Allergo-Immuno-Derma Flashcards
Atopy is not a risk factor for anaphylaxis from ____ and ____
drug reactions or hymenoptera stings
Atopy is not generally thought to be a risk factor for anaphylaxis from drug reactions or Hymenoptera stings, but it is associated with radiocontrast sensitivity, exercise-induced anaphylaxis, idiopathic anaphylaxis, and allergy to foods or latex.
Dose of epinephrine for anaphylaxis
Epinephrine 0.3-0.5 ml of 1:1000 concentration IM
More favorable outcomes are seen in patients with anaphylaxis who are given epinephrine within the first ____ minutes
20
If with persistent hypotension (anaphylactic shock): IV infusion of ___ mL epinephrine, diluted ______ at 5- to 10-min intervals
2.5 mL epinephrine, diluted 1:10,000, at 5- to 10-min intervals
key effector cell in asthma and allergic rhinitis?
mast cells
How do you differentiate SJS vs TEN
Extent of surface area involved
SJS – total body surface area of blistering and eventual detachment is <10%
SJS/TEN overlap – 10–30% epidermal detachment
TEN – >30 epidermal detachment
Poor prognostic factors for SJS/TEN
Intestinal and upper respiratory tract involvement
older age
greater extent of epidermal detachment
most common variety of psoriasis
plaque type
most common cause of chronic urticaria
idiopathic
Most important preventive strategy in px with prev hx of anaphylaxis
avoidance of trigger
Key pathway for ADR based on immune pathway
I
II
III
IVa
IVb
IVc
IVD
I - IgE
II - IgG mediated cytotoxicity
III- Immune complex
IVa- T cell mediated macrophage inflammation
IVb- T cell mediated eosinophil inflammation
IVc- T cell mediated Tcell inflammation
IVd- T cell mediated neutrophil inflammation
mnemonic: may MEeTiNg at 4pm
macrophage-eosino-t cell-neutro
Urticaria, angioedema and anaphylaxis are under what type of classification of adverse drug reaction
Type I
Drug induced hemolysis and thrombocytopenia are under what type of classification of adverse drug reaction
Type II
Vasculitis, Serum sickness, Drug induced lupus are under what type of classification of adverse drug reaction
Type III
TST and Contact dermatitis are under what type of classification of adverse drug reaction
Type IVA
DIHS and Morbiliform eruption are under what type of classification of adverse drug reaction
Type IVB
SJS and TEN and morbiliform eruption are under what type of classification of adverse drug reaction
Type IVC
AGEP is under what type of classification of adverse drug reaction
Type IVD
Aspirin exacerbated respiratory illness has 3 clinical features which include
Asthma
Sinus dse with recurrent nasal polyps
Sensitivity to aspirin and other NSAIDs
When treatment center that lacks access to recombinant C1NH, bradykinin 2 receptor antagonist, kallikrein inhibitor, what could be given for acute attacks of hereditary angioedema?
FFP
Most potent APC of the immune system
dendritic cells
% risk of atopic dermatitis for patients with both parents with AD
> 80%
One parent >50%
Most common site affected by seborrheic dermatitis
scalp
Number of weeks to classify urticaria and/or angioedema as chronic
> 6 weeks
Type of urticaria which presents in response to a sustained stimulus such as a shoulder strap or belt, running (feet), or manual labor (hands).
Pressure urticaria
Type of urticaria that is distinctive in that the pruritic wheals are of small size (1–2 mm) and are surrounded by a large area of erythema; attacks are precipitated by fever, a hot bath or shower, or exercise and are presumptively attributed to a rise in core body temperature.
Cholinergic urticaria
Angioedema without urticaria can be idiopathic or due to the generation of bradykinin in the setting of ______ deficiency that may be inborn as an autosomal dominant mutation or may be acquired through the appearance of an autoantibody in the setting of malignancy or autoimmune disease
C1 inhibitor (C1INH)
Urticarial eruptions are distinctly pruritic, may involve any area ofthe body from the scalp to the soles of the feet, and appear in crops of _ h duration, with old lesions fading as new ones appear.
12- to 36-h
Urticarial lesions that last longer than 36 h, result in scarring, and are reported as painful and not pruritic warrant ____ to evaluate for cellular infiltration, nuclear debris, and fibrinoid necrosis of the venules consistent with urticarial vasculitis.
biopsy
antifibrinolytic agent that may be used for preoperative prophylaxis of hereditary angioedema but is contraindicated in patients with thrombotic tendencies or arterial atherosclerosis.
ε-aminocaproic acid
most effective drugs available for the relief of established rhinitis, seasonal or perennial, and are effective in relieving nasal congestion as well as ocular symptoms
Intranasal high-potency glucocorticoids
Their most frequent side effect is local irritation, with fungal overgrowth being a rare occurrence.
In allergic rhinitis, the efficacy of SLIT is comparable to SCIT but only for the three allergen formulations currently available which include what?
dust mite, timothy/northern grasses, and short ragweed
most common presentation of anaphylaxis (>90% of cases)
Cutaneous manifestation
Example of delayed anaphylatic reaction
anaphylaxis to meats in alpha-gal–sensitized patients.
In anaphylaxis, The most obvious serum biomarker to assay,_____ , has an extremely short half-life with a measurable time-window that expires <1 h from the onset of anaphylaxis.
histamine
In anaphylaxis, A more practical and useful biomarker is ______ , which peaks 60–90 min after the onset of anaphylaxis and can be measured as long as 5 h after the onset of anaphylaxis
serum tryptase
it is recommended that patients who suffer from anaphylaxis be placed in the ____ position before receiving epinephrine.
Supine
an upright or sitting posture may lead to “empty ventricle syndrome” in which there is insufficient venous return to the heart from sudden-onset hypotension secondary to intravascular volume depletion. Epinephrine can further accelerate empty ventricle syndrome due to its chronotropic effects.
80% of children with _____ allergy remain sensitive for life
peanut
While most allergy to egg, milk, soy, and/or
wheat resolves spontaneously during childhood
Most forms of the disease (mastocytosis) are characterized by somatic gain-of-function mutations in the _____ gene.
stem cell factor receptor (KIT)
Systemic mastocytosis (SM) refers to involvement of a noncutaneous site usually _____
bone marrow
Type of systemic mastocytosis that accounts for the majority of adult patients.
Indolent systemic mastocytosis
Smoldering systemic mastocytosis (SSM) is characterized by high mast cell burden as evidenced by a bone marrow infiltration of > ___ % and a baseline serum tryptase > ___ ng/mL (B findings), but absence of systemic mastocytosis associated with clonal hematologic non–mast cell lineage disease (SM-AHNMD) or aggressive systemic mastocytosis (ASM)
> 30%
200 ng/mL
the rarest form of systemic mastocytosis and is invariably fatal at present
Mast cell leukemia (MCL)
The cutaneous lesions of Maculopapular cutaneous mastocytosis (MPCM) are reddish-brown macules, papules, or plaques that respond to trauma with urtication and erythema AKA ____ sign
Darier’s sign
Serum levels of this aracidonic acid dervided product diretcly correlates with anaphylaxis severity
Platelet activating factor
Mediator of anaphylaxis that causes hypotension and tachycardia when released in high concentration
Histamine
Type of psoriasis frequently after URTI
with B-hemolytic streptococci
Eruptive/Guttate psoariasis
also most common in children
What is the tx of choice for non pregnant px with pustular psoariasis
oral retinoid
why should you avoid oral glucocorticoids in severe widespread psoriasis
risk of life- threatening pustular psoriasis when therapy is discontinued
4 key elements of pathogenesis of acne vulgaris
- Follicular epidermal hyperprofliferation
- Excess sebum production
- Inflammation
- Presence and activity of Propionibacterium acnes
Most common form of pemphigus
pemphigus vulgaris
Autoantibodies for pemphigus vulgaris
desmoglein 3 and 1
Prevalent allele in bullous pemphigoid
MHC Class II allele HLA-DQβ1*0301
Autoantibodies for bullous pemphigoid
hemidesmosomes
Type of urticaria precipitated by fever, a hot bath or shower, or exercise
Cholinergic
contraindication for immunotherapy for allergy
significant cardiovascular disease or unstable asthma
Appropriate regimen for radiocontrast allergy prophylaxis
Prednisone 0.5mg/kg, 1 tablet at 13hrs, 6 hrs, 1hr prior to CT scan.
This syndrome is characterized by recurrent bacterial infections, eczema and bleeding from thrombocytopenia
Wiskott-Aldrich Syndrome
What should be given to patients with systemic mastocytosis with ssx of malabsorption
systemic steroids
most potent known vasoconstrictor
LTD4
lipid mediator responsible for leukocyte-endothelial cell adhesion and subsequent directed migration
LTB4
lipid mediator responsible for vascular leak and mediates the recruitment of eosinophils to the bronchial mucosa
LTE4
vascular leeeeeak
eeeeosinophils
How do you differentiate urticaria vs angioedema
known risk factors for ACE I related angioedema
Black race, organ transplant, female gender, smoking, increasing age
Heridary angioedema is aFully penetrant, autosomal dominant disease due to a mutation in the _____ gene (C1INH)
SERPING1
Bradykinin-mediated angioedema, whether caused by ACE inhibitors or by C1INH deficiency, is noteworthy for these characteristics (3)
> conspicuous absence of concomitant urticaria or pruritus
frequent involvement of the gastrointestinal tract
duration of symptoms >24 h
Other tx options for urticaria unresponsive to systemic glucocorticoids
Hydroxychloroquine, Dapsone, Colchicine
-Added to the regimen after hydroxyzine and before or along with systemic glucocorticoids
Cyclosporine
-Chronic idiopathic urticaria that is severe and poorly responsive to other modalities and/or where glucocorticoids are a requirement
Known predisposing risk factors for allergic rhinitis
Female sex, particulate air pollution exposure, maternal tobacco smoking
What constitues Aspirin-exacerbated respiratory disease (AERD), also known as Samter’s Triad
triad of asthma, rhinosinusitis, respiratory reactions to COX-1 inhibitors
Atopic triad
Bronchial asthma, allergic rhinitis, atopic dermatitis
Major criteria for atopic dermatitis
CHIP
Chronicity
History of atopy
Involvement of face and flexures
Pruritus
Mutation associated with atopic dermatitis
filaggrin mutation
Difference between irritant vs allergic contact dermatitis
See table
Allergic contact dermatitis also goes beyond area of exposure
Common sites of involvement of psoriasis
Scalp, elbows, knees, hands, feet,
trunk and nails
Phenomenon in psoriasis wherein Traumatized areas develop lesions
Koebner phenomenon
Sign in psoriasis wherein there is Bleeding after scale is removed
Auspitz sign
Organisms involved in dermatophytosis
Trichophyton
Microsporum spp
Epidermophyton
Treatment for pemphigus vulgaris
Treatment: Systemic glucorticoids alone/ in
combination with other immunosuppressive
agents
rituximab; azathioprine, mycophenolate mofetil,
or cyclophosphamide
Tx resistant disease: Plasmapheresis and/ IVIg
Treatment for bullous pemphigus
Local disease: Potent topical lucocorticoids
Extensive disease: Systemic Glucocorticoids alone/ with other adjuncts
Doxycycline, azathioprine, Mycophenolate mofetil, Rituximab
Which is nikolsky positive Pemphigus vulgaris or bullous pemphigoid?
pemphigus vulgaris
Risk factors for adverse drug reactions
Elderly patient
Patients with autoimmune disease
Hematopoietic stem cell transplant recipient
With acute EBV and HIV infection
Most common type of drueg eruptions
morbiliform eruptions
Common culprit drugs for drug induced hypersensitivity syndrome
Anticonvulsants, sulfonamides, allopurinol, minocycline
Color of tinea capitis and Microsporum canis under Wood’s lamp
Yellow fluorescence
What type of adverse drug reaction is a acute generalized exanthematous pustulosis?
a. Type IVa
b. Type IVb
c. Type IVc
d. Type IVd
d. Type IVd
A 35/F consulted your clinic due to dandruff. On physical examination, there are demarcated papules with silvery scales on the scalp, onycholysis and punctate pitting of the nails. Which is TRUE regarding the clinical manifestations of this condition?
a. Skin lesions evolve quickly
b. Lesions are typically observed in the axilla, groin, navel, and submammary region
c. Disease may remit spontaneously.
d. Presence of infection aggravates skin lesions
d. Presence of infection aggravates skin lesions
A. Skin lesions evolve quickly - indolent
B. Lesions are typically observed in the axilla, groin, navel, and submammary region – This is inverse psoriasis. Typical distribution is on the flexor surfaces usually.
