criterii de trimitere imunologie

7/29/2019 Criterii de Trimitere Imunologie

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I M M U N O L O G Y

National Referral Guidelines

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NATIONAL REFERRAL GUIDELINES : IMMUNOLOGY

Referral GuidelinesEvaluationDiagnosis Management Options

PRIM ARY

IMMUNODEFICIENCY

Refer t o Paediatrician,

Immunologist,

Respiratory physician or

physician with a special

interest.

Primary immunodeficiency

should be suspected in any

patient wit h recurrent or

persistent infection or

unusual in fection.

Recurrent sinopulmonary

infections such as recurrent

ot it is media unresponsive

to grommets, recurrentsinusitis, recurrent

pneumonia.

Persistent gastrointestinal

disease such as chronic

diarrhoea or failure to

thr ive, recurrent or

persistent giardiasis.

Unusually persistent or

recurrent staphylococcal

inf ections e.g. of nasal

cavities or eyelids or

osteomyelitis.

Difficult to eradicate oral

th rush in the absence of a

predisposing factor.

Any infant f rom a family

with known immune

deficiency

Confirmation of specific

types of infections by

culture or other laboratory

tests

Full blood count (with

reference to age related

ranges)

Measurement of serum

immunoglobulins (withreference to age related

ranges).

Note:normal

immunoglobulin levels do

not exclude

immunodeficiency.

Serum glucose

HIV serology

Chest x-ray

If immunodeficiency is

suspected, prompt

special ist assessment is

essential.

Infants suspected of

suffering from

immunodeficiency should

be discussed urgent ly with

a specialist.

Note: Blood transfusion or

vaccinations could be lif e

threatening

Refer t o Paediatrician,

Immunologist or physician

with specialist interest.

Bronchiectasis

consider in any pat ient

wit h chronic productive

cough, especially in

children or adult s in t he

absence of a significant

smoking history

As above Specialist assessment is

essential.

ISOLATED

ANGIOEDEMAPatients wit h C1 inhibi tor

def iciency shou ld be under

the care of an immunolog ist

C1 inhibi tor and

complement levels

Consider ACE inhibitor

withdrawal

Treat as for urticaria

May need adrenaline and

prednisone i f severe

Purified C1inh concentrate

is of proven value for

respirat ory t ract

obstruction and abdominal

crises. C1 inhibit or

concentrate for surgery and

dental prophylaxis.

Fresh frozen plasma if C1inh concentrate is not

available.

Version 1 Immuno logy Referr al Guidel ines and Prio risati on Crit eria Date: 21/5/2001 Aut hor ised: Elective Services, HFA


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LATEX ALLERGY

All patients should be

referred for assessment by

a Dermatologist i f there

are occupat ionalimplications to t he

diagnosis or t he patient is

resistant to treatment

Suspected latex allergy

Type 1 (IgE mediated)

History of

urticaria/angioedema/

wheeze or anaphylaxis

following suspected latex

contact e.g. contact withrubber gloves, balloons,

condoms, urinary

cathet ers or suspected

inhalation of latex

particles

Note: At r isk groups include

1. Health care workers

especially operat ing

theatre staff

2. Patient having undergone

multiple

procedures/operations

especially urinary

catheterisat ion (spina

bifida)

3. Contact dermatitis to latex

products

4. Occupational exposure

e.g. rubber w orker

5. A topy

If associated w it h

anaphylaxis provide

patient with and educate

in t he use of parenteral

adrenaline A suspected diagnosis

needs support of either

posit ive prick skin t ests to

latex or posit ive serum

latex specif ic IgE.

Advise on avoidance of

latex products especially

the use of powdered latex

gloves.

Document for management

options:

www.nz.org.nz/library/gl_complete/anaesth_latex/inde

x.cfm#contents

All patients suspected of

latex allergy should be

referred to a

Dermatologist or

Immunologist forconfirmation of t he

diagnosis and education.

(Desensit isation therapy

has not been tested as a

therapeutic option)

Suspected latex allergy

contact sensitivity

History of contact

dermatitis with latex

containing product e.g.

rubber gloves, balloons,condoms.

Note:At risk group as for

immediate sensit ivit y. Patients

wi th contact sensit ivity are at

high ri sk of latex immediate

type hypersensit ivit y

Avoidance of latex

products.

Use of alternative

products.

Note:The availability of

alternatives may vary

depending on local f eatures

VENOM ALLERGY

All patients with systemic

react ions should be

referred.

Patients who have

experienced cardio-

respiratory symptoms

during a systemic reaction

to an insect sting are likely

to be offered

desensitisation. Patients

who have had skin

symptoms only

(eg urt icaria/angioedema)

require assessment and

self-treatment

medications, but may not

require desensit isation.

Large local reactions arenot treated wit h

desensit isation. Referral is

not necessary

Insect venom allergy History: detail ed histo ry of

allergic reaction, including

nature of insect, t iming o f

onset, t ype of symptoms,

treatment given and H/Oprevious reactions.

