Tryptase Management in COVID-19 Patients with Mastocytosis or Severe Allergic History
Primary Recommendation
Patients with mastocytosis or elevated baseline tryptase should continue their standard mast cell disorder management during COVID-19 infection, including all antimediator therapies, while following general COVID-19 treatment protocols without modification. 1
Risk Assessment in COVID-19
Baseline Risk Profile
- Patients with mast cell disorders do not have an inherently increased risk of acquiring SARS-CoV-2 infection compared to the general population 1
- However, specific subgroups face elevated risk for severe COVID-19 outcomes 1:
- Those with cardiovascular comorbidities
- Those with bronchopulmonary involvement from mast cell activation
- Patients receiving chemotherapy or immunosuppressive drugs (excluding standard antimediator therapy)
- Patients experiencing frequent mast cell activation events affecting cardiopulmonary systems
Critical Distinction
- The hyperinflammatory "cytokine storm" in severe COVID-19 may involve mast cell activation pathways, with some evidence suggesting MCAS patients might experience atypical inflammatory responses to SARS-CoV-2 2
- Interestingly, preliminary observations suggest that well-controlled MCAS patients on appropriate antimediator therapy may not experience severe COVID-19 outcomes 2
Medication Management During Active COVID-19
Continue Without Interruption
All antimediator therapies must be maintained throughout COVID-19 infection 1:
- H1 antihistamines 3, 4
- H2 antihistamines 3, 4
- Leukotriene receptor antagonists 3, 4
- Cromolyn sodium 3, 4
- Vitamin D supplementation 1
- Venom immunotherapy (if applicable) 1
Evaluate Case-by-Case
- Chemotherapy or immunosuppressive drugs require careful risk-benefit assessment during active COVID-19 infection 1
- Standard antimediator drugs are not considered immunosuppressive in this context and should continue 1
Avoid Corticosteroid Escalation Unless Indicated
- While corticosteroids may benefit severe COVID-19 with hyperinflammation 5, routine escalation solely based on mastocytosis diagnosis is not warranted
- If corticosteroids are initiated for COVID-19 management, expect a 2-3 week taper to avoid rebound inflammation 5
Tryptase Monitoring Strategy
Baseline Tryptase Considerations
- Do not routinely measure tryptase during acute COVID-19 illness unless there is clinical suspicion of concurrent anaphylaxis or acute mast cell degranulation 3, 6
- Acute inflammatory states from COVID-19 may confound tryptase interpretation 6
- If baseline tryptase was previously >20 ng/mL, continue annual monitoring per standard mastocytosis protocols 3, 7
When to Measure Acute Tryptase
Obtain timed tryptase samples if the patient develops 3, 6:
- Sudden cardiovascular collapse (hypotension, tachycardia, syncope)
- Acute bronchospasm disproportionate to COVID-19 pneumonia
- Acute urticaria, angioedema, or flushing
- Multi-system symptoms suggesting anaphylaxis
Timing protocol: Initial sample immediately, second at 1-2 hours after symptom onset, third at 24 hours or after complete symptom resolution 3, 6
Emergency Preparedness
Mandatory Safety Equipment
All patients with confirmed mastocytosis or baseline tryptase >20 ng/mL must have 3, 4, 7:
- Two epinephrine auto-injectors available at all times
- Medic Alert identification documenting mast cell disorder
- Written emergency action plan
Trigger Avoidance During COVID-19
Patients remain at risk for mast cell degranulation from 3, 4:
- Fever and temperature fluctuations (common in COVID-19)
- Physical stress and hypoxia
- Certain COVID-19 medications (NSAIDs, opioids if used for symptom management)
- Contrast media if imaging required
- Emotional stress and anxiety
COVID-19 Vaccination Considerations
Strong Recommendation for Vaccination
Patients with mastocytosis should receive COVID-19 vaccination with appropriate precautions 8:
- The only contraindication is known or suspected allergy to vaccine constituents 8
- Severe adverse reactions are rare even in mastocytosis patients 8
Vaccination Protocol
- Consider premedication with H1 and H2 antihistamines 1 hour before vaccination 8
- Extended post-vaccination observation period (30-60 minutes minimum) 8
- Have epinephrine immediately available 8
- Schedule vaccination when patient is clinically stable without recent mast cell activation events 8
Post-Vaccination Monitoring
- Maintain longer follow-up beyond immediate observation period, as latent mastocytosis can be triggered by vaccination 9
- Instruct patients to report any new or worsening symptoms in the weeks following vaccination 9
Hospitalization Considerations
Anticoagulation Prophylaxis
- COVID-19 patients have elevated thrombotic risk 5
- Mastocytosis patients already have baseline increased thrombotic risk 5
- Implement standard COVID-19 anticoagulation protocols without modification for mastocytosis patients unless contraindicated 5
Medication Safety in Hospital
- Alert all providers to mastocytosis diagnosis 4
- Avoid direct mast cell degranulators: morphine, meperidine, vancomycin, contrast media without premedication 3, 4
- Prefer fentanyl or sufentanil over morphine if opioids needed 4
- Obtain baseline coagulation studies if procedures planned 4
Critical Pitfalls to Avoid
Do not discontinue antimediator therapy during COVID-19 infection, as this may worsen outcomes 1
Do not assume elevated inflammatory markers are solely from COVID-19 in patients with known mastocytosis—consider concurrent mast cell activation 2
Do not withhold necessary analgesics from mastocytosis patients with COVID-19, but exercise caution with direct mast cell degranulators 3
Do not delay epinephrine if anaphylaxis suspected, even during active COVID-19 infection 3, 4
Do not measure tryptase during acute COVID-19 illness unless specific clinical suspicion for concurrent anaphylaxis exists, as interpretation will be confounded 6