Chronic spontaneous urticaria and internal parasites--a systematic review

Schistosoma excretory/secretory products: an untapped library of tolerogenic immunotherapeutics against food allergy

Food allergy (FA) is considered the 'second wave' of the allergy epidemic in developed countries after asthma and allergic rhinitis with a steadily growing burden of 40%. The absence of early childhood pathogen stimulation embodied by the hygiene hypothesis is one explanation, and in particular, the eradication of parasitic helminths could be at play. Infections with parasites Schistosoma spp. have been found to have a negative correlation with allergic diseases. Schistosomes induce regulatory responses to evade immune detection and ensure their long-term survival. This is achieved via excretory/secretory (E/S) products, consisting of proteins, lipids, metabolites, nucleic acids and extracellular vesicles, representing an untapped therapeutic avenue for the treatment of FA without the unpleasant side-effects and risks associated with live infection. Schistosome-derived immunotherapeutic development is in its infancy and novel discoveries are heavily technology dependent; thus, it is essential to better understand how newly identified molecules interact with host immune systems to ensure safety and successful translation. This review will outline the identified Schistosoma-derived E/S products at all life cycle stages and discuss known mechanisms of action and their ability to suppress FA.

Effect of Blastocystis sp. infection on hematological parameters and trace element status in children with iron-deficiency anemia

Iron deficiency anemia (IDA), which causes greater morbidity and mortality in children, has multifactorial causes, including many helminthic and protozoal infections. Herein, the study aimed to find out the frequency and associated risk of Blastocystis sp. infection among children with IDA, together with the estimation of the serum levels of iron, zinc, copper, and vitamin A. Both stool and blood samples were obtained from 90 children with a confirmed diagnosis of IDA and 90 non-anemic children. Blastocystis sp. was diagnosed by direct stool examination and Invitro cultivation methods. Different hematological parameters were recorded, and the serum level of iron, zinc, copper, and vitamin A was measured in serum samples. The overall predominance of Blastocystis in children was 36.7%, significantly higher (P < 0.001) in children with IDA (55.6%) compared to non-anemic controls (17.8%). Furthermore, Blastocystis infected children were 5.781 times more prone to be anemic (OR = 5.781). All IDA cases with positive Blastocystis infection had a mean hemoglobin level of 9.55 g/dl (moderate anemia). While in other non-infected IDA cases, it was 9.56 g/dl, showing no statistical difference (P = 0.845). Serum levels of zinc, iron, and vitamin A considerably decreased, whereas serum copper levels significantly increased in IDA children infected with Blastocystis. The current research is the first in Egypt to indicate that Blastocystis infection in children is a high-risk factor for developing IDA. Blastocystis infection significantly alters the metabolic and biochemical processes and interferes with the absorption of micronutrients and vitamin A in IDA children.

Chronic Spontaneous Urticaria: Etiology and Pathogenesis

Urticaria, also known as hives, is a common condition thought to affect up to 20% of individuals worldwide in their lifetime. This skin condition is characterized by the appearance of pruritic, erythematous papules or plaques with superficial swelling of the dermis. The major complaint is the symptom of pruritus. Angioedema, which involves a deeper swelling of dermal or mucosal tissues, may accompany urticaria. Urticaria can be classified by both time course of symptoms and the underlying etiology.

Molecular prevalence, subtype distribution, and zoonotic potential of Blastocystis sp. in wild rodents and shrews inhabiting Zhejiang province of China

Introduction

Globally, rodents and shrew populations constitute crucial elements of diverse environments and animal communities. It is imperative to study their population dynamics to mitigate any potential negative impact on humans, as they can be involved in the transmission of critical zoonotic agents, such as Blastocystis. Therefore, this study aimed to identify the prevalence and genetic composition of Blastocystis in wild rodents and shrews residing in the Zhejiang provinces of China.

Methods

A total of 652 wild rodents and and shrews were captured from three different regions in Zhejiang Province from April 1st to October 31, 2023. The DNA was isolated by collecting fresh feces from the intestines of each rodent or and shrew. Rodent and shrew species were examined by vertebrate cytochrome b (cytb) analysis and PCR amplification. Blastocystis was also found in all fecal samples using PCR analysis and sequencing of the partial small subunit of ribosomal RNA (SSU rRNA) gene.

Results

Among all the samples, 6.6% (43/652) showed a positive result for Blastocystis. In the results, 6 species of rodent and shrew were identified with Blastocystis, including Apodemus agrarius (n = 36) (2.8%), Niviventer confucianus (n = 75) (17.3%), Rattus losea (n = 18) (5.6%), R. norvegicus (n = 155) (2.6%), R. tanezumi (n = 86) (3.5%), and Suncus murinus (n = 282) (7.4%). The existence of 6 Blastocystis subtypes, ST4 (n = 33), ST1 (4), ST7 (n = 3), ST2 (n = 1), ST3 (n = 1), and ST5 (n = 1), were confirmed by sequence analysis.

Discussion

Based on the molecular data obtained, the wild rodents and shrews under investigation were found to be concurrently infected with zoonotic subtypes of Blastocystis, including ST1 to ST5 and ST7. This suggests that these animals could potentially pose a zoonotic threat to humans and other animals susceptible to Blastocystis infection.

A Retrospective Cohort Study on the Comorbidity in 19,264 Chinese Patients of Different Ages with Urticaria

To examine the prevalence of comorbidities in Chinese urticaria patients and assess medication use patterns across different ages (6-11 years, 12-17 years, above 18 years), a retrospective cohort study was performed in 192,647 urticaria patients within the Health Database. After 1:1 propensity score matching, 166,921 people were divided into the urticaria group and the control group, and the follow-up data were collected within 2 years. During the 12-month and 24-month follow-up period, significant comorbidities identified included allergic rhinitis and asthma, with distinct patterns observed across age groups. Chronic urticaria patients often have complications, such as allergic rhinitis, upper respiratory infection, oropharyngeal infection, and dental caries. The study underscores the need for age-specific treatment strategies in urticaria management.

