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Dreher K, Rick JW, Nymeyer H, Evans MS. Multiple Hyperpigmented Lesions in a Young Girl. Pediatr Rev 2023; 44:33-36. [PMID: 36587023 DOI: 10.1542/pir.2021-005106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Katie Dreher
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Jonathan W Rick
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Hugh Nymeyer
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Megan S Evans
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR
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2
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Pucci S, Ciccarelli F, De Pasquale T, D'Alò S, Incorvaia C. Maintenance venom immunotherapy administered at 12-week intervals in patients with high basal tryptase. Ann Allergy Asthma Immunol 2022; 128:474-475. [PMID: 35032675 DOI: 10.1016/j.anai.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/18/2021] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Stefano Pucci
- Allergy Unit, General Hospital, Civitanova Marche, Italy.
| | | | | | - Simona D'Alò
- Allergy Unit, General Hospital, Civitanova Marche, Italy
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3
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Jackson CW, Pratt CM, Rupprecht CP, Pattanaik D, Krishnaswamy G. Mastocytosis and Mast Cell Activation Disorders: Clearing the Air. Int J Mol Sci 2021; 22:ijms222011270. [PMID: 34681933 PMCID: PMC8540348 DOI: 10.3390/ijms222011270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 12/11/2022] Open
Abstract
Mast cells are derived from hematopoietic stem cell precursors and are essential to the genesis and manifestations of the allergic response. Activation of these cells by allergens leads to degranulation and elaboration of inflammatory mediators, responsible for regulating the acute dramatic inflammatory response seen. Mast cells have also been incriminated in such diverse disorders as malignancy, arthritis, coronary artery disease, and osteoporosis. There has been a recent explosion in our understanding of the mast cell and the associated clinical conditions that affect this cell type. Some mast cell disorders are associated with specific genetic mutations (such as the D816V gain-of-function mutation) with resultant clonal disease. Such disorders include cutaneous mastocytosis, systemic mastocytosis (SM), its variants (indolent/ISM, smoldering/SSM, aggressive systemic mastocytosis/ASM) and clonal (or monoclonal) mast cell activation disorders or syndromes (CMCAS/MMAS). Besides clonal mast cell activations disorders/CMCAS (also referred to as monoclonal mast cell activation syndromes/MMAS), mast cell activation can also occur secondary to allergic, inflammatory, or paraneoplastic disease. Some disorders are idiopathic as their molecular pathogenesis and evolution are unclear. A genetic disorder, referred to as hereditary alpha-tryptasemia (HαT) has also been described recently. This condition has been shown to be associated with increased severity of allergic and anaphylactic reactions and may interact variably with primary and secondary mast cell disease, resulting in complex combined disorders. The role of this review is to clarify the classification of mast cell disorders, point to molecular aspects of mast cell signaling, elucidate underlying genetic defects, and provide approaches to targeted therapies that may benefit such patients.
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Affiliation(s)
- Clayton Webster Jackson
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA; (C.W.J.); (C.M.P.)
| | - Cristina Marie Pratt
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA; (C.W.J.); (C.M.P.)
| | | | - Debendra Pattanaik
- The Division of Allergy and Immunology, UT Memphis College of Medicine, Memphis, TN 38103, USA;
| | - Guha Krishnaswamy
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA; (C.W.J.); (C.M.P.)
- The Bill Hefner VA Medical Center, The Division of Allergy and Immunology, Salisbury, NC 28144, USA
- Correspondence: or
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4
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Kopač P, Custovic A, Zidarn M, Šilar M, Šelb J, Bajrović N, Eržen R, Košnik M, Korošec P. Biomarkers of the Severity of Honeybee Sting Reactions and the Severity and Threshold of Systemic Adverse Events During Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3157-3163.e5. [PMID: 33962066 DOI: 10.1016/j.jaip.2021.04.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND A biomarker that could identify individuals at high risk for severe honeybee sting allergic reaction and/or systemic adverse events (SAEs) during venom immunotherapy (VIT) would improve the management of patients with honeybee (HB) venom allergy. OBJECTIVE To identify biomarkers for risk of severe sting reactions or SAEs during VIT. METHODS We recruited 332 patients undergoing HB VIT. We ascertained predictors of the severity of the field-sting reaction and the severity and threshold of SAEs during VIT. We assessed the use of cardiovascular medications; baseline serum tryptase (BST) levels; specific IgEs to HB venom, rApi m 1, and rApi m 10; and basophil activation test (BAT) response. RESULTS Significant and independent predictors of a severe HB field-sting reaction were age (P = .008), an absence of skin symptoms (P = .001), BST (P = .014), and BAT response at an HB venom concentration of 0.1 μg/mL (P = .001). Predictors of severe SAEs during HB VIT were age (P = .025), BST (P = .006), and BAT response (P = .001). BAT response was also an individual and significant predictor of any SAEs and SAEs at a low cumulative allergen dose (median, 55 μg) during VIT build-up (P < .001). The use of β-blockers and angiotensin-converting-enzyme inhibitors and specific IgE levels were not associated with the severity of HB field-sting reactions or VIT SAEs. CONCLUSIONS BST and basophil activation are independent risk factors for severe HB sting anaphylaxis and SAEs during HB VIT. BAT response was the best biomarker for any SAEs and a lower threshold of SAEs during HB VIT. These risk factors can help guide recommendations for VIT and overcome systemic reactions to HB VIT.
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Affiliation(s)
- Peter Kopač
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Mihaela Zidarn
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mira Šilar
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Julij Šelb
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nissera Bajrović
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Renato Eržen
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mitja Košnik
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Korošec
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia
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5
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Zanotti R, Tanasi I, Bernardelli A, Orsolini G, Bonadonna P. Bone Marrow Mastocytosis: A Diagnostic Challenge. J Clin Med 2021; 10:1420. [PMID: 33915965 PMCID: PMC8037514 DOI: 10.3390/jcm10071420] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 12/12/2022] Open
Abstract
Bone marrow mastocytosis (BMM) represents a provisional, indolent subvariant of systemic mastocytosis (SM). Utilizing WHO criteria, BMM requires bone marrow (BM) involvement and the absence of mastocytosis skin lesions. BMM is characterized by male sex prevalence, a slight increase of serum tryptase levels, low BM mast cells (MC) burden, and an indolent clinical course. BMM shows a strong correlation with severe anaphylaxis, mainly due to an IgE-mediated allergy to bee or wasp venom and, less frequently, to unexplained (idiopathic) anaphylaxis. Furthermore, BMM is often associated with osteoporosis which could be the only presenting symptom of the disease. BMM is an undervalued disease as serum tryptase levels are not routinely measured in the presence of unexplained osteoporosis or anaphylaxis. Moreover, BMM patients are often symptom-free except for severe allergic reactions. These factors, along with typical low BM MCs infiltration, may contribute to physicians overlooking BMM diagnosis, especially in medical centers that lack appropriately sensitive diagnostic techniques. This review highlights the need for a correct diagnostic pathway to diagnose BMM in patients with suspected symptoms but lacking typical skin lesions, even in the case of normal serum tryptase levels. Early diagnosis may prevent potential life-threatening anaphylaxis or severe skeletal complications.
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Affiliation(s)
- Roberta Zanotti
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (I.T.); (A.B.)
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
| | - Ilaria Tanasi
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (I.T.); (A.B.)
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
| | - Andrea Bernardelli
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (I.T.); (A.B.)
