Immunology - Pacific University

Front 1

Solid Organ Transplant: Matching Organs: Blood Typing

Back 1

HLA (Human Leukocyte Antigen), PRA (Panel Reactive Antibody), & Crossmatch (XM)

Hint 1

• Matching 6 = 0 mismatch / matching 0 = 6 mismatch
• HLA Class I: A, B, & C
o CD8 T-cells (cytotoxic)
• HLA Class II: DR, DP, & DQ
o CD4 T-cells (helper)

Front 2

Solid Organ Transplant: Matching Organs: Blood Typing - HLA

Back 2

encodes MHC; match A, B & DR

Hint 2

Screens for anti-HLA cytotoxic antibodies
• ≥ 80% PRA = Poor Match
• 20%-80% PRA= Moderate Match
• ≤ 20% PRA = Good Match

Front 3

Solid Organ Transplant: Matching Organs: Blood Typing - PRA

Back 3

mix the donor & recipient serum and see what % react

Hint 3

Screens for anti-HLA cytotoxic antibodies specific to that donor
• Positive = Bad (usually)
• Negative = Good (usually)

Front 4

Solid Organ Transplant: Matching Organs: Blood Typing - Crossmatch

Back 4

donor lymphocytes mixed with patient serum

Front 5

Solid Organ Transplant: Allorecognition

Back 5

Direct: A donor cell floats around out of the donated organ and initiates an issue (lymphatic system → CD8→ destruction)

Hint 5

Indirect: An recipient APC goes into new organ, grabs some of the donor tissue, and reports the issue

Front 6

Solid Organ Transplant: Support Medications: Opportunistic Infections

Back 6

UTI (women), Pneumocystis pneumonia, Oral candidiasis, Cytomegalovirus

Front 7

Solid Organ Transplant: Support Medications: Opportunistic Infections: UTI (women)

Back 7

Bactrim or Nitrofurantoin for 2 months

Front 8

Solid Organ Transplant: Support Medications: Opportunistic Infections: Pneumocystis pneumonia

Back 8

maybe Bactrim for those at risk or heart/lung transplants

Front 9

Solid Organ Transplant: Support Medications: Opportunistic Infections: Oral candidiasis

Back 9

fluconazole 50mg qd for 2 months (or clotrimazole troches or nystatin)

Front 10

Solid Organ Transplant: Support Medications: Opportunistic Infections: Cytomegalovirus

Back 10

Valganciclovir

Hint 10

Adjust for Renal Function:
• Recip +/Donor + and Donor -: 450 mg daily for 3 months
• Recip -/Donor +: 900 mg daily for 6 months
• Recip -/Donor -: None

Front 11

Solid Organ Transplant: Support Medications: Other Infections

Back 11

Anemia, Leukopenia/Neutropenia, Dyspepsia, Osteoporosis, Hypophosphatemia, Hypomagnesemia, HTN, Hyperlipidemia

Front 12

Solid Organ Transplant: Support Medications: Other Infections: Anemia

Back 12

Fe or EPO if deficient; maybe ↓ MMF

Front 13

Solid Organ Transplant: Support Medications: Other InfectionsLeukopenia/Neutropenia

Back 13

dose reduction of immunosuppressants

Front 14

Solid Organ Transplant: Support Medications: Other Infections: Dyspepsia

Back 14

Famotidine or PPI

Front 15

Solid Organ Transplant: Support Medications: Other Infections: Osteoporosis

Back 15

(from Prednisone) Ca (1000-1500mg/d) & Vit D (400-800mg/d)

Front 16

Solid Organ Transplant: Support Medications: Other Infections: Hypophosphatemia

Back 16

(from steroid)

Front 17

Solid Organ Transplant: Support Medications: Other Infections: Hypomagnesemia

Back 17

(from CNI)

Front 18

Solid Organ Transplant: Support Medications: Other Infections: HTN

Back 18

BP Goal <130/80; add ACEI/ARB for renal protection

Front 19

Solid Organ Transplant: Support Medications: Other Infections: Hyperlipidemia

Back 19

LDL <100 for most; add statins

Front 20

Solid Organ Transplant: Rejection

Back 20

Acute: ≤3 months; H>K>L

Front 21

Solid Organ Transplant: Rejection: Cellular

Back 21

• T-cells (90%)
o Methylprednisolone: 1st line
o rATG: severe or MP-resistant

Front 22

Solid Organ Transplant: Rejection: Humoral/Antibody mediated

Back 22

• B-cells (10%)
o IV Immune Globulin from pooled patients (competition for binding)
o Plasmapheresis: machine strains proteins (Ab) from blood
o Rituximab: mab against B-cells (CD20)
 375mg/m2 = most 600-700 mg/day

