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\begin{document}

\title{Molecular allergology and its impact in specific allergy diagnosis and
therapy}



\author[1]{Domingo Barber Hernández}%
\author[2]{Araceli Diaz Perales}%
\author[3]{Maria Escribese}%
\author[4]{Jörg Kleine-Tebbe}%
\author[5]{Paolo Matricardi}%
\author[6]{Markus Ollert}%
\author[7]{Alexandra Santos}%
\author[8]{Joaquin Sastre}%
\affil[1]{Universidad San Pablo CEU}%
\affil[2]{Centro de Biotecnologia y Genomica de Plantas}%
\affil[3]{Universidad CEU San Pablo}%
\affil[4]{Berlin, Germany}%
\affil[5]{Charitè University Medical Center}%
\affil[6]{Luxembourg Institute of Health}%
\affil[7]{King's College London}%
\affil[8]{Fundacion Jimenez Diaz}%


\vspace{-1em}



  
  \date{March 13, 2025}


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\selectlanguage{english}
\begin{abstract}
Progressive knowledge of allergenic structures resulted in a broad
availability of allergenic molecules for diagnosis. Component resolved
diagnosis allowed a better understanding of patient sensitization
patterns, facilitating allergen immunotherapy decisions. In parallel to
the discovery of allergenic molecules, there was a progressive
development of a regulation framework that affected both in vitro
diagnostics and Allergen Immunotherapy products. With a progressive
understanding of underlying mechanisms associated to Allergen
immunotherapy and an increasing experience of application of molecular
diagnosis in daily life, we focus in analyzing the evidences of the
value provided by molecular allergology in daily clinical practice, with
a focus on Allergen Immunotherapy decissions.%
\end{abstract}%



\sloppy


\textbf{Molecular allergology and its impact in specific allergy
diagnosis and therapy}

D. Barber\textsuperscript{1,2} (Orcid ID:0000-0002-5488-5700), A
Diaz-Perales\textsuperscript{2,3} (Orcid ID: 0000-0002-1093-3627), MM.
Escribese\textsuperscript{1,2} (Orcid ID: 0000-0001-5057-5150), J
Kleine-Tebbe\textsuperscript{4} (Orcid ID: 000-0002-2862-7353) P
Matricardi\textsuperscript{5} (Orcid ID : 0000-0002-2145-3776), M
Ollert\textsuperscript{6,7} (Orcid ID:
0000-0002-8055-0103),\textsuperscript{,} AF.
Santos\textsuperscript{8,9,10,11} (Orcid ID 0000-0002-7805-1436), J
Sastre\textsuperscript{12} (Orcid ID: 0000-0003-4689-6837)

1 IMMA, Departamento de Ciencias M\selectlanguage{ngerman}édicas Básicas, Facultad de Medicina,
Universidad San Pablo CEU, CEU Universities, Madrid, Spain.

2 ARADyAL-RD16/0006/0015 RD16/0006/0003, Thematic Network and
Cooperative Research Centers, ISCIII, Madrid, Spain

3 Center for Plant Biotechnology and Genomic. Universidad Politécnica de
Madrid. Pozuelo de Alarcon, Spain

4 Allergy and Asthma Center Westend, Berlin.

5 Department of Pediatric Pneumology and Immunology, Charitè Medical
University of Berlin, Berlin, Germany.

6 Department of Infection and Immunity, Luxembourg Institute of Health,
Esch-sur-Alzette, Luxembourg

7. Department of Dermatology and Allergy Centre, Odense University
Hospital, Odense, Denmark

8.Department of Women and Children's Health (Pediatric Allergy), School
of Life Course Sciences, Faculty of Life Sciences and Medicine, King's
College London, London, United Kingdom

9.Peter Gorer Department of Immunobiology, School of Immunology and
Microbial Sciences, King's College London, London, United Kingdom

10.Asthma UK Centre in Allergic Mechanisms of Asthma, London, United
Kingdom

11.Children's Allergy Service, Guy's and St Thomas' Hospital, London,
United Kingdom

12. Fundación Jiménez Diaz, Allergy Department, Universidad Autonoma de
Madrid, CIBERES, Instituto de Salud Carlos III, Spain

\textbf{Corresponding author:}

Domingo Barber, PhD

IMMA, Instituto de Medicina Molecular Aplicada, Facultad de Medicina,
Universidad San Pablo CEU.

Avda. Monteprincipe s/n, 28668 Boadilla del Monte, Madrid, España.

Tlf: 91 372 47 00 ext. 4662

E-mail: domingo.barberhernandez@ceu.es

All the Authors contributed to the writing of the manuscript. D.B
coordinated the work

\textbf{Sources of funding for the research reported in the article:}

This work was supported by Instituto de Salud Carlos III (Project
numbers PI19/00044 and PI18/01467) This work was also supported by the
grant from Ministerio de Ciencia, Innovación y Universidades
RTI2018-095166-B-I00.

\textbf{Short title:} Influence of Component resolved diagnosis in
Allergen Immunotherapy

\textbf{Word count} : 5093

\textbf{Key words:} Component-resolved diagnosis, CRD, AIT, Allergen
immunotherapy, Major allergen, Pan-allergen, respiratory allergy, food
allergy

\textbf{Abbreviations:}

EMA: European Medicine Agency

EDQM: European Directorate for the Quality of Medicines

AIT: Allergen Immunotherapy

CRD: Component-resolved diagnosis

LTP: Lipid transfer protein

HBV: Honeybee venom

YJV: Yellow Jacket venom

PDV: Polistes Dominula venom

POIT: Peanut Oral Immunotherapy

Abstract:

Progressive knowledge of allergenic structures resulted in a broad
availability of allergenic molecules for diagnosis. Component resolved
diagnosis allowed a better understanding of patient sensitization
patterns, facilitating allergen immunotherapy decisions. In parallel to
the discovery of allergenic molecules, there was a progressive
development of a regulation framework that affected both in vitro
diagnostics and Allergen Immunotherapy products. With a progressive
understanding of underlying mechanisms associated to Allergen
immunotherapy and an increasing experience of application of molecular
diagnosis in daily life, we focus in analyzing the evidences of the
value provided by molecular allergology in daily clinical practice, with
a focus on Allergen Immunotherapy decissions.

