Egg white

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Code: f1
Latin name: Gallus spp.
Source material: Freeze-dried hen’s egg-white

Allergen Exposure

Bird eggs are a common food source. The most commonly-used bird eggs are those from the chicken, duck, and goose, but smaller eggs such as quail eggs are occasionally used as a gourmet ingredient – as are the largest bird eggs, from ostriches. Most commercially-produced chicken eggs intended for human consumption are unfertilised, since the laying hens are kept without any roosters. Fertile eggs can be eaten as well, with little nutritional difference. Fertile eggs will not contain a developed embryo, as refrigeration prohibits cellular growth. Chicken eggs are widely used in many types of cooking. Eggs may be pickled; hard-boiled, scrambled, fried and refrigerated; or eaten raw, though the latter is not recommended for people who may be susceptible to salmonella, such as the elderly, the infirm or pregnant women. Egg white is the common name for the clear liquid (also called the albumen) contained within an egg.(1, 2, 3, 4, 5) The protein in raw eggs is only 51% bio-available, whereas a cooked egg has nearer 91% protein bio-available, meaning the protein of cooked eggs is nearly twice as absorbable as the protein from raw eggs. (1, 6)

Foods that may contain egg include salad dressings, breads, breaded foods, muffins, pancakes, waffles, meringues, marshmallows, prepared soups and beverages, frostings, ice cream and sherbets, pie fillings, sausages, prepared meats (egg as a binding agent), mayonnaise, coatings and breading for fried foods, tartar and hollandaise and other sauces.

Egg yolks are used to make mayonnaise and other dishes high in fat. Egg yolks are important as binding agents in many preparations in European cooking due to the emulsifying action of lecithin. This property is crucial for mayonnaise and sauces such as Béarnaise and Hollandaise; custards such as crème anglaise, crème brûlée, crème caramel, lemon custard, and key lime pie; and meat dishes such as pâté and meatloaf. (1)

The albumen or egg white contains protein but little or no fat. It is used in cooking separately from the yolk, and can be aerated or whipped to a light, fluffy consistency. Beaten egg whites are used in desserts such as meringues and mousse. (1)

Egg white is sometimes used for producing foam in root beer, and in some coffee and wines for clarification. (7) For the latter, its role is as a fining agent. In a German study of fining agent proteins and lysozyme in various German wines, no detectable amounts of fining agents in wines were demonstrated except for dried egg white and lysozyme (both derived from hen's egg white). However, whether the residual levels were significant enough to result in adverse effects was not evaluated. (8)

Allergen Description

The total number of egg proteins is not known, but more than 40 have been suggested for egg-white alone, (9) and up to 24 different antigenic protein fractions have been isolated.

Egg white has been considered the most important source of allergens, but IgE-binding allergens have also been described in egg yolk, suggesting that both common and distinct allergenic molecules are present. This was demonstrated in a study of 11 patients with a history of egg allergy, in all of whom sera reacted positively to both white and yolk. Eight patients reacted equally or more strongly to white, and even though white and yolk could each inhibit the IgE binding of the other to some degree, yolk could only be partly inhibited by white in eight sera. (10)

Gal d 1 (Ovomucoid), Gal d 2 (Ovalbumin), Gal d 3 (Ovotransferrin, also called conalbumin) and Gal d 4 (Lysozyme) are the most important allergens in Egg white. (11) All are glycoproteins. Ovomucoid (Gal d 1) makes up approximately 10% of Egg white and is the major allergen. (12, 13, 14, 15 )Although the main allergens in egg are found in the Egg white, Egg yolk also contains a large portion of specific IgE-binding allergens. (16) Allergens have also been found in hen and chicken meat (flesh) and sera. (17)

Egg white allergens characterised to date:

Allergen name

Nomeclature

Size

% of Egg white

Major/
minor
allergen

Stability

Ovomucoid

Gal d 1

28 kDa

11%

Major

Stable

Ovalbumin

Gal d 2

44 kDa

54%

 

Unstable

Conalbumin, Ovotransferrin

Gal d 3

78 kDa

12-13%

 

Unstable

Lysozyme

Gal d 4

14 kDa

3.5%

 

Unstable

 

Ovomucoid (Gal d 1) has been shown to be the immunodominant protein in egg white. (18) Children with persistent egg allergy have significantly higher ovomucoid-specific serum IgE levels than children who have outgrown their egg allergy. (12) Other Egg white proteins, including ovotransferrin and lysozyme, appear to be less important in the pathogenesis of egg allergy. Another study demonstrated that children with persistent egg allergy had significantly higher levels of serum IgE to ovomucoid and ovalbumin than those with transient egg allergy. (19) Ovomucoid is resistant to heat, acid and proteolytic enzymes.

