Allergen Book Original

Allergens
Contents
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House dust mite

Cat
Dog
Egg
Milk
Fish
Wheat
Peanut
Soybean
Hazelnut
Shrimp
Timothy
Cockroach
Mold
Birch
Olive
Mugwort
Wall pellitory
Reference Lists
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d1 House dust mite

Dermatophagoides pteronyssinus
Allergen description
Dermatophagoides pteronyssinus
Cross-reactivity
Allergens from mites have both common and speciesspecic determinants. Allergenic determinants are shared
with other mites belonging to the Pyroglyphidae family
and are highly cross-reactive with other Dermatophagoides
species (2, 3). There seems to be a limited cross-reactivity
with storage mites (nonpyroglyphid) (3). Some mite allergenic
proteins such as tropomyosin are widely cross-reactive
among invertebrates such as shrimps, snails, cockroaches
and chironomids (3).
Family: Pyroglyphidae
House dust mites are one of the most common sources of
sensitization in all parts of the world. Dermatophagoides
pteronyssinus, D. farinae and D. microceras occur in the
same areas, but the relative proportions of their distribution
vary geographically.
Mites have a life cycle of about 2 to 3 months. The size of
the mite is up to 0.3 mm. They live in house dust and thrive
in warmth and high humidity. Mites faeces seem to be the
major source of allergenic exposure. They are about the
size of a pollen grain and can therefore very easily become
airborne and penetrate the lung alveolus (1).
Clinical experience
IgE-mediated reactions
Studies of house dust allergic individuals around the world
have shown that house dust mites are one of the most
common causes of symptoms such as perennial type asthma,
rhinitis and conjunctivitis, often with nocturnal or early
morning episodes (4).
There is evidence that reduction of mite-allergen levels
can cause a major improvement in symptoms of asthma (5).
So far the only effective way to get a permanent reduction
of house-dust mite allergens seems to be lowering of the air
humidity and temperature together with efcient cleaning (4).
Allergen exposure
Dust, carpets, pillows, mattresses and upholstering furniture
containing biological material, especially human dander, are
reservoirs of house dust mites. Other sources of exposure
are damp houses (>45% relative humidity) or dwellings at
low altitudes.
e1 Cat
Epithelium and dander
Felis domesticus
Clinical experience
IgE-mediated sensitization to cat is a risk factor for asthma.
Allergen exposure plays a causal role in the development of
bronchial hyperreactivity and of the chronic inammatory
responses seen in patients with asthma (11). Infants exposed
to cats developed skin prick test sensitivity about three times
more often than those without such exposure (12).
Furthermore, the low level cat exposure that occurs in
many homes without cats can induce symptoms in some
patients who are sensitive to cats (13).
Tobacco smoke, prenatal and postnatal, has been shown
to have an adjuvant effect on cat sensitization in exposed
children (14). Allergic reactivity to pollens may also be
aggravated by environmental priming with ubiquitous
animal dander (15). Furthermore, allergy to cats or dogs
seems to be an important risk factor for the development of
laboratory animal allergy (16). Avoidance of cat allergens is
an important measure to take in the treatment of sensitized
asthmatics, decreasing symptoms and decreasing the need
for drugs (17).
Only removal of the cat leads to a lasting decrease of the
allergen exposure (1820).
Family: Felidae
Allergens from cat epithelium and dander are one of the
most common causes of respiratory allergic disease.
Several cat allergens have been identied and
characterized (1).
Allergen exposure
Carpets, mattresses and upholstered chairs are reservoirs of
cat allergens. Cat allergens are carried on human clothing
into environments never visited by cats. Transport of cat
allergens on clothing from the domestic to the school
environment is in fact a major source of cat allergens in
classrooms.
Cross-reactivity
Cat-allergic patients have been shown also to react to big
cats e.g. ocelot, tiger and lion (2).
A subgroup of cat-allergic patients also reacts to dogs
and sometimes to other animals. Serum albumin is the main
common component (3, 4). Extensive cross-reactivity even
occurs between albumins of distantly related species such as
horse, cattle, pig, rodents and furred animals (57).
However, great variability exists between patients and
selective sensitivity to limited numbers of species occurs.
Allergy to cat dander and pork meat, also referred to as
the pork/cat syndrome (8), was shown to be mediated by IgE
antibodies recognizing cat and pig serum albumin (9). In
addition, other kinds of meat may be a risk for patients with
this type of sensitivity (10).
e5 Dog
Dander
Canis familiaris
Cross-reactivity
An extensive cross-reactivity among the different breeds
could be expected.
It has been noted that many patients allergic to cats are
also allergic to dogs. Many studies suggest evidence for
cross-reactivity between some cat and dog allergens (35).
Family: Canidae
The dog, a relative of the wolf, the jackal and the fox, was
one of the earliest domestic animals, living in human
communities as early as 12 000 years ago. More than 800
breeds have been developed.
Dog allergens have been found in serum, dander, pelt, hair
and saliva (1, 2).
Although allergen differences occur according to the
origin of the allergen (e.g. dander or saliva), no breedspecic allergens occur. But the concentration of allergens
varies within breeds and among them.
Dog dander contains the highest proportion of dog-specic
allergens. Animal dander is extremely lightweight and tiny
in size and can stay airborne for hours.
Clinical experience
Dog dander is an important source of inhalant allergens, and
may frequently induce symptoms in sensitized individuals
(1, 2, 5, 6). Symptoms include asthma, allergic rhinitis and
allergic conjunctivitis. 3035% of atopic individuals display
allergic symptoms on exposure to dog allergens (79).
Symptoms can be caused by indirect exposure to dog
dander in schools, at work and on public transport. In
sensitized subjects, repeated exposure to allergens also
contributes to subclinical inammation, hyperresponsiveness
and general worsening of asthma (10, 11).
Eczema following exposure to dog allergens has been
reported (12).
Occupational allergy to dog may also occur in animal
workers, animal pelt workers and laboratory workers.
Allergen exposure
Levels of dog allergens in houses with dogs may reach high
levels. Levels in homes without dogs are generally 10 to 100
times lower, but can still be detected.
In houses with dog allergens, the highest concentration
appears to occur on the living-room oor, on furniture, and
in bedrooms.
Dog allergens can be detected also in other places, such
as schools and day-care centers where dogs are not present
on a regular basis. The allergens appear to be transported on
clothes and may be present in relatively high concentrations.
f1 Egg
Egg white
Gallus spp.
Clinical experience
Egg-specic IgE antibodies are usually the rst antibodies
to appear in children developing atopic disease.
Allergy to egg is generally considered to be one of the
most common causes of food allergy in infants and young
children (2). When studying egg-allergic children, IgE
antibodies were found in more than 65% of children with
eczema and respiratory tract symptoms (3).
Egg-white specic IgE antibodies may predict the
development of atopic respiratory allergy. In a follow-up
study of infants where the authors had concluded that eggwhite sensitivity was a better indicator of atopy than total
serum IgE, the infants presenting with egg-white allergy
were more likely to have developed inhalant allergy by 7
years of age (4). Other studies show similar results (5, 6).
Egg white is often responsible for early development of
urticaria and eczema during infancy (7).
Remaining egg intolerance in older children and adults
may be linked to exposure to cage birds and chicken meat.
Certain vaccines grown on chicken embryos have been
reported to cause severe allergic reactions in patients when
injected (8). Further development of vaccines seems to have
decreased or even eliminated the risk for egg-allergic
children (9, 10).
Egg is a major cause of adverse reactions in infants and