Emergency treatment: As for

Anaphylaxis

For large local reactions early

treatment with

antihistamines and steroids is

useful.

Version 1 Immunology Referral Guidelines and Priorisation Criteria Date: 21/5/2001 Aut horised: Elective Services, HFA


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ANAPHYLAXIS If a t rigger is found, avoidif possible eg drugs, foods,

exercise

Reduce risk of severe

reaction eg changing f rom

beta Blockers. Desensitisation for insect

stings

(see venom guidelines)

Teach pat ient s to self

administer injectable

adrenaline

Instruct when to use

adrenaline

Advise caregivers (if child)

when t o administer

adrenaline

Consider Medic Alert

bracelet

Adrenaline Intramuscular

dosage

From immunisation

handbook

Adrenaline 1:1000:

0.01ml/kg to maximum

0.5ml(ie 10 mcg/kg

adrenaline)

If weight unknown:

0-6 mon ths 0.05ml

7-23 months 0.1ml

2 years 0.2ml

3 years 0.3ml

4 years 0.4ml

5 years 0.5ml

or EPIPEN Jr (0.15 mg

adrenaline) children 10-20

kg

EPIPEN (0.3 mgadrenaline) for children

>20 kg and adult s

History and examination, p lus

detailed history of allergic

reaction including symptoms

of hypotension, respiratory

obstruction, abdominal

cramps, history of drug

treatment.

Determine if there were any

tri ggering factors (foods,

stings, exercise, drugs esp

NSAIDS, lat ex or blood

products). Many cases are

idiopathic.

If diagnosis is uncertain,

serum t rypt ase levels* 1-2

hours after onset of

symptoms.

Identif y factors conferring

higher r isk of death; asthma,cardiovascular disease, beta

blocker or MAO inhibitor

therapy, pregnancy (fet al

death)

* 5ml clott ed tube

Referral to Allergy service for

Investigation and

education



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ANTIBIOTIC ALLERGY Patients with drug-induced anaphylaxis orStevens Johnson syndromeshould not receive theoffending drug again.

Patient s wi th serumsickness due to cefaclorshould not receive furthercourses of cefaclor butmay receive othercephalosporins andpenicillins.

Non urticarialerythematous rashese.g. Maculopapular rashesto a -lactam (penicillin orcephalosporin) are not IgEmediated. While thecurrent course should be

discont inued it may bepossible for patients toreceive future courses ofb-lactam drugs. As aprecaution the initial doseshould be given undersupervision.

Penicillin skin test ing israrely indicated, aspenicillin is seldom t heonly appropriateantibiotic. Penicillin testingis indicated f or patient swith a history suggesting

penicillin allergy in whoma penicillin is the onlyappropriate antibiotic.

In other sit uationsalternate antibioticsshould be used. Penicillinskin t esti ng should not bedone to satisfy thecuriosity of pat ient , parentor doctor.

History and examinat ion, plusdetailed history of allergicreaction (precise details aboutany rash including t iming ofonset and nat ure, plus otherfeatures of reaction)

Patients with mu lti ple drugallergies should be ref erredfor evaluation.

CHRONIC URTICRIA /

ANGIOEDEMAPatients who cannot becontrolled with regularantihistamines alone

Anyone w ith suspectedvasculitis

(>6 weeks duration)

Standard h isto ry andexamination, plus detailedhistory of urt icaria. Seekfeatures suggestive ofanaphylaxis includinghypotension, respiratoryobstruction, abdominalcramps. Histo ry of drugtherapy.

Identif y those who may haveurt icarial vasculit is for earlyreferral eg persistent lesions> 24 hours, bru ising,haematuria, purpura.

Determine if there were anyaggravating factors (foods,

drugs esp NSAIDS, ACEinhibitors, exercise, coldinduced).

If a trigger is found, avoidif possible eg drugs, foods,exercise, NSAIDS,Progesterone.

Commence on regularantihistamines. Ifunresponsive, increasedose or changeantihistamines.

Consider addition of H2blocker and continue ifeffective.

One 7-14 day course of oralsteroids.

If not respond ing discuss

wi th specialist. Early referral f or f eatures

of vasculitis

If cold induced, warn ofdangers ofswimming/diving int o coldwater.


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FOOD ALLERGY

Referral t o Paediatric or Adult

services as appropriat e.

History and examination,

including detailed h istory

of allergic reaction (timing

of onset, nature and

severity of reaction,

therapy required,

reproducibilit y of

reaction).

Food allergy tests (skin or

RAST) may not be

diagnostic of food allergy

because of t he high

frequency of false posit ive

reactions.

Negative tests are

reassuring that t he food

is not implicated in causing

IgE mediated allergy.

Patients with a history of

anaphylaxis or immediate

hypersensit ivit y react ions

should be referred for

conf irmat ion of diagnosis,

and home adrenaline

education/ action p lan

and dietician review if

needed.

Most food allergy in

children is transient

follow -up including food

challenge may be required

to determine if the allergy

has been out grow n. Food

challenge should not be

undertaken wit hout

resources for resuscitation.

