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Lisa Klimas

I'm a 35 year old microbiologist and molecular biologist with systemic mastocytosis, Ehlers Danlos Syndrome, Postural Orthostatic Tachycardia Syndrome, Adrenal Insufficiency, and an assortment of other chronic health issues. My life is pretty much a blast.

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 50

62. Is it possible to become tolerant of a trigger again?

Yes, sometimes.

Desensitization is the term for when your body becomes tolerant of something that it previously reacted to. While it usually means becoming tolerant of a medication, it is a general term so many mast cell patients use “desensitization” to mean becoming tolerant of anything they used to react to, including food or environmental triggers.

Traditionally, desensitizing is done by exposing the body to a small amount of a trigger, then a little more at a later time, and so on until the body accepts a reasonable amount. In the regular allergies, in the US, “allergy shots” are used for this. A patient is injected with a tiny amount of an allergen repeatedly until their immune system stays calm when exposed to the trigger.

There are some newer approaches for desensitization that use certain newer medications. In particular, anti-IgE therapy has been very well described for helping to force a patient to tolerate a trigger. Antihistamines and/or corticosteroids can be used to control the level of allergic response.

In some instances, a rapid desensitization procedure can be used to force tolerance. These procedures are performed in a medical setting and may provide tolerance in a matter of days. They are usually used in situations where the benefit of a drug to which the patient reacts outweighs the risk of anaphylaxis, such as patients who need to use a specific chemotherapy drug to treat an aggressive disease.

Importantly, if a patient becomes desensitized to a substance, they must be regularly exposed to that substance in order to continue tolerating it. Sometimes, a patient must be exposed daily in order to not react to the trigger. This is very patient and substance specific.

Mast cell patients are different from typical allergy patients in a lot of ways, many of which we don’t understand. Patients ask from time to time if “allergy shots” or something similar will help them. Mast cell patients who have an IgE allergy to a substance may get some benefit from allergy shots. Specifically, allergy shots are recommended for mastocytosis patients who have allergies to certain insect stings.

But what if they don’t have an IgE allergy? Will gradually increasing the amount of trigger in a series of exposures allow the body to accept it?  I know plenty of mast cell patients who have used allergy shots or oral immunotherapy to improve trigger tolerance. I can’t think of any reason why this wouldn’t help if you could safely increase the exposures.

For mast cell patients, the issue is that reactions can be so serious that desensitization is difficult to achieve. Patients can sometimes overcome this by using IV Benadryl, IV steroids, or a continuous IV epinephrine infusion. Mast cell patients should never attempt to force tolerance to any trigger without receiving advice from a health care provider that understands their specific health situation.

Food allergies are widely recognized as being different from other kinds of allergies. We are learning about food allergies in real time right now. Food allergies are on the rise and now affect huge numbers of people around the world. This means that there’s tons of research on it, which is great. But it means that we still don’t understand them that well. For this reason, desensitization to food is trickier.

There are a few methods commonly used in mast cell patients to manage food reactions. Sometimes a gradually increasing amount of trigger is eaten while the patient is monitored and given medications to manage any reactions, essentially a rapid desensitization for food. I find this approach is taken more commonly with children, largely because it is the recommended procedure for reintroducing triggers to children with FPIES. Sometimes people find that when they are exposed to a trigger for the first time in a while, they tolerate it until a second exposure. In these scenarios, rotation diets can be helpful. Allergy shots or oral immunotherapy for substances found in food are sometimes given. Results vary.

I have talked a lot before about the fact that mast cell reactions are often the cumulative result of things that activate your mast cells. This means that if you do something that activates your mast cells before eating a trigger, your reaction may be worse. In some instances, you may only react if you do something irritating to your mast cells shortly before eating it. This doesn’t just happen to mast cell patients. There are many mentions in literature of allergy patients who only experience anaphylaxis to trigger foods if they have exercised shortly before eating.

This means that if you are able to control the experience of eating triggers, you may have better success. You may do better if you refrain from doing anything irritating to mast cells like exercising, getting too hot, or being in a stressful situation. Food temperature can play a role. Many patients react to foods that are too hot or too cold. How you time medications can help. If you eat in the window of time when your medications are most active, you might find that a trigger is less activating. Solids are harder to digest and cause more histamine release than liquids (even thick liquids) so what form your food takes can matter, too.

