ACAAI Review Book Ch 5: Hypersensitivity Disorders Flashcards
All but which of the following is associated with a decrease in the risk of allergen sensitization and clinical allergy:
A. rural upbringing with exposure to farm animals
B. not attending daycare
C. increased number of siblings and family size
D. exposure to household pets
E. increased grass pollen count
B. not attending daycare- FALSE
Which of the following is not correctly matched with its mediator and acute symptoms in the immediate allergic response?
A. PGD2: nasal congestion
B. Leukotrienes: itch, sneeze, rhinorrhea
C. Histamine: itch, sneeze, rhinorrhea
D. Kinins: : nasal congestion and/or blockage
B. Leukotrienes: itch, sneeze, rhinorrhea
cause nasal congestion
All but which of the following are preformed mediator in mast cells in the immediate allergic response?
A. histamine
B. Proteases (tryptase)
C. kinins (kallidin and bradykinin)
D. GM-CSF
D. GM-CSF (and eosinophil growth factor)
part of late phase, released by nasal mucosal epithelial cells with SCF (mast cell growth factor), and eotaxin –> sx: nasal congestion and mucous production
All but which of the following are newly formed mediators in mast cells in the immediate allergic response?
A. histamine B. PGD2 C. LTC4 D. LTD4 E. LTE4
A. histamine
difference b/w mast cells and basos: basos do NOT produce- PGD2 LTB4 (little) tryptase chymase heparin carboxypeptidase
What are the two signals that induce IgE production?
1) Th2 lymphocyte secrete IL-4 and IL-13
2) CD40-CD40L B and T cell interaction
What is the mechanism of H1 antihistamines?
inverse agonists, downregulate H1 receptor constitutive activity
All but which of the following are side effects from first generation antihistamine receptor activity?
A. H1 receptor- sedation
B. Beta adrenergic receptor- bronchodilation
C. Alpha adrenergic receptor- hypotension, dizziness, reflex tachycardia
D. 5-HT receptor- increased appetite
E. Muscarinic acetylcholine receptor- dry mouth, urinary retention
B. Beta adrenergic receptor- bronchodilation
all but which of the following is true about allergen immunotherapy?
A. it decreases the risk of new sensitizations
B. it improves atopic dermatitis
C. it helps decrease the risk of developing asthma in children
D. it improves allergic rhinitis symptoms
E. it improves pulmonary function testing
E. it improves pulmonary function testing
see table 5-1 for summary of ddx NAR
see pages 133-135 for different types of rhinitis
INCS are not effective in what type of rhinitis?
pregnancy
What do you check in a patient with unilateral unexplained rhinorrhea s/p trauma?
Beta2-transferrin for CSF leak
What medications can worsen rhinitis?
Beta blockers, other antiHTN, sildenafil and other phosphodiesterases, OCPs, ACE-I, ASA and NSAIDs in AERD
An 18 yo male with history of atopic dermatitis living in Arizona presents with bilateral eye inflammation, severe photophobia, intense ocular itching, papillary hypertrophy, cobblestone papillae, thick ropy discharge, and white spots around his limbi. What is the most appropriate treatment?
A. allergen avoidance and high dose pulse topical corticosteroids
B. allergen avoidance and transient topical corticosteroids
C. allergen immunotherapy
D. reducing contact lens wearing and using artificial tears
A. allergen avoidance and high dose pulse topical corticosteroids
Vernal keratoconjunctivitis
- M>F
- 3-20 yo
- young atopic males, seasonally (Spring)
- warm dry climates
see pictures of papillary hypertrophy, cobblestone papillae, thick ropy discharge, and white spots around his limbi
A 35 yo female with history of atopic dermatitis and asthma presents with ocular pruritis, dry sensation, some photophobia and blurred visions, that seems to worsen during an AD flare. Loss of vision can result if this condition progresses to all but which of the following?
A. superficial punctate keratitis B. corneal infiltrates C. papillary hypertrophy D. keratoconus and scarring E. anterior subcapsular cataracts
C. papillary hypertrophy - this is seen in VC and GPC
Dx- atopic keratoconjunctivitis
- 20-50yos
- atopic hx
A 35 yo female with history of atopic dermatitis and asthma presents with ocular pruritis, dry sensation, some photophobia and blurred visions, that seems to worsen during an AD flare. What is the most appropriate treatment?
A. allergen avoidance and high dose pulse topical corticosteroids
B. allergen avoidance and transient topical corticosteroids
C. allergen immunotherapy
D. reducing contact lens wearing and using artificial tears
B. allergen avoidance and transient topical corticosteroids
A 45 yo female presents with ocular itching, morning ocular mucous, photophobia and blurred vision, foreign body sensation, and wears contact lenses. What is the most appropriate treatment?
A. allergen avoidance and high dose pulse topical corticosteroids
B. allergen avoidance and transient topical corticosteroids
C. allergen immunotherapy
D. reducing contact lens wearing and using artificial tears
D. reducing contact lens wearing and using artificial tears
Giant Papillary conjunctivitis
All but which of the following are true about atopic dermatitis?
