DoozlyGirl

Hi Jen, You have a really great outlook, especially considering your journey. I hope my story will shed some light on a possible path to better health for you. There IS a link that connects EDS and dysautonomia, and its dysfunctional mast cells. Research has shown that misbehavin' mast cells can wreak havoc throughout the entire body or localized in one area. There are a bunch of us who are being diagnosed with all three of these disorders. Dr Afrin, a hematolgist/oncologist at Medical University of South Carolina in Charleston firmly believes that EDS and POTS/Autonomic Neuropathy is caused by these overreactive mast cells, and since these mast cells are also linked to just about any inflammatory disorder, it could cover the autoimmune side to your AN. He is curently treating over 300 patients with mast cell issues, seeing his first patient in 2008. Mayo is not yet on board with this connection, but Dr Afrin and Dr Mairianna Castells, an allergist/immunologist at Brigham and Womens/Harvard in Boston are the two leading physicians in the US who ARE conecting those dots. I met with Dr Afrin last week Monday and he is absolutely convinced that chronic mast cell activation is to blame for my entire 37 year history of ongoing chronic health issues. We are now testing to find out which mediators are causing my issues. I have a strong family and personal history of autoimmune and inflammatory diseases, as well as aneurysms, atrial septal defect (hole in heart), and pulmonary hypertension in my mom, and aneurysms in her brother, 2 sisters and father, as well as dozens of her distant relatives. I've had a cavernous hemagioma of my skull, which all point to EDS, vascular subtype. I have autonomic neuropathy and severe orthostatic hypotension, and have gone from bedridden for 6 months to somewhat 20 percent functioning with dysutonomic treatment and after being on excalating doses of MCAS medications, histamine-reducing diet and other adaptations, I am at 60 percent functioning 70 percent of the time. Misbehavin' mast cells will release histamine and begin a cascade of releasing potentially hundreds of chemicals into the body. Several of these chemicals are known to increase vascular permeability, which leads to hypovolemia and in order to save the heart and brain, counter regulatory mechanisms kick in (i e sympathetic overdrive/adrenaline rush). For me, I get flush, which is a sign of histamine release, I get puffy, and sometimes even swell, a sign of vascular leaking, and my brain fog, pooling and erratic HR and BP, (especially narrow pulse pressure) are signs of low volume in my circulation. I have experienced syncope, but now recognize that I have to lie down and raise my legs to get blood immediately back to my brain and heart. I will chug fluids, pop a benedryl or other HI and a H2, and in time my cascade will stop and I will be able to function again. There are tons of mediators that are released so the treatment depends upon those chemicals that are released, but in general antihistamines (both H1 and H2) are the place to start. Many of us are unable to tolerate meds, so we start out slow and begin with the OTC meds that have less potential of causing issues. For me, I can't tolerate the FD&C dyes. Others can't tolerate the fillers. Check out the mast cell discussions on this forum as well as the Mast Cell Disorders Forum and see if you can find any other similarities. I'd love to hear Dr Afrin's thoughts on your experience with IVIG. I wonder if IVIG contains mast cell degranulators, which are things that are known to cause these cascading reactions called degranulation. You may want to consider contacting Dr Afrin by email with a brief synopsis of your journey and ask for his perspective to see if mast cell issues could be causing your issues. You could ask if he'd be interested in working with one of your docs. Testing could be tricky, since it has to be performed to his specificiations and samples kept chilled from the time collected all the way though testing. That's the reason I traveled all the way to South Carolina to have testing performed the correct way to ensure best possible chance at confirming my diagnosis. Let me know if you have any questions. Best wishes, Lyn

Looking forward to hearing about your appointment.

Tachy, Cardiac perfusion imaging is a nuclear medicine procedure and most often performed as two scans, one at rest, and the second after an excercise stress test. This test mainly looks for heart disease by determining which coronary arteries are blocked. Doppler is an ultrasound technique of looking at blood flow. Lyn

Issie, Is it fatigue or sedation that you are feeling, or can anyone tell the difference when we have so much going on? I've read that to get over the sedative effects of the antihistamines that cross the blood brain barrier, start out with a small dose and taper up, taking the antihistamines at night until your body gets used to them. I've had to do this with hydroxyzine (crosses BBB) , the precurser to Zyrtec (doesn't cross the BBB). Hydorxyzine is available by prescription (2.5 x stronger than zxyrtec), which took about a week at half dose, before I began taking full tablet. Haven't yet tried to take during day. I don't mind the sedative effects of the hydroxyzine, because in combination with a dye free liquid gel of diphenhydramine, I was able to stop taking Ambien and as a bonus I can actually function in the morning now! Lyn

