PART XIV Immunology

QUESTIONS
KHALID ALAARJI
1. A 9-month-old boy presented with recurrent attacks of diarrhea, thrush, and failure
to thrive shortly after birth. You suspect immune deficiency.
Of the following, the MOST common cause of this condition is
A. hyper-IgE syndrome
B. defect in phagocytic cells
C. deficiencies in T-cell function
D. defect in antibody production
E. defect in complement proteins

2. A 17-month-old girl presented with history of recurrent attacks of pneumonia since

the age of 8 months. You suspect a predominant B-cell defect.
Of the following, the BEST simple initial screening test is
A. IgA measurement
B. IgG measurement
C. IgM measurement
D. IgE measurement
E. isohemagglutinins titer

3. A very high serum concentrations of one or more immunoglobulin classes, suggest all
the following EXCEPT
A. HIV infection
B. chronic inflammation
C. intestinal lymphangiectasia
D. chronic granulomatous disease
E. autoimmune lymphoproliferative syndrome

4. A 3-year-old boy presented with recurrent attacks of pneumonia and otitis media
since the 1st birthday. Your diagnosis is X-linked agammaglobulinemia.
Of the following, the MOST likely offending organism is
A. CMV
B. Mycoplasma
C. Pneumocystis jiroveci
D. Staphylococcus aureus
E. Streptococcus pneumonia

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5. A 4.5-year-old boy presented with history of recurrent attack of secretary otitis
media and purulent nasal discharge, Haemophilus influenza revealed by culture of ear
discharge, on physical examination there is no tonsillar tissue and no palpable lymph
nodes.
Of the following, the MOST appropriate test to confirm the diagnosis is measurement
of
A. flow cytometry
B. IgA concenteration
C. isohemagglutinins titer
D. IgG and IgM concenteration
E. antibodies to antigens of routine immunizations

6. A 3-year-old girl presented with recurrent attacks of chest infection and frequent
episodes of chronic diarrhea, stool examination revealed Giardia lamblia and serum IgA
level was very low.
Regarding this condition, all the following are true EXCEPT
A. autosomal dominant inheritance
B. phenotypically normal blood B cells
C. administration of IVIG is not indicated
D. environmental factors may trigger the disease
E. it is associated with a celiac-like syndrome with dramatic response to gluten-
free diet

7. A 2-year-old boy presented with failure to thrive, neonatal hypocalcemic seizure, and
three attacks of sepsis. Examination reveals cleft palate and holo-systolic murmur.
Of the following, the genetic predisposition of this condition is
A. microdeletions of chromosome 22q11.2
B. interstitial deletion of the long arm of chromosome 15 (15q11-13)
C. presence of two copies of paternally derived chromosome 11p15.5
D. presence of mutated gene on long arm of chromosome 11 (11q22-23)
E. presence of abnormal gene, on the proximal arm of the X chromosome at
Xp11.22-11.23

8. Of the following, the findings that are MOST suggestive of DiGeorge syndrome are
A. cataract and a congenital heart defect
B. hypotonia and a congenital heart defect
C. cutis aplasia and a congenital heart defect
D. hypocalcemia and a congenital heart defect
E. mongoloid slant to the eyes and a congenital heart defect

9. The MOST appropriate method to correct the immune deficiency in complete

DiGeorge syndrome is

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 A. vaccination
B. administration of IVIG
C. judicious use of antibiotics
D. transplantation of thymic tissue
E. transplantation of hematopoietic stem cells

10. In addition to infection and bleeding, the MOST common cause of death in Wiskott-
Aldrich syndrome is
A. renal failure
B. graft versus host disease
C. protracted bloody diarrhea
D. EBV-associated malignancies
E. development of autoimmune disease

11. The treatment of choice for a 3-year-old boy with Wiskott-Aldrich syndrome is
A. splenectomy
B. use of killed vaccines
C. aggressive antibiotics
D. administration of IVIG
E. bone marrow or cord blood transplantation

12. All the following are features of ataxia-telangiectasia EXCEPT

A. hepatic manifestation
B. high incidence of malignancy
C. chronic sinopulmonary disease
D. oculocutaneous telangiectasias
E. variable humoral and cellular immunodeficiency

13. The earliest clinical feature of ataxia-telangiectasia is

A. ataxia
B. jaundice
C. inability to walk
D. ocular telangiectasias
E. cutaneous telangiectasias

14. Severe eosinophilia, defined as an absolute eosinophil count (AEC) more than
A. 750 cells/µL
B. 1,000 cells/µL
C. 1,500 cells/µL
D. 5,000 cells/µL
E. 7,500 cells/µL

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15. Which of the following statements is TRUE regarding diurnal variation of the
absolute eosinophil count (AEC)?
A. higher in the evening
B. lower in the afternoon
C. higher in the afternoon
D. lower in the early morning
E. higher in the early morning

16. Eosinophilia can be seen in all the following EXCEPT

A. scabies
B. urticaria
C. corticosteroid therapy
D. Hodgkin disease
E. hypersensitivity drug reactions

17. The following conditions can cause eosinophilia EXCEPT

A. malaria
B. filariasis
C. giardiasis
D. ascariasis
E. amebiasis

18. The highest white blood cells count is seen at

A. birth
B. 12 hour of life
C. 1 week of life
D. 1 year of life
E. adolescence

19. Severe neutropenia is defined as absolute neutrophil count (ANC) less than
A. 500/µL
B. 750/µL
C. 1000/µL
D. 1250/µL
E. 1500/µL

20. Chronic neutropenia by definition lasts longer than

A. 1 mo
B. 3 mo
C. 6 mo
D. 9 mo
E. 12 mo

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21. Chronic neutropenia may be induced by
A. adenovirus
B. enteroviruses
C. cytomegalovirus
D. influenzas A and B
E. respiratory syncytial virus

22. A 4-year-old boy presented with high fever, decreased appetite, aphthous
stomatitis, and cellulitis of the right calf muscle. His absolute neutrophil count (ANC)
was 600/µL.
The MOST likely organisms causing this condition are
A. Staphylococcus aureus and Histoplsmosis
B. Staphylococcus aureus and rickettsial pox
C. Staphylococcus aureus and Cytomegalovirus
D. Staphylococcus aureus and Pneumocystis carinii
E. Staphylococcus aureus and gram-negative bacteria

23. Recurrent infections with neutropenia are a distinctive feature of

A. Pompe disease
B. Hurler disease
C. Gaucher disease
D. Glycogen storage disease Ia (GSDIa)
E. Glycogen storage disease Ib (GSDIb)

24. All the following drugs can induce neutropenia EXCEPT

A. penicillin
B. tetracycline
C. phenobarbital
D. phenothiazine
E. chloramphenicol

25. A 15-year-old boy with rheumatoid arthritis, on quinine for 6 months, presented
with fever, aphthous stomatitis, and fatigue for the last 5 days. His absolute neutrophil
count (ANC) was 700/µL.
The MOST next appropriate therapeutic measure to be done when quinine withdrawal
fails to improve neutropenia is
A. administration of IVIG
B. aggressive use of antibiotics
C. transplantation of hematopoietic stem cells
D. administration of pulse methylprednisolone
E. administration of recombinant human granulocyte colony-stimulating factor

