Nursing Case Study For Immune Function

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A Case Study Involving Influenza and the Influenza Vaccine
This interrupted case study presents a discussion about the benefits of the influenza vaccine between Mary, a nursing student, and her coworker, Karen. Karen is not convinced by Mary’s arguments in favor of vaccination, and she counters with seve...


A Diet to Die For
This clicker case is designed to lead students to a conceptual understanding of oxidative phosphorylation (and, by analogy, photosynthesis). Students begin with a pre-class handout that presents background information on DNP, a weight-loss drug that wa...


A Question of Responsibility
Most students are aware that asbestos is a health hazard, but don’t know that “asbestos” refers to a variety of minerals with both useful and harmful properties. In this case, students answer questions they have about asbestos in the ...


A Search for the Right Answer
In this role-playing case study on Parkinson’s disease, students learn about brain injury and brain repair mechanisms, the physical and psychological effects of a degenerative disease on a patient and her family, the ethics of fetal tissue resear...


A Simple Plan
This case study introduces students to Dr. E.L. Trudeau, who performed a seminal early experiment validating the germ theory of infection. Part I introduces Trudeau's Rabbit Island experiment, which is simple and easy for beginning or non-major student...


Abracadabra
This case introduces students to HIV, its life cycle, treatment, and problems associated with treatment options. The case, which incorporates critical thinking skills, active learning, self-directed study, and peer-to-peer learning, was developed for u...


African Illness: A Case of Parasites?
This case is based on a British patient presenting to a hospital with an array of symptoms after returning from an African safari. Students learn about potential causes of the symptoms based on the patient's potential exposure to parasites endemic to A...


Agony and Ecstasy
This interrupted case study explores the scientific, legal, and societal complexities of repurposing an illicit substance, 3,4-methylenedioxymethamphetamine (MDMA), also known as "Ecstasy" or "Molly," into a clinically accepted medicine for treating po...


AH-CHOO!
As the carbon dioxide concentration of our atmosphere increases and our climate warms, the hay fever season seems to be getting longer and more severe. In this case study, students assume the a role of a public relations specialist contracted to commun...


All That Glitters May Not Be Gold
In this decision case, a congressional staffer must weigh a number of competing concerns and issues, including popular reactions to genetically modified organisms, in deciding how to present information to her boss, an influential congressman drafting ...


An Infectious Cure
This four-part interrupted case on phage therapy was developed for a freshmen non-majors course in molecular biology. The case begins with a story inspired by real events where Europeans imposed a treatment for cholera on the unwilling population of an...


And Baby Makes Four
This case study is based on stories reported in the media and is used to examine biological and ethical dimensions of assisted reproductive technologies, specifically egg donation and gestational surrogacy.  The case follows an Indian woman as she...


Anencephaly in Yakima
This case study explores the recent (2010 - 2016) outbreak of neural tube defects, specifically anencephaly, in a rural three-county region of Washington state, particularly Yakima, WA. The case study focuses on the biological aspects of teratogens tha...


Anthrax Attack!
This case study presents a fictitious bio-terrorist plan to release anthrax in the United States. Students are assigned character roles and, through research, role-playing, and teamwork, develop a plan to minimize or avert the attack. The case is appro...


Antibiotic Resistance
Resistance to antibiotics arose very shortly after these "wonder drugs" were first introduced.  This case study examines resistance to the most commonly used antibiotics, penicillin and its derivatives.  In particular, it examines a recent st...


Antibiotic Resistance in a Russian Prison
In this case study, students will have the opportunity to model the spread of tuberculosis and development of antibiotic resistance in a hypothetical prison environment. After reading a brief handout and viewing a short video, students play a simulatio...


Bad Blood
The ethics of human experimentation are explored in this case about the infamous syphilis studies performed at the Tuskegee Institute from the 1930s to the 1960s. Sponsored by the U.S. Public Health Service, 399 African American men with syphilis were ...


Biological Terrorism
In the weeks following the September 11, 2001, terrorist attacks on the World Trade Center and the Pentagon, anthrax-laced envelopes were mailed to individuals in government and the news media. Thousands were treated for exposure, and five people were...


Bringing Home More than a Medal
This case study was inspired by the Zika virus outbreak that occurred around the time of the 2016 Olympic Games. Many athletes were fearful of attending because of the link between Zika virus infection and microcephaly in infants. This concern, however...


BSL-4: Authorized Personnel Only
This case study is based on the 2014 Ebola epidemic that spread to multiple highly populated countries in West Africa, making it the largest and most devastating outbreak in the history of the virus. The storyline, inspired by a compilation of factual ...


