Knowledge guides

LG16: Allergy and hypersensitivity reactions

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Advanced Trainees will understand these presentations and conditions.

Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.

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Presentations
  • Airway symptoms:
    • lower, such as:
      • dyspnoea
      • wheezing
    • upper, such as:
      • cough
      • dysphonia
      • stridor
  • Anaphylaxis
  • Angioedema
  • Arrest:
    • cardiac
    • respiratory
  • Gastrointestinal (GI) symptoms, such as nausea / vomiting
  • Hepatitis
  • Nephritis
  • Pericarditis
  • Presyncope
  • Rash:
    • non-urticarial rash
    • urticaria:
      • acute
      • chronic
  • Systemic allergic reaction without anaphylaxis
Conditions
  • Allergic rhinitis / sinusitis:
    • allergic fungal rhinosinusitis
    • allergic versus non-allergic
    • chronic rhinosinusitis with nasal polyposis
  • Asthma:
    • allergic versus non-allergic
    • thunderstorm
  • Atopic dermatitis / eczema
  • Contact dermatitis:
    • irritant, such as excessive hand washing
    • phytophotodermatitis, including toxic reactions such as Margarita syndrome
  • Drug allergies:
    • type I-IV drug allergies
  • Food allergy and other adverse reactions to food, including:
    • food-dependent exercise-induced anaphylaxis, such as:
      • wheat dependant exercise-induced anaphylaxis
    • immunoglobulin E (IgE)-mediated reactions to food allergens:
      • cross-sensitisation between phylogenetically related foods, such as:
        • cashew / pistachio
        • pecan / walnut
      • heat-labile versus heat-stable allergens, such as egg
      • hidden allergens and cofactors
    • insect-food cross-sensitisation syndromes, such as:
      • crustacean / house dust mite allergy
      • oral mite anaphylaxis syndrome
      • tick bite / mammalian meat allergy
    • non-IgE-mediated food-associated syndromes:
      • delayed cow’s milk allergy (food protein-induced allergic proctocolitis and enteropathy)
      • eosinophilic GI disorders, such as eosinophilic oesophagitis
      • food protein-induced enterocolitis syndrome (FPIES)
      • other food intolerances, such as:
        • food chemical additive intolerance
    • pollen-food oral allergy syndrome
  • Inducible laryngeal obstruction / Vocal cord dysfunction
  • Insect allergy:
    • IgE-mediated reactions, such as:
      • tick-bite anaphylaxis
      • venom:
        • ant
        • bee
        • wasp
    • localised reactions – small and large
    • serum sickness
  • Ocular hypersensitivity:
    • conjunctivitis:
      • allergic
      • keratoconjunctivitis:
        • atopic
        • vernal
  • Urticaria and angioedema:
    • urticaria with or without angioedema:
      • acute
      • chronic spontaneous urticaria
      • isolated angioedema – acute, recurrent, or persistent:
        • drug-induced
        • hereditary angioedema, such as type I, II, III, and new emerging forms
        • idiopathic angioedema
        • orofacial granulomatosis
      • physical urticarias:
        • aquagenic
        • cholinergic
        • cold-induced
        • delayed pressure-induced
        • dermographism
        • exercise-induced
        • pressure-induced
        • solar
        • vibration-induced
  • Vaccine hypersensitivity reactions

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients’ needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
Mast cell disorders
  • Hereditary alpha tryptasemia
  • Mast cell activation syndrome:
    • biopsychosocial context
    • published diagnostic criteria
  • Mastocytosis (multidisciplinary care with haematologist and dermatologist):
    • cutaneous, including:
      • diffuse, including:
        • telangiectasia macularis eruptiva perstans (TMEP)
      • urticaria pigmentosa
    • systemic – diagnostic criteria:
      • aggressive
      • indolent
      • mast cell leukemia
      • mast cell sarcoma
      • smouldering
      • with associated haematological malignancy, such as myelodysplasia or chronic myelomonocytic leukaemia (CMML)

