Identification of enolases and aldolases as important fish allergens in cod, salmon and tuna: component resolved diagnosis using parvalbumin and the new allergens

Simultaneous Determination of Animal Products from Ruminant, Pig, Poultry, and Fish in Feedingstuff by Targeted High-Resolution LC-MS/MS

The prohibition of processed animal proteins (PAPs) has been relaxed gradually since 2007. The official control method for PAPs in feedingstuff, a combination of light microscopy (LM) followed by PCR, is no longer sufficient. Thus, a targeted LC-MS/MS method was developed, which enables a tissue-specific distinction between egg and dairy products, gelatine, and PAPs derived from blood or muscle tissue of the species ruminants, pigs, poultry, and fish. Tissue-specific proteins were analyzed after tryptic digestion to peptides with high-resolution ESI-QTOF-MS. A targeted method was developed based on untargeted proteomics approaches and the selection of specific peptides (45 unique peptides in total). Proficiency testing of blank and spiked samples revealed excellent results for trueness and selectivity. Furthermore, sensitivity was achieved at a level of 0.1% (w/w) for assessed peptides. Summing up, the developed method seems to be suitable for routine analysis after verification by ring trials.

In silico evaluation of the potential allergenicity of a fungal biomass from Rhizomucor pusillus for use as a novel food ingredient

The world's hunger for novel food ingredients drives the development of safe, sustainable, and nutritious novel food products. For foods containing novel proteins, potential allergenicity of the proteins is a key safety consideration. One such product is a fungal biomass obtained from the fermentation of Rhizomucor pusillus. The annotated whole genome sequence of this strain was subjected to sequence homology searches against the AllergenOnline database (sliding 80-amino acid windows and full sequence searches). In a stepwise manner, proteins were designated as potentially allergenic and were further compared to proteins from commonly consumed foods and from humans. From the sliding 80-mer searches, 356 proteins met the conservative >35% Codex Alimentarius threshold, 72 of which shared ≥50% identity over the full sequence. Although matches were identified between R. pusillus proteins and proteins from allergenic food sources, the matches were limited to minor allergens from these sources, and they shared a greater degree of sequence homology with those from commonly consumed foods and human proteins. Based on the in silico analysis and a literature review for the source organism, the risk of allergenic cross-reactivity of R. pusillus is low.

Preparation of Blinded Food Matrixes for Clinical Oral Challenges

Clinically, oral food challenges have value in the diagnosis and management of food allergy. Oral food challenges are used not only for diagnostic confirmation that ingestion of a specific food elicits an adverse reaction, but also for determining individual threshold doses, tracking the progress toward desensitization during immunotherapy, determining the effect of processing on the allergenicity of a specific food, assessing the allergenicity of an ingredient derived from an allergenic source, and tracking the progress toward development of age-related tolerance to a specific food. To eliminate bias in oral challenges, the food under investigation is masked in a matrix so that it is not sensorially detectable by the patient or the clinical observer. The preparation of oral challenge foods requires care in the selection of the allergenic components, the selection of the components of the matrix, the masking of the allergenic component, and the homogeneity of the allergen in the overall matrix.

Immunochemical Characterization of Salix alba (S. alba) Pollen Allergens and Evaluation of the Cross-Reactivity Pattern with Common Allergenic Pollen Grains

BACKGROUND

Pollens, particularly tree and plant pollens, are one of the major causes of allergic respiratory diseases worldwide. Allergy to pollens of different species of Salix trees has been reported in various regions of the world. The most common type of Salix tree in Iran is white willow (Salix alba).

OBJECTIVES

This study aimed to identify and determine the immunochemical characteristics of allergenic proteins in S. alba tree pollen extract using SDS-PAGE and IgE- immunoblotting methods. Moreover, the cross-reaction pattern of the specific IgE antibody of S. alba tree pollen proteins with pollen allergens of common allergenic trees, i.e., Populus nigra (P. nigra), Cupressus sempervirens (C. sempervirens), Pinus brutia (P. brutia) and Platanus orientalis (P. orientalis) in the region was investigated.

METHODS

The reaction of allergenic proteins in S. alba pollen extract with specific IgE antibodies in patients' sera was investigated using SDS-PAGE and IgE-immunoblotting methods. The cross-reaction of specific IgE antibodies of the proteins present in S. alba pollen extract with pollen allergens of common allergenic trees in the region was investigated using ELISA and immunoblotting inhibition methods. In silico methods such as phylogenetic tree drawing and alignment of amino acid sequences were used to examine the evolutionary relationship and homology structure of common allergenic proteins (Panallergens) responsible for cross reactions.

RESULTS

More than 11 protein bands binding to specific IgE antibodies in patients' sera with a molecular weight between 13 and 95 kDa were identified in the S. alba tree pollen extract. ELISA and immunoblotting inhibition results showed that P. nigra extract could inhibit the binding of IgE antibodies to S. alba pollen extract proteins to a greater extent than C. sempervirens, P. brutia, and P. orientalis tree extracts. In silico methods investigated the results of ELISA and immunoblotting inhibition methods. Moreover, a high structural homology and evolutionary relationship were observed between S. alba and P. nigra tree pollen panallergens.

CONCLUSION

In this study, it was found that more than 80 % of the sensitive patients who were examined had specific IgE antibodies reacting with the approximately a 15 kDa-protein present in the S. alba pollen extract. Furthermore, the specific IgE-binding proteins found in the pollens of S. alba and P. nigra trees had relative structural homology, and it is likely that if recombinant forms are produced, they can be used for diagnostic and therapeutic purposes for both of the trees.

