Clinical relevance is associated with allergen-specific wheal size in skin prick testing

Association between short-term pollen exposure and blood pressure in adults: A repeated-measures study

BACKGROUND

Recent studies have related high pollen concentrations to increased cardiovascular morbidity and mortality, yet very little research concerns pre-clinical cardiovascular health, including effects on blood pressure (BP). The EPOCHAL panel study investigated the exposure-response relationship between ambient pollen exposure and systolic and diastolic BP in adults.

METHODS

BP was measured in 302 adults with and in 94 without pollen allergy during the pollen season, on approximately 16 days per person (6253 observations). Average individually-relevant pollen exposure in the 96 h prior to each BP measurement was calculated by summing up the averages of all ambient pollen concentrations to which the individual was found to be sensitized in a skin prick test, and which originated from seven highly allergenic pollen types (hazel, alder, birch, ash, grasses, mugwort and ragweed). Generalized additive mixed models were used to study the association between mean individually-relevant pollen exposure in the last 96 h and BP, adjusting for individual and environmental time-varying covariates. Effect modification by pollen allergy status, sex and BMI was evaluated.

RESULTS

Positive non-linear associations between individually-relevant pollen exposure and both systolic and diastolic BP were found in the allergic but not in the non-allergic group. BP increased sharply for exposures from zero to 60/80 pollen/m3 (diastolic/systolic BP), followed by a tempered further increase at higher concentrations. Increases of 2.00 mmHg [95% confidence interval (CI): 0.80-3.19] in systolic and 1.51 mmHg [95% CI: 0.58-2.45] in diastolic BP were associated with 96-h average pollen exposure of 400 pollen/m3, compared to no exposure. Obesity and female sex were associated with larger BP increases.

CONCLUSIONS

The finding that short-term pollen concentration is associated with increased systolic and diastolic BP in persons with pollen allergy strengthens the evidence that pollen may cause systemic health effects and trigger cardiovascular events.

Ambient pollen exposure and pollen allergy symptom severity in the EPOCHAL study

BACKGROUND

Ambient pollen exposure causes nasal, ocular, and pulmonary symptoms in allergic individuals, but the shape of the exposure-response association is not well characterized. We evaluated this association and determined (1) whether symptom severity differs between subpopulations; (2) how the association changes over the course of the pollen season; and (3) which pollen exposure time lags affect symptoms.

METHODS

Adult study participants (n = 396) repeatedly scored severity of nasal, ocular, and pulmonary allergic symptoms, resulting in three composite symptom scores. We calculated hourly individually relevant pollen exposure to seven allergenic plants (alder, ash, birch, hazel, grasses, mugwort, and ragweed) considering personal sensitization and exposure time lags of up to 96 h. We fitted generalized additive mixed models, with a random personal intercept, adjusting for weather and air pollution as potential time-varying confounders.

RESULTS

We identified a clear nonlinear positive association between pollen exposure and ocular and nasal symptom severity in the pollen allergy group: Symptom severity increased steeply with increasing exposure initially, but attenuated beyond approximately 80 pollen/m3. We found no evidence of an exposure threshold, below which no symptoms occur. While recent pollen exposure in the last approximately 5 h affected symptoms most, associations lingered for up to 60 h. Grass pollen exposure (compared to tree pollen) and younger age (18-30 years, as opposed to 30-65 years) were both associated with higher nasal and ocular symptom severity.

CONCLUSIONS

The lack of a threshold and attenuated dose-response curve may have implications for pollen warning systems, which may be revised to include multiday pollen concentrations in the future.

Incidence of grass and weed sensitization in Bangkok, Thailand: a clinical study

Background

Allergic rhinitis (AR) is a prevalent public health concern globally, significantly impacting quality of life. In Thailand, the prevalence of AR is rising, with grass and weed pollen identified as primary outdoor triggers.

Objectives

This study aimed to (1) assess patterns of pollen sensitization in Thai AR patients and (2) investigate correlations between demographics/clinical data and SPT results.

Methods

A total of 121 individuals aged ≥18 years with clinically diagnosed AR were recruited. Skin prick testing (SPT) was performed using a panel of commonly encountered tropical grass and weed pollen extracts. SPT wheal sizes and clinical symptom scores were recorded. Correlations between SPT outcomes and symptom scores were analyzed.

Results

Among the participants, 104 (85.95%) exhibited positive SPT reactions to at least one pollen type. Nutsedge (76/121), para grass (57/121), and Bermuda grass (48/121) were the most frequently identified allergens. Hurricane grass elicited the strongest reaction, evidenced by the highest average wheal size (6.2 mm). Poly-sensitization was observed in 77 (63.6%) of the SPT-positive individuals, with most cases involving two different pollen extracts (35/77). Notably, AR severity positively correlated with both average wheal size and the number of positive SPT tests.

Conclusion

This study highlights nutsedge, para grass, and Bermuda grass as major allergenic pollen sources for Thai AR patients. Including nutsedge, hurricane grass, and careless weed in clinical SPT panels is recommended for improved diagnostic accuracy. Additionally, the positive correlation between AR severity and pollen reaction strength emphasizes the importance of implementing patient education and avoidance strategies.

Horse allergy: Curly Horses can mediate immune tolerance

American Bashkir Curly Horses are claimed to be hypoallergenic, but this has not been clinically proven. In the present study, the effect of exposure to Curly Horses was investigated in 141 patients allergic to horses by measuring their lung function and nasal patency during Curly Horse contact. Continuous contact with Curly Horses, including riding and brushing, decreased the allergic riders' reactivity as measured by FEV1, PEF, and PNIF. Subsequent visits (up to 40 or more hours of riding) further reduced reactivity to the Curly Horses. Allergic events to horses occurred only in 72 out of 1312 riding hours, mainly in the first ten riding hours.In 41 out of the 141 patients, it was further investigated whether repeated exposure to Curly Horses could induce tolerance to other horses. Patients in the tolerance induction study were tested annually for horse allergy using a nasal provocation test. The tolerance induction study showed that exposure to Curly Horses induced immune tolerance to other horses in 88% of patients who completed the study.To understand the mechanism causing hypoallergenicity, we performed IgE immunoblots to determine whether Curly Horse hairs contain IgE binding proteins. However, no differences in IgE reactivity were found between Curly and non-Curly Horses. Moreover, the immune tolerance induction study patients did not show decreased IgE reactivity to hairs from Curly or non-Curly Horses even though patients had developed tolerance. However, we did find increasing levels of anti-horse IgG antibodies in the study patients.Overall, our data strongly suggests that continuous exposure to Curly Horses can induce immune tolerance, rendering these patients non-reactive to horses. The reason for the reduced clinical allergenicity of Curly Horses remains unclear, but the data suggest that blocking IgG antibodies may be of importance for immune tolerance development.

The importance of skin prick test in differentiating cat sensitivities and allergies in children

BACKGROUND

The incidence of cat allergies in children has increased over the years. Children with cat allergies have mostly reported respiratory symptoms. The skin prick test (SPT) is the most preferred method to demonstrate sensitization to allergens. However, not all children who develop cat sensitization due to environmental exposure become allergic to cats. In our study, we aimed to determine the frequency of sensitization to cat and cat allergy, cat-related symptoms, and the cut-off value for the SPT that may indicate cat allergy.

METHODS

Patients aged 2-18 years, who applied to the Health Sciences University İzmir Dr Behçet Uz Pediatrics and Surgery Training and Research Hospital and Balıkesir University Application and Research Hospital Pediatric Allergy outpatient clinics between January 01, 2019 and December 31, 2020, were included in the study. Patients who underwent SPT and found to be sensitized to cat allergen, were evaluated retrospectively. Clinical and laboratory findings of the patients were recorded. Receiver operating characteristics (ROC) analysis was performed to determine the cut-off value for the SPT.

RESULTS

Sensitization to cat was detected in 140 (4%) out of 3499 patients who underwent SPT. The median age of the patients was 12 years (min-max: 5-18) and 67.1% were male. Eighty-eight (62.9%) patients were symptomatic upon contact with cats, predominantly with nasal symptoms. These patients had significantly larger cat SPT wheal size than asymptomatic patients. The cut-off value was determined as 5.5 mm with a sensitivity of 72.7% and a specificity of 61.5% (95% CI, 60.5%-78.4%). Symptoms resolved in about half of our patients by reducing contact with cats.

