Nasal allergen-neutralizing antibodies correlate closely with tolerated intranasal allergen challenge dose following grass pollen subcutaneous immunotherapy in patients with local allergic rhinitis.

BACKGROUND: Local allergic rhinitis (LAR) is defined by chronic nasal symptoms, absence of atopy, positive nasal allergen challenge (NAC) and a good response to subcutaneous allergen immunotherapy (SCIT). We sought to investigate SCIT capacity to induce local and systemic blocking antibodies in LAR patients. METHODS: A RDBPC study of grass SCIT was performed, with participants receiving either SCIT (Group A; n = 10) or placebo (Group B; n = 14) in the first 6 months. Both groups subsequently received SCIT for 12 months at Year 2. Nasal and serum antibodies (IgG4 , IgA1 and IgA2 ) and their inhibitory capacity were measured at multiple timepoints. RESULTS: The allergen concentration tolerated increased significantly at 6 months (Group A; p = .047) and 24 months (Group B; p = .049) compared with baseline and persisted until the end of the study. Induction of serum sIgA1 to Phl p was seen in Groups A and B, albeit the former being induced earlier (1.71-fold, p = .027). A significant induction in sIgG4 to Phl p 1 and 5 was observed in serum of Group A (p = .047 and p = .0039) and sIgA2 to Phl p in Group B (p = .032 and p = .0098) at 18 and 24 months, respectively. Both local and systemic blocking antibodies can inhibit allergen-IgE complexes binding to CD23 on B cells, and this correlated with level of allergen tolerated intra-nasally in Group A (serum; 𝜌 = -.47, p = .0006, nasal; 𝜌 = -.38, p = .0294). CONCLUSIONS: Grass pollen SCIT induced functional systemic blocking antibodies that correlate with the concentration of allergen tolerated following NAC, highlighting their potential as a biomarker of SCIT in LAR.

Alternaria Allergy and Immunotherapy.

BACKGROUND: Allergen immunotherapy (AIT) is the only known causative treatment for Alternaria allergy, but the difficulty in standardizing Alternaria extracts hampers its effectiveness and safety. SUMMARY: Alternaria, a potent airborne allergen, has a high sensitization rate and is known to trigger the onset and exacerbation of respiratory allergies, even inducing fungal food allergy syndrome in some cases. It can trigger a type 2 inflammatory response, leading to an increase in the secretion of type 2 inflammatory cytokines and eosinophils, which are the culprits behind allergic symptoms. Diagnosing Alternaria allergy is a multistep process, involving a careful examination of clinical symptoms, medical history, skin prick tests, serum-specific IgE detection, or provocation tests. Alt a1, the major component of Alternaria, is a vital player in diagnosing Alternaria allergy through component-resolved diagnosis. Interestingly, Alternaria can reduce the protein activity of other allergens like pollen and cat dander when mixed with them. In order to solve the problems of standardization, efficacy and safety of traditional Alternaria AIT, novel AIT methods targeting Alt a1 and innovative vaccines such as epitope, DNA, and mRNA vaccines seem promising in bypassing the standardization issue of Alternaria extracts. But these studies are in early stages, and most researches are still focused on animal models, calling for more evidence to validate their use in humans. KEY MESSAGES: This review delves into the various aspects of Alternaria allergy, including characteristics, epidemiology, immune mechanisms, diagnosis, clinical manifestations, and the application and limitations of Alternaria AIT, aiming to provide a foundation for the management of patients with Alternaria allergy.

Single-cell RNA sequencing identifies precise tolerogenic cellular and molecular pathways induced by depigmented-polymerized grass pollen allergen extract.

