Allergen-specific immunoglobulin E and allergic rhinitis severity

Focused allergic rhinitis practice parameter for Canada

Allergic rhinitis (AR) is a prevalent disease in Canada that affects both children and adults. Several guidelines for the management of AR have been published by professional allergy societies worldwide. However, there are regional differences in the clinical management of AR, and regulatory approval of some AR pharmacotherapies varies among countries. Thus, six research questions specific to the treatment of AR in Canada were identified for this focused practice parameter. Reviews of the literature published since 2016 were conducted to obtain evidence-based support for the responses of the Work Group to each research question. In response to research question 1 "In patients with symptoms indicative of AR, is serum-specific IgE sufficient to identify candidates for immunotherapy or is a skin prick test mandatory?" the Work Group concluded that either sIgE testing or skin prick test are acceptable for diagnosing AR and guiding immunotherapy. In response to research question 2 "When taking into account the preferences of the patient and the prescriber (stakeholder engagement) should second-generation oral antihistamine (OAH) or intranasal corticosteroid (INCS) be first line?" the Work Group concluded that existing guidelines generally agree on the use of INCS as a first-line therapy used for AR, however, patient and provider preferences and considerations can easily shift the first choice to a second-generation OAH. In response to research question 3 "Is a combination intranasal antihistamine (INAH)/INCS formulation superior to INCS plus OAH? Do they become equivalent after prolonged use?" the Work Group concluded that that the combination INAH/INCS is superior to an INCS plus OAH. However, there was insufficient evidence to answer the second question. In response to research question 4 "Do leukotriene receptor antagonists (LTRA) have a greater benefit than OAH in AR for some symptoms to justify a therapeutic trial in those who cannot tolerate INCS?" the Work Group concluded that LTRAs have inferior, or at best equivalent, daytime or overall symptom control compared with OAH, but LTRAs may improve nighttime symptom control and provide benefits in patients with AR and concomitant asthma. In response to research question 5 "Should sublingual immunotherapy (SLIT) tablets be considered first-line immunotherapeutic options over subcutaneous immunotherapy (SCIT) based on the evidence of efficacy?" the Work Group concluded that the choice of SLIT or SCIT cannot be made on efficacy alone, and differences in other factors outweigh any differences in efficacy. In response to research question 6 "Based on efficacy data, should ALL patients seen by an allergist be offered SLIT or SCIT as a treatment option?" the Work Group concluded that the efficacy data suggests that SLIT or SCIT should be used broadly in patients with AR, but other clinical concerns also need to be taken into consideration.

Endotyping Chronic Respiratory Diseases: T2 Inflammation in the United Airways Model

Over the past 15 years, the paradigm of viewing the upper and lower airways as a unified system has progressively shifted the approach to chronic respiratory diseases (CRDs). As the global prevalence of CRDs continues to increase, it becomes evident that acknowledging the presence of airway pathology as an integrated entity could profoundly impact healthcare resource allocation and guide the implementation of pharmacological and rehabilitation strategies. In the era of precision medicine, endotyping has emerged as another novel approach to CRDs, whereby pathologies are categorized into distinct subtypes based on specific molecular mechanisms. This has contributed to the growing acknowledgment of a group of conditions that, in both the upper and lower airways, share a common type 2 (T2) inflammatory signature. These diverse pathologies, ranging from allergic rhinitis to severe asthma, frequently coexist and share diagnostic and prognostic biomarkers, as well as therapeutic strategies targeting common molecular pathways. Thus, T2 inflammation may serve as a unifying endotypic trait for the upper and lower airways, reinforcing the practical significance of the united airways model. This review aims to summarize the literature on the role of T2 inflammation in major CRDs, emphasizing the value of common biomarkers and integrated treatment strategies targeting shared molecular mechanisms.

Quantitative assessment and correlational analysis of subjective and objective indicators in patients with allergic rhinitis

Background

The diagnosis of allergic rhinitis is mainly based on the typical medical history, clinical manifestations, and corresponding allergen test results of the patients. However, there are often clinical inconsistencies among the 3.

Objective

To study the clinical characteristics of patients with allergic rhinitis from both subjective and objective aspects to determine the correlations between the quantitative assessment outcomes of subjective and objective indicators.

Methods

A total of 111 patients with allergic rhinitis who visited our outpatient clinic from June 2022 to December 2022 were selected. The 22-item sino-nasal outcome test (SNOT-22) and the visual analog scale (VAS) for the severity of the disease were used to score the subjective indicators of allergic rhinitis. The objective indicators of allergic rhinitis were evaluated by serum inhalant allergens immunoglobulin E test, nasal endoscopy modified Lund-Kennedy (MLK) scoring method, and acoustic rhinometry.

Results

SNOT-22 score, total VAS score for symptoms, and the VAS score for nasal itching were positively correlated with the number of positive allergens (r = 0.266, P = 0.005, r = 0.576, P < 0.001, and r = 0.271, P = 0.004, respectively). No differences were found in all subjective indicators scores between the total immunoglobulin E positive and negative groups (P > 0.05). SNOT-22 score, total VAS score for symptoms, and the VAS score for nasal congestion were positively correlated with MLK total score of nasal endoscopy (r = 0.343, P < 0.001, r = 0.438, P < 0.001, and r = 0.225, P = 0.018, respectively). Parameters of acoustic rhinometry were not correlated with the subjective indicators scores of allergic rhinitis (P > 0.05).

Conclusion

A multifaceted quantitative assessment of allergic rhinitis using a combination of subjective and objective methods can help physicians make an accurate diagnosis and create reasonable treatment plans.

