Immunologic Disorders
What diagnostics are done for hypersensitivities (allergies)?
(not really done in hospitals) Labs: - CBC - ELISA for serum IgE - Skin testing Tests: - None note: - severe seasonal allergies like allergic rhinitis/hay fever (eosinophils increased to 5-12%; normal is 1-2%) - pts with increased total WBC, but %neutrophils is normal --> typical for pts with allergies (since neutrophils increase d/t bacteria)
What are the signs of systemic lupus erythematosus (SLE)?
(so many diff Sx, can be hard to Dx) Skin manifestations (discoid lupus) - Inflamed, red rash (butterfly rash - face & other sun exposed areas - sun irritates their disease); discoid lesions; oral ulcers Renal manifestations - Nephritis; kidney failure Cardiovascular manifestations - Pericarditis; myocarditis; hypertension; dysrhythmias; atherosclerosis; Raynaud's phenomenon Pulmonary manifestations - Pleural effusions
What are the common causes of anaphylaxis? (Type I hypersensitivity)
- Acute care settings: drugs and dyes - Community settings: food and insect stings/bites note: drugs are leading cause of fatal _____________
What drugs are used for chronic gout?
- Allopurinol (xanthine oxidized inhibitors, take after meals w/ glass of water) ---- NOTE: stop if having an acute attack, need colchicine - Febuxostat (increases excretion of uric acid) KNOW***
What happens in a transplant rejection? (Type IV delayed reaction)
- Although this action is normal and is usually helpful, it is also responsible for rejection of tissue grafts and transplanted organs (also termed grafts) (***why they go on immunosuppressants) - Because the solid organ transplanted into the recipient is seldom (rarely) a perfectly identical match of HLAs between the donated organ and the recipient host, the patient's immune system cells recognize a newly transplanted organ as non-self - Without intervention, the recipient's immune system starts inflammatory and immunologic actions to destroy or eliminate these non-self cells. This activity causes rejection of the transplanted organ
What drugs are used for Rheumatoid Arthritis? (Type III immune complex reaction)
- Anti-inflammatory & analgesics - NSAIDs, COX2 inhibitors (COX2 better for older pts stomachs) - Glucocorticoids - Immunosuppressives / DMARDs (1st line therapy, need kidney/liver monitored tho) --- Methotrexate (Rheumatrex), hydroxychloroquine (Plaquenil)
What drugs are used for allergic rhinitis? (Type I hypersensitivity)
- Antihistamines** - Corticosteroid nasal sprays** (help w/ congestion/runny nose) - Adrenergic agents - Mast cell stabilizers - Steroids - Leukotriene modifiers
What are the signs of a hyperacute rejection? (Type IV delayed reaction)
- Apparent within minutes of attachment - Organ becomes mottled / cyanotic - Organ fails (swollen, red, hemorrhage)
What are the interventions for anaphylaxis? (Type I hypersensitivity)
- Assess ABCs - Call the Rapid Response Team (RRT) (asap, don't leave pt, call from room) - Apply oxygen using high-flow non-rebreather mask at 90-100% - Remove allergen if possible (stop new med if started) - Be prepared to administer epinephrine IV or IM - Administer NS (fluids b/c going into shock) - Position the patient with HOB elevated 10-45 degrees and raise the feet and legs (help w/ CO, breathing) - Stay with the patient - Pharmacological **major fatal factor is delaying epinephrin**
What are the interventions for allergic rhinitis? (Type I hypersensitivity)
- Avoidance therapy (avoid cause; allergic to cats/dogs? avoid them; allergic to dust/dander? remove curtains/rugs that harbor these) - Pharmacological - Desensitization therapy/immunotherapy
What GI infections should we monitor for? (AIDS manifestations and opportunistic infections)
- Candidiasis: oropharyngeal and esophageal painless creamy white plaque-like lesions - HIV wasting syndrome: loss of more than 10% of body weight with diarrhea or weakness and fever for more than 30 days
What are the signs of fibromyalgia?
- Chronic fatigue - Generalized muscle aching - Stiffness - Sleep disturbances - Functional impairment - Forgetfulness - Concentration problems
What are the interventions for Type II cytotoxic reactions?
- Discontinuing the offending drug or blood product - Plasmapheresis to remove autoantibodies may be beneficial (potentially) - Symptomatic (treat Sx) - Monitor for complications
What are the signs of Sjögren's syndrome (SS)?
- Dry eyes - Blurred vision, burning and itching of the eyes - Thick mattering in the conjunctiva - Dry mouth, difficulty swallowing - Changes in taste - Epistaxis (dry nose --> bloody nose) - Frequent upper respiratory infections (don't have much mucous membrane protection anymore) - Vasculitis, arthralgia, neuropathy
What is the life cycle of HIV?
