Scenario 1: A 16-year-old boy comes to clinic with chief complaint of sore throat for 3 days. Denies fever or chills. PMH negative for recurrent colds, influenza, ear infections or pneumonias. NKDA or food allergies. Physical exam reveals temp of 99.6 F, pulse 78 and regular with respirations of 18. HEENT normal with exception of reddened posterior pharynx with white exudate on tonsils that are enlarged to 3+. Positive anterior and posterior cervical adenopathy. Rapid strep test performed in office was positive. His HCP wrote a prescription for amoxicillin 500 mg po q 12 hours x 10 days disp #20. He took the first capsule when he got home and immediately complained of swelling of his tongue and lips, difficulty breathing with audible wheezing. 911 was called and he was taken to the hospital, where he received emergency treatment for his allergic reaction.
Read a selection of your colleagues’ responses. Respond to at least two of your colleagues and respectfully agree or disagree with your colleague’s assessment and explain your reasoning. In your explanation, include why their explanations make physiological sense or why they do not
COLLEAGUE ONE:
The patient presents with + streptococcus (likely Strep A) infection with an anaphylactic allergic reaction to his amoxicillin. Children and adolescents are more likely to present with acute pharyngitis than adults based on their higher likelihood of exposure to other school-aged children and disease transmission (Streptococcal pharyngitis – StatPearls – NCBI bookshelf, 2021).
The patient presents with classic signs of inflammation – pain, redness, temperature, and swelling as evidenced by his sore throat, a temperature of 99.6, swelling of tonsils, tonsil exudate, and adenopathy (Rote, 2019, p. 194). The bacteria (strep) releases molecules in his throat activating the mast cells, and releasing histamine which acts on the endothelial cells causing separation in capillaries causing vasodilation (swelling) and vascular permeability (Khan Academy, 2010). Neutrophils and macrophages are now able to move through the spaces caused by the vasodilation moving to the area of infection to eat the bacterial molecules (Soo, 2018). B cells and T cells are also activated to assist the immune system in fighting strep infections (Khan Academy, 2010). The fluid and blood from the capillaries into the interstitial space causes the exudate seen in his tonsils. The physiologic response to the bacteria present occurred because this child’s immune system is intact and appropriately responding to the foreign cells present.
If this patient was younger than three years or an adult, a rapid strep test would not be indicated (CDC, 2021). Untreated strep infections can increase the likelihood of developing rheumatic fever in children and adolescents (Pharyngitis (Strep throat), 2021). Additionally, delays in treatment can lead to sepsis. Genetically, some people are prone to recurrent strep infections and receive surgery (tonsillectomy) to remove the source of the infection point.
Allergic response to amoxicillin creates the same inflammation process but as a hypersensitivity reaction as indicated by the patients swelling of tongue/lips and bronchoconstriction (wheezing). The immediate anaphylactic response is caused by IgE attaching to the mast cells and releasing pro-inflammatory mediators with the most problematic being histamine (Rote & McCance, 2019).
COLLEAGUE TWO:
The scenario given here suggests that the disease could be anaphylaxis. Anaphylaxis is an acute, potentially life-threatening allergic reaction that occurs within minutes or hours of exposure to an allergen. It can affect multiple body systems and may cause death if not treated immediately. Anaphylaxis can occur in response to insect stings or bites, foods, drugs, latex, and other allergens. In young people, food allergies are among the most common causes of anaphylaxis (Faridaalaee & Heris, 2018). A person who has had an allergic reaction to penicillin in the past may also have a genetic predisposition to having an allergic reaction if they are exposed again. This means that their immune system will recognize penicillin as foreign and attack it, which causes symptoms of an allergic reaction. Genetics also plays a role in anaphylaxis because you inherit your genes from your parents. If one parent has allergic reactions, then there is a high chance that the child will have allergic reactions too. If both parents have allergic reactions the chances that their child will develop allergic reactions is even higher.
The symptoms presented by the 16-year-old patient are common with anaphylaxis. Swelling of the tongue and lips, difficulty breathing, and wheezing are all signs of anaphylaxis. When a person has an allergic reaction to penicillin their immune system will recognize it as foreign and attack it which causes swelling in areas like his throat and tongue. This swelling can block airways making it difficult to breathe which leads to wheezing. Sore throat for 3 days suggests that he may have had strep throat for those three days before developing anaphylaxis. A person who has been exposed to penicillin within 72 hours of developing a sore throat may develop a drug allergy from taking amoxicillin because they share similar structures that cause cross-reactivity (McCance & Huether, 2019). Cross-reactivity means that your body mistakes one thing for another thing because they look similar or have similar functions in your body so it attacks them both causing symptoms like itching, hives, and swelling.
The physiologic response to the stimulus presented in the scenario occurs when penicillin enters his body. When he takes it, his immune system recognizes it as foreign and attacks it causing anaphylaxis. Penicillin is a drug that is used to treat bacterial infections like strep throat and ear infections. It works by killing bacteria which then helps your body fight off infection. But when someone has an allergy to penicillin their immune system will attack it because they have antibodies against it so they are unable to fight off any infections they may have had before taking penicillin. The cells that are involved in this process include mast cells, basophils, and eosinophils. Mast cells play a role because they release histamine which causes inflammation when you have an allergic reaction. Basophils and eosinophils also release chemicals like histamine when you have an allergic reaction but they do it at different times than mast cells (McCance & Huether, 2019). Eosinophils will release their chemicals during anaphylaxis while basophils will release their chemicals before anaphylaxis occurs.
Finally, other than genetics, factors such as stress and lack of sleep can contribute to anaphylaxis. When one is stressed the body releases chemicals that cause inflammation which can lead to an allergic reaction. If you do not get enough sleep it can also increase your risk of developing an allergic reaction because your immune system does not work as well when you are tired. To prevent anaphylaxis one should avoid triggers like penicillin or certain foods if they have food allergies and make sure they get enough sleep so their immune system works properly.
