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Korošec P, Sturm GJ, Lyons JJ, Marolt TP, Svetina M, Košnik M, Zidarn M, Kačar M, Frelih N, Lalek N, Luzar AD, Zver S, Škerget M, Czarnobilska E, Dyga W, Grle SP, Samarzija M, Arzt-Gradwohl L, Čerpes U, Porebski G, Pevec B, Schadelbauer E, Kopač P, Šelb J, Rijavec M. High burden of clonal mast cell disorders and hereditary α-tryptasemia in patients who need Hymenoptera venom immunotherapy. Allergy 2024; 79:2458-2469. [PMID: 38477502 DOI: 10.1111/all.16084] [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] [Received: 11/23/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND In patients who require venom immunotherapy (VIT), there is a need to identify underlying mast cell (MC) disorders since these may affect the risk and severity of future sting reactions and the long-term effectiveness of VIT. METHODS 1319 individuals with Hymenoptera venom allergy (HVA) who needed VIT from referral centers in Slovenia, Austria, Croatia, and Poland underwent examination for KIT p.D816V in peripheral blood leukocytes (PBL) using a highly sensitive PCR test and tryptase genotyping by digital droplet PCR. We also included 183 control individuals with large local reactions (LLRs) to Hymenoptera stings and with asymptomatic sensitization to Hymenoptera venoms. RESULTS 285 of 1319 individuals recommended for VIT (21.6%) were positive for KIT p.D816V in PBL, preferably those who present with severe reaction (33.9% [n = 207 of 610] with Ring-Messmer grade 3-4 vs. 11% [n = 78 of 709] with Grade 1-2; p < .0001), whereas only 1.3% (n = 2 of 152) of controls with LLR and none with asymptomatic sensitization (n = 31) had KIT p.D816V. KIT p.D816V allelic burden was higher in those with severe reaction (median 0.018% [n = 207] in Grade 3-4 vs. 0.001% [n = 78] in Grade 1-2; p < .0001), and the majority had normal baseline serum tryptase levels (69% [n = 196 of 285]). All KIT p.D816V-positive individuals (n = 41) who underwent bone marrow (BM) biopsy were found to have underlying clonal diseases, principally BM mastocytosis. HαT was also associated with severe HVA and symptoms (p < .01), and remarkably, 31.0% (n = 31 of 100) were found to have concomitant KIT p.D816V. Concomitant HαT and KIT p.D816V showed an additive effect, and having both was associated with the highest risk for severe HVA, even higher than having either HαT or KIT p.D816V alone (OR = 3.8; p < .01). CONCLUSIONS By employing prospective universal tryptase genotyping and examination for KIT p.D816V in PBL in large HVA populations, we have demonstrated a high burden of clonal MC disorders and HαT in patients who require VIT.
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Affiliation(s)
- Peter Korošec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Gunter J Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
- Allergy Outpatient Clinic Reumannplatz, Vienna, Austria
| | - Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Manca Svetina
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mihaela Zidarn
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mark Kačar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nina Frelih
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nika Lalek
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Ajda Demšar Luzar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Samo Zver
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- The Department of Hematology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Matevž Škerget
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- The Department of Hematology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Ewa Czarnobilska
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Dyga
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Sanja Popović Grle
- Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Miroslav Samarzija
- Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Urban Čerpes
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Branko Pevec
- Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Eva Schadelbauer
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Peter Kopač
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Julij Šelb
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Wang J, Lieberman JA, Wallace DV, Waserman S, Golden DBK. Anaphylaxis in Practice: A Guide to the 2023 Practice Parameter Update. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2325-2336. [PMID: 38944199 DOI: 10.1016/j.jaip.2024.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/03/2024] [Accepted: 06/14/2024] [Indexed: 07/01/2024]
Abstract
This review summarizes new research developments and clinical practice recommendations for the diagnosis and management of anaphylaxis presented in the Joint Task Force on Practice Parameters 2023 Anaphylaxis practice parameter Update. It is intended to serve as a high-level summary of the 2023 practice parameter, which makes clinically impactful recommendations based on evidence that has emerged since the 2015 practice parameter. We invite clinicians to explore the full 2023 practice parameter to understand the research methods and underlying evidence that have informed the recommendations summarized here. There are new and evolving diagnostic criteria for anaphylaxis, rules for defining elevated tryptase levels, and recognition of signs and symptoms particular to infants and toddlers. The administration of epinephrine should not be used as a surrogate to diagnose anaphylaxis. Risk factors for anaphylaxis should be assessed on a case-by-case basis. Patient counseling and shared decision-making are essential to support patients' treatment decisions and capacity to manage the risk of anaphylaxis at home and in other community settings. Activation of emergency medical services after home epinephrine administration may not be required in all cases, and patients should be engaged in shared decision-making to determine when home management may be appropriate.
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Affiliation(s)
- Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Jay A Lieberman
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tenn
| | - Dana V Wallace
- Department of Medicine, Dr Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Fla
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins School of Medicine, Baltimore, Md
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Boggs NA, Tanasi I, Hartmann K, Zanotti R, Gonzalez-de-Olano D. Mast Cell Disorders and Hymenoptera Venom-Triggered Anaphylaxis: Evaluation and Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00853-5. [PMID: 39187156 DOI: 10.1016/j.jaip.2024.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 08/08/2024] [Accepted: 08/15/2024] [Indexed: 08/28/2024]
Abstract
Patients with Hymenoptera venom allergy (HVA), especially those with severe anaphylaxis, frequently have concomitant clonal mast cell disease (MCD) in the form of systemic mastocytosis or monoclonal mast cell activation syndrome. Detection of clonal MCD is important because it will have significant consequences for managing HVA. Therefore, we recommend patients with HVA be systematically screened for clonal MCD. The pretest probability of clonal MCD can be assessed in a stepwise fashion starting with examination of the skin for typical monomorphic maculopapular cutaneous mastocytosis lesions; measurement of the baseline serum tryptase (BST) and tryptase genotyping for patients with BST greater than 11 ng/mL; followed by the Red Española de Mastocitosis score, which is calculated using anaphylaxis clinical features, BST, and the patient's sex. A bone marrow biopsy should be performed in patients with monomorphic maculopapular cutaneous mastocytosis, a Red Española de Mastocitosis score of 2 or greater, or an elevated BST based on tryptase genotype. Patients with HVA and a clonal MCD should be treated with immunotherapy directed against the Hymenoptera venom for which they are sensitized. For this high-risk subgroup of patients with HVA, it is recommended to continue immunotherapy for more than 5 years or indefinitely and to carry at least three epinephrine autoinjectors. Future studies should determine whether KIT D816V-selective tyrosine kinase inhibitors are effective at preventing or reducing the severity of Hymenoptera-venom triggered anaphylaxis in patients with clonal MCD.
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Affiliation(s)
- Nathan A Boggs
- Department of Medicine, Uniformed Services University, Bethesda, Md; Allergy, Immunology, and Immunizations Service, Walter Reed National Military Medical Center, Bethesda, Md.
| | - Ilaria Tanasi
- Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Universitaria di Verona, Verona, Italy
| | - 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
| | - Roberta Zanotti
- IRCCS Ospedale Sacro Cuore Don Calabria di Negrar, Medicine Unit, Negrar di Valpolicella, Verona, Italy
| | - David Gonzalez-de-Olano
- Department of Allergy, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain; Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Salamanca, Spain
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Sturm GJ, Schadelbauer E, Marta G, Bonadonna P, Kosnik M. Risk Factors for Severe Sting Reactions and Side Effects During Venom Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00845-6. [PMID: 39173970 DOI: 10.1016/j.jaip.2024.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/20/2024] [Accepted: 08/05/2024] [Indexed: 08/24/2024]
Abstract
Understanding the risk factors leading to severe systemic sting reactions (SSRs) is crucial for initiating venom immunotherapy (VIT) and for educating affected individuals and their families. Some of these risk factors are well established, some are no longer considered risk factors, and some remain controversial. Well-established risk factors for severe SSRs include clonal mast cell disease, high baseline serum tryptase, and advanced age. The absence of skin symptoms and the rapid onset of symptoms are indicators of severe SSRs. Recent publications indicate that antihypertensive treatment and stings in the head and neck area are not risk factors for severe SSRs. VIT is the only available treatment that can potentially prevent further anaphylactic reactions. Although rare and generally manageable, individuals undergoing VIT may experience systemic adverse events (sAEs). More sAEs are expected in patients undergoing bee VIT compared with vespid VIT. The role of elevated baseline serum tryptase as a risk factor for sAEs remains debated, but if it is a factor, the risk is increased by only about 1.5-fold. Rapid updosing protocols, depending on the specific regimen, can also be associated with more sAEs. Severe initial SSRs, antihypertensive medication, high skin test reactivity, and high specific IgE levels are not risk factors for sAEs.
