Substance Info: (and synonyms)
Alternaria alternata / Alternaria tenuis

Background Info:

A. alternata is a common and cosmopolitan mould species occurring on many plants and other substrates including soils, food stuffs and textiles. Known habitats are soils, corn silage, rotten wood, composts, bird nests, and various forest plants. Black spots on tomatoes may be caused by A. Alternata. It is frequently found on water condensed on window frames. It is considered an outdoor mould and appears when the weather is warm.

Of 981 children on the Isle of Wight followed for atopy at age 4 years, and skin-prick tested with a battery of allergens, 61 (6%) reacted positively to Alternaria alternata and Cladosporium herbarum (Tariq 1996 ref.2647 8).


Adverse Reactions:


[ 1 / 42 ]

Alt a 1, which has been described as the major allergen in A alternata, shows a good correlation with A alternata spores only when they have germinated. This study correlated spore counts and clinical symptoms in patients with allergic asthma and/or rhinitis monosensitized to A alternata. A alternata spores were detected throughout the year, whereas Alt a 1 was detected only between March and December. Symptoms showed positive and significant correlations with spore counts, and Alt a 1 levels. The correlation between spores and Alt a 1 was low. In patients who are allergic to A alternata, Alt a 1 levels can be considered an important marker for predicting the risk of respiratory symptoms. (Feo 2012 ref.28421 2)

Feo BF, Alonso AM, Carnes J, Martin-Martin R, Fernandez-Caldas E, Galindo PA, Alfaya T, mo-Salas M. Correlation between Alt a 1 levels and clinical symptoms in Alternaria alternata-monosensitized patients. J Investig Allergol Clin Immunol 2012;22(3):154-159

[ 2 / 42 ]

This study suggests Alternaria as a major allergen that its presence in the nasal cavity and subsequent development of sensitization have significant role in the induction of allergic rhinitis. (Mokhtari 2011 ref.26859 7)

Mokhtari AM, Mokhtari Amirmajdi NA, Eftekharzadeh M, Jabari AF, Tavakol AJ, Shakeri MT. Alternaria in patients with allergic rhinitis. Iran J Allergy Asthma Immunol 2011 Sep;10(3):221-226

[ 3 / 42 ]

The objective of this study was to examine the relationship between skin test reactivity (STR) to molds and specifically to Alternaria and asthma severity in a group of ethnically diverse children in Connecticut. Demographics and STR to 14 local allergens, including Alternaria, Penicillium, and mold mix, were obtained for 914 Puerto Rican, African American, and non-Hispanic white children. A total of 126 children (14%) had a positive skin test result to mold, and 58 (6%) demonstrated STR to Alternaria. Compared with non-Hispanic white children, there was no difference in the likelihood of being sensitized to Alternaria for Puerto Rican and African American children. In an adjusted analysis, Alternaria STR was associated with severe, persistent asthma but did not predict increasing asthma severity. STR to cat was also associated with severe persistent asthma. Alternaria STR was associated with severe persistent asthma independent of the total number of positive skin test results. (Lyons 2011 ref.26144 8)

Lyons TW, Wakefield DB, Cloutier MM. Mold and Alternaria skin test reactivity and asthma in children in Connecticut. Ann Allergy Asthma Immunol 2011 Apr;106(4):301-307

[ 4 / 42 ]

This study aimed to investigate the effect of outdoor Alternaria spore concentrations on monthly lung function tests, symptoms, and medication scores in children sensitised only to Alternaria. Twenty-five patients with a clinical diagnosis of asthma and/or rhinitis sensitised only to Alternaria were enrolled in the prospective study. The outdoor Alternaria spore concentrations were significantly correlated with the monthly average temperature and monthly average barometric pressure. Similarly, the outdoor Alternaria spore concentrations were significantly correlated with mean monthly asthma medication score, value monthly PEF, value monthly FEF25-75% and, variation in PEF. (Kilic 2010 ref.26240 0)

Kilic M, Ufuk AD, Yilmaz M, Guneser KS, Bingol KG, Taskin E, Ceter T, Pinar NM. The effects of meteorological factors and Alternaria spore concentrations on children sensitised to Alternaria. Allergol Immunopathol (Madr ) 2010 May;38(3):122-128

[ 5 / 42 ]

This study assessed the efficacy of standardized SLIT in patients sensitized to Alternaria in a randomized, prospective, double-blind, placebo-controlled trial. After treatment, patients receiving SLIT had a significant improvement in symptoms and a reduction in medication intake vs placebo and vs the run-in season, whereas no change was seen in the placebo group. Skin prick test reactivity significantly decreased only in the SLIT group. No change was seen in specific IgG4 levels in the 2 groups, whereas Alt a 1 specific IgE levels significantly increased in the active group. One patient in the active group reported oral itching and conjunctivitis at the beginning of treatment. (Cortellini 2010 ref.25491 7)

Cortellini G, Spadolini I, Patella V, Fabbri E, Santucci A, Severino M, Corvetta A, Canonica GW, Passalacqua G. Sublingual immunotherapy for Alternaria-induced allergic rhinitis: a randomized placebo-controlled trial. Ann Allergy Asthma Immunol 2010 Nov;105(5):382-386

[ 6 / 42 ]

