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Penny HA, Aziz I, Lam C. Mast cell activation and nutritional disorders in patients with hypermobility. Curr Opin Gastroenterol 2024; 40:225-232. [PMID: 38393310 DOI: 10.1097/mog.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
PURPOSE OF REVIEW Individuals with joint hypermobility disorders are increasingly referred to gastroenterology services for support with the investigation and management of gastrointestinal complaints. Individuals can present with a myriad of complex coexisting diagnoses, the inter-relationship of which is unclear. This review discusses the proposed association between hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD) with disorders of mast cell activation and provides an overview of gastrointestinal symptoms and nutritional outcomes in this patient cohort. RECENT FINDINGS It is unclear whether a true association between hEDS/HSD and mast cell activation disorders exists. There is a high prevalence of nonspecific gastrointestinal symptoms in individuals with hEDS/HSD and patients may be at risk of macro-nutrient and micro-nutrient deficiencies, although the current evidence base is limited. SUMMARY We advocate a pragmatic approach to the investigation and management of gastrointestinal symptoms in patients with hEDS/HSD. This centres on excluding organic pathology, discussing the overlap with disorders of gut-brain interactions, trialling evidence-based therapies targeting individual symptoms, and supporting nutritional deficiencies where present via the least invasive approach. Engagement with a broad multidisciplinary team is also important to support the holistic needs of this patient cohort.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Imran Aziz
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Ching Lam
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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2
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Brum EDS, Fialho MFP, Becker G, Nogueira CW, Oliveira SM. Involvement of peripheral mast cells in a fibromyalgia model in mice. Eur J Pharmacol 2024; 967:176385. [PMID: 38311276 DOI: 10.1016/j.ejphar.2024.176385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 01/19/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
Fibromyalgia is a painful disorder of unknown aetiology that presents activation and recruitment of innate immune cells, including mast cells. Efforts have been made to understand its pathogenesis to manage it better. Thus, we explored the involvement of peripheral mast cells in an experimental model of fibromyalgia induced by reserpine. Reserpine (1 mg/kg) was subcutaneously (s.c.) injected once daily in the back of male Swiss mice for three consecutive days. We analysed mechanical and cold allodynia, muscle fatigue and number of mast cell in plantar tissue. The fibromyalgia induction produced mast cell infiltration (i.e., mastocytosis) in the mice's plantar tissue. The depletion of mast cell mediators with the compound 48/80 (0.5-4 mg/kg, intraperitoneal (i.p.)) or the mast cell membrane stabilizer ketotifen fumarate (10 mg/kg, oral route (p.o.) widely (80-90 %) and extensively (from 1 up to 10 days) prevented reserpine-induced mechanical and cold allodynia and muscle fatigue. Compound 48/80 also prevented the reserpine-induced mastocytosis. Finally, we demonstrated that PAR-2, 5-HT2A, 5-HT3, H1, NK1 and MrgprB2 receptors, expressed in neuronal or mast cells, seem crucial to mediate fibromyalgia-related cardinal symptoms since antagonists or inhibitors of these receptors (gabexate (10 mg/kg, s.c.), ENMD-1068 (10 mg/kg, i.p.), ketanserin (1 mg/kg, i.p.), ondansetron (1 mg/kg, p.o.), promethazine (1 mg/kg, i.p.), and L733,060 (5 mg/kg, s.c.), respectively) transiently reversed the reserpine-induced allodynia and fatigue. The results indicate that mast cells mediate painful and fatigue behaviours in this fibromyalgia model, representing potential therapy targets to treat fibromyalgia syndrome.
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Affiliation(s)
- Evelyne da Silva Brum
- Graduate Program in Biological Sciences: Toxicological Biochemistry, Centre of Natural and Exact Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Maria Fernanda Pessano Fialho
- Graduate Program in Biological Sciences: Toxicological Biochemistry, Centre of Natural and Exact Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Gabriela Becker
- Graduate Program in Biological Sciences: Toxicological Biochemistry, Centre of Natural and Exact Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Cristina Wayne Nogueira
- Graduate Program in Biological Sciences: Toxicological Biochemistry, Centre of Natural and Exact Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil; Department of Biochemistry and Molecular Biology, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Sara Marchesan Oliveira
- Graduate Program in Biological Sciences: Toxicological Biochemistry, Centre of Natural and Exact Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil; Department of Biochemistry and Molecular Biology, Federal University of Santa Maria, Santa Maria, RS, Brazil.
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3
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Mohammad A, Laboulaye MA, Shenhar C, Dobberfuhl AD. Mechanisms of oxidative stress in interstitial cystitis/bladder pain syndrome. Nat Rev Urol 2024:10.1038/s41585-023-00850-y. [PMID: 38326514 DOI: 10.1038/s41585-023-00850-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 02/09/2024]
Abstract
Interstitial cystitis/bladder pain syndrome (IC/BPS) is characterized by bladder and/or pelvic pain, increased urinary urgency and frequency and nocturia. The pathophysiology of IC/BPS is poorly understood, and theories include chronic inflammation, autoimmune dysregulation, bacterial cystitis, urothelial dysfunction, deficiency of the glycosaminoglycan (GAG) barrier and urine cytotoxicity. Multiple treatment options exist, including behavioural interventions, oral medications, intravesical instillations and procedures such as hydrodistension; however, many clinical trials fail, and patients experience an unsatisfactory treatment response, likely owing to IC/BPS phenotype heterogeneity and the use of non-targeted interventions. Oxidative stress is implicated in the pathogenesis of IC/BPS as reactive oxygen species impair bladder function via their involvement in multiple molecular mechanisms. Kinase signalling pathways, nociceptive receptors, mast-cell activation, urothelial dysregulation and circadian rhythm disturbance have all been linked to reactive oxygen species and IC/BPS. However, further research is necessary to fully uncover the role of oxidative stress in the pathways driving IC/BPS pathogenesis. The development of new models in which these pathways can be manipulated will aid this research and enable further investigation of promising therapeutic targets.
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Affiliation(s)
- Ashu Mohammad
- Department of Urology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mallory A Laboulaye
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Chen Shenhar
- Department of Urology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Amy D Dobberfuhl
- Department of Urology, Stanford University School of Medicine, Palo Alto, CA, USA.
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Palmer RF, Dempsey TT, Afrin LB. Chemical Intolerance and Mast Cell Activation: A Suspicious Synchronicity. J Xenobiot 2023; 13:704-718. [PMID: 37987446 PMCID: PMC10660865 DOI: 10.3390/jox13040045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/19/2023] [Accepted: 11/10/2023] [Indexed: 11/22/2023] Open
Abstract
Background: Chemical Intolerance (CI) is characterized by intolerances for chemicals, foods, and drugs with multi-system symptoms. As yet, the biomechanism remains unclear. One study reported converging lines of evidence supporting a substantive association between mast cell activation syndrome (MCAS) and CI. The purpose of this study is to (1) confirm a previous report demonstrating that 60% of MCAS patients report CI and (2) examine the parallels between symptoms and intolerances in CI and MCAS. Methods: Five hundred forty-four MCAS patients were assigned a clinical MCAS score using a validated assessment instrument and were assessed for CI using the validated Quick Environmental Exposure Sensitivity Index. Results: Our outcomes confirm the previously published study where the majority of MCAS patients also have CI. There was a clear overlap between various ICD-10 diagnostic categories and CI symptoms, providing further support for a potential shared mechanism. Conclusions: Exposures to pesticides, volatile organic compounds, combustion products, and mold have previously been reported as initiators of CI. However, until recently, little was known about the biological mechanism involved that could explain the multisystem symptoms associated with CI. This paper addresses a newly identified biomechanism for disease, which may underlie a host of "medically unexplained symptoms" triggered by xenobiotics.
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Affiliation(s)
- Raymond F Palmer
- Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA
| | - Tania T Dempsey
- AIM Center for Personalized Medicine, Purchase, NY 10577, USA
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Molderings GJ, Afrin LB. A survey of the currently known mast cell mediators with potential relevance for therapy of mast cell-induced symptoms. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:2881-2891. [PMID: 37243761 PMCID: PMC10567897 DOI: 10.1007/s00210-023-02545-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 05/29/2023]
Abstract
Mast cells (MCs) occupy a central role in immunological as well as non-immunological processes as reflected in the variety of the mediators by which MCs influence other cells. Published lists of MC mediators have all shown only subsets-usually quite small-of the full repertoire. The full repertoire of MC mediators released by exocytosis is comprehensively compiled here for the first time. The compilation of the data is essentially based on the largely cytokine-focused database COPE®, supplemented with data on the expression of substances in human MCs published in several articles, plus extensive research in the PubMed database. Three hundred and ninety substances could be identified as mediators of human MCs which can be secreted into the extracellular space by activation of the MC. This number might still be an underestimate of the actual number of MC mediators since, in principle, all substances produced by MCs can become mediators because of the possibility of their release by diffusion into the extracellular space, mast cell extracellular traps, and intercellular exchange via nanotubules. When human MCs release mediators in inappropriate manners, this may lead to symptoms in any or all organs/tissues. Thus, such MC activation disorders may clinically present with a myriad of potential combinations of symptoms ranging from trivial to disabling or even life-threatening. The present compilation can be consulted by physicians when trying to gain clarity about MC mediators which may be involved in patients with MC disease symptoms refractory to most therapies.
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Affiliation(s)
- Gerhard J Molderings
- Institute for Human Genetics, University Hospital of Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany.
