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Mastocytosis and mast cell disorders

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Synonym: systemic mast cell disease

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What is mastocytosis?

Mast cells are found in the perivascular spaces of most tissues and contain pro-inflammatory and vasoactive mediators. These mediators are released after IgE receptor cross-linking induced by allergens or other stimuli1 . Mast cell disorders may involve either of the following:

  • Excessive proliferation of mast cells (mastocytosis).

  • Normal numbers of cells but abnormal reactivity.

The excess release of mediators can cause clinical features such as pruritus, flushing, nausea, vomiting, diarrhoea, abdominal pain, vascular instability and anaphylaxis. Also, complications may arise when mast cells accumulate in the skin, gastrointestinal tract, bone marrow, liver, spleen, and lymph nodes2 . The clinical features of systemic mastocytosis are caused by accumulation of clonally derived mast cells in different tissues, including bone marrow, skin, gastrointestinal tract, liver and spleen. Systemic mastocytosis is now classified as a myeloproliferative neoplasm3 .

Classification of mast cell disorders


The World Health Organization (WHO) classification (simplified here) is:

  • Cutaneous mastocytosis - usually children:

    • Urticaria pigmentosa (maculopapular cutaneous mastocytosis) - the most common type.

    • Diffuse cutaneous mastocytosis (very rare).

    • Mastocytoma of skin.

  • Systemic mastocytosis:

    • Indolent systemic mastocytosis.

    • Systemic mastocytosis with associated haematological non-mast cell lineage disease (SM-AHNMD).

    • Aggressive systemic mastocytosis.

    • Mast cell leukaemia (very rare).

  • Localised mast cell proliferations (very rare):

    • Extracutaneous mastocytoma.

    • Extracutaneous mast cell sarcoma.

Telangiectasia macularis eruptiva perstans (TMEP) is a rare form of cutaneous mastocytosis, in which telangiectasias occur together with the rash4 .

Mast cell activation syndrome (MCAS)

  • MCAS - synonym: mast cell activation disorder (MCAD) - is characterised by the accumulation of genetically altered mast cells and/or abnormal release of mast cell mediators, affecting functions in potentially every organ system, particularly the skin, the gastrointestinal tract and the cardiovascular and nervous systems5 .

  • Patients experience many of the same symptoms as with mastocytosis. Chronic MCAS can be difficult to diagnose, especially when symptoms are mild or atypical6 .

  • The use of antihistamines and mast cell membrane-stabilising drugs with symptomatic treatment is often effective7 .

The classification of MCAS is a gradually evolving process, with additions and amendments occurring on a regular basis as more becomes known about the condition. Current classification systems rely on the following criteria:

  • Recurrent or chronic symptoms of mast cell activation.

  • Laboratory results showing evidence of mast cell activation (eg, a transient rise in serum tryptase or urinary N-methyl histamine, or the histamine metabolites prostaglandin D2 and prostaglandin F2-alpha).

  • Response of clinical symptoms to anti-mediator therapy.

  • Histopathological changes.

The debate continues concerning various aspects of diagnosis, notably the cut-off levels of laboratory results. Every classification amendment has had its critics with regard to over- or under-diagnosis8 .

The Mast Cell Disease Society advocates the following diagnostic criteria9 :

  • Criterion 1: the patient exhibits symptoms involving two or more organ systems in parallel, which recur, or are chronic, are found not to be caused by any other condition or disorder other than mast cell activation, and require treatment or therapy.

  • Criterion 2: documented evidence that mast cells are directly involved in the symptomatology. This is best demonstrated by an increase in the serum level of tryptase, above baseline and within a narrow (generally accepted as one to two hour) window of time after a symptomatic episode. If tryptase estimation is not available or is equivocal, other mediator tests can be used - eg, 24-hour urinary n-methyl histamine, prostaglandin-D2, or its metabolite, 11β-prostaglandin-F2α.

  • Criterion 3: a response to medications that inhibit the action of histamine, in addition to a complete or major response to drugs that inhibit other mediators produced by mast cells or block mast cell mediator release.

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Mastocytosis causes (aetiology)

The cause is unknown but is probably multifactorial. A mutation of the oncogene C-KIT D816V is found in many (but not all) cases10 . There is no evidence that this is an inherited condition3 .

Who gets mastocytosis? (Epidemiology)

Mastocytosis is a rare disorder with an estimated prevalence of 1 in 10,000 persons11 . 95% of the systemic form occurs in adults and it affects men and women equally12 .

90% of the cutaneous form occurs in children13 .

