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McMurray JC, Pacheco CS, Schornack BJ, Sun X, Brunader JA, Scott AE, Ariza JS, Kou CTJ, Costantino RC, Pittman LM, Adams KE, Waters AM, Pryor EM, Lyons JJ, Metcalfe DD, Maric I, Boggs NA. Standardized indolent systemic mastocytosis evaluations across a health care system: implications for screening accuracy. Blood 2024; 144:408-419. [PMID: 38635793 PMCID: PMC11418066 DOI: 10.1182/blood.2023023347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/11/2024] [Accepted: 04/07/2024] [Indexed: 04/20/2024] Open
Abstract
ABSTRACT Timely diagnosis of systemic mastocytosis (SM) remains challenging because of care heterogeneity. We implemented a standardized approach for SM screening and diagnosis using a novel health care system-wide international screening registry. A retrospective analysis assessed rates of SM, cutaneous mastocytosis (CM), and molecular diagnoses before and 2 years after care standardization. The accuracy of individual and combined SM screening tests, basal serum tryptase (BST) ≥11.5 and ≥20.0 ng/mL, REMA ≥2, monomorphic maculopapular CM (MPCM), and elevated BST based upon tryptase genotype, was analyzed. Tryptase genotyping and high-sensitivity KIT p.D816V testing increased substantially 2 years after care standardization. SM diagnoses doubled from 47 to 94, and KIT p.D816V molecular diagnoses increased from 24 to 79. Mean BST and KIT p.D816V variant allele frequency values were significantly lower in patients diagnosed after standardization. Hereditary-alpha tryptasemia prevalence was increased in SM before care standardization (4/30 [13.3%]) but reflected the general population prevalence 2 years later at (5/76 [6.6%]). Elevated BST based upon genotype and BST ≥11.5 ng/mL had the highest sensitivities at 84.2% and 88.3%, respectively. The presence of monomorphic MPCM, elevated BST based upon tryptase genotype, and the combination of REMA ≥2 with elevated BST based upon tryptase genotype had specificities >90%. BST >20.0 ng/mL had low sensitivity and specificity and was not required to establish any indolent SM (ISM) diagnosis. Care standardization increased SM diagnosis rates, particularly in patients with low BSTs. Stratifying BST based upon genotype had the best overall sensitivity and specificity of any ISM screening test and improved the REMA score specificity.
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Affiliation(s)
- Jeremy C. McMurray
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Curtis S. Pacheco
- Department of Internal Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Brandon J. Schornack
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Xiaoping Sun
- Hematology Section, Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
| | - Janet A. Brunader
- Immunization Healthcare Division, Defense Health Agency, Falls Church, VA
| | - Alexis E. Scott
- Immunization Healthcare Division, Defense Health Agency, Falls Church, VA
| | - Juan S. Ariza
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Chung-Ting J. Kou
- Hematology and Oncology Service, Brooke Army Medical Center, San Antonio, TX
| | - Ryan C. Costantino
- Enterprise Intelligence and Data Solutions Program Office, Program Executive Office, Defense Healthcare Management Systems, San Antonio, TX
| | - Luke M. Pittman
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Karla E. Adams
- Department of Medicine, Allergy and Immunology Service, Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, San Antonio, TX
| | - Aubri M. Waters
- Allergy and Immunology Service, Brooke Army Medical Center, San Antonio, TX
| | - Eric M. Pryor
- Hematopathology Service, Department of Pathology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jonathan J. Lyons
- Division of Allergy and Immunology, Department of Medicine, University of California San Diego, La Jolla, CA
- Veterans Affairs San Diego Health Care System, La Jolla, CA
| | - Dean D. Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Irina Maric
- Hematology Section, Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
| | - Nathan A. Boggs
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Medicine, Uniformed Services University, Bethesda, MD
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2
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Gonzalez-de-Olano D, Álvarez-Twose I. Predictors of Clonality and Underlying Mastocytosis in Mast Cell Activation Syndromes. Curr Allergy Asthma Rep 2024; 24:25-32. [PMID: 38270805 DOI: 10.1007/s11882-023-01122-w] [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: 12/22/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE OF REVIEW Mast cell (MC) activation can present with a wide range of symptoms. The mechanisms that cause such activation are varied. One of them is the presence of clonal MCs which is defined, within other possible changes, by the presence of a somatic, activating mutation in the KIT gene. The clinical course and prognosis of patients with this underlying disease may be different from other causes of MC activation (MCA). For this reason, it is important to early diagnose, or at least suspect, which patients with MCA are due to clonal MCs. RECENT FINDINGS The diagnosis of clonality must be made in a comprehensive manner. However, this paper reviews chronologically each of the stages from the patient's first visit to the doctor's office which can be indicative of clonality: clinical presentation of MCA, physical examination, analytical determinations of tryptase, and/or KIT mutational analysis and bone involvement, among others. The different clonality predictive scores proposed are also reviewed and compared. Although the gold standard for the diagnosis of certainty of MC clonality is the performance of a bone marrow (BM) biopsy, there are clinical symptoms, signs, and biological parameters suggestive of clonality, as well as predictive scores, which can guide (or rule out) an early diagnosis and avoid unnecessary BM biopsies.
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Affiliation(s)
- David Gonzalez-de-Olano
- Department of Allergy, Hospital Ramón y Cajal, IRYCIS, Ctra. Colmenar Viejo km 9,1, 28034, Madrid, Spain.
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain.
| | - Iván Álvarez-Twose
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain.
- Reference Center (CSUR) for Mastocytosis, Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast), Virgen del Valle Hospital, Complejo Hospitalario Universitario de Toledo (CHUT), Ctra. Cobisa s/n, 45071, Toledo, Spain.
