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Occupational asthma due to cricket powder in a cricket breeder
Insects are increasingly being considered as occupational and food allergens. Occupational allergy to crickets may be triggered in factory workers who manufacture food for reptiles, in professionals who raise reptiles as pets or in the zoos, and in cooks who make culinary recipes with insects. Additionally, edible insects are gradually being included in the western diet.
Purpose:
Work-related asthma (WRA) occupies about 10%-30% of all asthma cases. Among 2 subtypes of WRA (occupational asthma [OA] and work-exacerbated asthma [WEA]), the rate of WEA has been reported to increase recently. WRA is described as having worse characteristics than non-WRA (NWRA), while WEA is known to show similar severity to OA in terms of symptoms and exacerbations. However, these data were mainly based on indirect surveys. Ulsan is a highly industrialized city in Korea; therefore, it is estimated to have a high incidence of WRA. This study aimed to identify the characteristics of WRA in the city.
Methods:
This was a prospective asthma cohort study of individuals diagnosed with asthma and treated at Ulsan University Hospital between Jan 2015 and Dec 2016. Baseline characteristics and work-related inquiry (9 questionnaires) were investigated at enrollment. Various severity indices and job change were then investigated for the longitudinal analysis at 12 months after enrollment.
Results:
In total, 217 asthma patients completed the study. WRA accounted for 17% (36/217), with an equal number of WEA and OA (18 patients each). Before the work-related survey, only 33% (n = 12) of WRA patients (22% [4/18] of WEA and 44% [8/18] of OA) were diagnosed with WRA by the attending physicians. Compared to the NWRA group and the OA subgroup, the WEA subgroup had more outpatient visits, more oral corticosteroids prescriptions, and trends of low asthma control test scores and severe asthma. The rate of job change was markedly lower in the WEA subgroup than in the OA subgroup (20% vs. 5%).
Conclusions:
The overall prevalence of WRA (17%) was similar to those of previous studies, but the share of WEA was high (50% of WRA). WEA was more severe than OA or NWRA. The possible reason for this severity is ongoing workplace exposure.
Background
Insects have become increasingly interesting as alternative nutrient sources for feeding humans and animals, most reasonably in processed form. Initially, some safety aspects — among them allergenicity — need to be addressed.
Objective
To reveal the cross-reactivity of shrimp-, mite- and flies-allergic patients to different edible insects, and further to assess the efficacy of food processing in reducing the recognition of insect proteins by patients' IgE and in skin prick testing of shrimp-allergic patients.
Methods
IgE from patients allergic to crustaceans, house dust mite or flies was evaluated for cross-recognition of proteins in house cricket Acheta domesticus (AD), desert locust Schistocerca gregaria (SG) and Yellow mealworm Tenebrio molitor (TM). Changes in IgE-binding and SPT-reactivity to processed insect extracts were determined for migratory locust (Locusta migratoria, LM), after different extraction methods, enzymatic hydrolysis, and thermal processing were applied.
Results
IgE from patients with crustacean-allergy shows cross-recognition of AD, SG and stable flies; house dust mite allergics' IgE binds to AD and SG; and the flies-allergic patient recognized cricket, desert locust and migratory locust. Cross-reactivity and allergenicity in SPT to LM can be deleted by conventional processing steps, such as hydrolysis with different enzymes or heat treatment, during the preparation of protein concentrates.
Conclusion
The results show that crustacean-, HDM- and stable flies-allergic patients cross-recognize desert locust and house cricket proteins, and crustacean-allergic patients also flies proteins. Furthermore, this study shows that appropriate food processing methods can reduce the risk of cross-reactivity and allergenicity of edible insects.
