Mastocitosi nella pratica allergologica quotidiana Patrizia - PowerPoint PPT Presentation

Mastocitosi nella pratica allergologica quotidiana Patrizia Bonadonna, Allergologia Azienda Ospedaleira Universitaria Integrata: di Verona

MASTOCYTOSIS SKIN G-I TRACT Mast Cells LIVER BONE MARROW LYMPH NODES SPLEEN

Pathogenesis Receptor for gene KIT Sterm Cell Factor MUTATION D816V

WHO Classification 2001 SYSTEMIC CUTANEOUS MASTOCYTOSIS MASTOCYTOSIS (10-20%) (80-90%)

Cutaneous Mastocytosis - Urticaria Pigmentosa 2/3 of cases children - Diffuse cutaneous mastocytosis - Cutaneous Mastocytoma - Teleangectasia Macularis Eruptiva Perstans (TMEP) adults 90 % of CM in adults is SM

Urticaria Pigmentosa

Darier’s sign DD: Dermatoghraphism!

Systemic Mastocytosis MINOR CRITERIA MAJOR CRITERIA a) Abnormal morphology of Multifocal dense infiltrates extra-cutaneous mast cells of mast cells in BM (spindle- shaped) or b) Increased serum tryptase in other extra-cutaneous level (> 20 ng/ml) organs c) Mutation in the KIT proto- oncogene at codon 816 ( D816V mutation) in an extra- cutaneous organ d) Expression of CD2 and/or CD25 on BM mast cells DIAGNOSIS: 1 MAJOR CRITERION + 1 MINOR CRITERION or 3 MINOR CRITERIA

MMAS Monoclonal MC Activation Syndrome Patients with 1 or 2 of the MINOR CRITERIA and “…..with unexplained and /or recurrent anaphylaxis , without skin lesions and without the major criterion but with proof of mast cell clonality” Sonneck Inter Arch 2007

Triggers of Anaphylaxis in SM patients K.Brockow Allergy 2008 210 patients 210 patients D. Gonzales de Olano Cl Exp T. Gulen Clin Exp Allergy 2013 Allergy 2007

Prevalence of Clonal Mast Cells Disorders in Patients with Hymenoptera Venom Allergy Bonadonna P.Curr Opin Allergy Clin Immunol 2010

Bonadonna P. 88.2%Clonal Mast Cell 379 Zanotti R. et al Diseases subjects with JACI: 2009 - 61.7% ISM HVA - 26.5% MMAS Skin, ID and Serum assay 375 positive for HVA 4 negative 10 refused 44 pts TRYPTASE  11.4 34 consented Flow cytometric BM biopsy BM aspiration KIT analysis of MCs MUTATION 14/33 26/33 20/34 17/31 42.4% 78.8% 58.8% 54.8%

Do patients with venom- induced anaphylaxis and SM have a characteristic phenotype ?

Skin Involvement in Patients with Systemic Mastocytosis and HVA  4 / 21 ISM = 19% with skin involvement ( UP) (Bonadonna P et al . JACI 2009 Mar; 123:680-6)  5/ 21 ISM = 23% with skin involvement (4 UP + ( De Olano GZ et al JACI 2008 Feb;121: 519-26) 1 TMEP)

Haematologica 2011 ,96 482-483 MMAS ISMs- ISMs+ Characteristics 4 72 20 Male gender, n° (%) 4 (100) 51 (71%) 11 (55%) Age at diagnosis, median (range) 59 (52-69) 52 (19-74) 43 (27-60) Grading of Systemic reaction to HV n° (%) - I 1 (25) 1 (1) 0 - II 1 (25) 2 (3) 0 - III 0 5 (7) 0 2 (50) 20 (100%) - IV 64 (89%) sIgE and skin test for HV, n° (%) - Vespula 0 35 (49) 7 (35) - Polistes 3 (75) 21 (29) 7 (35) - Apis 0 8 (11) 3 (15) - Bombo 1 (25) 1 (1) 0 - Crabro 0 1 (1) 0 0 3 (15%) - Negative 6 (8%) 18.2 (17.4-23.3) 24.0 (8.4-68) 29.6 (9.9-103) basal s-Tryptase, median (range) ng/mL Atypical MC type I >25% of BMMC, n° 2 (50) 51 (71) 19 (95) (%) BM Multifocal, dense MC aggregates, n° 0 17 (24%) 11(55%) (%) 4 (100)° 54/63 (78) 19/19 (100) BM D816V mutation of KIT, n° (%) BM MCs CD25 pos by flow citometry 0 67/67 (100%) 20 (100%) 0 0.06 (0.003-0.6) 0.08 (0.008-1.4) - median % of MNC (range)

