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Allergy to grass pollen: mapping of Dactylis glomerata and Phleum pratense allergens for dogs by two-dimensional immunoblotting. Postepy Dermatol Alergol 2017; 34:60-69. [PMID: 28261033 PMCID: PMC5329108 DOI: 10.5114/ada.2017.65623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 12/25/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Much less is known about grass-pollen allergens to dogs, when compared with humans. Genetic-based patterns might play an important role in sensitization profiles, conditioning the success of allergen-specific immunotherapy. AIM Mapping of Dactylis glomerata (D. glomerata) and Phleum pratense (P. pratense) allergens for grass pollen-sensitized atopic dogs, for better understanding how individual allergograms may influence the response to grass-pollen immunotherapy. MATERIAL AND METHODS To identify D. glomerata and P. pratense allergoms for dogs, 15 individuals allergic to grass pollen and sensitized to D. glomerata and P. pratense were selected. D. glomerata and P. pratense proteomes were separated by isoelectric focusing (IEF), one-dimensional (1-D) and two-dimensional (2-D) sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE). Separated proteins were blotted onto Polyvinylidene difluoride (PVDF) membranes and allergens were identified by patient sera IgE in Western Blotting (WB). RESULTS In D. glomerata, 17 allergens were identified from IEF and 11 from 1-D SDS-PAGE, while from P. pratense, 18 and 6 allergens were identified, respectively. From 2-D SDS-PAGE 13 spots were identified from D. glomerata and 27 from P. pratense. CONCLUSIONS Several similarities were found between dog and human D. glomerata and P. pratense sensitization profiles but no relationship between clinical signs and a specific pattern of allergen recognition was observed. Similarities were found in each patient pattern of sensitization between D. glomerata and P. pratense, also suggesting cross-reactive phenomena. Further molecular epidemiology approach is needed to understand the role of the sensitization pattern in allergen-specific immunotherapy effectiveness in grass-pollen allergic dogs.
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Mahajan A, Youssef LA, Cleyrat C, Grattan R, Lucero SR, Mattison CP, Erasmus MF, Jacobson B, Tapia L, Hlavacek WS, Schuyler M, Wilson BS. Allergen Valency, Dose, and FcεRI Occupancy Set Thresholds for Secretory Responses to Pen a 1 and Motivate Design of Hypoallergens. THE JOURNAL OF IMMUNOLOGY 2016; 198:1034-1046. [PMID: 28039304 DOI: 10.4049/jimmunol.1601334] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/30/2016] [Indexed: 11/19/2022]
Abstract
Ag-mediated crosslinking of IgE-FcεRI complexes activates mast cells and basophils, initiating the allergic response. Of 34 donors recruited having self-reported shrimp allergy, only 35% had significant levels of shrimp-specific IgE in serum and measurable basophil secretory responses to rPen a 1 (shrimp tropomyosin). We report that degranulation is linked to the number of FcεRI occupied with allergen-specific IgE, as well as the dose and valency of Pen a 1. Using clustered regularly interspaced palindromic repeat-based gene editing, human RBLrαKO cells were created that exclusively express the human FcεRIα subunit. Pen a 1-specific IgE was affinity purified from shrimp-positive plasma. Cells primed with a range of Pen a 1-specific IgE and challenged with Pen a 1 showed a bell-shaped dose response for secretion, with optimal Pen a 1 doses of 0.1-10 ng/ml. Mathematical modeling provided estimates of receptor aggregation kinetics based on FcεRI occupancy with IgE and allergen dose. Maximal degranulation was elicited when ∼2700 IgE-FcεRI complexes were occupied with specific IgE and challenged with Pen a 1 (IgE epitope valency of ≥8), although measurable responses were achieved when only a few hundred FcεRI were occupied. Prolonged periods of pepsin-mediated Pen a 1 proteolysis, which simulates gastric digestion, were required to diminish secretory responses. Recombinant fragments (60-79 aa), which together span the entire length of tropomyosin, were weak secretagogues. These fragments have reduced dimerization capacity, compete with intact Pen a 1 for binding to IgE-FcεRI complexes, and represent a starting point for the design of promising hypoallergens for immunotherapy.
