CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS (HPI)

EXTRA HELPFUL INFORMATION 

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 ANGIOEDEMA
 Angioedema is the swelling of the deeper layers
of the skin, caused by a build-up of fluid. The
symptoms of angioedema can affect any part of
the body, but swelling usually affects the: eyes.
lips.

PHYSICAL EXAMINATION

ATOPIC DERMATITIS
 Atopic dermatitis,
often referred to as
eczema, is a
chronic (long-
lasting) disease
that causes
inflammation,
redness, and
irritation of the skin.
It is a common
condition that
usually begins in
childhood;
however, anyone
can get the
disease at any age

Note from Doc :

 A good physical exam finding that we can find

with patient with atopic dermatitis especially with
those who had flares for weeks, months or may
URTICARIA
 Urticaria – also known as hives, weals, welts or be years, is with the presence of the Dennie –
nettle rash – is a raised, itchy rash that appears Morgan Folds (fold or line in the skin below the
on the skin. It may appear on one part of the lower eyelid.)
body or be spread across large areas. The rash is
usually very itchy and ranges in size from a few
millimetres to the size of a hand.

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 XEROSIS
 The medical term for dry skin is xerosis.
 Xerosis refers to abnormally dry skin or
membranes, such as those found in the mouth or
the conjunctiva of the eye. This picture shows a
close-up of xerotic skin.
 Note the dry and scaly appearance.
KERATOSIS PILARIS
 Also known as Chicken Skin
 Harmless skin condition
 It is a common skin condition that causes
patches of rough-feeling bumps to appear on
the skin
ALLERGIC RHINITIS / ALLERGIC RHINOCONJUNCTIVITIS
 Transverse nasal creases, which result from
frequent upward pushing of the nose, referred to
as the "allergic salute," are a classic sign of
allergic rhinitis, which may develop in children
and patients with atopic conditions.
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ALLERGIC SHINERS
 Allergic shiners are dark circles under the eyes
caused by congestion of the nose and sinuses.
 They’re usually described as dark, shadowy
pigments that resemble bruises.
 There are many possible causes of dark circles
under your eyes, but allergic shiners got their
name because allergies are best known for
causing them.
 Allergic shiners are also called allergic facies and
periorbital hyperpigmentation.
ALLERGIC RHINITIS
 Allergic rhinitis is caused by the immune system
reacting to an allergen as if it were harmful. This
results in cells releasing a number of chemicals
that cause the inside layer of your nose (the
mucous membrane) to become swollen and
excessive levels of mucus to be produced.
 Physical clues to allergic rhinitis include boggy,
pale, or “bluish” nasal turbinates, with watery
discharge on nasal speculum exam.
 Patients may also have a nasal crease on the
external nose caused by repeated rubbing or
itching (the so-called “allergic salute”).
 Patients with Allergic Rhinitis can also experience
Conjunctivitis or also known as Allergic
Rhinoconjunctivitis.
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 CHEMOSIS
 Chemosis is a sign of eye irritation.
 The outer surface of the eye (conjunctiva) may
look like a big blister.
 It can also look like it has fluid in it. When severe,
the tissue swells so much that you can't close
your eyes properly. Chemosis is often related to
allergies or an eye infection.
PALPEBRAL COBBLESTONING
 May be seen in Vernal keratoconjunctivitis
 Usually, the palpebral conjunctiva of the upper
eyelid is involved, but the bulbar conjunctiva is
sometimes affected
 In the palpebral form, square, hard, flattened,
closely packed, pale pink to grayish cobblestone
papillae are present in the upper tarsal
conjunctiva
FOOD ALLERGY / DRUG ALLERGY
MACULOPAPULAR RASHES
 A maculopapular rash is a mix of macules (flat
discolored areas of skin) and papules (small
raised bumps) that usually covers a large area of
skin. It may appear red or pink if your skin is light,
or darker than your natural tone if your skin is
dark.
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ERYTHEMATOUS PATCHES
 Erythematous Patches or Erythema Multiforme is
a skin reaction that can be triggered by an
infection or some medicines. It's usually mild and
goes away in a few weeks. There's also a rare,
severe form that can affect the mouth, genitals
and eyes and can be life-threatening. This is
known as erythema multiforme major.
