This is a 15-year-old with one year history of chronic urticaria and angioedema which is generally responsive to antihistamines and Singulair. However, he is not compliant with his medications and gets outbreaks which have included tongue swelling as well as mild throat tightness and difficulty breathing requiring treatment in the ER. Routine labs including CBC with diff, CMP, thyroid studies and ESR were unremarkable. However, his total tryptase was 21 ng/mL (2-10 ng/mL) and 16.8 ng/mL (<11.5 ng/mL) on repeat testing one month later in a different lab. Skin biopsy was consistent with neutrophil-rich urticaria without evidence of mast cell disease. Would you recommend a bone marrow biopsy to further evaluate this elevated tryptase? Thank you.