Correlation between allergic rhinitis or hay fever and lung cancer: A systematic review and meta-analysis

BACKGROUND

The association between allergies and cancer is contradictory, whereas some forms of cancer have inverse associations with allergies. Allergic rhinitis (AR) is the most prevalent form of allergy, and lung cancer is one of the most prevalent forms of cancer with the highest mortality rate. Recent studies have reported a positive association between asthma and lung cancer; however, this association is inconclusive. Furthermore, AR is positively associated with asthma; therefore, our research question was to explore whether there is any correlation between AR and lung cancer epidemiologically.

METHODS

After a rigorous search of PubMed, Google Scholar, and ScienceDirect, 7 eligible articles were included in this systematic review and meta-analysis, including 4724 cases and 9059 controls, 5 from the USA, and one each from Canada and Germany.

RESULTS

Pooled analysis (OR, 0.55; 95% CI: 0.45-0.68; P value < .00001) showed a strong inverse relationship between AR and lung cancer.

CONCLUSION

The current meta-analysis suggests an inverse relationship between AR and lung cancer; however, new epidemiological studies are required to observe the current scenario more comprehensively.

The importance of specific IgE antibodies in the epidemiology of allergic rhinitis and asthma (ECAP survey): part five. The relationship between the concentration of specific IgE antibodies in serum and types of rhinitis

Introduction

Specific immunoglobulins E (sIgE) are important parameters for the estimation of severity of allergic diseases.

Aim

To determine the relationship between the concentration of specific IgE antibodies in serum and types of rhinitis.

Material and methods

The concentration of sIgE antibodies against allergens Dermatophagoides pteronyssinus, cat dander, timothy grass, and Alternaria alternata were determined in the serum of 4077 respondents randomly selected from 8 regions (ECAP study). The positive results of sIgE (≥ 0.35 IU/ml or ≥ 0.7 IU/ml) were correlated to clinical diagnosis (types of rhinitis, skin-prick tests).

Results

sIgE antibodies are more frequently detected in respondents with intermittent/seasonal allergic rhinitis and a negative skin-prick test as compared to healthy respondents with a negative skin-prick test (p < 0.05 to p < 0.001). Relating to allergens of D. pteronyssinus and cat dander, sIgE antibodies are more frequently detected in respondents with persistent/perennial allergic rhinitis and a negative or weakly positive skin-prick test as compared to healthy respondents with a negative or weakly positive skin-prick test (p < 0.05 to p < 0.001).

Conclusions

The occurrence of intermittent/seasonal allergic rhinitis is much more probable in respondents with a negative skin-prick test, when IgE antibodies against the same allergen are detected. And the occurrence of persistent/perennial allergic rhinitis is much more probable in respondents with a negative or weakly positive skin-prick test with allergens of D. pteronyssinus or cat dander, when IgE antibodies against the same allergen are detected.

Validation of AI-based software for objectification of conjunctival provocation test

Background

Provocation tests are widely used in allergology to objectively reveal patients' sensitivity to specific allergens. The objective quantification of an allergic reaction is a crucial characteristic of these tests. Because of the absence of objective quantitative measurements, the conjunctival provocation test (CPT) is a less frequently used method despite its sensitivity and simplicity.

Objective

We developed a new artificial intelligence (AI)-based method, called AllergoEye, for quantitative evaluation of conjunctival allergic reactions and validated it in a clinical study.

Methods

AllergoEye was implemented as a 2-component system. The first component is based on an Android smartphone camera for screening and imaging the patient's eye, and the second is personal computer-based for image analysis and quantification. For the validation of AllergoEye, an open-label, prospective, monocentric study was carried out on 41 patients. Standardized CPT was performed with sequential titration of grass allergens in 4 dilutions, with the reaction evaluated by subjective/qualitative symptom scores and by quantitative AllergoEye scores.

Results

AllergoEye demonstrated high sensitivity (98%) and specificity (90%) as compared with human estimation of allergic reaction. Tuning cutoff thresholds allowed us to increase the specificity of AllergoEye to 97%, at which point the correlation between detected sensitivity to allergen and specific IgE carrier-polymer system class becomes obvious. Strikingly, such correlation was not found with sensitivity to allergen detected on the basis of subjective and qualitative symptom scores.

Conclusion

The clinical validation demonstrated that AllergoEye is a sensitive and efficient instrument for objective measurement of allergic reactions in CPT for clinical studies as well as for routine therapy control.

Pharmacoeconomic Assessment of Antiallergic Drugs by Comparing Serum Immunoglobulin E Level as a Diagnostic and Monitoring Indicator of Allergic Rhinitis in Rural Population of India

Allergic rhinitis (AR) is a chronic inflammatory disease induced by IgE mediated reaction and identified clinically by presence of nasal discharge, sneezing, itching and nasal congestion. Aim of this study was to determine Serum IgE level which is an important indicator of AR. To analyse the diagnostic significance of serum IgE level and their pharmacoeconomic status in the management of AR with commonly used antihistaminic. Estimation of serum IgE can serve as a simple and reliable investigative tool in the diagnostic and management of AR. Fifty two adult patient with history of allergic rhinitis were randomly divided into four study groups and administered either Cetirizine, Levocetirizine, Loratidine or Fexofenadine respectively for one week. Blood samples were analysed to determine serum IgE level and the results were subjected to statistical analysis. The mean value and standard deviation were obtained and tabulated using paired t test. A total 52 patient were divided into four group, 13 in each group of age between 18 and 65 years (mean age 33.73 ± 10.23 years); 48.08% females and 51.92% male were randomized. Mean compliance with treatment was 100% for all study groups. The mean serum IgE level was significantly reduced in Levocetirizine as compared to Cetirizine, Loratidine and Fexofenadine groups. Levocetirizine controls the symptoms of AR better as compared to Cetirizine, Loratidine and Fexofenadine and is a better choice due to its cost effectiveness, tolerability and safety profile.

