64 patients, 41 had a positive OFC result and 23 had a consistent history. Of 54 sesame OFCs, 10 patients had a positive outcome. Of 44 with a negative outcome of sesame OFC, 4 experienced allergic reactions with tahini at home and 22 patients had a positive result for tahini OFC. In multivariate logistic regression analysis, clinical reactivity of sesame (either a consistent history or a positive OFC) was positively associated with sesame SPT (odds ratio, 2.120; 95% confidence interval, 1.136-3.957; P = .01) and tahini SPT (odds ratio, 1.661; 95% confidence interval, 1.143-2.413; P = .008). Nevertheless, sesame-specific immunoglobulin E did not predict clinical reactivity. Tahini OFC outcomes were well predicted for both sesame and tahini SPTs (area under the curves of 0.937 and 0.896, respectively, P < .001 for both). A sesame SPT wheal size of 5.25 mm had 90.6% sensitivity, 82.1% specificity, and 5.1 positive likelihood ratio. For tahini SPT, the 6-mm threshold had 100% sensitivity, 82.1% specificity, and 5.6 positive likelihood ratio.

CONCLUSION

In the OFC, tahini emerged as a more optimal diagnostic tool to avoid false negatives. Furthermore, both high sesame and tahini SPT levels individually can help predict the diagnosis of sesame allergy.

Combinatorial advantage of Ses i 1-specific IgE and basophil activation for diagnosis of sesame food allergy

BACKGROUND

The prevalence of sesame food allergy (SFA) is increasing worldwide with the potential of anaphylactic reactions upon exposure. Utility of specific component IgE testing as an alternative to the oral food challenge (OFC), the diagnostic standard, is being investigated.

METHODS

Patients (n = 42) with suspected SFA completed an open OFC to sesame. Diagnostic testing included serum levels of Ses i 1-specific IgE, skin prick test with high-protein extract, and basophil reactivity (% induced CD63 expression) for each patient. The diagnostic utility of these tests was evaluated at a 95% sensitivity, with the outcome measure being the number of OFCs required.

RESULTS

Twenty-seven patients (64%) were diagnosed with SFA. Ses i 1 IgE differed significantly between allergic and tolerant patients (p = .0001). ROC curve analysis for Ses i 1 IgE yielded an AUC of 0.88 ± 0.05. Levels of Ses i 1 IgE correlated to induced CD63+ expression on basophils (p = .0001). Ses i 1 IgE was not sufficiently robust as a single step for diagnosis. Used concurrently, BAT and Ses i 1 IgE yielded correct positive classifications for 25 of 27 sesame-allergic patients with two false positives (93% PPV). Both tests were negative in 5 non-allergic patients. Patients with divergent Ses i 1 IgE and BAT results required OFC (n = 10, 24% of patients). Alternatively, sequential use of BAT, ruling in SFA followed by Ses i 1 IgE diagnosing non-allergic patients, yielded a 89% PPV, with 19% requiring OFC.

CONCLUSION

Ses i 1 IgE and BAT used together can decrease the need for OFC in most SFA patients. A prospective cohort trial is necessary to validate these results.

Peanut Can Be Used as a Reference Allergen for Hazard Characterization in Food Allergen Risk Management: A Rapid Evidence Assessment and Meta-Analysis

Regional and national legislation mandates the disclosure of “priority” allergens when present as an ingredient in foods, but this does not extend to the unintended presence of allergens due to shared production facilities. This has resulted in a proliferation of precautionary allergen (“may contain”) labels (PAL) that are frequently ignored by food-allergic consumers. Attempts have been made to improve allergen risk management to better inform the use of PAL, but a lack of consensus has led to variety of regulatory approaches and nonuniformity in the use of PAL by food businesses. One potential solution would be to establish internationally agreed “reference doses,” below which no PAL would be needed. However, if reference doses are to be used to inform the need for PAL, then it is essential to characterize the hazard associated with these low-level exposures. For peanut, there are now published data relating to over 3000 double-blind, placebo-controlled challenges in allergic individuals, but a similar level of evidence is lacking for other priority allergens. We present the results of a rapid evidence assessment and meta-analysis for the risk of anaphylaxis to a low-level allergen exposure for priority allergens. On the basis of this analysis, we propose that peanut can and should be considered an exemplar allergen for the hazard characterization at a low-level allergen exposure.

Improving Diagnostic Accuracy in Food Allergy

The diagnosis of food allergy can have a major impact on the lives of patients and families, imposing dietary restrictions and limitations on social activities. On the other hand, misdiagnosis can place the patient at risk of a potentially severe allergic reaction. Therefore, an accurate diagnosis of food allergy is of utmost importance. The diagnosis of food allergy is often established by the combination of the clinical history and allergen-specific IgE; however, without a clear history of an allergic reaction, the interpretation of IgE sensitization tests can be difficult. There are also rare cases of clinical food allergy in the absence of IgE sensitization. For that reason, testing for suspected food allergy ideally requires access to oral food challenges (OFCs), which are currently the gold standard tests to diagnose food allergy. As OFCs are time consuming and involve the risk of acute allergic reactions of unpredictable severity, the question remains: how can we improve the accuracy of diagnosis before referring the patient for an OFC? Herein, we review the predictive value of different tests used to support the diagnosis of food allergy, discuss implications for therapy and prognosis, and propose a diagnostic approach to be applied in clinical practice.

Cell-Based Functional IgE Assays Are Superior to Conventional Allergy Tests for Shrimp Allergy Diagnosis

BACKGROUND

The diagnosis of shellfish allergy currently relies on patient history, skin prick test (SPT), and serum specific IgE (sIgE) quantification. These methods lack sufficient diagnostic accuracy, whereas the gold standard of oral food challenges is risky and burdensome. Markers of reactivity and severity of allergic reactions to shellfish will improve clinical care of these patients.

OBJECTIVES

This study compared the diagnostic performance of SPT, sIgE, basophil activation test (BAT), and IgE crosslinking-induced luciferase expression (EXiLE) test for shrimp allergy.

METHODS

Thirty-five subjects with documented history of shrimp allergic reactions were recruited and grouped according to results of double-blind, placebo-controlled food challenge (DBPCFC). In addition to routine diagnostics, BAT (Flow CAST) and EXiLE test with shrimp extract and tropomyosin were performed.

RESULTS

Of 35 subjects, 15 were shrimp allergic with pruritus, urticaria, and itchy mouth on DBPCFC, whereas 20 were tolerant to shrimp. Tropomyosin only accounted for 53.3% of sensitization among subjects with challenge-proven shrimp allergy. BAT using shrimp extract as stimulant showed the highest area under curve value (0.88), Youden Index (0.81), likelihood ratio (14.73), odds ratio (104), and variable importance (4.27) when compared with other assays and tropomyosin diagnosis. Results of BAT significantly correlated with those of EXiLE (r = 0.664, P < .0001).

CONCLUSIONS

BAT is a more accurate diagnostic marker for shrimp allergy than SPT and shrimp sIgE, whereas the EXiLE test based on an IgE crosslinking assay is a good alternative to BAT. Tropomyosin may not be the most important shrimp allergen in Chinese, which warrants further investigation to search for other major allergens and diagnostic markers.