SlideShare una empresa de Scribd logo
1 de 100
Descargar para leer sin conexión
LALITA TEAR PRA SERT
Insect allergy
4 Nov 2016
• Epidemiology
• Etiology
• Taxonomy
• Insect venom
• Clinical features
• Evaluation & Diagnosis
• Treatment and Prevention
• Predictors of risk for sting anaphylaxis
• Venom immunotherapy
Outline
• 56%-94% of adults worldwide have been stung a least once in their lifetime
• Can occur any age
• Only a weak correlation with other allergic conditions
• Most reactions are localized and self limited
- Large local reaction 5-25%
- Systemic reactions
>> Children 0.4-0.8%
>> Adults 3%
Epidemiology
Middleton'sEd8.
Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
• Stinging insects belong to the order Hymenoptera
• Sting apparatus is a modified ovipositor, only the female
insects can sting
• Almost sting primarily in defense of themselves and their nest
Etiology
Middleton'sEd8.
Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
Taxonomy
Hymenoptera
Formicidae
(Ant)
Vespidae
(Vespid)
Apidae
(Bee)
PolistinaeVespinae
Vespula
(YellowJacket)
Vespa
(Hornet)
Dolichovespula
(White-Faced&YellowJacket)
Polistes
(PaperWasp)
Apinae
Bombus
(Bumblebee)
Apis
(Honeybee)
Myrmecinae
Provespa
(ต่อนอนวัน)
Family
Order
BombinaeSubfamily
Genus
Ponerinae
Pachycondyla
(มดปุยฝ้ายจั่วจีน)
Pseudo
Myrmecinae
Odontoponera
(มดไอ้ชื่นดำ)
Diacamma
(มดหนามคู่สีเทา)
Tetraponera
(มดตะนอย)
Solenopsis
(FireAnt)
Adapted From :
Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
ไม่พบในไทย
FamilyApidae
• Feral honeybees often nest in natural hollows such as in trees
• Domestic honeybees : Rarely sting or swarm without considerable
provocation, mostly in defense of their nest and their queen
• "Sting autotomy"
Sting apparatus of the honeybee is barbed and breaks away
from the insect body when it remains in the skin after a sting
and leads to its death
Middleton's Ed 8.
Apis (Honeybee)
(ผึ้งน้ำหวาน)
• Unusual tendency to swarm
with little provocation and to
sting in large numbers
• Large numbers of stings at
one time can cause toxic
reactions --> Fatal to human
• Not found in Thailand
Middleton's Ed 8.
National Pest Management Association
Bombus (Bumblebee)
(ผึ้งหึ่ง)
• Not aggressive and do not usually sting
• Very uncommon causes of sting
• “fuzzy” appearing hair and loud buzzing sound
• Report to cause anaphylaxis during occupational exposure
especially in areas of higher exposure (e.g., greenhouse
workers)
• Found in Northern of Thailand
• Very limited cross-reactivity with honeybee sting reactions
Middleton's Ed 8.
Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
• Apis mellifera : Western honeybee
(ผึ้งพันธ์ุต่างประเทศ)
• Apis florea : Dwarf honeybee
(ผึ้งมิ้ม)
• Apis cerana : Asiatic honeybee
(ผึ้งโพรง)
• Apis dorsata : Giant honeybee
(ผึ้งหลวง)
Apis (Honeybee)
(ผึ้งน้ำหวาน)
Thailand
Bombus (Bumblebee)
(ผึ้งหึ่ง)
Middleton's Ed 8.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
FamilyVespidae
Middleton's Ed 8.
Makoto Matsuura. The Social Biology Of Wasps.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
Provespa (ต่อนอนวัน)
• Typical nocturnal habits (peak:1-3 hr. after sunset)
• Nest in shrubs or trees
Thai : Provespa Barthelemyi
Provespa Anomala
• Use a wood pulp to construct nests that contain one or more
layers of comb, each of which contain a large number of cells,
attached in a vertical arrangement and usually are enclosed in
papier mâché outer layers
• Does not commonly autotomize, and vespids are able to
sting repeatedly
Vespa (Tropical Hornet)
(ต่อหัวเสือ)
Middleton's Ed 8.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
Thai : Vespa Affinis
Vespa Tropica
Polistes (Paper Wasp)
(ต่อกระดาษ)
• Narrow wasp waist and dangling legs when in flight
• Commonly build nests on human habitation
• Nest limited to single-layer of open cells with minimal outer covering
• Generally not aggressive but can sting readily when disturbed and can sting repeatedly
• Very commonly mistaken for a yellow jacket, as it is black, strongly marked with yellow
Thai : Polistes Sagitharius
Middleton's Ed 8.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
Vespula (Yellow Jacket)
• Scavengers
• Seek their food at picnics and in orchards, trashcans, and dumpsters
• Highly aggressive and sting for no apparent reason
• Nests are located in the ground or in cracks in buildings or
residential landscape materials
• Not found in Thailand
Middleton's Ed 8.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
Dolichovespula
(White-Faced & Yellow Hornet)
• Their sensitivity to vibration can initiate their defensive sting behavior
• Not found in Thailand
Middleton's Ed 8.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
FamilyFormicidae
• When they bite, they anchor by their mandibles and
pivot to administer multiple stings
• Unique lesions : "sterile pustules" within 24 hr. that can
become infected if excoriated or opened
Middleton's Ed 8.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
Solenopsis (Imported Fire Ant)
(มดคันไฟ)
Tetraponera (มดตะนอย)
Pachycondyla (มดปุยฝ้ายจั่วจีน)
Odontoponera (มดไอ้ชื่นดำ)
In Thailand
• Solenopsis germinata
• Solenopsis invicta (Red imported fire ant)
• Solenopsis richtera (Black imported fire ant)
Middleton's Ed 8.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
Middleton's Ed 8.
Bilò Mb, Et Al. Allergy 2005; 60: 1339-49.
• Typically contain a mixture of 3 to 4 major proteins
• Contain active peptides, vasoactive substances and enzymes
• Common proteins shared amongst the various Hymenoptera species
• Major allergens primarily protein enzymes : phospholipase,
hyaluronidase, and acid phosphatase
- Glycoproteins of 10-50 kDa containing 100 – 400 amino acid residues
Insect venom
• Toxin
• Vasoactive amines (histamine,
dopamine, norepinephrine)
• Acetylcholine
• Kinins
Middleton's Ed 8.
Bilò Mb, Et Al. Allergy 2005; 60: 1339-49.
burning, pain, itching
renal failure, rhabdomyolysis
• Honeybee : PLA2 (Api m1)
• Vespid : Antigen5 (Ves v 5)
Allergenic component
(Major allergen)
Non-allergenic component
Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
Ollert M. Curr Allergy Asthma Rep (2015) 15: 26.
Apidae
Api m1
Api m2
Api m3
Api m7
Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
Vespidae
Ves v1
Ves v2
Ves v5
Phospholipases found in vespid venoms (PLA 1)
differ from those found in bee venoms (PLA 2)
Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
Formicidae
Sol i1
Sol i3
• Hymenoptera deliver between 50 ng (fire ants) and 140 μg (honeybees)
of venom with each sting
- Honeybee : 50 - 140 µg of venom protein
- Bumblebee : 10 - 31 µg of venom protein
- Vespula : 1.7 - 3.1 µg of venom protein
Dolichovespula : 2.4 - 5.0 µg of venom protein
Polistes : 4.2 - 17 µg of venom protein
- Fire ant : 50 ng of venom protein
Venom Dose
Middleton's Ed 8.
Bilò Mb, Et Al. Allergy 2005; 60: 1339-49.
Between family
• Less common between honeybee and the other venoms
• Limited cross-reactivity exists between the antigens in
fire ant venom and the antigens in venoms of other
Hymenoptera
• Different insect families have almost no cross-reactivity
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Cross-reactivity
• Bumblebee show very limited cross-reactivity
with honeybee sting reactions
Apidae family
Vespidae family
• Extensive cross-reactivity in different genus
esp. hornet (vespa) and yellow jacket (vespula)
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Within family
Formicidae family • limited cross-reactivity
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Hymenoptera
Formicidae
(Ant)
Vespidae
(Vespid)
Apidae
(Bee)
PolistinaeVespinae
Vespula
(YellowJacket)
Vespa
(Hornet)
Dolichovespula
(White-Faced&YellowJacket)
Polistes
(PaperWasp)
Apinae
Bombus
(Bumblebee)
Apis
(Honeybee)
Myrmecinae
Provespa
(ต่อนอนวัน)
Family
Order
BombinaeSubfamily
Genus
Ponerinae
Pachycondyla
(มดปุยฝ้ายจั่วจีน)
Pseudo
Myrmecinae
Odontoponera
(มดไอ้ชื่นดำ)
Diacamma
(มดหนามคู่สีเทา)
Tetraponera
(มดตะนอย)
Solenopsis
(FireAnt)
Adapted From :
Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
ไม่พบในไทย
Cross-reactivity
• Classified as “local” or “systemic” in distribution and
an “immediate” or “delayed” time course
• Most insect stings are transient local reactions
- pain, swelling, and redness usually last from
a few hours to a few days and generally resolve
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Clinical features
• Limited to the area contiguous with the sting site
• Redness, Swelling, Itching and pain
• Late-phase, IgE-dependent reaction
• Increase in size for 24 to 48 hours
• Larger than 10 cm in diameter, and can
involve an entire extremity (crossing joint lines)
• Not dangerous except for potential local anatomic
compression, especially on the head, neck, tongue, or throat
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Local reaction
Large local reaction (LLR)
Systemic reaction (SR)
• Typically IgE mediated
• May present with a variety of symptoms, involving multiple organ
symptoms
1.) Cutaneous systemic reactions are limited to skin manifestations
2.) Anaphylaxis includes hypotension or involvement of at
least 2 organ systems
3.) Systemic toxic reaction
- Non-IgE mediated (anaphylatoid reaction) : onset < 24 hr.-6 days
- ex. Renal failure, rhabdomyolysis, DIC, N/V, diarrhea
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Middleton's Ed 8.
Thomas B. Casale, Et Al. N Engl J Med 2014;370:1432-9.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
• Unusual reactions of unknown mechanisms are usually delayed (> 4 hr.) :
sickness-like reactions, encephalitis, peripheral and cranial neuropathies,
glomerulonephritis, myocarditis, and Guillain-Barré syndrome.
Kounis syndrome
(Allergic angina)
most
Brehler R, Et Al. Curr Opin Allergy Clin Immunol 2013, 13:360–364.
Matysiak J, Et Al. Ann Agric Environ Med. 2013; 20(4):875–879.
Grading of systemic reactions
Grading Muller Ring & Messmer
I
Generalized urticaria, periorbital edema, itching,
malaise, anxiety
Cutaneous manifestations
(flushing, pruritus, urticaria, angioedema)
II
Angioedema or
two or more of following:
chest/throat tightness, nausea,vomiting
Mild respiratory, CV, GI
(Rhinorrhea, hoarseness, dyspnea,
tachycardia, BP change, arrhythmia)
III
Dyspnea, wheezing, or stridor or
two or more of following:
dysphagia, dysarthria, hoarseness, weakness,
confusion, feeling of impending diaster
Severe multisystem involvement
(Laryngeal edema, bronchospasm,
anaphylaxis, cyanosis, shock, collapse)
IV
Hypotension, collapse, loss of consciousness,
incontinence, cyanosis
Cardiac arrest
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
Evaluation & Diagnosis
• Diagnosis requires a clear, thorough medical history
• Quite high sensitization rate (positive tests to hymenoptera venom
but with a negative history)
• However, people with a clear documented history of a venom
reaction can have negative tests, and occasionally testing can be
positive to both honey bee and wasp venom
• Diagnosis of insect sting allergy rests on the history as the primary
evidence
- Nature and timing of stings in the past
- Time course of the reaction
- All associated symptoms and treatments
- Number of stings and the location on the body (systemic or local reactions)
- Concurrent medications : β-adrenergic blocking agents, ACEIs
(contribute significantly to the severity of the anaphylactic reaction)
- Underlying disease : heart disease
- Medications used for treatment of the reaction
Clinical history
Middleton's Ed 8.
Identity of the culprit insect :
- notoriously unreliable part of the history
- location and timing of the sting or the location of the nest
may suggest the type of insect
Middleton's Ed 8.
• In Vivo
- Skin prick test (SPT)
- Intradermal test (ID)
- Sting challenge
• In Vitro
- sIgE : RAST
- Serum tryptase
- Basophil activation test (BAT)
Middleton's Ed 8.
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89.
Diagnostic tests
Purpose
1.) Confirm allergic sensitization
2.) Define the risk of future systemic
reaction to stings (Candidates VIT)
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
• Should be performed at least 2 weeks after a sting reaction,
ideally 1–2 months later in case of false negatives due to a refractory
period after a sting
• Sensitivity : SPT < ID
• Increasing doses in 10-fold increments of venom traditionally have
been used for either SPT or ID
SPT & ID (Apid, Vespid)
SPT : Start 1.0 µg/mL (max 100 µg/mL)
ID : Start 0.001-0.01 µg/mL (max 1 µg/mL)
If >1.0 mcg/ml : nonallergenic ingredients can cause nonspecific reaction (False positive)
WWW.drugs.com
Venom extract
• Honey Bee (Apis mellifera)
• Yellow Jacket (Vespula spp.)
• Yellow Hornet (Dolichovespula arenaria)
• White Faced Hornet (Dolichovespula maculata)
• Wasp (Polistes spp.)
• Mixed Vespid (Yellow Jacket, Yellow Hornet & White Faced Hornet)
Tracy Et Al. Curr Opin Allergy Clin Immunol 2015, 15:358–363.
• Difficulty in collecting all species for the yellow-jacket and paper wasp
venom mixes, not all lots contain every species
Thailand
(Freeze-dried venom)
WWW.drugs.com
Shelf life
12 mo.
1 mo.
2 wk.
daily
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
Rutcharin Potiwat. Asian Pac J Allergy Immunol 2015;33:267-75.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016
SPT & ID (Fire Ant)
• Imported fire ant whole-body extract
• Screening SPT : 1:1000 (w/v) of imported fire ant WBE
• Intradermal skin test :
- initial concentrations of approximately 1 x 10-6 (1:1 million) wt/vol.
- increased by increments until a positive response is elicited or a
maximum concentration of 1 x 10-3 (1:1,000) or 2 x 10-3 (1:500) wt/vol
Interpretation
Thomas B. Casale, Et Al. N Engl J Med 2014;370:1432-9.
Positive skin test
• ID skin test
- Inconsistency in the description of the technique and interpretation
- No definitive studies to suggest any specific intradermal technique
to be superior for determining specific IgE for venom
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
North America,
Europe, and many
countries
United Kingdom
ALK
(manufacture)
Method
Injection of 0.02 -
0.03 mL of venom
to produce a bleb
of 3 mm
Injection of 0.03 mL
of venom to raise a
bleb of 3 to 5 mm.
Injection of 0.05 mL
of venom
Interpretation
- wheal 3 - 5 mm. >
negative control
- with appropriate
surrounding
erythema
- wheal 3 mm. >
negative control
- at 20 minutes
- wheal 5 - 10 mm
and erythema
11 - 20 mm
Negative skin test
• Patients with a convincing history but negative skin test results
may consider
- Refractory period of anergy : skin tests should be repeated
after 4 to 6 weeks
- Confounding medicine
- Not used culprit insect
- Maybe non-IgE mediated
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
" If skin test results are negative in a patient with a clear history of
systemic sting reaction, further testing (in vitro testing, repeat skin 