In children with Alternaria-sensitive moderate-severe asthma, there was increased Th2 sensitivity to Alternaria stimulation. This was associated with HLA-DR restriction and with increased frequency of HLA-DRB1*13 and HLA-DRB1*03. There was decreased frequency of HLA-DQB1*03 in Alternaria-sensitive moderate-severe asthma, suggesting HLA-DQB1*03 may be protective of the development of Alternaria-sensitive severe asthma. (Knutsen 2010 ref.24997 5)

Knutsen AP, Vijay HM, Kumar V, Kariuki B, Santiago LA, Graff R, Wofford JD, Shah MR. Mold-sensitivity in children with moderate-severe asthma is associated with HLA-DR and HLA-DQ. Allergy 2010 May 10;

[ 7 / 42 ]

The aim of this Six Cities Study was to assess at the population level the relationships in childhood between Alternaria sensitization and 'past-year rhinoconjunctivitis' (PYRC), 'ever hay fever' (EHF) and 'ever allergic rhinitis caused by allergens other than pollens' (EAR) according to the presence or the absence of asthma. Some 6726 children with a mean age of 10 years were examined. The overall prevalence of Alternaria sensitization was 2.8%, 0.8% for monosensitization. Prevalences of symptoms in sensitized children were 27.7% for PYRC, 27.0% for EHF and 30.4% for EAR. Adjusted Odds Ratios (OR) between Alternaria sensitization and allergic rhinitis phenotypes were 2.34 (95% confidence interval: 1.51-3.63) for PYRC, 2.40 (1.65-3.50) for EHF and 2.95 (2.05-4.23) for EAR. The relationship still remained in the case of monosensitization to Alternaria for both PYRC and EAR when excluding the asthmatic children [OR = 3.87 (1.54-9.78) and 2.88 (1.10-7.55) respectively]. (Randriamanantany 2009 ref.24061 5)

Randriamanantany ZA, nnesi-Maesano I, Moreau D, Raherison C, Charpin D, Kopferschmitt C, Lavaud F, Taytard A, De BF, Caillaud D. Alternaria sensitization and allergic rhinitis with or without asthma in the French Six Cities study. Allergy 2010 Mar;65(3):368-75.

[ 8 / 42 ]

Thirty-four adult atopic subjects were randomized into mold-sensitive groups based on skin test reactivity by skin percutaneous testing (SPT) and/or intradermal (ID) testing to a mixed mold (MM) extract preparation (Aspergillus fumigatus, Aspergillus niger, Fusarium oxysporum, Alternaria tenuis, Epicoccum nigrum, Hormodendrum cladosporioides, Pullularia sp., Penicillium notatum, Mucor racemosus, and Trichophyton rubrum). Based on challenge results and scoring model, mold-sensitive subjects compared with nonmold-sensitive subjects experienced cumulatively higher symptom scores after oral challenge to an MM extract preparation. Future studies are warranted to confirm whether ingestion of aeroallergenic molds in food may be another contributor to symptoms in mold-sensitive individuals. (Luccioli 2009 ref.24507 7)

Luccioli S, Malka-Rais J, Nsouli TM, Bellanti JA. Clinical reactivity to ingestion challenge with mixed mold extract may be enhanced in subjects sensitized to molds. Allergy Asthma Proc 2009 Jul;30(4):433-442

[ 9 / 42 ]

Alternaria alternata sensitivity is a compelling predictor of epidemic asthma in patients with seasonal asthma and grass pollen allergy and is likely to be the important factor in thunderstorm-related asthma. (Pulimood 2007 ref.20272 9)

Pulimood T, Corden J, Bryden C, Sharples L, Nasser S. Epidemic asthma and the role of the fungal mold Alternaria alternata. J Allergy Clin Immunol 2007 Jul 9;

[ 10 / 42 ]

Alternaria was assessed in USA homes. Lifetime prevalence of doctor-diagnosed asthma was 11.2%, and 6.9% of the study subjects reported active asthma symptoms in the past 12 months. The prevalence of current symptomatic asthma increased with increasing Alternaria concentrations in US homes; higher levels of A alternata antigens increased the odds of having asthma symptoms in the past year. (Salo 2006 ref.15959 5)

Salo PM, Arbes SJ, Sever M, Jaramillo R, Cohn RD, London SJ, Zeldin DC. Exposure to Alternaria alternata in US homes is associated with asthma symptoms. J Allergy Clin Immunol 2006 Oct;118(4):892-898

[ 11 / 42 ]

The presented study concerned mycological analysis of buildings in Lodz and evaluation of the role between filamentous fungi contaminated flats and inhabitants health (allergic airway diseases). 49 inhabitants of 20 flats with signs of moulds contamination were examined. Air samples were collected in houses and outdoors. In all inhabitants skin prick tests (SPT) to common allergens and to standardized particular fungal extracts were performed. Moreover, total and serum specific IgE to moulds, rest spirometry were measured in all subjects. Level of moulds contamination in the air of flats was high and in 75% cases exceed accepted limits. The most frequent species isolated from examined rooms were: Penicillium, Cladosporium, Aspergillus, Acremoniu and Alternaria. The most frequent symptoms reported by examined subjects were rhinitis (N = 29, 59.2%), conjunctivitis (N = 29, 59.2%), chronic cough (N = 24, 49%), dyspnea (N = 15, 30.6%) and skin symptoms (N = 24, 49%). Elevated IgE level was found in 12 subjects (2 4.5%) and in three patients (6.1%) mould specific serum IgE were detected. Nineteen out of all subjects (38.8%) had positive SPT to common allergens (house dust mites, grass and tree pollens). Eight out of these patients (16.3% of the group) were sensitized to moulds (Candida albicans, Alternaria alternata, Botrytis cinerea, Trichophyton mentagrophytes, Helminthosporium halodes, Aspergillus). In all cases sensitisation to moulds was accompanied by allergy to other common allergens. No isolated hypersensitivity to moulds was found. Although the frequency of self-reported symptoms was high, the prevalence of atopy and allergic diseases seems to be similar to that found in general population, but that statement must be confirmed by comparison of the control group (Gutarowska 2005 ref.15852 7)

Gutarowska B, Wiszniewska M, Walusiak J, Piotrowska M, Palczynski C, Zakowska Z. Exposure to moulds in flats and the prevalence of allergic diseases--preliminary study. Pol J Microbiol. 2005;54 Suppl(0):13-20.