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Weinstock LB, Nelson RM, Blitshteyn S. Neuropsychiatric Manifestations of Mast Cell Activation Syndrome and Response to Mast-Cell-Directed Treatment: A Case Series. J Pers Med 2023; 13:1562. [PMID: 38003876 PMCID: PMC10672129 DOI: 10.3390/jpm13111562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
Mast cell activation syndrome (MCAS) is an immune disease with an estimated prevalence of 17%. Mast cell chemical mediators lead to heterogeneous multisystemic inflammatory and allergic manifestations. This syndrome is associated with various neurologic and psychiatric disorders, including headache, dysautonomia, depression, generalized anxiety disorder, and many others. Although MCAS is common, it is rarely recognized, and thus, patients can suffer for decades. The syndrome is caused by aberrant mast cell reactivity due to the mutation of the controller gene. A case series is presented herein including eight patients with significant neuropsychiatric disorders that were often refractory to standard medical therapeutics. Five patients had depression, five had generalized anxiety disorder, and four had panic disorder. Other psychiatric disorders included attention-deficit hyperactivity disorder, obsessive compulsive disorder, phobias, and bipolar disorder. All eight patients were subsequently diagnosed with mast cell activation syndrome; six had comorbid autonomic disorders, the most common being postural orthostatic tachycardia syndrome; and four had hypermobile Ehlers-Danlos syndrome. All patients experienced significant improvements regarding neuropsychiatric and multisystemic symptoms after mast-cell-directed therapy. In neuropsychiatric patients who have systemic symptoms and syndromes, it is important to consider the presence of an underlying or comorbid MCAS.
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Affiliation(s)
- Leonard B. Weinstock
- Independent Researcher, Specialists in Gastroenterology, St. Louis, MO 63141, USA
| | - Renee M. Nelson
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA; (R.M.N.); (S.B.)
| | - Svetlana Blitshteyn
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA; (R.M.N.); (S.B.)
- Dysautonomia Clinic, Williamsville, NY 14221, USA
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Baran J, Sobiepanek A, Mazurkiewicz-Pisarek A, Rogalska M, Gryciuk A, Kuryk L, Abraham SN, Staniszewska M. Mast Cells as a Target-A Comprehensive Review of Recent Therapeutic Approaches. Cells 2023; 12:cells12081187. [PMID: 37190096 DOI: 10.3390/cells12081187] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/04/2023] [Accepted: 04/16/2023] [Indexed: 05/17/2023] Open
Abstract
Mast cells (MCs) are the immune cells distributed throughout nearly all tissues, mainly in the skin, near blood vessels and lymph vessels, nerves, lungs, and the intestines. Although MCs are essential to the healthy immune response, their overactivity and pathological states can lead to numerous health hazards. The side effect of mast cell activity is usually caused by degranulation. It can be triggered by immunological factors, such as immunoglobulins, lymphocytes, or antigen-antibody complexes, and non-immune factors, such as radiation and pathogens. An intensive reaction of mast cells can even lead to anaphylaxis, one of the most life-threatening allergic reactions. What is more, mast cells play a role in the tumor microenvironment by modulating various events of tumor biology, such as cell proliferation and survival, angiogenesis, invasiveness, and metastasis. The mechanisms of the mast cell actions are still poorly understood, making it difficult to develop therapies for their pathological condition. This review focuses on the possible therapies targeting mast cell degranulation, anaphylaxis, and MC-derived tumors.
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Affiliation(s)
- Joanna Baran
- Centre for Advanced Materials and Technologies CEZAMAT, Warsaw University of Technology, 02-822 Warsaw, Poland
| | - Anna Sobiepanek
- Faculty of Chemistry, Warsaw University of Technology, 00-664 Warsaw, Poland
| | - Anna Mazurkiewicz-Pisarek
- Centre for Advanced Materials and Technologies CEZAMAT, Warsaw University of Technology, 02-822 Warsaw, Poland
| | - Marta Rogalska
- Centre for Advanced Materials and Technologies CEZAMAT, Warsaw University of Technology, 02-822 Warsaw, Poland
| | - Aleksander Gryciuk
- Centre for Advanced Materials and Technologies CEZAMAT, Warsaw University of Technology, 02-822 Warsaw, Poland
| | - Lukasz Kuryk
- Department of Virology, National Institute of Public Health NIH-NRI, 00-791 Warsaw, Poland
| | - Soman N Abraham
- Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA
| | - Monika Staniszewska
- Centre for Advanced Materials and Technologies CEZAMAT, Warsaw University of Technology, 02-822 Warsaw, Poland
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Häder T, Molderings GJ, Klawonn F, Conrad R, Mücke M, Sellin J. Cluster-Analytic Identification of Clinically Meaningful Subtypes in MCAS: The Relevance of Heat and Cold. Dig Dis Sci 2023:10.1007/s10620-023-07921-5. [PMID: 37029308 PMCID: PMC10352424 DOI: 10.1007/s10620-023-07921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/10/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Mast cell activation syndrome (MCAS) is a clinically heterogeneous disease with allergy-like symptoms and abdominal complaints. Its etiology is only partially understood and it is often overlooked. AIMS The aim of this study was to identify subgroups of MCAS patients to facilitate diagnosis and allow a personalized therapy. METHODS Based on data from 250 MCAS patients, hierarchical and two-step cluster analyses as well as association analyses were performed. The data used included data from a MCAS checklist asking about symptoms and triggers and a set of diagnostically relevant laboratory parameters. RESULTS Using a two-step cluster analysis, MCAS patients could be divided into three clusters. Physical trigger factors were particularly decisive for the classification as they showed remarkable differences between the three clusters. Cluster 1, labeled high responders, showed high values for the triggers heat and cold, whereas cluster 2, labeled intermediate responders, presented with high values for the trigger heat and low values for cold. The third cluster, labeled low responders, did not react to thermal triggers. The first two clusters showed more divers clinical symptoms especially with regard to dermatological and cardiological complaints. Subsequent association analyses revealed relationships between triggers and clinical complaints: Abdominal discomfort is mainly triggered by histamine consumption, dermatological discomfort by exercise, and neurological symptoms are related to physical exertion and periods of starvation. The reasons for the occurrence of cardiological complaints are manifold and triggers for respiratory complaints still need better identification. CONCLUSION Our study identified three distinct clusters on the basis of physical triggers, which also differ significantly in their clinical symptoms. A trigger-related classification can be helpful in clinical practice for diagnosis and therapy. Longitudinal studies should be conducted to further understand the relationship between triggers and symptoms.
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Affiliation(s)
- Tinus Häder
- Institute for Digitalization and General Medicine, University Hospital RWTH Aachen, Aachen, Germany
- Center for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany
| | | | - Frank Klawonn
- Biostatistics Group, Helmholtz Centre for Infection Research, Braunschweig, Germany
- Department of Computer Science, Ostfalia University, Wolfenbuettel, Germany
| | - Rupert Conrad
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Muenster, Muenster, Germany
| | - Martin Mücke
- Institute for Digitalization and General Medicine, University Hospital RWTH Aachen, Aachen, Germany
- Center for Rare Diseases Aachen (ZSEA), University Hospital RWTH Aachen, Aachen, Germany
| | - Julia Sellin
- Institute for Digitalization and General Medicine, University Hospital RWTH Aachen, Aachen, Germany.
- Center for Rare Diseases Aachen (ZSEA), University Hospital RWTH Aachen, Aachen, Germany.
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Molina P, Ojeda R, Blanco A, Alcalde G, Prieto-Velasco M, Aresté N, Buades JM, Simó VE, Goicoechea M, Pérez-Morales RE, Sánchez-Álvarez E, Sánchez-Villanueva R, Montesa M, Arenas MD. Etiopathogenesis of chronic kidney disease-associated pruritus: putting the pieces of the puzzle together. Nefrologia 2023; 43:48-62. [PMID: 37173258 DOI: 10.1016/j.nefroe.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/28/2022] [Indexed: 05/15/2023] Open
Abstract
Defined as the unpleasant sensation that causes the desire to scratch, pruritus is the most common skin symptom associated with uremia and appears in almost half of patients with advanced chronic kidney disease (CKD). Beyond its direct impact on quality of life, CKD-associated pruritus (CKD-aP) is an independent predictor of mortality that also has a synergistic effect with other quality of life-related symptoms, such as insomnia, depression, and anxiety. Although different mechanisms have been proposed to explain the origin of Pa-ERC, its etiopathogenesis is still not fully understood. Since new therapeutic targets have been identified and several clinical trials have recently shown promising results, our current understanding of the interrelationships has expanded significantly and the pathophysiological mechanisms underlying CKD-aP are now considered to be multifactorial. The potential triggers of pruritus in patients with CKD are discussed in this review, including hypotheses about skin xerosis, accumulation of uremic toxins, dysregulation of the immune system and systemic inflammation, uremic neuropathy, and imbalances in the endogenous opioid system. Other non-uremic causes of pruritus are also discussed, with the aim of guiding the physicians to apply an adequate aetiopathogenic approach to CKD-aP in their day-to-day clinical practice.
