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Nishio Y, Hara M, Oshita K, Jotaki S, Murotani K, Hiraki T. Relationship between Tryptase and Hypotension in Anaphylaxis during Anesthesia. Kurume Med J 2024; 70:19-27. [PMID: 38763736 DOI: 10.2739/kurumemedj.ms7012012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Hypotension is a cardiovascular symptom that appears at the onset of anaphylaxis. It is considered an important factor as it affects the severity of anaphylaxis; however, its details remain to be elucidated. In this study, we investigated the characteristics of hypotension at the onset of anaphylaxis during anesthesia, along with the relationship between hypotension, tryptase and histamine. MATERIALS AND METHODS The minimum systolic blood pressures of patients diagnosed with anaphylaxis using the clinical diagnostic criteria of the World Allergy Organization guidelines were extracted from electronic anesthesia records. We analyzed changes in tryptase and histamine that were measured after the onset of anaphylaxis. We analyzed the relationship of tryptase and histamine with the minimum systolic blood pressure and the severity of anaphylaxis. RESULTS Of 55,996 patients, 25 were diagnosed with anaphylaxis during anesthesia (0.045%). Among these patients, the minimum systolic blood pressure was less than 90 mmHg. Furthermore, the minimum systolic blood pressure was inversely correlated with tryptase levels immediately to 1 hour, and 2 to 4 hours after the onset of anaphylaxis. The minimum systolic blood pressure was inversely correlated with the severity of anaphylaxis. The severity of anaphylaxis was positively correlated with tryptase levels immediately to 1 hour, and 2 to 4 hours after the onset of anaphylaxis. CONCLUSION Hypotension tended to reflect the severity of anaphylaxis. Tryptase is an adjunct in the diagnosis of hypotension and may be a useful indicator of the severity of anaphylaxis. A larger-scale study is needed to validate these results.
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Affiliation(s)
- Yumiko Nishio
- Department of Anesthesiology, Kurume University School of Medicine
| | - Masato Hara
- Department of Anesthesiology, Kurume University School of Medicine
| | - Kensuke Oshita
- Department of Anesthesiology, Kurume University School of Medicine
| | - Shosaburo Jotaki
- Department of Anesthesiology, Kurume University School of Medicine
| | | | - Teruyuki Hiraki
- Department of Anesthesiology, Kurume University School of Medicine
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Akin C, Siebenhaar F, Wechsler JB, Youngblood BA, Maurer M. Detecting Changes in Mast Cell Numbers Versus Activation in Human Disease: A Roadblock for Current Biomarkers? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1727-1737. [PMID: 38467332 DOI: 10.1016/j.jaip.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/09/2024] [Accepted: 03/01/2024] [Indexed: 03/13/2024]
Abstract
The pathophysiology of mast cell (MC)-driven disorders is diverse, ranging from localized reactions to systemic disorders caused by abnormal accumulation and activation in multiorgan systems. Prompt and accurate diagnosis is critically important, both for informing treatment and objective assessment of treatment outcomes. As new therapeutics are being developed to deplete MCs or silence them (eg, by engaging inhibitory receptors that block activation), new biomarkers are needed that can distinguish between MC activation versus burden. Serum tryptase is the gold standard for assessing both MC burden and activation; however, commercial tryptase assays have limitations related to timing of release, lack of discernment between inactive (α) and active (β) forms of tryptase, and interpatient variability of baseline levels. Alternative approaches to measuring MC activation include urinary MC mediators, flow cytometry-based assays or gene expression profiling. Additional markers of MC activation are needed for use in clinical diagnostics, to help selection of treatment of MC diseases, and for assessing outcomes of therapy. We review the spectrum of disorders with known or suspected MC contribution, describe the utility and limitations of current MC markers and assays, and discuss the need for new markers that can differentiate between MC activation and burden.
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Affiliation(s)
- Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| | - Frank Siebenhaar
- Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | | | - Marcus Maurer
- Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany.
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3
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Ebo DG, Lang DM, Ledford DK. Perioperative Anaphylaxis: Light at the End of the Tunnel. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1603-1604. [PMID: 38851254 DOI: 10.1016/j.jaip.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Didier G Ebo
- Department of Immunology, Allergology and Rheumatology and the Infla-Med Centre of Excellence, University Antwerp, Antwerp University Hospital, Antwerpen, Belgium.
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital Morsani College of Medicine, University of South Florida, Tampa, Fla
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Gonzalez-Estrada A, Carrillo-Martin I, Morgenstern-Kaplan D, Rukasin CRF, Rank MA, Park MA, Yee CI, Volcheck GW. A US-Based Multicenter Retrospective Report of Perioperative Anaphylaxis, 2010-2021. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1594-1602.e9. [PMID: 38580206 DOI: 10.1016/j.jaip.2024.02.042] [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: 01/13/2023] [Revised: 01/18/2024] [Accepted: 02/17/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND US-based perioperative anaphylaxis (POA) studies are limited to single-center experiences. A recent report found that a serum acute tryptase (sAT) >9.8 ng/mL or mast cell activation (MCA) can predict POA causal agent identification. Urinary mast cell mediator metabolites (uMC) have not been studied in POA. OBJECTIVE To analyze the epidemiologic data of POA, to determine if sAT or MCA can predict suspected causal agent identification, and to evaluate uMC utility in POA. METHODS This study is a retrospective multicenter review of POA cases that were subcategorized by suspected causal agent identification status. sAT, MCA (defined as sAT >2 + 1.2 × serum baseline tryptase), and uMC (N-methylhistamine [N-MH], 11β-prostaglandin-F2α [11β-PGF2α], leukotriene E4 [LTE4]) were recorded. RESULTS Of 100 patients (mean age 52 [standard deviation 17] years, 94% adult, 50% female, 90% White, and 2% Hispanic) with POA, 73% had an sAT available, 41% had MCA, 16% had uMC available, and 50% had an identifiable suspected cause. POA cases with an identifiable suspected cause had a positive MCA status (100% vs 78%; P = .01) compared with POA with an unidentifiable cause. An elevated median sAT did not predict causal agent identification. Positive uMC were not associated with suspected causal agent identification during POA. Patients with positive uMC had a higher median sAT (30 vs 6.45 ng/mL; P = .001) and MCA status (96% vs 12%; P = .001) compared with negative uMC patients. Patients with POA had an elevated acute/baseline uMC ratios: 11β-PGF2α ratio > 1.6, N-MH ratio >1.7, and LTE4 ratio >1.8. CONCLUSIONS The presence of MCA in POA is associated with suspected causal agent identification. Positive uMC possibly correlate with a higher sAT level and MCA status but require further study. The authors suggest applying an acute/baseline uMC ratio (11β-PGF2α ratio >1.6, N-MH ratio >1.7, and LTE4 ratio >1.87) in patients with POA for MCA when a tryptase level is inconclusive during POA evaluations.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla.
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Dan Morgenstern-Kaplan
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Christine R F Rukasin
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Matthew A Rank
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Miguel A Park
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Claire I Yee
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, Ariz
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
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An J, Lee CE, Kim SY, Park SY, Kim S, Sim DW, Yang MS, Park HK, Kim SH, Kim SH, Ye YM, Lee JH, Hur GY, Park HK, Koh Y, Park JW, Lee J, Lee BJ, Kim TB. Serum MRGPRX2 as a Long-term Biomarker for Iodinated Contrast Media-Induced Anaphylaxis. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2024; 16:308-316. [PMID: 38910288 PMCID: PMC11199152 DOI: 10.4168/aair.2024.16.3.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/29/2024] [Accepted: 04/16/2024] [Indexed: 06/25/2024]
Abstract
The diagnosis of anaphylaxis is based on the clinical history. The utility of tryptase measurements in clinical setting is limited. Mas-related G protein-coupled receptor-X2 (MRGPRX2) is expressed in mast cells and is involved in the degranulation of these cells. We evaluated the potential of MRGPRX2 as a diagnostic biomarker in patients with iodinated contrast media (ICM)-induced immediate hypersensitivity reactions (IHRs). A total of 173 patients with documented ICM-induced IHR within 4 months from registration were enrolled and skin tests for the culprit ICM were performed. The time interval was evaluated as the duration between the onset of ICM-induced IHR and the measurement of serum MRGPRX2 levels. Serum MRGPRX2 concentration was determined using an enzyme-linked immunosorbent assay kit. Of the 173 patients, 33 and 140 were included in the anaphylaxis and non-anaphylaxis groups, respectively. Serum MRGPRX2 levels were significantly higher in the anaphylaxis than in the non-anaphylaxis group (29.9 ± 24.1 vs. 20.7±17.5, P = 0.044). Serum MRGPRX2 showed a moderate predictive ability for anaphylaxis, with an area under the curve of 0.61 (P = 0.058). When groups were classified based on the time interval, T1(0-2months) and T2 (2-4months), patients with anaphylaxis had higher MRGPRX2 levels compared to the non-anaphylaxis group in the T2 group (36.5±19.2 vs. 20.5±19.0, P = 0.035). This pilot study shows that serum MRGPRX2 is a potential long-term biomarker for predicting anaphylaxis, particularly ICM-induced anaphylaxis. Further studies are needed to determine the role of MRGPRX2 in anaphylaxis in a larger population of patients with various drug-induced IHRs.