DISCUSSION

The present study is the first to report the frequency and clinical findings of cat sensitizations and allergies in Turkish children. For effective treatment, cat allergy must be diagnosed. In this regard, the use of a practical, readily accessible 5.5 mm cut-off point on the SPT may be helpful.

Emergent Inflammatory Markers and Echocardiographic Indices in Patients with Bronchial Asthma

Asthma is a heterogeneous disease, characterized by chronic inflammation and oxidative stress of the airways. Several inflammatory pathways including activation of the receptor for advanced glycation end products (RAGE) have been described in the course of the disease. DJ-1 is a redox-sensitive protein with multifaceted roles in mast cell homeostasis and an emerging role in the pathogenesis of asthma. Moreover, cardiac function abnormalities have been described via echocardiography in patients with asthma. The main aim of this study was to investigate the plasma levels of RAGE, its ligands and DJ-1 in asthmatic patients pre- and post-treatment along with echocardiographic indices of cardiovascular function. The study population was divided into two groups. Group A included 13 patients with newly diagnosed bronchial asthma who were free of treatment for at least two weeks and Group B included 12 patients without asthma. An echocardiography examination was performed on all patients. The plasma levels of RAGE, its ligands (AGEs, S100A12, S100B, S100A8/A9), the interleukins (IL-6, IL-1β) and DJ-1 were measured. No differences were noted among the two groups for baseline characteristics and echocardiographic indices of cardiac function. In Group A, 31% suffered from mild asthma, 54% from moderate asthma and 15% from severe asthma. Plasma levels of IL-6, AGEs and AGE/RAGE ratio were increased and those of S100A12 and DJ-1 were decreased in asthmatics. Pharmacotherapy with corticosteroids/β2-agonists decreased IL-6, and AGEs, and increased DJ-1. In search of novel approaches in diagnosing and treating patients with asthma, S100A12, ratio AGE/sRAGE, and DJ-1 in addition to IL-6 may prove to be useful tools.

Comparison of commercial allergen extract with various milk products of skin prick tests in diagnosing cow's milk protein allergy

Introduction: In this study, we aimed to solve the incompatibilities between the skin prick test (SPT) result and the clinical picture encountered among patients. Thus, we used various milk products (raw, ultrahigh temperature [UHT], and pasteurized cow's milk) with commercial milk allergen extract in patients we think may have cow's milk protein allergy (CMPA) and made a comparison among the milk types. Methods: This study was conducted retrospectively between February 1, 2019, to June 1, 2019, at a pediatric allergy polyclinic of the university training/research hospital. A pair of 79 individuals, as control and patient groups, ages between 1 month and 21 years who were presented with a suspicion of CMPA and defined with SPT and/or allergen-specific immunoglobulin E (IgE) levels were included in the study. Allergen-specific IgE tests (specific IgE cow's milk, β-lactoglobulin, α-lactalbumin, casein) were evaluated. SPT was performed with fresh/raw, UHT, and pasteurized (daily) cow's milk besides the standard used commercial extract. Results: In the group included in the study and defined as IgE-mediated CMPA, 52.9% of the 79 patients were boys (n = 46), 47.1% were girls (n = 33), and the median age was 6 months (5.0-8.0 months). In the group of specific IgE cow's milk reaction that was sought, frequency and wheal (induration) size of SPT reaction to fresh/raw milk was also found to be statistically significant between positive- and negative-reaction groups, not detected against other milk products. The area under the curve for the diagnostic value of fresh milk was 93.1%. For the cutoff value of 2.50 mm, 88.1% sensitivity and 90.8% specificity were determined. In the group of specific IgE β-lactoglobulin reaction searched, there was a statistically significant difference in the frequency of SPT positivity and wheal size against UHT, fresh, and daily/pasteurized milk between positive and negative reaction groups. When the correlations of the mean induration axis in the tests were examined, it was found that, among raw milk, daily milk, cow's milk allergen extract, and UHT milk, a strong positive correlation was also statistically significant. Conclusion: The positivity that could not be detected with SPT when using allergen extract in a patient with positive specific IgE cow's milk result in the clinic can be detected with SPT made with fresh (raw) milk, which can be an alternative. In addition, specific IgE β-lactoglobulin seems to be the most compatible with the SPT wheal size (induration) of other milk types rather than extract. Comparative studies of SPT allergen extracts and various milk types used in the diagnosis of CMPA are very scarce in the literature, and more studies are needed on this subject.

Nasal epithelium: new insights and differences of the cytokine profile between normal subjects and subjects with allergic rhinitis

Background: The role of the nasal epithelium in the induction of a proper cytokine response in normal subjects and subjects with allergic rhinitis is still not completely elucidated. Methodology: We aimed to compare nasal epithelial immune responses in allergic rhinitis patients of different ages compared to healthy volunteers. Primary nasal epithelial cells from 47 subjects (33 normal and 17 with allergic rhinitis) were collected and cultured. Their unstimulated supernatants were analysed for 21 cytokines and chemokines. Statistical analysis was performed with the R statistical software and the RStudio interface. Results: Differences of the spontaneous release of epithelial cytokines and chemokines were noticed between the two study groups. The levels of GMCSF, MIP1A, MIP1B, IL28A, TNFA, CCL5 were significantly lower in the allergic rhinitis group compared to healthy volunteers’ group, independent of age. Most differences were noticed in the younger allergic rhinitis group (0-12 years old). Conclusions: Despite the cross-sectional nature of the study and the limited number of subjects, allergic rhinitis appears to be associated with dysfunction of cytokine and chemokine spontaneous release from nasal epithelial cells which may represent an abnormal innate immunity maturation pattern.

The majority of children sensitized before school-age develop allergic disease before adulthood: a longitudinal population-based study

BACKGROUND

Allergic sensitization increases the risk of and asthma and allergic rhinitis, but the impact of age at onset of sensitization is less studied.

OBJECTIVE

To examine the cumulative incidence of asthma and rhinitis up to age 19 years in relation to age at onset of sensitization to airborne allergens.

METHOD

All children in grade one and two (median age 8 years) in two municipalities in Northern Sweden were invited to skin prick tests and a questionnaire about allergic diseases, and 88% participated. At ages 12 and 19 years the protocol was repeated, and n=1510 individuals participated in all three examinations. Specific IgE was collected in a random sample at age 19, n=770. Onset of sensitization was defined; ≤8 years, 8-12 years, 12-19 years, and never sensitized. Adjusted Poisson regression was utilized to calculate risk ratios.

RESULTS

At age 19, those sensitized ≤8 year had the highest risk of asthma (RR 4.68 (95%CI 3.14-6.97)) and rhinitis (RR 22.3 (95%CI 13.3-37.6)), and 84% had developed either asthma or rhinitis. The combination of sensitization ≤8 year and family history of allergic diseases rendered high risks for asthma (RR 10.6 (6.71-16.7)) and rhinitis (RR 36.3 (18.9-69.7). Individuals sensitized ≤8 year showed significantly highest level of sensitization, as judged by number of positive skin tests and titers of specific IgE.

CONCLUSION

The majority of individuals with sensitization ≤8 years developed asthma or rhinitis before young adulthood. The high level of sensitization in early sensitized contribute to the high incidence of allergic airway conditions.

The Role of IgE in Upper and Lower Airway Disease: More Than Just Allergy!

Immunoglobulin E (IgE) is a well-known key factor in allergic airway disease; however, its central role in non-allergic airway inflammation is often underestimated. In some airway diseases, IgE is produced as a result of allergic sensitization. However, in others, IgE production occurs despite the lack of a specific allergen. Although multiple pathways contribute to the production of IgE in airway disease, it is its activity in mediating the inflammatory response that is associated with disease. Therefore, an understanding of IgE as the unifying component of upper and lower airway diseases has important implications for both diagnosis and treatment. Understanding the role of IgE in each upper and lower airway disease highlights its potential utility as a diagnostic marker and therapeutic target. Further classification of these diseases by whether they are IgE mediated or non–IgE mediated, rather than by the existence of an underlying allergic component, accounts for both systemic and localized IgE activity. Improvements in diagnostic methodologies and standardization of clinical practices with this classification in mind can help identify patients with IgE-mediated diseases. In doing so, this group of patients can receive optimal care through targeted anti-IgE therapeutics, which have already demonstrated efficacy across numerous IgE-mediated upper and lower airway diseases.

