Download Allergy/Respiratory cases

Dr Basil Nasrallah
MD,FAAP,MRCPCH,CCT
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Why allergy diseases are on rise
Discuss different types of allergies, IgE and
non IgE mediated allergies
Discuss different phenotypes of Asthma and
how they present
Update on asthma management
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Globally 250-300 millions have an allergy
Food allergies are estimated to affect 4-6% of
children and 2-4% of adults
Quality of life scores worse than Type 1 DM
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39% longer to shop
Significantly greater expense
Risk of compromised nutrition
Risk of fatal reaction
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Avery NJ, Assessment of quality of life in children with peanut allergy. Ped All Immunol 2003;14:378-82.
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Fox AT et al. Food Allergy as a risk factor for Nutritional Rickets. Ped All Immunol 2004 Dec;15 (6):566-
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Bock SA et al Fatalities due to anaphylactic reactions to food. J Allergy Clin Immunol. 2001;107(1):191-3.
9.
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Allergy and Asthma on rise every day
"hygiene hypothesis
 individuals living on farms develop fewer allergic
diseases
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Antibiotics and Acetaminophen
Caesarian sections
Obesity and Asthma
Vitamin D Deficiency
Food allergy the start of the
"Atopic March"
As t h ma
Allergic
Rhinitis
Atopic
eczem
a
Food
allergy
Food IgE
Risk
factors
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2 years old boy – previously well other than
some mild eczema
At a birthday party he developed:
• facial swelling
• itchy eyes
• cough
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IgE mediated food allergy
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Infection related angioedema
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Allergic conjunctivitis
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Nephrotic syndrome
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Refer for peanut immunotherapy to
desensitise child
Refer to dietician to advise peanut avoidance
Provide antihistamine/adrenaline injector
with training
Order skin prick or blood specific IgE tests to
confirm cause of reaction and screen for
other food allergies
Arrange IgG blood tests to exclude coexistent
food intolerances
Pediatrics 2007;120:1304-1310
5 months Fully breast fed
Urticaria within 5 minutes of
eating 1 teaspoon of egg
pasta with cheese sauce
Good history of allergic
Reaction
? But what to????
Cow’s milk
?Fine with formula milk
Egg
Vomited previously following taste of
scrambled
Wheat
Never had wheat
Cow’s
Milk
Skin prick
test
(mm)
0
Egg
Wheat
7
4
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Cow’s milk - Allergy excluded
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Egg – confirmed allergy
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Wheat - ? Equivocal , needs OFC
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Exclusively breast fed 4 month old infant
First child of healthy parents
Since 2-3 weeks age dry red skin
Irritable child – unsettled - parents distressed
Watery stools 8-10 times per day
Poor weight gain
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5-15%
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15-35%
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35-55%
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55-75%
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Cow’s Milk
Egg
Peanut
Wheat
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Topical corticosteroids/protopic/emollients
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Topical treatment + maternal exclusion diet
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Topical Rx + amino acid formula + stop
breast feeding
Investigation for failure to thrive
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J.S is exclusively breast-fed, gaining weight
and thriving.
At 5 months, ER , 2-3 episodes of vomiting
& diarrhea
viral gastroenteritis and discharged home
1 week later, severe repetitive attacks of
vomiting and diarrhea for the second time
◦ lethargic, pale and hypotensive.
◦ resuscitated with IV fluids and admitted to the
paediatric ward.
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Improved and was back to his normal self in
3 hrs
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Full septic, metabolic and toxicology screens
all were normal.
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Highest CRP was only 12.
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Received two days of Cefotaxime and
discharged home
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Detailed history revealed:
◦ J.S had baby rice mixed with cow’s milk 2-3 hours
prior to beginning of the symptoms.
◦ Cow & Gate 4m+ Pure Baby Rice with ingredients of
Baby-Grade Rice (99.999%); Thiamin (Vitamin B1)
(0.001%) according to the manufacture labeling.
