Forensic Science, Medicine and Pathology

https://doi.org/10.1007/s12024-018-9980-z

REVIEW

Diagnostic role of serum tryptase in anaphylactic deaths in forensic

medicine: a systematic review and meta-analysis
Kai-Jian Sun 1 & Jie-Tao He 2 & Hong-Yan Huang 2 & Ye Xue 2 & Xiao-Li Xie 3 & Qi Wang 2

Accepted: 5 April 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

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 signifi-
cantly 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.

Keywords Forensic medicine . Serum tryptase . Anaphylactic deaths . Meta-analysis

Introduction
* Xiao-Li Xie
xiexiaoli1999@126.com Anaphylactic shock (AS) is an immediate metamorphosis, also
* Qi Wang known as a type I allergy [1, 2]. It refers to a group of complex
wangqi_legmed@126.com syndromes mediated by IgE involving multiple organs in a
short period of time after external antigenic substances enter
1
The First Clinical Medical College, Southern Medical University, the sensitized body. It is a serious allergic reaction that is rapid
Guangzhou, China
in onset and may cause death. In forensic practice, however, the
2
Department of Forensic Pathology, School of Forensic Medicine, diagnosis of death due to AS is often difficult because of poor
Southern Medical University, No. 1023, South Shatai Road, Baiyun
or nonspecific gross and microscopic findings [3–5]. Current
District, Guangzhou, Guangdong, China
3
diagnosis of AS is often based on clinical manifestations; non-
Department of Toxicology, School of Public Health and Tropical
specific morphological changes [6], such as pulmonary edema,
Medicine, Southern Medical University, No. 1023, South Shatai
Road, Baiyun District, Guangzhou, Guangdong, China multiple organ congestion etc., were usually detected. Any
 Forensic Sci Med Pathol

Fig. 1 Flow diagram of study

48 of records identified through 0 of additional records
selection process
database searching identified through other sources

44 of records after duplicates removed

39 of records screened 5 of records excluded

9 of full-text articles 30 of full-text articles excluded:

assessed for eligibility 18 for insufficient data
12 for not focusing on this topic

9 of studies included in
qualitative synthesis

9 of studies included in
qualitative synthesis
(meta-analysis)

other pathologies that may contribute to death should be ex-
cluded. Therefore, it is of overriding importance for forensic
pathologists to identify accurate and reliable diagnostic indica-
tors and simple diagnostic methods. Tryptase, an indicator of
possible antemortem anaphylaxis, is gaining attention because
of its long shelf life in serum [7].
Various studies have investigated the diagnostic role of
tryptase in AS, but the reported associations have remained
inconsistent. Mayer reported that postmortem determina-
tion of serum tryptase is useful in the diagnosis of fatal
anaphylaxis [8], and it can be used as a biochemical indi-
cator. However, some scholars have reported that in the
case of non-allergic shock deaths, tryptase levels also in-
creased [9]. Another study reported that about 13% of oth-
er deaths in adults had increased levels of tryptase [10].
Furthermore, the tryptase cutoff values of the above-
mentioned studies are also different. In this study, we con-
ducted a systematic review and meta-analysis to better de-
fine the association between serum tryptase and AS, as
well as to reassess the cutoff value of serum tryptase in
the forensic identification of lethal anaphylaxis.
Materials and methods
Literature search strategy
Two researchers (Sun, Liu) independently performed a com-
plete computer-based search of the PubMed, Embase, CNKI
and the Cochrane Library databases for retrospective control

Table 1 Characteristics of the

included studies Study Year Country Patients (n) Age (years) PMI

Guo [11] 2015 China 60 1 to 60 24 h to 15d

Wu [12] 2012 China 63 21 to 75 –
Fu [13] 2012 China 61 – –
Yu et al. [14] 2016 China 20 42.6 ± 4.6 4 to 48 h
Edston et al. [15] 1995 Sweden 56 59 ± 13 –
Edston et al. [16] 2006 Sweden 44 – 44 ± 17 h
Horn et al. [17] 2004 USA 44 – 1 to 126 h
Mayer et al. [8] 2011 Austria 58 67.6 ± 16.8 –
Wang et al. [18] 2015 China 35 – 72 h
Forensic Sci Med Pathol