Paradoxical Worsening of Chronic Spontaneous Urticaria Following Omalizumab Administration: The Missing Link

Omalizumab, a humanized anti-IgE monoclonal antibody, is commonly employed in the treatment of antihistamine-refractory chronic spontaneous urticaria (CSU), where it significantly reduces free IgE levels, minimizing histamine release from basophils and mast cells. Despite its efficacy, there are concerns regarding its effect on parasitic defense due to IgE's role in combating parasitic infestations. We present a case of a 28-year-old female agriculturist with a six-month history of CSU who experienced a paradoxical exacerbation of her symptoms following an increase in the omalizumab treatment dose. This deterioration coincided with a serologically confirmed parasitic infection with Echinococcus granulosus and Toxocara canis. Despite normal eosinophil counts and IgE levels, which are typically used to identify parasitic infections, the patient's clinical worsening prompted further investigation that led to the identification of the parasitic infection. Treatment with albendazole and omalizumab discontinuation led to the resolution of her CSU, suggesting that the parasitic infection was contributing to the symptom exacerbation. This case highlights the need for careful screening for parasitic infections before initiating omalizumab in antihistamine-refractory CSU patients from endemic regions, or patients who deteriorate clinically on omalizumab, especially when other indicators such as eosinophil count and IgE levels might not suggest infection. It also underscores the importance of considering a tailored approach to managing CSU that balances effective treatment with the potential for adverse effects related to immunomodulation.

[Which augmentation and trigger factors are relevant in urticaria?]

The aim of this review is to present relevant trigger as well as augmentation factors that can induce or exacerbate urticaria on the basis of a current, PubMed-based literature search. In addition to a brief description of relevant influencing factors in acute and chronic inducible urticaria, the focus will be on chronic spontaneous urticaria. In particular, the aggravating role of medication, stress, food, psychological and metabolic comorbidities, infections and inflammation as well as hormonal processes will be discussed.

Current insights on gut microbiome and chronic urticaria: progress in the pathogenesis and opportunities for novel therapeutic approaches

Chronic urticaria (CU) is a prevalent skin disorder greatly impacting the patients' life quality, in which immune dysregulation mediated by gut microbiome plays a significant role. Several studies have found the gut dysbiosis exists in patients with CU. In addition, infection may also be one of the causes of CU. The primary treatment currently used for CU is the second-generation non-sedating H1-antihistamines (nsAH). However, there are some limitations in current therapies. Based on the latest evidence, this review provides an updated overview of how the gut dysbiosis influences CU development, explores potential therapeutic approaches based on the gut microbiota and summarizes the interaction between gut microbiota and current treatment.

Recent updates in urticaria

Urticaria is a skin-condition characterized by sudden-onset pruritic wheals with/without angioedema. Urticaria can be acute or chronic. Chronic urticaria may be spontaneous or inducible, based on absence/presence of specific triggers. Chronic spontaneous urticaria is most frequent (∼80%). Urticaria is primarily a mast-cell mediated histaminergic-disorder. Recently, other inflammatory cells and pro-inflammatory cytokines have been implicated. Deeper understanding has unmasked two endotypes - IgE-mediated type I autoimmunity/autoallergy and IgG-mediated type IIb autoimmunity. Current treatment recommendation involving second-generation H1-antihistamines, omalizumab and cyclosporine is effective in 60-80% patients. So, newer treatment options are being explored based on emerging targets. Despite being non-lethal, urticaria considerably impairs patient's quality-of-life and may be associated with extra-cutaneous comorbidities. Several "patient reported outcome measures" have been proposed to evaluate disease-activity, impact and control, for effective treatment modulation till complete disease control. This review discusses the current understanding about urticaria and its future directions, to facilitate optimum evidenced-based care.

Treatment of Urticaria caused by severe cryptosporidiosis in a 17-month-old child - a case report

BACKGROUND

Cryptosporidium is an intracellular protozoan that causes gastrointestinal symptoms in humans and animals. In immunocompromised patients and children under 5 years of age, the infection is severe and can be life-threatening due to severe diarrhea.

CASE PRESENTATION

We report a case of urticaria associated with Cryptosporidium in a 17-month-old female Iranian child. The patient had moderate diarrhea (> 3 loose, watery stools but not more than 10 diarrhea stools in a day), weight loss, and acute urticarial (rash clears completely within 6 weeks). Since the child's father worked in livestock farming, the parasite may have been transferred from the cow or calve to the house and the child. Several Cryptosporidium oocysts were detected in the modified acid-fast staining of the child's stool sample. The patient was successfully treated with nitazoxanide (100 mg twice daily) and became negative for parasites three days after treatment and one week after discharge from the hospital. The child was observed to produce < 3 loose stools in the previous 24 h after 1-week post-treatment and after 6 months of follow-up.

CONCLUSION

A number of parasites are associated with urticaria, but to our knowledge, there is no information on Cryptosporidium-induced urticaria. Therefore, our result may be evidence for the role of this parasite in the development of urticaria if other causes such as food allergies, autoimmune diseases and etc. don't role in urticaria.

Molecular characteristics and zoonotic potential of enteric protists in domestic dogs and cats in Egypt

Introduction

Domestic dogs and cats can be a source of human infection by a wide diversity of zoonotic pathogens including parasites. Genotyping and subtyping tools are useful in assessing the true public health relevance of canine and feline infections by these pathogens. This study investigated the occurrence, genetic diversity, and zoonotic potential of common diarrhea-causing enteric protist parasites in household dogs and cats in Egypt, a country where this information is particularly scarce.

Methods

In this prospective, cross-sectional study a total of 352 individual fecal samples were collected from dogs (n = 218) and cats (n = 134) in three Egyptian governorates (Dakahlia, Gharbeya, and Giza) during July-December 2021. Detection and identification of Cryptosporidium spp., Giardia duodenalis, Enterocytozoon bieneusi, and Blastocystis sp. were carried out by PCR and Sanger sequencing. Basic epidemiological variables (geographical origin, sex, age, and breed) were examined for association with occurrence of infection by enteric protists.

