[Food allergy at school: Personalized healthcare project and adrenaline]

In Europe, the prevalence of food allergy is estimated at 6-8% of children. Ten to 20% of pediatric food-induced anaphylaxis reactions occur at school. Individual healthcare plans (IHP) for food allergy aim at: identifying children at risk of allergic reactions; reducing the risk of allergen exposure; providing emergency kits containing adrenaline auto-injectors (AAI) if needed with emergency action plans and instructions about when and how to use AAI. In France, IHP were introduced into law in 2003 and was updated in 2021. The number of IHP for allergy is increasing since 10 years (50,000 IHP for allergy/year). While the recommendations of the learned societies have resulted in the national harmonization of criteria for the implementation of IHP for allergy and for the prescription of emergency kits with AAI, adrenaline remains underused. In 2019, a national policy stated that all high schools must have a provision of spare AAI in case of anaphylaxis and the promotion of school staff training about food allergy and anaphylaxis was encouraged. These recommendations should be assessed widely and allergy training should be widespread. Pharmacists play an important role to take care of food-allergic children: provision of AAI prescribed for the most at-risk food allergic patients, advice and information on AAI. The pharmacist is therefore a key player in the therapeutic education of the patient to reinforce the key messages on the efficacy and safety of adrenaline used for anaphylaxis.

[Tryptase: A practical guide for the physician]

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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Zusammenfassung. Die Anaphylaxie als schwerwiegendste Manifestation einer in der Regel allergischen Soforttypreaktion stellt eine potenziell lebensbedrohliche Notfallsituation dar, mit der jeder Arzt auch in der Praxis konfrontiert sein kann. Durch steigende Prävalenzzahlen gewinnt das Thema zunehmend an Bedeutung. Im folgenden Artikel beschreiben wir Auslöser, Klinik, diagnostische Hilfsmittel, Risiko- und Augmentationsfaktoren sowie medikamentöse Therapie in dieser Altersgruppe und klären die Frage, welchem Patienten Sie einen Adrenalinautoinjektor rezeptieren sollen. Daten zur Beeinträchtigung der Lebensqualität nach durchgemachter Anaphylaxie zeigen, wie wichtig die weitere Betreuung nach dem Akutereignis ist. Diagnostik zur Klärung des Auslösers, aber vor allem auch Schulung zur Selbsthilfe und Abgabe eines individualisierten Behandlungsplans können die Situation für die Betroffenen und deren Eltern vereinfachen.

[IgE mediated anaphylaxis in a patient with systemic mastocytosis]

BACKGROUND

Anaphylaxis is a severe, generalized, life-threatening reaction of rapid onset. We report the case of a patient presenting several systemic anaphylactic reactions over many years, initially ascribed to a cereals allergy but which finally proved to be due to systemic mastocytosis hidden for a long time.

PATIENTS AND METHODS

A 53-year-old man consulted for an eruption consisting of monomorphic pigmented maculopapular lesions on the trunk associated with itching and urticaria. He was a farmer and presented severe sensitivity to cereals, with anaphylaxis, which continued despite withdrawal of these allergens. Skin and bone marrow infiltration, abnormal mast cells, positivity for c-kit 816 mutation and the persistent elevation of serum tryptase enabled a diagnosis of indolent systemic mastocytosis to be made.

DISCUSSION

In systemic mastocytosis anaphylaxis is an expected complication relating to the proliferation of mast cells and a massive increase in mediator release (non-immunological mechanism). All patients with severe and recurrent anaphylaxis should be analyzed for underlying mastocytosis by careful physical examination and assay of baseline tryptase.