Mast Cell Mediators Research Articles

Biomarkers in the diagnosis of mast cell activation

Purpose of review Mast cell activation is defined by activation of mast cells by varying stimuli with release of chemical mediators either through degranulation or release of de novo synthesized proteins or lipid mediators. Currently, tryptase measurement increase during symptomatic episodes is the most accepted biomarker measurement for mast cell activation. However, newer diagnostic tools including clinically available urinary mast cell mediators are noninvasive and can be more readily obtained compared to serum tryptase levels. This review will highlight biomarker measurement in the diagnosis of mast cell activation. Recent findings This review will highlight biomarker measurement in mast cell activation including serum tryptase and urinary mast cell mediators including N-methylhistamine, leukotriene E4, and 2,3-dinor-11beta-prostaglandin F2 alpha. Summary Urine mast cell mediators obtained at baseline and during symptom exacerbation are emerging biomarkers in the diagnosis of mast cell activation. Tryptase measurement and urinary mast cell mediator measurement are currently the most accepted biomarkers for mast cell activation. Further research is needed to establish new biomarkers for mast cell activation.

Progression of Mast Cell Activation Syndrome to Systemic Mastocytosis

Abstract Introduction/Objective Mast cell activation syndrome (MCAS) is characterized by the abnormal release of mast cell mediators, leading to symptoms such as flushing, abdominal pain, and allergic reactions. In some cases, MCAS progresses to systemic mastocytosis (SM), a mast cell disorder marked by organ infiltration and dysfunction. However, predictors of MCAS progression to SM remain poorly understood, and long-term prognosis data are limited. Methods/Case Report We conducted a retrospective study of patients diagnosed with MCAS at Penn Medicine from January 1, 2019, through December 30, 2021. The primary endpoint was progression to SM, defined by World Health Organization criteria, with a secondary endpoint set for September 24, 2023. Results (if a Case Study enter NA) We identified 47 patients with MCAS (Table 1). Of these, 11 patients (23.4%) progressed to SM. Notably, all five patients with c-KIT mutations progressed to SM (100%, 5/5), while six out of 22 patients without c-KIT mutations also progressed (27.2%). Additionally, baseline serum tryptase levels were identified as a significant predictor of progression at two years. Conclusion The relative risk of progression varied depending on the subtype of MCAS, with higher rates observed in those with KIT D816V presence. Compared to the incidence of SM in the general population, our findings suggest a higher risk of progression from MCAS to SM, even without a c-KIT mutation. Identification of prognostic factors, such as specific genetic mutations and baseline serum tryptase levels, may aid in risk stratification and early intervention strategies for individuals with MCAS. HaT mutation testing should be considered in future studies on this topic. Our findings have important implications for the clinical management and understanding of MCAS progression to SM. Additionally, our data imply the importance of recognizing MCAS in the early phase and proper monitoring, considering the low rate of MCAS diagnosis. Patients with MCAS may need annual monitoring, including serum tryptase levels, to detect progression to SM and related complications. Early detection and intervention may improve outcomes and quality of life for individuals with MCAS.

CREB Is Critically Implicated in Skin Mast Cell Degranulation Elicited via FcεRI and MRGPRX2.

Skin mast cells (MCs) mediate acute allergic reactions in the cutaneous environment and contribute to chronic dermatoses, including urticaria, and atopic or contact dermatitis. The cAMP response element binding protein (CREB), an evolutionarily well conserved transcription factor (TF) with over 4,000 binding sites in the genome, was recently found to form a feedforward loop with KIT, maintaining MC survival. The most selective MC function is degranulation with its acute release of prestored mediators. Herein, we asked whether CREB contributes to the expression and function of the degranulation-competent receptors FcεRI and MRGPRX2. Interference with CREB by pharmacological inhibition (CREBi, 666-15) or RNA interference only slightly affected the expression of these receptors, while KIT was strongly attenuated. Interestingly, MRGPRX2 surface expression moderately increased following CREB-knockdown, whereas MRGPRX2-dependent exocytosis simultaneously decreased. FcεRI expression and function were regulated consistently, although the effect was stronger at the functional level. Preformed MC mediators (tryptase, histamine, β-hexosaminidase) remained comparable following CREB attenuation, suggesting that granule synthesis did not rely on CREB function. Collectively, in contrast to KIT, FcεRI and MRGPRX2 moderately depend on unperturbed CREB function. Nevertheless, CREB is required to maintain MC releasability irrespective of stimulus, insinuating that CREB may operate by safeguarding the degranulation machinery. To our knowledge, CREB is the first factor identified to regulate MRGPRX2 expression and function in opposite direction. Overall, the ancient TF is an indispensable component of skin MCs, orchestrating not only survival and proliferation but also their secretory competence.

