THE MASTOCYTOSIS SYNDROME: CLINICAL AND BIOLOGICAL STUDIES

The role of mast cells in human skin cancers

Mast cells (MCs) are immune cells derived from myeloid lineage present in all classes of vertebrates and have emerged preceding much time the development of adaptive immunity. MCs are involved in inflammatory processes, allergic reactions, and host responses to parasites and bacteria infectious diseases. MCs are located at the host-environment interface, at many sites of initial antigen entry, including skin, lung and gastrointestinal tract, and have part of a protective mechanism. Skin has an important role in protecting the host from invasion both as physical barriers and by employing an intricate network of resident immune and non-immune cells include macrophages, T and B lymphocytes, MCs, neutrophils, eosinophils, and Langerhans cells. In this review we discussed the role of MCs in human skin cancers.

Indolent Systemic Mastocytosis – a Case Report

Indolent systemic mastocytosis is a benign form of systemic mastocytosis characterized by an abnormal proliferation of mast cells either in the bone marrow or in numerous tissues. Case Report: A 27-year-old female patient was admitted to our department due to urticaria which started a month ago. Before the skin changes appeared, our patient suffered from a toothache, so she took various painkillers (nimesulide, ibuprofen, acetylsalicylic acid, paracetamol). During skin examination, individual hyperpigmented macules on the trunk and lower limbs were observed as incidental findings. The patient reported having them for the last two years. Darier's sign was positive. Following the examination, she was admitted due to suspected urticaria pigmentosa. Laboratory Findings: erythrocyte sedimentation rate: 9 mm/h; complete blood count, urine, blood glucose, total and direct bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase, urea, creatinine, and uric acid were within normal ranges. Electrolytes: sodium, potassium, chlorine clearance, total calcium and calcium ionized, osteocalcin, and crosslaps were within normal ranges as well. Fibrinogen: 5.57 g/l; 5-Hydroxyindoleacetic acid: 49.8 umol/dU (10.4 - 31.2). Bone densitometry, chest x-ray and upper abdomen ultrasound findings were normal. The suspected clinical diagnosis of urticaria pigmentosa was confirmed by skin biopsy. Histopathological examination of the bone marrow showed moderately increased cellularity (60 - 70%). All three types of blood cells were slightly multiplied. Focal infiltrations were found in the perivascular area, consisting of elongated, oval cells with abundant eosinophilic granular cytoplasm. The nuclei were regular, oval shaped with finely granular chromatin and inconspicuous nucleoli. No nuclear atypia was found. These cells are highly CD117-positive. This finding strongly indicated bone marrow infiltration in systemic mastocytosis. The diagnosis was based on ‘major’ and ‘minor’ diagnostic criteria. The recommended therapy included H1 and H2 antagonists and topical corticosteroids. Conclusion: Regular follow-up was recommended in order to prevent complications and malignant alterations.

Mastocytosis: the puzzling clinical spectrum and challenging diagnostic aspects of an enigmatic disease

Mastocytosis is a complex disorder characterized by the accumulation of abnormal mast cells (MC) in the skin, bone marrow and/or other visceral organs. The clinical manifestations result from MC-derived mediators and, less frequently, from destructive infiltration of MCs. Patients suffer from a variety of symptoms including pruritus, flushing and life-threatening anaphylaxis. Whilst mastocytosis is likely to be suspected in a patient with typical skin lesions [i.e. urticaria pigmentosa (UP)], the absence of cutaneous signs does not rule out the diagnosis of this disease. Mastocytosis should be suspected in cases of recurrent, unexplained or severe insect-induced anaphylaxis or symptoms of MC degranulation without true allergy. In rare cases, unexplained osteoporosis or unexplained haematological abnormalities can be underlying feature of mastocytosis, particularly when these conditions are associated with elevated baseline serum tryptase levels. The diagnosis is based on the World Health Organization criteria, in which the tryptase level, histopathological and immunophenotypic evaluation of MCs and molecular analysis are crucial. A somatic KIT mutation, the most common of which is D816V, is usually detectable in MCs and their progenitors. Once a diagnosis of systemic mastocytosis (SM) is made, it is mandatory to assess the burden of the disease, its activity, subtype and prognosis, and the appropriate therapy. Mastocytosis comprises seven different categories that range from indolent forms, such as cutaneous and indolent SM, to progressive forms, such as aggressive SM and MC leukaemia. Although prognosis is good in patients with indolent forms of the disease, patients with advanced categories have a poor prognosis.

Gastrointestinal manifestations in mastocytosis: a study of 83 patients

BACKGROUND

Mastocytosis is a heterogeneous disease characterized by mast cell accumulation in 1 or more organs. Gastrointestinal manifestations of systemic mastocytosis have been previously studied in small cohorts of patients, and no specific histologic description is available.

OBJECTIVE

We sought to assess the clinical and pathologic features of gastrointestinal manifestations in patients with mastocytosis.

METHODS

Medical history and gastrointestinal symptoms of patients with mastocytosis (n = 83) were compared with those of matched healthy subjects (n = 83) by means of patient questionnaire. Data were analyzed for epidemiologic, clinical, biological, and genetic factors associated with gastrointestinal symptoms for patients with mastocytosis. A comparative analysis of gastrointestinal histology from patients with mastocytosis (n = 23), control subjects with inflammatory bowel disease (n = 17), and healthy subjects (n = 19) was performed.

