Sublingual immunotherapy for hazelnut
food allergy: A randomized, double-blind,
placebo-controlled study with a standardized
hazelnut extract
Ernesto Enrique, MD, PhD,a Fernando Pineda, PhD,b Tamim Malek, MD,a Joan Bartra,
MD, PhD,c Marı́a Basagaña, MD,d Raquel Tella, MD,c José Vicente Castelló, MD,a
Rosario Alonso, MD,d José Antonio de Mateo, MD,a Teresa Cerdá-Trias, MD,c
Marı́a del Mar San Miguel-Moncı́n, MD,d Susana Monzón, MD,d Marı́a Garcı́a, PhD,e
Ricardo Palacios, PhD,b and Anna Cisteró-Bahı́ma, MD, PhDd Castellón, Madrid,
Girona, and Barcelona, Spain
From athe Allergy Department, Hospital General de Castellón; bthe
Investigación y Desarrollo Department, Laboratorios Diater, Madrid; cthe
Allergy Department, Hospital General de Girona Dr Joseph Trueta,
Girona; dthe Allergy Department, Institut Universitari Dexeus, Universitat
Autònoma de Barcelona; and ethe Institut d’Investigació Biomédica,
Girona.
Disclosure of potential conflict of interest: F. Pineda and R. Palacios are
employed by Research and Development, a private laboratory. The other
authors have none to disclose.
Received for publication June 22, 2005; revised August 16, 2005; accepted
for publication August 16, 2005.
Available online October 3, 2005.
Reprint requests: Ernesto Enrique, MD, PhD, Allergy Department, Hospital
General de Castellón, Avda, Benicasim s/n, 12004 Castellón, Spain.
E-mail: [email protected].
0091-6749/$30.00
Ó 2005 American Academy of Allergy, Asthma and Immunology
doi:10.1016/j.jaci.2005.08.027
Conclusion: Our data confirm significant increases in tolerance
to hazelnut after sublingual immunotherapy as assessed by
double-blind, placebo-controlled food challenge, and good
tolerance to this treatment. (J Allergy Clin Immunol
2005;116:1073-9.)
Key words: Sublingual immunotherapy, food immunotherapy,
hazelnut allergy, biological standardization in mass units, doubleblind, placebo-controlled food challenge, Cor a 1, Cor a 8
Food allergy, like other atopic disorders, appears to be
on the increase. Moreover, food allergy remains a leading
cause of anaphylaxis treated in emergency departments
in several countries, and the general public has become
increasingly aware of the problem.1
Peanut and tree nuts are some of the most allergenic
foods worldwide.2 In the United States, peanut and tree
nut allergy affects approximately 1.1% of the population.3
In the tree nut group, hazelnut (Corylus avellana) is frequently implicated in allergic reactions.4 In a recent report,
Pastorello et al5 analyzed the allergen profile of patients
with hazelnut allergic reactions and positive double-blind,
placebo-controlled food challenge (DBPCFC). All sera
from patients recognized an 18-kd allergen; other major
allergens recognized were at molecular weights of 47,
32, and 35 kd. The 18-kd allergen, Cor a 1, is a protein
homologous to Bet v 1 allergen. Patients with severe allergic reactions to hazelnut showed IgE reactivity to a 9-kd
allergen.5 This allergen was shown to be a hazelnut lipid
transfer protein, registered as Cor a 8, and it is a major
allergen for Spanish patients with allergy to hazelnut
without birch pollen allergy.6
In Europe, it has been estimated that hazelnut allergy
affects between 0.1% and 0.5% of the population.7,8
Hazelnut is largely used in prepackaged foods, particularly in the production of pastry and ice creams. The
wide use of hazelnut in the food industry represents a considerable risk for subjects with hazelnut allergy, because
trace quantities can induce systemic allergic reactions in
highly sensitized individuals. Moreover, some food labels
may not list a small quantity of a foodstuff, or this may
be included as a contaminant, with accidental ingestion
1073
Food allergy, dermatologic
diseases, and anaphylaxis
Background: Food allergy may be life-threatening, and patients
affected need to receive accurate diagnoses and treatment.
Hazelnut has often been implicated as responsible for allergic
reactions, and trace quantities can induce systemic reactions.
Objective: The aim of this study was to evaluate the efficacy
and tolerance of sublingual immunotherapy with a
standardized hazelnut extract in patients allergic to hazelnut.
