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Quiz
Question 1/101/10
Basic and Clinical Immunology
Basic and Clinical Immunology
Basic and Clinical Immunology
A researcher studies the high-affinity IgE receptor on human mast cells. Compared with the receptor expressed on circulating human basophils and dendritic cells, which structural feature characterizes the mast cell receptor and is responsible for amplifying downstream signaling?
Select the answer:Select the answer
1 correct answer
A.
It signals through an intrinsic tyrosine kinase domain in the alpha chain
B.
It is a tetramer composed of one alpha, one beta, and two disulfide-linked gamma chains
C.
It binds the Fab region of IgE through its alpha chain
D.
It is a trimeric receptor lacking the beta chain
Explanation: The high-affinity IgE receptor on mast cells and basophils is a tetramer with one alpha chain, one beta chain, and a disulfide-linked gamma-chain homodimer. The alpha chain binds the Fc (constant) region of IgE, specifically the Cepsilon3 domains, with very high affinity. The alpha chain has no intrinsic kinase activity; instead, the beta and gamma chains carry immunoreceptor tyrosine-based activation motifs (ITAMs) that are phosphorylated by Lyn after receptor aggregation, recruiting Syk and triggering degranulation. The beta chain functions as a signal amplifier, increasing both surface expression and signal strength. On human dendritic cells, Langerhans cells, and some monocytes, the receptor exists as a trimer (alpha plus the gamma dimer) lacking the beta chain, which reduces signaling amplification and surface density. Cross-linking of receptor-bound IgE by multivalent allergen aggregates adjacent receptors, initiating the signaling cascade that releases preformed mediators and generates lipid mediators. Understanding this architecture explains why the beta chain is a key amplifier of mast cell reactivity and why trimeric receptors on antigen-presenting cells serve more in facilitated antigen presentation than in explosive degranulation.
Right Answer: B
Quiz
Question 2/102/10
Diagnostic Testing and Pulmonary Function
Diagnostic Testing and Pulmonary Function
Diagnostic Testing and Pulmonary Function
A clinician performs skin prick testing for aeroallergens. When interpreting the results, which control reaction must produce an appropriate wheal for the test to be considered valid?
Select the answer:Select the answer
1 correct answer
A.
A histamine positive control producing an adequate wheal, typically 3 mm or larger
B.
A saline negative control producing a 5 mm wheal
C.
A glycerin control producing no reaction
D.
An allergen extract producing a flare without a wheal
Explanation: Valid skin prick testing depends on paired positive and negative controls that confirm the skin is capable of reacting and that nonspecific reactivity is absent. The positive control is histamine, which should produce a clear wheal, conventionally at least 3 mm larger than the negative control, usually read at about 15 minutes. An absent or blunted histamine response indicates that testing is unreliable, often because of antihistamine use, other suppressive medication, or reduced skin reactivity, and allergen results cannot be interpreted as negative in that setting. The negative control is the diluent, commonly saline or glycerinated saline, which should produce no significant wheal; a reaction to the negative control suggests dermatographism or irritant responses that would cause false-positive allergen interpretations. An allergen wheal is considered positive when it exceeds the negative control by a defined margin, typically 3 mm, accompanied by a flare. A positive skin test indicates sensitization, meaning the presence of specific IgE, but does not by itself establish clinical allergy, which requires correlation with history. Confirming an adequate histamine response and an inert negative control before reading allergen reactions is essential to avoid both false-negative and false-positive conclusions.
Right Answer: A
Quiz
Question 3/103/10
Primary Immunodeficiency Diseases
Primary Immunodeficiency Diseases
Primary Immunodeficiency Diseases
A 6-day-old full-term boy is referred because his state newborn screen showed undetectable T-cell receptor excision circles (TRECs) with a normal beta-actin internal control. He is feeding well, has no rash, and the physical examination is normal. There is no family history of immunodeficiency. Which of the following is the most appropriate next step in evaluation?
Select the answer:Select the answer
1 correct answer
A.
Targeted next-generation sequencing panel as the sole confirmatory test
B.
