Block 10 Board ReviewPart 1 of 4

Allergy/Immunology14March2014

Chauncey D. Tarrant, M.D.Chief of Residents 13-14

3.5% of Initial Certifying Exam!!!

Pediatrics In Review Articles

• Asthma• Atopic Dermatitis

PIR Quizzes

1. An 11-month-old boy presents with fever, runny nose, and difficulty breathing for 1 day. Physical examination shows an axillary temperature of 37.8°C, respiratory rate of 32 breaths/min, and heart rate of 110 beats/min. Diffuse expiratory wheezes are audible bilaterally. He had similar illness 2 months ago. The mother is concerned about her son developing asthma during his childhood. Which of the following is the most appropriate response to her concerns about her son?A. If he has two more episodes of wheezing during the next year, his chances of having asthma during childhood are greater than 80%.B. If he responds to bronchodilators such as albuterol, there is a greater than 80% risk that he will have asthma during childhood.C. If the respiratory infection is due to RSV, he should have less than a 20% risk of developing asthma during childhood.D. More than 80% of infants who have a history of wheezing after respiratory infection in the first postnatal year do not wheeze after age 3 years.E. More than 80% of infants younger than 1 year of age who have respiratory tract infections wheeze during their illness.

1. An 11-month-old boy presents with fever, runny nose, and difficulty breathing for 1 day. Physical examination shows an axillary temperature of 37.8°C, respiratory rate of 32 breaths/min, and heart rate of 110 beats/min. Diffuse expiratory wheezes are audible bilaterally. He had similar illness 2 months ago. The mother is concerned about her son developing asthma during his childhood. Which of the following is the most appropriate response to her concerns about her son?A. If he has two more episodes of wheezing during the next year, his chances of having asthma during childhood are greater than 80%.B. If he responds to bronchodilators such as albuterol, there is a greater than 80% risk that he will have asthma during childhood.C. If the respiratory infection is due to RSV, he should have less than a 20% risk of developing asthma during childhood.D. More than 80% of infants who have a history of wheezing after respiratory infection in the first postnatal year do not wheeze after age 3 years.E. More than 80% of infants younger than 1 year of age who have respiratory tract infections wheeze during their illness.

2. A 3-year-old boy who has a previous history of allergic rhinitis and eczema presents to your office with cough and wheezing for 2 days. The symptoms started after he visited his uncle’s house and played with a cat. Which of the following statements about his current state is true?A. Airway inflammation has occurred due to action of cytokines and chemokines.B. Airway remodeling has occurred, characterized by mucous gland hyperplasia and bronchial smooth muscle hypertrophy.C. Current illness represents the early phase of mast cell activation, causing bronchospasm.D. Eosinophils have been activated by IgE, causing IL-4 release.E. Th1 lymphocyte activation by IgA has caused airway hyperreactivity.

2. A 3-year-old boy who has a previous history of allergic rhinitis and eczema presents to your office with cough and wheezing for 2 days. The symptoms started after he visited his uncle’s house and played with a cat. Which of the following statements about his current state is true?A. Airway inflammation has occurred due to action of cytokines and chemokines.B. Airway remodeling has occurred, characterized by mucous gland hyperplasia and bronchial smooth muscle hypertrophy.C. Current illness represents the early phase of mast cell activation, causing bronchospasm.D. Eosinophils have been activated by IgE, causing IL-4 release.E. Th1 lymphocyte activation by IgA has caused airway hyperreactivity.

3. A 6-year-old girl is brought in for evaluation of nighttime cough and wheezing after being exposed to secondhand smoke. A pulmonary function test (PFT) using a forced expiratory maneuver to display a flow volume curve is ordered. Which of the following statements is most accurate regarding PFT in this situation?A. Flattening of the inspiratory portion of the flow volume loop and decreased forced vital capacity suggest the presence of asthma.B. Increase in FEV1 by at least 12% after administration of a bronchodilator is indicative of asthma.C. Normal PFT indicates that the patient does not have airway hyperresponsiveness and, therefore, retesting with a bronchodilator is unnecessary.D. PFT assessment in those younger than age 8 years is unreliable due to lack of patient cooperation.E. PFT should be performed after challenging the patient with secondhand smoke and retesting after administration of a bronchodilator.

