Diagnostic role of serum tryptase in anaphylactic deaths in forensic medicine: a systematic review and meta-analysis

Abstract

Postmortem diagnosis of sudden death due to anaphylaxis can be very difficult due to the non-specific pathological findings in forensic practice. Postmortem serum tryptase has been used as an indicator of possible ante-mortem anaphylaxis. Though many previous studies have been conducted to explore the diagnostic significance of serum tryptase for lethal anaphylaxis, inconsistent results were documented. In this study, we made a retrospective study and presented a systematic review and meta-analysis that aims to summarize the diagnostic significance of postmortem serum tryptase in the deceased with and without anaphylactic shock and to calculate a cutoff value for future reference in the identification of deaths due to anaphylactic shock. A complete literature search in the PubMed, Cochrane Library, CNKI and Embase databases (published prior to March 1st, 2017) was performed. The quality of the eligible literature was evaluated according to the Newcastle-Ottawa Quality Assessment Scale (NOS), and the relevant data was extracted. The procedure of meta-analysis was performed by RevMan 5.3 software. Subgroup analysis was performed according to different causes of death. A total of nine studies with 296 patients were identified. The NOS of each included study was equal to 7. The results indicated that high concentrations of tryptase were significantly associated with anaphylactic shock when compared to the other causes of death. The weighted mean difference (WMD) was 29.53 (95% CI = 7.58–51.47, p = 0.008). Similar results were detected in the subgroup analysis when compared to deaths due to cardiovascular disease (CVD). However, no obvious elevation of tryptase in decedents with CVD compared to the other cause of death was observed (WMD = 4.42, 95% CI = −0.94–9.79). We concluded that high serum tryptase is a promising diagnostic biomarker for deaths due to anaphylactic shock, especially when it is higher than 30.4 μg/L.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

References

  1. 1.

    Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF, Bock SA, Branum A, et al. Second symposium on the definition and management of anaphylaxis: summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Ann Emerg Med. 2006;47:373–80.

    Article  PubMed  Google Scholar 

  2. 2.

    Sampson HA, Muñoz-Furlong A, Bock SA, Schmitt C, Bass R, Chowdhury BA, et al. Symposium on the definition and management of anaphylaxis: summary report. J Allergy Clin Immunol. 2005;115:584.

    Article  PubMed  Google Scholar 

  3. 3.

    Bohlke K, Davis RL, DeStefano F, Marcy SM, Braun MM, Thompson RS, et al. Epidemiology of anaphylaxis among children and adolescents enrolled in a health maintenance organization. J Allergy Clin Immunol. 2004;113:536–42.

    Article  PubMed  Google Scholar 

  4. 4.

    Yocum MW, Butterfield JH, Klein JS, Volcheck GW, Schroeder DR, Silverstein MD. Epidemiology of anaphylaxis in Olmsted County: a population-based study. J Allergy Clin Immunol. 1999;104:452–6.

    Article  PubMed  CAS  Google Scholar 

  5. 5.

    Mullins R. Anaphylaxis: risk factors for recurrence. Clin Exp Allergy. 2003;33:1033–40.

    Article  PubMed  CAS  Google Scholar 

  6. 6.

    Shen Y, Li L, Grant J, Rubio A, Zhao Z, Zhang X, et al. Anaphylactic deaths in Maryland (United States) and Shanghai (China): a review of forensic autopsy cases from 2004 to 2006. Forensic Sci Int. 2009;186:1–5.

    Article  PubMed  Google Scholar 

  7. 7.

    Ordoqui E, Zubeldia J, Aranzabal A, Rubio M, Herrero T, Tornero P, et al. Serum tryptase levels in adverse drug reactions. Allergy. 1997;52:1102–5.

    Article  PubMed  CAS  Google Scholar 

  8. 8.

    Mayer DE, Krauskopf A, Hemmer W, Moritz K, Jarisch R, Reiter C. Usefulness of post mortem determination of serum tryptase, histamine and diamine oxidase in the diagnosis of fatal anaphylaxis. Forensic Sci Int. 2011;212:96–101.

    Article  PubMed  CAS  Google Scholar 

  9. 9.

    Randall B, Butts J, Halsey J. Elevated postmortem tryptase in the absence of anaphylaxis. J Forensic Sci. 1995;40:208–11.

    Article  PubMed  CAS  Google Scholar 

  10. 10.

    Schwartz H, Yunginger J, Schwartz L. Is unrecognized anaphylaxis a cause of sudden unexpected death? Clin Exp Allergy. 1995;25:866–70.

    Article  PubMed  CAS  Google Scholar 

  11. 11.

    Wells G, Shea B, O'Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of non randomized studies in meta-analysis. Appl Eng Agric. 2012;18:727–34.

    Google Scholar 

  12. 12.

    Xiangjie G. The study of the diagnosis of anaphylaxis shock caused by drug using mast cell and protease. School of Forensic Medicine: Shanxi Medical University; 2015. http://kns.cnki.net/KCMS/detail/detail.aspx?dbcode=CDFD&dbname=CDFDLAST2016&filename=1015984436.nh&uid=WEEvREcwSlJHSldRa1FhcEE0RVZxejAxcWwrejJ5Q0JxVng1Yk5FL0gyRT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw!!&v=MTY3NTZQSVI4ZVgxTHV4WVM3RGgxVDNxVHJXTTFGckNVUkxLZlpPUnVGeTdtVTd6TFZGMjZHN3F3R3RYUHFaRWI=

  13. 13.

