immunologic emergencies: core content
DESCRIPTION
Immunologic Emergencies: Core Content. Andrew Choi M.D. PGY 3 North Shore University Hospital. Rapid Review. Natural/Innate Immunity Non-specific immune system Macrophages, neutrophils , NKC, cytokines Adaptive Immunity Specific and stored T and B lymphocyte memory - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/1.jpg)
Immunologic Emergencies:Core Content
Andrew Choi M.D. PGY 3North Shore University Hospital
![Page 2: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/2.jpg)
Rapid Review
• Natural/Innate Immunity– Non-specific immune system– Macrophages, neutrophils, NKC, cytokines
• Adaptive Immunity– Specific and stored T and B lymphocyte memory– T-cell recognition of antigen on MHC proteins– B-cell – immunoglobulin production
![Page 3: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/3.jpg)
![Page 4: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/4.jpg)
![Page 5: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/5.jpg)
Angioedema
• Self-limited, localized subcutaneous (or submucosal) swelling
• Extravasation of fluid into interstitial tissues• May occur with urticaria/anaphylaxis or in isolation• Clinical characteristics– Acute onset (minutes to hours)– Asymmetric distribution– Tendency not to involve dependent areas– Face, lips, larynx and bowel
![Page 6: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/6.jpg)
Pathophysiology
![Page 7: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/7.jpg)
Hereditary Angioedema (HAE)
• Three types classified by genetic mutation– Type I: SERPING1 low C1 inhibitor levels in blood
increased bradykinin levels– Type II: SERPING1 low activity of C1 inhibitor
increased bradykinin levels– Type III: F12 abnormal activity of Factor XII
increased bradykinin levels • Clinical trials for long term prophylaxis – Bradykinin receptor antagonist– C1 inhibitor
![Page 8: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/8.jpg)
What exactly is a bradykinin?
• Vasoactive peptide– Vasodilation– ACE inhibition increased bradykinin (inhibiting
its degradation)
![Page 9: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/9.jpg)
Associated Symptoms
• Laryngeal attacks– Lips, tongue, uvula, soft palate– 50% of patients in their lifetime involve airway– <1% of angioedema attacks laryngeal– Can be triggered by dental work
• GI Symptoms– Wall edema nausea, vomiting, diarrhea, GI colic
• Harbingers of doom – the “Predyspnea Phase”– Lump in throat – feeling of tightness– Progresses to dyspnea phase and LOC and death
![Page 10: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/10.jpg)
![Page 11: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/11.jpg)
HAE Acute Therapy
• C1-inhibitor (plasma derived)– Weight based IV formulation
• Kallikrein inhibitor– Ecallantide– Blocks bradykinin by inhibiting kallikrein
• Cost??– 5,000$-10,000$
• Epi? Steroids?
![Page 12: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/12.jpg)
![Page 13: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/13.jpg)
34yoF rash, fever, arthralgiaDescribe the rash?Differential?
![Page 14: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/14.jpg)
Systemic Lupus Erythematosus
• Multiorgan autoimmune disorder– Polyclonal B Cell and autoimmune antibody activation– Complex pathology – small vessel end-organ damage –
DM?• Wide variety of presenting symptoms– Ask your patient about flares
• Medical therapy and comorbidities may complicate ED workup– Steroidal immune suppression– Hydroxychloroquin, anti-TNF MAB
![Page 15: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/15.jpg)
Lupus Nephritis
• Manifested as proteinuria from complement deposition and glomerulonephritis
• Progresses to end stage renal failure– +/- dialysis– Renal transplant– Leading cause of death in SLE
![Page 16: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/16.jpg)
Pop Quiz
What is the most common cardiac manifestation of SLE?
A. ACSB. MyocarditisC. EndocarditisD. Pericarditis
![Page 17: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/17.jpg)
Pop Quiz
• Pericarditis– 50% of patients at time of autopsy– EKG and clinical diagnosis– May be complicated by effusion
• Myocarditis – 10% with LV dysfunction• Endocarditis – non-infectious valvular
vegetations typically on MV• ACS – increased frequency
![Page 18: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/18.jpg)
Pop Quiz Inside a Pop Quiz
On an EKG, how do you differentiate pericarditis vs. STEMI?
