The efficacy of IgG-ELISA/IEA as a new diagnostic method in dogs with adverse food reactions S. Smits* * solisID: 3546179, Utrecht University, Faculty of Veterinary Medicine, Yalelaan 1, 3584 CL Utrecht, the Netherlands. Supervisior: E.A. Hagen-Plantinga. Date: 11-2015 Abstract Nowadays the best reliable diagnostic method to diagnose adverse food reactions (AFR) is an elimination-challenge diet trial. Since this cost a lot of time and effort, an easier diagnostic method is of interest. The IgG-ELISA/IEA test might be a new diagnostic method. To test the reliability of this IgG-ELISA as a diagnostic method in AFR, blood was taken from 40 dogs, of this group 16 dogs belonged to the healthy control group and 24 dogs belonged to the test group, suffering from adverse food reactions. This blood was send, in duplo, to the laboratory, for an IgG-ELISA/EIA on 39 food antigens. The results showed that the ELISA is not able to detect a significant difference between the outcome of the control and test group. Significant correlations were found between the different antigen groups, suggesting that the ELISA is not able to differentiate between all 39 ingredients. This study demonstrated that the IgG-ELISA/IEA of this laboratory does not seem to be an effective diagnostic method for diagnosing AFR in dogs. Samenvatting Momenteel wordt de diagnose voedselovergevoeligheid veelal gesteld door middel van een eliminatie dieet. Omdat dit erg veel tijd en moeite kost is het van belang dat er een eenvoudigere diagnostische tool ontwikkeld wordt. De IgG-ELISA/IEA is een potentieel nieuwe diagnostische methode. Om de betrouwbaarheid van deze IgG-ELISA/IEA te testen is bloed afgenomen van 40 honden. Van deze groep behoorden 16 honden tot de gezonde controlegroep en 24 honden tot de testgroep, welke waren gediagnosticeerd met voedselovergevoeligheid. Dit bloed is, in duplo, verzonden naar een laboratorium voor een IgG-ELISA/IEA voor 39 voedselallergenen. De resultaten laten zien dat de ELISA geen significant verschil kon aantonen tussen de uitslagen van de test- en controlegroep. Ook is er een significant verband gezien tussen de verschillende antigeen groepen. Het is hierdoor waarschijnlijk dat de ELISA test niet gevoelig genoeg is om onderscheid te kunnen maken tussen de 39 verschillende ingrediënten. Deze studie uitslagen tonen aan dat de onderzochte IgG-ELISA/IEA geen effectieve diagnostische methode is voor het aantonen van voedselovergevoeligheid bij honden. 1 Introduction Adverse food reactions An adverse food reaction (AFR) is an abnormal response to an ingested food ingredient. AFR is considered as an abnormally high sensitivity to harmless environmental substances, in this case food or food additives.1, 2 The prevalence of adverse food reactions in the dog population in 2012 was estimated to be up to 8%. 7-25% of all allergic skin diseases are cutaneous adverse food reaction (CAFR). The literature is spread whether there is any breed or sex predisposition. Veenhof reports that there is no breed or sex predisposition,1, 3 but Hensel reported that there is a higher risk for breeds such as Boxers, West Highland White Terriers, Retrievers and Cocker/Springer Spaniels.4 CAFR often occurs at young age, especially at dogs under the age of 3.1, 5 Phillip Roudebush states that there is not a clear conspectus about the prevalence of adverse food reactions, because AFR looks similar to other diseases, like pruritic dermatoses, pyoderma, ectoparasitism, folliculitis2 and atopic dermatitis.5 The classic clinical signs of cutaneous adverse food reactions are: nonseasonal pruritic dermatitis2, 6, pruritus of the ears, axillae, distal limbs and the inguinal area4, 5 sometimes accompanied with gastrointestinal signs.1, 2, 5, 6 Secondary infections may occur and impede the diagnosis.5 Immune reactions There are different types of immune reactions which may influence an adverse food reaction: type I, type III and type IV.1, 4, 7 Type I hypersensitivity is mediated by IgE antibodies,1, 7, 8 and gives an acute hypersensitivity reaction.2 Although food allergy in human is in most cases IgEmediated5, 8 it is unlikely to be the basis of AFR, especially in chronic cases.2 There is no evidence that IgE is involved in CAFR,1 even though there are some cases reported which suggest the influence of IgE in dogs with CAFR.5 Type III and type IV hypersensitivity are delayed types of hypersensitivity (DTH), of which type III is mediated by IgG antibodies. 