BACKGROUND: Immunologic mechanism of action of allergoids remains poorly understood. Previous models of allergenicity and immunogenicity have yielded suboptimal knowledge of these immunotherapeutic vaccine products. Novel single-cell RNA sequencing technology offers a bridge to this gap in knowledge. OBJECTIVE: We sought to identify the underpinning tolerogenic molecular and cellular mechanisms of depigmented-polymerized Phleum pratense (Phl p) extract. METHODS: The molecular mechanisms underlying native Phl p, depigmented Phl p (DPG-Phl p), and depigmented-polymerized (DPG-POL-Phl p) allergoid were investigated by single-cell RNA sequencing. Allergen-specific TH2A, T follicular helper (Tfh), and IL-10+ regulatory B cells were quantified by flow cytometry in peripheral blood mononuclear cells from 16 grass pollen-allergic and 8 nonatopic control subjects. The ability of Phl p, DPG-Phl p, and DPG-POL-Phl p to elicit FcεRI- and FcεRII-mediated IgE responses was measured by basophil activation test and IgE-facilitated allergen binding assay. RESULTS: Analysis revealed that DPG-POL-Phl p downregulated genes associated with TH2 signaling, induced functional regulatory T cells exhibiting immunosuppressive roles through CD52 and Siglec-10, modulated genes encoding immunoproteasome that dysregulate the processing and presentation of antigens to T cells and promoted a shift from IgE toward an IgA1 and IgG responses. In grass pollen-allergic subjects, DPG-POL-Phl p exhibited reduced capacity to elicit proliferation of TH2A, IL-4+ Tfh and IL-21+ Tfh cells while being the most prominent at inducing IL-10+CD19+CD5hi and IL-10+CD19+CD5hiCD38intCD24int regulatory B-cell subsets compared to Phl p (all P < .05). Furthermore, DPG-POL-Phl p demonstrated a hypoallergenic profile through basophil activation and histamine release compared to Phl p (31.54-fold, P < .001). CONCLUSIONS: Single-cell RNA sequencing provides an in-depth resolution of the mechanisms underlying the tolerogenic profile of DPG-POL-Phl p.

A Survey of Airborne Fungi and Their Sensitization Profile in Wuhan, China.

INTRODUCTION: Airborne fungi induce allergic symptoms in 3-10% of the population worldwide. To better prevent and manage fungi-related allergic diseases, it is essential to identify the genus and the distribution profile of airborne fungi. METHODS: With this purpose in mind, we carried out a 12-month volumetric sampling study to monitor the airborne fungi and retrospectively analyzed the sensitization profile of four dominant fungi (Cladosporium, Alternaria, Aspergillus, and Penicillium) among respiratory allergies during the same study period in Wuhan, China. RESULTS: A total of 29 different fungal genuses were identified, and the peak fungal concentration period was found to be in September and October, followed by May and June. The most prevalent fungi in this area were Cladosporium (36.36%), Ustilago (20.12%), and Alternaria (13.87%). In addition, the skin prick test data from 1,365 respiratory allergies patients showed that 202 (14.80%) of them were sensitized to fungi. The sensitization rates to Cladosporium, Alternaria, Aspergillus, and Penicillium were 11.72%, 4.69%, 1.98%, and 4.76%, respectively. The seasonal fluctuation of Alternaria and Aspergillus correlated with their sensitization rates. Among the fungal sensitized patients, 76 (37.62%) were sensitized to two or more kinds of fungi. The serum-specific IgE tests suggested low to high correlations existed between these fungi; however, these correlations were not found between fungi and other allergens. CONCLUSION: Our study provides the distribution profile and reveals the clinical significance of the airborne fungi in Wuhan, which will facilitate the precise management of fungal allergy.

Diverse immune mechanisms of allergen immunotherapy for allergic rhinitis with and without asthma.

Allergen immunotherapy (AIT) is an effective treatment for allergic rhinitis, inducing long-term clinical tolerance to the sensitizing allergen. Clinical tolerance induction can be achieved when AIT is administered for at least 3 years. AIT is associated with the modulation of innate and adaptive immune systems. This comprises inhibition of IgE-dependent activation of mast cells and basophils in the local target organ, suppression of TH2 cells, immune deviation toward TH1 cells, induction of T and B regulatory cells, and production of allergen-neutralizing antibodies. However, recent developments in their underpinning mechanisms have revealed that AIT, administered subcutaneously or sublingually, induces immune regulation through novel cell targets and molecular mechanisms. This comprehensive review discusses how immune tolerance driven by subcutaneous immunotherapy and sublingual immunotherapy is associated with the induction of a novel regulatory subset of innate lymphoid cells and suppression of proinflammatory TH2, allergen-specific TH2 (TH2A), and T follicular helper cells. Moreover, they are associated with exhaustion of TH2A cells and differential expression of nasal and systemic IgA antibodies. Uncovering the underpinning mechanisms of a successful AIT and immune tolerance induction will allow the development of targeted therapeutics for allergic rhinitis with and without asthma.