Table 2 Assessment of study quality Exclusion criteria

Study Quality indicators from the Newcastle-Ottawa scale Score
The exclusion criteria were as follows: 1) non-controlled stud-
Selection Comparable Outcome assessment ies; 2) studies without sufficient data to pool the WMD; 3)
studies not focusing on the role of tryptase in different causes
1 2 3 4 5 6 7 8 9
of death; 4) death merge for multiple reasons.
Guo2015 * * * * * * * 7
Wu2012 * * * * * * * 7
Fu2012 * * * * * * * 7 Data abstraction and quality assessment
Yu2016 * * * * * * * 7
Edston1995 * * * * * * * 7
Edston2006 * * * * * * * 7 Two investigators independently fully reviewed all the manu-
Horn2004 * * * * * * * 7 scripts. The following data was extracted: first name of the
Mayer2011 * * * * * * * 7
Wang2015 * * * * * * * 7 author, publication year, country of the study, sample size,
standard deviation, and mean value of tryptase. Similar data
was consolidated using statistical methods. The Newcastle-
Ottawa Quality Assessment Scale (NOS) was applied to as-
sess the quality of each included study [11], and NOS scores
studies in original articles up to the date of March 1st, 2017. ≥6 were considered to represent high-quality studies. Any
The search strategy was conducted with a combination of the discrepancy was discussed with a third investigator.
following terms: “anaphylactic shock AND tryptase AND
control”, “anaphylaxis AND tryptase AND control”, “anaphy-
lactic reaction AND tryptase AND control” respectively. To Statistical analysis
avoid missing studies, the search terms were kept intentionally
broad. Articles appearing in more than one search were con- Pooled analyses were carried out by Review Manager
sidered at once. Irrelevant articles were directly excluded by Version 5.3 software. The diagnosis outcomes were ex-
scanning the titles or abstracts. We also examined reference plored using the WMD and the corresponding 95% CI.
lists of selected fields for each original article that may fulfill Heterogeneity was assessed across all studies by Cochran’s
our eligibility requirements in order to avoid missing relevant Q test and Higgins I2. Heterogeneity was significant when
studies. The remaining articles were then reviewed compre- p < 0.05 and/or I2 > 50%, and the random- effect model was
hensively by reading the full text. Details are shown in Fig. 1. used; if not, the fixed-effect model was applied. In addition,
a funnel plot was conducted to evaluate bias by the Review
Manager Version 5.3 software. Sensitivity analysis was per-
Inclusion criteria formed to evaluate the effect of each study on the combined
WMDs by deleting each study each time, and to evaluate
Studies meeting all the following criteria were included: 1) the effect of studies with low quality on the pooled WMDs
retrospective control studies; 2) paid attention to the role of by deleting these studies. All the p was two-sided and
tryptase in AS; 3) provided mean, standard deviation and p < 0.05 was considered statistically significant. Based on
enough data to get the Weighted Mean Difference (WMD) the mean value and the number of cases, a receiver operat-
for diagnosis outcomes, along with their 95% confidence in- ing characteristic curve (ROC) was plotted by SPSS22.0 to
tervals (CIs) or p values. speculate on the cut-off value of tryptase concentration.

Fig. 2 Forest plots of tryptase levels in different causes of death. (AS ∖ N)