\textbf{Introduction:}

The progressive advance in the knowledge and characterization of
allergenic molecules responsible for allergic sensitization to most
sources have had a profound impact in the etiological management of
allergic disease. This impact can be summarized in three main aspects.
Firstly, it has profoundly transformed the way allergenic extracts are
characterized and standardized which is legally reflected in the
regulatory framework for allergens, especially on the Note for Guidance
on Allergenic Extracts, issued by the European Medicine Agency (EMA) and
on the allergen monograph of the European Pharmacopoeia, issued by EDQM
(Council of Europe), that is adopted by European Directives for
Medicinal products \textsuperscript{1-3}. Secondly, it improved the
accuracy of allergy diagnosis. Single or multiplexed, allergenic
molecules are routinely used and have changed the way we diagnose
\textsuperscript{4}. Lastly, but not least, some sensitization profiles
are linked to different clinical phenotypes, and can be used to stratify
allergic patients, to predict intervention outcomes, and to perform
system biology studies that open new avenues for allergy disease
management\textsuperscript{5-11}.

The implementation of a new regulatory framework led to the
commercialization of allergy vaccines with registration clinical trials
performed during five years. Based on these studies, a better
understanding of AIT mechanisms is now possible. From allergen-specific
effector cell desensitization\textsuperscript{5,12-14}to a progressive
onset of T and B cell-mediated regulatory
mechanisms\textsuperscript{15-19} responsible for the disease-modifying
effect, their temporal alignment is critical to establish best AIT
practices. In this context, the quality of the extract used \selectlanguage{english}- and its
standardization \selectlanguage{english}-, the knowledge of patient's sensitization profiles,
and the link to the AIT product used are pivotal to maximize the odds of
AIT success. In this review, we discuss the different aspects of
molecular allergology, from an overview of allergenic molecules and
diagnostic methods to the quality of allergen preparation and the
clinical approaches to AIT. We aim to offer a practical document to
support the allergy specialist in the daily clinical management of
allergic patients.

\textbf{Overview of allergenic molecules}

Currently, more than one thousand allergens from various allergenic
sources have been described. Most of these molecules, that are relevant
for AIT decisions, belong to a limited number of protein families and
have been extensively revised\textsuperscript{4,20,21}. More than 40 \%
of the relevant plant allergens belong to six protein families: 2S
albumins ,non-specific lipid transfer proteins (nsLTP)), legumins,
vicilins , profilins and pathogenesis-related (PR)-10
proteins\textsuperscript{22}. In contrast, there are other families with
only a few but very relevant members, as they include major pollen
allergens such as expansins, polcalcins, pectate lyases and
defensin-like proteins. Concerning animal allergen families, four of
them (cysteine proteases, lipocalins, tropomyosins and parvalbumins),
account for over 70\% of the relevant allergens (Table 1)
\textsuperscript{23}. A separate category is formed by the allergens
from hymenoptera venom (Table 2).

\textbf{Diagnosis methods and European regulation}

There are different methods available for sIgE determinations of single
allergenic components. These components might be available as individual
diagnostics or multiplexed in arrays. These technologies are
commercialized by Thermo Fisher, MADx, Hycor, Euroline and Siemens. The
list of available allergens in each platform has recently been described
in detail\textsuperscript{20} . Most of the existing methods for CRD
(Component-resolved diagnosis) and multiplexed platforms, have been
commercialized for research purposes and will need an adaptation and
upgrade to comply with new regulatory EU framework as required by the
regulation affecting in vitro diagnostics and medical devices, with a
transition implementation phase ending by 2025 (REGULATION (EU)
2017/746). This regulation implementation will secure the adequate
performance of commercialized diagnostics

The best diagnostic strategies \selectlanguage{english}- using a combination of clinical
evaluation, extract-based diagnosis and CRD \selectlanguage{english}- that set the basis for the
present document has also been extensively discussed by Matricardi and
cols.\textsuperscript{4}

\textbf{AIT regulations, biological potency, and link to clinical
effect.}

The characterization of the main allergenic molecules led to the
development of quantification methods and their progressive
incorporation into regulations of extract preparation of AIT. In
parallel, Create International project ended in the first available
reference methods for major allergen content
determination\textsuperscript{3,24-26}. Today, for any AIT product
intended for human use, a proper measurement of biological potency and
major allergen content is required. Major allergens use to be the most
abundant proteins of allergenic sources and their content in AIT
products is closely related to total biological potency. Moreover, most
of the patients included in clinical trials are sensitized to major
allergens and in a significant percentage monosensitized to
them\textsuperscript{27}. In consequence, as a general criterium,
patients elected for AIT must be sensitized to major allergens as there
is no evidence of the clinical effect of AIT products in patients
sensitized only to minor allergens. Unfortunately, the content for minor
allergens in AIT preparations is, in the vast majority of cases, unknown
and variable. In areas where pollen exposure is very intense, and
sensitization to minor allergens is very frequent, side reactions to AIT
preparations containing assigned to minor allergens variability have
been described\textsuperscript{28,29}.

Main AIT mechanisms involve early effector cells de-sensitization and
progressive onset of tolerance through a regulatory response that needs
at least three years to be consolidated\textsuperscript{5,13}.
Dose-finding studies are usually performed during relatively short
times, and thus effective dose is adjusted to target desensitization
mechanism and to major allergen doses

\textbf{CRD: Monitoring of allergy progression}

Birth cohort studies have shown a sequential broadening of the IgE
response to complex allergen sources. The IgE response starts in general
with a monomolecular stage and then, through an oligomolecular
sensitization pattern becomes polymolecular\textsuperscript{30}. This
``molecular spreading'' has been observed in many participants in the
MAS birth cohort allergic to Timothy grass. In this case, the
``initiator molecule'' was Phl p 1. However, only a few patients develop
an extremely polymolecular response, producing IgE antibodies to all the
best known allergenic molecules of \emph{Phleum pratense} (Phl p 1, Phl
p 2, Phl p 4, Phl p 5, Phl p 6, Phl p 7, Phl p 11 and Phl p
12)\textsuperscript{30}. Similarly, molecular spreading has been
observed in the MAS cohort among children developing IgE sensitization
against \emph{Dermatophagoides pteronyssinus} \textsuperscript{31}. In
this case, multiple ``initiator molecules'' have been observed (Der p 1,
Der p 2, Der p 23). In these children, sensitization started with Der p
1 and/or Der p 2 and/or Der p 23 (defined as group ``A'' molecules);
then involved Der p 4, Der p 5, Der p 7, and Der p 21 (group ``B''
molecules); and was completed with IgE to Der p 11, Der p 14, Der p 15,
Der p 18, and clone 16 (group ``C'' molecules). This expansion of the
IgE response has also been defined as ``the ABC march'' of mite
allergy\textsuperscript{31}. Children with a broader polymolecular IgE
sensitization pattern were also more frequently affected by asthma when
compared with those who remained in the ``A'' stage of IgE
sensitization\textsuperscript{31}. A similar trend was observed among
grass pollen allergic children in the Manchester Allergy and Asthma
Study (MAAS)\textsuperscript{32}. In this case, children with broader
molecular patterns of IgE sensitization had also a significantly
increased risk for asthma, eczema, and rhinitis\textsuperscript{32}. It
has also been proposed that earlier administration of AIT, i.e. at a
mono- or oligomolecular stage of sensitization, may be more effective
than at later stages \textsuperscript{33}.

