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ALLERGYDR. MA. TERESA S. FAJARDOPEDIATRICSHEMATOLOGY / ONCOLOGY
IMMUNOLOGIC BASISOF ALLERGIC DISEASETO DETECT AND ELIMINATE ANYTHING FOREIGNTO THE BODYBENEFICIAL (IMMUNITY) OR HARMFUL (ALLERGY)
COMPONENTS IN HOST'S RESPONSE TO THE ALLERGEN ENVIRONMENT
TARGET CELLS
B AND T LYMPHOCYTES
IMMUNOLOGIC CAPABILITIES OF THE HOSTPRIMARY ( NON- SPECIFIC )SECONDARY (SPECIFIC)TERTIARY ( TISSUE DAMAGING RESPONSE)
PRIMARY RESPONSE
MOST PRIMITIVE
PHAGOCYTOSIS / INFLAMMATION
SECONDARY RESPONSESPECIFIC RESPONSEMECHANISMS : B CELL / T CELL RESPONSECOMPLEMENT SYSTEMCOAGULATIPON SYSTEM
TERTIARY RESPONSE
TISSUE – DAMAGING RESPONSES ( TYPES I, II, III, IV )PROPOSED BY GELL AND COOMBS
MEDIATORS OF ALLERGYPREFORMED MAST CELL MEDIATORSRAPIDLY FORMED MAST CELL MEDIATORS
PREFORMED MAST CELLMEDIATORSVASOACTIVE MEDIATORSCHEMOTACTIC MEDIATORSENZYMESPROTEOGLYCANS
PREFORMED MAST CELLMEDIATORS ( VASOACTIVE MEDIATORS)1. HISTAMINE BRONCHOSPASM AND
VASCULAR PERMEABILITY2. ADENOSINE INHIBIT PLATELET
AGGREGATION STIMULATE IRRITANT
RECEPTORS
PREFORMED MAST CELLMEDIATOR (CHEMOTACTIC MEDIATORS ) 1. NEUTROPHIL FACTOR RECRUITMENT /
ACTIVATION OF NEUTROPHIL2. EOSINOPHIL FACTOR RECRUITMENT /ACTIVATION
OF EOSINOPHIL
PREFORMED MAST CELLMEDIATOR ( ENZYMES)1. NEUTRAL PROTEASES
( TRYPTASE , CHYMASE ) COMPLEMENT/ KININ
ACTIVATION2. ACID HYDROLASES ( BETA-
GLUCORONIDASE) INFLAMMATION
PREFORMED MAST CELLMEDIATOR (PROTEOGLYCANS)HEPARIN ANTICOAGULANT ANTICOMPLEMENT ACTIVITY
RAPIDLY FORMED MAST CELL MEDIATORSPLATELET- ACTIVATING FACTORPROSTAGLANDINLEUKOTRIENES
RAPIDLY FORMED MASTCELL MEDIATORSBIOLOGIC ACTIVITY : VASODILATATION VASCULAR LEAKAGE SMOOTH MUSCLE CONTRACTION GLANDULAR SECRETION STIMULATION OF THE IRRITANT ( ITCH / SNEEZE ) RECEPTORS PRO –ANTI-INFLAMMATORY MEDIATOR
CYTOKINESNEWLY SYNTHESIZED PROTEINS THAT REGULATE IMMUNE RESPONSEPOTENT PRO- INFLAMMATORY MEDIATORSGROWTH / DIFFERENTIATION OF EOSINOPHILS AND MAST CELLS
CYTOKINES AND ALLERGYIgE REGULATIONEOSINOPHILIAMAST CELL DEV ‘T AND ACTIVATIONINFLAMMATION
IMMUNOLOGIC MECHANISM IN ALLERGIC INFLAMMATION
ALLERGEN EXPOSURE ----MAST CELL ACTIVATION----
VASOACTIVE AMINE ACTIVATION ---- IMMEDIATE REACTIONS ( VASODILATATION, EDEMA, SM
CONTRACTION, MUCUS SECRETION) ------------ 3 -8 HRS
LATE PHASE RESPONSE (INFILTRATION OF EOSINOPHILS
MONONUCLEARS AND NEUTROPHILS) ----------- AFTER 24 -48 HRS ------
T- CELL ACTIVATION --------- CHEMOTACTIC MEDIATORS -------- CELLULAR INFILTRATION ------
