Block 10 Board Review Part 2 of 4

1. Block 10 Board ReviewPart 2 of 4 Allergy/Immunology 21March2014 Chauncey D. Tarrant, M.D. Chief of Residents 13-14

2. 3.5% of Initial Certifying Exam!!!

3. Pediatrics In Review Articles • Allergic Rhinitis • Cases in Immunology

4. PIR Quiz

5. 5. You are evaluating a 3-year-old boy whose mother reports that he has had a “stuffy nose” almost every day for the past 4 months. He has not had a fever or a cough, but he sneezes frequently. She gives him an oral antihistamine periodically, which has not helped much. He has no other medical problems and recently started going to a child care center during the day. His physical examination reveals swollen nasal turbinatesbilaterally and purplish discoloration under his eyes. Which of the following is the most likely diagnosis? A. Allergic rhinitis. B. Bacterial sinusitis. C. Cystic fibrosis. D. Recurrent upper respiratory tract infections. E. Rhinitis medicamentosa.

6. 5. You are evaluating a 3-year-old boy whose mother reports that he has had a “stuffy nose” almost every day for the past 4 months. He has not had a fever or a cough, but he sneezes frequently. She gives him an oral antihistamine periodically, which has not helped much. He has no other medical problems and recently started going to a child care center during the day. His physical examination reveals swollen nasal turbinatesbilaterally and purplish discoloration under his eyes. Which of the following is the most likely diagnosis? A. Allergic rhinitis. B. Bacterial sinusitis. C. Cystic fibrosis. D. Recurrent upper respiratory tract infections. E. Rhinitis medicamentosa.

7. 6. One of your 4-year-old patients has nasal congestion several days a week and constantly rubs her nose. She also has a history of intermittent wheezing with viral infections. You suspect allergic rhinitis and would like to initiate treatment. Which of the following is the most appropriate initial treatment? A. Intranasal corticosteroid. B. Intranasal decongestant. C. Oral antihistamine. D. Oral decongestant. E. Oral leukotriene antagonist.

8. 6. One of your 4-year-old patients has nasal congestion several days a week and constantly rubs her nose. She also has a history of intermittent wheezing with viral infections. You suspect allergic rhinitis and would like to initiate treatment. Which of the following is the most appropriate initial treatment? A. Intranasal corticosteroid. B. Intranasal decongestant. C. Oral antihistamine. D. Oral decongestant. E. Oral leukotriene antagonist.

9. 7. You have just prescribed an intranasal corticosteroid for a patient who has allergic rhinitis. Her mother, however, is concerned about giving her daughter steroids because she has heard that they are associated with serious adverse effects. Which of the following is the most likely adverse effect that her daughter will experience while taking intranasal corticosteroids? A. Epistaxis. B. Hypertension. C. Oral candidiasis. D. Poor linear growth. E. Rebound symptoms after stopping the medication.

10. 7. You have just prescribed an intranasal corticosteroid for a patient who has allergic rhinitis. Her mother, however, is concerned about giving her daughter steroids because she has heard that they are associated with serious adverse effects. Which of the following is the most likely adverse effect that her daughter will experience while taking intranasal corticosteroids? A. Epistaxis. B. Hypertension. C. Oral candidiasis. D. Poor linear growth. E. Rebound symptoms after stopping the medication.

11. 8. The mother of a 12-month-old girl is concerned about her daughter’s nasal congestion, which she reports has been present since birth. She reports clear rhinorrhea daily, which always is from the right nostril. Daily treatment with an intranasal corticosteroid has not helped her symptoms. She received one course of amoxicillin several months ago when she was diagnosed with sinusitis. She occasionally had difficulty feeding as a young infant, but this has resolved and she has grown well. Her physical examination findings are normal, with the exception of mucoid nasal discharge from her right naris. Which of the following is the best course of action? A. Obtain a computed tomography scan of the nasopharynx. B. Order a sweat test. C. Prescribe a course of oral amoxicillin-clavulanic acid. D. Prescribe a course of oral antihistamines. E. Refer her for allergy testing.

12. 8. The mother of a 12-month-old girl is concerned about her daughter’s nasal congestion, which she reports has been present since birth. She reports clear rhinorrhea daily, which always is from the right nostril. Daily treatment with an intranasal corticosteroid has not helped her symptoms. She received one course of amoxicillin several months ago when she was diagnosed with sinusitis. She occasionally had difficulty feeding as a young infant, but this has resolved and she has grown well. Her physical examination findings are normal, with the exception of mucoid nasal discharge from her right naris. Which of the following is the best course of action? A. Obtain a computed tomography scan of the nasopharynx. B. Order a sweat test. C. Prescribe a course of oral amoxicillin-clavulanic acid. D. Prescribe a course of oral antihistamines. E. Refer her for allergy testing.