Additionally, if you are able to control your disease and inflammation, you may find yourself more tolerant of triggers overall. Patients who find that their symptoms are better controlled should discuss trials with their health care providers to see if they can try exposures to previous triggers.

I can tell you that I have personally had a lot of success with using an anti-IgE medication to help me regain foods I lost. I have one IgE food allergy (chicken egg whites) and have no plans to ever try to consume them without thorough cooking (I’m tolerant of well cooked egg whites.) However, I do have a spectacular amount of food triggers that cause reactions ranging in severity from flushing to anaphylactic shock. My severe food reactions largely resolved when I started anti-IgE injections a few months ago. I eat all kinds of things I used to react badly to. I can eat cookies. I can eat cherry pie. I can eat bread. I try not to push my luck with things that have are loaded in histamine. I will never try alcohol or anything fermented again.

Prior to taking the anti-IgE medication, I had some success with rotation diets in which I ate gradually increasing amounts of a trigger every four days. It didn’t really make the reactions stop but it did make them less severe, enough that I could reintroduce small amounts of some previous triggers into my diet. This happened after I had GI surgery that decreased my overall level of inflammation and mast cell reactivity.

For more detailed reading, please visit these posts:

Food allergy series: FPIES (Part 1)

Food allergy series: FPIES (Part 2)

Food allergy series: Mast cell food reactions and the low histamine diet

Reintroduction of food to a child with SM

The Devil’s Arithmetic

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 46

In which I share the MastAttack end game and I hope you guys like it

Dear MastAttackers,

I have some news to share. I hadn’t planned to announce it until September but it has been a rough few days as a community and I thought sharing something positive might be helpful.

A couple of years ago, I made a list of the goals I wanted to achieve through MastAttack. The most ambitious of those goals was to teach five other people everything I know about mast cell disease. The idea was that I would mentor and teach these people with the understanding that they would become responsible for teaching a certain number of people everything they had learned from me. In this way, my knowledge would be redundant and information much more readily accessible for patients and providers. The point was to nurture and protect an open flow of knowledge that increases as more people learn about these diseases in depth.

So I had this idea and I spent several months turning it over and over in my mind. I knew it would take up a lot of my time and mental capacity. To be worth the huge time investment, it had to be effective. I had to figure out exactly what I knew that and how to teach that to other people, especially people who do not have a strong science background. I needed people to already have some basic understanding of mast cell disease in order to be able to teach the more technical points. I also had to figure out how to do it without it stressing me out and jeopardizing my health.

Along those lines, I have been working on a secret project for over a year. I organized all the information that I felt a person had to understand to learn everything I knew. I divided it into sections and developed a syllabus for three university style courses on mast cell disease and mast cell biology.

The first of these courses will start in the spring of 2018. It will teach intermediate topics beyond the basics of diagnosis/treatment/activation biology. It will run for 8 weeks. I will post a 20-25 minute video lecture on YouTube on a specified topic. The following week, we will meet online to discuss specific questions or issues associated with the topic. These discussions will happen in the MastAttack Facebook group, to which I will be returning later this year. I will also provide some handout style materials. I’m sure the first run of this course will have some growing pains and we can see what works and what doesn’t for subsequent teaching activities.

I also wrote an introductory text specifically to give a knowledge base for students to build upon in this course. You are all currently reading that introductory text. It is the MastAttack 107 series.

The most amazing part of MastAttack is seeing people who knew nothing about mast cell disease grow in their knowledge of these complicated concepts. For people who have a very solid understanding of mast cell disease and want to learn much more detailed, technical concepts, I plan to offer a Master class. I do not yet know the format this will take. I will let you all know when I’ve developed the idea further.

I strongly believe that people should not have to pay for access to information that allows them to understand their health. For this reason, this course will be free. Lectures and materials will be publicly available. Given how much time and effort it has taken to put this all together, I am open to the idea of compensation if people want to and are able to. However, this will not affect your access to this course or the information taught in it, or your personal standing with me. No one will have to pay. I mean it.

The last few days have been hard for a lot of people. The reason for this is largely because we rely on specific people to educate others on our behalves. The solution to this specific issue is to learn how to educate others ourselves. This will never replace the need for the support of well informed providers and researchers, but it will help people to regain some agency in their own care.

The best possible situation for our community is a legion of well informed patients that can advocate for themselves and help others. The best possible scenario is for me to be obsolete. This is the MastAttack end game, and has been from the beginning.

So now you all know my big secret. I’m really excited to do this. I hope you guys are, too.