7-9 The prevalence of DTH to food is unknown in the canine population but the clinical picture of dogs with AFR and the chronic nature of the disease, indicate their event.7 There is still no evidence that IgG is a good indicator of AFR in dogs.2, 9 Although IgG-ELISA tests are already performed in human,10, 11 it is questionable whether IgG is the suitable antibody for testing AFR in dogs, as the pathogenesis of AFR is not fully elucidated.1, 2, 5, 7 Diagnosis There are several ways to diagnose cutaneous adverse food reactions, but the eliminationchallenge diet trial is the mostly used method and with the most reliable results.1, 2, 4, 6 This food trial is seen as the golden standard.1 For this diagnostic method the owner’s education and compliance is very important.4 An elimination diet is a home cooked or commercial diet, consisting of novel proteins and carbohydrates.1, 2, 4 The elimination diet is first fed, during 8 10 weeks.1 Mostly, the reduction in symptoms is seen within 4 weeks, but in some dogs improvement is seen after 10 – 12 weeks.4 With this elimination diet the clinical symptoms, primary caused by an allergic food reaction, disappear. Secondary infections might remain and will need medical therapy. When the dogs are fully recovered, dogs are provoked with their original diet. When the clinical symptoms reappear during provocation, the diagnosis AFR is confirmed.1, 2, 4 After diagnosis a suitable maintenance feed has to be found by ‘trial and error’. 2 One (commercial) feed after another has to be tried, until a feed is found on which the dog does not respond allergic. Aim of the study Because of the high effort needed to make a reliable diagnosis and to find a suitable maintenance feed nowadays, an easier diagnostic method is desired. This method preferably is as reliable as the elimination challenge and gives information about which ingredients are suitable. The aim of this study is to determine the efficacy of IgG-ELISA/IEA as a new diagnostic method in dogs with AFR. Materials and Methods Experimental design 40 Dogs were included in this study; 24 dogs diagnosed, using the elimination-challenge diet trial, with cutaneous adverse food reactions (test group) and 16 dogs without clinical signs of adverse reactions to food (control group). Blood was taken by jugular venipuncture and sampled in two serum tubes. Blood was stored in the refrigerator before sending it to the laboratory for an IgG-ELISA/IEA. The results of the lab were compared with the ingredients of the regular diet of the dogs. Animals and inclusion criteria All 40 dogs included in this study belonged to the customer base of the dermatology departments of the clinic MCD Amsterdam or Veterinaire Specialisten Oisterwijk. Dogs selected for this study where over one year of age. All dogs were owned privately. The dogs were free of systemic or topical corticosteroid therapy or other pharmaceuticals which influence the immune system of the skin. All dogs were free of ectoparasites. The 24 dogs in the test group were included in the study after the diagnosis ‘food allergy’ was confirmed by the dermatologists. This diagnosis was made with the elimination-challenge diet trial. The 16 dogs of the control group did not suffer from skin problems or from intestinal problems caused by food which was concluded after a physical exam by the dermatologists and after questionnaire for the owner’s about their dogs health. Diet Background information about food consumption, functioning of the gastro-intestinal tract and the dermatologic health of the dogs over the last half year, was collected using specific questionnaires and interviews with the owners. Food composition was first determined by consulting the package labels and internet website of the specific brands. In case of a closed or inconclusive declaration on the packaging, manufacturers were contacted by phone or via email to obtain further compositional information of the diet. All ingredients fed were compared with the ELISA outcome. Blood analyses After the blood was collected, the serum tubes were stored in the refrigerator, at 7°C, before sending to the laboratory once every two weeks. A minimum of 3 patients (6 tubes) was sent at a time for ELISA analysis. All tubes had a code matched to the dogs, the laboratory staff was not aware of the coding-system, so the ELISA IgG/IEA tests was performed single-blind. 