Your SlideShare is downloading. ×
Wheat allergy
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Wheat allergy

1,550
views

Published on

Wheat allergy …

Wheat allergy

Presented by Planee Vatanasurkitt,MD.,

20110923

Published in: Health & Medicine, Technology

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,550
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
56
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Wheat allergy
    PlaneeVatanasurkitt,MD
  • 2. Topic outline
    Prevalence
    Manifestation : children, adult
    Natural history
    Wheat allergen
    Diagnosis
    Cross-reactivity with grass
    Processing on allergenicity of wheat allergen
    WDEIA: pathogenesis
  • 3. prevalence
    0.4-1 % of children
    Venter C. incidence of parentally reported and clinically diagnosed food allergy in the first year of life JACI 2006;117:1118-24
    0.3-0.5 % of children 0-14 yr
    Roehr CC. food allergy and nonallergic food hypersensitivity in children and adolecent. Clin Exp Allergy 2004:34:1534-41
  • 4. 0.4% in adult
    Vierk KA. Prevalence of self-reported food allergy in american adult and use of food label.JACI 2007;119:1504-1510
  • 5. Natural history of wheat allergy
    From Johns Hopkins pediatric allergy clinic 1999-2006 total 5000 children
    103 patient had symptomatic reaction to wheat and positive wheat IgE test result
    Keet et al .The natural history of wheat allergy
    :Ann Allergy Asthma immunol.2009;102:410-15
  • 6. Keet et al .The natural history of wheat allergy
    :Ann Allergy Asthma immunol.2009;102:410-15
  • 7. Keet et al .The natural history of wheat allergy
    :Ann Allergy Asthma immunol.2009;102:410-15
  • 8. Rate of resolution
    Keet et al .The natural history of wheat allergy
    :Ann Allergy Asthma immunol.2009;102:410-15
  • 9. Predictors of prognosis
    Wheat IgE level correlated with resolution of allergy and peak wheat IgE level predict rate of resolution
    Keet et al .The natural history of wheat allergy
    :Ann Allergy Asthma immunol.2009;102:410-15
  • 10. Wheat allergy : study
    retrospective study ;350 children
    aged less than 7 yr
    with food hypersensitivity treated in the Department of Allergology, Helsinki University Central Hospital, Helsinki, Finland,
    between 1992 and 1998, were reviewed to identify patients with wheat hypersensitivity.
    Kotaniemi-Syrjanenet al. The prognosis of wheat hypersensitivity
    :Pediatr Allergy Immunol 2010: 21: e421–e428.
  • 11. Kotaniemi-Syrjanenet al. The prognosis of wheat hypersensitivity
    :Pediatr Allergy Immunol 2010: 21: e421–e428.
  • 12. Sensitization to wheat and gliadin, and other food
    15/21 IgE mediated wheat hypersensitivity had positive SPT reaction to cow’s milk
    18/21 had positive SPT to hen’s egg
    25/28 wheat allergic children had challenge proven cow milk allergy
    Sensitization to giadin is associated with slower achievement of tolerance and increased risk of asthma
    Kotaniemi-Syrjanenet al. The prognosis of wheat hypersensitivity
    :Pediatr Allergy Immunol 2010: 21: e421–e428.
  • 13. Risk factors for development respiratory allergy and asthma
    62% had become sensitized to birch pollen
    68% had symptoms of allergic rhinoconjunctivitis during follow up at median age 4.4 yr
    89% of children positive SPT to both wheat and hen egg development allergic rhinitis later in childhood
    Kotaniemi-Syrjanenet al. The prognosis of wheat hypersensitivity
    :Pediatr Allergy Immunol 2010: 21: e421–e428.
  • 14. Risk factors for development respiratory allergy and asthma
    Asthma was diagnosed in 12 [43%] at median age 1.9 yr
    Incidence of asthma 64% in gliadin sensitized children comparison with 21% in gliadin-negative children
    Kotaniemi-Syrjanenet al. The prognosis of wheat hypersensitivity
    :Pediatr Allergy Immunol 2010: 21: e421–e428.
  • 15. Wheat allergy: a double-blind,Placebo-controlled study in adults
    27 patients
    Age 14-60 years
    History suspected wheat allergy
