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Pouessel G, Dribin TE, Tacquard C, Tanno LK, Cardona V, Worm M, Deschildre A, Muraro A, Garvey LH, Turner PJ. Management of Refractory Anaphylaxis: An Overview of Current Guidelines. Clin Exp Allergy 2024. [PMID: 38866583 DOI: 10.1111/cea.14514] [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: 03/04/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/14/2024]
Abstract
In this review, we compare different refractory anaphylaxis (RA) management guidelines focusing on cardiovascular involvement and best practice recommendations, discuss postulated pathogenic mechanisms underlining RA and highlight knowledge gaps and research priorities. There is a paucity of data supporting existing management guidelines. Therapeutic recommendations include the need for the timely administration of appropriate doses of aggressive fluid resuscitation and intravenous (IV) adrenaline in RA. The preferred second-line vasopressor (noradrenaline, vasopressin, metaraminol and dopamine) is unknown. Most guidelines recommend IV glucagon for patients on beta-blockers, despite a lack of evidence. The use of methylene blue or extracorporeal life support (ECLS) is also suggested as rescue therapy. Despite recent advances in understanding the pathogenesis of anaphylaxis, the factors that lead to a lack of response to the initial adrenaline and thus RA are unclear. Genetic factors, such as deficiency in platelet activating factor-acetyl hydrolase or hereditary alpha-tryptasaemia, mastocytosis may modulate reaction severity or response to treatment. Further research into the underlying pathophysiology of RA may help define potential new therapeutic approaches and reduce the morbidity and mortality of anaphylaxis.
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Affiliation(s)
- Guillaume Pouessel
- Department of Paediatrics, Children's Hospital, Roubaix, France
- Paediatric Pulmonology and Allergy Department, Jeanne de Flandre Hospital, CHU Lille, Lille, France
- Univ Lille, ULR 2694: METRICS, Lille, France
| | - Timothy E Dribin
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles Tacquard
- Department of Anaesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Luciana Kase Tanno
- University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, University of Montpellier - INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Victoria Cardona
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Berlin, Germany
| | - Antoine Deschildre
- Paediatric Pulmonology and Allergy Department, Jeanne de Flandre Hospital, CHU Lille, Lille, France
| | - Antonella Muraro
- Food Allergy Referral Centres, Padua University Hospital, Padua, Italy
| | - Lene H Garvey
- Department of Dermatology and Allergy, Danish Anaesthesia Allergy Centre, Allergy Clinic, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
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Khalid MB, Zektser E, Chu E, Li M, Utoh J, Ryan P, Loving HS, Harb R, Kattappuram R, Chatman L, Hartono S, Claudio-Etienne E, Sun G, Feener EP, Li Z, Lai SK, Le Q, Schwartz LB, Lyons JJ, Komarow H, Zhou ZH, Raza H, Pao M, Laky K, Holland SM, Brittain E, Frischmeyer-Guerrerio PA. A randomized double-blinded trial to assess recurrence of systemic allergic reactions following COVID-19 mRNA vaccination. J Allergy Clin Immunol 2024; 153:1634-1646. [PMID: 38460680 PMCID: PMC11162316 DOI: 10.1016/j.jaci.2024.03.001] [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: 11/28/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Systemic allergic reactions (sARs) following coronavirus disease 2019 (COVID-19) mRNA vaccines were initially reported at a higher rate than after traditional vaccines. OBJECTIVE We aimed to evaluate the safety of revaccination in these individuals and to interrogate mechanisms underlying these reactions. METHODS In this randomized, double-blinded, phase 2 trial, participants aged 16 to 69 years who previously reported a convincing sAR to their first dose of COVID-19 mRNA vaccine were randomly assigned to receive a second dose of BNT162b2 (Comirnaty) vaccine and placebo on consecutive days in a blinded, 1:1 crossover fashion at the National Institutes of Health. An open-label BNT162b2 booster was offered 5 months later if the second dose did not result in severe sAR. None of the participants received the mRNA-1273 (Spikevax) vaccine during the study. The primary end point was recurrence of sAR following second dose and booster vaccination; exploratory end points included biomarker measurements. RESULTS Of 111 screened participants, 18 were randomly assigned to receive study interventions. Eight received BNT162b2 second dose followed by placebo; 8 received placebo followed by BNT162b2 second dose; 2 withdrew before receiving any study intervention. All 16 participants received the booster dose. Following second dose and booster vaccination, sARs recurred in 2 participants (12.5%; 95% CI, 1.6 to 38.3). No sAR occurred after placebo. An anaphylaxis mimic, immunization stress-related response (ISRR), occurred more commonly than sARs following both vaccine and placebo and was associated with higher predose anxiety scores, paresthesias, and distinct vital sign and biomarker changes. CONCLUSIONS Our findings support revaccination of individuals who report sARs to COVID-19 mRNA vaccines. Distinct clinical and laboratory features may distinguish sARs from ISRRs.
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Affiliation(s)
- Muhammad B Khalid
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Ellen Zektser
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Eric Chu
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Md
| | - Min Li
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Joanna Utoh
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Patrick Ryan
- Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Md
| | - Hanna S Loving
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Roa Harb
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Robbie Kattappuram
- Investigational Drug Management and Research Section, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Lindsay Chatman
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Stella Hartono
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Estefania Claudio-Etienne
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Guangping Sun
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | | | - Zhongbo Li
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Samuel K Lai
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Quang Le
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, Va
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, Va
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Hirsh Komarow
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Zhao-Hua Zhou
- Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Md
| | - Haniya Raza
- Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Md
| | - Maryland Pao
- Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Md
| | - Karen Laky
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Erica Brittain
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Pamela A Frischmeyer-Guerrerio
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
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Tanasi I, Crosera L, Taus F, Orsolini G, Adami G, Olivieri F, Bernardelli A, Bonadonna P, Nalin F, Sella S, Giannini S, Liu Y, Mannelli F, Vanderwert F, Bonifacio M, Krampera M, Rossini M, Lyons JJ, Zanotti R. Underlying systemic mastocytosis in patients with unexplained osteoporosis: score proposal. Bone 2024; 186:117141. [PMID: 38823568 DOI: 10.1016/j.bone.2024.117141] [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: 02/06/2024] [Revised: 05/12/2024] [Accepted: 05/29/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND A score to predict the association between unexplained osteoporosis and an underlying systemic Mastocytosis (SM) is lacking. OBJECTIVE This study aimed at identifying criteria able to predict the diagnosis of SM without skin involvement and provide an indication for bone marrow (BM) assessment. METHODS We included 139 adult patients with unexplained osteoporosis and suspected SM. After BM evaluation, 63 patients (45.3 %) were diagnosed with SM, while the remaining 76 patients (54.7 %) negative for clonal mast cell (MC) disorders, constituted our control group. Univariate and multivariate analysis identified three independent predictive factors: age (<54 years: +1 point, >64 years: -1 point), serum basal tryptase (sBT) levels >19 ng/mL (+2 points) and vertebral fractures (+2 points). RESULTS These variables were used to build the OSTEO-score, able to predict the diagnosis of SM before BM assessment with a sensitivity of 73.5 % and a specificity of 67.1 %. Patients with a score < 3 had a lower probability of having SM compared to patients with a score ≥ 3 (28.5 % and 71.4 %, respectively, p < 0.0001). When sBT levels were corrected for the presence of hereditary alpha-tryptasemia (HαT) using the BST calculater (https://bst-calculater.niaid.nih.gov/) recently published [1,2], the sensitivity of ΗαT-adjusted OSTEO-score increased to 87.8 %, and the specificity reached 76.1 %. Also, the positive predictive value of a score ≥ 3 increased to 85.2 %. CONCLUSIONS Further studies are needed to validate these results and characterize the role of tryptase genotyping in patients with unexplained osteoporosis in reducing the risk of misdiagnosing patients with SM. Our proposed scoring model allows the identification of patients with the highest probability of having SM, avoiding unnecessary BM studies.
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Affiliation(s)
- Ilaria Tanasi
- Unità Operativa di Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy.
| | - Lara Crosera
- Unità Operativa di Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Francesco Taus
- Department of Diagnostic and Public Health, Section of Epidemiology and Medical Statistics, University of Verona, Verona, Italy
| | - Giovanni Orsolini
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Unità Operativa di Reumatologia, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Giovanni Adami
- Unità Operativa di Reumatologia, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Francesco Olivieri
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Unità Operativa di Allergologia e Asma Center, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Andrea Bernardelli
- Unità Operativa di Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Patrizia Bonadonna
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Unità Operativa di Allergologia e Asma Center, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Francesca Nalin
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Unità Operativa di Allergologia e Asma Center, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Stefania Sella
- Clinica Medica 1, Azienda Ospedale Università di Padova, Padova, Italy
| | - Sandro Giannini
- Clinica Medica 1, Azienda Ospedale Università di Padova, Padova, Italy
| | - Yihui Liu
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - Francesco Mannelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Università di Firenze, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi di Firenze, Firenze, Italy
| | - Fiorenza Vanderwert
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Università di Firenze, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi di Firenze, Firenze, Italy
| | - Massimiliano Bonifacio
- Unità Operativa di Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Department of Engineering for Innovation Medicine, Section of Innovation Biomedicine, Hematology Area, University of Verona, Verona, Italy
| | - Mauro Krampera
- Unità Operativa di Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Department of Engineering for Innovation Medicine, Section of Innovation Biomedicine, Hematology Area, University of Verona, Verona, Italy
| | - Maurizio Rossini
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Unità Operativa di Reumatologia, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - Roberta Zanotti
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
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4
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Niedoszytko M, Gorska A, Brockow K, Bonadonna P, Lange M, Kluin-Nelemans H, Oude-Elberink H, Sabato V, Shoumariyeh K, von Bubnoff D, Müller S, Illerhaus A, Doubek M, Angelova-Fischer I, Hermine O, Arock M, Elena C, Malcovati L, Yavuz AS, Schug TD, Fortina AB, Judit V, Gotlib J, Panse J, Vucinic V, Reiter A, Schwaab J, Triggiani M, Mattsson M, Breynaert C, Romantowski J, Zanotti R, Olivieri E, Zink A, van de Ven A, Stefan A, Barete S, Caroppo F, Perkins C, Kennedy V, Christen D, Jawhar M, Luebke J, Parente R, Levedahl K, Hadzijusufovic E, Hartmann K, Nedoszytko B, Sperr WR, Valent P. Prevalence of hypersensitivity reactions in various forms of mastocytosis: A pilot study of 2485 adult patients with mastocytosis collected in the ECNM registry. Allergy 2024. [PMID: 38651829 DOI: 10.1111/all.16132] [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: 10/07/2023] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Hypersensitivity reactions (HR) are common in mastocytosis. However, little is known about triggers and risk factors. The registry of the European Competence Network on Mastocytosis (ECNM) enables reliable studies in a larger cohort of mastocytosis patients. We assessed prevalence, triggers and risk factors of HR in adults with mastocytosis in the ECNM registry. METHODS Data were collected in 27 ECNM centers. We analyzed potential triggers (Hymenoptera venoms, food, drug, inhalant and others) and risk factors at diagnosis and during follow-up. The study group consisted of 2485 adults with mastocytosis, 1379 women (55.5%) and 1106 men (44.5%). Median age was 48.2 years (range 18-91 years). RESULTS Nine hundred and forty eight patients (38.1%) reported one or more HR`. Most common triggers were Hymenoptera venoms in cutaneous mastocytosis (CM) and indolent systemic mastocytosis (ISM), whereas in advanced SM (advSM), most common elicitors were drugs, including nonsteroidal anti-inflammatory agents and penicillin. In multivariate analyses, tryptase level < 90 ng/mL, <15% infiltration by mast cells in bone marrow biopsy-sections, and diagnosis of ISM were identified as independent risk factors for HR. For drug-induced HR, prominent risk factors were advSM and high tryptase levels. New reactions were observed in 4.8% of all patients during 4 years follow-up. CONCLUSIONS HR are mainly triggered by Hymenoptera venoms in patients with CM and ISM and by drugs in patients with advSM. Tryptase levels <90 ng/mL, mast cell bone marrow infiltration <15%, and WHO category ISM are predictors of HR. New HR occur in 4.8% of all patients within 4 years.
