1
|
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.
Collapse
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
| |
Collapse
|
2
|
Motta RV, Culver EL. IgG4 autoantibodies and autoantigens in the context of IgG4-autoimmune disease and IgG4-related disease. Front Immunol 2024; 15:1272084. [PMID: 38433835 PMCID: PMC10904653 DOI: 10.3389/fimmu.2024.1272084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024] Open
Abstract
Immunoglobulins are an essential part of the humoral immune response. IgG4 antibodies are the least prevalent subclass and have unique structural and functional properties. In this review, we discuss IgG4 class switch and B cell production. We review the importance of IgG4 antibodies in the context of allergic responses, helminth infections and malignancy. We discuss their anti-inflammatory and tolerogenic effects in allergen-specific immunotherapy, and ability to evade the immune system in parasitic infection and tumour cells. We then focus on the role of IgG4 autoantibodies and autoantigens in IgG4-autoimmune diseases and IgG4-related disease, highlighting important parallels and differences between them. In IgG4-autoimmune diseases, pathogenesis is based on a direct role of IgG4 antibodies binding to self-antigens and disturbing homeostasis. In IgG4-related disease, where affected organs are infiltrated with IgG4-expressing plasma cells, IgG4 antibodies may also directly target a number of self-antigens or be overexpressed as an epiphenomenon of the disease. These antigen-driven processes require critical T and B cell interaction. Lastly, we explore the current gaps in our knowledge and how these may be addressed.
Collapse
Affiliation(s)
- Rodrigo V. Motta
- Translational Gastroenterology and Liver Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Emma L. Culver
- Translational Gastroenterology and Liver Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| |
Collapse
|
3
|
Gulen T. Using the Right Criteria for MCAS. Curr Allergy Asthma Rep 2024; 24:39-51. [PMID: 38243020 PMCID: PMC10866766 DOI: 10.1007/s11882-024-01126-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 01/21/2024]
Abstract
PURPOSE OF REVIEW The current article aims to provide a comprehensive update on diagnostic criteria for mast cell activation syndrome (MCAS), addressing challenges in diagnosing and classifying MCAS and its variants. RECENT FINDINGS In recent years, there has been a significant increase in our knowledge regarding the underlying mechanisms responsible for the activation of mast cells (MCs) in various pathological conditions. Furthermore, a set of criteria and a classification for MCASs have been established. MCAS is characterized by the presence of typical clinical symptoms, a substantial elevation in serum tryptase levels during an attack compared to the patient's baseline tryptase levels, and a response to MC mediator-targeting therapy. In this report, a thorough examination was conducted on the contemporary literature relating to MCAS, with a focus on comparing the specificity, sensitivity, and robustness of MCAS-related parameters within proposals for diagnosing and classifying MCAS and its variants. Moreover, the significance of employing specific consensus criteria in the assessment and categorization of MCAS in individual patients was underscored, due to the escalating occurrence of patients receiving a misdiagnosis of MCAS based on nonspecific criteria.
Collapse
Affiliation(s)
- Theo Gulen
- Department of Respiratory Medicine and Allergy, K85, Karolinska University Hospital Huddinge, Stockholm, SE-14186, Sweden.
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
- Clinical Lung and Allergy Research Unit, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.
- Mastocytosis Centre Karolinska, Karolinska University Hospital Huddinge, Stockholm, Sweden.
| |
Collapse
|
4
|
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.
Collapse
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.
| |
Collapse
|
5
|
Giannetti MP, Nicoloro-SantaBarbara J, Godwin G, Middlesworth J, Espeland A, Castells MC. Drug and Venom Allergy in Mastocytosis. Immunol Allergy Clin North Am 2023; 43:699-710. [PMID: 37758407 DOI: 10.1016/j.iac.2023.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Patients with mastocytosis have an increased risk for mast cell activation events including anaphylaxis when exposed to certain drugs and Hymenoptera venom. Hypotension and cardiovascular collapse without skin or other systemic manifestations can occur after Hymenoptera stings, during the perioperative period, and after exposure to nonsteroidal ntiinflammatory drugs, opioids, and other mast cell activating medications, including vancomycin and quinolones. This chapter reviews the epidemiology, mechanisms, diagnosis, management, and treatment options for Hymenoptera venom and drug-induced reactions in patients with mastocytosis.
Collapse
Affiliation(s)
- Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, Alumni Hall, Room 303, Boston, MA 02115, USA; Harvard Medical School, 41 Avenue Louis Pasteur, Alumni Hall, Room 303, Boston, MA 02115, USA.
