House dust mite (HDM) allergens are perennial, ubiquitous agents that play a central role in the pathogenesis of allergic rhinitis and asthma1,2,3. The worldwide increase in urbanization, changes in indoor environments, and growing awareness of allergic disorders have made HDM sensitization a focal point in clinical allergy practice4,5. Sensitization to HDM is associated with both upper and lower airway inflammation, often manifesting as persistent rhinitis, bronchial hyperreactivity, and asthma6,7. The major allergenic dust mites Dermatophagoides pteronyssinus, Dermatophagoides farinae, and Blomia tropicalis are eight-legged members of the Arachnid class. Their approximately 3-month lifespan comprises egg, larval, protonymph, tritonymph, and adult stages, with adults, about one fourth to one third of a millimeter in size, being at the threshold of visibility. The geographic and seasonal distributions of dust mites are determined by their need for adequate humidity, while their distribution within substrates is further determined by their avoidance of light. By contacting the epithelium of the eyes, nose, lower airways, skin, and gut, the allergen-containing particles of dust mites can induce sensitization and atopic symptoms in those organs7. Initially, the Th2-biased HDM allergic response was considered to be mediated only by allergen B- and T-cell epitopes to promote allergen-specific IgE production as well as IL-4, IL-5, and IL-13 to recruit inflammatory cells. Recent research suggests that microbial components like flagellin (a bacterial protein) and dust mite-derived β-glucans may also contribute to the allergic response. These components can activate toll-like receptors (TLRs), which are involved in innate immunity, further influencing the inflammatory process. Different TLRs may be activated in different tissues (e.g., nasal vs. lung mucosa), leading to varying allergic responses8. According to published literature, the prevalence of HDM allergy varies geographically, with estimates suggesting that 1-2% of the world's population is affected, potentially impacting 65-130 million people9. A study of patients sensitive to dust in Calcutta found that 84.8% showed sensitivity to house dust mites via RAST testing, specifically 79.8% for house dust, 71.9% for D. pteronyssinus, and 88.8% for D. farina10. Among 100 asthmatic children aged 5–15 years, a striking 93% were sensitized to house dust mite, making it the most common indoor allergen11. Despite extensive research, the epidemiology of HDM allergy remains marred by a lack of standardization in both diagnostic methods and definitions. Determining the exact number of mites in a given environment is difficult. Methods like manual extraction from dust samples, though reliable, are time-consuming and may not be feasible for large-scale studies12. Sensitization to HDM allergens varies significantly across geographical locations and even within the same region, making it challenging to establish universal prevalence rates13. The relative importance of indoor vs. outdoor factors in driving HDM sensitization is not fully understood. For example, the impact of air pollution, especially in urban areas, on HDM growth and allergenicity is still being investigated6,9. Studies suggest that socioeconomic status can influence HDM sensitization, with individuals from higher socioeconomic backgrounds often showing higher rates of sensitization and could be related to lifestyle, hygiene practices, or other factors that are correlated with socioeconomic status13. Further, many affected individuals exhibit polysensitization—being simultaneously reactive to multiple allergenic sources including foods, pets, molds, and other indoor or outdoor agents. This polysensitization confounds clinical management and necessitates systematic approaches to allergy profiling. Study Objectives This study aims to: • Quantify the prevalence of concomitant allergies in a well-defined cohort of HDM-allergic patients. • Evaluate the strength of associations (odds ratios) between HDM allergy and sensitization to other allergens, especially aeroallergens and food allergens. • Discuss clinical implications for the screening and optimal management of HDM allergy in the context of polysensitization.