Flow cytometry for T-, B-, and NK-cell subsets including naive (CD45RA) and memory (CD45RO) T-cell markers
C.
Repeat the dried blood spot TREC assay in 2 weeks before any further testing
D.
Measure serum IgG, IgA, and IgM levels
Explanation: An undetectable TREC result with an adequate internal control in a term infant is an urgent abnormal screen that requires prompt confirmatory testing, not a repeat screen. TRECs are circular DNA fragments generated during T-cell receptor alpha gene rearrangement in the thymus and mark recent thymic emigrants. The confirmatory test of choice is peripheral blood lymphocyte enumeration by flow cytometry, including CD3, CD4, CD8, CD19 or CD20, and CD16/CD56, together with naive versus memory markers such as CD45RA and CD45RO. Very low autologous naive T cells define typical SCID, while low but present T cells suggest leaky SCID, Omenn syndrome, maternal engraftment, or secondary causes such as 22q11.2 deletion, trisomy 21, prematurity, congenital heart surgery with thymectomy, or chylothorax. The T-B-NK phenotype then directs genetic testing (for example IL2RG or JAK3 in T-B+NK-, RAG1/RAG2 or Artemis in T-B-NK+). Serum immunoglobulins are uninformative in the first months of life because maternal IgG is present. Genetic testing is essential but should follow and be interpreted alongside immunophenotyping and must never delay protective measures, including avoiding live vaccines, using irradiated CMV-safe blood products, and early referral to a transplant center.
Right Answer: B
Quiz
Question 4/104/10
Eosinophilic and Other Immunologic Disorders
Eosinophilic and Other Immunologic Disorders
Eosinophilic and Other Immunologic Disorders
A 42-year-old man has fatigue, weight loss, and exertional dyspnea. Absolute eosinophil count is 8,200/uL. He has splenomegaly, serum tryptase of 24 ng/mL, and an elevated serum vitamin B12. Echocardiography shows apical thrombus and early endomyocardial thickening. Stool studies and Strongyloides serology are negative. FISH on peripheral blood demonstrates a CHIC2 deletion. Which therapy is most likely to induce a complete and durable hematologic and molecular remission?
Select the answer:Select the answer
1 correct answer
A.
Imatinib
B.
High-dose systemic glucocorticoids
C.
Mepolizumab 300 mg every 4 weeks
D.
Hydroxyurea
Explanation: Deletion of CHIC2 on chromosome 4q12, detected by FISH, is a surrogate marker for the FIP1L1-PDGFRA fusion gene, which encodes a constitutively active tyrosine kinase and defines a myeloid neoplasm with eosinophilia. This variant occurs almost exclusively in men and is characterized by splenomegaly, elevated serum tryptase and vitamin B12, increased atypical spindle-shaped mast cells in the marrow, and a high risk of endomyocardial fibrosis, thrombosis, and restrictive cardiomyopathy. Fusion-positive disease is exquisitely sensitive to imatinib, typically at low doses such as 100 mg daily, with nearly universal complete hematologic and molecular remission and excellent long-term survival; some patients maintain remission after carefully monitored discontinuation. Because imatinib initiation can precipitate necrotizing myocarditis in patients with cardiac involvement, troponin should be checked and glucocorticoids given concurrently when cardiac involvement or elevated troponin is present. Glucocorticoids are typically less effective in this variant, and hydroxyurea and interferon-alpha are older alternatives with lower response rates. Mepolizumab is approved for idiopathic hypereosinophilic syndrome without an identifiable secondary cause and is not appropriate as first-line therapy for a kinase-driven neoplasm. Other rearrangements, such as PDGFRB, also respond to imatinib, whereas FGFR1 and JAK2 rearrangements have poorer prognoses and require different targeted therapy.
Right Answer: A
Quiz
Question 5/105/10
Asthma
Asthma
Asthma
A 34-year-old woman with asthma uses low-dose fluticasone propionate daily plus albuterol as needed. She reports daytime symptoms 4 days per week, night awakenings twice monthly, and one exacerbation requiring oral corticosteroids in the past year. Inhaler technique and adherence are confirmed to be good. According to GINA Track 1, which change is preferred?
