NCM 220
FINALS - LECTURE
ALTERATIONS W/ INFECTIOUS,
INFLAMMATORY AND IMMUNOLOGIC
RESPONSE
➔​ Disorders of the immune system can be
the result of an underactive or functional
system (immunodeficiency)
➔​ Overactive or poorly regulated system
​
IMMUNE RESPONSE (The immune system)
Physical Barriers:
➔​ Skin; organ muscles
Chemical Barriers:
➔​ Stomach acid
➔​ Lysosomes in eye
Innate Responses: Inflammatory Response
Cells
➔​ Mast Cells
➔​ Neutrophils
➔​ Natural Killer Cells
absent is agammaglobulinemia
➔​ T. lymphocyte – inadequate number or
inadequate functioning, one or more
types of lymphocyte. DiGeorge, problem
on number chromosome 22. Trisomy 21,
three copies.
➔​ Combined B&T – severed, the most
frequently seen disorder. Absent or
reduced cell mediated immunity or
humoral.
Secondary
➔​ loss immunity response. Occur in severe
systemic infection, cancer, undergoing
radiation
therapy, severe stress,
malnutrition,
immunosuppressive
therapy, and aging.
➔​ HIV Infection and Aids – prominent
End stage of acquired immunodeficiency
Caused by infection with RNA human
deficiency
Transmission:
➔​ Spread by exposure to blood and
other body secretions through
◆​ Sexual contact
◆​ Sharing of contaminated
needles for injection
◆​ Transfusion of contaminated
blood or blood products
◆​ Perinatally from mother to
fetus or newborn or through
BF*
Helper T cells- immunoglobulin
Cytotoxic T cells – lymphokines, example
interferon
IgE – responsible for allergic and
hypersensitivity reaction
Immunodeficiency Disorders
Assessment
➔​ HIV long incubation (10 years in adults)
➔​ Appears to progress more rapidly
in children and infants who receive
the virus through placental
transmission if they do not receive
treatment.
DIVIDED INTO TWO:
Primary immunodeficiency
➔​ b lymphocyte or humoral deficiency
– creating abnormal low level
immunoglobulin causes
hypogammaglobulinemia. While
Preliminary symptoms
❖​ poor resistance to infection (dali ra ma
sakit, common pneumonia)
❖​ fever
❖​ swollen lymph nodes
❖​ respiratory tract infections
❖​ thrush
CLASSIFICATION OF HIV IN CHILDREN
(CDC)
CATEGORY A (Mildly symptomatic)
➔​ 2 or more symptoms like enlarged lymph
node hepato/spleno, URTI
CATEGORY B (Moderately symptomatic)
➔​ more serious illness oropharyngeal
candidiasis, meningitis, pneumonia,
sepsis.
CATEGORY C (severely symptomatic)
➔​ Serious bacterial infection like septicemia
➔​ PCP
Diagnostic Tests
❖​ PCR (polymerase chain reaction)
– detect antigen
❖​ ELISA (enzyme linked
immunosorbent assay) – detect
antibody
❖​ Western blot – to confirm HIV blood
Therapeutic Management
➔​ Zidovudine administration during
pregnancy
Symptomatic period- a woman develops
opportunistic infections and possible
malignancies.
Therapeutic Management
➔​ Advised not to get pregnant
➔​ Goal: maintain CD4 cell count at greater
than 500 cells/mm3 by administering one
or more protease inhibitors (ritonavir
(Norvir), indinavir (Crixivan) with a
nucleoside reverse transcriptase inhibitor
drug.
➔​ If pneumonia develops - treats with
trimetrophin w/ sulfamethoxazole
(Bactrim)
➔​ Trimetrophin - teratogenic in early
pregnancy sulfamethoxazole (Gantanol)
increased bilirubin level in NB if
administered late in pregnancy.
❖​ Kaposi's sarcoma - rare malignancy,
treat chemotherapy (contraindicated in
pregnancy)
❖​ Thrombocytopenia - low platelet,
transfuse platelet
➔​ Women are offered option for CS
➔​ Follow up testing of newborns being
treated w/ Zidovudine for the first 6
weeks (two (-) cultures at 4 mos
age-reasonably excluded)
A pregnant woman w/ HIV infection
Risk factor for contracting HIV in women
❖​ Multiple sexual partners
❖​ Bisexual partners
❖​ Intravenous drug use
Progression of HIV infection
Initial invasion seroconversion
– flu-like symptoms
▪​ Seroconversion – convert from
no HIV antibodies is detected
to have HIV. Happen 6 weeks
of exposure to 1 year
exposure.