- Effects of HIV infection are related to the new genetic instructions that now direct CD4+ T-cells to change their role in immune system defenses --- HIV "hijacks" certain cells, especially the CD4+ T-cell, also known as the CD4+ cell, helper/inducer T-cell, or T4-cell --- These CD4+ cells directs immune system defenses and regulates the activity of all immune system cells, so the immune system is made weaker by removing some CD4+ T-cells from circulation - Gradually, CD4+ T-cell counts fall, viral numbers (viral load) rise, and without treatment, the patient eventually dies of opportunistic infection or cancer
How do we screen for HIV treatment adherence?
- Every health care encounter should be used as an opportunity to briefly review the treatment regimen, identify any new issues, and reinforce successful behaviors (insurance issues? lifestyle? etc.) - Laboratory tests evaluate whether ART is effective for a specific patient - Viral load should be measured at baseline and on a regular basis thereafter because viral load is the most important indicator of response to ART
What are signs of Type III immune complex reactions?
- Fever - Arthralgia (joint pain) - Rash - Malaise - Lymphadenopathy - Polyarthritis - Nephritis
What are signs of acute HIV infection?
- Fever - Night sweats - Chills - Headache - Muscle aches - Sore throat - Rash note: some develop this within 4 weeks of infection - 40-80% of these pts develop Sx of nonspecific viral illness (fever, fatigue, rash) for 1-2weeks
What are the types of immunoglobulins (antibodies)?
- IgG (75% of all)*** - IgA (15% of all) - IgM (10% of all) - IgD (0.2% of all) - IgE (0.004% of all)
What are examples of Type II cytotoxic reactions?
- Immune hemolytic anemias - Immune thrombocytopenic purpura - Hemolytic transfusion reactions - Drug-induced hemolytic anemia - myasthenia gravis
What should be know about gout?
- Incidence of this increases with age, body mass index, alcohol consumption, hypertension, and diuretic use - Uric acid is a by-product of purine metabolism; purines are basic chemical compounds found in high concentrations in meat products (red meat, liver eaters are more common to have attacks of this disease) - Trauma, alcohol ingestion, dieting, medications, surgical stress, or illness may trigger the acute attack
What is stage 0 of HIV?
- Interval between the appearance of detectable HIV RNA and the first detection of antibodies - About 40-80% of patients develop clinical symptoms of a nonspecific viral illness (e.g., fever, fatigue, or rash) lasting 1 to 2 weeks
How else does immunity change during a person's life?
- It also changes as a result of nutrition status, environmental conditions, drugs, disease, and age - It is most efficient when people are in their 20s and 30s and slowly declines with increasing age
What are signs of gout?
- Joint inflammation - Painful even to touch (usually @ joint) - Swelling (usually @ joint) - Redness (usually @ joint) - Warmth (usually @ joint) - Tophi - Renal calculi (commonly affects toes)
What are the late signs of Rheumatoid Arthritis? (Type III immune complex reaction)
- Joint: deformities (i.e. swan neck** or ulnar deviation** KNOW), moderate to severe pain, morning stiffness, swelling, warmth, erythema, lack of function - Systemic: fever, weight loss, fatigue, anemia, lymph node enlargement, subcutaneous nodules, peripheral neuropathy, pericarditis and cardiovascular disease
What are the early signs of Rheumatoid Arthritis? (Type III immune complex reaction)
- Joint: symmetric joint pain, inflammation and stiffness (especially in the morning) - Systemic: low-grade fever, fatigue, weakness, anorexia, paresthesia's (b/c autoimmune DO, circulating thru whole body)
In relation to cancer, what should we monitor for? (AIDS manifestations and opportunistic infections)
- Kaposi sarcoma: variable course from brownish-pink to deep purpose cutaneous lesions to multiple organ system involvement (looks like a bunch of circular, round, raised lesions everywhere; not painful/itchy)
What are the two general types of immunity?
- Natural (innate) - Acquired (adaptive)
What are physical assessment techniques?
- Neurosensory: cognitive dysfunction, hearing loss, visual changes, headaches, ataxia, tetany - Respiratory: changes in RR, cough, abnormal lung sounds, rhinitis, bronchospasm - Cardiovascular: hypotension, tachycardia, dysrhythmia, vasculitis, anemia - Gastrointestinal: hepatosplenomegaly, colitis, vomiting, diarrhea - Genitourinary: frequency and burning, hematuria, discharge - Musculoskeletal: joints mobility, edema and pain - Integumentary: lesions, dermatitis, purpura, urticaria, inflammation, or any discharge - Lymph: lymph nodes are palpated for location, size, consistency, and tenderness - Vital signs: temperature is recorded, and the patient is observed for chills and sweating
What are the interventions for gout?
