ALEX²

Case Studies

With our case studies, we showcase how ALEX² can help to answer open questions about patients' sensitisation profiles.

Browse through various cases and find out how ALEX² helped to arrive at the correct diagnosis:

54 years from Austria
Thomas

Is Thomas a suitable candidate for allergen-specific immunotherapy regarding his grass and tree pollen allergies? Let's find out together!

Clinical history
  • Rhino-conjunctivitis & asthmatic exacerbations with and without physical exercise observed from the age of 5 years on
  • Skin Prick Testing in 1976: sensitisations against cat dander, various grass & tree pollen
  • Symptomatic treatment with inhalative corticosteroids & antihistamines; allergen specific immunotherapy (AIT) was initiated in 1977 against birch- & grass pollen
  • Respiratory symptoms improved significantly after completion of AIT, especially the asthmatic episodes
Family history
  • Both father and grandfather: allergic with rhino-conjunctivitis
Present situation (2018)
  • Experiences allergy-like symptoms in the car or in households with cats and dogs, and near horses
  • Recent skin prick testing revealed sensitisations to pollen from trees, grasses and weeds
  • Further sensitisations were found for cat-, dog- and horse dander, as well as house dust mites
  • As AIT against animal dander and various pollen is considered as a treatment option, an ALEX test was requested by Thomas’ allergist
Summary
  • Thomas’ skin test results were confirmed: responsible allergens detected on molecular level
  • Suitable candidate for AIT against various grass and tree pollen (genuine sensitisation). Positive SPT results for weed pollen caused by the sensitisation against Polcalcin (Phl p 7), a highly cross-reactive allergen
  • Further possible AIT for house dust mite (if encasings do not show the desired effect), Alternaria and against furry animals (first therapeutic step: avoidance), as in all sources the major allergen is positive
  • Sensitisation against Gly m 4 from soy could cause severe reactions, if soy is consumed in higher doses and soy product is not heavily processed (e.g., soy milk).
28 years from Hong Kong
Lu

Learn how Lu's dust mite allergy leads to clinically relevant cross-reactions to seafood!

Clinical history
  • Rhino-conjuctivitis observed during childhood
  • Asthmatic exacerbations without physical exercise also registered -In-vitro test for house dust was positive in 1998
Family history
  • Both parents are allergic to mites
Present situation (2019)
  • Lu suffered severe allergic symptoms (skin rash, swellings & itching) after the intake of a Thai dish containing seafood, peanuts and soy
  • Because of the complex nature of the consumed dish and the potentially dangerous reactions an ALEX test was requested by Lu’ allergist
Summary
  • Lu’s mite allergy (Tropomyosin sensitisation, Der p 10) leads to clinically relevant cross-reactions to seafood
  • Mite encasing, AIT against house dust mite and avoidance of seafood is advised
  • Aside from the Tropomyosin syndrome, Lu has a risk of severe reactions when consuming peanuts, as sensitisations to two storage proteins (Ara h 1+3) were detected – avoidance is advised
  • An emergency set could be prescribed, as both seafood and peanut can cause severe allergic reactions
Novel findings by ALEX²
  • Tropomyosin syndrome
  • Peanut allergy
22 years from Valencia
Nestor

What's responsible for Nestor's strong allergic reaction after eating grilled fish?

Clinical history
  • Since late childhood: Perennial rhino-conjunctivitis with accentuated severity from end of April to beginning of June
  • In-vitro tests and SPTs: positive for mites, olive and mugwort
  • AIT for olive and mites was initiated and significantly relieved the respiratory symptoms
Family history
  • Parents: no allergic disease
Present situation (2019)
  • After a recent intake of grilled fish, angioedema of lips and eyelids, as well as abdominal pain was observed
  • Oral allergy syndrome and nausea/vomiting was reported after the ingestion of peach and other stone fruits
Summary
  • Extensive sensitisations to potentially high-risk allergens like the nsLTPs (Ara h 9, Cor a 8, Mal d 3, Pru p 3) and Parvalbumins (Cyp c 1 & Gad m 1)
  • Only the nsLTPs from stone fruit and the parvalbumins were of clinical importance
  • Avoidance and the prescription of an emergency kit is advised
  • Past respiratory symptoms can be explained by sensitisations against allergens from the Ole e 1 family (Fra e 1, Ole e 1)
  • New AIT treatment could be beneficial
  • Encasings can be a possible intervention to lower the allergen load
19 years from South-Eastern Europe
Rodica

Learn how ALEX² helped to determine whether Rodica would profit from allergen-specific immunotherapy!