RESULTS

The following gastrointestinal symptoms occurred more frequently and were more severe in patients with mastocytosis than in healthy subjects: bloating (33% vs 7.2%, P < .0001), abdominal pain (27.3% vs 4.8%, P < .0001), nausea (23% vs 8.4%, P = .02), and diarrhea (33.85% vs 1.2%, P < .0001). Patients with mastocytosis had a significantly higher incidence of personal history of duodenal ulcer (P = .02). Wild-type (WT) c-Kit was associated with diarrhea (P = .03). Specific histologic lesions were present in patients with mastocytosis but were not correlated with clinical symptoms.

CONCLUSION

Gastrointestinal manifestations in patients with mastocytosis are highly prevalent and often severe. Clinical symptoms do not correspond to histologic findings, are nonspecific, and can simulate irritable bowel syndrome.

Polycythemia from mast cell activation syndrome: lessons learned

A middle-aged woman presented with fatigue and mild increases in hematocrit and red cell mass. Polycythemia vera was diagnosed. She underwent therapeutic phlebotomy but clinically worsened. On reevaluation, other problems were noted including episodic malaise, nausea, rash and vasomotor issues. The JAK2V617F mutation was absent; paraneoplastic erythrocytosis was investigated. Serum tryptase and urinary N-methylhistamine were normal, but urinary prostaglandin D2 was elevated. Skin and marrow biopsies showed no mast cell abnormalities. Extensive other evaluation was negative. Gastrointestinal tract biopsies were histologically normal but revealed increased, aberrant mast cells on immunohistochemistry; the KITD816V mutation was absent. Mast cell activation syndrome, recently identified as a clonal disorder involving assorted KIT mutations, was diagnosed. Imatinib 200 mg/d rapidly effected complete, sustained response. Diagnosis of mast cell activation syndrome is hindered by multiple factors, but existing therapies for mast cell disease are usually achieve significant benefit, highlighting the importance of early diagnosis. Multiple important aspects of clinical reasoning are illustrated by the case.

Gastrointestinal involvement and manifestations in systemic mastocytosis

Mastocytosis is a rare and heterogeneous disease characterized by various biological and clinical features with different prognosis and treatments. The disease is usually divided into 2 categories: a pure cutaneous and a systemic disease. Clinical features can be related to mast cells' mediators release or to pathological mast cells infiltration. The diagnosis of mastocytosis is based on clinical, biological, histological, and molecular international criteria. Among all manifestations of the disease, gastrointestinal (GI) symptoms are common and can significantly impair the quality of life. The aim of this article is to review the data regarding GI involvement in mastocytosis. Articles dealing with clinical, pathophysiological, and therapeutic aspects of mastocytosis GI tract involvement were searched for using PubMed. GI manifestations in mastocytosis are reviewed. Pathogenesis of GI symptoms in systemic mastocytosis and their treatment are critically discussed. The most frequent GI symptoms are abdominal pain, diarrhea, nausea, and vomiting. GI lesions may involve all the digestive tract, from the esophagus to the rectum. The histological diagnosis of GI involvement is difficult. The treatment of GI symptoms aims to prevent and limit mast cells degranulation and/or its consequences and more rarely to control tumoral mast cells infiltration. The high prevalence of GI symptoms in mastocytosis and their important functional impact deserves better characterization and treatment in order to improve patients' quality of life. Diagnosis of mastocytosis GI manifestations should be evoked in the case of unexplained severe GI disorders.

Current approaches to the diagnosis and treatment of systemic mastocytosis

OBJECTIVE

To review the clinical manifestations of mastocytosis and examine the recommended diagnostic procedures and therapeutic options available for the treatment of this condition.

DATA SOURCES

PubMed searches were performed for articles published regarding presentation and classification of mastocytosis and the diagnostic criteria and treatment options for this condition using the keywords mastocytosis, clinical features, World Health Organization diagnostic criteria, management, pathogenesis, and urticaria pigmentosa. Retrieved articles were surveyed for additional citations.

STUDY SELECTION

Articles were reviewed for relevance to the study objectives, and more recent articles were preferentially included. Prospective studies were preferentially included when available.

RESULTS

Mastocytosis is a heterogeneous disorder that results from clonal mast cell proliferation. Symptoms are typically limited to the skin in the pediatric population, requiring only symptomatic treatment with spontaneous resolution by puberty. Disease course in adults ranges from minimally symptomatic in most to highly aggressive but tends to be persistent. Symptoms can be protean and nonspecific. The mainstay of treatment consists of avoidance of triggers of mast cell degranulation and symptom-based therapy.

CONCLUSIONS

Mastocytosis should be suspected in patients who present with a constellation of symptoms, including flushing, abdominal pain, diarrhea, unexplained syncope, and classic urticaria pigmentosa lesions. Diagnosis should be established by a bone marrow biopsy in all adults. Staging should be performed to assess disease burden and evidence of end-stage organ damage. Patients should be offered symptom-based treatment and cytoreductive therapy only for aggressive systemic mastocytosis or an associated hematologic malignant neoplasm.

Hypercalcitoninaemia in a patient with urticaria pigmentosa. A possible cause of diarrhoea

Mastocytosis gives rise to clinical symptoms such as flushing, itching and diarrhoea. We report a patient with urticaria pigmentosa without evidence of systemic involvement but with recurrent episodes of diarrhoea. The patient had elevated circulating levels of calcitonin, which might have been a mediator of her diarrhoea. We suggest that serum calcitonin level should be checked in patients with mast cell disease and diarrhoea.

Systemic Mastocytosis: Clinical Manifestations and Differential Diagnosis

Mast cells produce symptoms by local and remote effects of mediator release and by their presence in increased numbers in normal tissue and bone marrow, where they damage and impair normal organ function. Moreover, mast cells are long-lived and heterogeneous in their response to secretagogues and to inhibitors of mediator release. Clinicians sorting out the diagnosis of SM on the basis of presenting signs and symptoms continue to have their diagnostic skills challenged because of the rarity of this disorder, the fact that many symptoms of SM are present in more common disorders, and the multiple guises that SM may assume at the time of presentation.