| | - Jennifer Nicoloro-SantaBarbara
- Harvard Medical School, 41 Avenue Louis Pasteur, Alumni Hall, Room 303, Boston, MA 02115, USA; Department of Psychiatry, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, Alumni Hall, Room 303, Boston, MA 02115, USA
| | - Grace Godwin
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, Alumni Hall, Room 303, Boston, MA 02115, USA
| | - Julia Middlesworth
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, Alumni Hall, Room 303, Boston, MA 02115, USA
| | - Andrew Espeland
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, Alumni Hall, Room 303, Boston, MA 02115, USA
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, Alumni Hall, Room 303, Boston, MA 02115, USA; Harvard Medical School, 41 Avenue Louis Pasteur, Alumni Hall, Room 303, Boston, MA 02115, USA
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Qin L, Tang LF, Cheng L, Wang HY. The clinical significance of allergen-specific IgG4 in allergic diseases. Front Immunol 2022; 13:1032909. [PMID: 36389804 PMCID: PMC9648126 DOI: 10.3389/fimmu.2022.1032909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/20/2022] [Indexed: 09/10/2023] Open
Abstract
IgG4 is a subclass of IgG antibody with a unique molecular feature of (Fragment antigen- binding) Fab-arm exchange, allowing bispecific antigen binding in a mono-valent manner. With low binding affinity to C1q and Fcγreceptors, IgG4 is incapable of forming immune complexes and activating the complement pathway, exhibiting a non-inflammatory feature. IgG4 is produced similarly to IgE and is considered a modified reaction to IgE class-switching response under certain conditions. It could also counteract IgE-activated inflammation. However, the clinical significance of IgG4 in allergic diseases is complex and controversial. Three viewpoints have been suggested to describe the role of IgG4. IgG4 can act as a tolerance-inducer to play a protective role under repeated and rapid incremental dosing of allergen exposure in allergen immunotherapy (AIT), supported by allergies in cat raisers and venom desensitization in beekeepers. Another viewpoint accepted by mainstream specialists and guidelines of Food Allergy and Management in different countries points out that food-specific IgG4 is a bystander in food allergy and should not be used as a diagnostic tool in clinical work. However, eosinophilic esophagitis (EoE) investigation revealed a direct clinical relevance between physiopathology and serum IgG4 in cow milk and wheat. These factors indicate that allergen-specific IgG4 plays a multifaceted role in allergic diseases that is protective or pathogenic depending on different allergens or exposure conditions.
Collapse
Affiliation(s)
- Lu Qin
- Department of Pulmonology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lan-Fang Tang
- Department of Pulmonology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lei Cheng
- Department of Otorhinolaryngology & Clinical Allergy Center, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Hui-Ying Wang
- Department of Allergy and Clinical Immunology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
8
|
Ungerstedt J, Ljung C, Klimkowska M, Gülen T. Clinical Outcomes of Adults with Systemic Mastocytosis: A 15-Year Multidisciplinary Experience. Cancers (Basel) 2022; 14:cancers14163942. [PMID: 36010937 PMCID: PMC9405903 DOI: 10.3390/cancers14163942] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/08/2022] [Accepted: 08/14/2022] [Indexed: 11/16/2022] Open
Abstract
Systemic mastocytosis (SM) is a rare, clonal, clinically heterogeneous disorder of the mast cells (MCs), and mainly affects adults. The present study aims to describe the clinical and laboratory features as well as the outcomes of SM. A 15-year retrospective study was conducted on 195 consecutive SM patients (aged ≥ 18 years) diagnosed in 2006−2020 at the Multidisciplinary Mastocytosis Center at Karolinska University Hospital. Patients with indolent SM (ISM) represented the most common SM variant (88.2%). Furthermore, the frequencies of aggressive SM and SM with associated non-mast-cell hematological neoplasm were 4.1% and 7.7%, respectively. The prevalence of SM in the adult population of the Stockholm region was estimated to be 10.6/100,000 inhabitants, and the mean incidence of SM cases in the Stockholm region was 0.77/100,000 people per year. In this series, tryptase levels were below 20 ng/mL in 51 patients (26%). Osteoporosis was present in 21.9% of all cases. Interestingly, there was no progression from ISM to advanced SM variants in our study. Furthermore, overall survival was significantly better in ISM patients compared to advanced SM patients (p < 0.0001). Our data suggest that the early recognition and correct diagnosis of SM has prognostic significance.
Collapse
Affiliation(s)
- Johanna Ungerstedt
- HERM Hematology and Regenerative Center, Department of Medicine Huddinge Karolinska Institutet, SE-14183 Stockholm, Sweden
- ME Hematology, Karolinska University Hospital, SE-14186 Stockholm, Sweden
| | - Christopher Ljung
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, SE-14186 Stockholm, Sweden
| | - Monika Klimkowska
- Pathology Unit, Department of Laboratory Medicine, Karolinska Institutet, SE-14183 Huddinge, Sweden
- Department of Clinical Pathology and Cytology, Karolinska University Hospital, SE-14186 Huddinge, Sweden
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, SE-14186 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, SE-17177 Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, SE-14183 Stockholm, Sweden
- Correspondence: or
| |
Collapse
|
9
|
Pyatilova P, Akin C, Alvarez-Twose I, Arock M, Bonadonna P, Brockow K, Butterfield JH, Broesby-Olsen S, Carter MC, Castells M, George TI, Gotlib J, Greiner G, Gülen T, Hartmann K, Hermine O, Horny HP, Jawhar M, Lange M, Lyons JJ, Maurer M, Metcalfe DD, Nedoszytko B, Niedoszytko M, Orfao A, Reiter A, Schwaab J, Sotlar K, Sperr WR, Triggiani M, Valent P, Siebenhaar F. Refined Treatment Response Criteria for Indolent Systemic Mastocytosis Proposed by the ECNM-AIM Consortium. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2015-2024. [PMID: 35724950 DOI: 10.1016/j.jaip.2022.05.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/12/2022] [Accepted: 05/15/2022] [Indexed: 01/08/2023]
Abstract
Indolent systemic mastocytosis (ISM) has a favorable prognosis and normal life expectancy. However, many patients suffer from mast cell (MC) mediator-related symptoms, which significantly affect quality of life (QoL). Cutaneous, gastrointestinal, and neurological complaints, musculoskeletal pain, and the presence of skin lesions, anaphylaxis, and osteoporosis are the main symptoms and signs in ISM and must be assessed in all patients before and during treatment. Validated mastocytosis-specific patient-reported outcome measures (PROMs) should be used for this purpose. Serum tryptase and KIT D816V allele burden are recommended as secondary outcome parameters, noting that they do not reflect the severity of signs, symptoms, and related QoL impairment, but indirectly express MC burden. Changes from baseline of 90%, 60%, and 30% indicate complete response >90%, major response 60% to 90%, partial response 30% to 60%, and no response <30% to treatment. To conclude, we recommend the use of PROMs as primary outcome parameters to define treatment response in patients with ISM in clinical trials and in everyday clinical practice.
