Double-blind, randomized, placebo-controlled trial of allergen-specific immunotherapy with the major allergen Alt a 1

Efficacy of Subcutaneous, Sublingual and Oral Immunotherapy for Allergens: A Comparative Study

The purpose of this study was to compare the efficacy and safety of subcutaneous, sublingual, oral specific immunotherapy in patients who suffer from allergic conditions to pollen from trees, grasses and weeds, house dust mites and Alternaria alternata spores. A literature search was performed separately for each type of allergen and each administration route of the drug. As a result, it was found that all administration routes were quite effective. However, each type of immunotherapy was most effective for certain allergens. Subcutaneous and sublingual immunotherapy have proven effective for aeroallergens such as pollen from grass, trees, weeds and house dust mites. Despite this, subcutaneous immunotherapy had a number of disadvantages in the form of the duration of treatment and a greater prevalence of side effects. Some authors suggest that for allergies to house dust mites, the most effective method of immunotherapy was the subcutaneous method of administration, compared with sublingual and nasal. Sublingual therapy was safe enough for all types of allergens under study, however, to achieve the same effect as the subcutaneous method of administration. In addition, oral immunotherapy has been shown to be effective for food allergies with obvious symptoms of gastrointestinal disorders. In addition, oral immunotherapy is the only approved treatment for allergies in the elderly, due to the low risk of side effects. The time-accelerated and dosage-enhanced immunotherapy was also effective and safe. These data prove the effectiveness and safety of each administration route of specific allergens for specific immunotherapy in patients suffering from allergic rhinitis, bronchial asthma and even atopic dermatitis.

A Delphi consensus on diagnosis, management, and treatment with allergen immunotherapy of polysensitized children in Spain: CAPP study, Part 2

BACKGROUND

The study aimed to evaluate the level of agreement between specialists in pediatric allergology regarding the diagnosis and indications for allergen immunotherapy (AIT) for dust mites, molds, animal dander, and Hymenoptera venom allergen, as well as mixtures of several allergen sources in polysensitized children in Spain.

MATERIALS AND METHODS

A Delphi study was performed using an online survey designed by a committee of pediatric AIT experts: 46 and 44 panelists participated in Rounds 1 and 2, respectively. In Round 1, 204 statements on 8 dimensions were evaluated (Diagnosis, Therapeutic management, and Pollens - Part I; Mites, molds, animals, hymenoptera venom, and mixtures - Part II). A total of 148 statements were finally accepted after Round 2. Panel members rated their level of agreement with assessments on a 9-point Likert scale based on acceptance by ≥ 66.7 of them.

RESULTS

Panel experts recommended molecular diagnosis for dust mite allergy diagnosis in polysensitized pediatrics and mixtures of nonhomologous mites (Dermatophagoides and Lepidoglyphus) for optimal AIT management. Subcutaneous AIT with mold extracts is recommended, but no agreement was reached on mixing different mold types. Panel experts agreed that Fel d 1 and Can f 1 sIgE are better predictors for animal dander allergy , but no agreement exists on the acceptance of AIT with dander mixtures. Panelists accepted that Api m 2 (hyaluronidase) sIgE indicates Vespid and Apis mellifera cross-reactivity in children; and Api m 4 (melittin) sIgE is a marker of risk for systemic reaction with AIT in Apis mellifera allergy. According to the consensus, SCIT is more suitable for allergen mixtures than SLIT. and agreement was reached for pollen allergens and Alternaria alternata mixtures if stability, safety, and efficacy have been demonstrated.

CONCLUSIONS

This Delphi study provides, where evidence is lacking, current expert-based opinions on clinical decision-making for managing polysensitized children.

Immunotherapy against environmental fungi causing respiratory allergy

Allergic respiratory diseases (ARDs) have been one of the major global health problems of the 21st century with an increasing prevalence. A significant proportion of aerobiological particles in the environment is constituted by fungal structures, including those from Alternaria, Cladosporium, Penicillium, and Aspergillus species which are regarded as the four most common fungal genera associated with allergic fungal airway diseases (AFADs). Allergen specific immunotherapy (AIT) has capacity to promote protection as well as long-term tolerance to the allergen, however there have not been adequate number of studies evaluating the efficacy of against AFADs, up till today. Our review would like to draw more attention to the field by summarizing the current literature regarding the clinical use of the immunotherapy, with special focus on Alternaria, and Cladosporium AITs. The area is considered to be vital to public health due to the potential increase in global AFAD cases because of ongoing air pollution and climate impacts. The review also aims to sum up immunological findings associated with mould-AIT which would help further studies to be performed in order to develop an objective method to identify non-responders early in the course of therapy.

Allergen-specific immunotherapy at the extremes of age: below 5 years and elderly: evidence beyond indications?

PURPOSE OF REVIEW

Allergen-specific immunotherapy (AIT) has been used in clinical practice to treat allergic diseases for over 100 years. The effectiveness and safety of AIT have been substantiated in numerous studies; however, children before 5 years of age and elderly are not encompassed generally. This review aims to present the current understanding of AIT in the extremes of age.

RECENT FINDINGS

Early allergen immunotherapy during infancy or early childhood may prevent the development of allergic sensitization to common allergens, thereby reducing the risk of developing allergic diseases later in life. In the elderly, improved symptoms and quality of life and reduced dependence on medication are indicated the importance on the implementation of AIT. Both clinical and immunological parameters demonstrated that the treatment was effective at the time of cessation and trend to sustained tolerance.

SUMMARY

There is no specific lower or upper age limit for initiating immunotherapy; however, it is important to thoroughly evaluate the severity of disease and the risks and benefits in each case.

