Allergen chip diagnosis for soy-allergic patients: Gly m 4 as a marker for severe food-allergic reactions to soy

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.

Structural and Immunologic Properties of the Major Soybean Allergen Gly m 4 Causing Anaphylaxis

Gly m 4 is the major soybean allergen, causing birch pollen cross allergic reactions. In some cases, Gly m 4-mediated anaphylaxis takes place, but the causative factors are still unknown. Here, we studied the structural and immunologic properties of Gly m 4 to shed light on this phenomenon. We showed that Gly m 4 retained its structure and IgE-binding capacity after heating. Gly m 4 was cleaved slowly under nonoptimal gastric conditions mimicking duodenal digestion, and IgE from the sera of allergic patients interacted with the intact allergen rather than with its proteolytic fragments. Similar peptide clusters of Bet v 1 and Gly m 4 were formed during allergen endolysosomal degradation in vitro, but their sequence identity was insignificant. Animal polyclonal anti-Gly m 4 and anti-Bet v 1 IgG weakly cross-reacted with Bet v 1 and Gly m 4, respectively. Thus, we supposed that not only conserved epitopes elicited cross-reactivity with Bet v 1, but also variable epitopes were present in the Gly m 4 structure. Our data suggests that consumption of moderately processed soybean-based drinks may lead to the neutralizing of gastric pH as a result of which intact Gly m 4 can reach the human intestine and cause IgE-mediated system allergic reactions.

Investigation of differences in allergenicity of protein from different soybean cultivars through LC/MS-MS

Soybean allergy is a health-threatening issue and identifying raw soybeans with low allergenicity is important for producing hypoallergenic soybean products. Soybean allergy is mainly triggered by soybean proteins. In this study, the protein profiles, allergen compositions, and epitopes in protein from different soybean cultivars (R1, R2 and R3) were evaluated by SDS-PAGE and LC/MS-MS, and their allergenicity was assessed by indirect ELISA and Western blot analysis using the serum IgE of patients allergic to soybeans. The lowest allergenicity was observed in R3, probably resulting from the low concentration of Gly m 4-Gly m 6. The allergenicity of soybeans is affected by multiple allergens rather than a single allergen. Venn diagram, PCA, heatmap, and peptide map analyses have shown the differences in protein and peptide profiles among soybean proteins from different soybean cultivars. Epitope analysis further demonstrated that low contents of dominant epitopes in Gly m 4 and Gly m 5 contributed to low allergenicity in R3, although R3 contained high contents of no-dominant epitopes.

BSACI guideline for the diagnosis and management of pollen food syndrome in the UK

Pollen food syndrome (PFS) is a highly prevalent food allergy affecting pollen-sensitized children and adults. Sufferers experience allergic symptoms when consuming raw plant foods, due to the homology between the pollen allergens and unstable proteins in these foods. The triggers involved can vary depending on the pollen sensitization, which in turn is affected by geographical location. The British Society of Allergy and Clinical Immunology (BSACI) Standards of Care Committee (SOCC) identified a need to develop a guideline for the diagnosis and management of PFS in the United Kingdom (UK). Guidelines produced by the BSACI use either the GRADE or SIGN methodology; due to a lack of high-quality evidence these recommendations were formulated using the SIGN guidelines, which is acknowledged to be less robust than the GRADE approach. The correct diagnosis of PFS ensures the avoidance of a misdiagnosis of a primary peanut or tree nut allergy or confusion with another plant food allergy to non-specific lipid transfer proteins. The characteristic foods involved, and rapid-onset oropharyngeal symptoms, mean PFS can often be diagnosed from the clinical history alone. However, reactions involving tree nuts, peanuts and soya milk or severe/atypical reactions to fruits and vegetables may require additional diagnostic tests. Management is through the exclusion of known trigger foods, which may appear to be simple, but is highly problematic if coupled with a pre-existing food allergy or for individuals following a vegetarian/vegan diet. Immunotherapy to pollens is not an effective treatment for PFS, and although oral or sublingual immunotherapy to foods seems more promising, large, controlled studies are needed. The typically mild symptoms of PFS can lead to an erroneous perception that this condition is always easily managed, but severe reactions can occur, and anxiety about the onset of symptoms to new foods can have a profound effect on quality of life.

Diagnostic therapeutic care pathway for pediatric food allergies and intolerances in Italy: a joint position paper by the Italian Society for Pediatric Gastroenterology Hepatology and Nutrition (SIGENP) and the Italian Society for Pediatric Allergy and Immunology (SIAIP)

Epidemiologic data suggest an increased prevalence of pediatric food allergies and intolerances (FAIs) during the last decades. This changing scenario has led to an increase in the overall healthcare costs, due to a growing demand for diagnostic and treatment services. There is the need to establish Evidence-based practices for diagnostic and therapeutic intervention that could  be adopted in the context of public health policies for FAIs are needed.

This joint position paper has been prepared by a group of experts in pediatric gastroenterology, allergy and nutrition from the Italian Society for Pediatric Gastroenterology Hepatology and Nutrition (SIGENP) and the Italian Society for Pediatric Allergy and Immunology (SIAIP). The paper is focused on the Diagnostic Therapeutic Care Pathway (DTCP) for pediatric FAIs in Italy.

Utility of the Basophil Activation Test Using Gly m 4, Gly m 5 and Gly m 6 Molecular Allergens for Characterizing Anaphylactic Reactions to Soy

There are two major clinically described forms of IgE-dependent soy allergy: (i) a primary dietary form, linked to sensitization against soy storage proteins Gly m 5 and Glym 6, and (ii) a form included in birch-soy syndromes linked to Gly m 4, a PR-10-like allergen. This second form sometimes causes severe systemic reactions, even anaphylaxis, especially on consuming certain forms of soy such as soymilks or smoothies. Skin prick tests and specific IgE assays against soy whole extracts lack sensitivity. Assays of anti-Gly m 4, Gly m 5 and Gly m 6 specific IgEs have been developed to overcome this obstacle, but they unfortunately lack specificity, especially for anti-Gly m 4. We hypothesized that the basophil activation test (BAT) using molecular soy allergens Gly m 4, Gly m 5 and Gly m 6 would both remedy the lack of sensitivity of other tests and offer, through its mechanistic contribution, greater specificity than the assay of anti-Gly m 4 specific IgEs. This would enable the two types of soy allergy to be separately identified. In a characteristic clinical example of PR-10-induced anaphylactic reaction after consuming soymilk, we report preliminary results of Gly m 4-exclusive positivity of BAT supporting our hypothesis. It will be necessary to confirm these results on more patients in subsequent studies, and to specify the place of the BAT in an overall diagnostic strategy. Meanwhile, soy BAT using molecular allergens is a promising diagnostic tool for soy allergy and probably also for follow-up in specific immunotherapies.