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Affiliation(s)
- Avanika Mahajan
- Department of Pathology, University of New Mexico, Albuquerque, NM 87131
| | - Lama A Youssef
- Department of Pharmaceutics and Pharmaceutical Technology, School of Pharmacy, Damascus University, Damascus, Syria.,National Commission for Biotechnology, Damascus, Syria
| | - Cédric Cleyrat
- Department of Pathology, University of New Mexico, Albuquerque, NM 87131
| | - Rachel Grattan
- Department of Pathology, University of New Mexico, Albuquerque, NM 87131
| | - Shayna R Lucero
- Department of Pathology, University of New Mexico, Albuquerque, NM 87131
| | - Christopher P Mattison
- Southern Regional Research Center, Agricultural Research Service, U.S. Department of Agriculture, New Orleans, LA 70124
| | - M Frank Erasmus
- Department of Pathology, University of New Mexico, Albuquerque, NM 87131
| | - Bruna Jacobson
- Department of Computer Sciences, University of New Mexico, Albuquerque, NM 87131
| | - Lydia Tapia
- Department of Computer Sciences, University of New Mexico, Albuquerque, NM 87131
| | - William S Hlavacek
- Theoretical Biology and Biophysics Group, Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM 87545.,Theoretical Biology and Biophysics Group, Center for Nonlinear Studies, Los Alamos National Laboratory, Los Alamos, NM 87545; and
| | - Mark Schuyler
- Department of Medicine, University of New Mexico, Albuquerque, NM 87131
| | - Bridget S Wilson
- Department of Pathology, University of New Mexico, Albuquerque, NM 87131;
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Jongejan L, van Ree R, Poulsen LK. Hypoallergenic molecules for subcutaneous immunotherapy. Expert Rev Clin Immunol 2015; 12:5-7. [PMID: 26558320 DOI: 10.1586/1744666x.2016.1103182] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although a large part of the population suffers from allergies, a cure is not yet available. Allergen-specific immunotherapy (AIT) offers promise for these patients. AIT has proven successful in insect and venom allergies; however, for food allergy this is still unclear. In this editorial we focus on the recent advances in a proof of concept study in food allergy, FAST (Food allergy specific immunotherapy), which may increase interest within the biomolecular and pharmaceutical industry to embark on similar projects of immunology driven precision medicine within the allergy field.
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Affiliation(s)
- Laurian Jongejan
- a Department of Experimental Immunology , Academic Medical Center , Amsterdam , The Netherlands
| | - Ronald van Ree
- a Department of Experimental Immunology , Academic Medical Center , Amsterdam , The Netherlands.,b Department of Otorhinolaryngology , Academic Medical Center , Amsterdam , The Netherlands
| | - Lars K Poulsen
- b Department of Otorhinolaryngology , Academic Medical Center , Amsterdam , The Netherlands
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House-dust mite allergy: mapping of Dermatophagoides pteronyssinus allergens for dogs by two-dimensional immunoblotting. Postepy Dermatol Alergol 2015; 32:73-81. [PMID: 26015775 PMCID: PMC4436239 DOI: 10.5114/pdia.2015.48067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/05/2014] [Accepted: 11/12/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction Specific immunotherapy has shown to be very useful for allergy control in dogs, with a common success rate ranging from 65% to 70%. However, this efficacy could probably be improved and the identification of individual allergomes, with the choice of more adequate molecular allergen pools for specific immunotherapy, being the strategy. Aim To map Dermatophagoides pteronyssinus (Der p) allergens for mite-sensitized atopic dogs, for better understanding how individual allergograms may influence the response to house-dust mite immunotherapy. Material and methods To identify the Der p mite allergome for dogs, 20 individuals allergic to dust-mites and sensitized to Der p, were selected. The extract from Der p was submitted to isoelectric focusing (IEF), one-dimensional (1-D) and two-dimensional (2-D) sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE). Separated proteins were blotted onto polyvinylidene difluoride (PVDF) membranes and immunoblottings were performed with patient sera. Allergen-bound specific IgE was detected. Results Eleven allergens were identified from isoelectric focusing (IEF), as well as from 1-D SDS PAGE. From 2-D SDS-PAGE, 24 spots were identified. Conclusions Several similarities were found between dog and human allergograms and no absolute correlation between sensitization and allergy was observed either. As in humans, different individual allergograms do not seem to implicate different clinical patterns, but may influence the response to specific immunotherapy. The molecular epidemiology approach in veterinary allergy management, by the characterization of individual patients’ allergoms and by choosing the best molecular allergen pool for each patient could also improve the efficacy of allergy immunotherapy.