hidden exposure is common.
Hens eggs are composed of about 60% egg white and
30% egg yolk. Egg white contains approximately 88%
water and 10% protein.
The major allergens of egg white are ovomucoid, ovalbumin,
ovotransferrin (also called conalbumin), and lysozyme (1).
Allergen exposure
Expected exposure
Cooked or raw eggs
Bread and pastry
Numerous dishes like pancakes, sauces, etc.
Unexpected exposure
Candy
Beverages
Meat products like sausages, pts, etc.
A great variety of foods may contain egg or traces of egg and
patients allergic to egg need to be aware of egg as a frequent
hidden allergen.
Cross-reactivity
Eggs from related animals
Presence of shared allergens in egg-white, egg-yolk, serum
and meat from hen and chicken has been demonstrated.
f2 Milk
Cows milk
Bos spp.
Clinical experience
Cows milk is a major cause of adverse reactions in infants
with prevalence 0.57.5% (4, 5). Some patients retain a
lifelong allergy (6). Cows milk-induced asthma is often
observed in infants with food hypersensitivity as well as
rhinoconjunctivitis and possibly also serous otitis media (7).
Cows milk allergy in infants has a much better prognosis for
outgrowth than in older children or adults (4).
IgE antibodies to milk may develop before the onset of
clinical allergy, indicating that in vitro measurements can be
good predictive tools (8). Correlation of milk-specic IgE
antibody levels with the development of tolerance to milk
has been reported (9, 10).
The symptoms in infants are usually dermatological and
gastrointestinal (GI), with eczema often appearing early (11).
In children retaining milk allergy, cutaneous symptoms
decrease while respiratory and GI symptoms increase with
age (9, 12). Infants with early sensitization to cows milk
proteins have an increased risk for later development of
other food allergies and sensitization to inhalant allergens
(1315).
Cows milk is a major cause of adverse reactions in infants

and hidden exposure is common.
There are many allergenic proteins in milk and caseins,
alpha-lactalbumin and beta-lactoglobulin are considered as
some of the major allergens. Caseins are heat stable
allergens (1).
Allergen exposure
Expected exposure
Milk, cheese and other dairy products
Bread and pastry
Numerous dishes like pancakes, soups etc.
Unexpected exposure
Candy
Toppings
Processed meat like ham, sausages, pts, etc.
Hydrolyzed milk formulas
Milk and milk derivatives are used in a wide variety of