Microarray Technology May Reveal the Contribution of Allergen Exposure and Rhinovirus Infections as Possible Triggers for Acute Wheezing Attacks in Preschool Children

Allergen exposure and rhinovirus (RV) infections are common triggers of acute wheezing exacerbations in early childhood. The identification of such trigger factors is difficult but may have therapeutic implications. Increases of IgE and IgG in sera, were shown against allergens and the N-terminal portion of the VP1 proteins of RV species, respectively, several weeks after allergen exposure or RV infection. Hence, increases in VP1-specific IgG and in allergen-specific IgE may serve as biomarkers for RV infections or allergen exposure. The MeDALL-allergen chip containing comprehensive panels of allergens and the PreDicta RV chip equipped with VP1-derived peptides, representative of three genetic RV species, were used to measure allergen-specific IgE levels and RV-species-specific IgG levels in sera obtained from 120 preschool children at the time of an acute wheezing attack and convalescence. Nearly 20% of the children (22/120) showed specific IgE sensitizations to at least one of the allergen molecules on the MeDALL chip. For 87% of the children, increases in RV-specific IgG could be detected in the follow-up sera. This percentage of RV-specific IgG increases was equal in IgE-positive and -negative children. In 10% of the children, increases or de novo appearances of IgE sensitizations indicative of allergen exposure could be detected. Our results suggest that, in the majority of preschool children, RV infections trigger wheezing attacks, but, in addition, allergen exposure seems to play a role as a trigger factor. RV-induced wheezing attacks occur in IgE-sensitized and non-IgE-sensitized children, indicating that allergic sensitization is not a prerequisite for RV-induced wheeze.

A feasibility study to assess Imbrasia belina (mopane worm) sensitisation and related respiratory health outcomes in a rural community in Gwanda district, Zimbabwe

Background

Allergic diseases are considered to be some of the fastest growing chronic conditions in Africa. Of concern is the paucity of knowledge about the local environment and its role in allergic disease development. In response to this, we explored whether Imbrasia belina, a popular indigenous edible insect commonly known as mopane worm, is a potential allergen of clinical and public health significance in Zimbabwe. This study was intended to assess the plausibility and feasibility of this hypothesis with a view to evaluate the insect’s health impact in a larger study.

Methods

The study participants included male and female villagers aged 10 years and above in Gwanda district, Zimbabwe. Eligible participants who completed the household questionnaire were referred to the local clinic for skin prick tests and to measure lung function and allergic airway inflammation. Allergen sensitisation patterns were evaluated using 10 different inhalant allergen extracts including an in-house preparation of mopane worm. Lung function was measured with a Koko Legend spirometer, and fractional exhaled nitric oxide levels (FeNO) (NIOX VERO) were measured in participants with at least one abnormal spirometric parameter. Data was analysed using Stata version 13 software.

Results

Of the 46 eligible participants that completed the household questionnaire, 17 went to the clinic giving a response rate of 37%. The majority who completed the questionnaire were adults (91%) and the children (9%) were all female. The prevalence of sensitisation to Imbrasia belina was 50%, and the prevalence ranged from 22 to 72% for the other allergens including cockroach, mosquito and house dust mites. The data collection tools were safe and well tolerated by participants with no adverse events reported. Self-reported respiratory symptoms, abnormal lung function and elevated FeNO were recorded amongst participants sensitised to mopane worm.

Conclusion

Pre-defined feasibility criteria were met with the exception of a lower than expected response rate for clinic data collection in this pilot study. For the main study, modifying the sampling strategy and applying more consistent community engagement will improve the response rates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00780-9.

Allergy-Related Symptoms Are Poorly Predicted by IgE and Skin Prick Testing in Early Life

INTRODUCTION

In childhood, the so-called allergic march involves progression from IgE sensitization to allergy-related symptoms. Both IgE sensitization and relevant clinical symptoms are required for the diagnosis of allergy, but concordance between test results and clinical symptoms varies greatly, creating challenges for the diagnostics and for the prediction of outcomes. We assessed the prevalence of IgE sensitization and allergy symptoms, concordance between 2 IgE sensitization testing methods, and predictive value of these tests in relation to clinical symptoms in young Finnish children.

METHODS

The current study included 2 series of children: a birth cohort, in which the participants were followed prospectively from birth up to 3 years, and a young children cohort observed from 3 to 5 years of age. They were regularly monitored for sensitization by measuring serum allergen-specific IgEs (sIgEs) and performing skin prick tests (SPTs). The emergence of atopic dermatitis, wheezing, and symptoms associated with food allergies was recorded.

RESULTS

Over the first 5 years of life, the prevalence of sIgE sensitization was 46%, while it was 36% for positive SPTs. Disease prevalence was 26% for atopic dermatitis, 25% for wheezing, and 19% for symptoms associated with food allergies. Concordance between sIgE and SPT results was good for aeroallergens, but poor for dietary allergens. The association between clinical symptoms and sensitization was stronger at 5 years than at 3 years of age. The proportion of children with concordant combinations of allergy symptoms and sensitization markers in contrast to those with discordant combinations increased from 3 to 5 years.

CONCLUSION

In early childhood, testing for IgE sensitization predicts allergy-related symptoms in an age-dependent manner, but not particularly well. Tests predict symptoms caused by aeroallergens clearly better than those caused by dietary allergens. The clinical relevance of sensitization testing in early life is therefore limited in the prediction of true allergy.

Clinical Efficacy and Possible Mechanism of Endoscopic Vidian Neurectomy for House Dust Mite-Sensitive Allergic Rhinitis

BACKGROUND/AIMS

Endoscopic vidian neurectomy (EVN) for allergic rhinitis (AR) has good clinical effects. However, the pathophysiological basis of the effect of EVN on AR is still poorly understood. This study aimed to investigate the efficacy of EVN on house dust mite (HDM)-sensitive AR and the dynamic changes of serum immunoglobulin E and some immune regulatory factors.

METHODS

Twenty HDM-sensitive AR patients were treated with bilateral EVN (EVN group), 15 HDM-sensitive AR patients were treated with subcutaneous immunotherapy (SCIT group), and 15 healthy subjects served as healthy controls. Quality of daily life was assessed by the scores of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQs). The visual analog scale was used to assess clinical efficacy. Serum molecules were measured by ELISA and the UNICAP system.

RESULTS

Compared with the SCIT group, the RQLQs in the EVN group were lower 12 months after treatment (both p < 0.05). There was no significant difference in improving nasal itching and sneezing (both p > 0.05), but the clinical efficacy of bilateral EVN was greater than SCIT in improving nasal obstruction, rhinorrhea, eye itching, and lachrymation 12 months after treatment (all p < 0.05). Compared with before treatment, the serum levels of total immunoglobulin E (tIgE), Dermatophagoides pteronyssinus- and Dermatophagoides farinae-specific immunoglobulin E (sIgE), and tumor necrosis factor (TNF)-α in the EVN group and the serum levels of TNF-α and interleukin-4 in the SCIT group were lower 12 months after treatment (all p < 0.05).

CONCLUSION

The short-term efficacy of bilateral EVN is more effective than SCIT in treating HDM-sensitive AR. This may be because the surgery reduced the tIgE and sIgE levels. TNF-α may be involved in the therapeutic mechanism.

The most common allergens according to skin prick test: The role of wheal diameter in clinical relevancy

The skin prick test (SPT) could be applied as a useful in vivo method for the detection of sensitization in epidemiological and diagnostic studies if the wheal size is ideally evaluated. We focused on SPT wheal size to identify sensitization pattern to common inhalant and food allergens. In this cross-sectional study, SPT results were obtained from a total of 972 allergic patients. Common allergen extracts for SPT were selected according to the type of allergic diseases, and the geographical pattern. SPT with food allergens was performed for patients with atopic dermatitis (AD) and chronic urticaria (CU). A total of 461 male (47.4%) and 511 female (52.6%) participated in this study (median age: 31 years). The majority of individuals were affected with allergic rhinitis (AR) (n = 624) and asthma (n = 224); while 129 and 67 patients suffered from AD and CU, respectively. The most common aeroallergens were Russian thistle (52.1%) and lamb's quarter (50.7%) with the largest wheal diameter. The wheal size of lamb's quarter was significantly different between patients with asthma and AR (P<.001). In addition, a significant difference was detected in wheal diameter in response to the Russian thistle between patients with AR and AD (P = .001). Shrimp (23.6%) and Peanut (22.5%) caused the most common food sensitization in patients with AD and CU. Having in mind the most common weed pollens including the Russian thistle and lamb's quarter, preventive strategies, such as, removing unwanted weeds or preventing them from growing, avoidance, and specific immunotherapy may be crucial for better disease control.