Anxiety and depression in allergic rhinitis patients during COVID-19 pandemic in Wuhan, China.

BACKGROUND: During COVID-19 pandemic, many allergic rhinitis (AR) patients stopped their treatment including pharmacotherapy and allergen immunotherapy. OBJECTIVE: This study aimed to investigate the anxiety and depression and general effect of COVID-19 pandemic on AR patients' psychological status in Wuhan, China. METHODS: In October 2019, 222 outpatients suffering from AR in our department and 133 healthy controls were enrolled. All participants were asked to finish the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) questionnaire. The demographic characteristics and the severity of AR symptoms were recorded. In April 2020, the AR patients and healthy controls were re-contacted to finish the questionnaires by telephone or online. The SAS and SDS scores in AR patients and healthy controls and the correlation with other variables were analyzed. RESULTS: For AR patients, the SAS and SDS scores were significantly higher than healthy controls. Meanwhile, the rates of anxiety and depression were 24.8% and 19.4% respectively. The education level and symptoms severity were correlated with SAS and SDS scores. Ninety-eight AR patients and 56 healthy controls finished the questionnaires after COVID-19 pandemic. The AR patients' SAS and SDS scores were lower than before COVID-19 pandemic and were correlated with AR symptom scores. The scores of healthy controls were not different with before COVID-19 pandemic. CONCLUSIONS: The occurrence of anxiety and depression is common in AR patients. Severity of symptoms and low education level are the risk factors causing anxiety and depression. COVID-19 pandemic has no significant negative impact on the AR patients' psychological status.

IgE and IgG4 Repertoire in Asymptomatic HDM-Sensitized and HDM-Induced Allergic Rhinitis Patients.

INTRODUCTION: Asymptomatic sensitization is defined as the presence of positive skin prick test (SPT) and/or positive serum allergen-specific IgE in the absence of clinical allergic symptoms. Currently, there is no convincing explanation why some people with positive allergen tests do not show symptoms. We aimed to investigate the house dust mite (HDM)-specific IgE and IgG4 repertoire in asymptomatic HDM-sensitized subjects and HDM-induced allergic rhinitis (AR) patients. METHODS: A total of 48 subjects sensitized to HDM were included in this study: 27 had AR with/without asthma (symptomatic group), and 21 had no allergic symptoms (asymptomatic group). Six healthy individuals served as control group. Peripheral blood samples were collected for serum IgE and IgG4 assay and basophil activation tests (BATs). IgE and IgG4 assay included antibodies to Dermatophagoides (Der) p1, 2, 7, 10, 21, 23, and Der f1, 2. RESULTS: AR patients had a larger wheal diameter of SPT (7.0 vs. 3.0 mm, p < 0.0001) and a higher specific IgE to Der p (15.50 vs. 0.70 KU/L, p < 0.0001) than asymptomatic subjects. They also showed more frequent sensitization to Der p1 and Der p2 (both p < 0.05). However, the total IgE and specific IgG4 did not differ significantly between the 2 groups. The basophil activation response after being stimulated with HDM was observed to be higher in AR patients (all p < 0.05). CONCLUSIONS: There are differences in SPT, serum-specific IgE to Der p, component allergen Der p1 and Der p2 level and BAT between AR patients and asymptomatic subjects sensitized to HDM. IgG4 alone cannot differentiate asymptomatic individuals from AR patients.

Alternaria B Cell Mimotope Immunotherapy Alleviates Allergic Responses in a Mouse Model.