13. CONTENT SPECS!!!

14. Allergic Rhinitis

15. What is the most effective drug treatment for allergic rhinitis?

16. What is the most effective drug treatment for allergic rhinitis? • Topical Corticalsteroids • Can also use oral and topical antihistamines

17. What is the relationship between allergic rhinitis and sinuses and/or otitis media?

18. What is the relationship between allergic rhinitis and sinuses and/or otitis media? • Studies showing kids with allergies get more Viral URIsmore mucus and sinus congestionmay predispose to SINUSITIS • AR is a known risk factor for otitis media • 20% of kids with AR have OME • 50% of kids with chronic OME have AR

19. Which form of AR is caused by indoor allergens? (dust mites/animal dander)

20. Which form of AR is caused by indoor allergens? (dust mites/animal dander) • Persistent (Perennial) • >4days/wk for >4wks

21. What are the treatments for Allergic Rhinitis?

22. What are the treatments for Allergic Rhinitis? • Allergen avoidance • Antihistamines • Intranasal Corticosteroids • Immunotherapy* (severe cases only)

23. Immunology

24. What are the clinical characteristics of antibody deficiency syndromes after 4-6 months of age?

25. What are the clinical characteristics of antibody deficiency syndromes after 4-6 months of age? • Severe first infections and/or chronic recurrent bacterial infections in more than one anatomic site

26. What are the clinical characteristics of cellular immunodeficiency present in the first few months after birth?

27. What are the clinical characteristics of cellular immunodeficiency present in the first few months after birth? • Failure to thrive • Chronic Diarrhea • Overwhelming infections with viral, bacterial, and/or opportunistic infections

28. What is the lab evaluation for antibody function?

29. What is the lab evaluation for antibody function? • Quantitative immunoglobulin concentrations • Specific antibody responses to protein (diptheria/tetanus) and polysaccharide vaccines (pneumococcus or meningicoccus)

30. What is the lab evaluation for cell mediated immunity?

31. What is the lab evaluation for cell mediated immunity? • Lymphocyte counts and Lymphocyte function

32. PREP

33. The parents of a 4-year-old boy have questions about their son’s food allergies and what foods he will need to avoid when he starts kindergarten next year. They were advised that he was allergic to milk, egg, and soy products on blood testing (serum specific IgE) performed in infancy as part of an evaluation of atopic dermatitis. His eczema worsened when he consumed milk, but he has never eaten egg or soy. He has been strictly avoiding all these foods, and he outgrew his atopic dermatitis 2 years ago. You discuss your plan to reevaluate the status of the boy’s food allergies with his parents. Of the following and according to the natural history of food allergies, the MOST appropriate response is to advise the parents that in kindergarten their son may

34. A. be able to tolerate eggs but not milk and soy products B. be able to tolerate milk and soy products but not egg products C. be able to tolerate milk, egg, and soy products D. need to avoid all milk, egg, and soy products E. need to avoid egg and soy products but not milk products

35. A. be able to tolerate eggs but not milk and soy products B. be able to tolerate milk and soy products but not egg products C. be able to tolerate milk, egg, and soy products D. need to avoid all milk, egg, and soy products E. need to avoid egg and soy products but not milk products

36. A 9-year-old girl presents with symptoms of an itchy, raised rash. The rash started 2 weeks ago, but she has had similar episodes intermittently for the previous 4 months. The rash consists of multiple erythematous, slightly elevated lesions ranging in size from a dime to a golf ball (Item Q53). The lesions resolve in a few hours without bruising or discoloration. Diphenhydramine as needed and daily cetirizine help minimize the frequency and severity of her symptoms, but she still gets breakthrough episodes. Her parents have not found any association of the eruption with foods, cosmetics, or medications. At times, the rash occurs after the girl becomes hot and sweaty. The parents have heard that food allergies might be a trigger for their daughter’s episodes and wonder if she should undergo testing. Of the following, the MOST appropriate response is to

38. A. order allergen-specific IgE tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food additives B. order allergen-specific IgG4 tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food additives C. reassure the parents that allergy testing is not needed; an undiscovered allergy to foods or food additives is unlikely to be the cause D. recommend an elimination diet of home-cooked rice or oats, chicken or turkey, and vegetables for a trial period of 2 weeks E. refer them to an allergist for skin testing to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food additives

