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Vlaeminck N, Poorten MLVD, Nygaard Madsen C, Bech Melchiors B, Michel M, Gonzalez C, Schrijvers R, Elst J, Mertens C, Saldien V, Vitte J, Garvey LH, Sabato V, Ebo DG. Paediatric perioperative hypersensitivity: the performance of the current consensus formula and the effect of uneventful anaesthesia on serum tryptase. BJA OPEN 2024; 9:100254. [PMID: 38261931 PMCID: PMC10797541 DOI: 10.1016/j.bjao.2023.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/16/2023] [Indexed: 01/25/2024]
Abstract
Background Paired sampling of acute (aST) and basal (bST) serum tryptase has been recommended when investigating patients with a suspected perioperative hypersensitivity (POH) reaction. In the current consensus formula, an aST value exceeding (1.2×bST+2) confirms mast cell activation. The current consensus formula has been validated in adults but not in children. Methods We prospectively included 96 children who underwent uneventful anaesthesia and sampled serum tryptase at baseline and 60-90 min after induction. Tryptase changes were then compared with those in 94 children with suspected POH who were retrospectively included from four reference centres in Belgium, France, and Denmark. Results We observed a median decrease in serum tryptase during uneventful anaesthesia of 0.41 μg L-1 (-15.9%; P<0.001). The current consensus formula identified mast cell activation in 31.9% of paediatric POH patients. After generating receiver operating characteristic curves through 100 repeated five-fold cross-validation, aST>bST+0.71 was identified as the optimal cut-off point to identify mast cell activation. This new paediatric formula has higher sensitivity than the current consensus formula (53.2% vs 31.9%, P<0.001) with a specificity of 96.9%. Analysis in the subpopulation where a culprit was identified and in grade 3-4 reactions similarly yielded higher sensitivity for the new paediatric formula when compared with the current consensus formula (85.3% vs 61.8%; P=0.008 and 78.0% vs 48.8%; P<0.001, respectively). Internally cross-validated sensitivity and specificity were 53.3% and 93.3%, respectively. Conclusions This is the first study suggesting the need for an adjusted formula in children to identify perioperative mast cell activation as tryptase is significantly lowered during uneventful anaesthesia. We propose a new formula (aST>bST+0.71) which performs significantly better than the current consensus formula in our multicentric paediatric population.
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Affiliation(s)
- Nils Vlaeminck
- Department of Anaesthesiology, Antwerp University Hospital, Belgium
| | - Marie-Line van der Poorten
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
- Department of Paediatrics, Faculty of Medicine and Health Science, University of Antwerp, Antwerp University Hospital, Belgium
| | - Cecilie Nygaard Madsen
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Birgitte Bech Melchiors
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Moïse Michel
- Aix-Marseille Université, MEPHI, Marseille, France
- IHU Méditerranée Infection, Marseille, France
- CHU Nîmes, Laboratoire d’Immunologie, Nîmes, France
| | - Constance Gonzalez
- Aix-Marseille Univ, University Hospitals of Marseille, Laboratoire d’Immunologie, Marseille, France
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Faculty of Medicine, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Jessy Elst
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Christel Mertens
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Vera Saldien
- Department of Anaesthesiology, Antwerp University Hospital, Belgium
| | - Joana Vitte
- University of Reims Champagne-Ardenne, INSERM UMR-S 1205 P3CELL and Immunology Laboratory, University Hospital of Reims, Reims, France
| | - Lene H. Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Vito Sabato
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Didier G. Ebo
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium
- Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
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2
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Beyens M, Toscano A, Ebo D, Gülen T, Sabato V. Diagnostic Significance of Tryptase for Suspected Mast Cell Disorders. Diagnostics (Basel) 2023; 13:3662. [PMID: 38132246 PMCID: PMC10742504 DOI: 10.3390/diagnostics13243662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
Tryptase has proven to be a very useful and specific marker to demonstrate mast cell activation and degranulation when an acute (i.e., within 4 h after the event) and baseline value (i.e., at least 24 h after the event) are compared and meet the consensus formula (i.e., an increase of 20% + 2). The upper limit of normal determined by the manufacturer is 11.4 ng/mL; however, this boundary has been the subject of debate. According to ECNM and AIM experts, the normal range of baseline tryptase should be 1 to 15 ng/mL. A genetic trait, hereditary alpha tryptasemia, characterized by an increased alpha coding TPSAB1 copy number is associated with a baseline value above 8 ng/mL. Elevated tryptase can also be found in chronic kidney disease, obesity, and hematological neoplasms. A tryptase > 20 ng/mL serves as a minor criterion to diagnose systemic mastocytosis and an increase in tryptase > 20% + 2 during an acute event is a required criterion in the diagnosis of mast cell activation syndrome. The goal of this review is to demonstrate the (in)significance of tryptase using some clinical vignettes and to provide a practical guide on how to manage and interpret an elevated tryptase level.
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Affiliation(s)
- Michiel Beyens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
| | - Alessandro Toscano
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
| | - Didier Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Gent, 9000 Ghent, Belgium
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy, K85, Karolinska University Hospital Huddinge, SE-14186 Stockholm, Sweden;
- Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, SE-17177 Stockholm, Sweden
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology and Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, 2610 Antwerp, Belgium (A.T.); (V.S.)
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, 2610 Antwerp, Belgium
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Bonadonna P, Korosec P, Nalin F, Golden DBK. Venom Anaphylaxis: Decision Points for a More Aggressive Workup. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2024-2031. [PMID: 37119981 DOI: 10.1016/j.jaip.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 05/01/2023]
Abstract
Diagnostic testing of patients who present for evaluation of insect venom allergy can involve many levels of investigation. A detailed initial history is critical for diagnosis and prognosis. The severity of previous sting reactions and the presence or absence of urticaria or hypotension predict severe future sting reactions and underlying mast cell disorders. Venom skin tests and specific IgE measurement can confirm the diagnosis but have limited positive predictive value for the frequency and severity of future sting reactions. Testing for serum IgE to recombinant venom component allergens can distinguish true allergy from cross-reactivity to honey bee and yellowjacket venoms. Basophil activation tests can improve the detection of venom allergy and predict the severity of reactions and the efficacy of venom immunotherapy but are limited in availability. An elevated basal serum tryptase level is an important marker for severe sting anaphylaxis and underlying mast cell disorders (eg, hereditary α-tryptasemia and clonal mast cell disease). When there is high suspicion (eg, using the Red Espanola de Mastocytosis score), bone marrow biopsy is the definitive tool to characterize mast cell disorders that are associated with the most severe outcomes in patients with insect sting allergy.
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Affiliation(s)
| | - Peter Korosec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia; Medical Faculty, University of Maribor, Maribor, Slovenia
| | | | - David B K Golden
- Dvision of Allergy and Clinical Immunology, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Md.
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Floyd ML, Adams KE, Golden DBK. Updates and Recent Advances on Venom Immunotherapy. CURRENT TREATMENT OPTIONS IN ALLERGY 2023; 10:1-19. [PMID: 37361640 PMCID: PMC10148014 DOI: 10.1007/s40521-023-00336-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review Venom immunotherapy has been utilized to treat Hymenoptera venom allergy since the 1920s. Over the last century, significant advances in the fields of immunology and genetics have led to improvements in the practice of venom immunotherapy. This review encompasses recent advances in the use of venom immunotherapy to provide precise, patient-centered care. Recent Findings Research about the mechanism of action of venom immunotherapy continues to highlight the modification of both the innate and adaptive immune systems. Molecular techniques have allowed for the identification of specific venom allergens to improve the diagnostic accuracy and safety of venom immunotherapy. Research continues to support the safety of accelerated schedules which can impact the cost, adherence, and quality of life for patients receiving this treatment modality. Finally, significant advances have led to the elucidation of risk factors that place patients at risk for reactions during and after venom immunotherapy. Creation of risk profiles for venom-allergic patients can thus inform the process of immunotherapy in order to provide personalized and precise care. Summary Significant progress in the use of venom immunotherapy makes the practice a dynamic and active field for continued research. Future research needs to build on these recent advances to continue to optimize and enhance this life-saving treatment.
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Affiliation(s)
- Michelle L. Floyd
- 42d Medical Group, Maxwell AFB, 300 South Twining Street, Building 760, Montgomery, AL 36112 USA
| | - Karla E. Adams
- Department of Medicine, Allergy and Immunology Division, Wilford Hall Ambulatory Surgical Center, Lackland AFB, 1100 Wilford Hall Loop, Bldg 4554, San Antonio, TX 78236 USA
| | - David B. K. Golden
- Johns Hopkins University, 25 Crossroads Drive #410, Owings Mills, MD 21117 USA
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Nuñez-Borque E, Betancor D, Pastor-Vargas C, Fernández-Bravo S, Martin-Blazquez A, Casado-Navarro N, López-Domínguez D, Gómez-López A, Rodriguez Del Rio P, Tramón P, Beitia JM, Moreno-Aguilar C, González-de-Olano D, Goikoetxea MJ, Ibáñez-Sandín MD, Laguna JJ, Cuesta-Herranz J, Esteban V. Personalized diagnostic approach and indirect quantification of extravasation in human anaphylaxis. Allergy 2023; 78:202-213. [PMID: 35841381 PMCID: PMC10087983 DOI: 10.1111/all.15443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Anaphylaxis is the most acute and life-threatening manifestation of allergic disorders. Currently, there is a need to improve its medical management and increase the understanding of its molecular mechanisms. This study aimed to quantify the extravasation underlying human anaphylactic reactions and propose new theragnostic approaches. METHODS Molecular determinations were performed in paired serum samples obtained during the acute phase and at baseline from patients presenting with hypersensitivity reactions. These were classified according to their severity as Grades 1, 2 and 3, the two latter being considered anaphylaxis. Tryptase levels were measured by ImmunoCAP, and serum protein concentration was quantified by Bradford assay. Human serum albumin (HSA) and haemoglobin beta subunit (HBB) levels were determined by Western blot and polyacrylamide gel electrophoresis, respectively. RESULTS A total of 150 patients were included in the study. Of them, 112 had experienced anaphylaxis (83 and 29 with Grade 2 and 3 reactions, respectively). Tryptase diagnostic efficiency substantially improved when considering patients' baseline values (33%-54%) instead of the acute value threshold (21%). Serum protein concentration and HSA significantly decreased in anaphylaxis (p < .0001). HSA levels dropped with the severity of the reaction (6% and 15% for Grade 2 and 3 reactions, respectively). Furthermore, HBB levels increased during the acute phase of all hypersensitivity reactions (p < .0001). CONCLUSIONS For the first time, the extravasation underlying human anaphylaxis has been evaluated based on the severity of the reaction using HSA and protein concentration measurements. Additionally, our findings propose new diagnostic and potential therapeutic approaches for this pathological event.