Asymptomatic period
Weight loss & fatigue, period averages 3-11
yrs
A.J.B
Assessment of allergy in children
History
➔​ Family history - ask family about their
allergies
➔​ Obtaining exact symptoms
Laboratory testing
➔​ Increase eosinophils
➔​ Radioallergosorbent test
Skin testing
➔​ 0.1 mL of medicine and 0.9 water
indicates allergy (WHAL)
➔​ Done to detect
Therapeutic Management
3 goals:
❖​ Reduce the child’s exposure to allergen
❖​ Hyposensitive the child to produce a
state of increased clinical tolerance
❖​ Modify the child’s response to the
allergen e/ a pharmacologic agent
❖​ Environmental control – removal as
many allergens
❖​ Hyposensitization
❖​ Pharmacologic therapy
❖​ Antihistamine
has ever had a reaction to drugs before
(penicillin, aspirin, antitoxin serums).
➔​ Child should wear bracelet or necklace
identifying the drug to which they are
allergic
➔​ Epinephrine – drug of choice for
anaphylaxis.
URTICARIA AND ANGIOEDEMA
❖​ URTICARIA – of hives refers to macular
wheals surrounded by erythema
❖​ ANGIOEDEMA – is an edema of skin and
subcutaneous tissue occurs most
frequently on the eyelids & hands.
Allergens: drugs, foods, and insect stings
Therapy: subcutaneous epinephrine or an
oral antihistamine.
Common Immune Reactions
Anaphylactic Shock
➔​ immediate life-threatening type 1
hypersensitivity reaction occurs after
exposure to an allergen in a previously
sensitized child
Assessment
❖​ Breathing
❖​ Circulation – pale or blue in color,
decreased pulse rate (below 60),
lightheadedness, low BP, Loss of
consciousness
❖​ Skin – redness, hives, swelling, rashes, etc
❖​ Stomach – nausea, cramps, vomiting,
diarrhea.
❖​ Others- anxious, watery eyes, cramping
of the uterus, feeling impending.
Therapeutic Management
➔​ Be certain to ask parents if their child
SERUM SICKNESS
➔​ A type III hypersensitivity response
of the body to a foreign serum
antigen or drug
➔​ Foreign sera: tetanus,
antitoxin, rabies, antiserum
Assessment
➔​ Begins 7-12 days after the serum
injection, if child received the same
serum previously symptoms may
occur 1-5 days
➔​ Notice itching, edema,
erythema at the injection site
➔​ Generalized urticarial w/
or without angioedema
➔​ Erythematous maculopapular rashes,
A.J.B
erythema multiforme or purpura may
result
➔​ Fever, arthralgia, swollen lymph nodes
➔​ Weight gain, nausea, vomiting, abdominal
pain
➔​ Optic neuritis, stupor. Coma-extreme
instances
➔​ Paramount symptoms that need
treatment- laryngeal edema
Therapeutic Management
Antihistamine – Diphenhydramine
(Benadryl) or epinephrine
NSAID- Ibuprofen (Motrin)
The child should not receive the serum again
Children should wear a bracelet or
necklace stating solutions to which are
hypersensitive.
ATOPIC DISORDER
Allergic Rhinitis
➔​ Caused by a type I or immediate
hypersensitivity immune response, pollens
or molds rather than drugs or foods.
Assessment
➔​ Sneezing, nasal engorgement, profuse
watery discharge
➔​ Mucous membrane of the nose – generally
paler than normal, edematous adding to
nasal congestion
➔​ Eyes tend to water, conjunctivae may
be pruritic often with a distinctive
pebbly appearance.
➔​ Children constantly rub their noses in
an upward motion (allergic salute)- lead
to horizontal crease across the tip of
the nose (allergic crease)
➔​ Congestion to the nose – back pressure to
the blood circulation around the eye orbitleads to blackened areas under the eyes
(allergic shiners)
➔​ Children older than 6 yrs old may
develop frontal headache
➔​ Recurrent otitis media may occur
because of swollen pharyngeal tissue
➔​ A smear of nasal discharge will
reveal an increased eosinophil count.
Therapeutic Management
3 prolonged program
❖​ Avoidance of allergens
❖​ Use of pharmacological agents
❖​ Immunotherapy
❖​ Intranasal corticosteroids or
antihistamines
Atopic Dermatitis (Infantile Eczema)
➔​ Primarily a disease of infants (2nd month
2-3 years old)
➔​ Maybe related to food allergy, occurs
more often to formula-fed than BF
infants
➔​ Sweating, tight clothing, contact irritants
(soap) – increase pruritus
Assessment
➔​ Increase capillary permeability –
causing a loss of serous fluid into the
tissues
➔​ Develops popular and vesicular skin
eruptions with surrounding erythema
➔​ Vesicles rupture-exude yellow, sticky
secretions that forms crusts on the skin
as they dry
➔​ Infected lesion heals-skin becomes
depigmented and lichenified (shiny
and dry flaky scaled form
➔​ Low grade fever, swollen lymph
nodes, increased eosinophil
count (secondary infection)
➔​ Common sites: scalp, forehead,
cheeks, neck, behind the ears,
extensor surfaces of the extremities.
