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Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
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Topic urticaria, angioedema and anaphylaxis final

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  • 1. URTICARIA, ANGIOEDEMA นสพ.อาทิ ต ย์ เชยคาดี AND ANAPHYLAXIS
  • 2. URTICARIADefinition Urtica in Latin is Nettle rash Urticaria (or hives)  irregularly shaped wheal with a blanched center surrounded by a red flare  itchy rash consisting of a raised  Rapid disappear to normal skin in 1-24 hr.  But can appear in other area
  • 3. URTICARIA
  • 4. URTICARIAClassification Spontaneous urticaria Acute Urticaria  Episodes of hives that continue for <6 wk Chronic Urticaria  persist for >6 wk  Chronic continuous urticaria  Chronic recurrent urticaria
  • 5. URTICARIAClassification  Physical urticaria  Cold contact urticaria  Delayed pressure urticaria  Heat contact urticaria  Solar urticaria  Urticaria factitia/dermographic urticaria  Vibratory urticaria/angioedema  Aquagenic urticaria  Cholinergic urticaria  Contact urticaria  Exercise-induced urticaria
  • 6. ETIOLOGY OF ACUTE URTICARIA Foods Egg, milk, wheat, peanuts Medications Suspect all medications Insect stings Hymenoptera (honeybee, yellow jacket, hornets, wasp, fire ants), biting insects ( papular urticaria) Infections Contact allergy Latex, pollen, animal saliva, nettle plants, caterpillars Transfusion reactions Blood, blood products, or IV immunoglobulin administration Idiopathic EBV, Epstein-Barr virus.
  • 7. ETIOLOGY OF CHRONIC URTICARIA Idiopathic 75–90% Rheumatologic  Systemic lupus erythematosus  Juvenile rheumatoid arthritis Endocrine Hyperthyroidism  Hypothyroidism Neoplastic Lymphoma  Mastocytosis  Leukemia Angioedema Hereditary angioedema  Acquired angioedema  Angiotensin-converting enzyme inhibitors
  • 8. URTICARIA - MECHANISMSImmunologic IgE-mediated – histamine, PAF, PGD 2, LTC, LTD  Foods/food additives  Medications  Hymenoptera venom Complement system activation  Blood/blood products Neuropeptides  Substance-P, Somatostatin, VIP Cytokines
  • 9. MECHANISMS OF URTICARIANon-Immunologic Direct mast cell activation  Radio contrast dye, opiates, polymyxin Modulation of the mast cell responsiveness  Arachidonic acid metabolism (NSAIDs, Aspirin) Miscellaneous  Physical, Cold, Pressure
  • 10. DIFFERENTIAL DIAGNOSIS OF URTICARIA Urticaria pigmentosa Urticaria Vasculitis Erythema multiforme Insect bite reaction = papular urticaria Collagen vascular Immunobullous disease  Bullous pemphigoid Annular erythema  Erythema marginatum  Pityriasis Rosea  Guttate psoriasis  Erythema annulare centrifugum  Erythema chronicum migrans
  • 11. DIFFERENTIAL DIAGNOSIS OF URTICARIA Juvenile rheumatoid arthritis Kawasaki disease Viral examthems Acute febrile neutrophilic dermatosis (Sweet’s syndrome) Scabies Parasite  S.stercoralis  larva currens
  • 12. Urticaria pigmentosa Urticaria Vasculitis
  • 13. Erythema multiforme Sweet’s syndrome
  • 14. Erythema annulare centrifugum larva currens
  • 15. DIAGNOSIS
  • 16. ANGIOEDEMADefinition Angioedema is the swelling of deep dermis, subcutaneous, or submucosal tissue due to vascular leakage Pain > itchy Often at Mucous membrane Recovery slower than wheal Duration 72 hr.