confectionery products. Contamination during processing or
addition of sodium caseinate has also been reported (2, 3).
Other reactions
Lactase deciency (lactose intolerance)
Immune reactions without IgE antibody involvement
Cross-reactivity
Milk from related animals
Presence of shared allergens in milk, meat, and dander
from cow has been demonstrated.
In adults lactase deciency is a common cause of milk

hypersensitivity (16).
f3 Fish
Cod
Gadus morhua
Clinical experience
Allergic reactions to sh are a common cause of food allergy.
Prevalence gures vary from approx. 10% to approx. 40% in
atopic populations. In Norway sh allergy was found in
1/1000 of the general population. While many children often
outgrow allergy to cows milk and egg white, those allergic to
sh may continue to be hypersensitive to sh later in life (2).
Reactions to sh allergens are often severe. Systemic
reactions after eating sh, but also after inhaling steam or
aerosol in connection with cooking or handling sh or after
skin contact are reported in several studies (3).
Extremely sensitive patients have suffered anaphylactic
shock after eating foods cooked in re-used cooking-oil, or
when utensils and containers have been used earlier for
cooking sh (4).
Many patients avoid all species of sh and others may
tolerate a few, thus indicating specic allergens.
Because patients react to both cooked and raw sh, it is
assumed that the allergens are heat-resistant. However, more
recent studies indicate that patients may react differently to
processed food (5) and that allergic reactions may also be
species-specic (3, 6).
Family: Gadidae
The Atlantic cod is one of the worlds most important food
sh. It is sold fresh, frozen, smoked, salted and canned.
Patients allergic to sh often have dramatic symptoms,
such as asthma or anaphylactic reactions. Some patients
allergic to one sh may tolerate other sh species.
Allergen exposure
Expected exposure
Meat from cod
Unexpected exposure
Undeclared ingredient in industrially prepared food,
such as cured meat products
Contamination of cooking oil, utensils and containers
Inhalation of steam or dried fragments
Cross-reactivity
Species within groups of sh, like Gadiformes (e.g. codsh
and hake) and Scombroid shes (e.g. mackerel and tuna)
seem to share allergenic components. The overlap of allergen
specicity between the groups seems to be moderate.
However the major cod allergen (parvalbumin) seems to be
a good representative for many sh species (1).
10
f4 Wheat
Clinical experience
Wheat is one of the major cereal grains belonging to the

grass family and a staple food item in most diets worldwide.
There are many different types of wheat, but the hexaploid
Triticum aestivum is by far the most important of the Western
species.
The major proteins in wheat (albumins, globulins and
glutens) vary in proportion according to the type of wheat.
This variability is one reason why reactions to different
wheat products are not consistent.
Wheat is among the six most important food items accounting

for IgE mediated allergic reactions in children.
IgE mediated allergic reactions to ingested wheat protein
include gastrointestinal, respiratory and cutaneous symptoms
(3). Reactions typically occur within an hour of wheat
ingestion. Affected individuals are usually sensitized during
infancy (4) and the clinical reactivity typically resolves
before adulthood.
Wheat exposure may result in different life-threatening
anaphylactic reactions (5). Wheat dependent exercise-induced
anaphylaxis (WDEIA) is a severe IgE-mediated allergic
reaction provoked by the combination of wheat or wheat
our ingestion and intense physical exercise during the next
few hours (610).
Sensitization by inhalation can cause bakers asthma, a
frequent allergy in the baking industry (11, 12). Occupational exposure to wheat or wheat dust may also result in other
allergic conditions affecting animal, bakery, food industry
and mill workers.
Allergen exposure
Expected exposure
Softer wheat with lower protein content is used for biscuits,
cakes and pastry, harder wheat with higher protein content
for bread, semolina, cous-cous, macaroni and pasta. Durum
wheat is a source of Italian pasta, Indian chappatis and Chinese
noodles. Wheat is also a source of alcoholic beverages such
as beer.
Unexpected exposure
Other reactions
Wheat is used in livestock feed. Wheat starch is used for

pastes and for sizing textiles.
Wheat allergy and celiac disease are two distinct conditions.

Celiac disease is a permanent non-IgE mediated reaction
caused by intolerance to gluten.
Cross-reactivity
An extensive cross-reactivity among different individual
species of wheat as well as some cross-reactivity to grass
pollens could be expected (1, 2).
11
f13 Peanut
genuine cross-reactivity or to the coexistence of separate