Correlation between ABO Blood Grouping & Allergic Rhinosinusitis with and without Polyposis & Role of TNF-α Polymorphism in Allergic Rhinosinusitis

The objective of this study was to find distribution of ABO blood group in patients of allergic rhinosinusitis and also to map evidence of the association of TNF-α in different blood groups of patients suffering from allergic rhinitis with or without nasal polyp. Prospective Observational study. Patients with allergic nasal symptoms aged between 18 and 70 years attending outpatient department were assessed and eligible patients who gave consent for the study were included. Patients of allergic rhinosinusitis with nasal polyp had higher serum Ig E count as compared to patients without nasal polyp. 97 patients of allergic rhinosinusitis were Rh positive. Allergic rhinosinusitis was most common in blood group O + ve and B + ve. Allergic rhinosinusitis with polyp was most common in B + ve and without polyp was in O + ve. The frequency of GG, GA and AA genotypes of TNF-α (-308) G/A were 40%, 58%, 2%. The frequency TNF-α (-308) GA was maximum in patients of allergic rhinosinusitis with polyp. In patients of allergic rhinosinusitis without polyp TNF-α (-308) GA and GG had equal distribution of patients (48.6%). The frequency of single allele G in both groups was high as compared to allele A. Association of blood group with allergic rhinitis and TNF-α might help clinicians in better understanding and management of patients suffering from allergic rhinitis in future.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Allergic airway inflammation delays glioblastoma progression and reinvigorates systemic and local immunity in mice

BACKGROUND

Numerous patient-based studies have highlighted the protective role of immunoglobulin E-mediated allergic diseases on glioblastoma (GBM) susceptibility and prognosis. However, the mechanisms behind this observation remain elusive. Our objective was to establish a preclinical model able to recapitulate this phenomenon and investigate the role of immunity underlying such protection.

METHODS

An immunocompetent mouse model of allergic airway inflammation (AAI) was initiated before intracranial implantation of mouse GBM cells (GL261). RAG1-KO mice served to assess tumor growth in a model deficient for adaptive immunity. Tumor development was monitored by MRI. Microglia were isolated for functional analyses and RNA-sequencing. Peripheral as well as tumor-associated immune cells were characterized by flow cytometry. The impact of allergy-related microglial genes on patient survival was analyzed by Cox regression using publicly available datasets.

RESULTS

We found that allergy establishment in mice delayed tumor engraftment in the brain and reduced tumor growth resulting in increased mouse survival. AAI induced a transcriptional reprogramming of microglia towards a pro-inflammatory-like state, uncovering a microglia gene signature, which correlated with limited local immunosuppression in glioma patients. AAI increased effector memory T-cells in the circulation as well as tumor-infiltrating CD4⁺ T-cells. The survival benefit conferred by AAI was lost in mice devoid of adaptive immunity.

CONCLUSION

Our results demonstrate that AAI limits both tumor take and progression in mice, providing a preclinical model to study the impact of allergy on GBM susceptibility and prognosis, respectively. We identify a potentiation of local and adaptive systemic immunity, suggesting a reciprocal crosstalk that orchestrates allergy-induced immune protection against GBM.

Bilirubin level is decreased in patients with allergic rhinitis

BACKGROUND

There are limitations in detecting methods for early diagnosis and screening of allergic rhinitis. Considering the anti-inflammatory and anti-oxidative effects of bilirubin, this study aims to explore the relationship between bilirubin and allergic rhinitis and to identify bilirubin-related candidate urinary protein biomarkers associated with allergic rhinitis.

METHODS

63 allergic rhinitis patients (AR group) and 86 healthy controls (NC group) were enrolled. Venous blood was obtained to measure serum total IgE levels and bilirubin parameters. Patients in the AR group were then classified into the AR1 group (IgE > 125 IU/mL) and the AR2 group (IgE ≤ 125 IU/mL). After randomly selecting ten urine samples from the AR1 group, ten samples were chosen from the AR2 and the NC groups, respectively, according to age and gender matching. We employed a Tandem Mass Tag-Based liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) proteomics approach and targeted parallel-reaction monitoring(PRM) to identify and validate urinary biomarkers for allergic rhinitis.

RESULTS

Compared with the NC group, the bilirubin levels of the AR group, AR1 group, and AR2 group were significantly lower. Although the bilirubin level of the AR1 group was lower than that of the AR2 group, the difference was not significant. Further urinary proteomics analysis found that the expression levels of proteins related to bilirubin metabolism and transportation in the AR1 and AR2 groups, including ABCC1, GSTA1, GSTO1, GSTM3, GSTM5, and BLVRB, were significantly higher than those in the NC group. By PRM-based quantification, GSTA1 and GSTO1 showed significant differences in different degrees of Allergic Rhinitis groups and healthy controls. The AUC of the combined diagnosis of GSTA1 and GSTO1 was 0.79 (95% CI 0.583-0.997, P = 0.007), and the sensitivity and specificity were 100% and 60.0%, respectively.

CONCLUSIONS

Bilirubin levels are associated with allergic rhinitis. Our study revealed that urine proteomics has a specific value for exploring the pathophysiological mechanism of bilirubin changes in AR patients and screening possible biomarkers.

