Allergy and Immunology Review Corner: Chapter 57 of Middleton s Allergy Principles and Practice, 7 th Edition, edited by N. Franklin Adkinson, et al.

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1 Allergy and Immunology Review Corner: Chapter 57 of Middleton s Allergy Principles and Practice, 7 th Edition, edited by N. Franklin Adkinson, et al. Chapter 57: Insect Allergy Pages Prepared by Jacob Turnquist, MD, Walter Reed Army Medical Center, and John Seyerle, MD, Ohio State University 1. Vespula venom extracts are standardized to which protein? A. Phospholipase A B. Mellitin C. Hyaluronidase D. Piperidine Alkaloids 2. What is the major allergen in honeybee venom? A. Phospholipase A B. Mellitin C. Hyaluronidase D. Piperidine Alkaloids 3. What is the cause of the pustular lesions that develop following fire ant stings? A. Phospholipase A B. Mellitin C. Hyaluronidase D. Piperidine Alkaloids 4. Which of the following species would most likely cross react with yellow hornet? A. A. mellifera B. V. squamosa C. D. maculate D. S. invicta 5. What is the general dose of each venom in standard immunotherapy? A. 10μg B. 100μg C. 1000μg D. 10,000μg 6. Which of the following is true regarding large local reactions to a sting? A. They are late-phase, IgE-dependent reactions B. They usually develop hours after the sting C. Lymphangitic streaking is indicative of superinfection D. They may involve non-contiguous sites as long as they are on the same extremity 7. In a patient who has experienced anaphylaxis after a sting, which of the following characteristics impart a higher risk of anaphylaxis recurrence with subsequent stings?

2 A. Vespid sting (versus honeybee) B. Mild anaphylaxis (versus severe anaphylaxis) C. Increased time since last anaphylactic reaction D. Adult patient (versus child) 8. Which of the following statements are true? A. Rush schedules have increased rates of local and systemic reactions compared to conventional schedules. B. Most fatal sting reactions occur under the age of 45 years. C. Sensitization to multiple venoms can occur after only one sting. D. Venom immunotherapy does not improve the severity of large local reactions. 9. Which of the following is the duration of venom immunotherapy as described in the US product package inserts? A. 1-3 years B. 3-5 years C. At least 5 years D. Indefinitely 10. What is the approximate risk of a systemic reaction with a subsequent sting in a child if the original sting reaction was cutaneous systemic and occurred in the last 10 years? A. 10% B. 20% C. 40% D. 60% Answers 1. C, page 1008 While antigen 5 is the major allergen, Vespula venom extracts are standardized to hyaluronidase. 2. A, page 1008 While mellitin is a unique antigen for honeybees, the major antigen is Phospoholipase A. This is the antigen that is standardized in honeybee extracts. 3. D, page 1008 Fire ant venoms contain alkaloid toxins which cause the characteristic vesicular eruption. 4. C, page 1008 Within the vespid family there is extensive cross-allergenicity of the venoms of different genera. Yellow hornet is Dolichovespula arenaria and its venom cross reacts with thatof the white faced hornet, Dolichovespula maculate. V. squamosa and P. dominulus belong to the vespid family but show only limited cross-reactivity. Apis mellifera is honeybee and Solenopsis invicta is fire ant, neither of which cross-react with vespids. 5. B, page 1012 The general efficacy of the 100μgdose hads led to its widespread acceptance. Lower