\textbf{CRD and selection of preparations for AIT:}

\textbf{Grass pollen allergy}

Grass pollen allergy is probably the most studied allergic pathology.
There is a broad allergen panel for CRD of grass allergy, and a SLIT AIT
product that is the only one with a complete clinical program, including
several five-years studies,\textsuperscript{12} that provides the best
available information to understand the link between sensitization
profiles and AIT.

Allergen composition studies of a Phleum pollen
extract\textsuperscript{34} allowed to establish that Phl p 5 and its
related allergen Phl p 6 are the most abundant proteins, accounting for
more of 50\% of protein content. Accumulated content of Phl p 1
represents less than 10\%. The rest of allergen components are in a
range from 1-10\% of total protein. Despite the relatively low
abundance, Phl p 1 is the most relevant single allergen sensitizer of
grass allergic patients. Epidemiological studies performed in
Spain\textsuperscript{35,36}and CRD analysis of 1905 patients included
in AIT clinical trials of grass pollen allergy in North
America\textsuperscript{27} demonstrated the preponderance of Phl p1 as
primary sensitizer to grass pollen. In fact, a significant proportion of
patients were mono sensitized to this allergen. Similar results in
pediatric grass allergen patients have been reported
\textsuperscript{37}.

Recently a potential explanation for this has been
published\textsuperscript{38}. Group 1 grass allergens, belonging to the
beta expansins family, are present in other plant parts. In Autumn, upon
plant death, plant particles are aerosolized and might be presented
together with Alternaria spores, initiating sensitization process. No
loss of effect in AIT is observed in patients mono-sensitized to either
Phl p 1 or Phl p 5\textsuperscript{27}; however, patients with low
(first tercile) sIgE to any of the two major allergens presented no
clinical benefit in the first pollen treatment season. As we have
already mentioned, early effect is governed by desensitization in a
dose-dependent manner. Patients with low sIgE levels might need a higher
allergen dose to get desensitized; however, in a five-year mechanistic
study \textsuperscript{9}, an impaired regulatory response for this type
of patients was not observed, and thus they should not be excluded for
AIT if they meet clinical inclusion criteria.

\textbf{The role of pan-allergens}

An interesting subgroup of grass pollen allergic patients are sensitized
to profilin, a pan-allergen present in all vegetable tissues, with a
highly conserved structure. Usually, profilin is a confounding
diagnostic factor, which is minimized by CRD diagnosis either ``in
vitro'' or even ``in vivo''\textsuperscript{39}. Profilin sensitization
strongly associates with grass pollen allergy\textsuperscript{35} in
base to a relatively high profilin content in grass pollen compared to
other pollens \textsuperscript{40}. Usually, sensitized profilin
patients present no food-mediated reaction or only local (oral) ones.
However, in areas of very high grass pollen exposure, some allergic
patients do not respond to AIT and present severe food profilin-mediated
reactions\textsuperscript{41,42}. In fact, T cell reactivity to profilin
increases along with grass pollen intensity exposure. Moreover, in
patients from central Spain, T cell proliferation induced by profilin is
similar to that induced by the major allergen Phl p
1\textsuperscript{34}. These peculiar patients, as well as others
exposed to very high pollen levels, can be identified by combining CRD
with clinical evaluation and provide invaluable models to understand
allergic inflammation and AIT mechanisms and its limitations.

Finally, patients sensitized simultaneously to the pollen pan-allergens
polcalcin and profilin have been shown to have twice as many primary
sensitizations and to duplicate as well allergy disease evolution
time\textsuperscript{36}, suggesting that AIT might not be effective.
Similar results supporting clinical value for Phl p 7 and Phl p 12 have
been described in pediatric cohorts\textsuperscript{37}.Moreover, this
specific double sensitization profile to pan-allergens is not linked to
any particular pollen\textsuperscript{36}. At this moment other grass
allergens present a limited diagnostic value for AIT decisions and some
of them provide confounding information due to lack of specificity
\textsuperscript{43}.

Figure 1 represents an algorithm to support decision-making in the
selection of AIT for grass pollen allergy.

\textbf{Olive pollen allergy and nsLTP food allergy:}

One of the best models to understand the link between pollen exposure,
sensitization profiles, and clinical impact is the olive pollen allergy
model. Minor allergen sensitization is frequent in areas of very high
exposure. Interestingly, sensitization to Ole e 7 \selectlanguage{english}- the nsLTP from olive
pollen \selectlanguage{english}- is associated with a unique clinical
phenotype\textsuperscript{29,35}. Patients living in areas with high
olive pollen exposure and sensitized to Ole e 7 develop a severe
respiratory allergic phenotype. These patients do not respond to AIT and
constitute another model to understand evolution to severe allergic
phenotypes. In Figure 2 an algorithm to support the selection of olive
pollen AIT is shown.

There are other pollens where nsLTPs play a preponderant role,
as\emph{Parietaria judaica} , whose main allergen is a LTPs,
or\emph{Artemisia artimisifolia} and \emph{Platanus orientalis} , whose
Art v 3 or Pla a 3 are LTPs. Art v 3 and Pla a 3 cross-react with Pru p
3 which complicates the differential diagnosis of the primary
sensitization (to pollen or peach).