Prevalence, causes and treatments of allergic rhinitis in Malaysia: a literature review

Recently, allergic rhinitis (AR) cases have been surging rapidly in many developing countries. However, the prevalence, risk factors and treatment modalities for AR within the Malaysian population have not been thoroughly evaluated. The present study aimed to provide a complete review of literature on allergic rhinitis in Malaysia. Available data indicated that the prevalence of AR varied across different age groups and regions in Malaysia, but there is an increasing trend among the younger population. The key contributing factor is exposure and sensitization towards several airborne allergens, mainly house dust mites, cat fur and fungi, with possible genetic predispositions. In addition, variations in the symptom severity may be associated with racial orientations. For management of the disease, standard prescriptions of conventional drugs (antihistamines, intranasal corticosteroids and nasal decongestants) remain as the treatment of choice. A small proportion of the native residents tend to resort to alternative approaches of self-healing through aromatherapy and natural food consumption such as tiger’s milk mushroom and Tualang honey. In conclusion, the increase in the cases of AR in Malaysia is due to environmental and genetic factors which requires proper medical intervention as treatment strategies. The utilization of holistic approaches requires further studies and clear understanding prior to their integration into the standard of care. There are still many gaps in the knowledge and management of allergic rhinitis which demands further attention from the research community.

Correlation between sensitization to house dust mite major allergens, age, and symptoms in Japanese house dust mite allergic subjects

Der p 23 has recently been recognized as a new house dust mite (HDM) major allergen that may be linked to the development of asthma in HDM allergic patients. This study aimed to investigate the frequency of sensitization to HDM major allergen components including Der p 23 and to examine the correlation between HDM-sensitization and AR symptom score in Japanese HDM allergic rhinitis (AR) patients without allergic asthma. Serum samples (n = 120) collected from Japanese HDM AR patients (12 to 64 years) without asthma were assessed for allergen-specific IgE (s-IgE) by ImmunoCAP (Dermatophagoides pteronyssinus (D. pteronyssinus; Der p) extract, Der p 23) or immunosolid-phase allergen chip (Der p 1, Der p 2). Japanese HDM AR patients without asthma showed a high prevalence of allergic sensitization to the HDM major allergens Der p 1 (94.2%), Der p 2 (97.5%) and Der p 23 (71.7%). No difference in the prevalence was detected for Der p 1 and Der p 2 s-IgE among three age groups. However, the prevalence of Der p 23 s-IgE was significantly higher in the younger group compared to the elderly group. No significant correlation was found between AR symptom scores and concentration of s-IgE towards Der p extract and any of the three HDM major allergens. Although the prevalence of sensitization towards D. pteronyssinus major allergens is high in Japanese AR patients without asthma, there was no correlation between allergen specific IgE including IgE towards Der p 23 and AR symptom in this population.

Gardenia jasminoides Attenuates Allergic Rhinitis-Induced Inflammation by Inhibiting Periostin Production

Allergic rhinitis (AR) is a chronic inflammatory condition affecting the nasal mucosa of the upper airways. Herein, we investigated the effects of extracts from Gardenia jasminoides (GJ), a traditional herbal medicine with anti-inflammatory properties, on AR-associated inflammatory responses that cause epithelial damage. We investigated the inhibitory effects of water- and ethanol-extracted GJ (GJW and GJE, respectively) in an ovalbumin-induced AR mouse model and in splenocytes, differentiated Th2 cells, and primary human nasal epithelial cells (HNEpCs). Administering GJW and GJE to ovalbumin-induced AR mice improved clinical symptoms including behavior (sneezing and rubbing), serum cytokine levels, immune cell counts, and histopathological marker levels. Treatment with GJW and GJE reduced the secretion of Th2 cytokines in Th2 cells isolated and differentiated from the splenocytes of these mice. To investigate the underlying molecular mechanisms of AR, we treated IL-4/IL-13-stimulated HNEpCs with GJW and GJE; we found that these extracts significantly reduced the production of mitochondrial reactive oxygen species via the uncoupling protein-2 and periostin, a biomarker of the Th2 inflammatory response. Our results suggest that GJ extracts may potentially serve as therapeutic agents to improve the symptoms of AR by regulating the Th2 inflammatory response of the nasal epithelium.

The Similarity of Biomarkers Level between Direct Nasal Fluid and Nasal Lavage Fluid in Allergic Rhinitis Patients

Background and Objectives: Biomarkers of allergic rhinitis (AR) have been studied; however, little is known regarding their practical application in the diagnosis of AR. Previous studies collected samples using saline lavage, nasal brushing, or nasal biopsy. To utilize nasal fluid as a diagnostic tool, we need to standardize the method of sample collection. Therefore, this study aimed to evaluate the difference in concentration of biomarkers depending on the method of nasal fluid collection.Materials and Method: Forty-five AR patients who had greater than moderate AR symptoms and who had positive results on skin prick test and serum-specific IgE tests were enrolled in this study. Nasal fluid was collected using the direct method or saline lavage method. The concentration of each biomarker was analyzed using enzyme-linked immunosorbent assay and the values compared.Results: Nasal fluid samples were collected directly from 14 patients and were collected via saline lavage in 31 patients. No significant differences were found in the median value of each biomarker between the two methods of nasal sample collection.Conclusion: Nasal fluid collection method does not significantly affect biomarker concentration.

Fermented Red Ginseng Alleviates Ovalbumin-Induced Inflammation in Mice by Suppressing Interleukin-4 and Immunoglobulin E Expression

Ginseng (the root of Panax ginseng Meyer) has been reported to have many biologic therapeutic effects, including anti-inflammatory properties, and ginsenosides are considered as one of the factors responsible for these therapeutic effects. To improve their therapeutic action, probiotic bacteria are used to ferment and chemically transform ginsenosides in red ginseng (RG). In this study, we aimed to investigate the beneficial effects of RG fermented by probiotic bacteria (FRG) against ovalbumin (OVA)-induced allergic rhinitis in a mouse model. We induced the mouse model via OVA inhalation; experimental results revealed increased immunoglobulin E (IgE) and interleukin (IL)-4 levels, leading to Th2-type cytokine response. The mice with induced allergy were then orally administered RG and FRG over 2 weeks, as a result of which, IL-4 and IgE levels in bronchoalveolar lavage fluid, nasal fluid, and serum were found to be ameliorated more effectively by FRG than by RG, suggesting that FRG has better immune regulatory effects than RG. FRG also downregulated immune cell levels, such as those of eosinophils and basophils, and significantly decreased the thickness of OVA-induced respiratory epithelium compared to RG. Collectively, the results showed that FRG treatment alleviates inflammation, thereby extending a protective effect to mice with OVA-induced inflammatory allergic rhinitis.

