2002 Self-Assessment Exercise VIII. Allergy and related disorders [Return to Category List] Questions Question 16. Answer.

A 10-year-old boy has received allergen immunotherapy for allergic rhinitis for approximately 6 months. Fifteen minutes after receiving his latest injections, the nurse checks his arm. She requests that you evaluate it because he has some redness and swelling that is about 2 inches in diameter at the injection site. He has no other symptoms. Of the following, the MOST appropriate course of action is to: A. B. C. D. E. add saline to his next injection administer epinephrine decrease the dosage for his next injection discontinue immunotherapy re-evaluate him in another 15 minutes Answer.

Question 55.

A mother brings her 1-year-old son to your office because she thinks he is allergic to grass pollen. He has had intermittent rhinitis for several months. It is December, and the family lives in the northeast United States. Both parents have seasonal allergic rhinitis. Of the following, your BEST advice to the mother is to: A. B. C. D. E. begin a long-acting antihistamine to control the boys symptoms explain that he does have allergies, but he cannot be treated until he is older explain that it is not allergy because of the boys age and exposure history recommend an adenoidectomy to relieve his symptoms refer the boy to an allergist for testing for sensitivity to grass pollens Answer.

Question 97.

You are seeing a 4-year-old girl in the emergency department for treatment of an episode of anaphylaxis. She is currently taking amoxicillin for treatment of otitis media. She had just finished lunch today and taken her medication when she experienced respiratory difficulties, urticaria, and general discomfort. Lunch included foods she normally eats, except for a new

brand of chicken noodle soup and plain M & M's for dessert. She does not like eggs, and when she has eaten them in the past, she spat them out. Of the following, the MOST likely cause of her reaction is: A. B. C. D. E. drug allergy food allergy food poisoning serum sickness viral urticaria

Question 143. Answer. A 10-year-old boy who has hypertension needs a contrast study of his kidneys. He is allergic to shrimp, and his parents are worried that he will have a reaction to the iodine content in the radiocontrast media. Of the following, the MOST appropriate management is to: A. perform allergy tests for radiocontrast media

B. pretreat the child with antihistamines and corticosteroids 1 week prior to the procedure C. D. E. pretreat the child with antihistamines immediately before the procedure reassure parents that the risk of reaction is negligible undertake a food challenge with shrimp to confirm the diagnosis

Question 174. Answer. A frantic mother calls you in the early evening. The family has just returned from dinner at their favorite Mexican restaurant, and her 12-year-old son is complaining of abdominal pain and discomfort. He feels nauseated. The mother has just read an article on the Internet about food anaphylaxis, and she is concerned about his reaction. He has eaten all of the foods he ate tonight previously, but this time he ate a very spicy type of salsa. He has no other symptoms and no history of any other allergies. Of the following, the MOST probable type of reaction he is experiencing is: A. B. C. D. food sensitivity type I, immunoglobulin E-mediated type II, antibody-antigen complex type III, antibody-antigen complex with complement

E.

type IV, cell-mediated immunity

Question 217. Answer. Your practice group has decided to create a comprehensive plan of action for your patients who have asthma. You have been assigned to create the new hospital discharge plan. The current plan includes the initiation of inhaled corticosteroids, as-needed short-acting beta agonists, and tapering doses of prednisone that vary with the severity of the exacerbation. Of the following, The BEST option to add to the plan is: A. B. C. D. E. an assessment of asthma triggers daily oral antihistamines excuse from gym class for 2 months pneumococcal vaccine for children weekly spirometry for the 2 months following discharge

Answers Critique 16. Preferred Response: E

[View Question] Allergic rhinitis is treated by a variety of therapies. For mild-to-moderate symptoms, treatment with either oral antihistamines or topical therapy is extremely effective. The oral antihistamines are approved for children as young as 2 years of age. Some literature states that antileukotriene medications also are effective in allergic rhinitis. Topical therapies range from ipratropium bromide, which decreases secretions, to intranasal antihistamines and corticosteroids. Of these therapies, the intranasal corticosteroids are the most effective. Allergen immunotherapy is the most efficacious therapy for patients who have severe allergic rhinitis. It has several advantages over other therapies. First, it is the only therapy that eventually can cure patients of their allergies; all other therapies only provide symptomatic relief. Monthly allergen immunotherapy also is administered less frequently than the other therapies once maintenance levels are achieved. The duration of allergen immunotherapy is usually 5 years. Choosing the appropriate patient for immunotherapy is extremely important and should be based on a combination of the patients personal preference and the severity of disease. Many patients prefer monthly injections of immunotherapy to continuous topical or antihistamine therapy. Even once-daily administration can total approximately 800 doses a year of medication for a patient using oral and topical therapies. Also, many patients cannot tolerate topical or oral therapies due to sedation, lack of efficacy, or epistaxis. Allergen immunotherapy does have some risk. Indeed, even fatalities have been reported in rare cases. The most severe reactions usually occur in patients who are very atopic as well as asthmatic. The American Academy of Asthma, Allergy, and Immunology

recommends that all patients should receive allergen immunotherapy in a medical facility/office and be observed for 30 minutes after the injection for signs of anaphylaxis, including respiratory symptoms, lightheadedness, impending sense of doom, and urticaria. This time period was decided upon after a review of the literature that demonstrated that most patients had a reaction within 20 minutes of the allergen injection. It is also recommended that asthmatic patients be evaluated either by auscultation or peak-flow meter readings prior to receiving their injections. If they are symptomatic or have decreased pulmonary function, the immunotherapy should be delayed. Adverse reactions to immunotherapy can range from local reactions, which are characterized by pain and swelling at the site of the injection, to anaphylaxis. Local swelling can, in fact, encompass several centimeters, such as described for the boy in the vignette. Such a reaction 15 minutes after the injection requires careful re-evaluation in another 15 minutes to determine whether systemic symptoms are present. If no systemic symptoms arise by 30 minutes after the injection, the next step is to adjust the dosage of medication. Some patients will have pain at the site of the injection, which can be relieved by adding an equal amount of saline to the injection and/or changing the contents of the immunotherapy injection. Even in patients who experience anaphylaxis following an injection, immunotherapy is not contraindicated if the risks are outweighed by the benefits. For patients who do have a severe reaction, the first-line therapy is subcutaneous epinephrine. A recommended course involves placing a tourniquet above the site of the injection and administering two full-dose injections of epinephrine: one at the site of the injection to decrease absorption of the allergen and the other in the opposite arm for treatment of the symptoms. References: AAAI Board of Directors. American Academy of Allergy and Immunology. Guidelines to minimize the risk from systemic reactions caused by immunotherapy with allergenic extracts. J Allergy Clin Immunol. 1994;93:811-812 Druce HM. Allergic and nonallergic rhinitis. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1005-1016 Nelson HS. Immunotherapy for inhalant allergens. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1050-1062 Sly M. Allergic rhinitis. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:662-663 Critique 55. Preferred Response: C

[View Question] An allergy to pollens occurs only after repeated exposures and, thus, is rare before age 3 years. Because there are virtually no grass pollens in the northern United States in

December, it is nearly impossible for a child, such as the boy in the vignette, to have symptoms due to grass pollen allergy. Children who will be atopic commonly become so by the age of 5 years. In the northern climates of the United States, pollen seasons are discrete, making the history invaluable in determining the correct diagnosis. Tree pollen is present February through April, grass pollen from April through June, weed pollen from August to mid-September, and molds routinely from August through the first hard frost, although they can be present throughout the year. Children as young as 2 years of age can have allergies to animal dander and pollens, but usually they require significant exposure to develop reactions. Examples of significant exposure include having multiple pets in the home or a family member who is a landscaper or gardener and, thus, brings pollen into the home on his or her clothes. It is unlikely that the child described in the vignette has obstructive adenoidal tissue because his symptoms are intermittent. Thus, an adenoidectomy is not appropriate treatment. Referring the child to an allergist for allergy skin testing for pollens would not be appropriate because it is unlikely that the child has a pollen allergy. Many medications can be used to treat allergic symptoms in children, but none is approved for children younger than 2 years of age. References: Druce HM. Allergic and nonallergic rhinitis. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1005-1016 Naclerio R, Solomon W. Rhinitis and inhalant allergens. JAMA. 1997;278:1842-1848 Sly M. Allergic rhinitis. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:662-663 Critique 97. Preferred Response: B

[View Question] The child described in the vignette has classic symptoms of anaphylaxis: respiratory difficulties, urticaria, and generalized discomfort. Many patients who experience anaphylaxis describe an impending sense of doom. Studies have demonstrated that patients who do not have an urticarial rash are at much higher risk of death than those who have one. The most likely cause of this childs anaphylaxis is a food allergy. Because she has been receiving amoxicillin for several days, it is unlikely that the reaction is due to that medication. The history of disliking eggs and usually not eating them provides a clue to the potential food allergy; many children who have a food allergy will refuse to eat the offending food long before the food is identified as an allergen. The primary cause of anaphylaxis in children is foods; bee stings and drugs are much less likely causative agents. The primary food allergens in infants and toddlers are eggs, milk, wheat, and soy. Among older children, shellfish, fish, nuts, and peanuts are also common triggers.

The mainstay of therapy for anaphylaxis is administration of subcutaneous epinephrine. Studies have demonstrated that patients in whom administration of the initial epinephrine is delayed have a higher mortality rate than those who are promptly given epinephrine. Patients usually have symptoms within 10 minutes of ingestion, but may not develop all the symptoms of anaphylaxis for up to 2 hours after the ingestion. Accordingly, epinephrine should be given at the first sign of symptoms, and the child should be transferred promptly to a medical facility. Food poisoning does not cause respiratory difficulties or urticaria. Serum sickness can cause urticaria and general discomfort, but it is not abrupt in onset and does not have respiratory symptoms. Viral urticaria is not seen acutely in a previously well child. References: deShazo RD, Kemp SF. Allergic reactions to drugs and biologic agents. JAMA. 1997;278:18951906 Lieberman P. Anaphylaxis and anaphylactoid reactions. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1079-1092 Sampson HA. Adverse reactions to foods. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1162-1182 Sampson HA. Food allergy. JAMA. 1997;278:1888-1894 Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med. 1992;327:380-384 Critique 143. Preferred Response: D

[View Question] Adverse reactions occur in 4% to 13% of patients who are administered radiocontrast media. These reactions long have been thought to be associated with allergy to seafood perhaps due to iodine. However, studies have documented no association between seafood allergy and reactions to radiocontrast media. Rather, the reaction to radiocontrast media is caused by the hypertonic nature of the media. Fatal reactions usually occur in patients between the ages of 20 and 50 years at a rate ranging from 1 in 100,000 to 170,000. These reactions are not thought to be mediated by immunoglobulin E. Instead, it is believed that the osmolality/hypertonicity of the radiocontrast media causes degranulation of the mast cells and basophils, releasing their mediators. For most patients undergoing contrast studies, including the boy described in the vignette, no preventive therapy is needed prior to the study because the risk of anaphylaxis is low (0.04% to 0.36%).

The administration of antihistamines has been shown to be beneficial for patients who have a history of adverse reactions to radiocontrast media and need repeat studies. The following regimen is employed: 1. prednisone 1 mg/kg up to 50 mg at 13 hours, 7 hours, and 1 hour before the procedure; 2. diphenhydramine 1 mg/kg up to 50 mg 1 hour before the procedure; 3. in some cases, ephedrine 25 mg 1 hour before the procedure; 4. use of low-osmolality radiocontrast media. This combination has decreased the risk of reaction to 0.7% to 3.1% and the fatality rate to 0 to 0.04%. Pretreating a child with antihistamines and corticosteroids 1 week prior to the study is too long before the procedure. Pretreatment with only antihistamines is not adequate. There is no allergy testing for radiocontrast media because the trigger is the hypertonicity of the media. Evaluating for a shrimp allergy is not helpful because the adverse reactions are unrelated. References: deShazo RD, Kemp SF. Allergic reactions to drugs and biologic agents. JAMA. 1997;278:18951906 Lieberman P. Anaphylaxis and anaphylactoid reactions. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1079-1092 Critique 174. Preferred Response: A

[View Question] Distinguishing between anaphylaxis and food poisoning can be difficult because many foods can cause a variety of different responses. The following examples and others are grouped in a category termed food sensitivities. For example, caffeine has a diuretic affect, beans create flatus, and spicy foods can cause abdominal discomfort. Food poisoning is a very general term that is used when a person has a significant reaction to a food or meal. In the strict definition, it relates to a toxin-mediated event, as in scombroid poisoning due to contaminated fish, or proliferation of a pathogenic organism, such as Salmonella. Therefore, identifying the cause of symptoms after ingesting foods depends on a good history and knowing the different types of reactions that can occur. There are four types of immunologic reactions. Food allergies represent a Type I reaction. Type I immunoglobulin E (IgE)-mediated antigen-antibody response is an allergic reaction and may progress to anaphylaxis. Antigen crosslinks IgE molecules attached to a mast cell, causing degranulation and the signs and symptoms of anaphylaxis. In a Type II

reaction, IgG antibody plus an antigen cause a reaction. An example is Rh incompatibility in which maternal IgG antibodies cross the placenta, attach to fetal red blood cells and destroy them, causing hemolysis. In Type III reaction, IgG antibody-antigen complexes react with complement. Serum sickness is an example of this reaction in which an antibody binds to an antigen and is deposited in the skin or other organs where it activates the complement cascade. A Type IV reaction is delayed hypersensitivity, as seen in tuberculin skin testing in which T cells react to an antigen. The child described in the vignette has no history of food allergy. He has eaten a very spicy food, and his abdominal discomfort is most consistent with a nonallergic reaction to eating a very spicy meal. Although anaphylaxis can result in only abdominal symptoms, a constellation of symptoms is more indicative of these reactions. This constellation of symptoms includes respiratory difficulties, lightheadedness, fainting, urticaria, and an impending sense of doom. The diagnosis of food sensitivity is supported by the lack of other symptoms or history of any atopy. References: Sampson HA. Adverse reactions to foods. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1162-1182 Sampson HA. Food allergy. JAMA. 1997;278:1888-1894 Sly M. Adverse reactions to foods. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:695-697 Critique 217. Preferred Response: A

[View Question] Identifying the triggers of asthma exacerbations assists the clinician in planning discharge therapy, including future medications. For example, if an upper respiratory tract infection is found to be the trigger, the hospitalization may have been unavoidable. However, if there were no triggers and the admission was due to noncompliance with therapy, a change in management may be appropriate. If the trigger is an allergen, identification and removal of the allergen will be extremely helpful. Returning a child to an environment in which there is an allergen trigger may result in repeated hospitalizations despite appropriate medications. In contrast, elimination of a trigger, such as home remodeling, a new pet, or the addition of a feather pillow, may be the first step toward dramatic improvement in the childs overall health. The use of daily oral antihistamines is an inappropriate part of a discharge plan unless the child has been identified as atopic. Excusing a child from gym is not helpful because asthmatic children need regular exercise. Only the rare child who has severe disease should be excused from activities. The pneumococcal vaccine is recommended for all children younger than age 2 years, but it is not normally included as part of a standard

asthma plan. Although weekly spirometry would allow for charting a childs slow improvement over time, it is of little clinical benefit. The use of peak flow meters has met with differing opinions. Almost all experts agree that their use is helpful in the extremely compliant and motivated patient. Many experts feel, though, that their use sometimes interferes with the patients therapy because it adds a step and actually may decreases overall compliance. Peak flow meters generally are not used in children younger than 6 years of age. References: AAAAI Initiatives: Update on pediatric asthma: promoting best practice. Available at: http://www.aaaai.org/professional/initiatives/pediatricasthmaguidelines/default.stm. Lemanske RE Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900 National Asthma Education Program, Expert Panel II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997;No. 97-4051 2001 Self-Assessment Exercise VIII. Allergy and related disorders [Return to Category List] Questions [Print Directions] Question 10. Answer.