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26. A 9-year-old boy with acute lymphoblastic leukemia on chemotherapy, presented
with fever, aphthous stomatitis, and fatigue for the last 5 days. His absolute neutrophil
count (ANC) was 450/µL and hemoglobin level was 10gm/dl.
The NEXT appropriate therapeutic measure is
A. administration of IVIG
B. transplantation of hematopoietic stem cells
C. administration of pulse methylprednisolone
D. aggressive use of broad-spectrum antibiotics
E. administration of recombinant human granulocyte colony-stimulating factor

27. A 13-month-old girl presented with failure to thrive, repeated chest infection, and
fatty offensive diarrhea. Hemoglobin level 8.8gm/dl, platelate count 150/mm3, white
blood cell count 3.500/mm3, with absolute neutrophil count (ANC) 500/µL.
Of the following, the MOST likely diagnosis is
A. Kostmann disease
B. cyclic neutropenia
C. drug-induced neutropenia
D. acute lymphoblastic leukemia
E. Shwachman-Diamond syndrome

28. Leukemoid reactions (WBC count > 50,000/µL) are characterized by abundant
A. blasts
B. band form
C. myelocytes
D. promyelocytes
E. metamyelocytes

29. Leukemoid reactions (WBC count >50,000/µL) are caused by all the following
EXCEPT
A. shigellosis
B. septicemia
C. salmonellosis
D. chronic granulomatous disease
E. leukocyte adhesion defect with infection

30. Shifting to the left (proportion of immature neutrophil cells >5%) may occasionally
be caused by all the following EXCEPT
A. burns
B. trauma
C. hemorrhage
D. acute hemolysis
E. megaloblastic anemia

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31. A 15-year-old boy presented with high fever, lymphadenopathy,
hepatosplenomegaly, recurrent skin infections, silvery hair, and photophobia. Last year,
he developed ataxia.
The MOST characteristic finding in this condition is
A. neutropenia
B. thrombocytopenia
C. prolonged bleeding time
D. prolonged prothrombine time
E. prolonged partial prothrombine time

32. In patient with Chédiak-Higashi syndrome, the only curative therapy is

hematopoietic stem cell transplantation which correct all the following EXCEPT
A. neuropathy
B. immunologic function
C. hematopoietic function
D. natural killer cell deficiency
E. conversion to the accelerated phase

33. A 3-year-old boy presented with recurrent subcutaneous abscesses, lymphadenitis,

osteomyelitis, and family history of recurrent infections.
The hallmark of this condition is
A. hypocalcemia
B. atopic dermatitis
C. thrombocytopenia
D. granuloma formation
E. prolonged bleeding time

34. The MOST common pathogen in chronic granulomatous disease (CGD) is

A. S. aureus
B. Aspergillus
C. Salmonella
D. Mycobacterium
E. Candida albicans

35. The diagnosis of chronic granulomatous disease CGD is MOST often made by
A. DNA analysis
B. flow cytometry
C. neutrophil G6PD assay
D. erythrocyte G6PD assay
E. nitroblue tetrazolium dye test

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36. To reduce the number of bacterial infection in patients with chronic granulomatous
disease (CGD), they should be given daily
A. penicillin
B. cloxacillin
C. interferon-γ
D. itraconazole
E. trimethoprim-sulfamethoxazole

37. In chronic granulomatous disease (CGD), the best method to detect and follow up
deep-seated infection is
A. ESR
B. blood culture
C. WBC count
D. C-reactive protein
E. immature to mature neutrophil ratio

38. All the following are characteristic in properdin deficiency EXCEPT

A. dermal vasculitis
B. male predominance
C. systemic lupus erythematosus
D. susceptibility to N. meningitidis meningitis
E. normal serum hemolytic complement activity

39. All the following matching about genetic deficiencies of plasma complement
components and associated clinical findings are true EXCEPT
A. C4 --------------------- discoid lupus erythematosus
B. C1q------------------ systemic lupus erythematosus
C. C1 INH ---------------------- hereditary angioedema
D. factor H---- atypical hemolytic-uremic syndrome
E. properdin --------------- N. meningitidis meningitis

40. The complement component of both the classical and alternative pathways is
A. C2
B. C3
C. C4
D. C5
E. C6

41. All the following conditions can induce lymphopenia EXCEPT

A. sepsis
B. typhoid
C. brucellosis

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D. corticosteroid use
E. cartilage-hair hypoplasia

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PART XIV Immunology
ANSWERS
KHALID ALAARJI
1.(C). Children with defects in antibody production, phagocytic cells, or complement
proteins have recurrent infections with encapsulated bacteria and may grow and
develop normally despite their recurring infections, unless they develop bronchiectasis
from repeated lower respiratory tract bacterial infections or persistent enteroviral
infections of the central nervous system. By contrast, patients with deficiencies in T-cell
function usually develop opportunistic infections or serious illnesses from common
viral agents early in life, and they fail to thrive.
2.(A). If the IgA level is normal, selective IgA deficiency, which is the most common B-
cell defect, is excluded, as are most of the permanent types of
hypogammaglobulinemia, as IgA is usually very low or absent in those conditions. If IgA
is low, IgG and IgM should also be measured.
3.(C). There is a possible loss of immunoglobulins through the urinary or
gastrointestinal tracts (nephrotic syndrome, protein-losing enteropathies, intestinal
lymphangiectasia).
4.(E). They acquire infections with extracellular pyogenic organisms, such as
Streptococcus pneumoniae and Haemophilus influenzae, unless they are given
prophylactic antibiotics or immunoglobulin therapy.
5.(A). The diagnosis of X-linked agammaglobulinemia (XLA) should be suspected if
lymphoid hypoplasia is found on physical examination (minimal or no tonsillar tissue
and no palpable lymph nodes). Flow cytometry is an important test to demonstrate the
absence of circulating B cells, which will distinguish this disorder from common variable
immunodeficiency, the hyper-IgM syndrome, and transient hypogammaglobulinemia of
infancy.
6.(E). An isolated absence or near absence (<10 mg/dL) of serum and secretory IgA is
the most common well-defined immunodeficiency disorder. IgA deficiency is associated
with a celiac-like syndrome, which may or may not respond to a gluten-free diet.
7.(A). A. DiGeorge syndrome, B. Prader-Willi syndrome, C. Beckwith-Wiedemann
syndrome, D. Wiskott-Aldrich syndrome, and E. ataxia-telangiectasia.
8.(D). Digeroge syndrome; associated with congenital heart disease (conotruncal, atrial,
and ventricular septal defects). The diagnosis is often first suggested by hypocalcemic
seizures during the neonatal period.
9.(D).
10.(D). Wiskott-Aldrich syndrome, an X-linked recessive syndrome, is characterized by
atopic dermatitis, thrombocytopenic purpura with normal-appearing megakaryocytes
but small defective platelets, and undue susceptibility to infection. Survival beyond the