Results and discussion

The overall prevalence rates of Cryptosporidium spp. and G. duodenalis were 1.8% (95% CI: 0.5-4.6) and 38.5% (95% CI: 32.0-45.3), respectively, in dogs, and 6.0% (95% CI: 2.6-11.4) and 32.1% (95% CI: 24.3-40.7), respectively, in cats. All canine and feline fecal samples analyzed tested negative for E. bieneusi and Blastocystis sp. Dogs from Giza governorate and cats from Dakahlia governorate were at higher risk of infection by Cryptosporidium spp. (p = 0.0006) and G. duodenalis (p = 0.00001), respectively. Sequence analyses identified host-adapted Cryptosporidium canis (n = 4, one of them belonging to novel subtype XXe2) and G. duodenalis assemblages C (n = 1) and D (n = 3) in dogs. In cats the zoonotic C. parvum (n = 5) was more prevalent than host-adapted C. felis (n = 1). Household dogs had a limited (but not negligible) role as source of human giardiasis and cryptosporidiosis, but the unexpected high frequency of zoonotic C. parvum in domestic cats might be a public health concern. This is the first molecular-based description of Cryptosporidium spp. infections in cats in the African continent to date. Molecular epidemiological data provided here can assist health authorities and policy makers in designing and implementing effective campaigns to minimize the transmission of enteric protists in Egypt.

Possible microRNA-based mechanism underlying relationship between chronic spontaneous urticaria and Blastocystis

BACKGROUND

Blastocystis spp. has been proposed as a possible cause of extraintestinal clinical signs such as urticaria pathogenesis.

OBJECTIVES

The aim of this study was to investigate the differences between microRNA (miRNA) expression profiles of Chronic spontaneous urticaria (CSU) patients in the presence or absence of Blastocystis spp. as well as healthy controls. Additionally, cellular pathways which are affected in the presence of Blastocystis spp. were identified.

METHODS

Twenty patients diagnosed with CSU were enrolled in the study and divided into equally two groups according to the presence of Blastocystis spp. Besides, six healthy individuals were included in the study. The expression profiles of 372 human-derived miRNAs have been investigated in serum samples from CSU patients and healthy controls with miScript miRNA PCR Array Human miRBase Profiler.

RESULTS

Compared to Blastocystis-negative (BN)-CSU patients, expression of 3 miRNAs (hsa-miR-3183, hsa-miR-4469, hsa-miR-5191) were found to be downregulated by at least two-fold (p < 0.05) in Blastocystis-positive (BP)-CSU patients. Additionally, the miRNA expression profiles of six healthy individuals (n = 3 Blastocystis-positive, n = 3 Blastocystis-negative) were analyzed and it was determined that the expressions of 7 miRNAs (hsa-miR-4661-5p, hsa-miR-4666a-5p, hsa-miR-4803, hsa-miR-5587-5p, hsa-miR-4500, hsa-miR-5680, hsa-miR-382-3p) increased at least 3-fold in the serum of individuals with Blastocystis-positive compared to Blastocystis-negative subjects. Most down-regulated miRNAs, in BP-CSU patients, affect cell adhesion molecules (CAMs), and signaling pathways therefore, Blastocystis spp. presence may influence the clinical presentation of urticaria by leading to unbalanced immunity. In addition, Blastocystis spp. presence may be influenced TGF- β signaling pathway through altered miRNAs and may be laying the groundwork for the development of CSU in healthy individuals.

CONCLUSIONS

As a consequence, this is the first report to show that the miRNA expression profile is affected by the presence of Blastocystis spp. Further miRNA-based studies are needed in order to enlighten the exact underlying molecular mechanisms of the relationship between Blastocystis spp. and CSU.

Urticaria and Angioedema: Understanding Complex Pathomechanisms to Facilitate Patient Communication, Disease Management, and Future Treatment

Chronic spontaneous urticaria (CSU) is primarily a T2-dominant disease with a complex genetic background. Skin mast cell activation can be induced not only via the IgE-FcεRI axis but also from several other distinct mechanisms, molecules, and receptors involved in CSU onset, persistence, and exacerbation. These include autoallergy, autoimmunity, central or peripheral neuroimmune dysregulation, activation of both extrinsic and intrinsic coagulation pathways, and microbial infections. Besides mast cells, recent reports suggest the active and direct involvement of basophils and eosinophils. Several biological characteristics or biomarkers have been linked with CSU's known endotypes and may help forecast therapeutic responses. The introduction of biologic therapy for CSU has been a major advance in the last 10 years. The cornerstone of angioedema (AE) pathogenesis is increased vascular permeability and plasma leakage into the deeper dermis and subcutis, either mediated by histamine or bradykinin (BK). C1-inhibitor deficiency, hereditary or acquired, is the primary cause of BK-mediated AE due to increased plasma BK concentration. Other complex conditions have been identified, with some likely involving contact system dysregulation and other putative mechanisms related to vascular endothelial dysfunction. The approval of multiple hereditary-AE-specific therapies for both prevention and acute attacks has revolutionized treatment of this disease. Any new knowledge of the pathogenesis of CSU and AE offers the opportunity to improve patient information, physician-patient communication, prediction of therapeutic responses, selection of precise tailor-made treatment for each patient, and exploration of novel treatment options for those who do not achieve disease control with current medications.

Prevalence, Clinical Manifestations, Treatment, and Clinical Course of Chronic Urticaria in Elderly: A Systematic Review

Purpose

Data specific to the epidemiology, clinical features, and management of chronic urticaria (CU) in the geriatric population remain limited and not well understood. We aim to systematically review the prevalence, clinical manifestations, treatment, and clinical course of elderly patients with CU.

Patients and methods

Original articles that included data of elderly (aged >60 years) with CU that were published until February 2021 were searched in PubMed, Scopus, and Embase using predfefined search terms. Related articles were evaluated according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

Results

Among the included 85 studies and 1,112,066 elderly CU patients, most (57.4%) were women. The prevalence of elderly CU in the general population ranged from 0.2–2.8%, and from 0.7–33.3% among all CU patients. Compared to adult CU, elderly CU patients had a higher percentage of wheal alone (73.9%), and lower rate of positive autologous serum skin test and atopy. Gastrointestinal diseases were the most common comorbidity (71.9%), and there was a high rate of malignancies and autoimmune diseases. Second generation H₁-antihistamines were commonly used, and achievement of complete control was most often reported. Omalizumab was prescribed in 59 refractory patients, and a significant response to treatment was reported in most patients. The treatment of comorbidities also yielded significant improvement in CU.