[ 12 / 42 ]

Mold-induced hypersensitivity pneumonitis. (Greenberger 2004 ref.11182 5)

Greenberger PA. Mold-induced hypersensitivity pneumonitis. Allergy Asthma Proc 2004;25(4):219-23

[ 13 / 42 ]

Alternaria is a major aeroallergen in many parts of the world. Sensitivity to Alternaria has been increasingly recognized as a risk factor for the development and persistence of asthma, asthma severity, and potentially fatal asthma exacerbations. A 9-year-old boy with IgE-mediated sensitivity to Alternaria who developed an acute, life-threatening asthma attack during the peak Alternaria season. We describe the aerobiology, pathophysiobiology, diagnosis, and treatment options for patients with Alternaria-induced asthma. (Bush 2004 ref.9102 4)

Bush RK, Prochnau JJ. Alternaria-induced asthma. J Allergy Clin Immunol 2004;113(2):227-34

[ 14 / 42 ]

A total of 6840 Italian children with asthma or allergic rhinitis were evaluated. Among the 6840 children 213 were positive to Alternaria alternate (3.3%), only 89/6840 children (1.3%) had A. alternate monosensitization, a concordance between SPTs and RAST was present in 21/89 (23.6%) children, and only 9 children out of 89 were SIT treated. 83 had asthma or allergic rhinitis, and 6 had asthma associated with atopic dermatitis. The mean onset of A. alternate sensitivity was at age 4 for males, and at age 5 for females. (Cantani 2004 ref.13889 3)

Cantani A, Ciaschi V. Epidemiology of alternaria alternata allergy: a prospective study in 6840 Italian asthmatic children. Eur Rev Med Pharmacol Sci 2004 Nov-Dec;8(6):289-94.

[ 15 / 42 ]

In this New York study, analysis showed that the presence of hypersensitivity to either A. tenuis or C. herbarum had a significant independent association with asthma after adjustment for cat/dust mite hypersensitivity and after adjustment for other clinical factors. (Lin 2003 ref.24956 8)

Lin RY, Williams KD. Hypersensitivity to molds in New York City in adults who have asthma. Allergy Asthma Proc 2003 Jan-Feb;24(1):13-8.

[ 16 / 42 ]

In an Italian study, skin prick tests were applied to a cohort of 4962 respiratory subjects, aged 3-80 years. Fungal extracts from Alternaria, Aspergillus, Candida, Cladosporium, Penicillium, Saccharomyces, and Trichophyton were used, along with extracts from pollens, mites, and animal dander. Nineteen percent of the allergic population reacted to at least one fungal extract by means of the skin test. Alternaria and Candida accounted for the largest number of positive tests, and along with Trichophyton they were the main sensitizers in the subset of patients with an isolated sensitization. (Mari 2003 ref.10913 4)

Mari A, Schneider P, Wally V, Breitenbach M, Simon-Nobbe B. Sensitization to fungi: epidemiology, comparative skin tests, and IgE reactivity of fungal extracts. Clin Exp Allergy 2003;33(10):1429-38

[ 17 / 42 ]

A study to determine whether natural exposure to Alternaria induces rhinoconjuctivitis symptoms in 132 alternaria-sensitized children (aged 7-12 years) in inland New South Wales Australia, demonstrated that the proportion of children atopic to Alternaria reporting symptoms of rhinitis and using anti-allergic medication was significantly higher in the summer, when airborne concentrations of Alternaria were high, than in the winter, when airborne concentrations were low. A strong correlation between airborne concentrations of grass pollen and Alternaria was found. However, when all children atopic to ryegrass were excluded from the analyses, significant associations between symptoms and season remained. (Andersson 2003 ref.11198 5)

Andersson M, Downs S, Mitakakis T, Leuppi J, Marks G. Natural exposure to Alternaria spores induces allergic rhinitis symptoms in sensitized children. Pediatr Allergy Immunol 2003;14(2):100-5

[ 18 / 42 ]

39 patients with Alternaria allergy, aged between 7 and 17 years. (Criado 2002 ref.11170 5)

Criado Molina A, Guerra Pasadas F, Daza Munoz JC, Moreno Aguilar C, Almeda Llamas E, Munoz Gomariz E, et al. Immunotherapy with an oral Alternaria extract in childhood asthma. Clinical safety and efficacy and effects on in vivo and in vitro parameters. [Spanish] Allergol Immunopathol (Madr) 2002;30(6):319-30

[ 19 / 42 ]