    Wenjie W. Measurement of tryptase and chymase plasm contents of heroin intoxatoon person: Shanxi Medical University; 2012. http://kns.cnki.net/KCMS/detail/detail.aspx?dbcode=CMFD&dbname=CMFD2012&filename=1012357793.nh&uid=WEEvREcwSlJHSldRa1FhcEE0RVZxejAxcWwrejJ5Q0JxVng1Yk5FL0gyRT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw!!&v=MjkwNDhHZGJGckpFYlBJUjhlWDFMdXhZUzdEaDFUM3FUcldNMUZyQ1VSTEtmWk9SdUZ5N21VYnZQVkYyNkhMQzk=.

  14. 14.

    Liping F. Studies on the expression of tryptase and chymase in anaphylactic reaction death and sudden coronary death disease and its significance in forensic medicine. Southern Medical University; 2012. http://kns.cnki.net/KCMS/detail/detail.aspx?dbcode=CMFD&dbname=CMFD201301&filename=1013123401.nh&uid=WEEvREcwSlJHSldRa1FhcEE0RVZxejAxcWwrejJ5Q0JxVng1Yk5FL0gyRT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw!!&v=MjMyNTRxVHJXTTFGckNVUkxLZlpPUnVGeTdtVjcvTVZGMjZIYks2SGRYTXJwRWJQSVI4ZVgxTHV4WVM3RGgxVDM=.

  15. 15.

    Yong Y. Forensic pathological diagnosis of anaphylactic shock and sudden death. Fa Yi Xue Za Zhi. 2014;30:267.

    Google Scholar 

  16. 16.

    Edston E, van Hage-Hamsten M. Immunoglobulin E, mast cell-specific tryptase and the complement system in sudden death from coronary artery thrombosis. Int J Cardiol. 1995;52:77–81.

    Article  PubMed  CAS  Google Scholar 

  17. 17.

    Edston E, Eriksson O, van Hage M. Mast cell tryptase in postmortem serum-reference values and confounders. Int J Legal Med. 2007;121:275–80.

    Article  PubMed  Google Scholar 

  18. 18.

    Horn KD, Halsey JF, Zumwalt RE. Utilization of serum tryptase and immunoglobulin E assay in the postmortem diagnosis of anaphylaxis. Am J Forensic Med Pathol. 2004;25:37–43.

    Article  PubMed  Google Scholar 

  19. 19.

    Guo XJ, Wang YY, Zhang HY, Jin QQ, Gao CR. Mast cell tryptase and carboxypeptidase a expression in body fluid and gastrointestinal tract associated with drug-related fatal anaphylaxis. World J Gastroenterol. 2015;21:13288–93.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  20. 20.

    Hung OL, Nelson L. Tintinalli's emergency medicine: a comprehensive study guide. J Am Med Assoc. 2011;306:100.

    Google Scholar 

  21. 21.

    Schwartz L, Yunginger J, Miller J, Bokhari R, Dull D. Time course of appearance and disappearance of human mast cell tryptase in the circulation after anaphylaxis. J Clin Invest. 1989;83:1551.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  22. 22.

    Fineschi V, Monasterolo G, Rosi R, Turillazzi E. Fatal anaphylactic shock during a fluorescein angiography. Forensic Sci Int. 1999;100:137–42.

    Article  PubMed  CAS  Google Scholar 

  23. 23.

    Bonelli A, Bacci S, Norelli G. Affinity cytochemistry analysis of mast cells in skin lesions: a possible tool to assess the timing of lesions after death. Int J Legal Med. 2003;117:331–4.

    Article  PubMed  CAS  Google Scholar 

  24. 24.

    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88.

    Article  PubMed  CAS  Google Scholar 

  25. 25.

    Brown M, Ind P, Causon R, Lee T. A novel double-isotope technique for the enzymatic assay of plasma histamine: application to estimation of mast cell activation assessed by antigen challenge in asthmatics. J Allergy Clin Immunol. 1982;69:20–4.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

This research was supported by the National Natural Science Foundation of China (Grant No. 81401556 and 81601641), the Natural Science Foundation of Guangdong Province (No. 2014A030310504 and 2014A030310293), the Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry(No.2015-311), and the Special Foundation of President of School of Public Health of Southern Medical University (Grant No.GW201619).

Author information

Affiliations

Authors

Corresponding authors

Correspondence to Xiao-Li Xie or Qi Wang.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sun, KJ., He, JT., Huang, HY. et al. Diagnostic role of serum tryptase in anaphylactic deaths in forensic medicine: a systematic review and meta-analysis. Forensic Sci Med Pathol 14, 209–215 (2018). https://doi.org/10.1007/s12024-018-9980-z

Download citation

Keywords

  • Forensic medicine
  • Serum tryptase
  • Anaphylactic deaths
  • Meta-analysis