Latin name: Cladosporium herbarum (obsolete name Hormodendrum)
A mold, which may result in allergy symptoms in sensitized individuals. Cladosporium is the most frequently encountered mold in the air (1).
Spores of Cladosporium spp. probably occur more abundantly worldwide than any other spore type and are the dominant airborne spores in many areas, especially in temperate climates. (1, 2, 3, 4) Although C. cladosporioides may be the most prevalent airborne species, C. herbarum frequently dominates indoor and outdoor air and is a major source of fungal inhalant allergens. (3, 5)
There are about 500 species of Cladosporium. Many are saprophytic on plant litter.
C. herbarum is widely distributed in our environment and is a major source of fungal inhalant allergen. (4) C. herbarum is one of the most common environmental fungi to be isolated worldwide. It occurs abundantly on fading or dead leaves of herbaceous and woody plants, as a secondary invader on necrotic leaf spots, and has frequently been isolated from air, foodstuffs, paints, textiles, humans and numerous other substrates. It is also known to occur on old carpophores of mushrooms and other fungi and as a common endophyte, especially in temperate regions. Under favourable climatic conditions C. herbarum also germinates and grows as an epiphyte on the surface of green, healthy leaves. (6)
While Alternaria alternata is a major allergen in houses as well as in outdoor air in humid climates (such as the southern part of the United States), Cladosporium is the leading allergenic mould in cooler climates (such as Scandinavia). (7) The most common in temperate and arctic climates is C. herbarum, accounting for the largest number of spores recovered in outdoor sampling. (8)
Due to the nature of this allergen, nearly all exposure is unexpected.
Thread mould is a defect which occurs sporadically in maturing vacuum-packaged Cheddar cheese and is caused by the growth of fungi in the folds and wrinkles of the plastic film in which the cheese is packaged. In a study of 110 Cheddar cheese blocks exhibiting this thread mould defect, the major causative species were found to be C. cladosporioides, Penicillium commune, C. herbarum, P. glabrum and a Phoma species. Yeasts were also frequently isolated from the cheese, the majority belonging to the genus Candida. These species were also found in the cheese factory environment, on cheese-making equipment and in air, which suggests it may be a risk for occupational sensitisation. (9)
About 60 antigens from C. herbarum have been identified, of which at least 36 react with IgE antibodies from patients' sera. (10)
Fungal allergens can be grouped into several categories: proteases; glycosidases; components of protein production; oxidative stress response proteins; and enzymes involved in gluconeogenesis or the pentose phosphate shunt. Proteases and glycosidases are secreted enzymes that have a direct effect on the host. The latter three are suggestive of metabolism in spores germinating in a hostile environment. (11)
The following allergens have been identified to date:
- Cla h 1, a 13 kDa protein. (3, 7, 12, 13)
- Cla h 2, a 23 kDa protein. (3, 12, 13, 14, 15, 16, 17, 18, 19, 20)
- Cla h 3, an aldehyde dehydrogenase. (21)
- Cla h 4 is now known as Cla h 5.
