Developmental immunotoxicity of ethanol in an extended one-generation reproductive toxicity study.

The susceptibility of developing immune system to chemical disruption warrants the assessment of immune parameters in reproductive and developmental testing protocols. In this study, a wide range of immune endpoints was included in an extended one-generation reproduction toxicity study (EOGRTS) design to determine the relative sensitivity of immune and developmental parameters to ethanol (EtOH), a well-known developmental toxicant with immunomodulatory properties. Adult Wistar rats were exposed to EtOH via drinking water (0, 1.5, 4, 6.5, 9, 11.5 and 14 % (w/v EtOH)) during premating, mating, gestation and lactation and continuation of exposure of the F(1) from weaning until killed. Immune assessments were performed at postnatal days (PNDs) 21, 42 and 70. Keyhole limpet hemocyanin (KLH)-specific immune responses were evaluated following subcutaneous immunizations on PNDs 21 and 35. EtOH exposure affected innate as well as adaptive immune responses. The most sensitive immune parameters included white blood cell subpopulations, ConA-stimulated splenocyte proliferation, LPS-induced NO and TNF-α production by adherent splenocytes and KLH-specific immune responses. Most parameters showed recovery after cessation of EtOH exposure after weaning in the 14 % exposure group. However, effects on LPS-induced NO and TNF-α production by adherent splenocytes and KLH-specific parameters persisted until PND 70. The results demonstrate the relative sensitivity to EtOH of especially functional immune parameters and confirm the added value of immune parameters in the EOGRTS. Furthermore, this study identified an expanded KLH-specific parameter set and LPS-induced NO and TNF-α production by adherent splenocytes as valuable parameters that can provide additional information on functional immune effects.

Nasal passages of Göttingen minipigs from the neonatal period to young adult.

Histopathological examination of the nasal passages requires a standardized approach for recording lesion distribution patterns. Nasal diagrams provide guidance to map the lesions. Information on lesions exists for rodents, dogs, and monkeys, which all have been used in inhalation studies. Recently, minipigs have garnered interest as an inhalation model because minipigs resemble humans in many features of anatomy, physiology, and biochemistry and may be a good alternative to monkeys and dogs. The present work explored the microanatomy and histology of the nasal passages of Göttingen minipigs from postnatal day 1 until 6 months of age. Six nasal levels were selected, which allow examination of the squamous, transitional (nonciliated) and ciliated respiratory, and olfactory epithelia; the nasopharynx; and relevant structures such as the vomeronasal organ, olfactory bulb, and nasal/nasopharynx-associated lymphoid tissue.

A search for biomarkers as diagnostic tools for food allergy: a pilot study in peanut-allergic patients.

BACKGROUND: The impact of peanut allergy is large and accidental ingestion of peanut can lead to severe reactions. Currently used diagnostic tests, such as skin prick tests (SPT) and determination of specific immunoglobulins (IgE) have, however, limited sensitivity and specificity. Therefore, new tools have to be developed to improve the accuracy of the diagnostic work-up of food-allergic patients. Comprehensive metabolite analysis may provide biomarkers for diagnosing food allergy as metabolite levels reflect actual physiological conditions. We investigated whether metabolites can be found that discriminate between peanut-allergic patients and non-peanut-allergic subjects. Such metabolites may be used for future diagnostic purposes. METHODS: Plasma and saliva samples were obtained from 23 participants (12 peanut allergic and 11 peanut tolerant) prior to and after a peanut challenge and measured with (1)H nuclear magnetic resonance (NMR) spectroscopy with subsequent multivariate data analysis. RESULTS: Clear differences were observed between NMR spectra of peanut-allergic and peanut-tolerant subjects in plasma as well as saliva. Allergic patients already showed aberrant metabolite levels prior to peanut ingestion, thus before the onset of allergic reactions. CONCLUSION: This pilot study shows that aberrant metabolite levels as determined by NMR in combination with multivariate statistics may serve as novel biomarkers for food allergy.

Integration of efficacy, pharmacokinetic and safety assessment of interleukin-1 receptor antagonist in a preclinical model of arthritis.

