Case 14: extra and anaemia Flashcards
Questions to ask with allergy symptoms during weaning
- What foods have they tried?
- Which formulas have they been given?
- Has they tried lactose free milk?
- Has they had any medications for eczema?
Allergy tests- when they may be inaccurate
- Specific IgE testing: can be falsely negative if high total IgE levels (eczema, atopy)
- Allergy testing should be 4-6 weeks after symptoms i.e. anaphylaxis or severe allergic response
Management for weaning child with food allergies
- Cows milk allergy: stop formula milks & change to eHF and subsequent amino acid formula. In non IgE reactions a ‘milk ladder’ can be used to reintroduce dairy back in the diet
- Allergen free diet
- Iron, vitamin D and calcium supplements
- Food challenge/feed
- Optimise eczema management with emollients, steroid creams, skinnies and garments
- Children can grow out of allergies and are offered periodic investigation (IgE testing and food challenge). >16 have it life long
Why are drug allergy histories difficult
- Patients may have no first hand recollection of an allergic response if the reaction occurred at a young age or under anaesthesia
- In the acutely ill patient many drugs may have been administered together making identification of the culprit drug difficult
- Infection is a potent trigger for urticaria and angioedema
Types of drug reactions
- Immediate: includes urticaria, angiodema, rhinitis, bronchospasm, N+V and anaphylaxis. Occurs within 6 hours of administration. Typically first hours
- Non-immediate drug reactions: includes maculopapular rashes, Steven Johnson syndrome, toxic epidermal necrolysis, serum sickness, drug fevers, pneumonitis and nephritis. Occurs within 8-12+ hrs post administration
Drug allergy: history
- 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 and what was the effect
- Photograph of reaction illness for which drug was taken (illness may be cause)
- Other medications which being taken at the time
Management of Drug allergies
- Add an allergy alert to avoid certain medications to the patients records
- Drug allergy testing is not indicated if other medication choices available
Drug reactions with Eosinophilia and Systemic Symptoms (DRESS)
- Typically begins three weeks after starting medication
- Involved: skin rash, fever, enlarged lymph nodes, and involvement of internal organs
- Eosinophilia
- Caused by: anticonvulsants (such as phenytoin, carbamazepine), allopurinol (used for gout), sulfa antibiotics, and some antiviral medications
- Manged conservatively by stopping meds and systemic corticosteroids
Pollen count
- Tree pollens counts are high between March and April
- Grass pollen from May through to August
- Weeds from June – September.
How to use nasal sprays
head forward looking at the feet with the nozzle pointed away from the midline.
Conjunctivitis
Inflammation go the outermost layer of the white of eye and inner surface of eyelid. When the small blood vessels in the conjunctiva become inflamed, they are more visible.
Season allergic rhino conjunctivitis (Hay fever)
- Investigations: skin prick testing, specific IgE testing
- Medications: Over-the-counter or prescription antihistamines (Cetirizine, Fexofenidine), decongestants, nasal corticosteroids (don’t use Kenalog), or eye drops (Cromoglicate, nedocromil) can help relieve symptoms. If poor control offer short course of oral prednisolone.
- Immunotherapy: for severe allergy
- Typical management: Antihistamine (Flexofenandine), nasal steroids (Avamys- Flucticasone) and eye drops (olopatadine)
Desensitisation therapy for Allergic rhinoconjunctivits
- offered if triple therapy (Antihistamine, nasal corticosteroids and eye drops) doesn’t work and oral steroids are required.
- Reduces symptom burden though some medication may still be required
- Done for a minimum of 3 years. Treatment can wear off and may need to be repeated
Causes of non allergic rhinitis
- Infection: Usually self -resolving
- Environmental triggers: Smoke, perfume, paint fumes, changes in weather / temperature, alcohol, spicy food, stress
- Medicines and recreational drugs: ACE inhibitors, beta blockers, NSAIDs, cocaine
- Overuse of nasal decongestants: Reduce swelling of the blood vessels. If used for >5-7 days then rebound symptoms
- Hormone changes: Pregnancy, puberty, HRT, OCP, Hypothyroidism
- Structural nasal problems: **Deviated nasal septum; polyps
Anaemia
- Haemoglobin concentration of blood below normal range for age and sex: Adult male <130, Adult female <115
- Causes tissue hypoxia
RBC cycle
- Erythropoiesis: Megakaryocyte Erythroid Progenitor → Erythroblast -) Nucleus extrusion (nucleus expelled) → Reticulocyte → RBC
- Low blood levels stimulate kidney to produce erythropoietin
- Erythropoietin (EPO)stimulates Erythropoiesis on the bone marrow: takes 3 weeks
- Old RBC’s (after 3 months) are phagocytised in the spleen/liver
- Haemoglobin is broken down and either re-used in the body i.e. iron or excreted i.e. bilirubin
Causes of reduced RBC production
- Reduced EPO response: kidney disease (low EPO production) or chronic inflammation (reduced response)
- Iron, B12 or folate deficiency: poor dietary intake, malabsorption, chronic inflammation
- Reduced bone marrow production: Malignancy, infection, aplastic anaemia, Myelosuppressive drugs (chloramphenicol, alcohol) and Myelosuppressive infection (parvovirus or HIV)
Causes of anaemia
- Reduced RBC production
- Increased demand: Pregnancy and lactation. Can get folate deficiency as erythropoiesis increases
- Blood loss: acute or chronic
Causes of increased RBC destruction
- Haemolytic anaemias (autoimmune, drug induced, Hereditary spherocytosis)
- Haemoglobinopathies (Thalassaemia, sickle cell disease),
- Hypersplenism when RBC are pooled in the spleen (Portal hypertension i.e. liver disease)
Clinical assessment of anaemia history
Anaemia symptoms: lethargy, lightheaded, SOB, palpitations, angina
Clinical Assessment of anaemia history
- Bleeding history
- Features of cancer/infection: weight loss, change in bowel habit, fever
- Symptoms of specific anaemias: fluctuating jaundice in haemolytic anaemias. Memory loss/paraesthesis in severe B12 deficiency
- Dietary history
- Menstrual history
- PMH: CKD, cancer
- past surgical: bariatric or GI
