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Hypersensitivity disorders cld


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The four types of Hypersensitivity reactions

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Hypersensitivity disorders cld

  2. 2. 2 Inflammatory and immunologic response is normally helpful and protect against infection and can development These responses also stimulates tissue growth and repair after injury But if prolonged and excessive or occur at inappropriate time Effect: normal cells, tissues or organs are damagedMaria Carmela L.Domocmat, RN, MSN
  4. 4. 4 Overreaction Underreaction Hypersensitivity Immunodeficiency Overreactions to invaders and Congenital foreign antigens Acquired Autoimmune response When it fails to recognize self- cells and attack normal body tissuesMaria Carmela L.Domocmat, RN, MSN
  5. 5. Hypersensitivity Reaction
  6. 6. Hypersensitivity Reaction or Allergic Reaction 6 an immune malfunction whereby a persons body is hypersensitized to react immunologically to typically non-immunogenic substances.Maria Carmela L.Domocmat, RN, MSN
  7. 7. Definition of terms 7 Atopy: the tendency to develop allergies for which there is a genetic disposition and that involve immunoglobulin E (IgE) antibody formation AKA – atopic, allergic, hypersensitive Allergy: describes the increased immune response to the presence of an allergen (i.e., antigen)Maria Carmela L.Domocmat, RN, MSN
  8. 8. 8Maria Carmela L.Domocmat, RN, MSN
  9. 9. 9 People must progress through two-step process to become allergic 1) sensitization 2) reexposure to the allergenMaria Carmela L.Domocmat, RN, MSN
  10. 10. General categories of hypersensitivity reactions 10 Immediate humoral or antigen-antibody Delayed cell-mediatedMaria Carmela L.Domocmat, RN, MSN
  11. 11. Types of Hypersensitivity 11 IMMEDIATE Type I: Immediate hypersensitivity Type II: Cytotoxic hypersensitivity Type III: Immune complex-mediated hypersensitivity DELAYED Type IV: Delayed HypersensitivityMaria Carmela L.Domocmat, RN, MSN
  12. 12. Hypersensitivity 12There are four different types of hypersensitivities that result from different responses of the immune system:Type I: Immediate hypersensitivity - onset within minutes of antigen challenge - examples are allergies to molds, insect bitesType II: Cytotoxic hypersensitivity - onset within minutes or a few hours of antigen challenge - examples are adult hemolytic anemia and drug allergiesMaria Carmela L.Domocmat, RN, MSN
  13. 13. Hypersensitivity 13There are four different types of hypersensitivities that result from different responses of the immune system:Type III: Immune complex-mediated hypersensitivity - onset usually within 2-6 hours - examples include serum sickness and systemic lupus erythematosus Type IV: Delayed Hypersensitivity - inflammation by 2-6 hours; peaks by 24-48 hours - examples include poison ivy and chronic asthmaMaria Carmela L.Domocmat, RN, MSN
  14. 14. ATOPIC ALLERGIES Allergic rhinitis or hay fever Urticaria or HivesALLERGIC ASTHMAANAPHYLAXISALLERGY TO SPECIFIC ALLERGEN Latex allergy bee venom, peanut, iodine, shellfish, drugs
  15. 15. Type I: Immediate hypersensitivity 15 This is the type of hypersensitivity usually referred to as “allergy”.Maria Carmela L.Domocmat, RN, MSN
  16. 16. Type I: Immediate hypersensitivity 16 occurs when an IgE antibody response is mounted against an antigen in the environment that is usually harmless A single exposure to antigen isn’t enough to trigger hypersensitivity, but the immune response may become more severe with repeated exposure.Maria Carmela L.Domocmat, RN, MSN
  17. 17. Type I hypersensitivity – sensitization to an inhaled allergenor bee sting 17 cytokines → → Mast cell Antigens (red dots) from inhaled pollen are ingested and presented by macrophages to T cells. Activated T cells produce cytokines leading to the production of IgE, which binds to receptors on mast cells and causes the release of histamine, which is responsible for allergy symptoms. Onset is usually within minutes of contact with antigen.Maria Carmela L.Domocmat, RN, MSN