allergies in widely atopic individuals.
Although peanut shares homologous proteins with botanically
related beans and legumes, the majority of patients do not
show clinical reactions to other legumes (4, 5, 6). Although
one would expect that peanut-allergic individuals would
have a high risk of cross- or co-reactivity to soybean
(a family member), blinded food challenges have shown a
low rate of these reactions (4). However, it is still not clear
whether peanut allergic patients also should avoid soybeans
or not (7).
Arachis hypogaea
Family: Fabaceae
Peanut is not a nut, but a seed of an annual legume. It grows
close to the ground and produces its fruit below the soil
surface, in contrast to tree nuts like walnuts and almonds.
Peanut is a member of the Fabaceae or legume family,
whereas tree nuts are not.
Peanuts were rst cultivated in South America. Portuguese
explorers then transplanted peanut plants to Africa, and from
there peanuts were spread to the rest of the world by explorers.
Clinical experience
Peanuts are a signicant cause of serious food allergy in both
adults and children. Peanut allergy usually begins in childhood
and unlike other food allergies often persists throughout the
affected individuals lifetime. Only approx. 20% of young
children will develop tolerance (6, 8).
Allergic reactions to peanut can be mild to moderate, but
compared to reactions to other food allergens they might be
more likely to be severe or even fatal (9). Atopic dermatitis,
angioedema, asthma, diarrhea, nausea and vomiting,
and anaphylaxis have been reported. Urticaria may be a
prominent symptom (10). Although not reported frequently,
asthma may be a signicant feature in peanut allergy. As
severe peanut allergy in asthmatic infants carries a risk of
anaphylaxis, it is useful to look for peanut allergy in all
infants with severe asthma (11). Peanut dust can also act as
an inhalant allergen.
Allergen exposure
Expected exposure
Peanuts are consumed mainly as peanut butter and as snacks
(roasted, salted, plain or dry roasted), but also in other foods.
Unexpected exposure
Peanuts occur in candy and in baked goods. Peanuts also
yield widely used oils. Arachis oil is peanut oil. Peanut our
is an important ingredient in a variety of processed foods.
Another unexpected source of peanuts is foods served at
restaurants often using peanut as an ingredient, such as the
Asian and African cuisines.
Cross-reactivity
Peanut and tree nut allergic reactions coexist in 25-50% of
peanut allergic patients, and allergic reactions to tree nuts
such as walnuts, cashews, pecans and pistachios can develop
even though tree nuts belong to a different botanical family
(1, 2, 3). Reactions frequently occur on rst exposure and
may be life-threatening. It is unclear whether this is due to
12
f14 Soybean
derable cross-reactivity with other legume family members

(6). While the clinical relevance of eliminating legumes as
a food group from the diet of allergic patients is disputed,
several reports conrm cross-reactivity e.g. to peas, lentils,
peanuts, kidney, lima and navy beans (7).
Glycine max (Soja hispida)
Family: Fabaceae
Soybeans are dried ripe seeds and a high-protein legume
grown as food for both humans and animals. It is an important
source of protein to many vegetarians and vegans. The word
soy is derived from the Japanese word shoyu (soy sauce).
Clinical experience
Soybean is considered a classical food allergen (8) and is
one of the foods to which children often have allergic reactions.
Allergic reactions to soybean are dominated by stomach and
skin problems, but also include respiratory symptom as well
as severe allergic reactions. With its expanding use as a
constituent in many different foods, soybean may be an
underestimated cause of severe allergic reactions (9).
There is an ongoing debate on the use of soy formula as a
safe substitute for infants with cows milk allergy.
In some countries it is recommended as a safe alternative
when screening results indicate no existing soy allergy (10).
However, there are also studies reporting on the risk of
developing allergy to soy when using soy formula, and about
one-fourth of cows milk-sensitive patients have been reported
to become allergic to soy protein (11, 12). Therefore, some
countries recommend that breast-feeding or less allergenic
formulas should be preferred (13, 14).
Patients experiencing IgE-mediated symptoms after
ingesting peas, beans, lentils, peanuts or soybeans have been
reported (15).
Soybean dust can also act as an inhalant allergen. Epidemic asthma in areas around harbors, where soybeans were
unloaded from ships, has been reported from several places
around the world (1620). A large number of fatal cases
probably involving anaphylaxis were recorded. Occupational
asthma in bakers and workers in food processing plants may
be caused by soy our (2122).
Allergen exposure
Expected exposure
The bean can be fresh, processed into soybean our or pressed
for oil. Soybean oil is put to many uses. For example it is
included in salad oil and margarine. Some soy allergic patients
may safely eat soybean oil (not cold pressed, expeller pressed
or extruded oil) and soy lecithin, while extremely soy allergic
patients may react to traces of soy protein in soybean oil and
soy lecithin (1).
Soybeans and products made from the bean (miso, tofu,
natto, douchi, etc.) are signicant parts of the diet in Asia. Soy
sauce, or shoyu, is a fermented product of soybean and wheat.
Soybean oil is also used in industrial components and in
linoleum and glue in the plywood industry, where it is
considered an occupational allergen.
Unexpected exposure
Soy proteins are frequently found in meat products, bread
and other industrially produced food products (2). The list of
food products presenting potential risk is expanding. Some
examples are sausage products (3), pizza (4) and candy
containing soy lecithin (5).
Cross-reactivity
Already in studies of soybean allergenicity, soybean was
found to contain several antigenic components with consi-
13
f17 Hazelnut
Corylus avellana
Cross-reactivity
An extensive cross-reactivity among the different individual
species of the genus could be expected (1). Cross-reactivity
between hazelnut and hazel tree pollen may occur (2). There
is also a relationship between birch pollinosis and sensitization
to hazelnut, apple, kiwi, carrot, potato and other vegetables
(34). In birch pollen-hypersensitive patients with oral
allergy syndrome it is very common with apple and/or
hazelnut allergy (5).
An important cross-reactivity between the pollen of
Platanus acerifolia (London plane tree), hazelnut and banana
has been reported (6). Partial cross-reactivity has been
reported to occur between hazelnut and macadamia nuts (7).
Family: Corylacaea (Betulaceae)