Collapse
Affiliation(s)
- Polina Pyatilova
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | - Iván Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) and CIBERONC, Hospital Virgen del Valle, Toledo, Spain
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Paris Sorbonne University, Paris, France
| | | | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - Sigurd Broesby-Olsen
- Mastocytosis Centre, Odense University Hospital, Odense, Denmark; Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Melody C Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Md
| | - Mariana Castells
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tracy I George
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Jason Gotlib
- Stanford University School of Medicine/Stanford Cancer Institute, Stanford, Calif
| | - Georg Greiner
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria; Ihr Labor, Medical Diagnostic Laboratories, Vienna, Austria
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - 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
| | - Olivier Hermine
- Imagine Institute Université de Paris, Sorbonne, INSERM U1163, Centre national de référence des mastocytoses, Hôpital Necker, Assistance publique hôpitaux de Paris, Paris, France
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig Maximilians University, Munich, Germany
| | - Mohamed Jawhar
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Md
| | - Marcus Maurer
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Dean D Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Md
| | - Boguslaw Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland; Invicta Fertility and Reproductive Centre, Molecular Laboratory, Gdansk, Poland
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdańsk, Gdansk, Poland
| | - Alberto Orfao
- Servicio General 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
| | - Andreas Reiter
- Institute of Pathology, Ludwig Maximilians University, Munich, Germany
| | - Juliana Schwaab
- Institute of Pathology, Ludwig Maximilians University, Munich, Germany
| | - Karl Sotlar
- Institute of Pathology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Wolfgang R Sperr
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Peter Valent
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Frank Siebenhaar
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.
| |
Collapse
|
10
|
Lazarinis N, Bossios A, Gülen T. COVID-19 vaccination in the setting of mastocytosis-Pfizer-BioNTech mRNA vaccine is safe and well tolerated. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1377-1379. [PMID: 35123098 PMCID: PMC8810433 DOI: 10.1016/j.jaip.2022.01.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Nikolaos Lazarinis
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Apostolos Bossios
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden; Clinical Immunology and Allergy Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Mastocytosis Center Karolinska, Karolinska Institutet and Karolinska University, Hospital Huddinge, Stockholm, Sweden.
| |
Collapse
|
11
|
Ensina LF, Min TK, Félix MMR, de Alcântara CT, Costa C. Acute Urticaria and Anaphylaxis: Differences and Similarities in Clinical Management. FRONTIERS IN ALLERGY 2022; 3:840999. [PMID: 35958944 PMCID: PMC9361476 DOI: 10.3389/falgy.2022.840999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
Acute urticaria is a common condition that presents with wheals and/or angioedema. However, these symptoms are also frequent in anaphylaxis, a life-threatening reaction that should be immediately diagnosed and treated. In both, mast cells play a central role in the physiopathology. Causes and triggers of acute urticaria and anaphylaxis are similar in general, but some peculiarities can be observed. The diagnostic approach may differ, accordingly to the condition, suspicious causes, age groups and regions. Adrenaline is the first-line treatment for anaphylaxis, but not for acute urticaria, where H1-antihistamines are the first choice. In this paper, we review the main aspects, similarities and differences regarding definitions, mechanisms, causes, diagnosis and treatment of acute urticaria and anaphylaxis.
Collapse
Affiliation(s)
- Luis Felipe Ensina
- Division of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
- *Correspondence: Luis Felipe Ensina
| | - Taek Ki Min
- Department of Pediatrics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Mara Morelo Rocha Félix
- Division of Allergy and Immunology, Department of General Medicine, School of Medicine and Surgery, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Célia Costa
- Immunoallergology Department, Hospital de Santa Maria, Centro Hospitalar Universitario de Lisboa Norte (CHLN), EPE, Lisbon, Portugal
| |
Collapse
|
12
|
Risikofaktoren bei Bienen- und Wespengiftallergie: aktuelle Bewertung. ALLERGO JOURNAL 2022. [DOI: 10.1007/s15007-021-4938-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
13
|
Abstract
There is strong evidence of an association between severe anaphylaxis, especially hymenoptera venom induced, and mast cell (MC) disorders. It has been thought that intrinsic abnormalities in MCs, including the presence of the activating KIT D816V mutation in mastocytosis or of genetic trait, hereditary alpha-tryptasemia, may influence susceptibility to severe anaphylaxis. This article evaluates the potential mechanisms leading to severe MC activation, as well as the differential diagnosis of and range of symptoms attributable to MC mediator release. Also, we offer a global classification for disorders related to MC activation.