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Affiliation(s)
- Jin An
- Department of Pulmonary, Allergy and Critical Care Medicine, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, Seoul, Korea
| | - Chea Eun Lee
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seo-Young Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So-Young Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sujeong Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Da Woon Sim
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Han-Ki Park
- Department of Allergy and Clinical Immunology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sae-Hoon Kim
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Young-Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Jae Hyun Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Gyu Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Youngil Koh
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jung-Won Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jaechun Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Byung-Jae Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Mayorga C, Ariza A, Muñoz-Cano R, Sabato V, Doña I, Torres MJ. Biomarkers of immediate drug hypersensitivity. Allergy 2024; 79:601-612. [PMID: 37947156 DOI: 10.1111/all.15933] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/29/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
Immediate drug hypersensitivity reactions (IDHRs) are a burden for patients and the health systems. This problem increases when taking into account that only a small proportion of patients initially labelled as allergic are finally confirmed after an allergological workup. The diverse nature of drugs involved will imply different interactions with the immunological system. Therefore, IDHRs can be produced by a wide array of mechanisms mediated by the drug interaction with specific antibodies or directly on effector target cells. These heterogeneous mechanisms imply an enhanced complexity for an accurate diagnosis and the identification of the phenotype and endotype at early stages of the reaction is of vital importance. Currently, several endophenotypic categories (type I IgE/non-IgE, cytokine release, Mast-related G-protein coupled receptor X2 (MRGPRX2) or Cyclooxygenase-1 (COX-1) inhibition and their associated biomarkers have been proposed. A precise knowledge of endotypes will permit to discriminate patients within the same phenotype, which is crucial in order to personalise diagnosis, future treatment and prevention to improve the patient's quality of life.
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Affiliation(s)
- Cristobalina Mayorga
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina - IBIMA Plataforma BIONAND, Málaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-HRUM, Málaga, Spain
| | - Adriana Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina - IBIMA Plataforma BIONAND, Málaga, Spain
| | - Rosa Muñoz-Cano
- Allergy Department, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer - IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Vito Sabato
- Department of Immunology, Allergology, Rheumatology, Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Inmaculada Doña
- Allergy Unit, Hospital Regional Universitario de Málaga-HRUM, Málaga, Spain
| | - Maria J Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina - IBIMA Plataforma BIONAND, Málaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-HRUM, Málaga, Spain
- Medicine Department, Universidad de Málaga-UMA, Málaga, Spain
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Vlaeminck N, Poorten MLVD, Nygaard Madsen C, Bech Melchiors B, Michel M, Gonzalez C, Schrijvers R, Elst J, Mertens C, Saldien V, Vitte J, Garvey LH, Sabato V, Ebo DG. Paediatric perioperative hypersensitivity: the performance of the current consensus formula and the effect of uneventful anaesthesia on serum tryptase. BJA OPEN 2024; 9:100254. [PMID: 38261931 PMCID: PMC10797541 DOI: 10.1016/j.bjao.2023.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/16/2023] [Indexed: 01/25/2024]
Abstract
Background Paired sampling of acute (aST) and basal (bST) serum tryptase has been recommended when investigating patients with a suspected perioperative hypersensitivity (POH) reaction. In the current consensus formula, an aST value exceeding (1.2×bST+2) confirms mast cell activation. The current consensus formula has been validated in adults but not in children. Methods We prospectively included 96 children who underwent uneventful anaesthesia and sampled serum tryptase at baseline and 60-90 min after induction. Tryptase changes were then compared with those in 94 children with suspected POH who were retrospectively included from four reference centres in Belgium, France, and Denmark. Results We observed a median decrease in serum tryptase during uneventful anaesthesia of 0.41 μg L-1 (-15.9%; P<0.001). The current consensus formula identified mast cell activation in 31.9% of paediatric POH patients. After generating receiver operating characteristic curves through 100 repeated five-fold cross-validation, aST>bST+0.71 was identified as the optimal cut-off point to identify mast cell activation. This new paediatric formula has higher sensitivity than the current consensus formula (53.2% vs 31.9%, P<0.001) with a specificity of 96.9%. Analysis in the subpopulation where a culprit was identified and in grade 3-4 reactions similarly yielded higher sensitivity for the new paediatric formula when compared with the current consensus formula (85.3% vs 61.8%; P=0.008 and 78.0% vs 48.8%; P<0.001, respectively). Internally cross-validated sensitivity and specificity were 53.3% and 93.3%, respectively. Conclusions This is the first study suggesting the need for an adjusted formula in children to identify perioperative mast cell activation as tryptase is significantly lowered during uneventful anaesthesia. We propose a new formula (aST>bST+0.71) which performs significantly better than the current consensus formula in our multicentric paediatric population.
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Affiliation(s)
- Nils Vlaeminck
- Department of Anaesthesiology, Antwerp University Hospital, Belgium
| | - Marie-Line van der Poorten
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
- Department of Paediatrics, Faculty of Medicine and Health Science, University of Antwerp, Antwerp University Hospital, Belgium
| | - Cecilie Nygaard Madsen
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Birgitte Bech Melchiors
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Moïse Michel
- Aix-Marseille Université, MEPHI, Marseille, France
- IHU Méditerranée Infection, Marseille, France
- CHU Nîmes, Laboratoire d’Immunologie, Nîmes, France
| | - Constance Gonzalez
- Aix-Marseille Univ, University Hospitals of Marseille, Laboratoire d’Immunologie, Marseille, France
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Faculty of Medicine, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Jessy Elst
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Christel Mertens
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Vera Saldien
- Department of Anaesthesiology, Antwerp University Hospital, Belgium
| | - Joana Vitte
- University of Reims Champagne-Ardenne, INSERM UMR-S 1205 P3CELL and Immunology Laboratory, University Hospital of Reims, Reims, France
| | - Lene H. Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Vito Sabato
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Didier G. Ebo
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium
- Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
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Jimenez-Rodriguez TW, de Las Vecillas L, Labella M, Lynch DM, Besz KM, Marquis K, Burgos A, Soriano Gomis V, Lozano I, Antón RAM, de la Calle FM, González Delgado MP, Gutiérrez A, Montenegro E, Rodríguez F, Fernández Sánchez FJ, Castells M. Differential presentation of hypersensitivity reactions to carboplatin and oxaliplatin: Phenotypes, endotypes, and management with desensitization. Allergy 2024; 79:679-689. [PMID: 37916741 DOI: 10.1111/all.15940] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Drug hypersensitivity reactions (DHRs) to platinum-based drugs are heterogenous and restrict their access, and drug desensitization (DD) has provided a ground-breaking procedure for their re-introduction, although the response is heterogeneous. We aimed to identify the phenotypes, endotypes, and biomarkers of reactions to carboplatin and oxaliplatin and their response to DD. METHODS Seventy-nine patients presenting with DHRs to oxaliplatin (N = 46) and carboplatin (N = 33) were evaluated at the Allergy Departments of two tertiary care hospitals in Spain. Patient symptoms, skin testing, biomarkers, and outcomes of 267 DDs were retrospectively analyzed. RESULTS Oxaliplatin-reactive patients presented with type I (74%), cytokine release reaction (CRR) (11%), and mixed (Mx) (15%) phenotypes. In contrast, carboplatin reactive patients presented with predominantly type I (85%) and Mx (15%) but no CRRs. Out of 267 DDs, breakthrough reactions (BTRs) to oxaliplatin occurred twice as frequently as carboplatin (32% vs. 15%; p < .05). Phenotype switching from type I to another phenotype was observed in 46% of oxaliplatin DDs compared to 21% of carboplatin DDs. Tryptase was elevated in type I and Mx reactions, and IL-6 in CRR and Mx, indicating different mechanisms and endotypes. CONCLUSION Carboplatin and oxaliplatin induced three different types of reactions with defined phenotypes and endotypes amendable to DD. Although most of the initial reactions for both were type I, oxaliplatin presented with unique CRR reactions. During DD, carboplatin reactive patients presented mostly type I BTR, while oxaliplatin-reactive patients frequently switched from type I to CRR, providing a critical difference and the need for personalized DD protocols.