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Effect of heat treatment on structure and immunogenicity of recombinant peanut protein Ara h 2.01. Lebensm Wiss Technol 2015. [DOI: 10.1016/j.lwt.2014.10.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Halim A, Carlsson MC, Madsen CB, Brand S, Møller SR, Olsen CE, Vakhrushev SY, Brimnes J, Wurtzen PA, Ipsen H, Petersen BL, Wandall HH. Glycoproteomic analysis of seven major allergenic proteins reveals novel post-translational modifications. Mol Cell Proteomics 2014; 14:191-204. [PMID: 25389185 DOI: 10.1074/mcp.m114.042614] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Allergenic proteins such as grass pollen and house dust mite (HDM) proteins are known to trigger hypersensitivity reactions of the immune system, leading to what is commonly known as allergy. Key allergenic proteins including sequence variants have been identified but characterization of their post-translational modifications (PTMs) is still limited. Here, we present a detailed PTM(1) characterization of a series of the main and clinically relevant allergens used in allergy tests and vaccines. We employ Orbitrap-based mass spectrometry with complementary fragmentation techniques (HCD/ETD) for site-specific PTM characterization by bottom-up analysis. In addition, top-down mass spectrometry is utilized for targeted analysis of individual proteins, revealing hitherto unknown PTMs of HDM allergens. We demonstrate the presence of lysine-linked polyhexose glycans and asparagine-linked N-acetylhexosamine glycans on HDM allergens. Moreover, we identified more complex glycan structures than previously reported on the major grass pollen group 1 and 5 allergens, implicating important roles for carbohydrates in allergen recognition and response by the immune system. The new findings are important for understanding basic disease-causing mechanisms at the cellular level, which ultimately may pave the way for instigating novel approaches for targeted desensitization strategies and improved allergy vaccines.
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Affiliation(s)
- Adnan Halim
- From the ‡Copenhagen Center for Glycomics and Department of Cellular and Molecular Medicine, Faculty of Health Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark
| | - Michael C Carlsson
- From the ‡Copenhagen Center for Glycomics and Department of Cellular and Molecular Medicine, Faculty of Health Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark
| | - Caroline Benedicte Madsen
- From the ‡Copenhagen Center for Glycomics and Department of Cellular and Molecular Medicine, Faculty of Health Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark
| | | | - Svenning Rune Møller
- From the ‡Copenhagen Center for Glycomics and Department of Cellular and Molecular Medicine, Faculty of Health Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark; ¶Department of Plant and Environmental Biology, Glyco section, Faculty of Science, University of Copenhagen 1871 Frederiksberg C, Denmark
| | - Carl Erik Olsen
- ¶Department of Plant and Environmental Biology, Glyco section, Faculty of Science, University of Copenhagen 1871 Frederiksberg C, Denmark
| | - Sergey Y Vakhrushev
- From the ‡Copenhagen Center for Glycomics and Department of Cellular and Molecular Medicine, Faculty of Health Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark
| | | | | | | | - Bent L Petersen
- From the ‡Copenhagen Center for Glycomics and Department of Cellular and Molecular Medicine, Faculty of Health Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark; ¶Department of Plant and Environmental Biology, Glyco section, Faculty of Science, University of Copenhagen 1871 Frederiksberg C, Denmark
| | - Hans H Wandall
- From the ‡Copenhagen Center for Glycomics and Department of Cellular and Molecular Medicine, Faculty of Health Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark;
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Weiss R, Scheiblhofer S, Roesler E, Weinberger E, Thalhamer J. mRNA vaccination as a safe approach for specific protection from type I allergy. Expert Rev Vaccines 2014; 11:55-67. [DOI: 10.1586/erv.11.168] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Makatsori M, Pfaar O, Lleonart R, Calderon MA. Recombinant allergen immunotherapy: clinical evidence of efficacy--a review. Curr Allergy Asthma Rep 2013; 13:371-80. [PMID: 23740287 DOI: 10.1007/s11882-013-0359-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Recombinant allergens for immunotherapy aim to overcome the problems of natural extracts as they can be produced in unlimited amounts with exact physiochemical and immunological properties. These can be modified to have more favourable characteristics including reduced IgE reactivity or enhanced immunogenicity. Different types of recombinant allergens have been evaluated in clinical phase II and III trials whilst others are currently under development. In this review, we identified double-blind, placebo-controlled randomised clinical trials assessing the efficacy and safety of various recombinant allergen preparations. The majority of studies have up to now focused on cat, grass, birch, ragweed and bee venom allergens. Some studies have shown some of these preparations to be effective and well tolerated. However, there are still outstanding issues regarding optimum doses, minimising side effects and long-term effects.