Future, have you had a reaction to the Zantac in addition to the insomnia? I react to red # 40 and yellow #5 and yellow #6, but am still trying to decide if I react to the zantac. Brand Name Zantac uses iron oxide dye, which is a natural dye and comes from the earth. I definitley react to several generic zantac products that incidentally have the Red #40 dyes made from petroleum. Thanks, Lyn

My autonoamic testing was ordered by Dr Beth Lalande, an endocrinologist. Dr Jaredeh read my studies and Dr Barboi and Mary, the Neuro NP has been treating me. Dr Jaredeh is now at Stanford in California, starting up a autonomic lab there. Dr Barboi is soon relocating his practice to Rush in Chicago. Dr Chelminisky, an autonoiamic neurologist, and his wife Gisella, an pediatric GI, formerly of Case Western, have now joined the staff at Froedtert. I hear they are also hiring another autonomic neurologist. Dr Linda Lee, a dermatolgist will be working with Dr Afrin, from MUSC, in South Carolina, to treat my mast cell activation syndrome (MCAS). I have been pleased with my care at Froedtert/Medical College of Wisconsin. Considering I have seen literally a hundred physicians and health care practitioners in 30 years for my ongoing issues, I have made most progress in u nderstanding what is going on in the past 2 years. Best wishes, Lyn

Michelle, I see Dr Barboi and Mary, his NP for my autonomic neuropathy at Froedtert/Medical College of WI. He recognized my rashes, hives, and blotching and sent me for a skin biopsy and tryptase. I've seen Dr Linda Lee in Dermatology, and she is willing to serve as my local physician and follow Dr Afrin's recommendations. I see her again next week. She is the first MD I've found in Wisconsin who is familiar and comfortable with mast cells. She wrote her PhD disertation was on mast cells and impact of histamine. You may want to consider having Dr Lee look at your rashes. Lyn

Spent the afternoon with Dr Afrin and his staff. He confirmed many of my suspicions and feels that misbehvin' mast cells is the only disorder that can explain my vast array of diagnoses and dysfunction. Will have to see if any of my testing comes up positive before he can confirm my diagnosis. Meanwhile he advised me to hit the antihistamines HARD whenever I have any symptoms. Prostaglandins can cause pain and swelling, which is why NSAIDS (ibuprofen, asprin, advil, naproxen) will block these, often eliminating pain. But many of the pain meds also flare mast cell reactions, so tylenol and tramadol are recommended. While asprin can flare symptoms, at the right dose, asprin can also block the prostaglandins. Dr Afrin also shared that my forced sleep episodes are likely caused by PGD2, which he calls the worlds best natural sedative. Most of the 17 tubes of blood I had drawn today also needed to be drawn into prechilled vials and put on ice as soon as drawn. This chilling stablizes the mediators and may influence the results. Sounds like no one else in the country is talking this much care in chilling and then keeping the samples cold throughout the entire process. Urine must also be kept on ice/refrigerated the entire collection time, processing time and testing time. Lyn

Jen, I've seen Dr Marilyn Kay, a neuro-opthamologist from Milwaukee (Offices at both Aurora St Lukes and Medical College/Froedtert) twice in the past decade. I just got a letter saying she is moving her practice to UW in Madison. Should be a shorter drive for you. She isn't warm and fuzzy, but she is thorough and competent. Let me know if you find a different doc. Lyn

Claire, Hormonal flushing or hot flashes due to hormones should last a minute or two. I will flush and t look like a tomatoe or sometimes just a light pink, but it is still flushing. Lyn

I've gone into anaphyaxis three times in the past month, and am really reactive. I'm popping my antihistamines like candy, so my NP suggested a stronger antihistamine. The hydroxyzine is the precurser to zyrtec and 1 dose is equivalent to 2.5 zyrtec.

futurehope, Nope, I'm a patient. I did work in healthcare for 20 years before becoming too ill to get out of bed. I wrote health system policy for the last 10 years and had to do tons of research, so I guess I'm just comfotable in that mode.

