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Mast cell activation predicts causal agent identification in perioperative anaphylaxis

Published: April 3, 2024

Perioperative anaphylaxis (POA) is a severe potentially life-threatening hypersensitivity reaction that may occur during the perioperative period. The most common causal agents of POA include neuromuscular blocking agents (NMBAs), antibiotics, and antiseptics. US-based POA studies are limited to single-center experiences. Anaphylaxis biomarkers include serum tryptase and urinary mast cell mediator metabolites (uMCs). A recent report found that a serum acute tryptase (sAT) > 9.8 ng/mL or mast cell activation (MCA) defined as sAT >2 +1.2 x serum baseline tryptase can predict POA causal agent identification. uMCs have not been studied in POA.  

In a recent study in The Journal of Allergy and Clinical Immunology: In Practice, Gonzalez-Estrada et al. performed an epidemiologic study of all POA cases at three large tertiary care centers in the US (Arizona, Florida, and Minnesota) between 2010 and 2021. The aims of the study were to determine if sAT or MCA can predict causal agent identification in POA and to evaluate uMC utility in POA. uMCs included N-methylhistamine (N-MH), 11β-prostaglandin-F2α (11β-PGF2α), and leukotriene E4 (LTE4).

A total of 100 patients were included in the study, 73% had a sAT available, 41% had MCA, 16% had uMC available, and 50% had an identifiable cause. POA cases with an identifiable cause had a positive MCA status compared with POA with an unidentifiable cause. An elevated median sAT or positive acute uMC were not associated with causal agent identification. Patients with POA had an elevated acute/baseline uMC ratios: 11β-PGF2α ratio >1.6, N-MH ratio >1.7, and LTE4 ratio >1.8. The authors were able to confirm that evidence of MCA (sAT >2 +1.2 x serum baseline tryptase) during a POA evaluation correlates with causal agent identification. An acute elevated uMC level during POA appears to correlate with sAT levels/MCA status. The authors suggest applying an acute/baseline uMC ratio (11β-PGF2α ratio >1.6, N-MH ratio >1.7, and LTE4 ratio >1.8) when a tryptase level is inconclusive during POA evaluations.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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