SlideShare a Scribd company logo
1 of 4
27




    Allergy to Insect Stings

                                        By SusanWaserman, MD, FRCP; and
                                        Abdullah Aburiziza, MD, XXX



                                        S
                                             tinging insects which cause IgE-mediated reactions belong to the order
                                             Hymenoptera. There are four families within that order, and including
                      ent                    Vespidae (yellow jackets, hornets and paper wasps), Apidae (bees), Halic-
              pla cem                   tidae (sweatbees) and Formicidae (ants). Two families, the Vespidae and the
       fo r
Ju s t                                  Apidae are associated with most stinging insect allergy.
                                          Hymenoptera venom anaphylaxis has been associated with about 40 deaths
                                        per year in the U.S., yellow jackets the most common cause in North America.1
                                        Asymptomatic venom sensitization is common in adults but transient, and
                                        can disappear at a rate of 12% per year.2
                                          Fatalities are less common in children than adults.3 Approximately one half
                                        of fatal reactions occur in individuals with no previous history of allergic re-
                                        actions to stings.4 Though patients with atopy have an increased risk of be-
                                        coming sensitized, they do not seem to develop systemic reactions more
    Dr. Waserman is an Associate        frequently than non atopics.5
    Professor of Medicine and the         This article reviews the clinical features of stinging-insect allergy, as well as
    Training Program Director for       diagnosis and treatment, including avoidance, injectable epinephrine, and
    Allergy and Clinical Immunology     venom immunotherapy.
    at McMaster University, Hamilton,
    Ontario.                            Classification of Reactions
                                        Reactions from insect stings are classified as local (normal or large local) or sys-
                                        temic (allergic and non-allergic). Local reactions are limited to the area con-
                                        tiguous with the sting site. Large local reactions are also contiguous but are
    Dr. Aburiziza is an                 defined as being 10 cm in diameter or larger and lasting longer than 24 hours.6
    xxxxxxxxxxxxxxxxxxxxxxxxxxxxx       Frequently, these are misdiagnosed as cellulitis and treated with antibiotics.
    xxxxxxxxxxxxxxxxxxxxxxxxxxxxx       Local reactions are not IgE-mediated, hence venom skin testing and im-
    xxxxxxxxxxxxxxxxxxxxxxxxxxxxx       munotherapy are not indicated, however large locals may be and should be
                                        evaluated by an allergist.
                                          Systemic allergic reactions occur at sites distant to the sting and affect 0.4%
                                        to 0.8% of children and 3% of adults.1 These are IgE-mediated. Symptoms
                                        range from mild (cutaneous manifestations) to severe, with symptoms such as
                                        laryngeal edema, bronchospasm, and hypotension. Non-allergic systemic re-
                                        actions are less common and are not IgE-mediated. These include nephrotic
                                        syndrome, serum sickness, neurologic manifestations (Guillain Barre), rhab-
                                        domyolysis, and hemolysis.7