Fig. 3 Forest plots of tryptase levels in different causes of death. (CVD ∖ N)
Results
Literature search
A total of 48 papers were identified, of which four dupli-
cate papers were excluded. Of the remaining 44 papers,
five were excluded by scanning either the titles or ab-
stracts. For the 39 remaining potentially related studies,
the full-text was carefully read. Eighteen were excluded
for insufficient data to assess the WMD of diagnosis out-
comes, and 12 were excluded for not focusing on the role
of tryptase in AS. Finally, nine studies involving 296 pa-
tients, were eligible for this meta-analysis (Fig. 1).
Characteristics of included studies
The detailed characteristics of the nine included studies are
shown in Table 1 (Guo [12], Wu [13], Fu [14], Yu et al.
[15], Edston et al. [16], Edston et al. [17], Horn et al. [18],
Mayer et al. [8],Wang et al. [19]). The patients came from four
different countries, China, Sweden, America and Austria.
Their ages ranged from 1 to 70. Meanwhile, the postmortem
interval (PMI) varied between hours and days. In addition, the
sample sizes were different, varying from 35 patients to 63
patients. As for assessment of included studies, the NOS of all
included studies was 7 (Table 2). Seven studies focused on the
comparison between AS and the other causes of death. In
subgroups, seven studies focused on the comparison between
cardiovascular disease death and the other causes of death and
five studies involved the comparison between AS and cardio-
vascular disease (Figs. 2, 3 and 4).
Fig. 4 Forest plots of tryptase levels in different causes of death. (AS ∖ CVD
Forensic Sci Med Pathol
Meta-analysis
Deaths due to AS showed higher concentrations of serum
tryptase than other deaths (WMD = 29.53, 95% CI = 7.58–
51.47, p = 0.008; I2 = 100%, p < 0.00001) (Fig. 2) (Table 3).
No evident difference of serum tryptase concentrations was
observed between CVD and other groups except for AS
(WMD = 4.42, 95% CI = −0.94 − 9.79, p = 0.11; I2 = 96%,
p < 0.00001) (Fig. 3) (Table 3).
The AS group had higher concentrations of tryptase than
the CVD group (WMD = 25.35, 95% CI = 1.75–48.96, p =
0.04; I2 = 99%, p < 0.00001) (Fig. 4) (Table 3).
Receiver operating characteristic
As is shown in Table 4, using the SPSS22.0 software for data
analysis, we can conclude the cutoff value of tryptase is
30.4 μg/L (Fig. 5). The specificity and sensitivity of tryptase
in the diagnosis of allergic reactions were calculated based on
the levels of tryptase in the serum of the AS and other cause of
death groups. The area under the curve is 0.797 and the con-
fidence interval is 0.730–0.863, suggesting that serum
tryptase is a reliable indicator and can be used in the postmor-
tem diagnosis of lethal anaphylaxis.
Discussion
Anaphylaxis is categorized as a type I hypersensitivity,
which is a serious allergic reaction that is rapid in onset
and may cause death [1, 20]. The common causes of
Forensic Sci Med Pathol

Table 3 The main results of

subgroup analysis Terms Included studies WMD 95% CI p I2 p value
for heterogeneity

