Le diagnostic de l allergie aux dermatophages: Un défi mondial. Dr.Alain Jacquet Chulalongkorn University Thailand

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1 Le diagnostic de l allergie aux dermatophages: Un défi mondial Dr.Alain Jacquet Chulalongkorn University Thailand

2 Prevalence of asthma symptoms among year olds (ISAAC). Thorax 2009;64:

3 Geographical distribution of Der p, Der f and Blo t mites D. pteronyssinus D. farinae B. tropicalis Almost absent in the artic or high altitude regions, or in highly cold and dry climates area APJAI 2010;28:211-24

4 Sensitizations to HDM allergens: In-vitro and In-vivo specific IgE assays SPT ImmunoCap (Thermo) Immulite (Siemens) Hytec-288 (Hytec Biomedical) Using heterogeneous HDM allergen extracts Mite bodies But also eggs J Proteomics. 2017;162:11-19 Ann Allergy Asthma Immunol. 2017;118: Mite feces

5 Commercial HDM allergen extracts: heterogeneities [total prot] (µg/ml) (µg/ml) Many HDM allergens not or poorly detectable as intact proteins: Der p 5, Der p 7, Der p 21, Der p 23 at least Allergy. 2010;65: JI 2013;190: IAAI 2015;168: Allergy. 2016;71:220-9

6 Mean wheal area (mm 2 ) Values 7 mm 2 were regarded as positive Up to now: no universal standardized HDM allergen extracts available for diagnosis but also AIT Allergy. 2010;65:

7 From HDM extracts to molecular allergy diagnosis 1988 Important dates: HDM allergen identification 2006 J Exp Med. 1988;167: IAAI 2006;140: JACI 2015;135: Genome Announc 2017;5: e PLoS One 2017;12:e JACI 2018; 141: Genome Transcriptome Proteome 2015, 2017, 2018

8 ImmunoCAP Immuno Solid-phase Allergen Chip (ISAC) VBC-Genomics 2003 (Der p 1, 2, 5, 7, 8, 10, Tyr p 2, Lep d 2, Lep d 13) Phadia, Thermo Fisher Scientific 2009 rblo t 5 nder f 1 rder f 2 nder p 1 rder p 2 rder p 10 rlep d 2 ISAC commercially available (112 allergens) Experimental MeDALL allergen-chip 2014 ISAC112 + rder p 4 rder p 5 rder p 7 rder p 11 rder p 14 rder p 15 rder p 18 rder p 21 rder p 23 Clone 6 But also Single ImmunoCap: nder p 1/rDer p 2/rDer p 10/rDer p 23 FASEB J. 2002, 16, Methods. 2014;66:106-19

9 Extract-based assays underestimate HDM-specific IgE detection N=53 HDM-specific IgE levels with CAP allergen> with CAP extracts v Some clinically relevant HDM allergens underrepresented in natural allergen extracts v Competition with large amount of non allergenic proteins in HDM extracts for coupling At least, underrepresentation of Der p 5 in HDM allergen extracts Inappropriate amount of coupled important mite allergens for the detection of high specific IgE levels JACI 2018 pii: S (18)

10 Step 1: crude extracts VS Der p 1/Der p 2 nder p 1 and rder p 2, major HDM allergens and most abundant Patients (children or adults) with AA, AR, AD and with Dp IgE 1 ku/l Dp IgE very good predictors of the levels of Der p 1 and Der p 2 serum IgE levels. CEA. 2012;42:

11 sige to nder p 1 and rder p 2 as a diagnostic tool for genuine HDM allergy: highly predictive of IAR after BP Clinical relevance of sensitization to Der p 1 and Der p 2 Allergol Int. 2015;64:90-5

12 Diagnostic value of Der p 1 and Der p 2 specific IgE v No association between the prevalence of IgE reactivity to Der p 1 and Der p 2 and the occurrence of AA or AR v Association between Der p 1 or Der p 2 IgE levels and the occurrence of AA v Strong correlation between sige to crude extracts and to Der p 1 and Der p 2. JACI 2015;136: JIACI 2016;26:

13 But HDM allergic patients NOT sensitized to Der p 1/Der p 2 Symptoms N Population Der p 1+ and/ or Der p 2 + Der p 1- and Der p 2- AD, AA or AR 123 Children/Adults 94% 6% France 2012 AA 55 Adults 89% 11% Japan 2015 AA or AR 384 Adults 90% 10% Spain 2016 AD, C,AA or AR 100 Children/Adults 98% 2% China 2015 AA or AR 158 Children 89% 11% Germany/ Austria 2015 AR 97 Children/Adults 84% 16% Germany 2016 ARC 919 Children/Adults 89% 11% Europe 2015 AR,AA 47? 96% 4% USA 2016 AR,AA 200 Children/Adults 92% 8% China 2015 Ref. CEA 2012;42: JIACI 2016;26: Allergol Int 2015;64:90-5. IAAI 2016;170:132-7 IAAI 2015;167: Allergy 2016;71:220-9 JACI 2015;136: CEA 2016;46: JIACI 2015;25:343-51

14 Step 2: Tropomyosin Der p 10 Not useful to detect genuine HDM sensitizations but crossreactivity (allergy to seafood, snails or edible insects!!) Minor HDM allergen No correlation between sige Dpt and sige rder p 10 levels CEA. 2012;42: JACIP 2015;3:863-9

15 HDM allergy but without sensitizations to Der p 1, Der p 2, Der p 10 Standardization for AIT based on Der p 1/Der p 2. rder p 10 - What about AIT for patients not sensitized to Der p 1 or Der p 2? IAAI 2016;170:132-7

16 Step 3: Der p 23, the third major HDM allergen N Prevalence (%) nder p 1 rder p 2 rder p 23 Europe USA Germany Thailand Europe Canada Japan Levels of sige to Der p 23 ~5 to 10 fold lower than to Der p 1 or Der p 2 Der p 1 Der p 2 Der p 5 Der p 7 Der p 8 Der p 23 % total sige JI 2013;190: IAAI 2015;168: JACI 2015;136: CEA 2016;46: Allergy 2016;71:220-9.

17 Discovery of Der p 23 monosensitization v Study 1: N=97 (adults) 11 negative for Der p 1, Der p 2, Der p 4, Der p 5, Der p 7, Der p 10, Der p 11, Der p14, Der p 15, Der p 18, Der p 21, and clone 16 5 positive ONLY for Der p 23 Symptoms of Der p 23-positive patients did not differ from symptoms of patients who tested negative for this component v Study 2: N= 119 (age 20) 10 negative for Der p 1, Der p 2, Der p 4, Der p 5, Der p 7, Der p 10, Der p 11, Der p14, Der p 15, Der p 18, Der p 21, and clone 16 7 positive only for Der p 23 IAAI 2016;170: JACI 2017;139:

18 Does Abundance Correlate with IgE Response? FPKM (Fragments Per Kilobase Million) Der p 23 expression level 30-fold less than Der p 1 and 7-fold less than Der p 2. IgE responses to Der p 23 (and Der p 5) disproportionately high compared to the expression level. v mrna abundance not necessarily correlated with human exposure v other factors likely contribute to the high sensitization levels Innate immune activation? CEA 2016;46:365-76

19 Importance of allergen stability: the Der p 3 case Der p 3 = trypsin-like serine protease N-glyco Ser196 Der p 1 cleavage site rproder p 3 (inactive) rder p 3 (active) JBC 2008;283:

20 Der p 3 stability (2) Autolysis of rder p 3 at 37 C Inactivation by point mutation: rder p 3-S196A rder p 3 rder p 3-S196A Clin Exp Allergy Apr;45(4):823-34