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teens is rare; infections, bleeding, and EBV-associated malignancies are major causes of
death.
11.(E). Treatment; Good supportive care includes appropriate nutrition, routine IVIG,
use of killed vaccines, aggressive management of eczema and associated cutaneous
infections, platelet transfusion for serious bleeding episodes, splenectomy if a
transplant is not going to be done, and high-dose IVIG with systemic steroids for
autoimmune complications. Bone marrow or cord blood transplantation is the
treatment of choice and is usually curative.
12.(A). The most prominent clinical features are progressive cerebellar ataxia,
oculocutaneous telangiectasias, chronic sinopulmonary disease, a high incidence of
malignancy, and variable humoral and cellular immunodeficiency.
13.(A). Ataxia typically becomes evident soon after these children begin to walk and
progresses until they are confined to a wheelchair, usually by the age of 10-12 yr. The
telangiectasias begin to develop at 3-6 yr of age.
14.(D). Moderate (AEC 1,500-5,000 cells/µL) and severe (AEC >5,000 cells/µL).
15.(E). The absolute eosinophil count (AEC) is calculated as the white blood cell
count/µL × percent of eosinophils, it is usually <450 cells/µL and varies diurnally, with
eosinophil numbers higher in the early morning and diminishing as endogenous
glucocorticoid levels rise.
16.(C). Exogenous and endogenous glucocorticoid suppresses absolute eosinophil
count.
17.(C). Eosinophilia are caused by tissue-invasive as helminth infections; ascariasis,
filariasis, amebiasis, malaria, and scabies whereas entrobius vermicularis and Giardia
lamblia are solely intraluminal in gastrointestinal tract.
18.(A). For newborns, the mean WBC count at birth is high, followed by a rapid fall
beginning at 12 hr through the 1st wk of life. Thereafter, values are stable until 1 yr of
age, after which a slow steady decline in the WBC count continues throughout
childhood until adult values are reached during adolescence.
19.(A). Mild neutropenia, is an absolute neutrophil count (ANC) of 1,000-1,500/µL.
Moderate neutropenia, is an absolute neutrophil count (ANC) of 500- 1,000/µL. Severe
neutropenia, is an absolute neutrophil count (ANC) <500/µL.
20.(B). Chronic neutropenia by definition lasts longer than 3 months and arises from
reduced production, increased destruction or excessive splenic sequestration of
neutrophils.
21.(C). Chronic neutropenia often accompanies infection with Epstein-Barr virus,
cytomegalovirus, or HIV while the other distracters cause acute neutropenia.
22.(E). Infections commonly associated with neutropenia include cellulitis, furunculosis,
perirectal inflammation, colitis, sinusitis, and otitis media, as well as more serious
infections such as pneumonia, deep tissue abscess, and sepsis.
23.(E). Recurrent infections with neutropenia are a distinctive feature of glycogen
storage disease (GSD) type Ib. As in classic von Gierke disease (GSDIa), glycogen storage
in GSDIb causes massive hepatomegaly and severe growth retardation.

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24.(B). The process of neutropenia likely arises from effects of drugs, such as
propylthiouracil or penicillin, that act as haptens to stimulate antibody formation, or
drugs, such as quinine, that induce immune complex formation. Late-onset
neutropenia can occur after rituximab therapy. Idiosyncratic reactions, for example to
chloramphenicol, are unpredictable with regard to dose or duration of use.
Hypersensitivity reactions are rare and may involve arene oxide metabolites of
aromatic anticonvulsants (phenytoin or phenobarbital).
25.(E).
26.(D). A decline in the WBC count typically occurs 7-10 days after administration of
the anticancer drug and may persist for 1-2 wk. Patients with chemotherapy/ radiation-
related neutropenia and fever must be treated aggressively with broad-spectrum
antibiotics.
27.(E). Shwachman-Diamond syndrome (SDS) is an autosomal recessive disorder
classically characterized by neutropenia, pancreatic insufficiency, and short stature
with skeletal abnormalities. The initial symptoms are usually steatorrhea and failure to
thrive because of malabsorption, which usually develops by 4 mo of age, although the
gastrointestinal symptoms may be subtle in some patients and go unrecognized.
Virtually all patients with SDS have neutropenia, with the ANC periodically <1000/µL.
28.(B). Leukemoid reactions are usually neutrophilic, and unlike true leukemia, show
only small proportions of immature myeloid cells, consisting primarily of band forms,
occasional metamyelocytes, and progressively rarer myelocytes, promyelocytes, and
blasts.
29.(D).
30.(E). Higher degrees of left shift with more immature neutrophil precursors are
indicative of serious bacterial infections and may be a direct sign of depletion of the
bone marrow reserve pool of neutrophils. Marked left shift may occasionally be
encountered with trauma, burns, surgery, acute hemolysis, or hemorrhage.
31.(C). Patients with Chédiak-Higashi syndrome (CHS) have prolonged bleeding times
with normal platelet counts, resulting from impaired platelet aggregation associated
with a deficiency of the dense granules containing adenosine diphosphate and
serotonin.
32.(A).
33.(D). Granuloma formation and inflammatory processes are a hallmark of chronic
granulomatous disease CGD and may be the presenting symptoms that prompt testing
for CGD if they cause pyloric outlet obstruction, bladder outlet or ureter obstruction, or
rectal fistulas and granulomatous colitis simulating Crohn disease.
34.(A). The most common pathogen is S. aureus, although any catalase-positive
microorganism may be involved.
35.(B). The diagnosis is most often made by performing flow cytometry using
dihydrorhodamine 123 (DHR) to measure oxidant production through its increased
fluorescence when oxidized by H2O2.

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36.(E). A placebo-controlled study found that interferon-γ significantly reduces the
number of hospitalizations and serious infections. Itraconazole administered
prophylactically reduces the frequency of fungal infections.
37.(A). The erythrocyte sedimentation rate (ESR) can be quite helpful. If the child does
not have a deep-seated infection, the ESR will be normal or will normalize within
several days with standard management. However, if it does not, a search for deep
tissues is warranted, as is consideration of empiric antibiotics.
38.(C). Typical discoid lupus erythematosus is common.
39.(A). Systemic lupus erythematosus (SLE) is very common in C4 deficiency.
40. (B).
41.(C). Chronic bacterial infections such as tuberculosis and brucellosis may lead to a
sustained lymphocytosis.

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PART XV Allergic Disorders
QUESTIONS
HASANEIN GHALI
1. The recognition of allergic rhinitis as a major chronic respiratory disease of children
rests largely on all the following features EXCEPT
A. high prevalence
B. effect on quality of life
C. school performance
D. other comorbidities
E. presentation in infancy

2. The diagnosis of allergic rhinitis is established by the time the child reaches age of
A. 2 yr
B. 4 yr
C. 6 yr
D. 8 yr
E. 10 yr

3. A significant risk factor in the development of allergic rhinitis in children is

A. positive family history
B. serum IgA higher than 100 iu/ml
C. alcoholic mother
D. diabetic mother
E. father with renal disease

4. The critical period for the development of allergic rhinitis exists when the genetically
susceptible individual at greatest risk of sensitization in
A. early adolescence
B. late adolescence
C. school age
D. toddlerhood
E. early infancy

5. The occurrence of 3 or more episodes of rhinorrhea in the first year of life is

associated with allergic rhinitis (AR) at age of
A. 11 yr
B. 9 yr
C. 7 yr
D. 5 yr

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 E. 3 yr

6. Early introduction of all the following decrease the risk of asthma and allergic rhinitis
EXCEPT
A. rye
B. fish
C. egg
D. meat
E. wheat

7. The exposure to which of the following early in childhood protects against the
development of atopy
A. smoking
B. alcohol
C. rodents
D. dogs
E. indoor allergen

8. The main differentiating item between intermittent versus persistent allergic rhinitis
is
A. school performance
B. troublesome symptoms
C. daily activities
D. number of attacks per week
E. sleep pattern

