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Madsen AT, Kristiansen HP, Winther-Larsen A. Short-term biological variation of serum tryptase. Clin Chem Lab Med 2024; 62:713-719. [PMID: 37882699 DOI: 10.1515/cclm-2023-0606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVES Serum tryptase is a biomarker of mast cell activation. Among others, it is used in the diagnosis of anaphylaxis where a significant increase during the acute phase supports the diagnosis. When evaluating changes in biomarker levels, it is of utmost importance to consider the biological variation of the marker. Therefore, the aim of this study was to evaluate the short-term biological variation of serum tryptase. METHODS Blood samples were drawn at 9 AM three days in a row from apparently healthy subjects. On day two, additional blood samples were drawn every third hour for 12 h. The tryptase concentration was measured in serum using a fluoroenzyme immunoassay (ImmunoCAP™, Thermo Fisher Scientific). Linear mixed-effects models were used to calculate components of biological variation. RESULTS In 32 subjects, the overall mean concentration of tryptase was 4.0 ng/mL (range, 1.3-8.0 ng/mL). The within-subject variation was 3.7 % (95 % confidence interval (CI) 3.0-4.4 %), the between-subject variation was 31.5 % (95 % CI 23.1-39.8 %), and the analytical variation was 3.4 % (95 % CI 2.9-4.1 %). The reference change value was 13.3 % for an increase in tryptase at a 95 % level of significance. No significant day-to-day variation was observed (p=0.77), while a minute decrease in the serum concentration was observed during the day (p<0.0001). CONCLUSIONS Serum tryptase is a tightly regulated biomarker with very low within-subject variation, no significant day-to-day variation, and only minor semidiurnal variation. In contrast, a considerable between-subject variation exists. This establishes serum tryptase as a well-suited biomarker for monitoring.
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Affiliation(s)
- Anne Tranberg Madsen
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Anne Winther-Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
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Akin C, Siebenhaar F, Wechsler JB, Youngblood BA, Maurer M. Detecting Changes in Mast Cell Numbers Versus Activation in Human Disease: A Roadblock for Current Biomarkers? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00271-X. [PMID: 38467332 DOI: 10.1016/j.jaip.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/09/2024] [Accepted: 03/01/2024] [Indexed: 03/13/2024]
Abstract
The pathophysiology of mast cell (MC)-driven disorders is diverse, ranging from localized reactions to systemic disorders caused by abnormal accumulation and activation in multiorgan systems. Prompt and accurate diagnosis is critically important, both for informing treatment and objective assessment of treatment outcomes. As new therapeutics are being developed to deplete MCs or silence them (eg, by engaging inhibitory receptors that block activation), new biomarkers are needed that can distinguish between MC activation versus burden. Serum tryptase is the gold standard for assessing both MC burden and activation; however, commercial tryptase assays have limitations related to timing of release, lack of discernment between inactive (α) and active (β) forms of tryptase, and interpatient variability of baseline levels. Alternative approaches to measuring MC activation include urinary MC mediators, flow cytometry-based assays or gene expression profiling. Additional markers of MC activation are needed for use in clinical diagnostics, to help selection of treatment of MC diseases, and for assessing outcomes of therapy. We review the spectrum of disorders with known or suspected MC contribution, describe the utility and limitations of current MC markers and assays, and discuss the need for new markers that can differentiate between MC activation and burden.
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Affiliation(s)
- Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | - Frank Siebenhaar
- Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | | | - Marcus Maurer
- Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany.
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3
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Valent P, Akin C, Arock M. Reversible Elevation of Tryptase Over the Individual's Baseline: Why is It the Best Biomarker for Severe Systemic Mast Cell Activation and MCAS? Curr Allergy Asthma Rep 2024; 24:133-141. [PMID: 38308674 PMCID: PMC10960756 DOI: 10.1007/s11882-024-01124-2] [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: 01/03/2024] [Indexed: 02/05/2024]
Abstract
PURPOSE OF REVIEW Mast cell (MC) activation syndromes (MCAS) are conditions defined by recurrent episodes of severe systemic anaphylaxis or similar systemic events triggered by MC-derived mediators that can be measured in biological fluids. Since some symptoms of MC activation may occur due to other, non-MC etiologies and lead to confusion over diagnosis, it is of crucial importance to document the involvement of MC and their products in the patients´ symptomatology. RECENT FINDINGS The most specific and generally accepted marker of severe systemic MC activation is an event-related, transient increase in the serum tryptase level over the individual baseline of the affected individual. However, baseline concentrations of serum tryptase vary among donors, depending on the genetic background, age, kidney function, and underlying disease. As a result, it is of critical importance to provide a flexible equation that defines the diagnostic increase in tryptase qualifying as MCAS criterion in all patients, all situations, and all ranges of baseline serum tryptase. In 2012, the consensus group proposed the 120% + 2 ng/ml formula, which covers the great majority of groups, including cases with low, normal, or elevated basal serum tryptase level. This formula has been validated in subsequent studies and has proven to be a robust and consistent diagnostic criterion of MCAS. The present article is discussing the impact of this formula and possible limitations as well as alternative markers and mediators that may be indicative of MCAS.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria.
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria.
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, MI, USA
| | - Michel Arock
- Platform of Molecular Analysis for Mastocytosis and MCAD (CEREMAST), Department of Biological Hematology, Pitié-Salpêtrière Hospital, AP-HP, Paris Sorbonne University, Paris, France
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4
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Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Abrams EM, Bernstein JA, Chu DK, Horner CC, Rank MA, Stukus DR, Burrows AG, Cruickshank H, Golden DBK, Wang J, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Waserman S, Abrams EM, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt M, Horner CC, Ledford DK, Lieberman J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol 2024; 132:124-176. [PMID: 38108678 DOI: 10.1016/j.anai.2023.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 12/19/2023]
Abstract
This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.
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Affiliation(s)
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Alyssa G Burrows
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Heather Cruickshank
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | | | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
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Costa A, Scalzulli E, Carmosino I, Capriata M, Ielo C, Masucci C, Passucci M, Martelli M, Breccia M. Systemic mastocytosis: 2023 update on diagnosis and management in adults. Expert Opin Emerg Drugs 2023; 28:153-165. [PMID: 37256917 DOI: 10.1080/14728214.2023.2221028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Systemic mastocytosis (SM) is a complex and heterogeneous disease, characterized by the clonal accumulation of mast cells in one or more organs. In 2022 both the World Health Organization (WHO) and the International Consensus Classification (ICC) modified the diagnostic and classification criteria of SM. Moreover, the identification of new clinical and molecular variables has improved prognostic tools and led to increasingly individualized therapeutic strategies. AREAS COVERED The aim of this review is to present the updates introduced by the International Consensus Classification in diagnostic criteria of SM. In addition, we report the latest data available from the most important clinical trials in patients both with non-advanced and advanced disease, including elenestinib and bezuclastinib. EXPERT OPINION Diagnosis and classification of SM has evolved over years. The most recent WHO and ICC classification improved SM diagnostic work-up, providing clinicians with a clear and simplified diagnostic scheme. New approved targeted therapies such as midostaurin and avapritinib modified the treatment paradigm in patients in advanced stage, and next-generation inhibitors actually investigated in clinical trials are expected in the next future.
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Affiliation(s)
- Alessandro Costa
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Emilia Scalzulli
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Ida Carmosino
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Marcello Capriata
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Claudia Ielo
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Chiara Masucci
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Mauro Passucci
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
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6
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Valent P, Hoermann G, Bonadonna P, Hartmann K, Sperr WR, Broesby-Olsen S, Brockow K, Niedoszytko M, Hermine O, Chantran Y, Butterfield JH, Greiner G, Carter MC, Sabato V, Radia DH, Siebenhaar F, Triggiani M, Gülen T, Alvarez-Twose I, Staudinger T, Traby L, Sotlar K, Reiter A, Horny HP, Orfao A, Galli SJ, Schwartz LB, Lyons JJ, Gotlib J, Metcalfe DD, Arock M, Akin C. The Normal Range of Baseline Tryptase Should Be 1 to 15 ng/mL and Covers Healthy Individuals With HαT. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3010-3020. [PMID: 37572755 DOI: 10.1016/j.jaip.2023.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/14/2023]
Abstract
Physiological levels of basal serum tryptase vary among healthy individuals, depending on the numbers of mast cells, basal secretion rate, copy numbers of the TPSAB1 gene encoding alpha tryptase, and renal function. Recently, there has been a growing debate about the normal range of tryptase because individuals with the hereditary alpha tryptasemia (HαT) trait may or may not be symptomatic, and if symptomatic, uncertainty exists as to whether this trait directly causes clinical phenotypes or aggravates certain conditions. In fact, most HαT-positive cases are regarded as asymptomatic concerning mast cell activation. To address this point, experts of the European Competence Network on Mastocytosis (ECNM) and the American Initiative in Mast Cell Diseases met at the 2022 Annual ECNM meeting and discussed the physiological tryptase range. Based on this discussion, our faculty concluded that the normal serum tryptase range should be defined in asymptomatic controls, inclusive of individuals with HαT, and based on 2 SDs covering the 95% confidence interval. By applying this definition in a literature screen, the normal basal tryptase in asymptomatic controls (HαT-positive persons included) ranges between 1 and 15 ng/mL. This definition should avoid overinterpretation, unnecessary referrals, and unnecessary anxiety or anticipatory fear of illness in healthy individuals.
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Affiliation(s)
- Peter Valent
- Division of Haematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria.
| | - Gregor Hoermann
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; MLL Munich Leukemia Laboratory, Munich, Germany
| | | | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Wolfgang R Sperr
- Division of Haematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Olivier Hermine
- Service d'hématologie, Imagine Institute Université de Paris, Centre national de référence des mastocytoses, Hôpital Necker, Assistance publique hôpitaux de Paris, Paris, France
| | - Yannick Chantran
- Department of Biological Immunology, Saint-Antoine Hospital, Paris Sorbonne University, Paris, France
| | | | - Georg Greiner
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Ihr Labor, Medical Diagnostic Laboratories, Vienna, Austria
| | - Melody C Carter
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Md
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology-Allergology-Rheumatology, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Deepti H Radia
- Guy's & St. Thomas' National Health Service (NHS) Foundation Trust, Guy's Hospital, London, UK
| | - Frank Siebenhaar
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Immunology and Allergology (IA), Berlin, Germany
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm, Sweden
| | - Ivan Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) and CIBERONC, Hospital Virgen del Valle, Toledo, Spain
| | - Thomas Staudinger
- Department of Internal Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna, Austria
| | - Ludwig Traby
- Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Karl Sotlar
- Institute of Pathology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Alberto Orfao
- Servicio Central de Citometria, Centro de Investigacion del Cancer (IBMCC CSIC/USAL) Instituto Biosanitario de Salamanca (IBSAL), CIBERONC and Department of Medicine, University of Salamanca, Salamanca, Spain
| | - Stephen J Galli
- Department of Pathology, Department of Microbiology and Immunology, Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, Calif
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, Va
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Md
| | - Jason Gotlib
- Stanford University School of Medicine/Stanford Cancer Institute, Stanford, Calif
| | - Dean D Metcalfe
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Md
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Paris Sorbonne University, Paris, France
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
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7
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Babu B, Subbiah Nagaraj S, Gopalam V, Vaiphei K. Small bowel obstruction: a rare presentation of systemic mastocytosis. BMJ Case Rep 2023; 16:e255882. [PMID: 37751976 PMCID: PMC10533659 DOI: 10.1136/bcr-2023-255882] [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: 09/30/2023] Open
Abstract
Mastocytosis (MC) is a heterogeneous group of disorders characterised by abnormal growth, neoplastic proliferation and accumulation of mast cells. Approximately, 80% of patients with MC have evidence of skin involvement, while the rest may involve the gastrointestinal tract, liver, spleen or bone. Isolated gastrointestinal presentation of aggressive MC without bone marrow involvement and cutaneous symptoms is rare. Isolated MC with tumour cells infiltrating the ileum presenting with mechanical obstruction has not been reported in the literature to date. Here, we present a case of a patient in his late 50s who presented with malignant MC of the small bowel with obstruction in the emergency surgical outpatient department. The patient underwent surgical resection of the affected bowel. Histopathological examination along with immunohistochemistry revealed malignant MC. The further evaluation consisted of bone marrow biopsies, PET CT and other mutation analyses. However, the patient succumbed to death during the further course of treatment. The differential of MC must be kept in mind when there is the presence of abnormal hematopoietic cells in gastrointestinal biopsies even in the absence of cutaneous manifestations and bone marrow abnormalities.
