Dramatic augmentation of wheat allergy by aspirin in a dose-dependent manner

Evaluation and Updated Classification of Acute Hypersensitivity Reactions to Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAID-Exacerbated or -Induced Food Allergy

BACKGROUND

There are hypersensitivity reactions (HRs) to foods in which nonsteroidal anti-inflammatory drugs (NSAIDs) act as aggravating factors (NSAID-exacerbated food allergy [NEFA]) or cofactors (NSAID-induced food allergy [NIFA]), often misdiagnosed as HRs to NSAIDs. Urticarial/angioedematous and/or anaphylactic reactions to two or more chemically unrelated NSAIDs do not meet current classification criteria. However, they may be considered part of a cross-reactive type of acute HR, which is NSAID-induced urticaria/angioedema with or without respiratory or systemic symptoms of anaphylaxis.

OBJECTIVE

To evaluate patients reporting acute HRs to NSAIDs and classify them according to updated criteria.

METHODS

We prospectively studied 414 patients with suspected HRs to NSAIDs. For all whom met these criteria, NEFA/NIFA was diagnosed: (1) mild reactions to (NEFA) or tolerance of (NIFA) the suspected foods without taking NSAIDs; (2) cutaneous and/or anaphylactic reactions to the combination foods plus NSAIDs; (3) positive allergy tests to the suspected foods; and (4) negative drug challenges (DCs) with the NSAIDs involved.

RESULTS

A total of 252 patients were given the diagnosis of NSAID hypersensitivity (60.9%), 108 of whom had NSAID-induced urticaria/angioedema with or without respiratory or systemic symptoms of anaphylaxis. We excluded NSAID hypersensitivity in 162 patients (39.1%) who tolerated DCs with the suspected NSAIDs, nine of whom received a diagnosis of NEFA, and 66 of NIFA. Pru p 3 was implicated in 67 of those 75 patients who received a diagnosis of NEFA or NIFA.

CONCLUSIONS

NEFA and NIFA account for about 18% of patients reporting HRs to NSAIDs, in which Pru p 3 is the main responsible food allergen. Therefore, patients with cutaneous and/or anaphylactic reactions to NSAIDs should be carefully questioned about all foods ingested within 4 hours before or after NSAID exposure, and targeted food allergy tests should be considered in the diagnostic workup of these patients. If testing is positive, DCs with the suspected NSAIDs should also be considered.

Progress in understanding hypersensitivity reactions to nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs), the medications most commonly used for treating pain and inflammation, are the main triggers of drug hypersensitivity reactions. The latest classification of NSAIDs hypersensitivity by the European Academy of Allergy and Clinical Immunology (EAACI) differentiates between cross-hypersensitivity reactions (CRs), associated with COX-1 inhibition, and selective reactions, associated with immunological mechanisms. Three phenotypes fill into the first group: NSAIDs-exacerbated respiratory disease, NSAIDs-exacerbated cutaneous disease and NSAIDs-induced urticaria/angioedema. Two phenotypes fill into the second one: single-NSAID-induced urticaria/angioedema/anaphylaxis and single-NSAID-induced delayed reactions. Diagnosis of NSAIDs hypersensitivity is hampered by different factors, including the lack of validated in vitro biomarkers and the uselessness of skin tests. The advances achieved over recent years recommend a re-evaluation of the EAACI classification, as it does not consider other phenotypes such as blended reactions (coexistence of cutaneous and respiratory symptoms) or food-dependent NSAID-induced anaphylaxis. In addition, it does not regard the natural evolution of phenotypes and their potential interconversion, the development of tolerance over time or the role of atopy. Here, we address these topics. A state of the art on the underlying mechanisms and on the approaches for biomarkers discovery is also provided, including genetic studies and available information on transcriptomics and metabolomics.