LTP-mediated allergy is the predominant food allergy in adults in the
Mediterranean Area and Southern European
countries\textsuperscript{44,45}. Pru p 3 \selectlanguage{english}- the peach LTP \selectlanguage{english}- is the best
marker for LTP allergy. Sublingual AIT has proved to be effective for
the treatment of LTP allergy, with clinical effect not only against
allergy to closely related food species such as \emph{Rosaceae}
fruits\textsuperscript{46}, but also against allergy to species with
about only 60\% sequence identity, such as the Peanut LTP, Ara h
9\textsuperscript{47,48}. Evaluating the spectrum of recognition to
multiple LTPs is needed to make a potential AIT therapeutic decision.
Patients sensitized to LTPs distant to Pru p 3 such as wheat Tri a 14
might not benefit completely from AIT based on Pru p 3. Unfortunately,
SLIT AIT for LTP allergy is only available in a limited number of
Countries. Figure 3 summarizes decision trees for LTP mediated AIT

\textbf{Birch and Oak tree pollen allergy and PR-10 proteins}

PR10 allergens are present in multiple species of deciduous trees
pollen. Among them, birch in Europe\textsuperscript{49} and oak in North
America are regarded as primary sensitizers. There are products,
registered worldwide for the treatment of birch pollen
allergy\textsuperscript{50}. Recent data suggest that a birch-based
vaccine has clinical benefit during oak pollen season in North America
\textsuperscript{51}. Interestingly, a study analyzed the effect of
birch-based AIT in cross-reactive T cell response to homologous PR10
allergens from other trees \textsuperscript{52}. This study demonstrated
that down-regulation of T cell reactivity can be achieved against
multiple, T cell cross-reactive PR-10 molecules. The control of T cell
proliferation based on T cell cross-reactivity might be the most
relevant endpoint for successful AIT. As in the case of profilins, PR10
proteins are also present in multiple vegetable species, leading to the
concept of a PR10 allergy syndrome. There is very limited evidence on
the clinical benefit of PR10 based pollen AIT in the amelioration of
pollen-related food allergy syndrome
(FPAS)\textsuperscript{53},\textsuperscript{54}. However, immunotherapy
with Mal d 1 has been associated with clinical improvement
\textsuperscript{55}. More studies will be needed to clarify potential
use of PR10 pollen vaccines in this particular type of food allergy.

\textbf{Cypress/cedar allergy}

Japanese cedar pollen is the main cause for seasonal respiratory allergy
in Japan and Cupressaceae are relevant allergens in the US and southern
Europe as well. Major allergens belonging to the pectate lyase family
(Cup a 1, Cup s 1, Jun a 1 and Cry j 1) show a very high
cross-reactivity.

There is only one AIT product\textsuperscript{56,57}with clinically
documented efficacy. The recent registration of a Japanese cedar vaccine
in Japan opens the possibility \selectlanguage{english}- as in the case of birch/oak vaccines \selectlanguage{english}-
to explore its value for treating cedar/cypress allergy worldwide.

\textbf{Ragweed pollen allergy}

Ragweed allergy dominates weed pollen allergy in North America and,
after the accidental introduction of ragweed in Europe about one hundred
years ago, is in continuous progression in the continent.

Major allergen Amb a 1, a pectate lyase, is a true marker of ragweed
allergy and presents low cross-reactivity with related proteins from
other pollen sources\textsuperscript{58}. However, there is an extensive
cross-reactivity among different \emph{Ambrosia}
species\textsuperscript{59}. Currently, there are AIT products
extensively documented in adults\textsuperscript{60} both in American
and European patients as well as in children\textsuperscript{61} and
these products are available worldwide for AIT practice.

\textbf{Other pollen allergies:}

There is a limited clinical evidence of AIT benefit in the treatment of
other pollen allergies. However, data on major allergens can be
extrapolated from studies on existing registered pollen vaccines. Major
specific allergens available for diagnosis include: Art v 1
(\emph{Artemisia artimisifolia} ), Salk k 1 (\emph{Salsola Kali} ), Pla
l 1 (\emph{Plantago lanceolata} ), and Pla a 1 (\emph{Platanus
acerifolia} )\textsuperscript{58}.

\textbf{Cat and dog allergies}

In general, the severity and progression of cat and dog allergies
involve IgE recognition of a progressively increasing number of
components from the sensitizing allergen source (molecular
spreading)\emph{\textsuperscript{30,62-65}.}

The availability of CRD for different cat and dog allergens has also
raised the possibility of more precisely targeted AIT, mainly because it
may distinguish primary sensitization from cross-sensitization, thereby
enabling selection of the primary sensitizing allergen source for
therapy.

In a recent, comprehensive study\textsuperscript{66}, including most of
the components available, the pattern of IgE sensitization to cat
allergens showed that 92\% of cat-allergic patients had positive IgE
antibodies results to Fel d 1. Other allergens also seem important, such
as Fel d 4 and Fel d 7. Previous studies reported similar
results\textsuperscript{67}. The content of Feld d 1 in allergenic
extracts varies substantially. Nevertheless, it has been demonstrated
that the maintenance efficacy dose of Fel d 1 is 15
mg/ml\textsuperscript{68}.

In the same study, in patients with dog allergy, 52.4\% were positive to
Can f 1, and 57.2\% to Can f 5. The most frequent monomolecular
sensitization was to Can f 5.

The content of different dog allergen molecules in European AIT extracts
has been recently studied\textsuperscript{69}. These authors
demonstrated great variability in extracts from five companies and
scarce content of major allergens\textsuperscript{70}.

In general, AIT with cat extracts yield better clinical results than
with dog ones. The higher complexity of dog allergy sensitization
patterns, the lack of preparations with an adequate balance of major
allergens is likely to explain this
divergence\textsuperscript{66,71,72}.

Further studies are needed to determine whether CRD could be used to
identify patients who are most likely to respond to AIT specially in dog
allergy.

Figure 5 summarizes decision-making algorithms in cat and dog allergy
AIT selection.

\textbf{Mite allergy}

Mite major allergens Der p 1/Der f 1 and Der p 2/Der f 2 sensitize the
vast majority of mite allergic patients, being the double sensitization
to groups 1 and 2 strongly associated with asthma\textsuperscript{32}.
Group 1 sensitization is more prevalent in children than in adults,
suggesting an initiation role probably associated with its proteolytic
properties\textsuperscript{73}. Recently Der p 23 has been described to
be associated with increased asthma risk\textsuperscript{74}. Other mite
species, known as minor or storage mites, have a limited allergenic
cross-reactivity with major mites. Interestingly, they display a
significant cross-reactivity between them. Lep d 2 could be a good
marker for minor storage allergy sensitization\textsuperscript{75}. Some
patients exposed to high mite allergen levels, and sensitized to storage
mites, develop anaphylactic reactions when exposed to foods contaminated
with mites \textsuperscript{76}. Interestingly, these patients present
NSAIDs intolerance and recently they have been described to present
extensive oral mucosa barrier damage\textsuperscript{8}.