  18. 18. 18 When the antigen enters through a respiratory mucosal surface, it is taken up, processed and displayed by antigen- presenting cells. When the presented fragments “lock on” to helper T cell receptors, the T cells become activated, secreting cytokines. The cytokines, in turn, stimulate IgE-producing B cells. IgE binds to IgE-receptors on the surfaces of mast cells, sensitizing them.Maria Carmela L.Domocmat, RN, MSN
  19. 19. 19Maria Carmela L.Domocmat, RN, MSN
  20. 20. histamineMaria Carmela L.Domocmat, RN, MSN 20
  21. 21. 21Maria Carmela L.Domocmat, RN, MSN
  22. 22. Maria Carmela L.Domocmat, RN, MSN 22
  23. 23. 23 Allergens can be contacted in the ff ways Inhaled Ingested Injected contactedMaria Carmela L.Domocmat, RN, MSN
  24. 24. Atopic allergy 24 Inhaled Injected Plant pollens Bee venom Fungal spores Drugs Animal dander Biologic subtances House dust (ex: contrast dyes, Grass Adenocotricotropic hormone) Ragweed Contacted Ingested Pollens Foods Foods Food additives Envt proteins DrugsMaria Carmela L.Domocmat, RN, MSN
  25. 25. Maria Carmela L.Domocmat, RN, MSN 25
  26. 26. 26Maria Carmela L.Domocmat, RN, MSN
  27. 27. 27Maria Carmela L.Domocmat, RN, MSN
  28. 28. Common Causes of Allergy
  29. 29. What are common allergenic foods?Legumes (Peanuts and Soybeans)Mollusks (snails, mussels, oysters, scallops, clams, squid)MilkEggsFish (cod, salmon, haddock, etc.)Crustacea (shrimp, crawfish, lobster. etc.)WheatTree nuts (almonds, walnuts, Brazil nuts, etc.)Selected food additives
  30. 30. Atopic allergy 30 MOST COMMON TYPE INCLUDES : Allergic rhinitis or hay fever Urticaria or hay feverMaria Carmela L.Domocmat, RN, MSN
  31. 31. Allergic Rhinitis 31 AKA: HAY FEVERMaria Carmela L.Domocmat, RN, MSN
  32. 32. 32Maria Carmela L.Domocmat, RN, MSN
  33. 33. Allergic Rhinitis 33 Triggered by reactions to airborne allergens Types: Seasonal: recur to same time of each of the year Often coincide with timing of large environmental exposure Chronic: or perennial rhinitis Occur intermittently or continuous when exposed to allergen Non-allergic rhinitis Same manifestations are present Although no allergic cause is identified immune system does not appear to be involvedMaria Carmela L.Domocmat, RN, MSN
  34. 34. 34Maria Carmela L.Domocmat, RN, MSN
  35. 35. 35Maria Carmela L.Domocmat, RN, MSN
  36. 36. Urticaria 36Maria Carmela L.Domocmat, RN, MSN
  37. 37. 37 Urticaria may be acute (lasting less than 6 wk) or chronic (lasting more than 6 wk).Maria Carmela L.Domocmat, RN, MSN
  38. 38. 38 Many substances can trigger hives, including: Animal dander (especially cats) Insect bites Medications Pollen Shellfish, fish, nuts, eggs, milk, and other foods Hives may also develop as a result of: Emotional stress Extreme cold or sun exposure Excessive perspiration Illness (including lupus, other autoimmune diseases, and leukemia Infections such as mononucleosisMaria Carmela L.Domocmat, RN, MSN
  39. 39. Symptoms 39 Itching Swelling of the surface of the skin into red- or skin-colored welts (called wheals) with clearly defined edges The welts may get bigger, spread, and join together to form larger areas of flat, raised skin. They can also change shape, disappear, and reappear within minutes or hours. The welts tend to start suddenly and go away quickly. When you press the center of a red welt, it turns white. This is called blanching.Maria Carmela L.Domocmat, RN, MSN
  40. 40. Hives or urticaria
  41. 41. Hives (urticaria) on the back and buttocks 41These are hives (urticaria) with the typical slightly-raised redappearance, and are accompanied by itching. These arelocated on the buttocks. Hives can be generalized over theentire body or may be localized, and usually result from anallergic reaction.