Front 23

Hypersensitivity: Type I

Back 23

Anaphylactic
• 30 min; Allergen binds to IgE
• Allergens: large molecular weight that bind to IgE on mast cells; smaller allergens (drugs) bind to proteins (haptenation)
o Sensitization occurs on first exposure; reaction on subsequent exposures

Front 24

Hypersensitivity: Type II

Back 24

Cytotoxic
• 5-12 hours;

Front 25

Hypersensitivity: Type III

Back 25

Immune Complex Mediated
• 3-8 hours;

Front 26

Hypersensitivity: Type IV

Back 26

Cell Mediated (delayed)
• 24-72 hours;

Front 27

Allergic Rhinitis: Pathophysiology:

Back 27

 Minutes: sneezing & pruritus …. histamine, leukotrienes, & cytokines
 Hours: earlier + postnasal drip…. cytokines & chemokines

Front 28

Allergic Rhinitis: Pathophysiology: 1st Exposure:

Back 28

allergen in nose -> processes by lymphocytes -> IgE Ab made

Front 29

Allergic Rhinitis: Pathophysiology: 2nd Exposure

Back 29

IgE bound to mast cells/basophils bind to allergen -> inflammatory mediators

Front 30

Allergic Rhinitis: Seasonal

Back 30

symptoms present <4 days OR <4 weeks
• Trees, grasses, weeds, mold

Front 31

Allergic Rhinitis: Perennial

Back 31

>4 days AND >4 weeks
• House mites, animals, roaches, indoor mold/fungi

Front 32

Allergic Rhinitis: Mild

Back 32

• Rhinorrhea
• Sneezing
• Nasal congestion
• Postnasal drip
• Itchy eyes, ears, nose, throat

Front 33

Allergic Rhinitis: Moderate-Severe (Mild+)

Back 33

• Sleep disturbance
• School/work impair
• Impair daily life
• Troublesome sx

Front 34

Allergic Rhinitis: Antihistamines (systemic)

Back 34

Sneezing/Itching: ++
Rhinorrhea: ++
Congestion: +/-
Ocular/Conjunctivitis: ++

Front 35

Allergic Rhinitis: Decongestants

Back 35

Sneezing/Itching: -
Rhinorrhea: -
Congestion: ++
Ocular/Conjunctivitis: -

Front 36

Allergic Rhinitis: Intranasal Steriods

Back 36

Sneezing/Itching: ++
Rhinorrhea: ++
Congestion: ++
Ocular/Conjunctivitis: +

Front 37

Allergic Rhinitis: Cromolyn Nasal

Back 37

Sneezing/Itching: +
Rhinorrhea: +
Congestion: +
Ocular/Conjunctivitis: +/-

Front 38

Allergic Rhinitis: Ipratropium Nasal

Back 38

Sneezing/Itching: -
Rhinorrhea: ++
Congestion: -
Ocular/Conjunctivitis: -

Front 39

Allergic Rhinitis: Ocular Antihistamines

Back 39

Sneezing/Itching: -
Rhinorrhea: -
Congestion: -
Ocular/Conjunctivitis: ++

Front 40

Allergic Rhinitis: Leukotriene Antagonist

Back 40

Sneezing/Itching: ++
Rhinorrhea: ++
Congestion: +/-
Ocular/Conjunctivitis: ++

Front 41

Burns: Types

Back 41

Superficial, Superficial partial thickness, Deep partial thickness, Full thickness

Front 42

Burns: Superficial

Back 42

epidermis, no blisters, 3-6 days

Front 43

Burns: Superficial partial thickness

Back 43

blisters, moist, weeping, 2-3 weeks

Front 44

Burns: Deep partial thickness

Back 44

blanched, drier, scarring, 6 weeks – go to ER

Front 45

Burns: Full thickness

Back 45

skin death, dry, leathery, no pain, scarring, grafting, PT needed

Front 46

Burns: Minor

Back 46

• 15% BSA Superficial partial thickness
• 2% BSA Deep partial thickness / Full thickness

Front 47

Burns: Moderate

Back 47

• 15-25% BSA Superficial partial thickness
• 2-10% BSA Deep partial thickness / Full thickness