For those of you intersted in learning more about mast cell disorders, I'd like to share some things I've learned. The concept of mast cell activation has been around in the publications for decades, but it was clinically associated with local degranulation, as in asthma, interstitial cystitis or systemic degranulation due to true IgE allergy (ie peanut allergies, bee stings, penicillin) OR mastocytosis, a RARE, and little known disorder of the mast cells, which includes both proliferation (over abundance) and excessive mast cell activation. It IS common knowledge that systemic mast cell activation leads to anaphylaxis . Look up EMS protocols and ER physicians journals and surgery/anesthesia journals, if you'd like. The hitch here is that previously, conventional medical wisdom believed that excessive mast cells or IgE triggered mast cells were responsible for the mast cell activation causing anaphylaxis and didn't account for defective or overly trigger happy mast cells as a link to systemic mast cell activation. Mastocytosis experts had established very strict WHO guidelines and many people showed evidence of mast cell activation but just didn't meet the firm criteria (excessive number of mast cells) for mastocytosis diagnosis. So were left out in the cold and dark. The lucky ones got the diagnosis of idiopathic anaphylaxis, told to take antihistamines, go on a low histamine diet and carry an EPI pen. While a small to moderate percent of these people could figure out their triggers through intensive allergy testing, the vast majority (60-77 percent or more) was told they's likely never figure out why they anaphylax. Dr Cem Akin, from Harvard, the leading US authority on mastocytosis, began to study these IA patients and he was one of the first to break ranks and suspect that there could be an abnormality in the mast cells that causes degranulation. He spoke of mast cell activation tied to a trigger happy defect at the 2009 Annual Mastoytosis Society conference. This is a very political battle, and the researchers who origianly established the WHO criteria are holding onto their life's work and some are not budging. But as the publications and data are reviewed, many researchers are stepping forward the this concept of mast cell activation without excessive mast cell or IgE involvement grow, the movement of mast cell activation syndrome (MCAS) moves forward. An international panal had now defined some criteria for mast cell activation and several of us on this site are running with it, likely because we have easily identifiable symptoms. I flush so much that many docs just thought I was sunburned, but I live in Wisconsin, have red hair and fair skin, so finally that assumption is being broken down. My pheo and cardinoid tests were negative, so they moved on. I attended a talk on Wednesday given by Drs Thomas and Gisella Chelminsky, formerly of Case Western, and now at the Medical College of Wisconsin. I posed the question (sent it ahed of time in writing) and asked if he had any experience with mast cell activation disorders being tied to autonmic dysfunction. He said classicl mastocytosis is so rare, that no, he has not. He went on to describe proliferation, so I immediately knew he was not familiar with mast cell activation syndrome. His wife, a pediatric GI, said she will routinely biopsy for it, but rarely finds it. After reading about Dr Afrin's 90% success rate in finding mast cells in the GI with the addition of non-standard but readily available stains, I highly suspect Dr G Chelminsky would likely see more cases by using the same stains that Dr Afrin's patholgists use. Which brings up my next point, many leading researchers have publicly stated that better more senstivie testing is needed to capture the metabolites that are released after a degranulation episode. Currently, mastocytosis is deignosed after a hugh tryptase or bone marrow biopsy finds accumulation of mast cells, both pointing to excessive numbers of most cells, NOT how they function. Current testing has to capture the blood or urine within an hour or two after the degranulatin began. Very difficult to figure out how to capute when my orthostatic hypotension is so bad, I can't get out of bed during an episode, and many times I am not awake, as i lose consciousness for hours. I don't have orthostatic issues without flushing. Kind of telling to me. Stop the flushing, and I feel great!! I am so close to feeling normal again, I can almost taste my freedom from all this. Does the fact that autonomic neurologists aren't up on mast cells mean that mast cells may not be a leading cause of my autonomic neuropathy? **** NO! To me, it just means that science hasn't caught up yet. Just as my my other physicians don't know about autonomic dysfunction, I can't assume these neurologists would be up on recent data on mast cell disorders. Lastly, the WHO would NOT have moved around it's claffication of proliferative disorders, added mastocytosis to that proliferation bucket and then drafted a guideline for mast cell activation syndrome if there wasn't enough proof to justify it's existance. Regarding the link to POTS, Vandy has an old article out there on HPOTS and mast cells, and I bet once more POTS patients start to to chase down a mast cell diagnosis, we'll start to see more autonomic neurologists buying into this as a possible explanation why SOME of us have autonaomic neuropathy, orthostatic hypotension, orthostatic hypertension, or POTS. I didn't think that mast cells were my issue at first, but once I got on anihistamines, I couldn't deny it. I wish you all the best in finding the cause of your own symtoms. Lyn

