Allergen component testing

Allergens by the numbers

Testing for whole allergen proteins can help you better diagnose allergies/sensitizations and prepare personalized management plans. Allergen component testing

Find out more about the allergens listed below, inside.

Peanut allergen 77.6 % Egg allergen of peanut-sensitive of children with egg patients may not % pg 4 70 allergy do not react be at risk for a to baked egg.2 systemic reaction.1

pg 6

Walnut, cashew, and Brazil nut allergen

pg 8 Milk allergen

Hazelnut allergen pg 12 75% Among the of children with milk top 5 allergy do not react to causes of serious baked milk.3 food allergic pg 10 reactions.4 Peanut allergen component testing

Measurement of specific IgE by blood test that provides Determine objective assessment of sensitization to the whole peanut is the first step in discovering the likelihood of a which proteins systemic reaction and the necessary precautions that your patient is may be prescribed. sensitized to. High levels of peanut IgE can predict the likelihood of peanut sensitivity, but may not be solely predictive of reactions or allergic response.1

Knowing to which protein your patient is sensitized can help you develop a management plan.1,5,11-13

Reduce patient anxiety with individualized management plans. Ara h1 Ara h2 Ara Ara Ara h8 h9 h3

LOWER RISK VARIABLE RISK HIGHER RISK of systemic reaction5 of systemic reaction of systemic reaction 7 9,10 • Risk of mild, localized symptoms, including anaphylaxis including anaphylaxis such as itching/tingling of the lips, • Often accompanied by • Sensitization to Ara h2 is nearly mouth, and oropharynx6 sensitization to other always associated with clinical 8 5 • Cross-reactive with pollens peanut proteins peanut allergy (e.g., birch)6 • Cross-reactive with fruits with pits (e.g., peaches)7

Ara h8 Ara h9 Ara h1, 2, 3 Test interpretations and next steps

Oral food challenge (OFC) with a specialist may be recommended. High likelihood that patient may pass OFC. If patient passes an OFC: + - - • Foods prepared with or around peanuts may be consumed • Patient not restricted to peanut-free zones

5 If there is no clinical history of symptoms, please see considerations above +/- + - 6 If there is a clinical history of symptoms, please see considerations below

• Choose peanut-free zones for patient’s safety • Prescribe epinephrine auto-injector +/- +/- + • Family, colleagues, and teachers should be made aware of allergy and have a plan

As in all diagnostic testing, a diagnosis must be made by the physician based on test results, individual patient history, the physician’s knowledge of the patient, and the physician’s clinical judgement. Egg allergen component testing

Measurement of specific IgE by blood test that provides Determine objective assessment of sensitization to egg white is the first step in discovering your patient’s allergy. Egg which proteins allergen component tests can help you determine the your patient is likelihood of reaction to products baked with egg, such sensitized to. as muffins or cookies, as well as the likelihood of allergy persistence.

High levels of egg white IgE may predict the likelihood of sensitivity, but may not be solely predictive of reactions to baked egg or allergy duration.14

Knowing which protein your patient is sensitized to can help you develop a management plan.14,15,2,22 Gal Gal d2 d1

Ovalbumin Ovomucoid

• Susceptible to heat • Resistant to heat denaturation15 15 denaturation • HIGHER RISK of reaction to all • HIGHER RISK of reaction forms of egg14 14,16 to uncooked egg • Patient unlikely to outgrow • LOWER RISK of reaction egg allergy with high levels of to baked egg14,16,a specific IgE to ovomucoid18-21 • Patient likely to outgrow egg allergy17

Ovalbumin Ovomucoid Test interpretations and next steps

• Avoid uncooked eggs • Likely to tolerate baked egg • Baked egg oral food challenge with a specialist may be appropriate • Consider repeating IgE component test + - biennially during childhood to determine potential tolerance • May be transferred via breast milk, so mothers of infants with egg allergy should take caution when breastfeeding

