Food Infants/Young children

Older Children And Adults

Anaphylaxis

Milk (cow/goat) •   •

Chicken egg •   •

Soy •    

Peanut • • •

Tree nuts (walnut, hazel/filbert, cashew, pistachio, Brazil , pine nut, almond)

  • •

Wheat •    

Fish   •  

Shellfish (shrimp, crab, lobster, oyster, scallops)

  • •

Fruit   • •

Vegetables   • •

Seeds (cotton, sesame, psyllium, mustard)   • •

Spices   •  

Common Food Allergens

Inhalant Allergen

Food Allergens

Birch pollen Apple, raw potato, carrot, celery, hazelnut, pear, peach, plum, cherry

Mugwort pollen Celery, apple, peanut, kiwi fruit, carrot, parsley, spices (fennel, coriander, aniseed, cumin)

Ragweed pollen Melons, e.g., watermelon, cantaloupe, and honeydew, bananas

Latex Avocado, kiwi fruit, chestnut

Chironomidae Crustaceans (shellfish)

Typical cross reactivity associations include:

Allergic disease is the 5th leading chronic disease among all ages

3rd common chronic disease among children under 18 years old; up to one child in three is affected

Trends indicate that by 2015, half of all Europeans may be suffering from an allergy

Allergies affect people from the early stages of their life and continue until their late adult ages

The history. Evaluation begins with a careful allergy/environmental history to identify exposures and triggers. The clinical history should include

(1) the nature of the illness/symptoms; (2) precipitators and eleviators of symptoms; (3) the frequency and duration of attacks; (4) time lost from school or work; (5) prior evaluation and treatment; (6) medical history; (7) family history; (8) past and current medications; (9) occupation and hobbies.

NosePharynx

Stomach

OesophagusLungs

““Global diseases” – due to the large Global diseases” – due to the large spectrum of symptoms affecting the spectrum of symptoms affecting the

whole bodywhole body

SkinFood allergyFood allergy

Allergic rhinitisAllergic rhinitisAsthmaAsthma

EczemaEczemaUrticariaUrticariaAllergic dermatitisAllergic dermatitis

B lymphocyte needs 2 signals to mature to IgE producing plasma cell.› IL-4 secreted by Th2 cells› Interaction of CD40 ligand on the surface of

T-cell with the CD40 receptor on the B cell IgE antibody

› Unbounded IgE with half life of 2-3 days› Bound to receptor on the surface of mast cell,

basophil, dendritic cell, and eosinophil with half life of several weeks

Performed mediators: › Vascular permeability factor (VPF) / vascular

endothelial cell growth factor – enhancing vascular permeability

› Histamine, proteoglycan, chymase, tryptase, carboxypeptidase A. heparin

› TNF-alpha, IL-2,3,4,13, CSF, chemokine Product inflammatory mediators: prostaglandin D2 leukotriene C4, D4, B4

Developed in bone marrow under stimulation of IL3,IL5, CSF

Half life of 8-18 hours in the blood, half life of several days in the peripheral tissue

Eosinophil migration ( into peripheral tissue) Toxic inflammatory mediators in eosinophil:

› major basic protein, eosinophil peroxidase, eosinophil cationic protein,

Synthesize lipid mediators: › leukotriene C4

I. Allergic anamnesis. A detailed anamnesis is a basic information source, necessary for diagnostics and treatment of the allergic diseases. While examining patients with the allergic diseases special attention should be paid to:

1. variability of the symptoms (they develop and disappear rapidly, they develop in the specific place or in the specific season)

2. individual allergic anamnesis 3. family allergic anamnesis

The organs and the systems, which are most frequently affected with the allergic diseases: the skin, eye, respiratory organs are examined especially attentively.

Basic principles: 1. Not to fail to note the affection of the

skin, it is necessary to investigate the entire skin. A patient can not mention about the skin manifestations, considering them insignificant, not related to the disease or feeling shy of them.