Work-related asthma is the most common occupational lung disease encountered in clinical practice. In adult asthmatics, work-relatedness can account for 15%-33% of cases, but delays in diagnosis remain common and lead to worse outcomes. Accurate diagnosis of asthma is the first step to managing occupational asthma, which can be sensitizer-induced or irritant-induced asthma. While latency has traditionally been recognized as a hallmark of sensitizer-induced asthma and rapid-onset a defining feature of irritant-induced asthma (as in Reactive Airway Dysfunction Syndrome), there is epidemiological evidence for irritant-induced asthma with latency from chronic moderate exposure. Diagnostic testing while the patient is still in the workplace significantly improves sensitivity. While specific inhalational challenges remain the gold-standard for the diagnosis of occupational asthma, they are not available outside of specialized centers. Commonly available tests including bronchoprovocation challenges and peak flow monitoring are important tools for practicing clinicians. Management of sensitizer-induced occupational asthma is notable for the central importance of removal from the causative agent: ideally, removal of the culprit agent; but if not feasible, this may require changes in the work process or ultimately, removal of the worker from the workplace. While workers' compensation programs may reduce income loss, these are not universal and there can be significant socio-economic impact from work-related asthma. Primary prevention remains the preferred method of reducing the burden of occupational asthma, which may include modification to work processes, better worker education and substitution of sensitizing agents from the workplace with safer compounds. Copyright © 2019 The Korean Academy of Asthma, Allergy and Clinical Immunology • The Korean Academy of Pediatric Allergy and Respiratory Disease
Background
Asthma is a prevalent chronic disease and occupation contributes to approximately 15 % of cases among adults. However, there are still few studies on risk factors for work-exacerbated asthma. The current study investigated the association between asthma exacerbations and occupational exposures. Methods
The study comprised all currently working adults (n = 1356) who reported ever asthma in prior population-based cohorts. All subjects completed a questionnaire about exposures, occupations and exacerbations of asthma. Exposure to high and low molecular weight agents, irritating agents and asthmagens were classified using the asthma-specific job exposure matrix for northern Europe (N-JEM). Severe exacerbation of asthma was defined as sought emergency care at a hospital, admitted to a hospital overnight, or made an urgent visit to a primary care physician or district medical office due to breathing problems during the last 12 months. Moderate exacerbation was defined as both being not severe exacerbation and an additional visit to a primary care physician or district medical office, or had extra treatments with corticosteroid tablets. Mild exacerbation was defined as being neither severe nor moderate exacerbation, and increasing usage of inhaled corticosteroids.Multiple logistic regression was applied to investigate the association between exacerbation of asthma and occupational exposures while adjusting for potential confounders. ResultsApproximately 26 % of the working asthmatics reported exacerbation, and more than two-thirds of them had moderate or severe exacerbation. From 23 to 49 % of the asthmatics reported occupational exposure to a variety of different types of agents. Exposure to any gas, smoke or dust (OR 1.7[95 % CI 1.2–2.6]) was associated with severe exacerbation of asthma, as were organic dust (OR 1.7[1.2–2.5]), dampness and mold (OR 1.8[1.2–2.7]), cold conditions (OR 1.7[1.1–2.7]), and a physically strenuous job (OR 1.6[1.03–2.3]). Asthmagens and low molecular weight agents classified by the N-JEM were associated with mild exacerbation, with OR 1.6[1.1–2.5] and OR 2.2[1.1–4.4], respectively. Conclusions
Self-reported exposure to any gas, smoke or dust, organic dust, dampness and mold, cold conditions and physically strenuous work, and jobs handling low molecular weight agents were associated with exacerbation of asthma. Reduction of these occupational exposures may help to reduce exacerbation of asthma.
Work-related asthma, which includes occupational asthma and work-aggravated asthma, has become one of the most prevalent occupational lung diseases. These guidelines aim to upgrade occupational health standards, contribute importantly to transnational legal harmonisation and reduce the high socio-economic burden caused by this disorder.
A systematic literature search related to five key questions was performed: diagnostics; risk factors; outcome of management options; medical screening and surveillance; controlling exposure for primary prevention. Each of the 1,329 retrieved papers was reviewed by two experts, followed by Scottish Intercollegiate Guidelines Network grading, and formulation of statements graded according to the Royal College of General Practitioners’ three-star system.
Recommendations were made on the basis of the evidence-based statements, which comprise the following major evidence-based strategic points. 1) A comprehensive diagnostic approach considering the individual specific aspects is recommended. 2) Early recognition and diagnosis is necessary for timely and appropriate preventative measures. 3) A stratified medical screening strategy and surveillance programme should be applied to at-risk workers. 4) Whenever possible, removing exposure to the causative agent should be achieved, as it leads to the best health outcome. If this is not possible, reduction is the second best option, whereas respirators are of limited value. 5) Exposure elimination should be the preferred primary prevention approach.
The development of occupational asthma (OA) is likely to result from the complex interaction of environmental and host factors. This article addresses a series of issues relating to the multiple environmental factors that could affect the initiation of OA, including the intrinsic characteristics of causative agents, as well as the influence of the level, mode and route of exposure.