                                                                                                          Allergy&Asthma
28    Allergy to Insect Stings



A positive skin or RAST (radioallergosorbent                           A positive skin or radioallergosorbent test
                                                                    (RAST), a blood test which measures IgE to each of
test), a blood test which measures IgE to each                      the venoms, in conjunction with a systemic reac-
of the venoms, in conjunction with a systemic                       tion is diagnostic of venom allergy. In the weeks
                                                                    after a sting reaction, some patients have negative
reaction is diagnostic of venom allergy.
                                                                    skin tests attributable to a refractory period. They
                                                                    should have repeat skin testing after four to six
           Diagnosis                                                weeks. Patients with a negative skin test and a his-
           Recognition of anaphylaxis is often difficult, es-       tory of anaphylaxis should have a RAST. If results
           pecially with the first sting and if urticaria are ab-   are still negative, skin tests should be repeated
           sent. Vasovagal responses may be confused with           after three to six months.8
           anaphylaxis, however these are usually accompa-
           nied by bradycardia and anaphylaxis with com-            Treatment
           pensatory tachycardia. An elevated serum                 Acute Therapy. Avoidance of stinging insects is
           tryptase, a mast-cell-specific enzyme, provides ad-      important. Patients are advised to destroy nests,
           ditional evidence for anaphylaxis, but it is not         wear shoes, avoid perfumes outdoors, cover
           very sensitive.                                          garbage receptacles and use insecticides. Treat-
              Insect identification is also difficult, however      ment of local reactions includes icing, elevation,
           certain factors may be helpful. Honeybees leave a        analgesics, and antihistamines.
           stinger behind, whereas vespids do not. Yellow              For acute systemic reactions, epinephrine
           jackets tend to be aggressive, and will sting if un-     1:1,000 solution, given as 0.01 ml/kg (maximum
           provoked. They are found around food and                 dose 0.3 ml/kg) is injected intramuscularly. All pa-
           garbage cans. Since they nest in the ground peo-         tients with insect-sting anaphylaxis should carry
           ple are often stung while mowing the lawn. Hor-          an epinephrine autoinjector, prescribed according
           nets are also aggressive and are found in nests,         to weight. A “junior” dose of 0.15 mg of epi-
           trees and shrubs.                                        nephrine is for patients weighing 15 kg to 30 kg
              Skin testing to the five Hymenoptera standard-        and the regular dose of 0.30 mg of epinephrine is
           ized venoms is the standard method of diagnosis.         for patients weighing greater than 30 kg. Patients
           Skin-prick tests to venoms, if negative, are fol-        should be taught to self inject if necessary after a
                                                                    sting. The dose can be repeated in five to 10 min-
                                                                    utes if symptoms persist and patients should be
Systemic allergic reactions occur at sites distant                  instructed to call 911. An antihistamine can be
to the sting and affect 0.4% to 0.8% of chil-                       given, but is second-line therapy, and its use
                                                                    should not delay the administration of epineph-
dren and 3% of adults.1                                             rine. Corticosteroids have no proven benefit in
                                                                    the acute period but may be useful in treating the
           lowed by intradermal skin tests. Intradermal con-        late-phase manifestations of anaphylaxis.
           centrations start at 0.001 µg/ml to 0.01 µg/ml and          Referral to an allergist is extremely important
           increase 10 fold to a maximum of 1 µg/ml. Skin           for diagnostic skin testing, patient education, and
           tests are indicated when immunotherapy is being          venom immunotherapy.
           considered, namely for individuals who have had             Immunotherapy. Venom-specific immunother-
           a systemic allergic reaction. For children aged two      apy is the treatment of choice for stinging-insect
           to 16 years who have had only cutaneous reac-            allergy. It is safe and highly effective for prevent-
           tions, immunotherapy is not given since most             ing future reactions. Immunotherapy is 97% to
           (90%) will not experience more severe or progres-        100% effective in preventing systemic reac-
           sive symptoms with their next sting (Table 1).           tions,9whereas reactions in untreated individuals




           Allergy&Asthma
29




 Table 1
 Selection of Patients for Immunotherapy
 Reaction to sting                                  Result of skin test or RAST    Venom
                                                                                   immunotherapy?
 Child
 Systemic, non-life-threatening,
 immediate, generalized urticaria,
 angiodema, erythema, pruritus                      + or −                         No
 Systemic, life-threatening, possible
 cutaneous symptoms, but also
 respiratory symptoms (laryngeal edema
 or bronchospasm) or cardiovascular
 symptoms (hypotension, shock)                      +                              Yes

 Adult
 Systemic                                           +                              Yes
 Systemic                                           −                              No

 Child/Adult
 Large local (> 2 inches, > 24 hour
 duration)                                          + or −                         No
 Normal (< 2 inches, < 24 hour
 duration)                                          + or −                         No


is as high as 60%.                                        temic reaction. About 3% to 12% of patients
   The venoms used for immunotherapy are the              have treatment-induced systemic reactions that
same as those used for skin testing (honeybee, yel-       generally are mild and occur in the early phases of
low jacket, yellow hornet, white-faced hornet,            immunotherapy. If a systemic reaction occurs,
wasp, and fire ant, if applicable). The routine reg-      one half of the dose is given the next week. This
imen begins with an injection of 0.01 µg and ad-          approach, however, is individualized to the pa-
vances weekly to 100 µg (equivalent to two
stings). The maintenance dose of 100 µg is given
                                                                  Avoidance of stinging insects is important.
every four weeks for a year, and then every six to
eight weeks. Venom selection is based mainly on            Patients are advised to destroy nests, wear shoes,
skin-test results, clinical history and a pattern of                avoid perfumes outdoors, cover garbage
venom cross-reactivity. One recommendation is
that immunotherapy includes all venoms giving a
                                                                             receptacles and use insecticides.
positive skin test. However there is allergenic
cross-reactivity of the four vespid venoms, hence         tient. Pretreatment with antihistamines were
most patients with multiple sensitivities can be          found to be effective in reducing immunother-
protected by immunotherapy with yellow jacket             apy reactions. Large local reactions occur in
venom alone.10                                            25% of children and 50% of adults, usually at
   Venom immunotherapy is well tolerated. Most            higher doses. Although troublesome, they do
patients receive their injections in an allergist’s of-   not predict an increased risk of future systemic
fice until the maintenance dose is reached. Pa-           reactions to treatment.
tients should remain for 30 minutes after each              No long-term side effects have been associated
injection in a setting equipped to handle a sys-          with venom immunotherapy thus far. It is safe




