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Warner JO. Ockham's Razor: The Application of Parsimonious Medicine in Allergy/Immunology. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1150-1152. [PMID: 38316183 DOI: 10.1016/j.jaip.2024.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/23/2024] [Indexed: 02/07/2024]
Abstract
The spectacular advances of modern medicine have distracted clinicians from applying the age-old principles of thorough history and examination followed by only ordering tests relevant to the patient's presentation. The most obvious diagnosis is the most likely and should be addressed first. Ockham's razor, or parsimonious medicine, should be applied because plurality of diagnoses is less likely than a single explanation. Component-resolved diagnostics and biological therapies for allergy/immune-mediated diseases have been highly effective when used by specialist allergy services. However, they are accessed too easily and frequently, either before diagnostically appropriate allergy skin testing and challenge have been employed or before the reasons for poor disease control have been investigated. The current fashion to test for vitamin D insufficiency in patients with poorly controlled allergic diseases has rarely achieved benefit but significantly increased costs. There are considerable health/economic benefits from following the proven value of a thorough clinical history, examination, focused allergy/immunology testing, and the judicious use of Ockham's razor.
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Affiliation(s)
- John O Warner
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Imperial College, London, United Kingdom; Department of Paediatrics, University of Cape Town, Cape Town, South Africa.
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Sharma A, Rijavec M, Tomar S, Yamani A, Ganesan V, Krempski J, Schuler CF, Bunyavanich S, Korosec P, Hogan SP. Acute systemic myeloid inflammatory and stress response in severe food allergic reactions. Clin Exp Allergy 2023; 53:536-549. [PMID: 36756745 PMCID: PMC11157667 DOI: 10.1111/cea.14273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/28/2022] [Accepted: 11/20/2022] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Food allergic reactions can be severe and potentially life-threatening and the underlying immunological processes that contribute to the severity of reactions are poorly understood. The aim of this study is to integrate bulk RNA-sequencing of human and mouse peripheral blood mononuclear cells during food allergic reactions and in vivo mouse models of food allergy to identify dysregulated immunological processes associated with severe food allergic reactions. METHODS Bulk transcriptomics of whole blood from human and mouse following food allergic reactions combined with integrative differential expressed gene bivariate and module eigengene network analyses to identify the whole blood transcriptome associated with food allergy severity. In vivo validation immune cell and gene expression in mice following IgE-mediated reaction. RESULTS Bulk transcriptomics of whole blood from mice with different severity of food allergy identified gene ontology (GO) biological processes associated with innate and inflammatory immune responses, dysregulation of MAPK and NFkB signalling and identified 429 genes that correlated with reaction severity. Utilizing two independent human cohorts, we identified 335 genes that correlated with severity of peanut-induced food allergic reactions. Mapping mouse food allergy severity transcriptome onto the human transcriptome revealed 11 genes significantly dysregulated and correlated with severity. Analyses of whole blood from mice undergoing an IgE-mediated reaction revealed a rapid change in blood leukocytes particularly inflammatory monocytes (Ly6Chi Ly6G- ) and neutrophils that was associated with changes in CLEC4E, CD218A and GPR27 surface expression. CONCLUSIONS Collectively, IgE-mediated food allergy severity is associated with a rapid innate inflammatory response associated with acute cellular stress processes and dysregulation of peripheral blood inflammatory myeloid cell frequencies.
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Affiliation(s)
- Ankit Sharma
- Mary H Weiser Food Allergy Center, Department of Pathology, Michigan Medicine, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Sunil Tomar
- Mary H Weiser Food Allergy Center, Department of Pathology, Michigan Medicine, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200
| | - Amnah Yamani
- Mary H Weiser Food Allergy Center, Department of Pathology, Michigan Medicine, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Varsha Ganesan
- Mary H Weiser Food Allergy Center, Department of Pathology, Michigan Medicine, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200
| | - James Krempski
- Mary H Weiser Food Allergy Center, Department of Pathology, Michigan Medicine, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200
| | - Charles F Schuler
- Mary H Weiser Food Allergy Center, Department of Pathology, Michigan Medicine, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200
- Division of Allergy and Immunology, Michigan medicine University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200
| | - Supinda Bunyavanich
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY; Icahn Institute for Data Science and Genome Technology, Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Korosec
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Simon P. Hogan
- Mary H Weiser Food Allergy Center, Department of Pathology, Michigan Medicine, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200
- Department of Pathology, Michigan Medicine, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200
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Dua S, Ruiz-Garcia M, Bond S, Dowey J, Durham SR, Kimber I, Mills C, Roberts G, Skypala I, Wason J, Ewan P, Boyle RJ, Clark A. Effects of Exercise and Sleep Deprivation on Reaction Severity During Oral Peanut Challenge: A Randomized Controlled Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2404-2413.e1. [PMID: 35623576 DOI: 10.1016/j.jaip.2022.04.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The severity of allergic reactions to foods can vary markedly. Little is known of variations in reaction severity within or between individuals or the effects of cofactors. OBJECTIVE We examined the effects of sleep deprivation and exercise and repeat challenges on the severity and patterns of allergic reactions to peanut. METHODS In a randomized crossover study, adults with peanut allergy underwent 3 open peanut challenges in random order: with exercise after each dose, with sleep deprivation preceding challenge, and with no intervention. The primary outcome was eliciting dose, reported elsewhere. Reaction severity was a secondary outcome, evaluated using a weighted log-transformed numerical severity score. Analyses estimated the difference in severity between nonintervention challenge and challenges with exercise or sleep deprivation, adjusting for challenge order and using the highest dose tolerated by each individual across all their challenges. Symptom pattern reproducibility was assessed by comparing symptom sequences using pairwise sequence alignment to obtain a percentage match in symptom pattern. RESULTS Eighty-one participants (mean age 25 y) completed at least 1 postbaseline challenge. Sleep deprivation, but not exercise, significantly increased severity score by 48% (95% CI 12%-84%; P = .009) compared with no intervention. A 38% increase in severity was observed between the first and the last postbaseline challenge (95% CI 1%-75%; P = .044). The average pairwise match of symptoms within individuals was 82.4% and across individuals was 78.3%. CONCLUSIONS A novel severity score demonstrates that sleep deprivation and repeated challenges increase reaction severity. Understanding factors affecting severity is essential for effective risk management. We also show that symptom patterns in repeat peanut challenges are similar within and between individuals.
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Affiliation(s)
- Shelley Dua
- Department of Allergy, Cambridge University Hospitals, Cambridge, UK.
| | - Monica Ruiz-Garcia
- Section of Paediatrics, Department of Medicine, Imperial College London, London, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - James Dowey
- Department of Economic History, London School of Economics, London, UK
| | - Stephen R Durham
- Section for Allergy and Clinical Immunology, National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK; Department of Allergy, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ian Kimber
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - Clare Mills
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Graham Roberts
- NIHR Southampton Respiratory Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine, University of Southampton, Southampton, UK
| | - Isabel Skypala
- Department of Allergy, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - James Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Pamela Ewan
- Department of Allergy, Cambridge University Hospitals, Cambridge, UK
| | - Robert J Boyle
- Section for Allergy and Clinical Immunology, National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK
| | - Andrew Clark
- Department of Allergy, Cambridge University Hospitals, Cambridge, UK
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Greenhawt M, Shaker M, Wang J, Oppenheimer JJ, Sicherer S, Keet C, Swaggart K, Rank M, Portnoy JM, Bernstein J, Chu DK, Dinakar C, Golden D, Horner C, Lang DM, Lang ES, Khan DA, Lieberman J, Stukus D, Wallace D. Peanut allergy diagnosis: A 2020 practice parameter update, systematic review, and GRADE analysis. J Allergy Clin Immunol 2020; 146:1302-1334. [PMID: 32810515 DOI: 10.1016/j.jaci.2020.07.031] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/14/2020] [Accepted: 07/17/2020] [Indexed: 12/14/2022]
Abstract
Given the burden of disease and the consequences of a diagnosis of peanut allergy, it is important that peanut allergy be accurately diagnosed so that an appropriate treatment plan can be developed. However, a test that indicates there is peanut sensitization present (eg, a "positive" test) is not always associated with clinical reactivity. This practice parameter addresses the diagnosis of IgE-mediated peanut allergy, both in children and adults, as pertaining to 3 fundamental questions, and based on the systematic reviews and meta-analyses, makes recommendations for the clinician who is evaluating a patient for peanut allergy. These questions relate to when diagnostic tests should be completed, which diagnostic tests to utilize, and the utility (or lack thereof) of diagnostic testing to predict the severity of a future allergic reaction to peanut.