    Method : DBPCFC raw and cooked wheat, SPT, Ig E
    JACI 2006;117:433-9
  • 16. 14/27 [52%] had positive result for glass pollen
    Most subjects also report food allergy to other fruits and vegetables
    13/27 [48%] positive to wheat DBPCFC
    38% of challenge positive patients were grass pollen positive compared with 64% in the challenge negative group
    JACI 2006;117:433-9
  • 17. JACI 2006;117:433-9
  • 18. JACI 2006;117:433-9
  • 19. JACI 2006;117:433-9
  • 20. JACI 2006;117:433-9
  • 21. Wheat allergy
    Low incidence <1 %
    presentation : skin > GI > RS
    Immediate reaction > delayed reaction
    age of tolerance 6-7 years
    Associated with development of allergic rhinoconjunctivitis
    Wheat allergy does occur in adult patient
    Sensitivity and specificity of SPT and specific IgE for wheat in diagnosis of wheat allergy are low
  • 22. Allergen involved in wheat allergy
    Categorized in to four fraction on basis of solubility
    Water soluble: albumin
    Salt soluble : globulin
    Aqueous alcohol: gliadins
    Dilute alkali/acid : glutelins
    Pastorello EA et al. European patients: alpha-amylase inhibitors , lipid transferproteins and low molecular-weight glutenins. Allergenic molecules recognized by double blind, placebo-controlled food challenge.
    Int Arch Allergy Immunol 2007; 144:10 – 22.
  • 23. Sera of 16 wheat challenge-positive patients and 6 patient with wheat anaphylaxis
    Immunobloting of three Osborne’s protein fraction
    Pastorello EA et al. European patients: alpha-amylase inhibitors , lipid transferproteins and low molecular-weight glutenins. Allergenic molecules recognized by double blind, placebo-controlled food challenge.
    Int Arch Allergy Immunol 2007; 144:10 – 22.
  • 24. Raw wheat
    Cooked wheat
    Pastorello EA et al. European patients: alpha-amylase inhibitors , lipid transferproteins and low molecular-weight glutenins. Allergenic molecules recognized by double blind, placebo-controlled food challenge.
    Int Arch Allergy Immunol 2007; 144:10 – 22.
  • 25. Albumin/globulin fraction of Raw wheat
  • 26. Gliadin fraction of raw wheat
  • 27. Glutenin fraction of raw wheat
  • 28.
  • 29. In water/salt-soluble albumin/globulin
    Most important allergen are amylase/trypsin inhibitor subunit
    Responsible for classic food allergy in children with atopic dermatitis and adult
    Pastorello EA et al. European patients: alpha-amylase inhibitors , lipid transferproteins and low molecular-weight glutenins. Allergenic molecules recognized by double blind, placebo-controlled food challenge.
    Int Arch Allergy Immunol 2007; 144:10 – 22.
  • 30. In water/ salt-insoluble gluten
    gliadinsare involved in WDEIA, some cases of atopic dermatitis and in anaphylaxis in adults and children.
    Among the gliadins, ώ-5 gliadin(Tri a 19) was identified as a major allergen of WDEIA
    JACI 1999; 103 :912 -17
    J DermatolSci 2003; 33: 99 – 104.
  • 31. Gliadin
    Four of seven B-cell epitopes of ώ -5 gliadinidentified in WDEIA (QQI PQQQ , QQF PQQQ , QQS PEQQ , and QQ SPQQQ ) were found to be dominant
    Battais et al. reported that IgE antibodies of patients with WDEIA and classic wheat allergy recognized sequential epitopes of repetitive domains of ώ -5 gliadin.
    J BiolChem 2004;279:12135-40
    Allergy 2005;60:815-21
  • 32. Glutenins
    Glutenins in the water/salt-insoluble fraction are polymeric proteins made up of subunits of HMW and low molecular weight (LMW)
    Three B-cell epitopes of HMW glutenin subunits from repetitive domains, QQPG Q, QQPG QGQQ,and QQS GQSGQ, were identified in a minor subgroup of WDEIA
    LMW glutenin subunit s are also involved in child and adult wheat immediate allergies , including WDEIA
    J Immunol 2005;175:8116-22
  • 33. Non specific lipid transfer protein
