Allergy and Immunology 2023 FINAL
Allergy and Immunology 2023 FINAL
Allergy and Immunology 2023 FINAL
2
Primary Immunodeficiency (PID)
General Approach:
• Rule out secondary causes of immunodeficiency:
– DM, HIV infection, Cirrhosis, Nephrotic syndrome, Autoimmune disease, Malignancy,
Splenectomy/Asplenia, Immunomodulatory drugs
– Structural (obstructive tumours, urethral strictures), dermatitis, burns
• Identify type of infections (see below) to direct investigation
PREDOMINANT INFECTIONS TYPE OF IMMUNO- Investigations
DEFICIENCY
Repeated pyogenic infections B- cell Lymphocyte count, Lymphocyte subsets,
Immunoglobulins (IgG, IgA, IgM),
vaccination titres
Severe mycotic infection and T- cell Lymphocyte count, Lymphocyte subsets
opportunistic infections
Abscess-forming infection with Neutrophil deficiency Neutrophil count, Chronic Granulomatous
low-grade pathogens Disease (CGD) Assay
Repeated infections w/ Complement C3, C4, CH50
Neisseria sp. deficiency
Immunodeficiency to know: CVID
Combined Variable Immunodeficiency (CVID)
• Most common symptomatic PID in adults
– Recurrent sinopulmonary infections
– Dx: LOW IgG + LOW IgA or IgM + poor response to vaccination;
other immunodeficiency causes ruled out (e.g. CLL)
– Tx: IVIG or SCIG (sub-cutaneous Immunoglobulin)
4
Urticaria (1)
Acute Urticaria
• Common antigens/triggers = antibiotics (PCN, Sulfa), NSAIDs, insects, food
(shellfish in adults) - if there’s a trigger, there will be an obvious relationship
• Lasts < 6 weeks
• Work-up: Allergy referral for skin testing
• First line treatment: STOP medication/AVOID trigger if identified, anti-
histamines PRN: ex. Cetirizine (Reactine)
• PEARL: in general, a normal C4 level (in acute setting) rules OUT HAE Type II Normal/High Low Low
PEARL: As a general rule, any time you have more than one system involved, you should suspect anaphylaxis!
Penicillin Allergy
Approach:
– IgE-Mediated: pruritus, urticaria, angioedema, etc.
– Non-IgE-Mediated: SJS-TENS (blistering, desquamation, conjunctivitis), DRESS (eosinophilia, fever, end-organ
involvement), serum sickness (arthritis, fever)
Management: IgE-mediated Reactions
– Allergy referral for Penicillin Skin Testing + Oral Challenge
• ~90% “PCN allergic” patients will test negative – can safely receive beta-lactam and cephalosporin antibiotics
• Positive skin test – AVOID penicillin, higher likelihood of reacting to 1st gen cephalosporins
– Drug Desensitization (under close observation, OK to do even in Pregnant patient (eg) with syphilis))
• If penicillin is required acutely and no time for skin testing, or skin test positive
• Note: this is a temporary induction of ‘tolerance’, and does NOT rule out allergy
• Note: this is only used in cases of IgE-mediated drug reactions (NOT if any suspicion of serum sickness, SJS-TENS,
DRESS, etc.)
– Note: Aztreonam (monobactam) – generally tolerated in penicillin allergic patients
• exception: if they have reacted to ceftazidime!
Patient history not very reliable (JAMA 2001):
PCN allergy history positive: LR+ 1.9 for +ve skin test
PCN allergy history negative: LR- 0.5 for +ve skin test
Example Question
A 30-year-old woman presents with a second pneumonia in the last
six months. She has a past medical history of recurrent pneumonias
and sinusitis. Investigations show: WBC 6, Neutrophils 3,
Lymphocytes 2, Monocytes 1.
What is most likely diagnosis?
1. Complement deficiency
2. Common variable immunodeficiency
3. HIV
4. Chronic granulomatous disease
Answer
A 30-year-old woman presents with a second pneumonia in the last
six months. She has a past medical history of recurrent pneumonias
and sinusitis. Investigations show: WBC 6, Neutrophils 3,
Lymphocytes 2, Monocytes 1.
What is most likely diagnosis?
1. Complement deficiency
2. Common variable immunodeficiency
3. HIV
4. Chronic granulomatous disease
Example Question
A middle-aged female presents with a 6 month history of urticaria. She
has never had any episodes of swelling. The urticaria resolve within 12hr,
with no residual bruising or scarring. She reports that she has been eating
out at restaurants more recently. She is otherwise well. Initial bloodwork
is normal including a CBC, creatinine and liver profile. What is the most
likely cause of this patient’s symptoms?
1. Chronic Idiopathic Urticaria
2. Food allergy
3. C1 esterase deficiency
4. Autoimmune Disease
Answer
A middle-aged female presents with a 6 month history of urticaria. She
has never had any episodes of swelling. The urticaria resolve within 12hr,
with no residual bruising or scarring. She reports that she has been eating
out at restaurants more recently. She is otherwise well. Initial bloodwork
is normal including a CBC, creatinine and liver profile. What is the most
likely cause of this patient’s symptoms?
1. Chronic Idiopathic Urticaria
2. Food allergy
3. C1 esterase deficiency
4. Autoimmune Disease
Example Question
A pregnant patient with a history of asthma states she is allergic to
penicillin. She developed wheeze the last time she took it, while
admitted for an upper respiratory tract infection. She was referred
for penicillin skin testing, which was negative.
Penicillin is now indicated for a pregnancy acquired syphilis infection.
Which drug would you use?
1. Penicillin
2. Second-Generation Cephalosporin
3. Doxycycline
Answer
A pregnant patient with a history of asthma states she is allergic to
penicillin. She developed wheeze the last time she took it, while
admitted for an upper respiratory tract infection. She was referred
for penicillin skin testing, which was negative.
Penicillin is now indicated for a pregnancy acquired syphilis infection.
Which drug would you use?
1. Penicillin
2. Second-Generation Cephalosporin
3. Doxycycline
Example Question
A young man presents with occasional angioedema of his lips and
hands. Which of the following features make it least consistent with
C1 esterase deficiency?
1. Occasional GI symptoms
2. Triggered by dental procedure
3. Presence of urticaria
4. Laryngeal involvement
Answer
A young man presents with occasional angioedema of his lips and
hands. Which of the following features make it least consistent with
C1 esterase deficiency?
1. Occasional GI symptoms
2. Triggered by dental procedure
3. Presence of urticaria
4. Laryngeal involvement