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Allergies

Allergy
*Inappropriate and often harmful response of the immune system to normally
harmless substances. In this case the substance is called an allergen.

Allergic Reaction
o Occurs when the body is invaded by an antigen.
o Antigens are usually proteins.
o The body thinks that the antigen is a foreign invader and sends
lymphocytes to the rescue, when they respond then antibodies are
produced to interact with (get rid of) the antigen and protect the
body from the foreign “invader”.
o Macrophages take antigens to T cells.
o These antibodies are then called immunoglobulins.

Classes of Immunoglobulins
o Include IgA, IgE, IgD, IgG, and IgM
o They are found in lymph nodes, tonsils, appendix, Peyer’s patches
of intestinal tract, and blood and lymph circulation.
o Each type has its’ own functions.
o IgE is the one we will be talking about for this class.
o IgE is located in the respiratory tract and intestinal mucosa.
o IgE bind together with that allergen and they produce Mast cells
•These mast cells are also known as basophils. They release chemical
mediators.
•With the IgE immunoglobulin in the allergic reaction there is going to be an
increase in eosinophils.
•When histamine comes out, it causes vasodilatation. So we are going to take
antihistamines. We do not want to give Benadryl to someone with glaucoma
unless it is an emergency.
•Histamine is released and you give an antihistamine. Any time that histamine is
released with an allergic reaction is called Histamine 1 (H1), so you give an H1
Blocker. There are also H2 Blockers (Tagamet, Zantac).
•Leukotrienes cause bronchospasms. Bronchospasms provide airway problems.
Zyflo, Singulair – block the synthysis of the leukotrienes. So if you don’t have
leukotrienes that are being produced and letting loose, that means that you are
going to prevent some of the bronchospasms and this is why they give these
for asthma. If you have severe allergies, you are probably also going to be on
Singulair.

Bronchospasms – airway
Bronchial edema - airway
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Atophy
*Refers to allergic reactions characterized by the action of IgE antibodies and a
genetic predisposition to allergic reactions

Hypersensitivity Reaction
*An abnormal heightened reaction to any type of stimuli.
*Usually does not occur with first exposure. The body is still happy with it. But
the second exposure may not cause a reaction but the body is not liking it and
will have a reaction the next time it is exposed to it. So you develop the
allergy.
*Let’s go back to penicillin. You always give the penicillin shot in the clinic and
you have the patient wait for an hour or so to make sure that they do not have
a reaction. Sometimes this will be the first time that they have had a penicillin
shot and they have a bad reaction. How can this be if they never have had
penicillin before? More than likely the mother or father is allergic to penicillin.
The other thing is that they might have had a drug that was of a similar
chemical makeup to penicillin. This is why there is such a strong cross
reaction between like your Ancef, Rocephin, Ceflaxin.
*Four types of hypersensitivity reactions
i.Anaphylactic (Type I) Hypersensitivity – this is
based on IgE mediators
ii.Cytotoxic (Type II) Hypersensitivity
iii.Immune Complex (Type III) Hypersensitivity
iv.Delayed-Type (Type IV) Hypersensitivity – may
take some time – may come in contact today, but
will not see signs and symptoms for a couple of
days (poison ivy)

Anaphylactic (Type I) Hypersensitivity

*Immediate reaction beginning within minutes of exposure to an antigen.
*May be local or systemic response.
*Mediated by IgE antibodies.
*Requires previous exposure to the antigen.
*Characterized by vasodilatation (capillaries become more permeable, you can
have any of those inflammatory responses)

Delayed-Type (Type IV ) Hypersensitivity

*Also known as cellular hypersensitivity.
*Occurs 24-72 hours after exposure to the allergen.
*Mediated by sensitized T cells and macrophages.
*Examples; Contact dermatitis, reaction to PPD (TB skin test), Poison Ivy
*With the TB skin test, if you have a positive reading – it is because your body
has been exposed to it and has developed antibodies against it. That is why if
you have one positive test, it will always be positive after that because you
have these antibodies in your body.
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Diagnostic Tests for allergies

*CBC - eosinophils
*Serum IgE levels – elevated because of the IgE mediated response
*Skin tests – when giving these tests you need to have epinephrine and a crash
cart available because of a potential anaphylactic reaction to the proteins they
are putting into the skin.
*Scratch
*Prick
*Intradermal
*RAST test – will draw blood – put it in a test tube with the different proteins and
see what happens. It is expensive, but you do not have the risk of an allergic
reaction.

Anaphylaxis
o Clinical response to an (Type I hypersensitivity reaction, IgE
mediated) immunologic reaction between a specific antigen and an
antibody.
o Triggered by exposure via inhalation, injection, ingestion, or skin
contact.
o Life threatening.
o Happens within seconds to minutes from exposure to antigen.
o The more allergic you are to the antigen, the more rapid the
reaction occurs.

Anaphylactic Reactions are Characterized as:

o Mild
*Peripheral tingling, fullness in mouth and throat, nasal congestion, sneezing,
tearing
o Moderate (becoming more systemic)
*Flushing, warmth, anxiety, bronchospasm, edema of airways, cough,
wheezing, and itching is added
o Severe (really fast, symptoms get worse)
*Same symptoms as moderate but abrupt onset, can have abdominal
cramping, vomiting and diarrhea and advance to cardiac arrest
*Get away from the antigen – check the airway, breathing, etc.
*Remember when someone has major reaction to something and you think
that they are o.k. – several hours later they may start with these symptoms
again. That is why when someone goes into severe anaphylactic shock
they will usually keep them in the ER for 24 hours to monitor them.