Pharmacokinetic properties and safety profile of a drug are likely influenced by the disease state of a patient. In this study, we investigated the influence of arthritic processes on pharmacokinetics and immunotoxicity of interleukin-1 receptor antagonist (Anakinra) in the rat adjuvant arthritis model. Anakinra dose-dependently suppressed joint inflammation and degradation as demonstrated by reduced clinical arthritis score, paw thickness, synovial infiltration and bone degradation. In addition, plasma levels of chemokines MCP-1 and GRO/KC were reduced. Pharmacokinetic behaviour of Anakinra was influenced by disease state of the rats as judged from a decrease in C(max) and an increase of the MRT as the disease progressed at a dose of 24 and 72 mg Anakinra/kg body weight. The pharmacokinetic parameters increased dose-dependently, but non-proportionally with increasing dose. Low level anti-Anakinra antibody formation was observed at prolonged exposure to the biologic. Safety parameters, including haematology, splenic lymphocyte subset analysis, ex vivo stimulation of spleen cells and histopathology of immune system organs were affected by the disease itself to such extent that no additional effects of Anakinra could be observed. In conclusion, we demonstrated that pharmacokinetic behaviour of Anakinra was influenced by the arthritis background of the rats resulting in decreased internal exposure.

Lactobacillus casei Shirota does not decrease the food allergic response to peanut extract in Brown Norway rats.

Probiotics are claimed to beneficially affect the immune system and their involvement in allergy prevention is being investigated extensively. However, the efficacy of probiotics in allergy prevention remains controversial. We investigated whether the probiotic Lactobacillus casei Shirota (LcS) could modulate the food allergic response against peanut extract (PE) in Brown Norway (BN) rats. For this purpose BN rats were sensitized to PE (0, 1 and 10 mg/(rat d)) by daily oral gavage and the LcS-groups were additionally orally dosed with 1 x 10(9) colony forming units LcS/(rat d). LcS administration had minor effects in animals that were not sensitized. LcS increased Th1-(PE-specific IgG1), whereas the Th1/Th2 ratio based on PE-specific IgG1/PE-specific IgG2a shifted towards Th2 dominance in rats sensitized to PE in the presence of LcS as compared to rats that were sensitized to PE only. LcS stimulated PE-specific IgG2a; but for PE-specific IgE the effect was less clear; whereas there was no overall effect, two rats did not show detectable specific IgE antibodies, whereas the remainder showed significantly increased levels. LcS also resulted in increased numbers of basophilic granulocytes in blood. Furthermore, LcS increased levels of both Th1-(IFN-gamma) and Th2-(IL-4) related cytokines in PE stimulated spleen and mesenteric lymph node (MLN) cells, but predominantly IL-4 levels in the supernatants of both spleens and MLNs. Our study does not support the hypothesis that LcS down-regulates food allergic responses in a BN rat model for food allergy to peanut.

Bis(tributyltin)oxide (TBTO) decreases the food allergic response against peanut and ovalbumin in Brown Norway rats.

Other factors than the allergen itself may be of importance in the development of food allergy. This report describes the influence of the immunosuppressive compound bis(tributyltin)oxide (TBTO), present in the food chain, on the development of food allergy to peanut or ovalbumin in Brown Norway (BN) rats. To study these effects BN rats were sensitized to either 1 or 10mg peanut or ovalbumin by daily oral gavage and the TBTO-groups were fed a diet containing 80 mg TBTO per kg diet. Co-exposure to TBTO not only resulted in decreased general immunologic parameters such as weights of mesenteric lymph nodes and Peyer's patches, lymphocyte proliferation rates in splenocytes, but also on allergic parameters. In the peanut allergen-model TBTO decreased allergen-specific Th2 cytokine production by spleen cells, number of eosinophilic and basophilic granulocytes in the blood and production of mast cell protease II after oral food challenge. In the ovalbumin allergen-model TBTO decreased the number of eosinophilic and basophilic granulocytes, allergen-specific IgE and production of mast cell protease II after oral food challenge. The data imply that in the process of risk assessment of food allergy attention should be given to immunomodulating compounds present in the diet.

Recent advances using rodent models for predicting human allergenicity.

The potential allergenicity of newly introduced proteins in genetically engineered foods has become an important safety evaluation issue. However, to evaluate the potential allergenicity and the potency of new proteins in our food, there are still no widely accepted and reliable test systems. The best-known allergy assessment proposal for foods derived from genetically engineered plants was the careful stepwise process presented in the so-called ILSI/IFBC decision tree. A revision of this decision tree strategy was proposed by a FAO/WHO expert consultation. As prediction of the sensitizing potential of the novel introduced protein based on animal testing was considered to be very important, animal models were introduced as one of the new test items, despite the fact that non of the currently studied models has been widely accepted and validated yet. In this paper, recent results are summarized of promising models developed in rat and mouse.

