Mastocytosis in childhood

Assessing vaccination reactions in pediatric patients with maculopapular cutaneous mastocytosis

Immunization compliance in the United States is declining, in part due to misinformation and fear surrounding adverse vaccination reactions. Recently, there have been data published in the allergy and immunology literature to show that there may be a relationship between routine vaccinations and induction of symptoms in cutaneous mastocytosis patients; however, this has not yet been explored in the dermatology literature. We sought to uncover the prevalence of vaccine reactions due to mast cell activation within our cohort of maculopapular cutaneous mastocytosis (MPCM) patients in order to contribute to ensuring administration safety, managing familial expectations, and encouraging continued adherence. Our results indicate that while incidence of reaction rates may be higher than the national average, they are mild and families should be counseled to follow recommended immunization schedule guidelines.

Pediatric Mastocytosis: Recognition and Management

Mastocytosis is a heterogeneous group of disorders characterized by the accumulation of clonal mast cells in organs such as the skin and bone marrow. In contrast to adults, most affected children have only cutaneous involvement. This article reviews the molecular pathogenesis, skin findings, mast cell mediator-related symptoms, evaluation, and management of childhood-onset mastocytosis, noting differences from adult-onset disease. Current classification of cutaneous mastocytosis and the natural histories of different variants in pediatric patients are highlighted, with a focus on clinical manifestations with prognostic implications. A practical algorithm is provided to guide clinical assessment, laboratory and other investigations, and longitudinal monitoring, including recognition of hepatosplenomegaly as a marker of systemic disease and utilization of allele-specific quantitative PCR (ASqPCR) to detect KIT mutations in the peripheral blood. Updated information and consensus-based recommendations regarding possible triggers of mast-cell degranulation (e.g., physical, medications) are discussed, with an emphasis on patient-specific factors and avoiding excessive parental concern. Lastly, an individualized, stepwise approach to treatment of symptoms, skin-directed therapy, and potential use of kinase inhibitors for severe systemic disease is outlined.

Pediatric maculopapular cutaneous mastocytosis: Retrospective review of signs, symptoms, and associated conditions

BACKGROUND/OBJECTIVES

Though maculopapular cutaneous mastocytosis is the most common form of pediatric mastocytosis, it remains unclear which patients will experience severe symptoms. We sought to better define the presentation and the cutaneous and systemic signs and symptoms in patients with maculopapular cutaneous mastocytosis.

METHODS

We analyzed retrospective data on 227 patients diagnosed with maculopapular cutaneous mastocytosis prior to age 15 years from five US clinical sites. We collected data on signs, symptoms, age of onset, and laboratory testing.

RESULTS

Median age of onset of maculopapular cutaneous mastocytosis was 3 months, with 94% of patients presenting prior to age 2 (range 0-15 years). Patients presenting before age 2 had significantly lower serum tryptase level (P = .019). Greater number of skin lesions (P = .006), number of reported skin signs and symptoms (P < .001), and higher tryptase levels (P < .001) were associated with more systemic symptoms.

CONCLUSION

Children with maculopapular cutaneous mastocytosis, who have greater skin involvement, higher serum tryptase level, and more skin signs and symptoms, are more likely to have systemic symptoms.

Maculopapular Cutaneous Mastocytosis in a Six-month-old Boy Who Presented with Respiratory Distress

Mastocytosis is a diverse group of rare disorders characterized by mast cell proliferation and its aberrant accumulation within various organs including respiratory, gastrointestinal, genitourinary mucosa and most commonly the skin. The spectrum of presentations ranges from torpid disease (cutaneous mastocytosis) having normal life span with transient sign and symptoms to highly vigorous disease (systemic mastocytosis) and life-threatening malignant conditions. Prevalence of the disease in general population is unknown. It occurs in all races and there is no sex predilection. Peak incidence is during infancy and early childhood with second peak occurring in middle age. We report a case of maculopapular cutaneous mastocytosis (MCM) in a six-month-old male child who presented with respiratory distress. According to our literature search it is one of the least frequent cases reported in our country, Pakistan.

Update on Mastocytosis (Part 2): Categories, Prognosis, and Treatment

Mastocytosis is a term used to describe a heterogeneous group of disorders characterized by clonal proliferation of mast cells in different organs. The organ most often affected is the skin. The World Health Organization classifies cutaneous mastocytosis into mastocytoma, maculopapular cutaneous mastocytosis, and diffuse mastocytosis. The systemic variants in this classification are as follows: indolent systemic mastocytosis (SM), aggressive SM, SM with an associated clonal hematological non-mast cell lineage disease, mast cell leukemia, mast cell sarcoma, and extracutaneous mastocytoma. The two latest systemic variants are rare. Although the course of disease is unpredictable in children, lesions generally resolve by early adulthood. In adults, however, the disease tends to persist. The goal of treatment should be to control clinical manifestations caused by the release of mast cell mediators and, in more aggressive forms of the disease, to reduce mast cell burden.

