Hidden allergens and oral mite anaphylaxis: the pancake syndrome revisited

Genomic and metagenomic analyses of the domestic mite Tyrophagus putrescentiae identify it as a widespread environmental contaminant and a host of a basal, mite-specific Wolbachia lineage (supergroup Q)

Tyrophagus putrescentiae (mould mite) is a global, microscopic trophic generalist that commonly occurs in various human-created habitats, causing allergies and damaging stored food. Its ubiquity and extraordinary ability to penetrate research samples or cultures through air currents or by active walking through tights spaces (such as treads of screw caps) may lead to sample contamination and introduction of its DNA to research materials in the laboratory. This prompts a thorough investigation into potential sequence contamination in public genomic databases. The trophic success of T. putrescentiae is primarily attributed to the symbiotic bacteria housed in specialized internal mite structures, facilitating adaptation to varied nutritional niches. However, recent work suggests that horizontal transfer of bacterial/fungal genes related to nutritional functionality may also contribute to the mite's trophic versatility. This aspect requires independent confirmation. Additionally, T. putrescentiae harbors an uncharacterized and genetically divergent bacterium, Wolbachia, displaying blocking and microbiome-modifying effects. The phylogenomic position and supergroup assignment of this bacterium are unknown. Here, we sequenced and assembled the T. putrescentiae genome, analyzed its microbiome, and performed detailed phylogenomic analyses of the mite-specific Wolbachia. We show that T. putrescentiae DNA is a substantial source of contamination of research samples. Its DNA may inadvertently be co-extracted with the DNA of the target organism, eventually leading to sequence contamination in public databases. We identified a diversity of bacterial species associated with T. putrescentiae, including those capable of rapidly developing antibiotic resistance, such as Escherichia coli. Despite the presence of diverse bacterial communities in T. putrescentiae, we did not detect any recent horizontal gene transfers in this mite species and/or in astigmatid (domestic) mites in general. Our phylogenomic analysis of Wolbachia recovered a basal, mite-specific lineage (supergroup Q) represented by two Wolbachia spp. from the mould mite and a gall-inducing plant mite. Fluorescence in situ hybridization confirmed the presence of Wolbachia inside the mould mite. The discovery of an early derivative Wolbachia lineage (supergroup Q) in two phylogenetically unrelated and ecologically dissimilar mites suggests that this endosymbiotic bacterial lineage formed a long-term association with mites. This finding provides a unique insight into the early evolution and host associations of Wolbachia. Further discoveries of Wolbachia diversity in acariform mites are anticipated.

Plant and Arthropod IgE-Binding Papain-like Cysteine Proteases: Multiple Contributions to Allergenicity

Papain-like cysteine proteases are widespread and can be detected in all domains of life. They share structural and enzymatic properties with the group's namesake member, papain. They show a broad range of protein substrates and are involved in several biological processes. These proteases are widely exploited for food, pharmaceutical, chemical and cosmetic biotechnological applications. However, some of them are known to cause allergic reactions. In this context, the objective of this review is to report an overview of some general properties of papain-like cysteine proteases and to highlight their contributions to allergy reactions observed in humans. For instance, the literature shows that their proteolytic activity can cause an increase in tissue permeability, which favours the crossing of allergens through the skin, intestinal and respiratory barriers. The observation that allergy to PLCPs is mostly detected for inhaled proteins is in line with the reports describing mite homologs, such as Der p 1 and Der f 1, as major allergens showing a frequent correlation between sensitisation and clinical allergic reactions. In contrast, the plant food homologs are often digested in the gastrointestinal tract. Therefore, they only rarely can cause allergic reactions in humans. Accordingly, they are reported mainly as a cause of occupational diseases.

Mite secretions from three traditional mite-ripened cheese types: are ripened French cheeses flavored by the mites (Acari: Astigmata)?

The opisthonotal glands of Astigmata contain monoterpenes, aromatics, aliphatics, and other volatile compounds; some of these compounds act as pheromones and have antifungal effects. This study analyzed volatile compounds secreted by mites on three traditional mite-ripened cheeses from producers (Milbenkäse from Germany, Mimolette and Artisou from France). The mites obtained from various traditional ripened French cheeses (Mimolette, Laguiole, Salers, and Cantal vieux) from stores were also investigated. The gas chromatography (GC) profiles of all their hexane extracts, except the Cantal vieux one, showed almost no differences and were identical to that of Tyrolichus casei Oudemans except for trace components. Based on the GC results, the mites of Cantal vieux were identified as Acarus siro L. For the Artisou and Cantal vieux, not studied before, the influence of the mite secretions on their characteristics was investigated by analyzing the headspace volatiles from the cheeses. According to the results, neral secreted from T. casei is the main compound responsible for the lemon-like flavor of the mite-ripened cheeses, which is, hence, due to a component of the mite secretions rather than the fermentation of the cheese itself. Moreover, the compounds secreted by the mites are not directly added to the cheese through ripening as they were not detected in the odors of the Artisou and Cantal vieux after the mites were removed. However, the consumers of the Artisou usually eat also the cheese rind, and thus, can enjoy its lemon-like flavor fully.

