Allergy and asthma : practical diagnosis and management

1. Introduction to the Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Massoud Mahmoudi, DO, PhD The Immune System 1 Cells of the Immune System 7 Innate Immunity 1 Mast cells 7 Natural Killer Cells 1 Basophils 8 Complement System 2 Eosinophils 8 Adaptive Immunity 2 Defective Immune System 8 Humoral Immunity 2 Hypersensitivity Diseases 8 Cell-Mediated Immunity 2 Type I: Immediate Hypersensitivity or Anaphylactic 8 Interaction of Antigen and Antibody 4 Type II: Antibody-Mediated Hypersensitivity 8 B Cells: Responsible for the Production of Antibodies 4 Type III: Immune Complex–Mediated Hypersensitivity 10 Autoimmunity 4 Type IV: Cell-Mediated Hypersensitivity 11 T Cell–Antigen Interaction 6 Evidence-Based Medicine 11 T Helper Cell Regulation 6 Bibliography 11 2. The History and Physical Examination of the Allergic Patient . . . . . . . . . . . . . . . . . . . . . . . 12 Mary Alice Murphy, MD, MPH The Physical Examination 12 The Physical Examination of the Allergic Patient 14 The Medical History 12 Vital Signs 14 Chief Complaint 12 General Appearance 15 Review of Systems 12 Skin 15 Medications 13 Face 15 Drug Allergies 13 HEENT: Head, Eyes, Ears, Nose, and Throat 15 Current Medications 13 Neck 15 Past Medications 13 Chest 16 Hospitalizations 13 Cardiovascular 16 The Clinic or Large Health Maintenance Additional Examination (as Indicated Organization Settings 13 by the Patient Complaint) 16 Occupational History 13 Procedures 16 Social History 13 Skin Testing 16 Environmental Exposures 14 Spirometry and Peak Flow Meters 16 Personal Habits 14 Pulse Oximetry 16 Dietary (Food) History 14 Nitrous Oxide Measurement 17 Geographic History 14 Endoscopy 17 Family History 14 Evidence-Based Medicine 17 Previous Allergy Diagnosis and Conclusion 17 Treatments 14 Bibliography 17 3. Prevalence of Allergic Diseases in Children, Adults, and the Elderly . . . . . . . . . . . . . . . . . . . 18 Massoud Mahmoudi, DO, PhD Allergic Rhinitis 18 Occupational Allergy 20 Respiratory Allergy-Allergic Asthma 18 Evidence-Based Medicine 20 Food Allergy 19 Bibliography 20 Atopic Dermatitis 20 v For more information about this title, click here 4. Allergic Diseases of the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Eric Kavosh, MD and Leonard Bielory, MD The Ocular Surface 21 Contact Dermatitis of the Eyelids 27 Clinical Examination 21 Blepharoconjunctivitis 27 Immunopathophysiology of Ocular Allergy 22 Ocular Allergy Treatment 27 Acute Allergic Conjunctivitis 24 Vasomotor Conjunctivitis or Perennial Chronic Vernal Keratoconjunctivitis 25 Conjunctivitis 30 Atopic Keratoconjunctivitis 25 Conclusion 30 Giant Papillary Conjunctivitis 26 Evidence-Based Medicine 30 Dry-eye Syndrome (Tear Film Dysfunction) 26 Bibliography 31 5. Prevalence of Pollens in the United States and Elsewhere . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Jennifer Yoo, MD and Massoud Mahmoudi, DO, PhD Tree Pollen 32 Africa 33 Grass Pollen 32 Asia 33 Weed Pollen 32 Europe 36 Methods of Pollen Collection 33 Evidence-Based Medicine 36 Worldwide Prevalence of Pollens 33 Bibliography 37 North America 33 6. Allergic Rhinitis: Diagnosis and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Dennis K. Ledford, MD Pathophysiology and Specific IgE 38 Rhinitis Associated with Systemic Diseases Epidemiology 40 or Anatomic