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Affiliation(s)
- Teodorikez-Wilfox Jimenez-Rodriguez
- Allergy Section, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- ARADyAL Spanish Network (RD16/0006), Instituto de Salud Carlos III (ISCIII), Fundación Española para la Ciencia y la Tecnología (FECyT), Madrid, Spain
| | - Leticia de Las Vecillas
- Allergy Section, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Marina Labella
- ARADyAL Spanish Network (RD16/0006), Instituto de Salud Carlos III (ISCIII), Fundación Española para la Ciencia y la Tecnología (FECyT), Madrid, Spain
- Allergy Clinical Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain
| | - Donna-Marie Lynch
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kylie Marie Besz
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen Marquis
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amparo Burgos
- Pharmacy Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Victor Soriano Gomis
- Allergy Section, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- ARADyAL Spanish Network (RD16/0006), Instituto de Salud Carlos III (ISCIII), Fundación Española para la Ciencia y la Tecnología (FECyT), Madrid, Spain
- Department of Clinical Medicine, Miguel Hernández University, Alicante, Spain
| | - Inmaculada Lozano
- Oncology Section, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Rosa Ana Montoyo Antón
- Oncology Day Hospital Nursing Service, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Francisco Marco de la Calle
- Immunology Section, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - María Purificación González Delgado
- Allergy Section, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- ARADyAL Spanish Network (RD16/0006), Instituto de Salud Carlos III (ISCIII), Fundación Española para la Ciencia y la Tecnología (FECyT), Madrid, Spain
- Department of Clinical Medicine, Miguel Hernández University, Alicante, Spain
| | - Aurora Gutiérrez
- Allergy Section, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | - Estefanía Montenegro
- Allergy Section, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | - Fernando Rodríguez
- Allergy Section, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | - Francisco Javier Fernández Sánchez
- Allergy Section, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- ARADyAL Spanish Network (RD16/0006), Instituto de Salud Carlos III (ISCIII), Fundación Española para la Ciencia y la Tecnología (FECyT), Madrid, Spain
- Department of Clinical Medicine, Miguel Hernández University, Alicante, Spain
| | - Mariana Castells
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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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: 13] [Impact Index Per Article: 13.0] [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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10
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Horiuchi T, Takazawa T. Perioperative anaphylaxis with no identifiable cause. JA Clin Rep 2024; 10:3. [PMID: 38253957 PMCID: PMC10803722 DOI: 10.1186/s40981-024-00688-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Affiliation(s)
- Tatsuo Horiuchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511, Japan
| | - Tomonori Takazawa
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
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11
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Pouessel G, Tacquard C, Tanno LK, Mertes PM, Lezmi G. Anaphylaxis mortality in the perioperative setting: Epidemiology, elicitors, risk factors and knowledge gaps. Clin Exp Allergy 2024; 54:11-20. [PMID: 38168878 DOI: 10.1111/cea.14434] [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: 07/03/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Abstract
Perioperative anaphylaxis (PA) is a severe condition that can be fatal, but data on PA mortality are scarce. The aim of this article is to review the epidemiology, elicitors and risk factors for PA mortality and identify knowledge gaps and areas for improvement regarding the management of severe PA. PA affects about 100 cases per million procedures. Mortality is rare, estimated at 3 to 5 cases per million procedures, but the PA mortality rate is higher than for other anaphylaxis aetiologies, at 1.4% to 4.8%. However, the data are incomplete. Published data mention neuromuscular blocking agents and antibiotics, mainly penicillin and cefazolin, as the main causes of fatal PA. Reported risk factors for fatal PA vary in different countries. Most frequently occurring comorbidities are obesity, male gender, cardiovascular diseases and ongoing treatment with beta-blockers. However, there are no clues about how these factors interact and the impact of individual risk factors. The pathophysiology of fatal PA is still not completely known. Genetic factors such as deficiency in PAF-acetyl hydrolase and hereditary alpha-tryptasemia, have been reported as modulators of severe anaphylaxis and possible targets for specific treatments. Our review underlines unmet needs in the field of fatal PA. Although we confirmed the need for timely administration of an adequate dose of adrenaline and the proper infusion of fluids, there is no evidence-based data on the proper dose of intravenous titrated adrenaline and which clinical manifestations would flag the need for fluid therapy. There are no large clinical studies supporting the administration of alternative vasopressors, such as glucagon and methylene blue. Further research on pathophysiological mechanisms of PA and its severity may address these issues and help clinicians to define new therapeutic approaches.
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Affiliation(s)
- Guillaume Pouessel
- Department of Pediatrics, Children's Hospital, CH Roubaix, Roubaix, France
- Pediatric Pulmonology and Allergy Department, Pôle enfant, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
- ULR 2694: METRICS, Univ Lille, Lille, France
| | - Charles Tacquard
- Department of Anaesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Luciana Kase Tanno
- Division of Allergy, Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA11 University of Montpellier - INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Paul Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Guillaume Lezmi
- Paediatric Pneumology and Allergology Unit, Children's Hospital Necker, Paris, France
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12
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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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13
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Villarreal-González RV, González-Díaz S, Vidal-Gutiérrez O, de la Cruz-de la Cruz C, Pérez-Ibave DC, Garza-Rodríguez ML. Interleukin-6 as a biomarker of hypersensitivity reactions in chemotherapeutics and monoclonal antibodies. J Oncol Pharm Pract 2023:10781552231204367. [PMID: 37817577 DOI: 10.1177/10781552231204367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
BACKGROUND In recent years, a new type of immediate hypersensitivity reaction known as cytokine release began to emerge, and within this phenotype of reactions, interleukin-6 is the most frequently associated with the presence during drug administration. Chemotherapeutic agents (QT) and monoclonal antibodies. OBJECTIVE Determine interleukin-6 levels in hypersensitivity reactions to QT and monoclonal antibodies. METHODS Observational and prospective study that was carried out from March 1, 2021 to March 1, 2022 in a university hospital in northeastern Mexico. Symptoms, severity, interleukin-6 levels, and skin tests of hypersensitivity reaction were evaluated at QT and monoclonal antibodies. RESULTS A total of 41 patients with oncological disease were included, the most frequent being ovarian cancer. Symptoms as initial hypersensitivity reaction were neuromuscular in taxanes and cutaneous in Platinums.41.5% presented elevation of interleukin-6, and it was found more frequently in presence of metastases. Positive skin tests were found more frequently in the carboplatin and doxorubicin groups. The most frequently presented phenotype was type I in paclitaxel, carboplatin, and doxorubicin, and mixed-reaction (type I and cytokine release) in oxaliplatin. CONCLUSION With the increasing prevalence of hypersensitivity reactions to biologic and antineoplastic therapies, interleukin-6 should be recognized as a biomarker in immediate hypersensitivity reactions to QT and monoclonal antibodies.
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Affiliation(s)
- Rosalaura V Villarreal-González
- Faculty of Medicine, Oncology Service, Centro Universitario Contra el Cáncer (CUCC), Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
| | - Sandra González-Díaz
- Faculty of Medicine, Regional Center of Allergy and Clinical Immunology, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
| | - Oscar Vidal-Gutiérrez
- Faculty of Medicine, Oncology Service, Centro Universitario Contra el Cáncer (CUCC), Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
| | - Carlos de la Cruz-de la Cruz
- Department of Internal Medicine, Universidad de Monterrey, Christus Muguerza Alta Especialidad, Monterrey, Nuevo León, Mexico
| | - Diana C Pérez-Ibave
- Faculty of Medicine, Oncology Service, Centro Universitario Contra el Cáncer (CUCC), Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
| | - María L Garza-Rodríguez
- Faculty of Medicine, Oncology Service, Centro Universitario Contra el Cáncer (CUCC), Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
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14
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Hong AD, Fleissner ZJ, Campos-Cuellar C, Gonzalez-Estrada A, Mao SA, Doris Wang R, Pai SL. Kounis Syndrome, an Unrecognized Presentation of Perioperative Anaphylaxis in a Transplant Candidate. Prog Transplant 2023; 33:270-271. [PMID: 37533329 DOI: 10.1177/15269248231191485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Affiliation(s)
- Andrew D Hong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Zachary J Fleissner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Shennen A Mao
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - R Doris Wang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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15
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Klingebiel C, Belhocine W, Vitte J. Serum tryptase and drug hypersensitivity: why, how and what? A systematic review. Curr Opin Allergy Clin Immunol 2023; 23:294-299. [PMID: 37357783 DOI: 10.1097/aci.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW Serum tryptase, a mast cell marker, provides clues for the mechanism, severity, and management of drug hypersensitivity induced by immunoglobulin E dependent or independent mast cell activation. RECENT FINDINGS The interpretation of serum tryptase levels has been challenged during the last 2 years by major advances in tryptase genetics and their rapid incorporation into clinical practice. On the contrary, new pathophysiological insight into nonmast cell-dependent immediate hypersensitivity has been gained. SUMMARY This review provides up-to-date information on the pathophysiology and recommended use and interpretation of tryptase in the context of drug hypersensitivity reactions as a function of their endotype.