One month ago you prescribed sodium cromolyn three times a day for a 7-year-old patient who has mild persistent asthma. She states that she feels much better. Of the following, the BEST explanation for her improvement is that A. B. C. D. E. cromolyn sodium has anti-inflammatory effects cromolyn sodium is an excellent bronchodilator no allergens currently are present she has outgrown her asthma the cold and flu season has passed Answer.

Question 35.

You have been asked to evaluate a 7-year-old boy who has moderate persistent asthma. He has not seen any primary care physician for more than 6 months. You decide to formulate an appropriate treatment plan for him.

Of the following, the BEST maintenance therapy is A. B. C. D. E. inhaled beta-agonist inhaled corticosteroid daily leukotriene receptor antagonist daily nebulized cromolyn sodium oral theophylline Answer.

Question 60.

You are evaluating a 12-year-old boy who, for the past year, has had wheezing that occurs during exercise. He states that he begins to wheeze shortly after beginning any physical exertion. He also complains of a nighttime cough that interferes with his sleep. Of the following, the MOST likely diagnosis is A. B. C. D. E. cough variant asthma exercise-induced asthma poor physical conditioning poorly controlled asthma upper respiratory tract infection Answer.

Question 91.

A 5-year-old boy from Philadelphia has had nasal congestion and sneezing throughout the spring. His mother feels that these symptoms are due to his excessive milk consumption. She eliminated whole milk from his diet 1 week ago, but his symptoms have not improved. Of the following, the MOST likely cause of this child's persistent symptoms is A. B. C. D. E. dust mite allergy food allergy, but not to milk milk allergy outdoor pollen allergy upper respiratory tract infection

Question 116. Answer. A 12-year-old boy presents with urticaria of 8 weeks' duration. Four weeks ago you evaluated him for allergies, and the results were negative. History reveals that he has a pet bird and is a conscientious student. His father has recently become unemployed. A review of

systems produces unremarkable findings. Results of an erythrocyte sedimentation rate, complete blood count with differential, liver function tests, and thyroid function tests are normal. Of the following, the MOST likely cause of this boy's chronic urticaria is A. B. C. D. E. a viral infection allergic reaction to a pet bird drug allergy food allergy stress reaction

Question 141. Answer. As part of a 4-year-old child's health supervision visit, you discuss his moderate persistent asthma with his mother, reinforcing the need to use preventive medicine. You also review the appropriate treatment plan for him when he has an acute exacerbation. Of the following, the MOST appropriate first-line therapy for an acute exacerbation of asthma is A. B. C. D. E. high-dose inhaled corticosteroids inhaled anticholinergic bronchodilators inhaled long-acting beta-agonists inhaled short-acting beta-agonists leukotriene receptor antagonists

Question 167. Answer. You are seeing a 6-year-old girl for her quarterly asthma evaluation. She had been well until the age of 4 years. At her last visit, you prescribed an inhaled corticosteroid. She has continued to have significant symptoms, with coughing occurring at night and with exercise. The child and her mother both insist that she is using the inhaler twice a day, as you prescribed. Of the following, the MOST likely reason for her poor response to the therapy is that A. B. C. D. the asthma is responding poorly to inhaled corticosteroids the child and parent are not telling the truth about compliance the girl has cystic fibrosis the girl is not using the metered dose inhaler correctly

E.

theophylline must be added to the regimen

Question 198. Answer. A mother brings in her teenage daughter for evaluation of difficulty in breathing. The mother believes the symptoms are due to asthma and has given the girl a trial of her own albuterol inhaler, but the daughter has not responded after 2 hours. The mother is concerned because albuterol works faster for her. She requests information about the onset of action of albuterol. Of the following, the MOST appropriate response is that albuterol has A. B. C. D. E. peak effect in 2 minutes, duration of 2 hours peak effect in 5 minutes, duration of 8 hours peak effect in 10 minutes, duration of 6 hours peak effect in 15 minutes, duration of 4 hours peak effect in 30 minutes, duration of 12 hours

Question 223. Answer. A 17-year-old boy presents to the emergency department immediately after being stung on the lip by a yellow jacket. He has significant swelling of his face and diffuse urticaria on his body. Of the following, the BEST management for this boy is A. B. C. D. E. intramuscular antihistamines intravenous corticosteroids no treatment referral to allergist subcutaneous epinephrine

Question 248. Answer. A 14-year-old boy who lives in the inner city is experiencing difficulty controlling his asthma. His wheezing occurs primarily during exercise, and he is having trouble completing his summer football workouts. He feels that some weeks have been better than others. Of the following, the MOST likely cause of his increased symptoms is A. B. C. a new pet cat decreasing efficacy of his asthma medication expected seasonal exacerbations of asthma

D. E.

summer upper respiratory tract infection unhealthy air quality

Answers Critique 10. Preferred Response: A

[View Question] Cromolyn sodium is an excellent anti-inflammatory agent that is believed to work by stabilizing mast cells or other, yet undefined mechanisms. Its efficacy in mild persistent asthma is well proven. Cromolyn sodium is not a bronchodilator. Initially it was delivered in a dry powder form, which caused some bronchial constriction, but the new metered dose inhaler and nebulized solution forms have eliminated this side effect. It is unlikely that all of the allergens that initially triggered this girls symptoms have disappeared. It also is not possible for a child to outgrow asthma within 1 month. Even if cold and flu season has ended, it would not result in such a dramatic improvement in only 1 month. References: AAAAI Initiatives: Update on Pediatric Asthma: Promoting Best Practice. Available at: http://www.aaaai.org/professional/initiatives/pediatricasthmaguidelines/default.stm Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, et al, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Sly RM. Asthma. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:664-679 Critique 35. Preferred Response: B

[View Question] The treatment for chronic asthma is based upon the severity of the disease. Severity is classified according to the symptomology (eg, cough at night, cough with exercise), need for beta-agonist medication, and results of pulmonary function tests. The National Heart, Lung, and Blood Institute Guidelines for the Diagnosis and Management of Asthma recommend that patients be started on aggressive therapy, then stepped down to the lowest amount of therapy that maintains good control. A person who has well-controlled asthma is defined as someone needing fewer than two treatments of a

beta-agonist per week. The Guidelines outline specific levels of therapy based on disease classification. A child who has moderate persistent asthma is considered to have significant disease. These patients have symptoms on a daily basis, nocturnal symptoms more than once a week, and pulmonary function findings that are significantly decreased. Therefore, the appropriate course of therapy includes an inhaled steroid at either a medium or low dose. If the patient is having nocturnal symptoms, a long-acting beta-agonist or leukotriene antagonist should be considered. Children who have moderate persistent asthma require inhaled corticosteroids several times daily, not just on an as-needed basis. A leukotriene receptor antagonist or cromolyn sodium on a daily basis eventually may be required for the boy described in the vignette, but his symptoms are severe enough to warrant more aggressive therapy at this time. Oral theophylline is only a bronchodilator and, therefore, would not be appropriate as the sole therapy. The child described in the vignette requires a chronic anti-inflammatory medication to control his disease. Theophylline can be an effective adjunctive therapy in some patients instead of a long-acting bronchodilator, but the long-acting inhaled betaagonists are considered more effective and easier to administer than oral theophylline. References: AAAAI Initiatives: Update on Pediatric Asthma: Promoting Best Practice. Available at: http://www.aaaai.org/professional/initiatives/pediatricasthmaguidelines/default.stm Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, et al, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Sly RM. Asthma. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:664-679 Critique 60. Preferred Response: D

[View Question] Poorly controlled asthma is commonly misdiagnosed as exercise-induced asthma. Exerciseinduced asthma by definition occurs toward the end of exercise, but more commonly after the patient has stopped exercising. It usually takes up to 10 minutes for symptoms to appear. In contrast, the child described in the vignette develops symptoms shortly after beginning exercise, which is more characteristic of poorly controlled asthma in which symptoms worsen immediately upon exercising. The poorly controlled asthma makes it impossible for him to complete any significant amount of physical activity. The symptom of nighttime cough also is indicative of chronic asthma. Occasionally, a child who has exercise-

induced asthma will experience symptoms at night after exercising, which is a late-phase reaction. An upper respiratory tract infection would not be associated with long-term symptoms. Poor physical conditioning may result in a child becoming out of breath, but not developing wheezing. Differentiating out of breath from short of breath is very difficult based only on history. Many children will complain that they cannot walk a flight of stairs without their asthma bothering them, especially if they are poorly conditioned. However, this response often is due to poor conditioning. Peak flow meter readings are extremely helpful in making the distinction. A child who is out of breath due to poor conditioning will have normal peak flow meter readings; a child who is short of breath as a result of poorly controlled asthma will have decreased values. The significant wheezing reported by the boy described in the vignette eliminates the diagnosis of cough variant asthma. References: AAAAI Initiatives: Update on Pediatric Asthma: Promoting Best Practice. Available at: http://www.aaaai.org/professional/initiatives/pediatricasthmaguidelines/default.stm National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Critique 91. Preferred Response: D

[View Question] Pollen allergies are more common among children who are older than 4 years of age, and food allergies are more common among younger children. The symptoms experienced by the child described in the vignette are more consistent with a pollen allergy than a food allergy. Further, 5 years of age is the common age of initial presentation of allergic rhinitis. Families routinely blame food allergy for a variety of allergic symptoms. Foods commonly are a trigger for eczema or anaphylaxis in the child younger than 3 years of age; children have been found to be allergic to foods as early as several days of life. These children are sensitized in utero, making them allergic virtually at birth. However, food allergies rarely if ever cause rhinitis or asthma. The most common sensitizing foods in children younger than age 7 are eggs, milk, and wheat. Eggs, milk, wheat, peanuts, and seafood are the most common allergens among those older than 7 years. It is unlikely that the symptoms experienced by the boy described in the vignette are caused by upper respiratory tract infection because they have been occurring for several weeks. Dust mite allergy results in symptoms throughout the year unless a new item has been brought into the bedroom. References: Sampson HA. Adverse reactions to food. In: Middleton E Jr, Ellis EF, Yunginger JW, et al, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1162-1182

Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med. 1992;327:380-384 Sly RM. Adverse reactions to foods. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:695-697 Critique 116. Preferred Response: E

[View Question] Chronic urticaria (Figure 116A) is a difficult entity to diagnose and treat properly. The causes differ, depending on the duration of the symptoms. Urticaria of less than 6 weeks duration is considered acute, and the primary cause is often viral infections or occasionally recent streptococcal infections. Determining the etiology for chronic urticaria is more difficult because the potential etiologies are more extensive. However, etiologic determination is somewhat easier in children than adults because the incidence of occult malignancy and autoimmune disease is much lower. The evaluation for chronic urticaria usually begins with eliminating the most common causes, but rarely is a definitive etiology identified. The normal laboratory results determined for the boy in the vignette eliminate liver disease, autoimmune disease, infection, and thyroid disease as potential etiologies. An upper respiratory tract infection is a common cause of urticaria, but in this child the infection occurred several weeks after the onset of urticaria. Viral urticaria can occur weeks or months after an exposure, but that is a diagnosis of exclusion. A bird rarely causes chronic symptoms of urticaria because its feathers are contained within a cage and would not cause a systemic reaction. Foods and drugs can cause urticaria, but this finding usually is in the context of a more severe allergic reaction. Further, the urticaria would occur only when the medication or food was ingested and would not continue for 8 weeks after the ingestion. One diagnosis of exclusion for urticaria is stress. The child who has stress-induced urticaria usually has somatic symptoms at other times in his life, such as headaches and abdominal pain. Because the father of the child in the vignette recently became unemployed, it is likely that the boy and his family are under stress. Children who develop urticaria in such a situation frequently have conscientious personalities and are compulsive and driven to complete tasks. An effective treatment plan for the child described in the vignette includes identifying and addressing the stress that is causing the urticaria, which may be induced at school or home. Therapy is primarily supportive once other etiologies are excluded. The mainstay of treatment is chronic antihistamine therapy; second-generation formulations (eg, loratadine, cetirizine, fexofenadine) are very effective. Cautious use of oral corticosteroids is indicated if antihistamines do not control the urticaria. If oral corticosteroids are not effective, the stress inducers may need to be addressed more directly. References:

Kaplan AP. Urticaria and angioedema. In: Middleton E Jr, Ellis EF, Yunginger JW, et al, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1104-1122 Sly RM. Urticaria-angioedema. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:684-685 Critique 141. Preferred Response: D

[View Question] The most appropriate first-line therapy for an exacerbation of asthma is an inhaled shortacting beta-agonist. These agents have an onset of action of 15 minutes and a duration of action of up to 4 hours. The use of high-dose inhaled corticosteroids is recommended for patients who have asthma, but it is not helpful for acute exacerbations. Some studies have implied that high-dose inhaled corticosteroids may obviate the need for a course of oral corticosteroids, but this has not been proven conclusively and must be implemented carefully. A long-acting beta-agonist is contraindicated in an acute exacerbation of asthma because its onset of action is 30 minutes. Leukotriene receptor antagonists have no place in the treatment of an acute exacerbation because they are not bronchodilators. Inhaled anticholinergic bronchodilators are not as effective as beta-agonists in an acute situation. They have been shown to be effective in patients who are still symptomatic after receiving a significant amount of beta-agonist. Frequently they are used in an alternating manner with inhaled short acting beta-agonists. The dose of an inhaled short-acting beta-agonist can be repeated as often as needed; in the inpatient setting, they frequently will be administered continuously. Shortacting beta-agonists have a very wide therapeutic index and, therefore, can be used safely. Patients who do not respond to this medication should be transferred to a setting where more aggressive therapies can be implemented. References: AAAAI Initiatives: Update on Pediatric Asthma: Promoting Best Practice. Available at: http://www.aaaai.org/professional/initiatives/pediatricasthmaguidelines/default.stm Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, et al, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Sly RM. Asthma. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:664-679 Critique 167. Preferred Response: D

