Block 10 Board Review
Part 2 of 4
Allergy/Immunology
21March2014
Chauncey D. Tarrant, M.D.
Chief of Residents 13-14
3.5% of Initial Certifying Exam!!!
Pediatrics In Review Articles
• Allergic Rhinitis
• Cases in Immunology
PIR Quiz
5. You are evaluating a 3-year-old boy whose mother reports that he
has had a “stuffy nose” almost every day for the past 4 months. He
has not had a fever or a cough, but he sneezes frequently. She gives
him an oral antihistamine periodically, which has not helped much.
He has no other medical problems and recently started going to a
child care center during the day. His physical examination reveals
swollen nasal turbinates bilaterally and purplish discoloration under
his eyes. Which of the following is the most likely
diagnosis?
A. Allergic rhinitis.
B. Bacterial sinusitis.
C. Cystic fibrosis.
D. Recurrent upper respiratory tract infections.
E. Rhinitis medicamentosa.
5. You are evaluating a 3-year-old boy whose mother reports that he
has had a “stuffy nose” almost every day for the past 4 months. He
has not had a fever or a cough, but he sneezes frequently. She gives
him an oral antihistamine periodically, which has not helped much.
He has no other medical problems and recently started going to a
child care center during the day. His physical examination reveals
swollen nasal turbinates bilaterally and purplish discoloration under
his eyes. Which of the following is the most likely
diagnosis?
A. Allergic rhinitis.
B. Bacterial sinusitis.
C. Cystic fibrosis.
D. Recurrent upper respiratory tract infections.
E. Rhinitis medicamentosa.
6. One of your 4-year-old patients has nasal congestion
several days a week and constantly rubs her nose.
She also has a history of intermittent wheezing with
viral infections. You suspect allergic rhinitis and would
like to initiate treatment. Which of the following is the
most appropriate initial treatment?
A. Intranasal corticosteroid.
B. Intranasal decongestant.
C. Oral antihistamine.
D. Oral decongestant.
E. Oral leukotriene antagonist.
6. One of your 4-year-old patients has nasal congestion
several days a week and constantly rubs her nose.
She also has a history of intermittent wheezing with
viral infections. You suspect allergic rhinitis and would
like to initiate treatment. Which of the following is the
most appropriate initial treatment?
A. Intranasal corticosteroid.
B. Intranasal decongestant.
C. Oral antihistamine.
D. Oral decongestant.
E. Oral leukotriene antagonist.
7. You have just prescribed an intranasal corticosteroid for a
patient who has allergic rhinitis. Her mother,
however, is concerned about giving her daughter steroids
because she has heard that they are associated
with serious adverse effects. Which of the following is the
most likely adverse effect that her daughter will
experience while taking intranasal corticosteroids?
A. Epistaxis.
B. Hypertension.
C. Oral candidiasis.
D. Poor linear growth.
E. Rebound symptoms after stopping the medication.
7. You have just prescribed an intranasal corticosteroid for a
patient who has allergic rhinitis. Her mother,
however, is concerned about giving her daughter steroids
because she has heard that they are associated
with serious adverse effects. Which of the following is the
most likely adverse effect that her daughter will
experience while taking intranasal corticosteroids?
A. Epistaxis.
B. Hypertension.
C. Oral candidiasis.
D. Poor linear growth.
E. Rebound symptoms after stopping the medication.
8. The mother of a 12-month-old girl is concerned about her
daughter’s nasal congestion, which she reports has been present
since birth. She reports clear rhinorrhea daily, which always is from
the right nostril. Daily treatment with an intranasal corticosteroid has
not helped her symptoms. She received one course of amoxicillin
several months ago when she was diagnosed with sinusitis. She
occasionally had difficulty feeding as a young infant, but this has
resolved and she has grown well. Her physical examination findings
are normal, with the exception of mucoid nasal discharge from her
right naris. Which of the following is the best course of action?
A. Obtain a computed tomography scan of the nasopharynx.
B. Order a sweat test.
C. Prescribe a course of oral amoxicillin-clavulanic acid.
D. Prescribe a course of oral antihistamines.
E. Refer her for allergy testing.
8. The mother of a 12-month-old girl is concerned about her
daughter’s nasal congestion, which she reports has been present
since birth. She reports clear rhinorrhea daily, which always is from
the right nostril. Daily treatment with an intranasal corticosteroid has
not helped her symptoms. She received one course of amoxicillin
several months ago when she was diagnosed with sinusitis. She
occasionally had difficulty feeding as a young infant, but this has
resolved and she has grown well. Her physical examination findings
are normal, with the exception of mucoid nasal discharge from her
right naris. Which of the following is the best course of action?