  • 17. ANGIOEDEMA
  • 18. ANGIOEDEMA Hereditary  Type I  Type II  Hereditary angioedema with normal C1 INH in woman Acquired  Allergic : food, drug, insect venoms, radiocontrast media etc.  Idiopathic angioedema  Drug : NSAID induced  Angioedema associated with idiopathic or autoimmune urticaria  Angioedema associated with enzyme-inhibitor-induced  Angioedema associated with eosinophilia  Angioedema associated with physical urticaria and with cholinergic urticaria
  • 19. ANGIOEDEMA Acquired  Angioedema associated with allergic contact urticaria  Angioedema associated with urticarial vasculitis  Angioedema associated with infection and infestation  Acquired C1 INH deficiency
  • 20. ANGIOEDEMA Normal or elevated serum complement levels  IgE-mediated (atopic, specific antigen, exercise)  Induced by physical agents  Drug : Aspirin, NSAID, contrast media, opiates, polyanionic antibiotic Low serum complement levels  Low C1 INH  Genetic (Hereditary C1 INH deficiency; HAE)  C1 INH deficiency type I and II  Acquired (Acquired C1 INH deficiency; AAE)  Lyphoproliferative disorders  Anti-C1 INH antibodies  Normal C1 INH  Serum sickness, blood product reaction  Necrotizing vasculitis  Dyes : contrast media  Idiosyncratic
  • 21. HEREDITARY ANGIOEDEMA Autosomal dominant with incomplete penetrance.  Spontaneous mutations in 50%  Diminished C4 between attacks  Very low C4 during attacks HAE I  Low levels of C1 esterase inhibitor HAE II  Dysfunctional C1 INH HAE III (estrogen-dependent angioedema)  Normal C1 INH amount and function  Normal complement levels
  • 22. DIFFERENTIAL DIAGNOSIS OF ANGIOEDEMACHFLymphedemaThrombophlebitisErysipelasCellulitisChild abuseNephrotic syndrome
  • 23. DIFFERENTIAL DIAGNOSIS OF ANGIOEDEMASuperior vena cava syndromeMyxedema from congenital hypothyroidismDermatomyositisSclerodermaParasite  Trichinella spiralisAllergic contact dermatitisCrohn’s diseaseMelkersson-Rosenthal syndromeCheilitis granulomatosa
  • 24. ThrombophlebitisCellulitis
  • 25. DIAGNOSIS OF URTICARIA/ANGIOEDEMAHistory  Time of onset of disease  Frequency and Duration of healing  Size, shape, area and distribution  Urticaria and angioedema  Pruritus or pain  Family history (atopy)  Present illness and past history about allergy  Physical stimulation or exercise
  • 26. DIAGNOSIS OF URTICARIA/ANGIOEDEMAHistory  Drug used history  Food  Smoking  Occupation  Relati onship to the menstrua l cycle  Travel  Surgical implantations  Insect bite  Stress  Response to treatment
  • 27. Urticaria/angioedema superficial deep> 24 hr. < 24 hr. + Urticaria - Urticaria Biopsy Urticaria+angioedema Unknown /phatology cause < 6 WK > 6 WK Vasculitis Abnormal Pressure Drug C1INH test + Yes No History/ Demographism test Delayed HAE AAE Urticaria pressure Vasculitis urticaria Acute urticaria Work up / Physical / Cholinergic Chronic urticaria autoimmune urticaria
  • 28. MANAGEMENTIdentification and elimination of the underlying cause and/or triggerSymptomatic therapy  Drug  Cold pack  Avoid drug is trigger urticaria (NSAID, morphine, ACE inhibitor, ingredient  alcohol )