- Cla h 5, a 11 kDa protein, an acid ribosomal protein P2. (7, 14, 22, 23)
- Cla h 6, a 48 kDa protein, an enolase. (7, 24, 25, 26)
- Cla h 7, a YCP4 protein. (1, 7, 14)
- Cla h 8, a mannitol dehydrogenase (14, 27, 28)
- Cla h 9, a vacuolar serine protease. (14, 29, 30)
- Cla h 10, an aldehyde dehydrogenase. (3, 7, 14, 21)
- Cla h 12, an acid ribosomal protein P1. (14, 21, 31)
- Cla h 42kD, a 42 kDa protein. (7)
- Cla h abH, an alpha/beta hydrolase. (32)
- Cla h 8 CSP, a cold shock protein (CSP). (7, 33)
- Cla h GST, a glutathione-S-transferase. (34)
- Cla h HCh1, a hydrophobin. (35 )
- Cla h HSP70, Heat Shock Protein 70. (21, 36, 37)
- Cla h NTF2, Nuclear Transport Factor 2. (21, 24)
- Cla h TCTP, Translationally Controlled Tumour Protein, also known as Histamine Releasing Factor, HRF, TCTP. (38, 39)
Cla h 5, a ribosomal P2 protein, previously known as Cla h 4, shares 60% sequence homology with other ribosomal P2 proteins. (23)
Until recently, no dominant major allergen of this species had been found, until the identification of NADP-dependent mannitol dehydrogenase (Cla h 8), which has been demonstrated to be a major allergen recognised by the IgE antibodies of 57% of all Cladosporium-allergic patients. (48)
Extensive cross-reactivity between the different individual species of the genus may be expected. (1)
Cross-reactivity is seen between Alternaria and Cladosporium as a result of homologous allergens (Alt a 10 and Cla h 3), aldehyde dehydrogenase (Alt a 6 and Cla h 4), acidic ribosomal protein P2 (Alt a 7 and Cla h 5), Saccharomyces cerevisiae protein (YCP4); and Alt a 11 and Cla h 6 (enolase, a major allergen). (7, 16, 40)
Fifty percent of Cladosporium and Alternaria-sensitive patients have been shown to react to recombinant enolase (rCla h 6). Inhibition studies show essential identity between Alt a 11 and Cla h 6. (16) Cla h 6, an enolase, is recognised by approximately 22% of sera of Alternaria-allergic patients tested. (15) Saccharomyces cerevisiae (Baker's yeast) enolase was shown to exhibit high cross-reactivity to other fungal enolases, including Cladosporium herbarum, alternaria alternata, Candida albicans and Aspergillus fumigatus. (26) Hev b 9, an enolase present in Natural rubber latex, is cross-reactive with enolases from C. herbarum and Alternaria alternata. (25)
Enolase is a common allergen found in many species of mould, and has been shown to exhibit high cross-reactivity to other fungal enolases. In particular, enolase from Alternaria alternata and Cladosporium herbarum are major allergens, and about 50% of the sera from patients have been reported to be reactive to each Cladosporium and Alternaria. (16) IgE cross-reactivity has also been reported to occur between enolases from A. fumigatus, P. citrinum and A. alternata. (16) Extensive cross-reactivity has been reported to occur between the enolases of C. herbarum, A. alternata, S. cerevisiae, C. albicans and A. fumigatus. (16) The enolase from R. mucilaginosa shares high sequence identity with enolase allergens from Candida albicans (85%), Saccharomyces cerevisiae (76%), Penicillium citrinum (76%), Aspergillus fumigatus (76%), Cladosporium herbarum (76.5%), and Alternaria alternata (74%). Although enolases are highly conserved allergens among different fungal species, most of the allergic patients examined in this study differed in their IgE reactivity to the 5 different fungal enolases tested. (16) The Latex allergen Hev b 9 is an enolase and has been shown to be cross-reactive with enolases from Cladosporium herbarum and Alternaria alternata. (16, 41)
The nuclear transport factor 2 (NTF2) allergen from A. alternata has sequence homology with allergens from Cladosporium herbarum and Aspergillus fumigatus. (16)
Epi p 1 allergen from Epicoccum purpurascens has been reported to exhibit dose-dependent inhibition with Aspergillus fumigatus, Alternaria alternata, Curvularia lunata, Cladosporium herbarum and Fusarium solani, confirming cross-reactivity of this allergen. Other laboratory methods confirmed that Epi p 1 shares common epitopes with the fungi tested. (42)
A 45 kDa protein isolated from Fusarium solani demonstrated cross-reactivity with Epicoccum nigrum, Curvularia lunata, Cladosporium herbarum and Alternaria alternata. The allergen involved did not show homology to enolase or other known fungal proteins. (43) Marked cross-reactivity has also been reported between Epicoccum nigrum and A. alternata, with less reported for C. lunata, C. herbarum, and P. citrinum. (44)