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3
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Brockow K, Bent RK, Schneider S, Spies S, Kranen K, Hindelang B, Kurgyis Z, Broesby-Olsen S, Biedermann T, Grattan CE. Challenges in the Diagnosis of Cutaneous Mastocytosis. Diagnostics (Basel) 2024; 14:161. [PMID: 38248039 PMCID: PMC10814739 DOI: 10.3390/diagnostics14020161] [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: 11/20/2023] [Revised: 12/19/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Mastocytosis is characterized by an accumulation of clonal mast cells (MCs) in tissues such as the skin. Skin lesions in mastocytosis may be clinically subtle or heterogeneous, and giving the correct diagnosis can be difficult. METHODS This study compiles personal experiences together with relevant literature, discussing possible obstacles encountered in diagnosing skin involvement in mastocytosis and cutaneous mastocytosis (CM). RESULTS The nomenclature of the term "CM" is ambiguous. The WHO classification defines CM as mastocytosis solely present in the skin. However, the term is also used as a morphological description, e.g., in maculopapular cutaneous mastocytosis (MPCM). This is often seen in systemic, as well as cutaneous, mastocytosis. Typical CM manifestations (MPCM), including mastocytoma or diffuse cutaneous mastocytosis (DCM), all share a positive Darier's sign, and can thus be clinically recognized. Nevertheless, distinguishing monomorphic versus polymorphic MPCM may be challenging, even for experienced dermatologists. Less typical clinical presentations, such as MPCM with telangiectatic erythemas (formerly called telangiectasia macularis eruptiva perstans), confluent, nodular or xanthelasmoid variants may require a skin biopsy for histopathological confirmation. Because MC numbers in CM have a large overlap to those in healthy and inflamed skin, detailed histopathological criteria to diagnose mastocytosis in MPCM are needed and have been proposed. D816V KIT mutational analysis in tissue is helpful for confirming the diagnosis. Biomarkers allow the prediction of the course of CM into regression or evolution of the disease. Further diagnostic measures should screen for concomitant diseases, such as malignant melanoma, and for systemic involvement. CONCLUSIONS Whereas in typical cases the diagnosis of CM may be uncomplicated, less typical manifestations may require specific investigations for making the diagnosis and predicting its course.
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Affiliation(s)
- Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine and Health, Technical University of Munich, 80802 Munich, Germany (T.B.)
- Department of Dermatology and Allergy Centre, Odense University Hospital, 5000 Odense, Denmark
| | - Rebekka Karolin Bent
- Department of Dermatology and Allergy Biederstein, School of Medicine and Health, Technical University of Munich, 80802 Munich, Germany (T.B.)
| | - Simon Schneider
- Department of Dermatology and Allergy Biederstein, School of Medicine and Health, Technical University of Munich, 80802 Munich, Germany (T.B.)
| | - Sophie Spies
- Department of Dermatology and Allergy Biederstein, School of Medicine and Health, Technical University of Munich, 80802 Munich, Germany (T.B.)
| | - Katja Kranen
- Department of Dermatology and Allergy Biederstein, School of Medicine and Health, Technical University of Munich, 80802 Munich, Germany (T.B.)
| | - Benedikt Hindelang
- Department of Dermatology and Allergy Biederstein, School of Medicine and Health, Technical University of Munich, 80802 Munich, Germany (T.B.)
| | - Zsuzsanna Kurgyis
- Department of Dermatology and Allergy Biederstein, School of Medicine and Health, Technical University of Munich, 80802 Munich, Germany (T.B.)
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, 5000 Odense, Denmark
| | - Tilo Biedermann
- Department of Dermatology and Allergy Biederstein, School of Medicine and Health, Technical University of Munich, 80802 Munich, Germany (T.B.)
| | - Clive E. Grattan
- St John’s Institute of Dermatology, Guy’s Hospital, London SE1 9RT, UK
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Conner JE, Steinberg JA. Approach to Idiopathic Anaphylaxis in Adolescents. Med Clin North Am 2024; 108:123-155. [PMID: 37951646 DOI: 10.1016/j.mcna.2023.05.018] [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: 11/14/2023]
Abstract
Anaphylaxis is a potentially-life threatening condition. Adolescents are particularly vulnerable due to increased risk-taking behaviors, poor disease management, and minimized perception of risk. Although most anaphylaxis can be attributed to food, drug, or venom allergy via a detailed history and confirmatory studies, in nearly 1 in 5 cases, the cause may not be obvious. Clinical differentials including rare allergens, cofactors, mast-cell disorders, and mimic disorders can increase the likelihood of discovering of the cause of anaphylaxis.
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Affiliation(s)
- Jeanne E Conner
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, 9000 West Wisconsin Avenue. B440, Milwaukee, WI 53226, USA
| | - Joshua A Steinberg
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, 9000 West Wisconsin Avenue. B440, Milwaukee, WI 53226, USA; Section of Allergy, Department of Medicine, Clement J. Zablocki Veterans' Affairs Medical Center, 5000 West National Avenue, 1AN, Milwaukee, WI 53295, USA.
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5
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Patel K, Cuervo-Pardo L, Cresoe S, Cavero-Chavez V. An Unusual Transition from Cutaneous to Systemic Mastocytosis in a Pediatric Patient. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2023; 36:150-152. [PMID: 38134319 DOI: 10.1089/ped.2023.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Background: Cutaneous mastocytosis (CM) occurs when abnormal mast cells accumulate in the skin, whereas in systemic mastocytosis (SM), accumulation also occurs in other tissues. A transition from CM to SM is an atypical occurrence in pediatric patients. Case Presentation: An 8-month-old female presented with a 3-month history of whole body hyperpigmented macules with a normal serum tryptase level, consistent with a diagnosis of CM. At age 2.5 years, cutaneous lesions increased and repeat serum tryptase levels were elevated. Subsequent positive peripheral blood KIT D816V mutation testing furthered concern for a monoclonal mast cell disorder; therefore, prompting a bone marrow biopsy which was consistent with a diagnosis of SM. Conclusion: Our case depicts the possible transition from CM to SM in a pediatric patient. Despite an initial presentation consistent with a diagnosis of CM, watchful monitoring for signs and symptoms indicative of systemic involvement may be warranted in some pediatric patients.
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Affiliation(s)
- Keval Patel
- Department of Medicine, University of Florida Gainesville, Florida, USA
| | - Lyda Cuervo-Pardo
- Department of Pediatrics, University of Florida Gainesville, Florida, USA
| | - Samantha Cresoe
- Division of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, University of Florida Gainesville, Florida, USA
| | - Vanessa Cavero-Chavez
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, University of Florida Gainesville, Florida, USA
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6
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Abstract
To a large extent, the clinical picture of pediatric mastocytosis depends on the age at which it is diagnosed. A neonate with diffuse cutaneous mastocytosis may frequently present in a severe state requiring treatment. Toddlers may require long-term anti-mediator therapy, and this may lead to concerns such as organizing preschool education due to the need for epinephrine injections. A teenager may have to face cutaneous disease persistence or a diagnosis of systemic mastocytosis. Further studies are needed to refine the available treatment options and prognosis for different age groups.
