ALTERED IMMUNE RESPONSE

ALLERGIC REACTIONS

When the antigen is environmental or exogenous and triggers the immune process, it is called an allergy. The antigen that initiates the immune process is called an allergen.

Type:

There are two types of allergic reactions; Atopic and non-atopic disorders.

In atopic disorders there is an inherited local reaction to IgE and the production of antibodies. For example: allergic rhinitis, asthma and atopic dermatitis.

Non atopic dermatitis: It is not hereditary. For example: latex allergy. One type is type 1 and type 4 hypersensitivity reactions.

ANAPHYLAXIS

An immediate immunologic reaction (hypersensitivity) between a specific antigen and antibody is known as anaphylaxis. Anaphylaxis reactions occur when mediators release certain types of reactions. This is a life-threatening allergic reaction and can happen within minutes. (For example: after drug injection, after fly bite).

PATHOPHYSIOLOGY

Anaphylaxis is a rapid-onset severe allergic reaction that affects multiple body systems. The process is mediated by an immunologic reaction mediated by inflammatory mediators and cytokines released from mast cells and basophils, but often by nonimmunologic mechanisms.

IMMUNOLOGIC:

Immunoglobulin E (IgE) binds to an antigen in an immunologic mechanism. Foreign material activates an allergic reaction; Foreign material means an antigen introduced into the body from outside). Antigen-bound IgE activates the FcaRI receptor on mast cells and basophils, releasing inflammatory mediators such as histamine. These mediators then increase bronchial smooth muscle contraction, promote vasodilation, increase fluid leakage from blood vessels, and depress cardiac muscle. This is also an immunologic mechanism that does not depend on IgE, but it is not known whether it occurs in humans.

NON-IMMUNOLOGIC:

Non-immunologic mechanisms include substances that directly cause degranulation of mast cells and basophils. (Degranulation – This is a cellular process in which substances such as histamine are released when an allergen enters the body). These include factors such as different media, opioids, temperature (hot or cold) and vibration.

Foreign antigen

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Certain types of antibodies are present on mast cells and basophils

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This will release histamine and other bioactive mediators

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Now platelets, eosinophils and neutrophils will become active

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Vascular permeability will change and cause flushing, urticaria, angioedema and hypotension and bronchoconstriction.

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Bronchospasm, mucosal ED and inflammation will be present.

CAUSES OF ANAPHYLAXIS

Anaphylaxis is the process of response to any foreign substance. It usually involves insect bites or stings, food and medicine. Food-induced anaphylaxis reactions are more common in children, and anaphylaxis reactions to drugs and insect bites and stings are commonly seen in young adults and the elderly.

Less common causes include:

Physiological factors, biological agents such as latex (rubber), hormonal changes, semen (semen), food additives such as monosodium glutamate and food colors, and topical medications. Physiological factors such as exercise and exposure to temperature (hot or cold) also affect mast cells. Exercise is associated with eating a lot of food.

Common anaphylaxis reactions occur when anesthesia is administered to neuromuscular blocking agents, antibiotics, and latex.32-50% of cases have no known cause, called “idiopathic anaphylaxis”.

Food:

Many foods can cause anaphylaxis. This is mostly due to the food eaten at that time. Foods such as peanuts, wheat, shellfish, fish, milk, eggs, rice and chickpeas vary around the world and can also cause anaphylaxis. More severe cases can be caused by ingesting the allergen, but many people experience severe reactions simply by coming into contact with it.

Medication:

Any drug can trigger anaphylaxis. The most common are a-lactam antibiotics (such as penicillin) followed by aspirin and NSAIDs. Other causes include chemotherapy, vaccines, protamine, and herbal preparations. Many drugs (vancomycin, morphine) cause anaphylaxis by directly triggering mast cell degranulation.

Venom:

The venom of stinging and stinging insects such as Hymenoptera (bees and wasps) or Triatomine (kissing bugs) can trigger anaphylaxis in susceptible people. A systemic reaction, greater than a local reaction around the sting, is a risk factor for future anaphylaxis.

RISK FACTORS

People with atopic diseases such as asthma, eczema, or allergic rhinitis are at increased risk of anaphylaxis to foods, latex, and radiocontrast, but not to drug injections and stings.

CLINICAL MANIFESTATIONS

Symptoms of an anaphylaxis reaction appear within 5 – 30 minutes of exposure to the allergen that causes an allergy to you. In a few cases, symptoms of anaphylaxis appear more than an hour later.

Mild reactions: Itching at the site of exposure, tingling in the hands and feet, warmth, fullness in the mouth and throat, swelling around the eyes, sneezing and tearing in the eyes.