[View Question]

The child described in the vignette most likely is continuing to experience symptoms because she is not using the metered dose inhaler (MDI) properly and, therefore, is not receiving a therapeutic dose of the corticosteroid. It has been shown that improper use of MDIs is common. Inhaled medications differ substantially from orally administered medication. With oral drugs, the dose prescribed generally is the dose delivered, but with inhaled drugs, the patients ability to inhale it affects the amount of medication that is delivered. Additionally, the medication is delivered to areas of the body other than the respiratory tract, such as the oral pharynx and the alimentary canal. A child who does not use an MDI properly will not receive an optimal dose of medication; approximately 80% to 90% of the medication will be deposited in the oropharynx or swallowed and only 10% to 15% will be delivered to the lungs. Proper MDI technique is especially important when delivering inhaled steroids. Inappropriately delivered inhaled steroids are associated with a higher incidence of adverse effects such as hoarseness and oral thrush and are less beneficial because inadequate amounts reach the lower airways. Use of a spacer device with an MDI increases the chances of delivering the correct dose to the respiratory tract. Almost all spacing devices work by creating a holding area in which the medication rests until the child inhales, although the devices vary greatly. A true spacer has a one-way valve that allows the patient to receive the medication upon inhalation, but does not deliver it into the oral pharynx when the MDI is actuated. Another advantage of spacer use is that nonrespirable, large particles of the medication (>10 microns) are deposited into the spacer and are not inhaled, which decreases the total dose and potentially decreases the incidence of adverse effects. All patients respond at least minimally to proper doses of inhaled corticosteroids, although some may require additional medication. The addition of theophylline to this childs regimen may be helpful, but she will benefit more from receiving a full dose of the inhaled corticosteroid. The symptoms described for the girl in the vignette are much more characteristic of poorly controlled asthma than cystic fibrosis. References: AAAAI Initiatives: Update on Pediatric Asthma: Promoting Best Practice. Available at: http://www.aaaai.org/professional/initiatives/pediatricasthmaguidelines/default.stm Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, et al, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Sly RM. Asthma. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:664-679

Critique 198.

Preferred Response: D

[View Question] Albuterol is the most commonly prescribed beta-adrenergic agonist for asthma. Its onset of action is 15 minutes, and it has a duration of action of 4 hours, which makes it appropriate for use as a rescue medication. It has been shown to have a shorter duration of action in patients who have severe airway obstruction. Other beta-adrenergic agonist agents, such as metaproterenol and pirbuterol, have similar onsets and durations of action. Newer medications will be available in the near future that will have a similar onset of action, but a duration of action of 12 hours. References: Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, et al, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Critique 223. Preferred Response: E

[View Question] Treatment for Hymenoptera sting (Figure 223A) varies substantially, based on a childs age. Children younger than 16 years of age who have diffuse urticaria have no greater risk of anaphylaxis than the general population. Children who are older than 16 years must be treated as adults, and diffuse urticaria, such as that described for the boy in the vignette, is considered a systemic, life-threatening reaction. Any patient who experiences a systemic reaction to a bee sting eventually must be referred to an allergist for a complete evaluation. The allergist can perform testing to identify whether the patient is truly allergic and provide therapy to reduce his or her future risk for anaphylaxis. However, the best initial treatment for the boy described in the vignette is administration of subcutaneous epinephrine to address the acute anaphylactic reaction. In the absence of systemic manifestations, oral or intravenous antihistamines would be appropriate. Intramuscular antihistamines are not helpful and actually would be counterproductive because they have a delayed onset of action. Similarly, intravenous corticosteroids require up to 1 hour for the onset of action, making them unhelpful for acute reactions. The life-threatening quality of this boys reaction mandates therapy; no treatment might be an option if he was younger than 16 years of age. The dose of subcutaneous epinephrine varies by patient weight, but many patients require more than a single dose. The dose may be repeated every 5 to 10 minutes if there is no response to the initial therapy. References:

Barach EM, Nowak RM, Lee TG, Tomlanovich MC. Epinephrine for treatment of anaphylactic shock. JAMA. 1984;251:2118-2122 Savliwala MN, Reisman RE. Studies of the natural history of stinging-insect allergy: long-term follow-up of patients without immunotherapy. J Allergy Clin Immunol. 1987;80:741-745 Yunginger JW. Insect allergy. In: Middleton E Jr, Ellis EF, Yunginger JW, et al, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1063-1072 Critique 248. Preferred Response: E

[View Question] The child described in the vignette is having symptoms only when he exercises, which suggests that the trigger is either related to exercise or is an irritant to which he is exposed at the time of exercising. Exercise-induced bronchospasm is characterized by the occurrence of symptoms approximately 10 minutes after exercise, rather than during exercise. Poorly controlled asthma could worsen with exercise, but symptoms would be present at other times as well. When the air quality is unhealthy, pollutants adversely affect patients who have a variety of respiratory diseases, including asthma. The pollutants cause a nonspecific hyperreactivity that leads to respiratory symptoms such as those experienced by the patient in the vignette. It had been thought that unhealthy air quality was a leading factor in the increase that has been documented in asthma symptoms and deaths. However, a study examining asthma mortality and air quality in Philadelphia demonstrated that despite significant improvements in air quality from the 1970s to the 1990s, asthma death rates and incidence continued to rise. Asthma medications do not lose their efficacy. Patients can become less responsive to excessively used beta-agonist therapy through downregulation of beta receptors. However, a patient whose asthma is well-controlled should be using the beta-agonist medication only a few times a week, which is not frequent enough to downregulate the receptors. Patients who have asthma experience greater difficulty in controlling symptoms at certain times of the year, but the worst season typically is the winter because of exposure to colder temperatures and numerous viral infections. A new antigen in a patients environment, such as a pet cat, would cause chronic rather than intermittent symptoms. A viral upper respiratory tract infection would cause only a short-term exacerbation, not a prolonged one, as described for the patient in the vignette. References: Lang DM, Polansky M. Patterns of asthma mortality in Philadelphia from 1969 to 1991. N Engl J Med. 1994;331:1542-1546 Orenstein DM. Bronchitis. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:1284-1285

Wiesch DG, Samet JM. Epidemiology and natural history of asthma. In: Middleton E Jr, Reed CE, Ellis EF, et al, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:799-815 2000 Self-Assessment Exercise VIII. Allergy and related disorders [Return to Category List] Questions [Print Directions] Question 23. Answer.

A teenage patient asks you about recent advances in asthma therapy for his science project. You describe a new class of agents called antileukotrienes. Of the following, the BEST response concerning the impact of this new class of drugs on the lives of patients who have asthma is that the antileukotrienes A. B. C. D. E. are equal in effectiveness to theophylline have decreased the mortality rate due to asthma have eliminated the need for beta-agonist medication have had no impact show promise for better control and convenience Answer.

Question 24.

A 12-year-old boy is brought to the emergency department because of lethargy and poor oral intake. On physical examination, his blood pressure is 110/70 mm Hg and his pulse is 120 beats/min. Results of laboratory evaluation include: creatinine, 0.7 mg/dL; sodium, 125 mEq/L; potassium, 5.4 mEq/L; chloride, 90 mEq/L; bicarbonate, 15 mEq/L; glucose, 1,000 mg/dL; calcium, 9.0 mg/dL; phosphorus, 2.5 mg/dL. The MOST likely explanation for this hyponatremia is A. B. C. D. E. dehydration hyperglycemia hypophosphatemia metabolic acidosis syndrome of inappropriate antidiuretic hormone secretion Answer.

Question 43.

A 10-month-old boy has a history of repeated bouts of sinusitis and chronic otitis media. He has been hospitalized twice for treatment of pneumonia. Physical examination reveals no

palpable lymph nodes and absent tonsillar tissue. Results of laboratory testing include a normal complete blood count and nondetectable levels of immunoglobulin A (IgA), IgE, IgG, and IgM. Of the following, the most appropriate INITIAL management of this child is A. B. C. D. E. antibiotic prophylaxis bone marrow transplantation granulocyte transfusions monthly intravenous immune globulin infusions splenectomy Answer.

Question 64.

A 15-year-old patient who has stable asthma brings you a school medical form to complete. The only medication she is receiving is albuterol via metered dose inhaler. You describe the known side effects of this medication, including the effects of an overdose. Of the following, the MOST common side effect of this agent is A. B. C. D. E. hyperkalemia muscle weakness oral thrush somnolence tachycardia Answer.

Question 84.

A 14-year-old girl is undergoing a sports preparticipation evaluation. She has asthma that is triggered by both exercise and exposure to allergens. She has been using her albuterol metered dose inhaler prior to exercise. She feels fine initially, but becomes symptomatic several hours later. Of the following, the MOST appropriate management is to A. B. C. D. E. advise her to discontinue exercise completely prescribe an inhaled corticosteroid for use prior to exercise prescribe inhaled albuterol for use after her symptoms develop prescribe inhaled sodium cromolyn for use prior to exercise prescribe oral antihistamines for use prior to exercise

Question 101. Answer. A 14-year-old patient is seen in September for routine evaluation of allergic rhinitis and asthma. Immediately upon entering the room you are struck by his weight gain and the round, flushed appearance of his face. Of the following, the MOST likely explanation for these findings is A. B. C. D. E. Addison disease exposure to adult dosages of both nasal and inhaled steroids hypothyroidism overeating throughout the summer side effects from anabolic steroid use for weightlifting

Question 123. Answer. A 15-year-old boy who has asthma is working on a school project explaining the triggers for an asthmatic attack. He knows that irritants such as cigarette smoke and strong fumes, upper respiratory tract infections, and exposure to pets and allergens can trigger his attacks. He read that aspirin may provoke symptoms and asks you about any other medications that should be avoided. Of the following, you are MOST likely to mention that such patients should avoid A. B. C. D. E. acetaminophen antihistamines beta-adrenergic blocking agents inhaled corticosteroids penicillin-derived antibiotics

Question 162. Answer. A 4-month-old child is brought to your office because he became irritable and developed diarrhea and emesis shortly after his third feeding with a milk-based formula. The first time he had taken this formula there were no problems, and the second time he developed an urticarial rash. He had not received any milk-based products previously because of severe eczema. Examination reveals only a few eczematous patches. Of the following, the most appropriate INITIAL step in evaluation of this child is to A. B. begin immunotherapy against milk protein based on history alone eliminate milk from the diet for only 1 month

C. D. E.

order radioallergosorbent (RAST) testing to milk perform a milk challenge in the office refer to a pediatric allergist for skin testing to milk

Question 180. Answer. During a health supervision visit, you discover that a patient has daily symptoms of cough and shortness of breath with exercise as well as nighttime cough (usually in the middle of the night). She has been seen in the emergency department four times this year and has been hospitalized twice for treatment of asthma. Physical examination reveals mild scattered wheezing. Peak flow measurement is 60% of predicted. Of the following, the MOST appropriate classification of this girl's symptoms is A. B. C. D. E. extrinsic asthma mild asthma mild asthma with an exacerbation moderate persistent asthma severe persistent asthma

Question 202. Answer. You are seeing a 7-year-old girl who has allergic rhinitis and has had documented reactions to multiple pollens. Oral antihistamines have been effective in controlling her symptoms until recently. Of the following, the BEST management at this time is to A. B. C. D. E. administer an intranasal corticosteroid administer an oral decongestant administer sodium cromolyn nasal spray begin saline nasal washes continue the current antihistamine therapy

Question 222. Answer. During a health supervision visit, you note clear rhinorrhea in a 4-year-old child who has eczema. The parents report that the symptoms appear each spring as the trees began to blossom, and you diagnose allergic rhinitis. You counsel the parents that when a child has one atopic syndrome, such as eczema, he or she has a threefold greater risk of developing another component, such as rhinitis or asthma.

Of the following, the MOST important factor influencing atopy in this child is A. B. C. D. E. allergy to peanuts in the child's cousin asthma in the child's brother asthma in the father's uncle atopy in both of the child's parents the month of the year in which the child was born

Question 242. Answer. A school nurse contacts you about ways to improve the classroom environment for children who have asthma. Of the following, the MOST appropriate intervention to recommend is to A. have the windows open during classroom hours to provide better air circulation

B. place an air cleaner with a high-efficiency particulate arrestor (HEPA) filter in the classroom C. D. E. place a humidifier in the classroom during the winter months purchase a filter vacuum cleaner for the school remove any furred animals from the classroom

Question 261. Answer. A 12-year-old boy who has asthma is brought to the emergency department at midnight for the third time in 7 days with mild wheezing. His asthma had been well-controlled with asneeded albuterol by metered dose inhaler until this past week. He is known to be allergic to furry animals, and a rabbit has been placed in his classroom, but he appears fine when leaving school. Of the following, the MOST likely explanation for these findings is that the boy A. always has had these symptoms, but now is recognizing them and seeking care

B. has a newly acquired upper respiratory tract infection and requires the addition of theophylline C. D. E. has become tolerant to the inhaled albuterol therapy is experiencing a late-phase reaction to exposure to the rabbit in the classroom is suffering from gastroesophageal reflux at night that is worsening his asthma

Answers

Critique 23

Preferred Response: E

[View Question] The antileukotrienes (eg, monteleukast, zafirlukast) are a new class of anti-inflammatory asthma medications designed to inhibit the effects of leukotrienes on the airways. Leukotrienes are released from several different inflammatory cells, including the eosinophil and the mast cell, via the arachidonic acid pathway. Leukotriene D4 (LTD4) is the most potent of the leukotrienes and causes a constellation of symptoms that includes bronchoconstriction and increased secretion of mucus. Antileukotrienes affect the leukotriene pathway either as an antagonist to leukotriene receptors or as an inhibitor of 5-lipoxygenase. Similar to the manner in which antihistamines prevent histamine binding, a leukotriene receptor antagonist competitively inhibits LTD4 binding to leukotriene receptors. Inhibition of 5-lipoxygenase prevents the formation of LTD4. The primary advantage of this class of medication is that they can be administered orally. Many patients prefer oral administration to the use of metered dose inhalers. One agent from this class, monteleukast sodium, is available in a once-a-day formulation, which will increase compliance. Antileukotrienes appear to be more potent than sodium cromolyn, but they are not as effective as the inhaled corticosteroids. Their safety profile appears to be comparable to sodium cromolyn. There have been reports of Churg-Strauss syndrome, a vasculitic syndrome that is characterized by pulmonary infiltrates, eosinophilia, and cardiomyopathy, following withdrawal of corticosteroids in the presence of monteleukast and zafirlukast. Elevated liver enzymes have been associated with the use of zileuton, and this drug must be administered four times daily. Anti-inflammatory medications such as antileukotrienes work by a completely different mechanism than bronchodilators (eg, theophylline or beta agonists), and they cannot be used as rescue medications. The impact of these anti-inflammatory medications on the mortality rate of asthma has yet to be determined. References: Fischer AR, Drazen JM. Antileukotriene drugs in the treatment of asthma. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:678-684 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Critique 24 Preferred Response: B