Alt a 1 is the major Alternaria allergen causing sensitization in asthmatics. Of 43 asthma/rhinitis patients having an Alternaria CAP score > 2, a high percentage (93%) had both IgE and IgG antibody to Alt a 1, emphasizing its importance as a major allergen. Only, 47% of atopic dermatitis patients with CAP score greater than 2 had antibody to Alt a 1, and their levels were low when compared to the asthmatics. Overall, patients with a low CAP (1-2) had a low prevalence (20-30%) of IgE or IgG antibody to Alt a 1. The study concludes that IgE and IgG antibody to Alt a 1 in asthmatics are good markers for sensitization to Alternaria. Although atopic dermatitis patients gave high Alternaria CAP scores, they had low or undetectable levels of IgE to Alt a 1, suggesting that other Alternaria allergens may be important in atopic dermatitis or that the CAP results are non-specific. (Vailes 2001 ref.4869 8)

Vailes LD, Perzanowski MS, Wheatley LM, Platts-Mills TA, Chapman MD. IgE and IgG antibody responses to recombinant Alt a 1 as a marker of sensitization to Alternaria in asthma and atopic dermatitis. Clin Exp Allergy 2001;31(12):1891-5

[ 20 / 42 ]

Significant concentrations of whole antigen from cat, dog, oak, Alternaria, and Cladosporium were found in house dust of allergic children. Alt a 1 and Alt a 70 kD levels varied between 3.0 and 1000 U/g of dust, supporting the hypothesis that fungal allergen exposure is an important component in the pathogenesis of the clinical condition known as asthma (Barnes 2001 ref.4146 7)

Barnes C, Tuck J, Simon S, Pacheco F, Hu F, Portnoy J. Allergenic materials in the house dust of allergy clinic patients. Ann Allergy Asthma Immunol 2001;86(5):517-23

[ 21 / 42 ]

In a study to investigated the extent to which exposure to Alternaria increases the severity of asthma, a prospective cohort study in Australia of 399 school children who had positive skin tests to one or more aeroallergens were studied, and found that airway responsiveness, wheeze, and bronchodilator use increased significantly in association with increased spore concentrations and that the increase in airway responsiveness was greater in children sensitized to Alternaria than in other children. These results suggest that Alternaria allergens contribute to severe asthma in regions where exposure to the fungus is high. (Downs 2001 ref.11213 5)

Downs SH, Mitakakis TZ, Marks GB, Car NG, Belousova EG, Leuppi JD, Xuan W, Downie SR, Tobias A, Peat JK. Clinical importance of Alternaria exposure in children. Am J Respir Crit Care Med 2001;164(3):455-9.

[ 22 / 42 ]

The aim of the study was to evaluate a group of patients monosensitized to Alternaria and to establish the prevalence, periodicity and clinical profile of this kind of sensitization. 37 subjects who were monosensitized to Alternaria (prick-test positive), of which 20 patients (over 50%) included in the study proved to be affected by asthma associated with other allergic symptoms and 22 patients (60%) presented perennial symptoms. The RAST carried out on 34 monosensitized subjects proved positive in 11 and negative in 23. The study concludes that Alternaria sensitization is characterized by a perennial periodicity with severe respiratory symptoms (asthma) which occur primarily in children. (Negrini 2000 ref.11221 7)

Negrini AC, Berra D, Campi P, Cinti B, Corsico R, Feliziani V, Gallesio MT, et al. Clinical study on Alternaria spores sensitization. Allergol Immunopathol (Madr) 2000;28(2):71-3

[ 23 / 42 ]

In 553 asthmatics in Kuwait, sensitisation to common aeroallergens as measured by serum specific IgE was: pollens (87.1%), house dust (76.1%), and molds (30.3%). The three most prevalent sensitizing pollens were from Chenopodium (S. kali) (70.7%), Bermuda grass (62.9%), and Prosopis (62.7%), all of which are horticultural plants imported for the purpose of "greening" the desert.
Frequency of sensitization to individual allergens among confirmed extrinsic asthmatics:
Allergens All patients (n=482)
Chenopodium weed 70.7
Bermuda grass 62.9
Prosopis tree 62.7
Cockroach 58.5
Cajeput tree 53.5
D. pteronyssinus 46.5
D. microceras 44.8
Eucalyptus tree 42.9
Date palm 39.6
D. farinae 38.6
Cat dander 30.9
Aspergillus 22.2
Alternaria 14.7
Cladosporium 14.1
(Ezeamuzie 2000 ref.4940 5)

Ezeamuzie CI, Thomson MS, Al-Ali S, Dowaisan A, Khan M, Hijazi Z. Asthma in the desert: spectrum of the sensitizing aeroallergens. Allergy 2000;55(2):157-62

[ 24 / 42 ]

In a study of 12,086 asthmatic children with asthma residing in US inner cities, 38.3% had positive skin test reactions to Alternaria species. (Eggleston 1998 ref.11146 7)

Eggleston PA, Rosenstreich D, Lynn H, Gergen P, Baker D, Kattan M, et al. Relationship of indoor allergen exposure to skin test sensitivity in inner-city children with asthma. J Allergy Clin Immunol 1998;102:563-70.

[ 25 / 42 ]

Allergic fungal sinusitis (AFS) has been a described disease entity, usually occurring in immunocomponent individuals. Early reports cited Aspergillus as the causative organism. It is now recognized that the dematiaceous fungi, including Bipolaris, Culvularia, Exserohilum, and Alternaria are associated with AFS. (Chang 1997 ref.12955 5)

Chang CZ, Hwang SL, Howng SL. Allergical fungal sinusitis with intracranial abscess--a case report and literature review. Kaohsiung J Med Sci 1997 Nov;13(11):685-9.