9. Allergic shiners represent

A. an upward rubbing of the nose with an open palm
B. continuous open- mouth breathing
C. dark circles under the eyes
D. transverse crease of the nose
E. conjunctival edema and itching

10. Allergic rhinitis may be complicated by secondary bacterial infection as sinusitis.

Of the following, the MOST likely clue to infection is
A. hyperemia
B. swollen turbinates
C. thick nasal secretions
D. bluish mucus membranes
E. edematous mucus membranes

11. Causes of hormonal rhinitis include all the following EXCEPT

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 A. hypothyroidism
B. exercise
C. cancer
D. vaculitides
E. systemic lupus erythematosis

12. The reported rate of remission of allergic rhinitis among children is about
A. 1-10%
B. 11-20%
C. 21-30%
D. 31-40%
E. 41-50%

13. What percentage of allergic rhinitis patients has allergic conjunctivitis?

A. >30%
B. >40%
C. >50%
D. >60%
E. >70%

14. The percentage of allergic rhinitis in asthmatic patients is 78%, while the
percentage of asthma in patients with allergic rhinitis is
A. 18%
B. 28%
C. 38%
D. 48%
E. 58%

15. To avoid false-negative skin test results in atopic host, most sedating antihistamine
should be withheld for 3-4 days, and nonsedating antihistamines for 5-7 days, while
montelukast should be withheld for
A. 1 day
B. 3 day
C. 5 day
D. 7 day
E. 9 day

16. The best method for detection of allergen-specific IgE is

A. skin tests
B. serum immune assay for specific IgE
C. nasal smear study
D. eosinophilia in blood film

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 E. total serum IgE concentration

17. Second generation antihistamines are preferable to first generation antihistamines

because they have
A. longer action
B. less sedation
C. more potency
D. more palatable effect
E. more shelf life

18. The MOST effective therapy for persistent allergic rhinitis is

A. oral desloratadine
B. oral montelukast
C. subcutaneous omalizumab
D. nasal budesonide spray
E. nasal ipratropium bromide spray

19. Approximately 80% of all asthmatic patients report disease onset prior to the age of
A. 2 yr
B. 4 yr
C. 6 yr
D. 8 yr
E. 10 yr

20. Of the following, the major risk factor for persistent asthma is
A. eczema
B. allergic rhinitis
C. wheezing apart from colds
D. food allergen sensitization
E. ≥4% peripheral blood eosinophils

21. Of the following, the strongest identifiable factor for the persistence of childhood
asthma is
A. allergy
B. male gender
C. low birth weight
D. parental asthma
E. lower respiratory tract infection

22. The following actions may help reduce the likelihood of asthma development
EXCEPT
A. healthy diet

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 B. immunization
C. active lifestyle
D. avoidance of tobacco smoking
E. prolonged breastfeeding > 4 months

23. Recurrent coughing and wheezing occurs in 35% of preschool-age children.

Those who continue to have persistent asthma into later childhood are approximately
A. one-fifth
B. one-fourth
C. one-third
D. one-half
E. two-thirds

24. Indications of severe exacerbation of asthma include the following EXCEPT

A. breathlessness
B. accessory muscles use
C. labored breath
D. PEF or FEV1 value <70% of personal best values
E. mental status changes

25. Spirometry is a helpful objective measure of airflow limitation; it depends on

patient’s ability to properly perform a full, forceful, and prolonged expiratory
maneuver.
Spirometry usually feasible in children
A. ≥4 yr of age
B. ≥6 yr of age
C. ≥8 yr of age
D. ≥10 yr of age
E. ≥12 yr of age

26. The MOST vital initial treatment in the management of severe asthma
exacerbations is
A. supplemental oxygen
B. inhaled β -agonist
C. intramuscular injection of epinephrine
D. inhaled ipratropium
E. intramuscular injection of β-agonist

27. A patient with exacerbation of asthma being handled and managed in the ER may
be discharged home if all the following parameters are met EXCEPT
A. normal physical activity
B. PEF >70% of predicted or personal best

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 C. exercise tolerance
D. oxygen saturation >92% while the patient is breathing room air for 4 hr
E. no more use of accessory muscles

28. All the following are considered as risk factors for asthma morbidity and mortality
EXCEPT
A. poverty
B. air pollution exposure
C. female gender
D. poor response to systemic steroid therapy
E. sudden asphyxia episodes

29. The best ‘‘rescue’’ medication in the treatment of acute asthma symptoms is
A. oral SABA
B. inhaled SABA
C. oral corticosteroid
D. inhaled ipratropium
E. inhaled corticosteroid

30. The best treatment option for step -6- severe persistent asthma in a 6-year-old boy
is
A. medium dose inhaled corticosteroids with long acting B-agonists
B. high dose inhaled corticosteroids with leukotriene receptor antagonist
C. low dose inhaled corticosteroids with leukotriene receptor antagonist
D. high dose inhaled corticosteroids with long acting B-agonist and oral
corticosteroids
E. high dose inhaled corticosteroids with long acting B-agonist and oral
corticosteroidsalong with omalizumab therapy

31. A common finding of chest radiograph in a child with asthma is

A. peribronchial thickening
B. atelectasis
C. pneumothorax
D. bronchiectasis
E. pneumomediastinum

32. Bronchodilator response to an inhaled β-agonist (e.g., albuterol) is greater in

asthmatic patients than nonasthmatic persons, the rate of improvement in FEV1
consistent with asthma is
A. ≥10%
B. ≥12%
C. ≥14%

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 D. ≥16%
E. ≥18%

33. The diurnal variation in Peak Expiratory Flow (PEF) that is consistent with asthma is
more than
A. 10%
B. 20%
C. 30%
D. 40%
E. 50%

34. In emergency department, the patient may be discharged to home if there is

symptomatic improvement, normal physical findings, PEF >70% of predicted or
personal best, and oxygen saturation >92% in room air for 4hr.
Of the following, the MOST likely discharge medication used is
A. inhaled β-agonist only
B. oral corticosteroid only
C. inhaled corticosteroid only
D. inhaled β-agonist plus oral corticosteroid
E. oral β-agonist plus inhaled corticosteroid

35. All the following are a recognized features of a ‘’well-controlled’’ asthma in a 7-

year-old boy EXCEPT
A. FEV1:FVC ratio >80%
B. FEV1of >80% of predicted
C. daytime symptoms ≤2 days/wk
D. ≥4 exacerbations in the past year
E. need a rescue bronchodilator ≤2 days/wk

36. Use of a stoplight zone system (green, yellow, red) tailored to each child’s “personal
best” PEF values can optimize effectiveness and interest.
Of the following, the PEF value in yellow zone is
A. <10%
B. 10-30%
C. 30-50%
D. 50-80%
E. 80-100%

37. All levels of persistent asthma should be treated with daily medications to improve
long-term control.
All the following are long-term controller medications EXCEPT
A. albuterol

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 B. omalizumab
C. montaleukast
D. inhaled corticosteroid
E. sustained-release theophylline

38. Adverse effects of frequently administered β-agonist therapy in asthma include all
the following EXCEPT
A. tremor
B. irritability
C. tachycardia
D. hypokalemia
E. mouth dryness

39. Atopic dermatitis affects many children worldwide, the exact percentage
approximating
A. 5-10%
B. 10-30%
C. 30-50%
D. 50-70%
E. 70-90%

