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Allergy & Immunology Flashcards

1
Q

What is Anaphylaxis?

A
  • Acute systemic IgE-mediated reaction
  • Antigen binding to IgE on the surface of mast cells & basophils
  • Release of potent mediators
    • Vascular tone
    • Bronchial reactivity
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2
Q

What is the etiology of anaphylaxis?

A
  • Drugs
  • Insect venom
  • Foods
  • Latex
  • Biologic agents
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3
Q

What are the clinical features of anaphylaxis?

A
  • Pruritis, flushing, urticaria, angioedema
  • Dyspnea, wheezing
  • Nausea, vomiting, diarrhea, crampy abd pain
  • CV symptoms (mild hypotension to shock)
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4
Q

How is anaphylaxis diagnosed?

How is it treated?

A
  • Clinical signs & symptoms that appear w/i 30 min
  • Principal treatment: Epinephrine
    • Acute resp & CV complications
  • Systemic antihistamines, corticosteroids, ß-adrenergic agonists
    • Treat signs & symptoms
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5
Q

What are the 8 allergic conditions of childhood?

A
  • Allergic asthma
  • Anaphylaxis
  • Allergic rhinitis
  • Atopic dermatitis
  • Food allergies
  • Urticaria
  • Drug allergies
  • Insect venom allergy
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6
Q

Allergic rhinitis

definition

epidemiology

etiology

A
  • IgE-mediated inflammatory response in the nasal mucosa to inhaled antigens
  • 10-20% of children
  • Seasonal or perennial
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7
Q

Seasonal rhinitis vs. Perennial rhinitis

A
  • Seasonal rhinitis
    • Tree, grass, wood pollens
    • Grass in spring, ragweed in fall
  • Perennial rhinitis
    • Indoor allergens
    • Dust mites, animal dander
    • Molds (high-humidity)
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8
Q

What is the pathophysiology of Allergic Rhinitis?

A
  • Sensitization to airborne allergens induces IgE
  • Allergen-specific IgE binds to receptors on mast cells & basophils in the nasal mucosa
  • Subsequent exposure produces an IgE-mediated inflammatory response (minutes)
  • Mast cells degranulate
    • Histamine, leukotrienes, kinins, PGs
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9
Q

What are the signs & symptoms of allerigic rhinitis?

A
  • Sneezing, nasal congestion, rhinorrhea, nasal itching, pale nasal mucosa
  • Allergic shiners
    • Dark circles under the eyes
    • Caused by venous congestion
  • Dennie’s lines
    • Creases under the eyes
    • Result of chronic edema
  • Allergic salute
    • When patient uses the palm of the hand to elevate the tip of the nose to relieve itching
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10
Q

Allergic rhinitis is commonly associated with…….

A
  • Asthma
  • Chronic sinusitis
  • Otitis media w/ effusion
  • Nasal polyps
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11
Q

What medical history contributes to the diagnosis of allergic rhinitis?

A
  • Multiple episodes of otitis media
  • Sinusitis
  • Atopic dermatitis (eczema)
  • Food or drug allergies
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12
Q

What laboratory evaluation contributes to the diagnosis of allergic rhinitis?

A
  • Elevated total IgE concentration
  • Allergen skin testing (prick/intradermal)
    • Skin tests are the most effective
    • Discontinue antihistamines 4-7 days before
  • Nasal smear for cytology
    • >10% eosinophils
    • Preponderance of polymorphic leukocytes suggests infection
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13
Q

What are the 5 steps of managing allergic rhinitis?

A
  • Allergen avoidance
  • Pharmacotherapy
  • Immunotherapy
  • Patient education
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14
Q

What are some allergen avoidance measures?

A

IgE Ab production may decrease

  • Child’s bedroom should be free of allergens
  • Remove pets or keep outdoors
  • Dust mite control
    • Plastic mattress covers
    • Removal of carpets/stuffed animals
  • Reduce humidity (dust mites, mold)
  • Avoid open windows
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15
Q

What types of pharmacotherapy are used to treat allergic rhinitis?

A
  • Intranasal steroids
    • Most effective
    • SE: local irritation
  • Anti-histamines
    • 1st generation are first line
      • Diphenhydramine
      • SE: sedation, impair academic performance
    • 2nd generation
      • Cetirizine, fexofenadine, loratadine
      • Safer & better tolerated
      • No more effective
    • Intranasal may be effective
  • Intranasal cromolyn sodium
    • Prevents mast cell degranulation
  • Decongestants
    • Pseudoephedrine
    • Vasoconstriction, relieve congestion
    • SE: insomnia, nervousness, rebound rhinitis, decongestants
  • Leukotriene receptor antagonists
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16
Q

How/why is immunotherapy used for allergic rhinitis?