Clinical history
  • Atopic dermatitis observed in early childhood
  • Back then, skin prick tests showed positive results for hen’s egg and cow’s milk
  • The patient outgrew both allergies
  • Rhino-conjunctivitis observed as a young teenager
  • Blood- and skin tests revealed sensitisations to ragweed- and mugwort pollen.
Family history
  • Mother and one sibling allergic to pollen
Present situation (2018)
  • Now, certain fruits elicit mild to moderate symptoms when consumed fresh or processed
  • Symptoms include oral allergy syndrome, nausea and vomiting, as well as itchy hand palms & itchy soles of the feet
  • An ALEX test was requested to analyse the pollen allergies for a possible AIT prescription and for risk assessment of the presumed fruit allergies
Summary
  • SPT results were confirmed, and the responsible allergens were detected at the molecular level
  • She would be suitable for AIT against grass and various weed pollen (Timothy grass) – antibodies directed against this molecule can cross-react with related allergen
  • The profilin sensitisation originates from Phl p 12 s in various fruit species (e.g., melon, citrus, etc.)
  • Profilins are not resistant to digestion or heat treatment and usually cause only mild symptoms
  • nsLTPs are stable towards digestion and heat treatment and can cause mild to severe symptoms
  • Avoidance is advised
19 years from North-Western Europe
Eva

How does CCD-blocking change the interpretation of Eva's previous allergy test results?

Clinical history
  • Since late childhood: Allergic rhinitis caused by allergy to grass pollen and house dust mite
  • Eva’s mother has been advised to avoid peanuts and nuts during her pregnancy
  • Up to now Eva has avoided both peanuts and nuts, but traces of these foods were not avoided in the past
  • As a child she experienced atopic dermatitis and was treated with asthma medication in case of airway infections until the age of 12
Family history
  • Unknown
Present situation (2019)
  • Last year Eva visited a general practitioner (GP) because of stomachache and diarrhea after ingestion of an Asian dish
  • She asked the GP if allergy to peanuts could be the cause of her symptoms
  • Specific IgE tests (singleplex) were ordered by the GP
Summary
  • CCD epitopes have a major impact on IgE testing
  • Reduces false positive and falsely elevated results without clinical impact
  • Extracts and purified components (plant based, hymenoptera, mussles) contain CCD epitopes
  • Recombinantely produced allergens are CCD-free
  • Using a CCD inhibitor is recommended in molecular allergy tests
Novel findings by ALEX²
  • The CCD blocking of the ALEX² test dramatically reduces the number of falsely elevated results from 110 to 10.
14 years from Russia
Grigori

What caused Grigori's sudden allergic reactions during a football tournament?

Clinical history
  • 8 years: itchy, watery eyes, rhinitis
  • Blood and skin test: grass pollen and house dust mite allergy
  • Symptomatic treatment with antihistamines: significant improvement of symptoms
Family history
  • Mother suffered from severe grass pollen allergy for decades
  • Father is not allergic
Present situation (2021)
  • During a football tournament, he started coughing and sweating and felt his lips swelling and his throat constricting
  • Rushed to the emergency room: oxygen and adrenaline intravenously
What caused this vehement reaction?
  • Extensive medical history after the initial treatment reveals that an insect has stung him in the leg shortly before the match.
  • He has reacted strongly to insect bites several times before. Therefore, the suspicion is obvious: bee and/or wasp venom allergy.
  • Grigori also says that he ate a stuffed sandwich after school and then rushed to the football tournament.
  • A possible wheat allergy was considered unlikely, as the boy had never had problems with wheat-containing products before.
Interpretation
  • Major grass pollen allergens Lol p 1, Phl p 1 and wasp extract, Ves v 1, Ves v 5 were positive: allergen-specific immunotherapy (AIT) is indicated
  • Wheat food allergy: Sensitisation to Tri a 19, a major allergen in children with wheat allergy and a risk marker for severe allergic as well as wheat-dependent exercise-induced reactions
Summary
  • Results of ALEX² in conjunction with the medical history showed that Grigori suffers from wheat-depended exercise-induced anaphylaxis (wheat allergy triggered by physical exertion)
  • He was also diagnosed with a clinically relevant wasp venom sensitisation
  • Avoidance of wheat products to prevent anaphylactic shock is advised
  • Avoidance of rye and barley is also advised due to a possible cross-reactivity between gluten proteins (gliadins and glutenins)
  • He received an emergency kit containing an adrenaline autoinjector, a corticosteroid, and an antihistamine
Novel findings by ALEX²
  • Wheat-dependent exercise-induced anaphylaxis
  • Wasp venom allergy
22 years from India
Mala