Álvarez-Twose et al., JACI 2013

Distribution of clinical symptoms in between acute episodes

Clinical and laboratory features of patients with insects ISM - I. Alvarez Twose, R.Zanotti, P.Bonadonna et al. JACI.2013

Therefore, anaphylaxis in these patients with ISM- and HVA could mainly be related to pathological alterations in mast cell activation processes rather than mast cell numbers per se .

Which patients, in absence of skin involvement and with characteristics that could strongly indicate a Clonal Mast Cell disease would have to undergo a complete haematological work up?

Scoring model proposed by the REMA (Red Española de Mastocitosis) Variable score Male Gender +1 Female -1 Absence of urticaria and Clinical symptoms +1 angioedema Urticaria and/or angioedema -2 Presyncope and/or syncope +3 <15 ng/mL basal Tryptase -1 >25 ng/mL +2 SCORE < 2: low probability of clonal MCAD SCORE  2: high probability of clonal-MCAD I. Alvarez Twose J Allergy Clin Immunol. 2010

Sensitivity and Specificity of REMA score in SM patients without skin lesions I. Alvarez-Twose, R. Zanotti, P. Bonadonna et al JACI 2013

A Clonal Mast cell Disorder cannot be excluded in subjects with systemic severe HVA, but with normal sBT

Clonal Mast Cell Disorders in Patients with Severe Hymenoptera Allergy and Normal Tryptase Zanotti R and Bonadonna P. Submitted 2014 22 pts HVA anaphylaxis with : - No skin lesions - Anaphylaxis with hypotension - Basal tryptase ≤ 10.  g/l  BM evaluation( BM smear and biopsy)  Detection of D816V mutation of KIT  Flow-cytometry analysis  REMA scored evaluted

p Clonal non-Clonal Total n°patients :22 Mast Cell Mast Cell Disorder Disorder (N=16) (N=6) Male sex, n° (%) 11 (68.8%) 3 (50.0%) ns Age, median (IQR) 60,5 (15%) 63 (16%) ns Tryptase, median ng/mL 8.6 (2.27%) 7.1 (2.33%) 0.033 (IQR) Allergy test negative n° (%) 1 (6.2%) 1 (16.7%) ns Angiodema + Urticaria n° 2 (12.5%) 5 (83.3%) 0.004 (%) REMA SCORE ≥ 2 14 (87,5%) 1 (16.7%) 0.004 REMA SCORE≤ 2 2 (3,2%) 5 ( 83.3%)

