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Walters AS, Li Y, Koo BB, Ondo WG, Weinstock LB, Champion D, Afrin LB, Karroum EG, Bagai K, Spruyt K. Review of the role of the endogenous opioid and melanocortin systems in the restless legs syndrome. Brain 2024; 147:26-38. [PMID: 37633259 PMCID: PMC10796165 DOI: 10.1093/brain/awad283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/23/2023] [Accepted: 08/01/2023] [Indexed: 08/28/2023] Open
Abstract
Restless legs syndrome (RLS) is responsive to opioid, dopaminergic and iron-based treatments. Receptor blocker studies in RLS patients suggest that the therapeutic efficacy of opioids is specific to the opioid receptor and mediated indirectly through the dopaminergic system. An RLS autopsy study reveals decreases in endogenous opioids, β-endorphin and perhaps Met-enkephalin in the thalamus of RLS patients. A total opioid receptor knock-out (mu, delta and kappa) and a mu-opioid receptor knock-out mouse model of RLS show circadian motor changes akin to RLS and, although both models show sensory changes, the mu-opioid receptor knock mouse shows circadian sensory changes closest to those seen in idiopathic RLS. Both models show changes in striatal dopamine, anaemia and low serum iron. However, only in the total receptor knock-out mouse do we see the decreases in serum ferritin that are normally found in RLS. There are also decreases in serum iron when wild-type mice are administered a mu-opioid receptor blocker. In addition, the mu-opioid receptor knock-out mouse also shows increases in striatal zinc paralleling similar changes in RLS. Adrenocorticotropic hormone and α-melanocyte stimulating hormone are derived from pro-opiomelanocortin as is β-endorphin. However, they cause RLS-like symptoms and periodic limb movements when injected intraventricularly into rats. These results collectively suggest that an endogenous opioid deficiency is pathogenetic to RLS and that an altered melanocortin system may be causal to RLS as well.
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Affiliation(s)
- Arthur S Walters
- Sleep Division, Department of Neurology, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Yuqing Li
- Norman Fixel Institute for Neurological Diseases, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Brian B Koo
- Sleep Medicine Laboratory, VA Connecticut Health Care System, West Haven, CT 06516, USA
- Yale Center for Restless Legs Syndrome, Yale School of Medicine, New Haven, CT 06520, USA
| | - William G Ondo
- Department of Neurology, Methodist Hospital, Weill Cornell Medical School, Houston, TX 77030, USA
| | - Leonard B Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St.Louis, MO 63130, USA
| | - David Champion
- Sydney Children's Hospital, Department of Pain Medicine, Randwick, NSW 2031, Australia
| | - Lawrence B Afrin
- Hematology/Oncology, AIM Center for Personalized Medicine, Purchase, NY 10577, USA
| | - Elias G Karroum
- Department of Neurology and Rehabilitation Medicine, The George Washington University School of Medicine and Health Sciences, George Washington University, Washington, D.C. 20052, USA
| | - Kanika Bagai
- Sleep Division, Department of Neurology, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Karen Spruyt
- Université Paris Cité, NeuroDiderot Inserm, Paris 75019, France
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Palmer RF, Dempsey TT, Afrin LB. Chemical Intolerance and Mast Cell Activation: A Suspicious Synchronicity. J Xenobiot 2023; 13:704-718. [PMID: 37987446 PMCID: PMC10660865 DOI: 10.3390/jox13040045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/19/2023] [Accepted: 11/10/2023] [Indexed: 11/22/2023] Open
Abstract
Background: Chemical Intolerance (CI) is characterized by intolerances for chemicals, foods, and drugs with multi-system symptoms. As yet, the biomechanism remains unclear. One study reported converging lines of evidence supporting a substantive association between mast cell activation syndrome (MCAS) and CI. The purpose of this study is to (1) confirm a previous report demonstrating that 60% of MCAS patients report CI and (2) examine the parallels between symptoms and intolerances in CI and MCAS. Methods: Five hundred forty-four MCAS patients were assigned a clinical MCAS score using a validated assessment instrument and were assessed for CI using the validated Quick Environmental Exposure Sensitivity Index. Results: Our outcomes confirm the previously published study where the majority of MCAS patients also have CI. There was a clear overlap between various ICD-10 diagnostic categories and CI symptoms, providing further support for a potential shared mechanism. Conclusions: Exposures to pesticides, volatile organic compounds, combustion products, and mold have previously been reported as initiators of CI. However, until recently, little was known about the biological mechanism involved that could explain the multisystem symptoms associated with CI. This paper addresses a newly identified biomechanism for disease, which may underlie a host of "medically unexplained symptoms" triggered by xenobiotics.
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Affiliation(s)
- Raymond F Palmer
- Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA
| | - Tania T Dempsey
- AIM Center for Personalized Medicine, Purchase, NY 10577, USA
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Molderings GJ, Afrin LB. A survey of the currently known mast cell mediators with potential relevance for therapy of mast cell-induced symptoms. Naunyn Schmiedebergs Arch Pharmacol 2023; 396:2881-2891. [PMID: 37243761 PMCID: PMC10567897 DOI: 10.1007/s00210-023-02545-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 05/29/2023]
Abstract
Mast cells (MCs) occupy a central role in immunological as well as non-immunological processes as reflected in the variety of the mediators by which MCs influence other cells. Published lists of MC mediators have all shown only subsets-usually quite small-of the full repertoire. The full repertoire of MC mediators released by exocytosis is comprehensively compiled here for the first time. The compilation of the data is essentially based on the largely cytokine-focused database COPE®, supplemented with data on the expression of substances in human MCs published in several articles, plus extensive research in the PubMed database. Three hundred and ninety substances could be identified as mediators of human MCs which can be secreted into the extracellular space by activation of the MC. This number might still be an underestimate of the actual number of MC mediators since, in principle, all substances produced by MCs can become mediators because of the possibility of their release by diffusion into the extracellular space, mast cell extracellular traps, and intercellular exchange via nanotubules. When human MCs release mediators in inappropriate manners, this may lead to symptoms in any or all organs/tissues. Thus, such MC activation disorders may clinically present with a myriad of potential combinations of symptoms ranging from trivial to disabling or even life-threatening. The present compilation can be consulted by physicians when trying to gain clarity about MC mediators which may be involved in patients with MC disease symptoms refractory to most therapies.
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Affiliation(s)
- Gerhard J Molderings
- Institute for Human Genetics, University Hospital of Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany.
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Afrin LB, Dempsey TT, Molderings GJ. Learned cautions regarding antibody testing in mast cell activation syndrome. Diagnosis (Berl) 2023; 10:424-431. [PMID: 37566881 DOI: 10.1515/dx-2023-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVES To describe patterns observed in antibody titer trendlines in patients with mast cell activation syndrome (MCAS, a prevalent but underrecognized chronic multisystem inflammatory disorder of great clinical heterogeneity) and offer clinical lessons learned from such pattern recognition. METHODS The available records of 104 MCAS patients drawn from the authors' practices were reviewed, including all antibody tests therein. RESULTS All patients had positive/elevated antibodies of various sorts at various points, but for most of the antibodies which were found to be positive at least some points, the diseases classically associated with those antibodies were not present, marking such antibodies as clinically insignificant mimickers (likely consequent to inflammatory effects of MCAS on the immune system itself driving spurious/random antibody production) rather than "on-target" and pathogenic antibodies reflecting true disease warranting treatment. We also observed two distinct patterns in trendlines of the titers of the mimickers vs. the trendline pattern expected in a true case of an antibody-associated disease (AAD). CONCLUSIONS Our observations suggest most positive antibody tests in MCAS patients represent detection of clinically insignificant mimicking antibodies. As such, to reduce incorrect diagnoses of AADs and inappropriate treatment in MCAS patients, caution is warranted in interpreting positive antibody tests in these patients. Except in clinically urgent/emergent situations, patience in determining the trendline of a positive antibody in an MCAS patient, and more carefully assessing whether the AAD is truly present, is to be preferred.
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Zienkiewicz T, Homann J, Mücke M, Seidel H, Hertfelder HJ, Weinstock LB, Afrin LB, Molderings GJ. Evaluation of a tryptase depletion index for better pathologic identification of mast cell activation syndrome. Z Gastroenterol 2023; 61:268-274. [PMID: 35576976 DOI: 10.1055/a-1833-9226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Laboratory evidence supporting diagnosis of the prevalent condition of mast cell activation syndrome (MCAS) currently includes elevated levels in blood or urine of mediators relatively specific to mast cells (MCs) and/or increased numbers of MCs in luminal gastrointestinal (GI) tract tissues. However, identification of elevated mediators is technically challenging and expensive, and controversy persists regarding the normal ranges of numbers/counts of MCs in various GI tract segments, let alone challenges in determining how many of the visualized MCs are activated. To aid diagnosis of MCAS, we developed a potential new approach for the pathologist to identify the extent of GI tract MC activation easily and inexpensively. PARTICIPANTS AND METHODS Visualization of MCs in gastrointestinal biopsies from 251 patients vs. 95 controls using antibodies against CD117 and tryptase; MC counting per mm2; calculation of the difference between the CD117-positive MCs (identifying all MCs) vs. tryptase-positive MCs (identifying non-activated tryptase-containing MCs), which we define as the tryptase depletion index (TDI). RESULTS Mean total MC counts did not differ significantly between patients and controls, but mean TDIs differed significantly. Non-overlapping confidence intervals at the 99.9% level identified cut-offs of TDIs between patients vs. controls of 26, 45 and 32 MCs/mm2 in gastric antrum, duodenum, and colon, respectively. CONCLUSIONS The TDI may discriminate between MCAS patients vs. controls. If this preliminary work can be independently confirmed, the TDI may become a useful additional minor diagnostic criterion for MCAS.