• Avoid all forms of egg • Consider repeating IgE component test biennially during childhood to determine potential tolerance +/- + • Patients sensitized to ovalbumin with low levels of IgE to ovomucoid may react to egg that is not fully baked

As in all diagnostic testing, a diagnosis must be made by the physician based on test results, individual patient history, the physician’s knowledge of the patient, and the physician’s clinical judgement. aIn clinical studies, extensively baked muffin and waffle were heated to the point of protein denaturation. Walnut, cashew, and Brazil nut allergen component testing

Measurement of specific IgE by Walnut blood test that provides objective TC 3489 assessment of sensitization to One of the most common causes 23,24 whole nut proteins is the first Walnut of allergic reactions to tree nuts. step in discovering the likelihood • Estimated prevalence of walnut allergy of a systemic reaction and the in the general population is up to 0.7%.24 necessary precautions that • Potentially life-threatening, increasing may be prescribed. in prevalence and rarely outgrown.24,25 Knowing which protein your patient is sensitized to can help you develop a management plan. Associated with Jug 24 r1 systemic reactions • Storage protein (2s albumin) 25,26 • Heat and digestion stable26 • Highly abundant in walnut

Associated with local Jug 24 r3 and systemic reactions • Lipid transfer protein (LTP)23,26 • Heat and digestion stable

Determine Positive 3489 with negative Jug r1 which proteins and Jug r3 results may be explained your patient is by sensitization to27: • Other walnut storage proteins sensitized to. • Pollen proteins like profilin or PR-10 proteins • CCD (cross-reacting carbohydrate determinants) Cashew nut Brazil nut

TC 2608 TC 2818 Allergy on the rise with increased Hidden allergen often found in Cashew consumption in snack foods, Asian Brazil cookies, insect repellent, and foods, baked goods, nut butters, and beauty products.31 pestos.29,30 • Extensive cross-reactivity within the • Sensitized patients have a risk of experiencing family can be expected.32 severe allergic reactions; the risk has been • Generally persists and is potentially reported to be even higher than for peanut life-threatening.33 allergic patients (74% vs. 30%).28

• Potentially life-threatening, can start early in 23,30 life and is rarely outgrown. Associated with systemic Ber 34,35 e1 reactions • Storage protein (2s albumin)31 • Resistant to digestion by pepsin, Associated with systemic and a major allergen31 Ana 29 o3 reactions • Very stable to gastric digestion31 29 • Storage protein (2s albumin) • Major allergen in Brazil nut31 • Heat and digestion stable23,26 • Highly abundant in cashew nut

Positive 2608 with negative Ana o3 Positive 2818 with negative Ber e1 results may be explained by results may be explained by sensitization to27: sensitization to27: • Other cashew nut storage proteins or lipid • Other Brazil nut storage proteins or lipid transfer protein (LTP) transfer protein (LTP) • Pollen proteins like profilin or PR-10 proteins • Pollen proteins like profilin or PR-10 proteins • CCD (cross-reacting carbohydrate • CCD (cross-reacting carbohydrate determinants) determinants) Milk allergen component testing

Measurement of specific IgE by blood test that Determine provides objective assessment of sensitization to milk is the first step in discovering your patient’s which proteins allergy. Milk allergen component tests can help your patient is you determine the likelihood of reaction to baked sensitized to. goods, such as cookies or cheese pizza, as well as the likelihood of allergy persistence.

