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Sagües‐Sesé E, García‐Casares N, Álvarez‐Twose I. Cognitive, neuropsychiatric and neurological alterations in mastocytosis: A systematic review. Clin Transl Allergy 2023; 13:e12319. [PMID: 38146805 PMCID: PMC10718195 DOI: 10.1002/clt2.12319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Mastocytosis manifests with multisystemic symptoms, often involving the nervous system. Numerous cognitive, neuropsychiatric and neurological alterations have been reported in multiple observational studies. METHODS We performed a qualitative systematic literature review of reported data consulting the electronic databases Medline, Scopus, Web of Science, Cochrane, and BASE until June 2023. RESULTS We selected 24 studies in which the majority showed that a high proportion of mastocytosis patients suffer cognitive, neuropsychiatric and neurological alterations. The most common disorders and estimated ranges of frequency observed in adults were depression (68%-75%), anxiety, high stress or irritability (27%-54%), cognitive impairment (27%-39%, primarily affecting memory skills), and headaches (55%-69%). Attention challenges and learning difficulties were reported in children at a rate of 13%, while neurodevelopmental disorders occurred at rates of 8%-12%. Frequent white abnormalities in mastocytosis patients with concomitant psychocognitive symptoms have been reported although neuroimaging studies have been performed rarely in this population. CONCLUSION Further studies with more comprehensive and homogeneous evaluations and neuroimaging and histological analysis should be performed for a better understanding of these manifestations. An earlier detection and proper management of these symptoms could greatly improve the quality of life of these patients.
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Affiliation(s)
- Elena Sagües‐Sesé
- Departamento de Medicina, Facultad de MedicinaUniversidad de MálagaMálagaSpain
| | - Natalia García‐Casares
- Departamento de Medicina, Facultad de MedicinaUniversidad de MálagaMálagaSpain
- Centro de Investigaciones Médico‐Sanitarias (CIMES), Fundación General de la Universidad de Málaga, Universidad de MálagaMálagaSpain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA Plataforma BIONAND)MálagaSpain
| | - Ivan Álvarez‐Twose
- Instituto de Estudios de Mastocitosis de Castilla‐La Mancha (CLMast)Reference Center for Mastocytosis and CIBERONCToledoSpain
- Spanish Network on Mastocytosis (REMA)Toledo and SalamancaSpain
- Instituto de Investigación Sanitaria de Castilla‐La Mancha (IDISCAM)ToledoSpain
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Guillaume-Jugnot P, Shor N, Bielle F, Zavanone C, Barete S, Maillart E. Atypical multiple sclerosis associated with indolent systemic mastocytosis treated by cladribine. Rev Neurol (Paris) 2023; 179:925-927. [PMID: 37500352 DOI: 10.1016/j.neurol.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/14/2022] [Accepted: 03/11/2023] [Indexed: 07/29/2023]
Affiliation(s)
- P Guillaume-Jugnot
- Department of Internal Medicine and Clinical Immunology, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France.
| | - N Shor
- Department of Neuroradiology, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - F Bielle
- Department of Neuropathology, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France; Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière (ICM), Sorbonne Université, Paris, France
| | - C Zavanone
- Department of Neurology, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - S Barete
- Unit of Dermatology, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France; Reference center for mastocytosis (CEREMAST), Hôpital Pitié-Salpêtrière, Paris, France
| | - E Maillart
- Department of Neurology, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
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3
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Di Mauro P, Anzivino R, Distefano M, Borzì DD. Systemic mastocytosis: The roles of histamine and its receptors in the central nervous system disorders. J Neurol Sci 2021; 427:117541. [PMID: 34139449 DOI: 10.1016/j.jns.2021.117541] [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: 04/26/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/28/2022]
Abstract
Mastocytosis is a rare disease of clonal hematological disorders characterized by a pathological accumulation of Mast Cells (MCs) in different tissues, with variable symptomatology and prognosis. Signs and symptoms of Systemic Mastocytosis (SM) are due to pathological infiltration of MCs and to the release of chemical mediators, mainly histamine. Patients with SM may also present with neurological symptoms or complications. The pathophysiology of these neurological disorders remains uncertain to this day, but it can be associated with the infiltration of tissue mastocytes, release of mastocytes' mediators or both. Moreover, there is a lot to understand about the role of neurological symptoms in SM and knowing, for example, what is the real frequency of neurological disorders in SM and if is present a relation between other SM subtypes, because it has been noted that the alteration of the histamine expression may be an initiating factor for susceptibility, gravity and progression of the epigenetic disease. In this review we explain the possible pathophysiological mechanism about neurological symptomatology found in some patients affected by SM, describing the role of histamine and its receptors in the nervous system and, in light of the results, what the future prospects may be for a more specific course of treatment.
