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mast cell disease

Chronic mast cell leukemia: A new variant of systemic mastocytosis

Mast cell leukemia (MCL) is a variant of systemic mastocytosis (SM) marked by a significantly shortened lifespan.  In MCL, patients experience massive and devastating proliferation of immature mast cells.  The bone marrow is always affected and the huge amount of mast cells means there is no room for other types of blood cells. Usually, the bone marrow smear reveals over 20% of nucleated cells in bone marrow are atypical mast cells, as well as large quantities present in the blood.  In the aleukemic variant, less than 10% of all white cells in the blood are mast cells.

In most patients with MCL, C-findings (markers of organ infiltration and damage progressing to organ failure) are present.  These include such features as hypersplenism, liver damage, very low blood cell counts, and others.  However, in the last several years, a number of MCL patients described who do not have C findings.  These patients have over 20% mast cells in the nucleated cells of the bone marrow, but the mast cells are mostly mature, and most do not circulate in the blood stream.  This population often demonstrates stability rather than rapid progression toward death, as was previously seen in most MCL patients.  The term “chronic MCL” has been suggested to describe this group.

The more classic MCL presentation (now called acute MCL) has a number of differences from chronic MCL.  In acute MCL, most of the mast cells are not mature, with metachromatic blast cells.  In acute MCL, CD25 receptor is always present on the cells, while this only sometimes occurs in the chronic course.  Chronic MCL never expresses Ki-67 on the outside of the cells, while this is sometimes seen in acute MCL.  Both acute and chronic sometimes have CD2 and D816V mutation, but not always.  Spindle shaped mast cells are almost never present in acute MCL.  Swelling of the spleen is always seen in acute MCL, but only sometimes in the chronic form.  Chronic MCL patients have no C findings.  If they develop a C finding, they are reclassified as acute MCL.

Acute MCL has long been associated with very short survival times following diagnosis, most often less than a year.  This can be extended in some patients with the use of newer medications.  Remarkably, patients with chronic MCL demonstrate a largely stable clinical course comparable to smouldering SM.  In both of these conditions, tryptase levels are high but stable; the spleen is most often swollen; and mast cell burden is high.  Patients with chronic MCL usually have no mast cell skin lesions.

Chronic MCL patients can be stable for years, but can progress to acute MCL or MCL-AHNMD at any time.  Mediator release symptoms more often seen in indolent mast cell diseases are also common in chronic MCL, while less so in acute MCL.


P. Valent et al. Chronic mast cell leukemia: A novel leukemia-variant with distinct morphological and clinical features. 23eukemia Research 39 (2015) 1-5.

Glossary of mast cell related terms: F-L

FceRI: the high affinity IgE receptor; where IgE molecules bind to the outside of cells, like mast cells; binding the FceRI receptor triggers mast cell activation

Food associated, exercise induced anaphylaxis: An IgE mediated reaction that is triggered by ingesting certain foods in close time proximity to exercise

Food protein induced enterocolitis syndrome (FPIES): An allergic reaction to food proteins that is not mediated by IgE, usually found in infants; the most severe non-IgE mediated food hypersensitivity

Gastroparesis: a condition in which stomach contents are not emptied into the small intestine within an appropriate time period without an obvious anatomical explanation

Granule: a pocket inside a cell that holds molecules to be released outside of the cell

Granulocyte: white blood cells that have granules inside the cells that hold molecules to be released outside of the cell; mast cells, eosinophils, basophils and neutrophils are granulocytes

H1: histamine 1 receptor

H1 inverse agonist: a class of drugs that interferes with the effect of histamine at the H1 receptor

H2: histamine 2 receptor

H2 blocker: a class of drugs that interferes with the effect of histamine at the H2 receptor

Heparin: a mast cell mediator; a blood thinner

Hepatomegaly: swelling of the liver

Hepatosplenomegaly: swelling of the liver and spleen

Hereditary angioedema (HAE): a heritable blood disorder that causes episodes of protracted swelling that can be life threatening.

Histamine: a neurotransmitter; responsible for a large portion of symptoms seen in mast cell disease and anaphylaxis

HPA axis: the signals and feedback loops that regulate the activities of the hypothalamus, pituitary gland and adrenal glands to coordinate the body’s stress response; also helps regulate digestion, immune activation, sexuality and energy metabolism

Hypersensitivity: allergic reaction

Hypersplenism: overactivity of the spleen

IgE: an antibody that triggers allergic responses

Kounis Syndrome: an event in which a patient experiences severe chest pain or heart attack as the result of an allergic reaction; also called allergic angina or allergic myocardial infarction

Late onset anaphylaxis: Anaphylaxis that begins several hours after exposure to trigger

Leukotrienes: Structural class related to prostaglandins produced by the enzyme 5-lipoxygenase (5-LO); mediators released by mast cells.

Leukotriene receptor antagonist: A class of drugs that interferes with the function of leukotrienes; examples include montelukast and zafirlukast.