- Nonpharmacological --- Low-purine diet --- also avoid: alcohol, any fad starvation diets, aspirin & diuretics*** (can also precipitate an attack) - Acute attacks (very painful) - Chronic gout
What are the signs of chronic rejection? (Type IV delayed reaction)
- Pain/tenderness of the organ/site - General discomfort, uneasiness, or ill feeling - Flu-like symptoms - Organ dysfunction
What are the standard precautions to prevent the spread of HIV?
- Perform hand hygiene - Wear personal protective equipment - Handle soiled patient care equipment appropriately with gloves (ANY bodily fluids**) - Follow procedures for environmental control - Handle textiles and laundry in a manner that prevents transfer - Handle needs and other sharps appropriately - Use devices during patient resuscitation - Prioritize patient placement as needed - Educate on proper respiratory hygiene and cough etiquette KNOW***
What respiratory infections should we monitor for? (AIDS manifestations and opportunistic infections)
- Pneumocystis jiroveci pneumonia (PCP): SOB, cough, chest pain, fever (most common opportunistic inf.) - Tuberculosis (TB): cough, night sweats, weight loss, hemoptysis (need isolation room ASAP) (KNOW***)
What are examples of Type IV delayed reactions?
- Positive purified protein derivative (PPD) test for TB (positive TB skin test) - Contact dermatitis - Poison ivy skin rashes - Local response to insect stings - Tissue transplant rejections - Sarcoidosis
What are the interventions for HIV/AIDS?
- Prevention is key - education! (biggest focus on exam!!; don't need to wear N95s, they're on contact precautions) - Pre-exposure prophylaxis --- Truvada "PREP" (emtricitabine and tenofovir) for HIV-negative sexual partners of known HIV positive people to reduce HIV transmission - Highly active antiretroviral therapy (HAART) (treatment for HIV) - starting HAART therapy is recommended for ALL HIV pts right away now - screening for adherence
How does inflammation change with aging?
- Reduced neutrophil function (can't fight off infection as much) - Leukocytosis does not occur during acute infection (may not have means to do it) - Older adults may not have a fever during inflammatory or infectious episodes (see: confusion/altered LOC & increased falls)
What is highly active antiretroviral therapy (HAART)?
- Reduces viral load to help reduce transmission - Improves CD4+ T-cell counts and restores immunologic function - Slows disease progression and reduces HIV-associated morbidity/mortality
What are the interventions for Type IV delayed reactions?
- Removal of the offending antigen is the major focus of management - The reaction is self-limiting in 5 to 7 days - The patient is treated symptomatically (Tx Sx) - Pharmacological --- Diphenhydramine (Benadryl) is not useful for type IV reactions because histamine is not the main mediator --- Corticosteroids can reduce the discomfort and help resolve the reaction more quickly (reduces inflammation; great for autoimmune reactions) note: monitor reaction site & site distal for any circulatory issues (6 P's)
What can we monitor for AIDS manifestations and opportunistic infections?
- Respiratory infections - GI infections - Oncological
What are types of rheumatic disorders?
- Rheumatoid Arthritis - Lupus Erythematosus - Sjögren's Syndrome (said wouldn't test) - Gout - Fibromyalgia Syndrome
What are examples of Type III immune complex reactions?
- Rheumatoid arthritis (immune complexes lodged into joints; become inflamed, red, swollen) - Systemic lupus erythematosus (SLE)
What are the signs of allergic rhinitis? (Type I hypersensitivity)
- Rhinorrhea --- Clear or white drainage --- Nasal mucosa is swollen and pink - Itchy, watery eyes - Mouth breathing - Nasal voice quality - Headache or sinus pressure - Dry, scratchy or sore throat
What does natural (innate) immunity include?
- Skin - Mucosa - Cilia of the respiratory tract - Acidic gastric secretions - Antimicrobial chemicals on the skin
Where do Type I rapid hypersensitivity reactions occur?
- Some reactions occur just in the areas exposed to the antigen, such as the mucous membranes of the nose and eyes, causing symptoms of rhinorrhea, sneezing, and itchy, red, watery eyes - Other reactions may involve all blood vessels and bronchiolar smooth muscle causing widespread blood vessel dilation, decreased cardiac output, and bronchoconstriction (leading to anaphylaxis) note: the most common vasoactive amine is histamine, causes capillary leak, nasal and conjunctival mucous secretion, and itching (itchy, watery eyes, redness); these manifestations of inflammation last about 10mins after histamine is first released
What are the interventions for Type III immune complex reactions?