Sensitization rates to common inhaled allergens in Germany - increase and change patterns over the last 20 years

BACKGROUND

Sensitization rates to aeroallergens are rising worldwide. The prevalence is increasing, especially in Western countries. We aimed to investigate (1) sensitization rates and (2) cross-sensitization patterns in skin prick tests (SPTs) for the most relevant inhaled allergens in central Germany over 20 years, adjusted for regional pollen counts.

PATIENTS AND METHODS

This monocentric study evaluated SPTs for tree pollen, grass pollen and house dust mites (HDMs) in 4,315 patients (including children) with suspected airway allergies, from 1998-2017.

RESULTS

Sensitization rates to almost all aeroallergens have increased significantly over time, without relevant changes in regional pollen counts. Current sensitization rates in all our symptomatic patients were highest for grass (55.3 %) and rye pollen (59.6 %), with most pronounced increases in HDM sensitization over time (from 37.8 % to the current figure of 50.1 %). However, a low but consistent proportion of tree-sensitized patients (3.6-7.8 %) showed isolated positive SPTs to alder and/or hazel pollen without sensitization to birch pollen.

CONCLUSIONS

We demonstrate a significant rise in the total number of sensitized patients as well as increases in cross-sensitization between closely related allergens. Individuals with unusual mono-sensitization profiles to common inhaled allergens should be studied in more detail, since these patients are currently excluded from clinical trials for allergen immunotherapy.

IgE Antibodies against Cancer: Efficacy and Safety

Immunoglobulin E (IgE) antibodies are well known for their role in allergic diseases and for contributions to antiparasitic immune responses. Properties of this antibody class that mediate powerful effector functions may be redirected for the treatment of solid tumours. This has led to the rise of a new class of therapeutic antibodies to complement the armamentarium of approved tumour targeting antibodies, which to date are all IgG class. The perceived risk of type I hypersensitivity reactions following administration of IgE has necessitated particular consideration in the development of these therapeutic agents. Here, we bring together the properties of IgE antibodies pivotal to the hypothesis for superior antitumour activity compared to IgG, observations of in vitro and in vivo efficacy and mechanisms of action, and a focus on the safety considerations for this novel class of therapeutic agent. These include in vitro studies of potential hypersensitivity, selection of and observations from appropriate in vivo animal models and possible implications of the high degree of glycosylation of IgE. We also discuss the use of ex vivo predictive and monitoring clinical tools, as well as the risk mitigation steps employed in, and the preliminary outcomes from, the first-in-human clinical trial of a candidate anticancer IgE therapeutic.

Objective evaluation of immediate reading skin prick test applying image planimetric and reaction thermometry analyses

The skin prick test is used to diagnose patients' sensitization to antigens through a mediated IgE response. It is a practical and quick exam, but its diagnosis depends on instruments for measuring the allergic response and observer's interpretation. The conventional method for inferring about the allergic reaction is performed from the dimensions of the wheals, which are measured using a ruler or a caliper. To make this diagnosis less dependent on human interpretation, the present study proposes two alternative methods to infer about the allergic reaction: computational determination of the wheal area and a study of the temperature variation of the patient's skin in the puncture region. For this purpose, prick test using histamine was performed on 20 patients randomly selected. The areas were determined by the conventional method using the dimensions of the wheals measured with a digital caliper 30 min after the puncture. The wheal areas were also determined by a Python algorithm using photographs of the puncture region obtained with a smartphone. A variable named circularity deviation was also determined for each analyzed wheal. The temperature variation was monitored using an infrared temperature sensor, which collected temperature data for 30 min. All results were statistically compared or correlated. The results showed that the computational method to infer the wheal areas did not differ significantly from the areas determined by the conventional method (p-value = 0.07585). Temperature monitoring revealed that there was a consistent temperature increase in the first minutes after the puncture, followed by stabilization, so that the data could be adjusted by a logistic equation (R² = 0.96). This adjustment showed that the optimal time to measure the temperature is 800 s after the puncture, when the temperature stabilization occurs. The results have also shown that this temperature stabilization has a significant positive correlation with wheal area (p-value = 0.0015). Thus, we concluded that the proposed computational method is more accurate to infer the wheal area when compared to the traditional method, and that the temperature may be used as an alternative parameter to infer about the allergic reaction.

Skin prick reactivity among asthmatics in East Africa

Background

The burden of asthma in Africa is high, and yet the disease is not universally prioritised. Data on allergic asthma and its impact on asthma morbidity are limited in Africa. Our aim was to describe the distribution of skin prick positivity among asthmatics in Eastern Africa.

Methods

From August 2016 to May 2018, 1671 asthmatic patients were enrolled from Uganda, Kenya, and Ethiopia as part of the African Severe Asthma Program clinical study. Skin prick testing was performed at baseline using a panel of 12 allergens, and factors associated with skin prick reactivity determined.

Results

Of the 1, 671 patients recruited, 71% were female with a median age of 40 years, 93.6% were aged >15 years and the patterns of asthma symptom frequency was intermittent in 2.9%, mild persistent in 19.9%, moderate persistent in 42.6% and severe persistent in 34.6% at baseline. Self-reported triggers, were dust (92%), cold weather (89%), upper respiratory infections (84%), strong smells (79%) and exposure to tobacco (78%). The majority (90%) of the participants had at least 1 positive allergen reaction, with 0.9% participants reacting to all the 12 allergens. Participants commonly reacted to house dust mites (66%), Blomia tropicalis (62%), and the German cockroach (52%). Patients sensitized to more allergens (>2) had significantly reduced lung function (FEV ≤ 80%; p = 0.001) and were more likely to visit the emergency department due to asthma (p = 0.012). There was no significant relationship between number of allergens and measures of asthma control, quality of life, and other clinical outcomes. Only the country of origin was independently associated with atopy among African asthmatics.

Conclusion

There is a high prevalence of skin prick positivity among East African patients with asthma, with the commonest allergen being house dust mite. Skin reactivity did not correlate well with asthma severity and poor asthma control. The relation between atopy, measured through skin prick testing, and measures of asthma control among asthma patients in Eastern Africa is unclear and needs further study.

Trial registration

The ASAP study was registered prospectively. ClinicalTrials.gov Identifier: NCT03065920; Registration date: February 28, 2017; Last verified: February 28, 2017.

Could FeNO Predict Asthma in Patients with House Dust Mites Allergic Rhinitis?

Background and Objectives: The evolution of allergic rhinitis to asthma is a part of "atopic march". The aim of this study was to analyze possible predictive markers for asthma occurrence in patients with allergic rhinitis to house dust mites (HDM). Materials and Methods: Fifty-eight patients with persistent allergic rhinitis (PAR) were included. The clinical, biological evaluation and fractionated exhaled nitric oxide (FeNO) measurement were performed at enrolment. The patients were clinically evaluated after one year to determine asthma occurrence. Results: The severity of rhinitis symptoms, levels of total immunoglobulin E (IgE), ICAM-1, VCAM-1, E-selectin and IL-6, but not IL-8 and TNF-α were higher in patients with allergic rhinitis who developed asthma compared to non-asthmatics, but the differences were not significant to considered them as predictive factors for asthma occurrence. The risk of asthma was independently influenced by patients aged over 30 years ((OR-3.74; CI95% 0.86-16.31; p = 0.07), a duration of allergic rhinitis over 12 months ((OR-4.20; CI95% 0.88-20; p = 0.07) and a basal FeNO over 28 parts per billion (pbb) ((OR-18.68; CI95% 3.79-92.05; p < 0.001). Conclusion: Clinical and biological parameters may predict asthma occurrence in patients with persistent allergic rhinitis to HDM. Adult patients with a longer duration of rhinitis symptoms and a high level of FeNO have a greater risk to develop asthma.

Induction of IgG2 and IgG4 B-cell memory following sublingual immunotherapy for ryegrass pollen allergy

BACKGROUND

While treatment for atopic rhinitis is aimed mostly to relieve symptoms, only allergen-specific immunotherapy (AIT) is targeted to modify the natural history of allergic diseases. This results in sustained clinical tolerance, even when treatment has stopped. The immunomodulatory effects of AIT are attributed mainly to increased regulatory T-cell function and increased allergen-specific IgG₄ , yet little is known about the effect on the memory B-cell compartment.

OBJECTIVE

We aimed to examine the effects of AIT on the IgE- and IgG subclass-expressing memory B cells.

