ORIGINAL ARTICLE Indian J Allergy Asthma Immunol 2008; 22(1) : 7-13

Identification of Common Allergens by Skin Prick Test associated with United Airway Disease in Allahabad, Uttar Pradesh, India R.L. Agrawal1, A.Chandra1, Sachin Jain2, Gaurav Agrawal3, Snehlata1 of Tuberculosis and Chest diseases, 2Department of Ear, Nose and Throat, Motilal Nehru Medical College, University of Allahabad and 3Holistic Chest Clinic, Allahabad, Uttar Pradesh 1Department

Abstract Skin prick tests were performed on 50 respiratory allergy patients (allergic rhinitis, asthma or both) to identify common aeroallergens at Allahabad, Uttar Pradesh, India. The testing kit contained 87 allergen extracts including pollens, fungi, insects, danders, dusts and miscellaneous type triggers. Cynodon dactylon, Sorghum vulgare, Pennisetum typhoides from grass pollens, Gynandropsis gynandra, Brassica campestris, Rannunculus sceleratus from herbs/shrubs and Putranjiva roxburghii, Albizzia lebbeck and Ailanthus excelsa tree pollen allergens were the major sensitizer. Aspergillus fumigatus, Candida albicans and A.niger were the dominant allergens amongst the fungi. The insect allergen extracts showing markedly positive skin reactions were Cockroach (female) and Cockroach (male) in most cases. House dust and Paper dust among dusts, Kapok cotton among fabric and feathers and Dust Mite and Parthenium leaves among miscellaneous group were the dominant types eliciting marked positive skin reactions. The trend for marked positive skin reactions to allergen extracts of pollen, fungi, insects and dusts observed in this study was similar to a study performed at Lucknow in 2001 but differed for fabrics and feathers showing low incidence of markedly positive skin reaction. In conclusion, the knowledge obtained in the present study will help to treat the patients by allergen avoidance or immunotherapy. Key words: Bronchial asthma, Allergic rhinitis, Skin Prick test, Aeroallergens

rhinitis constitutes >50% of all allergies in India2 .A study carried out over 4 decades ago in India reported around 10% allergic rhinitis and 1% asthma3. A recent survey carried out in India shows that 20-30% of the population suffers from allergic rhinitis and that 15% develop asthma4 indicating the rising trend. In India 15-20% of the people suffer from various allergic manifestations such as urticarial skin rash, allergic rhinitis and bronchial asthma, thus impairing the quality of life and considerably affecting the public health

INTRODUCTION Epidemiological studies carried out in different countries report the prevalence of respiratory allergy from 12-20% of the population worldwide1.Allergic Address for correspondence: Dr. R.L. Agrawal, M.D.,D.C.H., Head of the Department, Department of Tuberculosis and Chest Diseases, Motilal Nehru Medical college, Allahabad University Allahabad, U.P., India. Tel: 05322256122 IJAAI, 2008, XXII (1) p 7-13. 11

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management system of the country5. In recent years more evidence have been provided of the frequent coexistence of allergic rhinitis and bronchial asthma. The frequent co-existence of rhinitis and asthma (up to 80% of asthmatic patients have co-existing allergic rhinitis, while up to 40% of allergic rhinitis patients have asthma, lead to the definition of United Airway Disease (UAD)6. Aeroallergens play a major role in the pathogenesis of respiratory allergic diseases, particularly asthma and rhinitis. The role of the aeroallergens varies with environmental conditions, such as climatic factors, pollution and degree of exposure. Previous studies has shown the relationship between asthma and family history of asthma and indicated that sensitivity to aeroallergen at younger age and severity of asthma particularly in atopic children suggests that genetic and environmental factor go hand in hand. Studies4,7 have shown the prevalence of allergic rhinitis and asthma more in the children dwelling in urban environment. Previous studies have identified airborne pollen, spores and other bioparticles responsible for allergies from different cities of Uttar Pradesh8-10. The present study was undertaken to identify the common allergens at Allahabad responsible for inducing united airway disease in subjects.

