Scientific Letter
Diffuse cutaneous mastocytosis. Presentation of 3 cases and therapeutic management review
Mastocitosis cutánea difusa. Presentación de 3 casos y revisión de su manejo terapéutico
B. Selva Folcha,
, R. López Almarazb, R. Sánchez Gonzálezc, B. Martinez de las Herasa
Corresponding author
a Servicio de Pediatría, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
b Sección de Hematología/Oncología Pediátricas, Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain
c Servicio de Dermatología (Dermatología pediátrica), Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
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Presentation of 3 cases and therapeutic management review" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "286" "paginaFinal" => "288" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "B. Selva Folch, R. López Almaraz, R. Sánchez González, B. Martinez de las Heras" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Selva Folch" "email" => array:1 [ 0 => "blancaselvafolch@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "López Almaraz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "R." 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Presentación de 3 casos y revisión de su manejo terapéutico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2167 "Ancho" => 1528 "Tamanyo" => 233859 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SCORMA Index<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>A/5<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>5B<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2C/5.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diffuse cutaneous mastocytosis (DCM) is the least frequent and most severe form of cutaneous mastocytosis. It is characterised by diffuse mast cell infiltration in the dermis. Its clinical manifestations consist of progressive thickening of the skin, pruritus and systemic involvement due to mast cell degranulation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our objective was to review the clinical manifestations and management of cases of DCM in a tertiary care hospital, analysing their diagnosis, treatment, and exacerbations.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a)</span><p id="par0015" class="elsevierStylePara elsevierViewall">Male infant aged 4 months with a history of atopic dermatitis and bronchiolitis presenting with recurring urticarial lesions. The patient was referred to the department of paediatric gastroenterology (PGE) for suspected cow's milk protein allergy (CMPA). Nutrition with hydrolysed formula was initiated with no improvement, leading to referral to Dermatology, where the patient received a diagnosis of DCM after undergoing a cutaneous biopsy and laboratory testing (tryptase, 62.4<span class="elsevierStyleHsp" style=""></span>μg/L).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient has been treated with H1 and H2 receptor blockers, ketotifen, oral disodium cromoglycate and sessions of psoralen plus ultraviolet A phototherapy (PUVA). He has been admitted to hospital four times and visited the paediatric emergency department (PED) ten times due to exacerbations.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0025" class="elsevierStylePara elsevierViewall">Male infant aged 6 months, with no history of interest, with repeated episodes of diarrhoea, urticarial rashes and fever. The patient was referred to PGE for suspected CMPA and nutrition with hydrolysed formula was initiated with no improvement. The patient was then referred to Dermatology, where DCM was confirmed by means of skin biopsy, laboratory testing (tryptase, 16<span class="elsevierStyleHsp" style=""></span>μg/L) and a bone marrow biopsy (BMB), which was performed to rule out systemic mastocytosis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was treated with H1 and H2 receptor blockers, ketotifen, disodium cromoglycate and PUVA. He has been admitted twice and visited the PED three times due to exacerbations.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case 3 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b)</span><p id="par0035" class="elsevierStylePara elsevierViewall">Female newborn aged 13 days, with no history of interest, presenting in the PED with toxic erythema of the newborn and referred to Dermatology, where nodular DCM was diagnosed following a skin biopsy and laboratory testing (tryptase: 13.2<span class="elsevierStyleHsp" style=""></span>μg/l).</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient is being managed with H1 and H2 receptor blockers, ketotifen and disodium cromoglycate. She has required one admission and six visits to the PED due to exacerbations.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The maintenance treatment of our patients includes antihistamines, ketotifen, oral disodium cromoglycate, environmental measures and PUVA; and during exacerbations, they are treated with systemic corticosteroids and topical disodium cromoglycate.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Two cases have been assessed at the Centro de Estudios de Mastocitosis (Centre for the Study of Mastocytosis [CLMast]), located in the Hospital Virgen del Valle in Toledo (a centre of excellence in the Red Española de Mastocitosis [Spanish Mastocytosis, REMA]).</p><p id="par0055" class="elsevierStylePara elsevierViewall">Diffuse cutaneous mastocytosis consists in a diffuse increase of mast cells in the entire dermis that release the contents of their granules (histamine, tryptase, prostaglandins…) in response to different stimuli, triggering a systemic response: bronchoconstriction, increased permeability, intestinal hypermotility …</p><p id="par0060" class="elsevierStylePara elsevierViewall">The disease manifests with recurrent bullous rashes that result in a characteristic thickening of the skin (“peau d’orange”) and difficult-to-manage pruritus.