Allergic Rhinitis
o
Seasonal
 Aka hay fever
 Develop mannerisms
 Nose wrinkling
 Very itchy
 Only develop during certain seasons
 Pollens - most common allergens
 In the Philippines - season is end of Oct to February
 Bronchial asthma is peak during these months
 Molds, fungi - during autumn and winter
o
Perineal
 Chronic allergic
 Have it all thru the year
 House dust - most common
 Studies made
 Considered most allergenic allergen
 Compose of so many substances
 Secondary to house dust mite
 Waste product of the mite (dead cells)
 In the house, the dead mosquitoes, roaches - their
debris becomes the house dust
 Why very allergenic - dead debris of insects
 Develop polyps
 Nasal polyps common with pt's with chronic allergic
rhinitis
 Allergic siners
 Skin around the eyes (eyebags), have a baggy
appearance with dark lines
 Develop lacrimation from watery renunia
o
Symptoms
 Watery renunia
 Sneezing episodes
 Usually during the morning
 After which develop wateria renuria
 Itchy
 Mannerisms to get rid of itchiness
 No fever generally
 May get secondarily infected
 Develop
 If do physical exam, since it's chronic
 The mucosa is thickened
 Instead of red/congested, it's pale or gray
looking, boggy
 Example - allergy on the skin, thickening
o
Diagnosis
 Perform smear of nasal secretions
 See lots of eosinophilia
o
Treatment
 Use low dose inhaled steroids (steroid sprays)
o
Differential Diagnosis


Infective rhinitis - secondary to infection
 Viral
 Bacterial
 Becomes purulent - have manifestations of fever,
malay, etc
Vasomotor rhinitis - more of a physical allergy wherein you
develop manifestations of rhinitis with changes in the weather
 In air conditioned room, you go out. Very hot out --develop clogging of the nose
Bronchial Asthma
o Causes
 Inhalant allergens and oral ingestants can provoke attack
 Physical - exercise induced asthma
 Emotions - laughing
o Symptoms
 Develops bronchospasms
 Bronchiole edema
 Hypersecretion
o
Imagine the lumen of bronchus; in bronchial asthma, there are smooth
muscles around bronchus; it will try to constrict it
(bronchoconstriction); have edema of the mucosa - it will become
edematous; then you'll have secretion; from there you understand
why pts develop dyspnea; in asthma, what's more difficult is
expiratory phase
 In inspiration, there's expansion of the chest --expand diameter
 With expiration, you try to expel CO2 - more difficult
 Why you retain the gas inside
 With chronicity --increase in ap diameter --develop
barrel chest
 If you have a tube, and air passes thru it, usually no sound if
air goes in freely
 But if you decrease diameter of the tube, you'll hear a
high pitch sound
 Hence you develop wheezes --- hard to whistle
 Since there's also secretions, air will not travel freely but will
weave in and around the secretions
 You hear your rhonchi or sonorus and civilant trials
o
Treatment
 Give bronchodilator; steroids - anti-inflammatory - to decrease
the edema
 Since secretions, give expectorants
 All these are symptomatic treatments


 Just treating the acute attack
 Not treating/curing bronchial asthma -- there is no cure
You just treat the attack
Pt will be exposed to allergen again even after the treatment
o
Desensitization procedure as discussed before
 But new allergies may develop
o
Very young and very old patients are affected
 Children - once over 6 years old, the bronchial asthma attacks
stop for a long time; but not gone/not cured; allergic condition
is in you -- is in your genes
 Once you get older -- the attack will return
 In those who have very strong tendency to allergy
 Chronic bronchial asthma
 Attacks every so often
Other Allergic Conditions
o
Anaphylactic shock
 Usually secondary to something that's given parenterally (IV,
sub cutaneous)
 Some say that it can even occur after an oral dose
 Esp if pt is very sensitive to allergen
 But usually parenteral
 You develop laryngeal edema
 Difficulty in breathing (asphyxia)
 Secondary from hypoxia
 Develop also hypotension
 Motor collapse
 Why you develop anaphyl shock
 Should be the second or nth dose
 Should be a sensitizing dose
 Shouldn't be first dose of allergen
 Don't develop reaction to first
 Only the 2nd or nth time of exposure
 Example
 Nurse in the ICU who is heart disease pt; given penicillin
every 28 days; after so many years (6-8 years), he
developed anaphylactic shock
 Rare
 Usually the 2nd exposure