  42. 42. Hives (urticaria) - close-up 42 Hives (urticaria) are raised, red, itchy welts. The majority of urticaria develop as a result of allergic reactions. Occasionally, they may be associated with autoimmune diseases, infections (parasitosis), drugs, malignancy, or other causes.Maria Carmela L.Domocmat, RN, MSN
  43. 43. Hives (urticaria) on the chest 43 Hives develop when histamine is released into the small blood vessels (capillaries). The capillaries dilate which causes a welt, and fluid oozes into the surrounding tissue, causing swelling. Histamine also causes intense itching.Maria Carmela L.Domocmat, RN, MSN
  44. 44. 44Maria Carmela L.Domocmat, RN, MSN
  45. 45. 45 Latex is a milky fluid that comes from the tropical rubber tree,Hevea brasiliensis. Hundreds of everyday products contain latex. Some common ones are Gloves Condoms Balloons Rubber bands Shoe soles PacifiersMaria Carmela L.Domocmat, RN, MSN
  46. 46. Latex exposure is associated with 3 clinical syndromes 46 first syndrome - irritant dermatitis. It is a result of mechanical disruption of the skin due to the rubbing of gloves and accounts for the majority of latex-induced local skin rashes. It is not immune mediated, is not associated with allergic complications second syndrome - delayed (type IV) hypersensitivity reaction Result in a typical contact dermatitis. Symptoms usually develop within 24-48 hours of cutaneous or mucous membrane exposure to latex in a sensitized person. Third syndrome - immediate (type I) hypersensitivity most serious, and least common mediated by an immunoglobulin E (IgE) response specific for latex proteins.See for moreinformationMaria Carmela L.Domocmat, RN, MSN
  47. 47. 47Maria Carmela L.Domocmat, RN, MSN
  48. 48. Allergic asthma 48Maria Carmela L.Domocmat, RN, MSN
  49. 49. 49 See link: for additional informationMaria Carmela L.Domocmat, RN, MSN
  50. 50. 50Maria Carmela L.Domocmat, RN, MSN
  51. 51. ClinicalManifestations of ImmediateHypersensitivityASTHMA
  52. 52. Anaphylaxis 54Maria Carmela L.Domocmat, RN, MSN
  53. 53. 55Maria Carmela L.Domocmat, RN, MSN
  54. 54. 56Maria Carmela L.Domocmat, RN, MSN
  55. 55. Nursing assessment 57 H X : A C C U R A T E A N D D E TA I L E D H X Describe onset and duration of problems Ask abt work, school, home, environment, possible exposures through hobbies, leisure time or sports activities Ask presence of allergies among relatives PHYSICAL ASSESSMENTMaria Carmela L.Domocmat, RN, MSN
  56. 56. Clinical Manifestations ofImmediate Hypersensitivity
  57. 57. Allergy is characterized by a local or systemic inflammatory response to allergens 59Local symptoms: Nose: swelling of the nasal mucosa, rhinorrhea Eyes: redness and itching of the conjunctiva (allergic conjunctivitis) Airways: bronchoconstriction, wheezing, sometimes outright attacks of asthma Ears: feeling of fullness, possibly pain, and impaired hearing due to the lack of eustachian tube drainage. Skin: various rashes, such as eczema, hives and contact dermatitis. Head: while not as common, headaches are seen in some with environmental or chemical allergies.Maria Carmela L.Domocmat, RN, MSN
  58. 58. Allergy is characterized by a local or systemic inflammatory response to allergens 60Systemic allergic response Is also called anaphylaxis Depending of the rate of severity, it can cause cutaneous reactions, bronchoconstriction, edema, hypotension, coma and even death.Maria Carmela L.Domocmat, RN, MSN
  59. 59. Hives Symptoms 61 Itching Swelling of the surface of the skin into red- or skin-colored welts (called wheals) with clearly defined edges The welts may get bigger, spread, and join together to form larger areas of flat, raised skin. They can also change shape, disappear, and reappear within minutes or hours. The welts tend to start suddenly and go away quickly. When you press the center of a red welt, it turns white. This is called blanching. Carmela L.Domocmat, RN, MSN
  60. 60. Food allergies 62 The bodys immune system normally reacts to the presence of toxins, bacteria or viruses by producing a chemical reaction to fight these invaders. However, sometimes the immune system reacts to ordinarily benign substances such as food or pollen, to which it has become sensitive. This overreaction can cause symptoms from the mild (hives) to the severe (anaphylactic shock) upon subsequent exposure to the substance. An actual food allergy, as opposed to simple intolerance due to the lack of digesting enzymes, is indicated by the production of antibodies to the food allergen, and by the release of histamines and other chemicals into the blood.Maria Carmela L.Domocmat, RN, MSN
  61. 61. Food Allergy - SymptomsNauseaDiarrheaAbdominal crampsPruritic rashesAngioedemaAsthma/rhinitisVomitingHivesLaryngeal edemaAnaphylaxis
  62. 62. 64Maria Carmela L.Domocmat, RN, MSN
  63. 63. Allergy tests 65 SKIN TESTS • Scratch or prick test • Intradermal test •O R A L F O O D C H A L L E N G E O R E L I M I N A T I O N D I E T •L A B O R A T O R Y TESTS CBC Increased serum IgE RAST (radioallergosorbent test)Maria Carmela L.Domocmat, RN, MSN
  64. 64. 66 Skin Tests Individual is inoculated with allergen by scraping or injection Fast: results within 30’Maria Carmela L.Domocmat, RN, MSN
  65. 65. 67 Prep Discontinue Glucocorticoids and antihistamine 5 days b4 test (to avoid suppressing allergic response during the test) Nasal sprays to reduce mucous membrane swelling can be continued but shld be discontinued if with antihistamineMaria Carmela L.Domocmat, RN, MSN