Methods: This was a randomized, double-blind, placebocontrolled study. Inclusion criteria were a history of hazelnut
allergy and positive skin prick test and double-blind placebocontrolled food challenge results. Patients were then randomly
assigned into 2 treatment groups (hazelnut immunotherapy
or placebo). Efficacy was assessed by double-blind, placebocontrolled food challenge after 8 to 12 weeks of treatment.
Blood samples were drawn for measurement of specific IgE,
IgG4, and serum cytokines before and after treatment.
Results: Twenty-three patients were enrolled and divided into
2 treatment groups. Twenty-two patients reached the planned
maximum dose at 4 days. Systemic reactions were observed
in only 0.2% of the total doses administered. Mean hazelnut
quantity provoking objective symptoms increased from 2.29 g
to 11.56 g (P 5 .02; active group) versus 3.49 g to 4.14 g
(placebo; NS). Moreover, almost 50% of patients who
underwent active treatment reached the highest dose (20 g),
but only 9% in the placebo. Laboratory data showed an
increase in IgG4 and IL-10 levels after immunotherapy in only
the active group.
1074 Enrique et al
Abbreviations used
AU: Allergen unit
DBPCFC: Double-blind, placebo-controlled food challenge
n: Native
r: Recombinant
SLIT: Sublingual immunotherapy
SPT: Skin prick test
possible despite efforts at avoidance in unexpected food
products.9
The management of food allergies continues to consist
of educating patients on how to avoid relevant allergens,
recognize early symptoms of an allergic reaction in cases
of accidental ingestion, and initiate the appropriate emergency therapy. Nevertheless, because of the high risk
of life-threatening allergic reactions and the difficulty in
avoidance of the culprit food, allergen-specific immunotherapy has been studied as a treatment option. However,
subcutaneous immunotherapy was accompanied by a high
rate of systemic reactions.10,11
The aim of this study was to evaluate the response to
sublingual immunotherapy (SLIT) with hazelnut extract
standardized in unit masses of major allergens, Cor a 1
and Cor a 8, in a large group of patients allergic to hazelnut. Efficacy was assessed by double-blind, placebocontrolled food challenges with hazelnut before SLIT
and after 2 months of immunotherapy maintenance.
METHODS
Patients and study design
J ALLERGY CLIN IMMUNOL
NOVEMBER 2005
equal to or larger than the wheal obtained with histamine 10 mg/mL
15 minutes after testing was judged as positive.
Each patient was also skin prick tested in duplicate on the volar
surface of the forearm with four 10-fold serial dilutions (10, 1, 0.1,
and 0.01 mg/mL) of a raw hazelnut extract (Diater Laboratorios).
Wheal areas were marked with a fine-tipped ball-point pen and
transferred by transparent adhesive tape onto paper for subsequent
planimetric evaluation and statistical analysis. Skin wheal areas
were determined by computer scanning (AutoCAD; Autodesk, Inc,
San Rafael, Calif) in all patients.
DBPCFC
Double-blind, placebo-controlled food challenges to hazelnut
were performed in all patients. A single common protocol, based
on a previous European multicenter study, was adhered to in the 3
centers.4 Patients who had systemic reactions or anaphylaxis were
also challenged, but they were started with a modified schedule
proposed by Alonso et al,12 after which they continued with the
normal protocol, always within the double-blind, placebo-controlled
schedule.
Allergen sources and extracts
Raw hazelnuts were used for oral challenges and SPT and as
source material for production of allergen extracts. The extract was
prepared as follows: nuts were defatted with diethyl ether in Soxhlet
system and proteins extracted with PBS with 4% Tween 20 at a 50%
(wt/vol) ratio by stirring for 1 hour at 4°C. The soluble fraction was
separated by centrifugation at 22,000g for 20 minutes at 4°C. The
hazelnut extract was then dialyzed against distilled water, filtered,
and lyophilized.
The hazelnut extract was used for SPT, IgE, and IgG4 measurements. Recombinant hazelnut allergens recombinant (r) Cor a 1
(Biomay, Vienna) and rCor a 8 (Paul Ehrlich Institut, Langen,
Germany) were used to obtain rabbit polyclonal antibodies a-rCor
a 1 and a-rCor a 8, and biotinylated antibodies against native (n)
Cor a 1 and nCor a 8 by affinity purification.13,14 Protein concentration was determined by the Bradford15 method.