What is a silent sensitisation, and how did it lead to Mala's intense reactions after eating an Indian curry dish?

Clinical history
  • None
Family history
  • No known allergies
Present situation (2021)
  • After eating a nut mixture, she experiences tingling and itching in her mouth
  • Doctor prescribes antihistamines, and symptoms improve, she avoids nuts as much as possible
  • A few weeks later: she eats an Indian curry dish, without nuts but with soy milk and tofu
  • While eating, she feels dizzy, nauseous, and has to vomit and suspects traces of nuts in the dish
  • Friends take her to hospital because she also has difficulty breathing and a skin rash appears
Interpretation
  • Peanut risk components (Ara h 1, Ara h 2, Ara h 3, Ara h 6) were positive -> peanut allergy
  • Surprisingly soy allergens Gly m 5, Gly m 6 and Gly m 8 were also positive
  • Gly m 5/6 are also risk markers that can cross-react with Ara h 1/3
Summary
  • Mala regularly consumed soy products like soy milk and tofu over a long period of time (vegan diet)
  • Remained as a silent sensitisation until a peanut allergy also affected the soy allergy -> co-sensitisation
  • Avoidance of nut and soy products is strongly advised to prevent anaphylactic shock
  • Emergency kit with an adrenaline autoinjector, a corticosteroid, and an antihistamine is prescribed
Novel findings by ALEX²
  • Peanut allergy
  • Soy allergy
16 years from China
Ayleen

The curious case of Ayleen, who suffered from Atopic dermatis as a baby and from severly blemished skin as a teenager.

Clinical history
  • Since age 1: Atopic dermatitis (successfully treated)
  • Dry, itchy patches of skin when immune system was weak due to viral disease
  • Since age 13: blemished skin with small itchy pustules on her body, unsuccessfully tried many different washing solutions & creams
  • Dermatologist diagnosed her with hormonal acne & prescribed her high doses of vitamin C, which works well against inflammation & is effective in the fight against blemished skin & acne
  • Her skin condition did not improve
Family history
  • Mother is allergic to cats
Present situation (2021)
  • Ayleen still suffers a lot because of her blemished skin
  • Therefore, she consults a dermatologist who orders an ALEX² allergy test
Summary
  • Patient suffers from Malassezia allergy
  • Malassezia sympodialis is a yeast fungus commonly found in patients with atopic dermatitis
  • Especially seborrhoeic skin areas (e.g., head, neck) are preferred habitats
  • Consistent skin care is the basis of AD therapy
  • In case of clinically manifest skin inflammation in AD episodes, anti-inflammatory treatment is necessary
  • AD patients may benefit from antifungal therapy
  • Due to the strong cross-reactivity of Mn-superoxide dismutases, sensitisation to Aspergillus fumigatus could also be detected – but as Ayleen has no respiratory symptoms, therapy does not have to be considered
Novel findings by ALEX²
  • Sensitised to Malassezia sympodialis & Aspergillus fumigatus
13 years from Finland
Henrik

What is the cat-pork-syndrome, and how does it affect Henrik's ability to tolerate meat?