A New Diagnostic Criteria of Wheat-Dependent, Exercise-Induced Anaphylaxis in China

Background:

Wheat-dependent, exercise-induced anaphylaxis (WDEIA) is an allergic reaction induced by intense exercise combined with wheat ingestion. The gold standard for diagnosis of WDEIA is a food exercise challenge; however, this test is unacceptable for Chinese WDEIA patients and unable to be approved by the Ethics Committee of Chinese hospitals due to substantial risk. There are no diagnostic criteria for Chinese WDEIA patients. The aim of present study was to propose new practical diagnosis criteria for Chinese WDEIA patients.

Methods:

We prospectively included 283 clinically diagnosed WDEIA patients from January 1, 2010 to June 30, 2014, and in the meanwhile, three groups were enrolled which included 133 patients with the history of anaphylaxis induced by food other than wheat, 186 recurrent urticaria patients, and 94 healthy participants. Clinical comprehensive evaluation by allergists used as the reference gold standard, receiver operator characteristic (ROC) curves were plotted, areas under curve (AUC) for specific immunoglobin E (sIgE) were compared to evaluate the diagnostic value of IgE specific to wheat, gluten, and ω-5 gliadin. Patients were followed up by telephone questionnaire 1 year after diagnosis.

Results:

We reviewed 567 anaphylactic reactions in 283 WDEIA patients. Of these anaphylactic reactions, 415 (73.3%) reactions were potentially life-threatening anaphylaxis. Among the 567 anaphylactic reactions, 75% (425/567) occurred during exercise. The highest AUC (0.910) was observed for sIgE for gluten, followed by omega-5 gliadin (AUC 0.879). Combined gluten- and ω-5 gliadin-specific IgE testing provided sensitivity and specificity of 73.1% and 99.0%, respectively. During the 1-year follow-up period, repeat anaphylaxis was rare when patients observed strict avoidance of wheat products combined with exercise or other triggering agents.

Conclusions:

In this study, we proposed diagnostic criteria and management of WDEIA patients in China. Our present study suggested that confirmed anaphylactic reactions triggered by wheat with positive sIgE to gluten and omega-5-gliadin may provide supportive evidence for clinicians to make WDEIA diagnosis without performing a food exercise challenge.

Wheat-Dependent Cofactor-Augmented Anaphylaxis: A Prospective Study of Exercise, Aspirin, and Alcohol Efficacy as Cofactors

BACKGROUND

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a severe and potentially life-threatening allergy caused by wheat ingestion and most commonly in combination with exercise.

OBJECTIVE

To investigate the role and impact of different cofactors (exercise, aspirin, and alcohol) in patients with WDEIA.

METHODS

We studied 25 adult patients with WDEIA. Diagnostic workup included specific IgE to omega-5 gliadin and skin prick test with wheat flour and gluten. Titrated oral challenge was performed with gluten at rest, combined with treadmill exercise, aspirin, alcohol, or a combination of exercise and aspirin.

RESULTS

A positive challenge to gluten was found at rest (without cofactors) in 48% (12 of 25), with exercise in 92% (23 of 25), with aspirin in 84% (21 of 25), with alcohol in 56% (9 of 19), and with a combination of exercise and aspirin in 82% (18 of 22) of the patients. With exercise as a cofactor, the median threshold was 24 g (range, 4.8-80 g), with aspirin 8 g (range, 2.4-80 g), and with alcohol 28 g (range, 0-45 g). The combination of 2 cofactors (exercise and aspirin) resulted in a median threshold of 4.3 g (range, 1.1-48 g). The threshold for the clinical reaction was lowered by 63%, 83%, 36%, and 87%, respectively, compared with at rest. The mean severity grade (scale 0-5) according to the Sampson severity score at rest was 0.8 (range, 0-2), and when combined with exercise 2.1 (range, 0-5), with aspirin 1.9 (range, 0-5), with alcohol 0.8 (range, 0-2), and with the combination of exercise and aspirin 1.5 (range, 0-2).

