Pediatric Board Review - Allergy and Immunology Flashcards

Allergic rhinitis
Terms Definitions
True or False:
Breast feeding for the first 6 months of life reduces the risk of eczema.
False. It only delays the onset, and the risk beyond age 2 years is unchanged.
True or False:
Breast feeding or hypoallergenic formula reduce the risk of asthma, seasonal allergies and allergic gastroenteritis.
A 4yo is diagnosed with latex allergy. Which fruits should she avoid?
Papaya, avocado, banana, chestnut, passion fruit, fig, melon, mango, kiwi, pineapple, peach and tomato.
A 32yo mother of a 3yo who has multiple food allergies is pregnant again and would like to know if she should try an elimination diet to reduce the risk of her second baby having so many allergies. What do you say?
No. Elimination diets do not reduce the risk of allergies.
A 2yo presents to your office with moderate to severe atopic dermatitis The parents ask you what they can do, which foods could be triggering it. You are referring to an allergist for specific food testing, but in the meantime what should they do?
A) Begi
A 5yo presents to your office as an ED followup for asthma. His mother asks if he is at risk for anything else. How do you respond?
Any child who has one of the three below is at risk for the other two.
Allergic Rhinitis
What is the risk for eczema if one parent has it? What if both have it?
50% and 70% respectively
How do you confirim allergic rhinitis vs. a simple cold in a 10yo with runny nose, sneezing?
Allergic rhinitis will have eye symptoms (itching, swelling, tearing) and will also have eosinophils in the nose.
True or False:
Non-allerigic rhinitis with eosinophilia syndrome (NARES) presents with eosinophils on nasal smear and positive skin test and elevated serum IgE.
False. The serum IgE would not be elevated.
What is the first step in treating allergic rhinitis?
Eliminate the offending organism
What is the most effective treatment of allergic rhinitis?
What are the indications for immunotherapy for allergic rhinitis?
Child over age 5yo and persistent symptoms despite avoidance of allergen and medication.
What is the most effective class of medications for allergic rhinitis?
Nasal steroids
An 8yo child presents after a severe allergy to cat dander. Her mother is a veterinarian, but the family has taken extensive precautions short of mom switching careers. Can the child receive immunotherapy?
What are the catchy phrases for infectious rhinitis?
Young child and winter
What is the defining element of vasomotor rhinitis? What are 5 triggers?
Post-nasal drainage unrelated to specific or infectious agent.
Triggers are:
1. Emotions
2. Temperature change
3. Humidity change
4. Cold draft
5. Pollutions
What is the defining element of vasomotor rhinitis? What are 5 triggers?
Think of grandma's telling you not to go out with wet hair.
What is rhinitis medicamentosa?
Rebound reaction to adrenergic nose drops.
A 3yo is brought to your office. Her mother is concerned because the child has relentless runny nose. The child's older sister has severe spring allergies. The medical student would like to start allergy shots in her 3yo to help this child. What do you su
The child does not have pollen allergy because it requires years of exposure. Besides she is too young for allergy shots. She likely goes to preschool and has recurrent URI
What is the primary trigger of anaphylaxis in children?
A) Bee stings
B) Pollen
C) Medication
D) Food allergy
E) Pet dander
True or False:
Sunflower oil and Hot Pressed peanut oil need NOT be strictly avoided by those with peanut allergy.
True. Sunflower seeds are often processed with peanuts, so avoid those. And cold pressed peanut oil is also a problem, but well refined, hot pressed peanut oil is okay.
What are the most common food culprits in

Older kids?
Toddlers: Eggs, Milk, Wheat and Soy

Older Kids: Shellfish and peanuts
You receive a call from the school nurse who is seeing a 6yo just after lunch. The lunch was from home and prepared by her dad. The child is not feeling well and has a stomach ache but no respiratory distress or rash. The child has a known milk allergy. T
D. Abdominal pain and general discomfort could be the only signs of an anaphylactic reaction. Antihistamines may provide symptomatic relief but will never be the right answer in treatment of anaphylaxis
You receive a call from the school nurse who is seeing a 6yo just after lunch. The lunch was chili from the cafetaria. The child has a stomach ache but no respiratory distress or rash. The nurse gave mylanta but wants to know what else she should do. What
A. This child has food sensitivity likely due to either spicy foods or beans.
In addition to allergic reaction what else presents with acute eosinophilia?
