Cross-reactivity between deciduous trees during immunotherapy. I. In vivo results

The Lancet Weight Determines Wheal Diameter in Response to Skin Prick Testing with Histamine

BACKGROUND

Skin prick test (SPT) is a common test for diagnosing immunoglobulin E-mediated allergies. In clinical routine, technicalities, human errors or patient-related biases, occasionally results in suboptimal diagnosis of sensitization.

OBJECTIVE

Although not previously assessed qualitatively, lancet weight is hypothesized to be important when performing SPT to minimize the frequency of false positives, false negatives, and unwanted discomfort.

METHODS

Accurate weight-controlled SPT was performed on the volar forearms and backs of 20 healthy subjects. Four predetermined lancet weights were applied (25 g, 85 g, 135 g and 265 g) using two positive control histamine solutions (1 mg/mL and 10 mg/mL) and one negative control (saline). A total of 400 SPTs were conducted. The outcome parameters were: wheal size, neurogenic inflammation (measured by superficial blood perfusion), frequency of bleeding, and the lancet provoked pain response.

RESULTS

The mean wheal diameter increased significantly as higher weights were applied to the SPT lancet, e.g. from 3.2 ± 0.28 mm at 25 g to 5.4 ± 1.7 mm at 265 g (p<0.01). Similarly, the frequency of bleeding, the provoked pain, and the neurogenic inflammatory response increased significantly. At 265 g saline evoked two wheal responses (/160 pricks) below 3 mm.

CONCLUSION AND CLINICAL RELEVANCE

The applied weight of the lancet during the SPT-procedure is an important factor. Higher lancet weights precipitate significantly larger wheal reactions with potential diagnostic implications. This warrants additional research of the optimal lancet weight in relation to SPT-guidelines to improve the specificity and sensitivity of the procedure.

Allergic conjunctivitis: a comprehensive review of the literature

Ocular allergy represents one of the most common conditions encountered by allergists and ophthalmologists. Allergic conjunctivitis is often underdiagnosed and consequently undertreated. Basic and clinical research has provided a better understanding of the cells, mediators, and immunologic events, which occur in ocular allergy. New pharmacological agents have improved the efficacy and safety of ocular allergy treatment. An understanding of the immunologic mechanisms, clinical features, differential diagnosis, and treatment of ocular allergy may be useful to all specialists who deal with these patients. The purpose of this review is to systematically review literature underlining all the forms classified as ocular allergy: seasonal allergic conjunctivitis, perennial allergic conjunctivitis, vernal keratoconjunctivitis, atopic keratocongiuntivitis, contact allergy, and giant papillary conjunctivitis.

Immunotherapy with depigmented-polymerized mixed tree pollen extract: a clinical trial and responder analysis

BACKGROUND

Rhinoconjunctivitis because of tree pollen sensitization is common in Northern Europe. Specific subcutaneous immunotherapy (SCIT) is the only disease-modifying treatment, but unmodified allergen extracts carry a risk of allergic side-effects. Our objective was to examine efficacy and safety of a depigmented-polymerized mixed tree pollen extract.

METHODS

A double-blind, placebo-controlled trial of 184 tree pollen allergic adults was performed. SCIT consisted of four increasing doses at 7-day intervals, then maintenance injections every 6 weeks for 18 months. Primary outcome was combined symptom and medication score during the 2008 season. Secondary outcomes included analysis at different levels of pollen exposure and a responder analysis. Adverse events were classified using the EAACI scale. Birch pollen-specific IgE and IgG(4) were measured before and after treatment.

RESULTS

The combined symptom and medication score of actively treated patients was significantly lower than those on placebo (P < 0.04). Increased efficacy was seen at high pollen exposure (median score 2.1 for active [IQR 0.7-3.4] vs 4.2 [IQR 2.4-5.3] for placebo for days with 500 or more pollen grains per m(3) , a 50% reduction, P < 0.01). A modified responder analysis revealed 64% responders in the active and 32% in the placebo group (P < 0.01). There were 17 systemic reactions. All were mild (grade 1 or 2) and required no treatment. Serum birch-specific IgG(4) increased in the SCIT group (P < .01).

CONCLUSIONS

SCIT with depigmented- polymerized tree pollen extract was clinically effective and well tolerated. Responder analysis suggested that one-third of patients treated with immunotherapy may not respond.