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Affiliation(s)
- Emilio Nuñez-Borque
- Department of Allergy and Immunology, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
| | - Diana Betancor
- Department of Allergy and Immunology, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain.,Department of Allergy, Fundación Jiménez Díaz University Hospital, UAM, Madrid, Spain
| | | | | | | | - Natalia Casado-Navarro
- Department of Clinical Analysis, Fundación Jiménez Díaz University Hospital, UAM, Madrid, Spain
| | - David López-Domínguez
- Clinical Biostatistics Unit, IDIPHIM, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Alicia Gómez-López
- Department of Allergy, Fundación Jiménez Díaz University Hospital, UAM, Madrid, Spain
| | - Pablo Rodriguez Del Rio
- Allergy Department, Hospital Infantil Universitario Niño Jesús, Fundación HNJ, IIS-P, Madrid, Spain
| | - Paloma Tramón
- Department of Clinical Analysis, Fundación Jiménez Díaz University Hospital, UAM, Madrid, Spain
| | | | | | | | | | | | - José Julio Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Hospital Central de la Cruz Roja, Madrid, Spain.,Faculty of Medicine and Biomedicine, Alfonso X El Sabio University, Madrid, Spain
| | - Javier Cuesta-Herranz
- Department of Allergy, Fundación Jiménez Díaz University Hospital, UAM, Madrid, Spain
| | - Vanesa Esteban
- Department of Allergy and Immunology, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain.,Faculty of Medicine and Biomedicine, Alfonso X El Sabio University, Madrid, Spain
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Firrera L, Bottinelli C, Cartiser N, Nahamani I, Chatenay C, Allorge D, Fanton L, Hoizey G, Gaulier JM. Diagnostic biologique post-mortem d’anaphylaxie. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2022. [DOI: 10.1016/j.toxac.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Slot MC, Claessen LHJ, Bons JAP, Menheere PPCA, Nieuwhof CMG, de Boer D. Tryptase reference ranges are age-dependent in a large population-based cohort. Allergy 2022; 77:2833-2834. [PMID: 35567344 PMCID: PMC9544703 DOI: 10.1111/all.15369] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 04/19/2022] [Accepted: 05/03/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Marjan C. Slot
- Department of Allergology and Clinical ImmunologyMaastricht UMC+MaastrichtThe Netherlands
| | | | - Judith A. P. Bons
- Central Diagnostic LaboratoryMaastricht UMC+MaastrichtThe Netherlands
| | | | - Chris M. G. Nieuwhof
- Department of Allergology and Clinical ImmunologyMaastricht UMC+MaastrichtThe Netherlands
| | - Douwe de Boer
- Central Diagnostic LaboratoryMaastricht UMC+MaastrichtThe Netherlands
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8
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Da Broi U, Moreschi C, Marega G, Tse R, Garland J, Ondruschka B, Palmiere C. Medicolegal Implications of Biphasic Anaphylaxis. Am J Forensic Med Pathol 2021; 42:109-117. [PMID: 33031125 DOI: 10.1097/paf.0000000000000621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
ABSTRACT Biphasic anaphylaxis is an uncommon IgE-mediated condition whose pathophysiological mechanisms, risk factors, and predictive signs are not properly understood. Fortunately, the lethality of biphasic anaphylaxis, although probably underestimated, is low. Preventive clinical measures for biphasic anaphylaxis are neither standardized nor commonly applied. Furthermore, there are no laboratory protocols or anaphylactic markers to help identify the onset of biphasic anaphylaxis in clinical settings. The aim of this review is to highlight the medicolegal difficulties facing coroners and forensic pathologists in terms of the diagnosis and assessment of harm for victims and survivors of biphasic anaphylaxis.
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Affiliation(s)
- Ugo Da Broi
- From the Department of Medicine, Forensic Medicine, University of Udine, Udine, Italy
| | - Carlo Moreschi
- From the Department of Medicine, Forensic Medicine, University of Udine, Udine, Italy
| | - Giulia Marega
- From the Department of Medicine, Forensic Medicine, University of Udine, Udine, Italy
| | | | - Jack Garland
- Forensic and Analytical Science Service, NSW Health Pathology, New South Wales, Australia
| | - Benjamin Ondruschka
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cristian Palmiere
- CURML, University Center of Legal Medicine, Lausanne University Hospital, Lausanne, Switzerland
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9
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Ebo DG, De Puysseleyr LP, Van Gasse AL, Elst J, Poorten MLVD, Faber MA, Mertens C, Van Houdt M, Hagendorens MM, Sermeus L, Vitte J, Moise M, Garvey LH, Castells MC, Tacquard C, Mertes PM, Schwartz LB, Sabato V. Mast Cell Activation During Suspected Perioperative Hypersensitivity: A Need for Paired Samples Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3051-3059.e1. [PMID: 33862269 DOI: 10.1016/j.jaip.2021.03.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/12/2021] [Accepted: 03/27/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perioperative hypersensitivity (POH) reactions constitute a significant clinical and diagnostic challenge. A transient increase in serum tryptase during POH reflects mast cell activation (MCA) and helps to recognize an underlying hypersensitivity mechanism. OBJECTIVE To determine the diagnostic performance of different tryptase decision thresholds based on single and paired measurements to document MCA in suspected POH. METHODS Acute serum tryptase (aST) and baseline serum tryptase (bST) samples were obtained from patients referred to our outpatients clinic because of clinical POH. Tryptase samples from controls were obtained before induction (Tt0) and 1.5 hours after induction (Tt1) in uneventful anesthesia. Different cutoff points for tryptase increase over bST and the percentage increase in tryptase (%T) were calculated and compared with existing thresholds: aST > [1.2 × (bST) + 2] (consensus formula), aST higher than 11.4 ng/mL, and aST higher than 14 ng/mL. RESULTS Patients with POH had higher bST and aST levels compared with controls (respectively 5.15 vs 2.28 ng/mL for bST and 20.30 vs 1.92 ng/mL for aST). The consensus formula and a tryptase increase over bST of greater than or equal to 3.2 ng/mL held the highest accuracies to document MCA in POH (respectively 81% and 82%). A bST of higher than 8 ng/mL was present in 4% of controls, 5% of patients with grade 1 POH, 24% of patients with grade 2 POH, 15% of patients with grade 3 POH, and 17% of patients with grade 4 POH. CONCLUSIONS Our data endorse the consensus formula for detection of MCA in POH. Furthermore, it shows that a bST of higher than 8 ng/mL was associated with occurrence of anaphylaxis.
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Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium.
| | - Leander P De Puysseleyr
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Athina L Van Gasse
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Marie-Line van der Poorten
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Margaretha A Faber
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Christel Mertens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Michel Van Houdt
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Margo M Hagendorens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Luc Sermeus
- Department of Anaesthesia, Antwerp University Hospital, Antwerp, Belgium
| | - Joana Vitte
- Aix-Marseille University, IRD, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France; IDESP, INSERM, University of Montpellier, Montpellier, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Michel Moise
- Aix-Marseille University, IRD, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, Ha, Denmark
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Charles Tacquard
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, Strasbourg, France
| | - Paul-Michel Mertes
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, Strasbourg, France
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy & Immunologie, Virginia Commonwealth University, Richmond, Va
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
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Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: General Concepts. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:S3-S15. [PMID: 32791249 DOI: 10.1016/j.jaip.2020.08.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 01/19/2023]
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Post mortem tryptase: A review of literature on its use, sampling and interpretation in the investigation of fatal anaphylaxis. Forensic Sci Int 2020; 314:110415. [PMID: 32717658 DOI: 10.1016/j.forsciint.2020.110415] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 06/20/2020] [Accepted: 07/13/2020] [Indexed: 12/18/2022]
Abstract
Post mortem tryptase is a commonly-used ancillary test in the investigation of possible anaphylactic deaths. Ante mortem tryptase interpretation differs from post mortem interpretation due to differing priorities, biochemical behaviours and capacity for follow-up. Additionally, post mortem tryptase sampling site, method and even cut-off levels are not standardised between facilities. This review of the literature investigates the existing research and recommendations on the use of post mortem tryptase in suspected anaphylactic deaths. Currently, autopsy recommendations suggest early sampling, standardised sampling technique with clamping of and aspiration from the femoral vein, and for the results to be interpreted within the wider autopsy and clinical context. Areas in need of further research include the effects of cytolysis on tryptase levels and studies to stratify differing tryptase levels based on type of death and anaphylactic trigger.
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12
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Pansare M, Seth D, Kamat A, Kamat D. Summer Buzz: All You Need to Know about Insect Sting Allergies. Pediatr Rev 2020; 41:348-356. [PMID: 32611799 DOI: 10.1542/pir.2018-0358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Insect stings can generate a range of immune and clinical reactions. Most reactions are local and self-limiting. Allergic reactions to insect stings can occur at all ages, with or without previous stings. Individuals with a history of anaphylaxis carry a significant risk of life-threatening anaphylaxis with future stings. Health-care providers are often unaware of the tremendous clinical benefits of venom immunotherapy for these select patients. Scientific knowledge about the natural history, risk factors, and optimal therapy for insect sting allergies has improved considerably in recent years.