[Medical clinical diagnostics for indoor mould exposure - Update 2023 (AWMF Register No. 161/001)]

This article is an abridged version of the updated AWMF mould guideline "Medical clinical diagnostics in case of indoor mould exposure - Update 2023", presented in July 2023 by the German Society of Hygiene, Environmental Medicine and Preventive Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin, GHUP), in collaboration with German and Austrian scientific medical societies, and experts. Indoor mould growth is a potential health risk, even if a quantitative and/or causal relationship between the occurrence of individual mould species and health problems has yet to be established. There is no evidence for a causal relationship between moisture/mould damage and human diseases, mainly because of the ubiquitous presence of fungi and hitherto inadequate diagnostic methods. Sufficient evidence for an association between moisture/mould damage and the following health effects has been established for: allergic respiratory diseases, allergic rhinitis, allergic rhino-conjunctivitis, allergic bronchopulmonary aspergillosis (ABPA), other allergic bronchopulmonary mycosis (ABPM), aspergilloma, Aspergillus bronchitis, asthma (manifestation, progression, exacerbation), bronchitis (acute, chronic), community-acquired Aspergillus pneumonia, hypersensitivity pneumonitis (HP; extrinsic allergic alveolitis (EEA)), invasive Aspergillosis, mycoses, organic dust toxic syndrome (ODTS) [workplace exposure], promotion of respiratory infections, pulmonary aspergillosis (subacute, chronic), and rhinosinusitis (acute, chronically invasive, or granulomatous, allergic). In this context the sensitizing potential of moulds is obviously low compared to other environmental allergens. Recent studies show a comparatively low sensitization prevalence of 3-22,5 % in the general population across Europe. Limited or suspected evidence for an association exist with respect to atopic eczema (atopic dermatitis, neurodermatitis; manifestation), chronic obstructive pulmonary disease (COPD), mood disorders, mucous membrane irritation (MMI), odor effects, and sarcoidosis. (iv) Inadequate or insufficient evidence for an association exist for acute idiopathic pulmonary hemorrhage in infants, airborne transmitted mycotoxicosis, arthritis, autoimmune diseases, cancer, chronic fatigue syndrome (CFS), endocrinopathies, gastrointestinal effects, multiple chemical sensitivity (MCS), multiple sclerosis, neuropsychological effects, neurotoxic effects, renal effects, reproductive disorders, rheumatism, sick building syndrome (SBS), sudden infant death syndrome, teratogenicity, thyroid diseases, and urticaria.The risk of infection posed by moulds regularly occurring indoors is low for healthy persons; most species are in risk group 1 and a few in risk group 2 (Aspergillus fumigatus, A. flavus) of the German Biological Agents Act (Biostoffverordnung). Only moulds that are potentially able to form toxins can be triggers of toxic reactions. Whether or not toxin formation occurs in individual cases is determined by environmental and growth conditions, water activity, temperature and above all the growth substrates.In case of indoor moisture/mould damage, everyone can be affected by odor effects and/or mood disorders.However, this is not an acute health hazard. Predisposing factors for odor effects can include genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for mood disorders may include environmental concerns, anxiety, condition, and attribution, as well as various diseases. Risk groups to be protected particularly regarding infection risk are immunocompromised persons according to the classification of the German Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, KRINKO) at the Robert Koch-Institute (RKI), persons suffering from severe influenza, persons suffering from severe COVID-19, and persons with cystic fibrosis (mucoviscidosis); with regard to allergic risk, persons with cystic fibrosis (mucoviscidosis) and patients with bronchial asthma must be protected. The rational diagnostics include the medical history, physical examination, and conventional allergy diagnostics including provocation tests if necessary; sometimes cellular test systems are indicated. In the case of mould infections, the reader is referred to the specific guidelines. Regarding mycotoxins, there are currently no useful and validated test procedures for clinical diagnostics. From a preventive medical point of view, it is important that indoor mould infestation in relevant magnitudes cannot be tolerated for precautionary reasons.For evaluation of mould damage in the indoor environment and appropriate remedial procedures, the reader is referred to the mould guideline issued by the German Federal Environment Agency (Umweltbundesamt, UBA).

A retrospective analysis of the clinical efficacy in patients treated with Alternaria alternata and Dermatophagoides farinae immunotherapy

Background

The clinical efficacy of allergen-specific immunotherapy (AIT) for Alternaria alternata (A. alt) and Dermatophagoides farinae (Der f) extracts remains largely unknown in China. We sought to retrospectively evaluate the efficacy caused by AIT agents manufactured in China of patients who are sensitized to A. alt and Der f.

Methods

Patients aged 5-27 years with asthma and perennial allergic rhinitis (AR), and AIT with A. alt and Der f were recruited, and then classified into two groups: A. alt-AIT (n = 31) and A. alt + Der f-AIT group (n = 39). All data were gathered retrospectively, including biological parameters, pulmonary function, and symptom and medication scores.

Results

70 patients who underwent A. alt and Der f AIT were enrolled. A significant improvement was observed in the values of FEV1% (P < 0.0001) and MEF 25 (P = 0.023) of lung function. Both the rhinitis symptoms and combined symptoms and medication scores for asthma decreased after AIT (by 45.3% and 80.3%, respectively, P < 0.0001 for each). Nearly 67% improvement rate (P < 0.0001) occurred in rhinoconjunctivitis quality of life, and a great increase existed in Asthma Control Test (ACT) score (P < 0.0001) after at least 1 year AIT, although there were no significant changes between these two groups. Besides, no significance was displayed in specific IgE to different allergens.

Conclusion

AIT with A. alt and Der f extracts had clinical efficacy for many patients in China, with a reduction of symptom and medication scores, and great improvement in spirometry function.