Campus Outbreak!
This PowerPoint-driven case study follows the progress of three undergraduate students as they attempt to model the rapid spread of an influenza outbreak to determine whether their local newspaper's claim that "40% of the campus has the flu" is accurat...


Cancer Cluster or Coincidence?
In this interrupted case study students analyze the complexities surrounding identification and confirmation of cancer clusters. The case challenges students to consider the evidence from two different perspectives; a local family physician representin...


Cell Phone Use and Cancer
In this case study, students analyze a scientific study, first by analyzing news articles reporting on the research and then by reading the original research article. In working through the case, students identify the basic elements of a scientific stu...


Chickens and Humans and Pigs, Oh My!
Influenza is a common topic in the popular press and a point of interest for many students.  This case study was written to promote interdisciplinary connections between upper division virology and immunology classes.  Students that participa...


Childbed Fever
This case describes the pioneering work of Ignaz Semmelweis and his efforts to remedy the problem of childbed fever in mid-19th century Europe.  Its purpose is to teach students about the scientific method by "dissecting" the various steps involve...


Chimpanzee Droppings Lead Scientists to Evolutionary Discovery
This interrupted case study focuses on the research of Dr. Beatrice Hahn, who investigates DNA sequences in chimpanzee droppings in order to explore the origins of the human immunodeficiency virus (HIV). Students first consider the types of data that c...


Closing the Gap
In this problem-based learning/role playing case, students apply their knowledge of the biology of HIV/AIDS and antiretroviral therapy to developing foreign aid policy for the HIV/AIDS crisis in sub-Saharan Africa. The case was created for a non-majors...


Coffee and Cigarettes
This analysis case explores second-hand smoke and its impact on the decision to institute a smoking ban in the outdoor seating area of a popular coffee bar.  In working through the case, students discuss the medical, ethical, legal, and societal i...


Danielle's Difficulty
The incidence of Clostridium difficile infection (CDI), including severe infection, has increased in both institutional settings and the general community. This case study presents the story of an elderly woman who spent time in a hospital and...


Decoding the Flu
This "clicker case" was designed to develop students' ability to read and interpret information stored in DNA. Making use of personal response systems ("clickers") along with a PowerPoint presentation, students follow the story of "Jason," a student in...


Dengue in the Landscape
This interrupted case engages students in issues contributing to the increase of dengue fever in Jamaica. The overall goal of the case is to make clear the connections between land use management and public health, specifically dengue fever. Students l...


Disease Along the River: A Case Study and Cholera Outbreak Game
This case study centers on an active teaching game that simulates a cholera outbreak among five villages along a river, similar to the Haitian outbreak of 2010. By enacting the behaviors of fictional villagers, students learn how trade, travel, sanitat...


Dr. Collins and the Case of the Mysterious Infection
In this case study, Dr. Collins must diagnose and prescribe treatment for a young patient with a serious infection. Students receive pieces of the case in a progressive disclosure format and answer questions about bacterial infection, antibiotics, and ...


Drug Wars: An Epic Tale of Asthma and Bacterial Pneumonia
This case study is based on real events that the author experienced with her 10-year-old daughter. Although the names have been changed, all of the events (symptoms, diagnoses, treatments, types of healthcare professionals) are recorded exactly as they...


Earthquakes Damage Cells, Too
Cholera is a commonly explored disorder when teaching transmembrane transport. Expanding on this theme, this case study also introduces intracellular and extracellular signal transduction, the physiological basis of rehydration treatments, and provides...


Eating PCBs from Lake Ontario - Is There an Effect or Not?
This case is based on an actual news release reporting on research about the effects of eating Lake Ontario fish contaminated with PCBs. Developed to teach students about statistical analysis and experimental design, the case has been used in a senior-...


Eating PCBs from Lake Ontario - The Clicker Version
This is a “clicker” adaptation of another case in our collection, “Eating PCBs from Lake Ontario: Is There an Effect or Not?” (2001), written by the same author. It encourages students to examine how scientific results get prese...


Ethnomedicine in Latino Communities of Madison
This PowerPoint-delivered case study guides the reader, a hypothetical student intern with the City of Madison (Wisconsin) Public Health Department, as he/she assists a physician who was awarded a grant to investigate the use of herbal medicines by Lat...


Face the Fats
This clicker case introduces students to the biochemistry of lipids through the story of Pete, a college student who begins to consider his nutritional fat intake after watching a commercial for the cholesterol-lowering drug Vytorin. In this case, stud...