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Affiliation(s)
| | - Jürgen Homann
- Division of Internal Medicine, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - Martin Mücke
- Institute for Digitalization in General Practice and Center for Rare Diseases Aachen (ZSEA), University Hospital Aachen, Aachen, Germany
| | - Holger Seidel
- Center for Bleeding Disorders and Transfusion Medicine (CBT), Bonn, Germany
| | | | - Leonard B Weinstock
- Departments of Medicine, Missouri Baptist Medical Center and Washington University School of Medicine, St. Louis, MO, United States
| | - Lawrence B Afrin
- AIM Center for Personalized Medicine, Purchase, NY, United States
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Walters AS, Li Y, Karroum EG, Champion D, Weinstock LB, Bagai K, Afrin LB, Spruyt K. Exploring the role of the endogenous opiate system in the pathogenesis of anemia in an opiate receptor knock-out model of Restless Legs Syndrome. Med Hypotheses 2022; 167:110941. [PMID: 36505961 PMCID: PMC9731170 DOI: 10.1016/j.mehy.2022.110941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Restless Legs Syndrome (RLS) is characterized by bothersome leg discomfort accompanied by an urge to move to obtain relief and symptoms are worse at night and on lying down. There is at least partial and temporary relief with activity. It is also an opioid responsive disorder, often accompanied by iron deficiency with or without anemia, and inflammation may be a precipitating factor in some cases. We created two in-vivo opiate receptor knock out mouse models of RLS - a triple opiate receptor knock-out mouse and a mu opiate receptor knock-out mouse. Both sets of animals were restless during the sleep period as is also true of RLS. Both of our knockout models showed statistically significantly decreased Hemoglobin and Hematocrit indicating anemia and both models showed statistically significant decreases in serum iron suggestive of either iron deficiency anemia or inflammatory anemia. The rest of the hematologic studies were not consistent enough to determine which of these two types of anemia was present in either model. An additional experiment in normal wild type mice showed a statistically significant decrease in serum iron when an opiate receptor blocker was used. To our knowledge this is the first demonstration that deficiency of endogenous opioids might play a role in the production of anemia. Our hypothesis is that an intact endogenous opiate system is necessary for red cell homeostasis. The presence of opioid receptors both on red blood cells and on various immunologically based white blood cells suggest mechanisms by which deficiency in the endogenous opiate system could cause anemia of either the iron deficiency or inflammatory types. The administration of opioid agonists or antagonists to iron deficient cultures of red blood cell precursors is a next step in determining the role of the endogenous opiate system in the maintenance of red cell homeostasis and in the possible prevention of iron deficiency or inflammatory anemia where iron dysregulation is key.
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Affiliation(s)
- Arthur S. Walters
- Sleep Division, Dept of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yuqing Li
- Norman Fixel Institute for Neurological Diseases, Dept of Neurology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Elias G. Karroum
- Department of Neurology & Rehabilitation Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC., USA
| | - David Champion
- Sydney Children’s Hospital, Randwick, NSW 2031, Australia
| | - Leonard B. Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Kanika Bagai
- Sleep Division, Dept of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lawrence B. Afrin
- Hematology/Oncology, AIM Center for Personalized Medicine, Purchase, New York
| | - Karen Spruyt
- Université de Paris, NeuroDiderot Inserm, France
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Weinstock LB, Brook JB, Walters AS, Goris A, Afrin LB, Molderings GJ. Restless legs syndrome is associated with long-COVID in women. J Clin Sleep Med 2022; 18:1413-1418. [PMID: 35484639 PMCID: PMC9059584 DOI: 10.5664/jcsm.9898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Sleep disturbance is common in long-COVID (LC). Restless legs syndrome (RLS) is characterized by sleep disturbance and has been reported after viral infections. Therefore, we evaluated RLS symptoms cross-sectionally in individuals with LC at both current and pre-coronavirus disease 2019 (pre-COVID-19) time points. METHODS Adults on LC-focused Facebook pages were recruited for an online assessment of symptoms before COVID-19 infection and during their present LC state in a cross-sectional manner. The LC group documented baseline symptoms retrospectively. Questions were included about the presence/severity of RLS symptoms and assessments of fatigue, quality of life, and sleep apnea. A control group was recruited and included individuals ≥ 18 years of age who never had overt symptoms of COVID-19. Pregnancy was an exclusion criterion for both groups. RESULTS There were 136 participants with LC (89.7% females, age 46.9 ± 12.9 years) and 136 controls (65.4% females, age 49.2 ± 15.5). RLS prevalence in females with LC was 5.7% pre-COVID-19 and 14.8% post-COVID-19 (P < .01) vs 6.7% in control females. Severity of RLS was moderate in both groups. Logistic regression predicting post-COVID-19 RLS among females with LC failed to find significant effects of hospitalization, sleep apnea, neuropathic pain severity, or use of antihistamines and antidepressants. CONCLUSIONS The baseline prevalence of RLS in females with LC was similar to the general population group as well as to patients in epidemiological studies. The prevalence significantly increased in the LC state. Postinfectious immunological mechanisms may be at play in the production for RLS symptoms. CITATION Weinstock LB, Brook JB, Walters AS, Goris A, Afrin LB, Molderings GJ. Restless legs syndrome is associated with long-COVID in women. J Clin Sleep Med. 2022;18(5):1413-1418.
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Affiliation(s)
- Leonard B. Weinstock
- Departments of Medicine, Missouri Baptist Medical Center and Washington University School of Medicine, St. Louis, MO
| | | | - Arthur S. Walters
- Division of Sleep Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Ashleigh Goris
- Infection Prevention & Control and Clinical Quality, Missouri Baptist Medical Center, St. Louis, MO
| | - Lawrence B. Afrin
- Department of Mast Cell Studies, Hematology/Oncology, AIM Center for Personalized Medicine, Purchase, NY
| | - Gerhard J. Molderings
- Molecular Geneticist, Immunologist, Institute of Human Genetics, University Hospital Bonn, Bonn, Germany
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Afrin LB, Dempsey TT, Weinstock LB. Post-HPV-Vaccination Mast Cell Activation Syndrome: Possible Vaccine-Triggered Escalation of Undiagnosed Pre-Existing Mast Cell Disease? Vaccines (Basel) 2022; 10:127. [PMID: 35062788 PMCID: PMC8779641 DOI: 10.3390/vaccines10010127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/27/2023] Open
Abstract
For nearly a decade, case reports and series have emerged regarding dysautonomias-particularly postural orthostatic tachycardia syndrome (POTS)-presenting soon after vaccination against human papilloma virus (HPV). We too have observed a number of such cases (all following vaccination with the Gardasil product), and have found several to have detectable mast cell activation syndrome (MCAS) as well as histories suggesting that MCAS was likely present long before vaccination. We detail 11 such cases here, posing a hypothesis that HPV vaccination (at least with the Gardasil product) may have triggered or exacerbated MCAS in teenagers previously not recognized to have it. Only recently recognized, MCAS is being increasingly appreciated as a prevalent and chronic multisystem disorder, often emerging early in life and presenting with inflammatory ± allergic phenomena following from known mast cell (MC) mediator effects. There is rising recognition, too, of associations of MCAS with central and peripheral neuropathic disorders, including autonomic disorders such as POTS. Given the recognized potential for many antigens to trigger a major and permanent escalation of baseline MC misbehavior in a given MCAS patient, we hypothesize that in our patients described herein, vaccination with Gardasil may have caused pre-existing (but not yet clinically recognized) MCAS to worsen to a clinically significantly degree, with the emergence of POTS and other issues. The recognition and management of MCAS prior to vaccinations in general may be a strategy worth investigating for reducing adverse events following HPV vaccinations and perhaps even other types of vaccinations.
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Affiliation(s)
- Lawrence B. Afrin
- AIM Center for Personalized Medicine, Purchase, New York, NY 10577, USA;
| | - Tania T. Dempsey
- AIM Center for Personalized Medicine, Purchase, New York, NY 10577, USA;
| | - Leonard B. Weinstock
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
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Afrin LB. Some cases of hypermobile Ehlers-Danlos syndrome may be rooted in mast cell activation syndrome. Am J Med Genet C Semin Med Genet 2021; 187:466-472. [PMID: 34719842 DOI: 10.1002/ajmg.c.31944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 08/23/2021] [Accepted: 10/16/2021] [Indexed: 12/17/2022]
Abstract
Hypermobile Ehlers-Danlos syndrome (hEDS) is the most common type of EDS, yet has remained steadfastly inscrutable vis-à-vis efforts to identify its cellular, molecular, and pathophysiologic roots. Once thought to principally affect just connective tissues, hEDS is now appreciated to be a multisystem disease of great heterogeneity with many symptoms and findings difficult to attribute solely to disordered connective tissue development. In the last decade, there has been growth in the appreciation of the existence of a wide range of disorders of chronic inappropriate mast cell (MC) activation (a large heterogeneous pool of MC activation syndromes [MCAS]) distinguishable from other MC disorders such as rare neoplastic mastocytosis. Via chronic aberrant release of the MC's vast repertoire of potent mediators, MCAS can drive extraordinary arrays of pathologies, most commonly of inflammatory, allergic, and dystrophic natures. Although hEDS is seen in only a minority of MCAS cases, limited studies have identified an association between hEDS and MCAS, fueling speculation that certain variants of MCAS may drive hEDS. No laboratory studies probing cellular or molecular linkages between hEDS and MCAS have been conducted yet, and research efforts to identify the genetic roots of hEDS should also consider those of MCAS.
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Affiliation(s)
- Lawrence B Afrin
- Department of Mast Cell Studies, AIM Center for Personalized Medicine, Purchase, New York, USA
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Weinstock LB, Brook JB, Walters AS, Goris A, Afrin LB, Molderings GJ. Mast cell activation symptoms are prevalent in Long-COVID. Int J Infect Dis 2021; 112:217-226. [PMID: 34563706 PMCID: PMC8459548 DOI: 10.1016/j.ijid.2021.09.043] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/17/2021] [Accepted: 09/19/2021] [Indexed: 12/22/2022] Open
Abstract
Objectives Hyper-inflammation caused by COVID-19 may be mediated by mast cell activation (MCA) which has also been hypothesized to cause Long-COVID (LC) symptoms. We determined prevalence/severity of MCA symptoms in LC. Methods Adults in LC-focused Facebook support groups were recruited for online assessment of symptoms before and after COVID-19. Questions included presence and severity of known MCA and LC symptoms and validated assessments of fatigue and quality of life. General population controls and mast cell activation syndrome (MCAS) patients were recruited for comparison if they were ≥18 years of age and never had overt COVID-19 symptoms. Results There were 136 LC subjects (89.7% females, age 46.9 ±12.9 years), 136 controls (65.4% females, age 49.2 ±15.5), and 80 MCAS patients (85.0% females, age 47.7 ±16.4). Pre-COVID-19 LC subjects and controls had virtually identical MCA symptom and severity analysis. Post-COVID-19 LC subjects and MCAS patients prior to treatment had virtually identical MCA symptom and severity analysis. Conclusions MCA symptoms were increased in LC and mimicked the symptoms and severity reported by patients who have MCAS. Increased activation of aberrant mast cells induced by SARS-CoV-2 infection by various mechanisms may underlie part of the pathophysiology of LC, possibly suggesting routes to effective therapy.