A post-hoc analysis of a study with AIT with \emph{D}
.\emph{pteronnysinus} and \emph{D. farinae} found no association between
the clinical efficacy and sensitization to different mite
allergens\textsuperscript{77}.

Recently, the antibody response to a SCIT preparation for mite allergy
has been examined at the molecular level in 24 mite-allergic
patients\textsuperscript{78}. A protective IgG response has been
observed for Der p 1 and Der p 2 and, to a lesser extent, Der p 23. By
contrast, patients did not develop a strong response to other mite
allergens. Interestingly, a better clinical response to the AIT was
observed in patients sensitized only to Der p 1 and/or Der p 2, when
compared to patients with a broader IgE response\textsuperscript{78}.
This suggest that the molecular profile of IgE sensitization may be
useful in selecting patients that may benefit from subcutaneous
AIT\textsuperscript{78}, as previously hypothesized
\textsuperscript{79}. However, no studies are available so far to
ascertain whether this conclusion can be applied also to sublingual
immunotherapy.

\textbf{Hymenoptera venom allergy}

\emph{Apis mellifera} or honeybee venom (HBV) is the best-characterized
Hymenoptera venom due to the outstanding importance of this species as
elicitor of venom allergy worldwide. Detailed genomic information and
proteomic data of the pure venom is available\textsuperscript{8081-83}.
So far 12 allergens of HBV are identified\textsuperscript{84}. Only two
of them present substantial amounts in the venom, the major allergen
phospholipase A2 (Api m 1)(12\%) and the minor peptidic allergen
melittin (Api m 4)(50\%)\textsuperscript{85}. Despite their lower
abundance in HBV compared to Api m 1, a role as relevant major allergen
was also confirmed for Api m 2 (hyaluronidase), Api m 3 (acid
phosphatase), Api m 5 (dipeptidylpeptidase IV) and Api m 10 (icarapin)
with sIgE reactivity in the range of 47.9-52.2\%, 49.6-50\%, 58.3-61.7\%
and 61.8-72.2\% of allergic patients' sera,
respectively\textsuperscript{86,87}. For the other HBV allergens less
information about sensitization rates is available
\textsuperscript{88-90}. Some HBV allergens have been identified as risk
markers of more severe clinical phenotypes such as Api m 4 or of venom
immunotherapy (VIT) failure such as Api m 10\textsuperscript{86,91}.

Prominent \emph{Vespula} spp. (known as yellow jackets in the USA)
allergens include phospholipase A1 (Ves v 1), hyaluronidase (Ves v
2.0101) and antigen 5 (Ves v 5)\textsuperscript{92,93}. A second
hyaluronidase (Ves v 2.0201), carrying an inactivation mutation in the
active site of the enzyme, was identified, which seems to be the
predominant isoform\textsuperscript{94,95}. Yellow-jacket venom (YJV)
also contains a dipeptidylpeptidase IV (Ves v 3) which shows high
homology to HBV Api m 5\textsuperscript{96}. The sensitization rates of
YJV-allergic patients to Ves v 1, Ves v 3 and Ves v 5 are 33.3-54\%
\textsuperscript{97-102}, 50-62.8\%\textsuperscript{96,97}and
84.5-100\%, respectively\textsuperscript{97,99,100,102-104}. In contrast
to HBV hyaluronidase Api m 2, which is a major allergen, the YJV
homologue Ves v 2 seems to be of restricted relevance and sensitization
was reported in 5-25\% of YJV-allergic patients\textsuperscript{105}.

The allergen composition of \emph{Polistes dominula} venom (PDV) is very
similar to that of YJV and the most important allergens are
phospholipase A1 (Pol d 1), dipeptidylpeptidase IV (Pol d 3) and antigen
5 (Pol d 5) with sensitization rates of 87\%\textsuperscript{106},
66.7\%\textsuperscript{107} and 69-72\%\textsuperscript{106},
respectively.

CRD is helpful to discriminate between genuine double sensitization and
cross-reactivity, allowing physicians to optimize patient selection for
VIT. The potential of CRD becomes evident by the fact that HBV and YJV
in addition to homologous allergens also contain differentiating marker
allergens that are present in either HBV or YJV. This is not the case
when differential diagnosis between \emph{Vespula spp} .
and\emph{Polistes spp} . is required (Figure 6). CRD is also helpful in
identifying patients with Hymenoptera venom-induced anaphylaxis having
negative test results to whole venom extracts, as it can be the case in
hymenoptera venom-allergic patients with mast cell
disorders\textsuperscript{108}. Currently available allergens of
honeybee and vespid venoms (see Table 2) allow a molecular diagnosis in
the vast majority of patients, but not in 100\% of them. Moreover, not
all allergens are available for one assay system. New recombinant
molecules are needed to improve the diagnosis of\emph{Polistes}
\emph{spp} .-allergic patients, especially in the case of
double-positivity to both \emph{Polistes spp} . and \emph{Vespula spp} .
venom, in order to prevent unnecessary double VIT (Figure 7A). Although
diagnostic sensitivity of the currently available allergen panel,
particularly of HBV, is not 100\%, CRD has clearly improved
discrimination of primary allergy and cross-reactivity in YJV and HBV
allergy, thus facilitating correct prescription of VIT. A suggested
diagnostic algorithm to discriminate between HBV and YJV allergy using
CRD is given in Figure 7B. Of note, the same algorithm using the
corresponding PDV allergens can also be applied to discriminate between
HBV and PDV allergy.

\textbf{Peanut allergy}

A product for oral immunotherapy (OIT) to peanut has been recently
licensed by FDA and EMA and will soon become widely
available\textsuperscript{109,110}. Other products and routes of
administration have been explored\textsuperscript{111}.