Characterization of the Reduced IgE Binding Capacity in Boiled and Autoclaved Soybeans through Proteomic Approaches

The study investigated the changes in IgE binding capacity, protein profiles and peptide compositions after soybeans were boiled and autoclaved. The results of ELISA showed that the IgE binding capacity of soybean was reduced by 69.3% and 88.9% after boiling and autoclaving, respectively. Above 43 and 10 kDa proteins disappeared in boiled and autoclaved soybeans from SDS-PAGE, respectively. A Venn diagram and heat map showed that there was no change in allergen types and a reduction in allergen contents in the boiled and autoclaved soybeans. The changes in peptide compositions were also observed in the boiled and autoclaved soybeans through Venn diagram, PCA and heat map. LC/MS-MS and peptide mapping analysis demonstrated that boiling and autoclaving masked many epitopes in Gly m 4 and Gly m 5, such as ALVTDADNVIPK, SVENVEGNGGPGTIKK and KITFLEDGETK of Gly m 4 and VEKEECEEGEIPRPRPRPQHPER of Gly m 5, resulting in a reduction of IgE binding capacity in the extracted proteins. By contrast, the exposure of many epitopes in Gly m 6 was observed in boiled and autoclaved soybeans, which might be mainly responsible for the existing IgE binding capacity in the treated soybean proteins. Interestingly, the IgE binding capacity of soybeans showed a positive correlation with the total contents and number of peptides in Gly m 4-Gly m 6.

Isotretinoin-associated exercise-induced anaphylaxis in a patient with birch pollinosis and soybean sensitization: case presentation and literature review

Background

Peanut and soybean allergies are listed as contraindication in the package leaflet of isotretinoin, a widely used treatment of acne vulgaris. Cross-reactivity between PR10-proteins in peanut, tree nuts, and soybean is particularly common in patients with birch pollinosis and may lead to anaphylactic reactions in sensitized patients after intake of soybean oil containing isotretinoin capsules.

Case presentation

Here, we describe a young man with hazelnut and birch pollen allergy, who experienced exercise-induced anaphylaxis after isotretinoin intake on the third day of treatment. A complete allergy work-up was carried out, and sensitization to both peanut and soybean PR10-proteins was confirmed. However, oral provocation with isotretinoin remained negative in the absence of intense physical activity and longterm treatment was well tolerated.

Conclusion

To our knowledge, this is the first report of an exercise-induced anaphylaxis due to isotretinoin therapy. Our literature review to assess tolerability of isotretinoin in patients allergic to peanut, tree nuts or soybean revealed only one other case of anaphylaxis in a cashew-nut allergic patient sensitized to soybean PR10-protein Gly m 4. While there are no reports on soybean allergic patients treated with isotretinoin, the vast majority of peanut or tree nut allergic patients tolerated isotretinoin. Therefore, we conclude that sensitization to soybean, peanut or tree nuts should not preclude isotretinoin therapy. Particular caution is however warranted in patients with soybean sensitization. Pre-treatment oral challenges with isotretinoin may be recommended and physicians should be aware of the potential role of cofactors.

Investigation of Sensitization Potential of the Soybean Allergen Gly m 4 by Using Caco-2/Immune Cells Co-Culture Model

The soybean allergen Gly m 4 is known to cause severe allergic reactions including anaphylaxis, unlike other Bet v 1 homologues, which induce mainly local allergic reactions. In the present study, we aimed to investigate whether the food Bet v 1 homologue Gly m 4 can be a sensitizer of the immune system. Susceptibility to gastrointestinal digestion was assessed in vitro. Transport through intestinal epithelium was estimated using the Caco-2 monolayer. Cytokine response of different immunocompetent cells was evaluated by using Caco-2/Immune cells co-culture model. Absolute levels of 48 cytokines were measured by multiplex xMAP technology. It was shown that Gly m 4 can cross the epithelial barrier with a moderate rate and then induce production of IL-4 by mature dendritic cells in vitro. Although Gly m 4 was shown to be susceptible to gastrointestinal enzymes, some of its proteolytic fragments can selectively cross the epithelial barrier and induce production of Th2-polarizing IL-5, IL-10, and IL-13, which may point at the presence of the T-cell epitope among the crossed fragments. Our current data indicate that Gly m 4 can potentially be a sensitizer of the immune system, and intercommunication between immunocompetent and epithelial cells may play a key role in the sensitization process.

The Allergen: Sources, Extracts, and Molecules for Diagnosis of Allergic Disease

Allergenic source materials include pollen, molds, animal dander, and insects; food allergens from nuts, grains, and animals; venoms; and salivary proteins from insects and ticks. Clinical diagnostic tests have used heterogeneous extracts from allergen source materials for skin prick tests (SPTs). In vitro laboratory methods using immunoassays or microarrays can detect serum IgE directed against allergenic proteins where clinical testing may not be suitable. Clinicians rely primarily on licensed commercial extracts of allergens for SPTs. Manufacturers and regulatory agencies have standardized selected extracts for identity, composition, and potency. Allergen sources contain multiple proteins. The IgE antibody responses to these proteins vary between allergic subjects as does the quantity of specific IgE. Component-resolved molecular diagnostics can be used to improve the specificity of allergy testing and resolve clinical cross-reactivities that may affect treatment outcomes. This clinical commentary will review methods for the production, evaluation, and standardization of allergen extracts from the perspective of diagnostic testing that may be useful for allergists in practice.