IgE-Mediated and Non-IgE-Mediated Fish Allergy in Pediatric Age: A Holistic Approach-A Consensus by Diagnostic Commission of the Italian Society of Pediatric Allergy and Immunology

Fish is one of the "big nine" foods triggering allergic reactions. For this reason, fish allergens must be accurately specified on food labels. Fish allergy affects less than 1% of the world population, but a higher prevalence is observed in pediatric cohorts, up to 7%. Parvalbumin is the main fish allergen found in the muscles. In childhood, sensitization to fish allergens occurs most frequently through the ingestion of fish, rarely transcutaneously or by inhalation. Fish allergy symptoms usually appear within two hours of the allergen contact. The diagnosis begins with the collection of the history. If it is suggestive of fish allergy, prick tests or the measurement of serum-specific IgE should be performed to confirm the suspicion. The oral food challenge is the gold standard for the diagnosis. It is not recommended in case of a severe allergic reaction. It is important to make a differential diagnosis with anisakiasis or scombroid poisoning, which have overlapping clinical features but differ in pathogenesis. Traditionally, managing fish allergy involves avoiding the triggering species (sometimes all bony fish species) and requires an action plan for accidental exposures. The present review will analyze IgE- and non-IgE-mediated fish allergy in children from epidemiology, pathogenesis to clinical features. Moreover, clinical management will be addressed with a particular focus on potential nutritional deficiencies.

A comprehensive review on glycation and its potential application to reduce food allergenicity

Food allergens are a major concern for individuals who are susceptible to food allergies and may experience various health issues due to allergens in their food. Most allergenic foods are subjected to heat treatment before being consumed. However, thermal processing and prolonged storage can cause glycation reactions to occur in food. The glycation reaction is a common processing method requiring no special chemicals or equipment. It may affect the allergenicity of proteins by altering the structure of the epitope, revealing hidden epitopes, concealing linear epitopes, or creating new ones. Changes in food allergenicity following glycation processing depend on several factors, including the allergen's characteristics, processing parameters, and matrix, and are therefore hard to predict. This review examines how glycation reactions affect the allergenicity of different allergen groups in allergenic foods.

Physicochemical and immunological characterization of Amb a 12, a novel ragweed (Ambrosia artemisiifolia) pollen allergen

BACKGROUND

Ragweed is an invasive plant in Europe, causing hay fever and asthma in allergic patients. Climate change is predicted to increase expansion and allergenicity. Elevated NO₂ induced upregulation of a new allergen in ragweed pollen, an enolase, Amb a 12.

OBJECTIVE

of this study was producing ragweed enolase as a recombinant protein and characterizing its physicochemical and immunological features.

METHODS

Amb a 12 was designed for E. coli and insect cell expression. Physicochemical features were determined by mass spectrometry, circular dichroism measurements and enzymatic activity assay. Immunological characteristics were determined in ELISA, in a mediator release assay and by investigation of association with clinical symptoms. Common allergen sources were screened for similar proteins.

RESULTS

Ragweed enolase was produced as a 48 kDa protein forming oligomers in both expression systems, showing differences in secondary structure content and enzymatic activity depending on expression system. IgE frequency and allergenicity were low regardless of expression system. Enolase-specific serum bound to similar sized molecules in mugwort, timothy grass and birch pollen, as well as food allergen sources, while highest IgE inhibition was achieved with peach pulp extract.

CONCLUSIONS

Amb a 12 had high sequence similarity and comparable IgE frequency to enolase allergens from different sources. 50 kDa proteins were found in other pollen and food allergen sources, suggesting that enolases might be pan-allergens in pollen and plant foods.

Differential patterns of fish sensitization in Asian populations: Implication for precision diagnosis

BACKGROUND

The current diagnostics of fish allergy lack sufficient accuracy such that more reliable tests such as component-resolved diagnosis (CRD) are urgently needed. This study aimed at identifying fish allergens of salmon and grass carp and evaluating the sensitization pattern in fish allergic subjects from two distinct populations in Asia.

METHODS

One hundred and three fish allergic subjects were recruited from Hong Kong (67 subjects) and Japan (46 subjects). Western blot and mass spectrometry were used to identify allergens from salmon and grass carp. Fish allergens were purified and tested against 96 sera on ELISA to analyze patients' sensitization pattern. The protein profiles of salmon meat prepared under different cooking methods until core temperature reached 80 °C were evaluated by SDS-PAGE and mass spectrometry.

RESULTS

Three common allergens between salmon and grass carp, namely enolase, glycerldehyde-3-phosphate dehydrogenase (GAPDH) and parvalbumin, and two salmon-specific allergens collagen and aldolase were identified. Parvalbumin was the major allergen for both fishes showing an overall sensitization rate of 74.7%, followed by collagen (38.9%), aldolase (38.5%) and enolase (17.8%). Japanese subjects showed more diverse allergen sensitization pattern and more frequent IgE-binding to heat-labile salmon allergens. Compared with steaming and boiling, cooking by baking and frying retained more fish proteins inclusive of heat-labile allergens.

CONCLUSIONS

Fish allergic patients from different Asian populations show varying fish allergen sensitization profiles. The relevant extracts and components for diagnosis are population-dependent but parvalbumin and collagen are important biomarkers. Cooking methods modify allergen composition of salmon and appear to influence patients' allergic manifestations.

Comparative analysis of allergenicity and predicted linear epitopes in α and β parvalbumin from turbot (Scophthalmus maximus)

BACKGROUND

Parvalbumin (PV) can be subdivided into two phylogenetic lineages, αPV and βPV. The bony fish βPV is considered a major fish allergen. However, there is no available report on the immunological property and epitope mapping of bony fish αPV.

RESULTS

To characterize the allergenic property of bony fish αPV and investigate the difference in allergenic property of bony fish αPV and βPV, turbot (Scophthalmus maximus) αPV and βPV were identified by mass spectrometry and were expressed in Escherichia coli system in this study. Spectra analysis and three-dimensional (3D) modeling showed the similar structure between αPV and βPV. However, αPV exhibited lower immunoglobulin E/immunoglobulin G (IgE/IgG) binding capacity than βPV. Three identified βPV epitopes possessed higher IgE reactivity and more hydrophobic residues than three identified αPV epitopes. In addition, less similarity in sequence homology of αPV epitopes was observed with allergen sequences in database.

CONCLUSION

These finding expanded information on fish PV epitopes and substantiated the difference in allergenicity and epitope mapping between fish αPV and βPV, which will improve the epitope-based detection tools of PV and diagnostic of PV induced fish allergy. © 2023 Society of Chemical Industry.

