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September 2, 2009 Allergy and Immunology Review Corner: Chapter 59 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 59: Insect Sting Anaphylaxis Prepared by Cyrus H. Nozad, M.D., University of Tennessee, and Jennifer W. Mbuthia, M.D., Walter Reed Army Medical Center 1. Which of the following is the incidence of insect sting allergy in the general population? A. 5-10 percent B. .4-3 percent C. 10-15 percent D. 15-17 percent 2. Which statement about insect sting reactions is true? A. The majority of reactions that occur are in younger individuals, but the fatality rate is greater in adults. B. The majority of reactions that occur are in older individuals, but the fatality rate is greater in pediatric ages. C. The majority of reactions and fatalities occur in adults. D. 40 percent of individuals who have insect sting anaphylaxis also have at least one anaphylactic food allergy. 3. Positive skin test results in which patient would be MOST concerning for anaphylaxis to subsequent stings? A. Patient with asthma and no history of insect stings. B. Child with history of diffuse hives following insect sting. C. Adult with large local reactions following insect stings. D. Patient who recently had toxic reaction to multiple (50-100) simultaneous stings. 4. Which treatment is appropriate first-line management of a mild, large local reaction to insect sting? A. Antibiotics B. IV steroids C. Antihistamine D. Tetanus prophylaxis 5. Which of the following choices is the suggested starting and stopping concentrations for intradermal venom testing? A. .0001 mcg/ml to 10 mcg/ml B. .01 mcg/ml to 10 mcg/ml C. .001 mcg/ml to .1 mcg/ml D. .001 mcg/ml to 1 mcg/ml 6. Which criteria is the most important risk factor for a severe reaction on a re-sting? A. Age when first sting occurred B. The severity of the previous anaphylactic symptoms C. The time interval between previous sting reaction and re-sting D. The value of the RAST test (specific IgE antibody) 7. Which of the following extracts is prepared using the whole body of the insect? A. Honey bee B. Fire ant C. Yellow hornet D. White-faced hornet 8. Venom Immunotherapy (VIT) is indicated in which of these patients with a positive venom skin test or elevated venom-specific IgE? A. Adult with serum sickness-like reaction following insect sting B. Adult with extensive large local reaction to honeybee sting C. Child with cutaneous-only reaction D. Adult with cutaneous-only reaction 9. What is appropriate management if patient has re-sting allergic reaction while on appropriate venom immunotherapy (VIT)? A. Stop VIT due to higher risk of reaction to next VIT injection. B. Increase venom dose by 50 to 100 percent. C. Decrease venom dose by 50 percent. D. Instruct patient to take daily antihistamine during stinging insect season. 10. Which of the following is a factor that may influence the decision to stop VIT after 3 to 5 years on maintenance? A. Systemic reaction while on maintenance VIT B. Local injection site reactions during VIT C. Yellow jacket venom allergy D. Hypersensitivity to more than one vespid venom Answers 1. B, page 633. This is based on demographic studies of the general population. 2. A, pages 633, 635. The majority of reactions that occur are in younger individuals, but the fatality rate is greater in adults. No data reports rate of food allergy in insect-allergic patients, but 33 to 40 percent of those with insect sting anaphylaxis are atopic. 3. D, page 634. Exposure to large amounts of insect venom frequently stimulates production of IgE, and these people are at risk for allergic reaction to future single stings if skin test is positive. After a large local reaction, most patients have a positive skin test, but risk for subsequent re-sting anaphylaxis is very low. 4. C, page 634. Medical treatment with NSAIDs and antihistamines is appropriate first-line therapy, unless the swelling is extensive and debilitating. In that case, systemic steroids orally for 2-3 days can be beneficial. Cellulitis rarely develops, and tetanus prophylaxis is unnecessary. 5. D, page 635. Venom concentrations greater than 1 mcg/ml may cause irritative reactions and are not immunologically specific. 6. B, page 635. The incidence of field re-sting reactions is higher in adults than children, but averages about 60 percent. The severity of the anaphylactic symptoms was an important criterion, and individuals with more severe reactions had a higher incidence of re-sting reactions. In addition, the reactions were generally similar to those that had occurred previously. 7. B, page 635. Whole body extracts lack sufficient venom and are unreliable for diagnosis and ineffective for treatment, with the exception of whole body fire ant extract. There appear to be few false positive reactions in non-allergic patients. 8. D, page 637, Table 59-1. Normal local pain/swelling, large local reactions, and children with cutaneous-only reactions are not candidates for VIT even if they have a positive skin test or venom-specific IgE. 9. B, page 639. Assuming the specific treatment is correct, venom dose should be increased by 50 to 100 percent. If maintenance dose is 100 mcg, then dose should be increased to 150 to 200 mcg. 10. A, page 639, Table 59-4. Severe anaphylactic symptoms caused by insect sting, systemic reactions to VIT, unchanged venom skin test during VIT, honey bee allergy, other significant medical problems (such as cardiovascular disease), and access to emergency medical care are all factors that may influence the decision to stop VIT. A definitive recommendation concerning duration of therapy for patients with fire ant hypersensitivity cannot be made at this time. Hypersensitivity to more than one vespid is not a consideration for a longer duration of VIT. Allergy and Immunology Review Corner: Chapter 60 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 60: General Treatment of Anaphylaxis Prepared by John M. Pulcini, M.D., University of Mississippi, and Christopher R. Martin, M.D., Walter Reed Army Medical Center 1. What is the most common cause of fatal anaphylaxis in children? A. Peanuts and tree-nuts B. Venom hypersensitivity C. Penicillin D. Latex 2. Which of the following is the most common reaction seen in anaphylaxis (by consensus)? A. Dyspnea/wheezing B. Flushing C. GI complaints D. Urticaria/Angioedema E. Neurologic complaints F. Rhinitis 3. In Sampson’s and Bock’s series of patients, what was the major problem by far, leading to FATAL anaphylaxis in children? A. Failing to detect ongoing anaphylaxis B. Failing to give epinephrine C. Continuing to give the offending agent after multiple minor reactions D. Failing to administer CPR 4. Successful cardiopulmonary resuscitation is often dependent on what hemodynamic value? A. Aortic systolic pressure B. Aortic diastolic pressure C. Central venous pressure D. SVC diastolic pressure 5. A beta-agonist effect of epinephrine is? A. Arterial vasoconstriction B. Selective redistribution of cardiac output C. Inhibition of mast cell mediator release D. Negative inotrope E. Negative chronotrope 6. What is the most common cause of fatal food anaphylaxis in children? A. Shellfish B. Milk C. Eggs D. Peanuts and tree-nuts 7. Which of the following is universally recommended as the drug of choice in the treatment of acute anaphylaxis? A. Epinephrine B. Diphenhydramine C. Corticosteroids D. Supplemental oxygen 8. Which of the following statements correctly identifies the mechanism of H2 antagonists in acute anaphylaxis? A. H2 antagonists block H2 receptors on coronary arteries (H1 receptors and H1 blockers). B. H2 antagonists decrease neutrophils and platelet aggregation (corticosteroids). C. H2 antagonists block H2 receptors on the atria and ventricles. D. H2 antagonists have no role in the treatment of anaphylaxis. 9. Normal serum tryptase levels do not rule out the diagnosis of anaphylaxis if the reaction was mild or was caused by what etiology of anaphylaxis? A. Food-induced anaphylaxis B. Drug-induced anaphylaxis C. Venom-induced anaphylaxis D. Idiopathic-induced anaphylaxis 10. Which of the following concomitant medications should be discontinued in patients with a history of anaphylaxis due to its ability either exacerbate or inhibit treatment of an anaphylactic reaction? A. Calcium channel blockers B. Potassium sparing diuretics C. Selective Serotonin Reuptake Inhibitors D. MAO inhibitors Answers 1. A, pages 643-644. Foods are by far the most common cause of anaphylaxis in children, followed by drugs, hymenoptera, latex, AIT, exercise, vaccines, a host of miscellaneous agents, and lastly, idiopathic. 