Immunohistochemical analysis and distribution of epithelial mast cells in the rat larynx and trachea.

Mast cells (MCs) in rat airways have been classified into two subtypes: epithelial MCs and connective tissue MCs (CTMCs). However, the immunohistochemical characteristics, cellular morphology, and distribution of epithelial MCs in the upper airways remain unclear. The present study investigated the morphological characteristics and distribution of epithelial MCs using 5-hydroxytryptamine (5-HT) and other immunohistochemical markers in sectioned or whole-mount preparations of the rat larynx and trachea. A double immunofluorescence analysis revealed the colocalization of 5-HT immunoreactivity with c-kit, a stem cell factor receptor commonly used as a MC marker, in both epithelial MCs and CTMCs. Dopa decarboxylase, an enzyme involved in 5-HT synthesis, was detected in both subtypes, suggesting their ability to synthesize and release 5-HT. Tryptase and histidine decarboxylase (a biosynthetic enzyme of histamine), which are well-known mediators of MCs, were exclusive to CTMCs. Epithelial MCs were pleomorphic with long cytoplasmic processes, whereas CTMCs were round and lacked cytoplasmic processes. The density of epithelial MCs was significantly higher in the glottis and cranial part of the trachea than in the epiglottis and other parts of the trachea. The present results showed that the morphology and immunohistochemical characteristics of epithelial MCs were different from those of CTMCs in the rat larynx and trachea, and variform epithelial MCs were predominantly located at the entrance of the upper airways. Epithelial MCs may release 5-HT to regulate innate immune responses by modulating epithelial cell functions at the entrance gate of the upper airways.

Altered B-cell, plasma cell and antibody immune profiles in blood of systemic mastocytosis

Systemic mastocytosis (SM) is a heterogeneous disease characterised by an expansion of KIT-mutated constitutively activated mast cells (MC) which release MC mediators that might act on the tumour microenvironment including other immune cells. Here we investigated the blood distribution of B-cell, plasma cell (PC) and antibody-isotype compartments in SM. We used spectral flow cytometry and the EuroFlow Immunomonitoring panel and Lymphocyte Screening Tube to quantify B-cells, PC and their subsets in blood of 108 SM patients - 35 bone marrow mastocytosis (BMM), 64 indolent SM (ISM), 9 aggressive SM (ASM)- vs 117 age-matched healthy donors (HD) and paired bone marrow (BM) samples of 31 SM vs 17 controls, respectively. In parallel, immunoglobulin (Ig) M, IgD, IgG, IgA and IgE plasma levels of were measured. Compared to HD, SM patients showed an increased immature B-cell production in BM (P=0.003) associated with a greater release of pre-germinal center immature (P<0.001) and naive CD5+ B-lymphocytes (P<0.001) to blood, but a pronounced decrease in PC counts of all different IgH-isotypes and subclasses (P≤0.001) together with overall increased IgM (P=0.001) and IgD (P<0.001) plasma levels. Of note, different immune profiles were found per diagnostic subtype of the disease with progressively greater counts in blood of immature B-lymphocytes together with decreased IgMD+, IgG2+, IgA1+ and IgA2+ MBC (P≤0.032) and elevated IgM (P=0.017) plasma levels in ASM cases, increased IgM (P=0.001) and IgD (P=0.001) plasma levels in ISM patients and exacerbated IgE (P<0.001) with decreased IgG (P=0.008) plasma levels in BMM cases. Our results reveal a significant dysregulation of the B-cell and PC compartments in blood of SM patients, consistent with distinctly altered antibody-isotype profiles in plasma of BMM vs ISM vs ASM patients.

Mast cells: a double-edged sword in inflammation and fibrosis.

