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Allergy/ Immunology Board Review December 17, 2007 Overview of Topics Allergic Reactions Types 1-4 Systemic Anaphylaxis Stings Allergic Reactions to Foods, Contrast and Latex Serum Sickness Allergy Testing Therapy Medications Immunotherapy Physical Exam Findings Allergic and Vernal Conjunctivitis Allergic Reactions Types 1-4 Type 1 IgE Mediated Anaphylactic Reaction Examples: Allergic Rhinitis, Urticaria Type 2 Mediated by Antibodies Examples: Autoimmune Hemolytic Anemia, Rh and ABO Incompatibility Type 3 Immune Complex Examples: Serum Sickness, Immune Complex Mediated Renal Diseases Type 4 Delayed Hypersensitivity Examples: Poison Ivy, PPD Reactions Urticaria Well circumscribed, raised, palpable wheals that blanch with applied pressure Usually erythematous but may be pale or white with red halos Allergic Rhinitis Eosinophilic Inflammation of Nasal Mucosa Look for transverse nasal crease on physical exam Eosinophils will be present in nasal secretions Non-allergic rhinitis can be: Vasomotor rhinitis -presents with congestion, rhinnorhea and post nasal drainage unrelated to any trigger or infectious agent. Infectious rhinosinusitis -younger children worse in the winter Foreign body Allergic Rhinitis Medications Mild: Antihistamine prn or routine in season Moderate: Routine administration or Leukotriene Receptor Antagonist (LTRA) If poor response topical nasal steroid. If needed most of the year add immunotherapy. Severe: Topical nasal steroid, Immunotherapy, Antihistamine or LTRA, Rarely Brief oral Corticosteroid Systemic Anaphylaxis Due to widespread degranulation of mast cells after crosslinking of IgE on the mast cell surface. Rapid. Often after bee stings, food exposure, or drug administration. Severe Manifestations: Airway obstruction and hypotension Other signs: Urticaria, Angioedema Stings Treatment: Children younger than 16 with diffuse urticaria require epinephrine. Children >16 are treated as adults and require subcutaneous epi. Any child with a systemic reaction to a bee sting requires referral to an allergist. Any child with a life threatening reaction to a bee sting requires venom immunotherapy which is 98% effective in preventing future reactions. Food Allergy Immune Mediated Reactions IgE Mediated (Hypersensitivity)— Symptoms: Shortly after exposure Skin, Respiratory or GI manifestations Symptoms >2 hrs post exposure uncommon Food Allergy Anaphylaxis Severe systemic reaction not uncommon Asthmatics with peanut allergy are the highest risk group. Likeliest allergens: Infants and toddlers: Egg, Peanut, Milk Older kids: Peanut, Nut, Fish, Shellfish Therapy: Education—Avoidance Emergency Planning– Epi Pen and a plan Serum Sickness Circulating complexes of antibody and antigen Prior exposure not necessary Due to fairly persistent drug or hapten If severe steroids should suppress symptoms Classically associated with animal sera (diphtheria) Modern settings: Anti-venom for snake bites, Nonhumanized monoclonal antibodies Anaphylaxis Therapy Epinephrine is primary Antihistamines are secondary For severe event steroids may prevent late phase reaction. Angioedema Hereditary Angioedema: Autosomal Dominant Disorder characterized by the absence or abnormal function of the C1 Esterase Inhibitor which results in increased vascular permeability. Angioedema related to allergic reaction: Self limiting, episodic, commonly triggered by minor trauma. Allergic Reaction to Contrast Media Contrast reactions are not IgE mediated. They are an osmolality hypertonicity reaction that triggers degranulation of mast cells and basophils with release of mediators that then cause the reactions. Latex Allergy Significant problem in 80s 90s due to increased latex exposure with universal precautions. Pediatric high risk groups: Spina Bifida >40% Any child with repeated surgery early in life Common Indoor and Outdoor Allergens Indoor: Cat, Dog, Dust Mites, Cockroach, Molds Outdoor: Pollens, Molds Seasonality-Spring: Trees, Some Molds Summer: Grasses, Molds, Weeds Late Summer: Ragweed, Mold Skin Testing Useful to diagnose Type I Hypersensitivity Reactions In vivo method to detect the presence of IgE antibodies to specific allergens. Test interpreted by measuring the maximum diameter of the wheal and the flare and by comparison with control site. Contraindications: recent antihistamine use, skin disease in testing area, during asthma exacerbation or episode of anaphylaxis, if taking B blocker RAST RAST is done in vitro. Is not impacted by antihistamine treatment like skin testing No risk for anaphylactic reaction unlike skin testing Allergy Therapy Avoidance of Allergen Medication Allergen Immunotherapy Anti-IgE Prevention of Sensitization Allergy Medications Antihistamines 1st generation: sedation problems 2nd generation: preferred where sedation a problem Leukotriene receptor antagonists (LTRA) Similar efficacy to antihistamines Mast Cell Stabilizers Topical Corticosteroids Most effective, block more aspects of allergic inflammatory response Allergy Immunotherapy Proven benefit for allergic rhinitis Mixed studies with asthma Not indicated for atopic dermatitis Not indicated for food allergy Allergy-Physical Exam Eyes: Dennie-Morgan (infra-orbital pleats), Infra-orbital (allergic) shiners Nose: Boggy mucosa and airway impairment, Transverse nasal crease Throat/Mouth: Overbite, Lymphoid Cobblestoning of posterior pharyngeal wall Lungs: Wheezing Skin: Eczema Ocular Allergies My involve eyelid or conjunctiva Occur when exposed to triggering agent Allergic Conjunctivitis Allergic Conjunctivitis Acute or Chronic, Seasonal or Perennial Itching and Excessive tearing Physical Finding: Allergic Cobblestoning with fine granular appearance of the conjunctiva Vernal Conjunctivitis Uncommon and Chronic Mostly in young atopic boys Symptoms: Severe itching, photophobia, blurring of vision, and tearing Physical Exam Finding: White, Ropy secretions that contain many eosinophils, may see hypertrophic nodular papillae that resembles cobblestones usually on the upper eyelid. May be due to build up on foreign objects being placed in the eyes such as contacts for long durations with chronic exposure