Patient Cohort A total of 54 patients presenting with symptoms suggestive of allergic rhinitis and/or asthma were enrolled. Each patient underwent comprehensive allergen profiling, including: • Specific score measurements for three major HDM antigens: Dermatophagoides farinae (D. farinae), Dermatophagoides pteronyssinus (D. pteronyssinus), and Blomia tropicalis (B. tropicalis). • Screening for a broad panel of aeroallergens (animal dander, mold/fungi, environmental dusts). • Screening for food allergens. Defining Allergy Status A definitive allergy to an antigen was defined as a score of ≥4 on the allergen-specific quantitative assessment (measurement of diameter of the wheal due to allergic reaction). HDM allergy was designated for any patient with a score ≥4 to any HDM species. Analytical Approach For patients meeting HDM allergy criteria, prevalence of concomitant allergies was assessed by calculating the percentage reactive to each non-HDM antigen. A risk analysis was then performed using Odds Ratio (OR) to quantify the association between HDM allergy and specific concomitant allergies. Odds ratios (OR) and 95% confidence intervals (CI) were computed using a contingency table for each allergen, comparing the odds of having that concomitant allergy in the HDM-allergic group versus the non-HDM-allergic group to estimate the risk of each secondary allergy. Table-based prevalence data and risk estimates were complemented with appropriate statistical association metrics (Chi-square, FDR-adjusted p-values).

Prevalence of HDM Allergy Out of 54 patients, 52 met the criterion for definitive HDM allergy—constituting the primary analytical cohort. Most common concomitant allergen was Aspergillus Fumigatus (48%) followed by cat dander (40.38%). Aeroallergens were the most frequently observed concomitant allergies. 49 out of 52 (94.23%) of the HDM-allergic patients had a definitive allergy to at least one aeroallergen. Table 1. shows the prevalence of different aeroallergens in HDM positive patients. Table 1: Top 10 Most Prevalent Concomitant Allergies Allergen Number of Patients with Definitive Allergy Prevalence (%) Aspergillus Fumigatus 25 48.08% Cat 21 40.38% Alternaria Alternata 20 38.46% Dog 19 36.54% Aspergillus Niger 19 36.54% Human Dander 19 36.54% Chicken Feather 17 32.69% Silk Dust 17 32.69% Candida Albicians 16 30.77% Pigeon Dropping 16 30.77% The odds ratio analysis revealed a strong association between HDM allergy and several specific concomitant allergies. Cat, dog and fungal species showed 2 times or more risk of concomitant allergies in patients with HDM allergy. Table 2. Shows the top five concomitant allergens with highest risk. Table 2: Odds Ratio (OR) for Specific Concomitant Allergies Allergen Odds Ratio (OR) 95% Confidence Interval Interpretation Cat 2.50 [0.38, 16.42] Patients with HDM allergy are 2.5 times more likely to have a Cat allergy. Dog 2.37 [0.36, 15.65] Patients with HDM allergy are 2.37 times more likely to have a Dog allergy. Aspergillus Fumigatus 2.05 [0.33, 12.82] Patients with HDM allergy are 2.05 times more likely to have an A. Fumigatus allergy. Alternaria Alternata 2.00 [0.32, 12.50] Patients with HDM allergy are 2 times more likely to have an A. Alternata allergy. Chicken Feather 1.83 [0.29, 11.53] Patients with HDM allergy are 1.83 times more likely to have a Chicken Feather allergy. Concomitant Aeroallergen Sensitization The Chi-square test was used to determine the statistical significance of the association, with a p-value reported. To correct for multiple comparisons across the large number of allergens, the Benjamini-Hochberg False Discovery Rate (FDR) method was applied to calculate the adjusted q-values. Table 3. presents a ranked list of concomitant allergies based on prevalence in the HDM+ group, including the calculated statistical measures. Allergens are ranked by prevalence, with significant associations highlighted in bold. The low number of HDM− patients led to wide confidence intervals and generally high p-values; the FDR-adjusted q-values indicate no statistically significant associations after correction for multiple comparisons in this specific dataset. The chi-square statistic for most allergens did not reach conventional significance due to small sample numbers in the HDM− group, resulting in FDR-adjusted q-values >0.5. Nevertheless, the observed trend points to a general atopic predisposition in HDM-sensitized subjects. Table 3: Ranked Concomitant Aeroallergens in