Protracted severe food anaphylaxis: Should we incriminate expired epinephrine pen or clonal mast cell disorder?

We read with great interest the report by Doll et al1 on severe anaphylaxis in a 70-year-old woman after ingestion of pumpkin seed, beginning with nausea and a sense of impending doom, followed by several syncopal episodes, despite the use of an expired epinephrine pen. Three hours later, the patient was still found to be in shock and started recovering only after a second dose of epinephrine. Diagnostic workup found normal baseline serum tryptase levels at 6 ng/mL and positive skin prick test reactions to pumpkin seed.

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