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Beyens M, Sabato V, Ebo DG, Zaghmout T, GĂŒlen T. Drug-Induced Anaphylaxis Uncommon in Mastocytosis: Findings From Two Large Cohorts. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00333-7. [PMID: 38556047 DOI: 10.1016/j.jaip.2024.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/06/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Anaphylaxis is a common feature of patients with mastocytosis, particularly with Hymenoptera venoms. Hence, it is hypothesized that patients with mastocytosis may have an increased susceptibility to developing drug-induced anaphylaxis (DIA). Patients and medical practitioners are therefore concerned when there is a need to use various drugs. However, this issue has not been systematically investigated. OBJECTIVE To investigate the prevalence and clinical characteristics of anaphylaxis to various types of drugs among patients with mastocytosis. METHODS A retrospective study was conducted among 470 consecutive patients (18 years and older) with confirmed clonal mast cell diseases recruited from 2 independent mastocytosis reference centers. All patients underwent a comprehensive, individualized allergy workup with evaluation of the (self)reported drug hypersensitivity. RESULTS The overall prevalence of DIA was 6.3%, accounting for one-third of the confirmed drug hypersensitivity reactions. Nonsteroidal anti-inflammatory drugs were the most common elicitors of DIA (56%), followed by perioperative agents (23%) and antibiotics (13%). Anaphylactic reactions were severe in most cases, with 43% of patients experiencing hypotensive syncope. All drug-related hypersensitivity reactions occurred before mastocytosis was diagnosed. CONCLUSIONS The prevalence of DIA in mastocytosis tends to be higher than in the general population, but is overall low. However, its severity is more pronounced. Our results suggest that patients with mastocytosis with a previous reaction to drugs should undergo a thorough allergy workup. Well-tolerated drugs can be further used without specific precautions.
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Affiliation(s)
- Michiel Beyens
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Edegem, University Hospital Antwerp, Antwerp, Belgium
| | - Vito Sabato
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Edegem, University Hospital Antwerp, Antwerp, Belgium
| | - Didier G Ebo
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Edegem, University Hospital Antwerp, Antwerp, Belgium
| | - Taleb Zaghmout
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Division of Clinical Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Theo GĂŒlen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Division of Clinical Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Clinical Lung and Allergy Research Unit, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.
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Zaghmout T, Maclachlan L, Bedi N, GĂŒlen T. Low Prevalence of Idiopathic Mast Cell Activation Syndrome Among 703 Patients With Suspected Mast Cell Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:753-761. [PMID: 38056692 DOI: 10.1016/j.jaip.2023.11.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/03/2023] [Accepted: 11/24/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Idiopathic mast cell activation syndrome (iMCAS) is characterized by severe, episodic systemic mast cell (MC) activation and mediator-related symptoms, an event-related increase in serum tryptase levels, and response to MC-targeted therapies in the absence of underlying IgE-mediated allergy or clonal MC disorder. Studies indicating its prevalence using evidence-based diagnostic criteria are lacking. OBJECTIVE To assess the prevalence and clinical and laboratory features of patients with iMCAS. METHODS We conducted a retrospective evaluation of data from 703 consecutive patients (aged â„18 years) referred to our center based on suspicion of having MC disorders. Patients underwent a thorough clinical workup including patient history, allergy tests, KIT D816V mutation analysis, and/or bone marrow investigation. Disease activity was prospectively assessed during follow-up visits. RESULTS We identified 31 patients with confirmed iMCAS. Furthermore, hereditary α-tryptasemia was detected in three patients with baseline tryptase levels greater than 8 ng/mL. The most common clinical presentation during MCAS episodes was mucocutaneous symptoms in patients with iMCAS, especially urticaria or angioedema. However, these symptoms were less prevalent in patients with clonal MCAS (P = .015). The duration of diagnostic delay was significantly longer in patients with iMCAS compared to those with clonal MCAS (P = .02). CONCLUSIONS The overall prevalence of iMCAS was 4.4% in the entire cohort, which indicates that iMCAS is an uncommon condition. To accurately diagnose iMCAS, it is crucial to evaluate suspected patients using the three diagnostic MCAS criteria. This involves performing a comprehensive allergy work-up including laboratory tests and ultrasensitive mutation analysis of KIT D816V. Subsequently, recommended diagnostic algorithms should be applied.