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Affiliation(s)
- Paola Di Mauro
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia" A.O.U. "Policlinico - Vittorio Emanuele", University of Catania, Catania, Italy.
| | | | | | - Davide Domenico Borzì
- University of Catania, Italy and Italian Federation of Sports Medicine (FMSI), Rome, Italy
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4
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Jendoubi F, Severino-Freire M, Negretto M, Arbus C, Paul C, Bulai Livideanu C. Neuropsychiatric, cognitive and sexual impairment in mastocytosis patients. Orphanet J Rare Dis 2021; 16:118. [PMID: 33673856 PMCID: PMC7934538 DOI: 10.1186/s13023-021-01747-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/16/2021] [Indexed: 11/15/2022] Open
Abstract
Background Mastocytosis is a rare disease characterised by the accumulation and/or proliferation of abnormal mast cells (MCs) in one or several organs. It may present with a number of different symptoms that involve various organ systems. The current study aims to assess the prevalence of MC mediator-related symptoms in a cohort of mastocytosis patients with a specific focus on neurological, psychiatric, cognitive and sexual symptoms. We also assessed the impact of the disease on patients’ professional lives. Patients were administered a validated multidimensional questionnaire to collect information on patients’ perception of the severity of their symptoms. From the questionnaires we extracted the neurological, cognitive, psychiatric and sexual symptoms and the impact of the disease on patients’ professional lives as well as their grading. The affective status was assessed using the 17-item version of the Hamilton Depression Rating Scale. Results We included 139 patients. Mastocytosis was classified as systemic in 113 patients and cutaneous in 26 patients. The prevalence of MC mediator-related systemic symptoms was as follows: cutaneous (71%), gastro-intestinal (48%), cardio-vascular (36%), musculoskeletal (26.6%), fatigue (24%), urinary (14.4%) and respiratory (10%). Headaches and vertigo were noted in respectively 55% and 32% of patients. Irritability, episodes of memory loss and difficulty concentrating were reported in 54%, 52% and 40% of cases, respectively. Sexual impairment was noted in 24% of patients. No associations were found between neuropsychiatric/cognitive impairment and age, gender, diagnostic delay, disease form, the presence of cutaneous lesions, the level of serum and bone marrow tryptase and the presence of KIT mutation in bone marrow and/or skin. Depression was noted in 49% of patients. One in four patients reported a negative impact of the disease on their professional lives. Conclusion This current study provides some insights regarding symptoms related to mastocytosis and their impact on patients’ professional lives.
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Affiliation(s)
- Fatma Jendoubi
- Mastocytosis National Expert Centre (CEREMAST), Department of Dermatology, Toulouse University Hospital, 24 Chemin de Pouvourville, 31059, Toulouse, France
| | - Maella Severino-Freire
- Mastocytosis National Expert Centre (CEREMAST), Department of Dermatology, Toulouse University Hospital, 24 Chemin de Pouvourville, 31059, Toulouse, France
| | - Mathilde Negretto
- Mastocytosis National Expert Centre (CEREMAST), Department of Dermatology, Toulouse University Hospital, 24 Chemin de Pouvourville, 31059, Toulouse, France
| | - Christophe Arbus
- Department of Psychiatry, Toulouse University Hospital, Tonic Inserm 1214, Toulouse, France
| | - Carle Paul
- Mastocytosis National Expert Centre (CEREMAST), Department of Dermatology, Toulouse University Hospital, 24 Chemin de Pouvourville, 31059, Toulouse, France
| | - Cristina Bulai Livideanu
- Mastocytosis National Expert Centre (CEREMAST), Department of Dermatology, Toulouse University Hospital, 24 Chemin de Pouvourville, 31059, Toulouse, France.
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Rodrigues F, Edjlali M, Georgin-Lavialle S, Chandesris O, Barete S, Bouktit H, Dubreuil P, Hamidou M, Saadoun D, Gaillard R, Hermine O. Neuroinflammatory disorders and mastocytosis: A possible association? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:2878-2881.e1. [PMID: 31077881 DOI: 10.1016/j.jaip.2019.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/29/2019] [Accepted: 04/12/2019] [Indexed: 06/09/2023]
Affiliation(s)
- François Rodrigues
- Internal Medicine Department, Tenon Hospital, Université Pierre et Marie Curie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Myriam Edjlali
- Departments of Neuroradiology, Université Paris Descartes Sorbonne Paris Cité, INSERM S894, DHU Neurovasc, Sainte-Anne Hospital, Paris, France
| | - Sophie Georgin-Lavialle
- Internal Medicine Department, Tenon Hospital, Université Pierre et Marie Curie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivia Chandesris
- Centre de référence des mastocytoses (CEREMAST), Université Paris Descartes, Sorbonne, Paris Cité, Necker Enfants Malades Hospital, Imagine Foundation, Paris, France
| | - Stéphane Barete
- Centre de référence des mastocytoses (CEREMAST), Université Paris Descartes, Sorbonne, Paris Cité, Necker Enfants Malades Hospital, Imagine Foundation, Paris, France; Dermatology Department, Pitié-Salpêtrière Hospital, Université Pierre et Marie Curie, Paris, France
| | - Hassiba Bouktit
- Centre de référence des mastocytoses (CEREMAST), Université Paris Descartes, Sorbonne, Paris Cité, Necker Enfants Malades Hospital, Imagine Foundation, Paris, France
| | - Patrice Dubreuil
- Centre de référence des mastocytoses (CEREMAST), Université Paris Descartes, Sorbonne, Paris Cité, Necker Enfants Malades Hospital, Imagine Foundation, Paris, France
| | - Mohamed Hamidou
- Internal Medicine Department, Nantes Teaching Hospital, Université de Nantes, Nantes, France
| | - David Saadoun
- Internal Medicine Department, Pitié-Salpêtrière Hospital, Université Pierre et Marie Curie, Paris, France
| | - Raphaël Gaillard
- "Psychiatric Diseases Pathophysiology" Laboratory, Psychiatry and Neurosciences Centre U894, INSERM, Paris, France; Psychiatry Department, Sainte-Anne Hospital, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine Paris Descartes, Paris, France
| | - Olivier Hermine
- Centre de référence des mastocytoses (CEREMAST), Université Paris Descartes, Sorbonne, Paris Cité, Necker Enfants Malades Hospital, Imagine Foundation, Paris, France; INSERM U1163 and CNRS ERL 8254, Laboratory of Physiopathology and Treatment of Hematological Disorders, Paris, France; Adults Haematology Unit, Université Paris Descartes, Sorbonne, Paris Cité, Assistance Publique-Hôpitaux de Paris, Imagine Foundation, Necker-Enfants Malades Hospital, Paris, France.