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Affiliation(s)
- Basil Babu
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Satish Subbiah Nagaraj
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Gopalam
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kim Vaiphei
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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8
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Thomas EG, Thomas DJ. Mimics of Allergy and Angioedema: Scombroid, Mast Cell Activation Disorders, and Hereditary Alpha Tryptasemia. Immunol Allergy Clin North Am 2023; 43:553-568. [PMID: 37394259 DOI: 10.1016/j.iac.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Scombroid poisoning, systemic mastocytosis, and hereditary alpha tryptasemia all present with episodes that resemble allergic reactions. Knowledge regarding systemic mastocytosis and hereditary alpha tryptasemia is quickly evolving. Epidemiology, pathophysiology, and strategies to identify and diagnose are discussed. Evidence-based management in the emergency setting and beyond is also explored and summarized. Key differences are described between these events and allergic reactions.
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Affiliation(s)
- Elizabeth G Thomas
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, Jefferson, New Orleans, LA 70121, USA.
| | - Daniel James Thomas
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, Jefferson, New Orleans, LA 70121, USA
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9
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Sadovnik I, Ivanov D, Smiljkovic D, Stefanzl G, Degenfeld-Schonburg L, Herndlhofer S, Eisenwort G, Hauswirth AW, Sliwa T, Keil F, Sperr WR, Valent P. Identification of CD203c as a New Basophil-Specific Flow-Marker in Ph + Chronic Myeloid Leukemia. Cells 2022; 12:cells12010003. [PMID: 36611797 PMCID: PMC9818308 DOI: 10.3390/cells12010003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/25/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Basophilia is a crucial prognostic variable in Ph-chromosome-positive chronic myeloid leukemia (CML). The ectoenzyme CD203c is an activation-linked surface antigen that is expressed specifically on basophil-committed progenitor cells and mature basophils. We examined the expression of CD203c on progenitors and/or basophils in 21 healthy donors and 44 patients with CML. As expected, the numbers of CD203c+ blood leukocytes were significantly higher in CML patients compared to controls (percentage of CD203c+ cells among viable cells in CML at diagnosis: 4.19 ± 3.68% vs. controls: 0.53 ± 0.23%, p < 0.05). Moreover, CML basophils expressed higher levels of CD203c compared to normal basophils (median staining-index in CML at diagnosis: 29.41 ± 19.14 versus controls: 20.44 ± 13.45). We also found that the numbers and percentage of circulating CD203c+ cells at diagnosis correlate with the disease-related risk-profile. Incubation of CML basophils with an anti-IgE-antibody resulted in further upregulation of CD203c. After successful treatment with imatinib and/or other BCR::ABL1 inhibitors leading to major or complete molecular responses, the numbers of CD203c+ basophils decreased substantially in our CML patients compared to pre-treatment values. Together, CD203c is overexpressed on CML basophils, is further upregulated by IgE receptor cross-linking, and may serve as a biomarker to quantify basophilia in patients with CML at diagnosis and during therapy.
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Affiliation(s)
- Irina Sadovnik
- 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
| | - Daniel Ivanov
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
| | - Dubravka Smiljkovic
- 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
| | - Gabriele Stefanzl
- 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
| | - Lina Degenfeld-Schonburg
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
| | - Susanne Herndlhofer
- 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
| | - Gregor Eisenwort
- 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
- Third Medical Department for Hematology and Oncology, Hanusch Hospital Vienna, 1140 Vienna, Austria
| | - Alexander W. Hauswirth
- 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
| | - Thamer Sliwa
- Third Medical Department for Hematology and Oncology, Hanusch Hospital Vienna, 1140 Vienna, Austria
| | - Felix Keil
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, 1090 Vienna, Austria
- Third Medical Department for Hematology and Oncology, Hanusch Hospital Vienna, 1140 Vienna, Austria
| | - Wolfgang R. Sperr
- 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
| | - 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
- Correspondence:
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10
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Kranyak A, Shuler M, Williams KW, Wine Lee L. Case report of severe refractory inflammatory dermatoses in a young female diagnosed with hereditary alpha tryptasemia. Pediatr Dermatol 2022; 40:337-340. [PMID: 36281791 DOI: 10.1111/pde.15160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/25/2022] [Indexed: 12/01/2022]
Abstract
Hereditary alpha tryptasemia (HaT), an autosomal dominant condition first described in 2014, has previously been associated with multiple dermatologic, allergic, gastrointestinal, neuropsychiatric, autonomic, and connective tissue abnormalities. We describe a pediatric patient with predominantly mixed cutaneous inflammatory manifestations and atopic manifestations resistant to treatment who was found to have HaT. HaT should be considered in individuals with refractory inflammatory dermatologic disease and signs and/or symptoms concerning for mast cell activation.
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Affiliation(s)
- Allison Kranyak
- University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Marshall Shuler
- University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Kelli W Williams
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lara Wine Lee
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina, USA
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11
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Radia DH, Moonim MT. Update on diagnostic approaches and therapeutic strategies in systemic mastocytosis. Best Pract Res Clin Haematol 2022; 35:101380. [DOI: 10.1016/j.beha.2022.101380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/29/2022]
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12
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Terhorst-Molawi D, Lohse K, Ginter K, Puhl V, Metz M, Hu M, Maurer M, Altrichter S. Mast cells and tryptase are linked to itch and disease severity in mycosis fungoides: Results of a pilot study. Front Immunol 2022; 13:930979. [PMID: 36032167 PMCID: PMC9400509 DOI: 10.3389/fimmu.2022.930979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionIn mycosis fungoides (MF), the most common cutaneous T-cell lymphoma, itch is a frequent clinical symptom. Whether mast cells (MCs), eosinophils (Eos) or their mediators play a role in MF-associated itch or disease severity is controversially discussed. Here, we explored the role of MC and Eo numbers in the skin as well as blood levels of their mediators in disease severity and itch.MethodsIn 10 patients with MF and 10 matched control subjects we assessed disease severity, itch, and quality of life impairment using dedicated tools such as the mSWAT, ItchyQoL and DLQI. We analyzed skin biopsies and measured serum levels of tryptase, a mast cell mediator, as well as of the eosinophil products eosinophil cationic protein (ECP) and major basic protein (MBP).ResultsThe presence of chronic itch, in four of 10 patients, was associated with significantly higher disease severity (mSwat), larger body surface area affected, and stronger QoL impairment (Itchy-Qol, DLQI). Serum levels of tryptase, but not ECP and MBP, were linked with patient-reported disease severity, body surface area affected, and the presence of itch. Three of the four patients with chronic itch, but none of the six patients without, had tryptase levels above >6µg/l. Numbers of MCs in the papillary dermis were higher in MF skin lesions then in non-lesional skin of MF patients and skin of healthy controls.DiscussionThe MC-mediator tryptase, in MF, is linked to disease activity and impact, most prominently to itch. Our findings call for larger studies that explore the role of MCs, tryptase and other MC mediators as drivers of itch and their role in MF pathogenesis.
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Affiliation(s)
- Dorothea Terhorst-Molawi
- 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
- Institute of Clinical Physiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Katharina Lohse
- 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
| | - Katharina Ginter
- 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
| | - Viktoria Puhl
- 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
| | - Martin Metz
- 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
| | - Man Hu
- 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
| | - 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
- *Correspondence: Marcus Maurer,
| | - Sabine Altrichter
- 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
- Department of Dermatology and Venerology, Kepler University Hospital, Linz, Austria
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13
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Gotlib J, Schwaab J, Shomali W, George TI, Radia DH, Castells M, Carter MC, Hartmann K, Álvarez-Twose I, Brockow K, Bonadonna P, Hermine O, Niedoszytko M, Hoermann G, Sperr WR, Elberink HO, Siebenhaar F, Butterfield JH, Ustun C, Zanotti R, Triggiani M, Schwartz LB, Lyons JJ, Orfao A, Sotlar K, Horny HP, Arock M, Metcalfe DD, Akin C, Lübke J, Valent P, Reiter A. Proposed European Competence Network on Mastocytosis-American Initiative in Mast Cell Diseases (ECNM-AIM) Response Criteria in Advanced Systemic Mastocytosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2025-2038.e1. [PMID: 35724948 DOI: 10.1016/j.jaip.2022.05.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 12/18/2022]
Abstract
Advanced systemic mastocytosis (AdvSM) is characterized by the presence of KIT D816V and other somatic mutations (eg, in SRSF2, ASXL1, and RUNX1) in 95% and 60% to 70% of patients, respectively. The biological and clinical consequences of AdvSM include multilineage involvement (eg, associated hematologic neoplasm) in 60% to 80% of patients, variable infiltration and damage (C-findings) of predominantly bone marrow and visceral organs through affected mast cell (MC) and non-MC lineages, and elevated levels of serum tryptase. Recently, the treatment landscape has substantially changed with the introduction of the multikinase/KIT inhibitor midostaurin and the selective KIT D816V inhibitor avapritinib. In this review, we discuss the evolution of AdvSM response criteria that have been developed to better capture clinical benefit (eg, improved responses and progression-free and overall survival). We propose refined response criteria from European Competence Network on Mastocytosis and American Initiative in Mast Cell Diseases investigators that use a tiered approach to segregate the effects of histopathologic (eg, bone marrow MC burden, tryptase), molecular (eg, KIT D816V variant allele frequency), clinical (eg, C-findings), and symptom response on long-term outcomes. These response criteria require evaluation in future prospective clinical trials of selective KIT inhibitors and other novel agents.
