Ch. 5 Hypersensitivity Disorders Flashcards
the late allergic response is characterized by what symptoms?
nasal congestion, mucus production
what percentage of chronic rhinitis patients have non-allergic triggers?
30-50%
most effective medicine for AR?
intranasal steroid
side effects of H1 antihistamines?
muscarinic: dry mouth, urine retention
alpha: hypotension, dizziness, reflex tachycardia
5-HT: increased appetite
mechanism of H1 antihistamines
inverse agonists, down regulating H1 receptor constitutive activity
unlike NARES, localized AR (entropy) is diagnostically different how?
Local AR responds to nasal allergen provocation testing (local specific IgE)
NARES has what percentage of eosinophils on nasal smear?
> 20%
Colonization of which pathogen in primary atrophic rhinitis?
Klebsiella ozaenae
Treatment of atrophic rhinitis
nasal irrigation and topical antibiotics
symptoms of atrophic rhinitis
nasal crusting, pain, nasal congestion, foul smell
What medication is ineffective in rhinitis of pregnancy?
intranasal corticosteroids
Rhinitis of pregnancy begins and ends?
starts 2nd trimester, resolves within 2 weeks postpartum
Difference between AR and infectious rhinitis
infection is not pruritic and limited duration
CSF leak characteristics
triggered by trauma, unilateral, rhinorrhea
Evaluation for CSF leak
check B2-transferrin in nasal secretions
AFRS on CT scan?
hyperlattenuation, heterogeneous opacification with inspissated secretions in sinuses, bony demineralization, and erosion
AFRS on MRI?
peripheral enhancement with a dark center, higher peripheral signal characteristics corresponding to inflamed mucosa, reduced central signal intensity corresponding to fungal concretions
Fungi associated with AFRS
Aspergillus, Alternaria, Curvularia, Penicillium, Fusarium, Bipolaris
Diagnostic criteria for AFRS
+SPT or sIgE to fungi, nasal polyps, characteristic CT findings, non-invasive fungal hyphae (stain with PAS or GMS) in mucin OR positive fungal culture of mucin, eosinophil mucin without invasion into sinus tissue
Treatment of AFRS
endoscopic surgery, oral corticosteroids for 3 months, topical nasal corticosteroids, and AIT
conjunctivitis that occurs predominantly in males, peak incidence 3-20 years old
vernal keratoconjunctivitis
conjunctivitis with equal predilection for males and females, sight threatening, peak incidence age 20-50 years
atopic keratoconjunctivitis
symptoms and signs of VKC
severe photophobia, ocular itching papillary hypertrophy (>1mm), Horner-Trantas dots
symptoms and signs of AKC
ocular pruritus with atopic dermatitis, keratoconus is a distinguishing feature, anterior sub capsular cataracts
Steroid administration results in what type of cataract?
posterior sub capsular cataracts
features of GPC? giant papillary conjunctivitis
ocular itching after lens removal, intolerance to contact lens, morning mucus discharge, tarsal papillary hypertrophy (>0.3mm) smaller than VKC
IgE to what bacterial toxin is produced in AD (atopic dermatitis?)
IgE to S. aureus toxins
Which chemokines are specific for AD and increase with acute symptoms?
CTACK, CCL27, TARC
what may explain the increased susceptibility of AD skin to infections?
decrease or absence of human B defensins and cathelicidin LL-37
cytokines involved in acute AD?
acute: IL-4, -13
cytokines involved in chronic AD?
chronic: IL-5, -12, IFNg
which cytokines have been shown to down regulate filaggrin expression?
IL-4, -13
expression of what protein is inversely correlated to Th2 in AD?
claudin-1 (CLDN1)
most memory T lymphocytes in AD express what ligand that binds to E-selectin?
CLA (cutaneous lymphocyte associated antigen)
the FcER1 on Langerhans cells differs from that on mast cells and basophils how?
lacks the beta chain
What organisms are AD patients susceptible to?
S.aureus, herpes simplex, molluscum contagiosum, Malassezia fyrfur/Pityrosporum orbiculare, Pityrosporum ovale
severe reaction to smallpox vaccination in patients with AD
eczema vaccinatum
atopic keratoconjunctivitis is associated what type of cataracts?
anterior cataracts
what cell type is seen in fatal asthma
neutrophil accumulation
chromosome that contains IL-4 gene cluster important for atopy/asthma development
chr 5q
sensitization to what perennial allergen by age 6 years is associated with persistent asthma by age 11
Alternaria
Samter’s triad
asthma, nasal polyps, aspirin sensitivity
definition of reversibility on spirometry
improvement of 12% in FEV1 (and FEF25-75 in children only); increase in PEF >20%
methacholine challenge is positive for hyper responsiveness if
PC 20 <4mg/mL
4-16 mg/mL is probably if appropriate symptoms are present
asthma predictive index major criteria
parental asthma, physician dx of AD, sensitization to aeroallergens
asthma predictive index minor criteria
sensitization to food, >4% eosinophils, wheezing apart from colds
the API is positive if…?