Dr T Chelminsky is now at the Medical College of Wisconsin and I heard him speak the other night on one root cause of mitochonrial dysfunction leading to POTS/Dysautonomia. He is treating patients with L Carnitine, Co Q 10 and about to add additional supplements to his program. He mentioned Riboflavin. Since he mentioned Paul Cheney, a leading CFS researcher, I wonder if he will be adding D Ribose and other mitochonrial focussed supplements. When I had horrible fatigue, I began bey reading up on Jacob Teitlebaum's theories. He is quite controversial, but had books and a website that does a good explaining fatigue. He is pretty big into delivering the building blocks to feed your body chemistry and promting the body to make enzymes and cofactors to function. Best Wishes, Lyn

northerndarlene, Hydroxyzine is an old antihistamine which is KNOWN to be sedating. Just like diphenhydramine aka Benadryl is in many OTC sleep products because it has sedation products. Will be starting it myself when it arrives. I plan to take a 1/4 pill at night and work up to the full 25 mg. On the MCD forum, I've read that just about everyone feels major sedating properties at first, and it take awhile for the drowsiness to go away. When that happens, others recommend it is ok to try during the day. Lyn

Years ago, I was on Topamax for nearly a year for migraines. I had to take it with food, but still couldn't ever get past 25 mg without feeling like I was having a stroke. One day I had a catch a early flight, and the hotel or airport restaurants weren't open yet, so I didn't take it. Which was a BIG clue for me. It was the first day I didn't have have mini seizure-like episodes in nearly a year. Never took it again. If anyone has a sulfa allergy, be aware that in additon to the bad things in Tachy's post, it is a sulfa med and it can set off an allergic reaction or mast cell degranulation. Lyn

Claire, I will be seeing Dr Afrin in 11 days, and have a tryptase of 2.5, and skin biopsy confirming blood cells in my skin. I have not had any other mast cell tests. My symptoms and improvement with antihistamines (and mast cell stabilizers in the past) and this testing got me the clinical diagnosis and I hope Dr Afrin can nail down the biochemical diagnosis. I have been on H1 and H2 since January and had to add singulair due to chest congestion during my reactions. As I posted earlier in this thread, many of my crappy symptoms have gone away with the H1 and H2, and lots of trial and error to pinpoint what makes me trigger. For me, food drug and cosmetic dyes were my BIGGIE. I got rid of yellow #5 and red #40 and noticed a HUGE difference. I also react minimally to Blue #1. Right now, my big issue is chronic anaphylaxis. I just found the sweetspot in my meds and eliminating triggers and haven't had symptoms AT ALL for 2 days. I am sorry you have burned out on chasing this diagnosis. Just as others have done for me, I really do think it is well worth your time to pursue. One of the best and easiest things to try is add a decent H1 ( claritin [generic=loratidine] or zyrtec [generic = ceterizine). Take one dose of H1 in the morning with a H2 (like your zantac or pepcid [generic = famotidine]) and again at night. If you can tolerate these meds, then try to figure out what triggers it and eliminate those. Try the low histamine diet as a basis of figuring out if foods are an issues. If you notice a improvement in your severity, then its a pretty good clue to go full guns and learn everything you can about mast cells. For any one out there with mast cell suspicions, try this same plan and see if it makes any difference to you. Make sure your not reacting to any of your meds. I was!! And feel so much better now that I am on dye free meds. Best wishes and good health, all! Lyn