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Affiliation(s)
- Pablo Molina
- Servicio de Nefrología, FISABIO, Hospital Universitari Dr Peset, Departamento de Medicina, Universitat de València, Valencia, Spain.
| | - Raquel Ojeda
- Servicio de Nefrología, Hospital Universitario Renia Sofía, Córdoba, Spain
| | - Ana Blanco
- Fresenius Medical Care, Centro de Diálisis Alcobendas, Madrid, Spain; Servicio de Nefrología, Hospital Quirón Ruber Juan Bravo, Madrid, Spain
| | - Guillermo Alcalde
- Servicio de Nefrología, BIOARABA, Hospital Universitario Araba, Osakidetza, Universidad del País Vasco, Vitoria-Gasteiz, Álava, Spain
| | | | - Nuria Aresté
- Servicio de Nefrología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Juan Manuel Buades
- Servicio de Nefrología, Hospital Universitario Son Llàtzer, Institut d'Investigació Sanitària de les Illes Balears (IdISBa), Palma, Spain
| | - Vicent Esteve Simó
- Servicio de Nefrologia, Hospital Terrassa, Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
| | - Marian Goicoechea
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rosa Elena Pérez-Morales
- Servicio de Nefrología. Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Emilio Sánchez-Álvarez
- Servicio de Nefrología, Hospital Universitario de Cabueñes, Red de Investigación Renal (REDINREN), Gijón, Asturias, Spain
| | | | - María Montesa
- Servicio de Nefrología, FISABIO, Hospital Universitari Dr Peset, Departamento de Medicina, Universitat de València, Valencia, Spain
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Batiha GES, Al-kuraishy HM, Al-Gareeb AI, Welson NN. Pathophysiology of Post-COVID syndromes: a new perspective. Virol J 2022; 19:158. [PMID: 36210445 PMCID: PMC9548310 DOI: 10.1186/s12985-022-01891-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2022] Open
Abstract
Most COVID-19 patients recovered with low mortality; however, some patients experienced long-term symptoms described as “long-COVID” or “Post-COVID syndrome” (PCS). Patients may have persisting symptoms for weeks after acute SARS-CoV-2 infection, including dyspnea, fatigue, myalgia, insomnia, cognitive and olfactory disorders. These symptoms may last for months in some patients. PCS may progress in association with the development of mast cell activation syndrome (MCAS), which is a distinct kind of mast cell activation disorder, characterized by hyper-activation of mast cells with inappropriate and excessive release of chemical mediators. COVID-19 survivors, mainly women, and patients with persistent severe fatigue for 10 weeks after recovery with a history of neuropsychiatric disorders are more prone to develop PCS. High D-dimer levels and blood urea nitrogen were observed to be risk factors associated with pulmonary dysfunction in COVID-19 survivors 3 months post-hospital discharge with the development of PCS. PCS has systemic manifestations that resolve with time with no further complications. However, the final outcomes of PCS are chiefly unknown. Persistence of inflammatory reactions, autoimmune mimicry, and reactivation of pathogens together with host microbiome alterations may contribute to the development of PCS. The deregulated release of inflammatory mediators in MCAS produces extraordinary symptoms in patients with PCS. The development of MCAS during the course of SARS-CoV-2 infection is correlated to COVID-19 severity and the development of PCS. Therefore, MCAS is treated by antihistamines, inhibition of synthesis of mediators, inhibition of mediator release, and inhibition of degranulation of mast cells. Post-COVID (PCS) syndrome may progress in association with the development of mast cell activation syndrome (MCAS). High D-dimer levels and blood urea nitrogen were observed to be risk factors associated with pulmonary dysfunction in COVID-19 survivors 3 months post-hospital discharge with the development of PCS. Persistence of inflammatory reactions, autoimmune mimicry, and reactivation of pathogens together with host microbiome alterations may contribute to the development of PCS. MCAS is treated by antihistamines, inhibition of synthesis of mediators, inhibition of mediator release, and inhibition of degranulation of mast cells.
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Weinstock LB, Brook JB, Molderings GJ. Efficacy and toxicity of hydroxyurea in mast cell activation syndrome patients refractory to standard medical therapy: retrospective case series. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:1441-1447. [PMID: 35982335 PMCID: PMC9388361 DOI: 10.1007/s00210-022-02282-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/11/2022] [Indexed: 12/04/2022]
Abstract
Determine efficacy and adverse events (AEs) of hydroxyurea (HU) in mast cell activation syndrome (MCAS) patients who were refractory to standard medical therapy. An electronic chart review was performed to find MCAS patients who received HU in a MCAS medical practice. Diagnosis of MCAS was established on the basis of mast cell (MC) activation symptoms in ≥ 5 systems plus ≥ 1 abnormal MC mediators and/or ≥ 20 MC/high power field on duodenal biopsies. Medicines not providing significant clinical improvement prior to HU were tabulated. The following symptoms were evaluated by patients on a 0–10 scale prior to and at the study conclusion: bone pain, abdominal pain, diarrhea, bloating, and nausea. Safety labs were obtained on a regular basis. Twenty out of three hundred ten (8.4%) MCAS patients received HU. Patients included 22 females, average age 42.4 years. Dysautonomia was present in 60%. An average of 10.6 (SD 1.7, range 8–13) medications were used prior to adding HU to various concomitant medications. Average dose of HU was 634 mg. In 20 patients who continued therapy for ≥ 2 months, there was statistically significant reduction of bone pain, abdominal pain, diarrhea, bloating, and nausea. Fourteen patients noted prolonged success with therapy. Six patients stopped HU within 6 weeks owing to AEs. Four patients treated ≥ 2 months had AEs and 2 led to HU cessation. All AEs were reversible. Refractory MCAS patients showed clear significant improvement in bone pain and gastrointestinal symptoms on HU. Systematic monitoring was effective in preventing the occurrence of severe HU-induced adverse events.
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Affiliation(s)
- Leonard B Weinstock
- Clinical Medicine, Department of Medicine, Washington University School of Medicine, President, Specialists in Gastroenterology, 11525 Olde Cabin Road, St. Louis, MO, 63141, USA
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12
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Arun S, Storan A, Myers B. Mast cell activation syndrome and the link with long COVID. Br J Hosp Med (Lond) 2022; 83:1-10. [DOI: 10.12968/hmed.2022.0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Mast cells are innate immune cells found in connective tissues throughout the body, most prevalent at tissue-environment interfaces. They possess multiple cell-surface receptors which react to various stimuli and, after activation, release many mediators including histamine, heparin, cytokines, prostaglandins, leukotrienes and proteases. In mast cell activation syndrome, excessive amounts of inflammatory mediators are released in response to triggers such as foods, fragrances, stress, exercise, medications or temperature changes. Diagnostic markers may be difficult to assess because of their rapid degradation; these include urinary N-methyl histamine, urinary prostaglandins D2, DM and F2α and serum tryptase (which is stable) in the UK. Self-management techniques, medications and avoiding triggers may improve quality of life. Treatments include mast cell mediator blockers, mast cell stabilisers and anti-inflammatory agents. ‘Long COVID’ describes post-COVID-19 syndrome when symptoms persist for more than 12 weeks after initial infection with no alternative diagnosis. Both mast cell activation syndrome and long COVID cause multiple symptoms. It is theorised that COVID-19 infection could lead to exaggeration of existing undiagnosed mast cell activation syndrome, or could activate normal mast cells owing to the persistence of viral particles. Other similarities include the relapse-remission cycle and improvements with similar treatments. Importantly, however, aside from mast cell disorders, long COVID could potentially be attributed to several other conditions.
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Affiliation(s)
- Soumya Arun
- Division of Biosciences, University College London, London, UK
- Mast Cell Action, Leamington Spa, UK
| | - Abbie Storan
- Mast Cell Action, Leamington Spa, UK
- Department of Science, Engineering, and Environment, The University of Salford, Salford, UK
| | - Bethan Myers
- Haematology Department, University Hospitals of Leicester, Leicester, UK
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13
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Etiopatogenia del prurito asociado a la enfermedad renal crónica: recomponiendo las piezas del puzle. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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14
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Molderings GJ. Systemic mast cell activation disease variants and certain genetically determined comorbidities may be consequences of a common underlying epigenetic disease. Med Hypotheses 2022. [DOI: 10.1016/j.mehy.2022.110862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Trisvetova EL. Postural Orthostatic Tachycardia Syndrome as a Manifestation of Post-COVID-19 Syndrome. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-04-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The pandemic of coronavirus infection, the complex and insufficiently studied mechanisms of which cause disorders in the functions of many organs and systems of the body, has led to the emergence of new problems that are far from being resolved. Researchers note the difficulty in predicting the course of the disease and outcome due to the detection of many symptoms that arose at the height of the disease and persisted for 3-6 months after recovery. The term "post-COVID-19syndrome" has appeared, reflecting the condition of a patient who has undergone COVID-19, with a negative PCR test, and with symptoms lasting more than 12 weeks from the onset of the disease, which cannot be explained by an alternative diagnosis. Postural orthostatic tachycardia as a manifestation of the post-COVID-19syndrome has been described in young women who have undergone coronavirus infection of varying severity. In the case of the development of the syndrome of postural orthostatic tachycardia, the quality of life deteriorates, and the ability to work of patients is limited. There is no evidence base for drug therapy of postural tachycardia syndrome, in most cases empirical drug and non-drug methods of treatment are used.
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16
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[Cystic diseases in urology : Recommendations for patients with systemic mast cell disease]. Urologe A 2022; 61:1115-1121. [PMID: 35508639 DOI: 10.1007/s00120-022-01841-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
The systemic mast cell disease (MCAD; prevalence 17%) may occur frequently in urological patients. MCAD-induced changes include cysts in all organs, also in the urogenital system. In the presence of MCAD, the surgical removal of such cysts must consider specific features of the MCAD in order to reduce surgical and complication risks. Vice versa, if in urological examinations multiple cysts are found, this could be an indication of a possibly existing, in some circumstances, unrecognized MCAD.
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17
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Afrin LB, Dempsey TT, Weinstock LB. Post-HPV-Vaccination Mast Cell Activation Syndrome: Possible Vaccine-Triggered Escalation of Undiagnosed Pre-Existing Mast Cell Disease? Vaccines (Basel) 2022; 10:127. [PMID: 35062788 PMCID: PMC8779641 DOI: 10.3390/vaccines10010127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/27/2023] Open
Abstract
For nearly a decade, case reports and series have emerged regarding dysautonomias-particularly postural orthostatic tachycardia syndrome (POTS)-presenting soon after vaccination against human papilloma virus (HPV). We too have observed a number of such cases (all following vaccination with the Gardasil product), and have found several to have detectable mast cell activation syndrome (MCAS) as well as histories suggesting that MCAS was likely present long before vaccination. We detail 11 such cases here, posing a hypothesis that HPV vaccination (at least with the Gardasil product) may have triggered or exacerbated MCAS in teenagers previously not recognized to have it. Only recently recognized, MCAS is being increasingly appreciated as a prevalent and chronic multisystem disorder, often emerging early in life and presenting with inflammatory ± allergic phenomena following from known mast cell (MC) mediator effects. There is rising recognition, too, of associations of MCAS with central and peripheral neuropathic disorders, including autonomic disorders such as POTS. Given the recognized potential for many antigens to trigger a major and permanent escalation of baseline MC misbehavior in a given MCAS patient, we hypothesize that in our patients described herein, vaccination with Gardasil may have caused pre-existing (but not yet clinically recognized) MCAS to worsen to a clinically significantly degree, with the emergence of POTS and other issues. The recognition and management of MCAS prior to vaccinations in general may be a strategy worth investigating for reducing adverse events following HPV vaccinations and perhaps even other types of vaccinations.