➔​ Fussy and irritable
➔​ May not eat well (generalized discomfort)
Therapeutic Management
➔​ Aim: reduce amount of allergen
exposure, reduce pruritus
➔​ Foods which infant are allergic:
milk, eggs, wheat, chocolate, fish,
tomatoes, peanuts
➔​ Hydrate skin-bathing or applying wet
dressing for 15-20 – hydrating emollient
(petroleum jelly (Vaseline) or vegetable
A.J.B
shortening (Criscol)
➔​ Stockinette dressing
➔​ Prevent corneal irritation
➔​ Antihistamine
➔​ Topical steroids – 1% hydrocortisone cream
➔​ Dry lesions – corticosteroid ointment, if
moist- lotion
➔​ Apply cream or lotion – cover area w/
occlusive dressing (plastic wrap
overnight)
➔​ Hydrocortisone mixed w. antibiotic
(neomycin) – lesions are secondarily
affected
➔​ Caution: not to discontinue
applications abruptly – reduces
adrenal gland functioning
➔​ Immunomodulators tacrolimus
(protopic) and pimecrolimus (elidel)
for children 2yrs of age, prescribed at
lower possible dose, because of the
association of the development of skin
cancer.
Atopic Dermatitis in the older children
➔​ Prominent on the flexor surfaces of the
extremities and on the dorsal surface of the
extremities and on the dorsal surface of the
wrists and ankles.
➔​ Occurs in the eyebrows (leaving scanty
eyebrows)
➔​ Fingernails – glossy sheen from the buffing
action of constant rubbing and scratching.
➔​ Itch-scratch cycle- in response to stress
Therapeutic Management
➔​ Use only a prescription soap to prevent skin
drying or not to use soap
➔​ Avoid swimming in chlorinated pool
➔​ If required to swim-shower well afterward,
apply skin emollient and moisturizer such as
Eucerin
➔​ Child take showers to remove
perspiration after sweating occurs in
certain activities.
➔​ Avoid tight clothing at the flexor portions of
the extremities
➔​ Cautions: not to use medication intended
for acne cover-up causes drying of the skin
and itching.
➔​ Medical treatment: keeping skin hydrated,
identify allergens and any psychological
problems that are initiating an itch-scratch
style
➔​ Application of hydrocortisone cream
➔​ Phototherapy with ultraviolet light
Drugs Allergies
➔​ Toxin reaction – occurs when a child has
received too much of a drug
➔​ Side effects – those that are known to occur
in addition to a therapeutic effect
➔​ Allergic effect – unpredictable symptoms
occur
➔​ Reaction to drugs differ, skin
manifestations: urticaria, and angioedema,
allergic contact dermatitis, pruritus,
purpura
➔​ Thrombocytopenia and hemolytic anemia
➔​ Children should wear a
medical identification
bracelet
➔​ Drugs frequently involved in allergic
reactions: parenteral penicillin and
vaccines (discontinue drug or never use
again)
➔​ If urticuria or serum sickness
occurs- antihistamine is needed*
Food allergies
➔​ Symptoms: urticarial, angioedema,
pruritus, stomach pain, colic, cramps,
diarrhea, respiratory symptoms, atopic
dermatitis
➔​ Most common foods: egg white, fish
and other seafood, berries, and nuts
➔​ Delayed food reactions: cereals, milk,
chocolate, pork, legumes, white
potatoes, beef, food additives,
colorings, and oranges
Management:
➔​ Encourage a child or parents to keep a
food diary
➔​ Elimination diet
➔​ Permanently eliminate offending foods
➔​ Parents must be careful shoppers
Milk hypersensitivity
➔​ Allergy to milk – failure to gain
A.J.B
weight diarrhea, vomiting,
abdominal pain
➔​ If milk allergy is suspected – give
casein hydrolysate or soybean
formula-symptoms are dramatically
relieved
➔​ Caution; parents to read food labels
carefully to be certain that frozen
foods or hotdogs do not contain milk
➔​ Vitamin D and calcium supplements
Peanuts Hypersensitivity
Allergic to peanuts
Even smelling peanut butter in a cafeteria or
another child’s lunch can provoke acute
wheezing or anaphylaxis
Desensitization to peanuts can minimize
children’s response.
A.J.B