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Affiliation(s)
- Gunter J Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria; Allergy Outpatient Clinic Reumannplatz, Vienna, Austria.
| | - Eva Schadelbauer
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Giorgia Marta
- Allergy Unit and Multidisciplinary Mastocytosis Outpatient Clinic, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Patrizia Bonadonna
- Allergy Unit and Multidisciplinary Mastocytosis Outpatient Clinic, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Mitja Kosnik
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Castells M, Giannetti MP, Hamilton MJ, Novak P, Pozdnyakova O, Nicoloro-SantaBarbara J, Jennings SV, Francomano C, Kim B, Glover SC, Galli SJ, Maitland A, White A, Abonia JP, Slee V, Valent P, Butterfield JH, Carter M, Metcalfe DD, Akin C, Lyons JJ, Togias A, Wheatley L, Milner JD. Mast cell activation syndrome: Current understanding and research needs. J Allergy Clin Immunol 2024; 154:255-263. [PMID: 38851398 DOI: 10.1016/j.jaci.2024.05.025] [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: 02/12/2024] [Revised: 05/13/2024] [Accepted: 05/17/2024] [Indexed: 06/10/2024]
Abstract
Mast cell activation syndrome (MCAS) is a term applied to several clinical entities that have gained increased attention from patients and medical providers. Although several descriptive publications about MCAS exist, there are many gaps in knowledge, resulting in confusion about this clinical syndrome. Whether MCAS is a primary syndrome or exists as a constellation of symptoms in the context of known inflammatory, allergic, or clonal disorders associated with systemic mast cell activation is not well understood. More importantly, the underlying mechanisms and pathways that lead to mast cell activation in MCAS patients remain to be elucidated. Here we summarize the known literature, identify gaps in knowledge, and highlight research needs. Covered topics include contextualization of MCAS and MCAS-like endotypes and related diagnostic evaluations; mechanistic research; management of typical and refractory symptoms; and MCAS-specific education for patients and health care providers.
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Affiliation(s)
- Mariana Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Matthew J Hamilton
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Peter Novak
- Department of Neurology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Olga Pozdnyakova
- department of Pathology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | | | | | - Clair Francomano
- Medical and Molecular Genetics, Riley Children's Health, Indianapolis, Ind
| | - Brian Kim
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sarah C Glover
- Gastroenterology & Hepatology, Tulane University School of Medicine, New Orleans, La
| | - Stephen J Galli
- Departments of Pathology and Immunology and Microbiology, and the Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, Calif
| | - Anne Maitland
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Allergy and Immunology Services, Metrodora Institute, Salt Lake City, Utah
| | - Andrew White
- Division of Allergy and Immunology, Scripps Clinic, San Diego, Calif
| | - J Pablo Abonia
- Departent of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Valerie Slee
- The Mast Cell Disease Society Inc, Sterling, Mass
| | - 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
| | - Joseph H Butterfield
- Division of Allergic Diseases and the Mayo Clinic Program for Mast Cell and Eosinophilic Disorders, Mayo Clinic, Rochester, Minn
| | - Melody Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - 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
| | - Jonathan J Lyons
- Division of Allergy and Immunology, Department of Medicine, University of California-San Diego, La Jolla, Calif; Veterans Affairs San Diego Healthcare System, La Jolla, Calif
| | - Alkis Togias
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Lisa Wheatley
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Joshua D Milner
- Division of Pediatric Allergy, Immunology and Rheumatology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
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Rossignol J, Arock M. Diagnosis of mastocytosis: emerging iceberg? Blood 2024; 144:350-352. [PMID: 39052270 DOI: 10.1182/blood.2024024943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
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McMurray JC, Pacheco CS, Schornack BJ, Sun X, Brunader JA, Scott AE, Ariza JS, Kou CTJ, Costantino RC, Pittman LM, Adams KE, Waters AM, Pryor EM, Lyons JJ, Metcalfe DD, Maric I, Boggs NA. Standardized indolent systemic mastocytosis evaluations across a health care system: implications for screening accuracy. Blood 2024; 144:408-419. [PMID: 38635793 PMCID: PMC11418066 DOI: 10.1182/blood.2023023347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/11/2024] [Accepted: 04/07/2024] [Indexed: 04/20/2024] Open
Abstract
ABSTRACT Timely diagnosis of systemic mastocytosis (SM) remains challenging because of care heterogeneity. We implemented a standardized approach for SM screening and diagnosis using a novel health care system-wide international screening registry. A retrospective analysis assessed rates of SM, cutaneous mastocytosis (CM), and molecular diagnoses before and 2 years after care standardization. The accuracy of individual and combined SM screening tests, basal serum tryptase (BST) ≥11.5 and ≥20.0 ng/mL, REMA ≥2, monomorphic maculopapular CM (MPCM), and elevated BST based upon tryptase genotype, was analyzed. Tryptase genotyping and high-sensitivity KIT p.D816V testing increased substantially 2 years after care standardization. SM diagnoses doubled from 47 to 94, and KIT p.D816V molecular diagnoses increased from 24 to 79. Mean BST and KIT p.D816V variant allele frequency values were significantly lower in patients diagnosed after standardization. Hereditary-alpha tryptasemia prevalence was increased in SM before care standardization (4/30 [13.3%]) but reflected the general population prevalence 2 years later at (5/76 [6.6%]). Elevated BST based upon genotype and BST ≥11.5 ng/mL had the highest sensitivities at 84.2% and 88.3%, respectively. The presence of monomorphic MPCM, elevated BST based upon tryptase genotype, and the combination of REMA ≥2 with elevated BST based upon tryptase genotype had specificities >90%. BST >20.0 ng/mL had low sensitivity and specificity and was not required to establish any indolent SM (ISM) diagnosis. Care standardization increased SM diagnosis rates, particularly in patients with low BSTs. Stratifying BST based upon genotype had the best overall sensitivity and specificity of any ISM screening test and improved the REMA score specificity.
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Affiliation(s)
- Jeremy C. McMurray
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Curtis S. Pacheco
- Department of Internal Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Brandon J. Schornack
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Xiaoping Sun
- Hematology Section, Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
| | - Janet A. Brunader
- Immunization Healthcare Division, Defense Health Agency, Falls Church, VA
| | - Alexis E. Scott
- Immunization Healthcare Division, Defense Health Agency, Falls Church, VA
| | - Juan S. Ariza
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Chung-Ting J. Kou
- Hematology and Oncology Service, Brooke Army Medical Center, San Antonio, TX
| | - Ryan C. Costantino
- Enterprise Intelligence and Data Solutions Program Office, Program Executive Office, Defense Healthcare Management Systems, San Antonio, TX
| | - Luke M. Pittman
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Karla E. Adams
- Department of Medicine, Allergy and Immunology Service, Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, San Antonio, TX
| | - Aubri M. Waters
- Allergy and Immunology Service, Brooke Army Medical Center, San Antonio, TX
| | - Eric M. Pryor
- Hematopathology Service, Department of Pathology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jonathan J. Lyons
- Division of Allergy and Immunology, Department of Medicine, University of California San Diego, La Jolla, CA
- Veterans Affairs San Diego Health Care System, La Jolla, CA
| | - Dean D. Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Irina Maric
- Hematology Section, Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
| | - Nathan A. Boggs
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Medicine, Uniformed Services University, Bethesda, MD
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8
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Sturm GJ, Arzt-Gradwohl L. An algorithm for the diagnosis and treatment of Hymenoptera venom allergy, 2024 update. Allergy 2024. [PMID: 38978291 DOI: 10.1111/all.16219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/21/2024] [Accepted: 06/23/2024] [Indexed: 07/10/2024]
Affiliation(s)
- Gunter J Sturm
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
- Allergy Outpatient Clinic Reumannplatz, Vienna, Austria
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
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von Bubnoff D, Koch D, Stocker H, Ludwig RJ, Wortmann F, von Bubnoff N. The Clinical Features of Hereditary Alpha-Tryptasemia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:258-264. [PMID: 38260947 PMCID: PMC11381211 DOI: 10.3238/arztebl.m2023.0287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Hereditary alpha-tryptasemia (HAT) is a genetic predisposition of autosomal dominant inheritance that leads to a high normal (≥ 8-11.4 μg/L) or pathologically elevated (>11.4 μg/L) basal serum tryptase (BST) concentration. Its prevalence in the United Kingdom and France is reportedly 5%-6%; its prevalence in Germany is unknown. Symptomatic persons with HAT suffer from a complex constellation of symptoms. As described in this review, HAT is an important differential diagnosis in interdisciplinary practice. METHODS This review is based on publications about HAT retrieved by a selective search in PubMed, on relevant presentations at scientific meetings, and on our clinical experience. We also collected our own data on the prevalence and clinical manifestations of HAT. RESULTS According to the literature, HAT is very common among patients in medical centers with BST values of 8 μg/L or above (64-74%). HAT is most commonly associated with neuropsychiatric symptoms such as exhaustion (85%), depressive episodes (59%), sleep disturbances (69%), and memory impairment (59%-68%), followed by gastrointestinal symptoms such as irritable bowel (30%-60%), nausea (51%), and reflux (49%-77%). Typical mast cell-mediated symptoms, such as flushing (47%), itch (69%), urticaria (37%), and anaphylaxis (14%-28%), are reported as well. Less commonly reported are cardio vascular manifestations, such as hypotonia, dizziness, and tachycardia (34%), and joint hyper - mobility (28%). HAT is more common among patients with systemic mastocytosis (SM; 12%-21%). It is often associated with severe anaphylaxis induced by insect toxins or unknown triggers. The therapeutic options include treatment with antihistamines, mastcell stabilizers, or IgE antibodies. CONCLUSION A diagnosis of hereditary alphatryptasemia can be strongly suspected on the basis of thorough history-taking and BST measurement and then confirmed by molecular genetic testing.