Defects 46 Classification of Allergic Rhinitis 41 Treatment of Allergic Rhinitis 48 Differential Diagnosis of Allergic Rhinitis 41 Allergen Avoidance 48 Allergic Rhinitis 41 Allergen Immunotherapy 48 Perennial Nonallergic Rhinitis 43 Pharmacotherapy 51 Nonallergic Rhinitis with Eosinophilia 45 Future Therapeutic Options for Allergic Rhinitis 52 Rhinitis Induced by Drugs or Hormones Conclusion 53 (Rhinitis Medicamentosa) 46 Evidence-Based Medicine 53 Atrophic Rhinitis 46 Bibliography 53 7. The Effect of Rhinitis on Sleep, Quality of Life, Daytime Somnolence, and Fatigue . . . . . . . 55 Carah Santos, MS and Timothy J. Craig, DO Evidence for Sleep Impairment in Allergic Rhinitis 55 Effects of therapy 60 Mechanisms of Sleep Impairment 56 The Role of Intranasal Corticosteroids 60 Nasal Congestion 56 Conclusion 60 Immune Response Mediators 58 Evidence-Based Medicine 60 Sleep Impairment and Quality of Life 58 Bibliography 61 The Effects of Sleep Impairment 58 Measuring Sleep Impairment and Impact on Quality of Life 59 8. Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Kevin C. Welch, MD and Andrew N. Goldberg, MD, MSCE, FACS General Considerations 62 Bacteriology 66 Classification of Rhinosinusitis 62 Acute Bacterial Rhinosinusitis 67 Anatomy 62 Chronic Rhinosinusitis 67 The Septum and Turbinates 62 Diagnosis 68 The Ostiomeatal Complex 63 History and Physical Examination 68 The Paranasal Sinuses 63 Diagnostic Imaging 69 Pathophysiology 65 Culture 69 Acute Bacterial Rhinosinusitis 65 Treatment 69 Chronic Rhinosinusitis 66 Medical Therapy 69 vi / CONTENTS Antibiotic Therapy 69 Fungal Rhinosinusitis 72 Surgical Therapy 71 Allergic Fungal Sinusitis 72 Complications 71 Invasive Fungal Sinusitis 72 Orbital Complications 71 Evidence-Based Medicine 72 Intracranial Complications 72 Conclusion 73 Bibliography 73 9. Allergic Diseases of the Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Doris Lin, MD and Steven W. Cheung, MD General Considerations 74 Otitis Media with Effusion 76 Allergic Diseases of the External Ear 74 Food Allergy in Otitis Media with Effusion 76 Chronic Otitis Externa 74 Allergic Diseases of the Inner Ear 77 Contact Sensitivity 74 Ménière’s Disease 77 Dermatophytid Reaction 74 Evidence-Based Medicine 77 Allergic Diseases of the Middle Ear 74 Bibliography 77 Eustachian Tube Dysfunction 75 10. Cough and Allergic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Eric M. Chen, MD, FACP, FAAAAI, FACAAI Definition and Physiology 78 Asthma and Cough 80 Causes of Cough 78 Cough Variant Asthma 81 Upper Airway Cough Syndrome Nonasthmatic Eosinophilic Bronchitis 81 (Postnasal Drip Cough) 78 Gastroesophageal Reflux Disease and Cough 81 Allergic Rhinitis and Cough 78 Symptomatic Treatment of Cough 81 Nonallergic Rhinitis and Cough 79 Conclusion 83 Infectious Rhinitis and Cough 80 Evidence-Based Medicine 83 Angiotensin-Converting Enzyme Inhibitor Cough 80 Bibliography 83 11. Urticaria and Angioedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Bettina Wedi, MD, PhD and Alexander Kapp, MD, PhD Classification of Urticaria 84 Special Types of Urticaria 91 Spontaneous Urticaria 84 Cholinergic Urticaria 91 Acute Urticaria 84 Aquagenic Urticaria 91 Chronic Urticaria 85 Contact Urticaria 91 Physical Urticaria 88 Angioedema Without Urticaria 92 Dermographic Urticaria 88 Classification of Angioedema Without Urticaria 92 Delayed Pressure Urticaria 89 Non–C1 INH Deficient Angioedema Without Urticaria 92 Cold Urticaria 89 Hereditary Angioedema 93 Localized Heat Urticaria 90 Acquired C1 INH Deficiency Angioedema 93 Solar Urticaria 90 Evidence-Based Medicine 94 Vibratory Urticaria (Angioedema) 91 Bibliography 94 12. Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Satoshi Yoshida, MD, PhD, FACP, FAAAAI, FACAAI Pathogenesis of Atopic Dermatitis 95 Avoidance of Allergens 100 Immunohistology of atopic Dermatitis 95 Avoidance of Exacerbation Factors 101 Cutaneous Infections: Role for Superantigens 96 Probiotics 101 The Diagnosis of Atopic Dermatitis 97 Topical Corticosteroids 101 Differential Diagnosis 98 Topical Calcineurin Inhibitors 103 Complications 98 Specialized Therapy 104 The Treatment of Atopic Dermatitis 98 Future Perspective 105 Skin Hydration and Moisturizers 99 Evidence-Based Medicine 105 Avoidance of Irritancy 99 Diagnosis 105 Treatment for Pruritus and Deterrent Management (Indirect Outcome) 105 to Skin Scratching 100 Bibliography 105 CONTENTS / vii 13. Allergic Contact Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Bettina Wedi, MD, PhD Definition, Classification, Epidemiology 107 Patch Test Procedure 109 Recognizing Those at Risk 107 Repeat Open Application Test 112 Pathogenesis 107 Angry Back or Excited Skin Syndrome 112 Immunology 107 Pitfalls 112 Histology 108 Management 113 Clinical Symptoms 108 Evidence-Based Medicine 113 Diagnosis 109 Bibliography 114 14. Pediatric Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Sixto F. Guiang, MD Epidemiology of Pediatric Asthma 115 Goals of Treatment 119 Asthma in the Preschool––Age Child 116 Definition of Good Control 119 Natural History of Childhood Asthma 117 Managing Bronchial Asthma in Children 119 Will My Child Outgrow Peak Flow Monitoring 121 the Asthma? 117 Immunotherapy as a Treatment Option 121 Diagnosis of Asthma in the Older Child When does Referral to an Asthma Specialist or Adolescent 117 Become Desirable? 121 Assessing Severity of the Disease Before Evidence-Based Medicine 122 Initiation of Therapy 118 Bibliography 123 15. Adult Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Eric C. Chenworth, DO and Daniel E. Maddox, MD Definition 124 Asthma Exacerbations 130 Epidemiology 124 Maintaining Asthma Control 131 Pathogenesis 124 Special Considerations in the Management Asthma Diagnosis 125 of Adult Asthma 132 Diagnostic Studies 126 Pregnancy and Asthma 132 Asthma Management 129 Heart Disease and Asthma 132 Classification of Severity 129 Chronic Obstructive Pulmonary Disease and Asthma 132 Management 129 Evidence-Based Medicine 132 Exercise-Induced Asthma 130 Bibliography 133 16. Exercise-Induced Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Laura H. Fisher, MD and Timothy J. Craig, DO Clinical Characteristics 134 Scuba 142 Diagnosis 135 Hiking 143 Pathophysiology 137 Scuba Diving and EIA: Evidence-Based Medicine 143 Treatment 139 Conclusion 143 Special Considerations 141 Bibliography 143 Olympics 142 17. Occupational Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Jonathan A. Bernstein, MD Definition 145 Immunologic Assessment 151 Historical Perspective: Incidence and Prevalence 145 Physiologic Assessment 152 Pathogenesis 146 Clinical Assessment of Occupational Asthma 153 Mechanisms of Occupational Asthma 146 Treatment 154 Genetics of Occupational