C. Disease may remit spontaneously. - rarely
D. Presence of infection aggravates skin lesions
Which represents the end stage of a variety of eczematous disorders?
a. Nummular Eczema
b. Lichen Planus
c. Lichen Simplex Chronicus
d. Asteatotic Eczema
c. Lichen Simplex Chronicus
A 50/M consulted your clinic due to pruritic rash on his shins. On physical examination, there are circular scaly plaques on both pretibial areas. Which is an appropriate treatment for this case?
a. High-potency glucocorticoid
b. Cetirizine for pruritus
c. Emollient for dry areas
d. Use sulfur soap to clean the area
c. Emollient for dry areas
Diagnosis: Nummular eczema
Treatment is the same as atopic dermatitis.
A. High-potency glucocorticoid – low to mid-potency
B. Cetirizine for pruritus – sedating antihistamine
C. Emollient for dry areas
D. Use sulfur soap to clean the area – mild soap
A 48/F consulted your clinic due to bipedal edema of 1 year duration. It is usually worse at the end of the day, after prolonged standing. On physical examination, you observed the presence of varicose veins, and brawny edema of the distal lower extremities with scaling and hyperpigmentation. Which is TRUE regarding the pathophysiology of this condition?
a. Typical initial site of involvement is the medial aspect of the ankle
b. Hyperpigmentation is due to the proliferation of subdermal fibrocytes
c. The brawny edema observed is due to hemosiderin deposition
d. Ulceration precedes the development of edema
a. Typical initial site of involvement is the medial aspect of the ankle
A. Typical initial site of involvement is the medial aspect of the ankle
B. Hyperpigmentation is due to the proliferation of subdermal fibrocytes – hemosiderin deposition
C. The brawny edema observed is due to hemosiderin deposition – dermal fibrosis
D. Ulceration precedes the development of edema – stasis dermatitis precedes ulceration
A 45/F consulted your clinic due to dandruff. On physical examination you noted erythematous patches on the nasolabial fold, scalp, and eyebrows. What is the first line agent?
a. Clobetasol
b. Ciclopirox
c. Urea lotion
d. Tacrolimus
b. Ciclopirox
Diagnosis: Seborrheic dermatitis
A. Clobetasol
B. Ciclopirox – an antifungal
C. Urea lotion
D. Tacrolimus
A 50/M just returned from a winter vacation in Hokkaido, Japan and is consulting for burning and itchy sensation on both shins. On physical examination you observed dry, cracked skin in the pretibial area with some scaling. What is the diagnosis?
a. Asteatotic Eczema
b. Atopic Dermatitis
c. Lichen Simplex Chronicus
d. Nummular Eczema
A. Asteatotic Eczema – dry skin exacerbated by the dry, cold weather
A 48/F consulted your clinic due to cracked skin on her hands. She works as a laundrywoman and cleaner. On physical examination, you observed vesicles on the palms and lateral aspects of her fingers, some of which had erythematous bases and purulent discharge. Which of the following is an appropriate management for this case?
a. Advise patient to use latex gloves whenever her hands are exposed to water, detergents, and harsh chemicals.
b. Hot moist compress should be applied to the lesions.
c. Mid- to high-potency glucocorticoid ointment
d. Empiric coverage for dermatophyte infection.
c. Mid- to high-potency glucocorticoid ointment
A. Advise patient to use latex gloves whenever her hands are exposed to water, detergents, and harsh chemicals. - vinyl
B. Hot moist compress should be applied to the lesions. – cold moist
C. Mid- to high-potency glucocorticoid ointment
D. Empiric coverage for dermatophyte infection. - bacterial The correct answer is: Mid- to high-potency glucocorticoid ointment
A 50/M consulted your clinic due to an erythematous plaque on his hypogastric area (from his belt buckle). What is your diagnosis?
a. Psoriasis
b. Lichen simplex chronicus
c. Irritant Contact Dermatitis
D. Allergic Contact Dermatitis
D. Allergic Contact Dermatitis
How many grams of a topical agent is required to cover the entire body surface of an average adult?
a. 20 g
b. 30 g
c. 40 g
d. 50 g
b. 30 g
A patient is on pimecrolimus cream for atopic dermatitis. Which of the following is a side effect of this medication?
a. Lymphoma
b. Adrenal insufficiency
c. Skin atrophy
d. Rosacea
a. Lymphoma
B. Adrenal insufficiency – topical glucocorticoid
C. Skin atrophy – topical glucocorticoid
D. Rosacea – topical glucocorticoid
A 20/F consulted your clinic due to pruritic plaques on both popliteal fossae for the past 6 months. On physical examination, you observed xerotic skin and lichenified plaques on both popliteal fossae. Which of the following is an appropriate treatment to give?
a. High-potency topical glucocorticoid
b. Cetirizine
c. Tacrolimus ointment
d. Clindamycin
c. Tacrolimus ointment
A. High-potency topical glucocorticoid – NOT recommended for intertriginous areas
B. Cetirizine – non-sedating antihistamines are of little use in controlling pruritus of AD
C. Tacrolimus ointment – non-glucocorticoid anti-inflammatory that may be used in intertriginous areas D. Clindamycin – appropriate IF secondary infection is present
What is the typical histologic pattern of eczema?
a. Presence of melanocytic segments
b. Inflammatory cell infiltration of the dermis
c. Dermal fibrosis
d. Spongiosis
d. Spongiosis
Which cancer is associated with paraneoplastic pemphigus?
a. Acute myelocytic leukemia
b. Small cell lung cancer
c. Non-Hodgkin’s lymphoma
d. Papillary thyroid cancer
c. Non-Hodgkin’s lymphoma
A 70/M consulted due to a papule on his face. Physical examination showed a large dome-shaped with a central keratotic crater. What is the diagnosis?
a. Actinic keratosis
b. Basal cell cancer
c. Melanoma
d. Squamous cell cancer
d. Squamous cell cancer
the lesion being described is a keratoacanthoma
A 65/M was diagnosed with superficial basal cell carcinoma. What is the treatment of choice for this patient?
a. Wide excision
b. Electrodessication and curettage
c. Sonidegib
d. Laser therapy
b. Electrodessication and curettage
A. Wide excision – for invasive, ill-defined and aggressive tumors
B. Electrodessication and curettage – most commonly employed method
C. Sonidegib – metastatic or advanced BCC
D. Laser therapy
Most common histologic subtype of malignant melanoma?
a. Lentigo maligna
b. Superficial spreading
c. Nodular
d. Acral lentiginous
b. Superficial spreading
A 50/M consulted due to an enlarging mole on his nose. He is worried that it might be cancerous as his father was diagnosed with melanoma at age 60. Which is TRUE regarding risk factors for skin cancer?
a. First-degree relatives have a threefold risk of developing melanoma than those without a family history.
b. Majority of melanomas are familial.
c. The actual risk of transformation of nevus into melanoma is high
d. The presence of multiple nevi is one of the strongest risk factors
d. The presence of multiple nevi is one of the strongest risk factors
A. First-degree relatives have a threefold risk of developing melanoma than those without a family history. – twofold
B. Majority of melanomas are familial. – only 5-10% are truly familial
C. The actual risk of transformation of nevus into melanoma is high - LOW
D. The presence of multiple nevi is one of the strongest risk factors
Most common dermatologic problem in patients with HIV infection?
a. Seborrheic dermatitis
b. Folliculitis
c. Ichthyosis
d. Reactivation herpes zoster
a. Seborrheic dermatitis
A. Seborrheic dermatitis – occurs up to 50% of patients with HIV
B. Folliculitis – 20%
C. Ichthyosis – not increased in frequency, but if present may be severe
D. Reactivation herpes zoster – 10-20%
A 75/M was referred due to bullae formation on the trunk. On physical examination, there are tense vesicles & bullae on the trunk with erythematous urticarial bases. The lesions are non-pruritic and there are no oral lesions. What is the diagnosis?
a. Pemphigus vulgaris
b. Bullous pemphigoid
c. Pemphigus foliaceus
d. Epidermolysis bullosa acquisita
b. Bullous pemphigoid
A. Pemphigus vulgaris – has mucosal involvement
B. Bullous pemphigoid
C. Pemphigus foliaceus – crusts & shallow erosions on scalp, central face, upper chest, and back
D. Epidermolysis bullosa acquisita – blisters, erosions, scars, and milia on sites exposed to trauma; widespread; tense blisters may be seen initially
Which of the following is a skin biopsy finding in discoid lupus erythematosus?
a. Acantholysis in suprabasal epidermis
b. Sparse infiltrate of mononuclear cells in the dermis
c. Hydropic degeneration of basal keratinocytes
d. Epidermal atrophy
d. Epidermal atrophy
A. Acantholysis in suprabasal epidermis – pemphigus vulgaris
B. Sparse infiltrate of mononuclear cells in the dermis – acute cutaneous lupus
C. Hydropic degeneration of basal keratinocytes – acute cutaneous lupus
D. Epidermal atrophy – chronic/discoid lupus
Which of the following cutaneous manifestations are seen in ACUTE cutaneous lupus?
a. Evanescent erythema of upper chest
b. Psoriasiform eruption on chest and back
c. Discoid rash
d. Papulosquamous eruption on extensor surfaces
a. Evanescent erythema of upper chest
A. Evanescent erythema of upper chest
B. Psoriasiform eruption on chest and back - subacute C. Discoid rash - chronic
D. Papulosquamous eruption on extensor surfaces - subacute
Which skin finding is seen in dermatomyositis but is rare in lupus and scleroderma?
a. Raynaud’s phenomenon
b. Poikiloderma
c. Malar rash
d. Sclerodactyly
b. Poikiloderma - areas of hypopigmentation, hyperpigmentation, mild atrophy, and telangiectasia
The rest of the findings may be seen in SLE, Scleroderma or overlap syndromes.
A 25/M consulted due to fever. On physical examination, there are palpable nonblanching purpura on the lower extremities. Which is the LEAST likely differential?
a. Staphylococcal scalded skin syndrome
b. Ecthyma gangrenosum
c. Henoch-Schonlein purpura
d. Meningococcemia
a. Staphylococcal scalded skin syndrome
Diagnosis is meningococcemia
A. Staphylococcal scalded skin syndrome - only one that presents as bullae & not purpura
B. Ecthyma gangrenosum
C. Henoch-Schonlein purpura
D. Meningococcemia
A 38/F consulted due to hypopigmented patches on her face and hands. What is the disorder that is most frequently associated with this condition?
a. Addison’s disease
b. Type 1 Diabetes Mellitus
c. Hashimoto’s Thyroiditis
d. Pernicious anemia
c. Hashimoto’s Thyroiditis
A 30/F consulted due to red rash on her face and hands. On physical examination, there are oval macules less than 1 cm, which on closer inspection turned out to be telangiectasias. This patient needs to be worked up for what disease?
a. Hereditary hemorrhagic telangienctasia
b. Dermatomyositis
c. Systemic Lupus Erythematosus
d. Scleroderma
d. Scleroderma
remember cresT syndrome
Mat telangiectasia commonly seen in face, oral mucosa and hands
Which drug can cause anagen effluvium?
a. Colchicine
b. Daunorubicin
c. Warfarin
d. Lithium
b. Daunorubicin
The rest cause diffuse hair loss, usually by inducing a telogen effluvium
A 35/F was admitted due to fever and cough. She has a history of being treated for eczema of the knees and elbows. On physical examination, you observed generalized skin erythema with some areas studded with pustules. What is the diagnosis?
a. Exfoliative dermatitis
b. Pityriasis rubra pilaris
c. Pustular psoriasis
d. Sezary syndrome
c. Pustular psoriasis
History of eczema on knees and elbows points to psoriasis.
The presence of concomitant infection triggered the erythroderma.
A 48/F consulted your clinic due to scaly plaques of 6 months duration. She was previously told she had eczema and was prescribed topical steroids but her lesions failed to improve. Skin biopsy of the lesion showed atypical lymphocytes in the epidermis and dermis. What is the diagnosis?
a. Bowen’s Disease
b. Lichen Planus
c. Mycosis Fungoides
d. Psoriasis
c. Mycosis Fungoides
Most common malignancy associated with erythroderma?
a. Cutaneous T Cell Lymphoma
b. Non-Small Cell Lung Cancer
c. HTLV-1 Associated Adult T Cell Leukemia
d. Hodgkin’s Lymphoma
a. Cutaneous T Cell Lymphoma
There have been isolated case reports of erythroderma secondary to some solid tumors—lung, liver, prostate, thyroid, and colon
A 40/M consulted your clinic due to pruritic papules and plaques on his wrist (multiple flat-topped, violaceous papules and plaques). On physical examination, you also observed nail dystrophy.