High levels of milk IgE may predict the likelihood of sensitivity, but may not be solely predictive of reactions to baked milk or allergy duration.36

Knowing which protein your patient is sensitized to can help you develop a management plan.3,37-41 Bos Bos Bos d4 d5 d8

TC 2851 TC 2852 TC 2853 α-lactalbumin β-lactoglobulin Casein Bos d5 / f77 • Susceptible to heat • Susceptible to heat • Resistant to heat denaturation42 denaturation42 denaturation3 • HIGHER RISK of reaction • HIGHER RISK of reaction • HIGHER RISK of reaction to fresh milk3,36 to fresh milk3,36 to all forms of milk3,36,37 • LOWER RISK of reaction • LOWER RISK of reaction • Patient unlikely to outgrow to baked milk3,36,a to baked milk3,36,a milk allergy with high levels 43 • Patient likely to outgrow • Patient likely to outgrow of specific IgE to casein milk allergy43 milk allergy43

α-lactalbumin β-lactoglobulin Casein Test interpretations and next steps

• Avoid fresh milk + + - • Likely to tolerate baked milk products • Baked milk oral food challenge with a specialist may be appropriate + - - • Likely to outgrow allergy - + -

• Avoid all forms of milk • Unlikely to become tolerant of milk +/- +/- + over time • Avoid milk and baked milk products (yogurt, cookies, cakes), as well as products processed with milk (chocolate, sausage, potato chips)

As in all diagnostic testing, a diagnosis must be made by the physician based on test results, individual patient history, the physician’s knowledge of the patient, and the physician’s clinical judgement. aIn clinical studies, extensively baked muffin, waffle, and cheese pizza were heated to the point of protein denaturation. Hazelnut allergen component testing

Measurement of specific IgE by blood test that provides Hazelnut allergen objective assessment of sensitization to hazelnut is only the first step in discovering the likelihood of a systemic component test reaction and the necessary precautions that may be results can help prescribed. determine which Allergen components, in conjunction with whole-allergen specific proteins test results, help you better diagnose allergies, allowing your patient is you to prepare more comprehensive management plans. sensitized to. High levels of hazelnut IgE can predict the likelihood of hazelnut sensitivity, but may not be solely predictive of reactions or allergic response.44 Cor Cor Cor

a1 a8 a9 Cor a14

LOWER RISK of systemic VARIABLE RISK HIGHER RISK reaction primarily associated with local of systemic reaction associated with local and systemic reactions including anaphylaxis44,45,51,52 45 45,48,49 reactions including anaphylaxis • Heat and digestion stabile53 46 50 • Heat and digestion stabile • Heat and digestion stabile • Sensitization to these can • Cross-reactive with pollens • Indicates cross-reactivity, appear early in life and indicates (e.g., birch)44,47 often from a primary peach a primary hazelnut allergy1 sensitization48

Take the diagnosis and management of hazelnut-sensitized patients to a whole new level.

RISK ASSESSMENT TEST INTERPRETATIONS AND NEXT STEPS

IgE antibodies for Indication Patient suggestions

Test for sensitization to a14 Associated with systemic Cor a14 peanuts and other tree nuts reactions in hazelnut- and/or (e.g., walnuts and Brazil nuts), sensitized patients.44,45,51,52 a9 Cor a9 as cross-reactivity may occur.53,54 If both, avoid raw as well as roasted/ heated hazelnuts.50 Both local oral symptoms a8 Cor a8 and systemic reactions may occur.45,49

Typically associated with local reactions although Cor a1 systemic reactions to raw a1 Often tolerate roasted or heated hazelnuts.50 Mono-sensitization hazelnuts may occur in some cases, especially in adults.45

As in all diagnostic testing, a diagnosis must be made by the physician based on test results, individual patient history, the physician’s knowledge of the patient, and the physician’s clinical judgement. Test Name Test Code