METHODS

We recruited 29 patients with atopic seasonal rhinoconjunctivitis and performed a longitudinal analysis of the peripheral immune compartment before, during, and after sublingual immunotherapy (SLIT) for allergy to temperate grass pollen, predominantly to ryegrass pollen (RGP; Lolium perenne). Using flow cytometry on peripheral blood mononuclear cells and serum immunoassays, we analyzed the effects of a 4 months preseasonal treatment regimen comprising two or three courses in consecutive years on circulating IgE⁺ and IgG⁺ memory B cells and allergen-specific Ig levels.

RESULTS

SLIT increased RGP-specific serum IgG₂ and IgG₄ , as well as the frequencies of IgG₂ ⁺ and IgG₄ ⁺ memory B cells, whereas no effect was observed on the IgE⁺ memory B-cell compartment. Furthermore, SLIT enhanced proportions of regulatory T cells specific to RGP. These changes were associated with clinical improvement.

CONCLUSION

Our data provide evidence for immunological effects of SLIT on B-cell memory. Skewing responses toward IgG₂ and IgG₄ subclasses might be a mechanism to suppress IgE-mediated allergic responses.

Molecular sensitization patterns in birch pollen-sensitized Korean children according to the presence of oral allergy syndrome

The profiles of sensitization based on component-resolved diagnosis (CRD) differ from region to region in populations sensitized to birch pollen. We investigated the endotypes of birch pollen-sensitized Korean children with allergic diseases using CRD and distinguished the endotypes of oral allergy syndrome (OAS) among them.Thirty-one birch pollen-sensitized children with allergic diseases were enrolled. Specific immunoglobulin E (IgE) to birch pollen and fruit including apple, peach, and kiwi were evaluated via skin prick tests and ImmunoCAP in all subjects. Sensitization profiles based on CRD were evaluated with the Immuno-solid-phase Allergen Chip for birch pollen-sensitization using birch pollen components (Bet v 1, Bet v 2, and Bet v 4), and for OAS using the allergen families pathogenesis-related class 10 proteins (PR-10), lipid transfer proteins, and profilin.All patients (n = 13) with OAS were sensitive to Bet v 1. However, 61% (11/18) of patients without OAS were sensitized to Bet v 1. The level of specific IgE to Bet v 1 was higher in patients with OAS than in those without OAS. All birch pollen-sensitized Korean children with OAS were sensitized to PR-10, and 69% (9/13) of them were mono-sensitized to PR-10. Among patients without OAS, 33% (6/18) were not sensitized to any of the allergen families.Birch pollen-sensitized Korean children with allergic diseases showed unique patterns of sensitization to Bet v 1, Bet v 2, and Bet v 4, and the sensitization profiles based on CRD were totally different according to the presence of OAS.

IgE allergy diagnostics and other relevant tests in allergy, a World Allergy Organization position paper

Currently, testing for immunoglobulin E (IgE) sensitization is the cornerstone of diagnostic evaluation in suspected allergic conditions. This review provides a thorough and updated critical appraisal of the most frequently used diagnostic tests, both in vivo and in vitro. It discusses skin tests, challenges, and serological and cellular in vitro tests, and provides an overview of indications, advantages and disadvantages of each in conditions such as respiratory, food, venom, drug, and occupational allergy. Skin prick testing remains the first line approach in most instances; the added value of serum specific IgE to whole allergen extracts or components, as well as the role of basophil activation tests, is evaluated. Unproven, non-validated, diagnostic tests are also discussed. Throughout the review, the reader must bear in mind the relevance of differentiating between sensitization and allergy; the latter entails not only allergic sensitization, but also clinically relevant symptoms triggered by the culprit allergen.

Skin Prick Testing to Identify Food Allergens in 8393 Children and Adolescents with Asthma in Chongqing, Southwest China

BACKGROUND The prevalence of food allergies in asthmatic children and adolescents has significantly increased over recent years. Nevertheless, the relevant clinical analyses are still lacking in China. Therefore, the present study aimed to determine common food allergens in pediatric patients with asthma in Chongqing, Southwest China. MATERIAL AND METHODS A total of 8393 asthmatic patients from Children's Hospital of Chongqing Medical University (CHCMU) were enrolled in this retrospective study between October 2014 and July 2017. All patients underwent skin prick test (SPT) with 10 food allergens and recorded history of clinical reactivity. The correlations among the positive rates, categories of allergens, gender, age, and living environment were analyzed. RESULTS A total of 2544 patients (30.31%) had a positive SPT, while the prevalence of food allergy was 8%. Sea crab, peanut, and sea shrimp were the most common food allergens found in the studied population. The frequent food allergies were sea crab, peanuts, and sea shrimp. CONCLUSIONS Identifying allergens is important for the diagnosis and management of allergic disorders, and for performing immunotherapy.

Sensitization to subtropical grass pollens in patients with seasonal allergic rhinitis from Bahia Blanca, Argentina

Background

Grass pollinosis is an important contributor to allergic diseases, with varying patterns and frequency of allergens according to the geographical location studied. Our study aims to provide a better understanding of subtropical grass pollinosis in Argentinian patients with seasonal allergic rhinitis.

Methods

We conducted a retrospective cross-sectional study involving 894 patients with seasonal allergic rhinitis from Bahía Blanca, Argentina. Skin prick tests were performed to selected pollen species belonging to three subfamilies of the Poaceae genera. Frequency of sensitization to specific grass pollen extracts, cross-reactivity of allergens assessed by skin prick test, and possible associations between allergen extracts and asthma or allergic conjunctivitis were analyzed.

Results

Sensitization to the Pooideae subfamily was the most frequent, encompassing 86.8% (CI: 84.4%–88.9%) of the studied population. Positive reactions to allergen extracts from the Chloridoideae and the Panicoideae subfamilies showed smaller papule size than allergen extracts from the Pooideae subfamily (χ²(5) = 83.75, p < 0.001). Patients with a positive skin prick test (SPT) to a specific extract were more likely to present some degree of cross-reactivity to the remaining pollens when compared to patients with negative SPT to the same specific extract. Even though the proportion of patients presenting with asthma (46.9%) was higher than those with conjunctivitis (22.6%), there was only a statistically significant association between sensitization to Festuca arundinacea (φ = 0.089, p = .009), Phalaris arundinacea (φ = 0.074, p = .032) and Paspalum notatum (φ = 0.070, p = .038) and the presence of conjunctivitis.

Conclusions

Our results suggest a high frequency of sensitization to grass pollen extracts from the Poaceae family among patients with seasonal allergic rhinitis. Overall, sensitization to the Pooidae subfamily was the most common, where Phalaris arundinacea presented the highest frequency.

Sensitization to Cat: When Is Nasal Challenge Needed?

INTRODUCTION

Although the skin prick test (SPT) is a reliable diagnostic tool in perennial allergic rhinitis (PER) for patients allergic to cats, the minimum necessary SPT wheal size required to distinguish cat sensitization from true allergy remains controversial. The cat nasal challenge test (cNCT) could be considered the gold standard for detecting true cat allergy.

AIMS

To assess the difference in the frequency of cNCT positivity between cat owners and non-owners and to determine an appropriate cut-off level for SPT wheal size in detecting positive cNCT in PER patients who are candidates for allergen immunotherapy (AIT) with cat allergen extracts.

SUBJECTS AND METHODS

cNCT in the form of a nasal spray was administered to 60 adult patients with PER, i.e., cat owners (n = 19) and cat non-owners (n = 41) with positive SPT to cat fur allergen (Diater, Spain). Subjective (total nasal symptom score [TNSS]) and objective measurements (peak nasal inspiratory flow [PNIF]) for assessment of nasal patency and nasal eosinophil count [NEo]) were used to assess the nasal response. Peak expiratory flow (PEF) was used as a safety parameter during cNCT.

RESULTS

No differences were obtained in SPT wheal size and cNCT positivity between cat owners and non-owners. Positive cNCT detecting true cat allergy could be predicted by a cat SPT wheal size > 6.5 mm with 71.11% sensitivity and 100% specificity.

CONCLUSIONS

In adult patients with PER, the frequency of cat allergy was similar among cat owners and non-owners. A cat SPT wheal size ≥6.5 mm could be helpful in detecting true cat allergy by avoiding the demanding, time-consuming, and often unavailable cNCT when cat AIT is needed.

Sensitisation to airborne allergens as a risk factor for allergic rhinitis and asthma in the Polish population

Introduction

The patterns of sensitisation to airborne allergens and their association with allergic diseases have been analysed in different geographical regions.

