Prediction of mite allergen levels by guanine measurements in house-dust samples

[Allergenic and chemical pollutants of indoor environments and asthma: Characterization, assessment and eviction]

The environment of an asthmatic patient can contain numerous sources of pollutants that degrade the quality of indoor air and have major repercussions on the occurrence and control of asthma. Assessment and improvement of the quality of indoor air should be assigned a major role in pneumology and allergology consultations. Characterization of an asthmatic's environment entails a search for biological pollutants with mite allergens, mildew, and allergens resulting from the proximity of pets. It is important to evaluate the chemical pollution represented by exposure to volatile organic compounds, which are increasingly present in our lodgings. Active or second-hand smoking must in all circumstances be sought out and quantified. Assessment of the environment is mediated by several methods, of which the application depends not only on the pollutant sought out, but also on enzyme-linked immunosorbent assay (ELISA), which has an essential role in quantification of biological pollutants. Attempts at expulsion of the different indoor environment pollutants is mediated by indoor environment advisors, whose efforts are aimed at obtaining reliable evaluation and control of indoor air. Implemented as a form of tertiary prevention, their methods are conducive to improved asthma control, in adults as well as children.

[Diagnosis of allergy in asthma]

Allergy is a hypersensitivity reaction induced by immunological mechanisms. In asthma, allergy has a complex role and is usually IgE mediated. Allergy must be evaluated during the work up but evidence of IgE sensitivity does not mean that allergens play a role in the pathophysiology of the disease. The clinical relevance of the sensitivity has to be considered. This paper describes current available tools to screen for IgE sensitivity, allergen exposure and their role in asthma.

Insights into the metabolism and behaviour of Varroa destructor mites from analysis of their waste excretions

Varroa destructor mites (Acari: Varroidae) are harmful ectoparasites of Apis mellifera honey bees. Female foundresses of wax-capped pupal host cells and their daughters feed on host fluids from open wounds on the host's integument. Details of V. destructor mite nutrition are forthcoming, and little is known about the potential physical effects on hosts from mite feeding. Chemical analysis of waste excretions can infer details of animals’ nutrition. Here, chemical analysis by high-performance liquid chromatography/mass spectrometry (HPLC-MS/MS) of mite excretions showed that the purine content of V. destructor waste consists of guanine with traces of hypoxanthine. Traces of uric acid and caffeine were also detected. Concentrations of guanine attenuated over time and excretions collected from senescing mites did not contain detectable guanine. Non-reproducing individual female mites maintained in vitro, housed in gelatin capsules and provided a honey bee pupa, deposited an average of nearly 18 excretions daily, mostly on the host's integument rather than on the capsule wall. The weight and volume of excretions suggest mites can consume nearly a microlitre of host fluids each day. Compounded over 10 days, this together with open wounds, could lead to substantial water loss and stress to developing pupae.

How In Vitro Assays Contribute to Allergy Diagnosis

Diagnosis of allergic disorders is based upon the clinical history of the disease, the immunoglobulin E (IgE) antibody response, and the allergen exposure. During the last decade, many changes have occurred in the in vitro diagnostic tests used in daily practice. The most important one is the use of allergenic molecules, which helps to define severe profile of allergy and/or to better understand cross-reactivity. The correlation between IgE sensitization and bronchial or nasal response in provocation tests is not so clear, which implies that such tests are still helpful in allergy diagnosis. In order to strengthen the link between a real allergen exposure and allergic symptoms, environmental allergen load assessment can be performed. For clinicians, it appears obvious to know the pollen count to treat their patients; however, they rarely measure the allergen load in the indoor environment, while nowadays home-tests (semi-quantitative or quantitative) make the assessment very easy. In the future, assessment of the environmental exposure (preferably with an indoor technician) of an allergic patient should take into account not only the allergens but also the other indoor pollutants, which could enhance respiratory symptoms in allergic patients.

[House dust mites allergens]

INTRODUCTION

House dust mite allergens from the Pyroglyphidae family are one of the most frequent and potent causes of allergic sensitatisation. Since 1988, molecular knowledge has increased considerably and structures and functions have been determined for most of them.

