Hypersensitivity Disorders 2018-2020 Flashcards
1
Q
- Acute contact dermatitis caused by chromium (VI) (CrVI) has long been a
recognized occupationalproblem, especially from exposure to:
A. baking yeast.
B. hair dyes.
C. mobile phones.
D. wet cement.
A
- D, wet cement, p. 566.
During the construction of the Channel tunnel connecting continental Europe with Britain, the prevalence of chromate allergy in cement workers was reported to be as high as 17%. Subsequently, the European Union regulated the content of chromium in cement, and sensitization to chromate in construction works has since declined. No such legislation exists in the United States. Other sources of chromate exposure include contact with leather tanned with salts containing chromate and this has become increasingly recognized.
Chapter 35: Contact Dermatitis
Middleton’s Allergy Principles and Practice, 8th Edition
2
Q
- Irritant contact dermatitis is the most common form of contact dermatitis in the population. An irritant will cause direct injury to the skin in any person, if applied in a sufficient concentration for a sufficient amount of time, without prior sensitization or immunological memory. Irritants include wet work. “Wet work” is defined when individuals have their skin exposed to liquids longer than:
A. 1 hr per day, or use occlusive gloves longer than 1 hr per day, or clean the hands very often (eg 10 times per day or less, dependent
B. 2 hrs per day, or use occlusive gloves longer than 2 hrs per day, or clean the hands very often (eg 20 times per day or less, dependent
C. 3 hrs per day, or use occlusive gloves longer than 3 hrs per day, or clean the hands very often (eg 30 times per day or less, dependent
D. 4 hrs per day, or use occlusive gloves longer than 4 hrs per day, or clean the hands very often (eg 40 times per day or less, dependent
A
2. B. 2 hrs per day, or use occlusive gloves longer than 2 hrs per day, or clean the hands very often (eg 20 times per day or less, dependent, p. 567. According to the German regulation of hazardous substances at the workplace, “wet work” is defined when individuals have their skin exposed to liquids longer than 2 hrs per day, or use occlusive gloves longer than 2 hrs per day, or clean the hands very often (eg 20 times per day, or less dependent) if cleaning procedure is aggressive.
3
Q
- Topical agents causing phototoxic reactions particularly include plants containing
furocoumarins, such as:
A. Avocado, blueberries, strawberries
B. Celery, carrot, and citrus fruits
C. Spinach, red cabbage, brussels sprouts
D. Zucchini, cucumbers, squash
A
- B, Celery, carrot, and citrus fruits, p. 567.
Topical agents causing phototoxic reactions particularly include plants containing
furocoumarins, such as celery, carrot, and citrus fruits.
4
Q
- Which syndrome - a form of systemic contact dermatitis - can occur when sensitized
persons are exposedto allergens from routes other than skin exposure, such as orally,
intravenously, or by inhalation?
A. Baboon syndrome
B. Hippopotamus syndrome
C. Lemur syndrome
D. Rhinoceros syndrome
A
- A, Baboon syndrome, p. 568.
Systemic contact dermatitis may occur when sensitized persons are exposed to allergens from
routes other than skin exposure, such as orally, intravenously, or by inhalation. Clinical
manifestations may include flare-ups of dermatitis in previous sites or of positive patch test
site reactions, as well as vesicular hand eczema and “baboon syndrome,” which refers to a
well- demarcated rash on the buttocks, genital area, and thighs. Causes commonly include
metals such asnickel, cobalt, chromate, gold, and mercury. In certain case, treatment includes
dietary avoidance of the particular metal.
5
Q
- Contact dermatitis can be differentiated from irritant dermatitis based on which of the
following?
A. Evidence of urticarial reaction immediately upon contact with the skin
B. No involvement of part of the body that does not come in contact with the allergen
C. Poorly defined borders
D. Well defined borders
A
- C, Poorly defined borders, p. 568.
Unlike in irritant contact dermatitis, the borders of the lesions in allergic contact dermatitis
(ACD) are poorly defined. In ACD, additional lesions can appear on other parts of the body
that have not come into contact with the allergen (a phenomenon known as secondary
spread).
6
Q
6. What is an effective in treating chronic contact dermatitis, particularly that affecting the hands? A. Azathioprine B. Laser therapy C. Mycophenolate mofetil D. Phototherapy
A
- D, Phototherapy, p. 572.
In chronic contact dermatitis, particularly affecting the hands, phototherapy has proved
effective. Currently, therapy mainly consists of either UVB light or psoralens plus UVA light
(PUVA) applied topically or in a bath. With long-term therapy, the potential carcinogenic risk
must be considered.
7
Q
- In irritant contact dermatitis of the hands, the predominant areas involved include:
A. the fingernails initially, then the knuckles of the fingers.
B. the palmar areas of the hands initially.
C. the web spaces initially, the dorsal aspects of the hands and fingers.
D. the wrist areas
A
- A, the web spaces initially, the dorsal aspects of the hands and fingers., p. 568.
It often is not possible to distinguish the clinical findings in ICD from those in ACD. Classically,
the first signs of ICD are dry and slightly scaly skin, with increasing redness and lichenification
after prolonged or repeated exposure to an irritant(s). This may be followed by formation of
fissures, also known as rhagades. Itching is generally not as severe as in ACD. On thehands, the
predominant areas involved include the web spaces initially.
8
Q
- High molecular weight (HMW) compounds are mostly protein or polysaccharides and
act as completeantigens directly provoking an IgE-mediated response. Which of the
following agents is a HMW agent?
A. Cereals
B. Isocyanates
C. Metals
D. Wood dusts
A
- A, Cereals, p. 973, Table 59-2.
Cereals are high-molecular weight-agents that cause immunologic occupation asthma, while
isocyanates, metals (like chromium, nickel, cobalt, and platinum), and wood dusts are all lowmolecular-weight agents.
Chapter 59: Occupational Allergy and Asthma
Middleton’s Allergy Principles and Practice, 8th Edition
9
Q
- Which of the following agents is the most frequent and most often reported cause of
occupational asthma in Western countries?
A. Acrylates
B. Baking products
C. Diisocyanates
D. Wood dust
A
- B, Baking products, p. 981.
Baking products are the leading cause of occupation in most Western countries with 0.8-2.4
cases per 1000 exposed workers and a cumulative incidence rate of 12.4% for IgE mediated
sensitization to bakery allergens, 8.4% for OR and 6.1% for occupational asthma.
