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Hypersensitivity Reaction

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19141. Sarcoidosis (Diagnosis)

computed tomography (CT): Adds little to radiography High-resolution CT (HRCT) scanning of the chest: May be helpful; identifies active alveolitis versus fibrosis, and findings correlate with biopsy yield Gallium scans: Used infrequently; has low sensitivity and specificity, but may be helpful when the clinical picture remains confusing despite histologic evidence of noncaseating granulomas (eg, differentiating chronic hypersensitivity pneumonitis from sarcoidosis) Staging of sarcoidosis is as follows (...) a central role in the development of sarcoidosis, as they likely propagate an excessive cellular immune reaction. For example, there is an accumulation of CD4 cells accompanied by the release of interleukin (IL)–2 at sites of disease activity. This may manifest clinically by an inverted CD4/CD8 ratio. Pulmonary sarcoidosis is frequently characterized by a CD4 + /CD8 + ratio of at least 3.5 in bronchoalveolar lavage fluid (BALF), although up to 40% of the cases present a normal or even decreased ratio

2014 eMedicine.com

19142. Sarcosporidiosis (Diagnosis)

reaction assays in the study of cases with fatal sporadic myocarditis. Hum Pathol . 2007 Sep. 38(9):1412-9. . Wong KT, Pathmanathan R. High prevalence of human skeletal muscle sarcocystosis in south-east Asia. Trans R Soc Trop Med Hyg . 1992 Nov-Dec. 86(6):631-2. . Harvey K, Esposito DH, Han P, Kozarsky P, Freedman DO, Plier DA, et al. Surveillance for travel-related disease--GeoSentinel Surveillance System, United States, 1997-2011. MMWR Surveill Summ . 2013 Jul 19. 62:1-23. . Rezakhani A, Cheema AH (...) University Hospital Disclosure: Nothing to disclose. Coauthor(s) Nirav Patel, MD Assistant Professor of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, and Division of Pulmonary, Critical Care, and Sleep Medicine, St Louis University School of Medicine; Chief Medical Officer, Director of Antibiotic Stewardship, Infection Control Officer, St Louis University Hospital Nirav Patel, MD is a member of the following medical societies: , , , , Disclosure: Nothing to disclose

2014 eMedicine.com

19143. Scabies (Diagnosis)

(hematoxylin and eosin; original magnification, 100X). Classic scabies In classic scabies infection, typically 10-15 mites (range, 3-50) live on the host. [ ] Little evidence of infection exists during the first month (range, 2-6 wk), but after 4 weeks and with subsequent infections, a delayed type IV hypersensitivity reaction to the mites, eggs, and scybala (feces) occurs. The time required to induce immunity in primary infestations probably accounts for the 4-week asymptomatic latent period (...) identify various skin reactions, recognize potential comorbidities, and select treatment options. Also see the slideshow to help identify conditions that may occur in young patients after they return to the classroom. Signs and symptoms Burrows are a pathognomonic sign and represent the intraepidermal tunnel created by the moving female mite. They appear as serpiginous, grayish, threadlike elevations in the superficial epidermis, ranging from 2-10 mm long. High-yield locations for burrows include

2014 eMedicine.com

19144. Sarcoidosis (Diagnosis)

and early-onset sarcoidosis represent familial and sporadic forms of pediatric granulomatous autoinflammatory disease caused by mutations in the NOD2 gene. Clinical onset is usually early in life, with noncaseating granulomas affecting the skin, joints, and uveal tract. [ , ] Erythema nodosum EN is a hypersensitivity reaction resulting from exposure to a variety of infectious agents (especially recent streptococcal infection), drugs (including oral contraceptives), or systemic inflammatory disorders (eg (...) infiltration Infiltration of scars may occur (see the image below). Scars from previous trauma, surgery, venipuncture, or tattoo may become infiltrated and show a red or purple color. These lesions may be tender. Sarcoidosis with infiltration of a scar. The development of sarcoidal lesions within tattoos has been well documented, although hypersensitivity granulomatous reactions to tattoo pigment need to considered in the differential diagnosis and should be considered in the context of the overall