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Factitious hyponatremia results from the presence of impermeant solutes other than sodium in the serum. It is seen most commonly in patients who have diabetes and following the infusion of mannitol. Plasma osmolality is very high in patients who have factitious hyponatremia. In contrast to pseudohyponatremia, which occurs in patients who have hyperlipidemia, serum sodium levels truly are low. It is estimated that for every 100 mg/dL increase in the serum glucose (or mannitol) concentration above 200 mg/dL, a 1.6 mEq/L decrease occurs in the serum sodium concentration. The pathogenesis of the hyponatremia in the child described in the vignette is related to the increase in the effective osmotic pressure of the extracellular fluid caused by the hyperglycemia. This produces a shift of water out of some cells, primarily skeletal muscles, thereby decreasing serum sodium levels by dilution. In addition, sodium migrates into the intracellular compartment to replace cellular potassium losses. The increased filtered load of glucose due to the hyperglycemia produces glucosuria and secondary osmotic diuresis. Urinary water losses generally are greater than sodium losses. Accordingly, serum sodium concentration may normalize with time. Because of the greater urinary water losses compared with sodium in patients who have diabetes, episodes of dehydration are associated with mildly elevated serum sodium levels. In the presence of hyponatremia and dehydration, the secretion of antidiuretic hormone increases in response to the decreased intravascular volume. Thus, an elevated level of antidiuretic hormone is appropriate during the dehydration state. In patients who have diabetes, hypophosphatemia occurs because of increased urinary excretion of phosphorus. During treatment, there is increased entry of phosphorus into the cells under the influence of insulin, which aggravates the hypophosphatemia, but it does not cause hyponatremia. Similarly, metabolic acidosis does not result in hyponatremia. References: Adrogu HJ, Tannen RL. Ketoacidosis, hyperosmolar states, and lactic acidosis. In: Kokko JP, Tannen RL, eds. Fluids and Electrolytes. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:643674 Berry PL, Belsha CW. Hyponatremia. Pediatr Clin North Am. 1990;37:351-363 Critique 43 Preferred Response: D

[View Question] The clinical and laboratory findings for the child described in the vignette are consistent with an immunodeficiency that most likely is X-linked agammaglobulinemia. Generally, patients become symptomatic after 6 months of age, when maternally transmitted immunoglobulin has waned. Patients are susceptible to infections by pyogenic organisms, such as pneumococci, streptococci, and Haemophilus sp. They usually respond adequately to viral, fungal, and parasitic infections. Initial symptoms may consist of pneumonia, bronchitis, sinusitis, otitis media, pyoderma, osteomyelitis, or sepsis.

Characteristic physical findings in such patients include no palpable lymph nodes and absent tonsillar tissues. Laboratory evaluation reveals a complete absence or a marked decrease of all immunoglobulin classes. The level of serum immunoglobulin G (IgG) usually is below 200 mg/dL and often below 100 mg/dL, with an absence of IgM, IgA, IgD, and IgE. An essential part of the initial treatment of the child described in the vignette is adequate replacement of immunoglobulins. Starting doses of intravenous immune globulin range from 300 mg/kg to 600 mg/kg every 2 to 4 weeks. Depending on the patient's response, the amount and frequency of the infusions can be adjusted to achieve trough levels near to, or within, the normal range. Acute bacterial infections should be treated promptly with adequate amounts of appropriate antibiotics, but antibiotic prophylaxis is not recommended. Bone marrow transplantation, granulocyte transfusions, and splenectomy are not indicated as initial management steps for patients who have X-linked agammaglobulinemia. References: Iseki M, Heiner DC. Immunodeficiency disorders. Pediatr Rev. 1993;14:226-236 Skoner DP, Fireman P. B- and T-cell primary immunodeficiency diseases. In: Burg FD, Ingelfinger JR, Wald ER, Polin RA, eds. Gellis & Kagan's Current Pediatric Therapy. 16th ed. Philadelphia, Pa: WB Saunders Co; 1999:1071-1076 Critique 64 Preferred Response: E

[View Question] Beta-adrenergic agonists (eg, albuterol, metaproterenol, pirbuterol) can be associated with a variety of adverse reactions. These drugs have a wide therapeutic index, and most patients can use them without difficulty. Adverse symptoms usually occur when a patient has received frequent treatments for an exacerbation of asthma. The most common adverse reactions are muscle tremors, tachycardia, and hypokalemia (rather than hyperkalemia). However, in patients who have extreme sensitivity to the agents, symp-toms such as jitteriness and muscle tremors can occur at recommended doses. Most of the side effects associated with beta-adrenergic agonists are well tolerated and easily controlled. If persistent, hypokalemia can be treated with potassium supplementation. Tachycardia usually is not a significant symptom unless a child has underlying cardiac disease. Premature ventricular contractions may occur, but they may be related more to the underlying asthma exacerbation or the patient's normal rhythm than to the medication. Thrush sometimes develops in patients receiving oral corticosteroids, but not adrenergic agents. Muscle weakness and somnolence are not associated with this class of medications. References:

Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Sly RM. Asthma. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:628-641 Critique 84 Preferred Response: D

[View Question] The girl described in the vignette is demonstrating reactive airway symptoms due to a latephase response to exercise. When asthma symptoms develop early in the course of physical activity, this usually is a sign of uncontrolled disease. Patients who have exercise-induced symptoms of asthma usually become symptomatic within 15 minutes of completing their activity. If the activity is prolonged, the person may become symptomatic during the event. A subset of patients who have exercise-induced asthma experience a late-phase response of bronchospasm 4 to 6 hours after completing exercise. This is a response to an influx of inflammatory cells in the airway. Similar events occur in these patients when exposed to an allergen. Sodium cromolyn is an effective inhibitor of both the early- and late-phase response to exercise as well as allergens and some pollutants. Its exact mechanism of action is unknown, but when it is administered 30 minutes before exercise, it prevents symptoms from developing. Affected patients also should have rescue medication (eg, albuterol) available when undertaking exercise, but sodium cromolyn is the preferred treatment modality because it may prevent symptomatic episodes from even occurring. Avoidance of exercise is impractical for the girl described in the vignette because it would have a major negative impact on her psychosocial development. Intermittent use of albuterol may provide relief, but it would be a response to symptoms rather than a preventive measure. The use of oral antihistamines has a very limited role in patients who have asthma. Several of the newer antihistamines have been associated with a modest improvement in lung function in patients who have asthma, but this improvement occurred in conjunction with other asthma therapies. The administration of an inhaled corticosteroid prior to exercise would only inhibit the late-phase inflammatory response and have no effect on the early-phase response. References: McFadden ER Jr. Exercise-induced airway narrowing. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:953-962

National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997: No. 97-4051 Critique 101 Preferred Response: B

[View Question] The use of inhaled and nasal corticosteroids has become the standard of care for children and adults who have asthma, allergic rhinitis, or both. These compounds have different pharmacologic profiles than oral corticosteroids. Oral corticosteroids are inactive until they are metabolized by the liver. In contrast, inhaled or nasal corticosteroids are active compounds that begin to work immediately upon application to either the lungs or the nose. After working at the site of action, they are absorbed and remain active until inactivated by the liver. It is well known that corticosteroid concentrations exceeding the liver's metabolizing ability can lead to signs and symptoms consistent with chronic oral steroid use, including cushingoid appearance, weight gain, and moon facies. Many clinicians believe that administering 50% of the adult dose to children is safe and effective, although no wellcontrolled studies have confirmed this hypothesis. The boy described in the vignette appears to have been exposed to high doses of both inhaled and nasal corticosteroids, which would lead to the constellation of cushingoid symptoms he exhibits. Such symptoms could not be caused by overeating, hypothyroidism, or the use of anabolic steroids. Addison disease can cause hyperpigmentation, but it is not associated with cushingoid features. A further concern about the use of corticosteroids is their potential effect on growth in children. In July 1998 the United States Food and Drug Administration (FDA) ordered a formal review of this specific aspect of the safety of inhaled and nasal corticosteroids. None of these products had demonstrated any suppression of the hypothalamic-pituitary axis prior to their approval by the FDA. This review of all available data for all approved inhaled and nasal corticosteroids demonstrated a consistent decrease in growth velocity among children receiving these products. This led the FDA to require the placement of warning labels on all currently available formulations with the caveat that the label would be removed from any product for which no adverse effect on growth could be demonstrated. The FDA also recommended that all children receiving these products have precise height measurements obtained every 3 to 6 months with a stadiometer. The exact effect of these agents on final adult height is unknown. One retrospective study of adults who received inhaled or nasal corticosteroids during childhood demonstrated that they reached average adult height. These adults were children during the 1970s and 1980s when inhaled and nasal corticosteroids were not considered first-line therapy, which may have affected the results. The FDA recommends that the lowest possible dose of corticosteroids be administered to children, noting that there is no conclusive evidence at present that patients receiving inhaled and nasal corticosteroids will achieve a

shorter adult height than those who have similar medical conditions and do not receive these medications. References: DiGeorge AM, Levine LS. Adrenocortical insufficiency. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:1613-1666 FDA requires new pediatric labeling for inhaled, intranasal corticosteroids. FDA Talk Paper. Available at: http:/www.fda.gov/bbs/topics/answers/ans00922.html Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Critique 123 Preferred Response: C

[View Question] Asthma triggers include upper respiratory tract infections, irritants, and weather changes. Some medications also can have an adverse effect on patients who have asthma by inhibiting the efficacy of other medications (eg, beta-adrenergic blocking agents) or increasing asthma symptoms (eg, nonsteroidal anti-inflammatory drugs [NSAIDs]). Beta-adrenergic blocking agents are contraindicated in patients who have asthma because they prevent the bronchodilator effect of beta agonists. Also, patients receiving this class of medication have a decreased sense of symptoms and can experience a severe exacerbation without realizing their level of impairment. Patients who have asthma should avoid NSAIDS for two related reasons. NSAIDS can trigger an exacerbation of asthma by inhibiting cyclo-oxygenase in the prostaglandin pathway, which leads to an increase in leukotrienes. Patients also can be allergic to NSAIDS. This may be associated with Samter syndrome, which primarily affects patients 10 to 30 years of age and is characterized by asthma (usually severe), nasal polyps, sinusitis, and NSAID sensitivity. The allergy itself can cause respiratory symptoms, as may be seen with any drug allergy. Inhaled steroids and antihistamines may be helpful in many patients who have asthma. Acetaminophen and penicillin-derived antibiotics do not need to be avoided in these patients. References: Lemanske RF Jr, Busse WW. Asthma. JAMA. 1997;278: 1855-1873

Stevenson DD, Simon RA. Sensitivity to aspirin and nonsteroidal antiinflammatory drugs. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1225-1234 Critique 162 Preferred Response: E

[View Question] The 4-month-old infant described in the vignette has two potential diagnoses. The first is eczema, which usually presents between 2 and 6 months of age. The second is food allergy. It has been demonstrated that about 33% of patients younger than 3 years of age have a food allergy that triggers their eczema. This risk increases to 50% in children older than age 7 who have severe eczema. The most common food triggers are eggs, milk, and wheat. The child described in the vignette has had very limited exposure to milk protein. His first exposure was without incident, which is to be expected because a prior exposure is needed to cause a reaction. Children who have been reported to be allergic to milk-based products at a few days of age probably have had transfer of the antigen across the placenta from the mother. Upon his second exposure to a milk-based product, this boy developed an urticarial rash, which is a different type of immune reaction from that seen with eczema. Eczema is a T cell-mediated reaction that is associated with immunoglobulin E (IgE)-mediated disease. Because of this association, there is an almost 80% chance that a child who has severe eczema eventually will develop allergic rhinitis, asthma, or both. In contrast, the urticarial rash described in the vignette is an IgE-mediated reaction, which implies that he has a primary milk allergy. The most recent reaction to milk protein is of great concern because it is consistent with an anaphylactic reaction. A rash is not a necessary component of anaphylaxis and, in fact, the absence of a rash has been associated with increased mortality. Commonly, gastrointestinal and systemic reactions are the only symptoms noted in such patients. An impending sense of doom also is reported by patients who experience anaphylaxis. Clearly, an infant cannot report such a reaction directly, but the sudden onset of irritability could be consistent with this type of experience. The best means of evaluating the child in the vignette would be to refer him to a pediatric allergist for skin testing to milk. This also may identify other possible allergens. Skin testing is more sensitive than RAST testing, but if such testing could not be performed because there are no clear patches of skin due to the eczema, the RAST test should be considered. Because antihistamine medication must be withdrawn prior to skin testing, RAST testing also is helpful in patients who cannot tolerate withdrawal of antihistamine medication even for short periods. Eliminating milk from the diet for only 1 month or performing a milk challenge in the office would be dangerous for the child described in the vignette. Although some patients will outgrow food allergies to egg, milk, or wheat, this generally requires 1 to 2 years of avoidance rather than 1 month. After such a short period of avoidance, the child may have a

serious anaphylactic reaction when the milk is reintroduced. Performing a milk challenge in the office also is likely to result in an anaphylactic reaction if the challenge is not performed by an experienced clinician, and severe reactions still occur in these settings. Immunotherapy has no role in the treatment of patients who have eczema or food allergies. References: Leung DY, Diaz LA, DeLeo V, Soter NA. Allergic and immunologic skin disorders. JAMA. 1997;278:1914-1923 Sampson HA. Food allergy. JAMA. 1997;278:1888-1894 Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med. 1992;327:380-384 Critique 180 Preferred Response: E