testing , or both) should be performed, as well as basal serum tryptase "
Middleton's Ed 8.
Golden. Immunol Allergy Clin North Am. 2007 May ; 27(2): 261–Vii.
• Skin test results for individual venoms can vary over a short period, 

and identification of all sensitivities requiring treatment may require
skin testing on 2 separate occasions
• The strongest skin tests often occur in patients who have had 

only large local reactions and have a very low risk of anaphylaxis
" If negative skin test results and a convincing history of anaphylaxis 

should be further investigated with serologic testing, and if results 

remain negative, the skin tests should be repeated after 3 - 6 months "
• Sensitivity of venom sIgE is generally lower than ID

• sIgE increased in days-week maximum 2-3 week after sting than 

gradually decrased

• Perform for "Whole body extract" or "Components" (Natural or 

Recombinant components)

- Natural venom extracts can lead to clouding of the diagnostic 

process secondary to cross-reacting carbohydrate determinants
(CCDs) ex. HBV, YJV
sIgE
Middleton's Ed 8.
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89.
Ollert M, Et Al. Curr Allergy Asthma Rep (2015) 15: 26.
Cross-reactivity carbohydrate
determinants (CCD)
• In insects, the relevant CCD epitope is defined by an
alpha-1,3-linked fucose residue at the innermost N-
acetylglucosamine of the carbohydrate core structure
Ollert M, Et Al. Curr Allergy Asthma Rep (2015) 15: 26.
Brehler R, Et Al. Curr Opin Allergy Clin Immunol 2013, 13:360–364.
• IgE antibodies with specificity for the alpha-1,3-fucose epitope are
responsible for approximately 75 % of double sensitizations to HBV
and YJV
• Clinical relevance of these IgE antibodies appears to be rather low
Insect
MMF3F6: represents a typical structure
Plant
Brehler R, Et Al. Curr Opin Allergy Clin Immunol 2013, 13:360–364.
Matysiak J, Et Al. Ann Agric Environ Med. 2013; 20(4):875–879.
• IgE antibodies reacting with bee and wasp venom (Double sensitivity)
could be detected in about 30–50% may be due to 3 causes
(1) independent sensitization to both venoms (rare)
(2) cross-reactive IgE antibodies against to common protein
Hyaluronidase (Api m2 & Vas v2) or dipeptidylpeptidase
(Api m5 & Vas v3)
(3) cross-reactive IgE antibodies against CCD
Double sensitive to bee & wasp
Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449.
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89.
• Api m 1 (major honeybee allergen) : low sensitivity

• Ves v 1 & Ves v 5 

- Ves v 5 : good diagnostic performance

- Ves v 5 & Ves v 1 : sensitivity was significantly increased

• Pol d 1 & Pol d 5
• Crucial especially when the stinging insect was not identified 

and when skin tests and specific IgE to the native allergens are 

unsuccessful for the identification
Recombinent marker allergen
MUXF3 : glycan from bromelain is commercially available
Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449.
Example
Decreased false-positive and false-negative
Ollert M, Et Al. Curr Allergy Asthma Rep (2015) 15: 26.
• Cannot performed skin test

• Disconcordant between history and skin test

- sIgE test is positive in 10% of patients with negative skin test results

• Double sensitization 

- 50% of allergic reaction to honey bee or vespulae had positive both 

diagnostic test (homology in the hyaluronidase enzymes) , 

CRD can help to identify true culprit insect
Middleton's Ed 8.
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89.
sIgE benefit in patients
The level of sensitivity (skin test or serum IgE) is correlated 

with the frequency but not the severity of the reaction
Golden. J Allergy Clin Immunol 2005;115:439-47.
• Venom skin tests and venom-specific IgE assays correlate imperfectly

sIgE negative in 20% of skin test–positive
skin test negative in 10% of persons with elevated IgE antibodies
Basophil activation test (BAT)
Before test : Basophil > 50 cells
Matysiak J, Et Al. Ann Agric Environ Med. 2013; 20(4):875–879.
D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89.
Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449.
Can be useful in
• In cases of negative skin tests and negative specific IgE 

results or discrepancies in these tests

• Monitoring of VIT results
" Routine use of BAT in evaluating Hymenoptera sensitive 

patients is not recommended "
• Remains to be standardized in terms of methodology
and interpretation
• Should be done : severe
anaphylaxis