40. The hallmark of atopic dermatitis is

A. intense pruritus
B. cutaneous reactivity
C. lichenification
D. fibrotic papules
E. dry skin

41. Atopic dermatitis typically begins in

A. infancy
B. toddlerhood
C. preschooler age
D. school age
E. adolescence

42. The cardinal feature of atopic dermatitis is

A. skin rash
B. lichenification
C. fibrotic papules
D. intense pruritus
E. dry skin
43. All the following are triggers for pruritus in atopic dermatitis EXCEPT

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 A. grass
B. tree nuts
C. high humidity
D. herpes simplex
E. excessive sweating

44. In infancy, atopic dermatitis is usually acute and spares the

A. extensor surfaces of the extremities
B. forehead
C. scalp
D. diaper area
E. cheeks

45. Older children with chronic atopic dermatitis have lichenification and a tendency to
be localized to
A. flexural folds of the extremities
B. forehead
C. scalp
D. diaper area
E. cheeks

46. The following are the major clinical features of atopic dermatitis (AD) EXCEPT
A. pruritus
B. family history
C. relapsing dermatitis
D. facial eczema in infants
E. extensor eczema in adolescents

47. A high index of suspicion of which of the following conditions is to be undertaken in

a patient with atopic dermatitis and failure to thrive
A. Wiscott-Aldrich syndrome
B. severe combined immune deficiency
C. Histiocytosis
D. hyper IgE syndrome
E. chronic granulomatous disease

48. One of the following metabolic conditions is not deemed in the differential
diagnosis of atopic dermatitis
A. zinc deficiency
B. pyridoxine deficiency
C. cobalamin deficiency
D. niacin deficiency

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 E. phenylketonuria

49. The first line therapy of atopic dermatitis (AD) is

A. moisturizers
B. cyclosporine
C. antihistamine
D. tar preparations
E. topical corticosteroids

50. Prevention of atopic dermatitis in infancy includes the following measures EXCEPT
A. breast feeding
B. feeding with a hypoallergenic hydrolyzed formula
C. use of probiotics
D. elimination of implicated food allergen from the mother diet
E. use of special type napkins

51. Which of the following vitamin deficiencies often accompanies severe atopic
dermatitis?
A. E
B. C
C. A
D. D
E. B12

52. Predictive factors of a poor prognosis for atopic dermatitis includes all the following
EXCEPT
A. widespread atopic dermatitis in childhood
B. filaggrin gene null mutations
C. concomitant allergic rhinitis and asthma
D. family history of atopic dermatitis in parents or siblings
E. late age at onset of atopic dermatitis

53. The best choice of antibiotic in treating localized impetiginous lesions in patients
with atopic dermatitis is
A. oral erythromycin
B. oral cephalexin
C. topical mupirocin
D. topical ampicillin
E. topical gentamycin

54. IgE anti-bodies against Malassezia furfur have been found in patients with atopic
dermatitis of

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 A. head and neck
B. hands and arms
C. legs and feet
D. upper chest
E. lower abdomen

55. One of the following statements is TRUE regarding skin tests in identifying food
allergies in patients with atopic dermatitis
A. negative skin and blood test results for allergen-specific ige have a low
predictive value for excluding suspected allergens
B. positive results of skin or blood tests using foods often correlate with clinical
symptoms and no need to be confirmed with controlled food challenges
C. extensive elimination diets are commonly required
D. even with multiple majority of patients react to more than 3 foods
E. potential allergens can be identified by a careful history and performing
selective skin prick tests or in vitro blood testing for allergen- specific IgE

56. One of the following medications used in treatment of atopic dermatitis should be
discontinued after failure to achieve good results within 4-6 weeks
A. methotrexate
B. azathioprine
C. cyclosporine
D. mycophenolate mofetil
E. omalizumab

57. Systemic corticosteroids are rarely indicated in the treatment of atopic dermatitis
because
A. toxic side effects after long term use
B. rebound flare after therapy discontinuation
C. cannot do more than what topical can
D. tapering is required even after short term use
E. antimetabolites can do better in modifying disease course

58. The least potent topical steroid used in treatment of atopic dermatitis is
A. fluticasone
B. desonide
C. betamethasone dipropionate
D. hydrocortisone
E. clobetasol propionate

59. Which topical steroid is preferable to use for treatment of atopic dermatitis in the
face?

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 A. fluticasone 0.005%
B. desonide 05%
C. betamethasone dipropionate 0.05%
D. hydrocortisone 1%
E. clobetasol propionate 0.05%

60. In atopic dermatitis, the presence of punched out erosions, vesicles, and infected
skin lesions that fail to respond to oral antibiotics suggests infection with
A. Herpes zoster
B. Herpes simplex
C. cutaneous warts
D. Trichophyton rubrum
E. Molluscum contagiosum

61. Exfoliative dermatitis may develop in patients with atopic dermatitis and extensive
skin involvement, usually caused by inappropriate therapy or superinfection with
A. E. coli
B. Herpes zoster
C. Herpes simplex
D. Streptococcal pyogen
E. Trichophyton rubrum

62. Reactions to stinging and biting insects may cause

A. a limited lesion confined to the primary site
B. a pronounced localized reaction
C. a pronounced systemic reaction due to immediate hypersensitivity
D. a pronounced systemic reaction due to delayed hypersensitivity
E. no reaction

63. Systemic allergic responses to insects are attributed to IgE antibody response
caused primarily by
A. ticks
B. spiders
C. hymenoptera
D. scorpions
E. triatoma (kissing bug)

64. The MOST notorious stinging insect is

A. honeybee
B. harvester ants
C. hornet
D. bumblebee

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 E. yellow jackets

65. Delayed/Late reaction to stinging venom may precipitate all the following EXCEPT
A. vasculitis
B. serum sickness
C. encephalopathy
D. hemolytic anemia
E. nephrotic syndrome

66. The MOST reliable diagnostic modality for detection of venom-specific IgE is
A. in vitro serum assay for venom-specific IgE
B. skin test
C. serum tryptase level
D. plasma histamine
E. radioallergosorbent assay

67. In the presence of convincing history of a severe systemic reaction, the next
diagnostic step for those with initially negative skin test is
A. in vitro serum assay for venom-specific IgE
B. repeat skin test after 4-6 weeks
C. serum tryptase level
D. plasma histamine
E. basophil histamine release test

68. Sting sites rarely become infected possibly owing to

A. cleansing the area immediately after insect
B. the over use of antibacterial creams for the area
C. venom constituents have antibacterial action
D. vasospasm after stinging impedes bacterial invasion
E. venom immunotherapy has antibacterial properties

69. Anaphylactic reactions after a Hymenoptera sting are treated exactly like
anaphylaxis from any cause.
Of the following, the drug of choice is
A. oxygen
B. epinephrine
C. antihistamines
D. corticosteroids
E. intravenous fluids

70. A TRUE indication of venom immunotherapy in a six-year-old boy is

A. large local reaction with positive skin test and positive in vitro test

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 B. generalized cutaneous reaction with positive skin test and negative in vitro test
C. generalized cutaneous reaction with positive in vitro test and negative skin test
D. systemic reaction with positive skin test and negative in vitro test
E. systemic reaction with negative skin test and negative in vitro test

71. Skeeter syndrome is a large local reaction to stinging and biting insects.
Of the following, the TRUE statement is
A. Ig E mediated response
B. usually occurs in older children
C. usually followed by anaphylaxis
D. mosquito is the responsible agent
E. misdiagnosed as erythema nodosum