Food allergy, dermatologic
diseases, and anaphylaxis
This was a randomized, double-blind, placebo-controlled,
multicenter study. Patients provided written informed consent. The
study was approved by the ethics committees of the participating
hospitals. Potential subjects were preselected on the basis of a clear
history of hazelnut food allergy and positive skin prick test to
hazelnut. Definitive inclusion criteria then also included a positive
DBPCFC with hazelnuts. Eligible patients could not be pregnant, and
any asthma had to be under control. Systemic corticosteroids and
b-blockers were prohibited before screening and throughout the
study, and antihistamines and antidepressants were prohibited for
1 week and 2 weeks, respectively, before skin testing and oral food
challenge. Patients with systemic diseases and/or oral infection or
inflammation not compatible with the correct, easy, and safe administration of the treatment were excluded from the study.
Before the onset of treatment, a titrated skin prick test (SPT) with
hazelnut extract was performed, and blood samples were drawn
for in vitro standardization of a hazelnut extract in mass units of the
hazelnut major allergens Cor a 1 and Cor a 8.5,6
Patients were later randomly assigned to 2 treatment groups
(hazelnut extract or placebo). They then underwent a final DBPCFC 8
to 12 weeks later. At that time, a titrated SPT with hazelnut extract
was repeated, and blood samples were again drawn for in vitro
studies.
nCor a 1 and nCor a 8–specific IgE antibodies were measured by
an ELISA experiment similar to that described previously16,17 with
some modification. In brief, plates were coated with 0.02 mg/mL of
nCor a 1 and nCor a 8. A 50-mL serum sample from each patient
(before and after immunotherapy) was incubated for 2 hours at room
temperature. The bound IgE were detected by biotinylated mouse
monoclonal antihuman IgE antibody (1:1000, 50 mL/well; Operon,
Cuarte de Huerva, Zaragoza, Spain) followed by streptavidin–horseradish peroxidase—labeled antimouse IgG antibody (1:5000, 50 mL/
well; Sigma-Aldrich, St Louis, Mo); IgE binding was detected by using a solution of 3,3#,5#-tetramethyl-benzidine (50 mL/well; Sigma),
and optical densities were read at 450 nm.
SPT
Human serum cytokines
All patients underwent SPT performed according to standard
procedure with timothy, parietaria, mugwort, olive, plane tree, birch,
and hazel extracts (Diater Laboratorios, Madrid, Spain). A wheal size
Human serum IL-4, IL-5, IL-10, TGF-b, and IFN-g concentrations
were measured by ELISA using reagent kits of BLK (Biolink
2000, Barcelona, Spain), according to the manufacturer’s instructions.
Specific IgE
Specific IgE against hazelnut was measured by an enzyme
allergosorbent test (Hycor Biomedical Inc, Garden Grove, Calif)
according to the manufacturer’s instructions. Levels higher than 0.35
IU/mL were considered positive (Hytec-specific IgE enzyme immunoassay, Hycor Biomedical Inc).
ELISA for specific IgE
Enrique et al 1075
J ALLERGY CLIN IMMUNOL
VOLUME 116, NUMBER 5
TABLE I. Concentration of vials and build-up treatment schedule*
Daily dose (mg)
Day
1
Vial concentration (mg/mL)
Drops
211
(F0) 66.25 3 10
(F1) 66.25 3 1028
2
25
(F2) 66.25 3 10
(F3) 66.25 3 1022
3
(FA) 66.25
4
(FA) 66.25
1
10
1
10
1
10
1
10
1
2
3
4
10
25
Administered dose (mg)
Cumulative dose (mg)
211
Cor a 1
Cor a 8
5.68 3 1027
3.68 3 1027
211
2 3 10
2 3 10210
2 3 1028
2 3 1027
2 3 1025
2 3 1024
0.02
0.26
2.65
5.30
7.95
10.60
26.50
66.25
2 3 10
2 3 10210
2 3 1028
2 3 1027
2 3 1025
2 3 1024
0.02
0.26
2.91
8.21
16.16
26.76
53.26
119.51
0.99
0.48
150.5
188.15
97.5
121.9
*Doses were administered at 15-minute intervals.
The active specific immunotherapy consisted of a biologically
standardized hazelnut extract, graded in 5 strengths (F0, F1, F2, F3,
FA) in glycerosaline solution. The protein concentration of each vial
in milligrams per milliliter and the treatment schedule are detailed
in Table I.
Placebo was prepared as saline solution in vials with exactly the
same appearance, color, and taste, but without allergens, to guarantee
the double-blind design of the trial. All vials contained 50% glycerin
(vol/vol) and 0.3% phenol (wt/vol).
All doses of the build-up phase were administered in a hospital
setting with the availability of complete resuscitation equipment and
trained personnel; the patient was kept under constant observation
after each administration and for at least 60 minutes after each day’s
last administration.