Even though ovalbumin is probably one of the most studied antigens in immunology, it does not appear to be the most allergenic molecule in humans. In a study of 34 adults with confirmed egg allergy, conalbumin (ovotransferrin) and ovomucoid were demonstrated to be the most prevalent allergens. Using the agreement between two or more of four laboratory methods as a criterion for evidence of sensitisation, the frequencies of reactivity were found to be 53% (ovotransferrin), 38% (ovomucoid), 32% (ovalbumin) and 15% (lysozyme). (20)

However, different reports have emerged on the relative importance of the various allergens in Egg white. Some of the differences may be due to the studies of different populations, i.e. it is likely that the egg proteins are processed differently in the digestive systems of infants and adults. A rigorous purification of the reagents may be necessary to obtain pure proteins, since commercial preparations of individual Egg white proteins may be somewhat contaminated. (21)

Usually, cooked egg is slightly less allergenic than raw. (22)

Potential Cross-Reactivity

Although cross-reactivity between Egg white and Egg yolk is not common (unless there is contamination of either by the other), some degree of cross-allergenicity has been demonstrated between hen's Egg white and Egg yolk proteins, signifying that there are a number of common allergenic determinants on these egg proteins. (23)

There is cross-reactivity between Egg white from Chicken and Turkey, Duck, Goose and seagull egg whites. (17) However, this would depend on a specific cross-reactive allergen component: patients with an IgE-mediated allergy to Egg white from Duck and Goose may not necessarily be allergic to hen’s egg. (24)

Presence of shared allergens in egg-white, egg-yolk, serum and meat from hen and chicken has been demonstrated.

In the Orient, allergy to Bird's Nest soup occurs. An allergen isolated was found to be homologous to ovoinhibitor, one of the dominant allergens found in chicken Egg white. (25)

Clinical Experience

IgE-mediated reactions

Hen’s egg is one of the most frequent causes of immediate food allergy in infants and young children. Egg white is generally more allergenic than Egg yolk. Clinical reactions to egg are predominantly IgE-mediated immediate reactions characterised by atopic dermatitis, urticaria, angioedema, vomiting, diarrhoea, rhinoconjunctivitis and asthma. Children with atopic dermatitis may have an immediate exacerbation of symptoms or a delayed reaction causing a worsening of their dermatitis 1-2 days after exposure to egg. Delayed reactions are possible and are generally not IgE-mediated and are probably caused by T-cell sensitisation. Eosinophilic esophagitis as a result of allergy to Egg has been described. IgE-mediated sensitivity to Egg proteins in Egg-processing workers has been reported.

Hen’s egg is one of the most frequent causes of immediate food allergy in infants and children, affecting about 1-2% of preschool children, but may also commonly affect adults. (26, 27, 28, 29) Few studies on the prevalence of egg allergy have been performed. An observational study of 4 000 Spanish patients who consulted an allergist found that egg allergy accounted for 16% of food allergies in the general population and was the fourth most frequently implicated food. In the subgroup of children aged less than 5 years this frequency was 44%, and together with milk, egg was the main cause of sensitisation. (30) In another Spanish study of 355 paediatric patients with food allergy, the prevalence of allergy to egg proteins was 20.1%. (31)

Clinical reactions to egg are predominantly IgE-mediated immediate reactions, characterised by atopic dermatitis, urticaria, angioedema, vomiting, diarrhoea, rhinoconjunctivitis and asthma. (27, 32, 33, 34, 35, 36, 37) Isolated respiratory symptoms are infrequent and almost always associated with cutaneous or digestive symptoms. Respiratory symptoms after egg ingestion are more frequent in patients sensitised to bird proteins (bird-egg syndrome). (20) Children with atopic dermatitis may have an immediate exacerbation of symptoms or a delayed reaction causing a worsening of their dermatitis 1 to 2 days after exposure to egg. Acute dermatological manifestations consist of erythema, urticaria and angioedema clearly associated with egg ingestion. The onset of symptoms may be rapid, developing a few minutes after ingestion of the causative allergen. 93% of positive egg challenges elicited immediate symptoms, even though the child had not previously ingested egg. Symptoms developed within the first 20 minutes of egg ingestion, and 53% of the children presented cutaneous symptoms in the following order of frequency: pruritus, erythema, urticaria and angioedema. (38) Delayed reactions are generally not IgE-mediated and are probably caused by T-cell sensitisation. (39) Eosinophilic esophagitis as a result of allergy to egg has been described. (40, 41, 42 )Egg has also frequently been associated with childhood asthma. (43) Food-sensitive enteropathy may be caused by a number of foods, including egg. (44) Patients with oral allergy syndrome due to egg hypersensitivity have also been reported (one patient being monosensitised to egg). (45, 46)