Veganism and paediatric food allergy: two increasingly prevalent dietary issues that are challenging when co-occurring

Vegan diets – defined as the exclusion of all foods of animal origin from the diet- are becoming popular. In recent years, the prevalence of food allergy has also increased, and disproportionately affects children. When vegan diets and food allergy co-occur, this combination can be challenging and pose risks of nutritional deficiencies, particularly during childhood. In this paper, we aim to summarise the major concerns regarding vegan diets and food allergy, review the literature on this topic, and provide some suggestions for healthcare providers, particularly dietitians and nutritionists, who work with food allergic, vegan patients and their family. When working with this patient population, a regular and complete medical nutrition history, including screening for any possible nutritional deficiencies, is warranted. Likewise, the routine tracking of serum markers (especially iodine, iron, zinc, calcium, Vitamins B12, D, B2, and A, selected n-3 fatty acids and protein, which are more abundant in animal vs. plant foods) and symptoms of co-morbid diseases, including asthma, is important, as comorbid diseases may increase energy and nutrient requirements. For infants and children, anthropometry ought to be tracked longitudinally at regular intervals to identify any deviations from the child’s previous growth pattern, and to accommodate any increased requirements for growth and development. Correct diagnoses, education and allergy management must be disseminated to the family in a clear and appropriate manner. Children with allergy may have increased nutritional needs due to comorbidity. This is complicated by coincident food allergy and vegan diet as both impose diet restrictions (limiting sources of important nutrients, need for dietary variety and/or increased consumption due to reduced bioavaliability).

Molecular approach to a patient's tailored diagnosis of the oral allergy syndrome

Oral allergy syndrome (OAS) is one of the most common IgE-mediated allergic reactions. It is characterized by a number of symptoms induced by the exposure of the oral and pharyngeal mucosa to allergenic proteins belonging to class 1 or to class 2 food allergens. OAS occurring when patients sensitized to pollens are exposed to some fresh plant foods has been called pollen food allergy syndrome (PFAS). In the wake of PFAS, several different associations of allergenic sources have been progressively proposed and called syndromes. Molecular allergology has shown that these associations are based on IgE co-recognition taking place between homologous allergens present in different allergenic sources. In addition, the molecular approach reveals that some allergens involved in OAS are also responsible for systemic reactions, as in the case of some food Bet v 1-related proteins, lipid transfer proteins and gibberellin regulated proteins. Therefore, in the presence of a convincing history of OAS, it becomes crucial to perform a patient's tailored molecule-based diagnosis in order to identify the individual IgE sensitization profile. This information allows the prediction of possible cross-reactions with homologous molecules contained in other sources. In addition, it allows the assessment of the risk of developing more severe symptoms on the basis of the features of the allergenic proteins to which the patient is sensitized. In this context, we aimed to provide an overview of the features of relevant plant allergenic molecules and their involvement in the clinical onset of OAS. The value of a personalized molecule-based approach to OAS diagnosis is also analyzed and discussed.

A WAO - ARIA - GA2LEN consensus document on molecular-based allergy diagnosis (PAMD@): Update 2020

Precision allergy molecular diagnostic applications (PAMD@) is increasingly entering routine care. Currently, more than 130 allergenic molecules from more than 50 allergy sources are commercially available for in vitro specific immunoglobulin E (sIgE) testing. Since the last publication of this consensus document, a great deal of new information has become available regarding this topic, with over 100 publications in the last year alone. It thus seems quite reasonable to publish an update. It is imperative that clinicians and immunologists specifically trained in allergology keep abreast of the new and rapidly evolving evidence available for PAMD@.

PAMD@ may initially appear complex to interpret; however, with increasing experience, the information gained provides relevant information for the allergist. This is especially true for food allergy, Hymenoptera allergy, and for the selection of allergen immunotherapy. Nevertheless, all sIgE tests, including PAMD@, should be evaluated within the framework of a patient's clinical history, because allergen sensitization does not necessarily imply clinical relevant allergies.

Food-Induced Anaphylaxis: Role of Hidden Allergens and Cofactors

Food anaphylaxis is on the increase, with those who have an allergy to peanuts, tree nuts, milk, and seafood at the highest risk of developing such a reaction. However, the diet in many societies is increasingly varied, much of the food consumed is prepared outside the home, and meals are often composed of many different ingredients. Anaphylaxis may occur to a composite food, and it may be unclear whether the reaction is due to contamination or to a culprit allergen present in an added ingredient. Composite foods can contain many allergic proteins present in small amounts, which do not always have to be labeled, unless they feature in European or US labeling regulations. These “hidden” allergens include mustard, celery, spices, lupine, pea, natural food colourings, and preservatives, but can occasionally include allergenic material from contaminants such as cereal mites. Hidden allergens can provoke severe reactions to seemingly unconnected foods which might then lead to a diagnosis of idiopathic anaphylaxis. The same problem can arise with two well-known types of food allergy; wheat-dependant exercise induced anaphylaxis and allergy to non-specific Lipid Transfer Protein allergens, both of which might only manifest when linked to a cofactor such as exercise. Many of these risk factors for food anaphylaxis have a common link; the public's engagement with popular concepts of health and fitness. This includes the development of a food and exercise culture involving the promotion and marketing of foods for their health-giving properties i.e., meat substitutes, wheat substitutes, supplements and alternative, or “natural” remedies for common ailments. Some of these foods have been reported as the cause of severe allergic reactions, but because they are often viewed as benign unlikely causes of severe allergic reactions, could be considered to be hidden allergens. The best resource to elicit the likelihood of a hidden allergen provoking an allergic reaction is to take a detailed history of the allergic reaction, presence of co-factors, foods suspected, type of food and where it was consumed. A good knowledge of commonly used ingredients, and list of potential hidden allergen suspects are essential tools for the food allergy detective.

The immunome of soy bean allergy: Comprehensive identification and characterization of epitopes

BACKGROUND

The precise mapping of multiple antibody epitopes recognized by patients' sera allows a more detailed and differentiated understanding of immunological diseases. It may lead to the development of novel therapies and diagnostic tools.

OBJECTIVE

Mapping soy bean specific epitopes relevant for soy bean allergy patients and persons sensitized to soy bean, and analysis of their IgE/IgG binding spectrum.

METHODS

Identification of epitopes using sera, applying an optimized peptide phage display library followed by next-generation sequencing, specially designed in silico data analysis and subsequent peptide microarray analysis.