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Affiliation(s)
- Dagmar von Bubnoff
- Department of Dermatology, Allergology, and Venereology, University Hospital Schleswig-Holstein, Campus Lübeck, European Competence Network Mastocytosis (ECNM) Excellence Center for Mast Cell Diseases; Department of Hematology and Oncology, University Hospital Schleswig-Holstein (UKSH) and University Cancer Center Schleswig-Holstein (UCCSH), Campus Lübeck
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Shin H, Lyons JJ. Alpha-Tryptase as a Risk-Modifying Factor for Mast Cell-Mediated Reactions. Curr Allergy Asthma Rep 2024; 24:199-209. [PMID: 38460022 DOI: 10.1007/s11882-024-01136-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE OF REVIEW To provide an overview on the current understanding of genetic variability in human tryptases and summarize the literature demonstrating the differential impact of mature tryptases on mast cell-mediated reactions and associated clinical phenotypes. RECENT FINDINGS It is becoming increasingly recognized that tryptase gene composition, and in particular the common genetic trait hereditary alpha-tryptasemia (HαT), impacts clinical allergy. HαT has consistently been associated with clonal mast cell disorders (MCD) and has also been associated with more frequent anaphylaxis among these patients, and patients in whom no allergic trigger can be found, specifically idiopathic anaphylaxis. Additionally, more severe anaphylaxis among Hymenoptera venom allergy patients has been linked to HαT in both retrospective and prospective studies. An increased relative number of α-tryptase-encoding gene copies, even in the absence of HαT, has also been associated with systemic mastocytosis and has been shown to positively correlate with the severity of mast cell-mediated reactions to vibration and food. These findings may be due to increased generation of α/β-tryptase heterotetramers and differences in their enzymatic activity relative to β-tryptase homotetramers. HαT is a naturally occurring overexpression model of α-tryptase in humans. Increased relative α-tryptase expression modifies immediate hypersensitivity symptoms and is associated with more frequent and severe mast cell-mediated reactions, ostensibly due to increased α/β-tryptase heterotetramer production.
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Affiliation(s)
- Hannah Shin
- Division of Allergy & Immunology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jonathan J Lyons
- Division of Allergy & Immunology, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
- Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA.
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11
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Košnik M, Zugan L, Rijavec M. Prevention of Anaphylaxis Episodes in Idiopathic Anaphylaxis by Omalizumab. Int Arch Allergy Immunol 2024; 185:761-766. [PMID: 38527445 DOI: 10.1159/000538046] [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: 01/14/2024] [Accepted: 02/01/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION In 15-35 percent of patients with anaphylaxis, the triggering allergen cannot be found; therefore, a diagnosis of idiopathic anaphylaxis (IA) is made. We report on the outcomes in patients with IA treated with omalizumab. METHODS We included consequent omalizumab-treated IA adult patients treated with omalizumab 300 mg every 4 weeks. RESULTS Out of 7 patients, 6 were female, median age 40 years with the frequency of anaphylaxis episodes from 3 in 2 years to 5 in 4 months. Baseline tryptase ranged from 1.71 to 12.0 μg/L. An increase in tryptase during anaphylaxis was documented in 6 patients. Activating KIT p.D816V variant was detected in 2 patients. One patient also had hereditary alpha-tryptasemia (HαT). The duration of omalizumab treatment was 0.5-7.5 years. None of the patients have experienced an anaphylactic reaction since the start of treatment. Mild systemic reactions were reported in 6 patients (86%). The presence of underlying cMCD had no impact on the treatment outcome. CONCLUSION All patients in our study had complete responses to omalizumab. The presence of KIT p.D816V and HαT did not influence the response to omalizumab treatment.
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Affiliation(s)
- Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Lea Zugan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
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12
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Kačar M, Košnik M. Evaluating Hymenoptera Venom Allergy Severity: A Data-Centric Comparison of Grading Instruments. Int Arch Allergy Immunol 2024; 185:694-703. [PMID: 38503271 DOI: 10.1159/000537680] [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: 12/31/2023] [Accepted: 02/02/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION While a consensus seems to have been reached with regard to the definition of anaphylaxis, there is no universal instrument for scoring allergic reaction severity despite more than 30 having been proposed by the time of writing. This severely hampers comparison of data between studies. While scales have been compared with regard to their utility in grading food-related reactions, no such comparisons have been made for Hymenoptera venom-associated reactions. METHODS The study conducted a retrospective analysis to compare the severity of Hymenoptera venom allergy reactions in 104 participants with suspected Hymenoptera venom allergy. The study applied six grading instruments to each reaction, also evaluating them against the NIAID/FAAN anaphylaxis criteria. Sensitivity, specificity, and receiver operating characteristic area under the curve (AUC) for identifying anaphylaxis were calculated. Severity scales were simplified into "mild," "moderate," and "severe" categories. The most common severity grade across the five scales was determined using a custom function to establish a consensus severity grade. RESULTS The most common culprit insects were honeybees (49.0%). Among the 88 participants with generalized reactions, the highest proportion had involvement of four organ systems. The scales showed high specificity for detecting anaphylaxis, especially when using higher grades of the Mueller, WAO, and Dribin scales. The diagnostic yields (AUC) varied, with the WAO scale having the highest AUC (0.94) for grades 3, 4, and 5. Spearman correlation analysis showed the strongest correlations seen between the Brown and Dribin, Ring and Messmer and Dribin, and Ring and Messmer and Reisman scales. The lowest correlations were observed with the Mueller scale when paired with the WAO, Reisman, and Dribin scales. An inter-rater reliability analysis showed substantial agreement between scales with the same number of grading levels. The agreement was highest for the Brown and Dribin scales, indicating a strong consistency in reaction severity classification across different instruments. CONCLUSION While all instruments were effective in stratifying reactions, they showed limitations in differentiating milder phenotypes. The Brown and Dribin scales stood out for their high agreement with the consensus score and sensitivity in identifying anaphylaxis. Our findings suggest that adopting either of these scales could significantly unify the reporting of allergic reactions. We believe the format of an instrument should be tailored to its intended purpose, with clinical decision aids being simpler and research tools being more detailed.
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Affiliation(s)
- Mark Kačar
- Allergy and Clinical Immunology Unit, University Clinic Golnik, Golnik, Slovenia
- Department of Allergy and Clinical Immunology, St James's University Hospital, Leeds, UK
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Mitja Košnik
- Allergy and Clinical Immunology Unit, University Clinic Golnik, Golnik, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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13
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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: 48] [Impact Index Per Article: 48.0] [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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14
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Svetina M, Šelb J, Lyons JJ, Korošec P, Rijavec M. Clinically accessible amplitude-based multiplex ddPCR assay for tryptase genotyping. Sci Rep 2024; 14:2416. [PMID: 38287122 PMCID: PMC10825142 DOI: 10.1038/s41598-024-52983-8] [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] [Received: 10/13/2023] [Accepted: 01/25/2024] [Indexed: 01/31/2024] Open
Abstract
Hereditary α tryptasemia (HαT) is an autosomal dominant trait characterized by increased TPSAB1 copy number (CN) encoding α-tryptase. The determination of HαT is being discussed as an important biomarker to be included in risk assessment models and future diagnostic algorithms for patients with mastocytosis and anaphylaxis. Due to the complex genetic structure at the human tryptase locus, genetic testing for tryptase gene composition is presently notably limited and infrequently pursued. This study aimed to develop, optimise and validate a multiplex droplet digital PCR (ddPCR) assay that can reliably quantify α- and β-tryptase encoding sequences in a single reaction. To optimise the ddPCR conditions and establish an amplitude-based multiplex ddPCR assay, additional primers and probes, a thermal gradient with varying annealing temperatures, different primers/probe concentrations, and various initial DNA quantities were tested. Results obtained from all 114 samples analysed using multiplex ddPCR were identical to those obtained through the use of original duplex assays. Utilizing this multiplex ddPCR assay, in contrast to conducting distinct duplex ddPCRs, presents noteworthy benefits for tryptase genotyping. These advantages encompass a substantial threefold decrease in material costs and considerable time savings. Consequently, this approach exhibits high suitability and particularly captures interest for routine clinical implementation.