![Page 19: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/19.jpg)
Pericarditis• Classic Teaching– Diffuse ST-segment elevation– ST-segment elevation is concave upward– PR-segment depression– PR-segment elevation in aVR– Chest pain tends to be positional, pleuritic– Friction rub
This 5 minute detour brought to you byAmal Mattu – ECG of the week
![Page 20: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/20.jpg)
Pericarditis• Classic Teaching is wrong?– Diffuse ST-segment elevation• Can be localized! • Should be NO ST-segment depression (except V1, aVR)
– ST-segment elevation is concave upward• STEMI can also have upward sloping ST-elevations• ST-segment elevation with convex downward or
horizontal ACS
• STE II > STE III favors pericarditis• STE III > STE II very strongly favors AMI
![Page 21: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/21.jpg)
Pericarditis
• Classic Teaching is wrong?– PR-segment depression (down-sloping)
• Viral pericarditis and ACS • Often an early, transient finding
– PR-segment elevation in aVR• May also be present in other diseases (AMI – atrial infarct)• Often absent in constrictive pericarditis
– Chest pain tends to be positional, pleuritic• 16% of AMI can be positional or pleuritic
– Friction rub• Very uncommon
![Page 22: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/22.jpg)
Factors Favoring AMI
1. ST-segment depression (beyond V1 and aVR)?2. ST-segment elevation convex downward (tombstone) or horizontal?3. STE III > STE II?• If not then look for PR segment depression in
multiple leads• When in doubt – get serial ECG
![Page 23: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/23.jpg)
![Page 24: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/24.jpg)
![Page 25: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/25.jpg)
![Page 26: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/26.jpg)
25 year old male, no PMHx presents with the following intensely pruritic lesion.
What is causative agent?
What type of reaction is this?
![Page 27: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/27.jpg)
• Toxicodendron genus = “poisonous tree”• Clustered commonly as “poison ivy dermatitis”• Caused by powerful antigenic urushiol
![Page 28: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/28.jpg)
![Page 29: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/29.jpg)
![Page 30: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/30.jpg)
Clinical Features
• Onset of dermatitis– 4-96 hours after initial exposure– May take up to 21 days in unexposed patients– Peak between 1-14 days– Time to onset also concentration dependent (not
spreading)• Resolution in 1-3 weeks• May be complicated by bacterial super-infection
![Page 31: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/31.jpg)
Treatment• Post-exposure– Gentle washing with soap– Clothing should be washed with soap
• Topical soothing measures– Oatmeal, cold compress, Burow’s solution
• Antihistamines?• Topical corticosteroids• Oral steroids– 2-3 week taper– 60 x 1 week, 40 x 1 week, 20 x 1 week
![Page 32: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/32.jpg)
![Page 33: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/33.jpg)
Rejection and Transplant Medicine
![Page 34: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/34.jpg)
![Page 35: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/35.jpg)
Transplant Medicine
• MHC Structure and Function– Highly polymorphic genes– Principal antigenic determinants of graft rejection– Major component of displaying antigenic peptides
to T-Cells
![Page 36: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/36.jpg)
![Page 37: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/37.jpg)
Anatomic Complications
• Vascular Complications– Arterial and venous thromboses
• Nonvascular Complications– Biliary ducts, bronchi and ureters– Leaks and obstruction
![Page 38: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/38.jpg)
Hyperacute Rejection
• Pre-existing humoral immunity• Immediate and occurs in the perioperative
period
![Page 39: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/39.jpg)
Acute Rejection
• Attributed to cellular immunity• Will occur in all transplants without
immunosuppression• Onset from 1 week – 3 months• Constitutional symptoms and transplant organ
insufficiency• May require biopsy
![Page 40: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/40.jpg)
Chronic Rejection
• Long-term chronic allograft vasculopathy fibrosis
• Occurs over years• Presents as gradual failure of transplanted
organ
![Page 41: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/41.jpg)
Post Transplantation Infections
• First Month– Related to surgery
• 1-6 Months After Transplantation – Immunomodulating viral infections• CMV, HepB, HepC, Bk polyomavirus, HHV 6, EBV• CMV is most important and prevalent
– Opportunistic infections• Pneumocystis, Listeria and fungal species
![Page 42: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/42.jpg)
• 6 Months After Transplantation– Healthy Transplant• No chronic immunomodulating viral infections• Low dose immunospressant medications• Mildly increased risk of community-acquired infections
– Chronic Viral Infection• Recurrent viral hepatitis cirrhosis• EBV B-cell lymphoproliferative disorder• VZV pneumonia, pancreatitis, hepatitis, encephalitis,
DIC
Post Transplantation Infections
![Page 43: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/43.jpg)
Graft Versus Host Disease (GVHD)
• Commonly associated with stem cell or bone marrow transplant
• HLA haplotype incompatibility • Can occur with non-irradiated blood
transfusion• Clinical manifestation – Liver, skin, mucosa, GI tract, lung
• Treated with high dose glucocorticoids
![Page 44: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/44.jpg)
Immunosuppressive Therapy
What are some commonly used immunosuppressive drugs used?