As one of the key components of the immune system, mast cells are well known for their role in allergic reactions. However, they are also involved in inflammatory and fibrotic processes. Mast cells participate in all the stages of acute inflammatory responses, playing an immunomodulatory role in both innate and adaptive immunity. Mast cell-derived histamine, TNF-α, and IL-6 contribute to the inflammatory processes, while IL-10 mediates the suppression of inflammation. Crosstalk between mast cells and other immune cells is also involved in the development of inflammation. The cell-cell adhesion of mast cells and fibroblasts is crucial for fibrosis. Mast cell mediators, including cytokines and proteases, play contradictory roles in the fibrotic process. Here, we review the double-edged role of mast cells in inflammation and fibrosis.

NCCN Guidelines® Insights: Systemic Mastocytosis, Version 3.2024.

Mastocytosis is a heterogeneous group of disorders comprising cutaneous mastocytosis, systemic mastocytosis, and mast cell sarcoma. It is associated with a variety of symptoms related to the release of mast cell mediators and mast cell tissue infiltration. Referral to specialized centers with expertise in the management of mastocytosis and multidisciplinary collaboration with subspecialists (eg, allergists for the management of anaphylaxis and drug hypersensitivities, anesthesiologists for invasive procedures or surgery, high-risk obstetrician for pregnancy) is recommended. The NCCN Guidelines for Systemic Mastocytosis provide evidence- and consensus-based recommendations for the diagnosis and comprehensive care of patients with systemic mastocytosis. The multidisciplinary panel of experts convenes at least once a year to review requested changes to the guidelines from both internal and external entities as well as to discuss data on existing and new therapies. These NCCN Guidelines Insights focus on some of the recent updates to the guidelines.

Mast cell conditions and drug allergy: when to suspect and how to manage.

Patients with mast cell disorders frequently experience symptoms from excessive mediator release like histamine and tryptase, ranging from mild flushing to severe anaphylactic responses. Hypersensitivity reactions (HRs) to drugs are a major cause of anaphylaxis in these patients, who often worry about triggering mast cell degranulation when taking medications. The aim of this review is to explore the complex interactions between mast cell disorders and drug HRs, focusing on the clinical challenges of managing these conditions effectively to enhance understanding and guide safer clinical practices. Among the drugs most commonly associated with hypersensitivity reactions in patients with mast cell disorders are non-steroidal anti-inflammatory drugs, antibiotics, and perioperative agents. Recent studies have highlighted the role of Mas-related G-protein coupled receptor member X2 (MRGPRX2) - a receptor involved in non-immunoglobulin E mediated mast cell degranulation - in exacerbating HRs. Investigations reveal varied drug tolerance among patients, underscoring the need for individual risk assessments. Tailored diagnostic approaches are crucial for confirming drug allergies and assessing tolerance in patients with mastocytosis, preventing unnecessary medication avoidance and ensuring safety before acute situations arise.

Flushing in children with cutaneous mastocytosis

Introduction. Flushing is a subjective feeling of warmth that is accompanied by redness of the skin on any part of the body, but mainly on the face, neck and upper trunk. Episodic flushing with other symptoms associated with mast cell mediators can be observed in 30–50% of children with cutaneous mastocytosis (CM).Aim. To analyze the frequency of flushing in children with various clinical forms of cutaneous mastocytosis. To study serum tryptase levels in children with flushing.Materials and methods. The study included data from 275 children aged from 6 months to 17 years inclusive, who were undergoing outpatient treatment and observation at the Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology from March 2022 until January 2024. The concentration of tryptase in the blood was determined by immunofluo-rescence on a three-dimensional porous solid phase (ImmunoCAP technology, Pharmacia Diagnostics AB, Sweden). Polarization and immersion dermatoscopy with 20x magnification were performed.Results. Flushings were observed in 17.5% of patients out of 275 observed children with CM. The level of tryptase more than 15 µg/l was determined in 20.8% of children with flushing, above 11.0 µg/l – in 37.5%. Tryptase levels were higher than 8.0 µg/L in 22 (45.8%) patients. In 25.0% of patients with flushing, tryptase levels did not exceed 5 µg/L. The severity of the vascular pattern in lesions and apparently healthy skin was characteristic of patients with frequent or prolonged flushing and tryptase levels above 8.0 µg/L.Conclusion. This study was the first in the Russian Federation to demonstrate the prevalence of flushing in children with various clinical forms of cutaneous mastocytosis. The results showed that the assessment of serum tryptase levels should be performed in all children with flushing, regardless of the clinical form of mastocytosis, including those with isolated and multiple skin mastocytomas. Clinical laboratory and dermatoscopic monitoring are important for the development of individual therapeutic tactics and prevention of mediator reactions and anaphylaxis.

