Low Expression of ICAM-1 in Blood Eosinophils in Patients With Active Eosinophilic Esophagitis.

BACKGROUND AND OBJECTIVE: Eosinophilic esophagitis (EoE) is a chronic and isolated inflammation of the esophagus characterized by a marked infiltration of eosinophilic leukocytes. Diagnosis and course of the disease are based exclusively on histopathology. Therefore, patients must undergo several esophageal biopsies, implying a risk associated with the procedure and considerable use of resources. Objective: The presence of active circulating eosinophils, which are quantifiable through the expression of specific cellular activation proteins in their membrane, could be consistent with histopathological findings, which are currently the only valid parameters in studies on EoE. METHODS: The activity of peripheral blood eosinophils from patients with EoE was analyzed by identifying 5 surface molecules (CD69, IL- 5Rα, CD44, ICAM-1, CD63), which are seen to be expressed by the active eosinophils in flow cytometry. The results were compared with the infiltrate of eosinophils present in patients' esophageal biopsies. RESULTS: ICAM-1 levels decreased significantly in patients with active EoE compared with nonactive EoE patients, allergic patients, and healthy controls. In patients with EoE, an inverse correlation was observed between the number of eosinophils in the esophageal biopsy and the percentage of ICAM-1 expression in peripheral blood eosinophils. No differences were observed for the remaining molecules studied. CONCLUSION: Expression of ICAM-1 in blood eosinophils could be a useful noninvasive marker for the diagnosis and assessment of patients with EoE.

Seasonal Local Allergic Rhinitis in Areas With High Concentrations of Grass Pollen.

BACKGROUND: Local allergic rhinitis (LAR) is a phenotype of allergic rhinitis characterized by the presence of a localized immune response in the nasal mucosa of patients with negative skin prick test (SPT) results and undetectable serum specific IgE (sIgE). It unknown whether LAR is limited to areas with low or moderate aeroallergen exposure. OBJECTIVE: To explore the presence of LAR and the clinical and immunological characteristics of this entity in geographic areas with high grass pollen loads. METHODS: A cross-sectional observational study was carried out in 2 hospitals in central Spain (Madrid and Ciudad Real). Sixty-one patients with seasonal rhinitis and negative SPT results and undetectable serum sIgE were evaluated using a clinical questionnaire, determination of serum total IgE, and a nasal allergen provocation test (NAPT) with Phleum species. The response to NAPT was monitored using assessment of nasal symptoms, acoustic rhinometry, and determination of sIgE, tryptase, and eosinophil cationic protein in the nasal cavity. RESULTS: Seasonal LAR was detected in 37 patients (61%) using the techniques described above. Eleven percent of patients with LAR were adolescents or children, and 14% reported onset of rhinitis in childhood. Most patients reported persistent-moderate seasonal nasal symptoms, and 41% reported worsening of the disease during the last 2 years. Conjunctivitis was the most common comorbidity, affecting 95% of cases. CONCLUSIONS: LAR to grass pollen is relevant in patients with seasonal symptoms indicative of allergic rhinitis but with a negative skin test result who live in areas with high allergenic pollen loads. This entity should be included the differential diagnosis of rhinitis.

Is Microarray Analysis Really Useful and Sufficient to Diagnose Nut Allergy in the Mediterranean Area?

BACKGROUND: Component-based diagnosis on multiplex platforms is widely used in food allergy but its clinical performance has not been evaluated in nut allergy. OBJECTIVE: To assess the diagnostic performance of a commercial protein microarray in the determination of specific IgE (sIgE) in peanut, hazelnut, and walnut allergy. METHODS: sIgE was measured in 36 peanut-allergic, 36 hazelnut-allergic, and 44 walnut-allergic patients by ISAC 112, and subsequently, sIgE against available components was determined by ImmunoCAP in patients with negative ISAC results. ImmunoCAP was also used to measure sIgE to Ara h 9, Cora 8, and Jug r 3 in a subgroup of lipid transfer protein (LTP)-sensitized nut-allergic patients (positive skin prick test to LTP-enriched extract). sIgE levels by ImmunoCAP were compared with ISAC ranges. RESULTS: Most peanut-, hazelnut-, and walnut-allergic patients were sensitized to the corresponding nut LTP (Ara h 9, 66.7%; Cor a 8, 80.5%; Jug r 3, 84% respectively). However, ISAC did not detect sIgE in 33.3% of peanut-allergic patients, 13.9% of hazelnut-allergic patients, or 13.6% of walnut-allergic patients. sIgE determination by ImmunoCAP detected sensitization to Ara h 9, Cor a 8, and Jug r 3 in, respectively, 61.5% of peanut-allergic patients, 60% of hazelnut-allergic patients, and 88.3% of walnut-allergic patients with negative ISAC results. In the subgroup of peach LTP-sensitized patients, Ara h 9 sIgE was detected in more cases by ImmunoCAP than by ISAC (94.4% vs 72.2%, P < .05). Similar rates of Cora 8 and Jug r 3 sensitization were detected by both techniques. CONCLUSIONS: The diagnostic performance of ISAC was adequate for hazelnut and walnut allergy but not for peanut allergy. sIgE sensitivity against Ara h 9 in ISAC needs to be improved.