EAACI Molecular Allergology User's Guide 2.0

Since the discovery of immunoglobulin E (IgE) as a mediator of allergic diseases in 1967, our knowledge about the immunological mechanisms of IgE-mediated allergies has remarkably increased. In addition to understanding the immune response and clinical symptoms, allergy diagnosis and management depend strongly on the precise identification of the elicitors of the IgE-mediated allergic reaction. In the past four decades, innovations in bioscience and technology have facilitated the identification and production of well-defined, highly pure molecules for component-resolved diagnosis (CRD), allowing a personalized diagnosis and management of the allergic disease for individual patients. The first edition of the "EAACI Molecular Allergology User's Guide" (MAUG) in 2016 rapidly became a key reference for clinicians, scientists, and interested readers with a background in allergology, immunology, biology, and medicine. Nevertheless, the field of molecular allergology is moving fast, and after 6 years, a new EAACI Taskforce was established to provide an updated document. The Molecular Allergology User's Guide 2.0 summarizes state-of-the-art information on allergen molecules, their clinical relevance, and their application in diagnostic algorithms for clinical practice. It is designed for both, clinicians and scientists, guiding health care professionals through the overwhelming list of different allergen molecules available for testing. Further, it provides diagnostic algorithms on the clinical relevance of allergenic molecules and gives an overview of their biology, the basic mechanisms of test formats, and the application of tests to measure allergen exposure.

Seafood allergy: Allergen, epitope mapping and immunotherapy strategy

Seafoods are fashionable delicacies with high nutritional values and culinary properties, while seafood belongs to worldwide common food allergens. In recent years, many seafood allergens have been identified, while the diversity of various seafood species give a great challenge in identifying and characterizing seafood allergens, mapping IgE-binding epitopes and allergen immunotherapy development, which are critical for allergy diagnostics and immunotherapy treatments. This paper reviewed the recent progress on seafood (fish, crustacean, and mollusk) allergens, IgE-binding epitopes and allergen immunotherapy for seafood allergy. In recent years, many newly identified seafood allergens were reported, this work concluded the current situation of seafood allergen identification and designation by the World Health Organization (WHO)/International Union of Immunological Societies (IUIS) Allergen Nomenclature Sub-Committee. Moreover, this review represented the recent advances in identifying the IgE-binding epitopes of seafood allergens, which were helpful to the diagnosis, prevention and treatment for seafood allergy. Furthermore, the allergen immunotherapy could alleviate seafood allergy and provide promising approaches for seafood allergy treatment. This review represents the recent advances and future outlook on seafood allergen identification, IgE-binding epitope mapping and allergen immunotherapy strategies for seafood allergy prevention and treatment.

Cross-reactive monoclonal antibodies against fish parvalbumins as a tool for studying antigenic similarity of different parvalbumins and analysis of fish extracts

Fish parvalbumins are heat-stable calcium-binding proteins that are highly cross-reactive in causing allergy symptoms in fish-sensitized patients. The reactivities of parvalbumin-specific monoclonal or polyclonal antibodies with parvalbumins of different fish species allowed their application for development of various immunoassays for allergen identification in fish samples. In this study, monoclonal antibodies (MAbs) were generated against two parvalbumins - natural Atlantic cod parvalbumin and recombinant common carp β-parvalbumin expressed in E. coli. Large collections of recombinant parvalbumins and natural allergen extracts of different fish species and other animals were used to identify the specificities of these MAbs using ELISA, Western blot, and dot blot. MAbs demonstrated different patterns of cross-reactivities with recombinant parvalbumins. Their binding affinities were affected by the addition and removal of Ca²⁺ ions. Moreover, all MAbs showed a broad reactivity with the target antigens in natural fish, chicken, and pork extracts. The ability of two MAbs (clones 7B2 and 3F6) to identify and isolate native parvalbumins from allergen extracts was confirmed by Western blot. Epitope mapping using recombinant fragments of Atlantic cod parvalbumin (Gad m 1) and common carp parvalbumin (Cyp c 1) revealed that 4 out of 5 MAbs recognize parvalbumin regions that contain calcium binding sites. In conclusion, the generated broadly reactive well-characterized MAbs against fish β-parvalbumins could be applied for investigation of parvalbumins of fish and other animals and their detection in allergen extracts.

Detection of Fish Allergens in Foods Using an In-House Real-Time PCR Targeting the Ribosomal 18S rRNA Gene

Fish is one of the major food allergens which, in sensitised individuals, can cause life-threatening allergic reactions, even when present in small amounts. To protect consumers' health, the correct labeling of foods is important. The objective of the present study was to validate an in-house real-time PCR method targeting the ribosomal 18S rRNA gene as universal DNA marker for the detection of fish in foods. The specificity of the primers was assessed on 20 fish species commonly marketed in the Mediterranean basin and other species of molluscs and crustaceans and foods of animal and plant origin. The absolute detection of the method was assessed using DNA extracted from a fish mixture and the SureFood^® QUANTARD Allergen 40 reference material. The relative amount was assessed on a fish and béchamel sauce blend. Commercial food samples either labelled with or without fish in the ingredient list, were tested for the presence of fish DNA. The primer showed high specificity against the selected fish species. The limit of detection (LOD) and limit of quantification (LOQ) of the in-house method were 0.5 pg/µL and 5 pg/µL, respectively. The relative quantification in fish and béchamel blend samples detected a concentration as low as 0.000025%, corresponding to 0.25 mg/kg of fish, indicating the suitability of the method in a food matrix. The presence of fish DNA was always detected in commercial samples in which the presence of fish was listed in the ingredient list. The method was able to detect the presence of fish DNA also in samples in which the presence of fish was indicated as traces or was not declared on the label. The proposed method was demonstrated to be a reliable, specific, and sensitive method for the detection of fish allergens in foods. Therefore, the proposed real-time PCR method could be used as a useful instrument in the verification of compliance with allergen labelling regulations.

A comprehensive molecular approach in fish allergy: Usefulness in daily clinical practice

BACKGROUND AND AIMS

Diagnosis of fish may represent an important challenge for the allergists. This study aimed to evaluate the diagnostic sensitivity of an in vitro multiplex assay using a comprehensive panel of fish allergens and the cross-reactivity patterns between different molecular components.

