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Huber P, Becker S, Gröger M. [Pitfalls in the diagnosis of house dust mite allergy]. HNO 2024:10.1007/s00106-024-01425-y. [PMID: 38358481 DOI: 10.1007/s00106-024-01425-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/16/2024]
Abstract
House dust mite (HDM) is the most significant indoor allergen, responsible for not only many cases of rhinoconjunctivitis but also for many cases of bronchial asthma, rendering it of considerable socioeconomic relevance. Besides symptomatic treatment and avoidance measures, allergen immunotherapy (AIT) is crucial, as the only causal, disease-modifying therapeutic approach. However, high diagnostic certainty is essential for initiating AIT. The challenge in making a correct diagnosis lies in interpreting the demonstrated HDM sensitization regarding its clinical relevance (clinically silent sensitization vs. allergy). While the risk of allergy increases with the level of IgE titers against HDM extract, Der p 1, or Der p 2, as well as with the breadth of the molecular sensitization profile against HDM components (Der p 1, Der p 2, Der p 23), no threshold can be defined for the presence of allergy, nor can sensitization to a specific component be confidently considered allergy inducing. It should be noted that at least in Southern Bavaria, the prevalence of Der p 23 sensitization is too low to be considered a major allergen, and Der p 23 is not able to molecularly differentiate all HDM sensitizations when added to the two major allergens Der p 1 and Der p 2. Evidently, HDM possesses a diverse profile of allergens, with some relevant ones possibly yet to be described. Unfortunately, patient history does not provide a sufficient assessment of the clinical relevance of a demonstrated HDM sensitization, necessitating allergen provocation testing before initiating AIT with HDM, despite the relatively large effort involved.
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Affiliation(s)
- P Huber
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - S Becker
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinik Tübingen, Tübingen, Deutschland
| | - M Gröger
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
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Englhard AS, Holzer M, Eder K, Gellrich D, Gröger M. How reliable is anamnestic data in predicting the clinical relevance of house dust mite sensitization? Eur Arch Otorhinolaryngol 2022; 279:801-810. [PMID: 34019148 PMCID: PMC8794942 DOI: 10.1007/s00405-021-06862-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/30/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE For perennial inhalant allergens such as house dust mite (HDM), the German guideline on allergen-specific immunotherapy explicitly recommends provocation testing. This procedure is time-consuming, expensive, and potentially dangerous for the patient. Recently it has been discussed whether provocation tests are really necessary for diagnosing allergy to Dermatophagoides species. Thus, our study aimed to analyze the concordance between nasal provocation tests with Dermatophagoides species and anamnestic data. METHODS We retrospectively analyzed the concordance between patients' histories including self-reported symptom scores and the results of provocation testing in 471 individuals with proven sensitization to Dermatophagoides species. RESULTS 248 patients had a positive nasal provocation test (NPT) result to Dermatophagoides species and 223 individuals a negative NPT result. Patients allergic to HSM suffered significantly more often from atopic dermatitis (14% vs. 7%, p = 0.046) and more from asthma (20% vs. 19%, p = 0.851). Moreover, individuals with clinically silent sensitization complained less about nasal secretion (37% vs. 45%, p = 0.244) but significantly more about nasal dryness (46% vs. 34%, p = 0.046) whereas rates of nasal airway obstruction, ocular complaints and sleep quality were comparable in both groups. Allergic patients reported more often perennial (34% vs. 30%, p = 0.374) and location-dependent (39% vs. 31%, p = 0.090) symptoms. However, the discrepant prevalence of atopic dermatitis was the only statistically significant difference between both groups. CONCLUSION Despite slight differences between both patient groups, clinical data are not sufficient to distinguish between silent sensitization and clinically relevant allergic rhinitis to HDM. Therefore, nasal provocation testing remains the gold standard for assessing clinical relevance in patients sensitized to Dermatophagoides species.
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Affiliation(s)
- Anna S Englhard
- Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum der Universität München, Marchioninistr. 15, 81377, Munich, Germany.
