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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
.pdf
Toronto IMR 2024 Slides
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BONUS E-LECTURE:
Allergy & Clinical Immunology
With Contributions by Dr. Andrea Burke and Dr. David Fahmy
Clinical Immunology & Allergy
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Ten Red Flags of Immunodeficiency:
1. ≥ 2 new ear infections within 1 year
2. ≥ 2 new sinus infections within 1 year, in the absence of allergy
3. One pneumonia per year for more than 1 year
4. Chronic diarrhea with weight loss
5. Recurrent viral infections (colds, herpes, warts, condyloma)
6. Recurrent need for IV antibiotics to clear infections
7. Recurrent, deep abscesses of the skin or internal organs
8. Persistent thrush or fungal infection on skin or elsewhere
9. Infection with normally harmless tuberculosis-like bacteria
10. A family history of Primary Immunodeficiency
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-
DEFICIENCY
Investigations
Repeated pyogenic infections B- cell Lymphocyte count, Lymphocyte subsets,
Immunoglobulins (IgG, IgA, IgM),
vaccination titres
Severe mycotic infection and
opportunistic infections
T- cell Lymphocyte count, Lymphocyte subsets
Abscess-forming infection with
low-grade pathogens
Neutrophil deficiency Neutrophil count, Chronic Granulomatous
Disease (CGD) Assay
Repeated infections w/
Neisseria sp.
Complement
deficiency
C3, C4, CH50
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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)
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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)
Red Flags of Urticaria: Typical Urticaria:
Last longer than 48hr Last <48hr
Heal with a bruise, scar Heal without skin changes
Burning, pain PRURITUS!
PEARL: Red Flags should raise suspicion of autoimmune/
systemic disease!!!
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Chronic Spontaneous Urticaria (CSU)
• “Chronic”: >6 weeks, most days of the week, “Spontaneous”: no clear trigger
• Workup of CSU
– CBC + diff, ESR/CRP
• Workup of other causes of chronic urticaria – as directed by clinical picture:
– Autoimmune work-up: ANA, ds-DNA, RF
– Serum tryptase if systemic symptoms [Mastocytosis]
– Biopsy [urticarial vasculitis]
• Treatment of CSU
– 1
st
line: Daily non-sedating antihistamine (cetirizine)
– 2
nd
line: increased dose non-sedating antihistamine (4x
– 3
rd
line: Omalizumab (Xolair)
Physical Chronic Urticaria
• Trigger = Pressure (aka dermatographism), Heat, Cold
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Angioedema + pruritus/urticaria = most likely Mast cell mediated
• Related to a Specific Trigger (food, drug, insect bite, etc.)
• Idiopathic Angioedema (can be part of CSU)
Angioedema (NO pruritus/urticaria) = Mast cell OR Bradykinin-mediated
• Differential diagnosis:
– Related to Specific Trigger (see above)
– Idiopathic Angioedema
• Chronic Tx: Frequent episodes : Daily antihistamine (Cetirizine)
• Rare episodes: Prednisone + antihistamine for first sign of symptoms
• Epinephrine Auto-injector
– Hereditary Angioedema (HAE): C1 esterase inhibitor deficiency – Types I, II, III
• PEARL: in general, a normal C4 level (in acute setting) rules OUT
HAE Types I &II
• Chronic Tx: Prophylactic C1 esterase Inhibitor
– Acquired Angioedema (lymphoproliferative or autoimmune disease)
– ACE Inhibitor Angioedema
Acute Treatment Angioedema:
STOP offending agent/trigger, if possible
H1-Blocker: Diphenhydramine 25-50mg IV
H2-Blocker: Ranitidine 50mg IV
Steroids: Methylprednisolone ~60-80mg IV
*Anaphylaxis or oropharyngeal angioedema: Epi!
ACE Inhibitor Angioedema: Icatibant
Known HAE: skip above treatment, instead: C1
esterase inhibitor, Icatibant
Investigations:
Type
C1 Inhibitor
Level
C1
Inhibito r
Function
C4
HAE Type I
Low
Low
Low
HAE Type II
Normal/High
Low
Low
HAE Type III
Normal
Normal
Normal
Acquired
Low
Low
Low
ACE In
Normal
Normal
Normal
Idiopathic
Normal
Normal
Normal
NEW: NEJM 2015: A Randomized Trial of Icatibant in ACE-Inhibitor–Induced Angioedema
Conclusion: in this RCT involving patients with ACE-inhibitor–induced angioedema, complete resolution of edema was achieved
significantly more quickly with SQ icatibant than with standard therapy consisting of glucocorticoids and antihistamines.
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– Epinephrine IM:%H,HIII%EH#)A#JG%K%7<?C,%ILIH#)AM)%E#15%ILN#)G%
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• Consider IV aXer several (i.e. 3) doses IM, profound hypotension, obese
paZents
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– H1-Blocker: Rani8dine 50mg IV q8hr PRN
– H2-Blocker: Diphenhydramine 25-50mg IV q4-6hr PRN
– Steroids: Methylprednisolone 125mg IV q6hr PRN
– Glucagon – paZents on beta-blockers
– Salbutamol – paZents with signs of bronchoconstricZon
– Vasopressors – for persisZng hypotension
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IM EPINEPHRINE
0.01 mg/kg (max 0.5mg) IM
Repeat q5-15 min PRN
Note: 1:1000 solution = 1mg/mL
IV EPINEPHRINE
0.05-0.1 mg IV over 5 min
Then infuse 2-10 mcg/min titrated
to BP
Note: 1:10,000 solution =
0.1mg/mL
Discharge Plan:
Prescribe Epinephrine Autoinjector 0.3mg
IM PRN
Anaphylaxis Action Plan
Patient/Caregiver Education
MedicAlert bracelet
Referral to Allergist/Immunologist
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