21 IgE reactivities nder p 3: 10%, rder p 3: 25%, rder p 3S196A: 50%

22 HDM allergome from the WHO/IUIS database (2018) Der p Der f Blo t Biochemical function Der p Der f Blo t Biochemical function Cysteine protease 19 Anti-microbial peptide Lipid-binding protein Arginine kinase Trypsin Lipid-binding protein a-amylase 22 Unknown Lipid-binding protein 23 Chitin-binding protein? Chymotrypsin UQCRB-like protein Lipid-binding protein 25 TPI GST 26 Myosin 9 Collagenase 27 Serpin Tropomyosin 28 HSP Paramyosin 29 Cyclophilin 12 Chitin-binding protein 30 Ferritin Lipid-binding protein 31 Cofilin Apolipophorin 32 PPiase Chitinase 33 a-tubulin 16 Gelsolin-like protein 34 Deaminase 17 Ca 2+ -binding protein 35 MD-2 like Chitinase Profilin-like

23 New HDM allergens: Groups from D. farinae! Name Allergenicity Test using Country Year Der f % ELISA, N=22 recombinant China 2015 Der f 25 76% Blot, N= 41 Natural, semi-pure China 2013 Der f % ELISA, N=5? China 2014 (IUIS) Der f 27 42% SPT, N=19 Recombinant China 2015 Der f 28 68% Blot, N= 41 11% SPT, N= 26 Der f 29 89% Blot, N=41 21% SPT, N=14 Natural semi-pure Recombinant Natural semi-pure Recombinant China China China China Der f 30 63% Blot, N=41 Natural semi-pure China 2013 Der f 31 31% SPT, N= 42 Recombinant China 2014 (IUIS) Der f 32 15% SPT, N=52 Recombinant China 2014 (IUIS) Der f 33 23% SPT, N=17 Recombinant China 2016 Der f 34 68%, ELISA N=19 Natural pure Japan 2016 Der f 35 77%, Blot N=40 51% ELISA, N=35 Der f/p 36 42% Blot, N=19 60% Blot, N=10 2D gel, natural Recombinant Recombinant 2D gel, natural Japan 2017 France 2017 (IUIS) Mol Cell Prot 2013;12:1818 JACI 2015;135:539 J Thorac Dis 2015;7:1842 Am J Transl Res 2015;7:1260 Am J Transl Res 2015;7:1303 Immunobiology 2016:911-7 JBC 2016;291:21607 Allergy 2017;72: PLoS One. 2017;12:e

24 New HDM allergens from D. pteronyssinus (2018)! Gene sequence: Der p 16, Der p 22, Der p But no RNA sequence for Der p 34 and Der p 35 Name Allergenicity Test using Country Der p 25 54% ELISA, N=26 Recombinant Hong-Kong Der p 26 62% ELISA, N= 26 Recombinant Hong-Kong Der p 28 39% ELISA, N=26 Recombinant Hong-Kong Der p 32 46% ELISA, N=26 Recombinant Hong-Kong Der p 33 65% ELISA, N= 26 Recombinant Hong-Kong JACI 2018; 141:

25 Need more extensive studies for the relevance of these new D. pteronyssinus/farinae sensitizations v No comparison with well-known major HDM allergens v Only reports mainly from single regions (HK for pteronyssinus, China for farinae, geographically-specific?) v Small number of sera (single hospitals) v All recombinants produced in E.coli v No QC control (folded?), exception: Der f 34 with enzymatic assay. v No allergenicity testing (BAT, RBL) v Prevalence only but not specific IgE levels v No information about allergen localization

26 Europe-adults (n = 466) Europe-children (n = 423) Canada (n = 350) USA (n = 35) Japan (n = 28) IgE levels to Der p 1 Der p 2 Der p 4 = 95% Der p 5 Der p 7 Der p 21 Der p 23 Allergy 2016;71:220-9

27 Sensitizations to B.tropicalis Singapore 2011: 253 children with AA, AR or AD (mean age 7.3 yr) Sensitizations to D.pt 89%, to B.t 70% (SPT) Pediatr Allergy Immunol Mar;22(2):202-10

28 Sensitizations to B.tropicalis Brazil 2013 Children: N=35, Age (4 to 11), ImmunoCap positive for Dpt or B.t or Cockroach Adult : N= 28, moderate to severe AA BMC Immunol. 2013; 14: 11.