10
Q
3. What is the single most important risk factor for occupational asthma? A. Atopy B. Exposure C. Rhinoconjunctivitis D. Smoking
A
- B, Exposure, p. 974; Table 59-4.
The intensity of exposure to sensitizing agents is currently the most well-characterized
and most important environmental risk factor for the development of occupational
asthma.
11
Q
4. What agent should you suspect in an automobile worker with occupational asthma who works in finish coating? A. HDI (hexamethylene diisocyanate) B. LDI (lysine diisocyanate) C. MDI (methylene diphenyl diisocyante) D. TDI (toluene diisocyanate)
A
4. A, HDI (hexamethylene diisocyanate), p. 982. Hexamethylene diisocyanate (HDI) as it is used extensively in spray paints.
12
Q
5. Patients with occupational asthma and exposure to which of the following agents would have the best prognosis? A. HDI (hexamethylene diisocyanate) B. LDI (lysine diisocyanate) C. MDI (methylene diphenyl diisocyanate) D. TDI (toluene diisocyanate)
A
- A, HDI (hexamethylene diisocyanate), p. 983.
Occupational asthma due to HDI seems to carry a better prognosis than
occupational asthma due to TDI and MDI.
13
Q
- Which of the following conditions is characterized by the lack of a latency period and
immunologicsensitization, and occurs after a single massive irritant exposure?
A. Acute respiratory distress syndrome
B. Reactive airway dysfunction syndrome
C. Work-related asthma
D. Work-exacerbated asthma
A
- B, Reactive airways dysfunction syndrome, p. 970.
Reactive airways dysfunction syndrome refers to a type of occupational asthma without latency
and immunologic sensitization, occurring after a single massive irritant exposure with
consequent severe airway injury,and resulting in persistent airway inflammation and
nonspecific bronchial hyperresponsiveness.
14
Q
- The epidemiology of occupational asthma is challenging. Which of the following statements is
true?
A. Data generated by voluntary notification schemes rely mainly on confirmatory concrete data.
B. Medicolegal statistics from compensation boards may overestimate prevalence.
C. Occupational rhinitis is known to be equally as common as occupational asthma.
D. Population surveys minimize survivor bias but lack confirmatory testing data.
A
- D, Population surveys minimize survivor bias, but lack confirmatory testing data, p. 972.
Data generated by voluntary notification schemes rely on the physician’s diagnostic opinion and
no confirmatory tests are required. Medicolegal statistics may underestimate the true
incidence of occupational asthma because not everyone applies for compensation. Population
surveys minimize survivor bias but arelimited by the lack of confirmation testing. Occupational
rhinitis is 2-4 times more common than occupational asthma.
15
Q
- Sputum eosinophils have been used as an objective measure of airway inflammation in
occupational asthma. What is thought to be the ideal timeframe for sputum collection to
check for sputum eosinophils?
A. 1 hour post exposure
B. 3-5 days post exposure
C. 7-10 days post exposure
D. 7-24 hours post exposure
A
- D, 7-24 hours post exposure, p. 979.
The best timing for the collection of induced sputum with respect to exposure to occupational
agents is likely to be 7-24 hours after exposure.
16
Q
9. Exposure to which product is associated with work-related anaphylaxis in people who work in nail salons? A. Aldehydes B. Latex C. Methacrylates D. Terachlorophtalic acids
A
- C, Methacrylates, p. 978 and Table 59-2.
The answer is methacrylates. Acrylates are low molecular weight agents found in sculptured
fingernails which can result in immunologic reactions.
17
Q
10. Occupational asthma related to western red cedar is due to exposure to which of the following? A. Bromelain B. Carmine C. Plicatic acid D. Trimellitic acid
A
- C, Plicatic acid, p. 983.
Plicatic acid is present in western red cedar and in small amounts in eastern white cedar.
Plicatic acid has been shown to induce specific bronchial reactions on bronchial challenge
testing in exposed workers with a history compatible with occupational asthma.
18
Q
- What is the name for the eosinophil breakdown products that may be visible by
microscopy in the mucus of asthmatic patients?
A. Birbeck granules
B. Calcium oxalate crystals
C. Charcot-Leyden crystals
D. Curschmann crystals
A
- C, Charcot-Leyden crystals, p. 990-991.
Charcot-Leyden crystals are crystals derived from lysed eosinophils. They may be found in
mucus or mucus plugs and are one of several inflammatory changes that accompany severe
asthma. See Figure 60-8D for a photograph of Charcot-Leyden crystals
Chapter 60: Pathology of Asthma
Middleton’s Allergy Principles and Practice, 8th Edition
19
Q
2. What is the name for the distinctive spiral formations that may be found on microscopy in mucus of asthmatic patients? A. Azurophilic granules B. Charcot-Leyden spirals C. Curschmann spirals D. Döhle bodies
A
- C, Curschmann spirals, p. 990-991.
Curschmann spirals are distinctive spiral formationsthat may be found in mucus or sputum and
are associated with inflammatory changes of severe asthma.See Figure 60-8C for a photograph
of a Curschmann spiral.
20
Q
- A 30-year-old female presents as a new patient to Allergy and Immunology clinic. She
reports a history of cough, chest tightness, and wheezing that worsens when she exercises,
has an upper respiratory infection, or is around cats. She wakes up at night with these
symptoms approximately three times per week. She was prescribed an albuterol inhaler by
her primary care physician and reports that her symptoms are relieved by its use, but she does
feel the need to use it more days thannot. Spirometry reveals FEV1 68% predicted. A sputum
sample is obtained and exhaled fraction of nitric oxide is measured.
Which of the following clinical findings suggests that she would be likely to respond well to
treatment with corticosteroids?
A. Abundant sputum neutrophils
B. Elevated exhaled fraction of nitric oxide
C. Few or no sputum eosinophils
D. FEV1 less than 80% predicted
A
- B, Elevated exhaled fraction of nitric oxide, p. 994.
Airway epithelial cell nitric oxide production is increased in asthmatic inflammation.
Measurement of the fraction of exhaled nitric oxide (FeNO) is considered a marker of
eosinophilic asthma and may predict response to steroid treatmentin non-eosinophilic asthma.