  66. 66. Skin Tests: ID
  67. 67. Skin Tests: Intradermal or Scratch test 69• The allergens are either injected intradermally or into small scratchings made into the patients skin• If the patient is allergic to the substance, then a visible inflammatory reaction will usually occur within 30 minutes.• This response will range from slight reddening of the skin to full-blown hives in extremely sensitive patients.• Problems: some people may display a delayed-type hypersensitivity (DTH) reaction which can occur as far as 6 hours after application of the allergen and last up to 24 hours. This can also cause serious long- lasting tissue damage to the affected area. These types of serious reactions are quite rare.Maria Carmela L.Domocmat, RN, MSN
  68. 68. Maria Carmela L.Domocmat, RN, MSN 70
  69. 69. Maria Carmela L.Domocmat, RN, MSN 71
  70. 70. Oral Food Challenge 72 Used to identify specific allergen if skin testing is not conclusive and if keeping a food diary has failed to determine the offending food items Prep - eliminate suspected foods 7-14 days b4 test Eat defined suspected allergen for at least 1 day Monitor s/s of allergy If with many food allergies – eat only 1 food type/day of testingMaria Carmela L.Domocmat, RN, MSN
  71. 71. 73 Laboratory tests CBC Increased eosinophils 12% (normal 1-2%) Increased WBC count, but percentage of neutrophils is normal (55-70%) Note: if acute infection occurs with rhinitis – both WBC and neutrophils are increased) Increased serum IgE Only confirms the presence of infection But does not indicate specific allergen RAST (radioallergosorbent test) Shows blood level of IgE directed against a specific antigen Can determine specific allergies ExpensiveMaria Carmela L.Domocmat, RN, MSN
  72. 72. Management of Type I Hypersensitivity Reaction 74Maria Carmela L.Domocmat, RN, MSN
  73. 73. Allergy management 751. Avoidance therapy - identify and prevent exposure to allergen, control of environment2. Symptomatic therapy 1. Teach how to use Epi-pen3. Desensitization therapyMaria Carmela L.Domocmat, RN, MSN
  74. 74. 1. Avoidance therapy 76 Avoid direct contact with allergen Airborne allergen Air-conditioning and air cleaning units Remove cloth drapes, upholstered furniture, carpet Cover mattress and pillows with plastic or cotton fine mesh Pet-induced allergy Keep pet out of bedroom Thoroughly clean room to remove hair and dander Frequent bathing of petMaria Carmela L.Domocmat, RN, MSN
  75. 75. 1. Avoidance therapy 77 Avoid direct contact with allergen Latex allergy Avoid products with latex; use synthetic substances that do not contain latex protein Ex: Elastylite glove Note: always use latex-free products in the care of client with known latex allergyMaria Carmela L.Domocmat, RN, MSN
  76. 76. 2. Symptomatic therapy 78 Drug therapy or Pharmaceutical approaches to allergy treatment involve Decongestants Antihistamine Corticosteroids Mast cell stabilizers Leukotrine Antagonists Complementary and alternative Therapies Aromatherapy Eat unprocessed honeyMaria Carmela L.Domocmat, RN, MSN
  77. 77. 2. Symptomatic therapy 79 Nasal Decongestants Action: prevent release of mediators such as histamine but do not clear the allergen Have similar action to adrenergic agents - cause vasoconstriction in inflamed tissues Often contain ephedrine, phenylephrine, or pseudoephedrine Phenylephrine – 1 spray/nostril 4-6x/day ; Oxymetazoline -1 spray/nostril 2x/day ; pseudoephedrine (Sudafed) Note: caution not to use more frequently than directed or for longer than 4 days (overuse or continued use causes a rebound nasal congestion or rebound rhinitis and worsens the symptoms) S/E: dry mouth, increased BP, sleep difficultiesMaria Carmela L.Domocmat, RN, MSN
  78. 78. Nasal Spray 80Maria Carmela L.Domocmat, RN, MSN
  79. 79. Nasal Decongestants: Nursing ImplicationsDecongestants may cause hypertension, palpitations, andCNS stimulation—avoid in patients with these conditionsPatients on medication therapy for hypertension shouldcheck with their physician before taking OTCdecongestantsAssess for drug allergies Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  80. 80. Nasal Decongestants: Nursing ImplicationsPatients should avoid caffeine and caffeine-containingproductsReport a fever, cough, or other symptoms lasting longerthan a weekMonitor for intended therapeutic effects Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  81. 81. 2. Symptomatic therapy 83 Antihistamine Compete with histamine at receptor site and block histamine from binding to the receptor –prevents vasodilation and capillary leak first generation antihistamines diphenhydramine (Benadryl) and chlorpheniramine (Chloratrimeton) common side effect : sedation, drowsiness, and dry mouth Use at night before bedtime to avoid feeling tired the next day. second-generation antihistamines loratadine (Claritin), fexofenadine (Allegra), and certirizine (Zyrtec) less likely to cause drowsiness and can be taken during the daytime.Maria Carmela L.Domocmat, RN, MSN