[View Question] Classification of a patient's reactive airway disease is extremely difficult because disease severity may change frequently in response to infections, exposures, activities, and compliance with treatment modalities. The National Institutes of Health, National Heart, Lung and Blood Institute (NIH/NHLBI) has developed guidelines for the diagnosis and management of asthma based upon the severity of the disease. The NIH/NHLBI classification of asthma severity is outlined in the Table. The child described in the vignette is in the severe persistent asthma group because he has frequent nighttime symptoms. A patient may be asymptomatic at the time of an office evaluation, yet have had several emergency department visits and courses of oral corticosteroids over the preceding few months. To avoid misclassification, a careful history should include pointed questions. Does the patient have nocturnal symptoms of cough on awakening, cough with exercise, or decreased exercise tolerance? Does he or she seek medical attention frequently for asthma from other health-care providers, the school nurse, or another medical facility? Pulmonary function tests and peak flow meter readings also can help in proper classification. A thorough physical examination can reveal symptoms of a prolonged expiratory phase or wheezing in the patient who claims to be completely asymptomatic. Such findings indicate that the patient has accommodated to a lower level of lung function and considers the daily symptoms to be normal. Extrinsic asthma is an outdated term that refers to patients who have an allergic trigger for their symptoms. Now it is recognized that 60% to 80% of children who have asthma also have atopic disease. References: Kwong KYC, Jones CA. Chronic asthma therapy. Pediatr Rev. 1999;20:327-334

Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 (Also available at: http:// www.nhlbi.nih.gov/nhlbi/lung/asthma/prof/asthgdln.pdf) Sly RM. Asthma. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:628-641 Critique 202 Preferred Response: A

[View Question] An ideal therapy for the child who has allergic rhinitis would have no side effects and cause the least disruption of a patient's activities and family structure. Symptoms of allergic rhinitis can be treated by many different modalities, ranging from avoidance of a specific allergen to the administration of high-dose nasal corticosteroids. Administration of medication is the first line of therapy for many who have allergic rhinitis, and this approach would be appropriate for the child described in the vignette. She clearly has seasonal symptoms to outdoor pollens and may obtain some benefit from spending more time indoors and keeping her bedroom windows closed, but her persistent symptoms despite oral antihistamine therapy suggest that more aggressive treatment is warranted. Studies that have examined quality of life issues have shown that affected patients believe that allergic rhinitis can be as disruptive and debilitating to their activities of daily living as asthma. The mainstay of therapy for allergic rhinitis has been oral antihistamines because of their convenience. However, this form of therapy is not always completely effective, and some preparations are associated with side effects such as headache and drowsiness. The newer class of antihistamines cause fewer of these symptoms, but they still do occur. Oral decongestants provide short-term symptomatic benefits, but they can cause hyperactivity and irritability in some patients and should be used cautiously in children who have attention deficit with hyperactivity disorder or seizure disorders. Topical nasal therapy is the treatment of choice for those whose symptoms are limited to only the nose and who can tolerate a nasal spray. Corticosteroids are the most effective form of topical treatment because they inhibit release of mediators from a variety of inflammatory cells. They also are the most convenient; they can be administered once a day rather than the multiple daily dosing required with other preparations. There is a concern about the potential for inhaled corticosteroids to cause growth suppression, especially among those who are taking these agents to treat asthma. Accordingly, the United States Food and Drug Administration recently mandated that a warning label be placed on all inhaled and nasal corticosteroid products.

Saline nasal washes are effective in about 50% of patients who have allergic rhinitis. This therapy works in concert with the body to clear antigen, which is the source of the patient's symptoms. Sodium cromolyn is effective in many patients because it has both the cleansing action of saline and the benefit of a medication that stabilizes the mast cell, thereby decreasing release of mediators and reducing symptoms. However, it would not be the best choice for the child described in the vignette because at least 3 weeks of treatment are required before a beneficial effect is appreciated. References: Bjrkstn B, Kjellman BN-IM, Zeiger RS. Development and prevention of allergic disease in childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:816-837 FDA requires new pediatric labeling for inhaled, intranasal corticosteroids. FDA Talk Paper. Available at http:/www. fda.gov/bbs/topics/answers/ans00922.html. Sly RM. Asthma. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:628-641 Critique 222 Preferred Response: D

[View Question] Atopy in a child is regulated by multiple genetic factors and environmental experiences. Although the genetic influence of other family members is important, a history of atopy in the parents is of greatest significance. When one parent has atopy, the incidence of similar allergic disease in a child is approximately 50%; the incidence can increase to more than 70% if both parents have a history of atopy. Indeed, in one study of infants born to parents who both had atopic disease, approximately 80% of the children eventually developed symptoms of atopy. Allergic symptoms commonly present in the child before 18 months of age, and a large percentage develop symptoms by 9 months of age. One study has suggested that children born during allergy seasons (not a single month) had a higher incidence of atopy to allergens that were in highest concentration at that time. However, a parental history of atopy is a more important risk factor for the development of atopy. References: Bjorksten B, Kjellman B N-IM, Zeiger RS. Development and prevention of allergic disease in childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:816-837 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997: No. 97-4051

Sly RM. Asthma. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:628-641 Critique 242 Preferred Response: E

[View Question] The classroom can be a major source of allergen exposure for students who have allergic disorders or asthma. Approximately 60% to 80% of children who have asthma also will have positive reactions to immediate-type allergy skin tests. Older schools or those that have moisture problems routinely have high mold counts. Schools that do not have air conditioning must open the windows during the warmer months, which increases exposure to airborne allergens. Allergens also can be brought to the classroom by students and teachers who have pets in their homes. Finally, many schools allow classroom pets whose dander can be a source of allergen. Open windows in a classroom or home allow for the entry of multiple outdoor pollens from trees, grasses, weeds, and molds. During certain times of the year, this can present a significant quantity of allergen and can cause symptoms even in a mildly sensitive patient. Air cleaners with a high-efficiency particulate arrestor (HEPA) filter generally are useful only against allergens that are suspended in the air for a prolonged period of time, such as pet dander and outdoor pollens. They would not be helpful in counteracting indoor molds and dust mites that are not airborne for any significant amount of time unless there is an air-moving device, such as a ceiling fan, present. Dust mites rarely present a problem in the classroom because they require a source of dead skin and padded furniture to thrive. Most classrooms do not have that type of furniture. If the classroom has closed windows, an air cleaner would be unnecessary as long as no pets are in the room. A classroom humidifier would be of no benefit and may be a source of allergen because humidifiers are a reservoir for mold unless cleaned meticulously. They also can promote dust mite growth if the room also contains padded furniture. Filtered vacuum cleaners are not very helpful in the school setting because the only potential allergens in carpet are animal dander and dust mites. Animal dander can remain in the air for several hours after vacuuming, so it would be preferable to remove furred animals from the room rather than try to decrease the antigen load by vacuuming. Removing dust mites by vacuuming would not be helpful unless the child spends a significant amount of time on the carpet. Also, dust mites in carpeting usually are not allergic triggers in children older than 5 years of age. References: Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900

National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Critique 261 Preferred Response: D

[View Question] The patient described in the vignette most likely is experiencing late-phase reaction to the newly introduced allergen in his environment, namely, the rabbit in the classroom. The boy has had mild reactive airway disease that was well-controlled with as-needed albuterol by metered dose inhaler until this past week, but the constant exposure to the allergen is causing him to become symptomatic and seek care in the emergency department. A latephase response commonly occurs 4 to 12 hours following exposure to the allergen, which explains why the boy has no or only mild symptoms during the day and develops respiratory problems at night. Albuterol can cause tolerance or tachyphylaxis, but this only occurs following excessive or long-term use of the medication. Further, such tolerance would not be associated with asymptomatic periods, as described in the vignette. The late-phase reaction is due to the influx of inflammatory cells into the airway that causes airway obstruction. Pets in classrooms often are unexpected triggers for children who have asthma because they generally are added without the knowledge or consent of parents. Similar events can occur when a patient who is sensitive to animal dander is placed in close proximity to a person who has animal dander on his or her clothing. It is unlikely that the boy has had these symptoms for a prolonged period of time and only now is recognizing them. Patients who have chronic symptoms consider these symptoms as their baseline and do not seek medical care until a severe exacerbation or unrelated medical problem develops. An upper respiratory tract infection can trigger exacerbations in patients who have asthma, but associated symptoms such as cough or rhinorrhea should be present. Theophylline would not be the drug of choice in a patient who is experiencing acute asthma symptoms due to an upper respiratory tract infection, although it is an effective medication for chronic asthma. Gastroesophageal reflux can cause significant nocturnal respiratory symptoms. However, these symptoms usually occur in the middle of the night and are associated with complaints of heartburn, abdominal pain, or a sour taste in the mouth. Patients who have gastroesophageal reflux also usually experience similar symptoms during the day. In the boy described in the vignette, the symptoms only occurred following a 4 to 12 hour time lapse from his exposure to the rabbit at school. References: Lemanske RF Jr, Green CG. Asthma in infancy and childhood. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:877-900

National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Peters SP, Zangrilli JG, Fish JE. Late phase allergic reactions. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF Jr, Busse WW, eds. Allergy Principles & Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:342-355 1999 Self-Assessment Exercise VIII. Allergy and related disorders [Return to Category List] Questions [Print Directions] Question 9. Answer.

You are meeting with a couple for a prenatal visit. They are concerned because both have atopic disorders. Of the following, the factor that is MOST likely to modify the potential for allergic disease in their infant is A. B. breastfeeding exclusively during the first 6 months of life elimination of bananas, apples, and rice during the first 6 months of life

C. elimination of milk, eggs, wheat, and shellfish from the maternal diet during pregnancy D. life E. supplementation of human milk with cow milk formula during the first 6 months of

supplementation of human milk with soy formula during the first 3 months of life Answer.

Question 42.

For the past few months, a 3-year-old girl who has asthma has had repeated exacerbations treated with nebulized albuterol every 6 to 8 hours as needed. Previous attacks have responded to prednisone. Findings include mild bilateral expiratory wheezes without retractions. Results of a previous sweat test, chest radiography, and barium swallow were normal. Of the following, the BEST management is to A. B. C. D. add nebulized cromolyn sodium three times daily add oral beta2-agonist therapy add oral theophylline therapy change the nebulized albuterol schedule to every 4 hours

E.

continue with the current regimen Answer.

Question 79.

A 14-year-old boy who has allergic rhinitis reports that he frequently develops coughing and wheezing after about 5 minutes of playing soccer. These symptoms improve after resting for 30 minutes. Of the following, the drug that will give the BEST response in this patient if administered just prior to exercise is A. B. C. D. E. inhaled beta2-agonist inhaled corticosteroid oral beta2-agonist oral corticosteroid oral theophylline

Question 118. Answer. Findings from the history of a 12-year-old girl who has asthma suggest that she has been overusing her beta2-agonist inhaler. She states that over the past 3 months she felt the need to use it more frequently than prescribed. The dose of inhaled steroid she receives twice daily is appropriate, and results of pulmonary function studies are normal. Of the following, the BEST management is to A. B. C. D. E. begin regularly scheduled nebulized albuterol at home have her return for weekly pulmonary function studies increase her inhaled steroid dose to three times a day initiate oral theophylline therapy twice daily recommend she use home peak flow monitoring daily and when she feels tight

Question 154. Answer. A 12-year-old boy has a history of hives after receiving several antibiotics. He has had repeated episodes of pharyngitis and sinusitis that required antibiotic therapy, and his parents would like to know which antibiotics should be avoided. They have asked whether allergy skin testing would be helpful. For which ONE of the following antibiotics is an immunoglobulin E (IgE)-mediated skin test available? A. Cefaclor

B. C. D. E.

Clarithromycin Erythromycin Penicillin Vancomycin

Question 191. Answer. A 13-year-old boy is stung by a bee and develops hives and wheezing. He is hypotensive when evaluated in the emergency department. He is treated successfully with epinephrine, diphenhydramine, and fluids. He is given a prescription for injectable epinephrine at the time of discharge. Of the following, the BEST recommendation for the patient is to A. B. C. D. E. avoid all contact with bees carry an albuterol inhaler at all times have diphenhydramine available when outdoors not participate in any outdoor sports undergo skin testing for possible venom immunotherapy

Question 223. Answer. A 9-year-old girl has moderate persistent asthma that has been stable for several years. She has been hospitalized twice in the past few months. She has been using all of her usual medications as instructed. Additional questioning reveals that her family recently adopted a stray cat that has started to sleep in her bedroom. Of the following, the BEST management for this child is to A. B. cat C. D. E. add alternate-day prednisone to her daily regimen arrange a family conference to discuss the implications for her asthma of having a

install a special filter on the furnace instruct her parents that they have to remove the cat from the home suggest bathing the cat every 6 months

Question 252. Answer. A 15-year-old boy who has asthma takes theophylline and inhaled corticosteroids regularly as well as an inhaled beta2-agonist as needed. During a flare, he has received three

nebulized treatments of albuterol and intravenous methylprednisolone, which resulted in moderate improvement in his respiratory status. The finding that is MOST likely to predict that hospitalization now may be warranted is A. B. C. D. E. history of inhaled corticosteroid use history of intravenous corticosteroid use history of intubation during a prior asthma attack oxygen saturation of 91% by pulse oximetry the need for an aminophylline infusion during this episode

Answers Critique 9 Preferred Response: A

[View Question] The etiology of atopic diseases (eg, asthma, allergic rhinitis, atopic dermatitis, food allergy) is multifactorial. Often, an interaction between numerous risk factors or exposures results in sensitization and subsequent signs and symptoms of allergy. Because many breastfed infants receive at least some formula for supplementation, it is difficult to demonstrate a pure effect of breastfeeding on the prevention or delay in onset of allergic disease. However, a number of studies now support the positive effect of breastfeeding in delaying the development of allergy and atopic disease in infants who are predisposed to allergy. Thus, breastfeeding exclusively during the first 6 months appears to be an especially important factor in delaying atopic disease when there is a family history of allergy or when the infant has genetic markers associated with an increased risk of allergy (eg, high concentration of immunoglobulin E in cord blood). Small quantities of foods ingested by lactating females have been shown to pass into the human milk, which may warrant maternal elimination of certain foods during breastfeeding. Although the true frequency of sensitization of infants to highly allergenic food via human milk cannot be ascertained accurately, numerous reports have documented the ability of foods eaten by the mother to exacerbate allergic symptoms in already sensitized infants who are breastfed. The benefit of maternal elimination diets (eg, avoidance of cow milk, eggs, peanuts, shellfish, and other highly allergic foods) during pregnancy is unknown because in all studies the diet has been continued after birth and the introduction of the infant to various foods also has been delayed. Therefore, the effectiveness of an elimination diet alone during pregnancy as a means to reduce the potential for allergic disease in an infant cannot be determined.