Collapse
|
14
|
Low risk of contrast media-induced hypersensitivity reactions in all subtypes of systemic mastocytosis. Ann Allergy Asthma Immunol 2021; 128:314-318. [PMID: 34637924 DOI: 10.1016/j.anai.2021.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/27/2021] [Accepted: 10/06/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with systemic mastocytosis (SM) are at increased risk of hypersensitivity reactions (HRs). Although Hymenoptera venoms are the predominant triggers, cases of contrast media-induced HR (CMIHR) have also been reported and prophylactic premedication is often performed. However, data from larger series are limited and differences between indolent and advanced SM have not yet been investigated. OBJECTIVE To determine the incidence and severity of CMIHR in all subtypes of SM. METHODS We analyzed 162 adult patients with SM (indolent systemic mastocytosis [ISM], n = 65; advanced systemic mastocytosis [advSM], n = 97). First, the cumulative incidence of CMIHR was retrospectively assessed in the patient's history. Second, at our institution, patients underwent 332 contrast media (CM)-enhanced imaging including 80 computed tomography (CT) scans with iodine-based contrast agent and 252 magnetic resonance imaging (MRI) with a gadolinium-based contrast agent, and tolerance was assessed. RESULTS Previous CMIHRs to CT (vomiting, n = 1, erythema, n = 1, cardiovascular shock, n = 1), and MRI (dyspnea, n = 1, cardiovascular shock, n = 1) had been reported by 4 out of 162 (2.5%) patients (ISM, n = 3; advSM, n = 1). In contrast, during or after 332 CM-enhanced CT or MRI examinations at our institution, no CMIHRs were reported. Premedication was solely given to 3 patients before CT scans, including 1 with previous CMIHR, who tolerated the imaging well. CONCLUSION We conclude that: (1) there is a substantial discrepancy between the perception and prevalence of HRs to CM in SM; (2) reactions are scarce in ISM and even rarer in advSM; and (3) in SM patients without previous history of CM hypersensitivity, prophylactic premedication before CM-enhanced CT or MRI is dispensable.
Collapse
|
15
|
Abstract
Die Allergenimmuntherapie (AIT) ist – neben der oft nicht suffizient durchzuführenden Allergenmeidung – die einzige kausale Therapie Ig(Immunglobulin)E-vermittelter Allergien gegen Aeroallergene und Hymenopterengifte. Sie kann je nach Allergen als subkutane Injektion (subkutane Immuntherapie [SCIT]) oder über eine sublinguale Applikation (sublinguale Immuntherapie [SLIT]) erfolgen, kürzlich wurde zudem auch ein Verfahren zur oralen Immuntherapie zur Behandlung der Nahrungsmittelallergie zugelassen. Neben der korrekten Indikationsstellung (positive Anamnese und Diagnostik einer IgE-vermittelten Allergie, Allergenkarenz nicht ausreichend möglich) sind mögliche Kontraindikationen und Risikofaktoren zu beachten. Zudem kann es unter einer AIT zu – potenziell auch lebensgefährlichen – Nebenwirkungen kommen. Im Folgenden sollen häufig gestellte Fragen und Fakten zur Entscheidungsfindung für die Durchführung und zum Risikomanagement der AIT beleuchtet und unter Berücksichtigung der aktuellen Datenlage diskutiert werden.
Collapse
|
16
|
Gülen T, Akin C, Bonadonna P, Siebenhaar F, Broesby-Olsen S, Brockow K, Niedoszytko M, Nedoszytko B, Oude Elberink HNG, Butterfield JH, Sperr WR, Alvarez-Twose I, Horny HP, Sotlar K, Schwaab J, Jawhar M, Zanotti R, Nilsson G, Lyons JJ, Carter MC, George TI, Hermine O, Gotlib J, Orfao A, Triggiani M, Reiter A, Hartmann K, Castells M, Arock M, Schwartz LB, Metcalfe DD, Valent P. Selecting the Right Criteria and Proper Classification to Diagnose Mast Cell Activation Syndromes: A Critical Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3918-3928. [PMID: 34166845 DOI: 10.1016/j.jaip.2021.06.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/05/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022]
Abstract
In recent years, knowledge about mechanisms underlying mast cell activation (MCA) and accumulation in various pathologic conditions increased substantially. In addition, criteria and a classification of MCA syndromes (MCASs) have been set forth. MCAS is defined by typical clinical symptoms, a substantial increase in serum tryptase level during an attack over the patient's baseline tryptase, and a response of the symptoms to drugs targeting mast cells, mediator production, and/or mediator effects. Alternative diagnostic criteria of MCAS have also been suggested, but these alternative criteria often lack specificity and validation. In this report, we critically review the contemporary literature relating to MCAS and compare the specificity, sensitivity, and strength of MCAS-related parameters within proposals to diagnose and classify MCAS and its variants. Furthermore, we highlight the need to apply specific consensus criteria in the evaluation and classification of MCAS in individual patients. This is an urgent and important medical necessity because as an increasing number of patients are being given a misdiagnosis of MCAS based on nonspecific criteria, which contributes to confusion and frustration by patients and caregivers and sometimes may delay recognition and treatment of correct medical conditions that often turn out to be unrelated to MCA.
Collapse
Affiliation(s)
- 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.