2. D, page 644. An analysis of 4 studies showed that angioedema/urticaria was by far the most common presenting symptom (roughly 87 to 92 percent). 3. B, page 645. Failure to give epinephrine, or giving a sub-optimal dose, is implicated in almost 100 percent of deaths due to anaphylaxis in children. 4. B, page 646. Increasing diastolic pressure in the aorta enhances coronary perfusion, cerebral perfusion, and improves overall outcome following an arrest. 5. C, page 646. The beta-agonist effect of epinephrine results in positive inotropic and chronotropic effects, causes bronchodilation, and increases the production of intracellular cyclic AMP, which thus inhibits mediator release from mast cells. Arterial vasoconstriction and selective cardiac output redistribution are alpha-adrenergic effects of epinephrine. 6. D, page 643. More than 90 percent of fatal food anaphylaxis are caused by peanut and tree nuts. 7. A, page 646. Though the other treatments are often used in the management of anaphylaxis, numerous studies have shown epinephrine to be the drug of choice in acute anaphylaxis. 8. C, pages 649-650. H1 antagonists block H1 receptors on coronary arteries. Corticosteroids decrease neutrophils and platelet aggregation. Both H1 and H2 antagonists are recommended therapy in the treatment of acute anaphylaxis by many authors. 9. A, page 650. Food-induced anaphylaxis is the most likely etiology of anaphylaxis to be associated without an elevation of beta-tryptase. 10. D, page 651. Concomitant medication use, such as beta blockers, ACE inhibitors, and MAO inhibitors that may exacerbate anaphylaxis or its treatment, should be discontinued in patients with a history of anaphylaxis. August 5, 2009 Allergy and Immunology Review Corner: Chapter 57 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 57: Drug Allergy Prepared by Martha Karakelides, M.D., Mayo Clinic, and Jennifer W. Mbuthia, M.D., Walter Reed Army Medical Center 1. Which of the following is an example of an unpredictable adverse drug reaction? A. Hepatic necrosis from acetaminophen overdose B. Tinnitus following standard dose of aspirin C. Tremor following inhaled albuterol D. Pseudomembranous colitis after clindamycin 2. About 10 to 20 percent of truly penicillin-allergic patients are not detected with skin testing using: A. Penicilloyl (Pre-Pen) only B. Penicillin G only C. Pre-Pen and Penicillin G without minor determinant mixture (MDM) D. Pre-Pen and Penicillin G with MDM 3. If a patient has a history of penicillin allergy and skin testing with Pre-Pen and penicillin G without MDM is negative, how should penicillin be administered? A. Single dose, full strength B. Graded challenge, then desensitize if reaction occurs C. Single dose, half strength D. Give alternative antibiotic 4. A patient who needs to receive penicillin has a history of cephalosporin allergy and skin testing with penicillin is positive. What is your next step? A. Give full dose penicillin B. Give graded dose of penicillin C. Desensitize to penicillin D. Penicillin should never be given to a patient with cephalosporin allergy 5. Patients who are allergic to aztreonam cannot safely receive which cephalosporin? A. Ceftazidime B. Ceftriaxone C. Cefuroxime D. Cefixime 6. Which statement about sulphonamides is true? A. The majority of adverse reactions are IgE-mediated. B. Use of sulfa drugs like diuretics, oral hypoglycemics, and celecoxib is contraindicated in sulfa-allergic patients. C. Mild reactions during TMP-SMX “desensitization” are an indication to abort the procedure. D. Patients with HIV are at particularly high risk of developing various cutaneous reactions from sulfonamides. 7. If a patient had an allergic reaction to local anesthetic but does not know which one, what drug should you choose for testing? A. Lidocaine B. Benzocaine C. Procaine D. Tetracaine 8. What is the presumed immunologic mechanism of NSAID-induced aseptic meningitis? A. Type I hypersensitivity B. Type II hypersensitivity C. Type III hypersensitivity D. Type IV hypersensitivity 9. Reactions to NSAIDs that include anaphylaxis and angioedema: A. Show cross-reactivity with other NSAIDs B. Are only seen in patients with underlying chronic urticaria C. Are medication specific D. Are due to modifying effects on the arachadonic acid metabolism 10. In graded challenges, what is generally the starting dose? A. 1/10 to 1/100 of the full dose B. 1/1000 to 1/10,000 of the full dose C. 1/5 to 1/50 of the full dose D. Full-strength dose Answers 1. B, page 612, Table 57-2. Predictable reactions occur in otherwise healthy people, are usually dose-dependent, and are due to pharmacologic actions of the drug. Choices a, c, and d fall into this category. Unpredictable reactions occur in susceptible people, and include allergic reactions, intolerance, and idiosyncratic reactions. 2. C, page 612. Penicilloyl is the major determinant, and MDM contains penicilloate, penilloate, and penicillin, which can also be antigenic. 3. B, page 614. If only Pre-Pen and Penicillin G are used and the skin test is negative, penicillin should be given via graded challenge or desensitize if reaction is severe and recent. 4. C, page 617, Figure 57-5. If there is an absolute need for penicillin, then desensitization is recommended. 5. A, page 617. Ceftazidime is the only cephalosporin that shares an R-group side chain with aztreonam. Patients allergic to one should not receive the other. 6. D, page 618. The other answers are all false. During a TMP-SMX “desensitization,” you should continue to treat through mild reactions. 7. A, page 618-619. Benzoate esters (b, c, and d) show cross-reactivity with each other. Amides are not cross reactive with other amides or with esters. 8. D, page 619, Table 57-9. ASA and other NSAIDs have been associated with 5 types of allergic and pseudoallergic reactions. Aseptic meningitis and hypersensitivity pneumonitis from NSAIDs are presumed to be due to delayed hypersensitivity. 9. C, page 619. Anaphylaxis and angioedema resulting from an NSAID are IgE-mediated and generally other NSAIDs can be tolerated since it is medication-specific. 10. A, page 621. The starting dose is generally 1/10 to 1/100 the full-strength dose, and fivefold increasing doses are administered until the full dose is reached. Allergy and Immunology Review Corner: Chapter 58 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 58: Latex Allergy by Gregory Metz, M.D., Duke University, and Christopher R. Martin, M.D., Walter Reed Army Medical Center 1. Which of the following specific latex antigens are recognized by IgE and are important in sensitization of health care workers? A. Hev b 5, Hev b 8 B. Hev b 1, Hev b 3 C. Hev b 5, Hev b 6, Hev b 7 D. Hev b 1, Hev b 5, Hev b 8 2. The prevalence of latex allergy in healthcare workers is: A. 5-15 percent B. 15-25 percent C. 25-35 percent D. >35 percent 3. The most common reaction to latex products is which of the following? A. Allergic Contact Dermatitis B. Contact Urticaria C. Rhinitis D. Asthma E. Irritant Contact Dermatitis 4. Patients who are latex skin-prick test positive, or RAST positive, and have a symptomatic history of allergy by history should: A. Avoid all latex products B. Be patch-tested to latex C. Be patch-tested to the entire rubber series D. Undergo a latex “use test” 5. Due to false negatives and occasional false positives, tests such as CAP and Hy-TEC should be used only in conjunction with a good latex exposure history, skin testing (if indicated) and symptom questionnaire. What is the false negative rate for the latex CAP RAST (as of 1998)? A. <5 percent B. 5-10 percent C. 10-20 percent D. 25 percent 6. Which of the following may be a latex-containing product and must carry a label designating it as such? A. Glass thermometer B. Ventilation and airway equipment C. Infant bottles 7. Which of the following latex proteins is responsible for much of the cross-reactivity of latex with other plants? A. Hev b 1 B. Hev b 3 C. Hev b 6.01 D. Hev b 6.03 Answers 1. C, page 624. Hev b 1, Hev b 3, Hev b 7 are major antigens in children with congenital abnormalities, including spina bifida. Hev b 8 is Profilin. 