A. Obtain a computed tomography scan of the nasopharynx.
B. Order a sweat test.
C. Prescribe a course of oral amoxicillin-clavulanic acid.
D. Prescribe a course of oral antihistamines.
E. Refer her for allergy testing.
CONTENT SPECS!!!
Allergic Rhinitis
What is the most effective drug
treatment for allergic rhinitis?
What is the most effective drug
treatment for allergic rhinitis?
• Topical Corticalsteroids
• Can also use oral and topical antihistamines
What is the relationship between
allergic rhinitis and sinuses and/or
otitis media?
What is the relationship between
allergic rhinitis and sinuses and/or
otitis media?
• Studies showing kids with allergies get more
Viral URIsmore mucus and sinus
congestionmay predispose to SINUSITIS
• AR is a known risk factor for otitis media
– 20% of kids with AR have OME
– 50% of kids with chronic OME have AR
Which form of AR is caused by indoor
allergens? (dust mites/animal dander)
Which form of AR is caused by indoor
allergens? (dust mites/animal dander)
• Persistent (Perennial)
– >4days/wk for >4wks
What are the treatments for Allergic
Rhinitis?
What are the treatments for Allergic
Rhinitis?
•
•
•
•
Allergen avoidance
Antihistamines
Intranasal Corticosteroids
Immunotherapy* (severe cases only)
Immunology
What are the clinical characteristics of
antibody deficiency syndromes after 46 months of age?
What are the clinical characteristics of
antibody deficiency syndromes after 46 months of age?
• Severe first infections and/or chronic
recurrent bacterial infections in more than
one anatomic site
What are the clinical characteristics of
cellular immunodeficiency present in
the first few months after birth?
What are the clinical characteristics of
cellular immunodeficiency present in
the first few months after birth?
• Failure to thrive
• Chronic Diarrhea
• Overwhelming infections with viral, bacterial,
and/or opportunistic infections
What is the lab evaluation for antibody
function?
What is the lab evaluation for antibody
function?
• Quantitative immunoglobulin concentrations
• Specific antibody responses to protein
(diptheria/tetanus) and polysaccharide
vaccines (pneumococcus or meningicoccus)
What is the lab evaluation for cell
mediated immunity?
What is the lab evaluation for cell
mediated immunity?
• Lymphocyte counts and Lymphocyte function
PREP
The parents of a 4-year-old boy have questions about their
son’s food allergies and what foods he will need to avoid when
he starts kindergarten next year. They were advised that he
was allergic to milk, egg, and soy products on blood testing
(serum specific IgE) performed in infancy as part of an
evaluation of atopic dermatitis. His eczema worsened when
he consumed milk, but he has never eaten egg or soy. He has
been strictly avoiding all these foods, and he outgrew his
atopic dermatitis 2 years ago. You discuss your plan to
reevaluate the status of the boy’s food allergies with his
parents.
Of the following and according to the natural history of food
allergies, the MOST appropriate response is to advise the
parents that in kindergarten their son may
A. be able to tolerate eggs but not milk and soy products
B. be able to tolerate milk and soy products but not egg products
C. be able to tolerate milk, egg, and soy products
D. need to avoid all milk, egg, and soy products
E. need to avoid egg and soy products but not milk products
A. be able to tolerate eggs but not milk and soy products
B. be able to tolerate milk and soy products but not egg products
C. be able to tolerate milk, egg, and soy products
D. need to avoid all milk, egg, and soy products
E. need to avoid egg and soy products but not milk products
A 9-year-old girl presents with symptoms of an itchy, raised rash. The
rash started 2 weeks ago, but she has had similar episodes
intermittently for the previous 4 months. The rash consists of multiple
erythematous, slightly elevated lesions ranging in size from a dime to a
golf ball (Item Q53). The lesions resolve in a few hours without
bruising or discoloration. Diphenhydramine as needed and daily
cetirizine help minimize the frequency and severity of her symptoms,
but she still gets breakthrough episodes. Her parents have not found
any association of the eruption with foods, cosmetics, or medications.
At times, the rash occurs after the girl becomes hot and sweaty. The
parents have heard that food allergies might be a trigger for their
daughter’s episodes and wonder if she should undergo testing.