• Evaluation : Mastocytosis
or mast cells diseases

• Predict : Severity of
systemic reaction to sting
Serum tryptase
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Mast cell disorders
• Insect stings are the most common
cause of anaphylaxis in mastocytosis
• 25% of insect sting anaphylaxis --> have elevated baseline serum tryptase
• 2% mastocytosis --> insect sting anaphylaxis
Middleton's Ed 8.
Rueff Et Al. J Allergy Clin Immunol 2009;124:1047-54.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
• If the serum tryptase is elevated
(>11.4 ng/ml) bone marrow biopsy
should be considered

• Tryptase concentrations manifest a
significant correlation with severity
of clinical symptoms, especially
with a decrease in blood pressure
in the main arteries
Sting challenge
• Sting challenge is the most specific diagnostic test, but unethical
and impractical
• Recommended by some to better select those patients who need VIT
Middleton's Ed 8.
Agache Et Al. Allergy 70 (2015) 355–365.
Www.Eaaci.Org
Absolute contraindication 

- Pregnancy 

- Acute inflammatory disease

- Severe or uncontrolled cardiovascular or respiratory disease

- Treatment with beta-blockers
• Low negative predictive value (NPV) : A single negative challenge
sting does not preclude anaphylaxis to a subsequent sting
• Less reliable with vespids than with honeybees
Middleton's Ed 8.
Agache Et Al. Allergy 70 (2015) 355–365.
Www.Eaaci.Org
Limitation
• Same species as the one that
provoked the reaction

• Sting has to be confirmed by the
development of a wheal and flare
reaction and by the characteristic
burning pain

• After the sting challenge, all patients
have to be observed for at least 2 hr
in the hospital
D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89.
• Ice pack, elevation of the afftected limb
• Oral antihistamines
• Large local reactions, especially head and neck
- Oral corticosteroid 40-60 mg of prednisone 5 days
(steroids should be started within few hours of sting in patients
with known history of large local reactions)
- Analgesic : NSAIDs
• Antibiotics are not necessary
Treatment of acute reactions
Local & Large local
Middleton's Ed 8.
• Urticaria may respond to antihistamines alone

• Anaphylactic reactions require epinephrine injection IM (1:1000)
0.01 mg/kg (max 0.3 mg in children, 0.5 mg. in adult)
• Patients who have history of rapid onset or very severe systemic 

reactions may treatment immediately after the sting

• Hypotension should be supine with legs raised

• Delay in the use of epinephrine has contributed to fatal reactions

• Some individuals with anaphylactic shock are resistant to epinephrine

- Patients taking β-blocker medications Rx Glucagon
Middleton's Ed 8.
Systemic reactions
• Anaphylaxis requires patient education before discharge

• Use of self-injectable epinephrine requires consistent instruction 

and follow-up

• Referred for an allergy consultation : For VIT
• Preventive treatment : effective measures to avoid insect stings
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Patient education
Pitfall
• Patients often fail to carry the injector with them 

• Delay using when they have a reaction
Prevention
• Avoid eating outdoors
• Avoid flowering plants
• Avoid drinking from straws, cans,
or bottles outdoors
• Remove fallen fruit or pet feces
• Cover trash cans
• Watch for nests in bushes or in the
ground when mowing
• Avoid going barefoot outdoors
• Avoiding fragrances
• Avoiding brightly colored or floral
clothing
• Using insect repellants
• Running; flailing the arm
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Effective Ineffective
Predictors of risk for
sting anaphylaxis
Natural history
• Prognosis for affected patients is based on the understanding
of the natural history of the condition including clinical factors
and biologic markers
• Future sting will cause an allergic reaction depends on the history
and immunologic status of the patient
Middleton's Ed 8.
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Clinical markers Laboratory markers
Very severe previous reaction
Insect species
No urticaria/angioedema
Age (>45), Gender (male)
Medications (ACE inhibitors)
Multiple or sequential stings
acetylhydrolase
Venom skin test
Venom-specific IgE
Basal serum tryptase
Platelet activating factor (PAF)
Angiotensin converting enzyme
(ACE)
Predictors of risk of systemic reaction to insect sting
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
Venom immunotherapy
• Treatment of choice for prevention of systemic allergic reactions
to insect stings but it requires careful selection of patients
• All patients who have experienced a systemic allergic reaction to
an insect sting and who have specific IgE to venom allergens
- reduces the risk of a subsequent systemic sting reaction to
as low as 5% compared with up to 60% in untreated patients
• High risk patients : patient with mastocytosis, or an increased basal
serum tryptase level
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Indication for VIT
VIT
Middleton's Ed 8.
Change in practice parameter 2016
VIT
Optional
• VIT is generally not required for patients > 16 years of age who have
experienced only cutaneous systemic reactions
• Sting challenge studies suggest that these patients are very unlikely to have
severe anaphylactic reactions to subsequent stings
(Recommendation: C)
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
(1) Prevent systemic reactions
(2) Alleviate patients' anxiety related to insect stings
(with improved quality of life)
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Goals of VIT
Only large local reactions to stings that VIT is generally not necessary
(low risk of a systemic reaction 4-10%) , but might be considered in
those who have frequent unavoidable exposure for quality of life reason
• Malignancy
• Severe asthma
• Immunological conditions
• Chronic heart and lung disease
• Severe hypertensions
• Drug: beta blockers, tricyclic antidepressants,
monoamine oxidase inhibitors, ACEIs
• Initiation during pregnancy
(though maintenance can be continued in pregnancy)
Contraindications
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
• 95-100% effective in preventing systemic reactions to stings
- maintenance dose of 300 μg of mixed vespid venoms
• 75-95% efficacy
- 100 μg dose of individual venoms
(i.e., honeybee, yellow jacket, or Polistes wasp)
• Fire ant IT using wholebody extracts has been reported to be
reasonably safe and effective
• Repeat sting reactions usually are milder than pretreatment reactions
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Efficacy
95% to 100% effective in preventing
systemic reactions to stings
Failure of VIT
• Associated with
- abnormal basophil activation test responses
- underlying mastocytosis
Middleton's Ed 8.
Safety
Middleton's Ed 8.
Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449.
• Adverse reactions to VIT are no more common than reactions
during inhalant allergen immunotherapy
• Systemic symptoms occur in 5-15% (Most are mild)
- Severe systemic reactions to injections --> underlying mast cell
disease
• LLR to venom injections ~ 50% of patients, esp. dose 20 - 50 μg
- LLR to venom injections not predicted systemic reactions
Risk factors for side effect during IT
Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449.
• Antihistamines
- Reduce local and systemic reactions
• Leukotriene modifier
- Reduce LLR
• Recurrent systemic reactions to VIT: rush VIT, or omalizumab
Pre-medication
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
• Need only contain a single venom if the culprit is definitively
known
• Recombinant venom allergens has been able to resolve dual
sensitivity that may be due to CCD
• Mixed vespid efficacy > single vespid
• Therapy with yellow jacket or mixed vespid venoms can protect against
wasp stings
Venom species
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
• Increasing the maintenance dose up to 200 mcg per dose has
been effective in achieving protection in patients who had sting
reactions while receiving a 100-mcg maintenance dose of VIT
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Venom Dose
• Initial dose of up to 1 mcg
Increase to maintenance dose of at least 100 mcg of each venom
(equivalent to 2 honeybee stings : 50 mcg per sting)
• Children might be effectively treated with a maintenance dose of 50 mcg.
Change in practice parameter 2016
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
Schedules Different in Build-up phase
1.) Build-up
1.) Traditional/ conventional : 4-6 mo.
2.) Modified rush/ cluster : 6-8 wk.
3.) Rush : 2-7 days
4.) Ultra-rush : < 2 days
Golden. J Allergy Clin Immunol 2005;115:439-47.
4-6 mo.6-8 wk.2-7 days< 48 hr.
Middleton's Ed 8.
Conventional
Modified
rush
• 2 standard regimens in the US. aim to achieve the 100-mg dose in either 8 or 15 weeks
• Rush VIT is indicated in some patients in Europe
Patella V, Et Al. Journal Of Allergy Volume 2012.
Ultrarush Rush
Unlike inhalant allergen IT, the more rapid regimens of VIT appear
to have the same or greater safety as the traditional regimen
2.) Maintenance
• Onset of protection with VIT is quite rapid
• Sting challenge studies : protective is reached after an 8-week
build-up regimen
Every 4 weeks for 12-18 months
Every 6 weeks for 12-18 months
then Every 8 weeks
Middleton's Ed 8.
D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89.
12-week interval may be effective for extended maintenance
treatment after 4 years of routine therapy
• Repeat skin tests or immunoassays : every 2-3 years
• SPT
- After 5 years : negative < 20%
- After 7–10 years : negative 50–60%
(although most remain positive by RAST)
• Venom-specific IgE antibody levels
- level rises during the first months of therapy
- returns to baseline after 12 months
- declines steadily during maintenance treatment
(even after therapy is stopped and after a sting)
Maintenance evaluation
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
• Venom-specific IgG antibodies
- marker of clinical efficacy
- good PPV but poor NPV
- confirm protective levels after initial therapy
(especially honeybee or single venoms)
- considered protective: ≥ 3 μg/mL during the first 4 years
Maintenance evaluation
Middleton's Ed 8
Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Insect allergy
Duration
• Early studies : recommended 3 years (results included patients with
up to 10 years of treatment)
• Subsequent studies : 5 years of was associated with better
suppression of allergic sensitivity and lower risk of relapse
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Change in practice parameter 2016
• 5 years is better than 3 years
• Longer treatment recommended in high-risk patients; 3 years may be sufficient in children
Better for 5 years
25% 10%
2 yr.
> 5 yr.
Golden. J Allergy Clin Immunol 2005;115:439-47.
Risk of relapse after discontinuing VIT
• No specific tests to
distinguish which patients
will relapse after stopping
VIT
• Relapse
- 5 years < 3 years of VIT
- younger children < adults
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Maybe need longer than 5 years
• Honeybee allergy
• Had systemic reactions to an injection or sting during VIT
• Elevated baseline serum tryptase levels
• Very severe sting reactions before treatment
• Mastocytosis
- recommend VIT for life
- efficacy of VIT is less than optimal in mastocytosis patients, they
should continue to carry 2 epinephrine injectors
• Patients who are not willing to accept the 10%- 20% chance of
reaction to a subsequent sting
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Long-term extension of VIT
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
• The decision to stop immunotherapy can involve consideration
of several factors by the patient and physician
(1) severity of the initial reaction
(2) basal serum tryptase
(3) frequency of exposure
(4) presence of concomitant disease and medications
(5) effect of such action on work and leisure activities
(6) the patient's preferences
• Natural history of fire ant allergy is not as well described
• But clear need for effective IT
• IT using WBE : effective but no placebo-controlled trials
• The dosage maintenance schedule is less well defined
- most experts recommend maintenance dose : 0.5 mL ,1:100 wt/vol
- some experts : 0.5 mL , 1:10 wt/vol
• Duration is still uncertain, because discontinuation led to relapse
• Most allergists consider stopping after specified period (usually 3-5 years)
or only when skin test or in vitro test become negative
Middleton's Ed 8.
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
Fire Ant immunotherapy
Insect allergy
David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
50 mcg., 3 years
Thank You
Benefit in selected culprit For VIT