3. A 6-year-old girl is brought in for evaluation of nighttime cough and wheezing after being exposed to secondhand smoke. A pulmonary function test (PFT) using a forced expiratory maneuver to display a flow volume curve is ordered. Which of the following statements is most accurate regarding PFT in this situation?A. Flattening of the inspiratory portion of the flow volume loop and decreased forced vital capacity suggest the presence of asthma.B. Increase in FEV1 by at least 12% after administration of a bronchodilator is indicative of asthma.C. Normal PFT indicates that the patient does not have airway hyperresponsiveness and, therefore, retesting with a bronchodilator is unnecessary.D. PFT assessment in those younger than age 8 years is unreliable due to lack of patient cooperation.E. PFT should be performed after challenging the patient with secondhand smoke and retesting after administration of a bronchodilator.

4. A 15-year-old girl who has a known history of asthma is hospitalized for exacerbations of cough, wheezing, and shortness of breath. Her asthma has become increasingly unresponsive to bronchodilators and corticosteroids in the past 5 years. Flow-volume loop using a forced expiratory maneuver shows flattening of the inspiratory loop. Flexible fiberoptic laryngoscopy shows adduction of vocal cords and narrowing of the subglottic area during inspiration. Which of the following is the most likely diagnosis?A. Laryngomalacia.B. Subglottic hemangioma.C. Subglottic stenosis.D. Tethered vocal cord.E. Vocal cord dysfunction.

4. A 15-year-old girl who has a known history of asthma is hospitalized for exacerbations of cough, wheezing, and shortness of breath. Her asthma has become increasingly unresponsive to bronchodilators and corticosteroids in the past 5 years. Flow-volume loop using a forced expiratory maneuver shows flattening of the inspiratory loop. Flexible fiberoptic laryngoscopy shows adduction of vocal cords and narrowing of the subglottic area during inspiration. Which of the following is the most likely diagnosis?A. Laryngomalacia.B. Subglottic hemangioma.C. Subglottic stenosis.D. Tethered vocal cord.E. Vocal cord dysfunction.

5. Infants who have atopic dermatitis often have clinical features that are different from those of older affected children. Which of the following areas of the body is more likely to be affected in infants?A. Antecubital fossae.B. Cheeks.C. Eyelids.D. Genitals.E. Neck.

5. Infants who have atopic dermatitis often have clinical features that are different from those of older affected children. Which of the following areas of the body is more likely to be affected in infants?A. Antecubital fossae.B. Cheeks.C. Eyelids.D. Genitals.E. Neck.

6. You are evaluating a 4-year-old boy who has a history of atopic dermatitis that usually affects his feet and popliteal fossae. He complains of itching and increased rash on his feet for several weeks. His mother feels that his atopic dermatitis is flaring up. Which of the following features makes a diagnosis of tinea pedis more likely than an exacerbation of atopic dermatitis?A. Erythema.B. Lesions in web spaces.C. Plaques without central clearing.D. Pruritus.E. Scaling.

6. You are evaluating a 4-year-old boy who has a history of atopic dermatitis that usually affects his feet and popliteal fossae. He complains of itching and increased rash on his feet for several weeks. His mother feels that his atopic dermatitis is flaring up. Which of the following features makes a diagnosis of tinea pedis more likely than an exacerbation of atopic dermatitis?A. Erythema.B. Lesions in web spaces.C. Plaques without central clearing.D. Pruritus.E. Scaling.

7. Which of the following treatments is recommended for all patients who have atopic dermatitis?A. Complete avoidance of eggs and peanuts.B. Daily prophylactic topical antibiotic cream.C. Emollient application after a bath or shower.D. Frequent bathing with hot water.E. Periodic oral corticosteroid courses.

7. Which of the following treatments is recommended for all patients who have atopic dermatitis?A. Complete avoidance of eggs and peanuts.B. Daily prophylactic topical antibiotic cream.C. Emollient application after a bath or shower.D. Frequent bathing with hot water.E. Periodic oral corticosteroid courses.