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Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Lebanon, NH
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai and the Jaffe Food Allergy Institute, New York, NY
| | - John J Oppenheimer
- Department of Internal Medicine, New Jersey Medical School, Morristown, NJ
| | - Scott Sicherer
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai and the Jaffe Food Allergy Institute, New York, NY
| | - Corinne Keet
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Keri Swaggart
- Library Services, Children's Mercy Hospital, Kansas City, Mo
| | - Matthew Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Jay M Portnoy
- Division of Allergy, Asthma & Immunology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Mo
| | - Jonathan Bernstein
- Division of Immunology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence & Impact, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Chitra Dinakar
- Division of Allergy and Asthma, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif
| | - David Golden
- Department of Allergy-Clinical Immunology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Carolyn Horner
- Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David A Khan
- Division of Allergy & Immunology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Jay Lieberman
- Division of Allergy and Immunology, Department of Pediatrics, The University of Tennessee, Memphis, Tenn
| | - David Stukus
- Division of Allergy and Immunology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
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Buyuktiryaki B, Santos AF. Food allergy severity predictions based on cellular in vitro tests. Expert Rev Mol Diagn 2020; 20:679-692. [PMID: 32536279 DOI: 10.1080/14737159.2020.1782192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Food allergy is increasing in prevalence and the severity of allergic reactions is unpredictable. Identifying food-allergic patients at high risk of severe reactions would allow us to offer a personalized and improved management for these patients. AREAS COVERED We review the evidence for using the levels of specific IgE, the nature of the allergen, and cellular tests to identify patients at high risk of developing severe allergic reactions to foods. EXPERT OPINION The evidence about whether the quantity of allergen-specific IgE reflects the severity of allergic reactions to foods is conflicting, with some positive and some negative studies. For some foods, specific IgE to individual components (e.g. Ara h 2 in peanut) can provide additional information. However, more important than the quantity of IgE is possibly the quality of IgE, which can be captured by individual measurements of affinity/avidity, diversity, and specific activity, but is best measured overall using the basophil and mast cell activation tests, which assess the function of IgE in its ability to induce cell activation, degranulation, and mediator release. Biomarkers look at a single aspect of the allergic response and should be interpreted in the broader clinical context for each individual patient assessed.
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Affiliation(s)
- Betul Buyuktiryaki
- Division of Pediatric Allergy, Koc University Hospital , İstanbul, Turkey.,Department of Paediatric Allergy, Evelina London, Guy's and ST Thomas' Hospital NHS Foundation Trust , London, UK
| | - Alexandra F Santos
- Department of Paediatric Allergy, Evelina London, Guy's and ST Thomas' Hospital NHS Foundation Trust , London, UK.,Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , London, UK.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London , London, UK.,Asthma UK Centre in Allergic Mechanisms of Asthma , London, UK
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Affiliation(s)
- Alexandra F Santos
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , London, UK.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London , London, UK.,Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital , London, UK.,Asthma UK Centre in Allergic Mechanisms of Asthma , London, UK
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Hands CM, Sayers RL, Nitride C, Gethings LA, Mills ENC. A multiple reaction monitoring method for determining peanut (Arachis hypogea) allergens in serum using quadrupole and time-of-flight mass spectrometry. Anal Bioanal Chem 2020; 412:2815-2827. [PMID: 32125467 PMCID: PMC7196080 DOI: 10.1007/s00216-020-02508-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/21/2020] [Accepted: 02/11/2020] [Indexed: 11/30/2022]
Abstract
Peanut is a major cause of severe IgE-mediated food allergic reactions, which can be exacerbated by factors, such as exercise, that may increase allergen uptake into the circulation. Enzyme-linked immunosorbent assays (ELISAs) have been used to determine allergen uptake into serum, but there are concerns over their specificity and a confirmatory method is required. Mass spectrometry (MS) methods have the potential to provide rigorous alternatives for allergen determination. A suite of peptide targets representing the major clinically relevant peanut allergens previously applied in food analysis were used to develop a targeted multiple reaction monitoring (MRM) method for determination of peanut in serum. Depletion of serum using affinity chromatography was found to be essential to allow detection of the peptide targets. A comparison of triple quadrupole and Q-TOF methods showed that one Ara h 2 peptide was only detected by the Q-TOF, the other peptide targets giving similar assay sensitivities with both MS platforms, although transitions for all the peptides were detected more consistently with the Q-TOF. The Q-TOF MRM assay detected peanut from spiked serum more effectively than the triple quadrupole assay, with Ara h 3 being detected down to 3 mg total peanut protein/L of serum, comparable with an Ara h 3-specific ELISA. The poor recoveries observed for both methods are likely due to loss of peanut immune complexes during the serum depletion process. Nevertheless, the Q-TOF MRM method has much promise to confirm the uptake of peanut proteins in serum samples providing immune complexes can be disrupted effectively prior to depletion. Graphical abstract.
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Affiliation(s)
- Charlotte M Hands
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Manchester Institute of Biotechnology, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, M1 7DN, UK
| | - Rebekah L Sayers
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Manchester Institute of Biotechnology, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, M1 7DN, UK
| | - Chiara Nitride
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Manchester Institute of Biotechnology, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, M1 7DN, UK
| | - Lee A Gethings
- Waters Corporation, Stamford Avenue, Altrincham Road, Wilmslow, SK9 4AX, UK
| | - E N Clare Mills
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Manchester Institute of Biotechnology, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, M1 7DN, UK.
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8
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Do AN, Watson CT, Cohain AT, Griffin RS, Grishin A, Wood RA, Wesley Burks A, Jones SM, Scurlock A, Leung DYM, Sampson HA, Sicherer SH, Sharp AJ, Schadt EE, Bunyavanich S. Dual transcriptomic and epigenomic study of reaction severity in peanut-allergic children. J Allergy Clin Immunol 2020; 145:1219-1230. [PMID: 31838046 PMCID: PMC7192362 DOI: 10.1016/j.jaci.2019.10.040] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/27/2019] [Accepted: 10/29/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Unexpected allergic reactions to peanut are the most common cause of fatal food-related anaphylaxis. Mechanisms underlying the variable severity of peanut-allergic reactions remain unclear. OBJECTIVES We sought to expand mechanistic understanding of reaction severity in peanut allergy. METHODS We performed an integrated transcriptomic and epigenomic study of peanut-allergic children as they reacted in vivo during double-blind, placebo-controlled peanut challenges. We integrated whole-blood transcriptome and CD4+ T-cell epigenome profiles to identify molecular signatures of reaction severity (ie, how severely a peanut-allergic child reacts when exposed to peanut). A threshold-weighted reaction severity score was calculated for each subject based on symptoms experienced during peanut challenge and the eliciting dose. Through linear mixed effects modeling, network construction, and causal mediation analysis, we identified genes, CpGs, and their interactions that mediate reaction severity. Findings were replicated in an independent cohort. RESULTS We identified 318 genes with changes in expression during the course of reaction associated with reaction severity, and 203 CpG sites with differential DNA methylation associated with reaction severity. After replicating these findings in an independent cohort, we constructed interaction networks with the identified peanut severity genes and CpGs. These analyses and leukocyte deconvolution highlighted neutrophil-mediated immunity. We identified NFKBIA and ARG1 as hubs in the networks and 3 groups of interacting key node CpGs and peanut severity genes encompassing immune response, chemotaxis, and regulation of macroautophagy. In addition, we found that gene expression of PHACTR1 and ZNF121 causally mediates the association between methylation at corresponding CpGs and reaction severity, suggesting that methylation may serve as an anchor upon which gene expression modulates reaction severity. CONCLUSIONS Our findings enhance current mechanistic understanding of the genetic and epigenetic architecture of reaction severity in peanut allergy.
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Affiliation(s)
- Anh N Do
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Corey T Watson
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Biochemistry and Molecular Genetics, University of Louisville School of Medicine, Louisville, Ky
| | - Ariella T Cohain
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert S Griffin
- Department of Anesthesia, Hospital for Special Surgery, New York, NY
| | - Alexander Grishin
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert A Wood
- Department of Pediatrics, Johns Hopkins University, Baltimore, Md
| | - A Wesley Burks
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Stacie M Jones
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Amy Scurlock
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | | | - Hugh A Sampson
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Scott H Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew J Sharp
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eric E Schadt
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Supinda Bunyavanich
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY.
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Birot S, Crépet A, Remington BC, Madsen CB, Kruizinga AG, Baumert JL, Brockhoff PB. Frequentist and Bayesian approaches for food allergen risk assessment: risk outcome and uncertainty comparisons. Sci Rep 2019; 9:18206. [PMID: 31796875 PMCID: PMC6890679 DOI: 10.1038/s41598-019-54844-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/18/2019] [Indexed: 11/12/2022] Open
Abstract
Peer-reviewed probabilistic methods already predict the probability of an allergic reaction resulting from an accidental exposure to food allergens, however, the methods calculate it in different ways. The available methods utilize the same three major input parameters in the risk model: the risk is estimated from the amount of food consumed, the concentration of allergen in the contaminated product and the distribution of thresholds among allergic persons. However, consensus is lacking about the optimal method to estimate the risk of allergic reaction and the associated uncertainty. This study aims to compare estimation of the risk of allergic reaction and associated uncertainty using different methods and suggest improvements. Four cases were developed based on the previous publications and the risk estimations were compared. The risk estimation was found to agree within 0.5% with the different simulation cases. Finally, an uncertainty analysis method is also presented in order to evaluate the uncertainty propagation from the input parameters to the risk.