[ 26 / 42 ]

The relationships of asthma and allergic rhinitis with individual immediate skin test responses were examined for preferential associations and for changes with age in children raised in a semiarid environment. Immediate skin test responses to Bermuda grass were the most prevalent among children with allergic rhinitis and control subjects, whereas responses to the mold, Altenaria alternata, were the most prevalent among asthmatics. Skin test responses for crude house dust, Dermatophagoides farinae, and cat had low prevalences in all groups. Allergic rhinitis showed independent association with sensitization to Bermuda grass and mulberry tree pollen at age 11. The study concludes that Alternaria is the major allergen associated with the development of asthma in children raised in a semiarid environment and that skin test responses at age 6 are more closely linked to asthma than those at age 11. (Halonen 1997 ref.4810 8)

Halonen M, Stern DA, Wright AL, Taussig LM, Martinez FD. Alternaria as a major allergen for asthma in children raised in a desert environment. Am J Respir Crit Care Med 1997;155(4):1356-61

[ 27 / 42 ]

In 100 Thai individuals who were diagnosed with allergic rhinitis by history and clinical presentation who underwent a prick skin test with 30 aeroallergens:TREES: acacia 19%, mango 16%, coconut 12%. GRASSES: bermuda 17%, johnson 21%, timothy 16%, bahia 16% orchard 18%. WEEDS: pigweed 16%, kochia 14%. MOLDS: alternaria 11%, cladosporium 11%, aspergillus 12%, penicillium 16%, helminthosporium 16%, botrytis 15%, rhodotorula 20%, fusarium 26%, curvularia 26%, smut mix 11%, rust 9%. EPIDERMALS: cat 29%, dog 28%, feathers 37%. INDOOR ALLERGENS: house dust 72%, D. pteronyssinus 76%, D. farinae 79%, American cockroach 60%, German cockroach 41%, kapok 30%. Eighty-five percent of patients sensitive to house dust mites were positive to both D. pteronyssinus and D. farinae. (Pumhirun 1997 ref.2256 8)

Pumhirun P, Towiwat P, Mahakit P. Aeroallergen sensitivity of Thai patients with allergic rhinitis. Asian Pac J Allergy Immunol 1997;15(4):183-5

[ 28 / 42 ]

An association between emergency department visits for asthma in children who exhibited sensitivity to a variety of allergens including Alternaria has been reported. (Nelson 1996 ref.8061 7)

Nelson RP Jr, DiNicolo R, Fernandez-Caldas E, Seleznick MJ, Lockey RF, Good RA. Allergen-specific IgE levels and mite allergen exposure in children with acute asthma first seen in an emergency department and in nonasthmatic control subjects. J Allergy Clin Immunol 1996;98(2):258-63

[ 29 / 42 ]

Of 981 children on the Isle of Wight, followed for atopy at age 4 years, and skin-prick tested with a battery of allergens, 61 (6%) reacted positively to Alternaria alternata and Cladosporium herbarum. (Tariq 1996 ref.2647 3)

Tariq SM, Matthews SM, Stevens M, Hakim EA Sensitization to Alternaria and Cladosporium by the age of 4 years. Clin Exp Allergy 1996;26(7):794-8

[ 30 / 42 ]

In an Australian study examining sensitisation to Alternaria in different climatic regions, in the less humid interior, sensitivity to Alternaria was more likely to be associated with asthma than sensitivity to house dust mites. (Peat 1993 ref.11241 0)

Peat JK, Tovey E, Mellis CM, Leeder SR, Woolcock AJ. Importance of house dust mite and Alternaria allergens in childhood asthma: an epidemiological study in two climatic regions of Australia. Clin Exp Allergy 1993;23(10):812-20.

[ 31 / 42 ]

In an 1987 study of more than 17,000 US citizens, positive skin test responses to Alternaria occurred in 3.6% of the population, (Gergen, 1987 ref.6366 2) and that the independent association of individual allergen reactivity with respiratory disease on a sample of 4295, ages 6 to 24 years, that asthma was associated with reactivity to house dust and Alternaria. Allergic rhinitis was associated with reactivity to ragweed, ryegrass, house dust, and Alternaria. (Gergen 1992 ref.11239 3)

Gergen PJ, Turkeltaub PC. The association of individual allergen reactivity with respiratory disease in a national sample: data from the second National Health and Nutrition Examination Survey, 1976-80 (NHANES II). J Allergy Clin Immunol 1992;90(4 Pt 1):579-88

[ 32 / 42 ]

Alternaria is one of the most common astmospheric mold spores in the USA and the highest concentrations of spores are seen in grain-growing areas such as the Midwest. (O'Hollaren 1991 ref.6516 5)

O'Hollaren MT, Yunginger JW, Offord KP, Somers MJ, O'Connell EJ, Ballard DJ, Sachs MI. Exposure to an aeroallergen as a possible precipitating factor in respiratory arrest in young patients with asthma. N Engl J Med 1991;324:359-363

[ 33 / 42 ]

In a Japanes study, using skin prick tests and radioallergosorbent tests (RAST) on 94 asthmatic patients (mean age 12.0), A. restrictus, A. fumigatus, A. alternata and house dust elicited positive reactions in 8 (8.5%), 8 (8.5%), 15 (16.0%) and 69 (73.4%) patients, respectively. RAST showed positive reactions in 27 (28.7%) subjects for A. restrictus, 22 (23.4%) for A. fumigatus, 35 (37.2%) for A. alternata, and 75 (79.8%) for house dust.(Sakmoto 1990 ref.6926 4)

