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Thank your very much for the interest in our article.1Bankova L.G. Walter J.E. Iyengar S.R. Lorenzo M.E. Hornick J.L. Castells M.C. Generalized bullous eruption after routine vaccination in a child with diffuse cutaneous mastocytosis.J Allergy Clin Immunol Pract. 2013; 1: 94-96Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 2Renke J. Lange M. Routine vaccinations in DCM.J Allergy Clin Immunol Pract. 2015 Nov; 3Google Scholar Diffuse cutaneous mastocytosis (DCM) is a rare presentation of cutaneous mastocytosis, and there is no consensus regarding the use and schedule of routine vaccinations in this pediatric patient population. Because of the potential risk for severe or potentially fatal mast cell activation events after vaccination, it is desirable to establish consensus recommendations.3Castells M. Metcalfe D.D. Escribano L. Diagnosis and treatment of cutaneous mastocytosis in children: practical recommendations.Am J Clin Dermatol. 2011; 12: 259-270Crossref PubMed Scopus (145) Google Scholar The suggestion that the massive cutaneous mast cell activation reaction of the child described in the case report may represent the abortive course of rotavirus infection after vaccination is of interest, although there were no gastrointestinal manifestations. He had no diarrhea or vomiting, and generalized blistering was the most prominent symptom. Although children with cutaneous mastocytosis including DCM have prominent gastrointestinal symptoms, others and we have investigated the number and phenotype of mast cells in the gastric, intestinal, and colonic mucosa, without finding any increase in gastrointestinal mast cells. In a recent case in which a 4-month-old child (Castells, 2015, unpublished data) presented with generalized hemorrhagic blistering after treatment with vancomycin and other antibiotics prescribed during the course of a febrile disease, endoscopy and colonoscopy revealed no increase in the number of mast cells or an abnormal phenotype suggestive of systemic disease, despite a highly elevated tryptase level of 180 ng/mL. Gastrointestinal symptoms in these children are attributed to the systemic distribution of histamine, prostaglandins, and leukotrienes and other mast cell mediators generated in the skin.4Carter MC, Clayton ST, Komarow HD, Brittain EH, Scott LM, Cantave D, et al. Assessment of clinical findings, tryptase levels, and bone marrow histopathology in the management of pediatric mastocytosis [published online ahead of print June 1, 2015]. J Allergy Clin Immunol 2015 Dec; 136(6).Google Scholar Whether activation of mast cells through Toll-like receptors or other non-IgE receptors can occur at the time of vaccination is only speculation, and no data exist to support that highly conjugated vaccines would have less mast cell activation effect. Whether increased mast cell activation could occur because of the simultaneous action of multiple vaccines targeting different mast cell membrane receptors is also not known. Mast cells can act as antigen-presenting cells, and cell-cell interactions with T cells can lead to mast cell activation and apoptosis5Ding J, Fang Y, Xiang Z. Antigen/IgG immune complex-primed mucosal mast cells mediate antigen-specific activation of co-cultured T cells [published online ahead of print September 6, 2014]. Immunology. http://dx.doi.org/10.1111/imm.12379.Google Scholar: whether these interactions could lead to mast cell activation during vaccination in selected patients is not known.5Ding J, Fang Y, Xiang Z. Antigen/IgG immune complex-primed mucosal mast cells mediate antigen-specific activation of co-cultured T cells [published online ahead of print September 6, 2014]. Immunology. http://dx.doi.org/10.1111/imm.12379.Google Scholar At the Brigham and Women's Hospital Mastocytosis Center in Boston, we have recently implemented sequential vaccinations, one at a time, in 4 other patients with DCM without any adverse effects. Fatal outcomes occur in patients with cutaneous mastocytosis as has been shown in Méni et al6Méni C. Bruneau J. Georgin-Lavialle S. Le Saché de Peufeilhoux L. Damaj G. Hadj-Rabia S. et al.Paediatric mastocytosis: a systematic review of 1747 cases.Br J Dermatol. 2015; 172: 642-651Crossref PubMed Scopus (120) Google Scholar with up to 2% to 9% children dying of the 1747 total children from the recent world's literature review. After witnessing the severity of the reaction in our patient and the paucity of data regarding the mechanisms of the reaction, we cannot recommend more than 1 vaccination at each time, which has been 100% successful at getting current pediatric patients with DCM vaccinated. Routine Vaccinations in Diffuse Cutaneous MastocytosisThe Journal of Allergy and Clinical Immunology: In PracticeVol. 4Issue 1PreviewWith great pleasure we read the article by Bankova et al in the Journal of Allergy and Clinical Immunology: In Practice,1 concerning the important problem of vaccination in a child with the most severe form of cutaneous mastocytosis—diffuse cutaneous mastocytosis (DCM).1 In the case presented in the article, generalized bullous eruption appeared in a 5-month-old boy with DCM after scheduled 4-month vaccinations, including Haemophilus influenza vaccine, protein-conjugated pneumococcal vaccine, poliomyelitis vaccine, diphtheria, pertussis, tetanus toxoid, and rotavirus vaccines. Full-Text PDF