Select the answer:Select the answer
1 correct answer
A.
Switch to low-dose fluticasone-salmeterol daily with albuterol as needed
B.
Add montelukast 10 mg daily and continue albuterol as needed
C.
Switch to low-dose budesonide-formoterol as both maintenance and reliever therapy
D.
Switch to medium-dose fluticasone propionate daily with albuterol as needed
Explanation: GINA Track 1 uses low-dose ICS-formoterol as the reliever at every step, and at Step 3 the preferred controller is low-dose ICS-formoterol maintenance-and-reliever therapy (MART, also called SMART). This patient has uncontrolled asthma with a recent exacerbation despite adherent low-dose ICS, so step-up is warranted. MART with budesonide-formoterol (or beclometasone-formoterol) reduces severe exacerbations compared with the same or a higher dose of ICS-LABA plus SABA reliever, and compared with higher-dose ICS alone, while using a similar or lower total corticosteroid exposure. The mechanism of benefit is that every reliever inhalation delivers additional ICS exactly when inflammation and symptoms are increasing, which blunts the trajectory toward an exacerbation. Formoterol is suitable as a reliever because its onset of bronchodilation is within minutes, similar to albuterol, unlike salmeterol, which has a slow onset and cannot be used for MART. Increasing ICS alone gives a flat dose-response curve for most patients, and adding a leukotriene receptor antagonist is less effective than adding a LABA and carries the neuropsychiatric boxed warning. Fixed-dose ICS-LABA with SABA reliever is the Track 2 alternative, which is acceptable but less effective at preventing exacerbations than MART.
Right Answer: C
Quiz
Question 6/106/10
Rhinitis, Sinusitis and Ocular Allergy
Rhinitis, Sinusitis and Ocular Allergy
Rhinitis, Sinusitis and Ocular Allergy
A 28-year-old woman has watery rhinorrhea, sneezing, and nasal itching every spring when she gardens. Skin prick tests and serum specific IgE to a comprehensive aeroallergen panel, including tree and grass pollens, are negative, and total IgE is normal. Nasal allergen provocation with birch pollen reproduces her symptoms with an objective decrease in nasal airflow. What is the most likely diagnosis?
Select the answer:Select the answer
1 correct answer
A.
Vasomotor (nonallergic) rhinitis triggered by weather changes
B.
Atrophic rhinitis
C.
Local allergic rhinitis
D.
Nonallergic rhinitis with eosinophilia syndrome
Explanation: Local allergic rhinitis (LAR) is a phenotype in which patients have clinical symptoms typical of allergic rhinitis and a positive nasal allergen provocation test, but no evidence of systemic atopy on skin testing or serum specific IgE. The underlying mechanism is believed to be local production of allergen-specific IgE in the nasal mucosa, with a Th2-type inflammatory infiltrate and mediator release such as tryptase and eosinophil cationic protein after challenge. Nasal allergen provocation is the diagnostic gold standard; detection of specific IgE in nasal secretions and basophil activation tests may support the diagnosis but are less sensitive. LAR may affect a substantial proportion of patients previously labeled as nonallergic rhinitis, can be seasonal or perennial, and frequently coexists with conjunctival symptoms and asthma. Patients respond to the usual allergic rhinitis treatments, including intranasal corticosteroids and antihistamines, and randomized trials have shown benefit of subcutaneous allergen immunotherapy in LAR to pollen and house dust mite. NARES is defined by nasal eosinophilia without allergen-triggered symptoms or positive provocation. Vasomotor rhinitis is triggered by nonspecific irritants, odors, and temperature changes, not specific allergens. Atrophic rhinitis presents with crusting, fetor, and paradoxical congestion.