2. A, page 626. Of that 5-15 percent, over 50 percent had latex-induced asthma. 3. E, page 626. The most common reaction involves non-allergic, irritated, dry areas on the skin. These reactions are not immune mediated. Breakdown of skin can then allow antigen penetration leading to sensitization in some individuals. 4. A, page 627. It would be unwise to patch test someone who is IgE positive, with a good history for allergy, to latex or rubber products. Additionally, a trial of wearing (“use”) latex is not indicated. 5. D, page 628. A patient that has a convincing story for latex allergy during extensive history taking should have further testing (or be placed on latex avoidance) if the CAP RAST returns as negative. 6. B, page 629. Other common products that may contain latex includes catheters, drains, tape, electrocardiogram pads, med bottle stoppers, blood pressure cuffs, and syringe stoppers. 7. C, page 625. Hev b 6.01 is responsible for much of the cross-reactivity with other plants. July 1, 2009 Allergy and Immunology Review Corner: Chapter 55 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 55: Contact Dermatitis Prepared by Madhu B. Narra, M.D., Baylor College of Medicine, and Thomas G. Sternberg, M.D., Le Bonheur Children’s Medical Center. 1. Which of the following is true about irritant contact dermatitis? A. Presence of immunologic memory B. Prior sensitization is required C. Less common than allergic contact dermatitis D. Allergens are not implicated in its pathogenesis 2. The major effector cells in the initiation and propagation of contact irritant dermatitis are: A. CD8+ T cells B. CD4+ T cells C. Keratinocytes D. Dendritic Cells 3. Effector cells in allergic contact dermatitis are: A. Dendritic cells B. Predominantly CD4 T cells, with some CD8 T cell participation C. Predominantly CD8 T cells, with some CD4 T cell participation D. Keratinocytes 4. Which of the following areas is most resistant to allergic contact dermatitis? A. Palm B. Dorsum of hand C. Face D. Eyelid 5. Which class of medication should be avoided for 5-7 days prior to patch testing? A. Oral Antihistamines B. Potent Topical Steroids C. Antibiotics D. B-blockers 6. Which of the following is true about patch testing? A. Patch testing can be performed with an unknown substance when at least two control subjects are also tested. B. Children can tolerate adult allergen concentrations well for patch testing. C. Patch testing is initially read at 24 hours and finally at 48 hours after application. D. T.R.U.E. test contains a battery of 23 allergens, a positive control and a negative control. 7. Which antigen is correctly matched to appropriate exposure? A. Balsam of Peru–Jewelry B. Thimerosal–Topical antibiotics C. Potassium Dichromate–Cement D. Neomycin sulfate–Contact lens solution 8. Which of the following is the correct “causative substance — type of contact dermatitis” combination? A. Oxalate crystals in horseradish — allergic contact dermatitis B. Oleoresin in Toxicodendron plants — allergic contact dermatitis C. Cinnamon flavorings in toothpaste — irritant contact dermatitis D. Fragrances — irritant contact dermatitis 9. Common cause of allergic cheilitis is: A. Lip licking B. Peppermint in toothpaste C. Thumb sucking D. Drooling 10. The most effective treatment for localized dermatitis is A. Topical Antihistamines B. Benadryl C. Calamine lotion D. Topical Steroids Answers 1. D, pages 585,584. The skin-associated immune system is clearly involved in irritant contact dermatitis. It also does not require prior sensitization or immunologic memory. 2. C, page 585. The epidermal keratinocyte is the key effector cell in the initiation and propagation of contact irritancy. 3. C, page 587. Both CD4 and CD8 cells participate in allergic contact dermatitis, but CD8 cells predominate. 4. A, page 588. Because the palmar skin is much thicker than the dorsum of the hand, allergic contact dermatitis rarely involves the palm. 5. B, page 589. No topical steroids for 5 to 7 days where patch test is to be applied, avoid sun or UV exposure for 96 hours. Systemic antihistamines have no effect on patch testing. 6. B, pages 589,590. Children have been shown to tolerate adult concentrations for patch test. Patch test should never be performed with an unknown substance, but can be done with substance for which there is no standardized patch test. Patch test should be initially read at 48 hours. T.R.U.E. test does not contain a positive control. 7. C, page 589. Balsam of Peru is seen in foods, cosmetics, fragrances, and topical medications. Thimerisol is a preservative in contact lens solutions, cosmetics, and injectible drugs. Potassium dichromate is in tanned leather and cement. Neomycin is in topical antibiotics. 8. B, pages 591,592. Cinnamon flavorings and peppermint in toothpaste are most common cause of allergic cheilitis. Fragrances are one of the most common causes of allergic contact dermatitis. 9. B, page 591. Peppermint and cinnamon flavorings in toothpaste are the most common cause of allergic cheilitis. 10. D, page 593. The mainstay of treatment is compete avoidance of contact with the offending agent. Cool compresses can also provide relief of some symptoms, but topical steroids are considered first line therapy. Allergy and Immunology Review Corner: Chapter 56 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 56: Allergic and Immunologic Eye Disease Prepared by Kusum Sharma, M.D., Penn State University at Milton Hershey Medical Center, and Christopher R. Martin, M.D., Walter Reed Army Medical Center. 1. The primary lymphoid tissue responsible for responding to intraocular reactions is? A. Vitreous lymphoid cell clusters B. Peri-orbital lymph nodes C. Ciliary body tissue D. Spleen 2. Which layer of tear film contains immunoglobulins (IgA, IgG, IgM, and IgE)? A. Outer lipid layer B. Middle lipid layer C. Middle aqueous layer D. Inner aqueous layer E. Inner mucoprotein layer 3. Which of the following statements is true regarding allergic disorders of the eye? A. An estimated 50 million mast cells reside at the interface of the conjunctiva. B. Seasonal allergic conjunctivitis (SAC) represents about 20-25 percent of allergic conjunctivitis cases. C. The prevalence of perennial allergic conjunctivitis (PAC) is slightly more than SAC, but is generally less severe in nature. D. Pruritic symptoms of Giant Papillary Conjunctivitis (GPC) are typically worsened by exposure to wind, dust, bright light, hot weather, or physical exertion resulting in sweating. 4. Phlyctenule is? A. Synonymous with a sty. B. In-turned eyelashes; usually results from the softening of the tarsal plate within the eyelid. C. A chronic, granulomatous inflammation of the meibomian gland. D. The formation of a small, gray, circumscribed lesion at the corneal limbus that has been associated with staphylococcal sensitivity, tuberculosis, and malnutrition. E. Pale, grayish-red, uneven nodules with a gelatinous composition seen at the limbal conjunctiva in vernal conjunctivitis. 5. Panuveitis — involvement of the anterior, intermediate (pards plana), and posterior regions — is associated classically with what disease or process? A. Kawasaki’s Disease B. Sarcoidosis C. Juvenile Rheumatoid Arthritis (JRA) D. Behcet’s Disease 6. Cobblestoning of palpebral conjunctiva is present in all of the following except: A. Allergic conjunctivitis B. Vernal keratoconjuntivitis C. Giant papillary conjunctivitis D. Chlamydial conjunctivitis 7. Most common form of eye involvement in children with AIDS is the following: A. Herpes zoster retinitis B. CMV retinitis C. Toxoplasmosis retinitis D. Tranta’s dots 8. Which of the following acts as a vasoconstricting agent: A. Olopatadine B. Ketotifen C. Naphazoline D. Levocabastine 9. Which of the following is proposed as a mechanism for effectiveness of cromolyn in allergic conjunctivitis: A. Mast cell stabilizer B. Effect on phosphodiesterase C. Inhibits B lymphocyte class switch from IgM to IgE D. All of the above 10. Tacrolimus is effective in the treatment of immune mediated ocular diseases like uveitis through which mechanism: A. Inhibits IL-2 production by T lymphocytes B. Has been shown in vitro to inhibit histamine release C. Inhibits IL-1 production by T lymphocyte D. Inhibits IgE production Answers 1. D, page 595. The eye is immunologically distinctive in that it lacks formed lymph nodes in the orbit, lacrimal gland, eyelids, and conjunctiva. 