Autoantibodies to type I interferons in patients with systemic mastocytosis

Autoantibodies to type I interferons have been identified in association with a variety of inflammatory and autoimmune diseases. Type I interferons have demonstrated inhibitory effects on mast cell proliferation and degranulation. Systemic mastocytosis (SM) is a disease characterized by increased mast cell burden and mediator release. Whether autoantibodies to type I interferon are present in the sera of patients with SM, and if so, whether they correlate with characteristics of disease, is unknown. The purpose of this study was to determine whether autoantibodies to type I interferons are observed in the sera of patients with SM, and if so, whether they correlate with biomarkers of disease severity. We analyzed sera from 89 patients with SM for concentrations of autoantibodies to type I interferon by using a multiplex particle-based assay and signal neutralization capacity by using a STAT1 activity assay and then compared these measurements with those in a database of information on 1284 healthy controls. Our cohort was predominantly female (57.3%), with a median age of 56 years. Of the cohort members, 13 produced autoantibodies to IFN-β, 3 to IFN-ω, and 0 to IFN-α. None of the 13 sera demonstrated signal neutralization. Neither autoantibody concentration nor signaling inhibition measurements correlated with tryptase concentrations or D816V allele burden. Although a small subpopulation of patients with SM have autoantibodies to type I interferons, there was no correlation between autoantibody production and signaling inhibition. These data are consistent with the conclusion that autoantibodies to type I interferon do not play a significant role in the pathogenesis or severity of SM.

Hereditary angioedema with normal C1 esterase inhibitor: Current paradigms and clinical dilemmas.

Background: A diagnosis of hereditary angioedema (HAE) with normal C1 esterase inhibitor (HAE-nl-C1-INH) can be challenging and pharmacologic management is not well defined. Objective: The objective was to discuss practical considerations in the clinical management of HAE-nl-C1-INH by using illustrative clinical vignettes to highlight and/or address select challenges. Methods: This was a narrative review. Results: Symptoms of HAE-nl-C1-INH overlap with HAE types I and II; the heterogeneity of presentation and symptom burden are diagnostic challenges. A patient history, with particular attention to whether urticaria or other symptoms of mast cell mediator release are present, is important because such symptoms would strongly suggest a mast cell-mediated pathway. A family history of angioedema is informative but a lack thereof does not rule out diagnosis. Expected laboratory findings would be normal for C4, C1-INH level and function, and Complement 1q; a genetic mutational analysis may be helpful, but current assays do not include all known mutations; most cases are categorized as unknown. To align with guideline-directed treatment approaches, the following stepwise approach is suggested for suspected HAE-nl-C1-INH: (1) thoroughly investigate the possibility of response to histaminergic and/or mast cell-targeting treatments; (2) if patients with normal C4, C1-INH level and/or function fail adequate trials with histamine/mast cell-directed therapy or have a mutation that suggests bradykinin pathway involvement, follow HAE type I and II treatment guidelines. Response to medications approved for HAE types I/II provides compelling support for a high clinical suspicion of HAE-nl-C1-INH. De-labeling an HAE-nl-C1-INH diagnosis may be appropriate if the initial diagnosis was made without adequate evaluation or if new information and/or testing indicates that the patient does not actually have HAE. Conclusion: Key unmet needs in HAE-nl-C1-INH include lack of confirmatory biomarker(s) for diagnosis and lack of prospective controlled clinical studies of pharmacologic products in this patient population.