Patients were instructed to keep the allergen solution in the mouth
for at least 3 minutes and then to discharge (sublingual-discharge
technique). The build-up phase was completed in 4 days according to
a rush schedule. During the build-up phase, doses were administered
at 15 minutes intervals.18 After the build-up phase, all patients
followed the same daily maintenance schedule consisting of 5 drops
of the maximum concentration performed at home. SLIT was administered from November 2004 to March 2005 before the birch and
hazel pollen season. During the maintenance phase, patients attended
the clinic every 21 days.
TABLE II. Demographic characteristics and allergy history
of patients randomized in the study (n 5 23)*
Characteristics
Sex
Male
Female
Age, y, mean (range)
Hazelnut specific IgE, kU/L,
mean (quartiles)
Associated pollen allergy
Grass
Mugwort
Plane tree
Olea
Parietaria
Birch
Hazel
Hazelnut allergy symptoms
Oral allergy syndrome
Anaphylaxis
Urticaria-angioedema
Active treatment
(n 5 12)
3
9
29.2
5.34
8
5
6
5
5
0
2
1
(25%)
(75%)
(19-53)
(0.45-9.10)
(66.6%)
(41.6%)
(50%)
(41.6%)
(41.6%)
(0%)
(16.6%)
(8.3%)
6 (54.5%)
5 (45.5%)
0
Placebo
(n 5 11)
7
4
29.6
6.41
10
5
5
4
7
4
3
3
(63.3%)
(36.7%)
(19-42)
(4.02-9.91)
(81.8%)
(44.4%)
(44.4%)
(36.3%)
(63.6%)
(36.3%)
(27.2%)
(27.2%)
6 (54.5%)
1 (9%)
4 (36.5%)
*No statistical differences were found between placebo and active group
for all of the parameters.
Statistics
Results were expressed as percentages for categorical variables
and as mean or median (quartiles) for continuous variables.
Proportions were compared by using the x2 test, and the t test and
Mann-Whitney test were used to compare continuous variables
between the 2 treatment groups. The effect of treatment on interleukin
levels, TGF-b, IFN-g, IgG4, and IgE was analyzed by generalized
linear models (ANOVA) for repeated measurements. Significance
level was 5%, and the statistical program used was SPSS 10.0 (1999;
SPSS Inc, Chicago, Ill).
RESULTS
Study population
Forty-one adult patients age 18 to 60 years were
selected on the basis of a history of hazelnut allergy and
positive SPT. DBPCFCs to hazelnut were performed in all
of the patients and were positive in 29. All of these 29
patients (M/F, 17/12; mean age, 29.4 years; range, 19-53
years) were included to be randomized. Six of the 29
withdrew their consent for personal reasons, and 23 were
divided into 2 groups of treatment: active group (n 5 12)
and placebo (n 5 11). One patient of the treatment group
withdrew consent for professional reasons the first day of
starting the immunotherapy.
The main demographic characteristics and allergy
history of the randomized patients are summarized in
Table II and in Fig 1. No statistical differences were found
between placebo and active groups for sex; age; associated pollen sensitizations; clinical symptoms related to
Food allergy, dermatologic
diseases, and anaphylaxis
SLIT
1076 Enrique et al
J ALLERGY CLIN IMMUNOL
NOVEMBER 2005
FIG 2. Oral challenge tests: mean food amounts tolerated in
patients with hazelnut SLIT and placebo SLIT before and after
immunotherapy.
FIG 1. Oral challenge test results (quantity of hazelnut provoking
objective symptoms). *Cor a 8–specific IgE sensitive patients.
dCor a 1–specific IgE sensitive patients. A, Anaphylaxis; OAS,
oral allergy syndrome; U, urticaria; U-AE, urticaria-angioedema.
hazelnut ingestion; and levels of serum specific IgE to hazelnut, Cor a 1, or2 Cor a 8.
Food allergy, dermatologic
diseases, and anaphylaxis
SPT and hazelnut extract standardization
Each patient was also skin prick tested with a raw
hazelnut extract to determine the in vivo reactivity of the
extract. A concentration of 2.69 mg/mL hazelnut extract
was calculated to cause a wheal size equal to that obtained
with histamine. For this raw hazelnut extract, 1 mg corresponded to 1.84 mg of the allergen Cor a 8 and 2.88 mg of
the allergen Cor a 1 (data not shown).
Oral food challenges: efficacy assessment
Allergic reactions to hazelnut observed during
DBPCFC were generally well controlled by stopping the
oral food challenge and treatment with epinephrine,
antihistamines, and corticosteroids, as appropriate. No
patient required overnight hospitalization, and none of the
patients who had anaphylaxis presented severe symptoms
or hypotension.