RESULTS

We were able to identify more than 400 potential epitope motifs in soy bean proteins. More than 60% of them have not yet been described as potential epitopes. Eighty-three peptides, representing the 42 most frequently found epitope candidates, were validated by microarray analysis using 50 sera from people who have been tested positive in skin prick test (SPT). Of these peptides, 56 were bound by antibodies, 55 by serum IgE, 43 by serum IgG and 30 by both. Person-specific epitope patterns were found for each individual and protein.

CONCLUSIONS

For individuals with clinical symptoms, epitope resolved analyses reveal a high prevalence of IgE binding to a few soy bean specific epitopes. Evaluation of individual immune profiles of patients with soy bean sensitization allows the identification of peptides that do facilitate studying individual IgE/IgG epitope binding patterns. This enables discrimination of sensitization from disease, such assay test has the potential to replace SPT assays.

Gly m 5/Gly m 8 fusion component as a potential novel candidate molecule for diagnosing soya bean allergy in Japanese children

BACKGROUND

Soya bean is a major food allergen in children. Component-resolved diagnostics has improved the accuracy of diagnosing immunoglobulin E (IgE)-mediated food allergies.

OBJECTIVE

We aimed to develop a novel component for the diagnosis of soya bean allergy using recombinant technology.

METHODS

Japanese paediatric patients with suspected soya bean allergy (n = 91) were included, and symptomatic (n = 40) and asymptomatic (n = 51) cases were divided through oral food challenge testing. Specific IgE (sIgE) antibodies to each recombinant allergen component were analysed by enzyme-linked immunosorbent assay, and the diagnostic performances of the components were assessed by area under the receiver operating characteristic curves (AUC).

RESULTS

Among the recombinant components, sIgE antibody levels to Gly m 8 showed the highest AUC (0.706). A combination of Gly m 8 and α' subunit of Gly m 5, improved the diagnostic performance of the single components. Moreover, the N-terminal extension region of α' subunit of Gly m 5, which has low cross-reactivity among the vicilins, showed higher diagnostic performance (AUC 0.695) than the full-length α' subunit of Gly m 5 (AUC 0.613). Based on these findings, we developed a fusion protein of Gly m 8 plus the extension region of α' subunit of Gly m 5; this fusion protein was very efficient for diagnosing soya bean allergy (AUC 0.801).

CONCLUSION

A fusion protein of Gly m 8 and the extension region of α' subunit of Gly m 5 could potentially diagnose soya bean allergy in paediatric patients. Fusion proteins may be useful for producing novel allergen components with improved diagnostic value.

ImmunoCAP® ISAC and Microtest for multiplex allergen testing in people with difficult to manage allergic disease: a systematic review and cost analysis

BACKGROUND

Allergy is a form of immune-mediated exaggerated sensitivity (hypersensitivity) to a substance that is either inhaled, swallowed, injected or comes into contact with the skin. Foreign substances that provoke allergies are called allergens. It has been claimed that multiplex allergen testing may help in diagnosing the cause of symptoms in patients with an unclear cause of allergy or who are allergic to more than one substance.

OBJECTIVES

To evaluate multiplex allergen testing [devices that can measure the presence of multiple immunoglobulin E (IgE) antibodies in a patient's blood at the same time], by assessing (1) clinical effectiveness (allergy symptoms, incidence of acute exacerbations, mortality, adverse events of testing and treatment, health-care presentations or admissions, health-related quality of life); (2) effects on treatment (diet, immunotherapy medications, other potential testing); (3) any additional diagnostic information provided by multiplex allergen testing; and (4) cost-effectiveness (cost of different assessment strategies).

METHODS

Fifteen databases were searched from 2005 to April 2015, including MEDLINE (via OvidSp), MEDLINE In-Process Citations, MEDLINE Daily Update, PubMed (National Library of Medicine), EMBASE, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, Science Citation Index (SCI), Conference Proceedings Citation Index-Science (CPCI-S), BIOSIS Previews, Latin American and Caribbean Health Sciences Literature (LILACS), National Institute for Health Research (NIHR) HTA programme, and the US Food and Drug Administration (FDA); supplementary searches of conference proceedings and trials registries were performed. Review methods followed published guidance from the Cochrane Collaboration and the Centre for Reviews and Dissemination, University of York, UK. The methodological quality of included studies was assessed using appropriate published tools or a review-specific tool designed by the project team. Studies were summarised in a narrative synthesis. Owing to a lack of data on the clinical effectiveness of multiplex allergen testing, no long-term cost-effectiveness model was developed. A conceptual model structure was developed and cost analyses were performed to examine the short-term costs of various possible diagnostic pathways.

RESULTS

Fifteen studies were included in the review. The very limited available data indicated that the addition of multiplex allergen testing [ImmunoCAP(®) Immuno Solid-phase Allergen Chip (ISAC), Thermo Fisher Scientific/Phadia AB, Uppsala, Sweden] to standard diagnostic work-up can change the clinicians' views on the diagnosis, management and treatment of patients. There was some indication that the use of ImmunoCAP ISAC testing may be useful to guide decisions on the discontinuation of restrictive diets, the content of allergen-specific immunotherapy (SIT) prescriptions, and whether or not patients should receive SIT. However, none of the studies that we identified reported any information on clinical outcomes subsequent to changes in treatment or management. There was some evidence that ImmunoCAP ISAC may be useful for discriminating allergens that are structurally similar and are recognised by the same IgE antibody (cross-immunoreactive). No data were available for Microtest (Microtest Matrices Ltd, London, UK). Detailed cost analyses suggested that multiplex allergen testing would have to result in a substantial reduction of the proportions of patients receiving single IgE testing and oral food challenge tests in order to be cost-saving in the short term.

CONCLUSIONS

No recommendations for service provision can be made based on the analyses included in this report. It is suggested that a consensus-based protocol for the use of multiplex allergen testing be developed. The clinical effectiveness and cost-effectiveness of the proposed protocol should then be assessed by comparing long-term clinical and quality of life outcomes and resource use in patients managed using the protocol with those managed using a standard diagnostic pathway.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015019739.

FUNDING

This project was a Diagnostic Assessment Report commissioned by the NIHR HTA programme on behalf of the National Institute for Health and Care Excellence.

