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ALLERGIC DISORDERS
HYPERSENSITIVITY Abnormal heightened reaction to a stimulus of any kind Reflection of excessive or aberrant immune responses Types of Hypersensitivity (Acid) A = Anaphylactic (Type I) C = Cytotoxic (Type II) I = Immune Complex (Type III) D= Delayed Type (Type IV) Anaphylactic (Type I) Uncontrolled or excessive responses against foreign antigens IgE antibody mediated Immediate Hypersensitivity Antigen (Ag) induces crosslinking of IgE bound to mast cells and basophils with release of vasoactive mediators. Two (2) Phases of Type I Immediate Phase Reaction (w/in minutes) vascular and smooth muscle response to mediators minutes after repeated exposure to allergen

E = Eosinophilia (symptom of allergic states, increased eosinphils in the blood) Manifestations: Anaphylactic Shock Allergic Rhinitis Asthma Urticaria Eczema

Cytotoxic (Type II) Immune antibody response against selfantigen IgG antibody mediated Cytotoxic Hypersensitivity Antibody (Ab) directed against cell surface antigen mediates cell destruction via complement activation or ADCC (Antibody Dependent Cellmediated Cytotoxicity) Manifestations: Blood transfusion reactions Myasthenia Gravis Pernicious anemia Thrombocytopenia Immune Complex (Type III) Self antigens or foreign antigens with bound antibody Antibody-antigen complex mediated Hypersensitivity Antigen-Antibody (Ag-Ab) complexes deposited in various tissues induce compliment activation and an ensuing inflammatory response mediated by massive infiltration of neutrophils

Late Phase Reaction (2-4 hours) Can have chronic late phase response without obvious immediate phase (asthma & eczema) 2-4 hours after repeated exposure to allergen

Characteristics of Type I (VISE) V = Vasodilation I = Increased Capillary Permeability S = Smooth Muscle Contraction

Manifestations: Serum sickness Necrotizing vasculitis Glomerulnephritis Rheumatoid Arthritis SLE

Delayed Type (Type IV) Cellular Hypersensitivity (24-72 hours) T cell mediated Hypersensitivity Sensitized T helper cells release cytokines that activate macrophages or cytotoxic T cells which mediate direct cellular damage Manifestations: Contact dermatitis Tubercular lesions Graft rejection Types of Ig E-Mediated

Anaphylaxis Anaphylaxis is a severe systemic allergic reaction (respiratory sx and hypotension) Anaphylaxis, i.e. "without protection". Immunologic reaction to a specific antigen and an antibody, thus reaction results from a rapid release of IgE-mediated chemicals. Pathophysiology Leakage (capillary) Respiratory sx or Hypotension Edema (mucosal) Laryngeal edema, Rhinitis, Wheezing Smooth muscle contraction Wheezing, Abdominal pain

ATOPIC DISORDERS Characterized by hereditary predisposition and production of a local reaction to Ig E antibodies produce increased amounts of the allergic antibody immunoglobulin E (IgE) Anaphylaxis Allergic Rhinitis (Hay Fever) Asthma Atopic Dermatitis (Eczema) Urticaria and Angioneurotic Edema Dermatitis Medicamentosa (Drug Reactions)

Shock Types of Anaphylaxis IgE mediated (SHOCK) True anaphylaxis that requires an initial sensitizing exposure occurs on a subsequent exposure Within seconds or minutes after antigen exposure (often fatal) Non-Ig E mediated (Anaphylactoid reactions) Rarely fatal Do not require an IgE immune reaction

Caused by the direct stimulation of the mast cells and basophils Etiology: (FIDL) F = Food (36%) Top 8 Food Allergies (TEMPS WFS) I = Insect stings - Bee and wasp (15%) or Idiopathic (32%) D = Drugs (AAA CAN) L = Latex rubber (Slow) 30 mins Top 8 Food Allergies (TEMPS WFS) T = Tree nuts (almonds, cashews, walnuts) E = Egg white (not egg yolk) M = Milk P = Peanuts S = Shellfish (crab, lobster, shrimp) W = Wheat F = Fish (bass, cod, flounder) S = Soy Drugs (AAA CAN) A = Antibiotics (Penicillin) A = Anesthetic drugs, IV A=ASA (Aspirin) C = Contrast media for radiologic studies, IV A=Analgesic opioids N = NSAIDs Risk Factors Immunotherapy (OH BEA) O = Observation - insufficient, following injection H = High allergen dose B = Beta-blockers E = Errors in administration A = Asthma - poorly controlled