Asthma 146 Prevention and Immunosurveillance 154 Diagnosis of Occupational Asthma 147 Evidence-Based Medicine 155 History 147 Bibliography 155 Differential Diagnosis 148 viii / CONTENTS 18. Asthma and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Peg Strub, MD Adverse Pregnancy Outcomes for Patients Education 158 with Asthma 156 Smoking 158 Physiology 156 Triggers 158 Maternal Respiratory Physiology 156 Treatment Plans 158 Maternal Cardiovascular Physiology 156 Medications 158 Maternal Gastroesophageal Reflux 156 Treatment Guidelines 161 Fetal Physiology 157 Exacerbations 164 Asthma Treatment During Pregnancy 157 Mechanical Ventilation 164 Assessment of Asthma 157 Conclusion 164 Assessment of the Fetus 157 Evidence-Based Medicine 164 Reassurance 158 Bibliography 167 19. Pseudoasthma: When Cough, Wheezing, and Dyspnea Are Not Asthma . . . . . . . . . . . . . . . 168 Miles Weinberger, MD and Mutasim Abu-Hasan, MD What is Asthma? 168 Partial Airway Obstruction 172 When isn’t it Asthma? 168 Vocal Cord Dysfunction Syndrome 173 Cough that is not Asthma 168 Dyspnea that is not Asthma 173 Other Inflammatory Airway Diseases 168 Hyperventilation 173 Cystic Fibrosis 168 Exertional Dyspnea 173 Tracheomalacia and Bronchomalacia 170 Conclusion 174 Habit Cough Syndrome 171 Evidence-Based Medicine 175 Other Rare Causes of Chronic Cough 171 Bibliography 176 Wheezing that is not Asthma 172 20. Hypersensitivity Pneumonitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Joshua Gibbs, DO and Timothy J. Craig, DO Epidemiology 177 Pulmonary Function Testing 185 Prevalence 177 Bronchoscopy 185 Incidence 177 Histologic Analysis 185 Immunopathogenesis 181 Video-Assisted Thorascopic Surgery 186 Overview 181 Environmental History 186 Acute Phase of Hypersensitivity Pneumonitis 181 Environmental Sampling 186 Subacute Phase of Hypersensitivity Pneumonitis 181 Challenge Methods 187 Chronic Phase of Hypersensitivity Pneumonitis 182 Diagnostic Criteria 187 Clinical Presentation 182 Treatment 187 Acute Presentation 182 Avoidance of Antigen 187 Radiography and Pulmonary Function Testing 183 Environmental Remediation 187 Subacute Presentation 183 Corticosteroids 188 Radiography and Pulmonary Function Testing 183 Prognosis 188 Chronic Presentation 183 Evidence-Based Medicine 188 Diagnosis 183 Conclusion 189 Laboratory Findings 184 Bibliography 189 Radiographic Evaluation 184 21. Allergic Bronchopulmonary Aspergillosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Satoshi Yoshida, MD, PhD, FACP, FCCP, FAAAAI, FACAAI Pathogenesis 190 Treatment 193 Diagnosis 190 Evidence-Based Medicine 194 Staging 191 Diagnosis 194 Radiology 192 Management 194 Laboratory Findings 192 Bibiliography 194 CONTENTS / ix x / CONTENTS 22. Serum Sickness and Immune Complex Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Michael R. Nelson, MD, PhD Discovery 195 Laboratory 199 Definition 195 Differential Diagnosis 200 Epidemiology 195 Natural History 201 Pathophysiology 196 Management 201 Immune Complexes 196 Monitoring 201 End-Organ Damage Mediated by Therapeutic Options 201 Immune Complexes 197 Prevention 203 Human Disease 197 Future Directions and Evidence-Based Medicine 203 Triggers 197 Conclusion 203 Symptoms and Signs 198 Bibliography 204 Diagnosis 199 Clinical 199 23. Complement Systems and Allergy Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Marianne