Brazil Nut w/Reflexes 94464 - Brazil nut, f18; IgE with reflex to component Cashew Nut w/ Reflexes 94465 - Cashew nut, f202; IgE with reflex to component Childhood Allergy Profile - D. pteronyssinus (House mite), (NTC-2721) d1; D. farinae (House mite), (NTC-2722) d2; Cat dander, (NTC-2601) e1; Dog dander, (NTC-2605) e5; 10659 Egg white, f1; Milk, f2; Codfish, (NTC-2803) f3; Wheat, (NTC-2804) f4; Peanut, (NTC-2813) f13; Soybean, (NTC-2814) f14; Shrimp, (NTC-2824) f24; Walnut, f256; Cockroach, (NTC-2736) i6; Cladosporium herbarum, (NTC-2702) m2; Alternaria alternata, (NTC-2706) m6; Total IgE Childhood Allergy Profile w/Reflexes - Contains all components of the Childhood Allergy Profile (NTC-10659) with reflex to the following components, Egg Component Panel, (NTC- 91683 91372); Ovomucoid, f233; Ovalbumin, f232; Milk Component Panel, (NTC-91403); Casein, f78; Alpha-lactalbumin, f76; Beta-lactoglobulin, f77; Peanut Component Panel, (NTC-91681) Ara h1, f422; Ara h2, f423; Ara h3, f424; Ara h8, f352; Ara h9 Egg Component Panel 91372 - Ovomucoid, f233; Ovalbumin, f232 Food Allergy Panel - Milk, f2; IgE Egg white, f1; IgE Peanut, (NTC-2813) f13; IgE Walnut, f256; IgE Corn, (NTC-2808) f8; IgE Wheat, (NTC-2804) f4; IgE Soybean, (NTC- 38767 2814) f14; IgE Codfish, (NTC-2803) f3; IgE Clam, (NTC-8929) f207; IgE Shrimp, (NTC-2824) f24; Total IgE Food Allergy Profile - Egg white, f1; Milk, f2; Codfish, (NTC-2803) f3; Wheat, (NTC-2804) f4; Corn, (NTC-2808) f8; Sesame seed, f10; Peanut, (NTC-2813) f13; 10715 Soybean, (NTC-2814) f14; Shrimp, (NTC-2824) f24; Clam, (NTC-8929) f207; Walnut, f256; Scallop, (NTC-273) f338 Food Allergy Profile w/Reflexes - Contains all components of the Food Allergy Profile (NTC-10715) with reflex to the following components, with reflex to Egg Component 91682 Panel, (NTC-91372); Ovomucoid, f233; Ovalbumin, f232; Milk Component Panel, (NTC-91403); Casein, f78; Alpha-lactalbumin, f76; Beta- lactoglobulin, f77; Peanut Component Panel, (NTC-91681) Ara h1, f422; Ara h2, f423; Ara h3, f424; Ara h8, f352; Ara h9 Hazelnut w/Reflexes 94468 - Hazelnut, (NTC-2817) f17; IgE with reflex to component panel Milk Component Panel 91403 - Casein, f78; Alpha-lactalbumin, f76; Beta-lactoglobulin, f77 Nut Mix Group 18 - IgE allergy testing for: Almond, f20; Cashew nut, f202; Coconut, f36; Hazelnut, f17; Peanut (with reflexes), (NTC-91747) f13; Pecan, f201; 7918 Sesame seed, f10 Nut Panel 94462 - Macadamia nut; Pecan; Brazil nut; Walnut; Cashew nut; Pistachio, (NTC-2726); Hazelnut; Almond; Peanut, (NTC-2813) Nut Panel w/Reflexes - Macadamia nut; Pecan; Brazil nut (with reflexes), (NTC-94464); Cashew nut (with reflexes), (NTC-94465); Walnut (with reflexes); Hazelnut 94463 (with reflexes), (NTC-94468); Pistachio, (NTC-2726); Almond; Peanut (with reflex), (NTC-91747) Peanut Component Panel 91681 - Ara h1, f422; Ara h2, f423; Ara h3, f424; Ara h8, f352; Ara h9 Peanut (Total) w/Reflex - Peanut, (NTC-2813) f13 91747 *Positive result reflexes to 91681—Peanut Component Panel (Ara h1, f422; Ara h2, f423; Ara h3, f424; Ara h8, f352; Ara h9) Walnut w/Reflexes 94467 - Walnut, f256; IgE with reflex to component panel Almond 2820 Alpha-lactalbumin 2851 Beta-lactoglobulin 2852 Brazil nut 2818 Casein 2853 Cashew nut 2608 Coconut 2836 Egg white 2801 Egg yolk 2856 Hazelnut 2817 Macadamia rf345 IgE 38475 Milk 2802 Ovalbumin 2719 Ovomucoid 3046 Pecan 2864 Sesame seed 2810 Walnut 3489