FIXED DRUG ERUPTION
 Fixed drug eruption (FDE) is a well-defined,
circular, hyperpigmenting plaque that recurs as
one or a few lesions always in fixed locations
upon ingestion of a drug.
 FDE commonly occurs on the genitals, lips, trunk,
and hands.
 The diagnosis can be confirmed by
histopathologic examination of a small punch
biopsy specimen
 DRUG AVOIDANCE is the mainstay of treatment,
and antihistamines can reduce associated
pruritus
ACUTE GENERALIZED
EXANTHEMATOUS PUSTULITIS (AGEP)
 AGEP is characterized by
sudden skin eruptions that
appear on average five
days after a medication is
started. These eruptions
are pustules, i.e. small red
white or red elevations of
the skin that contain cloudy or purulent material
(pus).
 Adverese drug reactions specifically
penicillamines.
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 TOXIC EPIDERMAL NECROLYSIS (TEN)
 Toxic epidermal necrolysis (TEN) is a potentially
life-threatening dermatologic disorder
characterized by widespread erythema,
necrosis, and bullous detachment of the
epidermis and mucous membranes, resulting in
exfoliation and possible sepsis and/or death.
 Mucous membrane involvement can result in
gastrointestinal hemorrhage, respiratory failure,
ocular abnormalities, and genitourinary
complications. (Medscape)
 The Nikolsky sign, which refers to the shearing
away of normal-appearing skin at the edge of a
lesion by applying lateral pressure
 Can be mistaken by burns, but burns has
NO positive Nikolsky sign.
 Nikolsky's sign is almost always present in Stevens–
Johnson syndrome/toxic epidermal necrolysis
and staphylococcal scalded skin syndrome,
caused by the exfoliative toxin of
Staphylococcus aureus.
DIAGNOSTIC TESTING
In Vitro Test
 CBC with platelet count
o Eosinophilia ( >500 eosinophils/uL in
peripheral blood)
o >1500 without an identifiable etiology
(hypereosinophilia)
 Sputum/nasal/bronchial secretions – for
eosinophilia
 Serum IgE levels (Total and Specific)
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In Vivo Test
 Allergen skin testing (prick / puncture technique)
for IgE mediated reactions
 Intradermal technique - for IgE mediated
reactions
 Oral food challenges (GOLD STANDARD for
patients with food allergic reactions.)
 Note from Doc: “If you think that the patient has
allergic reaction or hypersensitivity reaction but
it’s NOT IgE mediated, this won’t work  “
ABSOLUTE EOSINOPHIL COUNT
Formula: WBC x Eosinophils x 1000
SKIN PRICK TESTING
 A skin prick test, also called a puncture or
scratch test, checks for immediate allergic
reactions to as many as 50 different substances
at once.
 This test is usually done to identify allergies to
pollen, mold, pet dander, dust mites and foods.
In adults, the test is usually done on the forearm
 Histamine should be positive all the time
o Because if the patient took antihistamine
it can affect the result of the patient, the
result can be False Negative.
CASES
1. 7/F, Pruritus
 Came in the clinic due to worsening pruritus
which affects her usual activities and sleep
 Hx: Noted to have dry, itchy skin on the
flexural areas of her arms and legs around 1 –
2 years ago and worsen during summer.
 Family MHx: Mom has allergic rhinitis and
bronchial asthma
 Labs: (+) Elevated total IgE
 Pertinent Physical Examination:
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 HANIFIN AND RAJKA DIAGNOSTIC CRITERIA FOR
ATOPIC DERMATITIS (AD)

Diagnosis: Atopic Dermatitis

 Chronic relapsing inflammatory skin disease

 Prevalence: 25% in children : 7% in adults (US)
 Onset: 1st year of life (60% to 85%)
 By 5 years of age (85%)
 Can present at any age

PATHOPHYSIOLOGY

Itch scratch cycle – exacerbate cellular damage and

facilitates secondary infections

1. Epidermal barrier dysfunction (reduced

FILAGGRIN production)
 Filaggrin plays an important role in the
skin's barrier function. It brings together
structural proteins in the outermost skin
cells to form tight bundles, flattening and
strengthening the cells to create a strong
barrier
2. Genetic Factors
3. Th – 2 cell skewed immune dysregulation
4. Altered skin microbiome
5. Environmental triggers of inflammation

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 SEVERITY SCORING OF ATOPIC DERMATITIS INDEX
(SCORAD) 2. BA, 7/M

 Chief complaint: Sneezing

 Hx: 2mos PTS (+) nasal congestion and
rhinorrhea associated with nasal itching and
sneezing

 Nasal congestion is more prominent at night

and would occur 4 days / week and due to
the nasal congestion would keep patient
awake from sleep.