A. high levels of FcERI-expressing IgE+ Langerhans cells
B. IgG to Staphylococcus aureus toxins
C. two distinct Ag-presenting DCs- Langerhans cells and IDECs (inflammatory dendritic epidermal cells)
D. decrease in antimicrobial peptides, human beta defensins (hBD-2, hBD-3), and human cathelicidin (LL-37)
E. acute associated with cytokines IL-4, IL-13
F. chronic associated with IL-5, IL-12, IFNy
B. IgG to Staphylococcus aureus toxins- its IgE!!! specific IgE antibodies against the toxins on their skin, levels correlate with disease severity
acute associated with cytokines IL-4, IL-13
“4 suits with 13 cards each, including Aces”
chronic associated with IL-5, IL-12, IFNy
“Education is chronic starting at 5 through Grade 12”
The FcERI-expressing IgE+ Langerhans cells lack what?
classic beta chain
contain Birbeck granules
All but which of the following can be associated with dermatitis?
A. XLP B. WAS C. SCID D. HIES E. IPEX F. Dock8 deficiency
A. XLP
see table 5-7 pg 149
All but which of the following are genetic factors contributing to the development of asthma?
A. chromosome 5q B. B2-adrenergic receptor C. CD14 D. Chromosome 20p13 E. ADAM33 F. filaggrin
F. filaggrin
see page 151
All but which of the following are risk factors contributing to the development of asthma?
A. female age <16 yo
B. female age >16 yo
C. atopy
D. exposure to viruses (rhino, RSV) during infancy in susceptible individuals
A. female age <16 yo
more common in males <16 yo
All but which of the following are environmental factors contributing to the development of asthma?
A. early life exposure to dogs or farm animals
B. sensitization to Alternaria by 6 yo a/w persistent asthma by 11 yo
C. higher levels of dust mites a/w wheezing and airway hyperresponsiveness in older children
D. higher production of IL-5 and IL-13 in lower socioeconomic status
A. early life exposure to dogs or farm animals-
protective effect on development of allergy, but not asthma (hygeine hypothesis suggets early exposure decreases risk of atopy overall)
pollen IT in childhood for AR can reduce risk of asthma development
All but which of the following are supportive criteria to diagnose asthma?
A. methacholine challenge- PC20 <4 mg/ml
B. PEF increase >20% after bronchodilator
C. improvement of 12% or greater in FVC or FEV1 after bronchodilator
D. clinical history
C. improvement of 12% or greater in FVC AND!!! FEV1 after bronchodilator (also FEF25-75 in kids)
True or false: a child with frequent wheezing and h/o parental asthma is likely to have asthma during school years
TRUE
2/3 with frequent wheezing and + API (asthma predictive index) is likely to have asthma during school years
\+ API = parental asthma MD dx AD aeroallergen sensitization 2: food sensitization, >4% eos, wheezing w/o URI
A child <4 yo can be initiated on long term control therapy for all but which of the following scenarios?
A. during periods or seasons of previously documented risk
B. oral steroids required twice in 6 months
C. family h/o asthma
D. requiring symptomatic treatment >2 days/week >4 weeks
E. at least 4 episodes of wheezing in the last year, > 1 day, affected sleep, + API
C. family h/o asthma
A patient with history of shortness of breath 10 minutes into exercise which resolves after he stops exercising can be diagnosed with EIB with which of the following criteria?
A. FEV1 decrease >12% after exercise challenge test
B. appropriate bronchodilator response
B. appropriate bronchodilator response
- FEV1 decrease >15%!!! after exercise challenge test
Uncontrolled asthma in pregnancy is associated with increased risk of all but which of the following?
A. perinatal mortality B. preeclampsia C. gestational diabetes D. preterm birth E. likelihood of low birth weight infant
C. gestational diabetes
see pages 155-159 for NHLBI guidelines for assessing asthma severity and control
table 5-10
Table 5-18 page 162 Class 1 allergens
review main allergen names
All of the following except which are factors associated with an increased risk for fatal anaphylactic reaction?
A. delayed epinephrine administration B. young adult or teen C. underlying asthma D. underlying allergic rhinitis E. absence of skin symptoms
D. underlying allergic rhinitis
What are the allergen names of cross reactive birch with apple or peach?
Bet v 1 and Mal d 1
What are the allergen names of cross reactive birch with latex?
Bet v 1 and Heb v 6
Latex allergy sensitive patients can cross react to all of the following fruits except:
A. apple B. banana C. avocado D. chestnut E. kiwi
A. apple
acronym BACK (banana, avocado, chestnut, kiwi)
The carbohydrate found as part of glycoproteins in mammalian meat and the chemotherapeutic monoclonal antibody cetuximab is?
Galactose-alpha-1-3-galactose
In a patient presenting with gluten sensitivity, abdominal pain, bloating, and vesicular pruritic eruption in an acral distribution of arms and legs, all of the following labs should be checked except:
A. IgE antibodies to wheat
B. IgA-antigliadin antibodies
C. IgA-tissue transglutaminase antibodies
D. total IgA
A. IgE antibodies to wheat
Which of the following components if elevated on testing indicate a higher likelihood of systemic reaction?