Bone marrow angiogenesis in systemic mast cell disease

Mast cells may participate in tumor angiogenesis through the release of angiogenic cytokines from their secretory granules. To gain additional insight into the role of mast cells in bone marrow angiogenesis, we performed a semiquantitative measurement of bone marrow microvessel density in 52 consecutive adult patients with systemic mast cell disease (SMCD). The results were examined for potential correlations with mast cell expression of angiogenic cytokines and with other histologic features of the bone marrow. Standard immunohistochemical methods were used to visualize bone marrow microvessels (CD34 staining) and mast cell expression of transforming growth factor-beta, basic fibroblast growth factor, and their respective receptors. An increase in microvessel density was demonstrated in 32 of the 52 patients (62%) with SMCD, and the degree of bone marrow angiogenesis did not correlate with either the mast cell expression pattern of the study cytokines or the presence (23 patients) or absence (29 patients) of an associated hematologic disorder. In the 29 patients without an associated hematologic disorder, microvessel density was correlated significantly with the presence of an abnormal pattern of hematopoiesis but not with the degree of bone marrow involvement by mast cells. Furthermore, areas occupied by mast cell lesions were often devoid of neovascularization. We conclude that bone marrow angiogenesis characterizes a percentage of patients with SMCD and that the pathogenesis may not necessarily be linked to the mast cells themselves.

Immunohistochemical studies of c-kit, transforming growth factor-beta, and basic fibroblast growth factor in mast cell disease

In 58 patients with mast cell disease (MCD) and three with basophilic leukemia, bone marrow (54 cases) or skin tissue (four cases) was studied immunohistochemically for expression of Kit (c-kit protein), the different isomers of transforming growth factor-beta (TGF-beta), basic fibroblast growth factor (bFGF), and their respective receptors. Kit was expressed in all cases of MCD but in none of basophilic leukemia. Expression pattern of cytokines and their receptors was variable in systemic MCD with (SMCD-HD) or without (SMCD) associated hematologic disorder. However, type I TGF-beta receptor (TGFbeta1R) was not expressed in 30% of SMCD-HD patients or in patients with mast cell leukemia, but the remaining cases of MCD showed near uniform expression. The associated hematologic disorders in TGFbeta1R-negative cases of SMCD-HD were prognostically less favorable than those associated with TGFbeta1R-positive cases of SMCD-HD. The results confirm the diagnostic value of Kit immunohistochemistry in MCD and suggest a biologically relevant heterogeneity in TGFbeta1R expression among patients with SMCD-HD.

Diagnosis of mastocytosis: value of cytochemistry and immunohistochemistry

The diagnosis of mastocytosis or mast cell disease may be difficult sometimes because of the wide variety of clinical presentation, abnormal morphology of mast cells, and variation in histologic features which may mimic varieties of other diseases. Over the years, several cell type specific cytochemical and immunochemical markers have been used for the identification of hematopoietic cells in order to establish the accurate diagnosis of mastocytosis and their associated hematologic diseases. Cytochemical stain for aminocaproate esterase is the most specific enzyme marker for identification of mast cells on cytologic specimens and the immunohistochemical stain for tryptase and/or c-kit has also been established as a sensitive and specific marker for mast cells in paraffin sections.

Mastocytosis and the skin

The most frequent site of organ involvement in individuals with any form of mastocytosis is the skin. Cutaneous lesions include urticaria pigmentosa, mastocytoma, diffuse and erythematous cutaneous mastocytosis, and telangiectasia macularis eruptiva perstans. The major histologic feature is an increase in the number of mast cells in the dermis. Treatment depends on the type of skin lesions.

Gastrointestinal abnormalities and involvement in systemic mastocytosis

Recent studies have shown that involvement of the gastrointestinal tract is much more frequent than originally reported in patients with systemic mastocytosis. Seventy percent to 80% of patients with systemic mastocytosis are found to have gastrointestinal symptoms when a careful history is taken, and abnormalities in the gastrointestinal tract are frequently detected by endoscopic studies, functional studies of absorption, and barium studies. Because of the rarity of the disease, there are few prospective studies of gastrointestinal involvement, so the actual frequency of upper and lower gastrointestinal lesions is unknown. Furthermore, there have been no studies correlating endoscopic abnormalities of the lower gastrointestinal tract with the presence or absence of diarrhea, which is a frequent symptom (mean, 43% [range 14%-100%]). A review of gastric acid studies reveals that a proportion of patients develop gastric acid hypersecretion because of the hyperhistaminemia, which can result in ulcer disease that in turn can cause dyspeptic pain, small intestinal mucosal damage, and malabsorption. In some patients gastric acid hypersecretion in the range seen in Zollinger-Ellison syndrome can develop. A number of studies suggest that the prevalence of peptic ulcer disease has been underestimated in these patients and is certainly higher than the general population. The exact physiologic basis for the diarrhea or nondyspeptic abdominal pain remains largely unknown in these patients. Whereas some studies suggest small intestinal mucosal abnormalities are responsible for most cases of malabsorption not associated with gastric acid hypersecretion, this supposition also remains unproven. Hepatomegaly, portal hypertension, splenomegaly, and ascites occur frequently in patients with systemic mastocytosis, especially those with category II through IV disease. Whereas the histology of the liver and spleen and alterations in hepatic function studies have been well studied, the pathogenesis of each of these abnormalities has not been well studied, and almost all the information comes from a few well-studied case reports.

