Master the board step 3

Allergy and Immunology
Answer: This patient should be placed in the intensive care unit. If the patient comes
with anaphylaxis from any cause, the placement of the patient for CCS is based entirely
on the response to therapy that occurs after treatment. In this case, the source of the
allergic reaction, an insect sting, is irrelevant. What matters is that after moving the
clock forward, the symptoms do not resolve. Any persistent lip, facial, or hemodynamic
involvement after initial therapy should place the patient in the ICU.
A man comes in with neurosyphilis. He has a history of life-threatening anaphylaxis
to penicillin. He has a history of essential tremor and is on propranolol. He
has asthma and is on an inhaled beta agonist and inhaled steroids.
Which of the following is most appropriate?
a. Use ceftriaxone instead of penicillin
b. Stop propranolol prior to desensitizing him
c. Bolus with oral steroids prior to penicillin use
d. Add long acting beta agonists to treatment
Answer: B. Neurosyphilis is only effectively treated with penicillin. The patient must be
desensitized. Prior for desensitization it is important to stop propranolol and all beta blockers.
This is because epinephrine may have to be used in the event of anaphylaxis when
you desensitize the patient. Bolusing with steroids in inappropriate, because anaphylaxis
is treated first with epinephrine.
Allergic Rhinitis
Allergic rhinitis presents with recurrent episodes of nasal itching, stuffiness,
rhinorrhea, and paroxysms of sneezing. There is also often eye itching
and dermatitis. Allergic rhinitis may be associated with the development of
asthma. Many patients present with wheezing as well.
Treatment
Avoidance
The mainstay of all therapy for those with extrinsic allergies is the avoidance of
the allergen. It is important to close windows and stay in air-conditioned rooms
to avoid pollen. In addition, an allergy to animal dander may mean avoiding a
pet. Mattresses and pillows must be covered with mite and dust-proof casings.
Drug Therapy
··
Intranasal corticosteroids
··
Antihistamines such as loratadine, fexofenadine, and cetirizine
··
Intranasal antihistamines (azelastine)
··
Cromolyn
··
Ipratropium bromide
··
Leukotriene inhibitors (e.g., montelukast)
··
Nasal saline spray and wash
Intranasal steroids are
the single most effective
treatment for allergic
rhinitis.
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