Alternaria is a major outdoor allergen. Immunotherapy with Alternaria extracts has been documented to be effective in the sensitized patients. However, Alternaria extracts are notoriously difficult to standardize. Our aim is to screen the B cell mimotopes of Alternaria and to evaluate the therapeutic effects of B cell mimotope peptides on a BALB/c mouse model of Alternaria allergy. After a human sera pool from Alternaria monosensitized patients was established, B cell mimotopes were screened by a phage-displayed random heptamer peptide library that was identified via mixed Alternaria-specific IgE in the sera pool. B cell mimotopes with phage as a carrier were used to perform immunotherapy in an Alternaria allergy mouse model. Serological Ab levels, lung histology, and cytokine profiles were compared in the mimotope immunotherapy group, natural extract immunotherapy group, irrelevant phage control group, Alternaria-sensitized model group, and saline-blank group. Two mimotopes (MISTSRK and QKRNTIT) presented high binding ability with the sera of the Alternaria-allergic patients and mice and, therefore, were selected for immunotherapy in the mouse model. Compared with irrelevant phage control, model, and natural extract immunotherapy group, mimotope immunotherapy group significantly reduced serum IgE levels, inflammatory cells infiltration in the lung tissue, and IL-4 levels in bronchoalveolar lavage fluid, whereas serum IgG1 and IFN-γ levels in bronchoalveolar lavage fluid were increased. Our results indicate that B cell mimotopes of Alternaria alleviates allergic response in a mouse model and have potential as novel therapeutic agents for IgE-mediated Alternaria-allergic diseases.

CD23 expression on switched memory B cells bridges T-B cell interaction in allergic rhinitis.

BACKGROUND: The contribution of B-cell subsets and T-B cell interaction to the pathogenesis of allergic rhinitis (AR) and mechanisms of allergen immunotherapy (AIT) remain poorly understood. This study aimed to outline circulating B-cell signature, the underlying mechanism, and its association with clinical response to AIT in patients with AR. METHODS: IgD/CD27 and CD24/CD38 core gating systems were used to determine frequencies and phenotypes of B cells. Correlations between B cells, T cells, antigen-specific IgE, and disease severity in AR patients were investigated. Switched memory B cells were co-cultured with type 2 follicular helper T (Tfh2) cells and follicular regulatory T (Tfr) cells. Associations between B-cell subsets and clinical benefits of AIT were analyzed. RESULTS: Frequencies and absolute numbers of circulating memory B cells were increased in AR patients. CD23 expression on CD19+ CD20+ CD27+ IgD- switched memory B cells was significantly enhanced and positively correlated with antigen-specific IgE levels, symptom scores, and Tfh2/Tfr cell ratio in AR patients. Compared with those from healthy controls, Tfh2 cells from AR patients had a greater capacity to induce CD23 expression on switched memory B cells via IL-4, which was unable to be sufficiently suppressed by AR-associated Tfr cells with defective IL-10 expression. CD23 expression on switched memory B cells was downregulated after 12-month AIT, which positively associated with disease remission in AR patients. CONCLUSION: T-B cell interaction, bridged by CD23 expression particularly on switched memory B cells, may be involved in the disease pathogenesis and mechanism of AIT in patients with AR.

Allergen immunotherapy improves defective follicular regulatory T cells in patients with allergic rhinitis.

BACKGROUND: The function of follicular regulatory T (TFR) cells, especially in regulating IgE production in patients with allergic diseases, is poorly understood. OBJECTIVE: We sought to investigate the phenotype, function, and clinical relevance of TFR cells in patients with allergic rhinitis (AR). METHODS: The phenotype and frequency of tonsillar and circulating TFR cells were characterized by using flow cytometry. TFR cell function was examined in an assay by coculturing with follicular helper T cells and B cells. The associations between TFR cells and the clinical features in patients with AR before and after allergen immunotherapy (AIT) were analyzed. RESULTS: TFR cells were detected in germinal centers of tonsils, but compared with subjects without AR, the frequencies decreased in patients with AR who were allergic to house dust mites. Circulating TFR cells in blood were phenotypically and numerically correlated with tonsillar TFR cells, and a reduction of circulating TFR cells but not total or CXCR5- regulatory T cells was noted in patients with AR compared with healthy control subjects. Moreover, circulating TFR cells in patients with AR showed a specific defect in suppressing IgE production but were capable of suppressing production of other immunoglobulin types. We identified negative associations of circulating TFR cell frequencies and function with antigen-specific IgE levels or disease severity in patients with AR. After AIT, the frequencies and function of circulating TFR cells were improved, which positively associated with disease remission. CONCLUSION: Impairment in TFR cells might contribute to aberrant IgE production in patients with AR, and AIT improves defective TFR cell function. TFR cells might serve as a potential biomarker to monitor clinical response to AIT.

Eight Aeroallergen Skin Extracts May Be the Optimal Panel for Allergic Rhinitis Patients in Central China.