 1mos PTC (+) persistence of symptoms with

more frequent episodes of sneezing and
would have difficulty doing school

 PMHx: (+) atopic dermatitis

 FMHx: (+) bronchial asthma and food allergy
– maternal
 Personal and Social Hx: (+) has 1 pet dog
 Pertinent PE:

Formula:
A/5 + 7B/2 + C
Legend: A –Extent; B – Intensity; C – Subjective Symptoms

 Mild eczema score - <25

 Moderate eczema score - >25 < 50
 Severe eczema score - >50

MANAGEMENT

Diagnosis: Allergic Rhinitis

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 PATHOPHYSIOLOGY DIAGNOSIS / TREATMENT

Ask the patient on how are they feeling for the past 24
hours.

 Allergic rhinitis (AR) is a symptomatic disorder of

the nose induced after exposure to allergens via
IgE-mediated hypersensitivity reactions, which
are characterized by 4 cardinal symptoms of
watery rhinorrhea, nasal obstruction, nasal
itching and sneezing.

CLINICAL MANIFESTATIONS
Nasal Symptoms Ocular Symptoms
Nasal itching Eye itching
Sneezing Red eyes
Rhinorrhea Conjuctival injections
Nasal obstruction Swollen eyes
Hyposmia

Physical Examination:
 Upward rubbing of the nose (Allergic salute)
 Horizontal skin fold over the bridge of nose (Nasal
crease)
 Dark circles under eye (Allergic shiners)
 Edematous boggy bluish nasal turbinates

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 ALLERGEN IMMUNOTHERAPHY PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS

3. 4/M, cough

 Cc: Productive cough

 Hx: 2 weeks PTC: (+) productive cough, slightly
distressing associated chest tightness
 Was given unrecalled cough medication with no
resolution of symptoms. On the interim patient
noted continuous cough and chest tightness with
associated fast breathing hence consult.

 PastMHx: (+) allergic rhinitis – triggers: house dust

mite, cockroaches
 FamilyHx: (+) atopic dermatitiss – maternal;
(+)bronchial asthma – paternal
 Environmental Hx: (+) smoker at home, pet dog
and cat, cleans house once to twice every 3
weeks with ongoing construction at home.

 Physical exam:

Diagnosis: Bronchial Asthma

 Chronic inflammatory condition of the lung

airways -> airflow obstruction, airway
hyperresponsiveness
 Cause not determined
 Combination of environmental exposures and
inherent biologic and genetic susceptibilities
indicated

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 Global Initiative for Asthma (GINA) Guidelines

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 PEDIATRICS
COMMON ALLERGIC DISEASES
Jenina Maree M. Tuozo, MD, DPPS 02/01/2023 Year 3 | Semester 1

CASE 1
12/ F, Difficulty of breathing

Chief complaint: DOB

Hx: Patient was noted to eat a cookie in a coffee shop and

after 5 mins was noted to have appearance of rashes on
face, chest and back with associated swelling of eyes and
mouth. She started to experience abdominal pain and
difficulty of breathing which opted consult at the ER.

Past MHx: (+) adverse food reaction to peanuts (+) bronchial

asthma

Family MHx: (+) adverse food reaction to ibuprofen –

maternal side

Physical examination: CLINICAL MANIFESTATIONS

DIAGNOSIS: ANAPHYLAXIS
 Serious, rapid-onset allergic reaction
 Life threatening multisystemic hypersensitivity
reaction
 Triggers: Food (Most common in children), milk, eggs,
wheat, soy, peanuts, shellfish, fish; insects; medicines,
etc.
 Age related factors: infants – unable to describe
symptoms; adolescents and young children – inc. risk
taking behavior; labor and delivery – risk from
medications; elderly- risk of fatality
 Concomitant Diseases: Asthma, atopic dermatitis,
allergic rhinitis