Clinical history
  • Henrik suffers from recurrent allergic rhino-conjunctivitis (RCA) and is treated symptomatically
  • Sensitisation to cat was detected through a skin test
  • He reduced his contact with cats, which also improved his symptoms
Family history
  • No known allergies
Present situation (2021)
  • Henrik gets recurrent stomach pain and diarrhea after eating ham and salami
  • His doctor orders an ALEX² allergy test
Summary
  • Sensitisation to cat and dog has been identified
  • Henrik is also sensitised to serum albumins, which are responsible for cross-reactions with albumins in meat and milk
  • An example for this kind of cross-reaction is the cat-pork syndrome
  • Since serum albumins are thermolabile proteins, thoroughly cooked meat is usually well tolerated
  • Patient education on avoidance measures is advised
  • Heat treatment (frying, boiling, etc.) or other procedures such as freeze-drying can reduce the allergenicity of pork in serum albumin associated pork allergy
  • Henrik should continue to avoid contact with cats.
Novel findings by ALEX²
  • Sensitised to cat epithelia
  • Due to strong cross-reactivity of serum albumins, sensitisation to dog and pork could also be detected
  • Cat-Pork-Syndrome
35 years from Germany
Clemens

Clemens is a surgical assistant who comes in contact with latex all the time - but is this also where his allergy symptoms come from?

Clinical history
  • Clemens is a surgical assistant and comes into contact with latex a lot due to his job
  • Over the years, he developed severe dermatitis from contact with latex and rubber materials
  • Since then, he only used latex-free gloves and his skin problems improved
Family history
  • No known allergies
Present situation (2021)
  • Even short periods of contact with latex trigger symptoms: When blowing up balloons, his lips start to tingle, swell up & he notices a feeling of tightness & pain in his chest
  • FFP3 masks with a latex seal inside of the mask cause redness & swelling in the area of the face it touches
  • While transporting a plastic spare part in his car, his chest became tight, & he experienced severe breathing difficulties
  • His doctor then ordered a serological blood test using the ALEX²® allergy test
Summary
  • Comprehensive patient education on avoidance measures is recommended
  • Prescription of an emergency kit (including epinephrine auto-injector)
  • The use of substitute products (e.g., nitrile gloves) is strongly recommended
Novel findings by ALEX²
  • Latex allergy
35 years from Austria
Helene

The mysterious case of Helene, a 35-year-old woman with a seemingly inexplicable reaction to nuts.

Clinical history
  • Urticaria and shortness of breath after consuming foods containing nuts.
  • Particularly severe symptoms after eating baklava (can contain pistachio, walnut, almond, and hazelnut)
  • Referred to allergologist because of suspected nut allergy
Family history
  • Unknown
Present situation (2021)
  • ImmunoCAP showed value of 12 kUA/L for cashew, while ALEX² including CCD blocker gave negative results for Ana o 2 and Ana o 3 from cashew extract, but several profilins were positive
  • ALEX² without CCD blocker was performed with a positive signal for CCD (Hom s LF) and cashew extract (2.15 kUA/L)
  • When ImmunoCAP was repeated including CCD blocking, cashew extract was also negative
Follow-up history

  • When Helene‘s allergy ananmnesis was reassessed, she reported an episode of eating two baklavas and dancing for 30 minutes at a wedding.

  • Shortly after, her face, especially her lips and eyes exhibited pronounced swelling and she suffered from acute shortness of breath due to laryngeal swelling and had to vomit.

  • Helene reported a similar episode after having eaten a nut bar followed by physical exercise.

  • Prick-to-prick test showed weak positive results for walnut

  • Provocation test showed very mild symptoms 15 minutes after ingesting cashews

  • Suspicion: Exercise-induced anaphylaxis due to nut profilins

  • Further testing with “research-use-only” Jug r 7 (walnut profilin) on ALEX² revealed a positive result (36.80 kUA/l).

Interpretation
  • ALEX² gave positive results for several profilins including walnut profilin (Jug r 7)
  • Nut allergy was initially suspected, but positive results for nut storage proteins were only obtained when ALEX² was performed without CCD inhibition: with CCD inhibition, these results disappeared again
  • Patient showed a positive result for Hom s LF, a marker for IgE reactivity with CCD
  • IgE antibodies to Jug r 7 were detected in accordance with reported clinical reaction to walnut: Based on the occurrence of symptoms after consumption of walnut in combination with physical exercise, walnut-dependent exercise-induced allergy was diagnosed.