#健康要有文化素養 & 健康要有哲學頭腦#
Episodic Hives and Abdominal Pain in a Hiker
Neil Khoury, MD; John W. Birk, MD
DISCLOSURES April 18, 2024
This patient smokes marijuana (one joint per week); however, it is unlikely that his recurrent episodes of nausea, vomiting, and abdominal pain are due to cannabinoid hyperemesis syndrome (CHS). The majority of patients with CHS use marijuana daily or more than once daily (47.9% and 23.7%, respectively).[5] This patient's symptoms are not relieved by hot showers, which makes CHS less likely. Although relief with hot showers is a common feature of CHS and should raise great suspicion for this diagnosis, it should not be considered a unique finding, because 48% of patients with cyclic vomiting syndrome who do not use cannabis and 72% of those who do use cannabis have reported symptom relief with hot baths.[6]
Moreover, a diagnosis of CHS would not explain the patient's diarrhea; this symptom is not routinely reported in patients with CHS. Additionally, this patient has no symptoms in between his episodes, which further tends to exclude CHS. Patients with CHS go through prodromal, hyperemetic, and recovery phases. This patient has not described any features consistent with passing through the prodromal phase, such as early-morning nausea in between episodes.
Question 1 of 2
A serum alpha-gal IgE antibody level is ordered for the patient in this case, and the result is 2.4 IU/mL (reference range, < 2.0 IU/mL), which confirms the suspected diagnosis of alpha-gal syndrome. What is the preferred initial treatment for him?
Dietary elimination of pork, beef, lamb, and mammalian-derived products
Omalizumab (monoclonal anti-IgE antibody)
Diphenhydramine as needed
Epinephrine pen as needed
Question 2 of 2
The patient returns to the gastroenterology clinic for routine follow-up. He has been doing well on an alpha-gal avoidance diet and has been cautious to avoid additional tick bites. It has been 6 months since the initial diagnosis, and he has not experienced further GI symptoms, hives, shortness of breath, or wheezing. What is the best next step for this patient?
Referral to an allergist
Auto-injectable epinephrine education
Empirical diphenhydramine 25 mg before red meat consumption
Repeated alpha-gal IgE antibody measurement
SAVE AND PROCEED
Question 1 of 2
A serum alpha-gal IgE antibody level is ordered for the patient in this case, and the result is 2.4 IU/mL (reference range, < 2.0 IU/mL), which confirms the suspected diagnosis of alpha-gal syndrome. What is the preferred initial treatment for him?
Your Peers Chose:
Dietary elimination of pork, beef, lamb, and mammalian-derived products
95%
Omalizumab (monoclonal anti-IgE antibody)
4%
Diphenhydramine as needed
1%
Epinephrine pen as needed
0%
Initial treatment includes an alpha-gal avoidance diet (elimination of pork, beef, lamb, and mammalian-derived products) and prevention of further tick bites. Patients with hives, breathing difficulty, voice changes, or swelling of the face and/or throat should be referred to an allergist and will need formal instruction on using an epinephrine auto-injector.
Omalizumab is a monoclonal anti-IgE antibody; however, it is not an appropriate choice for initial treatment. The US Food and Drug Administration approved omalizumab for patients with chronic idiopathic or spontaneous urticaria.[8] Although small studies and case reports have used omalizumab to treat chronic urticaria related to alpha-gal syndrome, it is typically used after an appropriate trial of dietary elimination.[9]
Diphenhydramine as needed is a reasonable choice; however, it is not the best option. Initial treatment for this patient should focus on addressing the underlying etiology of his condition rather than on treating symptoms. Additionally, this patient did not report urticaria; he presented with a GI-predominant phenotype.
The use of an epinephrine pen as needed is not the preferred initial step for this patient. Although the possibility of future anaphylactic events should be considered for all patients with alpha-gal syndrome, those who have a GI phenotype without any episodes of throat closing or shortness of breath are unlikely to require an allergist referral for education about auto-injectable epinephrine.