Naomi, I'd like to share what I've learned, so it may help you. When mast cells are overactive, the slightest assault (pressure, chemicals, cold, heat, alergens, etc) can trigger them to react. The mast cells release histamine and anywhere from a few to literally hundreds of mediators (ie prostaglandins, heparin, cytokines ,etc). While the things that make you allergic can trigger one type of degranulation, ie an allergic IgE response, people with mast cell disorders have other pathways that sets off these mediators and researchers are still learning about these pathways. If histamine is released into the body, it and other mediators can make the vasculature more pourous. In my case, I leak fluid into my tissues from my veins. And is written as vascular flushing. This is evident from my skin biopsy. I have plasma cells in my skin biopsy sample. I flush terribly everyday and get blotchy red patches on my neck and face. This usually is my first sign the reaction is beginning. If I don't get it under control and my reaction continues, the fluid part of my blood leaks into my tissues, giving me hypotenion due to low blood volume. I used to also get tachycardia at this point whenever I stood. Just as you'd expect in dysautonomia, the tachycardia happens to try to compensate for my low volume in the veins and low BP, as the heart senses something is wrong and tries to get blood back to my head. I am concerned that now with the low BP, I get bradycardia. Possibly a baroreflex dysfunction, but nontheless NOT GOOD. And yes, laying down can settle down a reaction. Once the BP drops this can signal the second phase of anaphylaxis. If you have two organs of symptoms (skin) at the same time as the low BP, this points to anaphylaxis. As Mack's Mom coined a term, low grade anaphylaxis, theses episodes can become strung together to become constant. It wasn't until I began antihistamines that many of my annoying symptoms faded (bone pain, sinus congestion, dry mouth and eyes (yes you'd think it would be worse with antihistamines), tachycardia, heavy menstrual bleeding, cramps, itching, paresthesias, constipation, GERD, belching, bruising, sympathetic overdrive symptoms, etc.) This pulled back the layers for me that now my episodes are clearly episodic and while they happen several times a day, They are timed. My mornings suck and I do great in the late evenings. I realized I react every night and face the hangover every morning. Last night I did not react and I felt great from the moment my eyes opened! One more piece of the puzzle for me. Naomi, In case no one has pointed this out: Hives, swelling of the throat, and breathing issues = anaphylaxis. Period. Your intolerances solidifies that your immune system is overactive for some reason. I encourage you to consider pursuing this angle. Now about finding the triggers, I wish it was easy. Dyes in food, medications, and cosmetics triggers anaphylaxis in me and I can provoke the reactions with food coloring drops. Consider absolutely EVERYTHING. The Mast Cell Disorders Forum can get you started. Really great folks on that forum and lots of advice, tips and knowledge. With your history of breathing issues, hives and throat tightening, an EPI pen would be wise, since you can never anticipate when it will hapen again. If you can't get to Dr Afrin or Dr Castells, one approach would be to have an allergist/immunologist give you the epi and order the tryptase within an hour or so from the start of a reaction. and give you a standing order for the 24 hour N methylhistamine. Start collecting the urine at the beginning of the reaction. The second approach, which worked for me is to have a skin biopsy by a dermatologist for the flushing/hives. I got an epi pen, tryptase and antihistamines from the dermatolgist. Then the rest fell into place for me. Good Luck! Let us know how it goes. Lyn

I'd like to add that if someone has episodes with mutiple symptoms (simultaneous or escalating symptoms) that includes flushing, hives, itching, GI issues such as "D" or vomiting, and low BP, then this satisfies the definition of anaphylaxis. Anaphylaxis = skin symptoms and one other organ, such as vomiting and/or breathing issues and/or low BP. Other symptoms such as night sweats/hot flashes, swelling, congnitive difficulties/brain fog, easy bruising, sensitivity to smells, meds, foods etc, pain that moves around the body, GERD, and dozens of other symtoms have been attributed to mast cell mediator release. As you can see, these symtoms fall outside of the classic POTS or other dysautonomia disorders definitions. I've been flushing and having anaphylaxis far longer than I've had orthostatic hypotension. I have "failed" conventional treatment protocols for orthostatic hypotention, and I have tried just about everything published. I am thankful that this site, because that 's how I learned about mast cell disorders. Patients who have pursued a mast cell disorder had PM'd me to nudge me in this direction. Congratulations futurehope on connecting some dots. I hope to connect some dots when I see Dr Afrin in 2 weeks. Lyn

Lindajoy, My heart breaks when I read your posts. No one deserves to be treated with such contempt and lack of respect and compassion, especially from loved ones. I will be sending you positive thoughts to help you through this difficult time and find the strength to carry on with such heavy burdens. I looked on the site for a summary of what journey you have taken and the current diagnoses and symptoms you have. If you are interested, you can add a "signature" that shows up on each posting. Several people have recognized that my episodes and symptoms fit MCAS and they PMd me to share their suspicions. This prompted me to learn all I can on mast cell disorders, and I will be seeing a mast cell specialist in a few weeks. This step was critical in opening my eyes to a mast cell disorder to explain my symptoms. Maybe this strategy could help you as well. Best wishes, Lyn

I am sorry you had that experience. This autonomic doc read my original autonomic tests and has always been very generous with his time to discuss my case with my NP and treating autonomic neurologist. I wonder if his autonomic lab is fully operational, as I had read somewhere he is having a hard time getting what he needs. Still, this is no excuse for his "aging" comments. Not off to a great start for a new practice.

