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Question . 21. A 7-yr-old girl presents with allergic nasal symptoms that are
prominent from the middle of August through the first frost. Which of the
following allergens is the most likely cause of her symptoms?
Milk protein
Tree pollen
Grass pollen
Weed pollen
Explanation: In temperate climates, airborne pollen
responsible for SAR appears in distinct phases: trees
pollinate in the spring, grasses in the early summer, and
weeds in the late summer. (See Chapter 133 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 22. A teenage boy presents in April with symptoms consistent with
seasonal allergic rhinitis. On examination of his nose, which of the following
findings suggest the need for further evaluation to exclude another diagnosis?
Nasal polyps
Explanation: Nasal polyps and nasal septal deviation are
structural disorders that can mimic allergic rhinitis. (See
Chapter 133 in Nelson Textbook of Pediatrics, 17th ed.)
Pale-to-purple nasal mucosa
Thin, clear nasal secretions
A transverse nasal crease
Continuous open-mouth breathing
Question . 23. A 12-yr-old presents with sneezing, clear rhinorrhea, and nasal
itching. Physical examination reveals boggy, pale nasal edema with a clear
discharge. The most likely diagnosis is:
Foreign body
Vasomotor rhinitis
Neutrophilic rhinitis
Nasal mastocytosis
Allergic rhinitis
Explanation: Allergic rhinitis is often seasonal and
associated with allergic conjunctivitis. Eosinophils
2-agonist
2-
Systemic glucocorticoids
Question . 33. A 7-yr-old girl has had intermittent asthma symptoms over the
past 5 yr. Her asthma symptoms have been treated with inhaled albuterol as
needed. She mostly has exercise-induced asthma symptoms, which happens
on most school days except when she uses her albuterol inhaler before going
to recess and physical education classes. In the past year, she has had two
asthma exacerbations with viral upper respiratory tract infections, and she has
used a total of 5 albuterol metered-dose inhalers. The most appropriate
management for this asthmatic girl is:
Continue albuterol as needed and before physical exercise
activities
Begin daily controller medication with an inhaled
glucocorticoid, initially used more frequently to gain
control, then a reduced amount in a few months to
maintain control
Explanation: Low-dose inhaled glucocorticoids,
leukotriene pathway modifiers, and cromolyn/nedocromil
are the recommended controllers for mild persistent
asthmatics; sustained-release theophylline is an alternative.
Chapter 134
Begin daily inhaled glucocorticoid in a low dose, increasing
the dose monthly until good control is obtained
Administer daily oral glucocorticoid treatment for one week,
with concurrent daily inhaled glucocorticoid
Begin use of a long-acting inhaled -agonist each morning
Question . 34. Components of the U.S. National Asthma Education &
Prevention Program (NAEPP) guidelines include all of the following except:
Regular assessment and monitoring
Control of factors contributing to asthma severity
Asthma pharmacotherapy, especially the use of antiinflammatory controller medications
Genetic profiling
Explanation: The NAEPP guidelines were recently
adapted for childhood asthma in a joint-effort publication of
the American Academy of Allergy, Asthma & Immunology
with the U.S. National Institutes of Health's National Heart,
Lung and Blood Institute and the American Academy of
Pediatrics entitled Pediatric Asthma: Promoting Best
Practice.Chapter 134
Patient education
Question . 35. Features characteristically associated with atopic dermatitis
include all of the following except:
Allergic rhinitis or asthma
Elevated serum IgE level
Peripheral blood eosinophilia
Lymphopenia
Explanation: Most patients with atopic dermatitis have
peripheral blood eosinophilia and elevated serum IgE level.
Nearly 80% of patients with atopic dermatitis develop
allergic rhinitis and/or asthma.
Question . 36. Major features of atopic dermatitis in children include all of the
following except:
Pruritus
Facial and extensor eczema
Angioedema
Explanation: Angioedema is similar to urticaria but has
deeper tissue involvement. Urticaria and angioedema are
not characteristic features of atopic dermatitis
Chronic or relapsing course
Personal or family history of atopic disease
Question . 37. A 2-yr-old is diagnosed with atopic dermatitis. Which of the
following environmental modifications is recommended?