Parasitic diseases
In addition to allergic reaction what else presents with acute eosinophilia?
Remember the medicine
What is the definition of chronic urticaria?
urticaria that lasts longer than 6 weeks
How do you treat chronic urticaria?
How does treatment with benadryl and prednisone prevent contrast media reaction?
Contrast media reactions are osmolality-hypertonicity reactions that trigger degranulation of mast cells and basophils with the release of mediators that then cause the reaction. Benadryl and Prednisone inhibit the response caused by the release of these mediators.
A 5yo boy has had previous severe allergic response to shrimp. He now comes in with abdominal pain and needs a CT with IV and PO contrast. What do you do?
A) Go ahead with the CT with IV and PO contrast
B) Go ahead with the CT with PO contrast only
C) Go
A. There is no association between shellfish allergy and contrast reaction.
What is the most effective preventive treatment for a child who has had a life threatening bee sting anaphylactic reaction.
Venom immunotherapy is 98% effective in prevention of future reaction.
What are 4 findings typical of ragweed reaction?
Sneezing, Wheezing, Squeezing (chest tightness), plus teary eyes
What are 4 findings typical of ragweed reaction?
R and R
What is a type I allergic reaction?
IgE mediated anaphylaxis
What is a type 2 reaction?
Mediated by antibodies
What is a type 3 reaction?
Immune complex reaction
What is a type 4 reaction?
Delayed hypersensitivity
True or False:
Antidepressants can interfere with allergy skin testing.
True. They sometimes contain antihistimines which interfere with allergy testing
True or False:
Trauma during testing may give a false positive skin test.
A 4yo visits his pediatrician and is prescribed amoxicillin for an ear infection. Two days after beginning amoxicillin, he develops a rash all over his body. His mother brings him to the ED and is concerned that this is an allergic reaction to penicillin.
B. If this were an actual allergy to amoxicillin, it would have occured within 1 hour (at most 24 hours) of giving the medication. True allergies would be IgE mediated. This child likely has a viral exanthem or a non-IgE mediated reaction.
Which is the one antibiotic that can be skin IgE tested?
What defines a positive skin test?
Local reaction within 24 hours of administering the allergen. It represents IgE response. If not within 24 hours it is not an IgE response.
A 4month old infant has just been switched from breast milk to formula. His mother brings him to the emergency room because shortly after his first bottle he developed "hives" You have done the appropriate medical management. What is your next s
A. This is a real milk allergy. This child should be closely monitored and pediatric allergist should be consulted. If it were an eczematic rash, that would be t-cell mediated milk intolerance which could be managed by switching formulas
A 4yo is brought in with itchy eyes and runny nose that began when the family started doing spring cleaning. The grandmother feels that the allergies are likely due to the new cat in the house. She would like to remove the cat. Do you agree?
No. Kids have an emotional attachment to pets, so while removing the allergen is usually the right answer, here she could be allergic to dust from the cleaning and before removing the pet she should be allergy tested.
What are 3 advantages of RAST testing over Skin testing?
1. Rast testing is in vitro, so there is no risk of anaphylaxis
2. RAST can be done even if there is not enough exposed skin to do skin testing as in severe eczema
3. RAST is not impacted by antihistamine use
What are 2 advantages of Skin testing over Rast testing?
1. It is more sensitive than RAST testing
2. It is less expensive than RAST testing
A father comes in with his 4yo daughter frustrated because she seems to either catch a cold or diarrhea every month. What do you do?
Reassure him that normal children may have one infection per month especially when in preschool or daycare.