                                                                                           Allergy&Asthma
30     Allergy to Insect Stings



Referral to an allergist is extremely important for                               leisure activities, medications, and coexistent dis-
                                                                                  eases should be considered); the conversion to a
diagnostic skin testing, patient education, and                                   negative skin test is one criterion for stopping
venom immunotherapy.                                                              venom immunotherapy. For most patients, it is
                                                                                  time-based and discontinued after five years, after
                                                                                  which protection is long-lasting in most, even if
           during pregnancy, with no increased risk of mis-                       the skin test remains positive. For those who had
           carriage or congenital anomalies, and it does not                      a severe initial allergic reaction, a decision to con-
           result in allergic sensitization in the child.                         tinue for longer or indefinitely may be made.
             Recommendations regarding discontinuation
           of venom immunotherapy include the following                           Conclusion
           from the American Academy of Allergy Asthma                            Venom allergy is one of the most common causes
           and Immunology: The decision to stop should be                         of anaphylaxis. All patients with a systemic aller-
           made after thorough discussion by the physician                        gic reaction should be evaluated by an allergist for
           and patient (patient variables such as vocation,                       consideration of immunotherapy.




           References:                                                                  study of the natural history of large local reactions after Hy-
           1. Golden DB, Marsh DG, Kagey-Sobotka A, et al. Epidemiology of              menoptera stings in children. J Pediatr 1984; 104:664–8.
               Insect Allergy. JAMA 1989; 262: 240-4.                             7.    Light WC, Reisman RE, Shimizu M, et al. Unusual reactions fol-
           2. Golden D, Marsh D, Freidhoff L, et al. Natural history of Hy-             lowing insect stings: clinical features and immunologic analysis. J
               menoptera venom sensitivity in adults. J Allergy Clin Immunol            Allergy Clin Immunol 1977; 59:391–7.
               1997: 100:760-6                                                    8.    Selcow J, Mendelson L, Rosen J: Anaphylactic reactions in skin
           3. Deaths from each cause by 5-year age groups, race, and sex:               test-negative patients. J Allergy Clin Immunol 1980; 67:400.
               United States, 1980–1999. Hyattsville (MD): National Center        9.    Hunt KJ, Valentine MD, Sobotka AK, et al. A controlled trial of
               for Health Statistics.                                                   immunotherapy in insect hypersensitivity. N Engl J Med 1978;
           4. Barnard JH. Studies of 400 Hymenoptera sting deaths in the                299:157.
               United States. J Allergy Clin Immunol 1973; 52:259–64.             10.   Reisman RE, Livingston A. Venom immunotherapy: 10 years of
           5. Birnbaum J,Vervloet D, Charpin D. Atopy and systemic reactions to         experience with administration of single venoms and 50 micro-
               hymenoptera stings. Allergy Proc 1994; 15(2):49-52.                      grams maintenance dose. J Allergy Clin Immunol 1992; 89:1189–
           6. Graft DF, Schuberth KC, Kagey-Sobotka A, et al. A prospective             95.




           Allergy&Asthma

More Related Content

What's hot

Hypersensitivity reactions for Medical Students
Hypersensitivity reactions for Medical StudentsHypersensitivity reactions for Medical Students
Hypersensitivity reactions for Medical StudentsNCRIMS, Meerut
 
Immunotherapy in Atopic Dermatitis in Dogs
Immunotherapy in Atopic Dermatitis in DogsImmunotherapy in Atopic Dermatitis in Dogs
Immunotherapy in Atopic Dermatitis in DogsBRNSS Publication Hub
 
Advances in atopic dermatitis
Advances in atopic dermatitis Advances in atopic dermatitis
Advances in atopic dermatitis Suman Khanal
 
Why do we must stop abusing antimicrobials
Why do we must stop abusing antimicrobialsWhy do we must stop abusing antimicrobials
Why do we must stop abusing antimicrobialsUbaidur Rahaman
 