Ligand: a molecule that binds to another molecule, triggering a specific effect; with regards to mast cell disease, ligands bind to receptors, such as IgE (ligand) binding to FceRI (receptor)

LO: lipoxygenase; the enzyme that produces leukotrienes

Low histamine diet: a diet which minimizes dietary sources of histamine, which can help reduce symptoms for some mast cell patients; there is no authoritative list of low histamine foods and some trial and error is required


Glossary of mast cell related terms: A-E

Allergic march: the progressive accumulation of atopic conditions beginning in the first year of life; usually atopic dermatitis, allergic rhinitis, asthma, food allergy

Anaphylaxis: a rapidly progressing allergic reaction that involves multiple organ systems; can be fatal

Angioedema: Swelling caused when fluid leaves the bloodstream and becomes trapped between the deep dermis and subcutaneous tissue.

Anticholinergic: blocking the molecule acetylcholine from sending signals in the nervous system.  Many medications are anticholinergic, which can cause many side effects.

Ascites: free fluid in the abdomen; a form of third spacing

Aggressive systemic mastocytosis (ASM): a form of systemic mastocytosis in which mast cells invade organs, causing damage and dysfunction; diagnosed when a person meeting the criteria for SM has one or more C finding, criteria that indicate organ damage caused by mast cells

Asthma: inflammation of the airways causing swelling, narrowing and extra mucus production; can be allergic in nature

Atopy: tendency of a person to develop allergic diseases like asthma

Autoimmune disease: a disease caused when the immune system attacks healthy cells; mast cell diseases are not autoimmune diseases

Autonomic nervous system: a part of the nervous system that controls many involuntary functions of the body, including digestion.  It is composed of both the parasympathetic nervous system and the sympathetic nervous system.

B finding: criteria that indicate SM is progressing towards mast cells invading organs and damaging them; if 2 or more are present, smouldering systemic mastocytosis (SSM) is diagnosed

Biphasic anaphylaxis: Second episode of anaphylaxis symptoms after resolution

Bradykinin: a mediator released by mast cells that causes inflammation, pain and swelling

CD117: another name for CKIT receptor, found normally on the outside of mast cells

CD2: a marker not usually found on the outside of mast cells; an indicator of systemic mastocytosis; a cell adhesion molecule

CD25: a marker not usually found on the outside of mast cells; an indicator of systemic mastocytosis; part of a receptor for IL-2

CD34: a marker normally found on the outside of cells that become mast cells, and on new mast cells

Chronic urticaria: hives lasting longer than six weeks; can include angioedema

Circadian rhythm: the body’s internal clock

CKIT: a receptor on the outside of mast cells that binds stem cell factor, telling mast cells to stay alive and make more cells; is often mutated in systemic mastocytosis

Complement : a system of many small proteins circulating in the blood that can attack infectious agent ; can also cause angioedema

Cortisol : a steroid hormone produced by the adrenal glands ; critical in regulating stress response

COX : cyclooxygenase; enzymes that produce prostaglandins

Cutaneous mastocytosis (CM): infiltration of the skin by excessive mast cells.  The most common type of mastocytosis.

D816V/CKIT+: a specific mutation at codon 816 of the CKIT gene that causes the CKIT receptor to be misshapen so that mast cells get inappropriate signals to stay alive and keep making more cells

Darier’s sign: a wheal and flare response elicited by touching mast cell lesions; caused by histamine release

Desensitization: the elimination of the body’s allergic response to something

Diffuse cutaneous mastocytosis (DCM): The most severe presentation of cutaneous mastocytosis.  Lesions cover much of the body and may blister or bleed.

Deconditioning: when the body becomes acclimated to less physical stress and becomes less able to function properly under normal conditions.

Degranulation: the release of mediators stored in granules inside a cell; mast cell degranulation contributes to immune response as well as symptom profile in mast cell disease and anaphylaxis

Delayed food-induced anaphylaxis to meat: An IgE mediated reaction to beef, pork or lamb that occurs several hours after eating; caused by a tick bite inducing production of antibodies to carbohydrate a-gal.

Dysautonomia: fundamental dysfunction of the autonomic nervous system; there are many types, including POTS

Ehlers-Danlos Syndrome (EDS): a group of conditions caused by hypermobility and/or known genetic mutation affecting production of connective tissue components; Hypermobility EDS is seen disproportionately in the mast cell community

Edema: swelling; excess fluid trapped in tissues

Eicosanoid: the molecular class that includes prostaglandins and leukotrienes

Eosinophilia: elevation of eosinophils in the blood

Eosinophilic esophagitis: infiltration of the esophagus by eosinophils

Eosinophilic GI disease: IgE and delayed cell mediated reactions to foods caused by overactive eosinophils, affecting the GI tract.