Never give up hope. Stand up and fight.

Xoxo,
Lisa Klimas
Author and founder of MastAttack

Non existent

One of the more arcane pieces of Lisa Klimas trivia is that I lost the majority of my hearing in 2009. I grew up hearing to hearing parents and am culturally hearing. I knew some sign language but it was pretty minimal. While I was losing my hearing, I focused all my available energy on learning ASL. I practiced for hours every day. I fingerspelled all day long and sang along to songs in ASL when I was driving or in the shower. My boyfriend at the time learned to sign as well and we signed at home.

After eight years of being Deaf, I straddle the worlds of the hearing and Deaf cultures. ASL has become a part of me. I no longer have to consciously translate from English. I can think in ASL. Sometimes the words that my brain generates in response to something are signs instead of English words. When this happens, it is often a word or concept that has no direct translation in English. Some ideas are just more natively ASL.

My post yesterday was written in response to a recent video that really downplays mast cell activation syndrome. I felt like the wind had been knocked out of me when I watched it. I had an immediate visceral reaction. My inner voice was signing to me. A flat palm brought up to the mouth and blowing gently across it. There are a lot of translations for this sign, none of which perfectly capture the meaning. It is close to nothing left or non-existent. Like you had something in your hand but now it is gone.

I thought a lot today about why exactly this interview upset me so much and what my motivations were for speaking about it publicly. I think it’s because as a community we are so small and hidden. We really can’t afford bad press or harmful misinformation. Most people will never know about mast cell disease. Many will never even hear those words at all. Our stories will never reach everyone.

But we try anyway. We try even when we know that our words will be swallowed by the cacophony of billions of voices talking over us. We shout as loud as we can that this is our story. That we exist. That we are falling through the holes in a health care system that isn’t prepared for us. That this is real and that we are scared and that we need help.

We are a tiny community, a fraction of a fraction of a percent of the people living in this world. A fraction of a fraction whose faces and voices and stories are at great risk every day of never been known. A fraction of a fraction that lives with the knowledge that at any time, this disease could take everything. That any story they tell might be their last. That they might leave this world and become a story.

That there will be nothing left of them. That they will cease to exist.

 

Raising hell

I started this blog in 2014 with the expectation that only a few people would read it. There were some educational posts but they were pretty cursory. They were very directed towards patients without a lot of science background. I sometimes included references. I didn’t fret over the wording or the way I presented facts because controversy seemed unlikely to strike. I was basically talking to myself in those early months.

Everyone who reads MastAttack knows where this ends up: that a lot of people started reading it. People came to me in droves for answers to their questions. Caregivers came for advice. Health care providers and researchers began to view me as an opinion leader and MastAttack as a reliable source of information about mast cell disease. I started working with patients and medical teams to advocate for appropriate management, diagnosis and treatment. I wrote and rewrote posts and read and reread literature and data about mast cell disease to guarantee its accuracy. I became an authority on mast cell disease and sort of authority figure in the mast cell community.

I spend a massive amount of time researching mast cell disease. I write and rewrite posts constantly. I read and reread literature and data. The pressure to be right is huge, and it should be. MastAttack is a readily available point of contact for any person trying to learn about mast cell biology or mast cell disease. Failing to accurately vet something could affect people’s lives.

Ultimately, I have to be right, every time, because when I speak, I am speaking for every mast cell patient. I take that responsibility very, very seriously. It is more than just understanding the science. I have to know the story I am trying to tell about these diseases that can direct patients and providers toward effective care. I have to convey the human impact of these diseases. As a representative of the mast cell community, I have to be on message.

I have philosophical and academic differences with mast cell researchers, providers, and patients, especially about some of the more nuanced science. Despite this fact, overwhelmingly, this community is united in telling one story with one message.

Mast cell disease is cruel and debilitating. It steals things from you. It steals your life. It is scary and graphic and gross and endless. It is handfuls of pills and organ damage and surgeries and central lines. It is so, so serious. It is epipens and swelling and wheezing and puke. It is danger. It is the exhaustion of arguing with insurance companies for hours at a time. It is the metal taste of fear when we wonder if our kids will get it. It is the quiet terror that this disease will get worse. It is the unutterable thought that maybe one day it will kill us.

It is also the strength of a patient’s bonds with their family. It is the discovery that you can keep going long after you are certain that you can’t. It is iron will. It is the exhilaration of achievement in spite of the damage your body sustains on a daily basis. It is love and joy and tears and uncertainty. Because this is real life and these are real people and real diseases. That is the message.

