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Original Paper
Int Arch Allergy Immunol 2013;162:65–74
DOI: 10.1159/000353113
A Molecular Diagnostic Algorithm to Guide
Pollen Immunotherapy in Southern Europe:
Towards Component-Resolved Management
of Allergic Diseases
NikolaosDouladiris SavvasSavvatianos IreneRoumpedaki
ChrysanthiSkevaki DimitriosMitsias NikolaosG.Papadopoulos
Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens , Greece
Introduction
Immunoglobulin E (IgE)-mediated allergic respirato-
ry diseases, namely allergic rhinitis/rhinoconjunctivitis
and asthma, represent a major health issue in most devel-
oped countries
[1, 2] . From a mechanistic point of view,
the central role of inhalant allergens in both disease
pathogenesis and the elicitation of symptoms are indis-
putable. However, allergen avoidance is generally thought
to be impractical and/or ineffective, both in the preven-
tion of allergy and the induction of clinical remission in
established disease, as most trials have failed to show sig-
nificant benefit from avoidance measures
[3, 4] .
Given the limited effectiveness of such a directly caus-
al approach, pharmacotherapy, mainly the use of anti-
histamines, bronchodilators and anti-inflammatory
agents, is considered the cornerstone of treatment
[1, 5] .
Nevertheless, allergen-specific immunotherapy (SIT)
represents an important intervention, currently adjunc-
tive to pharmacological treatment, which confers spe-
cific advantages over conventional management. SIT
has been shown to exhibit disease-modifying potential,
with a clinical benefit that outlasts treatment duration
Key Words
Allergen-specific immunotherapy · Molecular diagnosis ·
Panallergens · Pollen
Abstract
Correct identification of the culprit allergen is an essential
part of diagnosis and treatment in immunoglobulin E (IgE)-
mediated allergic diseases. In recent years, molecular biolo-
gy has made important advances facilitating such identifica-
tion and overcoming some of the drawbacks of natural al-
lergen extracts, which consist of mixtures of various proteins
that may be allergenic or not, specific for the allergen source
or widely distributed (panallergens). New technologies offer
the opportunity for a more accurate component-resolved di-
agnosis, of benefit especially to polysensitized allergic pa-
tients. The basic elements of molecular diagnostics with po-
tential relevance to immunotherapy prescription are re-
viewed here, with a focus on Southern European sensitization
patterns to pollen allergens. We propose a basic algorithm
regarding component-resolved diagnostic work-up for pol-
len allergen-specific immunotherapy candidates in South-
ern Europe; this and similar algorithms can form the basis of
improved patient management, conceptually a ‘Compo-
nent-Resolved Allergy Management’.
Copyright © 2013 S. Karger AG, Basel
Received: February 20, 2013
Accepted after revision: May 17, 2013
Published online: July 31, 2013
Correspondence to: Dr. Savvas Savvatianos
Allergy Department, 2nd Pediatric Clinic, University of Athens
41, Fidippidou Str.
GR–11527 Athens (Greece)
E-Mail ss
@ allergy.gr
© 2013 S. Karger AG, Basel
1018–2438/13/1622–0065$38.00/0
www.karger.com/iaa
N.D. and S.S. contributed equally to this manuscript.
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66
[6, 7] , and has been attributed preventive capacity against
the progression of allergic rhinitis to asthma and the de-
velopment of IgE-sensitization to additional allergens
[8, 9] .
Although much remains to be elucidated regarding
underlying mechanisms in different types of SIT, it is a
common understanding that SIT acts in an allergen-spe-
cific manner
[10] . It should therefore be anticipated that
the efficacy of SIT may be highly dependent on both the
ability to correctly identify the culprit allergen(s) and on
the availability and concentration of the relevant aller-
gens in therapeutic extracts. This represents a consider-
able challenge as diagnostic extracts, whether intended
for serological (in vitro) or skin-prick (in vivo) testing, are
traditionally based on crude extracts of the allergen
source, thus containing a mixture of allergens, relevant
and not relevant. The same applies for immunotherapy
vaccines, as recombinant allergens are currently not li-
censed for therapeutical use in humans, and all commer-
cial immunotherapy products are extracts of the raw al-
lergenic materials, containing variable levels of both al-
lergenic and nonallergenic substances. Moreover,
information is scarce regarding the relative concentration
of specific allergens in natural extracts, either diagnostic
or therapeutic, while methodological heterogeneity is the
rule for the sporadically published reports
[11–13] on the
topic; this further complicates the issue of matching im-
munotherapy prescription to specific IgE-sensitization
patterns and might at least partially account for some ob-
served ineffectiveness in immunotherapy trials and in
routine practice.