In the allergic population, sensitisation to moulds may vary from 5 to 30%. (45, 46) The wide range of allergenic proteins in C. herbarum may result in sensitisation and subsequent expression of a range of immune-related diseases. Cladosporium sensitisation is particularly associated with severe or life-threatening asthma. Upper respiratory symptoms occur with exposure to Cladosporium, but asthma symptoms are more prevalent. Cladosporium may also result in allergic bronchopulmonary cladosporiosis, having even been described in a child. (8) Other genus members have also been associated with a range of diseases, e.g. C. carrioni causes chromoblastomycosis, a verrucous dermatitis of the legs seen in the tropics. C. herhamm is the source of the mycotoxin epicladosporic acid, which has been implicated in toxic leukopenia from ingestion of contaminated grain. (8)
Mould may damage airways by production of toxins, proteases and enzymes, as well as by production of volatile organic compounds (VOCs). It actively produces a wide range of allergenic proteins. (11)
Therefore, mould may cause illness from growth and toxin production in individuals and immune-compromised hosts. Although VOCs may be detectable in (for example) compost heaps, exposure in other environments (such as a bedroom) and its effects are mostly unclear: VOCs may be an irritant of the respiratory mucosa. (11)
C. herbarum is an important allergenic fungal species that has been reported to cause allergic diseases in nearly all climatic zones, with 5 to 30% of the allergic population demonstrating IgE sensitisation against moulds. Sensitisation to Cladosporium may often be associated with severe or life-threatening asthma, and less frequently with chronic urticaria and atopic eczema. (8, 11, 47, 48, 56) Upper respiratory symptoms occur with exposure to Cladosporium, but asthma symptoms are more prevalent. (49,) (50)
A cross-sectional study of 1 132 adults with asthma found that sensitisation to Alternaria alternata or C. herbarum is a significant risk factor for severe asthma in several European countries, and also in Australia, New Zealand, and Portland in the USA. (48) Studies from California and Pennsylvania have reported that asthma symptoms are increased on days when spore counts are high. (51, 52)
In the six regions of the European Community respiratory health survey (ECRHS), the prevalence of sensitisation to C. herbarum was documented (see Table 1).
Table 1: Proportions (%) of participants with asthma with sensitisation to allergens tested in the six regions of the European Community respiratory health survey (ECRHS) (48)
UK and Republic of Ireland (n=205)
Northern Europe (n=264)
Central Europe (n=139)
Southern Europe (n=150)
Australia/New Zealand (n=335)
Portland (US) (n=39)
In children with asthma, sensitisation to common allergic fungi (A. fumigatus, Penicillium spp., Alternaria spp. and Cladosporium spp.) were found to be relatively uncommon in the UK and in Finnish schoolchildren (53) compared with Arizona (54) and Australia, where up to 31% of asthmatic children and up to 23% of non-asthmatic controls were found to be sensitised to at least one fungal allergen. (50, 55, 56) (Cited in (11))
Adults whose domestic exposure to Cladosporium had doubled over a 2-year period had 52% greater odds of reporting an attack of asthma in the previous 12 months. (57)
Sensitisation to C. herbarum has also been reported to occur in hot and humid climates, (58) as well as in desert climates such as Saudi Arabia and Kuwait. (59, 60, 61) As an indoor allergen source, seasonal peaks may occur in late summer and autumn. (15) An allergological study conducted for 12 months in three regions of Saudi Arabia to evaluate allergenicity to Cladosporium was conducted, including skin-prick tests on 605 allergic individuals using commercial extracts of C. herbarum. Overall, 19.67% of this group were shown to be sensitised, with the majority showing mild reactions. Cladosporium was the most prevalent genus in the outdoor environment, constituting up to 25% of all fungal spores in the dry region and 37.1 and 41.2% in two coastal cities. A number of species of Cladosporium were documented. (59)
Cladosporium has also been cultured from the nasal cavities of 135 subjects aged 18-35 years. All lived in the metropolitan area of Barcelona, Spain. Fungi were isolated from 41.5% of healthy people and 14.8% of allergy patients. 50.4% of the isolates were located within 4 genera: Cladosporium, Penicillium, Aspergillus and Alternaria, the fungi that are considered the most allergenic. Of the Cladosporium genus, the most prevalent species were C. herbarum and C. cladosporioides. (62)
A case of allergic broncho-pulmonary cladosporiosis has been reported in a child. (63)
Two hypersensitivity pneumonitis (HP) cases which developed in an office area and in a home in Japan have been described: a 47-year-old woman with acute-onset HP and a 72-year-old woman with chronic HP. Cladosporium cladosporioides and Cladosporium herbarum were isolated, respectively. (64)
Compiled by Dr Harris Steinman, firstname.lastname@example.org
- Vijay HM, Kurup VP. Fungal allergens. Clin Allergy Immunol 2004;18:223-49.