Distinct proteomes and allergen profiles appear across the life-cycle stages of Alternaria alternata

BACKGROUND

Alternaria alternata is associated with allergic respiratory diseases, which can be managed with allergen extract-based diagnostics and immunotherapy. It is not known how spores and hyphae contribute to allergen content. Commercial allergen extracts are manufactured by extracting proteins without separating the different forms of the fungus.

OBJECTIVE

We sought to determine differences between spore and hyphae proteomes and how allergens are distributed in Aalternata.

METHODS

Data-independent acquisition mass spectrometry was used to quantitatively compare the proteomes of asexual spores (nongerminating and germinating) with vegetative hyphae.

RESULTS

We identified 4515 proteins in nongerminating spores, germinating spores, and hyphae; most known allergens are more abundant in nongerminating spores. On comparing significant protein fold-change differences between nongerminating spores and hyphae, we found that 174 proteins were upregulated in nongerminating spores and 80 proteins in hyphae. Among the spore proteins are ones functionally involved in cell wall synthesis, responding to cellular stress, and maintaining redox balance and homeostasis. On comparing nongerminating and germinating spores, 25 proteins were found to be upregulated in nongerminating spores and 54 in germinating spores. Among the proteins specific to germinating spores were proteases known to be virulence factors. One of the most abundant proteins in the spore proteome is sialidase, which has not been identified as an allergen but may be important in the pathogenicity of this fungus. Major allergen Alt a 1 is present at low levels in spores and hyphae and appears to be largely secreted into growth media.

CONCLUSIONS

Spores and hyphae express overlapping but distinct proteomes. Most known allergens are found more abundantly in nongerminating spores.

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.

AllergoOncology: Biomarkers and refined classification for research in the allergy and glioma nexus-A joint EAACI-EANO position paper

Epidemiological studies have explored the relationship between allergic diseases and cancer risk or prognosis in AllergoOncology. Some studies suggest an inverse association, but uncertainties remain, including in IgE-mediated diseases and glioma. Allergic disease stems from a Th2-biased immune response to allergens in predisposed atopic individuals. Allergic disorders vary in phenotype, genotype and endotype, affecting their pathophysiology. Beyond clinical manifestation and commonly used clinical markers, there is ongoing research to identify novel biomarkers for allergy diagnosis, monitoring, severity assessment and treatment. Gliomas, the most common and diverse brain tumours, have in parallel undergone changes in classification over time, with specific molecular biomarkers defining glioma subtypes. Gliomas exhibit a complex tumour-immune interphase and distinct immune microenvironment features. Immunotherapy and targeted therapy hold promise for primary brain tumour treatment, but require more specific and effective approaches. Animal studies indicate allergic airway inflammation may delay glioma progression. This collaborative European Academy of Allergy and Clinical Immunology (EAACI) and European Association of Neuro-Oncology (EANO) Position Paper summarizes recent advances and emerging biomarkers for refined allergy and adult-type diffuse glioma classification to inform future epidemiological and clinical studies. Future research is needed to enhance our understanding of immune-glioma interactions to ultimately improve patient prognosis and survival.

Mould allergen Alt a 1 spiked with the micronutrient retinoic acid reduces Th2 response and ameliorates Alternaria allergy in BALB/c mice

BACKGROUND

We investigated the biological function of the mould allergen Alt a 1 as a carrier of micronutrients, such as the vitamin A metabolite retinoic acid (RA) and the influence of RA binding on its allergenicity in vitro and in vivo.

METHODS

Alt a 1-RA complex formation was analyzed in silico and in vitro. PBMCs from Alternaria-allergic donors were stimulated with Alt a 1 complexed with RA (holo-Alt a 1) or empty apo-Alt a 1 and analyzed for cytokine production and CD marker expression. Serum IgE-binding and crosslinking assays to apo- and holo-protein were correlated to B-cell epitope analysis. Female BALB/c mice already sensitized to Alt a 1 were intranasally treated with apo-Alt a 1, holo-Alt a 1 or RA alone before measuring anaphylactic response, serum antibody levels, splenic cytokines and CD marker expression.

RESULTS

In silico docking calculations and in vitro assays showed that the extent of RA binding depended on the higher quaternary state of Alt a 1. Holo-Alt a 1 loaded with RA reduced IL-13 released from PBMCs and CD3+CD4+CRTh2 cells. Complexing Alt a 1 to RA masked its IgE B-cell epitopes and reduced its IgE-binding capacity. In a therapeutic mouse model of Alternaria allergy nasal application of holo-Alt a 1, but not of apo-Alt a 1, significantly impeded the anaphylactic response, impaired splenic antigen-presenting cells and induced IL-10 production.

CONCLUSION

Holo-Alt a 1 binding to RA was able to alleviate Th2 immunity in vitro, modulate an ongoing Th2 response and prevent anaphylactic symptoms in vivo, presenting a novel option for improving allergen-specific immunotherapy in Alternaria allergy.