Do 'cheese factory-specific' mites (Acari: Astigmata) exist in the cheese-ripening cabinet?

To determine whether the mites used in the ripening process of traditional cheeses are genetically unique to cheese factories, we investigated mites from three types of traditional cheeses, that use mites in the ripening process: 'Würchwitzer Milbenkäse' from Germany and 'Mimolette' and 'Artisou' from France. In addition, traditional ripened cheeses were purchased from cheese specialty stores in France (Mimolette) and Japan ('Laguiole' from France) as well as stores in temporary markets in France ('Salers' and 'Cantal vieux') and the mites obtained from those cheeses were analyzed in this study. Partial sequences of the 28S rRNA gene (28S) were determined and used to reconstruct a phylogenetic tree. Tyrolichus casei, the dominant cheese mite species from the ripening cabinets of three traditional cheese producers and two cheese specialty stores in France and Japan, had identical partial 28S sequences. All specimens from Cantal vieux from a store in the temporary market in France had an identical sequence with Acarus siro and Acarus immobilis in the determined region of the 28S sequences. Mite individuals from Salers from a store in the temporary markets in France shared the same haplotype as Acotyledon paradoxa. For the T. casei individuals from five different localities (19 individuals in total), the nuclear loci were obtained using MIG-seq. More than several thousand genomic regions are amplified simultaneously by multiplex PCR, and targeting regions surrounded by inter-simple sequence repeats (ISSRs) in the genome were sequenced using the MiSeq system (Illumina). SNPs extracted from this genome-wide analysis showed that no genetic structure existed in the populations from any region. Among the five samples from the three regions, which were more than 500 km apart and from completely different environments, the mites had no geographic bias, but all mite individuals were genetically nearly identical. Thus, we found no evidence to support the existence of 'cheese factory-specific' T. casei mites, at least in terms of genetic analysis.

Microbial Communities of Stored Product Mites: Variation by Species and Population

Arthropod-associated microorganisms are important because they affect host fitness, protect hosts from pathogens, and influence the host's ability to vector pathogens. Stored product mites (Astigmata) often establish large populations in various types of food items, damaging the food by direct feeding and introducing contaminants, including their own bodies, allergen-containing feces, and associated microorganisms. Here we access the microbial structure and abundance in rearing diets, eggs, feces fraction, and mite bodies of 16 mite populations belonging to three species (Carpoglyphus lactis, Acarus siro, and Tyrophagus putrescentiae) using quantitative PCR and 16S ribosomal RNA (rRNA) gene amplicon sequencing. The mite microbiomes had a complex structure dominated by the following bacterial taxa (OTUs): (a) intracellular symbionts of the genera Cardinium and Wolbachia in the mite bodies and eggs; (b) putative gut symbionts of the genera Solitalea, Bartonella, and Sodalis abundant in mite bodies and also present in mite feces; (c) feces-associated or environmental bacteria of the genera Bacillus, Staphylococcus, and Kocuria in the diet, mite bodies, and feces. Interestingly and counterintuitively, the differences between microbial communities in various conspecific mite populations were higher than those between different mite species. To explain some of these differences, we hypothesize that the intracellular bacterial symbionts can affect microbiome composition in mite bodies, causing differences between microbial profiles. Microbial profiles differed between various sample types, such as mite eggs, bodies, and the environment (spent growth medium-SPGM). Low bacterial abundances in eggs may result in stochastic effects in parent-offspring microbial transmission, except for the intracellular symbionts. Bacteria in the rearing diet had little effect on the microbial community structure in SPGM and mite bodies. Mite fitness was positively correlated with bacterial abundance in SPGM and negatively correlated with bacterial abundances in mite bodies. Our study demonstrates critical host-microbe interactions, affecting all stages of mite growth and leading to alteration of the environmental microbiome. Correlational evidence based on absolute quantitation of bacterial 16S rRNA gene copies suggests that mite-associated microorganisms are critical for modulating important pest properties of mites by altering population growth.