A bland diet, especially minimizing meats
Installation of wool carpeting instead of synthetic carpeting
Use of a liquid rather than powder laundry detergent,
and adding a second rinse cycle
Explanation: Using a liquid rather than a powder laundry
detergent and adding a second rinse cycle will facilitate
removal of the detergent. Soaps should have minimal
defatting activity and a neutral pHChapter 135
Use of soaps that are especially effective in removing fatty
substances
Question . 40. A 5-yr-old boy with severe atopic dermatitis develops illness
with dozens of vesicles primarily covering areas of skin previously affected by
atopic dermatitis. The distribution crosses many dermatomes. Findings include
fever and lymphadenopathy. The most likely diagnosis is:
Chickenpox
Zoster
Kaposi varicelliform eruption
Explanation: Kaposi varicelliform eruption, or eczema
herpeticum, results from herpes simplex virus infection of
skin with altered immunity, usually from atopic dermatitis.
Kaposi varicelliform eruption is clinically distinguished from
zoster by its random distribution, which may involve many
dermatomes. Additionally, lesions of eczema herpeticum
are often isolated and are not grouped, as are the vesicles
of zoster. Similar eruptions have been described in
association with vaccinia virus (smallpox vaccination) and
coxsackievirus infections. (See Chapter 135 in Nelson
Textbook of Pediatrics, 17th ed.)
Eczema vaccinatum
Coxsackievirus infection
Question . 41. A 14-yr-old presents with acute-onset urticaria that has
gradually worsened over the past 10 days. Detailed history reveals no clues to
the possible etiology. Findings on physical examination are normal except for
urticaria. Which of the following diagnostic options is recommended?
Systematic elimination diets to determine a possible
ingestant cause
Allergy skin testing
Explanation: No laboratory test confirms or excludes the
diagnosis of urticaria. Allergy skin testing can be helpful in
sorting out causes of acute urticaria, especially when
supported by historical evidence. Drugs and foods are the
most common causes of acute urticaria. A skin biopsy is
indicated only if urticarial vasculitis is suspected. (See
Chapter 136 in Nelson Textbook of Pediatrics, 17th ed.)
Serum IgE and RAST
Skin biopsy
None of the above
Question . 59. A 14-yr-old girl, who has a long-standing seizure disorder for
which she takes phenytoin, develops fever and a urinary tract infection and is
prescribed trimethoprim-sulfamethoxazole. After 9 days of antibiotic treatment
she has recurrence of fever and develops confluent purpuric macules on her
face and trunk with erosive mucosal lesions of her mouth and conjunctivae. A
skin biopsy reveals 8% epidermal detachment. Which of the following best
describes this disorder?
Toxic shock syndrome
Anticonvulsant hypersensitivity syndrome
Allergy to sulfamethoxazole
Stevens-Johnson syndrome
Explanation: Stevens-Johnson syndrome is a blistering
mucocutaneous disorder induced by drugs, classically
sulfonamides. Epidermal detachment of less than 10%
suggests Stevens-Johnson syndrome. (See Chapter 139 in
Nelson Textbook of Pediatrics, 17th ed.)
Toxic epidermal necrolysis
Question . 60. All of the following may be manifestations of insect allergy
except:
Rhinitis and conjunctivitis
Asthma
Wheal and flare
Anaphylaxis
Uveitis
Explanation: Clinical findings in allergy caused by insects
are similar to those occurring with usual inhalant allergens
(e.g., rhinitis, conjunctivitis, asthma). Biting insects may
cause local reactions that do not involve IgE. Venom from
stinging insects causes IgE-mediated sensitivity that may
lead to urticaria and anaphylaxis. (See Chapter 140 in
Nelson Textbook of Pediatrics, 17th ed.)
Question . 65. A 7-yr-old boy was stung by an unidentified insect and within
minutes developed generalized urticaria, a repetitive cough, difficulty
breathing, and extreme dizziness. He was treated in the emergency
department with antihistamines, epinephrine, and corticosteroids. Which of the
following statements is accurate?
If skin tests to Hymenoptera venom are performed 1 wk
later and results are negative, he is not a candidate for
venom immunotherapy
Testing and venom immunotherapy cannot be undertaken
until the insect is identified
Venom immunotherapy could reduce the risk for a
severe anaphylaxis on a subsequent sting from more
than 50% to less than 3%
Explanation: Venom immunotherapy is highly effective in
reducing the risk of anaphylaxis. While venom
immunotherapy carries some risks for local and systemic
adverse effects, the benefits outweigh the risks for those at
high risk for anaphylaxis from a subsequent sting. Those at
high risk include any individual with positive results on skin
tests/RAST who experienced a systemic reaction to a sting
with symptoms beyond generalized skin rashes (e.g.,
respiratory, cardiovascular reactions) or those 17 yr of age
and older with systemic reactions confined to the skin
(generalized urticaria). Test results may be negative during
a refractory period in the weeks following the reaction, so
they should be repeated, along with RAST, after 4-6 wk if
they are negative initially. It is not necessary to know
exactly which insect caused the sting before proceeding
with testing and treatment. Although venom immunotherapy
may not be indicated for patients without identifiable IgE to
the venom, in cases of anaphylaxis proximate to a sting,
patients should be equipped with self-administered
epinephrine because the risk for a subsequent anaphylactic
reaction is increased. (See Chapter 140 in Nelson
Textbook of Pediatrics, 17th ed.)