A
  • Effective for allergic rhinitis, allergic asthma, insect venom allergy
  • Principle: repeated injections of allergens w/ time lead to better tolerance of the allergen by the patient
  • Indications
    • Other therapy is ineffective in controlling symptoms
    • Environmental controls have been tried & failed, or exposure is unavoidable
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17
Q

What is Atopic Dermatitis?

A
  • Chronic inflammatory dermatitis (eczema)
  • Dry skin & lichenification (thickening of skin)
  • Pruritis leads to scratching
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18
Q

Atopic dermatitis

prevalence

seasonal changes

family history

A
  • 5-8% of children
  • Begins in early infancy (85% <5 YO)
  • Worse in winter or w/ extremes of temp
  • Family members w/ atopic dermatitis, asthma, other allergic diseases
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19
Q

In atopic dermatitis, _______ is universal.

A

pruritis

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20
Q

What are the skin manifestations of atopic dermatitis?

A
  • Acute changes
    • Erythema
    • Weeping & crusting
    • Secondary bacterial (Staph aureus) or vial (HSV) infection
  • Chronic changes
    • Lichenification
    • Dry scaly skin
    • Pigmentary changes (hyper)
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21
Q

Clinical presentation of atopic dermatitis

  • Infantile form
  • Early childhood
  • Late childhood
A
  • Infantile form
    • Truncal & facial areas, scalp
    • Extensor surfaces
  • Early childhood
    • Flexural surfaces
    • Lichenification, chronic itching
  • Late childhood
    • Localized disease, remission
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22
Q

What are the major & minor criteria for diagnosis of atopic dermatitis?

A
  • 3 of 4 major criteria
    • Pruritis
    • Personal/family hx of atopy
    • Typical morphology/distribution
    • Relapsing or chronic dermatitis
  • Minor criteria
    • Xerosis (abnormal dryness)
    • Pruritis w/ sweating
    • Wool intolerance
    • Dermatographism: stroking of the skin w/ a dull instrument that produces a pale wheal w/ a red flare
    • Skin infections
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23
Q

How is atopic dermatitis managed?

A
  • Avoid known triggers
    • Wool, foods (egg, milk, peanuts), excessive heat/cold, harsh chemicals/soaps
  • Low-medium potency corticosteroids
    • Affected areas except the face
    • Systemic in severe cases
  • Antihistamines
    • Bedtime, reduce itch-scratch cycle
  • Baths
    • Tepid water, blot skin dry, lubricate
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24
Q