Front 48

Burns: Major

Back 48

• 25% BSA Superficial partial thickness

Front 49

Burns: Treatments

Back 49

• Skin protectants
• Systemic analgesics
• Topical Analgesics
• Antimicrobials

Front 50

Burns: Treatments: Systemic analgesics

Back 50

Ibuprofen, naproxen, aspirin

Front 51

Burns: Treatments: Topical Analgesics

Back 51

Benzocaine, Dibucaine, Lidocaine, Tetracaine (Rx) (NOT hydrocortisone)
o Deep burn = ↓ concentration (absorbtion)

Front 52

Burns: Treatments: Antimicrobials

Back 52

o Silver sulfadiazine (SSD) (Rx)
o Triple Antibiotic

Front 53

Burns: Refer Burns When...

Back 53

• ≥2% BSA
• Eyes, ears, face, hands, feet, perineum
• Chemical/Electrical/Inhalation
• Elderly
• DM or multiple issues
• Immunocompromised
• ≥7 days with no improvement

Front 54

Wounds: Stages

Back 54

Stage I: unbroken skin
Stage II: all epidermis & some dermis
Stage III: all dermis & some SQ
Stage IV: SQ & tissue/muscle/tendon/bone

Front 55

Wounds: Treatments: Antiseptics

Back 55

• Hydrogen Peroxide = Soap & Water effectiveness
• Ethyl Alcohol: apply around wound, not in; (dries skin)
• Isopropyl Alcohol: stronger than EtOH; (even drier)
• Iodine: works great! (stains skin)
• Camphorated phenol: caution; use on dry skin only

Front 56

Wounds: Treatments: Antibiotics

Back 56

• Bacitracin: Gram +
• Neomycin: Gram -; allergic contact dermatitis
• Polymixin B: Gram -

Front 57

Wounds: Refer Wounds When...

Back 57

• Junk in wound
• Chronic
• Animal/human bite
• Infection
• Face, mucus membranes, nuts
• Deep, acute wound

Front 58

Contact Dermatitis

Back 58

acute/chronic inflammatory condition after contact with offending agent

Front 59

Contact Dermatitis: Allergic

Back 59

Induced by antigen
• Delayed hypersensitivity (Type IV); genetic link potential
• Takes days to weeks

Hint 59

• Causes: “new offender” usually (may be not)
o Fragrance, rubber, metal, glues, plastics, formaldehyde, wool, neomycin, paraben, preservatives, Urushiol
• Sx: super itchy rash
• Treatment:
o Wet dressing; emollients, oatmeal
o Topical Corticosteroids (med-high potency)

Front 60

Contact Dermatitis: Irritant

Back 60

Induced by substance
• Epidermal barrier disrupted -> inflammation (secondary)
• Within hours

Hint 60

• Causes: physical, mechanical, or chemical
o over-washing hands, bleach, acids, alkalis
• Sx: erythema, chapped skin, dryness, fissures, itching
• Treatment:
o Avoidance
o Severe Cases: topical corticosteroid under occlusion
• Diaper: acute inflammatory dermatitis of baby butts
o Treatment: Talcum powder / Zinc oxide, titanium dioxide, petrolatum

Front 61

Atopic Dermatitis

Back 61

AKA eczema - Usually associated with hay fever, asthma, & allergic rhinitis

Hint 61

• Genetic Link (1 parent = 60% chance, both = 80% chance); ↑Eosinophils & IgE
• Sx: itching, flares -> abnormal protective layer

Front 62

Atopic Dermatitis: Types

Back 62

• Acute: rash with lesions that are itchy, erythematous
• Subacute: thicker and scaly
• Chronic: thickened plaques and accentuated skin markings

Front 63

Atopic Dermatitis: Treatments

Back 63

• Topical Corticosteroids
• Anti-Histamines
• Calcineurin Inhibitors
• Coal Tar Preps

Front 64

Atopic Dermatitis: Treatments:Topical Corticosteroids

Back 64

o High Potency: <3 weeks for acute or thickened
o Medium: chronic AD of trunk & extremities
o Low: children; sometimes face
o SE: skin atrophy, striae, hypopigment, acne

Front 65

Atopic Dermatitis: Treatments: Anti-Histamines

Back 65

meh

Front 66

Atopic Dermatitis: Treatments: Calcineurin Inhibitors

Back 66

Long term option; can be put anywhere:
o Tacrolimus: Moderate-to-severe AD… SE: burning/itching
o Pimecrolimus: Mild-to-moderate AD