S/Sx (S ECG) S = Skin (90%) E = Expiratory wheezing & other Respiratory symptoms (70%) C = Cardiovascular (40%) G = GI and oral (25%) Diagnostic Test Skin Prick Test Intradermal Skin Testing Interpretations of reactions: NEGATIVE = wheal soft within erythema 1+ = wheal present (5-8 mm) with associated erythema 2+ = wheal (7-10 mm) with associated erythema 3+ = wheal (9-15 mm), slight pseudopodia possible with associated erythema 4+ = wheal (12 mm),with pseudopodia possible and diffuse erythema Management: (SAFE) S= Seek support (Priority is patent airway) A = Allergen identification & Avoidance F = Follow-up for specialty care E = Epinephrine for emergencies Management DRUGS (EASI) E = Epinephrine IM A = Antihistamines PO, IM S = Steroids PO, IM, IV I = Inhaled b2-agonists (if wheezing. IV fluids if hypotension) Prevention: (ARP) A = Avoid exposure R = Refer to an Allergist P = Preloaded EpiPen syringes for self treatment of anaphylaxis.

Allergic Rhinitis Allergic rhinitis (AR) is an inflammation of the nasal mucosa characterized by pruritus, sneezing, discharge, and stuffiness. Induced by an IgE-mediated response and shares many features with asthma. Prevalence and Significance Patients with AR have asthma (40%) Patients with Asthma have AR (80%). AR is not seen until after age 4 or 5, it takes approximately 3 pollen season exposures. Peak age is 30 Fifty percent (50%) of children with otitis media with effusion have AR Pathophysiology Pollen(Allergen) interact with IgE (mucosal) mast cells

S/Sx (CS DIES) C = Congestion S = Smell Impairment D = Discharge I = Itching E = Eye symptoms S = Sneezing Classification of AR S = Seasonal Episodic, perennial, seasonal, or perennial with seasonal exacerbations. A = Allergic Rhinitis and its Impact on Asthma (ARIA) Frequency Intermittent Persistent Severity Moderate-severe Mild Diagnostic Test Skin Prick Test Rhinoscopy Management: (OASIS) O= Omit (avoid) allergens A=Antihistamines S= Steroids I= Immunotherapy (SCIT, SLIT) S = Surgery Management DRUG (SIE) S = Steroids I = INS (Intranasal Steriod) E = Epistaxis, side effect (in 5% of cases)

Mast cells release histamine & Leukotrienes

Symptoms of AR Etiology: (TGR MI) T = Tree Pollen (Early Spring) G = Grass Pollen (Early Summer) R= Ragweed and weeds (Early Fall) M = Mold (airborne mold spores) I = Indoor allergens (all year round)

Prevention: (A SWAPV) A = Avoid pollen exposure S = Sunglasses W = Windows shut A = Avoid open grassy places P = Pollen filter in the car V = Vacation, away during peak Atopic Dermatitis Atopic dermatitis is a chronic skin inflammation with pruritus as its most frequent symptom. Attempts to relieve the itch by scratching worsen the rash, creating a vicious circle ("an itch that rashes"). The disease course marked by exacerbations and remissions (reminiscent of disease course in asthma). Prevalence and Significance Up to 80% of children with atopic dermatitis will eventually develop allergic rhinitis or asthma later in childhood Pathophysiology Genetic abnormality Increased levels of cyclic adenosine monophosphate phosphodiesterase (cAMP) Intracellular cAMP leads to low level Hyperactive (basophils and mast cells) Increased histamine and leukotriene production and release