Food allergies

definition

etiology

A
  • IgE-mediated response to food antigens
  • Most allergic rxns to food (85-90%) caused by egg, milk, peanut, soy, wheat, fish
  • Exclusive breastfeeding for 6 mo may reduce food allergies/atopic dermatitis in the infant
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25
What are the 6 clinical features of food allergies?
* **Oral symptoms** * Itching/swelling of lips, tongue, throat * **GI symptoms** * N/V, diarrhea, abd pain * **Respiratory symptoms** * Nasal congestion, rhinorrhea, sneezing, wheezing * **Atopic dermatitis** * **Acute urticaria & angioedema** * **Anaphylaxis**
26
How are food allergies diagnosed?
* History (type, timing, severity of symptoms) * Labs * Skin tests * IgE mediated hypersensitivity * Radioallergosorbent (**RAST**) tests * IgE Ab to specific food antigens * Provocative oral food challenge * Double-blind placebo-controlled
27
How are food allergies managed?
* Strict avoidance of the responsible food allergen * Injectable epinephrine
28
**Insect venom allergy** definition etiology clinical features
* **IgE-mediated response** to the venom of stinging or biting insects * Venom of many insects (yellow jackets, hornets, wasps, bees, fire ants) * **Localized erythema & swelling** * Urticaria or anaphylaxis
29
How are insect venom allergies managed?
* Local skin reactions * Cold compresses, analgesics, antihistamines * Diffuse urticaria * Antihistamines, systemic steroids * Anaphylaxis (previous section) * Immunotherapy
30
What is the definition of **urticaria**?
**Hives** * Circumscribed, raised, evanescent (vanishing) areas of edema that are almost always pruritic * Symmetric & migratory
31
What are the **acute** causes of urticaria?
* Drugs (penicillin, aspirin, NSAIDs) * Foods & food additives * Eggs, shellfish, milk, nuts * Contactants (animal dander, latex) * Idiopathic * Infection * GABHS, infectious mono, myoplasma pneumoniae, hepatitis, coxsackie virus * Insect venoms * Transfusion rxn * Heat & cold * Skin pressure * Exercise
32
What are the **chronic** causes of urticaria?
* Malignancy * Rheumatologic disease * SLE, RA * IgG Ab to IgE receptors * Idiopathic * Thyroid disease
33
Acute vs. chronic urticaria
* **Acute** * Healthcare workers & patients w/ myelomingocele (exposed to latex due to repeated urinary catheterization) are at a risk for latex allergy * **Chronic** (\>6 mo) * Underlying conditions * IgG Ab to IgE receptor
34
How is urticaria managed?
* Precipitating factor should be avoided * **Antihistamines** are mainstay of therapy * Further evaluation for underlying systemic dz * w/ fever, arthralgias, weight loss, abd pain
35
Reactions to drugs are mediated by \_\_\_\_\_\_.
IgE or by direct mast cell degranulation
36
What is the **etiology** of drug allergies?
* Many pharm agents documented * Most common * **Penicillin** * Sulfonamides * Cephalosporins * **Aspirin, NSAIDs** * **Narcotics**
37
How are drug allergies managed?
* Antihistamines * Anaphylaxis (previous section) * Medic alert bracelets
38
What are the **innate** responses of the immune system?
* Phagocytic cells * NK cells * TLRs * MBP * Alternative pathway of complement
39
What are the **adaptive** responses of the immune system?
* T cells * B cells * Immunoglobulin molecules
40
Primary immunodeficiency states
* B-cell defects (disorders of humoral immunity) * T-cell defects (disorders of cell-mediated immunity) * Disorders of granulocytes * Complement deficiencies
41
Secondary immunodeficiency states
* AIDS * Meds (steroids, chemo) * Malnutrition * Nephrotic syndrome
42
What are the diagnostic tests to evaluate **humoral immunity**?
* Quantitative immunoglobulins * B-cell enumeration * Ab titers to immunization (diphtheria, tetanus) * Isohemagglutinin titers
43
What are the diagnostic tests to evaluate **cell-mediated immunity**?
* Peripheral smear (look for lymphopenia) * Anergy panel (delayed type hypersensitivity) * T-cell subsets (CD3, CD4, CD8) * In vitro T-cell proliferative responses to mitogens & antigens
44
What are the diagnostic tests to evaluate **phagocyte function**?
* Peripheral smear (look for neutropenia) * Nitroblue tetrazolium test * Measurements of neutrophil chemotaxis
45
What are the diagnostic tests to evaluate **complement**?
* Total hemolytic complement (CH50) * Assays of specific components of complement
46
75% of all primary immunodeficiency diseases involve abnormalities of \_\_\_\_\_\_\_\_.
Ab concentration or function
47
What are the 7 disorders of lymphocytes?
* IgA deficiency * Common variable immunodeficiency * Severe combined immunodeficiency disease (SCID) * Ataxia telangiectasia * DiGeorge syndrome * Wiskott-Aldrich syndrome * X-linked (Bruton's) agammaglobulinemia
48
What is IgA deficiency?
* **Serum IgA concentrations \<7 mg/dL** * Normal levels of other immunoglobulins * 50% have IgE deficiency * 20-30% have IgG2 & IgG4 subclass deficiencies