METHODS

56 subjects with fish allergy were enrolled. All patients underwent specific IgE measurement using the Allergy Explorer-Alex 2™ multiplex assay (Macroarray Diagnostics, Vienna, Austria) RESULTS: The single ß-parvalbumins Clu h 1, Cyp c 1, Gad m 1, Sal s 1, Sco s 1, Thu a 1 and Xyp g 1 scored positive in 75.0%, 67.8%, 62.5%, 80.3%,80.3%, 78.8% and 73,2% patients, respectively. 14.3% scored positive for the α-parvalbumin (Raj c-parvalbumin), and 16.1% for the aldolase + enolase (Gad m 2 + 3) components. 92.8% reacted to at least one ß-parvalbumin and 96.4% to at least one of the allergens tested. Overall sensitivity was higher than that obtained using commercial extracts of cod, salmon and tuna for skin prick test (75.8%) and IgE detection (92.3%).

CONCLUSIONS

The Alex 2 showed high diagnostic sensitivity and it might be used as an additional assay to investigate the cross-reactivity patterns between different molecular components, looking for potentially safe fish species.

A comprehensive overview of emerging processing techniques and detection methods for seafood allergens

Seafood is rich in nutrients and plays a significant role in human health. However, seafood allergy is a worldwide health issue by inducing adverse reactions ranging from mild to life-threatening in seafood-allergic individuals. Seafood consists of fish and shellfish, with the major allergens such as parvalbumin and tropomyosin, respectively. In the food industry, effective processing techniques are applied to seafood allergens to lower the allergenicity of seafood products. Also, sensitive and rapid allergen-detection methods are developed to identify and assess allergenic ingredients at varying times. This review paper provides an overview of recent advances in processing techniques (thermal, nonthermal, combined [hybrid] treatments) and main allergen-detection methods for seafood products. The article starts with the seafood consumption and classification, proceeding with the prevalence and symptoms of seafood allergy, followed by a description of biochemical characteristics of the major seafood allergens. As the topic is multidisciplinary in scope, it is intended to provide information for further research essential for food security and safety.

Fish Allergenicity Modulation Using Tailored Enriched Diets—Where Are We?

Food allergy is an abnormal immune response to specific proteins in a certain food. The chronicity, prevalence, and the potential fatality of food allergy, make it a serious socio-economic problem. Fish is considered the third most allergenic food in the world, affecting part of the world population with a higher incidence in children and adolescents. The main allergen in fish, responsible for the large majority of fish-allergic reactions in sensitized patients, is a small and stable calcium-binding muscle protein named beta-parvalbumin. Targeting the expression or/and the 3D conformation of this protein by adding specific molecules to fish diets has been the innovative strategy of some researchers in the fields of fish allergies and nutrition. This has shown promising results, namely when the apo-form of β-parvalbumin is induced, leading in the case of gilthead seabream to a 50% reduction of IgE-reactivity in fish allergic patients.

A new paradigm to search for allergenic proteins in novel foods by integrating proteomics analysis and in silico sequence homology prediction: Focus on spirulina and chlorella microalgae

Since novel nutrient sources with high protein content, such as yeast, fungi, bacteria, algae, and insects, are increasingly introduced in the consumer market, safety evaluation studies on their potentially allergenic proteins are required. A pipeline for in silico establishing the sequence-based homology between proteins of spirulina (Arthrospira platensis) and chlorella (Chlorella vulgaris) micro-algae and those included in the AllergenOnline (AO) database (AllergenOnline.org) is described. The extracted proteins were first identified through tryptic peptides analysis by reversed-phase liquid chromatography and high resolution/accuracy Fourier-transform tandem mass spectrometry (RPLC-ESI-FTMS/MS), followed by a quest on the UniProt database. The AO database was subsequently interrogated to assess sequence similarity between identified microalgal proteins and known allergens, based on criteria established by the World Health Organization (WHO) and Food and Agriculture Organization (FAO). A direct search for microalgal proteins already included in allergen databases was also performed using the Allergome database. Six proteins exhibiting a significant homology with food allergens were identified in spirulina extracts. Five of them, i.e., two thioredoxins (D4ZSU6, K1VP15), a superoxide dismutase (C3V3P3), a glyceraldehyde-3-phosphate dehydrogenase (K1W168), and a triosephosphate isomerase (D5A635), resulted from the search on AO. The sixth protein, C-phycocyanin beta subunit (P72508), was directly obtained after examining the Allergome database. Two proteins exhibiting significant sequence homology with food allergens were retrieved in chlorella extracts, viz. calmodulin (A0A2P6TFR8), which is related to troponin c (D7F1Q2), and fructose-bisphosphate aldolase (A0A2P6TDD0). Specific serum screenings based on immunochemical tests should be undertaken to confirm or rule out the allergenicity of the identified proteins.

Effect of creatine and EDTA supplemented diets on European seabass (Dicentrarchus labrax) allergenicity, fish muscle quality and omics fingerprint

The relatively easy access to fish worldwide, alongside the increase of aquaculture production contributes to increased fish consumption which result in higher prevalence of respective allergies. Allergies to fish constitute a significant concern worldwide. β-parvalbumin is the main elicitor for IgE-mediated reactions. Creatine, involved in the muscle energy metabolism, and ethylenediamine tetraacetic acid (EDTA), a calcium chelator, are potential molecules to modulate parvalbumin. The purpose of this study was to test creatine (2, 5 and 8%) and EDTA (1.5, 3 and 4.5%) supplementation in fish diets to modulate β-parvalbumin expression and structure and its allergenicity in farmed European seabass (Dicentrarchus labrax) while assessing its effects on the end-product quality. Fish welfare and muscle quality parameters were evaluated by plasma metabolites, rigor mortis, muscle pH and sensory and texture analysis. Proteomics was used to assess alterations in muscle proteome profile and metabolic fingerprinting by Fourier transform infrared spectroscopy was used to assess the liver metabolic profile. In addition, IgE-reactivity to parvalbumin was analysed using fish allergic patient sera. Metabolic fingerprinting of liver tissue revealed no major alterations in infrared spectra with creatine supplementation, while with EDTA, only absorption bands characteristic of lipids were altered. Comparative proteomics showed up regulation of (tropo) myosin and phosphoglycerate mutase 2 with Creatine supplementation. In the case of EDTA proteomics showed up regulation of proteins involved in cellular and ion homeostasis. Allergenicity seems not to be modulated with creatine or EDTA supplementation as no decreased expression levels were found and IgE-binding reactivity showed no quantitative differences.