Multiple test codes are available. Refer to the Quest Diagnostics Directory of Services or the online Test Center (QuestDiagnostics.com/testcenter) for test information. NTC = National test code References

1. Nicolaou N, Poorafshar M, Murray C, et al. Allergy or tolerance in children 26. Masthoff L, et al. A systematic review of the effect of thermal processing sensitized to peanut: prevalence and differentiation using component- on the allergenicity of tree nuts. Allergy. 2013; 68: 983-993. resolved diagnostics. J Allergy Clin Immunol. 2010;125(1):191-197. 27. www.phadia.com 2. Lemon-Mulé H, Sampson HA, Sicherer SH, Shreffler WG, Noone S, Nowak- 28. Davoren M, et al. Cashew nut allergy is associated with a high risk of Wegrzyn A. Immunologic changes in children with egg allergy ingesting anaphylaxis. Arch Dis Child. 2005; 90(10): 1084-1085. extensively heated egg. J Allergy Clin Immunol. 2008;122(5):977-983. 29. Robotham J, et al. Ana o 3, an important cashew nut (Anacardium 3. Nowak-Wegrzyn A, Bloom KA, Sicherer SH, et al. Tolerance to extensively occidentale L.) allergen of the 2S albumin family. J Allergy Clin Immunol. heated milk in children with cow’s milk allergy. J Allergy Clin Immunol. 2005; 115(6): 1284-1290. 2008;122(2):342-347. 30. Clark A, et al. Cashew nut causes more severe reactions than peanut: 4. Flinterman AE, et al. Hazelnut allergy: from pollen-associated mild allergy case-matched comparison in 141 children. Allergy. 2007; 62(8): 913-916. to severe anaphylactic reactions. Curr Opin Allergy Clin Immunol. 2008 Jun; 8(3): 261-265. 31. www.phadia.com/en/Products/Allergy-testing-products/ImmunoCAP- Allergen-Information/Food-of-Plant-Origin/Seeds--Nuts/Brazil-nut-/ 5. Asarnoj A, Nilsson C, Lidholm J, et al. Peanut component Ara h 8 sensitization and tolerance to peanut. J Allergy Clin Immunol. 32. Yman L. Botanical relations and immuno-logical cross-reactions in pollen 2012;130(2):468-472. allergy. 2nd ed. Pharmacia Diagnostics AB. Uppsala. Sweden. 1982: ISBN 91-970475-09. 6. Mittag D, Akkerdaas J, Ballmer-Weber BK, et al. Ara h 8, a Bet v 1-homologous allergen from peanut, is a major allergen in patients with 33. Bartolome B, Mendez JD, Armentia A, Vallverdu A, Palacios R. Allergens combined birch pollen and peanut allergy. from Brazil nut: immunochemical characterization. Allergol Immunopathol J Allergy Clin Immunol. 2004;114(6):1410-1417. (Madr) 1997;25(3):135-144. 7. Lauer I, Dueringer N, Pokoj S, et al. The non-specific lipid transfer 34. Borja J, et al. Anaphylaxis from Brazil nut. Allergy. 54, 1999/1004-1013. protein, Ara h 9, is an important allergen in peanut. Clin Exp Allergy. 35. Sicherer SH, Sampson HA. Peanut and tree nut allergy. Curr Opin Pediatr 2009;39(9):1427-1437. 2000;12(6):567-73. 8. Movérare R, Ahlstedt S, Bengtsson U, et al. Evaluation of IgE antibodies 36. Shek LP, Bardina L, Castro R, Sampson HA, Beyer K. Humoral and to recombinant peanut allergens in patients with reported reactions to cellular responses to cow milk proteins in patients with milk-induced peanut. Int Arch Allergy Immunol. 2011;156(3):282-290. IgE-mediated and non-IgE-mediated disorders. Allergy. 