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Affiliation(s)
- Jason Gotlib
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, Calif.
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - William Shomali
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, Calif
| | - Tracy I George
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Deepti H Radia
- Department of Clinical Haematology, Guys and St Thomas' NHS Hospitals, London, United Kingdom
| | - Mariana Castells
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Melody C Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - 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, Switzerland
| | - Ivan Álvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha and Centro de Investigación Biomédica en Red de Oncología (CIBERONC), Hospital Virgen del Valle, Toledo, Spain
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - 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
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Gregor Hoermann
- MLL Munich Leukemia Laboratory, Munich, Germany; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, 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
| | - Hanneke Oude Elberink
- Department of Allergology, University Medical Center Groningen and GRIAC Research Institute, University of Groningen, Groningen, The Netherlands
| | - Frank Siebenhaar
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Department of Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany
| | | | - Celalettin Ustun
- Department of Medicine, Division of Hematology, Oncology, and Cell Therapy, Coleman Foundation Blood and Marrow Transplant Center at Rush University Medical Center, Chicago, Ill
| | - Roberta Zanotti
- Section of Hematology, Multidisciplinary Outpatients Clinics for Mastocytosis, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, Va
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Alberto Orfao
- Servicio Central de Citometria (NUCLEUS), Instituto de Biología Molecular y Celular del Cáncer (IBMCC) Instituto Biosanitario de Salamanca, CIBERONC and Department of Medicine, University of Salamanca, Salamanca, Spain; Utah
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University, Paris, France
| | - Dean D Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | - Johannes Lübke
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - 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
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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De Vos S, Demeyere K, De Cock H, Devriendt N, Schwarzkopf I, Fortrie R, Roggeman T, Meyer E, De Spiegelaere W, de Rooster H. Comparison of serum tryptase as a diagnostic oncological marker in canine versus human mast cell neoplasms. Res Vet Sci 2022; 151:90-95. [DOI: 10.1016/j.rvsc.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 04/20/2022] [Accepted: 05/02/2022] [Indexed: 11/24/2022]
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Resolving the genetics of human tryptases: implications for health, disease, and clinical use as a biomarker. Curr Opin Allergy Clin Immunol 2022; 22:143-152. [PMID: 35197435 DOI: 10.1097/aci.0000000000000813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW To discuss our evolving understanding of the genetic variation in human tryptases and recent advances in associated clinical phenotypes. RECENT FINDINGS Serum tryptase levels have long been used as biomarkers in clinical practice to diagnose mast cell-associated disorders and mast cell-mediated reactions but the contribution of specific secreted isoforms of human tryptases and their role(s) in health and disease has only recently begun to be illuminated. It is now recognized that hereditary alpha-tryptasemia (HαT) is a common genetic trait and the commonest cause for elevated basal serum tryptase (BST), where it can both contribute to mast cell-associated phenotypes, and potentially confound their correct diagnosis. Expression of different tryptase isoforms is now recognized to be associated with specific clinical phenotypes including clonal and nonclonal mast cell-associated disorders as well as certain asthma endotypes. These disparate impacts on clinical disorders may result from differences in enzymatic activities of mature α-tryptases and β-tryptases, and the unique substrate profile and stability of heterotetrameric mature α/β-tryptases recently described to naturally occur. SUMMARY Variable copy number and isoform expression of tryptases differentially impact diseases and reactions associated with mast cells in humans. Recent advances in understanding of genetics governing BST levels have refined our understanding and the clinical use of this biomarker. In the future, incorporation of tryptase genotyping will likely be integral to the work-up and trial design of patients with phenotypes impacted by mast cells ranging from asthma to mastocytosis.
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16
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Skarbø BR, Vinnes EW, Wentzel‐Larsen T, Sylte MS, Apelseth TO. Estimating the within‐subject (CV
I
) and between‐subject (CV
G
) biological variation of serum tryptase. Immun Inflamm Dis 2022; 10:e578. [PMID: 34904391 PMCID: PMC8959422 DOI: 10.1002/iid3.578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 11/05/2021] [Accepted: 11/22/2021] [Indexed: 11/07/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Birthe R. Skarbø
- Department of Medical Biochemistry and PharmacologyHaukeland University HospitalBergenNorway
| | - Erik W. Vinnes
- Department of Medical Biochemistry and PharmacologyHaukeland University HospitalBergenNorway
| | - Tore Wentzel‐Larsen
- Centre for Clinical ResearchHaukeland University HospitalBergenNorway
- Centre for Child and Adolescent Mental HealthThe Regional Centres for Child and Adolescent Mental Health and Child Welfare, Eastern and Southern NorwayOsloNorway
- Norwegian Centre for Violence and Traumatic Stress StudiesNORCE researchOsloNorway
| | - Marit S. Sylte
- Department of Medical Biochemistry and PharmacologyHaukeland University HospitalBergenNorway
| | - Torunn O. Apelseth
- Department of Immunology and Transfusion MedicineHaukeland University HospitalBergenNorway
- Department of War Surgery and Emergency MedicineNorwegian Armed Forces Medical ServicesSessvollmoenNorway
- Faculty of MedicineUniversity of BergenBergenNorway
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17
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Thomas EG, Thomas DJ. Mimics of Allergy and Angioedema: Scombroid, Mast Cell Activation Disorders, and Hereditary Alpha Tryptasemia. Emerg Med Clin North Am 2021; 40:119-133. [PMID: 34782083 DOI: 10.1016/j.emc.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Scombroid poisoning, systemic mastocytosis, and hereditary alpha tryptasemia all present with episodes that resemble allergic reactions. Knowledge regarding systemic mastocytosis and hereditary alpha tryptasemia is quickly evolving. Epidemiology, pathophysiology, and strategies to identify and diagnose are discussed. Evidence-based management in the emergency setting and beyond is also explored and summarized. Key differences are described between these events and allergic reactions.
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Affiliation(s)
- Elizabeth G Thomas
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, Jefferson, New Orleans, LA 70121, USA.
| | - Daniel James Thomas
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, Jefferson, New Orleans, LA 70121, USA
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18
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Valent P, Akin C, Hartmann K, Alvarez-Twose I, Brockow K, Hermine O, Niedoszytko M, Schwaab J, Lyons JJ, Carter MC, Elberink HO, Butterfield JH, George TI, Greiner G, Ustun C, Bonadonna P, Sotlar K, Nilsson G, Jawhar M, Siebenhaar F, Broesby-Olsen S, Yavuz S, Zanotti R, Lange M, Nedoszytko B, Hoermann G, Castells M, Radia DH, Muñoz-Gonzalez JI, Sperr WR, Triggiani M, Kluin-Nelemans HC, Galli SJ, Schwartz LB, Reiter A, Orfao A, Gotlib J, Arock M, Horny HP, Metcalfe DD. Updated Diagnostic Criteria and Classification of Mast Cell Disorders: A Consensus Proposal. Hemasphere 2021; 5:e646. [PMID: 34901755 PMCID: PMC8659997 DOI: 10.1097/hs9.0000000000000646] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/06/2021] [Indexed: 12/19/2022] Open
Abstract
Mastocytosis is a hematologic neoplasm characterized by expansion and focal accumulation of neoplastic mast cells (MC) in diverse organs, including the skin, bone marrow (BM), spleen, liver, and gastrointestinal tract. The World Health Organization classification divides the disease into prognostically distinct variants of cutaneous mastocytosis (CM) and systemic mastocytosis (SM). Although this classification remains valid, recent developments in the field and the advent of new diagnostic and prognostic parameters created a need to update and refine definitions and diagnostic criteria in MC neoplasms. In addition, MC activation syndromes (MCAS) and genetic features predisposing to SM and MCAS have been identified. To discuss these developments and refinements in the classification, we organized a Working Conference comprised of experts from Europe and the United States in August 2020. This article reports on outcomes from this conference. Of particular note, we propose adjustments in the classification of CM and SM, refinements in diagnostic criteria of SM variants, including smoldering SM and BM mastocytosis (BMM), and updated criteria for MCAS and other conditions involving MC. CD30 expression in MC now qualifies as a minor SM criterion, and BMM is now defined by SM criteria, absence of skin lesions and absence of B- and C-findings. A basal serum tryptase level exceeding 20 ng/mL remains a minor SM criterion, with recognition that hereditary alpha-tryptasemia and various myeloid neoplasms may also cause elevations in tryptase. Our updated proposal will support diagnostic evaluations and prognostication in daily practice and the conduct of clinical trials in MC disorders.
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Affiliation(s)
- Peter Valent
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, Medical University of Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Austria
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Switzerland
- Department of Biomedicine, University Hospital Basel and University of Basel, Switzerland
| | - Ivan Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) and CIBERONC, Hospital Virgen del Valle, Toledo, Spain
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Germany
| | - Olivier Hermine
- Imagine Institute Université de Paris, Sorbonne, Institut national de la santé et de la recherche médicale U1163, Centre national de référence des mastocytoses, Hôpital Necker, Assistance publique hôpitaux de Paris, France
| | | | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Germany
| | - Jonathan J. Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Melody C. Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Hanneke Oude Elberink
- Department of Allergology, University Medical Center Groningen and GRIAC Research Institute, University of Groningen, The Netherlands
| | | | - Tracy I. George
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Georg Greiner
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Austria
- Department of Laboratory Medicine, Medical University of Vienna, Austria and Ihr Labor, Medical Diagnostic Laboratories, Vienna, Austria
| | - Celalettin Ustun
- Division of Hematology, Oncology and Cell Therapy, Department of Medicine, The Coleman Foundation Blood and Marrow Transplant Center at Rush University Medical Center, Chicago, Illinois, USA
| | | | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University Salzburg, Austria
| | - Gunnar Nilsson
- Department of Medicine Solna & Mastocytosis Centre, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Mohamad Jawhar
- Department of Hematology and Oncology, University Hospital Mannheim, Germany
| | - 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, Germany
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Selim Yavuz
- Division of Haematology, Department of Internal Medicine, University of Istanbul, Turkey
| | - Roberta Zanotti
- Section of Hematology, Multidisciplinary Outpatients Clinics for Mastocytosis, Department of Medicine, University Hospital of Verona, Italy
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Poland
| | - Boguslaw Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Poland
- Invicta Fertility and Reproductive Center, Molecular Laboratory, Sopot, Poland
| | - Gregor Hoermann
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Austria
- MLL Munich Leukemia Laboratory, Munich, Germany
| | - Mariana Castells
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepti H. Radia
- Department of Clinical Haematology, Guys and St Thomas’ NHS Hospitals, London, United Kingdom
| | - Javier I. Muñoz-Gonzalez
- Servicio Central de Citometria, Centro de Investigacion del Cancer (IBMCC; CSIC/USAL) Instituto Biosanitario de Salamanca (IBSAL) and Department of Medicine, University of Salamanca, Spain
| | - Wolfgang R. Sperr
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, Medical University of Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Austria
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Italy
| | - Hanneke C. Kluin-Nelemans
- Department of Haematology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Stephen J. Galli
- Department of Pathology and the Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, California, USA
| | - Lawrence B. Schwartz
- Division of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Germany
| | - Alberto Orfao
- Servicio Central de Citometria, Centro de Investigacion del Cancer (IBMCC; CSIC/USAL) Instituto Biosanitario de Salamanca (IBSAL) and Department of Medicine, University of Salamanca, Spain
| | - Jason Gotlib
- Stanford Cancer Institute/Stanford University School of Medicine/Stanford Cancer Institute, Stanford, California, USA
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (UPMC), Paris, France
| | - Hans-Peter Horny
- Institute of Pathology, Paracelsus Medical University Salzburg, Austria
- Institute of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Dean D. Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Maryland, USA
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Gobbo F, Sarli G, De Silva M, Galiazzo G, Chiocchetti R, Morini M. A Double Histochemical/Immunohistochemical Staining for the Identification of Canine Mast Cells in Light Microscopy. Vet Sci 2021; 8:vetsci8100229. [PMID: 34679059 PMCID: PMC8537840 DOI: 10.3390/vetsci8100229] [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] [Received: 08/03/2021] [Revised: 09/14/2021] [Accepted: 10/10/2021] [Indexed: 02/02/2023] Open
Abstract
Immunohistochemistry (IHC) is a widely used technique in diagnostic pathology, but the simultaneous analysis of more than one antibody at a time with different chromogens is rather complex, time-consuming, and quite expensive. In order to facilitate the identification of mast cells (MCs) during immunohistochemical analysis of membrane and/or nuclear markers, we propose a new staining method that includes the association of IHC and toluidine blue as a counterstain. To achieve this goal, we tested c-kit, Ki67, and cannabinoid receptor 2 on several cases of cutaneous canine mast cell tumors (MCTs), cutaneous mastocytosis, and atopic dermatitis. The results obtained show how this double staining technique, although limited to non-cytoplasmic markers and of little use in poorly differentiated MCTs in which MC metachromasia is hard to see, can be used during the evaluation of nuclear and/or membranous immunohistochemical markers in all canine cutaneous disorders, especially if characterized by the presence of a low number of MCs. It can help to evaluate those MCTs in which neoplastic MCs must be clearly distinguished from inflammatory cells that can infiltrate the tumor itself, in facilitating the calculation of the Ki67 index. Moreover, it can be used to study the expression of new markers in both animal and human tissues containing MCs and in MC disorders.