A. Ara h 1 B. Ara h 2 C. Ara h 3 D. Ara h 8 E. Ara h 9
B. Ara h 2
Which of the following components if elevated on testing indicate a higher likelihood of oral reaction?
A. Ara h 1 B. Ara h 2 C. Ara h 3 D. Ara h 8 E. Ara h 9
D. Ara h 8
Approximately 85% of IgE mediated food allergies are expected to remit by 5 years of age to all but which of the following foods?
A. soy B. milk C. egg D. shrimp E. wheat
D. shrimp
Most IgE mediated food allergies are expected to persist into adulthood in all but which of the following foods?
A. peanut B. tree nut C. egg D. fish E. shellfish
C. egg
20% outgrow peanut allergy
9% outgrow tree nut allergy
TBD on fish? book said only seafood
the LEAP trial demonstrated that early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk for peanut allergy, as determined by the following risk factors except?
A. severe eczema
B. egg allergy
C. family history of atopy
D. both egg allergy and severe eczema
C. family history of atopy
4-11 month old
6g peanut protein per week
86% primary prevention in SPT 0mm
70% relative reduction in SPT 1-4mm
The following are all risk factors for anaphylaxis except:
A. IV versus IM versus oral administration of allergen
B. child or adolecent versus adult age
C. females <15 yo, males >15 yo
D. atopy in relation to idiopathic anaphylaxis, exercise-induced anaphylaxis, radiocontrast material, and latex-induced reactions
C. females <15 yo, males >15 yo
MC in MALES <15 yo, then females after
atopy NOT in relation to medications or hymenoptera
The following are all risk factors for anaphylaxis except:
A. intermittent administration B. longer length of administration C. shorter time since reaction D. living in the southern part of the US vs northern E. higher socioeconomic status
E. higher socioeconomic status
higher SES a/w more frequent epi Rx
IL-4 and IL-13 play an important role in the initial responses to anaphylaxis via activation of what transcription factor?
STAT6
Levels of the this correlate with the severity of anaphylaxis:
A. tryptase B. chymase C. PAF D. PAF acetylhydrolase E. histamine
C. PAF
PAF acetylhydrolase correlates INVERSELY
see table 5-22 page 169 for mediators involved in anaphylaxis
know mediator and pathophysiologic activity? table 5-23 diagnostic criteria for anaphylaxis, table 5-24 DDX ANA
Levels of the following cytokines correlate with hypotension during anaphylaxis:
A. Mast cell tryptase B. IL-6 C. PAF D. TNF-receptor I E. histamine F. C3a
C. PAF
equation for tryptase
total (pro-B + mature) /mature
>20 mastocytosis
<10 other cause
Distinguish cholinergic urticaria vs EI ANA?
passive warming - will cause cholinergic urticaria
When to check:
- serum histamine
- urinary histamine metabolites
- serum tryptase
- serum histamine 15-60 min
- urinary histamine metabolites up to 24 hrs
- serum tryptase 15 min-3 hrs
table 5-25 histamine receptors in anaphylaxis
perform SPT 4-6 weeks s/p episode due to refractory period of mast cells that can create false negatives
Oversulfated chondroitin sulfate is a contaminant in heparin that when it interacts with what causes an activation of the contact system that results in hypotension, abdominal pain, variable angioedema, and w/o urticaria or pruritis?
A. elevated C3a
B. elevated C4a
C. elevated C5a
D. elevated C5b
C. elevated C5a
adult dose epinephrine
1: 1000 (1:1K)
0. 2-0.5 mL every 5-15 minutes prn
pediatric dose epinephrine
0.01 mg/kg IM max dose 0.3 mg
A pretreatment regimen with prednisone 50 mg 13, 7, 1 hr prior and diphenhydramine 50 mg 1 hour prior, along with the use of low osmolar contrast, has been shown to lower the risk of anaphylaxis in all of the following conditions except:
A. radiocontrast
B. latex
C. cold
D. fluorescein-related
B. latex
All of the following have been shown to be risk factors for perioperative anaphylaxis except:
A. asthma B. male sex C. atopy D. multiple past surgeries E. mast cell disorders
B. male sex
FEMALES are more likely
perioperative anaphylaxis has a higher mortality rate than other forms of ANA likely 2/2 impaired early recognition, IV meds, surgical stress
Healthcare workers react most frequently to which latex protein allergens? Spina bifida patients?
Hev b 5, 6, 7
SB- 1, 3
All of the following are associated with food dependent exercise induced anaphylaxis except:
A. wheat B. crustaceans C. chicken D. grapes E. celery F. cephalopods G. potato F. tomato
G. potato
MC wheat and celery
Intradermal skin tests for evaluation of stinging insect allergy should not be performed beyond a maximum concentration of:
A. 0.001 ug/mL B. 1 ug/mL C. 0.01 ug/mL D. 0.1 ug/mL E. 10 ug/mL
B. 1 ug/mL
start at 0.001-0.01 and increase 10-fold until positive result or max concentration
A patient presents with history of sudden unexpected hives, trouble breathing, and facial swelling while playing sports outdoors 2 weeks ago. EMS was called and resolved with epinephrine. You perform intradermal skin testing to hymenoptera and imported fire ant which are all negative. What is the next best step in management?