Possible triggers for mastocytosis symptoms14

Important information

Physical stimuli - eg, heat, cold, friction, sunlight, fatigue, exercise or fever.

Emotional stimuli - eg, stress.

Certain foods - eg, cheese, spices, shellfish, food preservatives, flavourings and colourings, monosodium glutamate.

Environmental toxins - eg, perfumes, pesticides.

Insect bites, jelly fish stings, snake bites.

Infection (bacterial, fungal or viral).

Drugs - eg, alcohol, anaesthetic agents, dextran, aspirin and non-steroidal anti-inflammatory drugs (NSAIDS), antibiotics, opioids, thiamine, quinine, gallamine, procaine, some radiographic dyes, polymyxin B, scopolamine and tubocurarine15 .

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Mastocytosis symptoms14

Cutaneous mastocytosis16

Urticaria pigmentosa

  • The rash comprises light brown, itchy, raised patches - on any part of the body.

  • The lesions blister when rubbed (Darier's sign) and become red, swollen and itchy. This confirms the presence of mastocytosis.

  • Rarely, anaphylactic reactions can occur after mechanical/thermal stimulation of skin lesions.

  • Dermatographism may be found on unaffected skin17 .

  • It usually affects infants from a few months of age. The lesions can persist and gradually increase in number for several months or years.

  • Symptoms gradually improve as the child gets older; the condition usually disappears by puberty. The younger the patient and the smaller the number of the lesions, the higher the probability of spontaneous remission. An adult onset increases the risk of systemic involvement and persistence.

Diffuse cutaneous mastocytosis

  • This usually occurs in the first year of life.

  • The rash is very itchy, with generalised yellowish, thickened skin.

  • Blisters are large and sometimes haemorrhagic; they occur spontaneously or following mild trauma.

  • With more extensive skin involvement, systemic symptoms are more likely. These include flushing, headache, palpitations, abdominal pain, diarrhoea, dyspnoea, wheezing, syncope, hypotensive shock and death.

  • Early onset of blisters worsens the prognosis.

Mastocytoma of skin
This is a macular, papular or nodular lesion of yellow, brown or reddish colour.

Systemic mastocytosis14 18 19 20

Patients may present with 'inexplicable' symptoms related to mast cell mediator release, such as vascular instability, anaphylactic shock, flushing, diarrhoea and headache (sometimes without skin lesions). There is a wide range of symptoms and a variety of triggers (see box, above). The condition may be unmasked by an anaphylactoid response to a stinging insect21 . Possible symptoms and signs of systemic mastocytosis are:

  • Skin:

    • Facial flushing (may be pruritic or burning)18 .

    • Urticaria pigmentosa (as above).

  • Gastrointestinal18 :

    • Abdominal pain.

    • Diarrhoea or steatorrhoea (due to malabsorption or altered motility).

    • Nausea and vomiting.

    • Hyperacidity, dyspepsia and peptic ulcers.

    • Hepatomegaly and splenomegaly.

  • Cardiovascular:

    • Syncope, hypotension or anaphylactic shock.

  • Haematological and bones:

    • Anaemia or other cytopenias (if bone marrow involvement).

    • Hypersplenism.

    • Lymphadenopathy.

    • Fractures (if bone marrow involved).

    • Rarely, a bleeding disorder due to heparin-like anticoagulant (case report)19 .

  • Respiratory:

    • Bronchospasm.

    • Nasal congestion and upper pharyngeal symptoms are also reported18 22 .

  • Neurological:

    • Headaches.

    • Peripheral neuropathy.

Localised mastocytosis14

  • Mastocytoma is a benign tumour with uniform growth.

  • Mast cell sarcoma is a locally destructive tumour.


  • Skin biopsy (with analysis of KIT mutations).

  • Blood tests:

    • FBC (anaemia, thrombocytopenia and leukocytosis), clotting studies, renal function tests and LFTs.

    • Serum tryptase - almost all patients with systemic mastocytosis have serum tryptase >20 ng/mL19 .

  • Urinary histamine metabolite levels (eg, 11β-prostaglandinF2α or N-methyl histamine) may be elevated23 .

  • If there is suspected systemic involvement (including most adults with suspected mast cell disorders) then complete staging is needed. This includes:

    • CXR (or chest CT scan) for lymphadenopathy.

    • Gastrointestinal investigations - eg, endoscopy and ultrasound of abdomen.

    • Bone density scan and skeletal X-rays.

    • Bone marrow biopsy/aspirate.

  • Other tests include:

    • Chromosomal analysis: 20% of patients with systemic mastocytosis have an abnormal karyotype.