BACKGROUND

Of the 22 defined allergens, the major IgE-binding has been reported for groups 1 and 2 accounting for 40-60% of the anti-house dust mite titres. Der p 1, 2, 4, 5, 7 allergens account for about 80% of the IgE-response. Der p 4, 5, 7, 11, 14, 15 have a prevalence of sensitization of about 10% each. The IgE-binding to groups 3, 8, 10, 20 is low. Most of the allergens can be identified by amino-acid sequences and the tertiary structures of the major allergens have been solved. Most allergens are proteolytic enzymes: Der p1 for instance is a cysteine protease. Der p 2 has structural homology with MD-2, a co-receptor of the Toll-like receptor (TLR4) whose ligand is LPS. Knowledge of the structure of mite allergens has allowed better interpretation of cross-reactions between allergens from the same family or from more distant families.

CONCLUSIONS

From a practical point of view: the occurrence of multisensitisation is better explained and molecular epidemiology has allowed a better choice of allergen molecules useful for diagnosis. Finally, new concepts of immunotherapy based on genetically engineered hypoallergenic variants of major allergens, used alone or in combination, may lead to useful therapeutic approach.

Sensitisation to mites in laboratory animal workers with rhinitis

AIMS

To determine the frequency of sensitisation to mites among rhinitic laboratory animal workers and to clarify whether sensitisation could be occupational.

METHODS

Skin prick tests (SPT) were performed in 40 subjects who were working with laboratory animals in Kuopio University research units and who had been referred to Kuopio University Hospital for work related rhinitis. The SPT panel consisted of three storage mites, two house dust mites, 11 other common environmental airborne allergens, latex, and 2-4 individually relevant laboratory animals. To determine signs of mites in animal facilities, guanine was determined in 22 dust samples taken from feedstuffs or bedding material used for laboratory animals and from rooms where these materials were stored and handled.

RESULTS

Positive SPT results were found in 35 out of 40 workers: in 14 for storage mites, four for house dust mites, 25 for other common aeroallergens, as well as positive reactions to laboratory animals in 19 individuals. The guanine test was positive, indicating the presence of mite derived material in 21 out of 22 dust samples.

CONCLUSIONS

This study suggests that subjects who are occupationally exposed to laboratory animals are also exposed to mite derived allergens. Sensitisation to mites is common and may be work related.

Allergic rhinitis due to house dust mites: evaluation of the efficacy of specific sublingual immunotherapy

BACKGROUND

The efficacy and safety of sublingual immunotherapy (SLIT) in patients with chronic rhinitis related to sensitization to house dust mites are still controversial.

METHODS

After application of an anti-mite mattress cover, patients were only included in the study when the cumulative symptom score over a fortnight was greater than 70 out of a possible total of 168. Thirty-two of the 120 patients selected were randomized to receive SLIT for 2 years: 17 received placebo and 15 received the Dermatophagoides pteronyssinus and D. farinae 50/50 allergen extract.

RESULTS

Significant between-group differences were observed after 1 year and persisted at the end of the second year for the rhinitis total score (P < 0.02), blocked nose score (P < 0.01) and nasal itching score (P < 0.01). Skin reactivity to house dust mites was significantly reduced in the group receiving house dust mite extract (P < 0.03). No statistical difference was observed between the two groups for medication scores, but a low medication consumption was observed in all patients. No serious and no systemic adverse reactions were reported.

CONCLUSION

This study indicates the superiority of active treatment vs. placebo, evaluated on efficacy criteria (rhinitis score) or objective criteria (skin reactivity). The availability of a solid form (tablet) could represent a progress in terms of patient acceptability.

House-dust-mite sublingual-swallow immunotherapy (SLIT) in perennial rhinitis: a double-blind, placebo-controlled study

BACKGROUND

The safety and efficacy of sublingual-swallow immunotherapy (SLIT) in rhinitis caused by house-dust mite were evaluated in a double-blind, placebo-controlled study including 75 patients for 24 months.

METHODS

Patients received either placebo or SLIT with a standardized Dermatophagoides pteronyssinus (D.pt.) - D. farinae (D.f) 50/50 extract. The mean cumulative dose was 90,000 IR, equivalent to 2.2 mg of Der p 1 and 1.7 mg of Der f I. Symptom and medication scores were assessed throughout the study. Exposure to house-dust mite, skin sensitivity, and serum specific IgE and IgG4 were assessed before starting treatment and after 12 and 24 months.