Note: Please refer to last page for a better view…

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 PEDIATRICS
COMMON ALLERGIC DISEASES
Jenina Maree M. Tuozo, MD, DPPS 02/05/2023 Year 3 | Semester 1

Note: Please refer to last page for a better view…

CASE 2
8/ M, RASHES

Chief complaint: Pruritus

Hx: 2 days PTC: (+) erythematous, raised wheals, pruritic

noted on abdomen and lower extremities. Even without any
medications, symptoms resolved. No other associated
symptoms were noted. However, he was recently diagnosed
with upper respiratory tract infection presenting with cough
and colds. On the interim, same rashes would come and go
on different parts of the body which prompted him to self-
medicate with cetirizine.

Past MHx: (-) asthma

Pertinent physical examination:

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 PEDIATRICS
COMMON ALLERGIC DISEASES
Jenina Maree M. Tuozo, MD, DPPS 02/05/2023 Year 3 | Semester 1

DIAGNOSIS: URTICARIA
 Affect 20%of individuals in their lives
 <6 weeks: Acute
 >6 weeks: Chronic
ANGIOEDEMA
 Involves deeper, subcutaneous tissues (eyes, lips,
tongue, genitals, dorsum of hands/ feet and GIT)
 Sometimes painful > pruritic
 Resolves w/o residual lesions
 Slower resolution (up to 3d)

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MANAGEMENTS

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 PEDIATRICS
COMMON ALLERGIC DISEASES
Jenina Maree M. Tuozo, MD, DPPS 02/05/2023 Year 3 | Semester 1

CASE 3  Cell mediated mechanisms

8 mo/ F, WHEALS

Chief complaint: Wheals

Hx: Patient has been breastfed since birth, however, since

mom would be going back to work, the patient started on
bonamil. After finishing one bottle, mom noted patient to be
irritable. Upon changing of diaper, she noted wheals all over
the back and legs of patient. This was also followed by
vomiting of approximately ½ cup of curdled milk which
prompted consult.

Past MHx: unremarkable

Family MHx: (+) atopic dermatitis, mom (+) allergic rhinitis,

dad

Pertinent physical examination:

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DIAGNOSIS: FOOD ALLERGY / ADVERSE FOOD REACTIONS

 Any untoward reaction following ingestion of a food
or food additive
 Food intolerance (lactose intolerance)
 Food allergies (adverse immunologic responses / IgE
and non-IgE mediated)
 6%: food allergic reactions in 1st 3 years of life
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 2.5% cow’s milk allergy
 1.5% egg allergy
 1% peanut allergy
Note:
Common allergens: SHELLFISH / SEAFOOD

PATHOLOGY
 IgE mediated

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 PEDIATRICS
COMMON ALLERGIC DISEASES
Jenina Maree M. Tuozo, MD, DPPS
Note: Please refer to last page for a better view…
MANAGEMENT
 Identification and elimination of foods responsible for
food hypersensitivity reactions
 Self-injectable epinephrine for IgE mediated
reactions
 Oral immunotherapy and anti-IgE treatment
(omalizumab)
 Regular ingestion of baked products with milk and
egg appears to accelerate resolution of milk and
egg allergy
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02/05/2023 Year 3 | Semester 1
FOOD ALLERGY AND VACCINES
COW’S MILK PROTEIN ALLERGY
 Hypersensitivity reaction brought on by specific
immunologic mechanisms to cow’s milk
 Within the first 6 months, before 1 year of age, often
within 1 week after the introduction of cow’s milk
proteins
 Incidence during first year of life: 2% to 7.5%. 7-9,
breast-fed infants: 0.5%
 Prevalence falls to <1% in children 6 years of age and
older
 Most common food allergy in children younger than
3 years
SYMPTOMS
 Gastrointestinal: 32 – 60%
 Skin symptoms in 5 – 90%
 Anaphylaxis in 0.8 – 9% of cases
 54% of CMPA is due to IgE-mediated reaction, 46%
non-IgE-mediated
ALLERGENS
 Casein fraction of proteins (αs1-, αs2-, β-, and k-
casein)
 80% of the total protein of cow’s milk
 Alphas1 and beta-casein make up for 70%
 Whey proteins (α-lactalbumin and β-lactoglobulin)
 Beta-lactoglobulin accounts for 50%
 CROSS-REACTIVITY
 Soy protein
 Cross-reactivity between cows, sheeps and
goats milk
 Less structural similarity with pig, horse and
donkey, camel, human milk
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 PEDIATRICS
COMMON ALLERGIC DISEASES
Jenina Maree M. Tuozo, MD, DPPS 02/05/2023 Year 3 | Semester 1