Is the ISAC 112 Microarray Useful in the Diagnosis of Pollinosis in Spain?

BACKGROUND: Multiple sensitization is frequent among pollen-allergic patients. The goal of this study was to determine the diagnostic accuracy of the ImmunoCAP ISAC 112 (ISAC112) microarray in allergy to pollen from several taxa and its clinical utility in a Spanish population. METHODS: Specific IgE was determined in 390 pollen-allergic patients using the ISAC112 microarray. Diagnostic accuracy (sensitivity, specificity, predictive values, and area under the ROC curve) was calculated for the diagnosis of allergy to pollen from grass (n=49), cypress (n=75), olive tree (n=33), plane tree (n=63), and pellitory of the wall (n=17) and compared with that of the singleplex ImmunoCAP immunoassay. RESULTS: The sensitivity of the ISAC112 microarray ranged from 68.2% for allergy to plane tree pollen to 93.9% for allergy to grass pollen. The specificity was >90%. The AUC for the diagnosis of allergy to plane tree pollen was 0.798, whereas the AUC for the remaining cases was ≥0.876. The accuracy of ISAC112 was higher than that of ImmunoCAP for plane tree pollen and similar for the remaining pollens. The frequency of sensitization to most species-specific allergenic components and profilins varied between the different geographical regions studied. A total of 73% of pollen-allergic patients were sensitized to species-specific components of more than 1 pollen type. CONCLUSIONS: The ISAC112 microarray is an accurate tool for the diagnosis of allergy to pollen from grass, cypress, olive tree, plane tree, and pellitory of the wall. The features of the ISAC112 microarray are similar or superior (in the case of plane tree pollen) to those of ImmunoCAP. This microarray is particularly useful for the etiologic diagnosis of pollinosis in patients sensitized to multiple pollen species whose pollination periods overlap.

Component-resolved diagnosis in vespid venom-allergic individuals.

BACKGROUND: Hymenoptera venom-allergic patients frequently present multiple sensitisations. OBJECTIVES: To define the allergic profile by components in wasp allergic patients. To study the usefulness of specific IgE to components in cases of double sensitisation. MATERIALS AND METHODS: Wasp allergic patients who needed Polistes and/or Vespula venom immunotherapy were included. Before immunotherapy and after two years of treatment the following specific IgE (sIgE) levels were measured: Apis mellifera, Vespula spp. Polistes spp., rVes v 5, rPol d 5, nVes v 5, nPol d 5, nVes v 1, nPol d 1, nApi m 1, nApi m 2 and peroxidase. Skin tests with venoms were performed. Based on the sIgE and the skin test results, Polistes and/or Vespula immunotherapy was administered. RESULTS: Thirteen patients were included. Double sensitisation to Polistes/Vespula was detected in eight patients. Sensitisation to rVes v 5 and rPol d 5 was found in two of eight cases, to nVes v 1 and nPol d 1 in eight of 13 cases, and to nVes v 5 and nPol d 5 in 2 of 13 cases. Three patients received double immunotherapy with both wasps. One patient was treated with Vespula and nine with Polistes. sIgE levels decreased after two years of treatment. In patients who showed double sensitisation but were treated with only one venom, sIgE to both venoms decreased. CONCLUSIONS: Components analysis can be useful to study double positivity. In case of doubt, double immunotherapy should be administered. Phospholipase was found to be a major allergen in our population.