The terms lbert and hazelnut are often used interchangeably for nuts from all plants in the genus Corylus,
such as C. silvestris, C. maxima and C. colurna.
These wild nuts grow in clusters on the hazel tree in
temperate zones around the world. Hazel is an aggressive
spreader and is particularly common in Europe.
Italy, Spain, France and Turkey lead in hazelnut production.
The nuts generally fall in autumn and are harvested from the
ground and then shelled and dried.
Clinical experience
Allergen exposure
Expected exposure
Hazelnuts are a common cause of food allergy (810).

Allergic sensitization may occur early on in life (11). Allergic
reactions to hazelnuts range from oral allergy syndrome to
severe anaphylactic reactions (12). Allergy to hazelnut is
frequently observed in patients with allergy to birch pollen.
Symptoms of food allergy in pollen-allergic patients are
usually mild and restricted to the oral cavity, i.e. oral allergy
syndrome. Allergy to hazelnuts without concomitant
pollen allergy is less common, but symptoms tend to be
more severe and are often systemic (1314).
Allergies to peanut (a legume) and tree nuts (walnut,
hazelnut, brazil nut, pecan) frequently have an onset in the
rst years of life, generally persist, and may account for
severe and potentially fatal allergic reactions.
The nuts are used chopped, ground, roasted, blanched,

sliced and as our and paste in all manner of sweets. They
are also eaten whole as a snack. Hazelnuts also add avor
and texture to savory items such as salads and main dishes.
Unexpected exposure
Hazelnut is widely used and can be a hidden allergen.
Nougat, an ingredient in secondary products such as
confections, is for example a hazelnut product.
14
f24 Shrimp
Pandalus borealis
Clinical experience
Shrimp has been recognized as potent allergen both in food
allergy and occupational allergy. While many children often
outgrow allergy to cows milk and egg white, they may
continue to be hypersensitive to shellsh later in life (2).
Shrimp allergy is common cause of anaphylaxis among
adults (3, 4). Other allergic reactions including urticaria,
angioedema, respiratory symptoms and gastrointestinal
problems have also been reported (4).
Shrimp-allergic patients often have respiratory allergy
and shrimp is also an occupational allergen for seafood
processors and workers in the shing industry (5).
Food-dependent exercise-induced anaphylaxis after
consumption of shrimp has occurred (6).
Family: Crangonidae
Shrimp is found in shallow and deep waters everywhere.
The largest of the species, mostly found in the Pacic, are
called prawns.
Allergen exposure
Expected exposure
Meat from shrimps or prawns can be canned, breaded, frozen,
sold in the shell or dried.
Some major shellsh allergens are heat-stable and watersoluble and can therefore enter the atmosphere in steam
aerosols from the cooking process.
Unexpected exposure
Shrimp can also be an undeclared ingredient in some processed
sh products and snacks.
Cross-reactivity
Common major allergens have been identied in shrimp,
crab, lobster and craysh. One of these allergens is
tropomyosin, which is a major allergen in shrimp, but is also
present in mites, cockroaches and other insects.
Of seven allergens detected, two appear to be shared by
other Crustacea and one may be a specic allergen present
only in shrimp (1).
15
g6 Timothy
Grass pollen
Phleum pratense
Clinical experience
IgE mediated reactions
Allergy to timothy grass pollen has been reported widely.
Timothy grass is one of the most important causes of allergic
rhinitis, asthma and allergic conjunctivitis during summer in
cool temperate climates (7).
A European Community respiratory health survey reported
that adults who had lived on farms as children were less
frequently sensitized to timothy grass, and were at lower
risk of having nasal symptoms in the presence of pollen in
general (8).
Timothy grass is a very prevalent aeroallergen in the
Mediterranean countries, including Spain (9). In a birchand ragweed-free area in Spain, 97.9% of patients allergic
to pollens were sensitized to timothy and rye grass (10). The
strongest associations between bronchial hyperreactivity and
specic IgE responses were seen with timothy grass (11).
In Sweden, in allergen-specic IgE tests on 7099 adult
patients with asthma and/or rhinitis, timothy, cat and birch
were the most prevalent allergens. Of these patients, 65%
were sensitized against several allergens and 35% had a
mono-allergy, most frequently to timothy grass (70%) (12).
Family: Poaceae (Gramineae)