    Wheat non specific lipid transfer protein (nsL TP) (Tri a 14) with a molecular weight of 9 kDa was recently identified as a new wheat allergen in nine out of 22 patients with wheat food allergy by IgEimmunoblotting followed by mass spectrometry, and was confirmed to have the biological activity in vivo by a positive SPT with purified wheat LTP
    Pastorello EA et al. European patients: alpha-amylase inhibitors , lipid transferproteins and low molecular-weight glutenins. Allergenic molecules recognized by double blind, placebo-controlled food challenge.
    Int Arch Allergy Immunol 2007; 144:10 – 22.
  • 34. Non specific lipid transfer protein
    28% of 60 patient with wheat food allergy shower IgE reaction with purified wheat LTP
    Wheat nsLTP has also been reported as an inhalant allergen in baker asthma
    Pastorello EA et al. European patients: alpha-amylase inhibitors , lipid transferproteins and low molecular-weight glutenins. Allergenic molecules recognized by double blind, placebo-controlled food challenge.
    Int Arch Allergy Immunol 2007; 144:10 – 22.
  • 35. other
    Some studies
    using proteomic analysis showed that several other proteins, such as b -amylase, peroxidase, thioredoxin (Tri a 25 ), and serpin (serine protease inhibit or), were also able to bind IgE from patients with wheat food allergy.
  • 36. Protein state and route of exposure to gluten structures probably orient pattern of epitope reactivity
    and wheat food allergy manifestion
  • 37. Cross-reactivity of wheat allergens with grass
  • 38. Cross-reactivity of wheat allergens with grass
    Jones et al. demonstrated clinically insignificant cross-reactivity between cereals and grasses in children with confirmed wheat allergy by oral challenge in US
    Pastorello et al. showed lack of cross-reactivity between α-amylase inhibitor and grass pollen allergen and between nsLTP and grass pollen allergens
    JACI1995;96:341-51
    Int Arch Allergy Immunol 2007;144:10-22
  • 39. Processing on allergenicity of wheat allergens
  • 40. Immunoblotting of cooked wheat
    When heating
    Some patient lost their IgE binding capacity toward LTP
  • 41. Diagnostic test for wheat allergy
    Using CAP system ,PPV less than 75%
    Poor capacity due to commercial test reagent are mixture of wheat/salt-soluble wheat protein which lack allergen from insoluble gliadin fraction
    Recently the role of ώ-5 gliadin for diagnosis of wheat allergy was highlighted
  • 42. Diagnostic test for wheat allergy
    Maximum efficiency of ώ-5 gliadin for diagnosis WDEIA was 0.89kUa/l
    Sensitivity 78% specificity 96%
    Matsuo et al sensitivity and specificity of recombinant omega 5 gliadin-specific IgE measurement in WDEIA
    Allergy 2008;63:233-36
  • 43. Sensitivity in 50 Japanese WDEIA
    By immunoCAP system
    Matsuo et al sensitivity and specificity of recombinant omega 5 gliadin-specific IgE measurement in WDEIA
    Allergy 2008;63:233-36
  • 44. Diagnosis test for wheat allergy
  • 45. diagnosis
    In vitro : specific IgE to 5 gliadin in immediate reaction to wheat
    In vivo : challenge test, SPT with purified and recombinant wheat allergen
  • 46. Wheat-dependent ,Exercise-induced Anaphylaxis in thai children
    Three-day challenge protocol
    Open challenge for wheat day 1
    Exercise challenge test day 2
    Exercise challenge test after meal containing wheat on day 3
  • 47. Open challenge for wheat
    The challenge protocol started with 1 gram of wheat. The amount was doubled every 30 minutes until a dose of 16 grams of wheat was reached (a cumulative dose of 31 grams)
  • 48. Exercise challenge
    an exercise challenge was performed on a steady-state, motor-driven treadmill with slope and velocities adjusted to achieve 80 percent of the maximum predicted workload for the individual age of the patients.
    The exercise was then maintained at this level for 6 minutes.
    lung function test was performed before, immediately after and at 3, 5, 10, 15, 20, and 30 minutes after the exercise challenge
  • 49. Exercise challenge after a meal containing wheat
    An exercise challenge test was performed within one hour after a meal containing at least 16 grams of wheat