- Supportive care (if chronic illness, no cure) - Pharmacological --- Antihistamines are given for itching --- Aspirin for arthralgias (joint pain) --- Prednisone is given if manifestations are severe
What mechanisms are responsible for acute rejection? (Type IV delayed reaction)
- The first mechanism is antibody mediated and results in vasculitis within the transplanted organ - The second mechanism is cellular. The recipient's cytotoxic T-cells and NK cells enter the transplanted organ and start an inflammatory response that causes lysis of the organ cells
How does cell-mediated immunity change with aging?
- The number of circulating T-lymphocytes decreases
What happens in fibromyalgia?
- The tender points are also known as trigger points and can typically be palpated to elicit pain in a predictable, reproducible pattern - Between 25% and 65% of patients with fibromyalgia have other rheumatologic conditions - There are a number of predisposing factors to pain, including anxiety, depression, physical trauma, emotional stress, sleep disorder, and viral infection note: pain described as burning/gnawing - increased muscle tenderness - DO is probably related to a dysfunction in the brain
How does antibody-mediated immunity change with aging?
- The total number of colony-forming B-lymphocytes and the ability of these cells to mature into antibody-secreting cells are diminished - There is a decline in natural antibodies, decreased response to antigens, and reduction in the amount of time the antibody response is maintained
What happens in a Type IV delayed reaction?
- This response typically occurs 24 - 48 hours after exposure - It consists of edema, induration (hardness of area), ischemia, and tissue damage at the site
What happens in Rheumatoid Arthritis? (Type III immune complex reaction)
- Transformed autoantibodies (rheumatoid factors [RFs]) are formed that attack healthy tissue, especially synovium, causing inflammation. The disease then begins to involve the articular cartilage, joint capsule, and surrounding ligaments and tendons - Characterized by natural remissions and exacerbations
What are the types of hypersensitivities?
- Type I: Immediate - Type II: Cytotoxic - Type III: Immune complex-mediated - Type IV: Delayed KNOW THESE***
What are types of Type I Hypersensitivity reactions?
- allergic rhinitis - anaphylaxis
What is IgA?
- appears in bodily fluids (blood, saliva, tears, breast milk, ect.) - protects against respiratory, GI and GU infections - prevents absorption of antigens from food - passes to neonate in breast milk for protection (not that important)
What is IgE?
- appears in serum - takes part in allergic and some hypersensitivity reactions - combats parasitic infections ***allergic & parasitic reactions***
What is IgD?
- appears in small amounts in serum - possibly influences B-lymphocyte differentiation, but role is unclear
What is IgM?
- appears mostly in intravascular serum - appears as the first immunoglobulin produced in response to bacterial & viral infections** - activates the complement system
What are examples of AIDS-defining conditions (illnesses) in adults?
- bacterial infections, multiple or recent - candidiasis of bronchi, trachea, lungs, or esophagus (typically healthy adults don't get fungal infections --> indicator somethings wrong) - encephalopathy, HIV-related (confusion, altered LOC) - Herpes simplex: chronic ulcers or bronchitis, pneumonitis, or esophagitis - kaposi's sarcoma (cancer --> rash on skin) - mycobacterium tuberculosis (TB --> HIV has increased risk of TB, if all of sudden a pt has night sweats & coughing up blood --> TB; KNOW*** need respiratory isolation) - pneumocystis jiroveci pneumonia (PCV pneumonia) - wasting syndrome attributed to HIV (severely underweight, skin & bones) KNOW THESE ONES**
How is HIV not transmitted?
- casual contact in the home, school, or workplace - Sharing household utensils, towels and linens, and toilet facilities - mosquitos or other insects. KNOW**
What are physical barriers?
- intact skin - mucous membranes - cilia of the respiratory tract, which prevent pathogens from gaining access to the body - The cilia of the respiratory tract, along with coughing and sneezing responses, filter and clear pathogens from the upper respiratory tract before they can invade the body further
What are chemical barriers?
- mucus - acidic gastric secretions - enzymes in tears and saliva - substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi
What else should be known about chronic rejection? (Type IV delayed reaction)
- probably occurs to some degree with all transplants - no cure b/c fibrotic changes are permanent; if causes organ to not function, need another transplant -- note: multiple transplants making finding a match more difficult (b/c even more HLA's to match now)
What else should be known about acute HIV infections?