2. C, page 596. The aqueous portion of the tear film contains a variety of solutes. 3. A, pages 600-601. SAC represents over 50 percent of allergic conjunctivitis. PAC prevalence is less than SAC, but subjectively more severe. Vernal Keratoconjunctivitis is typically worsened by the factors listed. 4. D, page 600. A is a Hordeolum, B is Trichiasis, C is a Chalazion, and E is a description of Trantas’ Dots. 5. D, page 602. Kawasaki’s is typically not associated with uveitis. JRA typically involves anterior only. Sarcoidosis can involve any region, but does not involve all at the same time. 6. A, page 598, Table 56-2. 7. B, page 604. CMV retinitis is the most frequently encountered eye manifestation affecting approximately 7 percent of children with AIDS. Herpes zoster and Toxoplasmosis retinitis occur less frequently. Tranta’s dots are not seen in association with AIDS, but seen in vernal keratoconjunctivitis. 8. C, page 605, Table 56-4. Naphazoline is the only topical decongestant listed which is a vasoconstrictor. Ketotifen and olopatadine are dual agents with antihistamine and mast cell stabilizer properties. Levocabastine is a topical antihistamine. 9. D, page 605. All of the above are proposed as possible mechanisms. Exact mechanisms are still unclear. 10. A, page 608. Tacrolimus is a macrolide antibiotic that acts primarily on T cells and inhibits IL-2 production. June 3, 2009 Allergy and Immunology Review Corner: Chapter 53 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 53: Atopic Dermatitis Prepared by Nathanael Brady, D.O., University Hospitals, Cleveland, and Jennifer W. Mbuthia, M.D., Walter Reed Army Medical Center. 1. Which are considered cardinal features of atopic dermatitis? A. Intense puritis and cutaneous reactivity B. Lichenification and xerosis C. Papules and lichenification D. Xerosis and serous exudate 2. Which of the following is a malignancy that can have similar skin manifestations as AD? A. Netherton syndrome B. Wiskott-Aldrich syndrome C. Dermatitis herpetiformis D. Letterer-Siwe disease 3. Increased T cells producing what cytokines have been found in peripheral blood of atopic dermatitis patients? A. IFN gamma and IL13 B. IL4, IL5 and IL13 C. IL5, IL13 and IL18 D. IL4, IL5 and IFN gamma 4. Which of the following is seen in acute eczematous skin lesions but NOT in chronic lichenified lesions? A. IgE-bearing Langerhans cells B. Eosinophils, basophils, and neutrophils C. Marked spongiosis D. Macrophages dominating the dermal infiltrate 5. Transition from acute to chronic AD is associated with which of the following: A. A switch from predominantly Th2 cytokines to a combination of Th1 and Th2 cytokine gene expression. B. A switch from predominantly Th1 cytokines to a combination of Th1 and Th2 cytokine gene expression. C. A switch from predominantly Th2 cytokines to Th1 cytokine gene expression. D. A switch from predominantly Th1 cytokines to Th2 cytokine gene expression. 6. Which of the following statements about AD and sensitization to immunologic triggers is true? A. The degree of sensitization to aeroallergens does not directly correlate to the severity of AD. B. The percentage of severe AD patients sensitized to dust mite is about ½ of the percentage of asthma patients sensitized to dust mite. C. Approximately 40 percent of infants and children with moderate to severe AD have food allergy. D. Infants and children with AD triggered by food never progress to having immediate hypersensitivity reactions to those same food items. 7. Which of the following is considered an immunologic trigger for atopic dermatitis? A. Asthma B. Celiac Disease C. Bacterial Skin Infections D. Primary Immunodeficiency 8. What is first line daily management for atopic dermatitis of any level of severity? A. Wet dressings B. Oral corticosteroids C. Topical calcineurin inhibitors D. Soaking baths 9. Which statement about topical treatment for AD is true? A. Pimecrolimus acts by binding to FK binding protein and interfering with calcineurin action. B. Creams have higher systemic absorption compared to ointments. C. It takes approximately 30 g of cream or ointment to cover the entire surface of an adult once. D. Tacrolimus is approved for short-term use in children 6 months and older. 10. A consideration for refractory atopic dermatitis is which of the following? A. Topical corticosteroids B. Phototherapy C. Removal of foods D. Antihistamines Answers 1. A, page 561 & Table 53-1. The essential features of AD are pruritis, facial and extensor eczema in children, flexural eczema in adults, and chronic or relapsing dermatitis. The other features listed are frequently associated with AD, but are not considered major diagnostic features. 2. D, page 562, Table 53-2. Letterer-Siwe disease is a disseminated form of Langerhans cell histiocytosis that presents with the diffuse involvement of multiple organs. Netherton syndrome is a congenital disorder characterized by ichthyosis, hair shaft abnormalities, FTT, elevated serum IgE, and other infectious manifestations. Wiskott-Aldrich syndrome is an X-linked disorder with thrombocytopenia and recurrent infections. Dermatitis herpetiformis is an autoimmune disorder with IgA antibodies that are directed at epidermal transglutaminase. Gluten-sensitive enteropathy is found most of these patients. 3. B, page 563. IL-4 and IL-13 are important for isotype switching to IgE and for expression of adhesion molecules involved in eosinophil infiltration. IL-5 is key in the development, activation, and cell survival of eosinophils. 4. C, page 563. In acute skin lesions, there is marked spongiosis, LCs have surface-bound IgE, there is marked periventricular T cell infiltrate with occasional monocyte-macrophages, and eosinophils, basophils, and neutrophils are rarely present. In chronic lichenified skin lesions, the epidermis is hyperplastic with hyperkeratosis, minimal spongiosis, increased IgE-bearing LCs, macrophages dominate the dermal mononuclear cell infiltrate, and increased numbers of eosinophils. 5. A, page 563, 571 Box 53-1. Acute and chronic skin lesions have greater numbers of cells positive for IL-4, IL-5, and IL-13 mRNA. Acute AD does not contain significant number of IFN-gamma or IL-12 mRNA-expressing cells, which are seen in chronic AD skin lesions. 6. C, page 565. Children with food-exacerbated AD can also have food-specific IgE found in SPT or RAST, therefore they can have an immediate hypersensitivity reaction. In one study, 95 percent of sera from patients with AD had IgE to dust mite compared to 42 percent of asthmatic subjects. The degree of sensitization to aeroallergens is directly associated with the severity of AD. 7. C, page 565. Staphylococcus aureus is found in over 90 percent of AD skin lesions and appears to secrete superantigens, which stimulate marked activation of T cells and macrophages. Other immunologic triggers are foods and aeroallergens. The other answers are not immunologic triggers for atopic dermatitis, but diseases associated with AD. 8. D, page 567. Soaking baths in lukewarm water followed by application of an occlusive emollient to retain moisture can give symptomatic relief and also restore and preserve the stratum corneum barrier. Wet dressings are recommended for use on severely affected areas of dermatitis refractory to skin care. Oral corticosteroids and topical calcineurin inhibitors are not first line therapy for any severity of AD. 9. D, page 568. Pimecrolimus binds macrophilin 12, and tacolimus binds FK binding protein. Tacrolimus is approved for children aged 2YO and older. Ointments have a greater potential to occlude the epidermis, resulting in enhanced systemic absorption compared to creams. 