Eosinophils: a granulocyte functioning similar to mast cells; mast cells and eosinophils can activate each other

Epinephrine: a hormone used to treat anaphylaxis

Exercise intolerance: diminished ability or inability to perform physical exercise; can be caused by a number of medical conditions

The only constant

Summer is over.  Maybe astronomically speaking it’s not, but it is.  When you close your eyes on August 31, warm windy days and bathing suits and beach towels and eating outside are all packed away by summer faeries and pushed to the back of the closet.  When you open your eyes on September 1, it is fall.

I had an amazing summer.  I could never have imagined that I would have a summer like this again.  I went swimming in the ocean and went to a water park and got sunburnt and walked around in the sunshine. I worked a lot and took the train and ate solid food and exercised.  I still have mast cell disease and it will never go away and no, my GI tract does not work well.  But I feel better in a lot of ways.  I feel better than I thought I would ever feel again.

Last week was a difficult week for me.  I have been pushing it the last few weeks, trying to do more than I probably should.  I started feeling gross again, burny hot skin, really bad nausea, more GI trouble than usual.  I started needing to sleep a lot longer.  It was so defeating.

I crawled into bed one day and lay awake, too tired to sleep, reliving the last several months.  I was scared.  I was scared that this was over.  I was scared that these three months were all I was going to get.  I was scared because it felt like I was finally living again and losing that would be too painful.  Because I was finally entertaining the thought that I could go back to school and travel and have fun without risking ending up in the hospital.

Last Friday, I realized I had a fever.  I was sick because I had a cold or something.  It hadn’t even crossed my mind that it was anything other than mast cell disease.  I slept most of this weekend and am getting better.

It only took a few days for my dreams to turn from school and travelling back to a stable accommodating job with good insurance.  You know.  My fall back dream.  The dream that I will retain the means to treat my myriad health issues and live independently in a clean, safe place.  That dream.  It sounds silly and narrow to people who have never been sick but let me tell you, it’s not silly to me.  Even when I am feeling better, even when I think I could do things I put aside long ago, even when I am embarrassed to admit it, this is my dream.  This is the dream that needs to come true for any other dream to be realized.

I like my life.  I have a great job.  I have an apartment I can afford in a convenient location.  I have a great support system.  I receive excellent health care.  I can walk my dogs at night.  I can pay my bills.  I am lucky.  I am so lucky.  And it feels wrong to risk losing all of these things to pursue another dream that could prevent me from getting the care I need.

So I push these thoughts aside and feel grateful for all that I have.  I focus on living the life I have now and try not to rock the boat.  I don’t make any changes.

There is this idea that by doing nothing, we can preserve our lives just the way they are.  That if we don’t change, we are guaranteeing the future provided by steadily travelling this same road.

It doesn’t work that way.  It never did.  Everything changes.  The only constant is you.

Yesterday I found out about some changes at work that will directly affect me and how I continue to do my job.  Maybe not in a bad way.  I went back to my desk and cried for a few minutes because I’m a crier and I get very attached to people.  Then I got up and got lunch and went back to work.  I was sad and anxious but also a little relieved and excited.

I don’t know the name of this feeling.  But I do know that I could choose to stay here in my little apartment with my job that I love close to my family and friends and doctors.  I could make that choice and it could all change anyway.

And I could make the choice to give all of this up and I could find myself without healthcare or money or a home.  Or I could find that I give it all up and succeed.

It feels like the stakes keep getting higher and higher.   But that doesn’t mean I shouldn’t try.

All the favors in pharmacy land

For most of my adult life, I have had the feeling that I didn’t have any money. I worked full time in college, and two full time jobs in grad school. I worked full time for a biotech company after I graduated, while also working side jobs. I certainly worked a lot for not having money.

At some point, I sat down and went through all my finances in detail. I looked at years of bank statements, credit card statements and student loan agreements. I tallied how much I spent on gas, on car repairs, on food, on fun. But none of those were the issue. I had one expense that was more than all of those put together: medical bills.

I literally just sighed as I typed that sentence. And you know what? I bet all the sick kids reading this sighed along with me. I don’t even get mad about it anymore. I am just resigned. Sigh.

I accepted a temporary position at my current company about two years ago. After six months as a contractor, I accepted a full time position. My contractor insurance was garbage and I needed comprehensive coverage badly. I eagerly flipped through the insurance information packets, basking in the golden glow of great medical coverage. It was overwhelming and wonderful. It was also a little sad that I was barely 30 years old and so excited about copayments and yearly out-of-pocket maximum costs that only had three zeros at the end.

I signed up for PPO insurance, which for our non-American readers means I can pick which doctors I see without being referred by my primary care physician (PCP, usually called general practitioner in other countries). There are caveats to PPO plans, but it is overall less restrictive and therefore desirable for me, as I often need specialist appointments on short notice.

In the US, it is not unusual for your medical insurance (doctor visits, hospital stays, medical supplies) to be managed by a different and completely separate company from your prescription coverage. So when I picked my PPO insurance, I also had to pick a large prescription carrier that forced upon the unwitting masses the bane of my existence: mail-order prescriptions.