![Page 45: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/45.jpg)
Immunosuppressive Therapy• Corticosteroids
– Prednisolone– Hydrocortisone
• Calcineurin– Cyclosporin– Tacrolimus
• Anti-proliferatives– Azathiprine– Mycophenolic acid
• mTOR inhibitors
– Sirolimus– Everolimus
• Synthetic antibody– Anti-IL-2Ra receptor
• Basiliximab• Daclizumab
– Polyclonal anti-T-cell• Anti-thymocyte globulin (ATG)• Anti-lymphocyte globulin
(ALG)– Monoclonal anti-CD20 Ab
• Rituximab
![Page 46: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/46.jpg)
![Page 47: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/47.jpg)
![Page 48: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/48.jpg)
Immunosuppression
• Calcineurin Inhibitors– Cyclosporine• Mainstay of transplant immunosupression• Inhibits lymphocyte signal transduction• Adverse Reactions: HTN, nephrotoxicity, gout
– Tacrolimus• Primary or rescue therapy for allografts• Binds lymphocyte proteins• Adverse Reactions: GI symptoms, hyperglycemia
![Page 49: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/49.jpg)
Immunosuppression
• Antimetabolites– Azathioprine
• Derivative of 6-mercaptopurine• Used to be mainstay• Adverse reactions: bone marrow, GI
– Mycophenolate Mofetil• Antimetabolite potent and selective inhibition of lymphocyte
proliferation• Low side effect profile: used with cyclosporine and
corticosteroids• Adverse reactions: GI upset, leukopenia and thrombocytopenia
![Page 50: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/50.jpg)
Immunosuppression• Corticosteroids
– Wide range of effects – specific reduction in T-Cell activity– Long-term adverse reactions are the worst – avoided if at all
possible– Osteoporosis, cataracts, GI bleed, glucose intolerance, adrenal
suppresion• Anti-lymphocyte Monoclonal Antibody – OKT3
– Short courses to reverse allograft rejection– Mouse-derived MAB to T-Cells– Chills, fever, hypotension occur– Effective in > 90% of first rejections in most patients
![Page 51: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/51.jpg)
HIT, ITP, TTP, HUS, WTF?!
![Page 52: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/52.jpg)
HIT
• Heparin Induced Thrombocytopenia• 2.6% unfractionated heparin and 0.2% of low-
molecular-weight heparin use• 5-7 days after initiation• Thrombosis loss of limb in 20% of cases, death in 30%• >50% reduction in platelet count after heparin• Delayed form can occur 14-40 days after initiation• Treatment is aimed at preventing thrombotic events
– Argatroban (direct thrombin inhibitor)
![Page 53: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/53.jpg)
![Page 54: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/54.jpg)
ITP• Idiopathic thrombocytopenic purpura• “I Trash Platelets”• Autoimmune idiopathic thrombocytopenic purpura• Acute (<10 mo.) and chronic form (>10 mo.)
– Acute form is 2-6 years of age after viral syndrome– Chronic form with female>male predominance with insidious
onset– Acute form can progress to chronic disease
• Treatment – steroids, IVIg, platelet transfusions, splenectomy– Most resolve on their own
![Page 55: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/55.jpg)
TTP / HUS
• Thrombotic thrombocytopenic purpura• “Thrombosis Trashes Platelets”• FAT RN• Classic Pentad - rare– Fever– Microangiopathic hemolytic anemia– Thrombocytopenia– Renal Injury – Neurological Abnormality (AMS, sz, CVA)
![Page 56: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/56.jpg)
TTP/HUS
• Microangiopathic Anemia + Thrombocytopenia = diagnosis
• Causes:– Infection (Shiga toxin, E. Coli 0157:H7)– Drugs (Clopidogrel, quinine)– Idiopathic – Autoimmune (PAN, SLE)– Bone marrow transplant
![Page 57: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/57.jpg)
TTP/HUS
• Plasma Exchange– Mainstay of treatment– Prior to development – TTP was progressively fatal
• Corticosteroids• Avoid platelet transfusions unless given a life-
threatening bleed
![Page 58: Immunologic Emergencies: Core Content](https://reader035.vdocuments.net/reader035/viewer/2022081502/568164db550346895dd72d6d/html5/thumbnails/58.jpg)