Biology of tree pollen allergens

More than 25% of the population suffer from type I allergy. Pollens from trees of the Fagales, Oleaceae, and Cupressaceae belong to the most potent and frequent allergen sources. During the past 15 years, the nature of the most important allergens has been identified by molecular biological techniques, and recombinant allergens equivalent to the natural allergens have been produced. These advances provide insight into the biological functions of important allergens and allow the development of novel forms of diagnosis and therapy. In this review, we focus on Fagales allergens to illustrate the impact of recombinant allergens on diagnosis and therapy. We discuss structural similarities as a molecular basis for cross-reactivities and develop diagnostic concepts by using species-specific marker allergens as well as highly cross-reactive allergens. The identification of the allergen recognition profiles of patients with recombinant allergens allows a more precise selection of patients for available forms of allergy treatment. Moreover, we describe novel recombinant allergen-based forms of specific immunotherapy.

Provocation testing with recombinant allergens

In the past few decades, DNA technology has enabled the production of defined recombinant allergen molecules for diagnostic and therapeutic purposes. Recombinant allergens containing most of the relevant IgE epitopes present in natural allergen sources are now available and allergen proteins can be produced that are identical, without biological or batch-to-batch variation. A great advantage of recombinant allergens is that they can be used for component-resolved diagnostics, which makes it possible to establish the patient's individual IgE reactivity profile before therapy is selected. However, before recombinant allergens can be applied in clinical practice their biological activity has to be carefully investigated in vivo. We here describe the most commonly used provocation methods (skin tests (prick and intradermal), nasal, bronchial, and conjunctival provocations) and how they can be performed. We also discuss the results so far obtained with in vivo testing using recombinant allergens and envisage their future use for immunotherapy.

Dominating IgE-binding epitope of Bet v 1, the major allergen of birch pollen, characterized by X-ray crystallography and site-directed mutagenesis

Specific allergy vaccination is an efficient treatment for allergic disease; however, the development of safer vaccines would enable a more general use of the treatment. Determination of molecular structures of allergens and allergen-Ab complexes facilitates epitope mapping and enables a rational approach to the engineering of allergen molecules with reduced IgE binding. In this study, we describe the identification and modification of a human IgE-binding epitope based on the crystal structure of Bet v 1 in complex with the BV16 Fab' fragment. The epitope occupies approximately 10% of the molecular surface area of Bet v 1 and is clearly conformational. A synthetic peptide representing a sequential motif in the epitope (11 of 16 residues) did not inhibit the binding of mAb BV16 to Bet v 1, illustrating limitations in the use of peptides for B cell epitope characterization. The single amino acid substitution, Glu(45)-Ser, was introduced in the epitope and completely abolished the binding of mAb BV16 to the Bet v 1 mutant within a concentration range 1000-fold higher than wild type. The mutant also showed up to 50% reduction in the binding of human polyclonal IgE, demonstrating that glutamic acid 45 is a critical amino acid also in a major human IgE-binding epitope. By solving the three-dimensional crystal structure of the Bet v 1 Glu(45)-Ser mutant, it was shown that the change in immunochemical activity is directly related to the Glu(45)-Ser substitution and not to long-range structural alterations or collapse of the Bet v 1 mutant tertiary structure.

Fusarium culmorum causes strong degradation of pollen allergens in extract mixtures

BACKGROUND

Therapeutic allergen extracts are frequently stored as mixtures to provide preparations used for specific immunotherapy. Substantial protease activity, found in certain mold extracts, has been suspected to cause a loss of allergenic activity as a result of self-degradation, as well as by means of degradation of allergens from pollen and other allergenic sources.

OBJECTIVE

This study was performed to address possible deterioration of individual pollen allergens during storage of extract mixtures, with a mold extract as the source of proteolytic activity.

METHODS

Aqueous birch and timothy pollen extracts were stored for 60 days at 6 degrees C with and without addition of an extract derived from the mold Fusarium culmorum. The stability of the pollen allergens Bet v 1, Bet v 6, Phl p 1, and Phl p 5, as well as 2 to-date-undefined F culmorum allergens was examined by using immunoblotting analysis with sera from allergic patients and allergen-specific mAbs. Furthermore, the residual allergenic activity of the pollen extracts was monitored by using the rat basophilic leukemia cell-mediator release assay. Proteolytic activity of extracts was determined by using a commercial protease assay and gelatinase zymography.