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Affiliation(s)
- Joanna Renke
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, ul. Skłodowskiej-Curie 3A, 80-210 Gdańsk.
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, ul. Skłodowskiej-Curie 3A, 80-210 Gdańsk
| | - Magdalena Lange
- Department of Dermatology, Venerology and Allergology, Medical University of Gdańsk, ul. Skłodowskiej-Curie 3A, 80-210 Gdańsk
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7
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González de Olano D, Cain WV, Bernstein JA, Akin C. Disease Spectrum of Anaphylaxis Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1989-1996. [PMID: 37220812 DOI: 10.1016/j.jaip.2023.05.012] [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: 04/21/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 05/25/2023]
Abstract
Anaphylaxis results from massive mast cell activation. Mechanisms of mast cell activation may involve IgE- and non-IgE-mediated triggers, clonal mast cell disease, or be idiopathic and may be modified by several factors including but not restricted to hormonal status, stress, heritable factors, mast cell burden, and simultaneous exposure to more than 1 factor. Patients with recurrent anaphylaxis with a nonidentifiable trigger present a particular challenge in diagnosis and management. Presence of clonal disease may be suggested by hypotensive episodes with urticaria and angioedema, and high baseline tryptase levels. A number of scoring systems have been developed to identify patients who are at high risk to have underlying mastocytosis. This review provides an overview of anaphylaxis disorders and our current understanding of their mechanisms of action, evaluation, and management.
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Affiliation(s)
| | - Wesley V Cain
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Cem Akin
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich.
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8
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Wassmer H, Hartmann K. [Mastocytosis in children]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2023; 74:323-329. [PMID: 37140636 PMCID: PMC10169881 DOI: 10.1007/s00105-023-05168-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Mastocytosis in children is a rare disease characterized by an abnormal accumulation of tissue mast cells. Mastocytosis in children presents with typical skin alterations that are classified as maculopapular cutaneous mastocytosis, diffuse cutaneous mastocytosis, or mastocytoma. Some patients also develop mast cell mediator symptoms, such as pruritus, flush, and anaphylaxis. In many children, the disease is characterized by a benign and usually self-limiting course; systemic mastocytosis with extracutaneous involvement and a chronic or progressive course is found only rarely. Therapeutically, H1 antihistamines are primarily used on an as-needed basis or as continuous treatment, depending on the severity. Children, parents and caregivers should be thoroughly educated about the clinical picture and possible trigger factors of mast cell mediator release. For children with extensive skin alterations and severe symptoms, the prescription of an epinephrine auto-injector is recommended for emergency treatment.
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Affiliation(s)
- Hanna Wassmer
- Allergologische Poliklinik, Klinik für Dermatologie, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz
| | - Karin Hartmann
- Allergologische Poliklinik, Klinik für Dermatologie, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz.
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9
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Popadic S, Lalosevic J, Lekic B, Gajić-Veljic M, Bonaci-Nikolic B, Nikolic M. Mastocytosis in children: a single-center long-term follow-up study. Int J Dermatol 2023; 62:616-620. [PMID: 36807903 DOI: 10.1111/ijd.16612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/29/2022] [Accepted: 01/20/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Mastocytosis is a heterogeneous group of rare disorders characterized by the accumulation of clonal mast cells in organs such as the skin and bone marrow. The diagnosis of cutaneous mastocytosis (CM) is based on clinical findings, positive Darier's sign, and histopathology, if necessary. METHODS Medical records of 86 children with CM diagnosed during a 35-year long period were reviewed. Most patients (93%) developed CM during the first year of life (median age 3 months). Clinical features at presentation and during the follow-up period were analyzed. Baseline serum tryptase level was measured in 28 patients. RESULTS A total of 85% of patients had maculopapular cutaneous mastocytosis/urticaria pigmentosa (MPCM/UP), 9% had mastocytoma, and 6% had diffuse cutaneous mastocytosis (DCM). Boy to girl ratio was 1.1:1. Fifty-four of 86 patients (63%) were followed from 2 to 37 years (median 13 years). Complete resolution was registered in 14% of mastocytoma cases, 14% of MCPM/UP, and in 25% of DCM patients. After the age of 18, skin lesion persisted in 14% mastocytoma, 7% MCPM/UP, and 25% children with DCM. Atopic dermatitis was diagnosed in 9.6% of patients with MPCM/UP. Three of 28 patients had elevated serum tryptase. Prognosis in all patients was good, and there were no signs of progression to systemic mastocytosis (SM). CONCLUSION To the best of our knowledge, our results represent the longest single-center follow-up study of childhood-onset CM. We found no complications of massive mast cell degranulation or progression to SM.