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Affiliation(s)
| | - Divya Seth
- Children's Hospital of Michigan, Detroit, MI
| | - Aarti Kamat
- Helen Devos Children's Hospital, Grand Rapids, MI
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13
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Passia E, Jandus P. Using Baseline and Peak Serum Tryptase Levels to Diagnose Anaphylaxis: a Review. Clin Rev Allergy Immunol 2020; 58:366-376. [PMID: 32034676 DOI: 10.1007/s12016-020-08777-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The diagnosis of anaphylaxis relies on a suggestive clinical history after exposure to a potential triggering factor. Serum tryptase concentrations increase on degranulation of mast cells and therefore serum tryptase levels are measured to diagnose anaphylaxis. There is no standardized method for assessing total serum mast cell tryptase (MCT) in anaphylaxis. The Working Conference in 2010 proposed a consensus equation (peak MCT should be > 1.2x baseline tryptase + 2 ng/L) to diagnose acute mast cell activation (aMCA). Our objective was to narratively review the literature since the Working Conference in 2010, examining the use of the consensus equation and other equations comparing baseline and peak serum tryptase during anaphylaxis. Computerized bibliographic searches of PUBMED and EMBASE were supplemented with a manual search of reference lists. English-language studies were included. Eleven studies met our inclusion criteria with a total of 4551 participants. However, only four studies with 653 participants used the consensus equation. The other seven studies used other methods to compare peak and baseline serum tryptase concentrations. Measuring serum tryptase levels is valuable in the diagnosis of anaphylaxis but is unable to detect all anaphylactic reactions. Based on our current literature review, the consensus equation is underused in the diagnosis of anaphylaxis. There is also a need for exploration of other biomarkers which could be used in parallel to peak and baseline serum tryptase measurements for further diagnostic certainty. Serum tryptase is the most studied biomarker in anaphylaxis but is still far from being the ideal biomarker for this. There is a need to identify new potential useful biomarkers. Serum tryptase levels are valuable in the diagnosis of anaphylaxis, but are unable to detect all anaphylactic reactions. Additionally serial tryptase measurements are laborious in daily clinical practice.
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Affiliation(s)
| | - Peter Jandus
- Department of Medicine, Division of Immunology and Allergy, University Hospital and Medical Faculty, Geneva, Switzerland.
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Diagnostic Challenges in Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1177-1184. [DOI: 10.1016/j.jaip.2019.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 12/18/2022]
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15
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Ariza A, Torres MJ, Moreno-Aguilar C, Fernández-Santamaría R, Fernández TD. Early Biomarkers for Severe Drug Hypersensitivity Reactions. Curr Pharm Des 2019; 25:3829-3839. [DOI: 10.2174/1381612825666191107105440] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/06/2019] [Indexed: 02/08/2023]
Abstract
Drug hypersensitivity reactions (DHRs) are typically classified into immediate and delayed reactions
based on the time interval between drug exposure and onset of symptoms. Clinical manifestations range from
mild to severe and life-threatening reactions. The most severe clinical entities are anaphylaxis and anaphylactic
shock for immediate reactions, and severe cutaneous adverse reactions such as Steven Johnson Syndrome and
Toxic Epidermal Necrolysis for delayed reactions. The diagnosis is complex and challenging, as drug provocation
tests and even skin tests can be very risky procedures, which makes them not recommended. Therefore, it is necessary
to search for useful early biomarkers to manage the diagnosis of these reactions. These biomarkers could
be useful to determine the clinical entity, but not to identify the culprit drug. Some of the currently available
biomarkers are few genetic associations of drug allergy with polymorphisms of human leukocyte antigen (HLA),
the detection of inflammatory and lipid mediators in serum, or the detection of cytokines, chemokines, and cytotoxic
markers in skin biopsies. In this literature review, it has been summarize the immunological mechanisms
involved in severe reactions, both immediate and delayed, and different early biomarkers: those currently used for
the diagnosis of these reactions as well as possible early biomarkers that could be useful with further studies to
standardize their clinical use.
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Affiliation(s)
- Adriana Ariza
- Allergy Research Group, Instituto de Investigacion Biomedica de Malaga-IBIMA, Malaga, Spain
| | - Maria J. Torres
- Allergy Research Group, Instituto de Investigacion Biomedica de Malaga-IBIMA, Malaga, Spain
| | - Carmen Moreno-Aguilar
- Immunology and Allergy Unit, IMIBICHospital Universitario Reina Sofía, Córdoba, Spain
| | | | - Tahia D. Fernández
- Allergy Research Group, Instituto de Investigacion Biomedica de Malaga-IBIMA, Malaga, Spain
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16
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Garvey LH, Ebo DG, Mertes P, Dewachter P, Garcez T, Kopac P, Laguna JJ, Chiriac AM, Terreehorst I, Voltolini S, Scherer K. An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions. Allergy 2019; 74:1872-1884. [PMID: 30964555 DOI: 10.1111/all.13820] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022]
Abstract
Perioperative immediate hypersensitivity reactions are rare. Subsequent allergy investigation is complicated by multiple simultaneous drug exposures, the use of drugs with potent effects and the many differential diagnoses to hypersensitivity in the perioperative setting. The approach to the investigation of these complex reactions is not standardized, and it is becoming increasingly apparent that collaboration between experts in the field of allergy/immunology/dermatology and anaesthesiology is needed to provide the best possible care for these patients. The EAACI task force behind this position paper has therefore combined the expertise of allergists, immunologists and anaesthesiologists. The aims of this position paper were to provide recommendations for the investigation of immediate-type perioperative hypersensitivity reactions and to provide practical information that can assist clinicians in planning and carrying out investigations.
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Affiliation(s)
- Lene Heise Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy Copenhagen University Hospital Gentofte Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Didier G. Ebo
- Faculty of Medicine and Health Science, Department of Immunology – Allergology – Rheumatology Antwerp University Hospital, University of Antwerp Antwerp Belgium
| | - Paul‐Michel Mertes
- Department of Anesthesia and Intensive Care Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, EA 3072, FMTS de Strasbourg Strasbourg France
| | - Pascale Dewachter
- Service d’Anesthésie‐Réanimation, Groupe Hospitalier de Paris‐Seine‐Saint‐Denis Assistance Publique‐Hôpitaux de Paris & Université Paris 13, Sorbonne Paris Cité Paris France
| | - Tomaz Garcez
- Immunology Department Manchester University NHS Foundation Trust Manchester UK
| | - Peter Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik Slovenia
| | - José Julio Laguna
- Allergy Unit, Allergo‐Anaesthesia Unit, Faculty of Medicine Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL Madrid Spain
| | - Anca Mirela Chiriac
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- Sorbonnes Universités, UPMC Paris 06, UMR‐S 1136, IPLESP, Equipe EPAR Paris France
| | - Ingrid Terreehorst
- Department of ENT and DPAC AUMCAmsterdam University Medical Center Amsterdam The Netherlands
| | | | - Kathrin Scherer
- Allergy Unit, Department of Dermatology, University Hospital University of Basel Basel Switzerland
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17
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Carter MC, Akin C, Castells MC, Scott EP, Lieberman P. Idiopathic anaphylaxis yardstick: Practical recommendations for clinical practice. Ann Allergy Asthma Immunol 2019; 124:16-27. [PMID: 31513910 DOI: 10.1016/j.anai.2019.08.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/20/2019] [Accepted: 08/27/2019] [Indexed: 12/18/2022]
Abstract
Anaphylaxis is considered idiopathic when there is no known trigger. The signs and symptoms of idiopathic anaphylaxis (IA) are identical to those of anaphylaxis because of a known cause and can include cutaneous, circulatory, respiratory, gastrointestinal, and neurologic symptoms. Idiopathic anaphylaxis can be a frustrating disease for patients and health care providers. Episodes are unpredictable, and differential diagnosis is challenging. Current anaphylaxis guidelines have little specific guidance regarding differential diagnosis and long-term management of IA. Therefore, the objective of the Idiopathic Anaphylaxis Yardstick is to use published data and the authors' combined clinical experience to provide practical recommendations for the diagnosis and management of patients with IA.
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Affiliation(s)
| | - Cem Akin
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mariana C Castells
- Department of Medicine, Division of Rheumatology, Immunology, and Allergy, Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Phil Lieberman
- Departments of Medicine and Pediatrics, Divisions of Allergy and Immunology, University of Tennessee, Memphis, Tennessee.
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18
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Gastaminza G, Lafuente A, Goikoetxea MJ, D'Amelio CM, Bernad-Alonso A, Vega O, Martinez-Molina JA, Ferrer M, Nuñez-Cordoba JM. Improvement of the Elevated Tryptase Criterion to Discriminate IgE- From Non-IgE-Mediated Allergic Reactions. Anesth Analg 2019; 127:414-419. [PMID: 29189281 DOI: 10.1213/ane.0000000000002656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Differentiating between immunoglobulin E (IgE)-dependent and IgE-independent hypersensitivity reactions may improve the etiologic orientation and clinical management of patients with allergic reactions in the anesthesia setting. Serum tryptase levels may be useful to discriminate the immune mechanism of allergic reactions, but the diagnostic accuracy and optimal cutpoint remain unclear.We aimed to compare the diagnostic accuracy of tryptase during reaction (TDR) alone and the TDR/basal tryptase (TDR/BT) ratio for discriminating IgE- from non-IgE-mediated allergic reactions, and to estimate the best cut point for these indicators. METHODS We included 111 patients (45% men; aged 3-99 years) who had experienced an allergic reaction, even though the allergic reaction could be nonanaphylactic. Allergy tests were performed to classify the reaction as an IgE- or non-IgE-mediated one. The area under the curve (AUC) of the receiver operating characteristic analysis was performed to estimate the discriminative ability of TDR and TDR/BT ratio. RESULTS An IgE-mediated reaction was diagnosed in 49.5% of patients, and 56% of patients met anaphylaxis criteria. The median (quartiles) TDR for the IgE-mediated reactions was 8.0 (4.9-19.6) and 5.1 (3.5-8.1) for the non-IgE-mediated (P = .022). The median (quartiles) TDR/BT ratio was 2.7 (1.7-4.5) in IgE-mediated and 1.1 (1.0-1.6) in non-IgE-mediated reactions (P < .001). The TDR/BT ratio showed the greatest ability to discriminate IgE- from non-IgE-mediated reactions compared to TDR (AUC TDR/BT = 0.79 [95% confidence interval (CI), 0.70-0.88] and AUC TDR = 0.66 [95% CI, 0.56-0.76]; P = .001). The optimal cut point for TDR/BT (maximization of the sum of the sensitivity and specificity) was 1.66 (95% CI, 1.1-2.2). CONCLUSIONS The TDR/BT ratio showed a significantly better discriminative ability than TDR to discriminate IgE- from non-IgE-mediated allergic reactions. An optimal TDR/BT ratio threshold of approximately 1.66 may be useful in clinical practice to classify allergic reactions as IgE- or non-IgE-mediated.