Formula feeding alone or supplementation of breastfeeding with soy formula or cow milk formula has not been shown to influence the incidence of allergic disease among infants. Late introduction of certain highly allergenic foods (eg, cow milk, eggs, wheat, soy, peanut-containing products) into the diets of infants in addition to breastfeeding for the first 6 months of life or longer has been found to delay the onset of food allergy and atopic dermatitis. However, bananas, apples, and rice are not highly allergenic foods during infancy, and their elimination does not appear to affect the subsequent development of allergic diseases. References: Friedman NJ, Zeiger RS. Risk factors and prevention of allergy. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:282-296 Kjellman N-IM, Bjrkstn B. Natural history and prevention of food hypersensitivity. In: Metcalfe DD, Sampson HA, Simon RA, eds. Food Allergy: Adverse Reactions to Foods and Food Additives. 2nd ed. Cambridge, Mass: Blackwell Science, Inc; 1995:445-459 Slusser W, Powers NG. Breastfeeding update 1: immunology, nutrition, and advocacy. Pediatrics in Review. 1997;18:111-119 Sly RM. Allergic disorders. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:619 Solomon WR. Prevention of allergic disorders. Pediatrics in Review. 1994;15:301-309 Critique 42 Preferred Response: A

[View Question] One of the characteristic features of asthma is airway hyperresponsiveness. This exaggerated hyperreactivity occurs following exposure to a variety of inhaled substances or irritants as well as cold air, exercise, or with hyperventilation. According to current guidelines for the diagnosis and management of asthma, a child who has mild persistent asthma, such as described in the vignette, should receive additional inhaled therapy with low-dose steroids, cromolyn sodium, or nedocromil sodium. Accordingly, of the options mentioned, the addition of nebulized cromolyn sodium would be the best treatment modification at this time. Cromolyn sodium and nedocromil sodium are structurally different antiinflammatory medications used for the treatment of chronic asthma that have similar properties. They are rapidly absorbed from the lungs and are impressively safe. These agents are effective in both adults and children. Neither are bronchodilators, but both have been shown to inhibit inflammatory cell activation, mediator release, early and late allergeninduced bronchoconstriction, and airway hyperresponsiveness. Their mechanism of action may be related to effects on epithelial chloride channels in the airway. Currently, cromolyn is

available in a metered dose inhaler (MDI) and nebulizer solution and has been studied and approved for use in adults and children of all ages. Nedocromil sodium is available as an MDI only and has been studied and approved for use in patients 12 years and older. Both drugs should be considered when managing patients who have mild persistent asthma. One point of confusion is the anticipated onset of action of these agents in treating various symptoms of asthma. For acute prophylaxis prior to allergen exposure or exercise, both drugs demonstrate significant effects 5 to 10 minutes following administration. In contrast, for the treatment of chronic asthma in which the drugs are working primarily by decreasing airway hyperresponsiveness, the maximum clinical benefit may require days (nedocromil) to weeks (cromolyn). Oral theophylline can be useful in the treatment of asthma in selected patients. Unfortunately, serum theophylline levels can be affected by a number of variables (eg, age, diet, concomitant disease states, drug interactions), which can contribute to the complexity of using this medication. Because of individual variability in the absorption and elimination of theophylline, as well as its narrow therapeutic index, it is prudent to monitor serum theophylline levels periodically. These complicating factors and the potential dose-related adverse effects limit this agent's usefulness in younger children who have asthma. Beta2-agonist therapy may be used for acute rescue management of asthma exacerbations, every 4 to 6 hours either orally or via MDI or nebulizer. However, administering nebulized albuterol every 4 hours or adding oral beta2-agonist agents to nebulized medication is not appropriate maintenance therapy. The child described in the vignette has not achieved control of her symptoms with intermittent nebulized albuterol, suggesting the need for the addition of a long-term controller or maintenance medication. References: Kemper KJ. Chronic asthma: an update. Pediatrics in Review. 1996;17:111-118 Lemanske RF Jr, Busse WW. Asthma. JAMA. 1997;278:1855-1873 Guidelines for the Diagnosis and Management of Asthma. Expert Panel Report II. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Critique 79 Preferred Response: A

[View Question] Exercise-induced asthma (EIA) is a temporary narrowing of the airways caused by strenuous exercise or activity. EIA may begin during exercise (typically within 15 minutes) or after exercise has ended. It usually resolves within 20 to 30 minutes of onset, though it may reappear as a seemingly unrelated episode hours later. The latter is referred to as a "latephase response" and may occur 4 to 12 hours following exercise. Symptoms of EIA may include coughing, chest tightness, wheezing, and difficulty breathing. Some patients describe feeling winded, tired, or dizzy following exercise, and

some may complain of stomach pain. EIA occurs in 80% to 90% of people who have asthma and in almost 50% of people who have allergic rhinitis (ie, hay fever). Studies have shown that about 5% to 10% of collegiate athletes have EIA, which is similar to the incidence in the general population. Children are more likely to have EIA than adults. They may notice that they have difficulty keeping up with friends when running and playing. However, EIA in children frequently is overlooked by parents, health-care professionals, teachers, and even the children. Unfortunately, many children and adolescents who have experienced respiratory difficulties during play, physical education classes, training, and competition learn to avoid outdoor play, sports, and other physical activities that produce such symptoms rather than investigating interventions that effectively prevent or treat EIA. Thus, untreated EIA can limit normal activities, which can result in negative long-term physical and psychologic effects. EIA can be prevented or inhibited by the use of a beta2-agonist, inhaled cromolyn, or oral theophylline prior to exercise. Inhalation of beta2-agonist before exercise is the best treatment for most patients. Beta2-agonists administered orally 30 minutes prior to exercise may be helpful in a younger child who cannot use inhaled medication. Theophylline may be used to prevent EIA, but when given orally, it requires at least 1 hour to reach peak levels, may cause headache or gastrointestinal symptoms, and is less effective than inhaled bronchodilators. Inhaled or oral corticosteroids are not effective when administered as a pretreatment for EIA. However, because corticosteroids reduce airway reactivity, they can decrease the overall severity of an episode of EIA. References: Eggleston PA. Exercise-induced asthma. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:520-528 Murphy SJ, Kelly HW. Advances in the management of acute asthma in children. Pediatrics in Review. 1996;17:227-234 Sly RM. Asthma. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:628-641 Critique 118 Preferred Response: E

[View Question] The availability of reliable peak flow meters has made peak expiratory flow (PEF) measurement invaluable in the outpatient treatment of asthma. Such measures of pulmonary function are essential to assess the severity of obstructive lung disease and are useful to monitor the course of disease and a patient's response to therapy. Further, PEF can be used for the assessment of acute obstruction, or, as in the girl described in the vignette, when there is a question of whether a patient is having an asthma flare.

Sometimes patients can begin to overuse their rescue inhalers. This can be an indication of worsening disease, but if all other parameters suggest that the asthma is under control, then misuse or confusion about the use of the inhaler must be suspected. Providing the girl described in the vignette with a peak flow meter to use at home daily and during those times that she feels "tight" will provide some objective findings that may help to clarify the situation. When using PEF, it is helpful to establish personal best values and the minimum diurnal variability during effective treatment. PEF measurements are taken at least twice a day during monitoring periods of 2 to 3 weeks, and the highest number is noted. The personal best is the highest PEF measurement achieved when the patient's asthma is under control. If this highest value during the monitoring period is less than 80% of predicted value after taking a bronchodilator (if the patient is receiving a bronchodilator) or daily variability is more than 20% after taking a bronchodilator, then more aggressive therapy and continued daily monitoring are indicated. To help manage asthma at home, a system of PEF zones can be used to correlate PEF measurements and variability with appropriate levels of medication. When using PEF monitoring, the clinician still must review symptoms and the overall clinical status of the patient to obtain the most comprehensive view of the degree of asthma control. Institution of regularly scheduled nebulized albuterol treatments is not warranted for the girl described in the vignette. Until further clarification of compliance and daily PEF values can be ascertained, increasing the frequency of or adding an additional agent to her daily medications is not appropriate. Performing pulmonary function studies on a weekly basis would not determine whether the girl is having trouble during those episodes when she feels tight and uses her beta2-agonist inhaler more frequently than prescribed. References: Lemanske RF Jr, Busse WW. Asthma. JAMA. 1997;278:1855-1873 National Asthma Education Program, Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1991:No. 91-3042 Voter KZ, McBride JT. Diagnostic tests of lung function. Pediatrics in Review. 1996;17:53-63 Critique 154 Preferred Response: D

[View Question] When a patient who requires antibiotic therapy presents with a history of allergy to an antibiotic, the best option is to administer a drug that does not cross-react with the suspect drug. However, in the patient who reports a history of sensitivity to multiple antibiotics this becomes more challenging. The most effective method of preventing an adverse reaction to a drug is to avoid using it. Importantly, a number of studies have shown that the number of adverse reactions to drugs is proportional to the number of drugs prescribed.

Both prick and intradermal skin testing are reliable methods of identifying immunoglobulin E (IgE)-mediated allergy to macromolecules. Before testing can be performed to look for an allergy to drugs of small molecular weight, the immunogenic metabolites and, if possible, the mode of their conjugation to macromolecular carriers should be identified. With the exception of penicillin, this prerequisite rarely has been achieved. Skin testing for penicillin allergy is a well-established procedure for patients who give histories of suspected previous reactions to one of the penicillins, but there are no currently established skin testing procedures for evaluating sensitivity to cefaclor, clarithromycin, erythromycin, or vancomycin. Penicillin is the only drug for which skin testing has been reliable in identifying patients who are at risk for anaphylactic hypersensitivity. Skin testing with both benzylpenicilloyl-polylysine (PrePen) and penicillin G identifies the majority of children who are at risk for developing anaphylactic reactions following penicillin administration. However, it is impossible to exclude anaphylactic sensitivity due to other haptenic determinants formed in vivo from penicillin (for which no skin tests are available). Furthermore, penicillin skin tests are predictive only of anaphylaxis and not of serum sickness or other reactions associated with the use of this drug. Skin testing for cephalosporins and other beta-lactam antibiotics has not been standardized, although some authorities have recommended prick and intradermal testing with antibiotic concentrations no greater than 3 mg/mL. References: deShazo RD, Kemp SF. Allergic reactions to drugs and biologic agents. JAMA. 1997;278:18951906 Sly RM. Adverse reactions to drugs. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:649-652 Sullivan TJ. Drug allergy. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF, Yuninger JW, Busse WW, eds. Allergy: Principles and Practice. 4th ed. St Louis, Mo: Mosby-Year Book, Inc; 1993:1726-1746 VanArsdel PP Jr. Drug hypersensitivity. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:320-347 Critique 191 Preferred Response: E

[View Question] Venom immunotherapy (VIT) is recommended for patients who have a history of systemic reactions following exposure to an allergen as well as following a positive diagnostic evaluation for allergy (ie, skin testing, radioallergosorbent test). Children who experience only cutaneous reactions, including a moderate or large local reaction, do not need to be treated with VIT. However, the patient described in the vignette has experienced a systemic

reaction characterized by wheezing and hypotension and needs to undergo an appropriate diagnostic evaluation and possible VIT if diagnostic allergy tests are positive. The best prophylaxis against sting reactions is avoidance. This includes conscientious use of insect repellants and avoidance of bright-colored clothing and perfumes when outdoors. However, such measures are not sufficient prophylaxis for someone who has had a systemic reaction. Because VIT does not totally eliminate the risk of a subsequent reaction (ie, only 98% effective in preventing reactions that require epinephrine), injectable epinephrine kits still must be carried by these individuals. Advising patients who have had systemic reactions to have albuterol or diphenhydramine available or to avoid outdoor sports would be inadequate protection against future serious reactions. The venoms available for both skin testing and VIT include those of the yellow jacket, yellow hornet, bald-faced hornet, honeybee, and wasp. For fire ants, only wholebody extracts are available commercially. VIT is generally well tolerated. Treatment-related reactions are seen in 5% to 15% of patients during the initial weeks of treatment, regardless of the specific regimen used. Most reactions are mild, and fewer than 5% require treatment with epinephrine. The incidence of systemic reactions to stings reported in the literature ranges from 0.4% to 0.8%. More recent studies report systemic reactions in approximately 3% of adults compared with less than 1% of children having severe sting reactions. The risk of developing a reaction following a subsequent sting in children who have had a previous cutaneous reaction only is estimated at less than 10%, and in all patients who experience large local reactions only, the risk also is less than 10%. References: Golden DBK. Allergic reactions to insect stings. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:348-354 Mendez E, Sicklick MJ. Hymenoptera reactions. Pediatrics in Review. 1995;16:355-356 Sly RM. Insect allergy. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:652-653 Valentine MD. Anaphylaxis and stinging insect hypersensitivity. JAMA. 1992;268:2830-2833 Critique 223 Preferred Response: B

[View Question] All pets can cause allergies, independent of the size of the animal, the specific breed, the hair length, or the amount of shedding. Most people who are sensitive to furred animals are allergic to the animal's dander. Dander is extremely "sticky" and attaches to many home furnishings, including floors, ceilings, clothing, furniture, and cushions. Of note, it can remain for months and even years after a pet has left the house. The most obvious reason for

worsening asthma in the girl described in the vignette is the addition of a cat to the household, and holding a family conference to discuss the implications of having a cat is warranted. However, asking the parents to remove the cat may not be necessary; a compromise might be reached that will spare the psychological trauma of removing the pet from the family. Administration of alternate-day prednisone would not be indicated as an initial intervention. In the United States, cats are the most common pet causing allergies. Fel d, a protein present in the dander and saliva of cats, appears to trigger the allergic reaction. Although individual cats may produce more or less of this allergen, there is no relationship between hair length and allergen production, and there is no breed that is nonallergic. Because cats clean themselves constantly, their fur is covered with dried saliva that flakes off and becomes airborne. The largest amount of cat allergen is present in homes with cats, but it also has been found in homes where cats have never been and in offices and public places where animals are not allowed. The explanation for this is that the extremely sticky cat allergen can be transported on inanimate objects. Increased levels of allergen in environments where cats are present increase the risk of allergy symptoms, such as sneezing, nasal congestion, runny nose, and red, itchy, watery eyes. Dogs also are commonly implicated in causing allergic rhinitis. Although dog allergens have not been investigated as thoroughly as cat and dust mite allergens, we do know that specific proteins can be found in dog dander and saliva; they also can be detected in dog hair, blood, urine, and feces, but these do not seem to trigger sensitization. Some people believe that they are not allergic to their own dog or cat, but only to other people's pets. This may be particularly true of people who experience symptoms that wax and wane in severity without any correlation to when they are exposed to their own pet. When such pet owners go into another home with a dog or cat, they are exposed to a different amount of allergen, particularly if the other home has pets that are kept both outdoors and indoors and their own pet is kept indoors solely. If this exposure is more intense than what they receive at home, they may become symptomatic. This scenario suggests that they are only allergic to other people's pets when, in fact, they are allergic to specific proteins that are identical in both animals. Other household pets that have fur, such as guinea pigs, gerbils, hamsters, rabbits, rats, and mice, also produce allergens. In some cases, mold in the pet's bedding is the cause of symptoms rather than the pet itself. Feathered animals also can present a problem in patients who have allergies. Birds have many allergens in their feathers, including dust and mold. Although it is possible to be allergic to feathers, many symptoms that are triggered when exposed to feather products may be due to dust mites rather than the feathers. Although the most effective treatment of pet allergen is removal of the pet, this may not always be an acceptable option to the family. In such cases, other steps can be taken within the home to decrease significantly the exposure to pet allergen. The pet can be kept outdoors all or some of the time or limited to a single area of the house. Pets must be kept