Although the clinical and pathological features of OA caused by low molecular weight agents resemble those of immunoglobulin (Ig)E-mediated asthma, the failure to detect specific IgE antibodies against most of these agents and/or poor association with disease status have resulted in intense speculation about alternative or complementary physiopathological mechanisms leading to airway sensitisation.
In this contribution, the roles of specific immunoglobulin E and G antibodies, cell-mediated immunity and inflammatory effector cells are critically reviewed. Recent advances in the characterisation of the molecular interactions between chemical sensitisers and human airway proteins provide promising avenues for elucidating the immunological basis of occupational asthma caused by low molecular weight agents.
Occupational allergies are among the most common recorded occupational diseases. The skin and the upper and lower respiratory tract are the classical manifestation organs. More than 400 occupational agents are currently documented as being potential "respiratory sensitizers" and new reported causative agents are reported each year. These agents may induce occupational rhinitis (OR) or occupational asthma (OA) and can be divided into high-molecular weight (HMW) and low-molecular weight (LMW) agents. The most common occupational HMW agents are (glycol)proteins found in flour and grains, enzymes, laboratory animals, fish and seafood, molds, and Hevea brasiliensis latex. Typical LMW substances are isocyanates, metals, quaternary ammonium persulfate, acid anhydrides, and cleaning products/disinfectants. Diagnosis of occupational respiratory allergy is made by a combination of medical history, physical examination, positive methacholine challenge result or bronchodilator responsiveness, determination of IgE-mediated sensitization, and specific inhalation challenge tests as the gold standard. Accurate diagnosis of asthma is the first step to managing OA as shown above. Removal from the causative agent is of central importance for the management of OA. The best strategy to avoid OA is primary prevention, ideally by avoiding the use of and exposure to the sensitizer or substituting safer substances for these agents.
Purpose of review:
The purpose of this review was to list all new confirmed cases of immunological occupational asthma (IOA) described between mid-2014 and April 2020.
Findings:
Several new agents, both of high and low molecular weight, have been identified in the last 6 years as potential respiratory sensitizers being able to induce immunological occupational asthma. This review confirms that new causes of IOA are still identified regularly, particularly in subjects exposed to high molecular agents, in the food industry (farming, pest control, food processing), pharmaceutical industry (antibiotics, various drugs) and cosmetic environment (dyes, powders).
Summary:
It stressed the need for clinicians to stay alert and suspect occupational asthma in any adult with new onset asthma or newly uncontrolled asthma.
Exposures at work can give rise to different phenotypes of “work-related asthma.” The focus of this review is on the diagnosis and management of sensitizer-induced occupational asthma (OA) caused by either a high- or low-molecular-weight agent encountered in the workplace. The diagnosis of OA remains a challenge for the clinician because there is no simple test with a sufficiently high level of accuracy. Instead, the diagnostic process combines different procedures in a stepwise manner. These procedures include a detailed clinical history, immunologic testing, measurement of lung function parameters and airway inflammatory markers, as well as various methods that relate changes in these functional and inflammatory indices to workplace exposure. Their diagnostic performances, alone and in combination, are critically reviewed and summarized into evidence-based key messages. A working diagnostic algorithm is proposed that can be adapted to the suspected agent, purpose of diagnosis, and available resources. Current information on the management options of OA is summarized to provide pragmatic guidance to clinicians who have to advise their patients with OA.
Food scarcity is a serious problem for many developing as well as developed countries. Edible insects have attracted attention recently as a novel food source. Crickets are especially high in nutritional value and easy to breed and harvest. In this study, we evaluated the risk of allergic reactions associated with cricket consumption in individuals with crustacean allergy.
We evaluated food allergy risk in the consumption of Gryllus bimaculatus (cricket) in patients with shrimp allergy, using enzyme-linked immunosorbent assay (ELISA) and IgE crosslinking-induced luciferase expression assay (EXiLE). Sera from individuals with shrimp allergy (positive for shrimp-specific IgE by ImmunoCAP (>0.35 UA/mL; n = 9) or without shrimp allergy (negative for shrimp-specific IgE; n = 6) were obtained.
There was a strong correlation between shrimp- and Gryllus-specific IgE levels obtained by ELISA (rs = 0.99; P < 0.001). The binding of shrimp-specific IgE on shrimp allergen was dose-dependently inhibited by Gryllus allergen (0–1.0 mg/mL). There was a strong correlation between shrimp- and Gryllus-specific IgE responses, as assessed by EXiLE assays (rs = 0.89; P < 0.001). We determined that a protein of approximately 40 kDa reacted with the positive, but not negative, sera for shrimp-specific IgE by ImmunoCAP. Liquid chromatography-tandem mass spectrometry (LC–MS/MS) analysis identified the major allergen in shrimp and Gryllus to be tropomyosin.