2005;60(7):912- 9. Peeters KA, Koppelman SJ, van Hoffen E, et al. Does skin prick test 919. reactivity to purified allergens correlate with clinical severity of peanut 37. Boyano-Martínez T, García-Ara C, Pedrosa M, Díaz-Pena JM, Quirce S. allergy? Clin Exp Allergy. 2007;37(1):108-115. Accidental allergic reactions in children allergic to cow’s milk proteins. 10. Asarnoj A, Movérare R, Östblom E, et al. IgE to peanut allergen J Allergy Clin Immunol. 2009;123(4):883-888. components: relation to peanut symptoms and pollen sensitization in 38. Caubet J, Nowak-Wegrzyn A, Moshier E, Godbold J, Wang J, Sampson HA. 8-year-olds. Allergy. 2010;65(9):1189-1195. Utility of casein-specific IgE levels in predicting reactivity to baked milk. J 11. Dang TD, et al. Increasing the accuracy of peanut allergy diagnosis by Allergy Clin Immunol. 2013;131(1):222-224. using Ara H 2. J Allergy Clin Immunol. 2012;129(4):1056-1063. 39. CM Allergy Review. Diagnosis of cow’s milk allergy in children: determining 12. Nicolaou N, et al. Quantification of specific IgE to whole peanut extract the gold standard? Expert Rev Clin Immunol. 2014;10(2):257-267. and peanut components in prediction of peanut allergy. J Allergy Clin 40. Kim JS, Nowak-Wegrzyn A, Sicherer SH, Noone S, Moshier EL, Sampson Immunol. 2011:1-2. HA. Dietary baked milk accelerates the resolution of cow’s milk allergy in 13. Vereda A, et al. Peanut allergy: Clinical and immunologic differences children. J Allergy Clin Immunol. 2011;128(1):125-131. among patients from 3 different geographic regions. 41. Ito K, Futamara M, Movérare R, et al. The usefulness of casein-specific IgE J Allergy Clin Immunol. 2010;3(2):1-5. and IgG4 antibodies in cow’s milk allergic children. Clinical and Molecular 14. Ando H, Movérare R, Kondo Y, et al. Utility of ovomucoid-specific IgE Allergy. 2012;10:1:1-7. concentrations in predicting symptomatic egg allergy. J Allergy Clin 42. Wal JM. Bovine milk allergenicity. Ann Allergy Asthma Immunol. 2004;93(5 Immunol. 2008;122(3):583-588. Suppl 3):S2-S11. 15. Benhamou AH, Caubet JC, Eigenmann PA, et al. State of the art and 43. Sicherer SH, Sampson HA. Cow’s milk protein-specific IgE concentrations new horizons in the diagnosis and management of egg allergy. Allergy. in two age groups of milk-allergic children and in children achieving 2010;65(3): 283-289. clinical tolerance. Clin Exp Allergy. 1999;29(4):507-512. 16. Shin M, Han Y, Ahn K. The influence of the time and temperature of heat 44. Masthoff L, et al. Sensitization to Cor a 9 and Cor a 14 is highly specific treatment on the allergenicity of egg white proteins. Allergy Asthma for a severe hazelnut allergy in Dutch children and adults. J Allergy Clin Immunol Res. 2013;5(2):96-101. Immunol. 2013(In press). 17. Tomicic S, Norrman G, Fälth-Magnusson K, Jenmalm MC, Devenney I, 45. De Knop KJ, et al. Age-related sensitization profiles for hazelnut (Corylus Böttcher MF. High levels of IgG4 antibodies to foods during infancy are avellana) in a birch-endemic region. Pediatr Allergy Immunol. 2011 Feb; associated with tolerance to corresponding foods later in life. Pediatr 22(1Pt 2): e139-149. Allergy Immunol. 2009;20(1):35-41. 