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Affiliation(s)
- Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Aleksandra Gorska
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany
| | - Patrizia Bonadonna
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Hanneke Kluin-Nelemans
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Vito Sabato
- Department of Immunology, Allergology Rheumatology University of Antwerp and Antwerp University Hospital, Edegem, Belgium
| | - Khalid Shoumariyeh
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany and German Cancer Consortium (DKTK), Partner Site Freiburg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dagmar von Bubnoff
- Dagmar von Bubnoff, Department of Dermatology, Allergy and Venerology, University of Schleswig Holstein, Lübeck, Germany
| | - Sabine Müller
- Department of Dermatology, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | | | | | - Olivier Hermine
- Unit of Dermatology and CEREMAST, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Michel Arock
- Department of Hematological Biology and CEREMAST, Pitié-Salpêtrière Hospital, Paris Sorbonne University, Paris, France
| | - Chiara Elena
- Department of Hematology, Fondazione IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Luca Malcovati
- Department of Hematology, Fondazione IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Akif Selim Yavuz
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | | | - Anna Belloni Fortina
- Pediatric Dermatology, Internal Medicine, Azienda Ospedaliera, Università di Padova, Padova, Italy
| | | | - Jason Gotlib
- Stanford University, School of Medicine, Hematology Clinic, Stanford, USA
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Center for Integrated Oncology Aachen, Bonn Cologne, Duesseldorf (CIO ABCD), Aachen, Germany
| | | | - Andreas Reiter
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
| | - Juliana Schwaab
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
| | | | | | - Christine Breynaert
- KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology ResearchGroup and MASTeL, University Hospitals Leuven, Leuven, Belgium
| | - Jan Romantowski
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Roberta Zanotti
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Elisa Olivieri
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Alexander Zink
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany
| | - Annick van de Ven
- Department of Allergology, University Medical Center, Groningen, The Netherlands
| | - Alex Stefan
- Clinic for Hematology and Oncology, Kepler University Hospital, Linz, Austria
| | - Stephane Barete
- Unit of Dermatology and CEREMAST, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Francesca Caroppo
- Pediatric Dermatology, Internal Medicine, Azienda Ospedaliera, Università di Padova, Padova, Italy
| | - Cecelia Perkins
- Stanford University, School of Medicine, Hematology Clinic, Stanford, USA
| | - Vanessa Kennedy
- Stanford University, School of Medicine, Hematology Clinic, Stanford, USA
| | - Deborah Christen
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Center for Integrated Oncology Aachen, Bonn Cologne, Duesseldorf (CIO ABCD), Aachen, Germany
| | - Mohamad Jawhar
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
- Department of Hematology and Oncology, Helios Pforzheim, Pforzheim, Germany
| | - Johannes Luebke
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
| | | | - Kerstin Levedahl
- Uppsala University Hospital, Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Emir Hadzijusufovic
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Boguslaw Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
- Invicta Fertility and Reproductive Center, Molecular Laboratory, Sopot, Poland
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
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5
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Shin H, Lyons JJ. Alpha-Tryptase as a Risk-Modifying Factor for Mast Cell-Mediated Reactions. Curr Allergy Asthma Rep 2024; 24:199-209. [PMID: 38460022 DOI: 10.1007/s11882-024-01136-y] [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] [Accepted: 02/12/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE OF REVIEW To provide an overview on the current understanding of genetic variability in human tryptases and summarize the literature demonstrating the differential impact of mature tryptases on mast cell-mediated reactions and associated clinical phenotypes. RECENT FINDINGS It is becoming increasingly recognized that tryptase gene composition, and in particular the common genetic trait hereditary alpha-tryptasemia (HαT), impacts clinical allergy. HαT has consistently been associated with clonal mast cell disorders (MCD) and has also been associated with more frequent anaphylaxis among these patients, and patients in whom no allergic trigger can be found, specifically idiopathic anaphylaxis. Additionally, more severe anaphylaxis among Hymenoptera venom allergy patients has been linked to HαT in both retrospective and prospective studies. An increased relative number of α-tryptase-encoding gene copies, even in the absence of HαT, has also been associated with systemic mastocytosis and has been shown to positively correlate with the severity of mast cell-mediated reactions to vibration and food. These findings may be due to increased generation of α/β-tryptase heterotetramers and differences in their enzymatic activity relative to β-tryptase homotetramers. HαT is a naturally occurring overexpression model of α-tryptase in humans. Increased relative α-tryptase expression modifies immediate hypersensitivity symptoms and is associated with more frequent and severe mast cell-mediated reactions, ostensibly due to increased α/β-tryptase heterotetramer production.
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Affiliation(s)
- Hannah Shin
- Division of Allergy & Immunology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jonathan J Lyons
- Division of Allergy & Immunology, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
- Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA.
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6
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Košnik M, Zugan L, Rijavec M. Prevention of Anaphylaxis Episodes in Idiopathic Anaphylaxis by Omalizumab. Int Arch Allergy Immunol 2024:1-6. [PMID: 38527445 DOI: 10.1159/000538046] [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: 01/14/2024] [Accepted: 02/01/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION In 15-35 percent of patients with anaphylaxis, the triggering allergen cannot be found; therefore, a diagnosis of idiopathic anaphylaxis (IA) is made. We report on the outcomes in patients with IA treated with omalizumab. METHODS We included consequent omalizumab-treated IA adult patients treated with omalizumab 300 mg every 4 weeks. RESULTS Out of 7 patients, 6 were female, median age 40 years with the frequency of anaphylaxis episodes from 3 in 2 years to 5 in 4 months. Baseline tryptase ranged from 1.71 to 12.0 μg/L. An increase in tryptase during anaphylaxis was documented in 6 patients. Activating KIT p.D816V variant was detected in 2 patients. One patient also had hereditary alpha-tryptasemia (HαT). The duration of omalizumab treatment was 0.5-7.5 years. None of the patients have experienced an anaphylactic reaction since the start of treatment. Mild systemic reactions were reported in 6 patients (86%). The presence of underlying cMCD had no impact on the treatment outcome. CONCLUSION All patients in our study had complete responses to omalizumab. The presence of KIT p.D816V and HαT did not influence the response to omalizumab treatment.
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Affiliation(s)
- Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Lea Zugan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
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7
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Korošec P, Sturm GJ, Lyons JJ, Marolt TP, Svetina M, Košnik M, Zidarn M, Kačar M, Frelih N, Lalek N, Luzar AD, Zver S, Škerget M, Czarnobilska E, Dyga W, Grle SP, Samarzija M, Arzt-Gradwohl L, Čerpes U, Porebski G, Pevec B, Schadelbauer E, Kopač P, Šelb J, Rijavec M. High burden of clonal mast cell disorders and hereditary α-tryptasemia in patients who need Hymenoptera venom immunotherapy. Allergy 2024. [PMID: 38477502 DOI: 10.1111/all.16084] [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: 11/23/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND In patients who require venom immunotherapy (VIT), there is a need to identify underlying mast cell (MC) disorders since these may affect the risk and severity of future sting reactions and the long-term effectiveness of VIT. METHODS 1319 individuals with Hymenoptera venom allergy (HVA) who needed VIT from referral centers in Slovenia, Austria, Croatia, and Poland underwent examination for KIT p.D816V in peripheral blood leukocytes (PBL) using a highly sensitive PCR test and tryptase genotyping by digital droplet PCR. We also included 183 control individuals with large local reactions (LLRs) to Hymenoptera stings and with asymptomatic sensitization to Hymenoptera venoms. RESULTS 285 of 1319 individuals recommended for VIT (21.6%) were positive for KIT p.D816V in PBL, preferably those who present with severe reaction (33.9% [n = 207 of 610] with Ring-Messmer grade 3-4 vs. 11% [n = 78 of 709] with Grade 1-2; p < .0001), whereas only 1.3% (n = 2 of 152) of controls with LLR and none with asymptomatic sensitization (n = 31) had KIT p.D816V. KIT p.D816V allelic burden was higher in those with severe reaction (median 0.018% [n = 207] in Grade 3-4 vs. 0.001% [n = 78] in Grade 1-2; p < .0001), and the majority had normal baseline serum tryptase levels (69% [n = 196 of 285]). All KIT p.D816V-positive individuals (n = 41) who underwent bone marrow (BM) biopsy were found to have underlying clonal diseases, principally BM mastocytosis. HαT was also associated with severe HVA and symptoms (p < .01), and remarkably, 31.0% (n = 31 of 100) were found to have concomitant KIT p.D816V. Concomitant HαT and KIT p.D816V showed an additive effect, and having both was associated with the highest risk for severe HVA, even higher than having either HαT or KIT p.D816V alone (OR = 3.8; p < .01). CONCLUSIONS By employing prospective universal tryptase genotyping and examination for KIT p.D816V in PBL in large HVA populations, we have demonstrated a high burden of clonal MC disorders and HαT in patients who require VIT.
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Affiliation(s)
- Peter Korošec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Gunter J Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
- Allergy Outpatient Clinic Reumannplatz, Vienna, Austria
| | - Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Manca Svetina
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mihaela Zidarn
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mark Kačar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nina Frelih
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nika Lalek
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Ajda Demšar Luzar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Samo Zver
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- The Department of Hematology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Matevž Škerget
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- The Department of Hematology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Ewa Czarnobilska
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Dyga
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Sanja Popović Grle
- Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Miroslav Samarzija
- Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Urban Čerpes
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Branko Pevec
- Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Eva Schadelbauer
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Peter Kopač
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Julij Šelb
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
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8
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González-de-Olano D, Navarro-Navarro P, Muñoz-González JI, Sánchez-Muñoz L, Henriques A, de-Andrés-Martín A, Peralta-Arjonilla D, Mayado A, Jara-Acevedo M, García-Montero AC, Orfao A, Álvarez-Twose I. Clinical impact of the TPSAB1 genotype in mast cell diseases: A REMA study in a cohort of 959 individuals. Allergy 2024; 79:711-723. [PMID: 37818990 DOI: 10.1111/all.15911] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/30/2023] [Accepted: 09/21/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND A close association between hereditary alpha-tryptasemia (HAT) and mast cell (MC) disorders has been previously reported. However, the relationship between HAT and the diagnostic subtypes and clinical features of MC disorders still remains to be established. OBJECTIVE To determine the prevalence of HAT in healthy donors (HD) vs patients with different diagnostic subtypes of MC activation syndromes (MCAS) and mastocytosis, and its relationship with the clinical behavior of the disease. METHODS A total of 959 subjects were studied including 346 healthy donors (HD), 464 mastocytosis, and 149 non-clonal MCAS patients. Molecular studies to assess the TPSAB1 genotype were performed, and data on serum baseline tryptase (sBT) and basal MC-mediator release episodes and triggers of anaphylaxis were collected. RESULTS HAT was detected in 15/346 (4%) HD versus 43/149 (29%) non-clonal MCAS and 84/464 (18%) mastocytosis cases. Among mastocytosis, HAT was more frequently found in patients with MC-restricted KITD816V (21% vs. 10% among multilineage KITD816V patients; p = .008). Overall, median sBT was higher in cases presenting with HAT (28.9 vs. 24.5 ng/mL; p = .008), while no significant differences in sBT were observed among HAT+ mastocytosis patients depending on the presence of 1 vs. ≥2 extra copies of the α-tryptase gene (44.1 vs. 35.2 ng/mL, p > .05). In turn, anaphylaxis was more frequently observed in HAT+ versus HAT- mastocytosis patients (76% vs. 65%; p = .018), while HAT+ and HAT- patients who did not refer anaphylaxis as the presenting symptom (n = 308) showed a similar prevalence of subsequent anaphylaxis (35% vs. 36%, respectively). CONCLUSION The frequency of HAT in MC disorders varies according to the diagnostic subtype of the disease. HAT does not imply a higher risk (and severity) of anaphylaxis in mastocytosis patients in whom anaphylaxis is not part of the presenting symptoms of the disease.
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Affiliation(s)
- David González-de-Olano
- Department of Allergy, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
| | - Paula Navarro-Navarro
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
- Department of Medicine and Citometry Service (NUCLEUS), Cancer Research Center (IBMCC, USAL-CSIC), Universidad de Salamanca, Salamanca, Spain
- Sequencing Service (NUCLEUS), Universidad de Salamanca, Salamanca, Spain
| | - Javier I Muñoz-González
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
- Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain
| | - Laura Sánchez-Muñoz
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast), Virgen del Valle Hospital, Toledo, Spain
| | - Ana Henriques
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast), Virgen del Valle Hospital, Toledo, Spain
| | | | | | - Andrea Mayado
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
- Department of Medicine and Citometry Service (NUCLEUS), Cancer Research Center (IBMCC, USAL-CSIC), Universidad de Salamanca, Salamanca, Spain
- Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - María Jara-Acevedo
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
- Sequencing Service (NUCLEUS), Universidad de Salamanca, Salamanca, Spain
- Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Andrés C García-Montero
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
- Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Alberto Orfao
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
- Department of Medicine and Citometry Service (NUCLEUS), Cancer Research Center (IBMCC, USAL-CSIC), Universidad de Salamanca, Salamanca, Spain
- Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Iván Álvarez-Twose
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
- Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast), Virgen del Valle Hospital, Toledo, Spain
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9
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Zaghmout T, Maclachlan L, Bedi N, Gülen 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 ≥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 Gülen
- 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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10
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Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Abrams EM, Bernstein JA, Chu DK, Horner CC, Rank MA, Stukus DR, Burrows AG, Cruickshank H, Golden DBK, Wang J, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Waserman S, Abrams EM, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt M, Horner CC, Ledford DK, Lieberman J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol 2024; 132:124-176. [PMID: 38108678 DOI: 10.1016/j.anai.2023.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 12/19/2023]
Abstract
This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.
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Affiliation(s)
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Alyssa G Burrows
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Heather Cruickshank
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | | | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
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11
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Svetina M, Šelb J, Lyons JJ, Korošec P, Rijavec M. Clinically accessible amplitude-based multiplex ddPCR assay for tryptase genotyping. Sci Rep 2024; 14:2416. [PMID: 38287122 PMCID: PMC10825142 DOI: 10.1038/s41598-024-52983-8] [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: 10/13/2023] [Accepted: 01/25/2024] [Indexed: 01/31/2024] Open
Abstract
Hereditary α tryptasemia (HαT) is an autosomal dominant trait characterized by increased TPSAB1 copy number (CN) encoding α-tryptase. The determination of HαT is being discussed as an important biomarker to be included in risk assessment models and future diagnostic algorithms for patients with mastocytosis and anaphylaxis. Due to the complex genetic structure at the human tryptase locus, genetic testing for tryptase gene composition is presently notably limited and infrequently pursued. This study aimed to develop, optimise and validate a multiplex droplet digital PCR (ddPCR) assay that can reliably quantify α- and β-tryptase encoding sequences in a single reaction. To optimise the ddPCR conditions and establish an amplitude-based multiplex ddPCR assay, additional primers and probes, a thermal gradient with varying annealing temperatures, different primers/probe concentrations, and various initial DNA quantities were tested. Results obtained from all 114 samples analysed using multiplex ddPCR were identical to those obtained through the use of original duplex assays. Utilizing this multiplex ddPCR assay, in contrast to conducting distinct duplex ddPCRs, presents noteworthy benefits for tryptase genotyping. These advantages encompass a substantial threefold decrease in material costs and considerable time savings. Consequently, this approach exhibits high suitability and particularly captures interest for routine clinical implementation.