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
| | - Giovanni Orsolini
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
- Reumathology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy
| | - Patrizia Bonadonna
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
- Allergy Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy
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Stock R, Fischer T, Aẞmus K, Zoeller N, Ackermann H, Kaufmann R, Meissner M, Valesky E. Safety and tolerability of venom immunotherapy: Evaluation of 581 rush- and ultra-rush induction protocols (safety of rush and ultra-rush venom immunotherapy). World Allergy Organ J 2020; 14:100496. [PMID: 33376576 PMCID: PMC7750415 DOI: 10.1016/j.waojou.2020.100496] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 11/05/2020] [Accepted: 11/20/2020] [Indexed: 12/26/2022] Open
Abstract
Background Current literature is inconsistent regarding the risk of severe side effects using accelerated induction protocols in Hymenoptera venom immunotherapy (VIT). In addition, several data indicate the influence of purity grade of venom preparation on tolerability. We evaluated the safety and tolerability of ultra-rush and rush build-up protocols using purified and non-purified venom preparations. Methods Retrospective single-center study of 581 VIT inductions (325 ultra-rush and 256 rush protocols) from 2005 to 2018 in 559 patients with bee and vespid venom allergy using aqueous purified (ALK SQ®) for ultra-rush protocol and aqueous non-purified (ALK Reless®) venom preparations for rush protocol. Results Urticaria (8% vs. 3.1%, p = 0,013) and dose reductions (4.3% vs. 1.2%, p = 0,026) were significantly more frequent in the ultra-rush group. Overall rate of moderate-to-severe side effects (anaphylaxis ≥grade 2 according to Ring and Meβmer) was low and did not differ significantly between protocols (p = 0.105). Severe events (grade 4 anaphylaxis) were not reported. Discontinuation rate was very low in both cohorts (0.6% vs 1.2%). The higher purity grade of venom preparations in the ultra-rush cohort did not improve tolerability. The bee venom group showed a non-significant trend towards higher incidence of mild reactions (urticaria), resulting in more frequent dose reductions and antiallergic therapy. Conclusion Rush and ultra-rush protocols show an excellent safety profile with only infrequent and mild anaphylactic reactions in bee and vespid venom allergy. Ultra-rush immunotherapy reduces the duration of the inpatient build-up phase setting and thus is viewed by the authors as preferred treatment in Hymenoptera venom allergic patients.
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Key Words
- BTC, basal tryptase concentration
- BV, bee venom
- Bee venom allergy
- Hymenoptera venom immunotherapy
- IgE, Immunoglobulin E
- R, rush
- Rush protocol
- UR, ultra-rush
- Ultra-rush protocol
- VIT, venom immunotherapy
- VV, vespid venom
- Vespid venom allergy
- f, female
- m, male
- ml, millilitres
- n, number of patients
- y, years
- μL, microlitres
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Affiliation(s)
- Richard Stock
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Tatjana Fischer
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Katharina Aẞmus
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Nadja Zoeller
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Hanns Ackermann
- Institute for Biostatistics, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt, Germany
| | - Roland Kaufmann
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Markus Meissner
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Eva Valesky
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
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7
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Di Raimondo C, Del Duca E, Silvaggio D, Di Prete M, Lombardo P, Mazzeo M, Spallone G, Campione E, Botti E, Bianchi L. Cutaneous mastocytosis: A dermatological perspective. Australas J Dermatol 2020; 62:e1-e7. [PMID: 33040350 DOI: 10.1111/ajd.13443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 12/01/2022]
Abstract
Mastocytosis is a rare disease characterised by expansion and collection of clonal mast cells in various organs including the skin, bone marrow, spleen, lymph nodes and gastrointestinal tract. The prevalence of mastocytosis has been estimated to be one in 10 000, while the estimated incidence is one per 100 000 people per year. Cutaneous mastocytosis is classified into (i) maculopapular cutaneous mastocytosis, also known as urticaria pigmentosa; (ii) diffuse cutaneous mastocytosis; and (iii) mastocytoma of the skin. In adults, cutaneous lesions are usually associated with indolent systemic mastocytosis and have a chronic evolution. Paediatric patients, on the contrary, have often cutaneous manifestations without systemic involvement and usually experience a spontaneous regression. Diagnosis of cutaneous mastocytosis may be challenging due to the rarity of the disease and the overlap of cutaneous manifestations. This short review describes pathogenesis and clinical aspects of cutaneous mastocytosis with a focus on diagnosis and currently available therapies.
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Affiliation(s)
| | - Ester Del Duca
- Department of Dermatology, University of Roma Tor Vergata, Rome, Italy
| | | | - Monia Di Prete
- Department of Anatomic Pathology, University of Rome Tor Vergata, Rome, Italy
| | - Paolo Lombardo
- Department of Dermatology, University of Roma Tor Vergata, Rome, Italy
| | - Mauro Mazzeo
- Department of Dermatology, University of Roma Tor Vergata, Rome, Italy
| | - Giulia Spallone
- Department of Dermatology, University of Roma Tor Vergata, Rome, Italy
| | - Elena Campione
- Department of Dermatology, University of Roma Tor Vergata, Rome, Italy
| | - Elisabetta Botti
- Department of Dermatology, University of Roma Tor Vergata, Rome, Italy
| | - Luca Bianchi
- Department of Dermatology, University of Roma Tor Vergata, Rome, Italy
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8
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Golden DBK, Carter MC. Insect Sting Anaphylaxis-Or Mastocytosis-Or Something Else? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1117-1123. [PMID: 30961837 DOI: 10.1016/j.jaip.2019.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 12/18/2022]
Abstract
Insect sting anaphylaxis and mast cell disorders are intertwined in a specific and unusual way. There may be specific subsets of clonal mast cell disorders that are predisposed to sting anaphylaxis. The clinical characteristics of the sting reactions should raise suspicion of underlying mastocytosis (eg, hypotension without hives especially in a male). A baseline serum tryptase level is helpful in the evaluation of patients with insect sting anaphylaxis because it correlates with important risks for these patients, and they have a high frequency of abnormally elevated baseline levels. Elevated baseline serum tryptase level has been reported to correlate with clonal mast cell disease in patients with insect sting anaphylaxis but may also indicate one of several possible underlying syndromes, including mast cell activation syndrome (MCAS), familial hypertryptasemia, and idiopathic anaphylaxis. There is some overlap in these conditions, so it is important to evaluate the clinical pattern at presentation as well as laboratory markers, and to consider bone marrow biopsy to make a final and specific diagnosis of clonal mast cell disease. The presence of venom-IgE does not prove that the patient's previous sting reactions were IgE-mediated, but even low levels of venom-IgE in patients with mastocytosis predispose to severe sting anaphylaxis. Evaluation of all these possible factors will affect the recommendation for venom immunotherapy.