Pediatric dermatohistopathology--histopathology of skin diseases in newborns and infants

While neonatal skin physiology has been thoroughly examined using non-invasive techniques in recent years, only few systematic studies and review articles addressing the histopathology of neonatal skin have been published thus far. In most cases, histopathological findings of dermatoses in neonatal skin do not significantly differ from those seen in adult skin. Nevertheless, a comprehensive knowledge of embryonic and fetal skin development as well as the microanatomical structure of neonatal skin can contribute to a better understanding of various dermatoses of infancy. In the first part of this review article, we present the histopathological features of such skin diseases, which, though generally rare, almost exclusively appear during the first weeks of life due to distinctive structural and functional features of neonatal skin. The second part is dedicated to classic dermatoses of infancy and their histopathological features.

Asymptomatic solitary cutaneous mastocytoma: a rare presentation

A 50-day-old female child presented with asymptomatic skin colored raised lesion on the dorsal aspect of the left wrist since the age of 10 days. The diagnosis of cutaneous mastocytoma was made based upon clinical and histopathological features.

A 1-year-old boy with persistent, generalized eruption. Urticaria pigmentosa

A healthy 1-year-old boy born at full term after an uncomplicated pregnancy presented to the dermatology clinic for a widespread eruption with gradual onset since 3 months of age. He was otherwise well, afebrile, feeding well, and gaining weight appropriately. The child was overall asymptomatic, though some of his lesions occasionally became red and pruritic. His mother noticed that after mild illnesses, he was more prone to these flares. She denied flushing, vomiting, diarrhea, respiratory distress, and irritability. He was meeting all developmental milestones and started walking at 11 months of age. The remainder of his review of systems was unremarkable, and family history was noncontributory. Physical exam revealed a well-appearing, well-nourished, playful, and interactive toddler. There were innumerable discrete and coalescing pink-brown macules and papules concentrated on the trunk and extending onto the proximal upper and lower extremities bilaterally, as well as the neck and lower face. Stroking the lesions quickly led to development of erythematous edematous wheals. There was no hepatosplenomegaly, and the lymph node exam was unremarkable.

Childhood mastocytosis

PURPOSE OF REVIEW

Important advances have been achieved in recent years in adult mastocytosis. However, our knowledge about childhood mastocytosis is limited because invasive tests are not routinely performed in children. We ignore the frequency of systemic involvement in childhood mastocytosis, its outcome, and which are the main clinical and laboratory parameters associated with persistence into adult mastocytosis and its severity.

RECENT FINDINGS

Childhood mastocytosis is a clonal mast cell disease, with different activating mutations in the KIT gene discovered in most patients. Serum tryptase is the best marker for mast cell burden in children, and, at baseline, correlates well with the severity of symptoms in childhood mastocytosis. Systemic mastocytosis definitely may occur in children, but bone marrow studies to demonstrate a systemic involvement are not routinely performed nor recommended; it can be estimated that around 30% of children may have bone marrow involvement as demonstrated by showing aggregates of mast cells or by flow cytometry of mast cells expressing the aberrant CD25 marker.

SUMMARY

A new and improved classification of childhood mastocytosis is needed, and should be based on the correlation of clinical manifestations, morphology of mast cells in the skin, and the predicted outcome of the disease. The current classifications of childhood mastocytosis do not address any of these important issues.

[Bullous mastocytosis in infancy: a rare presentation]

Mastocytosis is a rare condition related to an abnormal proliferation of mast cells and their accumulation in tissues. Cutaneous mastocytosis is the most common form and mainly affects newborns and infants. The symptoms are caused by the release of mediators contained in mast cells, including histamine. Mastocytosis may be associated with a mutation in the gene encoding the c-kit receptor. Clinically, there are different dermatological findings, which combine acute cutaneous, digestive, or even hemodynamic manifestations in varying degrees. The diagnosis is confirmed by the histological study of a skin sample. We report here the case of a 4-month-old infant suffering from diffuse cutaneous bullous mastocytosis, a very rare variety of mastocytosis. This infant had an erosive and bullous manifestation of dermatosis, initially confused with impetigo. The proliferation of bullous lesions led to her hospitalization. Codeine intake for pain was responsible for a large and extensive bullous reaction associated with anaphylactic shock. This context of bullous spread occurring after taking codeine led to the suspicion of bullous diffuse cutaneous mastocytosis, a diagnosis that was confirmed histologically. This observation demonstrates the difficulty of mastocytosis diagnosis, mostly due to its rarity, especially in its diffuse bullous forms. The rapid deterioration of this patient, after the codeine prescription, emphasizes the importance of the eviction of histamine-releaser compounds in the management of this disease.