High levels of neutrophils or few or absent eosinophils in sputum may be associated with a poor
response to corticosteroids. FEV1 may be reduced in either corticosteroid-responsive or
corticosteroid-resistant asthma.
21
Q
4. Corticosteroids have which of the following effects? A. Inhibit eosinophil apoptosis B. Inhibit neutrophil apoptosis C. Promote neutrophil apoptosis D. Trigger mast cell degranulation
A
- B, Inhibit neutrophil apoptosis, p. 992.
Corticosteroids selectively inhibit apoptosis of neutrophils and promote apoptosis of
eosinophils. Patients with asthma may develop neutrophilic inflammation in part because of
corticosteroid treatment, though neutrophilic inflammation may also be promoted by Th17 type
CD4+ T lymphocyte production of cytokines such as IL-17A.
22
Q
5. Which of the following is a chemoattractant that attracts eosinophils to the airway mucosa in asthma? A. CXCL5 B. CXCL7 C. CXCL8 D. CCL2
A
- A, CXCL5, p. 992.
CXCL5 is a chemoattractant present in the airway mucosa during asthma exacerbations. Its
presence correlates with increased numbers of eosinophils. The other answers listed are
chemokines that attract other types of cells of the immune system.
23
Q
- Which of the following cytokines is produced most abundantly by CD4+ T lymphocytes in
allergic asthmatic airway inflammation?
A. Granulocyte-macrophage colony-stimulating factor
B. IL-12
C. Interferon gamma
D. Thymic stromal lymphopoietin
A
- A, Granulocyte-macrophage colony-stimulating factor, p. 987.
In allergic asthma, CD4+T lymphocytes play a key role in airway inflammation and most exhibit a
Th2 profile of cytokine secretion with production of IL-4, IL-5, IL-9, IL-13, and granulocytemacrophage colony-stimulating factor (GM-CSF). Thymic stromal lymphopoietin is related to
Th2 differentiation of CD4+ T lymphocytes and is secreted by epithelial cells and keratinocytes,
notby Th2-type CD4+ T lymphocytes. Interferon gamma and IL-12 areTh1-type cytokines.
24
Q
7. Which of the following viruses has been associated with asthma exacerbations? A. Human rhinovirus species A B. Human rhinovirus species B C. Human rhinovirus species C D. Parainfluenza virus
A
- C, Human rhinovirusspecies C, p. 992.
Viral infections are a common trigger for asthma exacerbations and may enhance the
inflammatory response to allergen exposure. Rhinoviruses are the most common viruses to be
implicated in asthma exacerbations and human rhinovirus species C (HRV-C) is a subgroup of
rhinovirus that is particularly associated with asthma exacerbations
25
Q
1. Which of the following would you expect to be a cause of a subacute cough in adults? A. Allergic rhinitis B. Common cold C. Post-infectious cough D. Smoking
A
- C, Post-infectious cough, p. 1032, 1035.
Subacute cough has a duration of 3-8 weeks. Of the listed choices, only post-infectious cough
is expected to fit that duration. The common cold is a cause of acute cough, and both smoking
(via chronic bronchitis) and allergic rhinitis can lead to a chronic cough.Chapter 63: Approach to Patient with Chronic Cough
Middleton’s Allergy Principles and Practice, 8th Edition
26
Q
2. In children, to diagnose chronic cough, symptoms must be present for at least how long? A. 2 weeks B. 4 weeks C. 6 weeks D. 8 weeks
A
- B, 4 weeks, p. 1032.
In children, cough is defined as acute (< 4 weeks) or chronic (> 4 week). Subacute cough is
not defined in children.
27
Q
- After ruling out smoking and ACE-inhibitor use in a patient with a chronic cough, what is
the next best step in management?
A. Empiric treatment with antihistamines, PPI, and bronchodilator
B. Obtain CXR
C. Obtain esophageal pH studies
D. Obtain spirometry
A
- B, Obtain CXR, p. 1038.
The next step in management is to obtain a chest x-ray. If the x-ray is normal, thenthis patient
represents the “clinical profile” of cough usually associated with UACS (upper airway cough
syndrome), asthma, NAEB (nonasthmatic eosinophilic bronchitis), or GERD. Once a normal xray is obtained, empiric therapy can be started based on the history.
28
Q
- In adults, which of the following details in the history has been shown to be
helpful indiagnosing the cause of a chronic cough?
A. Character of cough
B. Duration of cough
C. Sound quality of cough
D. Timing of cough
A
- B, Duration of cough, p. 1033.
In evaluating a patient with a cough, it is important to first obtain a detailed history.The
character of cough (productive, dry), sound quality (barking, honking), and timing
(nocturnal) have not been proven to help in diagnosis. Determining the duration of cough,
however, can help guide the differential. If the cough is determined to be chronic, UACS,
asthma, NAEB, and GERD have been proven to be the most likely causes.
29
Q
- Which of the following provides the correct diagnosis of chronic bronchitis?
A. Exposure to cigarette smoke only, dry cough, on most days over two years
B. Exposure to cigarette smoke only, productive cough, on most days during three
consecutive months for one year
C. Exposure to respiratory irritant, dry cough on most days over six consecutive monthsfortwo
consecutive years
D. Exposure to respiratory irritant, productive cough on most days during three consecutive
months for two consecutive years
A
- D, Exposure to respiratory irritant, productive cough on most days during three
consecutive months for two consecutive years, p. 1035.
Chronic bronchitis can be diagnosed in patients with exposure to respiratory irritants(dust,
fumes, smoke). Patients must expectorate phlegm on most days for three consecutive months
over two consecutive years. Other common causes of cough-phlegm syndrome (e.g., UACS,
bronchiectasis, asthma, GERD) must be ruled out and the cough must resolve after elimination
of irritant.
30
Q
6. Which of the following is responsible for the most cases of upper airway cough syndrome? A. Allergic rhinitis B. Bacterial sinusitis C. Fungal sinusitis D. Nonallergic rhinitis
A
- B, Bacterial sinusitis, p. 1035.
Of the causes listed, bacterial sinusitis accounts for the most cases of chronic cough (39% of
cases) due to UACS. The next most frequent is nonallergic rhinitis, followed by allergic rhinitis.
31
Q
7. What would be appropriate treatment of vasomotor rhinitis leading to upper airway cough syndrome? A. Budesonide nasal spray B. Ipratropium bromide nasal spray C. Loratadine D. Montelukast
A
- B, Ipratropium bromide nasal spray, p. 1037.