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Affiliation(s)
- David B K Golden
- Allergy and Clinical Immunology, Johns Hopkins University, Baltimore, Md.
| | - Melody C Carter
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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9
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Mastocytosis as a risk factor for insect venom allergy. ALLERGO JOURNAL 2020. [DOI: 10.1007/s15007-020-2516-3] [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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10
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Venom immunotherapy in Europe and the United States. ALLERGO JOURNAL 2020. [DOI: 10.1007/s15007-020-0747-y] [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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11
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12
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Blank S, Pehlivanli S, Methe H, Schmidt-Weber CB, Biedermann T, Horny HP, Kristensen T, Amar Y, Köberle M, Brockow K, Stömmer PE. Fatal anaphylaxis following a hornet sting in a yellow jacket venom-sensitized patient with undetected monoclonal mast cell activation syndrome and without previous history of a systemic sting reaction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:401-403.e2. [PMID: 31279041 DOI: 10.1016/j.jaip.2019.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Simon Blank
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany.
| | - Sinan Pehlivanli
- Department of Internal Medicine/Cardiology, Kliniken an der Paar, Aichach, Germany
| | - Heiko Methe
- Department of Internal Medicine/Cardiology, Kliniken an der Paar, Aichach, Germany
| | - Carsten B Schmidt-Weber
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany
| | - Hans-Peter Horny
- Institute of Pathology, Ludwig-Maximilian University, Munich, Germany
| | - Thomas Kristensen
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Yacine Amar
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany
| | - Martin Köberle
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany; Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense, Denmark
| | - Peter E Stömmer
- Pathology Augsburg, Clinic for Pathology and Cytology, Augsburg, Germany
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13
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Requena López S, Matito A, Alvarez-Twose I, Torrelo A. Perioperative anaphylaxis in a patient with a solitary mastocytoma. Pediatr Dermatol 2019; 36:352-354. [PMID: 30854701 DOI: 10.1111/pde.13777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Children with more extensive cutaneous mastocytosis have a higher risk for symptoms secondary to release of mast cell mediators. However, the remote possibility of anaphylaxis in patients with a solitary lesion suggests the need for cautious use of general anesthesia in these children. We describe an unusual case of a patient with a solitary mastocytoma who experienced an anaphylactic reaction during a surgical procedure and make recommendations to reduce the risk of intraoperative anaphylaxis in mast cell disease.
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Affiliation(s)
- Sheila Requena López
- Department of Dermatology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Almudena Matito
- Departament of Dermatology, Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast), Hospital Virgen del Valle, Toledo, Spain
| | - Iván Alvarez-Twose
- Departament of Dermatology, Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast), Hospital Virgen del Valle, Toledo, Spain
| | - Antonio Torrelo
- Department of Dermatology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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14
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Wagner N, Staubach P. Mastocytosis - pathogenesis, clinical manifestation and treatment. J Dtsch Dermatol Ges 2019; 16:42-57. [PMID: 29314691 DOI: 10.1111/ddg.13418] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/14/2017] [Indexed: 01/08/2023]
Abstract
The term mastocytosis designates a group of rare disorders characterized by typical skin lesions, frequently associated episodes of anaphylaxis, and clinical symptoms related to the release of various mediators. Dermatologists/allergists are frequently the first to establish the diagnosis. The condition is based on clonal mast cell proliferation, usually in the skin or bone marrow and only rarely in the gastrointestinal tract or other tissues. In general, mastocytosis has a good prognosis in terms of life expectancy. Rare variants - including mast cell leukemia, aggressive mastocytosis, and the exceedingly rare mast cell sarcoma - require cytoreductive therapy. In cases associated with hematological neoplasms, the prognosis depends on the underlying hematologic disorder.
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Affiliation(s)
- Nicola Wagner
- Department of Dermatology, University Medical Center, Erlangen, Germany
| | - Petra Staubach
- Department of Dermatology, University Medical Center, Mainz, Germany
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15
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Carter MC, Metcalfe DD, Matito A, Escribano L, Butterfield JH, Schwartz LB, Bonadonna P, Zanotti R, Triggiani M, Castells M, Brockow K. Adverse reactions to drugs and biologics in patients with clonal mast cell disorders: A Work Group Report of the Mast Cells Disorder Committee, American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol 2018; 143:880-893. [PMID: 30528617 DOI: 10.1016/j.jaci.2018.10.063] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 09/06/2018] [Accepted: 10/09/2018] [Indexed: 12/27/2022]
Abstract
Providers caring for patients with mastocytosis are tasked with the decision to consider therapeutic options. This can come with some trepidation because information available in the public domain lists numerous mast cell (MC) activators based on data that do not discriminate between primates, rodents, and MC lines; do not consider dosage; and do not take into account previous exposure and resultant clinical findings. This being said, there is support in the literature for an enhanced MC response in some patients with mastocytosis and in cases in which there is a greater incidence of adverse reactions associated with certain antigens, such as venoms and drugs. Thus this report provides a comprehensive guide for those providers who must decide on therapeutic options in the management of patients with clonal MC disease.
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Affiliation(s)
- Melody C Carter
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Dean D Metcalfe
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Almudena Matito
- Instituto de Estudios de Mastocitosis de Castilla-La Mancha (CLMast), Hospital Virgen del Valle, Toledo, Spain; Spanish Network on Mastocytois (REMA), Toledo, Spain
| | - Luis Escribano
- Servicio General de Citometría, Centro de Investigación del Cáncer/IBMCC (USAL/CSIC) and Departamento de Medicina, Universidad de Salamanca and IBSAL, Salamanca, Spain; Spanish Network on Mastocytois (REMA), Toledo, Spain
| | - Joseph H Butterfield
- Division of Allergic Diseases and the Program for Mast Cell and Eosinophil Disorders, Mayo Clinic, Rochester, Minn
| | - Lawrence B Schwartz
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Va
| | - Patrizia Bonadonna
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy; Multidisplinary Outpatients Clinic for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Roberta Zanotti
- Multidisplinary Outpatients Clinic for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy; Department of Medicine, Haematology Unit, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Mariana Castells
- Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
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16
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Tratzmiller S, Klemke CD. [62/m with bee venom allergy and reddish-brown disseminated small macules and papules mainly localized on the trunk : Preparation for the specialist examination: part 5]. Hautarzt 2018; 69:96-99. [PMID: 30374555 DOI: 10.1007/s00105-018-4235-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Sabine Tratzmiller
- Hautklinik, Städtisches Klinikum Karlsruhe, Akademisches Lehrkrankenhaus der Universität Freiburg, Moltkestr. 120, 76133, Karlsruhe, Deutschland.
| | - Claus-Detlev Klemke
- Hautklinik, Städtisches Klinikum Karlsruhe, Akademisches Lehrkrankenhaus der Universität Freiburg, Moltkestr. 120, 76133, Karlsruhe, Deutschland
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Abstract
Bee venom is a blend of biochemicals ranging from small peptides and enzymes to biogenic amines. It is capable of triggering severe immunologic reactions owing to its allergenic fraction. Venom components are presented to the T cells by antigen-presenting cells within the skin. These Th2 type T cells then release IL-4 and IL-13 which subsequently direct B cells to class switch to production of IgE. Generating venom-specific IgE and crosslinking FcεR1(s) on the surface of mast cells complete the sensitizing stage in allergic individuals who are most likely to experience severe and even fatal allergic reactions after being stung. Specific IgE for bee venom is a double-edged sword as it is a powerful mediator in triggering allergic events but is also applied successfully in diagnosis of the venom allergic patient. The healing capacity of bee venom has been rediscovered under laboratory-controlled conditions using animal models and cell cultures. The potential role of enzymatic fraction of bee venom including phospholipase A2 in the initiation and development of immune responses also has been studied in numerous research settings. Undoubtedly, having insights into immunologic interactions between bee venom components and innate/specific immune cells both locally and systematically will contribute to the development of immunologic strategies in specific and epitope-based immunotherapy especially in individuals with Hymenoptera venom allergy.
