Allergens

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3d1 House dust mite 5e1 Cat 6e5 Dog 7f1 Egg 8f2 Milk 9f3 Fish 10f4 Wheat 11f13 Peanut 12f14 Soybean 13f17 Hazelnut 14f24 Shrimp 15g6 Timothy 16i6 Cockroach 17m6 Mold 18t3 Birch 19t9 Olive 20w6 Mugwort 21w21 Wall pellitory 22 Reference Lists 23

Contents

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5d1 House dust miteDermatophagoides pteronyssinus

Allergen descriptionDermatophagoides pteronyssinus

Family: Pyroglyphidae

House dust mites are one of the most common sources of sensitization in all parts of the world. Dermatophagoides pteronyssinus, D. farinae and D. microceras occur in the same areas, but the relative proportions of their distribution vary geographically. Mites have a life cycle of about 2 to 3 months. The size of the mite is up to 0.3 mm. They live in house dust and thrive in warmth and high humidity. Mites faeces seem to be the major source of allergenic exposure. They are about the size of a pollen grain and can therefore very easily become airborne and penetrate the lung alveolus (1).

Allergen exposureDust, carpets, pillows, mattresses and upholstering furniture containing biological material, especially human dander, are reservoirs of house dust mites. Other sources of exposure are damp houses (>45% relative humidity) or dwellings at low altitudes.

Cross-reactivityAllergens from mites have both common and species-specic determinants. Allergenic determinants are shared with other mites belonging to the Pyroglyphidae family and are highly cross-reactive with other Dermatophagoides species (2, 3). There seems to be a limited cross-reactivity with storage mites (nonpyroglyphid) (3). Some mite allergenic proteins such as tropomyosin are widely cross-reactive among invertebrates such as shrimps, snails, cockroaches and chironomids (3).

Clinical experienceIgE-mediated reactionsStudies of house dust allergic individuals around the world have shown that house dust mites are one of the most common causes of symptoms such as perennial type asthma, rhinitis and conjunctivitis, often with nocturnal or early morning episodes (4). There is evidence that reduction of mite-allergen levels can cause a major improvement in symptoms of asthma (5). So far the only effective way to get a permanent reduction of house-dust mite allergens seems to be lowering of the air humidity and temperature together with efcient cleaning (4).

6 e1 CatEpithelium and dander

Allergen descriptionFelis domesticus

Family: Felidae

Allergens from cat epithelium and dander are one of the most common causes of respiratory allergic disease. Several cat allergens have been identied and characterized (1).

Allergen exposureCarpets, mattresses and upholstered chairs are reservoirs of cat allergens. Cat allergens are carried on human clothing into environments never visited by cats. Transport of cat allergens on clothing from the domestic to the school environment is in fact a major source of cat allergens in classrooms.

Cross-reactivityCat-allergic patients have been shown also to react to big cats e.g. ocelot, tiger and lion (2). A subgroup of cat-allergic patients also reacts to dogs and sometimes to other animals. Serum albumin is the main common component (3, 4). Extensive cross-reactivity even occurs between albumins of distantly related species such as horse, cattle, pig, rodents and furred animals (57). However, great variability exists between patients and selective sensitivity to limited numbers of species occurs. Allergy to cat dander and pork meat, also referred to as the pork/cat syndrome (8), was shown to be mediated by IgE antibodies recognizing cat and pig serum albumin (9). In addition, other kinds of meat may be a risk for patients with this type of sensitivity (10).

Clinical experienceIgE-mediated reactionsIgE-mediated sensitization to cat is a risk factor for asthma. Allergen exposure plays a causal role in the development of bronchial hyperreactivity and of the chronic inammatory responses seen in patients with asthma (11). Infants exposed to cats developed skin prick test sensitivity about three times more often than those without such exposure (12). Furthermore, the low level cat exposure that occurs in many homes without cats can induce symptoms in some patients who are sensitive to cats (13). Tobacco smoke, prenatal and postnatal, has been shown to have an adjuvant effect on cat sensitization in exposed children (14). Allergic reactivity to pollens may also be aggravated by environmental priming with ubiquitous animal dander (15). Furthermore, allergy to cats or dogs seems to be an important risk factor for the development of laboratory animal allergy (16). Avoidance of cat allergens is an important measure to take in the treatment of sensitized asthmatics, decreasing symptoms and decreasing the need for drugs (17). Only removal of the cat leads to a lasting decrease of the allergen exposure (1820).