What's hot (20)

Hypersensitivity reactions for Medical Students
Hypersensitivity reactions for Medical StudentsHypersensitivity reactions for Medical Students
Hypersensitivity reactions for Medical Students
 
Immunotherapy in Atopic Dermatitis in Dogs
Immunotherapy in Atopic Dermatitis in DogsImmunotherapy in Atopic Dermatitis in Dogs
Immunotherapy in Atopic Dermatitis in Dogs
 
Advances in atopic dermatitis
Advances in atopic dermatitis Advances in atopic dermatitis
Advances in atopic dermatitis
 
Atopic dermatitis exacerbations
Atopic dermatitis exacerbationsAtopic dermatitis exacerbations
Atopic dermatitis exacerbations
 
Contact dermatitis
Contact dermatitisContact dermatitis
Contact dermatitis
 
Latex allergy
Latex allergyLatex allergy
Latex allergy
 
Patch test in dermatology
Patch test in dermatologyPatch test in dermatology
Patch test in dermatology
 
Occupational rhinitis
Occupational rhinitisOccupational rhinitis
Occupational rhinitis
 
Immunology in ent
Immunology in entImmunology in ent
Immunology in ent
 
Why do we must stop abusing antimicrobials
Why do we must stop abusing antimicrobialsWhy do we must stop abusing antimicrobials
Why do we must stop abusing antimicrobials
 
The therapeutic landscape in atopic dermatitis
The therapeutic landscape in atopic dermatitisThe therapeutic landscape in atopic dermatitis
The therapeutic landscape in atopic dermatitis
 
Anaphylaxis in Anesthesiology
Anaphylaxis in AnesthesiologyAnaphylaxis in Anesthesiology
Anaphylaxis in Anesthesiology
 
Atopy patch test
Atopy patch testAtopy patch test
Atopy patch test
 
Perioperative Anaphylaxis
Perioperative AnaphylaxisPerioperative Anaphylaxis
Perioperative Anaphylaxis
 
Allergy new
Allergy newAllergy new
Allergy new
 
Atopic dermatitis: mechanism of disease
Atopic dermatitis: mechanism of diseaseAtopic dermatitis: mechanism of disease
Atopic dermatitis: mechanism of disease
 
Ocular allergy
Ocular allergyOcular allergy
Ocular allergy
 
Anaphylaxis
AnaphylaxisAnaphylaxis
Anaphylaxis
 
Food-dependent exercise-induced anaphylaxis
Food-dependent exercise-induced anaphylaxisFood-dependent exercise-induced anaphylaxis
Food-dependent exercise-induced anaphylaxis
 
Common ocular allergy
Common ocular allergyCommon ocular allergy
Common ocular allergy
 

Viewers also liked (13)

Insect sting allergy
Insect sting allergyInsect sting allergy
Insect sting allergy
 
Insect Sting Allergy
Insect Sting AllergyInsect Sting Allergy
Insect Sting Allergy
 
Insect allergy
Insect allergyInsect allergy
Insect allergy
 
Stings and bites (2)
Stings and bites (2)Stings and bites (2)
Stings and bites (2)
 
Growth and Development
Growth and Development Growth and Development
Growth and Development
 
Insect allergy
Insect allergyInsect allergy
Insect allergy
 
8. all
8. all8. all
8. all
 
Approach to the child with rash
Approach to the child with rashApproach to the child with rash
Approach to the child with rash
 
Pediatric Skin Diseases by Dr. Ramkesh Meena
Pediatric Skin Diseases by Dr. Ramkesh MeenaPediatric Skin Diseases by Dr. Ramkesh Meena
Pediatric Skin Diseases by Dr. Ramkesh Meena
 
Pediatric History & Physical Examination
Pediatric History & Physical ExaminationPediatric History & Physical Examination
Pediatric History & Physical Examination
 
Pediatric assessment
Pediatric assessmentPediatric assessment
Pediatric assessment
 
Pediatric Case Study
Pediatric Case StudyPediatric Case Study
Pediatric Case Study
 
2. fever with rash
2. fever with rash2. fever with rash
2. fever with rash
 

Similar to Bee Sting Allergy

40.Allergic Diseases.pdf ………………………………………
40.Allergic Diseases.pdf ………………………………………40.Allergic Diseases.pdf ………………………………………
40.Allergic Diseases.pdf ………………………………………saleemsalem1987
 
hypersensitivityreactionscld-130203182150-phpapp01.pptx
hypersensitivityreactionscld-130203182150-phpapp01.pptxhypersensitivityreactionscld-130203182150-phpapp01.pptx
hypersensitivityreactionscld-130203182150-phpapp01.pptxSanskriti Shah
 