8. You are evaluating a 4-month-old boy during a health supervision visit. His mother complains that he is “always sick,” and she is concerned about his constant “dry skin.” She describes three upper respiratory tract infections and one episode of pneumonia that required hospitalization in the past 2 months. On physical examination, you note numerous scaly, erythematous patches on the infant’s face and the extensor surfaces of his arms and legs. In addition, an erythematous diaper rash with satellite lesions is visible. You obtain a complete blood count, which reveals eosinophilia but no other abnormalities. Which of the following is the most likely diagnosis?A. Allergic contact dermatitis.B. Hyper-immunoglobulin E syndrome.C. Lamellar ichthyosis.D. Tinea corporis.E. Wiskott-Aldrich syndrome.

8. You are evaluating a 4-month-old boy during a health supervision visit. His mother complains that he is “always sick,” and she is concerned about his constant “dry skin.” She describes three upper respiratory tract infections and one episode of pneumonia that required hospitalization in the past 2 months. On physical examination, you note numerous scaly, erythematous patches on the infant’s face and the extensor surfaces of his arms and legs. In addition, an erythematous diaper rash with satellite lesions is visible. You obtain a complete blood count, which reveals eosinophilia but no other abnormalities. Which of the following is the most likely diagnosis?A. Allergic contact dermatitis.B. Hyper-immunoglobulin E syndrome.C. Lamellar ichthyosis.D. Tinea corporis.E. Wiskott-Aldrich syndrome.

CONTENT SPECS!!!

Asthma

What are the characteristics of exercise induced asthma?

What are the characteristics of exercise induced asthma?

• Coughing and wheezing after 5-6mins of exercise

• Gradual improvement after 20-30mins of rest

• Smog increases the severity of exercise induced asthma. True or False?

• Smog increases the severity of exercise induced asthma. True or False?

What are some asthma triggers?

What are some asthma triggers?

• Exercise• Viral URI• Allergen Exposure• Weather Changes• Smoke Pollutants/other irritants• Aspirin• Beta Blockers

• Children with early onset asthma (<3yo), parental history of asthma, diagnosed atopic dermatitis, or sensitization to aeroallergens are least likely to outgrow asthma.

• True or False?

• Children with early onset asthma (<3yo), parental history of asthma, diagnosed atopic dermatitis, or sensitizations to aeroallergens are least likely to outgrow asthma.

• True or False?

What does IgE mediated allergen challenge in an asthmatic induce?

What does IgE mediated allergen challenge in an asthmatic induce?

• Immediate obstruction• Resolves and is followed in 4-12hrs by

persistent late phase obstruction

• Asthmatic patients have bronchial hyperresponsiveness with exaggerated bronchial response to environmental changes.

• True or False?

• Asthmatic patients have bronchial hyperresponsiveness with exaggerated bronchial response to environmental changes.

• True or False?

The pathology of asthma is characterized by….

The pathology of asthma is characterized by….

• Inflammation with predominance of eosinophils

• Epithelial Destruction• Glandular Hyperplasia• Collagen deposition in the submucosa

• Atelectasis associated with AAE requires bronchoscopy, antibiotics, and CPT

• True or False?

• Atelectasis associated with AAE requires bronchoscopy, antibiotics, and CPT

• True or False?

What are the signs of severe obstruction in AAE?

What are the signs of severe obstruction in AAE?

• Severe retractions• Inability to speak whole phrases• Cyanosis• Quiet breath sounds• Peak Expiratory flow rates <30% of predicted

Mild persistent asthma is characterized by….

Mild persistent asthma is characterized by….

• Symptoms >2x/week but <1x/day• Nighttime cough >2x/month• Exacerbations of variable intensity

• The majority of asthmatic school age children have positive immediate type allergy skin tests

• True or False?

• The majority of asthmatic school age children have positive immediate type allergy skin tests

• True or False?

Severe persistent asthma is characterized by….

Severe persistent asthma is characterized by….

• Daily symptoms• Limited physical activity• Frequent nighttime symptoms• Frequent exacerbations• Abnormal PE or PFTs

Mild Intermittent asthma is characterized by….

Mild Intermittent asthma is characterized by….