3 IgG-ELISA/IEA The microtitre plates for the IgG-ELISA were coated with the antigen extracts of European hake, herring, salmon, tuna, calf liver, calf, turkey, chicken, lamb, beef, beef liver, tripe, pork, potato, corn, beetroot, butter bean, sugar beet, tomato, carrot, garden pea, soy pulp, garlic, cress, casein, cow’s milk, linseed oil, barley, oats, wheat, buckwheat, cassava manioc, millet, rice, wild rice, bakingsoda, brewer’s yeast, candida albicans, gliadin, gluten, chicken egg yolk and chicken egg white. Diluted serum (1:401) was placed in duplicate into the wells, after which the plates were incubated at 5°C for 48 hours. After washing the plates, anti-dog peroxidase conjugate was added, followed by a 1-h incubation period at 37°C. After a second washing, a substrate solution of tetramethylbenzin (TMB) was pipetted into the wells. The plates were incubated at 22°C for 20 minutes in a dark space. The blue coloring that arose during the last incubation was stopped by adding an inhibitor into the wells. Within 30 minutes after adding the inhibitor the extinction was measured using spectrophotometry (at 450 nm). The ELISA was performed split sample. An outcome of ≥0.4U was considered positive, and a 10% difference between both samples was considered acceptable. Statistics Mann Whitney U-test IgG titers of individual ingredients were compared between control dogs and patient with an independent samples Mann Whitney U-test using SPSS version 19. The level of significance was set at p<0.05. An outcome of ≥0.4U/ml from the IgG-ELISA was considered positive. The following hypotheses were tested: H0: “The IgG-ELISA/EIA is not able to differentiate between healthy dogs (the control group) and dogs with an adverse food reaction (the test group)” H1: “The IgG-ELISA/EIA is able to differentiate between healthy dogs (the control group) and dogs with an adverse food reaction (the test group)” Pearson Correlation-test IgG titers of all 39 ingredients were compared, using the two tailed Pearson Correlation-test using SPSS version 19. p<0.05 was considered significant. The possibility that the IgGELISA/IEA could not differentiate between the different ingredient(group)s was hereby tested. Results Mann-Whitney U-test In Table 1 the mean IgG-titer for the test group and control group per tested ingredient is shown. The mean IgG-titer for 89,74% ingredients of the test group and for 94,87% of the control group was positive (>0.4U/ml). The mean (±SEM) number of ingredients that showed a positive titer in individual dogs was 17 (±2,0) for the control group and 16 (±1,3) for the test group, which was not significantly different (p=0,59). The p-value in Table 1 shows whether there is any significance (p<0.05) between the groups, per ingredient. With the p-values between 0.090 and 0.989, no significance is shown. 4 Pearson Correlation-test Significant correlations (p<0.05) has been seen between different antigens, but mostly between specific groups of ingredients, which are pointed out in appendix 1 – 4. Remarkable is the vegetable group (potato, corn, beetroot, butter bean, sugar beet, tomato, carrot and garden pea) 64.29% has a significant correlation (p<0.05), appendix 1. The cereals also show correlation within the group. 25.00% of this group shows a significant correlation (p<0.05), appendix 2. Remarkable is the fact that rice shows a significant correlation (p<0.05) with 31.71% of all antigens tested in the ELISA. Another remarkable group is the meat and dairy group (calf liver, calf, turkey, chicken, lamb, beef, beef liver, tripe, pork, casein and cow’s milk). 