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Bonadonna P, Scaffidi L. Hymenoptera Anaphylaxis as a Clonal Mast Cell Disorder. Immunol Allergy Clin North Am 2018; 38:455-468. [DOI: 10.1016/j.iac.2018.04.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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19
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Bonadonna P, Zanotti R, Pagani M, Bonifacio M, Scaffidi L, Olivieri E, Franchini M, Reccardini F, Costantino MT, Roncallo C, Mauro M, Boni E, Rizzini FL, Bilò MB, Marcarelli AR, Passalacqua G. Anaphylactic Reactions After Discontinuation of Hymenoptera Venom Immunotherapy: A Clonal Mast Cell Disorder Should Be Suspected. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1368-1372. [DOI: 10.1016/j.jaip.2017.11.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 11/09/2017] [Accepted: 11/16/2017] [Indexed: 11/15/2022]
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20
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Wagner N, Staubach P. Mastozytose - Pathogenese, Klinik und Therapie. J Dtsch Dermatol Ges 2018; 16:42-59. [PMID: 29314684 DOI: 10.1111/ddg.13418_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/14/2017] [Indexed: 01/08/2023]
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21
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Metcalfe DD, Mekori YA. Pathogenesis and Pathology of Mastocytosis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2017; 12:487-514. [PMID: 28135563 DOI: 10.1146/annurev-pathol-052016-100312] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Systemic mastocytosis is a clonal disorder of mast cells that may variably present with characteristic skin lesions, episodes of mast cell mediator release, and disturbances of hematopoiesis. No curative therapy presently exists. Conventional management has relied on agents that antagonize mediators released by mast cells, inhibit mediator secretion, or modulate mast cell proliferation. Recent advances in the molecular understanding of the pathophysiology of systemic mastocytosis have provided new therapeutic considerations, including new and novel tyrosine kinase inhibitors.
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Affiliation(s)
- Dean D Metcalfe
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892;
| | - Yoseph A Mekori
- Tel Hai College, Upper Galilee, 1220800 Israel; .,Meir Medical Center, Kfar Saba 44281, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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22
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Abstract
Abstract. Risk factors should be part of the decision, of which patient should be offered venom immunotherapy (VIT) and how VIT should be performed. Risk factors for a severe systemic anaphylactic reaction (SAR) after a Hymenoptera field sting include a preceding less severe sting reaction, a wasp sting, an increased baseline serum tryptase concentration (BSTC), mastocytosis, older age, ACE inhibitor medication, and male gender. During VIT, treatment with honey bee venom is the most important risk factor for a SAR. Further risk factors include a high BSTC (for vespid VIT only), presence of venom specific IgE in serum, any antihypertensive medication during therapy, and an ultra-rush protocol for build-up. Treatment failure is more common in patients suffering from honey bee venom allergy, high BSTC (for vespid VIT only) or mastocytosis, and in those who had experienced side effects during VIT. Besides discontinuing antihypertensive medication or switching to a moderate type of dose increase during build-up, little can be done to minimize the risks associated with VIT. Increasing the maintenance dose may improve the efficacy of VIT. In patients with a particularly high risk for treatment failure, or in case of treatment failure, VIT should include an increased maintenance dose right from the beginning. Usually, 200 µg will be sufficient.
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23
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Diaz JH. Hypersensitivity Reaction to Yellow Jacket Sting in a Previously Nonallergic Patient Taking an Angiotensin Receptor Blocker. Wilderness Environ Med 2017; 28:150-152. [PMID: 28385364 DOI: 10.1016/j.wem.2017.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 01/04/2017] [Accepted: 01/12/2017] [Indexed: 10/19/2022]
Affiliation(s)
- James H Diaz
- Department of Environmental and Occupational Health Sciences, School of Public Health, New Orleans, LA; Department of Anesthesiology, School of Medicine Louisiana State University Health Sciences Center New Orleans, LA.
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24
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Adams KE, Freeman TM. Venom Immunotherapy: Risk Factors, Predictors, Duration, and Other Unmet Needs. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0107-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
This article updates current knowledge on epidemiology, risk factors, triggers, and management of anaphylaxis in patients with mastocytosis. Hyperactive mast cells and higher number of effector mast cells are speculated to facilitate anaphylaxis in this condition. In children, increased risk is limited to those with extensive skin involvement and high tryptase. In adults, manifestations of anaphylaxis are severe with high frequency of cardiovascular symptoms. Hymenoptera stings are the most common triggers for these reactions; however, idiopathic anaphylaxis and reactions to food or drugs occur. Patients with mastocytosis should be informed about risk of anaphylaxis and prescribing emergency self-medication and installing emergency preparedness before general anesthesia is considered.
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Affiliation(s)
- Anna Schuch
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany.
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27
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Michel J, Brockow K, Darsow U, Ring J, Schmidt-Weber CB, Grunwald T, Blank S, Ollert M. Added sensitivity of component-resolved diagnosis in hymenoptera venom-allergic patients with elevated serum tryptase and/or mastocytosis. Allergy 2016; 71:651-60. [PMID: 26836051 DOI: 10.1111/all.12850] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anaphylaxis caused by hymenoptera venom allergy is associated with elevation of baseline serum tryptase (sBT) and/or mastocytosis in about 5% of patients. Up to now, no information has become available on single venom allergen sIgE reactivity and the usefulness of component-resolved approaches to diagnose this high-risk patient group. To address the component-resolved sIgE sensitization pattern and diagnostic sensitivity in hymenoptera venom-allergic patients with elevated sBT levels and/or mastocytosis, a panel of yellow jacket and honeybee venom allergens was applied on a widely used IgE immunoassay platform. METHODS Fifty-three patients with mastocytosis and/or elevated sBT tryptase level and systemic reactions to hymenoptera venoms were analyzed for their IgE reactivity to recombinant yellow jacket and honeybee venom allergens by Immulite3 g. RESULTS sIgE reactivity to Ves v 1, Ves v 5, Api m 1 to Api m 4 and Api m 10 was found at a similar frequency in hymenoptera venom-allergic patients with and without elevated sBT levels and/or mastocytosis. However, the use of the recombinant allergens and a diagnostic cutoff of 0.1 kUA /L allowed the diagnosis of patients with otherwise undetectable IgE to venom extract. The diagnostic sensitivity of yellow jacket venom allergy using the combination of Ves v 1 and Ves v 5 was 100%. CONCLUSIONS In high-risk patients with elevated sBT levels and/or mastocytosis, the use of molecular components and decreasing the threshold sIgE level to 0.1 kUA /L may be needed to avoid otherwise undetectable IgE to hymenoptera venom extracts in about 8% of such patients.
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Affiliation(s)
- J. Michel
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | - K. Brockow
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | - U. Darsow
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | - J. Ring
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | - C. B. Schmidt-Weber
- Center of Allergy and Environment (ZAUM); Technical University of Munich and Helmholtz Center Munich; Munich Germany
- Member of the German Center of Lung Research (DZL); Hamburg Germany
| | | | - S. Blank
- Center of Allergy and Environment (ZAUM); Technical University of Munich and Helmholtz Center Munich; Munich Germany
| | - M. Ollert
- Department of Infection and Immunity; Luxembourg Institute of Health (LIH); Esch-sur-Alzette Luxembourg
- Department of Dermatology and Allergy Center; Odense Research Center for Anaphylaxis; University of Southern Denmark; Odense Denmark
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Bonadonna P, Bonifacio M, Lombardo C, Zanotti R. Hymenoptera Allergy and Mast Cell Activation Syndromes. Curr Allergy Asthma Rep 2016; 16:5. [PMID: 26714690 DOI: 10.1007/s11882-015-0582-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mast cell activation syndrome (MCAS) can be diagnosed in patients with recurrent, severe symptoms from mast cell (MC)-derived mediators, which are transiently increased in serum and are attenuated by mediator-targeting drugs. When KIT-mutated, clonal MC are detected in these patients, a diagnosis of primary MCAS can be made. Severe systemic reactions to hymenoptera venom (HV) represent the most common form of anaphylaxis in patients with mastocytosis. Patients with primary MCAS and HV anaphylaxis are predominantly males and do not have skin lesions in the majority of cases, and anaphylaxis is characterized by hypotension and syncope in the absence of urticaria and angioedema. A normal value of tryptase (≤11.4 ng/ml) in these patients does not exclude a diagnosis of mastocytosis. Patients with primary MCAS and HV anaphylaxis have to undergo lifelong venom immunotherapy, in order to prevent further potentially fatal severe reactions.