Reversible denaturation of Brazil nut 2S albumin (Ber e1) and implication of structural destabilization on digestion by pepsin.

The high resistance of Brazil nut 2S albumin, previously identified as an allergen, against proteolysis by pepsin was examined in this work. Although the denaturation temperature of this protein exceeds the 110 degrees C at neutral pH, at low pH a fully reversible thermal denaturation was observed at approximately 82 degrees C. The poor digestibility of the protein by pepsin illustrates the tight globular packing. Chemical processing (i.e., subsequent reduction and alkylation of the protein) was used to destabilize the globular fold. Far-UV circular dichroism and infrared spectroscopy showed that the reduced and alkylated form had lost its beta-structures, whereas the alpha-helix content was conserved. The free energy of stabilization of the globular fold of the processed protein as assessed by a guanidine titration study was only 30-40% of that of the native form. Size exclusion chromatography indicated that the heavy chain lost its globular character once separated from the native 2S albumin. The consequences of these changes in structural stability for degradation by pepsin were analyzed using gel electrophoresis and mass spectrometry. Whereas native 2S albumin was digested slowly in 1 h, the reduced and alkylated protein was digested completely within 30 s. These results are discussed in view of the potential allergenicity of Brazil nut 2S albumin.

Food allergy: what do we learn from animal models?

PURPOSE OF REVIEW: This review summarizes selected articles on animal models of food allergy published in 2003. The research areas that are covered include mechanistic studies, the search for new therapies, as well as screening models for hazard identification of potential allergens. RECENT FINDINGS: Novel treatment options of both prevention and therapeutic strategies have been reported with promising results. The induction of de-sensitization to food proteins was achieved by exposure to a mixture of recombinant food allergens and T helper 1 (Th1)-skewing bacterial components. Furthermore, research in animal models has provided new insights into the role of protein structure, digestion, and gut permeability in sensitization and tolerance induction to food proteins. The Th2 hypothesis of food allergy was tested in mouse strains, linking genetic susceptibility to sensitization with differential Th1-Th2 responses. In this context, the role of the liver in development of food antigen-specific Th2 cells, and the importance of costimulatory molecules in Th2 skewing were demonstrated. Finally, rodent models to predict potential allergenicity of novel foods have been further developed using different routes of sensitization. SUMMARY: Currently, several animal models of food allergy are used, including mouse, rat, swine, and dog. Continuing research in these models may elucidate the immunological mechanisms that underlie the sensitization and challenge phase of food allergy and may result in improved therapeutic options. Furthermore, the development of animal models to predict relative allergenicity of novel foods remains an important topic.

Assessment of the allergic potential of food protein extracts and proteins on oral application using the brown Norway rat model.

The need for widely accepted and validated animal models to test the potential allergenicity and potency of novel (biotechnology-derived) proteins has become an important issue for their safety evaluation. In this article, we summarize the results of the development of an oral sensitization protocol for food proteins in the rat. Young Brown Norway rats were exposed to either various purified allergenic proteins (e.g., ovalbumin, partly purified), a whole food (cow's milk), or total protein extracts (hen's egg white, peanut) by daily gavage dosing during 42 days without the use of an adjuvant. The results showed that Brown Norway rats can be sensitized orally to the various allergenic food proteins tested, resulting in antigen-specific immunoglobulin (Ig) G and IgE responses, without the use of adjuvants. Animals orally exposed to cow's milk or total protein extracts of egg white also developed specific IgE and IgG antibodies that recognized the same proteins compared with antibodies from patients allergic to egg white or cow's milk. We also studied local and systemic immune-mediated effects. In ovalbumin-sensitized rats, some clinical symptoms of food allergy were studied upon an oral challenge with ovalbumin. The results demonstrated that gut permeability was increased and that in some animals breathing frequency and systolic blood pressure were temporarily decreased. The results obtained show that the Brown Norway rat provides a suitable animal model for food allergy research and for the study of relative allergenicity of existing and novel food proteins.

Assessment of protein allergenicity on the basis of immune reactivity: animal models.

Because of the public concern surrounding the issue of the safety of genetically modified organisms, it is critical to have appropriate methodologies to aid investigators in identifying potential hazards associated with consumption of foods produced with these materials. A recent panel of experts convened by the Food and Agriculture Organization and World Health Organization suggested there is scientific evidence that using data from animal studies will contribute important information regarding the allergenicity of foods derived from biotechnology. This view has given further impetus to the development of suitable animal models for allergenicity assessment. This article is a review of what has been achieved and what still has to be accomplished regarding several different animal models. Progress made in the design and evaluation of models in the rat, the mouse, the dog and in swine is reviewed and discussed.