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Affiliation(s)
- Lawrence B. Afrin
- AIM Center for Personalized Medicine, Purchase, New York, NY 10577, USA;
| | - Tania T. Dempsey
- AIM Center for Personalized Medicine, Purchase, New York, NY 10577, USA;
| | - Leonard B. Weinstock
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
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18
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Nurek M, Rayner C, Freyer A, Taylor S, Järte L, MacDermott N, Delaney BC. Recommendations for the recognition, diagnosis, and management of long COVID: a Delphi study. Br J Gen Pract 2021; 71:e815-e825. [PMID: 34607799 PMCID: PMC8510689 DOI: 10.3399/bjgp.2021.0265] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In the absence of research into therapies and care pathways for long COVID, guidance based on 'emerging experience' is needed. AIM To provide a rapid expert guide for GPs and long COVID clinical services. DESIGN AND SETTING A Delphi study was conducted with a panel of primary and secondary care doctors. METHOD Recommendations were generated relating to the investigation and management of long COVID. These were distributed online to a panel of UK doctors (any specialty) with an interest in, lived experience of, and/or experience treating long COVID. Over two rounds of Delphi testing, panellists indicated their agreement with each recommendation (using a five-point Likert scale) and provided comments. Recommendations eliciting a response of 'strongly agree', 'agree', or 'neither agree nor disagree' from 90% or more of responders were taken as showing consensus. RESULTS Thirty-three clinicians representing 14 specialties reached consensus on 35 recommendations. Chiefly, GPs should consider long COVID in the presence of a wide range of presenting features (not limited to fatigue and breathlessness) and exclude differential diagnoses where appropriate. Detailed history and examination with baseline investigations should be conducted in primary care. Indications for further investigation and specific therapies (for myocarditis, postural tachycardia syndrome, mast cell disorder) include hypoxia/desaturation, chest pain, palpitations, and histamine-related symptoms. Rehabilitation should be individualised, with careful activity pacing (to avoid relapse) and multidisciplinary support. CONCLUSION Long COVID clinics should operate as part of an integrated care system, with GPs playing a key role in the multidisciplinary team. Holistic care pathways, investigation of specific complications, management of potential symptom clusters, and tailored rehabilitation are needed.
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Affiliation(s)
- Martine Nurek
- Department of Surgery and Cancer, Imperial College London, London
| | - Clare Rayner
- Department of Acute Medicine, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham
| | - Anette Freyer
- Department of Acute Medicine, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham
| | - Sharon Taylor
- Central and North West London NHS Foundation Trust and honorary senior clinical lecturer, Imperial College School of Medicine, London
| | - Linn Järte
- Anaesthetics Department, Morriston Hospital, Swansea Bay University Health Board, Swansea
| | | | - Brendan C Delaney
- Department of Surgery and Cancer, Imperial College London, London, and principal in general practice, Albion Street Group Practice, London
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19
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Noto CN, Hoft SG, DiPaolo RJ. Mast Cells as Important Regulators in Autoimmunity and Cancer Development. Front Cell Dev Biol 2021; 9:752350. [PMID: 34712668 PMCID: PMC8546116 DOI: 10.3389/fcell.2021.752350] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/17/2021] [Indexed: 01/04/2023] Open
Abstract
Mast cells are an essential part of the immune system and are best known as important modulators of allergic and anaphylactic immune responses. Upon activation, mast cells release a multitude of inflammatory mediators with various effector functions that can be both protective and damage-inducing. Mast cells can have an anti-inflammatory or pro-inflammatory immunological effect and play important roles in regulating autoimmune diseases including rheumatoid arthritis, type 1 diabetes, and multiple sclerosis. Importantly, chronic inflammation and autoimmunity are linked to the development of specific cancers including pancreatic cancer, prostate cancer, colorectal cancer, and gastric cancer. Inflammatory mediators released from activated mast cells regulate immune responses and promote vascular permeability and the recruitment of immune cells to the site of inflammation. Mast cells are present in increased numbers in tissues affected by autoimmune diseases as well as in tumor microenvironments where they co-localize with T regulatory cells and T effector cells. Mast cells can regulate immune responses by expressing immune checkpoint molecules on their surface, releasing anti-inflammatory cytokines, and promoting vascularization of solid tumor sites. As a result of these immune modulating activities, mast cells have disease-modifying roles in specific autoimmune diseases and cancers. Therefore, determining how to regulate the activities of mast cells in different inflammatory and tumor microenvironments may be critical to discovering potential therapeutic targets to treat autoimmune diseases and cancer.
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Affiliation(s)
- Christine N Noto
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, Saint Louis University, St. Louis, MO, United States
| | - Stella G Hoft
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, Saint Louis University, St. Louis, MO, United States
| | - Richard J DiPaolo
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, Saint Louis University, St. Louis, MO, United States
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20
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Fortea M, Albert-Bayo M, Abril-Gil M, Ganda Mall JP, Serra-Ruiz X, Henao-Paez A, Expósito E, González-Castro AM, Guagnozzi D, Lobo B, Alonso-Cotoner C, Santos J. Present and Future Therapeutic Approaches to Barrier Dysfunction. Front Nutr 2021; 8:718093. [PMID: 34778332 PMCID: PMC8582318 DOI: 10.3389/fnut.2021.718093] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022] Open
Abstract
There is converging and increasing evidence, but also uncertainty, for the role of abnormal intestinal epithelial barrier function in the origin and development of a growing number of human gastrointestinal and extraintestinal inflammatory disorders, and their related complaints. Despite a vast literature addressing factors and mechanisms underlying changes in intestinal permeability in humans, and its connection to the appearance and severity of clinical symptoms, the ultimate link remains to be established in many cases. Accordingly, there are no directives or clinical guidelines related to the therapeutic management of intestinal permeability disorders that allow health professionals involved in the management of these patients to carry out a consensus treatment based on clinical evidence. Instead, there are multiple pseudoscientific approaches and commercial propaganda scattered on the internet that confuse those affected and health professionals and that often lack scientific rigor. Therefore, in this review we aim to shed light on the different therapeutic options, which include, among others, dietary management, nutraceuticals and medical devices, microbiota and drugs, and epigenetic and exosomes-manipulation, through an objective evaluation of the scientific publications in this field. Advances in the knowledge and management of intestinal permeability will sure enable better options of dealing with this group of common disorders to enhance quality of life of those affected.
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Affiliation(s)
- Marina Fortea
- Laboratory for Enteric NeuroScience, Translational Research Center for GastroIntestinal Disorders, University of Leuven, Leuven, Belgium
| | - Mercé Albert-Bayo
- Laboratory of Neuro-Immuno-Gastroenterology, Digestive System Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Mar Abril-Gil
- Laboratory of Neuro-Immuno-Gastroenterology, Digestive System Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - John-Peter Ganda Mall
- Laboratory of Neuro-Immuno-Gastroenterology, Digestive System Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Xavier Serra-Ruiz
- Department of Gastroenterology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Alejandro Henao-Paez
- Department of Gastroenterology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Elba Expósito
- Laboratory of Neuro-Immuno-Gastroenterology, Digestive System Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Ana María González-Castro
- Laboratory of Neuro-Immuno-Gastroenterology, Digestive System Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Danila Guagnozzi
- Laboratory of Neuro-Immuno-Gastroenterology, Digestive System Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Department of Gastroenterology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Facultad de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERHED), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Lobo
- Laboratory of Neuro-Immuno-Gastroenterology, Digestive System Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Department of Gastroenterology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Facultad de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Carmen Alonso-Cotoner
- Laboratory of Neuro-Immuno-Gastroenterology, Digestive System Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Department of Gastroenterology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Facultad de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERHED), Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Santos
- Laboratory of Neuro-Immuno-Gastroenterology, Digestive System Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Department of Gastroenterology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Facultad de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERHED), Instituto de Salud Carlos III, Madrid, Spain
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21
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Retornaz F, Grino M, Vanhaudenhuyse A, Chiche L, Stavris C, Bennani M, Faymonville ME, Alitta A. Hypnotherapy in Treatment of Mastocytosis: A Prospective Study. Int J Clin Exp Hypn 2021; 69:468-482. [PMID: 34474650 DOI: 10.1080/00207144.2021.1965484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Mastocytosis is an orphan disease associated with many systemic symptoms, chronic handicap, and potentially marked social consequences despite improved therapies. In this study, the authors aimed to measure the effect of 2 hypnosis sessions on mastocytosis symptoms in a clinical setting. Questionnaires (pain, flushes, energy, digestive symptoms, quality of life, perceived symptom severity, and global impression of change) were completed pre- and posthypnosis intervention. Data from 20 patients were analyzed (mean age: 53.3 years, 75% female). Compared to baseline assessment, patients exhibited a significant improvement immediately after the first and second hypnosis sessions with regard to the number of days with abdominal pain, abdominal pain intensity and fatigue (p = .03 and p = .005; p = .05 and p = .02; p = .034, and p = .039, respectively). Perceived severity of symptoms was significantly improved throughout the study (p = .0075). Long-term improvement in global impression of change was observed in half the responders (8/16). Patients with mastocytosis had an improvement in disabling symptoms with the impact of hypnotic intervention persisting at 1 month. Several patients experienced long-term improvement.