Diffuse cutaneous mastocytosis with bone marrow infiltration in a child: a case report

Mastocytosis encompasses a range of disorders characterized by overproliferation and accumulation of tissue mast cells. Mast cell disease is most commonly seen in the skin, but the skeleton, gastrointestinal tract, bone marrow, and central nervous system may also be involved. We present a 10-year-old boy with diffuse cutaneous mastocytosis characterized by disseminated papular, nodular, and infiltrated leathery lesions. The patient presented with chronic diarrhea and malnutrition. Laboratory studies were normal except for an elevated urinary 1-methylhistamine level. The bone marrow aspirate showed a dense mast cell infiltrate confirming systemic involvement.

Systemic mastocytosis presenting as profound cardiovascular collapse during anaesthesia

Mastocytosis is a rare disorder with serious anaesthetic implications. Anaesthetic management is hazardous since trauma, stress, extremes of temperature and drugs may precipitate intra-operative mast cell degranulation. Release of histamine and other mast cell mediators can lead to profound cardiovascular collapse and even death. We present a case report of a patient with mastocytosis who suffered cardiac arrest during anaesthesia. Anaphylactoid/anaphylactic shock may be delayed and lack supporting signs of histamine release such as cutaneous flushing and bronchospasm.

Endogenous histamine stimulates ischemically sensitive abdominal visceral afferents through H1 receptors

Abdominal ischemia stimulates sympathetic visceral afferents to reflexly activate the cardiovascular system. We have shown previously that topical application of histamine (HA) to the gastric wall causes reflex cardiovascular responses and have documented increased histamine concentrations in intestinal lymph and portal venous plasma during brief abdominal ischemia. In the present study, we hypothesized that histamine produced during ischemia activates ischemically sensitive C-fiber afferents by stimulation of H1 receptors. Nerve activity of single-unit abdominal visceral C-fiber afferents was recorded from the right thoracic sympathetic chain of anesthetized cats. Injection of histamine (25 micrograms/kg ia) significantly increased activity of nine ischemically sensitive C fibers from 0.09 +/- 0.06 to 1.11 +/- 0.20 imp/s. An H1-receptor agonist, 2-(3-chlorophenyl)histamine (250 micrograms/kg ia), also increased activity of these afferents from 0.11 +/- 0.04 to 0.64 +/- 0.18 imp/s (P < 0.05). Furthermore, an H1-receptor antagonist (pyrilamine, 0.2 mg/kg i.v.) significantly attenuated the increased activity in 11 other C fibers from 0.91 +/- 0.16 to 0.35 +/- 0.06 imp/s ischemia vs. pyrilamine + ischemia) and eliminated the response of 9 separate ischemically sensitive afferents to histamine. Conversely, both the H2-receptor agonist dimaprit (500 micrograms/kg ia) and the H3-receptor.agonist (R)-alpha-methylhistamine (250 micrograms/kg ia) did not significantly alter the activity of these nine afferents. In nine separate cats treated with indomethacin (5 mg/kg i.v.), pyrilamine (0.2 mg/kg i.v.) further significantly attenuated the increased activity in seven of nine C fibers during ischemia, and indomethacin (5 mg/kg i.v.) attenuated the response of eight other afferents to histamine. These data suggest that during mesenteric ischemia endogenous histamine contributes to the activation of afferents through direct stimulation of histamine H1 receptors and that histamine's stimulating effect on these afferents is dependent partially on production of prostaglandins.

Differential diagnosis of hot flashes

OBJECTIVE

The purpose of this study is to present the physiology and differential diagnosis of hot flashes, other than associated with menopause, in order to facilitate the proper evaluation of symptomatic patients with hot flashes.

STUDY DESIGN

Literature search using Med-Line computer access.

RESULTS

Interest in flushing reaction began in historic times. With the rapidly expanding population of women over the age of 45 and prevalence of hot flashes as menopausal symptoms, physicians need to be aware of other medical conditions which may mimic hot flashes. These include flushing due to systemic diseases, carcinoid syndrome, systemic mast cell disease, pheochromocytoma, medullary carcinoma of the thyroid, pancreatic islet-cell tumors, renal cell carcinoma, neurological flushing, emotional flushing, spinal cord injury, flushing reaction related to alcohol and drugs, flushing associated with food additives and eating.

CONCLUSION

There is a wide variety of disease processes that can cause hot flashes. Knowledge of the nature of these disease processes is necessary for quick recognition of patients with hot flashes who do not respond to estrogen replacement treatment, and to facilitate the proper evaluation of atypical patients.

Treatment of telangiectasia macularis eruptiva perstans with the 585-nm flashlamp-pumped dye laser

BACKGROUND

Telangiectasia macularis eruptiva perstans (TMEP) is a form of cutaneous mastocytosis characterized by truncal telangiectases that are refractory to treatment.

OBJECTIVE

The safety and efficacy of treating TMEP with laser surgery was tested in a patient with extensive truncal lesions.

METHODS

The patient was treated with the 585-nm flashlamp-pumped dye laser. Diphenhydramine and ranitidine or doxepin were used pre- and postoperatively to block the effects of mast cell mediator release during surgery.

RESULTS

All treated cutaneous lesions resolved completely, without scarring, after one treatment. Approximately 70% of the truncal lesions recurred 14 months postoperatively. Doxepin provided the best mast cell mediator blockade. Postoperative biopsy of a treated lesion demonstrated focal dermal vascular fibrosis with minimal telangiectasia and upper level of normal numbers of mast cells on the biopsy.