29 Sensitizations to B.tropicalis Singapore Children: N = 60, 30 AA (12 ± 3 yr), 30 Eczema (10 ± 4 yr) SPT to D.pt AND B.t Prevalence (%) Asthma Eczema Der p Der p Der p Blo t Blo t Prevalence (%) Asthma Eczema Blo t Blo t Blo t Dpt Extract Bt Extract Pediatr Allergy Immunol Jun;21(4 Pt 2):e718-22

30 Sensitization to Der p 11: marker of AD? Different routes of sensitization dependent of the HDM allergen localization? AD triggered by skin contact with mite body-associated allergens? AR/AA triggered by inhalations of FP (size exclusion of MB in the airways)? J Invest Dermatol 2015;135:

31 Sensitization profiles in HDM AR/AA and AD subjects Greater sensitizations to MINOR HDM allergens in HDM AD population CEA 2018;48:

32 Sensitizations profile in HDM allergic children with or without allergic asthma Non Asthma Asthma *P <.05 and **P <.01 Mean age (y) Non asthmatics: 9.74 Asthmatics: 10.5 Molecular spreading JACI 2015;136:

33 sige levels to Der p 1, Der p 2, Der p 5 and Der p 23 higher in HDM allergic children with asthma *P <.05 and **P <.01 JACI 2015;136:

34 Natural evolution of the IgE response to Der p allergens during the first 2 decades of life and relationship with disease progression Group A, B from mite feces; Group C from mite bodies JACI 2017;139:

35 Initiator allergens Group A Group B Group C Der p 2 Der p 1 Der p 23 Der p 5 Der p 4 Der p 7 Der p 21 Der p 11 Der p 14 Der p 15 Der p 18 Clone 16 A+AB+ABC= 97% of the sera! Very rare to detect: -) sensitizations to group B without the ones to group A -)sensitizations to group C without the ones to groups A AND B Participants from ABC group (A B C) developed more AR and AA than patients from AB or A

36 Very heterogenous sensitization profiles at age 20 years For N=119, 48 different profiles! Sensitizations Total N=119 Mono Der p 1 4 Mono Der p 2 15 Mono Der p 23 7 Bi- Der p 1/Der p 2 10 Bi- Der p 1/Der p 23 3 Bi- Der p 2/Der p 23 4 Tri- Der p 1/Der p 2/Der p 23 7 At least Der p 1 and/or Der p At least Der p 1 and/or Der p 2 and/or Der p Der p 1, 2, 4, 5, 7, 11, 14, 15, 18, 23 and clone 6 1 ZERO sensitizations to 12 HDM allergens 10 Broader IgE sensitization patterns associated with early IgE sensitization onset, parental hay fever, and higher exposure to HDM N

37 Take home messages v No unique HDM allergen to be used for the molecular diagnosis of genuine sensitizations v Molecular diagnosis of HDM allergy critical for more efficient personalized treatment (AIT not only based on Der p 1/ Der p 2): Precision Medicine (Right treatment for the Right patient) v Early monitoring of IgE sensitizations to HDM allergens could pave the way for simplified immunoprophylactic treatments (mainly Der p 1, Der p 2, Der p 23-based): Windows of opportunities for primary prevention

38 Acknowledgments Pattraporn Satitsuksanoa Wai Tuck Soh Tewarit Soongrung Karntichar Mongkorntanyatip Termsri Peepim Mite Allergy Research Cohort (MARC) study team Andy Chevigne Marie-Eve Dumez Moreno Galleni Surapon Piboonpocanun Emmanuel Nony Maxime Le Mignon