72. The eye is a common target of allergic disorders because of its marked vascularity
and direct contact with allergens in the environment.
Of the following, the MOST immunologically active tissue of the external eye is
A. iris
B. sclera
C. eyelids
D. eyelashes
E. conjunctiva

73. The MOST common hypersensitivity response of the eye is

A. allergic conjunctivitis
B. vernal keratoconjunctivitis
C. atopic keratoconjunctivitis
D. giant papillary conjunctivitis
E. contact allergy

74. The MOST sight-threatening type of ocular allergy is

A. contact allergy
B. vernal keratoconjunctivitis
C. giant papillary conjunctivitis
D. seasonal allergic conjunctivitis
E. perennial allergic conjunctivitis

75. The MOST common presenting complain of allergic conjunctivitis is

A. pain
B. itching
C. redness
D. blurred vision
E. purulent discharge

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76. Topical ophthalmic medications usually cause
A. contact allergy
B. allergic conjunctivitis
C. vernal keratoconjunctivitis
D. atopic keratoconjunctivitis
E. giant papillary conjunctivitis

77. Contact lenses are associated with

A. contact allergy
B. allergic conjunctivitis
C. vernal keratoconjunctivitis
D. atopic keratoconjunctivitis
E. giant papillary conjunctivitis

78. Conjunctivitis medicamentosa is a consequence of chronic use of

A. antihistamines
B. steroids
C. decongestants
D. anti-inflammatory
E. mast cell stabilizers

79. Non IgE mediated urticaria can be caused by

A. milk
B. hymenoptera
C. Epstein-barr virus
D. latex
E. blood

80. Chronic urticaria may be caused by

A. latex
B. peanut
C. IV immunoglobulin
D. streptococcal pharyngitis
E. systemic lupus erythematosus

81. The drug of choice for cold-induced urticaria is

A. loratadine
B. epinephrine IM
C. cyproheptadine
D. diphenhydramine
E. oral corticosteroid

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82. Acute urticaria is a self-limited illness requiring little treatment. All the following
can be used EXCEPT
A. loratadine
B. hydroxyzine
C. epinephrine IM
D. H2 antihistamines
E. oral corticosteroid

83. Skin biopsy for diagnosis of possible urticarial vasculitis is recommended for
A. urticarial lesions that persist at different locations for >24 hr
B. those with non- pigmented or non-purpuric components
C. those that burn more than itch
D. those with associated collagen vascular diseases
E. those appeared after peanuts ingestion

84. The differential diagnosis of chronic urticaria includes the following EXCEPT
A. cutaneous mastocytosis
B. systemic mastocytosis
C. complement- mediated mast cell degranulation in malignancies
D. cutaneous blistering disorders
E. dermatographism

85. The MOST common childhood symptoms of hereditary angioedema is

A. cutaneous non-pitting but pruritic edema associated with urticaria
B. cutaneous pitting but non-pruritic edema not associated with urticaria
C. cutaneous pitting and pruritic edema associated with urticaria
D. cutaneous non-pitting and non-pruritic edema associated with urticaria
E. cutaneous non-pitting and non-pruritic edema not associated with urticaria

86. All the following factors can amplify anaphylaxis EXCEPT

A. exercise
B. vaccination
C. upper respiratory tract infection
D. fever
E. emotional stress

87. One of the principal pathologic features in fatal anaphylaxis is

A. acute bronchial obstruction
B. hypotension
C. behavioral change
D. abdominal pain
E. vomiting

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88. Sudden collapse in the presence of cutaneous symptoms in a previously healthy
child should raise suspicion of
A. vasovagal collapse
B. anaphylaxis
C. aspiration
D. pulmonary embolism
E. seizure disorder

89. Cutaneous symptoms may be absent in anaphylaxis in

A. 5%
B. 10%
C. 20%
D. 30%
E. 40%

90. The best diagnostic test for anaphylaxis in a child exposed to an allergen 3 hours
before arrival to hospital is
A. plasma histamine
B. skin test
C. radioallergosorbent assay
D. plasma tryptase
E. immunoCAP IgE test

91. After institution of treatment of anaphylaxis, the patient should be monitored in

the emergency room for at least
A. 1 hour
B. 4 hours
C. 6 hours
D. 12 hours
E. 24 hours

92. In cases of food-associated exercise-induced anaphylaxis, the parents are advised

that children must not take exercise after ingestion of the triggering food for
A. 2-3 hours
B. 4-6 hours
C. 8-12 hours
D. 13-18 hours
E. 19-24 hours

93. All the following medications are encountered to cause serum sickness EXCEPT
A. ciprofloxacin
B. meropenem

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 C. rituximab
D. trimethoprim sulfate
E. carbamazepine

94. Once the offending agent causing serum sickness is discontinued, the symptoms
resolve spontaneously within
A. 1-4 days
B. 1-4 weeks
C. 5-8 weeks
D. 9-12 weeks
E. 13-18 weeks

95. Which of the following results of investigations is unlikely in serum sickness?

A. elevated erythrocyte sedimentation rate
B. thrombocytosis
C. reduced C3 activity
D. negative microbial cultures
E. microscopic hematuria

96. Skin biopsy is not usually necessary for confirming the diagnosis of serum sickness
because
A. the complement C3 and C4 yield better results
B. the clinical examination is enough for the diagnosis
C. skin test is superior to biopsy
D. the histopathological findings are not specific
E. it may be complicated by local infection

97. All the following are complications of serum sickness EXCEPT

A. carditis
B. glomerulonephritis
C. Guillain-barre syndrome
D. peripheral neuritis
E. colitis

98. All the following are symptoms of acute IgE mediated food allergy EXCEPT
A. urticaria
B. pruritis
C. abdominal pain
D. diarrhea
E. wheezing

99. One of the following presentations is a non-IgE mediated food allergy

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 A. Heiner syndrome
B. gastrointestinal anaphylaxis
C. rhino conjunctivitis
D. oral allergy syndrome
E. angioedema

100. The onset of presentation of food allergy is late in

A. hen’s egg white
B. peanuts
C. shellfish
D. soybean
E. cow’s milk

101. Food protein–induced enterocolitis syndrome is characterized by all the following

EXCEPT
A. manifests in the first months of life
B. vomiting occurs 1-3 hours after feeding
C. hypotension occurs in approximately 15% of cases
D. commonly improved with ingestion of soy protein based formula
E. usually resolve by the age of three years of life

102. The MOST common cause of food protein induced enteropathy is

A. peanuts
B. fish
C. cow’s milk
D. eggs
E. tree nuts

103. The MOST severe form of food protein-induced enteropathy is

A. celiac disease
B. eosinophilic esophagitis
C. oral allergy syndrome
D. acute gastrointestinal allergy
E. food protein proctocolitis

104. Wheezing occurs in approximately which percent of IgE-mediated food allergic

reactions?
A. 15%
B. 25%
C. 35%
D. 45%
E. 55%

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105. Administration of the following vaccine is contraindicated in children with egg
allergy
A. MMR
B. Influenza
C. DPT
D. yellow fever
E. rabies

106. The only way to establish the diagnosis of cell-mediated food reactions is
A. breath hydrogen test
B. endoscopy
C. elimination and challenge test
D. IgE testing
E. skin test