A. perform in-vitro specific IgE testing now
B. perform in-vitro specific IgE testing in 1 week
C. repeat intradermal skin testing in 2-4 weeks
D. perform intradermal skin testing and in-vitro specific IgE testing in 2-4 weeks
E. perform intradermal skin testing and in-vitro specific IgE testing in 12 months
F. obtain a tryptase level
A. perform in-vitro specific IgE testing now
***review lecture about this or PP or ask DK
an abnormal result is associated with severe anaphylaxis to stings,
increased risk of systemic reactions during VIT (to a sting or venom
injection), and greater risk of sting anaphylaxis after stopping VIT.
With these considerations in mind, measurement of basal serum
tryptase is highly recommended in patients who had hypotensive
reactions to a sting and should be considered in other patients with
systemic reactions to stings. In addition, elevated basal tryptase
may indicate the presence of an occult mast cell disorder and also
may be present in sting allergic patients with negative venom allergy
test results.
A patient presents with history of pronounced erythema, edema, and tenderness over his lower leg that lasted 1 week while playing sports outdoors 2 weeks ago. EMS was called and resolved with epinephrine. What is the next best step in management?
A. perform intradermal skin testing to hymenoptera and imported fire ant
B. prescribe an epinephrine pen
C. perform in-vitro specific IgE testing to hymenoptera and imported fire ant
D. recommend use of ice, NSAIDs, and H1 antihistamines in the future for similar reactions
E. perform intradermal skin testing and in-vitro specific IgE testing to hymenoptera and imported fire ant
F. obtain a tryptase level
D. recommend use of ice, NSAIDs, and H1 antihistamines in the future for similar reactions
Immunotherapy with all of the following extracts uses venom rather than whole body extracts except:
A. Ves v 1 B. Api m 1 C. Pol a 1 D. Sol i 1 E. Api m 10
D. Sol i 1
IFA use WBE
IFA venom is 95% piperadine alkaloids
Venom immunotherapy is indicated for patients with a clinical history of reaction to insect sting and evidence of venom specific IgE with skin or serologic testing in which of the following reactions and age groups:
A. large local reaction <16 yo B. urticaria/angioedema <16 yo C. anaphylaxis at any age D. large local reaction >16 yo E. urticaria/angioedema >16 yo
C. anaphylaxis at any age
no longer VIT for adults w/ urticaria/angioedema unless high risk for repeat stings/comfort
What is the maintenance dose for single antigen venom immunotherapy without treatment failure?
A. 100 ug
B. 200 ug
C. 300 ug
D. 0.5 mL 1:10 - 1:200 wt/vol extract
A. 100 ug
What is the maintenance dose for mixed vespid venom immunotherapy?
A. 100 ug
B. 200 ug
C. 300 ug
D. 0.5 mL 1:10 - 1:200 wt/vol extract
C. 300 ug
What is the maintenance dose for single antigen venom immunotherapy with treatment failure?
A. 100 ug
B. 200 ug
C. 300 ug
D. 0.5 mL 1:10 - 1:200 wt/vol extract
B. 200 ug
What is the maintenance dose for imported fire ant extract immunotherapy?
A. 100 ug
B. 200 ug
C. 300 ug
D. 0.5 mL 1:10 - 1:200 wt/vol extract
D. 0.5 mL 1:10 - 1:200 wt/vol extract
WBE
given monthly
All of the following are indications for lifetime or indefinite continuation of venom immunotherapy except:
A. patients with systemic reaction to injection while on therapy
B. patients with very severe initial reaction
C. patients with severe systemic urticaria and angioedema
D. patients with systemic reaction to sting while on therapy
E. patients with honeybee allergy
C. patients with severe systemic urticaria and angioedema
What is the percent risk of future systemic reaction to insect sting in a patient with no prior history of reaction?
A. 60 B. 10 C. 40 D. 5-10 E. 20 F. 1-3
F. 1-3
What is the percent risk of future systemic reaction to insect sting in a patient with history of large local reaction?
A. 60 B. 10 C. 40 D. 5-10 E. 20 F. 1-3
D. 5-10
What is the percent risk of future systemic reaction to insect sting in a patient >16 yo with history of urticaria/angioedema reaction?
A. 60 B. 10 C. 40 D. 5-10 E. 20 F. 1-3
E. 20
What is the percent risk of future systemic reaction to insect sting in a patient >16 yo with history of anaphylaxis?
A. 60 B. 10 C. 40 D. 5-10 E. 20 F. 1-3
A. 60
What is the percent risk of future systemic reaction to insect sting in a patient <16 yo with history of anaphylaxis?
A. 60 B. 10 C. 40 D. 5-10 E. 20 F. 1-3
C. 40
What is the percent risk of future systemic reaction to insect sting in a patient <16 yo with history of urticaria/angioedema reaction?
A. 60 B. 10 C. 40 D. 5-10 E. 20 F. 1-3
B. 10
VIT safety during build up- how many have LLR? SR? require epi?
50%, 5-15%, <5%
VIT efficacy for preventing SR- single Ag 100 ug maintenance? mixed vespid 300 ug maintenance?