Dizzyde, SPECT scans are performed laying down due to the equipment configuration. But 2 D planar imaging on some scanners could be done sitting. It wouldn't give as much detail, but could answer your questions. Lyn

Anoj, So glad to read you are getting some insight to your symptoms. Maybe my story can help you sort out your own situation. Two years ago, I was diagnosed with orthostatic hypotension(38 point drop in systolic number) on my TTT, and had severe venous pooling. I don't meet the 30 beat criteria for POTS, but was having moderate orthostatic tachycardia, until I took the betablocker (zabeta). I took 1/4 of the pill each morning and within 4 or 5 days, my resting HR shifted from 110 to 40's and stayed that way for weeks. It wasn't until I learned about mast cell disorders, that I realized that chronic flushing is a HUGE sign of mast cell degranulation. I've been flushing for 30 + years, but since carcinoid and pheochromocytoma have been ruled out several times, my docs never really pursued the flushing past those tests. I now realize flushing and blotching precedes my plummeting BP and now take antihistamines every morning and night and at the first sign mast cell degranulation (flushing or blotching). I also take singulair, which is a antileukotriene, and aborts my chest tightness during a reaction. I've learned it is important to take an H1 (zyrtec, clariten, etc) and H2 (zantac, pepcid, etc) at the same time to abort the reaction. While I can abort some reactions, I likely need other medications to stablilize my mast cells from being too sensitive, and I have been really super reactive lately. I've gone into anaphylaxis several times in the past few weeks. Its a good thing I'll be seeing Dr Afrin, a mast cell specialist in South Carolina, in 10 days. If mast cells are triggered to react, they release 200+ mediators into the body, which can include histamine, leukotrienes, heparin, cytokines, tryptase and others. Depending upon which of these mediators is released, the symptoms can vary. One of the most dramatic effects of these mediators is the inflammation and vascular flushing, where the liquid part of blood will seep into the tissues, triggering the BP to drop. I had a skin biopsy in December which showed plasma cells in my skin. The diagnosis of a mast cell disorder is dependent upon finding mast cell mediators in urine or blood, or localizing mast cells in a biopsy. I have many food intolerances/low grade allergies and am highly reactive to molds, yeast and candida. I also react to bread, but my allergy IgG testing shows I am reacting to baker's yeast and low grade to wheat, not the gluten itself. If you are having issues due to over reactive mast cells, you may not have taken enough antihistamines to completely stop the reaction, which could explain why some symptoms continued on, while others subsided. Patients with mast cell disorders take high doses of antihistamines several times a day, as well as other meds to keep the mast cells from degranulating. Best wishes in sorting out your symptoms, Lyn

Naomi, Congratulations in finding some answers to your puzzle. Do you know which radiopharmaceutical they gave you for your Nuclear Medicine Brain Scan? There are several different tracers available to image the brain. You are correct, that the radioisotope will show the perfusion/blood flow within the brain, which is called uptake. Diminished uptake can show lesser perfusion. You also are correct in that nuclear medicine scans provide information on the physiology or function of an organ, where CT and MRI's provide the anatomy, structure or shape of an organ. To answer Kimbellgirl, functional MRIs (fMRI) also provide physiology or function of the organ. BTW, SPECT is the name of the technique of the scanner and stands for Single Photon Emission Computerized Tomography, which means it gives 3 D images, similar to CT. Best wishes, Lyn

Since the IV morphine burned going in, I wonder if your IV wasn't fully patent, causing the morphine to be extravasated into the tissues, causing the redness and rash. But I also wanted to share that flushing and a rash is on the list of adverse reactions to IV morphine, so you may want to consider your redness and rash an allergic reaction instead of/in addition to mast cell degranulation. Lyn