Allergo Journal International最新文献

The term “molds” is defined and relevant sources of molds are given. The conditions and growth of mold fungi are explained. The determination of mould spores and colony-forming units (CFU) in the air is briefly explained and it is made clear that the total spore count is relevant for assessing the sensitizing and allergenic effect of moulds. Outdoor air-associated moulds such as Alternaria alternata, Aspergillus fumigatus, Cladosporium herbarum and Penicillium chrysogenum (mx1 mould mixture) are of particular importance due to their high degree of sensitization. Their concentration in the air is determined by the vegetation and is therefore dependent on the season. In people who were tested for mx1, sensitization to Alternaria alternata (m6) was predominantly observed for the individual allergens. For many indoor-associated moulds, no (valid) commercially available test extracts for the detection of sensitization, so-called allergy tests, are available. Allergy test results of mold mixtures, such as mx1, cannot be used to determine an indoor mold allergy, nor can the results of mold measurements in the rooms used by the respective persons be used for a risk assessment in the event of an existing mold infestation in the interior. The classification of mold fungi is explained.

The AWMF S2k guideline “Medical clinical diagnostics for indoor mold exposure” was introduced in 2016. The guideline is based on a standardized procedure of the AWMF including a systematic literature search involving several medical disciplines. The expert group has updated this guideline in accordance with AWMF specifications. For this purpose, a new Medline search was carried out for the current version of the guideline up to June 2022 with additional search terms. The search results were evaluated and further narrowed down by means of abstract screening and, where applicable, evidence-based evaluation of the full texts. Medical guidelines on related topics were also taken into account. The updated guideline is available since October 2023. This is intended to close the existing knowledge gap for rational and efficient medical diagnostics for indoor mold contamination and provides 26 core statements and recommendations, which are presented in detail.

The AWMF (Association of the Scientific Medical Societies) mold guideline “Medical clinical diagnostics for indoor mold exposure”—Update 2023 [44] concludes that there is limited or presumed evidence of a link between indoor dampness/mold exposure and health problems. However, there is inadequate or insufficient evidence for an association between indoor dampness/mold exposure and the environmental medical syndromes sick building syndrome (SBS), multiple chemical sensitivity (MCS) and chronic fatigue syndrome (CFS). Newly coined terms, such as biotoxicosis and mold and vapor hypersensitivity syndrome (MDHS) or volatoxins, suggest a nosological specificity of a pathophysiological connection for which, however, there is no evidence to date. The background to this assessment is presented in this paper.

Molds are ubiquitous in our environment and are considered by the population to be the most important indoor pollutant problem [1]. The current 2023 update to the AWMF mold guideline [1] is intended to allay or channel fears and provide assistance for a sensible diagnosis and treatment decision.

The detection of an IgE-mediated allergy implies for allergists Allergen immunotherapy (AIT) as an established treatment option. However, compared to the well-validated AIT with pollen and house dust mites, the decision to use AIT with mold extracts must be weighed more heavily between the benefits and risks.

Spores of Alternaria alternata are found in high concentrations in the outdoor air. Due to the high allergenic potential and the small size of the spores, an Alternaria allergy often leads to bronchial asthma, especially in children. The effectiveness of AIT with Alternaria extracts has been tested in several studies; for other molds, especially those from the indoor environment, the efficacy and applicability is very limited.

In terms of differential diagnosis, it must be borne in mind that molds can not only cause common allergic reactions but can also be responsible for allergic bronchopulmonary mycoses/aspergillosis (ABPA), Aspergillus bronchitis, exogenous allergic alveolitis (EAA), invasive aspergillosis, mycoses and rhinosinusitis. Very high concentrations, which can occur particularly in workplaces, can also result in toxic effects (“organic dust toxic syndrome”); molds are also held responsible for mucous membrane irritation, odor effects and mood disorders [1].

Purpose

In 2015, an interdisciplinary project was started to fill the gap of knowledge on the toxicokinetics of aluminium (Al) after exposure from adjuvanted products for subcutaneous immunotherapy (SCIT).

Methods

Two complementary initiatives of the project are explained. The results of two studies are reviewed and put in connection with the overarching goal. An estimate is given which steps have been reached and which are still needed.

Results

Recent in vivo data provided evidence of systemically available Al from SCIT products in rats (Weisser et al. 2020 [1]). The data are highly valuable for further development of the physiology-based toxicokinetic (PBTK) model for Al exposure which has been established in parallel (Hethey et al. 2021 [2]).

Conclusion

The Hethey model is an important step towards prediction of Al exposure in man from various sources. For use in risk assessment of Al exposure from SCIT products further extension of the model is warranted.

The prevalence of sensitization to molds is low in healthy people, but significant in asthmatics. As it has not yet been possible to establish a cause-and-effect relationship between the presence of mold allergens and the occurrence of allergic symptoms, there is a great deal of uncertainty. The update of the S2k guideline “Medical–clinical diagnostics for indoor mold exposure” should help to objectify the topic. Based on the recommendations listed there for the diagnosis of suspected IgE-mediated mold allergy, this article presents the possibilities of skin tests, IgE determinations, and other in vitro test options, but also their limitations in clarifying the cause. Potential possibilities include component-resolved allergy diagnostics, while the limitations include the difficult standardization of test allergen extracts due to the complex allergen source and the insufficient commercial availability of the test extracts. A diagnostic algorithm is presented as a tool for a systematic approach to patients with suspected mold-associated respiratory allergy.

Aspergillus-associated diseases are rare and pose challenges for practitioners. Diagnosis is complex and requires rational, targeted, and multidisciplinary collaboration, as well as a high degree of expertise and an individualized approach. For the infectious diseases physician, the focus is on the question of infection or colonization. In severely immunocompromised patients, invasive aspergillosis occurs, which most frequently affects the lungs (IPA) and is characterized by invasive, destructive growth. This acute clinical picture is associated with a high mortality rate. Chronic pulmonary aspergillosis (CPA) develops on the basis of pre-existing changes in lung structure caused by other pulmonary diseases and often requires surgical treatment. Another chronic form is allergic bronchopulmonary aspergillosis (ABPA). It is often associated with bronchiectasis in patients with bronchial asthma or cystic fibrosis. Sinus mycoses are divided into non-invasive and invasive forms, which can occur in immunocompromised patients and most commonly affect the maxillary sinus. Here, local surgical measures are an obligatory part of treatment, whereas the non-invasive form usually has an allergic component. In addition, drug-based antifungal and/or anti-inflammatory therapy is used for all entities.