75-95%
95-100%
The allergens in biting insects are found where:
saliva
Cross reactivity of venoms:
- hornets & yellow jackets (vespids)
- Polistes wasps less so with other vespids or honeybee
- variable b/w bumblebee and honeybee
Thyroid autoantibodies are found in what percent of chronic idiopathic urticaria patients?
A. 5 B. <1 C. >20 D. 25 E. 50
C. >20
doesn’t necessarily correlate with abnormal thyroid function
A proposed mechanism for CAU is activation of mast cells and basophils by IgG autoantibodies to what?
- IgE or
- alpha subunit of high-affinity IgE receptor
C5a augments histamine release with IgG anti-alpha autoantibodies
see table 5-30 page 182 for types of physical urticarias
see handwritten flashcards for urticaria questions
80% CIU pts have IgE-anti-IL24 ab
Which of the following is associated with anti-C1q antibodies?
A. urticarial vasculitis
B. crypoyrin associated periodic syndromes
C. familial cold autoinflammatory syndrome
D. hypocomplementemic urticarial vasculitis
E. hereditary angioedema
D. hypocomplementemic urticarial vasculitis
urticaria >6mo + vasculitis
low C3, C4, C1q
elevated ESR
venulitis, arthralgias, mild GN, uveitis/episcleritis, abdominal pain, +/- positive C1q precipitin test result
see page 184 for more on UV and HUV. find pics in lectures?
A patient with occupational asthma would be expected to have preceding symptoms of rhinoconjunctivitis if their job was any of the following except:
A. lab worker, veterinarian B. nail salon worker, dental hygienist C. seafood handler D. baker E. textile worker F. pharmaceutical
B. nail salon worker, dental hygienist
- acrylates (LMW agent)
HMW agents cause occupational rhinitis:
A. lab worker, veterinarian- animal proteins (2 years to sensitize)
C. seafood handler- crab/lobster
D. baker- flour (wheat, soya dust) (takes >2 years to sensitize)
E. textile worker, baker- wheat, coffee, tobacco dust, psyllium, latex
F. pharmaceutical, baker- enzymes (amylase, lipase, pectinase)
A patient with occupational asthma would be not expected to have preceding symptoms of rhinoconjunctivitis if their job was any of the following except:
A. Western red cedar mill, carpenter, woodworker
B. Auto industry, spray painter, foam coater, insulator, roofer
C. welder, metal/chemical worker
D. Hairdresser
E. veterinarian
E. veterinarian - HMW
LMW agents NOT a/w occupational rhinitis:
A. Western red cedar mill, carpenter, woodworker- Plicatic acid (activates compliment)
B. Auto industry, spray painter, foam coater, insulator, roofer- Isocyanates
C. welder, metal/chemical worker- platinum salts, potassium dichromate
D. Hairdresser- ammonium persulfate
A patient with develops cough, shortness of breath, and nightime awakenings slowly over the course of 3 years since starting a new job, and symptoms do not occur outside the workplace. This would be the expected pattern if their job was any of the following except:
A. lab worker, veterinarian B. textile worker C. seafood handler D. baker E. Western red cedar mill, carpenter, woodworker F. pharmaceutical
E. Western red cedar mill, carpenter, woodworker
Latency period occurs more with HMW agents
A patient with develops cough, shortness of breath, and nightime awakenings shortly after inhaling chlorine gas, sealant, caustic combustion and smoke after starting a new job, and symptoms do not occur outside the workplace. This would be the expected pattern if their job was any of the following except:
A. pharmaceutical
B. Auto industry, spray painter, foam coater, insulator, roofer
C. welder, metal/chemical worker
D. Hairdresser
E. Western red cedar mill, carpenter, woodworker
A. pharmaceutical - HMW
RADS w/ LMW
Reactive airway dysfunction syndrome or Irritant Induced Asthma- occurs after single high level exposure of LMW antigens.
NO latency.
+ methacholine challenge
All of the following are risk factors for occupational asthma except:
A. history of atopy B. smoking C. some HLA class I antigens D. HLA DQB1*0505/0201/0301 E. Glutamine S-transferase (GSTM1) enzyme polymorphisms
C. some HLA class I antigens
some HLA class II antigens (DR3)
A. history of atopy - especially animal workers
B. smoking - especially platinum workers
D. HLA DQB1*0505/0201/0301- diisocyanates
E. Glutamine S-transferase (GSTM1) enzyme polymorphisms
diisocyanates can induce immunologic and non-immunologic mechanisms
A patient with develops cough, shortness of breath, and nightime awakenings after starting a new job, and symptoms do not occur outside the workplace. This following pattern on pulmonary function testing would indicate a diagnosis of occupational asthma:
A. one time testing with 12% decline in FEV1
B. similar peak flow readings while at home and at work
C. FEV1 reduction by 10% after exposure to suggested agent
D. negative methacholine challenge performed when the patient is symptomatic and at work
E. positive methacholine challenge performed when the patient is symptomatic and at work, but then negative challenge when repeated 2-4 weeks later after work avoidance
E. positive methacholine challenge performed when the patient is symptomatic and at work, but then negative challenge when repeated 2-4 weeks later after work avoidance
A. SERIAL testing with 12% decline in FEV1 at home and in the workplace
B. PEFR lower at work vs home, variability >20 consistent w/ OA
C. FEV1 reduction by 15-20% after exposure to suggested agent
D. negative methacholine challenge performed when the patient is symptomatic and at work EXCLUDES OA
see page 185&186 table
Which of the following patterns on pulmonary function testing would indicate a diagnosis of vocal cord dysfunction?