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Affiliation(s)
- Manca Svetina
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Julij Šelb
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jonathan J Lyons
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia.
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia.
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Beyens M, Toscano A, Ebo D, Gülen T, Sabato V. Diagnostic Significance of Tryptase for Suspected Mast Cell Disorders. Diagnostics (Basel) 2023; 13:3662. [PMID: 38132246 PMCID: PMC10742504 DOI: 10.3390/diagnostics13243662] [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: 11/13/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
Tryptase has proven to be a very useful and specific marker to demonstrate mast cell activation and degranulation when an acute (i.e., within 4 h after the event) and baseline value (i.e., at least 24 h after the event) are compared and meet the consensus formula (i.e., an increase of 20% + 2). The upper limit of normal determined by the manufacturer is 11.4 ng/mL; however, this boundary has been the subject of debate. According to ECNM and AIM experts, the normal range of baseline tryptase should be 1 to 15 ng/mL. A genetic trait, hereditary alpha tryptasemia, characterized by an increased alpha coding TPSAB1 copy number is associated with a baseline value above 8 ng/mL. Elevated tryptase can also be found in chronic kidney disease, obesity, and hematological neoplasms. A tryptase > 20 ng/mL serves as a minor criterion to diagnose systemic mastocytosis and an increase in tryptase > 20% + 2 during an acute event is a required criterion in the diagnosis of mast cell activation syndrome. The goal of this review is to demonstrate the (in)significance of tryptase using some clinical vignettes and to provide a practical guide on how to manage and interpret an elevated tryptase level.
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Affiliation(s)
- Michiel Beyens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
| | - Alessandro Toscano
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
| | - Didier Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Gent, 9000 Ghent, Belgium
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy, K85, Karolinska University Hospital Huddinge, SE-14186 Stockholm, Sweden;
- Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, SE-17177 Stockholm, Sweden
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
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Rijavec M, Inkret J, Bidovec-Stojković U, Carli T, Frelih N, Kukec A, Korošec P, Košnik M. Fatal Hymenoptera Venom-Triggered Anaphylaxis in Patients with Unrecognized Clonal Mast Cell Disorder-Is Mastocytosis to Blame? Int J Mol Sci 2023; 24:16368. [PMID: 38003556 PMCID: PMC10671356 DOI: 10.3390/ijms242216368] [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] [Received: 10/04/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Hymenoptera venom-triggered anaphylaxis (HVA) affects up to 8.9% of the general population and is the most frequent cause of anaphylaxis in adults, accounting for approximately 20% of all fatal anaphylaxis cases. Quite often, a fatal reaction is a victim's first manifestation of HVA. Mastocytosis represents one of the most important risk factors for severe HVA. We analyzed patients with documented fatal HVA for the presence of underlying clonal mast cell disorder (cMCD). Here, we report three cases of fatal HVA, with undiagnosed underlying cMCD identified by the presence of the peripheral blood and/or bone marrow KIT p.D816V missense variant postmortem. In the first case, anaphylaxis was the initial episode and was fatal. In the other two cases, both patients were treated with specific venom immunotherapy (VIT), nevertheless, one died of HVA after VIT discontinuation, and the other during VIT; both patients had cardiovascular comorbidities and were taking beta-blockers and/or ACE inhibitors. Our results point to the importance of screening all high-risk individuals for underlying cMCD using highly sensitive molecular methods for peripheral blood KIT p.D816V variant detection, including severe HVA and possibly beekeepers, for proper management and the need for lifelong VIT to prevent unnecessary deaths. Patients at the highest risk of fatal HVA, with concomitant cardiovascular and cMCD comorbidities, might not be protected from field stings even during regular VIT. Therefore, two adrenaline autoinjectors and lifelong VIT, and possibly cotreatment with omalizumab, should be considered for high-risk patients to prevent fatal HVA episodes.
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Affiliation(s)
- Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
- Biotechnical Faculty, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Jezerka Inkret
- Institute of Forensic Medicine, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Urška Bidovec-Stojković
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
| | - Tanja Carli
- National Institute of Public Health, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Nina Frelih
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
| | - Andreja Kukec
- National Institute of Public Health, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
- Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia; (U.B.-S.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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Lang A, Kubala S, Grieco MC, Mateja A, Pongracic J, Liu Y, Frischmeyer-Guerrerio PA, Kumar R, Lyons JJ. Severe food allergy reactions are associated with α-tryptase. J Allergy Clin Immunol 2023; 152:933-939. [PMID: 37558059 PMCID: PMC10592152 DOI: 10.1016/j.jaci.2023.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/18/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Increased TPSAB1 copy numbers encoding ⍺-tryptase are associated with severe reactions in adults with Hymenoptera venom allergy, systemic mastocytosis, and idiopathic anaphylaxis. OBJECTIVE The primary objective was to assess the association between ⍺-tryptase and severity of food allergy. METHODS A total of 119 subjects underwent tryptase genotyping; 82 of them were from an observational food allergy cohort at the National Institute of Allergy and Infectious Disease (NIAID), and 37 were from a cohort of children who reacted to peanut oral food challenge (OFC) at Lurie Children's Hospital of Chicago. The primary predictor was presence or absence of ⍺-tryptase. The primary outcomes for both cohorts were measures of severity of food allergy reaction. Secondary outcomes included OFC symptom scores (Bock/Practical Allergy [PRACTALL] and Severity Grading Score for Acute Reactions [SGSAR]). Correlation between total α-tryptase isoforms and OFC scores was also assessed to account for gene dosage effects. RESULTS Among the subjects in the NIAID cohort, the presence of ⍺-tryptase was associated with a higher prevalence of food-triggered anaphylaxis than in those with only β-tryptase (P = .026). Similarly, only 1 of 6 subjects in the OFC cohort with only β-tryptase (17%) had a severe reaction, whereas 20 of 31 of subjects with α-tryptase (65%) had a severe reaction (P = .066). Subjects with ⍺-tryptase also had higher total SGSAR scores than did the subjects with no ⍺-tryptase (P = .003). In addition, there were also significant positive correlations between ⍺-tryptase isoform copy numbers and both higher total SGSAR and Bock/PRACTALL OFC scores (P = .008 and P = .003, respectively). CONCLUSION The presence of α-tryptase in subjects is correlated with a higher prevalence of anaphylaxis or severe reaction to food than in subjects without any α-tryptase.
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Affiliation(s)
- Abigail Lang
- Division of Allergy and Immunology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Stephanie Kubala
- Food Allergy Research Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Megan C Grieco
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md; Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Allyson Mateja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Md
| | - Jacqueline Pongracic
- Division of Allergy and Immunology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Yihui Liu
- Translational Allergic Immunopathology Unit, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Pamela A Frischmeyer-Guerrerio
- Food Allergy Research Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Rajesh Kumar
- Division of Allergy and Immunology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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Lyons JJ, Farkas H, Germenis AE, Rijavec M, Smith TD, Valent P. Genetic Variants Leading to Urticaria and Angioedema and Associated Biomarkers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2286-2301. [PMID: 37263349 DOI: 10.1016/j.jaip.2023.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/20/2023] [Accepted: 05/15/2023] [Indexed: 06/03/2023]
Abstract
Advances in next generation sequencing technologies, as well as their expanded accessibility and clinical use over the past 2 decades, have led to an exponential increase in the number of identified single gene disorders. Among these are primary atopic disorders-inborn errors of immunity resulting in severe allergic phenotypes as a primary presenting feature. Two cardinal aspects of type I immediate hypersensitivity allergic reactions are hives and angioedema. Mast cells (MCs) are frequent primary drivers of these symptoms, but other cells have also been implicated. Even where MC degranulation is believed to be the cause, mediator-induced symptoms may greatly vary among individuals. Angioedema-particularly in the absence of hives-may also be caused by hereditary angioedema conditions resulting from aberrant regulation of contact system activation and excessive bradykinin generation or impairment of vascular integrity. In these patients, swelling can affect unpredictable locations and fail to respond to MC-directed therapies. Genetic variants have helped delineate key pathways in the etiology of urticaria and nonatopic angioedema and led to the development of targeted therapies. Herein, we describe the currently known inherited and acquired genetic causes for these conditions, highlight specific features in their clinical presentations, and discuss the benefits and limitations of biomarkers that can help distinguish them.