S/Sx (PEX) P = Pruritus (scalp, cheeks, chin, neck , wrist and extremities (ankles) E = Eyes (Anterior subcapsular Cataracts) X = Xerosis (Dry Skin) Management: Daily bath (lukewarm) Moisturizer cream 2x/day (Eucerin in AM, Aquafor in PM) Diluted bleach weekly HC = Hydrocortisone cream (2x/day for 2-4 weeks) TAC = Triamcinolone cream (2x/day for 2-4 weeks) Do not use on face and genital area. E = Elidel (steroid-sparring cream) (2x/day for 4-6 weeks) Eladil is the "rescue" medication and HC &TAC are the maintenance therapy. Urticaria Urticaria (hives) is characterized by sudden appearance of pinkish edematous elevations that vary in size and shape, itch and cause local discomfort. Classification Acute Urticaria Chronic Urticaria Acute Urticaria Due to type 1 hypersensitivity (Allergy) Fifty percent (50%) have angioedema present for less than 6 weeks

Prevalence: Acute urticaria affects 15-25% of the population at some point in their lives. In 50% of patients, no cause is identified. Etiology of Acute Urticaria (IF DVR Stings) I = Idiopathic F = Food (fruits, seafood, nuts, dairy, spices, tea, chocolate) D = Drugs (Antibiotics (Penicillin) and sulphonamides; ASA, NSAIDs) V = Viral infections R = Radio contrast media S = Stings - wasp or bee Chronic urticaria Unknown cause (Idiopathic Urticaria), 75% more common in women than in men Types of Chronic Urticaria: (VIP) V = Vasculitis, confirmed by biopsy I = Idiopathic, 75% of patients P = Physical, benign Physical urticaria provoked by physical stimulus such as: (CDC S) Cold urticaria due to cooling the skin Dermographism (skin writing) due to stroking the skin Cholinergic urticaria due to exercise, emotion, or heat Solar urticaria due to sun exposure Testing procedure: (depends on the cause or stimulus): Dermographism Stroking with narrow object, e.g. a tongue depressor

Cold urticaria Ice cube test Heat urticaria test tube water at 44C (111F) Pressure urticaria Sandbag test or a bag with heavy books Vibratory urticaria vibration with laboratory vortex for four minutes Cholinergic urticaria exercise for 15-20 minutes or leg immersion in 44C (111F) bath Aquagenic urticaria challenge with tap water at various temperatures Screening tests CBC = Complete Blood Count ESR = Erythrocyte Sedimentation Rate UA = Urinalysis CMP = Comprehensive Metabolic Panel Thyroid function tests (TFTs) Total IgE Anti-FceR1 Autoantibodies Chronic urticaria index (positive if greater than 10) is a proprietary index, a positive result that makes autoimmune urticaria more likely Management: Acute and Chronic Urticaria: (ALAS) A = Avoidance of precipitating factors L = Local (topical) treatment are not generally helpful, on recommendation is 1% menthol in aqueous cream. A= Antihistamines: H1- and H2blockers S = Steroids

Dermatitis Medicamentosa (Drug Reactions) Drug reactions is a genetic predisposition combined with exposure to the allergens early in life through GI, RT or nasal mucosa Food Allergy = 6-8% children Two (2%) in adult population S/Sx: Classic allergic sx Urticaria, Cough, Dermatitis, Angioedema, Wheezing GI sx Itching, Abdominal pain, cramps, N/V, LBM Management: (AACH) A= Allergen identification and avoidance A = Antihistamine C = Caution Pregnant Mothers (eating peanut) H = Health teaching (signs of Anaphylactic reaction) Management DRUGS (EASI) E = Epinephrine IM A = Antihistamines PO, IM S = Steroids PO, IM, IV I = Inhaled b2-agonists (if wheezing. IV fluids if hypotension)