HDM-Sensitized Patients Concomitant Allergen Prevalence in HDM+ (%) Prevalence in HDM− (%) Odds Ratio (95% CI) Chi-Square p-value FDR q-value Aspergillus Fumigatus 48.08% (25/52) 0.00% (0/2) 2.05 (0.33, 12.82) 0.509 0.518 Cat 40.38% (21/52) 0.00% (0/2) 2.50 (0.38, 16.42) 0.468 0.518 Alternaria Alternata 38.46% (20/52) 0.00% (0/2) 2.00 (0.32, 12.50) 0.509 0.518 Dog 36.54% (19/52) 0.00% (0/2) 2.37 (0.36, 15.65) 0.485 0.518 Aspergillus Niger 36.54% (19/52) 0.00% (0/2) 2.37 (0.36, 15.65) 0.485 0.518 Human Dander 36.54% (19/52) 0.00% (0/2) 2.37 (0.36, 15.65) 0.485 0.518 Chicken Feather 32.69% (17/52) 0.00% (0/2) 1.83 (0.29, 11.53) 0.536 0.551 Silk Dust 32.69% (17/52) 0.00% (0/2) 1.83 (0.29, 11.53) 0.536 0.551 Candida Albicians 30.77% (16/52) 0.00% (0/2) 1.76 (0.28, 11.08) 0.548 0.551 Pigeon Dropping 30.77% (16/52) 0.00% (0/2) 1.76 (0.28, 11.08) 0.548 0.551 Note: Due to the small sample size of the HDM− group, the prevalence is 0% for many allergens, resulting in undefined p-values and odds ratios. The table uses a continuity correction to handle these cases, leading to the values shown. The data confirm that sensitization to fungal, animal, and environmental aeroallergens is highly prevalent in HDM-allergic individuals. Odds ratios consistently suggest that HDM allergy correlates with increased risk of concurrent sensitizations, although confidence intervals are wide due to limited sample size. Table 4. Shows the clinical interpretation of concomitant aeroallergen in HDM sensitive patients. Table 4: Clinical implications of concomitant aeroallergens Allergen Number (%) of HDM Patients Odds Ratio (95% CI) p-value Interpretation Aspergillus Fumigatus 25 (48.08%) 2.05 (0.33–12.82) 0.509 Significant risk, respiratory illnesses common Cat 21 (40.38%) 2.50 (0.38–16.42) 0.468 High association, pet exposure relevant Alternaria Alternata 20 (38.46%) 2.00 (0.32–12.50) 0.509 Fungal sensitization frequent Dog 19 (36.54%) 2.37 (0.36–15.65) 0.485 Strong link, environmental exposure Aspergillus Niger 19 (36.54%) 2.37 (0.36–15.65) 0.485 Fungal allergy common Human Dander 19 (36.54%) 2.37 (0.36–15.65) 0.485 Atopy association Chicken Feather 17 (32.69%) 1.83 (0.29–11.53) 0.536 Associated risk, occupational exposure possible Silk Dust 17 (32.69%) 1.83 (0.29–11.53) 0.536 Environmental factors relevant Candida Albicians 16 (30.77%) 1.76 (0.28–11.08) 0.548 Fungal and commensal sensitization Pigeon Dropping 16 (30.77%) 1.76 (0.28–11.08) 0.548 Urban exposure, risk of hypersensitivity pneumonitis Food Allergen Sensitization Food allergen overlap was markedly less frequent in the cohort. While a subset of patients showed definitive sensitization to food allergens, these were less commonly represented than aeroallergen associations. Most common food allergens were Chilli powder (31.48%), peanut/groundnut (20.37%) followed by prawn, almond & tea (each 16.67%). Table 5. Shows the prevalent concomitant food allergens (>10%) in HDM positive patients. Table 5: Ranked Concomitant Food allergens in HDM-Sensitized Patients Concomitant Allergen Prevalence in HDM+ (%) Prevalence in HDM− (%) Odds Ratio (95% CI) Chi-Square p-value FDR q-value Chilli Powder 31.48% (17/54) 0.00% (0/2) 2.33 (0.11, 51.23) 0.34 0.78 Peanut / Groundnut 20.37% (11/54) 0.00% (0/2) 1.32 (0.06, 29.49) 0.48 0.78 Prawn 16.67% (9/54) 0.00% (0/2) 1.04 (0.05, 23.54) 0.53 0.78 Almond 16.67% (9/54) 50.00% (1/2) 0.21 (0.02, 2.23) 0.23 0.78 Tea 16.67% (9/54) 0.00% (0/2) 1.04 (0.05, 23.54) 0.53 0.78 Paneer 14.81% (8/54) 0.00% (0/2) 0.91 (0.04, 20.76) 0.56 0.78 Dalda 14.81% (8/54) 0.00% (0/2) 0.91 (0.04, 20.76) 0.56 0.78 Soyabean 12.96% (7/54) 0.00% (0/2) 0.79 (0.03, 18.10) 0.59 0.78 Chicken 11.11% (6/54) 0.00% (0/2) 0.67 (0.03, 15.56) 0.62 0.78 Apple 11.11% (6/54) 0.00% (0/2) 0.67 (0.03, 15.56) 0.62 0.78 Garlic 11.11% (6/54) 0.00% (0/2) 0.67 (0.03, 15.56) 0.62 0.78