Recently, a major step forward in the direction of di-
agnostic optimization was signaled by the introduction of
component-resolved diagnostics (CRD)
[14] . Analyzing
patient serum IgE-specificity to the level of single aller-
gens is now possible, enhancing our overview of the IgE-
sensitization profile; this would be expected to facilitate
selection of candidates for immunotherapy and adminis-
tration of the appropriate extracts. However, to our
knowledge, since the introduction of component-re-
solved diagnosis, only a few published articles exist on
how to use the corresponding results for the optimal se-
lection of immunotherapy candidates
[15–18] . This is of
prime importance in the Mediterranean region; in con-
trast to the more or less clearly separated pollination pe-
riods of major allergenic plants in the north of Europe,
the overlapping flowering periods of allergenic plants in
the south, in conjunction with an abundance of multisen-
sitization profiles, frequently hamper diagnosis and make
it difficult to assess the clinical relevance of a given IgE
sensitization
[15, 16] . It is possible that such a diagnostic
work-up may also be applicable in regions across the
world with similar aerobiological characteristics, for ex-
ample, in parts of Australia or in the southern USA (e.g.
Florida).
Although the published reports provide a valuable
first insight in the utilization of these exciting new tech-
niques, they mainly focus on distinguishing patients
sensitized to species-specific allergens from those sensi-
tized to cross-reactive allergens. The basic principle is
that identification of IgE-sensitization to a species-spe-
cific allergen is a marker of genuine sensitization, rules
out positivity due to cross-reacting components and is
therefore a prerequisite for the selection of a therapeuti-
cal extract of the corresponding natural source. It is pos-
sible, nonetheless, that other elements may also be incor-
porated in such an analysis, like available published data
on the relative allergen representation in commercial ex-
tracts, confounding factors in in vitro diagnosis and po-
tential markers indicating a reduced anticipated re-
sponse to specific immunotherapy. By taking the above
points into account, we attempt to build upon existing
algorithms and propose a practical framework for opti-
mized immunotherapy candidate selection, with a focus
on the most important allergenic pollen sources in the
Mediterranean. This and other similar algorithms can
form the basis of improved patient management, con-
ceptually a ‘Component-Resolved Allergy Management’
(CRM).
P o l l e n A l l e r g y
There is general consensus that SIT should be indi-
cated in cases of established clinical relevance of an aller-
gen source
[19] . When seasonal symptoms point to pol-
len allergy, in vivo and/or in vitro testing typically con-
firm the presence of IgE to the specific pollen. In cases of
IgE-sensitization to more than one pollen source, it is im-
portant to identify the clinically significant pollens and
exclude any source that may appear positive exclusively
by cross-reactivity, as misrecognizing the primary sensi-
tizing source(s) may in turn compromise immunological
responses to SIT. This is especially relevant in southern
Europe, where a clinical history may be suboptimally in-
formative, owing to the partial overlap of the pollinating
periods of grasses, trees and weeds.
A number of assays are now routinely available, de-
tecting IgE towards pollen allergen components. These
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CRM of Allergic Disease in Southern
Europe
Int Arch Allergy Immunol 2013;162:65–74
DOI: 10.1159/000353113
67
can be classified to those signifying genuine sensitization
to a given source (species-specific allergens) and others,
indicating broad cross-sensitization.
Markers of Genuine Sensitization to Major Pollen
Sources
Grasses
Grasses are the only allergenic pollen species with
ubiquitous representation and clinical significance across
Europe. Therefore, it is not surprising that half of all com-
mercially marketed CRD assays for inhalant sources in-
volve grass allergens. Among these, Phl p 5 and Phl p 6 do
not exhibit significant serological cross-reactivity to pol-
len allergens outside the Pooideae subfamily, and are thus
regarded as species-specific allergens for Timothy grass
(Phleum pratense) and all other Pooideae members, in-
cluding common meadow grass (Poa pratensis) , orchard
grass (Dactylis glomerata) and perennial ryegrass (Lolium
perenne)
[20] . IgE to Phl p 2 may also be regarded as fair-
ly specific for patients sensitized to grass species of the
Pooideae subfamily; although Phl p 2 can also be found
in non-Pooideae grass species (e.g. Zea mays and Cyn-
odon dactylon ), its immunological importance seems to
be confined to the Pooideae subfamily
[21] .