Efficacy of IgE-targeted vs empiric six-food elimination diets for adult eosinophilic oesophagitis.

BACKGROUND: Skin testing-guided elimination diet has proved unsuccessful for adult eosinophilic oesophagitis (EoE), whereas empiric six-food elimination diet (SFED) achieves an efficacy of 70%. OBJECTIVE: To compare the efficacy of food-specific serum IgE-targeted elimination diet (sIgE-ED) and SFED. METHODS: Prospective study in adult patients with EoE. Food-specific serum IgE, skin prick test (SPT) and atopy patch test (APT) to foods included in SFED were performed. Those with ≥1 positive IgE test, defined by ≥0.1 kU/l, followed a 6-week sIgE-ED, whereas non-IgE-sensitized patients underwent a 6-week SFED. Responders to diet (<15 eos/HPF) underwent individual reintroduction of foods followed by histological assessment. RESULTS: Forty-three EoE patients were included (26 sIgE-ED and 17 SFED). Regarding sIgE-ED, the mean number of eliminated foods per patient was significantly lower than in SFED (3.81 vs 6; P < 0.001), being wheat (85%), nuts (73%) and cow's milk (61%) the most commonly foods withdrawn. No difference in histological response was observed between sIgE-ED and SFED (73% vs 53%, P = 0.17). Causative foods identified by food challenge were cow's milk (64%), wheat (28%), egg (21%) and legumes (7%), with a single food trigger in 71% of patients. sIgE exhibited the higher accuracy to predict offending foods in IgE-sensitized patients (sensitivity 87.5%, specificity 68% (κ = 0.43)), with k values of 1 for cow's milk. APT results were all negative. CONCLUSIONS: Histological remission was accomplished in 73% of patients undergoing sIgE-ED, which was nonsignificantly superior to SFED. sIgE effectively identified cow's milk as a food trigger in IgE-sensitized patients.

Molecular characterization of contact urticaria in patients with melon allergy.

BACKGROUND: The relevance of contact allergy to plant-related food has recently emerged. Oral allergy syndrome is one of the most characteristic symptoms of fruit allergy, although it also causes systemic reactions. Plant-food allergy is increasing at the same time as pollen allergy, and fruit-induced allergic contact urticaria could be rising as well. OBJECTIVES: The present study was carried out in order to investigate whether one particular primary melon-peel allergen is responsible for contact urticaria. METHODS: Fourteen patients presenting with contact urticaria after touching melon peel were evaluated. A melon-peel extract was prepared and analysed by immunoblotting using the patients' sera. Molecular characterization of IgE-binding bands was performed using mass spectrometry. Melon-peel lipid transfer protein (LTP) was purified. Inhibition studies and contact challenge with the protein were performed to confirm IgE reactivity to the purified allergen. RESULTS: An IgE-binding band of ~8-9 kDa was observed in an immunoblotting assay with all the patients' sera and was identified as an LTP. The melon-peel LTP was purified in two chromatography steps. Inhibition studies confirmed LTP as a major allergen in patients with melon-peel contact urticaria. Contact challenge with melon-peel LTP was performed in five patients, all of whom had positive results, exhibiting itchy erythema and hives in the area of contact. CONCLUSIONS: This study confirmed our previous findings that melon-peel LTP is a major allergen and is responsible for contact allergy. This knowledge may be used to improve both diagnosis and treatment of patients allergic to melon.

Immunotherapy reduces CD40L expression and modifies cytokine production in the CD4 cells of pollen allergy patients.

BACKGROUND: Allergen-specific immunotherapy (SIT) is the only intervention for IgE-mediated respiratory disorders. OBJECTIVE: The aim of the study was to investigate the immunological modifications induced by SIT in patients allergic to olive and/or grass pollen by attempting to establish an association between these modifications and clinical improvements. METHODS: We studied 29 patients who were allergic to olive and/or grass pollen. Patients were randomized to 2 groups: an active treatment group, comprising 19 allergic patients who received SIT, and a control group, formed by 10 allergic patients who received pharmacological treatment for their allergic symptoms but not immunotherapy. We used flow cytometry to analyze intracellular expression of the cytokines IL-4, IFN-gamma, IL-10, and TGF-beta1 in CD4+ T cells, as well as expression of Foxp3, the costimulatory CTLA-4 molecule, and the non-costimulatory CD40L molecule. To assess clinical changes, patients recorded their medication consumption, symptoms, and the limitation of daily activities using diary cards and quality of life questionnaires. RESULTS: Six months after initiation of SIT, we recorded a reduction in cell surface CD40L expression in the CD4+ T-cell population and a shift in the cytokine production profile (decrease in IL-4-producing CD4+ T cells and increase in IFN-gamma, IL-10, and TGF-beta1). These changes persisted after 12 months. Simultaneously, a clinical improvement was observed. CONCLUSIONS: SIT-induced clinical improvement is the result of immunological modifications such as a reduction in CD40L expression on CD4 cells and alteration in the cytokine production profile.