Frieri, MD, PhD The Complement System 206 Autoimmune Urticaria 212 Pathways and Physiologic Activities 206 Complement Therapeutics in Clinical Practice 212 Biologic Properties of Complement Fragments Evidence-Based Medicine 213 Related to Allergic Diseases 206 Bibliography 214 Cellular Receptors and Regulators 208 Clinical Associations 208 Immunomodulation of Autoimmunity with Intravenous Immune Globulin and Mechanisms of Immunomodulation 210 24. Food Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Oscar L. Frick, MD, PhD Mucosal Immunity and Tolerance 215 Prick Skin Tests 218 Pathogenesis 215 In Vitro Tests 219 Allergens 215 Basophil-Degranulation Tests 219 Cross-Reacting Food Allergens 216 Atopy Patch Tests 219 Clinical Manifestations 216 Food Elimination Diets 219 Skin 216 Management and Treatment 220 Gastrointestinal Tract 216 Elimination Diet 220 Respiratory 218 Pharmaceuticals 220 Genitourinary 218 New Experimental Approaches 220 Central Nervous System 218 Hypoallergenic Foods 220 Diagnosis 218 Evidence-Based Medicine 220 Oral Food Challenges 218 Bibliography 220 25. Insect Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 Donald F. German, MD, FAAAAI, FACAAI Stinging insects, Classification, Immunotherapy 226 and Characteristics 222 Reactions to Immunotherapy 227 Venoms 223 Duration of Immunotherapy 227 Insect Sting Reactions, Classification 224 Biting Insect Hypersensitivity 227 Normal Reaction 224 Insect Bite Reactions 228 Toxic Reaction 224 Antigens 228 Local Reactions 224 Immune Response to Insect Bites 228 Systemic Reactions 224 Diagnosis 229 Unusual Reactions 224 Treatment 229 Natural History of Sensitivity 224 The Future 229 Diagnosis 225 Evidence-Based Medicine 229 Treatment of Insect Sting Reactions 225 Bibliography 230 26. Latex Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Donald F. German, MD, FAAAAI, FACAAI History 231 Diagnosis 232 Epidemiology 231 Management 234 Natural Rubber Latex Products, The Future 234 Production, and Allergens 231 Evidence-Based Medicine 234 Pathogenesis 232 Bibliography 235 27. Drug Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Schuman Tam, MD, FACP, FAAAAI Classification 236 Evidence-Based Medicine 243 Type A Drug Reaction 236 Absence of Cross-Reactivity Between Sulfonamide Type B Drug Reaction 236 Antibiotics and Sulfonamide Nonantibiotics 243 Immunologic Drug Reaction (Drug Allergy) 236 The Risk of a Course of Penicillin Resensitizing the Patient Immunologic Drug Reaction Based on Gell and with a Positive History but Negative Skin Test Response Coombs Classification 236 is Low 244 Diagnosis of Drug Reaction/Allergy 238 Recent Advances 245 Clinical Assessment 238 The Role of T Cells in Drug Reaction 245 Diagnostic Investigation 238 Noncovalent Interactions of Drugs with Immune Receptors Graded Drug Challenge (Test Dosing) 240 May Mediate Drug-Induced Hypersensitivity Reactions 245 Management 240 Diagnostic Testing for T-Cell-Mediated (Type IV) General Considerations 240 Drug Reaction 245 Desensitization 240 Bibliography 245 Special Considerations 240 28. Smoke, Pollution, and Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Haig Tcheurekdjian, MD and Massoud Mahmoudi, DO, PhD Characteristics of Pollutants 247 Diesel Exhaust 250 Indoor Versus Outdoor Pollution 247 Nitrogen Dioxide 250 Actions of Pollution 247 Ozone 251 Characteristics of Individuals 248 Particulate Matter 251 Respiratory Tract Development 248 Sulfur Oxides 252 Immune System Development 249 Conclusion 252 Specific Pollutants 249 Evidence-Based Medicine 252 Tobacco Smoke 249 Bibliography 253 29. Sick Building Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Massoud Mahmoudi, DO, PhD Is Sick Building Syndrome an Allergic Condition? 