107. Unpredictable drug reactions include

A. dose dependent
B. drug toxicity
C. drug interactions
D. adverse effects
E. allergic reaction

108. Which of the following drugs can cause Stevens - Johnson syndrome?
A. dapsone
B. hydralazine
C. sulfonamide
D. procainamide
E. bleomycin

109. Which one of the following agents is implicated in causing cutaneous lupus?
A. corticosteroids
B. calcium-channel blockers
C. allopurinol
D. B-lactam antibiotics
E. sulfonamide

110. Fixed drug eruption can be caused by

A. allopurinol
B. cephalosporin
C. nonsteroidal anti-inflammatory drug
D. nitrofurantoin
E. infliximab

215
111. One of the following drug-induced allergic reactions is not included as an
indictment of allopurinol
A. exanthem
B. Stevens-Johnson syndrome
C. toxic epidermal necrolysis
D. pulmonary fibrosis
E. interstitial nephritis

112. Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) can be caused by all
the following EXCEPT
A. anticonvulsants
B. sulfonamides
C. B-lactam antibiotics
D. minocycline
E. allopurinol

113. Systemic lupus erythematosus can be caused by

A. isoniazid
B. sulfonamide
C. hydrochlorothiazide
D. allopurinol
E. nonsteroidal anti-inflammatory drug

114. Vasculitis can be cause by

A. isoniazid
B. sulfonamide
C. penicillamine
D. calcium channel blockers
E. tetracycline

115. All the following are risk factors for adverse drug reactions EXCEPT
A. prior exposure
B. route of administration
C. dosing schedule
D. genetic predisposition
E. atopy

116. Of the following, the agent that does not share an identical side chain with
penicillin is
A. cephalexin
B. cefotaxime
C. cefixime

216
D. ceftazidime
E. ceftriaxone

217
PART XV Allergic Disorders
ANSWERS
HASANEIN GHALI
1.(E). Recognition of allergic rhinitis as a major chronic respiratory disease of children
rests largely on its high prevalence, detrimental effects on quality of life and school
performance, and comorbidities. The prevalence peaks late in childhood.
2.(C). The symptoms may appear in infancy; with the diagnosis generally established by
the time the child reaches age 6 yr. The prevalence peaks late in childhood.
3.(A). Positive family history is the major risk factor. Other risk factors are raised serum
IgE more than 100 IU/ml, smoking mother, and those with heavy exposure to indoor
allergens.
4.(E).
5.(C).
6.(D). There is a decreased risk of asthma, allergic rhinitis (AR), and atopic sensitization
with early introduction to wheat, rye, oats, barley, fish and eggs.
7.(D). The exposure to dogs, cats and endotoxin early in childhood protects against the
development of atopy.
8.(D). The symptoms of intermittent allergic rhinitis occur on <4 days per week or for
<4 consecutive weeks. In persistent AR symptoms occur on >4 days per week and/or
for >4 consecutive weeks.
9.(C). Dark circles under the eyes. (A) represent allergic salute, while (B) represent
allergic gape.
10.(C). Thick, purulent nasal secretions indicate the presence of infection.
11.(E).
12.(B).
13.(D). Allergic conjunctivitis, characterized by itching, redness and swelling of the
conjunctivae, has been reported in at least 20% of the population and in more the 70%
of patients with allergic rhinitis, most frequently in older children and young adults.
14.(C).
15.(A).
16.(A). Epicutaneous skin tests provide the best method for detection of allergen-
specific IgE (positive predictive value of 48.7% for the epidemiologic diagnosis of AR).
They are inexpensive and sensitive, and the risks and discomfort are minimal.
17.(B).
18.(D). Patients with more persistent, severe symptoms require intranasal
corticosteroids, the most effective therapy for allergic rhinitis, a treatment that may be
beneficial also for concomitant allergic conjunctivitis.
19.(C).

218
20.(A). Early childhood risk factors for persistent asthma have been identified and have
been described as major (parent asthma, eczema, inhalant allergen sensitization) and
minor (allergic rhinitis, wheezing apart from colds, ≥4% peripheral blood eosinophils,
food allergen sensitization) risk factors.
21.(A).
22.(B).
23.(C). Of these, approximately one-third who continue to have persistent asthma into
later childhood, and approximately two-thirds improve on their own through their teen
years.
24.(D). Severe airflow limitation (PEF or FEV1 value <50% of personal best or predicted
values).
25.(B).
26.(A). Supplemental oxygen is the best to start with.
27.(C).
28.(C). Male gender.
29.(B). Inhaled SABA, up to 3 treatments in 1 hr. If the child has an incomplete
response to initial treatment with rescue medication (persistent symptoms and/or a
PEF value <80% of personal best), a short course of oral corticosteroid therapy
(prednisone 1-2 mg/kg/day [not to exceed 60 mg/day] for 4 days), in addition to
inhaled β-agonist therapy, should be instituted.
30.(D).
31.(A). Peribronchial thickening and flattening of diaphragm.
32.(B). In asthmatic patients, an improvement in FEV1≥12% or >200 mL in response to
bronchodilator is consistent with asthma, while FEV1 typically decreases during or after
exercise by >15%.
33.(B).
34.(D). Discharge medications include administration of an inhaled β-agonist up to
every 3-4 hr plus a 3-7 day course of an oral corticosteroid.
35.(D). Children with well-controlled asthma have daytime symptoms ≤2 days/wk and
need a rescue bronchodilator ≤2 days/wk; an FEV1of >80% of predicted (and an FEV1:
FVC ratio >80% for children 5-11 yr of age); no interference with normal activity; and <2
exacerbations in the past year.
36.(D). The green zone (80-100% of personal best) indicates good control; the yellow
zone (50-80%) indicates less-than-optimal control and necessitates increased
awareness and treatment; the red zone (<50%) indicates poor control and greater
likelihood of an exacerbation, requiring immediate intervention.
37.(A). Long-term controller medications are inhaled corticosteroid, LABAs, leukotriene
modifiers, sustained-release theophylline, and nonsteroidal antiinflammatory agents.
An anti-IgE preparation, omalizumab (Xolair), is approved by the FDA for use as an add-
on therapy in children ≥12 yr that have moderate to severe allergic asthma that is
difficult to control.
38.(E).

219
39.(B).
40.(E). The hallmark of atopic dermatitis is dry skin, is results from compromise of the
epidermal barrier, which leads to excess transepidermal water loss, allergen
penetration, and microbial colonization.
41.(A). Approximately 50% of patients experience symptoms in the 1st yr of life, and an
additional 30% are diagnosed between 1 and 5 yr of age.
42.(D). Intense pruritus, especially at night, and cutaneous reactivity are the cardinal
features of atopic dermatitis.
43.(C). Foods (cow milk, egg, peanut, tree nuts, soy, wheat, and shellfish), aeroallergens
(pollen, grass, animal dander, and dust mites), infection (staphylococcus, herpes
simplex, and molluscum), reduced humidity, excessive sweating, and irritants (wool,
acrylic, soaps, toiletries, fragrances, and detergents) can exacerbate (trigger) pruritus
and scratching.
44.(D).
45.(A).
46.(E). The major clinical features in atopic dermatitis are (pruritus, facial and extensor
eczema in infants and children, flexural eczema in adolescents, relapsing dermatitis and
personal or family history).
47.(C). Histiocytosis, other mentioned disorders are associated with infections.
48.(C).
49.(A). Because patients with AD have impaired skin barrier function from reduced lipid
levels, they present with diffuse, abnormally dry skin, or xerosis. Moisturizers are first-
line therapy.
50.(E).
51.(D). Vitamin D deficiency often accompanies severe AD. Vitamin D enhances skin
barrier function, reduces corticosteroid requirements to control inflammation and
augments skin antimicrobial function.
52.(E).
53.(C). Erythromycin and azithromycin are usually beneficial for patients who are not
colonized with a resistant S. aureus strain; a first-generation cephalosporin (cephalexin)
is recommended for macrolide-resistant S. aureus. Topical mupirocin is useful in the
treatment of localized impetiginous lesions, with systemic antibiotics for widespread
infections.
54.(A). There has been particular interest in the role of Malassezia furfur in atopic
dermatitis because it is lipophilic yeast commonly present in the seborrheic areas of
the skin.
55.(E). For the other stems; A- high predictive value, B- Positive skin test often do not
correlate with clinical symptoms, C- Rarely required, and D- The majority react to less
than 3 foods.
56.(D).