Misrepresenting that message in private or in public does more than a disservice to mast cell patients. It can be harmful. It can be dangerous. And since rare diseases are by their very nature scarce, media around them is also limited. A person without these diseases might only ever read one article about mast cell disease or see one interview. We do not have infinite opportunities to educate people about these diseases. We are not living in forever. When a person speaks to the public on behalf of the mast cell community, what they say MUST be correct. It MUST tell the real story. It MUST represent the experience of living with this disease accurately. It MUST be on message.

For patients who are wondering why I’m waxing philosophical at 3am about the onus upon subject matter experts in this community, there was a very recent televised interview about mast cell activation syndrome (MCAS). I’m sincerely trying not to be unkind but I was genuinely bewildered by the amount of inaccuracy jammed into a four minute video. I’m not going to link to it because frankly, I don’t want to generate additional traffic to the video. It was insulting and irresponsible at best.

Mast cell activation syndrome (MCAS) is a serious, chronic health condition that affects all organ systems. It increases the risk of anaphylaxis, which can be fatal. Complications of MCAS can include organ damage. It is often disabling. It is often found alongside other conditions such as Ehlers Danlos Syndrome and POTS. It is not well known among medical providers. It is difficult to test for. Treatment revolves around blocking mast cell mediators with things like antihistamines and mast cell stabilizers. Most people are not able to manage their diseases simply by avoiding triggers. Most people need medication, and often, a lot of it. Most people have symptoms every day and sometimes experience bad mast cell attacks and anaphylaxis. MCAS is in no way a mild or minor health issue. It should not be minimized and neither should the experiences of the people living with it.

In the same way that experts are responsible for sharing accurate information, patients also have a duty. This is your community. You have a voice and a duty to use it. If you are not being represented accurately, raise hell. If your disease is being minimized, raise hell. If the science is not being explained correctly, raise hell. When misinformation threatens your safety, You. Raise. Hell. Yes, you.

Use your voice. Tell your story.

Stand up and fight. And raise hell.

 

For people looking for reliable information to provide to lay people or providers about mast cell disease, please visit the following posts:

The Provider Primers Series
The MastAttack 107
The Mast Cell Disease Fact Sheet

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, part 49

60. Is anaphylaxis the same as anaphylactic shock?

No. Anaphylaxis can result in anaphylactic shock but it often doesn’t. When talking about anaphylactic shock, people are referring to circulatory shock that was caused by anaphylaxis. Circulatory shock occurs when there is not enough blood to carry oxygen to all the tissues that need it. When the tissues don’t get enough oxygen, your organs stop working correctly.

Circulatory shock is usually caused by low blood pressure. Anaphylaxis commonly causes low blood pressure and that can cause shock. However, anaphylaxis does not always cause low blood pressure, and it does not always cause shock.

61. If a tryptase level over 10.9 ng/mL is high, why is one of the criteria for systemic mastocytosis a tryptase level of 20.0 ng/mL or higher?

Tryptase level is used in two ways in assessing mast cell patients: as a marker for activation, and as a marker for how many mast cells are in the body.

There are two primary methods of using tryptase to indicate mast cell activation.

The first way is to compare a tryptase level when a patient is reacting to a tryptase level when they are not reacting (baseline). Mast cells release more tryptase when they are activated. For mast cell patients, an increase of 20% + 2 ng/mL is considered evidence of mast cell activation. So if a patient has a baseline tryptase of 5 ng/mL when they are not reacting, anything 8 ng/mL (20% of 5 ng/mL is 1 ng/mL, then add 2 ng/mL = 8 ng/mL) or higher is considered evidence of activation.

The second way is to count anything over 10.9 ng/mL as evidence of activation.

When you are using tryptase as a measure of how many mast cells are in the body, the patient should not be reacting beyond their normal day to day symptoms. This is because you don’t want an increase in tryptase from activation to make the baseline level look higher than it is. Tryptase is used to measure how many mast cells are present because mast cells release some tryptase all the time, even when they aren’t activated.

Anything over 10.9 ng/mL is considered an elevation of tryptase. The reason that 20 ng/mL is the cutoff for the SM criterion is that patients are likely to have a positive bone marrow biopsy when the tryptase level is twice normal (21.8 ng/mL). They round the number down to 20 ng/mL because all tests have a margin of error. By rounding down to 20 ng/mL, they catch patients that might not have made the cutoff before because of an error in the test. This means that a patient who has a tryptase level of 20 ng/mL or higher is likely to have a bone marrow biopsy that will be positive for systemic mastocytosis.