- Helbling A, Reimers A. Immunotherapy in fungal allergy. Curr Allergy Asthma Rep 2003;3(5):447-53.
- Vijay HM, Kurup VP. Fungal allergens. Clin Allergy Immunol 2008;21:141-60.
- Solomon WR, Matthews KP. Aerobiology and inhalant allergens. In: Middleton E, Reed CE, Ellis EF, Adkinson NF, et al, eds. Allergy: Principles and Practice. 3rd ed. St. Louis: The CV Mosby Co., 1989:312-72.
- Wickman M, Gravesen S, Nordvall SL, Pershagen G, Sundell J. Indoor viable dust-bound microfungi in relation to residential characteristics, living habits, and symptoms in atopic and control children. J Allergy Clin Immunol 1992;89(3):752-9.
- Schubert K, Groenewald JZ, Braun U, Dijksterhuis J, Starink M, Hill CF, Zalar P, de Hoog GS, Crous PW. Biodiversity in the Cladosporium herbarum complex (Davidiellaceae, Capnodiales), with standardisation of methods for Cladosporium taxonomy and diagnostics. Stud Mycol 2007;58:105-56.
- Achatz G, Oberkofler H, Lechenauer E, Simon B, Unger A, Kandler D, Ebner C, Prillinger H, Kraft D, Breitenbach M. Molecular cloning of major and minor allergens of Alternaria alternata and Cladosporium herbarum. Mol Immunol 1995;32(3):213-27.
- Weber RW. Species of Cladosporium. Ann Allergy Asthma Immunol 2002;89(6):A-6.
- Hocking AD, Faedo M. Fungi causing thread mould spoilage of vacuum packaged Cheddar cheese during maturation. Int J Food Microbiol 1992;16(2):123-30.
- Aukrust L. Crossed radioimmunoelectrophoretic studies of distinct allergens in two extracts of Cladosporium herbarum. Int Arch Allergy Appl Immunol 1979;58(4):375-90.
- Denning DW, O'Driscoll BR, Hogaboam CM, Bowyer P, Niven RM. The link between fungi and severe asthma: a summary of the evidence. Eur Respir J 2006;27(3):615-26.
- Sward-Nordmo M, Paulsen BS, Wold JK. The glycoprotein allergen Ag-54 (Cla h II) from Cladosporium herbarum. Structural studies of the carbohydrate moiety. Int Arch Allergy Appl Immunol 1988;85:288-94.
- Aukrust L, Borch SM. Partial purification and characterization of two Cladosporium herbarum allergens. Int Arch Allergy Appl Immunol 1979;60:68-79.
- International Union of Immunological Societies Allergen Nomenclature: IUIS official list http://www.allergen.org/ 2010.
- Breitenbach M, Simon-Nobbe B. The allergens of Cladosporium herbarum and Alternaria alternata. Chem Immunol 2002;81:48-72.
- Breitenbach M, Simon B, Probst G, Oberkofler H, Ferreira F, Briza P, Achatz G, Unger A, Ebner C, Kraft D, Hirschwehr R. Enolases are highly conserved fungal allergens. Int Arch Allergy Immunol 1997;113(1-3):114-7.
- Swärd-Nordmo M, Paulsen BS, Wold JK, Wehler T, Jansson PE. Further structural studies of the carbohydrate moiety of the allergen Ag-54 (Cla h II) from the mould Cladosporium herbarum. Carbohydr Res 1991;214(2):267-79.