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Affiliation(s)
- Leonard B Weinstock
- Associate Professor of Clinical Medicine, Departments of Medicine, Missouri Baptist Medical Center and Washington University School of Medicine, President, Specialists in Gastroenterology, 11525 Olde Cabin Road, St. Louis, MO, USA 63141, TEL 314-997-4627, FAX 314-997-5086.
| | - Jill B Brook
- Biostatistics, Private Practice, 13285 Roundhill, Truckee, CA, USA 96161, TEL 626-375-6725.
| | - Arthur S Walters
- Professor of Neurology, Division of Sleep Medicine, Vanderbilt University School of Medicine, Medical Center North A-0118, 1161 21(st) Ave South, Nashville, TN, USA 37232-2551, TEL 615-322-0283, FAX 615- 936-5663.
| | - Ashleigh Goris
- Manager, Infection Prevention & Control and Clinical Quality, Missouri Baptist Medical Center, Mailstop: 95, 3015 N. Ballas Road, St. Louis, MO, USA 63131, TEL 314-996-5421, FAX 314-996-5909.
| | - Lawrence B Afrin
- Department of Mast Cell Studies, Hematology/Oncology, AIM Center for Personalized Medicine, Purchase, NY, USA 10577, TEL 914-730-7390, FAX 914-730-7391.
| | - Gerhard J Molderings
- Associate Professor of Pharmacology and Toxicology, Molecular Geneticist, Immunologist, Institute of Human Genetics, University Hospital Bonn, D53127 Bonn, Germany, TEL ++49 1623322001, FAX ++49 2225 9984911.
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Seidel H, Hertfelder HJ, Oldenburg J, Kruppenbacher JP, Afrin LB, Molderings GJ. Effects of Primary Mast Cell Disease on Hemostasis and Erythropoiesis. Int J Mol Sci 2021; 22:ijms22168960. [PMID: 34445665 PMCID: PMC8396658 DOI: 10.3390/ijms22168960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/10/2021] [Accepted: 08/17/2021] [Indexed: 01/21/2023] Open
Abstract
Mast cell disease is an epigenetically and genetically determined disease entity with very diverse clinical manifestations in potentially every system and tissue due to inap pro priate release of variable subsets of mast cell mediators together with accumulation of either morphologically normal or altered mast cells. Easy bruising, excessive bleeding, and aberrancies of erythropoiesis can frequently be observed in patients with mast cell disease. A thorough history, including a family history, will guide the appropriate work-up, and laboratory evaluations may provide clues to diagnosis. In recent years, our understanding of the involvement of coagulation and anticoagulant pathways, the fibrinolytic system, and erythropoiesis in the pathophysiology of mast cell disease has increased considerably. This review summarizes current knowledge of the impact of the disturbed hemostatic and erythropoietic balance in patients with mast cell disease and describes options of treatment.
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Affiliation(s)
- Holger Seidel
- Center for Bleeding Disorders and Transfusion Medicine (CBT), Am Propsthof 3, D-53121 Bonn, Germany; (H.S.); (H.-J.H.); (J.P.K.)
| | - Hans-Jörg Hertfelder
- Center for Bleeding Disorders and Transfusion Medicine (CBT), Am Propsthof 3, D-53121 Bonn, Germany; (H.S.); (H.-J.H.); (J.P.K.)
- Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany;
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany;
| | - Johannes P. Kruppenbacher
- Center for Bleeding Disorders and Transfusion Medicine (CBT), Am Propsthof 3, D-53121 Bonn, Germany; (H.S.); (H.-J.H.); (J.P.K.)
| | - Lawrence B. Afrin
- Department of Mast Cell Studies, AIM Center for Personalized Medicine, 3010 Westchester Ave Suite 404, Purchase, NY 10577, USA;
| | - Gerhard J. Molderings
- Institute of Human Genetics, University Hospital of Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
- Correspondence: ; Tel.: +49-228-287-51000
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Afrin LB, Ackerley MB, Bluestein LS, Brewer JH, Brook JB, Buchanan AD, Cuni JR, Davey WP, Dempsey TT, Dorff SR, Dubravec MS, Guggenheim AG, Hindman KJ, Hoffman B, Kaufman DL, Kratzer SJ, Lee TM, Marantz MS, Maxwell AJ, McCann KK, McKee DL, Menk Otto L, Pace LA, Perkins DD, Radovsky L, Raleigh MS, Rapaport SA, Reinhold EJ, Renneker ML, Robinson WA, Roland AM, Rosenbloom ES, Rowe PC, Ruhoy IS, Saperstein DS, Schlosser DA, Schofield JR, Settle JE, Weinstock LB, Wengenroth M, Westaway M, Xi SC, Molderings GJ. Diagnosis of mast cell activation syndrome: a global "consensus-2". Diagnosis (Berl) 2021; 8:137-152. [PMID: 32324159 DOI: 10.1515/dx-2020-0005] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 02/15/2020] [Indexed: 02/06/2023]
Abstract
The concept that disease rooted principally in chronic aberrant constitutive and reactive activation of mast cells (MCs), without the gross MC neoplasia in mastocytosis, first emerged in the 1980s, but only in the last decade has recognition of "mast cell activation syndrome" (MCAS) grown significantly. Two principal proposals for diagnostic criteria have emerged. One, originally published in 2012, is labeled by its authors as a "consensus" (re-termed here as "consensus-1"). Another sizable contingent of investigators and practitioners favor a different approach (originally published in 2011, newly termed here as "consensus-2"), resembling "consensus-1" in some respects but differing in others, leading to substantial differences between these proposals in the numbers of patients qualifying for diagnosis (and thus treatment). Overdiagnosis by "consensus-2" criteria has potential to be problematic, but underdiagnosis by "consensus-1" criteria seems the far larger problem given (1) increasing appreciation that MCAS is prevalent (up to 17% of the general population), and (2) most MCAS patients, regardless of illness duration prior to diagnosis, can eventually identify treatment yielding sustained improvement. We analyze these proposals (and others) and suggest that, until careful research provides more definitive answers, diagnosis by either proposal is valid, reasonable, and helpful.
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Affiliation(s)
| | | | - Linda S Bluestein
- Department of Anesthesiology, Medical College of Wisconsin, Wausau, WI, USA
| | | | - Jill B Brook
- Alaska Internal Medicine and Pediatrics, Anchorage, AK, USA
| | | | - Jill R Cuni
- Division of Pediatrics, Beaver Medical Group, Banning, CA, USA
| | - William P Davey
- Department of Dermatology, University of Kentucky, Lexington, KY, USA
| | | | | | | | - Alena G Guggenheim
- Comprehensive Pain Center, Oregon Health and Science University, Portland, OR, USA
| | | | - Bruce Hoffman
- Hoffman Centre for Integrative and Functional Medicine, Calgary, Alberta, Canada
| | | | | | | | | | | | | | | | - Laurie Menk Otto
- Helfgott Research Institute, National College of Natural Medicine, Portland, OR, USA
| | - Laura A Pace
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, UT, USA
| | | | | | | | | | | | - Mark L Renneker
- Department of Family Medicine, University of California San Francisco, San Francisco, CA, USA
| | - William A Robinson
- Division of Hematology/Oncology, University of Colorado, Denver, CO, USA
| | - Aaron M Roland
- Department of Family Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Jill R Schofield
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Janet E Settle
- Department of Psychiatry, University of Colorado, Denver, CO, USA
| | | | - Martina Wengenroth
- Institute of Neuroradiology, University Hospital Lübeck, Lübeck, Germany
| | | | - Shijun Cindy Xi
- Section of Allergy and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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13
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Weinstock LB, Pace LA, Rezaie A, Afrin LB, Molderings GJ. Mast Cell Activation Syndrome: A Primer for the Gastroenterologist. Dig Dis Sci 2021; 66:965-982. [PMID: 32328892 DOI: 10.1007/s10620-020-06264-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
Mast cell activation syndrome is thought to be a common, yet under-recognized, chronic multi-system disorder caused by inappropriate mast cell activation. Gastrointestinal symptoms are frequently reported by these patients and are often mistaken by physicians as functional gastrointestinal disorders. This syndrome can be diagnosed by the medical history and measurable biomarkers. Gastroenterologists manage diseases associated with active inflammatory cells including neutrophils, lymphocytes, macrophages, and eosinophils. The mast cell has only recently been recognized as a major player in our specialty. Gastrointestinal disorders from mast cell mediators often present with apparent irritable bowel syndrome, dyspepsia, chronic or cyclical nausea, and heartburn. Individuals with mast cell activation syndrome experience significant delays in diagnosis. The gastrointestinal symptoms are often refractory to symptom-targeted prescription medications. Beyond avoiding triggers, the best therapy is directed at modulating mast cell activation and the effects of the mediators. Many of these therapies are simple over-the-counter medications. In this article, we review mast cell function and dysfunction and the gastrointestinal symptoms, comorbid conditions, diagnosis, and management of mast cell activation syndrome. Gastroenterologists who become aware of this syndrome can dramatically improve the quality of life for their patients who previously have been labeled with a functional gastrointestinal disorder.