Vasomotor rhinitis is treated with ipratropium nasal spray. The other medicationscan be
used to treat allergic rhinitis.
32
Q
- Which of the following is characteristic of NAEB (nonasthmatic eosinophilic bronchitis)
only and not asthma?
A. Chronic cough can be the only presenting symptom
B. Mast cells present in airway mucosa but not in smooth muscle layer
C. Positive methacholine challenge test
D. Sputum eosinophilia
A
- B, Mast cells present in airway mucosa but not in smooth muscle layer, p. 1037.
In NAEB mast cells are present in the airway mucosa only. In asthma, mast cells are present
in the airway mucosa, submucosa, and smooth muscle layer. Methacholine challenge test
would be negative in NAEB but positive in Asthma. Chronic cough as the only symptom,
sputumeosinophilia, and a response to inhaled steroids can be seen in both asthma and
NAEB.
33
Q
9. In children, which two diseases are the most common causes of nonspecific chronic cough? A. Asthma and bacterial bronchitis B. GERD and asthma C. UACS and asthma D. UACS and bacterial bronchitis
A
- A, Asthma and bacterial bronchitis, p. 1038-1039.
In children, chronic cough is divided into specific and nonspecific categories.A nonspecific
cough is a cough that occurs on its own. In children, asthma and protracted bacterial
bronchitis have been shown to be the most common causes of nonspecific cough.
34
Q
- Empiric treatment is often started in patients with chronic cough, then monitored for
improvement. Which etiology below is paired with the correct length of time before
symptoms are expected to improve from treatment and the effect of treatment can be fully
assessed?
A. Asthma - 1 week
B. GERD - 3 months
C. Smoking - 2 months
D. UACS - 2 weeks
A
- B, GERD – 3 months, p. 1039.
It is important to ensure that patients complete a full course of treatment before
determining that a treatment has failed. Asthma and UACS can take up to 4 weeks to
improve, chronic bronchitis from smoking can take up to 4 weeks after stopping smoking,
to improve and GERD can take up to 3 months to improve and 5-6 months to resolve.
35
Q
1. Which of the following options has listed the insect with its correct respective family? A. Bumblebee: Formicidae B. Fire Ant: Formicidae C. Honeybee: Vespidae D. White-faced Hornet: Apidae
A
- B, Fire Ant: Formicidae, p. 1261.
The honeybee, bumblebee, and sweat bee belong to the Apidae family. Theyellow
jacket, yellow hornet, white-faced hornet, and paper wasp belong to the Vespidae
family. The fire ant, jack jumper ant, and harvester ant belong to the Formicidae familyChapter 78: Insect Allergy
Middleton’s Allergy Principles and Practice, 8th Edition
36
Q
2. Which one of the following families contains extensive cross reactivity amongst the different genera? A. Apidae B. Formicidae C. Hominidae D. Vespidae
A
- D, Vespidae, p. 1263.
There is little to no cross reactivity amongst families. The vespid family has extensive crossallergenicity of the venoms of different genera. It should be noted that within each genus
there are some species even within the vespid family that have only limited cross-reactivity.
The Hominidae family is the family to which humans belong.
37
Q
3. How effective is venom immunotherapy in preventing sting anaphylaxis? A. 25%-44% B. 45%-64% C. 65%-74% D. 75%-98%
A
- D, 75%-98%, p. 1260.
Venom immunotherapy is 75-98% effect in preventing sting anaphylaxis. Ofnote, it is a
safe as inhalant allergen immunotherapy.
38
Q
- After an anaphylactic reaction to an insect sting, some patients are thought to
have a refractory period in which skin testing may be negative but can be positive
after the refractory period. How long is the refractory period thought to be?
A. 2-3 weeks
B. 4-6 weeks
C. 8-12 weeks
D. 3-6 months
A
- B, 4-6 weeks, p. 1264.
Some patients will have negative skin testing after a sting. This is attributed to arefractory
period of anergy. The skin tests should be repeated after 4 to 6 weeks. It should be noted that
some cases of sting anaphylaxis with negative skin testing may be because the sting
anaphylaxis is due to non-IgE mediated process or a subclinical mastocytosis.
39
Q
- Which of the following statements about hymenoptera venom is correct?
A. Melittin is predominantly found in hornet venom extract
B. The major allergenic component of honeybee venom extract is phospholipase A.
C. The major allergenic component of vespid venom extract is antigen 4.
D. Whole-body vespid extracts are as effective as vespid venoms for immunotherapy.
A
- B, The major allergenic component of honeybee venom extract is phospholipase A., p.
1263, 1265.
The major allergenic component of honeybee venom is phospholipase A. The major
allergenic component of vespid venoms is antigen 5. Whole-Body extracts (with the
exception of fire ants) are NOT effective for immunotherapy. The degree of skin test
sensitivity does NOT correlate reliably with the degree of sting reaction.
40
Q
6. Which of the following insects most commonly cause systemic reactions from bites? A. Deerfly (Tabanidae) B. Horsefly (Tabanidae) C. Kissing Bug (Triatoma) D. Mosquito (Culicidae)
A
- C, Kissing Bug (Triatoma), p. 1270 and 1271.
The most common cause of systemic reactions from insect bites isfrom the kissing bug.
41
Q
- Aspirin Exacerbated Respiratory Disease (AERD) describes a clinical syndrome with
three features - the “Samter’s triad.” Which of the following choices below is not
part of the triad?
A. Asthma
B. Chronic rhinosinusitis with polyps
C. Hypersensitivity reactions to aspirin and other cross-reacting NSAIDs
D. Increased pulmonary infections
A
- D, Increased pulmonary infections, p. 1296.
Patients with Aspirin Exacerbated Respiratory Disease (AERD), or Samter’s triad condition, usually present with chronic rhinosinusitis with polyps, moderate to severe asthma, and hypersensitivity reactions to aspirin and other cross-reacting NSAIDs.
Chapter 80: Hypersensitivity to Aspirin and Other Nonsteroidal
Anti-Inflammatory Drugs
Middleton’s Allergy Principles and Practice, 8th Edition
42
Q
- What cells with large amounts of infiltrates are most often found in the upper
and lower airway mucosa of patients with Aspirin Exacerbated Respiratory
Disease (AERD)?