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Affiliation(s)
- Patrizia Bonadonna
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale Stefani 1, 37126, Verona, Italy.
- Multidisciplinary Outpatients clinics for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
| | - Massimiliano Bonifacio
- Section of Hematology, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale L.A. Scuro, 10-37134, Verona, Italy.
- Multidisciplinary Outpatients clinics for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
| | - Carla Lombardo
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale Stefani 1, 37126, Verona, Italy.
- Multidisciplinary Outpatients clinics for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
| | - Roberta Zanotti
- Section of Hematology, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale L.A. Scuro, 10-37134, Verona, Italy.
- Multidisciplinary Outpatients clinics for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
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When can immunotherapy for insect sting allergy be stopped? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 3:324-8; quiz 329-30. [PMID: 25956311 DOI: 10.1016/j.jaip.2014.11.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 11/14/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Stings by Hymenoptera (honey bees, vespids, ants) can cause systemic allergic reactions (SARs). Venom immunotherapy (VIT) is highly effective and reduces an allergic patient's risk of a recurrent SAR to less than 5-20%. The risk of a recurrent SAR to a re-sting decreases the longer VIT is continued. The recommended duration of VIT is at least 3 to 5 years. RISK FACTORS Risk factors for recurrent SARs to a sting after stopping VIT have been identified and discussed: Recommendations concerning stopping VIT: For patients without any of the identified risk factors, VIT should be continued for 5 rather than 3 years. In patients with definite risk factors, a longer duration of VIT has to be discussed before stopping it. In mast cell disorders, VIT for life is recommended. Because of the residual risk of SARs after VIT, all patients are advised to carry an epinephrine autoinjector indefinitely and to continue to take measures to avoid Hymenoptera stings.
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Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J, Ellis A, Golden DBK, Greenberger P, Kemp S, Khan D, Ledford D, Lieberman J, Metcalfe D, Nowak-Wegrzyn A, Sicherer S, Wallace D, Blessing-Moore J, Lang D, Portnoy JM, Schuller D, Spector S, Tilles SA. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol 2016; 115:341-84. [PMID: 26505932 DOI: 10.1016/j.anai.2015.07.019] [Citation(s) in RCA: 304] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/12/2015] [Indexed: 12/12/2022]
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31
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Insektengiftallergie. ALLERGOLOGIE 2016. [DOI: 10.1007/978-3-642-37203-2_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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32
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Krishna MT, Huber PAJ, Nasser SM, Ewan PW, Clark AT. Prescription of adrenaline auto-injectors - A National Survey of UK Allergy Specialists. Clin Exp Allergy 2015; 46:172-7. [DOI: 10.1111/cea.12641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- M. T. Krishna
- Department of Allergy and Immunology; Birmingham Heartlands Hospital and Aston University; Birmingham UK
- British Society for Allergy and Clinical Immunology; London UK
| | - P. A. J. Huber
- British Society for Allergy and Clinical Immunology; London UK
| | - S. M. Nasser
- British Society for Allergy and Clinical Immunology; London UK
- Allergy department; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - P. W. Ewan
- British Society for Allergy and Clinical Immunology; London UK
- Allergy department; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - A. T. Clark
- British Society for Allergy and Clinical Immunology; London UK
- Allergy department; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
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Wieczorek D, Kapp A, Wedi B. [Intolerance of specific immunotherapy with Hymenoptera venom: jumping the hurdle with omalizumab]. Hautarzt 2015; 65:791-5. [PMID: 25234627 DOI: 10.1007/s00105-014-2778-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Specific immunotherapy is a very effective and well-tolerated therapeutic option in patients with Hymenoptera venom allergy. Many patients can be successfully treated, and severe side-effects are rarely seen. In most cases local swelling of the injection site is noticed, whereas systemic reactions are uncommon. No reliable biomarkers to prove the positive response to the specific immunotherapy have been validated. But on the other hand the failure of the venom immunotherapy can be verified by performing a sting challenge test; in this case the maintenance dose of the venom immunotherapy has to be increased and the sting challenge test has to be repeated. This approach works well most of the patients. In rare cases severe anaphylactic reactions occur during the initiation of the venom immunotherapy due to individual risk factors. While in the past this necessitated discontinuation of the specific immunotherapy, the current situation has remarkably changed. Since the IgE-antibody omalizumab has been licensed for different indications, a new therapeutic option is available. We have employed this approach since 2005. We share our own practical experience as well as recent data, presenting a management approach for Hymenoptera venom allergy in high-risk patients.
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Affiliation(s)
- D Wieczorek
- Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland,
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Arock M, Akin C, Hermine O, Valent P. Current treatment options in patients with mastocytosis: status in 2015 and future perspectives. Eur J Haematol 2015; 94:474-90. [PMID: 25753531 DOI: 10.1111/ejh.12544] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2015] [Indexed: 12/20/2022]
Abstract
Mastocytosis is a term referring to a heterogeneous group of disorders characterized by abnormal mast cell (MC) accumulation in the skin and/or internal organs. In children, the disease involves mostly the skin (cutaneous mastocytosis; CM), whereas in adults, the disease is usually systemic (systemic mastocytosis; SM). Advanced SM variants with end-organ damage and reduced life expectancy have also been described, but are rare. Clinical signs and symptoms in SM result from excessive mediator release by MCs and, in aggressive forms, from organ failure related to MC infiltration. As a consequence, treatment of indolent SM aims primarily at the control of symptoms caused by MC mediator release. By contrast, in advanced SM, such as aggressive SM, MC leukemia, and MC sarcoma, intensive (chemo)therapy with or without allogeneic stem cell transplantation has to be considered. In addition, activating mutations in KIT (mostly KIT D816V in adults) are found in most patients with SM, so that targeted therapies aimed at blocking mutant KIT variants or/and downstream signaling pathways are currently being developed. Other targets, such as specific surface antigens expressed on neoplastic MCs, might be considered for the development of future therapies in advanced SM.