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Affiliation(s)
- Leonard B Weinstock
- Specialists in Gastroenterology, 11525 Olde Cabin Rd, St. Louis, MO, 63141, USA.
| | - Laura A Pace
- Division of Gastroenterology, Department of Internal Medicine, University of Utah, 30 N 1900 E, SOM 4R118, Salt Lake City, UT, 84132, USA
| | - Ali Rezaie
- Cedars-Sinai Medical Center, Gastroenterology, 8730 Alden Dr., Suite 204E, Los Angeles, CA, 90048, USA
| | - Lawrence B Afrin
- Armonk Integrative Medicine, Hematology/Oncology, 3010 Westchester Avenue, Suite 401, Armonk, NY, 10577, USA
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14
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Afrin LB, Weinstock LB, Molderings GJ. Covid-19 hyperinflammation and post-Covid-19 illness may be rooted in mast cell activation syndrome. Int J Infect Dis 2020; 100:327-332. [PMID: 32920235 PMCID: PMC7529115 DOI: 10.1016/j.ijid.2020.09.016] [Citation(s) in RCA: 171] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 08/28/2020] [Accepted: 09/07/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES One-fifth of Covid-19 patients suffer a severe course of Covid-19 infection; however, the specific causes remain unclear. Mast cells (MCs) are activated by SARS-CoV-2. Although only recently recognized, MC activation syndrome (MCAS), usually due to acquired MC clonality, is a chronic multisystem disorder with inflammatory and allergic themes, and an estimated prevalence of 17%. This paper describes a novel conjecture explaining how MCAS might cause a propensity for severe acute Covid-19 infection and chronic post-Covid-19 illnesses. METHODS Observations of Covid-19 illness in patients with/without MCAS were compared with extensive clinical experience with MCAS. RESULTS The prevalence of MCAS is similar to that of severe cases within the Covid-19-infected population. Much of Covid-19's hyperinflammation is concordant with manners of inflammation which MC activation can drive. Drugs with activity against MCs or their mediators have preliminarily been observed to be helpful in Covid-19 patients. None of the authors' treated MCAS patients with Covid-19 suffered severe infection, let alone mortality. CONCLUSIONS Hyperinflammatory cytokine storms in many severely symptomatic Covid-19 patients may be rooted in an atypical response to SARS-CoV-2 by the dysfunctional MCs of MCAS rather than a normal response by normal MCs. If proven, this theory has significant therapeutic and prognostic implications.
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Affiliation(s)
- Lawrence B Afrin
- Department of Mast Cell Studies, AIM Center for Personalized Medicine, Purchase, New York, USA.
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Molderings GJ, Dumoulin FL, Homann J, Sido B, Textor J, Mücke M, Qagish GJ, Barion R, Raithel M, Klingmüller D, Schäfer VS, Hertfelder HJ, Berdel D, Tridente G, Weinstock LB, Afrin LB. Adrenal insufficiency is a contraindication for omalizumab therapy in mast cell activation disease: risk for serum sickness. Naunyn Schmiedebergs Arch Pharmacol 2020; 393:1573-1580. [PMID: 32377770 PMCID: PMC7419348 DOI: 10.1007/s00210-020-01886-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
Omalizumab is an effective therapeutic humanized murine IgE antibody in many cases of primary systemic mast cell activation disease (MCAD). The present study should enable the clinician to recognize when treatment of MCAD with omalizumab is contraindicated because of the potential risk of severe serum sickness and to report our successful therapeutic strategy for such adverse event (AE). Our clinical observations, a review of the literature including the event reports in the FDA AE Reporting System, the European Medicines Agency Eudra-Vigilance databases (preferred search terms: omalizumab, Xolair®, and serum sickness) and information from the manufacturer’s Novartis database were used. Omalizumab therapy may be more likely to cause serum sickness than previously thought. In patients with regular adrenal function, serum sickness can occur after 3 to 10 days which resolves after the antigen and circulating immune complexes are cleared. If the symptoms do not resolve within a week, injection of 20 to 40 mg of prednisolone on two consecutive days could be given. However, in MCAD patients whose adrenal cortical function is completely suppressed by exogenous glucocorticoid therapy, there is a high risk that serum sickness will be masked by the MCAD and evolve in a severe form with pronounced damage of organs and tissues, potentially leading to death. Therefore, before the application of the first omalizumab dose, it is important to ensure that the function of the adrenal cortex is not significantly limited so that any occurring type III allergy can be self-limiting.
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Affiliation(s)
- G J Molderings
- Institute of Human Genetics, University Hospital Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany.
| | - F L Dumoulin
- Department of Internal Medicine, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - J Homann
- Department of Internal Medicine, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - B Sido
- Department of General and Visceral Surgery, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - J Textor
- Department of Radiology, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - M Mücke
- Center for Rare Diseases, University Hospital Bonn, Bonn, Germany
| | - G J Qagish
- Medical Office for Internal Medicine, Meckenheim, Germany
| | - R Barion
- Medical Office for Diabetology, Niederkassel, Rheidt, Germany
| | - M Raithel
- Malteser Waldkrankenhaus St. Marien, Medical Clinic II, Erlangen, Germany
| | - D Klingmüller
- Department of Endocrinology, University Hospital Bonn, Bonn, Germany
| | - V S Schäfer
- Department of Rheumatology and Clinical Immunology, Clinic for Internal Medicine III, University Hospital Bonn, Bonn, Germany
| | - H J Hertfelder
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - D Berdel
- Marien Hospital Wesel, Wesel, Germany
| | | | - L B Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, 63141, USA
| | - L B Afrin
- Armonk Integrative Medicine, Hematology/Oncology, Purchase, New York, NY, 10577, USA
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Abstract
Mast cell activation syndrome (MCAS) is a chronic multisystem disease of aberrant constitutive and reactive mast cell mediator release causing generally inflammatory, allergic, and dystrophic issues. The pathobiology of MCAS drives extraordinary clinical complexity and heterogeneity, which led to only recent recognition despite increasingly apparent substantial prevalence, perhaps as high as 17%. It also has a strong female predilection. Thus, MCAS inescapably impacts pregnancy and the post-partum period in many women. No specific research in the pregnant or post-partum MCAS population has been performed yet. However, its prevalence and potential for driving substantial morbidity merit obstetric providers' acquaintance with this illness and its potential impacts on their patients during pregnancy, delivery, the post-partum period, and lactation. Extensive literature review across all medical specialities, plus direct experience in the authors' practices, provides guidance in recognising MCAS in pregnancy and diagnosing and effectively managing it. Described herein are manners in which MCAS, a protean multisystem disease, adversely affects all stages of pregnancy and post-partum. In order to reduce risks of MCAS causing complications before, during and after pregnancy, identifying and controlling the syndrome prior to pregnancy is best, but, even if the disease is not recognised until late, there may still be opportunities to mitigate its effects. There is precedent for improved outcomes if comorbid MCAS is recognised and controlled. This review provides the first comprehensive guide for obstetric providers regarding this emerging major comorbidity.
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Weinstock LB, Walters AS, Brook JB, Kaleem Z, Afrin LB, Molderings GJ. Restless legs syndrome is associated with mast cell activation syndrome. J Clin Sleep Med 2020; 16:401-408. [PMID: 31994488 DOI: 10.5664/jcsm.8216] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
STUDY OBJECTIVES Mast cell activation syndrome (MCAS) is an inflammatory and allergic disorder. We determined the prevalence of restless legs syndrome (RLS) in MCAS because each common syndrome may be inflammatory in nature and associated with dysautonomia. METHODS Individuals with MCAS were evaluated for RLS by two standard questionnaires. Prevalence comparisons included spouse control patients and two prevalence publications. MCAS diagnosis required mast cell (MC) symptoms in ≥ 2 organs plus ≥ 1 elevated MC mediators, improvement with MC therapy, and/or increased intestinal MC density. Clinical variables were studied. RESULTS There were 174 patients with MCAS (146 female, 28 male, mean age 44.8 years) and 85 spouse control patients (12 female, 73 male, mean age 50.9 years). Patients with MCAS as a whole had a higher prevalence of RLS (40.8%) than spouse control (12.9%) (P < .0001) Male patients with MCAS had a higher prevalence of RLS (32.1%) than male controls (12.3%, odds ratio [OR] 3.4, confidence interval [CI] 1.2-9.7, P = .025), American men (8.4%, OR 5.2, CI 2.2-12.0, P < .001), and French men (5.8%, OR 7.7, CI 3.4-17.1, P < .001). Female patients with MCAS also had a higher prevalence of RLS (42.5%) than female controls (16.7%) but this did not reach statistical significance perhaps because of the sample size of the female controls. However, female patients with MCAS had a statistically higher prevalence of RLS than American women (10.0%, OR 6.7, CI 4.5-9.7, P < .0001) and French women (10.8%, OR 6.1, CI 4.4-8.6, P < .0001). CONCLUSIONS RLS appears to be associated with MCAS. Effects of mast cell mediators, inflammation, immune mechanisms, dysautonomia, or hypoxia may theoretically activate RLS in MCAS.
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Affiliation(s)
- Leonard B Weinstock
- Washington University School of Medicine, Specialists in Gastroenterology, LLC, St. Louis, Missouri
| | - Arthur S Walters
- Division of Sleep Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Zahid Kaleem
- Specialists in Gastroenterology, LLC, St. Louis, Missouri
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Afrin LB, Dempsey TT, Rosenthal LS, Dorff SR. Successful mast-cell-targeted treatment of chronic dyspareunia, vaginitis, and dysfunctional uterine bleeding. J OBSTET GYNAECOL 2019; 39:664-669. [DOI: 10.1080/01443615.2018.1550475] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | - Shanda R. Dorff
- HealthPartners North Suburban Family Physicians, Roseville, MN, USA
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19
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Schofield JR, Afrin LB. Recognition and Management of Medication Excipient Reactivity in Patients With Mast Cell Activation Syndrome. Am J Med Sci 2019; 357:507-511. [PMID: 31126513 DOI: 10.1016/j.amjms.2019.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/26/2019] [Accepted: 03/15/2019] [Indexed: 01/27/2023]
Abstract
Mast cell activation syndrome (MCAS) is a complex disorder hallmarked by chronic multisystem inflammatory, allergic and growth dystrophic phenomena caused by inappropriate mast cell activation. MCAS has been estimated to affect as many as 17% of the population with a severity ranging from mild to life-threatening. MCAS patients are more sensitive than the average person to chemicals in the environment, including the nondrug ("inactive") ingredients (excipients) in medications and supplements. Excipient reactivity may explain unusual side effects to medications health professionals often find puzzling, such as the patient who appears intolerant of prednisone, acetaminophen, levothyroxine, or a vitamin. We present a series of patients with MCAS to illustrate important points regarding excipient reactivity which may be useful in everyday practice.