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6
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Birn CS. Mastocytosis. Gastroenterol Nurs 2018; 41:380-387. [PMID: 30272600 DOI: 10.1097/sga.0000000000000344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Mastocytosis is a rare and underdiagnosed disorder characterized by mast cell proliferation in the tissues and organs of the body. The gastrointestinal manifestations of the disease can be noted in approximately 70%-80% of those patients diagnosed with the disorder. Symptomatic manifestations of systemic mastocytosis can either be triggered spontaneously or be precipitated by a variety of situations, stimuli, and exposures. Common gastrointestinal complaints include abdominal pain, diarrhea, nausea, vomiting, and gastrointestinal reflux disease. Substantial numbers of mast cells have been noted in patients who have been diagnosed with gastritis, ulcerative colitis, and Crohn disease. Irreversible, with symptoms that run the gamut from the merely annoying to the severely life-threatening, mastocytosis is a disease that prevents an individual from leading a normal life. As the prevalence of gastrointestinal symptomatology in those patients who have been diagnosed with mastocytosis is so significant, it is an important and relevant disease of which gastroenterology nurses should be cognizant.
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Affiliation(s)
- Cathy S Birn
- Cathy S. Birn, MA, RN, CGRN, CNOR, is Pre-Procedure Assessment Coordinator, Endoscopy, Memorial Sloan-Kettering Cancer Center, New York
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8
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Rastogi V, Singh D, Mazza JJ, Parajuli D, Yale SH. Flushing Disorders Associated with Gastrointestinal Symptoms: Part 1, Neuroendocrine Tumors, Mast Cell Disorders and Hyperbasophila. Clin Med Res 2018; 16:16-28. [PMID: 29650525 PMCID: PMC6108509 DOI: 10.3121/cmr.2017.1379a] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/30/2017] [Accepted: 12/21/2017] [Indexed: 02/08/2023]
Abstract
Flushing is the subjective sensation of warmth accompanied by visible cutaneous erythema occurring throughout the body with a predilection for the face, neck, pinnae, and upper trunk where the skin is thinnest and cutaneous vessels are superficially located and in greatest numbers. Flushing can be present in either a wet or dry form depending upon whether neural-mediated mechanisms are involved. Activation of the sympathetic nervous system results in wet flushing, accompanied by diaphoresis, due to concomitant stimulation of eccrine sweat glands. Wet flushing is caused by certain medications, panic disorder and paroxysmal extreme pain disorder (PEPD). Vasodilator mediated flushing due to the formation and release of a variety of biogenic amines, neuropeptides and phospholipid mediators such as histamine, serotonin and prostaglandins, respectively, typically presents as dry flushing where sweating is characteristically absent. Flushing occurring with neuroendocrine tumors accompanied by gastrointestinal symptoms is generally of the dry flushing variant, which may be an important clinical clue to the differential diagnosis. A number of primary diseases of the gastrointestinal tract cause flushing, and conversely extra-intestinal conditions are associated with flushing and gastrointestinal symptoms. Gastrointestinal findings vary and include one or more of the following non-specific symptoms such as abdominal pain, nausea, vomiting, diarrhea or constipation. The purpose of this review is to provide a focused comprehensive discussion on the presentation, pathophysiology, diagnostic evaluation and management of those diseases that arise from the gastrointestinal tract or other site that may cause gastrointestinal symptoms secondarily accompanied by flushing. This review is divided into two parts given the scope of conditions that cause flushing and affect the gastrointestinal tract: Part 1 covers neuroendocrine tumors (carcinoid, pheochromocytomas, vasoactive intestinal polypeptide, medullary carcinoma of the thyroid), polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes (POEMS), and conditions involving mast cells and basophils; while Part 2 covers dumping syndrome, mesenteric traction syndrome, rosacea, hyperthyroidism and thyroid storm, anaphylaxis, panic disorders, paroxysmal extreme pain disorder, and food, alcohol and medications.
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Affiliation(s)
- Vaibhav Rastogi
- University of Central Florida College of Medicine/HCA Consortium Graduate Medical Education, North Florida Regional Medical Center, 6500 W Newberry Rd, Gainesville, FL 32605
- University of Central Florida College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827
| | - Devina Singh
- Feinstein Institute for Medical Research, 350 Community Dr. Manhasset, NY 11030
| | - Joseph J Mazza
- Marshfield Clinic Research Institute, 1000 North Oak Avenue, Marshfield, WI 54449
| | - Dipendra Parajuli
- University of Louisville, Department of Medicine, Gastroenterology, Hepatology and Nutrition. Director, Fellowship Training Program, Director, Medical Procedure Unit Louisville VAMC 401 East Chestnut Street, Louisville, KY 40202
| | - Steven H Yale
- University of Central Florida College of Medicine/HCA Consortium Graduate Medical Education, North Florida Regional Medical Center, 6500 W Newberry Rd, Gainesville, FL 32605.