Cutaneous mastocytosis in twins: multiple mastocytomas and urticaria pigmentosa in two pairs of monozygotic twins

We report two sets of monozygotic twins with cutaneous mastocytosis: one set with urticaria pigmentosa and the other set with multiple mastocytomas. This is the first report of multiple mastocytomas in twins to our knowledge.

Nodular Mastocytosis of the Vulva and Coexisting Urticaria Pigmentosa / Nodularna Mastocitoza vulve udružena sa urtikarijom pigmentozom

Nodular forms of mastocytosis are rather rare skin diseases, especially when localized on the vulva. A 9-year-old girl presented with urticaria pigmentosa type lesions since her 4th year, associated with several solitary or confluent vulvar nodules, varying in size from a pea to a walnut, and mild systemic symptoms. Diagnosis of mastocytosis was confirmed by histology, and apart from splenomegaly, no signs of systemic spread or associated hematologic disorders were detected. Therapeutic response of nodular lesions was rather poor, and further follow up is necessary.

Cutaneous mastocytosis: a review focusing on the pediatric population

Cutaneous mastocytosis can be divided into 4 different clinical variants--urticaria pigmentosa, solitary mastocytoma, diffuse cutaneous mastocytosis, and telangiectasia macularis eruptiva perstans. Skin findings are often accompanied by symptoms secondary to mast cell release of mediators. These symptoms can be both localized to the skin lesion and systemic because of the release of mediators into the bloodstream. The majority of pediatric cases of cutaneous mastocytosis show a good prognosis with gradual resolution of both symptoms and skin lesions. This article will review each of the 4 clinical presentations focusing on pediatric-onset of disease while reviewing the literature.

Aggressive systemic mastocytosis after germ cell tumor of the ovary: C-KIT mutation documentation in both disease states

We report a case of aggressive systemic mastocytosis in a 3-year-old girl, who had undergone treatment for ovarian germ cell tumor during the previous 8 months. On diagnosis of systemic mastocytosis, she was treated with interferon-alpha and steroids. She showed tolerable side effects of interferon-alpha infusion, but died of multiple organ failure after 2 months of treatment. Point mutations of the C-KIT gene, previously implicated in the genesis of mastocytosis, were discovered not only in the bone marrow and the peripheral blood of the patient, but also in the tissue of the previously diagnosed germ cell tumor as well.

Efficacy of 25% diluted fluticasone propionate 0.05% cream as wet-wrap treatment in cutaneous mastocytosis

BACKGROUND

Mastocytosis is a disorder that can be subdivided into two forms: cutaneous and systemic. Patients with cutaneous mastocytosis only may suffer from cosmetic problems. Topical steroid application has been shown to be effective in cases of limited skin lesions.

METHODS

A case-controlled pilot study was conducted during a 6-weeks treatment using diluted 25% fluticasone propionate 0.05% cream under wet-wrap occlusion in 5 adults and 6 children. Improvement was measured up to the 24th week after treatment using the SCORMA Index.

RESULTS

The results of this pilot study showed a partial but clear cosmetic improvement in 9 of the 11 patients. The mean SCORMA Index decreased after treatment from 38 to 26.

CONCLUSION

25% dilution of fluticasone propionate 0.05% cream under wet-wrap occlusion is an alternative treatment modality for alleviating the symptoms of cutaneous mastocytosis, but the improvement may be moderate and fall short of the patient's expectations.

Bullous dermatoses in childhood: part II

Bullous dermatoses are commonly encountered in childhood practice. Much confusion exists among clinicians because of the similarity of clinical lesions, paucity of relevant literature, and varied nomenclature used for these diseases. For a better understanding of the proposed classification, this second part is a review of diseases with nonhereditary characteristics of subepidermal cleavage and hereditary characteristics with intraepidermal and subepidermal cleavage.

An unusual presentation of mastocytosis: unilateral swelling of the vulva

Mastocytosis is a primary, abnormal accumulation of mast cells associated with a broad range of local and systemic symptoms. We report two female adolescents with episodic, unilateral, swelling of the labia majora that was discovered to be an unusual presentation of mastocytosis. Mastocytosis is frequently misdiagnosed because of its rarity and variable clinical presentation, which often mimics other conditions. In the appropriate setting, mastocytosis should be included in the differential diagnosis of labium majus swelling.

Therapeutic approach to selected neonatal eruptions

Management of numerous neonatal eruptions has been modified over the past 10 years. In this article, traditional and developing therapeutic insights are applied to both common and uncommon neonatal conditions.