Allergy Flashcards
What allergies respond to immunotherapy:
- venom sensitivity (sting)
- seasonal allergic rhino conjunctivitis
- asthma triggered by allergen
Can treated by immunotherapy?
- food allergy
- bee sting
- pen allergy
- atopic dermatitis
- cholinergic urticaria
Bee Sting
T or F: allergen immunotherapy is recommended for kids < 5.
False.
- increased risk of systemic rxn and difficulty treating anaphylaxis in this age
List 3 contraindication to immune therapy
- Beta blocker
- ACEI
- Allergic bronchopul aspergillosis
What is the interval btwn IVIG and live vaccination?
11 month.
IVIG can be given in EXCEPT:
- ITP
- bone marrow transplant
- nephrotic syn
- KD
- GBS
? Nephrotic syn
What is RAST?
Radioallergosorbent test
= Allergen specific IgE
Skin test has low (+) predictive value so definitive test= quantitive IgE= RAST.
T or F: skin testing is more sensitive than RAST.
True.
T or F: RAST is preferred for food allergies.
False
(-) skin test R/O IgE form of food allergy= prefer as more sensitive.
BUT most (+) do not react when ingested so definitive testing followup.
T or F: RAST false (+) can occurs in kids with hyper-IgE states.
True.
What is the benefit of RAST compared to skin testing:
- no risk allergic rxn
- not affected by med
- no reliant on skin integrity
Limit: only certain allergen (food, insect, venom, environment, med)
13 month old with rash + diarrhea w/ intro of new foods. Most likely?
Carb intolerance.
- loose stool, abdo pain
- typically w/ onset new food (fruit)
- sucrase-isomaltase deficiency (milk fine but sucrose and start get symptoms. Rx sacrosidase/ Sucraid)
Kid w/ peanut rxn. IgE test ordered. Why:
- RAST more sensitive
- RAST good predictor of future
- don’t have to stop montelukast
- prevent systemic rxn that could happen w/ skin
Prevent systemic rxn that could result from skin test.
- you don’t have to stop montelukast for either; antihistamine do affect skin
- denote sensitized state but NOT equivalent to severity
2 advantage for skin test and 1 disadvantage:
Adv:
- fast
- good sensitivity
Disadv:
- affected by antihistamine
- affected by extensive dermatitis
- risk of allergic rxn
T or F: Long term F/U show allergic rhinitis persist into adulthood.
True.
T or F: indoor mould is NOT a trigger for allergic rhinitis.
False.
T or F: most kids with allergic rhinitis will develop asthma.
False.
T or F: perennial rhinitis due to ingested rather than inhaled allergen.
False.
Mainly inhaled.
Best therapy for perennial allergic rhinitis:
Avoid exposure to allergy
Hamilton: best therapy- intranasal steroid chosen over avoidance as not always easy.
Best med for allergic rhinitis:
intranasal steroids (most effective)
list 3 signs off P/E expected to see with kid with runny nose and itchy eyes in summertime:
- Allergic Shiners
- Dennie Lines
- Transverse nasal crease
- Pale boggy nasal turbinates (compared to beefy red)
Name two adv to 2nd generation anti-histamine:
= less likely CNS effect (less sedating)
= quick onset
= longer acting
Mom worried about allergic rhinitis- 4 things on hx that suggest this?
- seasonal
- specific environmental trigger (dust, dander)
- (+) fhx
- maneuver= allergic salute (rubbing), allergic cluck , allergic conjunctivitis
- (+) pmhx atopy
What is the definition of anaphylaxis?
- Acute w/ skin or mucosa AND one of:
- resp
- low BP
OR
- **Two after likely allergen:
- Skin/mucosal
- Resp
- Low BP
- persistent GI
OR
- reduce BP after KNOWN exposure (low systole or > 30% drop systolic)
What is dose for epi in anaphylaxis?
1: 1 000
0.01 mg/kg IM lateral thigh.
q5-15 minute.
What is the CPS anaphylaxis algorithm:
- Epi 1 in 1K 0.01mg/kg IM thigh. Max 0.5mg. Repeat q5
- ABC- O2, monitor, IV access x 2
> Airway concern= prep intubation
> Circulatory concern= bolus NS 20 cc/kg - 2nd line med:
> PO/IV H1 and H2 antagonist
> IV steroids
> Salbutamol - Reassess.
Must observe min. 4-6 hour.
Why give epi IM thigh?
- higher peak plasma than arm
- IM faster
- SC may cause local vasoconstrictor = inhibit absorption
- IV dosing can be off and cause significant AE
T or F: benadryl can be given IV, IM, PO
True.
Which route should you always give epi in anaphylaxis?
IM
Lateral thigh.
Most common cause of anaphylaxis out of hosp? In hospital?
Food
- most common= milk, egg
- most potent= peanut, tree nut
> bee wasp
> Med
In hosp= med, latex
T or F: plasma tryptase is reliable BW for anaphylaxis.
False.
No reliable BW
Tryptase will stay elevated but not in food-induced.
List 4 preventive recommendation for anaphylaxis to cow’s milk:
- Allergen avoidance
- Education re: anaphylaxis symptoms
- Epi-Pen
- Emergency Plan
Name 4 Patient RF for anaphylaxis:
- infant or teen
- asthma
- beta blocker or ACEI
- exercise or fever
What is acute versus chronic urticaria def’n?