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Affiliation(s)
- Sophie Birot
- DTU Compute, Richard Petersens Plads, DK-2800 Kgs, Lyngby, Denmark
| | - Amélie Crépet
- ANSES, French Agency for Food, Environmental and Occupational Health Safety, 14 rue Pierre et Marie Curie, 94701, Maisons-Alfort, France
| | - Benjamin C Remington
- The Netherlands Organization for Applied Scientific Research (TNO), Zeist, The Netherlands
| | - Charlotte B Madsen
- National Food Institute, Technical University of Denmark, Lyngby, Denmark.
| | - Astrid G Kruizinga
- The Netherlands Organization for Applied Scientific Research (TNO), Zeist, The Netherlands
| | - Joseph L Baumert
- Food Allergy Research and Resource Program, Department of Food Science & Technology, University of Nebraska, 143 Food Industry Complex, Lincoln, Nebraska, 68583-0919, United States
| | - Per B Brockhoff
- DTU Compute, Richard Petersens Plads, DK-2800 Kgs, Lyngby, Denmark
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10
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A procedure for grouping food consumption data for use in food allergen risk assessment. J Food Compost Anal 2017. [DOI: 10.1016/j.jfca.2017.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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11
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Schwager C, Kull S, Behrends J, Röckendorf N, Schocker F, Frey A, Homann A, Becker WM, Jappe U. Peanut oleosins associated with severe peanut allergy-importance of lipophilic allergens for comprehensive allergy diagnostics. J Allergy Clin Immunol 2017; 140:1331-1338.e8. [PMID: 28342912 DOI: 10.1016/j.jaci.2017.02.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 12/15/2016] [Accepted: 02/08/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Peanut allergy is one of the most common and most severe food allergies in Western countries and its accurate diagnosis to prevent potential life-threatening allergic reactions is crucial. However, aqueous extracts used for routine diagnostic measurements are devoid of lipophilic allergens such as oleosins. We have recently succeeded in the isolation and purification of these unique proteins, and the present study evaluates their allergenic potential and clinical relevance. OBJECTIVE We sought to assess allergenicity and sensitization prevalence of oleosins obtained from both raw and in-shell roasted peanuts. In addition, we tested the utilization of natural and recombinant oleosins for allergy diagnostic purposes. METHODS Oleosin sensitization, prevalence, and impact of thermal processing were analyzed by immunoblot with sera from 52 peanut-allergic individuals displaying different clinical phenotypes. The application of natural and recombinant oleosins for allergy diagnostics was investigated by basophil activation test (BAT). IgE-binding epitopes were identified by oligopeptide microarray. RESULTS Sensitization to oleosins was observed exclusively in peanut-allergic subjects suffering from severe systemic reactions. IgE-binding capacity of oleosins derived from in-shell roasted peanuts was increased as shown by immunoblot analysis and BAT. Both natural and recombinant molecules can be used to identify oleosin-sensitized patients by BAT. A linear epitope of Ara h 15 was determined that displays high similarity to other seed-derived oleosins. CONCLUSIONS Oleosins are clinically relevant peanut allergens and most likely associated with severe allergic symptoms. In-shell roasting increases their allergenicity, which is consistent with the observation that most allergic reactions are in connection with roasted peanuts.
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Affiliation(s)
- Christian Schwager
- Division of Clinical and Molecular Allergology, Research Center Borstel, Priority Research Area Asthma and Allergy, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
| | - Skadi Kull
- Division of Clinical and Molecular Allergology, Research Center Borstel, Priority Research Area Asthma and Allergy, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
| | - Jochen Behrends
- Core Facility Fluorescence Cytometry, Research Center Borstel, Borstel, Germany
| | - Niels Röckendorf
- Division of Mucosal Immunology and Diagnostics, Research Center Borstel, Priority Research Area Asthma and Allergy, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
| | - Frauke Schocker
- Division of Clinical and Molecular Allergology, Research Center Borstel, Priority Research Area Asthma and Allergy, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
| | - Andreas Frey
- Division of Mucosal Immunology and Diagnostics, Research Center Borstel, Priority Research Area Asthma and Allergy, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
| | - Arne Homann
- Division of Clinical and Molecular Allergology, Research Center Borstel, Priority Research Area Asthma and Allergy, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
| | - Wolf-Meinhard Becker
- Division of Clinical and Molecular Allergology, Research Center Borstel, Priority Research Area Asthma and Allergy, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
| | - Uta Jappe
- Division of Clinical and Molecular Allergology, Research Center Borstel, Priority Research Area Asthma and Allergy, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany; Interdisciplinary Allergy Outpatient Clinic, Department of Internal Medicine, University of Luebeck, Luebeck, Germany.
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12
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Borres MP, Maruyama N, Sato S, Ebisawa M. Recent advances in component resolved diagnosis in food allergy. Allergol Int 2016; 65:378-387. [PMID: 27543004 DOI: 10.1016/j.alit.2016.07.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 07/07/2016] [Accepted: 07/07/2016] [Indexed: 12/30/2022] Open
Abstract
Due to the high prevalence of food allergic diseases globally there are increasing demands in clinical practice for managing IgE-mediated conditions. During the last decade, component resolved diagnostics has been introduced into the field of clinical allergology, providing information that cannot be obtained from extract-based tests. Component resolved data facilitate more precise diagnosis of allergic diseases and identify sensitizations attributable to cross-reactivity. Furthermore it assists risk assessment in clinical practice as sensitization to some allergenic molecules is related to persistence of clinical symptoms and systemic rather than local reactions. The information may also aid the clinician in prescription of oral immunotherapy (OIT) in patients with severe symptoms, and in giving advice on food allergen avoidance or on the need to perform food challenges. The use of allergen components is rapidly evolving and increases our possibility to treat food allergic patients with a more individual approach. Using molecular allergology, we can already now better diagnose, prognose and grade the food allergy. In summary, daily routine molecular allergy diagnostics offers a number of benefits that give us a higher diagnostic precision and allow for better management of the patient.
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13
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Turner PJ, Baumert JL, Beyer K, Boyle RJ, Chan CH, Clark AT, Crevel RWR, DunnGalvin A, Fernández-Rivas M, Gowland MH, Grabenhenrich L, Hardy S, Houben GF, O'B Hourihane J, Muraro A, Poulsen LK, Pyrz K, Remington BC, Schnadt S, van Ree R, Venter C, Worm M, Mills ENC, Roberts G, Ballmer-Weber BK. Can we identify patients at risk of life-threatening allergic reactions to food? Allergy 2016; 71:1241-55. [PMID: 27138061 DOI: 10.1111/all.12924] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 12/31/2022]
Abstract
Anaphylaxis has been defined as a 'severe, life-threatening generalized or systemic hypersensitivity reaction'. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors that might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps that need to be addressed to improve our ability to better identify those most at risk of severe food-induced allergic reactions.
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Affiliation(s)
- P. J. Turner
- Section of Paediatrics (Allergy and Infectious Diseases) & MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; Imperial College London; London UK
| | - J. L. Baumert
- Food Allergy Research and Resource Program; Department of Food Science and Technology; University of Nebraska; Lincoln NE USA
| | - K. Beyer
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
| | - R. J. Boyle
- Section of Paediatrics (Allergy and Infectious Diseases) & MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; Imperial College London; London UK
| | | | - A. T. Clark
- Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - R. W. R. Crevel
- Safety and Environmental Assurance Centre; Unilever; Colworth Science Park; Sharnbrook Bedford UK
| | - A. DunnGalvin
- Applied Psychology and Paediatrics and Child Health; University College Cork; Cork Ireland
| | | | | | - L. Grabenhenrich
- Institute for Social Medicine; Epidemiology and Health Economics; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - S. Hardy
- Food Standards Agency; London UK
| | | | - J. O'B Hourihane
- Paediatrics and Child Health; University College Cork; Cork Ireland
| | - A. Muraro
- Department of Paediatrics; Centre for Food Allergy Diagnosis and Treatment; University of Padua; Veneto Italy
| | - L. K. Poulsen
- Allergy Clinic; Copenhagen University Hospital at Gentofte; Copenhagen Denmark
| | - K. Pyrz
- Applied Psychology and Paediatrics and Child Health; University College Cork; Cork Ireland
| | | | - S. Schnadt
- German Allergy and Asthma Association (Deutscher Allergie- und Asthmabund (DAAB)); Mönchengladbach Germany
| | - R. van Ree
- Departments of Experimental Immunology and of Otorhinolaryngology; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - C. Venter
- School of Health Sciences and Social Work; University of Portsmouth; Portsmouth UK
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Isle of Wight UK
| | - M. Worm
- Allergy-Center Charité; Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - E. N. C. Mills
- Institute of Inflammation and Repair; Manchester Academic Health Science Centre; Manchester Institute of Biotechnology; The University of Manchester; Manchester UK
| | - G. Roberts
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Isle of Wight UK
- NIHR Respiratory Biomedical Research Unit; University Hospital Southampton NHS Foundation Trust and Human Development and Health Academic Unit; University of Southampton Faculty of Medicine; Southampton UK
| | - B. K. Ballmer-Weber
- Allergy Unit; Department of Dermatology; University Hospital; University Zürich; Zürich Switzerland
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14
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Umasunthar T, Leonardi-Bee J, Turner PJ, Hodes M, Gore C, Warner JO, Boyle RJ. Incidence of food anaphylaxis in people with food allergy: a systematic review and meta-analysis. Clin Exp Allergy 2016; 45:1621-36. [PMID: 25495886 DOI: 10.1111/cea.12477] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 08/04/2014] [Accepted: 10/15/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Food allergy is a common cause of anaphylaxis, but the incidence of anaphylaxis in food allergic people is unknown. METHODS We undertook a systematic review and meta-analysis, using the inverse variance method. Two authors selected studies by consensus, independently extracted data and assessed study quality using the Newcastle-Ottawa assessment scale. We searched Medline, Embase, PsychInfo, CINAHL, Web of Science, LILACS and AMED between January 1946 and September 2012 and recent conference abstracts. We included registries, databases or cohort studies which described the number of food anaphylaxis cases in a defined population and time period and applied an assumed population prevalence of food allergy. RESULTS We included data from 34 studies. There was high heterogeneity between study results, possibly due to variation in study populations, anaphylaxis definition and data collection methods. In food allergic people, medically coded food anaphylaxis had an incidence rate of 0.14 per 100 person-years (95% CI 0.05, 0.35; range 0.01, 1.28). In sensitivity analysis using different estimated food allergy prevalence, the incidence varied from 0.11 to 0.21 per 100 person-years. At age 0-19, the incidence rate for anaphylaxis in food allergic people was 0.20 (95% CI 0.09, 0.43; range 0.01, 2.55; sensitivity analysis 0.08, 0.39). At age 0-4, an incidence rate of up to 7.00 per 100 person-years has been reported. In food allergic people, hospital admission due to food anaphylaxis had an incidence rate of 0.09 (95% CI 0.01, 0.67; range 0.02, 0.81) per 1000 person-years; 0.20 (95% CI 0.10, 0.43; range 0.04, 2.25) at age 0-19 and 0.50 (0.26, 0.93; range 0.08, 2.82) at age 0-4. CONCLUSION In food allergic people, the incidence of food allergic reactions which are coded as anaphylaxis by healthcare systems is low at all ages, but appears to be highest in young children.
