JACI PRIMER EXAM 2023-2024 ACTUAL EXAM 120
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Question 1. Which of the following processes involved during natural allergen
sensitization through the nasal mucosa in patients with allergic rhinitis is most
specific for dust mite antigen?
A. elaboration of thymic stromal lymphopoietin by nasal epithelial cells
B. local and systemic production of allergen-specific IgE
C. enhancement through induction of Toll-like receptor 4 (TLR4) signaling
D. interaction of dust mite antigen with interepithelial and
subepithelial dendritic cells – ANSWER- 1. Answer: C
Rationale : The dust mite antigen has proteolytic activity that cleaves tight
junctions in the airway epithelium. Activated epithelial cells produce thymic
stromal lymphopoietin, a protein that interacts with interepithelial and subepithelial
dendritic cells to skew T-cell development toward TH2 allergic sensitization. The
house dust mite allergen Der p 2 has a unique property, namely that it mimics MD2, the LPS-binding component of the TLR4 signaling complex, and facilitates
TLR4 signaling and airway TH2-type inflammation. In the nose allergens are
processed by antigen-presenting cells (dendritic cells expressing CD1a and CD11c
and macrophages) in the nasal epithelial mucosa, with subsequent presentation of
allergenic peptides by MHC class II molecules to T-cell receptors on resting CD41
T lymphocytes in regional lymph nodes.
Question 2. Which of the following subtypes of nonallergic rhinitis is most likely
to be associated with eosinophilia?
A. irritant-induced rhinitis
B. cold-induced rhinitis
C. vasomotor rhinitis
D. rhinitis associated with aspirin sensitivity (aspirinexacerbated respiratory disease) – ANSWER- 2. Answer: D
Rationale : Nonallergic rhinitis often occurs without eosinophilia. The terms
nonallergic rhinitis without eosinophilia and idio- pathic rhinitis are used
interchangeably. Irritant-induced rhinitis, cold-induced rhinitis, and vasomotor
rhinitis are all considered subsets of this condition. Vasomotor rhinitis is
sometimes used synonymously with nonallergic rhinitis without eosinophilia, but it
sometimes can more specifically connote nasal symptoms that occur in response to
environmental conditions, such as changes in temperature or relative humidity,
odors (eg, perfume or cleaning materials), passive tobacco smoke, alcohol, sexual
arousal, and emotional factors. Nonallergic rhinitis with aspirin sensitivity is
usually associated with marked tissue eosinophilia (ie, nonallergic rhinitis with
eosinophilia).
Question 3. Which of the following pathologic processes impli- cated in the
pathogenesis of CRS is most specific for CRS with nasal polyposis?
A. TH2-type immune hyperresponsiveness (production of IL-5 and IL-13) directed
toward colonizing fungi in sinus secretions
B. glandular hyperplasia
C. formation of bacterial biofilm on sinus mucosal tissue
D. local production of IgE directed against staphylococcal enterotoxins (ie,
superantigens) from Staphylococcus aureus – ANSWER- 3. Answer: D
Rationale : TH2-type immune hyperresponsiveness in sinus tissue is an important
feature of CRS without distinction for the pres- ence of nasal polyps. Patients with
CRS typically have fungi, such as Alternaria species, in the mucus secretions and
in vitro hyper- responsiveness to Alternaria species, with production of IL-5 and
IL-13. Local production of IgE against staphylococcal enterotoxins (superantigens)
has been found in homogenates of nasal polyps and is regarded as specific for CRS
with nasal polyps. Pro- duction of bacterial biofilm on sinus mucosal tissue has
been demonstrated in several studies without distinction for the presence of nasal
polyps. Glandular hyperplasia is a feature of CRS without nasal polyps.
Question 4. In patients with CRS, the sinus CT scan might reveal hyperdensities
within an opacified sinus cavity. Which of the following statements best describes
the significance of hyperdensities?
A. They are pathognomonic of allergic fungal rhinosinusitis.
B. They are suggestive of the presence of necrotizing infection (abscess
formation).
C. They are often associated with mucocele formation.
D. They are suggestive of the presence of thick inspissated secretions containing
large numbers of degranulated eosinophils (allergic mucin) and possibly colonizing
fungi. – ANSWER- 4. Answer: D
Rationale : Opacified sinus cavities might contain inspissated mucus that produces
an inhomogeneous hyperdense pattern on sinus CT scanning. Hyperdensities
suggest the presence of allergic mucin. They are a classic feature of allergic fungal
rhinosinusitis (in which case the allergic mucin also contains fungal hyphae), but
they can be seen in both patients with CRS without nasal polyps and patients with
CRS with nasal polyps.