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20
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Wu R, Lyons JJ. Hereditary Alpha-Tryptasemia: a Commonly Inherited Modifier of Anaphylaxis. Curr Allergy Asthma Rep 2021; 21:33. [PMID: 33970354 DOI: 10.1007/s11882-021-01010-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Hereditary alpha-tryptasemia (HαT) is an autosomal dominant genetic trait and a common cause of elevated basal serum tryptase in Western populations. It is a risk factor for severe anaphylaxis among individuals with venom allergy and an established modifier of anaphylaxis and mast cell mediator-associated symptoms among patients with systemic mastocytosis. Understanding the physiology of tryptases and how this may relate to the clinical features associated with HαT is the first step in identifying optimal medical management and targets for novel therapeutics. RECENT FINDINGS HαT prevalence is increased in both clonal and non-clonal mast cell-associated disorders where it augments symptoms of immediate hypersensitivity, including anaphylaxis. The unique properties of naturally occurring α/β-tryptase heterotetramers may explain certain elements of phenotypes associated with HαT, though additional mechanisms are being evaluated. This review provides an overview of the clinical and translational studies that have identified HαT as a modifier of mast cell-associated disorders and anaphylaxis and discusses mechanisms that may potentially explain some of these clinical findings.
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Affiliation(s)
- Richard Wu
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, 9000 Rockville Pike, Building 29B, Room 5NN18, MSC 1889, Bethesda, MD, 20892, USA
| | - Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, 9000 Rockville Pike, Building 29B, Room 5NN18, MSC 1889, Bethesda, MD, 20892, USA.
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21
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Ebo DG, De Puysseleyr LP, Van Gasse AL, Elst J, Poorten MLVD, Faber MA, Mertens C, Van Houdt M, Hagendorens MM, Sermeus L, Vitte J, Moise M, Garvey LH, Castells MC, Tacquard C, Mertes PM, Schwartz LB, Sabato V. Mast Cell Activation During Suspected Perioperative Hypersensitivity: A Need for Paired Samples Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3051-3059.e1. [PMID: 33862269 DOI: 10.1016/j.jaip.2021.03.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/12/2021] [Accepted: 03/27/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perioperative hypersensitivity (POH) reactions constitute a significant clinical and diagnostic challenge. A transient increase in serum tryptase during POH reflects mast cell activation (MCA) and helps to recognize an underlying hypersensitivity mechanism. OBJECTIVE To determine the diagnostic performance of different tryptase decision thresholds based on single and paired measurements to document MCA in suspected POH. METHODS Acute serum tryptase (aST) and baseline serum tryptase (bST) samples were obtained from patients referred to our outpatients clinic because of clinical POH. Tryptase samples from controls were obtained before induction (Tt0) and 1.5 hours after induction (Tt1) in uneventful anesthesia. Different cutoff points for tryptase increase over bST and the percentage increase in tryptase (%T) were calculated and compared with existing thresholds: aST > [1.2 × (bST) + 2] (consensus formula), aST higher than 11.4 ng/mL, and aST higher than 14 ng/mL. RESULTS Patients with POH had higher bST and aST levels compared with controls (respectively 5.15 vs 2.28 ng/mL for bST and 20.30 vs 1.92 ng/mL for aST). The consensus formula and a tryptase increase over bST of greater than or equal to 3.2 ng/mL held the highest accuracies to document MCA in POH (respectively 81% and 82%). A bST of higher than 8 ng/mL was present in 4% of controls, 5% of patients with grade 1 POH, 24% of patients with grade 2 POH, 15% of patients with grade 3 POH, and 17% of patients with grade 4 POH. CONCLUSIONS Our data endorse the consensus formula for detection of MCA in POH. Furthermore, it shows that a bST of higher than 8 ng/mL was associated with occurrence of anaphylaxis.
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Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium.
| | - Leander P De Puysseleyr
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Athina L Van Gasse
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Marie-Line van der Poorten
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Margaretha A Faber
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Christel Mertens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Michel Van Houdt
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Margo M Hagendorens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Luc Sermeus
- Department of Anaesthesia, Antwerp University Hospital, Antwerp, Belgium
| | - Joana Vitte
- Aix-Marseille University, IRD, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France; IDESP, INSERM, University of Montpellier, Montpellier, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Michel Moise
- Aix-Marseille University, IRD, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, Ha, Denmark
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Charles Tacquard
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, Strasbourg, France
| | - Paul-Michel Mertes
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, Strasbourg, France
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy & Immunologie, Virginia Commonwealth University, Richmond, Va
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
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22
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Wen S, Unuma K, Chinuki Y, Hikino H, Uemura K. Fatal anaphylaxis due to alpha-gal syndrome after initial cetuximab administration: The first forensic case report. Leg Med (Tokyo) 2021; 51:101878. [PMID: 33892262 DOI: 10.1016/j.legalmed.2021.101878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/27/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Abstract
Cetuximab is mainly used for the treatment of advanced and metastatic colorectal cancer. Owing to the oligosaccharide galactose-α-1,3-galactose (α-gal) in its heavy chain, cetuximab can induce severe IgE-dependent anaphylaxis. α-Gal is also the antigen responsible for α-gal syndrome, known as mammalian meat allergy. Patients with α-gal syndrome may suffer from cetuximab-induced anaphylaxis at the first administration because of developed α-gal-specific IgE antibodies. A male patient in his 50 s with metastatic colon cancer was receiving chemotherapy involving scheduled cetuximab administration. However, he died soon after the first administration. Forensic autopsy confirmed rectal cancer, metastatic rectal cancer in the liver, and renal cancer. Laboratory blood tests revealed the presence of cetuximab- and beef-specific IgE antibodies before cetuximab administration and an extremely high level of tryptase after administration. Thus, we determined that the death was caused by cetuximab-induced anaphylaxis due to the preexisting α-gal syndrome. To the best of our knowledge, this is the first autopsy case report in forensic medicine of fatal anaphylaxis after initial cetuximab administration.
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Affiliation(s)
- Shuheng Wen
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Kana Unuma
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.
| | - Yuko Chinuki
- Department of Dermatology, Shimane University, Faculty of Medicine, Shimane, Japan
| | - Hajime Hikino
- Department of Breast Surgery, Matsue Red Cross Hospital, Matsue, Shimane, Japan
| | - Koichi Uemura
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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23
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Vitte J, Sabato V, Tacquard C, Garvey LH, Michel M, Mertes PM, Ebo DG, Schwartz LB, Castells MC. Use and Interpretation of Acute and Baseline Tryptase in Perioperative Hypersensitivity and Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2994-3005. [PMID: 33746087 DOI: 10.1016/j.jaip.2021.03.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Abstract
Paired acute and baseline serum or plasma tryptase sampling and determination have recently been included as a mechanistic approach in the diagnostic and management guidelines of perioperative immediate hypersensitivity and anaphylaxis. The timing of this paired sampling is clearly defined in international consensus statements, with the optimal window for acute tryptase sampling between 30 minutes and 2 hours after the initiation of symptoms, whereas baseline tryptase should be measured in a sample collected before the event (preop) or at least 24 hours after all signs and symptoms have resolved. A transient elevation of the acute tryptase level greater than [2 + (1.2 × baseline tryptase level)] supports the involvement and activation of mast cells. Here, we provide the clinical, pathophysiological, and technical rationale for the procedure and interpretation of paired acute and baseline tryptase. Clinical examples, up-to-date knowledge of hereditary α-tryptasemia as a frequent cause of baseline tryptase of 7 μg/L and higher, mastocytosis, other clonal myeloid disorders, cardiovascular or renal failure, and technical improvements resulting in continued lowering of the 95th percentile value are discussed. Clues for improved management of perioperative immediate hypersensitivity and anaphylaxis include (1) sustained dissemination and implementation of updated guidelines; (2) preoperative sample storage for deferred analysis; (3) referral for thorough allergy investigation, screening for mast cell-related disorders, and recommendations for future anesthetic procedures; and (4) sustained collaboration between anesthesiologists, immunologists, and allergists.
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Affiliation(s)
- Joana Vitte
- Aix-Marseille Univ, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; IDESP, INSERM UMR UA11, University of Montpellier, Montpellier, France
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Charles Tacquard
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, Strasbourg, France
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Moïse Michel
- Aix-Marseille Univ, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Paul-Michel Mertes
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, Strasbourg, France
| | - Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy & Immunology, Virginia Commonwealth University, Richmond, Va
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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24
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Muncey AR, Aldawoodi NN, Chitneni A, Hoffman JP, Escher AR. Intraoperative Hypotension in a Patient with Antithrombin Deficiency, Bilateral Pulmonary Emboli, and Cefazolin Allergy. Cureus 2021; 13:e13653. [PMID: 33665061 PMCID: PMC7924311 DOI: 10.7759/cureus.13653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In medicine, the search for a clear answer can at times be elusive. However, this does not necessarily preclude the administration of intelligent and thoughtful therapeutic treatments. Here, we describe a complicated emergent event of severe hypotension and near-arrest that occurred in the operating room in a young, healthy woman undergoing outpatient thyroid surgery. We detail the situation as it presented in the operating room and the measures taken to rule out potential life-threatening diagnoses and develop a thoughtful treatment plan. We further describe the evidence for and against the two remaining diagnostic possibilities: anaphylaxis versus acute pulmonary embolism.
