Ch. 5 Hypersensitivity Disorders Flashcards
1
Q
the late allergic response is characterized by what symptoms?
A
nasal congestion, mucus production
2
Q
what percentage of chronic rhinitis patients have non-allergic triggers?
A
30-50%
3
Q
most effective medicine for AR?
A
intranasal steroid
4
Q
side effects of H1 antihistamines?
A
muscarinic: dry mouth, urine retention
alpha: hypotension, dizziness, reflex tachycardia
5-HT: increased appetite
5
Q
mechanism of H1 antihistamines
A
inverse agonists, down regulating H1 receptor constitutive activity
6
Q
unlike NARES, localized AR (entropy) is diagnostically different how?
A
Local AR responds to nasal allergen provocation testing (local specific IgE)
7
Q
NARES has what percentage of eosinophils on nasal smear?
A
> 20%
8
Q
Colonization of which pathogen in primary atrophic rhinitis?
A
Klebsiella ozaenae
9
Q
Treatment of atrophic rhinitis
A
nasal irrigation and topical antibiotics
10
Q
symptoms of atrophic rhinitis
A
nasal crusting, pain, nasal congestion, foul smell
11
Q
What medication is ineffective in rhinitis of pregnancy?
A
intranasal corticosteroids
12
Q
Rhinitis of pregnancy begins and ends?
A
starts 2nd trimester, resolves within 2 weeks postpartum
13
Q
Difference between AR and infectious rhinitis
A
infection is not pruritic and limited duration
14
Q
CSF leak characteristics
A
triggered by trauma, unilateral, rhinorrhea
15
Q
Evaluation for CSF leak
A
check B2-transferrin in nasal secretions
16
Q
AFRS on CT scan?
A
hyperlattenuation, heterogeneous opacification with inspissated secretions in sinuses, bony demineralization, and erosion
17
Q
AFRS on MRI?
A
peripheral enhancement with a dark center, higher peripheral signal characteristics corresponding to inflamed mucosa, reduced central signal intensity corresponding to fungal concretions
18
Q
Fungi associated with AFRS
A
Aspergillus, Alternaria, Curvularia, Penicillium, Fusarium, Bipolaris
19
Q
Diagnostic criteria for AFRS
A
+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
20
Q
Treatment of AFRS
A
endoscopic surgery, oral corticosteroids for 3 months, topical nasal corticosteroids, and AIT
21
Q
conjunctivitis that occurs predominantly in males, peak incidence 3-20 years old
A
vernal keratoconjunctivitis
22
Q
conjunctivitis with equal predilection for males and females, sight threatening, peak incidence age 20-50 years
A
atopic keratoconjunctivitis
23
Q
symptoms and signs of VKC
A
severe photophobia, ocular itching papillary hypertrophy (>1mm), Horner-Trantas dots
24
Q
symptoms and signs of AKC
A
ocular pruritus with atopic dermatitis, keratoconus is a distinguishing feature, anterior sub capsular cataracts
25
Steroid administration results in what type of cataract?
posterior sub capsular cataracts
26
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
27
IgE to what bacterial toxin is produced in AD (atopic dermatitis?)
IgE to S. aureus toxins
28
Which chemokines are specific for AD and increase with acute symptoms?
CTACK, CCL27, TARC
29
what may explain the increased susceptibility of AD skin to infections?
decrease or absence of human B defensins and cathelicidin LL-37
30
cytokines involved in acute AD?
acute: IL-4, -13
31
cytokines involved in chronic AD?
chronic: IL-5, -12, IFNg
32
which cytokines have been shown to down regulate filaggrin expression?
IL-4, -13
33
expression of what protein is inversely correlated to Th2 in AD?
claudin-1 (CLDN1)
34
most memory T lymphocytes in AD express what ligand that binds to E-selectin?
CLA (cutaneous lymphocyte associated antigen)
35
the FcER1 on Langerhans cells differs from that on mast cells and basophils how?
lacks the beta chain
36
What organisms are AD patients susceptible to?