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Affiliation(s)
| | | | | | | | | | - Olga Vega
- From the Departments of Allergology and Clinical Immunology
| | | | - Marta Ferrer
- From the Departments of Allergology and Clinical Immunology
| | - Jorge M Nuñez-Cordoba
- Research Support Service, Central Clinical Trials Unit, Clínica Universidad de Navarra, Pamplona, Spain
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19
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Vitte J, Amadei L, Gouitaa M, Mezouar S, Zieleskiewicz L, Albanese J, Bruder N, Lagier D, Mertès PM, Mège J, Schwartz LB, Leone M. Paired acute-baseline serum tryptase levels in perioperative anaphylaxis: An observational study. Allergy 2019; 74:1157-1165. [PMID: 30793322 DOI: 10.1111/all.13752] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 11/30/2018] [Accepted: 12/21/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anaphylaxis is recognized mainly through clinical criteria, which may lack specificity or relevance in the perioperative setting. The transient increase in serum tryptase has been proposed since 1989 as a diagnostic tool. Sampling for well-defined acute and baseline determinations has been recommended. We assessed the performance of four proposed algorithms with tightly controlled time frames for tryptase sampling, their robustness with inadequate sampling times, and the possible use of mature tryptase determination. METHODS A retrospective study was performed on 102 adult patients from the Aix-Marseille University Hospitals who had experienced a perioperative hypersensitivity reaction clinically suggesting anaphylaxis. EAACI and ICON criteria were used to diagnose anaphylaxis. Mature and total serum tryptase levels were measured. RESULTS Based on EAACI guidelines, clinical diagnostic criteria for anaphylaxis were found in 76 patients and lacking in 26. The most effective algorithm was the international consensus recommendation of 2012 that acute total tryptase levels should be greater than ([1.2×baseline tryptase] + 2] μg/L to be considered a clinically significant rise. In our cohort, this algorithm achieved 94% positive predictive value (PPV), 53% negative predictive value (NPV), 75% sensitivity, 86% specificity, and a Youden's index value of 0.61. A detectable acute mature tryptase level showed lower sensitivity, particularly in patients with acute total tryptase levels lower than 16 μg/L. Acute tryptase levels varied as a function of the clinical severity of anaphylaxis. CONCLUSION Total tryptase levels in serum discriminated between nonanaphylactic and anaphylactic events in a perioperative setting when acute and baseline levels were collected and analyzed by the consensus algorithm.
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Affiliation(s)
- Joana Vitte
- Aix‐Marseille Univ, IRD, APHM, MEPHI, IHU Méditerranée Infection Marseille France
| | | | - Marion Gouitaa
- Aix‐Marseille Univ, APHM, Hôpital Nord Service de Pneumologie Marseille France
| | - Soraya Mezouar
- Aix‐Marseille Univ, IRD, APHM, MEPHI, IHU Méditerranée Infection Marseille France
| | | | - Jacques Albanese
- Aix‐Marseille Univ, APHM, Hôpital de la Conception Service d'Anesthésie et de Réanimation Marseille France
| | - Nicolas Bruder
- Aix‐Marseille Univ, APHM, Hôpital de la Timone Service d'Anesthésie et de Réanimation Marseille France
| | - David Lagier
- Aix‐Marseille Univ, APHM, Hôpital de la Timone Service d'Anesthésie et de Réanimation Marseille France
| | - Paul M. Mertès
- Strasbourg Univ, HUS, Nouvel Hôpital Civil, FMTS Service d'Anesthésie Réanimation Strasbourg France
| | - Jean‐Louis Mège
- Aix‐Marseille Univ, IRD, APHM, MEPHI, IHU Méditerranée Infection Marseille France
| | - Lawrence B. Schwartz
- Division of Rheumatology, Allergy and Immunology Virginia Commonwealth University Richmond Virginia, VA USA
| | - Marc Leone
- Aix‐Marseille Univ, IRD, APHM, MEPHI, IHU Méditerranée Infection Marseille France
- Aix‐Marseille Univ, APHM, Hôpital Nord Marseille France
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20
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Boehm T, Reiter B, Ristl R, Petroczi K, Sperr W, Stimpfl T, Valent P, Jilma B. Massive release of the histamine-degrading enzyme diamine oxidase during severe anaphylaxis in mastocytosis patients. Allergy 2019; 74:583-593. [PMID: 30418682 PMCID: PMC6590243 DOI: 10.1111/all.13663] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/12/2018] [Accepted: 10/18/2018] [Indexed: 12/19/2022]
Abstract
Background Histaminolytic activity mediated by diamine oxidase (DAO) is present in plasma after induction of severe anaphylaxis in rats, guinea pigs, and rabbits. Heparin released during mast cell degranulation in the gastrointestinal tract might liberate DAO from heparin‐sensitive storage sites. DAO release during anaphylaxis has not been demonstrated in humans. Methods Plasma DAO, tryptase, and histamine concentrations of four severe anaphylaxis events were determined at multiple serial time points in two patients with systemic mastocytosis. The histamine degradation rates were measured in anaphylaxis samples and in pregnancy sera and plasma with comparable DAO concentrations. Results Mean DAO (132 ng/mL) and tryptase (304 ng/mL) concentrations increased 187‐ and 4.0‐fold, respectively, over baseline values (DAO 0.7 ng/mL, tryptase 76 ng/mL) during severe anaphylaxis. Under non‐anaphylaxis conditions, DAO concentrations were not elevated in 29 mastocytosis patients compared to healthy volunteers and there was no correlation between DAO and tryptase levels in mastocytosis patients. The histamine degradation rate of DAO in plasma from mastocytosis patients during anaphylaxis is severely compromised compared to DAO from pregnancy samples. Conclusion During severe anaphylaxis in mastocytosis patients, DAO is likely released from heparin‐sensitive gastrointestinal storage sites. The measured concentrations can degrade histamine, but DAO activity is compromised compared to pregnancy samples. For accurate histamine measurements during anaphylaxis, DAO inhibition is essential to inhibit further histamine degradation after blood withdrawal. Determination of DAO antigen levels might be of clinical value to improve the diagnosis of mast cell activation.
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Affiliation(s)
- Thomas Boehm
- Department of Clinical Pharmacology; Medical University of Vienna; Vienna Austria
| | - Birgit Reiter
- Analytical Toxicology; Clinical Institute of Laboratory Medicine; Medical University of Vienna; Vienna Austria
| | - Robin Ristl
- Section for Medical Statistics (IMS); Center of Medical Statistics; Informatics and Intelligent Systems; Medical University of Vienna; Vienna Austria
| | - Karin Petroczi
- Department of Clinical Pharmacology; Medical University of Vienna; Vienna Austria
| | - Wolfgang Sperr
- Department of Internal Medicine I; Division of Hematology & Hemostaseology and Ludwig Boltzmann Cluster Oncology; Medical University of Vienna; Vienna Austria
| | - Thomas Stimpfl
- Analytical Toxicology; Clinical Institute of Laboratory Medicine; Medical University of Vienna; Vienna Austria
| | - Peter Valent
- Department of Internal Medicine I; Division of Hematology & Hemostaseology and Ludwig Boltzmann Cluster Oncology; Medical University of Vienna; Vienna Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology; Medical University of Vienna; Vienna Austria
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21
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Szari S, Wong PH, Crisp HC, Champoux E, Rans TS, Coop CA. Evaluation of tryptase after subcutaneous immunotherapy-associated systemic reactions. Ann Allergy Asthma Immunol 2019; 122:413-415.e1. [PMID: 30684737 DOI: 10.1016/j.anai.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Sofia Szari
- Allergy/Immunology Clinic, Wilford Hall Medical Center, Lackland AFB, Texas.