IgE Neutralization Reverses Trimellitic Anhydride-Induced Urticaria in Humanized CD34+ Mice

Abstract Urticaria is a significant challenge affecting the quality of life for a substantial population worldwide, manifested by the sudden appearance of wheals, erythema, and pruritus triggered by allergic reactions, infections, or physical stimuli. Immunoglobulin E (IgE) plays a pivotal role in urticaria pathogenesis by mediating mast cell accumulation and degranulation to regulate the release of inflammatory mediators such as histamine. We developed a humanized CD34+ mouse model of urticaria by sensitizing the depilated skin topically with Trimellitic anhydride (TMA) on four occasions, with anti-human IgE as the positive control. Four consecutive days after the final sensitization, we observed and scored animal ear conditions, and enumerated scratching frequency. Additionally, mast cell counts in the skin and ear were evaluated. TMA-sensitized animals exhibited increased ear thickness, scoring, scratching frequency, and mast cell numbers in both skin and ear compared to normal animals. Toluidine blue staining confirmed a significant rise in mast cell numbers in TMA-sensitized mice, correlating with elevated histamine levels. Treatment with anti-human IgE ameliorated urticaria symptoms, showcasing comparable ear thickness, mast cell numbers in the ear and skin, and scratching frequencies to the normal animals. Our findings indicate that IgE neutralization effectively reversed TMA-induced urticaria in humanized CD34+ mice.

Definition, acronyms, nomenclature, and classification of angioedema (DANCE): AAAAI, ACAAI, ACARE, and APAAACI DANCE consensus

BackgroundAngioedema (AE) manifests with intermittent, localized, self-limiting swelling of the subcutaneous and/or submucosal tissue. AE is heterogeneous, can be hereditary or acquired, occurs only once or be recurrent, with or without wheals, due to mast cell mediators, bradykinin or other mechanisms. Currently, different taxonomic systems are used, making it difficult to compare the results of studies, develop multicenter collaboration, and harmonize treatments of AE patients. ObjectiveTo develop a consensus on the definition, acronyms, nomenclature, and classification of angioedema (DANCE). MethodsThe initiative involved 91 experts from 35 countries and was endorsed by 53 scientific, medical societies, and patient organizations. A consensus was reached by online discussion and voting using the Delphi process over a period of 16 months (June 2021 to November 2022). ResultsThe DANCE initiative resulted in an international consensus on the definition, classification and terminology of AE. The new consensus classification features five types and endotypes of AE and a harmonized vocabulary of abbreviations and acronyms. ConclusionThe DANCE classification complements current clinical guidelines and expert consensus recommendations on the diagnostic workup and treatment of AE. DANCE does not replace current clinical guidelines and expert consensus algorithms and should not be misconstrued in a way that affects reimbursement of medicines prescribed by a physician using sound clinical judgment. We anticipate that the new AE taxonomy and nomenclature will harmonize and facilitate AE research and clinical studies, thereby improving patient care.

Integrin β1–mediated mast cell immune-surveillance of blood vessel content

BackgroundImmunoglobulin E, IgE)-mediated degranulation of mast cells, MCs) provides rapid protection against environmental hazards, including animal venoms. A fraction of tissue-resident MCs intimately associates with blood vessels. These perivascular MCs were reported to extend projections into the vessel lumen and to be the first MCs to acquire intravenously injected IgE, suggesting that IgE loading of MCs depends on their vascular association. ObjectiveWe sought to elucidate the molecular basis of the MC-blood vessel interaction and to determine its relevance for IgE-mediated immune responses. MethodsWe selectively inactivated the Itgb1 gene, encoding the β1 chain of integrin adhesion molecules, ITGB1; in MCs by conditional gene targeting in mice. We analyzed skin MCs for blood vessel association, surface IgE density, capability to bind circulating antibody specific for MC surface molecules, as well as in vivo responses to antigen administered via different routes. ResultsLack of ITGB1 expression severely compromised MC blood vessel association. ITGB1-deficient MCs showed normal densities of surface IgE but reduced binding of intravenously injected antibodies. While their capacity to degranulate in response to IgE ligation in vivo was unimpaired, anaphylactic responses to antigen circulating in the vasculature were largely abolished. ConclusionITGB1-mediated association of MCs with blood vessels is key for MC immune-surveillance of blood vessel content, but is dispensable for slow steady-state loading of endogenous IgE onto tissue-resident MCs.