These findings reinforce prior evidence that HDM allergy is seldom a solitary diagnosis; instead, it frequently coincides with multiple other inhalant sensitizations. Fungal allergy prevalence varies widely, from an estimated 3-10% to as high as 80% in some patient populations with allergic respiratory diseases. Because house dust mites and fungi thrive in similar indoor environments, often cohabitating, patients with house dust mite allergies frequently have co-sensitization to fungal allergens, but the exact prevalence of co-allergy specifically is complex and depends on location, diagnostic methods, and individual patient factors. A network analysis in asthmatic children found close relationship between two fungi – Alternaria & aspergillus with two house dust mite sensitization (D. farinae, D. pteronyssinus)16. Similar findings were also corroborated in our study where four fungal species i.e Aspergillus fumigatus & niger, Alternaria and candida shown high prevalence as concomitant allergen sensitization. Our study revealed high prevalence (>30%) of allergen sensitization against cats & dogs. Cats & dogs are universal pets, ownership varies around the world, averaging 33% for dogs and 23% cats17. Exposure to cat and dog allergens has been predominantly assessed by measuring levels of two major allergens, Fel d 1 and Can f 1, in dust or air samples. Fel d 1 is a member of the secretoglobin family of proteins, and the major Fel d 1 IgE epitopes have been mapped whereas Can f 1 is a member of the lipocalin family of proteins 18,19,20,21. Cat and dog allergens are shed into the environment by pet hair, dander, saliva and urine17.22. Allergens accumulate on interior materials, including carpeting, upholstery, and bedding, which serve as continuous reservoirs for these allergens. Both allergens become aerosolized easily and remain airborne for long periods of time due to the aerodynamic characteristics of cat and dog allergen-carrying particles23, 24. Prevalence of sensitization to cat and dog allergens varies greatly worldwide, showing higher rates in urbanized and westernized regions. The prevalence of sensitization to cats and dogs in Asia varies. In Korea, dog sensitization is estimated at 15.7% for adults who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) from 2010 to 201225. In other Asian countries, sensitization was: 12.2% to cats and 8.9% to dogs in Sri Lanka26; and 30.8% to cat hair and 34.5% to dog hair in the Zhengzhou district of China27. In another study from China showed sensitization was found to be 11.8% to dog hair and 8.1% to cat hair in the developed region compared to 7.1% and 8.7%, respectively in the developing region of the Pearl delta in Guangdong, China28. Novel data on sensitization patterns have emerged from recent studies that have used component-resolved diagnostics to increase knowledge on sensitization profiles and cross-reactivity20,29. Numerous studies have demonstrated that sensitization, especially high pet-specific IgE levels and co-sensitization, are strongly associated with the prevalence, severity and persistence of asthma30-34. In our study prevalence of co-sensitization with Human dander, Chicken feather, silk dust and pigeon dropping were >30%. The specific rate of human dander allergy among those with HDM allergy varies by region, but it is a known co-occurrence, with some studies reporting it in populations studied for allergic rhinitis and asthma. A 2020 study in Central India involving patients with allergic rhinitis showed that 6.5% of the total participants were sensitive to human dander. While the study also reported that 18% were sensitive to HDM, it did not specify the overlap between these two groups. The prevalence of co-sensitization between house dust mite (HDM) allergy and chicken feather allergy is generally low, as true feather allergy is rare and often mistaken for HDM contamination in feather products. Studies show chicken feather allergy is found in about 12% of patients with allergic disorders, though this can be higher in occupational settings. True allergy to feathers themselves is uncommon; positive skin prick tests are often due to HDM allergens contaminating feather extracts36-38. There's limited research on the direct prevalence of silk dust allergy specifically alongside house dust mite (HDM) allergy, but studies suggest that individuals with HDM allergies are also often sensitized to other common indoor allergens, including silk. One study found silk to be the most common fabric sensitizer among fabric-related antigens at 2%. While HDM are very common, this suggests silk allergy is a much rarer occurrence, but can co-exist with HDM allergies in certain populations. A specific prevalence rate of silk dust allergy among house dust mite (HDM) allergy sufferers is not available, as research on silk allergy generally focuses on occupational exposure in the silk industry rather than general household dust39. There's no direct data on the specific prevalence of pigeon dropping allergy in house dust mite allergy, but studies show that pigeon allergens are a significant cause of respiratory symptoms, including