Conclusion

Elderly CU was found to be different from adult CU in both clinical and laboratory aspects. H₁- antihistamines are effective as first-line therapy with minimal side-effects at licensed doses. Treatment of secondary causes is important since the elderly usually have age-related comorbidities.

Evaluation of association with subtypes and alleles of Blastocystis with chronic spontaneous urticaria

Blastocystis is a single-celled parasite commonly found in humans and its pathogenic role is still controversial. In recent years, some studies have suggested that Blastocystis may be a possible agent of gastrointestinal and dermatological symptoms such as acute or chronic urticaria, angioedema, rash, itch, palmoplantar, and diffuse pruritus. We aimed to investigate whether there is a relationship between Blastocystis subtypes and alleles in patients with chronic spontaneous urticaria (CSU) as a case-control study. In this study, stool samples were collected from patients with CSU (n=135) and healthy individuals (n=54). The presence of Blastocystis was investigated using the direct saline smear, Lugol's iodine staining, trichrome staining, Jones' medium culture and PCR assays in stool samples and subtypes (STs) were determined by sequencing according to DNA barcoding. The presence of Blastocystis was identified in 30.4% (64/210) the stool samples, including 31.9% (43/135) of the patients with CSU and 14.8% (8/54) of the control group. Moreover, it was found statistically significant the presence of Blastocystis in terms of both groups (p<0.018). ST3 was detected in 45.9% and 62.5 % as the most prevalent subtype the patients with CSU and the control group, respectively. ST1 (18.9%), ST2 (27%) and ST7 (8.1%) was identified in the patients with CSU group. There was no statistically significant correlation between Blastocystis subtypes and both the groups (p<0.240, p<0.323). Allele 4 for ST1; alleles 9, 10, 11 and 12 for ST2; alleles 34, 36 and 38 for ST3; alleles 41 and 101 for ST7 were detected. Allele 34 (ST3) was found significant in the patients with CSU as compared with control group (p<0.020). Moreover, statistically significant association was found between total IgE value and the certain subtypes (ST2 and ST3) (p<0.0001). As a result of this study, the presence of Blastocystis ST3 allele 34 significantly associated with chronic spontaneous urticaria was revealed.

An Association Between Blastocystis Subtypes and Colorectal Cancer Patients: A Significant Different Profile from Non-cancer Individuals

PURPOSE

Blastocystis is a common enteric human parasite of non-conclusive pathogenicity which may be determined by subtype (ST) variation. Colorectal cancer (CRC) is considered one of the primary causes of cancer mortality. Blastocystis ST7 has been shown to reduce beneficial intestinal microbiota and may exacerbate CRC. This study assessed the possible association between Blastocystis STs and CRC in comparison to non-cancer patients.

MATERIAL AND METHODS

A total of 200 fecal samples were obtained from CRC (100) and non-CRC (100) individuals attending Beni-Suef University Hospital, Egypt. Blastocystis was searched for in all samples using microscopy and culturing. Positive subculture samples were genetically sequenced and subtyped using conventional polymerase chain reaction (PCR). Blastocystis STs were determined by sequencing and a phylogenetic tree was created. Related patient characteristics and tumor stages were analyzed for association with presence of Blastocystis.

RESULTS

Blastocystis was identified in 52% and 42% of CRC and non-cancer individuals, respectively. ST1, 2, and 3 were isolated from both cancer and non-cancer individuals; however, for the first time, ST7 was only isolated from CRC stool samples with significant association. Associated patient characteristics were evaluated as predictors.

CONCLUSION

Blastocystosis is highly prevalent in CRC patients, predominantly in the latest CRC grades and stages. To the best of our knowledge, this is the first study to report the identification of Blastocystis ST7 in CRC patients. To determine whether certain STs of Blastocystis are associated with CRC would require further research, including the role played by gut microbiota.

Prevalence of Intestinal Parasitoses in a Non-Endemic Setting during a 10-Year Period (2011–2020): A Focus on Dientamoeba fragilis

Dientamoeba fragilis is a cosmopolitan and neglected protozoan. Although little is known concerning its pathogenicity and its true prevalence worldwide, its role as enteric pathogen is emerging, as the occurrence of dientamoebiasis has increased also in industrialised countries. This study investigated the occurrence and prevalence of intestinal parasites, focusing on D. fragilis in a 10-year period (2011–2020) in a single tertiary-care hospital located in Northern Italy. A statistical evaluation of the correlation between dientamoebiasis and specific signs other than gastrointestinal-related ones was performed. The laboratory diagnosis was performed on 16,275 cases of suspected intestinal parasitoses. Intestinal parasites were detected in 3254 cases, 606 of which were associated to D. fragilis, which represented 18.6% (606/3254) of all the intestinal parasitoses with a 3.7% (606/16,275) prevalence and an increasing trend during the last five years (2011–2015: 2.8% vs. 2016–2020: 4.8%). D. fragilis was commonly detected in foreigners, especially those from developing countries, as well as in children; prevalence was equal in males and females. With regard to the clinical aspect, the only putative sign statistically related to dientamoebiasis was anal pruritus. Despite the controversial epidemiological knowledges on dientamoebiasis, the prevalence of D. fragilis found in this study highlights the need to consider this parasite in any differential diagnosis of gastrointestinal disease.

Generalized cutaneous urticaria associated with Giardia infection in a five-month old puppy

Giardia cysts are commonly encountered in fecal examinations of dogs; intestinal infections can be asymptomatic or cause diarrhea but have not been previously associated with urticaria. A five-month old dalmatian puppy presented with a one-week history of cutaneous urticaria and pruritis. Wheals were most prominent on the head, abdomen, and inguinal region. A fecal flotation was performed to rule out internal parasites as a cause of hypersensitivity. Fecal float yielded many Giardia cysts, and treatment for giardiasis with fenbendazole was initiated. Urticaria improved drastically within a day after treatment initiation and completely resolved by the completion of the treatment regimen. No Giardia cysts were detected on the follow up fecal flotation three days later, and fecal Giardia antigen testing was negative at this time. No additional changes in management, housing, food, or environment were noted and the puppy has remained without additional clinical signs for three months following initial presentation.

The Diagnostic Workup in Chronic Spontaneous Urticaria-What to Test and Why

BACKGROUND

In chronic spontaneous urticaria (CSU), the guidelines recommend very limited diagnostic procedures during the routine workup, although additional investigations might be indicated in some patients with CSU. For physicians treating patients with CSU, it is often difficult to decide which diagnostic tests are useful.