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Affiliation(s)
- Michel Arock
- Molecular Oncology and Pharmacology, LBPA CNRS UMR8113, Ecole Normale Supérieure de Cachan, Cachan, France.,Laboratory of Hematology, Pitié-Salpêtrière Hospital, Paris, France
| | - Cem Akin
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Hermine
- Clinical Hematology Department, Faculty of Medicine and AP-HP Necker-Enfants Malades, Paris Descartes University, Paris, France.,Imagine Institute, INSERM U1168, CNRS ERL 8654, National Reference Center on Mastocytosis, Paris, France
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
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Gelincik A, İşsever H, Unal D, Işık E, Demirturk M, Gül H, İliaz R, Kara E, Ertek B, Özşeker F, Çolakoğlu B, Büyüköztürk S. The prevalence of Hymenoptera venom allergy in adults: the results of a very crowded city in Euroasia. Allergol Int 2015; 64:35-40. [PMID: 25605527 DOI: 10.1016/j.alit.2014.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 06/16/2014] [Accepted: 06/22/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There are scarce data about the prevalence of Hymenoptera venom allergy in the general population. The aim of this study was to determine the prevalence of Hymenoptera venom allergy in the general adult population of Istanbul. METHODS A total of 17,064 randomly selected telephone numbers were contacted and 11,816 (69.25%) individuals who agreed to participate completed a questionnaire. Those who disclosed hypersensitivity reactions due to Hymenoptera stings in this initial survey were called again and given another questionnaire. Those who were suspected of experiencing hypersensitivity reactions to Hymenoptera stings were invited for a clinical investigation with in vivo and in vitro diagnostic tests. RESULTS According to the first questionnaire, a total of 1171 (9.9%; 95% CI: 9.38-10.47%) were suspected of having a hypersensitivity to Hymenoptera stings. 51.75% (n: 606) answered the second questionnaire and 21% (n: 128) of these were still suspected of having a hypersensitivity to Hymenoptera stings (1.1%; 95% CI: 0.9-1.29%). The confirmed prevalence of hypersensitivity to Hymenoptera stings according to skin tests and in vitro sIgE levels was 0.2% (95% CI: 0.14-0.30%). Nearly all of the participants with systemic reactions were admitted to the emergency department, although only one tenth of them received adrenaline in the emergency room. 2.3% carried an adrenaline injector, whereas none of the patients received venom immunotherapy. CONCLUSIONS The prevalence of Hymenoptera sting reactions in our geographical region is comparable with other European studies. There is a need to increase the awareness of adrenaline in the emergency management of insect sting anaphylaxis and venom immunotherapy in the prophylaxis.
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Affiliation(s)
- Aslı Gelincik
- Division of Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Halim İşsever
- Department of Public Health, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Derya Unal
- Division of Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erol Işık
- Department of Public Health, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mustafa Demirturk
- Division of Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Hülya Gül
- Department of Public Health, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Raim İliaz
- Division of Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erdal Kara
- Division of Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Belkıs Ertek
- Division of Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ferhan Özşeker
- Division of Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bahattin Çolakoğlu
- Division of Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Suna Büyüköztürk
- Division of Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Campbell RL, Park MA, Kueber MA, Lee S, Hagan JB. Outcomes of allergy/immunology follow-up after an emergency department evaluation for anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 3:88-93. [PMID: 25577624 DOI: 10.1016/j.jaip.2014.07.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 07/17/2014] [Accepted: 07/21/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Anaphylaxis guidelines currently recommend referring patients with anaphylaxis seen in the emergency department (ED) to an allergist for follow up. OBJECTIVE The objective of our study was to evaluate outcomes of allergy/immunology follow-up after an ED visit for anaphylaxis. METHODS A retrospective health records review was conducted from April 2008 to August 2012. Charts were reviewed independently by 2 allergists to determine outcomes. Descriptive statistics with corresponding 95% CIs were calculated. RESULTS Among 573 patients seen in the ED who met anaphylaxis diagnostic criteria, 217 (38%) had a documented allergy/immunology follow-up. After allergy/immunology evaluation, 16 patients (7% [95% CI, 5%-12%]) had anaphylaxis ruled out. Among those with an unknown ED trigger (n = 74), 24 (32% [95% CI, 23%-44%]) had a trigger identified; and, among those who had a specific suspected ED trigger (n = 143), 9 (6% [95% CI, 3%-12%]) had a trigger identified in a category other than the one suspected in the ED, and 28 (20% [95% CI, 14%-27%]) had an unknown trigger. Thus, there were a total of 77 patients (35% [95% CI, 29%-42%]) who had an alteration in the diagnosis of anaphylaxis or trigger after allergy/immunology evaluation. Four patients (2% [95% CI, 0.7%-4.6%]) were diagnosed with a mast cell activation disorder, and 13 patients (6% [95% CI, 4%-10%]) underwent immunotherapy or desensitization. CONCLUSION Overall, 35% of the patients with suspected anaphylaxis in the ED had an alteration in the diagnosis or suspected trigger after allergy/immunology evaluation. These results underscore the importance of allergy/immunology follow-up after an ED visit for anaphylaxis.
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Affiliation(s)
| | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | | | - Sangil Lee
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minn
| | - John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
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Matito A, Alvarez-Twose I, Morgado JM, Sánchez-Muñoz L, Orfao A, Escribano L. Anaphylaxis as a clinical manifestation of clonal mast cell disorders. Curr Allergy Asthma Rep 2014; 14:450. [PMID: 24947681 DOI: 10.1007/s11882-014-0450-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Clonal mast cell disorders comprise a heterogeneous group of disorders characterized by the presence of gain of function KIT mutations and a constitutively altered activation-associated mast cell immunophenotype frequently associated with clinical manifestations related to the release of mast cells mediators. These disorders do not always fulfil the World Health Organization (WHO)-proposed criteria for mastocytosis, particularly when low-sensitive diagnostic approaches are performed. Anaphylaxis is a frequent presentation of clonal mast cell disorders, particularly in mastocytosis patients without typical skin lesions. The presence of cardiovascular symptoms, e.g., hypotension, occurring after a hymenoptera sting or spontaneously in the absence of cutaneous manifestations such as urticaria is characteristic and differs from the presentation of anaphylaxis in the general population without mastocytosis.