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Darier's sign (development of pruritic erythema, wheals or blisters following stroking of lesions due to mast cell degranulation) is pathognomonic,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> and dermographism is a frequent manifestation. Given its large extent, there is systemic involvement with acute episodes of flushing, diarrhoea and bronchospasm. The definitive diagnosis is based on skin biopsy, which evinces elevation of mast cells with perivascular or nodular dermal infiltration. The investigation must be completed with laboratory testing, including serum tryptase level<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> (a marker of mast cell activity). Ruling out systemic mastocytosis (systemic symptoms or tryptase >20<span class="elsevierStyleHsp" style=""></span>ng/mL) requires an abdominal ultrasound examination and a BMB.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3–5</span></a> In our patients, the diagnosis was made by means of skin biopsy, and they were referred from Dermatology to Haematology-Oncology for haematological testing, which revealed elevated tryptase levels (mean, 48<span class="elsevierStyleHsp" style=""></span>ng/mL) and a normal sonographic appearance of the abdomen.</p><p id="par0065" class="elsevierStylePara elsevierViewall">There is an index for monitoring the activity of mastocytosis, the SCORMA (<span class="elsevierStyleItalic">SCORing MAstocytosis</span>) index, which assesses the extent (A), intensity (B) and accompanying symptoms (C). Applying the formula A/5<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>5B<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2C/5, a score between 5.2 and 100 is obtained (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The index is positively correlated with serum tryptase levels, and is useful during exacerbations and for assessing response to treatment. Furthermore, it is less invasive and costly than the determination of tryptase levels.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The treatment is based on:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Avoiding factors that trigger the release of granules by mast cells: drugs (aspirin, NSAIDs, opiates, cough medicines, muscle relaxants, thiamine, quinine, aminoglycosides, sympathomimetic and parasympathomimetic drugs), foods rich in histamines or that trigger the release of histamine (chocolate, citrus fruits, shellfish…) and others (fever, exercise, friction…).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Pharmacological treatment: systemic and topical<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> agents to control pruritus and achieve a good quality of life. Drugs must be introduced in a stepwise manner: antihistamines, mast cell stabilisers (sodium cromoglycate and ketotifen) and antileukotrienes. Phototherapy with UVB/PUVA can also reduce the number of mast cells.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">At present, there are several areas of pharmacological research, such as c-kit inhibitors, anti-IgE (omalizumab) and interferon alpha.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,6</span></a> During acute exacerbations, the dosage of maintenance medications must be increased, adding topical or systemic corticosteroids (1–2<span class="elsevierStyleHsp" style=""></span>mg/kg/day) and topical sodium cromoglycate or antibiotics, if needed.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Patients must be provided with intramuscular adrenaline due to the risk of anaphylactic reactions, and adrenaline auto-injectors are commercially available.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion, early diagnosis and a multidisciplinary followup comprising paediatric primary care, dermatology, allergy and haematology/oncology, along with REMA, are needed to improve the management of these patients.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1 (Fig. 1a)" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 3 (Fig. 1b)" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Selva Folch B, López Almaraz R, Sánchez González R, Martinez de las Heras B. Mastocitosis cutánea difusa. Presentación de 3 casos y revisión de su manejo terapéutico. An Pediatr (Barc). 2016;84:286–288.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1702 "Ancho" => 2333 "Tamanyo" => 294871 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cases 1 and 3. Multiple erythematoedematous and bullous lesions, some of them slightly yellow, 1–2<span class="elsevierStyleHsp" style=""></span>cm in size and distributed through the entire body surface area.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2167 "Ancho" => 1528 "Tamanyo" => 233859 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SCORMA Index<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>A/5<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>5B<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2C/5.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mastocitosis cutánea: revisión de 10 años de experiencia en el Servicio de Dermatología del Hospital General de Niños Pedro de Elizalde" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.L. 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| Year/Month | Html | Total | |
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