Allergy immunotherapy for allergic fungal respiratory diseases

Background: Allergy immunotherapy (AIT) with fungal extracts is not as straight forward as that with other inhalants. The complexities relate to the number of airborne fungal spores, the limited data on the exposure to the spores of individual species of fungi and their clinical importance, the poor quality of the fungal allergen extracts that are available for the diagnosis and treatment, and the lack of controlled studies establishing dosing and efficacy of AIT with fungal extracts except for Alternaria. Objective: The objective was to review what is known with regard to the role of fungi in causing allergic respiratory diseases as well as the evidence that exists for the role of AIT as a treatment for these conditions. Methods: A search was conducted of PubMed, textbooks, known articles on immunotherapy with fungal extracts, and references derived from these primary sources. Results: Nine immunotherapy studies that used Alternaria or its major allergen Alt a 1 and two studies that used Cladosporium herbarum were identified. When a good quality extract was administered in adequate doses, immunotherapy with Alternaria was as effective as that with other inhalant allergens. There was a suggestion of efficacy with a specially prepared Cladosporium extract, but systemic reactions were common and limited the tolerated dose. The use of immunotherapy as an adjunct treatment for allergic fungal sinusitis is briefly reviewed, but controlled trials are lacking. Conclusion: Fungal immunotherapy should largely be limited to Alternaria alternata and perhaps C. herbarum. Under conditions of demonstrated exposure to a particular species of fungus and with symptoms that correlate with that exposure as well as availability of an apparently potent extract of that fungus to which the patient is sensitive that fungus may be considered for immunotherapy. Fungal (mold) mixes should not be used for diagnosis or therapy.

Changes of allergic inflammation and immunological parameters after Alt a 1 and A. alternata immunotherapy in mice

Background

The efficacy of allergen-specific subcutaneousimmunotherapy (SCIT) with Alt a 1 of the fungus A. alternata is still unknown. Yet, few studies compare the therapeutic effects and immunological mechanisms of Alt a 1 and A. alternata extracts. We aim to explore and compare the changes in allergic inflammation and immunological mechanisms of Alt a 1 and A. alternata in mice.

Methods

Female BALB/c mice administrated recombinant Alt a 1 (rAlt a 1), native Alt a 1 (nAlt a 1), and A. alternata. Lung histology, airway hyper-reactivity (AHR), bronchoalveolar lavage fluid (BALF) cytokine levels, serum immunoglobulin responses, the expression of Bcl-6, the percentages of T follicular helper cells (Tfh), cytokine-related Tfh subtypes, regulatory B cells (Breg), and IL-10+ Breg cells were detected.

Results

High-purity nAlt 1 protein was obtained. SCIT with Alt a 1 and Alternaria decreased airway and lung inflammation, including improvement of lung pathology, lower levels of AHR, reduction of total cell numbers, and IL-4 and IL-13 levels in BALF. Furthermore, Alt a 1-SCIT effectively suppressed the IgE responses, elevated IgG titers, and was superior in decreasing the expression of Bcl-6. Additionally, Alternaria-SCIT significantly decreased the expression of Tfh cells, L-4+ Tfh, and IL-5+ Tfh cells in the spleen, whereas Alt a 1 showed superior therapeutic effects in the lymph node. IL-13+ Tfh cells in these two treatment groups not being significant. IL-17A+ Tfh cells were alleviated most effectively after A. alternata-SCIT in both the spleen and lymph node. Intriguingly, IL-10+ Breg cells decreased remarkably in response to SCIT with rAlt a 1.

Conclusions

Treatments with Alt a 1 and A. alternata extracts had beneficial effects on allergic inflammation. Alt a 1-SCIT resulted in prominent improvement in the immunoglobulin responses, Bcl-6, and IL-10+ Breg cells. Alternaria-SCIT was more likely to suppress the expression of Tfh and cytokine-related Tfh subtypes.

Subcutaneous Immunotherapy (SCIT) with the New Polymerized Molecular Allergoid Alt a1: A Pilot Study in Children with Allergic Rhinitis Sensitized to Alternaria Alternata

BACKGROUND

We followed the effects of a new SCIT with a chemically polymerized allergen Alt a1, evaluating the trend of clinical and functional parameters in an observational-prospective study.

METHODS

42 children with AR and intermittent asthma sensitized to A.A.: 17 patients started SCIT (Modigoid^®), and 25 continued symptomatic therapy. At the initial visit (T0), all patients performed total IgE (tIgE) and specific IgE (sIgE) for Alt a1, nasal nitric oxide (nFeNo), nasal cytology, anterior active rhinomanometry (AAR) and spirometry. After 24 months (T1), they repeated the same procedures as in T0.

RESULTS

Patients treated with Modigoid presented a statistically significant (p < 0.001) reduction of nFeNO (T0:1651.06 ± 149.18; T1: 1394.12 ± 108.98), tIgE (T0: 311.48 ± 144.18; T1: 164.73 ± 50.69), sIgE for Alt a1 (T0: 28.59 ± 12.69; T1: 19.54 ± 7.37), an improvement of nasal airflow (T0: 71.62 ± 8.66; T1: 95.12 ± 5.91), nasal eosinophils (T0: 20.59 ± 2.35; T1: 14.88 ± 1.65) and FEV1 (T0: 95.58 ± 7.91; T1: 116.64 ± 5.94).

CONCLUSIONS

The new SCIT for Alt a1 significantly improves AR symptoms from a subjective, objective point of view and laboratory and functional parameters.