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Affiliation(s)
- Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Anastasios E Germenis
- Department of Immunology and Histocompatibility, School of Medicine, University of Thessaly, Larissa, Greece
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia; Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Tukisa D Smith
- Division of Rheumatology, Allergy and Immunology, University of California San Diego, La Jolla, Calif
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
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Bonadonna P, Korosec P, Nalin F, Golden DBK. Venom Anaphylaxis: Decision Points for a More Aggressive Workup. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2024-2031. [PMID: 37119981 DOI: 10.1016/j.jaip.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 05/01/2023]
Abstract
Diagnostic testing of patients who present for evaluation of insect venom allergy can involve many levels of investigation. A detailed initial history is critical for diagnosis and prognosis. The severity of previous sting reactions and the presence or absence of urticaria or hypotension predict severe future sting reactions and underlying mast cell disorders. Venom skin tests and specific IgE measurement can confirm the diagnosis but have limited positive predictive value for the frequency and severity of future sting reactions. Testing for serum IgE to recombinant venom component allergens can distinguish true allergy from cross-reactivity to honey bee and yellowjacket venoms. Basophil activation tests can improve the detection of venom allergy and predict the severity of reactions and the efficacy of venom immunotherapy but are limited in availability. An elevated basal serum tryptase level is an important marker for severe sting anaphylaxis and underlying mast cell disorders (eg, hereditary α-tryptasemia and clonal mast cell disease). When there is high suspicion (eg, using the Red Espanola de Mastocytosis score), bone marrow biopsy is the definitive tool to characterize mast cell disorders that are associated with the most severe outcomes in patients with insect sting allergy.
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Affiliation(s)
| | - Peter Korosec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia; Medical Faculty, University of Maribor, Maribor, Slovenia
| | | | - David B K Golden
- Dvision of Allergy and Clinical Immunology, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Md.
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20
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Floyd ML, Adams KE, Golden DBK. Updates and Recent Advances on Venom Immunotherapy. CURRENT TREATMENT OPTIONS IN ALLERGY 2023; 10:1-19. [PMID: 37361640 PMCID: PMC10148014 DOI: 10.1007/s40521-023-00336-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review Venom immunotherapy has been utilized to treat Hymenoptera venom allergy since the 1920s. Over the last century, significant advances in the fields of immunology and genetics have led to improvements in the practice of venom immunotherapy. This review encompasses recent advances in the use of venom immunotherapy to provide precise, patient-centered care. Recent Findings Research about the mechanism of action of venom immunotherapy continues to highlight the modification of both the innate and adaptive immune systems. Molecular techniques have allowed for the identification of specific venom allergens to improve the diagnostic accuracy and safety of venom immunotherapy. Research continues to support the safety of accelerated schedules which can impact the cost, adherence, and quality of life for patients receiving this treatment modality. Finally, significant advances have led to the elucidation of risk factors that place patients at risk for reactions during and after venom immunotherapy. Creation of risk profiles for venom-allergic patients can thus inform the process of immunotherapy in order to provide personalized and precise care. Summary Significant progress in the use of venom immunotherapy makes the practice a dynamic and active field for continued research. Future research needs to build on these recent advances to continue to optimize and enhance this life-saving treatment.
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Affiliation(s)
- Michelle L. Floyd
- 42d Medical Group, Maxwell AFB, 300 South Twining Street, Building 760, Montgomery, AL 36112 USA
| | - Karla E. Adams
- Department of Medicine, Allergy and Immunology Division, Wilford Hall Ambulatory Surgical Center, Lackland AFB, 1100 Wilford Hall Loop, Bldg 4554, San Antonio, TX 78236 USA
| | - David B. K. Golden
- Johns Hopkins University, 25 Crossroads Drive #410, Owings Mills, MD 21117 USA
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21
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Šelb J, Rijavec M, Kopač P, Lyons JJ, Korošec P. HαT is associated with increased risk for severe Hymenoptera venom-triggered anaphylaxis. J Allergy Clin Immunol 2023; 151:804-805. [PMID: 36529562 DOI: 10.1016/j.jaci.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Julij Šelb
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Kopač
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia.
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22
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Kačar M, Rijavec M, Šelb J, Korošec P. Clonal mast cell disorders and hereditary α-tryptasemia as risk factors for anaphylaxis. Clin Exp Allergy 2023; 53:392-404. [PMID: 36654513 DOI: 10.1111/cea.14264] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/12/2022] [Accepted: 11/23/2022] [Indexed: 01/20/2023]
Abstract
The association between Hymenoptera venom-triggered anaphylaxis (HVA) and clonal mast cell-related disorders (cMCD) has been known for decades. However, recent breakthroughs in peripheral blood screening for KIT p.D816V missense variant have revealed the true extent of this clinical association whilst adding to our understanding of the underlying aetiology. Thus, recent large studies highlighted the presence of KIT p.D816V among 18.2% and 23% of patients with severe Hymenoptera venom-triggered anaphylaxis. A significant proportion of those patients have normal serum basal tryptase (BST) levels, with no cutaneous findings such as urticaria pigmentosa or other systemic findings such as organomegaly that would have suggested the presence of cMCD. These findings of an increased prevalence suggest that the impact of cMCD on anaphylaxis could be clinically underestimated and that the leading question for clinicians could be changed from 'how many patients with cMCD have anaphylaxis?' to 'how many patients with anaphylaxis have cMCD?'. The discovery of hereditary α-tryptasemia (HαT)-a genetic trait caused by an increased copy number of the Tryptase Alpha/Beta 1 (TPSAB1) gene-, first described in 2016, is now known to underlie the majority of cases of elevated BST outside of cMCD and chronic kidney disease. HαT is the first common heritable genetic modifier of anaphylaxis described, and it is associated with increased risk for severe HVA (relative risk = 2.0), idiopathic anaphylaxis, and an increased prevalence of anaphylaxis in patients with cMCD, possibly due to the unique activity profile of α/β -tryptase heterotetramers that may potentiate immediate hypersensitivity reaction severity. Our narrative review aims to highlight recent research to have increased our understanding of cMCD and HαT, through recent lessons learned from studying their association with HVA. Additionally, we examined the studies of mast cell-related disorders in food and drug allergy in an effort to determine whether one should also consider cMCD and/or HαT in cases of severe anaphylaxis triggered by food or drugs.
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Affiliation(s)
- Mark Kačar
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Julij Šelb
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Korošec
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
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23
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Weiler CR, Schrijvers R, Golden DBK. Anaphylaxis: Advances in the Past 10 Years. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:51-62. [PMID: 36162799 DOI: 10.1016/j.jaip.2022.09.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/06/2022] [Accepted: 09/12/2022] [Indexed: 01/11/2023]
Abstract
In the past 10 years, anaphylaxis has grown into its own special area of study within Allergy-Immunology, both at the bench and at the bedside. This review focuses on some of the most clinically relevant advances over the past decade. These include simplified and more inclusive diagnostic criteria for adults and children, uniform definition of biphasic anaphylaxis, and improved systems for objective severity grading. Studies reported in the past decade have led to improved understanding of normal and abnormal regulation of mast cell function, translating into better diagnostic and therapeutic approaches to patients with anaphylaxis. Research has provided improved recognition and treatment of mast cell disorders and has identified a new condition, hereditary α-tryptasemia, that may impact anaphylactic syndromes. We have learned to recognize new causes (α-gal), new pathways (Mas-related G protein-coupled receptor-X2), and many risk factors for severe anaphylaxis. The stability of epinephrine in autoinjectors was reported to be very good for several years after the labeled expiry date, and it can tolerate freezing and thawing. Repeated and prolonged exposure to excessive heat leads to degradation of epinephrine activity. New treatments to prevent severe anaphylaxis have been described, using new ways to block the IgE receptor or modulate intracellular signaling pathways.
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Affiliation(s)
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, Leuven, Belgium
| | - David B K Golden
- Division of Allergy/Clinical Immunology, Johns Hopkins School of Medicine, Baltimore, Md.
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24
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Onnes MC, Alheraky A, Nawijn MC, Sluijter TE, Mulder AB, Arends S, Oude Elberink HNG. Detection of clonal mast cell disease in wasp venom allergic patients with normal tryptase. Clin Transl Allergy 2022; 12:e12174. [PMID: 36090584 PMCID: PMC9449818 DOI: 10.1002/clt2.12174] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/19/2022] [Accepted: 06/19/2022] [Indexed: 11/06/2022] Open
Abstract
Background Clonal mast cell disease (CMD) is an underlying aggravating condition in wasp venom allergy (WVA) which requires a different treatment strategy. CMD is increasingly recognized in patients with normal basal serum tryptase (bsT). However, methods to identify at risk patients have not yet been assessed in large cohorts of WVA patients with normal bsT. Methods This retrospective study evaluated the reliability of the REMA score in detecting CMD in a cohort of grade IV WVA patients with normal bsT and assessed the added value of other clinical parameters, KIT D816V mutation analysis in peripheral blood (PB) and the diagnosis of hereditary alpha tryptasemia (HAT). All patients had a conclusive bone marrow evaluation that demonstrated or excluded underlying CMD. Results In total 35 CMD and 96 non-CMD patients were included. REMA score had a sensitivity of 72% (95% CI 56%-88%) and specificity of 79% (95% CI 70%-87%) in this cohort. Loss of consciousness during systemic reaction and bsT between 6.3 and 11.4 ng/ml were additional parameters independently associated with CMD. Sensitivity of KIT in PB was relatively low, 56% (95% CI 36%-75%), but had added value as screening method in patients with a low REMA score due to 100% specificity. Conclusion The REMA score is a relatively reliable method to detect patients at risk of CMD among WVA patients with normal bsT. KIT mutation analysis in PB could serve as additional screening method in patients with low REMA scores.