For more detailed reading, please visit these posts:

Anaphylaxis and mast cell reactions

The Provider Primer Series: Mediator Testing

Patient questions: Everything you wanted to know about tryptase

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, part 8

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 48

59. Is systemic mastocytosis a form of cancer? Why do some papers say the life expectancy for systemic mastocytosis patients is much shorter?

Systemic mastocytosis is a term that different people use in different ways, often without defining them for the audience. This can lead to some confusion.

In its broadest sense, systemic mastocytosis is actually a disease category rather than one specific diagnosis. The subtypes of systemic mastocytosis are indolent systemic mastocytosis (ISM), smoldering systemic mastocytosis (SSM), systemic mastocytosis with associated hematologic disease (SM-AHD), aggressive systemic mastocytosis (ASM), and mast cell leukemia (MCL).

When patients talk about systemic mastocytosis without specifying which diagnosis, they almost always mean indolent systemic mastocytosis (ISM), the most common form of SM. ISM is benign and has a normal life expectancy. But when providers and researchers talk about systemic mastocytosis, they usually mean the disease category that includes all of these diagnoses.

I just recently explained in another post what a neoplasm is. It is essentially when the body grows something that doesn’t belong there, like extra cells or a tumor. Cancers are neoplasms but not all neoplasms are cancerous. Indolent systemic mastocytosis is not cancerous. Even without taking drugs to kill off lots of mast cells, the prognosis is excellent with a normal life span. However, aggressive systemic mastocytosis and mast cell leukemia are considered cancerous. Without taking drugs to kill off mast cells, the body would be unable to cope with the huge number of mast cells and the damage they cause. Smoldering systemic mastocytosis is sort of a bridge between ISM, which is benign, and ASM, which is not.

If you are not aware that research papers usually use the term systemic mastocytosis to mean all forms of systemic mastocytosis and not just indolent systemic mastocytosis (ISM), it is easy to get confused and misunderstand what is being said. There was a paper published in 2009 that discussed expected survival for the various forms of systemic mastocytosis. It provides a very jarring statistic for patients who may not understand the context. This study found that many patients with systemic mastocytosis died 3-5 years after diagnosis.

Let’s pull this apart. We know there are five forms of SM: indolent SM, the most common form, which usually has a normal life span; smoldering SM, which usually has a shortened life span; aggressive SM, which can have a very shortened life span; mast cell leukemia, which has a very shortened life span; and SM with an associated hematologic disorder, which may have a shortened life span. When you average the life expectancies for a mixed group of patients with these various diagnoses, it shows that overall, SM patients are more likely to die 3-5 years after diagnosis when compared to healthy people of the same age.

Additionally, a lot of the patients in this study group were older and died of causes unrelated to systemic mastocytosis. However, because they were part of the study, their deaths of unrelated causes were still included in this data.

Let’s recap: in a research paper, the term systemic mastocytosis includes forms of SM that are malignant and can really shorten your life expectancy as well as forms that are benign and do not shorten your life expectancy. When you average the life expectancies of all of these forms together, it looks like patients are more likely to die 3-5 years after diagnosis. A bunch of other papers then used the data from this study in 2009 without explaining the details behind it. However, most patients with SM have normal life spans.

For more detailed information, please visit these posts:

The Provider Primer Series: Diagnosis and natural history of systemic mastocytosis (ISM, SSM, ASM)

The Provider Primer Series: Natural history of SM-AHD, MCL and MCS

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 46

56. Why do I react every time I eat?

When you swallow food, your nervous system sends signals to tell the cells in the stomach that food is on the way. As a result of this neurologic signal, hormones are released to tell your stomach to get ready to digest. These hormones cause histamine to be released by cells in the stomach. The histamine tells your stomach to make acid to digest your food. Solid food is more activating to the stomach in this way than liquids are.

This is a normal function of the body and happens in everyone, not just people with mast cell disease. However, histamine released in the stomach can activate mast cells and cause typical mast cell symptoms. Like everything else in mast cell disease, how much this affects patients varies a lot. But something to keep in mind is that a lot of mast cell patients who are “allergic to everything they eat” are actually reacting to the normal histamine release that contributes to digestion. They are essentially allergic not just to what they are eating, but to the process of eating.