| | - Martin Holzer
- Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum der Universität München, Marchioninistr. 15, 81377, Munich, Germany
| | - Katharina Eder
- Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum der Universität München, Marchioninistr. 15, 81377, Munich, Germany
| | - Donata Gellrich
- Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum der Universität München, Marchioninistr. 15, 81377, Munich, Germany
| | - Moritz Gröger
- Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum der Universität München, Marchioninistr. 15, 81377, Munich, Germany
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Eder K, Becker S, Gellrich D, Zieglmayer P, Gröger M. The Role of Der p 23 Sensitization: An Analysis of 474 Patients Sensitized to Mite. Int Arch Allergy Immunol 2020; 181:689-698. [PMID: 32554970 DOI: 10.1159/000508522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/04/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION House dust mite contains several allergen components and causes perennial allergy. Lately, a new major allergen, Der p 23, was described with relatively high sensitization rates in different European Countries. In addition, Der p 23 is supposed to cause asthmatic disease. OBJECTIVE We would like to question the prevalence and clinical impact of specific immunoglobulin E to Der p 23 in a large patient sample in southern Bavaria, Germany. METHODS 474 patients from southern Bavaria, who visited the allergy department within the Department of Oto-Rhino-Laryngology of a university hospital, with sensitization to Dermatophagoides pteronyssinus were retrospectively compared regarding their sensitization profile to Der p 1, Der p 2, and Der p 23 and their clinical characteristics. RESULTS Among D. pteronyssinus-sensitized patients, the overall sensitization rate to Der p 23 was 42% in southern Bavaria. Most likely, patients were simultaneously sensitized to Der p 1, Der p 2, and Der p 23. Der p 23-sensitized patients reported more frequently asthma and showed higher prevalence of poly-sensitization towards 3 additional allergen groups and higher prevalence of double-sensitization to Der p 1 and Der p 2 compared to patients with missing sensitization to Der p 23. Considering the results of allergen provocation tests, neither IgE sensitization against Der p 23 nor levels of specific immunoglobulin E to Der p 23 allow a clear prediction of the clinical relevance of the sensitization. CONCLUSION With a sensitization rate of 42%, Der p 23 closely misses the criterion of a major allergen in our southern Bavarian patient collective. A higher prevalence of polysensitization and self-reported asthma was the only clinical feature found in Der p 23-sensitized patients.
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Affiliation(s)
- Katharina Eder
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, Germany,
| | - Sven Becker
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Donata Gellrich
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Petra Zieglmayer
- Vienna Challenge Chamber, Allergy Center Vienna West, Vienna, Austria
| | - Moritz Gröger
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, Germany
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Eder K, Gellrich D, Meßmer C, Canis M, Gröger M. Component resolved analysis of ash pollen allergy in Bavaria. Allergy Asthma Clin Immunol 2018; 14:76. [PMID: 30455718 PMCID: PMC6222990 DOI: 10.1186/s13223-018-0291-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 07/31/2018] [Indexed: 11/10/2022] Open
Abstract
Background Sensitization to ash pollen is underestimated in various regions. The prevalence in Germany is about 10%. However, allergy to ash pollen is widely overlooked by allergists, since the pollination period of ash and birch in central Europe closely overlap and rhinoconjunctival symptoms during April/May are often assigned to birch pollen. Component resolved analysis of the different ash allergens is not routinely available. Therefore, we would like to question the usefulness of component resolved diagnostic via olive components, as ash and olive are both part of the Oleaceae family. Methods 113 patients with nasal provocation and skin prick test to ash were retrospectively compared regarding their specific immunoglobulin E antibody profiles with response to native ash extract, rOle e 1, nOle e 7 and rOle e 9. Results In nasal provocation testing 58% of 113 patients sensitized to ash were allergic, 42% were only sensitized without showing symptoms. Skin prick testing and serology against native ash extract detected most patients sensitized to ash pollen, whereas rOle e 1 was less sensitive. However, the value of measurements of skin prick test, serology to native ash extract and rOle e 1 did not allow a differentiation between an allergy and clinically silent sensitization. Specific antibodies to nOle e 7 and rOle e 9 were only seen in individual patients and were all positive for native ash extract and rOle e 1. Conclusion Skin prick testing and serology to native extract of ash pollen are the most reliable tools to diagnose a sensitization to ash pollen for patients living in Germany. Component resolved diagnostic to the major allergen rOle e 1 as representative of the Oleaceae family is possible but was less sensitive. Diagnostic of nOle e 7 and rOle e 9 did not show any additional benefit. Regarding differentiation between allergy and clinically silent sensitization to ash pollen, provocation is the leading diagnostic tool. Concluding, in routine clinical practice the standard methods-skin prick test, serology to native ash extract and provocation testing-remain crucial in the diagnosis and differentiation of ash sensitization and allergy.