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Affiliation(s)
| | | | - Joana Vitte
- University of Montpellier, IDESP, INSERM UMR UA 11, Montpellier
- Aix-Marseille Univ, IRD, APHM, MEPHI
- IHU Méditerranée Infection, Marseille, France
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16
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Mertes PM, Tacquard C. Perioperative anaphylaxis: when the allergological work-up goes negative. Curr Opin Allergy Clin Immunol 2023; 23:287-293. [PMID: 37357801 DOI: 10.1097/aci.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW Perioperative anaphylaxis (POA) is rare but is associated with significant morbidity and mortality. Patients are referred to the allergist to identify the mechanism of the reaction, the causative agent and make recommendations regarding subsequent anaesthesia. Despite a well conducted allergological evaluation, the causative agent is not found in 30-60% of these reactions, leaving patients without a well established diagnosis. RECENT FINDINGS Several mechanisms can induce POA. In addition to the well known IgE-mediated reactions, IgG-mediated reaction, MRGPR-X2-related reaction or nonspecific histamine release may be involved. These situations are not easily assessed by the allergological workup. SUMMARY When the allergological workup is negative, the situation should be reassessed with the team present at the time of the reaction to confirm the reality of the hypersensitivity reaction and to search for a possible differential diagnosis. If POA is confirmed, the allergological evaluation should be repeated, ensuring proper execution according to current guidelines and including the search for hidden allergens. Specific IgE assays or basophil activation tests may be of interest. In case of negative results, a closely monitored drug challenge test, in coordination with the anaesthesia teams, may be useful to avoid the exclusion of any drug injected during the reaction.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Team EFS-INSERM U1255, EFS Grand-Est, Strasbourg, France
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17
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Gonzalez-Torres L, García-Paz V, Vila L. Interpreting serum tryptase levels in cases of anaphylaxis and concomitant bacterial infection. Ann Allergy Asthma Immunol 2023; 131:272-273. [PMID: 37116653 DOI: 10.1016/j.anai.2023.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/21/2023] [Accepted: 04/21/2023] [Indexed: 04/30/2023]
Affiliation(s)
| | - Vanesa García-Paz
- Pediatric Allergy Unit, Children's Hospital A Coruña, A Coruña, Spain
| | - Leticia Vila
- Pediatric Allergy Unit, Children's Hospital A Coruña, A Coruña, Spain.
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18
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Stone CA, Garvey LH, Nasser S, Lever C, Triggiani M, Parente R, Phillips EJ. Identifying and Managing Those at Risk for Vaccine-Related Allergy and Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2008-2022. [PMID: 37182566 DOI: 10.1016/j.jaip.2023.05.004] [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: 02/23/2023] [Revised: 04/13/2023] [Accepted: 05/01/2023] [Indexed: 05/16/2023]
Abstract
Immediate hypersensitivity reactions to vaccines, the most severe of which is anaphylaxis, are uncommon events occurring in fewer than 1 in a million doses administered. These reactions are infrequently immunoglobulin E-mediated. Because they are unlikely to recur, a reaction to a single dose of a vaccine is rarely a contraindication to redosing. This narrative review article contextualizes the recent knowledge we have gained from the coronavirus 2019 (COVID-19) pandemic rollout of the new mRNA platform with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines within the much broader context of what is known about immediate reactions to other vaccinations of routine and global importance. We focus on what is known about evidence-based approaches to diagnosis and management and what is new in our understanding of mechanisms of immediate vaccine reactions. Specifically, we review the epidemiology of immediate hypersensitivity vaccine reactions, differential diagnosis for immune-mediated and nonimmune reaction clinical phenotypes, including how to recognize immunization stress-related responses. In addition, we highlight what is known about mechanisms and review the rare but important contribution of excipient allergies and specifically when to consider testing for them as well as other key features that contribute to safe evaluation and management.
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Affiliation(s)
- Cosby A Stone
- Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charley Lever
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Roberta Parente
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Elizabeth J Phillips
- Department of Dermatology, Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Perth, Western Australia.
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19
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Ebo DG, van der Poorten MLM, Hopkins PM. Suspected perioperative anaphylaxis: are we making the correct diagnosis? Br J Anaesth 2023:S0007-0912(23)00235-0. [PMID: 37271719 DOI: 10.1016/j.bja.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
We provide a commentary on aspects of a prospective study of the epidemiology of perioperative anaphylaxis in Japan (Japanese Epidemiologic Study for Perioperative Anaphylaxis [JESPA]). Accurate diagnosis of perioperative anaphylaxis is important for research but essential for clinical safety. We evaluate the diagnostic approach used in the JESPA study and caution against over-reliance on diagnostic tests that lack sensitivity and specificity when clinical data suggest an immediate perioperative hypersensitivity reaction is likely.
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Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium.
| | - Marie-Line M van der Poorten
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Science, Department of Paediatrics, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Philip M Hopkins
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK; Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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20
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Horiuchi T, Takazawa T, Haraguchi T, Orihara M, Nagumo K, Saito S. Investigating the optimal diagnostic value of histamine for diagnosing perioperative hypersensitivity: a prospective, observational study. J Anesth 2023:10.1007/s00540-023-03199-z. [PMID: 37156974 DOI: 10.1007/s00540-023-03199-z] [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: 02/23/2023] [Accepted: 04/29/2023] [Indexed: 05/10/2023]
Abstract
Although several guidelines recommend measuring blood tryptase and histamine concentrations to diagnose perioperative anaphylaxis (POA), tryptase measurement is more common. The appropriate timing of blood collection and the diagnostic threshold for histamine measurement are still controversial. To address these issues, histamine concentrations in patients with anaphylaxis and those with anaphylaxis-uncertain were compared in our previous study, the Japanese Epidemiologic Study for Perioperative Anaphylaxis (JESPA). However, because we could not rule out the possibility that the anaphylactic-uncertain group included anaphylactic patients, histamine concentrations were measured in patients who underwent general anesthesia with no complications as controls in the present study. Histamine levels were measured at anesthesia induction (baseline), 30 min (first point), and 2 h (second point) after the start of surgery in 30 control patients. Histamine concentrations in controls were lower than in patients with POA in JESPA at the first and second points. At the first point, a threshold of 1.5 ng/ml resulted in sensitivity of 77% and specificity of 100%. A threshold of 1.1 ng/ml at the second point resulted in sensitivity of 67% and specificity of 87%. Measurement of histamine concentrations within two hours after symptom onset might help diagnose POA.
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Affiliation(s)
- Tatsuo Horiuchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Tomonori Takazawa
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371-8511, Japan.
| | - Takashi Haraguchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Masaki Orihara
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Kazuhiro Nagumo
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
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21
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Gold MS, Amarasinghe A, Greenhawt M, Kelso JM, Kochhar S, Yu-Hor Thong B, Top KA, Turner PJ, Worm M, Law B. Anaphylaxis: Revision of the Brighton collaboration case definition. Vaccine 2023; 41:2605-2614. [PMID: 36435707 DOI: 10.1016/j.vaccine.2022.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022]
Abstract
The Brighton Collaboration (BC) has formulated a number of case definitions which have primarily been applied to adverse events of special interest in the context of vaccine safety surveillance. This is a revision of the 2007 BC case definition for anaphylaxis. Recently, the BC definition has been widely used for evaluating reports of suspected anaphylaxis following COVID-19 vaccination. This has led to debate about the performance of the BC definition in comparison with those from the US National Institute of Allergy and Infectious Disease/Food Allergy Anaphylaxis Network (NIAID/FAAN) and the World Allergy Organization (WAO). BC convened an expert working group to revise the case definition based on their usual process of literature review and expert consensus. This manuscript presents the outcome of this process and proposes a revised case definition for anaphylaxis. Major and minor criteria have been re-evaluated with an emphasis on the reporting of observable clinical signs, rather than subjective symptoms, and a clearer approach to the ascertainment of levels of certainty is provided. The BC case definition has also been aligned with other contemporary and international case definitions for anaphylaxis.