Peanut allergic reactions can be triggered by storage proteins, such as
Ara h 1,2,3,6\textsuperscript{112}, which have been associated to
life-threatening symptoms, as well as by cross-reactive allergens, such
as Ara h 5\textsuperscript{113}, a profilin associated to grass pollen
allergy, Ara h 8, belonging to PR10 family and associated to birch
pollinosis and Ara h 9, a nsLTP, associated to the LTP syndrome
discussed earlier(Table 1). Symptoms elicited by Ara h 5 and Ara h 8 are
usually mild and limited to the oral cavity, the oropharynx, known as
oral allergy syndrome. Ara h 2 sIgE levels are associated to both
severity and threshold of allergic reactions during oral provocation
challenges, thus being a good biomarker for
severity.\textsuperscript{114,115}. In fact, Ara h 2 is the dominant 2S
globulin allergen\textsuperscript{116}. As storage proteins can trigger
systemic food allergic reactions and anaphylaxis, peanut allergy with
confirmed sensitization to seed storage proteins like Ara h 1,2,6 can
constitute an indication for POIT to peanut.

A summary of the decision process to select POIT is shown in Figure 8.

\textbf{CRD and AIT safety:}

There are different heterogeneous evidence showing an association of
risk factors for adverse events during AIT associated to particular IgE
sensitization profiles. The most studied model is grass pollen allergy.
Adverse reactions with subcutaneous immunotherapy, both local and
systemic, correlate with sensitization progression (Phl p 1+5+12
\textgreater{}Phl p 1+5 \textgreater{} Phl p 1/5)\textsuperscript{117}.
In sublingual AIT, adverse events were also related with highest levels
of Phl p 5 or Phl p 1 \textsuperscript{2727} and with allergen
sensitivity \textsuperscript{118}.~Under extreme exposure to grass
pollen, patients are frequently sensitized to profilin and present
severe adverse reactions to foods caused by profilin. Interestingly,
this type of these reactions to profilin-containing foods are similar to
the infrequent reactions observed during SLIT. This rare phenotype
constitutes therefore a unique model to understand disease severity and
limits for AIT. Profilin severe reactors undergo extensive oral mucosa
damage and present a unique systemic metabolic status that points to T
cell proliferation, sustained inflammation and altered repair function.
The fact that profilin-sensitized patients in Spain present an enhanced
T cell proliferation compared with similar patients from Denmark
suggests that progression to severe phenotypes might be linked to an
uncontrolled inflammation and T cell proliferation. Interestingly, in
the other severity models previously mentioned systemic barrier damage,
uncontrolled effector cell response, and altered repair-associated
biomarkers have been described. In all cases, might be explained by T
cell cross-reactive allergens: Profilin, Ole e 7 (a nsLTP from pollen)
and Lep d 2 (a frequent food contaminant inducing reactions in patients
with storage mite sensitization).

\textbf{Future directions:}

Accurate diagnosis is essential before AIT can be considered. The
routine use of molecular diagnosis for allergic diseases and AIT,
theorized in the late 1990s by Rudolf Valenta and
colleagues\textsuperscript{119}, is relatively recent and is still
evolving. Constraints include the perceived complexity of this
diagnostic approach and the slightly higher costs of test
execution\textsuperscript{120-122}. The recent development of a novel
multiplex test containing both extracts and molecules relevant for
pollen allergy (a sort of ``molecular pollen test'') may help doctors in
the prescription of the appropriate AIT products \textsuperscript{123}.
The development of algorithms and clinical decision support systems
integrated into apps for smartphones\textsuperscript{124} will
facilitate the clinical interpretation of the outcome of IgE molecular
assays, as shown in a recent pilot experience (Arasi, S et al. Clin Exp
Allergy, in press). Different estimates confirm that CRD has a
significant impact on AIT formula selection\textsuperscript{125-127}.

To rely on correctly standardized and clinically documented AIT
products, as well as to understand their limitations, is as important as
correctly diagnosing patients.

With an increasing number of new intervention possibilities, it is
essential to optimize the use of AIT\textsuperscript{58,128,129}. Major
allergen sensitization and the use of up to two different
clinically-documented allergen preparation is a must. In fact, even in
complex exposure regions, most of the patients are sensitized to a
limited number of allergens\textsuperscript{130} and thus potentially
eligible for AIT. An adequate dose of allergen as defined in
dose-finding clinical trials will guarantee an adequate safety/efficacy
balance. In the last years, an increasing number of allergen
preparations developed with the highest pharmacological standards are
available. This trend will continue and is expected to have a profound
impact on AIT practice and to position it in the center of etiological
management of allergic patients. In spite of correct diagnosis and the
use of high-quality AIT products, a fraction of treated patients will
not improve or will lose clinical benefit upon discontinuation after
three years of intervention\textsuperscript{13}. The need to advance on
personalized medicine approaches to predict intervention outcome and
safety \selectlanguage{english}- and to monitor AIT effect \selectlanguage{english}- is imperative\textsuperscript{131}.
System biology approaches are being explored to understand AIT
response\textsuperscript{5}. These new approaches help to understand
biological effect kinetics and provide new tools to evaluate new AIT
product approaches. The desensitization of allergen-specific effector
cells plays a determinant role for AIT effect during the first two years
of intervention, while regulatory response, which is initiated shortly
after AIT initiation, will only have a meaningful clinical benefit after
at least two/three years of administration. We need better formulas,
including adjuvants and tolerogenic signaling molecules to reduce AIT
duration\textsuperscript{6}. At the same time, understanding severe
phenotypes is needed. Recent data obtained by system biology approaches
identify T cell proliferation, inadequate regulatory function, and
collapse of repair homeostasis as main causes for non-response to
intervention and evolution to severe
phenotypes\textsuperscript{7-9,132}. There are new possibilities of
using these systemic signatures to explore the value of new biologics to
stabilize severe phenotypes allowing ulterior AIT intervention.

While CRD has proved the value for correct patient inclusion and AIT
standardization, we cannot expect that it will be of great value to
predict intervention outcome or safety\textsuperscript{77}. AIT is the
only treatment in allergy able to modify the course of the disease, but
for achieving this goal, the correct patients, with the correct product,
with adequate treatment duration and compliance are needed. Even so,
about 30\% of patients will not benefit from this disease-modifying
effect. This 70\% effect, however, ranks at the top of successful
pharmacological interventions. In 2003, Dr. Allen Roses, by that time
vice president of the genetics division for GSK, commented that ``The
vast majority of medicines, more than 90 percent, only work in 30 or 50
percent of people''. Since then, massive efforts on personalized
medicine are progressively changing the landscape. AIT has the potential
of being the reference intervention in allergy, but for that, we need a
commitment and upgrade of its clinical practice. The use of molecular
allergology for diagnostic purposes will rapidly evolve in the next
years and will be more linked to the identification of patients
phenotypes and endotypes for an improved therapeutic approach, which
implies the opening of the era of ``precision
allergology''\textsuperscript{121,122}. CRD, today, provides a good
starting point.