Demographic, clinical and allergological characteristics of Eosinophilic Esophagitis in a Spanish central region.

BACKGROUND: Eosinophilic esophagitis (EoE) is a chronic inflammatory emerging disease of the oesophagus with immunoallergic aetiology. The allergens involved have not been clearly defined and may depend on the exposure of the population to aeroallergens or food antigens. MATERIALS AND METHODS: Patients diagnosed with EoE between 2006 and 2011 were referred to our Allergy Section. Patch and skin prick tests (SPT) with aeroallergens and foods were performed, and total and specific IgE levels, eosinophil cationic protein levels and eosinophil count were determined. RESULTS: 43 patients were included. 36 (83.7%) were atopic. 29 patients presented choking, 19 dysphagia, 9 food impaction with urgent endoscopy, 4 chest pain, 1 isolated vomiting and 1 epigastric pain. 22 had two or more symptoms. The mean duration of symptoms was 3.73 years. Concomitant allergic diseases included rhinoconjunctivitis and/or asthma (31 patients), IgE food allergy (21 patients) and atopic dermatitis (3 patients). 32 (74%) were sensitized to aeroallergens, of which 90% were sensitized to pollens; 23 (54%) showed positive tests to foods and 12 of them (52%) to lipid transfer proteins (LTP). Of the 29 pollen-allergic patients, 15 (52%) were sensitized to plant foods and 10 (34.4%) to LTP. CONCLUSIONS: Our findings support those reported in the literature: the disease is more common in men aged 30-40 years with at least a three-year history of symptoms of esophageal dysfunction, sensitized to pollens, the predominant aeroallergen in our area, but also to plant foods or panallergens. These results increase the evidence for an immunoallergic aetiology and can help us in the early diagnosis of EoE.

Correlation between Alt a 1 levels and clinical symptoms in Alternaria alternata-monosensitized patients.

BACKGROUND: Alternaria alternata is a risk factor for developing asthma.Alt a 1, which has been described as the major allergen in A alternata, shows a good correlation with A alternata spores only when they have germinated. OBJECTIVES: The objective of this study was to determine the correlation between spore counts and clinical symptoms in patients with allergic asthma and/or rhinitis monosensitized to A alternata. METHODS: Two types of samplers were used to determine exposure: a Burkard spore trap to collect A alternata spores and a high-volume air sampler to collect airborne particles. A total of 366 air filters were collected. Alt a 1 levels were measured by monoclonal antibody-based enzyme-linked immunosorbent assay. Eighteen monosensitized patients were asked to record their daily symptoms throughout the year. RESULTS: A alternata spores were detected throughout the year, whereas Alt a 1 was detected only between March and December. Symptoms showed positive and significant correlations with spore counts (r=0.459, P<.001), and Alt a 1 levels (r=0.294, P<.001). The correlation between spores and Alt a 1 was low. The negative binomial model proved that an increase of 10 pg/m3 in Alt a 1 levels increased the number of symptoms at a 3-day lag by 5%. CONCLUSIONS: In patients who are allergic to A alternata, Alt a 1 levels can be considered an important marker for predicting the risk of respiratory symptoms.

Oral rush desensitization to egg: efficacy and safety.