Importantly, egg-allergic children may occasionally develop contact urticaria to hen's egg and yet have no overt symptoms on ingestion. It has been suggested that oral tolerance to ingestion of Egg white may be as a result of the allergens involved in skin contact reactions being unstable to digestive enzymes, and therefore being broken down. (47)

Allergy to egg is generally agreed to be one of the most common causes of food allergy in infants and young children. Some researchers reported that in Egg-allergic children, IgE antibodies were found in more than 65% of children with eczema and respiratory tract symptoms. (48) In a follow-up study of infants in which the authors had concluded that egg-white sensitivity was a better indicator of atopy than total serum IgE, the infants presenting with egg-white allergy were more likely to have developed inhalant allergy by 7 years of age. (49)

In a study in Singapore of 75 children, aged below 3 years, with symptoms of asthma, rhinitis, eczema, or food allergy, the prevalence of IgE sensitisation was highest for Cow's milk (45.9%) followed by Egg white (38.7%), Dermatophagoides pteronyssinus (31.4%) and Blomia tropicalis (25.5%). (50)

In 674 patients referred to an allergy unit in Spain, the prevalence of food allergy was found to be 9.1%. The foods most frequently involved in allergic reactions were fruits (56.6%) and tree nuts (22.6%). However, Egg white was implicated in about 10% of the food allergy group. (51)

An Australian study, evaluating skin-prick tests for 31 different food allergens in a selected population of predominantly breast-fed young infants who had moderate to severe generalised atopic dermatitis, reported that of the 59 infants (mean age 26.5 weeks) tested, 54 infants (91.5%) had positive responses to one or more foods, 53 infants (90%) were positive to one or more of the five common food allergens (Egg white, cow's milk, peanuts, wheat or soy) and 80% were positive to Egg white, which was by far the most common positive test. A total of 37 infants had strongly positive responses to one or more foods, with 33 of these 37 having strongly positive responses to Egg white. (52)

A study of 164 children with atopic dermatitis only reported that immediate-type allergic reactions were implicated in 11.6% of these children, whereas delayed-type allergic reactions were relevant in 44.5%. Of this group, 114 children (63.4%) were affected by gastrointestinal disorders, the most common gastrointestinal disorders being: abdominal pain, vomiting, diarrhoea, abdominal distension, and constipation. The most common food allergens implicated were Soy, Cow’s milk, Peanut, Corn, Carrots, Rye, Wheat, Egg white, Cod, and Chicken, as determined by skin-patch tests. (53)

Egg white is often responsible for the early development of urticaria and eczema during infancy. Pruritus and exacerbation of atopic dermatitis were the symptoms most often recorded in a study of 84 egg-allergic children. (34) Certain vaccines grown on chick embryos may cause severe allergic reactions in patients when injected. (54) However, other investigators have not found such reactions in children with documented egg-allergy. (55) Further development of vaccines, most of which are no longer grown on egg protein, seems to have decreased or even eliminated the risk. (56)

Egg white has also been implicated in adult patients with eosinophilic esophagitis (EE). In a study of 16 men and 7 women aged 18-57, 17 of 21 patients were polysensitised to several different environmental allergens, and 19 of 23 (82%) had serum IgE specific for one or more food-associated allergens. Of these, 17% were sensitised to Egg yolk and 30% to Egg white. (45)

Sensitisation to and symptoms of inhaled Egg-white allergens may occur: IgE-mediated sensitivity to Egg proteins has been reported in Egg-processing workers (57) as well as in bakers. (58)

Egg white-specific IgE level has been found to be an efficient tolerance marker in the follow-up procedure for egg allergy. (59) The relative likelihood of positive re-challenge was 9% in patients with levels > 1.2 kUA/l. Consequently, even low levels could be adequate grounds for delaying the follow-up of elimination diets with egg challenge. (8)

Specific oral tolerance induction for whole egg in school-age patients with severe Egg allergy has been successfully conducted. (60) Few studies with Egg white have been published, (61) although children desensitised to whole egg were demonstrated to have diminished reactivity to Egg white. (62)

Compiled by Dr Harris Steinman, developer of Allergy Advisor, harris@zingsolutions.com

 

Citing This Page

Steinman HA. f1 Egg white. http://www. phadia.com/en/Allergen-information/ImmunoCAP-Allergens/Food-of-Animal-Origin/Egg/Egg-white/. Accesed (date to be filled in)

 

 

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Updated 2010

As in all diagnostic testing, the diagnosis is made by the physican based on both test results and the patient history.