ALLLERGIC DISORDERS An allergic reaction is a manifestation of tissue injury resulting from interaction between an antigen and an antibody.

y Allergy- an inappropriate & often harmful response of the immune system to normally harmless substances, called allergens. y Immunoglobulins- antibodies that are formed by lymphocytes and plasma cells in response to an immunogenic stimulus constitute a group of serum proteins. y Immunoglobulins of the IgE class are involved in allergic disorders & some parasitic infections, located in the respiratory & intestinal mucosa. y Release chemical mediators such as histamine, serotonin, kinins, slow-reacting substances of anaphylaxis & the neutrophil factor w/c produces allergic skin reactions, asthma & hay fever. y Complete protein antigens stimulate a complete humoral response y Low-molecular-weight substances function as haptens (incomplete antigens), binding to tissue or serum proteins to produce a carrier complex that initiates an antibody response. y Mast cells are located in the skin and mucous membranes that play a major role in IgE mediated immediate hypersensitivity. y Primary mediators- mast cells or basophils  Histamine- greatest effect w/in 15 minutes after antigen contact; include erythema, localized edema(wheals), pruritus, contraction of bronchial smooth muscle(wheezing &bronchospasm), dilation of small venules & constriction of larger vessels, secretion of gastric and mucosal cells(diarrhea)  Eosinophil chemotactic factor of anaphylaxis  Platelet-activating factorinitiating platelet aggregation  Prostaglandinssmooth muscle contraction, vasodilation & capillary permeability y Secondary mediators-inactive precursors formed in response to primary mediators  Leukotrienes- smooth muscle contraction, bronchial constriction, mucus secretions(airway)  Bradykinin- vascular permeability  Serotonin- potent vasoconstrictor  Hypersensitivity- a reflection of excessive or aberrant immune response to any type of stimulus; does not occur w/ the 1st exposure to an allergen, the reaction follows a re-exposure after sensitization in a predisposed person. y Anaphylactic (Type I)  Most severe hypersensitivity reaction y

 Characterized by edema in many tissues(larynx) & often accompanied by hypotension  Immediate reactions begins w/in minutes of exposure to antigen y Cytotoxic (Type II)  Occurs when the symptom mistakenly identifies a normal constituent of the body as foreign  May be a result of a cross-reacting antibody possibly leading to cell & tissue damage  Myasthenia gravis and goodpasture syndrome y Immune Complex (Type III)  Involves immune complexes that formed when antigens bind to antibodies  Joints and kidneys (susceptible to this type of injury)  Assoc. w/ SLE, RA, certain types of nephritis, & some bacterial endocarditis y Delayed- Type (Type IV)  Cellular hypersensitivity, occurs 24-72 hrs after exposure to an allergen  Mediated by sensitized T cells & macrophages  Contact dermatitis  ASSESSMENT y Comprehensive allergy hx & a thorough physical exam y Assess and document the degree of difficulty and discomfort experienced by the pt because of allergic symptoms y Assess and document the degree of improvement in those symptoms w/ or w/o treatment  DIAGNOSTIC EVALUATION y Blood tests, smears of body secretions, skin tests and RAST (Radioallergosorbent test) y CBC w/ Differential  WBC count is usually normal except w/ infection  Eosinophils make up 1% to 3% of the total number WBCs  A level between 5% and 15% is nonspecific but does not suggest allergic reaction y Eosinophil Count  Smears obtained from nasal secretions, conjuctival secretions and sputum allergic pts usually reveal eosinophils, indicating an active allergic response (Symptomatic episodes) y Total Serum Immunoglobulin E Levels  High total serum IgE levels- allergic disease  Not as sensitive as the PRIST and ELISA y Skin Tests  Entails the ID injection or superficial application of solution to several sites  Positive (wheal-and-flare) reactions are clinically significant when correlated w/ history, physical findings and results of other lab tests.