Allergy to Peanut, Soybean, and Other Legumes: Recent Advances in Allergen Characterization, Stability to Processing and IgE Cross-Reactivity

Peanut and soybean are members of the Leguminosae family. They are two of the eight foods that account for the most significant food allergies in the United States and Europe. Allergic reactions to other legume species can be of importance in other regions of the world. The major allergens from peanut and soybean have been extensively analyzed and members of new protein families identified as potential marker allergens for symptom severity. Important recent advances concerning their molecular properties or clinical relevance have been made. Therefore, there is increasing interest in the characterization of allergens from other legume species such as lupine, lentil, chickpea, green bean, or pea. As legumes are mainly consumed after thermal processing, knowledge about the effect of such processing on the allergenicity of legumes has increased during the last years. In the present review, recent advances in the identification of allergens from peanut, soybean, lupine, and other legume species are summarized and discussed. An overview of the most recently described effects of thermal processing on the allergenic properties of legumes is provided and the potential IgE cross-reactivity among members of the Leguminosae family is discussed.

Comparing immediate-type food allergy in humans and companion animals-revealing unmet needs

Adverse food reactions occur in human as well as veterinary patients. Systematic comparison may lead to improved recommendations for prevention and treatment in both. In this position paper, we summarize the current knowledge on immediate-type food allergy vs other food adverse reactions in companion animals, and compare this to the human situation. While the prevalence of food allergy in humans has been well studied for some allergens, this remains to be investigated for animal patients, where owner-reported as well as veterinarian-diagnosed food adverse reactions are on the increase. The characteristics of the disease in humans vs dogs, cats, and horses are most often caused by similar, but sometimes species-dependent different pathophysiological mechanisms, prompting the specific clinical symptoms, diagnoses, and treatments. Furthermore, little is known about the allergen molecules causative for type I food allergy in animals, which, like in human patients, could represent predictive biomarkers for risk evaluation. The definite diagnosis of food allergy relies-as in humans-on elimination diet and provocation tests. Besides allergen avoidance in daily practice, novel treatment options and tolerization strategies are underway. Taken together, numerous knowledge gaps were identified in veterinary food allergy, which need to be filled by systematic comparative studies.

Diagnosis of Food Allergy

Food allergy diagnosis remains challenging. Most standard methods are unable to differentiate sensitization from clinical allergy. Recognizing food allergy is of utmost importance to prevent life-threatening reactions. On the other hand, faulty interpretation of tests leads to overdiagnosis and unnecessary food avoidances. Highly predictive models have been established for major food allergens based on skin prick testing and food-specific immunoglobulin E but are lacking for most other foods. Although many newer diagnostic techniques are improving the accuracy of food allergy diagnostics, an oral food challenge remains the only definitive method of confirming a food allergy.

Component-resolved diagnosis in anaphylaxis

PURPOSE OF REVIEW

Component-resolved diagnosis (CRD) is an advanced tool capable of aiding the clinician in fine tuning the diagnosis of the causal allergens of a reaction with the added value of providing information of severity risk, potential cross-reactivity, and subsequently, guiding management measures. This review will focus on the advantages of CRD of anaphylaxis in clinical practice.

RECENT FINDINGS

Research is continuously providing insight to which molecules are associated with genuine sensitization and/or potential severity risk for hymenoptera venom (Api m1, Ves v 1, Ves v 5, and Pol d 5), food allergy (seed storage proteins and nonspecific lipid transfer proteins), cofactor-enhanced food allergy (ω-5-gliadine, nonspecific lipid transfer proteins), red meat delayed anaphylaxis (α-gal), latex allergy (Hev b 1, Hev b 3, Hev b 5, and Hev b 6), and Anisakis allergy (Ani s 1, Ani s 4, Ani s 7, and Ani s 13); other molecules are primary associated with nonclinically relevant sensitizations, cross-reactivity, or mild reactions (carbohydrate determinants and profilins). New molecules, some minor allergens, are being identified as new potential biomarkers of severity.

SUMMARY

The usefulness of CRD in anaphylaxis is self-evident, since it improves the recognition of sensitization profiles associated with specific clinical outcomes and provides information to guide further management.

Combination of two epitope identification techniques enables the rational design of soy allergen Gly m 4 mutants

Detailed IgE-binding epitope analysis is a key requirement for the understanding and development of diagnostic and therapeutic agents to address food allergies. An IgE-specific linear peptide microarray with random phage peptide display for the high-resolution mapping of IgE-binding epitopes of the major soybean allergen Gly m 4, which is a homologue to the birch pollen allergen Bet v 1 is combined. Three epitopes are identified and mapped to a resolution of four key amino acids, allowing the rational design and the production of three Gly m 4 mutants with the aim to abolish or reduce the binding of epitope-specific IgE. In ELISA, the binding of the mutant allergens to polyclonal rabbit-anti Gly m 4 serum as well as IgE purified from Gly m 4-reactive soybean allergy patient sera is reduced by up to 63% compared to the wild-type allergen. Basophil stimulation experiments using RBL-SX38 cells loaded with patient IgE are showed a decreased stimulation from 25% for the wild-type Gly m 4 to 13% for one mutant. The presented approach demonstrates the feasibility of precise mapping of allergy-related IgE-binding epitopes, allowing the rational design of less allergenic mutants as potential therapeutic agents.

Recent advances in component resolved diagnosis in food allergy

Due to the high prevalence of food allergic diseases globally there are increasing demands in clinical practice for managing IgE-mediated conditions. During the last decade, component resolved diagnostics has been introduced into the field of clinical allergology, providing information that cannot be obtained from extract-based tests. Component resolved data facilitate more precise diagnosis of allergic diseases and identify sensitizations attributable to cross-reactivity. Furthermore it assists risk assessment in clinical practice as sensitization to some allergenic molecules is related to persistence of clinical symptoms and systemic rather than local reactions. The information may also aid the clinician in prescription of oral immunotherapy (OIT) in patients with severe symptoms, and in giving advice on food allergen avoidance or on the need to perform food challenges. The use of allergen components is rapidly evolving and increases our possibility to treat food allergic patients with a more individual approach. Using molecular allergology, we can already now better diagnose, prognose and grade the food allergy. In summary, daily routine molecular allergy diagnostics offers a number of benefits that give us a higher diagnostic precision and allow for better management of the patient.