| | - Priscilla H Wong
- Allergy/Immunology Clinic, Wilford Hall Medical Center, Lackland AFB, Texas
| | - Howard C Crisp
- Allergy/Immunology Clinic, Wilford Hall Medical Center, Lackland AFB, Texas
| | - Edward Champoux
- Allergy/Immunology Clinic, Wilford Hall Medical Center, Lackland AFB, Texas
| | - Tonya S Rans
- Allergy/Immunology Clinic, Wilford Hall Medical Center, Lackland AFB, Texas
| | - Christopher A Coop
- Allergy/Immunology Clinic, Wilford Hall Medical Center, Lackland AFB, Texas
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22
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Ayers LW, Barbachano-Guerrero A, McAllister SC, Ritchie JA, Asiago-Reddy E, Bartlett LC, Cesarman E, Wang D, Rochford R, Martin JN, King CA. Mast Cell Activation and KSHV Infection in Kaposi Sarcoma. Clin Cancer Res 2018; 24:5085-5097. [PMID: 30084838 PMCID: PMC6191350 DOI: 10.1158/1078-0432.ccr-18-0873] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/31/2018] [Accepted: 06/27/2018] [Indexed: 12/29/2022]
Abstract
Purpose: Kaposi sarcoma (KS) is a vascular tumor initiated by infection of endothelial cells (ECs) with KS-associated herpesvirus (KSHV). KS is dependent on sustained proinflammatory signals provided by intralesional leukocytes and continued infection of new ECs. However, the sources of these cytokines and infectious virus within lesions are not fully understood. Here, mast cells (MCs) are identified as proinflammatory cells within KS lesions that are permissive for, and activated by, infection with KSHV.Experimental Design: Three validated MC lines were used to assess permissivity of MCs to infection with KSHV and to evaluate MCs activation following infection. Biopsies from 31 AIDS-KS cases and 11 AIDS controls were evaluated by IHC for the presence of MCs in KS lesions and assessment of MC activation state and infection with KSHV. Plasma samples from 26 AIDS-KS, 13 classic KS, and 13 healthy adults were evaluated for levels of MC granule contents tryptase and histamine.Results: In culture, MCs supported latent and lytic KSHV infection, and infection-induced MC degranulation. Within KS lesions, MCs were closely associated with spindle cells. Furthermore, MC activation was extensive within patients with KS, reflected by elevated circulating levels of tryptase and a histamine metabolite. One patient with clinical signs of extensive MC activation was treated with antagonists of MC proinflammatory mediators, which resulted in a rapid and durable regression of AIDS-KS lesions.Conclusions: Using complimentary in vitro and in vivo studies we identify MCs as a potential long-lived reservoir for KSHV and a source of proinflammatory mediators within the KS lesional microenvironment. In addition, we identify MC antagonists as a promising novel therapeutic approach for KS. Clin Cancer Res; 24(20); 5085-97. ©2018 AACR.
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Affiliation(s)
- Leona W Ayers
- Department of Pathology, The Ohio State University, Columbus, Ohio
| | | | - Shane C McAllister
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Julie A Ritchie
- Department of Microbiology and Immunology, SUNY Upstate Medical University, Syracuse, New York
| | | | - Linda C Bartlett
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Ethel Cesarman
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York
| | - Dongliang Wang
- Department of Public Health and Preventative Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Rosemary Rochford
- Department of Microbiology and Immunology, SUNY Upstate Medical University, Syracuse, New York
| | - Jeffrey N Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Christine A King
- Department of Microbiology and Immunology, SUNY Upstate Medical University, Syracuse, New York.
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23
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Dua S, Dowey J, Foley L, Islam S, King Y, Ewan P, Clark AT. Diagnostic Value of Tryptase in Food Allergic Reactions: A Prospective Study of 160 Adult Peanut Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1692-1698.e1. [DOI: 10.1016/j.jaip.2018.01.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 12/28/2017] [Accepted: 01/03/2018] [Indexed: 10/17/2022]
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24
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In Vitro Diagnosis of Immediate Drug Hypersensitivity During Anesthesia: A Review of the Literature. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1176-1184. [DOI: 10.1016/j.jaip.2018.01.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/05/2018] [Accepted: 01/16/2018] [Indexed: 02/07/2023]
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25
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Buka RJ, Knibb RC, Crossman RJ, Melchior CL, Huissoon AP, Hackett S, Dorrian S, Cooke MW, Krishna MT. Anaphylaxis and Clinical Utility of Real-World Measurement of Acute Serum Tryptase in UK Emergency Departments. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:1280-1287.e2. [PMID: 28888252 DOI: 10.1016/j.jaip.2017.06.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 05/27/2017] [Accepted: 06/22/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND British guidelines recommend that serial acute serum tryptase measurements be checked in all adults and a subset of children presenting with anaphylaxis. This is the first study reporting the clinical utility of acute serum tryptase in a "real-world" emergency department (ED) setting following the publication of the World Allergy Organization (WAO) criteria for anaphylaxis. OBJECTIVES To (1) assess sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of acute serum tryptase in anaphylaxis; (b) determine factors associated with higher acute serum tryptase levels; and (c) audit compliance of acute serum tryptase measurement in the ED. METHODS The methods used were retrospective electronic search for ED admissions to 3 acute care hospitals in Birmingham, UK, with anaphylaxis in 2012 using wide search terms followed by scrutiny of electronic clinical records and application of the WAO diagnostic criteria for anaphylaxis. Patients with an acute serum tryptase measurement were included in the analysis. RESULTS Acute serum tryptase level was measured in 141 of 426 (33.1%) cases. Mean time from the onset of symptoms to the measurement of acute serum tryptase level was 4 hours 42 minutes (SD ± 05:03 hours) and no patients had serial measurements conforming to British guidelines. Acute serum tryptase level of more than 12.4 ng/mL (75th centile) was associated with a sensitivity, specificity, PPV, and NPV of 28%, 88%, 0.93, and 0.17, respectively. Multiple regression analysis showed that male sex (odds ratio, 2.66; P = .003) and hypotension (odds ratio, 7.08; P = .001) predicted higher acute serum tryptase level. CONCLUSIONS An acute serum tryptase level of more than 12.4 ng/mL in an ED setting carries high PPV and specificity, but poor sensitivity and NPV.
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Affiliation(s)
- Richard J Buka
- Department of Allergy and Immunology, Heart of England NHS Foundation Trust, Birmingham, United Kingdom; Institute of Inflammation & Ageing, University of Birmingham, Birmingham, United Kingdom.
| | - Rebecca C Knibb
- Department of Psychology, Aston University, Birmingham, United Kingdom
| | | | - Cathryn L Melchior
- Department of Allergy and Immunology, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Aarnoud P Huissoon
- Department of Allergy and Immunology, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Scott Hackett
- Department of Pediatric Allergy, Immunology and Infectious Diseases, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Susan Dorrian
- Department of Emergency Medicine, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Matthew W Cooke
- Department of Emergency Medicine, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Mamidipudi T Krishna
- Department of Allergy and Immunology, Heart of England NHS Foundation Trust, Birmingham, United Kingdom; Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Abstract
Background For most physicians, quantification of drug-specific immunoglobulin E (drug-sIgE) antibodies constitutes the primary in vitro measure to document immediate drug hypersensitivity reactions (IDHR). Unfortunately, this is often insufficient to correctly identify patients with IgE-mediated IDHR and impossible for non-IgE-mediated IDHR that result from alternative routes of basophil and mast cell activation. In these difficult cases, diagnosis might benefit from cellular tests such as basophil activation tests (BAT). Aim The aim was to review the potential and limitations of quantification of sIgE and BAT in diagnosing IDHR. The utility of quantification of serum tryptase is discussed. Methods A literature search was conducted using the key words allergy, basophil activation, CD63, CD203c, diagnosis, drugs, hypersensitivity, flow cytometry, specific IgE antibodies; this was complemented by the authors’ own experience. Results The drugs that have been most studied with both techniques are β-lactam antibiotics and curarizing neuromuscular blocking agents (NMBA). For sIgE morphine, data are available on the value of this test as a biomarker for sensitization to substituted ammonium structures that constitute the major epitope of NMBA, especially rocuronium and suxamethonium. For the BAT, there are also data on non-steroidal anti-inflammatory drugs (NSAIDs) and iodinated radiocontrast media. For β-lactam antibiotics, sensitivity and specificity of sIgE varies between 0 and 85% and 52 and 100%, respectively. For NMBA, sensitivity and specificity varies between 38.5 and 92% and 85.7 and 100%, respectively. Specific IgE to morphine should not be used in isolation to diagnose IDHR to NMBA nor opiates. For the BAT, sensitivity generally varies between 50 and 60%, whereas specificity attains 80%, except for quinolones and NSAIDs. Conclusions Although drug-sIgE assays and BAT can provide useful information in the diagnosis of IDHR, their predictive value is not absolute. Large-scale collaborative studies are mandatory to harmonize and optimize test protocols and to establish drug-specific decision thresholds.
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Golden DBK, Demain J, Freeman T, Graft D, Tankersley M, Tracy J, Blessing-Moore J, Bernstein D, Dinakar C, Greenhawt M, Khan D, Lang D, Nicklas R, Oppenheimer J, Portnoy J, Randolph C, Schuller D, Wallace D. Stinging insect hypersensitivity: A practice parameter update 2016. Ann Allergy Asthma Immunol 2017; 118:28-54. [PMID: 28007086 DOI: 10.1016/j.anai.2016.10.031] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
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Francis A, Fatovich DM, Arendts G, Macdonald SPJ, Bosio E, Nagree Y, Mitenko HMA, Brown SGA. Serum mast cell tryptase measurements: Sensitivity and specificity for a diagnosis of anaphylaxis in emergency department patients with shock or hypoxaemia. Emerg Med Australas 2017; 30:366-374. [DOI: 10.1111/1742-6723.12875] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 09/06/2017] [Accepted: 09/20/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Abbie Francis
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- School of Medicine; The University of Western Australia; Perth Western Australia Australia
| | - Daniel M Fatovich
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- School of Medicine; The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Royal Perth Hospital; Perth Western Australia Australia
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- School of Medicine; The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Royal Perth Hospital; Perth Western Australia Australia
- Emergency Department; Fiona Stanley Hospital; Perth Western Australia Australia
| | - Stephen PJ Macdonald
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- School of Medicine; The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Royal Perth Hospital; Perth Western Australia Australia
- Emergency Department; Armadale Kelmscott Memorial Hospital; Perth Western Australia Australia
| | - Erika Bosio
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- School of Medicine; The University of Western Australia; Perth Western Australia Australia
| | - Yusuf Nagree
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- Emergency Department; Fiona Stanley Hospital; Perth Western Australia Australia
- Emergency Department; Fremantle Hospital and Health Service; Fremantle Western Australia Australia
| | - Hugh MA Mitenko
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- Emergency Department; South West Health Campus; Bunbury Western Australia Australia
| | - Simon GA Brown
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- School of Medicine; The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Royal Perth Hospital; Perth Western Australia Australia
- Emergency Department; Royal Hobart Hospital; Hobart Tasmania Australia
- School of Medicine; University of Tasmania; Hobart Tasmania Australia
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Epidemiology of severe anaphylaxis: can we use population-based data to understand anaphylaxis? Curr Opin Allergy Clin Immunol 2017; 16:441-50. [PMID: 27490124 DOI: 10.1097/aci.0000000000000305] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW The observed increase in incidence of allergic disease in many regions over the past 3 decades has intensified interest in understanding the epidemiology of severe allergic reactions. We discuss the issues in collecting and interpreting these data and highlight current deficiencies in the current methods of data gathering. RECENT FINDINGS Anaphylaxis, as measured by hospital admission rates, is not uncommon and has increased in the United Kingdom, the United States, Canada, and Australia over the last 10-20 years. All large datasets are hampered by a large proportion of uncoded, 'unspecified' causes of anaphylaxis. Fatal anaphylaxis remains a rare event, but appears to be increasing for medication in Australia, Canada, and the United States. The rate of fatal food anaphylaxis is stable in the United Kingdom and the United States, but has increased in Australia. The age distribution for fatal food anaphylaxis is different to other causes, with data suggesting an age-related predisposition to fatal outcomes in teenagers and adults to the fourth decade of life. SUMMARY The increasing rates of food and medication allergy (the latter exacerbated by an ageing population) has significant implications for future fatality trends. An improved ability to accurately gather and analyse population-level anaphylaxis data in a harmonized fashion is required, so as to ultimately minimize risk and improve management.
