Block 10 Board Review
Part 1 of 4
Allergy/Immunology
14March2014
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 risktaking 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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