46. Hansen KS, et al. Roasted hazelnuts-allergenic activity evaluated by 18. Urisu A, Yamada K, Tokuda R, et al. Clinical significance of IgE-binding double-blind, placebo-controlled food challenge. Allergy. 2003 Feb; 58(2): activity to enzymatic digests of ovomucoid in the diagnosis and the 132-138. prediction of the outgrowing of egg white hypersensitivity. Int Arch Allergy 47. Pastorello EA, et al. Identification of hazelnut major allergens in sensitive Immunol. 1999;120(3):192-198. patients with positive double-blind, placebo-controlled food challenge 19. Bernhisel-Broadbent J, Dintzis HM, Dintzis RZ, Sampson HA. Allergenicity results. J Allergy Clin Immunol. 2002; 109(3): 563-570. and antigenicity of chicken egg ovomucoid (Gal d III) compared with 48. Lauer I, et al. The non-specific lipid transfer protein, Ara h 9, is an ovalbumin (Gal d I) in children with egg allergy and in mice. J Allergy Clin important allergen in peanut. Clinical & Experimental Allergy. 39: 1427- Immunol. 1994;93(6):1047-1059. 1437. 20. Montesinos E, Martorell A, Félix R, Cerdá JC. Egg white specific IgE levels 49. Schocker F, et al. Recombinant lipid transfer protein Cor a 8 from hazelnut: in serum as clinical reactivity predictors in the course of egg allergy A new tool for in vitro diagnosis of potentially severe hazelnut allergy. J follow-up. Pediatr Allergy Immunol. 2010;21(4 pt 1):634-639. Allergy Clin Immunol. 2004;113:141-147. 21. Järvinen KM, Beyer K, Vila L, Bardina L, Mishoe M, Sampson HA. 50. Masthoff L, et al. A systematic review of the effect of thermal processing Specificity of IgE antibodies to sequential epitopes of hen’s egg ovomucoid on the allergenicity of tree nuts. Allergy. 2013; 68: 983-993. as a marker for persistence of egg allergy. Allergy. 2007;62(7):758-765. 51. Hansen KS, et al. Component-resolved in vitro diagnosis of hazelnut 22. Boyano Martínez T, et al. Validity of specific IgE antibodies in children with allergy in Europe. J Allergy Clin Immunol. 2009 Apr 1; 123(5): 1134-1141. egg allergy. Clinical and Experimental Allergy. 2001;13:1464-1469. 52. Garino C, et al. Isolation, cloning, and characterization of the 2S albumin: a 23. Roux K, et al. Tree nut allergens. Int Arch Allergy Immunology. 2003; 131: new allergen from hazelnut. Mol Nutr Food Res. 2010; 54: 1257-1265. 234-244. 53. Asero R, et al. Walnut-induced anaphylaxis with cross-reactivity to 24. Pastorello E, et al. Lipid transfer protein and vicilin are important walnut hazelnut and Brazil nut. J Allergy Clin Immunol. 2004 Feb; 113(2): 358-360. allergens in patients not allergic to pollen. J Allergy Clin Immunol. 2004; 114(4): 908-914. 54. Verweij M, et al. Young infants with atopic dermatitis can display sensitization to Cor a 9, an 11S legumin-like, seed-storage protein from 25. Rosenfeld L, et al. Walnut allergy in peanut-allergic patients: significance hazelnut (Corylus avellana). Pediatric Allergy Immnol. 2011; 22: 196-201. of sequential epitopes of walnut homologous to linear epitopes of Ara h 1, 2 and 3 in relation to clinical reactivity. Int Arch Allergy Immunol. 2012; 157:238-245. Quest Diagnostics delivers critical information when you need it

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