The mean quantity of hazelnut provoking objective
symptoms increased from 2.29 g to 11.56 g (P 5 .02) in
the active group and from 3.49 g to 4.14 g in the placebo
group (without statistical significance; Fig 2). Furthermore, almost 50% of patients (5/11) who underwent hazelnut SLIT reached the highest level (20 g) compared with
9% (1/11) of the placebo group (Fig 1). This beneficial
effect has been observed in patiens with local reactions
and also in patients with systemic reactions after hazelnut
ingestion.
Tolerance and adverse reactions:
safety assessment
All patients reached the planned maximum dose of
25 drops from the most concentrated vial in 4 days. A total
of 1466 doses were administered: 309 during the build-up
phase and 1157 during maintenance.
Systemic reactions were observed in 0.2% (3 reactions/
1466 doses). They appeared only during the build-up
phase, and only antihistamines were required for their
control. One facial urticaria occurred in the placebo group
and 2 reactions in 1 patient of the active group: skin
pruritus a few minutes after the last dose of the second
day and 1 delayed urticaria several hours after the last
dose of the third day, probably associated with exercise
(the patient had urticaria after 1 hour of exercise).
Local reactions, mainly in the form of immediate
oral itching, were observed in 7.4% (109 reactions/1466
doses). Four patients in the active group reported abdominal pain several hours after the ingestion on 1 occasion
each and only during the build-up phase. All local
reactions during the maintenance phase were also oral
itching, and all were in the same patient.
Laboratory parameters
Hazelnut-specific IgE levels did not differ between
groups before treatment but were lower in both groups
after treatment, with no statistical significance both between both groups and within the same group (data not
shown).
As expected, because patients selected came from
birch-free areas, prevalence to Cor a 1–specific IgE was
low (22.14%), whereas Cor a 8–specific IgE was present
in 50% of the patients selected (Fig 1). Regarding Cor
a 1 and Cor a 8 specific IgE, there were no differences
between groups before treatment; however, lower rates
were observed in both groups after treatment, with no
statistical significance within and between both groups
(data not shown).
Regarding hazelnut-specific IgG4 levels, no statistical
significance was found between the studied groups;
however, in the active group, an increase in mean IgG4
levels from 7.34 allergen units (AU)/mL to 9.84 AU/mL
(P < .05) was observed (Fig 3).
Enrique et al 1077
J ALLERGY CLIN IMMUNOL
VOLUME 116, NUMBER 5
An increase in IL-10 levels after treatment was found
only in the active group, rising from 1.62 pg/mL to 2.24
pg/mL (P < .05). No differences were observed between
the placebo and active groups (Fig 3).
We were unable to obtain results of the other cytokines
because of the low sensitivity of the tests used.
DISCUSSION
Food allergy is potentially life-threatening, and there is
no known curative treatment to date. The recommended
treatment for individuals with known anaphylactic reactions to foods is avoidance and use of injected epinephrine
as soon as they become aware of an inadvertent ingestion.
However, avoidance of accidental ingestion is difficult
when eating away from home, and many people with
known food sensitivity do not routinely carry epinephrine
with them.19 Therefore, an improved treatment is needed
for anaphylactic reactions to foods.
Previous studies have used subcutaneous peanutspecific immunotherapy and have showed a decrease in
SPT reactions and decreased sensitivity to peanut ingestion. However, this therapy was accompanied by a high
rate of systemic reactions.10,11
Oral desensitization to foods has been reported in
numerous limited series but with varying results.20,21
Although oral desensitization is an attractive procedure,
well-designed studies are required. Other novel immunotherapeutic approaches have been reported with good
results: anti-IgE therapy,22 Chinese herbal medicines,23
the uses of subcutaneous birch pollen immunotherapy in
patients with oral allergy syndrome,24,25 and other laboratory studies with animal models.26
Food immunotherapy has recently been suggested
again as a food allergy treatment in 2 case report publications: one, oral immunotherapy in patients allergic to
peanut,27 and the other, sublingual immunotherapy in a
case of anaphylactic reaction to kiwi.28 Nevertheless,
double-blind, placebo-controlled randomized studies are
required to confirm these results.
The aim of this study was to evaluate a large group
of patients allergic to hazelnut for their response to a
sublingual immunotherapy with a biological extract standardized in unit mass of major allergens. In the current
study, efficacy was assessed by DBPCFC with hazelnut
performed before and after 2 to 3 months of maintenance
immunotherapy.