Family, Culture, Medicine
This four-part problem-based learning case examines cultural conflicts between Western medicine and non-Western traditional healing practices. Students consider notions of cultural relativism and ethnocentrism through the lens of social institutions, i...


Farmville Future?
Life has changed for the rural residents of Farmville County since the arrival of four concentrated animal feeding operations (CAFOs); the air has an odor, wildlife has decreased, and illnesses are on the rise. One of the town's residents has become ac...


Fat Facts
It's Mother's Day and Dolly, a high school senior, is making a Mediterranean salad for her mom, who is a college chemistry major and who likes to take every opportunity to teach Dolly what she has learned in school. Today is no exception, as she guides...


From Cow Juice to a Billion Dollar Drug, With Some Breakthroughs in Between
Before the discovery of insulin in 1921, being diagnosed with Type 1 diabetes was a death sentence. Despite the successful management of diabetes with purified animal insulin, potentially severe side effects were abundant, and alternative ways to produ...


Hidden in Plain Sight
As nonliving entities, viruses face specific challenges when replicating in a host.  Avoiding the host immune system is something that every virus aims for in order to successfully reproduce itself and infect another host.  Many viruses repli...


Holes in the Matter
This case centers on a fictional group of young adults who studied abroad together in Scotland as college students. A number of them develop disease symptoms and die a few years after the trip. The cause of death is determined to be a prion disease. Ap...


Hunting the Ebola Reservoir Host
This one-hour introduction to the study of infectious diseases uses recent research on the Ebola reservoir host to motivate students to consider the characteristics of a viral host species and how it can be identified. Presented in the form of an inter...


I Can Quit Anytime I Want
This “clicker case” explores the biological basis for the temporary euphoria that accompanies drug use as well as certain aspects of the biological basis of drug dependency. The case is called a clicker case because it is designed for use w...


I Don't Need a Flu Shot!
In this “clicker case,” Ryan, a college student, receives an email from the campus health education office urging students to get a flu shot. Ryan thinks it is too late since he just had the stomach flu, and besides, even if he did catch it...


Inactive Brains
Two speakers have been invited to a town hall meeting to help decide a hotly contested issue. A grant has been awarded to the school district with the stipulation that the money be dedicated to only one program. School officials wish to use the funds t...


Indigenous Knowledge and the Search for Medicine
This case study is based on a real scenario in which a high-profile ethnobotanical study in Chiapas, Mexico, ended when local and international organizations accused the managing researchers of biopiracy. Students will explore how the Maya Internationa...


Is it a Lemon or a Lyme?
This dilemma case was designed for a junior level immunology course. It could also be used in a microbiology or bacteriology course where the emphasis is on treatment as well as disease. Although the case revolves around a particular microbe that cause...


Is the Data Dirty or Clean?
This case study challenges students to differentiate between anecdotal evidence and science-based evidence related to human health. The case uses a "flipped" approach in which students watch two preparatory videos prior to attending class. The fir...


Katrina's Troubled Waters
This case study explores some of the health issues brought to light during the flooding in New Orleans caused by Hurricane Katrina. The case encourages students to think about a variety of problems that can occur when humans are exposed to unsanitary f...


Let's Get This Course Started
The first day of class is often a reading of the syllabus, even when active learning approaches are used throughout the rest of the term. This interrupted case uses the first day to model the expectations of a course that uses case method approaches. S...


MDR Tuberculosis
In this case study on multi-drug resistant (MDR) tuberculosis, students consider ways in which to preserve health as a human right without subjecting already marginalized communities susceptible to the disease to further discrimination. Students learn ...


Michael's Story
This interdisciplinary case study introduces us to the Greens, a family with a recently diagnosed autistic child. Autism is one of several disorders grouped within the acronym ASD, or autism spectrum disorders. Autistic children have problems with comm...


Microbial Pie, or What Did You Feed the Neighbors?
The Emergency Room seems busier than usual, and the cases coming in are all too similar.  Everyone seems to be suffering from the same symptoms - abdominal pain, vomiting, and bloody diarrhea.  Once the hospital staff identify the bacteria ca...


Mini Cases in Psychoactive Drugs and Their Effects on the Brain
Designed for an upper-level psychology class titled Brain & Behavior, this series of mini-cases can be used in any undergraduate course that covers the major classes of commonly abused legal and illicit psychoactive drugs from a biological...


Modern Frankenstein?
This interdisciplinary case study uses the format of a progressive disclosure to explore certain advances in biotechnology and evaluate them within the framework of societal needs, concerns and pressures.  When faced with a heart valve transplant,...