INFLAMMATORY MEDIATORS ------------ EDEMA, DESQUAMATION, CELLULAR INFI;LTRATION AND MUCUS
SECRETION
ALLERGIC RHINITISSYMPTOMS: “ SNEEZERS AND RUNNERS” -- PAROXYSMAL SNEEZING -- WATERY RHINORRHEA -- ITCHY NOSE ---NASAL BLOCKAGE (VARIABLE) -- DIURNAL RHYTHM (WORST DAYTIME IMPROVES AT NIGHT -- OFTEN ASSOCIATED WITHJ CONJUNCTIVITIS
ALLERGIC RHINITISSYMPTOMS: BLOCKERS -- LITTLE OR NO SNEEZING -- THICK NASAL MUCUS (CATARRH) MORE OFTEN POSTERIOR (POST NASAL DRIP) -- NO ITCH -- NASAL BLOCKAGE OFTEN SEVERE -- CONSTANT BUT MAYBE WORST AT NIGHT
RHINITIS DEFINITIONNASAL DISCHARGEBLOCKAGESNEEZE/ ITCH
TWO OR MORE SYMPTOMS FOR MORE THAN ONE HOUR ON MOST DAYS
ALLERGIC RHINITIS
TREATMENT ENVIRONMENTAL CONTROL IMMUNOTHERAPY PHARMACOTHERAPY PARENT/PATIENT EDUCATION
ASTHMA
CHRONIC, RECURRENT , OCCASIONALLY FATALCHRONIC INFLAMMATORY DISORDER OF THE AIRWAYS IN WHICH CELLS PLAY A ROLE, INCLUDING M MAST CELLS AND EOSINOPHILSWIDESPREAD BUT VARIABLE AIRFLOW OBSTRUCTION THAT IS OFTEN REVERSIBLE EITHER SPONTANEOUSLYOR WITH TREATMENT ASSSOCIATED WITH AIRWAYRESPONSIVENESS
PRECIPITANT OF ASTHMA
RESPIRATORY INFECTION (VIRAL)ALLERGENSFOODHOUSEHOLD INHALANTSOUTDOOR INHALANTSIRRITANTSEXERCISEEMOTIONAL FACTORS
PATHOPHYSIOLOGY OFASTHMA ,SEVEREASTHMA -- MUCUS SECRETION , BRONCHOSPASM ,EDEMA ---INCREASED RESISTANCE TO AIRFLOW---HYPERINFLATION, ATELECTASIS , CNS DEPRESSION--PULMONARY VASOCONSTRICTION--CARDIAC FAILURE AND COMA
ASTHMA
CLINICAL MS: WHEEZING , A HIGH- PITCHED OR SQUEAKING EXPIRATORY SOUND ONSET , ACUTE /INSIDIOUS COUGH , TACHYPNEA , DYSPNEA HYPERINFLATION OF THE CHEST, TACHYCARDIS ABDOMINAL PAIN WITH VOMITING LOW GRADE FEVER HUNCHED- OVER SITTING POSITIUON
MANAGEMENT OFASTHMAACHIEVE AND MAINTAIN CONTROL OF SYMPTOMSPREVENT ASTHMA EXACERBATIONSMAINTAIN PULMONARY FUNCTIONS AS CLOSE TO NORMAL LEVELSAVOID ADVERSE EFFECTS FROM ASTHMA MEDICATIONSPREVENT IRREVERSIBLE AIRWAY OBSTRUCTIONPREVENT ASTHMA MORBIDITY
MANAGEMENT PROGRAMS FOR ASTHMA
EDUCATE PATIENTS/PARENTS ASSESS AND MONITOR SEVERITYAVOID OR CONTROL TRIGGERSMEDICATION PLANS FOR CHRONIC ASTHMAPLANS FOR EXACERBATIONSPROVIDE REGULAR FOLLOW-UP
STATUS ASTHMATICUS
SEVERE ACUTE ASTHMALIFE-THREATENING EPISODEUNRESPONSIVE TO THE USUAL APPROPRIATE THERAPY WITH ADRENERGIC AGENT AND THEOPHYLINELEADS TO ACUTE RESPIRATORY INSUFFICIENCY
ATOPIC DERMATITISCHRONIC ,HERITABLE, DISTINCTIVE CUTANEOUS INFLAMMATORY DISEASE CHARACTERIZED BYEARLY AGE OF ONSET AND INTENSE PRURITUSSKIN LESION: DRY, IRRITATED, WEEPING, EXCORIATEDLICHENIFIED LESIONS ON THE FLEXURAL AREASIN LATE CHILDHOOD AND ADOLESCENSEWIIH GENETIC PREDISPOSITIONRELAPSING CAN DEVELOP ALLERGIC RHINITIS AND ASTHMA