Our clinical data confirm significant increases in the
threshold of sensitivity to hazelnut allergen to a level that
should translate into at least partial protection against most
unintended ingestion of hazelnuts. Moreover, almost 50%
of the patients who underwent active treatment tolerated
the highest dose of 20 g, about 15 to 20 hazelnuts, which
constitutes a high amount of hazelnuts that should translate into enough protection against most unintended
ingestion of hazelnuts.
Surprisingly, 1 patient (Cor a 1 sensitive) who received
placebo tolerated the same highest dose of 20 g, and
another patient who received placebo, with the same
characteristic allergen profile, increased his tolerance from
2 to 10 g hazelnut (Fig 1). These patients presented oral
allergy syndrome in the DBPCFC and had hazel pollinosis.
Although the second challenge test was performed
before hazel pollen season, it is tempting to speculate on
the possibility of a seasonal variation in hazelnut pollen–
dependent allergy.29
Mean provocative dose in a previous study ranged
from 1.4 and 2.7 g in patients with hazelnut allergy from
Zurich and Copenhagen to 15.3 g in patients from Milan.4
Nevertheless, the current study is conducted in a birch-free
area, contrary to Zurich, Copenhagen, and Milan which
are in an area of birch pollen exposure. We found a
mean provocative hazelnut dose similar to data observed
in Zurich and Copenhagen; however, Cor a 8 was
described as a major allergen in Milan and also in the
geographical area of the current study.4,6
Regarding safety aspects, in the current study, we observed very good tolerance because the rate of side effects
was very low and appeared in both groups of treatment.
Although the sublingual-discharge technique seems to
lead to better tolerance than the sublingual-swallow
Food allergy, dermatologic
diseases, and anaphylaxis
FIG 3. A, IgG4 levels before and after treatment. B, IL-10 levels before and after treatment.
1078 Enrique et al
Food allergy, dermatologic
diseases, and anaphylaxis
technique, mainly for gastrointestinal symptoms, 4 patients reported abdominal pain. Nevertheless, a relative
high rate of gastrointestinal symptoms has been reported
with sublingual-swallow immunotherapy with latex,18
and also with a high dose of parietaria extract.30
Our data also confirm regional differences in sensitization pattern reported for other birch pollen–related
foods.5,6 In a previous study conducted from Germany in
a group of patients with hazelnut allergy and birch pollen
allergy, the majority were sensitized to the pollen-related
hazelnut allergen Cor a 1.31 In other studies, Cor a 8 (hazelnut lipid transfer protein) was significant for a majority
of patients recruited in Spain or Northern Italy.5,6 In this
study, we partially repeat the same results. Nevertheless,
some patients of the current study with systemic reactions
did not react to Cor a 1 or to Cor a 8, suggesting the possible
presence of other important pollen-related or nonpollenrelated hazelnut allergens, such as Cor a 9, an 11S globulin
related to hazelnut-induced systemic reactions.32
Immunotherapy is capable of modifying the immunologic response to the offending allergen in the earliest
stages. The subcutaneous route of administration has been
well established, and its mechanisms of action have been
extensively investigated.33 However, the clinical use of
SLIT is recent. Therefore, some aspects have not been
fully investigated, and data on the mechanisms of action
are few and contradictory. A recent prospective study of
SLIT in children with allergic rhinitis found positive
effects on rescue and medication use but observed no
significant effects on in vitro T-cell immune responses
or immunoglobulins34; such effects were demonstrated
in another double-blind trial35 and in a case report of a
patient with severe anaphylaxis caused by kiwi allergy
treated with sublingual kiwi immunotherapy with good
tolerance and efficacy.27
In the current study, we observed, on the one hand, a
decrease in specific IgE levels in both treatment groups and
on the other hand, an increase in specific IgG4 and IL-10
levels only in the active group, suggesting the possibility
of immunoregulation through regulatory T cells producing
IL-10 and the oral mucosa Langerhans cells.36-38
In conclusion, this randomized and controlled clinical
trial of sublingual immunotherapy performed in patients
allergic to hazelnut has found significant increases in the
threshold of sensitivity to hazelnut allergen, as assessed by
DBPCFC after hazelnut SLIT, and good tolerance to this
treatment. This beneficial effect has been observed both in
local reactions and in systemic reactions after hazelnut
ingestion. Nevertheless, further studies and others on the
long-term efficacy of SLIT with food extracts are required.
We thank Dr Stephan Scheurer from the Paul-Ehrlich Institut
(Langen, Germany) for providing Cor a 8. We acknowledge Teresa
Piñón, Dolores Sánchis, Inés Saz, Marihor Aguilar, Josefa Fuentes,
and Magdalena Sánchez for technical assistance. We also thank
Ms Christine O’Hara for English review of the manuscript.
