Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

S40 Cox et al
J ALLERGY CLIN IMMUNOL
SEPTEMBER 2007
TABLE III. The major clinically relevant aeroallergens of
North America*
Tree pollen
Chinese elm (Ulmus parvifolia) à; Siberian elm (Ulmus
pumila) à; American elm (Ulmus Americana) à
Red oak (Quercus rubra) ; White oak (Quercus alba)
Paper birch (Betula papyrifera)
Alder (Alnus rubra)
Box elder (Acer negundo) ; Red maple (Acer rubra)
Eastern cottonwood (Populus deltoides)
Sycamore (Platanus occidentalis)
White ash (Fraxinus americana) ; Olive (Olea europaea) à
Black walnut (Juglans nigra)
Mulberry (Morus rubra)
Mountain cedar (Juniperus ashei)
Pecan (Carya illinoensis)
Grass pollen
Rye (Lolium perenne)§k
Timothy (Phleum pratense)§k
Meadow fescue (Festuca elatior)§k
Bermuda (Cynodon dactylon)k
Johnson (Holcus halepensis)
Bahia (Paspalum notatum)
Weed pollen
Short ragweed (Ambrosia artemisiifolia)k
English (narrow leaf) plantain (Plantago lanceolata)
Mugwort (Artemisia vulgaris)
Russian thistle (Salsola kali)
Burning bush (Kochia scoparia)
Sheet (red) sorrel (Rumex asetosella)
Red root pigweed (Amaranthus retroflexus)
Indoor aeroallergens
Cat epithelium (Felis domesticus)k
Dog epithelium (Canis familiaris)
Arthropods (domestic mites: Dermatophagoides farinae,
Dermatophagoides pteronyssinus)k
Insects (German cockroach: Blattella germanica)
Fungi
Alternaria alternata{
Cladosporium (C cladosporioides, C herbarum){
Penicillium (P chrysogenum, P expansum){
Aspergillus fumigatus{
Epicoccum nigrum, Drechslera or Bipolaris type
(eg, Helminthosporium solani){
*Compiled and selected in collaboration with the AAAAI Immunotherapy
Committee Allergen Subcommittee for the identification of 35 key
allergens of North America.
Extensive cross-reaction of species within the genus.
àApart from regional prevalence, they are limited to local sites with
substantial stands of these trees.
§Extensively cross-react with one another and bluegrass, orchard, red top,
and sweet vernal.
kAllergens for which standardized extracts are commercially available.
{Species that are widely distributed and clinically important.
and Bahia has become an important allergenic grass in the
lower southern states. Because it is uncertain whether
palms, sedges, and cattails have the ability to trigger allergy
symptoms, immunotherapy with these allergens is
generally not recommended.
Although cross-reactivity among tree pollens is not as
pronounced as that among grass or ragweed pollens, it
does occur. Pollen from members of the cypress family
(Cupressaceous; eg, juniper, cedar, and cypress) strongly
cross-react. 79-82 Therefore pollen from one member of this
family should be adequate for skin testing and immunotherapy.
The closely related birch family (Betulaceae;
eg, birch, alder, hazel, hornbeam, and hop hornbeam)
and oak (Fagaceae; eg, beech, oak, and chestnut) have
strong cross-allergenicity. 83-85 Significant cross-reactivity
between Betulaceae pollens and oak of the Fagaceae
family has been demonstrated with percutaneous skin
testing. 75 RAST inhibition studies have shown cross-inhibition
between oaks and other Fagales species. 86 IgE
immunoblot inhibition experiments have demonstrated
that the Fagales species might be strongly inhibited by
birch species. 87 The use of one of the locally prevalent
members (eg, birch and alder) should be adequate. 88
Ash and European olive trees are strongly cross-reactive;
the extract that is the most prevalent in the region and best
correlates with symptoms could be used. 89,90 Maple and
box elder trees are found throughout the United States,
except for the arid southwest. Although in the same genus
as maple, Acer, box elders appear different and should
be considered separately. Oaks and elms (eg, Chinese,
Siberian, some American) are prevalent in eastern and
central states but have a more limited distribution west of
the continental divide. The distribution of other trees is
variable enough to require botanical observation in a given
locale.
There is strong cross-reactivity between major allergens
of common ragweed species (eg, short, giant, false,
and western). However, southern and slender ragweed do
not cross-react as well, 91,92 and there are allergenic differences
between major and minor allergens of short and
giant ragweed that might be clinically significant. 93
Weeds other than ragweed, such as marsh elders, sages,
and mugwort, have an abundant distribution, predominantly
in the western states. These weeds and sages
(Artemisia species) must be treated separately from the
ragweeds. Sages are strongly cross-reactive, and a single
member can provide adequate coverage of the group. 94
Similarly, Chenopod-Amaranth families have wide ranges
in the western regions but are present throughout North
America. 95 Current information on cross-reactivity of
these families is limited. 96-98 Skin testing suggests strong
cross-reactivity across Chenopod and Amaranth family
boundaries. The Amaranth family also seems to have
strong cross-reactivity by means of RAST inhibition and
immunodiffusion. 99 The use of a single Amaranth extract
should be sufficient to cover this family. 100,101 Similarly,
Atriplex species (eg, saltbushes and scales) show near
identity, and use of a single member is adequate. Among
other subfamily Chenopod members, Russian thistle
appears to have the most cross-allergenicity.
The most prevalent house dust mites, D pteronyssinus
and D farinae, are ubiquitous except in arid or semiarid
climates and regions of higher altitudes. D pteronyssinus
and D farinae are members of the same family and genus.
They have allergens with extensive cross-reacting epitopes,
as well as unique allergenic epitopes. Generally,