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Affiliation(s)
- Melina Makatsori
- Section of Allergy and Clinical Immunology, Imperial College London, NHLI, Royal Brompton Hospital, London SW3 6LY, UK
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Zuidmeer-Jongejan L, Fernandez-Rivas M, Poulsen LK, Neubauer A, Asturias J, Blom L, Boye J, Bindslev-Jensen C, Clausen M, Ferrara R, Garosi P, Huber H, Jensen BM, Koppelman S, Kowalski ML, Lewandowska-Polak A, Linhart B, Maillere B, Mari A, Martinez A, Mills CE, Nicoletti C, Opstelten DJ, Papadopoulos NG, Portoles A, Rigby N, Scala E, Schnoor HJ, Sigurdardottir ST, Stavroulakis G, Stolz F, Swoboda I, Valenta R, van den Hout R, Versteeg SA, Witten M, van Ree R. FAST: towards safe and effective subcutaneous immunotherapy of persistent life-threatening food allergies. Clin Transl Allergy 2012; 2:5. [PMID: 22409908 PMCID: PMC3386014 DOI: 10.1186/2045-7022-2-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 03/09/2012] [Indexed: 11/24/2022] Open
Abstract
The FAST project (Food Allergy Specific Immunotherapy) aims at the development of safe and effective treatment of food allergies, targeting prevalent, persistent and severe allergy to fish and peach. Classical allergen-specific immunotherapy (SIT), using subcutaneous injections with aqueous food extracts may be effective but has proven to be accompanied by too many anaphylactic side-effects. FAST aims to develop a safe alternative by replacing food extracts with hypoallergenic recombinant major allergens as the active ingredients of SIT. Both severe fish and peach allergy are caused by a single major allergen, parvalbumin (Cyp c 1) and lipid transfer protein (Pru p 3), respectively. Two approaches are being evaluated for achieving hypoallergenicity, i.e. site-directed mutagenesis and chemical modification. The most promising hypoallergens will be produced under GMP conditions. After pre-clinical testing (toxicology testing and efficacy in mouse models), SCIT with alum-absorbed hypoallergens will be evaluated in phase I/IIa and IIb randomized double-blind placebo-controlled (DBPC) clinical trials, with the DBPC food challenge as primary read-out. To understand the underlying immune mechanisms in depth serological and cellular immune analyses will be performed, allowing identification of novel biomarkers for monitoring treatment efficacy. FAST aims at improving the quality of life of food allergic patients by providing a safe and effective treatment that will significantly lower their threshold for fish or peach intake, thereby decreasing their anxiety and dependence on rescue medication.
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De Souza Rebouças J, Esparza I, Ferrer M, Sanz ML, Irache JM, Gamazo C. Nanoparticulate adjuvants and delivery systems for allergen immunotherapy. J Biomed Biotechnol 2012; 2012:474605. [PMID: 22496608 PMCID: PMC3303624 DOI: 10.1155/2012/474605] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 10/19/2011] [Accepted: 10/25/2011] [Indexed: 12/21/2022] Open
Abstract
In the last decades, significant progress in research and clinics has been made to offer possible innovative therapeutics for the management of allergic diseases. However, current allergen immunotherapy shows limitations concerning the long-term efficacy and safety due to local side effects and risk of anaphylaxis. Thus, effective and safe vaccines with reduced dose of allergen have been developed using adjuvants. Nevertheless, the use of adjuvants still has several disadvantages, which limits its use in human vaccines. In this context, several novel adjuvants for allergen immunotherapy are currently being investigated and developed. Currently, nanoparticles-based allergen-delivery systems have received much interest as potential adjuvants for allergen immunotherapy. It has been demonstrated that the incorporation of allergens into a delivery system plays an important role in the efficacy of allergy vaccines. Several nanoparticles-based delivery systems have been described, including biodegradable and nondegradable polymeric carriers. Therefore, this paper provides an overview of the current adjuvants used for allergen immunotherapy. Furthermore, nanoparticles-based allergen-delivery systems are focused as a novel and promising strategy for allergy vaccines.