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Affiliation(s)
- Merel C. Onnes
- Department of Internal MedicineDivision of AllergologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Department of Pathology and Medical BiologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC) Research InstituteUniversity Medical Center GroningenGroningenThe Netherlands
| | - Abdulrazzaq Alheraky
- Department of Laboratory MedicineUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Martijn C. Nawijn
- Department of Pathology and Medical BiologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC) Research InstituteUniversity Medical Center GroningenGroningenThe Netherlands
| | - Tim E. Sluijter
- Department of Internal MedicineDivision of AllergologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - André B. Mulder
- Department of Laboratory MedicineUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Suzanne Arends
- Department of Rheumatology and Clinical ImmunologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Hanneke N. G. Oude Elberink
- Department of Internal MedicineDivision of AllergologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC) Research InstituteUniversity Medical Center GroningenGroningenThe Netherlands
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25
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Waters AM, Park HJ, Weskamp AL, Mateja A, Kachur ME, Lyons JJ, Rosen BJ, Boggs NA. Elevated Basal Serum Tryptase: Disease Distribution and Variability in a Regional Health System. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2424-2435.e5. [PMID: 35032694 PMCID: PMC9273808 DOI: 10.1016/j.jaip.2021.12.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hereditary-alpha tryptasemia (HαT) is the most common etiology for elevated basal serum tryptase (BST). However, the utility of tryptase genotyping of individuals with elevated BST in general clinical practice remains undefined. Moreover, studies showing associations between elevated BST and chronic kidney disease (CKD), myelodysplastic syndrome (MDS), rheumatoid arthritis, or eosinophilic esophagitis did not include tryptase genotyping. OBJECTIVE To determine the utility of tryptase genotyping among individuals with moderate elevations in BST at a regional health system. METHODS Clinical and laboratory data from 109 subjects with basal tryptase values of 7.5 ng/mL or greater who were tested for HαT or had a disorder previously linked to elevated BST were collected retrospectively by chart review. RESULTS Fifty-eight subjects had elevated BST defined as 11.5 ng/mL or greater. HαT was found in 63.8% (n = 37), 12.1% (n = 7) had CKD, and 20.7% (n = 12) had clonal myeloid disorders. A total of 6.9% (n = 4) with elevated BST had negative testing for HαT, CKD, and myeloid neoplasms. Two subjects with CKD, 1 subject with MDS, and 1 with myeloid hypereosinophilic syndrome had negative testing for HαT. Among subjects with elevated BST and more than 1 tryptase measurement, 41.5% (n = 22) had BST variability that exceeded the 20% plus 2 formula. Increased BST variability was found in subjects with HαT, all forms of mastocytosis, CKD, MDS, and those with no associated diagnosis. CONCLUSIONS HαT, CKD, and clonal myeloid disorders or a combination of the 3 constitute approximately 90% of individuals with elevated BST in clinical practice. Myeloid neoplasms were over-represented in this cohort relative to population prevalence data suggesting tryptase measurement selection bias by clinicians or higher prevalence. Elevated BST is associated with increased tryptase variability, regardless of etiology.
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Affiliation(s)
- Aubri M Waters
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, Md
| | - Hyun J Park
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, Md
| | - Andrew L Weskamp
- Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Md
| | - Allyson Mateja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Md
| | - Megan E Kachur
- Department of Pathology, Walter Reed National Military Medical Center, Bethesda, Md
| | - Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Benjamin J Rosen
- Hematopathology Service, Walter Reed National Military Medical Center, Bethesda, Md
| | - Nathan A Boggs
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, Md; Department of Medicine, Uniformed Services University, Bethesda, Md.
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26
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Valent P, Hartmann K, Bonadonna P, Gülen T, Brockow K, Alvarez-Twose I, Hermine O, Niedoszytko M, Carter MC, Hoermann G, Butterfield JH, Lyons JJ, Sperr WR, Greiner G, Sotlar K, Kluin-Nelemans HC, Schwaab J, Lange M, George TI, Siebenhaar F, Broesby-Olsen S, Jawhar M, Nedoszytko B, Castells M, Orfao A, Gotlib J, Reiter A, Horny HP, Triggiani M, Arock M, Metcalfe DD, Akin C. Global Classification of Mast Cell Activation Disorders: An ICD-10-CM-Adjusted Proposal of the ECNM-AIM Consortium. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1941-1950. [PMID: 35623575 DOI: 10.1016/j.jaip.2022.05.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 12/18/2022]
Abstract
Mast cell activation (MCA) is common and occurs in a number of pathologic conditions, including IgE-dependent and independent allergic reactions, atopic disorders, autoimmune processes, and mastocytosis. In a subset of patients, no underlying disease and no known trigger of MCA are found. When the symptoms are severe, systemic, and recurrent, and accompanied by a diagnostic increase in the serum tryptase level or other mast cell mediators, an MCA syndrome (MCAS) may be diagnosed. In these patients, the symptoms typically respond to drugs suppressing MCA, mediator production in mast cells, or mediator effects. In each case, diagnostic consensus criteria must be fulfilled to diagnose MCAS. In other patients, MCA may be local, less severe, or less acute, or may be suspected but not confirmed, so that the diagnostic criteria of MCAS are not fulfilled. In these patients, it may be difficult to prove MCA, for example, by measuring multiple mast cell mediators or basophil activation, the latter as a surrogate of IgE-dependent hypersensitivity. However, validated diagnostic criteria for implicating suspected MCA behind such conditions are lacking, even if some of these conditions have recently been assigned to an International Classification of Diseases-10-Clinical Modification code (ICD-10-CM). In this article, we discuss diagnostic features and criteria and propose a ICD-10-CM-adjusted classification for disorders associated with MCA, herein referred to as MCA disorders (MCADs), with special emphasis on the delineation between confirmed MCAS, MCAD not fulfilling MCAS criteria, and suspected MCAD that is not present. In addition, we discuss the discrimination between overt MCAD and predisposing conditions, such as atopic states, mastocytosis, and hereditary alpha tryptasemia.
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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.
| | - 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
| | | | - 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
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
| | - Ivan Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) and CIBERONC, Hospital Virgen del Valle, Toledo, Spain
| | - Olivier Hermine
- Service d'hématologie, Imagine Institute Université de Paris, Sorbonne, INSERM U1163, Centre national de référence des mastocytoses, Hôpital Necker, Assistance publiquehôpitaux de Paris, Paris, France
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Melody C Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Gregor Hoermann
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; MLL Munich Leukemia Laboratory, Munich, Germany
| | | | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Georg Greiner
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Department of Laboratory Medicine, Medical University of Vienna, and Ihr Labor, Vienna, Austria
| | - Karl Sotlar
- Institute of Pathology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Hanneke C Kluin-Nelemans
- Department of Haematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Tracy I George
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - 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, Allergology and Immunology, Berlin, Germany
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Mohamad Jawhar
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Boguslaw Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland; Invicta Fertility and Reproductive Center, Molecular Laboratory, Sopot, Poland
| | - Mariana Castells
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - 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
| | - Jason Gotlib
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, Calif
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilians-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
| | - 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
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27
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Lyons JJ, Greiner G, Hoermann G, Metcalfe DD. Incorporating Tryptase Genotyping Into the Workup and Diagnosis of Mast Cell Diseases and Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1964-1973. [PMID: 35597543 DOI: 10.1016/j.jaip.2022.05.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/29/2022] [Accepted: 05/10/2022] [Indexed: 12/18/2022]
Abstract
The measurement of mast cell tryptase levels in serum has found utility in the diagnosis and management of both clonal mast cell disorders and severe mast cell-dependent systemic reactions in the form of anaphylaxis. A more recent discovery is that a majority of individuals with elevated basal serum tryptase levels have increased germline TPSAB1 gene copy number encoding α-tryptase. This genetic trait is referred to as hereditary α-tryptasemia (HαT) and affects nearly 6% of the general population. In clinical practice, the presence or absence of HαT should thus now be determined when defining what constitutes an abnormal serum tryptase level in the diagnosis of mastocytosis. Further, as rises in serum tryptase levels are used to support the diagnosis of systemic anaphylaxis, variability in baseline serum tryptase levels should be factored into how significant a rise in serum tryptase is required to confirm the diagnosis of a systemic allergic reaction. In practicality, this dictates that symptomatic individuals undergoing evaluation for a mast cell-associated disorder or reaction with a baseline serum tryptase level exceeding 6.5 ng/mL should be considered for tryptase genotyping in order to screen for HαT. This review provides detailed information on how to use the results of such testing in the diagnosis and management of both mastocytosis and anaphylaxis.