Morgan: A Case of Diabetes
This case teaches about the causes and effects of Type 2 diabetes by working through the various options available to a young Native American woman suffering from the disease. The case can be used in a variety of settings, including nutrition classroom...


New Ways to Breathe
This case study follows a young cystic fibrosis (CF) patient named Lucas. Through Lucas's story and interactions between his parents and pediatrician, students learn about the scientific background and basis of CF. By reviewing email correspondence bet...


No Longer Fond of the Local Pond
When an elementary school teacher calls in sick to work, she finds out that she is not the only one who will be missing school that day.  Children from her fifth grade class have also become ill and parents are calling to report the absences. The ...


On a Clear Day You Can See Forever
In this case study, developed for an introductory environmental studies course, students grapple with the issue of air pollution, specifically the causes and effects of haze and smog as ubiquitous, persistent air quality problems that plague urban and ...


Patient Zero
Emerging diseases and potential pandemics make the news nearly every year. Students (and everyone else) may wonder where new infectious diseases come from, how scientists assess the risk of a pandemic, and how we might go about preventing one. This cas...


Pesticides
By simulating a public hearing, this case study requires that students sift through and organize information on pesticide use presented to them from the perspective of different stakeholders. The case asks a fundamental question, Can we do without ...


Resistance is Futile - Or Is It?
While the majority of people are prone to HIV infection, some individuals remain uninfected despite repeated exposure. This case study is based on the landmark paper by Paxton et al. (1996) that uncovered some of the mechanisms of protection against HI...


Resistance Is Futile, Or is It? The Clicker Version
This clicker case is an adaptation of a case by Annie Prud'homme-Généreux that was originally published by the National Center for Case Study Teaching in Science titled "Resistance Is Futile ... or Is It? The Immunity System and HIV Infec...


Resurrection
This case study examines the molecular methods that were used to reverse engineer the 1918 influenza virus strain in order to try and solve the mystery of why it was so deadly. The story starts in the 1950s with the unsuccessful attempts to culture the...


Retro Goes Modern
This case study considers the evolution of HIV from SIV, as well as the evolution of HIV within humans by mutation rate. It also discusses the immune evasion proteins NEF and VPU, and how anti-retroviral drugs act to stall viral replication. Finally, t...


Return of the Whoop!
This interrupted case study outlines the history of pertussis or whooping cough, a disease that in the early 1900s claimed the lives of more people than diphtheria, scarlet fever, and measles combined. Whooping cough continued to afflict and kill a lar...


Revolt on the Tuberculosis Ward
Monique is a 30-year-old Haitian woman with advanced pulmonary tuberculosis who has been transferred from a tuberculosis sanatorium to a large general hospital in Port au Prince after developing a secondary infection with Bacteroides fragilis ...


Sex and Vaccination
This case study focuses on the controversy surrounding the decision by Texas Governor Rick Perry to mandate the compulsory vaccination of girls in the Texas public school system against the human papillomavirus (HPV) prior to entering the sixth grade. ...


Shannon and Jake
This case was developed to teach first-year medical students the basics of medical ethics. It describes a situation in which a family physician is treating a teenage patient for a sexually transmitted disease. Based on information she gives him, he is ...


Sick on a South American Sugarcane Plantation
This case study familiarizes readers with a disease that affects millions of people in Central and South America while illustrating a relatively uncommon route of transmission.  The narrative is based on reports of oral transmission of Trypano...


Statins Stat!
This case study describes a visit by "Naomi" to her physician, who upon seeing Naomi's bloodwork decides to prescribe her a cholesterol-lowering agent, a statin. The case discusses (1) the prevalence of non-communicable diseases such as atherosclerosis...


Streams of Coal or Streams of Death?
Mary Beth was raised in Western Pennsylvania, an area where thousands of abandoned coal mines have led to extensive contamination of streams and associated ground waters. Aquatic life has clearly suffered, but the health effects on people living along...


Sunny Skies and a Lurking Microbe
Based on a true story, this case study chronicles the development of a wound infection that began as a minor cut that occurred while carrying out a typical household task (moving furniture).  Identifying the causative agent ultimately took three s...


Super Bug
Sam, a pre-med college student, routinely gets dialysis and develops a urinary tract infection. The infection is from a bacterium that the news media is calling a "superbug" from India. Sam does some internet searches to find out more information about...


The 1st New Disease of the 21st Century
This case study uses a PowerPoint (~1MB) combined with role-playing to present the epidemiology and pathophysiology of Severe Acute Respiratory Syndrome (SARS). Students learn about the etiology and pathophysiology of the disease, and then argue differ...