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Affiliation(s)
- Frédérique Retornaz
- Unité de Soins et de Recherche en Médecine Interne et Maladies Infectieuses, Hôpital Européen, Marseille, France
| | - Michel Grino
- Département de Recherche Clinique, Centre Gérontologique Départemental, Marseille, France.,C2VN, Aix Marseille Univ., INSERM, INRAE, France
| | - Audrey Vanhaudenhuyse
- Département d'Algologie, CHU De Liège-B35, and Sensation and Perception Research Group, GIGA Consciousness, University of Liège, Domaine Universitaire du Sart Tilman, Belgium
| | - Laurent Chiche
- Unité de Soins et de Recherche en Médecine Interne et Maladies Infectieuses, Hôpital Européen, Marseille, France
| | - Chloé Stavris
- Unité de Soins et de Recherche en Médecine Interne et Maladies Infectieuses, Hôpital Européen, Marseille, France
| | - Myriam Bennani
- Unité de Soins et de Recherche en Médecine Interne et Maladies Infectieuses, Hôpital Européen, Marseille, France
| | - Marie Elisabeth Faymonville
- Département d'Algologie, CHU De Liège-B35, and Sensation and Perception Research Group, GIGA Consciousness, University of Liège, Domaine Universitaire du Sart Tilman, Belgium
| | - Anouk Alitta
- Unité de Soins et de Recherche en Médecine Interne et Maladies Infectieuses, Hôpital Européen, Marseille, France
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22
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Seidel H, Hertfelder HJ, Oldenburg J, Kruppenbacher JP, Afrin LB, Molderings GJ. Effects of Primary Mast Cell Disease on Hemostasis and Erythropoiesis. Int J Mol Sci 2021; 22:ijms22168960. [PMID: 34445665 PMCID: PMC8396658 DOI: 10.3390/ijms22168960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/10/2021] [Accepted: 08/17/2021] [Indexed: 01/21/2023] Open
Abstract
Mast cell disease is an epigenetically and genetically determined disease entity with very diverse clinical manifestations in potentially every system and tissue due to inap pro priate release of variable subsets of mast cell mediators together with accumulation of either morphologically normal or altered mast cells. Easy bruising, excessive bleeding, and aberrancies of erythropoiesis can frequently be observed in patients with mast cell disease. A thorough history, including a family history, will guide the appropriate work-up, and laboratory evaluations may provide clues to diagnosis. In recent years, our understanding of the involvement of coagulation and anticoagulant pathways, the fibrinolytic system, and erythropoiesis in the pathophysiology of mast cell disease has increased considerably. This review summarizes current knowledge of the impact of the disturbed hemostatic and erythropoietic balance in patients with mast cell disease and describes options of treatment.
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Affiliation(s)
- Holger Seidel
- Center for Bleeding Disorders and Transfusion Medicine (CBT), Am Propsthof 3, D-53121 Bonn, Germany; (H.S.); (H.-J.H.); (J.P.K.)
| | - Hans-Jörg Hertfelder
- Center for Bleeding Disorders and Transfusion Medicine (CBT), Am Propsthof 3, D-53121 Bonn, Germany; (H.S.); (H.-J.H.); (J.P.K.)
- Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany;
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany;
| | - Johannes P. Kruppenbacher
- Center for Bleeding Disorders and Transfusion Medicine (CBT), Am Propsthof 3, D-53121 Bonn, Germany; (H.S.); (H.-J.H.); (J.P.K.)
| | - Lawrence B. Afrin
- Department of Mast Cell Studies, AIM Center for Personalized Medicine, 3010 Westchester Ave Suite 404, Purchase, NY 10577, USA;
| | - Gerhard J. Molderings
- Institute of Human Genetics, University Hospital of Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
- Correspondence: ; Tel.: +49-228-287-51000
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23
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Mai L, Liu Q, Huang F, He H, Fan W. Involvement of Mast Cells in the Pathophysiology of Pain. Front Cell Neurosci 2021; 15:665066. [PMID: 34177465 PMCID: PMC8222580 DOI: 10.3389/fncel.2021.665066] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/07/2021] [Indexed: 12/11/2022] Open
Abstract
Mast cells (MCs) are immune cells and are widely distributed throughout the body. MCs are not only classically viewed as effector cells of some allergic diseases but also participate in host defense, innate and acquired immunity, homeostatic responses, and immunoregulation. Mounting evidence indicates that activation of MCs releasing numerous vasoactive and inflammatory mediators has effects on the nervous system and has been involved in different pain conditions. Here, we review the latest advances made about the implication of MCs in pain. Possible cellular and molecular mechanisms regarding the crosstalk between MC and the nervous system in the initiation and maintenance of pain are also discussed.
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Affiliation(s)
- Lijia Mai
- Department of Anesthesiology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Institute of Stomatological Research, Sun Yat-sen University, Guangzhou, China
| | - Qing Liu
- Department of Anesthesiology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Institute of Stomatological Research, Sun Yat-sen University, Guangzhou, China
| | - Fang Huang
- Guangdong Provincial Key Laboratory of Stomatology, Institute of Stomatological Research, Sun Yat-sen University, Guangzhou, China
| | - Hongwen He
- Guangdong Provincial Key Laboratory of Stomatology, Institute of Stomatological Research, Sun Yat-sen University, Guangzhou, China
| | - Wenguo Fan
- Department of Anesthesiology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Institute of Stomatological Research, Sun Yat-sen University, Guangzhou, China
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24
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Afrin LB, Ackerley MB, Bluestein LS, Brewer JH, Brook JB, Buchanan AD, Cuni JR, Davey WP, Dempsey TT, Dorff SR, Dubravec MS, Guggenheim AG, Hindman KJ, Hoffman B, Kaufman DL, Kratzer SJ, Lee TM, Marantz MS, Maxwell AJ, McCann KK, McKee DL, Menk Otto L, Pace LA, Perkins DD, Radovsky L, Raleigh MS, Rapaport SA, Reinhold EJ, Renneker ML, Robinson WA, Roland AM, Rosenbloom ES, Rowe PC, Ruhoy IS, Saperstein DS, Schlosser DA, Schofield JR, Settle JE, Weinstock LB, Wengenroth M, Westaway M, Xi SC, Molderings GJ. Diagnosis of mast cell activation syndrome: a global "consensus-2". Diagnosis (Berl) 2021; 8:137-152. [PMID: 32324159 DOI: 10.1515/dx-2020-0005] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 02/15/2020] [Indexed: 02/06/2023]
Abstract
The concept that disease rooted principally in chronic aberrant constitutive and reactive activation of mast cells (MCs), without the gross MC neoplasia in mastocytosis, first emerged in the 1980s, but only in the last decade has recognition of "mast cell activation syndrome" (MCAS) grown significantly. Two principal proposals for diagnostic criteria have emerged. One, originally published in 2012, is labeled by its authors as a "consensus" (re-termed here as "consensus-1"). Another sizable contingent of investigators and practitioners favor a different approach (originally published in 2011, newly termed here as "consensus-2"), resembling "consensus-1" in some respects but differing in others, leading to substantial differences between these proposals in the numbers of patients qualifying for diagnosis (and thus treatment). Overdiagnosis by "consensus-2" criteria has potential to be problematic, but underdiagnosis by "consensus-1" criteria seems the far larger problem given (1) increasing appreciation that MCAS is prevalent (up to 17% of the general population), and (2) most MCAS patients, regardless of illness duration prior to diagnosis, can eventually identify treatment yielding sustained improvement. We analyze these proposals (and others) and suggest that, until careful research provides more definitive answers, diagnosis by either proposal is valid, reasonable, and helpful.
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Affiliation(s)
| | | | - Linda S Bluestein
- Department of Anesthesiology, Medical College of Wisconsin, Wausau, WI, USA
| | | | - Jill B Brook
- Alaska Internal Medicine and Pediatrics, Anchorage, AK, USA
| | | | - Jill R Cuni
- Division of Pediatrics, Beaver Medical Group, Banning, CA, USA
| | - William P Davey
- Department of Dermatology, University of Kentucky, Lexington, KY, USA
| | | | | | | | - Alena G Guggenheim
- Comprehensive Pain Center, Oregon Health and Science University, Portland, OR, USA
| | | | - Bruce Hoffman
- Hoffman Centre for Integrative and Functional Medicine, Calgary, Alberta, Canada
| | | | | | | | | | | | | | | | - Laurie Menk Otto
- Helfgott Research Institute, National College of Natural Medicine, Portland, OR, USA
| | - Laura A Pace
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, UT, USA
| | | | | | | | | | | | - Mark L Renneker
- Department of Family Medicine, University of California San Francisco, San Francisco, CA, USA
| | - William A Robinson
- Division of Hematology/Oncology, University of Colorado, Denver, CO, USA
| | - Aaron M Roland
- Department of Family Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Jill R Schofield
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Janet E Settle
- Department of Psychiatry, University of Colorado, Denver, CO, USA
| | | | - Martina Wengenroth
- Institute of Neuroradiology, University Hospital Lübeck, Lübeck, Germany
| | | | - Shijun Cindy Xi
- Section of Allergy and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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25
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Weinstock LB, Pace LA, Rezaie A, Afrin LB, Molderings GJ. Mast Cell Activation Syndrome: A Primer for the Gastroenterologist. Dig Dis Sci 2021; 66:965-982. [PMID: 32328892 DOI: 10.1007/s10620-020-06264-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
Mast cell activation syndrome is thought to be a common, yet under-recognized, chronic multi-system disorder caused by inappropriate mast cell activation. Gastrointestinal symptoms are frequently reported by these patients and are often mistaken by physicians as functional gastrointestinal disorders. This syndrome can be diagnosed by the medical history and measurable biomarkers. Gastroenterologists manage diseases associated with active inflammatory cells including neutrophils, lymphocytes, macrophages, and eosinophils. The mast cell has only recently been recognized as a major player in our specialty. Gastrointestinal disorders from mast cell mediators often present with apparent irritable bowel syndrome, dyspepsia, chronic or cyclical nausea, and heartburn. Individuals with mast cell activation syndrome experience significant delays in diagnosis. The gastrointestinal symptoms are often refractory to symptom-targeted prescription medications. Beyond avoiding triggers, the best therapy is directed at modulating mast cell activation and the effects of the mediators. Many of these therapies are simple over-the-counter medications. In this article, we review mast cell function and dysfunction and the gastrointestinal symptoms, comorbid conditions, diagnosis, and management of mast cell activation syndrome. Gastroenterologists who become aware of this syndrome can dramatically improve the quality of life for their patients who previously have been labeled with a functional gastrointestinal disorder.