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Affiliation(s)
- Svetlana Popadic
- Clinic of Dermatovenereology, University Clinical Center of Serbia, Belgrade, Serbia.,University of Belgrade School of Medicine, Belgrade, Serbia
| | - Jovan Lalosevic
- Clinic of Dermatovenereology, University Clinical Center of Serbia, Belgrade, Serbia.,University of Belgrade School of Medicine, Belgrade, Serbia
| | - Branislav Lekic
- Clinic of Dermatovenereology, University Clinical Center of Serbia, Belgrade, Serbia.,University of Belgrade School of Medicine, Belgrade, Serbia
| | - Mirjana Gajić-Veljic
- Clinic of Dermatovenereology, University Clinical Center of Serbia, Belgrade, Serbia.,University of Belgrade School of Medicine, Belgrade, Serbia
| | - Branka Bonaci-Nikolic
- University of Belgrade School of Medicine, Belgrade, Serbia.,Clinic of Allergy and Immunology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Milos Nikolic
- Clinic of Dermatovenereology, University Clinical Center of Serbia, Belgrade, Serbia.,University of Belgrade School of Medicine, Belgrade, Serbia
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10
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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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11
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Hermans MAW, Pasmans SGMA, Arends NJT, van den Bosch TPP, van Daele PLA, van Doorn MBA, Huisman EJ, Mooyaart AL, Damman J. Histopathological characteristics are instrumental to distinguish monomorphic from polymorphic maculopapular cutaneous mastocytosis in children. Clin Exp Dermatol 2022; 47:1694-1702. [PMID: 35596520 PMCID: PMC9544455 DOI: 10.1111/ced.15262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/29/2022]
Abstract
Background Mastocytosis is characterized by the accumulation of mast cells (MCs) in the skin or other organs, and can manifest at any age. A significant number of paediatric mastocytosis cases persist after puberty. In particular, monomorphic maculopapular cutaneous mastocytosis (mMPCM) is often persistent and associated with systemic mastocytosis. However, clinical differentiation of MPCM from polymorphic (p)MPCM can be difficult. Aim To identify histopathological features that can help to distinguish mMPCM from other subtypes of paediatric mastocytosis. Methods This was a retrospective study using skin biopsies from patients with any subtype of mastocytosis. The localization and density of the MC infiltrate, MC morphology and expression of aberrant markers were evaluated and correlated with clinical characteristics. Results In total, 33 biopsies were available for evaluation from 26 children [(10 with mMPCM, 5 with mastocytoma, 3 with diffuse cutaneous mastocytosis (DCM), 8 with pMPCM)] and 7 adults with MPCM. The MC number was increased in all patients, but was higher in children than adults (P < 0.01). The presence of mMPCM was associated with sparing of the papillary dermis from MC infiltration, whereas MC density in the papillary dermis was highest in pMPCM and DCM (P < 0.01). The positive predictive value of the presence of a reticular MC infiltrate for mMPCM was 72.7% (95% CI 51.4–87.0), and the negative predictive value was 83.3% (95% CI 42.2–97.2). There were no relevant differences in the expression of CD2, CD25 or CD30 between the different subtypes. Conclusion Skin histopathology might enhance the phenotypical differentiation of mMPCM from other subtypes in children, thereby increasing the accuracy of one's prognosis.
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Affiliation(s)
- Maud A W Hermans
- Department of internal medicine, section of allergy & clinical immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Suzanne G M A Pasmans
- Department of dermatology, Erasmus University MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nicolette J T Arends
- Department of pediatric medicine, section of allergy, Erasmus University MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Paul L A van Daele
- Department of internal medicine, section of allergy & clinical immunology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of pediatric hematology, Erasmus University MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martijn B A van Doorn
- Department of dermatology, Erasmus University MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elise J Huisman
- Department of pediatric hematology, Erasmus University MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Antien L Mooyaart
- Department of immunology, Erasmus University MC, Rotterdam, The Netherlands
| | - Jeffrey Damman
- Department of pathology, Erasmus University MC, Rotterdam, The Netherlands
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12
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Hoermann G, Sotlar K, Jawhar M, Kristensen T, Bachelot G, Nedoszytko B, Carter MC, Horny HP, Bonadonna P, Sperr WR, Hartmann K, Brockow K, Lyons JJ, Kluin-Nelemans HC, Hermine O, Akin C, Broesby-Olsen S, Triggiani M, Butterfield JH, Schwaab J, Reiter A, Gotlib J, Metcalfe DD, George TI, Orfao A, Valent P, Arock M. Standards of Genetic Testing in the Diagnosis and Prognostication of Systemic Mastocytosis in 2022: Recommendations of the EU-US Cooperative Group. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1953-1963. [PMID: 35283331 DOI: 10.1016/j.jaip.2022.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/23/2022] [Accepted: 03/02/2022] [Indexed: 10/18/2022]
Abstract
Mastocytosis comprises rare heterogeneous diseases characterized by an increased accumulation of abnormal mast cells in various organs/tissues. The pathogenesis of mastocytosis is strongly linked to the presence of KIT-activating mutations. In systemic mastocytosis (SM), the most frequent mutation encountered is KIT p.D816V, whose presence constitutes one of the minor diagnostic criteria. Different techniques are used to search and quantify the KIT p.D816V mutant; however, allele-specific quantitative PCR and droplet digital PCR are today the most sensitive. The analysis of the KIT p.D816V allele burden has undeniable interest for diagnostic, prognostic, and therapeutic monitoring. The analysis of non-mast cell hematological compartments in SM is similarly important because KIT p.D816V multilineage involvement is associated with a worse prognosis. In addition, in advanced forms of SM, mutations in genes other than KIT are frequently identified and affect negatively disease outcome and response to therapy. Thus, combined quantitative and sensitive analysis of KIT mutations and next-generation sequencing of other recurrently involved myeloid genes make it possible to better characterize the extent of the affected cellular compartments and additional molecular aberrations, providing a more detailed overview of the complex mutational landscape of SM, in relation with the clinical heterogeneity of the disease. In this article, we report the latest recommendations of the EU-US Cooperative Group presented in September 2020 in Vienna during an international working conference, on the techniques we consider standard to detect and quantify the KIT p.D816V mutant in SM and additional myeloid mutations found in SM subtypes.
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Affiliation(s)
- Gregor Hoermann
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; MLL Munich Leukemia Laboratory, 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
| | - Thomas Kristensen
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Guillaume Bachelot
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (UPMC), Paris, France
| | - Boguslaw Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Melody C Carter
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | | | - Wolfgang R Sperr
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Hanneke C Kluin-Nelemans
- Department of Haematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Olivier Hermine
- Imagine Institute, Université Paris Descartes, Sorbonne, Paris Cité, Centre national de référence des mastocytoses, Paris, France
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | | | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Jason Gotlib
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, Calif
| | - Dean D Metcalfe
- 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
| | - Alberto Orfao
- Servicio Central de Citometria, Centro de Investigacion del Cancer (IBMCC; CSIC/USAL), Instituto Biosanitario de Salamanca, Salamanca, Spain; Department of Medicine, University of Salamanca, Salamanca, Spain
| | - Peter Valent
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (UPMC), Paris, France.
