Learning Objectives After participating in this educational
program, participants should be able to: 1. Describe the causes,
signs, and symptoms of common allergic/immunologic conditions 2.
Understand diagnostic tests for these conditions 3. Discuss the
appropriate treatment of these conditions and long-term management
of patients at-risk
Slide 4
Mechanism of Hypersensitivity
Slide 5
IgE hypersensitivity
Slide 6
Angioedema of lips
Slide 7
Angioedema of eyes
Slide 8
Angioedema of hand
Slide 9
Urticaria Cholinergic urticaria Typical urticaria
Slide 10
Erythema marginatum Urticarial vasculitis
Slide 11
Urticaria pigmentosa
Slide 12
Serum sickness Morbilliform rash
Slide 13
Erythema multiforme Dermatitis Herpetiformis
Slide 14
Steven-Johnsons/TEN Bullous pemphigoid
Slide 15
Case 60 yo female presents with a 1 month history of persistent
daily generalized rashes suggestive of hives. She reports episodes
started when she was treated with Ciprofloxacin for a urinary tract
infection. Within 1 week of taking the antibiotic, she developed
this rash. She has since stopped the antibiotic but hives persist.
Interestingly, she has had several episodes of lip and eye swelling
as well as hives occurring intermittently over the past 10 years.
Angioedema not necessarily associated with the hives. She is taking
over the counter antihistamines and oral prednisone but they have
not controlled her rashes. She has avoided dairy and breads and has
resorted to a bland diet of soups as she thinks foods may be
causing her symptoms.
Slide 16
Review of systems: Positive for chronic headaches, fatigue,
heartburn, nausea, abdominal bloating, frequent upper respiratory
infections (bronchitis, sinusitis, pneumonias, strep throats, and
utis) and allergy symptoms (rhinorrhea, watery eyes, nasal
congestion all year round worse with scents) PMH/PSH: HTN, GERD,
Hypothyroidism, Hysterectomy, appendectomy, cholecystectomy,
tonsillectomy Social: ex-smoker 15 pk year, quit 10 years ago,
marijuana use weekly, but no history of IVDU or other illicit
drugs, drinks 1 glass of red wine daily, married for 30 years but
husband just passed away. she is a retired teacher.
Slide 17
Meds: Advil qd, Altace qd, Rabeprazole qd, Synthroid qd, ASA
qd, prednisone 40 mg qd Meds Allergies: Sulfa, Tetracycline, Cipro-
rashes FMH: Mother had emphysema and hypothyroidism, Father had
HTN, CAD, MI at 65 yo, Sister with hypothyroidism, Brother healthy.
No one with angioedema or infections in the family
Slide 18
Problem List?
Slide 19
Problem List Generalized urticaria- Acute on chronic Angioedema
Drug allergies Recurrent infections GERD, Abdominal bloating
Chronic fatigue Chronic rhinorrhea HTN Thyroid dz
Slide 20
Urticaria/angioedema definition Urticaria-raised erythematous
lesions involving superficial dermis, often generalized and
pruritic, lasts minutes to hours, and can recur. Acute urticaria 6
weeks. Multiple mechanisms-mast cells, basophils Angioedema-
self-limited nonpitting edema generally affecting the deeper layers
of skin and mucous membranes. A result of increased vascular
permeability causing the leakage of fluid into the skin in response
to vasodilators released by immunologic mediators. 50% of pts with
chronic urticaria are said to have angioedema - IgE, mast cells
releasing histamines, leukotrienes, prostaglandins -Kinin and
formation of bradykinin (vasodilator)
Investigations CBC, Creatinine, LFT, Ferritin Urinalysis
Anti-thyroid peroxidase, anti-thyroglobulin antibodies H.pylori
serology, biopsy CXR, CT sinus for chronic sinusitis Skin test for
environmental and food allergens-and ImmunoCap (RAST) to allergens
if skin test not possible- to evaluate for atopy, poor PPV Check
IgG, IgA, IgM, IgE. If IgG is low, then need to do IgG subclasses,
antibody responses to vaccines- i.e.-pneumococcal, tetanus titers,
HIB, CD markers (CD19, CD3, CD4, CD56). Hepatitis, MMR serology may
be helpful
Slide 27
Other studies Serum electrophoresis, Hepatitis B and C
serology, Monospot, antistreptolysin and anti- DNase Stool samples
for ova and parasite TTG screening, PATCH testing if warranted
Serum tryptase
Slide 28
C4, C1 esterase inhibitor (functional and qualitative) C1q,
genetic testing for HAE Drug testing- Penicillin skin testing, RAST
to penicillin minor determinants. If need PCN, oral challenge or
desensitization depending on history and risk of anaphylaxis. Other
drugs not standardized. Desensitization has to be carried out every
time. Testing and desensitization contraindicated in patients with
a history of TEN/Stevens-Johnson s reaction to a drug No sulfite
testing When in doubt, biopsy
Cyclosporine Low dose (3 mg/kg) cyclosporine (CsA) effective in
treating patients with CIU in 13/19 (full remission) and 6/19
(significant relief) compared to controls over three months Toubi E
et al Allergy 1997; 52: 312-6 DBPC trial with 4mg/kg CsA revealed
improvement in daily urticaria score (42 points max) by 12.7 (vs.
2.3 in placebo) Histamine release decreased from 36% to 5% (p
Our patient results UA-> 100,000 Staph, elevated
anti-thyroid peroxidase abs > 1300, and positive H.pylori
serology Skin test negative to environmental and food allergens,
IgE 330 IU/ml, IgG, IgA, IgM, CBC, LFT, Creatinine all wnl
Slide 34
Case in question Stopped ASA and ACEI, and switched to ARB
Treated H.pylori with triple therapy, and UTI Angioedema and hives
resolved She takes Reactine and Ranitidine only as needed now, and
off oral prednisone Nasocorticosteroids, Atrovent nasal spray,
nasal washes prn
Slide 35
Key points Through several mechanisms a variety of mediators
may lead to urticaria or angioedema Clinically, a causative agent
is much more often identified in acute than in chronic
urticaria/angioedema A number of medications are available to
control chronic urticaria while awaiting a spontaneous remission
Patients with angioedema without urticaria should be tested for C1
inhibitor deficiency Recurrent infections, especially with other
symptoms (rashes, alopecia, diarrhea) should be worked up for
primary immunodeficiency