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Immunology > Allergy > Flashcards

Allergy Flashcards

1
Q

Drugs most likely to be allergic to

A

Penicillin - offer testing so can access antibiotics
Cephalosporins
Anesthetic agents

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2
Q

Type 1 hypersensitivity

A

Immediate
Anaphylaxis, allergy
IgE mediated

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3
Q

Type II hypersenstivity reaction

A

Cytotoxic T cells
Anitbody and/or complemetn against cell surface
Incl gracves disease and myasthenia gravis

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4
Q

Type III HS reaction

A

Immune complex mediated
-> deposition in tissues - inflammation
Rheuamtoid arhtritis, SLE

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5
Q

HS reaction/type IV

A

Delayed
T cell mediated
Steven johnson syndrome, chronic transplant rejection, contact deramtitis

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6
Q

IgE released by what

A

Mast cells and basophils
Makes them release histamines et

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7
Q

Three pahses of anaphylaxis

A

Sesnsitisation
Immediate phase reaction
Late phas reaction 6-12 hours after first symptoms

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8
Q

Sensitisation

A

Allergens -> APCs -> MHC II and antigens -> naive T cells + IL-4 -> Th2 cells -> B cell activation -> class switching -> IgE antibody specific to allergen.
Coat surface of mast cells in circulation

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9
Q

Immediate phase reaction

A

Allergen encountered - IgE Cross linking on surface of mast cell -> degranulation mast cell -> histamine and triptase release

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10
Q

Effect of histamine release

A

Oedema, itching, rash
Bronchoconstriction, mucous secretion, reduced cardiac contractility, increased vascular pereability, vasoconstriction, venodilation - reduce blood to tissues and heart

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11
Q

Clinical features of anaphylaxis resp

A

SOB
Tachypnoea
Wheeze or stridor
Chest tightness
Resp arrest

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12
Q

CVS symtpoms of anaphylaxis

A

Tachy/brady
Palpitations
Hypotension/collapse
Cardiac arrest

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13
Q

GI symtpoms anaphylaxis and skin

A

ABdo pain
N+V, diarrhoea
Hypoglycaemia
Urticaria
Angioedema

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14
Q

CNS symtpoms in anaphylaxis

A

Feeling of impending doom
Headache
Altered mental status
Confusion, drowsiness

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15
Q

Mild symptoms of anaphylaxis

A

Oral symptoms
Urticaria
Angioedema - incl facial aslong as doesnt compromise airway

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16
Q

Modertae allergy symptoms

A

Abdominal pain
N+V, diarrhoea
Mild wheeze
Lum in throat

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17
Q

Treatment for mild/mod allergy

A

Mild - oral antihistamines
Mod - oral antihistamines +/- oral steroids + monitoring

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18
Q

Severe symtpoms or anaphylaxis

A

Any compromise of AW, breathing or circulation

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19
Q

What causes late phas reaction 6-12 hours after initial

A

Eosinophils and basophils - cytokines and leukotriens

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20
Q

What can repeat exposure of allergen cause

A

Strucutral damage - allergic rhinitis, allergic asthma

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21
Q

What is ahypersensitivity reaction

A

Reaction to normally harmless substance tolerated by others who are not allergic

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22
Q

What is delayed systemic allergy

A

Food protein indued enterocolitis - FPIES

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23
Q

IgE mediated allergy features

A

Acute onset, immediate
Release of histamine via IgE mechanisms
Urticaria, angioedema

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24
Q

Features of non IgE mediated allergy

A

Delayed onset, T cell mediated
Release of histamine via non IgE mechanisms
Dysmotility, eosinophilic oesophagitis, FPIES

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25
Q

Types of immune mediated food allergy

A

Cell mediated
Mixed IgE and nonIgE mediated
Non IgE mediated
IgE mediated

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26
Q

Allergic co-morbidities

A

Atopic dermatitis - eczema
Food allergy
Allergic rhinitis
Atopic asthma
Drug allergy

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27
Q

Clues to food allergy

A

Timing
Nature
Reproducibility
Amount of allergen
Tolerated before or not

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28
Q

IgE mediated skin

A

Pruritis
Eyrthema
Acute urticaria localised or generalised
Acute angioedema - lips, face and around eyes