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Affiliation(s)
- Manca Svetina
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Julij Šelb
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jonathan J Lyons
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia.
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia.
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12
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Chantran Y, Renaudin H, Arock M, Guiddir T, Nemni A. Case Report: A family history of peanut allergy and hereditary alpha-tryptasemia. FRONTIERS IN ALLERGY 2024; 4:1322117. [PMID: 38327735 PMCID: PMC10848325 DOI: 10.3389/falgy.2023.1322117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/15/2023] [Indexed: 02/09/2024] Open
Abstract
Context Hereditary alpha-tryptasemia (HαT) is associated with elevated basal serum tryptase (bST) and is associated with a higher risk of severe anaphylactic reactions in patients with clonal mast cell disorders or IgE-mediated Hymenoptera venom-induced anaphylaxis. The consequence of this genetic trait remains to be determined in other allergic diseases and food allergy in particular. Objectives Here, we describe three cases of peanut allergy among siblings from a single family of four: two of them were associated with HαT, and the third one was associated with the tryptase wild-type genotype. Methods TPSAB1/TPSB2 genotypes were determined by digital PCR. After the case description, we provided a review of the literature regarding bST levels and tryptase genotypes in anaphylaxis, with a particular focus on food allergy. Results Compared to the sibling with the conventional tryptase genotype, the two siblings with HαT presented a lower peanut threshold at the initial oral food challenge, higher peanut skin prick test reactivity, higher levels of specific IgE to peanut, Ara h 2, and Ara h 6, and a lower IgG4/IgE ratio after 10 years of oral immunotherapy. Conclusion The tryptase genotype and HαT status might modify the clinical presentation and biological features of food allergy.
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Affiliation(s)
- Yannick Chantran
- Molecular Platform for the Analysis of cKIT Mutations and Other Gene Defects, Centre National de Référence des Mastocytoses, Saint-Antoine Hospital, DMU BioGeMH, AP-HP.Sorbonne University, Paris, France
- Department of Biological Immunology, Saint-Antoine Hospital, DMU BioGeMH, AP-HP.Sorbonne University, Paris, France
- Health Environmental Risk Assessment (HERA) Team, Centre of Research in Epidemiology and Statistics (CRESS), Inserm/INRAE, Faculty of Pharmacy, Université Paris Cité, Paris, France
| | - Hélène Renaudin
- Children-Adult Allergology Department, Robert Ballanger Hospital, Aulnay Sous-Bois, France
| | - Michel Arock
- Molecular Platform for the Analysis of cKIT Mutations and Other Gene Defects, Centre National de Référence des Mastocytoses, Saint-Antoine Hospital, DMU BioGeMH, AP-HP.Sorbonne University, Paris, France
- Department of Biological Haematology, Pitié-Salpétrière Hospital, DMU BioGeMH, AP-HP.Sorbonne University, Paris, France
| | - Tamazoust Guiddir
- Pediatric Pulmonology and Allergology Unit, Bicêtre Hospital, AP-HP, Paris-Saclay University, Le Kremlin Bicêtre, France
| | - Ariane Nemni
- Children-Adult Allergology Department, Robert Ballanger Hospital, Aulnay Sous-Bois, France
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13
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Giannetti MP, Nicoloro-SantaBarbara J, Godwin G, Middlesworth J, Espeland A, Douvas JL, Castells MC. Challenges in Drug and Hymenoptera Venom Hypersensitivity Diagnosis and Management in Mastocytosis. Diagnostics (Basel) 2024; 14:123. [PMID: 38247999 PMCID: PMC10814166 DOI: 10.3390/diagnostics14020123] [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: 11/22/2023] [Revised: 12/26/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Abstract
Mastocytosis is a myeloproliferative neoplasm characterized by abnormal proliferation and activation of clonal mast cells typically bearing the KITD816V mutation. Symptoms manifest due to the release of bioactive mediators and the tissue infiltration by neoplastic mast cells. Mast cell activation symptoms include flushing, pruritus, urticaria, abdominal cramping, diarrhea, wheezing, neuropsychiatric symptoms, and anaphylaxis. Up to 50% of patients with mastocytosis report a history of provoked and unprovoked anaphylaxis, with Hymenoptera venom and drugs the most common culprits. NSAIDs, antibiotics, vaccines, perioperative medications, and radiocontrast media are often empirically avoided without evidence of reactions, depriving patients of needed medications and placing them at risk for unfavorable outcomes. The purpose of this review is to highlight the most common agents responsible for adverse drug reactions in patients with mastocytosis, with a review of current epidemiology, diagnosis, and management of drug hypersensitivity and Hymenoptera venom allergy.
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Affiliation(s)
- Matthew P. Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Jennifer Nicoloro-SantaBarbara
- Harvard Medical School, Boston, MA 02115, USA
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Grace Godwin
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Julia Middlesworth
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Andrew Espeland
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Julia L. Douvas
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Mariana C. Castells
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
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14
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Muñoz M, Siebenhaar F. [Mastocytosis-a frequently unrecognized disease]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:75-86. [PMID: 38085334 DOI: 10.1007/s00105-023-05258-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 01/12/2024]
Abstract
Mastocytosis is a rare disease characterized by clonal expansion and accumulation of mast cells (MC) in various organs. Mastocytosis results from an activating mutation of the KIT surface receptor leading to an increased proliferation of MC. There are significant differences between children and adult patients with mastocytosis. Children mainly present the cutaneous form, whereas adults more often exhibit the systemic form of mastocytosis. Patients with mastocytosis may be asymptomatic or affected by a variety of symptoms. Treatment is primarily supportive and aims at symptom control. New approved targeted therapies such as midostaurin and avapritinib changed the treatment paradigm in advanced forms of the disease, and next-generation inhibitors currently in clinical trials are expected in the near future.
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Affiliation(s)
- Melba Muñoz
- Institut für Allergieforschung, Charité - Universitätsmedizin Berlin, Hindenburgdamm 27 | Paul-Ehrlich-Haus/IFA, 12203, Berlin, Deutschland.
- Fraunhofer Institut für Translationale Medizin und Pharmakologie ITMP, Allergologie und Immunologie, Hindenburgdamm 27, 12203, Berlin, Deutschland.
| | - Frank Siebenhaar
- Institut für Allergieforschung, Charité - Universitätsmedizin Berlin, Hindenburgdamm 27 | Paul-Ehrlich-Haus/IFA, 12203, Berlin, Deutschland
- Fraunhofer Institut für Translationale Medizin und Pharmakologie ITMP, Allergologie und Immunologie, Hindenburgdamm 27, 12203, Berlin, Deutschland
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15
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Polivka L, Madrange M, Bulai-Livideanu C, Barete S, Ballul T, Neuraz A, Greco C, Agopian J, Brenet F, Dubreuil P, Burdet C, Lemal R, Tournilhac O, Terriou L, Launay D, Bouillet L, Gourguechon C, Damaj G, Frenzel L, Meni C, Bouktit H, Collange AF, Gaudy-Marqueste C, Gousseff M, Le Mouel E, Hamidou M, Neel A, Ranta D, Jaussaud R, Guilpain P, Canioni D, Molina TJ, Bruneau J, Lhermitte L, Garcelon N, Javier RM, Pelletier F, Castelain F, Retornaz F, Cabrera Q, Zunic P, Gourin MP, Wierzbicka-Hainaut E, Viallard JF, Lavigne C, Hoarau C, Durieu I, Heiblig M, Dimicoli-Salazar S, Torregrosa-Diaz JM, Soria A, Arock M, Lortholary O, Bodemer C, Hermine O, Rossignol J. Pathophysiologic implications of elevated prevalence of hereditary alpha-tryptasemia in all mastocytosis subtypes. J Allergy Clin Immunol 2024; 153:349-353.e4. [PMID: 37633651 DOI: 10.1016/j.jaci.2023.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/22/2023] [Accepted: 08/08/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Mastocytosis and monoclonal mast cell (MC) activation syndrome (MMAS) are heterogeneous conditions characterized by the accumulation of atypical MCs. Despite the recurrent involvement of KIT mutations, the pathophysiologic origin of mastocytosis and MMAS is unclear. Although hereditary α-tryptasemia (HαT, related to TPSAB1 gene duplication) is abnormally frequent in these diseases, it is not known whether the association is coincidental or causal. OBJECTIVE We evaluated the prevalence of HαT in all mastocytosis subtypes and MMAS and assessed the pathophysiologic association with HαT. METHODS Clinical data, laboratory data, KIT mutations, TPSAB1 duplication (assessed by droplet digital PCR), and HαT prevalence were retrospectively recorded for all patients with mastocytosis and MMAS registered in the French national referral center database and compared to a control cohort. To increase the power of our analysis for advanced systemic mastocytosis (advSM), we pooled our cohort with literature cases. RESULTS We included 583 patients (27 with MMAS and 556 with mastocytosis). The prevalence of HαT in mastocytosis was 12.6%, significantly higher than in the general population (5.7%, P = .002) and lower than in MMAS (33.3%, P = .02). HαT+ patients were more likely to have anaphylactic reactions and less likely to have cutaneous lesions than HαT- patients (43.0% vs 24.4%, P = .006; 57.7% vs 75.6%, respectively, P = .006). In the pooled analysis, the prevalence of HαT was higher in advSM (11.5%) than in control cohorts (5.2%, P = .01). CONCLUSION Here we confirm the increase incidence of anaphylaxis in HαT+ mastocytosis patients. The increased prevalence of HαT in all subtypes of systemic mastocytosis (including advSM) is suggestive of pathophysiologic involvement.
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Affiliation(s)
- Laura Polivka
- Department of Dermatology, Reference Center for Genodermatoses (MAGEC), AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France; CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France
| | - Marine Madrange
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France
| | | | - Stéphane Barete
- CEREMAST, the Department of Dermatology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Thomas Ballul
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France; CEREMAST, the Department of Hematology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Antoine Neuraz
- Department of Bioinformatics, Necker-Children's Hospital, AP-HP, Paris Centre University, Imagine Institute, INSERM U1163, Paris, France
| | - Celine Greco
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France; CEREMAST, the Department of Pain and Palliative Care Unit, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Julie Agopian
- Centre de Recherche en Cancérologie de Marseille, INSERM U1068, Marseille, France; Association Française pour les Initiatives de Recherche sur le Mastocyte et les Mastocytoses (AFIRMM), Marseille, France
| | - Fabienne Brenet
- Centre de Recherche en Cancérologie de Marseille, INSERM U1068, Marseille, France; Association Française pour les Initiatives de Recherche sur le Mastocyte et les Mastocytoses (AFIRMM), Marseille, France
| | - Patrice Dubreuil
- Centre de Recherche en Cancérologie de Marseille, INSERM U1068, Marseille, France; Association Française pour les Initiatives de Recherche sur le Mastocyte et les Mastocytoses (AFIRMM), Marseille, France
| | - Charles Burdet
- Centre d'Investigation Clinique, INSERM CIC 1425, AP-HP, Bichat Hospital, Paris Centre University, Paris, France
| | - Richard Lemal
- Histocompatibility Laboratory, EA 7453, Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Olivier Tournilhac
- CEREMAST, the Adult Clinical Hematology, CHU Clermont-Ferrand, INSERM CIC501, EA 7453, Clermont Auvergne University, Clermont-Ferrand, France
| | - Louis Terriou
- CEREMAST, the Department of Internal Medicine and Clinical Immunology, Claude Huriez Hospital, CHRU Lille, Lille, France
| | - David Launay
- CEREMAST, the Department of Internal Medicine and Clinical Immunology, Claude Huriez Hospital, CHRU Lille, Lille, France; Lille University, INSERM U995 LIRIC, CHU Lille, and Referral Center for Rare Systemic Autoimmune Diseases North and North-west of France, Lille, France
| | - Laurence Bouillet
- CEREMAST, the Clinical Immunology/Internal Medicine Department, National Reference Center for Angioedema, Grenoble University Hospital, Grenoble, France
| | | | - Ghandi Damaj
- CEREMAST, the Haematology Institute, Normandy University School of Medicine, Caen, France
| | - Laurent Frenzel
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France; CEREMAST, the Department of Hematology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Cécile Meni
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France
| | - Hassiba Bouktit
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France
| | - Anne Florence Collange
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France
| | - Caroline Gaudy-Marqueste
- CEREMAST, the Department of Dermatology, Aix-Marseille University, CHU Timone, Marseille, France
| | - Marie Gousseff
- Department of Internal Medicine, Centre Hospitalier Bretagne Atlantique, Vannes, France
| | - Edwige Le Mouel
- CEREMAST, the Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
| | - Mohamed Hamidou
- CEREMAST, the Department of Internal Medicine, Hôtel-Dieu University Hospital, Nantes, France
| | - Antoine Neel
- CEREMAST, the Department of Internal Medicine, Hôtel-Dieu University Hospital, Nantes, France
| | - Dana Ranta
- Department of Haematology, Nancy University Hospital, Nancy, France
| | - Roland Jaussaud
- Department of Internal Medicine and Clinical Immunology, Vandoeuvre-lès-Nancy, France
| | - Philippe Guilpain
- CEREMAST, the Department of Internal Medicine-Multi-organ Diseases, Saint-Eloi University Hospital, Montpellier University, Montpellier, France
| | - Danielle Canioni
- CEREMAST, the Department of Pathology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Thierry Jo Molina
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France; CEREMAST, the Department of Pathology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Julie Bruneau
- CEREMAST, the Department of Pathology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
| | - Ludovic Lhermitte
- CEREMAST, the Laboratory of Onco-hematology, Necker Children's Hospital, AP-HP, Paris, France
| | - Nicolas Garcelon
- Paris Centre University, Imagine Institute, Data Science Platform, INSERM UMR 1163, F-75015, Paris, France
| | - Rose-Marie Javier
- CEREMAST, the Department of Rheumatology, Strasbourg University Hospital, Strasbourg, France
| | - Fabien Pelletier
- CEREMAST, the Department of Dermatology, Allergology Unit, University Hospital of Besançon, Besançon, France
| | - Florence Castelain
- CEREMAST, the Department of Dermatology, Allergology Unit, University Hospital of Besançon, Besançon, France
| | - Frederique Retornaz
- Unité de soins et de recherche en médecine interne et maladies infectieuses, European Hospital, Marseille, France
| | - Quentin Cabrera
- Department of Haematology, Sud Reunion University Hospital, Saint Pierre, La Réunion, France
| | - Patricia Zunic
- Department of Haematology, Sud Reunion University Hospital, Saint Pierre, La Réunion, France
| | | | | | - Jean François Viallard
- Department of Internal Medicine and Infectious Diseases, Haut-Lévêque Hospital, CHRU Bordeaux, Bordeaux University, Bordeaux, France
| | - Christian Lavigne
- CEREMAST, the Department of Internal Medicine and Clinical Immunology, University Hospital, Angers, France
| | - Cyrille Hoarau
- CEREMAST, the Service d'Immunologie Clinique et d'Allergologie, Centre Hospitalier Régional Universitaire, Tours, France
| | - Isabelle Durieu
- CEREMAST, the Department of Internal Medicine, Adult Cystic Fibrosis Care Center, Hospices Civils de Lyon, Lyon, France
| | - Maël Heiblig
- CEREMAST, the Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | | | | | - Angèle Soria
- CEREMAST, the Department of Dermatology and Allergy, Tenon Hospital, Sorbonne University, Paris, France
| | - Michel Arock
- CEREMAST, the Laboratory of Hematology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Olivier Lortholary
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France
| | - Christine Bodemer
- Department of Dermatology, Reference Center for Genodermatoses (MAGEC), AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France; CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France
| | - Olivier Hermine
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France; CEREMAST, the Department of Hematology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France.