Pearls and Pitfalls in Diagnosing IgE-Mediated Food Allergy

The term "food allergy" is used by many patients and clinicians to describe a range of symptoms that occur after ingestion of specific foods. However, not all symptoms occurring after food exposure are due to an allergic, or immunologic, response. It is important to properly evaluate and diagnose immunoglobulin E (IgE)-mediated food allergy as this results in reproducible, immediate onset, allergic reactions that can progress toward life-threatening anaphylaxis. Proper diagnosis requires understanding of the common foods that cause these reactions in addition to key historical elements such as symptoms, timing and duration of reaction, and risk factors that may predispose to development of IgE-mediated food allergy. Diagnostic testing for food-specific IgE can greatly aid the diagnosis. However, false-positive test results are very common and can lead to overinterpretation, misdiagnosis, and unnecessary dietary elimination. This review discusses important aspects to consider during evaluation of a patient for suspected IgE-mediated food allergy.

Oral challenge tests for soybean allergies in Japan: A summary of 142 cases

BACKGROUND

Soybeans are one of causative foods for infantile onset allergies in Japan. This study aimed to analyze the results of soybean challenge tests that were conducted over approximately 7 years at our institution. Using the test data, we sought to identify the responses and clinical profiles of patients with soybean allergies, and to investigate the relationship between the responses and soybean sensitization status.

METHODS

Between July 2004 and May 2010, 142 cases (125 patients) underwent food challenge tests (100 g of silken tofu) for the diagnosis of soybean allergy or confirmation of their tolerance. The patients' characteristics, soybean sensitization status, and responses to the challenge tests were retrospectively evaluated.

RESULTS

Among the subjects who underwent the soybean challenge test, the male/female ratio was 1.6 (87/55), and the mean age at the test was 2.8 ± 1.7 years. The positive rate for the challenge test was 38.7%. Induced symptoms were observed in the skin (81.8%), respiratory system (50.9%), and gastrointestinal system/mucosal membrane/anaphylaxis (12.7%). Intramuscular epinephrine was administered to all 7 patients who experienced an anaphylactic reaction. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic efficiency of soybean-specific IgE titers were low for predicting the responses to the challenge test.

CONCLUSIONS

Soybean allergies were diagnosed in only 18% of the subjects with positive sensitization to soybeans. Therefore, soybean-specific IgE titers are not an effective predictor of a positive response to the challenge test.

Allergen Component Testing in the Diagnosis of Food Allergy

IgE-mediated food allergies are an important public health problem, affecting 5 % of adults and 8 % of children, with numerous studies indicating that the prevalence is increasing. Food allergic reactions can range in severity from mild to severe and life threatening. Accurate diagnosis of food allergy is necessary not only to provide appropriate and potentially life-saving preventive measures but also to prevent unwarranted dietary restrictions. The diagnosis of food allergy has traditionally been based on clinical history and food specific IgE (sIgE) testing, including skin prick testing (SPT), serum tests, or both. These tests tend to be extremely sensitive, but positive test results to foods that are tolerated are common. Studies of allergen component-resolved diagnostics (CRD) show that adjuvant use of this modality may provide a more accurate assessment in the diagnosis of food allergy, though the reported benefits are questionable for a number of major allergens. Furthermore, diagnostic cutoff values have been difficult to determine for allergens where component testing has been demonstrated to be beneficial.

Utility of Component-Resolved Diagnostics in Food Allergy

Allergen component-resolved diagnostic testing (CRD) is a new methodology in clinical food allergy diagnosis, improving the ability to identify specific clinical phenotypes. Instead of relying on the crude allergen extracts used in standard allergy diagnostics, CRD utilizes purified or recombinant allergens for identification of specific molecules causing sensitization or allergy. This method is able to determine risk of the severity of allergic reactions in specific cases, like soy, peanut, and hazelnut allergy. The severity of allergic reaction can be predicted in peanut allergy with Ara h 2, and clinically relevant disease in pollen-allergic patients can be identified. However, age and geographic differences affect CRD results and it should always be utilized in the context of a clinical history. In the future, clinical phenotypes may be differentiated with larger prospective studies utilizing food challenges.

Bet v 1- and Bet v 2-Associated Plant Food Sensitization in Uganda and Germany: Differences and Similarities

BACKGROUND

Birch pollen allergy and concomitant plant food sensitization are well documented in Europe. However, there are currently no data available on pollen-associated plant food sensitization or even pollen allergy in tropical Africa. Our study aimed to investigate Bet v 1- and Bet v 2-associated plant food sensitization in atopic patients from Uganda and compare it with sensitization rates in German patients.

METHODS

Sera from 83 Ugandan and 97 German atopic patients were analysed using UniCAP100™ for allergen-specific IgE against the birch tree pollen allergens Bet v 1 and Bet v 2 as well as the plant foods hazelnut, apple, kiwi, pea, peach, cherry, litchi, peanut, and soy.

RESULTS

As expected, sensitization to Bet v 1 and cross-reactive plant food allergens was more common in German atopic patients. In contrast, the prevalence of sensitization against Bet v 2 was remarkably similar in Ugandan and German patients. Interestingly, in Ugandan patients we found IgE-mediated sensitization against plant foods such as hazelnut, pea, peach, cherry, and litchi that are neither cultivated nor consumed in Uganda.

CONCLUSIONS

For Ugandan atopic patients, sensitization against the Bet v 2 allergen (a plant profilin) may explain cross-reactivity to several plant foods which are not consumed in Uganda. Additionally, it is probable that sensitization of Ugandan atopics to alder pollen (Alnus acuminata, plant family Betulaceae) caused serological cross-reactivity with Betula verrucosa-related allergens.

Position paper of the EAACI: food allergy due to immunological cross-reactions with common inhalant allergens

In older children, adolescents, and adults, a substantial part of all IgE-mediated food allergies is caused by cross-reacting allergenic structures shared by inhalants and foods. IgE stimulated by a cross-reactive inhalant allergen can result in diverse patterns of allergic reactions to various foods. Local, mild, or severe systemic reactions may occur already after the first consumption of a food containing a cross-reactive allergen. In clinical practice, clinically relevant sensitizations are elucidated by skin prick testing or by the determination of specific IgE in vitro. Component-resolved diagnosis may help to reach a diagnosis and may predict the risk of a systemic reaction. Allergy needs to be confirmed in cases of unclear history by oral challenge tests. The therapeutic potential of allergen immunotherapy with inhalant allergens in pollen-related food allergy is not clear, and more placebo-controlled studies are needed. As we are facing an increasing incidence of pollen allergies, a shift in sensitization patterns and changes in nutritional habits, and the occurrence of new, so far unknown allergies due to cross-reactions are expected.