    • Molecular testing for KIT D816V mutation is always positive but JAK2 V617F is rarely positive.

    • The mast cell clone is CD-117 positive and CD-25 and/or CD-2 positive. Expression of CD-25 on mast cells is seen in systemic mastocytosis but not in reactive states of mast cell hyperplasia.


There is a suggested diagnostic protocol. The diagnostic criteria are1 12 :

  • Major criteria:

    • Biopsy finding of multiple dense accumulations of mast cells (greater than 15% of mast cells in clusters) in bone marrow or in other non-skin tissue.

  • Minor criteria:

    • Detection of a point mutation at codon 816 in the KIT receptor gene. This may be found in bone marrow or blood or other internal organs.

    • Abnormal mast cell CD25 expression.

    • Serum total tryptase level persistently greater than 20 ng/mL.

    • Presence of KITD 816V mutation.

    • Presence of greater than 25% atypical mast cells.

  • The diagnosis of systemic mastocytosis may be made if one major and one minor criterion are present, or if three minor criteria are fulfilled.

Differential diagnosis

Mastocytosis treatment and management14 12

This is concerned mainly with symptom control, as there is currently no cure. Systemic mastocytosis is usually managed by haematologists.

Acute anaphylaxis20

  • Those prone to acute severe symptoms should avoid trigger factors where possible, wear a medical emergency identification bracelet or similar and carry written treatment protocols from their specialist.

  • Acute anaphylaxis is treated with intramuscular adrenaline (epinephrine), antihistamines (H1 and H2 receptor blockers), fluids and pressor agents22 .

  • Patients with recurrent anaphylactoid reactions should carry injectable adrenaline (epinephrine) in pen format for emergency use.

  • Consider immunotherapy against insect venom.

Skin and vascular symptoms

  • For pruritus, weals and flushing - H1 and H2 receptor antagonists such as chlorphenamine, ketotifen and cimetidine.

  • There is some evidence that long-term use of antihistamines can affect cognition, so these drugs should be titrated to the lowest effective dose and used for the shortest possible time.

  • Mast cell stabilisers - sodium cromoglicate, nedocromil and ketotifen.

  • Local corticosteroids for skin lesions. Intralesional steroid injection is sometimes used.

  • Psoralen in combination with ultraviolet A (PUVA) treatment - gives temporary benefit for skin lesions.


Inhaled bronchodilators - eg, salbutamol.

Gastrointestinal symptoms

  • H2 receptor antagonists or proton pump inhibitors for peptic ulceration.

  • Oral sodium cromoglicate for diarrhoea and abdominal pain25 .

  • Anticholinergics for diarrhoea.

Other possible systemic treatments26

  • Leukotriene inhibitors have been used in the treatment of systemic mastocytosis.

  • Systemic corticosteroids may be helpful for malabsorption, ascites and bone pain, to prevent anaphylaxis and for severe skin disease22 .

  • Low-dose aspirin may be helpful for symptoms resistant to H1 and H2 antagonists alone but must be started cautiously under supervision27 .

Bone pain

  • Oral sodium cromoglicate may help25 .

  • Osteoporosis prevention/treatment - calcium, vitamin D, and bisphosphonates15 .

Drugs to avoid28

  • Beta-blockers are contra-indicated in patients with systemic mastocytosis undergoing surgery - these drugs may counteract endogenous adrenaline (epinephrine) and may precipitate anaphylaxis.

  • Avoid alpha-blockers and cholinergic antagonists.

Aggressive disease2

  • Splenectomy may be helpful for patients with significant hypersplenism or portal hypertension (it may reduce the mast cell burden and improve cytopenias).

  • Aggressive systemic forms of mastocytosis may be treated with interferon alfa, pegylated interferon alpha, corticosteroids, or cladribine. In some cases, more intensive treatments such as imatinib, or drug combinations, may be considered26 .

  • The National Institute for Health and Care Excellence (NICE) recommends midostaurin monotherapy as an option for treating aggressive systemic mastocytosis, systemic mastocytosis with associated haematological neoplasm, or mast cell leukaemia in adults29 .

  • Bone marrow transplantation may be considered in some extreme cases30 . Haematopoietic stem cell transplant is being explored31 .

  • For patients with mast cell sarcoma, surgical excision with consecutive radiation and/or high-dose chemotherapy has been used32 . More latterly, stem cell therapy has been used28 .


Guidelines for management in children are available33 34 .

Prognosis2 14

Cutaneous mastocytosis

Childhood cases of urticaria pigmentosa and mastocytoma often resolve spontaneously. Adults are more likely to develop the systemic form of the disease.