Personalized Pollen Monitoring and Symptom Scores: A Feasibility Study in Grass Pollen Allergic Patients

Background: Pollen is a major trigger for allergic symptoms in sensitized individuals. Airborne pollen is usually monitored by Hirst type pollen samplers located at rooftop level, providing a general overview of the pollen distribution in the larger surroundings. In this feasibility study, grass pollen-sensitized subjects monitored the pollen in their direct environment using a portable pollen sampler (Pollensniffer) and scored their symptoms, to study the relation between symptom severity and personal grass pollen exposure. For comparison the symptoms were also correlated with pollen collected by the rooftop sampler.

Methods: After recruitment 18 participants were screened for grass pollen specific (GP-sIgE) of which 12 were eligible. Nine participants completed the study (May, 2018). They were asked to monitor personal pollen exposure using a Pollensniffer on their way to school, work or other destination, and to score their symptoms via a mobile app on a scale from 0 to 10. Daily pollen concentrations were collected by a Hirst type sampler at rooftop level. Pollen grains were analyzed using a microscope.

Results: Three of the four participants with high GP-sIgE (≥9.6 kU/l) reported high symptom scores (>4) and an analysis showed a significant correlation (CC) between eye, nose, and lung symptoms and the grass pollen counts collected by the Pollensniffer, as well as the daily grass pollen concentrations monitored by the rooftop sampler (CC≥0.54). In contrast, the participants with low GP-sIgE levels (<9.6 kU/l) reported low symptom scores (≤4) and often other sensitizations were present. For these subjects, no significant positive correlations (CC<0.3) of symptoms with either grass pollen collected by the personal or the rooftop sampler were found.

Conclusion: The results of this feasibility study suggest that correlations between the severity of clinical symptoms of grass pollen allergic patients, and grass pollen counts as determined by the Pollensniffer or a rooftop sampler, is restricted to patients with high GP-sIgE levels, high symptom scores, and no relevant other sensitizations. Based on the low numbers of subjects with severe symptoms included in this feasibility study, no conclusions can be drawn on the performance of the Pollensniffer in relating symptoms and pollen exposure in comparison with the rooftop sampler.

Trial Registration: The study was approved by the Committee Medical Ethics of the LUMC (approval numbers: NL63953.058.17/ P17.304).

Measurement of Tryptase and CC16/Albumin in Nasal Lavage Fluid as a Screening Tool of Allergic Rhinitis

BACKGROUND

There is no trial to make a diagnostic tool of allergic rhinitis (AR) utilizing biomarkers from nasal fluid. Base on previous studies, we selected following five biomarkers in nasal fluids that represent the characteristics of allergic reactions: tryptase, eosinophil cationic protein (ECP), interleukin 5 (IL-5), Clara cell protein 16 (CC16) and CC16-to-albumin ratio.

OBJECTIVE

This study aimed to identify biomarkers in nasal discharge that may be used in biosensors to diagnose AR as an additional diagnostic tool.

METHODS

Patients showed rhinorrhea and tested positive on allergic skin and specific immunoglobulin E (IgE) tests were included in the AR group. The non-AR group included individuals no dominant nasal symptoms and tested negative on allergy tests. Nasal lavage fluid samples were collected from all participants. Biomarkers in the samples were quantified using enzyme-linked immunosorbent assay.

RESULTS

Forty-five patients with AR and 28 non-AR subjects were enrolled in this study. Comparing the concentrations of biomarkers, the concentrations of tryptase and IL-5 were significantly higher in the AR group than in the NAR group. And CC16 level and CC16-to-albumin ratio were significantly lower in the AR group. In the combination of tryptase or CC16-to-albumin ratio, the sensitivity was 90.7% and the specificity was 64.3% (p = 0.013).

CONCLUSION

The combination of "tryptase or CC16-to-albumin" could be used as a screening tool for AR. Although this diagnostic method could not replace conventional diagnostic tools, we could consider the method we proposed as an additional screening tool for patients who could not undergo allergy tests.

Association of Serum Vitamin D and Immunoglobulin E Levels With Severity of Allergic Rhinitis

Objective The aim of this study was to determine the association of serum vitamin D and immunoglobulin E (IgE) levels with the severity of allergic rhinitis (AR). Methods This case-control study was conducted at Mayo Hospital, Lahore, from June to September 2020 after obtaining ethical approval. Patients of AR were included and divided with the help of allergic rhinitis and its impact on asthma (ARIA) classification, into group A (cases), patients presenting with moderate to severe symptoms, and into group B (control), patients with mild symptoms, after treatment of AR. The mean difference between serum IgE and serum Vitamin D levels of both groups were compared by t-test. Association was determined by logistic regression and odds ratio. Results A total of 224 patients were included in the study, 112 patients in group A and 112 patients in group B. There were 106 (47.3%) female and 118 (52.7%) male. The mean age of patients in group A was 26.78± 8.92 years and in group B, it was 25.72±8.12 years. Mean serum vitamin D levels in group A were 16.24±6.7 ng/ml and in group B 26.92±35 ng/ml (p=0.0001). Mean serum IgE levels in group A were 383.69±154.86 IU/ml and in group B, they were 373.03±106.83 IU/ml (p=0.0001). Vitamin D deficient patients were 24 times more likely to develop moderate to severe AR disease. Conclusion This study showed that in moderate-severe AR, IgE levels are raised statistically as compared to mild AR and the deficiency of Vitamin D is associated with increasing severity of allergic rhinitis symptoms.

