Clinical Cases: Immunodeficiency

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Immunodeficiency




Immunodeficiency Cases

How to Diagnose Common Variable Immunodeficiency (CVID)?
Antibody titer responses to pneumococcal vaccination in common variable immunodeficiency (CVID)
Headache After Treatment with Intravenous Immunoglobulin (IVIG)
Alpha-1 antitrypsin (AAT) deficiency and panniculitis
Case studies from Essentials of Clinical Immunology, 5th edition

Immunology Cases

MMR Immunization and Egg Allergy

Further Reading

Primary immunodeficiency disorders (PIDD)
Phagocyte Deficiencies
Chronic Granulomatous Disease (CGD)
Chediak-Higashi Syndrome (CHS)
Leukocyte adhesion deficiency (LAD)
Leukocyte adhesion deficiency type I (LAD I)
Leukocyte adhesion deficiency type II (LAD II)
Leukocyte adhesion deficiency type III (LAD III)
Hyper IgE Syndrome (HIES)
IPEX (immunodysregulation, polyendocrinopathy, enteropathy, X linked) syndrome
Autoimmune lymphoproliferative syndrome (ALPS)
Chronic Mucocutaneous Candidiasis (CMCC)
Diagnosis of T-cell Immunodeficiency
DiGeorge Syndrome (DGS)
Wiskott-Aldrich Syndrome (WAS)
Ataxia-Telangiectasia (A-T)
Complement Deficiencies
Mind maps: Primary Immunodeficiency Disorders (PIDD)
Mnemonics: Primary Immunodeficiency
Innate Immune System
Adaptive Humoral Immunity: B-cells and Immunoglobulins
Mast Cells and Basophils
Eosinophils
T Lymphocytes and Interferons
Immunology Resources: Audio and Video Lectures, PowerPoint Presentations, Q&A
Blog articles from AllergyNotes

Image source: Wikipedia.

Clinical Cases: Drug Allergy

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Clinical Cases: Dermatitis

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Clinical Cases: Angioedema

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Clinical Cases: Anaphylaxis

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Clinical Cases: Urticaria

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Clinical Cases: Food Allergy

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Clinical Cases: Allergic Rhinitis

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Clinical Cases: Asthma Clinical Cases

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Mnemonics in Allergy and Immunology

Mnemonics in Allergy and Immunology

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Clinical Notes in Allergy and Immunology

Clinical Notes in Allergy and Immunology

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immunology

Clinical Notes in Allergy and Immunology





This is a list of brief reviews of topics in allergy and immunology:

Basic Immunology

Innate Immune System
Neutrophils
Mononuclear phagocytes (monocytes)
Pathogen-associated molecular patterns (PAMPs) and receptors (PRRs)
Complement System
Complement receptors (CR)
Adhesion Molecules
Occupational Asthma
Novel approaches to immunotherapy
Punch Biopsy of the Skin

Examination of the Larynx and Pharynx. NEJM video (subscription required).
Cricothyroidotomy. NEJM video (subscription required).

Clinical Immunology

Primary immunodeficiency disorders (PIDD)
Phagocyte Deficiencies
Chronic Granulomatous Disease (CGD)
Chediak-Higashi Syndrome (CHS)
Leukocyte adhesion deficiency (LAD)
Leukocyte adhesion deficiency type I (LAD I)
Leukocyte adhesion deficiency type II (LAD II)
Leukocyte adhesion deficiency type III (LAD III)
Hyper IgE Syndrome (HIES)
IPEX (immunodysregulation, polyendocrinopathy, enteropathy, X linked) syndrome
Autoimmune lymphoproliferative syndrome (ALPS)
Chronic Mucocutaneous Candidiasis (CMCC)
Diagnosis of T-cell Immunodeficiency
DiGeorge Syndrome (DGS)
Wiskott-Aldrich Syndrome (WAS)
Ataxia-Telangiectasia (A-T)
Complement Deficiencies
Hypereosinophilic syndrome (HES)
Fellows-in-Training: Review Corner Archive, 2002-2009 by ACAAI

Microbiology: Mycology PPT

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Cardiology: Exercise Tolerance Test (ETT)