Patients wit h multiple foodint olerance (which may or

may not be allergic in

nature) should be referred

for evaluation and possible

food challenges

Children should be

referred t o Paediatric

Immunology or General

Paediatri cs depending on

service availabil it y

Adults should be referredto Allergy or General

Medicine, but wit h

multiple food intolerance

referral to

Gast roent erology may be

more appropriate.

Eczema ? food allergy History and examination,

plus detailed history of any

allergic react ions and of

eczema precipit ants and

therapies.

Food allergy tests (skin or

RAST) may not be

diagnostic of food allergy

because of t he high

frequency of false posit ive

reactions.

Food allergy p lays a role

in some eczema,

particularly in early

childhood. Evaluation may

be worthw hile in young

children w it h severe or

diff icult to cont rol eczema

Children should be

referred t o Paediatric

Immunology or General

Paediatr ics depending on

service availabil it y

Adults should be referred

to Allergy or General

Medicine

Egg allergy requiring

vaccination

People with egg allergy can

safely receive MMR

vaccine. If there is concern

about administering t hen

referral f or administrati on

under hospital supervision

should be made.

Infl uenza vaccine is

cont raindicated for peoplewit h egg allergy.



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RHINITIS

For those wit h poor

response to t reatment

For ident if ied or suspected

immune deficiency.

Seasonal Rhino-conjunctivitis History, including months

aff ected, symptoms,

known triggers.

Examination

Investigations may include

Skin Prick Test (or RAST)

to conf irm relevant

allergens

Avoidance advice

Usual t reatment s include

regular nasal

corticosteroids

commencing pre-seasonally, oral

antihistamines, topical

antihistamines, topical

mast cell stabil isers eye

drops. Short term oral

steroids may be useful.

For severe, uncontrolled

symptoms

For considerat ion of

initiation of

desensitisation

Perennial rhino-conjunctivitis History, including

symptoms, known triggers.

Examination

Invest igat ions include Skin

Pri ck Test (or RAST) to

conf irm atopy and

determine specific

allergens

Avoidance advice

(eg house dust mites,

household pets)

Usual t reatment s include

regular nasal

cort icosteroids, oral ortopical antihistamines,

anti -allergic eye drops.

When rhinorrhoea

dominates consider nasal

ipratropium

For severe, uncontrolled

symptoms

For considerat ion of

initiation of

desensitisation

If nasal blockage is the

major symptom consider

ENT referral

If conjunctivitis is severe

consider Opt halmologist

referral

Recurrent rhino-sinusitis History

Examination

Invest igat ions include Skin

Pri ck Test (or RAST) to

determine at opy,

immunoglobulins, CBC.

Treat allerg ic rhinit is if

present

Early t reatment of episodes

with decongestants,

antibiotics. May need

prolonged courses of

antibiotics

Skin prick testi ng f or

aeroallergens (part icularly

indoor aeroallergens) may

give useful inf ormation

for atopic asthmatics wit h

significant/ongoing

symptoms.

Environment al advice (e.g.

dust mite control, cat

avoidance) may be

provided on t he basis of

skin prick test results.Appendix 1

Most child asthmatics

(>80%) and a signi f icant

proportion of adult

asthmatics >70% are

atop ic. M any of these

patients will have other

allergic conditions (rhinitis,

eczema, food allergy).

Specif ic allergens may

contribute to chronic

asthmatic symptoms and

to acute flares.

Assessment of allergy to

aeroallergens by skin prick

testing may identif y

potential tri ggers of

asthma, and avoidance of

these allergens may

improve asthma control.

There is debate about the

use of immunot herapy for

patients wit h asthma;

there is some evidence of

its benefit , but it is not

wit hout risk.

Patients with atopic

asthma in w hom

desensitisation may be

useful should be

evaluated by an allergist/

immunologist for

consideration of safe and

appropriate

desensitisation.

ASTHMA



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Appendix 1

ADDITIONAL DUST MITE INFORMATION

I M M U N O L O G Y

PAGE 8

How to try and reduce dust mite exposure:

Your biggest exposure t o dust mit es is in your bed, so t his is probably t he best place to start .

The matt ress, base and pi llow s should be tot ally encased by special dust mit e covers. Duvets should alsobe covered, or it washable see below.

Dust mites are killed by heat.

All bedding used on t op o f mit e covers shou ld be washed each 1-2 weeks.

A hot water wash (>55C) will kill t he dust mit es and remove the allergen.

If hot washing is not possible t hen put ting dry garments using a hot cycle in t he dry >60 minut es) mayalso kill the mites aft er rout ine washing.

Sof t toys should either be hot -washed regularly, or mit es can be kill ed if the toy is put in t he f reezer(in a plast ic bag) for 24 hours.

Keep clutter to a minimum so surfaces can be damp wiped regularly.

If possible avoid having carpet on t he f loor.

Contact your local Asthma Society or Allergy Aw areness Association NZ Inc (email [email protected]).


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