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Affiliation(s)
- Jill R Schofield
- Center for Multisystem Disease, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado.
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Affiliation(s)
- Leonard B Weinstock
- Specialists in Gastroenterology, LLC, St. Louis, MO, USA. Department of Gastroenterology, Cedar Sinai, Los Angeles, CA, USA. Hematology and Oncology, Armonk Integrative Medicine, Armonk, NY, USA
| | - Ali Rezaie
- Specialists in Gastroenterology, LLC, St. Louis, MO, USA. Department of Gastroenterology, Cedar Sinai, Los Angeles, CA, USA. Hematology and Oncology, Armonk Integrative Medicine, Armonk, NY, USA
| | - Lawrence B Afrin
- Specialists in Gastroenterology, LLC, St. Louis, MO, USA. Department of Gastroenterology, Cedar Sinai, Los Angeles, CA, USA. Hematology and Oncology, Armonk Integrative Medicine, Armonk, NY, USA
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Abstract
Epiploic appendagitis is as an acute painful condition of the fat on the outside of the intestine. Thus far, there have been no publications to our knowledge that appendagitis can be caused by mast cells or can be associated with chronic pain. A patient with multisystemic disorders suffered with both chronic and acute attacks of abdominal pain for a year. The worst attack led to surgical resection of an enlarged sigmoid colon epiploic appendage. Careful review of her complex medical history and mast cell stains of gastrointestinal biopsies led to the diagnosis of mast cell activation syndrome. Re-examination of the resected appendage using an immunohistochemical stain demonstrated a high mast cell density which is a new histopathological finding. Treatment of mast cell activation syndrome and other related syndromes led to marked improvement in her health, including all types of chronic abdominal pain.
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Affiliation(s)
- Leonard B Weinstock
- Gastroenterology, GI, Washington University, Saint Louis, Missouri, USA.,Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Zahid Kaleem
- Gastroenterology, GI, Washington University, Saint Louis, Missouri, USA
| | - Dale Selby
- Department of Pathology, Missouri Baptist Medical Center, Saint Louis, Missouri, USA
| | - Lawrence B Afrin
- Internal Medicine, Armonk Integrative Medicine, Armonk, New York, USA
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Abstract
Mast cell activation disease typically presents as chronic multisystem polymorbidity of generally inflammatory ± allergic theme. Presently, treatment of the rare, cytoproliferative variant systemic mastocytosis employs empirically selected therapies to impede mast cell mediator production and action and, when necessary, inhibition of proliferation. Some tyrosine kinase inhibitors (TKIs) have been used successfully in uncommon cases of systemic mastocytosis not bearing that disease’s usual imatinib-resistant KIT
D816V mutation. Recently, sunitinib, a multi-targeted TKI, had been successful in a case of systemic mast cell activation syndrome. In addition, most allergy is principally a mast cell activation phenomenon, and sunitinib has been shown helpful in controlling a murine model of oral allergy syndrome. Here, we present the first use of sunitinib in systemic mastocytosis.
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Affiliation(s)
| | | | - Hans-Jörg Hertfelder
- Institute of Experimental Haematology & Transfusion Medicine, University Hospital of Bonn, Bonn, D-53127, Germany
| | - Stefan Brettner
- Department of Oncology, Hematology and Palliative Care, Kreiskrankenhaus Waldbröl, Waldbröl, D-51545, Germany
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Seneviratne SL, Maitland A, Afrin LB. Response to: "In reply to: 'Mast Cell Disorders in Ehlers-Danlos Syndrome' (Jaime Vengoechea, Department of Human Genetics, Emory University)". Am J Med Genet A 2017; 176:251-252. [PMID: 29160015 DOI: 10.1002/ajmg.a.38528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 10/08/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Suranjith L Seneviratne
- Institute of Immunity and Transplantation, Royal Free Hospital and University College London, London, United Kingdom
| | - Anne Maitland
- Division of Clinical Immunology, Department of Medicine, Mount Sinai Hospital, New York, New York
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Molderings GJ, Zienkiewicz T, Homann J, Menzen M, Afrin LB. Risk of solid cancer in patients with mast cell activation syndrome: Results from Germany and USA. F1000Res 2017; 6:1889. [PMID: 29225779 PMCID: PMC5710302 DOI: 10.12688/f1000research.12730.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2017] [Indexed: 01/20/2023] Open
Abstract
Background: It has been shown repeatedly that mast cells can promote or prevent cancer development and growth. If development and/or progression of a solid cancer is substantially influenced by mast cell activity, the frequencies of occurrence of solid cancers in patients with primary mast cells disorders would be expected to differ from the corresponding prevalence data in the general population. In fact, a recent study demonstrated that patients with systemic mastocytosis (i.e., a rare neoplastic variant of the primary mast cell activation disease) have increased risk for solid cancers, in particular melanoma and non-melanoma skin cancers. The aim of the present study is to examine whether the risk of solid cancer is increased in systemic mast cell activation syndrome (MCAS), the common systemic variant of mast cell activation disease. Methods: In the present descriptive study, we have analysed a large (n=828) patient group with MCAS, consisting of cohorts from Germany and the USA, for occurrence of solid forms of cancer and compared the frequencies of the different cancers with corresponding prevalence data for German and U.S. general populations. Results: Sixty-eight of the 828 MCAS patients (46 female, 22 male) had developed a solid tumor before the diagnosis of MCAS was made. Comparison of the frequencies of the malignancies in the MCAS patients with their prevalence in the general population revealed a significantly increased prevalence for melanoma and cancers of the breast, cervix uteri, ovary, lung, and thyroid in MCAS patients. Conclusions: Our data support the view that mast cells may promote development of certain malignant tumors. These findings indicate a need for increased surveillance of certain types of cancer in MCAS patients irrespective of its individual clinical presentation.
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Affiliation(s)
- Gerhard J Molderings
- Institute of Human Genetics, University Hospital of Bonn, Bonn, D-53127, Germany
| | | | - Jürgen Homann
- Division of Internal Medicine, Department of Gastroenterology and Diabetology, Gemeinschaftskrankenhaus Bonn, Bonn, D-53113, Germany
| | - Markus Menzen
- Division of Internal Medicine, Department of Gastroenterology and Diabetology, Gemeinschaftskrankenhaus Bonn, Bonn, D-53113, Germany
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25
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Afrin LB, Fox RW, Zito SL, Choe L, Glover SC. Successful targeted treatment of mast cell activation syndrome with tofacitinib. Eur J Haematol 2017; 99:190-193. [DOI: 10.1111/ejh.12893] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Lawrence B. Afrin
- Division of Hematology, Oncology and Transplantation; University of Minnesota; Minneapolis MN USA
| | - Roger W. Fox
- Division of Allergy and Immunology; University of South Florida; Tampa FL USA
| | - Susan L. Zito
- Suncoast Internal Medicine Consultants; Largo FL USA
| | - Leo Choe
- Suncoast Internal Medicine Consultants; Largo FL USA
| | - Sarah C. Glover
- Inflammatory Bowel and Celiac Disease Program; University of Florida; Gainesville FL USA
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Lortholary O, Chandesris MO, Bulai Livideanu C, Paul C, Guillet G, Jassem E, Niedoszytko M, Barete S, Verstovsek S, Grattan C, Damaj G, Canioni D, Fraitag S, Lhermitte L, Georgin Lavialle S, Frenzel L, Afrin LB, Hanssens K, Agopian J, Gaillard R, Kinet JP, Auclair C, Mansfield C, Moussy A, Dubreuil P, Hermine O. Masitinib for treatment of severely symptomatic indolent systemic mastocytosis: a randomised, placebo-controlled, phase 3 study. Lancet 2017; 389:612-620. [PMID: 28069279 PMCID: PMC5985971 DOI: 10.1016/s0140-6736(16)31403-9] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 08/04/2016] [Accepted: 08/09/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Indolent systemic mastocytosis, including the subvariant of smouldering systemic mastocytosis, is a lifelong condition associated with reduced quality of life. Masitinib inhibits KIT and LYN kinases that are involved in indolent systemic mastocytosis pathogenesis. We aimed to assess safety and efficacy of masitinib versus placebo in severely symptomatic patients who were unresponsive to optimal symptomatic treatments. METHODS In this randomised, double-blind, placebo-controlled, phase 3 study, we enrolled adults (aged 18-75 years) with indolent or smouldering systemic mastocytosis, according to WHO classification or documented mastocytosis based on histological criteria, at 50 centres in 15 countries. We excluded patients with cutaneous or non-severe systemic mastocytosis after a protocol amendment. Patients were centrally randomised (1:1) to receive either oral masitinib (6 mg/kg per day over 24 weeks with possible extension) or matched placebo with minimisation according to severe symptoms. The primary endpoint was cumulative response (≥75% improvement from baseline within weeks 8-24) in at least one severe baseline symptom from the following: pruritus score of 9 or more, eight or more flushes per week, Hamilton Rating Scale for Depression of 19 or more, or Fatigue Impact Scale of 75 or more. We assessed treatment effect using repeated measures methodology for rare diseases via the generalised estimating equation model in a modified intention-to-treat population, including all participants assigned to treatment minus those who withdrew due to a non-treatment-related cause. We assessed safety in all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT00814073. FINDINGS Between Feb 19, 2009, and July 15, 2015, 135 patients were randomly assigned to masitinib (n=71) or placebo (n=64). By 24 weeks, masitinib was associated with a cumulative response of 18·7% in the primary endpoint (122·6 responses of 656·5 possible responses [weighted generalised estimating equation]) compared with 7·4% for placebo (48·9 of 656·5; difference 11·3%; odds ratio 3·6; 95% CI 1·2-10·8; p=0·0076). Frequent severe adverse events (>4% difference from placebo) were diarrhoea (eight [11%] of 70 in the masitinib group vs one [2%] of 63 in the placebo group), rash (four [6%] vs none), and asthenia (four [6%] vs one [2%]). The most frequent serious adverse events were diarrhoea (three patients [4%] vs one [2%]) and urticaria (two [3%] vs none), and no life-threatening toxicities occurred. One patient in the placebo group died (unrelated to study treatment). INTERPRETATION These study findings indicate that masitinib is an effective and well tolerated agent for the treatment of severely symptomatic indolent or smouldering systemic mastocytosis. FUNDING AB Science (Paris, France).