OBJECTIVE

To provide recommendations on what diagnostic tests should be performed on which patients with CSU.

METHODS

We performed an extensive literature search on the respective topics and identified relevant questions that should prompt diagnostic procedures based on the published evidence and expert consensus among all authors.

RESULTS

We provide questions, diagnostic testing, where appropriate, and recommendation that should be included when assessing the history of a patient with CSU, to explore and rule out differential diagnoses, to assess patients for underlying causes and modifying conditions, to explore patients for comorbid diseases and consequences of having CSU, and to assess patients for CSU components that can help to predict their disease course and response to treatment.

CONCLUSIONS

Here, we provide physicians treating patients with CSU with information about which clues should lead to which tests and why.

Prevalence of Intestinal Parasites among Patients with Chronic Urticaria in Northern Iran

BACKGROUND

Chronic urticaria (CU) has a range of clinical demonstrations and causes. Parasitic infections are mentioned as one of the main causes of the CU.

OBJECTIVES

The aim of this study was to investigate the prevalence of intestinal parasites in patients with CU (with duration time of more than 6 weeks) compared healthy subjects.

METHODS

A total of 169 cases and 210 controls were included in this study. Ages ranged from 1 to 77 years old. Three samples were gathered from each patients and direct wet mount, formol-ether concentration, Ziehl-Neelsen and trichrome staining were used.

RESULTS

Out of the 379 individuals examined here, 208 were from urban areas and 171 from rural areas. Three stool samples were taken from each patient in three consecutive days. Based on parasitological tests, 7 (4.1%) cases from 169 patients with CU and 6 (2.9%) cases from 210 non- CU group individuals were positive for intestinal parasites.

CONCLUSION

The prevalence of various parasites between case and control groups was not significant.

Episodic Angioedema with Hypereosinophilia (Gleich's Syndrome): A Case Report and Extensive Review of the Literature

Episodic angioedema with eosinophilia (EAE) (Gleich's syndrome) is a rare disease characterized by hypereosinophilia (up to 95 × 10⁹ cells/L), recurrent episodes of angioedema, urticaria, weight gain, and fever, that occur at periodical intervals (usually every 3-4 weeks). The exact etiology of EAE is still unclear, but both eosinophils and abnormalities of cytokines homeostasis seem to play a pivotal role in the pathogenesis of the disease. In particular, the cyclic elevation of serum interleukin-5 before the increase in eosinophil count has been reported. Herein, we performed a broad literature review and report the case of a thirty-two-year-old woman with a two-year history of cyclic angioedema attacks, urticaria, periodic weight gain, and severe hypereosinophilia, diagnosed with EAE and treated with oral corticosteroids. Describing the most relevant clinical features of EAE reported so far in the literature, we aim to provide physicians with some useful tools to help them deal with this disease. In addition, we aim to raise awareness about this rare condition in which approved diagnostic classification criteria are currently missing.

Urticaria and the gut

PURPOSE OF REVIEW

To review recent evidence on the association of urticaria and the gut diseases, focusing on the roles of chronic inflammation with or without Helicobacter pylori (H. Pylori) infection.

RECENT FINDINGS

The connection between the gut and urticaria has been discussed for a long time. Some publications have shown that H. pylori can induce chronic spontaneous urticaria (CSU). Recently, it was reported that upper gastrointestinal inflammatory disorders can cause CSU and trigger exacerbations independently of H. pylori.

SUMMARY

Gastritis and especially H. pylori-induced gastritis has been implicated as potential trigger of CSU. Chronic parasite infection and inflammation of the gut are relevant comorbidities and also potential inducing factors for the development of urticaria.

Blastocystis, urticaria, and skin disorders: review of the current evidences

Blastocystis is one of the most common intestinal protozoan parasites worldwide, which is linked to cutaneous lesions and urticaria. In a setting of systematic review, the data on the association of Blastocystis infection with cutaneous lesions were searched in order to summarize the main clinical symptoms, diagnostic methods, treatment, and outcome of the patients. The search identified 28 eligible articles, including 12 cross-sectional studies and 16 case reports/case series (including 23 cases). A diverse spectrum of skin symptoms, mainly urticaria, rash, and itching, was reported from the studies. Of the 23 infected cases with the skin symptoms, gastrointestinal symptoms were reported from the 16 cases, whereas 7 cases with urticaria had asymptomatic infection. The most frequent subtypes were ST1, ST2, and ST3, respectively. Metronidazole, paromomycin, and tinidazole were the most prescribed drugs in patients with single Blastocystis infection. Notably, urticaria and other cutaneous symptoms of all treated patients were resolved after treatment. In conclusion, this study indicates that Blastocystis infection can be a neglected cause of urticaria and skin disorders. Since the treatment of Blastocystis infection is simple, screening and treatment of this infection should be considered in patients with urticaria and other skin disorders.

Urticaria and silent parasitism by Ascaridoidea: Component-resolved diagnosis reinforces the significance of this association

Urticaria remains a major problem in terms of aetiology, investigation, and management, and although parasitic diseases are considered potential causes, the absence of a consistent link between parasitic infections and skin allergy symptoms leads to the need for a deeper study of parameters that support this association. The objectives of this study were to analyse a possible relationship between parasitism by Ascarididae (Toxocara canis and Anisakis simplex) and the clinical expression of urticaria and to identify possible parasitic molecular markers for improving the diagnosis of unknown urticaria aetiology. The prevalence of Toxocara and Anisakis infestations was evaluated by measuring the levels of specific IgG (sIgG) and IgE (sIgE) antibodies against crude extracts and isolated components from whole larvae of Anisakis simplex (Ani s 1, Ani s 3 and Ani s 7) and Toxocara canis (TES-120, TES-70, TES-32 and TES-26) using immunologic and molecular diagnostic methods. A cross-sectional study was performed in a group of 400 individuals. The study group consisted of 95 patients diagnosed with urticaria (55 with chronic urticaria and 40 with acute urticaria). A control group consisted of 305 subjects without urticaria (182 diagnosed with respiratory allergy and 123 without allergy). Statistically significant differences were demonstrated in the seroprevalence of specific IgG and IgE antibodies between the urticaria patients and the healthy general population when isolated ascarid antigens were evaluated. The prevalence of IgG antibodies against Ani s 1, IgE antibodies against TES-120 and IgE antibodies against TES-70 were significantly different between the control individuals (healthy general population) and patients with urticaria. Moreover, the urticaria patient group demonstrated a higher seroprevalence of antibodies (sIgE and sIgG) against Anisakis simplex larva whole extract than the control group but just with statistically diferences when sIgE was evaluated. The presence of IgE and/or IgG antibodies against Ani s 3 (tropomyosin) can help to discriminate between patients with and without urticaria. Both ascarids seem to be associated with urticaria, although in our region, Anisakis seems to have greater involvement than Toxocara in this relationship. Molecular diagnostics can be used to associate urticaria with parasite infestations. Tropomyosin and Ani s 1 were the most relevant markers to demonstrate the association between urticaria and the most relevant Ascarididae parasites in our region.