2014 eMedicine.com

19145. Reactive Arthritis (Diagnosis)

extracellular antigens as part of the innate immune system. [ ] TLR-4 recognizes gram-negative lipopolysaccharide (LPS). Studies in mice and humans showed abnormalities in antigen presentation due to downregulation of TLR-4 costimulatory receptors in patients with ReA. Subsequent studies implicated TLR-2 polymorphism associated with acute ReA; however, its role is still disputed. [ , ] Molecular evidence of bacterial DNA (obtained via polymerase chain reaction [PCR] assay) in synovial fluids has been found (...) after tetanus and rabies vaccination. [ , ] Genetic factors ReA has an important genetic component; it tends to cluster in certain families and almost exclusively affects males, and HLA-B27 is identified in 70-80% of patients. [ ] HLA-B27 may share molecular characteristics with bacterial epitopes, facilitating an autoimmune cross-reaction instrumental in pathogenesis. HLA-B27 contributes to the pathogenesis of the disease and reportedly increases the risk of ReA 50-fold. [ ] HLA-B51 and HLA-DRB1

2014 eMedicine.com

19146. Pyogenic Granuloma (Lobular Capillary Hemangioma) (Diagnosis)

Physicians Surg Pak . 2013 Aug. 23(8):588-9. . Browning JC, Eldin KW, Kozakewich HP, Mulliken JB, Bree AF. Congenital disseminated pyogenic granuloma. Pediatr Dermatol . 2009 May-Jun. 26(3):323-7. . Palmero ML, Pope E. Eruptive pyogenic granulomas developing after drug hypersensitivity reaction. J Am Acad Dermatol . 2009 May. 60(5):855-7. . Netchiporouk E, Moreau L, Ramirez LP, Castillo PA, Bravo FP, Del Solar MC, et al. Eruptive Disseminated Pyogenic Granulomas following Lightning Injury. Dermatology

2014 eMedicine.com

19147. Reflex Sympathetic Dystrophy (Diagnosis)

lead to adrenergic hypersensitivity from peripheral denervation and/or sympathetic denervation. Thus, in CRPS I, the early inhibition of central cutaneous vasoconstrictor activity leads to vasodilation in the denervated area causing it to feel warm. The later increased sensitivity to circulating catecholamines due to upregulation of cutaneous adrenoreceptors causes vasoconstriction and coolness. Interestingly, studies of direct nerve injuries (CRPS II) show the same results. Initially, vasodilation (...) to be a normal postinjury reaction. After injury, the organism protects and guards the injured body part to optimize healing and prevent reinjury. A normally healing organism gradually increases its use of the injured region, which aids in recovery and reintegration of the body part into the organism’s normal sense of self. However, excessive protection and guarding, such as casting or splinting, is commonly promoted by care providers, increasing the patient’s disuse of the extremity and promoting fear

2014 eMedicine.com

19148. Pyelonephritis, Acute (Diagnosis)

and mortality. Once bacteriuria is established, these strains appear to stop producing adhesins, allowing them to survive and persist without producing an inflammatory reaction. Pathogens As noted above, UPEC account for most uncomplicated pyelonephritis cases and a significant portion of complicated pyelonephritis cases. The following microorganisms are also commonly isolated: Staphylococcus saprophyticus Klebsiella pneumoniae Proteus mirabilis Enterococci S aureus Pseudomonas aeruginosa Enterobacter (...) in pregnant patients); see Aminoglycosides, below Carbapenems: Meropenem (Merrem) 500 mg IV q8h or Ertapenem (Invanz) 1 g IV q24h or Doripenem (Doribax) 500 mg IV q8h Monobactam (for patients with penicillin allergy): Aztreonam (Azactam) 1 g IV q8-12h Alternative therapy Aminoglycosides (because of their potential nephrotoxicity, aminoglycoside antibiotics should be reserved for patients with serious and potentially life-threatening infections, and their dosage and blood levels should be carefully