| | - Julien Rossignol
- CEREMAST, the Imagine Institute, INSERM U1163, AP-HP, Necker-Children's Hospital, Paris Centre University, Paris, France; CEREMAST, the Department of Hematology, Necker-Children's Hospital, AP-HP, Paris Centre University, Paris, France
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Pouessel G, Tacquard C, Tanno LK, Mertes PM, Lezmi G. Anaphylaxis mortality in the perioperative setting: Epidemiology, elicitors, risk factors and knowledge gaps. Clin Exp Allergy 2024; 54:11-20. [PMID: 38168878 DOI: 10.1111/cea.14434] [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: 07/03/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Abstract
Perioperative anaphylaxis (PA) is a severe condition that can be fatal, but data on PA mortality are scarce. The aim of this article is to review the epidemiology, elicitors and risk factors for PA mortality and identify knowledge gaps and areas for improvement regarding the management of severe PA. PA affects about 100 cases per million procedures. Mortality is rare, estimated at 3 to 5 cases per million procedures, but the PA mortality rate is higher than for other anaphylaxis aetiologies, at 1.4% to 4.8%. However, the data are incomplete. Published data mention neuromuscular blocking agents and antibiotics, mainly penicillin and cefazolin, as the main causes of fatal PA. Reported risk factors for fatal PA vary in different countries. Most frequently occurring comorbidities are obesity, male gender, cardiovascular diseases and ongoing treatment with beta-blockers. However, there are no clues about how these factors interact and the impact of individual risk factors. The pathophysiology of fatal PA is still not completely known. Genetic factors such as deficiency in PAF-acetyl hydrolase and hereditary alpha-tryptasemia, have been reported as modulators of severe anaphylaxis and possible targets for specific treatments. Our review underlines unmet needs in the field of fatal PA. Although we confirmed the need for timely administration of an adequate dose of adrenaline and the proper infusion of fluids, there is no evidence-based data on the proper dose of intravenous titrated adrenaline and which clinical manifestations would flag the need for fluid therapy. There are no large clinical studies supporting the administration of alternative vasopressors, such as glucagon and methylene blue. Further research on pathophysiological mechanisms of PA and its severity may address these issues and help clinicians to define new therapeutic approaches.
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Affiliation(s)
- Guillaume Pouessel
- Department of Pediatrics, Children's Hospital, CH Roubaix, Roubaix, France
- Pediatric Pulmonology and Allergy Department, Pôle enfant, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
- ULR 2694: METRICS, Univ Lille, Lille, France
| | - Charles Tacquard
- Department of Anaesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Luciana Kase Tanno
- Division of Allergy, Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA11 University of Montpellier - INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Paul Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Guillaume Lezmi
- Paediatric Pneumology and Allergology Unit, Children's Hospital Necker, Paris, France
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Beyens M, Toscano A, Ebo D, Gülen 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 Gülen
- 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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18
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Costa A, Scalzulli E, Carmosino I, Capriata M, Ielo C, Masucci C, Passucci M, Martelli M, Breccia M. Systemic mastocytosis: 2023 update on diagnosis and management in adults. Expert Opin Emerg Drugs 2023; 28:153-165. [PMID: 37256917 DOI: 10.1080/14728214.2023.2221028] [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: 04/11/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Systemic mastocytosis (SM) is a complex and heterogeneous disease, characterized by the clonal accumulation of mast cells in one or more organs. In 2022 both the World Health Organization (WHO) and the International Consensus Classification (ICC) modified the diagnostic and classification criteria of SM. Moreover, the identification of new clinical and molecular variables has improved prognostic tools and led to increasingly individualized therapeutic strategies. AREAS COVERED The aim of this review is to present the updates introduced by the International Consensus Classification in diagnostic criteria of SM. In addition, we report the latest data available from the most important clinical trials in patients both with non-advanced and advanced disease, including elenestinib and bezuclastinib. EXPERT OPINION Diagnosis and classification of SM has evolved over years. The most recent WHO and ICC classification improved SM diagnostic work-up, providing clinicians with a clear and simplified diagnostic scheme. New approved targeted therapies such as midostaurin and avapritinib modified the treatment paradigm in patients in advanced stage, and next-generation inhibitors actually investigated in clinical trials are expected in the next future.
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Affiliation(s)
- Alessandro Costa
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Emilia Scalzulli
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Ida Carmosino
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Marcello Capriata
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Claudia Ielo
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Chiara Masucci
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Mauro Passucci
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
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Panarelli NC. Mast Cell Disorders of the Gastrointestinal Tract: Clarity out of Chaos. Surg Pathol Clin 2023; 16:755-764. [PMID: 37863564 DOI: 10.1016/j.path.2023.05.010] [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] [Indexed: 10/22/2023]
Abstract
Pathologists are increasingly asked to evaluate mast cell infiltrates in the gastrointestinal tract when there is clinical concern for systemic mastocytosis or a variety of functional disorders, including irritable bowel syndrome and mast cell activation syndrome. Neoplastic mast cells have established quantitative, morphologic, and immunohistochemical features that facilitate their identification in gastrointestinal mucosal biopsies. Specific qualitative and quantitative findings are lacking for inflammatory mast cell-mediated disorders. This review covers histopathologic features of mast cell disorders that affect the gastrointestinal tract and offers practical guidance for their assessment in mucosal biopsies.
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Affiliation(s)
- Nicole C Panarelli
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
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20
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Rijavec M, Inkret J, Bidovec-Stojković U, Carli T, Frelih N, Kukec A, Korošec P, Košnik M. Fatal Hymenoptera Venom-Triggered Anaphylaxis in Patients with Unrecognized Clonal Mast Cell Disorder-Is Mastocytosis to Blame? Int J Mol Sci 2023; 24:16368. [PMID: 38003556 PMCID: PMC10671356 DOI: 10.3390/ijms242216368] [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: 10/04/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Hymenoptera venom-triggered anaphylaxis (HVA) affects up to 8.9% of the general population and is the most frequent cause of anaphylaxis in adults, accounting for approximately 20% of all fatal anaphylaxis cases. Quite often, a fatal reaction is a victim's first manifestation of HVA. Mastocytosis represents one of the most important risk factors for severe HVA. We analyzed patients with documented fatal HVA for the presence of underlying clonal mast cell disorder (cMCD). Here, we report three cases of fatal HVA, with undiagnosed underlying cMCD identified by the presence of the peripheral blood and/or bone marrow KIT p.D816V missense variant postmortem. In the first case, anaphylaxis was the initial episode and was fatal. In the other two cases, both patients were treated with specific venom immunotherapy (VIT), nevertheless, one died of HVA after VIT discontinuation, and the other during VIT; both patients had cardiovascular comorbidities and were taking beta-blockers and/or ACE inhibitors. Our results point to the importance of screening all high-risk individuals for underlying cMCD using highly sensitive molecular methods for peripheral blood KIT p.D816V variant detection, including severe HVA and possibly beekeepers, for proper management and the need for lifelong VIT to prevent unnecessary deaths. Patients at the highest risk of fatal HVA, with concomitant cardiovascular and cMCD comorbidities, might not be protected from field stings even during regular VIT. Therefore, two adrenaline autoinjectors and lifelong VIT, and possibly cotreatment with omalizumab, should be considered for high-risk patients to prevent fatal HVA episodes.
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Affiliation(s)
- Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
- Biotechnical Faculty, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Jezerka Inkret
- Institute of Forensic Medicine, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Urška Bidovec-Stojković
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
| | - Tanja Carli
- National Institute of Public Health, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Nina Frelih
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
| | - Andreja Kukec
- National Institute of Public Health, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
- Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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21
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Valent P, Sotlar K, Horny HP, Arock M, Akin C. World Health Organization Classification and Diagnosis of Mastocytosis: Update 2023 and Future Perspectives. Immunol Allergy Clin North Am 2023; 43:627-649. [PMID: 37758403 DOI: 10.1016/j.iac.2023.04.011] [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] [Indexed: 10/03/2023]
Abstract
Experts of the European Competence Network on Mastocytosis (ECNM) and the American Initiative on Mast Cell Disorders have discussed and updated diagnostic criteria and the classification of mastocytosis, based on new insights in the field and data collected in recent years, mostly within ECNM registry projects in which studies on several thousand cases have been performed. Based on this proposal, the World Health Organization has updated its classification of mastocytosis. This article discusses the revised classification of mastocytosis in light of a rapidly moving field and the advent of new diagnostic parameters, new prognostication tools, and new therapies.
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Affiliation(s)
- Peter Valent
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Wäheringer Gürtel 18-20, A-1090 Vienna, Austria.
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University Salzburg, Austria
| | - Hans-Peter Horny
- Institute of Pathology, Paracelsus Medical University Salzburg, Austria; Institute of Pathology, Ludwig Maximilians University, Munich, Germany
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, DMU BioGem, AP-HP.Sorbonne University, Paris, France; Platform of Molecular Analysis for Mastocytosis and Mast Cell Activation Syndromes (MCAS), Saint-Antoine Hospital, DMU BioGem, AP-HP.Sorbonne University, Paris, France
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, MI, USA
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22
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Abstract
Mastocytosis is characterized by expansion and activation of clonally aberrant mast cells (MCs) in one or more organ systems. Inappropriate MC activation is a key finding in both allergy and mastocytosis; therefore, symptoms in both conditions show some degree of overlap. When mediator release is excessive and involves multiple systems, anaphylaxis may occur. In mastocytosis, the prevalence of atopy is similar to those of the general population, whereas the incidence of anaphylaxis is significantly higher. The purpose of this review is to discuss features of allergy and anaphylaxis as well as the principles of managing MC mediator release symptoms in mastocytosis.
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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; Mastocytosis Centre Karolinska, Karolinska University Hospital Huddinge, Stockholm, Sweden.
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23
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Gülen 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 Gülen
- 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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24
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Lang A, Kubala S, Grieco MC, Mateja A, Pongracic J, Liu Y, Frischmeyer-Guerrerio PA, Kumar R, Lyons JJ. Severe food allergy reactions are associated with α-tryptase. J Allergy Clin Immunol 2023; 152:933-939. [PMID: 37558059 PMCID: PMC10592152 DOI: 10.1016/j.jaci.2023.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/18/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Increased TPSAB1 copy numbers encoding ⍺-tryptase are associated with severe reactions in adults with Hymenoptera venom allergy, systemic mastocytosis, and idiopathic anaphylaxis. OBJECTIVE The primary objective was to assess the association between ⍺-tryptase and severity of food allergy. METHODS A total of 119 subjects underwent tryptase genotyping; 82 of them were from an observational food allergy cohort at the National Institute of Allergy and Infectious Disease (NIAID), and 37 were from a cohort of children who reacted to peanut oral food challenge (OFC) at Lurie Children's Hospital of Chicago. The primary predictor was presence or absence of ⍺-tryptase. The primary outcomes for both cohorts were measures of severity of food allergy reaction. Secondary outcomes included OFC symptom scores (Bock/Practical Allergy [PRACTALL] and Severity Grading Score for Acute Reactions [SGSAR]). Correlation between total α-tryptase isoforms and OFC scores was also assessed to account for gene dosage effects. RESULTS Among the subjects in the NIAID cohort, the presence of ⍺-tryptase was associated with a higher prevalence of food-triggered anaphylaxis than in those with only β-tryptase (P = .026). Similarly, only 1 of 6 subjects in the OFC cohort with only β-tryptase (17%) had a severe reaction, whereas 20 of 31 of subjects with α-tryptase (65%) had a severe reaction (P = .066). Subjects with ⍺-tryptase also had higher total SGSAR scores than did the subjects with no ⍺-tryptase (P = .003). In addition, there were also significant positive correlations between ⍺-tryptase isoform copy numbers and both higher total SGSAR and Bock/PRACTALL OFC scores (P = .008 and P = .003, respectively). CONCLUSION The presence of α-tryptase in subjects is correlated with a higher prevalence of anaphylaxis or severe reaction to food than in subjects without any α-tryptase.