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Affiliation(s)
- Olivier Lortholary
- Department of Infectious Diseases and Tropical Medicine and Centre d'Infectiologie Necker-Pasteur, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France; Centre de Référence des Mastocytoses, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France; Université Paris Descartes, Paris, France
| | - Marie Olivia Chandesris
- Department of Hematology, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Cristina Bulai Livideanu
- Department of Dermatology, Mastocytosis Competence Center, Paul Sabatier University, Hôpital Larrey, Toulouse, France
| | - Carle Paul
- Department of Dermatology, Mastocytosis Competence Center, Paul Sabatier University, Hôpital Larrey, Toulouse, France
| | - Gérard Guillet
- Department of Dermatology, CHU Poitiers, University Hospital, Poitiers, France
| | - Ewa Jassem
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Stéphane Barete
- Department of Dermatology and Allergology, Centre de Référence des Mastocytoses, Université Pierre et Marie Curie, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Srdan Verstovsek
- Hanns A Pielenz Clinical Research Center for Myeloproliferative Neoplasms, Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Clive Grattan
- Department of Dermatology, Norfolk & Norwich University Hospital, Norwich, UK
| | - Gandhi Damaj
- Department of Haematology, University Hospital of Caen, Institut d'Hématologie de Basse Normandie, School of Medicine, University of Lower Normandy, Caen, France
| | - Danielle Canioni
- Department of Pathology, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Sylvie Fraitag
- Department of Pathology, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Ludovic Lhermitte
- INSERM U1151 and Laboratory of Onco-Hematology, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Sophie Georgin Lavialle
- Department of Internal Medicine, DHU I2B, Université Pierre et Marie Curie, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Laurent Frenzel
- Department of Hematology, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France; Institut Imagine INSERM U1163 and CNRS ERL8654, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Lawrence B Afrin
- Division of Hematology, Oncology & Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Katia Hanssens
- Centre de Référence des Mastocytoses, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France; AB Science, Paris, France
| | - Julie Agopian
- Centre de Référence des Mastocytoses, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France; AB Science, Paris, France
| | - Raphael Gaillard
- Human Histopathology and Animal Models, Infection and Epidemiology Department, Institut Pasteur; Université Paris Descartes; Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-Pierre Kinet
- Department of Pathology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Christian Auclair
- Laboratoire de Biologie et Pharmacologie appliqué, CNRS UMR 8113, Ecole Normale Supérieure de Cachan, Université Paris Saclay, Paris, France; AB Science, Paris, France
| | | | | | - Patrice Dubreuil
- Centre de Référence des Mastocytoses, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France; INSERM U1068, CRCM (Signaling, Hematopoiesis and Mechanism of Oncogenesis), Institut Paoli-Calmettes, Aix-Marseille Université, CNRS, UMR7258, Marseille, France; AB Science, Paris, France; INSERM, La Ligue Nationale Contre le Cancer (équipe labelliseé), Paris, France
| | - Olivier Hermine
- Department of Hematology, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France; Institut Imagine INSERM U1163 and CNRS ERL8654, Université Paris Descartes, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France; AB Science, Paris, France.
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Afrin LB, Self S, Menk J, Lazarchick J. Characterization of Mast Cell Activation Syndrome. Am J Med Sci 2016; 353:207-215. [PMID: 28262205 DOI: 10.1016/j.amjms.2016.12.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/30/2016] [Accepted: 12/08/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Mast cell activation syndrome (MCAS), a recently recognized nonneoplastic mast cell disease driving chronic multisystem inflammation and allergy, appears prevalent and thus important. We report the first systematic characterization of a large MCAS population. METHOD Demographics, comorbidities, symptoms, family histories, physical examination and laboratory findings were reviewed in 298 retrospective and 115 prospective patients with MCAS. Blood samples from prospective subjects were examined by flow cytometry for clonal mast cell disease and tested for cytokines potentially driving the monocytosis frequent in MCAS. RESULTS Demographically, white females dominated. Median ages at symptom onset and diagnosis were 9 and 49 years, respectively (range: 0-88 and 16-92, respectively) and median time from symptom onset to diagnosis was 30 years (range: 1-85). Median numbers of comorbidities, symptoms, and family medical issues were 11, 20, and 4, respectively (range: 1-66, 2-84, and 0-33, respectively). Gastroesophageal reflux, fatigue and dermatographism were the most common comorbidity, symptom and examination finding. Abnormalities in routine laboratories were common and diverse but typically modest. The most useful diagnostic markers were heparin, prostaglandin D2, histamine and chromogranin A. Flow cytometric and cytokine assessments were unhelpful. CONCLUSIONS Our study highlights MCAS׳s morbidity burden and challenging heterogeneity. Recognition is important given good survival and treatment prospects.
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Affiliation(s)
- Lawrence B Afrin
- Division of Hematology, Oncology and Transplantation, University of Minnesota (UMN), Minneapolis, Minnesota.
| | - Sally Self
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jeremiah Menk
- Clinical and Translational Science Institute (CTSI), University of Minnesota, Minneapolis, Minnesota
| | - John Lazarchick
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
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Affiliation(s)
- Lawrence B Afrin
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minn.
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Molderings GJ, Haenisch B, Brettner S, Homann J, Menzen M, Dumoulin FL, Panse J, Butterfield J, Afrin LB. Pharmacological treatment options for mast cell activation disease. Naunyn Schmiedebergs Arch Pharmacol 2016; 389:671-94. [PMID: 27132234 PMCID: PMC4903110 DOI: 10.1007/s00210-016-1247-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 04/11/2016] [Indexed: 12/20/2022]
Abstract
Mast cell activation disease (MCAD) is a term referring to a heterogeneous group of disorders characterized by aberrant release of variable subsets of mast cell (MC) mediators together with accumulation of either morphologically altered and immunohistochemically identifiable mutated MCs due to MC proliferation (systemic mastocytosis [SM] and MC leukemia [MCL]) or morphologically ordinary MCs due to decreased apoptosis (MC activation syndrome [MCAS] and well-differentiated SM). Clinical signs and symptoms in MCAD vary depending on disease subtype and result from excessive mediator release by MCs and, in aggressive forms, from organ failure related to MC infiltration. In most cases, treatment of MCAD is directed primarily at controlling the symptoms associated with MC mediator release. In advanced forms, such as aggressive SM and MCL, agents targeting MC proliferation such as kinase inhibitors may be provided. Targeted therapies aimed at blocking mutant protein variants and/or downstream signaling pathways are currently being developed. Other targets, such as specific surface antigens expressed on neoplastic MCs, might be considered for the development of future therapies. Since clinicians are often underprepared to evaluate, diagnose, and effectively treat this clinically heterogeneous disease, we seek to familiarize clinicians with MCAD and review current and future treatment approaches.
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Affiliation(s)
- Gerhard J Molderings
- Institute of Human Genetics, University Hospital of Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany.
| | - Britta Haenisch
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Stefan Brettner
- Department of Oncology, Hematology and Palliative Care, Kreiskrankenhaus Waldbröl, Waldbröl, Germany
| | - Jürgen Homann
- Allgemeine Innere Medizin, Gastroenterologie und Diabetologie, Gemeinschaftskrankenhaus, Bonn, Germany
| | - Markus Menzen
- Allgemeine Innere Medizin, Gastroenterologie und Diabetologie, Gemeinschaftskrankenhaus, Bonn, Germany
| | - Franz Ludwig Dumoulin
- Allgemeine Innere Medizin, Gastroenterologie und Diabetologie, Gemeinschaftskrankenhaus, Bonn, Germany
| | - Jens Panse
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Joseph Butterfield
- Program for the Study of Mast Cell and Eosinophil Disorders, Mayo Clinic, Rochester, MN, 55905, USA
| | - Lawrence B Afrin
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, 55455, USA
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Costa LJ, Fanning SR, Stephenson J, Afrin LB, Kistner-Griffin E, Bentz TA, Stuart RK. Sequential ofatumumab and lenalidomide for the treatment of relapsed and refractory chronic lymphocytic leukemia and small lymphocytic lymphoma. Leuk Lymphoma 2016; 56:645-9. [PMID: 25130476 DOI: 10.3109/10428194.2014.935369] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Ofatumumab is a fully human anti-CD20 monoclonal antibody with enhanced antibody dependent and complement dependent cytotoxicity. Lenalidomide induces T cell and natural killer (NK) cell activation and in vitro enhances clearance of chronic lymphocytic leukemia (CLL) cells by monoclonal antibodies. We performed a multi-center, phase 2 trial of sequential treatment with ofatumumab and lenalidomide in patients with advanced, relapsed and refractory (R/R) CLL, consisting of ofatumumab 2000 mg intravenously on day 1 and lenalidomide 10 mg on days 8-28, for up to six cycles. Twenty-one subjects were included with median age of 63 years and two prior lines of therapy. The overall response rate was 47.6% and 23.8% had stable disease. Median overall survival was 21.5 months. Neutropenia and thrombocytopenia were the most frequent adverse events. Tumor flare reaction occurred in 43% of subjects. Intracycle sequential ofatumumab plus lenalidomide is active in high-risk R/R CLL and well tolerated except for frequent cytopenias.