Assessment of protein allergenicity: studies in brown norway rats.

For the safety evaluation of genetically engineered crops, the potential allergenicity of the newly introduced protein(s) has become an important issue. There is, however, no universal and reliable test system for the evaluation of the allergic sensitizing ability of food proteins. Therefore, there is a growing interest in the development of animal models. This paper summarizes the results of a promising food allergy model developed in Brown Norway (BN) rats. The results demonstrate that BN rats can be sensitized via the relevant oral route of exposure. Daily gavage dosing of the animals with several food proteins, without the use of adjuvants, resulted in significant antigen-specific IgE responses. In addition, the profile of allergens recognized by the immune system of the BN rat, appeared comparable to the profile of allergens recognized by allergic humans. Besides oral sensitization, local and systemic immune-mediated effects, such as increased gastrointestinal permeability, decreased breathing frequency, and decreased blood pressure, could also be observed in the sensitized animals after an oral challenge. All together, these observations suggest that this BN rat model might provide a suitable animal model to study the allergenicity of food proteins in humans.

The minipig as an alternative non-rodent model for immunogenicity testing using the TNFα blockers adalimumab and infliximab.

Immunogenicity is a major issue of concern for monoclonal antibodies used in human diseases and is by default mainly determined in non-human primates (NHP), as target molecules are considered most similar in NHP compared to human. In this manuscript the predictive value of immunogenicity testing in minipigs for human safety is evaluated, as the immune system of the pig is functionally similar to that in other mammalian species. Adalimumab and infliximab (both monoclonal antibodies blocking TNFα) were used as model substances. Female Göttingen minipigs (4/group) were treated every other week with low (0.1 mg/kg), mid (1.0 mg/kg), or high dose (5 mg/kg) adalimumab or 5 mg/kg infliximab subcutaneous (SC) over a period of 8 weeks. After first and last dosing, pharmacokinetic analysis was performed. Anti-drug antibodies (ADAs) were measured on several time points. Furthermore, hematology, clinical chemistry, body weight, clinical signs, and histopathology of several organs were evaluated. No signs of toxicity of the treatments were observed in the limited organs and tissues collected. Eleven out of 12 minipigs treated with adalimumab elicited a detectable ADA response. Induction of ADA was correlated with decreased plasma levels of adalimumab. Infliximab clearance was comparable after first and last dose. Therefore, the presence of ADA directed to infliximab was considered highly unlikely. It was concluded that the minipig and NHP showed comparable suitability for immunogenicity prediction in humans. More studies with other biopharmaceutical products are needed to strengthen the status of the minipig as an alternative model for immunotoxicity testing including immunogenicity.

The protein structure determines the sensitizing capacity of Brazil nut 2S albumin (Ber e1) in a rat food allergy model.

: It is not exactly known why certain food proteins are more likely to sensitize. One of the characteristics of most food allergens is that they are stable to the acidic and proteolytic conditions in the digestive tract. This property is thought to be a risk factor in allergic sensitization. The purpose of the present study was to investigate the contribution of the protein structure of 2S albumin (Ber e1), a major allergen from Brazil nut, on the sensitizing capacity in vivo using an oral Brown Norway rat food allergy model. Disulphide bridges of 2S albumin were reduced and alkylated resulting in loss of protein structure and an increased pepsin digestibility in vitro. Both native 2S albumin and reduced/alkylated 2S albumin were administered by daily gavage dosing (0.1 and 1 mg) to Brown Norway rats for 42 days. Intraperitoneal administration was used as a positive control. Sera were analysed by ELISA and passive cutaneous anaphylaxis. Oral exposure to native or reduced/alkylated 2S albumin resulted in specific IgG1 and IgG2a responses whereas only native 2S albumin induced specific IgE in this model, which was confirmed by passive cutaneous anaphylaxis. This study has shown that the disruption of the protein structure of Brazil nut 2S albumin decreased the sensitizing potential in a Brown Norway rat food allergy model, whereas the immunogenicity of 2S albumin remained preserved. This observation may open possibilities for developing immunotherapy for Brazil nut allergy.

The Göttingen minipig® as an alternative non-rodent species for immunogenicity testing: a demonstrator study using the IL-1 receptor antagonist anakinra.