S.aureus, herpes simplex, molluscum contagiosum, Malassezia fyrfur/Pityrosporum orbiculare, Pityrosporum ovale
37
severe reaction to smallpox vaccination in patients with AD
eczema vaccinatum
38
atopic keratoconjunctivitis is associated what type of cataracts?
anterior cataracts
39
what cell type is seen in fatal asthma
neutrophil accumulation
40
chromosome that contains IL-4 gene cluster important for atopy/asthma development
chr 5q
41
sensitization to what perennial allergen by age 6 years is associated with persistent asthma by age 11
Alternaria
42
Samter's triad
asthma, nasal polyps, aspirin sensitivity
43
definition of reversibility on spirometry
improvement of 12% in FEV1 (and FEF25-75 in children only); increase in PEF >20%
44
methacholine challenge is positive for hyper responsiveness if
PC 20 <4mg/mL
| 4-16 mg/mL is probably if appropriate symptoms are present
45
asthma predictive index major criteria
parental asthma, physician dx of AD, sensitization to aeroallergens
46
asthma predictive index minor criteria
sensitization to food, >4% eosinophils, wheezing apart from colds
47
the API is positive if...?
one major -OR- two minor criteria are met
48
asthma impairment domains
symptoms, functional limitation
49
asthma risk domains
exacerbations, lung function, medication adverse effects
50
diagnosis of exercise induced bronchospasm
FEV1 decrease >15% after exercise challenge test
51
asthma severity if child age 0-4 has >2 days/week symptoms, 1-2x month awakenings, >2 days/week SABA use?
mild persistent
52
asthma severity if child age 5-11, >2 days/week symptoms, 3-4x month awakenings, >2 days/week SABA?
mild persistent
53
asthma severity if child age 0-4, daily symptoms, 3-4x month nighttime awakening, daily SABA use?
moderate persistent
54
asthma severity if child, age 5-11, daily symptoms, >1x/week nighttime awakening, daily SABA use?
moderate persistent
55
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
56
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
57
asthma severity in patient age 12+, >2 days/week symptoms, >3-4x month awakenings, >2days/week SABA
mild persistent
58
asthma severity in patient age 12+, daily symptoms, >1/week awakening, daily SABA use
moderate persistent
59
Step 1 therapy
SABA prn
60
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+)
61
Step 3 preferred therapy? when to start?
moderate persistent asthma
medium dose ICS (age 0-4)
low dose ICS + LABA (age 5+)
62
what makes food allergens allergenic?
10-70kd, glycosylation, heat resistant, acid stable, stable to proteases, water soluble
63
Heiner syndrome symptoms
recurrent pneumonia, pulm infiltrate, hemosiderosis, iron def anemia, FTT
64
diagnosis of Heiner syndrome
history, peripheral eosinophilia, lung biopsy, milk precipitins, and elimination diet
65
foods implicated in food-associated exercise-induced
celery, wheat, milk
| shellfish, fish, fruit
66
fruits involved in latex fruit syndrome
banana, avocado, chestnut, kiwi
67
pollen-food association for timothy grass
swiss chard, orange
68
pollen-food association for orchard
cantaloupe, honeydew, watermelon, peanut, white potato, tomato
69
pollen-food association for ragweed
cantaloupe, honeydew, watermelon, zucchin, cucumber, banana
70
pollen-food association for mugwort
celery, carrot, parsley, caraway, fennel, coriander, mustard, cauliflower, cabbage, broccoli, garlic, onion
71
pollen-food association for birch
apple, beach, plum, pear, cherry, apricot, almond, celery, carrot, parsley, caraway, fennel, coriander, soybean, peanut, hazelnut
72
gal-alpha-1,3-gal is found in what drug?
cetuximab
73
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)
74
most common cause of anaphylaxis
food and drug
75
What marker has been shown to be positive correlated with the severity of anaphylaxis?
PAF levels
76
What marker has been shown to inversely correlate with anaphylaxis severity?
PAF acetylhydrolase levels
77
what 5 mediators positively correlate with hypotension during anaphylaxis?
IL-6, TNF receptor 1, tryptase, histamine, C3a
78
fatality in anaphylaxis is due to?
circulatory collapse or respiratory failure
79
what is the ratio of total/mature tryptase in mastocytosis?
>20 (note:<10 is other cause)
80
which mediator correlates best with symptoms of anaphylaxis?
histamine
81
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
82
histamine release is within 5 minutes, but levels remain elevated for how long?
30-60 minutes
83
urinary histamine metabolites remain elevated for?