A 4yo girl is brought in by her father as an ED followup because she seems to have recurrent urinary tract infections almost one every month. She is on the 10th percentile for height and weight and her parents are of average height. What do you do?
Pursue further investigation such as a VCUG and perhaps refer to an immunologist.
A child has recurrent pyogenic infections. What is this associated with?
Burton's B-Cell dysfunction
A child has chronic or recurrent candida infections of the nails, scalp or mouth. What is this associated with?
T cell dysfunction
A child has thrombocytopenia with petichiae and eczema? What do you suspect?
Wiskott-Aldrich syndrome
What is the underlying problem in Severe Combined Immunodeficiency?
Absence of lymphoid tissue
What are the x-ray findings of DiGeorge syndrome?
absence of thymic shadow
What is the key component in adaptive immunity?
Antigen presenting cells
What would be the expected finding on CBC with diff in a patient with T-Cell dysfunction?
Low lymphocyte count because the majority of lymphocytes are T-cells
A 4yo child presents to your office with a wobbly gait and recurrent sinus infections. You note discoloration of her conjunctiva on exam. What is your diagnosis?
Ataxia Telangectasia
True or False:
The T-cell count is often low in Bruton's Disease.
False. The T cell count is often elevated in Bruton's.
What is the other name for Bruton's disease?
X-linked agammaglobinemia
A 9month old is brought to the office with his 3rd ear infection. His mother is a pediatrician and is concerned because most kids don't get ear infections this early in life. What would be the best approach to coming up with a diagnosis?
Measure immunoglobulins. When they are all low, measure B and T cells.
What is the treatment for Bruton's disease?
What are two high risk severe complications of Bruton's disease?
Chronic pulmonary insufficiency and bronchiectasis
What are two high risk severe complications of Bruton's disease?
What is the most common primary immunodeficiency?
CVID. B cells do not become plasma cells, so no immunoglobulins and there is a T cell problem as well.
What are theo most common infections in kids with Common Variable Immunodeficiency?
Lower respiratory infection
Recurrent herpes and zoster
A an 8yo with hypothyroid disease and JRA comes in with sore throat, malaise and weight loss and diagnosed with mononucleosis
What is her most likely underlying diagnosis? What is she at risk of developing?
She is at increased risk of developing EBV related lymphoma
Why do you give kids with common variable immunodeficiency IVIG?
To prevent from bacterial infections.
True or False:
Most complement disorders are x-linked.
False. Only properdin deficiency is the only X-linked disorder. Most are autosomal recessive.
A 14yo girl has had 3 episodes for meningicocci, what is highest on your differential for underlying problems?
Complement deficiency
Describe DiGeorge's syndrome
Deletions are on the long arm of chromosome 22.
Cardiac defects, Abnormal face, Thymic hypoplasia, Cleft Palate and Hypocalcemia
A neonate has a dysmorphic face, a holosystolic murmer at the left sternal border, and presents with diarrhea and tetany. What do you see on x-ray? What would the calcium level be?
Absent thymus. low calcium. no parathyroid. This is DiGeorge syndrome.
What is the treatment of DiGeorge syndrome?
What is the general prognosis?
Thymic Transplant. Poor. They often die from sepsis.
What is X-linked Hyper IgM Syndrome?
Man who has gone hyper after losing his CD40, causing disruption of this boy.

CD40 ligand is missing, so there is disruption of B-cell differentiation.
How do kids present with X-linked hyper IgM syndrome?
Boys age 6mos - 1 year who have frequent OM and Sinupulmonary infections and diarrhea. Labs show low IgA, IgE, IgG but high IgM
An 8 month old who was not born to an HIV mother or father, is diagnosed with PCP pneumonia. What does this child have?
Hyper IgM syndrome where a T cell abnormality prevents conversion of IgM to IgG.
For which immunodefficiency is Ig replacement most appropriate?
x-linked hyper IgM syndrome.
True or False:
Over 80% of patients with Selective IgA deficiency are asymptomatic.
What is Job Syndrome?
Hyper IgE syndrome.