Systemic mastocytosis

  • This has no known cure and tends to be progressive.

  • Prognosis depends on the degree of haematological and organ involvement, as the classification (above) suggests.

    • Indolent systemic mastocytosis has a relatively good prognosis - decades of life, using mainly symptomatic treatment, although life-threatening problems can occur.

    • In SM-AHNMD, the prognosis depends on the course of the associated haematological disorder.

    • Aggressive systemic mastocytosis and mast cell leukaemia have a poorer prognosis. The median survival for aggressive systemic mastocytosis is 41 months and for mast cell leukaemia, less than six months35 36 .

Localised mastocytosis14

  • Mastocytoma is a benign tumour with a good prognosis.

  • Mast cell sarcoma is locally destructive and usually has a poor prognosis.

Further reading and references

  • Castells M, Metcalfe DD, Escribano L; Diagnosis and treatment of cutaneous mastocytosis in children: practical recommendations. Am J Clin Dermatol. 2011 Aug 1;12(4):259-70. doi: 10.2165/11588890-000000000-00000.
  • Cardet JC, Akin C, Lee MJ; Mastocytosis: update on pharmacotherapy and future directions. Expert Opin Pharmacother. 2013 Oct;14(15):2033-45. doi: 10.1517/14656566.2013.824424.
  1. Horny HP, Sotlar K, Valent P; Mastocytosis: state of the art. Pathobiology. 2007;74(2):121-32.
  2. Metcalfe DD; Mast cells and mastocytosis. Blood. 2008 Aug 15;112(4):946-56.
  3. Carter MC, Metcalfe DD, Komarow HD; Mastocytosis. Immunol Allergy Clin North Am. 2014 Feb;34(1):181-96. doi: 10.1016/j.iac.2013.09.001. Epub 2013 Oct 7.
  4. Costa DL, Moura HH, Rodrigues R, et al; Telangiectasia macularis eruptiva perstans: a rare form of adult mastocytosis. J Clin Aesthet Dermatol. 2011 Oct;4(10):52-4.
  5. Akin C, Valent P, Metcalfe DD; Mast cell activation syndrome: Proposed diagnostic criteria. J Allergy Clin Immunol. 2010 Dec;126(6):1099-104.e4. Epub 2010 Oct 28.
  6. Valent P, Horny HP, Triggiani M, et al; Clinical and Laboratory Parameters of Mast Cell Activation as Basis for the formulation of diagnostic criteria. Int Arch Allergy Immunol. 2011 May 16;156(2):119-127.
  7. Molderings GJ, Brettner S, Homann J, et al; Mast cell activation disease: a concise practical guide for diagnostic workup and therapeutic options. J Hematol Oncol. 2011 Mar 22;4:10.
  8. Afrin LB, Ackerley MB, Bluestein LS, et al; Diagnosis of mast cell activation syndrome: a global "consensus-2". Diagnosis (Berl). 2020 Apr 22;8(2):137-152. doi: 10.1515/dx-2020-0005. Print 2021 May 26.
  9. Overview and Diagnosis of MCAS; The Mast Cell Disease Society, 2021
  10. Kristensen T, Vestergaard H, Bindslev-Jensen C, et al; Sensitive KIT D816V mutation analysis of blood as a diagnostic test in mastocytosis. Am J Hematol. 2014 May;89(5):493-8. doi: 10.1002/ajh.23672. Epub 2014 Feb 21.
  11. Elsaiey A, Mahmoud HS, Jensen CT, et al; Mastocytosis-A Review of Disease Spectrum with Imaging Correlation. Cancers (Basel). 2021 Oct 12;13(20). pii: cancers13205102. doi: 10.3390/cancers13205102.
  12. Gangireddy M, Ciofoaia GA; Systemic Mastocytosis
  13. Sandru F, Petca RC, Costescu M, et al; Cutaneous Mastocytosis in Childhood-Update from the Literature. J Clin Med. 2021 Apr 2;10(7). pii: jcm10071474. doi: 10.3390/jcm10071474.
  14. Silva I, Carvalho S, Pinto PL, et al; Mastocytosis: a rare case of anaphylaxis in paediatric age and literature review. Allergol Immunopathol (Madr). 2008 May-Jun;36(3):154-63.
  15. Brockow K, Metcalfe DD; Mastocytosis. Chem Immunol Allergy. 2010;95:110-24. doi: 10.1159/000315946. Epub 2010 Jun 1.