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ORAL FOOD CHALLENGE

 Benefit if positive OFC: Conclusive diagnosis of CMA
 Strict avoidance of cow’s milk, reduction of the risk of
inadvertent exposures, reduction of anxiety about
the unknown, allows accurate prescription of
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elimination diet
 Benefits of negative OFC: include expansion of the

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 PEDIATRICS
COMMON ALLERGIC DISEASES
Jenina Maree M. Tuozo, MD, DPPS 02/05/2023 Year 3 | Semester 1

diet and improvement of the patients nutrition and No other symptoms were noted
quality of life
 Infants should only be tested 2 – 3 hours after their last Past MHx: (+) allergies to amoxicillin – rashes; (+) Atopic
meal dermatitis

MANAGEMENT Family MHx: (+) atopic dermatitis – both sides

 Avoidance of cow’s milk protein in any form
 Breastfed infants: mother should eliminate all dairy Pertinent physical examination findings:
products from her own diet
 <6 months old: extensively hydrolyzed protein or
amino acid-based formula
 >6 months: soy formula could be tried particularly in
IgE-mediated cases
 Non-IgE mediated: Elimination for at least 6 months or
until 9 – 12 months
 IgE mediated: elimination until 12 – 18 months
 Goat, sheep, donkey, horse and other mammals’
milks are NOT indicated for treatment of CMPA
 Prevention of accidental exposure

FORMULA OPTIONS

Extensively hydrolyzed formulas:

 Containing only oligopeptides that have a molecular
weight which <3,000Da to which at least 90% of DIAGNOSIS: ADVERSE DRUG EVENTS/ REACTIONS
infants do not manifest any clinical symptoms in PREDICTABLE DRUG REACTIONS
controlled double-blind studies  Drug toxicity
 Mild to moderate disease  Drug interactions
 With IgE-mediated CMA at low risk of anaphylactic  Adverse effects (dose dependent)
reactions UNPREDICTABLE DRUG REACTIONS
Amino acid formula  Idiosyncratic reactions
 Provide protein only in the form of free amino acids  Allergic reactions
and no peptides  Pseudoallergic reactions
 High cost
1. Severe CMA (failure to thrive and abundant
blood in stools)
2. Multiple food allergies
3. Allergic symptoms or severe atopic eczema
when exclusively breastfed
4. Severe forms of non-IgE mediated CMA, such
as eosinophilic esophagitis, enteropathies,
and food protein-induced enterocolitis
syndrome
5. Growth faltering, and/or
6. Infants at nutritional risk with reactions to or
refusal to ingest appropriate amounts of
extensively hydrolyzed formula
 Infants with IgE-mediated CMA at high risk of
anaphylactic reactions

CASE 4
14/F, bilateral eye swelling

Chief complaint: bilateral eye swelling

Hx: Patient was apparently well until 1 hour PTC when she
experiences dysmenorrhea (currently on day 2 of menses),
with 9/10 pain scale. She self-medicated with Faspic tablet
(Ibuprofen + arginine) and was immediately noted with
angioedema with a little bit of pain on affected area.
Note: Please refer to last page for a better view…

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 PEDIATRICS
COMMON ALLERGIC DISEASES
Jenina Maree M. Tuozo, MD, DPPS 02/05/2023 Year 3 | Semester 1

Note: Please refer to last page for a better view…

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TREATMENT
 Treat the symptoms and ELIMINATE the culprit
medications
 Oral drug challenges
 Specific desensitization
 Drug dose adjustments/ dosing intervals
 NO pre-treatment with oral steroids/ antihistamines

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COMMON ALLERGIC DISEASES
Jenina Maree M. Tuozo, MD, DPPS 02/01/2023 Year 3 | Semester 1

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COMMON ALLERGIC DISEASES
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FOOD ALLERGY AND VACCINES

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