◦ had vegetables and fruits before and tolerated
well.
◦ Other solids like cereals, chicken, fish, soya and
egg have not been tried yet.
◦ Skin prick testing (SPT) for cow’s milk, soya, wheat,
rice and egg all were negative.
◦ Serum food specific IgEs test for cow’s milk, soya,
wheat, rice and egg all came back as below lower
limit of detection ( <0.35 kU⁄ L).
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Based on the history, clinical presentation
and investigations, J.S was diagnosed to have:
food protein-induced enterocolitis syndrome
(FPIES) triggered by cow’s milk and rice.
His mother was advised to avoid all dairy
products and rice.
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Food protein-induced enterocolitis syndrome
(FPIES) is a non-(IgE) mediated hypersensitivity
that manifests as profuse, repetitive vomiting,
often with diarrhea
The diagnosis of FPIES is based upon the history,
clinical symptoms, if necessary, oral food
challenge (OFC)
no laboratory and radiographic findings specific
to FPIES. e
Resolution by age three years in 67 percent for
vegetables, 66 percent for oat, and 40 percent
for rice.
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5 months old baby with difficulty breathing
and refusing to feed
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Diagnosis ?
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Management?
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4 years old boy presented to ER with 1st
sudden attack of cough and SOB
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Diagnosis?
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2 years old girl presented to ER with 3rd
attack of cough, SOB in the last 4 months
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Diagnosis ?
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Viral respiratory infections, (RSV) and human
rhinovirus (HRV), are the most common
causes of wheezing in infants and young
children
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Risk factors associated with recurrent
wheezing
◦ parental history of asthma, maternal smoking
during pregnancy, patient history of
bronchopneumonia, daycare attendance, and early
exposure to pets
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Features in the history that favor the
diagnosis of asthma include:
◦ Intermittent episodes of wheezing, common trigger
(ie, upper respiratory infections, weather changes,
exercise, or allergens)
◦ Seasonal variation
◦ Family history of asthma and/or atopy
◦ Good response to asthma medications
◦ Positive asthma predictive index
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The 2007 National Heart, Lung and Blood
Institute (NHLBI) Guidelines for the Diagnosis
and Management of Asthma describes the
Asthma Predictive Index (API), a guide to
determining which small children will likely
have asthma in later years.
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Episodic therapy
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Inhaled short-acting beta2-agonists / in favor
Inhaled hypertonic saline / not
Inhaled glucocorticoids / not
Systemic steroids / not
Intermittent leukotriene-receptor antagonists / not
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Intermittent high-dose inhaled
glucocorticoids , started at the onset of a URI
and continued for up to 10 days.
Intermittent use of standard (low to medium)
doses of inhaled glucocorticoids does not
appear to be effective
Standard daily doses of inhaled
glucocorticoids or daily montelukast / mixed
results
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The optimal management for acute episodes
of virus-induced wheezing in infants and
preschool children has yet to be determined,
in part because of the heterogeneity of
wheezing phenotypes.
The specific therapy for each patient needs to
be individualized based upon the severity of
symptoms and prior responses to available
treatments.
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Shields MD, Bush A, Everard ML, et al. BTS guidelines:
Recommendations for the assessment and management of
cough in children. Thorax 2008; 63 Suppl 3:iii1.
Chang AB, Van Asperen PP, Glasgow N, et al. Children with
chronic cough: when is watchful waiting appropriate?
development of likelihood ratios for assessing children
with chronic cough. Chest 2015; 147:745.
Anderson SD, Brannan JD. Methods for "indirect" challenge
tests including exercise, eucapnic voluntary hyperpnea,
and hypertonic aerosols. Clin Rev Allergy Immunol 2003;
24:27.
Chang AB, Redding GJ, Everard ML. Chronic wet cough:
Protracted bronchitis, chronic suppurative lung disease
and bronchiectasis. Pediatr Pulmonol 2008; 43:519.