I worked in pharmacy for about ten years. In that time, prescription insurance companies directly caused most of the issues that made my job frustrating and difficult. The prescription carrier I got along with my (amazing, approves everything) PPO is well known for rejecting claims for stupid reasons. But I needed a PPO and this was the corresponding prescription insurance. I didn’t have a choice.

So I got my new prescription insurance card and used it to fill my monthly medications at my local pharmacy. That went okay for a couple of months. Then I got a notification that my insurance would only pay for three fills of a maintenance medication (one that is taken all the time as part of your baseline care). Any fills after that would have to be filled with a mail order pharmacy.

Because I need a million strange things, I called my health insurance case manager. She sympathized but had nothing to do with pharmacy benefits. I told her that I had called the prescription company and asked for a case manager. They wouldn’t give me one. She couldn’t do anything.

The mail order pharmacy got new prescriptions for my meds from my doctors. They filled them and shipped them out to me. I opened the first huge box of meds and immediately knew something was wrong. I take ondansetron (zofran) 8mg three times a day every day. I have done this for years. I have tried to decrease and it always goes very badly. I have a prior authorization done every year to approve for 270 tablets/90 days for four total fills to coverage three a day dosing for the entire year. The pharmacy received a prescription that said that.

Except the person filling the prescription looked at it and thought, nobody takes three of these a day every day. Surely this is a mistake! And bless their hearts, they did me the huge favor of correcting that prescription from 270 with 3 refills to 27 with 30 refills. That’s much better.

So I had nine days of zofran. I called them and told them what happened. I was on the phone for two hours. They told me it was all set and they were sending the rest. Three days later, a package arrived. It had one bottle of 27 ondansetron.

I’m not going to bore you with the sordid details because I bet you all know where this is going. You know, right? Yup. Nine phone calls and every single one of them went exactly the same way except by the ninth, I was crying in frustration. I was out of my medication and every time I called, they told me it was all set and they fixed the error. And then nine more tablets would show up and we would start all over again.

This is a repeating cycle. The mail-order pharmacy is forever filling my 270 tablet (insurance approval obtained) prescription for 27 tablets.

So, mail order pharmacies are difficult. I don’t think that is surprising anyone here. But at the same time as this was going on in what I assume was a distant state where everyone is brainwashed to reassure me that they are fixing my problem right before they throw my precious bottles of ondansetron into a bottomless pit, I started having some problems closer to home.

I still got some prescriptions filled at my local pharmacy (this is entirely at the discretion of the pharmacy insurance.) There were only three I got filled locally regularly – prednisone, fluticasone nasal spray, and Epipens. Last October, I was counting out my prednisone 1mg tablets to put into my pill organizer when I realized there were a bunch of 5mg tablets mixed in with the 1mg tablets. I had been sick for three weeks and wondering why I felt decent one day and miserable the next. That would be because I was dispensed two strengths of a medication for which 1mg differences matter a lot. So that sucked. I called the pharmacist and she apologized and filled my script with 1mg tablets instead of both and I got on with my life. I understand that mistakes get made sometimes. It’s fine.

Then in December, this same pharmacy lost a prescription from my PCP. In May, they lost a prescription for prednisone for premedication before surgery. I had called the previous week to make sure it was there and sent my mother to pick it up on the Monday before my Wednesday surgery. It was gone. So that was quite a circus getting that straightened out the day before major surgery. The district pharmacy supervisor called me and we had a long conversation about my weird diseases and surgery and she apologized and I needed to go have surgery so I just let it go.

Two weeks ago, I called to get my Epipens filled. I had a new prescription that was on file from March. Guess what, guys? GUESS WHAT. That prescription was gone, too.

At this point, I just hung up the phone because I was about to start screaming. I called the district pharmacy supervisor on Monday and she went by the pharmacy to pull the original prescription book from the day it was sent over in March. It was there. It was filled, returned to stock and never put on hold. This was three prescriptions, all from different offices, in under a year, with a dispensing error right off the top.

While I was dealing with the Epipen situation, I ordered refills for all of my mail order meds and GUESS HOW MANY ONDANSETRON CAME IN MY ORDER. JUST. GUESS.

I called the poor nurse at my PCP’s office who does all my prior authorizations and I literally sobbed over how sick I was of fighting for things like meds to not vomit up everything I eat. This woman is a saint and she tag teams my insurance company with me to get things taken care of. To demonstrate my gratitude, I hereby bestow upon her the internet moniker of Nurse Amazing.

In the last two weeks, Nurse Amazing and I made over a dozen phone calls between us and had the same conversation over a dozen times. After one particularly hopeless day, she asked if my IV meds were covered under my medical benefit. They are. “If we have to, maybe we can just call in enough IV Zofran to get you through.” HOW DO I LIVE IN A WORLD WHERE IT IS EASIER TO GET IV MEDS THAN NON-CONTROL SUBSTANCE TABLETS WITH NO POTENTIAL FOR ABUSE? HOW IS THE WORLD LIKE THIS?