3 doses have had variable efficacy. Higher doses may be needed if patient is not adequately protected with 100μg dose. 6. A, page 1008 They usually develop hours after the sting; lymphangitic streaking represents drainage of inflammatory mediators; any non-contiguous site is considered a cutaneous systemic reaction. 7. D, page 1011 Contrary to popular belief it is uncommon for patients to have more severe reactions with each subsequent sting. 8. C, page 1009 Therefore skin testing should be performed with a complete set of the 5 hymenoptera venoms. Rush is considered as safe as conventional; most fatal reactions occur after age 45 years; and VIT may improve severe large local reactions. 9. D, page 1013 Finite treatment options have been studied - the question is no longer if VIT can be discontinued but when and with what risk factors. 10. A, page Table 57.2 The risk declines further to 5% after 10 years since the sting. In general this risk is considered low enough in most patients to forgo VIT. In adults a cutaneous systemic reaction imparts a greater risk and thus usually warrants treatment. Allergy and Immunology Review Corner: Chapter 61 of Middleton s Allergy Principles and Practice, 7 th Edition, edited by N. Franklin Adkinson, et al. Chapter 61: Urticaria and Angioedema Pages Prepared by John Tole, MD, The University of Mississippi Medical Center, and Christopher Martin, MD, Walter Reed Army Medical Center 1. ACE inhibitors may lead to angioedema due to accumulation of: A. Angiotensinogen B. High molecular weight kininogen C. Bradykinin D. Activated Hageman factor 2. Which of the following are the most potent histamine-releasing factors as determined by basophil activation studies? A. Monocyte chemotactic peptide-1 (MCP-1) and MCP-3 B. Regulated on activation normal T cell expressed and secreted (RANTES) and MCP-2 C. Macrophage inflammatory peptide-i (MIP-I ) and MIP-I

4 D. Eotaxin 1 and eotaxin 2 3. Which of the following conditions/scenarios is most likely to cause urticaria lasting longer than 6 weeks? A. Shrimp allergy B. Infectious hepatitis C. Cytotoxic reaction to blood transfusion D. Hashimoto s thyroiditis 4. Which of the following food additives is most likely to cause chronic urticaria? A. Choline salicylate B. Tartrazine C. Benzoic acid D. Calcium bisulfite 5. The simplest lab evaluation to diagnose hereditary angioedema is: A. C1 INH level B. C1 INH function assay C. C4 D. Bradykinin level 6. A low level of which of the following complement proteins distinguishes acquired angioedema from hereditary angioedema? A. C1 B. C1q C. C3a D. C4 7. Which is true of angioedema or urticaria? A. Biopsy of tissues affected reveals venule constriction leading to extravasation B. Urticaria is characterized by pruritic lesions that do not blanch with pressure C. Angioedema is caused by the same (or similar) process as urticaria, just in a deeper tissue level D. Angioedema generally involves dependent areas of the body 8. The axon reflex that results in extension of the erythema around an urticarial lesion is primarily due to what mediator? A. Substance P B. Factor S C. Protein S D. Hageman Factor 9. The interleukin critical for mobilization of eosinophils from the bone marrow is? A. IL-4 B. IL-5 C. IL-3

5 D. PAF 10. Acute urticaria is extremely common, affecting up to what percentage of the population at some time during their lives? A. 5% B % C % D. >70% Answers 1. C, page ACE inhibitors inhibit the degradative enzyme angiotensin-converting enzyme, which liberates Phe-Arg from the C-terminus of bradykinin. 2. A, page 1065 MCP-1 = MCP-3 > RANTES = MCP-2 > MIP-I > MIP-I 3. D page 1077, Up to 24% of chronic urticaria is associated with an antibody to thyroid peroxidase or thyroglobulin. Reactions to foods and cytotoxic reactions are much more likely to cause acute urticaria than chronic. Underlying infections can cause chronic urticaria but hepatitis and infectious mononucleosis tend to cause acute, self-limited episodes. 4. B page 1066 Tartrazine (yellow No. 5) has an incidence rate of up to 8%, though Dr. Kaplan s experience is more in the range of % with sensitivity to salicylates or benzoates close to zero. 5. C page C4 is used as the screening lab while C1 inhibitor level and C1 inhibitor function assay are used to diagnose Type 1 HAE and Type 2 HAE, respectively. Bradykinin is increased but is not used to screen/diagnose HAE. 6. B page 1075 Acquired and hereditary angioedema, during an attack, both have low C4 and C2 but only acquired angioedema has low C1q. 7. C page 1063 Venules dilate leading to fluid loss. Urticarial lesions blanch, and angioedema occurs in non-dependent areas of the body in an asymmetrical fashion. 8. A page 1064 Substance P acts as a potent vasodilator and stimulates mast cells to release histamine, augmenting the reaction 9. B page 1065

6 IL-5 is weakly chemotactic by itself, but primes eosinophils to respond to other factors necessary for mobilization from the bone marrow 10. B page 1066 Acute urticaria affects approximately 10-20% of the population at least once in their lives.