Bp < 60, cold sweats

Treatment
 Give epinephrine (adrenalin) at (1:1000 concentration)
 0.2 - 0.5 ml
 Depends on degree
 Can give IM, IV, sub cutaneous


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Other



IM is faster; there are more blood
vessels in the muscles than the
subcutaneous tissues
 In pts with asthma, the bronchodilator
(terbutylin) is given subcutaneously; it will
take about 2-3 minutes before you see an
effect
 But in IM, within 1 minute you'll
feel effect
If already an IV line there already, give it if pt
has a pulse
 If pt in arrest (no pulse), IV ineffective circulation stopped, so what you gave
won't circulate
Give it every 10-15 minutes depending on degree
of the shock
 If you gave it once, pt reacts, then stop --once is enough
 If ana shock is secondary to snake bite,
still parenteral (bee stings), you can place
a tourniquet above the site of the injection
of the allergen
 If it's a snake bite or bee sting, you can
inject your adrenaline around the bite
(around site of sting)
drugs you can give once you gave epinephrine
Antihistamines
If secretions, give steroids
The medical bag always contains syringe and
ampere of your adrenaline
 Atropine and steroids included
Serum Sickness
o In DeMesa's 26 years of practice, he hasn't seen case of serum
sickness
o Secondary to an injection of a serum
 Anti--serum; before, most of your immunoglobs comes from
horse serum or pork; serums came from animals before
Insulin - now we have human insulin
 Before only had pork insulin (from pigs)
Antitetanus serum (ATS)
 Very popular
 Given and there's an incubation
 Don't develop reaction right away
 Example
 Given an injection; you don't have strong allergic
tendency to that serum; may develop an urtikaria ---so
you take antihistamine
 That's not serum sickness
 So test first
Incubation period

o
o
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
o
o
7-12 days before you develop allergic illness
To those with strong allergic tendency, may develop earlier but
still an incubation period

Manifestations
 Rash - urtikaria, morbiliform..etc
 Fever
 Body malay
 Joint pain
 Edema
 Organomegaly
Self-limiting
 It will resolve by itself in 2-4 weeks time
 Why it's difficult to make diagnosis
 Considered strongly if there's a history of injection of
serum
GIT/Food Allergy
o In most instances, usually not secondary to food itself
 It's secondary to something added to food
 Mostly colorings --FND yellow
 Any dye
 Colored drinks example - Tang (orange drink), Kool Aid,
gatorade
 Lots of dye added
 Gatorade is water and electrolytes
 Not allergic to that but to the additives
 Fish
 If smoked fish, determine what they added to it that
made you sick
o Urtikaria rash, ab cramps, vomiting, diarrhea
o
Generally, cow's milk allergy
 Allergic to cow milk proteins
 Protein enters intestinal mucosa and sensitizes the pts
 Once sensitized, the second dose of milk --develops
reaction -- cramps, rashes, diarrhea
Drug Allergy
o Differentiated from drug intolerance
o Drug sensitization
 You develop sensitization (allergy) to albutimol, develop
urtikarial arrest
 If you're also sensitive to albutimol, that person may develop
diarrhea or purfura simplex
 The next guy may develop a steron johnson syndrome
 In drug allergy, you develop manifestations regardless of the
drug
 Individualized
 One may develop rash, one may develop attack
o Drug intolerance
 You develop an exaggerated pharma effect of drug

Example - you're intolerant to salbutimol; even with small dose
of salbutimol, you develop tachycardia (palpitation)
 That's the effect of the drug
 You're not allergic to drug, but are intolerant to it
 Some aren't intolerant to the drug, but others are
 Develop same manifestations with the same drug
 Both pts will develop the tachycardia if both are
intolerant
Shifting Exam on Tues Aug 1
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Exam is true or false and matching
30 questions x 3 = 90
 You get 10 points