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Giona F. Pediatric Mastocytosis: An Update. Mediterr J Hematol Infect Dis 2021; 13:e2021069. [PMID: 34804443 PMCID: PMC8577558 DOI: 10.4084/mjhid.2021.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/23/2021] [Indexed: 12/15/2022] Open
Abstract
Mastocytosis is a rare clonal disorder characterized by excessive proliferation and accumulation of mast cells (MC) in various organs and tissues. Cutaneous mastocytosis (CM), the most common form in children, is defined when MC infiltration is limited to the skin. In adults, the most common form is systemic mastocytosis (SM), characterized by MC proliferation and accumulation in organs, such as bone marrow, lymph nodes, liver, and spleen.1 Genetic aberrations, mainly the KIT D816V mutation, play a crucial role in the pathogenesis of mastocytosis, enhancing MC survival and subsequent accumulation in organs and tissues.2,3 CM includes three forms: solitary mastocytoma, maculopapular cutaneous mastocytosis (MPCM), and diffuse cutaneous mastocytosis (DCM). In most children with CM, skin lesions regress spontaneously around puberty; unfortunately, it is not always a self-limiting disease.4 Even if SM occurs occasionally, all children with mastocytosis require planned follow-up over time. Children with mastocytosis often suffer from MC mediator-related symptoms, the most common of which is itching, often triggered by rubbing the lesions. Management of pediatric mastocytosis is mainly based on strict avoidance of triggers. Treatment with H1 and H2 histamine receptor blockers on demand and the availability of epinephrine auto-injectors for the patients to use in case of severe anaphylactic reactions are recommended.
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Affiliation(s)
- Fiorina Giona
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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14
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Abstract
Historically, understanding of the human mast cell (MC) compartment has lagged behind the appreciation of other cell lineages. MCs exist in vascularised tissues but do not under normal circumstances circulate in blood, and there has been no pharmacological agent identified that totally and selectively inhibits human MC function. There are no substantiated accounts of an apparently healthy individual who is severely lacking in MCs. Thus, some of the approaches employed to understand the function of a specific immune cell are not available to the MC biologist. The disease categories that have provided the greatest insight into MC biology have been monoclonal and IgE-mediated MC disorders. This has led to the categorisation of MC diseases as intrinsic or extrinsic to the MC compartment and to the recognition of the role of mediators in MC activation disorders. Mastocytosis as a clonal disorder not only impacts the MC compartment through changes intrinsic to the MC, but also by the effects of episodes of significant release of MC mediators. The availability of newer therapeutic approaches developed to treat monoclonal MC disorders offer insights into how to more selectively approach management of MC centric diseases.
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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, USA
| | - Dean D Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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15
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Torrelo A, Vergara-de-la-Campa L, Azaña JM, Greenberger S, Lam JM, Lawley LP, Morren MA, Schaffer JV, García-Doval I, Matito A, Alvarez-Twose I. Interobserver variability in the classification of childhood maculopapular cutaneous mastocytosis. J Eur Acad Dermatol Venereol 2021; 35:2079-2084. [PMID: 33988879 DOI: 10.1111/jdv.17345] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Maculopapular cutaneous mastocytosis (MPCM) in children is classified in two variants: (i) monomorphic variant, presenting with the small macules or papules typically seen in adult patients; and (ii) polymorphic variant with larger lesions of variable size and shape, typically seen in children. The definition of polymorphic and monomorphic variants is mostly intuitive, and a validation of this classification has not been done. OBJECTIVE To study interobserver variability in the classification of MPCM in two groups of observers: mastocytosis experts and general dermatologists. MATERIALS AND METHODS Nineteen cases of childhood MPCM were shown blindly, for classification as monomorphic or polymorphic type, to 10 independent observers (eight dermatologists, one allergist and one haematologist) from Europe and North America with a vast experience in the management of paediatric mastocytosis. Also, the same cases were shown on a screen to 129 general dermatologists attending a meeting; their votes were registered by remote controls. The interobserver variability kappa coefficient (with 95% confidence interval) was calculated to measure the reliability of the correlation. RESULTS The value of kappa interobserver variability coefficient for the group of 10 experts (95% confidence interval) was 0.39 (0.18-0.63), which is considered as 'fair'. The value of kappa interobserver variability coefficient for the group of 129 general dermatologists (95% confidence interval) was 0.17 (0.06-0.39), which is considered as 'slight'. A complete agreement of all 10 experts was achieved in only four of 19 cases (21.1%) The most voted choice was concordant between the two groups in only 11 of the 19 cases. CONCLUSIONS We failed to validate the classification system of childhood MPCM in monomorphic and polymorphic types. While the rate of agreement was low for mastocytosis experts, it was nearly the agreement expected by chance in general dermatologists.
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Affiliation(s)
- A Torrelo
- Department of Dermatology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | - J M Azaña
- Department of Dermatology, Complejo Hospitalario Universtario de Albacete, Albacete, Spain
| | - S Greenberger
- Pediatric Dermatology Service, Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Israel
| | - J M Lam
- Department of Pediatrics and Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - L P Lawley
- Department of Dermatology, Emory University, Atlanta, GA, USA
| | - M-A Morren
- Pediatric Dermatology Unit, Department of Pediatrics and Dermatology &Venereology, University hospital Lausanne and University of Lausanne, Lausanne, Switzerland
| | - J V Schaffer
- Division of Pediatric Dermatology, Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | | | - A Matito
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) - Spanish Reference Center for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | - I Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) - Spanish Reference Center for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain
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16
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Brockow K, Plata-Nazar K, Lange M, Nedoszytko B, Niedoszytko M, Valent P. Mediator-Related Symptoms and Anaphylaxis in Children with Mastocytosis. Int J Mol Sci 2021; 22:2684. [PMID: 33799959 PMCID: PMC7962052 DOI: 10.3390/ijms22052684] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/23/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Mastocytosis is characterized by the pathological accumulation of mast cells (MC) in various organs. In these patients, MC may degranulate and thereby contribute to clinical symptoms, especially when a concomitant allergy is present. However, MC activation can not only be induced by high-affinity receptors for IgE, but also by anaphylatoxins, neuropeptides, IgG immune complexes, complement-components, drugs, products of bacteria or parasites, as well as physical factors such as heat, cold, vibration, stress, sun, or physical effort. Symptoms due to mediators released by activated MC may develop in adults suffering from systemic mastocytosis, but also evolve in children who usually have cutaneous mastocytosis (CM). Clinically, CM is otherwise characterized by typical brown, maculopapular skin lesions or mastocytoma associated with a positive Darier's sign. Pruritus and flushing are common and blistering may also be recorded, especially in diffuse CM (DCM). Pediatric patients with mastocytosis may also have gastrointestinal, respiratory, and neurologic complaints. Although anaphylaxis is not a typical finding, pediatric patients with massive skin involvement and high tryptase levels have a relatively high risk to develop anaphylaxis. This paper reviews MC mediator-related symptoms and anaphylaxis in children with mastocytosis, with special emphasis on risk factors, triggers, and management.
