ALLERGY & IMMUNOLOGY

Allergic Rhinitis
Inflammation of nasal mucosal membranes
Causes:

Rhinorrhea

Nasal itching

Sneezing

Nasal congestion

Postnasal drainage
Seasonal/ perennial (existing for a long time; recurring)
RISK FACTOR FOR ASTHMA
DDX:
NON-ALLERGIC CAUSES OF RHINITIS:

Acute viral infections

Idiopathic (non-allergic rxn to nonspecific irritants)

Atrophic rhinitis (elderly)

Alpha-blockers
NONSELECTIVE
ALPHA-1
Phenoxybenzamine
Alfuzosin
Phentolamine
Prazosin
Tolazoline
Doxazosin
Trazadone
Tamsulosin
Typical and atypical
Terazosin
antipsychotics
Silodosin

Rhinitis medicamentosa/ rebound rhinitis

ALPHA-2
Atipamezole
Idazoxan
Mirtazapine
Yohimbine
*carvedilol/labetalol

Other DDX:
1. Mechanical obstruction (nasal septal deviation, nasal polyps)
2. Sinusitis
Systemic illness with nasal ULCERATION or
CHRONIC sinusitis
Young person, nasal polyposis, chronic sinusitis,
malnourishment, infertility
+ chronic/recurrent bronchitis
NONSEASONAL rhinitis with NEGATIVE skin tests
Refractory congestion after chronic use of topical
nasal decongestants
Nasal congestion in the LAST 6 or MORE WEEKS
of pregnancy

Wegener granulamatosis
Cystic Fibrosis
VASOMOTOR rhinitis
Rhinitis medicamentosa
TX: stop decongestant, replace with IN
corticosteroids
Pregnancy rhinitis

TREATMENT:
1. Empiric treatment
a. 1st LINE: Intranasal corticosteroid
b. 2nd LINE: Intranasal antihistamines, oral combination
antihistamine/decongestants/ oral leukotriene modifiers or intranasal
cromolyn
c. Removal of allergen
d. Pharmacotherapy/ immunotherapy
2. If ET fails, diagnostic testing may be appropriate:
a. In vitro specific IgE antibody assay (radioallergosorbent test)
b. Allergy skin test
c. Nasal cytology (eosinophils)
3. CT SCAN for REFRACTORY/ PERSISTENT RHINITIS

PENICILLIN
SULFONAMI
URTICARIA
DES
HM: Rapid appearance of WHEAL
Classification depends on DURATION and PRECIPITANTS
NSAIDS
ANGIOEDEMA EMERGENCY,CAREFUL OBSERVATION and CHECK AIRWAY Contrast Dye
Acute - < 24 hours, but may recur
Latex
> 24 hours look for UNDERLYING DISEASE ( urticarial vasculitis )
(condoms)
DX: CBC, ESR, CRP Eosinophilia, TSH r/o thyroid disease
NUTS
DDX:
FISH
EGGS
Inc. ESR and CRP
> 24 hours

Vasculitis urticaria

Fever, adenopathy, arthralgias

Antigen for drug exposure
Anaphylaxis, allergen exposure

Serum Sickness

Marked eosinophilia
+ Periorbital edema
(trichinosis)

Parasitic infection
Strongyloidiasis, Filariasis,
Trichinosis

Immediate Hypersensitivity
Reaction

Skin biopsy
Serum complement levels
Hep B and Hep C serology
Cryoglobulins
Serum protein electrophoresis
IgE levels elevated
Epinephrine
Corticosteroid
Antihistamine

TREATMENT:
1. 1st LINE: Non-sedating antihistamine
2. ADD H2-blocker ( Ranitidine, Cimetidine)
3. VERY SYMPTOMATIC: Short term oral corticosteroids
**ANGIOEDEMA + URTICARIA = FOOD/ DRUG ALLERGY**
ANGIOEDEMA
Sudden, temporary edema of a localized area of skin/mucosa
ANGIOEDEMA WITHOUT URTICARIA Hereditary angioedema due to C1 esterase inhibitor
deficiency
CASE: Genital edema in a child riding a bike; recurrent abdominal pain; refractory of epi +
antihis
DX:
1.
DDX:

C2, C4, C1 esterase inhibitor levels (functional and antigenic) to r/o HAE (low)
Food allergy
Drug-induced angioedema
Type 3 angioedema
Idiopathic angioedema

TX:
AIRWAY COMRPOMISED/
HYPOTENSION
1. Epinephrine
- racemic nebulized form
- SC injection
2. Antihistamine
3. Corticosteroid

STABLE
1.
2.