10. B, page 571, Box 53-2. Treatment considerations for refractory patients include phototherapy, systemic glucocorticoids, cyclosporine, IFN-gamma, MMF, and MTX. Allergy and Immunology Review Corner: Chapter 54 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 54: Urticaria and Angioedema Prepared by Christopher R. Martin, M.D., Walter Reed Army Medical Center, and Druhan L. Howell, M.D., Duke University Medical Center 1. Which syndrome associated with marked weight gain, severe urticaria/angioedema, pronounced leukocytosis, and eosinpohilia? A. Muckle-Wells syndrome B. Familial Cold Autoinflammatory Syndrome C. Gleich Syndrome D. C3 Inactivator Deficiency with Urticaria 2. Infections with what organisms are classic for causing erythema multiforme? A. Herpes virus and Mycoplasma pneumonia B. Staph aureus and poxviridae C. Candida sp. and Listeria D. Streptoccos pneumoniae and Mycobacterium 3. Which type of urticaria is frequently confused with exercise-induced anaphylaxis? A. Acquired Cold Urticaria B. Delayed Pressure Urticaria C. Chronic Idiopathic Urticaria D. Cholinergic Urticaria 4. Which is the best test for aquagenic urticaria? A. Towel soaked in 45°C water applied to skin for 10 minutes B. Towel soaked in 37°C water applied to skin for 10 minutes C. Towel soaked in 37°C water applied to skin for 30 minutes D. Towel soaked in 45°C water applied to skin for 30 minutes 5. Aspirin exacerbates urticaria in up to what percentage of chronic urticaria patients? A. 20 B. 30 C. 40 D. 50 6. Which of the following laboratory findings is consistent with Type II HAE
7. What percentage of patients with chronic idiopathic urticaria experiences a remission within 3 to 5 years? A. 20 B. 35 C. 50 D. 80 8. Which type of urticaria is a particularly difficult problem because of the poor response to antihistamines? A. Cholinergic Urticaria B. Acquired Cold Urticaria C. Delayed Pressure Urticaria D. Solar Urticaria 9. Which drug is considered first line therapy for urticaria? A. Corticosteroids B. Second-generation antihistamine C. Cyclosporin D. Hydroxychloroquine 10. For acute treatment of an attack of Hereditary Angioedema (HAE), the drug of choice is: A. Second-generation antihistamines and systemic corticosteroids B. Epsilon aminocaproic acid C. Danazol D. Purified C1 Inhibitor Answers 1. C, page 575. Gleich Syndrome is a rare cause, shown to differ from hypereosinophilic syndrome by the absence of cardiac involvement. A separate group of familial swelling disorders include Muckle-Wells syndrome (urticaria, deafness, and amyloidosis), FCAS (formerly called familial cold urticaria), C3 inactivation deficiency with urticaria, HAE, vibratory angioedema, and familial localized heat urticaria. 2. A, page 576. Infections, and less frequently drugs, can cause erythema multiforme. 3. D, page 577-8. Cholinergic urticaria can be associated with angioedema, wheezing, and syncope. It differs from exercise-induced anaphylaxis in that it has smaller wheals and is induced by heat as well as by exercise. 4. C, page 578. 5. B, page 579. Aspirin causes exacerbations of chronic urticaria or angioedema in up to 30 percent of patients, but hives generally continue even when aspirin is avoided. Other COX-1 inhibitors have a similar effect. 6. B, page 580, Table 54-3 7. C, page 580. Of patients with chronic idiopathic urticaria, 50 percent experience remission within 3 to 5 years. 8. C, page 581. Most patients with delayed pressure urticaria require systemic corticosteroids. Cyproheptadine works well for cold urticaria, and hydroxyzine is typically used for cholinergic or heat induced urticaria. 9. B, page 580-1 10. D, page 582. This drug is now available in the United States and works well for both short-term treatment of acute attacks, as well as long-term prophylaxis. May 6, 2009 Allergy and Immunology Review Corner: Chapter 51 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 51: Atopic Dermatitis and Food Hypersensitivity Prepared by Jeremy Katcher, M.D., University of Tennessee, and Jennifer W. Mbuthia, M.D., Walter Reed Army Medical Center. 1. The pattern of cytokine expression found in lymphocytes infiltrating acute atopic dermatitis (AD) lesions is predominantly: A. IL-10 and TGF-beta B. IL-2 and IL-6 C. IL-4, IL-13, and IL-18 D. IL-4, IL-5, and IL-13 2. Laboratory investigation of AD and food hypersensitivity have demonstrated: A. Positive food challenges are associated with increases in plasma histamine concentrations. B. Decreased spontaneous basophil histamine release in patients with food hypersensitivity. C. Negative food challenges are associated with increased activation of plasma eosinophils and eosinophils products. D. Patients with food hypersensitivity have similar spontaneous basophil histamine release to patients with no food allergy. 3. The most common foods that cause clinical symptoms in children with atopic dermatitis are: A. Fish, soy, wheat B. Peanut, fish, egg C. Milk, peanut, soy D. Milk, peanut, egg 4. The diagnosis of food allergy in AD is complicated by which factor related to the disease? A. Most patients have IgE to multiple allergens, making lab tests the preferred method to diagnose. B. Other environmental trigger factors may play a role in the waxing and waning of the disease. C. Immediate response to ingestion of causal foods is up-regulated with repetitive ingestion. D. Food additives cause a high percentage of AD flares. 5. What is the next appropriate step in pediatric food allergy evaluation if initial skin prick test(s) is/are positive? A. Initiate food challenge if questionable history B. Strictly avoid offending foods C. Determine quantity of serum food-specific IgE in vitro D. Check for cross-reactivity with inhalant skin testing 6. Which is true regarding the properties of diagnostic testing methods for food allergies? A. Prick testing is most valuable for its negative predictive value. B. Prick testing is most valuable for its positive predictive value. C. In vitro testing for serum specific IgE antibodies is more sensitive than skin prick testing. D. Intradermal skin testing should be performed when skin prick testing is negative and suspicion remains high. 7. Which of the following food allergies is most commonly outgrown by school age? A. Peanut B. Soy C. Fish D. Tree nuts 8. Which of the following statements regarding outgrowing AD-related food reactivity is true? A. Fifty percent of children allergic to peanut will outgrow the clinical reactivity. B. Strict dietary elimination for six months has been shown to improve clinical reactivity. C. Clinical reactivity is lost more quickly than food-specific IgE (as measured by skin prick or in vitro testing). D. Patients should be instructed to perform home food challenges to re-introduce an avoided/eliminated food. 9. Which of the following is a contraindication to oral food challenge? A. Vomiting upon ingestion of food being tested B. Skin itching upon ingestion of food being tested C. Urticaria where food being tested has come in contact with skin D. Airway reactivity after ingestion of food being tested 10. Which statement about food allergy and AD is true? A. The younger the child and the more severe the AD, the more likely primary immunodeficiency is the cause of the severe AD. B. More than 60 percent of children with moderate to severe AD are affected by food allergy. C. Egg allergy is the most common food hypersensitivity in children with AD. D. Infants with AD and egg allergy are at lower risk for developing asthma. Answers 1. D, page 538 2. A, page 539 3. D, page 540 4. B, page 540 5. C, page 541, Figure 51-1 6. A, page 541 7. B, page 543 8. C, pages 542-543 9. D, page 542 10. C, page 543, Box 51-1 Allergy and Immunology Review Corner: Chapter 52 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 52: Management of Food Allergy Prepared by Tracy Pitt, M.D., Winnipeg Children’s Hospital, and Christopher R. Martin, M.D., Walter Reed Army Medical Center. 