Right Answer: C
Quiz
Question 7/107/10
Anaphylaxis and Mast Cell Disorders
Anaphylaxis and Mast Cell Disorders
Anaphylaxis and Mast Cell Disorders
A 7-year-old boy with known peanut allergy, confirmed by a prior reaction and positive Ara h 2 specific IgE, accidentally eats a cookie containing peanut at school. Within 10 minutes he develops hoarseness, inspiratory stridor, and repetitive cough. He has no urticaria, flushing, angioedema, vomiting, or abdominal pain. His blood pressure is normal for age. Which of the following best describes this situation?
Select the answer:Select the answer
1 correct answer
A.
This is an isolated upper airway reaction that should be treated first with an oral antihistamine and observed
B.
Anaphylaxis requires involvement of at least two organ systems regardless of the type of exposure
C.
Anaphylaxis cannot be diagnosed because skin or mucosal involvement is absent
D.
This meets current criteria for anaphylaxis and intramuscular epinephrine is indicated
Explanation: The World Allergy Organization 2020 criteria, which are acknowledged in the 2023 anaphylaxis practice parameter, recognize that anaphylaxis is highly likely when there is acute onset of hypotension, bronchospasm, or laryngeal involvement after exposure to a known or highly probable allergen for that patient, even in the absence of typical skin involvement. This addition addresses a recognized gap in the older NIAID/FAAN framework, in which a patient with isolated respiratory compromise after a known allergen might not have satisfied a two-system requirement. Up to 10 to 20 percent of anaphylactic episodes lack cutaneous findings, and absence of skin signs is associated with delayed recognition and delayed epinephrine. Stridor and hoarseness reflect laryngeal edema, a potentially fatal manifestation. Antihistamines do not relieve airway obstruction or hypotension and have a slow onset; they should never substitute for or delay epinephrine. The two-organ-system requirement applies only when the allergen is not known or not established for that patient. Clinicians should teach families that respiratory symptoms alone after a known allergen warrant prompt intramuscular epinephrine in the anterolateral thigh, followed by activation of emergency services as appropriate, and that skin signs may be absent even in severe reactions.
Right Answer: D
Quiz
Question 8/108/10
Insect Hypersensitivity
Insect Hypersensitivity
Insect Hypersensitivity
A 42-year-old man was stung several times on the leg while mowing his lawn in late August when he ran over a hole in the ground from which aggressive black and yellow insects emerged. He developed generalized urticaria, wheezing, and lightheadedness. No stinger was found in the skin. Which insect is most likely responsible?
Select the answer:Select the answer
1 correct answer
A.
Yellow jacket (Vespula species)
B.
Bald-faced hornet (Dolichovespula maculata)
C.
Honeybee (Apis mellifera)
D.
Paper wasp (Polistes species)
Explanation: Stinging insects of the order Hymenoptera that cause allergic reactions belong to three families: Apidae, which includes honeybees and bumblebees; Vespidae, which includes yellow jackets, hornets, and paper wasps; and Formicidae, which includes fire ants and harvester ants. Yellow jackets are the most common cause of sting reactions in much of the United States. They typically nest in the ground, in wall voids, or in logs, become increasingly aggressive in late summer and fall as colonies peak and food becomes scarce, and are disturbed by activities such as mowing or gardening. Vespids have a smooth, minimally barbed stinger and can sting repeatedly without leaving the stinger behind. Honeybees have a heavily barbed stinger that usually remains in the skin with the venom sac attached, and honeybee stings occur most often near hives or flowering plants and in beekeepers. Paper wasps build open, umbrella-shaped combs under eaves and on shrubs. Bald-faced and yellow hornets, members of the genus Dolichovespula, build large enclosed aerial paper nests in trees and bushes. Because patient identification of the insect is often unreliable, testing usually includes all commercially available venoms, but environmental clues such as a ground nest strongly suggest yellow jackets.