Insect Allergens on the Dining Table

Edible insects are important sources of nutrition, particularly in Africa, Asia, and Latin America. Recently, edible insects have gained considerable interest as a possible solution to global exhaustion of the food supply with population growth. However, little attention has been given to the adverse reactions caused by insect consumption. Here, we provide an overview of the food allergens in edible insects and offer insights for further studies. Most of the edible insect allergens identified to date are highly cross-reactive invertebrate pan-allergens such as tropomyosin and arginine kinase. Allergic reactions to these allergens may be cross-reactions resulting from sensitization to shellfish and/or house dust mites. No unique insect allergen specifically eliciting a food allergy has been described. Many of the edible insect allergens described thus far have counterpart allergens in cockroaches, which are an important cause of respiratory allergies, but it is questionable whether inhalant allergens can cause food allergies. Greater effort is needed to characterize the allergens that are unique to edible insects so that safe edible insects can be developed. The changes in insect proteins upon food processing or cooking should also be examined to enhance our understanding of edible insect food allergies.

World allergy organization anaphylaxis guidance 2020

Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions. The occurrence of anaphylaxis has increased in recent years, and subsequently, there is a need to continue disseminating knowledge on the diagnosis and management, so every healthcare professional is prepared to deal with such emergencies. The rationale of this updated position document is the need to keep guidance aligned with the current state of the art of knowledge in anaphylaxis management. The World Allergy Organization (WAO) anaphylaxis guidelines were published in 2011, and the current guidance adopts their major indications, incorporating some novel changes. Intramuscular epinephrine (adrenaline) continues to be the first-line treatment for anaphylaxis. Nevertheless, its use remains suboptimal. After an anaphylaxis occurrence, patients should be referred to a specialist to assess the potential cause and to be educated on prevention of recurrences and self-management. The limited availability of epinephrine auto-injectors remains a major problem in many countries, as well as their affordability for some patients.

Oral mite anaphylaxis: who, when, and how?

PURPOSE OF REVIEW

To present an update on the recent advances in the understanding of the mechanisms and practical management of oral mite anaphylaxis (OMA, pancake syndrome).

RECENT FINDINGS

Among novel observations regarding OMA, this review highlights the increased prevalence of aspirin/NSAID hypersensitivity inpatients affected by OMA, the association of OMA with exercise-induced anaphylaxis, the presentation of OMA simulating acute asthma, the occurrence of OMA in childhood, the high severity and lethal potential of OMA, the contamination of other foods, such as oat and corn flour with mites, and the simultaneous induction of OMA symptoms in more than one individual exposed to the same food source.

SUMMARY

OMA is a severe, potentially lethal, acute allergic condition that should be suspected whenever symptoms begin soon after the intake of mite-contaminated foods. Physician awareness on this clinical picture is of paramount importance to establish a correct diagnosis and to implement adequate preventive measures to help patients at risk to avoid its occurrence.

A WAO - ARIA - GA2LEN consensus document on molecular-based allergy diagnosis (PAMD@): Update 2020

Precision allergy molecular diagnostic applications (PAMD@) is increasingly entering routine care. Currently, more than 130 allergenic molecules from more than 50 allergy sources are commercially available for in vitro specific immunoglobulin E (sIgE) testing. Since the last publication of this consensus document, a great deal of new information has become available regarding this topic, with over 100 publications in the last year alone. It thus seems quite reasonable to publish an update. It is imperative that clinicians and immunologists specifically trained in allergology keep abreast of the new and rapidly evolving evidence available for PAMD@.

PAMD@ may initially appear complex to interpret; however, with increasing experience, the information gained provides relevant information for the allergist. This is especially true for food allergy, Hymenoptera allergy, and for the selection of allergen immunotherapy. Nevertheless, all sIgE tests, including PAMD@, should be evaluated within the framework of a patient's clinical history, because allergen sensitization does not necessarily imply clinical relevant allergies.

Dust mite ingestion-associated, exercise-induced anaphylaxis: a case report and literature review

Background

Oral mite anaphylaxis (OMA) is a condition characterized by severe allergic reactions after ingesting food containing dust mite-contaminated flour. Physical exertion is recognized as a common trigger factor inducing anaphylaxis. The association of OMA with exercise-induced anaphylaxis has rarely been reported.

Case presentation

We report a 29-year-old Thai woman who had dust mite ingestion-associated, exercise-induced anaphylaxis who tolerated the same bag of contaminated flour without exercise. A sample of contaminated cooking flour was examined under a light microscope. Living mites, Dermatophagoides farinae, were detected by a medical entomologist based on the morphology. We performed skin test to both mite-contaminated and newly opened Gogi® cooking flour, common aeroallergens, food allergens, and all other ingredients in the fried coconut rice cake 5 weeks after the anaphylactic episode. Specific IgE tests, using ImmunoCAP were also performed.