What is your diagnosis?
a. Lichen planus
b. Psoriasis
c. Pityriasis Rosea
d. Dermatophytosis
a. Lichen planus
A 35/F has psoriasis and arthritis and was advised to start systemic therapy. The patient has not been compliant with previous medications as she kept forgetting to take them. Which medication would be appropriate to give to her?
a. Methotrexate
b. Acitrecin
c. Cyclosporine
d. Apremilast
a. Methotrexate
A. Methotrexate – the only one among the choices that is dosed once weekly making it better for compliance
A 32/F has psoriasis, spondylitis & arthritis. Which biologic agent is efficacious for both conditions?
a. Certolizumab pegol
b. Golimumab
c. Ixekizumab
d. Secukinumab
d. Secukinumab
A. Certolizumab pegol – Psoriatic arthritis (PsA)
B. Golimumab – Psoriatic arthritis (PsA)
C. Ixekizumab – Psoriasis (Ps)
A 25/F has a solitary silvery plaque on her right elbow. There are no other skin lesions nor nail changes on physical examination. Which is an appropriate treatment to give?
a. Anthralin
b. Coal Tar
c. Calcipotriene
d. Salicylic Acid
c. Calcipotriene
Diagnosis: Limited Psoriasis
A. Anthralin
B. Coal Tar
C. Calcipotriene – topical Vitamin D analogue which has replaced these other choices for limited psoriasis
D. Salicylic Acid
Which of the following treatments for psoriasis is correctly matched with the adverse effect?
a. Tazarotene – skin cancer
b. Oral glucocorticoid – pustular psoriasis
c. Apremilast – teratogenicity
d. Acitrecin – pancytopenia
b. Oral glucocorticoid – pustular psoriasis
A. Tazarotene – skin cancer (Psoralens are the ones which predisposes to skin cancer. Tazarotene is a topical retinoid)
B. Oral glucocorticoid – pustular psoriasis
C. Apremilast – teratogenicity (Hypersensitivity, GI symptoms)
D. Acitrecin – pancytopenia (Teratogenicity, as it is a retinoid)
A 28/M has erythematous scaly plaques on both knees and elbows. On physical examination, you observed sausage digits. What other disease will he need to be screened for?
a. Diabetes
b. Hepatitis A
c. Bronchial asthma
d. Colon cancer
a. Diabetes
Diagnosis is plaque-type psoriasis with psoriatic arthritis. Given increased risk of metabolic syndrome, he needs to be screened for diabetes.
In case he would need immunosuppressive therapy, he will also need to be screened for TB, HIV, and Hepatitis B or C.
Oral oral antifungal agents are often used in which type of dermatophyte infection?
a. Tinea cruris
b. Tinea pedis
c. Tinea capitis
d. Tinea corporis
c. Tinea capitis
For dermatophyte infections involving the hair and nails and for other infections unresponsive to topical therapy, oral antifungal agents are often used
Topical therapy is generally effective for uncomplicated tinea corporis, tinea cruris, and limited tinea pedis
Which of the agents used to treat leprosy is bactericidal?
a. Dapsone
b. Clofazimine
c. Streptomycin
d. Rifampin
d. Rifampin
Key immune mediators in SJS/TEN:
a. IgE
b. Eosinophils
c. IL-4, IL-5 and IL-13
d. Granulysin
d. Granulysin
Causes drug-induced lipofuscinosis with characteristic red-brown coloration
a. Clofazimine
b. Minocycline
c. Quinacrine
d. Bismuth
a. Clofazimine
- Blue gray pigmentation: long term minocycline and amiodarone, pefloxacin
- Gray-brown pigmentation: phenothiazine, gold, bismuth
- Red-brown coloration: clofazimine
- Yellow discoloration: quinacrine
True of fixed drug eruptions:
a. Hyperpigmentation often results after resolution of acute inflammation
b. With rechallenge, the process recurs a different location
c. Lesions often involve the scalp
d. Most patients have a single lesion
a. Hyperpigmentation often results after resolution of acute inflammation
One or more sharply demarcated, dull red to brown lesions, sometimes with central dusky violaceous erythema and central bulla
Hyperpigmentation often results after resolution of the acute inflammation
With rechallenge, the process recurs in the same (fixed) location but may spread to new areas as well
Lesions often involve the lips, hands, legs, face, genitalia, and oral mucosa, and cause a burning sensation
Most patients have multiple lesions
Fixed drug eruptions have been associated with pseudoephedrine (frequently a nonpigmenting reaction), phenolphthalein (in laxatives), sulfonamides, tetracyclines, NSAIDs, barbiturate
A 50/F was referred for evaluation of purpuric papules and macules involving the lower extremities. Further work up showed elevated creatinine. Cutaneous small vessel vasculitis was considered. This finding on skin biopsy can be a clue to possible drug etiology:
a. Presence of perivascular eosinophils
b. Nonspecific inflammatory changes
c. Collections of neutrophils and sparse necrotic keratinocytes in the upper part of the epidermis
d. Full thickness epidermal necrosis
a. Presence of perivascular eosinophils
Presents with purpuric papules and macules involving the lower extremities and other dependent areas
May involve other organs, including the kidneys, joints, gastrointestinal tract, and lungs, necessitating a thorough clinical evaluation for systemic involvement
Drugs are implicated as a cause of roughly 15% of all cases of small vessel vasculitis
May also be idiopathic or due to underlying infection, connective tissue disease, or (rarely) malignancy
Presence of perivascular eosinophils on skin biopsy can be a clue to possible drug etiology.
Drug associated with pemphigus:
a. Furosemide
b. Vancomycin
c. Terbinafine
d. D-penicillamine
d. D-penicillamine
New onset SLE: IL-2, IFN-α, and anti-TNF-α
Granulomatous disease and sarcoidosis: IFN and TNF-inhibitors
Pemphigus: D-penicillamine and ACE inhibitors
Bullous pemphigoid: furosemide and PD-1 inhibitors
Linear IgA bullous dermatosis: vancomycin
Nephrogenic systemic fibrosis: gadolinium contrast
Neutrophilic dermatoses: GCSF, azacitidine, ATRA and the FLT3- inhibitor class of drug
True of urticaria:
a. Most frequent type of cutaneous reaction to drugs
b. Characterized by blanching erythematous macules and papules
c. May be caused by an IgE-dependent mechanism, circulating immune complexes, or nonimmunologic activation of effector pathways
d. Rechallenge may be done in an outpatient setting
c. May be caused by an IgE-dependent mechanism, circulating immune complexes, or nonimmunologic activation of effector pathways
Second most frequent type of cutaneous reaction to drugs
Characterized by pruritic, red wheals of varying size rarely lasting more than 24 hours
Observed in association with nearly all drugs, most frequently ACE inhibitors, aspirin, NSAIDs, penicillin, and blood products
Drug-induced urticaria may be caused by three mechanisms: an IgE-dependent mechanism, circulating immune complexes (serum sickness), and nonimmunologic activation of effector pathways
Future drug avoidance is recommended
Rechallenge, especially in individuals with severe reactions, should only occur in an intensive care setting
True of furunculosis:
a. Caused by Group A Streptococcus
b. Characterized by annular scaly plaques
c. Family members or close contacts may also be affected
d. Treatment include topical selenium sulfide lotion or azoles
c. Family members or close contacts may also be affected
Caused by S. aureus, and this disorder has gained prominence in the last decade because of CA-MRSA
Painful, erythematous nodule that can occur on any cutaneous surface
Family members or close contacts may also be affected
Furuncles can rupture and drain spontaneously or may need incision and drainage, which may be adequate therapy for small solitary furuncles without cellulitis or systemic symptoms
Whenever possible, lesional material should be sent for culture
Current recommendations for methicillin-sensitive infections are β-lactam antibiotics
Warm compresses and nasal mupirocin are helpful therapeutic additions
Severe infections may require IV antibiotic
A 34/F was referred due to multiple warts on the face and neck. PE showed multiple sessile, dome-shaped lesions. The most useful and convenient method for treating warts in almost any location is:
a. Salicylic acid plasters or solutions
b. Cryotherapy with liquid nitrogen
c. Podophyllin solution
d. Topical imiquimod
b. Cryotherapy with liquid nitrogen
Caused by papillomaviruses
Filiform warts are most commonly seen on the face, neck, and skinfolds
Cryotherapy with liquid nitrogen: most useful and convenient method for treating warts in almost any location
Which of the following statement is correct regarding use of isotretinoin in patients with acne vulgaris?
a. Dose is based on patient’s weight
b. Isotretinoin is given twice daily for 5 months
c. Its use is highly regulated due to its potential for severe adverse events, primarily teratogenicity and anxiety
d. All female patients should have two negative pregnancy tests prior to each refill
a. Dose is based on patient’s weight
Patients with severe nodulocystic acne unresponsive to the therapies discussed above may benefit from treatment with the synthetic retinoid isotretinoin
Its dose is based on the patient’s weight, and it is given once daily for 5 months
Its use is highly regulated due to its potential for severe adverse events, primarily teratogenicity and depression
All female patients have two negative pregnancy tests prior to initiation of therapy and a negative pregnancy test prior to each refill
Isotretinioin causes hyperTAG
A 68/M with metastatic non-small cell lung cancer developed rash, pruritus and vitiliginous depigmentation after initiation of therapy. Which medication is responsible for this reaction?
a. Sorafenib
b. Erlotinib
c. Ipilimumab
d. Capecitabine
c. Ipilimumab
Acral erythema: cytarabine, doxorubicin, methotrexate, hydroxyurea, fluorouracil, and capecitabine
Hair textural changes: erlotinib
Follicular eruptions and focal bullous eruptions at palmoplantar, flexural sites or areas of frictional pressure: sorafenib
Rash, pruritus, and vitiliginous depigmentation: ipilimumab
A 60/F, known hypertensive on amlodipine 10mg OD, was referred for evaluation of rash. On PE, patient was highly febrile, with innumerable pinpoint pustules with underlying erythema. Lesions are most pronounced in the antecubital area. Which statement is true regarding this condition?
a. Erosions tend to be deep and prominently involve the mucosa
b. Skin biopsy shows full thickness epidermal necrosis
c. Principal differential diagnosis is erythema multiforme
d. Patch testing with the responsible drug often results in a localized pustular eruption
d. Patch testing with the responsible drug often results in a localized pustular eruption
Patients typically present with diffuse erythema or erythroderma, as well as high spiking fevers, and leukocytosisOne to two days later, innumerable pinpoint pustules develop overlying the erythema
Pustules are most pronounced in body fold areas; however, they may become generalized and, when coalescent, can lead to superficial erosion
Erosions tend to be more superficial, and prominent mucosal involvement is lacking
Skin biopsy shows collections of neutrophils and sparse necrotic keratinocytes in the upper part of the epidermis
The principal differential diagnosis for AGEP is acute pustular psoriasis, which has an identical clinical and histologic appearance
β-Lactam antibiotics, calcium channel blockers, macrolide antibiotics, and other inciting agents (including radiocontrast and dialysates) have been reported
Patch testing with the responsible drug often results in a localized pustular eruption
A 44-year-old female consulted due to fever and flu-like symptoms for 3 days followed by appearance of diffuse morbilliform rash involving the face. She was diagnosed to have hypertension and hyperuricemia 6 weeks ago and was prescribed amlodipine and allopurinol, which she took with good compliance. On PE, patient was hypotensive. You noted fever, icteric sclerae, cervical and inguinal lymphadenopathies and hepatomegaly. CBC showed mild eosinophilia and atypical lymphocytes. Which statement is correct?
a. Mycophenolate mofetil should be started
b. Patient should be closely monitored for development of early-onset autoimmune thyroiditis
c. Patient should undergo cardiac evaluation
d. Most fatalities result from heart failure
c. Patient should undergo cardiac evaluation
Mortality rates as high as 10% have been reported, with most fatalities resulting from liver failure
Systemic glucocorticoids (1.5–2 mg/kg/d prednisone equivalent) should be started and tapered slowly over 8–12 weeks, during which time clinical symptoms and labs (including complete blood count with differential, basic metabolic panel, and liver function tests) should be followed carefully
A steroid-sparing agent such as mycophenolate mofetil may be indicated in cases of rapid recurrence upon steroid taper
Given the severe long-term complications of myocarditis, patients should undergo cardiac evaluation in cases of severe DIHS or if heart involvement is suspected due to hypotension or arrhythmia
Patients should be closely monitored for resolution of organ dysfunction and for development of late-onset autoimmune thyroiditis and diabetes (up to 6 months)
A 23/M PLHIV developed morbilliform eruption in response to prior sulfonamide exposure. What will be your recommendation?