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Affiliation(s)
- T Umasunthar
- Department of Paediatrics, Imperial College, London, UK.,Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - J Leonardi-Bee
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - P J Turner
- Department of Paediatrics, Imperial College, London, UK.,Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - M Hodes
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK.,Centre for Mental Health, Imperial College, London, UK
| | - C Gore
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - J O Warner
- Department of Paediatrics, Imperial College, London, UK.,Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - R J Boyle
- Department of Paediatrics, Imperial College, London, UK.,Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
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15
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A retrospective analysis of allergic reaction severities and minimal eliciting doses for peanut, milk, egg, and soy oral food challenges. Food Chem Toxicol 2015; 80:92-100. [DOI: 10.1016/j.fct.2015.02.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 11/23/2022]
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16
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A review of biomarkers for predicting clinical reactivity to foods with a focus on specific immunoglobulin E antibodies. Curr Opin Allergy Clin Immunol 2015; 15:250-8. [DOI: 10.1097/aci.0000000000000162] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Smit JJ, Pennings MT, Willemsen K, van Roest M, van Hoffen E, Pieters RH. Heterogeneous responses and cross reactivity between the major peanut allergens Ara h 1, 2,3 and 6 in a mouse model for peanut allergy. Clin Transl Allergy 2015; 5:13. [PMID: 25802736 PMCID: PMC4369825 DOI: 10.1186/s13601-015-0056-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 02/28/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The relative contribution and the relation between individual peanut allergens in peanut allergic responses is still matter of debate. We determined the individual contribution of peanut proteins to B, T cell and allergic effector responses in a mouse model for peanut allergy. METHODS Mice were immunized and challenged by oral gavage with peanut protein extract or isolated allergens Ara h 1, 2, 3 and 6 followed by assessment of food allergic manifestations. In addition, T cell responses to the individual proteins were measured by an in vitro dendritic cell-T cell assay. RESULTS Sensitization with the individual peanut proteins elicited IgE responses with specificity to the allergen used as expected. However, cross reactivity among Ara h 1, 2, 3 and 6 was observed. T cell re-stimulations with peanut extract and individual peanut proteins also showed cross reactivity between Ara h 1, 2, 3 and 6. Despite the cross reactivity at the IgE level, only Ara h 2 and 6 were able to elicit mast cell degranulation after an oral challenge. However, after systemic challenge, Ara h 1, 2 and 6 and to lesser extent Ara h 3 were able to elicit anaphylactic responses. CONCLUSIONS Ara h 1, 2, 3 and 6 sensitize via the intra-gastric route, but differ in their capacity to cause allergic effector responses. Interestingly, extensive cross reactivity at T cell and antibody level is observed among Ara h 1, 2, 3 and 6, which may have important implications for the diagnosis and therapy of peanut allergy. Awareness about the relative contribution of individual peanut allergens and cross reactivity between these allergens is of importance for current research in diagnostics and therapeutics for and the mechanism of peanut allergy.
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Affiliation(s)
- Joost J Smit
- Immunotoxicology group, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands ; Utrecht Centre for Food Allergy, Utrecht, The Netherlands
| | - Maarten T Pennings
- Utrecht Centre for Food Allergy, Utrecht, The Netherlands ; Utrecht University Medical Center, Utrecht, The Netherlands ; Current affiliation: HU University of Applied Sciences, Utrecht, The Netherlands
| | - Karina Willemsen
- Immunotoxicology group, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
| | - Manon van Roest
- Immunotoxicology group, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
| | - Els van Hoffen
- Utrecht University Medical Center, Utrecht, The Netherlands ; Current affiliation: NIZO food research BV, Ede, The Netherlands
| | - Raymond H Pieters
- Immunotoxicology group, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
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18
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Santos AF, Du Toit G, Douiri A, Radulovic S, Stephens A, Turcanu V, Lack G. Distinct parameters of the basophil activation test reflect the severity and threshold of allergic reactions to peanut. J Allergy Clin Immunol 2015; 135:179-86. [PMID: 25567046 PMCID: PMC4282725 DOI: 10.1016/j.jaci.2014.09.001] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 08/27/2014] [Accepted: 09/02/2014] [Indexed: 11/03/2022]
Abstract
Background The management of peanut allergy relies on allergen avoidance and epinephrine autoinjector for rescue treatment in patients at risk of anaphylaxis. Biomarkers of severity and threshold of allergic reactions to peanut could significantly improve the care for patients with peanut allergy. Objective We sought to assess the utility of the basophil activation test (BAT) to predict the severity and threshold of reactivity to peanut during oral food challenges (OFCs). Methods The severity of the allergic reaction and the threshold dose during OFCs to peanut were determined. Skin prick tests, measurements of specific IgE to peanut and its components, and BATs to peanut were performed on the day of the challenge. Results Of the 124 children submitted to OFCs to peanut, 52 (median age, 5 years) reacted with clinical symptoms that ranged from mild oral symptoms to anaphylaxis. Severe reactions occurred in 41% of cases, and 57% reacted to 0.1 g or less of peanut protein. The ratio of the percentage of CD63+ basophils after stimulation with peanut and after stimulation with anti-IgE (CD63 peanut/anti-IgE) was independently associated with severity (P = .001), whereas the basophil allergen threshold sensitivity CD-sens (1/EC50 × 100, where EC50 is half maximal effective concentration) value was independently associated with the threshold (P = .020) of allergic reactions to peanut during OFCs. Patients with CD63 peanut/anti-IgE levels of 1.3 or greater had an increased risk of severe reactions (relative risk, 3.4; 95% CI, 1.8-6.2). Patients with a CD-sens value of 84 or greater had an increased risk of reacting to 0.1 g or less of peanut protein (relative risk, 1.9; 95% CI, 1.3-2.8). Conclusions Basophil reactivity is associated with severity and basophil sensitivity is associated with the threshold of allergic reactions to peanut. CD63 peanut/anti-IgE and CD-sens values can be used to estimate the severity and threshold of allergic reactions during OFCs.
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Affiliation(s)
- Alexandra F Santos
- Department of Pediatric Allergy, Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom; MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom; Immunoallergology Department, Coimbra University Hospital, Coimbra, Portugal; Gulbenkian Programme for Advanced Medical Education, Lisbon, Portugal
| | - George Du Toit
- Department of Pediatric Allergy, Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom; MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Abdel Douiri
- Department of Public Health Science, School of Medicine, King's College London, London, United Kingdom; National Institute for Health Research (NIHR), Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Suzana Radulovic
- Department of Pediatric Allergy, Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom; MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Alick Stephens
- Department of Pediatric Allergy, Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom; MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Victor Turcanu
- Department of Pediatric Allergy, Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom; MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Gideon Lack
- Department of Pediatric Allergy, Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom; MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.
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19
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20
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Scientific Opinion on the evaluation of allergenic foods and food ingredients for labelling purposes. EFSA J 2014. [DOI: 10.2903/j.efsa.2014.3894] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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21
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Umasunthar T, Leonardi-Bee J, Hodes M, Turner PJ, Gore C, Habibi P, Warner JO, Boyle RJ. Incidence of fatal food anaphylaxis in people with food allergy: a systematic review and meta-analysis. Clin Exp Allergy 2014; 43:1333-41. [PMID: 24118190 PMCID: PMC4165304 DOI: 10.1111/cea.12211] [Citation(s) in RCA: 167] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 09/24/2013] [Indexed: 01/12/2023]
Abstract
Background Food allergy is a common cause of anaphylaxis, but the incidence of fatal food anaphylaxis is not known. The aim of this study was to estimate the incidence of fatal food anaphylaxis for people with food allergy and relate this to other mortality risks in the general population. Methods We undertook a systematic review and meta-analysis, using the generic inverse variance method. Two authors selected studies by consensus, independently extracted data and assessed the quality of included studies using the Newcastle-Ottawa assessment scale. We searched Medline, Embase, PsychInfo, CINAHL, Web of Science, LILACS or AMED, between January 1946 and September 2012, and recent conference abstracts. We included registries, databases or cohort studies which described the number of fatal food anaphylaxis cases in a defined population and time period and applied an assumed population prevalence rate of food allergy. Results We included data from 13 studies describing 240 fatal food anaphylaxis episodes over an estimated 165 million food-allergic person-years. Study quality was mixed, and there was high heterogeneity between study results, possibly due to variation in food allergy prevalence and data collection methods. In food-allergic people, fatal food anaphylaxis has an incidence rate of 1.81 per million person-years (95%CI 0.94, 3.45; range 0.63, 6.68). In sensitivity analysis with different estimated food allergy prevalence, the incidence varied from 1.35 to 2.71 per million person-years. At age 0–19, the incidence rate is 3.25 (1.73, 6.10; range 0.94, 15.75; sensitivity analysis 1.18–6.13). The incidence of fatal food anaphylaxis in food-allergic people is lower than accidental death in the general European population. Conclusion Fatal food anaphylaxis for a food-allergic person is rarer than accidental death in the general population.