Our data suggest that the cricket allergen has the potential to induce an allergic reaction in individuals with crustacean allergy. Therefore, allergy risk and shrimp-specific IgE levels should be considered before consumption of cricket meal.
Making an accurate diagnosis of occupational asthma (OA) is, generally, important. The condition has not only significant health consequences for affected workers, but also substantial socio-economic impacts for workers, their employers and wider society. Missing a diagnosis of OA may lead to continued exposure to a causative agent and progressive worsening of disease; conversely, diagnosing OA when it is not present may lead to inappropriate removal from exposure and unnecessary financial and social consequences. While the most accurate investigation is specific inhalation challenge in an experienced centre, this is a scarce resource and in many cases reliance is on other tests. This review provides a technical dossier of the diagnostic value of the available methods which include an appropriate clinical history, the use of specific immunology and measurement of inflammatory markers, and various methods of relating functional changes in airway calibre to periods at work. It is recommended that these approaches are used iteratively and in judicious combination, in cognisance of the individual patient's circumstances and requirements. Based on available evidence, a working diagnostic algorithm is proposed that can be adapted to the suspected agent, purpose of diagnosis, and available resources. For better or worse, many of the techniques - and their interpretation - are available only in specialised centres and where there is room for doubt, referral to such a centre is probably wise. Accordingly, the implementation or development of such specialised centres with appropriate equipment and expertise should greatly improve the diagnostic evaluation of work-related asthma. This article is protected by copyright. All rights reserved.
Two employees developed allergic rhinitis and bronchial asthma which was occupationally related to raising crickets. Skin tests, bronchial challenge, radioallergosorbent test (RAST), in vitro histamine release and a passive transfer test supported the presence of type I hypersensitivity to cricket allergens. Skin tests of other employees and patients of an allergy clinic suggested that cricket emanations are potent allergens.
A monoclonal antibody to Dermatophagoides pteronyssinus is described that cross-reacts with an IgE-binding antigen present in insects, Crustacea (e.g. shrimp) and other invertebrates. By means of sodium dodecyl sulfate-polyacrylamide gel electrophoresis, gel filtration and immunofluorescence it was shown that this monoclonal antibody presumably recognizes tropomyosin. Tropomyosin was shown to be involved in cross-reactivity between mite, shrimp and insects in shrimp-allergic patients.
Insects may cause airborne hypersensitivity reactions. However, few reports exist on specific allergy to crickets.
To report a case of occupational rhinitis and bronchial asthma in a cricket farm worker.
A 28-year-old woman developed rhinitis and bronchial asthma related to her job in a farm where she was exposed to crickets: Gryllus campestris, Gryllus bimaculatus, and Acheta domestica. Extracts were prepared from whole and crushed bodies and analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Skin prick tests, specific IgE assays (enzyme allergosorbent test [EAST], immunoblotting, EAST inhibition assays), serial peak expiratory flow monitoring at work, and specific (A domestica) and nonspecific bronchial challenge tests were performed.
Skin prick test results were positive for G campestris, G bimaculatus, and A domestica. Levels of specific IgE were 2.9, 2.4, and 5.4 kU/L, respectively. The total IgE level was 131 kU/L. Serial peak expiratory flow monitoring at work was consistent with occupational asthma. The result of a bronchial challenge test with A domestica was positive with a dual response and elicited an increase in nonspecific bronchial hyperresponsiveness. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis immunoblotting revealed a similar pattern of IgE-binding bands with the 3 cricket extracts (bands of 78 and 64 kDa appeared in nonreducing conditions, whereas bands of 107 to 80, 58, and 52 kDa appeared in reducing conditions). None of these bands was detected by control sera. EAST inhibition studies showed a high degree of cross-reactivity among the 3 species.
Crickets are responsible for occupational rhinitis and asthma by an IgE mechanism. Cross-reactivity among the crickets tested in our study was found.
- C M Barber
- P Cullinan
- J Feary
- D Fishwick
- J Hoyle
- H Mainman
Barber CM, Cullinan P, Feary J, Fishwick D, Hoyle J, Mainman H, et al.
British Thoracic Society Clinical Statement on occupational asthma. Thorax 2022;77:433-42.