When IgE specific to one or more of these component
allergens is detected and the clinical history suggests
grass allergy, grass pollen immunotherapy is indicated.
Identification of the exact Pooideae member inducing
primary sensitization may not be as important; both
mixed grass pollen extracts and single representative spe-
cies ( P. pratense pollen) have been argued to be effective
[22–25] .
Phl p 1 represents the archetype of group 1 grass pollen
allergens and is the most prevalent allergen among grass-
allergic patients
[26, 27] . However, the corresponding IgE
is only partially specific for the Pooideae grass subfamily,
dominating in Europe; partial cross-reactivity between
Phl p 1 and Cyn d 1, the group 1 major allergen in Ber-
muda grass (C. dactylon) , frequently hampers correct
identification of the sensitizing allergen source
[28] . Spe-
cifically, when testing for Pooideae-specific molecules
(e.g. rPhl p 2, rPhl p 5 and rPhl p 6) is negative, relatively
higher levels of IgE specific to nCyn d 1 than to rPhl p 1
have been suggested to be indicative of primary sensitiza-
tion to Bermuda grass
[29] ; a SIT extract containing Ber-
muda grass pollen might then be suitable, especially as
such an extract may be quantitatively standardized ac-
cording to group 1 allergen (nCyn d 1) content. In con-
trast, if antibodies against Pooideae-specific molecules
(e.g. rPhl p 5) are positive and specific IgE levels against
rPhl p 1 are higher than those to nCyn d 1, the case is most
probably primary sensitization to Pooideae grasses and
Bermuda pollen representation can be omitted from the
SIT regimen. Finally, if both conditions are present (i.e.
group 5 antibodies-positive and specific IgE against nCyn
d 1 higher than to rPhl p 1), the clinician may be facing a
true double sensitization.
It should not be overlooked that clinical response to
immunotherapy relies on adequate representation of sen-
sitizing allergens in SIT extracts; in this regard, the con-
cept of maximum tolerated extract dose is advocated
[30] .
Most manufacturers determine the concentration of only
one major allergen as part of the standardization process
[12] ; information regarding additional allergen content is
generally not available. It is expected, therefore, that if
IgE-sensitization proves positive against the same major
allergen that is employed in extract standardization, this
would ensure the enhanced possibility of response to SIT.
This is underscored by the fact that the levels of major al-
lergen content and the biological potency of extracts have
repeatedly been found to correlate well
[13, 31] . In this
context, detection of anti-rPhl p 5 IgE, compared to other
grass-specific markers, has added value in terms of asso-
ciated grass-immunotherapy outcome, as rPhl p 5 quan-
tification is the rule for such standardization by compa-
nies and Phl p 5 is typically found in abundance in ex-
tracts
[12, 13, 28, 31, 32] .
T r e e s
In a similar fashion to grass pollen CRD, markers for
better response to immunotherapy can be utilized for the
most important allergenic tree pollen in southern Europe.
nOle e 1/rOle e 1 and nCup a 1 are specific markers for
olive and cypress pollen, respectively, and are available
for routine testing. Potential positivity suggests authentic
sensitization and validates selection of the corresponding
natural SIT extract, when compatible symptoms are pres-
ent. Briefly, Ole e 1 is the most frequent sensitizing aller-
gen in olive pollen
[33] ; it is also typically used in the
standardization process of olive pollen diagnostic and
therapeutic extracts, therefore it is not surprising that Ole
e 1 is the only allergen yet proven to induce immunolog-
ical changes during olive pollen SIT
[34] . Ole e 1-like mol-
ecules are also present in grass (Phl p 11), chenopod (Che
a 1), English plantain (Pla l 1) and saltwort pollen (Sal k
5)
[35] . It seems, however, that cross-reactivity of Ole e 1
with the molecules outside the Oleaceae family is limited,
probably nonsignificant
[36, 37] . Importantly, and owing
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to the high cross-reactivity between Ole e 1-like mole-
cules within the Oleaceae family, positivity to rOle e 1
may serve as a marker of the suitability of ash or privet
pollen SIT in olive-free areas with a high exposure to pol-
len of these closely related Oleaceae members
[36–38] .
nCup a 1 is the only available diagnostic marker for
primary sensitization to pollen of the Cupressaceae fam-
ily. Due to the structural homology of their major aller-
gens, genuine sensitization to either Cupressus arizonica
and/or C. sempervirens , both prevalent in the Mediterra-
nean basin, may be confirmed by this single assay
[39] . In
this case, the high level of cross-antigenicity between
members of the Cupressaceae family may justify thera-
peutic administration of a single representative pollen ex-
tract, even if it is not the same as the originally sensitizing
species
[40] .