A. Eosinophils
B. Lymphocytes
C. Macrophages
D. Neutrophils
A
- A, Eosinophils, p. 1298, 1301.
The pathogenesis of Aspirin Exacerbated Respiratory Disease (AERD) includes development
of chronic inflammation of the upper and lower airway mucosa. Abundant amounts of
eosinophils are found in mucosa of patients with AERD.
43
Q
- Aspirin Exacerbated Respiratory Disease (AERD) develops in a
distinctive pattern. What is the usual order of symptom development?
A. Aspirin allergy, asthma, rhinosinusitis with polyps
B. Aspirin allergy, rhinosinusitis with polyps, asthma
C. Asthma, aspirin allergy, rhinosinusitis with polyps
D. Rhinosinusitis with polyps, asthma, aspirin hypersensitivity
A
- D, Rhinosinusitis with polyps, asthma, aspirin hypersensitivity, p. 1301.
Nasal symptoms usually start by middle age and asthma develops a few years later.
Aspirin hypersensitivity is the last symptom to develop and usually manifested as
bronchospasm, rhinitis, and ocular injection.
44
Q
- How do you definitively diagnosis Aspirin Exacerbated Respiratory Disease (AERD)?
A. Aspirin provocation challenges
B. Clear history of adverse reaction to aspirin
C. Identifying nasal polyps in at risk patients on exam
D. Improvement of asthma when stopping aspirin
A
- A, Aspirin provocation challenges, p. 1301.
“The diagnosis of Aspirin Exacerbated Respiratory Disease (AERD) can be definitively
established only through aspirin-provocation challenges”. Challenges can be oral, inhaled,
nasal, or intravenous. Controlled oral challenge with aspirin is the gold standard.
45
Q
- Aspirin desensitization can be used as a treatment option for some
patients. What is the target dose of aspirin desensitization to maintain
cross-desensitization to any dose of all non-steroidal anti-inflammatory
drugs (NSAIDs)?
A. 81 mg
B. 162 mg
C. 325 mg
D. 650 mg
A
- C, 325 mg, p. 1304.
The target dose of desensitization depends on the diseases underlying the aspirin
desensitization. The target dose for cardiovascular disease prevention is 81 mg, the target
dose to maintain cross-desensitization to all non-steroidal anti-inflammatory drugs (NSAIDs)
is 325 mg, and the target dose for Aspirin Exacerbated Respiratory Disease (AERD) patients
is 650 mg twice daily.
46
Q
- Which of the following component proteins is most responsible for clinical reactivity to egg in
children with an IgE-mediated food allergy to hen’s egg?
A. Ovalbumin
B. Ovoglobulin
C. Ovomucoid
D. Ovotransferrin
A
- C, Ovomucoid, p. 1318.
Egg white is considered more allergenic than the yolk, and ovomucoid (Gal d 1) is the dominant
allergen in purified egg white protein. The egg white has more protein overall. Blinded OFCs
with ovomucoid-depleted egg white demonstrated that ovomucoid was responsible for clinical
reactivity in most egg-allergenic children.
Chapter 81: Reactions to Foods
Middleton’s Allergy Principles and Practice, 8th Edition
47
Q
2. What percentage of children with milk allergy typically tolerate extensively heated milk in baked products? A. 25% B. 50% C. 66% D. 75%
A
- D, 75%, p. 1317.
Most published series are 70-80%.
48
Q
3. There is high cross-reactivity between cow’s milk proteins with milk from which of the following animals? A. Camel B. Donkey C. Goat D. Horse/mare
A
- C, Goat, p. 1318.
Oral challenge studies indicate that at least 90% of cow’s milk-allergic children react to
goat/sheep milk, but there is nearly no cross-reactivity with mare, donkey, and camel milk.
49
Q
- Which of the following component proteins has been associated with environmental pollen
allergy and pollen food allergy syndrome, but not systemic reactions to peanuts?
A. Ara h 1
B. Ara h 2
C. Ara h 6
D. Ara h 8
A
- D, Ara h 8, p. 1318.
Ara h 8 is a Bet v 1 cross-reactive protein with low stability during roasting and no stability in
gastric digestion. It has been identified as a major allergen in adults with pollen allergy and oral
allergy symptoms to peanut.
50
Q
- Which of the following statements is most accurate regarding food-dependent, exerciseinduced anaphylaxis (FDEIA)?
A. In the absence of exercise, patients can typically ingest the trigger food without reaction
B. This disorder appears to be most prevalent in early 40s
C. Symptoms occur 4-6 hours after exercise following food ingestion
D. This disorder is more common in males than females
A
- A, In the absence of exercise, patients can typically ingest the trigger food without
reaction, p. 1329.
Food-Dependent, Exercise-Induced Anaphylaxis (FDEIA) occurs only when the patient exercises
within 2-4 hours of ingesting food, but in the absence of exercise, the patient can ingest the
food without any apparent reaction. This disorder appears to be more common in females than
males, with highest prevalence in the late teens to mid-30s.
51
Q
6. Which of the following pairs of vaccines are contraindicated in persons with an IgE-mediated food allergy to egg? A. DTaP and influenza B. Rabies and typhoid C. Yellow fever and MMR D. Yellow fever and rabies
A
- D, Yellow fever and rabies, p. 1331.
According to the National Institute of Allergy and Infectious Diseases (NIAID) sponsored clinical
guideline for the diagnosis and management of food allergy in the United States, yellow fever
and rabies vaccines are contraindicated in persons with history of urticaria, angioedema,
asthma or anaphylaxis to egg proteins. Currently, only one available rabies treatment contains
egg.
52
Q
7. How long does it typically take for cow’s milk and soy protein-induced proctocolitis to resolve after allergen avoidance? A. 3 – 6 months B. 6 months – 12 months C. 6 months – 2 years D. 12 months – 2 years
A
- C, 6 months – 2 years, p. 1325.
Cow’s milk and soy protein-induced proctocolitis generally resolve within 6 months to 2 years
of avoidance, though refractory cases may be seen.
53
Q
- Diagnosis of eosinophilic esophagitis depends on esophageal biopsy demonstrating
eosinophilic infiltration with typically more than how many eosinophils per high-power field?
A. 10
B. 15
C. 20
D. 25
A
- B, 15, p. 1324.