The use of recombinant human proteins for the treatment of several diseases has increased considerably during the last decades. A major safety and efficacy issue of biopharmaceuticals is their potential immunogenicity. To prevent immunogenicity, biotechnology-derived proteins are engineered to be as human-like as possible. Immunogenicity is mainly determined in non-human primates (NHP), as they are considered to be the best predictive animal species for human safety, based on their close relatedness to man. As minipigs are increasingly used in the safety evaluation of (bio)pharmaceuticals, the predictive value of the minipig in immunogenicity testing was evaluated in this study, using anakinra as a model compound. Animals were treated subcutaneously with either placebo, low- (0.5 mg/kg), or high-dose (5 mg/kg) anakinra daily on 29 consecutive days. After the first and last dose, the pharmacokinetic (PK) profile of anakinra was evaluated. Antibodies directed to anakinra were measured on several time points during the treatment period. Furthermore, hematology, clinical chemistry, body weight, clinical signs, and histopathology of several organs were evaluated. No signs of toxicity were observed upon treatment with anakinra. PK parameters were comparable with those found in human and NHP studies performed with anakinra. All animals developed anti-anakinra antibodies. The results obtained in minipigs were comparable to those observed in monkeys. For anakinra, the predictive value of the minipig for immunogenicity testing was found to be comparable to that seen in NHP. However, more studies evaluating additional biopharmaceutical products are needed to support the use of the minipig as an alternative model for (immuno)toxicity testing, including immunogenicity.

Developmental immunotoxicity of di-n-octyltin dichloride (DOTC) in an extended one-generation reproductive toxicity study.

Developmental immunotoxicity assessment is considered ready for inclusion in developmental toxicity studies. Further evaluation of proposed and additional assays is needed to determine their utility in assessing developmental immunotoxicity. In this study, a wide range of immunological parameters was included in an extended one-generation reproductive toxicity protocol. F(0) Wistar rats were exposed to DOTC via the feed (0, 3, 10, and 30mg/kg) during pre-mating, mating, gestation and lactation and subsequently F(1) were exposed from weaning until sacrifice. Immune assessments by several immune parameters were performed at PNDs 21, 42 and 70. The T cell-dependent antibody response to Keyhole Limpet hemocyanin (KLH) was assessed following subcutaneous immunizations with KLH on PNDs 21 and 35 and the delayed-type hypersensitivity response (DTH) against KLH was evaluated at PND 49. No effects were found on PND 21. While effects on lymphocyte subpopulations in the thymus were only observed in the 30mg/kg group on PND 42, effects on lymphocyte subpopulations in the spleen were found in the 30mg/kg group on both PNDs 42 and 70. The DTH response already showed an effect at 3mg/kg and was the overall critical endpoint. The results from this study support the inclusion of splenocyte subpopulation parameters in developmental toxicity studies and identified the DTH response as an important functional parameter.

Developmental immunotoxicity of methylmercury: the relative sensitivity of developmental and immune parameters.

Current developmental and reproductive toxicity protocols include only a limited set of parameters for effects on the developing immune system. In this study, a wide range of immunological parameters were included in a pre- and postnatal developmental toxicity study. Dose-response data were compared to determine the relative sensitivity of different immune and developmental parameters. Mated female Wistar rats were dosed daily by gavage with methylmercury (0, 0.1, 0.4, 0.7, 1.0, 1.5, and 2.0 mg/kg BW/day) from gestational day 6 to postnatal day (PND) 10. In addition to general, reproductive, and developmental parameters, a wide range of immunological parameters were assessed in male offspring at PNDs 21, 42, and 70. The T cell-dependent antibody response to keyhole limpet hemocyanin (KLH) was assessed following sc immunizations on PNDs 21 and 35. Dose-response data were analyzed using the benchmark dose (BMD) approach by fitting dose-response models to the various endpoints. Methylmercury induced effects on developmental parameters, such as growth parameters and pup mortality. Effects on the immune system were found at doses without observed developmental toxicity. Immune effects differed at the three time points and consisted mainly of effects on functional parameters. The parameter with the lowest 5% lower confidence bound of the BMD (BMDL) was the primary KLH-specific IgG antibody response, which showed a dose-dependent decrease with a BMD of 0.039 mg/kg BW/day (CI 0.010-0.12). These data show the relatively high sensitivity of the developing immune system and thereby illustrate the relevance of testing immune parameters in reproductive and developmental toxicity testing protocols.

The importance of dietary control in the development of a peanut allergy model in Brown Norway rats.