38.18% of the ingredients in this group show a significant correlation (p<0.05), appendix 3. Remarkable in the meatgroup is tripe, it has a significant correlation (p<0.05) with 41.46% of all antigens tested. The fishgroup (hake, herring, tuna and salmon) also show correlation, 33.33% has a significant correlation (p<0.05), see appendix 4. Tuna has a significant correlation (p<0.05) with 31.70% of all antigens tested. Correlation between the different groups is also seen. Between the vegetable- and cerealgroup 44.64% has a significant correlation (p<0.05). Between meat and fish a correlation is seen between 37.50% of the included ingredients. Ingredient – ELISA outcome comparison In Figure 1 and 2 show a graphic overview of the ingredient intake per dog, compared with the ELISA titers. All dogs, both in the control and test group, had one or more positive titers (>0,4U/ml). The dark blue colour indicates a positive titer and also showing that the ingredient is fed. Except for 2 dogs in the test group, all dogs are exposed to one or multiple food ingredients in their current diet for which they have a positive IgG titer. However, all of these dogs were free of clinical signs on their current diet. 5 Table 1: Mean IgG-titers per ingredient, inclusive the Standard Error of Mean (SEM) and the p-value which shows whether there was a significant difference between the test and control group. Patients Controls Patients Controls Ingredients Mean SEM Mean SEM p-value Hake Herring Salmon Tuna Calf liver Calf Beef Beef liver Tripe Lamb Pork Turkey Chicken Potato Corn Beetroot Butter bean Sugar beet Tomato Carrot 7,39 0,00 0,13 9,10 13,59 23,33 20,74 24,23 33,80 0,54 4,63 4,73 0,40 7,42 4,86 1,99 1,60 4,41 21,26 0,46 4,32 0,00 0,09 5,72 6,83 8,23 6,82 7,77 8,12 0,20 4,15 2,03 0,18 4,39 4,15 0,83 0,69 4,16 7,84 0,19 1,50 0,05 0,22 9,38 9,97 21,91 37,10 19,92 36,06 7,83 0,77 12,45 0,81 11,27 2,84 8,77 3,16 17,08 33,18 1,18 0,68 0,03 0,10 6,21 6,68 9,65 11,20 9,44 10,45 6,21 0,43 6,57 0,43 6,85 1,30 5,72 1,29 8,85 11,35 1,18 0,613 0,521 0,404 0,389 0,304 0,713 0,539 0,420 0,633 0,420 0,733 0,652 0,452 0,795 0,967 0,774 0,345 0,174 0,613 0,989 Ingredients Mean SEM Mean SEM p-value Garden pea Soy pulp Garlic Cress Casein Cow's milk Linseed oil Barley Oats Wheat Buckwheat Cassava manioc Millet Rice Wild rice Bakingsoda Brewer's yeast Chicken egg yolk Chicken egg white 2,38 0,60 2,91 2,46 15,94 5,42 14,69 0,32 0,24 0,89 0,16 2,18 3,45 0,44 0,52 36,73 32,79 4,53 1,96 0,85 0,21 0,93 0,80 6,75 4,13 6,25 0,13 0,06 0,37 0,05 1,67 1,41 0,24 0,19 8,80 9,06 4,15 1,24 10,71 9,52 16,23 11,73 10,47 8,66 1,55 1,77 1,75 7,17 3,25 1,11 3,63 1,81 1,55 21,30 27,07 1,58 1,55 6,19 6,20 7,19 6,90 6,52 6,21 0,66 0,93 0,98 6,21 2,75 0,55 0,92 0,98 0,60 9,84 10,92 0,84 0,89 0,292 0,090 0,183 0,946 0,733 0,774 0,967 0,157 0,452 0,557 0,304 0,613 0,613 0,345 0,436 0,107 0,486 0,420 0,389 6 Figure 1: Food ingredient exposure versus IgG ELISA results in healthy control dogs. 7 Figure 2: Food ingredient exposure versus IgG ELISA results in patient dogs. Discussions In this study the efficacy of IgG-ELISA/IEA as a diagnostic tool in case of cutaneous adverse food reaction was tested. Based on the available results of other studies the expectation was that the ELISA would not be suitable as a new diagnostic tool.6, 9, 11, 12 The results of this study confirms that the IgG-ELISA was not able to differentiate between the control- and test group, nor between the different ingredients tested. In 2003, 2004 and 2012, 3 similar studies were published. Foster, published in 2003, determined the serum IgG and IgE responses to food antigens in 3 groups of dogs; healthy dogs, dogs with gastrointestinal disease and atopic dogs. A higher total mean titer level for healthy dogs than for dogs with gastrointestinal disease or atopic dogs was shown.13 This is in contrast to the results of this study and the results of Halliwell, 2004 and Bethlehem 2012. Halliwell studied the IgE and IgG antibodies to food in sera from dogs with AFR, dogs with atopic dermatitis and healthy control dogs. This study showed that the dogs with AFR had the highest titers of these 8 3 groups.6 The study of Bethlehem was designed to determine whether patch tasting, ELISA IgE and IgG are suitable as a diagnostic tool in case of AFR. Hereby they tested healthy control dogs and dogs with proven AFR. The results show no titer level difference between the testand control dogs,12 the results of this study show the