  • 29. MANAGEMENT First-line drug therapies  Antihistamine  H1 –antihistamine first generation  Chlopheniramine  Diphenhydramine  Hydroxyzine  H1 –antihistamine second generation  Cetirizine  Desloratadine  Fexofenadine  Ketotifen  Loratadine  Levocetirizine
  • 30. MANAGEMENTSecond-line drug therapies  H2 –antihistamine  Cimetidine  Ranitidine Tricyclic antidepressant  Doxepin Corticosteroids Leukotriene receptor antagonist  Montelukast
  • 31. MANAGEMENTThird-line therapies Cyclosporine 2.5-5mg/kg/day Intravenous immnuoglobulin Immunosuppressive drugs  methotrexate
  • 32. Acute urticaria • History talking • Infection, drug, food, insect, physical • Physical examination • Severity • LAB investigation • Eliminate underlying cause Not severe Severe Epinephine inj,- H1 antagonist Anaphylaxis ? chlorpheniramine inj, Admit- Soothing lotion dexamethasone inj
  • 33. ผู้ป่วยมีภาวะ Anxiety หรื อผื่นเห่อช่วงกลางคืน ใช่ ไม่ใช่Sedating H1-antihistamine Non-sedating H1- antihistamine มีอาการมาก มี Angioedema ใช่ ไม่ใช่เพิ่ม prednisolone 25mg/day ให้ antihistamine ต่อ แล้ วหยุดยาใน 1-2 สัปดาห์ ยังควบคุมไม่ได้ หมด
  • 34. ยังควบคุมโรคไม่ได้ หมด ใช่ ไม่ใช่ Add Leukotriene ให้ antihistamine ยังควบคุมไม่ได้ ใช่ ไม่ใช่เพิ่ม prednisolone 25mg/day Anti histamine + ลดลงจนควบคุมอาการได้ leukotriene ยังควบคุมไม่ได้ หมด
  • 35. ยังควบคุมโรคไม่ได้ หมด ใช่ ไม่ใช่ยาทางเลือกอื่นๆ เช่น cyclosporine Anti histamine + corticosteroid
  • 36. CHRONIC URTICARIA
  • 37. TREATMENT OF HEREDITARY ANGIOEDEMA Patient education very important; test family No regular medication needed in many cases Prophylactic stanozolol or danozol Fresh frozen plasma before emergency surgery C1 inhibitor Symptomatic treatment during attacks Steroids and antihistamines are NOT effective
  • 38. SUMMARY OF TREATMENTS FOR C1 ESTERASE INHIBITOR DEFICIENCY
  • 39. CASE STUDY
  • 40. CASE ผู้ป่ วยเด็ ก ชายไทย อายุ 12 ปี ภู มิ ลาเนา จัง หวัด แพร่ CC : ปากบวมมี ผื่ น คั น หลั ง ฉี ด ยา 5 นาที PI : 1 วั น ก่ อ นมาโรงพยาบาล มี ไ ข้ ถ่ า ยอุ จ จาระเหลวเป็ นมู ก ปริ ม าณไม่ ม ากวั น ละ 3 – 4 ครั ง มี อ าการอ่ อ นเพลี ย ได้ มาตรวจและแพทย์ ใ ห้ admit รั ก ษาด้ วยการให้ ้ สารน ้าทางหลอดเลื อ ดดาและยาฉี ด ceftriaxone 500 mg IV q 12 hr. หลั ง ฉี ด ยา5 นาที ผู้ ป่ วยมี ริ ม ฝี ปากบวม ผื่ น แดงคั น ตามตั ว และเวี ย นศี ร ษะคล้ ายจะ เป็ นลม PH : ปฏิ เ สธโรคประจาตั ว แต่ เ มื่ อ 1 ปี ก่ อ น เคยกิ น ยาฆ่ า เชื อ รั ก ษาอาการเจ็ บ คอ ้ กิ น แล้ วมี ผื่ น ขึ น ตามตั ว อาการไม่ รุ น แรง หายไปเอง ไม่ ไ ด้ ไปพบแพทย์ ไม่ มี ป ระวั ติ แ พ้ ้ ยาในครอบครั ว
  • 41. CASE Physical examination  V/S BT = 38.5 C , PR 120/min, RR = 20 /min, BP =80/40mmHg  BW = 20 kg , Height 155 cm  GA : A thai boy with good consciousness, no pallor, no jaundice, no cyanosis  Skin : dry and swollen lips, flushing, generalized urticaria rash with facial angioedema  Heart : tachycardia wit normal S1 S2, no murmur  Lungs : expiratory Wheezing on both lungs, no crepitation  Other : unremarkable