- Swärd-Nordmo M, Smestad Paulsen B, Wold JK. Immunological studies of the glycoprotein allergen Ag-54 (Cla h II) in Cladosporium herbarum with special attention to the carbohydrate and protein moieties. Int Arch Allergy Appl Immunol 1989;90(2):155-61.
- Swärd-Nordmo M, Paulsen BS, Wold JK. The glycoprotein allergen Ag-54 (Cla h II) from Cladosporium herbarum. Further biochemical characterization. Int Arch Allergy Appl Immunol 1988;85(3):295-301.
- Swärd-Nordmo M, Almeland TL, Aukrust L. Variability in different strains of Cladosporium herbarum with special attention to carbohydrates and contents of two important allergens (Ag-32 and Ag-54). Allergy 1984;39(5):387-94.
- Bowyer P, Denning DW. Genomic analysis of allergen genes in Aspergillus spp: the relevance of genomics to everyday research. Med Mycol 2007;45(1):17-26.
- Mayer C, Appenzeller U, Seelbach H, Achatz G, Oberkofler H, Breitenbach M, Blaser K, Crameri R. Humoral and cell-mediated autoimmune reactions to human acidic ribosomal P2 protein in individuals sensitized to Aspergillus fumigatus P2 protein. J Exp Med 1999;189(9):1507-12.
- Zhang L, Muradia G, Curran IH, Rode H, Vijay HM. A cDNA clone coding for a novel allergen, Cla h III, of Cladosporium herbarum identified as a ribosomal P2 protein. J Immunol 1995;154(2):710-7.
- Weichel M, Schmid-Grendelmeier P, Fluckiger S, Breitenbach M, Blaser K, Crameri R. Nuclear transport factor 2 represents a novel cross-reactive fungal allergen. Allergy 2003;58(3):198-206.
- Wagner S, Breiteneder H, Simon-Nobbe B, Susani M, Krebitz M, Niggemann B, et al. Hev b 9, an enolase and a new cross-reactive allergen from hevea latex and molds. Purification, characterization, cloning and expression. Eur J Biochem 2000;267(24):7006-14.
- Simon-Nobbe B, Probst G, Kajava AV, Oberkofler H, Susani M, Crameri R, et al. IgE-binding epitopes of enolases, a class of highly conserved fungal allergens. J Allergy Clin Immunol 2000;106(5):887-95.
- Simon-Nobbe B, Denk U, Schneider PB, Radauer C, Teige M, Crameri R, Hawranek T, Lang R, Richter K, Schmid-Grendelmeier P, Nobbe S, Hartl A, Breitenbach M. NADP-dependent mannitol dehydrogenase, a major allergen of Cladosporium herbarum. J Biol Chem 2006;281(24):16354-60.
- Schneider PB, Denk U, Breitenbach M, Richter K, Schmid-Grendelmeier P, Nobbe S, Himly M, Mari A, Ebner C, Simon-Nobbe B. Alternaria alternata NADP-dependent mannitol dehydrogenase is an important fungal allergen. Clin Exp Allergy 2006;36(12):1513-24.
- Pöll V, Denk U, Shen HD, Panzani RC, Dissertori O, Lackner P, Hemmer W, Mari A, Crameri R, Lottspeich F, Rid R, Richter K, Breitenbach M, Simon-Nobbe B. The vacuolar serine protease, a cross-reactive allergen from Cladosporium herbarum. Mol Immunol 2009;46(7):1360-73.
- Bowyer P, Fraczek M, Denning DW. Comparative genomics of fungal allergens and epitopes shows widespread distribution of closely related allergen and epitope orthologues. BMC Genomics 2006;7:251.
- Crameri R, Zeller S, Glaser AG, Vilhelmsson M, Rhyner C. Cross-reactivity among fungal allergens: a clinically relevant phenomenon? Mycoses 2009;52(2):99-106.
- Rid R, Onder K, Hawranek T, Laimer M, Bauer JW, Holler C, Simon-Nobbe B, Breitenbach M Isolation and immunological characterization of a novel Cladosporium herbarum allergen structurally homologous to the alpha/beta hydrolase fold superfamily. Mol Immunol 2010;47(6):1366-77.
