What is the treatment for mast cell disease triggered by breathing mold?

Treatment of Mast Cell Disease Triggered by Mold Exposure

For mast cell disease triggered by mold exposure, the first-line treatment includes a combination of H1 and H2 antihistamines, mast cell stabilizers like cromolyn sodium, and avoidance of the mold trigger. 1

Medication Management

First-Line Medications

1. H1 Antihistamines

   • Non-sedating options (fexofenadine, cetirizine)
   • Can be increased to 2-4 times standard dose for better control 1
   • Take regularly, not just when symptoms occur

2. H2 Antihistamines

   • Famotidine, ranitidine, or cimetidine
   • Target abdominal discomfort, vascular symptoms, and GI symptoms
   • Should be used concurrently with H1 antihistamines for enhanced effect 1

3. Mast Cell Stabilizers

   • Cromolyn sodium - FDA-approved for mastocytosis 2
     • Starting dose: gradually increase to 200 mg 4 times daily before meals and at bedtime
     • Particularly effective for GI symptoms (diarrhea, abdominal pain, nausea)
     • May also benefit neuropsychiatric manifestations 1
     • Acts by inhibiting the release of histamine and leukotrienes from mast cells 2

Second-Line Medications

1. Leukotriene Receptor Antagonists

   • Montelukast - useful for skin and GI symptoms refractory to other treatments 1

2. Aspirin

   • Consider for patients with flushing and hypotension
   • Contraindicated in those with allergic reactions to NSAIDs
   • May require dosing up to 650 mg twice daily 1

3. Corticosteroids

   • For short-term management of severe symptoms
   • Initial oral dosage: 0.5 mg/kg/day with slow taper over 1-3 months
   • Not recommended for long-term use due to side effects 1

4. Omalizumab

   • Consider for antihistamine-resistant symptoms
   • Particularly effective for recurrent anaphylaxis and skin symptoms 1

Environmental Management

1. Mold Remediation

   • Remove the source of mold exposure
   • Professional assessment and remediation may be necessary
   • Consider HEPA air purifiers

2. Trigger Avoidance

   • Identify and avoid other potential triggers that may compound symptoms
   • Common triggers include certain foods, temperature extremes, medications, stress

Emergency Preparedness

1. Epinephrine Auto-Injectors

   • All patients should carry two epinephrine auto-injectors
   • Use immediately for anaphylaxis 1
   • Follow with emergency medical care

2. Emergency Action Plan

   • Create a written plan for severe reactions
   • Include medication doses and emergency contact information 1

3. Acute Management Protocol

   • For severe reactions, follow the ABC approach (Airway, Breathing, Circulation) 3
   • Administer adrenaline/epinephrine if indicated
   • Consider antihistamines (chlorphenamine 10 mg IV) and hydrocortisone (200 mg IV) 3

Monitoring and Follow-up

1. Laboratory Assessment

   • Measure mast cell mediators during symptomatic episodes:
     • Serum tryptase (1-4 hours after symptom onset)
     • 24-hour urine collection for N-methylhistamine, prostaglandin D2 metabolites, leukotriene E4 1

2. Specialist Referral

   • Allergist/immunologist for optimization of treatment
   • Gastroenterologist if GI symptoms predominate 1
   • Pulmonologist if respiratory symptoms are significant

Special Considerations

1. Medication Adjustments

   • Reduce doses of certain antihistamines in patients with renal impairment 1
   • Use medications metabolized by the liver with caution in hepatic impairment

2. Timing of Medications

   • Adjust timing to ensure highest drug levels when symptoms are anticipated
   • For nighttime symptoms, consider adding a sedating antihistamine at night 1

Treatment Pitfalls to Avoid

1. Avoid NSAIDs unless specifically tolerated, as they can trigger mast cell degranulation 1

2. Avoid opioids when possible due to risk of mast cell activation and dependence 1

3. Don't delay epinephrine in cases of anaphylaxis - it should be the first medication administered 3

4. Don't rely on corticosteroids alone for acute management - they have delayed onset of action

5. Don't overlook the importance of trigger avoidance - medication alone may be insufficient if mold exposure continues

By following this comprehensive treatment approach, most patients with mast cell disease triggered by mold exposure can achieve significant symptom control and improved quality of life.