- they have a large amount of virus in their blood and are very contagious - But people with acute infection are often unaware that they're infected because they may not feel sick right away or at all (increases risk of spread***)
What is the dose of epinephrine given for anaphylaxis?
1 : 1,000 dose (0.3 to 0.5mL)*** KNOW**
What drugs are used for fibromyalgia?
Antidepressants - TCAs, SNRIs, SSRIs Analgesics - NSAIDs, muscle relaxants, Tramadol (Ultram) Anticonvulsants (adjunct pain meds) - Gabapentin, pregabalin
What is stage II of HIV?
CD4+ T-cell count between 200 and 499 cells/mm3 with no AIDS-defining illnesses - "asymptomatic/chronic" infection; reproduces at slow levels - those not taking meds, this stage can last a decade or progress quick - those taking meds, this stage can last several decades (latent phase/dormancy)
What is stage III of HIV?
CD4+ T-cell count less than 200 cells/mm3 with an AIDS-defining illnesses OR a person who has higher CD4+ T-cell counts but has an AIDS-defining illness note: now say they have "AIDS" (w/o Tx, survive maybe 3yrs)
What is stage I of HIV?
CD4+ T-cell count of greater than 500 cells/mm3 with no AIDS-defining illnesses
What has low risk for HIV transmission?
Contact with tears, saliva, and sweat is considered low risk for transmission unless obvious blood is present.
What are signs of AIDS?
Immunologic manifestations - Lymphadenopathy; fatigue Integumentary manifestations - Dry skin; poor wound healing; skin lesions; night sweats Respiratory manifestations - Cough; shortness of breath Gastrointestinal manifestations - Diarrhea; weight loss; nausea and vomiting Central nervous system manifestations - Confusion; dementia; headache; fever; visual changes; memory loss; personality changes; pain; seizures
What are examples of Type I rapid hypersensitivity reactions? (how they can occur)
Inhaled - Plant pollens, fungal spores, animal dander, house dust, grass, ragweed - ex: allergic rhinitis/hay fever triggered by immunity & inflammation reaction to airborne antigens Ingested - Foods, food additives, drugs Injected - Bee venom, drugs, biologic substances such as contrast dyes Contacted - Latex, pollens, foods, environmental proteins
What is a hyperacute rejection? (Type IV delayed reaction)
It begins immediately on transplantation and is an antibody-mediated response - Antigen-antibody complexes form in the blood vessels of the transplanted organ. Widespread clotting occludes blood vessels and leads to ischemic necrosis, massive cellular destruction within the transplanted organ and graft loss note: reaction can't be stopped once begun, must remove organ asap
How does the immune system function?
It functions as the body's defense mechanism against invasion and allows a rapid response to foreign substances in a specific manner - Involves the concepts of both inflammation and immunity to work with other defenses in providing protection from harmful microorganisms and cells --- Inflammation and immunity are critical to maintaining health and preventing disease
How does HIV replicate?
It has to enter a cell, take over the cell, and force the cell into making more copies of the virus (viral particles). These new viral particles then are shed and look for additional cells to infect, repeating the cycle
What is fibromyalgia?
It is a chronic pain syndrome, not an inflammatory disease, where pain, stiffness, and tenderness are located at specific sites in the back of the neck, upper chest, trunk, low back, and extremities
What is Rheumatoid Arthritis? (Type III immune complex reaction)
It is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints
What is autoimmunity?
It is a process whereby a person develops an inappropriate immunity. In this response, antibodies or lymphocytes are directed against healthy normal cells and tissues - Antibodies directed against self tissues or cells are known as these (sees own body as foreign & attacks - ex: type 1 diabetes, rheumatoid arthritis)
What is human immune deficiency virus (HIV)?
It is a retrovirus that is transmitted through direct contact with infected body fluids, such as blood, semen, and genital secretions, or from an infected mother to her child during pregnancy, birth, or breastfeeding, and attacks the body's immune system
What is Sjögren's syndrome (SS)?
It is a systemic autoimmune disease that progressively affects the lacrimal and salivary glands of the body (dries everything up)
What is gout?
It is a type of inflammatory arthritis and a systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation
What is Type I rapid hypersensitivity reaction?
It is also called atopic allergy, is the most common type of hypersensitivity from excess immunity. - Primary chemical mediators are responsible for the symptoms of this hypersensitivity because of their effects on the skin, lungs, and gastrointestinal tract
What else should be known about natural (innate) immunity?