57. Do I have to go to the hospital every time I use an epipen?

Unless you have received very explicit instructions not to do so from a health care provider that is familiar with the particulars of your life and your health, you need to go to the hospital every time you use an epipen. The reason for this is because an epipen is a temporary measure. The purpose of the epipen is to give you time to get to a hospital for more advanced care. Epinephrine is broken down by your body in a matter of minutes so it only provides a small window of protection. While many patients only need one epipen, there is no way to know if you will have another wave of anaphylaxis after the first one. Additionally, many patients require other medications and IV fluids to treat anaphylaxis. These can be provided at a hospital.

The reason you have to go to the hospital is to give you access to more comprehensive care, not because using an epipen is dangerous.

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 47

  1. 58. What is mastocytic enterocolitis?

A high powered field (hpf) is what you see through a microscope when you use powerful magnifying lenses. With very few exceptions, high powered fields using the same lenses are the same size. Since they are the same size, you can directly compare results from various groups all over the world.

In 2006, a paper was published that coined the term “mastocytic enterocolitis”. The author described mastocytic enterocolitis as more than 20 mast cells per high powered field. This paper was about people with severe chronic diarrhea that did not improve with treatment. The author found that healthy people had about 13 mast cells/hpf while people with severe chronic diarrhea had about 20 mast cells/hpf. The author felt that the extra mast cells were responsible for the diarrhea and inflammation so they called the extra mast cells in the colon and the small intestine “mastocytic enterocolitis”. Enterocolitis is the term for inflammation in the small intestine and colon.

The author felt that 20 mast cells/hpf was the cutoff between a normal amount of mast cells in the GI tract and an abnormal amount. Under 20 was considered normal while 20 and above was considered abnormal. However, there have been a number of papers since that look at how many mast cells are present in the GI tract for patients with different conditions as well as healthy people. There are several conditions that can cause you to have 20 or more mast cells/hpf. (I wrote an exhaustive series on this in 2015-2016. Links are below.)

Additionally, in some situations, people have over 20 mast cells/hpf without having any symptoms. Sometimes healthy people without any GI conditions have over 20 mast cells/hpf. For this reason, there is not agreement about how many mast cells in the GI tract is too many. (If you’re looking for my opinion, I think the number for what is too many is around 25-30/hpf. This is just my opinion.)

In the last several years, some doctors have begun linking mastocytic enterocolitis to mast cell disease. This makes sense because we know that in those people, mast cell inflammation drives GI symptoms and damage. Mast cell patients certainly have a lot of inflammation in the GI tract so having extra mast cells there makes sense. Some experts think that mastocytic enterocolitis is a sign of mast cell activation syndrome and that patients with mastocytic enterocolitis all have mast cell activation syndrome.

Mastocytic enterocolitis is absolutely a real phenomenon. In these people, mast cells cause a lot of GI symptoms and damage the GI tract. Experts have not all agreed upon whether or not everyone with mastocytic enterocolitis has mast cell disease. Also, there are some researchers that feel that mastocytic enterocolitis is actually its own mast cell disease rather than just a feature of another mast cell disease like mast cell activation syndrome.

Currently, mastocytic enterocolitis is not recognized by the WHO as its own disorder. However, that could certainly change. It was only last year that MCAS was recognized by the CDC even though it was routinely recognized by researchers and providers. (Author’s note: This was initially published stating that the WHO recognized MCAS, rather than the CDC. MCAS has not yet been recognized by the WHO. This is a whopper mistake on my part. Many thanks to the reader who saw this. Sorry!) I personally expect this to change in the next few years as more mast cell patients are diagnosed and mastocytic enterocolitis is better recognized. I think it is suggestive of mast cell disease but I also think providers need to eliminate other possible causes for the extra mast cells in the GI tract.

For more detailed information, please visit these posts:

Mast cells in the GI tract: How many is too many? (Part One)

Mast cells in the GI tract: How many is too many? (Part Two)

Mast cells in the GI tract: How many is too many? (Part Three)

Mast cells in the GI tract: How many is too many? (Part Four)

Mast cells in the GI tract: How many is too many? (Part Five)

Mast cells in the GI tract: How many is too many? (Part Six)

Mast cells in the GI tract: How many is too many? (Part Seven)

Mast cells in the GI tract: How many is too many? (Part Eight)

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 45

54. How does mast cell disease affect clotting?

Heparin is a very potent blood thinner and inhibits the body’s ability to form clots.  Mast cells are full of heparin. Mast cells stores chemicals like heparin in little pouches inside them called granules. In the granules, histamine is stuck to heparin. This means that when mast cells open their granules and release histamine, heparin comes out with it. This can contribute to things like bruising or bleeding more than expected.