Moderate systemic reaction: Flushing, warmth, anxiety, itching are seen in it. In severe reactions, bronchospasm, airway swelling or phlegm, wheezing and difficulty breathing are seen.

Severe Systemic Reaction: It may cause severe bronchospasm, swelling of the larynx, difficulty in breathing, abdominal pain, cyanosis, hypotension, dysphagia (difficulty in swallowing food), vomiting, diarrhea and convulsions. This can lead to cardiac arrest and even coma.

DIAGNOSIS

Allergy tests are performed by an allergist or immunologist to determine the risk of anaphylaxis and whether it is related to previous symptoms. Your allergist will give you information about specific types of past allergens.

MANAGEMENT

Management depends on the severity of the systemic reaction. It assesses respiratory and circulatory functions.

Mild symptoms:

• 0.5 ml of epinephrine dilute 1 : 1000 subcutaneously or intramuscularly every 10 – 15 minutes is given to the patient as per the physician’s order.
• Antihistamines and corticosteroids are also given.

Moderate $ severe reaction :

• Maintain a patent airway.
• Giving oxygen therapy.
• 0.5 ml epinephrine intravenously given 5-10 minutes in case of severe reaction.
• Keep the patient warm.

.- Giving antihistamine if needed. For example: Benadryl (Diphenhydramine).

• Maintaining blood pressure with fluid volume expander, vasopressor (dopamine norepinephrine).
• Giving corticosteroids. For example: prednisolone, methylprednisolone.
• Monitor respiratory rate, SpO2, level of consciousness, cardiac rhythm.
• Intubate if the patient is in severe respiratory distress.
• Provide ventilatory support if needed.

NURSING MANAGEMENT

• Monitor airway, breathing and circulation (ABC).
• Assess vital signs (blood pressure, pulse, respiration, temperature) and SpO2.
• Maintain patency of intravenous (IV) line for administration of fluid and medicine.
• Keep intubation equipment ready if intubation is required.
• Give oxygen support if needed.
• Asking patient to avoid allergens to prevent anaphylaxis reaction (eg: Allergy test for drug or antibiotic to be given.)

ATOPIC ALLERGIC REACTIONS

Atopic allergic reactions include allergic rhinitis, asthma, atopic dermatitis, urticaria, and angioedema.

ALLERGIC RHINITIS

It is also known as hay fever or seasonal allergic rhinitis. This is a type-1 hypersensitivity reaction. Allergic rhinitis is caused by airborne particles, dust, pollen, weeds, grass, mold. It mostly affects the part of the conjunctiva of the eye and the part of the mucosa of the upper respiratory tract.

symptoms

• Sneezing
• Nasal congestion
• Clear and watery nasal discharge
• Itching in the nose
• Itching in the throat
• Soft palate and eye

Often the activation of the patient’s inflammatory mediators causes contraction of the smooth muscles of the airways and causes the patient to experience shortness of breath, cough, thick sputum, wheezing (this is an abnormal respiratory sound) and tightness in the chest.

ATOPIC DERMATITIS

It is a type-1 immediate hypersensitivity reaction caused by allergens in the environment. A patient has high levels of IgE.

• The patient has a family history of hypersensitivity.

Its symptoms include interstitial ED and vesicle formation due to vasodilation of blood vessels. The patient has itching, excessive skin irritation, skin dryness and sweating. If you repeatedly touch or scratch the skin, there is an immediate redness.

Atopic dermatitis

Urticaria (hives)

This is a type-1 hypersensitivity reaction characterized by transient wheals (pink, raised, inflamed and pus-filled areas), itching and local discomfort. They are found in any part of the body and vary in size and shape. It develops after exposure to an allergen and lasts for a few minutes or hours. Histamine is released and causes localized vasodilation, wheezing, and flaring, including mucus membranes, vocal folds, and the digestive tract.

Urticaria

ANGIONEUROTIC EDEMA

It is a type of local skin treatment. It also involves the deeper layers of the skin and is therefore more inflamed than a discrete lesion (lesions that have a distinguishable border). These lesions look normal on the skin but are often red hives. It mainly includes eyelids, lips, tongue, vocal cords, hands and feet, digestive tract and genital area. The swelling starts mainly on the face and then progresses to the airways and different areas of the body.

• Lesions are inflamed, sting or itch, and may cause abdominal pain if they are in the digestive tract.

Angioneurotic edema

CONTACT DERMATITIS

This is a type-4 delayed skin hypersensitivity reaction. Contact dermatitis occurs when the skin is exposed to direct allergens (for example; metals containing mercury or nickel, cosmetics, poisons, oak, rubber, etc.).

• Symptoms include itching, redness, inflammation, skin lesions (papules, vesicles and bullae) and swelling. It involves crusting, drying and finally peeling of the skin. Due to frequent occurrence of this, the skin thickens and pigmentary changes are observed.