  82. 82. Antihistamines: Nursing Implications Gather data about the condition or allergic reaction that required treatment; also assess for drug allergies Contraindicated in the presence of acute asthma attacks and lower respiratory diseases Use with caution in increased intraocular pressure, cardiac or renal disease, hypertension, asthma, COPD, peptic ulcer disease, BPH, or pregnancy Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  83. 83. Antihistamines: Nursing Implications Instruct patients to report excessive sedation, confusion, or hypotension Avoid driving or operating heavy machinery, and do not consume alcohol or other CNS depressants Do not take these medications with other prescribed or OTC medications without checking with prescriber Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  84. 84. Antihistamines: Nursing Implications Best tolerated when taken with meals—reduces GI upset If dry mouth occurs, teach patient to perform frequent mouth care, chew gum, or suck on hard candy (preferably sugarless) to ease discomfort Monitor for intended therapeutic effects Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  85. 85. 87 Combined products Claritin-D. loratadine (Claritin) and pseudoephedrine (Sudafed) are combined in the over-the-counter product This allergy relief medicine gives the benefit of the antihistamine to prevent nasal allergies and the decongestant to open swollen nasal passages.Maria Carmela L.Domocmat, RN, MSN
  86. 86. 2. Symptomatic therapy 88 Corticosteroids Decreased inflam and immune response in many ways One way – prevent synthesis of mediators Nasal spray – prevent symtpoms of rhinitis Systemic – can produce severe S/E; avoised for rhinites; used inly in short-term basis for other probmels assoc wth type I hypersen. Beclomethasone (Beconase) – 1-2 metered spray /nostril ; 1-2x/day fluticasone (Flovent, Flonase) 2 metered spray /nostril/dayMaria Carmela L.Domocmat, RN, MSN
  87. 87. Inhaled Corticosteroids: Nursing Implications Contraindicated in patients with psychosis, fungal infections, AIDS, TB Cautious use in patients with diabetes, glaucoma, osteoporosis, PUD, renal disease, HF, edema Teach patients to gargle and rinse the mouth with water afterward to prevent the development of oral fungal infections Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  88. 88. Inhaled Corticosteroids: Nursing Implications Abruptly discontinuing these medications can lead to serious problems If discontinuing, should be weaned for 1 to 2 weeks, only if recommended by physician Report any weight gain of more than 5 pounds a week or the occurrence of chest pain Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  89. 89. 2. Symptomatic therapy 91 Mast cell stabilizers Prevent mast cell membranes from opening when allergen bnds to the IgE Prevent symptomes of rhinits but not useful during acute episodes cromolyn (NasalCrom, Intal) 1 spray/nostril/4-6x/day Use as directed (effectiveness depends on regular use) Start therapy 2-4 weeks b4 expected allergy seasonMaria Carmela L.Domocmat, RN, MSN
  90. 90. Mast Cell Stabilizers: Nursing Implications For prophylactic use only Contraindicated for acute exacerbations Not recommended for children younger than age 5 Therapeutic effects may not be seen for up to 4 weeks Teach patients to gargle and rinse the mouth with water afterward to minimize irritation to the throat and oral mucosa Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  91. 91. 2. Symptomatic therapy 93 Leukotrine Antagonists or Antileukotrienes Also called leukotriene receptor antagonists (LRTAs) Currently available agents montelukast (Singulair) zafirlukast (Accolate) zileuton (Zyflo) 600mg 4x/day Do not take with terfenadine or theophylline – Zyflo increases plasma concentrations of these drugsMaria Carmela L.Domocmat, RN, MSN
  92. 92. 2. Symptomatic therapy 94 Leukotrine Antagonists Leukotrine Substances in the body that cause inflammation, bronchoconstriction, and mucus production Result: coughing, wheezing, shortness of breath Includes: zileuton (Zyflo) zafirlukast (Accolate)Maria Carmela L.Domocmat, RN, MSN
  93. 93. 2. Symptomatic therapy 95 Leukotrine Antagonists zileuton (Zyflo) 600mg 4x/day Do not take with terfenadine or theophylline – Zyflo increases plasma concentrations of these drugsMaria Carmela L.Domocmat, RN, MSN
  94. 94. 2. Symptomatic therapy; Leukotrine Antagonists 96 zafirlukast (Accolate) 20 mg BID Take 1 hr b4 or 2 hrs after eating (food slows absorption of drug) There is an increased incidence of URI when co-administered with inhaled corticosteroids (drug reduced local inflam and immune response) Reduce dose if also taking aspirin (aspirin increases plasea concentration of Accolate)Maria Carmela L.Domocmat, RN, MSN
  95. 95. Antileukotrienes: Drug Effects Keep bronchial airways relaxed (open) Decrease mucus secretion Prevent vascular permeability Preventing inflammation Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  96. 96. 98zileuton zafirlukastHeadache HeadacheDyspepsia NauseaNausea DiarrheaDizziness Liver dysfunctionInsomniaLiver dysfunction• montelukast has fewer side effects sciences/PowerPointPresentations/Pharmacology/Chapter_036.pptMaria Carmela L.Domocmat, RN, MSN
  97. 97. Antileukotrienes: Nursing Implications Ensure that the drug is being used for chronic management of asthma, not acute asthma Teach the patient the purpose of the therapy Improvement should be seen in about 1 week Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  98. 98. Antileukotrienes: Nursing Implications Check with physician before taking any OTC or prescribed medications—many drug interactions Assess liver function before beginning therapy Medications should be taken every night on a continuous schedule, even if symptoms improve Mosby items and derived items © 2005, 2002 by Mosby, Inc.