a. Skin prick testing
b. Patch testing
c. Intradermal testing
d. Desensitization
d. Desensitization
- Skin-prick testing
o In patients with a history suggesting immediate IgE-mediated reactions to penicillin, skin-prick testing with penicillins or cephalosporins has proven useful for identifying patients at risk of anaphylactic reactions to these agents
o Negative skin tests do not totally rule out IgE-mediated reactivity
Risk of anaphylaxis in response to penicillin administration in patients with negative skin tests is about 1%
Desensitization
o Considered in those with a history of reaction to a medication that must be used again
o Efficacy of such procedures has been demonstrated in cases of immediate reaction to penicillin and positive skin tests, anaphylactic reactions to platinum chemotherapy, and delayed reactions to sulfonamides in patients with AIDS
o Often successful in HIV-infected patients with morbilliform eruptions to sulfonamides but is not recommended in HIV-infected patients who developed erythroderma or a bullous reaction in response to prior sulfonamide exposure
A 44-year-old female consulted due to fever and flu-like symptoms for 3 days followed by appearance of diffuse morbilliform rash involving the face. She was diagnosed to have hypertension and hyperuricemia 6 weeks ago and was prescribed amlodipine and allopurinol, which she took with good compliance. On PE, you noted fever, icteric sclerae, cervical and inguinal lymphadenopathies and hepatomegaly. CBC showed mild eosinophilia and atypical lymphocytes. What is true about this condition?
a. Reactivation of herpesvirus 6 and Epstein-Barr virus (EBV) has been frequently reported in this syndrome
b. Mucosal erosions are frequent, usually at 2 or more sites
c. Skin biopsy showing full thickness epidermal necrosis in the absence of substantial dermal inflammation is consistent with the diagnosis
d. Patch testing the suspect drug would result in a localized pustular eruption
a. Reactivation of herpesvirus 6 and Epstein-Barr virus (EBV) has been frequently reported in this syndrome
DHIS
* Presents with a prodrome of fever and flu-like symptoms for several days, followed by the appearance of a diffuse morbilliform eruption usually involving the face
* Facial swelling and hand/foot swelling are often present
* Lymphadenopathy, fever, and leukocytosis (often with eosinophilia or atypical lymphocytosis)
* Hepatitis, nephritis, pneumonitis, myositis, and gastroenteritis (in descending order)
* Cutaneous reaction usually begins 2–8 weeks after the drug is started and persists after drug cessation
* Reactivation of herpes viruses, in particular human herpesviruses 6 and 7, EBV, and cytomegalovirus (CMV), has been frequently reported in this syndrome
Predominant cause of Tinea capitis
Tinea tonsurans
Px with erythema gyratum repens should be worked up for
underlying malignancy
Erythema migrans and marginatum are seen in
migrans: Lyme dse
marginatum Acute rheumatic fever
Nailfold telangiectesias are pathognomonic signs of 3 major autoimmune CTD which include
SLE
Systemic sclerosis
Dermatomyositis
What is Leser Trelat sign
Sudden appearance of multiple lesions often with an inflammatory base with acrochordons + acanthosis nigricans
Work up for internal malignancy
SSS is caused by this enzyme secreted by S. aureus
Exfoliatin
Genetic polymorphism associated with
Abacavir
Carbamazepine
Allopurinol
Abacavir = HLA B57:01
Carbamazepine = HLA B15:02
Allopurinol = HLA B*58:01
Onycholysis vs Onychomadesis
Onycholysis- detachment of distal part of nail
Onymadesis- detachment of proximal part of nail
HIV -1 infections are mostly from group
Group M subtype C
Chief predictor of heterosexual transmission in HIV
Level of plasma viremia
Blood products/ blood related products not associated with HIV transmission
HyperIg
HbIg
Plasma derived Hep b vaccine
Rho Immune globulin
Antibodies to HIV generally appear in the circulation ____ weeks following infection
3-12 weeks
Negative screening for HIV -1 and 2 should warrant retesting after ____ months if clinically indicated
3-6
Indeterminate HIV western blot result would warrant repeat testing after ______
4-6 weeks
A stable indeterminate western blot after 4-6 weeks makes HIV infection unlikely. However, it should be repeated twice in 3 month intervals to r/o HIV infection
T/F Positive 4th gen asssay for HIV confirmed by second HIV1 or 2 specific immunoassay or plasma HIV RNA is adequate for dx
True
Western blot is no longer used for this purpose
Best indicator of immunologic competence in PLHIV
CD4 count
Prophylaxis indicated when CD4 count is
<50
<200
< 50 MAC
<200 PCP
CD4 measurements should be performed at the time of diagnosis and 3-6 months thereafter but optional for px on ART for at least 2 yrs and HIV RNA <50 and CD4 >500
A 32/F with Protein C deficiency on 7th day of warfarin anticoagulation was referred due to a sharply demarcated, purpuric lesion with hemorrhagic bullae and eschar formation. How will you manage the patient?
a. Fluid management, atraumatic wound care, prednisone 1-2mg/kg
b. Epinephrine and intravenous glucocorticoids
c. Vitamin K, heparin, surgical debridement and intensive wound care
d. Oral antihistamine and emollients
c. Vitamin K, heparin, surgical debridement and intensive wound care
Common sites: breasts, thighs, and buttocks
* Sharply demarcated, erythematous, or purpuric, and may progress to form large, hemorrhagic bullae with necrosis and eschar formation
* Rare reaction (0.01–0.1%)
* Usually occurs between the third and tenth days of therapy with warfarin
* Usually in women
* Treated with vitamin K, heparin, surgical debridement, and intensive wound care
* Treatment with protein C concentrates may also be helpful.
* Newer anticoagulants such as dabigatran etexilate may avoid warfarin necrosis in high-risk patients
A 48/F started treatment for leprosy 6 months ago. She is currently consulting due to the appearance of painful papules on her arms associated with fever. What type of reactional state is the patient experiencing?
a. Type 1 lepra downgrading
b. Type 1 lepra reversal
c. Type 2 lepra
d. Lucio’s phenomenon
c. Type 2 lepra
A. Type 1 lepra downgrading – inflammation of lesions PRIOR to tx
B. Type 1 lepra reversal – inflammation of lesions AFTER initiation of tx
C. Type 2 lepra – diagnosis is erythema nodosum leprosum
D. Lucio’s phenomenon – recurrent crops of ulcerative lesions
A 50/F consulted due to skin nodules. On physical examination, there is loss of eyebrows, dry skin, symmetric nodular lesions, palpable ulnar nerve, and claw hand deformity. What is the classification of her leprosy?
a. Tuberculoid
b. Borderline Tuberculoid
c. Borderline Lepromatous
d. Lepromatous
d. Lepromatous
Which of the following is indication for oral antifungal treatment?
a. Uncomplicated tinea corporis
b. Tinea cruris
c. Limited tinea pedis
d. Hair and nail infection
d. Hair and nail infection
TNF inhibitors have been associated with which of the following conditions?
a. Amyloidosis
b. Bullous pemphigoid
c. Extensive seborrhea
d. Granulomatous diseases and sarcoidosis
d. Granulomatous diseases and sarcoidosis
Which of the following indicate severe cutaneous drug reaction?
a. Basophilia
b. Fever
c. Lymphocytopenia
d. Petechial rash
b. Fever
Contact dermatitis is considered a Type IVa adverse drug reaction. What is the key pathway involved in this reaction?
a. IgE
b. IgG-mediated toxicity
c. Immune complex
d. T lymphocyte-mediated macrophage inflammation
d. T lymphocyte-mediated macrophage inflammation
Gastrointestinal involvement in a Drug-induced Hypersensitivity Syndrome (DIHS) is almost exclusively seen in patients who use the following drug:
a. Minocycline
b. Allopurinol
c. Abacavir
d. Lamotrigine
c. Abacavir
Allopurinol classically induces DIHS with renal involvement (AllopuRENAL)
Cardiac and lung involvements are more common with minocycline
Gastrointestinal involvement is almost exclusively seen with abacavir (aBAKAvir–> Baka is kinakain –> GI)
True of scabies:
a. The etiologic agent is Pediculus humanus
b. Gravid female mites (~0.3 mm in length) burrow within the stratum basale, depositing several eggs per day
c. Newly fertilized female mites are transferred from person to person mainly by direct skin-to-skin contact
d. Scabies mites continue to live even in the absence of a suitable host.
c. Newly fertilized female mites are transferred from person to person mainly by direct skin-to-skin contact
Etiologic agent: Sarcoptes scabiei var. hominis
Gravid female mites (~0.3 mm in length) burrow superficially within the stratum corneum, depositing several eggs per day
Newly fertilized female mites are transferred from person to person mainly by direct skin-to-skin contact
Transfer is facilitated by crowding, poor hygiene, and sex with multiple partners
Generally, scabies mites die within a day or so in the absence of a suitable host
Transmission via sharing of contaminated bedding or clothing occurs less frequently than is often thought
A 23/F consulted due to nocturnal pruritus. On PE, small papules and vesicles were seen along the volar wrists and digital web spaces. The following statements are correct except:
a. Permethrin cream (5%) is less toxic than 1% lindane preparations
b. Scabicides are applied thinly but thoroughly from the jawline down after bathing and removed 8-14 hours later with soap and water
c. Within 1 day of effective treatment, scabies infestations become noncommunicable.
d. Only symptomatic close contacts of confirmed cases should be treated.
d. Only symptomatic close contacts of confirmed cases should be treated.
Pruritus typically intensifies at night and after hot showers.
Scabetic lesions are most common on the volar wrists and along the digital web spaces
In males, the penis and scrotum become involved
Small papules and vesicles, often accompanied by eczematous plaques, pustules, or nodules, appear symmetrically at those sites and within intertriginous areas, around the navel and belt line, in the axillae, and on the buttocks and upper thighs
Permethrin cream (5%) is less toxic than 1% lindane preparations and is effective against lindane-tolerant infestations
Scabicides are applied thinly but thoroughly from the jawline down after bathing—with careful application to interdigital spaces and the umbilicus and under the fingernails—and are removed 8–14 h later with soap and water
Within 1 day of effective treatment, scabies infestations become non-communicable, but the pruritic hypersensitivity dermatitis induced by the dead mites and their remnant products frequently persists for weeks
To prevent reinfestations, bedding and clothing should be washed and dried on high heat or heat-pressed
Close contacts of confirmed cases, even if asymptomatic, should be treated simultaneously.
True of head lice:
a. Transmitted mainly by fomites such as shared headgear, bed linens and grooming implements
b. Chronic infestations tend to be asymptomatic
c. Head lice are known to serve as a natural vector for any pathogens
d. Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb successfully eliminate infestations
b. Chronic infestations tend to be asymptomatic
Head lice are transmitted mainly by direct head-to-head contact rather than by fomites such as shared headgear, bed linens, and grooming implements
Chronic infestations by head lice tend to be asymptomatic
Head lice are not known to serve as a natural vector for any pathogens
Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb often fails to eliminate infestations
True regarding treatment of louse infestation:
a. Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb often fails to eliminate infestations
b. Treatment of newly identified active infestations traditionally relies on a 10-min topical application of ~1% permethrin or pyrethrins, daily for a total of 10 days
c. Chronic infestations may be treated for ≤12 h with 0.5% permethrin
d. Lindane is applied for just 4 min and is most effective
a. Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb often fails to eliminate infestations
Generally, treatment is justified only if live lice are discovered
The presence of nits alone is evidence of a former—not necessarily current—infestation
Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb often fails to eliminate infestations
Treatment of newly identified active infestations traditionally relies on a 10-min topical application of ~1% permethrin or pyrethrins, with a second application ~10 days later
Lice persisting after this treatment may be resistant to pyrethroids
Chronic infestations may be treated for ≤12 h with 0.5% malathion
Lindane is applied for just 4 min but seems less effective and may pose a greater risk of adverse reactions, particularly when misused.