- University of Central Florida College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827
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9
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Boddaert N, Salvador A, Chandesris MO, Lemaître H, Grévent D, Gauthier C, Naggara O, Georgin-Lavialle S, Moura DS, Munsch F, Jaafari N, Zilbovicius M, Lortholary O, Gaillard R, Hermine O. Neuroimaging evidence of brain abnormalities in mastocytosis. Transl Psychiatry 2017; 7:e1197. [PMID: 28786975 PMCID: PMC5611717 DOI: 10.1038/tp.2017.137] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 04/06/2017] [Accepted: 04/20/2017] [Indexed: 01/08/2023] Open
Abstract
Mastocytosis is a rare disease in which chronic symptoms are related to mast cell accumulation and activation. Patients can display depression-anxiety-like symptoms and cognitive impairment. The pathophysiology of these symptoms may be associated with tissular mast cell infiltration, mast cell mediator release or both. The objective of this study is to perform morphological or functional brain analyses in mastocytosis to identify brain changes associated with this mast cell disorder. We performed a prospective and monocentric comparative study to evaluate the link between subjective psycho-cognitive complaints, psychiatric evaluation and objective medical data using magnetic resonance imaging with morphological and perfusion sequences (arterial spin-labeled perfusion) in 39 patients with mastocytosis compared with 33 healthy controls. In the test cohort of 39 mastocytosis patients with psycho-cognitive complaints, we found that 49% of them had morphological brain abnormalities, mainly abnormal punctuated white matter abnormalities (WMA). WMA were equally frequent in cutaneous mastocytosis patients and indolent forms of systemic mastocytosis patients (42% and 41% of patients with WMA, respectively). Patients with WMA showed increased perfusion in the putamen compared with patients without WMA and with healthy controls. Putamen perfusion was also negatively correlated with depression subscores. This study demonstrates, for we believe the first time, a high prevalence of morphological and functional abnormalities in the brains of mastocytosis patients with neuropsychiatric complaints. Further studies are required to determine the mechanism underpinning this association and to ascertain its specificity.
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Affiliation(s)
- N Boddaert
- Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, University René Descartes, PRES Sorbonne Paris Cité, INSERM U1000 and UMR 1163, Institut Imagine, Paris, France,Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, University René Descartes, PRES Sorbonne Paris Cité, INSERM U1000 and UMR 1163, Institut Imagine, 149 rue de Sèvres, 75015 Paris, France. E-mail:
| | - A Salvador
- Laboratoire de “Physiopathologie des Maladies Psychiatriques”, Centre de Psychiatrie et Neurosciences U894, INSERM, Université Paris Descartes, Sorbonne Paris Cité, Paris, France,Service de Psychiatrie, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine Paris Descartes, Paris, France
| | - M O Chandesris
- Centre de Référence des Mastocytoses, Université Paris Descartes, Sorbonne, Paris Cité, Hôpital Necker-Enfants Malades, Fondation Imagine, Paris, France,Service d'Hématologie Adulte, Université Paris Descartes, Sorbonne, Paris Cité, Assistance Publique-Hôpitaux de Paris, Institut Imagine, Hôpital Necker-Enfants Malades, Paris, France
| | - H Lemaître
- Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, University René Descartes, PRES Sorbonne Paris Cité, INSERM U1000 and UMR 1163, Institut Imagine, Paris, France
| | - D Grévent
- Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, University René Descartes, PRES Sorbonne Paris Cité, INSERM U1000 and UMR 1163, Institut Imagine, Paris, France
| | - C Gauthier
- Service de Psychiatrie, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine Paris Descartes, Paris, France
| | - O Naggara
- Department of Neuroradiology, Service Hospitalo-Universitaire, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR894, Paris, France
| | - S Georgin-Lavialle
- Centre de Référence des Mastocytoses, Université Paris Descartes, Sorbonne, Paris Cité, Hôpital Necker-Enfants Malades, Fondation Imagine, Paris, France,INSERM U1163 and CNRS ERL 8254 and Laboratory of Physiopathology and Treatment of Hematological Disorders, Hôpital Necker-Enfants Malades, Paris, France,Service de Médecine Interne, Hôpital Tenon, Université Pierre et Marie Curie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - D S Moura
- Centre de Référence des Mastocytoses, Université Paris Descartes, Sorbonne, Paris Cité, Hôpital Necker-Enfants Malades, Fondation Imagine, Paris, France,INSERM U1163 and CNRS ERL 8254 and Laboratory of Physiopathology and Treatment of Hematological Disorders, Hôpital Necker-Enfants Malades, Paris, France,Laboratoire de Psychopathologie et Processus de Santé, EA 4057, IUPDP, Institut de Psychologie, Université Paris Descartes, Paris, France