The Universe cut me a break this time. I finally got the rest of my ondansetron delivered Saturday.

While Nurse Amazing was on the phone with my insurance, she noticed my Enbrel prescription was about to expire so she gave them a new one over the phone. “She hasn’t taken this since last year,” the agent told the nurse so apparently they are also throwing away any record of my monthly order for this (refrigerated, requires signature and scheduled delivery) medication. My Enbrel arrived expediently with no paperwork of any kind. Just a labelled box of prefilled syringes, an ice pack and nothing else.

I just went to pick up my Epipens. The pharmacist did not apologize and did not look the least bit like she gave a shit that I have spent over 65 hours in the last three weeks trying to fill my medications at SIX pharmacies as required by insurance (for those keeping score: retail pharmacy, mail order pharmacy, specialty mail order pharmacy for Enbrel, a second retail pharmacy that stocks one of my harder to source meds, compounding pharmacy for ketotifen, IV pharmacy for IV push meds/infusions). And you know what? It’s one thing to make consecutive mistakes, and it’s another thing to make consecutive mistakes and act like I am an asshole for expecting my medications to be filled and tracked correctly.

“This copay is high but I can only charge you half because of what happened,” she said. Where ‘what happened’ meant they lost the prescription for my lifesaving epinephrine autoinjectors.

“I would appreciate it if you would waive the copay in light of all the time spent getting this straightened out,” I said in my most exhausted voice both because I am so exhausted and also because it was either exhaustion or screaming vulgarities.

“Fine,” she said. You know that voice people use when they think they’re doing you a favor, like they’re giving you something that you shouldn’t expect? It was that voice. “Fine.” In that voice. I signed, took my Epipens and left.

On my way home, I remembered that I got shorted needles by my IV pharmacy (which has never made a mistake with my meds or supplies.) I stopped by the other pharmacy in walking distance because I just did not want to go back to the one where the pharmacist was doing me favors.

In Massachusetts, you can buy syringes without a prescription if you’re over 18. I walked up to the counter with my license out and prepared myself for the inevitable condescension that usually accompanies buying syringes without a prescription.

The technician came right over. “I need twenty syringes, inch long needle, any gauge you want,” I said.

“Okay,” she said, smiling. “Any specific volume?”

“It doesn’t really matter. My infusion pharmacy just didn’t send me enough for this week.”

“Well, that’s not okay,” she said and you know what? SHE ACTUALLY MEANT IT. “I’ll bring over a few and you can pick.”

She brought over a few types and I picked the one I wanted and she rang me out.

As a demonstration of my appreciation for her smile and sympathy, she shall hereafter be known as Technician Amazing throughout all the lands. I have a dream that one day she will be successively promoted to the position of Supreme Pharmacy Ruler and she will decree that it shall be illegal to provide any less than 270 tablets of ondansetron when the prescription says 270 tablets of ondansetron.

Probably won’t happen like that. But it’s okay to dream.


My body is changing. I am tired but do not sleep for twenty hours at a time. Bones and angles emerge as my swelling wanes. I exercise. I eat real food. I sleep at night.

At the same time, I am carefully engineering to encourage these continued changes. I still take a ton of medication. I still need IV fluids every day. I still need IV meds. I still need to manage my pain. I still need to be careful. This nethervoid I currently inhabit might never be mistaken for healthy, but it is healthy for me. It is stable at least, predictable. It is good for me.

Last week was composed of the oppressive, sticky summer days that Boston is known for. Heat, humidity and sunlight form my own personal triad of doom. I got halfway through my short walk between stations and started reacting badly. I went into a Starbucks and promptly threw up while hives appeared on my neck. All of my exposed skin was bright red. I took some Benadryl and drank some cold water and waited for things to calm down. They did. I continued on my way to work.

It is hard for me to gauge how bad I look on any given day, as I was for many years in a persistent reactive state. My only indication is that initial surprise when people look at me, that flash of concern as their eyes widen, a brief moment before they recover. I knew as soon as I got to work that I must look terrible.

We have a cold room at work that is essentially an enormous refrigerator. “Girl, you need to go stand in there,” one of my coworkers said with a supportive nod. So I did. It helped. When I emerged, multiple people told me they were worried I would anaphylax and to please take a cab home. I am so fortunate to work with this group of caring, wonderful people that understand my disease and want me to be safe.

I did end up taking a cab home. I didn’t want to, but I did. It’s hard for me to articulate why I didn’t want to, when I knew it was safer and easier, in a way that doesn’t make me sound crazy. Getting in that cab made me sad in this nebulous but palpable way.

Taking the train to work is a privilege. Going to work, cleaning your house, paying your bills, food shopping, making dinner, eating solids, crunching lettuce as you watch television, being part of the world. These are privileges. These are the things you miss when you are hospitalized or so tired that your whole body feels heavy or riding that knife’s edge of anaphylaxis because your body is fighting you on something you need to do.

