Ask the Expert

We wish to develop a screening test panel of 40 allergens containing at least 6 major molds and an extended panel with even more molds for SE USA and that would also cover AFS. Looking at the practice parameters for mold they recommend on the basic panel:
Alternaria alternata
Cladosproum (C. cladopsporoides, C. herbarum)
Penicllium (P. chrysoggenum, P expansum)
Aspergillus fumigatus
Epicoccum nigrum, Dreschlera or Bipolaris type

Several questions:
a) What is meant by Dreschlera or Bipolaris type?
b) In an article in 1995 by Horner et al (see below):"consensus is that skin test panels should include at a minimum: Alternaria alternata, Aspergillus fumigatus, Cladosproium herbarum, Epiccocum nigrum, Fusarium roseum, and Pencillium chrysogenum (notatum)." Parameters don't mention Fusarium roseum.

c) An extract companies' aerobiology expert recommended inclduing both C. cladosporoides and C. herbarum in the basic testing panel since they are antigenically unique.

d) One extract company has Fusarium solani and moniliforme in their catalog and another has Fusarium vasinfectum. Neither has the above Fusarium roseum, and the article referenced below states (2) analytic evidence that Fusarium solani has the most abundant antigens. Would you pick F. solani for the extended panel?

e) My hypothetical panel of 6 bsic molds includes:
A. Alternata, A. fumigatus, C. herbarum and C. cladospoides, P. notatum and E. nigrum. What are your thoughts on these six?

f) What molds should I select for an extended panel?
Helminthosporium solani or interseminatum, other?
Curvularia spiciferas?
Fusarium –species selection? -see above
Mucor racemosus or plumbeus?
Phoma betae or herbarum?
Pullularia pullulans?
Rhizopus nigricans?
Stemphylium solani?
Bipolaris sorkiniana?
Botrytis cinerea?
Trichophyton tonsurans?
Aspergillus niger?
Aspergillus flavus?
Exserohilum?
Acremomium?

What about other species not as common on allergy test sheets?
Candida
Chaetonium globosum
Slime molds
Nigrospora
Trichophyton
Smut molds

Note: Mabry et al test the following when evaluating suspected allergic fungal sinusitis:
Alternaria, Aspergillus, Curvularia, Epicoccum, Fusarium, Helminthosporium, Hormodendrum, Mucor, Penicillium, Pullularia, Stemphylium

1) Mabry RL, Marple BF, Mabry CS. Mold testing by RAST and skin test methods in patients with allergic fungal sinusitis. Otolaryngol Head Neck Surg. Sep 1999;121(3):252-4.

2) CLINICAL MICROBIOLOGY REVIEWS, Apr. 1995, p. 161–179 Vol. 8, No. 2
Fungal Allergens
W. E. HORNER,* A. HELBLING, J. E. SALVAGGIO, AND S. B. LEHRER
Section of Clinical Immunology and Allergy, Department of Medicine, Tulane University Medical Center, New Orleans, Louisiana 70112

Thank you for your recent inquiry.

I am going to ask Dr. Robert Bush, who is a nationally known expert in the aerobiology of mold allergens, to respond to your question. As soon as I hear from Dr. Bush, I will forward his response to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We have received a response from Dr. Robert Bush. Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Robert Bush:
As you are aware, fungal allergenic extracts for diagnostic (much less therapeutic) use are limited by variability in composition, lack of standardization, and frequent cross-reactivity. Also changes in nomenclature adds to the confusion.

Here are my suggestions:
For a general screening panel (prick skin testing):
Alternaria alternata
Aspergillus fumigatus
Penicillium chrysogenum (notatum)
Cladosporium herbarum, C. cladosporiodes, C.sphaerospermum [Hormodendrum hordei](consider mix)  Drechslera(Curvularia) spicifera or Bipolaris sorokiniana (Helminthosporium sativum) possibly Epicoccum nigrum

For the expanded panel:
Fusarium species- solani, vasoinfectum,moniliforme (consider mix) Mucor racemosus Aureobasidium (Pullularia) pullulans Aspergillus species -flavus, niger (consider mix) Trichophyton tonsurans Chaetonium globosum
+/- Candida albicans
Phoma and Stemphyllium share allergens with Alternaria. Aspergillus and Penicillium have cross-reactive allergens. I think this would be a reasonable approach. IT with fungi is another story, with limited published studies.

Dr Bob Esch from Greer Labs is a good reference source.

Best Regards,
Bob Bush