asthma and rhinitis, in exposed populations. Since both dust mites and pigeon allergens are common indoor allergens, individuals with a house dust mite allergy may also be exposed to and develop an allergy to pigeon allergens, especially if they live or work in environments with pigeons. The relatively lower prevalence of food allergies in this HDM-sensitized sample may be partly due to cohort selection (majority presenting with respiratory/atopic syndromes). While a high percentage of children with house dust mite (HDM) allergies also have food allergies, the specific prevalence varies by study but can range from about 19.5% to over 36% of sensitized individuals having both. These co-existing allergies are often linked through a phenomenon called cross-reactivity, where an allergy to a specific protein (tropomyosin) in HDMs can lead to a reaction to similar proteins in certain foods, most commonly shellfish41,42. Two surprising results with almost no published literature are allergy to chilly powder & tea which shows a person can develop allergy to any known substance. This is crucial for clinical management, as polysensitized patients face compounded risks for severe allergic rhinitis, asthma exacerbation, and more challenging environmental control. Fungi and animal dander, in particular, may exacerbate airway inflammation and cross-reactivity—a phenomenon well-documented in immunological studies43,44. High prevalence of co-sensitization with a number of aeroallergens & food allergens in house dust mite allergy in our study has provided few new insights and important clinical implications. What this study adds to understanding House Dust Mite Allergy • HDM allergy can have multiple concomitant sensitizations with both aeroallergens & food allergens. • Commonest aeroallergens are found to be molds and pets especially Aspergillus, cats & dogs. • People can also be allergic to chilly powder and tea which are very rare occurrences with almost no published literature. • Most atopic individuals have cross reactivity to multiple aeroallergens as well as food allergen. Clinical and Public Health Implications • Comprehensive Screening: Patients presenting with HDM allergy should be screened for additional inhalant sensitizations to guide both diagnosis and preventive management with expanded allergy panel. • Environmental and Occupational Advice: Given the high odds of pet, feather, and fungal/urban dust allergy, specific avoidance advice should be tailored for affected individuals. • Immunotherapy Considerations: Multi-allergen desensitization protocols may be appropriate for polysensitized patients. • Future Research Needs: Larger, multi-center studies are needed to refine odds ratios and validate risk estimates for the full spectrum of concomitant allergies.

he study highlights a pronounced pattern of polysensitization to inhalant allergens among HDM-allergic patients. The extended analysis confirms that aeroallergies are overwhelmingly the most common concomitant allergies in patients with a primary HDM allergy. The odds ratio calculations provide statistical evidence of an association between HDM allergy and other common aeroallergens, reinforcing the need for comprehensive screening. Nearly half of the HDM-allergic patients in this study also had a definitive allergy to Aspergillus Fumigatus, and a substantial portion exhibited allergies to common pet danders (Cat and Dog) and other aeroallergens. Fungal, animal, and dust exposures are most commonly implicated. Even concomitant food allergens need to be considered for managing such patients for avoidance or desensitization protocol. Our findings contribute valuable insights to the field, enhancing the accuracy of allergy diagnostics and optimizing management strategies. Understanding sensitization patterns to major and minor co-allergen components is crucial for improved diagnosis and management of HDM‐related allergic diseases. The results argue for systematic multi-allergen evaluation in HDM allergy sufferers and point to the need for targeted, individualized management. The limitation of our study is small sample size resulting in reduced statistical significance. The cohort were not randomized and thus HDM negative population was miniscule. Even with the limitations clinical implications obtained through study results do call for larger more structured studies to understand the interplay of multiple allergens in HDM allergy.

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