Anaphylactic Reactions are Characterized as:

o Local
*S/S appear at site of allergen –antibody interaction (like you breathe in
whatever you are allergic to and you have a nasal reaction or maybe you
eat the allergen and you have a GI reaction).
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*Includes hay fever, hives, allergic gastroenteritis

o Systemic
*When things get systemic you get peripheral vasodilatation, bronchospasms,
laryngeal edema, dyspnea, cyanosis, respiratory, skin and GI systems are
involved
*You have signs and symptoms away from the site of the allergen. When
things get systemic, they progress rapidly and they can become severe.
*Life threatening

Anaphylaxis Treatment
*#1 treatment is prevention – limit contact with the allergen.
*Close monitoring/assessment of CV and Respiratory status
*100% O2
*Epinephrine 1:1000 SC and /or IV
*Antihistamines and corticosteroids (probably going to get some Solumedrol by
IV, probably going to get some IV pain med or Zantac)
*Volume Expanders
*If your pressure starts losing you are going to be on your Vasopressors to
maintain your pressure.
*Aminophylline
*IV Glucagon
*Trach or intubation may be necessary if it is really bad, may keep on the
ventilator for up to 24 hrs.
*Once anaphylaxis starts to respond, it usually responds very rapidly.

Teach
*Avoidance of allergens
*Carry Epi Pen (0.3 mg adults and 0.15 for children).
*Inject Epi –Pen at mid part of outer thigh
*Medic Alert bracelet
*Healthcare providers must take careful histories and be alert to possibility of
allergy at all times.

Anaphylactoid (Anaphylaxis –Like) Reaction

o Closely related to anaphylaxis When you look at the person, you
do not know which it is.
o Does not involve IgE antibodies or allergens
o May occur with medications, food, or exercise
o May be local or systemic
o May be mild, moderate or severe
o Rarely fatal
o Should NOT be used as a term for mild anaphylaxis
o Treated same as anaphylaxis

If you have allergies, they are going to do the allergy testing to see what you are
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allergic to, if they are severe enough, they are going to get an allergy shot (the
idea with the shot is that you get very small amounts & they will slowly increase
the amount so that you body gets to the point where it is like crying wolf; it
doesn’t react as bad – desensitization). When giving allergy shots, you better
have epinephrine and a crash cart because you are actually injecting into
someone something that you know they are allergic to. They will start of with a
very small dose (1:1,000,000 or a 1:100,000 concentration).

Allergic Rhinitis
*Inflammation of nasal mucosa
*Most common form of respiratory allergy mediated by Type I immediate
reaction.
*Caused by air borne pollens or molds that are ingested or inhaled so it tends to
be seasonal.
*Nasal stuffiness, discharge, sneezing, headache, nasal itching
*Histamine is the major mediator for this.

Allergic Rhinitis Management

*Diagnosis is based on history, PE, and diagnostic test results. If having stopped
up nose or runny nose and you look up inside the nose, the mucous
membranes are pale. If it were a cold, the membranes would be red. This is
one way that you can tell.
*These are the people that use the nose sprays. Nose sprays give you rebound
effects and they are addictive. The more you use, the more you have to use.
They help briefly, but then you get worse infection.
*Goal is to provide relief of symptoms

Treatment may include

Pharmacological therapy – decongestants (Pseudofed) – be careful with
this because it will raise the blood pressure, Antihistamines, H1 Blockers,
Allegra is commonly used.
Adrenergic agents – these are your nasal decongestants. Be careful there
are CVS and CNS problems that go along with these
Avoidance therapy (keep away from smoke)
Mast cell stabilizers – (Cromolyn) – only good for allergic rhinitis –
Cromolyn is not going to help if you have a runny, stopped up nose from a
cold.
Immunotherapy

Contact Dermatitis
*Delayed Hypersensitivity reaction – (Type IV reaction) – delayed 24 to 72 hours
*S/S - Itching, burning, erythema, skin lesions, peeling’
*Patch test is used to diagnose – they get what they think that you are allergic to
put it under you skin and put an occlusive dressing over it and leave it for 72
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hours to see if it is going to turn red or burn.

*Treated with antihistamines, wash after exposure to allergen with soap and
water, topical corticosteroids
*If you have poison ivy and you have blisters. You will not spread the infection
by scratching it or by touching someone else. If someone else gets it, it is
because they were also exposed to poison ivy. Poison ivy is going to break
out where it is going to break out. It seems like it is spreading, but it is actually
slow in forming and it just spreads out as it is forming. Touching the allergen
itself is what gives you poison ivy.

Latex Allergy
*Allergic reaction to natural rubber proteins
*Be aware of high risk populations – (spinal bifida, anybody that has had frequent
surgeries)
*Cross reactions seen with kiwis, bananas, avocadoes
*S/S may include contact dermatitis with delayed hypersensitivity reactions, or
angioedema, laryngeal edema, hypotension, cardiac arrest if Type I reaction.