Subfamily: Pooideae
Tribe: Agrostideae
Timothy pollen often induces hay fever, asthma and
conjunctivitis in sensitized individuals. Timothy is one of
the worlds most common grasses and one of the most
common sources of animal fodder. It grows best in cooler,
humid climates.
A number of timothy allergenic proteins have been identied
and characterized (1).
Allergen exposure
Timothy owers from early summer to midsummer. Timothy
is widespread in elds and meadows, and on roadsides. It is
sown in pastures for forage, and is very common in hay.
Cross-reactivity
An extensive cross-reactivity among different related grasses
could be expected, in particular grasses belonging to the
subfamily Pooideae (2, 3).
Timothy grass pollen also seems to share allergens with
tomato, peanut, kiwi and other fruits and vegetables (4, 5).
It also shares IgE binding epitopes with glycoprotein latex
allergens, which might in part explain clinical symptoms in
pollen-allergic patients on contact with latex (6).
16
i6 Cockroach
German
Cockroach-specic IgE antibodies are frequently found in

patients with asthma and other allergic conditions all over
the world. The most important species in industrialized
countries are the German and the American cockroaches.
Allergic individuals can be exposed to cockroach allergens

by inhalation from living quarters and by ingestion due to
contamination of foodstuffs. The highest levels of cockroach
allergens are typically found in the kitchen. However, the
lower levels of allergen found in bedding, on the bedroom
oor and in sofa dust (4) may be more relevant in causing
sensitization.
Allergen exposure
Cross-reactivity
Blatella germanica
An extensive cross-reactivity among different species of the

genus has been demonstrated (5). Extensive cross-reactivity
has also been demonstrated between tropomyosin found in
shrimp and that in other Crustacean species, house dust mite
and German cockroach (6).
The distribution of cockroaches in the world varies with

geography, climate and culture. Cockroaches thrive in damp
and warm environments. They are rarely found in dry, high
altitude areas.
Several species are widespread and still expanding in new
areas. The most common of these is the German cockroach
(1). It is a small cockroach, growing up to approx. 2 cm in
length that is found throughout the world in association with
humans. Adults have wings, but rarely y. The nymphs are
darker and wingless.
Cockroaches are found in homes, restaurants, hotels, food
plants, warehouses, etc. During the day, the roaches may
cluster hidden behind baseboard molding, in cracks around
cabinets, closets or pantries and in and under stoves,
refrigerators and dishwashers.
Cockroaches produce potent allergens. At least 29 allergens
have been detected from German cockroach contributing to
asthma (2, 3).
Clinical experience
Cockroach may commonly induce symptoms of asthma,
allergic rhinitis, allergic conjunctivitis and allergic eczema in
sensitized individuals (7, 8).
The clinical presentation of asthmatic patients with
cockroach allergy is typically nonspecic (9). Most
commonly, patients have a history of perennial asthma,
possibly worse in the winter (10), without a clear history
of onset of symptoms on exposure to cockroaches.
Although some patients may be exclusively allergic to
cockroaches, sensitization is usually to multiple indoor
and/or outdoor allergens.
17
m6 Mold
Alternaria alternata
Alternaria alternata/Alternaria tenuis
Clinical experience
Sensitivity to Alternaria has been increasingly recognized
as a risk factor for the development, persistence and
exacerbation of asthma (3). Studies have suggested that
sensitivity to Alternaria may be a risk factor for life-threatening
asthma (4, 5, 6). Alternaria is one of the main allergens
affecting children.
Alternaria-sensitized patients may also be at risk for
allergic rhinitis (7). Severe cases of rhinitis may be
attributable to Alternaria sensitivity (8).
Alternaria sensitization may also occur in occupational
settings, including gardens, bakeries, forests and farms.
Alternaria is associated with bakers asthma and wood
pulp workers lung.
Alternaria alternata is one of the most important among