- Falsone SF, Weichel M, Crameri R, Breitenbach M, Kungl AJ. Unfolding and double-stranded DNA binding of the cold shock protein homologue Cla h 8 from Cladosporium herbarum. J Biol Chem 2002;277(19):16512-6.
- Shankar J, Gupta PD, Sridhara S, Singh BP, Gaur SN, Arora N. Immunobiochemical analysis of cross-reactive glutathione-S-transferase allergen from different fungal sources. Immunol Invest 2005;34(1):37-51.
- Weichel M, Schmid-Grendelmeier P, Rhyner C, Achatz G, Blaser K, Crameri R. Immunoglobulin E-binding and skin test reactivity to hydrophobin HCh-1 from Cladosporium herbarum, the first allergenic cell wall component of fungi. Clin Exp Allergy 2003;33(1):72-7.
- De Vouge MW, Thaker AJ, Zhang L, Muradia G, Rode H, Vijay HM. Molecular cloning of IgE-binding fragments of Alternaria alternata allergens. Int Arch Allergy Immunol 1998;116(4):261-8.
- Zhang L, Muradia G, De Vouge MW, Rode H, Vijay HM. An allergenic polypeptide representing a variable region of hsp 70 cloned from a cDNA library of Cladosporium herbarum. Clin Exp Allergy 1996;26(1):88-95.
- Rid R, Onder K, MacDonald S, Lang R, Hawranek T, Ebner C, Hemmer W, Richter K, Simon-Nobbe B, Breitenbach M. Alternaria alternata TCTP, a novel cross-reactive ascomycete allergen. Mol Immunol 2009;46(16):3476-87.
- Rid R, Simon-Nobbe B, Langdon J, Holler C, Wally V, Pöll V, Ebner C, Hemmer W, Hawranek T, Lang R, Richter K, MacDonald S, Rinnerthaler M, Laun P, Mari A, Breitenbach M. Cladosporium herbarum translationally controlled tumor protein (TCTP) is an IgE-binding antigen and is associated with disease severity. Mol Immunol 2008;45(2):406-18.
- Weber RW. Cross-reactivity of plant and animal allergens. Clin Rev Allergy Immunol 2001;21(2-3):153-202.
- Breiteneder H, Scheiner O. Molecular and immunological characteristics of latex allergens. Int Arch Allergy Immunol 1998;116(2):83-92.
- Bisht V, Arora N, Singh BP, Gaur SN, Sridhara S. Purification and Characterization of a Major Cross-Reactive Allergen from Epicoccum purpurascens. Int Arch Allergy Immunol 2004;133(3):217-24.
- Verma J, Singh BP, Sridhara S, Gaur SN, Arora N. Purification and characterization of a cross-reactive 45-kD major allergen of Fusarium solani. Int Arch Allergy Immunol 2003;130(3):193-9.
- Bisht V, Singh BP, Arora N, Gaur SN, Sridhara S. Antigenic and allergenic cross-reactivity of Epicoccum nigrum with other fungi. Ann Allergy Asthma Immunol 2002;89(3):285-91.
- Lodrup Carlsen KC, Carlsen KH, Buchmann MS, Wikstrom J, Mehl R; GAIN. Cockroach sensitivity in Norway: a previously unidentified problem? Allergy 2002;57(6):529-33.
- Horner WE, Helbling A, Salvaggio JE, Lehrer SB. Fungal allergens. Clin Microbiol Rev 1995;8(2):161-79
- Hasnain SM, Wilson JD, Newhook FJ. Fungal allergy and respiratory disease. N Z Med J 1985;98:342-6.
- Zureik M, Neukirch C, Leynaert B, Liard R, Bousquet J, Neukirch F; European Community Respiratory Health Survey. Sensitisation to airborne moulds and severity of asthma: cross sectional study from European Community respiratory health survey. BMJ 2002;325(7361):411-4.