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Affiliation(s)
- Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Georg Greiner
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria; Ihr Labor, Medical Diagnostic Laboratories Vienna, Vienna, Austria; Department of Laboratory Medicine, 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
| | - Dean D Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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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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Boyce JA. Advances in Mast Cell Biology. J Allergy Clin Immunol 2022; 149:1919-1925. [PMID: 35427642 DOI: 10.1016/j.jaci.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/19/2022]
Abstract
Mast cells (MCs) contribute prominently to all allergic diseases, yet are still poorly understood owing to their exclusive residence in tissues. Recently, the use of RNA-sequencing, proteomics, and other technological advances have accelerated the acquisition of new knowledge. This includes an expanded definition of MC heterogeneity and developmental origins, previously unrecognized functions for MCs, discoveries of genetic causes of MC-related disorders, the introduction of new therapies for clonal MC disease, and the identification of new potential target for treatments. This issue of Advances addresses key studies from 2020 to 2021.
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Affiliation(s)
- Joshua A Boyce
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass.
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Bizjak M, Košnik M, Dinevski D, Thomsen SF, Fomina D, Borzova E, Kulthanan K, Meshkova R, Ahsan DM, Al‐Ahmad M, Altrichter S, Bauer A, Brockstädt M, Costa C, Demir S, Fachini Criado R, Ensina LF, Gelincik A, Giménez‐Arnau AM, Gonçalo M, Gotua M, Holm JG, Inomata N, Kasperska‐Zajac A, Khoshkhui M, Klyucharova A, Kocatürk E, Lu R, Makris M, Maltseva N, Miljković J, Pasali M, Paulino M, Pesqué D, Peter J, Ramón GD, Ritchie C, Rodrigues Valle SO, Rudenko M, Sikora A, Souza Lima EM, Wagner N, Xepapadaki P, Xue X, Zhao Z, Terhorst‐Molawi D, Maurer M. Risk factors for systemic reactions in typical cold urticaria: Results from the COLD-CE study. Allergy 2021; 77:2185-2199. [PMID: 34862605 DOI: 10.1111/all.15194] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/11/2021] [Accepted: 11/20/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cold urticaria (ColdU), that is, the occurrence of wheals or angioedema in response to cold exposure, is classified into typical and atypical forms. The diagnosis of typical ColdU relies on whealing in response to local cold stimulation testing (CST). It can also manifest with cold-induced anaphylaxis (ColdA). We aimed to determine risk factors for ColdA in typical ColdU. METHODS An international, cross-sectional study COLD-CE was carried out at 32 urticaria centers of reference and excellence (UCAREs). Detailed history was taken and CST with an ice cube and/or TempTest® performed. ColdA was defined as an acute cold-induced involvement of the skin and/or visible mucosal tissue and at least one of: cardiovascular manifestations, difficulty breathing, or gastrointestinal symptoms. RESULTS Of 551 ColdU patients, 75% (n = 412) had a positive CST and ColdA occurred in 37% (n = 151) of the latter. Cold-induced generalized wheals, angioedema, acral swelling, oropharyngeal/laryngeal symptoms, and itch of earlobes were identified as signs/symptoms of severe disease. ColdA was most commonly provoked by complete cold water immersion and ColdA caused by cold air was more common in countries with a warmer climate. Ten percent (n = 40) of typical ColdU patients had a concomitant chronic spontaneous urticaria (CSU). They had a lower frequency of ColdA than those without CSU (4% vs. 39%, p = .003). We identified the following risk factors for cardiovascular manifestations: previous systemic reaction to a Hymenoptera sting, angioedema, oropharyngeal/laryngeal symptoms, and itchy earlobes. CONCLUSION ColdA is common in typical ColdU. High-risk patients require education about their condition and how to use an adrenaline autoinjector.
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Affiliation(s)
- Mojca Bizjak
- Division of Allergy Urticaria Center of Reference and Excellence (UCARE)University Clinic of Respiratory and Allergic Diseases Golnik Golnik Slovenia
- Faculty of Medicine University of Maribor Maribor Slovenia
| | - Mitja Košnik
- Division of Allergy Urticaria Center of Reference and Excellence (UCARE)University Clinic of Respiratory and Allergic Diseases Golnik Golnik Slovenia
- Faculty of Medicine University of Ljubljana Ljubljana Slovenia
| | - Dejan Dinevski
- Faculty of Medicine University of Maribor Maribor Slovenia
| | - Simon Francis Thomsen
- Department of Dermatology Urticaria Center of Reference and Excellence (UCARE)Bispebjerg HospitalUniversity of Copenhagen Copenhagen Denmark
| | - Daria Fomina
- Urticaria Center of Reference and Excellence (UCARE)Center of Allergy and ImmunologyClinical State Hospital 52Moscow Ministry of Healthcare Moscow Russian Federation
- Department of Clinical Immunology and Allergology I.M. Sechenov First Moscow State Medical University Moscow Russian Federation
| | - Elena Borzova
- Department of Dermatology and Venereology I.M. Sechenov First Moscow State Medical University Moscow Russian Federation
- Department of Clinical Genetics Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University Moscow Russian Federation
| | - Kanokvalai Kulthanan
- Department of Dermatology Urticaria Center of Reference and Excellence (UCARE)Faculty of Medicine Siriraj HospitalMahidol University Bangkok Thailand
| | - Raisa Meshkova
- Department of Clinical Immunology and Allergology Urticaria Center of Reference and Excellence (UCARE)Smolensk State Medical University Smolensk Russian Federation
| | - Dalia Melina Ahsan
- Urticaria Center of Reference and Excellence (UCARE) Institute for Allergology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology Berlin Germany
| | - Mona Al‐Ahmad
- Microbiology Department Faculty of Medicine Urticaria Center of Reference and Excellence (UCARE)Kuwait University Safat Kuwait
| | - Sabine Altrichter
- Urticaria Center of Reference and Excellence (UCARE) Institute for Allergology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology Berlin Germany
- Department of Dermatology and Venerology Urticaria Center of Reference and Excellence (UCARE)Comprehensive Allergy CenterKepler University Hospital Linz Austria
| | - Andrea Bauer
- Department of Dermatology Urticaria Center of Reference and Excellence (UCARE)University Allergy CenterUniversity Hospital Carl Gustav CarusTechnical University Dresden Germany
| | - Maxi Brockstädt
- Urticaria Center of Reference and Excellence (UCARE) Institute for Allergology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology Berlin Germany
| | - Célia Costa
- Immunoallergology Department Urticaria Center of Reference and Excellence (UCARE)Hospital de Santa MariaCHULN Lisbon Portugal
| | - Semra Demir
- Division of Allergy Department of Internal Medicine Istanbul Faculty of Medicine Urticaria Center of Reference and Excellence (UCARE)Istanbul University Istanbul Turkey
| | - Roberta Fachini Criado
- Faculdade de Medicina do ABC (FMABC)Urticaria Center of Reference and Excellence (UCARE) Santo André Brazil
| | - Luis Felipe Ensina
- Division of Allergy, Clinical Immunology and Rheumatology Department of Pediatrics Urticaria Center of Reference and Excellence (UCARE)Federal University of São Paulo São Paulo Brazil
| | - Asli Gelincik
- Division of Allergy Department of Internal Medicine Istanbul Faculty of Medicine Urticaria Center of Reference and Excellence (UCARE)Istanbul University Istanbul Turkey
| | - Ana Maria Giménez‐Arnau
- Department of Dermatology Urticaria Center of Reference and Excellence (UCARE)Hospital del MarIMIMUniversitat Autònoma Barcelona Spain
| | - Margarida Gonçalo
- Clinic of Dermatology Urticaria Center of Reference and Excellence (UCARE)University Hospital and Faculty of MedicineUniversity of Coimbra Coimbra Portugal
| | - Maia Gotua
- Center of Allergy and ImmunologyUrticaria Center of Reference and Excellence (UCARE) Tbilsi Georgia
| | - Jesper Grønlund Holm
- Department of Dermatology Urticaria Center of Reference and Excellence (UCARE)Bispebjerg HospitalUniversity of Copenhagen Copenhagen Denmark
| | - Naoko Inomata
- Department of Environmental Immuno‐Dermatology Urticaria Center of Reference and Excellence (UCARE)Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Alicja Kasperska‐Zajac
- Clinical Department of Internal Diseases European Center for Diagnosis and Treatment of UrticariaUrticaria Center of Reference and Excellence (UCARE)Dermatology and Allergology of Medical University of Silesia Zabrze Poland
| | - Maryam Khoshkhui
- Allergy Research CenterMashhad University of Medical Sciences Mashhad Iran
| | - Aliya Klyucharova
- Department of Clinical Immunology and Allergology Republican Center of Clinical Immunology and AllergologyUrticaria Center of Reference and Excellence (UCARE)Republican Clinical HospitalKazan State Medical University Kazan Russian Federation
- Department of Fundamental Principles of Clinical Medicine Institute of Fundamental Medicine and Biology (IFMB) of Kazan Federal University Kazan Russian Federation
| | - Emek Kocatürk
- Department of Dermatology Urticaria Center of Reference and Excellence (UCARE)Koç University School of Medicine Istanbul Turkey