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Affiliation(s)
- T Umasunthar
- Department of Paediatrics, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
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Flinn A, Hourihane JO. Allergic reaction to peanuts: can we predict reaction severity in the wild? Curr Allergy Asthma Rep 2014; 13:645-50. [PMID: 23832622 DOI: 10.1007/s11882-013-0369-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Peanut allergy (PNA) is the main cause of food-induced anaphylaxis. Severe allergic reactions are more likely to occur in older patients and those with underlying asthma. Skin prick testing and measuring serum-specific IgE and recombinant peanut protein levels have been shown to be useful in the diagnosis of PNA and prediction of reactivity, but these tests are less consistent and reliable in terms of predicting the severity of reactions. Recent research has examined the role of biological mediators in allergic reactions such as platelet-activating factor. These may provide a future tool in predicting those at risk of severe reactions. Currently, there are no parameters that can predict with certainty those at risk of anaphylaxis, and management of PNA should continue to focus on patient and family education.
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Affiliation(s)
- Aisling Flinn
- Department of Pediatrics, Cork University Hospital, Cork, Ireland,
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Taylor SL, Baumert JL, Kruizinga AG, Remington BC, Crevel RW, Brooke-Taylor S, Allen KJ, Houben G. Establishment of Reference Doses for residues of allergenic foods: Report of the VITAL Expert Panel. Food Chem Toxicol 2014; 63:9-17. [DOI: 10.1016/j.fct.2013.10.032] [Citation(s) in RCA: 193] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/01/2013] [Accepted: 10/23/2013] [Indexed: 11/30/2022]
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Sicherer SH, Sampson HA. Food allergy: Epidemiology, pathogenesis, diagnosis, and treatment. J Allergy Clin Immunol 2013; 133:291-307; quiz 308. [PMID: 24388012 DOI: 10.1016/j.jaci.2013.11.020] [Citation(s) in RCA: 848] [Impact Index Per Article: 77.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 11/25/2013] [Accepted: 11/25/2013] [Indexed: 01/04/2023]
Abstract
This review focuses on advances and updates in the epidemiology, pathogenesis, diagnosis, and treatment of food allergy over the past 3 years since our last comprehensive review. On the basis of numerous studies, food allergy likely affects nearly 5% of adults and 8% of children, with growing evidence of an increase in prevalence. Potentially rectifiable risk factors include vitamin D insufficiency, unhealthful dietary fat, obesity, increased hygiene, and the timing of exposure to foods, but genetics and other lifestyle issues play a role as well. Interesting clinical insights into pathogenesis include discoveries regarding gene-environment interactions and an increasing understanding of the role of nonoral sensitizing exposures causing food allergy, such as delayed allergic reactions to carbohydrate moieties in mammalian meats caused by sensitization from homologous substances transferred during tick bites. Component-resolved diagnosis is being rapidly incorporated into clinical use, and sophisticated diagnostic tests that indicate severity and prognosis are on the horizon. Current management relies heavily on avoidance and emergency preparedness, and recent studies, guidelines, and resources provide insight into improving the safety and well-being of patients and their families. Incorporation of extensively heated (heat-denatured) forms of milk and egg into the diets of children who tolerate these foods, rather than strict avoidance, represents a significant shift in clinical approach. Recommendations about the prevention of food allergy and atopic disease through diet have changed radically, with rescinding of many recommendations about extensive and prolonged allergen avoidance. Numerous therapies have reached clinical trials, with some showing promise to dramatically alter treatment. Ongoing studies will elucidate improved prevention, diagnosis, and treatment.
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Affiliation(s)
- Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Hugh A Sampson
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
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25
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Calamelli E, Caffarelli C, Ricci G. Peanut sensitization profiles in Italian children and adolescents with specific IgE to peanuts. BIOMED RESEARCH INTERNATIONAL 2013; 2013:170452. [PMID: 24324955 PMCID: PMC3845422 DOI: 10.1155/2013/170452] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 09/22/2013] [Accepted: 10/10/2013] [Indexed: 11/18/2022]
Abstract
Peanuts are one of the most relevant foods implicated in IgE-mediated adverse reactions in pediatric population. This study aimed to evaluate the pattern of sensitization towards five peanut allergenic components (rAra h 1, 2, 3, 8 and 9) in a population of Italian children and adolescents with specific IgE (sIgE) to peanut. rAra h 9 was the main allergen implicated in peanut sensitization (58%), followed by rAra h 8 (35%), rAra h 2 (27%), rAra h 3 (23%) and rAra h 1 (12.5%). rAra h 1, 2, and 3 were the main allergenic components in young children: 8/13 (62%) between 2 and 5 years, 8/23 (35%) between 6 and 11 years, and 3/12 (25%) between 1 and 16 years. No differences were found among the levels of sIgE towards rAra h 1, 2, 3, and 9 in the three groups; in contrast, the levels of sIgE against rAra h 8 showed an increasing trend according to age. In conclusion rAra h 1, 2, and 3 were the prevalent sensitizing allergens during the first years of life in Italian patients with sIgE to peanuts ("genuine" allergy); in contrast rAra h 9 and 8 were mainly involved in school-age children and adolescents with pollen allergy ("secondary" sensitization).
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Affiliation(s)
- Elisabetta Calamelli
- UO Pediatria, Dipartimento di Scienze Mediche e Chirurgiche, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
| | - Carlo Caffarelli
- Pediatric Department, Azienda Ospedaliera-Universitaria, Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Giampaolo Ricci
- UO Pediatria, Dipartimento di Scienze Mediche e Chirurgiche, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
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IgE cross-reactivity between the major peanut allergen Ara h 2 and the nonhomologous allergens Ara h 1 and Ara h 3. J Allergy Clin Immunol 2013; 132:118-24. [DOI: 10.1016/j.jaci.2013.01.022] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 12/14/2012] [Accepted: 01/17/2013] [Indexed: 11/20/2022]
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27
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Sicherer SH, Wood RA. Advances in diagnosing peanut allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2012; 1:1-13; quiz 14. [PMID: 24229816 DOI: 10.1016/j.jaip.2012.10.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 10/08/2012] [Accepted: 10/12/2012] [Indexed: 12/14/2022]
Abstract
Peanut allergy is often severe, potentially fatal, usually persistent, and appears to have increased in prevalence. An accurate diagnosis is essential because there is a significant burden on quality of life. The tools available for diagnosis include the medical history, skin prick test (SPT), determination of serum peanut-specific IgE antibodies (PN-IgE), and medically supervised oral food challenges. Numerous studies, almost exclusively in children, have correlated clinical outcomes against SPTs and PN-IgE with informative results. The diagnostic utility of SPT and PN-IgE is maximized by considering the degree of positive result and consideration of the medical history (a priori estimation of risk). Emerging tests that evaluate IgE binding to specific proteins in peanut (component testing) add important additional diagnostic information in specific settings. Studies are increasingly focused on how the results of tests considered in combination (or performed serially) may increase diagnostic accuracy. Here, we review the utility of currently available tests and provide suggestions on how to best use them to accurately predict peanut allergy. Still, the physician-supervised oral food challenge remains the most definitive test available.
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Affiliation(s)
- Scott H Sicherer
- Jaffe Food Allergy Institute, Mount Sinai School of Medicine, New York, NY.
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Hong X, Caruso D, Kumar R, Liu R, Liu X, Wang G, Pongracic JA, Wang X. IgE, but not IgG4, antibodies to Ara h 2 distinguish peanut allergy from asymptomatic peanut sensitization. Allergy 2012; 67:1538-46. [PMID: 23094689 DOI: 10.1111/all.12047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND There are no available clinical tests that can accurately predict peanut allergy (PA) and/or anaphylaxis. This study is aimed at evaluating whether the component-resolved diagnostic (CRD) IgE and IgG4 tests can (i) distinguish PA from asymptomatic peanut sensitization (PS) and (ii) differentiate anaphylactic from nonanaphylactic PA. METHODS This study included 20 nonatopic controls, 58 asymptomatically peanut-sensitized children, 55 nonanaphylactic, and 53 anaphylactic PA cases from the Chicago Food Allergy Study. IgE and IgG4 to 103 allergens were measured using the ImmunoCAP ISAC technology and were compared among each group of children. The random forest test was applied to estimate each allergen's ability to predict PA and/or peanut anaphylaxis. RESULTS Peanut allergy cases (with or without anaphylaxis) had significantly higher IgE reactivity to Ara h 1-3 (peanut allergens) and Gly m 5-6 (soy allergens) than asymptomatically sensitized children (P < 0.00001). Similar but more modest relationships were found for IgG4 to Ara h 2 (P < 0.01). IgE to Ara h 2 was the major contributor to accurate discrimination between PA and asymptomatic sensitization. With an optimal cutoff point of 0.65 ISU-E, it conferred 99.1% sensitivity, 98.3% specificity, and a 1.2% misclassification rate in the prediction of PA, which represented a higher discriminative accuracy than IgE to whole peanut extract (P = 0.008). However, none of the IgE and/or IgG4 tests could significantly differentiate peanut anaphylaxis from nonanaphylactic PA. CONCLUSIONS IgE to Ara h 2 can efficiently differentiate clinical PA from asymptomatic PS, which may represent a major step forward in the diagnosis of PA.