254 Characteristics of a Healthy Building Environment 255 Etiology of Sick Building Syndrome 254 How to Prevent Sick Building Syndrome 256 Stachybotrys Chartarum and Human Diseases 254 Management of Sick Building Syndrome 256 Where are the Molds Found? 254 Evidence-Based Medicine 257 Identification of Molds in the Building 254 Bibliography 257 Symptoms 255 30. Allergy in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258 Marianne Frieri, MD, PhD Chronic Rhinitis and Sinusitis 258 Evidence-Based Medicine 261 Asthma in the Elderly 258 Bibliography 261 Other Allergic Conditions 258 Acquired Angioedema, Anaphylaxis, Food and Drug Allergy 258 CONTENTS / xi 31. Diagnostic Testing in Allergic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 Paul Cheng, MD, PhD, FAAAAI Percutaneous Allergy Testing 262 In Vitro Measurement of Allergen-Specific Immunoglobulin E 264 Prick/Puncture Method 262 Allergy Testing with no Proven Value 265 Intradermal Testing 263 Evidence-Based Medicine: Newer Trends in Allergy Testing 265 Diagnostic Value of Percutaneous Allergy Testing 264 Bibliography 265 32. Primary Immunodeficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266 Pedro C. Avila, MD When to Suspect Immunodeficiency and How Other forms of Combined Cellular and to Work It Up 266 Humoral Deficiencies 283 Antibody Deficiencies 267 Bare Lymphocyte Syndromes Class I and II 283 X-Linked Agammaglobulinemia 267 Omenn Syndrome 283 Transient Hypogammaglobulinemia of Infancy 270 Wiskott-Aldrich Syndrome 283 Common Variable Immunodeficiency 270 Ataxia Telangiectasia 284 Hyper IgM Syndrome 271 X-Linked Lymphoproliferative Disease or Other Forms of Hyper-IgM Syndrome Duncan Syndrome 284 (Autosomal Recessive Forms) 272 Phagocyte Deficiencies 284 Selective IgA Deficiency 272 Neutropenic Syndromes 284 Other Antibody Deficiencies 273 Congenital Neutropenia or Kostmann Syndrome 284 Immunoglobulin Replacement Therapy 273 Chédiak-Higashi Syndrome 285 Complement Deficiencies 275 Chronic Granulomatous Disease 285 Laboratory Evaluation of the Other Enzyme Deficiencies 286 Complement System 276 Glucose-6-Phosphatase Dehydrogenase Deficiency 286 Treatment of Complement Deficiencies 277 Myeloperoxidase Deficiency 287 Cellular Immunodeficiencies 277 Hyper-IgE Syndrome or Job Syndrome 287 DiGeorge Syndrome 277 Leukocyte Adhesion Deficiency Type 1 287 Chronic Mucocutaneous Candidiasis 278 Leukocyte Adhesion Deficiency Type 2 288 Immunodysregulation, Polyendocrinopathy, Deficiency in the IL12/IFN-γ Pathway 288 Enteropathy, X-Linked Syndrome 278 Evidence-Based Medicine 288 Autoimmune Lymphoproliferative Syndrome 278 Prenatal Diagnosis 288 Other Cellular Deficiencies 279 Gene Therapy for Immunodeficiencies 288 Combined Cellular and Humoral Bibliography 288 Immunodeficiencies 280 Web-Based Resources 289 Severe Combined Immunodeficiencies 280 33. HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 Mitchell H. Katz, MD and Andrew R. Zolopa, MD Pathophysiology of HIV 290 Hypersensitivity Reactions 297 Immunologic