NAME: Cytotoxic (Type II), Immune Complex (Type III) and

NAME: Eleonor M. Olaybal                                                         DATE:
January 23, 2018

SECTION: B

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CASE TITLE: Baby, Shots Fired

 

DIFFERENTIAL DIAGNOSIS

 

The patient most likely suffered a
hypersensitivity reaction, specifically, a type III hypersensitivity reaction. A
few syndromes or sicknesses that can be associated with this hypersensitivity
reaction are Arthus reaction, serum sickness, and systemic lupus erythematosus,
based on the clinical findings.

 

What is the diagnosis of this case?

 

This type of hypersensitivity
reaction is an adverse effect of the vaccination, specifically Arthus reaction,
which occurs after administering vaccines of tetanus or diphtheria with
toxoids. Symptoms such as swelling, redness and pain begin 6-12 hours after
vaccination. The reaction is categorized as a ‘localized reaction’ as it only
occurred in the site of injection.

 

What is Acetaminophen and why did Dr. Demanarig
advised you to prescribe the drug?

 

            Acetaminophen
is a drug that is used to relieve mild to moderate pain. It can be used to
relieve conditions such as muscle pain, fever, and reactions to shots. It is
prescribed as it can be used to lessen the hypersensitive reaction, as it was
mentioned that the cause of the hypersensitivity reaction was the vaccination.  

 

How many kinds of hypersensitivity are generally
recognized?

 

Four types of hypersensitivity are generally
recognized, namely Anaphylactic (Type I), Cytotoxic (Type II), Immune Complex
(Type III) and T-Cell Dependent or Cell Mediated (Type IV).

 

What are the basic principles of the reactions
and give some clinical examples?

            Anaphylactic
– Vasoactive mediators are released due to activation of basophils and mast
cells by IgE antibodies. EX: Anaphylaxis, Hay Fever, Asthma

            Cytotoxic
– The reaction mediates cell destruction through complement activation or ADCC.
This type involves the antibodies binding to cell surface antigens. EX:
Transfusion reactions, Hemolytic Disease of the Newborn

            Immune
Complex – Immune complexes are deposited locally or systematically and cause
complement activation and an overactive neutrophil response. EX: Arthus
reaction, Serum sickness

            T-Cell
Dependent – This type involves cellular damage, as T-cells are involved. In here
sensitized helper T cells activate macrophages or cytotoxic T cells. EX:
Contact dermatitis, Tubercular lesions

 

What is the pathophysiological basis of this
presumed type III hypersensitivity reaction?

 

            The
reaction involves immune complexes, specifically antibody and soluble antigen
complexes. Normally, phagocytes can clear up these immune complexes but they
are too small to be noticed. Later on, these complexes are attracted to the
basement membrane of blood vessels and cause conditions such as vascular
permeability, which leads to the effusion of fluid into the tissues, causing
edema. Furthermore, it leads to the activation of the complement system, which
is used in large amounts. In addition, neutrophils are also attracted to the
site and generate a continuous inflammatory response. This type of reaction can
occur systematically or locally, depending on where the immune complexes are
deposited.

 

What could be done to further investigate the
reaction?

 

            Laboratory
tests such as determination of erythrocyte sedimentation rate, C-reactive
protein, immune complexes and complement studies can be helpful in tracking
and/or monitoring the hypersensitivity reaction.

 

What might be learned from this reaction that
might inform the location for administration of booster doses?

 

Learning from the reaction and its
causes, further administration of booster doses should not be injected at the
same site as the initial vaccination site. It should be administered at the
upper extremities instead, in order to avoid a condition that may cause the
patient to stop walking.

What might you advise the patients regarding further boosters?

 

Boosters can still be taken as the
symptoms are only the side effects of the vaccine. The reaction/s that occurred
mean that the vaccine is working and the body is responding. But they have
limitations on being administered such vaccines as they experienced a
hypersensitive reaction. They should not receive the vaccine more frequently
than every ten years, as recommended by the Advisory Committee on Immunization
Practices.

 

 

 

NAME: Eleonor M. Olaybal                                                         DATE:
January 23, 2018

SECTION: B

CASE TITLE: Mr. Land Dee’s Cauliflower

 

DIFFERENTIAL DIAGNOSIS

 

            The
possible diseases that correlate with the symptoms of the patient are:
HIV/AIDS, HPV Infection, as it was stated that the patient is sexually active,
so the disease could be sexually transmitted. Also, the disease is somehow
leaning towards HIV as the clinical findings include a positive ELISA and a
decreased CD4 count, as well as the genital wart presented in the beginning.

 

What is the diagnosis?

 

            The
disease is most likely related to human papillomavirus infection. Aside from it
being the most commonly transmitted pathogen through sexual contact, its main
and distinguishing symptom is the presence of warts. In this case, the patient was
also positive for the biopsy of wart and PCR biopsy for Buscke Lowenstein tumor
and HPV, respectively. Therefore, the diagnosis for this case is GCBL or Giant
Condyloma of Buscke and Lowenstein.

 

What are the most common presenting signs and
symptoms of GCBL?

 

            The
most common presenting sign and symptom of GCBL is the presence of a wart which
is described as ‘locally destructive’ and is a ‘verrucous plaque’. It typically
occurs on the penis but can also occur in the anogenital region.

 

What are the risk factors and predisposing
factors which promote HPV infection resulting in GCBL?

 

            The
factors included are: chronic phimosis and poor penile hygiene. The incidence
is higher in males who are uncircumcised or immunosuppression secondary to HIV infection.

 

What is the pathophysiology of HPV?

 

            HPV
targets the squamous epithelial cells and infects it possibly through skin
disruptions. The deepest epidermal layer, the basal epithelial cell, serves as
an important location for the replication of the virus. Afterward, the virus
can be shed the same time as keratinocytes. This is due to the fact that the
HPV takes advantage of the differentiation pathway of keratin cells. The
keratinocytes differentiate and affects the HPV by making their early genes
more expressed, amplifying the viral episome and is able to shed at the same
time with the keratinocyte. In addition, HPV does not cause viremia as it is
not a cytolytic virus.

How does HPV promote the development of carcinoma?

 

            There
are actually specific types of HPV that are labeled as oncogenic or
carcinogenic. When infections with these types become persistent, they can
cause cell abnormalities that lead to possible malignant transformation, thus
causing the development of carcinoma. This is dependent with the inactivation
of cellular tumor suppressor proteins and subsequent DNA damages by the virus.

 

What are the immune evasion strategies used by
HPV?

 

            The
immune system cannot be activated as there is no viremia, as stated above. Also,
specific proteins and oncoproteins of HPV affect different immune responses
such as: HPV E6 and E7 interfering type 1 interferon responses (no initation of
intracellular antiviral cascades) and escape from virus specific cells (e.g.
CD8 positive cytotoxic T cells) due to HPV E5 entrapment of peptide loaded HLA
class I receptor. Furthermore, its location is avascular, meaning there is a
lack of blood vessels, so it evades the immune system easier by being inaccessible
to the cells participating in the immune system.

 

Why is that the disease is positive for HIV but
negative in RPR?

 

            The
disease might have caused a false positive result in HIV, after all, the ELISA
test for HIV is a screening test and may be prone to false positives due to the
viral load of other infections. Furthermore, RPR tests can only produce false
positives from diseases like malaria, lupus erythematosus, infectious
mononucleosis.  

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