allergy questions Flashcards
15kg child dev anaphylaxis, how much 1:1000 epi do you inject?
child: 0.01 mg/kg = .15mL
adult 03.-0.5 mL
what is used in treatment vials as preservative? at what [ ] ? how long does it keep? as a bacteriostatic agent?
10% glycerin
breaks down after 6-8 weeks, so preserves vial for 12 weeks
phenol
what cytokines are halmark for Th1? Th2?
A major theory of allergy is based on the difference between Th1 and Th2 Tcells. Th1 steer the immune system towards fighting infection/autoimmunity by activating macrophages. The main cytokines of Th1 modulated defenses are IFN, IL2, and TNF. Th2 cells steer the immune system towards defense of parasites/worms which require the release of IgE. There is a main theory that an allergic person’s immune system is imbalanced, favoring Th2 reactions whenever an allergen is encountered. The cytokines involved in Th2 immunity are: IL4, IL5 (assoc’d with eos), IL10, IL13.
what are risk factors to anaphylaxis in immunotherapy?
. Risk factors for anaphylaxis include: labile/symptomatic asthma, buildup phase of IT, high sensitivity by testing, previous anaphylaxis during prior injections, active allergy season, new vial, vial prepared at another office, human error.
During traditional escalation schedule during injection immunotherapy, a patient tolerates 0.10 ml IT shot without acute/delayed symptoms. If no change in health, what volume in same vial is recommended in 7 days?
0.15mL
The traditional schedule goes: each 5-7 days, advance dose by an increment of 0.05ml up to a total 0.50 ml dose. At that point, make a new vial 5 times more concentrated than the one you just used.
You can judge whether a pt tolerated an injection by the size of the wheal. If <25mm, give the next dose. If 25-35 mm wheal, give same dose. If 35-50 mm wheal, decrease the dose by 0.05ml.
A patient is receiving SQ IT using standard techniques. A 0.1 ml injection from a second treatment vial should be antigenically equivalent to what volume in 1st treatment vial?
0.50
This question points out that once you get to the beginning 0.1ml from a second vial, it really is the same as the largest dose you can get from the last vial you used, which is 0.50ml. When escalating the dose during IT, a lot of people skip the 0.1ml dose from a second vial, since is it the same as the 0.50ml dose from the previous dose, going directly to 0.15ml from a second vial.
65yo patient is waiting after his allergy shot. He mentions his asthma is worse after beta blocker. How much epi to give for anaphylactic reaction?
0.15mL
The dose of IM epi given for anaphylaxis is 0.3 to 0.5 ml from a 1:1000 vial of epi in an adult. However, decrease this dose by ½ if the patient is on a beta blocker to prevent unopposed alpha adrenergic agonist activity. Repeat as necessary q5 minutes.
Other components of anaphylaxis management include ABC’s. You can also add on Benadryl IV, pepcid IV, IV fluids, heparin IV 100 units/kg, which binds histamine. If the patient develops uncontrolled hypertension, give the pt IV phentolamine and nitroglycerine. You can also give glucagon in lieu of epi.
An IT patient misses 2 consecutive weekly appointments during escalation. 20 days ago, he received 0.3 ml injection from a second vial with 15mm reaction at 20 minutes.
0.25mL from same vial
First of all, the patient tolerated his 0.3 ml dose since he only made a 15mm wheal in 20 minutes. If he had been on schedule, he would have received a 0.35 ml dose a week later. The schedule is altered if weeks are missed like this:
Miss 1 wk: repeat dose
Miss 2 wks: decrease dose
Miss 3-4 wks: repeat the vial test. (vial test is when you take 0.01ml of the vial and do a IDT test. If the wheal is <13mm, give the normal dose from that vial. If =13mm, wait 72 hrs and then give normal dose. If >13mm, then dilute vial by 1ml of diluent).
A cat allergic pt tolerated weekly maintenance IT for a year receiving 0.5 ml injection from 5 ml vials containing 0.20 ml of cat extract. Pt continues to have pruritis, sneezing.
escalate 5x more concentrated vial
In treatment of anaphylaxis that does not respond adequately to first dose of epi, how often can you readminister?
q5mins
Specific IgE class score best correlates with…
SPECIFIC IGE CORRELATE WELL WITH SKIN TEST AND NASAL CHALLENGES, NOT WITH SEVERTITY OF SYMPTOMS.
During IDT, results are obtained:
#6 #5 #4
5mm 5mm 13mm
Appropriate interpretation of test?
During intradermal testing, a positive test is when the wheal enlarges by 2mm. The endpoint of titration is the first or weakest titration that produces a positive wheal. Its importance is that it is the concentration that we can safely start immunotherapy. A confirming wheal is the next concentration that gives a + wheal after endpoint of titration.
However, if the response is very rigorous positive wheal, then it is called a flash response. You should stop testing. REPEAT THE TEST IN ONE WEEK.
A plateau response is when there is no progressive wheal growth after endpoint of titration. It is still safer to start immunotherapy at the first + wheal.
When preparing 5 fold dilutions of antigen for IDT, what is the appropriate diluents for testing vials
sterile NS
A patient’s current meds are reviewed prior to allergic testing. Which medications are contra indicated around time of testing?
TCA, antihistamine (beta agonists inhibit wheal formation too)
Which cell surface marker is present on all mature T cells:
a. CD 3
b. CD1
c. CD25
d. CD4
CD3 is known as the pan Tcell marker. CD4 and CD1 is for the T helper cell.
meningioma above planum sphenoidale, what vessel embolize?
ant ethmoid, can also do posterior ethmoid
strawberry mass in nose, what use to treat?
rhinosporidiosis–surgical excision!
what is deregulated in angioedema?
bradykinin
CT of mucous retention cyst, pt complains of sharp facial pain, what do?
trial NSAIDS for a week vs work up facial pain further
JNA vascular supply unilateral or bilateral?
30-70% bilateral SPA supply
HHT: how treat non bleeding septum prophylactically?
laser vs hormone therapy
what is the 10 year risk of malignant transformation of IP?
10%
what is best way to identify CSF leak location
CT cisternogram
what treat for invasive fungal aspergillus? mucor?
voriconazole vs amphoteracin