the allergenic molds. Although other Alternaria species are
probably also clinically relevant, especially as a result of
cross-reactivity between the species, most research has been
directed toward Alternaria alternata.
Allergen exposure
Alternaria occurs on many plants and other substrates,
including foodstuffs and textiles. Favorite habitats are soils,
corn silage, rotten wood, compost, bird nests, and various
forest plants. Black spots on tomatoes may be caused by
Alternaria. It is frequently found on water condensed on
window frames. It is one of the most common mold spores
found in dwelling dust in both North America and Europe.
Alternaria is predominantly an outdoor allergen favoring
damp spots, and most indoor concentrations may derive
from outdoor primary sources.
In temperate climates, airborne Alternaria spores are
detectable from May to November, with peaks in late summer
and autumn. Despite the large spore size, spores may
disperse for hundreds of miles from the source.
Cross-reactivity
species of the genus could be expected (1).
Enolase is a common allergen found in many species of
mold and has been shown to exhibit high cross-reactivity
to other fungal enolases (2).
18
t3 Birch
Common silver birch
Tree pollen
Betula verrucosa
Cross-reactivity
Cross-reactivity between pollens from species within
the Betulaceae family or closely related families can be
expected and is often seen (13).
Major allergens in hazelnut, apple, pear, apricot and sweet
cherry as well as minor allergens in other foods, e.g. peanut
and soy, are structural homologs to the birch pollen major
allergen Bet v 1 (1, 4, 5).
Cross-reactivity has also been frequently observed to
other substances containing prolin, e.g., hazel-nut, ragweed
pollen, mango, mugwort pollen, timothy pollen, celery, carrot,
peanut and spices (1, 511).
Family: Betulaceae
A tree species producing large amounts of pollen, often
inducing hay fever, asthma and conjunctivitis in sensitized
individuals.
The common silver birch is a single-stemmed, deciduous
tree with a height of up to about 25 meters. The bark is
smooth and silvery white, becoming black and ssured
into rectangular bosses.
Several birch pollen allergenic proteins have been identied
and characterized, such as Bet v 1 as a major allergen and
Bet v 2 as a prolin (1).
Clinical experience
Birch pollen is highly allergenic, causing allergic reactions
such as asthma, allergic rhinitis and conjunctivitis. Birch
is one of the most important causes of springtime hay fever
(3, 12).
Cross-reactivity between birch and food may result in
symptoms of Oral Allergy Syndrome in birch-sensitized
individuals (5, 13). Symptoms of food allergy in birch
pollinosis patients are usually mild and restricted to the
oral cavity. On the other hand, while allergy to a food, e.g.,
hazel-nut, without concomitant pollinosis is less common,
symptoms tend to be more severe and are often systemic (13).
Allergen exposure
The birch tree owers in late spring, usually at the same time
as the leaves appear. In North America it blooms in early
spring and occasionally again in late summer or fall. The
bloom time is usually short. The birch trees are windpollinated.
The birch occurs in woods, particularly where the soil is
lighter. It often grows in heath lands and clearings and is
also planted in gardens.
The common silver birch is native and common in most
of Europe, northwest Africa and western Siberia, but rare
in the southernmost parts of Europe. It is the most common
tree found in Scandinavia and the Alps and a potent pollen
producer in those areas. There are also closely related
species in East Asia and North America.
19
t9 Olive
Tree pollen
Olea europaea
Cross-reactivity
A high degree of cross-reactivity has been demonstrated
between olive tree, ash and privet and all members of the
Oleaceae family (2).
In a Spanish study on Cupressus sensitization, skin-prick
tests on 1532 patients suffering from respiratory disorders
(asthma and/or rhinoconjunctivitis) demonstrated that all of
the Cupressus-sensitive patients also reacted positively to
Olea and Fraxinus (3).
Due to the presence of the panallergen prolin a certain
degree of cross-reactivity to other plant allergens may
be expected.
Family: Oleaceae
Olive tree pollen often induces hay fever, asthma and
conjunctivitis in sensitized individuals.
The olive tree is an evergreen growing to 10 meters,
with a broad, round crown and a thick and knotty trunk.
Pollination is by insects, but also by wind when pollen is
in abundance.
Olives grow in plantations and woods, and as scrub in dry
rocky places.
Clinical experience
Allergen exposure
Olea europaea, the olive tree, has been recognized as one
of the most important causes of seasonal respiratory allergy
in the Mediterranean area (1) and in other parts of the world
where this tree is now grown.
The olive tree probably originated in Asia Minor, spread
to the Mediterranean region, and was then introduced into
North America (especially California and Arizona), South
America (Chile), Australia and South Africa. In North
America olive trees are found only in the Southwest.
The pollination period of Olea varies. It occurs in the
spring, but in Europe may start as early as January, depending
on the region (1).
Olive pollen can induce asthma, allergic rhinitis and allergic

conjunctivitis in sensitized individuals (1, 48).
The frequency of sensitization to olive tree pollen varies in
the Mediterranean region (1). In Greece, more than 37% of
atopic individuals are sensitized to Oleaceae (9).
The majority of studies demonstrate a higher prevalence
of rhinoconjunctival symptoms than asthma (1). Patients
are more likely to be polysensitized than monosensitized to
olive tree pollen. Monosensitized individuals, children and
adults, may have symptoms throughout the year without an
apparent increase during the olive pollination season (8).
20
w6 Mugwort
Weed pollen
Artemisia vulgaris
Cross-reactivity
species of the genus could be expected, as well as among
members of the family Asteraceae (Compositae) e.g. sage,
golden rod, ragweed, chrysanthemum and camomile (26).
Furthermore, cross-reactivity has been demonstrated to be
common between mugwort, celery, carrot and spices from
the Apiaceae family (celery-carrot-mugwort-spice syndrome) (7). There is also some cross-reactivity to lettuce, nuts,
mustard and leguminoseae vegetables (810).
The panallergen prolin has been identied as one of the
cross-reactive components in mugwort and ragweed pollen
(11). Prolin will result in varying degrees of cross-reactivity
between mugwort and other pollens and foods containing
this panallergen. Prolin is found in virtually all pollens and
foods of plant origin (12, 13).
Family: Asteraceae (Compositae)

Mugwort pollen often induces hay fever, asthma and
conjunctivitis in sensitized individuals.
The plant is an aggressive, coarse perennial that spreads
by persistent rhizomes. It generally reaches a meter or
more in height, and has a rather untidy and unattractive
appearance.
Small, greenish-yellow to red-brown ower heads appear
from summer to mid-autumn in clusters at the top of the plant,
and produce tiny, inconspicuous yellowish-green owers.
A number of mugwort allergenic proteins have been
identied and characterized (1).
Allergen exposure
Clinical experience
Mugwort is most common on rubbish heaps, roadsides,

sites of demolished buildings in towns, and a variety of
other disturbed situations. It is a problem weed in turf grass,
nurseries, and natural areas.
The plant is native to Europe and Asia, but is now also
found throughout the eastern US.
Mugwort sensitization and allergy has been reported widely.