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29
Q

Non IgE mediated skin reaction

A

Pruritis
Erythema
Atopic suppurative eczema
Refer multi system organ disease

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30
Q

What causes atopic dermatitis more high risk for food alelrgy

A

Genetic predisoposition- filaggrin mutation -> low collagen and elasticity -> sensitisation of all allergens through broken skin barrier -> high risk

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31
Q

Eczema linked confitions

A

Food allergies
Eczema herpeticum
Stpah aureus/strep infection

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32
Q

IgE mediated GI symptoms

A

Angioedema lips, tongue and palate
Oral pruritis
Nausea
Colicky abdo pain
Vomitting, diarrhoea
Faltering growth

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33
Q

Non IgE mediated GI symtpomms

A

Delayed, due to gutwall infalmmation
GORD
loos or frequent stools
Blood +/- mucus in stools
Abdo pain
Infantile colic
Food refusal or aversion
Constipation
Perianal redeness
Pallor and tiredness
Faltering growth

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34
Q

Most common food allergies

A

Cows milk
Eggs
Nits
Fish
Shellfish
Soya
Wheat Kiwi

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35
Q

Rescue medication pack for food allergy

A

ANtihistamine eg cetirazine
If asthma:
Bronchodilator eg salbutamol
Adrenaline auto-injector

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36
Q

What risks do not take with food allergy

A

Abroad
Remote area
Exercising
Dining out

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37
Q

Examination for allergy

A

Growth and physical signs of malnutrition and signs indicating allergy related co-morbidities

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38
Q

When consider non IgE mediated food allergy

A

atopic eczema, GORD, chronic GI symptoms, wheeze dont resolve on treatemnt
Consider dysphagia, water chasing, bolus obstruction in eosinophilic oesophagitis

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39
Q

When should food allergy be cnosidered in hildren

A

Faltering growth
Malnutrition
Pscyhlogu - anxiety, food refusal

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40
Q

What is best investigations for IgE mediated allergy suspected

A

Skin prick testing
Speciic IgE testing

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41
Q

What does positive result of skin prick or IgE test mean

A

Sensitisation - does not mean confirmed allergy, may have asymtomatic sensitisation

42
Q

What use as control in skin prick test

A

Saline
Some people will react just to pressure if sesntiive skin - dermographism

43
Q

Pros of skin prick testing

A

Rpaid
Wide range of allergens
Relatively cheap
Good sepcificity and les sprone to fals positives than bloods in atopic individuals

44
Q

Cons of skin prick tsting

A

Risk of allergy reaction
Difficult if skin pathology
Cant be on antihitamines/antipsychtoics
Labour intesive

45
Q

What is specific IgE testing

A

Enzyme immunoassay, IgE sitcks, incubates with anti-IgE antibody -> colour chagen
Quantitivae result - <0.35 is negative

46
Q

Pros and cons of specific IgE testign

A

No risk of reaction as no allergenc exposure
Not affected by drugs
Wide range of allergens
Individual compinenets can test

Cons - False positives esp in atopy (raised total IgE), expensive, some allergens not available, variable sensitivity

47
Q

What is intradermal testing

A

rug allergy testing - bleb injected into skin Diluted drug
Start w skin prick test then move onto this
Validated for small number of drugs, often antibiotics

48
Q

What is gold test in allergy

A

Food and drug challenge

49
Q

What is food and drug challenege pors and cons

A

Observed environemtn
Treatemnt readily available
If tolerated rules out allerfy
Difficutl differentiate non allergy symptoms and allergic symptoms

50
Q

Test for contact dermatitis (IVHS)

A

Patch testing - 48-72 hrs and see if erythematous reaction
Derm
Not useful in IgE mediated alergy

51
Q

ABCDE signs anaphylaxis

A

Hoarse voice, stridor
Increase work breathing, wheeze, fatigue, cyanosis, O2<94%
Low BP, shock, confusion, reduced consciousness
Glushed, urticaria, angioedmea

52
Q

Management of anaphylaxis

A

Remove trigger - stop any infusion
Lie patient falt iwth legs elevated (sat may be easier to breathe)
Pregnant lie on LHS
IM adrenaline 500mg 1:1000
O2 if 94-98%
IV fluid (IO if no route)
Consider bronchodilators eg salbutamol, iatropium neb aswell as further adrenaline first

