Expanding Spectrum of Mast Cell Activation Disorders: Monoclonal and Idiopathic Mast Cell Activation Syndromes

Successful prevention of extremely frequent and severe food anaphylaxis in three children by combined traditional Chinese medicine therapy

Background

Despite strict avoidance, severely food-allergic children experience frequent and potentially severe food-induced anaphylaxis (FSFA). There are no accepted preventive interventions for FSFA. A Traditional Chinese Medicine (TCM) formula prevents anaphylaxis in murine food allergy models, and has immunomodulatory effects in humans. We analyzed the effects of TCM treatment on three pediatric patients with FSFA.

Case description

Three FSFA patients (P) ages 9–16 years (P1 allergic to milk; P2 and P3 to tree nuts) qualified for case analysis. All experienced numerous reactions requiring administration of rescue medications and emergency room (ER) visits during the 2 years prior to starting TCM. P1 experienced approximately 100 reactions, 50 epinephrine administrations, 40 ER visits, and 3 admissions to intensive care units. P2 experienced 30 reactions, all requiring epinephrine administration, as well as 10 emergency hospitalizations. P3 experienced 400 reactions, five of which required epinephrine administration and ER visits. TCM treatment markedly reduced or eliminated reactions in all. P1 experienced no reactions after 2.5 years of TCM. P2 experienced no reactions after 1 year of TCM treatment, at which time she passed an oral almond food challenge. She continues to be reaction-free 6 months off TCM while consuming nuts. P3 has achieved a 94% reduction in reaction frequency following 7 months of TCM, has discontinued daily antihistamine use, and has required no epinephrine administrations or ER visits.

Conclusions

Three children treated with TCM experienced dramatic reductions or elimination of FSFA. This regimen appears to present a potential option for FSFA, and warrants further investigation in controlled clinical studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13223-014-0066-5) contains supplementary material, which is available to authorized users.

Outcomes of allergy/immunology follow-up after an emergency department evaluation for anaphylaxis

BACKGROUND

Anaphylaxis guidelines currently recommend referring patients with anaphylaxis seen in the emergency department (ED) to an allergist for follow up.

OBJECTIVE

The objective of our study was to evaluate outcomes of allergy/immunology follow-up after an ED visit for anaphylaxis.

METHODS

A retrospective health records review was conducted from April 2008 to August 2012. Charts were reviewed independently by 2 allergists to determine outcomes. Descriptive statistics with corresponding 95% CIs were calculated.

RESULTS

Among 573 patients seen in the ED who met anaphylaxis diagnostic criteria, 217 (38%) had a documented allergy/immunology follow-up. After allergy/immunology evaluation, 16 patients (7% [95% CI, 5%-12%]) had anaphylaxis ruled out. Among those with an unknown ED trigger (n = 74), 24 (32% [95% CI, 23%-44%]) had a trigger identified; and, among those who had a specific suspected ED trigger (n = 143), 9 (6% [95% CI, 3%-12%]) had a trigger identified in a category other than the one suspected in the ED, and 28 (20% [95% CI, 14%-27%]) had an unknown trigger. Thus, there were a total of 77 patients (35% [95% CI, 29%-42%]) who had an alteration in the diagnosis of anaphylaxis or trigger after allergy/immunology evaluation. Four patients (2% [95% CI, 0.7%-4.6%]) were diagnosed with a mast cell activation disorder, and 13 patients (6% [95% CI, 4%-10%]) underwent immunotherapy or desensitization.

CONCLUSION

Overall, 35% of the patients with suspected anaphylaxis in the ED had an alteration in the diagnosis or suspected trigger after allergy/immunology evaluation. These results underscore the importance of allergy/immunology follow-up after an ED visit for anaphylaxis.

Anaphylaxis as a clinical manifestation of clonal mast cell disorders

Clonal mast cell disorders comprise a heterogeneous group of disorders characterized by the presence of gain of function KIT mutations and a constitutively altered activation-associated mast cell immunophenotype frequently associated with clinical manifestations related to the release of mast cells mediators. These disorders do not always fulfil the World Health Organization (WHO)-proposed criteria for mastocytosis, particularly when low-sensitive diagnostic approaches are performed. Anaphylaxis is a frequent presentation of clonal mast cell disorders, particularly in mastocytosis patients without typical skin lesions. The presence of cardiovascular symptoms, e.g., hypotension, occurring after a hymenoptera sting or spontaneously in the absence of cutaneous manifestations such as urticaria is characteristic and differs from the presentation of anaphylaxis in the general population without mastocytosis.

Spectrum of mast cell activation disorders

Mast cell (MC) activation disorders present with multiple symptoms including flushing, pruritus, hypotension, gastrointestinal complaints, irritability, headaches, concentration/memory loss and neuropsychiatric issues. These disorders are classified as: cutaneous and systemic mastocytosis with a c-kit mutation and clonal MC activation disorder, allergies, urticarias and inflammatory disorders and mast cell activation syndrome (MCAS), idiopathic urticaria and angioedema. MCs are activated by IgE, but also by cytokines, environmental, food, infectious, drug and stress triggers, leading to secretion of multiple mediators. The symptom profile and comorbidities associated with these disorders, such as chronic fatigue syndrome and fibromyalgia, are confusing. We propose the use of the term 'spectrum' and highlight the main symptoms, useful diagnostic tests and treatment approaches.

Stress triggers coronary mast cells leading to cardiac events

OBJECTIVE

Stress precipitates and worsens not only asthma and atopic dermatitis but also acute coronary syndromes (ACSs), which are associated with coronary inflammation. Evidence linking stress to ACS was reviewed and indicated that activation of coronary mast cells (MCs) by stress, through corticotropin-releasing hormone (CRH) and other neuropeptides, contributes to coronary inflammation and coronary artery disease.

DATA SOURCES

PubMed was searched (2005-2013) for articles using the following keywords: allergies, anaphylaxis, anxiety, coronary arteries, coronary artery disease, C-reactive protein, cytokines, chymase, histamine, hypersensitivity, interleukin-6 (IL-6), inflammation, mast cells, myocardial ischemia, niacin, platelet-activating factor, rupture, spasm, statins, stress, treatment, tryptase, and uroctortin.

STUDY SELECTIONS

Articles were selected based on their relevance to how stress affects ACS and how it activates coronary MCs, leading to coronary hypersensitivity, inflammation, and coronary artery disease.

RESULTS

Stress can precipitate allergies and ACS. Stress stimulates MCs through the activation of high-affinity surface receptors for CRH, leading to a CRH-dependent increase in serum IL-6. Moreover, neurotensin secreted with CRH from peripheral nerves augments the effect of CRH and stimulates cardiac MCs to release IL-6, which is elevated in ACS and is an independent risk factor for myocardial ischemia. MCs also secrete CRH and uroctortin, which induces IL-6 release from cardiomyocytes. The presence of atherosclerosis increases the risk of cardiac MC activation owing to the stimulatory effect of lipoproteins and adipocytokines. Conditions such as Kounis syndrome, mastocytosis, and myalgic encephalopathy/chronic fatigue syndrome are particularly prone to coronary hypersensitivity reactions.

CONCLUSION

Inhibition of cardiac MCs may be a novel treatment approach.