Plane tree (Platanus acerifolia) pollen can be a cause of
respiratory allergy in some patients. Major allergens rPla
a 1 and nPla a 2 are commercially available only through
the ISAC allergen biochip immunoassay (Thermo Fisher
Scientific, Uppsala, Sweden) which, unfortunately, is not
very widely used. Positive specific IgE (sIgE) against these
components may serve as a marker of primary sensitiza-
tion to plane tree pollen
[41, 42] . In contrast, rPla a 3 is a
minor allergen that belongs to the nonspecific lipid trans-
fer protein (LTP) family and has been linked with IgE-
sensitization to plant-food LTPs
[43] .
W e e d s
Wall pellitory ( Parietaria judaica and P. officinalis ),
mugwort (Artemisia vulgaris) and, lately, saltwort (S.
kali) are regarded as the most prevalent allergenic weeds
in the Mediterranean
[44–46] . With respect to wall pelli-
tory allergy, Par j 1 and Par j 2 have been described as
major allergens in P. judaica pollen
[47, 48] . Although
they both belong to the largely cross-reactive LTP aller-
gen group, they in fact lack significant cross-reactivity to
other pollen or plant-food LTPs, thus conferring specific-
ity of induced IgE for the Parietaria genus
[49–51] . How-
ever, only rPar j 2 is commercially available for routine
testing. Theoretically, this would have an impact on the
assay’s sensitivity, i.e. the assay’s ability to detect weed-
allergic patients genuinely sensitized to Parietaria pollen.
Nonetheless, detection of IgE to rPar j 2 alone has been
proven to be sufficient in more than 80% of cases
[48] ,
probably owing to Par j 1 and Par j 2 sharing at least three
identical allergenic epitopes
[47] . The reported structural
similarity is primarily held to account for the demonstrat-
ed potency of Par j 1-standardized Parietaria pollen ex-
tracts in anti-rPar j 2-IgE-positive patients
[52] . By taking
the above into account, clinicians may use rPar j 2 as an
efficient Parietaria -specific marker when considering
weed-specific immunotherapy.
Although both nArt v 1 and nArt v 3 have been re-
ported to be species-specific molecules in mugwort-aller-
gic patients and potential markers of positive response to
SIT
[29] , the role of sensitization to the nsLTP Art v 3 may
not be as straightforward. There are conflicting data re-
garding the role of Art v 3 as a primary sensitizer. The
selection of the population is a probable reason for this,
but what seems to be of prime importance is the geo-
graphic area under study; in European (Mediterranean)
populations, Art v 3 may be of little clinical relevance,
generally considered to reflect primary sensitization to
cross-reacting plant-food LTPs
[53–56] . In contrast,
cross-reactivity between plant-food and mugwort LTP
has been shown to be inversely directed in selected pa-
tients and in patients in northern China
[57, 58] . In any
case, the total content of Art v 3 in crude pollen material
has been shown to strikingly vary from batch to batch,
hardly being detected in some
[51] ; this would put into
question the reliability/sufficiency of SIT natural extracts
for patients sensitized only to Art v 3. For the above rea-
sons, the role of detecting specific IgE to nArt v 3 in se-
lecting immunotherapy candidates remains rather con-
troversial at the moment.
On the other hand, nArt v 1 is considered a true major
mugwort pollen allergen, accounting for IgE-sensitiza-
tion in approximately 80% of mugwort-pollen-allergic
patients
[59, 60] . Importantly, it is an effective marker of
genuine sensitization to mugwort pollen, even when
cross-reactivity to minor ragweed allergen Amb v 4 oc-
curs
[61] . Furthermore, when major allergen quantifica-
tion is involved in the process of mugwort pollen extract
standardization, Art v 1 is typically used, suggesting a po-
tential increase in SIT efficacy in anti-Art v 1-IgE-positive
patients
[12] .