AllergoOncology: ultra-low IgE, a potential novel biomarker in cancer-a Position Paper of the European Academy of Allergy and Clinical Immunology (EAACI)

Elevated serum IgE levels are associated with allergic disorders, parasitosis and specific immunologic abnormalities. In addition, epidemiological and mechanistic evidence indicates an association between IgE-mediated immune surveillance and protection from tumour growth. Intriguingly, recent studies reveal a correlation between IgE deficiency and increased malignancy risk. This is the first review discussing IgE levels and links to pathological conditions, with special focus on the potential clinical significance of ultra-low serum IgE levels and risk of malignancy. In this Position Paper we discuss: (a) the utility of measuring total IgE levels in the management of allergies, parasitosis, and immunodeficiencies, (b) factors that may influence serum IgE levels, (c) IgE as a marker of different disorders, and d) the relationship between ultra-low IgE levels and malignancy susceptibility. While elevated serum IgE is generally associated with allergic/atopic conditions, very low or absent IgE may hamper anti-tumour surveillance, indicating the importance of a balanced IgE-mediated immune function. Ultra-low IgE may prove to be an unexpected biomarker for cancer risk. Nevertheless, given the early stage of investigations conducted mostly in patients with diseases that influence IgE levels, in-depth mechanistic studies and stratification of malignancy risk based on associated demographic, immunological and clinical co-factors are warranted.

Clinical symptoms and biomarkers of Bermuda grass-induced allergic rhinitis using the nasal allergen challenge model

BACKGROUND

Bermuda grass is a prevalent allergen that flourishes in tropical climates. Its exposure is traditionally believed to be low in Ontario due to the colder environment. However, high sensitization rates have been observed in Kingston, Ontario.

OBJECTIVE

We sought to investigate whether its allergens can provoke allergic rhinitis (AR) symptoms in sensitized participants from south-eastern Ontario and determine if nasal allergen challenge (NAC) model is appropriate to study Bermuda grass-induced AR.

METHODS

Twenty-one participants sensitized to Bermuda grass and 12 nonallergic participants completed a titrated NAC with increasing allergen concentrations at a screening visit. Total nasal symptom score (TNSS) and peak nasal inspiratory flow were collected before allergen exposure and 10 minutes after delivery of each concentration. Twelve participants with a Bermuda grass allergy who met the qualifying criteria (TNSS ≥ 8 and peak nasal inspiratory flow fall ≥ 50%) and 11 nonallergic controls returned for single-dose NAC visit.

RESULTS

At titrated NAC, 19 of 21 sensitized participants met the criteria of positive allergic response when challenged. During single-dose NAC, participants with allergy had significantly greater TNSS between 15 minutes and 3 hours after NAC than controls. Likewise, allergic participants had a significantly increased number of nasal lavage eosinophils at both 1 and 6 hours after NAC. Bermuda grass-specific immunoglobulin E was significantly increased in Bermuda grass allergic participants at NAC than screening visit.

CONCLUSION

Although Bermuda grass is a non-native allergen in Ontario, it can induce AR symptoms in sensitized participants, and the NAC model is appropriate to study Bermuda grass-induced AR.

Desloratadine Ameliorates Olfactory Disorder and Suppresses AMPA Receptor GluA1 Expression in Allergic Rhinitis Rat

Allergic rhinitis (AR) is an IgE-mediated inflammation which causes olfactory dysfunction. Antihistamines have been widely used to treat AR while few studies have investigated the effect of antihistamines on improving the sense of smell. In addition, the underlying mechanisms are not well elucidated. We established the ovalbumin (OVA)-induced allergic rhinitis rat model and administrated desloratadine to AR rats. The AR symptoms, serum level of OVA-specific IgE and IL-17, and expression of IL-4, IL-5 and IL-13 in nasal mucosa were measured. The olfactory dysfunction was monitored by buried food test and the expression of GluR1 was measured. Desloratadine treatment alleviated AR symptoms, decreased serum level of OVA-specific IgE and IL-17 in AR rats. Desloratadine decreased IL-4, IL-5, and IL-13 expression in nasal mucosa of AR rats. Desloratadine ameliorated olfactory dysfunction in AR rats and decreased GluR1 expression in AR rats. Desloratadine treatment alleviated AR symptoms and ameliorated olfactory dysfunction in AR rats. The expression of AMPA receptor subunit GluR1 in olfactory bulb was associated with olfactory disorder.

Allergic children with extremely high total IgE but no allergen identified in the initial screening panel

BACKGROUND

High serum IgE level in atopic children usually implies a highly sensitized condition. However, there is a subgroup of atopic children for whom a specific allergen cannot be identified. In this study, we analyzed follow-up data from these children.

METHODS

From March 2014 to July 2017, we recruited 14 atopic children with serum total IgE level higher than 500 Ku/L, but with no specific allergen identified by repeated MAST tests initially. Follow-up studies of specific IgE were conducted by the OPTIGEN MAST Allergy test and ImmunoCAP assays (Thermo Fisher Scientific/Phadia), while total IgE and specific IgG were measured by ImmunoCAP.