Right Answer: A
Quiz
Question 9/109/10
Food Allergy and Eosinophilic Gastrointestinal Disorders
Food Allergy and Eosinophilic Gastrointestinal Disorders
Food Allergy and Eosinophilic Gastrointestinal Disorders
A 7-year-old boy with birch pollen allergic rhinitis has never knowingly eaten peanut. Screening by his pediatrician showed peanut extract-specific IgE of 4.2 kU/L. Component testing shows Ara h 2 <0.10 kU/L, Ara h 1 and Ara h 3 undetectable, and Ara h 8 of 6.5 kU/L. Skin prick test to peanut is 4 mm. Which is the most appropriate interpretation and next step?
Select the answer:Select the answer
1 correct answer
A.
He should begin peanut oral immunotherapy because sensitization to Ara h 8 predicts persistent allergy
B.
His sensitization most likely reflects cross-reactivity with birch Bet v 1, and a supervised peanut oral food challenge is appropriate
C.
Component results are uninterpretable without a basophil activation test, which must be done before any challenge
D.
He has a high likelihood of peanut anaphylaxis and should strictly avoid peanut
Explanation: Ara h 8 is a PR-10 protein homologous to birch Bet v 1. Sensitization to Ara h 8 in a birch-sensitized patient frequently drives positive peanut extract tests without clinical risk of systemic reactions, because PR-10 proteins are heat- and digestion-labile and usually cause, at most, oral symptoms. Ara h 2, a 2S albumin seed storage protein, is the single best component predictor of clinical peanut allergy; values above roughly 1 to 2 kU/L carry a high positive predictive value in many cohorts, whereas an undetectable Ara h 2 with absent Ara h 1 and Ara h 3 makes clinically significant peanut allergy unlikely. In this child, the overall profile indicates pollen-related cross-sensitization, so the appropriate step is to confirm tolerance with a supervised oral food challenge rather than labeling him allergic and imposing unnecessary avoidance, which carries nutritional, social, and quality-of-life costs and may increase the risk of later true allergy. Oral immunotherapy is not indicated for a patient who may not be allergic. Basophil activation testing can be helpful in equivocal cases but is not required, is not widely available, and would not supersede a challenge when the pretest probability is low.
Right Answer: B
Quiz
Question 10/1010/10
Drug Allergy
Drug Allergy
Drug Allergy
A 45-year-old woman is labeled penicillin-allergic. Two years ago she developed hives on her trunk on day 3 of amoxicillin for sinusitis. The hives resolved after she stopped the drug, and she did not seek care or take any medication. She had no angioedema, hypotension, blistering, mucosal involvement, or organ involvement. She now needs treatment for a streptococcal infection. Which is the most appropriate next step?
Select the answer:Select the answer
1 correct answer
A.
Rapid drug desensitization to amoxicillin
B.
Avoid all beta-lactams and prescribe a fluoroquinolone
C.
Penicillin skin testing with major and minor determinants before any challenge
D.
Direct oral amoxicillin challenge under observation
Explanation: PEN-FAST is a validated point-of-care tool for risk-stratifying penicillin allergy labels. Points are assigned for a reaction five years ago or less (2 points), anaphylaxis or angioedema, or a severe cutaneous adverse reaction (2 points), and treatment required for the reaction (1 point); the PEN component simply confirms a penicillin allergy label. A total below 3 indicates low risk, with less than 5 percent likelihood of a positive penicillin allergy test, and a score of 0 or 1 indicates very low risk. This patient scores 2, placing her in the low-risk category. The 2022 drug allergy practice parameter supports direct oral challenge with amoxicillin, without preceding skin testing, for adults with low-risk histories such as remote or benign cutaneous reactions, and the PALACE randomized trial showed direct oral challenge was noninferior to skin testing followed by challenge in PEN-FAST low-risk adults. The parameter likewise recommends direct amoxicillin challenge for children with benign cutaneous reactions such as urticaria or maculopapular rash. Skin testing remains appropriate for higher-risk histories, such as recent anaphylaxis. Avoidance leads to broader-spectrum antibiotic use, higher costs, and increased C difficile and resistant infections. Desensitization is reserved for confirmed or high-risk allergy when the drug is essential.
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Quiz name:ABNM-MOC: American Board of Nuclear Medicine Maintenance of Certification Examination
Total number of questions:287
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