Mugwort pollen is a major cause of asthma, allergic rhinitis,
and allergic conjunctivitis (14). Exposure to mugwort pollen
may also contributes to the causation or exacerbation of the
oral allergy syndrome, eczema, urticaria and anaphylaxis
e.g. where pollen has contaminated a food, e.g., honey
(6, 10, 15).
Approximately 25% of mugwort-allergic patients have
reported subsequent hypersensitivity to a variety of foods
e.g. celery, spices and carrots (9, 10, 13).
21
w21 Wall pellitory

Weed pollen
Parietaria judaica
Cross-reactivity
species of the genus could be expected, as well as to a certain degree among members of the family Urticaceae (1). A
high homology has been shown between P. judaica,
P. ofcinalis, P. lusitanica and P. mauritanica (2).
However, for wall pellitory cross-reactivity with other
family members of different genuses can also be expected as
well as to a certain degree to other plants due to the presence
of the panallergen prolin (3).
Family: Urticaceae
Wall pellitory is a weed pollen, which often induces hay
fever, asthma and conjunctivitis in sensitized individuals.
It is a sprawling, many-branched, bushy perennial weed,
with brittle, reddish stems. It grows from 30 to 100 cm.
Wall pellitory is a common weed around the Mediterranean
and along the West Coast of Europe, as far north as central
England. It has been introduced in other parts of Western
Europe and in Australia and Argentina. Two closely related
species are found in the US and one in Brazil.
The genus Parietaria has about 10 species, which are
highly cross-reactive to each other. Parietaria pollen
allergens are one of the most common causes of pollinosis
in areas where the plants grow.
Clinical experience
Wall pellitory pollen has been recognized as an important
allergen, causing symptoms of asthma, allergic rhinitis and
allergic conjunctivitis (48).
Rhinoconjunctivitis and bronchial asthma, alone or in
association, are the most common clinical manifestations.
The season in which patients experience symptoms is
prevalently spring. However, many patients show a
multiseasonal pattern.
In children, sensitization to wall pellitory is low, but it may
become the most frequent cause of sensitivity as individuals
grow older (5, 6).
Allergen exposure
The plant preferably lives on walls, rocks, banks and
hedge banks.
In many countries the wall pellitory owers all year round,
but with distinct peaks in spring and around November.
Parietaria allergy is strongly associated with Mediterranean
countries.
22
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26
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Allergens

House dust mite

d1 House dust mite

Egg is a major cause of adverse reactions in infants and

Cows milk is a major cause of adverse reactions in infants

Milk and milk derivatives are used in a wide variety of

In adults lactase deciency is a common cause of milk

Wheat is one of the major cereal grains belonging to the

Wheat is among the six most important food items accounting

Wheat is used in livestock feed. Wheat starch is used for

Wheat allergy and celiac disease are two distinct conditions.

genuine cross-reactivity or to the coexistence of separate

derable cross-reactivity with other legume family members

Family: Corylacaea (Betulaceae)

Hazelnuts are a common cause of food allergy (810).

The nuts are used chopped, ground, roasted, blanched,

Family: Poaceae (Gramineae)

Cockroach-specic IgE antibodies are frequently found in

Allergic individuals can be exposed to cockroach allergens

An extensive cross-reactivity among different species of the

The distribution of cockroaches in the world varies with

Alternaria alternata is one of the most important among

Olive pollen can induce asthma, allergic rhinitis and allergic

Family: Asteraceae (Compositae)

Mugwort is most common on rubbish heaps, roadsides,

Mugwort sensitization and allergy has been reported widely.

w21 Wall pellitory

9. Hilger C, Kohnen M, Grigioni F,

4. Spitzauer S, Pandjaitan B, Muhl S,

6. Kulig,M et al. Long lasting

12. Amlot, PL; Kemeny, DM; Zachary,

4. Sampson HA. Food allergy. J Allergy

9. Scurlock AM, Burks AW. Peanut

16. Sunyer J, Anto JM, Rodrigo M-J,

8. de Groot H, de Jong NW, Vuijk MH,

2. Yman L. Botanical relations and

4. Black PN, Udy AA, Brodie SM.

10. Helbling A, Lopez M, Schwartz HJ,

14. DAmato G, Spieksma FT, Liccardi

w21 Wall pellitory

Phadia AB. P O Box 6460, SE-751 37 Uppsala, Sweden

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