Thunderstorm-related respiratory symptoms: An old story with a new ending?Francis ThienProfessor/Director of Respiratory MedicineEastern Health & Monash University,Box Hill, Victoria 3128, AUSTRALIAIsabella Annesi-MaesanoProfessor of Environmental Epidemiology, INSERM Research Director,Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, FranceGennaro D’Amato,Director, Division of Respiratory and Allergic Diseases, High Speciality Hospital ‘A. Cardarelli’,Professor of Respiratory Allergy School of Specialization in Respiratory Diseases,Federico II University of Naples, Rione Sirignano 10,80121 Naples, Italy

Letter to the Editor

Background: Diagnostic tests for allergy rely on detecting allergen-specific IgE. Component-resolved diagnostics incorporate multiple defined allergen components to improve the quality of diagnosis and patient care. Objective: To develop a new approach for determining sensitization to specific allergen components that utilizes fluorescent protein tetramers for direct staining of IgE on blood basophils by flow cytometry. Methods: Recombinant forms of Lol_p_1 and Lol_p_5 proteins from ryegrass pollen (RGP) and Api_m_1 from honeybee venom (BV) were produced, biotinylated and tetramerized with streptavidin-fluorophore conjugates. Blood samples from 50 RGP-allergic, 41 BV-allergic and 26 controls were incubated with fluorescent protein tetramers for flow cytometric evaluation of basophil allergen binding and activation. Results: Allergen tetramers bound to and activated basophils from relevant allergic patients but not controls. Direct fluorescence staining of Api_m_1 and Lol_p_1 tetramers had greater positive predictive values than basophil activation for BV and RGP allergy, respectively, as defined with receiver operator characteristics (ROC) curves. Staining intensities of allergen tetramers correlated with allergen-specific IgE levels in serum. Inclusion of multiple allergens coupled with distinct fluorochromes in a single tube assay enabled rapid detection of sensitization to both Lol_p_1 and Lol_p_5 in RGP-allergic patients and discriminated between controls, BV-allergic and RGP-allergic patients. Conclusion: Our novel flow cytometric assay, termed CytoBas, enables rapid and reliable detection of clinically relevant allergic sensitization. The intensity of fluorescent allergen tetramer staining of basophils has a high positive predictive value for disease and the assay can be multiplexed for a component-resolved and differential diagnostic test for allergy.