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Affiliation(s)
- Taleb Zaghmout
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine Solna, Division of Clinical Immunology and Allergy, Karolinska Institutet, Stockholm, Sweden
| | - Laura Maclachlan
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nawfal Bedi
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Theo GĂŒlen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine Solna, Division of Clinical Immunology and Allergy, Karolinska Institutet, Stockholm, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden; Mastocytosis Center Karolinska, Karolinska University Hospital, Stockholm, Sweden.
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Gulen T. Using the Right Criteria for MCAS. Curr Allergy Asthma Rep 2024; 24:39-51. [PMID: 38243020 PMCID: PMC10866766 DOI: 10.1007/s11882-024-01126-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 01/21/2024]
Abstract
PURPOSE OF REVIEW The current article aims to provide a comprehensive update on diagnostic criteria for mast cell activation syndrome (MCAS), addressing challenges in diagnosing and classifying MCAS and its variants. RECENT FINDINGS In recent years, there has been a significant increase in our knowledge regarding the underlying mechanisms responsible for the activation of mast cells (MCs) in various pathological conditions. Furthermore, a set of criteria and a classification for MCASs have been established. MCAS is characterized by the presence of typical clinical symptoms, a substantial elevation in serum tryptase levels during an attack compared to the patient's baseline tryptase levels, and a response to MC mediator-targeting therapy. In this report, a thorough examination was conducted on the contemporary literature relating to MCAS, with a focus on comparing the specificity, sensitivity, and robustness of MCAS-related parameters within proposals for diagnosing and classifying MCAS and its variants. Moreover, the significance of employing specific consensus criteria in the assessment and categorization of MCAS in individual patients was underscored, due to the escalating occurrence of patients receiving a misdiagnosis of MCAS based on nonspecific criteria.
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Affiliation(s)
- Theo Gulen
- Department of Respiratory Medicine and Allergy, K85, Karolinska University Hospital Huddinge, Stockholm, SE-14186, Sweden.
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
- Clinical Lung and Allergy Research Unit, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.
- Mastocytosis Centre Karolinska, Karolinska University Hospital Huddinge, Stockholm, Sweden.
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Rydz A, Lange M, Ćugowska-Umer H, Sikorska M, Nowicki RJ, Morales-Cabeza C, Alvarez-Twose I. Diffuse Cutaneous Mastocytosis: A Current Understanding of a Rare Disease. Int J Mol Sci 2024; 25:1401. [PMID: 38338679 PMCID: PMC11154339 DOI: 10.3390/ijms25031401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/06/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Mastocytosis is a heterogeneous disease characterized by the expansion and accumulation of neoplastic mast cells in various tissues. Diffuse cutaneous mastocytosis (DCM) is a rare and most severe form of cutaneous mastocytosis, which typically occurs in childhood. There have been reports of a familial DCM with specific gene mutations, indicating both sporadic and hereditary factors involved in its pathogenesis. DCM is associated with severe MC mediator-related symptoms and an increased risk of anaphylaxis. The diagnosis is based on the appearance of skin lesions, which typically show generalized thickening, erythroderma, blistering dermographism, and a positive Darier's sign. Recognition, particularly in infants, is challenging due to DCMs resemblance to other bullous skin disorders. Therefore, in unclear cases, a skin biopsy is crucial. Treatment focuses on symptom management, mainly including antihistamines and mast cell stabilizers. In extremely severe cases, systemic steroids, tyrosine kinase inhibitors, phototherapy, or omalizumab may be considered. Patients should be equipped with an adrenaline autoinjector. Herein, we conducted a comprehensive review of literature data on DCM since 1962, which could help to better understand both the management and prognosis of DCM, which depends on the severity of skin lesions, intensity of mediator-related symptoms, presence of anaphylaxis, and treatment response.