Sakamoto T, Ito K, Yamada M, Iguchi H, Ueda M, Matsuda Y, Torii S. Allergenicity of the osmophilic fungus Aspergillus restrictus evaluated by skin prick test and radioallergosorbent test. [Japanese] Arerugi 1990;39(11):1492-8

[ 34 / 42 ]

24 patients (5 to 56 years of age) only allergic to Alternaria. (Horst, 1990 ref.6454 2)

Horst, M., A. Hejjaoui, V. Horst, F. B. Michel, and J. Bousquet. Double-blind, placebo-controlled rush immunotherapy with a standardized Alternaria extract. J Allergy Clin Immunol 1990;85:460-472

[ 35 / 42 ]

Farmer's lung in infants and small children. A boy and a girl, 10 weeks and 3 years of age, respectively, were admitted with low temperature, dry cough, fatigue and weight loss. In both patients pulmonary X-rays showed diffuse, bilateral, micronodular infiltrations, and sparse signs of fibrosis. Serum IgG and blood eosinophils were abnormally high. However, after a few days at home, they were readmitted with the same symptoms. Family histories revealed that the children lived on farms with huge grain magazines and dryers, where moist grain and straw were stored. Massive amounts of mould spores were cultured from the residential areas, and, in addition, the male patient had an elevated titer to Micropolyspora faeni and the female patient, elevated titers to Thermoactinomyces vulgaris, Micropolyspora faeni, Aspergillus fumigatus and Alternaria alternans. The patients and their families moved from the farms and, for approximately a year, have been without lung symptoms. (Thorshauge 1989 ref.14256 7)

Thorshauge H, Fallesen I, Ostergaard PA. Farmer's lung in infants and small children. Allergy 1989 Feb;44(2):152-5.

[ 36 / 42 ]

In a study of hypersensitivity pneumonitis (humidifier lung) in 9 persons and isolated systemic symptoms without significant changes in lung function and chest x-rays (humidifier fever) in 3 persons, microbiological studies revealed a variety of fungi and bacteria in the water supplies of humidifiers and air conditioners at patients' workplaces. The detection of 4 members of the order Sphaeropsidales (Deuteromycotina), not previously associated with humidifier-induced diseases, is of special interest. Patients demonstrated low concentrations of IgG antibodies against thermophilic Actinomycetes, and other various fungi, such as Alternaria tenuis, Aureobasidium pullulans, Penicillium notatum, Aspergilli, and fungi of the order Sphaeropsidales, which were isolated and cultured from humidifier water supplies. (Baur 1988 ref.11481 7)

Baur X, Behr J, Dewair M, Ehret W, Fruhmann G, Vogelmeier C, Weiss W, Zinkernagel V. Humidifier lung and humidifier fever. Lung 1988;166(2):113-24

[ 37 / 42 ]

In a study in Sao Paulo, Brazil, evaluating sensitisation in 201 patients with asthma and/or allergic rhinitis to 42 airborne fungi using skin specific IgE tests, 15 were shown to be sensitised to Alternaria, 15 to Aspergillus, 23 to Aureobasidium, 37 to Candida, 15 to Chaetomium, 19 to Epicoccum, 17 to Mucor, 20 to Phoma, 19 to Trichoderma, and 14 to Rhizopus. . (Mohovic 1988 ref.11297 5)

Mohovic J, Gambale W, Croce J. Cutaneous positivity in patients with respiratory allergies to 42 allergenic extracts of airborne fungi isolated in Sao Paulo, Brazil. Allergol Immunopathol (Madr) 1988;16(6):397-402

[ 38 / 42 ]

In an 1987 study of more than 17,000 US citizens, positive skin test responses to Alternaria occurred in 3.6% of the population. (Gergen, 1987 ref.6366 2)

Gergen, P. J., P. C. Turkeltaub, and M. G. Kovar. The prevalence of allergic skin test reactivity to eight common aeroallergens in the U.S. population: results from the second National Health and Nutrition Examination Survey. J Allergy Clin Immunol 1987;80:669-679

[ 39 / 42 ]

This study asked whether immediate respiratory allergy with stemphylium exists? The authors present 39 children with positive cutaneous and/or RAST tests for stemphylium mold. Provocation tests were positive in 19 patients (14 boys and 4 girls, 10 to 16 years old in 17/19) with a respiratory sensitivity: 6/10 by passive anterior rhinomanometry and 13/15 by bronchial tests. Clinical symptoms were asthma and spasmodic rhinitis (14/19), predominantly from June to August. Eleven also had mite allergy and grass pollen allergy in 13. Positive cutaneous and/or RAST tests were also positive for Alternaria in 13/19. Specific hyposensitization was conducted in 14 children (3 years in 10 cases). Tolerance was excellent. (Lelong 1986 ref.25858 5)

Lelong M, Henard J, Wattre P, Duprey J, Thelliez P, Miersman R. Does immediate-type respiratory allergy occur regarding Stemphylium? Evaluation of 39 challenge tests. [French] Allerg Immunol (Paris) 1986 Oct;18(8):21, 23, 25-6.