Aim

To analyse the impact of sensitisation to airborne allergens on allergic rhinitis (AR) and asthma in different age groups of the Polish population.

Material and methods

Completed questionnaires of 18,617 subjects (53.8% females), collected within the ECAP, a cross-sectional multicentre study, were analysed. Three groups of respondents were included: 6-7-year-olds (24.2%), 13-14-year-olds (25.4%), 20-44-year-olds (50.4%). The clinical part (an anamnesis, physical examination, spirometry, skin prick tests and an assay of major airborne allergen-specific IgE) was attended by 25.7% of the respondents.

Results

The AR was most strongly related to sensitisation to Dermatophagoides pteronyssinus, with the highest odds ratios of 10 in two younger groups and of 16 for persistent AR in children. It was also the most important risk factor for allergic asthma, with odd ratios from 8.34 in children to 6.40 in adolescents. Sensitisation to grass pollen allergens was a major risk factor for both AR, with odds ratios from 9.16 in adults to 7.87 in adolescents, and asthma, with odds ratios from 6.16 in adolescents to 5.67 in adults.

Conclusions

AR and asthma shared common risk factors, independently of age. Sensitisation to airborne allergens was significantly associated with asthma and, even more strongly, with AR, across all age groups. The AR was the strongest risk factor for allergic asthma in the youngest group. Persistent AR increased asthma risk more than intermittent AR in all age groups.

[Mite sensitization in children followed for respiratory allergy in a tropical African environment in Cotonou, Benin]

INTRODUCTION

In tropical Africa, allergies are not well documented. The objective of this work was to evaluate, by two methods, the sensitization to mites in children followed for respiratory allergy.

METHODS

Skin prick-test and IgE assay by REAST test with 3 mites: Dermatophagoides pteronyssinus (D. pteronyssinus), Dermatophagoides farinae (D. farinae) and Blomia tropicalis (B. tropicalis) were carried out in children from 3 to 15 years followed up for asthma and/or allergic rhinitis. The positive results of the two tests were compared.

RESULTS

Of the 130 (100%) children included, all eligible for the assay, 119 (91.5%) had the prick-test. The mean age and sex ratio (M/F) were 7±1 year, and 1.6. The association of rhinitis and asthma was the most frequent and found in 66 (55.6%). The sensitivity frequencies for the prick-test and assay were respectively 79% versus 36.1% for B. tropicalis, 71.4% versus 33.4% for D. pteronyssinus and 38.7% versus 37.8% for D. farinae. A moderate correlation between mean papule diameter and mean IgE concentration was observed.

CONCLUSION

In African tropical environments, dust mite sensitization in children followed for respiratory allergy is frequent, with the order of frequency being: B. tropicalis, D. pteronyssinus, and D. farinae. The prick-test had better sensitivity than the assay for its evaluation.

Causal Relationship Between Anti-TPO IgE and Chronic Urticaria by In Vitro and In Vivo Tests

PURPOSE

Immunoglobulin (Ig) E autoantibodies against thyroid antigens such as thyroid peroxidase (TPO) have been demonstrated in chronic spontaneous urticaria (CSU) patients in higher frequency than healthy subjects. However, if these IgE autoantibodies can trigger urticaria is still a matter of study. The aim of this study was to investigate the relationship between concomitant IgE autoantibodies against thyroid antigens in CSU.

METHODS

Patients with CSU, healthy subjects and patients with autoimmune thyroid disease (ATD) were recruited. Total IgE and specific anti-TPO IgE and IgG were assessed in all subjects. The basophil activation test and skin tests with TPO were performed to demonstrate whether this antigen could selectively induce urticaria reaction in subjects with positive anti-TPO IgE.

RESULTS

Anti-TPO IgE was present in all 3 groups (CSU: 34.0%, ATD: 16.6%, healthy subjects: 8.1%). Anti-TPO IgE levels were higher in CSU patients, whereas anti-TPO IgG were higher in ATD patients. After exposure to TPO, CD203c expression from patients with CSU and anti-TPO IgE significantly increased in comparison to the other groups; 33.0% vs. 14.0% in ATD patients and 9.0% in control subjects (P < 0.05). Skin reactions with TPO were higher in patients with CSU according to the intradermal (CSU: 18.0%, ATD: 3.3%, control: 8.0%) and skin prick tests (12.0%, 0%, 0%, respectively). Passive transfer of anti-TPO IgE from a CSU patient to the skin of control subjects without anti-TPO IgE induced a positive skin reaction.

CONCLUSIONS

Anti-TPO IgE is not a specific biomarker for CSU. However, IgE against TPO plays a pathogenic role in inducing effector cell activation and skin exacerbation in some patients with CSU.

Prevalence of allergic and nonallergic rhinitis in a rural area of northern China based on sensitization to specific aeroallergens

BACKGROUND

Most epidemiologic studies reporting prevalence of allergic rhinitis (AR) and nonallergic rhinitis (NAR) have assessed solely self-reported prevalence, without confirmation by objective measures. Furthermore, reports of prevalence of NAR in Chinese subjects are scarce. Thus, we aimed to explore the prevalence and risk factors of AR and NAR in a Chinese, based on both clinical manifestation and allergic status.

METHODS

We conducted a population-based cross-sectional survey, involving 1084 local residents from a rural area of Beijing, China. Participants were enrolled using a stratified two-stage cluster sampling method. All adult participants or the guardians of children completed standardized questionnaires to provide relevant demographic and clinical information. Skin prick tests were also performed to determine sensitization to specific aeroallergens. AR/NAR was classified according to Allergic Rhinitis and its Impact on Asthma criteria.

RESULTS

Prevalence of self-reported AR was 46.80%. Based on SPT results, the confirmed standardized prevalence of AR and NAR were 16.78% and 24.60%, respectively. Severity scores for nasal itching, sneezing, rhinorrhea and congestion were significantly higher in subjects with AR, than subjects with NAR (P < 0.05 for all). The three most common aeroallergens in self-reported AR group were Blattella germanica (16.6%), Dermatophagoides farinae (14.6%), and Dermatophagoides pteronyssinus (13.9%). Family history of AR and atopic dermatitis were significantly associated with AR (adjusted OR: 4.97 and 2.69, respectively), whereas family history of AR and asthma were significantly associated with NAR (adjusted OR: 3.53 and 2.45, respectively). Similarly, comorbid asthma, CRS, and atopic dermatitis were significant risk factors for both AR and NAR.

CONCLUSIONS

Combination of standardized questionnaires and specific allergen tests may provide more accurate estimates of prevalence of AR and NAR and associated risk factors.

Exposure and sensitization to insects in allergic patients in the tropics

Introduction: Mites are an important source of allergens in the tropics. Other potential sources of allergens prevalent in the region such as insects have been poorly studied. Objective: To determine the relationship between exposure and allergic sensitization to cockroaches, mosquitos, ants and the interaction with mite sensitization. Materials and methods: We included patients with allergy tests for Blatella germanica, Aedes aegypti, Solenopsis invicta, Blomia tropicalis, Dermatophagoides farinae and D. pteronyssinus. IgE sensitization was evaluated by intraepidermal tests. Exposure to insects in houses was evaluated using traps for crawling and flying insects. Results: A total amount of 186 patients were included; 73 (39.2%) of them were sensitized to an insect (cockroaches: 21%, mosquitoes: 29%, ants: 26,3%), 71 (97.2%) also had sensitization to mites. Of the 148 patients sensitized to mites, only 47.9% were sensitized to an insect. In total, 104 houses were evaluated: 74% had cockroaches, 22% ants, and 52% mosquitoes. Among insect-sensitized patients, the number of insects at home was directly related to the size of the weal generated during the skin test: Cockroaches, r=0.781, p<0.001; mosquitoes, r=0.811, p<0.001, and ants, r=0.840, p<0.001. Conclusion: Sensitization to insects is frequent in allergic populations of the tropics and is strongly associated with sensitization to mites.

Elevated oxytocin and noradrenaline indicate higher stress levels in allergic rhinitis patients: Implications for the skin prick diagnosis in a pilot study

BACKGROUND & AIMS

The effects of acute stress on allergic symptoms are little understood. The intention of this clinical study was to study the effects of acute stress and related mediators in allergic rhinitis (AR), taking the wheal and flare reaction in skin prick testing (SPT) as a readout.