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Affiliation(s)
- Knut Brockow
- Department of Dermatology and Allergology Biederstein, School of Medicine, Technical University of Munich, Biedersteiner Strasse 29, D-80802 Munich, Germany
| | - Katarzyna Plata-Nazar
- Department of Paediatrics, Paediatric Gastroenterology, Allergology and Nutrition, Medical University of Gdańsk, 80803 Gdańsk, Poland
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80210 Gdansk, Poland; (M.L.); (B.N.)
| | - Bogusław Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80210 Gdansk, Poland; (M.L.); (B.N.)
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdańsk, 80210 Gdansk, Poland;
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria;
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, 1090 Vienna, Austria
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17
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Lange M, Hartmann K, Carter MC, Siebenhaar F, Alvarez-Twose I, Torrado I, Brockow K, Renke J, Irga-Jaworska N, Plata-Nazar K, Ługowska-Umer H, Czarny J, Belloni Fortina A, Caroppo F, Nowicki RJ, Nedoszytko B, Niedoszytko M, Valent P. Molecular Background, Clinical Features and Management of Pediatric Mastocytosis: Status 2021. Int J Mol Sci 2021; 22:2586. [PMID: 33806685 PMCID: PMC7961542 DOI: 10.3390/ijms22052586] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/24/2021] [Accepted: 02/27/2021] [Indexed: 12/12/2022] Open
Abstract
Pediatric mastocytosis is a heterogeneous disease characterized by accumulation of mast cells in the skin and less frequently in other organs. Somatic or germline mutations in the KIT proto-oncogene are detected in most patients. Cutaneous mastocytosis is the most common form of the disease in children. In the majority of cases, skin lesions regress spontaneously around puberty. However, in few patients, mastocytosis is not a self-limiting disease, but persists into adulthood and can show signs of systemic involvement, especially when skin lesions are small-sized and monomorphic. Children with mastocytosis often suffer from mast cell mediator-related symptoms. Severe hypersensitivity reactions can also occur, mostly in patients with extensive skin lesions and blistering. In a substantial number of these cases, the triggering factor of anaphylaxis remains unidentified. Management of pediatric mastocytosis is mainly based on strict avoidance of triggers, treatment with H1 and H2 histamine receptor blockers, and equipment of patients and their families with epinephrine auto-injectors for use in severe anaphylactic reactions. Advanced systemic mastocytosis occurs occasionally. All children with mastocytosis require follow-up examinations. A bone marrow investigation is performed when advanced systemic mastocytosis is suspected and has an impact on therapy or when cutaneous disease persists into adulthood.
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Affiliation(s)
- Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, 4031 Basel, Switzerland;
- Department of Biomedicine, University Hospital Basel and University of Basel, 4031 Basel, Switzerland
| | - Melody C. Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Frank Siebenhaar
- Dermatological Allergology, Department of Dermatology and Allergy, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany;
| | - Ivan Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla-La Mancha (CLMast)—Spanish Reference Center for Mastocytosis, Hospital Virgen del Valle—Complejo Hospitalario de Toledo, 45071 Toledo, Spain; (I.A.-T.); (I.T.)
| | - Inés Torrado
- Instituto de Estudios de Mastocitosis de Castilla-La Mancha (CLMast)—Spanish Reference Center for Mastocytosis, Hospital Virgen del Valle—Complejo Hospitalario de Toledo, 45071 Toledo, Spain; (I.A.-T.); (I.T.)
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, 80802 Munich, Germany;
| | - Joanna Renke
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (J.R.); (N.I.-J.)
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (J.R.); (N.I.-J.)
| | - Katarzyna Plata-Nazar
- Department of Pediatrics, Pediatric Gastroenterology, Allergology and Nutrition, Medical University of Gdańsk, 80-211 Gdańsk, Poland;
| | - Hanna Ługowska-Umer
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Justyna Czarny
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Anna Belloni Fortina
- Pediatric Dermatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy; (A.B.F.); (F.C.)
| | - Francesca Caroppo
- Pediatric Dermatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy; (A.B.F.); (F.C.)
| | - Roman J. Nowicki
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Bogusław Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland;
| | - Peter Valent
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, Medical University of Vienna, 1090 Vienna, Austria;
- Ludwig Boltzmann Institute for Hematology and Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
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18
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Abstract
Mastocytosis is a heterogeneous group of disorders characterized by the accumulation of clonal mast cells in organs such as the skin and bone marrow. In contrast to adults, most affected children have only cutaneous involvement. This article reviews the molecular pathogenesis, skin findings, mast cell mediator-related symptoms, evaluation, and management of childhood-onset mastocytosis, noting differences from adult-onset disease. Current classification of cutaneous mastocytosis and the natural histories of different variants in pediatric patients are highlighted, with a focus on clinical manifestations with prognostic implications. A practical algorithm is provided to guide clinical assessment, laboratory and other investigations, and longitudinal monitoring, including recognition of hepatosplenomegaly as a marker of systemic disease and utilization of allele-specific quantitative PCR (ASqPCR) to detect KIT mutations in the peripheral blood. Updated information and consensus-based recommendations regarding possible triggers of mast-cell degranulation (e.g., physical, medications) are discussed, with an emphasis on patient-specific factors and avoiding excessive parental concern. Lastly, an individualized, stepwise approach to treatment of symptoms, skin-directed therapy, and potential use of kinase inhibitors for severe systemic disease is outlined.