RESULTS

The patients were aged from 2 to 17 y/o. The follow-up MAST tests showed significantly positive results in 10 patients. There were no significant differences in any of the clinical characteristics between the MAST-positive and MAST-negative groups. In the MAST-negative group, five allergen-specific IgE antibodies, including those for cockroach, Euroglyphus maynei, Blomia tropicalis, shrimp, and crab, were strongly predictive of negative ImmunoCAP results, according to ROC (Receiver operating characteristic curve) analysis of the AUC (Area under the Curve of ROC) (0.70-0.95), with significance set at p < 0.05.

CONCLUSION

In two thirds of atopic children with a high serum IgE whose specific allergen had yet to be identified, it was possible to identify the specific MAST allergen(s) after an average follow-up of 33.2 months. For patients who still had negative results in follow-up MAST, mite DP, DF, and DM may be suitable choices for further allergen identification by ImmunoCAP.

Role of allergen-specific T-follicular helper cells in immunotherapy

PURPOSE OF REVIEW

The discovery of novel T-cell subsets including follicular helper T (Tfh) cells has broadened our knowledge on the complex immune networks in allergic diseases. This review summarizes the evidence for Tfh cells in controlling immune responses to allergens with a particular focus on immunoglobulin E (IgE) production and discusses the implication of such regulation in allergen-specific immunotherapy.

RECENT FINDINGS

Tfh cells support the production of IgE in animal models for allergic diseases. Among Tfh cells, the type 2 subset (Tfh2) is considered as the major player that secretes IL-4 and promotes the isotype switching to IgE. In human inflammatory airway diseases, including allergic rhinitis, asthma, and nasal polyps, the increased frequencies of circulating or tissue Tfh2 cells have been reported. Notably, the frequencies of Dermatophagoides pteronyssinus group 1 (Der p 1)-specific IL-4 Tfh cells in blood positively correlated with serum Der p-specific IgE levels in allergic rhinitis patients. After allergen immunotherapy (AIT), Der p 1-specific IL-4 Tfh cells declined in allergic rhinitis patients, which associated with the remission of clinical symptoms.

SUMMARY

Allergen-specific IL-4 Tfh cells contribute to the production of allergen-specific IgE and correlate with clinical efficacy of AIT in allergic rhinitis patients, which suggest allergen-specific Tfh cells as a promising therapeutic target and biomarker for AIT in allergic rhinitis.

Thunderstorm-triggered asthma: what we know so far

Thunderstorm-triggered asthma (TA) is the occurrence of acute asthma attacks immediately following a thunderstorm. Epidemics have occurred across the world during pollen season and have the capacity to rapidly inundate a health care service, resulting in potentially catastrophic outcomes for patients. TA occurs when specific meteorological and aerobiological factors combine to affect predisposed patients. Thunderstorm outflows can concentrate aeroallergens, most commonly grass pollen in TA, at ground level to release respirable allergenic particles after rupture by osmotic shock related to humidity and rainfall. Inhalation of high concentrations of these aeroallergens by sensitized individuals can induce early asthmatic responses which are followed by a late inflammatory phase. Other environmental factors such as rapid temperature change and agricultural practices contribute to the causation of TA. The most lethal TA event occurred in Melbourne, Australia, in 2016. Studies on the affected individuals found TA to be associated with allergic rhinitis, ryegrass pollen sensitization, pre-existing asthma, poor adherence to inhaled corticosteroid preventer therapy, hospital admission for asthma in the previous year and outdoor location at the time of the storm. Patients without a prior history of asthma were also affected. These factors are important in extending our understanding of the etiology of TA and associated clinical indicators as well as possible biomarkers which may aid in predicting those at risk and thus those who should be targeted in prevention campaigns. Education on the importance of recognizing asthma symptoms, adherence to asthma treatment and controlling seasonal allergic rhinitis is vital in preventing TA. Consideration of allergen immunotherapy in selected patients may also mitigate risk of future TA. Epidemic TA events are predicted to increase in frequency and severity with climate change, and identifying susceptible patients and preventing poor outcomes is a key research and public health policy priority.

Evaluation of Sub cutaneousRush Immunotherapy Effectiveness in Perennial Allergic Rhinitis after a Year from Treatment

INTRODUCTION

Allergen immunotherapy is an effective treatment for allergic rhinitis. Conventional immunotherapy takes at least 5 to 6 months to reach the maintenance dosage; nonetheless, rush immunotherapy accelerates to reach the maintenance dose several months earlier. However, the safety and efficacy of this treatment has not been widely investigated. The objective of the present study was to determine the efficacy of subcutaneous rush immunotherapy in the patients with perennial allergic rhinitis after a year from treatment.

MATERIALS AND METHODS

This study was carried out on a total of 15 patients with allergic rhinitis who received rush immunotherapy and were evaluated for the quality of life and clinical symptoms improvement with Sino-Nasal Outcome Test Questionnaire (SNOT-22) and Mini Rhino conjunctivitis Quality of Life Questionnaire (RQLQ) before and after a year from treatment. Moreover, specific weed mix Immunoglobulin E (IgE) was measured before and after a year from treatment. Statistical analysis was performed using SPSS software (version 16) (P<0.05).

RESULTS

The comparison of specific IgE indicated a significant reduction between before and after a year from treatment (P=0.005for pigweed)(P=0.022 for salsola). There was a significant decrease in clinical symptoms according to SNOT-22 Questionnaire [(mean score: 46.00, before the treatment) and (mean score: 14.06, after the treatment)]. The quality of life for most of the patients was moderate (46.7%) before the treatment and good (80%) after the treatment, which was considered statistically significant (P>0.001).

CONCLUSION

Rush immunotherapy is an effective treatment in the patients with allergic rhinitis. It seems to be an alternative treatment in cases that need more rapid treatment. However, it is recommended to carry out other studies on the control group.