A. one time testing with 12% decline in FEV1
B. reduced FEV1/FVC ratio
C. reduced FEV1 and FVC with a preserved ratio and blunted inspiratory loop
D. reduced FEV1 and FVC with a preserved ratio and blunted expiratory loop
E. reversibility on PFTs
C. reduced FEV1 and FVC with a preserved ratio and blunted inspiratory loop
see pics in word doc
Which of the following would be consistent findings in a patient with an acute presentation of lung disease that occurs in the pulmonary parenchyma and is caused by an accumulation of activated T cells?
A. cough, dyspnea, weight loss, fatigue that has progressed from months to year, fibrotic lung, irreversible restrictive pattern on PFTs, ground glass opacities, emphysema, honeycombing, parenchymal micronodules on HRCT
B. productive cough, dyspnea, anorexia, weight loss, fatigue that has progressed from weeks to months, tachypnea, diffuse crackles, air trapping, mild fibrosis and parenchymal micronodules on HRCT
C. abrupt onset respiratory symptoms (hours) with nonproductive cough, fever, chills, malaise, tachypnea, diffuse crackles, normal HRCT or fleeting GGO, reduced or normal FEV1 and FVC
C. abrupt onset respiratory symptoms (hours) with nonproductive cough, fever, chills, malaise, tachypnea, diffuse crackles, normal HRCT or fleeting GGO, reduced or normal FEV1 and FVC
= ACUTE HP
Which of the following would be consistent findings in a patient with an subacute presentation of lung disease that occurs in the pulmonary parenchyma and is caused by an accumulation of activated T cells?
A. cough, dyspnea, weight loss, fatigue that has progressed from months to year, fibrotic lung, irreversible restrictive pattern on PFTs, ground glass opacities, emphysema, honeycombing, parenchymal micronodules on HRCT
B. productive cough, dyspnea, anorexia, weight loss, fatigue that has progressed from weeks to months, tachypnea, diffuse crackles, air trapping, mild fibrosis and parenchymal micronodules on HRCT
C. abrupt onset respiratory symptoms (hours) with nonproductive cough, fever, chills, malaise, tachypnea, diffuse crackles, normal HRCT or fleeting GGO, reduced or normal FEV1 and FVC
B. productive cough, dyspnea, anorexia, weight loss, fatigue that has progressed from weeks to months, tachypnea, diffuse crackles, air trapping, mild fibrosis and parenchymal micronodules on HRCT
= SUBACUTE HP
Which of the following would be consistent findings in a patient with a chronic presentation of lung disease that occurs in the pulmonary parenchyma and is caused by an accumulation of activated T cells?
A. cough, dyspnea, weight loss, fatigue that has progressed from months to year, fibrotic lung, irreversible restrictive pattern on PFTs, ground glass opacities, emphysema, honeycombing, parenchymal micronodules on HRCT
B. productive cough, dyspnea, anorexia, weight loss, fatigue that has progressed from weeks to months, tachypnea, diffuse crackles, air trapping, mild fibrosis and parenchymal micronodules on HRCT
C. abrupt onset respiratory symptoms (hours) with nonproductive cough, fever, chills, malaise, tachypnea, diffuse crackles, normal HRCT or fleeting GGO, reduced or normal FEV1 and FVC
A. cough, dyspnea, weight loss, fatigue that has progressed from months to year, fibrotic lung, irreversible restrictive pattern on PFTs, ground glass opacities, emphysema, honeycombing, parenchymal micronodules on HRCT
= CHRONIC HP
Dx criteria (not inclusive):
- low CD4/CD8 ratio <1
- BAL lymphocytosis >50%
- path w/ poorly formed noncaseating granulomas
- sx + serum precipitins, but doesnt have to be present
see page 189 table 5-36 for HP associations
COPY table and cover up second column and fill in blanks
True or false: cigarette smoking is associated with an increased risk of HP
FALSE
An adult patient with history of asthma presents with progressively worsening dyspnea, cough productive of dark sputum, fever, malaise. IgE total >1100 and eosinophils 1300. CT chest with abnormalities. what is the most appropriate treatment?
A. ICS
B. short burst of oral steroids
C. longer course and taper of oral steroids
D. longer course and taper of oral steroids and oral antifungal therapy
E. immunotherapy
D. longer course and taper of oral steroids and oral antifungal therapy
ABPA
- doubling of BL IgE level indicates flare
- see page 192 for other eosinophilic lung disorders. didnt make Qs about these
A 30 year old patient presents with shortness of breath, FEV1/FVC <70% on multiple sets of spirometry with post bronchodilator FEV1 60% predicted without reversibility, no history of smoking. What is the next best step in management?