| | - F Munsch
- MRI France GE Healthcare, Vélizy Villacoublay, France and Université de Bordeaux, Bordeaux, France,Inserm U1215 - Neurocentre Magendie, Bordeaux, France
| | - N Jaafari
- Unité de Recherche Clinique Intersectorielle en Psychiatrie à Vocation Régionale Pierre Deniker du Centre Hospitalier Henri Laborit, INSERM CIC-P 1402, INSERM U 1084 Laboratoire Expérimental et Clinique en Neurosciences, Univ Poitiers, CHU Poitiers, Groupement De Recherche CNRS 3557, Poitiers, France
| | - M Zilbovicius
- Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, University René Descartes, PRES Sorbonne Paris Cité, INSERM U1000 and UMR 1163, Institut Imagine, Paris, France
| | - O Lortholary
- Centre de Référence des Mastocytoses, Université Paris Descartes, Sorbonne, Paris Cité, Hôpital Necker-Enfants Malades, Fondation Imagine, Paris, France,Infectious Diseases Unit, Necker-Enfants Malades Hospital, AP-HP Paris, Paris, France,Paris Descartes University, Imagine Institute, Paris, France
| | - R Gaillard
- Laboratoire de “Physiopathologie des Maladies Psychiatriques”, Centre de Psychiatrie et Neurosciences U894, INSERM, Université Paris Descartes, Sorbonne Paris Cité, Paris, France,Service de Psychiatrie, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine Paris Descartes, Paris, France,Centre de Référence des Mastocytoses, Université Paris Descartes, Sorbonne, Paris Cité, Hôpital Necker-Enfants Malades, Fondation Imagine, Paris, France,Human Histopathology and Animal Models, Infection and Epidemiology Department, Institut Pasteur, Paris, France
| | - O Hermine
- Centre de Référence des Mastocytoses, Université Paris Descartes, Sorbonne, Paris Cité, Hôpital Necker-Enfants Malades, Fondation Imagine, Paris, France,Service d'Hématologie Adulte, Université Paris Descartes, Sorbonne, Paris Cité, Assistance Publique-Hôpitaux de Paris, Institut Imagine, Hôpital Necker-Enfants Malades, Paris, France,INSERM U1163 and CNRS ERL 8254 and Laboratory of Physiopathology and Treatment of Hematological Disorders, Hôpital Necker-Enfants Malades, Paris, France
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Georgin-Lavialle S, Gaillard R, Moura D, Hermine O. Mastocytosis in adulthood and neuropsychiatric disorders. Transl Res 2016; 174:77-85.e1. [PMID: 27063957 DOI: 10.1016/j.trsl.2016.03.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/04/2016] [Accepted: 03/15/2016] [Indexed: 12/18/2022]
Abstract
Patients with mastocytosis can display various disabling general and neuropsychological symptoms among one third of them, including general signs such as fatigue and musculoskeletal pain, which can have a major impact on quality of life. Neurological symptoms are less frequent and mainly consist of acute or chronic headache (35%), rarely syncopes (5%), acute onset back pain (4%), and in a few cases, clinical and radiological symptoms resembling or allowing the diagnosis of multiple sclerosis (1.3%). Headaches are associated with symptoms related to mast cell activation syndrome (flushes, prurit, and so forth) and more frequently present as migraine (37.5%), with often aura (66%). Depression-anxiety like symptoms can occur in 40% to 60% of the patients and cognitive impairment is not rare (38.6%). The pathophysiology of these symptoms could be linked to tissular mast cell infiltration or to mast cell mediators release or both. The tryptophan metabolism could be involved in mast cell-induced neuroinflammation through indoleamine-2,3-dioxygenase activation. Treatments targeting mast cell may be useful to target neuropsychological features associated with mastocytosis, including tyrosine kinase inhibitors.
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Affiliation(s)
- Sophie Georgin-Lavialle
- Service de médecine Interne, Hôpital Tenon, Université Pierre et Marie Curie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Raphaël Gaillard
- Laboratoire de "Physiopathologie des maladies Psychiatriques", Centre de Psychiatrie et Neurosciences U894, INSERM; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Service de Psychiatrie, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine Paris Descartes, Paris, France; Human Histopathology and Animal Models, Infection and Epidemiology Department, Institut Pasteur, Paris, France
| | - Daniela Moura
- Centre de référence des mastocytoses, Université Paris Descartes, Sorbonne, Paris Cité, Hôpital Necker Enfants malades, Paris, France
| | - Olivier Hermine
- Centre de référence des mastocytoses, Université Paris Descartes, Sorbonne, Paris Cité, Hôpital Necker Enfants malades, Paris, France; INSERM U1163 and CNRS ERL 8254 and Laboratory of Physiopathology and Treatment of Hematological Disorders Hôpital Necker-Enfants malades, Institut Imagine, Paris, France; Service d'hématologie adulte, Université Paris Descartes, Sorbonne, Paris Cité, Assistance Publique-Hôpitaux de Paris, Institut Imagine, Hôpital Necker-Enfants malades, Paris, France.