Going over Fungal Allergy: Alternaria alternata and Its Allergens

Fungal allergy is the third most frequent cause of respiratory pathologies and the most related to a poor prognosis of asthma. The genera Alternaria and Cladosporium are the most frequently associated with allergic respiratory diseases, with Alternaria being the one with the highest prevalence of sensitization. Alternaria alternata is an outdoor fungus whose spores disseminate in warm and dry air, reaching peak levels in temperate summers. Alternaria can also be found in damp and insufficiently ventilated houses, causing what is known as sick building syndrome. Thus, exposure to fungal allergens can occur outdoors and indoors. However, not only spores but also fungal fragments contain detectable amounts of allergens and may function as aeroallergenic sources. Allergenic extracts of Alternaria hyphae and spores are still in use for the diagnosis and treatment of allergic diseases but are variable and insufficiently standardised, as they are often a random mixture of allergenic ingredients and casual impurities. Thus, diagnosis of fungal allergy has been difficult, and knowledge about new fungal allergens is stuck. The number of allergens described in Fungi remains almost constant while new allergens are being found in the Plantae and Animalia kingdoms. Given Alt a 1 is not the unique Alternaria allergen eliciting allergy symptoms, component-resolved diagnosis strategies should be applied to diagnose fungal allergy. To date, twelve A. alternata allergens are accepted in the WHO/IUIS Allergen Nomenclature Subcommittee, many of them are enzymes: Alt a 4 (disulfide isomerase), Alt a 6 (enolase), Alt a 8 (mannitol de-hydrogenase), Alt a 10 (aldehyde dehydrogenase), Alt a 13 (glutathione-S-transferase) and Alt a MnSOD (Mn superoxide dismutase), and others have structural and regulatory functions such as Alt a 5 and Alt a 12, Alt a 3, Alt a 7. The function of Alt a 1 and Alt a 9 remains unknown. Other four allergens are included in other medical databases (e.g., Allergome): Alt a NTF2, Alt a TCTP, and Alt a 70 kDa. Despite Alt a 1 being the A. alternata major allergen, other allergens, such as enolase, Alt a 6 or MnSOD, Alt a 14 have been suggested to be included in the diagnosis panel of fungal allergy.

EAACI Molecular Allergology User's Guide 2.0

Since the discovery of immunoglobulin E (IgE) as a mediator of allergic diseases in 1967, our knowledge about the immunological mechanisms of IgE-mediated allergies has remarkably increased. In addition to understanding the immune response and clinical symptoms, allergy diagnosis and management depend strongly on the precise identification of the elicitors of the IgE-mediated allergic reaction. In the past four decades, innovations in bioscience and technology have facilitated the identification and production of well-defined, highly pure molecules for component-resolved diagnosis (CRD), allowing a personalized diagnosis and management of the allergic disease for individual patients. The first edition of the "EAACI Molecular Allergology User's Guide" (MAUG) in 2016 rapidly became a key reference for clinicians, scientists, and interested readers with a background in allergology, immunology, biology, and medicine. Nevertheless, the field of molecular allergology is moving fast, and after 6 years, a new EAACI Taskforce was established to provide an updated document. The Molecular Allergology User's Guide 2.0 summarizes state-of-the-art information on allergen molecules, their clinical relevance, and their application in diagnostic algorithms for clinical practice. It is designed for both, clinicians and scientists, guiding health care professionals through the overwhelming list of different allergen molecules available for testing. Further, it provides diagnostic algorithms on the clinical relevance of allergenic molecules and gives an overview of their biology, the basic mechanisms of test formats, and the application of tests to measure allergen exposure.

Fungal Allergen and Mold Allergy Diagnosis: Role and Relevance of Alternaria alternata Alt a 1 Protein Family

Alternaria is a genus of worldwide fungi found in different habitats such as soil, the atmosphere, plants or indoor environments. Alternaria species are saprobic-largely involved in the decomposition of organic material-but they can also act as animal pathogens, causing disease in humans and animals, developing infections, toxicosis and allergic diseases. A. alternata is considered one of the most important sources of fungal allergens worldwide and it is associated with severe asthma and respiratory status. Among the A. alternata allergens, Alt a 1 is the main sensitizing allergen and its usefulness in diagnosis and immunotherapy has been demonstrated. Alt a 1 seems to define a protein family that can be used to identify related pathogenic fungi in plants and fruits, and to establish taxonomic relationships between the different fungal divisions.

Allergen Immunotherapy: Current and Future Trends

Allergen immunotherapy (AIT) is the sole disease-modifying treatment for allergic rhinitis; it prevents rhinitis from progressing to asthma and lowers medication use. AIT against mites, insect venom, and certain kinds of pollen is effective. The mechanism of action of AIT is based on inducing immunological tolerance characterized by increased IL-10, TGF-β, and IgG4 levels and Treg cell counts. However, AIT requires prolonged schemes of administration and is sometimes associated with adverse reactions. Over the last decade, novel forms of AIT have been developed, focused on better allergen identification, structural modifications to preserve epitopes for B or T cells, post-traductional alteration through chemical processes, and the addition of adjuvants. These modified allergens induce clinical-immunological effects similar to those mentioned above, increasing the tolerance to other related allergens but with fewer side effects. Clinical studies have shown that molecular AIT is efficient in treating grass and birch allergies. This article reviews the possibility of a new AIT to improve the treatment of allergic illness.

Immunotherapy With Recombinant Alt a 1 Suppresses Allergic Asthma and Influences T Follicular Cells and Regulatory B Cells in Mice

Background

Alternaria is a major source of asthma-inducing allergens. Allergen-specific immunotherapy improves the progression of allergic asthma. The current treatment is based on crude Alternaria extracts. Alt a 1 is the predominant allergen in Alternaria. However, the treatment efficacy of recombinant Alt a 1 (rAlt a 1) in an asthmatic animal model and its influence on Tfh and Breg cells are unknown.

Objective

To explore the therapeutic treatment effects of rAlt a 1 on the progress of an asthmatic mouse model and its effect on Tfh and Breg cells.

Methods

We synthesized and purified rAlt a 1. Alternaria-sensitized and challenged mice received subcutaneous immunotherapy (SCIT) with four different rAlt a 1 dosages (5, 50, 100, and 150 µg) or PBS only. Finally, lung and airway inflammation, mouse mast cell protease 1 (MMCP-1), serum immunoglobulin responses, Tfh and Breg cell levels, and the correlation between asthmatic features (inflammation grades and IL-4 and IL-10 levels) and these two cell types were measured after Alternaria rechallenge.