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Affiliation(s)
- Katharina Eder
- Department of Oto-Rhino-Laryngology, Head & Neck Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Donata Gellrich
- Department of Oto-Rhino-Laryngology, Head & Neck Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Catalina Meßmer
- Department of Oto-Rhino-Laryngology, Head & Neck Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Martin Canis
- Department of Oto-Rhino-Laryngology, Head & Neck Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Moritz Gröger
- Department of Oto-Rhino-Laryngology, Head & Neck Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
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Ruggieri S, Drago G, Longo V, Colombo P, Balzan M, Bilocca D, Zammit C, Montefort S, Scaccianoce G, Cuttitta G, Viegi G, Cibella F. Sensitization to dust mite defines different phenotypes of asthma: A multicenter study. Pediatr Allergy Immunol 2017; 28:675-682. [PMID: 28783215 DOI: 10.1111/pai.12768] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Indoor allergens are risk factors for asthma: Thus, the characterization of indoor air quality is important for studying environment-health relationships in children. In particular, Dermatophagoides pteronyssinus is the dominant allergen for asthma. We cross-sectionally investigated the relationships among respiratory symptoms and function, airway inflammation, allergen sensitization, and indoor allergen concentration. METHODS One hundred and thirty-two children aging 10-14 years and living in a Southern Mediterranean area were evaluated by parental questionnaires. Spirometry, exhaled nitric oxide (FeNO), skin prick tests, total, and specific serum IgE analyses were performed along with the evaluation of home dust samples for the content in Der p 1 allergen. Three clusters were created on the basis of the presence/absence of wheeze in the last 12 months (Wh12m) and Der p 1-specific IgE level. RESULTS Cluster 1 (Wh12m+/high Der p 1 IgE) presented higher FeNO and poorer pulmonary function (lower FEV1 and FEF25%-75% ), while its symptom score was not different from Cluster 2 (Wh12m+/low Der p 1 IgE). Cluster 3 (Wh12m-/low IgE) showed the lowest FeNO values and pulmonary function similar to Cluster 2. Within Cluster 1, both Der p 1-specific IgE and FeNO were positively correlated with dust Der p 1. CONCLUSIONS Similar asthma phenotypes may occur in children despite differences in their atopic state. In atopic children, sensitizing allergens in the indoor environment may increase airway inflammation worsening pulmonary function. Moreover, environmental exposures may contribute to the development of asthma-like symptoms also in the absence of atopic sensitization, thus contributing to asthma overdiagnosis.
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Affiliation(s)
- Silvia Ruggieri
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Gaspare Drago
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Valeria Longo
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Paolo Colombo
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Martin Balzan
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - David Bilocca
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | | | - Stephen Montefort
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Gianluca Scaccianoce
- Department of Energy, Information Engineering and Mathematical Models, University of Palermo, Palermo, Italy
| | - Giuseppina Cuttitta
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Giovanni Viegi
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
| | - Fabio Cibella
- Institute of Biomedicine and Molecular Immunology, National Research Council of Italy, Palermo, Italy
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Demoly P, Passalacqua G, Pfaar O, Sastre J, Wahn U. Management of the polyallergic patient with allergy immunotherapy: a practice-based approach. Allergy Asthma Clin Immunol 2016; 12:2. [PMID: 26759555 PMCID: PMC4709898 DOI: 10.1186/s13223-015-0109-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/22/2015] [Indexed: 11/21/2022] Open
Abstract
Background The great majority (60–80 %) of patients consulting specialist physicians for allergic respiratory disease are polysensitized and thus may be potentially clinically polyallergic. However, management approaches to allergen immunotherapy (AIT) in polysensitized and polyallergic patients are not standardized. Methods An international group of clinicians with in-depth expertise in AIT product development, clinical trials and clinical practice met to generate up-to-date, unambiguous, pragmatic guidance on AIT in polysensitized and polyallergic patients. The guidance was developed after reviewing (1) the current stance of regulatory bodies and learned societies, (2) the literature data on single- and multi-AIT and (3) the members’ confirmed clinical experience with polysensitized patients. Results AIT is safe and effective in polysensitized
and polyallergic patients, and should always be based on the identification of one or more clinically relevant allergens (based on the type and severity of symptoms, the duration of induced symptoms, the impact on quality of life and how difficult an allergen is to avoid). Single-AIT is recommended in polyallergic patients in whom one of the relevant allergens is nevertheless clearly responsible for the most intense and/or bothersome symptoms. Parallel 2-allergen immunotherapy or mixed 2-allergen immunotherapy is indicated in polyallergic patients in whom two causal relevant allergens have a marked clinical and QoL impact. In parallel 2-allergen immunotherapy (whether subcutaneous or sublingual), high-quality, standardized, single-allergen formulations must be administered with an interval of 30 min. Mixing of allergen extracts may be considered, as long as (1) the mixture is technically feasible, (2) the mixture is allowed from a regulatory standpoint, (3) the allergen doses are reduced in proportion to the number of components but are still at concentrations with demonstrated efficacy. Conclusions Physicians can prescribe AIT (preferably with high-quality, standardized, single-allergen formulations) with confidence in polysensitized and polyallergic patients by focusing on clinical/QoL relevance and safety.
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Affiliation(s)
- Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France ; Sorbonne Universités, UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, Paris, France
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino-IST, University of Genoa, Genoa, Italy
| | - Oliver Pfaar
- Center for Rhinology and Allergology, Wiesbaden, Germany ; Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty Mannheim, Universitatsmedizin Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Ulrich Wahn
- Department of Paediatric Pulmonology and Immunology, Charité Virchow-Klinikum, Humboldt University, Berlin, Germany
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