Transient, blanchable erythematous macules and papules, 2-4 mm, usually on trunk are seen in which of the following conditions?
a. Erythema multiforme
b. Erythema nodosum
c. Herpes simplex
d. Typhoid fever
d. Typhoid fever
Erythema infectiosum presents in adult patients as arthritis, fever and rash. Which of the following is the etiologic agent for this condition?
a. Epstein-Barr virus
b. Human Herpes Virus 6
c. Human Parvovirus B19
d. Paramyxovirus
c. Human Parvovirus B19
A 40 year old female complained of persistent facial flushing which started 1 month ago. The symptom worsened with alcohol intake, hot drinks and spicy foods. There were no other complaints. P.E findings revealed erythema, telangiectasia, scattered papules and small pustules that is more prominent on the cheeks and nose. What is your impression?
A. Acne rosacea
B. Pityriasis rosea
C. Seborrheic dermatitis
D. Hypersensitivity reaction
A. Acne rosacea
A 23/F consults for slowly enlarging sharply demarcated erythematous plaques over both elbows, knees and scalp
areas. Histologic features from the skin biopsy of the lesion will typically show:
a. Interface dermatitis
b. Hyphae and neutrophils in stratum corneum
c. Eosinophils and lymphocytes in the dermis
d. Acanthosis and vascular proliferation
d. Acanthosis and vascular proliferation
This case is consistent with psoriasis, a chronic inflammatory skin condition characterized by sharply demarcated erythematous plaques with silvery-white scales that commonly affect extensor surfaces like the elbows and knees, as well as the scalp.
29-year-old male soldier consulting for persistent nonpruritic, nonpainful, hyperpigmented patches on the trunk and back. KOH preparation demonstrates a confluence of “spaghetti and meatballs” configuration. What is the treatment of choice?
a. Ketoconazole 200mg/tab OD PO
b. Topical hydrocortisone TID
c. Topical selenium sulfide OD
d. Topical clotrimazole TID
c. Topical selenium sulfide OD
32-year-old female consulting for very slowly healing vesicles and bullae that rupture, producing moist erosions with a hemorrhagic base with crusting and purplish discoloration over the dorsal hands, forearms and face especially when exposed to sunlight. She is a smoker with a regular alcohol intake. She has no known comorbidities. She denies illicit drug use and only takes self-prescribed ASA and OCPs. Initial test show negative ANA result. What is the next best step?
a. Determine plasma porphyrin
b. Perform skin biopsy
c. Order phototest with UVB and UVA
d. Discontinue ASA
a. Determine plasma porphyrin
This presentation is highly suggestive of porphyria cutanea tarda (PCT), a disorder of heme biosynthesis resulting in photosensitivity and skin fragility due to accumulation of porphyrins. The next best step is to determine plasma porphyrin levels to confirm the diagnosis
Alcohol intake, smoking, and estrogen use (oral contraceptives) are all known triggers for PCT.
A 65-year-old hypertensive male presents with a generalized urticarial rash with pruritus and hypotension after undergoing whole abdominal CT Scan with contrast. He had been admitted for abdominal distension and is being worked up for mechanical bowel obstruction, probably due to a colonic mass. He claims to have no food and drug allergies and no prior exposure to diagnostic contrast media. Immediate allergic reactions which can occur on first exposure are most likely caused by which of the following mechanisms:
a. Immune complex dependent reactions
b. Non-immune cutaneous reactions
c. Ige dependent reactions
d. Mast cell degranulation
d. Mast cell degranulation
The patient’s presentation (urticaria, pruritus, hypotension) after contrast administration suggests an immediate hypersensitivity reaction to the contrast media. However, such reactions to iodinated contrast agents are often non-IgE-mediated and are instead caused by direct activation of mast cells and basophils, leading to degranulation.
A 55-year-old female consults for erythematous pustular lesions in the face with noted flushing associated with alcohol intake. Physical exam demonstrates erythematous papulopustular lesions with severe signs of inflammation and telangiectasia. Which is the best therapy to prescribe?
a. Topical glucocorticoids
b. Topical ivermectin
c. Oral glucocorticoids
d. Oral Doxycycline
d. Oral Doxycycline
The patient’s presentation is consistent with papulopustular rosacea, a subtype characterized by erythematous papules, pustules, telangiectasia, and associated flushing. In this case, the severity of inflammation and the presence of numerous papulopustular lesions warrant systemic therapy.
Why the Other Options Are Incorrect:
a. Topical glucocorticoids:
Topical steroids are not recommended for rosacea as they can exacerbate symptoms (steroid-induced rosacea).
b. Topical ivermectin:
Effective for mild to moderate papulopustular rosacea but insufficient for severe cases with systemic involvement.
c. Oral glucocorticoids:
Not indicated for rosacea; reserved for severe, refractory inflammatory diseases.
A 25-year-old student was referred for scalp itchiness. He initially dismissed the condition as simple dandruff but became anxious when the eyebrows, eyelashes and glabella were involved. He has central facial erythema with overlying greasy, yellowish scale. What is your best advise?
a. He needs high-potency topical glucocorticoid (betamethasone or clobetasol) for control of severe scalp involvement.
b. It does not spread to other areas of the body like the chest, groin, axilla and gluteal cleft.
c. Antidandruff shampoos are effective if left in place for 30 min before rinsing.
d. No treatment is necessary as it is self-limiting.
a. He needs high-potency topical glucocorticoid (betamethasone or clobetasol) for control of severe scalp involvement.
An excessive accumulation of stratum corneum is a secondary skin lesion called
A. Scale
B. Crust
C. Lichenification
D. Excoriation
A. Scale
33/F recently returned from a trip to Palawan where she took prophylactic antimalarial medications. After 1 week, she complained of severe pruritic rashes over both wrists and both lower extremities. She has no known comorbidities with no significant drug history or allergy. Skin exam reveals multiple flat topped violaceous papules and plaques with note of Wickham’s striae over both wrists and anterior lower leg areas. Her fingernails were dystrophic. What is the next best step?
A. Do skin biopsy
B. Send skin scraping specimen for KOH test
C. Start mometasone ointment
D. Start cloxacillin antibiotics
C. Start mometasone ointment
Lichen planus –> flat topped violaceous papules and plaques
Tx: steroids
A 42-year-old man, is recently diagnosed with HIV and has a CD4 count of 100. He is currentlyhospitalized due to pneumonia and receiving several courses of antibiotics. While doing rounds, he complains of discomfort and white patches on his tongue that he noticed while eating. On examination,creamy white, curd-like plaques are observed on the buccal mucosa and tongue. What is the best treatment
for this condition?
A. Nystatin
B. Fluconazole
C. Acyclovir
D. Hydrocortisone IV
B. Fluconazole
Since immunocompromised, fluco > nystatin
45/F with chronic psoriasis complains of severe pain and deformities of the small joints of both hands
and feet. What is this type of psoriatic arthritis?
A. Symmetric
B. Asymmetric
C. Distal psoriatic arthritis
D. Arthritis mutilans
D. Arthritis mutilans
A 28-year-old male, visits your clinic complaining of sudden hair loss. He reports noticing several coinsized, well-defined, bald patches on his scalp. There is no associated redness, scaling, or pain in the affected areas. He denies a history of recent illness or major life stressors nor any use of hairgel. What is the underlying pathogenesis of this condition?
A. Larger numbers of growing (anagen) hairs simultaneously enter the dying (telogen) phase
B. Increased sensitivity of affected hairs to the effects of androgens
C. The germinative zones of the hair follicles are surrounded by T lymphocytes
D. Mechanical pulling or by traction
C. The germinative zones of the hair follicles are surrounded by T lymphocytes
Alopecia areata
A 45/M farmer taking tetracycline for a week sought consult due to erythematous patches, stinging, and mild pruritus on the face, nape, neck, and dorsa of botharms. On further physical examination, the area under
the chin was spared. No lesions were noted on thechest, abdomen, and back. What is the cause of the patient’s clinical presentation?
A. Pigmentary changes due to drugs
B. Urticaria
C. Photosensitivity eruptions
D. Fixed drug eruption
C. Photosensitivity eruptions
Photosensitivity eruptions are usually most marked in sun-exposed areas, but they may extend to sun-protected areas. The mechanism is almost always phototoxicity. Common orally administered photosensitizing drugs include fluoroquinolones, tetracycline antibiotics, and trimethoprim/sulfamethoxazole. Other drugs less frequently implicated are chlorpromazine, thiazides, NSAIDs, and BRAF inhibitors. Voriconazole may result in severe photosensitivity, accelerated photoaging, and cutaneous carcinogenesis
A 63/F is on multiple medications for her rheumatoid arthritis, diabetes, and asthma. She recently developed a cutaneous drug reaction to one of her medications. You decided to do further testing to determine which specific drug caused her cutaneous drug reaction. Which of the following statement is true in determining the causality of a specific drug?
A. In vitro immunologic assays are now used by laboratories for accurate diagnosis.
B. Diagnostic rechallenge can be done even for drugs withhigh rates of adverse reactions.
C. The usefulness of laboratory tests, skin prick, or patch testing to determine causality has good practical value.
D. Two-thirds of patients with positive skin test carries 1% risk of anaphylaxis
B. Diagnostic rechallenge can be done even for drugs withhigh rates of adverse reactions.
A 43/M came to the clinical for consult. He was prescribed with topical corticosteroids for his dermatitis. However, he now presents with worsening symptoms, including increased redness, pain, and weeping lesions in the antecubital fossae. What is the most likely organism causing patient’s clinical manifestation?
A. Escherichia coli
B. Pseudomonas aeruginosa
C. Staphylococcus aureus
D. Streptococcus pyogenes
C. Staphylococcus aureus
A 40/M, presents with a chronic pruritic lesion on his left forearm that has been worsening over the past 6 months. Despite trying various over-the-counter creams, he has not experienced significant relief. On examination, a well demarcated, hyperpigmented plaque with lichenification and scratch marks is noted on the left forearm. What is the best management for the case?
A. High-potency topical corticosteroid creams or ointments
B. Moisturizers and emollients
C. Topical calcineurin inhibitors
D. Topical glucocorticoids under occlusion or intralesional injection of glucocorticoids
D. Topical glucocorticoids under occlusion or intralesional injection of glucocorticoids
Lichen simplex chronicus may represent the end stage of a variety of pruritic and eczematous disorders, including AD. It consists of a circumscribed plaque or plaques of lichenified skin due to chronic scratching or rubbing.
Common areas involved include the posterior nuchal region, dorsum of the feet, and ankles. Treatment of lichen simplex chronicus centers on breaking the cycle of chronic itching and scratching.
High-potency topical glucocorticoids are helpful in most cases, but, in recalcitrant cases, application of topical glucocorticoids under occlusion or intralesional injection of glucocorticoids may be required.
A 43/M consulted at the clinic with complaints of worsening skin lesions. He has a known history of psoriasis, which was initially diagnosed 10 years ago. Recently, he developed fatigue, generalized malaise, abdominal pain, and yellowing of the skin and eyes. Which drug is the likely offending agent?