Conclusions

Dust mite ingestion-associated, exercise-induced anaphylaxis may be misdiagnosed as wheat-dependent exercise-induced anaphylaxis and should be suspected in patients with anaphylaxis linked to food intake and exercise, but who have no apparent evidence to the index food ingredients on allergy workup.

Challenges of managing food allergy in the developing world

Food allergy (FA) is currently a significant health care problem in the developing world. Widely varying study populations and methodologies, the use of surrogate markers such as self report or hospitalization rates due to anaphylaxis rather than objective methods, limits robust estimation of FA prevalence in low income settings. Also, allergy is under-recognized as a clinical specialty in the developing world which compromises the chance for accurate diagnosis. In this review, most published data on food allergens from developing or low income countries are displayed. The diagnostic challenges and limitations of treatment options are discussed. It seems that FA is an under-appreciated health care issue in the developing world, and accurate determination of its burden in low-income settings represents an important unmet need. Multicenter surveillance studies, using standardized methodologies, are, therefore, needed to reveal the true extent of the problem and provide epidemiological clues for prevention. Preventive strategies should be tailored to fit local circumstances in different geographic regions. In addition, studying the gene environment interactions and impact of early life microbiota on the expression of FA in developing communities would be worthwhile. Efforts and resources should be directed toward public health education and training of health care providers dealing with food allergic patients.

Food-Induced Anaphylaxis: Role of Hidden Allergens and Cofactors

Food anaphylaxis is on the increase, with those who have an allergy to peanuts, tree nuts, milk, and seafood at the highest risk of developing such a reaction. However, the diet in many societies is increasingly varied, much of the food consumed is prepared outside the home, and meals are often composed of many different ingredients. Anaphylaxis may occur to a composite food, and it may be unclear whether the reaction is due to contamination or to a culprit allergen present in an added ingredient. Composite foods can contain many allergic proteins present in small amounts, which do not always have to be labeled, unless they feature in European or US labeling regulations. These "hidden" allergens include mustard, celery, spices, lupine, pea, natural food colourings, and preservatives, but can occasionally include allergenic material from contaminants such as cereal mites. Hidden allergens can provoke severe reactions to seemingly unconnected foods which might then lead to a diagnosis of idiopathic anaphylaxis. The same problem can arise with two well-known types of food allergy; wheat-dependant exercise induced anaphylaxis and allergy to non-specific Lipid Transfer Protein allergens, both of which might only manifest when linked to a cofactor such as exercise. Many of these risk factors for food anaphylaxis have a common link; the public's engagement with popular concepts of health and fitness. This includes the development of a food and exercise culture involving the promotion and marketing of foods for their health-giving properties i.e., meat substitutes, wheat substitutes, supplements and alternative, or "natural" remedies for common ailments. Some of these foods have been reported as the cause of severe allergic reactions, but because they are often viewed as benign unlikely causes of severe allergic reactions, could be considered to be hidden allergens. The best resource to elicit the likelihood of a hidden allergen provoking an allergic reaction is to take a detailed history of the allergic reaction, presence of co-factors, foods suspected, type of food and where it was consumed. A good knowledge of commonly used ingredients, and list of potential hidden allergen suspects are essential tools for the food allergy detective.

Rare presentation of anaphylaxis: pancake syndrome

A 43-year-old woman presented with oral discomfort, sneezing, urticaria, eyelid angioedema, abdominal pain, diarrhoea, dyspnoea and wheeze soon after eating a Japanese flour pancake (okonomiyaki, containing wheat, egg, yam, pork, prawn and squid). Subsequent analysis of the flour used in the pancake revealed the presence of Dermatophagoides farinae (4500 mites/g). The patient tested positive for specific IgE to D. farinae (15.2 kU/L) and D. pteronyssinus (14.0 kU/L) with negative responses to other ingredients in the pancake. Oral ingestion of dust mite in poorly stored foods can cause anaphylactic reactions in patients with allergy.

Cross-Reactive Aeroallergens: Which Need to Cross Our Mind in Food Allergy Diagnosis?

Secondary food allergies due to cross-reactivity between inhalant and food allergens are a significant and increasing global health issue. Cross-reactive food allergies predominantly involve plant-derived foods resulting from a prior sensitization to cross-reactive components present in pollen (grass, tree, weeds) and natural rubber latex. Also, primary sensitization to allergens present in fungi, insects, and both nonmammalian and mammalian meat might induce cross-reactive food allergic syndromes. Correct diagnosis of these associated food allergies is not always straightforward and can pose a difficult challenge. As a matter of fact, cross-reactive allergens might hamper food allergy diagnosis, as they can cause clinically irrelevant positive tests to cross-reacting foods that are safely consumed. This review summarizes the most relevant cross-reactivity syndromes between inhalant and food allergens. Particular focus is paid to the potential and limitations of confirmatory testing such as skin testing, specific IgE assays, molecular diagnosis, and basophil activation test.