1. A child restricted from eating eggs due to allergy is at risk for which vitamin or mineral deficiencies if not provided by another food? A. Vitamin A, vitamin D, riboflavin, calcium B. Thiamin, riboflavin, pyridoxine, folate, calcium, zinc C. Vitamin E, niacin, magnesium, manganese, chromium D. Vitamin B12, riboflavin, pantothenic acid, biotin, selenium 2. Which of the following statements is true regarding rice milk use in children? A. Children allergic to cow’s milk reacted with DBPCFC to rice milk and goat’s milk at a similar rate. B. Children with cow’s milk allergy were more likely to react to rice milk than to goat’s milk in DBPCFC. C. Enriched rice milk lacks sufficient protein, fat, and other nutrients that are necessary for the growth of infants and children. D. Enriched rice milk is a poor source of calcium and Vitamin D as compared to goat’s milk. 3. Which of the following statements is true regarding FPIES? A. Symptoms completely resolve when the offending food agent is eliminated. B. Apple, beef, walnut and peanut commonly cause refractory FPIES. C. Though a common cause of FPIES, wheat elimination is notorious for inducing no improvement in symptoms. D. A history of enterocolitis symptoms with rice, wheat, or egg should prompt additional testing, as these foods rarely, if ever, cause FPIES. 4. Since most fish allergic patients tolerate this “safe fish,” when designing a DBPCFC for a fish-allergic patient, this product can be used as the placebo and to mask the taste of the offending fish: A. Canned tuna B. Canned bass C. Canned red snapper D. Canned flounder 5. The AAP recommends which ages for introduction of the following foods? A. Milk and soy – after 2 years of age B. Eggs and fish – after 2 years of age C. Milk, soy, and eggs – after 1 year of age D. Tree nuts, fish, shellfish – after 3 years of age 6. Children with food allergies should have their growth and nutrition assessed. All of the following are true EXCEPT: A. Growth is assessed primarily by comparing values for weight, length, weight-to-length ratio, and head circumference against national growth standards. B. Growth velocity is a less sensitive index than weight or length obtained at a specific point in time. C. Recumbent length should be used in infants younger than 2 years of age. D. Height velocity and weight-to-length ratios are excellent measures of stature. 7. All of the following can be used to enhance the intake of particular nutrients in children with cow’s milk allergy EXCEPT: A. Amino acid and extensively hydrolyzed cows milk formula B. A multivitamin or mineral supplement provided they are not contaminated with milk protein C. Goat’s milk D. Fortified baby cereals such as beech nut, rice or oat cereal 8. Regarding food challenges: A. They do not need to be conducted under the supervision of trained medical personnel. B. In non-IgE-mediated hypersensitivities, such as eosinophilic esophagitis, a negative challenge may need to be followed by an open feeding of the food to rule out a false negative challenge. C. Specific IgE testing is the gold standard for the diagnosis of food allergy. D. In open challenges, the patient and clinician are blinded to the content of the challenge. 9. The Committee on Nutrition of the AAP recommends delayed introduction of solid foods until: A. 6 months B. 7 months C. 8 months D. 9 months 10. Factors that place some individuals at increased risk for more severe anaphylactic reactions include: A. A history of epinephrine use during a previous reaction B. Skin prick test with a wheal larger than 7mm C. Allergy to milk and egg D. Teenage patient Answers 1. D, page 548 2. C, page 550 3. A, page 551 4. A, page 553 5. D, page 555 6. B, page 546 7. C, page 555 8. B, page 553 9. A, page 555 10. D, page 556 April 8, 2009 Allergy and Immunology Review Corner: Chapter 50 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 50: Food Allergy, Respiratory Disease, and Anaphylaxis Prepared by John M. Pulcini, M.D., University of Mississippi, and Christopher R. Martin, M.D., Walter Reed Army Medical Center. 1. Which of the following is a true statement, according to the authors, regarding the epidemiology/etiology of food allergies? A. A vast minority of adverse food reactions can be categorized as adverse physiologic reactions or food intolerance. B. Food allergy is an immunologic-mediated food reaction related to an innate physiologic effect of the food or additive. C. The role of food allergy in otitis media is controversial and probably is extremely rare. D. Addition of the diagnosis of eczema to infantile egg allergy increased their positive predictive value of developing childhood problems to almost 40 percent. 2. Commonly linked to respiratory reactions in food allergies, this food is not usually associated with fatal or near-fatal anaphylaxis. A. Cow’s milk B. Peanuts C. Tree nuts D. Shellfish 3. Food additives such as MSG, sulfites, and aspartame worsen respiratory disease symptoms in what percentage of patients with asthma? A. <1 percent B. <5 percent C. 8-10 percent D. 15 percent 4. The true statement regarding “Baker’s asthma” is: A. Occupational exposure leads to acute respiratory symptoms with little chance of developing chronic asthma. B. Cough and shortness of breath are much less common than wheezing. C. Skin pricks are usually positive to extracted wheat proteins. D. Lupine seed flour-induced occupational asthma mimics wheat flour Baker’s asthma, but with a high incidence of concurrent fever. 5. During double-blinded food challenges, what percentage of respiratory symptoms experienced by children was due to rhinitis? A. 30 percent B. 50 percent C. 70 percent D. 90 percent 6. Which of the following is not a common food allergen implicated in respiratory disease? A. Cow’s milk B. Peanuts C. Fish D. Wheat 7. Which of the following statements accurately describes gustatory rhinitis? A. Gustatory rhinitis is a form of food intolerance that rarely provokes nasal symptoms. B. Affected individuals often develop sneezing, congestion, or pruritus. C. In gustatory rhinitis the associated rhinorrhea ceases rapidly after the food is eaten. D. The reaction is the result of stimulation of atropine-inhibitable nicotinic receptors. 8. Heiner’s Syndrome (Food-Induced Hemosiderosis) is most often associated with a non-IgE mediated hypersensitivity to what food? A. Cow’s milk B. Chicken egg C. Pork D. Peanuts 9. Which of the following is a true statement, according to the authors, regarding the usefulness of skin testing for IgE-mediated food allergies? A. Skin testing is an excellent method of excluding IgE-mediated food allergies with a negative predictive value greater than 95 percent. B. Skin testing is an excellent method of identifying IgE-mediated food allergies with a positive predictive value greater than 95 percent. C. Skin testing is a poor method of excluding IgE-mediated food allergies with a negative predictive value of 50 percent. D. Skin testing is a poor method of excluding IgE-mediated food allergies with a negative predictive value of 50 percent, but it is an excellent method of identifying IgE-mediated food allergies with a positive predictive value greater than 95 percent. 10. Which of the following diagnostic tests for food allergies have objective scientific data? A. Food-specific IgG or IgG subclass antibody concentrations B. Food antigen-antibody complexes C. Cytotoxic food tests D. Food-specific IgE RAST testing Answers 1. C, pages 529-530 2. A, page 530 3. B, page 530 4. C, page 531 5. C, page 531 6. D, page 530 7. C, page 532 8. A, page 532 9. A, page 534 10. D, page 534 March 25, 2009 Allergy and Immunology Review Corner: Chapter 49 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 49: Eosinophilic Esophagitis, Gastroenteritis, and Proctocolitis Prepared by Jennifer W. Mbuthia, M.D., Walter Reed Army Medical Center. 1. Which of the following statements about cow milk protein allergy is true? A. Whey is the most antigenic protein in cow milk. B. Approximately 15 percent to 50 percent of milk protein-sensitized patients are also soy protein intolerant. C. Less than 10 percent of eosinophilic proctocolitis occurs in breastfed infants. D. Allergic proctocolitis is a common cause of rectal bleeding in children older than 2 years. 