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Exercise Tolerance Test (ETT)
Exercise tolerance test(aka Exercise ECG testing)
Used to:
-       Confirm the diagnosis of angina
-       Give an indication of the severity of CAD – thus allowing you to asses risk. This can be done either in a patient with CAD, or in somebody with CAD who has had a previous MI.
It is possible to have a normal resting ECG, even if there is considerable narrowing of the coronary arteries.
The test has:
-       Specificity of 80%
-       Sensitivity of 70%
…for CAD
The Bruce protocol was established in the 1960’s, and this says that:
-       1) – the patient should at an incline of 10% at 1.7mph. This is gradually increased – both the incline and the speed. The gradient is increased by 2& each time, and the speed by roughly 0.8mph.
-       You continue to increase these until the patient reaches their target heart rate. The target rate is:
o   Men – 220 – age
o   Women – 210 – age
-       The target heart rate is approximately 85% of the maximum heart rate – the whole aim of the test is to reach this target heart rate! – note that the changes in the ECG can appear during the resting period after exercise, eve if they didn’t appear in the ECG during the original exercise!
-       Beta-blockers should be stopped the day before the test – as these can prevent the target heart rate being reached
-       Digoxin should be stopped a week before the test – as this can alter the ST segment, and make interpretation for the test difficult.
-       The Bruce protocol technically states that patients should exercise for 21 minutes, however they rarely exercise for this long. Normally the test is stopped once the target heart rate is reached.
Measurements during the test
-       The patent is hooked up to a 12 lead ECG – a reading is taken before the test, and also recorded throughout the duration of the test
-       Blood pressure should be taken at the beginning of the test, and at the beginning of each new stage of the test
o   Systolic BP often rises – it is not unusual for it to go above 220mmHg
o   Diastolic BP often falls slightly  
-       A normal test does not necessarily rule out CAD – however, if you have CAD and have a negative test, then your prognosis is still good
-       20% of those with a positive test result actually don’t have CAD. These kinds of results are much more common in young people, thus it is controversial to test young, asymptomatic patients.
o   Also note that a disproportionately small amount of women are tested – and as well as this, women are more likely to have atypical symptoms of CAD.
Those who have a strongly positive test (which is ST depression within 6 minutes) and those most suitable for coronary angiography.
The test is probably most useful as a prognostic tool – and not as useful as a diagnostic tool. If you already know the diagnosis, then a positive test at a low workload is a poor prognostic sign.
Complications
-       Death or MI occurs in 0.01% of patients. You should select patients carefully to minimise this risk
-       VT or VF can occur in 1 in 0.02%
Contraindications
-       Acute MI in the last 4-6 days
-       Unstable angina – with pain at rest in the last 48 hours
-       Uncontrolled heart failure
-       Systemic infection , myocarditis, pericarditis
-       DVT
-       Uncontrolled hypertension (sys >220, dias >120)
-       Severe aortic stenosis – this can cause sudden death!
-       Arrhythmia
-       Aneurysm
-       Recent aortic surgery
Findings
-       ST depression – should be >1mm. The deeper the depression, and the lower the HR at which is occrs generally indicate the severity of the disease
-       T wave elevation – where this occurs to >1mm and there are no Q waves (in that particular lead) then this can be a bad prognostic sign
Reasons to stop the test
-       ST depression >3mm
-       Target heart rate reached
-       ST elevation of >1mm in a lead with no Q waves
-       VT
-       New atrial fibrillation
-       Development of new BBB
-       Cardiac arrest
-       The most common reason the test is stopped is fatigue and breathlessness as the patient is unaccustomed to exercise!
REMEMBER!:
-       ST depression – Ischaemia
-       ST elevation - Infarction


Notes by Tom Leach

Cardiology: Echocardiogram

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Echocardiogram
Echocardiogram Notes
This is basically an ultrasound of the heart. It gives a reasonably accurate picture of the valves and chambers of the heart, and also gives an idea of the velocity of blood flow in certain areas (thus helping you to determine if there is backflow/ reduced flow in valve defects).
Structures visualised
-          Valves
-          All 4 chambers
-          Wall thickness
-          Amount of muscle contraction
-          Pericardium
-          Intracardiac masses
-          Ascending aorta
Types of echo
Transthoracic
-          The patient lies of their left hand side with their arm behind their head. The transducer is placed at various intercostal spaces to the left of the sternum, and at the anterior axillary line.
-          This is the preferred test for valve defects
Transoesophageal (TOE –Trans-Oesophageal Echocardiogram)
-          Usually performed under sedation (midazolam), and with facilities for resuscitation
-          It provides high resolution due to the probes proximity to the heart.
-          Provides good views of the posterior part of the heart – i.e. the left atrium, and descending aorta.
-          This is the investigation of choice for infective endocarditis, prosthetic valve management, and searching for causes of thromboembolism.
-          This is an invasive procedure!
Stress echocardiogram
-          You would normally do this is conjunction with a normal transthoracic echo and compare images. You can either stress the heart with exercise, or you can give an infusion of dobutamine.
-          It is basically used to evaluate CHD.
-          The presence of reversible systolic regional wall motion abnormalities are characteristic of CHD
-          This is basically an alternative to ETT (exercise tolerance testing) – but is not used as often
Uses of echo
-          Find valve dysfunction
-          Asses prosthetic valve function
-          Assessment of left ventricular function – can be used to estimate left ventricular ejection fraction
-          Atrial fibrillation
-          Congenital heart disease
-          Cardiomyopathy
-          IE
-          After embolic stroke – to try and find a possible cause; e.g. patent foramen ovale.
-          Pericardial disease
Other stuff
These things are generally not looked for on ECHO, unless you especially specify them to look!:
-          Right ventricular function
-          Diastolic function
-          Possible cause of stroke

Notes by Tom Leach