2014 eMedicine.com

19149. Pulmonary Disease and Pregnancy (Diagnosis)

vs 159.7 cases per 100,000 population). [ ] Objective diagnostic testing Venography is considered the criterion standard but is difficult to perform and interpret and might cause appreciable pain in the foot and calf or hypersensitivity reactions. Increasingly, noninvasive studies have replaced venography. Compression ultrasonography Real-time B-mode ultrasonography is the mainstay of objective testing. The most reliable ultrasound criterion for thrombosis is a failure to collapse the vascular (...) population of pregnant women in which blacks and whites have similar medical care access and benefits) found that black women had clinically significantly more morbidity than whites, thus indicating a racial difference between the two. [ ] For excellent patient education resources, visit eMedicineHealth's . Also, see eMedicineHealth's patient education articles and . Therapy [ , ] Avoidance and control of asthma triggers Asthma can be triggered by several factors, including allergy, upper respiratory

2014 eMedicine.com

19150. Hymenoptera Stings (Diagnosis)

Department of Agriculture. Courtesy of Wikimedia Commons. See , a Critical Images slideshow, for help identifying and treating various envenomations. See also , to help identify a variety of allergens and symptoms. Next: Pathophysiology Target organs are the skin, vascular system, and respiratory system. Pathology is similar to other immunoglobulin E (IgE)–mediated allergic reactions. Anaphylaxis is a common and life-threatening consequence of Hymenoptera stings and is typically a result of sudden (...) Author: Randy Park, MD; Chief Editor: Joe Alcock, MD, MS Share Email Print Feedback Close Sections Sections Hymenoptera Stings Overview Background Hymenoptera stings account for more deaths in the United States than any other envenomation. The order Hymenoptera includes Apis species, ie, bees (European, African), (wasps, yellow jackets, hornets), and ants (see the images below). Most deaths result from immediate hypersensitivity reactions and anaphylaxis. Severe anaphylactoid reactions occur

2014 eMedicine.com

19151. Hydatid Cysts (Diagnosis)

: Recurrence Metastasis Infection Spillage and seeding (secondary echinococcosis): Allergic reaction or anaphylactic shock Those related to the medical treatment include the following: Hepatotoxicity Anemia Thrombocytopenia Alopecia Embryotoxicity Teratogenicity Spillage and seeding (secondary echinococcosis) Complications related to puncture, aspiration, injection, and reaspiration (PAIR) intervention include the following: Hemorrhage Mechanical damage to other tissues Infections Allergic reaction

2014 eMedicine.com

19152. Human Herpesvirus Type 6 (Diagnosis)

have also been reported. [ , , ] In patients infected with HIV, HHV-6 infection may up-regulate HIV replication and hasten the progression toward AIDS. HHV-6 also has been implicated in the pathogenesis of white-matter demyelination in persons with ; however, causality has not been proven. HHV-6 has been isolated from various tissues, cells, and fluid in association with the following conditions: Lymphoma Lymphadenopathy Drug-induced hypersensitivity syndrome (DIHS), [ ] or drug reaction (...) , Razonable RR. Human herpesvirus-6 infections in kidney, liver, lung, and heart transplantation: review. Transpl Int . 2012 May. 25(5):493-502. . Corti M, Villafañe MF, Trione N, Mamanna L, Bouzas B. Human herpesvirus 6: report of emerging pathogen in five patients with HIV/AIDS and review of the literature. Rev Soc Bras Med Trop . 2011 Jul-Aug. 44(4):522-5. . Gentile I, Talamo M, Borgia G. Is the drug-induced hypersensitivity syndrome (DIHS) due to human herpesvirus 6 infection or to allergy-mediated