24 hours
84
serum tryptase levels are released within 15 minutes but peak when?
60-90 minutes
85
natural rubber latex is a cytoplasmic exudate of what tree?
Hevea brasiliensis
86
major latex allergen in sensitized patients with spina bifida that are minor allergens in health care workers
Hev b 1 and Hev b 3
87
major latex allergen in sensitized health care workers
Hev b 5, 6, 7
88
most common foods associated with EIA?
wheat, celery
89
fire ant venom contains what allergen
piperidine alkaloids
90
major allergen in honeybee venom
phospholipase A2, Api m 1
91
major allergen in hornet and yellow jacket
phospholipase A1, Ves v1 (does not cross react with honeybee)
hyaluronidase, Ves v2
antigen 5, Ves v5
92
major allergen in paper wasp
phospholipase A1, Pol a1
hyaluronidase, Pol a2
antigen 5, Pol a 5
93
mixed vespid maintenance dose
300ug
94
single antigen venom maintenance dose
100ug
95
what is Skeeter syndrome
large local reaction to mosquito bite with fever
96
allergen in biting insects are found in?
saliva
97
which biting insect has cross reactivity with cockroach on skin testing
asian lady beetle
98
which venoms are corss-reactive
hornet and yellow jacket
99
major allergen in ant
Phospholipase A2, Sol i1
| Antigen 5, Sol i 3
100
local heat urticaria test
apply water heated to 45C in a test tube on skin for 5 min
101
cold urticaria test
ice cube test place on skin for 5 min
102
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
103
solar urticaria test
skin exposed to UVA and UVB of varying wavelengths using a monochromatic light source
104
aquagenic urticaria test
apply 35C water compress to upper body for 30 minutes
105
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.
106
cold urticaria with negative ice cube test
cold-induced cholinergic urticaria, systemic cold urticaria, familial cold auto inflammatory syndromes, and cold-dependent dermatographism
107
Schnitzler syndrome is associated with what findings?
IgM monoclonal paraproteinemia, nonpruritic urticaria, elevated ESR, and neutrophilic infiltrate on biopsy
108
treatment of Schnitzler syndrome
anti-IL-1
109
lab findings in hypocomplementemic urticarial vasculitis
low C3, C4, C1q, anti-C1q antibody, elevated ESR
110
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
111
reactive airway dysfunction syndrome?
single high level exposure resulting in symptoms within 24 hours and are persistent.
112
laboratory workers may take how many years to sensitize?
2 years
113
occupational asthma in carpenters, woodworkers due to?
plicatic acid
114
occupational asthma in nail salon workers and dental hygienists due to?
acrylates
115
occupational asthma in body shop or auto industry or roofing/insulation or spray pain/foam coatings due to?
isocyanates
116
occupational asthma in welder, metal/chemical workers due to?
platinum salts, potassium dichromate
117
occupation asthma in hairdresser due to?
persulfate salts (ammonium persulfate)
118
occupational asthma in plastic due to?
anhydrides
119
PFT in occupational asthma
FEV1 reduction by 15-20% after exposure of occupation trigger; inhalation challenge is gold standard (limited availability)
120
hypersensitivity pneumonitis is characterized by what T cell phenotype?
Th1 phenotype
| predominance of CD8+ T cells
121
BAL findings in HP?
