A Case of Neuropathic Pain in Monoclonal Mast Cell Activation Syndrome

Rationale: Neuropathic pain is an uncommon symptom in Monoclonal Mast Cell Activation Syndrome (MMAS), but one that can have a significant impact on quality of life and has not yet been well described in the literature.  Mast cells are known to be gatekeepers of nociception and disruption of these cells’ normal homeostasis plays an important role in the development of neuropathic pain in the central and peripheral nervous system.  Currently, there are no well-defined guidelines for the management and treatment of neuropathic pain in mast cell activation disorders.  We present a patient with neuropathic pain associated with MMAS and a review of the agents used in his treatment.

Methods: Clinical exams, skin biopsy, and immunologic laboratory evaluation.

Results: 49 year-old male with a history of MMAS (baseline serum tryptase 14.4 ng/mL, bone marrow positive for c-Kit D816V, clonal mast cell population), autonomic dysregulation, and neuropathic pain of his bilateral hands, wrists, and feet.  Skin biopsies were negative for small fiber neuropathy.  Various medications were employed in the management of his pain including gabapentin, tricyclic antidepressants, opioids, celexocib, and minocycline.  Although an antibiotic, minocycline’s anti-inflammatory and anti-nociceptive properties have garnered increasing attention through several recent studies.

Conclusions: Providers should be aware that neuropathic pain is a rare but serious symptom in patients with MMAS, one that has not been well studied in the literature.  Managing neuropathic pain associated with MMAS can be difficult and requires a multidisciplinary approach to rule out other potential etiologies of pain and refine medication treatment approaches in these medically-complex patients.