\textbf{Acknowledgments}

We thank Tomas Barker-Tejeda for the critical reading of the manuscript.

Figure Legends

Figure 1: Diagnostic algorithm and decision tree for AIT using CRD in
Grass pollen allergy. Grass pollen allergy is one of the most studied
allergy models. Major allergen sensitization is required before
considering AIT. The combination of major allergens and pan-allergens
provides the necessary tools for AIT decisions. Profilin allergy, might
be a contraindication only in severe food allergic patients, while
double sensitization to both pan-allergens is associated to many years
of disease evolution, poly-sensitization and poor intervention outcome

Figure 2: Diagnostic algorithm and decision tree for AIT using CRD in
Olive pollen allergy. Olive pollen allergies is one of the most complex
allergy models. Usually olive cultivars cover homogeneous areas and
present acute differences in allergen pollen content. In dense pollen
areas, patients are exposed to the highest pollen counts recorded. Th
existing of complex profiles, marked by minor allergens sensitization,
makes CRD a fundamental tool for patient management and AIT decissions.

Figure 3: Diagnostic algorithm and decision tree for AIT using CRD in
nsLTPs mediated allergies. The existence of cross-reactivity between
nsLPTs from \emph{Artemisia} and \emph{Platanus} pollens, makes CRD
necessary. LTP immunotherapy with an enriched Pru p 3 can be considered
in Countries with availability of this type of therapy

Figure 4: Diagnostic algorithm for in vitro diagnostics and Decision
tree for AIT using CRD in pollen allergies. Discrimination of primary
sensitizers and pan-allergens positivity is needed. AIT guidelines do
not recommend AIT for poly-sensitized patients

Figure 5: Diagnostic algorithm for in vitro diagnostics in epithelia
allergy and associated decision tree for AIT using CRD. The proposed
algorithm discriminates between primary sensitization and cross-reactive
sIgE response. Only patients sensitized to major allergens should be
eligible for AIT.

Figure 6: Established discriminating and cross-reactive allergens of
HBV, YJV and PDV. While allergens are identified that enable a
differentiation between HBV (Api m 1, Api m 3, Api m 4 and Api m 10) and
YJV/PDV (Ves v 1/Pold 1 and Ves v 5/Pol d 5) sensitization, the so far
known allergens of YJV and PDV exhibit cross-reactivity.

Figure 7: Diagnostic algorithm for in vitro diagnostics of (A) HBV and
YJV allergy and (B) YJV and PDV allergy. The diagnostic algorithm shown
in (A), with the corresponding PDV allergens Pol d 1 and Pol d 5 can
also be used to discriminate between HBV and PDV allergy. In addition,
to discriminate in the case of double-positive test results, CRD might
also be useful in cases of negative results despite a convincing history
of venom allergy or in cases of discrepancies between history, skin
tests and venom extract-based testing. A plus indicates a positive and a
minus a negative test result. Of note, the allergens Api m 4 and Pol d 1
(in brackets) are only available for selected multiplex sIgE test
platforms. *The allergens Api m 2 and Api m 5 are potentially
cross-reactive with their homologues from YJV and PDV (not available for
CRD) and, hence, a positive test results does not necessarily exclude
allergy to vespid venom.

Figure 8: Diagnostic algorithm for in vitro diagnostics in peanut
allergy oriented to make POIT decision. Discriminant analysis between
storage allergens and cross-reactive to pollen and nsLTPs is proposed.
Only patients with positive sIgE to any of the Ara h 1,2,3,6 should be
eligible for POIT.

BOXES:

MAJOR MILESTONES:

\begin{itemize}
\tightlist
\item
  IgE Discovery (1968)
\item
  First commercial reagents for specific IgE (1973)
\item
  Knowledge and Characterization of the most relevant allergens
  (1985-2005)
\item
  Development of multiplexed allergens: 1999
\item
  Handbook of Molecular Allergology: 2016
\item
  Progressive use in clinical practice of CRD: 2010-2021
\item
  Progressive understanding of AIT mechanisms: 2010-2021
\item
  First AIT product registered following Pharmaceutical development
  guidelines: 2007
\item
  First OIT for peanut allergy registered: 2020
\end{itemize}

FUTURE RESEARCH PERSPECTIVES:

\begin{itemize}
\tightlist
\item
  Affinity and avidity need to be explored in IgE response to allergens
\item
  T-cell reactivity to allergens is a critical parameter
\item
  Combination of new biologics and AIT and associated diagnosis will
  open new intervention strategies
\item
  New regulation of in vitro diagnostics will increase the quality of
  CRD , but might limmit innovation and available molecules
\end{itemize}

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Table 1: Characteristics and significance of pollen, vegetables, mites
and epithelia allergens available for CRD and relevant for AIT decisions\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
SOURCE\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Allergen\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Sensitization rate\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Available for routine CRD\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Significance\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
POLLEN\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Grasses\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Phl p 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Expansin. Present in different plant parts. Major allergen and usually
initiates sensitization\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Phl p 5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}60\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Unknown function. Most abundant pollen protein\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Phl p 7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{}10\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pan-allergen in pollens. Calcium -binding\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Phl p 12\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5-50\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pan-allergen (food/pollen ). Structural protein\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Birch\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Bet v 1\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Pan-allergen (food/pollen) Regulatory protein. Highly expressed in case
of biotic stress.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Olive tree\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ole e 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Unknown function\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Olive\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ole e 7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0-50\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
nsLTP, minor allergen. Disease severity marker\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Olive\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ole e 9\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0-50\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Glucanase, minor allergen. Highly vairable in different olive
cultivars\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Russian thistle\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Sal k 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pectin methylesterase\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Plain tree\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pla a 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Invertase inhibitor\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Arizona cedar\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cup a 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pectate lyase. Homologous and cross-reactive to Cry j 1 from Japanesse
cedar and Jun a 1 from mountain cedar\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
English plantain\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pla l 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}70\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ole e 1 like. Non-cross reactive\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Artemisia\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Art v 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}70\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Defensin like\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ragweed\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Amb a 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pectate lyase\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Parietaria\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Parj 2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
ns LTP\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
FOODS\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Peach\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pru p 3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
ns LTP. Very stable. Frequent initiator in LTP syndrome\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Peanut\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ara h 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11S Albumin. Storage protein. Highly abundant\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ara h 2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2S albumin. Storage protein. \textgreater{}Highly abundant. Risk marker
for severe reactions\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ara h 3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11S Albumin. Storage protein. Highly abundant\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ara h 5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Profilin\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ara h 8\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
PR10. Bet v 1 like\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Ara h 9\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
nsLTP (Pru p 3 related)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
MITES\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\emph{Dermatophagoides pteronyssinus}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Der p 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cystein protease. Associated to mite fecal particles\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Der p 2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
NCP2. Lipid binding protein. MD2 link. Associated to mite bodies\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Der p 10\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{}10\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pan-allergen in arthropods.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Der p 23\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Peritrophin-like protein\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\emph{Lepidoglyphus destructor}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lep d 2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Related to Der p 2, but without IgE cross-reactivity. Cross-reactive
with Group 2 proteins from other minor/storage mites.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
EPITHELIA\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cat\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Fel d 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Secretoglobulin.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Fel d 4,7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{}50\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lipocalins. Cross-reactivity with Can f 1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Dog\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Can f 1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}50\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lipocalin\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Can f 5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textgreater{}50\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S,M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Kalikrein. Serin protease. Regulating semen liquefaction. Present in
male dogs\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