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Affiliation(s)
| | - Nasrin N Aldawoodi
- Anesthesiology, H Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Ahish Chitneni
- Physical Medicine and Rehabilitation, AT Still University, Arizona, USA
| | - Jamie P Hoffman
- Anesthesiology, H Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Allan R Escher
- Anesthesiology/Pain Medicine, H Lee Moffitt Cancer Center and Research Institute, Tampa, USA
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25
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Valent P, Orfao A, Kubicek S, Staber P, Haferlach T, Deininger M, Kollmann K, Lion T, Virgolini I, Winter G, Hantschel O, Kenner L, Zuber J, Grebien F, Moriggl R, Hoermann G, Hermine O, Andreeff M, Bock C, Mughal T, Constantinescu SN, Kralovics R, Sexl V, Skoda R, Superti-Furga G, Jäger U. Precision Medicine in Hematology 2021: Definitions, Tools, Perspectives, and Open Questions. Hemasphere 2021; 5:e536. [PMID: 33623882 PMCID: PMC7892291 DOI: 10.1097/hs9.0000000000000536] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/16/2020] [Indexed: 12/20/2022] Open
Abstract
During the past few years, our understanding of molecular mechanisms and cellular interactions relevant to malignant blood cell disorders has improved substantially. New insights include a detailed knowledge about disease-initiating exogenous factors, endogenous (genetic, somatic, epigenetic) elicitors or facilitators of disease evolution, and drug actions and interactions that underlie efficacy and adverse event profiles in defined cohorts of patients. As a result, precision medicine and personalized medicine are rapidly growing new disciplines that support the clinician in making the correct diagnosis, in predicting outcomes, and in optimally selecting patients for interventional therapies. In addition, precision medicine tools are greatly facilitating the development of new drugs, therapeutic approaches, and new multiparametric prognostic scoring models. However, although the emerging roles of precision medicine and personalized medicine in hematology and oncology are clearly visible, several questions remain. For example, it remains unknown how precision medicine tools can be implemented in healthcare systems and whether all possible approaches are also affordable. In addition, there is a need to define terminologies and to relate these to specific and context-related tools and strategies in basic and applied science. To discuss these issues, a working conference was organized in September 2019. The outcomes of this conference are summarized herein and include a proposal for definitions, terminologies, and applications of precision and personalized medicine concepts and tools in hematologic neoplasms. We also provide proposals aimed at reducing costs, thereby making these applications affordable in daily practice.
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Affiliation(s)
- Peter Valent
- Department of Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Austria
| | - Alberto Orfao
- Servicio Central de Citometria, Centro de Investigacion del Cancer (IBMCC; CSIC/USAL), IBSAL, CIBERONC and Department of Medicine, University of Salamanca, Spain
| | - Stefan Kubicek
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Philipp Staber
- Department of Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Austria
| | | | - Michael Deininger
- Division of Hematology and Hematologic Malignancies, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Karoline Kollmann
- Institute of Pharmacology and Toxicology, University of Veterinary Medicine Vienna, Austria
| | - Thomas Lion
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Austria
- Children’s Cancer Research Institute, Vienna, Austria
| | - Irene Virgolini
- Department of Nuclear Medicine, Medical University of Innsbruck, Austria
| | - Georg Winter
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Oliver Hantschel
- Institute of Physiological Chemistry, Faculty of Medicine, Philipps-University of Marburg, Germany
| | - Lukas Kenner
- Pathology of Laboratory Animals, University of Veterinary Medicine, Vienna, Austria
| | - Johannes Zuber
- Research Institute of Molecular Pathology (IMP), Vienna, Austria
| | - Florian Grebien
- Institute for Medical Biochemistry, University of Veterinary Medicine Vienna, Austria
| | - Richard Moriggl
- Institute of Animal Breeding and Genetics, Unit for Functional Cancer Genomics, University of Veterinary Medicine Vienna, Austria
| | - Gregor Hoermann
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Austria
- MLL Munich Leukemia Laboratory, Munich, Germany
| | - Olivier Hermine
- Imagine Institute Université Paris Descartes, Sorbonne, Paris Cité, Paris, France
- Department of Hematology, Necker Hospital, Paris, France
| | - Michael Andreeff
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christoph Bock
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Tariq Mughal
- Division of Hematology & Oncology, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Stefan N. Constantinescu
- de Duve Institute and Ludwig Cancer Research Brussels, Université catholique de Louvain, Brussels, Belgium
| | - Robert Kralovics
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Veronika Sexl
- Institute of Pharmacology and Toxicology, University of Veterinary Medicine Vienna, Austria
| | - Radek Skoda
- Departement of Biomedicine, University of Basel, Switzerland
| | - Giulio Superti-Furga
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Ulrich Jäger
- Department of Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Austria
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26
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Genetic Regulation of Tryptase Production and Clinical Impact: Hereditary Alpha Tryptasemia, Mastocytosis and Beyond. Int J Mol Sci 2021; 22:ijms22052458. [PMID: 33671092 PMCID: PMC7957558 DOI: 10.3390/ijms22052458] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/20/2021] [Accepted: 02/25/2021] [Indexed: 12/12/2022] Open
Abstract
Tryptase is a serine protease that is predominantly produced by tissue mast cells (MCs) and stored in secretory granules together with other pre-formed mediators. MC activation, degranulation and mediator release contribute to various immunological processes, but also to several specific diseases, such as IgE-dependent allergies and clonal MC disorders. Biologically active tryptase tetramers primarily derive from the two genes TPSB2 (encoding β-tryptase) and TPSAB1 (encoding either α- or β-tryptase). Based on the most common gene copy numbers, three genotypes, 0α:4β, 1α:3β and 2α:2β, were defined as “canonical”. About 4–6% of the general population carry germline TPSAB1-α copy number gains (2α:3β, 3α:2β or more α-extra-copies), resulting in elevated basal serum tryptase levels. This condition has recently been termed hereditary alpha tryptasemia (HαT). Although many carriers of HαT appear to be asymptomatic, a number of more or less specific symptoms have been associated with HαT. Recent studies have revealed a significantly higher HαT prevalence in patients with systemic mastocytosis (SM) and an association with concomitant severe Hymenoptera venom-induced anaphylaxis. Moreover, HαT seems to be more common in idiopathic anaphylaxis and MC activation syndromes (MCAS). Therefore, TPSAB1 genotyping should be included in the diagnostic algorithm in patients with symptomatic SM, severe anaphylaxis or MCAS.
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Ciriza de Los Ríos C, Castel de Lucas I, Canga Rodríguez-Valcárcel F, Diéguez Pastor MDC, de Las Cuevas Moreno N, Rey Díaz-Rubio E. IRRITABLE BOWEL SYNDROME AND BASAL SERUM TRYPTASE: THE CORRELATION BETWEEN SUBTYPE, SEVERITY AND COMORBIDITIES. A PILOT STUDY. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 114:22-27. [PMID: 33562988 DOI: 10.17235/reed.2021.7697/2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Activation of mast cells causes alteration in epithelial and neuromuscular function, and is involved in visceral hypersensitivity and dysmotility in gastrointestinal functional disorders. OBJECTIVES Primary: Evaluate differences in basal serum tryptase (BST) between patients with irritable bowel syndrome (IBS) and healthy controls. Secondary: BST depending on IBS subtype (diarrhea: IBS-D; constipation: IBS-C), comorbidities and correlations with IBS severity and quality of life. MATERIAL AND METHODS Prospective control-case study in IBS patients (Rome IV criteria). BST was determined (ImmunoCAP-Phadia, Sweden®) IBS Severity Score (IBSSS), pain, bloating and flatulence analogue scales, IBS quality of life (IBSQOL) and patient health status (PHQ-9) were performed. BST is the primary variable in achieving the primary end-point. RESULTS Thirty-two patients, 21 (65.6%) IBS-D, 11 (34.4%) IBS-C and 32 controls were included. Mean IBSSSS: 326.6 (± 71.4), IBSQOL: 76 (± 20.3) and PHQ9: 10.2 (± 5.9). BST was 4.8 ± 2.6 in IBS and 4.7± 2.6 in controls (p=0.875). There was no difference in BST between IBS subtypes (4.7 ± 2.9 in IBS-D and 5± 1.8 in IBS-C; p =0.315) or IBS severity (p=0.662). However, BST was higher in patients with IBS and extraintestinal comorbidities compared to other patients and controls (p=0.029). This subgroup also has more severe bloating (p=0.021). There was no correlation between BST, quality of life (p=0.9260) and health status (p=0.3985). CONCLUSION BST does not discriminate between IBS patients and controls. However, BST was higher in patients with IBS with extraintestinal comorbidities which have more severe bloating. This finding is worthy of investigation.
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Affiliation(s)
- Constanza Ciriza de Los Ríos
- Aparato Digestivo, Hospital Clínico San Carlos. Instituto de Investigacion Sanitaria San Carlos (IdISSC). , España
| | | | | | | | | | - Enrique Rey Díaz-Rubio
- Aparato Digestivo, Hospital Clínico San Carlos. Instituto de Investigacion Sanitaria San Carlos (IdISSC), España
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Shibata Y, Hirota S, Saito I, Asahina A. Diffuse cutaneous mastocytosis: Identification of KIT mutation and long-term follow-up with serum tryptase level. J Dermatol 2021; 48:672-675. [PMID: 33521998 DOI: 10.1111/1346-8138.15764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/24/2020] [Accepted: 12/25/2020] [Indexed: 11/27/2022]
Abstract
Diffuse cutaneous mastocytosis (DCM) is the least common subtype of cutaneous mastocytotis and is generally more severe than other subtypes. We herein report a case of DCM with the consequence of a long-term follow-up. A 4-month-old boy visited with a 3-month history of diffuse erythema that gradually worsened. Darier's sign was positive. The plasma histamine level was 4.95 ng/mL, and the serum tryptase and c-Kit (CD117) levels were 33.3 and 27.4 ng/mL, respectively. Histopathology of the biopsied specimen showed dermal papillary edema and infiltration of mast cells identified by c-Kit and toluidine blue staining. Amplification and direct sequencing of genomic DNA extracted from the skin biopsy specimen revealed the presence of a deletion of codon 419 in exon 8 (c.1255_1257delGAC [p. Asp419del]). There was no evidence of systemic infiltration of mast cells in this case, and we started topical corticosteroid and oral antihistamine with the diagnosis of DCM. Diffuse erythema subsided constantly with age in parallel with chronological decline of serum tryptase level, and it is no longer apparent presently at the age of 7 years, leaving only faint brown spots. Blister formation did not occur throughout the course. Our case indicates that spontaneous resolution can be expected even in DCM after a long period of time, and that serum tryptase level serves as a good surrogate marker to monitor the clinical course.