CONCLUSIONS

An excellent therapeutic result was obtained by treating TMEP with the 585-nm flashlamp-pumped dye laser, although the response was temporary. The therapeutic effect of the laser appears to be secondary to reduction of the vasculature with no apparent effect on the mast cells. Physicians treating TMEP with laser therapy must use proper H1 and H2 receptor blockade to avoid potential complications from laser-induced mediator release.

Clinical advances in mastocytosis

Mastocytosis is a disease characterized by an abnormal proliferation of tissue mast cells. The events primarily responsible for mast cell proliferation in mastocytosis are largely unknown, but a derangement of the network involving c-kit receptor and its natural ligand (stem cell factor, which promotes mast cell growth and differentiation in man) is likely to have a primary role in this disease. Mastocytosis comprises a wide spectrum of clinical conditions determined by the degree of mast cell proliferation, the organ systems involved, the age at onset and the association with hematologic diseases. Mastocytosis can occur in a pediatric or an adult form. In both groups of patients, the disease may be limited to the skin (cutaneous mastocytosis) or be systemic, involving predominantly the bone marrow and the gastrointestinal tract. The symptoms in patients with mastocytosis are generally related to the increased release of mast-cell-derived mediators, such as histamine, prostaglandin D2, peptide leukotrienes, platelet-activating factor, heparin and proteolytic enzymes. The measurement of these chemical mediators (histamine, tryptase and prostaglandin D2 and their metabolites) in body fluids is useful for the diagnosis and the laboratory evaluation of patients with systemic mastocytosis. As little is known about the pathogenesis of the different forms of mastocytosis, the treatment of the majority of these patients is largely symptomatic.

Southwestern Internal Medicine Conference: mastocytosis: developments during the past decade

Mastocytosis is a spectrum of disorders characterized by an aberrant proliferation of tissue mast cells. Although this disease process often affects the skin, it may involve multiple organs. The clinical disorder varies according to patient age, the clinical manifestations demonstrated, and the extent of the mast cell proliferative process. A myriad of clinical symptoms occur, and these may be localized to the organ system involved or may be systemic, depending on whether there is local or generalized mast cell mediator release. Diagnosis includes the demonstration of increased tissue mast cells in involved organs as well as increased levels of biochemical mediators. Patients with cutaneous involvement only have the best prognosis. Treatment is directed toward stabilizing mast cell mediator release and blocking the effects of those mediators generated.

The mast cell and mast cell disease

Mast cell disease or mastocytosis is a heterogeneous group of clinical disorders characterized by the proliferation and accumulation of mast cells in a variety of tissues, most often the skin. The signs and symptoms of mast cell disease are varied, dependent on the localization of mast cells in different organs and the local and systemic effects of mediators released from these cells. Although mast cell disease is most commonly identified in the skin, involvement of the skeletal, hematopoietic, gastrointestinal, cardiopulmonary, and central nervous systems may be seen. Clinical management of mastocytosis depends most heavily on knowledge of the diverse effects of mast cell mediators on various tissues and organs, the stimuli that can cause their release, and the different methods available for blocking the effects of these mediators.

Evaluation of anorectal physiology in patients with increased mast cells

Diarrhea, urgency, and fecal incontinence are common complaints in systemic mastocytosis and in patients with increased gastrointestinal mucosal mast cells. We performed anorectal manometry on six patients with clinical symptoms of mastocytosis and histologic evidence of increased mast cells and compared the results to anorectal manometry of six age- and sex-matched controls, with no bowel symptoms. Standard techniques with balloon volumes were used to measure maximal basal pressure, maximal squeeze pressure, smallest volume sensed, degree of relaxation of the internal sphincter, and the volume causing: (1) a strong urge to defecate and (2) pain. Patients with mastocytosis, compared with controls, had smaller balloon volumes induce rectal urgency (97 vs 164 ml) and pain (117 vs 278 ml). A trend was present for lower maximal basal pressure in mastocytosis, but was not statistically significant. Sensitivity to balloon inflation suggests decreased rectal compliance or overreactive rectal contractility. These findings provide an explanation for the anorectal symptoms in patients with increased mast cells.

Generalized mastocytosis and neurological complications in a 71-year-old patient

A woman born in 1917 presented with recurrent urticaria since childhood. In the course of her life she developed urticaria pigmentosa, followed by generalized mastocytosis involving the bones, gastro-intestinal tract, and liver. At the age of 71 years neurological symptoms of cranial nerves necessitated hospital admission. Within a month a concomitant conus medullaris syndrome caused sphincter dysfunction and sacral sensory disturbances. No cause or secondary abnormalities were found on myelography, CT and MRI of the brain and the spinal cord, and in the CSF.

Mastocytosis. Perioperative considerations

Mastocytosis, an uncommon clinical disorder, can present a variety of clinical manifestations ranging from an asymptomatic state to one characterized by recurrent episodes of severe vasodilatation. Even the patient whose disease appears to be well controlled and is asymptomatic preoperatively can develop serious intraoperative problems. Knowledge of the pathogenesis and treatment, avoidance of known provoking factors, and adherence to established precautionary measures, in particular the constant availability of IV epinephrine infusion throughout the perioperative period, enables members of the surgical team to safely support the patient throughout the operative experience.