53
Q

What are not part of emergency treatment for anaphylacis

A

Steroids - refractory w ashtma/shock
Antihistamines (AVOID chloramphenamine - sedating)

54
Q

What is refractory anaphylaxis

A

Support needed after 2 doses of adrenaline
ITU

55
Q

Investigations in anaphylaxis

A

12 lead ECG
CXR
U+Es
ABGs
Mast cell tryptase

56
Q

Mast cell peak

A

1 hr after sypmtom onset

56
Q

Mast cell triptase when take

A

Minimum one within 2 hours of anaphylaxis, no later than 4 hours after symptom onset
Ideally 3 times - asap after treatment, 1-2 hrs but not later than 4, at least 24 hours after complete resolution

57
Q

When can you consider fast track discharge after anaphylaxis (2 hrs after resolution)

A

Good response 5-10 minutes to single dose adrenaline given 30 mins onset
Complete symptom resolution
Unused adrenaline auto-injectors at home and trained
Adequate supervision following discharge

58
Q

When do you keep patient in for minimum 6 hrs observation after resolution

A

2 doses IM adrenaline needed
Prev biphasic reaction

59
Q

When do you need to monitor a patient for 12 hours after resolution symptoms

A

Sev reaction requiring >2 doses of adrenaline
Sev asthma or reaction incl sev resp compromise
Possibility of continuing absorption of allergen eg slow release medicines
Late at night presenation - may not respond to deterioration
Areas where access to emergency care is difficuly

60
Q

What give with discharge from anaphylaxis

A

Consider prescribing adernaline auto-injectors to everyone (except maybe drug, esp if unknown or common allergen)
Specialist refer
Patient education signs and symtpoms
Register anaphylaxis at the anaphylaxis registry

61
Q

Who shld adrenaline autoinjectors have cautino in

A

Cardiovascular disease esp if on beta blockers
Less effective
Rebound hypertension

62
Q

How many pens do patients need to carry

A

2
First device may not work or not get full dose
May need a second dose before get to a+e

63
Q

LOOK AT RESUS COUNCIL GUIDELINES

A
64
Q

What is urticaria and what cuses it

A

Superficial swelling of skin - epidermis and mucous membranes -> red, raised ithy rash
Can have pale centre
Surrounding ey=rythema - wheels
Histamine causes

65
Q

wHAT IS ANGIOEDMEA and what causes it

A

Deeper swelling in dermis or SC/submucosal tissues
Can be painfulk
Main mediator = bradykinin

66
Q

Acute vs chronic urticaria and angioedmea

A

Acute <6 weeks
Chronic >6 weeks, daily

67
Q

Treatment of local reaction to sting etc

A

Antihistamine eg cetirizine
Prednosolone rescue pack 20mg
Seek medical advise

68
Q

Which resolves faster, urticaria or angioedema

A

Urticaria - fleeting, returns to normal in 30 mins to 24 hours
Angioedema slower - up to 72 hrs

69
Q

Chronic urticaria features

A

Females 2:1
Peak 30-40 yrs
More common in atopy
2-3% of pop

70
Q

What is chronic spontaneous urticaria

A

Spontaneous appearance of wheels/angioedmea for >6 weeks due to unknown causes

71
Q

Types of acute urticaria

A

Cold
Delayed pressure
Solar
Vibratory
Cholinergic
Contact
Aquagenic

71
Q

Causes of urticaria

A

Idiopathic
Stress, infection
Meds - NSAIDs, opiates, ACEi (angioedema)
Environemntal - hot, cold, pressure
Minor trauma - dermogrpahism
Exercise
Vibration
Heta
Thyroud dysfunction
Electrolyes - B12, folate, ferriting, vitD
H.pylori infection
Urticarial vasculitis

72
Q

Diagnosis/investigation urticaria bloods

A

On exam/piture
Bloods - GBC,U+E, LFT,
B12, folate, ferritin, vit D
C4, C1 inhibitor - angioedmea
ANA, TPO/TG antibodies - AI
Provoking tests - cold, heat etc

73
Q

Chronic urticaria prognosis

A

Often relapsing remitting
Spontaneous resolution 60^ 1 year, 80% 5 years
20% remain symptomatic 10 years