out of the bedroom at all times. They could be trained to stay off furniture or owners can cover the animal's favorite resting places with sheets that can be washed easily and often. Individuals who have atopic disease should wash their hands immediately after petting an animal and, if possible, change clothing after contact with the pet. Daily vacuuming will get rid of shedding hair, but because vacuuming may blow allergens into the air, the vacuum cleaner should have a proven high-level allergen containment system. A person in the household who is not allergic should change the litter and wash or brush the pet weekly. Studies have shown that washing cats weekly also will help reduce the surface allergen and perhaps the amount of future allergen produced. However, bathing the animal's coat every 6 months is not frequent enough to be an effective intervention. Pet danders also settle onto carpets and soft furnishings, which act as reservoirs for the allergen, releasing it into the air when touched. It can take as long as 20 weeks for allergen levels throughout the home and up to 5 years for cat allergen levels in mattresses to decrease to baseline following removal of a pet. Removal or treatment of the carpet and sofa periodically and encasement of the mattress will reduce continued exposure to these reservoirs of allergen. Pet allergen also is found on vertical surfaces such as walls, and exposure can be decreased with wall cleaning and painting. Even if the pet is confined to a restricted area of the home, it is important to realize that air flow throughout the duct system in a home that has forced air heat may spread the allergen throughout the house. Use of efficient vent and furnace filters may help to trap some of the allergens and reduce this spread. For example, the use of a high-efficiency particle arresting (HEPA) air cleaner can reduce the level of airborne pet allergen by about 50%. However, that is not superior to a comprehensive environmental decontamination program. Currently, a HEPA system is not available for furnace filters. References: Solomon WR. Prevention of allergic disorders. Pediatrics in Review. 1994;15:301-309 Virant FS. Allergic rhinitis. Pediatrics in Review. 1992;13:323-329 Weber RW, Dolen WK. Other allergenic plants and animals. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:115-123 Critique 252 Preferred Response: C

[View Question] A stepwise approach for the classification of asthma has been developed to establish guidelines for diagnosis and treatment. These steps recognize the variable severity of the disease. Patients are placed into various "steps" according to: 1) the severity of asthma at the time of initial evaluation (when patients have not yet received medications) or 2) features of the disease and medications required to maintain maximal disease control.

Hospitalization usually is required if: 1) there is minimal response to the initial 1 to 2 hours of treatment; 2) pulmonary function tests show peak expiratory flow (PEF) or forced expiratory flow in 1 second (FEV1) to be less than 40% predicted (or personal best of the patient); 3) there is a history of severe asthma with need for hospitalization (particularly intubation or intensive care unit admissions); 4) the patient or family is incapable of rendering adequate home care (poor compliance, suboptimal knowledge or skills, an unacceptably long travel distance to a health-care facility that could provide emergency intervention, if needed). Although the moderate improvement following administration of initial therapy described for the boy in the vignette is encouraging, a history of having required intubation during a prior asthma attack merits conservative management and careful consideration of the need for hospitalization with this attack. A history of prior use of inhaled or intravenous corticosteroids or the potential need for an aminophylline infusion in the emergency department do not warrant such caution when considering the need for admission. Similarly, an oxygen saturation of 91% on room air is not of as great concern as a prior history of intubation. Patients who are classified as having severe disease and have an increased risk of death from asthma are those who have had life-threatening episodes, have required intubation, continue to have severe disease that requires chronic oral corticosteroids, have poor control of daily symptoms, exhibit abnormal pulmonary function testing at their baseline, have a history of poor compliance, or have family dysfunction that affects their treatment. References: Lemanske RF Jr, Busse WW. Asthma. JAMA. 1997;278:1855-1873 Guidelines for the Diagnosis and Management of Asthma. Expert Panel Report, II. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997:No. 97-4051 Sly RM. Asthma. In: Behrman RE, Kliegman RM, Nelson WE, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:628-641 1998 Self-Assessment Exercise VIII. Allergy and related disorders [Return to Category List] Questions [Print Directions] Question 34. Answer.

You are evaluating a 13-year-old boy who has asthma and required mechanical ventilation following a respiratory arrest 2 years ago. He is using an inhaled bronchodilator as needed, 3 to 4 times a day, and has not seen a physician in more than 8 months. He has no complaints, but reports he gets short of breath easily.

In addition to an inhaled bronchodilator as needed, the BEST drug to treat this patient's asthma is inhaled A. B. C. D. E. anticholinergic agent corticosteroid cromolyn sodium long-acting bronchodilator nedocromil sodium Answer.

Question 69.

Four days after receiving an intramuscular injection of benzathine penicillin to treat syphilis, a 17-year-old girl reports feeling "funny" in her chest and having a rash. She was told in the past that she was allergic to cefaclor. Results ofimmediate-type skin testing with major and minor determinants to penicillin are negative. If this patient receives another course of oral penicillin in the future, she is MOST likely to experience A. B. C. D. E. anaphylaxis hematuria hemolytic anemia maculopapular rash neutropenia

Question 101. Answer. At an outdoor party for your daughter, a 4-year-old who ate cake, candy, and peanuts develops diffuse urticaria, angioedema of the lips and eyelids, wheezing, dyspnea, and a cough. Of the following, the MOST likely cause of this child's symptoms is A. B. C. D. E. anaphylactoid reaction anaphylaxis exercise-induced asthma idiopathic urticaria/angioedema idiosyncratic reaction to artificial preservatives

Question 132. Answer.

Each May for the past 3 years, a 12-year-old boy has developed sneezing and itching of the nose and eyes. Symptoms generally last 4 to 6 weeks. Of the following, the MOST likely explanation for this boy's findings is A. B. C. D. E. allergic rhinitis infectious rhinitis irritant rhinitis rhinitis medicamentosa vasomotor rhinitis

Question 166. Answer. A 3-month-old infant has failure to thrive, oral candidiasis, and chronic diarrhea. Among the following, the diagnostic study MOST likely to explain these findings is A. B. C. D. E. CD4 lymphocyte count polymerase chain reaction for human immunodeficiency virus skin testing for delayed hypersensitivity stool culture for fungus total hemolytic complement level

Question 167. Answer. A 3-day-old girl who has had a lumbar sacral myelomeningocele repaired has vomited twice. Physical examination reveals fullness of the anterior fontanelle and opisthotonic posturing. The head size has increased 1 cm since birth. Of the following, the MOST likely cause of these findings is A. B. C. D. E. acute hydrocephalus seizures subdural effusion tethering of the spinal cord urosepsis

Question 202. Answer. A 13-month-old boy who has atopic dermatitis has had two significant flares in his skin disease recently. The first occurred 1 month ago when he was switched from soy formula to

cow milk. His skin condition improved when he was returned to soy formula. His parents allowed him to have cheese during the past week and his skin condition has worsened. Of the following, the most appropriate NEXT step in management is to A. B. C. D. E. diagnose him as being allergic to cow milk introduce cow milk in a slow, desensitizing fashion obtain a D-xylose test perform another challenge with cow milk refer him to an allergist for skin testing

Question 234. Answer. The parents of a 10-year-old boy who has mild asthma but no allergic symptoms ask whether their son will outgrow the asthma. Because he has no evidence of allergies, you tell them that the likelihood that he will outgrow his asthma by adulthood is CLOSEST to A. B. C. D. E. 20% 30% 40% 50% 60%

Question 267. Answer. A 10-year-old boy reports he has had wheezing following exercise and has had symptomatic relief after using his brother's albuterol inhaler when he has a cold. He never has required treatment in your office or at the hospital. Pulmonary function testing reveals that his forced expiratory volume in 1 second (FEV1) is 85% of predicted. Of the following, the MOST likely diagnosis is A. B. C. D. E. asthmatic bronchitis bronchitis exercise-induced asthma mild intermittent asthma moderate persistent asthma

Answers

Critique 34

Preferred Response: B

[View Question] Asthma is a disease characterized by airway inflammation, increased airway responsiveness, and reversible airway obstruction; it is not simply a bronchospastic disease that can be treated symptomatically. Therapy should be tailored to achieve well-defined goals, such as those proposed by the National Asthma Educational Program. Medication should be selected according to the symptoms, severity, and pathophysiology of asthma. The two basic classes of drugs for asthma, anti-inflammatory agents and bronchodilators, are directed at the two major components of the disease. Undertreatment of asthma is one of the greatest barriers to effective disease management. In moderate persistent or severe persistent asthma, effective pharmacologic treatment requires the use of long-term controllers (anti-inflammatory agents) and quick relievers (bronchodilators). Inhaled anti-inflammatory agents, usually inhaled corticosteroids, are the mainstay of therapy. Long-term use of anti-inflammatory agents decreases both bronchial inflammation and bronchial hyperresponsiveness. The noncorticosteroid anti-inflammatory agents (eg, cromolyn sodium and nedocromil sodium) may be used either in combination with inhaled steroids or occasionally, in milder cases, alone. Both agents have a prophylactic effect on the early- and late-phase allergen-induced bronchospasm, and they have few side effects. Bronchodilators should be used in addition to inhaled anti-inflammatory agents. Current data suggest that long-acting inhaled bronchodilators may be a good choice as an adjunct to inhaled anti-inflammatory agents, but not as a replacement for them. Inhaled anticholinergic agents (ie, ipratropium bromide) are an alternative for those patients who experience side effects with other medications, especially oral bronchodilators. Oral corticosteroids also are an important component of the pharmacologic management of asthma. Their use is beneficial in two situations: 1) in patients whose exacerbations are not completely responsive to acute use of bronchodilators, where they can increase the adrenergic response, improve forced expiratory volume in 1 second (FEV1), and improve oxygenation; and 2) in patients whose daily symptoms are unacceptably debilitating despite maximal doses of both bronchodilators and anti-inflammatory agents. References: Bierman CW, Shapiro GG, Carr DO, Bush RK, Busse WW. Evaluation and treatment of the patient with asthma. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:498-519 Global initiative for asthma: global strategy for asthma management and prevention. NHLBI/WHO Workshop Report. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute; 1993: No. 95-3659

Kemper KJ. Chronic asthma: an update.03580 Pediatrics in Review. 1996;17:111-117 Murphy SJ, Kelly HW. Advances in the management of acute asthma in children.03610 Pediatrics in Review. 1996;17:227-235 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1997: No. 97-4051 Critique 69 Preferred Response: D

[View Question] Most adverse reactions to drugs are toxic rather than allergic; they occur because of overdosage, impaired metabolism (or excretion), or drug interactions. Systemic anaphylaxis is the classic manifestation of immunoglobulin E (IgE)-mediated immediate hypersensitivity. Reactions range in severity as follows: mild pruritus, urticaria and angioedema, laryngeal edema, circulatory collapse, and death. In the patient in the vignette, the reaction to penicillin occurred 4 days after the injection and consisted primarily of a rash. This is most likely a dermatitis medicamentosa or drug rash. The onset of these eruptions usually occurs late in the treatment, and there is little to differentiate them from infectious exanthems. Accordingly, the most likely expected reaction to future penicillin exposure would be the development of a maculopapular rash. The likelihood of anaphylaxis after rechallenge in the patient in the vignette would be no greater than that expected for the general population because results of skin testing with major and minor determinates were negative. Generally, skin testing is indicated only when alternative forms of testing are not available or when anaphylaxis to penicillin has occurred and future use of antibiotics is anticipated. Most immediate-onset penicillin reactions are IgE-mediated. The most common drug-induced kidney disease is interstitial nephritis, which is characterized by hematuria, proteinuria, pyuria, and varying degrees of azotemia. Methicillin has been the most commonly identified cause of interstitial nephritis. Penicillin-induced hemolytic anemia is an example of a cytotoxic immune drug reaction. When IgG or IgM antibody develops with a specificity for a drug or drug metabolite, the antibody forms a complex with the antigen in the circulation. After reacting with complement, this complex develops a high affinity for red blood cells and attaches to them nonspecifically. Hemolytic anemia usually resolves rapidly after the offending drug is removed. Immune neutropenia is characterized by the acute onset of chills, fever, and arthralgias accompanied by a rapid fall in the leukocyte count. However, immune neutropenia following a short course of any drug is rare. References:

Anderson JA. Allergic reactions to drugs and biological agents. JAMA. 1992;268:2844-2857 VanArsdel PP. Drug hypersensitivity. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996: 320-347 Critique 101 Preferred Response: B

[View Question] Anaphylaxis is an acute reaction that occurs when antigen is introduced into an individual who has pre-existing immunoglobulin E (IgE) antibodies fixed to the surface of mast cells and basophils. Sometimes the reaction is unanticipated; within seconds to minutes, the patient manifests the clinical signs of anaphylaxis. These manifestations vary little from one reaction to another in the same person, but they differ greatly among individuals. Cutaneous symptoms include pruritus, flushing, urticaria, and angioedema. Respiratory symptoms can include laryngeal edema (with inspiratory stridor), bronchospasm (with expiratory wheezing), or dyspnea. The constellation of symptoms seen in the child in the vignette are consistent with anaphylaxis. Hypotension associated with either sinus tachycardia or sinus bradycardia may develop. Visceral symptoms include intestinal cramping, diarrhea, and vomiting. Severe symptoms have been associated with a feeling of impending doom. In some cases, shock and death may occur. Anaphylactoid reactions can be hard to distinguish from true anaphylaxis. However, these reactions are not caused by an IgE-mediated mechanism. Most have been associated with exposure to iodinated radiocontrast media and nonsteroidal anti-inflammatory drugs. Exercise-induced asthma (EIA) is defined as acute bronchospasm caused by exercise. It is due to airway narrowing that occurs shortly after the onset of exercise. It occurs in approximately 11% of the general population, but as many as 40% of children who have allergic rhinitis may have symptoms of EIA. Idiopathic urticaria or angioedema may be associated with pruritus but, by definition, wheezing is not a manifestation. A child who has asthma may have a flare-up caused by a viral illness, but rarely will the child have pruritus, urticaria, or angioedema as an associated symptom. An idiosyncratic reaction to artificial preservatives should be considered when a child has an acute allergic reaction to several seemingly unrelated drugs or foods. In the vignette, symptoms developed after the child ate peanuts, one of the foods more commonly linked to allergic reactions. Thus, idiosyncratic reaction to an artificial preservative would be a less likely explanation for the findings. If sensitivity to an additive or dye is suspected, the only reliable confirmatory test is a carefully graded and well-monitored challenge. Treatment is avoidance of the offending agent. References:

Liberman PL. Specific and idiopathic anaphylaxis: pathophysiology and treatment. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:297-319 Valentine MD. Amaphylaxis and stinging insect hypersensitivity. JAMA. 1992;268:2830-2833 Yunginger JW. Anaphylaxis. Ann Allergy. 1992;69:87-96 Critique 132 Preferred Response: A

[View Question] Allergic rhinitis affects approximately 20% of the American population. This seasonal or perennial disorder is characterized by nasal congestion, runny nose, sneezing, itching, and ocular symptoms (eg, itchy, watery, swollen eyes). These symptoms, which can vary in severity, are due to an underlying inflammatory process initiated by immunoglobulin E (IgE), neurogenic stimuli, and other complex cellular processes. Eliciting an accurate and complete patient history is critical to both the diagnosis and the treatment of allergic rhinitis. Although the usual associated symptoms involve the eyes, nose, and throat, as seen in the child in the vignette, patients who have allergic rhinitis also may complain about symptoms related to the sinuses, ears, and lower respiratory tract. Infectious rhinitis occurs during early childhood when allergic rhinitis is uncommon. Usually there are complaints of chronic rhinorrhea and nasal congestion that are worse during the colder months. Nasal secretions typically are mucopurulent, and postnasal discharge often is present. Infectious rhinitis may be the result of recurrent viral or, less frequently, bacterial respiratory infections. Vasomotor rhinitis is a perennial rhinitis of unknown cause. It is manifested by persistent nasal congestion, rhinorrhea, and postnasal drainage that are not related to exposure to a specific infection or allergen. Nasal congestion also can be triggered by rapid temperature changes, irritants, drafts, humidity changes, strong smells, air pollution, powerful emotions, and ingestion of alcoholic beverages. Irritant rhinitis, if caused by an unknown exposure, is one form of vasomotor rhinitis. The rebound congestion following treatment with topical adrenergic nose drops or sprays is known as rhinitis medicamentosa. It also can result from the oral administration of various drugs, including hormones (eg, oral contraceptives), reserpine derivatives, and hydralazine hydrochloride. References: Kaliner M, Lemanske R. Rhinitis and asthma. JAMA. 1992;268:2807-2829 Philip G, Naclerio RM. Physiology and diseases of the nose. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:393-410

Sly RM. Allergic rhinitis. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:626-627 Critique 166 Preferred Response: B

[View Question] The most likely immunologic disorder associated with recurrent bacterial infections in an infant or young child is a humoral (B cell or antibody) immunodeficiency. Such disorders include congenital diseases (eg, hypogammaglobulinemia, immunoglobulin G [IgG] subclass deficiency, common variable immunodeficiency) and acquired diseases (eg, human immunodeficiency virus [HIV]-related immunodeficiency). Children infected with HIV cannot be identified clinically until severe disease occurs or until chronic problems, including diarrhea; failure to thrive; overwhelming infections with viral, bacterial, or opportunistic pathogens; or oral candidiasis, suggest an underlying immunodeficiency. The clinical findings in the child in the vignette are consistent with HIV infection. In older children and adolescents, detection of HIV-1 antibody is both extremely sensitive and very specific, but maternal transplacental IgG obscures the usefulness of such diagnostic screening in infants. Methods for direct detection of virus proteins or nucleic acids, such as polymerase chain reaction (PCR) to detect HIV-1 nucleic acid sequences and direct virus isolation from peripheral blood, are helpful studies in such infants. Measurement of total hemolytic complement level would be appropriate for patients who have recurrent infections due to Neisseria species, especially meningococcemia, without evidence of a humoral immunodeficiency. Stool culture for fungus may be necessary eventually in the infant in the vignette, but it will not yield the underlying diagnosis of HIV disease. Intradermal testing for delayed-type hypersensitivity is a good measure of T-cell mediated immunity, but not B-cell or humoral immunodeficiency. Measurements of specific CD4 lymphocyte counts are interpreted as indirect evidence of HIV infection and should be used only in conjunction with specific tests for HIV-1 infection. References: Anderson MM, Morris RE. HIV and adolescents. Pediatr Ann. 1993;22:436-446 Annunziato PW, Frenkel LM. The epidemiology of pediatric HIV-1 infection. Pediatr Ann. 1993;22:401-405 Boyer PJJ. HIV infection in pregnancy. Pediatr Ann. 1993;22:406-412 Church JA. Clinical aspects of HIV infection in children. Pediatr Ann. 1993;22:417-427 Church JA. The diagnostic challenge of the child born "at risk" for HIV infection. Pediatr Clin North Am. 1994;41:715-726

Cvetkovich TA, Frenkel LM. Current management of HIV infection in children. Pediatr Ann. 1993;22:428-436 Hoekelman RA. A pediatrician's view: collaboration between pediatric subspecialists and generalists in the care of HIV-infected children. Pediatr Ann. 1993;22:399-400 Iseki M, Heiner DC. Immunodeficiency disorders.01726 Pediatrics in Review. 1993;14:226236 Lambert JS. Maternal-fetal transmission of HIV-1 infection. Pediatr Ann. 1993;22:413-416 Parks W. Human immunodeficiency virus. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:916-919 Critique 167 Preferred Response: A

[View Question] Myelomeningocele in a newborn requires surveillance of many body systems in anticipation of complications. The infant in the vignette may have undergone ultrasonography of the brain to assess baseline ventricular size. If so, these results can be compared to those found on a repeat study because the increasing size and fullness of the anterior fontanelle suggest the diagnosis of acute, progressive hydrocephalus. If available, ultrasonography at the bedside would be the most convenient and quick. However, magnetic resonance imaging (MRI) provides greater anatomic detail. Virtually all children who have lumbosacral myelomeningocele also have ArnoldChiari malformation. Many, but not all, of these children develop progressive hydrocephalus and require placement of a shunt. Those who have mildly dilated ventricles without progression may not need a shunt. Twenty percent of children who have myelomeningocele develop seizures at some time during their life; nearly all of these children have had shunts. One third of those who experience seizures will have other central nervous system malformations. However, seizures usually are not seen in the newborn. The opisthotonic posturing in the infant in the vignette more likely is due to increased intracranial pressure and possible herniation or irritation at the foramen magnum. Prophylactic anticonvulsants would not be warranted in this case because the majority of affected patients do not develop epilepsy. Subdural effusion is an uncommon complication of myelomeningocele; most effusions are sequelae of bacterial meningitis or head injury, especially after nonaccidental trauma. An imaging study would exclude this unlikely possibility. Tethering of the spinal cord is universal in older children who have myelomeningocele as the lumbosacral cord fails to ascend. Adhesions from surgical repair may restrict the cord further, preventing its normal ascent as the child grows. However, this problem usually is not manifested until preschool or school age; it would be extremely unusual in a newborn. The signs and symptoms of tethered cord include neurologic,

orthopedic, and urologic abnormalities. A tethered cord sometimes causes additional morbidity in the form of limb atrophy, paralysis, or incontinence. Urosepsis is a complication in patients who have myelomeningocele because of flaccid or spastic bladder paresis, incomplete emptying with residual urine, and vesicoureteral reflux. It is a common cause of morbidity and death in older children who have myelomeningocele, but is an unlikely cause of acute neurologic deterioration in a newborn. The potential for urinary tract complications necessitates early assessment by a urologist with efforts to empty the bladder by Crede maneuver or intermittent clean catheterization. Careful monitoring of serial urine cultures is necessary to exclude urinary tract infections over time. In the infant in the vignette, the repair site of the open defect may have become infected and led to the vomiting. If the child presented with fever or other signs of toxicity, cultures of the cerebrospinal fluid, blood, wound, and urine should be obtained urgently. It is likely that this infant already is receiving postoperative prophylactic antibiotics. While awaiting culture results, appropriate empiric therapy should cover Staphylococcus aureus, coagulase-negative staphylococci, and other neonatal pathogens (eg, group B streptococci, Listeria monocytogenes, Escherichia coli). The primary pediatrician has a large role in counseling parents of children who have myelomeningocele about current and anticipated handicaps, reasons for consultations with various specialists, and likelihood of ambulation and bowel and bladder control. It is important for the parents to be involved in both immediate and long-term decisions. In most patients, neurosurgery and urology consultations and involvement of genetics, social services, and rehabilitation experts may be appropriate. References: Blum RW, Pfaffinger K. Myelodysplasia in childhood and adolescence.02382 Pediatrics in Review. 1994;15:480-484 Hobbins JC. Diagnosis and management of neural-tube defects today. N Engl J Med. 1991;324:690-691 Marion RW, Chambers P, Schendel LF. Myelomeningocele. In: Johnson RT, ed. Current Therapy in Neurologic Disease. 3rd ed. Philadelphia, Pa: BC Decker Inc; 1990:85-89 McLone DG, Nadich TP. Myelomeningocele. In: Hoffman HJ, Epstein F, eds. Disorders of the Developing Nervous System: Diagnosis and Treatment. Boston, Mass: Blackwell Scientific Publications; 1986:87-108 Menkes JH, Till K. Malformations of the central nervous system. In: Menkes JH, ed. Textbook of Child Neurology. 5th ed. Baltimore, Md: Williams & Wilkins; 1995:240-324 Critique 202 Preferred Response: E

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The terms atopic dermatitis, atopic eczema, and eczema are used interchangeably. Atopic dermatitis is one manifestation of atopic diathesis, an inherited tendency toward developing either the skin hyperreactivity of atopy (atopic dermatitis) or the respiratory tract hyperreactivity of atopy (asthma, allergic rhinitis). The key feature of atopic dermatitis is an inherent sensitivity to multiple factors that cause pruritus and result in an itch-scratch cycle. Studies over the past 15 years have demonstrated clearly a pathogenic role for food allergy in some patients who have atopic dermatitis. Overall, approximately one third of children who have atopic dermatitis also have food hypersensitivity contributing to their symptoms. Research has shown that some young children who have atopic dermatitis develop immediate pruritic cutaneous reactions after the ingestion of certain foods. Furthermore, the intense itching and scratching can produce eczematous skin lesions, particularly when the offending food is ingested repeatedly. A remarkable improvement has been demonstrated in affected patients when the specific food is eliminated from the diet. Immediate hypersensitivity skin tests and radioabsorbent tests for various environmental or food allergens are positive in approximately 80% of patients who have atopic dermatitis. A positive skin prick test indicates the presence of allergen-specific immunoglobulin E (IgE) and should be considered suggestive of immediate food sensitivity that requires confirmation with a more definitive study, such as an oral challenge. These procedures are handled best by an allergist. Accordingly, referral of the child in the vignette for further evaluation by an allergist is warranted. Labeling the child as allergic to cow milk is premature without appropriate evaluation. Similarly, reintroduction of cow milk in any manner could exacerbate the condition. A d-xylose test is used to investigate the possibility of a proximal intestinal mucosal lesion and would not be appropriate in this patient. References: Adinoff AD, Clark RAF. Atopic dermatitis. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:613-632 Sly RM. Atopic dermatitis. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:641-644 Tanaka M, Aiba S, Matsumura N, et al. IgE-mediated hypersensitivity and contact sensitivity to multiple environmental allergens in atopic dermatitis. Arch Dermatol. 1994;130:13931401 Critique 234 Preferred Response: E

[View Question] Overall, the prognosis for children who have asthma is good. Whether the symptoms will remit with no further need for medication is an often-asked question from parents. The outcome depends partly on growth in the cross-sectional diameter of the airways.

Longitudinal studies indicate that approximately 60% of children who have asthma without other allergies will be virtually free of symptoms within 10 to 20 years after onset, although recurrences in adulthood are common. In contrast, the remission rate among children who have severe asthma or multiple allergies is approximately 30%. Finally, children who have severe, steroid-dependent disease and require frequent hospitalizations rarely improve; approximately 95% will continue to have the disease into adulthood. References: Pearlman DS, Lemanske RF. Asthma (bronchial asthma): principles of diagnosis and treatment. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:484-497 Shapiro GG. Childhood asthma: update.01315 Pediatrics in Review. 1992;13:403-412 Sly RM. Asthma. In: Nelson WE, Behrman RE, Kliegman RM, Arvin AM, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, Pa: WB Saunders Co; 1996:628-640 Critique 267 Preferred Response: D

[View Question] Asthma is characterized by airway inflammation, increased airway responsiveness, and reversible airway obstruction. Acute exacerbations can be fatal, but with proper ongoing monitoring and a comprehensive approach to management, symptoms can be controlled well. Therapy should be tailored to achieve well-defined goals, such as those proposed by the National Asthma Education and Prevention Program. Symptoms of intermittent persistent asthma usually are infrequent, and chronic inflammation is not believed to play a significant role. Quick reliever medications such as bronchodilators are most useful in treatment. However, when symptoms occur more frequently, the disease classification becomes mild persistent asthma. It has become increasingly apparent that those patients who have any degree of symptomatology on a recurrent or chronic basis have bronchial hyperresponsiveness as a result of airway inflammation. The patient in the vignette does not have exercise-induced asthma because symptoms are evident at times other than just with exercise and results of his pulmonary function studies are normal. The appropriate diagnosis is mild intermittent asthma, which is characterized by symptoms two or fewer times a week, normal peak expiratory flow rates and findings between episodes, and exacerbations that are brief (from a few hours to a few days) and of varying intensity. By definition, moderate persistent asthma is characterized by daily symptoms, with exacerbations occurring two times a week, possibly lasting days, and possibly affecting activity and sleep. Forced expiratory volume in 1 second (FEV1) is greater than 60% but 80% or less of predicted.

The actual definition of asthmatic bronchitis is vague, although it usually is considered to be a form of asthma. It is seen acutely in children who have an upper respiratory tract infection that includes bronchospasm similar to children who have asthma. Bronchitis is associated with several other conditions of the upper and lower respiratory tracts (eg, exposure to smoking, influenza), and the trachea usually is involved. References: Bierman CW, Shapiro GG, Carr DO, Bush RK, Busse WW. Evaluation and treatment of the patient with asthma. In: Bierman CW, Pearlman DS, Shapiro GG, Busse WW, eds. Allergy, Asthma, and Immunology from Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1996:498-519 Global initiative for asthma: global strategy for asthma management and prevention, NHLBI/WHO Workshop Report. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute; 1993: No. 95-3659 Kemper KJ. Chronic asthma: an update. Pediatrics in Review. 1996;17:111-117 Murphy SJ, Kelly HW. Advances in the management of acute asthma in children. Pediatrics in Review. 1966;17:227-235 National Asthma Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health;