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | | | - Frank Siebenhaar
- Dermatological Allergology, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Germany
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Boguslaw Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland; Invicta Fertility and Reproductive Center, Molecular Laboratory, Sopot, Poland
| | - Hanneke N G Oude Elberink
- Department of Allergology, GRIAC Research Institute, University of Groningen, University Medical Center of Groningen, Groningen, The Netherlands
| | | | - 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
| | - Ivan Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) and CIBERONC, Hospital Virgen del Valle, Toledo, Spain
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilian University, Munich, Germany
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | - Mohamad Jawhar
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Roberta Zanotti
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Gunnar Nilsson
- Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm, Sweden
| | - Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Melody C Carter
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Tracy I George
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Olivier Hermine
- Imagine Institute Université Paris Descartes, Sorbonne, Paris Cité, Centre National de Référence des Mastocytoses, Paris, France
| | - Jason Gotlib
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, Calif
| | - Alberto Orfao
- Servicio Central de Citometria, Centro de Investigacion del Cancer (IBMCC; CSIC/USAL), IBSAL, CIBERONC and Department of Medicine, University of Salamanca, Salamanca, Spain
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, 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
| | - Mariana Castells
- Brigham and Women's Hospital, Mastocytosis Center, Harvard Medical School, Boston, Mass
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (UPMC), Paris, France
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, Va
| | - Dean D Metcalfe
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - 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
| |
Collapse
|
17
|
Selcuk A, Baysan A. Venom immunotherapy in indolent systemic mastocytosis with high serum tryptase level. Hum Vaccin Immunother 2021; 17:1599-1603. [PMID: 33651660 PMCID: PMC8115573 DOI: 10.1080/21645515.2020.1846398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Mastocytosis is a rare group of disorders characterized by abnormal accumulation of mast cells in the skin, bone marrow, and internal organs. In particular, patients with systemic mastocytosis are at an increased risk of frequent and severe episodes of anaphylaxis. Hymenoptera venom allergy is the most common trigger of anaphylaxis in these patients. Immunotherapy is an effective and safe therapy recommended for patients with mastocytosis and venom allergy. Although this therapy can be administered according to different protocols, the preferred protocol for patients with mastocytosis remains unclear. Systemic side effects can occur, in particular, during the up-dosing phase of immunotherapy, making progression to the maintenance phase of therapy challenging. This case report presents the diagnosis and ultrarush immunotherapy process ended with anaphylaxis of a 33-y-old male patient with Apis mellifera allergy.
Collapse
Affiliation(s)
- Ali Selcuk
- Allergy and Immunology Department, Malatya Training and Research Hospital, Malatya, Turkey
| | - Abdullah Baysan
- Allergy and Immunology Department, Sultan II. Abdulhamid Han Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| |
Collapse
|
18
|
Association between Venom Immunotherapy and Changes in Serum Protein-Peptide Patterns. Vaccines (Basel) 2021; 9:vaccines9030249. [PMID: 33809001 PMCID: PMC8001044 DOI: 10.3390/vaccines9030249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/08/2021] [Accepted: 03/10/2021] [Indexed: 01/25/2023] Open
Abstract
Venom immunotherapy (VIT) is administered to allergic patients to reduce the risk of dangerous systemic reactions following an insect sting. To better understand the mechanism of this treatment and its impact on the human organism, we analysed serum proteomic patterns obtained at five time-points from Hymenoptera-venom-allergic patients undergoing VIT. For statistical analyses, patients were additionally divided into two groups (high responders and low responders) according to serum sIgG4 levels. VIT was found to be associated with changes in seven proteins: the fibrinogen alpha chain, complement C4-A, complement C3, filamin-B, kininogen-1, myosin-9 and inter-alpha-trypsin inhibitor heavy chain H1. The number of discriminative m/z (mass-to-charge ratio) features increased up to the 90th day of VIT, which may be associated with the development of immunity after the administration of increased venom doses. It may also suggest that during VIT, there may occur processes involved not only in protein synthesis but also in protein degradation (caused by proteolytic venom components). The results are consistent with measured serum sIgG4 levels, which increased from 2.04 mgA/I at baseline to 7.25 mgA/I at 90 days. Moreover, the major proteomic changes were detected separately in the high responder group. This may suggest that changes in protein–peptide profiles reflect the actual response to VIT.
Collapse
|
19
|
Romantowski J, Górska A, Niedoszytko M, Gulen T, Gruchała-Niedoszytko M, Nedoszytko B, Lange M, Brockow K, Arock M, Akin C, Valent P. A Challenge for Allergologist: Application of Allergy Diagnostic Methods in Mast Cell Disorders. Int J Mol Sci 2021; 22:1454. [PMID: 33535634 PMCID: PMC7867197 DOI: 10.3390/ijms22031454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/12/2022] Open
Abstract
Primary and secondary mast cell activation syndromes (MCAS) can occur in patients with mastocytosis. During the past few years our knowledge about the pathogenesis and disease-triggering mechanisms in MCAS and mastocytosis have increased substantially. Whereas mastocytosis is characterized by an accumulation of neoplastic (clonal) mast cells (MC) in various organ systems, MCAS is defined by a massive and systemic activation of these cells. Mast cells are crucial effector cells in allergic diseases, thus their elevated number and activation can cause severe anaphylactic reactions and MCAS in patients with mastocytosis. However, these cells may also degranulate spontaneously or degranulate in response to non-allergic triggers leading to clinical symptoms. In mastocytosis patients, such symptoms may lead to the diagnosis of a primary MCAS. The diagnosis of a concomitant allergy in mastocytosis patients is challenging. In these patients, a mixed form (primary and secondary) of MCAS may be diagnosed. These patients may also suffer from life-threatening anaphylactic reactions when exposed to allergens. In these cases, the possibility of severe side effects of in vivo provocations can sometimes also limit diagnostic evaluations. In the current article, we discuss the diagnosis and management of patients suffering from mastocytosis and concomitant MCAS, with special emphasis on novel diagnostic tests and management, including allergen microarrays, recombinant allergen analysis, basophil activation tests, optimal prophylaxis, and specific therapies.