Results

High purity and allergenic potency of rAlt a 1 protein were obtained. Following treatment with four different rAlt a 1 dosages, both lung and airway inflammation ameliorated, including lung pathology, serum MMCP-1 levels, inflammatory cell numbers, and cytokine levels in bronchoalveolar lavage fluid (BALF). Additionally, rAlt a 1-SCIT increased the expression of Alternaria-sIgG1, rAlt a 1-sIgG1, rAlt a 1-sIgG2a, and rAlt a 1-sIgG2b in serum. Moreover, the number and percentage of CXCR5⁺PD-1⁺Tfh cells were increased in the PC control, while they decreased in the rAlt a 1-SCIT groups. Meanwhile, the absolute numbers and proportions of Breg cells were evaluated after administration of rAlt a 1. A positive correlation was observed between CXCR5⁺PD-1⁺Tfh cells and inflammation grades (r = 0.50, p = 0.01), as well as a slightly strong positive relationship with IL-4 (r = 0.55, p = 0.005) and IL-10 (r = 0.58, p = 0.003) levels; Breg cells showed an opposite correlation with the grades of inflammation (r = -0.68, p = 0.0003), along with a negative correlation to IL-4 (r = -0.61, p = 0.001) and IL-10 (r = -0.53, p = 0.008) levels.

Conclusions

We verified that treatment with rAlt a 1 can alleviate asthma progression and further have a regulatory effect on Tfh and Breg cells in an Alternaria-induced asthmatic mouse model.

Changes in the Sensitization Pattern to Alternaria alternata Allergens in Patients Treated with Alt a 1 Immunotherapy

Alternaria alternata is the most important allergenic fungus, with up to 20% of allergic patients affected. The sensitization profile of patients sensitized to A. alternata and how it changes when treated with immunotherapy is not known. Our objective is to determine the allergen recognition pattern of allergic patients to A. alternata and to study its association to the parameters studied in a clinical trial recently published. Sera of 64 patients from the clinical trial of immunotherapy with native major allergen Alt a 1 were analyzed by immunoblotting; 98. 4% of the patients recognized Alt a 1. The percentage of recognition for Alt a 3, Alt a 4, and/or Alt a 6, Alt a 7, Alt a 8, Alt a 10 and/or Alt a 15 was 1.6%, 21.9%, 12.5%, 12.5%, and 12.5% respectively. Of the 64 patients, 45 (70.3%) only recognized Alt a 1 among the allergens present in the A. alternata extract. Immunotherapy with Alt a 1 desensitizes treated patients, reducing their symptoms and medication consumption through the elimination of Alt a 1 sensitization, which is no longer present in the immunoblotting of some patients. There may be gender differences in the pattern of sensitization to A. alternata allergens, among others.

Clinical relevance of Alternaria alternata sensitization in patients within type 2-high and type 2-low asthma

Alternaria sensitization is correlated with persistent asthma. Type 2 (T2)-asthma endotypes are characterized by the release of eosinophils. However, the prevalence and sensitization patterns in patients with Alternaria asthma between T2-high and T2-low endotypes are unknown. We retrospectively reviewed 582 patients with Alternaria asthma and divided them into T2-high (n = 376) and T2-low (n = 206) groups with a threshold of 300 cells/µL in blood eosinophil counts. Data for basic information, skin test or IgE detection results, and blood eosinophil counts were collected. The age of patients in the T2-high group (13.66 ± 13.23) was lower than that of the T2-low group (18.02 ± 15.03). Patients with T2-high asthma had relatively higher rates of taking inhaled corticosteroids (ICS) and positive family history than the T2-low group. Pet keepers and allergen immunotherapy (AIT) patients were comparable between these groups, In the T2-high group, patients had higher levels of total serum IgE (T-IgE) and showed a significant positive correlation with eosinophil counts (r = 0.166, P = 0.001), followed by higher Alternaria-specific IgE (sIgE) levels (median, 13.7; range, 4.86-25.3). Compared to the T2-low group, the frequency of poly-sensitized patients and the rate of each allergen among the nine common allergens were all higher in the T2-high group; the statistical differences mainly focused on pollens such as birch (P = 0.005), firmiana (P = 0.004), and mugwort (P = 0.005). Young, male patients had a high prevalence of T2-high Alternaria asthma, along with higher rates of T-IgE, sIgE levels, and poly-sensitized patterns.

Alternaria as an Inducer of Allergic Sensitization

Alternaria alternata is a saprophytic mold whose spores are disseminated in warm dry air, the typical weather of the Mediterranean climate region (from 30° to 45°), with a peak during the late summer and early autumn. Alternaria spores are known to be biological contaminants and a potent source of aeroallergens. One consequence of human exposure to Alternaria is an increased risk of developing asthma, with Alt a 1 as its main elicitor and a marker of primary sensitization. Although the action mechanism needs further investigation, a key role of the epithelium in cytokine production, TLR-activated alveolar macrophages and innate lymphoid cells in the adaptive response was demonstrated. Furthermore, sensitization to A. alternata seems to be a trigger for the development of co-sensitization to other allergen sources and may act as an exacerbator of symptoms and an elicitor of food allergies. The prevalence of A. alternata allergy is increasing and has led to expanding research on the role of this fungal species in the induction of IgE-mediated respiratory diseases. Indeed, recent research has allowed new perspectives to be considered in the assessment of exposure and diagnosis of fungi-induced allergies, although more studies are needed for the standardization of immunotherapy formulations.