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19
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Demain JG, Carter MC. Urticaria Pigmentosa in a Child: Special Considerations for Vaccines, Dietary Concerns, and Other Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1761-1762. [PMID: 33593685 DOI: 10.1016/j.jaip.2021.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Jeffrey G Demain
- Allergy Asthma & Immunology Center of Alaska, University of Washington, Seattle, Wash
| | - 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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20
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Fuchs D, Kilbertus A, Kofler K, von Bubnoff N, Shoumariyeh K, Zanotti R, Bonadonna P, Scaffidi L, Doubek M, Elberink HO, Span LFR, Hermine O, Elena C, Benvenuti P, Yavuz AS, Brockow K, Zink A, Aberer E, Gorska A, Romantowski J, Hadzijusufovic E, Fortina AB, Caroppo F, Perkins C, Illerhaus A, Panse J, Vucinic V, Jawhar M, Sabato V, Triggiani M, Parente R, Bergström A, Breynaert C, Gotlib J, Reiter A, Hartmann K, Niedoszytko M, Arock M, Kluin-Nelemans HC, Sperr WR, Greul R, Valent P. Scoring the Risk of Having Systemic Mastocytosis in Adult Patients with Mastocytosis in the Skin. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1705-1712.e4. [PMID: 33346151 DOI: 10.1016/j.jaip.2020.12.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mastocytosis in adults often presents with skin lesions. A bone marrow biopsy is necessary to confirm or exclude the presence of systemic mastocytosis (SM) in these cases. When a bone marrow biopsy is not performed, the provisional diagnosis is mastocytosis in the skin (MIS). No generally accepted scoring system has been established to estimate the risk of SM in these patients. OBJECTIVE To develop a risk score to predict SM in adults with MIS. METHODS We examined 1145 patients with MIS from the European Competence Network on Mastocytosis Registry who underwent a bone marrow biopsy. A total of 944 patients had SM and 201 patients had cutaneous mastocytosis; 63.7% were female, and 36.3% were male. Median age was 44 ± 13.3 years. The median serum tryptase level amounted to 29.3 ± 81.9 ng/mL. We established a multivariate regression model using the whole population of patients as a training and validation set (bootstrapping). A risk score was developed and validated with receiver-operating curves. RESULTS In the multivariate model, the tryptase level (P < .001), constitutional/cardiovascular symptoms (P = .014), and bone symptoms/osteoporosis (P < .001) were independent predictors of SM (P < .001; sensitivity, 90.7%; specificity, 69.1%). A 6-point risk score was established (risk, 10.7%-98.0%) and validated. CONCLUSIONS Using a large data set of the European Competence Network on Mastocytosis Registry, we created a risk score to predict the presence of SM in patients with MIS. Although the score will need further validation in independent cohorts, our score seems to discriminate safely between patients with SM and with pure cutaneous mastocytosis.
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Affiliation(s)
- David Fuchs
- Department for Hematology and Internal Oncology, Kepler University Hospital, Linz, Austria; Johannes Kepler University, Linz, Austria.
| | - Alex Kilbertus
- Department of Dermatology and Venerology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Karin Kofler
- Department for Hematology and Internal Oncology, Kepler University Hospital, Linz, Austria
| | - Nikolas von Bubnoff
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Hematology and Oncology, Medical Center, University of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Khalid Shoumariyeh
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK) Partner site Freiburg, Freiburg, Germany
| | - Roberta Zanotti
- Section of Hematology, Department of Medicine, Verona University Hospital, Verona, Italy
| | | | - Luigi Scaffidi
- Section of Hematology, Department of Medicine, Verona University Hospital, Verona, Italy
| | | | - Hanneke Oude Elberink
- Department of Internal Medicine, Section of Allergy, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lambert F R Span
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Olivier Hermine
- Imagine Institute Université Paris Descartes, Sorbonne, Paris Cité, Centre national de référence des mastocytoses, Paris, France
| | - Chiara Elena
- Department of Hematology Oncology, IRCCS Policlinico San Matteo Foundation Pavia, Pavia, Italy
| | - Pietro Benvenuti
- Department of Hematology Oncology, School of Hematology, University of Pavia and IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Akif Selim Yavuz
- Division of Hematology, Department of Internal Medicine, University of Istanbul, Istanbul, Turkey
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Alexander Zink
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Elisabeth Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Aleksandra Gorska
- Department of Allergology, Medical University of Gdańsk, Gdańsk, Poland
| | - Jan Romantowski
- Department of Allergology, Medical University of Gdańsk, Gdańsk, Poland
| | - 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; Department/Hospital for Companion Animals and Horses, University Clinic for Small Animals, Internal Medicine Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Anna Belloni Fortina
- Pediatric Dermatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Francesca Caroppo
- Pediatric Dermatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Cecelia Perkins
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, Calif
| | - Anja Illerhaus
- Department of Dermatology, University of Cologne, Cologne, Germany
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Mohamad Jawhar
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology-Allergology-Rheumatology, University of Antwerp and Antwerp University Hospital, Antwerpen, Belgium
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Salerno, Salerno, Italy
| | - Roberta Parente
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Salerno, Salerno, Italy
| | - Anna Bergström
- Department of Dermatology and Venereology, Akademiska University Hospital, Uppsala, and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Christine Breynaert
- Department of General Internal Medicine - Allergy and Clinical Immunology (MASTEL), University Hospitals Leuven and KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, Leuven, Belgium
| | - Jason Gotlib
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, Calif
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Karin Hartmann
- Department of Dermatology, University of Cologne, Cologne, Germany; Division of Allergy, Department of Dermatology, University of Basel, Basel, Switzerland
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdańsk, Gdańsk, Poland
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Paris Sorbonne University, Paris, France
| | - Hanneke C Kluin-Nelemans
- Department of Hematology, University Medical Center Groningen, University 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
| | - Rosemarie Greul
- Department for Hematology and Internal Oncology, Kepler University Hospital, Linz, 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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21
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Li Y, Li X, Liu X, Kang L, Liu X. Genotypic and phenotypic characteristics of Chinese neonates with cutaneous mastocytosis: a case report and literature review. J Int Med Res 2020; 48:300060520952621. [PMID: 32883129 PMCID: PMC7479863 DOI: 10.1177/0300060520952621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/04/2020] [Indexed: 11/17/2022] Open
Abstract
Mastocytosis is an accumulation of clonal mast cells within tissues and it is most commonly caused by an activating mutation in the KIT gene. In this study, we report a neonatal case who presented with diffuse cutaneous mastocytosis (CM) at birth. In China, nine other cases of neonatal-onset CM have been reported in the literature since 2006. In those cases, diffuse CM and urticaria pigmentosa were the main symptoms, and mutations in exon 17 at codon 816 in KIT were identified.