Mast cells release other chemicals that can affect clotting. Platelet activation factor and thromboxane A2 both encourage the body to make clots. Some chemicals that help to regulate when to make a clot can activate mast cells, like complement C3a and C5a.

55. How many people have mast cell disease?

It is hard to know exactly how many people have a rare disease because they are not reported if they are recognized and correctly diagnosed. As recognition and diagnosis improves, rare diseases are often found to be more prevalent than previously thought. The numbers below are current estimates.

Systemic mastocytosis is thought to affect around 0.3-13/100000 people. In one large study, indolent systemic mastocytosis (ISM) makes up 47% of cases. Aggressive systemic mastocytosis (ASM) has been described in various places as comprising 3-10%. Systemic mastocytosis with associated hematologic disease could count for as many of 40% of cases of SM. Mast cell leukemia is extremely rare and accounts for less than 1% of SM cases.

Systemic mastocytosis accounts for about 10% of total mastocytosis cases. This means that total mastocytosis cases come in at around 3-130/100000 people. The remaining 90% of mastocytosis cases are cutaneous with incidence roughly around 2.7-117/100000 people.

We do not have yet have a great grasp upon how many people have mast cell activation syndrome (MCAS) but from where I am sitting, it’s a lot and that number is likely to grow. We know that genetic studies have found mutations that might be linked to MCAS in up to 9% of the people in some groups. However, having a mutation is not the same thing as having a disease. As we learn more about MCAS, we will gain some clarity around how many people have it.

For more detailed reading, please visit the following posts:

Progression of mast cell diseases: Part 2

The Provider Primer Series: Diagnosis and natural history of systemic mastocytosis (ISM, SSM, ASM)

The Provider Primer Series: Natural history of SM-AHD, MCL and MCS

The Provider Primer Series: Cutaneous mastocytosis/Mastocytosis in the skin

 

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 44

53.  How do I get effective care from providers that don’t know anything about mast cell disease?

One of the most frustrating and concerning issues for mast cell patients is the need for involved specialty care when there are only a handful of experts worldwide. Many of us need so much care that there could be dozens of providers involved. Obviously there are no hard and fast rules that will guarantee a positive interaction with providers that don’t know about mast cell disease, but I will tell you what works for me.

My general recommendations about how to increase your chances of good care from providers are as follows:

  1. Do not expect most providers to know about mast cell disease or how to treat it. Patients are often upset to discover that healthcare providers know nothing about mast cell disease or how to treat it. There are currently over 7000 rare diseases described in literature. About 25,000,000 Americans have at least one rare disease. That is a lot of rare. It is impossible to know the ins and outs of so many diseases. Furthermore, medical education in recent years hinges not upon knowing everything but knowing where to find the knowledge you need. It is less important for your provider to know about mast cell disease than it is to know where they can find reliable information about it.
  • I never expect any provider to have heard of mast cell disease because it made me so mad so often when I did. I also find that I feel less hostile towards providers when I don’t expect them to have prior knowledge about my diseases. Less hostility improves any interaction.
  1. Have a script prepared for when you meet a provider that you don’t know. This is what I say after we exchange pleasantries:
  • “Before we get started, I want to make sure that you know that I have a rare blood disorder called systemic mastocytosis. Have you ever seen a patient with that before?”
  • If they have seen a patient with it before, great! Either way, I say this next:
  • “The hallmark of mast cell disease is severe allergic reaction or anaphylaxis to a variety of triggers without the involvement of IgE. It would really help me a lot if you could be really clear about what you’re doing and exactly what medications or materials I am being given. Also, if I feel anaphylaxis starting, I will use my Epipen first and then call for help.” (Please note that I administer epi myself immediately as directed by my immunologist. Speak with your doctor to find out what is the best course of action for you.)
  • This script does several things. Firstly, it lets them know that I have a reasonable understanding of my disease and the risks I face. This makes me a partner in my care. Secondly, it gives the provider a clear understanding of my expectations. They understand that I expect them to tell me everything they are doing and what materials and medications they are using. They understand there is the risk of anaphylaxis and that I have been given an Epipen to manage that. They understand that I will use this first and then call for help. In particular, the part about the Epipen is really important. Patients sometimes run into trouble when they use their own Epipen because providers are not expecting that and don’t react to it well. This conversation helps to avoid such a confrontration.
  • If I have seen this provider before, but it has been a while, or I remember them as being particularly unaware of mast cell disease, my script is basically the same. Something like,
  • “I just want to remind you that I have a rare blood disorder called systemic mastocytosis. The hallmark of mast cell disease is severe allergic reaction or anaphylaxis to a variety of triggers without the involvement of IgE. It would really help me a lot if you could be really clear about what you’re doing and exactly what medications or materials I am being given. Also, if I feel anaphylaxis starting, I will use my Epipen first and then call for help.”
  1. If you have a scheduled appointment or test somewhere you have not been seen before, call ahead a week or two before the appointment. Leave a message for the provider or their surrogate asking them to call you. This is the script I use:
  • “Hi, my name is Lisa Klimas, and I have an appointment with Dr. Yahoo at Some Date at Some Time Somewhere. I was just calling to make sure Dr. Yahoo is aware that I have a rare blood disorder called systemic mastocytosis. This disorder can cause allergic reactions to common things so there are certain precautions for mast cell patients. I would appreciate it if you could call me at your earliest convenience. Additionally, my mast cell specialist Dr. Mast Cell is available at Dr. Mast Cell’s number if you have any questions or concerns.”
  • Once again, we are clearly communicating our expectations. This also gives them extra time to learn a bit about mast cell disease or consult with your specialist so that they are comfortable seeing you.
  1. Be pleasant. This is hard to do sometimes, especially if you are scared. But if you can do this, things go much smoother. Nobody likes to be told what to do, even if they need to. Nobody likes to feel stupid. Be respectful. They will be much more likely to view you as an intriguing rare patient as opposed to some bitchy lady with masto (not speaking from personal experience, of course.)
  2. Do not argue. This is so, SO difficult sometimes but it is critical that you do not argue. Mast cell patients require a degree of control in order to mitigate the risk of reactions or anaphylaxis. Once you start arguing, you are no longer in control. You have given that control up. You will be viewed as an adversary. That is not going to get you anywhere.
  3. If you break rule 4 or 5, apologize.
  4. Be knowledgeable about your disease. You are your own best defense against dangerous health situations. You do not have to know everything but you should know where to direct providers for the information they need.
  5. When you give information about your disease, it has to be correct. This is so, so important. If you do not know the answer to something, do not invent one. Just say that you don’t know and that you can find out, or suggest a place where they can get that information.
  6. Limit the drama and intrigue when you are telling providers about your disease. There is a very fine line between being informative and scaring them. Help providers to feel comfortable about treating you.
  7. Have handy literature to educate providers about mast cell disease and how to manage mast cell patients safely. The literature should be short and comprehensive. They are much more likely to read something if it’s short and to the point. I let them know if that they are interested in further resources that I can provide those as well. I personally prefer to email literature to providers but hard copies are okay, too.
  • There are a few concise, effective papers that are great for this. This paper by Molderings and Afrin is one of my favorites. This one by Valent is good, too.
  • There are also materials prepared by organizations that are helpful for this. The Mastocytosis Society has materials for providers. On this site, I wrote the Provider Primer series for this specific purpose.
  1. Know the premedication and rescue medication protocols by heart. Also carry them in hard copy. You can find that here. If your protocols vary a lot from the general recommendations, ask for your doctor to write a letter describing your protocol that can be given to providers as needed.
  2. Know the difference between inconvenience and danger. This is critical. You have to know when a situation is dangerous and not just frustrating. There’s a big difference between refusing to give you epi during flagrant anaphylaxis and a provider making a stupid comment that being too hot can’t cause anaphylaxis. Your end game is always to get the care you need in a safe environment. Not every provider is going to be nice about your needs but if they are getting met, it’s not always worth it to argue.
  3. Remember that providers are doing their job. I have seen people report doctors who see multiple mast cell patients because the doctor was rude. I cannot stress enough that there is not a limitless pool of providers willing to treat mast cell patients. We do not want to give providers a reason to refuse to treat us. As much as possible, if you really can’t let a situation go, try to resolve it directly with the provider.
  4. Strongly encourage that your local providers establish a relationship with experts. This improves communication and encourages your local providers to seek help when they are unsure about how to help you.