  16. Miller MD, Nery NS, Gripp AC, et al; Dermatoscopic findings of urticaria pigmentosa. An Bras Dermatol. 2013 Nov-Dec;88(6):986-8. doi: 10.1590/abd1806-4841.20132217.
  17. Bulat V, Mihic LL, Situm M, et al; Most common clinical presentations of cutaneous mastocytosis. Acta Clin Croat. 2009 Mar;48(1):59-64.
  18. Lee JK, Whittaker SJ, Enns RA, et al; Gastrointestinal manifestations of systemic mastocytosis. World J Gastroenterol. 2008 Dec 7;14(45):7005-8.
  19. Koenig M, Morel J, Reynaud J, et al; An unusual cause of spontaneous bleeding in the intensive care unit - mastocytosis: a case report. Cases J. 2008 Aug 18;1(1):100.
  20. van der Weide HY, van Westerloo DJ, van den Bergh WM; Critical care management of systemic mastocytosis: when every wasp is a killer bee. Crit Care. 2015 Jun 3;19:238. doi: 10.1186/s13054-015-0956-z.
  21. Dubois AE; Mastocytosis and Hymenoptera allergy. Curr Opin Allergy Clin Immunol. 2004 Aug;4(4):291-5.
  22. Tamhankar PM, Suvarna J, Deshmukh CT; Cutaneous Mastocytosis. Getting beneath the skin of the issue: a case report. Cases J. 2009 Jan 20;2(1):69.
  23. Divekar R, Butterfield J; Urinary 11beta-PGF2alpha and N-methyl histamine correlate with bone marrow biopsy findings in mast cell disorders. Allergy. 2015 Oct;70(10):1230-8. doi: 10.1111/all.12668. Epub 2015 Jun 24.
  24. Izikson L, English JC 3rd, Zirwas MJ; The flushing patient: differential diagnosis, workup, and treatment. J Am Acad Dermatol. 2006 Aug;55(2):193-208.
  25. Edwards AM, Hagberg H; Oral and inhaled sodium cromoglicate in the management of systemic mastocytosis: a case report. J Med Case Rep. 2010 Jun 26;4:193. doi: 10.1186/1752-1947-4-193.
  26. Magliacane D, Parente R, Triggiani M; Current concepts on diagnosis and treatment of mastocytosis. Transl Med UniSa. 2014 Feb 4;8:65-74. eCollection 2014 Jan.
  27. Butterfield JH; Survey of aspirin administration in systemic mastocytosis. Prostaglandins Other Lipid Mediat. 2009 Apr;88(3-4):122-4. doi: 10.1016/j.prostaglandins.2009.01.001. Epub 2009 Jan 22.
  28. Mastocytosis; DermNet NZ
  29. Midostaurin for treating advanced systemic mastocytosis; NICE Technology appraisal guidance, September 2021
  30. Stoecker MM, Wang E; Systemic mastocytosis with associated clonal hematologic nonmast cell lineage disease: a clinicopathologic review. Arch Pathol Lab Med. 2012 Jul;136(7):832-8. doi: 10.5858/arpa.2011-0325-RS.
  31. Ustun C, Reiter A, Scott BL, et al; Hematopoietic stem-cell transplantation for advanced systemic mastocytosis. J Clin Oncol. 2014 Oct 10;32(29):3264-74. doi: 10.1200/JCO.2014.55.2018. Epub 2014 Aug 25.
  32. Ryan RJ, Akin C, Castells M, et al; Mast cell sarcoma: a rare and potentially under-recognized diagnostic entity with specific therapeutic implications. Mod Pathol. 2013 Apr;26(4):533-43. doi: 10.1038/modpathol.2012.199. Epub 2012 Nov 30.
  33. Heide R, Beishuizen A, De Groot H, et al; Mastocytosis in children: a protocol for management. Pediatr Dermatol. 2008 Jul-Aug;25(4):493-500.
  34. Lange M, Hartmann K, Carter MC, et al; Molecular Background, Clinical Features and Management of Pediatric Mastocytosis: Status 2021. Int J Mol Sci. 2021 Mar 4;22(5). pii: ijms22052586. doi: 10.3390/ijms22052586.
  35. Lim KH, Tefferi A, Lasho TL, et al; Systemic mastocytosis in 342 consecutive adults: survival studies and prognostic factors. Blood. 2009 Jun 4;113(23):5727-36. doi: 10.1182/blood-2009-02-205237. Epub 2009 Apr 10.
  36. Joris M, Georgin-Lavialle S, Chandesris MO, et al; Mast Cell Leukaemia: c-KIT Mutations Are Not Always Positive. Case Rep Hematol. 2012;2012:517546. Epub 2012 Sep 10.

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