2. Which feature is consistent with eosinophilic proctocolitis? A. Elevated serum eosinophil count B. Toxic or septic appearance C. Weight loss or failure to thrive D. Vomiting with abdominal distension 3. In eosinophilic proctocolitis, if symptoms persist beyond _______ after elimination of the problematic food then other antigens should be considered. A. 2 to 5 days B. 1 to 2 weeks C. 4 to 6 weeks D. 8 to 10 weeks 4. In eosinophilic gastroenteritis, which site(s) along the GI tract are most frequently affected? A. Esophagus and gastric antrum B. Gastric antrum and small bowel C. Small bowel D. Small bowel and colon 5. Which statement about eosinophilic gastroenteritis is true? A. Past patient history or family history of atopy is rare, seen in less than 10 percent of cases. B. Females are more commonly affected. C. GI bleeding is common in mild disease. D. 75 percent of patients have increased blood eosinophil counts. 6. Idiopathic Hypereosinophilic Syndrome can cause eosinophilia in which portions of the GI tract? A. Esophagus and stomach B. Esophagus and colon C. Stomach and small intestine D. Small intestine and colon 7. Leukotriene receptor antagonists have been considered for use in eosinophilic gastroenteritis. Which of the following is the most potent chemotactic factor for eosinophils? A. LTE4 B. LTB4 C. LTC4 D. LTD4 8. Which of the following is not a symptom seen in eosinophilic esophagitis? A. Hematemesis B. Chest pain C. Dysphagia D. Vomiting 9. When comparing eosinophilic esophagitis and reflux esophagitis, which feature is usually seen more often in eosinophilic esophagitis? A. Nausea, vomiting, and epigastric pain B. Esophageal strictures C. Increased incidence of asthma, rhinitis, and atopic dermatitis D. Significant improvement of symptoms after proton pump inhibitor therapy started 10. In normal healthy individuals, eosinophils are seen in almost all portions of the GI tract EXCEPT: A. Esophagus B. Proximal small intestine C. Distal small intestine D. Colon Answers 1. B, page 518 2. A, page 519 3. C, page 519 4. B, page 519 5. D, page 520 6. C, page 520, table 49-1 7. D, page 521 8. A, page 521 9. C, page 522 10. A, page 521 March 11, 2009 Allergy and Immunology Review Corner: Chapter 48 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 48:Food Allergy – Enterocolitis, Proctocolitis, and Enteropathy Prepared by Gregory Metz, M.D., Duke University, and Christopher R. Martin, M.D., Walter Reed Army Medical Center. 1. Which of the following is correct regarding dietary protein proctocolitis? A. Often presents as bloody stools in an ill-appearing infant B. Lower occurrence in breastfed infants vs. formula fed infants C. Anemia develops in most cases due to chronic blood loss D. Typically caused by an immune response against cow’s milk protein 2. Dietary protein enterocolitis or food protein-induced enterocolitis (FPIES) syndrome is characterized by: A. Bloody diarrhea in an otherwise healthy child B. Profuse vomiting and diarrhea that can lead to poor growth C. Late onset, usually after 6 months of life D. An immunologic reaction to cow’s milk protein that is entirely IgE-mediated. 3. Celiac disease is associated with: A. HLA-DQ1 B. HLA-DQ2 C. HLA-DQ3 D. HLA-DQ4 4. Biopsies of the small bowel during active celiac disease will typically reveal: A. Minimal cellular infiltrates B. Extensive eosinophilic infiltrates C. Total villous atrophy D. Frequent neutrophilic abscesses 5. Roughly what percentage of infants with IgE-mediated cow’s milk allergy will react to soy? A. 0 to 5 percent B. 10 to 15 percent C. 50 to 65 percent D. 90 to 95 percent 6. At what mean age is the diagnosis of dietary protein proctocolitis usually made? A. 60 days B. 180 days C. 1 to 2 years D. 3 to 5 years 7. Small bowel biopsies done in dietary protein enteropathy generally reveal what? A. Villus injury with abundant eosinophils B. Decreased crypt length and intraepithelial monocytes C. Submucosal fibrosis and intraepithelial neutrophils D. Few eosinophils and increased crypt length 8. Which is a classic sign or symptom of celiac disease: A. Bloody diarrhea B. Eczema C. Anemia D. Advanced bone age 9. Gliadin is a one of the few substrates for this tissue enzyme: A. Transdeaminase B. Cis-gliadinase C. Transglutaminase D. Transcholinase 10. Which of the following is an approved test for diagnosing the non-IgE mediated gastrointestinal disorders? A. IgG4 measurement B. Elimination diet C. Applied kinesiology D. Provocation-neutralization testing Answers 1. D, page 510 2. B, page 511 3. B, page 512 4. C, page 511 5. B, page 515 Only a small proportion of infants with IgE-mediated cow milk allergy (14 percent) will react to soy; however infants with non-IgE mediated cow milk reactions frequently react to soy protein. 6. A, page 510 7. D, page 510 8. C, page 515 9. C, page 512 10. B, pages 512-513 February 25, 2009 Allergy and Immunology Review Corner: Chapter 47 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 47: Prevention and Natural History of Food Allergy Prepared by Martha Karakelides, M.D., Mayo Clinic, and Jennifer W. Mbuthia, M.D., Walter Reed Army Medical Center. 1. In terms of allergy prevention and how it is categorized, Tertiary Prevention is defined as: A. Prevention of allergy before any IgE-mediated disease has occurred B. Prevention of further sensitivities once IgE-mediated disease has developed C. Prevention of manifestations of allergic disease once IgE-mediated sensitivity has occurred D. Prevention of end-organ damage after an IgE-mediated allergic reaction has occurred 2. Which cytokines are predominant in human breast milk? A. IL-13 B. IL-13 and IL-4 C. TGF-beta and IL-6 D. TGF-beta and IL-13 3. Which factors are protective against the development of allergic disease in infants? A. Polyamines B. IL-8 C. Arachadonic acid D. IL-4 4. Probiotics have been looked at immunologically for use in primary and secondary prevention of food allergies because: A. Probiotics increase the effect of bovine casein on lymphocyte proliferation. B. Probiotics have been shown to increase soluble CD4 in the serum. C. Probiotics increase anti-CD3 antibody induced IL-4 production in vitro. D. Probiotics suppress naturally fed antigen-specific IgE production by stimulation of IL-12 production in mice. 5. In clinical practice, what is the most clinically useful determinant of risk of atopy in a child? A. Cord blood IgE B. Family history C. Whether child was breastfed D. Presence of susceptibility markers on chromosome 11 6. What do the AAP and ESPACI/ESPGHAN committees recommend as the hallmark for allergy prevention? A. Soy formula B. Exclusive breastfeeding C. Cow milk formula D. Organic cow milk formula 7. Due to contradictory information on dietary advice for lactating mothers, which recommendation should be given to lactating mothers? A. Elimination of peanuts and tree nuts is recommended for all lactating mothers. B. Elimination of dairy products if breastfeeding is planned for 6 months or longer. C. Elimination of seafood and peanuts for first 8 weeks of breastfeeding. D. Institute dietary elimination on a case-by-case basis. 8. Which formula is recommended in primary prevention of food allergy in high-risk infants who are bottle-fed? A. Partially hydrolyzed casein hydrosylate formulas B. Amino acid-derived elemental formula C. Partially hydrolyzed whey hydrosylate formula D. Soy formula 9. What is the incidence of food allergy in infants at 1 year of age? A. 10-12 percent B. 1-2 percent C. 20-25 percent D. 6-8 percent 10. According to studies on children and food allergies, what statement about pediatric food allergy is true? A. Milk and soy allergies are the most frequently outgrown by a child’s third birthday. B. 85 percent of children with milk allergy will be able to tolerate milk by 3 years old. C. Cow’s milk IgE from patients with persistent cow’s milk allergy is more likely to bind to conformational epitopes rather than sequential epitopes. D. The IgG:IgE ratio was significantly higher in children with persistent cow’s milk allergy. Answers 1. C, page 495 2. C, page 495 3. A, page 496 4. D, page 496 5. B, page 497 6. C, page 498 7. D, page 499 8. A, page 501 9. D, page 504 10. B, page 505 February 11, 2009 Allergy and Immunology Review Corner: Chapter 46 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 46: Approach to Feeding Problems in the Infant and Young Child Prepared by Christopher R. Martin, M.D., Walter Reed Army Medical Center, and Madhu B. Narra, M.D., Baylor College of Medicine. 