Integration of in vitro allergy test results and ratio analysis for the diagnosis and treatment of allergic patients (INTEGRA)

The introduction of molecular diagnosis into routine clinical practice has substantially improved the diagnosis and management of allergic patients by allowing clinicians to precisely identify the allergenic molecule responsible for immunoglobulin E (IgE)-mediated allergies. However, it can be challenging to accurately interpret the results of molecular assays, partly due to the limited evidence base. In this context, a panel of experts with extensive experience in interpreting in vitro measures of total and serum specific IgE reviewed the available scientific evidence. After this review, the panel selected a series of representative case studies to demonstrate how determination of specific and total IgE values and the relationship between them (ratio analysis) can add value to the diagnostic process by more precisely defining the patient's sensitization profile. Finally, the experts developed a series of recommendations on the clinical application of ratio analysis to optimize and complement the classical approach to allergy diagnosis.

Sensitization against Fungi in Patients with Airway Allergies over 20 Years in Germany

BACKGROUND

Fungal spores are ubiquitous allergens. Severe forms of asthma are particularly highly associated with fungal sensitization. National and international asthma guidelines recommend the implementation of allergen immunotherapy if indicated. Thus, detection and treatment of relevant allergies are key components of primary care of these patients.

OBJECTIVES

The aims of the study were (i) to investigate trends in the prevalence of sensitization to twelve fungi in central Germany over the last 20 years and (ii) to dissect specific sensitization patterns among the 3 most important fungi: Aspergillus, Alternaria, and Cladosporium.

METHODS

This single-center study evaluated skin prick test (SPT) results of 3,358 patients with suspected airway allergies over a period of 20 years (1998-2017).

RESULTS

While 19.2% of all study patients had positive test results to at least 1 of the 3 fungi (Alternaria, Aspergillus, or Cladosporium) in the first study decade, this rate increased to 22.5% in the second decade. Slight increases in sensitization rates to almost all fungi were observed over the 20-year period. In the last decade, polysensitization to Alternaria, Aspergillus, and Cladosporium increased significantly. Sensitization to fungi is age-dependent and peaks in the age-group of 21-40 years during the second decade.

CONCLUSION

Fungi are relevant allergens for perennial and seasonal allergy symptoms. We currently recommend including Aspergillus, Alternaria, and Cladosporium in the standard series of SPTs for airway allergies.

Changes in Immunologic Indicators During Allergen-Specific Immunotherapy for Allergic Rhinitis and Determinants of Variability: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

To date, there are no generally recognized biomarkers for allergen immunotherapy (AIT) and even the changes in immunological indicators during AIT are inconsistent in different publications.

OBJECTIVE

This study was conducted to quantify the immunological changes that occur during AIT and identify the determinants of heterogeneity.

METHODS

Randomized controlled trials of AIT published in the past 10 years were searched in Medline, Embase and Cochrane CENTRAL. Data on immunological indicators were extracted, and the characteristics of the included studies were collected. Meta-analysis and meta-regression were conducted for each indicator. The study was registered on the PROSPERO website (CRD42020176127).

RESULTS

We reviewed 1898 studies. Forty-six studies met the inclusion criteria, and 31 studies were included in the quantitative analyses. Subset analyses by time demonstrated that serum allergen-specific IgE (sIgE) of AIT patients increased in the first 12 months, then decreased and became slightly lower than that of control patients. Allergen-specific IgG4 (sIgG4) was elevated in the AIT group during and after treatment. IgE-blocking factor (IgE-BF) was increased and IgE-facilitated allergen binding (IgE-FAB) was reduced in AIT patients. Both of them of the 2 factors were associated with clinical efficacy in the multivariate regression analysis. sIgE/sIgG4 decreased in AIT patients, while there was no change in total IgE.

CONCLUSION

The levels of serum sIgE and sIgG4 during AIT showed a time-dependent pattern. IgE-BF and IgE-FAB should be further investigated as biomarkers for predicting and monitoring AIT efficacy.

Novel vaccines for allergen-specific immunotherapy

PURPOSE OF REVIEW

Allergen-specific immunotherapy (AIT) is a highly economic, effective and disease-modifying form of allergy treatment but requires accurate prescription and monitoring. New molecular approaches are currently under development to improve AIT by reducing treatment-related side effects, cumbersome protocols and patients' compliance. We review the current advances regarding refined diagnosis for prescription and monitoring of AIT and the development of novel molecular vaccines for AIT. Finally, we discuss prophylactic application of AIT.

RECENT FINDINGS

There is evidence that molecular allergy diagnosis not only assists in the prescription and monitoring of AIT but also allows a refined selection of patients to increase the likelihood of treatment success. New data regarding the effects of AIT treatment with traditional allergen extracts by alternative routes have become available. Experimental approaches for AIT, such as virus-like particles and cell-based treatments have been described. New results from clinical trials performed with recombinant hypoallergens and passive immunization with allergen-specific antibodies highlight the importance of allergen-specific IgG antibodies for the effect of AIT and indicate opportunities for preventive allergen-specific vaccination.

SUMMARY

Molecular allergy diagnosis is useful for the prescription and monitoring of AIT and may improve the success of AIT. Results with molecular allergy vaccines and by passive immunization with allergen-specific IgG antibodies indicate the importance of allergen-specific IgG capable of blocking allergen recognition by IgE and IgE-mediated allergic inflammation as important mechanism for the success of AIT. New molecular vaccines may pave the road towards prophylactic allergen-specific vaccination.