REFERENCES
1. Sampson HA. Update on food allergy. J Allergy Clin Immunol 2004;
113:805-9.
J ALLERGY CLIN IMMUNOL
NOVEMBER 2005
2. Björkstén B. How allergenic is food? Clin Exp Allergy 2004;34:673-5.
3. Sicherer SH, Muñoz-Furlong A, Burks W, Sampson HA. Prevalence of
peanut and tree nut allergy in the US determined by a random digit dial
telephone survey. J Allergy Clin Immunol 1999;103:559-62.
4. Ortolani C, Ballmer-Weber BK, Skamstrup Hansen K, Ispano M,
Wütrich B, Bindslev-Jensen C, et al. Hazelnut allergy: a double-blind,
placebo-controlled food challenge multicenter study. J Allergy Clin
Immunol 2000;105:577-81.
5. Pastorello EA, Vieths S, Pravettoni V, Farioli L, Trambaioli C, Fortunato
D, et al. Identification of hazelnut major allergens in sensitive patients
with positive double-blind, placebo-controlled food challenge results.
J Allergy Clin Immunol 2002;109:563-70.
6. Schocker F, Lüttkopf D, Scheurer S, Petersen A, Cisteró-Bahı́ma A,
Enrique E, et al. Recombinant lipid transfer protein Cor a 8 from hazelnut:
a new tool for in vitro diagnosis of potentially severe hazelnut allergy.
J Allergy Clin Immunol 2004;113:141-7.
7. Tariq SM, Stevens M, Rideout S, Twinselton R, Hide RW. Cohort study of
peanut and tree nut sensitization by age of 4 years. BMJ 1996;313:514-7.
8. Groot H, Jong NW, Vuijk MH, Gerth van Wijk R. Birch pollinosis and
atopy caused by apple, peach, and hazelnut; comparison of three extraction procedures with two apple strains. Allergy 1996;51:712-8.
9. Steinman H. ‘‘Hidden’’ allergens in foods. J Allergy Clin Immunol 1996;
98:241-50.
10. Oppenheimer JJ, Nelson HS, Bock SA, Christensen F, Leung DYM.
Treatment of peanut allergy with rush immunotherapy. J Allergy Clin
Immunol 1992;90:256-62.
11. Nelson HS, Lahr J, Rule R, Bock A, Leung D. Treatment of anaphylactic
sensitivity to peanuts by immunotherapy with injections of aqueous
peanut extract. J Allergy Clin Immunol 1997;99:744-51.
12. Alonso R, Enrique E, San Miguel-Moncı́n MM, Tella R, FernándezParra B, Bartra J, et al. An alternative challenge in oral allergy syndrome.
J Allergy Clin Immunol 2004;113:S152.
13. Chapman MD, Heymann PW, Wilkins SR, Brown MJ, Platts-Mills TA.
Monoclonal immunoassays for major dust mite (Dermatophagoides) allergens, Der p 1 and Der f 1, and quantitative analysis of the allergen content
of mite and house dust extracts. J Allergy Clin Immunol 1987;80:184-94.
14. O’Shannessy DJ, Dobersen MJ, Quarles RH. A novel procedure for
labeling immunoglobulins by conjugation to oligosaccharide moieties.
Immunol Lett 1984;8:273-7.
15. Bradford M. A rapid and rensitive method for the quantitation of microgram quantities of protein utilizing the principle of protein-dye binding.
Ann Biochem 1976;72:248-54.
16. Boluda L, Alonso C, Fernández Caldas E. Purification, characterization
and partial sequencing of 2 new allergens of Olea europaea. J Allergy
Clin Immunol 1998;101:210-6.
17. Boluda L, Sastre J, Casanovas M, Fernandez Caldas E. Determination of
Ole e 1 by enzyme immunoassay and scanning densitometry: validation
by skin-prick testing. J Immunol Methods 1999;223:17-26.
18. Cisteró-Bahı́ma A, Sastre J, Enrique E, Fernández M, Alonso R, Quirce
S, et al. Tolerance and effects on skin reactivity to latex of sublingual
rush immunotherapy with latex extract. J Invest Allergol Clin Immunol
2004;14:17-25.
19. Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001;107:191-3.
20. Bauer A, Ekanayake MS, Wigger-Alberti W, Elsner P. Oral rush
desensitization to milk. Allergy 1999;54:894-5.