Question 2 of 2
The patient returns to the gastroenterology clinic for routine follow-up. He has been doing well on an alpha-gal avoidance diet and has been cautious to avoid additional tick bites. It has been 6 months since the initial diagnosis, and he has not experienced further GI symptoms, hives, shortness of breath, or wheezing. What is the best next step for this patient?
Your Peers Chose:
Referral to an allergist
12%
Auto-injectable epinephrine education
7%
Empirical diphenhydramine 25 mg before red meat consumption
13%
Repeated alpha-gal IgE antibody measurement
68%
It may be beneficial to repeat measurement of alpha-gal IgE antibodies in 6-12 months to re-evaluate levels. Those with low levels may tolerate reintroduction of small amounts of mammalian products, starting with dairy alone.[4] The possibility of future anaphylactic events is a consideration for all patients with alpha-gal syndrome; however, those with a GI phenotype who have not experienced hives, throat closing, or dyspnea are unlikely to need an allergist referral for auto-injectable epinephrine education. Finally, red meat should not be reintroduced into this patient's diet at this time.
Episodic Hives and Abdominal Pain in a Hiker
Neil Khoury, MD; John W. Birk, MD
DISCLOSURES April 18, 2024
This patient smokes marijuana (one joint per week); however, it is unlikely that his recurrent episodes of nausea, vomiting, and abdominal pain are due to cannabinoid hyperemesis syndrome (CHS). The majority of patients with CHS use marijuana daily or more than once daily (47.9% and 23.7%, respectively).[5] This patient's symptoms are not relieved by hot showers, which makes CHS less likely. Although relief with hot showers is a common feature of CHS and should raise great suspicion for this diagnosis, it should not be considered a unique finding, because 48% of patients with cyclic vomiting syndrome who do not use cannabis and 72% of those who do use cannabis have reported symptom relief with hot baths.[6]
Moreover, a diagnosis of CHS would not explain the patient's diarrhea; this symptom is not routinely reported in patients with CHS. Additionally, this patient has no symptoms in between his episodes, which further tends to exclude CHS. Patients with CHS go through prodromal, hyperemetic, and recovery phases. This patient has not described any features consistent with passing through the prodromal phase, such as early-morning nausea in between episodes.
Question 1 of 2
A serum alpha-gal IgE antibody level is ordered for the patient in this case, and the result is 2.4 IU/mL (reference range, < 2.0 IU/mL), which confirms the suspected diagnosis of alpha-gal syndrome. What is the preferred initial treatment for him?
Dietary elimination of pork, beef, lamb, and mammalian-derived products
Omalizumab (monoclonal anti-IgE antibody)
Diphenhydramine as needed
Epinephrine pen as needed
Question 2 of 2
The patient returns to the gastroenterology clinic for routine follow-up. He has been doing well on an alpha-gal avoidance diet and has been cautious to avoid additional tick bites. It has been 6 months since the initial diagnosis, and he has not experienced further GI symptoms, hives, shortness of breath, or wheezing. What is the best next step for this patient?
Referral to an allergist
Auto-injectable epinephrine education
Empirical diphenhydramine 25 mg before red meat consumption
Repeated alpha-gal IgE antibody measurement
SAVE AND PROCEED
Question 1 of 2
A serum alpha-gal IgE antibody level is ordered for the patient in this case, and the result is 2.4 IU/mL (reference range, < 2.0 IU/mL), which confirms the suspected diagnosis of alpha-gal syndrome. What is the preferred initial treatment for him?
Your Peers Chose:
Dietary elimination of pork, beef, lamb, and mammalian-derived products
95%
Omalizumab (monoclonal anti-IgE antibody)
4%
Diphenhydramine as needed
1%
Epinephrine pen as needed
0%
Initial treatment includes an alpha-gal avoidance diet (elimination of pork, beef, lamb, and mammalian-derived products) and prevention of further tick bites. Patients with hives, breathing difficulty, voice changes, or swelling of the face and/or throat should be referred to an allergist and will need formal instruction on using an epinephrine auto-injector.