1) An increase in the number of the eosinophils up to 5-15%.

2) Absolute and relative lymphocytosis. A substantial change in the relationship of neutrophils/leukocytes

In exacerbation of the allergic diseases eosinophils predominate among the cells in the smears of the phlegm, discharge from the nose or eyes, in the concomitant infection there are neutrophils

An increase in the total level of IgE in the serum confirms the diagnosis of the allergic disease, although the normal level of IgE does not exclude it.

4. Determination of the levels of specific IgE in blood serum (IFA diagnostics, ELISA and immunoblotting) to different allergens.

Polycheck-Polycheck- PanelPanel (Bio(BioССheck GmbH, heck GmbH, Germany)Germany)

The signs of the allergic diseases: - Absolute and relative lymphocytosis; - Eosinophilia; - An increase (more than 2.8) in the index of

immunoregulation (Tx/Tc) (CD4/CD8): - An increase in the absolute and relative

quantity of the B-lymphocytes; - A reduction of the complement content; - An increase in the levels of the circulating

immune complexes; - An increase in the autoantibodies to the tissues

of the organs - targets (the skin, mucous membrane of the nose, bronchi, lungs)

There are cutaneous – puncture and scarification and intracutaneous tests. The positive results of skin tests (erythema and blister at the site of the allergen introduction) are of a diagnostic value only in combination with the data of the anamnesis, physical and laboratory investigations.

Skin-prick testing remain the "gold standard" for identifying clinically relevant allergens.

Grade Criteria Significance

+ / - Mild erythema and no edema

Doubtful

1 + Erythema, edema and induration

Positive

2 + Erythema, edema and isolated vesicles

Positive

3 + Erythema, edema and confluent vesicles

Positive

Grading of Patch Tests

The allergen extracts in the dilution of 1: 100 are used for the intracutaneous tests. When less than five puncture or scarification tests are positive, intracutaneous tests can be carried out immediately. If the positive puncture or scarification tests are more, intracutaneous tests are carried out next day. Intracutaneous tests with the food allergens are not made.

1) Impairment of the technology of skin tests, the use of the allergen preparations with expired date, the tests made against the background of treatment with drugs decreasing skin sensitivity lead to the pseudonegative results. The intake of H1- blockers is withdrawn for 48 hr, hydroxizine, terfenadine, loratadin and tricyclic antidepressants – for 96 hr and astemizole - 4 weeks prior to the study. Theophylline, adrenostimulators (inhalation and for the internal administration) and cromolin do not influence the skin sensitivity.

2) Introduction of the incorrectly prepared solutions of the allergens (incorrect selection of osmolarity and pH, presence of the irritating substances), impairment of the technology of making skin tests, for example, intracutaneous introduction of more than 0.02 ml of the allergen solution, urticate dermographism, introduction of the substances, which cause the release of histamine (for example, the extracts of food allergens), leads to the pseudopositive results.

3) Results of the skin tests are compulsorily compared with the data of anamnesis, physical and laboratory investigations.

is a method of development of sensitization, based on the introduction of the allergen in the target organ. There are sublingual, endonasal and inhalation provocation tests.

› Type I: anaphylactic reaction: mediated by IgE antibodies, which trigger the mast cells and basophils to release pharmacologically active agents.

Urticaria

Quinke Oedema

› Type II: cytotoxic reaction: IgM or IgG antibodies bind to antigen on the surface of cells and activate complement cascade.