The Case of a Tropical Disease and its Treatment
This case study highlights the epidemiological and socioeconomic factors associated with a disease which plagues thousands of people in Central and South America.  The case follows the story of Adrian, a banana plantation worker in southwestern Co...


The Case of the Newborn Nightmare
Three newborns left in the care of "Dr. Mark Maddison" have developed a mysterious rash. Under increasing pressure from hospital administrators and distressed parents, the doctor must diagnose and treat the infants. Students are given discrete pieces o...


The Dilution Effect
In this case study students are provided with information for piecing together the story of how forest fragmentation and biodiversity loss can affect the risk of Lyme disease transmission to humans. The case introduces the dilution effect, a widely acc...


The Evolving Genetics of Disease Resistance
This interrupted case study for the flipped classroom applies evolutionary genetics research to human health. Students learn about a naturally occurring, but rare, allele of the CCR5 gene, CCR5-Δ32, which provides resistance to ...


The Haemophilus Vaccine
This case study focuses on a young mother whose child attends a day care center where there has been an outbreak of bacterial meningitis. The case explores the need for health care workers to provide relevant medical information and advice to patients,...


The Medicinal Use of Marijuana
Whether marijuana should be legalized for medicinal purposes has been contested for decades. The claims, counter-claims, issues, and judgments in this high profile controversy make it an excellent candidate for “intimate debate.” While simi...


The Modern Caveman’s Dilemma
During the Paleolithic era, human life expectancy was only 33 years—roughly half of what it is today. We owe our more extended lives in part to better hygiene, medicines, and more plentiful foods. Yet some people aspire to return to that earlier ...


The Mystery of the Blue Death
This historical case study describes the story of John Snow’s discovery of water-borne transmission of cholera in 19th-century London. Designed for use in a Global Health class, the case explores cholera outbreaks and their causes as well as mode...


The Never-Ending Contamination
This case study discusses a possible national security crisis of a terrorist group stealing radioactive materials in an attempt to build and detonate a dirty bomb over a densely populated metropolitan area. Specifically, this case discusses radioactive...


The Unfortunate Nurse
Dengue (pronounced "deng-ee") is a viral disease transmitted by the bite of an infected mosquito, usually Aedes aegypti. It is common in tropical regions, especially Southeast Asia, India, South and Central America, and Mexico. There is conc...


The Water in Weberville
This case study presents a realistic example of drinking water contamination within a fictional local community and leads students through an abbreviated human health risk assessment. Students are provided background information about the extent of the...


The Write Weight
Kasey is a busy undergraduate student who is struggling with her body image and wants to lose weight. To aid in this process, Kasey keeps a food and activity journal. Students review Kasey's food and exercise choices, calculate Kasey's daily caloric in...


To Spray or Not to Spray
In this case study, students grapple with the complex issues surrounding the use of DDT to control malaria in the developing world. In their examination of the issue, students consider risk/benefit analysis and the precautionary principle, two techniqu...


To Vaccinate, or Not to Vaccinate
The case was prompted by a newspaper story about a couple who refused on religious grounds to have their son vaccinated even though vaccination is a requirement for admission to the public schools. It explores the issues surrounding the necessity and c...


Tragic Choices: Autism, Measles, and the MMR Vaccine
This case explores the purported connection between vaccines in general, and the MMR vaccine specifically, and autism. Students examine results from the 1998 Lancet article that ignited and still fuels the anti-vaccine movement; students are t...


Tuna for Lunch?
This case examines mercury bioaccumulation and biomagnification within the context of the human health impacts of ingesting food (specifically, fish) contaminated with mercury. It was inspired by a 2009 USGS report on mercury in fish, sediment, and wat...


Under the Knife and Completely Aware
This case study is based on a newspaper article about the suicide of Sherman Sizemore shortly after he underwent an exploratory laparotomy (abdominal surgery).  After his surgery, Sherman experienced symptoms similar to post-traumatic stress disor...


Vaccines, Social Media, and the Public Health
While the "vaccine controversy" has made headlines since the late 1990s, the emergence and popularity of social media has created a public opinion space bursting with pseudoscience, debatable claims and anecdotes regarding the value and importance of c...


When Work Makes You Sick
This case study was inspired by a real-life scenario, and follows the story of Roberto, a migrant farmworker whose health is impacted by the usage of pesticides on a farm.  With the help of a health care provider, Roberto becomes aware of the effe...