consequences of HIV Infection 290 Immune Reconstitution Inflammatory Syndrome 297 Treatment of HIV Infection 291 Evidence-Based Medicine 298 Antiretroviral Treatment 291 Resources 298 Prophylaxis of Opportunistic Infections 296 Bibliography 298 Treatment of HIV Manifestations 297 34. Complementary and Alternative Medicine in the Treatment of Allergic and Asthmatic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Jennifer Heimall, MD and Leonard Bielory, MD What is Complementary and Alternative Medicine? 299 How Modalities have been Studied to Date 300 Definitions and Descriptions of Commonly Identifying Patients most Likely to Use CAM 300 Used Modalities 299 Epidemiology of CAM Use 300 Herbal Therapies 299 Why Patients May Use CAM 301 Homeopathy 299 Identifying Populations Likely to Use CAM 301 Acupuncture 299 Screening for CAM Use by Patients 302 Ayurveda 300 Behavior Modification Techniques 300 xii / CONTENTS Modalities Commonly Used in the Treatment Nontraditional Immunotherapy 304 of Asthma 302 Behavioral Techniques and Behavior Modification 304 Herbals 302 Ethical and Legal Issues Raised by Patient’s Use of CAM 304 Acupuncture 302 Side Effects of CAM 304 Homeopathy 302 Significant Interactions with Western Therapies 307 Behavioral Techniques and Behavior Risks Associated with Lack of Western Modification 303 Therapeutic Involvement 307 Modalities Commonly Used in the Treatment of Liability Risks for Physicians 308 Allergic Rhinoconjunctivitis 303 Conclusion 308 Herbals 303 Evidence-Based Medicine 308 Acupuncture 303 CAM in the Prevention of Allergic and Asthmatic Disease 308 Homeopathy 304 Bibliography 309 35. Nutrition, Diet, and Allergic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310 Avraham Giannini, MD Controlling One’s Destiny 310 Evidence-Based Medicine 313 Historical Perspective 310 Conclusion 313 Dietary Guidelines 311 Bibliography 313 Supplements with an Eye on Allergy 311 36. Prevention and Control Measures in the Management of Allergic Diseases . . . . . . . . . . . . . 315 Shuba Rajashri Iyengar, MD, MPH and Massoud Mahmoudi, DO, PhD Indoor Allergens 315 Outdoor Allergens 318 Dust Mite 315 Background 318 Control Strategies 315 Control Strategies 319 Animal Dander 316 Evidence-Based Home intervention Methods 319 Cockroach 317 Bibliography 319 Control Strategies 318 37. Antihistamines and Mast Cell Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Giselle S. Mosnaim, MD, MS and Timothy J. Craig, DO Mechanism of Allergic Disease 321 Mast Cell Stabilizers 327 Antihistamine Mechanism of Action 321 Intranasal Chromomes/Mast Cell Stabilizers 327 Antihistamines 321 Intraocular Mast Cell Stabilizers 327 Oral First-Generation Antihistamines 321 Conclusion 327 Oral Second-Generation Antihistamines 322 Evidence-Based Medicine 327 Topical Nasal Antihistamines 326 Bibliography 327 Topical Skin Antihistamines 326 Ocular Antihistamines and Antihistamine/Mast Cell Stabilizer Combination Products 326 38. Bronchodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 Jennifer S. Kim, MD and Rachel E. Story, MD, MPH Pharmacology of Bronchodilators 329 Devices for Aerosolized Administration β-Agonists 329 of β-Agonists 331 β-Adrenoreceptors 329 Metered-Dose Inhalers 331 Mechanism of Action and Cellular Effects 329 Nebulizers 331 Structure and Development Dry Powder Inhalers 331 of β-Adrenergic Agents 329 