same. Bethlehem also found that there were many high serum levels in dogs without clinical symptoms12; this is also seen in the present study. As stated before, a significant correlation is seen between different groups of ingredients. Foster et al. also mentioned an association between different ingredients.13Similarly to this study, between pork and beef and between chicken and beef. The results of this study also show that even the dogs in the control group or test group that are not eating particular ingredients can have high IgG serum levels. Notwithstanding, all dogs were symptom free on their current feed. The appearance of positive titers could be explained by the fact that IgG might be an indicator for food exposure.9, 12 For this study a feed history of the dogs of six months is known. It is possible that the dogs have had exposure to some of the ingredients before these six months. The fact that in this study all dogs in the control group and 22 out of 24 dogs in the test group had positive titers and also had these ingredients fed (see figure 1 and 2) but were free of clinical symptoms, makes the ELISA outcome less reliable. Another difficulty is that not all the feed ingredients are known. Contact with manufactures of cheaper feed brands revealed that some of the feeds are produced according to a least-cost formulation model. This means that the composition of the feeds may vary with varying ingredient prizes. It is known that the amount of feed/allergen intake may influence the immune response.10 Beef, wheat, dairy products, lamb,1, 2 chicken, soybean, eggs and corn are most commonly reported as causing AFR.21 But also rabbit, venison, fish, rice and potato are reported.2 The results show that chicken, lamb, cow’s milk and egg are not the most important allergens according to this ELISA test. A possible reason for this remarkable outcome is the fact that the antigen extracts on the ELISA plates could have been manufactured incorrectly.11 The method used to manufacture the plates for this test is unknown. According to Miller11, a possible risk of homemade plates is the fact that all food is coated with microorganisms. Also the presence of pesticides or other organic solvents in the wells cannot be excluded.11 These possible disturbances could explain the fact that all dogs (n=40) showed high IgG titers for tripe. It is not sure that the antibodies really bound to the tripe-antigens. Furthermore, the exact allergenic molecules have not been identified.1 Since the exact molecules are unknown, it is possible that the ELISA plates used in this test are not coated with the right antigen extracts. The typical result seen for herring, the only antigen with no positive titers at all, shows that there could have been nothing in the ELISA-wells for the antiherring-antibodies to bond on. Remarkable is the fact that the ELISA tests for calf, calf liver, beef, beef liver and tripe antigens separately. Since a calf is a baby cow, it is not unthinkable that these antigens could have cross reactivity and so create a similar output of the ELISA. It is known that in dogs with cow’s milk and beef related AFR the major allergen is bovine IgG.1, 2, 4 The correlation between cow’s milk and calf-/beef liver and tripe, seen in this study between these antigens supports this theory. In this study no correlation between beef- and calf meat and cow’s milk is seen, this is not fitting 9 in the cross reactivity theory; the same results were mentioned in the articles of Verlinden et al. and Roudebush et al2, 7 Although the results of the ELISA show that all 40 dogs suffer from a multi antigen AFR, adverse food reactions to multiple food ingredients are unusual in dogs.1, 4 It is possible that a dog is multisensitive,6 it had been identified in 35% to 48% of food allergic dogs.4, 7 Cross reactivity, as mentioned before, is better known.4, 11 The amount of positive titers, in this test, was almost 50/50 in both groups. The study of Bethlehem in 2012 also showed that the amount of positive titers was about 50/50, respectively it is hard to tell that there is a positive correlation between a positive titer and AFR because even 57% of the healthy dogs in the control group of this study showed a positive titer. In