one major -OR- two minor criteria are met
asthma impairment domains
symptoms, functional limitation
asthma risk domains
exacerbations, lung function, medication adverse effects
diagnosis of exercise induced bronchospasm
FEV1 decrease >15% after exercise challenge test
asthma severity if child age 0-4 has >2 days/week symptoms, 1-2x month awakenings, >2 days/week SABA use?
mild persistent
asthma severity if child age 5-11, >2 days/week symptoms, 3-4x month awakenings, >2 days/week SABA?
mild persistent
asthma severity if child age 0-4, daily symptoms, 3-4x month nighttime awakening, daily SABA use?
moderate persistent
asthma severity if child, age 5-11, daily symptoms, >1x/week nighttime awakening, daily SABA use?
moderate persistent
start a controller in child <4 years if….
> 2 exacerbations in 6 months, or >4 wheezing episodes in 1 year lasting >1 day AND risk factors for persistent asthma
asthma severity in patient age 12 or older, <2 days/week symptoms, <2x/month awakening, <2 days/week SABA, 0-1 prednisone in 1 year
intermittent asthma
asthma severity in patient age 12+, >2 days/week symptoms, >3-4x month awakenings, >2days/week SABA
mild persistent
asthma severity in patient age 12+, daily symptoms, >1/week awakening, daily SABA use
moderate persistent
Step 1 therapy
SABA prn
Step 2 therapy? which severity to start?
mild persistent for all ages
low dose ICS (preferred)
montelukast (alternative for age <4 and +)
nedocromil or theophylline (also alternatives for age 5+)
Step 3 preferred therapy? when to start?
moderate persistent asthma
medium dose ICS (age 0-4)
low dose ICS + LABA (age 5+)
what makes food allergens allergenic?
10-70kd, glycosylation, heat resistant, acid stable, stable to proteases, water soluble
Heiner syndrome symptoms
recurrent pneumonia, pulm infiltrate, hemosiderosis, iron def anemia, FTT
diagnosis of Heiner syndrome
history, peripheral eosinophilia, lung biopsy, milk precipitins, and elimination diet
foods implicated in food-associated exercise-induced
celery, wheat, milk
shellfish, fish, fruit
fruits involved in latex fruit syndrome
banana, avocado, chestnut, kiwi
pollen-food association for timothy grass
swiss chard, orange
pollen-food association for orchard
cantaloupe, honeydew, watermelon, peanut, white potato, tomato
pollen-food association for ragweed
cantaloupe, honeydew, watermelon, zucchin, cucumber, banana
pollen-food association for mugwort
celery, carrot, parsley, caraway, fennel, coriander, mustard, cauliflower, cabbage, broccoli, garlic, onion
pollen-food association for birch
apple, beach, plum, pear, cherry, apricot, almond, celery, carrot, parsley, caraway, fennel, coriander, soybean, peanut, hazelnut
gal-alpha-1,3-gal is found in what drug?
cetuximab
LEAP study results - infants with atopic dermatitis and/or egg allergy - fed peanut starting age 4 months until 60 months.
86% RR in peanut allergy for infants without sensitization, 77% RR in peanut allergy for infants with sensitization (W1-4mm)
most common cause of anaphylaxis
food and drug
What marker has been shown to be positive correlated with the severity of anaphylaxis?
PAF levels
What marker has been shown to inversely correlate with anaphylaxis severity?
PAF acetylhydrolase levels
what 5 mediators positively correlate with hypotension during anaphylaxis?
IL-6, TNF receptor 1, tryptase, histamine, C3a
fatality in anaphylaxis is due to?
circulatory collapse or respiratory failure
what is the ratio of total/mature tryptase in mastocytosis?
> 20 (note:<10 is other cause)
which mediator correlates best with symptoms of anaphylaxis?
histamine
What is oversulfated chrondroitin sulfate?
contaminant in heparin that is cuased by activation of the contact system, contains C5a and results in hypotension, abd pain, variable angioedema, but no pruritus or urticaria
histamine release is within 5 minutes, but levels remain elevated for how long?
30-60 minutes
urinary histamine metabolites remain elevated for?
24 hours
serum tryptase levels are released within 15 minutes but peak when?
60-90 minutes
natural rubber latex is a cytoplasmic exudate of what tree?