Of the following, the MOST appropriate response is to
A. order allergen-specific IgE tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food
additives
B. order allergen-specific IgG4 tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food
additives
C. reassure the parents that allergy testing is not needed; an undiscovered allergy to foods or food
additives is unlikely to be the cause
D. recommend an elimination diet of home-cooked rice or oats, chicken or turkey, and vegetables for a
trial period of 2 weeks
E. refer them to an allergist for skin testing to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and
food additives
A. order allergen-specific IgE tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food
additives
B. order allergen-specific IgG4 tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food
additives
C. reassure the parents that allergy testing is not needed; an undiscovered allergy to foods or food
additives is unlikely to be the cause
D. recommend an elimination diet of home-cooked rice or oats, chicken or turkey, and vegetables for a
trial period of 2 weeks
E. refer them to an allergist for skin testing to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and
food additives
The parents of a 3-year-old boy would like him tested for
allergies. The parents report that the boy has had
worsening symptoms of itchy eyes, sneezing fits, and
nasal congestion since the family got a new dog 1 year
ago. The parents would like the boy tested to determine if
they need to give the dog away. They are reluctant to
stop the boy’s daily antihistamine and are disappointed to
learn that skin testing cannot be performed while taking
this medication. You decide to obtain blood-specific IgE
testing. However, the parents have read on the internet
that the “scratch test” is a better test.
Of the following, you are MOST likely to advise the
parents that in this situation, blood-specific IgE testing
A. comparable to skin testing
B. less expensive and better tolerated by children than skin testing
C. more accurate than skin testing
D. the only testing that can be done because he is too young for skin testing
E. a preliminary test and you will obtain skin testing to confirm the results
A. comparable to skin testing
B. less expensive and better tolerated by children than skin testing
C. more accurate than skin testing
D. the only testing that can be done because he is too young for skin testing
E. a preliminary test and you will obtain skin testing to confirm the results
The mother of a 7-month-old infant is frustrated that the
infant’s atopic dermatitis is not getting better. He is awake “all
night” scratching and is irritable and fussy. She has been giving
him diphenhydramine every 8 hours and applying
hypoallergenic moisturizer and a topical corticosteroid cream
twice a day. The infant was breastfed until 3 months ago and
then switched to a cow milk–based formula. On physical
examination, you notice that he has dry, erythematous
papules and patches, with excoriation marks on his face, neck,
antecubital fossae, popliteal fossae, and back. He has normal
growth parameters.
Of the following, the MOST appropriate next step in this
infant’s management is to recommend
A. discontinuing diphenhydramine and switching him to daily loratadine
B. eliminating cow milk, egg, soy, and wheat from his diet
C. introducing cow milk on a trial basis to see if the rash worsens
D. switching to hypoallergenic formula and a diet of only rice and chicken
E. testing for pertinent, potential food allergen triggers
A. discontinuing diphenhydramine and switching him to daily loratadine
B. eliminating cow milk, egg, soy, and wheat from his diet
C. introducing cow milk on a trial basis to see if the rash worsens
D. switching to hypoallergenic formula and a diet of only rice and chicken
E. testing for pertinent, potential food allergen triggers
A 2-year-old girl presented to the urgent care center for
rash and swelling of her lips. While visiting a neighbor,
the girl took a few bites of a peanut butter cracker and
started coughing. The mother initially thought that her
daughter had choked on the cracker but then noticed that
the girl had developed hives on her face. The mother
wiped her daughter’s face and mouth and gave her a
teaspoon of diphenhydramine. The hives began to fade,
but the girl then developed lip swelling and a raspy voice.
She became progressively irritable and now appears to be
breathing fast, although she is also crying.
Of the following, the MOST appropriate step in this girl’s
management is to administer
A. injectable corticosteroid
B. injectable epinephrine
C. nebulized albuterol
D. ranitidine and diphenhydramine
E. scheduled diphenhydramine
A. injectable corticosteroid
B. injectable epinephrine
C. nebulized albuterol
D. ranitidine and diphenhydramine
E. scheduled diphenhydramine
You are seeing a 3-year-old girl after hospital discharge.
The girl was seen in the emergency department yesterday
after she developed an erythematous, itchy, raised,
blotchy rash, marked swelling of the eyes and lips, and
raspy breathing. According to the mother, the child was
given injectable epinephrine, diphenhydramine, and
systemic corticosteroids. Altough the symptoms improved
after a couple of hours, the child was admitted overnight
for observation. The girl’s mother is shaken by this event
and would like you to determine what triggered this
reaction.
Of the following, the MOST common triggers for events
such as those experienced by the girl are
A. aeroallergens, contact allergens, latex, cleaning agents
B. foods, medications, hereditary angioedema, idiopathic triggers
C. infections (viral or bacterial), foods, medications, insect stings
D. mast cell disorders, hereditary angioedema, urticarial vasculitis
E. nonsteroidal anti-inflammatory drugs, antibiotics, narcotics, and radiocontrast
media
A. aeroallergens, contact allergens, latex, cleaning agents
B. foods, medications, hereditary angioedema, idiopathic triggers
C. infections (viral or bacterial), foods, medications, insect stings
D. mast cell disorders, hereditary angioedema, urticarial vasculitis
E. nonsteroidal anti-inflammatory drugs, antibiotics, narcotics, and radiocontrast
media
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