• Symptoms <2x/week• Long periods without symptoms• Normal PFTs• Exacerbations last hours to days

• EIA is a sign of poorly controlled asthma• True or False?

• EIA is a sign of poorly controlled asthma• True or False?

How do you treat AAE??

How do you treat AAE??

• Inhaled adrenergic agonists• Systemic steroids (severe)

What is the MOA of Corticosteroids in AAE?

What is the MOA of Corticosteroids in AAE?

• Increase adrenergic response• Improve FEV1• Improve oxygenation

What does adrenergic toxicity look like?

What does adrenergic toxicity look like?

• Tremor• Tachycardia• Hypo K

When is an AAE PICU worthy?

When is an AAE PICU worthy?

• 1 or more life threatening episodes in the past

• Severe case requiring chronic steroids• Poor control of daily symptoms• Abnormal FEV1• Significant Noncompliance • Depression/stress

How are peak flows helpful?

How are peak flows helpful?

• Objective confirmation of symptoms• Assessment of variations in daily obstruction• Assessment of acute obstruction

What are outpatient treatment options?

What are outpatient treatment options?

• Many options• (see handout)

• Excessive daily use of beta agonists is associated with increased mortality and diminished symptom control

• True or False?

• Excessive daily use of beta agonists is associated with increased mortality and diminished symptom control

• True or False?

• Corticosteroids do not interfere with late phase but do interfere with immediate response to allergy exposure

• True or False?

• Corticosteroids do not interfere with late phase but do interfere with immediate response to allergy exposure

• True or False?– Interferes with late phase– Doesn’t interfere with immediate response

• Long term ICS treatment decreases bronchial inflammation and bronchial hyperresponsiveness

• True or False?

• Long term ICS treatment decreases bronchial inflammation and bronchial hyperresponsiveness

• True or False?

General Info• Sustained release theophylline preparations may

have different absorption• Maintenance meds in anyone with symptoms

>2x/wk• Patient education is PARAMOUNT• CPT, Mucolytics, and anxiolytics are NOT

recommended in asthma management

Atopic Dermatitis

How do you evaluate a patient with eczema AND food allergies?

How do you evaluate a patient with eczema AND food allergies?

General Info

• Some patients with moderate or severe eczema have positive skin tests to food, may or may not have acute symptoms on ingesting these foods, and experience improvement in eczema upon eliminating these foods

PREP

You are evaluating a 6-month-old girl who has mild eczema that improves with regular use of a topical moisturizer with a group of pediatric residents. After evaluating the infant, you decide to discuss atopy and its components with them.Of the following, the MOST accurate statement regarding components of atopy is that

A. allergic rhinitis is not a risk factor for the development of asthma

B. children who wheeze before 1 year of age are at higher risk for persistent asthma compared with children who begin wheezing after 6 years of age

C. early child care exposure reduces the risk for the development of asthma

D. exclusive breastfeeding longer than 6 months significantly reduces asthma incidence beyond 6 years of age

E. maternal dietary restriction during breastfeeding prevents the development of atopy

A. allergic rhinitis is not a risk factor for the development of asthma

B. children who wheeze before 1 year of age are at higher risk for persistent asthma compared with children who begin wheezing after 6 years of age

C. early child care exposure reduces the risk for the development of asthma

D. exclusive breastfeeding longer than 6 months significantly reduces asthma incidence beyond 6 years of age

E. maternal dietary restriction during breastfeeding prevents the development of atopy

A 12-month-old boy presents with a 7-month history of a worsening skin rash. The rash is pruritic and involves his neck, anterior and posterior trunk, antecubital and popliteal fossae, and hands and feet. Use of a moisturizer and topical corticosteroid has resulted in some improvement. The remainder of his past medical history is unremarkable. On physical examination, you observe multiple erythematous, lichenified patches and diagnose severe atopic dermatitis.Of the following, the MOST helpful next step is to