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Affiliation(s)
- Abigail Lang
- Division of Allergy and Immunology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Stephanie Kubala
- Food Allergy Research Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Megan C Grieco
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md; Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Allyson Mateja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Md
| | - Jacqueline Pongracic
- Division of Allergy and Immunology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Yihui Liu
- Translational Allergic Immunopathology Unit, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Pamela A Frischmeyer-Guerrerio
- Food Allergy Research Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Rajesh Kumar
- Division of Allergy and Immunology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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25
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Valent P, Hoermann G, Bonadonna P, Hartmann K, Sperr WR, Broesby-Olsen S, Brockow K, Niedoszytko M, Hermine O, Chantran Y, Butterfield JH, Greiner G, Carter MC, Sabato V, Radia DH, Siebenhaar F, Triggiani M, Gülen T, Alvarez-Twose I, Staudinger T, Traby L, Sotlar K, Reiter A, Horny HP, Orfao A, Galli SJ, Schwartz LB, Lyons JJ, Gotlib J, Metcalfe DD, Arock M, Akin C. The Normal Range of Baseline Tryptase Should Be 1 to 15 ng/mL and Covers Healthy Individuals With HαT. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3010-3020. [PMID: 37572755 DOI: 10.1016/j.jaip.2023.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/14/2023]
Abstract
Physiological levels of basal serum tryptase vary among healthy individuals, depending on the numbers of mast cells, basal secretion rate, copy numbers of the TPSAB1 gene encoding alpha tryptase, and renal function. Recently, there has been a growing debate about the normal range of tryptase because individuals with the hereditary alpha tryptasemia (HαT) trait may or may not be symptomatic, and if symptomatic, uncertainty exists as to whether this trait directly causes clinical phenotypes or aggravates certain conditions. In fact, most HαT-positive cases are regarded as asymptomatic concerning mast cell activation. To address this point, experts of the European Competence Network on Mastocytosis (ECNM) and the American Initiative in Mast Cell Diseases met at the 2022 Annual ECNM meeting and discussed the physiological tryptase range. Based on this discussion, our faculty concluded that the normal serum tryptase range should be defined in asymptomatic controls, inclusive of individuals with HαT, and based on 2 SDs covering the 95% confidence interval. By applying this definition in a literature screen, the normal basal tryptase in asymptomatic controls (HαT-positive persons included) ranges between 1 and 15 ng/mL. This definition should avoid overinterpretation, unnecessary referrals, and unnecessary anxiety or anticipatory fear of illness in healthy individuals.
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Affiliation(s)
- Peter Valent
- Division of Haematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria.
| | - Gregor Hoermann
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; MLL Munich Leukemia Laboratory, Munich, Germany
| | | | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Wolfgang R Sperr
- Division of Haematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Olivier Hermine
- Service d'hématologie, Imagine Institute Université de Paris, Centre national de référence des mastocytoses, Hôpital Necker, Assistance publique hôpitaux de Paris, Paris, France
| | - Yannick Chantran
- Department of Biological Immunology, Saint-Antoine Hospital, Paris Sorbonne University, Paris, France
| | | | - Georg Greiner
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Ihr Labor, Medical Diagnostic Laboratories, Vienna, Austria
| | - Melody C Carter
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Md
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology-Allergology-Rheumatology, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Deepti H Radia
- Guy's & St. Thomas' National Health Service (NHS) Foundation Trust, Guy's Hospital, London, UK
| | - Frank Siebenhaar
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Immunology and Allergology (IA), Berlin, Germany
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm, Sweden
| | - Ivan Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) and CIBERONC, Hospital Virgen del Valle, Toledo, Spain
| | - Thomas Staudinger
- Department of Internal Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna, Austria
| | - Ludwig Traby
- Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Karl Sotlar
- Institute of Pathology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Alberto Orfao
- Servicio Central de Citometria, Centro de Investigacion del Cancer (IBMCC CSIC/USAL) Instituto Biosanitario de Salamanca (IBSAL), CIBERONC and Department of Medicine, University of Salamanca, Salamanca, Spain
| | - Stephen J Galli
- Department of Pathology, Department of Microbiology and Immunology, Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, Calif
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, Va
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Md
| | - Jason Gotlib
- Stanford University School of Medicine/Stanford Cancer Institute, Stanford, Calif
| | - Dean D Metcalfe
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Md
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Paris Sorbonne University, Paris, France
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
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26
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Klingebiel C, Belhocine W, Vitte J. Serum tryptase and drug hypersensitivity: why, how and what? A systematic review. Curr Opin Allergy Clin Immunol 2023; 23:294-299. [PMID: 37357783 DOI: 10.1097/aci.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW Serum tryptase, a mast cell marker, provides clues for the mechanism, severity, and management of drug hypersensitivity induced by immunoglobulin E dependent or independent mast cell activation. RECENT FINDINGS The interpretation of serum tryptase levels has been challenged during the last 2 years by major advances in tryptase genetics and their rapid incorporation into clinical practice. On the contrary, new pathophysiological insight into nonmast cell-dependent immediate hypersensitivity has been gained. SUMMARY This review provides up-to-date information on the pathophysiology and recommended use and interpretation of tryptase in the context of drug hypersensitivity reactions as a function of their endotype.
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Affiliation(s)
| | | | - Joana Vitte
- University of Montpellier, IDESP, INSERM UMR UA 11, Montpellier
- Aix-Marseille Univ, IRD, APHM, MEPHI
- IHU Méditerranée Infection, Marseille, France
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27
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Lyons JJ, Farkas H, Germenis AE, Rijavec M, Smith TD, Valent P. Genetic Variants Leading to Urticaria and Angioedema and Associated Biomarkers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2286-2301. [PMID: 37263349 DOI: 10.1016/j.jaip.2023.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/20/2023] [Accepted: 05/15/2023] [Indexed: 06/03/2023]
Abstract
Advances in next generation sequencing technologies, as well as their expanded accessibility and clinical use over the past 2 decades, have led to an exponential increase in the number of identified single gene disorders. Among these are primary atopic disorders-inborn errors of immunity resulting in severe allergic phenotypes as a primary presenting feature. Two cardinal aspects of type I immediate hypersensitivity allergic reactions are hives and angioedema. Mast cells (MCs) are frequent primary drivers of these symptoms, but other cells have also been implicated. Even where MC degranulation is believed to be the cause, mediator-induced symptoms may greatly vary among individuals. Angioedema-particularly in the absence of hives-may also be caused by hereditary angioedema conditions resulting from aberrant regulation of contact system activation and excessive bradykinin generation or impairment of vascular integrity. In these patients, swelling can affect unpredictable locations and fail to respond to MC-directed therapies. Genetic variants have helped delineate key pathways in the etiology of urticaria and nonatopic angioedema and led to the development of targeted therapies. Herein, we describe the currently known inherited and acquired genetic causes for these conditions, highlight specific features in their clinical presentations, and discuss the benefits and limitations of biomarkers that can help distinguish them.
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Affiliation(s)
- Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Anastasios E Germenis
- Department of Immunology and Histocompatibility, School of Medicine, University of Thessaly, Larissa, Greece
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia; Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Tukisa D Smith
- Division of Rheumatology, Allergy and Immunology, University of California San Diego, La Jolla, Calif
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
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28
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Mihele DM, Nistor PA, Bruma G, Mitran CI, Mitran MI, Condrat CE, Tovaru M, Tampa M, Georgescu SR. Mast Cell Activation Syndrome Update-A Dermatological Perspective. J Pers Med 2023; 13:1116. [PMID: 37511729 PMCID: PMC10381535 DOI: 10.3390/jpm13071116] [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: 05/31/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Mast cells (MCs) are infamous for their role in potentially fatal anaphylaxis reactions. In the last two decades, a more complex picture has emerged, as it has become obvious that MCs are much more than just IgE effectors of anaphylaxis. MCs are defenders against a host of infectious and toxic aggressions (their interactions with other components of the immune system are not yet fully understood) and after the insult has ended, MCs continue to play a role in inflammation regulation and tissue repair. Unfortunately, MC involvement in pathology is also significant. Apart from their role in allergies, MCs can proliferate clonally to produce systemic mastocytosis. They have also been implicated in excessive fibrosis, keloid scaring, graft rejection and chronic inflammation, especially at the level of the skin and gut. In recent years, the term MC activation syndrome (MCAS) was proposed to account for symptoms caused by MC activation, and clear diagnostic criteria have been defined. However, not all authors agree with these criteria, as some find them too restrictive, potentially leaving much of the MC-related pathology unaccounted for. Here, we review the current knowledge on the physiological and pathological roles of MCs, with a dermatological emphasis, and discuss the MCAS classification.
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Affiliation(s)
- Dana Mihaela Mihele
- Dermatology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
| | - Paul Andrei Nistor
- Internal Medicine Department, Emergency University Hospital Bucharest, 169 Independence Blvd, 050098 Bucharest, Romania
| | - Gabriela Bruma
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
| | - Cristina Iulia Mitran
- Microbiology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Madalina Irina Mitran
- Microbiology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Carmen Elena Condrat
- Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Mihaela Tovaru
- Dermatology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
| | - Mircea Tampa
- Dermatology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
| | - Simona Roxana Georgescu
- Dermatology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
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Jiang M, Vadas P. Hereditary alpha-tryptasemia and complete deletion of exon 8 of the c-kit gene in patients with mast cell activation syndrome. Leuk Lymphoma 2023; 64:1348-1351. [PMID: 37086476 DOI: 10.1080/10428194.2023.2203286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/16/2023] [Accepted: 04/11/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Maggie Jiang
- Division of Allergy and Clinical Immunology, St. Michael's Hospital/University of Toronto, Toronto, Canada
| | - Peter Vadas
- Division of Allergy and Clinical Immunology, St. Michael's Hospital/University of Toronto, Toronto, Canada
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Golden DBK, Carter MC. Anaphylaxis: Bench to Bedside. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2049-2050. [PMID: 37244441 DOI: 10.1016/j.jaip.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Affiliation(s)
- David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Melody C Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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Pardanani A. Systemic mastocytosis in adults: 2023 update on diagnosis, risk stratification and management. Am J Hematol 2023; 98:1097-1116. [PMID: 37309222 DOI: 10.1002/ajh.26962] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 06/14/2023]
Abstract
OVERVIEW Systemic mastocytosis (SM) results from clonal proliferation of mast cells (MC) in extracutaneous organs. DIAGNOSIS The major criterion is presence of multifocal MC clusters in the bone marrow and/or extracutaneous organs. Minor diagnostic criteria include elevated serum tryptase level, MC CD25/CD2/CD30 expression, and presence of activating KIT mutations. RISK STRATIFICATION Establishing SM subtype as per the International Consensus Classification/World Health Organization classification systems is an important first step. Patients either have indolent/smoldering SM (ISM/SSM) or advanced SM, including aggressive SM (ASM), SM with associated myeloid neoplasm (SM-AMN), and mast cell leukemia. Identification of poor-risk mutations (i.e., ASXL1, RUNX1, SRSF2, NRAS) further refines the risk stratification. Several risk models are available to help assign prognosis in SM patients. MANAGEMENT Treatment goals for ISM patients are primarily directed toward anaphylaxis prevention/symptom control/osteoporosis treatment. Patients with advanced SM frequently need MC cytoreductive therapy to reverse disease-related organ dysfunction. Tyrosine kinase inhibitors (TKI) (midostaurin, avapritinib) have changed the treatment landscape in SM. While deep biochemical, histological and molecular responses have been documented with avapritinib treatment, its efficacy as monotherapy against a multimutated AMN disease component in SM-AMN patients remains unclear. Cladribine continues to have a role for MC debulking, whereas interferon-α has a diminishing role in the TKI era. Treatment of SM-AMN primarily targets the AMN component, particularly if an aggressive disease such as acute leukemia is present. Allogeneic stem cell transplant has a role in such patients. Imatinib has a therapeutic role only in the rare patient with an imatinib-sensitive KIT mutation.
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Affiliation(s)
- Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Bonadonna P, Korosec P, Nalin F, Golden DBK. Venom Anaphylaxis: Decision Points for a More Aggressive Workup. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2024-2031. [PMID: 37119981 DOI: 10.1016/j.jaip.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 05/01/2023]
Abstract
Diagnostic testing of patients who present for evaluation of insect venom allergy can involve many levels of investigation. A detailed initial history is critical for diagnosis and prognosis. The severity of previous sting reactions and the presence or absence of urticaria or hypotension predict severe future sting reactions and underlying mast cell disorders. Venom skin tests and specific IgE measurement can confirm the diagnosis but have limited positive predictive value for the frequency and severity of future sting reactions. Testing for serum IgE to recombinant venom component allergens can distinguish true allergy from cross-reactivity to honey bee and yellowjacket venoms. Basophil activation tests can improve the detection of venom allergy and predict the severity of reactions and the efficacy of venom immunotherapy but are limited in availability. An elevated basal serum tryptase level is an important marker for severe sting anaphylaxis and underlying mast cell disorders (eg, hereditary α-tryptasemia and clonal mast cell disease). When there is high suspicion (eg, using the Red Espanola de Mastocytosis score), bone marrow biopsy is the definitive tool to characterize mast cell disorders that are associated with the most severe outcomes in patients with insect sting allergy.