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Affiliation(s)
- Luciano J Costa
- Division of Hematology and Oncology, Department of Medicine, Medical University of South Carolina , Charleston, SC , USA
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Abstract
Mast cell (MC) disease has long been thought to be just the rare disease of mastocytosis (in various forms, principally cutaneous and systemic), with aberrant MC mediator release at symptomatic levels due to neoplastic MC proliferation. Recent discoveries now show a new view is in order, with mastocytosis capping a metaphorical iceberg now called "MC activation disease" (MCAD, i.e. disease principally manifesting inappropriate MC activation), with the bulk of the iceberg being the recently recognized "MC activation syndrome" (MCAS), featuring inappropriate MC activation to symptomatic levels with little to no inappropriate MC proliferation. Given increasing appreciation of a great menagerie of mutations in MC regulatory elements in mastocytosis and MCAS, the great heterogeneity of MCAD's clinical presentation is unsurprising. Most MCAD patients present with decades of chronic multisystem polymorbidity generally of an inflammatory ± allergic theme. Preliminary epidemiologic investigation suggests MCAD, while often misrecognized, may be substantially prevalent, making it increasingly important that practitioners of all stripes learn how to recognize its more common forms such as MCAS. We review the diagnostically challenging presentation of MCAD (with an emphasis on MCAS) and current thoughts regarding its biology, epidemiology, natural history, diagnostic evaluation, and treatment.
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Affiliation(s)
- Lawrence B Afrin
- a Division of Hematology, Oncology, and Transplantation , University of Minnesota , Minneapolis , MN , USA
| | - Joseph H Butterfield
- b Program for the Study of Mast Cell and Eosinophil Disorders , Mayo Clinic , Rochester , MN , USA
| | - Martin Raithel
- c Department of Internal Medicine , Waldkrankenhaus St. Marien , Erlangen , Germany
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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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Afrin LB, Cichocki FM, Patel K, Molderings GJ. Successful treatment of mast cell activation syndrome with sunitinib. Eur J Haematol 2015; 95:595-7. [PMID: 26072665 DOI: 10.1111/ejh.12606] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2015] [Indexed: 01/01/2023]
Abstract
Mast cell (MC) activation syndrome (MCAS) is a recently recognized, likely prevalent collection of heterogeneous illnesses of inappropriate MC activation with little to no MC neoplasia likely driven by heterogeneous patterns of constitutively activating mutations in MC regulatory elements including various tyrosine kinases (TKs, dominantly KIT). MCAS typically presents as chronic multisystem polymorbidity of generally inflammatory ± allergic theme. As with indolent systemic mastocytosis (SM), treatment of MCAS focuses more against MC mediators than MC neoplasia, but some cases prove refractory even to the TK inhibitor (TKI) imatinib reported useful both in uncommon SM cases not bearing SM's usual imatinib-resistant KIT-D816V mutation and in some cases of MCAS (which rarely bears KIT-D816V). Most allergy is principally a MC activation phenomenon and sunitinib is a multitargeted TKI shown helpful in controlling a murine model of oral allergy syndrome. We present the first report of use of sunitinib in life-threatening MCAS refractory to multiple agents including imatinib achieving immediate, complete, sustained, non-toxic remission suggesting a new option for treatment of aggressive MC disease.
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Affiliation(s)
- Lawrence B Afrin
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Frank M Cichocki
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Kamal Patel
- CARTI Hematology/Oncology, Little Rock, AR, USA
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Afrin LB. The Good, The Bad, and The Ugly of the New Doctor-Patient-Computer Relationship of the 21st Century. J S C Med Assoc 2015; 111:48-54. [PMID: 27132331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Abstract
PURPOSE This article reviews the diagnostically challenging presentation of mast cell activation disease (MCAD) and current thoughts regarding interactions between microbiota and MCs. METHODS A search for all studies on interactions between mast cells, mast cell activation disease, and microbiota published on pubmed.gov and scholar.google.com between 1960 and 2015 was conducted using the search terms mast cell, mastocyte, mastocytosis, mast cell activation, mast cell activation disease, mast cell activation syndrome, microbiome, microbiota. A manual review of the references from identified studies was also conducted. Studies were excluded if they were not accessible electronically or by interlibrary loan. FINDINGS Research increasingly is revealing essential involvement of MCs in normal human biology and in human disease. Via many methods, normal MCs-present sparsely in every tissue-sense their environment and reactively exert influences that, directly and indirectly, locally and remotely, improve health. The dysfunctional MCs of the "iceberg" of MCAD, on the other hand, sense abnormally, react abnormally, activate constitutively, and sometimes (in mastocytosis, the "tip" of the MCAD iceberg) even proliferate neoplastically. MCAD causes chronic multisystem illness generally, but not necessarily, of an inflammatory ± allergic theme and with great variability in behavior among patients and within any patient over time. Furthermore, the range of signals to which MCs respond and react include signals from the body's microbiota, and regardless of whether an MCAD patient has clonal mastocytosis or the bulk of the iceberg now known as MC activation syndrome (also suspected to be clonal but without significant MC proliferation), dysfunctional MCs interact as dysfunctionally with those microbiota as they interact with other human tissues, potentially leading to many adverse consequences. IMPLICATIONS Interactions between microbiota and MCs are complex at baseline. The potential for both pathology and benefit may be amplified when compositionally variant microbiota interact with aberrant MCs in various types of MCAD. More research is needed to better understand and leverage these interactions.
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Affiliation(s)
- Lawrence B Afrin
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota.
| | - Alexander Khoruts
- Division of Gastroenterology and Center for Immunology, BioTechnology Institute, University of Minnesota, Minneapolis, Minnesota
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Afrin LB, Oates JC, Kamen DL. Improving clinical trial accrual by streamlining the referral process. Int J Med Inform 2014; 84:15-23. [PMID: 25256066 DOI: 10.1016/j.ijmedinf.2014.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 07/15/2014] [Accepted: 09/03/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Poor accrual rates impede clinical trial efficiency and significantly contribute to development costs for new interventions. Many providers recognize investigational treatments are their patients' best opportunities for improvement, but operational clinical burdens impede providers' awareness of, and ability to leverage, such opportunities. We aimed to develop a new workflow for non-intrusively apprising providers of trial opportunities for their patients and enabling providers to efficiently refer potential trial candidates to study teams for preliminary eligibility review. MATERIALS AND METHODS We developed a small information system to monitor institutional systems, identify patients potentially eligible for ongoing clinical trials, and give providers a non-intrusive, one-click method to refer such patients to study teams for preliminary eligibility vetting. RESULTS In 18 months of pilot experience, providers invited study teams to vet 11% of 1844 patients found potentially eligible for 38 trials registered with the system. Seventy-nine patients were conservatively estimated to be accrued. Accrual rates were boosted for several trials. Results of a survey indicated most users were satisfied with the system. DISCUSSION Providers' time constraints impede their pursuit of investigational opportunities for their patients. In pilot experience, our novel approach to facilitating such pursuits yielded improved accrual, benefiting trials and presumably patients, too. Our approach may bear particular fruit for cross-disciplinary referrals for screening. CONCLUSION Systems for assisting providers in making investigational opportunities available to their patients may benefit from careful attention to provider workflow and time constraints. Our system might further benefit from improved patient/trial matching and shorter messages.
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Affiliation(s)
- Lawrence B Afrin
- Division of Hematology, Oncology & Transplantation, University of Minnesota, Minneapolis, MN, USA.
| | - James C Oates
- Division of Rheumatology, Medical University of South Carolina, Charleston, SC, USA
| | - Diane L Kamen
- Division of Rheumatology, Medical University of South Carolina, Charleston, SC, USA
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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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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, Spruill LS, Schabel SI, Young-Pierce JL. Improved metastatic uterine papillary serous cancer outcome with treatment of mast cell activation syndrome. Oncology (Williston Park) 2014; 28:129-134. [PMID: 24701700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Abstract
Mast cell activation syndrome (MCAS) is a relatively recently recognized cause of chronic multisystem polymorbidity of a generally inflammatory theme. Patients with MCAS often report migratory soft tissue and/or bone pain which frequently responds poorly to typical (narcotic and non-narcotic) analgesics as well as atypical analgesics such as antidepressants and anticonvulsants. Hydroxyurea (HU) is an oral ribonucleotide reductase inhibitor commonly used in the treatment of chronic myeloproliferative neoplasms and sickle cell anemia. HU has been used to treat systemic mastocytosis, sometimes effecting improvement in MC activation symptoms but not tumor burden, suggesting potential utility of the drug in MCAS, too. Reported here are five cases of successful use of relatively low-dose HU in MCAS to reduce symptoms including previously refractory soft tissue and/or bone pain. HU may be useful in treating mediator symptoms in MCAS, but further study is needed to define optimal dosing strategies and patient subpopulations most likely to benefit.
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Affiliation(s)
- Lawrence B Afrin
- Division of Hematology/Oncology, Medical University of South Carolina, Charleston, South Carolina, USA.
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Afrin LB. Nonhistaminergic idiopathic angioedema may be a presentation of mast cell activation syndrome. J Investig Allergol Clin Immunol 2013; 23:212. [PMID: 23967766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
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Abstract
Acquired agranulocytosis is a rare, life-threatening disorder. The few known causes/associations usually are readily identifiable (e.g., drug reaction, Felty syndrome, megaloblastosis, large granular lymphocytic leukemia, etc.). We report a novel association with mast cell disease. A 61-year-old morbidly obese man developed rheumatoid arthritis unresponsive to several medications. Agranulocytosis developed shortly after sulfasalazine was started but did not improve when the drug was soon stopped. Other symptoms across many systems developed including hives and presyncope. Marrow aspiration and biopsy showed only neutropenia. Serum tryptase was mildly elevated; urinary prostaglandin D2 was markedly elevated. Other causes were not found. Mast cell activation syndrome (MCAS) was diagnosed. Oral antihistamines, montelukast, and cromolyn were unhelpful; aspirin was initially felt contraindicated. Imatinib immediately increased neutrophils from 0% to 25% but did not help symptoms; subsequent addition of aspirin increased neutrophils further and abated symptoms. Different presentations of different MCAS patients reflect elaboration of different mediators likely consequent to different Kit mutations. Mast cells (MCs) help regulate adipocytes, and adipocytes can inhibit granulopoiesis; thus, a Kit-mutated MC clone may have directly and/or indirectly driven agranulocytosis. MCAS should be considered in otherwise idiopathic agranulocytosis presenting with comorbidities best explained by MC mediator release.