Más contenido relacionado

La actualidad más candente (20)

Angioedema
AngioedemaAngioedema
Angioedema
 
Urticaria part I
Urticaria part IUrticaria part I
Urticaria part I
 
Insect bites
Insect bitesInsect bites
Insect bites
 
Angioedema
AngioedemaAngioedema
Angioedema
 
Cat and dog allergy
Cat and dog allergyCat and dog allergy
Cat and dog allergy
 
Cockroach allergy
Cockroach allergyCockroach allergy
Cockroach allergy
 
Types of Allergies
Types of AllergiesTypes of Allergies
Types of Allergies
 
Allergy- Laboratory Diagnostic Tests
Allergy- Laboratory Diagnostic TestsAllergy- Laboratory Diagnostic Tests
Allergy- Laboratory Diagnostic Tests
 
Allergic diseases SLIDES
Allergic diseases SLIDESAllergic diseases SLIDES
Allergic diseases SLIDES
 
Allergy
AllergyAllergy
Allergy
 
Diagnosis and management of hymenoptera sting
Diagnosis and management of hymenoptera stingDiagnosis and management of hymenoptera sting
Diagnosis and management of hymenoptera sting
 
Tularemia
TularemiaTularemia
Tularemia
 
Allergic Disorders In Children
Allergic Disorders In ChildrenAllergic Disorders In Children
Allergic Disorders In Children
 
Allergy Power Point Presentation
Allergy Power Point PresentationAllergy Power Point Presentation
Allergy Power Point Presentation
 
Bee sting MANAGEMENT
Bee sting MANAGEMENT Bee sting MANAGEMENT
Bee sting MANAGEMENT
 
Viral exanthems-module
Viral exanthems-moduleViral exanthems-module
Viral exanthems-module
 
Seasonal Allergies
Seasonal AllergiesSeasonal Allergies
Seasonal Allergies
 
Anaphylaxis Disease
Anaphylaxis DiseaseAnaphylaxis Disease
Anaphylaxis Disease
 
IMMUNOLOGY (ALLERGIC REACTIONS AND ANAPHYLAXIS)
IMMUNOLOGY (ALLERGIC REACTIONS AND ANAPHYLAXIS)IMMUNOLOGY (ALLERGIC REACTIONS AND ANAPHYLAXIS)
IMMUNOLOGY (ALLERGIC REACTIONS AND ANAPHYLAXIS)
 
Diagnosis and treatment of URTI
Diagnosis and treatment of URTI Diagnosis and treatment of URTI
Diagnosis and treatment of URTI
 

Destacado

Bee Sting Allergy
Bee Sting AllergyBee Sting Allergy
Bee Sting Allergyaburiziza
 
Stings and bites (2)
Stings and bites (2)Stings and bites (2)
Stings and bites (2)Nunkoo Raj
 
Basicity of heterocyclics pdf
Basicity of heterocyclics pdfBasicity of heterocyclics pdf
Basicity of heterocyclics pdfRawat DA Greatt
 
Research & Reviews: A Journal of Pharmacognosy vol 3 issue 3
Research & Reviews: A Journal of Pharmacognosy  vol 3 issue 3Research & Reviews: A Journal of Pharmacognosy  vol 3 issue 3
Research & Reviews: A Journal of Pharmacognosy vol 3 issue 3STM Journals
 
Physical and biological method of drug evaluation by Dr.U.Srinivasa
Physical and biological method of drug evaluation by Dr.U.SrinivasaPhysical and biological method of drug evaluation by Dr.U.Srinivasa
Physical and biological method of drug evaluation by Dr.U.Srinivasaummanabadsrinivas
 

Destacado (20)

Studies of biologic agents in severe asthma
Studies of biologic agents in severe asthmaStudies of biologic agents in severe asthma
Studies of biologic agents in severe asthma
 
Latex allergy
Latex allergyLatex allergy
Latex allergy
 
Insect sting allergy
Insect sting allergyInsect sting allergy
Insect sting allergy
 
Insect Sting Allergy
Insect Sting AllergyInsect Sting Allergy
Insect Sting Allergy
 
Bee Sting Allergy
Bee Sting AllergyBee Sting Allergy
Bee Sting Allergy
 
Stings and bites (2)
Stings and bites (2)Stings and bites (2)
Stings and bites (2)
 
Lobelia
LobeliaLobelia
Lobelia
 
Lobelia
LobeliaLobelia
Lobelia
 
The Roles Of iNKT Cells In Asthma
The Roles Of iNKT Cells In AsthmaThe Roles Of iNKT Cells In Asthma
The Roles Of iNKT Cells In Asthma
 
Chronic spontaneous urticaria (part2)
Chronic spontaneous urticaria (part2)Chronic spontaneous urticaria (part2)
Chronic spontaneous urticaria (part2)
 
Chronic rhinosinusitis in children
Chronic rhinosinusitis in childrenChronic rhinosinusitis in children
Chronic rhinosinusitis in children
 
Basicity of heterocyclics pdf
Basicity of heterocyclics pdfBasicity of heterocyclics pdf
Basicity of heterocyclics pdf
 
Chronic rhinosinusitis in children
Chronic rhinosinusitis in childrenChronic rhinosinusitis in children
Chronic rhinosinusitis in children
 
Mendelian susceptibility to mycobacterial diseases
Mendelian susceptibility to mycobacterial diseasesMendelian susceptibility to mycobacterial diseases
Mendelian susceptibility to mycobacterial diseases
 
Research & Reviews: A Journal of Pharmacognosy vol 3 issue 3
Research & Reviews: A Journal of Pharmacognosy  vol 3 issue 3Research & Reviews: A Journal of Pharmacognosy  vol 3 issue 3
Research & Reviews: A Journal of Pharmacognosy vol 3 issue 3
 
Physical and biological method of drug evaluation by Dr.U.Srinivasa
Physical and biological method of drug evaluation by Dr.U.SrinivasaPhysical and biological method of drug evaluation by Dr.U.Srinivasa
Physical and biological method of drug evaluation by Dr.U.Srinivasa
 
Interferon-gamma and immune system
Interferon-gamma and immune systemInterferon-gamma and immune system
Interferon-gamma and immune system
 
Stevens johnson syndrome & toxic epidermal necrolysis
Stevens johnson syndrome & toxic epidermal necrolysisStevens johnson syndrome & toxic epidermal necrolysis
Stevens johnson syndrome & toxic epidermal necrolysis
 
Hyper-IgE syndrome
Hyper-IgE syndromeHyper-IgE syndrome
Hyper-IgE syndrome
 
Corneal Allograft Rejection
Corneal Allograft RejectionCorneal Allograft Rejection
Corneal Allograft Rejection
 

Similar a Insect allergy

2006-public-health-pests.ppt
2006-public-health-pests.ppt2006-public-health-pests.ppt
2006-public-health-pests.pptAli Hassan
 
2010.05.17_FRACP_Insect_Sting_Allergy-2.pdf
2010.05.17_FRACP_Insect_Sting_Allergy-2.pdf2010.05.17_FRACP_Insect_Sting_Allergy-2.pdf
2010.05.17_FRACP_Insect_Sting_Allergy-2.pdfAssemAssem6
 
Generalhealthproblems 140219011807-phpapp01
Generalhealthproblems 140219011807-phpapp01Generalhealthproblems 140219011807-phpapp01
Generalhealthproblems 140219011807-phpapp01Jeff Semler
 
Medical Entomology
 Medical Entomology Medical Entomology
Medical EntomologyWani Insha
 