Diagnosis of eosinophilic esophagitis depends on esophageal biopsy demonstrating eosinophilic
infiltration, typically more than 15 eosinophils per high-power field.
54
Q
9. Heiner syndrome, a rare condition resulting in food-induced pulmonary hemosiderosis, is most often associated with which food? A. Beef B. Egg C. Milk D. Wheat
A
- C, Milk, p. 1324.
Food-induced pulmonary hemosiderosis or Heiner syndrome, is a rare condition characterized
by recurrent pneumonia associated with pulmonary infiltrates and hemorrhage, hemosiderosis,
gastrointestinal blood loss, iron-deficiency anemia, and failure to thrive. Heiner syndrome is
most often associated with a non-IgE mediated hypersensitivity to cow’s milk, though reactions
to egg, pork and buckwheat have also been reported.
55
Q
- Which of the following describes the United States Food Allergen Labeling and
ConsumerProtection Act of 2004?
A. Applies to agricultural products and alcoholic beverages
B. Regulates the use of advisory labeling, including statements about potential presence of
unintentional ingredients
C. Requires milk, egg, peanut, tree nuts, fish, crustacean shellfish, wheat, and soy be
declared on ingredient labels
D. Requires the listing of rye, barley, oats, celery, mustard, and sesame seeds on
ingredient labels
A
- C, Requires milk, egg, peanut, tree nuts, fish, crustacean shellfish, wheat, and soy be
declared on ingredient labels, p. 1366.
In the United States, the Food Allergen Labeling and Consumer Protection Act (FALCPA) of 2004
requires that milk, egg, peanut, tree nuts, fish, crustacean shellfish, wheat, and soy be listed on
ingredient labels using plain English words. The law also requires that the specific type of
allergen within a category be named (ie ‘walnut’ or ‘shrimp’). FALCPA applies only to foods
manufactured in or imported into the United States and does not apply to agricultural products
of alcoholic beverages that may use food proteins as ingredients or processing agents. The
European Union enacted legislation in 2005 requiring six allergens that are not cover in FALCPA
to be declared (rye, barley, oats, celery, mustard, and sesame seed). FALCPA of 2004 does not
regulate the use of advisory labeling, including statements about potential presence of
unintentional ingredients; these declarations are done so voluntarily in the United States.
Chapter 84: Food Allergy Management
Middleton’s Allergy Principles and Practice, 8th Edition
56
Q
2. Which of the following is a risk factor associated with fatal food anaphylaxis? A. Asthma B. Dairy or egg allergy C. Presence of skin symptoms D. Young child
A
- A, Asthma, p. 1369, Box 84-1.
Co-morbid risk factors associated with fatal food anaphylaxis include delayed treatment with
epinephrine, allergy to peanut, tree nuts, fish or shellfish, an adolescent or young adult,
asthma, cardiovascular disease in a middle-aged or older patient, and lack of skin symptoms.
57
Q
3. Which one of the following immune parameters is increased in effective immunotherapy? A. Helper T cell (Th2) cytokines B. Mast cell reactivity C. Serum IgE D. Serum IgG4
A
- D. Serum IgG4, p. 1376 Table 84-7.
With effective immunotherapy, increases in both serum IgG4 and regulatory T cell
activation are seen. Immune parameters including serumIgE, mast cell reactivity, basophil
activation and helper T cell cytokines are decreased in effective immunotherapy.
58
Q
1. Which important cytokine is involved in the proliferation and function of natural killer cells and T-regulatory lymphocytes? A. Interleukin 2 B. Interleukin 4 C. Interleukin 10 D. Interleukin 12
A
IL-2 is a potent activator of the proliferation and function of T lymphocytes and natural killer cells. IL-2 functions as a T cell growth factor, can augment natural killer (NK) cell cytolytic activity, contributes to the development of regulatory T (Treg) cells and promotes immunoglobulin production by B cells, as well as regulating the expansion and apoptosis of activated T cells
Chapter 93: Cytokine-Specific Therapy in Asthma
Middleton’s Allergy Principles and Practice, 8th Edition1. A, Interleukin 2, p. 1492.
59
Q
2. Which cytokines are considered the “Th2 defining” cytokines and regarded as being the most important cytokines in Th2 high-asthma pathogenesis? A. IL-2 and IL-13 B. IL-4 and IL-2 C. IL-4 and IL-6 D. IL-4 and IL-13
A
- D. IL-4 and IL-13, p. 1495.
IL-4 and IL-13 are the “Th2 defining” cytokines and arguably are the most important cytokines
in asthma pathogenesis in Th2 asthma. Owing to structural homogeneity, their actions are
broadly similar, and they are therefore considered together.
60
Q
3. Which cytokine modulates eosinophilic production, maturation, activation, and survival in blood? A. IL-4 B. IL-5 C. IL-9 D. IL-13
A
- B. IL-5, p. 1496.
IL-5 modulates eosinophil progenitor production, maturation, activation, and survival in blood and can induce airway eosinophilia.
61
Q
- Which cytokine uniquely promotes airway mastocytosis and mast cell progenitor
development andlocalization to the airway?
A. IL-1
B. IL-2
C. IL-9
D. IL-13
A
- C, IL-9, p. 1498.
IL-9 is derived from CD4+ (Th9) cells, eosinophils, and mast cells. It causes T cell proliferation, increases IgE production by B cells, and increases expression of the α-subunit of IgE receptors. It uniquely promotes airway mastocytosis and mast cell progenitor development
and localization to the airway
62
Q
5. Which pleiotropic cytokine is considered the principle Th1 effector cytokine and plays an important role in Th1 differentiation? A. IFN-γ B. IL-2 C. IL-12 D. TNF-α
A
- A, IFN-γ. p. 1500.
IFN-γ is a pleiotropic cytokine that induces and modulates an array of immune responses.
Most importantly, it is the principal Th1 effector cytokine with a crucial role in Th1 differentiation. IFN-γ mainly inhibits eosinophils, a crucial cell type in the allergic Th2 model of asthma, as evidenced when targeted disruption of the IFNγR receptor gene resulted in a prolonged airway eosinophilia in response to allergen.
63
Q
6. Which family of cytokines are linked to autoimmune diseases (rheumatoid arthritis, inflammatory bowel diseases, multiple sclerosis), in addition to increased expression in Th2 low-asthmatic patients? A. IFN-γ B. IL-16 family cytokines C. IL-17 family cytokines D. TNF-α
A
- C, IL-17 family cytokines, p. 1500.