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Affiliation(s)
- Juliana De Souza Rebouças
- Adjuvant Unit, Department of Pharmacy and Pharmaceutical Technology, and Department of Microbiology, University of Navarra, 31008 Pamplona, Spain
| | - Irene Esparza
- Adjuvant Unit, Department of Pharmacy and Pharmaceutical Technology, and Department of Microbiology, University of Navarra, 31008 Pamplona, Spain
| | - Marta Ferrer
- Department of Allergy and Clinical Immunology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - María Luisa Sanz
- Department of Allergy and Clinical Immunology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Juan Manuel Irache
- Adjuvant Unit, Department of Pharmacy and Pharmaceutical Technology, and Department of Microbiology, University of Navarra, 31008 Pamplona, Spain
| | - Carlos Gamazo
- Adjuvant Unit, Department of Pharmacy and Pharmaceutical Technology, and Department of Microbiology, University of Navarra, 31008 Pamplona, Spain
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Bordas-Le Floch V, Bussières L, Airouche S, Lautrette A, Bouley J, Berjont N, Horiot S, Huet A, Jain K, Lemoine P, Chabre H, Batard T, Mascarell L, Baron-Bodo V, Tourdot S, Nony E, Moingeon P. Expression and characterization of natural-like recombinant Der p 2 for sublingual immunotherapy. Int Arch Allergy Immunol 2012; 158:157-67. [PMID: 22286395 DOI: 10.1159/000331143] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 07/25/2011] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Recombinant allergens with a native conformation represent an alternative to natural extracts for immunotherapy and diagnostic purposes. METHODS We produced the Der p 2 mite allergen in Pichia pastoris and Escherichia coli. After purification by cation exchange chromatography, recombinant molecules were compared to their natural counterpart based upon structural (disulfide bonds, secondary structure, thermal stability) and immunological properties (antibody reactivity, basophil and T cell activation, tolerance induction in a murine sublingual immunotherapy model). RESULTS The Der p 2.0101 isoform was confirmed to be prevalent in Dermatophagoides pteronyssinus extracts. It was then produced as a secreted molecule in P. pastoris or refolded from E. coli inclusion bodies. The yeast-expressed rDer p 2 molecule exhibits a natural-like disulfide bridge distribution and secondary structure, whereas the E. coli-derived rDer p 2 presents some heterogeneity in cysteine bonds and a lower stability following thermal stress. The two recombinant as well as natural Der p 2 molecules exhibit comparable IgE recognition and activate basophil and CD4+ T cells. Sublingual immunotherapy of nDer p 2- sensitized mice using either one of the rDer p 2 molecules efficiently decreases airway hyperresponsiveness as well as Th2 responses. CONCLUSIONS Natural and recombinant Der p 2 molecules produced in P. pastoris and E. coli exhibit comparable immunological properties despite distinct structural features. Natural-like cysteine pairing is a critical parameter to identify stable, well-folded and homogenous proteins appropriate for immunotherapy and diagnostic purposes.
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Current world literature. Curr Opin Allergy Clin Immunol 2011; 11:594-8. [PMID: 22027954 DOI: 10.1097/aci.0b013e32834d9a9f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW To identify and discuss studies on the molecular diagnosis of cow's milk allergy (CMA) with a view to update allergists since a general review of the methodology in 2006. RECENT FINDINGS Seven basic research studies reporting the use of component-resolved diagnostics in CMA were found. All studies were on children positively reacting to a formal challenge with cow's milk. Six studies used natural allergens and three used recombinant milk proteins. Microarray platforms were customized and, thus, differed across studies. Three studies assessed the association between molecular-scale patterns and different presentations of the condition, that is the association between anaphylaxis, gastrointestinal symptoms and other severe phenotypes and the pattern of protein sensitization. Two studies assessed the association between positive oral food challenge and the persistence of milk allergy over time. Protein profiling could be useful to indicate appropriate specific immunotherapy. SUMMARY Accurate diagnosis of CMA is challenging and essential. The determination of the immunoglobulin E (IgE)-mediated response to sequenced and characterized allergens may be more useful in predicting the presence and severity of clinical allergy than the currently used skin or blood tests performed with whole extracts. However, as component recognition pattern heterogeneity is observed in different areas, further clinical studies are essential to correlate useful molecular diagnostics and biological markers with disease and patient profiles. Until such markers are found and validated in different age groups, oral food challenge remains the reference standard for the diagnosis of CMA.
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