7Allergen descriptionCanis familiaris

Family: Canidae

The dog, a relative of the wolf, the jackal and the fox, was one of the earliest domestic animals, living in human communities as early as 12 000 years ago. More than 800 breeds have been developed. Dog allergens have been found in serum, dander, pelt, hair and saliva (1, 2). Although allergen differences occur according to the origin of the allergen (e.g. dander or saliva), no breed-specic allergens occur. But the concentration of allergens varies within breeds and among them. Dog dander contains the highest proportion of dog-specic allergens. Animal dander is extremely lightweight and tiny in size and can stay airborne for hours.

Allergen exposureLevels of dog allergens in houses with dogs may reach high levels. Levels in homes without dogs are generally 10 to 100 times lower, but can still be detected. In houses with dog allergens, the highest concentration appears to occur on the living-room oor, on furniture, and in bedrooms. Dog allergens can be detected also in other places, such as schools and day-care centers where dogs are not present on a regular basis. The allergens appear to be transported on clothes and may be present in relatively high concentrations.

Cross-reactivityAn extensive cross-reactivity among the different breeds could be expected. It has been noted that many patients allergic to cats are also allergic to dogs. Many studies suggest evidence for cross-reactivity between some cat and dog allergens (35).

Clinical experienceIgE-mediated reactionsDog dander is an important source of inhalant allergens, and may frequently induce symptoms in sensitized individuals (1, 2, 5, 6). Symptoms include asthma, allergic rhinitis and allergic conjunctivitis. 3035% of atopic individuals display allergic symptoms on exposure to dog allergens (79). Symptoms can be caused by indirect exposure to dog dander in schools, at work and on public transport. In sensitized subjects, repeated exposure to allergens also contributes to subclinical inammation, hyperresponsiveness and general worsening of asthma (10, 11). Eczema following exposure to dog allergens has been reported (12). Occupational allergy to dog may also occur in animal workers, animal pelt workers and laboratory workers.

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8Allergen descriptionGallus spp.

Egg is a major cause of adverse reactions in infants and hidden exposure is common. Hens eggs are composed of about 60% egg white and 30% egg yolk. Egg white contains approximately 88% water and 10% protein. The major allergens of egg white are ovomucoid, ovalbumin, ovotransferrin (also called conalbumin), and lysozyme (1).

Allergen exposureExpected exposure Cooked or raw eggs Bread and pastry Numerous dishes like pancakes, sauces, etc.

Unexpected exposure Candy Beverages Meat products like sausages, pts, etc.

A great variety of foods may contain egg or traces of egg and patients allergic to egg need to be aware of egg as a frequent hidden allergen.

Cross-reactivity Eggs from related animals Presence of shared allergens in egg-white, egg-yolk, serum and meat from hen and chicken has been demonstrated.

f1 EggEgg white

Clinical experienceIgE-mediated reactionsEgg-specic IgE antibodies are usually the rst antibodies to appear in children developing atopic disease. Allergy to egg is generally considered to be one of the most common causes of food allergy in infants and young children (2). When studying egg-allergic children, IgE antibodies were found in more than 65% of children with eczema and respiratory tract symptoms (3). Egg-white specic IgE antibodies may predict the development of atopic respiratory allergy. In a follow-up study of infants where the authors had concluded that egg-white sensitivity was a better indicator of atopy than total serum IgE, the infants presenting with egg-white allergy were more likely to have developed inhalant allergy by 7 years of age (4). Other studies show similar results (5, 6). Egg white is often responsible for early development of urticaria and eczema during infancy (7). Remaining egg intolerance in older children and adults may be linked to exposure to cage birds and chicken meat. Certain vaccines grown on chicken embryos have been reported to cause severe allergic reactions in patients when injected (8). Further development of vaccines seems to have decreased or even eliminated the risk for egg-allergic children (9, 10).

9f2 MilkCows milk

Allergen descriptionBos spp.

Cows milk is a major cause of adverse reactions in infants and hidden exposure is common. There are many allergenic proteins in milk and caseins, alpha-lactalbumin and beta-lactoglobulin are considered as some of the major allergens. Caseins are heat stable allergens (1).

Allergen exposureExpected exposure Milk, cheese and other dairy products Bread and pastry Numerous dishes like pancakes, soups etc.

Unexpected exposure Candy Toppings Processed meat like ham, sausages, pts, etc. Hydrolyzed milk formulas

Milk and milk derivatives are used in a wide variety of confectionery products. Contamination during processing or addition of sodium caseinate has also been reported (2, 3).

Cross-reactivity Milk from related animals Presence of shared allergens in milk, meat, and dander from cow has been demonstrated.