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Affiliation(s)
- Michael S Gold
- Discipline of Paediatrics, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - John M Kelso
- Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego CA, USA
| | - Sonali Kochhar
- Department of Global Health, University of Washington, Seattle, USA; Global Healthcare Consulting, India
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Karina A Top
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, United Kingdom; University of Sydney, Sydney, Australia
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology and Allergy, Charité Universitätsmedizin, Berlin, Germany
| | - Barbara Law
- SPEAC, Brighton Collaboration, Independent Consultant, Vancouver, BC, Canada
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22
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Takazawa T, Horiuchi T, Nagumo K, Sugiyama Y, Akune T, Amano Y, Fukuda M, Haraguchi T, Ishibashi C, Kanemaru E, Kato T, Katoh K, Kawano T, Kochiyama T, Kuri M, Kurita A, Matsuoka Y, Muramatsu T, Orihara M, Saito Y, Sato N, Shiraishi T, Suzuki K, Takahashi M, Takahashi T, Tanabe K, Tomioka A, Tomita Y, Tsuji T, Watanabe I, Yamada T, Yoshida N, Yamaguchi M, Saito S. The Japanese Epidemiologic Study for Perioperative Anaphylaxis, a prospective nationwide study: allergen exposure, epidemiology, and diagnosis of anaphylaxis during general anaesthesia. Br J Anaesth 2023:S0007-0912(23)00080-6. [PMID: 36990827 DOI: 10.1016/j.bja.2023.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/03/2023] [Accepted: 02/06/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Diagnosis of perioperative anaphylaxis is often challenging. This study describes the utility of a newly developed tool for identifying patients with a high possibility of anaphylaxis, and aimed to investigate the frequency of anaphylaxis with each drug during the perioperative period in Japan. METHODS This study included patients with anaphylaxis of Grade 2 or higher severity during general anaesthesia at 42 facilities across Japan in 2019 and 2020. We developed and adopted a unique objective evaluation tool yielding a composite score for diagnosing anaphylaxis, which includes the results of skin tests and basophil activation tests, and clinical scores for perioperative anaphylaxis. The number of cases using each drug and the total number of anaphylaxis cases were investigated to calculate the frequency of anaphylaxis. RESULTS General anaesthesia was performed in 218 936 cases, which included 55 patients with suspected perioperative anaphylaxis. The developed composite score diagnosed 43 of them with a high probability of anaphylaxis. The causative agent was identified in 32 cases. Plasma histamine levels showed high diagnostic accuracy for anaphylaxis. The top causative agents were rocuronium (10 cases in 210 852 patients, 0.005%), sugammadex (7 cases in 150 629 patients, 0.005%), and cefazolin (7 cases in 106 005 patients, 0.007%). CONCLUSIONS We developed a composite tool to diagnose anaphylaxis, and found that the combination of tryptase levels, skin testing, and basophil activation testing results and clinical score improved the certainty of anaphylaxis diagnosis. The incidence of perioperative anaphylaxis in our study was 1 in about 5000 general anaesthesia cases. CLINICAL TRIAL REGISTRATION UMIN000035350.
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23
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Ebo DG, Vlaeminck N, van der Poorten MLM, Elst J, Toscano A, Van Gasse AL, Hagendorens MM, Aerts S, Adriaensens I, Saldien V, Sabato V. A quarter of a century fundamental and translational research in perioperative hypersensitivity and anaphylaxis at the Antwerp university hospital, a Belgian Centre of Excellence of the World Allergy Organization. World Allergy Organ J 2023; 16:100759. [PMID: 37025251 PMCID: PMC10070178 DOI: 10.1016/j.waojou.2023.100759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/20/2023] [Accepted: 03/05/2023] [Indexed: 04/03/2023] Open
Abstract
Perioperative hypersensitivity constitutes an important health issue, with potential dramatic consequences of diagnostic mistakes. However, safe and correct diagnosis is not always straightforward, mainly because of the application of incorrect nomenclature, absence of easy accessible in-vitro/ex-vivo tests and uncertainties associated with the non-irritating skin test concentrations. In this editorial we summarize the time line, seminal findings, and major realizations of 25 years of research on the mechanisms, diagnosis, and management of perioperative hypersensitivity.
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24
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Au EYL, Mak HWF, Yeung MHY, Chiang V, Lam K, Wong JCY, Yeung HHF, Chan EYT, Lau CS, Li PH. Ten-year outcomes of Perioperative Anaphylaxis Workup Study in Hong Kong (PAWS-HK): Performance of diagnostic modalities. Ann Allergy Asthma Immunol 2023:S1081-1206(23)00125-4. [PMID: 36842494 DOI: 10.1016/j.anai.2023.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Studies on perioperative anaphylaxis (PA) in Asia are lacking. Furthermore, allergy workup for PA has largely been limited to the "silver standard" of skin tests (ST). Using in vitro tests as an adjunct to ST may improve and overcome these diagnostic challenges. OBJECTIVE To evaluate the clinical characteristics and diagnostic tests of patients with suspected PA through the Perioperative Anaphylaxis Workup Study in Hong Kong cohort. METHODS Patients with a diagnosis of PA over a 10-year period were recruited into the Perioperative Anaphylaxis Workup Study in Hong Kong. We reviewed the medical records, tryptase elevation, and diagnostic tests including ST, specific immunoglobulin E, and basophil activation tests (BAT). RESULTS In 151 patients with PA, diagnosis was reached in three-fourths of the cases (113/151, 74.8%). The most common culprits identified were neuromuscular blocking agents (25.8%), β lactams (17.2%) and chlorhexidine (13.9%). Severe anaphylaxis was associated with female sex, older age, elevated acute tryptase levels, and more cardiovascular manifestations during induction. Skin tests remained the most sensitive diagnostic modality overall (66.2%). BAT showed better performance for chlorhexidine and gelofusine anaphylaxis, with sensitivity of 80.0% and 79.6%, respectively. Specific Immunoglobulin E indicated even higher sensitivity (95.2%) than did ST (85.0%) and BAT (80.0%) for chlorhexidine anaphylaxis but performed poorly for other drugs. CONCLUSION Neuromuscular blocking agents remain the most common culprit in PA. There was a higher prevalence of gelofusine anaphylaxis in our cohort than was seen in the literature. Skin tests remain the most sensitive testing modality. In vitro tests for chlorhexidine and gelofusine showed promising results, but more studies to further elucidate its use are warranted.
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Affiliation(s)
- Elaine Y L Au
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Hugo W F Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Maegan H Y Yeung
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Ki Lam
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Heather H F Yeung
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Eric Y T Chan
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Chak-Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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25
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Lee EY, Jakubovic BD. Interleukin-6 and cytokine release syndrome: A new understanding in drug hypersensitivity reactions. Ann Allergy Asthma Immunol 2023; 130:178-184. [PMID: 36343890 DOI: 10.1016/j.anai.2022.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/25/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
Immediate drug hypersensitivity reactions (DHRs) are historically thought to be because of immunoglobulin E (IgE) cross-linking, causing mast cell degranulation and release of mediators like tryptase and histamine. With the increasing use of monoclonal antibodies, it has become apparent that some patients present atypical features during immediate DHRs, including occurrence in initial exposure, a lack of urticaria and angioedema, and the presence of fever, chills, rigors and musculoskeletal pain as the predominant symptoms. This observation led to the recognition of a novel phenotype of immediate DHRs called cytokine release syndrome (CRS). Other types of immediate DHRs include infusion-related reactions (which present similarly to CRS), and mixed reactions (which share overlapping features of both type 1 reactions and CRS). Desensitization to culprit drugs can be a lifesaving option in patients who develop immediate DHRs to first-line treatment. Whereas robust data are supporting the safety and efficacy of drug desensitization, breakthrough reactions can still occur and CRS seems to be a more common cause than type 1 reactions. Tryptase has been the only available biomarker for immediate DHRs and is associated with type 1 reactions. Emerging evidence consistently found the association between increased serum interleukin 6 level and DHR-related CRS, suggesting that interleukin 6 can be a novel biomarker, in addition to tryptase, to distinguish various types of DHRs. In the era of precision medicine, phenotyping and endotyping hypersensitivity reactions to chemotherapy and monoclonal antibodies using validated biomarkers should be part of routine drug allergy care.