The IL-17 family cytokines, IL-17A to IL-17F, are linked with several autoimmune diseases such as rheumatoid arthritis, inflammatory bowel disease, and multiple sclerosis. IL-17E and IL-17F are of interest in asthma because their expression is increased in the airways of
asthmatic patients; levels have been correlated with disease severity.
64
Q
7. Which anti-IL5 allows for successful oral corticosteroid withdrawal in prednisonedependent patients with asthma? A. Dupilumab B. Mepolizumab C. Omalizumab D. Tralokinumab
A
- B, Mepolizumab, p. 1497-1498.
Mepolizumab therapy allowed for successful oral corticosteroid withdrawal in prednisonedependent patients with asthma compared with placebo. The median time to exacerbation was 20 weeks in the mepolizumab group and 12 weeks in the placebo group (P = .003).
65
Q
1. In children with asthma, lower blood levels of which of the following nutrients has been associated with increased asthma severity, including increased IgE levels, eosinophilia, methacholine responsiveness, asthma-related hospitalization, asthma exacerbations, use of anti-inflammatory medication, use of oral corticosteroids, and reduced asthma control scores? A. Vitamin A B. Vitamin C C. Vitamin D D. Zinc
A
- C, Vitamin D, p. 768.
In children with asthma, lower blood levels of vitamin D have been associated with increased asthma severity, including increased IgE levels, eosinophilia, methacholine responsiveness, asthma-related hospitalization, asthma exacerbations, use of anti-inflammatory medication, use of oral corticosteroids, and reduced asthma control scores. Similar findings have been reported for adults with asthma. Lower serum 25-OH-D concentrations have been associated
with increase severity of disease in children with atopic dermatitis. Please also reference Table 48-4 on p. 767 to review nutrients implicated in asthma as well as their activity and potential mechanisms of action.
Chapter 48(1): Epidemiology of Asthma and Allergic Diseases Middleton’s Allergy Principles and Practice, 8th Edition
66
Q
2. The Wisconsin Childhood Origins of Asthma (COAST) study found that wheezing in the first year of life associated with a particular virus is the strongest predictor of wheezing in the third year of life. Which of the following is that virus? A. Human rhinovirus (HRV) B. Influenza C. Respiratory syncytial virus (RSV) D. Enterovirus
A
- A, Human rhinovirus (HRV), p. 770.
The COAST study prospectively evaluated timing, frequency, severity and cause of symptomatic viral infection in the first 3 years of life in relation to later wheezing illness in a cohort of 289 neonates at high familial risk for asthma. This study highlighted the prognostic importance of HRV. Having one or more HRV-associated wheezing episodes during the first year of life was more strongly associated with wheezing in the third year than having one or more RSV-associated wheezing episodes in the first three years of life. Also, first-year wheezing associated with HRV was the strongest predictor for third-year wheeze.
67
Q
3. Which of the following is an associated risk factor for allergic rhinitis? A. Low socioeconomic status B. Parental history C. Vaginal delivery D. Young age
A
- B, Parental history, p. 777.
The most frequently cited risk factors of allergic rhinitis include increasing age, atopy, and high socioeconomic status. Parental history is positively associated with development of allergic rhinitis in offspring. Younger gestational age at birth has been associated with decreased risk of
allergic rhinitis. Some researchers have postulated early-life microbial exposure may modulate risk of allergic rhinitis. This hypothesis is supported by the observations that birth by caesarean
section is a risk factor for allergic rhinitis.
68
Q
- Females over age 15 have higher rate of anaphylaxis than males. The reason for this is unknown but may be due to which of the following?
A. Hormonal changes which increase sensitivity to anaphylaxis
B. Increased incidence of food allergies
C. Increased exposure to stinging insects
D. Reporting bias since females more likely to seek medical care for anaphylaxis
A
- A, Hormonal changes, such as progesterone, which increases sensitivity to anaphylaxis
in animal models, p. 1239.
Men are more likely to have anaphylaxis to stinging insects. Women report more
anaphylaxis to medications. Adult females do report more food allergies than men, but this
does not account for the increase in anaphylaxis.
Chapter 77(a): Anaphylaxis Middleton’s Allergy Principles and Practice, 8th Edition
69
Q
- Platelet-activating factor has been shown to be important for anaphylaxis due to its role in which of the following?
A. Clotting and disseminated intravascular coagulation
B. Inotropy
C. Smooth muscle contraction
D. Vascular permeability
A
- A, Clotting and disseminated intravascular coagulation, p. 1243.
Platelet activating factor (PAF) induces clotting and DIC. Levels of PAF have been shown to
correlate directly with severity of anaphylaxis in humans.
70
Q
- IL-33 may be important in anaphylaxis due to its role in which of the following?
A. Activation of ILC2s leading to more cytokine release
B. Chemotactic effect on eosinophils which contributes to late phase responses
C. Direct induction of degranulation and cytokine production in IgE-sensitized mast cells
D. Potentiation of IgE-mediated release of mediators from mast cells
A
- C, Direct induction of degranulation and cytokine production in IgE-sensitized mast cells,
p. 1243.
In a mouse model, IL-33 was important for direct induction of cytokine and eicosanoid release
from mast cells. Its role in humans is unclear, although levels have been shown tobe higher in
patients after perioperative anaphylaxis. IL-33 can stimulate ILC2s but it is unknown if this has
any role in anaphylaxis.
71
Q
4. Vasodilation in anaphylaxis is mediated by which of the following? A. H1 and H2 receptors B. H1 and H3 receptors C. H1 and H4 receptors D. H2 and H3 receptors
A
- A, H1 and H2 receptors, p. 1243.
[ ** error; site said B; books says A]
H2 receptors directly act on smooth muscle cells and H1 receptors mainly work by stimulating endothelial cells to manufacture nitric oxide.
H3 ‘receptor found on presynaptic sites of histaminergic nerve terminals & tend to be inhibitory receptors. stimulated presynaptic terminals of sympathetic effector nerves innervating the heart and systemic vasculature resulting in inhibition of NE release; blockading may help reverse hypotesion’
72
Q
- The main pathophysiologic feature of anaphylactic shock is which of the following?
