Alterations in Immunological Status: Allergies, JRA
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Transcript of Alterations in Immunological Status: Allergies, JRA
Alterations in
Immunological Status:
Allergies, JRA
Allergies
Reactions involving immunologic mechanism,
usually IgE responses
Allergens
Foods (Box 13-2, p. 528 Hockenberry 9th ed.)
Lactose IntoleranceAvoid foods HIGH in lactoseInfancy-- Soy formula In older children NO MILK Lactaid, etc
Atopic Dermatitis (eczema) (Box 13-5.p
541) Treat pruritis and inflammation,hydrate skin, prevent 2ndary infectionsTopical corticosteroids—1st-line tx
Symptoms of Milk Allergy
p. 530 Box 13-3 (Hockenberry, 9th ed.)GIRespiratoryOthersPREVENT FOOD ALLERGIES
No solids for 4-6 months of ageUntil 12 months of age = no cow’s milk, eggs, fish, corn, citrus, peanuts, chocolateIntroduce foods 1 every 5-7 days
Drug Allergies
Usually skin responseOr
ANAPHYLAXSIS !!
Environmental
AirborneHouse dust mitesCigarette smokeCat/Dog Dander
DiagnosisHX & Physical
Skin Testing
Specific IgE Immunoassays—
No patient risk other than blood draw
Not influenced by medications
May be used for patient’s with rashes
Lower sensitivity than skin testing (~70%)
Only a potential of allergy
Not as cost effective as skin testing for
screening.
RAST test(Radio/allergo/Sorbent Test)—
Skin Testing
Prick
Safe for any ageRapidMultiple testsMinimal discomfortResults in 15 minutesOver 80% accuracy for inhalantsOver 90% accurate for foods
Intradermal
Not tolerated by young patientsMore sensitive (1000X)Results in 15 minutesIf negative, results are near 100% predictiveNot used for foods
TreatmentMeds—
Topical corticosteroids, Oral Antihistamines, Nasal steroid sprays, Leukotriene antagonists, Nasal antihistamines, oral decongestants
Desensitization shotsTakes months to show effect, over 80% efficacy
Environmental ChangesMattress & pillow covers; wash bed linens weekly
Ø carpet especially shag; reduce humidity level
Ø blinds; should be replaced with curtains
Ø pets; no stuffed animals unless washableFrequent filter changes on furnace
Treatment for Food Allergies#1—Avoidance!!Research studies are being performed at Duke and Mt. Sinai specifically focusing on food desensitizations
10 years from now, there may be other treatmentsAt this time, only research protocols exist
Management of Food AllergiesHave an individual management plan—know food triggersHave a Food Allergy Action PlanEducate yourself and others—know school interventionsSeek help from food allergy resources: www.foodallergy.org Join a food allergy support group
Epipen and Epipen Jr.
Epipen: patients over 66 lbs (33kg)Epipen Jr: patient 33 lbs –66 lbs (15-30kg)
Patients who require the use of an Epipen should go to the Evergency Room for further evaluation
TO MAKE SURE THE EMERGENCY IS OVERTO PREVENT RECURRENCE OF ANAPHYLAXIS (MAY OCCUR 6-8 HURS AFTER INITIAL SYMPTOMS)
Juvenile Rheumatoid Arthritis (JRA)
Inflammatory Disease with an unknown etiology
PathophysiologyNIH resource
Chronic inflammation of synovial lining of the joint with fluid buildup (effusion)
into joint space joint erosion, and adhesion
formation
Incidence
Also called juvenile chronic arthritis or idiopathic arthritis of childhoodPeak ages: 1to 3 years and 8 to 10 yearsGirls > boysOften undiagnosed
Prognosis
Actually a heterogenous group of diseases
Pauciarticular onset (involves ≤4 joints)Polyarticular onset (involves ≥5 joints)Systemic onset (high fever, rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy)
Poorest prognosis w/systemic onset; > 4
joints
Common symptoms
StiffnessPain & SwellingLoss of mobility in affected jointsWarm to touch, usually without erythemaTender to touch in some casesSymptoms increase with stressorsGrowth retardation
Affiliated symptoms
Iridocyclitis/uveitisInflammation of iris and ciliary bodyUnique to JRARequires treatment by ophthalmologist
90% children have negative rheumatic factorSymptoms may “burn out” and become inactive Chronic inflammation of synovium with joint effusion, destruction of cartilage, and adhesion formation as disease progresses
Diagnostic Evaluation
No definitive diagnostic testsElevated sedimentation rate in some casesX-ray 1st: widening of joint space,
2nd: fusion and articular erosionAntinuclear antibodies (ANA) common, but not specific for JRALeukocytosis during exacerbationsDiagnosis based on criteria of American College of Rheumatology
American College of Rheumatology Diagnostic Criteria
Age of onset younger than 16 yearsOne or more affected jointsDuration of arthritis more than 6 weeksExclusion of other forms of arthritis
Management Goals
Preserve Joint Function
Prevent Physical Deformity
Relieve Symptoms w/o further
complications
TreatmentExercise/PTMedications
NSAIDS Ibuprofen, Tolmetin, Naprosyn
SAARD’sD-Penicillamine, Gold, Quinine
OthersCytoxic drugs (Methotrexate) & Corticosteroids
TNF Blockers—new kid on the block
Etanercept (Enbrel) IM 2X/wk self administeredInfliximab (Remicade) IV q 2mos
Nursing Measures
Careful AssessmentAdminister medications and teach family about managementMoist heatReferrals
American Juvenile Arthritis Organizationhttp://www.arthritis.org