Alternative Fish Species for Nutritional Management of Children with Fish-FPIES—A Clinical Approach

In the Mediterranean region, fish is a common cause of food protein-induced enterocolitis syndrome (FPIES) in children. No laboratory tests specific to FPIES are available, and oral food challenge (OFC) is the gold standard for its diagnosis and testing for achievement of tolerance. Children with FPIES to fish are usually advised to avoid all fish, regardless of the species. Fish are typically classified into bony and cartilaginous, which are phylogenetically distant species and therefore contain less cross-reacting allergens. The protein β-parvalbumin, considered a pan-allergenic, is found in bony fish, while the non-allergenic α-parvalbumin is commonly found in cartilaginous fish. Based on this difference, as a first step in the therapeutic process of children with FPIES caused by a certain fish in the bony fish category (i.e., hake, cod, perch, sardine, gilthead sea bream, red mullet, sole, megrim, sea bass, anchovy, tuna, swordfish, trout, etc.), an OFC to an alternative from the category of cartilaginous fish is suggested (i.e., blue shark, tope shark, dogfish, monkfish, skate, and ray) and vice versa. Regarding the increased mercury content in some sharks and other large species, the maximum limit imposed by the European Food Safety Authority (EFSA) for weekly mercury intake must be considered. An algorithm for the management of fish-FPIES, including alternative fish species, is proposed.

Proteomics for species authentication of cod and corresponding fishery products

Seafood substitutions is a global problem and come under the spotlight in recent years. In Taiwan, Greenland halibut is usually substituted for the cod because of its lower price. Nowadays, DNA technology is widely used for fish species identifications; however, it still has concern about the DNA of processed fishery products might be destroyed. This study was designed to develop a proteomic-based method for fish and fishery product authentication by using ultra performance liquid chromatography/quadrupole time-of-flight mass spectrometry (UPLC-QTOF-MS/MS) with Sequential window acquisition of all theoretical fragment ion spectra (SWATH). The protein biomarkers from the meat of Alaska pollock, Atlantic cod, and Greenland halibut were identified and validated for species authentication of cod and corresponding fishery products, which might prevent consumer substitutions and fish product mislabeling. Besides, the E. coli proteins can be measured from existing SWATH-MS data though retrospective analysis successfully, it might present the quality of fish meat.

Newly defined allergens in the WHO/IUIS Allergen Nomenclature Database during 01/2019-03/2021

The WHO/IUIS Allergen Nomenclature Database (http://allergen.org) provides up‐to‐date expert‐reviewed data on newly discovered allergens and their unambiguous nomenclature to allergen researchers worldwide. This review discusses the 106 allergens that were accepted by the Allergen Nomenclature Sub‐Committee between 01/2019 and 03/2021. Information about protein family membership, patient cohorts, and assays used for allergen characterization is summarized. A first allergenic fungal triosephosphate isomerase, Asp t 36, was discovered in Aspergillus terreus. Plant allergens contained 1 contact, 38 respiratory, and 16 food allergens. Can s 4 from Indian hemp was identified as the first allergenic oxygen‐evolving enhancer protein 2 and Cic a 1 from chickpeas as the first allergenic group 4 late embryogenesis abundant protein. Among the animal allergens were 19 respiratory, 28 food, and 3 venom allergens. Important discoveries include Rap v 2, an allergenic paramyosin in molluscs, and Sal s 4 and Pan h 4, allergenic fish tropomyosins. Paramyosins and tropomyosins were previously known mainly as arthropod allergens. Collagens from barramundi, Lat c 6, and salmon, Sal s 6, were the first members from the collagen superfamily added to the database. In summary, the addition of 106 new allergens to the previously listed 930 allergens reflects the continuous linear growth of the allergen database. In addition, 17 newly described allergen sources were included.

Fish Allergy Around the World—Precise Diagnosis to Facilitate Patient Management

The accurate and precise diagnosis of IgE-mediated fish allergy is one of the biggest challenges in allergy diagnostics. A wide range of fish species that belong to evolutionary distant classes are consumed globally. Moreover, each fish species may contain multiple isoforms of a given allergen that often differ in their allergenicity. Recent studies indicated that the cross-reactivity between different fish species is limited in some cases and depends on the evolutionary conservation of the involved allergens. Fish allergens belong to several protein families with different levels of stability to food processing. Additionally, different preparation methods may contribute to specific sensitization patterns to specific fish species and allergens in different geographic regions. Here, we review the challenges and opportunities for improved diagnostic approaches to fish allergy. Current diagnostic shortcomings include the absence of important region-specific fish species in commercial in vitro and in vivo tests as well as the lack of their standardization as has been recently demonstrated for skin prick test solutions. These diagnostic shortcomings may compromise patients' safety by missing some of the relevant species and yielding false negative test results. In contrast, the avoidance of all fish as a common management approach is usually not necessary as many patients may be only sensitized to specific species and allergens. Although food challenges remain the gold standard, other diagnostic approaches are investigated such as the basophil activation test. In the context of molecular allergy diagnosis, we discuss the usefulness of single allergens and raw and heated fish extracts. Recent developments such as allergen microarrays offer the possibility to simultaneously quantify serum IgE specific to multiple allergens and allergen sources. Such multiplex platforms may be used in the future to design diagnostic allergen panels covering evolutionary distant fish species and allergens relevant for particular geographic regions.

Development and Characterization of Monoclonal Antibodies for the Detection of Fish Protein

This study developed and characterized anti-fish monoclonal antibodies (mAbs) capable of detecting fish, a major allergenic food, in processed food products to protect fish sensitized individuals. Of the three mAbs raised against crude protein extract of cooked fish muscle, mAb 8F5 exhibited a positive reaction to all 50 common food fish species tested with no cross-reactions to shellfish, land animals, or food additives. Although the ELISA results were negative against swordfish and yellowfin tuna, western blot clearly detected both after cooking. The ~36 kDa antigenic protein of mAb 8F5, which was found in all fish species, was detectable by mAb 8F5 in all of the fish samples even after prolonged heat treatment (100 °C, up to 60 min). These findings suggest that mAb 8F5 has great potential utility as a probe for the immunochemical detection of fish tissue in cooked food.