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Affiliation(s)
| | - Peter Korosec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia; Medical Faculty, University of Maribor, Maribor, Slovenia
| | | | - David B K Golden
- Dvision of Allergy and Clinical Immunology, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Md.
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Carter MC, Park J, Vadas P, Worm M. Extrinsic and Intrinsic Modulators of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1998-2006. [PMID: 37230384 DOI: 10.1016/j.jaip.2023.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023]
Abstract
The severity of anaphylaxis is determined by many factors. The allergenic source as well as the age of the affected individual and the route of allergen exposure encompass the major contributors of the clinical outcome. Moreover, the severity can be modulated further by intrinsic and extrinsic factors. Among these, the genetic predisposition, certain comorbidities such as uncontrolled asthma, and hormonal fluctuations have been proposed as intrinsic and antihypertensive medications or physical activity as extrinsic factors. Recent advances have highlighted immunologic pathways that may exacerbate the response to allergens through receptors on mast cells, basophils, platelets, and other granulocytes. Atopy, platelet-activating factor acetylhydrolase deficiency, hereditary alpha tryptasemia, and clonal mast cell disorders are examples associated with genetic alterations that may predispose to severe anaphylaxis. Identifying risk factors that lower the threshold of reactivity or increase the severity of multisystem reactions is important in the management of this patient population.
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Affiliation(s)
- Melody C Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Jane Park
- Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Peter Vadas
- Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité Universitätsmedizin Berlin, Berlin, Germany
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Chovanec J, Tunc I, Hughes J, Halstead J, Mateja A, Liu Y, O’Connell MP, Kim J, Park YH, Wang Q, Le Q, Pirooznia M, Trivedi NN, Bai Y, Yin Y, Hsu AP, McElwee J, Lassiter S, Nelson C, Bandoh J, DiMaggio T, Šelb J, Rijavec M, Carter MC, Komarow HD, Sabato V, Steinberg J, Hafer KM, Feuille E, Hourigan CS, Lack J, Khoury P, Maric I, Zanotti R, Bonadonna P, Schwartz LB, Milner JD, Glover SC, Ebo DG, Korošec P, Caughey GH, Brittain EH, Busby B, Metcalfe DD, Lyons JJ. Genetically defined individual reference ranges for tryptase limit unnecessary procedures and unmask myeloid neoplasms. Blood Adv 2023; 7:1796-1810. [PMID: 36170795 PMCID: PMC10164828 DOI: 10.1182/bloodadvances.2022007936] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/09/2022] [Accepted: 08/26/2022] [Indexed: 11/20/2022] Open
Abstract
Serum tryptase is a biomarker used to aid in the identification of certain myeloid neoplasms, most notably systemic mastocytosis, where basal serum tryptase (BST) levels >20 ng/mL are a minor criterion for diagnosis. Although clonal myeloid neoplasms are rare, the common cause for elevated BST levels is the genetic trait hereditary α-tryptasemia (HαT) caused by increased germline TPSAB1 copy number. To date, the precise structural variation and mechanism(s) underlying elevated BST in HαT and the general clinical utility of tryptase genotyping, remain undefined. Through cloning, long-read sequencing, and assembling of the human tryptase locus from an individual with HαT, and validating our findings in vitro and in silico, we demonstrate that BST elevations arise from overexpression of replicated TPSAB1 loci encoding canonical α-tryptase protein owing to coinheritance of a linked overactive promoter element. Modeling BST levels based on TPSAB1 replication number, we generate new individualized clinical reference values for the upper limit of normal. Using this personalized laboratory medicine approach, we demonstrate the clinical utility of tryptase genotyping, finding that in the absence of HαT, BST levels >11.4 ng/mL frequently identify indolent clonal mast cell disease. Moreover, substantial BST elevations (eg, >100 ng/mL), which would ordinarily prompt bone marrow biopsy, can result from TPSAB1 replications alone and thus be within normal limits for certain individuals with HαT.
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Affiliation(s)
- Jack Chovanec
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD
| | - Ilker Tunc
- Bioinformatics and Computational Biology Core, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
| | | | - Joseph Halstead
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Allyson Mateja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Yihui Liu
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD
| | - Michael P. O’Connell
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD
| | - Jiwon Kim
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD
| | - Young Hwan Park
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD
| | - Qinlu Wang
- Bioinformatics and Computational Biosciences Branch, Office of Cyber Infrastructure and Computational Biology, NIAID, NIH, Bethesda, MD
| | - Quang Le
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Mehdi Pirooznia
- Bioinformatics and Computational Biology Core, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
| | - Neil N. Trivedi
- Cardiovascular Research Institute and Department of Medicine, University of California San Francisco, San Francisco, CA
- Veterans Affairs Medical Center, San Francisco, CA
| | - Yun Bai
- Mast Cell Biology Section, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, MD
| | - Yuzhi Yin
- Mast Cell Biology Section, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, MD
| | - Amy P. Hsu
- Immunopathogenesis Section, Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD
| | | | - Sheryce Lassiter
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Celeste Nelson
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD
| | - Judy Bandoh
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD
| | - Thomas DiMaggio
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD
| | - Julij Šelb
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Melody C. Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, MD
| | - Hirsh D. Komarow
- Mast Cell Biology Section, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, MD
| | - Vito Sabato
- Department of Immunology, Allergology, and Rheumatology, Infla-Med Centre of Excellence, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Joshua Steinberg
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Kurt M. Hafer
- Department of Medicine, Stanford University, Stanford, CA
| | - Elizabeth Feuille
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Weill Cornell Medical College, Cornell University, New York, NY
| | | | - Justin Lack
- NIAID Collaborative Bioinformatics Resource, NIAID, NIH, Bethesda, MD
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, NIAID, NIH, Bethesda, MD
| | - Irina Maric
- Hematology Service, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD
| | - Roberta Zanotti
- Department of Medicine, Section of Hematology, Verona University Hospital, Verona, Italy
| | | | | | - Joshua D. Milner
- Division of Allergy, Immunology and Rheumatology, Columbia University, New York, NY
| | - Sarah C. Glover
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Didier G. Ebo
- Department of Immunology, Allergology, and Rheumatology, Infla-Med Centre of Excellence, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - George H. Caughey
- Cardiovascular Research Institute and Department of Medicine, University of California San Francisco, San Francisco, CA
- Veterans Affairs Medical Center, San Francisco, CA
| | | | - Ben Busby
- National Library of Medicine, National Center for Biotechnology Information, NIH, Bethesda, MD
| | - Dean D. Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, MD
| | - Jonathan J. Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD
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Floyd ML, Adams KE, Golden DBK. Updates and Recent Advances on Venom Immunotherapy. CURRENT TREATMENT OPTIONS IN ALLERGY 2023; 10:1-19. [PMID: 37361640 PMCID: PMC10148014 DOI: 10.1007/s40521-023-00336-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review Venom immunotherapy has been utilized to treat Hymenoptera venom allergy since the 1920s. Over the last century, significant advances in the fields of immunology and genetics have led to improvements in the practice of venom immunotherapy. This review encompasses recent advances in the use of venom immunotherapy to provide precise, patient-centered care. Recent Findings Research about the mechanism of action of venom immunotherapy continues to highlight the modification of both the innate and adaptive immune systems. Molecular techniques have allowed for the identification of specific venom allergens to improve the diagnostic accuracy and safety of venom immunotherapy. Research continues to support the safety of accelerated schedules which can impact the cost, adherence, and quality of life for patients receiving this treatment modality. Finally, significant advances have led to the elucidation of risk factors that place patients at risk for reactions during and after venom immunotherapy. Creation of risk profiles for venom-allergic patients can thus inform the process of immunotherapy in order to provide personalized and precise care. Summary Significant progress in the use of venom immunotherapy makes the practice a dynamic and active field for continued research. Future research needs to build on these recent advances to continue to optimize and enhance this life-saving treatment.
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Affiliation(s)
- Michelle L. Floyd
- 42d Medical Group, Maxwell AFB, 300 South Twining Street, Building 760, Montgomery, AL 36112 USA
| | - Karla E. Adams
- Department of Medicine, Allergy and Immunology Division, Wilford Hall Ambulatory Surgical Center, Lackland AFB, 1100 Wilford Hall Loop, Bldg 4554, San Antonio, TX 78236 USA
| | - David B. K. Golden
- Johns Hopkins University, 25 Crossroads Drive #410, Owings Mills, MD 21117 USA
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36
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Woźniak E, Owczarczyk-Saczonek A, Lange M, Czarny J, Wygonowska E, Placek W, Nedoszytko B. The Role of Mast Cells in the Induction and Maintenance of Inflammation in Selected Skin Diseases. Int J Mol Sci 2023; 24:ijms24087021. [PMID: 37108184 PMCID: PMC10139379 DOI: 10.3390/ijms24087021] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/23/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Under physiological conditions, skin mast cells play an important role as guardians that quickly react to stimuli that disturb homeostasis. These cells efficiently support, fight infection, and heal the injured tissue. The substances secreted by mast cells allow for communication inside the body, including the immune, nervous, and blood systems. Pathologically non-cancerous mast cells participate in allergic processes but also may promote the development of autoinflammatory or neoplastic disease. In this article, we review the current literature regarding the role of mast cells in autoinflammatory, allergic, neoplastic skin disease, as well as the importance of these cells in systemic diseases with a pronounced course with skin symptoms.
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Affiliation(s)
- Ewelina Woźniak
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The University of Warmia and Mazury, 10-229 Olsztyn, Poland
| | - Agnieszka Owczarczyk-Saczonek
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The University of Warmia and Mazury, 10-229 Olsztyn, Poland
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, 80-214 Gdansk, Poland
| | - Justyna Czarny
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, 80-214 Gdansk, Poland
| | - Ewa Wygonowska
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The University of Warmia and Mazury, 10-229 Olsztyn, Poland
| | - Waldemar Placek
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The University of Warmia and Mazury, 10-229 Olsztyn, Poland
| | - Bogusław Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, 80-214 Gdansk, Poland
- Invicta Fertility and Reproductive Centre, Molecular Laboratory, 81-740 Sopot, Poland
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Stevens WW, Kraft M, Eisenbarth SC. Recent insights into the mechanisms of anaphylaxis. Curr Opin Immunol 2023; 81:102288. [PMID: 36848746 PMCID: PMC10023498 DOI: 10.1016/j.coi.2023.102288] [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: 11/10/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/27/2023]
Abstract
Anaphylaxis is an acute life-threatening systemic allergic reaction that can have a wide range of clinical manifestations. The most common triggers for anaphylaxis include food, medication, and venom. What is curious regarding anaphylaxis is how so many different agents can induce a severe systemic clinical response but only in a select subgroup of patients. Over the past decade, several important advances have been made in understanding the underlying cellular and molecular mechanisms contributing to anaphylaxis, with mast cells (MCs) being an essential component. Classically, cross-linked immunoglobulin E (IgE) bound to its high- affinity receptor induces MC mediator release. However, toll-like, complement, or Mas-related G-protein-coupled receptors also activate mouse and human MCs. While anaphylaxis secondary to foods historically has been more extensively characterized clinically and mechanistically, more recent studies have shifted focus toward understanding drug-induced anaphylaxis. The focus of this review is to highlight recent basic science developments and compare what is currently known regarding anaphylaxis to food, medications, and venom.
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Affiliation(s)
- Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Magdalena Kraft
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephanie C Eisenbarth
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Rama TA, Torrado I, Henriques AF, Sánchez-Muñoz L, Jara-Acevedo M, Navarro-Navarro P, Caldas C, Mayado A, Muñoz-González J, García-Montero A, Mollejo M, Redondo E, Garbán A, Moreira A, Órfão A, Álvarez-Twose I. Mast Cell Activation Syndromes: Comparison Between Two Scoring Models to Predict for Mast Cell Clonality. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:908-919.e4. [PMID: 36535520 DOI: 10.1016/j.jaip.2022.11.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/24/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Red Española de Mastocitosis (Spanish Network on Mastocytosis) score (REMAs) and the National Institutes of Health idiopathic clonal anaphylaxis score (NICAS) were developed for more efficient screening of mast cell (MC) clonality in MC activation syndromes. In a limited idiopathic anaphylaxis case series, the NICAS showed higher accuracy compared with the REMAs. OBJECTIVE To compare the performance of the REMAs against the NICAS in the diagnosis of MC clonality. METHODS We compared the diagnostic value of the REMAs against the NICAS in 182 patients (63% men, median age 56 years) who presented with anaphylaxis triggered by Hymenoptera venom allergy (45%), drugs (15%), food (11%), idiopathic anaphylaxis (20%), and mixed causes (10%). KIT mutation was assessed in parallel in whole blood and bone marrow (BM) and, when negative, in highly purified BM MC. TPSAB1 was genotyped in a subset of 71 patients. RESULTS We found higher accuracy and rates of correctly classified patients for the REMAs (82% and 84%) compared with the NICAS (75% and 75%; P = .02 and P = .03, respectively), particularly among men (P = .05), patients with systemic mastocytosis (P = .05), those presenting anaphylaxis owing to any cause featuring urticaria (P = .04), cardiovascular symptoms (P = .02), and/or presyncope (P = .02) and those with a blood-negative/BM-positive KIT mutational profile (P = .002), but not hereditary α-tryptasemia-associated genotypes. Combined assessment of the REMAs and KITD816V in blood yielded an overall improved classification efficiency of 86% versus 84% for REMAs. CONCLUSIONS The combined use of the REMAs and blood detection of KITD816V is recommended, but more sensitive blood-based molecular assays to detect KITD816V are needed.