  • 50.
  • 51. Pathophysiological mechanism for food dependent exercise-induced anaphylaxis
    Exercise-induced change in plasma osmolarity
    Alteration in blood pH with exercise
    Tissue transglutaminase activity .IL-6 and exercise
    Redistribution of blood during exercise and mast cell heterogeneity
    Changes in gut permeability and exercise
    Paula Robson-ansley ,George Du Toit.
    pathophysiology diagnosis and management of exercise-induced anaphylaxis
    Current Opinion in allergy and clinical immunology 2010,10:312-317
  • 52. Exercise-induced change in plasma osmolarity
    Recent research demonstrated that in vitro alteration in osmolarity can increase basophil activation and histamine releasability
    Barg et al. food dependent exercised induced anaphylaxis
    J InvestigAllergolClinImmunol 2008;18:312-315
  • 53. Exercise-induced change in plasma osmolarity
    Barg et al. performed histamine releasing assays using a range of buffers 280, 340, 450 mOsm in FDEIA ,food allergy and healthy
    Demonstrated an increase histamine release in the FDEIA at 340 mOsm but not other group
    340 mOsm are pathological and would not be achieved even vigorous exercise
    Barg et al. food dependent exercised induced anaphylaxis
    J InvestigAllergolClinImmunol 2008;18:312-315
  • 54. Alteration in blood pH with exercise
    Optimal mast cell degranulation occur at a pH 7.0
    During sub optimal exercise pH remain the same at rest but during very heavy exercise pH decrease and may be low as 7.0 in the arterial blood
    Saeki K.histamine release by inorganic from mast cell granules isoloated by different procedureJpn J pharmacol 1972;22:27-32
    Hultman E. acid-base balance during exercised.Exec Sport Sci Rev 1980;8:41-128
  • 55. Tissue transglutaminase activity IL-6,exercise
    During exercise IL-6 is actively produced within contracting skeletal muscle and central nervous system
    IL-6 increase expression of tTG
    Tissue transglutaminase enzyme may result in peptide aggregation that leads to increase IgEcrosslinking
    PalosuoK.transglutaminase-mediated cross linking of o peptic fraction of omega-5 gliadin enhance igE
    reactivity in wheat-dependent exercise induced anaphylaxis. JACI 2003 .111:1386-1392
  • 56. Redistribution of blood during exercise and mast cell heterogeneity
    Exercise –induced redistribution of blood flow away from the viscera to skeletal muscle
    Gut tolerated peptide are redistributed to sensitized mast cell inducing EIA
    Paula Robson-ansley ,George Du Toit.
    pathophysiology diagnosis and management of exercise-induced anaphylaxis
    Current Opinion in allergy and clinical immunology 2010,10:312-317
  • 57. Change in gut permeability and exercise
    Tight junction in GI tract can become relaxed
    Allerginic peptide having greater access to gut associated immune system
    Paula Robson-ansley ,George Du Toit.
    pathophysiology diagnosis and management of exercise-induced anaphylaxis
    Current Opinion in allergy and clinical immunology 2010,10:312-317
  • 58. management
    If a diagnosis of FDEIA has been made then allergen should be avoid both prior to and after exercise
    Suggest a 3h avoidance prior to exercise and 1 h following exercise
    Recognition of prodromal manifestation of EIA is important to discontinue exercise at the earliest warning sign
    Emergency plan and medication
    Exercise with a companion who aware of the condition
    Paula Robson-ansley ,George Du Toit.
    pathophysiology diagnosis and management of exercise-induced anaphylaxis
    Current Opinion in allergy and clinical immunology 2010,10:312-317
  • 59. summary
    Wheat allergy are low prevalence
    Important allergen in wheat :amylase/trypsin inhibitor subunit, ώ-5 gliadin,nsLTP
    Manifestation: skin ,GI,RS
    Diagnosis : challenge , IgE to ώ-5 gliadin in immediated reaction to wheat
    Treatment : avoid
    Prognosis : 50 % tolerance in age 6-7 years