Occupational Allergic Sensitization Among Workers Processing King Crab (Paralithodes camtschaticus) and Edible Crab (Cancer pagurus) in Norway and Identification of Novel Putative Allergenic Proteins

Introduction: Asthma and allergy occur frequently among seafood processing workers, with the highest prevalence seen in the crustacean processing industry. In this study we established for the first time the prevalence of allergic sensitization in the Norwegian king- and edible crab processing industry and characterized the IgE-reactive proteins.

Materials and Methods: Two populations of crab processing workers participated; 119 king crab and 65 edible crab workers. The investigation included information on work tasks and health through a detailed questionnaire. Allergic sensitization was investigated by crab-specific IgE quantification and skin prick tests (SPT) to four in-house prepared crab extracts; raw meat, cooked meat, raw intestines and raw shell. Allergen-specific IgE binding patterns were analyzed by IgE immunoblotting to the four allergen extracts using worker serum samples. Total proteins in crab SPT extracts and immunoblot-based IgE binding proteins were identified by mass spectrometric analysis.

Results: Positive SPTs were established in 17.5% of king- and 18.1% of edible crab workers, while elevated IgE to crab were demonstrated in 8.9% of king- and 12.2% of edible crab processing workers. There was no significant difference between the king and edible crab workers with respect to self-reported respiratory symptoms, elevated specific IgE to crab or SPT results. Individual workers exhibited differential IgE binding patterns to different crab extracts, with most frequent binding to tropomyosin and arginine kinase and two novel IgE binding proteins, hemocyanin and enolase, identified as king- and edible crab allergens.

Conclusions: Occupational exposure to king- and edible crabs may frequently cause IgE mediated allergic sensitization. Future investigations addressing the diagnostic value of crab allergens including tropomyosin and arginine kinase and the less well-known IgE-binding proteins hemocyanin and enolase in a component-resolved diagnostic approach to crab allergy should be encouraged.

Seafood Allergy in Asia: Geographical Specificity and Beyond

Asian countries have unique ways of food processing and dietary habits that may explain the observed differences in the prevalence, natural history, epidemiology and sensitization pattern of food allergic diseases when compared to western countries. Per capita consumption of seafood, including fish and shellfish, is well above the global average for many Asian countries because of their coastal geographical location and rich seafood supply. The wide availability and high abundance of seafood in Asian countries have shaped a diverse way of processing and eating this major food group. Such unique features have significant impact on the sensitization profile and allergenicity of Asians to fish and shellfish. For example, fish and shellfish are eaten raw in some countries that may promote sensitization to heat-labile allergens not otherwise seen in other regions. Fermented fish sauce is commonly used as a condiment in some countries which may promote fish sensitization. Shrimp head and shrimp roe are regarded as delicacies in some countries, but their allergen profiles are yet to be characterized. Freshwater fish and shellfish are a common food source in many Asian countries but the allergenicity of many such species remains unknown. In this review, we discuss factors that may contribute to differences in molecular profile and sensitization pattern for fish and shellfish that are observed in Asian populations and revisit the current status of seafood allergy in this part of the world. Acknowledging the similarities and differences of seafood allergy patterns between Asian and western populations can help us refine a better strategy for diagnosing and managing seafood allergy.

DNA, protein and aptamer-based methods for seafood allergens detection: Principles, comparisons and updated applications

The increasing number of people with seafood allergy has caused a series of problems for practitioners and consumers in the seafood industry year by year. Thereby, development of efficient, convenient and low-cost allergen detection methods is urgently needed. This review introduces three important existing seafood allergen detection methods associated with DNA-based, protein-based and aptamer-based. Their principles and biological characteristics are firstly presented. The core of these three methods are DNA amplification techniques, specific binding of antigens and antibodies, and specific binding of aptamers and ligands, respectively. Among them, DNA-based detection method is an indirect analysis, which takes the gene of allergen as the detection object and is characterized by good stability and high sensitivity. Protein-based and aptamer-based, methods employ indirect analysis for allergen detection. The difference is that the latter uses an easily synthesized and highly efficient aptamer as the detection probe, showing great promising potentials. The advantages and disadvantages of the three mentioned detection methods are also discussed. In the future, as more efficient and reliable detection methods for seafood allergens come into practice, the possibility of seafood allergy patients eating seafood products by mistake will be greatly reduced, which will ensure the food safety and the health of allergy patients.

Clinical Management of Seafood Allergy

Seafood plays an important role in human nutrition and health. A good patient workup and sensitive diagnostic analysis of IgE antibody reactivity can distinguish between a true seafood allergy and other adverse reactions generated by toxins or parasites contaminating ingested seafood. The 2 most important seafood groupings include the fish and shellfish. Shellfish, in the context of seafood consumption, constitutes a diverse group of species subdivided into crustaceans and mollusks. The prevalence of shellfish allergy seems to be higher than that of fish allergy, with an estimate of up to 3% in the adult population and fin fish allergy prevalence of approximately 1%. Clinical evaluation of the seafood-allergic patient involves obtaining a detailed history and obtaining in vivo and/or in vitro testing with careful interpretation of results with consideration of cross-reactivity features of the major allergens. Oral food challenge is useful not only for the diagnosis but also for avoiding unnecessary dietary restrictions. In this review, we highlight some of the recent reports to provide solid clinical and laboratory tools for the differentiation of fish allergy from shellfish allergy, enabling best treatment and management of these patients.

Dietary Management of Food Allergy

Worldwide food allergy prevalence is increasing, especially in children. Food allergy management strategies include appropriate avoidance measures and identifying suitable alternatives for a nutritionally sound diet. Individualized dietary intervention begins teaching label reading, which differs among countries or regions. Dietary intervention must result in a nutritionally sound plan including alternatives to support optimal growth and development. Inappropriate or incomplete dietary advice may increase the risk of adverse reactions, growth faltering, and nutrient deficiencies. Evidence indicates input from a registered dietitian improves nutritional outcomes. Nutritional input plays a critical role managing nutritional disorders related to food allergy.