All of the days you spend fighting – this is what it is for. You fight for these privileges. You fight to be in the world. These are the things you will miss. All you can ever hope for is to wake each day to a world full of mundane privileges.

Some days I want to take the train even if there is a chance I will get sick. Because there is a chance that I won’t. Once that was impossible. Maybe it will be again. Maybe tomorrow it will be impossible, but not today.

I am still sick. I am still in pain. I still have a poorly functioning GI tract. I still carry two Epipens and a backpack full of meds everywhere I go. I am still nauseous. After all of the effort put forth in the last three months, I did not get cured. I got to walk to work sometimes. I got to eat salad. I got to feel the sunlight on my skin. That’s what I got. And it’s enough, and even more than it’s enough, it’s amazing. All of this is amazing. I am alive this summer and I am alive in the heat and I am alive when I’m too hot and I’m alive in the sun.

You cannot always decide what you do, but you can always decide who you are. I cannot always walk in the summer sun, but I am always a person who wants to.

I choose to live in the world and to enjoy it and be alive. I choose this even when it might hurt me. I choose this even when it might kill me. It is where I want to be.

It is a privilege to participate in this world. It is a privilege to be alive.

This universe inside

Last summer I went to Maine with my sister, cousins and some friends for my cousin’s bachelorette party. I had a PICC line and couldn’t swim, was throwing up most of my food and the loop of bowel behind my stoma twisted on itself. I slept a lot and spent all day in the hotel room with air conditioning in order to muster enough energy to go out at night. I still had a good time largely due to good company, but it was a good time I fought pretty damn hard for.

This past weekend, I went back to Maine with the same group of girls with a couple of substitutions. We stayed in a hotel with a pool about 200 yards from the ocean. It was sweltering in a way that makes even healthy people tired. I crossed my fingers and hoped for the best.

On Saturday night, we all went out and had a nice dinner at a restaurant in town. After, I went for a long walk before bed. It was still hot and sticky out, but the wind blowing off the ocean felt like a big hug. It was one of those nights when you feel connected to the world. The waves crashed on the beach, this soft, wet percussion. The stars were bright.

It felt like I could look all the way across the universe. It felt like I could look all the way across my universe, the one I contain inside my body. I walked along the water and thought about my limits, the limits of that expanse.

The next morning, I deaccessed my port, put on my bathing suit and sunglasses, and went to the beach. I waded into the ocean. The water was cold, but not frigid. I floated in the shallows, rising and falling with waves. It was very serene.

I took some IM benadryl at lunch since I was deaccessed. I went swimming in the ocean again. I swam in the pool. I reaccessed my port. I ate a fancy dinner at a nice restaurant. I fell asleep at a reasonable hour, slept all night and woke up in the morning. The trip was completely uneventful concerning my health. My body worked fine the entire time.

It doesn’t feel like this is my body. It is like I borrowed one, a better model. It continues to demonstrate its new durability. Eating sweet potato fries with ketchup. Taking the train to and from work. Being in the office 3-4 days a week. Walking in oppressive heat. Swimming in the ocean. Thirty minutes of cardio. It is tolerant. Sturdy, even.

I am torn between being cautious in this capable new vessel and pushing all the limits. I am afraid of not knowing how far I can go. I am scared that all of this will go away.

But it’s here now. It feels like the universe inside me is expanding, the boundaries pushed further away with every beat of my heart.

Independence Day

I live my life as a series of wagers. A lot of these wagers involve my health. I bet that I can fly if I take enough steroids. I bet that I will get better if I get an ostomy. I bet that I will be more stable if I use IV hydration. I bet that taking this med or that will make me less tired. Sometimes I win. Sometimes I don’t.

The last 18 months of my life have all been one large scale bet. It has been many months of moving the pieces around and trying to shove them into place. It has been emotional and stressful and scary.

I slept through the four weeks following my surgery. I did some other things too, but mostly I slept. One day while I was resting in bed, it occurred to me that all of the strength and stamina I had lost was perhaps for the best. There are few opportunities to reset your body and this was one of them. I wasn’t reacting because I was heavily medicating and resting most of the time. I realized that this might be an opportunity to rebuild my body in a calculated way.

Once I was cleared by my surgeon to exercise, I started an exercise program designed for POTS patients. It was pretty detailed (I’ll do a separate post about this) but involved cardio exercise 3-4 days a week. I haven’t been able to do cardio in years. But I figured it was worth a shot.

The first two weeks were brutally hard. Then it got easier. I am now on the sixth week of a twelve week program. For the first time in many years, I can do cardio (with premedication in a controlled environment) without having a reaction.

I went back to work last week. I took the train to and from work on Monday, Wednesday and Thursday, which also involves about a mile and a half of walking each day. It was pouring torrentially on Wednesday and hot as hell on Thursday. I was exhausted when I got home but I managed to get through each day without napping. I slept every night last week. Getting myself to and from work is a level of independence I have not achieved in a year.