A. Acitretin
B. Apremilast
C. Cyclosporine
D. Methotrexate
D. Methotrexate
Adverse effects of methotrexate include hepatotoxicity, pulmonary toxicity, pancytopenia, potential for increased malignancies, ulcerative stomatitis, nausea, diarrhea, and teratogenicity. Adverse effects of other choices:
A - Teratogenicity, hepatotoxicity, hyperostosis, hyperlipidemia, pancreatitis, depression, ophthalmologic effects, pseudotumor cerebri
B - Hypersensitivity reaction, depression, nausea, diarrhea, vomiting, dyspepsia, weight loss, headache, fatigue
C - Renal dysfunction, hypertension, hyperkalemia, hyperuricemia, hypomagnesemia, hyperlipidemia, increased risk of malignancies
HIV medication associated with lactic acidosis, lipid abonormalities and hyperglycemia
Zidovudine
Ritonavir can also cause lipid abnormalities and hyperglycemia
HIV medication associated with abnormal dreams
Efavirenz
HIV medication associated with PR prolongation , transaminase elevaation, renal stones
Atazanavir
HIV medication associated with inc rate of bacterial pneumonia
Enfurvitide
HIV medication associated with rhabdomyolysis
Raltegravir
Most common sites of angioedema
Periorbital and Perioral
Initial dx test for CHRONIC urticaria should include these lab tests
CBC with assessment of eosinopilia
ESR
TSH
Prophylaxis for acute HAE attacks
Infusion of isolated or recombinant C1 INH protein
Treatment of acute HAE
Bradykinin 2 receptor antagonist (Icatibant)
Kallikrein inhibitor (Ecallantide)
Hallmarks of allergic rhinitis
Episodic rhinorrhea
Sneezing
Obstruction of nasal passages
Lacrimation
Pruritus
Nasal antihistamine with dysgeusia as side effect
Azelastine and Olopatadine
Contraindication of pseudoephedrine
Narrow angle glaucoma
urinary retention
Severe hypertension
Marked CAD
1st trimester pregnancy
Contraindications of Immunotherapy (Hyposensitization)
Significant CV dse
Unstable asthma
Caution in any px on BB
What is the underlying pathology in patients who die from anaphylaxis without antecedent respiratory insufficiency?
a. Visceral congestion leading to loss of intravascular volume
b. Mechanical laryngeal obstruction
c. Bronchospasm and peribronchial congestion
d. Volume depletion due to profuse vomiting
a. Visceral congestion leading to loss of intravascular volume
A 20/F presented in the OPD due to recurrent urticaria. On probing, you note that the wheals often show up on her bilateral shoulders after a long day of carrying her backpack around. Which of the following is NOT an appropriate treatment for this patient?
a. H1 antagonist
b. H2 antagonist
c. CysLT1 receptor antagonist
d. Topical steroid
d. Topical steroid
No value in urticaria
Which of the following conditions involve deficiency in the innate immune system?
a. IgA deficiency
b. DiGeorge’s syndrome
c. Leukocyte adhesion deficiency
d. Severe-combined immune deficiency
c. Leukocyte adhesion deficiency
Which of the following is a risk factor for developing allergic rhinitis?
a. Male sex
b. Younger age
c. Maternal smoking
d. Being underweight
c. Maternal smoking
Which of the following responses is associated with biopsy findings of infiltrating and activated TH2 cells and various leukocytes?
a. Skin erythema with swelling
b. Wheal-and-flare response with pruritus
c. Bronchospasm and mucus secretion
d. Nasal pruritus and watery discharge
a. Skin erythema with swelling
ALLERGIC INFLAMMATION
Immediate phase
* Pruritus and watery discharge in the nose
* Bronchospasm and mucus secretion in the lung
* Wheal-and-flare response with pruritus in the skin
Late phase (6-8 hrs)
* Reduced nasal patency
* Reduced pulmonary function
* Erythema with swelling at the skin site
* Biopsy findings: Infiltrating and activated TH2 cells, eosinophils, basophils, and some neutrophils
During which decades are chronic urticaria/angioedema the most common?
a. Second to fourth
b. Third to fifth
c. Fourth to sixth
d. Fifth to sevenths
b. Third to fifth
CHRONIC URTICARIA/ANGIOEDEMA
Can occur at any time, with the third to fifth decade being the most common
Women > men
Slight predominance for those with a history of atopy
Who among the following could be the most at risk for ACE inhibitor related angioedema?
a. White male
b. Elderly smoker
c. Young asthmatic
d. Female cancer patient
b. Elderly smoker
RISK FACTORS FOR ACE-INHIBITOR RELATED ANGIOEDEMA
* Black race
* Organ transplant
* Female gender
* Smoking
* Increasing age
Which of the following types of physical urticaria is not influenced by atopy?
a. Cholinergic
b. Cold
c. Dermatographic
d. Solar
c. Dermatographic
DERMOGRAPHISM/DERMATOGRAPHISM
* Appearance of a linear wheal with surrounding erythema at the site of a brisk stroke with a firm object
* Peaks in the second to third decades
* Duration generally <5 years
* Not influenced by atopy
Which of the following is the best evidence for IgE and mast cell involvement in urticaria and angioedema?
a. Cholinergic urticaria
b. Cold urticaria
c. Pressure urticaria
d. Urticaria pigmentosa
b. Cold urticaria
COLD URTICARIA
* Cryoglobulins or cold agglutinins are present in up to 5%
* Histology: Marked mast cell degranulation with associated edema of the dermis and subcutaneous tissues
* Elevated histamine levels
Which of the following is the most likely diagnosis in a patient presenting with isolated angioedema and abdominal colic, nausea, and vomiting?
a. C1 inhibitor deficiency
b. Gleich syndrome
c. Mastocytosis
d. Urticarial vasculitis
a. C1 inhibitor deficiency
BRADYKININ-MEDIATED ANGIOEDEMA (ACE INHIBITORS/C1INH DEFICIENCY)
* Absence of concomitant urticaria or pruritus
* Frequent involvement of the GI tract
* Duration of symptoms >24 hrs
* *Gleich syndrome = episodic angioedema with eosinophilia
Which of the following histologic features is most likely to be found in a patient complaining of prolonged episodes of painful and nonpruritic urticaria with resultant scarring?
a. Adventitial and medial fibrosis
b. Fibrinoid necrosis of the venules
c. Perivascular lymphocytic infiltrate
d. Necrotizing granulomatous inflammation of vessel walls
b. Fibrinoid necrosis of the venules
URTICARIAL VASCULITIS
* Painful, nonpruritic urticarial lesions that last >36 hrs with subsequent scarring
* Warrants biopsy
o Cellular infiltration and nuclear debris (leukocytoclastic vasculitis)
o Fibrinoid necrosis of the venules
Which of the following is the next line of therapy for a patient with recurrent episodes of hives and wheezing upon exposure to low ambient temperatures that does not adequately respond to first-line treatments?
a. Cyclosporine
b. Hydroxychloroquine
c. Methylprednisolone
d. Omalizumab
d. Omalizumab
COLD URTICARIA
IgE and mast cell involvement
Omalizumab (monoclonal anti-IgE antibody) – next line of therapy for chronic urticaria which has failed to respond to a combination of long-acting H1 antihistamines QID and a CysLT1 receptor antagonist or cold urticaria
For which of the following types of urticaria should the addition of systemic glucocorticoids be considered in the presence of severe disease that is poorly responsive to conventional therapies?
a. Allergen-induced
b. Cold
c. Cholinergic
d. Pressure
d. Pressure
SYSTEMIC GLUCOCORTICOIDS
Useful in patients with debilitating disease that responds poorly to conventional treatment:
* Pressure urticaria
* Vasculitic urticaria (esp. with eosinophil prominence)
* Idiopathic angioedema ± urticaria
* Chronic urticaria
Generally avoided due to long-term toxicity:
* Idiopathic urticaria
* Allergen-induced urticaria
* Physical urticarias
Which of the following medications is an appropriate option for a patient experiencing sneezing and ocular itching around 2 days a week with no impairment in sleep or daily activities?
a. Intranasal glucocorticoid
b. Intranasal ipratropium bromide
c. Oral corticosteroid
d. Oral antihistamine
d. Oral antihistamine
MILD INTERMITTENT AR
* <4 days/week or
* <4 weeks
* No troublesome symptoms or impairment in sleep/daily activities
ARIA 2008
Which of the following medications is the best option for a patient suffering from daytime somnolence and fatigue due to allergic rhinitis symptoms occurring around 4 days a week for 2 weeks?
a. CysLT1 receptor antagonist
b. Intranasal glucocorticoid
c. Intranasal ipratropium bromide
d. Oral corticosteroid
b. Intranasal glucocorticoid
MODERATE-SEVERE INTERMITTENT AR
* <4 days/week, or
* <4 weeks
* (+) Troublesome symptoms or impairment in sleep/daily activities
Intranasal decongestants should be given for less than how many days to prevent rhinitis medicamentosa?
a. 10
b. 14
c. 21
d. 30
a. 10
RHINITIS MEDICAMENTOSA
Rebound nasal congestion that occurs with prolonged use (more than 10 days) of topical decongestants such as oxymetazoline and phenylephrine
In patients with seasonal allergic rhinitis, which of the following concomitant conditions might make them benefit more from a CysLT1 receptor antagonist vs. an oral antihistamine?
a. Allergic conjunctivitis
b. Brittle asthma
c. Exercise-induced bronchoconstriction
d. Postnasal drip
c. Exercise-induced bronchoconstriction
What are the most commonly involved vessels in cutaneous vasculitides?
a. Capillaries
b. Vasa vasorum
c. Terminal arterioles
d. Postcapillary venules
d. Postcapillary venules
HISTOLOGIC FINDINGS IN CUTANEOUS VASCULITIDES
* Postcapillary venules – most commonly involved vessels
* Acute: Leukocytoclasis (nuclear debris remaining from the neutrophils that have infiltrated in and around the vessels)
* Subacute/chronic: Mononuclear cell infiltration
Which of the following is a risk factor for increased mortality from anaphylaxis?
a. Asian ethnicity
b. History of beta agonist use
c. Preexisting bronchial asthma
d. Young age
c. Preexisting bronchial asthma
RISK FACTORS FOR RAPID DECOMPENSATION FROM ANAPHYLAXIS
(a) Underlying cardiovascular disease
* one of the most dangerous manifestations of anaphylaxis is involvement of the cardiovascular system
(b) Underlying bronchial asthma
* predisposed to having severe involvement of the lower airways –> leading to increased mortality
History of atopy increases the risk for which type of anaphylactic reaction?
a. Exercise-induced anaphylaxis
b. Severe hymenoptera sting
c. Anaphylaxis from insulin
d. Anaphylaxis from penicillin
a. Exercise-induced anaphylaxis
ATOPY
* Increases risk of:
(a) exercise-induced anaphylaxis
(b) Idiopathic anaphylaxis
(c) Latex-induced anaphylaxis
(d) Radiocontrast allergy
(e) Food allergy
* Not associated with:
(a) Drug allergies (insulin, penicillin, muscle relaxants
(b) Hymenoptera stings
Which gastrointestinal finding in anaphylaxis may contribute to possible cardiovascular collapse?
a. Angioedema of intestinal wall
b. Bowel ischemia
c. Bowel ulceration
d. Ileus
a. Angioedema of intestinal wall
Which case exhibits an IgE-mediated hypersensitivity reaction?
a. A 60/F with ovarian cancer, developing urticarial lesions during her first carboplatin infusion
b. A 24/F developed auricular wheals 3 days after she had new ear piercings
c. A 45/M, post kidney transplant with antibody-mediated rejection, developed arthalgias, fever, and maculopapular eruptions on the face and torso 5 days after infusion of Anti-thymocyte globulin
d. A 7/M with wheals 4 days after accidental contact with poison ivy plant
a. A 60/F with ovarian cancer, developing urticarial lesions during her first carboplatin infusion
TYPES OF HYPERSENSITIVITY REACTIONS
(A) Type 1: Immediate hypersensitivity
IgE-mediated drug allergies are most common with antibiotics and certain chemotherapeutic agents (notably platinum-based)
(B) Type II: Antibody-dependent reaction
Hemolytic anemia
(C) Type III: Immune complex reaction
Serum sickness, SLE
(D) Type IV: Delayed type hypersensitivity
Contact dermatitis, PPD test
Which is true regarding the use of serum biomarkers in anaphylaxis?
a. Serum histamine is a practical biomarker to determine severity of anaphylaxis.
b. An elevated baseline serum histamine level should prompt the clinician to investigate possible mastocytosis.
c. Serum tryptase level can remain elevated as long as 5 hours after the episode of anaphylaxis.
d. A second serum tryptase determination after an elevated initial test is not recommended.
c. Serum tryptase level can remain elevated as long as 5 hours after the episode of anaphylaxis.
SERUM BIOMARKERS
(a) Serum histamine
* Can only remain elevated up to 1 hour from onset of anaphylaxis
(b) Serum tryptase: more practical
* Peaks at 60-90 minutes after onset of symptoms
* Elevated up to 5 hours after episode of anaphylaxis
* Elevated baseline level may warrant work-up for mastocytosis
* Another determination is helpful (after resolution of symptoms) to establish baseline
* May not be elevated in food allergy
Which of the following leads to ‘empty heart syndrome’ in cases of anaphylaxis?
a. Patient in the supine position
b. Epinephrine use
c. Administration of vasopressor agents
d. Vigorous fluid resuscitation
b. Epinephrine use
EMPTY HEART SYNDROME
* Insufficient venous return to the heart from sudden onset hypotension secondary to intravascular volume depletion
* Epinephrine accelerates empty heart syndrome (chronotropic effect of drug)
* In the acute setting, patients should be placed in supine position when receiving epinephrine
* Vasopressor support and IV fluids should be given to patients with refractory hypotension
Which is true of desensitization?
a. It entails the administration of incremental increases in doses of the drug to induce permanent tolerance.
b. It is effective for penicillin and platinum-based chemotherapy allergies.
c. It works best for non IgE-mediated reactions.
d. Hypersensitivity to the drug does not recur when the medication is discontinued or treatment is interrupted.
b. It is effective for penicillin and platinum-based chemotherapy allergies.