*Estimated from publications. S: Available in singlepex assays. M
Available in Multiplex assays.

Prevalence on food allergens depends on geographical locations and age.
In general, storage protein allergy is frequent in pediatric cohorts,
while LTP and PR10 linked allergy is of a later onset.



\textbf{Table 2. Characteristics and significance of Hymenoptera venom
allergens available for routine CRD (modified according
to\textsuperscript{133}).}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Allergen}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Sensitization} \textbf{rate\textsuperscript{*}}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Available for} \textbf{routine CRD}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Significance}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Honeybee venom} (\emph{Apis mellifera})\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Honeybee venom} (\emph{Apis mellifera})\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Honeybee venom} (\emph{Apis mellifera})\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Honeybee venom} (\emph{Apis mellifera})\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Api m 1} Phospholipase A2\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
57-97\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S\textsuperscript{1,2,3}, M\textsuperscript{4,5,6}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Marker allergen for HBV sensitization; Allows discrimination between HBV
and YJV/PDV sensitization\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Api m 2} Hyaluronidase\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
28-60\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S\textsuperscript{1,2,3}, M\textsuperscript{4}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Due to limited cross-reactivity with Ves v 2 and Pol d 2 in the absence
of CCDs, potential marker for HBV
sensitization\textsuperscript{**}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Api m 3} Acid phosphatase\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
28-63\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S\textsuperscript{1}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Marker allergen for HBV sensitization; Allows discrimination between HBV
and YJV/PDV sensitization; Valuable marker allergen to diagnose HBV
allergy in Api m 1-negative patients\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Api m 4} Melittin\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
17-54\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
M\textsuperscript{6}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Marker allergen for HBV sensitization; Allows discrimination between HBV
and YJV/PDV sensitization; Putative marker allergen for severe VIT
side-effects\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Api m 5} Dipeptidylpeptidase IV\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
16-70\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S\textsuperscript{1}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
High cross-reactivity with Ves v 3 and Pol d 3 prevents its use as
marker allergen\textsuperscript{***}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Api m 10} Icarapin\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
35-73\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S\textsuperscript{1,3}, M\textsuperscript{4,5}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Marker allergen for HBV sensitization; Allows discrimination between HBV
and YJV/PDV sensitization; Valuable marker allergen to diagnose HBV
allergy in Api m 1-negative patients; Dominant Api m 10 sensitization is
a putative marker for risk of VIT failure\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Yellow jacket venom} (\emph{Vespula vulgaris})\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Yellow jacket venom} (\emph{Vespula vulgaris})\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Yellow jacket venom} (\emph{Vespula vulgaris})\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Yellow jacket venom} (\emph{Vespula vulgaris})\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Ves v 1} Phospholipase A1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
39-66\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S\textsuperscript{1}, M\textsuperscript{4,5}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Marker allergen for YJV sensitization; Allows discrimination between YJV
and HBV sensitization; High cross-reactivity with Pol d 1prevents its
use as marker allergen to discriminate between YJV and PDV
sensitization\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Ves v 5} Antigen 5\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
82-98\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S\textsuperscript{1,2,3}, M\textsuperscript{4,5}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Marker allergen for YJV sensitization; Allows discrimination between YJV
and HBV sensitization; High cross-reactivity with Pol d 5 prevents its
use as marker allergen to discriminate between YJV and PDV
sensitization\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{European paper wasp venom} (\emph{Polistes dominula})\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{European paper wasp venom} (\emph{Polistes dominula})\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{European paper wasp venom} (\emph{Polistes dominula})\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{European paper wasp venom} (\emph{Polistes dominula})\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Pol d 1} Phospholipase A1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
87\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
M\textsuperscript{4}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Marker allergen for PDV sensitization; Allows discrimination between PDV
and HBV sensitization; High cross-reactivity with Ves v 1 prevents its
use as marker allergen to discriminate between PDV and YJV
sensitization\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Pol d 5} Antigen 5\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
72\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S\textsuperscript{1}, M\textsuperscript{4,5}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Marker allergen for PDV sensitization; Allows discrimination between PDV
and HBV sensitization; High cross-reactivity with Ves v 5 prevents its
use as marker allergen to discriminate between PDV and YJV
sensitization\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textsuperscript{*}Defined by different immunoassays and in different
patient populations. Sensitization rates are referenced in the main
text. \textsuperscript{**}Cross-reactivity with Ves v 2 and Pol d 2 is
possible. ***Api m 5 monosensitization may occur in HBV-allergic
patients. CCDs, cross-reactive carbohydrate determinants; CRD,
component-resolved diagnostics; HBV, honeybee venom; M, multiplex sIgE
assay system; PDV, \emph{Polistes dominula} venom; S, singleplex sIgE
assay system; YJV, yellow jacket venom. \textsuperscript{1}Thermo Fisher
Scientific, \textsuperscript{2}Siemens Healthcare
Diagnostics,\textsuperscript{3}Dr. Fooke Laboratories,
\textsuperscript{4}Euroimmun,\textsuperscript{5}Macro Array Diagnostics,
\textsuperscript{6}Faber test (different suppliers).

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