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients’ needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
  • Clinical utility of component allergen testing, such as that it may help resolve cross-reactive carbohydrate reactivity in multiple positive venom ssIgE testing
  • Component allergens and risk stratification of anaphylaxis
  • Geographic distribution of relevant insects, such as:
    • ants
    • certain flies
    • ticks
  • Insect venom and bite allergy, such as hymenoptera and tick
  • Physicochemical features:
    • carbohydrates – galactose α-1,3-galactose
    • nomenclature of allergens, such as the first three letters of genus, first letter of species, and numerical assignment based on order of discovery (such as Der p10 – dermatophagoides pteronyssinus tropomyosin)
    • proteins, often with repeating structures and different structural stability with heating
Anaphylaxis
  • Cofactor relevance to each patient
  • Contraindications, indications, precautions required, and risks:
    • benefits / risks of immunotherapy for anaphylaxis, such as insect venoms, and emerging food protocols for particular demographics
    • tests to identify triggers and cofactors involved in anaphylaxis
  • Differential diagnoses of recurrent anaphylaxis
  • Pathophysiology of acute systemic mast cell-mediated medical emergency, including acute lung pathology and cardiovascular consequences, in addition to mechanisms of mast cell activation
Angioedema and urticaria
  • Different endotypes of chronic spontaneous urticaria, and appreciation of endotype impact on treatment response
  • Differential diagnosis of acute and chronic urticaria
Atopic dematitis / eczema
  • Complications
  • Differential diagnoses and mimics
  • Full spectrum of clinical presentations, including contribution of cofactors
Drug allergy
  • Assessment of cross-reactive drugs
  • Assessment of penicillin allergy, especially considering de-labelling penicillin allergy in the low-risk population
  • Contraindications, indications, interpretation and the role of drug skin tests in investigations of drug hypersensitivity
  • Diagnosis of delayed-type hypersensitivity reactions, including severe cutaneous adverse reactions (SCAR), such as:
    • acute generalized exanthematous pustulosis
    • drug reaction with eosinophilia and systemic symptoms
    • Stevens–Johnson syndrome
    • toxic epidermal necrolysis
  • Differences between hypersensitivity and intolerance
  • Mechanisms of drug hypersensitivity:
    • altered peptide repertoire
    • hapten mechanism
    • p-i concept
  • Severe adverse drug reactions, including use and interpretation of intradermal, skin patch, skin prick, and in vitro testing for various type IV hypersensitivities
  • Type 1 adverse reactions to drugs
Food allergy
  • Avoidance measures in the management of eosinophilic GI diseases
  • Clinical presentation and natural history of intolerances to additives, foods, lactose, and other substances
  • Community and legislative matters
  • Concepts of food science as applicable to food allergies and intolerances
  • Distinguish between hypersensitivity and intolerance
  • Education regarding current theories of food allergy sensitisation pathways
  • Indications, modes of delivery, preparations, and potential adverse effects of pharmacotherapies for eosinophilic GI diseases
  • Natural history of food allergy (from infant to adulthood) relating to persistent food allergy, and encompassing primary versus secondary allergies
  • Potential cross-reactivity with non-food allergens
  • Role of microbiome / meta-metabolome in food allergy
Occupational allergens
  • Management of occupational allergens, such as latex
Rhinitis
  • Consideration of severity and awareness of geographical variation of triggers, such as pollen distribution in Australia
  • Different phenotypes / endotypes, and epidemiology
  • Differential diagnoses of allergic versus non-allergic rhinitis / sinusitis
  • Inflammatory changes in chronic rhinosinusitis, with and without nasal polyposis
  • Sinonasal anatomy, and changes associated with allergic or eosinophilic inflammation
  • Surgical therapies of the nasal airway