Regulation of immunity and allergy by helminth parasites

There is increasing interest in helminth parasite modulation of the immune system, both from the fundamental perspective of the "arms race" between host and parasite, and equally importantly, to understand if parasites offer new pathways to abate and control untoward immune responses in humans. This article reviews the epidemiological and experimental evidence for parasite down-regulation of host immunity and immunopathology, in allergy and other immune disorders, and recent progress towards defining the mechanisms and molecular mediators which parasites exploit in order to modulate their host. Among these are novel products that interfere with epithelial cell alarmins, dendritic cell activation, macrophage function and T-cell responsiveness through the promotion of an immunoregulatory environment. These modulatory effects assist parasites to establish and survive, while dampening immune reactivity to allergens, autoantigens and microbiome determinants.

Pharmacologic Management of Chronic Urticaria in Pediatric Patients: The Gap Between Guidelines and Practice

Chronic urticaria is an uncommon disorder in children but can present considerable morbidity, as well as frustration for the healthcare provider and parent. The prevalence is 0.1-0.3% but can vary considerably by country. Chronic spontaneous urticaria (no identifiable cause) is responsible for 70-80% of chronic urticaria, about half of this due to a subtype called chronic autoimmune urticaria identified by the presence of autoantibodies to IgE or the IgE receptor. Chronic urticaria that is triggered by external physical stimuli is called chronic inducible urticaria and is present in another 15-20%. Allergies, infection, and other underlying diseases such as thyroid disease, celiac disease, or Helicobacter pylori infection cause a minor proportion of cases. Chronic urticaria has considerable impact on quality of life and healthcare costs. An adverse impact on quality of life is more prevalent in older children and adolescents and can be comparable to other diseases of childhood such as diabetes and epilepsy. Healthcare costs can be 50% higher than the national estimates for healthy patients and include more hospitalizations, longer duration of hospitalizations, and more emergency department (ED) and outpatient visits. Allergic and autoimmune diseases can be comorbidities that add to healthcare utilization. Resolution can take years. Guidelines are available for diagnosis and treatment. A good history is the key to identifying the cause. Minimal laboratory tests are required and should be guided by the history. Patients with easily controlled urticaria may not need any laboratory tests. Suggested treatment emphasizes the use of non-sedating antihistamines, utilized in a step-wise fashion beginning with normal doses and advancing the dose based on the response up to four times the recommended dose for age. Other treatments are left to the urticaria specialist and are not discussed in this paper. These guidelines are not well utilized based on real-world studies; sedating antihistamines and oral steroids are overutilized. Medications should be taken daily, not as needed. Additional medications, if required, should be added to prior medications in a step-wise fashion. The gap between the guidelines for diagnosis and treatment and what is happening in the real world needs to be closed to reduce the cost and morbidity associated with this disorder.

Anisakis Sensitization in the Croatian fish processing workers: Behavioral instead of occupational risk factors?

We undertook the first study systematically evaluating the risk of Anisakis-sensitization in Croatian fish-processing workers and potential genetic susceptibility to anisakiasis. Anti-Anisakis IgE seroprevalence and risk factors for 600 employees of Croatian fish processing facilities and 466 blood donor controls, were assessed by indirect ELISA targeted with: recombinant Ani s 1 and Ani s 7 allergens, an Anisakis crude extract, the commercial ImmunoCAP kit, and questionnaires. Genetic susceptibility to anisakiasis was evaluated by genotypisation of human leukocytes alleles (HLA). Anti-Anisakis seropositive and a fraction of negative subjects were also assessed by ELISA and Western Blot (WB) for IgG seroprevalence to Trichinella spp. Overall, the observed anti-Anisakis seroprevalence inferred by indirect ELISA was significantly higher in fish processing workers (1.8%, 95% CI 0.9–3.3%) compared to the controls (0%, 0–0.8%). Seven out of 11 Ani s 1 and Ani s 7-positives and none of selected 65 negative sera, tested positive on whole-Anisakis extract (ImmunoCAP), whereas Anisakis crude extract ELISA detected 3.9% (2.4–6.0%) seropositives in fish processing workers, three (14%) of which showed IgE reactivity to milk proteins. The highest risk associated with Anisakis-sensitization among workers was fishing in the free time, rather than any of attributes related to the occupational exposure. Although no association was observed between anti-Anisakis seropositivity and wearing gloves or protective goggles, the majority of workers (92%) wore protective gloves, minimizing the risk for Anisakis sensitization via skin contact. Six HLA alleles within DRB1 gene were significantly associated with seropositivity under dominant, allelic or recessive models. All sera confirmed negative for anti-Trichinella spp. IgG. The study exhaustively covered almost all marine fish processing workers in Croatia, reflecting real-time Anisakis sensitization status within the industry, already under the influence of wide array of allergens.