Skin and bones. II

Skin disorders in which a radiograph may detect associated bony changes or abnormalities of calcification are discussed. They are grouped into eight categories: (1) inherited diseases (e.g., alkaptonuria, neurofibromatosis); (2) congenital disorders (e.g., Sturge-Weber and Proteus syndromes); (3) inflammatory conditions (e.g., dermatomyositis, sarcoidosis); (4) infections (e.g., dental sinus, syphilis); (5) neoplasias (e.g., histiocytosis, mastocytosis); (6) drug- and environment-induced (e.g., acroosteolysis, retinoid toxicity); (7) calcinosis cutis; and (8) osteoma cutis. The first part of this review, published in the August 1991 issue of this JOURNAL, dealt with the first two categories; part II discusses categories 3 through 8.

The Skin in Mastocytosis

The most frequent site of organ involvement in patients with any form of mastocytosis is the skin. Cutaneous expressions include urticaria pigmentosa, mastocytoma, diffuse and erythrodermic cutaneous mastocytosis, and telangiectasia macularis eruptiva perstans. The cutaneous lesions tend to appear early in life. Although urticaria pigmentosa has been reported in 12 pairs of twins and one set of triplets, the majority of affected individuals have no familial association. Most patients with systemic mastocytosis have skin lesions; however, an occasional patient will have systemic disease with no other skin features than flushing. In lesional cutaneous sites and in non-lesional skin, there is an increase in the number of mast cells. Electron microscopy shows quantitative differences between lesional skin mast cells from patients with and without systemic disease. The mast cells from adult patients with systemic disease have a larger mean cytoplasmic area, nuclear size, and granule diameter. The granules contain predominantly grating/lattice structures. The cutaneous mast cells contain tryptase and chymase. They retain their functional reactivities to relevant secretory stimuli, such as C3a, morphine sulfate, and calcium ionophore A23187. Lesional skin contains histamine, leukotriene B4, prostaglandin D2, 5-hydroxyeicosatetraenoic acid, platelet-activating factor, and heparin. Treatment of the cutaneous manifestations includes the use of H1 and H2 antihistamines, oral disodium cromoglycate, psoralens plus ultraviolet A photochemotherapy, and potent topical corticosteroid preparations.

Systemic Mastocytosis: Retrospective Review of a Decade's Clinical Experience at the Brigham and Women's Hospital

The clinical experience with a group of 21 patients with systemic mastocytosis followed at our institution is summarized. Cutaneous and gastrointestinal symptoms and findings were the most prominent chronic manifestations; episodic vascular collapse was the most dramatic acute event. All patients had indolent mastocytosis. There was no mortality.

Pediatric Mastocytosis

The onset of mastocytosis occurs between birth and 2 years of age in approximately 55% of all cases; an additional 10% develop the disease before the age of 15 years. Mastocytosis in these age groups differs in many respects from mastocytosis that has its onset in adulthood. The typical presentation of pediatric-onset mastocytosis consists of cutaneous manifestations: either a solitary mastocytoma, urticaria pigmentosa, or, less commonly, diffuse cutaneous mastocytosis. Particularly in infants, bullous eruptions may occur. Mastocytosis in infants and children may involve internal organs, including the bone marrow and the gastrointestinal tract, although such manifestations appear to be less common in children than in adults. Plasma histamine levels may be elevated in pediatric-onset mastocytosis. Treatment usually involves the use of H1 and H2 antihistamines to control itching and to control the hypersecretion of gastric acid that may occur. The prognosis for children with mast cell disease is variable; approximately half of the children with urticaria pigmentosa may experience resolution of lesions and symptoms by adolescence.

Photochemotherapy of dominant, diffuse, cutaneous mastocytosis

Diffuse, cutaneous mastocytosis is a rare variant of cutaneous mast cell infiltration that can arise in neonates or infants as a generalized bullous eruption. The mode of transmission is suggested as autosomal dominant. We report four infants from two unrelated families with diffuse cutaneous mastocytosis whose cutaneous disease was not controlled by initial therapies. Treatment of the four infants with photochemotherapy dramatically reduced or eliminated symptoms. One course of therapy resulted in improvement, and retreatment has not been required two to six years later.

Inhibition of mediator release in systemic mastocytosis is associated with reversal of bone changes

A 59-year-old male presented with systemic mastocytosis with extensive skeletal involvement resulting in vertebral compression fractures and bone pain. Histomorphometric analysis of bone revealed increased mast cells, elevated static parameters of bone resorption, and low bone formation. Serum calcium, phosphorus, and alkaline phosphatase were normal; however, serum 1,25-dihydroxyvitamin D3 and osteocalcin levels were low. Histamine levels in plasma and urine were elevated. Following therapy with ketotifen, the patient had resolution of bone pain along with decreased flushing and pruritus. Elevated plasma and urine histamine levels normalized, as did 1,25-dihydroxyvitamin D3 and osteocalcin levels. Indices of low bone formation improved on therapy. Eroded surfaces improved but remained elevated. This case is the first demonstration that bone symptoms and histomorphometric change in systemic mastocytosis are reversed with inhibition of mast cell degranulation. The role of mast cells and their products in bone metabolism is poorly understood, but the therapy of bone disease in systemic mastocytosis should include inhibition of the release of mast cell products along with the use of histamine antagonist.

A case of POEMS syndrome associated with essential thrombocythaemia and dermal mastocytosis

We describe a case of POEMS syndrome presenting with the recognized features of polyneuropathy, organomegaly, endocrine abnormalities, monoclonal protein, skin changes and anasarca. The patient was found to have both a solitary sclerotic plasmacytoma of the pelvis and evidence of Castleman's disease of lymph nodes. A number of unusual and unique features are also documented. Histological examination of affected skin demonstrated changes similar to urticaria pigmentosa including local oedema and mast cell infiltration. There was marked thrombocythaemia which has been seen in only one previous case and in addition the patient developed diffuse vascular calcification in the absence of recognized aetiological factors. Radiotherapy of the pelvic lesion and chemotherapy to control the myeloproliferative disorder gave rise to significant improvement in neuropathy. Control of anasarca required steroid therapy in addition to diuretics. The significance of these observations is discussed in relation to previous reports.