Fungi classification plant pathology.pptx
Fungi classification  plant  pathology.pptxFungi classification  plant  pathology.pptx
Fungi classification plant pathology.pptxAjayDesouza V
 
Fungi classification plant pathology.pptx
Fungi classification  plant  pathology.pptxFungi classification  plant  pathology.pptx
Fungi classification plant pathology.pptxAjayDesouza V
 
PRESENTS STATUS OF INSECTICIDE RESISTANCE IN INSECTS
PRESENTS STATUS OF INSECTICIDE RESISTANCE IN INSECTSPRESENTS STATUS OF INSECTICIDE RESISTANCE IN INSECTS
PRESENTS STATUS OF INSECTICIDE RESISTANCE IN INSECTSAGRITECH4
 
Insect classification lab24
Insect classification lab24Insect classification lab24
Insect classification lab24Hama Nabaz
 
Insect classification lab24
Insect classification lab24Insect classification lab24
Insect classification lab24Hama Nabaz
 
Insect classification lab21
Insect classification lab21Insect classification lab21
Insect classification lab21Hama Nabaz
 

Similar a Insect allergy (20)

Hymenoptera venom hypersensitivity 2020
Hymenoptera venom hypersensitivity 2020Hymenoptera venom hypersensitivity 2020
Hymenoptera venom hypersensitivity 2020
 
Fire ant hypersensitivity.pdf
Fire ant hypersensitivity.pdfFire ant hypersensitivity.pdf
Fire ant hypersensitivity.pdf
 
2006-public-health-pests.ppt
2006-public-health-pests.ppt2006-public-health-pests.ppt
2006-public-health-pests.ppt
 
2010.05.17_FRACP_Insect_Sting_Allergy-2.pdf
2010.05.17_FRACP_Insect_Sting_Allergy-2.pdf2010.05.17_FRACP_Insect_Sting_Allergy-2.pdf
2010.05.17_FRACP_Insect_Sting_Allergy-2.pdf
 
Hymenoptera sting allergy.pdf
Hymenoptera sting allergy.pdfHymenoptera sting allergy.pdf
Hymenoptera sting allergy.pdf
 
Equine skin allergies
Equine skin allergiesEquine skin allergies
Equine skin allergies
 
Generalhealthproblems 140219011807-phpapp01
Generalhealthproblems 140219011807-phpapp01Generalhealthproblems 140219011807-phpapp01
Generalhealthproblems 140219011807-phpapp01
 
Medical Entomology
 Medical Entomology Medical Entomology
Medical Entomology
 
General Health Problems of Sheep/Goats
General Health Problems of Sheep/GoatsGeneral Health Problems of Sheep/Goats
General Health Problems of Sheep/Goats
 
Hymenoptera venom hypersensitivity 1 (focused on apidae &amp; vespidae)
Hymenoptera venom hypersensitivity 1 (focused on apidae &amp; vespidae)Hymenoptera venom hypersensitivity 1 (focused on apidae &amp; vespidae)
Hymenoptera venom hypersensitivity 1 (focused on apidae &amp; vespidae)
 
Entomology Spotters
Entomology SpottersEntomology Spotters
Entomology Spotters
 
Ant venom allergy
Ant venom allergyAnt venom allergy
Ant venom allergy
 
Fire ant hypersensitivity
Fire ant hypersensitivityFire ant hypersensitivity
Fire ant hypersensitivity
 
Ticks and its parasitic adaptations
Ticks and its parasitic adaptationsTicks and its parasitic adaptations
Ticks and its parasitic adaptations
 
Fungi classification plant pathology.pptx
Fungi classification  plant  pathology.pptxFungi classification  plant  pathology.pptx
Fungi classification plant pathology.pptx
 
Fungi classification plant pathology.pptx
Fungi classification  plant  pathology.pptxFungi classification  plant  pathology.pptx
Fungi classification plant pathology.pptx
 
PRESENTS STATUS OF INSECTICIDE RESISTANCE IN INSECTS
PRESENTS STATUS OF INSECTICIDE RESISTANCE IN INSECTSPRESENTS STATUS OF INSECTICIDE RESISTANCE IN INSECTS
PRESENTS STATUS OF INSECTICIDE RESISTANCE IN INSECTS
 
Insect classification lab24
Insect classification lab24Insect classification lab24
Insect classification lab24
 
Insect classification lab24
Insect classification lab24Insect classification lab24
Insect classification lab24
 
Insect classification lab21
Insect classification lab21Insect classification lab21
Insect classification lab21
 

Más de Chulalongkorn Allergy and Clinical Immunology Research Group

Más de Chulalongkorn Allergy and Clinical Immunology Research Group (20)

Cat and dog allergy and exotic pets 2024
Cat and dog allergy and exotic pets 2024Cat and dog allergy and exotic pets 2024
Cat and dog allergy and exotic pets 2024
 
Anti-interferon-gamma autoantibody associated immunodeficiency
Anti-interferon-gamma autoantibody associated immunodeficiencyAnti-interferon-gamma autoantibody associated immunodeficiency
Anti-interferon-gamma autoantibody associated immunodeficiency
 
DRESS syndrome.pdf
DRESS syndrome.pdfDRESS syndrome.pdf
DRESS syndrome.pdf
 
Wheat allergy.pdf
Wheat allergy.pdfWheat allergy.pdf
Wheat allergy.pdf
 
Indoor allergen avoidance.pdf
Indoor allergen avoidance.pdfIndoor allergen avoidance.pdf
Indoor allergen avoidance.pdf
 
AERD and NSAID hypersensitivity
AERD and NSAID hypersensitivityAERD and NSAID hypersensitivity
AERD and NSAID hypersensitivity
 
Food immunotherapy.pdf
Food immunotherapy.pdfFood immunotherapy.pdf
Food immunotherapy.pdf
 
Agammaglobulinemia.pdf
Agammaglobulinemia.pdfAgammaglobulinemia.pdf
Agammaglobulinemia.pdf
 
Histamine and anti histamines.pdf
Histamine and anti histamines.pdfHistamine and anti histamines.pdf
Histamine and anti histamines.pdf
 
Food-dependent, exercise-induced anaphylaxis
Food-dependent, exercise-induced anaphylaxis Food-dependent, exercise-induced anaphylaxis
Food-dependent, exercise-induced anaphylaxis
 
Beta-lactam allergy.pdf
Beta-lactam allergy.pdfBeta-lactam allergy.pdf
Beta-lactam allergy.pdf
 
Immunoglobulin therapy
Immunoglobulin therapyImmunoglobulin therapy
Immunoglobulin therapy
 
Local anesthetic drug allergy.pdf
Local anesthetic drug allergy.pdfLocal anesthetic drug allergy.pdf
Local anesthetic drug allergy.pdf
 
Iodinated contrast media Hypersensitivity
Iodinated contrast media HypersensitivityIodinated contrast media Hypersensitivity
Iodinated contrast media Hypersensitivity
 
Urticaria.pdf
Urticaria.pdfUrticaria.pdf
Urticaria.pdf
 
Serum sickness & SSLR
Serum sickness & SSLRSerum sickness & SSLR
Serum sickness & SSLR
 
Vaccine Hypersensitivity.pdf
Vaccine Hypersensitivity.pdfVaccine Hypersensitivity.pdf
Vaccine Hypersensitivity.pdf
 
HyperIgM syndrome.pdf
HyperIgM syndrome.pdfHyperIgM syndrome.pdf
HyperIgM syndrome.pdf
 
Hypersensitivity pneumonitis and occupational asthma
Hypersensitivity pneumonitis and occupational asthmaHypersensitivity pneumonitis and occupational asthma
Hypersensitivity pneumonitis and occupational asthma
 
Allergen immunotherapy.pdf
Allergen immunotherapy.pdfAllergen immunotherapy.pdf
Allergen immunotherapy.pdf
 

Último

FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 

Último (20)

FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 

Insect allergy

  • 1. LALITA TEAR PRA SERT Insect allergy 4 Nov 2016
  • 2. • Epidemiology • Etiology • Taxonomy • Insect venom • Clinical features • Evaluation & Diagnosis • Treatment and Prevention • Predictors of risk for sting anaphylaxis • Venom immunotherapy Outline
  • 3. • 56%-94% of adults worldwide have been stung a least once in their lifetime • Can occur any age • Only a weak correlation with other allergic conditions • Most reactions are localized and self limited - Large local reaction 5-25% - Systemic reactions >> Children 0.4-0.8% >> Adults 3% Epidemiology Middleton'sEd8. Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
  • 4. • Stinging insects belong to the order Hymenoptera • Sting apparatus is a modified ovipositor, only the female insects can sting • Almost sting primarily in defense of themselves and their nest Etiology Middleton'sEd8. Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137.
  • 5. Taxonomy Hymenoptera Formicidae (Ant) Vespidae (Vespid) Apidae (Bee) PolistinaeVespinae Vespula (YellowJacket) Vespa (Hornet) Dolichovespula (White-Faced&YellowJacket) Polistes (PaperWasp) Apinae Bombus (Bumblebee) Apis (Honeybee) Myrmecinae Provespa (ต่อนอนวัน) Family Order BombinaeSubfamily Genus Ponerinae Pachycondyla (มดปุยฝ้ายจั่วจีน) Pseudo Myrmecinae Odontoponera (มดไอ้ชื่นดำ) Diacamma (มดหนามคู่สีเทา) Tetraponera (มดตะนอย) Solenopsis (FireAnt) Adapted From : Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94. ไม่พบในไทย
  • 6. FamilyApidae • Feral honeybees often nest in natural hollows such as in trees • Domestic honeybees : Rarely sting or swarm without considerable provocation, mostly in defense of their nest and their queen • "Sting autotomy" Sting apparatus of the honeybee is barbed and breaks away from the insect body when it remains in the skin after a sting and leads to its death Middleton's Ed 8. Apis (Honeybee) (ผึ้งน้ำหวาน)
  • 7. • Unusual tendency to swarm with little provocation and to sting in large numbers • Large numbers of stings at one time can cause toxic reactions --> Fatal to human • Not found in Thailand Middleton's Ed 8. National Pest Management Association
  • 8. Bombus (Bumblebee) (ผึ้งหึ่ง) • Not aggressive and do not usually sting • Very uncommon causes of sting • “fuzzy” appearing hair and loud buzzing sound • Report to cause anaphylaxis during occupational exposure especially in areas of higher exposure (e.g., greenhouse workers) • Found in Northern of Thailand • Very limited cross-reactivity with honeybee sting reactions Middleton's Ed 8. Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
  • 9. • Apis mellifera : Western honeybee (ผึ้งพันธ์ุต่างประเทศ) • Apis florea : Dwarf honeybee (ผึ้งมิ้ม) • Apis cerana : Asiatic honeybee (ผึ้งโพรง) • Apis dorsata : Giant honeybee (ผึ้งหลวง) Apis (Honeybee) (ผึ้งน้ำหวาน) Thailand Bombus (Bumblebee) (ผึ้งหึ่ง) Middleton's Ed 8. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
  • 10. FamilyVespidae Middleton's Ed 8. Makoto Matsuura. The Social Biology Of Wasps. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94. Provespa (ต่อนอนวัน) • Typical nocturnal habits (peak:1-3 hr. after sunset) • Nest in shrubs or trees Thai : Provespa Barthelemyi Provespa Anomala
  • 11. • Use a wood pulp to construct nests that contain one or more layers of comb, each of which contain a large number of cells, attached in a vertical arrangement and usually are enclosed in papier mâché outer layers • Does not commonly autotomize, and vespids are able to sting repeatedly Vespa (Tropical Hornet) (ต่อหัวเสือ) Middleton's Ed 8. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94. Thai : Vespa Affinis Vespa Tropica
  • 12. Polistes (Paper Wasp) (ต่อกระดาษ) • Narrow wasp waist and dangling legs when in flight • Commonly build nests on human habitation • Nest limited to single-layer of open cells with minimal outer covering • Generally not aggressive but can sting readily when disturbed and can sting repeatedly • Very commonly mistaken for a yellow jacket, as it is black, strongly marked with yellow Thai : Polistes Sagitharius Middleton's Ed 8. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
  • 13. Vespula (Yellow Jacket) • Scavengers • Seek their food at picnics and in orchards, trashcans, and dumpsters • Highly aggressive and sting for no apparent reason • Nests are located in the ground or in cracks in buildings or residential landscape materials • Not found in Thailand Middleton's Ed 8. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
  • 14. Dolichovespula (White-Faced & Yellow Hornet) • Their sensitivity to vibration can initiate their defensive sting behavior • Not found in Thailand Middleton's Ed 8. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
  • 15. FamilyFormicidae • When they bite, they anchor by their mandibles and pivot to administer multiple stings • Unique lesions : "sterile pustules" within 24 hr. that can become infected if excoriated or opened Middleton's Ed 8. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
  • 16. Solenopsis (Imported Fire Ant) (มดคันไฟ) Tetraponera (มดตะนอย) Pachycondyla (มดปุยฝ้ายจั่วจีน) Odontoponera (มดไอ้ชื่นดำ) In Thailand • Solenopsis germinata • Solenopsis invicta (Red imported fire ant) • Solenopsis richtera (Black imported fire ant) Middleton's Ed 8. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94.
  • 17. Middleton's Ed 8. Bilò Mb, Et Al. Allergy 2005; 60: 1339-49. • Typically contain a mixture of 3 to 4 major proteins • Contain active peptides, vasoactive substances and enzymes • Common proteins shared amongst the various Hymenoptera species • Major allergens primarily protein enzymes : phospholipase, hyaluronidase, and acid phosphatase - Glycoproteins of 10-50 kDa containing 100 – 400 amino acid residues Insect venom
  • 18. • Toxin • Vasoactive amines (histamine, dopamine, norepinephrine) • Acetylcholine • Kinins Middleton's Ed 8. Bilò Mb, Et Al. Allergy 2005; 60: 1339-49. burning, pain, itching renal failure, rhabdomyolysis • Honeybee : PLA2 (Api m1) • Vespid : Antigen5 (Ves v 5) Allergenic component (Major allergen) Non-allergenic component
  • 19. Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137. Ollert M. Curr Allergy Asthma Rep (2015) 15: 26. Apidae Api m1 Api m2 Api m3 Api m7
  • 20. Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137. Vespidae Ves v1 Ves v2 Ves v5 Phospholipases found in vespid venoms (PLA 1) differ from those found in bee venoms (PLA 2)
  • 21. Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137. Formicidae Sol i1 Sol i3
  • 22. • Hymenoptera deliver between 50 ng (fire ants) and 140 μg (honeybees) of venom with each sting - Honeybee : 50 - 140 µg of venom protein - Bumblebee : 10 - 31 µg of venom protein - Vespula : 1.7 - 3.1 µg of venom protein Dolichovespula : 2.4 - 5.0 µg of venom protein Polistes : 4.2 - 17 µg of venom protein - Fire ant : 50 ng of venom protein Venom Dose Middleton's Ed 8. Bilò Mb, Et Al. Allergy 2005; 60: 1339-49.
  • 23. Between family • Less common between honeybee and the other venoms • Limited cross-reactivity exists between the antigens in fire ant venom and the antigens in venoms of other Hymenoptera • Different insect families have almost no cross-reactivity Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Cross-reactivity
  • 24. • Bumblebee show very limited cross-reactivity with honeybee sting reactions Apidae family Vespidae family • Extensive cross-reactivity in different genus esp. hornet (vespa) and yellow jacket (vespula) Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Within family Formicidae family • limited cross-reactivity
  • 25. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 26. Hymenoptera Formicidae (Ant) Vespidae (Vespid) Apidae (Bee) PolistinaeVespinae Vespula (YellowJacket) Vespa (Hornet) Dolichovespula (White-Faced&YellowJacket) Polistes (PaperWasp) Apinae Bombus (Bumblebee) Apis (Honeybee) Myrmecinae Provespa (ต่อนอนวัน) Family Order BombinaeSubfamily Genus Ponerinae Pachycondyla (มดปุยฝ้ายจั่วจีน) Pseudo Myrmecinae Odontoponera (มดไอ้ชื่นดำ) Diacamma (มดหนามคู่สีเทา) Tetraponera (มดตะนอย) Solenopsis (FireAnt) Adapted From : Pesek Et Al. Allergy Asthma Immunol Res. 2013 May; 5(3):129-137. วิภาดา ปาริยะประเสริฐ และนวลอนงค์ วิศิษฏสุนทร . โรคภูมิแพ้จากแมลงต่อย. ศิริราช 353-94. ไม่พบในไทย Cross-reactivity
  • 27. • Classified as “local” or “systemic” in distribution and an “immediate” or “delayed” time course • Most insect stings are transient local reactions - pain, swelling, and redness usually last from a few hours to a few days and generally resolve Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Clinical features
  • 28. • Limited to the area contiguous with the sting site • Redness, Swelling, Itching and pain • Late-phase, IgE-dependent reaction • Increase in size for 24 to 48 hours • Larger than 10 cm in diameter, and can involve an entire extremity (crossing joint lines) • Not dangerous except for potential local anatomic compression, especially on the head, neck, tongue, or throat Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Local reaction Large local reaction (LLR)
  • 29. Systemic reaction (SR) • Typically IgE mediated • May present with a variety of symptoms, involving multiple organ symptoms 1.) Cutaneous systemic reactions are limited to skin manifestations 2.) Anaphylaxis includes hypotension or involvement of at least 2 organ systems 3.) Systemic toxic reaction - Non-IgE mediated (anaphylatoid reaction) : onset < 24 hr.-6 days - ex. Renal failure, rhabdomyolysis, DIC, N/V, diarrhea Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 30. Middleton's Ed 8. Thomas B. Casale, Et Al. N Engl J Med 2014;370:1432-9. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. • Unusual reactions of unknown mechanisms are usually delayed (> 4 hr.) : sickness-like reactions, encephalitis, peripheral and cranial neuropathies, glomerulonephritis, myocarditis, and Guillain-Barré syndrome. Kounis syndrome (Allergic angina) most
  • 31. Brehler R, Et Al. Curr Opin Allergy Clin Immunol 2013, 13:360–364. Matysiak J, Et Al. Ann Agric Environ Med. 2013; 20(4):875–879. Grading of systemic reactions Grading Muller Ring & Messmer I Generalized urticaria, periorbital edema, itching, malaise, anxiety Cutaneous manifestations (flushing, pruritus, urticaria, angioedema) II Angioedema or two or more of following: chest/throat tightness, nausea,vomiting Mild respiratory, CV, GI (Rhinorrhea, hoarseness, dyspnea, tachycardia, BP change, arrhythmia) III Dyspnea, wheezing, or stridor or two or more of following: dysphagia, dysarthria, hoarseness, weakness, confusion, feeling of impending diaster Severe multisystem involvement (Laryngeal edema, bronchospasm, anaphylaxis, cyanosis, shock, collapse) IV Hypotension, collapse, loss of consciousness, incontinence, cyanosis Cardiac arrest