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Affiliation(s)
- Yuka Shibata
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Seiichi Hirota
- Department of Surgical Pathology, Hyogo College of Medicine, Hyogo, Japan
| | - Ikuo Saito
- Department of Pathology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Akihiko Asahina
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
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Masala C, Firinu D, Piras R, Deidda M, Cinetto F, Del Giacco S. Olfactory Function Is Impaired in Patients with Mastocytosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1359-1364. [PMID: 33059098 DOI: 10.1016/j.jaip.2020.09.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mastocytosis is a clinically heterogeneous disorder associated with abnormal mast cell accumulation in different organs. No data are available as regards the assessment of olfactory function and its association with mastocytosis. OBJECTIVE The aim of the study was first to investigate odor threshold, discrimination, and identification in patients with mastocytosis compared with age-matched healthy controls (HC), and furthermore, to correlate olfactory function with the other clinical symptoms of mastocytosis. METHODS Eighty-one participants were enrolled: 41 patients with mastocytosis (23 males and 18 females; mean age, 47.95 years; standard deviation [SD], 14.7 years) were compared with 40 HC (23 males and 17 females; mean age, 47.88 years; SD, 14.6 years). Olfactory function among participants was evaluated using the "Sniffin' Sticks" test for odor detection threshold (OT), odor discrimination (OD), and odor identification (OI). RESULTS Patients with systemic mastocytosis showed a significant decrease in the total olfactory function (Threshold-Discrimination-Identification [TDI] score), OT, OD, and OI compared with HC. A significant negative correlation was observed only between TDI score and serum tryptase concentration (μg/L). No correlation was observed between disease duration versus OT, OD, OI, and TDI score. CONCLUSIONS Our results suggest that the olfactory function is impaired in patients compared with HC; a significant negative correlation was found between TDI score and the level of serum tryptase. Olfactory dysfunction in mastocytosis may be considered among the clinical manifestations contributing to the burden of this disease.
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Affiliation(s)
- Carla Masala
- Department of Biomedical Sciences, Physiology Section, University of Cagliari, Monserrato, Cagliari, Italy
| | - Davide Firinu
- Allergy and Clinical Immunology Unit, Department of Medical Sciences and Public Health, University Hospital "Duilio Casula," Monserrato, Cagliari, Italy
| | - Raffaella Piras
- Department of Biomedical Sciences, Physiology Section, University of Cagliari, Monserrato, Cagliari, Italy
| | - Margherita Deidda
- Allergy and Clinical Immunology Unit, Department of Medical Sciences and Public Health, University Hospital "Duilio Casula," Monserrato, Cagliari, Italy
| | - Francesco Cinetto
- Department of Medicine-DIMED, University of Padova, Padova, Italy; Internal Medicine I, Ca' Foncello Hospital, Treviso, Italy
| | - Stefano Del Giacco
- Allergy and Clinical Immunology Unit, Department of Medical Sciences and Public Health, University Hospital "Duilio Casula," Monserrato, Cagliari, Italy.
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Valent P, Akin C. Doctor, I Think I Am Suffering from MCAS: Differential Diagnosis and Separating Facts from Fiction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1109-1114. [PMID: 30961836 DOI: 10.1016/j.jaip.2018.11.045] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 12/18/2022]
Abstract
Mast cell activation syndrome (MCAS) is a rare condition defined by a severe systemic reaction to mast cell (MC)-derived mediators. Most cases present with clinical signs of anaphylaxis, and some have an underlying IgE-dependent allergy. A primary MC disease (mastocytosis) may also be detected. Severe recurrent MCAS episodes requiring intensive care or even resuscitation are typically found in patients who suffer from both mastocytosis and allergy against certain triggers, such as hymenoptera venom components. A less severe form and a local form of MC activation (MCA) also exist. For these patients, diagnostic criteria are lacking. Moreover, a number of different, unrelated, conditions with overlapping symptoms may be confused with MCAS. As a result, many patients believe that they are suffering from MCAS but have in fact a less severe form of MCA or another underlying disease. In the current article, we review the potential differential diagnoses of MCA and MCAS and discuss available diagnostic criteria and diagnostic tools. These criteria and assays may be useful in daily practice and help avoid unnecessary referrals and unjustified fears in patients.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology and Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria.
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
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Lobbes H, Reynaud Q, Mainbourg S, Lega JC, Durieu I, Durupt S. [Tryptase: A practical guide for the physician]. Rev Med Interne 2020; 41:748-755. [PMID: 32712042 DOI: 10.1016/j.revmed.2020.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/24/2020] [Accepted: 06/07/2020] [Indexed: 12/19/2022]
Abstract
Tryptase is the most abundant endopeptidase released by mast cells degranulation, involved in many pro and anti-inflammatory processes. Normal serum tryptase range is 0-11.4 μg/L. Tryptase is a useful diagnostic tool for anaphylaxis, systemic mastocytosis (SM) and mast cell activation syndrome (MCAS), where specific threshold values must be used. SM diagnosis criteria include evidence of dense mast cell infiltrate either in the bone marrow or the affected organ (such as skin), presence of KIT D816V mutation and elevated serum tryptase level (>20 μg/L). In SM, tryptase level is correlated with the burden of mast cells in bone marrow. MCAS should be considered in case of severe and recurrent typical clinical signs of systemic mast cell activation involving at least two organs, associated with an increase in serum tryptase level of 20% + 2 μg/L from the individual's baseline. Anaphylaxis is the most severe among hypersensitivity reactions. A clonal mast cell disorder is a central question in anaphylaxis and appropriate explorations should be conducted in these patients. Triggers for anaphylactic reactions vary significantly in the general population and in patients with MS or MCAS. Finally, physicians must be aware of the many pathological and physiological situations that affect tryptase levels.
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Affiliation(s)
- H Lobbes
- Service de Médecine Interne, Hôpital Estaing, CHU de Clermont-Ferrand, 1 Place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France; Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, 165 Chemin du grand Revoyet, 69310 Pierre-Bénite, France.
| | - Q Reynaud
- Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, 165 Chemin du grand Revoyet, 69310 Pierre-Bénite, France
| | - S Mainbourg
- Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, 165 Chemin du grand Revoyet, 69310 Pierre-Bénite, France
| | - J C Lega
- Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, 165 Chemin du grand Revoyet, 69310 Pierre-Bénite, France
| | - I Durieu
- Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, 165 Chemin du grand Revoyet, 69310 Pierre-Bénite, France
| | - S Durupt
- Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, 165 Chemin du grand Revoyet, 69310 Pierre-Bénite, France
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Usefulness of testing for hereditary alpha tryptasemia in symptomatic patients with elevated tryptase. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2066-2067. [DOI: 10.1016/j.jaip.2020.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/26/2019] [Accepted: 01/06/2020] [Indexed: 12/18/2022]
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New developments in diagnosis, prognostication, and treatment of advanced systemic mastocytosis. Blood 2020; 135:1365-1376. [DOI: 10.1182/blood.2019000932] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/30/2019] [Indexed: 12/26/2022] Open
Abstract
AbstractSystemic mastocytosis (SM) has greatly benefited from the broad application of precision medicine techniques to hematolymphoid neoplasms. Sensitive detection of the recurrent KIT D816V mutation and use of next-generation sequencing (NGS) panels to profile the genetic landscape of SM variants have been critical adjuncts to the diagnosis and subclassification of SM, and development of clinical-molecular prognostic scoring systems. Multilineage KIT involvement and multimutated clones are characteristic of advanced SM (advSM), especially SM with an associated hematologic neoplasm (AHN). A major challenge is how to integrate conventional markers of mast cell disease burden (percentage of bone marrow mast cell infiltration and serum tryptase levels) with molecular data (serial monitoring of both KIT D816V variant allele frequency and NGS panels) to lend more diagnostic and prognostic clarity to the heterogeneous clinical presentations and natural histories of advSM. The approval of the multikinase/KIT inhibitor midostaurin has validated the paradigm of KIT inhibition in advSM, and the efficacy and safety of second-generation agents, such as the switch-control inhibitor ripretinib (DCC-2618) and the D816V-selective inhibitor avapritinib (BLU-285) are being further defined in ongoing clinical trials. Looking forward, perhaps the most fruitful marriage of the advances in molecular genetics and treatment will be the design of adaptive basket trials that combine histopathology and genetic profiling to individualize treatment approaches for patients with diverse AHNs and relapsed/refractory SM.
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Ozturk K, Cayci Z, Gotlib J, Akin C, George TI, Ustun C. Non-hematologic diagnosis of systemic mastocytosis: Collaboration of radiology and pathology. Blood Rev 2020; 45:100693. [PMID: 32334853 DOI: 10.1016/j.blre.2020.100693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/28/2020] [Accepted: 04/02/2020] [Indexed: 11/19/2022]
Abstract
Systemic mastocytosis (SM) is a hematologic disease with a wide range of clinical courses ranging from an indolent condition with normal life expectancy to exceedingly aggressive disorder with a poor prognosis. The symptoms and signs of SM result from the release of mast cell mediators with heterogeneous functions, and/or organ damage from neoplastic mast cell infiltration, or both. Diagnostic criteria for SM are well-defined by the World Health Organization (WHO). However, the diagnosis of SM can be difficult when especially it is not in the differential diagnosis. Routinely used radiologic techniques (e.g., X-ray, ultrasound, CT scans can show findings such as lytic-, sclerotic- or mixed-bone lesions, splenomegaly, hepatomegaly, retroperitoneal or periportal mesenteric lymphadenopathy, and omental thickening). It is essential to emphasize that the constellation of these radiologic findings should strongly concern of SM, especially in patients who also have a skin rash, allergic reactions, gastrointestinal tract symptoms (lasting, intermittent nausea, diarrhea), paroxysmal tachycardias, unexplained weight loss, persistent bone pain, cytopenias, liver dysfunction, eosinophilia. These findings, even coincidentally noted, will likely lead to a tissue biopsy, which reveals diagnosis (as we discussed and illustrated some tissue biopsies here). Moreover, the role of MRI and new techniques such as [18-fluorodeoxyglucose positron emission computed tomography, fibroscan] in the diagnosis of SM have been discussed. Furthermore, we reviewed the use of radiologic methods to evaluate treatment response and prognostication of SM..
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Affiliation(s)
- Kerem Ozturk
- Department of Radiology, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Zuzan Cayci
- Department of Radiology, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Jason Gotlib
- Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, CA, USA
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, MI, USA
| | - Tracy I George
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Celalettin Ustun
- Division of Hematology, Oncology and Cellular Therapy, Department of Medicine, Rush University, Chicago, IL, USA.