Clinical experienceIgE-mediated reactionsCows milk is a major cause of adverse reactions in infants with prevalence 0.57.5% (4, 5). Some patients retain a lifelong allergy (6). Cows milk-induced asthma is often observed in infants with food hypersensitivity as well as rhinoconjunctivitis and possibly also serous otitis media (7). Cows milk allergy in infants has a much better prognosis for outgrowth than in older children or adults (4). IgE antibodies to milk may develop before the onset of clinical allergy, indicating that in vitro measurements can be good predictive tools (8). Correlation of milk-specic IgE antibody levels with the development of tolerance to milk has been reported (9, 10). The symptoms in infants are usually dermatological and gastrointestinal (GI), with eczema often appearing early (11). In children retaining milk allergy, cutaneous symptoms decrease while respiratory and GI symptoms increase with age (9, 12). Infants with early sensitization to cows milk proteins have an increased risk for later development of other food allergies and sensitization to inhalant allergens (1315).

Other reactions Lactase deciency (lactose intolerance) Immune reactions without IgE antibody involvement

In adults lactase deciency is a common cause of milk hypersensitivity (16).

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f3 FishCod

Allergen descriptionGadus morhua

Family: Gadidae

The Atlantic cod is one of the worlds most important food sh. It is sold fresh, frozen, smoked, salted and canned. Patients allergic to sh often have dramatic symptoms, such as asthma or anaphylactic reactions. Some patients allergic to one sh may tolerate other sh species.

Allergen exposureExpected exposure Meat from cod

Unexpected exposure Undeclared ingredient in industrially prepared food, such as cured meat products Contamination of cooking oil, utensils and containers Inhalation of steam or dried fragments

Cross-reactivitySpecies within groups of sh, like Gadiformes (e.g. codsh and hake) and Scombroid shes (e.g. mackerel and tuna) seem to share allergenic components. The overlap of allergen specicity between the groups seems to be moderate. However the major cod allergen (parvalbumin) seems to be a good representative for many sh species (1).

Clinical experienceIgE-mediated reactionsAllergic reactions to sh are a common cause of food allergy. Prevalence gures vary from approx. 10% to approx. 40% in atopic populations. In Norway sh allergy was found in 1/1000 of the general population. While many children often outgrow allergy to cows milk and egg white, those allergic to sh may continue to be hypersensitive to sh later in life (2). Reactions to sh allergens are often severe. Systemic reactions after eating sh, but also after inhaling steam or aerosol in connection with cooking or handling sh or after skin contact are reported in several studies (3). Extremely sensitive patients have suffered anaphylactic shock after eating foods cooked in re-used cooking-oil, or when utensils and containers have been used earlier for cooking sh (4). Many patients avoid all species of sh and others may tolerate a few, thus indicating specic allergens. Because patients react to both cooked and raw sh, it is assumed that the allergens are heat-resistant. However, more recent studies indicate that patients may react differently to processed food (5) and that allergic reactions may also be species-specic (3, 6).

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Allergen description

Wheat is one of the major cereal grains belonging to the grass family and a staple food item in most diets worldwide. There are many different types of wheat, but the hexaploid Triticum aestivum is by far the most important of the Western species. The major proteins in wheat (albumins, globulins and glutens) vary in proportion according to the type of wheat. This variability is one reason why reactions to different wheat products are not consistent.

Allergen exposureExpected exposureSofter wheat with lower protein content is used for biscuits, cakes and pastry, harder wheat with higher protein content for bread, semolina, cous-cous, macaroni and pasta. Durum wheat is a source of Italian pasta, Indian chappatis and Chinese noodles. Wheat is also a source of alcoholic beverages such as beer.

Unexpected exposureWheat is used in livestock feed. Wheat starch is used for pastes and for sizing textiles.

Cross-reactivityAn extensive cross-reactivity among different individual species of wheat as well as some cross-reactivity to grass pollens could be expected (1, 2).

Clinical experienceIgE-mediated reactionsWheat is among the six most important food items accounting for IgE mediated allergic reactions in children. IgE mediated allergic reactions to ingested wheat protein include gastrointestinal, respiratory and cutaneous symptoms (3). Reactions typically occur within an hour of wheat ingestion. Affected individuals are usually sensitized during infancy (4) and the clinical reactivity typically resolves before adulthood. Wheat exposure may result in different life-threatening anaphylactic reactions (5). Wheat dependent exercise-induced anaphylaxis (WDEIA) is a severe IgE-mediated allergic reaction provoked by the combination of wheat or wheat our ingestion and intense physical exercise during the next few hours (610). Sensitization by inhalation can cause bakers asthma, a frequent allergy in the baking industry (11, 12). Occupatio-nal exposure to wheat or wheat dust may also result in other allergic conditions affecting animal, bakery, food industry and mill workers.