220
57.(B). The dramatic clinical improvement that may occur with systemic corticosteroids
is frequently associated with a severe rebound flare of atopic dermatitis after therapy
discontinuation.
58.(D). Hydrocortisone is labeled as group 7 topical steroids which is the least potent
one.
59.(D). Use the least potent steroid in the face and intertriginous areas.
60.(B). Herpes simplex virus (HSV) can provoke recurrent dermatitis and may be
misdiagnosed as S. aureusinfection, which can be diagnosed by a Giemsa-stained
Tzanck smear of cells scraped from the vesicle base or by viral polymerase chain
reaction or culture.
61.(C). Exfoliative dermatitis associated with generalized redness, scaling, weeping,
crusting, systemic toxicity, lymphadenopathy, and fever, and is usually caused by
superinfection (e.g., with toxin-producing S. aureus or HSV infection) or inappropriate
therapy. In some cases, the withdrawal of systemic glucocorticoids used to control
severe AD precipitates exfoliative erythroderma.
62.(A).
63.(C).
64.(E). Yellow jackets are aggressive and ground dwelling, and they linger near activities
involving food.
65.(D).
66.(B).
67.(A). In vitro serum assay for venom-specific IgE is recommended if skin test results
are negative in the presence of a convincing history of a severe systemic reaction.
68.(C).
69.(B). Adjunctive treatment includes antihistamines, corticosteroids, intravenous
fluids, oxygen, and transport to the emergency room.
70.(D). Systemic reaction at any age with positive skin test / in vitro test is an indication
for venom immunotherapy. Large local reaction and generalized cutaneous reactions in
children are not indications for both diagnostic tests (skin and in vitro tests) and venom
immunotherapy.
71.(D). Skeeter syndrome is a large local reaction to mosquito bite, it happens usually
in young children and misdiagnosed as cellulitis. This is not an Ig E mediated reaction
but because of the vasoactive and irritant material from the mosquito, it does not
cause anaphylaxis.
72.(E).
73.(A). Allergic conjunctivitis is the most common hypersensitivity response of the eye,
affecting approximately 25% of the general population and 30% of children with atopy.
74.(B). Vernal keratoconjunctivitis and atopic keratoconjunctivitis are sight-threatening
entities and causes visual morbidity and suspected cases need to be referred to an
ophthalmologist.
75.(B). Patients with allergic conjunctivitis complain of variable ocular itching, rather
than pain, with increased tearing.

221
76.(A). Contact allergy typically involves the eyelids but can also involve the
conjunctivae. It is being recognized more frequently in association with increased
exposure to topical medications, contact lens solutions, and preservatives.
77.(E). Giant papillary conjunctivitis has been linked to chronic exposure to foreign
bodies, such as contact lenses, both hard and soft, ocular prostheses, and sutures.
78.(C). Topical decongestants act as vasoconstrictors; adverse effects of topical include
burning and rebound hyperemia or conjunctivitis medicamentosa with chronic use.
79.(C). Acute urticaria can also result from non–IgE-mediated stimulation of mast cells,
caused by radiocontrast agents, viral agents (including hepatitis B and Epstein-Barr
virus), opiates, and nonsteroidal anti-inflammatory agents.
80.(E). Autoimmune disease, like SLE, Juvenile rheumatoid arthritis, thyroid disease,
inflammatory bowel diseases and celiac disease, are well established causes of chronic
urticaria.
81.(C).
82.(D). H2 antihistamines used in chronic urticaria.
83.(D). Skin biopsy is recommended for urticarial lesions that persist at the same
location for >24 hr, those with pigmented or purpuric components, and those that burn
more than itch. Collagen vascular diseases such as systemic lupus may manifest
urticarial vasculitis as a presenting feature.
84.(E).
85.(E).
86.(B). Vaccination is a trigger, not a cofactor in anaphylaxis, others are cofactors.
87.(A). Principal pathologic features in fatal anaphylaxis include acute bronchial
obstruction with pulmonary hyperinflation, pulmonary edema, intraalveolar
hemorrhaging, visceral congestion, laryngeal edema, and urticaria and angioedema.
Acute hypotension is attributed to vasomotor dilation and/or cardiac dysrhythmias.
88.(B). Other choices are to be considered in cases where there are no cutaneous
manifestations.
89.(C).
90.(D). Plasma histamine is elevated for a brief period but is unstable and difficult to
measure in a clinical setting. Plasma tryptase is more stable and remains elevated for
several hours but often is not elevated, especially in food-induced anaphylactic
reactions.
91.(B). Patients may experience biphasic anaphylaxis, which occurs when anaphylactic
symptoms recur after apparent resolution. More than 90% of biphasic responses occur
within 4 hours, so patients should be observed for at least 4 hr before being discharged
from the emergency department.
92.(A).
93.(A).
94.(B). Symptoms lasting longer suggest another diagnosis.
95.(B). Thrombocytopenia is often present.
96.(D). Not specific and not diagnostic.

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97.(E).
98.(B).
99.(A). Heiner syndrome (food induced pulmonary hemosiderosis) is a non-IgE
mediated food allergy.
100.(C). The onset is usually during adulthood. Others are earlier in presentation.
101.(D). Commonly provoked by ingestion of milk and soy based protein formula.
102.(C).
103.(A).
104.(B).
105.(D).
106.(C). There are no laboratory studies to help identify foods responsible for cell-
mediated reactions. Consequently, elimination diets followed by food challenges are
the only way to establish the diagnosis.
107.(E).
108.(C). Antibacterial sulfonamides, anticonvulsants, oxicam NSAIDs, and allopurinol
have been implicated in causing Stevens - Johnson syndrome and toxic epidermal
necrolysis.
109.(B). Hydrochlorothiazide and calcium channel blockers can cause cutaneous lupus.
110.(C). Tetracycline, NSAIDs, and carbamazepine are implicated in causing fixed drug
eruption.
111.(D). Nitrofurantoin, bleomycin and methotrexate are implicated in causing
pulmonary fibrosis.
112.(C). They can cause anaphylaxis.
113.(A). Along with Hydralazine and procainamide.
114.(C). Along with Hydralazine and propylthiouracil.
115.(E). Atopy does not appear to predispose patients to allergic reactions to low-
molecular-weight compounds, but atopic patients in whom an allergic reaction
develops have a significantly increased risk of serious reaction.
116.(C).

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