Intranasal administration of ceramide liposome suppresses allergic rhinitis by targeting CD300f in murine models

Allergic rhinitis (AR) is caused by type I hypersensitivity reaction in the nasal tissues. The interaction between CD300f and its ligand ceramide suppresses immunoglobulin E (IgE)-mediated mast cell activation. However, whether CD300f inhibits the development of allergic rhinitis (AR) remains elusive. We aimed to investigate the roles of CD300f in the development of AR and the effectiveness of intranasal administration of ceramide liposomes on AR in murine models. We used ragweed pollen-induced AR models in mice. Notably, CD300f deficiency did not significantly influence the ragweed-specific IgE production, but increased the frequency of mast cell-dependent sneezing as well as the numbers of degranulated mast cells and eosinophils in the nasal tissues in our models. Similar results were also obtained for MCPT5-exprssing mast cell-specific loss of CD300f. Importantly, intranasal administration of ceramide liposomes reduced the frequency of sneezing as well as the numbers of degranulated mast cells and eosinophils in the nasal tissues in AR models. Thus, CD300f–ceramide interaction, predominantly in mast cells, alleviates the symptoms and progression of AR. Therefore, intranasal administration of ceramide liposomes may be a promising therapeutic approach against AR by targeting CD300f.

A US-Based Multicenter Retrospective Report of Perioperative Anaphylaxis, 2010-2021

BackgroundUS-based perioperative anaphylaxis (POA) studies are limited to single center experiences. A recent report found that a serum acute tryptase (sAT) > 9.8 ng/mL or mast cell activation (MCA) can predict POA causal agent identification. Urinary mast cell mediator metabolites (uMC) have not been studied in POA. ObjectiveTo analyze the epidemiologic data of POA, to determine if sAT or MCA can predict suspected causal agent identification, and to evaluate uMC utility in POA. MethodsRetrospective multicenter review of POA cases which were subcategorized by suspected causal agent identification status. sAT, MCA (defined as sAT >2+1.2 x serum baseline tryptase), and uMC (N-methylhistamine[NMH], 11β-prostaglandin-F2α [11β-PGF2α], leukotriene E4 [LTE4]) were recorded. ResultsOf 100 patients (mean age 52 [SD 17], 94% adult, 50% female, 90% White, 2% Hispanic) with POA, 73% had a sAT available, 41% had MCA, 16% had uMC available, and 50% had an identifiable suspected cause. POA cases with an identifiable suspected cause had a positive MCA status (100% vs 78%; p=.01) compared to POA with an unidentifiable cause. An elevated median sAT did not predict causal agent identification. Positive uMC were not associated with suspected causal agent identification during POA. Patients with positive uMC had a higher median sAT (30 vs 6.45 ng/mL; p=.001) and MCA status (96% vs 12%; p=.001) compared to negative uMC patients. Patients with POA had an elevated acute/baseline uMC ratios: 11β-PGF2α ratio > 1.6, N-MH ratio >1.7, and LTE4 ratio >1.8. ConclusionPresence of MCA in POA is associated with suspected causal agent identification. Positive uMC possibly correlate with a higher sAT level and MCA status but require further study. The authors suggest applying an acute/baseline uMC ratio (11β-PGF2α ratio > 1.6, N-MH ratio >1.7, and LTE4 ratio >1.87) in POA patients for MCA when a tryptase level is inconclusive during POA evaluations.

Betulinic Acid Potentiates Mast Cell Degranulation by Compromising Cell Membrane Integrity and Without Involving Fcεri Receptors

ABSTRACT Mast cells play important role in acquired and natural immunity making these favorable therapeutic targets in various inflammatory diseases. Here we observed that, pentacyclic tri terpenoid betulinic acid (BA) treatment resulted in a significantly high number (9%) of cells positive for Hoechst and negative for annexin-V indicating that BA could interfere with plasma membrane integrity. The degranulation of both activated and non-activated mast cells was enhanced upon treatment with BA. The pre-treatment of BA had remarkable effect on calcium response in activated mast cells which showed increased calcium influx relative compared to untreated cells. The results also showed potentially less migration of BA treated mast cells signifying the possible effect of BA on cell membrane. BA treatment resulted in a significant increase in mRNA levels of IL-13 while as mRNA levels of other target cytokines, IL-6 and TNF-α seem to be not affected. Moreover, there was global Increase in phosphorylation of signaling proteins and no significant change in phosphorylation of FcεRI receptors indicating that the effect of BA was independent of signaling cascade or FcεRI receptor mediated mast cell aggregation. Overall, these results portray BA potentiates mast cell effector functions by compromising the membrane integrity and independent of FcεRI involvement.