Front 67

Atopic Dermatitis: Treatments: Coal Tar Preps

Back 67

stain, smelly, not on oozing, maybe photosensitivity

Front 68

Psoriasis:

Back 68

T-cell mediated autoimmune disease

Front 69

Psoriasis: Assessment

Back 69

PASI: Psoriasis Assessment & Severity Index
- tells you (1)redness, (2)thickness, (3)scaliness, & (4)area involved
• Mild: < 12
• Moderate: 12-18
• Severe: > 18

Hint 69

PGA: scaled 7-1 (1 worst)
NPF-PS: mild, moderate, or severe
- Incorporates QOL

Front 70

Psoriasis: Types

Back 70

Plaque, Guttate, Pustular (localized), Pustular (generalized), Erthrodermic

Front 71

Psoriasis: Types: Plaque

Back 71

Red, thick & silvery
- Scalp, hands, feet elbows

Front 72

Psoriasis: Types: Guttate

Back 72

Small drop-like plaques
- Trunk, torso / children & young adults

Front 73

Psoriasis: Types: Pustular (localized)

Back 73

Splitting of skin
- Hands & feet

Front 74

Psoriasis: Types: Pustular (generalized)

Back 74

11 – spread out more

Front 75

Psoriasis: Types: Erthrodermic

Back 75

Less common, more flattened;
- generalized redness all over

Front 76

Psoriasis: Non-Rx Treatment:

Back 76

• Emollients: 18
• Balneotherapy: salt water bath or mud/clay products; may ↓T-cell activity in skin
• Phototherapy: antiproliferation & anti-inflammatory/immunomodulatory
o PUVA: Psoralen + UVA
• Lasers

Front 77

Acne: Types

Back 77

Comedones:
• Blackhead: open comedo
• Whitehead: closed comedo
Pustule: elevated skin lesion with pus
Papule: small bump with no head
Nodule: cysts

Front 78

Acne: Types: Mild Comedonal

Back 78

• 1st: Topical Retinoid
• Alt: other TD, Salicyclic acid, ot azelacic acid
52!!!

Front 79

Acne: Types: Moderate Papular Pustule

Back 79

• 1st: Oral Antibiotic AND Topical Retinoid +/- BPO
• Alt: same with different TR
• Alt: Oral Antiandrogen

Front 80

Rosacea

Back 80

Chronic inflammatory disorder of facial pilobaceous units -> ↑capillary reactivity -> flushing & telangiectasia
- Starts at 30-50 yo peaking around 40-50; Females>male

Front 81

Rosacea: Type 1

Back 81

Erythematotelangiectatic - facial redness

Hint 81

• Topical metronidazole or azelaic acid or sulfacetamide/sulfur
• Oral tetracyclines (mino or doxy)
• Lasers

Front 82

Rosacea: Type 2

Back 82

Papilopustular - papules/pustules present

Hint 82

• Combo topical metronidazole or azelaic acid or sulfacetamide/sulfur AND Oral tetracyclines
• Lasers

Front 83

Rosacea: Type 3

Back 83

Phymatous - Cyrano nose

Hint 83

• Oral tetracyclines (mino or doxy)
• Referral for isotretinoin
• Dye Lasers / electrosurgery

Front 84

Rosacea: Type 4

Back 84

Ocular: eye irritation

Hint 84

• Topical or oral tetracyclines (mino or doxy)
• Eyelid Hygiene & maybe referral to ophthalmologist

Front 85

Cosmeceuticals:

Back 85

• Bimatoprost (Latisse®)
• Eflornithine (Vaniqa®)
• Minoxidil (Rogaine)
• Hydroquinone
• Dihydroxyacetone
• OnabotulinumtoxinA (Botox®)
• Arbutin (Uva Ursi)

Front 86

Cosmeceuticals: Bimatoprost (Latisse®)

Back 86

Eyelash growth
• Use caution with any other eye products; May cause permanent discoloration of eyes

Front 87

Cosmeceuticals: Eflornithine (Vaniqa®)

Back 87

Reduction of unwanted facial hair
• not a depilatory agent, but rather a hair growth retarding drug; condition may return to 8 weeks after stopping

Front 88

Cosmeceuticals: Minoxidil (Rogaine)

Back 88

Male pattern alopecia
• originally an anti-hypertensive agent; can be used in women

Front 89

Cosmeceuticals: Hydroquinone

Back 89

Removal pigmentation, Freckles, or Melasma
• effective for sun damage to the neck and upper chest; wear sunblock