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Affiliation(s)
- Leonard B Weinstock
- Specialists in Gastroenterology, 11525 Olde Cabin Rd, St. Louis, MO, 63141, USA.
| | - Laura A Pace
- Division of Gastroenterology, Department of Internal Medicine, University of Utah, 30 N 1900 E, SOM 4R118, Salt Lake City, UT, 84132, USA
| | - Ali Rezaie
- Cedars-Sinai Medical Center, Gastroenterology, 8730 Alden Dr., Suite 204E, Los Angeles, CA, 90048, USA
| | - Lawrence B Afrin
- Armonk Integrative Medicine, Hematology/Oncology, 3010 Westchester Avenue, Suite 401, Armonk, NY, 10577, USA
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Palmer R, Walker T, Perales R, Rincon R, Jaén C, Miller C. Disease comorbidities associated with chemical intolerance. ENVIRONMENTAL DISEASE 2021. [DOI: 10.4103/ed.ed_18_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kucharik AH, Chang C. The Relationship Between Hypermobile Ehlers-Danlos Syndrome (hEDS), Postural Orthostatic Tachycardia Syndrome (POTS), and Mast Cell Activation Syndrome (MCAS). Clin Rev Allergy Immunol 2020; 58:273-297. [PMID: 31267471 DOI: 10.1007/s12016-019-08755-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In recent years, an association between hypermobile Ehlers-Danlos syndrome (hEDS), mast cell activation syndrome (MCAS), and postural orthostatic tachycardia syndrome (POTS) has garnered attention and patients are increasingly presenting with this triad. However, a real relationship between these entities is unclear due to a lack of scientific validity. We conducted an extensive review of the literature using two different search strategies. A narrower strategy included 88 searches of various combinations of terms for each of the three conditions, yielding 19 unique papers. A broader search included 136 searches of various combinations of terms but included all forms of EDS and yielded 40 unique papers. Of these, only four and nine papers from the narrower and broader search strategies were original research articles. None of these papers resulted from a combination of the search terms for the three conditions. All three clinical entities are controversial in either existence or pathogenesis. MCAS is a poorly defined clinical entity, and many studies do not adhere to the proposed criteria when establishing the diagnosis. Patients previously diagnosed with EDS hypermobility type may not meet the new, stricter criteria for hEDS but may for a less severe hypermobility spectrum disorder (HSD). The pathophysiology of POTS is still unclear. An evidence-based, common pathophysiologic mechanism between any of the two, much less all three conditions, has yet to be described. Our review of the literature shows that current evidence is lacking on the existence of MCAS or hEDS as separate or significant clinical entities. Studies proposing a relationship between the three clinical entities are either biased or based on outdated criteria. The reason behind the purported association of these entities stems from an overlapping pool of vague, subjective symptoms, which is inadequate evidence to conclude that any such relationship exists.
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Affiliation(s)
| | - Christopher Chang
- Florida Atlantic University, Boca Raton, FL, USA.
- Joe DiMaggio Children's Hospital, 1131 North 35th Avenue, Suite 220, Hollywood, FL, 33021, USA.
- University of California, Davis, CA, USA.
- Florida International University, Miami, FL, USA.
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Molderings GJ, Dumoulin FL, Homann J, Sido B, Textor J, Mücke M, Qagish GJ, Barion R, Raithel M, Klingmüller D, Schäfer VS, Hertfelder HJ, Berdel D, Tridente G, Weinstock LB, Afrin LB. Adrenal insufficiency is a contraindication for omalizumab therapy in mast cell activation disease: risk for serum sickness. Naunyn Schmiedebergs Arch Pharmacol 2020; 393:1573-1580. [PMID: 32377770 PMCID: PMC7419348 DOI: 10.1007/s00210-020-01886-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
Omalizumab is an effective therapeutic humanized murine IgE antibody in many cases of primary systemic mast cell activation disease (MCAD). The present study should enable the clinician to recognize when treatment of MCAD with omalizumab is contraindicated because of the potential risk of severe serum sickness and to report our successful therapeutic strategy for such adverse event (AE). Our clinical observations, a review of the literature including the event reports in the FDA AE Reporting System, the European Medicines Agency Eudra-Vigilance databases (preferred search terms: omalizumab, Xolair®, and serum sickness) and information from the manufacturer’s Novartis database were used. Omalizumab therapy may be more likely to cause serum sickness than previously thought. In patients with regular adrenal function, serum sickness can occur after 3 to 10 days which resolves after the antigen and circulating immune complexes are cleared. If the symptoms do not resolve within a week, injection of 20 to 40 mg of prednisolone on two consecutive days could be given. However, in MCAD patients whose adrenal cortical function is completely suppressed by exogenous glucocorticoid therapy, there is a high risk that serum sickness will be masked by the MCAD and evolve in a severe form with pronounced damage of organs and tissues, potentially leading to death. Therefore, before the application of the first omalizumab dose, it is important to ensure that the function of the adrenal cortex is not significantly limited so that any occurring type III allergy can be self-limiting.
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Affiliation(s)
- G J Molderings
- Institute of Human Genetics, University Hospital Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany.
| | - F L Dumoulin
- Department of Internal Medicine, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - J Homann
- Department of Internal Medicine, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - B Sido
- Department of General and Visceral Surgery, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - J Textor
- Department of Radiology, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - M Mücke
- Center for Rare Diseases, University Hospital Bonn, Bonn, Germany
| | - G J Qagish
- Medical Office for Internal Medicine, Meckenheim, Germany
| | - R Barion
- Medical Office for Diabetology, Niederkassel, Rheidt, Germany
| | - M Raithel
- Malteser Waldkrankenhaus St. Marien, Medical Clinic II, Erlangen, Germany
| | - D Klingmüller
- Department of Endocrinology, University Hospital Bonn, Bonn, Germany
| | - V S Schäfer
- Department of Rheumatology and Clinical Immunology, Clinic for Internal Medicine III, University Hospital Bonn, Bonn, Germany
| | - H J Hertfelder
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - D Berdel
- Marien Hospital Wesel, Wesel, Germany
| | | | - L B Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, 63141, USA
| | - L B Afrin
- Armonk Integrative Medicine, Hematology/Oncology, Purchase, New York, NY, 10577, USA
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Chi Z, Xu J, Saxena R. Increased Mast Cell Counts and Degranulation in Microscopic Colitis. Gastroenterol Res Pract 2020; 2020:9089027. [PMID: 32148478 PMCID: PMC7057011 DOI: 10.1155/2020/9089027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/06/2019] [Accepted: 12/21/2019] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Microscopic colitis (MC) is characterized by chronic diarrhea, normal colonoscopy findings, and mucosal inflammation in colonic biopsies and can be classified as collagenous colitis (CC) or lymphocytic colitis (LC). However, the pathogenesis of MC is largely unknown. In this study, we aimed to study mast cell counts and activation in MC. METHODS We investigated 64 biopsy samples from the surgical pathology database of Indiana University Health, which met the diagnostic criteria for CC or LC along with 20 control samples collected from 2014 to 2015. The specimens were used for the quantification of mast cells by examining the presence of intracellular and extracellular tryptase by immunohistochemistry. RESULTS In the lamina propria, the mast cell count was higher in both CC and LC groups than the control (mean highest count, 39/high-power field (HPF) vs. 30/HPF vs. 23/HPF; P < 0.01). Extracellular tryptase was present in 10% of control subjects as compared to 41% of CC (P < 0.01). Extracellular tryptase was present in 10% of control subjects as compared to 41% of CC (P < 0.01). Extracellular tryptase was present in 10% of control subjects as compared to 41% of CC (. CONCLUSIONS The increased mast cell count and degranulation are identified in MC, suggesting that mast cell activation might be involved in the pathogenesis of MC.
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Affiliation(s)
- Zhikai Chi
- 1Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jing Xu
- 1Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Romil Saxena
- 2Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Abstract
Mast cell activation syndrome (MCAS) is a heterogeneous and rare disorder with episodic and severe activation of mast cells. Because symptoms of mast cell activation are nonspecific, it is important to base the diagnosis on best available clinical and scientific evidence, and not make it one of exclusion. MCAS, much like the mast cell itself, as a whole is greater than the sum of its proposed diagnostic criteria. When each component is considered in isolation, criteria can seem nonspecific, and thus, a broad constellation of symptoms can be attributed to MCAS when they may be due to other disease processes.
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Affiliation(s)
- Dilawar Khokhar
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby H Suite H-2100, Ann Arbor, MI 48106, USA
| | - Cem Akin
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby H Suite H-2100, Ann Arbor, MI 48106, USA.