Collapse
Affiliation(s)
- Jan Romantowski
- Department of Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (A.G.); (M.N.)
| | - Aleksandra Górska
- Department of Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (A.G.); (M.N.)
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (A.G.); (M.N.)
| | - Theo Gulen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, 14186 Huddinge, Sweden;
- Immunology and Allergy Unit, Department of Medicine Solna, Karolinska Institutet, 17177 Stockholm, Sweden
| | | | - Bogusław Nedoszytko
- Department of Dermatology, Venerology and Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (B.N.); (M.L.)
| | - Magdalena Lange
- Department of Dermatology, Venerology and Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (B.N.); (M.L.)
| | - Knut Brockow
- Department of Dermatology and Allergy, School of Medicine, Technical University of Munich, D-80802 Munich, Germany;
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (UPMC), 75005 Paris, France;
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, MI 48106, USA;
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria;
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, 1090 Vienna, Austria
| |
Collapse
|
20
|
Kucuksezer UC, Ozdemir C, Cevhertas L, Ogulur I, Akdis M, Akdis CA. Mechanisms of allergen-specific immunotherapy and allergen tolerance. Allergol Int 2020; 69:549-560. [PMID: 32900655 DOI: 10.1016/j.alit.2020.08.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/10/2020] [Indexed: 12/28/2022] Open
Abstract
Allergen-specific immunotherapy (AIT) is the mainstay treatment for the cure of allergic disorders, with depicted efficacy and safety by several trials and meta-analysis. AIT impressively contributes to the management of allergic rhinitis, asthma and venom allergies. Food allergy is a new arena for AIT with promising results, especially via novel administration routes. Cell subsets with regulatory capacities are induced during AIT. IL-10 and transforming growth factor (TGF)-β are the main suppressor cytokines, in addition to surface molecules such as cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) and programmed cell death protein-1 (PD-1) within the micro milieu. Modified T- and B-cell responses and antibody isotypes, increased activity thresholds for eosinophils, basophils and mast cells and consequent limitation of inflammatory cascades altogether induce and maintain a state of sustained allergen-specific unresponsiveness. Established tolerance is reflected into the clinical perspectives as improvement of allergy symptoms together with reduced medication requirements and evolved disease severity. Long treatment durations, costs, reduced patient compliance and risk of severe, even life-threatening adverse reactions during treatment stand as major limiting factors for AIT. By development of purified non-allergenic, highly-immunogenic modified allergen extracts, and combinational usage of them with novel adjuvant molecules via new routes may shorten treatment durations and possibly reduce these drawbacks. AIT is the best model for custom-tailored therapy of allergic disorders. Better characterization of disease endotypes, definition of specific biomarkers for diagnosis and therapy follow-up, as well as precision medicine approaches may further contribute to success of AIT in management of allergic disorders.
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW Allergen immunotherapy is the only treatment modality which alters the natural course of allergic diseases by restoring immune tolerance against allergens. Deeper understanding of tolerance mechanisms will lead to the development of new vaccines, which target immune responses and promote tolerance. RECENT FINDINGS Successful allergen immunotherapy (AIT) induces allergen-specific peripheral tolerance, characterized mainly by the generation of allergen-specific Treg cells and reduction of Th2 cells. At the early phase, AIT leads to a decrease in the activity and degranulation of mast cells and basophils and a decrease in inflammatory responses of eosinophils in inflamed tissues. Treg cells show their effects by secreting inhibitory cytokines including interleukin (IL)-10, transforming growth factor-β, interfering with cellular metabolisms, suppressing antigen presenting cells and innate lymphoid cells (ILCs) and by cytolysis. AIT induces the development of regulatory B cells producing IL-10 and B cells expressing allergen-specific IgG4. Recent investigations have demonstrated that AIT is also associated with the formation of ILC2reg and DCreg cells which contribute to tolerance induction. SUMMARY Research done so far, has shown that multiple molecular and cellular factors are dysregulated in allergic diseases and modified by AIT. Studies should now focus on finding the best target and ideal biomarkers to identify ideal candidates for AIT.
Collapse
|
22
|
Jarkvist J, Brockow K, Gülen T. Low Frequency of IgE-Mediated Food Hypersensitivity in Mastocytosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3093-3101. [PMID: 32534147 DOI: 10.1016/j.jaip.2020.05.044] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/07/2020] [Accepted: 05/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with mastocytosis have an increased risk for severe anaphylaxis, particularly to Hymenoptera venoms. These patients may also develop more often systemic hypersensitivity reactions to certain foods. However, this issue has not been systematically investigated. OBJECTIVE To determine prevalence and severity of food hypersensitivity (FH) reactions among patients with clonal mast cell disorders (CMDs). METHODS A retrospective study was conducted among 204 (age ≥18 years) consecutive patients who presented with confirmed CMD (170 with mastocytosis and 34 with monoclonal mast cell activation syndrome). All patients underwent thorough allergy workup where self-reported FH reactions were evaluated. RESULTS The prevalence of self-reported FH was 20.6%. The frequency of immunologically mediated reactions was uncommon, because only 3.4% were confirmed by relevant history and IgE sensitization. Among patients with FH, 5 had severe anaphylaxis corresponding to an overall prevalence of 2.5%. Most symptoms were restricted to skin (86%), followed by gastrointestinal tract symptoms (45%)-similar to symptoms that occur in patients with mastocytosis also without food intake. Nuts, spicy foods, seafood, and alcohol were the most common incriminated elicitors. There was no significant difference between the groups regarding age, sex, atopic status, or IgE levels. CONCLUSIONS Anaphylaxis from foods in mastocytosis does exist and is severe, although foods are less frequent elicitors than insect venoms. Furthermore, the frequency of overall FH reactions is comparable with that in the general population and most reactions are mild, nonallergic, and unconfirmed. Consequently, our results do not support the elimination of any diet in patients with CMD without a history of FH.