Hevea brasiliensis
major latex allergen in sensitized patients with spina bifida that are minor allergens in health care workers
Hev b 1 and Hev b 3
major latex allergen in sensitized health care workers
Hev b 5, 6, 7
most common foods associated with EIA?
wheat, celery
fire ant venom contains what allergen
piperidine alkaloids
major allergen in honeybee venom
phospholipase A2, Api m 1
major allergen in hornet and yellow jacket
phospholipase A1, Ves v1 (does not cross react with honeybee)
hyaluronidase, Ves v2
antigen 5, Ves v5
major allergen in paper wasp
phospholipase A1, Pol a1
hyaluronidase, Pol a2
antigen 5, Pol a 5
mixed vespid maintenance dose
300ug
single antigen venom maintenance dose
100ug
what is Skeeter syndrome
large local reaction to mosquito bite with fever
allergen in biting insects are found in?
saliva
which biting insect has cross reactivity with cockroach on skin testing
asian lady beetle
which venoms are corss-reactive
hornet and yellow jacket
major allergen in ant
Phospholipase A2, Sol i1
Antigen 5, Sol i 3
local heat urticaria test
apply water heated to 45C in a test tube on skin for 5 min
cold urticaria test
ice cube test place on skin for 5 min
cholinergic urticaria test
exercise for 15 mins past point of sweating or passive elevation of core body temperature by submerging patient’s arm in 42C hot water bath until core temp increases >0.7C
solar urticaria test
skin exposed to UVA and UVB of varying wavelengths using a monochromatic light source
aquagenic urticaria test
apply 35C water compress to upper body for 30 minutes
delayed pressure urticaria/angioedema test
sling attached to 10-15lb weight is placed over arm or shoulder for 15 minutes. Patient response over next 2-24 hours.
cold urticaria with negative ice cube test
cold-induced cholinergic urticaria, systemic cold urticaria, familial cold auto inflammatory syndromes, and cold-dependent dermatographism
Schnitzler syndrome is associated with what findings?
IgM monoclonal paraproteinemia, nonpruritic urticaria, elevated ESR, and neutrophilic infiltrate on biopsy
treatment of Schnitzler syndrome
anti-IL-1
lab findings in hypocomplementemic urticarial vasculitis
low C3, C4, C1q, anti-C1q antibody, elevated ESR
difference between work exacerbated asthma and occupational asthma
occupational asthma - symptoms do not occur outside of workplace. work-exacerbated asthma has asthma pre-existing with increased symptoms at work
reactive airway dysfunction syndrome?
single high level exposure resulting in symptoms within 24 hours and are persistent.
laboratory workers may take how many years to sensitize?
2 years
occupational asthma in carpenters, woodworkers due to?
plicatic acid
occupational asthma in nail salon workers and dental hygienists due to?
acrylates
occupational asthma in body shop or auto industry or roofing/insulation or spray pain/foam coatings due to?
isocyanates
occupational asthma in welder, metal/chemical workers due to?
platinum salts, potassium dichromate
occupation asthma in hairdresser due to?
persulfate salts (ammonium persulfate)
occupational asthma in plastic due to?
anhydrides
PFT in occupational asthma
FEV1 reduction by 15-20% after exposure of occupation trigger; inhalation challenge is gold standard (limited availability)
hypersensitivity pneumonitis is characterized by what T cell phenotype?
Th1 phenotype
predominance of CD8+ T cells
BAL findings in HP?
lymphocytosis >50%
low CD4/CD8 ratio <1
histopathology in HP
poorly formed, noncaseating granulomas or mononuclear infiltrate
PFT findings in HP
decreased FEV1, FVC, DLCO after 4-6 hours of exposure, restrictive pattern in advance disease
CT findings in acute HP
fleeting ground glass opacities
CT findings in subacute HP
diffuse micro nodules, air trapping, mild fibrosis
CT findings in chronic HP
ground glass opacities, emphysema, honeycombing, and parenchymal micronodules
what bad habit is associated with decreased risk of HP
smoking
antigen causing farmer’s lung
thermophilic actinomycetes (thermoactinomyces vulgarism, Saccharopolyspora rectivirgula)
antigen causing bagassosis (moldy sugar cane)
thermoactinomyces sacchari
antigen causing hot tub lung
mycobacterium avid complex or Cladosporium
antigen causing basement shower lung
epicoccum nigrum
antigen causing wine growers lung
botrytis cinerea
antigen causing malt worker’s lung
Aspergillus
antigen causing cheese worker’s lung
Penicillium casei
antigen causing detergent workers lung
Bacillus subtilis
chemical worker’s lung antigen
toluene diisocyante (TDI), diphenylmethane diisocyanate (MDI)
plastic workers lung antigen
trimellitic anhydride
epoxy resin worker’s lung antigen
phthalic acid
bird fancier’s lung antigen
Avian proteins
el niño lung antigen
Pezizia
Saxophonists lung antigen
Candida albicans
wheat weevil lung/miller’s lung antigen
Sitophilus
machine operators lung antigen
Pseudomonas, Acinetobacter, or Mycobacter
woodworker’s lung antigen
Alternaria
humidifier fever/AC lung antigen
thermoactinomyces (T. vulgarism, T. saccharin, T. candidus, Klebsiella, Acanthamoeba)
antigen in summer type HP (contaminated houses)
Trichosporum cutaneum (common in Japan)
What is organic dust toxic syndrome (ODTS, pulmonary mycotoxicosis)
non-infectious febrile illness after exposure to dust contaminated by toxin-producingg fungi (in grain, hay, textiles); usually young patients, no prior sensitization, lack of serologic response to common fungal antigens
What diagnosis is 50 times more common in farmers than farmer’s lung?