39. A. order allergen-specific IgE tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food additives B. order allergen-specific IgG4 tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food additives C. reassure the parents that allergy testing is not needed; an undiscovered allergy to foods or food additives is unlikely to be the cause D. recommend an elimination diet of home-cooked rice or oats, chicken or turkey, and vegetables for a trial period of 2 weeks E. refer them to an allergist for skin testing to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food additives

40. The parents of a 3-year-old boy would like him tested for allergies. The parents report that the boy has had worsening symptoms of itchy eyes, sneezing fits, and nasal congestion since the family got a new dog 1 year ago. The parents would like the boy tested to determine if they need to give the dog away. They are reluctant to stop the boy’s daily antihistamine and are disappointed to learn that skin testing cannot be performed while taking this medication. You decide to obtain blood-specific IgE testing. However, the parents have read on the internet that the “scratch test” is a better test. Of the following, you are MOST likely to advise the parents that in this situation, blood-specific IgE testing

41. A. comparable to skin testing B. less expensive and better tolerated by children than skin testing C. more accurate than skin testing D. the only testing that can be done because he is too young for skin testing E. a preliminary test and you will obtain skin testing to confirm the results

42. A. comparable to skin testing B. less expensive and better tolerated by children than skin testing C. more accurate than skin testing D. the only testing that can be done because he is too young for skin testing E. a preliminary test and you will obtain skin testing to confirm the results

43. The mother of a 7-month-old infant is frustrated that the infant’s atopic dermatitis is not getting better. He is awake “all night” scratching and is irritable and fussy. She has been giving him diphenhydramine every 8 hours and applying hypoallergenic moisturizer and a topical corticosteroid cream twice a day. The infant was breastfed until 3 months ago and then switched to a cow milk–based formula. On physical examination, you notice that he has dry, erythematous papules and patches, with excoriation marks on his face, neck, antecubital fossae, popliteal fossae, and back. He has normal growth parameters. Of the following, the MOST appropriate next step in this infant’s management is to recommend

44. A. discontinuing diphenhydramine and switching him to daily loratadine B. eliminating cow milk, egg, soy, and wheat from his diet C. introducing cow milk on a trial basis to see if the rash worsens D. switching to hypoallergenic formula and a diet of only rice and chicken E. testing for pertinent, potential food allergen triggers

45. A. discontinuing diphenhydramine and switching him to daily loratadine B. eliminating cow milk, egg, soy, and wheat from his diet C. introducing cow milk on a trial basis to see if the rash worsens D. switching to hypoallergenic formula and a diet of only rice and chicken E. testing for pertinent, potential food allergen triggers

46. A 2-year-old girl presented to the urgent care center for rash and swelling of her lips. While visiting a neighbor, the girl took a few bites of a peanut butter cracker and started coughing. The mother initially thought that her daughter had choked on the cracker but then noticed that the girl had developed hives on her face. The mother wiped her daughter’s face and mouth and gave her a teaspoon of diphenhydramine. The hives began to fade, but the girl then developed lip swelling and a raspy voice. She became progressively irritable and now appears to be breathing fast, although she is also crying. Of the following, the MOST appropriate step in this girl’s management is to administer

47. A. injectable corticosteroid B. injectable epinephrine C. nebulized albuterol D. ranitidine and diphenhydramine E. scheduled diphenhydramine

48. A. injectable corticosteroid B. injectable epinephrine C. nebulized albuterol D. ranitidine and diphenhydramine E. scheduled diphenhydramine

49. You are seeing a 3-year-old girl after hospital discharge. The girl was seen in the emergency department yesterday after she developed an erythematous, itchy, raised, blotchy rash, marked swelling of the eyes and lips, and raspy breathing. According to the mother, the child was given injectable epinephrine, diphenhydramine, and systemic corticosteroids. Altough the symptoms improved after a couple of hours, the child was admitted overnight for observation. The girl’s mother is shaken by this event and would like you to determine what triggered this reaction. Of the following, the MOST common triggers for events such as those experienced by the girl are

50. A. aeroallergens, contact allergens, latex, cleaning agents B. foods, medications, hereditary angioedema, idiopathic triggers C. infections (viral or bacterial), foods, medications, insect stings D. mast cell disorders, hereditary angioedema, urticarial vasculitis E. nonsteroidalanti-inflammatory drugs, antibiotics, narcotics, and radiocontrast media