A. check peripheral eosinophilia B. repeat PFTs C. methacholine challenge D. test for alpha-1-antitrypsin deficiency E. check total IgE
D. test for alpha-1-antitrypsin deficiency
pg 193
All of the following have been shown to prolong life in patients with COPD except:
A. supplemental oxygen use 24 hours a day
B. LABA use
C. smoking cessation
D. lung volume reduction surgery
B. LABA use
see page 195 for types of ILD
is this important? TBD
ILD PFTs:
- restriction
- LOW FEV1 and FVC, volumes, diffusion
- normal FEV1/FVC ratio
SX:
- exertional dyspnea, cough, BL fine crackles, reticulonodular opacities on CXR
Types:
- exposure- asbestos, silicosis, coal
- drug- chemo, abx, antiarrhythmics,, immunosuppressives
- systemic- CTD, sarcoid
- unknown- several
1) IPF- progressive, fibrotic, >60 yp, focal honeycombing, UIP usual interstitial pneumonitis heterogenous peripheral fibrosis, poor prognosis
2) NSIP- GGO, fibrosis, diffuse inflammation on bx, tx steroids & cytotoxics
3) COOP- acute dyspnea/cough not better w/ abx, air bronchograms like acute PNA, bx w/ small areas of organizing PNA looks like CTD, tx steroids & cytotoxics
Which of the following is the most common site for allergic contact dermatitis?
A. face B. eyelids C. hands D. trunk E. generalized F. feet
C. hands
- severe pruritis
- crescendo- + reactions worsen from read 1->3
- develop over 12-24 hours
What is the most prevalent form of contact hypersensitivity?
A. allergic
B. irritant
C. photocontact
D. contact urticaria
B. irritant
- stinging, less pruritic
- decresecendo- decrease in severity b/w readings
- reaction almost immediate
see page 198-202 for contact dermatitis. tables, descriptors
find some questions about this or make up more questions. skipped for now
see other deck for Qs on HAE
pages 203-206
All of the following are associated with pseudoallergic reactions due to activation of the MRGPRX2 receptor except:
A. vancomycin B. fluoroquinolones C. ecallantide D. NMBA E. icatibant
C. ecallantide
may occur with first exposure
What is the most common cause of serum sickness like reactions in children?
A. ceftriaxone B. cefazolin C. penicillin D. cefaclor E. ciprofloxacin
D. cefaclor
altered metabolism leads to toxic metabolites
Which of the following associated with immune-induced thrombocytopenia leads to immune complex formation with IgG?
A. vancomycin B. quinidine C. heparin D. propylthiouracil E. gold F. sulfonamides
C. heparin
IgG to heparin platelet factor 4 forms immune complex
Which of the following drugs associated with pulmonary drug hypersensitivity is causes symptoms of pleural effusion, pneumonitis, fibrosis?
A. nitrofurantoin
B. amiodarone
C. methotrexate
D. bleomycin
A. nitrofurantoin
Amiodarone- Pneumonitis, bronchioloitis obliterans , ARDS
Methotrexate- Acute granulomatous ILD
Chemotherapeutics- ILD from bleomycin , mitomycin C, busulfan , cyclophosphamide, nirosourea
AGEP lesional T cells secrete high amounts of what?
IL-8 (CXCL8)
Type 4d reaction
- Occurs < 48 hrs with aminopenicillins, <2 weeks for other drugs
- Characterized by fine pustules, fever, and neutrophilia
-Rash begins in intertriginous areas or face as edema and
erythema
- Nonfollicular sterile pustules develop afterwards
- Atypical target lesions, blisters and oral mucosal involvement uncommon but may be confused with SJS or TEN
Drug Reaction with and Eosinophilia and Systemic Symptoms (DRESS) is a type 4b reaction that has been associated with reactivation due to all of the following viruses except:
A. HHV-6 B. HIV C. HHV-7 D. EBV E. CMV
B. HIV
Drug specific TH2 cells
CD4+/CD8+
Drug Reaction with and Eosinophilia and Systemic Symptoms (DRESS) is a type 4b reaction that has been associated with all of the following except:
A. dapsone B. vancomycin C. anticonvulsants (carbemazepine, lamotrigine, phenytoin, phenobarbital) D. amlodipine and captopril E. acetaminophen
E. acetaminophen
- Rash - Exanthem, erythroderma , erythema multiforme , purpura,
purpura, SJS, TEN - Facial edema (~25%) is diffuse and may be mistaken for angioedema
- fever
- hypotension
- heme abnormalities- eosinophilia, cytopenias
- LAD (minocycline), liver (abacavir), renal (allopurinol)
All of the following are autoimmune complications which can occur up to 4 years later in patients who have experienced DRESS except:
A. SLE B. DM1 C. hepatitis D. glomerulonephritis E. RA F. thyroiditis G. hemolytic anemia
D. glomerulonephritis
Reaction occurs after 2 8 weeks of therapy
Symptoms may worsen after drug discontinued
Symptoms may last weeks to even months after drug discontinued
SJS and TEN are categorized as what type of reaction?