Collapse
Affiliation(s)
- Jesper Jarkvist
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Clinical Immunology and Allergy Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Mastocytosis Center Karolinska, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Clinical Immunology and Allergy Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Mastocytosis Center Karolinska, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
| |
Collapse
|
23
|
Alvaro-Lozano M, Akdis CA, Akdis M, Alviani C, Angier E, Arasi S, Arzt-Gradwohl L, Barber D, Bazire R, Cavkaytar O, Comberiati P, Dramburg S, Durham SR, Eifan AO, Forchert L, Halken S, Kirtland M, Kucuksezer UC, Layhadi JA, Matricardi PM, Muraro A, Ozdemir C, Pajno GB, Pfaar O, Potapova E, Riggioni C, Roberts G, Rodríguez Del Río P, Shamji MH, Sturm GJ, Vazquez-Ortiz M. EAACI Allergen Immunotherapy User's Guide. Pediatr Allergy Immunol 2020; 31 Suppl 25:1-101. [PMID: 32436290 PMCID: PMC7317851 DOI: 10.1111/pai.13189] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Allergen immunotherapy is a cornerstone in the treatment of allergic children. The clinical efficiency relies on a well-defined immunologic mechanism promoting regulatory T cells and downplaying the immune response induced by allergens. Clinical indications have been well documented for respiratory allergy in the presence of rhinitis and/or allergic asthma, to pollens and dust mites. Patients who have had an anaphylactic reaction to hymenoptera venom are also good candidates for allergen immunotherapy. Administration of allergen is currently mostly either by subcutaneous injections or by sublingual administration. Both methods have been extensively studied and have pros and cons. Specifically in children, the choice of the method of administration according to the patient's profile is important. Although allergen immunotherapy is widely used, there is a need for improvement. More particularly, biomarkers for prediction of the success of the treatments are needed. The strength and efficiency of the immune response may also be boosted by the use of better adjuvants. Finally, novel formulations might be more efficient and might improve the patient's adherence to the treatment. This user's guide reviews current knowledge and aims to provide clinical guidance to healthcare professionals taking care of children undergoing allergen immunotherapy.
Collapse
Affiliation(s)
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland.,Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland
| | - Mubeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Cherry Alviani
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK.,Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Elisabeth Angier
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Stefania Arasi
- Pediatric Allergology Unit, Department of Pediatric Medicine, Bambino Gesù Children's research Hospital (IRCCS), Rome, Italy
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Domingo Barber
- School of Medicine, Institute for Applied Molecular Medicine (IMMA), Universidad CEU San Pablo, Madrid, Spain.,RETIC ARADYAL RD16/0006/0015, Instituto de Salud Carlos III, Madrid, Spain
| | - Raphaëlle Bazire
- Allergy Department, Hospital Infantil Niño Jesús, ARADyAL RD16/0006/0026, Madrid, Spain
| | - Ozlem Cavkaytar
- Department of Paediatric Allergy and Immunology, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Pasquale Comberiati
- Department of Clinical Immunology and Allergology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, Pisa, Italy
| | - Stephanie Dramburg
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Stephen R Durham
- Immunomodulation and Tolerance Group; Allergy and Clinical Immunology, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK.,the MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Aarif O Eifan
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospitals NHS Foundation Trust, London, UK
| | - Leandra Forchert
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Susanne Halken
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Max Kirtland
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Inflammation, Repair and Development, National Heart and Lung Institute, Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK
| | - Umut C Kucuksezer
- Aziz Sancar Institute of Experimental Medicine, Department of Immunology, Istanbul University, Istanbul, Turkey
| | - Janice A Layhadi
- Immunomodulation and Tolerance Group; Allergy and Clinical Immunology, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK.,the MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK.,Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Inflammation, Repair and Development, National Heart and Lung Institute, Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK
| | - Paolo Maria Matricardi
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Antonella Muraro
- The Referral Centre for Food Allergy Diagnosis and Treatment Veneto Region, Department of Women and Child Health, University of Padua, Padua, Italy
| | - Cevdet Ozdemir
- Institute of Child Health, Department of Pediatric Basic Sciences, Istanbul University, Istanbul, Turkey.,Faculty of Medicine, Department of Pediatrics, Division of Pediatric Allergy and Immunology, Istanbul University, Istanbul, Turkey
| | | | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Ekaterina Potapova
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Carmen Riggioni
- Pediatric Allergy and Clinical Immunology Service, Institut de Reserca Sant Joan de Deú, Barcelona, Spain
| | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK.,NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Paediatric Allergy and Respiratory Medicine (MP803), Clinical & Experimental Sciences & Human Development in Health Academic Units University of Southampton Faculty of Medicine & University Hospital Southampton, Southampton, UK
