GoChi Notes

Immuno-Allergy Part V TH2-type cytokines (IL-3, IL-5, GM-CSF)

Lecturer: Dra. Eva Dizon secreted during allergic reactions can prolong
survival of allergic effector cells by delaying
apoptosis
Allergy Remodeling

Altered state of reactivity to common Genetics of Allergy

environmental and food antigens
Skin, nose, lungs, GIT 5q23-25 Region
IgE
Hyperesponsiveness Including genes coding for TH2 cytokines (IL-3,
IL-4, IL-5, IL-9, IL-13, GM-CSF)
Inflammation IL4 – nucleotide change at position 589 of the
IL-4 promoter region is associated with the
1. Early Phase Response formation of a unique binding site for NFAT
(Nuclear factor for Activated T cells)
Typically occurs within minutes or even transcription factor
seconds of allergen exposure Increased IL-4 gene transcription
Immediate allergic reaction Higher NFAT binding affinity
Type I allergic reaction Increased IgE production
Release of histamine and mast cell proteins
through degranulation History Taking
Production of leukotrienes, prostaglandins and
cytokines by mast cells Description of all symptoms
Itching Timing and duration
Mucus production Exposure to common allergens
Vasodilation Setting
Activity
2. Late Phase Response Animal
Plants
Occur within 6-12 hours of exposure Home (flood)
24 hours Responses to previous therapies
Skin – edema, redness and induration Family history of allergic disease
Nose – sustained mucosal blockage
Lung – airway obstruction and persistent 50% - one parent
wheezing 66% - both parents are allergic

3. Chronic Allergic Disease

Aeroallergens – pollens, spores
Infants – dust mites, animal danders,
Tissue inflammation can persist for days to
fungal spores, food
years.
Repeated stimulation of allergic effector cells
such as mast cells, basophils, eosinophils and
TH2 cells

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Physical Examination Salmeterol

Anticholinergic – Ipratropium
Pulsus paradoxicus Antihistamines
Allergic shiners Theophylline
Dennies line Glucocorticoids
Allergic conjunctivitis Anti-IgE
Keratoconus Immunotherapy
Keratosis pilaris

Environmental Control of Allergen Exposure Allergic Rhinitis (AR)

Dust Mites An inflammatory disorder of the nasal mucosa

Characterized by nasal congestion, rhinorrhea,
Encase bedding in airtight, allergen- itching
impermeable covers. Often accompanied by sneezing and
Wash bedding weekly in water at temperatures conjunctival irritation
>130ºF. Increase in risk for asthma at an older age
Remove wall to wall carpeting.
Replace curtains with blinds. Sinusitis
Remove upholstered furniture. Conjunctivitis
Reduce indoor humidity. Otitis media
Serous otitis
Animal Danders Hypertrophic tonsils and adenoids
eczema
Avoid furred pets.
Keep animals out of patient’s bedroom.
Symptoms may appear in infancy.
Cockroaches Diagnosis established by the time the child
reaches 6 years old.
Control available food and water sources. Prevalence peaks late in childhood.
Keep kitchen and bathroom surfaces dry and
free of standing water. Risk Factors:
Seal cracks in walls.
Use professionally extermination services. Family history of atopy
Safe pesticide should be used in baits. Serum IgE higher than 100 IU/ml
before age 6 yrs
Treatment Early introduction of foods or
formula during infancy
Alpha-adrenergic – nasal decongestant Mother who smokes especially
Beta-adrenergic – short acting (Salbutamol) before the children are 1 yr old
Heavy exposure to indoor allergens
Non-breastfeeding babies
Caesarian section