BACKGROUND: The prevalence of allergic rhinitis (AR) is increasing rapidly in Central China. The skin prick test (SPT) is the standard tool with which to determine the allergen sensitization status in AR patients. Changes in allergen sensitization patterns have been observed within countries and regions due to geographical and seasonal variations. OBJECTIVE: The aim of this study was to evaluate the profile of SPT reactivity to different aeroallergens in AR patients and to suggest a minimal panel of allergens to detect sensitized patients in Central China. METHODS: From January 2015 to December 2016, patients who presented to Tongji Hospital with suspected AR were tested with the same panel of 19 aeroallergens. The results of SPT were analyzed to determine the minimum test battery panel necessary to cover 99% of the cases of SPT sensitization in different age subgroups. RESULTS: A total of 2,416 patients (male:female ratio 1.2:1) were enrolled in our study with an average age of 22.0 years. The overall rate of sensitization to any allergen was 79.0%, and 64.3% of the subjects were monosensitized. The highest sensitized rate was found in the subgroup aged 14-18 years (92.0%), followed by the subgroups of 6-14 years (86.4%), >18 years (75.6%), and ≤6 years (74.9%). The most common sensitization was to Dermatophagoides farinae (71.1%). Testing with 8 allergens (D. pteronyssinus, D. farinae, Platanus, Artemisia, Cryptomeria, Blatella germanica, Humulus, and Alternaria) was sufficient to identify over 99% of the sensitized patients. CONCLUSION: An SPT panel covering 8 allergen extracts was able to detect almost all sensitized patients suffering from AR symptoms in Central China.

Early Intervention Improves Clinical Responses to House Dust Mite Immunotherapy in Allergic Rhinitis Patients.

BACKGROUND: Allergen immunotherapy (AIT) is the unique causal treatment for respiratory allergy. As AIT is expensive and of long duration, the availability of a marker predicting AIT responders is of crucial relevance. OBJECTIVE: To investigate clinical parameters correlated with effective AIT in allergic rhinitis (AR) patients. METHODS: This is a prospective, nonrandomized open study in which a total of 284 AR patients who had received house dust mite (HDM) subcutaneous AIT were enrolled from January 2011 to December 2015, and then followed up for 3 consecutive years. Demographic data, clinical history, laboratory tests (specific and total IgE levels), symptoms score, concomitant medication, and adverse reactions during AIT were collected. An AIT responder patient was defined when a visual analog score (assessing global symptoms) had decreased by >30% compared to baseline and concomitant medication was equal to or less than before AIT. RESULTS: Thirty-three patients dropped out, so 251 patients were analyzed; 175 (69.7%) patients were responders. This group had a higher baseline symptom score than the AIT nonresponder group (7.5 vs. 6.9). A significant negative correlation was found between AR symptom duration and the clinical response to AIT. Local reactions (LRs) during AIT had a positive correlation. Other variables such as a family history of atopy, combined asthma history, and the levels of specific and total IgE had no correlations with effective AIT. CONCLUSION: Early intervention with AIT helps to improve the efficacy of AR treatment. LRs might predict successful AIT. Highly symptomatic AR patients may develop increased clinical responses to AIT.

Low-dose oral immunotherapy in immunoglobulin E-mediated food allergies.

Nowadays, the management of food allergies has increasingly moved from conventional oral immunotherapy (OIT) to low-dose OIT or low-dose OIT utilizing hypoallergenic foods. This shift is largely because the latter appears to induce oral tolerance with fewer adverse effects than the former. However, the mechanisms underpinning such differences remain unclear. To better understand these mechanisms, we conducted a comparative study scrutinizing the mechanisms of OIT, especially those of low-dose desensitization. We also summarized articles on low-dose OIT and low-dose OIT using hypoallergenic foods. We examined the efficacy, safety, and immunological parameters of low-dose OIT and those of low-dose OIT with hypoallergenic foods with the aim of shedding some light on low-dose OIT and its therapeutic application in inducing oral tolerance for individuals with food allergies.

Vitamin D and allergic diseases.

In recent years, the relationship between vitamin D and allergic diseases has received widespread attention. As a fat-soluble vitamin, vitamin D plays a crucial role in regulating the immune system and may influence the onset and progression of diseases such as atopic dermatitis, allergic rhinitis, and asthma. To understand the underlying mechanisms, we have summarized the current research on the association between vitamin D and allergic diseases. We also discuss the impact of vitamin D on the immune system and its role in the course of allergic diseases, particularly focusing on how vitamin D supplementation affects the treatment outcomes of these conditions. We aim to provide a theoretical basis and practical guidance for optimizing the management and treatment of allergic diseases by modulating vitamin D levels.