Anisakiasis is a human disease caused by ingestion of live Anisakis spp. larvae by raw seafood. Fish processing and aquaculture workers (approximately 60 million people world-wide) are at occupational risk of becoming sensitized to Anisakis. This is the first study systematically evaluating the risk of Anisakis-sensitization in Croatian fish-processing workers and potential genetic susceptibility to anisakiasis in the analysed population. Observed seroprevalence was significantly higher in fish processing workers (1.8%) compared to the controls (0%). Surprisingly, the highest risk associated with Anisakis-sensitization among workers was fishing in their free time, rather than any of attributes related to the occupational exposure. While no association was observed between anti-Anisakis seropositivity and wearing gloves or protective goggles, the majority of workers (92%) wore protective gloves, minimizing the risk for Anisakis sensitization via skin contact. Additionally, seroprevalence to another important food-borne helminth, Trichinella spp. assessed in all Anisakis-positive subjects showed to be negative. Almost all marine fish processing workers in Croatia were part of this research, reflecting real-time Anisakis-sensitization status within the industry. This sets a baseline for the future tracking of sensitization in the sector already under the influence of wide array of allergens.

Diet and Chronic Urticaria: Dietary Modification as a Treatment Strategy

Patients with chronic urticaria (CU) often ask about dietary modification. Research has indicated that specific dietary changes may be helpful in a subset of patients. Immunological food reactions are rare, but potential triggers of CU include those seen in certain settings, as in patients with a history of tick bites, a history of raw or marinated fish ingestion, or those with celiac disease. Nonimmunological food intolerances may also contribute, although mechanism of action is not well understood. Trials of pseudoallergen-free diets and low-histamine diets have resulted in partial remission in a subset of patients, while oral provocation testing has confirmed that some patients experience worsening of symptoms after ingestion of food additives, tomatoes, herbs, seafood, alcohol, and other foods. An increased prevalence of vitamin D deficiency has also been noted in patients with CU compared with healthy controls. While oral antihistamines remain the mainstay of therapy in CU, education on potential dietary factors may be offered to a selection of the group of patients. For those at risk or reporting symptoms suggestive of celiac disease, vitamin D deficiency, delayed reactions to mammalian meat, or exposure to raw fish, further workup is recommended. While education on dietary modification may be offered to other patients, this approach may benefit only a subset, and no test is available to identify these patients. A minimum of 3 weeks may be needed to determine response, and only specific diets that have been systematically studied should be considered. Any elimination diet should be used with caution because of the potential for nutritional deficiencies.

The relationship between Toxocara species seropositivity and allergic skin disorders: a systematic review and meta-analysis

We performed a systematic review and meta-analysis on observational studies to evaluate the possible associations between Toxocara species seropositivity and allergic skin disorders (ASDs). We searched the MEDLINE, ScienceDirect, Scopus, Web of Science and Google Scholar databases to 15 May 2018 to identify the relevant studies. We used a random effects meta-analysis model to generate the pooled odds ratio (OR) and 95% confidence intervals (CIs). Fifteen studies, including eight studies with a case-control design (735 patients and 1342 controls) and seven studies with a cross-sectional design (a total of 4804 participants, 1302 individuals with ASDs and 3502 without ASDs), were included in the meta-analysis. We found an increased risk for ASDs in individuals with Toxocara seropositivity (OR 1.75 [95% CI 1.16 to 2.64]). Subanalysis showed that Toxocara seropositivity was significantly associated with urticaria (OR 2.97 [95% CI 1.53 to 5.76]), however, it was not significantly associated with atopy (OR 1.08 [95% CI 0.55 to 2.15]) and eczema (OR 1.62 [95% CI 0.95 to 2.78]). Moreover, the pooled ORs were 2.34 (95% CI 1.32 to 4.15) and 1.27 (95% CI 0.69 to 2.35) for case-control and cross-sectional studies, respectively. The results of our study support hypotheses regarding the existence of a positive relationship between Toxocara infection and allergic disorders, although this association should be further investigated by longitudinal and mechanism studies.

Stress, pseudoallergens, autoimmunity, infection and inflammation in chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is often associated with organ specific autoimmunity but is rarely caused by food allergy. Colourings and preservatives in pre-packaged foods, so called pseudoallergens, have also been implicated. Factors that promote inflammation or reduce anti-inflammatory mechanisms may however, predispose susceptible individuals to CSU. Chronic underlying infection and mental and emotional stress can sometimes precede the onset of CSU and once established can exacerbate the symptoms. There is early evidence of dysbiosis within the gastrointestinal tract in people with CSU and reduced levels of vitamin D are also evident. The latter may be related to the importance of vitamin D3 in increasing T regulatory function which can control a tendency to autoimmunity. It is quite possible that a state of on-going chronic inflammation with reduced anti-oxidant mechanisms may underlie the not infrequent association between CSU and metabolic syndrome. Effective treatment of CSU should involve the use of anti-histamines, intermittent steroids and anti-IgE therapy. For recalcitrant disease immune modulatory therapy has a place. However, talking therapies that reduce stress and anxiety, vitamin D3 supplementation, correction of intestinal dysbiosis and treatment of any chronic infection should also be considered.

Management of chronic urticaria in children: a clinical guideline

The aim of this guidance is to provide recommendations to clinicians and other interested parties on chronic urticaria in children. The Italian Society for Pediatrics (SIP), the Italian Society for Allergy and Immunology (SIAIP), the Italian Society for Pediatric dermatology (SIDerP) convened a multidisciplinary panel that prepared clinical guidelines for diagnosis and management of chronic urticaria in childhood. Key questions on epidemiology, natural history, diagnosis, and management were developed. The literature was systematically searched and evaluated, recommendations were rated and algorithms for diagnosis and treatment were developed. The recommendations focus on identification of diseases and comorbidities, strategies to recognize triggering factors, improvement of treatment by individualized care.

Strongyloides infection as a reversible cause of chronic urticaria

Recurrent urticaria is a frequent presenting complaint in the Allergy Clinic, despite the fact that chronic urticaria is not an IgE-mediated (atopic) condition in most cases. We present four cases assessed over 5 years in our allergy service who were found to have evidence of strongyloidiasis and whose clinical features resolved with standard anti-helminth treatment.