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Affiliation(s)
- Erika Yue Lee
- Department of Medicine, Institute of Health Policy, Management and Evaluation, Eliot Phillipson Clinician-Scientist Training Program, University of Toronto, Toronto, Ontario, Canada; Division of Allergy and Immunology, St. Michael's Hospital, Toronto, Ontario, Canada.
| | - Baruch D Jakubovic
- Department of Medicine, Humber River Hospital, Toronto, Ontario, Canada; Department of Medicine, Queen's University, Kingston, Ontario, Canada
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26
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Michel M, Klingebiel C, Vitte J. Tryptase in type I hypersensitivity. Ann Allergy Asthma Immunol 2023; 130:169-177. [PMID: 36084866 DOI: 10.1016/j.anai.2022.08.996] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/21/2022] [Accepted: 08/29/2022] [Indexed: 02/07/2023]
Abstract
Tryptase is currently the main mast cell biomarker available in medical practice. Tryptase determination is a quantitative test performed in serum or plasma for the diagnosis, stratification, and follow-up of mast cell-related conditions. The continuous secretion of monomeric α and β protryptases forms the baseline tryptase level. Transient, activation-induced release of tryptase is known as acute tryptase. Because mast cells are tissue-resident cells, the detection of an acute tryptase release in the bloodstream is protracted, with a delay of 15 to 20 minutes after the onset of symptoms and a peak at approximately 1 hour. Constitutive release of tryptase is a marker of mast cell number and activity status, whereas transient release of mature tryptase is a marker of mast cell degranulation. Although consensual as a concept, the application of this statement in clinical practice has only been clarified since 2020. For baseline tryptase to be used as a biomarker, reference values need to be established. In contrast, defining a transient increase using acute tryptase can only be achieved as a function of the baseline status.
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Affiliation(s)
- Moïse Michel
- Immunology Laboratory, Centre Hospitalier Universitaire Nîmes, Nîmes, France; Microbes, Evolution, Phylogénie et Infection (MEPHI), Aix-Marseille University, Marseille, France
| | | | - Joana Vitte
- Microbes, Evolution, Phylogénie et Infection (MEPHI), Aix-Marseille University, Marseille, France; Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Marseille, France; Montpellier University, Institut Desbrest d'Épidémiologie et de Santé Publique, Institut National de la Sante et de la Recherche Medicale, UMR UA 11, Montpellier, France.
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27
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Sabato V, Ebo DG, Van Der Poorten MLM, Toscano A, Van Gasse AL, Mertens C, Van Houdt M, Beyens M, Elst J. Allergenic and Mas-Related G Protein-Coupled Receptor X2-Activating Properties of Drugs: Resolving the Two. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:395-404. [PMID: 36581077 DOI: 10.1016/j.jaip.2022.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/02/2022] [Accepted: 12/11/2022] [Indexed: 12/27/2022]
Abstract
Since the seminal description implicating occupation of the Mas-related G protein-coupled receptor X2 (MRGPRX2) in mast cell (MC) degranulation by drugs, many investigations have been undertaken into this potential new endotype of immediate drug hypersensitivity reaction. However, current evidence for this mechanism predominantly comes from (mutant) animal models or in vitro studies, and irrefutable clinical evidence in humans is still missing. Moreover, translation of these preclinical findings into clinical relevance in humans is difficult and should be critically interpreted. Starting from our clinical priorities and experience with flow-assisted functional analyses of basophils and cultured human MCs, the objectives of this rostrum are to identify some of these difficulties, emphasize the obstacles that might hamper translation from preclinical observations into the clinics, and highlight differences between IgE- and MRPGRX2-mediated reactions. Inevitably, as with any subject still beset by many questions, alternative interpretations, hypotheses, or explanations expressed here may not find universal acceptance. Nevertheless, we believe that for the time being, many questions remain unanswered. Finally, a theoretical mechanistic algorithm is proposed that might advance discrimination between MC degranulation from MRGPRX2 activation and cross-linking of membrane-bound drug-reactive IgE antibodies.
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Affiliation(s)
- Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
| | - Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium.
| | - Marie-Line M Van Der Poorten
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, Antwerp, Belgium, and Paediatrics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Alessandro Toscano
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Athina L Van Gasse
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, Antwerp, Belgium, and Paediatrics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Christel Mertens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Michel Van Houdt
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Michiel Beyens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
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28
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Volcheck GW, Melchiors BB, Farooque S, Gonzalez-Estrada A, Mertes PM, Savic L, Tacquard C, Garvey LH. Perioperative Hypersensitivity Evaluation and Management: A Practical Approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:382-392. [PMID: 36436761 DOI: 10.1016/j.jaip.2022.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022]
Abstract
Perioperative hypersensitivity (POH) is an uncommon, potentially life-threatening event. Identification of POH can be difficult given the lack of familiarity, physiological effects of anesthesia, draping of the patient during surgery, and potential nonimmunological factors contributing to signs and symptoms. Given the unique nature and large number of medications administered in the perioperative setting, evaluation of POH can be challenging. In this paper, we present a practical approach to management with an emphasis on understanding what happens in the operating room, the overlap of signs and symptoms between nonimmunological and immunological reactions, acute management, and subsequent evaluation. In addition, we provide a strategy for further review of an initially negative evaluation and emphasize the importance of establishing management plans for the patient as well as providing recommendations to the medical, anesthesia, and surgical teams for future surgeries. A critical factor for successful management at all points in the process is a close collaboration between the anesthesia and the allergy teams.
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Affiliation(s)
- Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn.
| | | | - Sophie Farooque
- Frankland Allergy Clinic, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, UK
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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29
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Yang BC, Castells MC. Utilizing Biologics in Drug Desensitization. Curr Allergy Asthma Rep 2023; 23:1-11. [PMID: 36445652 PMCID: PMC9707161 DOI: 10.1007/s11882-022-01052-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE OF REVIEW The purpose of this literature review was to review the latest advancements with biologics in rapid drug desensitization. Our methodology was to highlight both desensitization to biologics themselves and the use of biologics in desensitization to both biologic and nonbiologic drugs. RECENT FINDINGS Biologics are a vast category of drugs that include monoclonal antibodies, nanobodies, modern vaccinations, and even hormones. Desensitization to biologics can be safely performed through standardized procedure. Biomarkers are used both in vitro and in vivo to help identify and classify hypersensitivity reactions. Hypersensitivity reactions to the mRNA vaccinations against SARS-CoV-2 present their own unique challenges to management. There are specific excipients in monoclonal antibodies that are thought to be responsible for many of their hypersensitivity reactions. Certain biologics can even be used to assist in desensitization to other drugs. Rapid drug desensitization is a standardized procedure that may be able to help many patients who have experienced hypersensitivity reactions to biologics and would best be treated with them to continue to receive them. Biologic drugs have opened a new era in medicine for the prevention and treatment of infectious diseases, cancer, and inflammatory diseases. Hypersensitivity reactions to biologics are quite common. This literature review presents the latest advancements in our understanding of hypersensitivity reactions to biologics, how rapid drug desensitization can be used to continue therapy despite history of hypersensitivity, and how biologics themselves can be used to aid in desensitization itself.
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Affiliation(s)
- Barbara C Yang
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Hale Building for Transformative Medicine, 60 Fenwood Road, Room 5002-B, Boston, MA, 02115, USA.
- Ribon Therapeutics, 35 Cambridgepark Drive Suite 300, Cambridge, MA, 02140, USA.
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Hale Building for Transformative Medicine, 60 Fenwood Road, Room 5002-B, Boston, MA, 02115, USA
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30
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Abstract
Anesthesiologists routinely manage patients receiving drugs and agents, all of which have the potential for anaphylaxis, the life-threatening presentation of an allergic reaction. Clinicians must be ready to diagnose and manage the acute cardiopulmonary dysfunction that occurs.