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Affiliation(s)
- A Matito
- Instituto de Estudios de Mastocitosis de Castilla-La Mancha, Hospital Virgen del Valle, Toledo, Spain
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Chirumbolo S. Basophil activation test in wasp venom allergy during mastocytosis. CYTOMETRY PART B-CLINICAL CYTOMETRY 2014; 88:3-4. [DOI: 10.1002/cyto.b.21182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 06/24/2014] [Accepted: 07/30/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Salvatore Chirumbolo
- Department of Medicine; University of Verona; LURM-Est Policlinico GB Rossi, Piazzale AL Scuro 10 37134 Verona Italy
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Epidemiology, Diagnosis, and Treatment of Hymenoptera Venom Allergy in Mastocytosis Patients. Immunol Allergy Clin North Am 2014; 34:365-81. [DOI: 10.1016/j.iac.2014.02.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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42
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Ruëff F, Vos B, Oude Elberink J, Bender A, Chatelain R, Dugas-Breit S, Horny HP, Küchenhoff H, Linhardt A, Mastnik S, Sotlar K, Stretz E, Vollrath R, Przybilla B, Flaig M. Predictors of clinical effectiveness of Hymenoptera venom immunotherapy. Clin Exp Allergy 2014; 44:736-46. [DOI: 10.1111/cea.12275] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/07/2013] [Accepted: 12/17/2013] [Indexed: 12/21/2022]
Affiliation(s)
- F. Ruëff
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
| | - B. Vos
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
- Department of Allergology; University of Groningen; University Medical Center Groningen; RB Groningen the Netherlands
- GRIAC research institute; University of Groningen; University Medical Center Groningen; AV Groningen the Netherlands
| | - J. Oude Elberink
- Department of Allergology; University of Groningen; University Medical Center Groningen; RB Groningen the Netherlands
- GRIAC research institute; University of Groningen; University Medical Center Groningen; AV Groningen the Netherlands
| | - A. Bender
- Statistical Consulting Unit; Department of Statistics; Ludwig-Maximilian University; Munich Germany
| | - R. Chatelain
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
- Fakultät für Gesundheit der Universität Witten/Herdecke; Witten Germany
| | - S. Dugas-Breit
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
| | - H.-P. Horny
- Department of Pathology; Ludwig-Maximilian University; Munich Germany
| | - H. Küchenhoff
- Statistical Consulting Unit; Department of Statistics; Ludwig-Maximilian University; Munich Germany
| | - A. Linhardt
- Department of Psychiatry and Psychotherapy; Ludwig-Maximilian University; Munich Germany
| | - S. Mastnik
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
| | - K. Sotlar
- Department of Pathology; Ludwig-Maximilian University; Munich Germany
| | - E. Stretz
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
| | - R. Vollrath
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
| | - B. Przybilla
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
| | - M. Flaig
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
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Lee SK, Ye YM, Park HS, Jang GC, Jee YK, Park HK, Koh YI, Kim JH, Kim CW, Hur GY, Kim MK, Kim TB, Choi GS, Kim SH, Sohn SW. Hymenoptera venom anaphylaxis in adult Korean: a multicenter retrospective case study. ALLERGY ASTHMA & RESPIRATORY DISEASE 2014. [DOI: 10.4168/aard.2014.2.5.344] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Su-Kyoung Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Young-Min Ye
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hae-Sim Park
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Gwang Cheon Jang
- Department of Pediatrics, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Young-Koo Jee
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Young-Il Koh
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Cheol-Woo Kim
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Gyu-Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Mi Kyoung Kim
- Department of Internal Medicine, Chungbuk National University, Cheongju, Korea
| | - Tae-Bum Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Soon Choi
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Seong-Wook Sohn
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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Gülen T, Dahlén B, Sander B, Hägglund H, Nilsson G. The significance of diagnosing associated clonal mast cell diseases in patients with venom-induced anaphylaxis and the role of bone marrow investigation. Clin Transl Allergy 2013; 3:22. [PMID: 23826821 PMCID: PMC3704971 DOI: 10.1186/2045-7022-3-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 06/16/2013] [Indexed: 11/10/2022] Open
Abstract
Hymenoptera venom allergy (HVA) represents a particular risk for exceptionally severe anaphylactic sting reactions in patients with clonal mast cell disorders (CMD). Nevertheless, conventional investigations are not sufficient to do accurate risk assessments. Increased levels of baseline serum tryptase (sBT) (>11.4 μg/L) is highly associated with severe anaphylactic reactions and with a possible underlying CMD. The measurement of baseline serum tryptase, thus, has opened the possibility to screen for CMD. In the present study, we sought to investigate whether bone marrow evaluation provides more accurate diagnosis in patients with HVA.Three patients of the same sex and similar age with HVA were enrolled in this clinical study. The patients underwent comprehensive allergy work-up including skin prick testing, measurements of serum total IgE concentrations and baseline serum tryptase. Bone-marrow biopsies were also performed in all three patients to assess underlying CMD.We evaluated characteristics of the bone marrow mast cells by pathology, flow cytometry and detection of D816V mutation by using current WHO-criteria, which led to changes in the final diagnosis compared to the assessments done by classical allergy work-up and measurements of sBT. Three distinct diagnostic outcomes including systemic mastocytosis, monoclonal mast cell activation syndrome and non-clonal HVA were revealed.We conclude that a bone marrow investigation is required for the correct diagnosis of hymenoptera venom-induced anaphylactic reactions in patients with elevated baseline tryptase levels (>11.4 μg/L), and this has important implications for management strategies.
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Affiliation(s)
- Theo Gülen
- Department of Respiratory Medicine and Allergy, M53, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden.
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Przybilla B, Ruëff F. Insect stings: clinical features and management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:238-48. [PMID: 22532821 PMCID: PMC3334720 DOI: 10.3238/arztebl.2012.0238] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 02/15/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND In human beings, local and systemic reactions can be caused both by blood-sucking insects and by venomous insect stings. In Central Europe, the insects that most commonly cause such reactions are honeybees, certain social wasps, mosquitoes, and flies. METHODS This article is based on a selective literature review, including guidelines from Germany and abroad. RESULTS Insect venom induces a toxic reaction at the site of the sting. Large local reactions are due to allergy and occur in up to 25% of the population; as many as 3.5% develop IgE-mediated, potentially life-threatening anaphylaxis, of which about 20 people die in Germany each year. Mastocytosis is found in 3% to 5% of patients with sting anaphylaxis, rendering these patients prone to very severe reactions. Blood-sucking by hematophagous insects can elicit a local allergic reaction, presenting as a wheal or papule, in at least 75% of the population. Large local reactions may ensue, but other diseases are rare. The acute symptoms of an insect sting are treated symptomatically. Patients who have had a systemic reaction or a large local reaction due to insect allergy must take permanent measures to avoid further allergen contact, and to make sure they can treat themselves adequately if stung again. Most patients with systemic anaphylactic reactions to bee or wasp stings need specific immunotherapy. CONCLUSION Insect stings can cause severe disease. Anaphylaxis due to bee or wasp stings is not a rare event; specific immunotherapy protects susceptible persons from further, potentially life-threatening reactions.
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Affiliation(s)
- Bernhard Przybilla
- Clinic and Policlinic for Dermatology and Allergology, Ludwig-Maximilians-Universität, Munich.