It is also called inflammation; provides immediate protection (but short-term) against the effects of tissue injury and invading foreign proteins - It is any natural protective feature of a person - It can be a barrier to prevent organisms from entering the body or can be an attacking force that eliminates organisms that have already entered the body note: doesn't provide any true immunity from repeat exposures; not adaptive, can't be transferred/given to someone
What is systemic lupus erythematosus (SLE)?
It is an inflammatory, autoimmune disorder that affects nearly every organ in the body - the disease process involves chronic states where symptoms are minimal or absent and acute flare ups - ONSET: 20-40yrs (childbearing years)
What else should be known about acquired (adaptive) immunity?
It is an internal protection that results in long-term resistance to the effects of invading microorganisms - This means that the responses are not automatic; the body has to learn to generate specific immune responses when it is infected by or exposed to specific organisms (not immediate, need to have repeated exposure to develop antibodies)
What is a hypersensitivity (allergy)?
It is excessive inflammation occurring in response to the presence of an antigen (foreign protein or allergen) to which the patient usually has been previously exposed (usually doesn't occur from 1st exposure; type I/IV; can develop over time but is usually quicker) - have increased IgE antibodies (even with skin issues, asthma, or hay fever)
What is Natural (innate) immunity?
It is nonspecific immunity, present at birth - First line of host defense following antigen exposure, because it protects the host without remembering prior contact with an infectious agent
What is a chronic rejection? (Type IV delayed reaction)
It is similar to chronic inflammation and scarring - The smooth muscles of blood vessels overgrow and occlude the vessels. The donated organ tissues are replaced with fibrotic, scar-like tissue. Because this fibrotic tissue is not organ tissue, the transplanted organ's function is reduced in proportion to the amount of normal tissue that is replaced by fibrotic tissue - Although good control over the recipient's immune function can delay this type of rejection, the process probably occurs to some degree with all transplanted solid organs
What is passive acquired immunity?
It is temporary immunity transmitted (transferred) from a source outside the body that has developed immunity through previous disease or immunization - shorter lasting (ex: vaccine, IVIG)
What is anaphylaxis? (Type I hypersensitivity)
It is the most life-threatening example of this type of hypersensitivity reaction; it occurs rapidly and systemically - affects many organs within seconds to minutes after allergen exposure note: the faster the onset, the more severe the reaction will be
What is immunocompetent?
It is when all the different parts and functions of inflammation and immunity are working well, giving the individual maximum protection against infection
What are the differences between rheumatoid arthritis and osteoarthritis?
KNOW**
What can we teach out pts to prevent the spread of HIV?
KNOW**
What diagnostics are done for HIV/AIDS?
Labs: - Antibody tests - Antigen/antibody tests - Nucleic acid (RNA) tests - Viral load testing - CD4+ T-cell count Tests: - None note: immediately after exposure, may not catch right away, too soon to know; different tests used at different times
What diagnostics are done for gout?
Labs: - Serum uric acid - ESR (may be increased d/t chronic inflammation) - Arthrocentesis*** (definitive diagnosis; aspirate fluid from joint & test for crystals) Tests: - None (may be done to rule out other things)
What are the interventions for transplant rejections? (Type IV delayed reaction)
Maintenance therapy is continuous immunosuppression** - The drugs used for routine therapy after solid organ transplantation are combinations of a calcineurin inhibitor, a corticosteroid, and an antiproliferative agent Rescue therapy is used to treat acute rejection episodes (wont test on drugs) - The drug categories for this purpose are the monoclonal and polyclonal antibodies - The drugs used for maintenance are often also used during rejection episodes at much higher dosages than for maintenance
What are the other signs of systemic lupus erythematosus (SLE)?
Neurologic manifestations - Psychosis; cognitive impairment; seizures; neuropathies; stroke Gastrointestinal manifestations - Abdominal pain Musculoskeletal manifestations - Joint inflammation; arthralgias; polyarthritis Other manifestations - Fever; fatigue; anorexia; weight loss note: fever & fatigue are classic signs of a flare up/exacerbation***; common b/c it's a systemic disease
What are the interventions for Sjögren's syndrome (SS)?
Nonpharmacological - Artificial tears, artificial saliva (&drink water), humidifiers, lubricants, moisturizers - Eat small frequent meals omitting spicy, salty, and irritating food (note: affects the way they taste, may not be able to taste at all..) - Avoiding smoking, excessive alcohol use, and drugs with anticholinergic side effects (b/c would dry stuff up even more) Pharmacological - Rituximab and interferone may be effevtive
What are the interventions for Rheumatoid Arthritis? (Type III immune complex reaction)
Nonpharmacological (chronic management) - Ice, heat, proper positioning, adequate rest, proper diet, hot shower in the morning Pharmacological (want early & aggressive Tx to delay long term joint deformity & help w/ remission) Surgery - Synovectomy - Total joint replacement
What are the other interventions for HIV/AIDS?