A. Type IVa
B. Type IVb
C. Type IVc
D. Type IVd
C. Type IVc
drug specific cytotoxic CD8+ T cells
Epidermal necrosis, separation of
epidermis, apoptotic keratinocytes,
subepidermal bullae
Onset 4 28 days following drug
- Aromatic anticonvulsants, allopurinol, sulfonamide antibiotics most common
What constitutes the multivalent skin test reagent PPL, Pre PEN?
Penicilloyl conjugated to polylysine
Penicillin major determinant
penicilloyl
Penicillin minor determinant
Penicilloate , penilloate , penicillin G (PCN G)
Which of the following is not a penicillin minor determinant?
A. Penicilloate
B. penicillin G (PCN
C. penicilloyl
D. penilloate
C. penicilloyl
Amoxicillin and ampicillin are associated with the development of a delayed maculopapular rash in about 5 10% of patients. What increases this risk to 100% in children?
EBV infection
There is generally low cross reactivity amongst beta lactams, except which combination?
A. penicillin and cephalosporins
B. penicillins and carbapenems
C. ceftazidime and aztreonam
D. penicillins and monobactams
C. ceftazidime and aztreonam
MCC perioperative ANA in US?
cefazolin
MCC perioperative ANA in non-US?
NMBA
What medications typically cause hypersensitivity reactions after completion of 7 treatment courses?
Platinum compounds (carboplatin, oxaliplatin > cisplatin)
Platinum compounds (carboplatin, oxaliplatin > cisplatin) typically cause hypersensitivity reactions after completion of how many treatment courses?
7
A patient develops ANA after completion of 7 treatment courses with a chemotherapeutic. is skin testing likely to be helpful?
yes. platins. Skin testing useful in patients with allergic reactions and identifies
patients at higher risk for reaction
Which chemotherapeutic medication typically causes anaphylactoid reactions that can be pretreated with systemic corticosteroids and antihistamines prevents most reactions?
Taxanes (paclitaxel, docetaxeldocetaxel)
excipients (e.g. CremophorCremophor-EL) may also cause
aparaginase (ANA and anaphylactoid)
true or false: Skin testing is the test of choice for evaluating potential local anesthetic allergy
Graded challenge test BEST
Skin tests are not adequate to diagnose
lidocaine allergy- false +
All of the following have been shown to be risk factors for hypersensitivity reactions to RCM except:
A. asthma B. male sex C. atopy D. severe cardiovascular disease E. previous reactions to RCM
B. male sex
FEMALE
All of the following are involved in the pathophysiology of AERD except:
A. increased urinary LTE 4
B. increased lipoxin generation & EP2 receptors
C. LTC 4 synthase expression in bronchial mucosa
D. increased cysLTR1 & cysLTR2 receptor
expression
E. increased response to inhaled LTD 4
F. increased LTE 4 and TXB 2 in BAL
B. increased lipoxin generation & EP2 receptors
DECREASED lipoxin & EP2
involves innate cytokines IL-33 and TSLP
All of the following are changes seen after an aspirin challenge in a patient with AERD except:
A. increased urinary LTE 4
B. increased histamine in serum and nasal secretions
C. increased tryptase in serum and nasal secretions
D. Inhibition of COX 1 & PGE 2 leading to decreased leukotrienes
D. Inhibition of COX 1 & PGE 2 leading to INCREASED leukotrienes
PGE 2 inhibits 5 lipoxygenase
Higher levels of uLTE4 & PGD2 (baseline and after ASA reactions) correlate with cutaneous/GI reactions, more bronchospasm and unsuccessful ASA desensitizations
after ASA desensitization:
After ASA desensitization
DECREASED uLTE4, BHR to LTE4, serum tryptase/histamine, nasal expression of cysLT1 receptor
A patient experiencing fever, rash, pulmonary edema, capillary leak
syndrome, GI sxs , coagulopathy, myalgias,
encephalopathy, and multiorgan failure after a rituximab infusion would be expected to have all of the following lab abnormalities except:
A. elevated LFTs B. elevated uric acid C. elevatedLDH D. decreased IL 6 E. increased TNF a
D. INCREASED IL 6
cytokine release syndrome
a/w biologics
A patient with pre existing antibodies to an
oligosaccharide, galactose a 1,3 galactose present on the Fab portion of of a medication would be expected to have a reaction to which medication?
Cetuximab (anti EGFR)
A patient develops tense blisters that mimic bullous pemphigoid within 24 hours to 15 days following administration of the offending drug. What is the disease and most likely offending drug?
Linear IgA bullous dermatosis
Vancomycin
Other medications: Captopril, furosemide, lithium, TMP/SMX
Which of the following genetic screens is indicated in a patient of southeast asian descent who you are planning to start on carbamazepime?
A. HLA-B*57:01 B. HLA-B*13:01 C. HLA-B*58:01 D. HLA-B*15:02 E. HLA-B*31:01
D. HLA-B*15:02 - SJS
A. HLA-B57:01- abacavir - SCREEN
B. HLA-B13:01 - dapsone- SE Asian
C. HLA-B58:01 - allopurinol- SE Asian, Japanese, European
E. HLA-B31:01 - N European and Asian