Development of a Sandwich ELISA for Quantification of Gly m 4, a Soybean Allergen

Gly m 4 is a key soybean allergen that causes allergic symptoms in the skin, gastrointestinal tract, or respiratory tract of sensitive individuals. To understand naturally variable levels of Gly m 4 among conventional soybean varieties, a sandwich ELISA was developed and validated using a mouse anti-Gly m 4 monoclonal antibody and a goat anti-Gly m 4 polyclonal antibody as capture and detection antibodies, respectively. The ELISA shows high specificity to Gly m 4 without any cross-reactivity to other soybean proteins and has a quantification range of 7.8-250 ng/mL using an Escherichia coli-produced recombinant Gly m 4, with 2.1 ng/mL being the limit of detection. Within the quantification range, the coefficients of variation of the intra-assay and interassay precision are less than 5 and 12%, respectively. Moreover, extraction efficiency and dilutional parallelism experiments were completed to demonstrate the assay is accurate. The validated assay was used to quantify Gly m 4 levels in 128 soybean samples from 24 conventional soybean varieties grown at 8 distinct geographical locations. There was a 13-fold difference between the least and greatest amounts of Gly m 4 concentrations among the samples, and the results demonstrate that the most significant sources of variability in Gly m 4 levels in the conventional varieties were related to location and variety.

Proteomic insights into synthesis of isoflavonoids in soybean seeds

Soybean seeds are the major human dietary source of isoflavonoids, a class of plant natural products almost entirely exclusive to legumes. Isoflavonoids reduce the risk of a number of chronic human illnesses. Biosynthesis and accumulation of this class of compounds is a multigenic and complex trait, with a great deal of variability among soybean cultivars and with respect to the environment. There is a wealth of genomic, transcriptomic, and metabolomics data regarding isoflavonoid biosynthesis, but the connection between multigene families and their cognate proteins is a missing link that could provide us with a great deal of functional information. The changing proteome of the developing seed can shed light on the correlative increase in isoflavonoids, while the maternal seed coat proteome can provide the link with inherited metabolic and signaling machinery. In this effort, 'seed-filling' proteomics has revealed key secondary metabolite enzymes that quantitatively vary throughout seed development. Seed coat proteomics has revealed the existence of metabolic apparatus specific to isoflavonoid biosynthesis (isoflavonoid reductase) that could potentially influence the chemical content of this organ. The future of proteomic analysis of isoflavonoid biosynthesis should be centered on the development of quantitative, tissue-specific proteomes that emphasize low-abundance metabolic proteins to extract the whole suite of factors involved.

IgE sensitization to lupine in bakers - cross-reactivity or co-sensitization to wheat flour?

BACKGROUND

Food allergy to lupine has frequently been reported in patients allergic to peanut or soy, and cross-reactivity between these legumes is known. Moreover, respiratory allergy to lupine has been described after inhalation, mostly at workplaces. Our aim was to study the frequency of lupine sensitization in European bakers with suspected bakers' allergy. Furthermore, associations between sensitizations to lupine and other plant allergens were investigated.

METHODS

One hundred and sixteen bakers with work-related allergic symptoms but without known food allergies were examined. Specific IgE (sIgE) antibodies to wheat flour, rye flour, lupine, peanut, soy and the recombinant single birch protein rBet v 1 were quantified. Selected sera were tested for cross-reactivity using ImmunoCAP inhibition and ISAC microarrays.

RESULTS

Whereas 67% of bakers were sensitized to wheat and/or rye flour, 35% showed sIgE to peanut and 33% to lupine. All lupine-positive bakers also had sIgE to either wheat flour (89%) and/or peanut (92%), and lupine sIgE correlated significantly with sIgE to peanut, soy, wheat and rye flour. Used as an inhibitor, wheat flour inhibited IgE binding to lupine in 4 out of 8 sera, indicating cross-reactivity. In microarrays, these sera showed IgE binding to lipid transfer proteins, profilins and/or cross-reactive carbohydrate determinants. Further inhibition experiments suggest that these single allergens are involved in cross-reactivity.

CONCLUSION

One third of 116 symptomatic bakers showed sIgE to lupine. At least some of these sensitizations were based on cross-reactivity between lupine and wheat flour. However, the considerable sensitization rate could also be a sign that the use of lupine flour in bakeries may be of occupational relevance.

Molecular allergy diagnosis: status anno 2015

IgE antibodies play a key role in type I allergic reactions. Today, different in vitro immunoassays for allergen-specific IgE antibodies are available. However, some major issues should be taken into account for correct interpretation of specific IgE (sIgE) antibody results, as these assays do not demonstrate absolute positive and negative predictive values. Therefore, additional diagnostic tests are needed to make the correct diagnosis. During the last two decades significant progress in biochemistry and molecular biology enabled the detection and quantification of sIgE antibodies to allergen protein components and epitope-emulating peptides, also called molecular allergy diagnosis or component resolved diagnosis (CRD). In contrast to conventional sIgE antibody assays, molecular allergy diagnosis makes it possible to discriminate between genuine allergy and merely sensitisation, to establish personalized sensitization patterns and to assess the individual risk of severity of an allergic reaction and finally it helps us to predict the natural course. In this review the use of CRD in inhalant, food, latex and hymenoptera venom allergy will be discussed. The primary focus will be on the most relevant clinical applications of CRD rather than to describe all the currently available allergen components and epitopes. Appropriate experience of our own research group is provided.

Food allergy testing

Food allergy (IgE-mediated hypersensitivity) is a common clinical problem affecting approximately 15% of children in the Western world. These hypersensitivity reactions tend to be "immediate" (typically within minutes of food exposure), and clinical features may range from mild to life threatening (anaphylaxis). Detailed clinical history is critical to correct diagnosis. Available laboratory tests have limitations not least poor positive predictive value and limited repertoire. Laboratory tests should support clinical diagno sis not vice versa.