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Affiliation(s)
- Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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31
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Vitte J, Sjölander A, Rydell N, Molin M, Pejler G, Hallgren J, Movérare R, Janson C, Malinovschi A. Tryptase reference values in a Swedish middle-aged general population and association with diabetes mellitus. Clin Exp Allergy 2022; 52:1330-1333. [PMID: 35771193 PMCID: PMC9795885 DOI: 10.1111/cea.14195] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/25/2022] [Accepted: 06/27/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Joana Vitte
- Aix‐Marseille Univ, IRD, MEPHI, IHU Méditerranée InfectionMarseilleFrance,University of MontpellierIDESP, INSERM UMR UA11MontpellierFrance
| | | | | | | | - Gunnar Pejler
- Department of Medical Biochemistry and MicrobiologyUppsala UniversityUppsalaSweden
| | - Jenny Hallgren
- Department of Medical Biochemistry and MicrobiologyUppsala UniversityUppsalaSweden
| | - Robert Movérare
- Thermo Fisher ScientificUppsalaSweden,Department of Medical Sciences Respiratory, Allergy and Sleep ResearchUppsala UniversityUppsalaSweden
| | - Christer Janson
- Department of Medical Sciences Respiratory, Allergy and Sleep ResearchUppsala UniversityUppsalaSweden
| | - Andrei Malinovschi
- Department of Medical Sciences Clinical PhysiologyUppsala UniversityUppsalaSweden
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Making a Diagnosis in Allergic Reactions Occurring in the Operating Room. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Awan SF, Schwartz LB, Maric I, Metcalfe DD, Carter MC. Acute increases in total serum tryptase unassociated with hemodynamic instability in diffuse cutaneous mastocytosis. Ann Allergy Asthma Immunol 2022; 129:249-252. [PMID: 35568301 DOI: 10.1016/j.anai.2022.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/13/2022] [Accepted: 04/27/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Seemal F Awan
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland.
| | - Larry B Schwartz
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Irina Maric
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Dean D Metcalfe
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Melody C Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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Nuñez-Borque E, Fernandez-Bravo S, Yuste-Montalvo A, Esteban V. Pathophysiological, Cellular, and Molecular Events of the Vascular System in Anaphylaxis. Front Immunol 2022; 13:836222. [PMID: 35371072 PMCID: PMC8965328 DOI: 10.3389/fimmu.2022.836222] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/07/2022] [Indexed: 01/10/2023] Open
Abstract
Anaphylaxis is a systemic hypersensitivity reaction that can be life threatening. Mechanistically, it results from the immune activation and release of a variety of mediators that give rise to the signs and symptoms of this pathological event. For years, most of the research in anaphylaxis has focused on the contribution of the immune component. However, approaches that shed light on the participation of other cellular and molecular agents are necessary. Among them, the vascular niche receives the various signals (e.g., histamine) that elicit the range of anaphylactic events. Cardiovascular manifestations such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and cardiac alterations are crucial in the pathophysiology of anaphylaxis and are highly involved to the development of the most severe cases. Specifically, the endothelium, vascular smooth muscle cells, and their molecular signaling outcomes play an essential role downstream of the immune reaction. Therefore, in this review, we synthesized the vascular changes observed during anaphylaxis as well as its cellular and molecular components. As the risk of anaphylaxis exists both in clinical procedures and in routine life, increasing our knowledge of the vascular physiology and their molecular mechanism will enable us to improve the clinical management and how to treat or prevent anaphylaxis. Key Message Anaphylaxis, the most severe allergic reaction, involves a variety of immune and non-immune molecular signals that give rise to its pathophysiological manifestations. Importantly, the vascular system is engaged in processes relevant to anaphylactic events such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and decreased cardiac output. The novelty of this review focuses on the fact that new studies will greatly improve the understanding of anaphylaxis when viewed from a vascular molecular angle and specifically from the endothelium. This knowledge will improve therapeutic options to treat or prevent anaphylaxis.
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Affiliation(s)
- Emilio Nuñez-Borque
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Sergio Fernandez-Bravo
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Alma Yuste-Montalvo
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Vanesa Esteban
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Faculty of Medicine and Biomedicine, Alfonso X El Sabio University, Madrid, Spain
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Vitte J, Gonzalez C, Klingebiel C, Michel M. Tryptase and anaphylaxis: The case for systematic paired samples in all settings, from the playground to the COVID-19 vaccination center. REVUE FRANÇAISE D'ALLERGOLOGIE 2022; 62:287-288. [PMID: 35169400 PMCID: PMC8831119 DOI: 10.1016/j.reval.2022.02.218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
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Levi-Schaffer F, Gibbs BF, Hallgren J, Pucillo C, Redegeld F, Siebenhaar F, Vitte J, Mezouar S, Michel M, Puzzovio PG, Maurer M. Selected recent advances in understanding the role of human mast cells in health and disease. J Allergy Clin Immunol 2022; 149:1833-1844. [PMID: 35276243 DOI: 10.1016/j.jaci.2022.01.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 01/12/2022] [Accepted: 01/26/2022] [Indexed: 11/17/2022]
Abstract
Mast cells are highly granular tissue-resident cells and key drivers of inflammation, particularly in allergies as well as in other inflammatory diseases. Most mast cell research was initially conducted in rodents but has increasingly shifted to the human system, with the advancement of research technologies and methodologies. Today we can analyze primary human cells including rare subpopulations, we can produce and maintain mast cells isolated from human tissues, and there are several human mast cell lines. These tools have substantially facilitated our understanding of their role and function in different organs in both health and disease. We can now define more clearly where human mast cells originate from, how they develop, which mediators they store, produce de novo, and release, how they are activated and by which receptors, and which neighbouring cells they interact with and by which mechanisms. Considerable progress has also been made regarding the potential contribution of mast cells to disease, which, in turn, has led to the development of novel approaches for preventing key pathogenic effects of mast cells, heralding the era of mast cell-targeted therapeutics. In this review, we present and discuss a selection of some of the most significant advancements and remaining gaps in our understanding of human mast cells during the last 25 years, with a focus on clinical relevance.
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Affiliation(s)
- Francesca Levi-Schaffer
- Pharmacology and Experimental Therapeutics Unit, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Bernhard F Gibbs
- Department of Human Medicine, University of Oldenburg, Oldenburg, Germany
| | - Jenny Hallgren
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Carlo Pucillo
- Laboratory of Immunology, Department of Medicine, University of Udine, Udine, Italy
| | - Frank Redegeld
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Frank Siebenhaar
- Institute for Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology, ITMP Allergology and Immunology, Berlin, Germany
| | - Joana Vitte
- Aix-Marseille University, IRD, APHM, MEPHI, Marseille, France; IDESP, INSERM UA 11, Montpellier, France
| | | | - Moïse Michel
- Aix-Marseille University, IRD, APHM, MEPHI, Marseille, France; Immunology Laboratory, CHU Nîmes, Nîmes, France
| | - Pier Giorgio Puzzovio
- Pharmacology and Experimental Therapeutics Unit, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marcus Maurer
- Institute for Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology, ITMP Allergology and Immunology, Berlin, Germany.
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Coury JR, Skaggs KF, Marciano GF, Pinyavat T, Naseef M, Roye BD, Vitale MG. Intraoperative Anaphylaxis to the Bovine Flowable Gelatin Matrix: A Report of 2 Cases. JBJS Case Connect 2022; 12:01709767-202203000-00063. [PMID: 35239550 DOI: 10.2106/jbjs.cc.21.00753] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CASE We present 2 cases of life-threatening intraoperative anaphylaxis to the bovine flowable gelatin matrix during pediatric spinal deformity surgery for kyphoscoliosis. Both patients had no known bovine or gelatin allergies. Anaphylaxis occurred shortly after pressurized injection into the first cannulated pedicle tract and was successfully treated with epinephrine, diphenhydramine, and methylprednisolone infusion. The allergic reaction was confirmed with tryptase levels and serum-specific immunoglobulin E for beef, pork, bovine collagen, and porcine collagen. CONCLUSION In patients with beef, pork, or gelatin intolerance, a significant atopic history or childhood vaccine reaction, preoperative allergy consultation, and testing should be performed to prevent this life-threatening complication.