Clinical Use of Bronchodilators for Acute Short-Acting Nonselective β-Agonists 329 Severe Asthma 332 Short-Acting Selective β2-Agonists 330 Selective Short-Acting β-Agonists 332 Long-Acting Selective β2-Agonists 330 Second-Line Agents for Acute Severe Asthma 332 Enantiomers 330 Long-Acting β2-Agonists 332 Xanthines 330 Long-Term Control Medication Use in Asthma 332 Magnesium Sulfate 330 Short-Acting β-Agonists 332 Routes of Administration for β-Agonists 331 Long-Acting β-Agonists 332 CONTENTS / xiii xiv / CONTENTS Methylxanthines 333 Evidence-Based Medicine 333 Exercised-Induced Bronchospasm 333 Bibliography 334 Adverse Effects and Safety of β-Agonists 333 Adverse Effects of β-Agonists 333 Safety of β-Agonists 333 39. Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Joseph D. Spahn, MD Chemistry 335 Available Inhaled Glucocorticoids 343 Mechanisms of Action 335 Dose/Frequency of Use 343 Systemic Glucocorticoid Therapy 335 Adverse Effects of Inhaled GC Therapy 345 Pharmacokinetics 335 Intranasal Glucocorticoids for the Treatment Efficacy of Oral Glucocorticoid Therapy of Allergic Rhinitis 346 in Asthma 338 Antiinflammatory Effects 346 Adverse Effects of Chronically Administered Clinical Efficacy 346 Systemic Glucocorticoids 340 Adverse Effects of Nasal Glucocorticoid Therapy 346 Inhaled Glucocorticoid Therapy 342 Conclusion 347 Efficacy of Inhaled Glucocorticoid Therapy 342 Evidence-Based Medicine 347 Inhaled Glucocorticoids as First-Line Therapy 343 Bibliography 348 40. Anti–Immunoglobulin E Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 Kari C. Nadeau, MD, PhD Background 349 Other Indications 353 Immunoglobulin E and Inflammation 349 Food Allergy 353 Measurement of IgE for Diagnostic Purposes 350 Allergic Rhinitis 353 Anti-IgE Therapy 350 Atopic Dermatitis 354 Anti-IgE Therapy in Asthma 350 Immunotherapy 354 Studies Using Anti-IgE in Asthma 350 Evidence-Based Medicine 354 Route of Administration 351 Randomized Controlled Study Using Anti-IgE Efficacy 351 in Rush Immunotherapy 354 Pediatric Trials 352 Use of Anti-IgE Therapy Reduces Leukotrienes in Studies Using Anti-IgE Therapy in Pediatric Children with Allergic Rhinitis 354 Subjects with Asthma 352 Future Directions 355 Cost-Effectiveness Studies 352 Conclusion 355 Omalizumab Indicated for Treatment of Asthma 353 Bibliography 355 Recommended Dosing 353 Indicated Patient Population 353 41. Allergy Immunotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356 Jeffrey R. Stokes, MD and Thomas B. Casale, MD Indications 356 Immunotherapy in General Practice 359 Mechanism 356 Efficacy and Outcomes 359 Contraindications 356 Evidence-Based Medicine 360 Dosing 357 Conclusion 360 Safety 358 Bibliography 360 Treatment of Anaphylaxis 359 42. Anaphylaxis and Its Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362 Sharon E. Leonard, MD and Lawrence Schwartz, MD, PhD Definition 362 Latex 364 Pathophysiology 362 Miscellaneous 365 Cells 362 Epidemiology 365 Mediators 363 Overall Incidence 365 Etiology 363 Foods 365 Foods 363 Drugs 365 Drugs 364 Insects 365 Insects 364 Latex 365 Diagnosis and Differential Diagnosis 365 Treatment 367 Signs and Symptoms 365 Acute 367 Time Course 366 Prevention 370 Laboratory Diagnosis 366 Evidence-Based Medicine and Future Directions 370 Differential Diagnosis 367 Bibliography 371 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373