Component resolved diagnosis: when should it be used?

The knowledge on molecular allergy diagnosis is continuously evolving. It is now time for the clinician to integrate this knowledge and use it when needed to improve the accuracy of diagnosis and thus provide more precise therapeutic and avoidance measures. This review does not intend to comprehensively analyze all the available allergen molecules, but to provide some practical clues on use and interpretation of molecular allergy diagnosis. The potential role of component resolved diagnosis in circumstances such as the indication of allergen immunotherapy, pollen polysensitization, food allergy, latex allergy or anaphylaxis, is assessed. Interpreting the information provided by molecular allergy diagnosis needs a structured approach. It is necessary to evaluate single positivities and negativities, but also to appraise "the big picture" with perspective.

EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy

Food allergy can result in considerable morbidity, impact negatively on quality of life, and prove costly in terms of medical care. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines for Food Allergy and Anaphylaxis Group, building on previous EAACI position papers on adverse reaction to foods and three recent systematic reviews on the epidemiology, diagnosis, and management of food allergy, and provide evidence-based recommendations for the diagnosis and management of food allergy. While the primary audience is allergists, this document is relevant for all other healthcare professionals, including primary care physicians, and pediatric and adult specialists, dieticians, pharmacists and paramedics. Our current understanding of the manifestations of food allergy, the role of diagnostic tests, and the effective management of patients of all ages with food allergy is presented. The acute management of non-life-threatening reactions is covered in these guidelines, but for guidance on the emergency management of anaphylaxis, readers are referred to the related EAACI Anaphylaxis Guidelines.

Molecular approach to allergy diagnosis and therapy

Presently, allergy diagnosis and therapy procedures are undergoing a transition phase in which allergen extracts are being step-by-step replaced by molecule-based products. The new developments will allow clinicians to obtain detailed information on sensitization patterns, more accurate interpretation of allergic symptoms, and thus improved patients' management. In this respect, recombinant technology has been applied to develop this new generation of molecule-based allergy products. The use of recombinant allergens allows full validation of identity, quantity, homogeneity, structure, aggregation, solubility, stability, IgE-binding and the biologic potency of the products. In contrast, such parameters are extremely difficult to assay and standardize for extract-based products. In addition to the possibility of bulk production of wild type molecules for diagnostic purposes, recombinant technology opened the possibility of developing safer and more efficacious products for allergy therapy. A number of molecule-based hypoallergenic preparations have already been successfully evaluated in clinical trials, bringing forward the next generation of allergy vaccines. In this contribution, we review the latest developments in allergen characterization, molecule-based allergy diagnosis, and the application of recombinant allergens in therapeutic setups. A comprehensive overview of clinical trials using recombinant allergens as well as synthetic peptides is presented.

Advances in allergen-microarray technology for diagnosis and monitoring of allergy: the MeDALL allergen-chip

Allergy diagnosis based on purified allergen molecules provides detailed information regarding the individual sensitization profile of allergic patients, allows monitoring of the development of allergic disease and of the effect of therapies on the immune response to individual allergen molecules. Allergen microarrays contain a large variety of allergen molecules and thus allow the simultaneous detection of allergic patients' antibody reactivity profiles towards each of the allergen molecules with only minute amounts of serum. In this article we summarize recent progress in the field of allergen microarray technology and introduce the MeDALL allergen-chip which has been developed for the specific and sensitive monitoring of IgE and IgG reactivity profiles towards more than 170 allergen molecules in sera collected in European birth cohorts. MeDALL is a European research program in which allergen microarray technology is used for the monitoring of the development of allergic disease in childhood, to draw a geographic map of the recognition of clinically relevant allergens in different populations and to establish reactivity profiles which are associated with and predict certain disease manifestations. We describe technical advances of the MeDALL allergen-chip regarding specificity, sensitivity and its ability to deliver test results which are close to in vivo reactivity. In addition, the usefulness and numerous advantages of allergen microarrays for allergy research, refined allergy diagnosis, monitoring of disease, of the effects of therapies, for improving the prescription of specific immunotherapy and for prevention are discussed.

Current overview of allergens of plant pathogenesis related protein families

Pathogenesis related (PR) proteins are one of the major sources of plant derived allergens. These proteins are induced by the plants as a defense response system in stress conditions like microbial and insect infections, wounding, exposure to harsh chemicals, and atmospheric conditions. However, some plant tissues that are more exposed to environmental conditions like UV irradiation and insect or fungal attacks express these proteins constitutively. These proteins are mostly resistant to proteases and most of them show considerable stability at low pH. Many of these plant pathogenesis related proteins are found to act as food allergens, latex allergens, and pollen allergens. Proteins having similar amino acid sequences among the members of PR proteins may be responsible for cross-reactivity among allergens from diverse plants. This review analyzes the different pathogenesis related protein families that have been reported as allergens. Proteins of these families have been characterized in regard to their biological functions, amino acid sequence, and cross-reactivity. The three-dimensional structures of some of these allergens have also been evaluated to elucidate the antigenic determinants of these molecules and to explain the cross-reactivity among the various allergens.

In vitro diagnosis of Hymenoptera venom allergy and further development of component resolved diagnostics

For most people Hymenoptera stings result in transient and bothersome local inflammatory responses characterized by pain, itching, redness and swelling. In contrast, for those presenting an IgE-mediated allergic reaction, a re-sting may cause life-threatening reactions. In such patients, correct diagnosis is an absolute prerequisite for effective management, i.e. venom-specific immunotherapy. Generally, identification of the offending insect involves a detailed history along with quantification of venom-specific IgE antibodies and venom skin tests. Unfortunately, due to uncertainties associated with both tests, correct diagnosis is not always straightforward. This review summarizes the potentials and limitations of the various in vitro tests that are currently being used in the diagnosis of Hymenoptera venom allergy. Particular attention is paid to the potential of novel cellular tests such as basophil activation tests and component-resolved diagnosis with recombinant venom allergens in the diagnostic approach of patients with difficult diagnosis, i.e. cases in whom traditional venom specific IgE and skin tests yield equivocal or negative results. Finally, this review also covers the recent discoveries in the field of proteome research of Hymenoptera venoms and the selection of cell types for recombinant allergens production.