Genome-wide identification of dysregulated alternative splicing and RNA-binding proteins involved in atopic dermatitis.

Objectives: We explored the role and molecular mechanisms of RNA-binding proteins (RBPs) and their regulated alternative splicing events (RASEs) in the pathogenesis of atopic dermatitis (AD). Methods: We downloaded RNA-seq data (GSE121212) from 10 healthy control skin samples (healthy, Ctrl), 10 non-lesional skin samples with AD damage (non-lesional, NL), and 10 lesional skin samples with AD damage (lesional, LS). We performed the analysis of differentially expressed genes (DEGs), differentially expressed RBPs (DE-RBPs), alternative splicing (AS), functional enrichment, the co-expression of RBPs and RASEs, and quantitative polymerase chain reaction (qPCR). Results: We identified 60 DE-RBP genes by intersecting 2141 RBP genes from existing reports with overall 2697 DEGs. Most of the DE-RBP genes were found to be upregulated in the AD LS group and related to immune and apoptosis pathways. We observed different ASEs and RASEs among the healthy, AD NL, and AD LS groups. In particular, alt3p and alt5p were the main ASEs and RASEs in AD NL and AD LS groups, compared to the healthy group. Furthermore, we constructed co-expression networks of DE-RBPs and RAS, with particular enrichment in biological pathways including cytoskeleton organization, inflammation, and immunity. Subsequently, we selected seven genes that are commonly present in these three pathways to assess their expression levels in the peripheral blood mononuclear cells (PBMCs) from both healthy individuals and AD patients. The results demonstrated the upregulation of four genes (IFI16, S100A9, PKM, and ENO1) in the PBMCs of AD patients, which is highly consistent with DE-RBP genes analysis. Finally, we selected four RAS genes regulated by RBPs that were related to immune pathways and examined their RASEs in PBMCs from both AD patients and healthy controls. The results revealed an increased percentage of RASEs in the DDX60 gene in AD, which is highly consistent with AS analysis. Conclusion: Dysregulated RBPs and their associated RASEs may have a significant regulatory role in the development of AD and could be potential therapeutic targets in the future.

A survey on prevalence and parents' perceptions of food allergy in 3- to 16-year-old children in Wuhan, China.

Background: The prevalence of food allergy (FA) has risen in recent decades, yet there is limited data on the cognition and beliefs of FA among the parents of FA children. Objective: To investigate the prevalence of FA and assess the knowledge and perception of FA among parents of FA children in Wuhan, China. Methods: Online questionnaires were conducted for the parents of 3- to 16-year-old children. They reported symptoms of suspected FA in the screening questionnaire were interviewed for further diagnostic evaluation. All the parents of the suspected FA children completed the subsequent assessments of the knowledge and perception on FA as well as their attitude towards the current online platforms. Results: A total of 1963 children were recruited. The prevalence of self-reported FA was 10.2% (95% CI: 8.1-12.4%) and the physician-diagnosed FA was 6.2% (95% CI: 5.1-7.2%) in 3- to 16-year-olds in Wuhan. And the children with family history (57.9%) were predisposed to developing FA (P＜0.001). The total Brief Illness Perception Questionnaire (B-IPQ) score was 41.3 ± 10.0 among the parents. The B-IPQ scores correlated with symptom onset, but not with family history or other atopic comorbidities. The parents who never sought treatments obtained lower B-IPQ scores on most items compared to those who received treatments. The accuracy rate of the FA knowledge questionnaire was 56.7%. 11.6% of participants reported that children's FA had an impact on their lives. 67.2% of participants had searched information of FA online, among whom 80% expected to obtain professional suggestions on management and prevention strategies of FA from online platform. Conclusion: In 3- to 16-year-old children in Wuhan, the prevalence of self-reported and physician-diagnosed FA was 10.2% and 6.2% respectively. Parents' knowledge of FA was insufficient and only a small proportion of parents perceived that their lives and careers have been affected considerably by FA of their children. Patient education and current online platforms should be improved among parents of FA children.