METHODS

19 healthy and 21 AR patients were first subjected to SPTs with grass pollen-, birch pollen- and house dust mite allergen extracts, histamine and negative control. Subsequently, participants were exposed to a standardized Trier Social Stress Test (TSST), followed by SPT on the contralateral forearm. Stress responders were identified based on the salivary cortisol levels and State-subscale of State-Trait-Anxiety Inventory (STAI-S). Blood samples were collected before and after TSST and adrenaline, noradrenaline, serotonin, oxytocin, platelet activating factor and prostaglandin D2 were analyzed by enzyme immunoassay (EIA).

RESULTS

SPT results of 14/21 allergics and 11/19 healthy who responded with stress after TSST were evaluated. No significant differences regarding SPT to allergens or histamine before and after the stress test could be calculated at the group level. But, the wheal and flare sizes after TSST increased or decreased substantially in several individuals, and unmasked sensitization in one "healthy" person, which could not be correlated with any mediator tested. The most significant finding, however, was that, independent of TSST, the baseline levels of oxytocin and noradrenaline were significantly higher in allergics.

CONCLUSION

High baseline levels of noradrenaline points toward higher stress levels in allergic patients, which might be counterregulated by elevated oxytocin. Moreover, our data indicate that acute stress may have a significant influence on SPT fidelity in susceptible individuals.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Linking iron-deficiency with allergy: role of molecular allergens and the microbiome

Atopic individuals tend to develop a Th2 dominant immune response, resulting in hyperresponsiveness to harmless antigens, termed allergens. In the last decade, epidemiological studies have emerged that connected allergy with a deficient iron-status. Immune activation under iron-deficient conditions results in the expansion of Th2-, but not Th1 cells, can induce class-switching in B-cells and hampers the proper activation of M2, but not M1 macrophages. Moreover, many allergens, in particular with the lipocalin and lipocalin-like folds, seem to be capable of binding iron indirectly via siderophores harboring catechol moieties. The resulting locally restricted iron-deficiency may then lead during immune activation to the generation of Th2-cells and thus prepare for allergic sensitization. Moreover, iron-chelators seem to also influence clinical reactivity: mast cells accumulate iron before degranulation and seem to respond differently depending on the type of the encountered siderophore. Whereas deferoxamine triggers degranulation of connective tissue-type mast cells, catechol-based siderophores reduce activation and degranulation and improve clinical symptoms. Considering the complex interplay of iron, siderophores and immune molecules, it remains to be determined whether iron-deficiencies are the cause or the result of allergy.

Debates in allergy medicine: Molecular allergy diagnosis with ISAC will replace screenings by skin prick test in the future

In today's clinical practice patients' skin is used as screening organ for diagnosing type 1 allergy. According to European guidelines skin prick testing with a panel of 18 allergen extracts is recommended, in the US between 10 to 50 allergens are used. The specificity and sensitivity of skin testing is individually highly variable depending on age, body mass, and skin barrier status. In atopic inflammation skin testing gives more false positive results. Smaller skin area and strain limits prick testing in small children. Although the risk for systemic reactions in skin prick testing is very small, emergency medications must be available. Considering the fact that IgE is the only reliable biomarker for type I allergy, upfront IgE screening with ISAC, followed by fewer skin tests to approve positive sensitizations, is proposed. It is time to arrive in the age of molecular allergy diagnosis in daily patient care.

Sensitization patterns and minimum screening panels for aeroallergens in self-reported allergic rhinitis in China

Optimization of skin prick test (SPT) panels, especially in view of significant differences in sensitizations patterns within different geographical areas, is an unmet need within China. Our aim was to assess the patterns and clinical relevance of aeroallergen sensitizations in allergic rhinitis (AR) and define the minimal battery of SPT allergens, classified according to the Köppen-Geiger climate map. Overall, 7148 subjects with self-reported AR completed a standard questionnaire and were assessed for sensitization to relevant allergens by SPT. 6340 (88.7%) patients had at least one positive skin prick reaction, and demonstrated unique sensitization patterns by stratification with age, gender, and geographic region. Sensitization to house dust mites (HDM) was highest in south China, whereas the three most prevalent aeroallergens were mugwort, ragweed and dandelion pollen in north-west China. Higher sensitization rates and multiple sensitizations were associated with AR comorbidities. Eight allergens (Der f, mugwort, Blatella, hazel, goosefoot, Penicillium notatum, animal dander and Der p) allowed identification >96% of sensitized subjects in central China. Differences in optimal panels were observed between regions, with five to six allergens being sufficient for north-east, north-west and south China. These SPT panels may provide a cost-effective tool for screening sensitized patients in China.

House Dust Mite Allergens: New Discoveries and Relevance to the Allergic Patient

PURPOSE OF REVIEW

Recent findings on house dust allergens and their contribution to knowledge that will significantly impact on current and future allergy treatments are appraised.

RECENT FINDINGS

Quantitation of IgE binding to a spectrum of allergen components in several independent studies in varying locations has largely affirmed the main components as the groups 1 and 2 and possibly 23 allergens with mid-tier contributions from the groups 4, 5, 7, and 21. Prevalent binding to Der p 23 has been recapitulated sometimes with low titers. The IgE of non-asthmatic atopic subjects binds at lower titer and to fewer components than that of asthmatics, and their IgG binding relative to IgE is higher especially for children hospitalized for exacerbation. The higher IgG ratios were associated with increased IL-10 a cytokine more readily induced from T cells of allergic subjects. Peptides representing the groups 1 and 2 allergens can be used to stimulate ex vivo T cells showing responses correlating with IgE binding and providing a valuable tool for ascertaining the contribution of IgE and T cells to disease. Also, the induction of Th2 and follicular helper T cells are shown to make different contributions in mice. Cross-reactivity of IgE binding assays with high-titer cross-reactive antibodies induced by scabies is a problem in the many areas of the world where scabies is highly prevalent and endemic and from recent increases in immigration. In the last few years, allergen research has produced results that warrant rapid translation into diagnostic tools and the formulation of allergen components for immunotherapy.

Expression of mRNA IL-17F and sIL-17F in atopic asthma patients

Background

Asthma is a chronic inflammatory disorder of airway that involves many cells and elements. Chronic inflammation caused by increase Airway hyperresponsiveness that cause recurrent episodic symptoms of breathlessness, wheezing, chest tightness and coughing, especially at night or early morning. Interleukin 17F is a cytokine that plays an important role in the pathophysiology of asthma attacks. Some studies show a variety of IL-17F roles in the pathogenesis of airway inflammation due to an allergic reaction.

Results

The study was conducted at the Prof. Dr. R. D. Kandou Manado Hospital, Indonesia. Samples were taken continuously until the number of meant samples was achieved. Blood samples were collected from 40 atopic asthmatic patients. From statistical analysis based on the hypothesis, there was positive correlation between mRNA levels of IL-17F and IL-17F in atopic asthmatic patient (p = 0.000 and r = 0.988).

Conclusions

According these data suggest that levels of mRNA IL-17F and IL17F might be useful parameters for the diagnosis of atopic asthma patient.

Evidence in immunotherapy for paediatric respiratory allergy: Advances and recommendations

Allergic respiratory diseases are major health problems in paediatric population due their high level of prevalence and chronicity, and to their relevance in the costs and quality of life. One of the most important risk factors for the development of airway diseases in children and adolescents is atopy. The mainstays for the treatment of these diseases are avoiding allergens, controlling symptoms, and preventing them through sustained desensitization by allergen immunotherapy (AIT). AIT is a treatment option that consists in the administration of increasing amounts of allergens to modify the biological response to them, inducing long-term tolerance even after treatment has ended. This treatment approach has shown to decrease symptoms and improve quality of life, becoming cost effective for a large number of patients. In addition, it is considered the only treatment that can influence the natural course of the disease by targeting the cause of the allergic inflammatory response. The aim of this publication is to reflect the advances of AIT in the diagnosis and treatment of allergic respiratory diseases in children and adolescents reviewing articles published since 2000, establishing evidence categories to support the strength of the recommendations based on evidence. The first part of the article covers the prerequisite issues to understand how AIT is effective, such as the correct etiologic and clinical diagnosis of allergic respiratory diseases. Following this, the article outlines the advancements in understanding the mechanisms by which AIT achieve immune tolerance to allergens. Administration routes, treatment regimens, dose and duration, efficacy, safety, and factors associated with adherence are also reviewed. Finally, the article reviews future advances in the research of AIT.