Association of serum specific IgE levels with asthma in autumn pollen-induced allergic rhinitis: A retrospective analysis

BACKGROUND

Artemisia and Humulus pollen are the two most important aeroallergens of autumn allergies in North China. Cross-sectional data in 2001 have shown that allergic rhinitis often preceded or occurred at the same time as asthma in patients with autumn pollinosis in North China.

OBJECTIVE

We used this cross-sectional data to investigate the association of serum specific IgE (sIgE) levels to Humulus and/or Artemisia pollen with the onset of asthma in patients with autumn pollen-induced allergic rhinitis.

METHODS

1096 patients with autumn pollinosis were face-to-face interviewed and underwent sIgE tests to Artemisia and Humulus. The temporal sequence of allergic rhinitis and asthma was documented. 1013 patients were positive to Artemisia and/or Humulus by sIgE. Multinomial logistic regression and survival analysis were used to examine the potential implication of sIgE levels for the progression of asthma in autumn pollen-induced allergic rhinitis.

RESULTS

Of the 1013 participants with a positive sIgE test to Artemisia and/or Humulus, 563 (55.6%) had a history of allergic rhinitis which preceded or occurred at the same time as asthma. 450 (44.4%) had allergic rhinitis alone. After controlling of sex, age at onset of allergic rhinitis, and parental asthma, the risk of developing asthma increased with the levels of sIgE to both Artemisia and Humulus (p < 0.05). In Kaplan-Meier analysis, IgE classes 5-6 to Humulus or Artemisia increased the risk of asthma development (p < 0.05).

CONCLUSION

Autumn pollen-induced allergic rhinitis often coexists with seasonal asthma. The incidence of asthma is more pronounced when the sIgE level was higher.

Rational Approach to Allergy Testing

Allergy testing is commonly used when symptoms of allergic rhinitis are refractory to symptoms and there is potential for treatment with institution of avoidance measures or immunotherapy. Once the decision for testing has been made, the method of testing by either in vivo skin testing by prick/puncture or intradermal testing or in vitro testing of serum-specific IgE is dictated by factors in the clinical history and an informed decision by the patient. Because there is no perfect testing method, understanding the benefits and limitations of each method is important in selecting the best testing option for each patient.

Determination of Serum IgE and Eosinophils as a Diagnostic Indicator in Allergic Rhinitis

Allergic Rhinitis is a chronic, inflammatory disease induced by an IgE-mediated reaction and identified clinically by the presence of symptoms of nasal discharge, itching, sneezing and nasal congestion. The aim and objectives of the study was to determine serum IgE and eosinophil levels in patients with allergic rhinitis and healthy controls, men and women, different age groups and to establish a correlation between serum IgE and eosinophil. A retrospective study was conducted in the outpatient department of ENT in ICARE institute of medical sciences and research, Haldia during the time span of March 2016 to February 2017. A total of 155 subjects (113 cases and 42 controls, 74 men and 81 women) of age 1 month-75 years were selected for the study. Blood samples obtained were analyzed to determine serum IgE and eosinophil levels and the results were subjected to statistical analysis using STATA 12 software. The mean values and standard deviation of the serum log IgE and eosinophil levels in cases and healthy controls, men and women, various age groups were obtained and tabulated using paired t test and MV test. Pearson's correlation was performed to establish a relationship between serum log IgE and eosinophil levels. The mean values of serum log IgE and eosinophil levels were found to be higher in cases (log IgE-5.65, IgE-814.36 IU/ml, eosinophil-4.49%) when compared to controls (log IgE-4.43, IgE-96.62 IU/ml, eosinophil-2.36%). Men predominance was seen in mean serum log IgE levels (IgE-1018.5 IU/ml, log IgE-5.92) whereas women predominance in mean eosinophil counts (4.96%) in allergic rhinitis. A weakly positive correlation of 0.194 was established between serum log IgE and eosinophil levels. Estimation of serum IgE and eosinophil can serve as a simple, non-invasive and reliable investigative tool in the diagnosis of allergic rhinitis.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Retrospective Study of Clinical Response Predictors in Subcutaneous Allergen Immunotherapy With House Dust Mites for Allergic Rhinitis

Purpose

House dust mites (HDM) are major allergens that cause allergic rhinitis (AR). Allergen-specific subcutaneous immunotherapy (SCIT) has been shown to be clinically beneficial in many clinical trials. Such trials, however, are not reflective of all patient populations. The aim of this study was to describe the efficacy and safety of SCIT in routine clinical practice in Korean adults with AR sensitized to HDM.

Methods

We reviewed medical records of 304 patients with AR treated at an allergy clinic of a tertiary hospital using SCIT with aluminum hydroxide-adsorbed allergen extract targeting HDM alone or with pollens for at least 1 year from 2000 to 2012. Patients with asthma were excluded. Rates of remission, defined as no further requirement of maintenance medication, over time were determined by means of life tables and extension of survival analysis. Specific immunoglobulin E (IgE) levels to HDM were categorized into 6 classes.

Results

The mean time until achieving remission was 4.9±0.1 years, and the cumulative incidence of remission from AR was 76.6%. Severe AR (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.23-0.69; P=0.001), specific IgE levels to HDM ≥17.5 kU/L (OR, 1.85; 95% CI, 1.01-3.37; P=0.045), and duration of immunotherapy ≥3 years (OR, 7.37; 95% CI, 3.50-15.51; P<0.001) were identified as significant predictors of clinical remission during SCIT for patients with AR sensitized to HDM. Overall, 73 patients (24.0%) experienced adverse reactions to SCIT, and only 1 case of anaphylaxis (0.3%) developed.

Conclusions

SCIT with HDM was found to be effective and safe for patients with AR. Specific IgE levels to HDM and a duration of SCIT ≥3 years may be predictors of clinical responses to SCIT in AR patients.