HAE
Antihistamine
corticosteroids

Acute:
1. IV C1 esterase
inhibitor
concentrate
Long term:
2. Danazol/ Stanozolol
(elevate hepatic
synthesis C1)

ANAPHYLAXIS
-

LIFE-THREATENING SYNDROME // WITHIN 30 minutes 1 hour(drugs)/ 2 hours(food)

Recurs within 12 hours (biphasic anaphylaxis)
Causes: anaphylactic reaction or anaphylactoid reaction

Flushing

Urticaria

Conjunctival pruritus

Bronchospasm

Nausea

Vomiting

TX:
1. 1st LINE: EPINEPHRINE (even if only with hives/pruritus)
a. Classic: SC epinephrine 0.3 0.5 mg of 1:1000
b. SHOCK: IV epinephrine 1:10,000
2. Corticosteroid tx for late onset
3. Antihistamine cutaneous reaction
4. Bronchodilator bronchospasm
5. IV saline shock/hypotension
6. Glucagon for epinephrine refractory anaphylaxis due to b-blocker
DRUG ALERGY
Signs:

Rash

Hives

Angioedema

SOB

Wheeze

Laryngeal edema

Anaphylactic shock

DRUG FEVER hypersensitivity is the most common cause of drug fever, and fever
may be the only manifestation. It appears days to 3 weeks after the drug has been
started and resolves 1 to 3 days after the drug withdrawal.

HIV patients are the most susceptible to drug reactions especially fever.
> Jarisch-Herxheimer reaction fever, headache, myalgia, rash and hypotension; within 2
hours, resolves by 48 hours; common in pregnant women; SUPPORTIVE TX
Maculopapular and morbiliform (small discrete
papules)
Urticaria
Erythema multiforme, SJS, TEN

Erythema nodosum
Exfoliative and erythrodermic
Fixed drug eruption

PENICILLIN/ SULFA DRUGS

PHENYTOIN/ CARBAMAZEPINE
Red man syndrome
Photosensitive skin reaction

MC
+ fever, pruritus
USE of AMPICILLIN in EBV and CMV infections or
Acute Lymphoblastic Leukemia
2nd MC; with or without URTICARIA
Classic target lesions >>
mucous membranes with systemic symptoms
(SJS) >>
life threatening loss of epidermis (TEN)
Tender subcutaneous NODULES on lower leg
Widespread generalized redness and scaling rxn
Discrete, round or oval lesions that recur in
exactly the same spot when rechallenged with
drug
BODY FLUSHING, muscle pain
VANCOMYCIN, CIPROFLOXACIN
Phototoxic reaction SUNBURN after drug
administration (tetracycline)
Photoallergic reaction rash after days/months
(sulfonamides)

TX:
1.
2.
3.

Discontinue offending medication

Treat anaphylaxis epinephrine, antihistamine, corticosteroids
Treat rash antihistamine and corticosteroid

IMMUNODEFICIENY
Common variable immunodeficiency (CVI) is the most common primary immunodeficiency that
present during ADULT life

Hypogammaglobulinemia and recurrent sinopulmonary infections

Recurrent infection with encapsulated bacteria (pneumococcus, haemophilus,

staphylococcus)

Giardia lamblia infection

Chronic diarrhea (50%)

Malabsorption
Autoimmune: hemolytic anemia, SLE, arthritis)
Increase risk: gastric adenocarcinoma, intestinal lymphoma, non-Hodgkin lymphoma
**Isolated IgA deficiency recurrent SP infections, giardiasis IVIG is CONTRAINIDICATED;
washed erythrocytes are used
DX:
1. Measurement of serum IG levels
2. Low IG levels antibody response to pneumococcal and tetanus vaccines
TX:
1. 1st LINE: Select IVIG for CVI
COMPLEMENT DEFICIENCY
C5-C9 deficiency recurrent neisserial infections
DX:
1. Total hemolytic complement (CH50) assay
2. If CH50 is low individual component measurements
3. SCREEN ALL PATIENTS with repeated episode of disseminated gonorrhea, or neisserial
meningitis with CH50 assay.
Presenting Pattern
Invasive skin infections
Viral, intracellular pathogenic
or fungal infections
Sinopulmonary infections,
bacteremia with encapsulated
organisms
Neisseria meningitides
meningitis and disseminated
gonorrhea

Defect
Granulocyte (Chronic
granulomatous disease)
Cell-mediated
Immunoglobulins

Terminal complement
components
(C5 C9)

Test
Nitroblue tetrazolium test
Skin test response to PPD,
mumps and Candida antigen
Quantitative serum
immunoglobulins and response
to tetanus and
pneumococcal vaccines
CH50 assay

TX:

1. Treat infection with ANTIBIOTICS (3G Cephalosporins: Ceftriaxone, Ceftaxime, Ceftazidime)