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Severino M, Chandesris MO, Barete S, Tournier E, Sans B, Laurent C, Apoil PA, Lamant L, Mailhol C, Laroche M, Fraitag S, Hanssens K, Dubreuil P, Hermine O, Paul C, Bulai Livideanu C. Telangiectasia macularis eruptiva perstans (TMEP): A form of cutaneous mastocytosis with potential systemic involvement. J Am Acad Dermatol 2016; 74:885-91.e1. [DOI: 10.1016/j.jaad.2015.10.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/26/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
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Mast cell activation disease: An underappreciated cause of neurologic and psychiatric symptoms and diseases. Brain Behav Immun 2015; 50:314-321. [PMID: 26162709 DOI: 10.1016/j.bbi.2015.07.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/15/2015] [Accepted: 07/01/2015] [Indexed: 02/07/2023] Open
Abstract
Neurologists and psychiatrists frequently encounter patients whose central and/or peripheral neurologic and/or psychiatric symptoms (NPS) are accompanied by other symptoms for which investigation finds no unifying cause and for which empiric therapy often provides little to no benefit. Systemic mast cell activation disease (MCAD) has rarely been considered in the differential diagnosis in such situations. Traditionally, MCAD has been considered as just one rare (neoplastic) disease, mastocytosis, generally focusing on the mast cell (MC) mediators tryptase and histamine and the suggestive, blatant symptoms of flushing and anaphylaxis. Recently another form of MCAD, MC activation syndrome (MC), has been recognized, featuring inappropriate MC activation with little to no neoplasia and likely much more heterogeneously clonal and far more prevalent than mastocytosis. There also has developed greater appreciation for the truly very large menagerie of MC mediators and their complex patterns of release, engendering complex, nebulous presentations of chronic and acute illness best characterized as multisystem polymorbidity of generally inflammatory ± allergic themes--including very wide arrays of central and peripheral NPS. Significantly helpful treatment--including for neuropsychiatric issues--usually can be identified once MCAD is accurately diagnosed. We describe MCAD's pathogenesis, presentation (focusing on NPS), and therapy, especially vis-à-vis neuropsychotropes. Since MCAD patients often present NPS, neurologists and psychiatrists have the opportunity, in recognizing the diagnostic possibility of MCAD, to short-circuit the often decades-long delay in establishing the correct diagnosis required to identify optimal therapy.
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Theoharides TC, Stewart JM, Hatziagelaki E, Kolaitis G. Brain "fog," inflammation and obesity: key aspects of neuropsychiatric disorders improved by luteolin. Front Neurosci 2015; 9:225. [PMID: 26190965 PMCID: PMC4490655 DOI: 10.3389/fnins.2015.00225] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/10/2015] [Indexed: 12/20/2022] Open
Abstract
Brain "fog" is a constellation of symptoms that include reduced cognition, inability to concentrate and multitask, as well as loss of short and long term memory. Brain "fog" characterizes patients with autism spectrum disorders (ASDs), celiac disease, chronic fatigue syndrome, fibromyalgia, mastocytosis, and postural tachycardia syndrome (POTS), as well as "minimal cognitive impairment," an early clinical presentation of Alzheimer's disease (AD), and other neuropsychiatric disorders. Brain "fog" may be due to inflammatory molecules, including adipocytokines and histamine released from mast cells (MCs) further stimulating microglia activation, and causing focal brain inflammation. Recent reviews have described the potential use of natural flavonoids for the treatment of neuropsychiatric and neurodegenerative diseases. The flavone luteolin has numerous useful actions that include: anti-oxidant, anti-inflammatory, microglia inhibition, neuroprotection, and memory increase. A liposomal luteolin formulation in olive fruit extract improved attention in children with ASDs and brain "fog" in mastocytosis patients. Methylated luteolin analogs with increased activity and better bioavailability could be developed into effective treatments for neuropsychiatric disorders and brain "fog."
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Affiliation(s)
- Theoharis C. Theoharides
- Laboratory of Molecular Immunopharmacology and Drug Discovery, Department of Integrative Physiology and Pathobiology, Tufts University School of MedicineBoston, MA, USA
- Departments of Internal Medicine, Tufts University School of Medicine and Tufts Medical CenterBoston, MA, USA
- Psychiatry, Tufts University School of Medicine and Tufts Medical CenterBoston, MA, USA
- Sackler School of Graduate Biomedical Sciences, Tufts University School of MedicineBoston, MA, USA
| | - Julia M. Stewart
- Laboratory of Molecular Immunopharmacology and Drug Discovery, Department of Integrative Physiology and Pathobiology, Tufts University School of MedicineBoston, MA, USA
| | - Erifili Hatziagelaki
- Second Department of Internal Medicine, Attikon General Hospital, Athens Medical SchoolAthens, Greece
| | - Gerasimos Kolaitis
- Department of Child Psychiatry, University of Athens Medical School, Aghia Sophia Children's HospitalAthens, Greece
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Theoharides TC, Stewart JM, Panagiotidou S, Melamed I. Mast cells, brain inflammation and autism. Eur J Pharmacol 2015; 778:96-102. [PMID: 25941080 DOI: 10.1016/j.ejphar.2015.03.086] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 02/15/2015] [Accepted: 03/05/2015] [Indexed: 12/28/2022]
Abstract
Increasing evidence indicates that brain inflammation is involved in the pathogenesis of neuropsychiatric diseases. Mast cells (MCs) are located perivascularly close to neurons and microglia, primarily in the leptomeninges, thalamus, hypothalamus and especially the median eminence. Corticotropin-releasing factor (CRF) is secreted from the hypothalamus under stress and, together with neurotensin (NT), can stimulate brain MCs to release inflammatory and neurotoxic mediators that disrupt the blood-brain barrier (BBB), stimulate microglia and cause focal inflammation. CRF and NT synergistically stimulate MCs and increase vascular permeability; these peptides can also induce each other׳s surface receptors on MCs leading to autocrine and paracrine effects. As a result, brain MCs may be involved in the pathogenesis of "brain fog," headaches, and autism spectrum disorders (ASDs), which worsen with stress. CRF and NT are significantly increased in serum of ASD children compared to normotypic controls further strengthening their role in the pathogenesis of autism. There are no clinically affective treatments for the core symptoms of ASDs, but pilot clinical trials using natural-antioxidant and anti-inflammatory molecules reported statistically significant benefit.