STAGES OF ATOPIC DERMATITISINFANTILE STAGE 4TH -6TH MONTH OF AGE ERYTHEMATOUS, PRURITIC, WEEPING DERMATITIS IN THE CHEEKS WHICH SPREADS TO THE FOREHEAD AND EXTENSOR SURFACES OF THE ARMS AND LEGS CIRCUMORAL AREA AND EYELIDS ARE USUALLY SPARED
STAGES OF ATOPIC DERMATITISCHILDHOOD STAGE: 2-4 YRS OF AGE PRURITIC, EXCORIATED PAPULESON THE FLEXURAL SURFACES OF EXTREMITIES AND FACE LICHENIFICATION IN THE POPLITEAL AND ANTECUBITAL FOSSAE AND ANKLES MAY DISAPPEAR BEFORE 10 YRS
STAGES OF ATOPIC DERMATITISADULT STAGE : HIGHLY PRURITIC , CONFLUENT PAPULES ON THE DORSAL ASPECT OF THE HANDS, UPPER EYELIDS AND FLEXURAL AREAS OF THE EXTREMITIES
STIGMAS OF ATOPICDERMATITISLICHENIFICATION DENNIE ‘S LINEATOPIC PALMSBUFFED NAILSWHITE DERMOGRAPHISMDELAYED BLANCHED PHENOMENONDRYNESS XEROSISATOPIC PERSONALITYHOUSEWIFE’S ECZEMAATOPIC FOOTALLERGIC SHINERS
CRITERIA FOR THE DIAGNOSISOF ATOPIC DERMATITISMUST HAVE 3 OR MORE BASIC FEATURES :1.PRURITUS2.TYPICAL MORPHOLOGY
/DISTRIBUTION3.TENDENCY TO RECURRENCES4.PERSONAL OR FAMILY HISTORY
CRITERIA FOR THE DIAGNOSIS OF ATOPIC DERMATITISPLUS ANY THREE OR MORE OF THE FF FEATURES: ICHTHYOSIS, ELEVATED SERUM IgE , EARLY AGE ONSET CUTANEOUS INFECTION, IMPAIRED T- CELL IMMUNITY HAND/FOOT DERMATITIS , NIPPLE ECZEMA, , CHEILITIS, RECURRENT CONJUNCTIVITIS, DENNIE MORGAN INFRAORBITAL FOLD CATARACT, ORBITAL DARKENING, PITYRIASIS ALBA FOOD HYPERSENSITIVITY
ATOPIC DERMATITISTREATMENT AVOID ENVIRONMENTAL FACTORS GOOD HYDRATION OF THE AFFECTED AREAS MOISTURIZERS CORTICOSTEROIDS IN THE SUBACUTE PHASE
URTICARIA ( HIVES)RAISED ERYTHEMATOUS SKIN LESIONS ASSOCIATEDWITH MARKED PRURITUSDUE TO VASODILATATION OF SMALL VENULESAND CAPILLARIES AND EXUDATION OF FLUIDINTO THE SUPERFICIAL DERMISANGIOEDEMA IS URTICARIA INVOLVING THE DEEPER SUBCUTANEOUS TISSUES
CLASSIFICATION OF URTICARIAIMMUNOLOGIC ANAPHYLACTIC / CYTOTOXIC/ IMMUNE COMPLEXANAPHYLACTOID HEREDITARY ANGIOEDEMA/ CHEMICAL/ ASPIRIN SENSITIVITY PHYSICAL DERMATODRAPHIA/ COLD/ CHOLINERGIC/ SOLAR/PRESSUREMISC INFECTION/ PIGMENTOSA/ PSYCHOGENIC/IDIOPATHIC
URTICARIA
TREATMENT SYMPATHOMIMETIC AGENTS : EPINEPHRINE ANTIHISTAMINICS CORTICOSTEROIDS
ALLERGIC CONTACT DERMATITISCOMMON DISORDER IN CHILDHOODERYTHEMA, PAPULES, VESICLES, SWELLINGWEEPING ANG ITCHING24 -48 HRS AFTER EXPOSURETYPE IV
CAUSES OF CONTACTDERMATITISIRRITANTS ANIMALSPLANTS CLOTHINGNICKEL DRUGSCHROMATEMERCURYCOSMETICS