 Testing is not performed during bronchospasm  Epicutaneous tests- performed before other testing methods  Emergency equipments must be readily available yo treat anaphylaxis  Prick skin tests, scratch tests, ID skin testing  The back is most suitable area of the body for skin testing y Provocative Testing  Direct administration of the suspected allergen to the sensitive tissue  With observation of target organ response  Contact Dermatitis  Type IV delayed hypersensitivity reaction  Acute or chronic skin inflammation that results from direct skin contact w/ chemicals or allergens  Allergic, Irritant, Phototoxic, & Photoallergic  Itching, burning, erythema, skin lesions(vesicles) and edema; weeping, crusting & finally drying & peeling of the skin  Severe responses- hemorrhagic bullae  Repeated reactions- thickening of the skin & pigmentary changes  Secondary invasion by bacteria may develop skin that is abraided by rubbing or scratching  Atopic Dermatitis  Type I immediate hypersensitivity disorder characterized by inflammation & hyperactivity of the skin  Other terms: atopic eczema, atopic dermatitis/eczema, & atopic dermatitis/eczema syndrome (AEDS)  Elevations of serum IgE & peripheral eosinophils  Pruritus & hyperirritability of the skin, excessive dryness of the skin, lesions  Chronic w/ remissions and exacerbations  itching & scratching by wearing cotton fabrics, washing w/ mild detergent, humidifying dry heat, maintaining room temperature  Antihistamines, Topical corticosteroids and Immunosuppressive agents  Avoid animals, dust, sprays & perfumes  Keep the skin moisturized  Dermatitis Medicamentosa (Drug Reactions)  Type I hypersensitivity disorder  The term applied to skin rashes assoc. w/ certain medications  Rashes- most common adverse reactions  Pts are warned that they have hypersensitivity to a particular medications & are advised not to take it again  Pts should carry information identifying the hypersensitivity w/ them at all times

 Skin eruptions r/t medication therapy suggest more serious hypersensitivities  Urticaria & Angioneurotic Edema  Type I hypersensitive allergic reaction of the skin (Urticaria)  Characterized by the sudden appearance of pinkish, edematous elevations that vary in size and shape, itch & cause local discomfort  Involve the mucous membranes, the larynx and the GI tract  Remains for a few minutes to several hours before disappearing  For hours or days- clusters of lesions come, go and return episodically  Chronic urticaria- more than 6 weeks  Involves the deeper layers of the skin (Angioneurotic edema)  More diffuse swelling rather than the discrete lesions characteristic of hives  It covers the entire back; the skin over the reaction may appear normal but often has a reddish hue  Lips, eyelids, cheeks, hands, feet, genitalia, and tongue- most often involved  Mucous membranes of the larynx, bronchi and GI canal- hereditary type  Swellings may appear suddenly in a few seconds or minutes, or slowly in 1-2 hours  Appearance may precede by itching or burning sensations  Hereditary Angioedema  Symptoms are caused by edema of the skin, the respi tract or the digestive tract  Attacks may be precipitated by trauma or occur spontaneously  Swelling is diffuse, does not itch, not accompanied by urticaria, GI edema can cause abdominal pain  Last for 1 to 4 days and are harmless  Autosomal dominant trait  The pt should be observed carefully for signs of laryngeal obstruction  Epinephrine, Antihistamines, Corticosteroids  Food Allergy  Type I hypersensitivity reaction, Occurs in 6% to 8% in children,2% in adult population  Seafood, legumes, seeds, tree nuts, berries, egg white, milk, chocolate- most common offenders  Occur in people w/ genetic predisposition combined w/ exposure to allergens early in life through GI, respi and nasal tract  Urticaria, dermatitis,wheezing, cough, laryngeal edema, angioedema, itching, swelling, abdominal pain, nausea, vomiting, cramps and diarrhea  Detailed allergy history, physical exam, pertinent diagnostic tests, skin testing

 Elimination of the food responsible for the hypersensitivity   blockers, Antihistamines, Adrenergic agents, Corticosteroids, Cromolyn sodium  Teach pt & family members how to recognize & manage the early stages of an acute anaphylactic reaction  Prevent future exposure of the pt to the food allergen  Importance of assessing foods prepared by others  Avoid locations and facilities where those allergens are likely to be present  Latex Allergy  Allergic reaction to natural rubber proteins  At risk, health care workers, pts w/ atopic allergies or multiple surgeries, people working in factories that manufacture latex products, females, pts w/ spina bifida, food handlers, hairdressers, automobile mechanics, police  Cutaneous, Percutaneous, Mucosal, Oarenteral, Aerosol (ROUTES)  Irritant contact dermatitis, erythema, pruritus  Symptoms can be eliminated by changing glove brands or using powder free gloves  Delayed hypersensitivity to latex - Type IV reaction mediated by T cells in the immune system - Characterized by contact dermatitis, vesicular skin lesions, papules, pruritus, edema, erythema, thickening of the skin - Usually appears on the back of the hands  Immediate hypersensitivity - Type I allergic reaction mediated by the IgE mast cell system - Rhinitis, conjuctivitis, asthma, anaphylaxis, urticaria, wheezing, dyspnea, laryngeal edema, bronchospasm, tachycardia, angioedema, hypotension, cardiac arrest  Avoid latex based products Warning labels; Changing to nonlatex gloves  Antihistamines and emergency kit containing epinephrine  Avoid direct contact w/ latex based medical equipments  Nurses working in OR, ICU, short procedure units, ER need to pay particular attention to latex surgery  Pts must become knowledgeable about products containing latex and nonlatex products, s/sx of latex allergy & emergency treatment & self-injection of epinephrine in case of allergic reaction