of the back and a no. 26G hypodermic needle was inserted about 0.5mm through the extract and then lifted slightly to allow adequate entry of antigen beneath the stratum corneum epidermis. The skin reactions were graded after 15 minutes according to criteria proposed by Agarwal et al, 2003. The tests were done considering all the prerequisites and 2+, 3+ and 4+ reactions were labeled as markedly positive skin reactions. RESULTS A total of 50 patients selected belonged to age group 12-40 years, of these 33 (66%) were females and 17(34%) were males. Out of 50 patients, 36 patients (72%) had family history of allergic rhinitis/ asthma. From the total, 30 patients (60%) resided in urban area while 20 patients (40%) were rural residents. All of the 50 patients exhibited marked positive skin reactions (2+ to 4+) to one or the other pollen extract. Thirty nine patients (78%) were positive with dust mite, 22 patients (44%) were positive with insects, 33 patients (66%) were positive with dusts, 21 patients (42%) were positive with fungi, 10 patients (20%) were positive with danders, 17 patients (34%) were positive with fabrics and feathers and 29 patients (58%) were positive with Parthenium leaves.

All the patients underwent PEFR and Spirometry. Skin prick tests were performed on 50 patients with 87 allergen extracts. The extracts included 46 pollens, 12 fungi, 4 insects, 10 types of dusts, 10 types of danders, 5 types of fabrics and feathers, dust mite and miscellaneous group. Allergen extracts for skin prick test were obtained from Alcit India (Pvt.) Limited, New Delhi.

Amongst pollens, Cynodon dactylon (56%) showed marked positive skin reactions in maximum patients followed by Gynandropis gynandra (54%), Brassica campestris (52%), Putranjiva roxburghii (52%), Albizzia lebbeck (50%), Sorghum vulgare (46%), Rumex dentatus (46%), Pennisetum typhoides (42%), Ricinus communis (40%), Artemisia scoparia (40%), Ailanthus excelsa (40%), Eucalyptus tereticornis (38%), Holoptelea integrifolia (38%), Broussonetia papyrifera (38%), Zea mays (38%), Argemone mexicana (36%), Cannabis sativa (36%), Chenopodium album (32%), Morus alba (32%), Lawsonia inermis (30%), Cyperus rotundus (30%), Xanthium strumarium (28%), Ageratum conyzoides (28%), Adhatoda vasica (28%), Dodonea viscosa (28%), Cenchrus ciliaris (26%), Amaranthus spinosus (26%), Prosopis julilora (26%), Parthenium hysterophorus (26%) and Ipomoea fistulosa (24%) (Table 1).

A drop of the allergen extract of 1:10 concentration was kept on the volar aspect of the forearm or skin

Amongst fungi, Aspergillus fumigatus (16%) elicited marked positive skin reactions in most patients

MATERIAL AND METHODS A total of 50 patients attending the out patient Department of T.B. and Chest Diseases and other Departments of S.R.N. Hospital, Allahabad with united airway disease having raised total sreum IgE level were included in the present study. The clinical diagnosis of allergic rhinitis and bronchial asthma was made according to ARIA guidelines11 and GINA guidelines12, respectively.

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Table 1. Results of Skin prick tests with pollen extracts on respiratory allergy patients S.No.

Allergen extract

A. 1. 2. 3. 4. 5. B. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. C. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Grasses Cynodon dactylon Sorghum vulgare Pennisetum typhoides Zea mays Cenchrus ciliaris Shrubs/Herbs Gynandropsis gynandra Brassica campestris Rannunculus sceleratus Rumex dentatus Ricinus communis Artemisia scoparia Argemone mexicana Cannabis sativa Chenopodium album Lawsonia inermis Cyperus rotundus Adhatoda vasica Ageratum conyzoides Xanthium strumarium Dodonea viscosa Amaranthus spinosus Parthenium hysterophorus Ipomoea fistulosa Maerua arenaria Suaeda fruticosa Chenopodium murale Typha angustata Asphodelus tenuifolius Cassia occidentalis Trees Putranjiva roxburghii Albizzia lebbeck Ailanthus excelsa Eucalyptus tereticornis Broussonetia papyrifera Holoptelea integrifolia Morus alba Prosopis juliflora Azadirachta indica Cocos nucifera Kigelia pinnata Carica papaya Melia azedarach Cassia fistula Crataeva nurvala Cassia siamea

Total patients Tested No.