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Sellaturay P, Nasser S, Ewan P. Skin testing in gadolinium allergy: 2 case reports. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:262-264.e1. [PMID: 28669891 DOI: 10.1016/j.jaip.2017.04.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/25/2017] [Accepted: 04/20/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Priya Sellaturay
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Pamela Ewan
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Montañez MI, Mayorga C, Bogas G, Barrionuevo E, Fernandez-Santamaria R, Martin-Serrano A, Laguna JJ, Torres MJ, Fernandez TD, Doña I. Epidemiology, Mechanisms, and Diagnosis of Drug-Induced Anaphylaxis. Front Immunol 2017; 8:614. [PMID: 28611774 PMCID: PMC5446992 DOI: 10.3389/fimmu.2017.00614] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/09/2017] [Indexed: 12/14/2022] Open
Abstract
Anaphylaxis is an acute, life-threatening, multisystem syndrome resulting from the sudden release of mediators by mast cells and basophils. Although anaphylaxis is often under-communicated and thus underestimated, its incidence appears to have risen over recent decades. Drugs are among the most common triggers in adults, being analgesics and antibiotics the most common causal agents. Anaphylaxis can be caused by immunologic or non-immunologic mechanisms. Immunologic anaphylaxis can be mediated by IgE-dependent or -independent pathways. The former involves activation of Th2 cells and the cross-linking of two or more specific IgE (sIgE) antibodies on the surface of mast cells or basophils. The IgE-independent mechanism can be mediated by IgG, involving the release of platelet-activating factor, and/or complement activation. Non-immunological anaphylaxis can occur through the direct stimulation of mast cell degranulation by some drugs, inducing histamine release and leading to anaphylactic symptoms. Work-up of a suspected drug-induced anaphylaxis should include clinical history; however, this can be unreliable, and skin tests should also be used if available and validated. Drug provocation testing is not recommended due to the risk of inducing a harmful reaction. In vitro testing can help to confirm anaphylaxis by analyzing the release of mediators such as tryptase or histamine by mast cells. When immunologic mechanisms are suspected, serum-sIgE quantification or the use of the basophil activation test can help confirm the culprit drug. In this review, we will discuss multiple aspects of drug-induced anaphylaxis, including epidemiology, mechanisms, and diagnosis.
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Affiliation(s)
- Maria Isabel Montañez
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain.,Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | - Cristobalina Mayorga
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain.,Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | - Gador Bogas
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | - Esther Barrionuevo
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | | | - Angela Martin-Serrano
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain.,Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | | | - Maria José Torres
- Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain.,Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | - Tahia Diana Fernandez
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | - Inmaculada Doña
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
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Cavkaytar O, Karaatmaca B, Arik Yilmaz E, Sahiner UM, Sackesen C, Sekerel BE, Soyer O. Basal serum tryptase is not a risk factor for immediate-type drug hypersensitivity during childhood. Pediatr Allergy Immunol 2016; 27:736-742. [PMID: 27288661 DOI: 10.1111/pai.12604] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND High serum basal tryptase (sBT) levels have been identified as a risk factor for both venom- and food-induced severe allergic reactions. The aim of this study was to compare sBT levels in children with different severity of actual drug hypersensitivity reactions (DHRs) with those of age- and sex-matched controls without any history of DHRs. METHOD Patients between 0 and 18 years of age with a history of immediate-type DHRs manifested in 0-6 h after the culprit drug intake were included. Following ENDA (European Network for Drug Allergy) inquiries, patients were evaluated with skin and/or provocation tests to define the actual drug-hypersensitive patients. Serum BT levels were determined for both patients and controls. RESULTS Of 345 children, 106 patients (30.7%) [(58.5% male), median age (interquartile range) 8.0 years (4.2-12.2)] were diagnosed as drug hypersensitive. Ninety-eight controls were also included. The sBT levels of drug-hypersensitive patients with and without anaphylaxis and the control group were similar [2.6 (2.0-3.6) μg/l vs. 2.8 (1.6-4.3) μg/l vs. 2.6 (1.8-3.6) μg/l, respectively, (p > 0.05)]. The sBT levels of the patients with sole cutaneous symptoms 2.8 (1.6-4.3) μg/l, mild anaphylaxis 3.0 (1.9-4.9) μg/l, and moderate-to-severe anaphylaxis 2.6 (2.0-3.6) μg/l were also comparable (p > 0.05). The onset of DHRs [those occurring in 1 h (n = 87) or in 1-6 h (n = 19) after the drug intake], positive results with skin tests with the culprit drug, or the classification of the patients according to different age groups [(0-2 years), (2-6 years), (6-12 years), (12-18 years)] did not correlate with sBT levels. CONCLUSION The sBT levels in children with actual drug hypersensitivity would not be a risk factor for severe systemic reactions on the contrary to children with allergic reactions to food or insect venom.
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Affiliation(s)
- Ozlem Cavkaytar
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Turkey
| | - Betul Karaatmaca
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ebru Arik Yilmaz
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Turkey
| | - Umit M Sahiner
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Turkey
| | - Cansın Sackesen
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Turkey.,Division of Pediatric Allergy, Koc University School of Medicine, Istanbul, Turkey
| | - Bulent E Sekerel
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ozge Soyer
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Turkey.
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Ledford DK. Omalizumab and Allergic Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:187-8. [PMID: 26772933 DOI: 10.1016/j.jaip.2015.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 07/14/2015] [Accepted: 08/11/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Dennis K Ledford
- Ellsworth and Mabel Simmons Professor of Allergy/Immunology, Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla.
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Egner W, Sargur R, Shrimpton A, York M, Green K. A 17-year experience in perioperative anaphylaxis 1998-2015: harmonizing optimal detection of mast cell mediator release. Clin Exp Allergy 2016; 46:1465-1473. [DOI: 10.1111/cea.12785] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 05/24/2016] [Accepted: 07/20/2016] [Indexed: 12/20/2022]
Affiliation(s)
- W. Egner
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - R. Sargur
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - A. Shrimpton
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - M. York
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - K. Green
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
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35
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Mast cell activation disease and the modern epidemic of chronic inflammatory disease. Transl Res 2016; 174:33-59. [PMID: 26850903 DOI: 10.1016/j.trsl.2016.01.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 12/18/2022]
Abstract
A large and growing portion of the human population, especially in developed countries, suffers 1 or more chronic, often quite burdensome ailments which either are overtly inflammatory in nature or are suspected to be of inflammatory origin, but for which investigations to date have failed to identify specific causes, let alone unifying mechanisms underlying the multiple such ailments that often afflict such patients. Relatively recently described as a non-neoplastic cousin of the rare hematologic disease mastocytosis, mast cell (MC) activation syndrome-suspected to be of greatly heterogeneous, complex acquired clonality in many cases-is a potential underlying/unifying explanation for a diverse assortment of inflammatory ailments. A brief review of MC biology and how aberrant primary MC activation might lead to such a vast range of illness is presented.
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Decuyper II, Ebo DG, Uyttebroek AP, Hagendorens MM, Faber MA, Bridts CH, De Clerck LS, Sabato V. Quantification of specific IgE antibodies in immediate drug hypersensitivity: More shortcomings than potentials? Clin Chim Acta 2016; 460:184-9. [PMID: 27376983 DOI: 10.1016/j.cca.2016.06.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND For many physicians, quantification of serum drug-specific IgE (sIgE) antibodies constitutes the first measure in the diagnostic approach of immediate drug hypersensitivity reactions (IDHR). AIM To review the accuracy and limitations of the main drug-sIgE tests, especially those that are commercially available. METHODS A literature search was conducted, using the key-words allergy, diagnosis, drugs, hypersensitivity, specific IgE antibodies; this was complemented by the authors' own experience. RESULTS The drugs that have mostly been studied appeared to be β-lactam antibiotics, neuromuscular blocking agents (NMBA) and morphine, the latter as a biomarker for sensitisation to substituted ammonium structures that constitute the major epitope of NMBA. For β-lactams sensitivity and specificity varied between 0-85% and 52-100%, respectively. For NMBA, sensitivity and specificity varied between 38.5-92% and 92-100%, respectively. With respect to sIgE to morphine it appears this drug to be a sensitive biomarker for sensitisation to rocuronium and suxamethonium but not for atracurium. However, sIgE morphine should not be applied in isolation to diagnose IDHR to NMBA nor opiates. CONCLUSIONS Although drug-sIgE assay can provide valuable information they should not be performed in isolation to establish correct diagnosis, as their predictive value is not per se absolute. Larger comprehensive studies are urgently required to determine the accuracy of drug-sIgE assays.