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Affiliation(s)
- Tiago Azenha Rama
- Serviço de Imunoalergologia, Centro Hospitalar Universitário São João, Porto, Portugal; Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Inés Torrado
- Instituto de Estudios de Mastocitosis de Castilla La Mancha, Reference Center for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | - Ana Filipa Henriques
- Instituto de Estudios de Mastocitosis de Castilla La Mancha, Reference Center for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain; Spanish Network on Mastocytosis, Toledo and Salamanca, Spain
| | - Laura Sánchez-Muñoz
- Instituto de Estudios de Mastocitosis de Castilla La Mancha, Reference Center for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain; Spanish Network on Mastocytosis, Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer, Instituto de Salud Carlos III, Madrid, Spain
| | - Maria Jara-Acevedo
- Spanish Network on Mastocytosis, Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer, Instituto de Salud Carlos III, Madrid, Spain; DNA Sequencing Service, Instituto de Investigación Biomédica de Salamanca, University of Salamanca, Salamanca, Spain
| | - Paula Navarro-Navarro
- Spanish Network on Mastocytosis, Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer, Instituto de Salud Carlos III, Madrid, Spain; DNA Sequencing Service, Instituto de Investigación Biomédica de Salamanca, University of Salamanca, Salamanca, Spain
| | - Carolina Caldas
- Spanish Network on Mastocytosis, Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer, Instituto de Salud Carlos III, Madrid, Spain; DNA Sequencing Service, Instituto de Investigación Biomédica de Salamanca, University of Salamanca, Salamanca, Spain
| | - Andrea Mayado
- Spanish Network on Mastocytosis, Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer, Instituto de Salud Carlos III, Madrid, Spain; Cancer Research Center, Department of Medicine, Cytometry Service, Instituto de Investigación Biomédica de Salamanca, University of Salamanca, Salamanca, Spain
| | - Javier Muñoz-González
- Spanish Network on Mastocytosis, Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer, Instituto de Salud Carlos III, Madrid, Spain; Cancer Research Center, Department of Medicine, Cytometry Service, Instituto de Investigación Biomédica de Salamanca, University of Salamanca, Salamanca, Spain
| | - Andrés García-Montero
- Spanish Network on Mastocytosis, Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer, Instituto de Salud Carlos III, Madrid, Spain; Cancer Research Center, Department of Medicine, Cytometry Service, Instituto de Investigación Biomédica de Salamanca, University of Salamanca, Salamanca, Spain
| | - Manuela Mollejo
- Pathology Department, Hospital Virgen de la Salud, Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | - Elba Redondo
- Servicio de Alergologia, Hospital Clínico San Carlos, Madrid, Spain
| | - Andrea Garbán
- Servicio de Alergologia, Hospital Clínico San Carlos, Madrid, Spain
| | - André Moreira
- Serviço de Imunoalergologia, Centro Hospitalar Universitário São João, Porto, Portugal; Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Alberto Órfão
- Spanish Network on Mastocytosis, Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer, Instituto de Salud Carlos III, Madrid, Spain; Cancer Research Center, Department of Medicine, Cytometry Service, Instituto de Investigación Biomédica de Salamanca, University of Salamanca, Salamanca, Spain
| | - Iván Álvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha, Reference Center for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain; Spanish Network on Mastocytosis, Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer, Instituto de Salud Carlos III, Madrid, Spain.
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Šelb J, Rijavec M, Kopač P, Lyons JJ, Korošec P. HαT is associated with increased risk for severe Hymenoptera venom-triggered anaphylaxis. J Allergy Clin Immunol 2023; 151:804-805. [PMID: 36529562 DOI: 10.1016/j.jaci.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Julij Šelb
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Kopač
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia.
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40
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Panarelli NC, Hornick JL, Yantiss RK. What Is the Value of Counting Mast Cells in Gastrointestinal Mucosal Biopsies? Mod Pathol 2023; 36:100005. [PMID: 36853780 DOI: 10.1016/j.modpat.2022.100005] [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: 06/27/2022] [Revised: 08/12/2022] [Accepted: 09/19/2022] [Indexed: 01/11/2023]
Abstract
Neoplastic and nonneoplastic mast cell disorders can cause diarrhea, nausea, and abdominal pain that result from heightened release of mast cell mediators. Systemic mastocytosis is characterized by neoplastic mast cell aggregates in the bone marrow and other sites, particularly the skin and gastrointestinal tract. In this situation, extramedullary mast cell aggregates display atypical morphology, with aberrant immunostaining for CD25 in addition to staining for other mast cell markers, such as mast cell tryptase and CD117. Morphologically normal mast cells have also been implicated in nonneoplastic conditions. For example, increased mast cell numbers have been reported in the mucosal biopsy samples from patients with irritable bowel syndrome and hereditary alpha-tryptasemia. Patients with mast cell activation syndrome presumably experience symptoms related to the aberrant elaboration of histamine and other mediators from normal-appearing mast cells present in normal numbers. Unfortunately, similarities in terminology among these biologically distinct clinical conditions have caused considerable diagnostic confusion among clinical colleagues, resulting in frequent requests for pathologists to quantify and characterize mast cells in normal gastrointestinal biopsy samples from patients with diarrheal symptoms. The purpose of this review is to summarize the available data related to mast cell assessment in the gastrointestinal tract and provide pathologists with practical information so that they can help their clinical colleagues manage patients with presumed mast cell disorders.
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Affiliation(s)
- Nicole C Panarelli
- Department of Pathology Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York.
| | - Jason L Hornick
- Department of Pathology, the Brigham and Women's Hospital of Harvard Medical School, Boston, Massachusetts
| | - Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York; Now with Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida
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41
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Sordi B, Vanderwert F, Crupi F, Gesullo F, Zanotti R, Bonadonna P, Crosera L, Elena C, Fiorelli N, Ferrari J, Grifoni F, Sciumè M, Parente R, Triggiani M, Palterer B, Mecheri V, Almerigogna F, Santi R, Di Medio L, Brandi ML, Iorno ML, Ciardetti I, Bencini S, Annunziato F, Mannarelli C, Pieri L, Guglielmelli P, Mannelli F, Vannucchi AM. Disease correlates and clinical relevance of hereditary α-tryptasemia in patients with systemic mastocytosis. J Allergy Clin Immunol 2023; 151:485-493.e11. [PMID: 36309122 DOI: 10.1016/j.jaci.2022.09.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/05/2022] [Accepted: 09/15/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Systemic mastocytosis (SM) encompasses a heterogeneous group of clonal disorders characterized by abnormal expansion of mast cells (MCs). Beyond KIT and other genes recurrently mutated in myeloid neoplasms, several genetic variants have been described as predisposing to the development of the disease and influencing its clinical phenotype. Increased copy number variants of the TPSAB1 gene were identified as a cause of nonclonal elevated tryptasemia and defined as hereditary α-tryptasemia (HαT). Moreover, HαT is enriched in patients with SM, where it can affect the incidence of mediator-related symptoms. OBJECTIVE In a multicenter data set of 444 patients with MC disorders, we aimed to investigate the clinical correlates of germline TPSAB1 copy number gains. METHODS Droplet digital PCR was performed in all cases to ascertain the presence of HαT. Clinical history along with blood values and bone marrow examination were analyzed. RESULTS We confirmed a higher incidence of HαT+ cases (n = 59, 13.3%) in patients diagnosed with mastocytosis with respect to the general population (approximately 5%). HαT+ patients were characterized by a lower MC-associated disease burden and higher levels of tryptase. Several disease variables were coherent with this pattern, from bone marrow MC infiltration to MC-related histopathologic traits, which also accounted for a significantly higher incidence of clonal MC activation syndrome in HαT+ (10.2%) compared to HαT- (3.4%, P = .029) patients. We also confirmed that HαT+ carriers had a significantly higher frequency of anaphylaxis, without relevant differences for other clinical manifestations. CONCLUSION These findings on a large patient series support and extend previous data, and suggest that knowledge of HαT status may be useful for personalized management of patients with SM.
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Affiliation(s)
- Benedetta Sordi
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi, Florence, Italy
| | - Fiorenza Vanderwert
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi, Florence, Italy
| | - Francesca Crupi
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi, Florence, Italy
| | - Francesca Gesullo
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi, Florence, Italy
| | - Roberta Zanotti
- UO Ematologia, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Patrizia Bonadonna
- UO Allergologia, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Lara Crosera
- UO Ematologia, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Chiara Elena
- Divisione di Ematologia, IRCCS S. Matteo Hospital Foundation, Pavia, Italy
| | - Nicolas Fiorelli
- Dipartimento di Medicina Molecolare, Università di Pavia, Pavia, Italy
| | | | - Federica Grifoni
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Mariarita Sciumè
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Roberta Parente
- Dipartimento di Medicina, Divisione di Allergologia e Immunologia Clinica, Università di Salerno, Salerno, Italy
| | - Massimo Triggiani
- Dipartimento di Medicina, Divisione di Allergologia e Immunologia Clinica, Università di Salerno, Salerno, Italy
| | - Boaz Palterer
- Centro di Diagnostica Citofluorimetrica e Immunoterapia, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Florence, Italy
| | - Valentina Mecheri
- SOD Immunoallergologia, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Florence, Italy
| | - Fabio Almerigogna
- SOD Immunoallergologia, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Florence, Italy
| | - Raffaella Santi
- Sezione di Patologia, Dipartimento di Scienze della Salute, Università di Florence, Florence, Italy
| | - Lisa Di Medio
- SOD Malattie del Metabolismo Minerale e Osseo, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Maria Luisa Brandi
- SOD Malattie del Metabolismo Minerale e Osseo, Azienda Ospedaliera Universitaria Careggi, Florence, Italy; FirmoLab, Fondazione FIRMO, Florence, Italy
| | - Maria Loredana Iorno
- Allergologia e Immunologia Clinica Azienda Toscana Centro Ospedale S. Giovanni di Dio, Florence, Italy
| | - Isabella Ciardetti
- Dipartimento di Scienze della Salute, sezione Dermatologia, Università degli Studi di Florence, Florence, Italy
| | - Sara Bencini
- Centro di Diagnostica Citofluorimetrica e Immunoterapia, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Florence, Italy
| | - Francesco Annunziato
- Centro di Diagnostica Citofluorimetrica e Immunoterapia, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Florence, Italy
| | - Carmela Mannarelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi, Florence, Italy
| | - Lisa Pieri
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi, Florence, Italy
| | - Paola Guglielmelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi, Florence, Italy
| | - Francesco Mannelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi, Florence, Italy
| | - Alessandro M Vannucchi
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Denothe Excellence Center, Università degli Studi, Florence, Italy.
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Michel M, Klingebiel C, Vitte J. Tryptase in type I hypersensitivity. Ann Allergy Asthma Immunol 2023; 130:169-177. [PMID: 36084866 DOI: 10.1016/j.anai.2022.08.996] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/21/2022] [Accepted: 08/29/2022] [Indexed: 02/07/2023]
Abstract
Tryptase is currently the main mast cell biomarker available in medical practice. Tryptase determination is a quantitative test performed in serum or plasma for the diagnosis, stratification, and follow-up of mast cell-related conditions. The continuous secretion of monomeric α and β protryptases forms the baseline tryptase level. Transient, activation-induced release of tryptase is known as acute tryptase. Because mast cells are tissue-resident cells, the detection of an acute tryptase release in the bloodstream is protracted, with a delay of 15 to 20 minutes after the onset of symptoms and a peak at approximately 1 hour. Constitutive release of tryptase is a marker of mast cell number and activity status, whereas transient release of mature tryptase is a marker of mast cell degranulation. Although consensual as a concept, the application of this statement in clinical practice has only been clarified since 2020. For baseline tryptase to be used as a biomarker, reference values need to be established. In contrast, defining a transient increase using acute tryptase can only be achieved as a function of the baseline status.
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Affiliation(s)
- Moïse Michel
- Immunology Laboratory, Centre Hospitalier Universitaire Nîmes, Nîmes, France; Microbes, Evolution, Phylogénie et Infection (MEPHI), Aix-Marseille University, Marseille, France
| | | | - Joana Vitte
- Microbes, Evolution, Phylogénie et Infection (MEPHI), Aix-Marseille University, Marseille, France; Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Marseille, France; Montpellier University, Institut Desbrest d'Épidémiologie et de Santé Publique, Institut National de la Sante et de la Recherche Medicale, UMR UA 11, Montpellier, France.