I very rarely drive anymore because I can’t use some of my medications if I need to drive and I have been so reactive that that might have been dangerous. But I made a huge wager on Saturday: I drove myself an hour away to New Hampshire to celebrate the Fourth of July with my friends and nieces. I stayed overnight and went swimming today, deaccessing and reaccessing my port. I drove myself home after being in cold water and direct sunlight for over an hour, stopping at Whole Foods and doing my grocery shopping on the way. I cleaned my apartment, did laundry, made lunch for tomorrow, ironed my work clothes, and watched Shark Week. I did all these things without any help.

The Fourth of July is Independence Day in the US. As I watched the fireworks, it felt like I was celebrating my own personal Day of Independence. I don’t know how long this will last.  But I got this one great week and this one Fourth of July.  And maybe I’ll get more.

How to eat low histamine if you’re me

As requested, the details on how I eat low histamine.

The low histamine diet is confusing. There are several lists of which foods are high and which are not. Various sources cite different instructions for food preparation, storage, etc. There isn’t a lot of agreement on what is considered best practice for following a low histamine diet. I figured out what works for me by trial and error and that is what most people need to do. This is what my life looks like on a low histamine diet.

I started the low histamine diet January 1, 2014. I found a bunch of recipes online and spent three hours in Whole Foods trying to find everything. That first month was phenomenally expensive as I needed to get organic and/or low histamine versions of typical pantry products like oils, flours, spices, sugars and so on. The good news is that after that first month, my food bill has been much more manageable (though still more expensive than competing supermarkets like Stop and Shop).

I chose to follow the low histamine/low tyramine diet you can find on the Canadian Mastocytosis Society page. Foods that are canned or preserved are generally considered not to be low histamine as preservatives can be triggered and something bad is supposedly generating by the canning process (I’m unclear on what that is, but it seems possible to me). Vinegar is not allowed and I used many types of vinegar regularly, so that was a bummer. No wine or liquor for cooking because no fermented products and no alcohol. Several of the prepared sauces I used to cook Thai and Vietnamese food also contained verboten ingredients. When you start this diet, I strongly urge you to look at the labels of everything in your kitchen and discard anything that doesn’t qualify. Most sources recommend doing the diet for thirty days to determine efficacy and using one unapproved ingredient in that time period can really make it hard to tell if it’s helping.

Another big no-no is leftovers, but again there isn’t a real consensus. Not being able to cook meals for an entire week really threw a wrench into my schedule. I used to cook two meals on Sunday and eat the leftovers all week. As a microbiologist, I can verify that bacterial degradation of meat begins quite soon after it’s done cooking and this generates histamine as a side product. So no meat leftovers seemed like a good idea to me. I had to trial other types of leftovers to see what I tolerated.

I eventually got to a decent place with this diet where I was spending more time preparing than before but not a ridiculous amount. This is what that looks like.

I juice a lot. I started juicing this past winter. I am not particularly sensitive to taste so I just chop up a bunch of stuff ahead of time and throw it in. I juice one large mason jar of chopped veggies and one small mason jar of chopped fruit in the morning on weekdays. This gives me about a full 8 oz glass. I chop all the veggies at once and set up the mason jars in the fridge for the whole week. It takes about 45 minutes. Vegetables include carrots, parsnips, celery, celeriac, fennel, parsley, kale, arugula, cucumbers and beets. Beets give me energy, and this is apparently a well known phenomenon. I use ¼ beet per juice because more than that gives me cramps. Fruits include apples, pears, mango, star fruit, passion fruit, pomegranate, longan fruit, lychee, rambutan, and kiwis. I sometimes add ginger. I’m not very sensitive to taste, but if it tastes really bad, I just add a little pomegranate juice and it covers it. So that’s usually what I do for breakfast.

Other breakfasts include apples or pears with honey and peanut butter, scrambled eggs, hash browns or home fries (potato or sweet potato) with onion and black pepper, and Applegate chicken and apple or chicken and maple breakfast sausages.

If I forget to pack a lunch and have to go to work, I eat one of the following: apples and peanut butter, mozzarella with yeast free crackers, or multiple pieces of fruit. I can get these items at a nearby supermarket and they are safe fall backs for me.

If I have some time to prepare food, I usually bring with me one of the following: mashed potatoes with salt and butter, sweet potato casserole, saffron rice, mixed cooked vegetables, various versions of daal (lentil dishes, I usually also add chickpeas) and sometimes yeast free flat bread. I can prepare any of these meals and eat them for the following two days without a problem (so if I cook on Sunday, I can eat it Sunday, Monday and Tuesday). This is really helpful. I store them in mason jars and stick them in the fridge. Some people find it is better for them to freeze anything they don’t eat immediately and then thaw and eat it when they choose. I don’t do well with that.