  99. 99. 2. Symptomatic therapy 101 Complementary and alternative Therapies Aromatherapy Possible mechanism of action – competition and desensitization Eat unprocessed honey Indicated for those who have pollen allergiesMaria Carmela L.Domocmat, RN, MSN
  100. 100. 3. Desensitization therapy 102 AKA: Hyposensitization Allergy shots Indicated when allergens are identified and cannot be avoided easily Immunize with increasing doses of allergen Mechanism of action – competitionMaria Carmela L.Domocmat, RN, MSN
  101. 101. 3. Desensitization therapy 103 Injection given weekly -1st year q other week – 2nd year q 3-4 wks – 3rd year 5 years- recommended course of treatment Or rally Sublingual immunotherapy (SLIT)Maria Carmela L.Domocmat, RN, MSN
  102. 102. Desensitization or Hyposensitization 104 has been effective for a few antigens, particularly bee venom. is designed to cause an IgG response instead of an IgE response. The allergen is either ingested or injected into the subject starting in small amounts and increased to larger amounts.Maria Carmela L.Domocmat, RN, MSN
  103. 103. Desensitization or Hyposensitization 105 This treatment can have 2 effects:1. T-helper 1 cells produce more IgG which binds to the antigen so that it can’t bind to IgE receptors on mast cells and cause release of histamines. – (Competition)2. IgG binds to and removes the antigen before it binds to T-helper 2 cells. The T- helper 2 cells will then not be able to produce the B cells that will produce IgE.Maria Carmela L.Domocmat, RN, MSN
  104. 104. Control of Type I Hypersensitivity Reactions 106 Epinephrine Increases cAMP levels and inhibits degranulation, relaxes smooth muscles, increases cardiac output, and decreases vascular permeability Antihistamines block the H1 and H2 histamine receptors on cells and prevent degranulationMaria Carmela L.Domocmat, RN, MSN
  105. 105. 107Maria Carmela L.Domocmat, RN, MSN
  106. 106. Type II:Cytotoxic hypersensitivity
  107. 107. 109 Antibody-mediated Cytotoxic Hypersensitivity Complement-mediated lysis Antibody dependent cell-mediated cytotoxicity (ADCC) OpsonizationMaria Carmela L.Domocmat, RN, MSN
  108. 108. 110Maria Carmela L.Domocmat, RN, MSN
  109. 109. 111 Hemolytic anemias Hemolytic Transfusion Reactions Hemolytic Disease of the Newborn Drug-Induced Hemolytic AnemiaMaria Carmela L.Domocmat, RN, MSN
  110. 110. Transfusion Reactions 112 Due to antibodies that react with antigens on red blood cells Transfused cells are killed by complement-mediated lysisMaria Carmela L.Domocmat, RN, MSN
  111. 111. 113Maria Carmela L.Domocmat, RN, MSN
  112. 112. ABO Blood Group System Table 19.2
  113. 113. Hemolytic Disease of the Newborn Figure 19.4
  114. 114. Hemolytic Disease of the Newborn 116 Maternal IgG specific for red blood cell antigens crosses the placenta and causes lysis. The most severe form of the disease, called erythroblastosis fetalis, develops in an Rh+ fetus carried in an Rh- mother. Rh is an antigen found on red blood cells.Maria Carmela L.Domocmat, RN, MSN
  115. 115. 117Maria Carmela L.Domocmat, RN, MSN
  116. 116. Child with Rh hemolytic disease of the newborn 118 Why is the fetus edematous? The child has hydrops fetalis. Patients with Rh hemolytic disease have severe anemias, which lead to high output failure and both left and right heart failure, the latter responsible for peripheral edema and ascites. The liver in this fetus had massive hepatomegaly secondary to extramedullary hematopoiesis. Carmela L.Domocmat, RN, MSN
  117. 117. 119 Brain of the above fetus. What is causing the yellowish discoloration? The yellow pigment is unconjugated, lipid soluble bilirubin derived from macrophage destruction of the Rh-sensitized fetal RBCs. The condition is called kernicterus.Maria Carmela L.Domocmat, RN, MSN
  118. 118. Kleihauer-Betke test in maternal blood post- delivery 120 The mother is O negative The normal staining cells and the baby is O positive. contain Hgb F and represent Who do the normal fetal RBCs, while the pale colored RBCs belong to staining cells contain Hgb A and what should the from the mother. She should mother be given to be given Rh immune prevent sensitization? globulin (anti-D) to prevent sensitization to the D antigen.Maria Carmela L.Domocmat, RN, MSN
