Patients with mast cell activation disorders safely tolerate COVID-19 vaccination
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Patients with mast cell activation disorders safely tolerated doses of four of the COVID-19 vaccines, although there was a relative increase in hypersensitivity and anaphylactic reactions, according to a letter published in Allergy.
Reports of anaphylaxis following vaccination have caused vaccine hesitancy among patients with mast cell activation disorders (MCAD), Matthew P. Giannetti, MD, assistant professor of medicine in the division of allergy and clinical immunology at Harvard Medical School and Brigham and Women’s Hospital, and colleagues wrote.
Conducted across three institutions in the United States and Europe, the retrospective study involved 323 patients with MCAD who received 666 vaccinations, including the Pfizer (89%), Moderna (10.1%), AstraZeneca (0.31%) and Johnson & Johnson (0.6%) vaccines.
These patients included 276 with clonal mast cell disorders, 18 with nonclonal mast cell disorders and 29 with hereditary alpha-tryptasemia.
Overall, the researchers said, patients tolerated the vaccines well, with 40 adverse events occurring after vaccination, for a 6% rate overall. The most common events were cutaneous (32.5%), including pruritis, urticaria and flushing. Gastrointestinal (27.5%), pulmonary (17.5%) and musculoskeletal (5%) symptoms also were reported.
One of the six patients who reported symptoms that involved more than one organ met the Brighton level 1 criteria for anaphylaxis, whereas the other five met level 3 or 4 criteria. Also, five of these patients experienced these adverse, multisystem reactions after the first dose, five experienced them after the Pfizer vaccine, and five were women.
Providers administered epinephrine to two of these six patients as well. Further, one of these patients was not taking scheduled H1 antihistamines and did not receive any antihistamine premedication.
Most of the cohort had received premedication before vaccination, the researchers continued, with 80.2% receiving H1 antihistamines and three patients receiving systemic steroids.
There were no statistically significant differences in rates of adverse reactions between the patients who did and did not receive any premedication, the researchers found, although they noted that few patients were not premedicated and that antihistamines taken for ongoing MCAD at baseline were not considered to be premedication.
Also, there were no significant differences in adverse reactions based on genotype among patients with hereditary alpha-tryptasemia.
None of the patients died, nor were there any intubations or ICU admissions, prompting the researchers to call the outcomes of the COVID-19 vaccines favorable in most patients with mast cell disorders.
Still, the researchers noted that the 6% rate of adverse reactions among this population was higher than the 2% rate reported in the general population as well as higher than other reports of patients with clonal MCAD. Rates of anaphylaxis among the study population outpaced rates in the general population as well.
Finally, the researchers said they did not find any statistically significant differences in rates of adverse reactions based on which vaccine patients received or based on what type of disease they had.
Balancing the safety and levels of tolerance with the relative increases in hypersensitivity and anaphylactic reactions that they found, the researchers cautioned that patients should carry epinephrine autoinjectors when they get vaccinated against COVID-19 and that these vaccinations should happen at locations that can manage adverse reactions.
Perspective
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Jill A. Poole, MD, FAAAAI, FACAAI
These results are interesting as patients with MCAD have increased frequency and severity of allergic reactions to various triggers. These patients tend to be vaccine-hesitant, and this study reported an increased rate of mild allergic reactions that would recommend observation by trained physicians.
Patients with known mast cell disorders should stay on their medications. Based upon the severity of their disease, they can consider receiving the vaccine at the office of their provider or allergist. Further research could stratify risk factors by disease severity or biomarkers.
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