| | - Rongbiao Lu
- Department of Dermatology Urticaria Center of Reference and Excellence (UCARE)The Third Affiliated Hospital of Sun Yat‐sen University Guangzhou China
| | - Michael Makris
- Allergy Unit Second Department of Dermatology and Venereology Urticaria Center of Reference and Excellence (UCARE)National and Kapodistrian University of AthensUniversity General Hospital “Attikon” Athens Greece
| | - Natalya Maltseva
- Urticaria Center of Reference and Excellence (UCARE)Center of Allergy and ImmunologyClinical State Hospital 52Moscow Ministry of Healthcare Moscow Russian Federation
| | | | - Maria Pasali
- Allergy Unit Second Department of Dermatology and Venereology Urticaria Center of Reference and Excellence (UCARE)National and Kapodistrian University of AthensUniversity General Hospital “Attikon” Athens Greece
| | - Marisa Paulino
- Immunoallergology Department Urticaria Center of Reference and Excellence (UCARE)Hospital de Santa MariaCHULN Lisbon Portugal
| | - David Pesqué
- Department of Dermatology Urticaria Center of Reference and Excellence (UCARE)Hospital del MarIMIMUniversitat Autònoma Barcelona Spain
| | - Jonny Peter
- Division of Allergy and Clinical Immunology Department of Medicine Urticaria Center of Reference and Excellence (UCARE)University of Cape Town Cape Town South Africa
- Allergy and Immunology Unit University of Cape Town Lung Institute Cape Town South Africa
| | - German Dario Ramón
- Urticaria Center of Reference and Excellence (UCARE)Instituto de Alergia e Inmunologia del Sur Buenos Aires Argentina
| | - Carla Ritchie
- Adults and Pediatrics Allergy Unit Urticaria Center of Reference and Excellence (UCARE)Hospital Italiano de Buenos Aires Buenos Aires Argentina
| | - Solange Oliveira Rodrigues Valle
- Department of Internal Medicine, Immunology Service Urticaria Center of Reference and Excellence (UCARE)Federal University of Rio de Janeiro Rio de Janeiro Brazil
| | - Michael Rudenko
- Urticaria Center of Reference and Excellence (UCARE)London Allergy and Immunology Centre London UK
| | - Agnieszka Sikora
- Clinical Department of Internal Diseases European Center for Diagnosis and Treatment of UrticariaUrticaria Center of Reference and Excellence (UCARE)Dermatology and Allergology of Medical University of Silesia Zabrze Poland
| | - Eduardo M. Souza Lima
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA)Urticaria Center of Reference and Excellence (UCARE)Hospital Maternidade Therezinha de Jesus Minas Gerais Brazil
| | - Nicola Wagner
- Department of Dermatology Urticaria Center of Reference and Excellence (UCARE)University Hospital of ErlangenUniversity of Erlangen‐Nuremberg (FAU) Germany
| | - Paraskevi Xepapadaki
- Allergy Unit 2nd Pediatric Clinic Urticaria Center of Reference and Excellence (UCARE)National and Kapodistrian University of Athens Greece
| | - Xiaoyang Xue
- Department of General Practice Urticaria Center of Reference and Excellence (UCARE)Community Health Service Center Guangzhou City China
| | - Zuotao Zhao
- Department of Dermatology and Venerology Urticaria Center of Reference and Excellence (UCARE)Beijing Key Laboratory of Molecular Diagnosis on Dermatoses and National Clinical Research Center for Skin and Immune DiseasesPeking University First Hospital Beijing China
| | - Dorothea Terhorst‐Molawi
- Urticaria Center of Reference and Excellence (UCARE) Institute for Allergology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology Berlin Germany
| | - Marcus Maurer
- Urticaria Center of Reference and Excellence (UCARE) Institute for Allergology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology Berlin Germany
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Clinical relevance of inherited genetic differences in human tryptases: Hereditary alpha-tryptasemia and beyond. Ann Allergy Asthma Immunol 2021; 127:638-647. [PMID: 34400315 DOI: 10.1016/j.anai.2021.08.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/09/2021] [Accepted: 08/09/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe our current understanding of hereditary α-tryptasemia (HαT), how HαT fits into the evolutionary context of tryptases and contemporary framework of mast cell-associated disorders, and to discuss the future clinical and therapeutic landscape for symptomatic individuals with HαT. DATA SOURCES Primary peer-reviewed literature. STUDY SELECTIONS Basic, clinical, and translational studies describing tryptase gene composition, generation, secretion, and elevation and the associated clinical impacts of HαT and treatment of such individuals were reviewed. RESULTS HαT is a common autosomal dominant genetic trait caused by increased TPSAB1 copy number encoding α-tryptase. Approximately 1 in 20 White individuals have HαT, making it by far the most common cause for elevated basal serum tryptase levels. Although many individuals with HαT may not manifest associated symptoms, the prevalence of HαT is increased in patients with clonal and nonclonal mast cell-associated disorders wherein it is linked to more prevalent and/or severe anaphylaxis and increased mast cell mediator-associated symptoms. Increased generation of mature α/β-tryptase heterotetramers, and their unique physiochemical properties, may be responsible for some of these clinical findings. CONCLUSION HαT is a common modifier of mast cell-associated disorders and reactions. Nevertheless, whether HαT may be an independent cause of clinical phenotypes with which it has been associated remains unproven. Correct identification of HαT is critical to accurate interpretation of serum tryptase levels in the clinical evaluation of patients. Beyond HαT, we foresee tryptase genotyping as an important parameter in the standard workup of patients with mast cell-associated disorders and development of therapeutic modalities targeting these patients and associated clinical phenotypes.
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Lyons JJ. Inherited and acquired determinants of serum tryptase levels in humans. Ann Allergy Asthma Immunol 2021; 127:420-426. [PMID: 34175497 DOI: 10.1016/j.anai.2021.06.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/06/2021] [Accepted: 06/19/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To aid the clinician in correctly interpreting serum tryptase levels. DATA SOURCES Primary peer-reviewed literature. STUDY SELECTIONS Clinical and basic science peer-reviewed studies characterizing the genetic and physiological bases for tryptase generation, secretion, and elevation, including those describing serum tryptase levels in population-based cohort studies. RESULTS Clinically measured basal serum tryptase (BST) consists of ostensibly inactive alpha- and beta-tryptase precursors. The autosomal dominant genetic trait hereditary alpha-tryptasemia is the most often cause for elevated BST levels, with other acquired causes, such as renal failure and clonal myeloid diseases being far less common. Acute increases in serum tryptase levels resulting from release of mature tryptase from secretory granules is specific to mast cell degranulation but is not detected in all cases of systemic anaphylaxis. CONCLUSION Understanding the differences and distinguishing between acute increases in serum tryptase and chronic elevations in BST owing to inherited or acquired conditions is critical in the correct interpretation of this useful clinical biomarker.
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Affiliation(s)
- Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland.
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Hymenoptera Venom Immunotherapy: Immune Mechanisms of Induced Protection and Tolerance. Cells 2021; 10:cells10071575. [PMID: 34206562 PMCID: PMC8306808 DOI: 10.3390/cells10071575] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/15/2021] [Accepted: 06/18/2021] [Indexed: 01/03/2023] Open
Abstract
Hymenoptera venom allergy is one of the most severe allergic diseases, with a considerable prevalence of anaphylactic reaction, making it potentially lethal. In this review, we provide an overview of the current knowledge and recent findings in understanding induced immune mechanisms during different phases of venom immunotherapy. We focus on protection mechanisms that occur early, during the build-up phase, and on the immune tolerance, which occurs later, during and after Hymenoptera venom immunotherapy. The short-term protection seems to be established by the early desensitization of mast cells and basophils, which plays a crucial role in preventing anaphylaxis during the build-up phase of treatment. The early generation of blocking IgG antibodies seems to be one of the main reasons for the lower activation of effector cells. Long-term tolerance is reached after at least three years of venom immunotherapy. A decrease in basophil responsiveness correlates with tolerated sting challenge. Furthermore, the persistent decline in IgE levels and, by monitoring the cytokine profiles, a shift from a Th2 to Th1 immune response, can be observed. In addition, the generation of regulatory T and B cells has proven to be essential for inducing allergen tolerance. Most studies on the mechanisms and effectiveness data have been obtained during venom immunotherapy (VIT). Despite the high success rate of VIT, allergen tolerance may not persist for a prolonged time. There is not much known about immune mechanisms that assure long-term tolerance post-therapy.
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