21. Patriarca G, Nucera E, Roncallo C, Pollastrini E, Bartolozzi F,
De Pasquale T, et al. Oral desensitizing treatment in food allergy: clinical
and immunological results. Aliment Pharmacol Ther 2003;17:459-65.
22. Leung DYM, Sampson HA, Yunginger JW, Burks AW, Schneider LC,
Wortel CH, et al. Effect of anti-IgE therapy in patients with peanut
allergy. N Engl J Med 2003;348:986-93.
23. Srivastava KD, Kattan JD, Zou ZM, Li JH, Zhang L, Wallenstein S, et al.
The Chinese herbal medicine formula FAHF-2 completely blocks
anaphylactic reactions in a murine model of peanut allergy. J Allergy
Clin Immunol 2005;115:171-8.
24. Bucher X, Pichler WJ, Dahinden CA, Helbing A. Effect of tree pollen
specific, subcutaneous immunotherapy on the oral allergy syndrome to
apple and hazelnut. Allergy 2004;59:1272-6.
25. Blotter ST, Tiemessen MM, Zuidmeer L, van Leeuwen A, HoffmanSommergruber K, Bruijnzeel-Koomen CAFM, et al. Efficacy of birchpollen immunotherapy on cross-reactive food allergy confirmed by
26.
27.
28.
29.
30.
31.
skin tests and double-blind food challenges. Clin Exp Allergy 2004;34:
761-9.
Eigenmann PA. Future therapeutic options in food allergy. Allergy 2003;
58:1217-23.
Scurlock AM, Steele PH, Andrzejewski SS, Pons LA, Althage KA,
Christie L, et al. Safety of oral peanut immunotherapy for peanut allergic
patients. J Allergy Clin Immunol 2005;115:S246.
Mempel M, Rakoski J, Ring J, Ollert M. Severe anaphylaxis to kiwi fruit:
Immunologic changes related to successful sublingual allergen immunotherapy. J Allergy Clin Immunol 2003;111:1406-9.
Skamstrup Hansen K, Vieths S, Vestergaard H, Skov PS, BindslevJensen C, Poulsen JH. Seasonal variation in food allergy to apple.
J Chromatogr B Biomed Sci Appl 2001;756:19-32.
La Rosa M, Ranno C, André C, Carat F, Tosca MA, Canonica GW.
Double-blind, placebo-controlled evaluation of sublingual-swallow
immunotherapy with standardized Parietaria judaica extract in children
with allergic rhinoconjunctivitis. J Allergy Clin Immunol 1999;104:
425-32.
Schocker F, Lüttkopf D, Müller U, Thomas P, Vieths S, Becker W-M.
IgE binding to unique hazelnut allergens: identification of non-pollenrelated and heat-stable hazelnut allergens eliciting severe allergic reactions. Eur J Nutr 2000;39:172-80.
Enrique et al 1079
32. Beyer K, Grishina G, Bardina L, Grishin A, Sampson HA. Identification
of an 11 S globulin as a major hazelnut food allergen in hazelnut-induced
systemic reactions. J Allergy Clin Immunol 2002;110:517-23.
33. Till SJ, Francis JN, Nouri Aria K, Durham SR. Mechanisms of immunotherapy. J Allergy Clin Immunol 2004;113:1025-34.
34. Rollinck-Werninghaus C, Kopp M, Liebke C, Lange J, Whan U,
Niggemann B. Lack of detectable alterations in immune responses during
sublingual immunotherapy in children with seasonal allergic rhinoconjunctivitis to grass pollen. Int Arch Allergy Immunol 2005;136:134-41.
35. Lima MT, Wilson D, Pitkin L, Roberts A, Nouri Aria K, Jacobson M,
et al. Grass pollen sublingual immunotherapy for seasonal rhinoconjunctivitis: a randomized controlled trial. Clin Exp Allergy 2002;32:507-14.
36. Sicherer SH, Leung DYM. Advances in allergic skin disease, anaphylaxis, and hypersensitivity to foods, drugs, and insects. J Allergy Clin
Immunol 2005;116:153-63.
37. Francis JN, Till SJ, Durham SR. Induction of IL-101CD41CD251
T cells by grass pollen immunotherapy. J Allergy Clin Immunol 2003;
111:1256-61.
38. Allam JP, Novak N, Fuchs C, Asen S, Bergé S, Appel T, et al. Characterization of dendritic cells from human oral mucosa: a new Langerhans’
cell type with high constitutive FceRI expression. J Allergy Clin Immunol 2003;112:141-8.
Food allergy, dermatologic
diseases, and anaphylaxis
J ALLERGY CLIN IMMUNOL
VOLUME 116, NUMBER 5