  119. 119. Drug Induced Hemolytic Anemia 121 Antibiotics covalently attach to proteins on red blood cells Penicillin, cephalosporin, Streptomycin This essentially creates a hapten-carrier complex that can result in a B cell response to the drug Red-blood cells bound to the drug are killed by complement-mediated lysisMaria Carmela L.Domocmat, RN, MSN
  120. 120. 122 Drug (p=penicillin) modified red blood cells induce the production of antibodies, because the bound drug makes them look foreign to the immune system. When these antibodies are bound to them, the red blood cells are more susceptible to lysis or phagocytosis. Onset is dependent on the presence of specific antibodies.Maria Carmela L.Domocmat, RN, MSN
  121. 121. 123 Symptoms: Fever, chills, nausea, clotting within vessels and lower back pain. Treatment: Stop the transfusion! Or discontinue offending drug Plasmapheresis Filtration of plasam to remove specific subtances to remove antibodies Symptomatic treatment Provide diuretic to increase urine output and reduce buildup of hemoglobin For Rh – mother Should be given Rh immune globulin (anti-D) or RhoGamMaria Carmela L.Domocmat, RN, MSN
  122. 122. 124 If mother has not yet been sensitized or exposed to the Rh+ fetus, She will be given an injection of Rh-immune globulin (Rhogam)at about 28 weeks of pregnancy, and within 72 hours after a birth, miscarriage, abortion, or amniocentesis. If receive injection at 28 weeks and after delivery, sensitization will be prevented and Rh incompatibility should not be a problem during your next pregnancy. Maria Carmela L.Domocmat, RN, MSN
  123. 123. 125 The Rh-immune globulin contains antibodies to the Rh D factor. These antibodies will destroy any red blood cells from the baby that have entered the mother’s blood. The mother will not have a chance to form own antibodies to the Rh D factor. Maria Carmela L.Domocmat, RN, MSN
  124. 124. 126 It is important to receive Rh-immune globulin in all cases when the babys blood could leak into the mother’s system, including: All pregnancies including ectopic (tubal) pregnancies Early miscarriages After chorionic villus sampling After amniocentesis Maria Carmela L.Domocmat, RN, MSN
  125. 125. 127 How Long Will the Effects Last? Sensitization usually doesnt happen until after the birth of an Rh- positive baby. Therefore, in most cases Rh incompatibility is not a problem during a womans first pregnancy and delivery of an Rh-positive baby. However, later pregnancies and deliveries may be affected unless the mother is treated with Rh-immune globulin after EVERY birth, miscarriage, and abortion. Sensitization is permanent and the effects are usually worse with each subsequent pregnancy. Maria Carmela L.Domocmat, RN, MSN
  126. 126. Type III: Immune complex-mediated hypersensitivitySERUM SICKNESSSLERHEUMATOID ARTHRITISAGE
  127. 127. Type III hypersensitivity 129 Involve reactions against soluble antigens circulating in serum. Usually involve IgM, IgG antibodies. Antibody-Antigen immune complexes are deposited in organs, activate complement, and cause inflammatory damage. Glomerulonephritis: Inflammatory kidney damage. Occurs with slightly high antigen-antibody ratio is present.Maria Carmela L.Domocmat, RN, MSN
  128. 128. Type III hypersensitivity – immune complex formation and deposition 130 Immune complexes activate complementImmune complexes of (green dots- C3a, C4a, Inflammation andantigen (red dots) and and C5a), and mast cells edema occur, andantibody form in (yellow cell) degranulate. organ is damagedtarget organMaria Carmela L.Domocmat, RN, MSN
  129. 129. Type III hypersensitivity – immune complex formation anddeposition 131 In sensitized individuals, allergen (antigen) combined with antibody leads to the formation of immune complexes, which activate complement and the inflammatory response. The location of the inflammation depends on the location of the antigen - inhaled, under skin, systemic. Onset is usually within 2-6 hours.Maria Carmela L.Domocmat, RN, MSN
  130. 130. Type III (Immune Complex) Reactions Figure 19.6IgG antibodies and antigens form complexes that lodge inbasement membranes.