- D'Amato G, Chatzigeorgiou G, Corsico R, Gioulekas D, Jäger L, Jäger S, Kontou-Fili K, Kouridakis S, Liccardi G, Meriggi A, Palma-Carlos A, Palma-Carlos ML, Pagan Aleman A, Parmiani S, Puccinelli P, Russo M, Spieksma FT, Torricelli R, Wüthrich B. Evaluation of the prevalence of skin prick test positivity to Alternaria and Cladosporium in patients with suspected respiratory allergy. A European multicenter study promoted by the Subcommittee on Aerobiology and Environmental Aspects of Inhalant Allergens of the European Academy of Allergology and Clinical Immunology. 1997;52(7):711-6.
- Garrett MH, Rayment PR, Hooper MA, Abramson MJ, Hooper BM. Indoor airborne fungal spores, house dampness and associations with environmental factors and respiratory health in children. Clin Exp Allergy 1998;28(4):459-67.
- Delfino RJ, Zeiger RS, Seltzer JM, Street DH, Matteucci RM, Anderson PR, Koutrakis P. The effect of outdoor fungal spore concentrations on daily asthma severity. Environ Health Perspect 1997;105(6):622-35.
- Neas LM, Dockery DW, Burge H, Koutrakis P, Speizer FE. Fungus spores, air pollutants, and other determinants of peak expiratory flow rate in children. Am J Epidemiol 1996;143(8):797-807.
- Taskinen T, Hyvärinen A, Meklin T, Husman T, Nevalainen A, Korppi M. Asthma and respiratory infections in school children with special reference to moisture and mold problems in the school. Acta Paediatr 1999;88(12):1373-9.
- 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.
- 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.
- Black PN, Udy AA, Brodie SM. Sensitivity to fungal allergens is a risk factor for life-threatening asthma. Allergy 2000;55(5):501-4.
- Matheson MC, Abramson MJ, Dharmage SC, Forbes AB, Raven JM, Thien FC, Walters EH. Changes in indoor allergen and fungal levels predict changes in asthma activity among young adults. Clin Exp Allergy 2005 Jul;35(7):907-13.
- Heinzerling L, Frew AJ, Bindslev-Jensen C, Bonini S, Bousquet J, Bresciani M, Carlsen KH, van Cauwenberge P, Darsow U, Fokkens WJ, Haahtela T, van Hoecke H, Jessberger B, Kowalski ML, Kopp T, Lahoz CN, Lodrup Carlsen KC, et al. Standard skin prick testing and sensitization to inhalant allergens across Europe--a survey from the GALEN network. Allergy 2005;60(10):1287-300.
- Hasnain SM, Al-Frayh AS, Al-Suwaine A, Gad-El-Rab MO, Fatima K, Al-Sedairy S. Cladosporium and respiratory allergy: diagnostic implications in Saudi Arabia. Mycopathologia 2004;157(2):171-9.
- Al-Mousawi MS, Lovel H, Behbehani N, Arifhodzic N, Woodcock A, Custovic A. Asthma and sensitization in a community with low indoor allergen levels and low pet-keeping frequency. J Allergy Clin Immunol. 2004;114(6):1389-94.
- A-Suwaini AS, Bahkali AH, Hasnain SM. Airborne viable fungi in Riyadh and allergenic response of their extracts. Mycoses 2001;44(9-10):401-6.
- Sellart-Altisent M, Torres-Rodríguez JM, Gómez de Ana S, Alvarado-Ramírez E. Nasal fungal microbiota in allergic and healthy subjects. [Spanish] Rev Iberoam Micol 2007;24(2):125-30.
- Moreno-Ancillo A, Díaz-Pena JM, Ferrer A, Martín-Muñoz F, Martín-Barroso JA, Martin-Esteban M, Ojeda JA. Allergic bronchopulmonary cladosporiosis in a child. J Allergy Clin Immunol 1996;97(2):714-5.
- Chiba S, Okada S, Suzuki Y, Watanuki Z, Mitsuishi Y, Igusa R, Sekii T, Uchiyama B. Cladosporium species-related hypersensitivity pneumonitis in household environments. Intern Med 2009;48(5):363-7.