A. eliminate milk, eggs, soy, and wheat from the diet

B. measure serum immunoglobulins (IgG, IgA, and IgM)

C. perform aeroallergen allergy testing

D. perform food allergy testing

E. start oral corticosteroids

A. eliminate milk, eggs, soy, and wheat from the diet

B. measure serum immunoglobulins (IgG, IgA, and IgM)

C. perform aeroallergen allergy testing

D. perform food allergy testing

E. start oral corticosteroids

The case manager of an 18-month-old child is concerned because the child is having recurrent wheezing episodes. The infant was hospitalized at 6 months of age with confirmed respiratory syncytial virus (RSV) infection. The wheezing sometimes but not always responds to albuterol treatment. There is no maternal history of asthma or allergies. The case manager is concerned that these episodes may be because of maternal neglect. Of the following, you are MOST likely to tell the case manager that after an initial RSV infection, the child

A. can have recurrent wheezing occur in up to 50% of babies with RSV bronchiolitis

B. can have recurrent wheezing which consistently responds to albuterol treatment

C. the recurrent wheezing represents RSV colonization and inadequate preventive care

D. should not have recurrent wheezing if there is no maternal history of asthma or atopy

E. should not have wheezing for more than 6 months after hospitalization

A. can have recurrent wheezing occur in up to 50% of babies with RSV bronchiolitis

B. can have recurrent wheezing which consistently responds to albuterol treatment

C. the recurrent wheezing represents RSV colonization and inadequate preventive care

D. should not have recurrent wheezing if there is no maternal history of asthma or atopy

E. should not have wheezing for more than 6 months after hospitalization

A 14-year-old boy who has seasonal allergic rhinitis and moderate persistent asthma is currently receiving allergen immunotherapy. Today in the clinic, he received his usual allergen injection, but after 10 minutes, he started coughing and complaining of dyspnea and throat swelling. On physical examination, he exhibits moderate respiratory distress and has diffuse expiratory wheezing on auscultation. His oropharynx appears normal and without tongue or uvula edema. Vital signs include a room air pulse oximetry reading of 97%, blood pressure of 130/70 mm Hg, and heart rate of 90 beats/minute.Of the following, the MOST appropriate next action is to administer

A. a short-acting beta-2 agonist nebulization

B. an oral antihistamine

C. an oral corticosteroid

D. intramuscular epinephrine

E.supplemental oxygen via face mask

A. a short-acting beta-2 agonist nebulization

B. an oral antihistamine

C. an oral corticosteroid

D. intramuscular epinephrine

E.supplemental oxygen via face mask

A 5-year-old boy presents with a history since 2 years of age of coughing, swelling of the lips, mouth, and eyes, and vomiting after ingestion of peanut butter. He has been seen by an allergist in the past. Skin prick testing showed a wheal of 10 mm and a flare of 20 mm to peanut. His reaction to histamine showed a wheal of 7 mm and a flare of 15 mm. He did not react to the negative control. He has been avoiding peanuts and nut products. His mother is worried about risk-taking behaviors in teens and wants to know if her son will outgrow his peanut allergy by the time he is in high school.Of the following, the BEST information to tell the boy’s mother is that

A. avoiding soy and other legumes will help him outgrow his peanut allergy

B. daily antihistamine therapy will help him outgrow his peanut allergy

C. he is likely to outgrow his allergy if he strictly avoids peanuts for 3 to 5 years

D. he is unlikely to outgrow his peanut allergy by adolescence

E. you will send him to the allergist for periodic skin testing to see if his reactivity decreases over time

A. avoiding soy and other legumes will help him outgrow his peanut allergy

B. daily antihistamine therapy will help him outgrow his peanut allergy

C. he is likely to outgrow his allergy if he strictly avoids peanuts for 3 to 5 years

D. he is unlikely to outgrow his peanut allergy by adolescence

E. you will send him to the allergist for periodic skin testing to see if his reactivity decreases over time

The parents of a 7-year-old girl who has asthma are concerned because her asthma symptoms have worsened recently. In the past, she has experienced asthma exacerbations with viral infections in the winter. The parents have recently noticed that her asthma also worsens during the summer soccer season, although she was fine playing indoor soccer in the winter. Of the following, you are MOST likely to advise them that their daughter needs to

A. get exercise challenge testing

B. get methacholine challenge testing

C. get skin testing

D. stop all sports

E. stop all summer sports

A. get exercise challenge testing

B. get methacholine challenge testing

C. get skin testing

D. stop all sports

E. stop all summer sports

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