CONCLUSION

Our results demonstrate that exercise and aspirin augment clinical reactions in WDEIA by lowering the threshold and increase the severity of the allergic reaction, whereas alcohol gives ambiguous results. Furthermore, a combination of 2 cofactors (exercise and aspirin) increases the risk of reactions.

Surfing as a risk factor for sensitization to poly(γ-glutamic acid) in fermented soybeans, natto, allergy

BACKGROUND

Poly(γ-glutamic acid) (PGA) is an allergen in natto, fermented soybeans, which causes late-onset anaphylaxis. We hypothesized that jellyfish stings sensitize adults to PGA because a surfer had allergies to both natto and jellyfish, whose sting contains PGA. The aim of the study was to identify behavioral factors, such as marine sports, associated with PGA sensitization.

METHODS

Outpatients diagnosed with food allergies based on relevant clinical history, positive skin test and/or food challenge test answered a questionnaire during a regular visit in 2016.

RESULTS

Questionnaire data from 140 outpatients were analyzed. These patients were divided into two groups: natto allergy group (13 patients, M:F = 10:3, mean age 40.6 years) and non-natto allergy group (127 patients, M:F = 46:81, mean age 44.5 years). All patients with natto allergy had positive results in skin prick test and basophil activation test with PGA. Of these, 92.3% had a marine sport hobby, especially surfing (84.6%). PGA sensitization was independently associated with marine sports (odds ratio, 278.0, 95 percent confidence interval, 36.9-6315.9, p < 0.001) adjusted for male sex and sea bathing, but not with male sex or sea bathing. In addition, although there was no significant difference in the experience of marine sports between natto and non-natto allergy groups, the natto allergy group participated significantly more frequently in marine sports than the non-natto allergy group (p < 0.001). There was no significant difference between natto consumption amount and PGA sensitization.

CONCLUSIONS

Surfing is a risk factor for PGA sensitization in those with allergy to natto.

Gibberellin-regulated protein in Japanese apricot is an allergen cross-reactive to Pru p 7

Background

Gibberellin‐regulated protein (GRP, also known as peamaclein) was recently identified as a new marker allergen related to systemic reactions in peach allergy; however, its role in other fruit allergies is unknown.

Objective

To investigate the allergenicity of Japanese apricot (JA) GRP and clarify the clinical characteristics of JA allergy patients with GRP sensitization.

Methods

Seven patients (two males, five females, mean age 28.0 years) diagnosed with JA allergy based on relevant clinical history, positive skin test and/or challenge test were enrolled. JA GRP with a molecular weight of 6896.5 Da was purified by ion‐exchange column chromatography. We performed enzyme‐linked immunosorbent assay (ELISA), IgE‐immunoblotting, basophil activating tests (BATs), and skin prick tests (SPTs) with purified JA GRP. To investigate the cross‐reactivity between JA GRP and native Pru p 7 (nPru p 7), we performed ELISA inhibition tests. We measured specific IgE levels against apricot, peach, rPru p 1, rPru p 3, and rPru p 4 using ImmunoCAP.

Results

ELISA and IgE‐immunoblotting using JA GRP showed positive reactions in six (85.7%) and seven (100%) patients, respectively. Five patients who provided informed consent for BATs and SPTs using JA GRP had positive results. In four patients who underwent ELISA inhibition tests using JA GRP and nPru p 7, IgE binding to one GRP inhibited binding to the other. The positivity for specific IgE against apricot, peach, rPru p 1, rPru p 3, and rPru p 4 was 14.3%, 57.1%, 0%, 0%, and 0%, respectively. Patients developed allergic reactions that were frequently accompanied with facial swelling, especially of the eyelids, which was dependent on cofactors, such as exercise.

Conclusions and Clinical Relevance

These results indicated that GRP might be a causative allergen of JA allergy, whose onset frequently requires a cofactor, such as exercise, and might be cross‐reactive between JAs and peaches.

Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs: from phenotyping to genotyping

PURPOSE OF REVIEW

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most frequent drugs involved in hypersensitivity drugs reactions. Both immunological and nonimmunological mechanisms can be involved. We describe the different phenotypes as well as analyze the genetic basis for NSAIDs hypersensitivity.

RECENT FINDINGS

Five major clinical entities are currently accepted in the classification of hypersensitivity reactions to NSAIDs. Three are mediated by nonspecific immunological mechanisms: NSAIDs-exacerbated respiratory disease, NSAIDs-exacerbated cutaneous disease and NSAIDs-induced urticaria/angioedema. Two are mediated by specific immunological mechanisms: single-NSAID-induced urticaria/angioedema or anaphylaxis and single-NSAID-induced delayed hypersensitivity reactions. The classification becomes more complex if we consider that in an important number of cases skin and airway involvement can occur, as well as the participation of other organs.

SUMMARY

Hypersensitivity reactions to NSAIDs are more complex than for other drugs like betalactams in terms of the number and types of reactions elicited, and mechanisms involved. As NSAIDs are the most frequent cause of drug hypersensitivity, it is feasible to gather a sufficient number of cases for undertaking pharmacogenetic studies.

Effective induction of oral anaphylaxis to ovalbumin in mice sensitized by feeding of the antigen with aid of oil emulsion and salicylate

It is important to evaluate the ability of novel proteins in food crops and products to elicit potentially harmful immunologic responses, including allergic hypersensitivity. We developed a novel mouse model of food allergy involving an oral challenge of a protein antigen after feeding of the antigen in combination with modulating factors often ingested in daily life, namely, dietary oil emulsion and salicylate. In the model, BALB/c mice were sensitized orally for three weeks with ovalbumin (OVA) in linoleic acid/lecithin emulsion, followed immediately by intraperitoneal injection of sodium salicylate. At the end of the sensitization, the incidence of mice positive for serum OVA-specific IgG1 but not IgE had significantly increased in the combined-sensitization group. After the 3-week sensitization, a single or double oral challenge with OVA effectively and significantly caused severe anaphylaxis, as compared with the groups sensitized with OVA in the emulsion or the vehicle alone. Moderate increase of plasma histamine and intestinal abnormality in histology was found only in the combined-sensitization group. Anaphylaxis symptoms in the sensitized mice were induced more by oral challenge than by intravenous challenge, suggesting a critical role for the mucosal system. This is the first model for successful induction of oral anaphylaxis in mice sensitized by feeding of food protein without adjuvant. It will be useful to elucidate the mechanism of food allergy and to detect modulating factors of oral allergy at sensitization using this model, which simulates real life conditions.

Co-factor-enhanced food allergy

BACKGROUND

Alcohol, exercise or non-steroidal anti-inflamatory drugs (NSAID) are frequently mentioned as amplifiers of food allergic reactions but only individual cases or small series have been previously published.

METHODS

Descriptive study including 74 cases of suspected co-factor enhanced food allergy, assessed by skin-prick tests, specific IgE and oral challenges.

RESULTS

Anaphylaxis accounted for 85.1% of reactions. In 99% of cases culprit food allergens were plant-derived, mainly vegetables and cereals. NSAID were involved in 58%, exercise in 52.7% and alcohol in 12.2%. Lipid transfer protein was the most frequently involved allergen.

CONCLUSIONS

Co-factor enhanced food allergy should be considered when assessing food, alcohol, exercise and NSAID allergic reactions.

Co-factor-enhanced food allergy

BACKGROUND

Alcohol, exercise or non-steroidal anti-inflamatory drugs (NSAID) are frequently mentioned as amplifiers of food allergic reactions but only individual cases or small series have been previously published.

METHODS

Descriptive study including 74 cases of suspected co-factor enhanced food allergy, assessed by skin-prick tests, specific IgE and oral challenges.