Malignant mastocytosis with circulating mast cells

A case of malignant mastocytosis with peripheral blood involvement is presented. The course of the patient's illness was complicated by recurrent hypotensive episodes, presumed to have been caused by mast cell degranulation. Treatment with hydroxyurea was associated with persistent hypotension which resulted in death. It has been proposed that the diagnosis of mast cell leukemia be given to patients presenting with greater than 10% atypical mast cells in the blood. However, review of 16 published cases of malignant mastocytosis with circulating mast cells reveals that the clinical manifestations, complications, and survival do not vary significantly with the percentage of peripheral blood mast cells. Patients with malignant mastocytosis with significant involvement by atypical mast cells in the bone marrow and peripheral blood should be considered as having an aggressive disease, regardless of the percentage of circulating mast cells.

A clinical and histological study of urticaria pigmentosa: relationships between mast cell proliferation and the clinical and histological manifestations

In 21 cases of urticaria pigmentosa (UP), clinical and histological observations and evaluation of mast cell (MC) volume density in the lesions using a morphometric point counting method were performed. The mutual correlations between clinical and histological findings were statistically assessed by a method of multiple regression analysis. Clinical items employed in the analyses were as follows: sex, the age of onset, the age of biopsy, the biopsy, the duration of lesions, the type of skin lesions, sites involved, the presence or absence of Darier's sign of Darier's sign and symptoms, and serum histamine level. Histological items included the localization and infiltration pattern of MC, the level of basal melanosis, the presence or absence of inflammatory cell infiltration, and the MC volume density in the lesions. Statistical significance of the partial regression coefficients was obtained for 6 pairs of the criteria (p = 0.05), including the age of onset and the age of biopsy, the age of onset and the level of basal melanosis, the duration of lesions and the level of basal melanosis, and the type of skin lesions and the level of basal melanosis. No significant correlations were observed between the MC volume density in the lesions and any of the other items. These results suggest that the basal melanosis in a UP lesion may not be a direct reaction to the transitory massive infiltration of MC, but rather be due to a relatively long-term effect of MC infiltration. Furthermore, the MC volume density in the lesion is not likely to be an important factor in determining the clinical manifestations of a UP lesion.

Urticaria pigmentosa: an anesthetic challenge

Urticaria pigmentosa is the most common form of mastocytosis, a disease in which abnormal proliferations of mast cells occur in various organs of the body. Multiple stimuli, including many drugs commonly used in anesthetic practice, can provoke mast cell degranulation and result in intraoperative hemodynamic instability. An anesthetic plan minimizing histamine release and utilizing vecuronium as the muscle relaxant is discussed, and the literature pertaining to urticaria pigmentosa is reviewed.

Skin mastocytosis with short stature, conductive hearing loss and microtia: a new syndrome

A 5 1/2-year-old Sephardic Jewish girl, born of consanguineous parents, is described. She has short stature, microcephaly, conductive hearing loss, skin mastocytosis and microtia. Since this constellation of findings has not been reported previously, we think that these findings represent a new congenital malformation, most probably of genetic etiology.

Increased urinary excretion of 1.4-methyl-imidazoleacetic acid in patients with atopic dermatitis

To investigate whether the overall histamine turnover is increased in patients with atopic dermatitis, without respiratory disease, the urinary excretion of the main histamine metabolite 1.4-methyl-imidazoleacetic acid (MIAA) was examined in 23 patients and in 23 age- and sex-matched non-atopic controls. The patients excreted significantly more MIAA than the controls. One third of the patients however, showed MIAA excretion within or below normal range. The MIAA excretion was neither correlated to the severity of the eczema nor to the total serum IgE. It was concluded that histamine does not play a significant role in the pathophysiology of atopic dermatitis, and that the great variation in MIAA excretion, and hence the histamine turnover, reflected the spectrum of histamine releasability in the patients.

Significance of systemic mast cell disease with associated hematologic disorders

A clinical and hematopathologic review of 66 patients with systemic mast cell disease (SMCD) was undertaken to investigate the frequency and the clinical significance of associated hematologic disorders. Twenty-two patients were found to have a second hematologic disorder, 19 of which involved the myeloid cells (ten dysmyelopoietic syndromes, five myeloproliferative disorders, three acute nonlymphocytic leukemias, and one chronic neutropenia), and three of which involved the lymphoid cells (three malignant lymphomas). A chromosome analysis of the bone marrow revealed abnormalities characteristic of neoplastic myeloid disorders in four patients. Five-year survival for patients with hematologic disorders was 28% compared with 61% for other SMCD patients (P = 0.004). Patients with hematologic disorders differed significantly from other SMCD patients in that they were about 7 years older (P = 0.039), and they presented more commonly with anemia (P less than 0.001) and constitutional symptoms (P = 0.007). These patients also had less frequent skin symptoms (P = 0.003) and urticaria pigmentosa (P = 0.018). By definition, patients with hematologic disorders had a greater percent of hematopoiesis (P less than 0.001) and decreased fat cells (P = 0.011) on bone marrow biopsies. A multivariate model demonstrated that the following independent variables were associated with the presence of hematologic disorders: low hemoglobin (P = 0.001), the absence of hepatomegaly (P = 0.016), high leukocyte count (P = 0.021), and the presence of pathologic fractures (P = 0.051). The frequent coexistence of SMCD with dysplastic and neoplastic disorders of myeloid cells is consistent with the concept that SMCD itself is a disorder of myeloid cells and that the mast cell may be myeloid in origin.