RESULTS

Pollen extracts were very stable, corresponding to the low proteolytic activity of these extracts. In contrast, high proteolytic activity was found for the F culmorum extract, resulting in self-degradation of mold proteins and deactivation of allergens. Similarly, the mixtures showed a strong decrease of allergenic potency in the mediator release assay. Bet v 1 and Phl p 1 were relatively stable, whereas Bet v 6 and Phl p 5 were almost entirely degraded within 1 day.

CONCLUSIONS

Proteases of the mold F culmorum clearly affected the overall allergenic activity of pollen extracts within a short time period. Apart from general objections against the use of mixtures of non-cross-reacting allergens, mixing of pollen extracts with extracts derived from molds for immunotherapy is not recommended unless they are applied directly after preparation of the mixture.

Interpreting atmospheric pollen counts for use in clinical allergy: allergic symptomology

BACKGROUND

Allergists generally consider atmospheric pollen counts to be an estimate of the antigenic challenge confronting allergic individuals. The nature of this challenge depends on the particular pollen types found in the atmosphere and also the airborne concentration of these pollen types. Both clinical experience and clinical investigations support these assumptions; however, a coherent system for relating pollen counts and allergic symptomology does not exist.

OBJECTIVE

This review article will systematically review the medical and technical literature concerning the clinical significance of atmospheric pollen counts.

DATA SOURCES

This review article will consider three independent bodies of literature: 1) data contrasting human exposure patterns with rooftop pollen counts; 2) data concerning dose-response relationships between atmospheric pollen counts and allergic symptomology; and 3) data concerning methods for indexing atmospheric pollen counts based on a pollen type's in vivo allergenicity and terminal velocity.

RESULTS

Three principal results emerged. First, rooftop pollen counts imperfectly approximate human exposure to atmospheric pollen. Differences in both the concentration and type of pollen encountered by humans can be expected to differ from samples obtained on rooftops. Second, allergic symptomology is positively correlated with atmospheric pollen counts. Investigations involving Betula (birch) pollen offer quantitative dose-response models. Complex, nonlinear relationships that seem to reflect both the priming effect and late-phase reactions exist. Last, atmospheric pollen counts can be indexed based on a contemporary application of Thommen's postulates. This system provides allergists with a means to estimate the clinical significance of various pollen types by combining data concerning in vivo allergenicity and terminal velocity.

CONCLUSIONS

These conclusions should allow allergists to judge the clinical significance of atmospheric pollen counts with greater sophistication than was previously possible.

Allergen-specific immunotherapy in birch- and grass-pollen-allergic rhinitis. II. Side-effects

BACKGROUND

Allergen-specific immunotherapy (IT) involves the risk of side-effects. Different side-effect profiles have been reported for different allergens, and it would be of great benefit to be able more precisely to predict patient- and allergen-related risk factors.

METHODS

Fifty-two patients with rhinoconjunctivitis and allergy to birch as well as grass pollen participated in a 3-year IT study, with a baseline year followed by 2 years of treatment. During the first treatment year, the patients received double-blinded IT with either birch (Betula verrucosa) or grass (Phleum pratense) pollen extracts adsorbed to aluminum hydroxide. The following year, the other allergen extract was added. Assessment of systemic reactions (SRs) was performed, and related to patient pretreatment parameters such as seasonal symptoms and medication requirement, skin prick test (SPT), conjunctival provocation test (CPT), nasal provocation test (NPT), total and specific IgE, basophil histamine release (HR), eosinophil count (EOS), eosinophil cationic protein (ECP), and eosinophil protein X (EPX).

RESULTS

In total, 44 and 47 patients started IT with birch- and grass-pollen extracts, respectively. All SRs occurred during the dose-increase phase. No life-threatening SRs were observed. There were a higher number of patients with SRs during IT with grass pollen than IT with birch pollen, 21 vs five patients (P<0.001), with SRs to 3.3% of grass-pollen injections compared to 0.7% of birch-pollen injections (P<0.0001). The SRs of birch-pollen IT were mild, consisting of rhinoconjunctivitis and oral-pharyngeal itching, whereas asthma and urticaria episodes were observed in the grass-pollen IT. No difference was found in sensitivity to birch and grass, when measured by SPT, CPT, NPT, specific IgE, or HR, and no difference was found in age, duration of allergic symptoms, prevalence of asthma, mean seasonal birch/grass symptom score, eye-drop use, or antihistamine or prednisolone intake between the group with and without subsequent SRs to IT. No difference was found in EOS, serum ECP, or EPX, between the group with and without subsequent SRs to IT.