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Affiliation(s)
- Agnieszka Rydz
- Studentâs Scientific Circle Practical and Experimental Dermatology, Medical University of Gdansk, 80-211 GdaĆsk, Poland;
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of GdaĆsk, 80-211 GdaĆsk, Poland; (H.Ć.-U.); (M.S.); (R.J.N.)
| | - Hanna Ćugowska-Umer
- Department of Dermatology, Venereology and Allergology, Medical University of GdaĆsk, 80-211 GdaĆsk, Poland; (H.Ć.-U.); (M.S.); (R.J.N.)
| | - Monika Sikorska
- Department of Dermatology, Venereology and Allergology, Medical University of GdaĆsk, 80-211 GdaĆsk, Poland; (H.Ć.-U.); (M.S.); (R.J.N.)
| | - Roman J. Nowicki
- Department of Dermatology, Venereology and Allergology, Medical University of GdaĆsk, 80-211 GdaĆsk, Poland; (H.Ć.-U.); (M.S.); (R.J.N.)
| | - Cristina Morales-Cabeza
- Instituto de Estudios de Mastocitosis de Castilla-La Mancha (CLMast)âSpanish Reference Center for Mastocytosis, Hospital Virgen del ValleâComplejo Hospitalario Universitario de Toledo, 45071 Toledo, Spain; (C.M.-C.); (I.A.-T.)
| | - IvĂĄn Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla-La Mancha (CLMast)âSpanish Reference Center for Mastocytosis, Hospital Virgen del ValleâComplejo Hospitalario Universitario de Toledo, 45071 Toledo, Spain; (C.M.-C.); (I.A.-T.)
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Beyens M, Toscano A, Ebo D, GĂŒlen T, Sabato V. Diagnostic Significance of Tryptase for Suspected Mast Cell Disorders. Diagnostics (Basel) 2023; 13:3662. [PMID: 38132246 PMCID: PMC10742504 DOI: 10.3390/diagnostics13243662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
Tryptase has proven to be a very useful and specific marker to demonstrate mast cell activation and degranulation when an acute (i.e., within 4 h after the event) and baseline value (i.e., at least 24 h after the event) are compared and meet the consensus formula (i.e., an increase of 20% + 2). The upper limit of normal determined by the manufacturer is 11.4 ng/mL; however, this boundary has been the subject of debate. According to ECNM and AIM experts, the normal range of baseline tryptase should be 1 to 15 ng/mL. A genetic trait, hereditary alpha tryptasemia, characterized by an increased alpha coding TPSAB1 copy number is associated with a baseline value above 8 ng/mL. Elevated tryptase can also be found in chronic kidney disease, obesity, and hematological neoplasms. A tryptase > 20 ng/mL serves as a minor criterion to diagnose systemic mastocytosis and an increase in tryptase > 20% + 2 during an acute event is a required criterion in the diagnosis of mast cell activation syndrome. The goal of this review is to demonstrate the (in)significance of tryptase using some clinical vignettes and to provide a practical guide on how to manage and interpret an elevated tryptase level.
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Affiliation(s)
- Michiel Beyens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
| | - Alessandro Toscano
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
| | - Didier Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Gent, 9000 Ghent, Belgium
| | - Theo GĂŒlen
- Department of Respiratory Medicine and Allergy, K85, Karolinska University Hospital Huddinge, SE-14186 Stockholm, Sweden;
- Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, SE-17177 Stockholm, Sweden
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
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GĂŒlen T. A Puzzling Mast Cell Trilogy: Anaphylaxis, MCAS, and Mastocytosis. Diagnostics (Basel) 2023; 13:3307. [PMID: 37958203 PMCID: PMC10647312 DOI: 10.3390/diagnostics13213307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 11/15/2023] Open
Abstract
Our knowledge of biology and mast cell (MC) function, as well as disorders associated with the pathologic activation of MCs, has evolved over the last few decades. Anaphylaxis, mast cell activation syndrome (MCAS), and mastocytosis are interrelated yet distinct conditions within the spectrum of mast cell activation disorders. Nevertheless, all three conditions can co-exist in one and the same patient, as pathologic MC activation is the key finding in all three. When mediator release is excessive and involves multiple systems, anaphylaxis and MCAS may occur. Furthermore, mastocytosis is a clonal disorder of MCs and often presents with anaphylaxis and MCAS. Nevertheless, in some cases, even the proliferative and accumulative features of MCs in mastocytosis can account for symptoms and disease progression. In each case, diagnosis can be only made when the diagnostic consensus criteria are fulfilled. The current article aims to provide a concise clinical update and pinpoint the main difficulties in diagnosing these puzzling disorders of MCs in medical practice.
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Affiliation(s)
- Theo GĂŒlen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden;
- Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, 171 77 Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, 141 52 Stockholm, Sweden
- Mastocytosis Centre Karolinska, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden
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