Pain management (not all have pain) - NSAIDs, Lyrica, TCAs, Neurontin, Dilantin, opioids Enhancing nutrition** - High-calorie and high-protein diet, good mouth care (d/t opportunistic infections), drink 2-3L of fluids per day - Appetite stimulants Monitor and treat opportunistic infections - Know the signs and symptoms and educate on self-management strategies Comfort measures and supportive care - Hydrotherapy, massage, heat or cold
What should be known about latex and Type 1 reactions?
People at greatest risk for latex allergies are those with a high exposure to natural latex products, such as: - patients with spina bifida - people who routinely use latex condoms - health care workers who use latex gloves, especially gloves that are powdered KNOW**
What are the signs of a mild systemic anaphylactic reaction? (Type I hypersensitivity)
Peripheral tingling and a sensation of warmth, sensation of fullness in the mouth and throat, nasal congestion, periorbital swelling, pruritus, sneezing, tearing of the eyes
What happens in Sjögren's syndrome (SS)?
Problems include: - Keratoconjunctivitis sicca (dry eyes) - Xerostomia (dry mouth) - Dry vagina These problems are caused by autoimmune destruction (excess immunity) of the lacrimal, salivary, and vaginal mucus-producing glands note: commonly manifests w/ other autoimmune diseases (rheumatoid arthritis, lupus); have been noticing links b/w autoimmune diseases
What are the signs of a moderate systemic anaphylactic reaction? (Type I hypersensitivity)
Some mild symptoms + flushing, warmth, anxiety, itching, bronchospasm and edema of the airways or larynx with dyspnea, cough and wheezing
What are the signs of a severe systemic anaphylactic reaction? (Type I hypersensitivity)
Some moderate symptoms + abrupt onset with rapid bronchospasm, laryngeal edema, severe dyspnea, cyanosis, hypotension, dysphagia, abdominal cramping, vomiting, diarrhea, seizures, coma and cardiac arrest
What are the interventions for fibromyalgia?
Supportive care - Limit caffeine and alcohol, exercise regularly, and establish a regular sleep pattern - Physical therapy - Cognitive behavioral therapy (esp. if depression/anxiety) Pharmacological
What are the interventions for systemic lupus erythematosus (SLE)?
Supportive care - use mild soaps - avoid harsh perfumes - lotion (avoid dry skin) - avoid sunlight (fluorescent too) - stop smoking Pharmacological: - Topical cortisone preparations (steroids for discoid lesions) - Analgesics - Anti-malarial agent --- Hydroxychloroquine (Plaquenil) (immunosuppressant properties) - Steroids - Immunosuppressive agents --- Methotrexate (Rheumatrex) or azathioprine (Imuran) - Biologic / monoclonal antibody --- Belimumab (Benlysta)=
What drugs are used for anaphylaxis? (Type I hypersensitivity)
Sympathomimetics*** - Epinephrine*** 1ST GIVEN Antihistamines - Benedryl (wont help with bronchospasms or decreased CO; help w/ other Sx) Corticosteroids - Decadron, solu-Medrol, prednisone (help w/ inflammatory response; doesn't help immediately - takes about 6hrs to kick in) Vasopressors - Levophed, dopamine IV fluids / volume expanders
What is a Type IV delayed reaction?
The reactive cell is the T-lymphocyte (T-cell), antibodies and complement are not involved - Sensitized T-cells (from a previous exposure) respond to an antigen by releasing chemical mediators and triggering macrophages to destroy the antigen
What is the first sign of a pt having an anaphylactic reaction? (Type I hypersensitivity)
They first have feelings of uneasiness, apprehension, weakness, and impending doom. Often he or she is anxious and frightened - These feelings are followed, often quickly, by generalized itching and urticaria. Erythema and sometimes angioedema (diffuse swelling) of the eyes, lips, or tongue occur next. Intensely itchy skin wheals or hives may appear and sometimes merge to form large, red blotches. - Dysrhythmias, shock, and cardiopulmonary arrest may occur within minutes as intravascular volume is lost and the heart becomes hypoxic
What is acquired immune deficiency syndrome (AIDS)?
a diagnosis of this requires that the person be HIV positive and have either: - CD4+ T-cell count of less than 200 cells/mm3 and/or - An opportunistic infection (____ defining illness)
What is lupus nephritis?