CONCLUSIONS

IT with grass-pollen extract seems to be associated with a higher number and more severe SRs than birch-pollen IT. Neither demographic data nor diagnostic tests of allergy such as specific IgE, HR, SPT, CPT, and NPT could identify the patients with subsequent SRs.

Evaluation of the new ophthalmic antihistamine, 0.05% levocabastine, in the clinical allergen challenge model of allergic conjunctivitis

The objective of this study was to evaluate the efficacy of 0.05% levocabastine, a new antihistamine formulated for ophthalmic use, compared with the placebo vehicle for the treatment of allergic conjunctivitis induced by ocular allergen challenge. Subjects who reacted. positively in both eyes on two separate occasions to ocular allergen challenge with grass, ragweed, or cat dander (N = 47) received one dose of 1 to 2 drops of 0.05% levocabastine in one eye and its vehicle in the other eye. After 10 minutes, the predetermined dose of allergen was instilled in both eyes. Signs and symptoms of allergic conjunctivitis were evaluated with biomicroscopy and subjective evaluation of itching after 3, 5, and 10 minutes. Four hours after drug administration, subjects were rechallenged and reevaluated to determine levocabastine's duration of action. Results showed that levocabastine was significantly more effective than placebo in inhibiting itching, hyperemia, eyelid swelling, chemosis, and tearing after the initial challenge and in inhibiting all parameters except eyelid swelling after the rechallenge 4 hours later (p < 0.05). These results demonstrate that levocabastine, currently the only ophthalmic antihistamine available that is not combined with a vasoconstrictor, is efficacious in the inhibition of itching, as well as all of the allergic signs of a vascular origin, with a duration of action of at least 4 hours. Because of its strong effects on itching and hyperemia, chemosis, lid swelling, and tearing, levocabastine would be a valuable therapeutic agent to add to the heterogeneous family of antiallergic compounds presently available for the treatment of seasonal allergic conjunctivitis.

Mechanism of allergenic cross-reactions--IV. Evidence for participation of aromatic residues in the ligand binding site of two multi-specific IgE monoclonal antibodies

The binding sites of two IgE monoclonal antibodies (mAbs), LA2 and LB4, were examined by absorption, fluorescence spectroscopy and computer-aided molecular modeling (CAMM). Absorption spectra revealed the formation of 1:1 molecular complexes for both LA2 and LB4 with a variety of structurally different ligands. For mAb LA2, the binding constants for ligands consisting of different amino acid derivatives coupled to DNP could be divided into two groups, suggesting that certain amino acid side chains (e.g. hydrophobic) of the derivatives were a contributing feature in ligand recognition. The presence of a charge-transfer band (320-340 nm) was also observed for complexation with several different ligands, indicative of aromatic ligand interactions with mAb binding site tryptophans. CAMM studies of the Fv region for both mAb support of the empirical observations and inspection of the Fv models reveal numerous binding site aromatic residues that are likely candidates for ligand recognition and complexation. The multi-specificity of these mAbs for different ligands may be due to a multitude of interactions with aromatic residues in the binding sites.

Specificity mapping of patients IgE response towards the tree pollen major allergens Aln g I, Bet v I and Cor a I

The specificity pattern of IgE from non-treated tree pollen allergic patients (n = 38) were evaluated by solid phase absorption of serum samples followed by CRIE on alder, birch and hazel CIE precipitation profiles. The majority of the serum samples seemed to contain IgE antibodies with the following characteristics: specific towards Bet v I alone and common between Aln g I, Bet v I and/or Cor a I, 'II'. The IgE specificity profiles observed for 95% of the sera tested are compatible with birch pollen allergens being the only sensitizing allergens, indicating that the patients react to allergens from other tree pollens of the Fagales order due to IgE cross-reaction with the major allergens of birch and alder and/or hazel pollens.

Immunotherapy of tree pollen allergy with a modified alginate conjugated birch pollen extract compared to an aluminium adsorbed extract

The safety and efficacy of two birch pollen extracts, one chemically conjugated to alginate (Anjuvac) the other adsorbed to aluminium hydroxide (Alutard), were investigated in an open multicentre comparative study of 63 birch pollen allergic patients. Both extracts decreased the nasal symptoms during the birch pollen season. The changes in specific IgE and IgG were much the same in both treatment groups. The adverse reactions recorded were mild in both groups, but more frequent in the Anjuvac group, probably because of a more aggressive dose schedule though there were twice as many asthmatics in the Anjuvac group. The two investigated allergen extracts were useful alternatives for immunotherapy.