ODTS (organic dust toxic syndrome)
ABPA occurs exclusively in which patients?
asthma or CF
ABPA diagnosis in asthma?
+SPT to A. fumigatus, total IgE>1000ng/mL (417 IU/mL), elevated IgG and IgE to A. fumigates, central bronchiectasis, peripheral eosinophilia >1000/mm3
ABPA diagnosis in CF?
+SPT A. fumigatus, total IgE >1200ng/mL (500 IU/mL), IgG or IgE to A. fumigatus, fixed chest film abnormalities, clinical deterioration not due to other causes
what is the purpose of anti fungal therapy (itraconazole or voriconazole) in ABPA?
for exacerbations or if patient cannot be tapered off steroids; it decreases antigenic stimulus for bronchial inflammation, decrease sIgE to Aspergillus, and decrease dose of steroids
what marker indicates a flare of ABPA?
doubling of baseline IgE
goal of treatment of ABPA
prevent bronchiectasis or pulmonary fibrosis and worsening lung function
airway inflammation in COPD is characterized by?
neutrophils, macrophages, and CD8+ T cells
the emphysematous findings of COPD and alpha-antitrypsin deficiency differs how?
COPD is centrilobular (proximal acinar) upper lobes vs AAT is pan lobular (panacinar) lower lobes
test for AAT in what patient?
young (<45 years), nonsmoker, symptoms of COPD and persistent airflow obstruction on spirometry
when do you use ICS in COPD
only in moderate to severe COPD with symptoms despite bronchodilators
what has smoking cessation been shown to do in COPD
returns rate of loss of function to normal (decline of 60cc/year to 30cc/year)
What treatments in COPD decreases mortality
supplemental oxygen, smoking cessation, and lung volume reduction surgery
Spirometry or PFTs in ILD
restriction: decrease FEV1 and FVC, normal or high FEV1/FVC, increased lung volumes, decrease DLCO
what is the pathologic pattern in UIP (usual interstitial pneumonitis)
heterogeneous fibrosis prominent in the periphery, minimal inflammation
CT findings in IPF
bibasilar, peripheral reticular pattern, focal honeycombing
CT findings in NSIP
ground glass and fibrotic changes
CT findings in COP
alveolar filling, air bronchograms mimicking acute pneumonia
histologic features of contact dermatitis
lymphocytic infiltration and spongiosis
+1 reaction in contact dermatitis?
erythema, edema that is palpable, occupies >50% of patch test site
+2 reaction in contact dermatitis
micro vesicles and erythema that occupy at least 50% of patch test site
+3 reaction in contact dermatitis
confluent vesicles or bullae, ulcerative
how to test for nickel in products?
dimethylglyoxime test (pink = positive)
allergen in stainless steel, metals?
potassium dichromate
allergen in poison ivy/sumac/oak
uroshiol (Toxicodendron dermatitis)
poison ivy is cross-reactive with?
mango peels
the sensitizing substances in most plants are present in?
oleoresin
Which plant in the US is the most common cause of hand eczema in flower workers?
Alstroemeria (Peruvian lily)
allergen in fragrances
balsam of peru
balsam of peru cross reacts with?
cinnamon and vanillin
allergen in cosmetic that is a preservative that is the most common cause of ACD in the U.S.
quarternium-15
most commonly used preservative in cosmetics, but an UNCOMMON cause of ACD
parabens
most common cause of ACD in hair dressers? also seen in henna tattoos
paraphenylenediamine
allergen in acrylic nails?
ethylacrylate
what are the 4 major classes of sensitizing corticosteroids?
A: hydrocortisone
B: triamcinolone
C: betamethasone
D: hydrocortisone-17-butyrate
if ACD to ethylenediamine dihydrochloride (EDTA), what you should avoid?
nystatin, aminophylline, meclizine, cyclizine
if ACD to neomycin, what to avoid?
gentamicin, kanamycin, streptomycin, tobramycin
What is “Baboon syndrome”
when patients allergic to topical antihistamines develop systemic CD after systemic administration of antihistamine- there is indurated erythema in the groin area of afflicted patients