BACKGROUND: Current management of egg allergy relies on egg elimination from the diet. It does not protect patients from reactions after accidental ingestion of the food and it has a negative influence on quality of life. To solve these problems, some desensitization protocols have been described that are safe and effective, but only one study of a rush regimen for egg with a small patient sample has been published. OBJECTIVE: To evaluate the safety, efficacy and immunologic effects of an oral rush desensitization protocol for immediate egg allergy. METHODS: Subjects aged 5 years or older with symptomatic IgE-mediated allergy to hen's egg underwent a 5-day oral tolerance induction regimen and were subsequently maintained on a regular egg intake. The variables studied were the reactions that occurred during the induction regimen and follow-up and the duration of desensitization. Prick test weal size and egg white-specific IgE and IgG concentrations were monitored. RESULTS: Twenty-three patients between 5 and 17 years of age entered the protocol. Twenty (86.9%) achieved the daily intake of a whole cooked egg, 14 of them within the scheduled 5 days. One abandoned the protocol and two were changed to a slower regimen because of repeated reactions. Allergic reactions were frequent but in general were mild. No severe reactions occurred. During follow-up of at least 6 months, egg was well tolerated by all patients. Compared with baseline, skin prick test weal size and egg white-sIgE levels had fallen at 3 months, although the differences were only significant at 6 months. CONCLUSIONS AND CLINICAL RELEVANCE: The rush protocol described is useful and safe for achieving tolerance to egg within a few days but it should always be performed in a highly supervised setting. A high proportion of patients allergic to egg can effectively be desensitized using the described schedule, with the advantage of shortening the time to become protected from reactions after inadvertent ingestion of egg, with no increase in the risk compared with the earlier reported slower protocols.

Grass pollen, aeroallergens, and clinical symptoms in Ciudad Real, Spain.

BACKGROUND: In allergic individuals, onset of symptoms is related to atmospheric pollen grain counts and aeroallergen concentrations. However, this relationship is not always clear. OBJECTIVES: To analyze the correlation between grass pollen grain and aeroallergen concentrations in Ciudad Real, Spain, during the year 2004 and establish their association with symptoms in patients with allergic asthma, rhinitis, or both. METHODS: Two different samplers were used to assess allergen exposure: a Burkard spore trap to collect pollen grains and a high-volume air sampler to collect airborne particles. Individual filters were extracted daily in phosphate-buffered serum and analyzed by enzyme-linked immunosorbent assay based on serum containing high titers of specific immunoglobulin (Ig) E to grasses. The study population comprised 27 grass-allergic patients whose symptoms and medication were recorded daily. RESULTS: Grass pollens were detected between April 28 and July 18. There was a positive correlation between pollen grain counts and symptoms (r = 0.62; P > .001). Grass aeroallergens were detected not only during the grass pollination period, but also before and after this period. There was also a very significant correlation between aeroallergen levels and symptoms (r = 0.76; P < .0001). The threshold level for grass pollen was 35 grains/m3. CONCLUSIONS: Grass-related allergenic activity is present throughout the year, demonstrating the existence of aeroallergens outside the pollen season. Symptoms in allergic patients may be related to airborne particle concentrations. This fact should be taken into account in the clinical follow-up and management of allergic patients.

Involvement of lipid transfer proteins in saffron hypersensitivity: molecular cloning of the potential allergens.

BACKGROUND: Lipid transfer proteins (LTPs) are relevant allergens, and have recently been proposed as model plant allergens from fruit, vegetables, seeds, and pollens. However, no LTP spice allergen has been characterized to date. OBJECTIVES: To identify and isolate saffron LTPs and to explore their relevance in saffron allergy. METHODS: Six patients with rhinitis and positive skin prick test (SPT) results to saffron extract were selected. Two recombinant LTPs from saffron were isolated, cloned into pPIC9 plasmid, and produced in Pichia pastoris. Immunoglobulin (Ig) E immunodetection and enzyme-linked immunosorbent assays were performed with the 2 purified allergens and with the major peach allergen Pru p 3. RESULTS: Full cDNA corresponding to 2 saffron LTP variants was isolated and expressed in P pastoris. The molecular weight of rCro s 3.01 and rCro s 3.02 was 9.15 kDa and 9.55 kDa, respectively. The sequences obtained had a 47% identity with each other and 51% and 43% with Pru p 3. Both proteins were recognized by anti-Pru p 3 antibodies. Specific IgE to the purified allergens was found in 50% of patients for rCro s 3.01 and 33% for rCro s 3.02 and Pru p 3 in the saffron-allergic patients. CONCLUSIONS: Our results indicated that rCro s 3.01 and rCro s 3.02 are minor allergens of saffron, at least in the study patients. To our knowledge, this is the first report on the implication of LTPs in spice allergy.