Why Was the 1918 Influenza So Deadly?
In this intimate debate, students examine the causes of the devastation wrought by the 1918 Spanish Influenza pandemic. Students consider whether the 1918 flu was exceptionally deadly because of its biology, or whether prevalent geopolitical-socioecono...


Earn 1 Contact Hour – Free of Charge

The goal of this CE activity is to provide nurses and nurse practitioners with knowledge and skills to recognize and manage acute hypersensitivity reactions (HSRs) occurring as a result of medication administration. After reading this article, you will be able to:

  • Recognize early signs and symptoms of acute HSRs
  • Describe evidence-based nursing and medical management of HSRs
  • Discuss prevention of HSRs

An acute hypersensitivity reaction is a rare but serious complication of exposure to foods, natural-rubber latex, medications, and other antigens. Patient allergies are not always clearly defined in the medical record, and severe reactions may not be anticipated. Nurses and nurse practitioners must recognize HSR risk factors, read early signs and symptoms, and intervene to protect the patient from further harm.

Authors: Brenda Shelton, MSN, RN, CCRN, AOCN; and Jane C. Shivnan, MScN, RN, AOCN



What are Hypersensitivity Reactions?

A hypersensitivity reaction (HSR) is an exaggerated immune response to an antigen which results in local tissue injury and may include life-threatening systemic effects. The most extreme form of HSR is anaphylaxis or anaphylactoid reactions, a life-threatening emergency. Common antigens eliciting HSRs include foods such as peanuts and shellfish, environmental antigens such as natural rubber latex, venoms such as those from bee stings and fire ants, and medications such as antibiotics, monoclonal anti-bodies and chemotherapy. Although acute HSRs generally occur within minutes of antigen exposure, there is a wide spectrum of HSR presentations-including biphasic and delayed reactions-that may occur hours to days after antigen exposure. The type of reaction is determined by the primary immunologic mechanism as outlined in Table 1, although it is important to be aware that HSRs in clinical practice often involve multiple immune pathways and may be difficult to categorize.

For the purposes of this CE activity, we will limit our discussion to acute HSRs resulting from exposure to medications and biologic agents. Most of these are categorized as Type I or anaphylactic HSRs. Type I reactions manifest almost immediately upon anti-gen exposure. The primary mediator of Type I reaction is immunoglobulin E (IgE). Anaphylactoid or pseudo-anaphylactic reactions produce identical symptoms, but are not charac-terized by progressive symptoms with each exposure or the presence of IgE antibody. All HSRs are complex immune responses of mast cell degranulation activating histamine release, complement system, prostaglandins, and inflammatory leuko-trienes. The effects of these immune response mediators are responsible for most of the symptoms seen in HSRs, whether they are cutaneous reaction char-ac-terized by itching and hives (histamine) or bronchospasm and vasospasm (leukotrienes and prostaglandins).

Table 1: Immunology of HSR’s

TypeMechanismSigns and Symptoms
IAnaphylactic: Immediate immunoglobin E-mediated reactionFever, nausea, vomiting, flushing, back pain, angioedema, rash, dyspnea, bronchospasm, feelings of impending doom, circulatory collapse
IICytotoxic: Antigen-antibody complexes activate inflammatory pathwaysHemolysis
IIISerum Sickness: Immune complexes form and deposit in various tissuesVasculitis, nephritis, arthritis
IVDelayed Cytotoxic: Activated T cells destroy targeted cellsGraft rejection, contact dermatitis, granuloma formation, Graft-Versus-Host Disease


When are acute HSRs likely to occur?

Acute HSRs are rare, with 1-15% of Americans considered at risk if exposed to known allergens.1 Of those who experience anaphylaxis, approximately 1% will die as a result.1 In hospitalized patients, anaphylactic reactions account for about 6% of reported adverse drug reactions.2 HSRs are more likely to occur with intravenous administration. Complex, protein-based molecules are more likely to elicit the immune-mediated response of an acute HSR, which accounts for the increased incidence of acute HSRs with infusions of biological agents such as antisera or monoclonal antibodies. These agents are often administered in ambulatory settings to patients with diseases such as Crohn’s disease, multiple sclerosis, auto-immune disorders, and cancers. Some smaller molecules, like the penicillins, bind to circulating serum proteins, resulting in increased size and antigenic potential in susceptible individuals. Some diluents used in medication admixture contribute to the risk for HSR.3 Cremophor, for example, is a diluent for paclitaxel, cyclosporin, and tenoposide.