Other reactionsWheat allergy and celiac disease are two distinct conditions. Celiac disease is a permanent non-IgE mediated reaction caused by intolerance to gluten.

f4 Wheat

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f13 Peanut

Allergen descriptionArachis hypogaea

Family: Fabaceae

Peanut is not a nut, but a seed of an annual legume. It grows close to the ground and produces its fruit below the soil surface, in contrast to tree nuts like walnuts and almonds. Peanut is a member of the Fabaceae or legume family, whereas tree nuts are not. Peanuts were rst cultivated in South America. Portuguese explorers then transplanted peanut plants to Africa, and from there peanuts were spread to the rest of the world by explorers.

Allergen exposureExpected exposurePeanuts are consumed mainly as peanut butter and as snacks (roasted, salted, plain or dry roasted), but also in other foods.

Unexpected exposurePeanuts occur in candy and in baked goods. Peanuts also yield widely used oils. Arachis oil is peanut oil. Peanut our is an important ingredient in a variety of processed foods. Another unexpected source of peanuts is foods served at restaurants often using peanut as an ingredient, such as the Asian and African cuisines.

Cross-reactivityPeanut and tree nut allergic reactions coexist in 25-50% of peanut allergic patients, and allergic reactions to tree nuts such as walnuts, cashews, pecans and pistachios can develop even though tree nuts belong to a different botanical family (1, 2, 3). Reactions frequently occur on rst exposure and may be life-threatening. It is unclear whether this is due to

genuine cross-reactivity or to the coexistence of separate allergies in widely atopic individuals. Although peanut shares homologous proteins with botanically related beans and legumes, the majority of patients do not show clinical reactions to other legumes (4, 5, 6). Although one would expect that peanut-allergic individuals would have a high risk of cross- or co-reactivity to soybean (a family member), blinded food challenges have shown a low rate of these reactions (4). However, it is still not clear whether peanut allergic patients also should avoid soybeans or not (7).

Clinical experienceIgE-mediated reactionsPeanuts are a signicant cause of serious food allergy in both adults and children. Peanut allergy usually begins in childhood and unlike other food allergies often persists throughout the affected individuals lifetime. Only approx. 20% of young children will develop tolerance (6, 8). Allergic reactions to peanut can be mild to moderate, but compared to reactions to other food allergens they might be more likely to be severe or even fatal (9). Atopic dermatitis, angioedema, asthma, diarrhea, nausea and vomiting, and anaphylaxis have been reported. Urticaria may be a prominent symptom (10). Although not reported frequently, asthma may be a signicant feature in peanut allergy. As severe peanut allergy in asthmatic infants carries a risk of anaphylaxis, it is useful to look for peanut allergy in all infants with severe asthma (11). Peanut dust can also act as an inhalant allergen.

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f14 Soybean

Allergen descriptionGlycine max (Soja hispida)

Family: Fabaceae

Soybeans are dried ripe seeds and a high-protein legume grown as food for both humans and animals. It is an important source of protein to many vegetarians and vegans. The word soy is derived from the Japanese word shoyu (soy sauce).

Allergen exposureExpected exposureThe bean can be fresh, processed into soybean our or pressed for oil. Soybean oil is put to many uses. For example it is included in salad oil and margarine. Some soy allergic patients may safely eat soybean oil (not cold pressed, expeller pressed or extruded oil) and soy lecithin, while extremely soy allergic patients may react to traces of soy protein in soybean oil and soy lecithin (1). Soybeans and products made from the bean (miso, tofu, natto, douchi, etc.) are signicant parts of the diet in Asia. Soy sauce, or shoyu, is a fermented product of soybean and wheat. Soybean oil is also used in industrial components and in linoleum and glue in the plywood industry, where it is considered an occupational allergen.

Unexpected exposureSoy proteins are frequently found in meat products, bread and other industrially produced food products (2). The list of food products presenting potential risk is expanding. Some examples are sausage products (3), pizza (4) and candy containing soy lecithin (5). Cross-reactivityAlready in studies of soybean allergenicity, soybean was found to contain several antigenic components with consi-

derable cross-reactivity with other legume family members (6). While the clinical relevance of eliminating legumes as a food group from the diet of allergic patients is disputed, several reports conrm cross-reactivity e.g. to peas, lentils, peanuts, kidney, lima and navy beans (7).