Omalizumab is a monoclonal anti-IgE antibody; however, it is not an appropriate choice for initial treatment. The US Food and Drug Administration approved omalizumab for patients with chronic idiopathic or spontaneous urticaria.[8] Although small studies and case reports have used omalizumab to treat chronic urticaria related to alpha-gal syndrome, it is typically used after an appropriate trial of dietary elimination.[9]
Diphenhydramine as needed is a reasonable choice; however, it is not the best option. Initial treatment for this patient should focus on addressing the underlying etiology of his condition rather than on treating symptoms. Additionally, this patient did not report urticaria; he presented with a GI-predominant phenotype.
The use of an epinephrine pen as needed is not the preferred initial step for this patient. Although the possibility of future anaphylactic events should be considered for all patients with alpha-gal syndrome, those who have a GI phenotype without any episodes of throat closing or shortness of breath are unlikely to require an allergist referral for education about auto-injectable epinephrine.
Question 2 of 2
The patient returns to the gastroenterology clinic for routine follow-up. He has been doing well on an alpha-gal avoidance diet and has been cautious to avoid additional tick bites. It has been 6 months since the initial diagnosis, and he has not experienced further GI symptoms, hives, shortness of breath, or wheezing. What is the best next step for this patient?
Your Peers Chose:
Referral to an allergist
12%
Auto-injectable epinephrine education
7%
Empirical diphenhydramine 25 mg before red meat consumption
13%
Repeated alpha-gal IgE antibody measurement
68%
It may be beneficial to repeat measurement of alpha-gal IgE antibodies in 6-12 months to re-evaluate levels. Those with low levels may tolerate reintroduction of small amounts of mammalian products, starting with dairy alone.[4] The possibility of future anaphylactic events is a consideration for all patients with alpha-gal syndrome; however, those with a GI phenotype who have not experienced hives, throat closing, or dyspnea are unlikely to need an allergist referral for auto-injectable epinephrine education. Finally, red meat should not be reintroduced into this patient's diet at this time.
Erich Heckel (31 July 1883 – 27 January 1970) was a German painter and printmaker, and a founding member of the group Die Brücke ("The Bridge") which existed 1905–1913. His work was part of the art competitions at the 1928 Summer Olympics and the 1932 Summer Olympics.
Heckel was born in Döbeln, Saxony, the son of a railway engineer. Between 1897 and 1904 he attended the Realgymnasium in Chemnitz, before studying architecture in Dresden. He left after three terms, shortly after the foundation of Die Brücke, an artists' group of which he was secretary and treasurer. The other founder-members, also architectural students, were Ernst Ludwig Kirchner, Karl Schmidt-Rottluff and Fritz Bleyl. He worked in the office of the architect Wilhelm Kreis until July 1907, when he resigned to become a full-time artist.
#美术馆##艺术##art#
Heckel was born in Döbeln, Saxony, the son of a railway engineer. Between 1897 and 1904 he attended the Realgymnasium in Chemnitz, before studying architecture in Dresden. He left after three terms, shortly after the foundation of Die Brücke, an artists' group of which he was secretary and treasurer. The other founder-members, also architectural students, were Ernst Ludwig Kirchner, Karl Schmidt-Rottluff and Fritz Bleyl. He worked in the office of the architect Wilhelm Kreis until July 1907, when he resigned to become a full-time artist.
#美术馆##艺术##art#
#正能量语录[超话]# I don't climb the rich, because I can't spend his money, I don't despise the poor, he doesn't live on me, he doesn't flatter the mean people, he can't get into my eyes, and I only believe in three kinds of people. People who share weal and woe with me, people who help me in trouble, I am a person who has nothing and still never gives up.
不攀有钱人，因为我花不到他的钱，不小瞧穷人，他不靠我生存，不奉承小人，他入不了我的眼，我只相信三种人。陪我同甘共苦的人，落难帮我一把的人，我以无所有，依然不离不弃的人。#第一次见男朋友家长送什么显得有诚意# https://t.cn/z82Uwk1
不攀有钱人，因为我花不到他的钱，不小瞧穷人，他不靠我生存，不奉承小人，他入不了我的眼，我只相信三种人。陪我同甘共苦的人，落难帮我一把的人，我以无所有，依然不离不弃的人。#第一次见男朋友家长送什么显得有诚意# https://t.cn/z82Uwk1
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