Past, present, and future of allergen immunotherapy vaccines

Allergen-specific immunotherapy (AIT) is an allergen-specific form of treatment for patients suffering from immunoglobulin E (IgE)-associated allergy; the most common and important immunologically mediated hypersensitivity disease. AIT is based on the administration of the disease-causing allergen with the goal to induce a protective immunity consisting of allergen-specific blocking IgG antibodies and alterations of the cellular immune response so that the patient can tolerate allergen contact. Major advantages of AIT over all other existing treatments for allergy are that AIT induces a long-lasting protection and prevents the progression of disease to severe manifestations. AIT is cost effective because it uses the patient´s own immune system for protection and potentially can be used as a preventive treatment. However, broad application of AIT is limited by mainly technical issues such as the quality of allergen preparations and the risk of inducing side effects which results in extremely cumbersome treatment schedules reducing patient´s compliance. In this article we review progress in AIT made from its beginning and provide an overview of the state of the art, the needs for further development, and possible technical solutions available through molecular allergology. Finally, we consider visions for AIT development towards prophylactic application.

Is immunotherapy with fungal vaccines effective?

PURPOSE OF REVIEW

Although allergen immunotherapy (AIT) for fungi has been performed for many years, evidence clearly demonstrating its clinical benefit are still lacking. Here, we reviewed the available studies assessing efficacy and safety of AIT for molds.

RECENT FINDINGS

Studies on AIT for fungi were performed only for the two predominating mold species in the external environment, namely Cladosporium and Alternaria. There is no evidence for other mold species. Recent finding in the literature are lacking; the 2 most recent studies on AIT for molds were published in 2011. Overall, 13 studies were identified (the first was published in 1986), but only nine of these compared AIT to placebo. The studies are small (median study sample size, 27 patients) and of low quality, owing to several defects leading to moderate-to-high risk of bias. Symptoms improvement and medication use reduction, which are the main outcome measures of the studies, were inconsistently demonstrated. There are some concerns about safety with Cladosporium extracts, whereas vaccines with Alternaria extracts seem to be safe and well tolerated.

SUMMARY

Low strength evidence suggests that mold AIT is efficacious for the treatment of respiratory allergies. High-quality studies with an adequate sample size are needed.

EAACI Allergen Immunotherapy User's Guide

Allergen immunotherapy is a cornerstone in the treatment of allergic children. The clinical efficiency relies on a well-defined immunologic mechanism promoting regulatory T cells and downplaying the immune response induced by allergens. Clinical indications have been well documented for respiratory allergy in the presence of rhinitis and/or allergic asthma, to pollens and dust mites. Patients who have had an anaphylactic reaction to hymenoptera venom are also good candidates for allergen immunotherapy. Administration of allergen is currently mostly either by subcutaneous injections or by sublingual administration. Both methods have been extensively studied and have pros and cons. Specifically in children, the choice of the method of administration according to the patient's profile is important. Although allergen immunotherapy is widely used, there is a need for improvement. More particularly, biomarkers for prediction of the success of the treatments are needed. The strength and efficiency of the immune response may also be boosted by the use of better adjuvants. Finally, novel formulations might be more efficient and might improve the patient's adherence to the treatment. This user's guide reviews current knowledge and aims to provide clinical guidance to healthcare professionals taking care of children undergoing allergen immunotherapy.

The allergenic activity and clinical impact of individual IgE-antibody binding molecules from indoor allergen sources

A large number of allergens have been discovered but we know little about their potential to induce inflammation (allergenic activity) and symptoms. Nowadays, the clinical importance of allergens is determined by the frequency and intensity of their IgE antibody binding (allergenicity). This is a rather limited parameter considering the development of experimental allergology in the last 20 years and the criteria that support personalized medicine. Now it is known that some allergens, in addition to their IgE antibody binding properties, can induce inflammation through non IgE mediated pathways, which can increase their allergenic activity. There are several ways to evaluate the allergenic activity, among them the provocation tests, the demonstration of non-IgE mediated pathways of inflammation, case control studies of IgE-binding frequencies, and animal models of respiratory allergy. In this review we have explored the current status of basic and clinical research on allergenic activity of indoor allergens and confirm that, for most of them, this important property has not been investigated. However, during recent years important advances have been made in the field, and we conclude that for at least the following, allergenic activity has been demonstrated: Der p 1, Der p 2, Der p 5 and Blo t 5 from HDMs; Per a 10 from P. americana; Asp f 1, Asp f 2, Asp f 3, Asp f 4 and Asp f 6 from A. fumigatus; Mala s 8 and Mala s 13 from M. sympodialis; Alt a 1 from A. alternata; Pen c 13 from P. chrysogenum; Fel d 1 from cats; Can f 1, Can f 2, Can f 3, Can f 4 and Can f 5 from dogs; Mus m 1 from mice and Bos d 2 from cows. Defining the allergenic activity of other indoor IgE antibody binding molecules is necessary for a precision-medicine-oriented management of allergic diseases.

Molecular approaches to allergen-specific immunotherapy: Are we so far from clinical implementation?

Conventional allergen-specific immunotherapy (AIT), based on administrations of allergen extracts, represents up to now the unique protocol for the desensitization of allergic patients. Whereas the effectiveness of AIT was evidenced for the treatment of allergic rhinitis and allergic asthma, such strategy remains experimental for food allergies up to now. However, important issues are commonly associated with AIT as the quality of natural allergen extracts, the long duration and adverse side-effects which negatively affect successful desensitization together with the patient compliance. The rapid progression of molecular allergology made possible the quest of safer, shorter and more effective immunotherapeutic approaches. The aim of this review was to provide an update on these different innovative recombinant derivatives including their efficacy but also their limitations. Despite promising preclinical and early clinical studies, the absence of convincing data in large phase III trials precludes so far the translation of these immunotherapeutic candidates into the clinic.