Clinical experienceIgE-mediated reactionsSoybean is considered a classical food allergen (8) and is one of the foods to which children often have allergic reactions. Allergic reactions to soybean are dominated by stomach and skin problems, but also include respiratory symptom as well as severe allergic reactions. With its expanding use as a constituent in many different foods, soybean may be an underestimated cause of severe allergic reactions (9). There is an ongoing debate on the use of soy formula as a safe substitute for infants with cows milk allergy.In some countries it is recommended as a safe alternative when screening results indicate no existing soy allergy (10). However, there are also studies reporting on the risk of developing allergy to soy when using soy formula, and about one-fourth of cows milk-sensitive patients have been reported to become allergic to soy protein (11, 12). Therefore, some countries recommend that breast-feeding or less allergenic formulas should be preferred (13, 14). Patients experiencing IgE-mediated symptoms after ingesting peas, beans, lentils, peanuts or soybeans have been reported (15). Soybean dust can also act as an inhalant allergen. Epide-mic asthma in areas around harbors, where soybeans were unloaded from ships, has been reported from several places around the world (1620). A large number of fatal cases probably involving anaphylaxis were recorded. Occupational asthma in bakers and workers in food processing plants may be caused by soy our (2122).

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f17 Hazelnut

Allergen descriptionCorylus avellana

Family: Corylacaea (Betulaceae)

The terms lbert and hazelnut are often used inter-changeably for nuts from all plants in the genus Corylus, such as C. silvestris, C. maxima and C. colurna. These wild nuts grow in clusters on the hazel tree in temperate zones around the world. Hazel is an aggressive spreader and is particularly common in Europe. Italy, Spain, France and Turkey lead in hazelnut production. The nuts generally fall in autumn and are harvested from the ground and then shelled and dried.

Allergen exposureExpected exposureThe nuts are used chopped, ground, roasted, blanched, sliced and as our and paste in all manner of sweets. They are also eaten whole as a snack. Hazelnuts also add avor and texture to savory items such as salads and main dishes.

Unexpected exposureHazelnut is widely used and can be a hidden allergen. Nougat, an ingredient in secondary products such as confections, is for example a hazelnut product.

Cross-reactivityAn extensive cross-reactivity among the different individual species of the genus could be expected (1). Cross-reactivity between hazelnut and hazel tree pollen may occur (2). There is also a relationship between birch pollinosis and sensitization to hazelnut, apple, kiwi, carrot, potato and other vegetables (34). In birch pollen-hypersensitive patients with oral allergy syndrome it is very common with apple and/or hazelnut allergy (5). An important cross-reactivity between the pollen of Platanus acerifolia (London plane tree), hazelnut and banana has been reported (6). Partial cross-reactivity has been reported to occur between hazelnut and macadamia nuts (7).

Clinical experienceIgE-mediated reactionsHazelnuts are a common cause of food allergy (810). Allergic sensitization may occur early on in life (11). Allergic reactions to hazelnuts range from oral allergy syndrome to severe anaphylactic reactions (12). Allergy to hazelnut is frequently observed in patients with allergy to birch pollen. Symptoms of food allergy in pollen-allergic patients are usually mild and restricted to the oral cavity, i.e. oral allergy syndrome. Allergy to hazelnuts without concomitant pollen allergy is less common, but symptoms tend to be more severe and are often systemic (1314). Allergies to peanut (a legume) and tree nuts (walnut, hazelnut, brazil nut, pecan) frequently have an onset in the rst years of life, generally persist, and may account for severe and potentially fatal allergic reactions.

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f24 Shrimp

Allergen descriptionPandalus borealis

Family: Crangonidae

Shrimp is found in shallow and deep waters everywhere. The largest of the species, mostly found in the Pacic, are called prawns.

Allergen exposureExpected exposureMeat from shrimps or prawns can be canned, breaded, frozen, sold in the shell or dried. Some major shellsh allergens are heat-stable and water-soluble and can therefore enter the atmosphere in steam aerosols from the cooking process.

Unexpected exposureShrimp can also be an undeclared ingredient in some processed sh products and snacks.

Cross-reactivityCommon major allergens have been identied in shrimp, crab, lobster and craysh. One of these allergens is tropomyosin, which is a major allergen in shrimp, but is also present in mites, cockroaches and other insects. Of seven allergens detected, two appear to be shared by other Crustacea and one may be a specic allergen present only in shrimp (1).

Clinical experienceIgE-mediated reactionsShrimp has been recognized as potent allergen both in food allergy and occupational allergy. While many children often outgrow allergy to cows milk and egg white, they may continue to be hypersensitive to shellsh later in life (2). Shrimp allergy is common cause of anaphylaxis among adults (3, 4). Other allergic reactions including urticaria, angioedema, respiratory symptoms and gastrointestinal problems have also been reported (4). Shrimp-allergic patients often have respiratory allergy and shrimp is also an occupational allergen for seafood processors and workers in the shing industry (5). Food-dependent exercise-induced anaphylaxis after consumption of shrimp has occurred (6).