Front 90

Cosmeceuticals: Dihydroxyacetone

Back 90

Darken light or unpigmented areas of skin affected by vitiligo, scars, and other
• May stain hair or clothing when wet; wear sunscreen

Front 91

Cosmeceuticals: OnabotulinumtoxinA (Botox®)

Back 91

“Wrinkled face”
• BBB for infection & hypersensitivity; Only FDA approved cosmetic use is glabellar lines

Front 92

Cosmeceuticals: Arbutin (Uva Ursi)

Back 92

Skin-lightening
• Use should not exceed 7-10 days; May turn your urine green; derived from Bearberries

Front 93

Psoriasis TX: Topical 1st Line Drugs

Back 93

• Corticosteroids
• Vit D Analogues
• Tazarotene

Front 94

Psoriasis TX: Topical 1st Line: Corticosteroids

Back 94

Prevents scales & itching:
o Use for finite period of time
o Class I for thick, chronic plaque (ointments best)
o Medium & low potency for face
o ADR: striae, skin atrophy, rare HPA suppression, rare hyperglycemia

Front 95

Psoriasis TX: Topical 1st Line: Vit D Analogues

Back 95

Plaque-type; inhibits keratinocyte differentiation/proliferation:
o Calcipotriene: 25
o Calcitriol: mild-moderate plaque
o ADR: hypercalcemia

Front 96

Psoriasis TX: Topical 1st Line: Tazarotene

Back 96

Modulates keratinocyte differentiation/proliferation:
o Never apply to >20% BSA!!
o ADR: burning, itching, redness, peeling

Front 97

Psoriasis TX: Topical 2nd Line Drugs

Back 97

• Coal tar
• Anthralin
• Calcineurin inhibitors

Front 98

Psoriasis TX: Topical 2nd Line: Coal tar

Back 98

Hyperplasia then epidermal thinning
o ADR: messy, smelly, stains, photosensitivity

Front 99

Psoriasis TX: Topical 2nd Line: Anthralin

Back 99

Inhibits DNA synthesis; skin or scalp (Dritho-Scalp)
o ADR: similar to coal tar

Front 100

Psoriasis TX: Topical 2nd Line: Calcineurin inhibitors

Back 100

NOT FDA approved; ↓T-cell activation:
o Do NOT induce skin atrophy like steroids

Front 101

Psoriasis TX: Systemic 1st Line Drug Types

Back 101

• TNF-α inhibitors
• T-cell activation inhibitors
• Oral

Front 102

Psoriasis TX: Systemic 1st Line: TNF-α inhibitors

Back 102

• BBB
• Infliximab
• Etanercept
• Adalimumab

Front 103

Psoriasis TX: Systemic 1st Line: TNF-α inhibitors: BBB

Back 103

HSTCL (hepatosplenic T-cell lymphoma), TB, other infections

Front 104

Psoriasis TX: Systemic 1st Line: TNF-α inhibitors: Infliximab

Back 104

Chronic severe plaque & arthritis:
- ADR: HA, fever, chills, fatigue, D, URTI, UTI, hypersensitivity, BBB

Front 105

Psoriasis TX: Systemic 1st Line: TNF-α inhibitors: Etanercept

Back 105

Chronic severe plaque & arthritis:
- 35

Front 106

Psoriasis TX: Systemic 1st Line: TNF-α inhibitors: Adalimumab

Back 106

Chronic severe plaque & arthritis:
- 36

Front 107

Psoriasis TX: Systemic 1st Line: T-cell activation inhibitors

Back 107

o Alefacept
o Ustekinumab

Front 108

Psoriasis TX: Systemic 1st Line: T-cell activation inhibitors: Alefacept

Back 108

Chronic severe plaque only:
- 39,40

Front 109

Psoriasis TX: Systemic 1st Line: T-cell activation inhibitors: Ustekinumab

Back 109

Chronic severe plaque only:
- 41,42,43

Front 110

Psoriasis TX: Systemic 1st Line: Oral

Back 110

o Acitretin: oral retinoid for psoriasis only
- 51,52
o Cyclosporine: immunosuppressant that ↓T-cell activation
- 53,55
- ADR: 53
o Methotrexate (MTX): 56,57

Front 111

Psoriasis TX: Systemic 2nd Line

Back 111

Only for failed others
o Bad ADRs – bone marrow suppression, GI effects

Hint 111

• Myclophenolate mofetil
• Sulfasalazine
• 6-thioguanine
• Hydroxyurea