Drug induced Hypersensitivity reactions Presentation by Supriya SUCP
Drug induced Hypersensitivity reactions Presentation by Supriya SUCPDrug induced Hypersensitivity reactions Presentation by Supriya SUCP
Drug induced Hypersensitivity reactions Presentation by Supriya SUCPPARUL UNIVERSITY
 
anaphylaxis.pptx
anaphylaxis.pptxanaphylaxis.pptx
anaphylaxis.pptxHiwaAhmed6
 
Allergic rhinitis.pptx
Allergic rhinitis.pptxAllergic rhinitis.pptx
Allergic rhinitis.pptxAhlam Alzuway
 
ANAPHYLACTIC REACTIONS DUE TO VACCINATIONS IN PAEDIATRIC PATIENTS
ANAPHYLACTIC REACTIONS DUE TO VACCINATIONS IN PAEDIATRIC PATIENTSANAPHYLACTIC REACTIONS DUE TO VACCINATIONS IN PAEDIATRIC PATIENTS
ANAPHYLACTIC REACTIONS DUE TO VACCINATIONS IN PAEDIATRIC PATIENTSKanmani Srinivasan
 
Poisoning snake2012+MCQs.
Poisoning snake2012+MCQs.Poisoning snake2012+MCQs.
Poisoning snake2012+MCQs.Shaikhani.
 
ALLERGIC REACTION OF LA.pdf
ALLERGIC REACTION OF LA.pdfALLERGIC REACTION OF LA.pdf
ALLERGIC REACTION OF LA.pdfNASERALHAQ
 
Hypersensitivity (Allergy) - Drug allergy, Contact dermatitis, Allergic asthma
Hypersensitivity (Allergy) - Drug allergy, Contact dermatitis, Allergic asthmaHypersensitivity (Allergy) - Drug allergy, Contact dermatitis, Allergic asthma
Hypersensitivity (Allergy) - Drug allergy, Contact dermatitis, Allergic asthmaAvinandan Jana
 
Allergy and Anaphylaxis..pptx
Allergy and Anaphylaxis..pptxAllergy and Anaphylaxis..pptx
Allergy and Anaphylaxis..pptxssuser71d7b1
 
Drug and the hypersensitivity reactions
Drug and the hypersensitivity reactionsDrug and the hypersensitivity reactions
Drug and the hypersensitivity reactionsChimi Handique
 
MANAGEMENT OF ALLERGIC RHINITIS
MANAGEMENT OF ALLERGIC RHINITISMANAGEMENT OF ALLERGIC RHINITIS
MANAGEMENT OF ALLERGIC RHINITISmayur warad
 

Similar to Bee Sting Allergy (20)

40.Allergic Diseases.pdf ………………………………………
40.Allergic Diseases.pdf ………………………………………40.Allergic Diseases.pdf ………………………………………
40.Allergic Diseases.pdf ………………………………………
 
hypersensitivityreactionscld-130203182150-phpapp01.pptx
hypersensitivityreactionscld-130203182150-phpapp01.pptxhypersensitivityreactionscld-130203182150-phpapp01.pptx
hypersensitivityreactionscld-130203182150-phpapp01.pptx
 
Drug allergy
Drug allergy Drug allergy
Drug allergy
 
Sulfonamide allergy
Sulfonamide allergySulfonamide allergy
Sulfonamide allergy
 
Penicillin Allergy
Penicillin AllergyPenicillin Allergy
Penicillin Allergy
 
Drug induced Hypersensitivity reactions Presentation by Supriya SUCP
Drug induced Hypersensitivity reactions Presentation by Supriya SUCPDrug induced Hypersensitivity reactions Presentation by Supriya SUCP
Drug induced Hypersensitivity reactions Presentation by Supriya SUCP
 
anaphylaxis.pptx
anaphylaxis.pptxanaphylaxis.pptx
anaphylaxis.pptx
 
Allergic rhinitis
Allergic rhinitisAllergic rhinitis
Allergic rhinitis
 
Refractory epilepsy
Refractory epilepsy Refractory epilepsy
Refractory epilepsy
 
Allergic rhinitis.pptx
Allergic rhinitis.pptxAllergic rhinitis.pptx
Allergic rhinitis.pptx
 
ANAPHYLACTIC REACTIONS DUE TO VACCINATIONS IN PAEDIATRIC PATIENTS
ANAPHYLACTIC REACTIONS DUE TO VACCINATIONS IN PAEDIATRIC PATIENTSANAPHYLACTIC REACTIONS DUE TO VACCINATIONS IN PAEDIATRIC PATIENTS
ANAPHYLACTIC REACTIONS DUE TO VACCINATIONS IN PAEDIATRIC PATIENTS
 
Poisoning snake2012+MCQs.
Poisoning snake2012+MCQs.Poisoning snake2012+MCQs.
Poisoning snake2012+MCQs.
 