Divisions of AAE: TYPE I (Lymphoproliferative disoders) - massive amounts of immune complexes TYPE II (Autoantibodies to C1 inhibitor) Both type I and II have low C1q level Acquired Angioedema ACE inhibitor, related Degrades Bradykinin, degrades (mediator to prevent angioedema, potent vasodilator) S/Sx (SIS ) S= Swelling of the deep dermal and subcutaneous / submucosal tissues (lips, tongue, eyelids, cheeks, feet, back) I = Itching or burning sensation S = Slower than for wheals (24-36 hrs to resolve) Diagnostic Test Cq, C4, C2 C-esterase inhibitor - qualitative and quantitative CH50 AAE are low C1q, C2, C4, and C1-INH levels Management (ACCN) A = Antihistamines C = Corticosteroids (short-term only) C= Clothing, loose N= No rubbing of skin

Angioedema Swelling of the deep dermal and subcutaneous/submucosal tissues. Approximately 50% of patients have both urticaria and angioedema. Categories: Acquired Angioedema (AAE) Hereditary Angioedema (HAE)

Precaution

ACE INHIBITOR PCN NSAIDS ASA

NON ATOPIC DISORDERS Not dependent on IgE but still involve an abnormal immune response to a wide variety of external environmental agents. Hereditary Angieodema Serum Sickness Contact Dermatitis Hereditary Angioedema Hereditary Angioedema (HAE) is an Autosomal dominant ( chromosome) condition associated with episodic attacks of non-pitting edema. Low levels of C inhibitor (a serine protease inhibitor). Edema is caused by unregulated generation of Bradykinin. In HAE the Cq level is normal HEA: C inhibitor is low C q level is normal chromosome years is the mean age of onset years before the diagnosis is made, on average

S= Swelling of the deep dermal and subcutaneous/submucosal tissues (Respiratory obstruction and asphyxiation) S = Sometimes pain rather than itching G = GI edema (severe abdominal pain leads to surgery) S = Slower than for wheals (24-36 hrs to resolve) Diagnostic Test Cq, C4, C2 C-esterase inhibitor - qualitative and quantitative CH50 In HAE, C1q levels are usually normal or only slightly decreased (rarely less than 50% of the normal values) Management (ALM CN) A = Androgen therapy L = Life Saving Measures (Laryngeal obstructions = Tracheostomy) M = Medications (Epinephrine, Antihistamine, Corticosteroids) C= Clothing, loose N= No rubbing of skin Serum Sickness Serum Sickness resulted from a reaction and immunologic attack on the serum or medication. Six to ten (6 10) days after administration.

S/Sx (SSGS)

S/Sx: (FRJ VSP) F = Fever

R = Rash (urticarial or puritic) J = Joints (tender & swollen) V = Vasculitis in kidney (proteinuria) S = Severe cardiac involvement P = Peripheral neuritis Management (MAT) M = Medications (Antihistamine, Corticosteroids) A= Aggressive therapy T= Therapeutic plasma exchange

S/Sx = dryness, vesiculation (blisters), cracks, hands & lower arms Dx = Patch testing Mngt Identification and removal of source of irritants Hydrophilic cream or petroleum jelly Topical Corticosteroids Cool water compress Antibiotics (infection) Antihistamine (pruritus) Phototoxic Contact Dermatitis S/Sx = (similar as irritant dermatitis) Dx = Photopatch testing Mngt (Similar as for allergic and irritant dermatitis) Photoallergic Contact Dermatitis S/Sx = (similar as allergic dermatitis) Dx = Photopatch testing Mngt (Similar as for allergic and irritant dermatitis)
Prepared by: Zussette O. Villar, RN, MAN

Contact Dermatitis Contact Dermatitis is an acute or chronic skin inflammation that results from direct skin contact with chemicals or allergens. Types: (AIPP) A = ALLERGIC (Allergens) I = IRRITANT (chemical or physical) P = PHOTOTOXIC (Sun+ chemical) P = PHOTOALLERGIC (Sun +allergens) Allergic Contact Dermatitis S/Sx = intracellular edema, dorsal aspect of hand Dx = Patch testing (C.I.= acute widespread dermatitis) Mngt Avoidance and Cool water compress Corticosteroids, Systemic Prednisone (7-10 days) or Topical C. (mild cases) Antihistamine (p.o. = pruritus)

Irritant Contact Dermatitis