2014 eMedicine.com

19153. Human Herpesvirus 6 (Diagnosis)

have also been reported. [ , , ] In patients infected with HIV, HHV-6 infection may up-regulate HIV replication and hasten the progression toward AIDS. HHV-6 also has been implicated in the pathogenesis of white-matter demyelination in persons with ; however, causality has not been proven. HHV-6 has been isolated from various tissues, cells, and fluid in association with the following conditions: Lymphoma Lymphadenopathy Drug-induced hypersensitivity syndrome (DIHS), [ ] or drug reaction (...) , Razonable RR. Human herpesvirus-6 infections in kidney, liver, lung, and heart transplantation: review. Transpl Int . 2012 May. 25(5):493-502. . Corti M, Villafañe MF, Trione N, Mamanna L, Bouzas B. Human herpesvirus 6: report of emerging pathogen in five patients with HIV/AIDS and review of the literature. Rev Soc Bras Med Trop . 2011 Jul-Aug. 44(4):522-5. . Gentile I, Talamo M, Borgia G. Is the drug-induced hypersensitivity syndrome (DIHS) due to human herpesvirus 6 infection or to allergy-mediated

2014 eMedicine.com

19154. Hookworms (Diagnosis)

for about 10 days before dying. In eosinophilic enteritis, A caninum larvae typically enter a human host by penetrating the skin, though infection by oral ingestion is also possible. These larvae probably remain dormant in skeletal muscles and create no symptoms. In some individuals, larvae may reach the gut and mature into adult worms. Why some individuals sustain A caninum development and then respond with a severe localized allergic reaction is unknown. Adult worms secrete various potential allergens (...) and autoimmune disease. The increased prevalence of atopy, , and food allergy in areas free of worm infestation has been cited as supportive of the hygiene hypothesis and has even prompted investigation of worms or worm products as therapy for such diseases. Similarly, areas of high hookworm endemicity have low rates of reaction to dust mite antigens. It is thought that worm-activated regulatory and counter-regulatory processes involving Th2 and T regulatory cells and cell products may paradoxically inhibit

2014 eMedicine.com

19155. Hemostatic Disorders, Nonplatelet (Diagnosis)

transmissions. McCarthy et al have treated more than 160 patients using FFP, solvent detergent (SD), and cryosupernatant as the exchange media. [ ] They showed that SD plasma has value in virtually eliminating all allergic reactions during treatment. Approximately 80% of patients respond to plasma exchange therapy. , a monoclonal antibody against CD20 present in B-lymphoid cells, has been successfully used in treating patients with acquired TTP who had failed to respond to plasma exchange. Severe ADAMTS13 (...) indicate anemia, rheumatoid factor, and decreased complement levels, as well as abnormal populations of paraproteins and/or immunoglobulins. [ , ] Purpuras Purpuras form another group of vascular hemostatic disorders. Hyperglobulinemic purpura caused by increased gamma-globulin levels is similar in presentation to those of the disorders described above. [ ] Henoch-Schönlein purpura (HSP) is a form of nonthrombocytopenic purpura due to hypersensitivity vasculitis and is primarily observed in children

2014 eMedicine.com

19156. History and Mental Status Examination (Diagnosis)

the patient who prescribed the medications and when or why the patient discontinued taking them. Allergies List all drug and food allergies the patient currently has or has had in the past, and list what type of reactions the patient had to the medications. Past psychiatric history List all of the patient's treatment, including outpatient, inpatient, and therapy-based (ie, individual, couples, family, group), including dates. Inquire about past psychotropic medications and response, compliance (...) complaint or reason for coming to the clinic. The patient's chief complaint should be a quote recorded just as it was spoken, in quotation marks, in the patient's record. This also is where all history of illness is recorded, including psychiatric history, medical history, surgical history, and medications and allergies. Of interest, it is important to make direct inquiry to items such a family history of members being murdered—patients often do not volunteer this information. Additionally, listing any