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Orhan F, Canitez Y, Bakirtas A, Yilmaz O, Boz AB, Can D, Kuyucu S, Harmanci K, Tahan F, Reisli I, Karakas T, Baki A, Cokugras H, Cakir M, Yuksel H. Anaphylaxis in Turkish children: a multi-centre, retrospective, case study. Clin Exp Allergy 2011; 41:1767-76. [DOI: 10.1111/j.1365-2222.2011.03859.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 07/12/2011] [Accepted: 08/03/2011] [Indexed: 01/02/2023]
Affiliation(s)
- F. Orhan
- Department of Pediatric Allergy; Karadeniz Technical University Faculty of Medicine; Trabzon; Turkey
| | - Y. Canitez
- Department of Pediatric Allergy; Uludag University Faculty of Medicine; Bursa; Turkey
| | - A. Bakirtas
- Department of Pediatric Allergy; Gazi University Faculty of Medicine; Ankara; Turkey
| | - O. Yilmaz
- Department of Pediatric Allergy; Celal Bayar University Faculty of Medicine; Manisa; Turkey
| | - A. B. Boz
- Department of Pediatric Allergy; Akdeniz University Faculty of Medicine; Antalya; Turkey
| | - D. Can
- Department of Pediatric Allergy; Dr Behcet Uz Children's Hospital; Izmir; Turkey
| | - S. Kuyucu
- Department of Pediatric Allergy; Mersin University Faculty of Medicine; Mersin; Turkey
| | - K. Harmanci
- Department of Pediatric Allergy; SSK Ankara Diskapi Hospital; Ankara; Turkey
| | - F. Tahan
- Department of Pediatric Allergy; Erciyes University Faculty of Medicine; Kayseri; Turkey
| | - I. Reisli
- Department of Pediatric Allergy and Immunology; Selcuk University Faculty of Medicine; Konya; Turkey
| | - T. Karakas
- Department of Pediatric Allergy; Karadeniz Technical University Faculty of Medicine; Trabzon; Turkey
| | - A. Baki
- Department of Pediatrics; Karadeniz Technical University Faculty of Medicine; Trabzon; Turkey
| | - H. Cokugras
- Department of Pediatric Allergy; Istanbul University Cerrahpasa Faculty of Medicine; Istanbul; Turkey
| | - M. Cakir
- Department of Pediatrics; Karadeniz Technical University Faculty of Medicine; Trabzon; Turkey
| | - H. Yuksel
- Department of Pediatric Allergy; Celal Bayar University Faculty of Medicine; Manisa; Turkey
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González-de-Olano D, Alvarez-Twose I, Vega A, Orfao A, Escribano L. Venom immunotherapy in patients with mastocytosis and hymenoptera venom anaphylaxis. Immunotherapy 2011; 3:637-51. [PMID: 21554093 DOI: 10.2217/imt.11.44] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Systemic mastocytosis (SM) is typically suspected in patients with cutaneous mastocytosis (CM). In recent years, the presence of clonal mast cells (MCs) in a subset of patients with systemic symptoms associated with MC activation in the absence of CM has been reported and termed monoclonal MC activation syndromes or clonal systemic MC activation syndromes. In these cases, bone marrow (BM) MC numbers are usually lower than in SM with CM, there are no detectable BM MC aggregates, and serum baseline tryptase is often <20 µg/l; thus, diagnosis of SM in these patients should be based on careful evaluation of other minor WHO criteria for SM in reference centers, where highly sensitive techniques for immunophenotypic analysis and investigation of KIT mutations on fluorescence-activated cell sorter-purified BM MCs are routinely performed. The prevalence of hymenoptera venom anaphylaxis (HVA) among SM patients is higher than among the normal population and it has been reported to be approximately 5%. In SM patients with IgE-mediated HVA, venom immunotherapy is safe and effective and it should be prescribed lifelong. Severe adverse reactions to hymenoptera stings or venom immunotherapy have been associated with increased serum baseline tryptase; however, presence of clonal MC has not been ruled out in most reports and thus both SM and clonal MC activation syndrome might be underdiagnosed in such patients. In fact, clonal BM MC appears to be a relevant risk factor for both HVA and severe reactions to venom immunotherapy, while the increase in serum baseline tryptase by itself should be considered as a powerful surrogate marker for anaphylaxis. The Spanish Network on Mastocytosis has developed a scoring system based on patient gender, the clinical symptoms observed during anaphylaxis and serum baseline tryptase to predict for the presence of both MC clonality and SM among individuals who suffer from anaphylaxis.
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48
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Belhocine W, Ibrahim Z, Grandné V, Buffat C, Robert P, Gras D, Cleach I, Bongrand P, Carayon P, Vitte J. Total serum tryptase levels are higher in young infants. Pediatr Allergy Immunol 2011; 22:600-7. [PMID: 21736626 DOI: 10.1111/j.1399-3038.2011.01166.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mast cells participate in immune defense and allergic disease. At baseline, serum tryptase levels primarily reflect mast cell burden, while mast cell degranulation leads to granule tryptase release, which may be detectable as a transitory elevation of serum tryptase levels. Thus, mast cell burden and mast cell activity are reflected by serum tryptase levels, but reports are scarce in infants under 1 yr. We aimed at defining levels of total serum tryptase levels in this population. METHODS Total serum tryptase levels (ImmunoCAP; Phadia) were measured in 372 sera from infants younger than 1 yr. Two hundred and forty-two sera came from non-atopic, non-allergic infants in good condition, who had blood drawn for routine follow-up or diagnosis of illnesses that are not known to induce changes in serum tryptase levels. Seventy-two sera were from atopic and/or allergic infants, and 58 sera were from non-atopic, non-allergic infants requiring intensive care. RESULTS Median serum tryptase levels were highest in infant2s under 3 months (6.12 ± 3.47 μg/l) and gradually decreased before reaching levels similar to those described in adults and older children (3.85 ± 1.8 μg/l between 9 and 12 months). Atopic/allergic status was associated with even higher tryptase levels (14.20 ± 10.22 μg/l in infants younger than 3 months). Intensive care patients had lower levels of serum tryptase (4.12 ± 3.38 μg/l in infants younger than 3 months). Longitudinal follow-up was performed in 27 patients and showed tryptase levels decrease over time in individual patients. Infants'sex was not found to interfere with serum tryptase levels. CONCLUSION Total serum tryptase levels are significantly higher in younger infants compared with older ones. In infants of the same age, serum tryptase levels may vary according to the clinical condition and thus suggest mast cell involvement in the physiologic as well as in the allergic immune responses of young infants.
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Affiliation(s)
- Wahib Belhocine
- Assistance Publique-Hôpitaux de Marseille, Laboratoire d'Immunologie, Hôpital de La Conception, Marseille, France
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Mayer DE, Krauskopf A, Hemmer W, Moritz K, Jarisch R, Reiter C. Usefulness of post mortem determination of serum tryptase, histamine and diamine oxidase in the diagnosis of fatal anaphylaxis. Forensic Sci Int 2011; 212:96-101. [PMID: 21664082 DOI: 10.1016/j.forsciint.2011.05.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 05/10/2011] [Accepted: 05/14/2011] [Indexed: 11/30/2022]
Abstract
The diagnosis of fatal anaphylaxis can be difficult for clinical features may not always be evident in necropsy. Therefore post mortem determination of tryptase and other blood parameters can be helpful in verifying the diagnosis. We compared post mortem tryptase, histamine and diamine oxidase (DAO) serum levels of two patients who had died after a Hymenoptera sting and one patient who died of bronchospasm during anaesthesia with data obtained from 55 control subjects who had died from other causes than anaphylaxis. In the three anaphylactic cases, serum tryptase level was 880, 68 and 200 μg/l (normal range in living subjects: <11.4 μg/l), histamine was 37.5, 8.5 and 23.2 ng/ml (normal range: <0.3 ng/ml) and DAO was 1, 30 and 4 U/ml (normal range 10-30 U/ml), respectively. Values in the control group were as follows: tryptase 1-340 μg/l (mean 24.2 ± 58.2), histamine 5.0-22.0 ng/ml (mean 14.7 ± 3.9) and DAO 0-114 U/ml (mean 21.1 ± 27.8). 19/55 (34.5%) of the controls had elevated tryptase levels >11.4 μg/l, with four of them showing values >45 μg/ml. Significantly higher histamine levels were seen in blood samples taken more than 24h post mortem (p<0.05), whereas the timing of blood collection had no effect on tryptase and DAO levels. While moderately elevated tryptase levels are common in post mortem sera, values above 45 μg/l may support the diagnosis of fatal anaphylaxis. Strongly elevated histamine levels might give an additional clue on fatal anaphylaxis, whereas DAO does not seem to be helpful.
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Affiliation(s)
- D E Mayer
- FAZ - Floridsdorf Allergy Center, Vienna, Austria
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50
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Abstract
Subcutaneous venom immunotherapy is the only effective treatment for patients who experience severe hymenoptera sting-induced allergic reactions, and the treatment also improves health-related quality of life. This article examines advances in various areas of this treatment, which include the immunological mechanisms of early and long-term efficacy, indications and contraindications, selection of venom, treatment protocols, duration, risk factors for systemic reactions in untreated and treated patients as well as for relapse following cessation of treatment. Current and future strategies for improving safety and efficacy are also examined. However, although progress in the past few years has been fruitful, much remains to be accomplished.
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Affiliation(s)
- Beatrice M Bilò
- Department of Internal Medicine, Immunology, Allergy & Respiratory Diseases, University Hospital, Ospedali Riuniti di Ancona, Ancona, Italy.
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