ALLERGIC REACTION OF LA.pdf
ALLERGIC REACTION OF LA.pdfALLERGIC REACTION OF LA.pdf
ALLERGIC REACTION OF LA.pdf
 
Hypersensitivity
HypersensitivityHypersensitivity
Hypersensitivity
 
Refractory epilepsy
Refractory epilepsy Refractory epilepsy
Refractory epilepsy
 
Hypersensitivity (Allergy) - Drug allergy, Contact dermatitis, Allergic asthma
Hypersensitivity (Allergy) - Drug allergy, Contact dermatitis, Allergic asthmaHypersensitivity (Allergy) - Drug allergy, Contact dermatitis, Allergic asthma
Hypersensitivity (Allergy) - Drug allergy, Contact dermatitis, Allergic asthma
 
Allergy and Anaphylaxis..pptx
Allergy and Anaphylaxis..pptxAllergy and Anaphylaxis..pptx
Allergy and Anaphylaxis..pptx
 
Drug and the hypersensitivity reactions
Drug and the hypersensitivity reactionsDrug and the hypersensitivity reactions
Drug and the hypersensitivity reactions
 
MANAGEMENT OF ALLERGIC RHINITIS
MANAGEMENT OF ALLERGIC RHINITISMANAGEMENT OF ALLERGIC RHINITIS
MANAGEMENT OF ALLERGIC RHINITIS
 
Allergies
AllergiesAllergies
Allergies
 

Recently uploaded

historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
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
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
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
 
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
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
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
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 

Recently uploaded (20)

GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
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...
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
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,...
 
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
 
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
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
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...
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
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
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
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...
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 