Expanding the allergen repertoire of salmon and catfish

BACKGROUND

Diagnostic tests for fish allergy are hampered by the large number of under-investigated fish species. Four salmon allergens are well-characterized and registered with the WHO/IUIS while no catfish allergens have been described so far. In 2008, freshwater-cultured catfish production surpassed that of salmon, the globally most-cultured marine species. We aimed to identify, quantify, and compare all IgE-binding proteins in salmon and catfish.

METHODS

Seventy-seven pediatric patients with clinically confirmed fish allergy underwent skin prick tests to salmon and catfish. The allergen repertoire of raw and heated protein extracts was evaluated by immunoblotting using five allergen-specific antibodies and patients' serum followed by mass spectrometric analyses.

RESULTS

Raw and heated extracts from catfish displayed a higher frequency of IgE-binding compared to those from salmon (77% vs 70% and 64% vs 53%, respectively). The major fish allergen parvalbumin demonstrated the highest IgE-binding capacity (10%-49%), followed by triosephosphate isomerase (TPI; 19%-34%) in raw and tropomyosin (6%-32%) in heated extracts. Six previously unidentified fish allergens, including TPI, were registered with the WHO/IUIS. Creatine kinase from salmon and catfish was detected by IgE from 14% and 10% of patients, respectively. Catfish L-lactate dehydrogenase, glyceraldehyde-3-phosphate dehydrogenase, pyruvate kinase, and glucose-6-phosphate isomerase showed IgE-binding for 6%-13% of patients. In salmon, these proteins could not be separated successfully.

CONCLUSIONS

We detail the allergen repertoire of two highly farmed fish species. IgE-binding to fish tropomyosins and TPIs was demonstrated for the first time in a large patient cohort. Tropomyosins, in addition to parvalbumins, should be considered for urgently needed improved fish allergy diagnostics.

The Role of Enolases in Allergic Disease

Enolase is one of the most abundant cytosolic enzymes as well as an important glycolytic metalloenzyme highly conserved among organisms from different taxonomical groups. Participation of enolase in processes in which its enzymatic activity is not required has been widely reported. Some of these processes provide special qualities to microorganisms, which favor, in some cases, their pathogenicity. Remarkably, enolase has been reported as an allergen by itself, it is well recognized as allergenic in molds and yeasts, whereas it has also been recognized by the immune system of susceptible individuals acting as a food and inhaled allergen from other diverse sources such as insects, birds, fishes, and plants. To date, 14 enolases have been officially recognized by the World Health Organization/International Union of Immunological Societies Allergen Nomenclature Subcommittee. The use of discovery proteomics has also uncovered novel allergenic enolases, particularly from pollen sources. Here, we review the relevance of enolases as sensitizers and as nonsensitizing cross-reactive allergens in allergic disease.

IgE-Mediated Fish Allergy in Children

Fish allergy constitutes a severe problem worldwide. Its prevalence has been calculated as high as 7% in paediatric populations, and in many cases, it persists into adulthood with life-threatening signs and symptoms. The following review focuses on the epidemiology of Immunoglobulin E (IgE)-mediated fish allergy, its pathogenesis, clinical manifestations, and a thorough approach to diagnosis and management in the paediatric population. The traditional approach for managing fish allergy is avoidance and rescue medication for accidental exposures. Food avoidance poses many obstacles and is not easily maintained. In the specific case of fish, food is also not the only source of allergens; aerosolisation of fish proteins when cooking is a common source of highly allergenic parvalbumin, and elimination diets cannot prevent these contacts. Novel management approaches based on immunomodulation are a promising strategy for the future of these patients.

Assessment of the effects of a work-related allergy to seafood on the reduction of earning capacity in the context of BK No. 5101

Fish, crustaceans, and mollusks are among the most potent allergenic foods of animal origin and are thus important triggers of work-related immediate-food allergies. In Germany, work-related seafood allergies are of great importance in the fishing and processing industries as well as in the areas of food preparation, food control, and food sales. There is no causal therapy of seafood allergy, only the strict and lifelong avoidance of allergens remains. The following recommendations serve to assess the impact of a seafood allergy with regard to the work opportunities ended by it for the assessment of the reduction of earning capacity (MdE (German for Minderung der Erwerbsfähigkeit)) in the context of the occupational disease number 5101 of the Annex to the German regulation for occupational diseases. As a special feature of work-related seafood allergy with regard to insurance law aspects, it must be taken into account that there is a potential risk of systemic reaction with subsequent multi-organ involvement. For the estimation of MdE in the general labor market, the impact of a seafood allergy can therefore be assessed, depending on its clinical severity, as generally “mild” to “severe” in justified individual cases.

IgE and IgG4 epitopes revealed on the major fish allergen Lat c 1

BACKGROUND

The IgE- and IgG₄-binding patterns of the major fish allergen parvalbumins are not clearly understood. IgE antibody-binding to parvalbumin from Asian seabass, Lat c 1.01, is implicated in up to 90 % of allergic reactions, although the region of IgE or IgG4 epitopes are unknown. In the present study, we characterized the specific IgE- and IgG₄-binding regions of Lat c 1.01 using serum from pediatric and adult patients with clinically-confirmed fish allergy.

METHODS

A comparative investigation of patient IgE- and IgG₄-binding to recombinant Lat c 1.01 was performed by immunoblotting and indirect ELISA using serum from 15 children and eight adults with clinically confirmed IgE-mediated reactions to fish. The IgE- and IgG₄-binding regions of Lat c 1.01 were determined by inhibition ELISA using seven overlapping peptides spanning the entire 102 amino acid sequence. Elucidated IgE-binding regions were modelled and compared to known antibody-binding regions of parvalbumins from five other fish species.

RESULTS

Ninety five percent (22/23) patients demonstrated IgE-binding to rLat c 1.01, while fewer patients (10/15 children and 7/8 adults) demonstrated robust IgG₄ binding when determined by immunoblots. IgE-binding for both cohorts was significantly higher compared to IgG₄-binding by ELISA. All patients in this study presented individual IgE and IgG₄ epitope-recognition profiles. In addition to these patient-specific antibody binding sites, general IgE epitopes were also identified at the C- and N-terminal regions of this major fish allergen.

CONCLUSIONS AND CLINICAL RELEVANCE

Our findings demonstrate two specific IgE epitopes on parvalbumin from Asian seabass, while IgG₄ binding is much lower and patient specific. This study highlights the importance of advancement in epitope analysis regardless of the age group for diagnostics and immunotherapies for fish allergy.