DRUG DESENSITIZATION
* Elicits temporary state of tolerance to the drug in sensitized patients
* Established technique in penicillin allergy
* Also effective for platinum-based chemotherapeutic agents
* Shown to work best in IgE-mediated reactions
* If patient is receiving drug in regular intervals, a desensitized state can be maintained
A 60-kg male will undergo abdominal CT scan with triphasic contrast for surveillance of treated liver cancer. On review of systems, he recalled appearance pruritic rashes during last year’s CT scan. What is the correct dose and frequency of his premedication regimen prior to contrast?
a. Prednisone 30 mg tablet, 6- and 1 hour prior to CT scan + Diphenhydramine 25 mg
b. Prednisone 60 mg tablet, 6- and 1 hour prior to CT scan + Diphenhydramine 25 mg
c. Prednisone 30 mg tablet, 13-, 6-, and 1 hour prior to CT scan + Diphenhydramine 25 mg
d. Prednisone 60 mg tablet, 13-, 6-, and 1 hour prior to CT scan + Diphenhydramine 25 mg
c. Prednisone 30 mg tablet, 13-, 6-, and 1 hour prior to CT scan + Diphenhydramine 25 mg
PREMEDICATION REGIMEN PRIOR TO RADIOCONTRAST
(a) Prednisone 0.5 mg/kg, 13-, 6-, and 1 hour prior
(b) Diphenhydramine 25 mg
Which is true regarding biphasic anaphylaxis?
a. This is a clinical entity wherein signs and symptoms do not fully respond to initial treatment.
b. It is more common than uniphasic anaphylaxis.
c. Signs and symptoms recur less than an hour after onset of initial anaphylactic reaction.
d. Signs and symptoms may recur as late as 72 hours after resolution of initial reaction.
d. Signs and symptoms may recur as late as 72 hours after resolution of initial reaction.
BIPHASIC ANAPHYLAXIS
* Less common than uniphasic reactions (80-90% of anaphylactic reactions are uniphasic)
* Biphasic anaphylaxis: defined as recurrent anaphylaxis after complete improvement
* Must be clinically differentiated from an episode that does not fully respond to treatment
* Reported to occur between 1 to 72 hours after resolution of initial reaction
Which of the following primary immunodeficiencies is secondary to impaired development of T lymphocytes?
a. Ataxia telangiectasia
b. Common variable immune deficiency (CVID)
c. Severe combined immune deficiencies (SCID)
d. Wiskott—Aldrich Syndrome
c. Severe combined immune deficiencies (SCID)
What is the hallmark of severe congenital neutropenia (SCN)?
a. Absence of pus
b. Florid mycobacterial infections
c. Localized fungal soft tissue infections
d. Refractory to GCSF
a. Absence of pus
SEVERE CONGENITAL NEUTROPENIA (SCN)
* A PID of the innate immune system
* Characterized by severely impaired neutrophil counts
* Bacterial and fungal infections rapidly disseminate through bloodstream
* Absence of pus is the hallmark of SCN
* In most cases, neutrophil counts improve with injection of GCSF
o Exception: + ELANE mutation (refractory to GCSF); same subset of patients are at increased risk of AML
Which is true of infections arising from chronic granulomatous diseases (CGD)?
a. Fungal elements are rarely isolated from deep tissue abscesses in the lungs and lymph nodes.
b. Recurrent skin infections are uncommon.
c. Macrophage-rich granulomas seen in the liver and spleen are often sterile.
d. Granulomatous lesions are mostly steroid-refractory.
c. Macrophage-rich granulomas seen in the liver and spleen are often sterile.
CHRONIC GRANULOMATOUS DISEASES
* Bacterial and fungal abscesses are usually seen; in fact, prophylactic regimen includes azole derivatives
* Recurrent skin infections, such as folliculitis, are common– that these prompt early diagnosis of disease
* Granulomas are often sterile and steroid-responsive
Which subset of CD4 T helper cells is activated when the immune system encounters Mycobacterium tuberculosis?
a. TH1
b.TH2
c.TH9
d.TH17
a. TH1
40/F with three pregnancy losses is being worked up for reproductive immune disorders. On lymphocyte subset enumeration, elevated CD16/56 levels were the only abnormal finding. What could possibly explain this?
a. Allergen immunotherapy
b. Breast cancer
c. HIV-1 infection
d. Parasitic infection
b. Breast cancer
Elevated levels of CD16/56+ natural killer (NK) cells can be associated with several conditions, including reproductive immune disorders, malignancies, and immune system dysregulation.
T cells must maintain tolerance to self antigens to avoid causing damage to cells. Which of the following demonstrates central tolerance of T cells?
a.T-cell anergy
b.Suppression by regulatory T cells
c.Clonal deletion in the lymph nodes
d.Modification of T cell receptors
d.Modification of T cell receptors
A 32/M is referred for recurrent abscesses in the lungs and liver. TB workups are negative, and the organism isolated is usually Staphylococcus. HIV test is negative. If his dihydrorhodamine fluorescence assay is positive, what is the underlying pathophysiology of his condition?
a.Defective interferon-dependent macrophage activation
b.Defective neutrophil development from precursor
c.Defective neutrophil migration to infected tissues
d.Defective reaction oxygen species production
d.Defective reaction oxygen species production
The patient’s presentation of recurrent abscesses caused by catalase-positive organisms like Staphylococcus suggests chronic granulomatous disease (CGD). A positive dihydrorhodamine (DHR) fluorescence assay indicates defective production of reactive oxygen species (ROS) by neutrophils.
A 25/M is referred for chronic bronchiectasis. He was treated for PTB twice due to apical infiltrates in his x-ray during his younger years, but all sputum samples were negative for MTB. He had frequent respiratory tract infections in childhood necessitating hospitalizations and IV antibiotics. Which of the following diagnostics would be most useful to investigate possible primary immunodeficiency in his case?
a.Absolute neutrophil count
b.Classic complement pathway assay
c.Post vaccination titers
d.Tuberculin skin testing
c.Post vaccination titers
The patient’s history of chronic bronchiectasis, recurrent respiratory infections requiring IV antibiotics, and repeated treatment for suspected tuberculosis despite negative sputum tests raises the suspicion of primary immunodeficiency, particularly antibody deficiency disorders such as common variable immunodeficiency (CVID) or specific antibody deficiency.
27/F presents with 2-month history of angioedema without wheals or pruritus. Which laboratory test can be used as a screening test for this disease?
a.Histamine
b.Complement levels
c.Serum IgE
d.Tryptase
b.Complement levels
This presentation is consistent with hereditary angioedema (HAE) or acquired angioedema (AAE), particularly since the angioedema is non-pruritic, without wheals, and has persisted for 2 months. These features strongly suggest bradykinin-mediated angioedema, not histamine-mediated processes like allergic reactions
Screening Test: Complement Levels
C4 levels:
C4 is typically low in both hereditary and acquired angioedema.
It is a sensitive and cost-effective screening test for these conditions.
C1 inhibitor (C1-INH):
If C4 is low, further testing for C1-INH levels and function can confirm the diagnosis.
In HAE, C1-INH is deficient (Type I) or dysfunctional (Type II).
In AAE, C1-INH is consumed due to an underlying condition like lymphoma or autoantibodies.
What is TRUE about the pathology in urticaria?
a.It is characterized by edema of the subcutaneous tissue and deep dermis.
b.The perivenular infiltrate consists of lymphocytes, monocytes, eosinophils and neutrophils.
c.Collagen bundles in the affected areas are packed tightly.
d.The venules are always constricted
b.The perivenular infiltrate consists of lymphocytes, monocytes, eosinophils and neutrophils.
Which of the following is part of the late cellular phase of allergic inflammation?
a.Reduced pulmonary function
b.Mucus secretion
c.Watery nasal discharge
d.Wheal and flare
a.Reduced pulmonary function
Which of the following antihistamines may be safely increased to four times the amount of the daily dose in the treatment of chronic urticaria?
a.Chlorpheniramine
b.Diphenhydramine
c.Fexofenadine
d. Hydroxyzine
c.Fexofenadine
In the treatment of chronic urticaria, second-generation antihistamines like fexofenadine can be safely increased up to four times the standard daily dose when symptoms are inadequately controlled with the regular dose.
28/F with bronchial asthma complains of nasal congestion, rhinorrhea and sneezing occurring daily for several months. She was prescribed an intranasal glucocorticoid/antihistamine spray and Montelukast but she still complains of difficulty sleeping due to nasal congestion. She also underwent skin prick testing which was positive to house dust mite, and she has since practiced environmental allergen control measures. What can be an additional treatment for this patient’s allergic rhinitis that is also beneficial for her asthma?
a.Immunotherapy
b.Oral glucocorticoids
c.Nasal decongestants
d.Intranasal ipratropium bromide
a.Immunotherapy
An 81/F church volunteer consults the clinic for episodes of purulent rhinosinusitis and dyspnea, worsened by exposure to incense and dust. She claims she recently developed an allergy to painkillers. Serum specific IgE to aeroallergens were negative, while serum eosinophil levels were elevated. What would be the most likely diagnosis for this patient?
a.Allergic rhinosinusitis with upper airway cough syndrome
b.Aspirin-exacerbated respiratory disease
c.Atrophic and vasomotor rhinitis in the elderly
d.Non-allergic rhinitis with eosinophilic syndrome
b.Aspirin-exacerbated respiratory disease
Which of the following T cells activate and recruit eosinophils and other cells required to fight helminthic infections?
a. CD4+ TH1 cells
b. CD4+ TH2 cells
c. CD4+ TH17 cells
d. Cytotoxic CD8+ T cells
b. CD4+ TH2 cells
T CELL EFFECTORS
* CD4+ TH1 cells: help in intracellular killing of Salmonella and mycobacterial infections
* CD4+ TH2 cells: activate eosinophils, among others, to help fight helminthic infections
* CD4+ TH17 cells: recruit neutrophils to skin and lungs to fight bacterial and fungal infections
* Cytotoxic CD8+ T cells: kill infected cells (viral infections)
Which is true of severe combined immune deficiencies (SCID)?
a. Failure to thrive and recurrent oral fungal infections are frequent manifestations of the disease.
b. Bacille Calmette-Guarin (BCG) vaccine can be safely given to infants with SCID.
c. Pneumocystis jiroveci pneumonia is exclusively seen in children afflicted with this T cell immunedeficiency.
d. Severe infections and other clinical consequences occur after the first year of life.
a. Failure to thrive and recurrent oral fungal infections are frequent manifestations of the disease.
SCID
* Most common manifestations: protracted diarrhea, recurrent oral candidiasis, and failure to thrive
* P. jiroveci pneumonia may also be seen during the first year of life in patients with B cell immunedeficiencies
* Administration of BCG vaccine may lead to complications, such as local and disseminated fatal infections
* These severe clinical consequences occur early in life (within 3 to 6 months of birth)
Which of the T cell immunodeficiencies places the affected individual at very high risk for development of hematopoietic and solid organ malignancies in his lifetime?
a. Ataxia-telangiectasia
b. Dyskeratosis congenita
c. Omenn Syndrome
d. SCID
a. Ataxia-telangiectasia
IMMUNODEFICIENCY WITH ATAXIA-TELANGIECTASIA
* T cell primary immunodeficiency associated with DNA repair defects
* Progressive disease
* Hallmark features: cerebellar ataxia and telangiectasia
* Affected individuals are at very high risk for lymphomas, leukemia, and carcinomas in adulthood
Which B cell immunodeficiency can be a manifestation of myelodysplastic syndrome?
a. Agammaglobulinemia
b. Common variable immunodeficiency (CVID)
c. Hyper IgM syndrome
d. IgA deficiency
a. Agammaglobulinemia
Which of the following is a common clinical manifestation of Wiskott-Aldrich Syndrome?
a. Alopecia
b. Cerebellar ataxia
c. Eczema
d. Pneumatoceles from complicated respiratory infections
c. Eczema
WATER
Wiskott Aldrich –> Thrombocytopenia, Eczema Recurrent infection
Which is the most frequent trigger of Hemophagocytic lymphohistiocytosis (HLH)?
a. CMV infections
b. EBV infections
c. Streptococcal infections
d. Enteroviral infections
b. EBV infections
HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH)
* Characterized by unremitting activation of CD8+ T cells and macrophages that lead to organ damage
o Often induced by viral infections
* Most frequent: EBV infections
Which of the following strongly suggests SCID?
a. Eosinophilia
b. Lymphocytopenia
c. Neutropenia
d. Platelet clumping
b. Lymphocytopenia
DIAGNOSIS OF SCID
* Lymphocytopenia – strongly suggests SCID (seen in at least 90% of cases)
* Caveat: this may be masked by presence of maternal T cells (derived by maternal-fetal blood transfers)
Which is true regarding management of SCID?
a. Hematopoietic stem cell transplantation (HSCT) is often not curative.
b. SCID does not respond to immunoglobulin replacement.
c. Gene therapy is effective in all phenotypes of SCID.
d. Aggressive antimicrobial prophylaxis/treatment should be instituted.
d. Aggressive antimicrobial prophylaxis/treatment should be instituted.