Acute < 6 wk
- likely food, med, sting, infection
Chronic > 6 wk
- like idiopathic, physical (inducible like dermatographism, cold, solar), AI (thyroid, SLE, JIA)
- CBC, U/A, LFT, thyroid, ESR +/- other
What is main treatment for urticaria:
- Remove trigger
- Histamine blocker
1st choice= Cetirizine - Max out H1 then H2 (ranitidine)
- Steroids if severe angioedema or not responsive to H1, H2
What is tx of chronic urticaria if failed h1 antihistamine?
H2 antihistamine.
Recurrent facial + ear swelling. FHX of same. Non pruritic. Likely Dx?
C1 esterase deficiency
= hereditary angioedema - AD - swell over 1.5 day OR bout of abdo pain - low C4 level Dx: C1 level Tx: replenish C1 inhibitor
Which is true of pen anaphylaxis:
- IgG against major determinant
- IgG against minor
- IgE against minor
- IgE against major
- IgM against major
IgE against major
13 mon. diarrhea + diaper rash.
- cow’s milk protein allergy
- carb intolerance
- immunodeficiency
Carb intolerance
T or F: all milk allergy develop by 12 months of age.
True.
Describe food protein (FP) induced enterocolitis syndrome versus FP induced protocolitis versus FP induced enteropathy?
FP induced enterocolitis:
- 1 wk-3 mo; up to 1yr
- hr after cow’s milk
- V/D, bloody stool, edema, FTT
- casein hydrolysate
- symp. improve 3-10d
- resolve by 2 y.o.
FP induced enteropathy:
- cows milk sensitivity common till 2 y.o.
- diarrhea, FTT, low alb
- rarely bloody stool
- celiac most severe
- Protein elimination; symp clear in 1-3 weeks
- rechallenge in 1-2 yr; most resolve by 2-3 y.o.
FP induced protocolitis:
- seen in first 6 mo.
- only bloody stool
- bloody streak food
- casein hydrolysate
- resolve by 9-12
- reintroduce over 2 wk
What is toddler’s diarrhea:
9-24 mo. explosive stool w/ flecked food particle no blood excessive juice, low fat, low fibre clinical dx limit fluid, increase dietary fat
How do you treat poison ivy?
- Wash skin and other items that may be contact
- Systemic antihistamine
- Topical steroids (mild-moderate typically)
List 2 cutaneous skin findings in anaphylaxis:
Urticaria
Angioedema
Pruritus
Flushing
List 2 resp skin findings in anaphylaxis:
Rhinorrhea Congestion Hoarseness Stridor Cough Wheeze SOB
List 2 GI skin findings in anaphylaxis:
Vomiting
Diarrhea
Abdo Pain
List 2 CVS skin findings in anaphylaxis:
Tachy HR
Low BP
Lethargy
LOC
When would you give IV epi for anaphylaxis?
- 3 doses IM
- persistent low BP despite 20cc/kg NS bolus
Goal: titrate until normal BP
Remember: change concentration (1 in 10K) titrate till normal BP.
What do you if patient w/ anaphylaxis on beta blocker and resistant to epi?
Glucagon Bolus
Antihistamines work on which system in anaphylaxis?
Cutaneous
If no vomit= use cetirizine PO
If vomit= diphenhydramine
List risk factors for anaphylaxis biphasic response
Severe symptom at ppt
Delayed epi
> 1 epi dose
Which is true regarding serum specific IGE?
- more sensitive
- affected by steroid
- affected by antihistamine
- false (+) if elevated total IgE
False (+) in pt with elevated total IgE
How do you prevent food allergy in high risk infant (1st degree relative w/ atopy)
- No dietary restriction in pregnancy/BF
- BF exclusive x 6 mo
- hydrolyzed formula if not BF
- do not delay intro to specific food (including allergenic) > 6 mo.
- regular new intro (several time per week) key to keep up maintenance
When do you offer allergy testing and possible immunotherapy for stings or bites?
Anaphylaxis
OR
> 16 AND high (frequent exposure) AND generalized cutaneous rxn
6 y.o. on amox. After 10d- arthritis, rash, fever. Management:
- NSAID
- Pred
- IVIG
- Plasmaphoresis
Serum Sickness Like.
Severe= Pred
What is the cross reactivity between pen and cephalosporin?
2%
Get same red spot in exact same area every time med taken. Dx?
Fixed drug eruption.
Tx: D/C med
Topical steroid, antihistamine
What is serum sickness?
1-3 wk post drug
Rash
Fever
Arthralgia/arthritis
Low complement
D/C med
Steroids if severe
What is the diff between serum sickness like and serum sickness?
SS- Like:
- Cefaclor, Pen common
- NO renal dx
- NORM complement
Patient w/ egg allergy need flu shot.
- Allergy test
- Vaccine split dose
- Full dose
- No vaccine
Full dose
What vaccine can people allergic to eggs NOT get?
Yellow fever vaccine.
Need skin testing prior to vaccine given.
Teenager has tingling/pruritus in mouth w/ apple + peace. Best test for dx?
- skin prick apple, peach
- serum specific IgE apple, peach
- oral food challenge
- skin test to birch
Skin test to birch pollen
** oral allergy syndrome
How do you treat oral allergy syndrome?
- pollen testing +/- fresh fruit testing (IgE useless)
- AVOID raw food; can have cooked
- Epi pen (esp if high risk peanut allergy or systemic rxn)
How do you confirm milk intolerance?
- D-xylose
- jejunal bx
- milk RAST
- serum IgE
- milk challenge
Milk Challenge
Drug non IgE reaction. Likely immune mech:
- type 1
- type 2
- type 3
- type 4 hypersensitivity
type 3
T or F: You can give diphenhydramine IV or PO only.
False.
IM too.