Allergenicity and Stability of 6 New Korean Bony Fish Extracts

Purpose

Diagnostic tests for allergen sensitization should reflect real exposure. We made 6 new bony fish extracts, which are consumed popularly in Korea, and evaluated their allergenicity and stability.

Methods

We manufactured fish extracts from codfish, mackerel, common eel, flounder, cutlass, and catfish. Protein and parvalbumin (PV) were evaluated by Bradford assay, 2-site enzyme-linked immunosorbent assay, sodium dodecyl sulphate–polyacrylamide gel electrophoresis (SDS-PAGE), and anti-PV immunoblotting. The immunoglobulin E (IgE) reactivities of the extracts were evaluated with ImmunoCAP and IgE immunoblotting using sera from 24 Korean fish allergy patients, 5 asymptomatic sensitizers, and 11 non-atopic subjects. Stability of the extracts stored in 4 different buffers were evaluated for up to a year.

Results

The protein concentrations of commercial SPT fish extracts varied with up to a 7.5-fold difference. SDS-PAGE showed marked differences in the PV concentrations of commercial SPT reagents. Specific IgE measurements for the following investigatory fish extracts—iCodfish, iMackerel, and iEel—were concordant with that of their corresponding Phadia ImmunoCAP measurements. ImmunoCAP results showed marked IgE cross-reactivity among the fish species, and the overall sensitivity of ImmunoCAP with the investigatory fish extracts for identification of culprit fish species was 85.7%. The protein and PV concentrations in the investigatory extracts were highly stable in saline with 0.3% phenol–50% glycerol at 4°C for up to a year.

Conclusions

The commercial SPT fish extracts exhibited considerable variation in terms of allergenicity, which may impact on diagnostic accuracy. Our new fish extracts have sufficient allergenicity and stability and may be adequate to various clinical applications.

Novel Allergen Discovery through Comprehensive De Novo Transcriptomic Analyses of Five Shrimp Species

Shellfish allergy affects 2% of the world's population and persists for life in most patients. The diagnosis of shellfish allergy, in particular shrimp, is challenging due to the similarity of allergenic proteins from other invertebrates. Despite the clinical importance of immunological cross-reactivity among shellfish species and between allergenic invertebrates such as dust mites, the underlying molecular basis is not well understood. Here we mine the complete transcriptome of five frequently consumed shrimp species to identify and compare allergens with all known allergen sources. The transcriptomes were assembled de novo, using Trinity, from raw RNA-Seq data of the whiteleg shrimp (Litopenaeus vannamei), black tiger shrimp (Penaeus monodon), banana shrimp (Fenneropenaeus merguiensis), king shrimp (Melicertus latisulcatus), and endeavour shrimp (Metapenaeus endeavouri). BLAST searching using the two major allergen databases, WHO/IUIS Allergen Nomenclature and AllergenOnline, successfully identified all seven known crustacean allergens. The analyses revealed up to 39 unreported allergens in the different shrimp species, including heat shock protein (HSP), alpha-tubulin, chymotrypsin, cyclophilin, beta-enolase, aldolase A, and glyceraldehyde-3-phosphate dehydrogenase (G3PD). Multiple sequence alignment (Clustal Omega) demonstrated high homology with allergens from other invertebrates including mites and cockroaches. This first transcriptomic analyses of allergens in a major food source provides a valuable resource for investigating shellfish allergens, comparing invertebrate allergens and future development of improved diagnostics for food allergy.

A review on food processing and preparation methods for altering fish allergenicity

People eat many varieties of food to satiate their hunger. Among them, a few numbers of food cause overreaction of the body's immune system, and fish holds a permanent position on that list. Processing methods, including one treatment or a combination, can have different effects on the allergenic potential of food proteins. An important point to note, however, is that not all of these methods can eliminate the potential for protein allergy. Thus, it is essential to understand the risk involved with the consumption of processed fish and its derivatives. Fish could be prepared in various ways before come to the dining plate. It has shown some of these methods can effectively manipulate the allergenicity owing to the alterations occurred in the protein conformation. This article provides an overview of the impact of fish processing methods (thermal and non-thermal) on the allergenic potential of fish along with possible causative structural modification provokes allergen stability. The article begins with current trends related to fish consumption, proceeds with the prevalence and underlying mechanism of fish allergy. Properties of clinically relevant fish proteins, projected IgE epitopes of PV, cross-reactivity of fish allergens are also addressed in this context to understand and compare the behavioral patterns of PV profiles of different species on processing methods.

[Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis]

This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis

This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

Molecular and immunological characterization of grass carp (Ctenopharyngodon idella) parvalbumin Cten i 1: A major fish allergen in Hong Kong

BACKGROUND

Grass carp is the most commonly consumed fish species in Hong Kong. The allergenicity of grass carp and its allergen content are yet to be reported. This study characterized the major allergen in grass carp and investigated its allergenicity.

METHODS

Sixty-nine subjects with history of IgE-mediated allergic reaction to grass carp were recruited. The protein content in steamed grass carp extract was resolved by SDS-PAGE, and the major allergen was identified by immunoblotting with serum from subjects allergic to grass carp. The identity of allergen was elucidated by mass spectrometry and amino acid sequence obtained by amplifying the specific gene from cDNA library of grass carp. The cross-reactivity between parvalbumins from grass carp and other phylogenetically close (common carp) or commercially important (cod and salmon) species was investigated by competitive inhibition ELISA.

RESULTS

A major IgE-binding protein was found at approximately 9 kDa and identified as parvalbumin by immunoblotting and mass spectrometry. Grass carp parvalbumin was more allergenic than common carp, salmon, and cod parvalbumins despite sharing high sequence homology. This newly identified major allergenic parvalbumin isoform from grass carp was registered as Cten i 1 in the World Health Organization and International Union of Immunological Societies allergen database.

CONCLUSIONS

Grass carp parvalbumin is identified as the major fish allergen in Hong Kong. The strong allergenicity of Cten i 1 contributes to the high IgE reactivity of grass carp. Grass carp, among other fish species, should be considered when managing fish-allergic patients.