1. The most common food allergy in early infancy is: A. Breast milk protein allergy B. Cow’s milk protein allergy C. Peanut allergy D. Egg allergy 2. Which of the following symptoms are most commonly manifested by infants with food allergy? A. Respiratory symptoms B. Systemic anaphylaxis C. Gastrointestinal symptoms D. Oral allergy syndrome 3. Which of the following combinations of pollen-food cross-reactivities is involved in oral allergy syndrome? A. Ragweed-banana B. Birch-melon C. Mugwort-tomato D. Grass-carrot 4. Which of the following is true about acquired or adult-type lactase deficiency? A. Usually occurs from malnutrition or gastrointestinal infections B. Symptoms are usually transient, followed by complete recovery C. More common in whites than in African or Asian ancestries D. Avoidance of milk and dairy products with lactose does not need to be complete 5. Toddler’s diarrhea A. Is due to food allergy B. Causes abnormal growth and development C. Is a normal cause of diarrhea D. Is treated with high intake of dietary fiber from fruits, vegetables and raisins 6. What percent of children referred for a suspected food additive allergy will end up having a positive DBPCFC (Double-Blinded Placebo-Controlled Food Challenge)? A. <1% B. 2% C. 6% D. 10% E. >20% 7. In children with a suspected food allergy, confirmation of the diagnosis can eventually be made in this percent when using controlled elimination/challenge procedures? A. 20% B. 25% C. 33% D. 50% E. 66% 8. What percent of true cow’s milk allergy patients have respiratory symptoms? A. 10-20% B. 20-30% C. 40-50% D. 60-70% E. >90% 9. Which of the following is a non-IgE mediated respiratory reaction? A. Rhinoconjunctivitis B. Asthma C. Laryngeal edema D. Food-dependent exercise induced asthma E. Pulmonary hemosiderosis 10. Banana, peach, kiwi and chestnut all cross-react with this substance. A. Birch B. Mugwort C. Latex D. Ragweed E. Celery Answers 1. B, page 489 2. C, page 489 3. A, page 490 4. D, pages 491,492 5. C, page 492 6. B, page 488 7. C, page 489 8. B, page 489 9. E, page 489 10. C, page 490 January 28, 2009 Allergy and Immunology Review Corner: Chapter 45 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 45: Evaluation of Food Allergy Thomas G. Sternberg, M.D., Le Bonheur Children’s Medical Center and Jennifer W. Mbuthia, M.D., Walter Reed Army Medical Center. 1. The European Academy of Allergy and Clinical Immunology definitions for food reactions include: A. Scrombroid fish poisoning is an example of an immune mediated adverse reaction to food. B. IgE-mediated adverse food reactions are divided into immediate onset and immediate plus late phase. C. Non-toxic adverse reactions to food are always mediated by the immune system. D. Food protein-induced GI illnesses such as allergic proctocolitis are IgE-mediated. 2. A concordance of 60 to 70 percent in monozygotic twins has been shown for what food? A. Peanut B. Shellfish C. Milk D. Wheat 3. Which statement about the foods causing hypersensitivity reactions in children is true? A. Food allergens are lipid soluble glycoproteins B. Food allergens are usually heat labile C. Food allergens are carbohydrates D. Food allergens are usually stable to proteases 4. Atopic dermatitis complicated by food allergy______ A. Is seen in 75 percent of children with atopic dermatitis B. Is often less severe C. Often involves egg, milk, wheat, soy, peanut/tree nuts D. Is most often secondary to shellfish allergy 5. Which statement about food allergy and skin symptoms is true? A. Food allergy is the most common cause of chronic urticaria in children B. Food hypersensitivity provokes cutaneous symptoms in about one-third of children with moderate to severe atopic dermatitis C. Children can never become allergic to a food they ingest on a daily basis D. Angioedema without urticaria is common in infants and children 6. The double-blind placebo-controlled food challenge _______ A. Is the gold standard for detecting adverse food reactions B. Is practical for use in everyday clinical practice C. Is less specific than lymphoblast transformation testing D. Is less time-consuming than an open or single blind food challenge 7. RAST is the preferred test for which patients? A. Patients with non-IgE-mediated reactions to foods B. All patients with negative intradermal food testing C. Patients with severe dermatographism D. All children with asthma and suspected food allergy 8. Delayed-onset reactions to food are most likely to affect what system? A. Skin B. Respiratory C. Gastrointestinal D. Cardiovascular 9. Which statement is true about using a vehicle/placebo for blinded food challenges? A. It is difficult to administer adequate quantities of food using a capsule as a vehicle. B. Carob is not an effective placebo for chocolate due to cross-reactivity. C. Children can often detect hidden material in foods. D. Due to food texture, most foods cannot be hidden using a tolerated food as the vehicle. 10. When performing food challenges, A. All children must come off asthma medication for seven days, despite severity of asthma. B. A challenge cannot be performed if a child is taking antihistamines. C. There are no circumstances where a child should be challenged at home. D. Asthma medications and antihistamines are not likely to be sufficient to prevent allergic reactions to food during challenge. 11. Which statement about long-term treatment of food allergy is true? A. Studies show children do not outgrow reactivity to peanut. B. Determination of specific IgE to some foods can help determine the challenge interval. C. Foods for which there is no in vitro test should be challenged at intervals of 4 to 6 months. D. The most important aspect of managing food hypersensitivity is support for frustrated parents. 12. Atopy Patch Testing_______ A. Is the gold standard test for the diagnosis of food allergy B. May be useful in the diagnosis of non-IgE-mediated food reactions C. Is more sensitive than skin prick testing in the diagnosis of food allergy D. Has no utility in evaluation of gastrointestinal food hypersensitivities Answers 1. B, page 478, table 45-1 2. A, page 479 3. D, page 479 4. C, page 479 5. B, page 480 6. A, page 483 7. C, page 482 8. C, pages 483-484 9. A, page 484 10. D, page 484 11. B, Page 484 12. B, Page 482 January 14, 2009 Allergy and Immunology Review Corner: Chapter 44 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 44: Food Allergy — Mucosal Immunity: An Overview Prepared by Druhan L. Howell, M.D., Duke University Medical Center, and Christopher Martin, M.D., Walter Reed Army Medical Center 1. Which of the following type of antigens are most likely to induce tolerance? A. Soluble, carbohydrate B. Particulate, protein C. Soluble, protein D. Particulate, carbohydrate 2. The location of “controlled or physiologic inflammation” in the gut is the: A. Epithelium B. Lamina propria C. Cryptopatches D. Mucularis mucosae 3. When compared to peripheral macrophages, intestinal macrophages are more likely to have which of the following characteristics important for induction of tolerance: A. Increased lipopolysaccharide responsiveness B. Ability to adhere to plastic C. Inability to migrate to local lymph node D. Lack of CD14 expression 4. The most abundant immunoglobulin in the gastrointestinal tract is: A. IgA B. IgE C. IgG D. IgM 5. Intestinal epithelial cells are able to do which of the following: A. Take up particulate carbohydrate B. Express the low-affinity IgE receptor (CD23-Fc epsilonR) C. Suppress CD8+ T cells activity in vitro D. Express MHC II but not MHC I 6. Intestinal differentiated cells (DC) secrete this substance, critical for IgA regulation: A. TNF-alpha B. TNF-beta C. IFN-alpha D. TGF-beta 7. A factor that oral tolerance is not associated with is: A. Age of the person B. Nature of the antigen C. Cross reactivity of undigested remnants D. Dose of the antigen E. Nature of the APC 8. Which has been described as an example of MALT compartmentalization: A. Exposure in mammary gland leads to immunity in the small bowel B. Exposure in small bowel leads to nasal immunity C. Nasal exposure leads to genitourinary immunity D. Nasal exposure leads to mammary immunity Answers 1. C, page 474 2. B, pages 473 and 475 3. D, page 474 4. A, page 475 5. B, pages 476 and 474 6. D, page 474 7. C, page 474 8. C, page 474 |
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