Alterations in Immunological Status: Allergies, JRA

1. Alterations in Immunological Status:Allergies, JRA

2. Allergies Reactions involving immunologic mechanism, usually IgE responses

3. Allergens • Foods (Box 13-2, p. 528 Hockenberry 9th ed.) • Lactose Intolerance • Avoid foods HIGH in lactose • Infancy-- Soy formula • In older children NO MILK Lactaid, etc • Atopic Dermatitis (eczema) (Box 13-5.p 541) • Treat pruritis and inflammation, hydrate skin, prevent 2ndary infections • Topical corticosteroids—1st-line tx

4. Symptoms of Milk Allergy • p. 530 Box 13-3 (Hockenberry, 9th ed.) • GI • Respiratory • Others • PREVENT FOOD ALLERGIES • No solids for 4-6 months of age • Until 12 months of age = no cow’s milk, eggs, fish, corn, citrus, peanuts, chocolate • Introduce foods 1 every 5-7 days

5. Drug Allergies Usually skin response Or ANAPHYLAXSIS !!

6. Environmental • Airborne • House dust mites • Cigarette smoke • Cat/Dog Dander

7. Diagnosis • HX & Physical • Skin Testing • Specific IgE Immunoassays— • No patient risk other than blood draw • Not influenced by medications • May be used for patient’s with rashes • Lower sensitivity than skin testing (~70%) • Only a potential of allergy • Not as cost effective as skin testing for screening. • RAST test(Radio/allergo/Sorbent Test)—

8. Skin Testing Prick Intradermal Not tolerated by young patients More sensitive (1000X) Results in 15 minutes If negative, results are near 100% predictive Not used for foods • Safe for any age • Rapid • Multiple tests • Minimal discomfort • Results in 15 minutes • Over 80% accuracy for inhalants • Over 90% accurate for foods

9. Treatment • Meds— • Topical corticosteroids, Oral Antihistamines, Nasal steroid sprays, Leukotriene antagonists, Nasal antihistamines, oral decongestants • Desensitization shots • Takes months to show effect, over 80% efficacy • Environmental Changes • Mattress & pillow covers; wash bed linens weekly • Ø carpet especially shag; reduce humidity level • Ø blinds; should be replaced with curtains • Ø pets; no stuffed animals unless washable • Frequent filter changes on furnace

10. Treatment for Food Allergies • #1—Avoidance!! • Research studies are being performed at Duke and Mt. Sinai specifically focusing on food desensitizations • 10 years from now, there may be other treatments • At this time, only research protocols exist • Management of Food Allergies • Have an individual management plan—know food triggers • Have a Food Allergy Action Plan • Educate yourself and others—know school interventions • Seek help from food allergy resources: www.foodallergy.org • Join a food allergy support group

11. Epipen and Epipen Jr. • Epipen: patients over 66 lbs (33kg) • EpipenJr: patient 33 lbs –66 lbs (15-30kg) • Patients who require the use of an Epipen should go to the Evergency Room for further evaluation • To make sure the emergency is over • To prevent recurrence of anaphylaxis (may occur 6-8 hurs after initial symptoms)

12. Juvenile Rheumatoid Arthritis (JRA) Inflammatory Disease with an unknown etiology

13. Pathophysiologyhttp://www.arthritis9.com/what-are-juvenile-rheumatoid-arthritis-symptoms.htmlPathophysiologyhttp://www.arthritis9.com/what-are-juvenile-rheumatoid-arthritis-symptoms.html Chronic inflammation of synovial lining of the joint with fluid buildup (effusion) into joint space  joint erosion, and adhesion formation

14. Incidence • Also called juvenile chronic arthritis or idiopathic arthritis of childhood • Peak ages: 1to 3 years and 8 to 10 years • Girls > boys • Often undiagnosed

15. Prognosis • Actually a heterogenous group of diseases • Pauciarticular onset (involves ≤4 joints) • Polyarticular onset (involves ≥5 joints) • Systemic onset (high fever, rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy) • Poorest prognosis w/systemic onset; > 4 joints

16. Common symptoms • Stiffness • Pain & Swelling • Loss of mobility in affected joints • Warm to touch, usually without erythema • Tender to touch in some cases • Symptoms increase with stressors • Growth retardation

17. Affiliated symptoms • Iridocyclitis/uveitis • Inflammation of iris and ciliary body • Unique to JRA • Requires treatment by ophthalmologist

18. 90% children have negative rheumatic factor • Symptoms may “burn out” and become inactive • Chronic inflammation of synovium with joint effusion, destruction of cartilage, and adhesion formation as disease progresses

19. Diagnostic Evaluation • No definitive diagnostic tests • Elevated sedimentation rate in some cases • X-ray 1st: widening of joint space, 2nd: fusion and articular erosion • Antinuclear antibodies (ANA) common, but not specific for JRA • Leukocytosis during exacerbations • Diagnosis based on criteria of American College of Rheumatology

20. American College of Rheumatology Diagnostic Criteria • Age of onset younger than 16 years • One or more affected joints • Duration of arthritis more than 6 weeks • Exclusion of other forms of arthritis

21. Management Goals • Preserve Joint Function • Prevent Physical Deformity • Relieve Symptoms w/o further complications

22. Treatment • Exercise/PT • Medications • NSAIDS • Ibuprofen, Tolmetin, Naprosyn • SAARD’s • D-Penicillamine, Gold, Quinine • Others • Cytoxic drugs (Methotrexate) & Corticosteroids • TNF Blockers—new kid on the block • Etanercept (Enbrel) IM 2X/wk self administered • Infliximab (Remicade) IV q 2mos

23. Nursing Measures • Careful Assessment • Administer medications and teach family about management • Moist heat • Referrals • American Juvenile Arthritis Organization • http://www.arthritis.org