Bee Sting Allergy

  • 1. 27 Allergy to Insect Stings By SusanWaserman, MD, FRCP; and Abdullah Aburiziza, MD, XXX S tinging insects which cause IgE-mediated reactions belong to the order Hymenoptera. There are four families within that order, and including ent Vespidae (yellow jackets, hornets and paper wasps), Apidae (bees), Halic- pla cem tidae (sweatbees) and Formicidae (ants). Two families, the Vespidae and the fo r Ju s t Apidae are associated with most stinging insect allergy. Hymenoptera venom anaphylaxis has been associated with about 40 deaths per year in the U.S., yellow jackets the most common cause in North America.1 Asymptomatic venom sensitization is common in adults but transient, and can disappear at a rate of 12% per year.2 Fatalities are less common in children than adults.3 Approximately one half of fatal reactions occur in individuals with no previous history of allergic re- actions to stings.4 Though patients with atopy have an increased risk of be- coming sensitized, they do not seem to develop systemic reactions more Dr. Waserman is an Associate frequently than non atopics.5 Professor of Medicine and the This article reviews the clinical features of stinging-insect allergy, as well as Training Program Director for diagnosis and treatment, including avoidance, injectable epinephrine, and Allergy and Clinical Immunology venom immunotherapy. at McMaster University, Hamilton, Ontario. Classification of Reactions Reactions from insect stings are classified as local (normal or large local) or sys- temic (allergic and non-allergic). Local reactions are limited to the area con- tiguous with the sting site. Large local reactions are also contiguous but are Dr. Aburiziza is an defined as being 10 cm in diameter or larger and lasting longer than 24 hours.6 xxxxxxxxxxxxxxxxxxxxxxxxxxxxx Frequently, these are misdiagnosed as cellulitis and treated with antibiotics. xxxxxxxxxxxxxxxxxxxxxxxxxxxxx Local reactions are not IgE-mediated, hence venom skin testing and im- xxxxxxxxxxxxxxxxxxxxxxxxxxxxx munotherapy are not indicated, however large locals may be and should be evaluated by an allergist. Systemic allergic reactions occur at sites distant to the sting and affect 0.4% to 0.8% of children and 3% of adults.1 These are IgE-mediated. Symptoms range from mild (cutaneous manifestations) to severe, with symptoms such as laryngeal edema, bronchospasm, and hypotension. Non-allergic systemic re- actions are less common and are not IgE-mediated. These include nephrotic syndrome, serum sickness, neurologic manifestations (Guillain Barre), rhab- domyolysis, and hemolysis.7 Allergy&Asthma
  • 2. 28 Allergy to Insect Stings A positive skin or RAST (radioallergosorbent A positive skin or radioallergosorbent test (RAST), a blood test which measures IgE to each of test), a blood test which measures IgE to each the venoms, in conjunction with a systemic reac- of the venoms, in conjunction with a systemic tion is diagnostic of venom allergy. In the weeks after a sting reaction, some patients have negative reaction is diagnostic of venom allergy. skin tests attributable to a refractory period. They should have repeat skin testing after four to six Diagnosis weeks. Patients with a negative skin test and a his- Recognition of anaphylaxis is often difficult, es- tory of anaphylaxis should have a RAST. If results pecially with the first sting and if urticaria are ab- are still negative, skin tests should be repeated sent. Vasovagal responses may be confused with after three to six months.8 anaphylaxis, however these are usually accompa- nied by bradycardia and anaphylaxis with com- Treatment pensatory tachycardia. An elevated serum Acute Therapy. Avoidance of stinging insects is tryptase, a mast-cell-specific enzyme, provides ad- important. Patients are advised to destroy nests, ditional evidence for anaphylaxis, but it is not wear shoes, avoid perfumes outdoors, cover very sensitive. garbage receptacles and use insecticides. Treat- Insect identification is also difficult, however ment of local reactions includes icing, elevation, certain factors may be helpful. Honeybees leave a analgesics, and antihistamines. stinger behind, whereas vespids do not. Yellow For acute systemic reactions, epinephrine jackets tend to be aggressive, and will sting if un- 1:1,000 solution, given as 0.01 ml/kg (maximum provoked. They are found around food and dose 0.3 ml/kg) is injected intramuscularly. All pa- garbage cans. Since they nest in the ground peo- tients with insect-sting anaphylaxis should carry ple are often stung while mowing the lawn. Hor- an epinephrine autoinjector, prescribed according nets are also aggressive and are found in nests, to weight. A “junior” dose of 0.15 mg of epi- trees and shrubs. nephrine is for patients weighing 15 kg to 30 kg Skin testing to the five Hymenoptera standard- and the regular dose of 0.30 mg of epinephrine is ized venoms is the standard method of diagnosis. for patients weighing greater than 30 kg. Patients Skin-prick tests to venoms, if negative, are fol- should be taught to self inject if necessary after a sting. The dose can be repeated in five to 10 min- utes if symptoms persist and patients should be Systemic allergic reactions occur at sites distant instructed to call 911. An antihistamine can be to the sting and affect 0.4% to 0.8% of chil- given, but is second-line therapy, and its use should not delay the administration of epineph- dren and 3% of adults.1 rine. Corticosteroids have no proven benefit in the acute period but may be useful in treating the lowed by intradermal skin tests. Intradermal con- late-phase manifestations of anaphylaxis. centrations start at 0.001 µg/ml to 0.01 µg/ml and Referral to an allergist is extremely important increase 10 fold to a maximum of 1 µg/ml. Skin for diagnostic skin testing, patient education, and tests are indicated when immunotherapy is being venom immunotherapy. considered, namely for individuals who have had Immunotherapy. Venom-specific immunother- a systemic allergic reaction. For children aged two apy is the treatment of choice for stinging-insect to 16 years who have had only cutaneous reac- allergy. It is safe and highly effective for prevent- tions, immunotherapy is not given since most ing future reactions. Immunotherapy is 97% to (90%) will not experience more severe or progres- 100% effective in preventing systemic reac- sive symptoms with their next sting (Table 1). tions,9whereas reactions in untreated individuals Allergy&Asthma