RESULTS

Anaphylaxis accounted for 85.1% of reactions. In 99% of cases culprit food allergens were plant-derived, mainly vegetables and cereals. NSAID were involved in 58%, exercise in 52.7% and alcohol in 12.2%. Lipid transfer protein was the most frequently involved allergen.

CONCLUSIONS

Co-factor enhanced food allergy should be considered when assessing food, alcohol, exercise and NSAID allergic reactions.

Diagnostic value of the serum-specific IgE ratio of ω-5 gliadin to wheat in adult patients with wheat-induced anaphylaxis

BACKGROUND

Wheat is an important food allergen associated with severe allergic reactions, including wheat-dependent exercise-induced anaphylaxis (WDEIA) and wheat-induced anaphylaxis (WIA). To diagnose WDEIA, an exercise challenge test following wheat ingestion is performed, which is time-consuming and unsafe. The compound ω-5 gliadin has been identified as a major allergen for WDEIA and WIA. We evaluated the diagnostic value of serum immunoglobulin E (IgE) ratios of ω-5 gliadin to wheat in adult patients with WDEIA or WIA.

METHODS

In total, 27 patients were enrolled and classified into 2 groups according to the severity of their allergic reactions to wheat. Serum IgE, specific to wheat and ω-5 gliadin, was measured using the ImmunoCAP system. To evaluate the diagnostic value, receiver operator characteristic curves were produced.

RESULTS

Group 1 included 17 patients with a history of anaphylaxis and group 2 included 10 patients having urticaria or atopic dermatitis. Serum IgE specific to wheat was increased in 47% of group 1 and 100% of group 2. However, all patients in group 1 had high serum IgE specific to ω-5 gliadin, whereas only 20% of group 2 showed increased levels. To identify a better diagnostic value, the log-transformed IgE ratio of ω-5 gliadin to wheat was calculated, with the cutoff value at 0.3. Based on these criteria, we found 100% sensitivity and specificity.

CONCLUSIONS

This study confirms that the serum IgE ratio of ω-5 gliadin to wheat may be a useful marker for the diagnosis of WDEIA and WIA.

Diagnosis and management of drug hypersensitivity reactions

The present article addresses the advances in the diagnosis and management of drug hypersensitivity reactions that were discussed in the 4th Drug Hypersensitivity Meeting held in Rome in April 2010. Such reactions can be classified as immediate or nonimmediate according to the time interval between the last drug administration and onset. Immediate reactions occur within 1 hour, and nonimmediate reactions occur after more than 1 hour. Clinical and immunologic studies suggest that type-I (IgE-mediated) and type-IV (T cell-mediated) pathogenic mechanisms are involved in most immediate and nonimmediate reactions, respectively. In diagnosis prick, patch, and intradermal tests are the most readily available tools. Determination of specific IgE levels is still the most common in vitro method for diagnosing immediate reactions. New diagnostic tools, such as the basophil activation test, the lymphocyte activation test, and enzyme-linked immunospot assays for analysis of the frequency of antigen-specific, cytokine-producing cells, have been developed for evaluating either immediate or nonimmediate reactions. The sensitivity of allergologic tests is not 100%; therefore in selected cases provocation tests are necessary. In the diagnosis of nonallergic hypersensitivity reactions to nonsteroidal anti-inflammatory drugs, the provocation test with the suspected drug still represents the "gold standard." However, there was no consensus regarding the use of this test in subjects with histories of hypersensitivity reactions to 1 (single reactors) or more (multiple reactors) nonsteroidal anti-inflammatory drugs. With regard to management, desensitization allows patients to be treated with irreplaceable chemotherapy agents, such as taxanes, platinum salts, and mAbs, to which they have presented hypersensitivity reactions. Desensitization also permits the use of aspirin in aspirin-sensitive patients undergoing revascularization and in subjects with aspirin-exacerbated respiratory disease.