Immune

A 25-year-old man is brought to the emergency department by ambulance after eating satay sauce containing peanuts at a restaurant. He has a known peanut allergy but was not carrying an adrenaline autoinjector. Within ten minutes of eating, he developed facial flushing, lip and tongue swelling, and audible wheeze, followed by dizziness. On arrival he is anxious, diaphoretic and using accessory muscles to breathe. Observations are BP 80/50 mmHg, HR 132 bpm, RR 28/min, SpO2 92% on room air, and temperature 36.8°C. Examination reveals a diffuse urticarial rash, angioedema of the lips and tongue, and bilateral expiratory wheeze on auscultation. He is placed supine with legs elevated and given high-flow oxygen via non-rebreather mask, and IV access is obtained. What is the most appropriate immediate pharmacological intervention?

A 45-year-old man presents to the emergency department after collapsing during a fun run. He reports that approximately 40 minutes into his usual training route, roughly two hours after eating a sandwich, he developed generalised itching, widespread hives, facial swelling and light-headedness, then collapsed. His training partner called an ambulance; paramedics noted a blood pressure of 78/42 mmHg and gave intramuscular adrenaline with good effect. On direct questioning, the patient says he has eaten bread and pasta on many occasions with no reaction, and he has completed identical training runs on an empty stomach without any symptoms. He denies alcohol intake, NSAID use or recent illness. On examination in the ED he is well-appearing with resolving urticarial wheals on the trunk, normal heart sounds, clear chest and no further hypotension. ECG shows sinus rhythm with no ischaemic changes. Which of the following is the most likely diagnosis?

A 34-year-old woman with homozygous sickle cell disease and a splenectomy performed 8 years ago for recurrent splenic sequestration presents to the emergency department with a 4-hour history of fever, rigors and malaise. She has no localising symptoms and reports she is up to date with her pneumococcal, meningococcal and Haemophilus influenzae type b vaccinations, though she admits she stopped her prophylactic penicillin some years ago. On examination she is alert but unwell-looking, temperature 39.4°C, heart rate 128/min, blood pressure 98/62 mmHg, respiratory rate 24/min and SpO2 97% on room air. There is no rash, no neck stiffness and no focal source of infection is identified on examination. What is the most important immediate management priority?

A 52-year-old man presents to the emergency department with a six-week history of progressive burning pain and numbness in both feet, followed more recently by a right foot drop. He was diagnosed with chronic hepatitis C fifteen years ago after a blood transfusion but has never received antiviral treatment. On examination he has reduced pinprick sensation in a stocking distribution, weakness of right ankle dorsiflexion, and palpable purpura over both shins and buttocks. He also reports arthralgia and fatigue. Observations are unremarkable. Urinalysis shows microscopic haematuria and 2+ proteinuria. Bloods reveal a low C4 with normal C3, positive rheumatoid factor, positive hepatitis C RNA, and a positive serum cryoglobulin screen (collected and transported warm). Renal biopsy is pending. Which of the following is the most appropriate management strategy?

A 70-year-old woman with biopsy-proven giant cell arteritis, diagnosed three weeks ago after presenting with right eye visual loss, has been on prednisolone 50 mg daily since diagnosis. She now presents to the emergency department with sudden, painless loss of vision in the left eye over the past two hours. She reports recurrent temporal headache, scalp tenderness when brushing her hair, and jaw pain on chewing. Observations are stable (BP 138/82 mmHg, HR 88 bpm, afebrile). Examination reveals a tender, thickened right temporal artery, visual acuity of hand movements only in the left eye, a relative afferent pupillary defect on the left, and a pale, swollen optic disc on fundoscopy. Repeat bloods show CRP 65 mg/L and ESR 78 mm/hr, both elevated despite ongoing steroid therapy. What is the most appropriate immediate management?

A 30-year-old woman presents to the emergency department with a 3-day history of worsening dyspnoea, chest tightness and wheeze. She has a 15-year history of asthma and has required four courses of oral corticosteroids in the past year. She is maintained on high-dose inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) combination therapy plus a long-acting muscarinic antagonist (LAMA) as add-on triple therapy, with confirmed correct inhaler technique and good adherence. She denies smoking, reports no reflux symptoms and has no chronic rhinosinusitis. On examination she is alert, RR 22, SpO2 95% on room air, HR 98, afebrile, with bilateral expiratory wheeze and no accessory muscle use at rest. Following bronchodilator therapy in the ED her symptoms settle and post-treatment spirometry shows an FEV1 of 65% predicted. Blood tests reveal a peripheral eosinophil count of 800 cells/microL, and exhaled nitric oxide (FeNO) is elevated at 45 ppb. She is referred to the respiratory outpatient clinic for optimisation of her long-term asthma management. What is the most appropriate next step?