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Activity and Exercise Intolerance After Concussion: Identification and Management of Postural Orthostatic Tachycardia Syndrome. J Neurol Phys Ther 2019; 42:163-171. [PMID: 29864098 PMCID: PMC6023605 DOI: 10.1097/npt.0000000000000231] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background and Purpose: Postural orthostatic tachycardia syndrome (POTS) is increasingly recognized as a complication affecting recovery from concussion. Individuals with POTS demonstrate refractory dizziness, lightheadedness, cognitive dysfunction, fatigue, headache, chronic pain, nausea and gastrointestinal dysmotility, activity and exercise intolerance, syncope, and tachycardia. Subtypes of POTS may include hypovolemia, hyperadrenergic states, autonomic neuropathy, and underlying autoimmunity, which may variably impact response to rehabilitation in varying ways. The subtle presentation of POTS postconcussion is often mistaken for underlying anxiety, conversion disorder, or lack of motivation for recovery. This article will present clinical features of POTS that may arise after concussion, and propose a role for physical therapists in the diagnosis and management of POTS during concussion recovery. Summary of Key Points: Data recorded and entered into a database during clinic visits from a large pediatric institution indicate that 11.4% of individuals diagnosed with POTS report onset of symptoms within 3 months of sustaining a concussion. Activation of the sympathetic nervous system can result in lightheadedness, shortness of breath, chest pain, tachycardia, palpitations on standing or with exertion, and activity and exercise intolerance. Identified comorbidities in people with POTS such as joint hypermobility and autoimmune disorders can further influence recovery. Recommendations for Clinical Practice: Physical therapists may identify signs and symptoms of POTS in a subset of individuals who remain refractory to typical interventions and who exhibit symptom exacerbation with orthostatic activity. Incorporation of an individualized POTS exercise program into current established concussion interventions may be useful, with emphasis on initial recumbent exercises and ongoing physical therapy assessment of exercise tolerance for dosing of activity intensity and duration. Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A211).
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The Role of Rhodomyrtus tomentosa (Aiton) Hassk. Fruits in Downregulation of Mast Cells-Mediated Allergic Responses. BIOMED RESEARCH INTERNATIONAL 2019; 2019:3505034. [PMID: 31281834 PMCID: PMC6590610 DOI: 10.1155/2019/3505034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 04/29/2019] [Accepted: 05/26/2019] [Indexed: 01/12/2023]
Abstract
Rhodomyrtus tomentosa, a flowering plant of Myrtaceae family from southern and southeastern Asia, was known to possess a rich source of structurally diverse and various biological activities. In this study, the inhibitory effect of R. tomentosa fruit extract (RFE) on allergic responses in calcium ionophore A23187-activated RBL-2H3 mast cells was investigated. The result showed that RFE was able to inhibit mast cell degranulation via decreasing β-hexosaminidase release and intracellular Ca2+ elevation at the concentration of 400 μg/ml. Moreover, the suppressive effects of RFE on the production of interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) were evidenced. In addition, RFE effectively scavenged DPPH radical and suppressed the reactive oxygen species generation in a dose-dependent manner. Notably, the pretreatment of RFE caused the downregulation of tyrosine kinase Fyn phospholipid enzyme phospholipase Cγ (PLCγ), extracellular-signal-regulated kinase (ERK), and nuclear factor kappa B (NF-κB) phosphorylation. These results indicated that RFE could be a promising inhibitor of allergic responses and may be developed as bioactive ingredient for prevention or treatment of allergic diseases.
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Theoharides TC, Tsilioni I, Ren H. Recent advances in our understanding of mast cell activation - or should it be mast cell mediator disorders? Expert Rev Clin Immunol 2019; 15:639-656. [PMID: 30884251 PMCID: PMC7003574 DOI: 10.1080/1744666x.2019.1596800] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 03/14/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION An increasing number of patients present with multiple symptoms affecting many organs including the brain due to multiple mediators released by mast cells. These unique tissue immune cells are critical for allergic reactions triggered by immunoglobulin E (IgE), but are also stimulated (not activated) by immune, drug, environmental, food, infectious, and stress triggers, leading to secretion of multiple mediators often without histamine and tryptase. The presentation, diagnosis, and management of the spectrum of mast cell disorders are very confusing. As a result, neuropsychiatric symptoms have been left out, and diagnostic criteria made stricter excluding most patients. Areas covered: A literature search was performed on papers published between January 1990 and November 2018 using MEDLINE. Terms used were activation, antihistamines, atopy, autism, brain fog, heparin, KIT mutation, IgE, inflammation, IL-6, IL-31, IL-37, luteolin, mast cells, mastocytosis, mediators, mycotoxins, release, secretion, tetramethoxyluteolin, and tryptase. Expert opinion: Conditions associated with elevated serum or urine levels of any mast cell mediator, in the absence of comorbidities that could explain elevated levels, should be considered 'Mast Cell Mediator Disorders (MCMD).' Emphasis should be placed on the identification of unique mast cell mediators, and development of drugs or supplements that inhibit their release.
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Affiliation(s)
- Theoharis C. Theoharides
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Immunology, Tufts University School of Medicine, Boston, MA, USA
- Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
- Department of Internal Medicine, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, USA
- Department of Psychiatry, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, USA
| | - Irene Tsilioni
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Immunology, Tufts University School of Medicine, Boston, MA, USA
| | - Huali Ren
- Department of Otolaryngology, Beijing Electric Power Hospital, Beijing, China
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Schofield JR, Afrin LB. Recognition and Management of Medication Excipient Reactivity in Patients With Mast Cell Activation Syndrome. Am J Med Sci 2019; 357:507-511. [PMID: 31126513 DOI: 10.1016/j.amjms.2019.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/26/2019] [Accepted: 03/15/2019] [Indexed: 01/27/2023]
Abstract
Mast cell activation syndrome (MCAS) is a complex disorder hallmarked by chronic multisystem inflammatory, allergic and growth dystrophic phenomena caused by inappropriate mast cell activation. MCAS has been estimated to affect as many as 17% of the population with a severity ranging from mild to life-threatening. MCAS patients are more sensitive than the average person to chemicals in the environment, including the nondrug ("inactive") ingredients (excipients) in medications and supplements. Excipient reactivity may explain unusual side effects to medications health professionals often find puzzling, such as the patient who appears intolerant of prednisone, acetaminophen, levothyroxine, or a vitamin. We present a series of patients with MCAS to illustrate important points regarding excipient reactivity which may be useful in everyday practice.
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Affiliation(s)
- Jill R Schofield
- Center for Multisystem Disease, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado.
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Role of Mast Cells and Type 2 Innate Lymphoid (ILC2) Cells in Lung Transplantation. J Immunol Res 2018; 2018:2785971. [PMID: 30510964 PMCID: PMC6232810 DOI: 10.1155/2018/2785971] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/10/2018] [Accepted: 09/14/2018] [Indexed: 01/10/2023] Open
Abstract
The multifunctional role of mast cells (MCs) in the immune system is complex and has not fully been explored. MCs reside in tissues and mucous membranes such as the lung, digestive tract, and skin which are strategically located at interfaces with the external environment. These cells, therefore, will encounter external stimuli and pathogens. MCs modulate both the innate and the adaptive immune response in inflammatory disorders including transplantation. MCs can have pro- and anti-inflammatory functions, thereby regulating the outcome of lung transplantation through secretion of mediators that allow interaction with other cell types, particularly innate lymphoid cells (ILC2). ILC2 cells are a unique population of hematopoietic cells that coordinate the innate immune response against a variety of threats including infection, tissue damage, and homeostatic disruption. In addition, MCs can modulate alloreactive T cell responses or assist in T regulatory (Treg) cell activity. This paper outlines the current understanding of the role of MCs in lung transplantation, with a specific focus on their interaction with ILC2 cells within the engrafted organ.
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Abstract
Mast cells (MCs) are physiologically activated by binding of stem cell factor (SCF) to the extracellular domains of the Kit receptor. This binding increases the proliferation and prolongs the survival of normal mature MCs, as well as intensifies the release of mediators. In mastocytosis, somatic mutations of the coding Kit gene cause autocrine dysregulation and lead to constitutive KIT activation even in the absence of its ligand SCF. Clinical symptoms are caused by MC-mediator release and/or infiltration of MCs into tissues. Aberrant KIT activation may result in increased production of MCs in the skin and extracutaneous organs. Depending on the affected organ(s), the disease can be divided into cutaneous mastocytosis (CM), systemic mastocytosis (SM), and localized MC tumors. The updated classification of WHO discriminates between several distinct subvariants of CM and SM. While the prognosis in CM and indolent SM (ISM) is excellent with (almost) normal life expectancy, the prognosis in aggressive SM (ASM) and MC leukemia (MCL) is dismal. The symptoms may comprise urticaria, angioedema, flush, pruritus, abdominal pain, diarrhea, hypotension, syncope, and musculoskeletal pain and are the results of MC infiltration and mediator release into target organs, i.e., the skin, gastrointestinal tract, liver, spleen, lymph nodes, and bone marrow. Mastocytosis differs from a lot of other hematological disorders because its pathology is not only based on the lack of normal function of a specific pathway or of a specific cell type but additionally is a proliferative disease. Currently available treatments of mastocytosis include symptomatic, antimediator and cytoreductive targeted therapies.