Table 2: Definition of Anaphylaxis
(National Institute of Allergy and Infectious Disease/ Food Allergy and Anaphylaxis Network)

Diagnostic Criteria for AnaphylaxisSymptom onset within minutes to hours of exposure to antigen including symptoms involving the skin or mucosal tissue with any one of the following: hives, pruritis, airway edema, with respiratory difficulty or hypotension.ORAny two of the following within minutes to hours of antigen exposure:

  • Skin or mucosa involvement
  • Respiratory distress
  • Hypotension, or
  • Gastrointestinal symptomsORHypotension within minutes to hours after antigen exposure

Source: Sampson HA, Munoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report-Second National Institute of Allergy and Infectious Disease/ Food Allergy and Anaphylaxis Network symposium, J Allergy Clin Immunol, 2006; 117(2): 391-397.

Oncology nurses are particularly likely to witness HSRs from antimicrobials, biological and chemotherapeutic agents. All chemotherapy has the potential to cause an HSR. Chemotherapeutic agents with the highest reported incidence of HSRs include L-asparaginase (10-35%), taxanes (2-5%), platinum compounds (10-27%), etoposide and teniposide (6-40%), and procabazine.4 Platinum compound HSRs are considered IgE-mediated, occurring after seven to nine doses have been safely administered. On the other hand, nearly 95% of reactions to taxanes and L-asparaginase occur during the first or second infusion.

Monoclonal antibodies used in medi-cine, neurology, cardiology and oncology can cause severe infusion reactions induced by cytokine release. Although these are not Type I acute HSRs, their implications for assessment and management are similar. The incidence of reactions with monoclonal antibodies varies: rituximab (up to 75%), trastuzumab (up to 40%), cetuximab (19%), infliximab (1-6%), bevacizumab (1%), natalizumab (1%), and abiciximab (0.6%).

Severe HSRs may also be triggered by medications used to manage general medical-surgical conditions. As many as seven individuals in a thousand may experience angioedema upon exposure to ACE inhibitors.2 Other medications known to cause significant HSRs include anesthetics, anticonvulsants, antiarrhythmics, aspirin, radiocontrast media, and sedative-hypnotics. Antibiotics such as penicillins, beta lactams, sulfonamides, and trimethoprim sulfamethoxazole also commonly trigger HSRs of variable severity.


What are the signs and symptoms of acute HSRs?

Some of the signs and symptoms of acute HSRs overlap with milder infusion reactions. Patients may experience fevers, chills, rigors, flushing, and diaphoresis (sweating) as temperature regulation is disrupted by circulating cytokines. Histamine release from mast cell degranulation may cause pruritis (itching) and rashes, including hives. Arthralgias (joint pain) and myalgias (muscle pain) may occur. The patient may complain of a headache, dizziness, abdominal pain, or nausea.

Serious systemic effects include dyspnea, bronchospasm, cyanosis, tachycardia, and hypotension or hypertension. Abdominal or lower back pain may indicate visceral smooth muscle contraction. The patient may also experience a sense of impending doom, may lose consciousness, and may suffer a circulatory collapse. A uniquely life-threatening event in an acute anaphylactic HSR is angioedema, a rapid swelling of tongue and throat tissues that can obstruct the patient’s airway. Life-threatening HSRs are more likely to occur with intravenous administration, which places the antigen into the blood-stream, particularly with more rapid infusion rates.
Nurses should be alert to possible symptoms during and immediately after administration of the at-risk agent. Initial subtle symptoms may progress to life-threatening complications within minutes. Anaphylaxis diagnostic criteria are described in Table 2. Clinical suspicion is augmented with diagnostic tests to validate HSRs, so that future antigen exposure can be controlled. Allergen-specific IgE levels are available for some drug allergens, but can be complemented with nonspecific tests of immunologic activity such as eosinophilia, serum total tryptase, or flow-cytometry basophil activation assays on CD63 and CD203c.


How should acute HSRs be managed?

Stop, Call, Assess, Prepare.

If you suspect your patient is experiencing early symptoms of an acute HSR, donÕt hesitate to implement your emergency interventions. STOP the infusion but maintain IV access. CALL the provider. ASSESS your patient further: collect vital signs, use a pulse oximeter to obtain oxygen saturation, listen to breath sounds, and check for symptom progression. Finally, PREPARE for emergency treatment, including the potential need to administer IV fluids, oxygen, and resuscitative medications.