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Affiliation(s)
- X. Hong
- Center on the Early Life Origins of Disease; Department of Population, Family and Reproductive Health; Johns Hopkins Bloomberg School of Public Health; Baltimore; MD; USA
| | - D. Caruso
- Center on the Early Life Origins of Disease; Department of Population, Family and Reproductive Health; Johns Hopkins Bloomberg School of Public Health; Baltimore; MD; USA
| | - R. Kumar
- Division of Allergy & Immunology; Children's Memorial Hospital; Chicago; IL; USA
| | - R. Liu
- Mary Ann and J. Milburn Smith Child Health Research Program; Children's Memorial Hospital and Children's Memorial Research Center; Department of Pediatrics; Feinberg School of Medicine, Northwestern University; Chicago; IL; USA
| | - X. Liu
- Mary Ann and J. Milburn Smith Child Health Research Program; Children's Memorial Hospital and Children's Memorial Research Center; Department of Pediatrics; Feinberg School of Medicine, Northwestern University; Chicago; IL; USA
| | - G. Wang
- Center on the Early Life Origins of Disease; Department of Population, Family and Reproductive Health; Johns Hopkins Bloomberg School of Public Health; Baltimore; MD; USA
| | - J. A. Pongracic
- Division of Allergy & Immunology; Children's Memorial Hospital; Chicago; IL; USA
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Mueller GA, Gosavi RA, Pomés A, Wünschmann S, Moon AF, London RE, Pedersen LC. Ara h 2: crystal structure and IgE binding distinguish two subpopulations of peanut allergic patients by epitope diversity. Allergy 2011; 66:878-85. [PMID: 21255036 DOI: 10.1111/j.1398-9995.2010.02532.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Peanut allergy affects 1% of the population and causes the most fatal food-related anaphylactic reactions. The protein Ara h 2 is the most potent peanut allergen recognized by 80-90% of peanut allergic patients. METHODS The crystal structure of the major peanut allergen Ara h 2 was determined for the first time at 2.7 Å resolution using a customized maltose-binding protein (MBP)-fusion system. IgE antibody binding to the MBP fusion construct vs the natural allergen was compared by ELISA using sera from peanut allergic patients. RESULTS The structure of Ara h 2 is a five-helix bundle held together by four disulfide bonds and related to the prolamin protein superfamily. The fold is most similar to other amylase and trypsin inhibitors. The MBP--Ara h 2 fusion construct was positively recognized by IgE from 76% of allergic patients (25/33). Two populations of patients could be identified. Subpopulation 1 (n = 14) showed an excellent correlation of IgE antibody binding to natural vs recombinant Ara h 2. Subpopulation 2 (n = 15) showed significantly reduced IgE binding to the MBP fusion protein. Interestingly, about 20% of the IgE binding in subpopulation 2 could be recovered by increasing the distance between MBP and Ara h 2 in a second construct. DISCUSSION The reduced IgE binding to the MBP--Ara h 2 of subpopulation 2 indicates that the MBP molecule protects an immunodominant epitope region near the first helix of Ara h 2. Residues involved in the epitope(s) are suggested by the crystal structure. The MBP--Ara h 2 fusion constructs will be useful to further elucidate the relevance of certain epitopes to peanut allergy.
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MESH Headings
- 2S Albumins, Plant/chemistry
- 2S Albumins, Plant/genetics
- 2S Albumins, Plant/immunology
- 2S Albumins, Plant/metabolism
- Antigens, Plant/chemistry
- Antigens, Plant/genetics
- Antigens, Plant/immunology
- Antigens, Plant/metabolism
- Arachis/genetics
- Arachis/immunology
- Arachis/metabolism
- Crystallization
- Crystallography, X-Ray
- Glycoproteins/chemistry
- Glycoproteins/genetics
- Glycoproteins/immunology
- Glycoproteins/metabolism
- Humans
- Immunodominant Epitopes/chemistry
- Immunodominant Epitopes/genetics
- Immunodominant Epitopes/immunology
- Immunoglobulin E/immunology
- Immunoglobulin E/metabolism
- Maltose-Binding Proteins/chemistry
- Maltose-Binding Proteins/genetics
- Maltose-Binding Proteins/metabolism
- Models, Molecular
- Peanut Hypersensitivity/classification
- Peanut Hypersensitivity/diagnosis
- Peanut Hypersensitivity/immunology
- Recombinant Fusion Proteins/chemistry
- Recombinant Fusion Proteins/genetics
- Recombinant Fusion Proteins/metabolism
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Affiliation(s)
- G A Mueller
- Laboratory of Structural Biology, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA.
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The fascinating world of molecular diagnosis in the management of food allergy: nondum matura est. Curr Opin Allergy Clin Immunol 2011; 11:200-3. [DOI: 10.1097/aci.0b013e32834694ae] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Sirtori E, Resta D, Arnoldi A, Savelkoul HF, Wichers HJ. Cross-reactivity between peanut and lupin proteins. Food Chem 2011. [DOI: 10.1016/j.foodchem.2010.11.073] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shreffler WG. Microarrayed recombinant allergens for diagnostic testing. J Allergy Clin Immunol 2011; 127:843-9; quiz 850-1. [PMID: 21458654 DOI: 10.1016/j.jaci.2011.02.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 02/01/2011] [Accepted: 02/03/2011] [Indexed: 11/17/2022]
Abstract
The development of protein microarray-based immunoassays and the availability of recombinant allergens have, to a significant extent, emerged together over the past decade. Their long-anticipated wider application to allergy diagnosis has recently begun to accelerate. This review discusses some of the strengths and weaknesses of molecularly defined allergy testing and the microarray platform. Several recent applications of microarray assays to allergy testing are also summarized. Promising findings, particularly in the context of food and latex allergy, point to the potential for greater resolution between clinical reactivity and asymptomatic sensitization with this platform.
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Affiliation(s)
- Wayne G Shreffler
- Food Allergy Center and Center for Immunology and Inflammatory Diseases at Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Abstract
Peanut allergy may affect up to 2% of children in some countries, making it one of the most common conditions of childhood. Peanut allergy is a marker of a broad and possibly severe atopic phenotype. Nearly all children with peanut allergy have other allergic conditions. Peanut accounts for a disproportionate number of fatal and near fatal food-related allergies. Families with a child or children with peanut allergy can struggle to adapt to the stringent avoidance measures required. Although oral induction of tolerance represents the cutting edge of peanut allergy management, it is not yet ready for routine practice.
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Affiliation(s)
- Jonathan O'B Hourihane
- Department of Paediatrics and Child Health, Clinical Investigations Unit, Cork University Hospital, University College Cork, Wilton, Cork, Ireland.
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Abstract
Development and progress made in the field of recombinant allergens have allowed for the development of a new concept in allergy diagnosis, molecular diagnosis (MD), which makes it possible to identify potential disease-eliciting molecules. Microarray-based testing performed with a small amount of serum sample enables clinicians to determine specific-IgE antibodies against multiple recombinants or purified natural allergen components. Performance characteristics of allergens so far tested are comparable with current diagnostic tests, but have to be confirmed in larger studies. The use of allergen components and the successful interpretation of test results in the clinic require some degree of knowledge about the basis of allergen components and their clinical implications. Allergen components can be classified by protein families based on their function and structure. This review provides a brief overview of basic information on allergen components, recombinants or purified, currently available or soon to become commercially available in ImmunoCAP or ISAC systems, including names, protein family and function. Special consideration is given to primary or species-specific sensitization and possible cross-reactivity, because one of the most important clinical utility of MD is its ability to reveal whether the sensitization is genuine in nature (primary, species-specific) or if it is due to cross-reactivity to proteins with similar protein structures, which may help to evaluate the risk of reaction on exposure to different allergen sources. MD can be a support tool for choosing the right treatment for the right patient with the right timing. Such information will eventually give clinicians the possibility to individualize the actions taken, including an advice on targeted allergen exposure reduction, selection of suitable allergens for specific immunotherapy, or the need to perform food challenges. Nevertheless, all in vitro tests should be evaluated together with the clinical history, because allergen sensitization does not necessarily imply clinical responsiveness.
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Affiliation(s)
- J Sastre
- Allergy Department, Fundación Jiménez Díaz, Madrid, Spain.
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Sirtori E, Resta D, Brambilla F, Zacherl C, Arnoldi A. The effects of various processing conditions on a protein isolate from Lupinus angustifolius. Food Chem 2010. [DOI: 10.1016/j.foodchem.2009.10.043] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Correlation of IgE/IgG4 milk epitopes and affinity of milk-specific IgE antibodies with different phenotypes of clinical milk allergy. J Allergy Clin Immunol 2010; 125:695-702, 702.e1-702.e6. [PMID: 20226304 DOI: 10.1016/j.jaci.2009.12.017] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 12/03/2009] [Accepted: 12/04/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND Results from large-scale epitope mapping with a peptide microarray have been shown to correlate with clinical features of milk allergy. OBJECTIVES We sought to assess IgE and IgG4 epitope diversity and IgE affinity in different clinical phenotypes of milk allergy and identify informative epitopes that might be predictive of clinical outcomes of milk allergy. METHODS Forty-one subjects were recruited from a larger study on the effects of ingesting heat-denatured milk proteins in subjects with milk allergy. Using food challenges, subjects were characterized as being clinically reactive to all forms of milk (n = 17), being tolerant to heated milk (HM) products (n = 16), or having outgrown their milk allergy (n = 8). Eleven healthy volunteers without milk allergy served as control subjects. A peptide microarray was performed by using the previously published protocol. RESULTS Subjects with milk allergy had increased epitope diversity compared with those who outgrew their allergy. HM-tolerant subjects had IgE-binding patterns similar to those who had outgrown their allergy, but IgG4-binding patterns that were more similar to those of the allergic group. Binding to higher numbers of IgE peptides was associated with more severe allergic reactions during challenge. There was no association between IgG4 peptides and clinical features of milk allergy. Using a competitive peptide microarray assay, allergic patients demonstrated a combination of high- and low-affinity IgE binding, whereas HM-tolerant subjects and those who had outgrown their milk allergy had primarily low-affinity binding. CONCLUSIONS Greater IgE epitope diversity and higher affinity, as determined by using the peptide microarray, were associated with clinical phenotypes and severity of milk allergy.