  • 3. 29 Table 1 Selection of Patients for Immunotherapy Reaction to sting Result of skin test or RAST Venom immunotherapy? Child Systemic, non-life-threatening, immediate, generalized urticaria, angiodema, erythema, pruritus + or − No Systemic, life-threatening, possible cutaneous symptoms, but also respiratory symptoms (laryngeal edema or bronchospasm) or cardiovascular symptoms (hypotension, shock) + Yes Adult Systemic + Yes Systemic − No Child/Adult Large local (> 2 inches, > 24 hour duration) + or − No Normal (< 2 inches, < 24 hour duration) + or − No is as high as 60%. temic reaction. About 3% to 12% of patients The venoms used for immunotherapy are the have treatment-induced systemic reactions that same as those used for skin testing (honeybee, yel- generally are mild and occur in the early phases of low jacket, yellow hornet, white-faced hornet, immunotherapy. If a systemic reaction occurs, wasp, and fire ant, if applicable). The routine reg- one half of the dose is given the next week. This imen begins with an injection of 0.01 µg and ad- approach, however, is individualized to the pa- vances weekly to 100 µg (equivalent to two stings). The maintenance dose of 100 µg is given Avoidance of stinging insects is important. every four weeks for a year, and then every six to eight weeks. Venom selection is based mainly on Patients are advised to destroy nests, wear shoes, skin-test results, clinical history and a pattern of avoid perfumes outdoors, cover garbage venom cross-reactivity. One recommendation is that immunotherapy includes all venoms giving a receptacles and use insecticides. positive skin test. However there is allergenic cross-reactivity of the four vespid venoms, hence tient. Pretreatment with antihistamines were most patients with multiple sensitivities can be found to be effective in reducing immunother- protected by immunotherapy with yellow jacket apy reactions. Large local reactions occur in venom alone.10 25% of children and 50% of adults, usually at Venom immunotherapy is well tolerated. Most higher doses. Although troublesome, they do patients receive their injections in an allergist’s of- not predict an increased risk of future systemic fice until the maintenance dose is reached. Pa- reactions to treatment. tients should remain for 30 minutes after each No long-term side effects have been associated injection in a setting equipped to handle a sys- with venom immunotherapy thus far. It is safe Allergy&Asthma
  • 4. 30 Allergy to Insect Stings Referral to an allergist is extremely important for leisure activities, medications, and coexistent dis- eases should be considered); the conversion to a diagnostic skin testing, patient education, and negative skin test is one criterion for stopping venom immunotherapy. venom immunotherapy. For most patients, it is time-based and discontinued after five years, after which protection is long-lasting in most, even if during pregnancy, with no increased risk of mis- the skin test remains positive. For those who had carriage or congenital anomalies, and it does not a severe initial allergic reaction, a decision to con- result in allergic sensitization in the child. tinue for longer or indefinitely may be made. Recommendations regarding discontinuation of venom immunotherapy include the following Conclusion from the American Academy of Allergy Asthma Venom allergy is one of the most common causes and Immunology: The decision to stop should be of anaphylaxis. All patients with a systemic aller- made after thorough discussion by the physician gic reaction should be evaluated by an allergist for and patient (patient variables such as vocation, consideration of immunotherapy. References: study of the natural history of large local reactions after Hy- 1. Golden DB, Marsh DG, Kagey-Sobotka A, et al. Epidemiology of menoptera stings in children. J Pediatr 1984; 104:664–8. Insect Allergy. JAMA 1989; 262: 240-4. 7. Light WC, Reisman RE, Shimizu M, et al. Unusual reactions fol- 2. Golden D, Marsh D, Freidhoff L, et al. Natural history of Hy- lowing insect stings: clinical features and immunologic analysis. J menoptera venom sensitivity in adults. J Allergy Clin Immunol Allergy Clin Immunol 1977; 59:391–7. 1997: 100:760-6 8. Selcow J, Mendelson L, Rosen J: Anaphylactic reactions in skin 3. Deaths from each cause by 5-year age groups, race, and sex: test-negative patients. J Allergy Clin Immunol 1980; 67:400. United States, 1980–1999. Hyattsville (MD): National Center 9. Hunt KJ, Valentine MD, Sobotka AK, et al. A controlled trial of for Health Statistics. immunotherapy in insect hypersensitivity. N Engl J Med 1978; 4. Barnard JH. Studies of 400 Hymenoptera sting deaths in the 299:157. United States. J Allergy Clin Immunol 1973; 52:259–64. 10. Reisman RE, Livingston A. Venom immunotherapy: 10 years of 5. Birnbaum J,Vervloet D, Charpin D. Atopy and systemic reactions to experience with administration of single venoms and 50 micro- hymenoptera stings. Allergy Proc 1994; 15(2):49-52. grams maintenance dose. J Allergy Clin Immunol 1992; 89:1189– 6. Graft DF, Schuberth KC, Kagey-Sobotka A, et al. A prospective 95. Allergy&Asthma