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Allergen descriptionPhleum pratense

Family: Poaceae (Gramineae)Subfamily: PooideaeTribe: Agrostideae

Timothy pollen often induces hay fever, asthma and conjunctivitis in sensitized individuals. Timothy is one of the worlds most common grasses and one of the most common sources of animal fodder. It grows best in cooler, humid climates. A number of timothy allergenic proteins have been identied and characterized (1).

Allergen exposureTimothy owers from early summer to midsummer. Timothy is widespread in elds and meadows, and on roadsides. It is sown in pastures for forage, and is very common in hay.

Cross-reactivityAn extensive cross-reactivity among different related grasses could be expected, in particular grasses belonging to the subfamily Pooideae (2, 3). Timothy grass pollen also seems to share allergens with tomato, peanut, kiwi and other fruits and vegetables (4, 5). It also shares IgE binding epitopes with glycoprotein latex allergens, which might in part explain clinical symptoms in pollen-allergic patients on contact with latex (6).

g6 TimothyGrass pollen

Clinical experienceIgE mediated reactionsAllergy to timothy grass pollen has been reported widely. Timothy grass is one of the most important causes of allergic rhinitis, asthma and allergic conjunctivitis during summer in cool temperate climates (7). A European Community respiratory health survey reported that adults who had lived on farms as children were less frequently sensitized to timothy grass, and were at lower risk of having nasal symptoms in the presence of pollen in general (8). Timothy grass is a very prevalent aeroallergen in the Mediterranean countries, including Spain (9). In a birch- and ragweed-free area in Spain, 97.9% of patients allergic to pollens were sensitized to timothy and rye grass (10). The strongest associations between bronchial hyperreactivity and specic IgE responses were seen with timothy grass (11). In Sweden, in allergen-specic IgE tests on 7099 adult patients with asthma and/or rhinitis, timothy, cat and birch were the most prevalent allergens. Of these patients, 65% were sensitized against several allergens and 35% had a mono-allergy, most frequently to timothy grass (70%) (12).

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i6 CockroachGerman

Allergen descriptionBlatella germanica

Cockroach-specic IgE antibodies are frequently found in patients with asthma and other allergic conditions all over the world. The most important species in industrialized countries are the German and the American cockroaches.

Allergen exposureThe distribution of cockroaches in the world varies with geography, climate and culture. Cockroaches thrive in damp and warm environments. They are rarely found in dry, high altitude areas. Several species are widespread and still expanding in new areas. The most common of these is the German cockroach (1). It is a small cockroach, growing up to approx. 2 cm in length that is found throughout the world in association with humans. Adults have wings, but rarely y. The nymphs are darker and wingless. Cockroaches are found in homes, restaurants, hotels, food plants, warehouses, etc. During the day, the roaches may cluster hidden behind baseboard molding, in cracks around cabinets, closets or pantries and in and under stoves, refrigerators and dishwashers. Cockroaches produce potent allergens. At least 29 allergens have been detected from German cockroach contributing to asthma (2, 3).

Allergic individuals can be exposed to cockroach allergens by inhalation from living quarters and by ingestion due to contamination of foodstuffs. The highest levels of cockroach allergens are typically found in the kitchen. However, the lower levels of allergen found in bedding, on the bedroom oor and in sofa dust (4) may be more relevant in causing sensitization.

Cross-reactivityAn extensive cross-reactivity among different species of the genus has been demonstrated (5). Extensive cross-reactivity has also been demonstrated between tropomyosin found in shrimp and that in other Crustacean species, house dust mite and German cockroach (6).

Clinical experienceIgE-mediated reactionsCockroach may commonly induce symptoms of asthma, allergic rhinitis, allergic conjunctivitis and allergic eczema in sensitized individuals (7, 8). The clinical presentation of asthmatic patients with cockroach allergy is typically nonspecic (9). Most commonly, patients have a history of perennial asthma, possibly worse in the winter (10), without a clear history of onset of symptoms on exposure to cockroaches. Although some patients may be exclusively allergic to cockroaches, sensitization is usually to multiple indoor and/or outdoor allergens.

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m6 MoldAlternaria alternata

Allergen descriptionAlternaria alternata /Alternaria tenuis

Alternaria alternata is one of the most important among the allergenic molds. Although other Alternaria species are probably also clinically relevant, especially as a result of cross-reactivity between the species, most research has been directed toward Alternaria alternata.

Allergen exposureAlternaria occurs on many plants and other substrates, including foodstuffs and textiles. Favorite habitats are soils, corn silage, rotten wood, compost, bird nests, and various forest plants. Black spots on tomatoes may be caused by Alternaria. It is frequently found on water condensed on window frames. It is one of the most common mold spores found in dwelling dust in both North America and Europe. Alternaria is predominantly an outdoor allergen favoring damp spots, and most indoor concentrations may derive from outdoor primary sources. In temperate climates, airborne Alternaria spores are detectable from May to November, with peaks in late summer and autumn. Despite the large spore size, spores may disperse for hundreds of miles from the source.