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Lee AYS. Elevated Serum Tryptase in Non-Anaphylaxis Cases: A Concise Review. Int Arch Allergy Immunol 2020; 181:357-364. [PMID: 32126554 DOI: 10.1159/000506199] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 01/27/2020] [Indexed: 11/19/2022] Open
Abstract
One of the most important blood tests in the field of allergy, mast cell tryptase has numerous diagnostic uses, particularly for anaphylactic reactions and for the diagnosis of mastocytosis. However, there are numerous other non-anaphylactic conditions where clinicians may see elevated serum tryptase (hypertryptasemia) and the practicing clinician ought to be aware of these important differential diagnoses. Such conditions include systemic mastocytosis, hematological malignancies, and chronic kidney disease. This article provides a comprehensive, updated summary on the variety of non-anaphylactic conditions where hypertryptasemia may be seen.
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Affiliation(s)
- Adrian Y S Lee
- Department of Allergy/Clinical Immunology and SA Pathology, Flinders Medical Centre, Bedford Park, South Australia, Australia, .,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia,
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Greiner G, Gurbisz M, Ratzinger F, Witzeneder N, Class SV, Eisenwort G, Simonitsch-Klupp I, Esterbauer H, Mayerhofer M, Müllauer L, Sperr WR, Valent P, Hoermann G. Molecular quantification of tissue disease burden is a new biomarker and independent predictor of survival in mastocytosis. Haematologica 2020; 105:366-374. [PMID: 31018976 PMCID: PMC7012478 DOI: 10.3324/haematol.2019.217950] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/18/2019] [Indexed: 12/15/2022] Open
Abstract
A high allele burden of the KIT D816V mutation in peripheral blood or bone marrow aspirates indicates multi-lineage hematopoietic involvement and has been associated with an aggressive clinical course of systemic mastocytosis. Since mast cells are substantially underrepresented in these liquid specimens, their mutation burden likely underestimates the tumor burden of the disease. We used a novel previously validated digital polymerase chain reaction (PCR) method for KIT D816V analysis to systematically analyze the mutation burden in formalin-fixed, paraffin-embedded bone marrow tissue sections of 116 mastocytosis patients (91 with indolent and 25 with advanced systemic mastocytosis), and to evaluate for the first time the clinical value of the tissue mutation burden as a novel biomarker. The KIT D816V mutation burden in the tissue was significantly higher and correlated better with bone marrow mast cell infiltration (r=0.68 vs. 0.48) and serum tryptase levels (r=0.68 vs. 0.58) compared to that in liquid specimens. Furthermore, the KIT D816V tissue mutation burden was: (i) significantly higher in advanced than in indolent systemic mastocytosis (P=0.001); (ii) predicted survival of patients in multivariate analyses independently; and (iii) was significantly reduced after response to cytoreductive therapy. Finally, digital PCR was more sensitive in detecting KIT D816V in bone marrow sections of indolent systemic mastocytosis patients than melting curve analysis after peptide nucleic acid-mediated PCR clamping (97% vs. 89%; P<0.05). In summary, digital PCR-based measurement of KIT D816V mutation burden in the tissue represents a novel biomarker with independent prognostic significance that can also be employed for monitoring disease progression and treatment response in systemic mastocytosis.
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Affiliation(s)
- Georg Greiner
- Department of Laboratory Medicine, Medical University of Vienna, Vienna.,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna
| | - Michael Gurbisz
- Department of Laboratory Medicine, Medical University of Vienna, Vienna
| | - Franz Ratzinger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna
| | - Nadine Witzeneder
- Department of Laboratory Medicine, Medical University of Vienna, Vienna.,Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna
| | | | - Gregor Eisenwort
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna.,Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna
| | | | - Harald Esterbauer
- Department of Laboratory Medicine, Medical University of Vienna, Vienna.,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna
| | | | | | - Wolfgang R Sperr
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna.,Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna
| | - Peter Valent
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna.,Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna
| | - Gregor Hoermann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna .,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna.,Central Institute of Medical and Chemical Laboratory Diagnostics, University Hospital Innsbruck, Innsbruck, Austria
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Costagliola G, Marco SD, Comberiati P, D'Elios S, Petashvili N, Di Cicco ME, Peroni D. Practical Approach to Children Presenting with Eosinophila and Hypereosinophilia. Curr Pediatr Rev 2020; 16:81-88. [PMID: 31729944 DOI: 10.2174/1573396315666191114150438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 11/22/2022]
Abstract
Eosinophilia is not a rare finding in clinical practice, and often poses problems in terms of etiologic research and differential diagnosis. Peripheral eosinophilia is defined by a blood eosinophil count > 500 cells/μL. It is classified into mild (500-1500 cells/μl), moderate (1500-5000 cells/μl) and severe for an eosinophil count > 5000 cells /μl. The term "hypereosinophilia" defines a condition characterized by a blood eosinophil count >1500 cells/μl in at least two consecutive tests made with a minimum of a 4-week interval. The causes of eosinophilia are various, and can be summarized by the acronym "APLV" which refers to Allergic disorders, Parasitic infections, Leukemia/ Lymphomas (and solid tumors) and Vasculitis-Immunodeficiency diseases, with allergic disorders and parasitic infections representing the most commonly identified causes. Allergic disorders are usually associated with mild eosinophilia, whereas values >20.000 cell/μl are highly suggestive for myeloproliferative disorders. Eosinophils may also be directly responsible for organ damage, mainly at cardiac, pulmonary and cutaneous level, deriving from the release of the granule products, of lipidic mediators and cytokines. Therefore, in the physician's approach to a patient with persistent hypereosinophilia, it is also important to investigate the presence of organ involvement. In this review, we propose a diagnostic algorithm for children presenting with either blood eosinophilia or hypereosinophilia. This algorithm focuses on the patient's history and clinical manifestations as the first step and the level and persistence of blood eosinophilia as the second, and this can help the physician to identify patients presenting with an elevated blood eosinophil count that need further laboratory or instrumental investigations.
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Affiliation(s)
- Giorgio Costagliola
- Section of Paediatrics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Serena Di Marco
- Section of Paediatrics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Pasquale Comberiati
- Section of Paediatrics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Sofia D'Elios
- Section of Paediatrics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | | | - Maria Elisa Di Cicco
- Section of Paediatrics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Diego Peroni
- Section of Paediatrics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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Mast cell activation in the context of elevated basal serum tryptase: genetics and presentations. Curr Allergy Asthma Rep 2019; 19:55. [PMID: 31776770 DOI: 10.1007/s11882-019-0887-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To describe inherited and acquired genetic variants and clinical entities associated with increased basal serum tryptase (BST), distinguish these levels from those which acutely rise due to mast cell activation, and finally to characterize the association between chronically elevated basal serum tryptase and episodic mast cell activation. RECENT FINDINGS Hereditary alpha-tryptasemia is a commonly inherited genetic cause for basally elevated serum tryptase and explains elevated BST in many individuals who do not have evidence of clonal myeloid or mast cell disease. When clonal myeloid disease is present, BST may be elevated and can be a biomarker of a number of disparate disorders of the myeloid compartment. Elevated BST is most commonly caused by hereditary alpha tryptasemia but may also be indicative of clonal myeloid disease. Clinical reports suggest that elevated BST is associated with increased risk for more severe systemic allergic reactions to a number of eliciting agents and exposures. Additional studies are needed to determine the role that inherited or acquired genetic variants associated with elevated BST and clonal or non-clonal myeloid diseases may play in these reactions.
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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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Efficacy of Omalizumab in Indolent Systemic Mastocytosis. Case Rep Hematol 2019; 2019:3787586. [PMID: 31637065 PMCID: PMC6766258 DOI: 10.1155/2019/3787586] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/22/2019] [Accepted: 08/26/2019] [Indexed: 11/30/2022] Open
Abstract
Background Systemic mastocytosis (SM) comprises a heterogeneous group of disorders characterized by the proliferation of clonal mast cells in skin and various internal organs. Omalizumab is an established, labelled therapy for allergic asthma and chronic urticaria, but its experience in the efficacy of SM is limited. Methods A retrospective analysis of 6 patients diagnosed with indolent SM treated with omalizumab at St. Michael's Hospital between 2009 and 2018 is described. Reported frequency of anaphylaxis, baseline and follow-up tryptase levels, and SM-related symptoms were captured to measure the control of the disease. Results Of the 5 patients who had experienced unprovoked anaphylaxis prior to treatment with omalizumab, 3 had no further episodes of anaphylaxis following initiation of omalizumab, while the remaining 2 patients had milder multisystem reactions. Significant improvement in cutaneous symptoms was also observed. Conclusion These data suggest that omalizumab provides benefit to patients with SM who remain highly symptomatic in spite of treatment with conventional therapies.
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Valent P, Bonadonna P, Hartmann K, Broesby-Olsen S, Brockow K, Butterfield JH, Triggiani M, Lyons JJ, Oude Elberink JNG, Arock M, Metcalfe DD, Akin C. Why the 20% + 2 Tryptase Formula Is a Diagnostic Gold Standard for Severe Systemic Mast Cell Activation and Mast Cell Activation Syndrome. Int Arch Allergy Immunol 2019; 180:44-51. [PMID: 31256161 DOI: 10.1159/000501079] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
Mast cell activation syndrome (MCAS) is a condition characterized by recurrent episodes of clinically relevant, systemic, severe reactions to mast cell (MC)-derived mediators released in the context of anaphylaxis or another acute MC-related event. It is important to document MC involvement in these reactions in order to establish the diagnosis MCAS. The most specific and reliable marker of systemic MC activation is an acute and substantial event-related (transient) increase in the serum tryptase level over the individual's baseline value. However, the baseline level of tryptase varies depending on the underlying disease and the genetic background. For example, an estimated 3-5% of healthy individuals exhibit duplications or multiple copies of the TPSAB1 gene encoding for alpha-tryptase, and over 30% of all patients with myeloid neoplasms, including mastocytosis, have elevated basal tryptase levels. Therefore, it is of utmost importance to adjust the event-related diagnostic (MCAS-confirming) increase in tryptase over the individual baseline in a robust approach. To address this challenge, the 20% + 2 formula was proposed by the consensus group in 2012. Since then, this approach has been validated in clinical practice by independent groups and found to be sound. In the current article, we discuss the emerging importance and value of the 20% + 2 formula in clinical practice and its role as a criterion of severe systemic MC activation and MCAS.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, and Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria,
| | | | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University of Basel, Basel, Switzerland
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
| | | | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Jonathan J Lyons
- Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Joanna N G Oude Elberink
- Department of Allergology, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (UPMC), Paris, France
| | - Dean D Metcalfe
- Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Michigan, USA
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Beck SC, Wilding T, Buka RJ, Baretto RL, Huissoon AP, Krishna MT. Biomarkers in Human Anaphylaxis: A Critical Appraisal of Current Evidence and Perspectives. Front Immunol 2019; 10:494. [PMID: 31024519 PMCID: PMC6459955 DOI: 10.3389/fimmu.2019.00494] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/25/2019] [Indexed: 12/12/2022] Open
Abstract
Anaphylaxis is a type I hypersensitivity reaction that is potentially fatal if not promptly treated. It is a clinical diagnosis, although measurement of serial serum total mast cell tryptase (MCT) is gold standard and may help differentiate anaphylaxis from its mimics. The performance characteristics of MCT assays in anaphylaxis has been variable in previous studies, due to multiple factors including differences in the definition of anaphylaxis, methods of MCT interpretation, clinical setting of anaphylaxis, causative agents, and timing of blood sample. An international consensus equation for MCT to interpret mast cell activation has been proposed and recently validated in the context of peri-operative anaphylaxis during general anesthesia. There has been an interest in the detection of newer biomarkers in anaphylaxis including platelet activation factor (PAF), chymase, carboxypeptidase A3, dipeptidyl peptidase I (DPPI), basogranulin, and CCL-2. The key determinants of an ideal biomarker in anaphylaxis are half-life, sample handling and processing requirements, and cost. There may be a role for metabolomics and systems biology in the exploration of novel biomarkers in anaphylaxis. Future studies applying these approaches might provide greater insight into factors determining severity, clinical risk stratification, identification of mast cell disorders and improving our understanding of this relatively complex acute immunological condition. Post mortem MCT evaluation is used in Forensic Medicine during autopsy for cases involving sudden death or suspected anaphylaxis. Interpretation of post mortem MCT is challenging since there is limited published evidence and the test is confounded by multiple variables largely linked to putrefaction and site of sampling. Thus, there is no international consensus on a reference range. In this state of the art review, we will focus on the practical challenges in the laboratory diagnosis of anaphylaxis and critically appraise (a) performance characteristics of MCT in anaphylaxis in different clinical scenarios (b) the role for novel biomarkers and (c) post mortem MCT and its role in fatal anaphylaxis.
