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Symptoms and findings in mast cell activation illness System Potential manifestations of mast cell illness Constitutional Fatigue, malaise, asthenia, "chronic fatigue syndrome," subjective and/or objective hyperthermia and/or hypothermia, "sense of feeling chilly much of the time," sweats/diaphoresis (not always nocturnal), flushing, plethora or pallor, elevated or decreased urge for food, early satiety, weight gain or loss, pruritus, environmental sensitivities (typically odd) Integumentary Rashes and lesions of many kinds (classic urticaria pigmentosa, “freckles,” telangiectatic/angiomatous lesions, xerosis, warts, tags, folliculitis, ulcers, diffusely migratory but sometimes focally persistent patchy erythema), pruritus (typically diffusely migratory, generally aquagenic), flushing, angioedema, striae, dermatographism, poor therapeutic, alopecia, onychodystrophy Ophthalmologic Irritated eyes, increased or decreased lacrimation, suffusion, conjunctivitis, problem focusing, lid tremor/tic, photo voltaic sensitivity, infectious or sterile inflammation Otologic Infectious or sterile otitis externa and/or media, hearing loss or hyperacusis, tinnitus, otosclerosis Oral/oropharyngeal Pain (sometimes "burning"), leukoplakia, fibrosis, lichen planus, ulcers, sores, angioedema, dental decay, dysgeusia, throat tickle/discomfort/irritation/ache, publish-nasal drip Lymphatic Adenopathy, often sub-pathologic and sometimes waxing/waning in dimension, typically asymptomatic but not uncommonly tender, typically focal, sometimes migratory, pathology often shows a reactive lymphocytosis or sometimes an atypical non-particular lymphoproliferative dysfunction; left higher quadrant discomfort (likely from release of mediators from splenic mast cells with or with out detectable splenomegaly) Pulmonary Rhinitis, sinusitis, pharyngitis, laryngitis, bronchitis, pneumonitis (typically confused with infectious pneumonia), cough, dyspnea (usually low-grade, inconstant, "I simply can't catch a deep breath" despite regular pulmonary function exams), wheezing, obstructive sleep apnea, pulmonary hypertension Cardiovascular Presyncope (lightheadedness, weak point, dizziness, vertigo) and/or syncope, hypertension and/or hypotension, palpitations, dysrhythmias, chest discomfort or ache (often non-anginal in character), coronary and peripheral arterial atherosclerosis/spasm/infarction, aneurysms, hemorrhoids, varicosities, aberrant angiogenesis (hemangiomas, arteriovenous malformations, telangiectasias), migratory edema (typically non-dependent and in spite of normal cardiac and renal function) Presentation, Diagnosis, and Management of Mast Cell Activation Syndrome 205 Table 1. 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