1)Transfusion reaction 2) Hemolytic disease of newborn 3) Autoimmune hemolytic anemia

and type II drug reaction

Type III: Immune complex reaction: complexes of antigen and IgM or IgG antibodies accumulate in the circulation or in tissue and activate the complement cascade. Granulocytes are attracted to the site of activation and release lytic enzymes

1. Local immune complex disease 2. Acute systemic immune complex disease 3. Chronic immune complex disease

Type IV hypersensitivity Type IV hypersensitivity

mediated by T cells, which release cytokines

upon activation to cause accumulation and

activation of macrophages. 1) Infectious delayed type hypersensitivity

OT( Old Tuberculin ) test

2) Contact dermatitis :

3) Acute rejection of allogenic transplantation and

immune response in local tumor mass

Eczematous skin lesions (age dependent) Early onset and typical localization of skin

lesions according to age Pruritis Stigmata of atopy Personal or family history of atopy IgE mediated sensitization (demonstrated

by skin prick test serum IgE measurement

Dry skin Hyperlinearity of palms and soles Linear grooves of fingertips Dennie-Morgan fold (atopy fold, doubled intraorbicular

fold) Hertoghe’s sign (hypodense lateral eyebrows) Short distance between scalp hair growth in the

temporal hairline and eyebrows Periorbital shadow (halo) Delayed blanching after intracutaneous injection of acetylcholine White dermatographism

They are used: - in acute states - parenterally (prednisolone,

hydrocortisone, dexamethasone) - systematically - orally and intramuscularly

prolonged forms - drugs- depot – effect for a month (polcortolon, diprospan)

- locally - inhalation forms, nasal sprays, ointments and creams.

Antihistamine drugs (blockers of H1 Antihistamine drugs (blockers of H1 - histamine receptors)- histamine receptors)They are effective only upon transfer from They are effective only upon transfer from the pathochemical stage to the the pathochemical stage to the pathophysiological one. pathophysiological one.

Competitive (with histamine) blockade of H1 - receptors – drugs should be taken frequently (3-4 times in a 24 hour period), and in the large doses (risk of the toxic action);

- penetrate through the blood-brain barrier - sedative side-effect (sleepiness) + potentiate the effect of analgesics and antipyretics;

- Irritate the GIT mucosa - the side-effect is diarrhea, therefore the intake is after meal (adsorption velocity from the bowels is lowered);

- In the prolonged intake (more than 10 days) tachyphylaxis develops (addiction) - effectiveness is lowered;

- bind with the blood proteins (risk of the toxic effect during dehydration, cachexia and secretory dysfunction of the kidneys);

- muscarine-like effect (anticholinergic action) - they decrease the secretion of the mucous glands of the respiratory system – they are contraindicated in diseases of the respiration organs in presence of the thick phlegm in the bronchi (they reduce the drainage function of the bronchi).

Hismanal, histalong (Astemizol), Claritin (Loratadine), Zirtek (Cetirizine), Cestin (Ebastine), Trexil (terfenadine)

Peculiarities of pharmacokinetics and the mechanism of action:

They are noncompetitive blockade of H1 - histaminic receptors; they do not penetrate through the blood-brain barrier; they do not irritate the GIT mucosa; tachyphylaxis does not develop; do not bind with the blood proteins; anticholinergic action is absent.

Telfast (Fexofenadine), Erius (dezloratadine), Aleron (levocetirizine)

According to the last recommendations of allergologists intake of the drugs of the first generation is indicated in the emergency allergic states, since they are in the injection forms, and the administration of the drugs of the second and third generation is indicated for the course therapy.

At the same time the drugs of the second and third generation do not exceed those of the first generation in the manifestation of the antiallergic effect. Furthermore, many people are noted to have individual sensitivity (selective) to the antihistamine drugs. There may be higher efficacy in intake of the drugs of the first generation and minimum reaction after the intake of the drug of the second or third generation.

They are effective at the pathochemical stage and ketotifen - upon transfer from the pathochemical stage to the pathophysiological one.

Cetotifen, sodium cromolin (intal, cromolin, cromogexal, cromoglin etc), Nedocromil of sodium (Tiled).

Anti-leucotriene drugs (inhibitors of leucotriene metabolism)

Selectively binds to human immunoglobulin E (Omalizumab)

Specific immunotherapy

Thank you for your attention!Thank you for your attention!