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Affiliation(s)
- I I Decuyper
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Belgium
| | - D G Ebo
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium.
| | - A P Uyttebroek
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - M M Hagendorens
- Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Belgium
| | - M A Faber
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - C H Bridts
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - L S De Clerck
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - V Sabato
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
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Abstract
PURPOSE OF REVIEW Anaphylaxis is a serious allergic reaction that can be life threatening. We will review the most recent evidence regarding the diagnosis, treatment, monitoring, and prevention of anaphylaxis in children. RECENT FINDINGS Histamine and tryptase are not sufficiently accurate for the routine diagnosis of anaphylaxis, so providers should continue to rely on clinical signs. Platelet-activating factor shows some promise in the diagnosis of anaphylaxis. Intramuscular is the best route for epinephrine administration for children of all weights. Glucocorticoids may reduce prolonged hospitalizations for anaphylaxis. Children with anaphylaxis who have resolving symptoms and no history of asthma or previous biphasic reactions may be observed for as few as 3-4 h before emergency department discharge. Early peanut introduction reduces the risk of peanut allergy. SUMMARY Epinephrine remains the mainstay of anaphylaxis treatment, and adjuvant medications should not be used in its place. All patients with anaphylaxis should be prescribed and trained to use an epinephrine autoinjector. Clinically important biphasic reactions are rare. Observation in the emergency department for most anaphylaxis patients is recommended, with the duration determined by risk factors. Admission is reserved for patients with unimproved or worsening symptoms, or prior biphasic reaction.
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Affiliation(s)
- Karen S. Farbman
- Boston Children's Hospital, Division of Emergency Medicine, Boston, MA
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Kuhlen JL, Camargo CA, Balekian DS, Blumenthal KG, Guyer A, Morris T, Long A, Banerji A. Antibiotics Are the Most Commonly Identified Cause of Perioperative Hypersensitivity Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:697-704. [PMID: 27039234 DOI: 10.1016/j.jaip.2016.02.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 02/15/2016] [Accepted: 02/19/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hypersensitivity reactions (HSRs) during the perioperative period are unpredictable and can be life threatening. Prospective studies for the evaluation of perioperative HSRs are lacking, and data on causative agents vary between different studies. OBJECTIVE The objective of this study was to prospectively determine the success of a comprehensive allergy evaluation plan for patients with HSRs during anesthesia, including identification of a causative agent and outcomes during subsequent anesthesia exposure. METHODS All patients referred for a perioperative HSR between November 2013 and March 2015, from a Boston teaching hospital, were evaluated using a standardized protocol with skin testing (ST) within 6 months of HSR. Comprehensive allergy evaluation included collection of patient information, including characteristics of HSR during anesthesia. We reviewed the results of ST and/or test doses for all potential causative medications Event-related tryptase levels were reviewed when available. RESULTS Over 17 months, 25 patients completed the comprehensive allergy evaluation. Fifty-two percent (13 of 25) were female with a median age of 52 (interquartile range 43-66) years. The most frequently observed HSR systems were cutaneous (68%), cardiovascular (64%), and pulmonary (24%). A culprit drug, defined as a positive ST, was identified in 36% (9 of 25) of patients. The most common agent identified was cefazolin (6 of 9). After our comprehensive evaluation and management plan, 7 (7 of 8, 88%) patients tolerated subsequent anesthesia. CONCLUSIONS Cefazolin was the most commonly identified cause of a perioperative HSR in our study population. Skin testing patients within 6 months of a perioperative HSR may improve the odds of finding a positive result. Tolerance of subsequent anesthesia is generally achieved in patients undergoing our comprehensive evaluation.
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Affiliation(s)
- James L Kuhlen
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Carlos A Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Diana S Balekian
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Allergy and Inflammation, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, Calif
| | - Theresa Morris
- Department of Anesthesia, Massachusetts General Hospital, Boston, Mass
| | - Aidan Long
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
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Perioperative Hypersensitivity Reactions: Diagnosis, Treatment and Evaluation. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0078-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Aich A, Afrin LB, Gupta K. Mast Cell-Mediated Mechanisms of Nociception. Int J Mol Sci 2015; 16:29069-92. [PMID: 26690128 PMCID: PMC4691098 DOI: 10.3390/ijms161226151] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 11/28/2015] [Accepted: 12/01/2015] [Indexed: 12/12/2022] Open
Abstract
Mast cells are tissue-resident immune cells that release immuno-modulators, chemo-attractants, vasoactive compounds, neuropeptides and growth factors in response to allergens and pathogens constituting a first line of host defense. The neuroimmune interface of immune cells modulating synaptic responses has been of increasing interest, and mast cells have been proposed as key players in orchestrating inflammation-associated pain pathobiology due to their proximity to both vasculature and nerve fibers. Molecular underpinnings of mast cell-mediated pain can be disease-specific. Understanding such mechanisms is critical for developing disease-specific targeted therapeutics to improve analgesic outcomes. We review molecular mechanisms that may contribute to nociception in a disease-specific manner.
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Affiliation(s)
- Anupam Aich
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Lawrence B Afrin
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Kalpna Gupta
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
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Polyethylene glycols (PEG) and related structures: overlooked allergens in the perioperative setting. ACTA ACUST UNITED AC 2015; 4:61-4. [PMID: 25730412 DOI: 10.1213/xaa.0000000000000126] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe hypersensitivity to polyethylene glycols (PEGs), with cross-reactivity to a structural analog, polysorbate 80, in a 69-year-old patient with perioperative anaphylaxis and subsequent, severe anaphylactic reactions to unrelated medical products. PEGs and PEG analogs are prevalent in the perioperative setting, contained in a wide range of products seldom suspected of causing hypersensitivity reactions and thus rarely documented in surgical/anesthetic records. We suggest routine testing for PEGs after perioperative anaphylaxis because exposure to these polymers often is significant. Comprehensive brand name documentation on the anesthetic chart of all product exposures is central to identifying the responsible allergen.
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Bonadonna P, Pagani M, Aberer W, Bilò MB, Brockow K, Oude Elberink H, Garvey L, Mosbech H, Romano A, Zanotti R, Torres MJ. Drug hypersensitivity in clonal mast cell disorders: ENDA/EAACI position paper. Allergy 2015; 70:755-63. [PMID: 25824492 DOI: 10.1111/all.12617] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 01/08/2023]
Abstract
Mastocytosis is a clonal disorder characterized by the proliferation and accumulation of mast cells (MC) in different tissues, with a preferential localization in skin and bone marrow (BM). The excess of MC in mastocytosis as well as the increased releasability of MC may lead to a higher frequency and severity of immediate hypersensitivity reactions. Mastocytosis in adults is associated with a history of anaphylaxis in 22-49%. Fatal anaphylaxis has been described particularly following hymenoptera stings, but also occasionally after the intake of drugs such as nonsteroidal anti-inflammatory drugs, opioids and drugs in the perioperative setting. However, data on the frequency of drug hypersensitivity in mastocytosis and vice versa are scarce and evidence for an association appears to be limited. Nevertheless, clonal MC disorders should be ruled out in cases of severe anaphylaxis: basal serum tryptase determination, physical examination for cutaneous mastocytosis lesions, and clinical characteristics of anaphylactic reaction might be useful for differential diagnosis. In this position paper, the ENDA group performed a literature search on immediate drug hypersensitivity reactions in clonal MC disorders using MEDLINE, EMBASE, and Cochrane Library, reviewed and evaluated the literature in five languages using the GRADE system for quality of evidence and strength of recommendation.
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Affiliation(s)
- P. Bonadonna
- Allergy Unit; Azienda Ospedaliera Universitaria Intergrata of Verona; Verona Italy
| | - M. Pagani
- Medicine Ward; Pieve di Coriano Hospital Azienda Ospedaliera Carlo Poma Mantova; Mantova Italy
| | - W. Aberer
- Department of Dermatology and Venerology; Medizinische Universitat Graz; Graz Austria
| | - M. B. Bilò
- Allergy Unit; Department of Internal Medicine; Ospedali Riuniti di Ancona; Ancona Italy
| | - K. Brockow
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | - H. Oude Elberink
- Department of Allergology; GRIAC Research Institute; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - L. Garvey
- Allergy Clinic; Copenhagen University Hospital; Gentofte Denmark
| | - H. Mosbech
- Allergy Clinic; Copenhagen University Hospital; Gentofte Denmark
| | - A. Romano
- Allergy Unit Complesso Integrato Columbus; Rome and IRCCS Oasi Maria S.S.; Troina Italy
| | - R. Zanotti
- Department of Medicine; Hematology Section; Azienda Ospedaliera Universitaria Intergrata of Verona; Verona Italy
| | - M. J. Torres
- Allergy Unit; Regional University Hospital-IBIMA; UMA; Málaga Spain
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Abstract
Drug-induced anaphylaxis is a common cause of anaphylaxis and a leading cause of fatal anaphylaxis. Antibiotics, radiocontrast, and nonsteroidal anti-inflammatory drugs are commonly implicated drugs. Vocal cord dysfunction can mimic anaphylaxis and is often overlooked. β-Lactams are a common cause of anaphylaxis; however, skin testing and drug challenge can usually determine tolerability of other classes of β-lactams. Nonionic contrast agents cause anaphylaxis less frequently than ionic contrast, and immunoglobulin E-mediated mechanisms may have a role in some of these reactions. Skin testing with radiocontrast may have a role in evaluating patients with anaphylaxis to nonionic contrast.
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Affiliation(s)
- Merin Kuruvilla
- Atlanta ENT, 5555 Peachtree Dunwoody Rd, Suite 125, Atlanta, GA-30342, USA
| | - David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8859, USA.