PCH

  • Basis of infant nutrition and feeding-related immune adaptation, including the role of breastfeeding and hypo-allergenic formulae
Drug allergy
  • Assess cross-reactivity between drugs
  • Challenge procedures when indicated using established protocols
  • Drug desensitisation
Investigations
  • Assays:
    • C1 esterase inhibitor – quantitative and functional
    • different platforms for serum specific IgE testing, previously known as radioallergosorbent test (RAST):
      • component resolved testing, such as arachis hypogaea 2 (Ara-H2), and appraisal of evidence around clinical utility of these more expensive tests
      • performance of assay for each allergen differs, including:
        • laboratory versus clinical context
        • screening versus diagnostic intent
        • utility of total IgE
  • False negatives and positives, likelihood ratios, positive and negative predictive values, pre-test probability, sensitivity, and specificity, and incorporate these into routine practice
  • Serum mast cell tryptase
  • Skin biopsy
  • Skin prick testing and intradermal testing (for medications, if appropriate):
    • interpretation
    • safety
    • quality
  • Spirometry
Procedures
  • Adrenaline autoinjectors
  • Drug tests:
    • drug challenges
    • intradermal testing
    • patch tests
    • skin prick testing
  • Food challenges:
    • double blind
    • open
    • single
  • Specific allergen immunotherapy:
    • oral
    • subcutaneous
    • sublingual
  • Systemic mast cell disease:
    • emerging therapies
    • symptomatic therapy
    • systemic immune suppressive therapy, practice, and principles for:
      • biologic agents
      • conventional disease-modifying antirheumatic drugs (DMARDs)
  • Venom immunotherapy
Action / Management plans
  • National best practice standards around the management of patients with allergy
  • Reduction of risk of re-exposure through use of:
    • alert systems
    • education
    • institution of allergen minimising environments
  • Standardised action and management plans for anaphylaxis and/or allergic reactions, as per the Australasian Society of Clinical Immunology and Allergy
  • Venom immunotherapy:
    • anaphylaxis action plans, incorporating adrenaline autoinjectors when appropriate
    • natural history of allergy to stinging insects without, during, and after venom immunotherapy
Anaphylaxis
  • Co-factors / Exacerbators
  • Drug metabolism, entomology, and food science as relevant to investigation of anaphylaxis
  • Psychosocial aspects
  • Refractory, rebound, and treatments beyond adrenaline
  • Resources required to prevent and manage acute anaphylaxis in the community
  • Risk factors, such as asthma, and education regarding risky situations
Angioedema and urticaria
  • Adverse effects and efficacy of treatments for hereditary angioedema
  • Dental management of patients with hereditary angioedema
  • Hereditary angioedema when present in patients presenting with oedema
  • Management plans to include:
    • avoidance of exacerbating / precipitating factors
    • pharmacotherapy:
      • first line agents
      • immunomodulatory strategies for refractory urticaria
      • second line agents
  • Peridental, perioperative, and obstetric management of patients with hereditary angioneurotic oedema
  • Prescribing practice for Berinert and icatibant in Australia, and awareness of newer therapeutics
Asthma
  • Assessment, management, and monitoring of patients:
    • biologics
    • immunotherapy
Atopic dermatitis / eczema
  • Community resources available to patients with atopic dermatitis
  • Comorbidities
  • Contraindications, indications, and potential beneficial and adverse effects of medical therapies, such as:
    • topical and systemic calcineurin inhibitors
    • topical glucocorticoids
    • other immunosuppressive strategies:
      • indications and management practices for biologic agents, such as dupilumab
  • Epidemiology of allergic disorders in childhood
  • Immunological comorbidities, such as immune deficiency, that may exist in patients with atopic eczema
  • Management plans, such as from the Australian Society of Clinical Immunology and Allergy
Food allergy
  • Management of food allergy in the community, such as:
    • action plans
    • provision of adrenalin autoinjectors when appropriate
    • school and travel plans

PCH

  • Dietary restrictions while ensuring adequate nutrition, especially in infancy
  • Efficacy of interventions to reduce the risk of the development of allergic disorders in children