2014 eMedicine.com

19157. Herpes Simplex (Diagnosis)

-cell immunity, such as in organ transplant recipients and in individuals with . Herpes simplex infection can also complicate burn wounds or damaged skin such as in atopic dermatitis or other allergic dermatoses. HSV is distributed worldwide. Humans are the only natural reservoirs, and no vectors are involved in transmission. Endemicity is easily maintained in most human communities owing to latent infection, periodic reactivation, and asymptomatic virus shedding. [ ] HSV is transmitted by close (...) A, Forsgren M. Rapid diagnosis of herpes simplex encephalitis by nested polymerase chain reaction assay of cerebrospinal fluid. Lancet . 1991 Jan 26. 337(8735):189-92. . Liang QN, Zhou JW, Liu TC, Lin GF, Dong ZN, Chen ZH, et al. Development of a time-resolved fluorescence immunoassay for herpes simplex virus type 1 and type 2 IgG antibodies. Luminescence . 2014 Nov 5. . Gnann JW, Salvaggio MR. Drugs for Herpesvirus Infections. Cohen J, Powderly W, eds. Infectious Diseases . 2nd ed. New York: Mosby; 2004

2014 eMedicine.com

19158. Herpes Zoster (Diagnosis)

with motor complications See for more detail. Diagnosis Diagnosis is based primarily on the history and physical findings. In most cases, confirming the diagnosis via laboratory testing has no utility. In select patient populations, however—particularly immunocompromised patients—the presentation can be atypical and may require additional testing. Laboratory studies for VZV include the following: Direct fluorescent antibody (DFA) testing of vesicular fluid or a corneal lesion Polymerase chain reaction (...) , results from the reactivation of VZV in the trigeminal (fifth cranial) nerve. Any branch of the nerve may be affected, though the frontal branch within the first division of the trigeminal nerve is most commonly involved. This branch innervates nearly all of the ocular and periocular structures. Polymerase chain reaction (PCR) nerve studies have detected latent trigeminal VZV in as many as 87% of patients. [ ] Clinical disease has been reported in as few as 8% and as many as 56% of patients in studies

2014 eMedicine.com

19159. Herpes Simplex Encephalitis (Diagnosis)

. 247(3):317-20. . Tan IL, McArthur JC, Venkatesan A, Nath A. Atypical manifestations and poor outcome of herpes simplex encephalitis in the immunocompromised. Neurology . 2012 Nov 20. 79(21):2125-32. . . Lakeman FD, Whitley RJ. Diagnosis of herpes simplex encephalitis: application of polymerase chain reaction to cerebrospinal fluid from brain-biopsied patients and correlation with disease. National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. J Infect Dis . 1995 (...) to the brain via the trigeminal or olfactory nerve. The exact pathogenesis is unclear, and factors that precipitate HSE are unknown. See the image below. Axial diffusion-weighted image reveals restricted diffusion in left medial temporal lobe consistent with herpes encephalitis. This patient also had positive result on polymerase chain reaction assay for herpes simplex virus, which is both sensitive and specific. In addition, patient had periodic lateralized epileptiform discharges

2014 eMedicine.com

19160. Herpes Zoster (Diagnosis)

with motor complications See for more detail. Diagnosis Diagnosis is based primarily on the history and physical findings. In most cases, confirming the diagnosis via laboratory testing has no utility. In select patient populations, however—particularly immunocompromised patients—the presentation can be atypical and may require additional testing. Laboratory studies for VZV include the following: Direct fluorescent antibody (DFA) testing of vesicular fluid or a corneal lesion Polymerase chain reaction (...) , results from the reactivation of VZV in the trigeminal (fifth cranial) nerve. Any branch of the nerve may be affected, though the frontal branch within the first division of the trigeminal nerve is most commonly involved. This branch innervates nearly all of the ocular and periocular structures. Polymerase chain reaction (PCR) nerve studies have detected latent trigeminal VZV in as many as 87% of patients. [ ] Clinical disease has been reported in as few as 8% and as many as 56% of patients in studies

2014 eMedicine.com

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