Cross-reactivityAn extensive cross-reactivity among the different individual species of the genus could be expected (1). Enolase is a common allergen found in many species of mold and has been shown to exhibit high cross-reactivity to other fungal enolases (2).

Clinical experienceIgE-mediated reactionsSensitivity to Alternaria has been increasingly recognized as a risk factor for the development, persistence and exacerbation of asthma (3). Studies have suggested that sensitivity to Alternaria may be a risk factor for life-threatening asthma (4, 5, 6). Alternaria is one of the main allergens affecting children. Alternaria-sensitized patients may also be at risk for allergic rhinitis (7). Severe cases of rhinitis may be attributable to Alternaria sensitivity (8). Alternaria sensitization may also occur in occupational settings, including gardens, bakeries, forests and farms. Alternaria is associated with bakers asthma and wood pulp workers lung.

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Allergen descriptionBetula verrucosa

Family: Betulaceae

A tree species producing large amounts of pollen, often inducing hay fever, asthma and conjunctivitis in sensitized individuals. The common silver birch is a single-stemmed, deciduous tree with a height of up to about 25 meters. The bark is smooth and silvery white, becoming black and ssured into rectangular bosses. Several birch pollen allergenic proteins have been identied and characterized, such as Bet v 1 as a major allergen and Bet v 2 as a prolin (1).

Allergen exposureThe birch tree owers in late spring, usually at the same time as the leaves appear. In North America it blooms in early spring and occasionally again in late summer or fall. The bloom time is usually short. The birch trees are wind-pollinated. The birch occurs in woods, particularly where the soil is lighter. It often grows in heath lands and clearings and is also planted in gardens. The common silver birch is native and common in most of Europe, northwest Africa and western Siberia, but rare in the southernmost parts of Europe. It is the most common tree found in Scandinavia and the Alps and a potent pollen producer in those areas. There are also closely related species in East Asia and North America.

t3 BirchCommon silver birch

Tree pollen

Cross-reactivityCross-reactivity between pollens from species within the Betulaceae family or closely related families can be expected and is often seen (13). Major allergens in hazelnut, apple, pear, apricot and sweet cherry as well as minor allergens in other foods, e.g. peanut and soy, are structural homologs to the birch pollen major allergen Bet v 1 (1, 4, 5). Cross-reactivity has also been frequently observed to other substances containing prolin, e.g., hazel-nut, ragweed pollen, mango, mugwort pollen, timothy pollen, celery, carrot, peanut and spices (1, 511).

Clinical experienceIgE mediated reactionsBirch pollen is highly allergenic, causing allergic reactions such as asthma, allergic rhinitis and conjunctivitis. Birch is one of the most important causes of springtime hay fever (3, 12). Cross-reactivity between birch and food may result in symptoms of Oral Allergy Syndrome in birch-sensitized individuals (5, 13). Symptoms of food allergy in birch pollinosis patients are usually mild and restricted to the oral cavity. On the other hand, while allergy to a food, e.g., hazel-nut, without concomitant pollinosis is less common, symptoms tend to be more severe and are often systemic (13).

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Allergen descriptionOlea europaea

Family: Oleaceae

Olive tree pollen often induces hay fever, asthma and conjunctivitis in sensitized individuals. The olive tree is an evergreen growing to 10 meters, with a broad, round crown and a thick and knotty trunk. Pollination is by insects, but also by wind when pollen is in abundance. Olives grow in plantations and woods, and as scrub in dry rocky places.

Allergen exposureOlea europaea, the olive tree, has been recognized as one of the most important causes of seasonal respiratory allergy in the Mediterranean area (1) and in other parts of the world where this tree is now grown. The olive tree probably originated in Asia Minor, spread to the Mediterranean region, and was then introduced into North America (especially California and Arizona), South America (Chile), Australia and South Africa. In North America olive trees are found only in the Southwest. The pollination period of Olea varies. It occurs in the spring, but in Europe may start as early as January, depending on the region (1).

t9 OliveTree pollen

Cross-reactivityA high degree of cross-reactivity has been demonstrated between olive tree, ash and privet and all members of the Oleaceae family (2). In a Spanish study on Cupressus sensitization, skin-prick tests on 1532 patients suffering from respiratory disorders (asthma and/or rhinoconjunctivitis) demonstrated that all of the Cupressus-sensitive patients also reacted positively to Olea and Fraxinus (3). Due to the presence of the panallergen prolin a certain degree of cross-reactivity to other plant allergens may be expected.