Cofactors and comorbidities in patients with aspirin/NSAID hypersensitivity

Hypersensitivity reactions to aspirin and other NSAIDs occur in individuals genetically predisposed and exhibit different clinical manifestations, especially respiratory, cutaneous, and generalised. Five different phenotypes define distinct clinical pictures: aspirin-exacerbated respiratory disease, aspirin/NSAID cutaneous disease, NSAID-induced urticaria, angio-oedema and anaphylaxis, single NSAID reactions, and delayed reactions. They are observed more frequently in middle-aged women, and in atopic individuals. While ASA/NSAID hypersensitivity shares comorbidities with asthma, chronic rhinosinusitis, nasal polyposis, chronic urticaria and angio-oedema, ASA and other NSAIDs can also be cofactors for other clinically relevant conditions, especially food-dependent exercise-induced anaphylaxis, angio-oedema induced by angiotensin-converting enzyme inhibitors, and oral mite anaphylaxis. Awareness on these relationships is required for the correct diagnosis, classification, and treatment of affected patients.

Hidden Causes of Anaphylaxis

PURPOSE OF REVIEW

This study aimed to review important hidden causes of anaphylaxis in ingestants, non-ingestants, and uncommon settings.

RECENT FINDINGS

Multiple new and elusive causes of anaphylaxis have been described over the past 35 years. Further research is required to identify the epidemiology, pathophysiology, and clinical impact of these hidden causes. Although these culprits should be considered in the appropriate clinical scenarios, many remain exceedingly rare.

Scent of a mite: origin and chemical characterization of the lemon-like flavor of mite-ripened cheeses

Cheese infested with cheese mites is usually treated as unpalatable. Nevertheless, some traditional cheese manufactories in Germany and France intentionally use mites for fermentation of special varieties (i.e. Milbenkäse and Mimolette). While their production includes different mite species, both are characterized by a "lemon-like" flavor. However, the chemical nature and origin of this flavor-component is unknown. The cheese mites possess a pair of opisthosomal glands producing blends of hydrocarbons, terpenes and aromatics. Here, we describe the chemical profiles of the astigmatid mite species Tyrolichus casei (Milbenkäse) and Acarus siro (Mimolette). Although the chemical profiles differ in several aspects, both mite species produce neral (a volatile flavor component of lemon oil), which was absent from the headspace of both cheeses without mites. We conclude that the lemon-like flavor of mite cheese is not a consequence of fermentation of the cheese itself but a component from secretions of the cheese mites.

Particularities of allergy in the Tropics

Allergic diseases are distributed worldwide and their risk factors and triggers vary according to geographical and socioeconomic conditions. Allergies are frequent in the Tropics but aspects of their prevalence, natural history, risk factors, sensitizers and triggers are not well defined and some are expected to be different from those in temperate zone countries. The aim of this review is to investigate if allergic diseases in the Tropics have particularities that deserve special attention for research and clinical practice. Such information will help to form a better understanding of the pathogenesis, diagnosis and management of allergic diseases in the Tropics. As expected, we found particularities in the Tropics that merit further study because they strongly affect the natural history of common allergic diseases; most of them related to climate conditions that favor permanent exposure to mite allergens, helminth infections and stinging insects. In addition, we detected several unmet needs in important areas which should be investigated and solved by collaborative efforts led by the emergent research groups on allergy from tropical countries.

Clinical presentation, allergens, and management of wheat allergy

IgE-mediated allergy to wheat proteins can be caused by exposure through ingestion, inhalation, or skin/mucosal contact, and can affect various populations and age groups. Respiratory allergy to wheat proteins is commonly observed in adult patients occupationally exposed to flour, whereas wheat food allergy is more common in children. Wheat allergy is of growing importance for patients with recurrent anaphylaxis, especially when exercise related. The diagnosis of wheat allergy relies on a consistent clinical history, skin prick testing with well-characterized extracts and specific IgE tests. The accuracy of wheat allergy diagnosis may be improved by measuring IgE responses to several wheat components. However, a high degree of heterogeneity has been found in the recognition pattern of allergens among patient groups with different clinical profiles, as well as within each group. Thus, oral provocation with wheat or the implicated cereal is the reference test for the definitive diagnosis of ingested wheat/cereal allergy.