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Risk Factors:
Occurrence of 3 or more episodes
of rhinorrhea in the first year of life
is associated with allergic rhinitis at
age 7 yrs.
2 Classifications:
Seasonal (SAR) intermittent – outdoors
Perennial (PAR) persistent rhinitis -
indoors
Physical Signs of Allergic Rhinitis in Children
Allergic Salute – frequent upward rubbing of
nose with the palm of the hand to reduce itching
and open the nasal passage
Allergic shiners – darkening of the lower
eyelids as a result of suborbital edema
Allergic crease – transverse skin line above
the tip and below the bridge of the nose caused
by continuous rubbing
Dennie-Morgan lines – radiating lines in the
lower orbitopalpebral grooves that extend from
the inner corner of the eye with a downward
slant and an upward swing especially in
children with eczema
Bunny or rabbit nose – frequent wrinkling of
the nose
Injected eyes – result of allergic conjunctivitis
Cobblestone appearance of the pharynx –
sign of hypertrophied lymphoid follicles or the
pharyngeal wall caused by chronic mouth
breathing
High arched, V-shaped palate – sign of a
chronic mouth breather from prolonged nasal
congestion
Geographic tongue – patchy or rugged
appearance of the tongue, may be associated
with chronic mouth breathing
Dental malocclusions and overbite –
changes to dental structure from powerful thrust
GoChi Notes
of tongue on weakened maxillary incisors as a
result of venous stasis in the chronically
inflamed nasal mucosa
Allergy:
Intermittent - <4 days per week or < 4
weeks
Persistent - >4 days per week and >4
weeks
Mild – normal sleep, no impairment of
daily activities, sports and leisure,
normal work and school, no
troublesome symptoms
Moderate – severe (one or more items) –
abnormal sleep, impairment of daily
activities, sports and leisure, abnormal
work and school, troublesome
symptoms
Diagnosis
Skin test
Serum IgE level
Nasal smear – eosinophil
Cetirizine
6-12 months – 2.5 mg qd
1-2 yrs – 2.5 mg qd, dosage may be
increased to 2.5 mg bid
2-5 yrs – 2.5 mg/day, dosage may be
increased to a maximum of 5 mg/day
given either as a single dose or divided
into 2 doses
>6 yrs – 5-10 mg/day as a single dose or
divided into 2 doses
Levocetirizine
6-11 yrs – 2.5 mg PO once daily
>12 yrs – 5 mg PO once daily
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 GoChi Notes

Loratidine Pathophysiology

2-5 yrs – 5 mg qd Innate and adaptive immune development

>6 yrs – 10 mg qd (atopy)

Lower airway injury

Fexofenadine
Respiratory viral infections
6-11 yrs – 30 mg PO bid Aeroallergens
>12 yrs – 60 mg bid or 160 mg PO qd ETS
Pollutants
Toxicants
Desloratadine
Aberrant repair
6-11 months – 1 mg qd
1-5 yrs – 1.25 mg qd Persistent inflammation
6-11 yrs – 2.5 mg qd AHR
>12 yrs – 5 mg qd Remodeling
Airway growth and differentiation

Childhood Asthma Genetics

Asthma – a heterogenous disease IL4 gene cluster on chromosome 5

characterized by chronic airway inflammation ADAM 33
Gene for Prostanoid DP receptor
Environment Risks Genes on chromosome 5 q31
RSV, rhinovirus, influenza, parainfluenza,
Allergens human metapneumovirus, adenovirus
Infections
Microbes Early Childhood Risk factors for Persistent
Pollutants Asthma
Stress
1. Parenteral Asthma
Biological and Genetic Risks 2. Allergy

Immune Atopic dermatitis

Lung Allergic rhinitis
Repair Food allergy
Inhalant allergen sensitization
Other factors Food allergen sensitization

Age 3. Severe lower respiratory tract infection

Pneumonia
Bronchiolitis requiring hospitalization
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4. Wheezing apart from colds Bronchodilator Response to inhaled beta-

5. Male gender agonist
6. Environmental tobacco smoke exposure
7. Possible use of Acetaminophen Improvement in FEV1 greater than or equal to
(Paracetamol) 12% and greater than or equal to 200 ml
8. Exposure to chlorinated swimming pools
9. Reduced lung function at birth Exercise Challenge

2 Main Types of Childhood Asthma Worsening of FEV1 greater than or equal to

1. Recurrent wheezing in early childhood
Primarily triggered by common viral infections
of the respiratory tract
2. Chronic Asthma associated with allergy that
persists into later childhood and often
adulthood
3. 3rd type of childhood asthma typically
emerges in females who experience obesity and
early onset puberty (by 11 yrs of age)
15%
Main criteria consistent with asthma:
Daily peak flow or FEV1 monitoring: day to
day and/or Am to PM variation greater than
or equal to 20%
FEV1 – forced expiratory volume in 1 sec
FVC – forced vital capcity
Diagnosis

Clinical Physical Differential Spirometry

Manifestation Examination Diagnosis
Bronchoprovocation challenge
Dry cough Normal Chronic upper Exercise induced
Expiratory Expiratory airway cough Peak expiratory flow
wheezing wheezing syndrome
Nocturnal Rales Inhaled foreign
Inhaled nitric oxide measurement
cough Rhonchi body
Chest tightness Retractions Bronchiectasis
with pain Decreased Pulmonary
Fatigue breath dyskinesia
Relieved by sounds BPD
bronchodilators CF
Expiratory CHD
airflow TB
limitation

Lung Function Abnormalities in Asthma

Spirometry

Airflow limitation

Low FEV1 (relative to percentage of predicted

norms)
FEV1/FVC ratio <0.80\

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