A. Arterial vasodilation
B. Fluid extravasation causing hemoconcentration and hypovolemia
C. Increased intrathoracic pressure due to air trapping from bronchospasm
D. Profound bradycardia
A
- B, Fluid extravasation causing hemoconcentration and hypovolemia, p. 1245.
Fluid extravasation of up to 35% of circulating blood volume has been demonstrated. There is a relative bradycardia to level of hypotension, but this is not the main driver of shock. Arterial vasodilation has been postulated as a cause, but not proven. Air trapping does not have a role
in causing anaphylactic shock.
73
Q
- The reason that initial treatment for anaphylactic shock is unsuccessful is most often due to which of the following?
A. Inadequate doses of epinephrine
B. Insufficient fluid resuscitation
C. Insufficient use of antihistamines
D. Need for atropine to treat bradycardia
A
- B, Insufficient fluid resuscitation, p. 1246.
Up to 5 L of fluid may be needed in the first 20 minutes to compensate for the extravasation of fluid. Epinephrine may not be adequately absorbed from hypoperfused muscle, but ultimately epinephrine alone cannot reverse anaphylactic shock. Atropine and antihistamines are also ineffective without adequate fluid resuscitation
74
Q
1. Patients taking which of the following medications may have enhanced susceptibility to episodes of scombroidosis? A. Cephalosporins B. Disulfiram C. Griseofulvin D. Isoniazid
A
- D, Isoniazid, p. 1249.
Scombroidosis, which is histamine poisoning caused by ingestion of histamine in spoiled fish may mimic anaphylaxis. Patients taking isoniazid appear to have increased susceptibility to episode of scombroidosis. Alcohol-induced flush may also mimic anaphylaxis and has been linked to drugs including disulfiram, griseofulvin and cephalosporins.
Chapter 77(b): Anaphylaxis
Middleton’s Allergy Principles and Practice, 8th Edition
75
Q
2. During menses, patients may be predisposed to anaphylactoid reactions to infusions of luteinizing hormone-releasing hormone (LHRH) and intradermal injections of medroxyprogesterone due to elevated levels of? A. Estrogen B. Progesterone C. Luteinizing hormone (LH) D. Follicle-stimulating hormone
A
- B, Progesterone, p. 1250.
Patients with progesterone-related anaphylactic episodes have anaphylactoid reactions with the infusion of LHRH and intradermal administration of medroxyprogesterone. The mechanism of this disorder is unknown but increased levels of progesterone associated with
menses may predispose patients to anaphylactic events. LHRH analog therapy is beneficial. The disorder should be suggested in women, typically over age 35 with recurrent episodes of
anaphylaxis with temporal relationship with menstrual cycle.
76
Q
3. Which of the following medications interfere with endogenous compensatory responses to hypotension during anaphylaxis? A. ACE-inhibitors B. β-blockers C. Monamine oxidase inhibitors (MAOIs) D. Tricyclic antidepressants (TCAs)
A
- A, ACE-inhibitors, p. 1251.
Patients who are at risk for anaphylaxis should not take the following medications if other
agents willsuffice: β-adrenergic blockers, ACE inhibitors, angiotensin receptor blockers
(ARBs), MAOIs and TCAs. ACE inhibitors and ARBs interfere with endogenous compensatory
responses to hypotension.β-blockers decrease efficacy of epinephrine whereas MAOIs and
some TCAs affect the use of epinephrine through side effects.
77
Q
4. Which of the following is the appropriate range of dosing and concentration of epinephrine to be administered to an adult intramuscularly in the lateral thigh? A. 0.1-0.3 mL of 1:1,000 solution B. 0.1-0.3 mL of 1:10,000 solution C. 0.3-0.5 mL of 1:1,000 solution D. 0.3-0.5 mL of 1:10,000 solution
A
- CN 0.3-0.5 mL of 1:1,000 solution, p. 1252 and Table 77-7.
The concentration of epinephrine for IM administration is 1:1000. The dose for adults is 0.3 to 0.5 mLof 1:1000 solution or 0.3 to 0.5 mg.
In children, the dose of IM epinephrine is 0.01 mg/kg up to the maximal adult dose. The dose of epinephrine may be repeated two to three
times as needed, at intervals of 5 to 15 minutes.
78
Q
- Which of the following is the best predictor for a serious recurrence of anaphylaxis?
A. Asthma
B. Ability to avoid exposures to triggering agents
C. Amount of allergen necessary to produce reaction
D. Serious symptoms at time of initial event
A
- D, Serious symptoms at time of initial event, p. 1255.
Prognosis for patients with recurrent anaphylactic episodes is reasonably good. Prognosis is based on natural history, amount of allergen necessary to produce reaction, and ability to avoid triggering agents. However, the best predictor for recurrence was presence of serious symptoms during initial event. In one study cited, neither asthma nor atopy were risk factors for recurrence of anaphylaxis.
79
Q
6. Based on a compilation of 1784 patients which were reviewed in a published series entitled “Anaphylaxis and anaphylactoid reactions,” the most common clinical manifestation of anaphylaxis is which of the following? A. Cardiovascular symptoms B. Cutaneous symptoms C. Gastrointestinal symptoms D. Respiratory symptoms
A
- B, Cutaneous symptoms, p. 1246 and Table 77-6.
The reviewed series included one series of patients with exercise-induced anaphylaxis or
idiopathic anaphylaxis, one series limited to pediatric patients and another limited to
randomly selected patientsof all ages. The most common manifestation in the cases were
cutaneous, followed by respiratory, cardiovascular and gastrointestinal.
80
Q
- Which of the following predisposes one to a late phase response in anaphylaxis?
A. Delayed administration and underdosing of epinephrine
B. Lack of corticosteroid administration
C. Immediacy of symptoms
D. Severity of the first response
A
- A, Delayed administration and under dosing of epinephrine, p. 1247.
Biphasic anaphylaxis describes an anaphylactic episode that can abate and then recur several hours after symptoms have disappeared. Most biphasic reactions occur within the first 8 hours after the first reaction has resolved, but recurrent episodes have been reported as late as 72 hours. Exact incidence of biphasic reactions is unknown but range from 1 to 20% in reports. The severity of the second response also ranges from mild to severe. Delayed administration and underdosing of epinephrine predisposes to late phase response. No clear evidence shows that recurrent response can be suppressed by corticosteroids.