this study the mean titer per ingredient for the control group was not significantly different from the test group. This is in contrast to what is mentioned by Roudebush et al2, they mentioned that the mean titer for healthy dogs where higher than for test dogs, this is in contrast to what is seen in human.2, 10 A study of Stapel et al showed that it is more likely that the presence of IgG is an indicator for prolonged exposure to food components rather than being an indicator for AFR in human9, 12 This way the IgG food antibodies seen by healthy human can be explained. Knowing that the presence of IgG might be an indicator for exposure to the feed in the past, it might be helpful to use IgG-ELISA-IEA to determine which food is, or is not, safe for the elimination diet. This usage of the IgG-ELISA is also suggested in the study of Bethlehem.12 To support the outcome of this study, a food challenge based on the ELISA results is recommended. This way the sensitivity and the specificity of the IgG-ELISA/EIA can be determined. Because of the prevalence of cutaneous adverse food reactions a minimal specificity and sensitivity of 80% is appropriate to call the IgG-ELISA/EIA a good diagnostic method. Conclusion The results show that H0 is the right hypothesis and that H1 can be rejected. This means that the tested IgG-ELISA/IEA is not able to differentiate between healthy dogs and dogs with adverse food reactions. The fact that correlations were found between the different antigen(groups) and the fact that dogs showing a positive titer to some ingredients, while having these specific ingredients in the diet without clinical symptoms of allergy, suggests that this test is not sensitive enough. It may thus be concluded that the IgG-ELISA/IEA tested in this study is not efficient as a diagnostic tool in case of AFR. Acknowledgement I would like to thank the owners of the dogs for being so cooperative during this study. Also, the dermatologist for helping to select the dogs and collecting the blood needed for the ELISA tests. I might not forget to thank Esther Plantinga for her support and sharing her experiences writing a good article. And last but not least I would like to thank Koen Bleeker, for living with me in such turbulent moods and giving pep talks. 10 Appendix 1, correlation matrix of vegetables Tomato Tomato Carrot Gardenpea Sugarbeet Beetroot Corn Potato Butterbean 0,007 0,006 0,039 0,006 0,113 0 0,007 Carrot 0,007 0,367 0,058 0,304 0,229 0 0,012 Gardenpea Sugarbeet Beetroot 0,006 0,039 0,006 0,367 0,058 0,304 0 0 0 0 0 0 0,136 0 0,131 0,009 0,024 0,003 0,003 0,056 0 Corn 0,113 0,229 0,136 0 0,131 0,429 0,457 Potato 0 0 0,009 0,024 0,003 0,426 Butterbean 0,007 0,012 0,003 0,056 0 0,457 0 0 Appendix 2, correlation matrix of cereals Barley Barley Oats Wheat Cassava Buckwheat Millet Rice Wildrice 0,976 0,585 0,961 0,794 0,08 0,444 0,011 Oats 0,976 0,734 0,805 0 0,338 0,004 0,632 Wheat 0,585 0,734 0,791 0,847 0,65 0,795 0,048 Cassava Buckwheat 0,961 0,794 0,805 0 0,791 0,847 0,53 0,53 0,852 0,205 0,279 0 0,839 0,161 Millet 0,08 0,338 0,65 0,852 0,205 0,037 0,003 Rice 0,444 0,004 0,795 0,279 0 0,037 Wildrice 0,011 0,632 0,048 0,839 0,161 0,003 0,225 0,225 11 Appendix 3, correlation matrix of meat Casein Cow's milk Calf liver Calf Beef Beef liver Tripe Turkey Chicken Lamb Pork Casein Cow's milk Calf liver Calf 0,047 0,55 0,123 Beef 0,074 Beef liver 0,812 Tripe 0,07 Turkey Chicken 0,093 0,03 Lamb 0,755 Pork 0,003 0,047 0,55 0,123 0,074 0,812 0,07 0,093 0,03 0,755 0,003 0,188 0,265 0,006 0,001 0 0,098 0,013 0,006 0,705 0,71 0,028 0,007 0,652 0,396 0,616 0,004 0,496 0,273 0,818 0,903 0,014 0,016 0,77 0,432 0,83 0,991 0,845 0,783 0,04 0,043 0,665 0,648 0,017 0,574 0,973 0 0 0,2 0,188 0,001 0,006 0,652 0,113 0,818 0,845 0,2 0,015 0,015 0,265 0 0,705 0,396 0,176 0,903 0,783 0,006 0,098 0,71 0,616 0,123 0,014 0,04 0,013 0,028 0,004 0 0,016 0,043 0,007 0,496 0,101 0,77 0,665 0,273 0,014 0,432 0,648 0 0,83 0,017 0,113 0,176 0,123 0 0,101 0,014 0 0,991 0,574 0,973 Appendix 4, correlation matrix of fish Hake Hake Herring Tuna Salmon Herring Tuna Salmon 0,867 0,672 0,508 0,867 0,013 0,053 0,672 0,013 0,001 0,508 0,053 0,001 12 References 1. 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