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Affiliation(s)
- Lawrence B Afrin
- Section of Hematology/Oncology, Medical Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401, USA
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Abstract
BACKGROUND Sclerosing mediastinitis (ScM) is a rare, potentially life-threatening disorder, idiopathic in roughly half the cases. Systemic symptoms not attributable to sclerosis often appear in idiopathic ScM. Mast cell activation disease (MCAD) is a potential cause of these symptoms and also can cause sclerosis. ScM has not previously been associated with MCAD. Presented here are the first two cases of ScM associated with MCAD, specifically mast cell activation syndrome (MCAS). CASE 1: A 58-year-old chronically polymorbid woman developed ScM following matched sibling allogeneic stem cell transplantation. Eight years later MCAS, likely underlying most of her chronic issues, was identified. CASE 2: A 30-year-old chronically polymorbid woman presented with superior vena cava syndrome and was diagnosed with ScM. On further evaluation, MCAS was identified. Treatment promptly effected symptomatic improvement; sclerosis has been stable. Non-compliance yielded symptomatic relapse; restored compliance re-achieved symptomatic remission. CONCLUSIONS Different MCAS presentations reflect elaboration of different mediators, some of which can induce inflammation and fibrosis. Thus, MCAS may have directly and/or indirectly driven ScM in these patients. MCAS should be considered in ScM presenting with comorbidities better explained by mast cell mediator release.
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Affiliation(s)
- Lawrence B Afrin
- Division of Hematology/Oncology, Medical University of South Carolina, Charleston, SC, USA.
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Molderings GJ, Brettner S, Homann J, Afrin LB. Mast cell activation disease: a concise practical guide for diagnostic workup and therapeutic options. J Hematol Oncol 2011; 4:10. [PMID: 21418662 PMCID: PMC3069946 DOI: 10.1186/1756-8722-4-10] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 03/22/2011] [Indexed: 12/30/2022] Open
Abstract
Mast cell activation disease comprises disorders characterized by accumulation of genetically altered mast cells and/or abnormal release of these cells' mediators, affecting functions in potentially every organ system, often without causing abnormalities in routine laboratory or radiologic testing. In most cases of mast cell activation disease, diagnosis is possible by relatively non-invasive investigation. Effective therapy often consists simply of antihistamines and mast cell membrane-stabilising compounds supplemented with medications targeted at specific symptoms and complications. Mast cell activation disease is now appreciated to likely be considerably prevalent and thus should be considered routinely in the differential diagnosis of patients with chronic multisystem polymorbidity or patients in whom a definitively diagnosed major illness does not well account for the entirety of the patient's presentation.
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Affiliation(s)
- Gerhard J Molderings
- Institute of Human Genetics, University Hospital of Bonn, Sigmund-Freud-Str. 25, D-53127 Bonn, Germany
| | - Stefan Brettner
- Department of Oncology, Hematology and Palliative Care, Kreiskrankenhaus Waldbröl, Dr.-Goldenburgen-Str. 10, D-51545 Waldbröl, Germany
| | - Jürgen Homann
- Department of Internal Medicine, Evangelische Kliniken Bonn, Waldkrankenhaus, Waldstrasse 73, D-53177 Bonn, Germany
| | - Lawrence B Afrin
- Division of Hematology/Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
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Afrin LB, Afrin JB. Value of preemptive CYP2C19 genotyping in allogeneic stem cell transplant patients considered for pentamidine administration. Clin Transplant 2011; 25:E271-5. [PMID: 21299635 DOI: 10.1111/j.1399-0012.2011.01399.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pneumocystis jirovecii prophylaxis is standard in allogeneic stem cell transplantation (alloSCT), sometimes with pentamidine at a low dose inhaled monthly. Human metabolism of pentamidine depends on cytochrome P450 2C19 (CYP2C19). The frequency of mutant CYP2C19 forms with decreased function (from 2% of Caucasians to 30% of Asians and 79% of certain Polynesians), together with common use of CYP2C19 inhibitors in the alloSCT process, creates risk for impaired pentamidine clearance resulting in toxicity ordinarily expected only with high doses given for active infection. We examined the charts of 32 consecutive pentamidine-prophylaxed alloSCT patients at our center. We assessed hospital charges for the management of toxicities unexplained at the time but likely attributable, in retrospect, to pentamidine. Twenty-eight percent experienced significant toxicities (incurring added charges of at least US$5000). Thirteen percent suffered major toxicity (incurring added charges of at least US$25, 000; median added charge $351, 701) and shorter survival (326 vs. 622 d for all pentamidine recipients), including 6% who died of pentamidine toxicities [one proven postmortem to have a (non-functional) homozygous CYP2C19*2 mutation]. Charges for care attributable to pentamidine toxicity exceeded what preemptive genotyping would have cost by 73-fold. These findings encourage routine use of preemptive CYP2C19 genotyping in alloSCT patients considered for pentamidine.
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Serber ER, Finch NJ, Afrin LB, Greenland WJ. Using a webcast support service: Experiences of in-person attendees of an implantable cardioverter defibrillator support group. Heart Lung 2010; 39:94-104. [DOI: 10.1016/j.hrtlng.2009.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 05/26/2009] [Accepted: 06/08/2009] [Indexed: 10/20/2022]
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Demiris G, Afrin LB, Speedie S, Courtney KL, Sondhi M, Vimarlund V, Lovis C, Goossen W, Lynch C. Patient-centered applications: use of information technology to promote disease management and wellness. A white paper by the AMIA knowledge in motion working group. J Am Med Inform Assoc 2008; 15:8-13. [PMID: 17947617 PMCID: PMC2274880 DOI: 10.1197/jamia.m2492] [Citation(s) in RCA: 150] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Accepted: 10/03/2007] [Indexed: 11/10/2022] Open
Abstract
Advances in information technology (IT) enable a fundamental redesign of health care processes based on the use and integration of electronic communication at all levels. New communication technologies can support a transition from institution centric to patient-centric applications. This white paper defines key principles and challenges for designers, policy makers, and evaluators of patient-centered technologies for disease management and prevention. It reviews current and emerging trends; highlights challenges related to design, evaluation, reimbursement and usability; and reaches conclusions for next steps that will advance the domain.
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Affiliation(s)
- George Demiris
- University of Washington, BNHS-Box 357266, Seattle, WA 98195-7266, USA.
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Afrin LB, Arana GW, Medio FJ, Ybarra AFN, Clarke HS. Improving oversight of the graduate medical education enterprise: one institution's strategies and tools. Acad Med 2006; 81:419-25. [PMID: 16639192 DOI: 10.1097/01.acm.0000222258.55266.6a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Accreditation organizations, financial stakeholders, legal systems, and regulatory agencies have increased the need for accountability in educational processes and curricular outcomes of graduate medical education. This demand for greater programmatic monitoring has placed pressure on institutions with graduate medical education (GME) programs to develop greater oversight of these programs. Meeting these challenges requires development of new GME management strategies and tools for institutional GME administrators to scrutinize programs, while still allowing these programs the autonomy to develop and implement educational methods to meet their unique training needs. At the Medical University of South Carolina (MUSC), senior administrators in the college of medicine felt electronic information management was a critical strategy for success and thus proceeded to carefully select an electronic residency management system (ERMS) to provide functionality for both individual programs and the GME enterprise as a whole. Initial plans in 2002 for a phased deployment had to be changed to a much more rapid deployment due to regulatory issues. Extensive communication and cooperation among MUSC's GME leaders resulted in a successful deployment in 2003. Evaluation completion rates have substantially improved, duty hours are carefully monitored, patient safety has improved through more careful oversight of residents' procedural privileges, regulators have been pleased, and central GME administrative visibility of program performance has dramatically improved. The system is now being expanded to MUSC's medical school and other health professions colleges. The authors discuss lessons learned and opportunities and challenges ahead, which include improving tracking of development of procedural competency, establishing and monitoring program performance standards, and integrating the ERMS with GME reimbursement systems.
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Affiliation(s)
- Lawrence B Afrin
- Office of Graduate Medical Education, the Medical University of South Carolina (MUSC), Charleston, South Carolina, USA.
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Onitilo AA, Lin YH, Okonofua EC, Afrin LB, Ariail J, Tilley BC. Race, education, and knowledge of bone marrow registry: indicators of willingness to donate bone marrow among African Americans and Caucasians. Transplant Proc 2005; 36:3212-9. [PMID: 15686731 DOI: 10.1016/j.transproceed.2004.10.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND As bone marrow transplantation (BMT) increases, the availability of suitable donors becomes critical, especially for African Americans, who require a large donor pool to find a suitable match. Previous studies indicated willingness to donate marrow may be a barrier for achieving a large donor pool. METHODS We conducted a random-sample, statewide telephone survey of 421 Caucasians and 408 African Americans in South Carolina to determine if racial differences in willingness to donate bone marrow exist. We assessed a general level of willingness, asking, "Will you be willing to be a marrow donor?" We assessed an additional level of willingness, asking, "Are you willing to be contacted about bone marrow donation?" RESULTS We detected no racial differences in general willingness to donate (Caucasians 34%, African Americans 32%, P=.52), although there was a difference in willingness to be contacted to sign-up for the registry (Caucasians 18.3%, African Americans 11%, P=.003). African Americans were more aware that better matches occur within the same race (P <.0001). Caucasians were more knowledgeable about the registry (P <.0001). Younger, more highly educated respondents indicated a greater willingness to be donors. In both races, fear of pain was the most common reason for unwillingness to donate, and it was significantly higher in African Americans. CONCLUSION Our study suggests reported lack of general willingness does not explain the racial disparities in BMT. Many who expressed willingness to donate were not willing to be contacted to sign up for the registry, especially African Americans. Education and adequate pain control may improve minority recruitment.
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Affiliation(s)
- A A Onitilo
- Division of Hematology/Oncology, Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina 29414, USA.
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Afrin LB. General medicine in South Carolina, 1905-2005: the science and the art as recorded in The Journal of the South Carolina Medical Association. J S C Med Assoc 2005; 101:129-36. [PMID: 16187488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Lawrence B Afrin
- Division of Hematology/Oncology, Medical University of South Carolina, Charleston, SC 29425, USA
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