Contact dermatitis

DIAGNOSTIC TEST FOR ALLERGIC DISORDERS

• Complete Blood Count (CBC)
• Radioallergio Sorbent Test (RAST)
• Test of pharyngeal, nasal and bronchial secretions to check the presence of eosinophils
• If you have asthma; Pulmonary function test and checking expiratory volume.
• Allergen test is followed by epicutaneous and intradermal skin test.

NURSING MANAGEMENT

• Check vital signs (temperature, pulse, respirations and blood pressure) frequently and check for hypotension, tachycardia and tachypnea.
• Check the skin for color, capillary refill, temperature and swelling.
• Checking the level of concentration.
• Take adequate health history to prevent allergic reactions, be aware of allergens and be aware of blood transfusions.
• Counseling the patient to identify allergens (eg meditation, food, insect and environmental allergens).
• Advise the patient to avoid exposure to pollen and mold by recognizing the seasons of the year.
• Identifying specific foods and medications that cause allergies.
• Advise the patient to reduce dust in the home and ask to wipe with a damp cloth.
• asking the patient to avoid using fur teddy bears, feather pillows and artificial flowers; Because it contains a lot of dust.
• Advise the patient to maintain a dust-free environment by removing dressings, curtains, rugs or carpets in the room.
• Counseling the patient about symptoms and treatment of previous allergic reactions.
• Closely care and monitor the patient after giving a new drug, after eating a food, after exposure to rubber or other allergens.
• Counseling the patient to recognize allergic reactions.
• Advising the patient to take the medicine as prescribed by the doctor.

Latex allergy

Latex allergy is a medical term that includes allergic reactions to natural rubber and synthetic rubber. A latex allergy is a reaction to certain proteins found in latex, which is caused by natural rubber, the milky liquid that comes from the rubber tree.

• Gloves and many other latex products are used in the healthcare sector. For example: lV tubing, syringes, oxygen masks, urinary catheters, adhesive tape. Gloves are powdered with corn starch and when removed these particles become airborne. This causes both the respiratory system and the skin to come into contact with latex.

Natural rubber is made from the liquid extracted from the latex rubber tree. Latex surgical gloves, balloons, condoms, rubber bands, rubber balls, baby feeding bottles – all contain natural rubber. The protein found in fruits such as bananas, avocados, chestnuts, kiwi and tomatoes is similar to the protein found in natural rubber. All these foods increase the chances of latex allergy.

TYPES OF LATEX ALLERGY

Type 4 allergic contact dermatitis and type 1 allergic reactions.

• Latex protein is the allergen that causes latex allergy. The more a person is exposed to latex proteins, the more likely they are to develop a latex allergy.

SYMPTOMS – symptoms

Symptoms such as itching, dryness, cracking of the skin followed by redness, swelling and crusting occur within 24-48 hours. Most often these symptoms are seen on the back of the hand. Prolonged exposure to this can lead to lichenification (thickening and hardening of the skin), scalig (roughening) and hyperpigmentation.

Type 1 hypersensitivity has rhinitis, asthma, conjunctivitis and anaphylaxis. Patients may present with urticaria, wheezing, dyspnea, sarcoid swelling, increased heart rate, in NGOED, hypotension and cardiac arrest.

DIAGNOSTIC EVALUATION

The doctor will know about the experiences and symptoms of latex allergy. Along with this, the doctor will do a complete physical examination so that any other medical problem can be identified.

Two other tests may also be advised:

1 – Skin Test :

In this test, the skin is punctured and exposed to latex and the reaction to the latex is identified. In this test, a small amount of latex is placed on the front or back of the skin of the hand. The skin is then pricked with a needle to release a small amount of latex under the skin. If you are allergic to this particular substance, it will look like a raised blister in the skin (allergic reaction). Only specific allergy centers are able to perform latex skin tests.

2- Blood Test :

A blood test checks the immune system’s response to latex, which is checked by allergy antibodies in the blood called immunoglobulin E antibodies. The blood sample is sent to a medical laboratory where it is checked for sensitivity to latex.

MEDICAL MANAGEMENT

• Avoid using products that contain latex.
• Using antihistamines and epinephrine.
• Ask health care providers to use non-latex products.
• Advise hand washing after removing gloves to minimize exposure to latex.

NURSING MANAGEMENT

• Obtain a thorough history from a health care provider to identify workers who are sensitive to latex.
• Assessment of risk factors in people with hay fever, asthma and certain food allergies.
• Asking people to use powder-free gloves.
• Using non-latex gloves
• Wash hands after removing gloves
• Clean the area where there is latex dust.