lymphocytosis >50%
| low CD4/CD8 ratio <1
122
histopathology in HP
poorly formed, noncaseating granulomas or mononuclear infiltrate
123
PFT findings in HP
decreased FEV1, FVC, DLCO after 4-6 hours of exposure, restrictive pattern in advance disease
124
CT findings in acute HP
fleeting ground glass opacities
125
CT findings in subacute HP
diffuse micro nodules, air trapping, mild fibrosis
126
CT findings in chronic HP
ground glass opacities, emphysema, honeycombing, and parenchymal micronodules
127
what bad habit is associated with decreased risk of HP
smoking
128
antigen causing farmer's lung
```
thermophilic actinomycetes
(thermoactinomyces vulgarism, Saccharopolyspora rectivirgula)
```
129
antigen causing bagassosis (moldy sugar cane)
thermoactinomyces sacchari
130
antigen causing hot tub lung
mycobacterium avid complex or Cladosporium
131
antigen causing basement shower lung
epicoccum nigrum
132
antigen causing wine growers lung
botrytis cinerea
133
antigen causing malt worker's lung
Aspergillus
134
antigen causing cheese worker's lung
Penicillium casei
135
antigen causing detergent workers lung
Bacillus subtilis
136
chemical worker's lung antigen
toluene diisocyante (TDI), diphenylmethane diisocyanate (MDI)
137
plastic workers lung antigen
trimellitic anhydride
138
epoxy resin worker's lung antigen
phthalic acid
139
bird fancier's lung antigen
Avian proteins
140
el niño lung antigen
Pezizia
141
Saxophonists lung antigen
Candida albicans
142
wheat weevil lung/miller's lung antigen
Sitophilus
143
machine operators lung antigen
Pseudomonas, Acinetobacter, or Mycobacter
144
woodworker's lung antigen
Alternaria
145
humidifier fever/AC lung antigen
thermoactinomyces (T. vulgarism, T. saccharin, T. candidus, Klebsiella, Acanthamoeba)
146
antigen in summer type HP (contaminated houses)
Trichosporum cutaneum (common in Japan)
147
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
148
What diagnosis is 50 times more common in farmers than farmer's lung?
ODTS (organic dust toxic syndrome)
149
ABPA occurs exclusively in which patients?
asthma or CF
150
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
151
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
152
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
153
what marker indicates a flare of ABPA?
doubling of baseline IgE
154
goal of treatment of ABPA
prevent bronchiectasis or pulmonary fibrosis and worsening lung function
155
airway inflammation in COPD is characterized by?
neutrophils, macrophages, and CD8+ T cells
156
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
157
test for AAT in what patient?
young (<45 years), nonsmoker, symptoms of COPD and persistent airflow obstruction on spirometry
158
when do you use ICS in COPD
only in moderate to severe COPD with symptoms despite bronchodilators
159
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)
160
What treatments in COPD decreases mortality
supplemental oxygen, smoking cessation, and lung volume reduction surgery
161
Spirometry or PFTs in ILD
restriction: decrease FEV1 and FVC, normal or high FEV1/FVC, increased lung volumes, decrease DLCO
162
what is the pathologic pattern in UIP (usual interstitial pneumonitis)
heterogeneous fibrosis prominent in the periphery, minimal inflammation
163
CT findings in IPF
bibasilar, peripheral reticular pattern, focal honeycombing
164
CT findings in NSIP
ground glass and fibrotic changes
165
CT findings in COP
alveolar filling, air bronchograms mimicking acute pneumonia
166
histologic features of contact dermatitis
lymphocytic infiltration and spongiosis
167
+1 reaction in contact dermatitis?
erythema, edema that is palpable, occupies >50% of patch test site
168
+2 reaction in contact dermatitis
micro vesicles and erythema that occupy at least 50% of patch test site
169
+3 reaction in contact dermatitis
confluent vesicles or bullae, ulcerative
170
how to test for nickel in products?
dimethylglyoxime test (pink = positive)
171
allergen in stainless steel, metals?
potassium dichromate
172
allergen in poison ivy/sumac/oak
uroshiol (Toxicodendron dermatitis)
173
poison ivy is cross-reactive with?
mango peels
174
the sensitizing substances in most plants are present in?
oleoresin
175
Which plant in the US is the most common cause of hand eczema in flower workers?
Alstroemeria (Peruvian lily)
176
allergen in fragrances
balsam of peru
177
balsam of peru cross reacts with?
cinnamon and vanillin
178
allergen in cosmetic that is a preservative that is the most common cause of ACD in the U.S.
quarternium-15
179
most commonly used preservative in cosmetics, but an UNCOMMON cause of ACD
parabens
180
most common cause of ACD in hair dressers? also seen in henna tattoos
paraphenylenediamine
181
allergen in acrylic nails?
ethylacrylate
182
what are the 4 major classes of sensitizing corticosteroids?
A: hydrocortisone
B: triamcinolone
C: betamethasone
D: hydrocortisone-17-butyrate
183
if ACD to ethylenediamine dihydrochloride (EDTA), what you should avoid?
nystatin, aminophylline, meclizine, cyclizine
184
if ACD to neomycin, what to avoid?
gentamicin, kanamycin, streptomycin, tobramycin
185
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