The most likely acute HSR medica-tion orders for adults include epinephrine (0.3-0.5 ml of a 1:1000 solution as intramuscular or subcutaneous injection, repeated every five to fifteen minutes), albuterol (two puffs from a multi-dose inhaler), a rapid-acting corticosteroid such as hydrocortisone 100 mg, and an antihistamine such as diphenhydramine 50 mg. For pediatric patients, epinephrine at 0.01 mg/kg is repeated every five minutes as necessary. IV fluids, vasopressors such as norepinephrine, and histamine 1 receptor blocker such as ranitidine may also be ordered. Oxygen therapy is appropriate for most patients, but is only effective if bronchospasm is effectively controlled.

Your organization may have developed a protocol for managing severe anaphy-lactic hypersensitivity reactions. These treatment algorithms are generally based on expert opinion and consensus; there is limited published evidence due to the rarity of HSRs and the urgency of management.2 Some controversial components of therapy include the best route for epinephrine administration and preferred vasopressor agents. Intravenous epinephrine administration is associated with extreme tachycardia and myocardial ischemia. Intramuscular and subcutaneous administration may be equivalent if there is not excess edema or obesity. Dopamine is associated with enhanced tachycardia, but higher efficacy of norepinephrine has not been established. The administration of histamine 2 receptor blockers such as ranitidine (50 mg IV) is a common practice, but is not based upon clinical evidence of efficacy.

If your patient is experiencing angio-edema, be aware that an emergency crychothryrotomy or tracheostomy may be needed. Availability of emergency surgical airway supplies and expert clini-cians is recommended when admin-istering agents with high risk for HSRs.

An acute HSR is a frightening experience. After the initial event, supportive care and close monitoring will be needed for several hours to ensure that symptoms do not recur. Immediate-acting medications treating the reaction may dissipate before the agent that triggered it does, and residual antigens can cause a recurrence of symptoms 4Ð6 hours after the initial event.5 The patient and family members will need explanations of treatments and reassurance that close monitoring and proactive strategies can prevent harm. For some patients who experience mild HSRs, it may be appropriate to consider readministration of the agent in spite of the reaction. This should only be attempted under carefully controlled and monitored conditions, with premedications and a slower infusion rate. Published desensitization protocols exist for some medications and may be useful in these situations.

An acute HSR is also an adverse drug reaction (ADR) and should be reported according to your organizationÕs policies. The World Health Organization defines an ADR as “any response to a drug which is noxious and unintended, and which occurs at doses normally used in humans for prophylaxis, diagnosis, or therapy of disease, or for the modification of physiological function.”6 Enhanced reporting of ADRs will assist in defining true incidences of drug reactions.


Can acute HSRs be prevented?

Recognizing high-risk patients and situations is an essential first step in reducing HSR morbidity and mortality. Clinical variables known to increase risk for HSRs include personal history of drug allergy, multiple allergy syndrome, presence of Epstein-Barr or HIV infection, or concurrent asthma. For high-risk medications, premedications with antihistamines and corticosteroids are widely used. Skin testing may be performed before administration of medications with high incidence of HSRs. Desensitization protocols may also be useful in preventing IgE-mediated HSRs. Most involve administering a greatly diluted amount of the antigenic agent (usually a dose in micrograms, rather than milligrams) and then gradually increasing the dose every 15 to 30 minutes to induce tolerance.2 The patient must be closely monitored by experienced healthcare personnel, as reactions are still possible.


Key Points

In summary, hypersensitivity reactions to food, medications and biological agents are uncommon but potentially serious reactions that require astute nursing assessment and critical thinking skills.Paramount to this proactive approach is recognition of allergenic risk factors and significant signs or symptoms before they become life-threatening. Readily available emergency supplies and medications can minimize the adverse outcomes of severe HSRs.

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References
1Neugut AJ, Ghatak AT, Miller RL. (2001). Anaphylaxis in the United States: An investigation into its epidemiology. Arch Intern Med, 161(1): 15-21.
2Kanji S & Chant C. (2010). Allergic and hypersensitivity reactions in the intensive care unit. Crit Care Med, 38(6), S162-S168.
3Gobel BH. (2005). Chemotherapy-induced hypersensitivity reactions. Onc Nurs Forum, 32(5), 1027-1035.
4Syrigou E, Makrilia N, Koti I, et. al. (2009). Hypersensitivity reactions to antineoplastic agents: an overview. Anti-Cancer Drugs, 20, 1-6.
5Viale PH. (2009). Management of hypersensitivity reactions: A nursing perspective. Onc Nurs Forum, 23(2),
6Safety of Medicines: A Guide to Detecting and Reporting Adverse Drug Reactions. Geneva, Switzerland, World Health Organiza-tion, 2002. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_QSM_2002.2.pdf. Accessed January 26, 2010
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