74
Q

Stepwise treatment for urticaria

A

1 - Standard dose non sdeating H1 antihistamine
2 - Higher dose - 4x recommended dose or add in 2nd antihistamine
3 - Consider a second line agent anti-leukotriene eg montelukast (angioedema - tranexamic acid)
4 - immunomodulant eg omalizumab, cyclosporine, mycophenolate, methotrexate

75
Q

2nd generation antihistamines how use in urticaria

A

Certizine, loratidine 20mg BD fexofenadine 360mg BD
Daily dose, titrate to higher

76
Q

What can use in severe urticaria

A

Steroids eg prednisolone for 3-5 dyas

76
Q

When is montelukast esp helpful in urticaria

A

Conurrent reactivity to aspirin, NSAIDs, AI or pressure urticaria

77
Q

How does cyclosporin treat urticaria

A

Ibhibits mast cella nd basophil degranulation

78
Q

Side effects of cyclosporin

A

Headache, nausea tremor, renal impariemtn

79
Q

What need to monitor in cyclosporin

A

BP, FBC, U+Es, urinalysis

80
Q

What is omalizumab

A

Monoclonal antibody against IgE

81
Q

What is omaluzimab used in

A

Treatment of CSU and sev asthma
300mg SC monthly injection

82
Q

When is omaluzimab used in CSU

A

Severe in adults and children >12 if:
Evidence of disease severity eg UAS7 score >28
Failed maximal medical therapy ie antihistamines + LTRA

83
Q

Side effects of omaluzimab

A

Injection site reactions
Sinusitis, headache, arthralgia, transient worsening of urticaria

84
Q

How assess urticaria severity

A

Urticaria actiity score - UAS7
<7 = good control
>28 = severe disease

85
Q

How soon after anaphylaxis can do skin prick test

A

4-6 weeks

86
Q

Immediate drug reaction features and onset

A

Urticaria, angioedmea, bronchospasm, N+V abdo pain, anaphylaci
1-6 hrs, typically in 1st

87
Q

Non immediate drug reactions and when

A

Maculopapular rashes, steven johnson syndrome, toxic epidermal necrolysis, serum sickness, drug fevers, pneumonitis, nephritis
8-12 hrs to days

88
Q

Key areas to consider in relation to drug reactions

A

Description of reaction
Symptoms sequence and duration
Treatment provided
Outcome
Timing in relation to drug administration
How long had the drug been taken before the onset of the reaction
When was drug stopped ?
What was the effect of stopping the drug
Photograph of reaction illness for which drug was taken (illness may be cause)
Other medications which being taken at the time
Other allergies Other illnesse

89
Q

What is DRESS syndrome

A

Drug reaction with eosinophilia and systemic symptoms
Begins in 3rd week of being on drug
10% mortality

90
Q

What is allergic rhinpconjucntivitis

A

Hayfever

91
Q

Signs of vernal conjunctivits

A

Hard flat topped papillae in cobblestone or pavement stone fashion on conjunctiva

92
Q

Treatment for hayfever

A

Long act 2nd gen antihistamines eg cetirazine, fexofenadine
Regular nasal steroids
Eye drops - cromoglicate, nedocromil, olopatadine
Start before pollen arrives and maintain throughout season
If poor control oral pred 5-7 dyas

93
Q

What steroid cant use in allet=rgic rhinoconjunctiitis

A

Kenalog eg triamcinolone
Risk of avascular necorsis of arge joints

94
Q

When is desensitisation therapy indicated in rhinoconjunctivitis

A

triple therapy, oral steroids required

95
Q

When is desnesitisation helpful and how is it provided

A

helpful in severe cases and reduces symptoms and need other medication - some may still be required
Requires commitmnet and 3 years of treatment
Continious sublingual therapy or winter courses of 4-6 injections

96
Q

Considering triggers for allergic rhinoconjunctivitis

A

Infection
Environemntal triggers - smoke, perfume, weather, alcohol, spicy food, stress
Medicines and recreational drugs - ACEis, beta blockers, NSAIds, cocaine
Overuse of nasal congestatnts >5-7 dyas then rebound
Hormone changes- pregnanyc, oubertuy, HRT, OCP
Structural nasal problems - deviated septum, polyps

97
Q
A

Immunology (4 decks)

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