PREVENTING LATEX ALLERGY

Avoid using powdered gloves

• Latex gloves are often coated with a fine latex powder that helps them stick together. However, these powders carry latex proteins into the air, making them inhaled. Powder-free gloves help prevent the spread of latex proteins in the air, reducing the risk of latex allergy. So give your workers powder-free and low-protein latex gloves.

Choose gloves carefully

• To select non-latex gloves if available.
• Use thick rubber gloves rather than latex surgical gloves for housework.
• Do not wear gloves if not required. For example, there is no need to wear gloves while taking blood pressure or pulse.
• If gloves are required while preparing food, p…

Avoid using powdered gloves

Using latex gloves properly

FOOD ALLERGY

A food allergy reaction occurs when the immune system overreacts to a food or any substance in the food.

• A hypersensitivity reaction begins within minutes of exposure to an allergen (food). It is dangerous and can be treated immediately by giving an injection of epinephrine (adrenaline).
• The most severe allergic reaction is anaphylaxis – a life-threatening reaction to the whole body that causes shortness of breath, a drop in blood pressure (hypotension) and a drop in heart rate.

Foods which can cause allergy :-

egg

• Milk
• Peanuts
• Nuts of trees
• Seeds (sesame and mustard seeds)
• Fish
• Shellfish
• Wheat
• Soy products

symptoms

• Local reactions may cause nausea or vomiting
• Urticaria (systemic response when food is absorbed)
• Shortness of breath (shortness of breath, shortness of breath)
• whizzing sound
• Frequent cough
• Shock or circulatory collapse (not having proper blood circulation)
• Seen in angioedema (local tissue swelling) in the tongue, lips, hands, feet and genital area.
• Cracking in the throat and difficulty in swallowing
• Skin becomes pale (dull) or blue

All of these symptoms occur within about two hours of eating the food or within minutes. A late reaction (after 4-6 hours) may also occur. Eczema is mostly seen as a symptom in children.

DIAGNOSTIC TEST

1 – History taking in detail of symptoms

• How much and what has he eaten?
• How long did it take for symptoms to appear?
• What symptoms did you experience and how long did they last?

2 – Skin Test :

For food allergens, a small amount of food in liquid form is placed on or behind the skin, then the skin is pricked with a needle and the liquid is let down. If it looks like a raised blister then it is a positive test meaning that food is considered as an allergen.

3- Blood Test :

This test is done to know the amount of antibody IgE to any particular food.

TREATMENT

The main goal of treatment is to avoid the foods that cause the problem.

• Advising patients to carefully check labels on food products.
• Tell the patient to be careful while eating in any hotel.
• Epinephrine is a safe drug.
• Steroids (eg cortisone) can be given in an emergency.
• Antihistamines: Diphenhydramine (Bendryl) and Cetirizine can be given.
• Short acting bronchodilators can also be given.

SERUM SICKNESS

Serum sickness is a type 3 hypersensitivity reaction that can occur after injection of a heterologous or foreign protein or as a response to certain drugs such as penicillins and sulfonamides. This leads to the formation of IgG or lgM antigen-antibody immune complexes in the circulation. This complex is deposited in the walls of small blood vessels in the kidneys and joints.

ETIOLOGY – Causes

1 – Medicines :

Antitoxins (tetanum antitoxin), antivenoms, streptokinase vaccine, antibiotics (cephalosporin, ciprofloxacin, furoxane, metronidazole, penicillin, streptomycin, tetracycline, sulfonamide, allopurinol, barbiturates, carbamazepine, Methymagnol.

2 – Antibodies :

Monoclonal antibodies. For example: Infliximab (used in Crohn’s disease and rheumatoid arthritis), omalizub is used in the treatment of allergy-related asthma, rituximab is used to treat many diseases such as rheumatologic disorders, in lymphoma.

symptoms

• Fever (temperature of 104°F), usually preceded by a rash.
• Urticaria or itching and rash
• Arthralgia is mainly seen in finger and toe joints.
• Lymphadenopathy (swelling of the lymph nodes, mainly near the site of injection, in the neck and head).
• Getting tired
• Hypotension
• Glomerulonephritis
• Proteinuria (presence of protein in urine)
• Hematuria (presence of blood in urine)
• Mourning

DIAGNOSIS

Diagnosis can be made based on sufficient history from the patient and on the basis of current medications.

TREATMENT

• Symptoms usually disappear within 4-5 days after discontinuation of the drug causing the allergic reaction.
• Corticosteroids. For example: hydrocortisone and antihistamines and analgesics (ibrufen) are the main line of treatment.
• Plasmapheresis (removal of harmful components in plasma) can also be done.

PREVENTION

• Avoid antitoxins that induce serum sickness. It is the best way to prevent it.
• Skin test should be done before giving antibiotic (penicillin).