  • 32. Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. Evaluation & Diagnosis • Diagnosis requires a clear, thorough medical history • Quite high sensitization rate (positive tests to hymenoptera venom but with a negative history) • However, people with a clear documented history of a venom reaction can have negative tests, and occasionally testing can be positive to both honey bee and wasp venom
  • 33. • Diagnosis of insect sting allergy rests on the history as the primary evidence - Nature and timing of stings in the past - Time course of the reaction - All associated symptoms and treatments - Number of stings and the location on the body (systemic or local reactions) - Concurrent medications : β-adrenergic blocking agents, ACEIs (contribute significantly to the severity of the anaphylactic reaction) - Underlying disease : heart disease - Medications used for treatment of the reaction Clinical history Middleton's Ed 8.
  • 34. Identity of the culprit insect : - notoriously unreliable part of the history - location and timing of the sting or the location of the nest may suggest the type of insect Middleton's Ed 8.
  • 35. • In Vivo - Skin prick test (SPT) - Intradermal test (ID) - Sting challenge • In Vitro - sIgE : RAST - Serum tryptase - Basophil activation test (BAT) Middleton's Ed 8. Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89. Diagnostic tests Purpose 1.) Confirm allergic sensitization 2.) Define the risk of future systemic reaction to stings (Candidates VIT)
  • 36. Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. • Should be performed at least 2 weeks after a sting reaction, ideally 1–2 months later in case of false negatives due to a refractory period after a sting • Sensitivity : SPT < ID • Increasing doses in 10-fold increments of venom traditionally have been used for either SPT or ID SPT & ID (Apid, Vespid) SPT : Start 1.0 µg/mL (max 100 µg/mL) ID : Start 0.001-0.01 µg/mL (max 1 µg/mL) If >1.0 mcg/ml : nonallergenic ingredients can cause nonspecific reaction (False positive)
  • 37. WWW.drugs.com Venom extract • Honey Bee (Apis mellifera) • Yellow Jacket (Vespula spp.) • Yellow Hornet (Dolichovespula arenaria) • White Faced Hornet (Dolichovespula maculata) • Wasp (Polistes spp.) • Mixed Vespid (Yellow Jacket, Yellow Hornet & White Faced Hornet)
  • 38. Tracy Et Al. Curr Opin Allergy Clin Immunol 2015, 15:358–363. • Difficulty in collecting all species for the yellow-jacket and paper wasp venom mixes, not all lots contain every species Thailand (Freeze-dried venom)
  • 40. Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. Rutcharin Potiwat. Asian Pac J Allergy Immunol 2015;33:267-75. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016 SPT & ID (Fire Ant) • Imported fire ant whole-body extract • Screening SPT : 1:1000 (w/v) of imported fire ant WBE • Intradermal skin test : - initial concentrations of approximately 1 x 10-6 (1:1 million) wt/vol. - increased by increments until a positive response is elicited or a maximum concentration of 1 x 10-3 (1:1,000) or 2 x 10-3 (1:500) wt/vol
  • 41. Interpretation Thomas B. Casale, Et Al. N Engl J Med 2014;370:1432-9. Positive skin test
  • 42. • ID skin test - Inconsistency in the description of the technique and interpretation - No definitive studies to suggest any specific intradermal technique to be superior for determining specific IgE for venom David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. North America, Europe, and many countries United Kingdom ALK (manufacture) Method Injection of 0.02 - 0.03 mL of venom to produce a bleb of 3 mm Injection of 0.03 mL of venom to raise a bleb of 3 to 5 mm. Injection of 0.05 mL of venom Interpretation - wheal 3 - 5 mm. > negative control - with appropriate surrounding erythema - wheal 3 mm. > negative control - at 20 minutes - wheal 5 - 10 mm and erythema 11 - 20 mm
  • 43. Negative skin test • Patients with a convincing history but negative skin test results may consider - Refractory period of anergy : skin tests should be repeated after 4 to 6 weeks - Confounding medicine - Not used culprit insect - Maybe non-IgE mediated Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. " If skin test results are negative in a patient with a clear history of systemic sting reaction, further testing (in vitro testing, repeat skin testing , or both) should be performed, as well as basal serum tryptase "
  • 44. Middleton's Ed 8. Golden. Immunol Allergy Clin North Am. 2007 May ; 27(2): 261–Vii. • Skin test results for individual venoms can vary over a short period, and identification of all sensitivities requiring treatment may require skin testing on 2 separate occasions • The strongest skin tests often occur in patients who have had only large local reactions and have a very low risk of anaphylaxis " If negative skin test results and a convincing history of anaphylaxis should be further investigated with serologic testing, and if results remain negative, the skin tests should be repeated after 3 - 6 months "
  • 45. • Sensitivity of venom sIgE is generally lower than ID • sIgE increased in days-week maximum 2-3 week after sting than gradually decrased • Perform for "Whole body extract" or "Components" (Natural or Recombinant components) - Natural venom extracts can lead to clouding of the diagnostic process secondary to cross-reacting carbohydrate determinants (CCDs) ex. HBV, YJV sIgE Middleton's Ed 8. Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89.
  • 46. Ollert M, Et Al. Curr Allergy Asthma Rep (2015) 15: 26. Cross-reactivity carbohydrate determinants (CCD) • In insects, the relevant CCD epitope is defined by an alpha-1,3-linked fucose residue at the innermost N- acetylglucosamine of the carbohydrate core structure
  • 47. Ollert M, Et Al. Curr Allergy Asthma Rep (2015) 15: 26. Brehler R, Et Al. Curr Opin Allergy Clin Immunol 2013, 13:360–364. • IgE antibodies with specificity for the alpha-1,3-fucose epitope are responsible for approximately 75 % of double sensitizations to HBV and YJV • Clinical relevance of these IgE antibodies appears to be rather low Insect MMF3F6: represents a typical structure Plant
  • 48. Brehler R, Et Al. Curr Opin Allergy Clin Immunol 2013, 13:360–364. Matysiak J, Et Al. Ann Agric Environ Med. 2013; 20(4):875–879. • IgE antibodies reacting with bee and wasp venom (Double sensitivity) could be detected in about 30–50% may be due to 3 causes (1) independent sensitization to both venoms (rare) (2) cross-reactive IgE antibodies against to common protein Hyaluronidase (Api m2 & Vas v2) or dipeptidylpeptidase (Api m5 & Vas v3) (3) cross-reactive IgE antibodies against CCD Double sensitive to bee & wasp
  • 49. Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449. Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89. • Api m 1 (major honeybee allergen) : low sensitivity • Ves v 1 & Ves v 5 - Ves v 5 : good diagnostic performance - Ves v 5 & Ves v 1 : sensitivity was significantly increased • Pol d 1 & Pol d 5 • Crucial especially when the stinging insect was not identified and when skin tests and specific IgE to the native allergens are unsuccessful for the identification Recombinent marker allergen
  • 50. MUXF3 : glycan from bromelain is commercially available Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449.
  • 51. Example Decreased false-positive and false-negative Ollert M, Et Al. Curr Allergy Asthma Rep (2015) 15: 26.
  • 52. • Cannot performed skin test • Disconcordant between history and skin test - sIgE test is positive in 10% of patients with negative skin test results • Double sensitization - 50% of allergic reaction to honey bee or vespulae had positive both diagnostic test (homology in the hyaluronidase enzymes) , CRD can help to identify true culprit insect Middleton's Ed 8. Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89. sIgE benefit in patients The level of sensitivity (skin test or serum IgE) is correlated with the frequency but not the severity of the reaction
  • 53. Golden. J Allergy Clin Immunol 2005;115:439-47. • Venom skin tests and venom-specific IgE assays correlate imperfectly sIgE negative in 20% of skin test–positive skin test negative in 10% of persons with elevated IgE antibodies
  • 54. Basophil activation test (BAT) Before test : Basophil > 50 cells
  • 55. Matysiak J, Et Al. Ann Agric Environ Med. 2013; 20(4):875–879. D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89. Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449. Can be useful in • In cases of negative skin tests and negative specific IgE results or discrepancies in these tests • Monitoring of VIT results " Routine use of BAT in evaluating Hymenoptera sensitive patients is not recommended " • Remains to be standardized in terms of methodology and interpretation
  • 56. • Should be done : severe anaphylaxis • Evaluation : Mastocytosis or mast cells diseases • Predict : Severity of systemic reaction to sting Serum tryptase David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 57. Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Mast cell disorders • Insect stings are the most common cause of anaphylaxis in mastocytosis • 25% of insect sting anaphylaxis --> have elevated baseline serum tryptase • 2% mastocytosis --> insect sting anaphylaxis
  • 58. Middleton's Ed 8. Rueff Et Al. J Allergy Clin Immunol 2009;124:1047-54. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. • If the serum tryptase is elevated (>11.4 ng/ml) bone marrow biopsy should be considered • Tryptase concentrations manifest a significant correlation with severity of clinical symptoms, especially with a decrease in blood pressure in the main arteries
  • 59. Sting challenge • Sting challenge is the most specific diagnostic test, but unethical and impractical • Recommended by some to better select those patients who need VIT Middleton's Ed 8. Agache Et Al. Allergy 70 (2015) 355–365. Www.Eaaci.Org Absolute contraindication - Pregnancy - Acute inflammatory disease - Severe or uncontrolled cardiovascular or respiratory disease - Treatment with beta-blockers
  • 60. • Low negative predictive value (NPV) : A single negative challenge sting does not preclude anaphylaxis to a subsequent sting • Less reliable with vespids than with honeybees Middleton's Ed 8. Agache Et Al. Allergy 70 (2015) 355–365. Www.Eaaci.Org Limitation • Same species as the one that provoked the reaction • Sting has to be confirmed by the development of a wheal and flare reaction and by the characteristic burning pain • After the sting challenge, all patients have to be observed for at least 2 hr in the hospital
  • 61. D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89.
  • 62. • Ice pack, elevation of the afftected limb • Oral antihistamines • Large local reactions, especially head and neck - Oral corticosteroid 40-60 mg of prednisone 5 days (steroids should be started within few hours of sting in patients with known history of large local reactions) - Analgesic : NSAIDs • Antibiotics are not necessary Treatment of acute reactions Local & Large local Middleton's Ed 8.