Finally, commercially marketed nSal k 1-IgE assay
may provide a species-specific marker for primary salt-
wort pollen allergy, which is steadily gaining significance
across extensive areas in southern Europe due to ongoing
desertification
[46, 62] . Quite importantly, detection of
specific IgE to nSal k 1 is able to distinguish the majority
of patients sensitized to saltwort from those sensitized to
closely related chenopod (Chenopodium album) pollen
[63] . As both weeds pollinate at overlapping periods and
often appear double-positive in extract-based diagnos-
tics, identification of the primary sensitizing source may
be of added value, allowing more specific immunothera-
py
[63] .
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Markers of Cross-Reactivity: Panallergens
In essentially birch-free southern Europe, profilin and
polcalcin molecules are the main cause of in vitro and in
vivo cross-reactivity across a broad spectrum of allergen-
ic pollen. The highly conserved structure and ubiquitous
distribution of these molecules among plant species are
the basis for their ascribed ‘pan-allergenicity’
[64] . Unfor-
tunately, this presents additional challenges, when it
comes to evaluating the sensitization profiles of immuno-
therapy candidates; profilin- and polcalcin-sensitized pa-
tients tend to recognize these molecules in numerous
sources and, as a consequence, score positive in extract-
based diagnostic testing with most pollen species
[65–67] .
Analysis by CRD partially resolves this problem. In fact,
only a limited number of pollen panallergens are available
for routine use (grass profilin, rPhl p 12, and birch pro-
filin, rBet v 2; grass polcalcin, rPhl p 7 and birch polcalcin,
rBet v 4), but due to marked structural homology among
allergenic species, these serve as efficient markers of hy-
persensitivity to the entire group of homologous proteins,
with the possible exception of Parietaria and cypress pro-
filins
[68–72] . The fact that grass pollen is the most prev-
alent cause of both profilin and polcalcin sensitization in
the Mediterranean, along with an excellent cross-reactiv-
ity spectrum of both molecules, favors the use of the
grass-derived allergens over the birch-derived ones, at
least in this geographic region
[66, 68, 70, 73] .
The presence of IgE-sensitization to such panallergens
has been suggested to be a marker of poor outcome in
pollen immunotherapy, especially in the absence of IgE
to species-specific molecules
[16, 20] . In our opinion,
sensitization to pollen profilins and/or polcalcins would
be expected to decrease, at least to some extent, the effi-
cacy of SIT for the following reasons.
i) Whether profilin and polcalcin are clinically rele-
vant allergens is an ongoing matter of debate; recently, it
was demonstrated that they may actually elicit symptoms
in sensitized patients
[74–76] . Moreover, the content in
various pollen SIT extracts, at least for profilin, has been
shown to be remarkably low
[74] , meaning that profilin-
sensitized patients are expected to receive a therapeutic
extract of little immune-modulatory capacity against
profilin.
ii) Sensitization to both profilin and/or polcalcin al-
lergens has been associated with a longer duration of al-
lergic disease and with resulting cosensitization to a larg-
er number of species-specific allergen molecules, com-
pared to patients that do not recognize panallergens
[46,
65, 66]
. This increases the number of genuine sensitiza-
tions to different pollen and would theoretically require
multiple pollen representation for immunotherapy to be
effective.
iii) Sensitization to both profilin and/or polcalcin al-
lergens typically follows previous cosensitization to other
molecular allergens from the same pollen source, as has
been elegantly shown in the grass pollen model
[77, 78] .
It is proposed that, at least for grass pollen allergy, panal-
lergens are only being recognized at the late stage of this
‘molecular spreading’, where the pattern of molecular
sensitization is more complex and the favorable window
of ‘early immunological intervention’ has probably passed
[77, 79] . This is especially relevant, since therapeutic ex-
tracts do not contain all relevant allergens at high doses
[32] ; at best, the concentration of just one major allergen
is ensured
[12] .
In summary, there are theoretical grounds to suggest
that the detection of anti-rPhl p 12-IgE and/or anti-rPhl
p 7-IgE may reduce the anticipated response to pollen
SIT, due to associated molecular multisensitization and
the practical inability to administer an ‘appropriate’, al-
lergen-matching therapeutic extract. However, in case
sIgE against major allergens is present, SIT with extracts
containing these allergens can be administered, especial-
ly as the clinical relevance of profilins and polcalcins is
still arguable.