Question 1. Which of the following most accurately describes an epidemiologic
feature of food allergy?
A. Allergy to fish/shellfish is more prevalent among children than among adults.
B. On the basis of studies from a referral center in the United States, allergy to
milk and egg might be more persistent than noted in past decades, with fewer than
20% resolving these allergies by age 4 years.
C. Food allergy has approximately doubled in children over the past decade.
D. Peanut allergy resolves by school age for 35% of children given diagnoses at
less than 2 years of age. – ANSWER- 1. Answer: B
Rationale : Studies of a referral population in the United States indicated that only
11% resolved egg and 19% resolved milk allergy by age 4 years; however, about
80% resolved these allergies by age 16 years. Allergy to fish/shellfish is reported
more often in adults compared with children. Although several studies showed an
increase, approximately doubling, in peanut allergy among children in the past 10
to 15 years, there are no data to indicate a general doubling of food allergy. Peanut
allergy resolves for about 20% of young children by school age.
Question 2. A 27-year-old atopic man experienced mild oral pruritus when eating
raw apples but tolerates apple juice and baked apple. Which of the following is
most likely to be true?
A. He has an increased IgE level that binds lipid transfer protein in apple.
B. He has positive skin test results to commercial extract of apple.
C. He has an increased IgE level to Bet v 1.
D. The Maillard reaction during heating apple results in a change in conformation
that abrogates IgE binding for this subject. – ANSWER- 2. Answer: C
Rationale : The symptom complex of having mild oral pruritis to raw apple but
tolerating cooked apple is consistent with a diagnosis of oral allergy
syndrome/pollen-food syndrome, in which initial sensitization to pollen results in
reactions to homologous proteins in a raw food. Here there was likely sensitization
to birch pollen protein in this ”atopic” man; the birch pollen protein Bet v 1 is
homologous to Mal d 1 in apple. Lipid transfer protein is more stable to heat and
less likely to result in mild symptoms. Although he might have a positive skin test
result to commercial apple extract, the birch-related protein is less stable, and
testing with fresh raw juice of an apple is more likely to show a positive result in
this scenario. Although heating apple reduces the Mal d 1 protein level and
generally results in a form of the food that does not trigger symptoms in persons
with birch pollen-related allergy, this is not a Maillard reaction. High heat resulting
in a Maillard reaction, a chemical reaction between an amino acid and a reducing
sugar, has been proposed to increase the allergenicity of some foods (roasted
peanut) by increasing the stability of allergens.
Question 3. Which of the following clinical descriptions is most likely to represent
a food allergy?
A. A 3-year-old experiences acute, transient, nonpruritic erythema over the left
cheek minutes after she ingests, on separate occasions, lemonade, spicy potato
chips, and sour candy.
B. A breast-fed 5-month-old infant experiences severe vomiting, lethargy, and an
increased white blood cell count with bandemia 2 hours after she is fed rice cereal.
Skin test results to rice are negative.
C. An 18-year-old experiences cramps and diarrhea after ingesting a large milk
shake.
D. A 47-year-old experiences facial flushing and a tingling sensation in the mouth
after ingesting tuna in a restaurant. He previously tolerated all fish. – ANSWER- 3.
Answer: B
Rationale : Food allergy requires an adverse immune response. This description
fits rice-induced enterocolitis syndrome. This is a non-IgE-mediated food allergy,
and results of skin testing are expected to be negative. Choice A describes
auriculotemporal syndrome, which is a neurologic response to the spicy or tart
triggers for the child described. Choice C describes lactose intolerance, which is
dose dependent. Choice D most likely describes an episode of scombroid fish
poisoning.
Question 4. An infant experienced urticaria and angioedema when introduced to
egg, and the egg-specific IgE concentration was 4.7 kIU/L. At age 2 years, she
accidentally ingested a bite of egg and experienced wheezing and generalized
urticaria and around that time had an egg IgE level of 1.7 kIU/L. At age 3 years,
she accidentally ingested a small amount of egg and ex- perienced generalized
urticaria. At age 31⁄2 years, she presents for evaluation, and the serum egg IgE
level was less than
0.35 kIU/L. Which of the following would be the most reason- able next step
toward diagnosis?
A. Perform an open oral food challenge to egg.
B. Perform a double-blind, placebo-controlled oral food challenge to egg.
C. Perform a skin prick test to egg.
D. Allow the child to add egg to the diet. – ANSWER- 4. Answer: C