Blastocystis prevalence and subtypes in autochthonous and immigrant patients in a referral centre for parasitic infections in Italy

In this study we characterized the presence and subtype (ST1-ST4) of Blastocystis in patients attended at a referral center for tropical diseases in Northern Italy. We also, evaluated the organism's association with other intestinal parasites. Parasite screening was performed on 756 patients, from different geographical origins (namely, Italians, Africans, South Americans, Asian and non-Italian Europeans) in which Italians represented the largest group. Blastocystis was seen to be the most prevalent parasite in the study. Subtype 3 and 1 were the most frequently found in the Italians and Africans. Our data confirmed previous studies performed in Italy, in which ST3 proved to be the most prevalent subtype, but we highlighted also a high frequency of mixed subtypes, which were probably underestimated in former analyses. Interestingly, the mixed subtypes group was the most prevalent in all the analysed geographical areas. About half of our cases showed other co-infecting parasites and the most frequent was Dientamoeba fragilis. Our study confirms that, in Blastocystis infection, multiple subtypes and co-infecting parasites are very frequently present, in particular Dientamoeba fragilis.

The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria

This evidence- and consensus-based guideline was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The conference was held on 1 December 2016. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-founded network of excellence, the Global Allergy and Asthma European Network (GA²LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) with the participation of 48 delegates of 42 national and international societies. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria are disabling, impair quality of life and affect performance at work and school. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Occurrence of anthropozoonotic parasitic infections and faecal microbes in free-ranging sperm whales (Physeter macrocephalus) from the Mediterranean Sea

Sperm whales (Physeter macrocephalus) are the largest toothed whales and only living member of family Physeteridae. Present survey represents first report on cultivable faecal microbes and gastrointestinal helminths and protozoans infecting free-ranging sperm whales inhabiting Mediterranean Sea waters surrounding Balearic Archipelago, Spain. Twenty-five individual sperm whale scat samples, including one calf, were collected without disturbance of animals during the summer of 2016. Parasitological diagnostic methods, such as sodium acetate acetic formalin (SAF) method, carbol fuchsin-stained faecal smears, Giardia/Cryptosporidium coproantigen ELISAs and an Anisakis-specific PCR were applied for further identification. Five bacterial genera, i.e. Acinetobacter, Clostridium, Enterococcus, Staphylococcus and Streptococcus, and one fungus namely Cladosporium were identified. Parasitological infections included seven different parasite species with some of them bearing anthropozoonotic potential. Thus, four of these parasites were zoonotic, i.e. Anisakis, Balantidium, Diphyllobothriidae gen. sp. and Giardia. Additionally, Zalophotrema curilensis eggs, spirurid-like eggs and Cystoisospora-like oocysts were identified. Molecular characterization identified Anisakis physeteris as the species infecting these whales. This survey provides first records on occurrence of two zoonotic enteropathogenic protozoan parasites (Giardia and Balantidium) and of facultative pathogenic bacteria (Clostridium and Enterococcus) in sperm whales. Presented data should be considered as a baseline study for future monitoring surveys on anthropozoonotic pathogens affecting free-living sperm whale populations and enhance investigations on possible impact on public health as well as on isolated Mediterranean sperm whale subpopulation.

Management of Pediatric Urticaria with Review of the Literature on Chronic Spontaneous Urticaria in Children

There are substantial knowledge gaps related to diagnosis and management of pediatric cases of chronic urticaria, and in particular chronic spontaneous urticaria (CSU). In this article we aimed to review the diagnosis and management of chronic urticaria in children and CSU in particular. We conducted a systematic review of articles published in English and French on pediatric CSU management in the last 10 years. We included experimental studies (eg, randomized controlled trials), other experimental designs (eg, nonrandomized methods of assignment, controlled before-after studies, and interrupted time series), and observational studies (eg, prospective or retrospective cohort studies, cross-sectional studies, case-control studies, and case reports). Our findings highlight the efficacy of second-generation antihistamines for the treatment of CSU in children and supports the use of omalizumab for more severe cases. However, our study also reveals severe knowledge gaps related to the best management strategy in children with more severe/refractory cases of CSU. Future studies are required to establish the beneficial effect of high doses of second-generation antihistamines as well as the effectiveness and safety of omalizumab and other biologics in young children.

Eosinophils from Physiology to Disease: A Comprehensive Review

Despite being the second least represented granulocyte subpopulation in the circulating blood, eosinophils are receiving a growing interest from the scientific community, due to their complex pathophysiological role in a broad range of local and systemic inflammatory diseases as well as in cancer and thrombosis. Eosinophils are crucial for the control of parasitic infections, but increasing evidence suggests that they are also involved in vital defensive tasks against bacterial and viral pathogens including HIV. On the other side of the coin, eosinophil potential to provide a strong defensive response against invading microbes through the release of a large array of compounds can prove toxic to the host tissues and dysregulate haemostasis. Increasing knowledge of eosinophil biological behaviour is leading to major changes in established paradigms for the classification and diagnosis of several allergic and autoimmune diseases and has paved the way to a "golden age" of eosinophil-targeted agents. In this review, we provide a comprehensive update on the pathophysiological role of eosinophils in host defence, inflammation, and cancer and discuss potential clinical implications in light of recent therapeutic advances.

Consensus Statement for the Diagnosis and Treatment of Urticaria: A 2017 Update

This article is developed by the Skin Allergy Research Society of India for an updated evidence-based consensus statement for the management of urticaria, with a special reference to the Indian context. This guideline includes updated definition, causes, classification, and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is by identification and elimination of the underlying cause(s) and/or eliciting trigger(s) while the second one is by treatment for providing symptomatic relief. This guideline recommends the use of second-generation nonsedating H1-antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the associated medical condition, severity of the symptoms, affordability of the drugs, and accessibility of modern biologics such as omalizumab.

Proteomic Analysis of Antiprotease Immunoglobulin-E Anti-Sperm Autoantibodies in Chronic Urticaria After Vasectomy

Some types of chronic urticaria (CU) are associated with autoreactive immunoglobulin (Ig)E, as well as IgG. In the syndrome of autoimmune thyroid disease and CU, autoreactive IgE, as well as IgG against host thyroid tissue, is present. The author describes a patient with new onset of CU after vasectomy with evidence of both autoreactive IgE and IgG anti-sperm antibodies (ASA). Autoreactive sperm proteins are enzymes opposed to structural sperm antigens producing ASA in infertility and after anti-spermatocyte vaccines. The author suggests that autoreactive proteins with enzymatic activity either in host proteins, aeroallergens, or viral proteins may have increased propensity to generate autoreactive IgE. This model of autoimmune IgE ASA generation by sperm and other host enzymatic proteins in CU can be tested using proteomic technology. INTRODUCTION