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43
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Valent P, Akin C, Sperr WR, Horny HP, Arock M, Metcalfe DD, Galli SJ. New Insights into the Pathogenesis of Mastocytosis: Emerging Concepts in Diagnosis and Therapy. ANNUAL REVIEW OF PATHOLOGY 2023; 18:361-386. [PMID: 36270293 DOI: 10.1146/annurev-pathmechdis-031521-042618] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mastocytosis is a heterogeneous group of neoplasms defined by a numerical increase and accumulation of clonal mast cells (MCs) in various organ systems. The disease may present as cutaneous mastocytosis or systemic mastocytosis (SM). On the basis of histopathological and molecular features, clinical variables, and organ involvement, SM is divided into indolent SM, smoldering SM, SM with an associated hematologic neoplasm, aggressive SM, and MC leukemia. Each variant is defined by unique diagnostic criteria and a unique spectrum of clinical presentations. A key driver of MC expansion and disease evolution is the oncogenic machinery triggered by mutant forms of KIT. The genetic background, additional somatic mutations, and comorbidities also contribute to the course and prognosis. Patients with SM may also suffer from mediator-related symptoms or even an MC activation syndrome. This article provides an update of concepts on the genetics, etiology, and pathology of mastocytosis, with emphasis on diagnostic criteria and new treatment concepts.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria; .,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria; .,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilian University, Munich, Germany
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Charles-Foix Hospital, AP-HP Sorbonne University, Paris, France
| | - Dean D Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Stephen J Galli
- Department of Pathology, Department of Microbiology and Immunology, Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, California, USA
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44
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Kačar M, Rijavec M, Šelb J, Korošec P. Clonal mast cell disorders and hereditary α-tryptasemia as risk factors for anaphylaxis. Clin Exp Allergy 2023; 53:392-404. [PMID: 36654513 DOI: 10.1111/cea.14264] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/12/2022] [Accepted: 11/23/2022] [Indexed: 01/20/2023]
Abstract
The association between Hymenoptera venom-triggered anaphylaxis (HVA) and clonal mast cell-related disorders (cMCD) has been known for decades. However, recent breakthroughs in peripheral blood screening for KIT p.D816V missense variant have revealed the true extent of this clinical association whilst adding to our understanding of the underlying aetiology. Thus, recent large studies highlighted the presence of KIT p.D816V among 18.2% and 23% of patients with severe Hymenoptera venom-triggered anaphylaxis. A significant proportion of those patients have normal serum basal tryptase (BST) levels, with no cutaneous findings such as urticaria pigmentosa or other systemic findings such as organomegaly that would have suggested the presence of cMCD. These findings of an increased prevalence suggest that the impact of cMCD on anaphylaxis could be clinically underestimated and that the leading question for clinicians could be changed from 'how many patients with cMCD have anaphylaxis?' to 'how many patients with anaphylaxis have cMCD?'. The discovery of hereditary α-tryptasemia (HαT)-a genetic trait caused by an increased copy number of the Tryptase Alpha/Beta 1 (TPSAB1) gene-, first described in 2016, is now known to underlie the majority of cases of elevated BST outside of cMCD and chronic kidney disease. HαT is the first common heritable genetic modifier of anaphylaxis described, and it is associated with increased risk for severe HVA (relative risk = 2.0), idiopathic anaphylaxis, and an increased prevalence of anaphylaxis in patients with cMCD, possibly due to the unique activity profile of α/β -tryptase heterotetramers that may potentiate immediate hypersensitivity reaction severity. Our narrative review aims to highlight recent research to have increased our understanding of cMCD and HαT, through recent lessons learned from studying their association with HVA. Additionally, we examined the studies of mast cell-related disorders in food and drug allergy in an effort to determine whether one should also consider cMCD and/or HαT in cases of severe anaphylaxis triggered by food or drugs.
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Affiliation(s)
- Mark Kačar
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Julij Šelb
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Korošec
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
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45
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Lamprinou M, Sachinidis A, Stamoula E, Vavilis T, Papazisis G. COVID-19 vaccines adverse events: potential molecular mechanisms. Immunol Res 2023; 71:356-372. [PMID: 36607502 PMCID: PMC9821369 DOI: 10.1007/s12026-023-09357-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/01/2023] [Indexed: 01/07/2023]
Abstract
COVID-19 is an infectious disease caused by a single-stranded RNA (ssRNA) virus, known as SARS-CoV-2. The disease, since its first outbreak in Wuhan, China, in December 2019, has led to a global pandemic. The pharmaceutical industry has developed several vaccines, of different vector technologies, against the virus. Of note, among these vaccines, seven have been fully approved by WHO. However, despite the benefits of COVID-19 vaccination, some rare adverse effects have been reported and have been associated with the use of the vaccines developed against SARS-CoV-2, especially those based on mRNA and non-replicating viral vector technology. Rare adverse events reported include allergic and anaphylactic reactions, thrombosis and thrombocytopenia, myocarditis, Bell's palsy, transient myelitis, Guillen-Barre syndrome, recurrences of herpes-zoster, autoimmunity flares, epilepsy, and tachycardia. In this review, we discuss the potential molecular mechanisms leading to these rare adverse events of interest and we also attempt an association with the various vaccine components and platforms. A better understanding of the underlying mechanisms, according to which the vaccines cause side effects, in conjunction with the identification of the vaccine components and/or platforms that are responsible for these reactions, in terms of pharmacovigilance, could probably enable the improvement of future vaccines against COVID-19 and/or even other pathological conditions.
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Affiliation(s)
- Malamatenia Lamprinou
- Laboratory of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, 54124 Greece
| | - Athanasios Sachinidis
- 4th Department of Internal Medicine, School of Medicine, Hippokration General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Stamoula
- Laboratory of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, 54124 Greece
| | - Theofanis Vavilis
- Laboratory of Medical Biology and Genetics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece ,Department of Dentistry, School of Medicine, European University of Cyprus, Nicosia, Cyprus
| | - Georgios Papazisis
- Laboratory of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, 54124 Greece ,Clinical Research Unit, Special Unit for Biomedical Research and Education (SUBRE), School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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46
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Oettgen HC. Mast cells in food allergy: Inducing immediate reactions and shaping long-term immunity. J Allergy Clin Immunol 2023; 151:21-25. [PMID: 36328809 DOI: 10.1016/j.jaci.2022.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/08/2022] [Accepted: 10/04/2022] [Indexed: 11/11/2022]
Abstract
Mast cells are distributed throughout the gastrointestinal tract and function as the main effector cells of IgE-mediated allergic reactions to foods. Allergen-induced cross-linking of IgE antibodies bound to high-affinity IgE receptors, FcεRI, on the surface of mast cells triggers their activation, resulting in the release of mediators of immediate hypersensitivity. These mediators rapidly induce both local gastrointestinal and systemic physiological responses including anaphylaxis. Emerging evidence has revealed that, in addition to inciting immediate reactions, mast cells are key regulators of adaptive immunity to foods. In the gastrointestinal mucosa they provide the priming cytokines that initiate and, over time, consolidate adaptive TH2 responses to ingested allergens as well as TNF and chemokines that orchestrate the recruitment of tissue-infiltrating leukocytes that drive type 2 tissue inflammation. Patients with atopic dermatitis have increased intestinal mast cell numbers and are at a greater risk for food allergy. Recent studies have uncovered a skin-gut axis in which epicutaneous allergen exposure drives intestinal mast cell expansion. The activating effects of IgE antibodies in mast cells are countered by food-specific IgG antibodies that signal via the inhibitory IgG receptor, FcγR2b, suppressing both immediate allergic reactions to foods and the type 2 immune adjuvant activity of mast cells.
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Affiliation(s)
- Hans C Oettgen
- Department of Pediatrics, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass.
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47
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Leguit RJ, Wang SA, George TI, Tzankov A, Orazi A. The international consensus classification of mastocytosis and related entities. Virchows Arch 2023; 482:99-112. [PMID: 36214901 DOI: 10.1007/s00428-022-03423-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 01/24/2023]
Abstract
Mastocytosis is a neoplasm characterized by a clonal proliferation of mast cells, which accumulate in one or multiple organs, associated with an extremely heterogeneous clinical presentation. The disease can be limited to the skin (cutaneous mastocytosis) that is mostly seen in childhood and usually behaves in a benign fashion. Adult patients most often present with systemic disease with or without skin lesions. This includes indolent forms such as indolent systemic mastocytosis and its subvariant bone marrow mastocytosis, and smoldering systemic mastocytosis as well as aggressive forms including aggressive systemic mastocytosis, systemic mastocytosis with an associated myeloid neoplasm (previously called systemic mastocytosis with an associated hematologic neoplasm), and mast cell leukemia. In addition, mast cell sarcoma is a rare aggressive form of mastocytosis that can present in the skin as well as at extracutaneous sites. This review article focuses on the updates in mastocytosis of the 2022 international consensus classification (ICC).
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Affiliation(s)
- Roos J Leguit
- Department of Pathology, University Medical Center Utrecht, H04-312, POB 85500, 3508 GA, Utrecht, Netherlands
| | - Sa A Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tracy I George
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Alexandar Tzankov
- Institute of Pathology, University of Basel, University Hospital Basel, Schönbeinstrasse 40, 4031, Basel, Switzerland
| | - Attilio Orazi
- Department of Pathology, PL Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Avenue, El Paso, TX, 79905, USA.
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48
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Weiler CR, Schrijvers R, Golden DBK. Anaphylaxis: Advances in the Past 10 Years. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:51-62. [PMID: 36162799 DOI: 10.1016/j.jaip.2022.09.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/06/2022] [Accepted: 09/12/2022] [Indexed: 01/11/2023]
Abstract
In the past 10 years, anaphylaxis has grown into its own special area of study within Allergy-Immunology, both at the bench and at the bedside. This review focuses on some of the most clinically relevant advances over the past decade. These include simplified and more inclusive diagnostic criteria for adults and children, uniform definition of biphasic anaphylaxis, and improved systems for objective severity grading. Studies reported in the past decade have led to improved understanding of normal and abnormal regulation of mast cell function, translating into better diagnostic and therapeutic approaches to patients with anaphylaxis. Research has provided improved recognition and treatment of mast cell disorders and has identified a new condition, hereditary α-tryptasemia, that may impact anaphylactic syndromes. We have learned to recognize new causes (α-gal), new pathways (Mas-related G protein-coupled receptor-X2), and many risk factors for severe anaphylaxis. The stability of epinephrine in autoinjectors was reported to be very good for several years after the labeled expiry date, and it can tolerate freezing and thawing. Repeated and prolonged exposure to excessive heat leads to degradation of epinephrine activity. New treatments to prevent severe anaphylaxis have been described, using new ways to block the IgE receptor or modulate intracellular signaling pathways.
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Affiliation(s)
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, Leuven, Belgium
| | - David B K Golden
- Division of Allergy/Clinical Immunology, Johns Hopkins School of Medicine, Baltimore, Md.
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How to evaluate the patient with a suspected mast cell disorder and how/when to manage symptoms. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:55-63. [PMID: 36485101 PMCID: PMC9820312 DOI: 10.1182/hematology.2022000366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Mast cell disorders include mastocytosis and mast cell activation syndromes. Mastocytosis is a rare clonal disorder of the mast cell, driven by KIT D816V mutation in most cases. Mastocytosis is diagnosed and classified according to World Health Organization criteria. Mast cell activation syndromes encompass a diverse group of disorders and may have clonal or nonclonal etiologies. Hematologists may be consulted to assist in the diagnostic workup and/or management of mast cell disorders. A consult to the hematologist for mast cell disorders may provoke anxiety due to the rare nature of these diseases and the management of nonhematologic mast cell activation symptoms. This article presents recommendations on how to approach the diagnosis and management of patients referred for common clinical scenarios.
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Rijavec M, Maver A, Turner PJ, Hočevar K, Košnik M, Yamani A, Hogan S, Custovic A, Peterlin B, Korošec P. Integrative transcriptomic analysis in human and mouse model of anaphylaxis identifies gene signatures associated with cell movement, migration and neuroinflammatory signalling. Front Immunol 2022; 13:1016165. [PMID: 36569939 PMCID: PMC9772259 DOI: 10.3389/fimmu.2022.1016165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
Background Anaphylaxis is an acute life-threatening allergic reaction and a concern at a global level; therefore, further progress in understanding the underlying mechanisms and more effective strategies for diagnosis, prevention and management are needed. Objective We sought to identify the global architecture of blood transcriptomic features of anaphylaxis by integrating expression data from human patients and mouse model of anaphylaxis. Methods Bulk RNA-sequencings of peripheral whole blood were performed in: i) 14 emergency department (ED) patients with acute anaphylaxis, predominantly to Hymenoptera venom, ii) 11 patients with peanut allergy undergoing double-blind, placebo-controlled food challenge (DBPCFC) to peanut, iii) murine model of IgE-mediated anaphylaxis. Integrative characterisation of differential gene expression, immune cell-type-specific gene expression profiles, and functional and pathway analysis was undertaken. Results 1023 genes were commonly and significantly dysregulated during anaphylaxis in ED and DBPCFC patients; of those genes, 29 were also dysregulated in the mouse model. Cell-type-specific gene expression profiles showed a rapid downregulation of blood basophil and upregulation of neutrophil signature in ED and DBPCFC patients and the mouse model, but no consistent and/or significant differences were found for other blood cells. Functional and pathway analysis demonstrated that human and mouse blood transcriptomic signatures of anaphylaxis follow trajectories of upregulation of cell movement, migration and neuroinflammatory signalling, and downregulation of lipid activating nuclear receptors signalling. Conclusion Our study highlights the matched and extensive blood transcriptomic changes and suggests the involvement of discrete cellular components and upregulation of migration and neuroinflammatory pathways during anaphylaxis.
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Affiliation(s)
- Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Aleš Maver
- Clinical Institute of Medical Genetics, University Medical Centre, Ljubljana, Slovenia
| | - Paul J. Turner
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Keli Hočevar
- Clinical Institute of Medical Genetics, University Medical Centre, Ljubljana, Slovenia
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Amnah Yamani
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
- Mary H. Weiser Food Allergy Center (MHWFAC), Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Simon P. Hogan
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
- Mary H. Weiser Food Allergy Center (MHWFAC), Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Borut Peterlin
- Clinical Institute of Medical Genetics, University Medical Centre, Ljubljana, Slovenia
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
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