ADVERSE FOOD REACTIONIMMUNOLOGIC REACTION RESULTING FROM INGESTION OF FOOD PRODUCTSAND ADDITIVES
I
FOOD ALLERGY(HYPERSENSITIVITY)IMMUNOLOGIC REACTION RESULTING FROM INGESTION OF FOOD ADDITIVE , IgE MEDIATED
FOOD ANAPHYLAXISCLASSIC ALLERGIC HYPERSENSITIVITY REACTION TO FOOD OR FOOD ADDITIVES INVOLVING IgE AND THE RELEASE OF CHEMICAL MEDIATORS
FOOD INTOLERANCEABNORMAL NON-IMMUNOLOGIC PHYSIOLOGIC RESPONSE TO FOOD OR FOOD ADDITIVES
FOOD IDIOSYNCRASYHYPERSENSITIVITY WITHOUT IMMUNE RESPONSE
FOOD TOXICITYADVERSE REACTION CAUSED BY DIRECT ACTION OF FOOD ADDITIVE/ FOOD ON THE HOST RECIPIENT WITHOUT IMMUNE MECHANISM FOUND NATURALLY IN FOOD OR SECONDARY TO CONTAMINATION BY MICROORGANISM OR PARASITES
RISK OF MANIFESTINGATOPY BASED ON FAMILYHISTORY OF ATOPYFAMILY HISTORY OF ATOPY RISK OF ATOPY
BIPARENTAL( SAME ALLERGY) 50-80 %BIPARENTAL OR UNIPARENTAL 40-60% PLUS ONE SIBLINGUNIPARENTAL OR SIBLING 20-49%NEGATIVE 5-15 %
MANIFESTATIONS OFFOOD ALLERGYGASTROINTESTINAL:: VOMITING, ENTEROCOLITIS,MALABSORPTION, BLEEDING RESPIRATORY : RHINITIS, ASTHMA, OTITIS MEDIADERMATOLOGY : URTICARIA, ATOPIC DERMATITIS,ALOPECIANEUROLOGIC : SEIZURE, LETHARGYHEMATOLOGY : ANEMIAANAPHYLACTIC SHOCK
ADVERSE DRUG REACTION“ AN EFFECT WHICH IS UNINTENDED AND OCCURSAT DOSES NORMALLY USED IN MAN FOR PROPHYLAXISDIAGNOSIS AND THERAPY “ OCCURS WITHIN A REASONABLE TIME FOLLOWING ADMINISTRATION OF THE DRUGREACTIONS : INTOLERANCE, IDIOSYNCRASY, HYPERSENSITIVITY ,PSYCHOGENIC
CLASSIC ANTIHISTAMINICSETHANOLAMINES EXAMPLES : DIPHENHYDRAMINE , CARBINOXAMINE CLEMASTINE, DIMENHYDRINATE GENERAL COMMENTS: SEDATIVE EFFECT HIGH, MODERATE ANTICHOLINERGIC EFFECTS, RELATIVE LOW GIT EFFECTS
CLASSIC ANTIHISTAMINICSALKYLAMINES : CHLORPHENIRAMINE , TRIPROLIDINE, BROMPHENIRAMINE, PHENIRAMINEGENERAL COMMENTS : LOW SEDATIVE , ANTICHOLINERGIC AND GI EFFECTS , BEST GROUPFOR DAYTIME USE
CLASSIC ANTIHISTAMINICSETHYLENEDIAMINES: ANTAZOLINE TRIPELENNAMINEGENERAL COMMENTS :LOW SEDATIVE , ANTICHOLINERGIC EFFECTS , GI EFFECTS COMMON
CLASSIC ANTIHISTAMINICSPIPERAZINES : HYDROXYZINE , MECLIZINE , CHLORCYCLIZINEGENERAL COMMENTS : DROWSINESS IS FREQUENT ,DRY MOUTH A USUAL CHOLINERGIC EFFECT
CLASSIC ANTIHISTAMINICSPHENOTHAZINE : METHDILAZINE , PROMETHAZINETRIMEPRAZINEGENERAL COMMENTS : MARKED SEDATIVE EFFECT( USEFUL TREATMENT OF PRURITUS )
CLASSIC ANTIHISTAMINICSPIPERIDINES : CYPROHEPTADINE , BENZOCYCLOHEPTATHIPINEAZATADINEGENERAL COMMENTS : DROWSINESS IS COMMONUSEFUL IN THE TREATMENT OF URTICARIA