Gastrointestinal dysfunction in systemic mastocytosis. A prospective study

In 16 consecutive patients with systemic mastocytosis, we prospectively evaluated a variety of gastrointestinal functions and examined how they relate to the occurrence of gastrointestinal symptoms. Nine patients had either a duodenal ulcer or duodenitis. Hypersecretion of gastric acid was present in 6 patients, and in these patients the mean basal acid output was 20.7 +/- 4.1 mEq/h (range 14-39 mEq/h). Impaired small intestinal absorption occurred in 5 patients, although this was usually mild. The mean fractional emptying rate of liquids for all patients (14.7% +/- 2.3% per minute) did not differ from that for controls (10.7% +/- 0.6% per minute). Mean mouth-to-cecum transit time measured by breath hydrogen testing was the same among patients (87.7 +/- 6.7 min) and controls (86.7 +/- 8.0 min). Plasma histamine concentrations were increased in all patients (mean 1886 pg/ml, range 480-7450) and correlated with the basal acid output (r = 0.64, p less than 0.02) but not maximal acid output or the presence or absence of pain or diarrhea. Mean fasting plasma concentrations of motilin, substance P, and neurotensin from 6 patients did not differ significantly from controls, whereas gastrin and vasoactive intestinal peptide were significantly less than in controls (p less than 0.01). Gastrointestinal symptoms, consisting of abdominal pain or diarrhea, occurred in 80% of patients. Abdominal pain classified as dyspeptic was usually associated with acid-peptic disease of the duodenum and hypersecretion of gastric acid, whereas abdominal pain of a nondyspeptic character was not. Only in those cases of diarrhea consisting of greater than 200 g stool/day was gastric acid hypersecretion frequently found. Neither fecal urgency nor nondyspeptic pain could be accounted for by alterations of gastrointestinal transit. These results demonstrate that gastrointestinal symptoms, peptic disease, and mild malabsorption are much more common than described previously in patients with systemic mastocytosis. Furthermore, the results provide no evidence for the contention that altered gastrointestinal transit is involved in the pathogenesis of these symptoms.

Malignant systemic mastocytosis

Malignant systemic mastocytosis is a rare disorder, a subgroup of the mast cell neoplasms. Its clinical and histological diagnosis is often difficult, especially in patients without cutaneous involvement. We report an unsuspected case who underwent laparotomy complicated by life-threatening hypotension consistent with vasoactive mediator release from mast cells. The subsequent use of two chemotherapy regimens is detailed and both induced transient reduction in disease bulk.

The immunoglobulin E- and calcium-dependent release of histamine and eicosanoids from human dispersed mastocytosis spleen cells

The clinical features of systemic mastocytosis have been ascribed to mast cell-dependent mediators, but there have been no studies of their release from isolated cells. We have investigated the release of histamine and eicosanoids from isolated spleen cells obtained from tissue of a mastocytosis patient undergoing therapeutic splenectomy. Dispersed cell preparations contained lymphocytes 65.9%, monocytes/macrophages 22.3%, neutrophils 9.9%, mast cells 1.1%, and eosinophils 0.8%; upon challenge with 0.1-3.0 microM A23187 they released histamine much greater than PGD2 greater than TXB2 greater than LTB4 greater than LTC4 approximately equal to LTD4 greater than LTE4. With immunological activation of passively sensitized cells, histamine and PGD2 release had similar dose-response characteristics, but TXB2, LTC4, LTD4, and LTE4 release differed in reaching maximum at 50 micrograms/ml and declining at 125 micrograms/ml anti-human IgE. Percoll centrifugation separated most of the histamine-containing cells to the middle of the gradient, but they were refractory to release with 0.3 microM A23187 or 50 micrograms/ml anti-IgE. Spontaneous release of histamine from these cells was not abnormally high (1.3%-4.5%). Electron microscopy of tissue sections revealed large numbers of mast cells with empty granules. It is possible that the refractory cells observed are such mast cells where intracellular histamine is no longer granule-associated. Most net histamine and PGD2 release was confined to cells at the bottom of the gradients (1.078-1.09 g/ml), although some release of PGD2 occurred near the top (1.05-1.058 g/ml). There was a significant correlation between the net release of histamine and PGD2 with both immunological (r = 0.92; n = 16) and A23187 (r = 0.97, n = 14) activation. These studies provide evidence for a link between PGD2 and histamine release in mastocytosis spleen cells.

Ultrastructural morphometric analysis of lesional skin: mast cells from patients with systemic and nonsystemic mastocytosis

Lesional skin mast cells from some patients with mastocytosis appear morphologically atypical; however, these subjective differences have not been quantified. Herein we describe an objective method for analyzing cutaneous mastocytosis mast cells by a combination of morphometric analysis and electron microscopy. By this technique, lesional mast cells from patients with adult systemic mastocytosis had a significantly larger mean cytoplasmic area (53.3 microns2), nuclear size (20.4 microns2), and granule diameter (0.81 micron) when compared with mast cells from adults with nonsystemic mastocytosis (36.3 micron 2, 15.4 microns2, and 0.67 micron, respectively) and normal age-matched control subjects (34.4 microns2, 14.1 microns2, and 0.67 micron, respectively). Lesional skin mast cells from infants with nonsytemic mastocytosis were very similar to adult nonsystemic mastocytosis mast cells but differed by several parameters from mast cells in adults with systemic involvement. This study demonstrates that there are quantitative differences between lesional skin mast cells from patients with systemic mastocytosis and those with nonsystemic disease.