If results of venom skin tests are negative, he does not
need to have self-administered epinephrine readily
available
Question . 66. A 15-yr-old with a history of seasonal hay fever now also has
itchy eyes, profuse tearing, and reddened and edematous conjunctivae. A
treatment option effective for the ocular symptoms would be:
Topical antihistamines
Topical decongestants
Topical mast cell stabilizers
Topical nonsteroidal anti-inflammatory drugs
All of the above?each is an effective secondary
treatment regimen for ocular allergies
Explanation: Allergic conjunctivitis in the patient with hay
fever generally responds well to treatment regimens
including topical application of antihistamines, topical
decongestants, topical mast cell stabilizers, and topical
nonsteroidal anti-inflammatory drugs. Children often
complain of stinging or burning with use of topical
ophthalmic preparations and usually prefer oral
antihistamines for allergic conjunctivitis. (See Chapter 141
in Nelson Textbook of Pediatrics, 17th ed.)
Question . 67. The patient described in Question 66 continues to have
symptoms. The most appropriate next step in management would be:
Combination therapy such as with an antihistamine and a
vasoconstrictive agent
Immunotherapy
Topical corticosteroids
Oral corticosteroids
All of the above?each is an effective tertiary treatment
regimen for ocular allergies
Explanation: Tertiary treatment of ocular allergy includes
topical, or rarely oral, corticosteroids. Local administration
of topical corticosteroids may be associated with increased
intraocular pressure, viral infections, and cataract
formation. Allergen immunotherapy can be very effective in
seasonal and perennial allergic conjunctivitis, especially
when associated with rhinitis. It can decrease the need for
oral or topical medications to control allergy symptoms.
(See Chapter 141 in Nelson Textbook of Pediatrics, 17th
ed.)
Question . 70. All of the following foods are characteristically associated with
allergy except:
Peanuts
Tree nuts
Legumes
Explanation: Peanuts, tree nuts, eggs, and seafood all are
characteristically associated with food allergies. (See
Chapter 142 in Nelson Textbook of Pediatrics, 17th ed.)
Eggs
Seafood
Question . 71. Because of a strong family history on both sides, the parents of
a newborn baby ask for guidance about preventing their child from developing
an allergy to peanuts. Which of the following approaches is recommended?
Begin and extend breast-feeding until age 2 yr, with
exclusion of peanuts from the mother's diet while breastfeeding
Begin and extend breast-feeding until age 2 yr, with the
mother ingesting gradually increasing amounts of creamy
peanut butter from 18-24 mo of age
Begin and continue breast-feeding as routinely
recommended, with the mother regularly ingesting small
amounts of peanuts but not introducing peanuts in the
child's diet until age 1 yr
Begin and continue breast-feeding as routinely
recommended, excluding peanuts from the mother's
diet while breast-feeding and from the child's diet until
age 3 yr
Explanation: There is no consensus on whether food
allergies can be prevented. However, several authorities
recommend delaying introduction of major food allergens to
infants from atopic families. Recommendations include
promotion of breast-feeding with maternal exclusion of
peanut and nut products from the mother's diet and delay in
introducing major allergenic foods: cow's milk until 1 yr of
age; egg until 18-24 mo of age, and peanuts, tree nuts, and
seafood until 3 yr of age. (See Chapter 142 in Nelson
Textbook of Pediatrics, 17th ed.)
Use only creamy peanut butter and not chunky peanut
butter or whole peanuts in the child's diet (after 1 yr of age)
Question . 73. Which of the following is the most definitive test for diagnosing
a food protein-induced enterocolitis?
Positive clinical history
Positive food challenge
Explanation: Unfortunately there are no laboratory studies
that help identify foods responsible for cell-mediated
reactions. Consequently, elimination diets followed by food
challenges are the only way to establish the diagnosis.
(See Chapter 142 in Nelson Textbook of Pediatrics, 17th
ed.)
Positive result on skin prick test
Positive RAST result
Quantitative IgE level