| | | | - Mohamed H Shamji
- Immunomodulation and Tolerance Group; Allergy and Clinical Immunology, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK.,the MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Gunter J Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | | |
Collapse
|
24
|
Venom immunotherapy in patients with mastocytosis. ALLERGO JOURNAL 2020. [DOI: 10.1007/s15007-020-2514-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
25
|
Weinfeld D, Westin U, Hellkvist L, Mellqvist UH, Jacobsson I, Cardell LO. A preseason booster prolongs the increase of allergen specific IgG4 levels, after basic allergen intralymphatic immunotherapy, against grass pollen seasonal allergy. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2020; 16:31. [PMID: 32368217 PMCID: PMC7189556 DOI: 10.1186/s13223-020-00427-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/13/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Allergen specific IgG4 levels have been monitored as a surrogate marker for the tolerance inducing effect of subcutaneous immunotherapy (SCIT) in many studies. Its accuracy at group level has been well established, but IgG4 has not yet found its place in the daily care of immunotherapy patients. METHODS Intralymphatic immunotherapy (ILIT) is a novel route for allergy vaccination against pollen allergy, where an ultrasound-guided injection of 1000 SQ-U Alutard is given directly into a groin lymph node. The suggested standard dosing so far has been one injection with 4 weeks in-between. In total 3000 SQ-U with the treatment completed in 2 months. IgG4 was measured with Immulite technique and rhinoconjunctivitis symptoms were estimated with daily online questionnaires. Mann-Whitney U-test and Wilcoxon Signed Rank test were applied for comparisons between groups and within groups, respectively. RESULTS The present study demonstrates that a single, preseason ILIT booster of 1000 SQ-U Alutard 5-grasses®, re-increases the allergen specific timothy-IgG4 levels, in patients already treated with ILIT before the previous pollen season. It also shows the feasibility of the ILIT-route for allergy vaccination of rhinitis patients, with or without concomitant asthma, with low degree of side effects and reconfirms high and sustained patient satisfaction. CONCLUSIONS It is tempting to suggest that the allergen specific IgG4 levels can be used to build an intuitive algorithm for future clinical guidance of ILIT patients.Trial registration Is Intralymphatic Allergen Immunotherapy Effective and Safe?, ClinicalTrials.gov Identifier NCT04210193. Registered 24 December 2019-Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT04210193?term=NCT04210193&draw=2&rank=1.
Collapse
Affiliation(s)
- Dan Weinfeld
- Asthma and Allergy Clinic Outpatient Unit (Adults), Department of Internal Medicine, South Alvsborgs Central Hospital, 50182 Boras, Sweden
| | - Ulla Westin
- Division of Ear, Nose and Throat Diseases, Head and Neck Surgery, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Laila Hellkvist
- Department of ENT Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf-Henrik Mellqvist
- Section of Hematology, Department of Internal Medicine, South Alvsborgs Central Hospital, Boras, Sweden
| | - Ingvar Jacobsson
- Clinical Chemistry, Department of Medical Imaging and Laboratory Medicine, South Alvsborgs Central Hospital, Boras, Sweden
| | - Lars-Olaf Cardell
- Department of ENT Diseases, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
26
|
Krishna MT, Worm M, Bilo MB. Editorial: Anaphylaxis - A Distinct Immunological Syndrome, but How Much Do We Really Understand? Front Immunol 2019; 10:2943. [PMID: 31921193 PMCID: PMC6930909 DOI: 10.3389/fimmu.2019.02943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/02/2019] [Indexed: 01/17/2023] Open
Affiliation(s)
- Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venereology and Allergy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maria Beatrice Bilo
- Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Ancona, Italy.,Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| |
Collapse
|
27
|
Wilson JM, Platts-Mills TAE. α-Gal and other recent findings that have informed our understanding of anaphylaxis. Ann Allergy Asthma Immunol 2019; 124:135-142. [PMID: 31785367 DOI: 10.1016/j.anai.2019.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To summarize the current understanding of anaphylaxis, with an emphasis on major findings that have been reported within the last 10 years. DATA SOURCES Queries relating to anaphylaxis, immunoglobulin E (IgE), and mast cells were conducted with PubMed and Google Scholar, searching for primary articles and review papers. STUDY SELECTIONS We focused on articles written in English and which were reported in major allergy and immunology journals. RESULTS Anaphylaxis represents an extreme manifestation of a form of allergic immunity that appears to have evolved to protect against "toxic" threats that present at skin and mucosal barriers. The factors that have contributed to a rise in anaphylaxis are increasingly appreciated to relate to changes in hygiene and microbial ecology that have occurred with industrialization. Induction of allergen-specific IgG4 is often part of the allergic response and is associated with protection against anaphylaxis. The recognition of the α-Gal syndrome suggests that carbohydrates can be epitopes that are relevant to anaphylaxis and that IgE-mediated reactions do not always occur "immediately." CONCLUSION Our understanding of anaphylaxis has advanced significantly over the past 10 years. It is anticipated that ongoing research will build on this foundation to further advance our knowledge of anaphylaxis and also translate into clinically meaningful therapies.
Collapse
Affiliation(s)
- Jeffrey M Wilson
- Division of Allergy & Immunology, University of Virginia, Charlottesville, VA, 22908
| | | |
Collapse
|