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Affiliation(s)
- Yanfang Li
- Department of Neonatology, Qilu Children’s Hospital, Cheeloo
College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Pediatrics, Qilu Hospital, Cheeloo College of
Medicine, Shandong University, Jinan, Shandong, China
| | - Xiaoying Li
- Department of Neonatology, Qilu Children’s Hospital, Shandong
University, Jinan, Shandong, China
| | - Xianghong Liu
- Department of Neonatology, Qilu Children’s Hospital, Shandong
University, Jinan, Shandong, China
| | - Lili Kang
- Department of Neonatology, Qilu Children’s Hospital, Shandong
University, Jinan, Shandong, China
| | - Xinjie Liu
- Department of Pediatrics, Qilu Hospital, Cheeloo College of
Medicine, Shandong University, Jinan, Shandong, China
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22
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Abstract
PURPOSE OF REVIEW The current article highlights recent developments in the field of pediatric cutaneous mastocytosis. Mastocytosis is a spectrum of conditions that range from fleetingly benign to aggressively malignant. Through recognizing the natural progression of disease, the role of biomarkers and mutational analysis, treatment and risk of triggers, physicians can confidently stage, counsel and manage patients with pediatric cutaneous mastocytosis. RECENT FINDINGS Many lesions of cutaneous mastocytosis are chronic with some resolving around the mid-teenage years. KIT mutations are found in the majority of pediatric cutaneous mastocytosis but are not correlated with prognosis. Serum tryptase levels may be elevated in pediatric cutaneous mastocytosis patients without systemic mastocytosis. Pimecrolimus, omalizumab and tyrosine kinase inhibitors are effective treatment options. The low risk of NSAIDs and vaccinations has been characterized and epinephrine autoinjectors are rarely utilized in the pediatric cutaneous mastocytosis patient. SUMMARY Pediatric cutaneous mastocytosis is a heterogeneous disease with good outcome overall. Organomegaly, elevated tryptase levels and the presence of KIT mutation in peripheral blood may aid in the decision to pursue bone marrow biopsy. The armamentarium of treatments has expanded and better understanding of the significance of triggers and vaccination safety allows the clinician to thoughtfully counsel and allay anxiety around pediatric cutaneous mastocytosis.
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23
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Seth N, Tuano KT, Buheis M, Chan A, Chinen J. Serum tryptase levels in pediatric mastocytosis and association with systemic symptoms. Ann Allergy Asthma Immunol 2020; 125:219-221. [PMID: 32371241 DOI: 10.1016/j.anai.2020.04.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 03/25/2020] [Accepted: 04/22/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Neha Seth
- Section of Allergy and Immunology, Department of Pediatrics Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston and The Woodlands, Texas
| | - Karen T Tuano
- Section of Allergy and Immunology, Department of Pediatrics Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston and The Woodlands, Texas
| | - Maria Buheis
- Section of Allergy and Immunology, Department of Pediatrics Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston and The Woodlands, Texas
| | - Audrey Chan
- Texas Children's Hospital, Houston and The Woodlands, Texas; Section of Dermatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Javier Chinen
- Section of Allergy and Immunology, Department of Pediatrics Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston and The Woodlands, Texas.
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24
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Weiler CR, Austen KF, Akin C, Barkoff MS, Bernstein JA, Bonadonna P, Butterfield JH, Carter M, Fox CC, Maitland A, Pongdee T, Mustafa SS, Ravi A, Tobin MC, Vliagoftis H, Schwartz LB. AAAAI Mast Cell Disorders Committee Work Group Report: Mast cell activation syndrome (MCAS) diagnosis and management. J Allergy Clin Immunol 2019; 144:883-896. [DOI: 10.1016/j.jaci.2019.08.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/20/2019] [Accepted: 08/27/2019] [Indexed: 12/18/2022]
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25
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Dölle-Bierke S, Siebenhaar F, Burmeister T, Worm M. Detection of KIT D816V mutation in patients with severe anaphylaxis and normal basal tryptase-first data from the Anaphylaxis Registry (NORA). J Allergy Clin Immunol 2019; 144:1448-1450.e1. [PMID: 31415784 DOI: 10.1016/j.jaci.2019.07.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 07/21/2019] [Accepted: 07/24/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Sabine Dölle-Bierke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology and Allergology, Berlin, Germany
| | - Frank Siebenhaar
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology and Allergology, Berlin, Germany
| | - Thomas Burmeister
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Hematology, Oncology and Tumor Immunology, Berlin, Germany; Labor Berlin, Hematology - Tumor Genetics, Berlin, Germany
| | - Margitta Worm
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology and Allergology, Berlin, Germany.
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26
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Theoharides TC, Tsilioni I, Ren H. Recent advances in our understanding of mast cell activation - or should it be mast cell mediator disorders? Expert Rev Clin Immunol 2019; 15:639-656. [PMID: 30884251 PMCID: PMC7003574 DOI: 10.1080/1744666x.2019.1596800] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 03/14/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION An increasing number of patients present with multiple symptoms affecting many organs including the brain due to multiple mediators released by mast cells. These unique tissue immune cells are critical for allergic reactions triggered by immunoglobulin E (IgE), but are also stimulated (not activated) by immune, drug, environmental, food, infectious, and stress triggers, leading to secretion of multiple mediators often without histamine and tryptase. The presentation, diagnosis, and management of the spectrum of mast cell disorders are very confusing. As a result, neuropsychiatric symptoms have been left out, and diagnostic criteria made stricter excluding most patients. Areas covered: A literature search was performed on papers published between January 1990 and November 2018 using MEDLINE. Terms used were activation, antihistamines, atopy, autism, brain fog, heparin, KIT mutation, IgE, inflammation, IL-6, IL-31, IL-37, luteolin, mast cells, mastocytosis, mediators, mycotoxins, release, secretion, tetramethoxyluteolin, and tryptase. Expert opinion: Conditions associated with elevated serum or urine levels of any mast cell mediator, in the absence of comorbidities that could explain elevated levels, should be considered 'Mast Cell Mediator Disorders (MCMD).' Emphasis should be placed on the identification of unique mast cell mediators, and development of drugs or supplements that inhibit their release.
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Affiliation(s)
- Theoharis C. Theoharides
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Immunology, Tufts University School of Medicine, Boston, MA, USA
- Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
- Department of Internal Medicine, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, USA
- Department of Psychiatry, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, USA
| | - Irene Tsilioni
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Immunology, Tufts University School of Medicine, Boston, MA, USA
| | - Huali Ren
- Department of Otolaryngology, Beijing Electric Power Hospital, Beijing, China
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