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Affiliation(s)
- Sarah C Beck
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Thomas Wilding
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Richard J Buka
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Richard L Baretto
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Aarnoud P Huissoon
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Mamidipudi T Krishna
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Valent P, Akin C, Bonadonna P, Hartmann K, Brockow K, Niedoszytko M, Nedoszytko B, Siebenhaar F, Sperr WR, Oude Elberink JNG, Butterfield JH, Alvarez-Twose I, Sotlar K, Reiter A, Kluin-Nelemans HC, Hermine O, Gotlib J, Broesby-Olsen S, Orfao A, Horny HP, Triggiani M, Arock M, Schwartz LB, Metcalfe DD. Proposed Diagnostic Algorithm for Patients with Suspected Mast Cell Activation Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1125-1133.e1. [PMID: 30737190 DOI: 10.1016/j.jaip.2019.01.006] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 12/31/2018] [Accepted: 01/05/2019] [Indexed: 12/18/2022]
Abstract
Mast cell activation (MCA) accompanies diverse physiologic and pathologic processes and is one of the more frequently encountered conditions in medicine. MCA-related symptoms are usually mild and often transient. In such cases, histamine receptor blockers and other mediator-targeting drugs can usually control MCA. In severe cases, an MCA syndrome (MCAS) may be diagnosed. However, overt MCAS is an unusual condition, and many patients referred because of suspected MCAS are diagnosed with other diseases (autoimmune, neoplastic, or infectious) unrelated to MCA or suffer from MCA-related (eg, allergic) disorders and/or comorbidities without fulfilling criteria of an overt MCAS. These considerations are important as more and more patients are informed that they may have MCA or even MCAS without completing a thorough medical evaluation. In fact, in several instances, symptoms are misinterpreted as MCA/MCAS, and other clinically relevant conditions are not thoroughly pursued. The number of such referrals is increasing. To avoid such unnecessary referrals and to prevent misdiagnoses, we here propose a diagnostic algorithm through which a clinically relevant (systemic) MCA can be suspected and MCAS can subsequently be documented or excluded. In addition, the algorithm proposed should help guide the investigating care providers to consider the 2 principal diagnoses that may underlie MCAS, namely, severe allergy and systemic mastocytosis accompanied by severe MCA. Although validation is required, we anticipate that this algorithm will facilitate the management of patients with suspected MCAS.
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | | | - Karin Hartmann
- Department of Dermatology, University of Luebeck, Luebeck, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | | | - Frank Siebenhaar
- Department of Dermatology & Allergy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Joanna N G Oude Elberink
- Department of Allergology, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Ivan Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) and CIBERONC, Hospital Virgen del Valle, Toledo, Spain
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Andreas Reiter
- III. Medizinische Klinik, Universitäts-Medizin Mannheim, Universität Heidelberg, Mannheim, Germany
| | - 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
| | - Jason Gotlib
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, Calif
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - 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
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilian University, Munich, Germany
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - 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 & 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
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Mastocytosis-derived extracellular vesicles exhibit a mast cell signature, transfer KIT to stellate cells, and promote their activation. Proc Natl Acad Sci U S A 2018; 115:E10692-E10701. [PMID: 30352845 DOI: 10.1073/pnas.1809938115] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Extracellular vesicles (EVs) have been implicated in the development and progression of hematological malignancies. We thus examined serum samples from patients with systemic mastocytosis (SM) and found EVs with a mast cell signature including the presence of tryptase, FcεRI, MRGX2, and KIT. The concentration of these EVs correlated with parameters of disease including levels of serum tryptase, IL-6, and alkaline phosphatase and physical findings including hepatosplenomegaly. Given reports that EVs from one cell type may influence another cell's behavior, we asked whether SM-EVs might affect hepatic stellate cells (HSCs), based on the abnormal liver pathology associated with mastocytosis. We found that KIT was transferred from SM-EVs into an HSC line eliciting proliferation, cytokine production, and differentiation, processes that have been associated with liver pathology. These effects were reduced by KIT inhibition or neutralization and recapitulated by enforced expression of KIT or constitutively active D816V-KIT, a gain-of-function variant associated with SM. Furthermore, HSCs in liver from mice injected with SM-EVs had increased expression of α-SMA and human KIT, particularly around portal areas, compared with mice injected with EVs from normal individuals, suggesting that SM-EVs can also initiate HSC activation in vivo. Our data are thus consistent with the conclusion that SM-EVs have the potential to influence cells outside the hematological compartment and that therapeutic approaches for treatment of SM may be effective in part through inhibition of effects of EVs on target tissues, findings important both to understanding complex disease pathology and in developing interventional agents for the treatment of hematologic diseases.
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Abstract
Patients who present with typical features of mast cell activation with laboratory confirmation and without evidence of a clonal mast cell disorder or other medical condition should be initiated on medical treatment to block mast cells and their mediators. If a major response is achieved, a diagnosis of nonclonal mast cell activation syndrome (NC-MCAS) is likely and treatment should be optimized, including management of any associated conditions. In this review, the latest evidence with regard to the diagnosis and treatment of NC-MCAS is presented.
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Lyons JJ. Hereditary Alpha Tryptasemia: Genotyping and Associated Clinical Features. Immunol Allergy Clin North Am 2018; 38:483-495. [PMID: 30007465 DOI: 10.1016/j.iac.2018.04.003] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hereditary alpha tryptasemia is an autosomal dominant genetic trait caused by increased germline copies of TPSAB1 encoding alpha-tryptase. Individuals with this trait have elevated basal serum tryptase, and may present with associated multisystem complaints. Both basal serum tryptase levels and severity of clinical symptoms display a gene-dose relationship with TPSAB1, whereby higher tryptase levels and greater symptom severity are correlated with increasing numbers of alpha-encoding TPSAB1. As the functional effects of increased basal serum tryptase and/or altered tryptase gene expression are elucidated, greater insights will be gained into the symptoms associated with hereditary alpha tryptasemia and their potential therapy.
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Affiliation(s)
- Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Building 10, Room 11N240 MSC 1889, 10 Center Drive, Bethesda, MD 20892, USA.
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Paolino G, Corsetti P, Moliterni E, Corsetti S, Didona D, Albanesi M, Mattozzi C, Lido P, Calvieri S. Mast cells and cancer. GIORN ITAL DERMAT V 2017; 154:650-668. [PMID: 29192477 DOI: 10.23736/s0392-0488.17.05818-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Mast cells (MCs) are a potent proangiogenic factor in tumors, they product several pro-angiogenic factors such as fibroblast growth factor 2 (FGF-2), vascular epithelial growth factor (VEGF), tryptase and chymase. Tryptase is a serine protease classified as α-tryptase and β-tryptase, both produced by MCs. Tryptase degrades the tissues, playing an important role in angiogenesis and in the development of metastases. Serum tryptase increases with age, with increased damage to cells and risk of developing a malignancy and it could be considered the expression of a fundamental role of MCs in tumor growth or, on the contrary, in the antitumor response. Many biomarkers have been developed in clinical practice for improving diagnosis and prognosis of some neoplasms. Elevated tryptase levels are found in subgroups of patients with haematologic and solid cancers. In the current review, we want to update the perspectives of tryptase as a potential biomarker in daily practice in different neoplasms.
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Affiliation(s)
| | | | | | - Serena Corsetti
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, San Vito al Tagliamento, Pordenone, Italy -
| | - Dario Didona
- First Division of Dermatology, Istituto Dermopatico dell'Immacolata IRCCS, Rome, Italy
| | - Marcello Albanesi
- Department of Emergency and Organ Transplantation, School of Allergology and Clinical Immunology, University of Bari Aldo Moro, Bari, Italy
| | | | - Paolo Lido
- Internal Medicine Residency Program, Tor Vergata University, Rome, Italy
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48
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Mechanism-based biomarker discovery. Drug Discov Today 2017; 22:1209-1215. [DOI: 10.1016/j.drudis.2017.04.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/12/2017] [Accepted: 04/20/2017] [Indexed: 11/22/2022]
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Kárai B, Bedekovics J, Miltényi Z, Gergely L, Szerafin L, Ujfalusi A, Kappelmayer J, Hevessy Z. A single-tube flow cytometric procedure for enhancing the diagnosis and prognostic classification of patients with myelodysplastic syndromes. Int J Lab Hematol 2017. [DOI: 10.1111/ijlh.12700] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- B. Kárai
- Department of Laboratory Medicine; Faculty of Medicine; University of Debrecen; Debrecen Hungary
| | - J. Bedekovics
- Department of Pathology; Faculty of Medicine; University of Debrecen; Debrecen Hungary
| | - Zs. Miltényi
- Department of Medicine; Faculty of Medicine; University of Debrecen; Debrecen Hungary
| | - L. Gergely
- Department of Medicine; Faculty of Medicine; University of Debrecen; Debrecen Hungary
| | - L. Szerafin
- Department of Hematology; Jósa András County Hospital; Nyíregyháza Hungary
| | - A. Ujfalusi
- Department of Laboratory Medicine; Faculty of Medicine; University of Debrecen; Debrecen Hungary
| | - J. Kappelmayer
- Department of Laboratory Medicine; Faculty of Medicine; University of Debrecen; Debrecen Hungary
| | - Zs. Hevessy
- Department of Laboratory Medicine; Faculty of Medicine; University of Debrecen; Debrecen Hungary
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