[ 40 / 42 ]

290 asthmatic patients with positive skin tests for mould allergens were analyzed retrospectively. Tests with Alternaria alternata, Aureobasidium pullulans, Penicillium notatum, Fusarium culmorum, Aspergilus fumigatus and Cladosporium herbarum showed the highest correlation with clinical allergy. (Kersten 1980 ref.11485 7)

Kersten W, Hoek GT. Mould allergy (author's transl). [German] Wien Med Wochenschr 1980;130(8):275-82

[ 41 / 42 ]

Quincke's edema due to Alternaria and Stemphylium. (Gaudibert 1971 ref.25865 7)

Gaudibert R. Quincke's edema due to Alternaria and Stemphylium. [French] Rev Fr Allergol 1971 Jan-Mar;11(1):75-7.

[ 42 / 42 ]

A. alternata is considered one of the most important allergenic moulds in the United States and one of the most widely studied, though only one allergenic fraction has been studied in detail. Several studies have reported cross reactivity between A. alternata, Stemphylium and Curvularia

Editor Comment Editorial comment, common knowledge, or still to add - -

Non-Immune reactions

[ 1 ]

Subcutaneous alternariosis caused by Alternaria alternata in a 52-year-old male who underwent kidney transplantation 1 year earlier. The infection manifested as a vegetating mass about 7 cm in diameter on the right forearm. (Romano 2005 ref.13886 5)

Romano C, Vanzi L, Massi D, Difonzo EM. Subcutaneous alternariosis. Mycoses 2005 Nov;48(6):408-12.

[ 2 ]

"Toxic mold syndrome" is a controversial diagnosis associated with exposure to mold-contaminated environments. Molds are known to induce asthma and allergic rhinitis through IgE-mediated mechanisms, to cause hypersensitivity pneumonitis through other immune mechanisms, and to cause life-threatening primary and secondary infections in immunocompromised patients. Mold metabolites may be irritants and may be involved in "sick building syndrome." Patients with environmental mold exposure have presented with atypical constitutional and systemic symptoms, associating those symptoms with the contaminated environment. This study's objective was to characterize the clinical features and possible etiology of symptoms in patients with chief complaints related to mold exposure. The distribution of fungal species in patients with positive SPT or ICT reactions attributed 5 patients to Chaetomium globosum. (No details though). (Edmondson 2005 ref.11405 8)

Species Number of patients
Alternaria alternata 5
Acremonium strictum 4
Apiospora montagnei 2
Aspergillus fumigatus 6
Aspergillus niger 2
Aureobasidium pullulans 5
Botrytis cinerea 2
Candida albicans 3
Candida tropicalis 3
Cladosporium cladosporioides 3
Cladosporium fulvum 5
Chaetomium globosum 5
Chrysosporium pruinosum 5
Colletotrichum atramentarium 2
Drechslera sorokiniana 2
Drechslera spicifera 5
Epicoccum nigrum 8
Fusarium oxysporum 6
Geotrichum candidum 2
Gliocladium fimbriatum 4
Hypocrea rufa 3
Microsporum audouinii 3
Microsporum canis 7
Monilia sitophila 5
Mucor racemosus 6
Nigrospora oryzae 7
Paecilomyces variotii 2
Penicillium chrysogenum 9
Phoma destructiva 5
Rhizopus nigricans 5
Rhodotorula rubra 9
Saccharomyces cerevisiae 6
Scopulariopsis brevicaulis 4
Stachybotrys chartarum 5
Stemphylium herbarum 10
Streptomyces griseus* 7
Syncephalastrum species 5
Tetracoccosporium species 3
Trichothecium roseum 2
Trichophyton rubrum 3
(Edmondson 2005 ref.11405 8)

Edmondson DA, Nordness ME, Zacharisen MC, Kurup VP, Fink JN. Allergy and "toxic mold syndrome". Ann Allergy Asthma Immunol 2005;94(2):234-9.

[ 3 ]

A case of keratitis caused by Alternaria alternata in a diabetic male, after traumatic corneal injury with a sharp object, is described. (Zahra 2002 ref.13895 3)

Zahra LV, Mallia D, Hardie JG, Bezzina A, Fenech T. Case Report. Keratomycosis due to Alternaria alternata in a diabetic patient. Mycoses 2002 Dec;45(11-12):512-4.

[ 4 ]

Pulmonary fungal infections. (Wheat 2002 ref.11205 7)

Wheat LJ, Goldman M, Sarosi G. State-of-the-art review of pulmonary fungal infections. Semin Respir Infect 2002;17(2):158-81

[ 5 ]

Localized skin infections, in particular in patients receiving long-term glucocorticoid therapy, but may also be encountered in immune-compromised patients.

Cutaneous alternariosis with a well-delimited lesion of traumatic origin is described in a renal transplant recipient. (Mayser 2002 ref.11201 2)

Mayser P, Nilles M, de Hoog GS. Case report. Cutaneous phaeohyphomycosis due to Alternaria alternata. Mycoses 2002;45(8):338-40

[ 6 ]

Two cases of cutaneous phaeohyphomycosis, one with a nodular appearance and the other with an erythematous infiltrating patch, are reported in immunocompromised patients. Diagnosis was based on histological examination. (Romano 1997 ref.13900 3)

Romano C, Valenti L, Miracco C, Alessandrini C, Paccagnini E, Faggi E, Difonzo EM. Two cases of cutaneous phaeohyphomycosis by Alternaria alternata and Alternaria tenuissima. Mycopathologia 1997;137(2):65-74.