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Affiliation(s)
- Theoharis C Theoharides
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, USA; Department of Internal Medicine, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, USA; Department of Psychiatry, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, USA.
| | - Julia M Stewart
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, USA
| | - Smaro Panagiotidou
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, USA
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Perales Chordá C, Fabregat Nebot S, Moral Moral P, Jarque Ramos I, Hernández Fernandez de Rojas D. Syncope as a manifestation of mast cell activation disorder. Ann Allergy Asthma Immunol 2015; 114:153-4. [PMID: 25624133 DOI: 10.1016/j.anai.2014.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 11/13/2014] [Accepted: 11/19/2014] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - Pedro Moral Moral
- Department of Internal Medicine, IIS Hospital La Fe, Valencia, Spain
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Theoharides TC, Athanassiou M, Panagiotidou S, Doyle R. Dysregulated brain immunity and neurotrophin signaling in Rett syndrome and autism spectrum disorders. J Neuroimmunol 2014; 279:33-8. [PMID: 25669997 DOI: 10.1016/j.jneuroim.2014.12.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Revised: 11/18/2014] [Accepted: 12/02/2014] [Indexed: 12/21/2022]
Abstract
Rett syndrome is a neurodevelopmental disorder, which occurs in about 1:15,000 females and presents with neurologic and communication defects. It is transmitted as an X-linked dominant linked to mutations of the methyl-CpG-binding protein (MeCP2), a gene transcription suppressor, but its definitive pathogenesis is unknown thus hindering development of effective treatments. Almost half of children with Rett syndrome also have behavioral symptoms consistent with those of autism spectrum disorders (ASDs). PubMed was searched (2005-2014) using the terms: allergy, atopy, brain, brain-derived neurotrophic factor (BDNF), corticotropin-releasing hormone (CRH), cytokines, gene mutations, inflammation, mast cells (MCs), microglia, mitochondria, neurotensin (NT), neurotrophins, seizures, stress, and treatment. There are a number of intriguing differences and similarities between Rett syndrome and ASDs. Rett syndrome occurs in females, while ASDs more often in males, and the former has neurologic disabilities unlike ASDs. There is evidence of dysregulated immune system early in life in both conditions. Lack of microglial phagocytosis and decreased levels of BDNF appear to distinguish Rett syndrome from ASDs, in which there is instead microglia activation and/or proliferation and possibly defective BDNF signaling. Moreover, brain mast cell (MC) activation and focal inflammation may be more prominent in ASDs than Rett syndrome. The flavonoid luteolin blocks microglia and MC activation, provides BDNF-like activity, reverses Rett phenotype in mouse models, and has a significant benefit in children with ASDs. Appropriate formulations of luteolin or other natural molecules may be useful in the treatment of Rett syndrome.
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Affiliation(s)
- Theoharis C Theoharides
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, USA; Department of Internal Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, USA; Tufts Medical Center, Boston, MA, USA; Department of Psychiatry, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, USA.
| | - Marianna Athanassiou
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, USA
| | - Smaro Panagiotidou
- Molecular Immunopharmacology and Drug Discovery Laboratory, Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, USA
| | - Robert Doyle
- Pediatric Psychopharmacology Unit, Massachusetts General Hospital, Boston MA, USA; Harvard Medical School, Boston MA, USA
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Abstract
Migraine is one of the most common neurological disorders. Despite its prevalence, the basic physiology of the molecules and mechanisms that contribute to migraine headache is still poorly understood, making the discovery of more effective treatments extremely difficult. The consistent presence of head-specific pain during migraine suggests an important role for activation of the peripheral nociceptors localized to the head. Accordingly, this review will cover the current understanding of the biological mechanisms leading to episodic activation and sensitization of the trigeminovascular pain pathway, focusing on recent advances regarding activation and modulation of ion channels.
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Affiliation(s)
- Jin Yan
- Department of Pharmacology, University of Washington, Seattle, WA, USA
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Yan J, Wei X, Bischoff C, Edelmayer RM, Dussor G. pH-evoked dural afferent signaling is mediated by ASIC3 and is sensitized by mast cell mediators. Headache 2013; 53:1250-61. [PMID: 23808707 DOI: 10.1111/head.12152] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prior studies have shown that decreased meningeal pH activates dural afferents via opening of acid-sensing ion channels (ASICs), suggesting one pathophysiological mechanism for the generation of headaches. The studies described here further examined the ASIC subtype mediating pH-induced dural-afferent activation and examined whether sensitization influences pH responses. OBJECTIVE Given the potential importance of meningeal mast cells to headache, the goal of this study was to evaluate dural afferent responses to pH following sensitization with mast cell mediators. METHODS Cutaneous allodynia was measured in rats following stimulation of the dura with decreased pH alone or in combination with mast cell mediators. Trigeminal ganglion neurons retrogradely labeled from the dura were stained with an ASIC3 antibody using immunohistochemistry. Current and action potentials evoked by changes in pH alone or in combination with mast cell mediators were measured in retrogradely labeled dural afferents using patch-clamp electrophysiology. RESULTS pH-sensitive dural afferents generated currents in response to the ASIC3 activator 2-guanidine-4-methylquinazoline (GMQ), approximately 80% of these neurons express ASIC3 protein, and pH-evoked behavioral responses were inhibited by the ASIC3 blocker APETx2. Following exposure to mast cell mediators, dural afferents exhibited increased pH-evoked excitability, and cutaneous allodynia was observed at higher pH than with pH stimuli alone. CONCLUSIONS These data indicate that the predominant ASIC subtype responding to decreased meningeal pH is ASIC3. Additionally, they demonstrate that in the presence of inflammation, dural afferents respond to even smaller decreases in pH providing further support for the ability of small pH changes within the meninges to initiate afferent input leading to headache.