For dinner, I generally have mashed potatoes and an Applegate chicken and apple sausage. I peel and dice two medium, yellow organic potatoes and add to small pot of boiling water. I then put the sausage in its own small pot of boiling water and both are done in about ten minutes. Quick and easy. Sometimes I use a little turnip instead of the second potato and whip it with butter and sage.

If I’m feeling more adventurous or have more time, I have some other dinner dishes. Saffron chicken and rice is really good. I buy organic meat and eat it the day I bought it. Any meat not eaten is either given to someone who can eat it or thrown away. This also includes anything cooked directly with meat, like the rice in the saffron chicken and rice.

Squash risotto is good. Squash lasagna is good. I eat a lot of squash. I make decent squash soups. There are many different types of squash so if you can eat squash, you can often get a lot of variety in taste and texture with squash. Sometimes I candy squash and beets and walnuts with brown sugar, salt and maple syrup. I can eat the risotto and lasagna for two days after cooking and I can successfully freeze and thaw the squash soup.

I strongly recommend making your own stock, both because it is much cheaper and also because it is much safer for mast cell patients who react to lots of foods. I boil down entire bones. I get bones from an organic food store or keep the bones from something I have cooked (like turkey or chicken). I soak the bones in cold water with the juice of one lemon for a few hours. While I’m doing that, I cook celery, carrots, onions and garlic in butter in a large pot. I add the bones and cold water to that pot. I add quartered onions, turnips and potatoes and whatever miscellaneous veggie odds and ends I have. I season it and add water until it’s about an inch from the top, then turn the heat down really low. Every couple of hours, I remove the debris that has floated to the top and stir the pot. I add more water as needed. I cook it for about twenty four hours, then pour it (with funnel) into mason jars and freeze immediately. This stock is really soothing on my GI tract when it has that burny type of pain.

For snacks, I usually eat peanut butter or potato chips. Plain potato chips are generally safe for me. I will sometimes indulge in chocolate or ice cream if I’m not pushing my luck already that day. I can eat most versions of Rice Krispies treats safely. I can eat cake if I make it (and the frosting) myself. I have some low histamine cookie recipes. I make my own low histamine hummus (I tolerate tahini okay, so sometimes I include it and sometimes I don’t) and will eat that with carrot and cucumber spears.

I really enjoy salads but my GI tract has a hard time with them so I am only recently eating them again. I make salads with lettuce or a green that’s not spinach, cucumbers, lots of chickpeas, black olives (safe for me) and a hummus based salad dressing. It’s pretty good. I pack the salads up in mason jars and the lettuce stays crunchy for a few days.

Eating low histamine can really be a royal pain in the ass because of how much work goes into food prep. However, if you can identify some quick items for when you’re really not feeling well or out of your house, it will seem a lot less stressful. Knowing that I can get a Rice Krispies treat at Starbucks to hold me over until I get home helps a lot. Finding out I can eat some Applegate products which can be prepared in a few minutes has made my life much less stressful. It is really difficult in the beginning because you have to check everything and cook everything from scratch, but once you get in a routine it’s not that bad.



The high water mark

I spent most of the latter half of May in bed. People woke me up take medication on schedule and I fed myself small meals periodically. I watched movies and TV and drifted in and out of sleep, pain killers and Benadryl making the world soft around the edges.

Every day, even as I felt myself healing, my strength and stamina waned. My legs felt weak when I stood up. I got winded walking around the block. Holding my head up felt difficult. All of the stamina I had built up before surgery was gone. All of my progress was undone.

I spend so much energy trying to get somewhere I’m never going to get – to this place of physical health where I can exercise and sleep at night and wake in the morning without bleary eyes and a pounding headache. I have been trying to reach this milestone since well before I knew I was sick.

I’m not even sure I know the closest I ever came. What is the highwater mark of this particular struggle? Was it the few weeks before my last birthday when I was sleeping at night and waking without an alarm? Or that really good day last September? The few weeks after my colostomy healed? I don’t know. I’m not sure there is a high water mark. Everything is relative.

Living with a sickness that causes regular setbacks – and requires treatments that sometimes do the same – is difficult. This halting start has become a sort of rhythm, the timing an inherent part of this experience. I’m never getting anywhere. I’m always getting it wrong. It feels like if I could do the right things in the right order that it would make a difference. `

But what if every time I started again, it didn’t mean that every time before was a failure? All those times before, all the moves in the wrong order, kept me alive and participating in the world. How wrong could they be? What if the high water mark of this struggle is just being alive?

Reversing the ostomy was the right move. I am noticeably less inflamed and my body is responding. I am having fewer reactions. I am eating without vomiting. The squishiness, the swelling weight is melting away so I can see the features beneath. I am still in pain, but I think I always will be.

I’m getting stronger. It’s slow, but it’s happening. I can walk for twenty minutes now, Astoria happily padding along beside me. I’m short of breath and sweaty when I’m done, but I can do it.

Maybe it’s time to stop blaming myself for all the times I had to start over. Maybe it’s time to see these setbacks as opportunities to understand my body and learn from it.

Maybe this is enough.