age sBT HVA Kit MC CD25 >25% Final Diagnosis ng/mL mutation positive (% of BM atypical BM MNC) MC 65 9.0 Polistes d neg 0.001 neg MMAS 61 10.8 Vespula D816V 0.210 pos ISM 60 8.4 Polistes d D816V 0.006 pos ISM 64 10 Polistes d D816V 0.032 pos ISM 63 8.9 Polistes d D816V 0.002 pos ISM 65 10.7 Vespula D816V 0.078 pos ISM 50 7.8 Vespula D816V 0.006 pos ISM 51 8.0 Crabro D816V 0.040 pos ISM 52 7.2 Polistes d D816V 0.004 pos ISM 51 6.6 Vespula D816V 0.001 pos ISM 39 9.4 Polistes d D816V 0.030 pos ISM 66 7.5 Vespids D816V 0.009 pos ISM 35 4.2 D816V 0.002 pos ISM Vespula 67 11.2 D816V 0.004 pos ISM Vespula 42 8.3 Apis D816V 0.023 pos ISM 74 8.8 Vespula D816V 0.130 pos ISM 55 4.0 Vespids neg 0.000 neg non-CMD 69 7.9 neg 0.000 neg Vespula non-CMD 54 8.5 neg 0.000 neg Vespula non-CMD 61 7.7 Vespula neg 0.000 neg non-CMD 65 6.3 Crabro neg 0.000 neg non-CMD 75 6.5 Apis neg 0.000 neg non-CMD In all cases of ISM the diagnosis was based only on minor criteria, since the major criterion was not present at BM biopsy.

Flow cytometry : atypical BM Mast cells that co- Flow cytometry : atypical BM Mast cells that co- express CD25 and CD2 express CD25 and CD2 CD25- CD25+ CD2- CD2+ gc. Dr. Omar Perbellini Multiparametric study Escribano L, 1998, Blood,91:2731-36 CD45/CD34/CD117/CD25/CD2 Sánchez-Muñoz L et al Methods Cell Biol. 2011;103:333-59 Perbellini O et al Cytometry B Clin Cytom. 2011;80:362-8

Management of patients with HVA and Mastocytosis

Skin test: sensitivity > 90% Diagnosis specificity > 90% Specific IgE

 Is it possible and safe to perform skin tests in Mastocytosis patients with HVA? YES Intradermal Test: 0,001- Prick test:100 mcg/ml 0,01-0,1-1 mcg/ml 92 ISM : No Reaction

Diagnostic tests negative in patients with Systemic Mastocytosis and HVA 375 POSITIVES 379 pts 4 Skin / intradermal and NEGATIVES serological tests Tryptase  11.4 ng/ml 3 ISM 1 MMAS JACI 2009 123: 680-686

2009 2009 Basophil histamine release test could be a suitable diagnostic option in skin testing and sIgE - negative patients with mastocytosis

63 SM 63 SM 52 Systemic Reactions 52 Systemic Reactions 11 LLR 11 LLR 7 negative 7 negative 45 positive specific and /or 45 positive specific and /or ( ID 10 mcg: 4 pos all ( ID 10 mcg: 4 pos all skin tests skin tests extracts) extracts) 6 controls : SM pts ,No 6 controls : SM pts ,No reactions, tests negative reactions, tests negative  None of the patients had adverse reactions to the skin tests. (Prick e ID)  Increasing dilution to 10 mcg it is not useful in the diagnosis

Results in negative patients  The use of a concentration of 10 μg/ml for IDTs is useless  BAT test did not add valuable information

Venom Immunotherapy

Venom Immunotherapy in Patients with Clonal Mast Cell Disorders: Efficacy, Safety and Practical Considerations. Allergy accepted Multidisciplinary Mastocytosis Spanish Network on Outpatient Clinic Mastocytosis REMA Verona, Italy

Demographic Characteristics: Total Italian vs Population Spanish (%) p / Patients 84 45 39 Mean age [range] 51.2 [26-81] 53.2 [29-81] 49.8 [26-77] ns Male 70 (83%) 37 (82%) 33 (84%) ns Diagnosis SM ISM+ skin lesions 12 (14%) 7 (15%) 5 (13%) ns ISM- skin lesions 65 (77%) 35 (77%) 30 (77%) MMAS 7 (9%) 3 (8%) 4 (10%) Severity reactions to 1 st sting Grade 1 1 (1.2%) 1 (2.3%) 0 Grade 2 7 (8.3%) 3 (6.7%) 4 (10%) ns Grade 3 8 (9.5%) 0 8 (20%) Grade 4 68 (81%) 41 (91%) 27 (70%) Grade 4 + loss of consciousness 53 (63%) 32 (71%) 21 (54%) ns