Marked positive reactions (2+ to 4+) No

%

50 50 50 50 50

28 23 21 19 13

56 46 42 38 26

50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50

27 26 29 23 20 20 18 18 16 15 15 14 14 14 14 13 13 12 10 7 5 4 -

54 52 58 46 40 40 36 36 32 30 30 28 28 28 28 26 26 24 20 14 10 8 -

50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50

26 25 20 19 19 19 16 13 10 8 8 3 1 1 1 -

52 50 40 38 38 38 32 26 20 16 16 6 2 2 2 -

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INDIAN J ALLERGY ASTHMA IMMUNOL 2008; 22(1)

followed by Candida albicans (10%) and Aspergillus niger (10%) (Table 2). The prevalence of marked positive skin reactions, amongst insects, was maximum with Cockroach (female) (42%) followed by Cockroach (male) (38%), moth (16%), and rice weevil

(10%) (Table 3). Among dusts, House dust exhibited marked positive skin response in maximum cases (60%) followed by paper dust (58%), cotton dust (50%), and hay dust (42%) (Table 4). Cat dander (8%), and Dog dander (6%) (Table 5) were amongst

Table 2. Results of skin Prick Tests with fungal allergen extracts on respiratory allergy patients Fungi

Allergen extract

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Aspergillus fumigatus Candida albicans Aspergillus niger Phoma betae Aspergillus versicolor Aspergillus flavus Curvularia lunata Fusarium solani Mucor mucedo Rhizopus nigricans Aspergillus tamari Trichoderma sp.

Total patients tested No.

Marked positive reaction 2+ to 4+ No.

%

50 50 50 50 50 50 50 50 50 50 50 50

8 5 5 2 1 1 1 1 1 1 -

16 10 10 4 2 2 2 2 2 2 -

Table 3. Results of skin prick tests with insect allergen extracts on respiratory allergy patients Insects

Allergen extract

1. 2. 3. 4.

Cockroach(female) Cockroach(male) Moth Rice weevil

Total patients tested No.

Marked positive reaction 2+ to 4+ No.

%

50 50 50 50

21 19 8 5

42 38 16 10

Table 4. Results of Skin prick tests with in dust allergen extracts on respiratory allergy patients Dusts

Allergen extract

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

House dust Paper dust Cotton mill dust Hay dust Grain dust rice Straw dust Grain dust bajra Grain dust wheat Grain dust jowar Thrashing dust wheat

Total patients tested No.

Marked positive reaction 2+ to 4+ No.

%

50 50 50 50 50 50 50 50 50 50

30 29 25 21 7 6 4 1 -

60 58 50 42 14 12 8 2 -

IDENTIFICATION OF COMMON ALLERGENS BY SPT AT ALLAHABAD

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Table 5. Results of Skin prick tests with dander allergen extracts on respiratory allergy patients Dander

Allergen extract

Total patients tested No.

Marked positive reaction 2+ to 4+ No.

%

1. 2.

Cat dander

50

4

8

Dog dander

50

3

6

3.

Cow dander

50

1

2

4.

Human dander

50

1

2

5.

Horse dander

50

1

2

6.

Buffalo dander

50

-

-

Table 6. Results of Skin prick tests with fabrics and feathers and miscellaneous allergen extracts on respiratory allergy patients Fabrics andFeathers

Allergen extract

Total patients tested No.

Marked positive reaction 2+ to 4+ No.

%

1. 2.

Kapok cotton

50

9

18

Silk raw

50

3

6

3.

Sheep wool

50

1

2

4.

Wool mixed

50

-

-

5.

Pigeon feather

50

-

-

1.

Dust Mite (Dermatophagoides farinae)

50

39

78

2.

Parthenium leaves

50

29

58

Miscellaneous

the danders showing marked positive skin reaction in a few patients. Amongst fabric and feathers, it was Kapok cotton that showed marked positive reaction in 18% cases. Parthenium leaves extract and dust mite extracts demonstrated marked positive skin reactions in 58% and 78% cases, respectively (Table 6). Analysis of skin pricle test positivity with different allergen groups is presented in Fig 1. DISCUSSION Pollens and other aeroallergens are variable in different ecozones, and it is important to identify them for diagnosis and immunotherapy of allergy sufferers. Recently under All India coordinated Project on Aeroallergens and Human Health sponsored by the Ministry of Environment and Forests, Government of India (2000), 43 types of pollens were recorded from

Northern India9. The dominant types were Holoptelea, Poaceae, Eucalyptus, Casuarina, Putranjiva, Cassia, Quercus, Pinus and Cedrus. Holoptelea contributed 22.2% pollen to the air from March to May. Poaceae pollens were recorded 11.8% with maximum concentration in April to June, followed by Asteraceae, Prosopis juliflora, Ricinus communis, Morus, Mallotus, Alnus, Argemone, Amaranthus, Chenopodium and grasses. In the present study, most of the above mentioned pollens were skin tested to evaluate sensitization, except Causarina, Quercus, Pinus, Mallotus and Alnus, that were not available for the test. According to a study10 in Botany department, University of Allahabad, during September1990-August 1991, the dominant pollen types recorded were Poaceae (Cenchrus ciliaris, Cynodon dactylon,