49
What is the **epidemiology** & **etiology** of IgA deficiency?
* IgA is the most common immune deficiency * 1/500-1,000 * Genetic basis sometimes present, usually unclear
50
What are the 4 clinical features of IgA deficiency?
* **Respiratory infections** * Sinusitis, pneumonia, otitis media, bronchitis * **GI manifestations** * Chronic diarrhea, Giardia lamblia * **Autoimmune & rheumatic diseases** * SLE, JRA, celiac disease * **Atopic diseases** (50%) * Allergic rhinitis, eczema, urticaria, asthma
51
**IgA deficiency** diagnosis management
* Quantitative measurement of serum immunoglobulins (\<7 mg/dL) * Management of infections & other complications * IVIG _NOT_ indicated (almost all IgG)
52
What is Common Variable Immunodeficiency (**CVID**)? Prevalence? Etiology?
* **Hypogammaglobulinemia** * 1 in 10,000-100,000 * Variety of defects in B-cell function or B-cell & T-cell interaction
53
What are the 4 clinical features of CVID?
* **Respiratory infections** * *H. influenzae* * *Moraxella catarrhalis* * *Strep pneumoniae* * **GI infections** * *Giardia lamblia* * *Campylobacter jejuni* * **Autoimmune disorders** * RA, autoimmune thyroiditis, autoimmune thrombocytopenia, autoimmune hemolytic anemia * **Increased risk of malignancy**
54
How is CVID diagnosed?
* Quantitative immunoglobulin measurement * Decreased * Diminished Ab function * Measure titers in response to vaccines * T-cell proliferation to mitogens (nonspecific stimulators of lymphocytic production) may be diminished
55
How is CVID managed?
* Monthly IVIG replacement * Aggressive management of infections w/ abx * Chronic diarrhea management * Nutritional support
56
What is Severe Combined Immunodeficiency Disease (**SCID**)? What is the etiology?
* Defective T-cell & B-cell function * **X-linked SCID** * Deficiency in common gamma chain of the receptor for IL-2, IL-4, IL-7, IL-9, IL-15 * 50% of all SCID cases * **Autosomal recessive SCID** * Genetic defects of T-cell ontogeny/function * Adenosine deaminase deficiency (30%)
57
What are the **clinical** features of SCID?
* Infection w/i the first few mo of life * *Candida albicans* * *Pneumocystis carinii* * Chronic diarrhea * Failure to thrive
58
What are the 4 components of **diagnosing** SCID?
* **Persistent lymphopenia** * \<1,500 lymphocytes/mL * **Enumeration of lymphocyte populations** * Flow cytometry, decreased T cells * **Quantitative measurement of serum Ig** * Severe hypogammaglobulinemia * **T-cell responses to mitogens & antigens** * Severely depressed
59
How is SCID managed?
* **Supportive care** (abx, nutrition, psych) * **Blood products should be irradiated** (GVHD) * **Monthly IVIG replacement** (normal serum IgG) * *P. carinii pneumonia* **(PCP) prophylaxis** * TMP-SMX * **Bone marrow transplant curative** * GVHD, infection, med toxicity * Cord blood stem cell or peripheral blood stem cell transplant (alternative) * **Gene therapy** (future)
60
**Ataxia telangiectasia** definition etiology
* **Autosomal recessive disorder** * Characterized by: * Combined immunodeficiency * Cerebellar ataxia * Oculocutaneous telangiectasias * Predisposition to malignancy * **Mutation of gene on long arm of chr 11** * Cell cycle control * DNA recombination * Cellular responses to DNA damage
61
What are the 4 main clinical features of ataxia telangiectasia?
* Variable immunodeficiency * **Chronic sinopulmonary infections** * Severe progressive cerebellar ataxia * **Wheelchair** in early adolescence * Telangiectasias * **Bulbar conjunctiva (2-5 YO)** * Later on exposed skin, areas of trauma * High risk of malignancy * **Defects in DNA repair** * Lymphoma, carcinoma
62
Additional clinical features of ataxia telangiectasia?
* Cafe-au-lait spots * Vitiligo * Prematurely gray hair * Multiple endocrine abnormalities
63
How is ataxia telangiectasia diagnosed?
* **Quantitative measurement of serum Ig** * IgE deficiency (85%) * IgA deficiency (75%) * **Evaluation of T-cell function** * Skin test anergy * Diminished T-cell proliferation to mitogens
64
How is ataxia telangiectasia managed?
* Treat the neurologic complications * Aggressively treat infections * Monitor for malignancies * Avoid ionizing radiation * Exacerbates DNA breakage & repair * Increases risk of malignancy
65
What is DiGeorge syndrome?
* Congenital immunodeficiency syndrome * Submicroscopic deletion on chr arm 22q11 * **CATCH-22** * **C**ardiac defects * **A**bnormal facies * **T**hymic hypoplasia * **C**left palate * **H**ypocalcemia
66
What is **Wiskott-Aldrich syndrome**?
* **X-linked disorder** * Characterized by: * Combined immunodeficiency * Eczema * Congenital thrombocytopenia * Small platelets
67
What is the **etiology** of Wiskott-Aldrich syndrome?
* Mutation of gene on _short arm_ of X chromosome * Gene product important in **T-cell receptor signaling & cytoskeletal organization**