[ 7 ]

A patient presented with hypoxemia and diffuse bilateral pulmonary infiltrates. Eosinophilic pneumonia was confirmed by bronchoalveolar lavage and transbronchial lung biopsy. An environmental survey of the patient's house yielded Alternaria alternata. A high titer of anti-A. alternata antibody (IgG) was detected in his serum, and the inhalation bronchoprovocation test with A. alternata antigen was positive. (Ogawa 1997 ref.13899 5)

Ogawa H, Fujimura M, Amaike S, Matsumoto Y, Kitagawa M, Matsuda T. Eosinophilic pneumonia caused by Alternaria alternata. Allergy 1997 Oct;52(10):1005-8.

[ 8 ]

Alternaria alternata, Aspergillus spp., Bipolaris spicifera, Curvularia lunata, Epicoccum nigrum and Fusarium solani were isolated repeatedly from groups of patients among 96 diagnosed with allergic fungal sinusitis (AFS). Epicoccum nigrum was obtained consistently from four patients, one of whom yielded mycelial masses consistent in morphology with E. nigrum. (Noble 1997 ref.13898 9)

Noble JA, Crow SA, Ahearn DG, Kuhn FA. Allergic fungal sinusitis in the southeastern USA: involvement of a new agent Epicoccum nigrum Ehrenb. ex Schlecht. 1824. J Med Vet Mycol 1997 Nov-Dec;35(6):405-9.

[ 9 ]

Incidence of mycoses in bronchopulmonary disorders: 274 samples were collected. Main fungus was Candida albicans from sputum (45.5 percent), from bronchial secretions (14.6 percent). Rest were Aspergillus, Alternaria and Helminthosporium. All the pleural aspirates were negative for fungus. (Kumar 1992 ref.25881 0)

Kumar S, Kumar R, Saini S, Sabherwal U, Arora DR. Incidence of mycoses in bronchopulmonary disorders. Indian J Pathol Microbiol 1992 Jul;35(3):237-40.

Occupational reactions

[ 1 ]

Day-care facilities might be a source of clinically relevant exposures to indoor allergens. This study examined levels of 7 indoor allergens in 89 day-care facilities in 2 North Carolina counties. Each allergen was detected in a majority of facilities (52% to 100%). Geometric mean concentrations were 5.19 mug/g for Alternaria alternata , 2.06 mug/g for Can f 1, 1.43 mug/g for Fel d 1, 0.21 U/g for Bla g 1, 0.20 mug/g for Der p 1, 0.10 mug/g for Der f 1, and 0.01 mug/g for Mus m 1. (Arbes 2005 ref.12205 6)

Arbes SJ, Sever M, Mehta J, Collette N, Thomas B, Zeldin DC. Exposure to indoor allergens in day-care facilities: results from 2 North Carolina counties. J Allergy Clin Immunol 2005 Jul;116(1):133-9.

[ 2 ]

Air contamination inside greenhouses is mainly related to moulds, and is facilitated by the high indoor temperature and humidity. Cladosporium, Penicillium, Aspergillus, and Alternaria and a wide range of flower pollens are able to sensitize the greenhouse worker and cause occupational asthma. (Monso 2004 ref.11189 8)

Monso E. Occupational asthma in greenhouse workers. Curr Opin Pulm Med 2004;10(2):147-50.

[ 3 ]

Asthma in a patient, which was difficult to diagnosis from an etiological viewpoint. Routine diagnostic tests were unhelpful in determining the causal allergens, although the clinical history suggested that allergens were confined to a restricted environment. Aerobiological sampling using a battery-powered portable device allowed identification of the responsible allergen, Alternaria in one case and thuja pollen in the other. Once environmental care had been performed, the patients' symptoms rapidly improved and antiasthma therapy could be stepped down or discontinued. This study suggests that, in selected cases of difficult diagnosis the presence of proximity allergens is suspected, aerobiological sampling with a portable device should be considered. (Monso 2004 ref.11189 7)

Monso E. Occupational asthma in greenhouse workers. Curr Opin Pulm Med 2004;10(2):147-50.

[ 4 ]

Cladosporium and Alternaria were the leading strains of fungi in fur processing procedures, resulting in cough, sputum, chest tightness, dyspnea, and fever. Antibodies to Cladosporium and Alternaria (44.2%, 42.8%) were significantly higher than those in the control workers. (Chen 2002 ref.11191 7)

Chen J, Liu Z, Liu H, Shi C, Gong H, Yang S, Qiu L. Study on occupational respiratory diseases in fur-processing workers. [Chinese] Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi 2002;20(1):32-4.

[ 5 ]

Occupational acute lung injury due to Alternaria alternata. (Rivoire 2001 ref.11212 7)

Rivoire B, Attucci S, Anthonioz P, Carre P, Lemarie E, Hazouard E. Occupational acute lung injury due to Alternaria alternata: early stage of organic dust toxic syndrome requires no corticosteroids. Intensive Care Med 2001;27(7):1236-7.

[ 6 ]

Gardening - unexpected exposure, baker & bakery, forestry worker, farming

Occupational asthma precipitated by fungal spores. Fungal spores of Alternaria, Macrosporium and Stemphylium were recovered during asparagus and strawberry harvesting times year-round.

Alternaria may be connected with Baker's Asthma and in Wood Pulp worker's lung.

Editor Comment Editorial comment, common knowledge, or still to add - -

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