a subtype of lupus due to the autoimmune complexes in SLE tend to be most attracted to the glomeruli of the kidneys (& not so much rest of body)
What is discoid lupus erythematosus?
a subtype of lupus that primary affects the skin on the face (& not so much rest of body)
What are the two types of acquired (adaptive) immunity?
active and passive
How can a pt have a low purine diet?
avoid these foods: - beefs - red meets - shell fish - oily fish w/ bones especially
What are the signs of an acute rejection? (Type IV delayed reaction)
depends on organ (would see organ failure of that organ) - Pain/tenderness of the organ/site - General discomfort, uneasiness, or ill feeling - Flu-like symptoms (fatigue, fever, chills, feel bad) - Organ dysfunction note: - kidney failure --> decreased urine output** (KNOW) - liver failure --> ascites, jaundice - etc.
What are discoid lesions?
discrete eythematous plaques covered by a scale - circular-ish rash w/ redness around border, usually asymptomatic, can cause scarring
What is a Type III immune complex reaction?
excess antigens cause immune complexes to form in the blood that usually lodge in small blood vessel walls of the kidneys, skin, and joints - The complexes trigger inflammation, and tissue or vessel damage/permeability (leakage) results
What is an acute rejection? (Type IV delayed reaction)
first occurs within 1 week to 3 months after transplantation - two mechanisms are responsible note: - all have some amount of this, keep a close eye on them, giving meds asap - doesn't mean will automatically lose the organ; hopefully give more drugs to help delay/limit damage to the organ
What drugs are needed for acute attacks of gout?
inflammation typically subsides on own in 3-10 days - Colchicine*** (1st day, get rid of attacks) - NSAIDs*** (inflammation) - Corticosteroids* (potentially; 4-7days) KNOW***
How is the Natural (innate) immunity enhanced?
it is enhanced by physical and chemical barriers of the body
What should be known about uric acid in gout?
it is increased (can be altered by food intake but..) - consistent level above 6.5 is indicative of this disease*** KNOW
What are tophi? (gout)
little white dots, they are crystalline deposits accumulating in soft tissue & cartilage (sodium/crystal deposits) - hard on palpitation, irregular shape (crystalline deposits accumulating in articular tissue, osseous tissue, soft tissue, and cartilage)
How are autoimmunity's managed?
management of these depends on the organ or organs affected, as there is no cure - Anti-inflammatory drugs and immunosuppressive drugs are commonly used along with symptomatic treatment to suppress the excess immunity
When is the onset of Rheumatoid Arthritis most common? (Type III immune complex reaction)
most common in the winter months (not warmer)
What is IgG?
most common type** know - appears in serum and tissues (interstitial fluid) - assumes a major role in bloodborne and tissue infections - activates the complement system - enhances phagocytosis - crosses the placenta
What should be known about the diagnostics for Rheumatoid Arthritis? (Type III immune complex reaction)
not one specific test to diagnose - ESR & CRP may be elevated (but they're non-specific inflammatory markers --> could mean something else) - may have rheumatoid factor (blood draw); but absence doesn't rule out & presence alone is not diagnostic (70-80% of pts have this present) - draw antibodies (anti-CPP - 95% specificity for RA)
What is transplant rejection? (Type IV delayed reaction)
occurs due to natural killer (NK) cells and cytotoxic/cytolytic T-cells that destroy cells from other people or animals - reaction can be hyperacute, acute, or chronic
What happens once a pt is diagnosed with AIDS?
once this happens, even if the patient's T-cell count goes higher than 200 cells/mm3 or the infection is successfully treated, the diagnosis remains and the patient does not revert to being just HIV positive **don't reverse diagnose
What else should be known about anaphylaxis? (Type I hypersensitivity)
patients must carry an emergency anaphylaxis kit or an epinephrine injector, such as the EpiPen*** - NEED to carry one at all times in case this occurs, b/c it's life threatening
What is active acquired immunity?
refers to immunologic defenses developed by the person's own body - most effective, lasts the longest
What fluids have the highest concentration of HIV?
semen, blood, breast milk, and vaginal secretions
What should be known about desensitization therapy (immunotherapy)?
takes about 5yrs to work - diluted solution of antigen, given weekly, slowly increase doses; risky --> have emergency equipment at bedside*** (KNOW) - allergy shots (done out pt) - usually only done for pts who absolutely can't avoid cause OR is so severe (not for ppl who want an animal they're allergic to)
What is a Type II cytotoxic reaction?
the body makes autoantibodies directed against self cells that have some form of foreign protein attached to them - The autoantibody binds to the self cell and forms an immune complex, the self cell is then destroyed along with the attached protein