This report describes the further development of a peanut allergy model in Brown Norway (BN) rats and in particular the importance of allergen-free breeding of the laboratory animals for the allergen to be used. For this purpose BN rats were bred for 3 generations on soy- and peanut-free feed since it is known that the legumes peanut and soy are cross-reactive. In addition, the effect of cholera toxin (CT), an oral adjuvant often used to increase the sensitivity of food allergy models, was investigated in the BN rat model. BN rats that were bred on both soy- and peanut-free feed could be sensitized orally to peanut (all exposed rats developed peanut-specific IgE, IgG2a and IgG1) and the adjuvant CT could only enhance this sensitization to a limited extent. We also found different protein recognition patterns against purified peanut allergens (Ara h1, Ara h2 and Ara h3) between intraperitoneally (i.p.) and orally sensitized BN rats. Orally sensitized rats recognized all tested allergens whereas i.p. sensitized rats only recognized Ara h1 and Ara h2. Our conclusion is that a model for food allergy should preferably be (A) oral and (B) if possible without the use of adjuvantia. Our model in BN rats unites these preferred characteristics. In addition, we show the importance of dietary control when conducting oral sensitization studies. Special attention must be paid to unscheduled dietary pre-exposure of the animals to the protein under investigation to obtain optimal oral sensitization.

Lupine allergy: not simply cross-reactivity with peanut or soy.

BACKGROUND: Reports of lupine allergy are increasing as its use in food products increases. Lupine allergy might be the consequence of cross-reactivity after sensitization to peanut or other legumes or de novo sensitization. Lupine allergens have not been completely characterized. OBJECTIVES: We sought to identify allergens associated with lupine allergy, evaluate potential cross-reactivity with peanut, and determine eliciting doses (EDs) for lupine allergy by using double-blind, placebo-controlled food challenges. METHODS: Six patients with a history of allergic reactions to lupine flour were evaluated by using skin prick tests, CAP tests, and double-blind, placebo-controlled food challenges. Three of these patients were also allergic to peanut. Lupine allergens were characterized by means of IgE immunoblotting and peptide sequencing. RESULTS: In all 6 patients the ED for lupine flour was 3 mg or less for subjective symptoms and 300 mg or more for objective symptoms. The low ED and moderate-to-severe historical symptoms indicate significant allergenicity of lupine flour. Two patients allergic to lupine but not to peanut displayed IgE binding predominantly to approximately 66-kd proteins and weak binding to 14- and 24-kd proteins, whereas patients with peanut allergy and lupine allergy showed weak binding to lupine proteins of about 14 to 21 or 66 kd. Inhibition of binding was primarily species specific. CONCLUSION: Lupine allergy can occur either separately or together with peanut allergy, as demonstrated by 3 patients who are cosensitized to peanut and lupine. CLINICAL IMPLICATIONS: Lupine flour is allergenic and potentially cross-reactive with peanut allergen, thus posing some risk if used as a replacement for soy flour.

The distribution of individual threshold doses eliciting allergic reactions in a population with peanut allergy.

BACKGROUND: Hidden peanut in consumer products can endanger patients with peanut allergy. Individual threshold doses for eliciting allergic reactions need to be elucidated to assess the risks for development of allergic reactions after accidental ingestion of peanut in a population with peanut allergy. OBJECTIVE: We sought to determine the distribution of individual threshold doses in a population with peanut allergy and to correlate these thresholds to the severity of peanut-induced symptoms. METHODS: Twenty-six adult patients with a convincing history of peanut-related symptoms, a specific IgE level of 0.7 kU/L or greater, or a positive skin prick test response of 2+ or greater to peanut were included. These patients underwent double-blind, placebo-controlled food challenges with increasing doses of peanut. A threshold dose could be established when objective or repetitive subjective reactions occurred after active doses. RESULTS: All patients had subjective oral symptoms (n = 26), prior subjective gastrointestinal symptoms (n = 14), or objective symptoms (n = 5). Reactions started within 30 minutes after ingestion of peanut, but in 2 patients additional symptoms were delayed by 1 to 2 hours. Threshold doses for allergic reactions ranged from a dose as low as 100 microg up to 1 g of peanut protein. Fifty percent of the study population (95% CI, 30%-70%) already had an allergic reaction after ingestion of 3 mg of peanut protein. Patients with severe symptoms had lower threshold doses compared with those of patients with mild symptoms (P =.027). CONCLUSIONS: A substantial part of a population with peanut allergy will react to very low amounts of peanut, requiring accurate declaration of peanut content in consumer products. This is even more important because patients with severe reactions react to lower doses than patients with mild symptoms.