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Vitte J. Human mast cell tryptase in biology and medicine. Mol Immunol 2015; 63:18-24. [DOI: 10.1016/j.molimm.2014.04.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 04/01/2014] [Accepted: 04/02/2014] [Indexed: 12/25/2022]
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Cetirizine anaphylaxis. Ann Allergy Asthma Immunol 2014; 113:247-9. [PMID: 25168222 DOI: 10.1016/j.anai.2014.06.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 05/30/2014] [Accepted: 06/25/2014] [Indexed: 11/22/2022]
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Diagnostic value of histamine and tryptase concentrations in severe anaphylaxis with shock or cardiac arrest during anesthesia. Anesthesiology 2014; 121:272-9. [PMID: 24787350 DOI: 10.1097/aln.0000000000000276] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The diagnosis of acute life-threatening allergic reactions during anesthesia relies on clinical signs, histamine and/or tryptase measurements, and allergic testing. In patients who die after the reaction, skin tests cannot be performed, and the effect of resuscitation manoeuvres on mediator concentrations is unknown. The authors compared plasma histamine and tryptase concentrations in patients with severe allergic reactions during anesthesia with those measured in patients with shock due to other causes. METHODS Patients with life-threatening allergic reactions were retrieved from a previous database (Group ALLERGY). All had positive allergy tests to administered agents. Patients with severe septic/cardiogenic shock or cardiac arrest (Group CONTROL) had histamine and tryptase measurements during resuscitation manoeuvres. Receiver operating characteristics curves were built to calculate the optimal mediator thresholds differentiating allergic reactions from others. RESULTS One hundred patients were included, 75 in Group ALLERGY (cardiovascular collapse, 67; cardiac arrest, 8) and 25 in Group CONTROL (shock, 11; cardiac arrest, 14). Mean histamine and tryptase concentrations remained unchanged throughout resuscitation in Group CONTROL and were significantly higher in Group ALLERGY. The optimal thresholds indicating an allergic mechanism were determined as 6.35 nmol/l for histamine (sensitivity: 90.7% [95% CI, 81.7 to 96.1]; specificity: 91.7% [73.0 to 98.9]) and 7.35 μg/l for tryptase (sensitivity: 92% [83.4 to 97.0]; specificity: 92% [73.9 to 99.0]). CONCLUSIONS Resuscitation manoeuvres by themselves did not modify mediator concentrations. Virtually all life-threatening reactions during anesthesia associated with mediator concentrations exceeding the thresholds were allergic events. These findings have potential forensic interest when a patient dies during anesthesia.
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Serum eosinophil cationic protein is superior to mast cell tryptase as marker for response to topical corticosteroid therapy in eosinophilic esophagitis. J Clin Gastroenterol 2014; 48:600-6. [PMID: 24177377 DOI: 10.1097/01.mcg.0000436439.67768.8d] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
GOALS We evaluated the serum levels of eosinophil cationic protein (ECP) and mast cell tryptase (MCT) as surrogate markers for response to treatment in adults with eosinophilic esophagitis (EoE) under topical steroid therapy with fluticasone. BACKGROUND EoE is a chronic disease characterized histologically by eosinophilic inflammation of the esophagus. Esophageal mastocytosis and mast cell activation have been implicated in EoE pathogenesis. STUDY Fifteen patients with EoE completed this prospective observational study. Before and after 3 months of therapy with fluticasone, eosinophilic and mast cell counts were analyzed from histologic samples of the esophagus and were correlated with serum markers ECP and MCT. RESULTS Fluticasone-therapy significantly decreased mean eosinophils [from 42.2 to 16.2 eosinophils/high-power field (hpf); P=0.004] and mast cells (from 13.9 to 5.1 mast cells/hpf; P=0.001) in the esophageal epithelium. There was a significant decrease of mean ECP (from 15.6 to 5.5 μg/L; P=0.024) and MCT-serum-values (from 4.7 to 3.8 μg/L; P=0.029) under therapy. Serum-ECP correlated significantly with histologic eosinophilic counts after fluticasone-therapy (r=0.54; P=0.038) in contrast to serum-MCT. CONCLUSIONS Serum-ECP but not serum-MCT could be a promising noninvasive biomarker to assess response to topical corticosteroid therapy in EoE. These findings should be confirmed by larger studies; ClincialTrials.gov number, NCT01624129.
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Wongkaewpothong P, Pacharn P, Sripramong C, Boonchoo S, Piboonpocanun S, Visitsunthorn N, Vichyanond P, Jirapongsananuruk O. The utility of serum tryptase in the diagnosis of food-induced anaphylaxis. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2014; 6:304-9. [PMID: 24991453 PMCID: PMC4077956 DOI: 10.4168/aair.2014.6.4.304] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 06/06/2013] [Accepted: 07/04/2013] [Indexed: 12/02/2022]
Abstract
Purpose This study investigates the utility of serum tryptase for the confirmation of shrimp-induced anaphylaxis. Methods Patients with a history of shrimp allergy and positive skin prick tests (SPT) to commercial shrimp extract were recruited for shrimp challenges. Serum total tryptase was obtained at baseline and 60 min (peak) after the onset of symptoms. Results Thirty-nine patients were challenged. There were 12 patients with anaphylaxis, 20 with mild reactions and 7 without symptoms (control group). Characteristic features and baseline tryptase were not different among the 3 groups. The peak tryptase levels were higher than the baseline in anaphylaxis and mild reaction groups (P<0.05). The delta-tryptase (peak minus baseline) and the tryptase ratio (peak divided by baseline) in the anaphylaxis group were higher than the mild reaction and control groups (P<0.01). The optimum cut-off for peak tryptase to confirm anaphylaxis was 2.99 µg/L with 50% sensitivity, 85% specificity, 3.33 positive likelihood ratio (LR) and 0.59 negative LR. The manufacturer's cut-off for peak tryptase was >11.4 µg/L with 17% sensitivity, 100% specificity, infinity positive LR and 0.83 negative LR. The best cut-off for delta-tryptase was ≥0.8 µg/L with 83% sensitivity, 93% specificity, 11.86 positive LR and 0.18 negative LR. The best cut-off for tryptase ratio was ≥1.5 with 92% sensitivity, 96% specificity, 23 positive LR and 0.08 negative LR. Conclusions The peak tryptase level should be compared with the baseline value to confirm anaphylaxis. The tryptase ratio provide the best sensitivity, specificity, positive and negative LR than a single peak serum tryptase for the confirmation of shrimp-induced anaphylaxis.
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Affiliation(s)
- Patcharaporn Wongkaewpothong
- Department of Pediatrics, School of Medicine, Institute of Medicine, Suranaree University of Technology, Nakhonratchasima, Thailand
| | - Punchama Pacharn
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand
| | - Chaweewan Sripramong
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand
| | - Siribangon Boonchoo
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand
| | | | - Nualanong Visitsunthorn
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand
| | - Pakit Vichyanond
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand
| | - Orathai Jirapongsananuruk
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand
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Afrin LB, Molderings GJ. A concise, practical guide to diagnostic assessment for mast cell activation disease. World J Hematol 2014; 3:1-17. [DOI: 10.5315/wjh.v3.i1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
As recognition of mast cell (MC) involvement in a range of chronic inflammatory disorders has increased, diagnosticians’ suspicions of MC activation disease (MCAD) in their chronically mysteriously inflamed patients have similarly increased. It is now understood that the various forms of systemic mastocytosis - diseases of inappropriate activation and proliferation of MCs seemingly driven by a small set of rare, usually constitutively activating mutations in assorted MC regulatory elements - comprise merely the tip of the MCAD iceberg, whereas the far larger and far more clinically heterogeneous (and thus more difficult to recognize) bulk of the iceberg consists of assorted forms of MC activation syndrome (MCAS) which manifest little to no abnormal MC proliferation and may originate from a far more heterogeneous set of MC mutations. It is reasonable to suspect MCAD when symptoms and signs of MC activation are present and no other diagnosis better accounting for the full range of findings is present. Initial laboratory assessment should include not only routine blood counts and serum chemistries but also a serum total tryptase level, which helps direct further evaluation for mastocytosis vs MCAS. Appropriate tissue examinations are needed to diagnose mastocytosis, while elevated levels of relatively specific mast cell mediators are sought to support diagnosis of MCAS. Whether assessing for mastocytosis or MCAS, testing is fraught with potential pitfalls which can easily yield false negatives leading to erroneous rejection of diagnostic consideration of MCAD in spite of a clinical history highly consistent with MCAD. Efforts at accurate diagnosis of MCAD are worthwhile, as many patients then respond well to appropriately directed therapeutic efforts.
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Afrin LB, Molderings GJ. A concise, practical guide to diagnostic assessment for mast cell activation disease. World J Hematol 2014; 3:1-17. [DOI: 10.5315/wjh.v3.i1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
As recognition of mast cell (MC) involvement in a range of chronic inflammatory disorders has increased, diagnosticians’ suspicions of MC activation disease (MCAD) in their chronically mysteriously inflamed patients have similarly increased. It is now understood that the various forms of systemic mastocytosis - diseases of inappropriate activation and proliferation of MCs seemingly driven by a small set of rare, usually constitutively activating mutations in assorted MC regulatory elements - comprise merely the tip of the MCAD iceberg, whereas the far larger and far more clinically heterogeneous (and thus more difficult to recognize) bulk of the iceberg consists of assorted forms of MC activation syndrome (MCAS) which manifest little to no abnormal MC proliferation and may originate from a far more heterogeneous set of MC mutations. It is reasonable to suspect MCAD when symptoms and signs of MC activation are present and no other diagnosis better accounting for the full range of findings is present. Initial laboratory assessment should include not only routine blood counts and serum chemistries but also a serum total tryptase level, which helps direct further evaluation for mastocytosis vs MCAS. Appropriate tissue examinations are needed to diagnose mastocytosis, while elevated levels of relatively specific mast cell mediators are sought to support diagnosis of MCAS. Whether assessing for mastocytosis or MCAS, testing is fraught with potential pitfalls which can easily yield false negatives leading to erroneous rejection of diagnostic consideration of MCAD in spite of a clinical history highly consistent with MCAD. Efforts at accurate diagnosis of MCAD are worthwhile, as many patients then respond well to appropriately directed therapeutic efforts.
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