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Hydroxychloroquine as a novel therapeutic approach in mast cell activation diseases. Clin Immunol 2018; 194:75-79. [DOI: 10.1016/j.clim.2018.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/05/2018] [Accepted: 07/05/2018] [Indexed: 11/15/2022]
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Caslin HL, Kiwanuka KN, Haque TT, Taruselli MT, MacKnight HP, Paranjape A, Ryan JJ. Controlling Mast Cell Activation and Homeostasis: Work Influenced by Bill Paul That Continues Today. Front Immunol 2018; 9:868. [PMID: 29755466 PMCID: PMC5932183 DOI: 10.3389/fimmu.2018.00868] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/09/2018] [Indexed: 01/13/2023] Open
Abstract
Mast cells are tissue resident, innate immune cells with heterogenous phenotypes tuned by cytokines and other microenvironmental stimuli. Playing a protective role in parasitic, bacterial, and viral infections, mast cells are also known for their role in the pathogenesis of allergy, asthma, and autoimmune diseases. Here, we review factors controlling mast cell activation, with a focus on receptor signaling and potential therapies for allergic disease. Specifically, we will discuss our work with FcεRI and FγR signaling, IL-4, IL-10, and TGF-β1 treatment, and Stat5. We conclude with potential therapeutics for allergic disease. Much of these efforts have been influenced by the work of Bill Paul. With many mechanistic targets for mast cell activation and different classes of therapeutics being studied, there is reason to be hopeful for continued clinical progress in this area.
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Affiliation(s)
- Heather L Caslin
- Department of Biology, Virginia Commonwealth University, Richmond, VA, United States
| | - Kasalina N Kiwanuka
- Department of Biology, Virginia Commonwealth University, Richmond, VA, United States
| | - Tamara T Haque
- Department of Biology, Virginia Commonwealth University, Richmond, VA, United States
| | - Marcela T Taruselli
- Department of Biology, Virginia Commonwealth University, Richmond, VA, United States
| | - H Patrick MacKnight
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, Richmond, VA, United States
| | - Anuya Paranjape
- Department of Biology, Virginia Commonwealth University, Richmond, VA, United States
| | - John J Ryan
- Department of Biology, Virginia Commonwealth University, Richmond, VA, United States
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Stewart JM, Boris JR, Chelimsky G, Fischer PR, Fortunato JE, Grubb BP, Heyer GL, Jarjour IT, Medow MS, Numan MT, Pianosi PT, Singer W, Tarbell S, Chelimsky TC. Pediatric Disorders of Orthostatic Intolerance. Pediatrics 2018; 141:peds.2017-1673. [PMID: 29222399 PMCID: PMC5744271 DOI: 10.1542/peds.2017-1673] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2017] [Indexed: 01/18/2023] Open
Abstract
Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ∼40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.
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Affiliation(s)
| | | | | | | | - John E. Fortunato
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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Molderings GJ, Afrin LB, Hertfelder HJ, Brettner S. Case Report: Treatment of systemic mastocytosis with sunitinib. F1000Res 2017; 6:2182. [PMID: 29770197 PMCID: PMC5946163 DOI: 10.12688/f1000research.13343.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 12/16/2022] Open
Abstract
Mast cell activation disease typically presents as chronic multisystem polymorbidity of generally inflammatory ± allergic theme. Presently, treatment of the rare, cytoproliferative variant systemic mastocytosis employs empirically selected therapies to impede mast cell mediator production and action and, when necessary, inhibition of proliferation. Some tyrosine kinase inhibitors (TKIs) have been used successfully in uncommon cases of systemic mastocytosis not bearing that disease’s usual imatinib-resistant KIT
D816V mutation. Recently, sunitinib, a multi-targeted TKI, had been successful in a case of systemic mast cell activation syndrome. In addition, most allergy is principally a mast cell activation phenomenon, and sunitinib has been shown helpful in controlling a murine model of oral allergy syndrome. Here, we present the first use of sunitinib in systemic mastocytosis.
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Affiliation(s)
| | | | - Hans-Jörg Hertfelder
- Institute of Experimental Haematology & Transfusion Medicine, University Hospital of Bonn, Bonn, D-53127, Germany
| | - Stefan Brettner
- Department of Oncology, Hematology and Palliative Care, Kreiskrankenhaus Waldbröl, Waldbröl, D-51545, Germany
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Siglec-8 as mast cell selective target: developing paradigms amidst inconvenient truths. Naunyn Schmiedebergs Arch Pharmacol 2017; 390:1173-1175. [PMID: 28905193 DOI: 10.1007/s00210-017-1425-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 09/04/2017] [Indexed: 10/18/2022]
Abstract
Due to the limited efficacy of current drugs in treating systemic mast cell activation disease, there is an urgent need for more effective drugs selectively acting at mast cells. In the past, a large number of compounds have been claimed to be effective and mast cell selective on the basis of cell culture experiments and studies on blood leukocytes which could not be verified in organ and animal studies. Nevertheless, over time in review papers about potential mast cell targets mast cell selectivity of these targets has been no longer challenged. A recent example for such developing paradigms amidst inconvenient truths is the hype on the purported selective expression of the putative adhesion molecule sialic acid binding Ig-like lectin 8 (Siglec-8) in mast cells and eosinophils, although current data from different publically available databases/sources clearly demonstrate a widespread expression of Siglec-8 in the cells of most tissues. Two suggestions are presented: (1) In the specific case of Siglec-8, the limited mast cell selectivity should be kept in mind in the development and surveillance of Siglec-8-based mast cell- and eosinophil-targeted therapeutic strategies because of potential severe adverse effects in the Siglec-8-positive tissues. (2) In general, readers should always challenge reports about the selective expression of potential targets for drugs in a few cell types of the organism, even if they are published in highly renown journals.
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Malik F, Ali N, Jafri SIM, Ghani A, Hamid M, Boigon M, Fidler C. Continuous diphenhydramine infusion and imatinib for KIT-D816V-negative mast cell activation syndrome: a case report. J Med Case Rep 2017; 11:119. [PMID: 28438191 PMCID: PMC5402659 DOI: 10.1186/s13256-017-1278-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 03/25/2017] [Indexed: 12/01/2022] Open
Abstract
Background We present the first full case report of the treatment of mast cell activation syndrome with continuous diphenhydramine infusion, which resulted in the improvement of anaphylactic reactions and a decrease in hospital readmission. Furthermore, the patient received imatinib in the absence of the KIT-D816V mutation, which led to further improvement of quality of life. Currently, we are trying to wean this patient off diphenhydramine; if successful, this attempt will represent the first reported case. Case presentation An 18-year-old white girl presented with a flare of mast cell activation syndrome and received epinephrine and steroids. She had failed multiple previous therapies, and her quality of life was affected due to two to three flares/week. She was started on continuous diphenhydramine infusion and imatinib, which led to a decrease in hospital admissions and marked improvement in her quality of life. Conclusions Continuous diphenhydramine infusion can provide promising outcomes following the failure of intermittent antihistamine dosing in patients with severe mast cell activation syndrome. Initiating continuous diphenhydramine infusion may be helpful in an intensive care setting when the patient is particularly prone to anaphylaxis and/or the resources needed to manage anaphylaxis are not available outside the intensive care unit. Furthermore, imatinib provides benefits in KIT-D816V-negative mast cell disorders due to other unknown mutations.
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Affiliation(s)
- Faizan Malik
- Department of Internal Medicine, Abington Jefferson Health, 1200 Old York Road, Abington, PA, 19001, USA.
| | - Naveed Ali
- Department of Internal Medicine, Abington Jefferson Health, 1200 Old York Road, Abington, PA, 19001, USA
| | - Syed Imran Mustafa Jafri
- Department of Internal Medicine, Abington Jefferson Health, 1200 Old York Road, Abington, PA, 19001, USA
| | - Ali Ghani
- Department of Internal Medicine, Abington Jefferson Health, 1200 Old York Road, Abington, PA, 19001, USA
| | - Mohsin Hamid
- Department of Internal Medicine, Abington Jefferson Health, 1200 Old York Road, Abington, PA, 19001, USA
| | - Margot Boigon
- Department of Internal Medicine, Abington Jefferson Health, 1200 Old York Road, Abington, PA, 19001, USA
| | - Christian Fidler
- Rosenfeld Cancer Center, Abington Jefferson Health, 1200 Old York Road, Abington, PA, 19001, USA
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Afrin LB, Self S, Menk J, Lazarchick J. Characterization of Mast Cell Activation Syndrome. Am J Med Sci 2017; 353:207-215. [PMID: 28262205 PMCID: PMC5341697 DOI: 10.1016/j.amjms.2016.12.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/30/2016] [Accepted: 12/08/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Mast cell activation syndrome (MCAS), a recently recognized nonneoplastic mast cell disease driving chronic multisystem inflammation and allergy, appears prevalent and thus important. We report the first systematic characterization of a large MCAS population. METHOD Demographics, comorbidities, symptoms, family histories, physical examination and laboratory findings were reviewed in 298 retrospective and 115 prospective patients with MCAS. Blood samples from prospective subjects were examined by flow cytometry for clonal mast cell disease and tested for cytokines potentially driving the monocytosis frequent in MCAS. RESULTS Demographically, white females dominated. Median ages at symptom onset and diagnosis were 9 and 49 years, respectively (range: 0-88 and 16-92, respectively) and median time from symptom onset to diagnosis was 30 years (range: 1-85). Median numbers of comorbidities, symptoms, and family medical issues were 11, 20, and 4, respectively (range: 1-66, 2-84, and 0-33, respectively). Gastroesophageal reflux, fatigue and dermatographism were the most common comorbidity, symptom and examination finding. Abnormalities in routine laboratories were common and diverse but typically modest. The most useful diagnostic markers were heparin, prostaglandin D2, histamine and chromogranin A. Flow cytometric and cytokine assessments were unhelpful. CONCLUSIONS Our study highlights MCAS׳s morbidity burden and challenging heterogeneity. Recognition is important given good survival and treatment prospects.
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Affiliation(s)
- Lawrence B. Afrin
- Division of Hematology, Oncology & Transplantation, 420 Delaware St. SE, MMC 480, University of Minnesota (UMN), Minneapolis, MN 55455,
| | - Sally Self
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425,
| | - Jeremiah Menk
- Clinical and Translational Science Institute (CTSI), University of Minnesota, 717 Delaware St. SE, Room 140-23, Minneapolis, MN 55414,
| | - John Lazarchick
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425,
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