RESULTS

Seventy-two patients (36 active-36 placebo) were eligible for intent-to-treat analysis. Thirty-six patients dropped out of the study. The number of patients who dropped out due to lack of efficacy was eight out of 37 (21.6%) in the active treatment group compared to 15 out of 38 (39.5%) in the placebo group (chi-square=2.81, P=0.09). Total symptom and medication scores decreased significantly after 12 and 24 months (P<0.05) of treatment in both groups, but no significant difference was observed between the active and placebo groups. After 24 months, the number of patients with high levels of indoor allergenic load decreased significantly in both groups compared to baseline data (P=0.01). Specific IgE (D.pt. and D.f.) increased significantly in the active treatment group after 12 and 24 months, while no change was observed in the placebo group. Specific IgG4 levels were not significantly modified in either group. Two patients in each group reported mild adverse effects. No severe adverse effects were reported.

CONCLUSIONS

We conclude that SLIT in rhinitis caused by house-dust mite was safe, but there was a lack of consistent clinical benefit compared to placebo, probably due to the impact of the allergen avoidance measures that lowered the allergen burden.

Mite fauna in the home and sensitivity to house-dust and storage mites

In search of potential new indoor allergen sources, all mites in dust from homes of 55 asthmatic children living in three climatic regions in Sweden were counted and identified by light microscope. Antibodies of the IgE class against three house-dust mites and three storage mites were measured in corresponding serum samples. Mites were found in all but two homes from the northernmost area, where levels also were lower than in the other regions. The highest mite densities were most often found in bedrooms (50%) and living rooms (40%). Mite density was increased in homes with high humidity and was higher in bungalows than in flats. House-dust mites predominated in the south and storage mites in the east central area, particularly in kitchens and bathrooms. Mite-density and IgE-antibody levels against house-dust mites were significantly associated. The same association applied to storage mites. Other species numbered around 100 mites/g dust in some homes. Microscopy helps to identify potentially important mites. Analysing home dust only for house-dust mites will underestimate mite exposure. Storage mites may be as relevant to sensitivity as house-dust mites. As other species occasionally were found in high numbers, their relevance should also be assessed.

Sublingual-swallow immunotherapy (SLIT) in patients with asthma due to house-dust mites: a double-blind, placebo-controlled study

A double-blind, placebo-controlled study was carried out in 85 patients with a well-documented history of perennial asthma caused by house-dust mites. Patients received either placebo or sublingual immunotherapy (SLIT) with a standardized Dermatophagoides pteronyssinus (DP)-D. farinae (DF) 50/50 extract. After a run-in period, patients received increasing doses up to 300 IR every day for 4 weeks and then three times a week for the following 24 months. The cumulative dose was about 104000 IR, equivalent to 4.2 mg Der p 1 and 7.3 mg Der f 1. Symptom and medication scores and respiratory function were assessed throughout the trial. Serum specific IgE and IgG4 were determined before SLIT (t0) and after 6 (t1), 11 (t2), 17 (t3), and 25 months (t4) of SLIT. Mite exposure was evaluated at t0, t2, and t4 by semiquantitative guanine determinations. Patients aged 15 years and older were asked to assess their quality of life (QoL) by completing the SF20 (Short Form Health Status Survey) plus two items at t0, t2, and t4. Use of inhaled corticosteroids and beta2-agonists was significantly decreased after 25 months of treatment in both groups (P<0.03). SLIT patients showed significant improvements in respiratory function at t4 (% predicted FEV1 (P = 0.01), VC (P = 0.002), morning (P = 0.01) and evening (P = 0.03) PEFR), and reduction in daytime asthma score (P = 0.02). In the SLIT group, the post-treatment PD20 was 1.75 times higher than the baseline value. There was no change in PD20 in the placebo group. Compared to the placebo group, the SLIT group showed a significant increase in specific IgE DP(P = 0.05), IgE DF(P = 0.02), IgG4 DP(P = 0.001), and IgG4 DF (P = 0.001) levels after SLIT. QoL scores were similar in both groups at t0 and t2. At t4, all scores were better in the SLIT group than in the placebo group, with the differences being most marked for the general perception of health (P = 0.01) and physical pain (P = 0.02). Adverse events were similar in the two groups. This study shows that SLIT in house-dust-mite-related asthma has a good safety profile and improves respiratory function, bronchial hyperreactivity, and QoL.