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Affiliation(s)
- Jin Yan
- Department of Pharmacology, University of Washington, Seattle, WA, USA
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How I treat patients with indolent and smoldering mastocytosis (rare conditions but difficult to manage). Blood 2013; 121:3085-94. [DOI: 10.1182/blood-2013-01-453183] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
Indolent systemic mastocytosis (SM) patients have a varied clinical presentation, ranging from predominantly cutaneous symptoms to recurrent systemic symptoms (eg, flushing, palpitations, dyspepsia, diarrhea, bone pain) that can be severe and potentially life threatening (anaphylaxis). Mastocytosis patients without skin involvement pose a diagnostic challenge; a high index of suspicion is needed in those with mast cell–degranulation symptoms, including anaphylaxis following Hymenoptera stings or other triggers. Modern-era molecular and flow-cytometric diagnostic methods are very sensitive and can detect minimal involvement of bone marrow with atypical/clonal mast cells; in some cases, full diagnostic criteria for SM are not fulfilled. An important aspect of treatment is avoidance of known symptom triggers; other treatment principles include a stepwise escalation of antimediator therapies and consideration of cytoreductive therapies for those with treatment-refractory symptoms. The perioperative management of mastocytosis patients is nontrivial; a multidisciplinary preoperative assessment, adequate premedications, and close intra- and postoperative monitoring are critical. Smoldering mastocytosis is a variant with high systemic mast cell burden. While its clinical course can be variable, there is greater potential need for cytoreductive therapies (eg, interferon-alpha, cladribine) in this setting. A systematic approach to the diagnosis and treatment of indolent SM using a case-based approach of representative clinical scenarios is presented here.
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Abstract
The prominent role for mast cells in the inflammatory response has been increasingly well documented in recent years. Mast cells not only contribute to maintain homeostasis via degranulation and to generate IgE-mediated allergic reactions, but also sit at a major crossroads for both innate and adaptive immune responses. The part played by mast cells in chronic inflammatory diseases such as rheumatoid arthritis and multiple sclerosis identifies mast cells as a valuable treatment target in these diseases. Tyrosine-kinase inhibitors targeting the c-Kit mast cell receptor have been found effective in treating rheumatoid arthritis, asthma, and multiple sclerosis. When used in combination with other available drugs, tyrosine-kinase inhibitors may improve the therapeutic management of these diseases.
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Affiliation(s)
- Laurent Frenzel
- Service d'Hématologie Adulte, Centre de référence des mastocytoses, CNRS UMR 8147, Institut Imagine, Hôpital Necker-Enfants-Malades, 75015 Paris, France.
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Watkins CE, Bokor WB, Leicht S, Youngberg G, Krishnaswamy G. Telangiectasia macularis eruptiva perstans: more than skin deep. Dermatol Reports 2011; 3:e12. [PMID: 25386256 PMCID: PMC4211494 DOI: 10.4081/dr.2011.e12] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 07/06/2011] [Accepted: 07/07/2011] [Indexed: 01/08/2023] Open
Abstract
Systemic mastocytosis is a rare disease involving the infiltration and accumulation of active mast cells within any organ system. By far, the most common organ affected is the skin. Cutaneous manifestations of mastocytosis, including Urticaria Pigmentosa (UP), cutaneous mastocytoma or telangiectasia macularis eruptive perstans (TMEP), may indicate a more serious and potentially life-threatening underlying disease. The presence of either UP or TMEP in a patient with anaphylactic symptoms should suggest the likelihood of systemic mastocytosis, with the caveat that systemic complications are more likely to occur in patients with UP. TMEP can usually be identified by the typical morphology, but a skin biopsy is confirmative. In patients with elevated tryptase levels or those with frequent systemic manifestations, a bone marrow biopsy is essential in order to demonstrate mast cell infiltration. Further genetic testing for mutations of c-kit gene or the FIP1L1 gene may help with disease classification and/or therapeutic approaches. Rarely, TMEP has been described with malignancy, radiation therapy, and myeloproliferative disorders. A few familial cases have also been described. In this review, we discuss the clinical features, diagnosis and management of patients with TMEP. We also discuss the possible molecular pathogenesis and the role of genetics in disease classification and treatment.
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Affiliation(s)
- Casey E Watkins
- East Tennessee State University, Quillen College of Medicine, Johnson City, TN
| | - Winston B Bokor
- East Tennessee State University, Quillen College of Medicine, Johnson City, TN
| | - Stuart Leicht
- East Tennessee State University, Quillen College of Medicine, Johnson City, TN; ; Department of Dermatology, Quillen College of Medicine, Johnson City, TN
| | - George Youngberg
- East Tennessee State University, Quillen College of Medicine, Johnson City, TN; ; Department of Pathology, Quillen College of Medicine, Johnson City, TN
| | - Guha Krishnaswamy
- East Tennessee State University, Quillen College of Medicine, Johnson City, TN; ; Department Allergy and Immunology, Quillen College of Medicine, Johnson City, TN; ; Veterans Affairs Medical Center, Mountain Home, TN, USA
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