The Role of Cross-Reactive Carbohydrate
Determinants
Cross-reactive carbohydrate determinants (CCDs) are
not only present in the glycoproteins of virtually all pol-
len, but are regarded as the most frequently encountered
individual epitope structures for IgE
[80] . Nonetheless,
after years of debate about their actual participation in the
induction of symptoms, there is now enough evidence to
support the view that IgE-sensitization to CCDs is clini-
cally insignificant, as these carbohydrates seem to be able
to activate basophils by IgE-binding only ex vivo
[80, 81] .
Either due to insufficient representation, low binding-af-
finity of IgE to carbohydrate epitopes or the presence of
CCD-blocking IgG4 antibodies, glycans do not behave as
allergens in vivo
[80, 81] . In contrast, IgE to CCDs does
become evident by ‘contaminating’ extract-based in vitro
specific-IgE testing; widespread positivity is then the rule
[82] .
If these apparently multisensitized patients undergo
CRD, there is a similar possibility of misleading, false-
positive results when glycosylated component allergens
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are utilized. Such CCD-containing natural purified gly-
coproteins include nCyn d 1, nOle e 1, nCup a 1, nSal k 1,
nPla a 2 and nArt v 1, used for the detection of primary
sensitization to Bermuda grass, olive, cypress, saltwort,
plane tree and mugwort pollen, respectively. On the con-
trary, recombinant forms of proteins are typically pro-
duced in the reducing cytoplasmic environment of Esch-
erichia coli bacteria, which is unable to host posttransla-
tional modification, and thus the glycosylation of proteins
[83] . As a result, IgE to CCDs does not interfere with re-
combinant CRD pollen allergens. It must be noted, none-
theless, that the lack of posttranslational modifications in
E. coli -produced recombinant allergens may theoretically
result in improper folding of the allergen protein, leading
to potentially false-negative results due to reduced aller-
gen recognition by the patient IgE
[83] .
When considering CRD results in the formulation of
SIT extracts for apparently multisensitized patients, it is
imperative to exclude potentially CCD-restricted IgE-
sensitization to natural glycosylated species-specific al-
lergens, i.e. the presence of IgE directed only to the carbo-
hydrate moiety in the absence of IgE specific for the pro-
tein fragment. Available markers of sensitization to CCDs
are bromelain (nAna c 2) and MUXF3, the purified N-
glycan from bromelain (on a peptide backbone)
[29] .
These are able to detect IgE to N-glycans in most pollen
sources. When the clinician is confronted with positive in
vitro results to a natural glycoprotein, negative sIgE re-
sults to CCD markers reveal the protein nature of IgE
epitopes. An exception is the case of positivity to nArt v
1; IgE-sensitization to CCD may not be excluded by test-
ing with bromelain or MUXF3, as these markers detect
IgE to N-glycans, whereas nArt v 1 is known to primarily
contain O-glycans
[84] . On the contrary, positive sIgE re-
sults to CCD markers should optimally be accompanied
by assessment of biological activity, i.e. by positive skin-
prick testing or nasal/conjunctival challenge with the al-
lergen source
[80, 81] . This approach may serve to prove
the concomitant presence of sIgE against protein epit-
opes, and thus validate the inclusion of the allergen source
in the SIT regimen.
A Clinical Algorithm for Using CRD in Pollen-Specific
Immunotherapy: Introducing ‘Component-Resolved
Management’
The use of a panel of species-specific allergen markers,
representing the most common allergenic species in the
Mediterranean, along with the panallergen screening
molecules rPhl p 7 and rPhl p 12, may facilitate the selec-
tion of those immunotherapy candidates who would have
an increased probability of benefitting from SIT. A pro-
posed clinical algorithm for the assessment of pollen-al-
lergic patients suitable for extract-based immunotherapy
in the birch-pollen-free areas of southern Europe is de-
picted in figure 1 .
Initially, a basic diagnostic discrimination between
mono/oligo- and multisensitization may be performed,
based on skin test readings and/or sIgE in vitro results us-
ing common pollen extracts. In the case of mono-
or oli-
gosensitization, an individual assessment of patient suit-
ability for SIT is carried out on the basis of sensitization
to major species-specific molecules that are contained in
commercial therapeutical extracts in as close to ‘high
dose’ as possible.