  • 42. CASE Positive finding  Fever  Tachycardia  Hypotension  Hx of Drug allery  Angioedema  Urticaria  expiratory Wheezing on both lungs Negative finding  No stress  No redness of body  No brown macule  No hx of psychological disorder
  • 43. CASE Problem list  Angioedema with generalize urticaria rash with anaphylaxis  Fever with mucous diarrhea
  • 44. PROVISIONAL DIAGNOSISAnaphylactic shockAcute gastroenteritis
  • 45. TREATMENT IN THIS CASEStop ceftriaxoneAdrenaline (1:1000) IM0.9 % NaCl IV loadingAntihistamine
  • 46. ANAPHYLAXIS
  • 47. DEFINITION OF ANAPHYLAXIS systemic, immediate hypersensitivity  Affects body as a whole  Multiple organ systems may be involved  Onset generally acute  Manifestations vary from mild to fatal  immunoglobulin E (IgE)-mediated Anaphylatoid  Non – immunoglobulin E (IgE)-mediated
  • 48. ANAPHYLACTOID REACTIONS Non–IgE-mediated  Complement-mediated  Anaphylatoxins, eg, blood products  Direct stimulation  eg, radiocontrast media  Mechanism unknown  Exercise  NSAIDs
  • 49. COMMON TRIGGERS OF PEDIATRIC ANAPHYLAXIS Foods (most common cause in children) – Milk, eggs, wheat, soy, fish, shellfish, Medicinals – Antibiotics (penicillins, cephalosporins), local anesthetics, NSAID, opiates,dextran, radiocontrast media Biologics – Venoms (bee sting, ant or snake bite), blood and blood products, vaccines, allergen extracts Preservatives and additives – Metabisulfite, monosodium glutamate Other – Latex, unknown/idiopathic
  • 50. CLINICAL MANIFESTATIONS OF ANAPHYLAXIS Skin: Flushing, pruritus, urticaria, angioedema Upper respiratory: Congestion, rhinorrhea Lower respiratory: Bronchospasm, throat or chest tightness, hoarseness, wheezing, shortness of breath, cough
  • 51. CLINICAL MANIFESTATIONS OF ANAPHYLAXISGastrointestinal tract: Oral pruritus Cramps, nausea, vomiting, diarrheaCardiovascular system: Tachycardia, bradycardia, hypotension/shock, arrhythmias, ischemia, chest pain
  • 52. CRITERIA FOR ANAPHYLAXISCriterion 1 – Acute onset of an illness involving the skin, mucous membranes at least one of the following: Respiratory compromise Decreased blood pressure or associated symptoms of end-organ dysfunction
  • 53. CRITERIA FOR ANAPHYLAXISCriterion 2 – Two or more of the following that occur rapidly after exposure to an allergen that is likely for that patient Involvement of the skin and/or mucous membranes Respiratory compromise Decreased blood pressure or associated symptoms Persistent gastrointestinal symptoms
  • 54. CRITERIA FOR ANAPHYLAXISCriterion 3 – Decreased blood pressure after exposure of a known allergen for that patient  Decreased blood pressure is defined in adults as a systolic BP of less than 90 mmHg or >30% decrease from that patient’s baseline.  In infants and children, decreased BP is defined as low systolic  BP of less than 70 mmHg from one month up to one year  less than (70mmHg + [2 x age]} from one to ten years  less than 90 mmHg from 11 to 17 years.