What are the three major characteristics of hyper IgE syndrome?
E on the nose (sinopulmonary infections)
Aside from Eosinophilia, Eczema and Sinopulmonary infections. What are 3 other frequent complications of Job's Syndrome?
Kids with Job Syndrome tend to get infections with Staph aureus and chronic thrush as well as fractures and other skeletal abnormalities.
What differentiates Job Syndrome from atopic dermatitis?
Eosinophilia, Skeletal problems and abnormal facies.
What differentiates Job's Syndrome from Wiskott Aldrich?
Wiskott Aldrich has bleeding from the thrombocytopenia
How do you treat Job's Syndrome?
Antibiotcs and steroids
What is SCID?
Severe Combined Immune Deficiency caused by abnormal B and T cells
What are the typical presentations of kids with SCID?
1. Present before age 3 months
2. Otitis
3. Thrush
4. Dermatitis
5. Diarrhea
6. FTT
True or False:
SCID may have normal B cell count
What is the diagnostic test for SCID?
Flurometric analysis of B, T, and NK cells. There will be low to no T cells.
What enzyme deficiency did the Bubble Boy have when he appeared on Seinfeld?
ADA deficiency leading to B and T cell dysfunction (SCID)
What is transient hypogammaglobinemia of infancy?
Transient decrease in IgG and IgA which presents around 6 months of age when mom's IgG is breaking down. They usually outgrow it.
What is the hallmark of transient hypogammaglobinemia of infancy?
Very low IgG in a 6-7 month old
What is the hallmark of Wiskott Aldrich?
What is the immune deficiency?
What is the cure?
Thrombocytopenia and low IgM
Bone Marrow Transplant
What is chronic granulomatous disease?
It is a phagocyte dysfunction in which phagocytes are not able to kill ingested bacteria and fungi.
What is the genetic transmission of Chronic granulomatous disease?
2/3 are x-linked and rest are autosomal recessive
Which organs are most affected in Chronic granulomatous disease?
The front line organs. Skin, GI, Spleen, Lymph, Lungs and Liver.
How do most kids with Chronic granulomatous disease present?
Before age 5 and with multiple Staph aureus abscesses or recurrent UTI with Serratia
What is the diagnostic test for Chronic granulomatous disease?
Nitrobluetetrazolium (NBT)
What is the treatment for Chronic granulomatous disease?
Aggressive antibiotics and interferon gamma
A neonate has not had separation of her umbilical cord and it is now about 4 weeks. What do you suspect?
Leukocyte adhesion deficiency.
A 4yo has recurrent perirectal abscesses. The mother is hyper about hygiene but these boils don't seem to heal despite antibiotics. What is your suspicion?
Leucocyte adhesion deficiency
What is the cure for leukocyte adhesion deficiency?
Bone Marrow Transplant
True or False:
A child who has acquired HIV from his mother may have elevated immunoglobins during his first year of life.
What is the mechanism of action of the following medications?
Zidovudine is a Nucleoside analog
Neveripine is a reverse transcriptase inhibitor
Indinavir is a protease inhibitor.
True or False:
HIV treatment usually involves 2 protease inhibitors, and 2 nucleaoside analog.
False it is 2 nucleoside analogs and one protease inhibitor
What does NBT test?
Neutrophil activity (not number). Normal is blue.
Clear is a sign of Chronic granulomatous disease
What does CH50 test?
When do you order it?
Complement disorder. Order when a patient has repeated serious bacterial infections.
What is the TB/Candida test useful for besides TB?
Any t-cell disorder such as AIDS
A child is healthy until age 6 months but then begins to recurrent ear infections and diarrhea. What is your test of choice?
A) CH50
C) Measure immunoglobulins
D) TB Skin Test
E) Rebuck Skin Window
C. This child had normal humoral system because she was relying on mom. Now mom's system has faded, so she's got a be a stand up comic on her own.
What does the Rebuck skin test measure?
The ability of cells to migrate. It is useful in diagnosing leukocyte adhesion deficiency.
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