Detecting Changes in Mast Cell Numbers Versus Activation in Human Disease: A Roadblock for Current Biomarkers?

The pathophysiology of mast cell (MC)-driven disorders is diverse, ranging from localized reactions to systemic disorders caused by abnormal accumulation and activation in multi-organ systems. Prompt and accurate diagnosis is critically important, both for informing treatment and objective assessment of treatment outcomes. As new therapeutics are being developed to deplete MCs or silence them (e.g., by engaging inhibitory receptors that block activation), new biomarkers are needed that can distinguish between MC activation vs. burden. Serum tryptase is the gold standard for assessing both mast cell burden and activation; however, commercial tryptase assays have limitations related to timing of release, lack of discernment between inactive (α) and active (β) forms of tryptase, and interpatient variability of baseline levels. Alternative approaches to measuring MC activation include urinary mast cell mediators, flow cytometry-based assays or gene expression profiling. Additional markers of MC activation are needed for use in clinical diagnostics, to help selection of treatment of MC diseases, and for assessing outcomes of therapy. We review the spectrum of disorders with known or suspected MC contribution, describe the utility and limitations of current MC markers and assays, and discuss the need for new markers that can differentiate between MC activation and burden.

Mast Cell Activation Syndrome and Gut Dysfunction: Diagnosis and Management.

Mast cell activation syndrome (MCAS) is a clinical disorder that may explain irritable bowel syndrome (IBS) type symptoms as well as other allergic symptoms experienced by an individual. The diagnosis and treatment of MCAS with specific focus on gastrointestinal (GI) manifestations is reviewed. Although biomarkers for MCAS remain elusive, testing for baseline serum tryptase will distinguish the type of mast cell disorder and urine tests for mast cell mediator metabolites may support the diagnosis. Endoscopy and Colonoscopy with biopsies is not used to diagnose MCAS but is important to rule out other conditions that may cause symptoms. There is increased awareness of the association between MCAS and autonomic dysfunction, small fiber neuropathy, and connective tissue disorders which all impact GI symptoms. MCAS is a disorder often of unknown etiology (idiopathic) and characterized by intermittent allergy type symptoms that affect multiple organ systems after exposure to a trigger. GI symptoms including abdominal cramping and loose stool are prominent and mimic those of IBS. Diagnostic testing is performed to assess for elevations in mast cell mediators during symptoms and to rule out other conditions. A comprehensive treatment plan includes medications that target mast cells, treatments for associated conditions including autonomic dysfunction, and management of comorbid psychiatric illness and nutritional deficits.

T-cell immune profile in blood of systemic mastocytosis: Association with disease features.

Systemic mastocytosis (SM) is a heterogeneous disease characterized by an expansion of KIT-mutated mast cells (MC). KIT-mutated MC display activated features and release MC mediators that might act on the tumour microenvironment and other immune cells. Here, we investigated the distribution of lymphocyte subsets in blood of patients with distinct subtypes of SM and determined its association with other disease features. We studied the distribution of TCD4+ and TCD4- cytotoxic cells and their subsets, as well as total NK- and B cells, in blood of 115 SM patients-38 bone marrow mastocytosis (BMM), 67 indolent SM (ISM), 10 aggressive SM (ASM)- and 83 age-matched healthy donors (HD), using spectral flow cytometry and the EuroFlow Immunomonitoring panel, and correlated it with multilineage KITD816V, the alpha-tryptasemia genotype (HαT) and the clinical manifestations of the disease. SM patients showed decreased counts (vs. HD) of TCD4- cytotoxic cells, NK cells and several functional subsets of TCD4+ cells (total Th1, Th2-effector memory, Th22-terminal effector and Th1-like Tregs), together with increased T-follicular-helper and Th1/Th17-like Treg counts, associated with different immune profiles per diagnostic subtype of SM, in multilineal versus MC-restricted KITD816V and in cases with a HαT+ versus HαT- genotype. Unique immune profiles were found among BMM and ISM patients with MC-restricted KITD816V who displayed HαT, anaphylaxis, hymenoptera venom allergy, bone disease, pruritus, flushing and GI symptoms. Our results reveal altered T- and NK-cell immune profiles in blood of SM, which vary per disease subtype, the pattern of involvement of haematopoiesis by KITD816V, the HαT genotype and specific clinical manifestations of the disease.