TREATMENT OF SCID
* Anti-infective therapies
* Nutritional support
* Immunoglobulin replacement
* HSCT: high curative potential
A 55 year old female sought consult after developing pruritic, red wheals of varying sizes at the torso, and both upper and lower extremities that started last night. She also complained of body malaise and fever up to 38.3o C which was relieved with paracetamol. She denies any allergies to food and medications. However, around a week ago, she visited the local health center to get injected with tetanus toxoid after a pedicure accident. What classification of allergic reaction would most likely explain the patient’s symptoms?
a. Type I: IgE-mediated
b. Type II: IgG mediated cytotoxicity
c. Type III: Immune-complex mediated
d. Type IV: T-lymphocytic mediated inflammation
c. Type III: Immune-complex mediated
A 30 year old woman came in for 1 week history of cough with nasal catarrh. She was treated as a case of Community Acquired Pneumonia Low Risk, and was started on Cefaclor 500 mg/tablet 1 tablet BID. She subsequently developed generalized pruritic rash, joint pains, and fever. She improved upon treatment with systemic steroids. Available laboratories showed normal CBC, Creatinine and Complement Levels. Which one of the following diagnoses is most likely in this case?
A. Serum sickness reaction to Cefaclor
B. Serum sickness-like reaction to Cefaclor
C. Delayed-type hypersensitivity reaction to Cefaclor
D. Immunoglobulin E–mediated allergy to Cefaclor
A. Serum sickness reaction to Cefaclor
Which of the following statements is true regarding allergic rhinitis?
a. Almost 70-80% of patients with allergic rhinitis have asthma
b. In the acute attack of allergic rhinitis, TH1-mediated inIammation predominate over TH2-mediated inIammation
c. Total serum IgE is usually elevated and is enough to establish the etiologic diagnosis
d. It involves interaction occurs between the allergen and intraepithelial mast cells as well as deeper perivenular mast cells
d. It involves interaction occurs between the allergen and intraepithelial mast cells as well as deeper perivenular mast ce
a– 50% of px with allergic rhinitis have asthma
b TH2 >TH1
A 34 year old American male tourist was rushed to the emergency room due to severe dyspnea after eating karekare in a turo-turo restaurant. He was previously diagnosed to have peanut allergy and was previously attempteddesensitization but failed.
Which of the following statements is true regarding his condition?
a. Typical symptom onset ranges from a few minutes to a few hours after exposure to offending agent
b. People with asthma are at increased risk of dying from this condition
c. Cutaneous manifestations are rare, typically involving only <10% of the cases; majority of the symptoms are respiratory
d. Histamine release causes fIushing, urticaria, pruritus and bronchoconstriction
b. People with asthma are at increased risk of dying from this condition
a. usually <1 hr
c. cutaneous –> majority
d. histamine does not cause bronchoconstriction
A 18 year old college student came in to your clinic for recurrent cough with productive sputum, sometimes reported to be foul smelling. Since he was a growing child, his mother reported that his son has always been “sickly” and he had many bouts of recurrent pneumonia which were managed with unrecalled antibiotics, only to recur a few months after. High resolution chest CT scan revealed dilatation of the airways predominantly involving the lower lobes. Which of the following conditions is most likely present in the patient?
a. Cystic Fibrosis
b. Alpha-1 antitrypsin deficiency
c. Hypogammaglobulinemia
d. Non-tuberculous mycobacteria (NTM) infection
c. Hypogammaglobulinemia
The patient’s recurrent respiratory infections, productive cough, and bronchiectasis predominantly involving the lower lobes are suggestive of an underlying immunodeficiency disorder, specifically hypogammaglobulinemia, such as common variable immunodeficiency (CVID)
A 50-year-old woman with breast cancer recently received her 2nd cycle of Trastuzumab, a monoclonal antibody targeting the HER/neu in breast cancer cells. The infusion was unremarkable. 2 days later, however, she developed fever with temperatures from 38.4 to 38.7C, well-circumscribed raised ovoid skin lesions with serpiginous borders, multiple joint pains, tender and swollen axillary and inguinal lymph nodes. What is the underlying pathophysiology of this reaction?
a. Immune complex
b. IgG-mediated cytotoxicity
c. T-lymphocyte mediated inflammation
d. IgE-mediated
a. Immune complex
The patient’s symptoms—fever, ovoid skin lesions with serpiginous borders, lymphadenopathy, and joint pains—suggest serum sickness-like reaction (SSLR), which can occur after administration of certain medications, including monoclonal antibodies like trastuzumab.
A 24-year-old man consults you for sneezing, tearing, and itchiness of the eyes and nose for the past 3 days. He mentioned having acquired a new pet cat. He has congested nasal mucosa but no nasal polyp. He wakes up with headache on the morning of this consultation with you. Which of the following is consistent with your diagnosis?
a.You need to avoid NSAIDs for his headache as these can reproduce his symptoms
b.His condition can also develop among individuals with chronic staphylococcal colonization of the nasal mucosa
c.If he develops fever, it is likely due to secondary infection of the sinuses or the middle ear
d.Being a male is risk factor for this condition
c.If he develops fever, it is likely due to secondary infection of the sinuses or the middle ear
The patient’s symptoms of sneezing, tearing, nasal congestion, and itchiness that began after acquiring a cat strongly suggest allergic rhinitis. Morning headaches are common in allergic rhinitis due to nasal congestion and sinus pressure. Fever, however, is not typical of allergic rhinitis and, if present, suggests a secondary bacterial infection, such as sinusitis or otitis media.
A 55-year-old woman was referred for rashes after an IV contrast scan. The lesions appear as oval, raised erythematous, with distinct borders and blanched center appearing on the hands, chest and back. The patient mentions the rashes to be very itchy. There is no shortness of breath. What is your initial intervention?
a. Hydrocortisone 100mg IV every 8 hours
b. Loratadine 10mg tablet PO
c. Montelukast 10mg tablet PO
d. Ranitidine 150mg tablet PO
b. Loratadine 10mg tablet PO
The patient’s presentation suggests acute urticaria following IV contrast administration. This is a histamine-mediated hypersensitivity reaction that is non-life-threatening (no shortness of breath or anaphylaxis is mentioned). The primary treatment for this condition is an oral second-generation antihistamine like loratadine, which effectively blocks histamine-mediated symptoms such as itching and erythema.
KT, a 24-year old female came for evaluation of scarring rashes. 2 weeks ago, after attending a buffet party, noted wheal-like lesions on the arms and trunk, described as painful and non-pruritic. These persisted despite the intake of Diphenhydramine 25mg/cap and lesions were noted to scar and persist until today. Skin biopsy showed cellular infiltration with nuclear debris and fibrinoid necrosis with prominence of eosinophils. Management for this condition would include:
a. Clobetasol ointment
b. Montelukast
c. Mupirocin ointment
d. Prednisone
d. Prednisone
First-line therapy for urticarial vasculitis is systemic corticosteroids to reduce inflammation and immune activation.
A 28/F, presents to your clinic multiple maculopapular lesion, recurrent diarrhea and abdominal pain. Bone marrow biopsy showing 50% mast cell infiltration. Serum tryptase is significantly elevated. Which of the following is the appropriate symptom directed management?
a. Proton Pump Inhibitor
b. Oral cromolyn sodium
c. Loratadine
d. Systemic glucocorticoid
b. Oral cromolyn sodium
A 25/M presents with recurrent episodes of gastrointestinal colic and laryngeal edema. He denies pruritus and does not have urticarial lesions. Laboratory testing reveals a deficiency of C1INH antigen. Which type of hereditary angioedema (HAE) is most likely?
a. Type 1
b. Type 2
c. Type 3
d. Acquired C1INH deficiency
a. Type 1
A 44/M had a 10-year history of epilepsy which was well controlled on sodium valproate. He recently had an episode of seizure and was prescribed with Carbamazepine. After 8 days, he presented at the ER with general malaise, fever and tachycardia. He had widespread blisters accompanied by mucosal and genital ulcerations. What is the key pathway in this case?
a. IgE
b. Immune Complex
c. T lymphocyte-mediated cytotoxic T lymphocyte inflammation
d. T lymphocyte mediated neutrophil inflammation
c. T lymphocyte-mediated cytotoxic T lymphocyte inflammation
Patient has SJS/TEN due to widespread blisters and mucosal ulcerations
A 25/F, with history of recurrent crampy abdominal painand diarrhea was diagnosed with aggressive systemicmastocytosis. Which of the following is a consistentclinical feature?
A. ANC 1,500/uL
B. Hemoglobin 11 g/dL
C. Platelet 90,000/uL
D. Albumin > 3.5 g/dL
C. Platelet 90,000/uL
Patient EG came to the ER due to dizziness, dyspnea and generalized wheals after running 5km running in treadmill. He claimed that he ate muffins for his lunch before running. Which of the following allergens is most commonly implicated in exercise-induced anaphylaxis?
A. Eggs
B. Milk
C. Wheat
D. Peanuts
C. Wheat
Exercise-induced anaphylaxis can be precipitated by exertion alone or can be dependent on food ingestion prior to exercise. There is an association with the presence of IgE specific for α-5 gliadin, a component of wheat.
40-year-old female was recently diagnosed with hypertension and was started with Enalapril. She complained of periorbital edema and dyspnea. What is the pathophysiology of her condition?
A. Impaired bradykinin degradation
B. Mutation in SERPING1 gene
C. Binding of IgE to human mast cells and basophils
D. Generation of bradykinin in the setting of C1 inhibitor (C1INH)
A. Impaired bradykinin degradation
Angioedema without urticaria can be idiopathic or due to the generation of bradykinin in the setting of C1 inhibitor (C1INH) deficiency that may be inborn as an autosomal dominant mutation or may be acquired through the appearance of an autoantibody in the setting of malignancy or autoimmune disease.
The angiotensin-converting enzyme (ACE) inhibitors can provoke a similar clinical presentation in 0.2–0.7% of exposed patients due to delayed degradation of bradykinin. Black race, organ transplant, female gender, smoking, and increasing age are known risk factors for ACE inhibitor–related angioedema
35-year-old female was diagnosed with urticaria. She was given cetirizine 10 mg ODHS but noted to have
persistent urticaria. What is the next best step of action?
A. Add montelukast 10 mg OD
B. Add famotidine 20 mg OD
C. Increase dose of cetirizine
D. Shift to levocetirizine
C. Increase dose of cetirizine
For most forms of urticaria, H1 antihistamines effectively attenuate both urtication and pruritus; long-acting, non sedating agents, such as loratadine, desloratadine, and fexofenadine, or low-sedating agents, such as cetirizine or levocetirizine, generally are used first and can be increased to up to four times daily dosing.
A 40-year-old male complains of recurrent nasal congestion and postnasal discharge when exposed to cold environment. You diagnosed him with vasomotor rhinitis and started with olopatadine. What adverse effect of the medication should you tell your patient to watch out for?
A. Dysgeusia
B. Insomnia
C. Glaucoma
D. Urinary retention
A. Dysgeusia
The nasal antihistamines azelastine and olopatadine may benefit individuals with nonallergic vasomotor rhinitis as well as have additive benefit to intranasal steroids in allergic rhinitis, but they have an adverse effect of dysgeusia (taste perversion) in some patients.
The typical skin lesion seen in patients with serum sickness or serum sickness like reaction
A. Small blisters form from dusky macules
B. Diffuse red morbilliform eruption
C. Purpuric eruption along sides of hands and feet
D. Swelling of central face
B. Diffuse red morbilliform eruption
A - Steven Johnson Syndrome
B - Drug-induced hypersensitivity syndrome
C - Serum sickness or serum sickness-like reaciton
D - Angioedema