  • 55. DIFFERENTIAL DIAGNOSIS Vasovagal reactions Flush syndrome  Carcinoid  Pheochromcytoma  Medullary thyroid carcinoma Resturant syndrome  Monosodium glutamate Excessive production of histamine  Systemic maastocytosis  Basophilic leukemia Shock  Hemorrhagic / hypovolemic  Cardiogenic  Septic
  • 56. DIFFERENTIAL DIAGNOSIS Acute respiratory failure  Status asthmaticus  Foreign body aspiration  Pulmonary embolism  Epiglottitis Non organic disease  Panic attack  Munchausen’s stridor  Vocal cord dysfunction Other  Red man syndrome (Vancomycin)  Hereditary angioedema
  • 57. LAB INVESTIGATION Serum tryptase  Peak at 60- 90 min  > 10 nanogram/ml  > 1.4 times or 2 nanogram/ml at 1-2 wk after anaphylaxis  Sensitivity 73% specific 98 %  In some case are normal but mastocytosis  rise Specific – IgE  Skin test 6 wk after anaphylaxis  Serum specific IgE antibody
  • 58. TREATMENT Support the airway and ventilation; and Give supplementary oxygen. Intramuscular 1: 1000 (1 mg/ml) adrenaline at a dose of 0.01 mg/kg (0.01 ml/kg) body weight up to a maximum dose of 0.5 mg (0.5 ml) Resuscitate with intravenous saline (20 ml/kg body weight) Bronchodilator Systemic corticosteroid  Hydrocortisone (5mg/kg q 6 hr.)  Methylprednisolone (1mg/kg q 6 hr.)
  • 59. TREATMENT Antihistamine  Chlorpheniramine 0.1mg/kg q 6 hr.  Cimetidine 4mg/kg max 300mg q 8-12 hr. Refractory anaphylaxis in patient used beta -blocker  Glucagon 20-30 mcg/kg max 1 mg slow push in 5 min and IV drip 5-15 mcg/min until BP stable Bradycardia  Atropine 0.5 mg q 10 min cumulative dose 2 mg
  • 60. PREVENTION Agents causing anaphylaxis should be identified when possible and avoided Individuals at high risk for anaphylaxis should be issued epinephrine syringes for self -administration and instructed in their use Beta-adrenergic antagonists should be avoided, whenever possible. Children and their care -givers should be offered a written emergency plan in case of accidental ingestion. Pre-treatment with glucocorticosteroids and H1 and H2 antihistamines when used radio contrast media in some case
  • 61. PREVENTION Patients with egg allergy should be tested before receiving measles, influenza or yellow fever vaccines which contain egg protein. In cases of food-associated exercise-induced anaphylaxis, children must not exercise within 4 hours of ingesting the triggering food Reactions to medications can be reduced and minimized by using oral medications in preference to injected forms. The use of powder-free, low allergen gloves and materials should be used in children undergoing multiple surgeries.
  • 62. REFERENCE Zuberbier T, Bindslev-Jensen C, Canonica W, Grattan CE, Greaves MW, Henz BM, et al. EAACI/GA2LEN/EDF guideline: definition, classifica tion and diagnosis of urticaria. Allergy 2006; 61:316-20. Zuberbier T, Bindslev-Jensen C, Canonica W, Grattan CE, Greaves MW, Henz BM, et al. EAACI/GA2LEN/EDF guideline: management of urticaria. Allergy 2006; 61:321-31. Grattan CEH, Humphreys. Guidelines for evaluation and management of urticaria in adults and children. Br J Dermatol 2007; 157: 1116-23. M. Scott Linscott, Anaphylaxis: Diagnosis and Management in the Rural Emergency Department. American Journal of Clinical Medicine 2012 ; 91. Donald Y.M. Leung, Stephen C. Dreskin. Urticaria (Hives) and Angioedema. In: Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics. 18th ed. Philadelphia PA: W.B. Saunders; 2007. Elham Hossny. Anaphylaxis in children. Egypt J Pediatr Allergy Immunol 2007; 5(2): 47-54.

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