AS \ N 7 29.53 [7.58, 51.47] 0.008 100% < 0.00001

AS\ CVD 5 25.35 [1.75, 48.96] 0.04 99% < 0.00001
CVD\N 7 4.42 [−0.94, 9.79] 0.11 96% < 0.00001

Abbreviations: AS anaphylactic shock, CVD cardiovascular disease, N not AS

AS include insect bites and stings, foods, and medica- practical for analysis compared to IgE and histamine.
tions. In severe cases, it can cause anaphylactic shock, As early as 1991, tryptase was applied to forensic pa-
sometimes even causing death. Although anaphylaxis thology body examination [22]. It has also been report-
typically causes many symptoms, morphologic changes ed that serum tryptase levels are an effective indicator
are nonspecific, if present at all, making it difficult to of preclinical allergic reactions [23]. After that, some
identify at autopsy. Therefore, determination of certain other scholars also confirmed this view in their own
blood indicators for AS has been the focus of investi- studies [8]. However, at the same time, some studies
gations over the past decade. reported that in non-allergic shock deaths tryptase also
Mast cells have been the main cells investigated in increased, especially in cases of cardiovascular disease
the study of allergic reactions. The test indicators of [9]. Subject to the limitations of their own research
lethal anaphylaxis in the laboratory are mainly centered samples, the results are controversial. In view of the
around several markers from mast cell degranulation inconsistent results of previous studies and the small
[21]. Among these markers, serum tryptase, which is amount of single study samples, we conducted this
the most abundant neutral protein in mast cell granules, meta-analysis to try to arrive at a comprehensive
is becoming a research hotspot. The half-life of tryptase conclusion.
is longer than other markers (about 2 h), which is more Meta-analysis is a method of systematic analysis and
quantitative synthesis of multiple independent research
results with the same research purpose. It aims to im-
prove the effectiveness of statistical tests, and to evalu-
Table 4 Coordinates of the curve ate the inconsistency and contradiction of the research
results to find the deficiency of a single research study.
Test result variable(s): 41.57
The method is not limited by the number of studies and
Positive if greater than Sensitivity 1 - Specificity plays an important role in clinical diagnosis, treatment,
or equal toa risk assessment, prevention interventions, health services
and decision-making [24]. The advantage of this study
1.890000 1.000 1.000 is that the combination of multiple small sample studies
3.005000 1.000 .823 provides a quantitative average effect, making the con-
3.753300 1.000 .783 fidence interval more convergent, and thus the conclu-
4.893300 .793 .783 sion more comprehensive and reliable.
8.020000 .793 .703 In our study, we systematically reviewed and meta-
11.342000 .793 .542 analyzed nine eligible studies involving 296 patients
12.697000 .793 .382 from different sources that focused on the role of serum
18.775000 .685 .382 tryptase in determining deaths due to AS. All the arti-
30.438750 .685 .161 cles met the high criteria of NOS quality evaluation and
39.123750 .685 .000 all of them achieved scores of 7. The results from these
42.535000 .467 .000 studies were heterogeneous, so we used a random effect
84.466500 .304 .000 model accordingly and created subgroups. Some impor-
139.616500 .076 .000 tant and consistent differences in tryptase concentrations
271.250000 .033 .000 between groups of AS death and other causes of death
389.700000 .000 .000 were found (WMD = 29.53, 95% CI = 7.58–51.47, p =
a
0.008). At the same time, we plotted a ROC curve
The smallest cutoff value is the minimum observed test value minus 1,
and the largest cutoff value is the maximum observed test value plus 1.
and calculated the cutoff value based on the obtained
All the other cutoff values are the averages of two consecutive ordered data. The sensitivity and specificity for serum tryptase
observed test values. were 0.797 and 0.730–0.863 at a cutoff value of

Fig. 5 ROC curve
30.4 μg/L in distinguishing AS and other groups, in-
cluding CVD. This serum concentration of tryptase is
three times higher than the previously reported tryptase
concentration (10 μg/L) to diagnose death due to AS
[25]. However, in subgroup analysis, which is inconsis-
tent with Randall’s study, we found no significant ele-
vation of tryptase in deaths due to CVD compared to
the other cause of death (WMD = 4.42, 95% CI = −0.94
− 9.79, p = 0.11). At the same time, when we solely
compared the serum tryptase concentrations of the AS
group and CVD groups, it was also found that the for-
mer had significantly higher tryptase concentrations
(WMD = 25.35, 95% CI = 1.75–48.96, p = 0.04). The
main reason for this result is that the weight of a single
study decreases after a large number of results are
integrated.
With more high quality studies and an enlarged sample
size, our study provides a valid reference for future foren-
sic identification. The detection of serum tryptase concen-
tration and content is of great significance for the forensic
diagnosis of AS. The major limitation of this study is that
although we performed subgroup analysis, the heterogene-
ity is still obvious. It is difficult to explore the sources of
heterogeneity, because the quantity of documents is not
enough. Therefore, the results should be carefully used
in forensic practice. We expect more high quality research
to be conducted in the future.
Forensic Sci Med Pathol
ROC curve
Conclusions
Our data demonstrated that high serum tryptase is a reliable
indicator that can be used in the postmortem diagnosis of
lethal anaphylaxis, especially when concentrations are higher
than 30.4 μg/L.
Key points
1. A retrospective study with a systematic review and meta-
analysis was made to summarize the diagnostic significance
of postmortem serum tryptase in the deceased with and
without anaphylactic shock.
2. A complete literature search in the PubMed, Cochrane
Library, CNKI and Embase databases (published prior
to March 1st, 2017) was performed, which resulted in
us including a total of nine studies with 296 patients in
our research.
3. High serum tryptase is a promising diagnostic biomarker
for deaths due to anaphylactic shock, especially when it is
higher than 30.4 μg/L.
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
Forensic Sci Med Pathol
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).
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