Clinical experienceIgE mediated reactionsOlive pollen can induce asthma, allergic rhinitis and allergic conjunctivitis in sensitized individuals (1, 48). The frequency of sensitization to olive tree pollen varies in the Mediterranean region (1). In Greece, more than 37% of atopic individuals are sensitized to Oleaceae (9). The majority of studies demonstrate a higher prevalence of rhinoconjunctival symptoms than asthma (1). Patients are more likely to be polysensitized than monosensitized to olive tree pollen. Monosensitized individuals, children and adults, may have symptoms throughout the year without an apparent increase during the olive pollination season (8).

21

Allergen descriptionArtemisia vulgaris

Family: Asteraceae (Compositae)

Mugwort pollen often induces hay fever, asthma and conjunctivitis in sensitized individuals. The plant is an aggressive, coarse perennial that spreads by persistent rhizomes. It generally reaches a meter or more in height, and has a rather untidy and unattractive appearance. Small, greenish-yellow to red-brown ower heads appear from summer to mid-autumn in clusters at the top of the plant, and produce tiny, inconspicuous yellowish-green owers. A number of mugwort allergenic proteins have been identied and characterized (1).

Allergen exposureMugwort is most common on rubbish heaps, roadsides, sites of demolished buildings in towns, and a variety of other disturbed situations. It is a problem weed in turf grass, nurseries, and natural areas. The plant is native to Europe and Asia, but is now also found throughout the eastern US.

w6 MugwortWeed pollen

Cross-reactivityAn extensive cross-reactivity among the different individual species of the genus could be expected, as well as among members of the family Asteraceae (Compositae) e.g. sage, golden rod, ragweed, chrysanthemum and camomile (26). Furthermore, cross-reactivity has been demonstrated to be common between mugwort, celery, carrot and spices from the Apiaceae family (celery-carrot-mugwort-spice syndro-me) (7). There is also some cross-reactivity to lettuce, nuts, mustard and leguminoseae vegetables (810). The panallergen prolin has been identied as one of the cross-reactive components in mugwort and ragweed pollen (11). Prolin will result in varying degrees of cross-reactivity between mugwort and other pollens and foods containing this panallergen. Prolin is found in virtually all pollens and foods of plant origin (12, 13).

Clinical experienceIgE mediated reactionsMugwort sensitization and allergy has been reported widely. Mugwort pollen is a major cause of asthma, allergic rhinitis, and allergic conjunctivitis (14). Exposure to mugwort pollen may also contributes to the causation or exacerbation of the oral allergy syndrome, eczema, urticaria and anaphylaxis e.g. where pollen has contaminated a food, e.g., honey (6, 10, 15). Approximately 25% of mugwort-allergic patients have reported subsequent hypersensitivity to a variety of foods e.g. celery, spices and carrots (9, 10, 13).

22

Allergen descriptionParietaria judaica

Family: Urticaceae

Wall pellitory is a weed pollen, which often induces hay fever, asthma and conjunctivitis in sensitized individuals. It is a sprawling, many-branched, bushy perennial weed, with brittle, reddish stems. It grows from 30 to 100 cm. Wall pellitory is a common weed around the Mediterranean and along the West Coast of Europe, as far north as central England. It has been introduced in other parts of Western Europe and in Australia and Argentina. Two closely related species are found in the US and one in Brazil. The genus Parietaria has about 10 species, which are highly cross-reactive to each other. Parietaria pollen allergens are one of the most common causes of pollinosis in areas where the plants grow.

Allergen exposureThe plant preferably lives on walls, rocks, banks and hedge banks. In many countries the wall pellitory owers all year round, but with distinct peaks in spring and around November. Parietaria allergy is strongly associated with Mediterranean countries.

Cross-reactivityAn extensive cross-reactivity among the different individual species of the genus could be expected, as well as to a cer-tain degree among members of the family Urticaceae (1). A high homology has been shown between P. judaica, P. ofcinalis, P. lusitanica and P. mauritanica (2). However, for wall pellitory cross-reactivity with other family members of different genuses can also be expected as well as to a certain degree to other plants due to the presence of the panallergen prolin (3).

Clinical experienceIgE-mediated reactionsWall pellitory pollen has been recognized as an important allergen, causing symptoms of asthma, allergic rhinitis and allergic conjunctivitis (48). Rhinoconjunctivitis and bronchial asthma, alone or in association, are the most common clinical manifestations. The season in which patients experience symptoms is prevalently spring. However, many patients show a multiseasonal pattern. In children, sensitization to wall pellitory is low, but it may become the most frequent cause of sensitivity as individuals grow older (5, 6).

w21 Wall pellitoryWeed pollen

23

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