Specific IgE and IgG antibody responses in children to timothy pollen components during immunotherapy

Fourteen children with timothy grass pollinosis were given immunotherapy (IT) for 3 years with a purified and characterized timothy grass pollen preparation or a crude aqueous timothy pollen extract. Crossed radioimmunoelectrophoresis (CRIE) showed that 75% of the children under 11 years of age developed new specificities of IgE antibodies against timothy antigens, in contrast to older children, where no development of IgE antibodies against new timothy antigens could be detected. IgE antibodies were only detected against antigens formerly known as allergens. Timothy-specific IgG antibodies increased in most children during hyposensitization against the major allergens Ag 19 and Ag 24/25 and several other IgE-binding timothy antigens.

Immunotherapy with partially purified and standardized tree pollen extracts. I. Clinical results from a three-year double-blind study of patients treated with pollen extracts either of birch or combinations of alder, birch and hazel

Fifty-four adult patients with tree pollen-induced rhinitis (28), asthma (1), or rhinitis and asthma (25) were selected for immunotherapy with standardized and partly purified tree pollen extracts using a double blind protocol. The selection was based on clinical history, results of nasal or bronchial challenge, skin prick tests and RAST. Further, based on crossed radio-immunoelectrophoresis, sex, age and severity of symptoms, the patients were allocated in matched pairs and the treatment alternatives were randomly distributed within the pairs. Twenty-three patients treated with extracts composed of any combination of alder, birch and hazel pollen which matched their IgE response in CRIE (Group 1 (ABC)) and 22 patients receiving birch pollen extracts (Group 2 (B)) completed all 3 years of treatment. The in vivo results comprising symptom and medicine consumption scores are given here. Changes in specific skin and nasal reactivity as well as in immunological parameters are presented separately. No significant differences were demonstrated between the treatment groups in the two parameters. Both extracts were effective and reduced in general the symptom scores to one tenth of the starting level. Expressed another way, at the end of the study, the patients tolerated 30 times more pollen until symptoms of the same severity were elicited, compared to before. In the Nordic countries, spring-time asthma and rhino-conjunctivitis caused by pollen from deciduous trees can be effectively treated with an extract of birch pollen alone.

Immunotherapy to deciduous tree pollens: specific IgE and IgG antibody patterns

Thirty-nine children with birch pollinosis were given immunotherapy (IT) for 3 years with a purified, characterized and biologically standardized pollen preparation made from either birch or a mixture of birch, alder and hazel. Levels of IgE antibodies against birch, alder and oak increased early during IT (P less than 0.01) and then decreased below the initial level (P less than 0.01). Birch-specific IgG antibodies also increased (P less than 0.01) but not as rapidly as birch-specific IgE antibodies and the levels remained increased throughout IT. There were only weak correlations between immunochemical findings before IT or during early IT on one hand and the improvement during IT on the other hand. The ratio birch-specific IgG:IgE after 1.5 and 2.5 years of IT correlated with symptom scores the following season (P less than 0.01). In 60% of the children below 13 years of age, new IgE specificities developed during IT as demonstrated with crossed radioimmunoelectrophoresis. No such new IgE specificities were found in older children. These 'new sensitivities' did not appear to have any clinical implication.

Tree pollen allergy. III. Cross reactions based on results from skin prick tests and the RAST in hay fever patients. A multi-centre study

872 adult hay fever patients were investigated with skin tests, using 20 different tree pollen allergens, and Phadebas RAST, using eight different tree pollen allergens. Correlation between test results with the different allergens were studied employing the Spearman's correlation coefficient (Rho). Most combinations showed statistically significant correlations. The highest values of Rho (0.8-0.9) were found for pollen from combinations of trees belonging to the families Betulaceae, Corylaceae and Fagaceae (birch, alder, hazel, beech and oak). High values were also found between pollens from aspen and sallow (belonging to Salicaceae). With several of the trees a high degree of pollen cross sensitization was found, even with trees from a different plant family. Since most of the patients were allergic to birch pollen, some of the reactions to other pollens could be due to allergens shared by birch. To exclude this possibility, a separate analysis was performed for patients having no birch pollen allergy. Even in these patients evidence of cross sensitization was found. It is concluded that cross reactions are common among tree pollens and are most pronounced within botanical families.