Abnormal vocal cord movement in patients with and without airway obstruction and asthma symptoms

BACKGROUND

Abnormal vocal cord movements can cause laryngeal extrathoracic airway obstruction (often called vocal cord dysfunction - VCD) leading to asthma-like symptoms. These aberrant movements are characteristically present during inspiration and termed paradoxical vocal cord movement (PVCM). We have reported PVCM in up to 40% of severe asthmatics, but it is not known if PVCM is detectable in all patients with asthma-like symptoms and if the condition is more often associated with abnormal lung function.

OBJECTIVE

We hypothesized that PVCM is frequently associated with asthma symptoms accompanied by airflow limitation. Studies examined whether PVCM is solely linked to experiencing asthma symptoms, or if PVCM is related to airflow limitation and/or other disease characteristics.

METHODS

Patients with asthma symptoms were recruited from general practice and severe asthma clinics (n = 155). Pulmonary function measurements were conducted, asthma control and Nijmegen (dysfunctional breathing) questionnaires were administered and skin prick testing was carried out. PVCM was quantified using dynamic 320-slice computerized tomography of the larynx. Groups were divided into patients with FEV₁ ≥ 80% predicted or FEV₁ < 80% predicted and FEV₁ /FVC < 0.7. ATS/ERS definitions of severity were also applied and evaluated. Detection of PVCM in the groups was compared and analyses performed to identify features associated with PVCM.

RESULTS

Overall (n = 155), PVCM was detected in 42 cases (27.1%). Patients with FEV₁ < 80% predicted had PVCM more often (25/68, 36.8%) than individuals with normal spirometry (17/87, 19.5%; P = 0.016). PVCM was associated with older age (P = 0.003) and with Nijmegen scores > 20 (P = 0.04). Patients with FEV₁ < 80% predicted plus Nijmegen scores > 20 were more likely to have PVCM (OR = 9.3, P = 0.02).

CONCLUSIONS AND CLINICAL RELEVANCE

Paradoxical vocal cord movement is more often associated with asthma symptoms accompanied by airflow limitation and dysfunctional breathing. Further studies are needed to determine whether PVCM is induced by dysfunctional breathing practices and/or airway obstruction. How PVCM links with symptomatic asthma and VCD also requires evaluation.

Local allergic rhinitis: A critical reappraisal from a paediatric perspective

The so-called local allergic rhinitis (LAR) has been proposed as a phenotype of rhinitis with Th2-driven prominent local allergic inflammation, nasal synthesis of specific IgE and a positive response to a nasal allergen provocation test, in the absence of 'systemic' atopy (negative skin prick test and serum allergen-specific IgE antibodies). To date, available data on LAR are mostly focused on adults. The purpose of this 'Rostrum' was to critically discuss data and implications of the 'LAR concept' in paediatrics. In the natural history of rhinitis due to IgE-mediated reactions triggered by exposure to allergens, a 'LAR' can be either the initial, transient stage of classical allergic rhinitis or a stable phenotype never evolving to 'systemic' IgE sensitization. Given the present difficulties in performing routinely nasal allergen provocation test in children, the development of sensitive and specific tests to detect IgE in the child's nasal secretions is a research priority. We suggest also the hypothetical role of allergen immunoprophylaxis or immunotherapy in LAR. Last, the term 'local allergic rhinitis' may be inappropriate, as rhinitis is always 'local', while IgE sensitization can be either 'local' or 'systemic'.

Developments in the field of allergy in 2014 through the eyes of Clinical and Experimental Allergy

The pathogenesis of asthma continues to be a major topic of interest to our authors with reviews and original papers on the role of viruses, mechanisms of inflammation, biomarkers, and phenotypes of asthma being major topics. A number of papers described new treatments for asthma focusing on blocking the Th2 response reflecting the fact that two decades of work in this area is finally bearing fruit. The pathogenesis of chronic rhinosinusitis is a growing area of interest, but there has been less on the genetics of airways disease than in previous years possibly reflecting the degree of rigour (and therefore a smaller body of work), with which these sorts of studies are now being undertaken. There continues to be a wide range of papers dealing with mechanisms of allergic disease ranging from clinical-based studies to basic research and the use of in vivo animal models especially mice. As before, mechanisms and new approaches to immunotherapy are common themes. Several were published in the allergens section investigating modification of allergens to increase their effectiveness and reduce the risk of adverse events. Risk factors for allergic disease was a common theme in the epidemiology section and food allergy a common theme in clinical allergy with papers on the development of protocols to induce tolerance and attempts to find biomarkers to distinguish sensitization from allergic disease. This was another exciting year for the editors, and we hope the readers of the journal.

How to diagnose mould allergy? Comparison of skin prick tests with specific IgE results

BACKGROUND

Diagnosis of mould allergy is complicated due to the heterogeneity of the test material and the decrease in the number of commercial mould skin test solutions that are currently available.

OBJECTIVES

The aim of this study was to compare skin prick tests (SPT) from different manufacturers to one another and concurrently with sIgE tests for Aspergillus fumigatus (Asp f), Cladosporium herbarum (Cla h), Penicillium chrysogenum (Pen ch), Alternaria alternata (Alt a) and Aspergillus versicolor (Asp v) to ascertain a feasible diagnostic procedure for mould sensitization.

METHODS

In this multi-centre study, 168 patients with mould exposure and/or mould-induced respiratory symptoms were included. Mould SPT solutions were analysed biochemically and tested in duplicate on patients' arms. Specific IgE (sIgE) concentrations to corresponding mould species and mould mix (mx1) were measured by ImmunoCAP. SPTs in accordance with one another and with sIgE were further considered. The test efficiency was calculated using receiver-operating characteristic (ROC) analysis.

RESULTS

Mould sensitization was more frequently detected by the SPT (90 of 168) than by the sIgE tests (56 of 168). Concordances of double SPT positives were only sufficient (≥ 80%) for environmental allergens, two Asp f and three Alt a SPT solutions, whereas all other mould solutions revealed concordances < 80%. The antigen content of SPT solutions was positively associated with concordant SPT double values as well as with sIgE. Taking sIgE as the 'positive standard', all mould SPT solutions revealed test efficiencies > 80%, but varied up to 20% in sensitivity and positive predictive value with the exception of Alt a.

CONCLUSIONS

SPT solutions are sensitive and essential diagnostic tools for the detection of mould sensitization. Our recommendation for diagnosis would be to test at least Alt a, Asp f and Pen ch using SPT and additional sIgE test to mx1.

Skin Testing for Allergic Rhinitis: A Health Technology Assessment

BACKGROUND

Allergic rhinitis is the most common type of allergy worldwide. The accuracy of skin testing for allergic rhinitis is still debated. This health technology assessment had two objectives: to determine the diagnostic accuracy of skin-prick and intradermal testing in patients with suspected allergic rhinitis and to estimate the costs to the Ontario health system of skin testing for allergic rhinitis.

METHODS

We searched All Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, CRD Health Technology Assessment Database, Cochrane Central Register of Controlled Trials, and NHS Economic Evaluation Database for studies that evaluated the diagnostic accuracy of skin-prick and intradermal testing for allergic rhinitis using nasal provocation as the reference standard. For the clinical evidence review, data extraction and quality assessment were performed using the QUADAS-2 tool. We used the bivariate random-effects model for meta-analysis. For the economic evidence review, we assessed studies using a modified checklist developed by the (United Kingdom) National Institute for Health and Care Excellence. We estimated the annual cost of skin testing for allergic rhinitis in Ontario for 2015 to 2017 using provincial data on testing volumes and costs.

RESULTS

We meta-analyzed seven studies with a total of 430 patients that assessed the accuracy of skin-prick testing. The pooled pair of sensitivity and specificity for skin-prick testing was 85% and 77%, respectively. We did not perform a meta-analysis for the diagnostic accuracy of intradermal testing due to the small number of studies (n = 4). Of these, two evaluated the accuracy of intradermal testing in confirming negative skin-prick testing results, with sensitivity ranging from 27% to 50% and specificity ranging from 60% to 100%. The other two studies evaluated the accuracy of intradermal testing as a stand-alone tool for diagnosing allergic rhinitis, with sensitivity ranging from 60% to 79% and specificity ranging from 68% to 69%. We estimated the budget impact of continuing to publicly fund skin testing for allergic rhinitis in Ontario to be between $2.5 million and $3.0 million per year.

CONCLUSIONS

Skin-prick testing is moderately accurate in identifying subjects with or without allergic rhinitis. The diagnostic accuracy of intradermal testing could not be well established from this review. Our best estimate is that publicly funding skin testing for allergic rhinitis costs the Ontario government approximately $2.5 million to $3.0 million per year.