  131. 131. Serum sickness 133 Group of symptoms that occur after receiving serum or certain drugs Most common causes: Penicillin Other antibiotics Some animal-based drugs Less common- vaccinesSerum - does not contain white or red blood cells nor a clotting factorMaria Carmela L.Domocmat, RN, MSN
  132. 132. 134 s/s 7-12 days after receiving the causative agent Fever arthralgia (achy joints) Rash Lymphadenopathy Malaise Polyarthritis and nephritisMaria Carmela L.Domocmat, RN, MSN
  133. 133. SLE 135 Caused by immune-complexes lodged in : Vessels(vasculitis) Glomeruli (nephritis) Joints (arthralgia, arthritis) Other organs and tissuesMaria Carmela L.Domocmat, RN, MSN
  134. 134. Rheumatoid arthritis 136 Caused by immune-complexes lodged in joint spaces followed by destruction of tissue , and later, scarring and fibrous changesMaria Carmela L.Domocmat, RN, MSN
  135. 135. Management 137 Usually self-limiting Symptoms subside after several days Symptomatic treatment Antihistamine for itching Aspirin for arthralgia Prednisone if severe symptomsMaria Carmela L.Domocmat, RN, MSN
  137. 137. Type IV hypersensitivity – delayed-type or contact 139 T cells (blue cells) that Antigen (red dots) recognize antigen are Inflammatory are processed by activated and release response causes local APCs cytokines tissue injury. Antigen is presented by APCs to antigen-specific memory T cells that become activated and produce chemicals that cause inflammatory cells to move into the area, leading to tissue injury.Maria Carmela L.Domocmat, RN, MSN peaks by 24-48 hours. Inflammation by 2-6 hours;
  138. 138. Type IV hypersensitivity 140 the only type that is not antibody-mediated. This is the type involved in contact hypersensitivity (poison ivy, reactions to metals in jewelry); tuberculin-type hypersensitivity (the tuberculosis skin test); and granulomatous hypersensitivity (leprosy, tuberculosis, schistosomiasis and Crohn’s disease).Maria Carmela L.Domocmat, RN, MSN
  139. 139. 141 It is called delayed because its onset may vary; the length of the delay varies from 72 hours in contact and tuberculin-type to 21-28 days in granulomatous hypersensitivity.Maria Carmela L.Domocmat, RN, MSN
  140. 140. 142 In Type IV hypersensitivity, antigen presented by APCs activates antigen-specific memory T cells (which have been sensitized by prior exposure), causing them to release cytokines that activate and attract other T cells and phagocytic cells to the area. Where the source of antigen is at the skin surface, the APC migrates from the dermis, through lymphatic vessels to a lymph node in order to present antigen to a T cell.Maria Carmela L.Domocmat, RN, MSN
  141. 141. 143 In the TB skin test, a small amount of soluble antigen (tuberculin) is injected into the skin. The T cells that are activated by the antigen secrete cytokines that draw other cells to the site. Within four hours, neutrophils have arrived, followed by an influx of monocytes and T cells at about 12 hours. The peak of activity is at about 48-72 hours, at which point the area has become red and swollen.Maria Carmela L.Domocmat, RN, MSN
  142. 142. 144Maria Carmela L.Domocmat, RN, MSN
  143. 143. 145Maria Carmela L.Domocmat, RN, MSN
  144. 144. Contact HypersentivityHistory and physicalexamination providediagnostic clues
  145. 145. Jelly Fish HypersensitivityIn this case, theerythematous reactiondeveloped one weekafter the contact with ajelly fish
  146. 146. Acute Graft Rejection is a manifestation of delayed hypersensitivity
  147. 147. Fluid Accumulation in Delayed Hypersensitivity Reactions
  148. 148. Fluid Accumulation in Delayed Hypersensitivity Reactions
  149. 149. Patch test to identify the allergen for contact eczema 151
  150. 150. Dendritic cell
  151. 151. Management 153 Removal of offending allergen Reaction is self-limiting – 5-7 days Symptomatic treatment Monitor reaction site and sites distal for circulation adequacy Corticosteroids or other anti-inflam Benadryl is not recommended – bcoz histamine is not the main mediator and IgE is not the causeMaria Carmela L.Domocmat, RN, MSN
  152. 152. 154Maria Carmela L.Domocmat, RN, MSN
  153. 153. Have an allergy-free day! 155