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Abstract
PURPOSE OF REVIEW The prevalence of allergic disorders has more than doubled in the last two decades leading to increased community concern and anxiety, and unprecedented demand for allergy-specialist services. However, although allergic reactions are common, anaphylaxis is uncommon and fatal anaphylaxis is rare. This review examines recent developments in the epidemiology of anaphylaxis, focusing on new information that may assist in identifying those at increased risk of severe reactions and adverse outcomes. RECENT FINDINGS Recent studies suggest an increase in prevalence of anaphylaxis in industrialized countries. Examination of the demographic characteristics of anaphylaxis has revealed potential approaches to better recognize those at greatest risk. Novel laboratory approaches to identify patients at increased risk of severe reactions have been suggested. SUMMARY Increased knowledge of the epidemiology of anaphylaxis has provided insights into the characteristics of those patient groups most at risk of adverse outcomes. However, these characteristics have poor specificity and limited applicability for detection of at-risk individuals in the clinical setting. Further research is required to facilitate more accurate assessment of an individual's risk for anaphylaxis or fatal outcome. This would represent a major advance in clinical management and enable better allocation of existing healthcare resources.
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Vidal C, Vizcaino L, Díaz-Peromingo J, Garrido M, Gomez-Rial J, Linneberg A, Gonzalez-Quintela A. Immunoglobulin-E Reactivity to a Glycosylated Food Allergen (Peanuts) Due to Interference With Cross-Reactive Carbohydrate Determinants in Heavy Drinkers. Alcohol Clin Exp Res 2009; 33:1322-8. [DOI: 10.1111/j.1530-0277.2009.00961.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Taylor SL, Crevel RWR, Sheffield D, Kabourek J, Baumert J. Threshold dose for peanut: risk characterization based upon published results from challenges of peanut-allergic individuals. Food Chem Toxicol 2009; 47:1198-204. [PMID: 19232533 DOI: 10.1016/j.fct.2009.02.011] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 01/20/2009] [Accepted: 02/08/2009] [Indexed: 11/28/2022]
Abstract
Population thresholds for peanut are unknown. However, lowest- and no-observed adverse effect levels (LOAELs and NOAELs) are published for an unknown number of peanut-allergic individuals. Publications were screened for LOAELs and NOAELs from blinded, low-dose oral challenges. Data were obtained from 185 peanut-allergic individuals (12 publications). Data were analyzed by interval-censoring survival analysis and three probability distribution models fitted to it (Log-Normal, Log-Logistic, and Weibull) to estimate the ED(10). All three models described the data well and provided ED(10)'s in close agreement: 17.6, 17.0, and 14.6 mg of whole peanut for the Log-Normal, Log-Logistic, and Weibull models, respectively. The 95% lower confidence intervals for the ED(10)'s were 9.2, 8.1, and 6.0mg of whole peanut for the Log-Normal, Log-Logistic, and Weibull models, respectively. The modeling of individual NOAELs and LOAELs identified from three different types of published studies - diagnostic series, threshold studies, and immunotherapy trials - yielded significantly different whole peanut ED(10)'s of 11.9 mg for threshold studies, 18.0mg for diagnostic series and 65.5mg for immunotherapy trials; patient selection and other biases may have influenced the estimates. These data and risk assessment models provide the type of information that is necessary to establish regulatory thresholds for peanut.
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Affiliation(s)
- Steve L Taylor
- Food Allergy Research & Resource Program, Department of Food Science & Technology, University of Nebraska-Lincoln, 255 Food Industry Complex, Lincoln, NE 68583-0919, USA.
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Du Toit G, Santos A, Roberts G, Fox AT, Smith P, Lack G. The diagnosis of IgE-mediated food allergy in childhood. Pediatr Allergy Immunol 2009; 20:309-19. [PMID: 19538353 DOI: 10.1111/j.1399-3038.2009.00887.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
IgE-mediated food allergy is a common condition in childhood and a recognized public health concern. An accurate diagnosis of food allergy facilitates the avoidance of the allergen - and cross-reactive allergens - and allows for safe dietary expansion. The diagnosis of food allergy relies on a combination of rigorous history, physical examination, allergy tests [skin prick tests (SPT) and/or serum-specific IgE] and oral food challenges. Diagnostic cut-off values for SPT and specific IgE results have improved the diagnosis of food allergy and thereby reduced the need to perform oral food challenges. This clinical case series seeks to highlight a contemporary approach to the diagnosis of food allergy in children strategies.
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Affiliation(s)
- G Du Toit
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.
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Ramos ML, Huntley JJ, Maleki SJ, Ozias-Akins P. Identification and characterization of a hypoallergenic ortholog of Ara h 2.01. PLANT MOLECULAR BIOLOGY 2009; 69:325-335. [PMID: 19009240 DOI: 10.1007/s11103-008-9428-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 10/29/2008] [Indexed: 05/27/2023]
Abstract
Peanut (Arachis hypogaea L.), can elicit type I allergy becoming the most common cause of fatal food-induced anaphylactic reactions. Strict avoidance is the only effective means of dealing with this allergy. Ara h 2, a peanut seed storage protein, has been identified as the most potent peanut allergen and is recognized by approximately 90% of peanut hypersensitive individuals in the US. Because peanut has limited genetic variation, wild relatives are a good source of genetic diversity. After screening 30 Arachis duranensis accessions by EcoTILLing, we characterized five different missense mutations in ara d 2.01. None of these polymorphisms induced major conformational modifications. Nevertheless, a polymorphism in the immunodominant epitope #7 (S73T) showed a 56-99% reduction in IgE-binding activity and did not affect T cell epitopes, which must be retained for effective immunotherapy. The identification of natural hypoallergenic isoforms positively contributes to future immunological and therapeutic studies and peanut cultivar development.
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Affiliation(s)
- M Laura Ramos
- Department of Horticulture, University of Georgia, Tifton Campus, Tifton, GA 31793, USA
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Clare DA, Gharst G, Maleki SJ, Sanders TH. Effects of transglutaminase catalysis on the functional and immunoglobulin binding properties of peanut flour dispersions containing casein. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2008; 56:10913-10921. [PMID: 18975960 DOI: 10.1021/jf801641d] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The functionality of light roasted peanut flour (PF) dispersions containing supplemental casein (CN) was altered after polymerization with microbial transglutaminase (TGase). The formation of high molecular weight covalent cross-links was observed with likely development of PF-PF, PF-CN, and CN-CN polymers based on Western blotting patterns visualized using antiserum directed against Ara h 1, Ara h 2, Ara h 3, or casein. The gelling temperature of TGase-treated PF dispersions containing 2.5% CN was significantly raised compared to the nontreated PF-CN control solutions. Furthermore, the gel strength and water holding capacity of cross-linked PF-CN test samples containing 5% CN was increased, while the yield stress and apparent viscosity were lowered compared to control dispersions. The immunological staining patterns were also changed where, in some cases, IgE binding to TGase-treated PF-CN fractions appeared less reactive compared to equivalent polymeric PF dispersions lacking supplemental CN and non-cross-linked PF-CN samples. Perhaps, covalent modification masked IgE peanut protein binding epitopes, at least to some degree, on an individual patient basis. Casein proved to be an effective cosubstrate with PF for creating Tgase modified PF-CN dispersions for use as a novel high protein food ingredient.
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Affiliation(s)
- Debra A Clare
- Department of Food, Bioprocessing and Nutrition Sciences, North Carolina State University, Raleigh, North Carolina 27695-7624, USA.
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Hazelnut allergy: from pollen-associated mild allergy to severe anaphylactic reactions. Curr Opin Allergy Clin Immunol 2008; 8:261-5. [PMID: 18560303 DOI: 10.1097/aci.0b013e3282ffb145] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Hazelnut allergy can vary between mild oral symptoms and potentially dangerous anaphylaxis. There is a need to predict which subjects are at risk for severe reactions. In this study, possibilities for 'component-resolved diagnosis', based on sensitization to different allergens in hazelnut, are discussed. RECENT FINDINGS One type of hazelnut allergy can be associated with sensitization to homologues of pollen allergens, predominantly birch, in hazelnut: Cor a 1 (Bet v 1) and Cor a 2 (profilin). These allergens account for relatively mild symptoms. However, subjects can also be sensitized to several other allergens in hazelnut that are related to more severe symptoms. These allergens are homologues of allergens in other nuts and peanut: Cor a 8 (lipid transfer protein) and Cor a 9 (11S globulin) and perhaps Cor a 11 (7S globulin). The clinical relevance of these and other potential hazelnut allergens has to be further defined. The diagnosis of hazelnut has to be confirmed by oral double-blind placebo-controlled food challenge. SUMMARY Sensitization to hazelnut can either be associated with mild oral symptoms, depending on sensitization to pollen, or with more serious allergic symptoms, related to sensitization to homologues of nut and peanut allergens.
