Chapter 56: Allergic and Immunologic Eye Disease 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. |
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