68
What are the **3 clinical features** of Wiskott Aldrich syndrome?
* Susceptibility to infections w/ **encapsulated organisms** * *H. influenzae, S. pneumonaie* * No Ab to polysaccharide antigens * Thrombocytopenia * **Small defective platelets** * Frequent bleeding episodes * Risk of intracranial hemorrhage * **Eczema**
69
How is Wiskott Aldrich syndrome **diagnosed**?
* CBC * Thrombocytopenia, small platelets * Decreased IgM * Ab response to polysaccharide An defective * Cellular immune function defective * Anergy present * Near normal # T-cells but respond poorly * Don't develop antigen-specific cytotoxic T-cells
70
How is Wiskott Aldrich syndrome managed?
* **HLA-matched bone marrow transplantation** * **IVIG** for hypogammaglobulinemia * **Splenectomy** cures thrombocytopenia (\>90%) * Prophylactic abx or IVIG afterwards
71
What is X-linked (**Bruton's**) Agammaglobulinemia?
* Severe hypogammaglobulinemia * Paucity of mature B cells * \<1% B cells in peripheral blood * Normal T-cell number & function
72
What is the **etiology** of Bruton's Agammaglobulinemia?
* **Mutations in the BTK gene on X chr** * Critical to normal B-cell otogeny * Mutations lead to block in development from pre-B cell to mature B-cell
73
What are the **clinical** features of Bruton's Agammaglobulinemia?
Increased susceptibility to infections w/ encapsulated bacteria (*S. pneumoniae, H. influenzae*), *S. aureus* & chronic enteroviral infection
74
How is **Bruton's** **Agammaglobulinemia** diagnosed? Management?
* Quantitative immunoglobulin * B cells absent/diminished * T cells present, cell-mediated functions ok * Mutations in BTK gene * Treatment: **monthly IVIG replacement** * Prevents infection
75
What are the 3 disorders of granulocytes?
* Chronic granulomatous disease * Schwachman-Diamond syndrome * Chediak-Higashi syndrome
76
What is Chronic Granulomatous Disease (**CGD**)? What is the etiology?
* **Defective neutrophil oxidative metabolism** * Defects in multi-component reduced NADPH oxidase system * Severely **impaired intracellular killing of catalase+ bacteria** & some fungal pathogens * Inheritance: X-linked (70%)
77
What are the **clinical** features of CGD?
* Increased susceptibility to **infections** * Lungs, lymph nodes, liver, spleen, bones, skin * **Abscess formation** is characteristic * Major pathogens * *S. aureus, P. aeruginosa, Salmonella, Klebsiella pneumoniae, Serratia marcescens, E. coli, C. albicans, Aspergillus*
78
How is CGD diagnosed?
* Demonstration of defective neutrophil oxidative burst * Nitroblue tetrazolium (NBT) test * Flow cytometric assay
79
Management of CGD?
* Abscesses require **surgical drainage/abx** * Prophylactic **TMP/SMX** reduces infections * Prophylactic **itraconazole** (*Aspergillus*) * **Interferon-gamma** * **Bone marrow transplant** is curative * **Gene therapy** is a future cure
80
**Schwachman-Diamond Syndrome** * definition * inheritance * clinical presentation
* Autosomal recessive * **Characterized by:** * Decreased neutrophil chemotaxis * Cyclic neutropenia * Pancreatic exocrine insufficiency * **Clinical presentation** * Recurrent soft tissue infection * Chronic diarrhea * Failure to thrive
81
**Chediak-Higashi Syndrome** * definition * clinical presentation
* Neutropenia & thrombocytopenia * Giant lysosomal granules in neutrophils * Neutrophils & monocytes have functional defects * NK cell function impaired * Majority of infections: *S. aureus* * Clinical: **partial oculocutaneous albinism**
82
The **complement** system is composed of......
* Plasma proteins & cellular receptors * Intregrated series of rxns to prevent infection
83
**Disorders of the Complement System** definition etiology
* Absence/dysfunction of individual complement components or regulatory proteins * Genetically determined (autosomal recessive)
84
Clinical features of deficiencies of the early components of the **classic pathway (C1q, C2, C4)**
* Autoimmune diseases * Example: SLE
85
Clinical features of the late components of the **classic pathway (C5, C6, C8)**
Increased susceptibility to disseminated **meningococcal** & **gonococcal** infections
86
Clinical features of deficiency/dysfunction of **C1 esterase inhibitor**
* **Hereditary angioedema** * Episodic swelling of various body parts * Hands & feet * Bowel wall swelling * Severe abdominal pain * Angioedema affecting the airway * FATAL
87
How are disorders of the complement system **diagnosed**?
* **Quantitative**: specific assays * **Qualitative**: total serum hemolytic complement (CH50)
88
How are disorders of the complement system **managed**?
* Prompt diagnosis & treatment of bacterial infections * Management of autoimmune disease * **Therapy w/ fibrinolysis inhibitors & attenuated androgens (danazol) for hereditary angioedema**

Pediatrics (24 decks)

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