In a multisensitized pollen-allergic patient, an addi-
tional assessment of (co)sensitization to panallergens is
important, as detection of sIgE directed towards profilins
and/or polcalcins would possibly mean a poorer outcome
of immunotherapy for the reasons discussed above. With
respect to species-specific markers, when nonglycosylat-
ed recombinant allergens are used in in vitro tests, posi-
tive sIgE results to major grass-specific rPhl p 5/rPhl p 1,
Parietaria -specific rPar j 2 or olive-specific rOle e 1 may
justify immunotherapy with the respective pollen extract.
In the case of positive in vitro results for Bermuda grass,
cypress, olive, saltwort or mugwort pollen major aller-
gens (nCyn d 1, nCup a 1, nOle e 1, nSal k 1, and nArt v
1 respectively) in multisensitized patients, sensitization
restricted to the CCD component must be optimally
ruled out, as these molecules are used in diagnostics as
purified natural CCD-rich isoforms. As the role of CCDs
in clinical allergy is generally disputed, it would be of
questionable value to specifically target these molecules;
only in the case of concurrent sensitization to a protein
component would immunotherapy to the allergen source
be a prudent choice.
C o n c l u s i o n
We propose a CRM plan for pollinosis in southern
Europe, based on molecular sensitization patterns for the
most common pollens in the area. At the moment, there
are no prospective studies to evaluate the added benefit of
applying CRD in terms of SIT efficacy. However, in a pro-
spective study, it has recently been shown that the incor-
poration of CRD results was able to alter initial SIT indi-
cation and allergen prescription in more than half of the
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DOI: 10.1159/000353113
71
patients studied [85] . Moreover, results from a retrospec-
tive analysis of SIT efficacy with respect to molecular sen-
sitization patterns favor such an approach and are com-
patible with the underlying rationale
[18] .
Of course, for the moment, these remain mainly theo-
retical considerations; significant limitations include in-
complete and sometimes conflicting published data, in-
adequate information about the allergen content of com-
mercial SIT extracts as well as reported qualitative and
quantitative variability between different SIT products
and manufacturers
[12, 31, 86–88] . In addition, taking
into account the limited number of allergen components
currently available for clinical use and the fact that exact
matching of natural SIT extracts to individual sensitiza-
tion profiles may probably be a Utopian goal, one could
reasonably argue against the practical value of such an at-
tempt. However, until patient-tailored recombinant ex-
tracts are licensed for clinical use and until prospective
controlled studies provide solid data on all significant as-
pects, we argue that CRM, based on the best-available sci-
entific knowledge, may enhance our diagnostic and ther-
apeutic accuracy.
Fig. 1. Proposal for a basic CRD work-up for pollen SIT candidates
in southern Europe. For the purposes of the current figure, com-
ponent allergens’ names denote the detection of corresponding
specific IgE. * In cases with nCyn d 1 (+) > rPhl p 1 (+) and nega-
tive species-specific allergen markers for Timothy grass (e.g. rPhl
p 2, rPhl p 5 and rPhl p 6), a Bermuda grass standardized extract
may be sufficient for the treatment of clinical allergy to grass pol-
len (please refer to text). * * Both natural nOle e 1 and recombinant
rOle e 1 are commercially available in Europe. * * * For optimal SIT
efficacy, the use of standardized extracts containing the species-
specific major allergen at high-dose concentration may be re-
quired. * * * * rPhl p 7, as a polcalcin marker and rPhl p 12, as a pro-
filin marker are typically used. In areas with a high prevalence of
birch pollen allergy (not typical of the Mediterranean region), rBet
v 4 and rBet v 2 may respectively be used, along with the essential
rBet v 1 birch pollen major allergen.
Color version available online
Clinical history
SPT/In vitro extract-based slgE assay
Mono-/Oligo-sensitization
Check for major species-specific
allergen markers
rPhl p 1*
rPhl p 5
rPar j 2
rOle e 1**
rPla a 1
Uncertain SIT efficacy
Non-glycosylated
allergen markers
nCyn d 1*
nCup a 1
nOle e1**
nArt v 1
nSal k 1
nPla a 2
Natural purified
glycoproteins
E\²DQWL&&',J(
E\H[WUDFWVNLQWHVWLQJ
E\QDVDOFRQMXQFWLYDODOOHUJHQ
challenge
Assess protein nature of epitope(s)
in multi-sensitized patients
Suitability for SIT***
Check for sensitization
to panallergens****
Multi-sensitization
²
²
SIT efficacy expected
rPhl p 7/12
rPhl p 7/12
²
rPhl p 7/12
²
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DOI: 10.1159/000353113
72
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