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Affiliation(s)
- Josephine R Coury
- Department of Pediatric Orthopedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Kira F Skaggs
- Department of Pediatric Orthopedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Gerard F Marciano
- Department of Pediatric Orthopedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Teeda Pinyavat
- Department of Pediatric Anesthesiology, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Mervat Naseef
- Department of Pediatric Allergy and Immunology, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Benjamin D Roye
- Department of Pediatric Orthopedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Michael G Vitale
- Department of Pediatric Orthopedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
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Jimenez-Rodriguez TW, Manuel Marco de la Calle F, Lozano-Cubo I, Montoyo-Anton RA, Soriano-Gomis V, Gonzalez-Delgado P, Burgos-San José A, Climent-Ballester S, Martínez-Banaclocha N, Fernández-Sanchez J. Converter Phenotype: A New Profile That Is Not Exclusive to Taxanes. FRONTIERS IN ALLERGY 2022; 2:785259. [PMID: 35387038 PMCID: PMC8974675 DOI: 10.3389/falgy.2021.785259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/17/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Phenotype I hypersensitivity reactions are the most commonly reported drug reactions; however, precision medicine has made it possible to characterize new phenotypes. A recent communication proposed the existence of a “converter phenotype,” which would affect patients who present non-immediate hypersensitivity reactions and in subsequent exposures develop immediate hypersensitivity reactions. This study aimed to describe the clinical characteristics of converter phenotype reactions and their evolution during desensitization to chemotherapeutic drugs and monoclonal antibodies. Methods: We retrospectively reviewed our database of patients undergoing desensitization to chemotherapy or biological agents and selected those with a converter phenotype. Demographic and clinical characteristics of the patients, the results of skin tests, tryptase and IL-6 levels, and desensitization outcomes were assessed. Results: Of 116 patients evaluated, 12 (10.3%) were identified as having a converter phenotype. The median interval between drug exposure and reaction was 90.6 h (range 8-288 h). After the conversion, phenotype I was the most frequent (58.3%), followed by cytokine release reactions (33.3%). Fifty-one desensitizations were undertaken and all treatments completed, with 10 (19.6%) breakthrough reactions. No new changes in the phenotype were detected. Conclusions: The symptoms of non-immediate drug hypersensitivity reactions may indicate the need for an early allergological evaluation to assess the risk of future immediate drug reactions. Clinical characteristics, skin test results, and biomarkers can help predict responses to rapid drug desensitization, guiding clinicians on how to optimize therapy delivery while maintaining patient safety.
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Affiliation(s)
- Teodorikez Wilfox Jimenez-Rodriguez
- Allergy Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), UMH, Alicante, Spain
- Spanish Research Network on Asthma and Adverse and Allergic Reactions (ARADyAL) Spanish Network (RD16/0006), Instituto de Salud Carlos III, Fundación Española para la Ciencia y la Tecnología, Madrid, Spain
| | - Francisco Manuel Marco de la Calle
- Immunology Service, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Inmaculada Lozano-Cubo
- Oncology Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Rosa Ana Montoyo-Anton
- Oncology Day Hospital Nursing Service, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Victor Soriano-Gomis
- Allergy Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), UMH, Alicante, Spain
- Spanish Research Network on Asthma and Adverse and Allergic Reactions (ARADyAL) Spanish Network (RD16/0006), Instituto de Salud Carlos III, Fundación Española para la Ciencia y la Tecnología, Madrid, Spain
| | - Purificación Gonzalez-Delgado
- Allergy Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), UMH, Alicante, Spain
- Spanish Research Network on Asthma and Adverse and Allergic Reactions (ARADyAL) Spanish Network (RD16/0006), Instituto de Salud Carlos III, Fundación Española para la Ciencia y la Tecnología, Madrid, Spain
| | - Amparo Burgos-San José
- Pharmacy Department, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Seira Climent-Ballester
- Pharmacy Department, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Natividad Martínez-Banaclocha
- Oncology Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Javier Fernández-Sanchez
- Allergy Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), UMH, Alicante, Spain
- Spanish Research Network on Asthma and Adverse and Allergic Reactions (ARADyAL) Spanish Network (RD16/0006), Instituto de Salud Carlos III, Fundación Española para la Ciencia y la Tecnología, Madrid, Spain
- *Correspondence: Javier Fernández-Sanchez
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Quoc QL, Bich TCT, Jang JH, Park HS. Recent update on the management of anaphylaxis. Clin Exp Emerg Med 2021; 8:160-172. [PMID: 34649404 PMCID: PMC8517462 DOI: 10.15441/ceem.21.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/04/2021] [Indexed: 12/12/2022] Open
Abstract
Anaphylaxis is a life-threatening systemic allergic reaction presenting various clinical manifestations. Its prevalence has increased in almost all age groups and both sexes. Food, venom, and drugs are major causes in both children and adults; a higher prevalence of food-induced anaphylaxis is noted in children, while a higher prevalence of drug-induced anaphylaxis is noted in adults. The pathogenic mechanism is mediated by immunologic and nonimmunologic mechanisms, where mast cells and basophils are key cells that release mediators. A diagnosis of anaphylaxis is mainly based on clinical symptoms and physical findings; however, an increased serum tryptase level is a useful biomarker. Epinephrine is the first-line drug to treat acute symptoms, and an epinephrine auto-injector should be prescribed for each patient. Antihistamines and systemic corticosteroids are used to relieve symptoms. This review updates current issues in the management of anaphylaxis as well as the new guidelines for proper diagnosis and treatment.
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Affiliation(s)
- Quang Luu Quoc
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Tra Cao Thi Bich
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Hyuk Jang
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
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Abstract
PURPOSE OF REVIEW The purpose of the review is to identify unmet needs in the management of anaphylaxis, covering aspects such as epidemiology, diagnosis, treatment and prevention. RECENT FINDINGS Redefinition of clinical diagnostic criteria may allow a better identification of anaphylaxis. International diagnostic coding system improvement will be major step for future policies and epidemiological studies. Digital health can aid in managing anaphylaxis. SUMMARY Anaphylaxis is a medical emergency; current data show that frequently identification of the reaction, acute and long-term management, are not optimal. Therefore, there is a need to implement strategies to improve the situation. This review has identified unmet needs in anaphylaxis regarding aspects such as epidemiology, severity scoring, definition and diagnostic criteria, anaphylaxis in infants and toddlers, cofactors, biomarkers, long-term management, undertreatment and availability of epinephrine autoinjectors. Strategies focused on education, legislation, digital health and research are proposed.
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Mast cell activation syndrome: is anaphylaxis part of the phenotype? A systematic review. Curr Opin Allergy Clin Immunol 2021; 21:426-434. [PMID: 34292177 DOI: 10.1097/aci.0000000000000768] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Mast cell activation syndrome (MCAS) and anaphylaxis are the result of a spontaneous or triggered pathological degranulation of mast cells (MCs) and might have as substrate normal or pathological MCs (increased burden, aberrant MCs or both). RECENT FINDINGS This review summarizes the most recent evidence on immunoglobulin E (IgE)-mediated and non IgE-mediated mechanisms underlying MC activation and degranulation and highlights the importance of standardized diagnostic criteria for MCAS. Application of these criteria implies that in most cases the clinical presentation of MCAS meets the diagnostic criteria for anaphylaxis. SUMMARY Integrating clinical parameters and diagnostic test recognition and underlying clonal MC disease are of utmost importance for a patient-tailored approach. Hereditary alpha-tryptasemia can be encountered in context of anaphylaxis, MCAS and primary MC disorders.
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Demoly P, Ramsey A. Drug Allergy Management on the Move. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3021-3022. [PMID: 34366095 DOI: 10.1016/j.jaip.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Pascal Demoly
- Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, Montpellier, France; IDESP UA11 INSERM-Univ Montpellier, Montpellier, France.
| | - Allison Ramsey
- Rochester Regional Health, Rochester, NY; University of Rochester, Rochester, NY.
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Nilsson L, Csuth Á, Storsaeter J, Garvey LH, Jenmalm MC. Vaccine allergy: evidence to consider for COVID-19 vaccines. Curr Opin Allergy Clin Immunol 2021; 21:401-409. [PMID: 34091550 PMCID: PMC8270228 DOI: 10.1097/aci.0000000000000762] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Whereas the COVID-19 pandemic has changed our lives worldwide, we hope that vaccination can combat the disease. We propose how to evaluate suspected severe allergic reactions to the vaccines so that as many as possible may be safely vaccinated. RECENT FINDINGS Rare cases of severe allergic reactions after COVID-19 vaccination have been observed, seemingly at a higher frequency than for other vaccines. Few excipients are likely to have caused these reactions. IgE-mediated reactions to polyethylene glycol (PEG) and its derivatives are the most suspected, albeit hitherto unproven, causes. We suggest to make a diagnosis based on skin tests with PEG and PEG derivatives and that these be considered in relation to the decisions required before the first and the second vaccine dose. A vaccine without these excipients is available, but published data about its side effects are limited. SUMMARY The underlying immunological mechanisms of the rare severe allergic reactions to the COVID-19 vaccines are poorly understood and need to be clarified. Identifying those who have an undiagnosed allergy to PEG and PEG derivatives is crucial before vaccination, and these substances are found in laxatives, cosmetics and in 30% of all our medications today.
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Affiliation(s)
- Lennart Nilsson
- Department of Biomedical and Clinical Sciences, Allergy Center, Linköping University, Linköping
| | - Ágnes Csuth
- Department of Biomedical and Clinical Sciences, Allergy Center, Linköping University, Linköping
| | - Jann Storsaeter
- Department of Vaccines, Public Health Agency of Sweden, Solna, Sweden
| | - Lene H. Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital Gentofte
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Maria C. Jenmalm
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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