  • 63. • Urticaria may respond to antihistamines alone • Anaphylactic reactions require epinephrine injection IM (1:1000) 0.01 mg/kg (max 0.3 mg in children, 0.5 mg. in adult) • Patients who have history of rapid onset or very severe systemic reactions may treatment immediately after the sting • Hypotension should be supine with legs raised • Delay in the use of epinephrine has contributed to fatal reactions • Some individuals with anaphylactic shock are resistant to epinephrine - Patients taking β-blocker medications Rx Glucagon Middleton's Ed 8. Systemic reactions
  • 64. • Anaphylaxis requires patient education before discharge • Use of self-injectable epinephrine requires consistent instruction and follow-up • Referred for an allergy consultation : For VIT • Preventive treatment : effective measures to avoid insect stings Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Patient education Pitfall • Patients often fail to carry the injector with them • Delay using when they have a reaction
  • 65. Prevention • Avoid eating outdoors • Avoid flowering plants • Avoid drinking from straws, cans, or bottles outdoors • Remove fallen fruit or pet feces • Cover trash cans • Watch for nests in bushes or in the ground when mowing • Avoid going barefoot outdoors • Avoiding fragrances • Avoiding brightly colored or floral clothing • Using insect repellants • Running; flailing the arm David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Effective Ineffective
  • 66. Predictors of risk for sting anaphylaxis Natural history • Prognosis for affected patients is based on the understanding of the natural history of the condition including clinical factors and biologic markers • Future sting will cause an allergic reaction depends on the history and immunologic status of the patient Middleton's Ed 8.
  • 68. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Clinical markers Laboratory markers Very severe previous reaction Insect species No urticaria/angioedema Age (>45), Gender (male) Medications (ACE inhibitors) Multiple or sequential stings acetylhydrolase Venom skin test Venom-specific IgE Basal serum tryptase Platelet activating factor (PAF) Angiotensin converting enzyme (ACE) Predictors of risk of systemic reaction to insect sting
  • 69. Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. Venom immunotherapy • Treatment of choice for prevention of systemic allergic reactions to insect stings but it requires careful selection of patients
  • 70. • All patients who have experienced a systemic allergic reaction to an insect sting and who have specific IgE to venom allergens - reduces the risk of a subsequent systemic sting reaction to as low as 5% compared with up to 60% in untreated patients • High risk patients : patient with mastocytosis, or an increased basal serum tryptase level Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Indication for VIT
  • 72. Change in practice parameter 2016 VIT Optional • VIT is generally not required for patients > 16 years of age who have experienced only cutaneous systemic reactions • Sting challenge studies suggest that these patients are very unlikely to have severe anaphylactic reactions to subsequent stings (Recommendation: C) David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 73. (1) Prevent systemic reactions (2) Alleviate patients' anxiety related to insect stings (with improved quality of life) Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Goals of VIT Only large local reactions to stings that VIT is generally not necessary (low risk of a systemic reaction 4-10%) , but might be considered in those who have frequent unavoidable exposure for quality of life reason
  • 74. • Malignancy • Severe asthma • Immunological conditions • Chronic heart and lung disease • Severe hypertensions • Drug: beta blockers, tricyclic antidepressants, monoamine oxidase inhibitors, ACEIs • Initiation during pregnancy (though maintenance can be continued in pregnancy) Contraindications Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 75. • 95-100% effective in preventing systemic reactions to stings - maintenance dose of 300 μg of mixed vespid venoms • 75-95% efficacy - 100 μg dose of individual venoms (i.e., honeybee, yellow jacket, or Polistes wasp) • Fire ant IT using wholebody extracts has been reported to be reasonably safe and effective • Repeat sting reactions usually are milder than pretreatment reactions Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Efficacy 95% to 100% effective in preventing systemic reactions to stings
  • 76. Failure of VIT • Associated with - abnormal basophil activation test responses - underlying mastocytosis Middleton's Ed 8.
  • 77. Safety Middleton's Ed 8. Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449. • Adverse reactions to VIT are no more common than reactions during inhalant allergen immunotherapy • Systemic symptoms occur in 5-15% (Most are mild) - Severe systemic reactions to injections --> underlying mast cell disease • LLR to venom injections ~ 50% of patients, esp. dose 20 - 50 μg - LLR to venom injections not predicted systemic reactions
  • 78. Risk factors for side effect during IT Darío Antolín-Amérigo, Et Al. Curr Allergy Asthma Rep (2014) 14:449.
  • 79. • Antihistamines - Reduce local and systemic reactions • Leukotriene modifier - Reduce LLR • Recurrent systemic reactions to VIT: rush VIT, or omalizumab Pre-medication Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 80. • Need only contain a single venom if the culprit is definitively known • Recombinant venom allergens has been able to resolve dual sensitivity that may be due to CCD • Mixed vespid efficacy > single vespid • Therapy with yellow jacket or mixed vespid venoms can protect against wasp stings Venom species Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 81. • Increasing the maintenance dose up to 200 mcg per dose has been effective in achieving protection in patients who had sting reactions while receiving a 100-mcg maintenance dose of VIT Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Venom Dose • Initial dose of up to 1 mcg Increase to maintenance dose of at least 100 mcg of each venom (equivalent to 2 honeybee stings : 50 mcg per sting) • Children might be effectively treated with a maintenance dose of 50 mcg. Change in practice parameter 2016
  • 82. Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. Schedules Different in Build-up phase 1.) Build-up 1.) Traditional/ conventional : 4-6 mo. 2.) Modified rush/ cluster : 6-8 wk. 3.) Rush : 2-7 days 4.) Ultra-rush : < 2 days
  • 83. Golden. J Allergy Clin Immunol 2005;115:439-47. 4-6 mo.6-8 wk.2-7 days< 48 hr.
  • 84. Middleton's Ed 8. Conventional Modified rush • 2 standard regimens in the US. aim to achieve the 100-mg dose in either 8 or 15 weeks • Rush VIT is indicated in some patients in Europe
  • 85. Patella V, Et Al. Journal Of Allergy Volume 2012. Ultrarush Rush Unlike inhalant allergen IT, the more rapid regimens of VIT appear to have the same or greater safety as the traditional regimen
  • 86. 2.) Maintenance • Onset of protection with VIT is quite rapid • Sting challenge studies : protective is reached after an 8-week build-up regimen Every 4 weeks for 12-18 months Every 6 weeks for 12-18 months then Every 8 weeks Middleton's Ed 8. D.B.K. Golden / Ann Allergy Asthma Immunol 111 (2013) 84-89. 12-week interval may be effective for extended maintenance treatment after 4 years of routine therapy
  • 87. • Repeat skin tests or immunoassays : every 2-3 years • SPT - After 5 years : negative < 20% - After 7–10 years : negative 50–60% (although most remain positive by RAST) • Venom-specific IgE antibody levels - level rises during the first months of therapy - returns to baseline after 12 months - declines steadily during maintenance treatment (even after therapy is stopped and after a sting) Maintenance evaluation Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 88. • Venom-specific IgG antibodies - marker of clinical efficacy - good PPV but poor NPV - confirm protective levels after initial therapy (especially honeybee or single venoms) - considered protective: ≥ 3 μg/mL during the first 4 years Maintenance evaluation Middleton's Ed 8 Ludman And Boyle. Journal Of Asthma And Allergy 2015:8 75–86. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 90. Duration • Early studies : recommended 3 years (results included patients with up to 10 years of treatment) • Subsequent studies : 5 years of was associated with better suppression of allergic sensitivity and lower risk of relapse Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Change in practice parameter 2016 • 5 years is better than 3 years • Longer treatment recommended in high-risk patients; 3 years may be sufficient in children Better for 5 years
  • 91. 25% 10% 2 yr. > 5 yr. Golden. J Allergy Clin Immunol 2005;115:439-47.
  • 92. Risk of relapse after discontinuing VIT • No specific tests to distinguish which patients will relapse after stopping VIT • Relapse - 5 years < 3 years of VIT - younger children < adults Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016.
  • 93. Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Maybe need longer than 5 years • Honeybee allergy • Had systemic reactions to an injection or sting during VIT • Elevated baseline serum tryptase levels • Very severe sting reactions before treatment
  • 94. • Mastocytosis - recommend VIT for life - efficacy of VIT is less than optimal in mastocytosis patients, they should continue to carry 2 epinephrine injectors • Patients who are not willing to accept the 10%- 20% chance of reaction to a subsequent sting Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Long-term extension of VIT
  • 95. Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. • The decision to stop immunotherapy can involve consideration of several factors by the patient and physician (1) severity of the initial reaction (2) basal serum tryptase (3) frequency of exposure (4) presence of concomitant disease and medications (5) effect of such action on work and leisure activities (6) the patient's preferences
  • 96. • Natural history of fire ant allergy is not as well described • But clear need for effective IT • IT using WBE : effective but no placebo-controlled trials • The dosage maintenance schedule is less well defined - most experts recommend maintenance dose : 0.5 mL ,1:100 wt/vol - some experts : 0.5 mL , 1:10 wt/vol • Duration is still uncertain, because discontinuation led to relapse • Most allergists consider stopping after specified period (usually 3-5 years) or only when skin test or in vitro test become negative Middleton's Ed 8. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. Fire Ant immunotherapy
  • 98. David B.K. Golden, Et Al. Stinging Insect Hypersensitivity. Practice Parameter 2016. 50 mcg., 3 years
  • 100. Benefit in selected culprit For VIT