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Peanut epitopes for IgE and IgG4 in peanut-sensitized children in relation to severity of peanut allergy. J Allergy Clin Immunol 2008; 121:737-743.e10. [PMID: 18234310 DOI: 10.1016/j.jaci.2007.11.039] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2007] [Revised: 11/27/2007] [Accepted: 11/28/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND Better understanding of the relationship between antibody response to peanut and clinical sensitivity might lead to more accurate prognostication. OBJECTIVE We sought to investigate peanut-specific IgE and IgG4 epitope diversity in relation to challenge-defined clinical sensitivity to peanut in a group of peanut-sensitized children. METHODS Clinical sensitivity was determined by means of double-blind, placebo-controlled peanut challenges in 24 sensitized children. Six atopic control subjects were included. Specific IgE and IgG4 binding to 419 overlapping 15-amino-acid peptides representing the sequence of recombinant Ara h 1, Ara h 2, and Ara h3 was analyzed by means of microarray immunoassay. RESULTS Peanut-sensitized patient sera bound significantly more IgE and IgG4 epitopes than control sera. This patient group reacted to the same Ara h 1, Ara h 2, and Ara h 3 epitopes as reported previously. There was a positive correlation between IgE epitope diversity (ie, number of epitopes recognized) and clinical sensitivity (r = 0.6), such that patients with the greatest epitope diversity were significantly more sensitive than those with the lowest diversity (P = .021). No specific epitopes were associated with severe reactions to peanut. IgG4 binding was observed to largely similar epitopes but was less pronounced than IgE binding and did not relate to the clinical sensitivity to peanut. IgE and IgG4 epitope-recognition patterns were largely stable over a 20-month period. CONCLUSION Clinical sensitivity, as determined by means of double-blind, placebo-controlled peanut challenge, is positively related to a more polyclonal IgE response, which remains stable over time.
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El-Khouly F, Lewis SA, Pons L, Burks AW, Hourihane JO. IgG and IgE avidity characteristics of peanut allergic individuals. Pediatr Allergy Immunol 2007; 18:607-13. [PMID: 18001431 DOI: 10.1111/j.1399-3038.2007.00542.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The role of antibody avidity in allergy is poorly understood and there is no existing literature describing antibody avidity in food allergy. The main aim of this study was to investigate IgE and IgG avidity to a total peanut protein extract (TPPE) and purified Ara h 2 in a group of well-characterized peanut allergic individuals. Forty peanut allergic patients underwent a double-blind placebo-controlled low-dose peanut challenge, during which the severity of the patients' peanut allergy was scored. Serum peanut-specific IgE (psIgE) and IgG (psIgG) concentrations were measured for 37 individuals and the avidities of the same antibodies to a TPPE and purified Ara h 2 were determined using a thiocyanate ELISA method. Both IgE and IgG avidity to Ara h 2 showed weak positive correlations with challenge score [r = 0.459 (p = 0.012) and r = 0.486 (p = 0.003), respectively]. IgE avidity to TPPE showed a weak positive correlation with skin prick test results (SPT), r = 0.467 (p = 0.004) and there was an inverse relationship between the ratio of total IgE:psIgE and challenge score r = -0.561 (p < 0.001). No significant relationship was found between the ratios of IgE avidity:IgG avidity and challenge score or SPT. This is the first description of IgE and IgG avidity in peanut allergy, and it appears that the avidities of IgE and IgG antibodies to purified Ara h 2 are weakly related to the severity of peanut allergy (as measured by a challenge score).
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Affiliation(s)
- Fatima El-Khouly
- Department of Infection and Inflammation Research, University of Southampton, Southampton, UK
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Peeters KABM, Koppelman SJ, van Hoffen E, van der Tas CWH, den Hartog Jager CF, Penninks AH, Hefle SL, Bruijnzeel-Koomen CAFM, Knol EF, Knulst AC. Does skin prick test reactivity to purified allergens correlate with clinical severity of peanut allergy? Clin Exp Allergy 2007; 37:108-15. [PMID: 17210048 DOI: 10.1111/j.1365-2222.2006.02628.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recognition of specific peanut allergens or the diversity of IgE binding to peanut allergens may play a role in the elicitation of severe allergic reactions. OBJECTIVE To investigate whether sensitization to individual allergens Ara h 1, Ara h 2, Ara h 3 and Ara h 6 is correlated with clinical severity. METHODS The reactivity of purified peanut allergens was measured by skin prick test (SPT) and by IgE immunoblot in 30 patients. The results were related to the clinical reactivity by history, and in 25 of them to the eliciting dose (ED). RESULTS The majority of patients recognized Ara h 2 and Ara h 6. Patients with severe symptoms had a higher SPT response to Ara h 2 and Ara h 6 at low concentrations (0.1 micro g/mL) and to Ara h 1 and Ara h 3 at higher concentrations (100 micro g/mL), compared with patients with mild symptoms. They also recognized a greater number of allergens and showed a higher cumulative SPT response compared with patients with mild symptoms. No significant differences were observed between patients with a low or high ED. CONCLUSIONS Ara h 2 and Ara h 6 appeared to be more potent than Ara h 1 and Ara h 3. Both SPT reactivity to low concentrations of Ara h 2 and Ara h 6 and to higher concentrations of Ara h 1 and Ara h 3 were shown to be indicative of severe symptoms.
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Affiliation(s)
- K A B M Peeters
- Department of Dermatology/Allergology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Sicherer SH, Sampson HA. Peanut allergy: Emerging concepts and approaches for an apparent epidemic. J Allergy Clin Immunol 2007; 120:491-503; quiz 504-5. [PMID: 17689596 DOI: 10.1016/j.jaci.2007.07.015] [Citation(s) in RCA: 216] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Revised: 07/13/2007] [Accepted: 07/13/2007] [Indexed: 01/14/2023]
Abstract
Peanut allergy is typically lifelong, often severe, and potentially fatal. Because reactions can occur from small amounts, the allergy presents patients with significant obstacles to avoid allergic reactions. In North America and the United Kingdom, prevalence rates among schoolchildren are now in excess of 1%, framing an increasing public health concern and raising research questions about environmental, immunologic, and genetic factors that may influence outcomes of peanut allergy. This review focuses on recent observations that continue to question the influences of maternal and infant diet on outcomes of peanut allergy, and explore how peanut may be uniquely suited to induce an allergic response. We highlight studies that affect current diagnosis, management, and the nature of advice that can be provided to patients, including the utility of diagnostic tests, doses that elicit reactions, characteristics of reactions from exposure, issues of cross-reactivity, concerns about peanut contamination of manufactured goods, and the natural course of the allergy. Clinical, molecular, and immunologic advances are reviewed, highlighting research discoveries that influence strategies for improved diagnosis, prevention, and treatment. Among the therapeutic strategies reviewed are sublingual and oral immunotherapy, anti-IgE, Chinese herbal medicine, and vaccine strategies.
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Affiliation(s)
- Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Department of Pediatrics, Mount Sinai School of Medicine, New York, NY, USA.
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Flinterman AE, van Hoffen E, den Hartog Jager CF, Koppelman S, Pasmans SG, Hoekstra MO, Bruijnzeel-Koomen CA, Knulst AC, Knol EF. Children with peanut allergy recognize predominantly Ara h2 and Ara h6, which remains stable over time. Clin Exp Allergy 2007; 37:1221-8. [PMID: 17651153 DOI: 10.1111/j.1365-2222.2007.02764.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In peanut-allergic adults, IgE is mainly directed to Ara h1 and Ara h2. More recently, a role for Ara h6 has been suggested. In contrast to adults, IgE in children can fluctuate over time. Therefore, children may have a more dynamic reactivity to peanut. OBJECTIVE To examine the IgE reactivity to major peanut allergens in peanut-allergic children at two subsequent time-points. METHODS Twenty children (3-15 years old) with peanut allergy, confirmed by a double-blind placebo-controlled food challenge (DBPCFC), were included. Just before and 20 months after DBPCFC, IgE reactivity to purified Ara h1, Ara h2, Ara h3 and Ara h6 was studied by immunoblots and skin prick tests (SPTs). RESULTS Before DBPCFC, all peanut-allergic children showed IgE reactivity to Ara h2; Ara h6 was recognized by 16 children, and Ara h1 and Ara h3 by 10 children. After 20 months, peanut-specific IgE levels (median 23 kU/L) and the individual recognition of major allergens were comparable with the levels and recognition before challenge (median 28.2 kU/L). SPT with Ara h2 and Ara h6 was positive in most children, whereas SPT with Ara h1 and Ara h3 was positive in approximately half of the children. Ara h6 induced the largest weals. None of the parameters were related to the severity of peanut allergy. CONCLUSION Ara h2 and Ara h6 are the most frequently recognized major peanut allergens in children. The individual reactivity to the major peanut allergens remained stable over time, despite DBPCFC.
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Affiliation(s)
- A E Flinterman
- Department of Dermatology/Allergology, University Medical Centre Utrecht, The Netherlands
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Crameri R, Rhyner C. Impact of native, recombinant, and cross-reactive allergens on humoral and T-cell-mediated immune responses. Immunol Allergy Clin North Am 2007; 27:65-78. [PMID: 17276879 DOI: 10.1016/j.iac.2006.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Many native allergens have been purified to homogeneity from natural sources, and whole arrays of recombinant and cross-reactive allergens have been produced in large amounts as biologically active molecules. These allergens offer potent research tools to investigate humoral and T cell-mediated immune responses to allergens in healthy and allergic individuals, providing methods for verifying the responses in a reproducible and dose-dependent manner. Dissecting the immune responses to allergens at cellular and molecular levels provides models for studying the different aspects of T-cell activation and the development of immunologic memory and effector functions. A deep understanding of these mechanisms will fundamentally change the current practice of allergy diagnosis, treatment, and prevention.
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Affiliation(s)
- Reto Crameri
- Division of Molecular Allergology, Swiss Institute of Allergy and Asthma Research (SIAF), Obere Strasse 22, CH-7270 Davos, Switzerland.
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