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INDIAN J ALLERGY ASTHMA IMMUNOL 2008; 22(1)

Azadirachta and Chenopodium showed markedly positive skin reaction while Typha, Pennisetum and Dodonea did not show any markedly positive skin reaction. As compared to the above study, certain new pollen allergens namely Albizzia, Artemisia, Broussonetia, Cannabis, Ageratum, Adhatoda, Dodonea, Zea mays, and Ipomoea were identified in the present study.

Fig 1. Total positivity of allergens

Pennisetum typhoides and Sorghum vulgare) and Holoptelea integrifolia. The other important pollen types were Pinus roxburghii, Ricinus communis, Madhuca longifolia, Putranjiva roxburghii, Amaranthaceae-Chenopodiaceae, Caryota urens, Pongamia pinnata, Brassica sp., Azadirachta indica, Parthenium hysterophorus, Typha angustata and Polyalthia longifolia10. In the present study, Pinus roxburghii, Madhuca, Caryota, Pongamia and Polyalthia pinnata were not tested due to non availability of antigen extracts. Cynodon dactylon, Sorghum vulgare and Pennisetum typhoides from grass pollens, Gynandropsis gynandra, Brassica campestris and Rannunculus sceleratus from herbs/ shrubs, whereas Putranjiva roxburghii, Albizzia lebbecs and Ailanthus excelsa tree pollen were the major sensitizer. Asphodelus tenuifolius, Cassia occidentales and Cassia siamea however, did not show sensitization in any of the patients tested. In a similar study by Prasad et al14 at Lucknow (2001), Cynodon, Cyperus, Lawsonia, Eucalyptus, Holoptelea, Brassica, Melia, Prosopis, Amaranthus,

Fungi are considered to be one of the most common allergens worldwide in the present study, Aspergillus fumigatus was the top sensitizer (16%) followed by C. albicans and A. niger in most cases. Other fungi showed sensitized in the range of 4 to 2% only. The findings are consistent with the study of Prasad et al14 for A. fumigatus but in the present study Candida albicans was also markedly positive in 10% cases which was not there in the previous study. The results of skin tests with the allergen extracts of insects (cockroach-male) and dusts (paper dust) are comparable with Prasad et al14. The findings are also in accodance with the study by Podder et al5 at Kolkata and other studies14-16 across the country in relation to the skin positivity of fungi (A. fumigatus), danders (dog dander and cat dander), fabrics and feathers (kapok cotton), dust mite, house dust, Parthenium leaves, insects (cockroach) responsible for United Airway Diseases at Allahabad. In conclusion, it is suggested that such studies should be conducted from time to time to know the changing trend of prevalence of allergens and allergy in Allahabad and other cities of Uttar Pradesh that can help clinicians in management of patients. ACKNOWLEDGEMENT Authors acknowledge Professor Manju Sahni, Department of Botany, University of Allahabad, Allahabad, and Miss Swati Chaurasia, Research Fellow in Botany, for their invaluable support throughout the study. REFERENCES 1.

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13. Agarwal MK, Gupta S, Bansal SK, Vijayan VK. Cross reacting and Unique allergenic components in insect extracts used for the diagnosis and immunotherapy of patients suffering with respiratory allergy. In : Sarma PU, Singh BP, Rao DN et al eds. Trends in Clin Biochem and Lab. Med., Association of Clinical Biochemists, Delhi, India, 2003; 314-324. 14. Prasad R, Kumar R, Verma SK, Pandey US. A study of skin sensitivity to various allergens by intradermal test in patients of bronchial asthma. Indian J Allergy Asthma Immunol 2001; 15(1): 17-21. 15. Gupta S, Jain S, Chowdhary S, Agarwal MK. Role of insects as inhalant allergens in bronchial asthma with special reference to the clinical characteristics of patients. Clin Exp Allergy 1990; 20(5): 519-524. 16. Gupta S, Bidani RK, Jhamb S, Agarwal H. Role of animal danders as inhalant allergens in bronchial asthma in India. J. Asthma 1996; 33: 339-348.